■ W ^PPPW^rW""'* T^^"
~&m&i
 wo
D794s
1854 a,
*^sf**»
3%

§*##►•
r^ebu^v
••■ <r
.•*.*■
•;%?&£.
#Q;



WvV-,

"&**?/**!>'■.

■'■'►''■' - *VJT
?." .'■•V,
,**&* 
NATIONAL LIBRARY OF MEDICINE




          Bethesda, Maryland
■<tfl 
f
i
 I  .■ 
 
THE
PEINCIPLES AND PEACTICE
ODERN  SURGERY. 
 
THE
      PEINCIPLES  AND  PEACTICE
                         or
MODERN   SURGERY.
            BY ROBERT DRUITT,
          FELLOW OF THE ROYAL, COLLEGE OF SURGEONS.

    "Id potissimum agens, ut omissis hypothesibus, in praxi nihil adstruat quod
  multiplici experientia non sit roboratum."
                             Act. Erijd. Lips., 1722.

              A NEW AMERICAN

                     FROM THE

    LAST A.ND IMPROVED LONDON EDITION.

                     EDITED BY
           F. W.  SARGENT, M.D.
               AUTHOR OF " MINOR S'JRGEHY," ETC.


ILLUSTRATED WITH ONE HUNDRED AND NINETY-THREE
               WOOD ENGRAVINGS.
       PHILADELPHIA:
BL AN CHARD  AND LEA.
              1854. 
vi
-5

vV
      Entered, according to Act oi Congress, in the /ear 1S48, by

               LKA  AND  BLANCHARD.

in  tba clerk's office of the District  Court  of the United  States lor the
                  Eastern District of Pennsylvania.
Piiuted by T.  K.  & P.  Q  Collins. 
ro
       CHARLES   MAYO,   ESQ.,

            SENIOR SURGEON TO THi! "WINCHESTER HOSPITAL,



IN ADMIRATION OF HIS SOUND JUDGMENT AND SKILL IN SURGERY,




     IN GRATEFUL  ACKNOWLEDGMENT OF EARLY KINDNESS,






         IS DEDICATED BY HIS AFFECTIONATE NEPHEW


                       AND OBEDIENT SERVANT,



                                  ROBERT DRUITT.
39 a, Ctjrzon Street, Mat Fair, Londou,
        20th March, 1647.
i*                                               \y) 
 
THE  AUTHOE'S  PEEFACE.
  It is with feelings of no slight gratification that I have found myself
called upon to prepare a fourth edition of the present work for the press;
and I have endeavoured, as far as lay in my power, to make it deserving
of the extensive circulation it has the good fortune to enjoy.
  The labour of such a revisal as was necessary to bring this edition up
to the present level of surgical knowledge,—short as has  been the inter-
val between it and the preceding edition,—has been very little less  than
that required for  the original  composition of the work.  It is, as Dr.
Johnson  observed, very difficult to alter without leaving a blot;  and,
therefore, wherever extensive alterations have been required, I have thought
it best to write the whole passage afresh.
  The present edition is about fifty pages longer than the preceding one ;
but the additions have been expended on the practical  parts of the work
exclusively.  Not that I have neglected the theoretical or pathological por-
tions   The theories which prevail from time to time  consist of the expla-
nations by which the leading  minds of the day attempt  to connect one
fact with another, and to make what is known, a step to the discovery of
the unknown.   Every person  of intelligence will therefore desire to know
what the most advanced pathological doctrines are ;  since, when properly
tested by experience, they often disclose the germs  of the greatest im-
provements in practice.  It would be  easy to illustrate  this position by
reference to the past and present treatment of very many  diseases.
  Amongst the departments of the work which have received the  greatest
improvements, I may mention the section on Inflammation, in  which I
have  availed  myself of  the labours of Hughes  Bennett, Travers, the
Goodsirs, Wharton Jones,  Addison of Malvern,  and Gulliver ;—on
Malignant Disease, in which I have made use of the admirable Treatise
of Dr. Walshe ;—on Diseases of the Bones and Joints;  on Aneurism, in
which I have  made mention of the improved plan of treatment introduced
by that excellent body of men who are at the head of the Surgical Profes-
sion in Ireland ;—on Diseases of the  Spinal Cord ;—on Diseases of the
Ear, the whole of the chapter on which is new;—on Fissured Palate, a
subject which has lately received so much elucidation from the dissections
of Mr. W. Fergusson ;—on those Affections of the Air Passages which
require the operation of  Tracheotomy;—and  on Diseased Conditions of
the Urinary Apparatus.   I have besides added an entirely new chapter on
the art of Bandaging, with copious illustrations, drawn from nature under
my own superintendence.
                                                        (vii) 
viii
THE AUTHOR'S PREFACE.
    The notes which occur at the foot of almost every page will, I hope
 show my anxiety to  acknowledge  every  source  of information wnich I
 have availed myself of.
    The Appendix of Formulae, which I am told  has proved of oreat ser-
 vice to young practitioners, has been entirely re-arranged, and very much
 enlarged.   I may observe, that all the Formulae  have been  amply tested
 by experience, and that they agree in all  essential  particulars with those
 used by the ablest practitioners of the day.
    The number of Wood Engravings has  been increased.   Those which
 have been added to this edition have been  drawn under ray superintend-
 ence by my friend Dr. Westmacott, and in every case  the  drawing  is a
 faithful representation of nature;—not an imaginary diagram.
    I have now the grateful task of expressing  my thanks to the numerous
 friends who have in  many ways assisted  me in  my labours.   To  Mr.
 Partridge, Mr.  Fergusson, Dr. Todd, and their colleagues, the other
 Professors in King's College, and Medical Officers at the College Hospital,
 I  am under particular obligations for  the privilege of constantly witnessing
 their practice, and for the permission they gave me to have drawings made
 from a great number of the preparations in the College Museum.  To Mr
 Arnott and the Medical Officers of the Middlesex Hospital, to Mr  Pres-
 cott Hewett and the Medical  Officers of St. George's, and  to Mr. Lane
 I am likewise indebted for permission to avail myself of some of the pre-
 parations in their respective Museums  for a similar purpose.   I  have to
 thank Dr. George Johnson  for an  admirable drawing  of Pus Globules
 (the most correct I believe that has yet been published), as well as for the
 opportunity of inspecting his microscopic preparations of Kidney Disease ;
 and Mr. Tomes for much valuable information respecting Diseased Bone
 and Teeth   To  Mr. Toynbee, Mr.  Lonsdale, Mr. James Duncan, Mr.
 r™N'fR'  ^prague  of Ba*h, and  Mr. Masters the Curator of  the
 King s College Museum ; to these, and to many other friends and corre-
 spondents at home and in America, with whom I have had the privilege
 of  becoming acquainted by means of  this work, I must return my warmest

 Ofthe fct    v  LT°rk w ™nged ™J °e very brieflyexplained.
 de™L In 5?   '° 7  Ch j 1 dlVlded' the first two are  more especially
 Thefil nart trP,TiPfeS' Td *? thr!e  °therS t0 the P™tice of sWr/
 thataccomniJ Tf n  "T"  d*urbances of ^  constitution at large,
 Sfs^onPis?XH     ^\Va"0U;  aCCid6ntS and  local ^«eases which
 coLnsfthat folhw^ T?H    ^f5 bGginnin^  With the simPle faintness or
 feverP tetanus 1uH ,   7' andProce^ing to consider those varieties of
   The second ri "Sf T" ?* ^ be CaUSed bv Iocal Nation.






sues, r their nutHtlnthl  "^T* ^^ °n the vita% of the tis-
^^XV^^^^T^  and,their othe' m?steriou's
operation J SK      10nS' &nd by other causes whose
bribed h&o^^^Fm^™^.1001*** Pr0C6SSeS ^
                    wnicn seemed  most conducive to  practical utility, 
                     THE  AUTHOR'S  PREFACE.                    !X

without any attempt at philosophical arrangement.   Simple inflammation,
and its varieties, are described first, then in succession the processes which
are commonly called  consequences  of inflammation ;  and, lastly, those
diseases, such as cancer and scrofula, which depend on some  peculiarity
in the constitution, and are  consequently termed specific.  Our knowledge
of the intimate processes of nutrition, normal, and abnormal, will, it is to
be hoped, soon  enlighten the present obscure and unsatisfactory state of
this department of surgery.
   The third part treats  of the various kinds of injuries, beginning with the
simplest mechanical injuries: then proceeding to the effects of chemical
agents, and lastly, considering the effects of animal poisons.  With regard
to the last-mentioned case of morbific agents, I may observe, that without
a knowledge  of hospital gangrene, dissection wounds, and glanders, no
one can have  very clear ideas on the subjects of infection and  contagion,
or of the action of those other morbid poisons, whose effects come  within
the so-called domain of physic.
   The  fourth part considers the various tissues,  organs, and regions of the
body in order, and describes the various accidents  they are liable to, and
such  of their  diseases as are commonly assigned to the care of the  sur-
geon.
   The  fifth part describes  the  amputations, the ligature of arteries, and
such  other operations as were not included in the   former parts.  Whilst
on the subject of operations, I have noticed the  newly proposed plan of
inhaling ether.  I hope  that I shall be considered to  have spoken with due
caution of an agent whose effects are so powerful, and as yet so little
known.
                                                              R. D.

   London, 39 a, Curzon Street, May Fair,
                Jipril,  1847.
• 
 
THE EDITOE'S  PEEFACE.
  The speedy demand for a new edition of this work is suffi-
cient evidence of the high estimation in which it is held by
the profession of this country.  The previous  editions were
passed through the press under the editorial supervision of Dr.
Flint, of Louisville, Ky.  The distance of his residence, how-
ever, from the point of publication, has induced him to decline
the revision of the present reprint,  on account  of the close
superintendence demanded by the numerous additions  of text
and illustration, now introduced by the  author.   Under these
circumstances, I have been invited to assume the editorship
of the work.
  The labour and learning of the author have rendered my
duties necessarily light, and I have,  in a great measure, con-
fined myself to adding such of the results of the skill and in-
dustry of American surgeons as appeared  to me most worthy
of mention.   These additions will be found  enclosed iu
[ ] brackets.
  The text and general arrangement of the author have not
been  altered, while  his  illustrations  have all  been  repro
duced, except in  one or two instances  in which an ad- 
 Xii                THE EDITOR'S PREFACE.
 vantageous  substitution  could  be made.  .1 have, however,
 introduced  many new cuts where I  deemed  such  further
 elucidation  of  importance.  The amount of these  changes
 may  be understood,  from the  fact  that more  than  one-
 half of the wood-cuts in the present publication have appeared
 m no previous American  edition.
   The valuable annotations of Dr. Flint to the former editions
 have been retained, except where they have been already em-
 bodied  in the  text.  The title adopted  by him also  re-
 mains unaltered, the reasons  given in his preface applyino
even more strongly to the present than to former editions.
                                 F. W. Sargent, M. D.
  Philadelphia,  September, 3848 
PEEFACE  TO  THE  FIEST  AMEEICAN  EDITION.
   The American Editor of the present volume  can claim  but little parti.
eipation in the merits of it beyond what is due to an early appreciation of
the excellencies of Mr.  Druitt's book, and an earnest and successful effort
to procure its republication.   Upon a thorough examination of it with a
view to this undertaking, it appeared that its author had been so eminently
successful in collecting and arranging whatever could be introduced into
such a work with advantage, as to forbid any aspirations for the  honours
of authorship to a revising Editor, even in the humble offices of annotation
and commentary,  and he engaged in the enterprise, ambitious only to
be instrumental in introducing to  his profession in this country, and espe-
cially in the West, the best  compend  of the principles  and practice  of
surgery extant.
   The only work of the kind to  be  compared  with  it, is  the  admirable
Dictionary of Mr. Samuel Cooper, and though a high  compliment, it is
not an undeserved one to this volume, to say that, in view of its final pur-
pose  and uses,  it is, in many respects, entitled to  a preference.  Mr.
Cooper's  disquisitions—historical and  speculative—on various  subjects,
though always learned,  ingenious and interesting, are frequently too elabo-
rate and discursive for  a book of practical reference, and the substance
of them may generally be found given in brief and comprehensive para-
graphs, by Mr. Druitt, and accompanied by such ample bibliographical
references as will enable the surgical student to  prosecute his  inquiries
under the light of all the best guides and authorities which the science can
supply.  The systematic and methodical  arrangement of topics in one
volume, while it may be a little less convenient  in a manual for the prac-
titioner, than the alphabetical order of the " Dictionary,"  nevertheless
contributes essentially to its excellencies as a text-book for the student. In
this respect it will  be found  to answer an important desideratum in the
apparatus  of teaching, and cannot fail to become  a favourite  as well with
Professors of Surgery as with tffeir pupils.
  A full course of surgical instruction, of which this should be an epitome
or synopsis, would be as nearly a  complete one, both in arrangement and
matter, as the present state of the science and the didactic genius of the
best teachers could produce.
  The extensive circulation which such claims cannot fail  to secure to a
work of this kind, among the teachers and practitioners of our art in this
country, offered a tempting opportunity for the Editor to introduce to their
     2                                                  (xiii) 
XIV
PREFACE TO THE FIRST AMERICAN EDITION.
notice such views and principles of practice, on the various surgical topics,
as his own observation and reflection  had contributed to establish and
render favourite and important ones, in his own estimation.
   A few brief notes of a practical character,  the  transposition of two or
three sections, and  the change of name, from " The Surgeon's Vade Me-
cum" to the one  now substituted—comprise, however, the only material
alterations on which he has ventured.   The  latter alteration was  made
partly as a matter of taste, but chiefly upon considerations of significancy
and  pertinence.   " Vade Mecum" is a  title by no means expressive  of the
true character of this work—it indicates,  indeed, the modesty of its  au-
thor, but is far from comporting with the real  dignity and merit of its pro-
duction.
   " The Principles and Practice of Modern Subgery" is certainly a
significant title for a book which, like the present, is a faithful codification
of the  opinions and practice of Hunter, Pott, B. Gooch, Abernethy, the
Bells,  Physick, Dupuytren, Hennen, Macartney, Larrey, the Coopers,
Scarpa, Lawrence, Liston,  Guthrie, Mayo, Brodie, Carmichael, Warren,
Wardrop, Key,  Travers,  Dudley,  Breschet, Tyrrell, Green, Diffenbach,
Civiale, Leroy, Arnott, Barton, Ricord, Colles, Stanley, and  most of the
other distinguished surgeons who have flourished since the commencement
of the  Hunterian epoch.   Without any of the adventitious aids to which
most publications  of the  present day  owe their success—the previous
heralding, and subsequent  puffing which  are usually in requisition  at a
literary debut—without the prestige  of  rank or official  distinction  on the
part of its author,  the " Vade Mecum"  has secured  an  extraordinary
popularity in Great Britain, and  the most flattering  commendations of
medical critics.
   Such testimony to its intrinsic merits  has encouraged its republication
here, and will bespeak for it a favourable reception among the practitioners
of our country, to whom it is respectfully commended, by
                                   '  Their Friend and Brother,
                                                          J. B. F.
Ijouisville, April bth, 1842. 
LIST  OF  THE  WOOD-ENGRAYINGS.
FIG.                                                                     FAG I
 1 Microscopic view of Fibrine.   From Gulliver's  Translation of perber's  General
     Anatomy..........................................................  63
 2 Microscopic Drawing of Pus Globules.  From nature.......................  67
 3 Mucus Globules.   From Vogel...................................  .....  68
 4 Exudation Corpuscles.  From Dr. Hughes Bennet.........................  69
 5 Bandage for the Ankle................................................  88
 6 Baynton's Treatment of Ulcers........................................  89
 7 Gangrene of the Foot.  From a cast in the King's College Museum........ .. 102
 8 Microscopic Characters  of Tubercle....................................109
 9 Scrofulous Disease of the Mesenteric Glands..............................115
10 Microscopic Characters of Cancer....................................... 116
11 Ulcerated Scirrhus of the Breast.  From the King's College Museum..........118
12 Fungus Haeinatodes. From the  same................................... 122
13 Colloid Cancer.  From the same.......................................123
14 Melanosis.  From the same............................................ 124
15 Interrupted Suture...................................................126
16 Twisted Suture...................................................... 126
17 Quilled Suture. ..........................,.......................... 126
18 Bandage for Longitudinal Wounds......................................127
19   Do.           do.      do.......................................127
20 Bandage  for Transverse Wounds.......................................128
21 Rupia Syphilitica.  From  the King's College Museum...................... 199
22 Syphilitic Disease of the Skull.  From the same...........................200
23 Lupus.  From the same..............................................209
24 Treatment of Rupture of the Tendo Achillis..............................212
25 Chalk-stone Deposit in the Sheath of Tendons.    From Cruveilhier...........214
26 Ganglion on the Finger.  From the King's College Museum.................214
27 Exostosis of the Femur.  From the same................................217
28 Section of  a Rachitic Tibia.   From the same.............................218
29 Bone enlarged through Chronic Inflammation.  From the same..............220
30 Abscess in  Bone.  From the same......................................221
31 Necrosis.   From  the same.............................................221
32 Microscopic Drawing of a Section of dense  healthy Bone.   From Mr.  Tomes's
     Collection.........................................................~*~
33 Similar Drawing  of Inflamed and softened Bone.  From the same............222
34 Section of a Phalanx during Process of Exfoliation.  (This cut has unfortunately
     been printed upside down)...........................................224
35 Caries of  Bone.   From the King's College Museum.......................224
36 Bony Skeleton of Osteo-sarcoma.  From the same.........................226
37 Callus after Fracture.  From, the same...................................227
38 False Joint.  From the same..........................................231
39 Four-tailed Bandage for Fractured Jaw..................................234
40 Gibson's Bandage for Fractured Jaw....................................235
41 Barton's  do.         do.     do.....................................23.<
42 Fiiiure of  8 Bandage for Fractured Clavicle..............................236
                                                                (XV) 
Wl
LIST  OF THE  WOOD-ENGRAVINGS.
FIG.                                                                           pA0«
 43 Mr. James Duncan's Bandage for Fractured Clavicle.......................236
 44 Fox's Apparatus for Fractured Clavicle...................................238
 45 Section of United Fracture of the Cervix Humeri, from an aged subject.  From
     the King's College Museum..........................................240
 46 Fracture of the lower extremity of the Radius.............................243
 17 Atrophy of the Bony Tissue of the Cervix Femoris, from an aged subject. From
     the King's College Museum..........................................246
 48 Another view of similar changes which might be mistaken  for an United Fracture 246
 49 Appearance  of a Patient after  Fracture  of  the  Cervix Femoris.  From Sir A.
     Cooper...........................................................247
 50 Fracture of the Cervix Femoris external  to  the Capsular Ligament.   From the
     King's College Museum.............................................248
 51 Mr. Liston's Long Thigh Splint........................................249
 52 Mr. Fergusson's Splint................................................250
 53 Physick's Long Splint................................................250
 54 Gaiter for extending a Fractured Thigh..................................251
 55 Extension by Handkerchief............................................252
 56 Gibson's Splint......................................................254
 57 Comminuted Fracture of the Femur,—union with great  deformity.  From the
     King's College Museum.............................................255
 58 Mr. Lonsdale's Splint for Fractured Patella................................257
 59 Many-tailed Bandage.................................................259
 60 Mr. Fergusson's Leg Splint............................................259
 61 Mr. Fergusson's Side Splint............................................260
 62 Dupuytren's Splint  for Fractures of the lower part of  the  Leg...............261
 63 Fracture-box........................................................261
 64 Fracture of the Bones of the Leg......................................261
 65 Parasitic Cartilage attached to one of the Semilunar Fibro-Cartilages of the Knee-
     joint.   From the  Museum  of the Middlesex Hospital.....................266
 66 Section of Caries of the Astragalus.  From the King's College Museum.......271
 67 Spina Ventosa of the Lower  Extremity of the Femur.    From the  same.......271
 68 Miitter's Splint for  Partial Anchylosis...........................       _ 273
 69 Anchylosis of the Ankle-joint.  From  the King's College  Museum...........274
 70 Bird's-eye View of  Child in  Second Stage of Hip Disease.................! 275
 71 Shortening of the Limb from advanced  Hip Disease........................275
 72 Position of  the Bones in Dislocation of the Humerus downwards.............279
 73 Position of the Bones in Dislocation inwards................                 279
 74 The Knot called Clove-hitch.............................                 280
 75 White's Manner of  Reducing dislocated Shoulder.   Sketched from nature."...... 281
 76 Position of the Bones in  Dislocation of the Elbow............              " 282
 77 Position of the Bones in Dislocation of the Radius forwards................. 283
 78 Dislocation  of the Finger, and Manner of Reduction................. '.'. .. !. 284
 79 Dislocation  of Femur on the Dorsum  Ilii.   From Sir  A. Cooper..'..".".!'.'."..!. 285
 80 Manner of reducing the same. Sketched  from nature.............      !'.!.' 286
 81 Dislocation into  the Sciatic Notch.  From Sir A. Cooper].'.'...'.'.           !. 287
 82 Dislocation  of the Os Femoris downwards............                      287
 83 Reduction of this Dislocation.................."                           288
 84 Dislocation  forwards..................                                  '' noo
 85 Reduction of Dislocation of the Femur by the'use of a twisted rope!..'........289
 86 Ligature of  Arteries....................                          .......094
 87 Aneurism of the Common Femoral Artery!'  The Ex'tern'al YliVc'had been'tied  by
     Sir  B. C.  Brodie.   From the Museum of St. George's Hospital.............299
 88 r ront view of Aneurism  of the Arch of the Aorta                             300
 R9 Back view of the same  preparation, exhibiting the" small' ulcerated opening' by
     which the  Aneurism burst into the  trachea.   From  Mr.  Lane's Museum in
     Grosvenor  Place......................                                 „nfl
 90 Signoroni's  Tourniquet.........          ...........................on2

 92 tTIT^J Ana/:°m0SiS-   Fr°m *e' ^i"'" Allege' Museum!!!!!.'!'.'.'.!!!! 305
 9-J 1 wisted Suture of Veins tor the cure  of Varix                                <iin
 93 Fractured Skull............               ............................^jj

 E D^ctl^^                                                          328
     Museum of StT Blfifa„From,a Preparation by Mr. Prescott Hewett, in  the
     museum oi St. George's Hospital...............                           339 
LIST  OF  THE  WOOD-ENGRAVINGS.
xvii
96 Spina Bifida,—external appearance of Tumour.  From a cast in the King's Col-
     lege Museum....................................................330
97 Fracture of the Vertebrae............................................333
98   do.           do...............................................333
99 Ectropion...........................................................33°
100 The same  cured by Operation..........................................^°
101 Puncture of Distended Lachrymal Sac...................................339
102 Style for Fistula Lachrymalis...................................•......3*^
103 Healing Ulcer of the Cornea.  From a drawing in Mr. Partridge's collection----347
104 Staphyloma Corneae..................................................
105     do.       do..................................................3y
106 Syphilitic Iritis.   From Mr. Partridge's collection..........................*°U
107 Operation for Extraction of Cataract................................•• • • 3ob
108 Atrophy of the Optic Nerve, and  corresponding tractus opticus.  From the Mid-
      dlesex Hospital Museum  ............................................"i  '
109 Diagram exhibiting the effects  of  Concave Glasses in relieving Myopia.........360
110 Diagram showing the effects of Convex Glasses...........................36?
Ill Operation  for Strabismus.............................................."
112 Malignant disease of the Eye.   From Mr. Partridge's  collection..............J7U
113 Speculum  Auris....................................................."
 114 Belloc's Instrument for arresting Epistaxis................................*°"
 115 Forceps for Extracting Nasal Polypus.   From Mr. Fergusson................<«'
 116 Double Canula and Wire for the  same.    From the same....................384
 117 Puncture of the Antrum..............................................'
 118 Restoration of the  Nose..............................................
 119 Fissure of the Palate.   From a preparation of  Mr. Fergusson s..............^sa
 120 Knife used by  Mr.  Fergusson  in operating upon  the Palate..................o9U
 121 Knot employed by  Mr. Fergusson in the  operation of Staphyloraphe..........3J0
 122 Cancer of the  Lip...................................................„„„
 123 Extraction of Molar Teeth with  the Forceps.............................^'
 124     do.    of Lower Incisors..........................................
 125 Extraction of  Molars with the Key.....................................
 126 Fahnestock's Instrument for Excision  of  the Tonsils..................... Vi.
 127 Stricture of the CEsophagus.   From the  Museum of the  Middlesex Hospital. . . 404
 128 Tracheotomy  Tube..................................................   q
 129 CEdema  Glottidis.   From the Middlesex Hospital Museum..................*"»
 130 Warty Excrescences about the Larynx.  From  the same................----41U
  131 Extensive Ulceration  of the  Larynx.   From a preparation  in the Author s pos-
       session...........................................................  ., o
  132 Bronchocele.  From  the King's  College Museum...........----•• ••• ••••■ *ld
  133 Section of a Bronchocele, showing calcareous concretions.  From the Middlesex
       Hospital Museum................................; • • •..............    '
  134 Drawing of the parts concerned in  Inguinal Hernia.  After Tiedemann.........  4d0
  135 Congenital Omental Hernia on the right side.   From the King s College collec- ^
        tion.............................•.................................  ,\H
  136 Encysted Hernia.   From the same collection........................^... ■
  137 Drawing, showing the difference  between Oblique and Direct  Ingu.nal  Hern.a. ^
        From  Tiedemann........................■ • • • • • • • ■_•.....; '• ■.......
  138 The Parts connected in the Formation of Crural Hernia.   From  a dried prepara-
        tion in the King's College  Museum....................-....•..•• .•■■■•
  139 Obturator, or  Thyroid Hernia.   From  a preparation in  the King s  College Ma- ^
        seum.........................................................447
   140 Section of Haemorrhoids......................................      ■ • ^
   141 Mr. Fergusson's  Speculum.......................................  •
   142 Prolapsus Ani.   From the King's College Museum. .      ..................**J
   143 Stricture of the Rectum.   From the Middlesex Hospital Museum.............454
   144 Puncture of the Bladder from the  Rectum...............................  *'
   145 Stricture of the Urethra.  From  the King's College Museum................*••«
   146 Stricture, False Passages, and Urinary Abscess.   From the same.............4I..J
   147 Chronic Enlargement of the Prostate.   From  the same.....................««
   118 Encysted Tumour attached to the  Prostate.  From the same.......... ....... 4b,
   149 Drawing of a Preparation in the Middlesex Hospital  Museum, exhibiting  S.ric-

          2*                             B 
xviu
LIST  OF THE  WOOD-ENGRAVINGS.
 KIG.                                                                          _
       tures. False Passages,  Hypertrophied  Bladder, enormously dilated Ureter  ^nd
       Diseased Kidney.............................................     i~,
  150 Microscopic View  of Epithelium  Cells  and Fibrinous Shreds from  the  Tubuli
       Uriniferi of a  Kidney affected with Bright's Disease.  From Dr. G. Johnson.  472
  151 Crystals of Lithic Acid.   After Dr. Golding Bird........................   47-
  152 Crystals of Oxalate of Lime.   From the same...........................   4..q
  153 Crystals of Phosphatic Gravel.  From the same........................    40A
  154. 155, 156 Lithotrity Instrument....................................!!!!  487
  157 Operation of Lithotomy.........................................        .„.
  158 Diagram of Parts at the Neck of the Bladder......................!!!!.'!! 492
  159 Operation for Phymosis.......................................        " .„„
  160 Fricke's Treatment  of Epidydimitis...............................      " 4g9
  161 Hydrocele.  From  the King's College Museum....................        " 50°
  162 Hydrocele, together  with a Serous Cyst  in  the Spermatic Cord.   From't'he Mid-
       dlesex Hospital Museum.............................*                 ,.„.
 163 Talipes Equinus.   From a cast in the King's College Museum..........!..!' 514
 164 Talipes varus.   From the  same..........................            " " 114
 165 Onchia maligna.   From the same......................                  517
 166 Air. Fergusson's Knot for the Strangulation of Tumours......!..!.'.'........524
 167 and 168 Anatomy of the .parts at the bend of the Elbow, that  are  concerned i.i
       Venaesection......................
 169 Bandage  after Venisection.  This,  with  the  other' drawings''of bandages''was  5
      copied from  nature by Dr. Westmacott .                                   -„.
 170 Bandage  for the Finger...............        '"            .............J?
 171 Bandage for the Hand and  Wrist.......'.".'.'.'.'.'.'.'.'.'.'.'.'.'.".'...........'.....L!
 172 Bandage for the Forearm.............'                  ..............„
 173 Bandage for the Leg..................................................
 174 Bandage  for the Knee......•'.'.'.'.'.'.'.'.'.'.. ..'.'.'.'.          ......'.........eo"
 175 Four-tailed Bandage for the Knee.....!..!'.     ........................Ill
 176 Bandage  for the  Groin and Hip......!!.".!!!!!!.'.'                   .....too
 177 Bandage for the Chest and Axilla.......!......                  ..........J."
 178 Bandage  for the  Head—four-tailed. ...'.".'.'.'.'."          ..................„~
 179 Bandage  for the  Perinaeum.............. .      ......................... '1
 180 Common  Tourniquet..........             ............................ ,
 181 Flap  amputation of the Thigh...............................'.........co'*
 182 Flap  amputation of the Leg......!.               ...................... „
 183 Circular amputation of the Arm...!.'.!........        ...................coq
 184 Flap  amputation of  the Forearm.......................................At
 185 Flap amputation of the Wrist........! \'  "       ....................... *.
 186 Flap amputation  of the Finger.  ......................................I
 187 Amputation of the Head of a Metacarpal  Bone!!!..........................S,
 188 Ohopart s  amputation of the Foot.....................
 189 Viewof the parts  concerned in  the'opera^m''f^'tying't^ cJmm^n'Carotid

190 View  of the Relative"  Ana.'o'my 'of'the" Rad'ial'and Ulnar Arteries..............552
 92 XT   f  te ^ at'Ve  Anat°my °f the Fem™' Artery. .       ..............
192 V.evv  of the Relative  Anatomy of the Posterior Tibial   ....................55
193 View of the  Relative Anatomy of the An
tenor Tibial............            55^ 
CONTENTS.
                                PART  I.

    OF THE  CONSTITUTIONAL EFFECTS  OF LOCAL INJURY AND DISEASE.

CHAP.                                                                    PAGE
   I. Of Prostration or Collapse  ............................................25
  II. Of Prostration with Excitement and Delirium Traumaticum.................28
 III. Of Fever...........................................................30
        Sect. 1.  Of Fever generally........................................30
              2.  Of Inflammatory Fever....................................30
              3.  Of Irritative Fever........................................34
              4.  Of Hectic Fever..........................................35
              5.  Of Typhoid Fever........................................37
 IV. Of Tetanus.........................................................3S
        Sect. 1.  Introductory.............................................33
              2.  Of Acute Tetanus.......•.................................33
              3,  Of Chronic, Infantile, and  Hysterical Tetanus..............'....  45
  V. Of Convulsions......................................................46



                                PART  II.

             OF THE  PRINCIPAL PROCESSES OF  LOCAL DISEASE.

   I. Of the General Phenomena of Inflammation..............................47
  II. Of Acute Inflammation................................................5i
 III. Of Chronic Inflammation..............................................»•*
 IV. Of Effusion of Serum.................................................61
  V. Of Adhesion or the Production of New  Tissues...........................62  .
 VI. Of Hemorrhage.....................................................'''»'
                                                                 (xixj 
XX
CONTENTS.
CHAP.                                                                         tiOK
 VII. Of Suppuration and Abscess..........................................  6(1
         Sect. 1.  Of the Theory of Suppuration.............................  60
               2.  Of Acute Abscess........................................  71
               3.  Of Chronic Abscess......................................  74
VIII. Of Erysipelas......................................................  77
         Sect. 1.  Pathology of Erysipelatous Inflammation.....................  77
               2.  Of the Cutaneous and Cellulo-Cutaneous Erysipelas...........  78
               3.  Erysipelatous or Diffuse Inflammation of the Cellular Tissue.....  82
  IX. Of Ulceration......................................................  83
         Sect. 1.  Of the Pathology of Ulceration.............................  83
               2.  Of the Varieties of Ulcers.................................  85
  X. Of Mortification............................................  .......  99
         Sect. 1.  Of the Pathology of Mortification...........................  99
               2.  Of the Varieties, Symptoms, and Treatment...................101
  XI. Of Scrofula.......................................................106
 XII. Of Malignant Diseases...............................................US
         Sect. 1.  Introductory............................................115
               2.  Of Scirrhus.............................................117
               3.  Of Medullary Sarcoma, and Fungus Hsematodes...............122
               4.  Of Gelatiniform Cancer____.'..............................123
               5.  Of Melanosis............................................123




                                 PART  III.

                  OF  THE DIFFERENT SPECIES OF INJURIES.

   I. Of Incised Wounds.................................................125
  II. Of Punctured Wounds...............................................129
  III. Of Lacerations and Contusions........................................130
         Sect. 1.  Of Contusion and Ecchymosis.............................130
               2.  Of Lacerated and Contused Wounds........................132
  IV. Of Gunshot Wounds................................................133
  V. Of the Effects of Heat, Burns, and Scalds...............................143
  VI. Of the Effects of Cold...............................................149
 VII. Of the Effects of Mineral and Vegetable  Irritants.........................152
VIII. Of the Effects of the Poison of Healthy  Animals.........................153
         Sect. 1.  Of the Effects of Poisonous Insects and Serpents.......'.......153
               2.  Treatment of Poisoned Wounds............................156
               3.  Of Insects which bury themselves under the Skin..............157 
                                  CONTENTS.                               XXI
CHAP.                                                                        PAGE
  IX. Of Septic Poisons...................................................  158
         Sect. 1. Of the Poisons contained in Dead Bodies, and of the Influence of
                     Dissection on the Health................................158
               2. Of Dissection Wounds...................................159
   X. On the Effects of Poisons generated by Diseased Animals..................164
         Sect. I. Of Hydrophobia..........................................164
               2. Of the Glanders.................*.......................173
  XI. Of the Venereal Disease..............................................176
         Sect. 1. Of its General History and Pathology.......................176
               2. Of Gonorrhoea..........................................180
                3. Of Primary Syphilitic Ulcers...............................188
                4. Of the Diagnosis of Chancre, and of the  Affections that may be
                      mistaken for it........................................191
                5.  Of the Treatment of Primary Syphilis.......................192
                6.  Of Bubo...............................................196
                7.  Of Secondary and Tertiary Syphilis.........................198
                                 PART  IV.

OF  INJURIES  AND SURGICAL  DISEASES  OF VARIOUS  TISSUES,  ORGANS,  AND
                                    REGIONS.

   I. Of  the Diseases of the Cellular Tissue.................................203
         Sect. 1. Carbuncle and Boil......................................203
               2. Tumours...............................................*05
  II. Of the Surgical Diseases  of  the Skin...................................207
  III. Of Diseases and Injuries  of  Muscles, Tendons, and Bursas..................211
  IV. Of the Diseases and Injuries of the Lymphatics...........................215
  V. Of the Diseases and Injuries of Bone...................................217
         Sect. 1. Of the Diseases..........................................217
               2. Of Fracture generally.....................................227
               3. Of Non-union  and False Joint.............................230
               4. Of Compound Fracture...................................232
               5. Of Particular Fractures...................................233
  VI. Of the Diseases and Injuries of the Joints...............................263
         Sect. 1. Of the Diseases of the Synovial Membrane...................263
               2. Inflammation of  the Cellular Tissue.........................267
               3. The Ligaments..........................................267
               4. The Cartilage...........................................268
               5. Articular Caries.........................................271
               6. Anchylosis..............................................2' * 
xxii
CONTENTS.
CHAP.                                                                          PAOK
  VI.      Sect. 7. Of Disease of the Hip Joint..............................274
               8. Wounds of Joints........................................277
               9. Of Dislocation generally...................................277
              10. Of Particular Dislocations .................................278
 VII. Of Injuries  and  Diseases of Arteries....................................292
         Sect. 1.  Of Wounds of Arteries....................................292
               2.  Of Inflammation of Arteries................................297
               3.  Of Aneurism........................................___£98
               4.  Varieties of Aneurism ....................................303
               5. Of Aneurism  by Anastomosis and Naevus.....................304
VIII. Of Injuries and Diseases of Veins......................................305
 IX. Of Injuries and Diseases of the Nerves..................................311
  X. Of Injuries of the Head..............................................315
         Sect. 1.  Wounds of the Scalp..............................,......315
              2.  Concussion of the Brain...................................315
              3.  Compression from Extravasated Blood.......................317
              4.  Fractures of the Skull....................................319
              5.  Wounds of the Brain.....................................321
              6.  Hernia  Cerebri  and  Malignant  Growths  of  the  Cranium and
                   Meninges.............................................321
              7.  Inflammation of the Brain.................................322
              8.  Trephining and Paracentesis...............................324
 XI. Of the Diseases and Injuries of the Spine...............................325
         Sect. 1.  Of  the Diseases and Deformities............................325
              2.  Injuries of  the Spine......................................332
UI. Of the Injuries and Diseases of the Eye.................................334
         Sect. 1.  Of  Wounds and  Foreign  Bodies............................334
              2.  Diseases of the Eyelids..........................         .. 335
              3. Diseases of the Lachrymal Apparatus........................338
              4.  Of  Inflammation  of the Eye, generally, and of the Diseases of the
                   Conjunctiva.....................                         340
              5.  Of  the Diseases of the Cornea.............            .....345
              6. Diseases of the Sclerotic..............                      .. 348
              7.  Inflammation of the Anterior Chamber.......................349
              8.  Of  the Diseases of the Iris.................            .....349
              9. Inflammation of the Capsule of Crystalline Lens..............353
              10. Of  Cataract.................                                353
             11.  Of Glaucoma.............                                  359
             12.  Of the  Diseases of the Choroid ;  and of Synchysis and Hydroph-
                  thalmia..............                                      3gp
             13.  Of Retinitis..............                                   35]
             14.  Of Amaurosis..............                                  362 
                                   contents.                             xxiii
chap.                                                                         page
   XII.  Sect. 15.  Of Short and Long Sight..................................366
              16.  Of Squinting............................................367
              17.  Of Malignant Diseases of the Eye...........................370
  XIII.  Of the Diseases and Injuries of the Ear...............................371
         Sect. 1.  Of the Examination of the Ear.............................371
               2. Affections of the External Ear..............................373
               3.  Affections of the Tympanum...............................376
  XIV.  Of the Diseases and Injuries of the Face, Nose, Palate, Lips, Mouth, Tongue,
           and Teeth.....................................................379
   XV.  Of the Surgical Diseases and Injuries of the Neck, CEsophagus, and Trachea  402
         Sect. 1.  Surgical Diseases of the Fauces............................402
               2.  Surgical Affections of the QJsophagus.......................403
               3. Surgical Affections of the Larynx and Trachea................407
               4. Surgical Affections of the Neck and Throat...................411
  XVI.  Of the Surgical Diseases and Injuries of the Chest......................417
 XVII.  Of the Surgical Diseases and Injuries of the Abdomen...................42U
 XVIII.  Of Hernia.......................................................42S
         Sect. 1. Of  the Nature and Causes of Hernia generally................428
               2. Of  the Reducible Hernia..................................430
               3. Of  the Irreducible Hernia.................................431
               4. Of  Strangulated Hernia...................................432
               5. Of  Inguinal Hernia.......................................437
               6. Of  Femoral or Crural Hernia...............................412
               7. Of  the Umbilical, Ventral, and other remaining Species of Hernia  444
  XIX.  Of the Surgical Diseases and Injuries of the Rectum and Anus.............445
   XX.  Of the Diseases of the Urinary Organs................................456
         Sect. 1. Of  Retention of Urine  and Spasmodic Stricture of the Male
                     Urethra..............................................456
               2.  Of  Permanent Stricture .,.................................458
               3. Of  Urinary Abscess,  Extravasation of  Urine,  and  Fistula  in
                     Perinaeo.............................................462
               4. Of  some other Affections of the Male Urethra.................404
               5. Of  the Diseases of the Prostate.............................465
               6.  Of the Diseases of the Bladder.............................467
               7. Of  Disease of the Kidneys, Hsematuria, and Suppression of Urine  471
               8. Of  Urinary  Deposits and  Gravel; and of the  Diatheses which
                    give rise to them.......................................475
               9.  Of  the Various kinds of Calculi............................482
              10. Of  Stone in the Kidney and Ureter.........................483
              11.  Of  Stone in the Bladder...................................484
              12.  Of Lithotrity............................................486
              13.  Of Lithotomy..........................................489 
 xxiy                             CONTENTS.

 CHAP.                                                                         PAB*
  XXI. Of the Diseases of the Male Genitals..................................497
          Sect.  1. Of  the Diseases of the Penis...............................497
                2. Of  the Diseases of the Testis...............................499
                3. Of  the Diseases of the Scrotum.............................506
                4. Of Impotence...........................................507
 XXII.  Of the Surgical Diseases of the Female Genitals........................508
 XXIII.  Of the Diseases of the Breast........................................510
 XXIV.  Of Clubfoot, Bunion,  Whitlow,  Contracted  Joints, and other Affections  of
           the Extremities................................................514



                                  PART  V.

                      OF  THE OPERATIONS  OF  SURGERY.

     I.  Of Operations in General, and of the Extirpation of Tumours............519
    II.  Of the Minor Operations............................................524
   III.  Of Bandaging............................'........................529
   IV.  Of the Amputations................................................t-34
    V.  Of the Excision of Joints...........................................517
   VI.  Of the Ligature of Arteries.........................................548
Appendix of Formulx.................................;................557
Ihdex.................................................................573 
                      THE

PRINCIPLES  AND   PRACTICE

                        OF

     MODERN  SURGERY.
                        PART I.

OF THE CONSTITUTIONAL EFFECTS OF LOCAL INJURY AND
                          DISEASE.
                        CHAPTER I.

                 OF PROSTRATION OR COLLAPSE*

  Definition. — As the most proper  commencement of a systematic
treatise on Surgery, we shall begin by describing a state commonly known
as prostration, or collapse, or slwck to the nervous system; by which terms
we signify that general depression of the powers and actions of life, which
immediately follows any severe injury, such  as a compound fracture or
gunshot wound.
  Symptoms.—The usual symptoms are, that the patient lies cold, shiv-
ering, and half-unconscious; with a feeble pulse and imperfect sighing
respiration.  But these symptoms are liable to great variety ; for they may
not only differ in degree, but the principal bodily functions may be une-
qually disordered in different cases.  Sometimes depression of the vascu-
lar system predominates, and the patient lies in a state of perfect  syncope,
with  the pulse and respiration imperceptible.  Sometimes the nervous sys-
tem  is chiefly affected, the patient being bewildered and incoherent, as
though intoxicated;  or even comatose,  as though he had taken a narcotic
poison.  Nausea and  vomiting; hiccup; suppression of urine; and in
children, convulsions are also very frequent symptoms.
  The duration of these symptoms is also extremely various.  Sometimes
they  pass off very quickly; but they may remain even for forty-eight hours
before reaction is thoroughly established.
  * The principal authorities to be consulted on the  subjects of the first and second
chapters, are Travers on Constitutional Irritation, third edition, and Hunter on the Blood,
chap.  ii.
      3                                               (25) 
26     ,              PROSTRATION  OR COLLAPSE.
   Terminations.—The  process of recovery from  collapse  is  commonly
called reaction;  and  the manner in which the  case may terminate  must
depend on the nature and degree of that reaction.   Thus,
   First, if it is healthy and moderate, and especially if the  collapse arise
merely from  concussion  (or violent  shaking) of an  organ, without  actual
injury to  its  structure, it will lead  to complete recovery.   Thus it very
often happens that a slight  blow on  the  testicle or stomach causes an ex-
treme degree of sickness and faintness, which, however, pass  off gradu-
ally,  and leave no  ill consequences.*
   Secondly.  If reaction be  excessive, the  state  of collapse  will be gradu-
ally succeeded  by fever, symptomatic of the inflammation to which the
local injury has given origin.
   Thirdly. If reaction be imperfectly developed, it will be  converted into
the state of prostration with excitement, of which we shall  speak in the next
chapter.
   Fourthly.  If reaction be altogether wanting, the collapse will terminate
in death.    And death may occur immediately on the receipt of the injury,
if it be of extreme  severity  ; or otherwise the patient may  die more slowly,
the pulse at the wrist becoming fainter,  and finally ceasing; and  the res-
piration more and  more slow and  oppressed, till life  is  gradually extin-
guished, f

   * A case has lately been published in the Medical Journals, in which a man had his
'esticles crushed during some barbarous sports, and the shock to the  nervous system was
so great as to be speedily mortal.
   + Various modes of dying.—So long as the functions of circulation, and respiration,
and the action  of the nervous system, are properly performed, life continues ; but if any
one of these functions is suspended, the others also fail, and life soon ceases.  But the
order, and the manner, in which the various phenomena of life are extinguished vary
extremely in different cases, so  that we may enumerate several modes of dying, and the
surgeon ought to be well acquainted with these in order to counteract the tendency to
dissolution in any particular case.
   The first  is  death by syncope, or by ancemia ;—that is, from profuse loss of blood, as
after  severe wounds, bursting of aneurisms, &c.   The symptoms observable are cold
skin,  weak fluttering pulse, gasping respiration, and convulsions.  In  this mode, death
occurs because there is not a sufficiency of blood  for the heart to propel, and so the res-
piratory and nervous  functions  cease in consequence.   After death  the  heart  is found
contracted.
   The second  is death by asthenia.—This is caused by circumstances producing a de-
pressing effect  on  the system, either sudden and violent, or prolonged.  The heart ceases
to act, not from want of blood, as  in the  preceding mode, but from want of power to
propel its contents; and therefore after death it is found full and distended,  the left ca-
vities with red blood.   Sudden death from shocks to the nervous system; from the con-
dition, in fact, which  forms the  subject of the present  chapter; and gradual  death from
nervous exhaustion, from severe pain,  (as after burns and scalds,) and from tetanus and
hydrophobia, are  instances of  death by  asthenia.  Where this form of  death  occurs
gradually, (as in inflammation of the bowels) the pulse is very frequent and feeble, but
the intellect perfect, and senses acute to the last.
   The third is death  by aptuEa, or from interruption to respiration.  (Dr. Watson has
judiciously substituted the term apnaa for asphyxia, which is generally used to denote
this kind of death, although incorrectly, since asphyxia literally signifies want of pulse.)
Familiar instances of this mode are afforded by the various forms of suffocation, drown-
ing, violent inflammation of the lungs; injury to the spinal cord in  the cervical region,
&c.   The immediate effects of the privation of air, are, a stagnation of blood  in the
lungs, the circulation of venous blood to the brain and body, and consequent impairment
of their functions.  After death, the right  side of the heart is found full of black blood,
which it has been  unable to propel through the densely congested lungs; the left side
partially full of black blood.  When this  mode of death is  slow, as in croup, &c, the
phenomena are, great  dyspnoea, with lividity of the countenance, ar.d delirium arising
from  the circulation of venous blood in the head. 
PROSTRATION OR  COLLAPSE.
27
   Causes.—These symptoms may be  caused  by every variety of injury
 to which the body is liable.   Great and sudden extremes of grief, or joy,
 or fear, or cold ;—large  doses of  any active  poison, such as arsenic, or
 sulphuric acid, or tobacco ;—the sudden  impression of miasmata, or  of
 morbid poisons,  as the plague ;—great  loss of blood, and mechanical in-
 juries.   It is most important  that the surgeon should know what  injuries
 are  most likely to be followed by fatal collapse, in order that he may have
 proper materials for giving his prognosis.   They  are,
   First, those of organs that are necessary to life, as the  stomach  and
 brain ; and it is well known that a severe concussion of either of these
 organs may extinguish life instantaneously.
   Secondly.  Injuries of  organs which do  not easily admit  of reparation;
 as the joints.
   Thirdly.  Injuries that are severe in their nature; as punctured, lacerated,
 contused, and especially gunshot,  wounds.
   Fourthly. Injuries of great extent, although  they may be trivial in de-
 gree ;—as extensive burns ; or injuries  that cause very great pain. Severe
 pain, by itself, is capable of exhausting the vital  powers.
   Lastly. Injuries occurring to young  infants,  or to the very aged ; or to
 constitutions  that are enfeebled by excess and intemperance,* or by long-
 standing bodily disease, or mental depression.  From this it will be learned
 that the slightest injury  or surgical operation  may prove  fatal to  persons
 who labour under chronic organic disease, such  as tubercles in the  liver
> or lungs, or disease of the kidneys ;   or who have been harassed by  con-
 tinued anxiety and  despondency of  mind ; so  that  in  almost any case a
 linn persuasion that recovery  is impossible is almost sufficient  to  render
 it so.
   Treatment.—The indication is,  to  excite the vital  organs to a mode-
 rate and healthy reaction.   If the patient is shivering, with cold skin  and
 feeble pulse,  diffusive   stimulants should be administered,  such  as hot
 brandy and water, asther, and ammonia;  and heated bricks,  or bottles of
 hot water, should be put under the axillae, and between the thighs, and the
 patient should be covered warmly till the circulation is restored, and the
 pulse has acquired permanent strength  and firmness.   Vomiting  may be
   The fourth is death by coma.  This is what occurs from such compression of the  brain
 as tells upon the medulla oblongata, and from  poisoning by opium, and in  other  cases
 in which the functions of the brain are suspended. In these cases the immediate  man-
 ner  of dying is the same as in the  last mode, (viz. by apnaa.) but, whereas in the  latter
 it is caused by interruption  to the access of air to the lungs, in these cases it  arises from
 want of action in the respiratory muscles, which  lose their natural stimulus when the
 functions of the nervous system are destroyed.  In cases  of coma produced by ardent
 spirits, opium, and some other poisons, life  may often  be preserved if the respiration be
 kept up artificially, so as to keep the lungs  and heart at work, and the  blood aerated till
 the  stupifying effects of the poison have passed off.
   The above are the different modes of dying, which it is necessary to understand, in
 order to counteract them successfully.  It must be observed, in conclusion, that although
 pure and well marked instances of each are often met with, yet  that  two or more are
 very frequently combined.   Thus in phthisis, death is often the conjoint result of asthe-
 nia,  of anaemia, and of apncea ; and in mortification, the asthenia is often combined with
 coma, or delirium arising from the circulation of contaminated blood.  But in most cases
 the  study of the mode of death is of utility as well as  interest.  For an excellent  ac-
 count of this subject, see Dr. Watson's Lectures, vol. i.
   *  Those who always live above par, says Hunter, are extremely liable to sink when
 attacked by disease or injury; for, as they  are habitually  at the  full  stretch of living
 their powers cannot be excited further to meet any casual emergency.—On the Blood
 chap ii. sect. 1. 
28
PROSTRATION  WITH EXCITEMENT.
allayed by a large  dose of solid opium (gr. ii.);  or by an opiate enema
(vide Formula 85) if the bowels are relaxed, or an aperient enema, espe-
cially of turpentine (F. 86), if they are confined.  Counter-irritation to the
epigastrium, by means of very hot water, or a mustard poultice (F. 74), is
also highly useful.—Hiccup may be relieved by small doses of sp. aetheris
comp.— Convulsions, delirium, and coma, are to be treated according to
fhe state of the circulation ; by ammonia and  stimulants whilst  it is de-
pressed, but by a very cautious bleeding, or leeching, or purging, or appli-
cation of cold to the head, if they remain after the circulation is restored,
and fiie pulse has become firm.—One remedy that it might be well worth
while to try in an extreme case, is the wrapping a patient in the skin of a
sheep, stripped off immediately after its death.  Baron  Larrey had seen
this done by certain humane Esquimaux, with the greatest benefit, to some
shipwrecked  Frenchmen  that were  half  dead with cold,  fatigue, and
hunger; and he put it in practice with equal success in the case of Marshal
Lannes, Due de Montebello, when he was dangerously bruised by a fall
from his horse during one of Napoleon's Spanish campaigns.
   Cautions.—Care must be taken on the one  hand to continue the use of
stimulants long enough, and to desist from them gradually if there is any
fear that the  collapse may return; and, on the other, not to carry them too
far—for if the action of the heart is excited beyond its powers, it will be
more  liable to be  permanently exhausted.   Finally, the vulgar and mis-
chievous habit of bleeding patients immediately after an injury, before they
have recovered from a state of faintness and depression, needs only to be
mentioned to be condemned.
                         CHAPTER II.

 OF PROSTRATION WITH EXCITEMENT, AND DELIRIUM TRAUMA-
                              TICUM.

  Definition.—" Prostration with excitement and excessive reaction," is
the  term used by Mr. Travers to signify a state which sometimes follows
the  collapse from a severe injury; in which there is a violent but transient
excitement of the nervous and vascular systems, without the  development
of that more permanent and sthenic action which constitutes inflammatory
fever.
  Symptoms.—The symptoms vary extremely in different cases, although
they present the uniform character of extreme  and exhausting excitement,
without genuine febrile action.  There is great anxiety about the region of
the  heart: the respiration is oppressed and sighing; the pulse exceedingly
rapid and bounding, but soft and compressible ; the face is  flushed, and
there is vomiting.  But, in the majority of these cases, the principal feature
is the excitement of the  nervous system, which  is  manifested by a pecu-
liar  delirium  {delirium traumaticum) precisely similar to the  delirium tre-
mens*    The tongue is moist and tremulous ;  there is a general tremor of
the  muscles ; the  skin covered with perspiration; the patient is totally
           • Copland's Diet. Pract Med. Art. Delirium with Tremor. 
PROSTRATION WITH  EXCITEMENT.
29
sleepless,  irritable in his temper, answers questions  in a snappish, or
peevish, or incoherent manner;  is often  anxious to call himself perfectly
well; and as the  malady increases, he  becomes restless, impatient,  and
talkative; wishes,  perhaps, to get out of  bed, and attempts to  injure his
attendants, and soon becomes most furiously maniacal.  In some cases,
however,  the delirium is of a  milder cast; the patient is  haunted with
extravagant ideas and spectral illusions ;  or fancies himself busied in hit
ordinary  avocations, and talks perpetually about them.   [Instead of being
violent towards, and  disposed  to  injure his attendants, the patient thus
affected is generally timid, easily cowed, and rarely attempts to strike or
struggle with those who wait upon him ; and most of all is he afraid of tne
spectral shapes which his own fancy conjures up, but which to him are the
most dreaded realities.—Ed.]
   Terminations.—The prognosis will be  the more unfavourable in pro-
portion as the  excitement is  violent, as that cannot fail to lead to exhaus-
tion ; the pulse becoming irregular, the aspect livid and haggard, the ex-
tremities cold, and coma supervening, which is soon  followed by death.
There will be some hope, however, if the pulse becomes more tranquil and
firm, and especially if the patient sleeps.
   Causes.—The exciting causes of  this state are (surgically considered)
the various mechanical injuries enumerated in the last chapter ;—acting on
constitutions  that  are weak, and consequently irritable ;* that  have " an
increased disposition to  act,  without the power to act with." Some exam-
ples of it occur in children,  especially after burns ; but they are  most fre-
quently met with in the case of persons of middle age and plethoric habit,
who habitually indulge in excess of food and spirituous liquors, and who,
as is well known, often  die from injuries and accidents, which more tem-
perate  persons might have recovered from  without difficulty.
   Treatment.—The indications are to moderate the excitement, procure
sleep, and support the strength.  If the delirium be purely nervous, opium
is the remedy, given either in one  full dose, (such as gr. ii.—iii. of solid
opium, or \\ xl.—lx. of Battley's solution,) or in repeated small  doses
(such as  gr. \—^, every two or three hours) according to the surgeon's
judgment; the repeated small doses  being, perhaps, best, if debility and
restlessness are very great.  Dupuytren believed that  opium was most ef-
ficacious in these cases when administered  in the form of enema.   Some
surgeon's prefer henbane.   Musk  and assafoetida are useful in  some  few-
cases.   Beef-tea and other mild nourishment should be given, and, if the
patient be an habitual drunkard, it will be advisable to allow him some ot
his favourite stimulus.  Nervous excitement is better allayed  by one or
two kind  but firm  attendants than by  straps and straight waistcoats.  The
head should be frequently bathed with  tepid water;  and the bowels be
opened by mild aperients.   In cases in which the excitement presents
somewhat of an  inflammatory character, it may be advisable to try the
effects  of tartar emetic with the opium F.  103.  In the last stage, when
coma supervenes,  counter-irritation by means of sinapisms orv blisters to
the scalp, or feet,  or calves  of the legs, may be tried, but scarcely  an)
means  will avail.f
                * Omne infirmum, natura, querulum.
                f Vide  Graves's Clinical Medicine, 1S43, p. 452.
3* 
30
FEVER.
                        CHAPTER III.

                             OF FEVER.

            SECTION  I.--OF FEVER  GENERALLY.

  General Description.—Fever may be  described  as a state  .n which
all, or most of the functions of the  body are deranged.   The nervous
system is shown to be  deranged, by the headache, pain in the back, las-
situde, muscular weakness, mental torpor,  and confusion of the senses.
Chilliness and  burning heat  testify to disorder of the process by which
animal heat is  produced or regulated.  Respiration  and circulation  are
either slow and embarrassed, or performed  with  preternatural frequency
and force.   Digestion and nutrition are suspended, hence the rapid ema-
ciation.  The secretions are either deficient, or, if abundant, are depraved ;
hence  the  thirst, dry  skin,  scanty urine,  and costiveness  or  diarrhoea.
Moreover, the fluids have a tendency to be  vitiated, and the  solids to be
diseased, as shown by congestion and effusion in either of the three great
cavities.
  Fevers  are often divided into two  great families; the idiopathic and
the symptomatic.   The former arise from agents operating on the blood or
nervous system  : ague  and typhus are examples.   The  latter are called
symptomatic, because produced by disease  or injury of some part.   It is
with these that the surgeon has to deal; and there are the following varie-
ties,  which we shall treat of successively:
  (1.)  If there be violent inflammation in a healthy system,  the fever will
be inflammatory, which is commonly called symptomatic fever.   (2.) If
there be acute inflammation in a weakened or cachectic system,—or if the
inflammation arise from certain specific causes of a depressing tendency,
such as morbid poisons,—or if it attack certain structures, as the  veins ;—
the fever is generally called irritative.   (3.)  If the inflammation have ter-
minated in an exhausting suppuration, or if there be a permanent disease,
which  the  constitution has no power to vanquish, hectic fever will be es-
tablished.  (4.) When the vital powers are entirely exhausted the fever
assumes what is called a typhoid type ;  which, in the emphatic language of
Hunter, is termed dissolution.  (5.) Lastly, fever, even when arising from  a
local cause that is permanent, may be intermittent; that  is,  may occur in
definite paroxysms, with intervals of health, like ague fits.   This is often
the case in diseases of  the urinary organs, such as strictures and fistulas in
perinaeo;  and  sometimes in  worms  and other states  of irritation of the
intestines.

         section ii. —of  inflammatory  fever.

                       Syn.—Synocha, Cullen.

  General Description.—This fever accompanies every acute inflam-
mation which arises from a severe or considerable injury, or which  affects
parts of great  sensibility and importance in  healthy subjects.   And it is
almost a natural concomitant.   " Nature," says Hunter, " requires to feel
the injuiy ; for where after a considerable operation there is rather a weak, 
INFLAMMATORY FEVER.
31
quiet pulse, often with a nervous oppression, with a seeming difficulty of
breathing and loathing of food, the patient is in a dangerous way.  Fever
shows  powers of resistance; the other symptoms show weakness, sinking
under  the injury."*
   Symptoms.—Shivering;  succeeded by increased heat:f  preternaturally
frequent, hard, and vibratory pulse ;—pain and aching in the head, back,
and limbs,  with  a  sense of lassitude and weakness ;—general  deficiency
of the  secretions ;  dry skin ;  dry and white tongue ; thirst; nausea and
.oss of appetite; constipation ;  scanty and high-coloured urine ;—the blood
generally buffed  and cupped;—slight aggravation of the symptoms in the
evening, often delirium in  the night, and slight remission in the morning.
   Terminations.—(1.) If the patient recover, the urine  becomes  more
copious, and deposits a lateritious, or brick-dust, sediment;  the tongue
becomes moist and clean, the  skin cool and perspiring;  the local inflam-
mation either is  resolved, or proceeds to a healthy suppuration ;  and the
return  of the appetite and of the other natural  functions  indicates the pa-
tient's recovery.   The  formation of pus  often  appears to be a natural
crisis.J  (2.) But if from the  irreparable nature of the  disease or injury,
or from the irritability of the system, life is destined to  be destroyed, the
pulse becomes continually more frequent, and subsequently weak, irregular,
and intermittent, the extremities cold, and life soon  ceases with the failure
of the circulation.
   Treatment.—The treatment of this fever is included in that  of acute
inflammation, of which it is the shadow.   But it must be observed in this
place,  that when it is  symptomatic of an inflammation that is unavoidable,
(as after a compound  fracture, and  most other severe injuries,) it cannot
be cut short, although its undue violence may be abated ;—and that, great
care should be  taken not to weaken the patient too much by depletion,
especially if the  part injured be not of vital importance, and its reparation
will require time  and strength.   The indications  are, to allay  vascular
action and  nervous  irritation,  and to  restore  the  secretions.    And the
means are,  rest,  low diet, aperient  and  febrifuge  medicines, anodynes  at
bed-time when the bowels have been cleared, and general  or local bleed-
ing, if demanded  by the exigencies of the case.   We must add  that pur-
gatives should be  avoided when it is likely that they may occasion an in-
jurious  disturbance of any diseased or injured  part, as a compound frac-
ture, for instance.
   Of  the Pulse.—It may be convenient to say a few words in this  place
about  the pulse.    The elements of the pulse are three ;  namely, first, the
contraction of the  heart, which propels blood into the arteries;—secondly.
the yielding and dilatation of  the artery, which when felt  constitutes the
pulse  ;§—and, thirdly, the return of the artery to its former calibre.  Now
   *  On the blood.  Chap. iv. sect. 6.
  t The increased  heat of fever depends, according to Liebig, on an  unnaturally rapid
transformation and  oxydation of the animal tissues, by which an unnatural amount  of
heat is  generated, as well as of circulating force.  Liebig's Animal Chemistry by Gre-
gory, p. 256.   In ordinary fever, the heat of the blood does not rise more than three 01
four degrees above  the natural standard; but in scarlet fever it is said to have risen as
high as 116°.
  t Kptcyij, any important phenomenon in a disease (mostly an evacuation of some sort)
by which the patient's safety or danger may be judged of.
  § "The coats of arteries," says W. Hunter, "are elastic, and  therefore whatever dis
'.ends, must at the same time lengthen  them, and thereby produce serpentine turns.'
JTet if the artery is  perfectly straight, and  the circulation tranquil, the dilatations will 
32
INFLAMMATORY FEVER.
some of the properties of the pulse depend on the heart, and some on the
arteries.   Thus its frequency and  slowness  correspond to the number of
ihe heart's contractions  in a given time.   Its quiclcness (or sharpness) de-
pends on the velocity and impetus with which each individual contraction
is made.  If the artery, through what is called  its tonic contraction, offers
some considerable resistance to the ingress  of the blood, the pulse will be
hard; feeling like whip-cord, and not stopped by very slight pressure with
the finger; whilst, on the other hand, if that contraction is trifling, so that
the vessel yields readily to the impulse of the blood, or the pressure of the
ringer, the pulse will  be soft.   The vibratory feel,  or thrill,  or jar, is
:aused by an irregular dilatation of the artery, which dilates with an innu-
merable number of stops and interruptions.  The full  and small  pulse
depend in some measure on the quantity of blood in the system, but prin-
cipally on the state  of the vessel; for if  that does not  dilate  freely, the
pulse will be  small.   A small  hard  pulse  is a much safer indication for
bleeding than a full soft one.
   In the fever accompanying acute inflammation of any common part, such
as skin, cellular tissue, or muscle, or .of the  eye, dura mater, or pleura, the
pulse is generally frequent, hard, and full.
   During acute inflammation, however, of  the  brain and stomach—parts
most essential to life—or of  the  peritoneum, testicle, and kidney, which
are most intimately connected with the stomach by the sympathetic nerve,
the vital powers seem to be depressed, and the pulse is frequent, hard, and
small.
   Again, during acute inflammation  in a  very weak and irritable constitu-
tion, the pulse may either be very frequent, soft, and small, or frequent,
soft, large, and jer/cing; the soft jerking quality indicating an almost pas-
sive yielding to the heart's impulse, and being caused by an  absence of
that contractile tone which renders the pulse small and hard.*  A frequent,
sharp, and jer/cing but soft pulse is also found  after great loss  of blood,
and in other cases of great debility and great excitement combined.
   [The remarks  of Laennec and  Hope, with reference  to the  pulse as a
criterion of the  condition and  character of the circulation  generally, are
very important.  Laennec says, (Forbe's translation,  Am. ed. page 624,)
" The examination of the pulse, at least as  it has been hitherto  done with-
out any corresponding exploration of the heart, is  as often calculated to
mislead as to supply us with useful indications." " It frequently supplies us
with no indications at all, or  with such as are deceitful in many important
respects, for instance, in relation  to  bloodletting, in the  prognosis  in all
diseases,  and to the diagnosis in several,"  &c.  &c.  In all cases in which
the surgeon feels any doubt as to the propriety  and expediency of deple-
tion, he should not fail to examine the heart as well  as  the  pulse before
deciding upon this important question, since diseases of the  heart are by
no means uncommon, and since these diseases  almost always  modify the
character of the pulse very decidedly.  The reader will find an interesting
tabular view of the modifications impressed upon  the pulse by the various
affections of  the central organ of the circulation, in Hope's treatise on
Diseases of the Heart (Am. ed. p. 555-6).—Ed.]
not be so great as to be perceptible to the eye, and  can be appreciated only by compress
ing the vessel slightly between the ringers; whereas if  it is curved, each impulse of the
blood will slightly straighten it, and cause a sensible motion.
   * Wilson Philip.  Experimental Inquiry  into the Laws of the Vital Functions p. 323,
"d edition.  Soe also Hunter on the Blood,  Chap. iii. sect. 8. 
BUFFY  BLOOD.
33
   Buffy Blood.—The  reader  needs scarcely  be reminded, that  after
healthy blood has co'agulaied, it divides into two portions, serum and eras
samentum;—that the serum is a watery solution  of the albumen and salts,
whilst the crassamentum consists of the fibrine  and red particles ;—and
that the fibrine, which by itself  is yellowish white, derives an uniformly
red tinge from the  equal diffusion of these  particles.   But, on the other
hand, when blood is drawn during the fever which accompanies acute in-
flammation, the crassamentum is generally found to be covered with what
is called a  " buffy coat,'''' that is, a  yellowish white layer of fibrine, free
from red particles ;—which layer may vary from  one line to one third of
the clot in thickness, and is frequently so strongly contracted  as to make
its surface concave, or cupped, and its edges fringed.
   What is the exact physical condition of the  blood, to which the buffy
coat is owing?  This  is a question which has received many discordant
answers.  It was formerly said that blood which exhibited the buff coagu-
lated very slowly, so that the red particles had time to sink, and leave the
upper surface of the clot colourless.   Hunter supposed that  the  specific
gravity of the red particles was increased, through which they sank to the
bottom more quickly than in healthy blood.
   The following, however, is  the  most modern account  of  the subject,
which has been advanced by Mr. Wharton Jones as the result of  his mi-
croscopical  examination of the  blood.   In the coagulation of  healthy
blood, the following phenomena  are observed.   First, the red  globules, by
a mutual attraction, unite themselves into rolls, which soon break up into
a kind of sponge-work, in the meshes of which all the liquor sanguinis is
contained ; then the fibrine of the liquor sanguinis solidifies;  and lastly.
the sponge-work formed  by the blood globules contracts itself, squeezing
out most of  the serum from between its meshes,  but retaining  the fibrine.,
   In inflamed blood, on  the other hand, the  attraction of the red globules
for each other is greatly increased ; so that they  form themselves  quickly
into a sponge-work, which quickly contracts,  and sinks towards the bottom
of the vessel, squeezing out some of the liquor sanguinis from its meshes,
before the latter has separated into fibrine and serum.   And this liquor
sanguinis, so separated from  the  globules,  forms  the bluish  white layer
which is well known to appear on the surface of inflamed blood very soon
after it is drawn.  And the fibrine which it  contains being deposited on
the surface  of the  sponge-work formed by the  globules  constitutes the
buffy coat.
   We have  next to consider by what  states  of the system these changes
in the blood  are produced.   Hunter says, that they are produced by an
increase of the powers of life,  and by an increase of the  disposition to act
with those powers.   And we have both positive and negative evidence
that this is correct.   For the buffy coat is found  on  the  blood of  healthy
pregnant worffen and animals, in whom the powers and actions of life are
augmented without  doubt;  and it is always  most  conspicuous when the
circulation is rapid, and when the blood is drawn in such a manner as to
preserve its  vital properties; that  is, in a full  rapid stream, into  a deep
vessel, the temperature of the apartment being high.
   On the other hand, the buff will be deficient, when the blood is drawn
in such a manner as to deprive  it speedily  of its life ;  that is, in  a small
slow stream,  into a  flat and shallow basin, the temperature being low.  h
is a remarkable fact that the buffy coat  is occasionally absent  at the com
                                  c 
34
IRRITATIVE FEVER.
 inencement of some inflammations, especially of the lungs, whilst the cir
 culation is slow, and labouring, and embarrassed, and whilst  it mav be
 supposed that the nervous system  is oppressed by the intensity of the  in-
 flammation ; and that it may make its appearance as soon as the oppression
 is removed by bleeding.   Thus, during one venaesection, it has liappened
 that the blood first drawn has not been buffed, owing, as we  presume, to
 the embarrassed circulation;—the  buff has appeared in  a second portion,
 when enough has been drawn to  relieve that  embarrassment;—and has
 again disappeared in a third, when the  circulation has become languid at
 the approach  of syncope.
  -We must observe, in conclusion, that  the  buffy coat  is not to be con-
 sidered as an invariable evidence of inflammation. For, in the first place,
 it may be present when there is no inflammation ;—as in pregnant women ;
 in the plethoric; in persons accustomed to be periodically bled, or who
 are  habitually exposed to the  night  air.*  Again,  its  quantity is by no
 means  proportioned to the  intensity of inflammation ; for it is constant to
 the last in rheumatism,! even when subdued by bleeding.   And there  are
 certain  inflammations of great  intensity in which it does  not exist at  all;
 as in the commencement of some cases which we  have just alluded to ;—
 in inflammations that have little of the adhesive tendency, as those of mu-
 cous membranes, and diffuse inflammation of the cellular tissue; and in
 the inflammations arising from certain morbid poisons,  as  glanders, or in
 the course of  typhus fever,  when the blood, having lost its vital qualities,
 scarcely coagulates at all.J

           SECTION III.--OF  IRRITATIVE  FEVER.
   General Description.—The term Irritative Fever seems to be conven-
 tionally assigned to a form  of violent and dangerous constitutional dis-
 turbance, which apparently combines the characters of inflammatory fever
 and  of that state which we have before described under the term, prostra-
 tion  with excitement.   Or perhaps it may be more convenient to describe
 it as the set of constitutional symptoms which attend phlebitis, diffuse in-
 flammation of the cellular tissue;  the disease arising from  glanders, and
 from wounds poisoned during  dissection ;—also severe phlegmonous ery-
 sipelas and inflammations in which  there is great pain from the confine-
 ment of matter;—all of which cases exhibit  a combination of violent
local inflammation, great febrile commotion, and  great  depression of the
vital powers.
  The Symptoms and Treatment will be  particularised under  the head  of
the various local affections which  this fever accompanies.  The leading
  * Samuel Cooper.  First Lines of Surgery.
  t Some authors state that the blood is most buffed when there is an inflammation with
considerable tendency to effusion of fibrine, as pleurisy or pericarditis pothers state that
H is most buffed when the inflammation has no adhesive tendency, as acute rheumatism,
so that the fibrine cannot escape from the blood ; a curious instance of contrary deduc-
 tions  from the self-same facts, when partially viewed and hastily generalised.
  \ Vide Hewson,  Experimental Enquiry into the Blood. Lond. 1772, ch. ii. pp. 34, et
 seq.  Palmer's edition of Hunter, vol. iii. p. 39, note.  For  further information on  this
 subject, consult also Co'pland"s Diet. Pract. Med. Art. Blood ; Thackrah, C. T. on the
Blood, Lond. 1S34; Davy's Experimental Researches, vol. i. Lond. 1839;  Miiller's Phy-
 siology by Baly,  2d ed. vol. i.; Andral, Arch. Gen. de Med. 1840, and Brit, and For,
 Med. R. vol. xi. p.  243; T. Wharton Jones, B. and F. Med. Review, Oct. 1842.  And
 some observations  of Mr. Gulliver, quoted in Ranking's Half-yearly Abstract, vol i p
 25.. 
HECTIC  FEVER.
35
features are great restlessness and anxiety, debility, depression of spirits,
weight  at  the  praecordia, oppressed  respiration;  frequent rigors; pulse
rapid and  sharp, but variable in force;  death, preceded by low delirium,
and signs of great exhaustion.   The  treatment must, as  a general rule,
consist in invigoration of the vital powers by cordial stimulants and tonics,
the evacuation  of depraved secretions, and the removal of pain and irrita-
tion, and of local disease, by whatever measures are most appropriate.*

              SECTION  IV.--OF  HECTIC  FEVER.f
   Definition.—Hectic fever is an habitual disorder of the system, when
 rritated by some long-standing disease, or source of weakness which if is
unable to remove.   It is a remittent fever, and  is  generally accompanied
by a tendency to increase of one or more secretions.
   Symptoms.-—Emaciation and debility ; tongue  morbidly clean and  red,
especially at the  tip  and edges ;  appetite often inordinate ; disposition al-
ternately to diarrhoea and profuse perspiration ; ^ pulse frequent and small;
— a febrile exacerbation comes on every evening (or  oftener, especially
after meals) with slight chills, followed  by heat  of skin, burning of the
soles of the feet and palms of the hands, and a circumscribed flush in the
cheeks ;—thirst and  restlessness, preventing sleep  till after the middle of
the night, when the  patient falls asleep, and suddenly awakes in a profuse
perspiration ;—often buoyancy of spirits and hope to the last.
   Terminations.—(1.) If it be about to terminate fatally, the debility in-
creases ; the diarrhoea and perspiration become more profuse and exhaust-
ing: the legs become cedematus; apfhse form;  and  great pain, griping,
and tenesmus attend the diarrhoea, owing to an inflammatory or ulcerated
condition of the  intestines.   The patient may expire  suddenly, the heart
failing from mere debility; or death may be preceded by typhoid  symp-
toms.   And this fatal termination may be owing either to the continuance
of the original  disease, or to the induction of secondary disease in the
lungs or mesenteric  glands.  (2.) Recovery from hectic is often remarkably
rapid, if the causes be removed; provided that no secondary disease has
commenced.
   Causes.—Any chronic  organic incurable disease ;—whether incurable
from its nature, as scirrhus,  or tubercle ;—from its extent;—or from  con-
stitutional  debility;  also exhaustion  from profuse  suppuration ;—or from
any other great and  continued discharge; as prolonged lactation, leucor-
rhcea, and  so forth.  Hectic  is so frequently caused by profuse suppura-
tion, that an absorption of pus was formerly deemed to be  its invariable
and efficient cause.  Hunter denied this  theory—1st,  because hectic  may
arise from  organic disease, or from  excessive  discharge of any secretion
when there is no suppuration; 2dly, because pus may be absorbed (as it
often is from chronic abscesses and  buboes, which are discussed without
being opened) without the production of hectic. §   It  is certain, therefore,
that absorption of pus is not the  only cause of hectic.   But it is  equally
certain that pus, or at least its constituent elements, are absorbed from ex-
tensive suppurating surfaces; and it is probable that  its presence in the
  * Vide part ii. chap. viii. sect. ii. on Diffuse Inflammation of the Cellular Tissue; and
part iii. ch. ix. sect, ii on Dissection Wounds.
  •j- From t|tj, ixtcxbi, habit, habitual.
  $ Called colliquative ;  (liquo, I melt;) because they exhaust the system.
  j Jtethe Blood.  Ch.  ix. sect. 1. 
36
HECTIC  FEVER.
blood adds to the hectic and constitutional  debility ;  and that (especially
if it be vitiated or decomposed) it tends greatly to the  production of co
liquative diarrhoea and ulceration of the intestines.  For the  injection  l
pus or putrid matter into the blood almost invariably causes  diarrhtEa ;—
an effect also which is notoriously produced among students, who absorb
the putrid  vapours  of the dissecting-room.*
   Treatment.—The indications are (1) to remove the  local cause ; or (2
if that be impracticable, to enable the system to support it.
   The first indication may often be fulfilled by  an  amputation  or othei
operation ; and it is well known that hectic patients often bear operations
extremely  well, recovering from them rapidly, and making but one step,
as it were, from death's door to perfect health.f   In  cases not admitting
or requiring an operation, local mischief must be remedied, and profuse
discharges restrained as far as possible.
   As for the second indication, the  strength must be maintained by giving
as much food  as the stomach can digest with comfort; but  the  quantity
of animal food and of fermented liquors must not be large enough to add
to the excitement, or  increase the heat of skin, thirst, and  perspirations.
Arrowroot, and other farinaceous preparations; jellies,  Iceland and carra-
geen moss, are useful as mild nutritives occasionally, when there is an ex-
cess of heat and feverishness ; but  these slops should not be  given at such
times,  or in such quantities as to interfere with the digestion  of more solid
food, if there is an  appetite for it.   Tonics  may be given to support .the
strength ; such as bark, quinine, or cascarilla  ; or sometimes the prepara-
tions of iron ;  but if,  at any time, in the varying progress of the  disease,
excitement appear to  prevail, the pulse being  more accelerated, and pain
aggravated, tonics and animal food must be for a time exchanged for sa-
line medicines, and farinaceous or  milk diet.  Digitalis, a remedy much
abused in hectic, may be of service at such  times, if given in a few mode-
rate doses, for not too  long a time.   Ten minims in a saline  draught, at
bed-time, are a proper dose.   Opiates must be given to procure sleep and
allay pain.  Change of air is always advantageous.  Profuse perspirations
may be checked by diluted sulphuric or nitric acid, with tonics, as in F. 1,
and by tepid sponging, [with simple water, or with a watery or spirituous
solution of alumn,  or of some vegetable astringent.—Ed.]   As it will be
recollected that the diarrhoea often  depends on  an inflamed  or ulcerated
condition of the intestinal mucous membrane, reason will suggest that at-
tempts to stop it by port wine, and large doses of catechu, or other stimu-
lants and astringents, will often be not only unavailing, but irritating and
mischievous ; J although good enough in cases of mere  debility.  If, there-
fore, the diarrhoea is attended with  tenderness, much  pain, and tenesmus,
the proper remedies are, rest in bed ; mustard poultices to the abdomen,
—the very mildest  diet of milk,  arrowroot, &c, enemata  of starch, con-
taining from twenty  to sixty  minims of laudanum (F.  85);—Dover'3
powder or F. 32, 33 at bed-time, and small doses of chalk mixture, with
a few minims of laudanum, during the day; and one or two grains of blue
  • Copland; Diet. Pract. Med. Art. Hectic, p. 965.  See also  the section on Chronic
Abscess.
  ■f- "The removal of a diseased part which the constitution has become accustomed to
nnd which is rather fretting the constitution, is adding less violence than the removal
ȣ a sound part in harmony with the whole."  Hunter on the Blood, Ch. ii. sect. 2.
  \ The author has known  large doses of catechu purge violently, when administered
W) a young woman for passive menorrhagia. 
TYPHOID FEVER.                       37
) ill, with three or four of rhubarb occasionally, if the liver is inactive.  It
may be added, that copious injections of warm water give  great relief in
all cases of diarrhoea; soothing the irritated membrane, washing away
acrid  secretions,  and  enabling  the  patient to pass easily  at once what
otherwise would occasion severe painful efforts.

              section  v. — of  typhoid  fever.*
  General Description.—This fever is an acute form  of  constitutional
disturbance, occurring when the  powers of life are much  exhausted  or
depressed.   It may be a sequel of the hectic ; or of the  state of prostra-
tion with excitement;  or it may supervene  very soon after an injury.
  Symptoms.—Pulse very frequent and weak, or jerking; skin hot and
very dry; all the secretions  deficient; tongue  dry, brown, and tremulous;
lips parched;  if there be a wound, it becomes dry,  livid, and glassy, and
ceases to suppurate.
  Terminations.—(1.) If the patient is to die, the  pulse becomes more
rapid, thready, and tremulous, and at last  is  imperceptible  at  the wrist;
the eyes look dull, and glassy, and sunken; the temples  and nostrils  are
pinched, from atony of their muscles ;—the patient  lies on  his  back, and
sinks  towards  the foot  of the bed ; there is frequent  hiccough; the abdo-
men is tightly  distended with flatus, and the sphincter is  relaxed, so that
stools  are passed  involuntarily; the patient  dozes  imperfectly, awaking
with a start; he picks imaginary objects on the bedclothes, and mutters to
nimself;—there is starting or twitching  of the tendons;  at last the skin
becomes cold  and clammy, respiration  slow and laborious, and coma su-
pervenes, soon followed by death.  (2.)  If recovery  occurs, the surest
sign of amendment is a diminution of the  frequency and increase of the
firmness of the pulse, with sound sleep; the  patient being sensible and
composed, the eyes brighter, the tongue  cleaning, and above all, suppu-
ration returning, if there be a wound.
  Causes.—Typhoid  fever may be caused (1)  by some circumstances
producing immediate and direct depression of vital power; such as trau-
matic gangrene ;  a wound poisoned  during dissection ; or a severe injury
or operation suffered by an habitual drunkard.  (2.) It maybe  caused by
some  disease of  long standing, which has completely exhausted the con-
stitutional powers—as profuse suppuration with hectic.   And both these
conditions  may be, and frequently are, combined with a third ; namely,
(3.)  contamination of the  blood by putrid  or other poisonous matter.
Thus  it is sure to supervene if putrid pus be confined in  an  abscess, or if
putrid urine escape into the  cellular tissue of the  perinaeum.   M. Bonnet
has proved incontestably that the hydro-sulphate of  ammonia, the product
of putrefaction, is absorbed in these cases, and is one cause of the typhoid
fever, f
  Prognosis.—The prognosis will,  of course, be  always doubtful;  but
there  may be a chance of recovery, if the cause is of recent existence, and
admits of removal by operation or otherwise ; whilst there can be scarcely
any, if the constitution has been exhausted by its long continuance. Thus,
if this fever comes on in erysipelas or small-pox, diseases of no long con-
  * It  must be understood that the term typhoid fever is here  used  to signify a typhoid
type of symptomatic fever, that is, of fever  arising  from local disease; ana not the idio
pathic  typhus, or fievre typhoide.
  j See Chronic  Abscess. 
38
TETANUS.
tinuance, the constitution may rally;—or if it is caused by a recent injur}-,
or by extravasation of urine, it may be removed, perhaps, by an amputa
tion, or incisions  in the perinreum;  but  it will  scarcely be removed il
caused by chronic abscess or disease  of a joint,  and preceded by hectic.
And thus, if the hectic has been suffered to pass into the typhoid state, the
season of amputation and hope of recovery are also past.   " It is," says
Hunter, " the more incurable, as  it is more connected with  the  past than
with the present."
  Treatment.—The indications  are to remove the cause ; allay irritation,
and  support  the  strength.   If the removal of the cause by operation is
likely to be successful, upon the principles just laid  down, it should be
done without delay;  and, even if not, it may be better to try a doubtful
remedy than none at all.
  As for the general treatment, opium, or some of its preparations, should
be given in small doses, repeated frequently, or in a large dose at once,
according to the judgment of the practitioner, for the relief of restlessness
and delirium.   The strength must be  supported  by quinine and tonics ;
by wine, and other stimulants, and by moderate quantities of broth, beef-
tea, arrowroot,  &c, if the patient will take them.   Hiccough is best re-
lieved by a tea-spoonful of sp.  aether, c.;  and flatulence by an enema of
turpentine.   The catheter should be used if the  patient  cannot  pass his
water; a point that should always be inquired into.
                         CHAPTER IV.

                           OF TETANUS.

                SECTION  I.—introductory.

  Definition.—Tetanus  is a  disease manifested by tonic* spasm and
rigidity of some, or many, of the muscles of voluntary motion.
  Divisions.—There are several varieties of tetanus.   (1.) It is  divided
into the idiopathic, or that which arises solely from  some  disorder of the
system, and the traumatic, or that which is  caused by a wound.   (2.) It
may be acute or chronic; the former arising suddenly, and soon terminat-
ing, generally affecting the whole body, and being often fatal; the chronic
being of less intensity and of longer duration, usually partial in its ex-
tent, and mostly terminating in  recovery.  (3.) Tetanus may be general or
partial;  and when partial it is mostly confined to the neck and jaws, con-
stituting trismus, or locked jaw.  (4.) It may be divided according to the
set  of muscles  predominantly affected:  being  called opisthotonos, when
the body is curved backwards so as to rest on the occiput and heels, which
it most commonly is;  emprosthotonos, when  it is  curved forward from a
preponderance  of the abdominal muscles; and pleurosthotonos, when it is
  * Spasms are of two kinds; the tonic in  which the rigidity is permanent; and the
eumic, in which contraction alternates quickly with relaxation, as in  epilepsy and hys-
teria. 
ACUTE  TETANUS.
39
 drawn to one side, this being the most uncommon.*  (5.) The trismus in-
 fantum, or neonatorum, which attacks children soon after birth, is usually
 made  a distinct species.  (6.)  Tetanus may in its type  be intermittent,
 when it is caused by marsh miasmata, as it may be occasionally, like al-
 most every  other  nervous affection.   (7.)  Lastly, there is  the hysterical
 tetanus; in which all the outward symptoms of tetanus are produced, as
 a consequence  of an hysterical state of the system.
   We shall first describe the acute tetanus; then the chronic; and after-
 wards,  the infantine  and hysterical varieties.

             SECTION  II.--OF  ACUTE  TETANUS.
   Symptoms.—The patient first  complains of stiffness and pain of the
 neck and jaws, as from a cold;  and his countenance is observed to have
 a peculiar expression,  resembling a painful smile, because the corners of
 the mouth and eyes  are distorted and puckered by incipient spasm of the
 facial muscles.   In the next place, the muscles of mastication and deglu-
 tition become fixed  and rigid with  spasm, so  that the  mouth  is perma-
 nently closed, and there is great difficulty of swallowing, especially liquids.
 To these  symptoms  succeed a fixed  pain at the pit of the stomach, shoot-
 ing to  the back, and a convulsive difficulty of breathing, indicating that
 the diaphragm  and  muscles  of the  glottis are affected ;  and the spasm
 now extends to the muscles of the trunk and limbs, rendering them com-
 pletely  fixed and rigid.   The abdomen feels remarkably hard;  there is
 obstinate  constipation, and frequently difficult  micturition from spasm of
 the perinaeal muscles;  the pupils are contracted; and the saliva flows from
 the mouth, because the patient is unable to swallow it.  This spasm never
 ceases entirely; but it has occasional  remissions of violence, alternating
 with aggravated paroxysms, which are easily induced by the slightest irri-
 tation or disturbance.   Meanwhile the intellects  are undisturbed, and the
 pulse may be natural,  except during a severe  paroxysm, which quickens
 it, and  causes perspiration and thirst.
   Terminations.—(1.) If the case is about to end fatally, the paroxysms
 become more frequent and violent, and the breathing more and more em-
 barrassed by spasm of the diaphragm  and  of the muscles of the glottis;
 and at last the patient  dies, either from exhaustion or from suffocation;—
 either the nervous system being worn out by the violence of the spasm, or
 the respiratory action being suspended long enough to cut off the neces-
 sary supply  of arterial  blood  from the  brain, and so induce insensibility.
 The most usual period of death is the third or fourth day; sometimes it is
 postponed till the eighth or tenth, but  rarely later.  On the other hand,
 there is the casef recorded of a negro who  injured his hand, and died of
 tetanus  in a quarter of an hour; and cases of  death within twenty-four
hours are  by no means uncommon.  (2.) When  acute tetanus terminates
favourably,  still  the  patient's  recovery is  not complete for weeks or
months;—partly because of the strainings and lacerations which the mus-
cles have suffered,—partly because  of the remaining tendency to spasm,
which very  slowly yields, and  is apt to be temporarily aggravated by
very slight causes, especially cold and damp.   But in some rare instances
 the disease  has been removed almost instantaneously by the  removal of
 its exciting cause.
          * See a case  of acute pleurosthotonos, Med. Gaz., May 12, 1S38.
         f Rees's Encyclopaedia, Art. Tetanus 
40
ACUTE  TETANUS.
   Prognosis.—The prognosis in acute tetanus is extremely unfavourable,
 especially if traumatic;  it is more favourable in the idiopathic, and the
 chronic generally gets well of itself.   Death very seldom  occurs  after the
 twelfth day.  Dr.  Parry* attempted  to  found a prognosis on the state
 of the pulse, and thought that if on the fourth day it was under 100 or 110,
 the patient being an  adult, the prognosis was favourable  ;—but  if above
 120, unfavourable.  But although it  is true that the pulse is  in general
 accelerated towards the close of the  malady, still some  fatal cases have
 occurred in which it never rose above 80  or 90.  As a general rule, it may
 be said that the prognosis is favourable if the  complaint is partial;—if it
 does not affect the muscles of the glottis ;—if it has lasted some  days with-
 out increasing  materially in  severity;—if it is sensibly mitigated by the
 remedies employed ;—if the pulse is not much accelerated  ;—if  the patient
 sleeps; and if  he  has been subject to it  before  in  an intermittent form.
 On the other hand, the prospect will be unfavourable, if the spasms con-
 tinually increase in severity,  and especially if  they affect  the muscles of
 the glottis.
  Diagnosis.—Tetanus resembles hydrophobia in the difficulty of swallow-
 ing and aggravation of the spasms by slight external  irritants;  but it may
 be distinguished by the spasms being continuous, and by the patient being
 in general sensible, and calm to the last;—whereas in hydrophobia, there
 are  fits of general convulsions \s\th perfect intermissions, and the patient is
 mostly delirious, with a peculiarly wild haggard expression of countenance.
 Inflammation of the spinal cord, or its membranes, resembles  tetanus in
 being accompanied by opisthotonos and spasmodic difficulty of swallowing;
 but it may  be distinguished by the pain in the back, and fever being more
 predominant than in any case of mere tetanus, and by the  paraplegia and
 coma which supervene in most cases.
  Morbid  Anatomy.—The morbid appearances that have been found in
 different cases are as follow:  Increased vascularity of the membranes  and
 substance of the spinal cord,  with or without effusion of serum ;f—more
 rarely the same appearances have been found in  the  cranium ;—flakes of
 cartilage and spicula of bone deposited in the membranes of  the spinal
 cord ;\—vascularity of the nerves leading  from the wounded part;—of the
 mucous membrane of the stomach ; and of the sympathetic ganglia;—and
 congestion of the lungs.  But there is not one of these morbid  changes
that is constantly,  and, except the  first, there is  not  one of them that is
 even frequently found.   The muscles are  extremely rigid after death, and
ecchymosed or ruptured in many parts ;—the blood is mostly uncoagulated.
  Causes.—Tetanus may be  caused by wounds and external injuries of
 every description, but  especially by lacerated and  punctured wounds of
the hands and feet, gun-shot wounds, compound fractures,  compound dis-
location of the thumb, and wounds irritated by foreign matters, or in which
nerves are  exposed.  Mr. Morgan  has known it even  caused by a blow

  * Caleb Hillier Parry, M. D.  Cases of Tetanus and of Rabies Contagiosa, Bath, 1814.
  + Refer to  the cases at p. 42.
  * Extract from the report by Mr. Arnold of post mortem  appearances in the  case of a
 man  who died of idiopathic  tetanus in  Guy's Hospital, Lancet, 1844, vol. ii. p. 353.
 'Blood-vessels on the spinal marrow much congested; frequent adhesions between the
 layers of the arachnoid from  about the seventh  dorsal vertebra  upwards; arachnoid
 lining the dura mater presents a minutely granular appearance.  Several plates of bone
upon the free arachnoid, chiefly opposite the seventh  dorsal vertebra.   These  plater, of
 bone  ai3 confined entirely to the posterior surfaces." 
ACUTE TETANUS.
41
with a schoolmaster's ferule ;  but it is very rarely caused by clean  simple
.ncisions.  The period at which it may come  on  after the injury is very
uncertain.   Sometimes it occurs very quickly, if the patient is predisposed
to it.   Sometimes it seems to be induced by the great pain and irritation
of a wound during its inflammatory state :  but the most common  period
is, when the wound is nearly healed.   Why this is so, is very  difficult to
explain ; but  some attribute it to a rapid  cessation of  suppuration, and
others (as Trnka and Travers) to an irritation of the nerves by the contrac-
tion of the cicatrix.
   It is probable, however, that in most instances some concurrent or pre-
disposing cause, in addition to an external injury, is required to produce
tetanus.   Thus, in a case which occurred in St. Bartholomew's Hospital,
ten days after a wound on the toe, and proved fatal in a fortnight,  almost
all the intestinal canal was inflamed, and  there were ulcers in  the ilium
and coecum.1   Dr. Dickson2 and Mr.  M'Arthur3 relate cases in which the
intestines were filled with a peculiar unhealthy,yellow viscid secretion ;—
Mr. Abemethy4 commemorates the peculiarly unhealthy stools, like sloughs,
in a case which he observed ;  Mr. Travers5 strongly suspects that  dysen-
tery and ulcers of  the  intestines may be  coincident causes;  and some
authors6 have  affirmed that intestinal worms  are a  strongly predisposing,
if not really efficient cause.   But of all the  concurrent  causes which are
liable to induce tetanus in the wounded, exposure to cold damp night air
during warm weather, or in a warm climate, is the most  frequent;  and,
consequently, tetanus is much more prevalent and  fatal  in warm than in •
cold or temperate climates.
   The same causes, cold and visceral irritation namely, which  predispose
to the traumatic variety, may of themselves produce  the idiopathic tetanus.
Thus the latter has been a consequence of gastritis ;  of strangulated hernia ;7
of the irritation of an emetic on a stomach disordered by habitual drunken-
ness.6  Begin8 states that it has arisen from pericarditis;  Gooch9 gives a
case produced by disease of the breast; and Farr7 knew it caused by pul-
monary  abscess.  Uterine irritation is by no means an uncommon cause.
Whytt7 gives  the case of a girl,  aged twenty, who caught cold during the
menstrual period, and died of tetanus in  eighteen  hours; and the author
knows a case in which fatal trismus followed uterine irritation, consequent
on abortion.*
   Tetanus  may also be  caused by certain  narcotico-acrid poisons, espe-
cially  the  nux  vomica,  cicuta aquatica,  and  a Javanese  poison  called
chetilc.
   Pathology.—The spasms of tetanus, affecting as they do all the volun-
tary muscles,  must evidently depend  on some  morbid  condition of that
central organ, the spinal cord and medulla oblongata, from which all the
voluntary muscles are supplied with nerves.   And this  morbid condition
may depend on centric causes, that  is on causes affecting the spinal mar-
   (>) Med. Gaz. vol. i. p. G4G. (") Med. Chir. Trans, vol.  vii. p. 459.  (s) Ibid. vol.
vii. p.  4 74 et seq.   (4) Lectures on  Surgery.  Renshaw, London, 1S35, p. 23.   (6) Tra-
vers.  Further Inquiry concerning Constitutional Irritation, London, IS'!'), p. 397.  (6)
Vide F. Pe*cay, Die. de So. Med.   Paris, 1821, vol. lv. p. 9.  (') Quoted in Wincelslai
Trnka de  Kr'zowitz, Commentarius de Tetano, Vindobonia, 1777 — the very best work
on the  subject extant.  (e) Dictionnaire  de  Medecine  et Chirurgie  Pratiques.  Paris,
lS.'it).   Art. Tetanos.  (")  B. Gooch, Chirurgical works.  Lond. 1792.  Vol. ii.
  * This case was  related in preceding editions of this work.  Similar cases are to be
found in Trnka.  bee also Cooke*s Morgagni,  vol. i. p. 129; and the Lancet for June 2d
1S3S
        4* 
42                         ACUTE TETANUS.
row itself; or on excentric  causes;  that  is to  say, on irritation  of some
other part of the body, which  irritation is convened to the spinal cord by
the sentient or afferent, or, in Dr. Hall's language, excito-motor nerves.
   With respect  to  the nature of this morbid  condition,  it cannot be re-
garded as essentially inflammatory, because the spinal cord is often found
after  death without  a trace of vascularity, and because  tetanus  may be
established during a state of depression  and collapse that would be quite
incompatible with inflammation.*
   Although, however, it is  most certain that inflammation is not essential
to the existence of tetanus,  still it is  equally certain that there is one class
of tetanic cases  which presents a  well-marked  inflammatory character.
They commence with shivering and  pain, are  attended with fever,  and,
if fatal,  display on  inspection,  congestion, serous effusion,  softening or
purulent deposit, in some part of the brain or spinal cord.f  But this class
is by no means a majority.
   It  must be concluded, therefore,  that tetanus is merely a manifestation
of functional disorder in one department of the nervous system, and  that
the nearest approach we can make  to a  correct pathological  definition is
to say, that  it consists in  an  unnatural excitability of the  spinal  cord,
through which it produces spasm of the voluntary muscles;  a spasm  that
is aggravated by the  slightest  impression on  the sentient or afferent or
excito-motor nerves.
   Treatment.—Bearing in mind what has been just said,  viz. that tetanus
seems to depend on an  unnatural excitability of the spinal cord;  and  that
it may be  caused  either by (centric) changes in the  cord  itself, or by
(excentnc) irritation  of other parts of the body, it  will be evident that the
rational indications  in the treatment of tetanus must be,  first, to remove
all excentric causes of irritation, whether caused by a wound, by sordes in
the bowels, or the like; 2, to diminish  centric  irritation depending on a
diseased  or congested  state of the  cord; and  3, to relieve the unnatural
excitability.^
  * " I have observed,  sometimes after severe  gun-shot wounds, attended with  great
disturbance and stunning, {fracas et commotion,) and after considerable haemorrhages, a
state of constant atony (atonic) during the course of tetanus.  The pulse was slow, inter-
mittent, small, and thready; — stupor and apparent insensibility preceded the spasms,
and, so to say, announced them. The tetanus was universal, but the rigidity and tension
of the muscles were moderate.   This state was but of short duration; death occurred
in fifteen or twenty hours."—Fournier-Pescay, Op. Cit.
  j- The following are examples.  (1.) Case in which the disease was caused by a blow
on the back of the neck—next day patient was seized with shivering and fixed pain at
the injured part — pulse 130, and full — death in thirty-six hours.  Head found loaded
with blood, and cervical portion of the cord softened.—Med. Gaz. vol. i. p. 645.  (2.) A
cavalier cut his hand, and applied cold — was immediately seized with shivering  and
fever and tetanus — was bled, but died in  fourteen hours. — Fournier-Pescay, Op. Cit.
(3.) Patient was labouring under simple continued fever from cold and wet — tetanus
came on after a week, with aggravation of fever and pain in  the head and back ; treated
successfully by large bleedings, warm  bath, purgatives, and mercury.— Burmester in
Med. Chir. Trans, vol. ii.  (4.) A man after violent exercise was seized with rigors__
fever — pain in forehead — emprosthotonos, and subsequently opisthotonos — was bled,
but died comatose in five days—serum and blood found effused between the membranes
of brain; cervical portion of cord softened.—Francesco in Forbes's Review, Jan. 1838.
(5.) A woman died of tetanus from cold, with decided inflammatory symptoms.   The
spinal canal contained much bloody serum ; the pia mater was inflamed in the anterior
columns, the white substance was converted into a number of whitish yellow bodies
fmm the size of a millet to that of a lentil, very soft, with red spots; the posterior co-
lumns healthy.—Poggi, Lond. Med. and Phys. Jour. vol.  lxi. p. 132.
  J Vide Dr. M. Hall's fourth Memoir on  the Nervous System, Med. Chir. Trans,  vol.
lxi* 
ACUTE  TETANUS.
43
  In the local treatment, the first points to be accomplished are, to remove
all extraneous bodies from the wound, if there be one; to make incisions,
if necessary, for the free discharge of pus, or for the relief of inflammatory
swelling and tension; and if any isolated portion of nerve or tendon hap-
pens to be on the stretch, to divide it.   Then  the part may be fomented
with warm decoction of poppies; after which, a  solution of a scruple of
opium, or extract of belladonna in an ounce of water, may be applied on
lint, and the whole part be  enveloped in  large  soft poultices.   Sundry
other measures have  been proposed, in order more effectually to remove
local irritation: such as the  division of  the  principal nerve  leading from
the wound;  or, as Mr. Liston has proposed, the making a \  incision
above, so as to isolate it, and cut off as  much nervous communication as
possible ; or the destruction of a ragged, contused, ill-conditioned wound
by actual cautery, as Larrey  and others have practised with great  benefit;
or the  excision of the wound, if cicatrized or nearly so.   Sometimes, when
the wound is nearly cicatrized,  or has  ceased to suppurate, the application
of a blister or of strong stimulating ointments has  been of service ; but, as
Mr. Curling* observes, it happens, unfortunately, that the  tetanic condition
of the  spinal cord, when fully established, is mostly independent of its
local exciting cause, and does not cease on its removal.   Hence amputa-
tion of the  injured part has very rarely been successful, and has even
aggravated the mischief; so that, as a general  rule, it ought not to be per-
formed, unless desirable for some other reason besides the tetanus.
   We must next review the constitutional  remedies that have been  em-
ployed in tetanus, stating their relative utility,  and the cases in which they
are most likely to be beneficial.
   1. Bleeding. — In all cases attended with marked inflammatory  symp-
toms,  or if the habit  be full, and the wound hot, swelled, and  painful,
bleeding from the arm, and cupping from the  spine, are clearly indicated.
But, in non-inflammatory cases, it should not be employed at all;  for its
influence on  the muscular  system is but  secondary;  and though it may
diminish spasm for a time, it consumes the materials of  life, and hastens
death  from  exhaustion.
   2. Mercury, given so as  to  induce ptyalism,  has often appeared to do
good ;  therefore in any inflammatory case  two or three grains of calomel
may be given every two or three hours; or large  quantities of strong mer-
curial  ointment may be rubbed into the thighs and  legs till the gums are
affected.  In similar cases  tartar emetic may be given in repeated nau-
seating doses.
   3. Purgatives are always indicated, unless there is some peculiar cause
to the  contrary; both because there is  always obstinate constipation, and
because worms, or vitiated secretions in the digestive tube, may be among
the exciting causes: and the most active ones must be chosen.  Thus, at
the outset of the malady, a powder of calomel  and jalap mixed with butter
should be put at the  back of the tongue  for the patient to swallow, and
should be followed in an hour with a  draught  containing gj. of turpentine
and a  similar quantity of castor oil, or by a drop or two of croton  oil; and
enemata of  turpentine should be frequently administered until the bowels
are completely  unloaded.   The circumstances which forbid the use of
purgatives,  are  previous disease  of  the  alimentary  canal; dysentery,
  * A Treatise on Tetanus,  being the Jicksonian Prize Essay for 1834.  By T.  Blizard
Curling.  London, 1S3G, p. 122. 
14
ACUTE  TETANUS.
ulcers, &c.; but even  then  there would be  no objection to  unirntating
enemata.
  4.  Tobacco has the credit  of being one of the most efficacious remedies
in tetanus.  An enema, therefore, of four ounces of  the  encma^ labaci
(F.  50) may be given after the bowels are cleared, or without  waiting for
that, if the symptoms are urgent.   It soon induces deadly sickness, cold
perspiration, fainting, and relaxation of the muscles, followed  perhaps by
sleep.   And the enema may be repeated twice or thrice a day, or just
often enough to keep the muscles constantly relaxed.  But care must be
taken to keep up the strength, and to administer hot brandy and water, or
other stimulants, if the heart's action appear enfeebled.
  5.  Cold is of eminent service to animals affected with tetanus; and a
soldier was once most unexpectedly cured by exposure all night in severe
weather.  It may therefore do good in  some instances to apply cold ex-
tensively to the surface by means of bladders filled with various frigorific
mixtures; taking care to support  the circulation by internal  stimulants.
But the cold bath,  and cold  affusion, although they are of great service in
chronic tetanus, are most hazardous  in the acute, and have more than once
proved instantly fatal.
  6. Tonics,  especially the  muriated tincture of iron, quinine, &c, and
wine  in  considerable quantity,  are  likely to be of great  service in cases
attended with  debility.
  7.  Opium is of most undoubted efficacy in some instances, probably
those attended with  a painful wound,  and weakness.  When  it  produces
good effects, they are  soon manifest.  The  best way of using it appears
to be  by frictions with liniments  containing it;  or by removing a small
portion of cuticle  over the  spine with a blister, and sprinkling a grain of
finely powdered acetate, or hydro-chlorate  of morphia,  on the denuded
cutis.   If given internally it should be in large doses, and  in the liquid
form; and it should be recollected that very large doses  may be given
with very little effect.
  . 8.  The resin of the Cannabis Indica, or Indian  hemp,  a mild  stimulant
and narcotic, has been employed, with very good effects, by Dr. O'Shaugh-
nessy and others at  Calcutta, and by several practitioners in this country.
The dose is gr. iij. every half hour  till the symptoms are mitigated.
   9.  Several  cases  are on  record  in which recovery followed the use oi
ardent  spirits in very  large quantities.*   It is scarcely worth while to
mention the various antispasmodics, such as camphor,  musk, aether, cas-
tor, the warm-bath,  assafcetida, nor yet stramonium, belladonna,  or digi-
talis.  Colchicum has been of service in some few cases ; phosphorus given
in the quantity of one  grain daily, gradually increased to four in divided
 doses, is also said to have produced a cure in twelve days; and Cruveil-
hier thought  that in one case, great relief was  afforded by  making the
 patient breathe rapidly and voluntarily with the diaphragm, f
   10. Nutriment.—It is in  all  cases necessary to keep up the strength by
 beef-tea, wine, &c.   Mr. Travers believes that more patients have been
 lost from want of nutriment than from want of medicine.   But it is often
 by no means  easy to administer food or medicine, in consequence of the
 closure of the ;aws, and difficulty  of deglutition.  The former difficulty
 may  sometimes be  overcome by passing an elastic catheter  through the
                 •  See two cases in the Lancet for 1845, vol. i.
                 f Lancet, May 29, 1824. 
CHRONIC TETANUS.
45
nose, or behind the last molar teeth.   But if the attempt at swallowing is
attended with much spasm in the larynx, it must be abandoned, and our
remedies be introduced solely through the skin,  or by enema.   It is both
unnecessary and barbarous to force the jaws asunder, or to extract any of
the teeth.
   11. It  is also very important to protect the  patient from all  sources of
irritation and disturbance, since in the excitable  condition of the nervous
system which characterises this disease, the smallest impression upon any
of the organs of sense, especially touching or blowing on the skin,  is apt
to excite a severe degree of spasm.   He should be kept quiet and  in the
dark; and the  administration of remedies should be managed so as to
cause as  little annoyance as possible.   Bleeding  (if judged necessary) and
the evacuation of the  bowels, should be effected thoroughly once, for all;
and the  patient be cautioned  against speaking, moving, or swallowing
oftener than he can help.
   12. In two cases of animals affected with tetanus, the woorali or woo-
rara poison (a deadly narcotic, which instantaneously suspends conscious-
ness, voluntary motion, and  of course respiration) has  been  introduced
through a wound ;  and respiration having been kept up artificially  till the
nervous system recovered itself from the effects of the  poison, the animals,
on returning to consciousness, were  free from the disease.   Mr. Morgan
has, therefore, proposed that the same practice  shall be hazarded on the
human subject, when  afflicted with hopeless  tetanus.*  [Inhalations of
ether and of chloroform have been  resorted to in many cases  of tetanus,
of which reports have been made in  the Journals ; the result, however, has
not  been at all uniform.  For the mention of a  case  treated successfully
by the inhalation of ether, see Am. Journ. Med.  Sc. for April,  1848, page
561.—Ed.]

     section iii.--of the chronic, infantile, and
                    hysterical tetanus.

   Chronic Tetanus is very seldom fatal, although in some rare  instances
the patient has died, completely exhausted by  its long continuance ; for it
sometimes lasts several weeks.  The principal remedies  are aperients,
tonics, and the shower-bath.   The bowels should be kept freely open, but
the indiscriminate  exhibition  of drastics should  be avoided.  Electricity,
in the form of sparks, or weak shocks down the spine, would probably be
of service.f
   Trismus  Infantum  is a form of tetanus wThich is almost unknown  in
England.  It  was  formerly, however, exceedingly prevalent in Ireland,
and appears to be  met with there occasionally  even at present.   It  carries
off a vast number of children in the West India  islands; and  we learn
from Dr. Holland, that in the desolate  rocky Vestmann islands, on the
south coast of Iceland, one hundred and eighty-six infants perished of it
in twentv-five years, although the population does not exceed one hundred
and fifty souls.   The  causes appear to be, want of ventilation, and filth,
or the innutritious  and unwholesome diet of the parents, such as the fish
and sea-bird eggs that form the only sustenance of the Vestmann islanders;
   * Vide Waterton's Wanderings; Brodie*s Papers.—Phil. Trans,  for 1811, p. 178, and
181?., p. 205, and Morgan Op. Cit.
   j- Holland. Med. Notes and Refl.; and Addison on Electricity in Convulsive Disease!
Guy's liosp. Rop. vol. ii. 
4G
CONVULSIONS.
and the use of irritating applications to the wound  left by the  falling  off
of the navel  string.    The time at which the disease appears is generally
from the fifth to the tenth day after birth; hence the  popular  Irish term
nine-duyfits.
   The symptoms are, locked jaw, spasmodic difficulty of breathing and
swallowing, and general convulsions.  They are almost invariably attended
with diarrhoea,  and preceded by fretfulness, startings during  sleep, and
unusual greediness for the breast.
   Treatment of any kind is  seldom successful;  but it may be presumed
that  the warm bath, four or five doses of calomel (gr. i.—ii.) at intervals
of four or five hours, a teaspoonful or two of castor oil to clear the bowels,
and  minute  doses of laudanum (ojie-eighth  of  a minim cautiously  in-
creased) every two hours afterwards, are the measures  most likely to be
of service.*
   Hysterical Tf.tanus.—It is one characteristic of hysteria,  that it  fre-
quently assumes the more palpable outward symptoms of various diseases,
so as to  simulate  them pretty completely;  although proper  investigation
may always detect the real features of hysteria, under any mask whatever.
Thus an hysterical female may be seized with stiffness of the muscles of
the face and jaws, which may extend to the  neck, and gradually invade
the trunk and limbs, so as completely to close the  mouth, and render the
whole body rigid and motionless.   The chief points of diagnosis are,  the
hysterical state of the mind ; and the fact that the muscular contraction,
however great, may almost always be overcome for the moment by forcing
the patient to exert her volition.  The best remedies are, warm aloetic
purgatives, and  turpentine enemata, and valerian, galbanum, and  other
antispasmodics of that class.
                         CHAPTER  V.

                       OF CONVULSIONS.

  In order to complete the view of general disorders produced by local
injury or disease, it is necessary briefly to allude to convulsions, occurring
in epileptic paroxysms.   These are familiar in medical practice, and arise
from irritation of the gums, of the stomach, of the uterus, &c.; they also
occur occasionally from  some  of the local affections which custom has
assigned to the surgeon.  In particular, they may arise from  spicula of
bone growing from the inner surface of  the skull;  or from slight injuries
to the skull which have left the  bone unsound; and especially from irrita-
tion of the urinary organs; retention of urine, renal calculus, and the like.
In children, convulsions are apt to be produced by severe injuries of any-
kind.
  Into the symptoms and treatment it is not the author's province to enter
■n this place.   It will suffice to give the general rule,  that in all obscure
■^ases  of convulsions, search should be made for excentiic causes of irrita-
rion, and that  the surgeon will do  well most carefully to scrutinize the
urinary and genital system.
  • See a paper by Joseph Clarke, M. D., in Med. Facts and Obs. vol. iii., Lond. 1792 •
l>r. Holland's Med. Notes anc' Reflections. 2d Ed. p. 29: Maunsell and Evanson on Dis-
enses of Children, 4th Ed. Dublin, 184?, p. 219; and  Maxwell on Yaws and Tetanus
Ean. 1839. 
                    PART  II.

OP THE PRINCIPAL PROCESSES OF LOCAL DISEASE.
                          CHAPTER I.

         OF THE GENERAL PHENOMENA OF INFLAMMATION.

  Definition. — Inflammation may be defined to be a state  of altered
nutrition, attended with increased vascularity and sensibility, and with a
tendency to morbid secretion and change of structure.
  Symptoms.—The symptoms are redness, pain, heat, and swelling, with
impaired function of the inflamed part;—each of these symptoms requires
a few observations in detail.
  (1.) The redness is owing to  the increased quantity  of blood  in the
inflamed part;* so that the  smallest  capillaries are  distended with red
particles, and  rendered visible to  the naked eye.   When inflammation is
acute, the  redness is of the bright scarlet tint of arterial blood ;  when
chronic, it  is of a darker venous  hue;  and in certain  specific  inflamma-
tions  it is  purple or copper-coloured.   Again, in common inflammation,
it is gradually diffused, and lost in the neighbouring parts,  whilst in some
forms of specific inflammation* it is abruptly circumscribed.   There are
several terms  used  by authors  to express  the  varieties, degrees, and
appearances of redness.f   Thus,  1. It is called ramiform, when seated in
the small arteries and veins only, and not  in the capillaries.   2.  It is said
to be capilliform when some of the capillaries are  also distended.   3. It
is uniform, when all the capillaries are injected ; as  in erysipelas.   4. It
is punctiform  when occurring in  minute dots;  as when the villi of a mu-
cous  membrane are  injected, but not the mucous tissue itself.  5.  It is
called maculiform, when  the blood is  either extremely accumulated, or
else extravasated at certain points.   This form of redness accompanies
hemorrhagic inflammation.
  (2.) The pain of inflammation may be  attributed  partly  to a stretching
of the nerves  by the distended blood-vessels, partly to a disorder of sen-
sation, accompanying the  disorder of nutrition and function.  It differs in
its  character and intensity according to the  cause producing it, and the
part which  is affected.   Thus it is burning or tingling in the skin ;  throb-
bing in the cellular tissue; sharp  and lancinating  in the pleura; a meie
sense of heat  and soreness in the bronchial mucous membrane ; and ex-
tremely dull and oppressing in a part supplied with ganglionic nerves ;  as
the  stomach, kidneys, or testicles.  It is  always  less severe if the  fluid
products of inflammation can readily escape,  than if they are confined ;—
and comparatively slight if the part inflamed be  yielding  and extensile,

  *  Hunters  Works by Palmer.  Vol. iii. p. 330.
  r  Carswell, Illustrations of the Elementary forms of Disease.  Lond. fol. 1S37.
                                                          (47) 
48           GENERAL PHENOMENA  OF  INFLAMMATION.
but most severe if it be  hard and  dense, as bone or ligament;  although
these structures possess very little sensibility in  health.  It is also  in
general greater in common inflammation than in specific,  with the excep-
tion of the gout.  It is sometimes felt at a distance from the inflamed part;
thus pain in the shoulder is often the first symptom of inflamed liver, and
pain in the knee, of diseased hip.   Lastly, it may be  entirely absent;  as
when inflammation occurs in a healthy constitution, and merely produces
adhesion ;  so that adhesions  are often  found  between the pleura} after
death, that  never  were suspected  during life; — or when  inflammation,
although disorganising, is very insidious and indolent,  as  in scrofula;—or
when the patient's mental and physical sensibilities have been benumbed
by the habitual use of intoxicating liquors;*—or when  the nervous system
is stupified by the influence of poisonous blood in fever, [and in those dis-
eases of the liver and kidneys in which the secretion of bile and urine is
arrested, or but very imperfectly accomplished, and the blood consequently
vitiated ;—or when the brain is rendered incapable, from existing disease,
of receiving,  or responding  to, impressions made  upon  sentient  sur-
faces.—Ed.]; — or when the  part  inflamed is deprived  of its nerves  of
sensation.
  (3.) The heat of inflammation was supposed by Hunter to be a mere
effect of the increased afflux of blood.   For it is  most remarkable in in-
flammation of those parts which  are furthest from the heart, and  naturally
the coldest; and in them it often does not rise so high  as the mean tem-
perature of the blood; — whilst in inflammation of internal parts, whose
heat is uniform, and not depressed  by  external vicissitudes, it sometimes
does not rise at all. We may however suppose with Liebig, that, togethei
with this increased afflux of blood, there is also a more  rapid oxydation
of the tissues of the inflamed part, which will of necessity produce  a greatei
evolution of heat.f
  (4.) The swelling is caused at first by the increased  quantity of blood,
and subsequently by the effusion of serum, blood, lymph, and pus.  It is
most remarkable in loose textures; also  in the breast, testicle, and lym-
phatic  glands.
  (5.)  The impairment of function which inflammation produces, consists
at first in an increased irritability and morbid sensibility  of external im-
pression ;  but,  subsequently, of  an utter incapability  of performing the
usual offices, in consequence of structural change.
  (6.)  Inflammation may produce  every possible alteration of secretion.
First,  in quantity; secretion is generally diminished  at  the  commence-
ment of inflammation, but increased at its close, as is the case with mucous
membranes.  Secondly, in chemical composition; — as  the tears which  in
certain cases become hot and scalding, and excoriate the cheek.   Thirdly,
the  secretions may be mixed with the  products of inflammation;  thus
mucus is often mixed with blood, serum, lymph, and pus.
  (7.)  Alteration in Structure. — Inflammation is capable of altering
all the mechanical qualities of parts.  1. The weight is always increased
if the inflammation be recent, and if it  have not  existed long enough to
induce  atrophy.  2.  Cohesion or  hardness  is always diminished in  acute
inflammation, although this is apt to be overlooked  in consequence of the

 • Latham, Lectures on Subjects connected with Clinical Medicine.—Lect. iv.
 f James on  Inflammation, p. 239; Macartney on Inflammation, p. 14; I atour, Revue
Mod.. Jan. IS 10; Liebig, Op. Cit. p. 254. 
GENERAL PHENOMENA  OF  INFLAMMATION.           49
increased density.   This softening arises from the effusions which infil-
trate the tissues.  Hardness may be increased in chronic inflammation;
sometimes because the whole bulk of the part is shrunken; sometimes be-
cause of the organisation of lymph.  Hardening from chronic inflammation
was formerly termed scirrhus ;  and the term is  still used  in this sense by
the French, although it is far better to employ it solely to designate a defi-
nite malignant disease.   3.  Transparency and polish are always impaired.
   Morbid Anatomy. — The ordinary post mortem appearances of recent
inflammation are, redness, softening, swelling, and infiltration with serum.
It is necessary, however, to make a few observations respecting these phe-
nomena, and especially  concerning redness;  because, in the first place, it
may disappear  altogether after  death — secondly, it may be stimulated  by
redness from congestion which  existed during life—and thirdly, it mav be
stimulated by certain appearances produced after death.
   In the first place, then, redness, if very* slight,  may disappear from in-
flamed skin after death; but if  the blood-vessels were injected, the vascu-
larity would be found increased;  besides that the part would be softened,
and slightly infiltrated with serum, and that the epidermis would peel off
more readily than natural.
   Secondly. Redness may have been caused  during life, not by inflamma-
tion, but by congestion, from an obstacle to the return of blood; and con-
gestion may also be attended with softening, and serous effusion, so that
in some instances it cannot be distinguished at  all  from  inflammation, and
in others not with certainty.   The general distinction is, that in congestion
the larger veins are distended more than  the capillaries, and previously 4o
them; whereas  it is the reverse  in inflammation.   [In  congestion, more-
over, the blood  is usually of a darker hue  than in inflammation.—Ed.]
The diagnosis will  be aided by observing whether there  is any cause of
obstruction  to the venous circulation.*
   Thirdly.  The redness of inflammation may require to be distinguished
from  certain appearances produced after death.   And these may be pro-
duced,  (1.) By the action of the  capillaries, which continues after that of
the heart has ceased;  so that the  arteries are emptied, and the blood
accumulated in  various internal organs,  especially the lungs  and spleen.
(2.) By gravitation; by which  the most depending parts of the body, and
especially of the lungs, are always more  or  less  congested.  (3.) By
transudation of the serum and colouring matter through the coats of the
vessels  in incipient  putrefaction; which  is a frequent cause of red spots
and stains on internal surfaces,  and of collections of bloody serum in the
various cavities.  But the author's  space does not permit him to  dilate
upon these topics: they are merely adverted to for the purpose of show-
ing, that redness, swelling,  softening, and  serous effusion must not be
hastily received as evidence of inflammation, unless accompanied by some
more decided effect, such as lymph or pus; seeing that they may be pro-
duced by other causes, both before  death and after it.
   Fffects and Terminations.—Inflammation has only one genuine ter-
mination, namely, resolution, or recovery; the inflammatory action subsid-
ing, and the part returning to its former state ; — but, beside resolution, it
may have either of  the following  six terminations, or effects, or conse-
quences, as  they ought  rather to be called.   1. Hemorrhage; an escape

                * Andral, Anatomie  Pathologique, torn. i. p. Sf.
       5                          D 
50           GENERAL PHENOMENA  OK  INFLAMMATION.
of blood from the distended vessels.   2. Fffusion of serum.  3. F.fusion
of fibrine, or of coagulable lymph, which, when organised, produces adhe-
sion.   4. Suppuration, the formation of a peculiar fluid called pus, closely
allied  with  which is the change  called ramollissement, or softening.  5.
Ulceration ; the disappearance or  removal of the inflamed part.   6. Mor-
tification, or its  death. To each of these effects a chapter will be devoted.*
  Forms of Inflammation. — Inflammation  may be  divided—1. Into
healthy and unhealthy, — the former being that which naturally ensues in
healthy constitutions, when a part of the organisation is impaired ;—being
restorative in its tendencies, injurious only if excessive or misplaced, and
usually concentrated towards one point:  whereas the unhealthy is essen-
tially destructive, has little  or  no  spontaneous  tendency to recovery, and
is liable to  be  diffused  widely.   2.  Into common and specific; the com-
mon  arising from ordinary causes acting on healthy constitutions ; — the
specific arising either because the  constitution  is unsound,  as in scrofula ;
so that (to  use  Hunter's words) it gives or reflects back upon the part in-
flamed a diseased disposition or action ;—or because it  is produced by a
cause  which is  specific; as the poisons of small-pox or syphilis.   3. It
may be divided into acute  and  chronic;  the  acute being sudden  in  its
seizure, violent in its action, and rapid in its progress;—the chronic being
less  violent and more tardy.   Acute inflammation is  sometimes called
active; and the  term passive is applied  to chronic inflammations in weak
constitutions.   4.  It may be classified  according to its tendency to pro-
duce  particular local  effects;  thus  we  speak  of  adhesive, suppurative,
hsemorrhagic,  ulcerative, and gangrenous inflammation.
  Modifications.—Inflammation always  is modified by the state of con-
stitution in which  it occurs: being  active and  rapid in the young and
healthy, but more indolent, and tending to destructive processes (such as
ulceration and mortification) in the aged  and debilitated.  It also presents
divers variations, according to the cause producing it: and will  be greatly
influenced by the  epidemic constitution of the  air.   It is further modified
by the structure  of the parts which it invades: for it has a greater ten-
dency to produce  certain effects in some structures than in others.   Thus
in the  serous cavities and cellular tissue, parts  which have no natural out-
let, it is more  disposed  to produce  adhesion  than  suppuration.  But in
the  mucous  membranes it tends to produce suppuration  before  adhesion:
because suppuration is  but  a  trifling evil compared with the danger that
would ensue if the  mucous canals were closed by adhesive matter, from
the  slight inflammations  to  which they are perpetually subject.  Yet if
inflammation be of extreme violence, or if there be something particularly
morbid in its cause, or in the constitution, the natural precedence of these
two  effects will  be inverted.  Thus  in  violent inflammation of mucous
membranes, as croup, lymph is poured out on the surface ;— and inflam-
mation of the  cellular tissue, arising in a vitiated habit, or from a morbid
poison, may induce  a  diffused and widely spreading suppuration, which
is not  limited by  adhesion; as, for example, in phlegmonous  erysipelas
and the disease arising from dissection wounds.f

  * It must be understood that except suppuration and adhesion, these effects may all
:»e produced by other causes besides inflammation—congestion in particular may cause
haemorrhage, serous effusion, ulceration, and gangrene.
  ■J- See John Hunter's observations on Erysipelatous Inflammation.  In Palmer's edi
tion of his works, vol. iii. 
GENES./L PHENOMENA  OF  INFLAMMATION.
51
    Predisposing Cau.^s.—The predisposing causes of inflammation may
 be constitutional or ?ocal.  The constitutional predisposing causes,  are
 plethora, the sanguine temperament, excess in food, drink, bodily exertion,
 exposure  to  noxious miasmata, and disorder of the  liver, kidneys, skin,
 and other organs whose office it is to purify the blood.   When  inflamma-
 tion arises from these  oauses  alone, it  is said  to be spontaneous or idio-
 pathic, or constitutional.   The local exciting causes are chiefly  over-stim-
 ulation or exertion  beyond power;  besides previous  disease, and original
 weakness of organization.
    Exciting Causes. — The  exciting  causes  may be divided into two
 classes.   1.  Those  which act primarily on the structure of a part,—as
 mechanical  and  chemical injuries of all sorts.  2.  Those which act pri-
 marily on its functions and vital endowments,—as over-exertion;—and the
 poisons, such as  cantharides, which  affect living matters only.   The for-
 mer class act directly;  that  is, they  inflame the  part which they  are
 applied to :  the latter class may act indirectly; just as cold  applied to the
 feet causes inflammation of the lungs.   The former also act  immediately;
 whilst some of the latter may take some time (which  is called the stage of
 incubation) to produce  their effects.   Lastly,  causes may be common or
 specific;—the former being those which are daily met with, and which can
 act on all constitutions ;—the latter being unable to affect all  constitutions,
 being peculiar in their origin, and producing a modified inflammation, with
 a specific train of consequences.  The vaccine virus may be an example.
    Diagnosis.—Inflammation  does not consist  of mere increased vascula-
 rity, nor yet of pain, although it  is attended by both these symptoms;
 therefore a few words must be said on the means of distinguishing it from
 increased accumulation of blood, or hypercemia, and from various  kinds
 of non-inflammatory pain.
     (a) Congestion signifies an accumulation or stagnation of blood in a part,
  which'may be caused by some  mechanical obstacle to its return  through
  the veins ;  or by weakness and atony ;  it is a very frequent sequel of in-
  flammation.  It  produces more or less  weight  and pain, with disturbance
  of function, especially of secretion ;  but it does not cause fever like acute
  inflammation, nor interstitial deposition like chronic ; although it may ter-
  minate in either.
     (b) Active determination of blood consists in a dilatation and  expansion
 of the capillaries, whereby they attract more blood to a part, and circulate
 it more rapidly.  It is a process necessary to many natural actions; as,
 for instance, the  enlargement of the womb during gestation and the secre-
 tion of milk after delivery;—blushing affords  a very familiar example of
 it.  When  morbid,  it causes  excitement and  functional  derangement.
 Instances of it are  seen in the  injected  capillaries of the intestines in the
 cholera, and in headaches from excitement;—in many cases it is  the first
 stage of incipient inflammation.
    (c) Pain, not of  an inflammatory  character,  may depend on  spasms, or
 cramp, and in particular on what is called nervous irritation, or  neuralgia.
 The irritable breast, irritable testicle, tic douloureux, neuralgic toothache
' and headache, and the mock inflammations which occur in weak, irritable,
 and hysteric subjects, (especially from  abuse of blood-letting,)  are exam-
 ples of this state.  The pain of nervous irritation  may in general be dis-
 tinguished from that  of inflammation by its  coming on and disappearing
 suddenly without apparent cause;—by its being often  relieved by measures 
52           GENERAL PHENOMENA  OF  INFLAMMATION.

that would aggravate inflammation, such as pressure, friction, and  stimu-
lants ;  by the pain being severe out of all proportion to heat, redness, and
swelling, even if they exist at all; and by  the circumstance that  although
the pain may last for weeks or months, no  local disorganization or suppu-
ration follows.
  Theory of Inflammation.—It is not compatible with the scope of this
work to give a detailed account of the various  theories that have been in
vented respecting the proximate cause or essential nature of inflammation
Of the older writers, some attributed it to a lentor or viscidity of the blood
—others to an error loci, that is, an obstruction of the capillaries by the
entrance of globules too large to pass through them.  Cullen supposed
that it  consisted  in  spasm of the extreme vessels.   Hunter ascribed it to
an increased action ;—Wilson Philip and Hastings to a debility ;—-Henle'
to a  paralysis;—and Mr. J. W. Earle to an obstruction of the capillaries.
   In assenting to these theories it was of course taken for granted that the
capillaries are the  essential seat of inflammation, and that it  is to some
action  or condition of them that the phenomena of inflammation are due.
  But Dr. Macartney showed clearly that it could not be the blood-vessels
which were the parts originally affected, and proposed a theory that a sense
of injury felt by organic nerves is the point de depart in inflammation ;  a
theory not without  its practical results, since  it is very certain that inflam-
mation after an injury may be prevented or mitigated by  measures calcu-
lated to soothe and allay all sense of irritation.
   The next step arrived at was the conviction  as stated by Mr. Travers,*
that  inflammation was  not a  disorder in  any one element of the  tissues
alone; neither in the blood, blood-vessels,  nerves,  nor  lymphatics;  nor
yet that it was a  change purely physical, or chemical,  or nervous;  but
that  the ^issues are involved as a  living whole, and all their properties
simultaneously.
   So  Liebig's theory*,  that  in  inflammation there is an unnaturally rapid
oxydation of the inflamed  tissues,  is no doubt true, although  not  the
whole truth.
   If we consider for a  moment the relation which the living  tissues and
the blood-vessels have to each other in health, we shall acquire a more
 just idea of the share which they take respectively in inflammation.  The
blood-vessels are but carriers; the arteries bring oxygen to excite the dif-
leient functions,  and to dissolve and destroy tissues that have played their
part and are become effete;  they also bring new material, which the tis-
sues  attract out of the capillaries,  and employ by means of their vital
forces for their cure, reparation, and  increase ;  and the veins carry away
effete  and superfluous  matters.  But they  do no more ; they are  not, as it
has been the custom to term them, the agents of organization,  the builders
of the tissues;  for in  the foetus much  of organization  is  accomplished
 before blood-vessels are formed at all; and  there are many tissues in the
 adult, such as the cornea, wThich have no vessels, but nourish themselves
 out of the fluids exuding from the vessels in the vicinity.
   Wherever in  health the vital forces  are most active, there  most blood is
 conveyed.  When  the womb or breasts enlarge in pregnancy, their vessels
 become infinitely more voluminous; but the enlargement of the womb is
 not the consequence of the dilatation  of the blood-vessels, but the cause
   * Travers on Inflammation, 1844, p. 20.  This work contains copious and.  accurate
 acjrunts of microscopical observations on inflammation excited in frogs. &c. 
             GENERAL  PHENOMENA OF INFLAMMATION.           53

of  it; more blood  is demanded there, more blood is brought, and the
arteries enlarge in obedience to the wants of the part they supply.
   If we apply tiiese views to explain the essential nature of inflammation,
we shall be compelled to admit that its seat is — not mere vessel or nerve
— but the living  tissue,  the organic  cell.   That the tissue, which, in its
normal condition, attracts out of the neighbouring blood-vessels the neces-
sary materials for its own life and growth, if  its vitality be interfered with
—by injury, by poison, by heat or cold, or any other source of disease—
sets up another series of actions, of which the attraction of considerable
quantities of arterial blood is one of the most conspicuous, and which in
their totality constitute inflammation.
   That, under favourable  circumstances, if for instance there is a phy-
sical breach of continuity to be repaired, the  tissue attracts from the ves-
sels some of the liquor sanguinis, which forms a blastema* or  plastic ma-
terial,  in which new organic cells are developed and become a living tis-
sue  by which the injury is repaired.  The adhesion of a wound and
reparation of a simple fracture are familiar instances.
   That,  under less favourable circumstances,  whether arising  from the
amount of injury inflicted, or from  the want of proper vital power in the
cell, or from a defective  state  of the  liquor sanguinis,  a series of further
changes ensues.  The plasma attracted from the blood-vessels begets within
itself a kind of cell—incapable of further life or development—which is
well known as the pus-corpuscle.
   That, under still more unfavourable circumstances,  the tissues, after a
violent struggle, perish and mortify.
   That, under certain unhealthy conditions, the liquor  sanguinis, whether
that supplied for the common  purposes of nutrition, or that  supplied  in
greater quantity through a slight degree of inflammation, begets various
morbid cells, such as those of  cancer, tubercle, &c.
   We are thus compelled to take from the capillaries the office which has
been so long assigned to them  as the factors of inflammation.  But  yet
the great  afflux of arterial blood is a most important  instrument in  the
changes which inflammation produces, and  the  prevention of it is one of
the most efficient means  for controlling these changes.  And there is little
doubt  but that the lax state of  the blood-vessels in a chronically  inflamed
part is often one great obstacle to a perfect recovery.
   We are further compelled to deny the various theories which take a dis-
tended state  of the capillaries as their basis, and  account for the various
effects of  inflammation as so many mechanical consequences of that dis-
tension.   Thus it has been common  to say that serum exudes from  the
blood-vessels in the first  stage, when but slightly distended;  that, under
the influence of greater distension, the liquor sanguinis  is forced out; that
if  the inflammation still progress, blood will be extravasated, &c.
   But, granting th*at when the vessels are much  distended,  serum will
exude  from them, and that if they are further distended they may be rup-
tured and give exit to blood, yet this theory is quite insufficient to account
for the effusion of liquor sanguinis or of lymph.  In  inflammation of se-
rous membranes for instance, " the blood-vessels are all on one side of the
membrane, and yet  the  serum  and lymph are on the other."f  If the
lvmph were  merely effused mechanically from distended capillaries, it
  * YfkOLn-trua, gertnen ; B»ui<j*ai/o. germi/w, pullulo.
  ■j- Vide Goodsir's Anatomical and. Pathological observations.  Edinburgh, 1845.
       5* 
54
ACUTE INFLAMMATION.
ought to be found where the capillaries are—in the subserous  cellular tis-
sue ;  its being found where it  is  can only be accounted for on the theory
we have been labouring to prove, viz., that it is attracted out of the capil-
laries by the cells on the free surface of the serous membrane.
   Microscopical Observations.—We must say a  very few words on
what  the microscope has revealed concerning the actual facts of inflamma-
tion after it has  been excited in the frog's foot, or the mesentery of the
rabbit.   The facts that seem to be the  best established are the following:
—That in the capillaries of every acutely inflamed part, and the larger
vessels in its vicinity, the blood is  circulated with preternatural  rapidity
and abundance ;  and serum is exuded into the interstices of the part.
   This may be called the^r.9^ stage.
   In  the next stage  the blood stagnates in the focus of the inflammation,
the red globules  adhere  to each other,  and to the sides of the  capillaries,
and liquor sanguinis, or lymph,  is exuded (adhesion).   Or pft-haps the
blood-vessels are ruptured, and a small quantity of blood becomes extra-
vasated (hcemorrhage).   If the inflammation continue, the tissues become
completely broken down and disorganized at the points where the inflam-
mation is most intense, and pus is there formed out of the exuded lymph
{suppuration).  If the inflammation increases in  severity, the blood ceases
to circulate  in the vessels, the tissue becomes  soft and flaccid,  and in fact
mortifies*
                          CHAPTER II.

                     OF ACUTE INFLAMMATION.

   Definition.—Acute inflammation is that which is sudden in its origin,
violent in  its action, and rapid in terminating; and it is attended with
fever,  either if it be considerable in its extent, or if it affect parts of great
sensibility  and importance, or if the constitution be highly irritable.
   Treatment.—In the treatment of acute inflammation and its attendant
fever,  the indications are, to  reduce the increased action of the heart  and
arteries, and diminish the quantity of arterial blood sent to the  inflamed
part; to allay pain and nervous excitement, and to restore  the secretions.
The chief  means are, evacuants, sedatives, and narcotics.
   (1.) Blood-letting, Objects of—The first and most important measure
is  general blood-letting;—which, if carried far  enough^ induces a state of

  * Vide  Cullen's First Lines, book ii. chap. i. sect. 2 ;  Hunter on the Blood • Thomp-
son s Lectures  on Inflammation;  Gendrin, Histoire Anatomique des Inflammations:
Andral, Anatomie Pathologique ; Wilson Philip's Treatise on Fevers, and Experimental
Inquiry into  the Laws of the Vital Functions. 3d ed.;  Mayo's Outlines of Physiology
5th ed.; the  Papers by Mr.  J. W.  Earle in Lond. Med. Gaz. vol. xvi. ; Latour, op. cit. •
Macartney, op. cit; Gulliver, Phil. Mag. Sept. 1838; Kaltenbrunner de Statu Vasorum
et Sanguinis  in Inflammatione, 1826; The Lecture on Inflammation in Graves's Clinical
Mfdicine. T. Wharton Jones in B. and F. MM. Rev., Oct.  1842; Liebig, op. cit.-  Ms
<*artney on Inflammation, Lond. 1838: J. Hughes Bennet, Lond. and Ed. Jour. Med. So
Dec 1842 : and Treatise on Inflammation, Edinburgh, 1844. 
ACUTE  INFLAMMATION.
55
aisensibility, and suspended circulation, to which  the  name  syncope, or
fainting, is given.  Now it requires to  be understood, that this suspen-
sion of the heart's action depends upon two causes; first, on  the abstrac-
tion of its natural stimulus, the  blood;—secondly, and principally, on a
peculiar sedative influence transmitted to it from the brain, when the latter
does not receive its due share of  arterial blood.   And although  the mere
loss of blood per se may  be  of service (when that  fluid is  morbidly
abundant) by relieving the  system from a source of excitement, still the
principal good effects of bleeding in inflammation depend o/> its sedative
effects on the brain, and through the brain on the heart.  And as it is often
absolutely necessary to bleed persons in  acute diseases who  are extremely
debilitated,  it is of importance  to produce as much of  that sedative effect
with as little loss of  blood as possible.
   Manner of Bleeding.—For this purpose the blood should be drawn as
quickly as possible,  from a large  orifice ; and, above all, the patient should
sit or stand  upright.   For if the blood is drawn slowly, so that the vessels
have time to adapt themselves to their diminished contents, or if the patient
is in the recumbent posture, so as to assist the flow of blood to the brain,
the bleeding may be continued almost to death without the occurrence of
faintness.
   Quantity to be taken.—As a  general rule, the blood should be permitted
to flow till  paleness of the  lips, lividity about the eyes, sighing, nausea,
fluttering pulse, and relief of the pain, indicate the approach of syncope;
but full syncope should always be avoided.
   Tolerance.—The tolerance, or power  of bearing bleeding without faint-
ing, varies according to the age,  sex, and temperament of the patient.  It
is less in  the very  young and old than in the middle-aged ;—less  in the
female than in the male;—and less in the nervous and lymphatic tempera-
ments than  in the  sanguine  and phlegmatic.   But the tolerance is besides
affected most remarkably by the  existing disease.  Thus it has been ascer-
tained by Dr. Marshall Hall, that 15 oz. is the average quantity that will
produce syncope  in a healthy adult if bled whilst  standing upright; but
that in some diseases much more requires  to be  taken, and  in  others
much  less.
   The diseases in which bleeding is best borne, are inflammations  of the
head,  or of other vital parts.   Those  in which it  is most  injurious  and
worst,  borne, are putrid fevers and diseases  of debility.  And so,  an ob-
servation of the tolerance is sometimes a very important aid to diagnosis.
Supposing a woman to complain of violent pain in the  head or abdomen,
which is suspected to be inflammatory:  if faintness occurs  from the  loss
of a very small quantity of  blood, it will be certain either that it is not in-
flammatory, but nervous ;—or that, if  inflammatory, it must be treated by
other measures than blood-letting.   But the junior practitioner must  bear
in mind that he may occasionally meet writh some thin,  bloodless patients,
whom it  would be very injurious to  bleed, but who  nevertheless, from
some peculiarity of constitution, do not faint, even  though bled to excess.
   Reaction.—After the depressing effects of bleeding there naturally en-
sues a degree of reaction ;  the pulse rising in frequency, and the local  pain
returning; and this  reaction will be the greater if the venesection has been
carried to the extent of producing full syncope;—hence the importance
of stopping  short  of this point.   This  reaction is, if possible, to be  pre-
vented by the  sedatives, which we shall mention  presently;  but if,  not 
56
ACUTE  INFLAMMATION.
withstanding, well-marked inflammatory symptoms return,  the  bleeding
must be repeated,—provided that the strength permit.
   Indications for Bleeding.—But as general venesection is not to be re-
sorted  to indiscriminately in  every case of acute inflammation, a few words
must be added on the principles that regulate its employment. And there
are three  things to be  considered;  viz. 1st, the patient's  strength, and
state of constitution ; 2dly, the part affected;  3dly, the nature and amount
of the  injury Or exciting cause which has produced the disease.
   (1.)  With regard to the state of the constitution : bleeding  is most re-
quired, and best borne, when the temperament is sanguine, or that mixture
of the  sanguine and phlegmatic termed rustic;—when  the muscles  are
large and  firm ;—when the blood-making powers are vigorous and the cir-
culation strong, as indicated by redness of the face and lips, and by a full,
hard, and frequent pulse.  On the other  hand, it will  be borne worse
when the  muscles  are large and flabby, and the pulse  habitually open,
soft, and full.   And it will be borne worst of all when the  complexion is
sickly and pale,—the  pulse  quick, small, and feeble,—the lips, conjunc-
tiva, and tongue pale.   And if there should happen  to be a state of pas-
sive dilatation  and  weakness of the heart, syncope would most  likely be
instantly fatal;—and if there should be any organic disease which impedes
the formation of blood,  its loss is liable to  be  followed  by irrecoverable
sinking and exhaustion.   Fat people  generally bear bleeding worse, and
in fact  contain  less blood, proportionably to their bulk, than  those of a
spare, lean habit and rigid fibre.
   The  propriety of a second bleeding must  in a great measure be deter-
mined  by  the effect which the first has  had  on  the pulse;  for if that be
more frequent and  quick, or  more sharp and jerking, instead  of slower and
softer,  it would seem that the bleeding had diminished the strength more
than it  had reduced the  disease.   The  state of the blood  must also be re-
garded ; for if the  surface of the coagulum  be fiat, and  its consistence
loose, it is a sign that the vital powers are depressed ; that  further bleed-
ing will be injurious;  and that the case must be committed to the other
antiphlogistic powers.
   (2.)  Respecting the part affected, it may be observed, that the  necessity
for venesection, and its beneficial effects, will be greater in  proportion as
the tolerance is greater,—and that  it would  be indispensable where the
organ affected  is important to life, or to its enjoyment; whilst it might not
be so if an equal degree of  inflammation affected an unimportant part,-^-
and that its good influence in inflammation of a vital organ will often be
marked by a rise in the strength and fulness of the pulse.
   (3.)  With regard to the nature of the cause: bleeding is not well borne
when that  is such as to produce great depression of the vital powers, as in
the case of dissection wounds:—nor when the inflammation itself causes
great depression, as in phlebitis;—nor in the  case  of an  injury requiring
great constitutional  efforts for its restoration, as a compound fracture ;—
nor if the  disease be advanced towards suppuration or gangrene.
   II. Evacuant Sedatives.—Under this title may be included a number
of antiphlogistic remedies, which act,  either  by producing  a great  dis-
charge  of certain secretions, or by some specific lowering  agency inde-
pendent of  any evacuation,   (a) Purgatives are admissible at the com-
mencement of all cases, except  when they would cause  irritation or dis-
turbance of a diseased or injured part,  as might be the case in wounds of 
ACUTE  INFLAMMATION.                     57
the alimentary canal, and in compound fracture.  Those should be selected
which excite free secretion from the liver  and intestines, and  evacuate
them rapidly: such as a good dose  of calomel, followed by F. 16.  (b)
Mercury reduces the heart's action, restores the secretions, and excites the
absorption of diseased products; it  is chiefly advantageous  in idiopathic
inflammations of serous structures,  with  a tendency to  adhesion.  But
when the nature of the disease and state of the pulse demand blood-letting,
mercury cannot be regarded as a substitute, but only as an auxiliary; and,
if employed to the neglect of bleeding, will  most likely do  more harm
than good.*   The best form  for its  administration is  calomel,  of  which
from one to five grains may be given, at intervals of from two to six hours,
till a slight affection of the mouth is  manifested, which should be kept up
by smaller doses if  necessary ; but all violent salivation  is an  evil.   The
calomel should be combined with opium or hyoscyamus,  to prevent it from
purging too freely,   (c) Antimony is another direct antiphlogistic;  it may
be administered in  doses of ^-^ grain, with  each dose of calomel and
opium;  in larger doses, such as gr. ii., it is a most potent remedy, espe-
cially in pneumonia; it does not cause vomiting after the  first few doses,
but exerts its sedative influence without producing any evacuation,  (d)
Colchicum is a remedy most useful in gouty and rheumatic affections.  It
seems to have the power of freeing the system from excess of lithic acid.
(e) Nitre and the other salines, as in F. 30, may also be given with great
advantage ; they abate heat and thirst, purify the blood, and increase the
secretion of urine.
   III.  Sedatives not evacuant.—These remedies reduce  fever and in-
flammation, by acting on the nervous system without increasing the  secre-
tions ;  they are hyoscyamus, conium, and digitalis, the two first  of  which
in particular are of eminent service, when combined with calomel and an-
timony,  (F. 31,) to  prevent  reaction, and soothe pain in  inflammatory
cases attended with great nervous irritability.
   IV.  Narcotics.— Opium primarily  decreases the secretions, and in-
creases vascular excitement;  hence it must  not be given in  acute inflam-
mation  till after bleeding; but then  a large dose (such  as gr.  ii.) may be
given in combination with five of calomel, to  allay pain and  prevent re-
action.  But it is the sine qua non, and may be given without reserve in in-
flammations occurring in very debilitated habits, such as  peritoneal inflam-
mations from perforation of the intestine after fever; or acute inflammation
occurring after profuse haemorrhage.
   The warm bath acts in every way analogously to  opium, and requires
the same  precautions; viz. as it stimulates before  it soothes,  it  must be
preceded by evacuations, if the habit be plethoric.   The proper  tempera-
ture is 97° Fahrenheit, and it should be continued  long  enough to induce
a complete relaxation.
   V. Diet.—The  diet in acute inflammation should, as  a general rule, be
of the least stimulating nature.  But although  water-gruel and tea  might
for many days suffice for the robust and plethoric, the starving system
must not be indiscriminately applied  to children, or the old or debilitated ;
on the contrary, their strength must be supported by mild fluid nutriment,
arrowroot, beef-tea, &c, and even by wine if necessary.
   VI. Regimen.—There  must be a total  avoidance of everything thai
would irritate mind or body.   Perfect rest in the recumbent  posture and
          * Vidctfrt. Calomel by the Author, in the Cycl.  Pract.  Surgery. 
58
ACUTE  INFLAMMATION.
in a position as easy as it can be made,—cool air,—free ventilation,—the
exclusion of light and sound,—with  mental consolation, to allay doubts
and fears, and inspire resignation and cheerfulness, are most  potent  aids
to medical treatment, which without them would often be utterly fruitless.*
   Local Treatment.—In the local  treatment  of inflammation, the first
 hing to be done  is to remove all exciting causes if possible, and to place
the part at perfect rest, and in an elevated posture, so  as to favour the re-
turn of blood from it;—and then the  indications  are, to diminish  the
morbid heat and  afflux of blood, and to allay irritation and pain.
   1. The local means of abstracting blood are leeches,  cupping, and scari-
fications.   In  order to apply leeches, the parts should first be washed, and
if they will not stick, a little milk or blood  should  be smeared on  it, or
some small punctures should be made with  the point of a lancet; and the
leeches should be well   dried in a cloth.    The  best plan of stopping
haemorrhage from leech-bites is to dip small pellets of lint in the tinct. ferri
sesquichloridi, and press them on the holes  for  a few minutes, or to insert
a finely pointed pencil of lunar caustic  into them.   Other plans are, to
touch them with a red hot knitting needle, or to stitch them up with a very
fine needle and silk, or  to apply a small piece  of  matico leaf.  But in
order to prevent the very serious consequences that  sometimes happen
from this source to children and delicate persons, directions should always
be given that the  bleeding from leech-bites  should be stopped before  the
patient is left for the night.   Moreover it will be prudent  to apply them
over some bone, so that the  pressure may be applied effectually.  Again,
leeches, if they stick too long, should be removed by touching them with
salt, and should not be pulled off forcibly;  nor should they be  applied to
the eyelids or  prepuce, otherwise  they will probably be followed by cede-
matous swelling,  or even erysipelas.   [The bite of the American leech is
less severe than that of the Spanish and Swedish leeches,  and protracted
bleeding is less  likely to follow  it.   As a general rule, therefore,  the
American leech is used on children, and on those surfaces  from which the
blood flows freely and abundantly.   Six American  leeches are supposed
to abstract an  ounce of blood, while  the same quantity will be drawn by
two, or at most by three, of the others.—Ed.]   Cupping,  when it can be
adopted, is a more active measure,  and relieves pain sooner than leeches.
Scarifications or incisions are of use when inflamed parts are covered with
a dense unyielding fascia, as in whitlow ; or when there is great tension,
as in phlegmonous  erysipelas ; or when the inflamed part is infiltrated with
an irritating fluid, as in extravasation of urine, or with unhealthy matter,
as in carbuncle.
   2. Cold applications are of use to diminish heat, and cause contraction
of the capillaries; but they should be applied continuously, otherwise the
pain will be aggravated when  the heat  returns.   The  best lotion is one
containing lead and spirit, as F. 55; it should be applied  by means of a
single piece of thin linen frequently changed;  and care should be taken
that the vapour may pass off freely, otherwise the cold lotion will soon be
•.'onverted into a hot fomentation.   In some severe cases,  ice or frigorific
mixtures (F. 56)  may be applied in bladders.  The following very effec-
•ual means of  applying a continuous degree of cold is recommended by
  * A most instructive commentary on the value of antiphlogistic remedies of various
Kinas, is to be found in Dr. Latham's second series  of Lectures  on subjects connected
with clinical medicine. 
CHRONIC INFLAMMATION.                      59
Dr. Macartney.   The inflamed limb is to be placed in a trough  or piece
of oilcloth, with a piece of lint on the inflamed part.  A large vessel full
of cold water being then placed on a table by the bedside, one  end of a
broad  strip  of cloth should  be dipped in the water, and the other end
(which should be cut to a point) laid on  the lint;  and so the water will
be carried in a constant gentle stream down the cloth to the inflamed part.
   3. Warmth.  Very often cold adds to  irritation, and  perhaps in most
cases tepid applications (85° Fah.) are preferable; for they do not  stimu-
late like heat, nor occasion painful reaction like cold, and are more directly
sedative than either.  Warm fomentations (92°—98° Fah.) are useful by
relaxing the skin, soothing pain, and promoting perspiration, and are es-
pecially indicated  in inflammations of dense  tendinous parts.   But  in
every case the patient's feelings should be consulted, and the application
be warm or cold according to his choice.  Dr. Macartney very justly in-
sists on the necessity of producing an agreeable state  of feeling  in  in-
flamed parts, as a means of relieving that sense of irritation in the organic
nerves which he considers as the point de depart in inflammation.  He has
contrived an apparatus for conveying steam to  any part of the body, which
affords an excellent means of applying heat and moisture.  It consists of
a tube of wyoollen cloth, three feet long, twelve inches wide, and fitted
with hoops of  whalebone to keep it open; one end of it is applied to the
part which it is desired to foment,  the other is tied round the neck of a
tin boiler in which the steam is generated.
   4.  Stimulants, and astringent solutions, are of great  service in inflam-
mation of mucous membranes, by decomposing and washing away their
irritating secretions, and inducing contraction of the  capillaries.
   5.  Counter-irntants.  Blisters are the best  form of counter-irritants  in
recent inflammation ; but they should never be applied too  near the seat
of an acute disease, and  never till its  activity has been subdued by pre-
vious antiphlogistic measures.
                         CHAPTER  III.

                    OF CHRONIC INFLAMMATION.

   Definition.—Inflammation is said to be chronic when it is slow in its
 progress, and tends  to last long, or even  indefinitely.   Its  consequences
 may be adhesion, thickening, induration, ulceration, or suppuration.
   Causes.—Its causes may be local  or constitutional.   Thus  it may in
 the healthiest subjects be  caused by any slight  and continued irritant;—
 or it may be the  sequel of acute  inflammation, the vessels being left di-
lated,  weak, and irritable.  But more frequently it is the  local manifesta-
 tion of some constitutional  disorder, such as general debility, with a ten-
 dency to local congestion,—or over-stimulation and plethora,—or disorder
 of  some important organ, as of the stomach or liver.
   Treatment.—The indications are, to remove all constitutional disorder,
 to allay local irritation, and restore the tone of the distended vessels. 
00                   CHRONIC INFLAMMATION
  Constitutional Treatment.—On this  part of the subject, our space
forbids us to do more than make a few remarks on the most obvious forms
of constitutional derangement, which  accompany chronic inflammation,
and on the remedies that are  known by experience  to be most  useful as
alteratives.
  If the  patient is bloated and plethoric, with red  lips  and  conjunctiva,
and a full hard pulse, and indulges freely in stimulating  food and drink,
and has unimpaired digestive organs, so that blood  is constantly formed
in too great abundance, the diet must be lowered and restricted  chiefly to
vegetable substances ; free exercise should  be taken in the air ; the bowels
should be actively purged with calomel  and black  draught; and then  a
course of alterative  medicine  should be commenced  in  order to  increase
the secretions, and relieve the system of its superabundant material. Mer-
cury, given in small doses at  bed-time, with saline aperients  in the morn-
ing,  deserves to be  mentioned  first: Plummer's pill, in doses of  gr. v.
every night, is an excellent form ; but in severe and obstinate cases it may
be necessary to administer larger doses of the mercury so as  to  bring the
system fully under its influence ; taking care however to desist at the least
appearance of ptyalism, and maintain a gentle and continued, but not vio-
lent  action.  Next  to mercury, tartar  emetic, given  in very small  doses
three or four times daily, F. 36, is most deserving of notice; it is highly
advantageous to combine it with the mercury, as in F. 37.
  But if the chronic inflammation occur in  an enfeebled and irritable con-
stitution, (as when it succeeds an acute attack that has been too actively
treated by bleeding  and mercury,) a nutritious and  liberal diet must be
adopted, wine and tonics (F. 4, 6, 7, 8, 14,) should be administered in
order to  improve the digestion and vigour of the circulation ; irritation and
pain must be allayed by sedatives and opiates ;  and  the  secretions of the
bowels be maintained by the  gentlest laxatives.
  If the  tongue is furred and red at its tip and edges, and there are heart-
burn, flatulence, pain at the  chest after meals,  and other signs of a weak
and  irritated stomach, the  diet should  consist of the plainest  and most
easily digestible articles; and small doses  of alkalis (F.  91, 92) may be
given after meals, whilst some tonic is given before them; and the bowels
may be kept open by the compound rhubarb pill.
   If the complexion and eye are sallow, and the stools clay-coloured,  a
few doses of blue pill, with morning aperients, are indicated.  The  nitro-
muriatic acid is also likely to be of service, F. 14.
   When steel or bark is administered, it  is always necessary to have  a
proper action of the liver  and bowels, otherwise headache and feverish-
ness will ensue.
  In all  cases the condition of the urine should be inspected, to ascertain
whether  albumen, or blood discs,—indications of congestion or degenera-
tion  of the kidneys, — are present.  In such  cases, and in all others in
which the skin is dry and harsh, it should be stimulated by exercise, by
warm clothing, especially flannel, by the flesh brush or horse-hair gloves,
and by an occasional ten minutes' immersion in the hot bath; 92°—100°*
Fah.
   In females  the uterine system must  be  regulated by the exhibition of
steel, aloes, galbanum, or other emmenagogues, if necessary.
   Of the alteratives that are most useful in dispelling chronic inflammation
we have already mentioned mercury  and antimony; next  to  these in 
EFFUSION  OF  SERUM.
61
importance is the iodide of potassium, F. 44, 51, 52, in combination with •
Ionics, sedatives, alkalis, iodine or steel, as circumstances may direct.  Its
powers of unloading congestion,  allaying irritability, and  restoring secre-
tion, no one can doubt.  Alkalis, especially the liq. potassse, are of great
service in full-blooded people, with scanty red urine: the best rule which
we can give is, that they will most likely be useful  if the face is  flushed
after meals.  On the value of sarsaparilla wTe shall speak when treating of
scrofula.   Serpentaria and senega are of great  service in chronic  inflam-
mation of mucous  membranes.   Small  doses  of corrosive sublimate in
tincture of bark, F. 76, and  the  liquor arsenicalis, F. 94, are also useful
in certain cases ; but their employment is so purely empirical that we can-
not give any definite rules on the subject.
   Local  Treatment. — This has  for  its objects, to remove exciting
causes, to unload the distended vessels and make them contract to  their
natural calibre, and to exercise the  part in its proper functions, so that it
may gradually resume the actions and  sensations of health.
   Local  bleeding must be employed at  intervals to  unload the vessels,
whilst they must be excited  to contract  by various stimulants and astrin-
gents ; such as the sulphates  of zinc, copper, and alumina, nitrate of sil-
ver, salts of mercury, &c.  The  application of cold by pumping is often
highly serviceable.   These or any other measures will be known to do
good if they make  the part feel stronger and more comfortable, although
their first application may have been painful; but if they render it hotter
and more vascular, it is  a sign  that they stimulate too highly, and  may
thus endanger the production of acute  inflammation.
   Counter-irritants are  more useful in  chronic  inflammation than in the
acute, especially those which  establish a permanent suppurative  discharge.
   Pressure, if gentle, equal,  and continuous, is of material use in many
chronic inflammations, and even  in acute inflammation of the breast and
testicle, when its first violence has been diminished by bleeding.
                         CHAPTER  IV.

                       OF EFFUSION OF SERUM.

   General Description.—Effusion of serum, as a local disease, is gene-
rally produced either by obstruction to the return of venous blood, or by
inflammation.  Of inflammation it is the earliest and most constant effect,
occurring equally into the interstitial cellular tissue,—into the parenchyma
of oro-ans,—from mucous and serous surfaces, and from the skin.  If it is
followed by any of the other effects of inflammation, it is  always more
widely extended than they are.  But it may be the chief or only effect of
inflammation, as in acute dropsy, which is an example of an inflammatory
state rapidly producing serous effusion into the  cellular tissue or serous
cavities.   The serum in these cases is always  of greater specific  gravity.
and contains more albumen, than in dropsy from debility.   In patients of
a lax, flabby habit of body, and in parts of loose and cellular structure,
inflammation  alwa}^  produces more of this effect than in those of a firme?
texture.
       6 
62
ADHESIVE INFLAMMATION
  After inflammation in any part, some degree of cedema is apt to remain
in consequence of the distension and weakened  tone  of the  capillaries ;
and if the habit be weak, great cedema  may arise from a very slight cause,
as a blister.   It must be treated by flannel or other bandages, gentle fric-
tion, cold affusion, and attention to the  general health.
  Great distension of the subcutaneous tissues  by serum  is very apt  to
cause sloughing of large patches of the  skin, by mechanically interrupting
its supply of blood.  This  should be prevented  by making numerous
punctures with a grooved needle, and allowing the  serum to ooze out.
  CEdematous Inflammation.—Under this term Hunter describes a pe-
culiar form of inflammation  terminating rapidly in  serous effusion, which
occurs in those who are affected  with dropsy, or  disposed to it.  It mostly
attacks the lower extremities; the swelling  is bright red, much  diffused,
very sore, but not throbbing.  It is very apt to terminate in sloughing  or
suppuration, but not adhesion, and is the frequent cause of  ulcers on the
legs of the dropsical.
  Treatment.—The bowels must be well cleared ; but other constitutional
measures (whether antiphlogistic or tonic) must depend on the state of the
system.   The best local application is  a tepid spirituous lotion  (F. 57);
leeches should be avoided, as they may cause ulceration and sloughing.
The needle should be used if there is much distension from serum.*
                         CHAPTER  V.

  OF THE ADHESIVE INFLAMMATION, AND THE REPARATION OF
                             TISSUES.

  Adhesion, or the Adhesive Inflammation, is a  process in which the
fibrine of the  liquor sanguinis is effused, organized, and  converted into
some  of the normal tissues of the body.   It  is  the means  by which
wrounded and fractured parts are united ;—by which loss of substance  is
restored, whether produced by  injury or  disease;—by which cysts are
formed for abscesses, so as to prevent the diffusion of pus or other morbid
fluids through the cellular tissue ;—by which wTounded intestines are glued
together so as to prevent the extravasation of their contents;  and which
in disease produces thickening, consolidation and hypertrophy of organs,
and obliteration of their cavities.
  When first effused, the fibrine appears to the naked eye a soft and ge-
latinous mass of a yellowish white or pinkish colour.  At first it is very
soft, or  almost diffluent;  but  it gradually increases in  consistence, and
acquires a reticular texture, containing serum in its meshes ;  and  when
squeezed between the fingers, it  is compared by Dr. Carswell, to a mass
of cobwebs moistened with water.  Under the microscope it appears com-
posed of a number of very thin transparent fibrils, running in  a straight
and parallel  direction, and having  numerous very small  molecules  inter-
  • Mayo. H. Outlines of Pathology, p. 428; Copland, Diet, of Pract. Med. Art. Dropsy
Andrai, Anatomie Pathologique, vol. i. p. 320; Hunter on the Blood, Palmer's Ed vol'
iii. pp. 314, 3^1. 
AND  REPARATION  OF TISSUES.
63
spersed  amongst  them.   These molecules, through          Fig
their own vital forces, collect themselves into groups
of nuclei, which (it  is  supposed) become converted
into  cells,*  from  which  the future  tissue  is  devel-
oped.!   The fibrine soon becomes  permeated  with
Dlood-vessels, which convey the  materials for the fu-
ture  nutrition and growth  of the  tissue  into  which
it  is  converted;  and  these  are,  most probably,
formed as in  the embryo, by the development of cells
which open into each other in continuous lines.  The
time within  which recently effused  fibrine  may ac-
quire vascularity, varies  according to  the vigour  of
the   constitution;   Sir E.  Home  relates  a case  in
which  some  lymph, effused  on  the surface of the peritonaeum,  became
vascular within  twenty-nine  hours;  but  in  feeble habits  it  may require
some days.
   Fibrine appears capable of being converted into almost any of the tis-
sues of the body;  the conversion in any particular case being determined
by the surface from which the fibrine was effused, or by the function which

  * Fig. 1, copied  from  Gulliver's Trans, of  Gerber, may be taken as an explanatory
diagram.
  •(-Theory or cellular development. — According  to  the  researches of modern
physiologists, the manner in which the tissues are originally formed in the embryo, and
in which they are restored after injury; as well as the manner in which accidental and
abnormal tissues (such as scirrhus) are formed, is identical.  The first step towards de-
velopment in  the  structureless jelly of the embryo, and also  in  the  recently effused
fibrine, is the  formation of minute granules  or molecules, called nuclei or cytoblasts
(cell germs) : the fibrine  or other structureless medium in which they are  imbedded
being called cytoblastema.  The next step is  the conversion of the granules  into cells,
which appears to be  effected in several ways.  Sometimes a number of granules collect
and become fused  together into  spherical globules, in which a central  cavity is after-
wards produced, as if by an attraction of their solid matter to their circumference.   In
this manner the globules of pus appear to be formed.   Sometimes a group  of two  or
three granules, imbibing fluid from the cytoblastema, throw out a delicate vesicle, which
projects from them as a watch-glass does from a watch, and increasing in size becomes
a cell, with the primary group of granules imbedded in  its  parietes, and called its nu-
cleus.  The nucleus again becomes hollow itself, and one of the largest of the granules
composing it becomes a nucleolus.  Nucleated cells thus formed are divisible into five
varieties.   1st.  Those which float in a liquid,  as the globules of the blood and pus. 2dly.
Those which cohere and form a tissue, as the cuticle.  3dly. Tho»e which remain im-
bedded in a substance formed out of the cytoblastema, as the corpuscles  of bone and
cartilage.  4thly. Those  which become elongated  into  fibres.  5thly. Those which are
converted into tubes and  cavities, as the blood-vessels and  nerve tubes.  It must  be
added that the structureless cytoblastema has  an important  share in the constitution  of
manv tissues, forming a basis in which the cells are imbedded ;  and the fibrillar observed
in recent fibrine are certainly not developed from cells, but from the cytoblastema. We
may thus  readily comprehend  how, in inflammation, the effused liquor sanguinis., ac-
cording to the particular variety of cellular development which occurs in it, may be con-
verted into pus, or  into some normal tissue, or into some  abnormal  tissue such as scir-
rhus, tumors, &.c.   The cells which are capable of conversion into tissue are sometimes
distinguished by the term plastic cells, and are  generally found in the lymph effused from
serous membranes; but it is commonly believed  that cells of another kind, called exu
dation cells, or  compound  granule capsules, larger than plastic cells, are  formed  in the
lymph which is effused into the substance of  organs, as the brain, lungs, cellular tissue,
&,c.;  and that these exudation cells undergo a process of disintegration, constituting what
Is sometimes called purulent softening, as observed in the lungs after hepatization.—See
the next chapter.  Vide Paget's Report on the Use of the Microscope.   Lond. 1842, p
6 . Dr. Goodfellow's translation of Griiby on the Morphology of Diseased Fluids, in the
Microscopical Journal for 1S42; and  Gulliver's translation of Gerber's General Ana
tomy; Hughes Bennett, op. cit. 
C4
ADHESIVE INFLAMMATION
'.t is made to perform.   Thus, if a bone be broken or inflamed, the effused
fibrine will be converted into bone.   If a  bone die, or is abstracted, still
the lymph effused from the surrounding parts—from bone, muscle, fascia,
cellular tissue, indiscriminately will become bone.   If (as in the case of
unreduced dislocation) the lymph is subject to frequent motion, part ot it
will be converted into bone, part into ligament, so as to form a new joint.
But there are some tissues which  cannot be replaced; and then the lymph
which they secrete is transformed into some  other tissue, which  occupies
a similar place in other animals.   Thus, muscle cannot be formed anew;
but if divided, the uniting lymph will become ligament, or  dense  fascia-
like cellular tissue, which occupies the place of many muscles in animals
of inferior development.
  It appears that almost all the simple tissues are  capable, if divided, of
being thus united by a tissue similar to themselves, and of being to  a cer-
tain extent restored, if partially abstracted.  But complex organs, such as
muscle or gland, do not enjoy this faculty.
  All newly formed tissues possess certain common properties.  They are
less vascular, and less endowed with vitality than  the  original;—they are
more  prone  to run into disease during states of constitutional cachexy ;*
and they are liable to shrink  and become  atrophied, (which  is especially
the case with new cellular tissue,) or even  (as in the case of pleuritic and
peritonaeal adhesions) to disappear altogether.f
  As we observed in the  introductory chapter on inflammation, serous
membranes  are very liable to adhesive inflammation, mucous membranes
quite  the reverse.  But if two abraded and inflamed mucous surfaces are
placed in apposition  and left undisturbed, they may adhere;—as some-
times happens in the vaginas of female children ;—in the  os uteri and Fal-
lopian tubes of prostitutes, and  in the  ureters and biliary  ducts  when
abraded by  the passage of calculi.
  When adhesion occurs for the  normal purpose of reparation after injury,
and proceeds favourably, it is attended with a very slight amount  of in-
flammatory action, with no pain, and no heat; in fact, if there be  more
than a certain degree of excitement, the lymph effused will be broken up
by fresh  exudations, pus will be  formed,  and the process  of reparation
must be commenced anew by means of granulations, as will  be described
in the section on acute abscess.   Hence Dr. Macartney and others have
denied that  adhesion is an inflammatory process at all. The process how-
ever is essentially the same,—namely, increased  attraction of blood, and
exudation of lymph which  becomes organized;  whether  accompanied
with sensible pain and heat or not.
  Is blood organizable ?—It has been a matter  of dispute, whether coagu-
lated  blood, like pure  fibrine, is capable of becoming organised.   We
think  there can be little doubt, especially after the  researches of Mr. Pres-
cott Hewett on extravasations into the cavity of the arachnoid, but that it
is capable of conversion into an  organized  fibro-cellular substance pre-
cisely like the false membrane  formed under the  adhesive  inflammation.
  *  Thus in the scurvy, old cicatrices have been known to break out afresh into ulcers
and  old fractures to become disunited.
  +  In examining the body of a madman who had stabbed  himself in the abdomen
filteen different times during his life, the parts near the most recent wounds were found
united by considerable false  membranes;—at the situation of some that were older
there were only a few thin cellular adhesions ; whilst, at the oldest, there was no trace
of adhesion of false membrane whatever.  Andral, Anat. Path. vol. i. p. lj>G. 
AND REPARATION  OF TISSUES.
65
This is of common occurrence after the  blood has  been extravasated in
the brain ;  moreover the coagula in obstructed blood-vessels, and in ob-
literated aneurisms also become covered  with a thin  false membrane, evi-
dently formed out of the coagulum itself.  Then it was long ago proved
by Hunter, and has since been confirmed by Home, Macartney, Kiernan,
and Dalrymple, that coagula are capable of becoming vascular.  But yet,
for all practical purposes, it suffices to know  that lymph, and not blood, is
the material  employed by nature,  under ordinary circumstances, for the
production of new tissues, and reparation of injuries.*
   Treatment.—If it be the object to promote adhesion, the general prin-
ciples of treatment are, to  maintain the most perfect rest and apposition,
and to use such local and constitutional measures  as  will prevent heat,
pain, and throbbing; in other words, to prevent the  inflammation from
proceeding to a grade  of  greater intensity than the  adhesive.   In a few
cases (as  after the operation  for harelip in a languid scrofulous habit) it
may be necessary to excite the energies  of the system  by wine, to render
them sufficient for the production and organization of lymph.
   If  it be wished to counteract the adhesive  inflammation; then use must
be made of the  antiphlogistic treatment generally, and  of calomel  in
particular.
   If  it be wished to remove adhesions, or thickening, the results of pre-
vious acute or existing chronic inflammation, the  general rules must be
attended to which were laid down for the treatment of  chronic  inflamma-
tion.   Mercury is the most efficient internal remedy, and for an example
of its use to remove  adhesion, reference may be  made to  chronic iritis.
The local means  that may  be used to remove the thickening left by a quite
subdued inflammation of any external part,  are friction, stimulating lini-
ments, F.  71,  ointments containing iodine, F. 45,  or mercury; gentle
exercise ; passive motion, shampooing, pressure by bandages or otherwise;
cold  affusion; electricity  and galvanism;   discutient  lotions,  especially
those of zinc,  F. 58,  or  muriate  of ammonia, F. 59; blisters, or other
counter-irritants—always taking care not to reproduce active inflammation
by too violent stimulation.
                          CHAPTER  VI.

                       OF  HEMORRHAGE.

  Haemorrhage, like serous effusion, may be  a consequence, lstly, of
inflammation or excitement;  2dly, of obstruction to the  return of venous
blood;  and 3dly, of structural weakness of the blood-vessels and thin
ness of  the blood, as in scurvy and putrid fevers.  The first form is called
active, the last twTo passive.

  * Vide Palmer's Ed. of Hunter,  vol. iii.; Catalogue of the Hunterian Museum, vol. i..
Carswell, op. cit.; Macartney, op. cit. p. 51; Home, Phil. Trans. 1818; Wardrop on
Aneurism, in  the Cyclop. Pract.  Surgery; Dalrymple, Med. Chir. Trans, vol. ix.; P
Hewett, ibid, vol.  x., see also Lancet for 1845, vol. i. p. 219.
       6*                         E 
66
SUPPURATION AND ABSCESS.
   (1.) Active hemorrhage consists in an escape of arterial blood lrom the
capillaries, which are most probably ruptured by the distension caused by
acute inflammation or violent excitement;  and more or less of it doubtless
occurs in every case of violent inflammation.  It occurs during the form-
ation of abscess in  the cellular tissue and  in  the  liver.  But the  most
common seat  of inflammatory haemorrhage  is mucous  membrane, espe-
cially that of the lungs.  The principal instances of it which fall  under
the surgeon's care, are epistaxis or haemorrhage from the  nose;  haemor-
rhois or haemorrhage  from the rectum;  haemorrhage  from  the urethra
during  gonorrhoea;  and  from granulating  wounds.  It has  also  been
known to occur from the conjunctiva;  and more rarely from the pleura,
pericardium, and peritonaeum.
   Diagnosis.—Inflammatory or active haemorrhage  is distinguished  from
that which is the result of congestion or debility, by the presence of local
pain, heat, and throbbing, and of a febrile state of the pulse  and system
generally.
   Treatment.—This form of haemorrhage  is to be treated by bleeding if
it can be borne ; and it may be observed,  that it is less debilitating to em-
ploy one full venesection, so that the cause may be at once removed, than
to let the blood dribble perpetually away from the part in small quantities.
Purgatives and  sedatives, especially lead, (F. 21, 128,) are also useful.
Cold, if it can be applied,  perfect rest, and  an  elevated position, are the
local measures.
   (2.) In passive hemorrhage the blood which escapes is venous.   The
principal instances  of it are haemorrhage  from  the  nose in  old subjects
with diseased liver;  melaena, or haemorrhage from the liver, and passive
menorrhagia and haemorrhois.  The chief remedies are, dilute sulphuric
acid, sulphate of alumina, acetate of lead, catechu, tannin, and other ve-
getable  astringents,  and ergot of rye.
                        CHAPTER  VII.

    SECT.  I.--OF  THE  THEORY  OF  SUPPURATION AND
                     PROPERTIES  OF  PUS.

  Properties of healthy Pus.—Pus is  a  yellowish white, opake fluid,
of the consistence of cream: free from smell, neither acid nor alkaline,
said to have a sweetish, mawkish taste, insoluble in water, although freely
miscible with it, and very slow to putrify.  Like many other animal fluids,
it consists of a thin serum, holding a vast number of globules in suspen-
sion, from which it derives its colour and opacity.
  Chemical Analysis.—The  most recent analyses, especially those of
Bonnet of Lyons, Gueterbock, and Davy,* show that pus contains water
(86T  per cent.), fat soluble in alcohol (T6), fat and osmazome soluble in
cold alcohol (4*3), and albumen and the  matter of the globules, soluble

  » Vide Mayo, Med. Gaz., Oct. 19th, 1839; Vogel,  tlber Eiter and Eiterung,  p. 35;
Davy, op. cit., vol. ii. p. 468; Bonnet,  Med. Gaz. vol. xxi.; Gueterbock de Pure et Gran-
ulations, Berol, 1837. 
VARIETIES OF  PUS.
67
m neither hot nor cold alcohol (7*4).  The substance of which the globules
are  composed has received the name of pyine;  but it seems to differ very
little from fibrine.  Pus also contains about 0-8 per cent, of salts;  chiefly
common salt,  and muriate of ammonia.
  Pus Globules.—When these are examined under the microscope, they
are  found to be opake spherical globules apparently granulated  like mul-
berries, but in reality smooth, as may be known by examining their circum-
ference.   They measure from l-5000fh to l-2000th of  an inch in  diame-
ter ; some even are much larger;  especially if they proceed from a  surface
that is actively inflamed.  They may be shown  to consist of an envelope,
or cell-membrane, containing nuclei, oil  globules, and  minute granules.
If acetic acid be added, it  brings clearly into view two,  three, or four
nuclei; and renders the other parts transparent, or so invisible that they
seem to have dissolved.   They are not really dissolved, however, because
the  nuclei retain  their adhesion  to each other;
and because  if liq. potassse  be added, the  ori-           Fig. 2*
ginal appearance is restored.  If kept till  pu-
trefaction is commencing, or if treated with a
small quantity of liq. potassae, the  oil globules
become extremely distinct;  but too much either
of  the  alkali,  or of  decomposition,  dissolves
the   outer  envelope.    Besides  the  globules,
other smaller  albuminous molecules  are   also
found in pus  in great abundance, of the same
nature apparently as  the central  molecules of
the  globules.
  Many of the properties of pus  depend on these globules.  Its specific
gravity, for instance,  (which  varies from  1-021 to  1*040,) and its density,
depend on the number of them.  Moreover,  pus is coagulated by a strong
solution of hydrochlorate of  ammonia.   But this  coagulation is  not pro-
duced by the solidification of matters previously fluid,  like the coagulation
of  blood or milk; neither is it caused by the salt merely abstracting the
water of the pus, as Pearson supposed; but it depends on a change in
the globules,  which become more  transparent, elongated, and adherent.
Freezing also renders pus viscid, and has a  similar effect on the globules.
A heat of 165°, however, coagulates it by acting upon the albumen of the
serous portion.
  Varieties of Pus.  — 1. Healthy Pus (called also creamy or laudable) is
that which has already been  described, and  is the product of healthy in-
flammation in healthy parts.   It is album, laeve, liquidum, et laudabile.
  2.  Serous Pus is thin, almost transparent, and yellowish or reddish.  It
differs from the last  in containing very  little fatty matter or fibrinous glo-
bules, and in  being the product of a law degree of inflammation in weak
constitutions.
  3.  Clotty or Curdy Pus resembles the serous,  but has numerous white
clots  or flocculi of coagulated fibrine floating in it. Under the microscope
it displays the globules of healthy pus, and numerous  other particles of

  *  The uppermost group gives a pretty accurate idea of the appearance of pus gloo
ules magnified  400 diameters.  The middle figures represent globules treated with
acetic acid ;—the lowest  represent the  appearances when  pus is partially decomposed
or treated with liq. potass:e.   These figures were drawn from  nature by Dr. Westraa
iott, under the superintendence of Dr. Johnson of King's College. 
68
VARIETIES  OF PIS.
irregular shape.   It contains very little  fatty matter, and is commonly
found in scrofulous abscesses.
  4. Mucous Pus or Muco-purulcnt matter. — The mucus which proceeds
from healthy mucous membranes is seen under the microscope to be com-
posed of abraded epithelium cells—flat, irregularly five-sided, and  with a
centra] nucleus; — with numerous granular  masses, and  a few spherical
               bodies very much like pus  corpuscles, except  that they
     Fig. 3.     contain  much  fewer oil  globules;  and  these  are sus-
               pended  in a viscid  ductile fluid.  Under inflammation
               there is  an increased  exudation  of  albuminous liquid ;
               the epithelium cells are perhaps shed more quickly  before
               they have been flattened out; the quantity of globules is
          g^N  greatly increased, and they acquire  the  exact  character
          *^) of pus globules.  The once much-agitated question  of
               the diagnosis between pus and mucus is one that belongs
               to a bygone pathology.
  [With regard to the diagnosis of pus, Vogel remarks, " The  examina-
tion of the fluid by the microscope is the best, and, indeed, the  only cer-
tain means of guarding against deception.   If this instrument reveals the
presence of normal pus corpuscles, and if, on the addition of acetic acid,
the  characteristic  nuclei  appear, then we may be sure that we have been
examining pus, and normal pus."  Yet,  as it  is very often a matter of
much interest and importance to determine wrhether a certain fluid pre-
sented, either during life or after death, is mucus or  pus,  or a mixture of
both, and  as, in the  absence of a microscope, the examiner is apt to trust
to an inspection by the  unassisted eye, the following remarks of Simon
(vol. ii.  p. 100) may be very properly introduced here :—
  " 1.  Pure mucus  floats on water for a considerable time, if air-bubbles
are entangled in it;  pure pus sinks rapidly to the bottom;  purulent mucus
swims, if  it  contain air-bubbles, but allows the pus to deposit itself;  the
deposit frequently takes place in the form of pendent fibres.  If pure mucus
contains no air-bubbles, it sinks.
  " 2.  Pure  mucus, lying in water, appears  as a homogeneous,  streaked,
vesicular,  viscid, and tenacious mass, of a white or whitish-yellow colour,
and yielding readily to pressure.   Pure pus forms a stratum at the bottom
of water, of a white  or greenish-yellow colour, and sometimes tinged with
blood ; by agitation it is diffused through the water, and in a short time
again sinks  to the bottom.  Purulent  mucus forms  streaked,  vesicular,
often discoloured masses, or mucous sediments; they are easily diffused
through water, and have a granular, non-homogeneous appearance.
  " 3.  Pure mucus imparts no albumen or mucin to water; mucus  which
is mixed with much saliva does, however, render water a little albuminous;
pure pus communicates a large am»unt of albumen to water, and purulent
mucus imparts a quantity of albumen proportionate to the amount of pus."
  It must be borne in mind that, if pus has really been formed,  it will be
acted  upon, and  its physical appearances modified, by the various che-
mical reagents  with which it meets  in the  body, as well as out  of it.
Thus, "when, in  disease of the bladder, alkaline urine containing a large
quantity of carbonate  of ammonia is  mixed with pus, the pus-corpuscles
undergo the same change in the bladder, from the alkaline reaction  of the
fluid contained in it, as they do  in the application of the so-called pus-
tests ; they become  converted into a viscid mass, which physicians often
 
SUPPURATION.
69
mistake for mucus."   Vogel, Am. ed.  p. 144. — Ed.]  Muco-purulent
matter is  pus, only mixed, perhaps, with epithelium, or modified chemi-
cally by various local conditions;—the contact of urine, for instance.
   A very viscid pus, like mucus, is occasionally found in  chronic  ab-
scesses, containing a large quantity of hydrochlorate of ammonia,—a  salt
which abounds in unhealthy pus.*
   5.  Concrete or Lardaceous Pus may  either consist of common pus,
thickened by  the absorption of its watery parts, in consequence of having
remained for  a long time in a chronic abscess,  or bony cavityf—as the
antrum and nasal  sinuses: — or it may originally be secreted in a thick
condition;  and in this  latter case differs little or nothing from  the  meli-
cerous and  atheromatous matter found in wens or other encysted tumours.
   6.  Putrid Pus has a foetid smell, and  alkaline  reaction, in consequence
of the presence of  hydrosulphate of ammonia: which is formed by the de-
composition of albumen, when pus is exposed  long enough to air and heat.
   7.  Specific  Pus,  capable of producing the venereal disease or the small-
pox,  may not differ in its  sensible qualities  from the healthiest, but must
include some matter in a peculiar state of decomposition, which state is
capable of  being imparted to other living matter.
   8.  The pus from spreading ulcers and cancers is thin and serous, con-
taining blood-globules,  and shreds and debris of the ulcerating tissue.  It
is said to  be ichorous, when thin and  acrid;  sanious,  when  thin  and
bloody ;  and grumous,  when mingled with dark  half-curdled blood.
   Production of Pus. — We may suppose  that  pus (according to the
views detailed in pp. 53, 63) is liquor sanguinis, whose fibrine has assumed
 a peculiar low form of  organization.^
   Ramollissement. — This is  a peculiar effect  of inflammation which is
 observed in  greatest perfection in the brain  and spinal cord, pprtions of
 which become soft, pulpy,  and at last  diffluent, like
 thick cream.   It has been shown conclusively by Dr.         lg' '
 Hughes  Bennett,  of Edinburgh, that this process is a
 mere variation from the ordinary course of suppuration.
 The  affected  tissue is first infiltrated with fibrine, which
 " coagulates  in the  form of granules, which may be
 seen coating the vessels,  and filling  up all the  space
 between  the ultimate tissue of the organ."   Thus the
 organ affected is rendered perfectly dense or hepatized.
 The  orranules next form themselves into nucleated cells
 (exudation  corpuscles), which after a time break up, and
 are disintegrated, together with  the tissue which they infiltrate; and on
 examining the softened mass with lthe microscope, it is seen to consist of
 a mass of granules,  either  diffused  or  amalgamated  in masses, or con-
 tained in  nucleated cells,  and mixed  with the debris of  the softened
 tissue. §
   * Pearson, Phil. Trans. 1 810.  Mucus gives out more ammonia, when treated by lime
 or potass,  than  pus does.
   ■f Mayo, Pathology, p. 159.
   t The second Edition of this Work contained a tolerably copious account of the pre-
 vious  theories of Home, Gendrin, &c, on this  subject; especially of Gendrin's theory
 that pus might be formed of softened  and disintegrated fibrine,  and that pus  globules
 are enlarged and decolorized  blood globules.
   § See Microscopal  Journal  for Jan. 1843, and Bennett  on Softening of the Brain, Ed
 Med. and Surg. Journ., Dec. 1S42.  Fig. 4 represents the granules mixed with broken
 nerve-tubes; from a  case of softening of the brain.
 
70
SUPPURATION.
   Suppuration in the Cellular Tissue.—The  successive steps in the form
 ation of pus in this tissue are as follow: First,  there is an  effusion of
 serum;—next, an effusion of fibrine, known by its faculty of coagulating
 spontaneously;  and  this fibrine may  be combined  with  more  or less
 blood ;—or pure blood may even be effused with it at  the spots where the
 inflammation is  most intense.   These effusions increase; the tissues  be-
 come distended and  broken down,  and at last pus  appears in the thin
 reddish mixture  of serum and lymph with which they were infiltrated.
 It is at first dispersed in  minute collections; but these soon communicate
 by the solution of the intervening  parts, and form a cavity termed an
 abscess.   Meanwhile (in healthy inflammation) the lymph, which  is effused
 into the  parts around the pus, becomes organised and converted into a
 cyst or sac,—which circumscribes the pus already formed, and may secrete
 fresh quantities of it, or absorb  some of it,  according to circumstances.
   Pus in the  blood.—There is a peculiar state of the system, sometimes
 called the  suppurative or purulent  diathesis,  in which  abscesses form in
 rapid succession in the liver, lungs, joints, or other parts of the body; and
this diathesis generally accompanies some disease, such  as erysipelas, or
puerperal fever, in which there is great vitiation of the blood, and also a
profuse formation of pus.  It is  most common as a consequence of phle-
 bitis, in which  disease the purulent or other diseased secretions from the
lining of the veins is mingled with the whole mass of circulating blood.
   One peculiarity of these local suppurations is the extreme rapidity with
which they often form; insomuch that authors have  denied that the pus
 can be elaborated, in  consequence of inflammation at the parts where they
are found; but  have  considered them to be  deposits of pus which  has
been absorbed into the  circulation  from some other part;  hence  they
have been  called commonly purulent depots, or consecutive or metastatic
 abscesses.
   But although it is very possible that pus, if  present in the blood, might
be  deposited  in  the  lungs or  liver, (because we know that quicksilver,
 when injected into the  blood, is quickly found  in those parts,) still it is
 very certain that consecutive  abscesses are not  universally caused  by a
 deposit of pus into an inflamed part.   For abscesses in the liver often fol-
 low injuries of the head; and  other consecutive abscesses  sometimes fol-
 low other injuries, which do not give rise to any suppuration, and from
 which, consequently, there is no  pus to be absorbed.
   Again, it appears certain that after abscess in the liver, large  quantities
 of pus find their way into the circulation through veins which open by
 large orifices into the cavity of the abscess; and this pus  is excreted by
 stool, urine, and vomit,  without  the formation of consecutive abscesses.
 So that, at all  events, healthy pus can pass through the system without oc-
 casioning any severe  derangement.*
   But if pus  be taken into the blood which  is vitiated or putrid, it will
 cause severe constitutional derangement and diarrhoea;  as will be  exem-
 plified in the remarks on  Chronic Abscess, f
  * Vide Copland, Diet.  Pract. Med.  Art. Abscess; Carswell, op. cit.; Ferguson on
 Puerperal Fever, Lond. 1839; Ancell,  case of purulent deposit into all the joints after
 small-pox; Med. Chir. Trans, vol. xxi.   The author has also borrowed from a lecture
 on Phlebitis delivered by Sir B. C. Brodie, at St. George's Hospital, in Nov. 1839.
  + Most probably pus cannot be absorbed, as such ; but only the elements of  it when
 its globules have become ruptured  or dissolved.  Vide Gruby on the Morphology of
 Pathological Fluids, translated by Dr. Goodfellow in the Microscopical Journal, vol. ii
 Gerbei. Anatomy translated by Gulliver. 
ACUTE  ABSCESS.
71
              SECTION II. — of acute  abscess.

  Definition.—An abscess may be defined to be a collection of pus in
the  substance of any part, or in any cavity.   There are two kinds;  1.
The acute or phlegmonous;  2. The chronic or cold; besides the diffused
abscess, or diffused  suppuration  in  the cellular tissue, of which we shall
speak in the next chapter.
  Symptoms.—Acute abscess (which, when occurring in the subcutaneous
cellular tissue, is called phlegmon) commences with all the ordinary signs
of acute inflammation;  namely, inflammatory fever;  severe throbbing
pain ; bright redness ;  and much swelling,—firm in the centre, and cede-
matous around.  The occurrence  of suppuration is indicated by severe
rigors, by an abatement of the fever, and a change in the pain,—which is
converted into a sense of weight and tension, with a pulsatory feel at each
beat of the arteries.   Then the tumour becomes softer, and loses its bright
arterial colour; and as the quantity of matter  increases, its centre begins
to point, that is, to project in a pyramidal form, and fluctuation can be felt
by alternate pressure with the fingers.
  Progress.—The pus having been formed, the next step is its  evacua-
tion, which is effected either by what Hunter called progressive absorption;
that is, the successive absorption of all the  parts intervening  between the
abscess and the surface ; or, just as probably,  by their successive  atrophy
and disintegration.   Be  this, however, as  it  may, the tumour  becomes
more and more prominent and  soft; the  surrounding inflammation and
tumefaction subside;  the centre becomes of a dusky red or bluish  tint,
the cutis is removed, the cuticle bursts, and the pus escapes.
  Although abscesses may burst into serous cavities, or mucous canals if
they happen to be near, still their general course is that which is least pre-
judicial ;—namely,  towards the skin.   The cause of this happy provision
has much engaged  the attention of pathologists.  The best explanation
that can be  offered, although not quite a satisfactory one,  is, that the pus,
as  it increases in quantity, advances towards the skin, because in that
direction it is opposed by the least pressure.
  Granulation.—The matter having been discharged, the  cavity of the
abscess contracts, the pellicle of lymph which  lines it is cast off, and its
surface becomes covered with numerous small, red, vascular eminences
called granulations.   These are formed by the effusion of lymph, part of
which takes on vital organization, and becomes part of the living surface ;
part degenerates into pus.   If the restorative actions  are  vigorous, the
granulations will be numerous, but small, and florid, from containing many
capillaries;—whilst in the  opposite  state  they will be large, pale, and
flabby.  And the pus from healthy granulations will  be laudable  and
creamy,—from the other, thin and flaky.
  Cicatrization.—When the cavity has become filled up by the growth
and union of granulations, the red inflamed skin around  its orifice is re-
moved by ulceration, so that the margin of the  sore becomes adherent and
fixed ; and then cicatiization begins.  A white pellicle  extends  from the
circumference, gradually covers the  whole surface, and becomes organised
into a new cutis and cuticle, called  a cicatrix.   The cicatrix is at first thin
and red, but soon becomes denser and paler than the original skin, and,
like all new textures, is less  vascular and less vital.  The colouring matter
between die cutis and the cuticle is later in appearing   But this  process 
72
ACUTE  ABSCESS.
is accompanied by two others, namely, the contraction of the surrounding
skin, so that the surface to be healed is very much diminished before cica-
trization commences, and  the  contraction of the cicatrix subsequently.
The preliminary contraction of  the skin appears  intended to diminish  the
labour of an  extensive reparation;—the  subsequent contraction  of  the
cicatrix is in conformity with a law mentioned in the Chapter on Adhesion,
and depends on the atrophy of the  newly-formed  subcutaneous cellular
tissue.  It is always greatest where the preceding granulations have been
pale, flabby, and exuberant, as in burns.
  But it is to be remarked, that the filling up of a vacancy in the tissues,
whether in consequence of accident, abscess, or ulceration, need not ne-
cessarily be attended with suppuration, nor with the  peculiar appearance
of granulations.  On the contrary, if all inflammation be subdued, and all
irritation excluded, the chasm may fill up  with red lymph, which speedily
cicatrizes.  This is constantly observed after trifling injuries ; they speedily
become covered with a scab formed  of dried  blood or lymph, under the
protection  of  which they soon  cicatrize;  and when  it can  be  effected,
larger wounds should be made  to heal in  the  same way.   This form of
reparation is called by Macartney, the modelling process; and he  contends
that neither this process, nor adhesion, ought to be  considered inflamma-
tory, but rather processes of growth or nutrition.
  Causes.—Acute abscess is mostly idiopathic, that is, depends on con-
stitutional causes, and is a frequent sequel of fevers;—it  may, however,
be caused by blows, ecchymoses, or by foreign bodies introduced into the
skin or flesh.
  Treatment.—In a case of idiopathic abscess the indication always is
to remove, if possible, the morbid state of constitution on which  it  de-
pends, and to  hasten the process of  suppuration by warm  poultices.  In
abscesses arising from local injury,  all exciting causes, such as foreign
bodies, should  be removed, and inflammation be  combated  at first by
leeches; but, as soon as suppuration  seems inevitable, poultices should be
applied.
  Poultices are admirable remedies;—they relax the  skin, promote per-
spiration, soothe pain, encourage the  formation  of  pus, and  expedite its
progress to the surface.   They should be large,—so as not  soon to become
cold or dry; they should be soft, that they  may not irritate; light,  that they
may not  fatigue,—and they should be  renewed very frequently.   They
may be made of bread and water, or of oatmeal, boiled till it is soft, or
linseed meal, F. 75, 77, or of camomile flowers  boiled till they are soft,
or of bran sewed up  in a linen  bag, which may be dipped into boiling
water as often  as it becomes cold.
  The warm-water dressing,—that is, a piece of soft lint or folded linen
dipped in warm water, and covered with oiled silk to prevent evaporation,
—is a good substitute for poultices in many cases,  especially for irritable
sores;  but when there is much pain it is not so soothing as the large soft
warm mass of a well-made poultice.
  Respecting the opening of abscesses, it may be laid down as a general
rule, that if they point and become pyramidal, without enlarging in cir-
cumference, they may be left to burst  of themselves ;  but that if they en-
large in breadth and  circumference, without tending to the  surface, they
should be opened.  In the following six cases, however, the surgeon's aid
>s imperatively demanded. 
ACUTE  ABSCESS.
73
   1. When matter forms beneath fasciae and other dense ligamentous tex-
tures, such  as  the sheaths  of tendons, or under the thick  cuticle of the
fingers.   Because, as these are absorbed or softened with the utmost diffi-
culty,  the pus, instead  of coming  to  the  surface,  will burrow amongst
muscles and tendons, extending the abscess to great distances;—produc-
ing extreme pain and constitutional disturbance, by its tension of the fasciae
which cover it, and pressure on the parts beneath,—endangering extensive
sloughing, and impairing the  future motions of the part.   Hence, as  a
general rule, all abscesses beneath fasciae, or among tendons, or under the
thick cuticle of the fingers, should be freely opened, as soon as the  exist-
ence of  matter is suspected.
   [The  same remark is equally applicable to those collections of matter
which sometimes  form  beneath the periosteum, in inflammation of that
membrane.  The pain which accompanies periostitis  is very violent,  but
yields quite promptly when an incision is  made through  the inflamed tis-
sue ;  the pus is thus permitted to escape, instead  of denuding the bone
more and more, and causing its subsequent death.  The incision may be
safely practised in most  cases; for, as a general rule, inflammation of the
periosteum  is most frequent in those bones, and in those portions of the
bone, which are nearest  the surface, as the spine of  the tibia, the clavicle,
and the  sternum.—Ed.]
   2.  When abscess is caused by the extravasation of urine, or other irri-
tant fluids, or when it contains  an  unhealthy matter, which  might diffuse
itself and spread the disease ; as in carbuncle.
   3.  When an abscess  is  formed in loose cellular tissue (as around the
anus,) which would readily admit  of great distension and enlargement of
the sac,  and more especially if the cellular tissue is  partially covered with
muscles (as in the axilla), under which the matter might burrow.
   4. In suppuration near a joint; or in the parietes of the chest or abdomen ;
or under the deep fascia of the neck ; lest the abscess burst into the serous
cavities, or the trachea;  or cause compression of the trachea, oesophagus,
or jugular veins.*
   5. In suppuration of very sensitive organs, as the eye or testis.
   6.  When it is desirable to avoid the scar which always will ensue when
an abscess ulcerates spontaneously.
   [Mr. South very properly insists upon the importance of promptly open-
ing abscesses of glandular organs, particularly those of which the capsule
is firm and not prone to  ulcerate, and thus allow the  pus to evacuate  itself.
If the incision  be delayed  in such  cases, the entire glandular  structure
may become replaced by pus.—(South's transl.  of Chelius, Am. ed.,vol.
i., p. 103.)—Ed.]
  And in the first three  of these cases it is much better to make an open-
ing before matter has formed, than to delay it for one moment afterwards.
  The  best  instrument  for  puncturing abscesses  is  a straight-pointed,
double-edged bistoury.   Holding  it like a pen, the surgeon should gently
plunge it in at a right angle to the surface, till it has entered the cavity;
which may be known by a  diminution  to the feeling of resistance,  or by
gently turning the  instrument on its long axis, so that a drop of pus may
well up by its side.  Then the aperture may be enlarged sufficiently as the

  • In Dr. Cormaek's Lond.  and Ed. Med. Journ., March IS 13, is related  a case in
which an  abscess  burst into the internal jugular vein; other cases are known in  which
abscesses huve burst into arteries.
       7 
74                      CHRONIC ABSCESS.

instrument is being withdrawn.  The puncture should be made either at
the most depending part of the  abscess, or else where  the  matter point.s
most decidedly and the skin is the thinnest; and a very fine strip of oiled
lint (formerly called a tent) may  be gently introduced between  the edges
of the  opening, and be allowed  to remain for the first forty-eight hours, to
prevent them from closing  again.   [Some  abscesses  may be very conve-
niently opened by making  several  small punctures at different points,  and
allowing the matter to  exude through them.  In this way no scar of  any
size will be left.—Ed.]  When  there is a doubt of the  existence of mat-
ter, some surgeons pass in  a grooved needle, by way of exploration ;  but
the author does not recommend this practice.  No rude attempts should be
made to squeeze out matter; but it should  be allowed gradually to exude
into a poultice or fomentation.
   The poultices may be continued till all the pain  has subsided, and  the
cavity  has begun to granulate ; but not too long, lest the granulations be-
come weak and flabby.  And then the best plan is to  apply a compress
of linen, and  a  bandage.  If the  cavity does not  contract speedily, it
must be treated as a weak  ulcer  ox fistula.   If the suppuration continues
profuse, tonics, change of air, and a gdod diet, are advisable, in order to
prevent hectic, and enable  the constitution  to repair the  local mischief.
   It occasionally happens that acute abscesses (especially those occurring
in glandular textures and venereal cases) are cured by the  absorption of
their pus.  This is likely  to  happen when, after acute  inflammation, the
matter remains without tending to  come to the surface, and without pain:
the means best adapted to promote it are cold lotions,—mercurial plaster,
—purgatives  and tonics,—[gentle  continued pressure by means of a com-
press  and bandage,—mild cutaneous stimulation  by frictions  with  the
ointment or tincture of iodine, or a blister applied from' time to time to
excite redness of the skin;—Ed.],—and  above all things a sea voyage, so
as to cause considerable sickness.

              SECTION   III.--CHRONIC  ABSCESS.

   General Description.—Chronic abscesses are  the result of a low de-
gree of inflammation ;  so slight indeed, that their existence is often unsus-
pected for a long time.  They are mostly lined with a thin, reddish grey,
distinctly-organised cyst;—and there is little or no vascularity in the parts
adjoining;—and the pus usually is serous or curdy.   But sometimes  the
cyst is thick  and  cellulo-fibrous, and the matter concrete, so as  hardly to
differ from an encysted tumour.  Chronic abscesses are often deep-seated,
whilst the acute are mostly superficial.
   Causes.—The causes are chronic disease of bone, or other source of
slow irritation, in a weak and  scrofulous habit.
   Symptoms.—When  first  detected, a chronic abscess appears as  an  ob-
scure tumour, with a fluctuation  more or  less distinct according to  its  dis-
tance from the surface.  It is free from pain, tenderness, swelling,  and
redness, unless far advanced or accidentally inflamed.
   Progress.—These abscesses may attain an enormous magnitude, partly
because the sac being thin is readily extensible,—and partly because of the
atonic and indolent grade of the inflammation, which is  insufficient to  im-
plicate the adjoining textures,  and  make  the coverings ulcerate.   When,
however, from the increasing distension, or from some accidental irritation, 
CHRONIC ABSCESS.
75
this does happen, the  skin reddens, inflames, and ulcerates, and so  the
matter is discharged.
  Terminations.—(1.) In slight cases the stimulus of the air causes  the
interior of the sac to pour out granulations ;—the reddened  skin around
the orifice ulcerates;—and the sore'so formed  may heal.   (2.) If the  re-
storative powers are weak, or the parietes of  the sac have been unequally
pressed together, or the abscess  is caused by a piece  of diseased bone or
some other permanent source of irritation which is not  removed, one or
more sinuses may remain. (3.) If, on the other hand, the abscess is very large,
or if, after the admission of air, the pus have  not a free exit, a most serious
train of consequences  will ensue.   The  pus, exposed to the atmosphere,
putrifies;—the hydrosulphate of ammonia (the product of  putrefaction) is
absorbed into the blood ;*—the interior of the sac inflames, partly from
the irritation  of the air, but chiefly from that  of the putrid pus ;—and then
the grave and irreparable local disease, together with the  contamination of
the blood, induce typhoid  fever, under which the patient sinks.
   Prognosis.—Hence the danger of these  abscesses will  be great, if  the
sac has attained  a large size, and has advanced so far towards ulceration,
that a spontaneous and permanent aperture is inevitable ;—more especially
if it is  connected with diseased hip or  vertebras, which will keep up  the
secretion of pus,  and prevent it from closing.
   Treatment.—There are three indications; (1.)  To amend the general
health  by pure air, proper regimen,  and other means  detailed in  the
Chapters on Chronic Inflammation  and Scrofula.  If (as  in the case of
psoas and  lumbar abscess) the abscess has  been caused by some local
disease, the latter must, if possible, be ascertained, and removed by proper
measures.
   (2.)  To procure absorption of the matter, if possible.  This may some-
times be effected by stimulants and counter-irritants applied to the tumour
or its  vicinity.   Plasters of Emp. Ammoniaci cum  Hydrarg.; or of F.
66 ; or a succession of blisters, when one is nearly healed, another being
placed  beside it; or friction with  Ung. iodin.; electric sparks; and cold
affusion, are  the  most useful remedies; but  they do harm if they cause
heat or pain.
   (3.)  But  if, notwithstanding these efforts, the tumour  continues  to
enlarge, it cannot be opened too soon ;—especially if there  is  any incipient
redness  of the skin.   And a different proceeding is  requisite in different
cases.
   If the abscess is superficial and small it may be opened with  a lancet or
bistoury ; the raspberry-cream-looking matter, with flakes  of lymph float-
ing in it, should  be gently evacuated, and some strips of adhesive plaster,
or a compress and bandage wetted with zinc lotion, should  be passed
round the part, so as to keep the sides  of the sac in apposition with a
moderate degree of pressure.  Thus, a free exit being provided for  the
pus, the opposing surfaces of the cavity will often granulate  and adhere;
then the external aperture heals, and the case is cured. If from deficiency
of action this  adhesion will not take  place, weak, stimulating injections
may be used, such as  F. 58,  diluted; or another aperture may be made,

  * It may be detected in the blood and urine.  The blood in these cases is black, and
refuses to coagulate ;—which is precisely the effect produced by adding the hydro-
gulphate  of ammonia to healthy blood.  Vide  M. Bonnet's Papers  in  the Med. Gas
vol. xxi. 
76
CHRONIC ABSCESS.
and a seton be passed through the sac ;—or if it be long and fistulous, it
may be slit up, and made to heal from the bottom.
   In some cases, when a considerable portion  of  skin  has  become thin
and red—evincing that it will certainly ulcerate and form a large aperture,
it will be advisable  to apply the  caustic potass, so as to destroy it, and
avoid the more painful and tedious process of ulceration.
   If an abscess is seated in the neck of a female, it is of the  greatest con-
sequence to make an  early opening, so that no  scars may be left.   The
instrument recommended by Sir A. Cooper for this purpose is  a very fine
1-Mcet, only one-eighth of  an inch broad.  The puncture should be large
enough to extract all flakes, but no larger; and it should be made trans-
versely, so that its minute cicatrix may be hidden by the folds of the neck.
Adhesive plaster should then be applied with  moderate pressure ;—and
weak injections, especially F. 46, may be used, if the sac  does  not be-
come obliterated in the course of a few days.
   Large Chronic Abscesses.—If the abscess is so large that  the exposure
of its cavity would lead to the evil consequences that have  been enu-
merated ; or, if it is connected with disease of the spine  or other bone (as
in the  case of psoas  abscess), the  following plan  should be resorted to,
with a view of inducing a contraction of the sac, and of diminishing the
danger  from  a permanent opening,  should  one  be established subse-
quently.   A small puncture should be made  at the most depending part
of the tumour.  It may be made valvular, by drawing the skin a little to
one side before introducing the bistoury;  but this is not of  much conse-
quence.   As  much matter as flows spontaneously should be permitted to
escape, and then the puncture should  be carefully closed by lint and
plaster, and the patient be  kept at rest till  it is healed.   During the flow
of the matter, the greatest care ought to be  taken to prevent the admission
of air into the sac.  At the expiration of ten days  or a fortnight, when it
is nearly refilled, a second  puncture should be made (but not too near to
the former), and should be healed again in like manner.  This operation
should be repeated at proper intervals, taking  care never to let the  abscess
become so distended as it was before  the previous puncture,—and using
moderate support by bandages in the intervals.   Thus, in fortunate cases,
these repeated partial evacuations, combined with proper constitutional
measures,  will cause  the   abscess  gradually to  contract; — so  that  it
either becomes completely  obliterated, or degenerates  into an insignificant
fistula.*
  This  method of treatment was  introduced by the  late Mr. Abernethy.
He, however,  recommended as  much as possible of the matter to be
evacuated  at  each operation, instead of  allowing it to run spontane-
ously ;—which latter method  is much better calculated to preclude the
admission of air, and avoids all irritation of the cyst by rough handling or
squeezing.
  But if air have gained admission into the cavity of the abscess, and the
pus  have become putrid,  and prostration of  strength  and dry brown
tongue show its influence on the system, then the indications plainly are,

  * Vide Fergusson's Practical Surgery, 2d Ed. p. 79, and Lancet, Nov.  6, 1841, for an
excellent case treated successfully in this way in the Kings College  Hospital.  M.
Bonnet has suggested, that the part in which the abscess is situated might be immersed
under water at the time it is punctured.   This would, of course, render the incress of
air impossible. 
ERYSIPELAS.
77
to make free openings and counter-openings, so as to prevent all lodg-
ment of the putrid pus ; and to wash out the sac occasionally with injec-
tions of warm water,  containing a very little of the solution of chloride of
soda.   At the same  time the general treatment of typhoid  fever  must
be  adopted,  and  the strength  be   supported by wine,  nourishment
opium, &c.
                        CHAPTER  VIII.

OF ERYSIPELAS AND DIFFUSE INFLAMMATION OF THE CELLULAR
                               TISSUE.
                                                                i
       SECTION  I.--PATHOLOGY   OF  ERYSIPELATOUS
                         IN FL AMM ATION.

   Instead of treating of erysipelas amongst the diseases of the skin, as
if it were a mere example of ordinary inflammation, attacking the  skin,
and deriving its peculiarities solely from  the structure affected, we  shall
adopt  the  opinion that was  doubtfully held by John Hunter,* but which
has been clearly substantiated by recent pathologists, and  describe it as a
peculiar unhealthy form of inflammation, which may attack various tissues,
but which, wherever situated, exhibits certain characters that distinguish it
from ordinary healthy inflammation.
   These characters of erysipelatous inflammation are the following:—It
has a disposition to spread widely along  the surface of membranes, or in
the cellular tissue.   The  lymph wThich is secreted is incapable of organi-
zation, and instead of confining effusions into the  cavity of an abscess,
permits them to be diffused widely, and  thus to extend the  disease into
sound parts.  Erysipelatous inflammation is liable to attack different parts,
sometimes simultaneously, sometimes by metastasis ; that is, leaving one
part and flying to another, thus giving evidence of  its origin in a vitiated
state of the blood.   Lastly, the different  varieties of erysipelatous disease
prevail epidemically together, and are capable of propagation by infection
and contagion.
   The diseases which  may be grouped together as partaking of the erysi-
pelatous character, and which are all probably caused by the admission of
some  nearly-allied varieties of  putrid miasmata into  the blood are, the
simple or cutaneous, and the phlegmonous or cellulo-cutaneous erysipelas;
the diffuse inflammation of the  cellular tissue ; acute phlebitis ; puerperal
fever, and the suppurative diathesis, i. e.  the peculiar state of constitution
in which abscesses or purulent depots are  liable to form suddenly and un-
expectedly in the liver, joints, lungs, and other parts of the body.   Thus

  • Hunter's words are, "in some constitutions,  every inflammation wherever it exists,
will probably be of this kind ;" and  (speaking  doubtfully of the erysipelatous nature
o:' inflammations of mucous membranes he adds), " whatever the inflammation maybe,
it is certainly attended with nearly the same kind of constitutional affection. The lev
in both appears to be the same ;"'  i. e. as in erysipelas. 
78
ERYSIPELAS.
Dr. Ferguson tells us, that erysipelas and puerperal fever are generally co-
existent in his lying-in hospital, the mothers perishing of one, and the in-
fants of the other.   Instances are now common enough, showing that the
infection  of either of these two diseases may produce the other:  and it
has long been known that inoculation with the fluids  of a female who has
died of puerperal fever is a most fatal source of diffuse cellular inflamma-
tion to the dissector.   Moreover,  during the prevalence  of erysipelas in
the London hospitals, phlebitis and purulent depots are generally prevalent
likewise.*
   In the present chapter we shall speak first of the  simple or cutaneous
and phlegmonous or cellulo-cutaneous  erysipelas ; and in the following
section of the  diffuse cellular inflammation ;   which, however,  will be
treated of more fully under the head of dissection wrounds.


SECTION II.—OF  THE  CUTANEOUS AND  CELLULO-CUTA-
                      NEOUS  ERYSIPELAS.f

   Definition.—Diffused inflammation of the  skin, or skin  and cellular
tissue, with a tendency to spread.
   Symptoms.—The cutaneous or simple erysipelas is known by redness of
the skin, which disappears momentarily on pressure ;—considerable  puffy
swelling from serous effusion into  the cellular tissue ;—and severe sting-
ing, burning,  or smarting  pain.   The redness  is generally of a  vivid
scarlet hue;  but it will be faint and yellowish  if the  disease  is attended
with much debility,  or if it affect the eyelids, scrotum, or other loose cel-
lular parts, where it always produces a good deal of serous effusion.
   In the cellulo-cutaneous, ox phlegmonous erysipelas, the redness is deeper,
and sometimes  dusky or purple, and  it is scarcely, if at all, dispelled by
pressure ;—the  swelling is much greater, and is hard, brawny, and tense ;
—and the pain is not only burning, but throbbing.
   Constitutional symptoms.—Both varieties are ushered in with shivering,
headache, pain  in the back, nausea, and  bilious vomiting; and both are
attended with fever, which will vary in its type  according to the intensity
of the cause,  the vigour of the constitution, and the nature of the prevail-
ing epidemic.   It may be  of an ardent, sthenic, inflammatory character,
requiring free blood-letting, if the  disease affect a young robust country-
man ;  but it soon assumes a low typhoid character, if the  patient  is old
and weak ; or if the disease were  contracted in some close, foul, ill-ven-
tilated hospital, or if a large portion of cellular tissue has begun to slough.
When erysipelas is situated on  the face  and scalp, it will be  liable  to be
complicated with delirium in its early stages, and coma in the latter, from
the irritation propagated to the brain and its membranes.
   Terminations.—The cutaneous erysipelas may terminate,  1, in resolu-
tion, leaving nothing  but desquamation of the  cuticle with slight cedema
  * Vide  Ferguson on  Puerperal Fever, p. 29;  Mr. Storrs, of Doncaster, who most
f learly  proved the common origin of these and other septic diseases, in the Prov. Med.
Tour. 23d April, 1842, Paley, Lond. Med. Gaz. June 6, 1842, on the Production of Puer-
peral Fever by infection from Erysipelas; and Nunnely on Erysipelas, Lond.  1841, a
work that deserves to be attentively studied.
  t The terms cutaneous and cellulo-cutaneous, which Mr. Nunneley has proposed, are
far preferable to the terms simple and phlegmonous, because the word phlegmonous is
often used in contradistinction to erysipelatous, to express a different kind of inflamma-
tion • the former circumscribed and adhesive j the latter diffused. 
ERYSIPELAS.
79
 this mild form is often called erythema); 2, bat more frequently it pro-
duces large bulle or vesicles from effusion of serum under the cuticle ,—
and these dry into scabs, which peel off, and leave die cutis either healed,
or superficially  ulcerated.  3. Sometimes, however, it  is followed by
small abscesses.  The ordinary duration is from seven to fourteen days.
  Before  its  termination, however, this variety  of erysipelas sometimes
assumes a lingering  erratic  character, wandering progressively along the
skin, and spreading  in one direction as it fades in another.  Sometimes it
disappears entirely from one part, and flies by metastasis to a distant one;
and  sometimes it quits the skin suddenly,  and some internal  organ  is
affected with an inflammation  having the same constitutional characters.
  The phlegmonous or cellulo-cutaneous erysipelas may terminate as favour-
ably as  the simple variety;—but it  more generally leads to unhealthy sup-
puration and sloughing of the cellular tissue;—in which case the swelling
becomes flaccid  and quaggy;—patches of the skin  become  purple, and
covered with livid vesications, and  these  patches slough, giving exit to a
thin sanious  pus, and to flakes of  disorganised cellular tissue.   And not
only  the  subcutaneous,  but  the  intermuscular  tissue and  fasciae may
slough,  rendering the limb useless,  even if the patient escape with his life.
Moreover, after a very severe attack of erysipelas, the  cellular  tissue  is
apt to be left in a hardened, brawny state, through infiltration with lymph.
  Prognosis.—This must be guarded if the patient is old, enfeebled, and
habitually intemperate;—if the constitutional  affection is low and typhoid;
—if the malady  is  situated on the head  or throat, and there  is  coma or
great dyspnoea ;—or if the erysipelas is of the phlegmonous variety, and a
large portion of the cellular tissue  and  skin is on the point of sloughing.
Mr. Nunneley observes, that if the frequency of the pulse is not abated by
the seventh  day, the prognosis will be unfavourable, even although the
local symptoms appear to be improving.
   Causes.—The causes which render the constitution liable to erysipela-
 tous inflammation are threefold.  First, intemperance, fatigue, close con-
 finement  in  foul air, and whatever other causes are capable of irritating
 the  digestive organs, exhausting the  nervous system, and vitiating the
 blood.   The origin  of erysipelas in the close air  of hospitals is unhappifv
 too notorious to  need mention.  Secondly, the disease may be epidemic
that is, may  be produced by certain states of the  atmosphere at  large
affecting several people in the same district simultaneously.   Thirdly,  i
may be propagated by contagion  or infection, by means of  emanations
from patients affected with it.
  These  causes  may be  sufficient  of themselves to produce  the disease
(which then is said  to be  idiopathic); or they may  merely predispose the
patient to suffer,  on  the occurrence  of some injury to the skin, which acts
as an exciting cause; such as leech-bites, caustic, and burns.   Idiopathic
erysipelas generally attacks the face and scalp.
  Treatment.—The indications for the constitutional treatment are, to
diminish  inflammatory  action  and febrile  excitement — to support the
strength — and to correct the secretions — and for the local treatment to
allay irritation—to arrest  the extension of the disease—and  to give free
exit  to  sloughs  and discharge.   But the  surgeon must never forget that
erysipelas varies  so  much in  its type  at different periods, sometimes re
quiring  free antiphlogistic measures, and sometimes bark and opium, that
when a  new epidemic arises he must carefully study what Sydenham calls 
«
SO                          ERYSIPELAS.

the  genius of the disease, and observe the effect of remedies, in order .0
determine what plan of treatment is the best.*
  Emetics and Purgatives.—On the first occurrence of the symptoms  an
emetic may be given, composed of a scruple of ipecacuanha  with a grain
tartar emetic.   It should be followed by a good dose of  calomel, and  by
black draughts (F. 16) containing a few grains of soda, every six or eight
hours, as long as they bring away hardened  lumps of fasces, or as long as
the secretions continue to amend under their use.  If, however, the pa-
tient be weak, an emetic  of ipecacuanha and ammonia (F. 120) may  be
substituted for the  tartar emetic, and  a  warmer aperient for the  black
draught, F. 17, 27,  28.
  Antiphlogistic  measures.—Bleeding may  be  required  if the patient is
young and vigorous, the pulse full and  strong, the face  flushed, and de-
lirium violent; and  if the inflamed part  is full, tense,  and vividly red,
and especially if seated on  the head or throat.  In similar active inflam-
matory cases,  calomel may be given in  doses  of two  grains every six
hours with antimony (F. 31); and saline draughts with  excess  of alkali
(such as F. 30, or liq. am. acet, &c.)  in the  intervals; — but in most
cases of simple erysipelas  a small dose of mercury at bed-time (F. 32,
33), and purges and  salines during the day will suffice.   For it must
be  recollected that  as  the  disease is not purely inflammatory,  it  cannot
be cut short by mere antiphlogistic  measures; and that debility is  much
to be dreaded; especially in cases occurring in the crowded habitations
of London.
   Tonics and stimulants.—Bark should be given in all cases  as soon  as
the tongue becomes  clean and the  skin moist;  but it should be resorted
to without  delay if the pulse is  soft, tremulous,  or very rapid, the heat
moderate, and the  delirium low and muttering, or if the patient is na-
turally delicate, and subject to periodic or recurrent attacks;—or if anti-
phlogistic measures do not arrest the disease, or if suppuration or slough-
ing have commenced.  Wine and good  nourishment will also be requisite,
and it is on these that we must principally depend for the patient's safety
in severe cases of any kind; and especially those attended with sloughing
and profuse suppuration.
   Opium may be given in full doses at bed-time  in the  latter stages, to
allay restlessness, provided there is no cerebral congestion nor coma.
  If there  is great  irritation of the  stomach, with  sickness  or diarrhoea,
small repeated doses of hydr. c. creta  et pulv. ipec. c. should be  given
with  effervescing draughts, F. 30; and fomentations or rubefacients  be
applied  to the  abdomen.
  And in what may be called chronic or habitual erysipelas, when it comes
on at intervals, when the stomach is disordered, or the general health de-
ranged, a course  of  aperients, alteratives, and tonics  (especially sarsapa-
rilla and alkalis), should be  administered according to the principles laid
down in the Chapter on Chronic Inflammation.
  Local Measures.—Leeches are useful in the early stages, provided the
patient can bear the loss of blood.  Minute punctures about  one-fifth  of
an inch  deep,  made with the point of a lancet, may be  used as  substi-
tutes ; and often permit the discharge of considerable quantities  of blooc
and serum.
   Cold  Lotions may be used when  the  heat is great, the redness vivid
                 • See also Graves's Clinical Medicine, p. 575. 
ERYSIPELAS.                          81
and the pulse good, and especially in erysipelas of the head.   But they
must be avoided if the circulation is languid, or if the erysipelas is mani-
festly connected with gastric irritation, or any other internal disorder.
   Warm ox  Tepid poppy fomentations will generally be found more sooth-
ing, and theoretically are safer than cold applications.
   Flour, dusted on the inflamed part, is often very soothing;  and is well
calculated to allay the heat and itching of simple erysipelas, and to absorb
the acrid serum that escapes from the vesications.
   Pressure by bandages is serviceable in the latter stage  of most cases:
—and from Vie very first, if the inflammation be atonic and cedematous.
   Mercurial ointment smeared  on  the  part, or applied as  a plaster, has
been much praised by some people, but its efficacy is questionable.
   Stimulants.—The nitrate  of silver in substance or solution ; or blisters,
or fomentation of dec. cydonii  oj.  cum. liq.  am.  sesquicarb.  3j.  are  of
great use in putting a stop to tedious erratic cases of simple erysipelas,
after proper constitutional remedies have been used.
   In  similar cases, the extension of the  disease may sometimes be arrested
by applying  a strip of blistering plaster,  or still better, the nitrate of silver,
so as completely to encircle  the inflamed part.  The skin should be well
washed first, and care should  be  taken to leave no  interstices through
which the disease might creep and  extend itself.   When  there  is a ten-
dency to sinking, with diminution or disappearance of the external inflam-
mation, warm cloths, moistened with turpentine or sp.  camp, may be
applied externally, whilst diffusive stimulants are administered internally.
   Incisions are, to use a French expression, the heroic remedy in phleo--
monous erysipelas.   When  the  swelling is great, and increases  rapidly ;
—when  it is hard, tense,  and resisting, not  soft and cedematous  as in
simple erysipelas ;—when the pain is severe, and throbbing, and not  re-
lieved by leeches;—when  there is the least  sensation of  fluctuation or
quaggimss ;  or when the skin is becoming livid or dusky, or covered with
livid vesicles, they are imperatively demanded.   They are absolutely ne-
cessary for the discharge of pus and sloughs;—for, as James  observes,
these matters are neither brought to the surface by pointing, nor walled in
by adhesion.   And they are not merely apertures for the discharge  of
matter; but  a very effectual means of cutting  short the inflammation, by
relieving the tension, and by emptying the distended blood-vessels.  They
are also requisite in erysipelas of the throat, when great swelling threatens
suffocation by pressure on the trachea.  They should be made of sufficient
length,—in  as many places  as required;—they should be carried  quite
deeply through the diseased  tissues, and should  be repeated as  often as
necessary.   Twc, three, or four inches will be a sufficient  length in most
cases ; but no precise rule can be laid down on this subject. At all events
they should be made long enough, but no incisions should be made from
hip to  ankle out of wantonness or bravado.  They should not be permitted
to bleed long;—and haemorrhage, if profuse, is best stopped by continued
pressure with the fingers on the bleeding points.   The subsequent  mea-
sures are poultices, followed by nitric acid lotion;  and bandages to pre-
vent lodgment of matter and sinuses.*
  * Vide James, op. cit.; Copland, Diet.; Higginbottom on Nitrate of Silver; Copland
Hutchinson's Surgical Observations: the Lectures of Abemethy, and Cooper; and twu
Lectures by Velpean, Med. Gaz., Aug. 14 and 21, 1840
F 
82
DIFFUSE  CELLULAR INFLAMMATION.
 SECTION III.--ERYSIPELATOUS OR  DIFFUSED  INFLAM-
            MATION  OF  THE  CELLULAR  TISSUE.

  Symptoms.—This disease  exhibits the symptoms  of cellulo-cutaneous
erysipelas,  without the affection of the skin.   A rapidly-increasing swell-
ing appears on one of the limbs,  or on some part  of  the  trunk.   Its sur-
face is tense, shining, and usually pale.  When pressed  upon it feels in
some  cases hard and resisting,  but more frequently it yields that  peculiar,
semi-elastic sensation described by the  term boggy, or quaggy.   There is
always  most excruciating  pain,—which in  some cases is  burning and
throbbing, in others heavy and tensive.  The disease is invariably attended
with fever of an irritative or typhoid character.  The pulse is always  fre-
quent ;  it may be sharp and jerking, but is without strength and steadiness.
The countenance is anxious  and haggard;—the  mind  irritable  and  de-
sponding, and  delirious at intervals.  Respiration is quick  and laborious,
—more especially if the disease be  seated on the chest, as it frequently is,
—because the pleura is affected through contiguous sympathy.   In unfa-
vourable cases, low muttering delirium, copious offensive perspiration, and
jaundiced skin, usher in the  fatal termination.
  Causes.—The predisposing causes of this disease are those of the other
varieties of  erysipelas.  The exciting causes may be of the most trivial
nature,  if the  patient be predisposed; such as very slight punctures or
abrasions.   This is the disease which is excited by the bites of venomous
serpents ;—and by inoculation  with septic animal  poisons ;—especially by
that which  is generated in bodies recently dead ;—it also occasionally fol-
lows certain surgical operations, as  lithotomy and  vensesection.
  Morbid  Anatomy.—On examination of the parts affected, at  an early
period of the  disease, the  cellular tissue is  found loaded with  a limpid
reddish serum.  In a more advanced stage this fluid becomes thicker, and
less highly  coloured.  Subsequently,  the  cellular tissue is found  to be
gorged, partly  with white semifluid  matter,  partly with a brownish  puru-
lent sanies,  which is mingled with detached  flakes of the sphacelated  tis-
sue.  The  muscles, and other structures in the vicinity, are discoloured
and softened ;  and  the larger veins which permeate the  diseased part, have
their coats  inflamed, and often  in a  state of suppuration.
  Diagnosis.—This disease is to be distinguished  from the common phleg-
monous abscess by its having a smooth and level surface, without any ten-
dency to point;—also by the asthenic nature of the accompanying fever.
  Treatment.—This will be more fully discussed in the Chapter on Dis-
section Wounds (Part iii. ch.  9). It may, however, be summarily observed,
that leeches, hot fomentations, and free incisions,—emetics, purgatives,
and enemata, followed by ammonia, bark,  opium, and wine, are  the mea-
sures  that  are sanctioned by  the  most authoritative  and  experienced
writers.*
  * Vide »*vo papers  t; p>  _Jinburgh Medical and Surgical  Journal for 1825, vol
xxv.;  (Ypland's Diet., Art. Cellular Tissue; James on Inflammation; Travers on Coi
stitutional Irritation, and Butter on Irritative Fever, Devonport, 1825, which gives an
account of an extraordinaiy visitation of this disease in Plymouth dock-yard  in 1824, 
ULCERATION.
83
                         CHAPTER  IX.

                          OF ULCERATION.

     SECT.  I.--OF  THE  PATHOLOGY OF  ULCERATION.

  Pathology.—The observations  of the  most recent pathologists have
shown that ulceration consists in the progressive softening, disintegration,
and removal  of successive layers of the ulcerating tissue.
  Now ulceration, like  mortification, may occur in two different ways.
First, it may be preceded by inflammation of the ulcerating part; secondly,
by congestion ; that is, by a stagnation of  venous blood in the capillaries.
  (1.) Inflammatory Ulceration.—The formation of an  ulcer through in-
flammation is precisely similar to the formation of an  abscess; the  only
difference being that the former commences on the  surface, the latter in
the substance of a part.   Supposing the  skin to ulcerate from the applica-
tion of venereal poison, for instance.  In  the  first  place, its surface in-
flames, and exudes serum or unhealthy pus, which  elevates the  cuticle
into a pimple or pustule.   When the pustule is opened, there appears a
little  hollow, filled with a whitish or greyish tenacious  matter, consisting
of the substance of the skin itself, which has lost  its  vitality and  is about
to separate, aud of lymph or of unhealthy flaky pus with which it is  infil-
trated.   If this is wiped off, the surface underneath  is seen to be red, and
it easily bleeds.   Supposing the case to proceed, there is formed a chasm,
eaten into irregular hollows, with intervening red  eminences, which easily
bleed jf  touched;  its edges are ragged, loose, and  undermined, the sur-
rounding skin red, hot, and  swollen;  there  is a thin  serous, or  bloody
discharge, and a constant, severe  gnawing pain.  An  ulcer having these
characters may always be  considered as extending itself.
   An excoriation is often the  first stage  of this kind of ulcer; that  is to
say, a portion of skin inflames, loses its  cuticle, and  discharges matter,
and the excoriated portion may either heal, or  as  we have just observed,
may ulcerate.
   Of course, ulcers spread with varying degrees  of rapidity.  An attack
of violent inflammation may cause  the death of a considerable portion in
a very short  time ;  this is said to be a sloughing  ulcer.   When  an ulcer
spreads very rapidly,  but  regularly and without  sloughing of any great
portion at one time, it is called phagedenic.  And when it spreads more
rapidly still,  not by one fit of sloughing,  but  by the constant reiterated
mortification  of considerable  layers, it  receives  the name of sloughing
phagedena.
   (2.) Congestive Ulceration.—This  may  be very briefly described  as  it
occurs on the legs  of old  dropsical people.  A small portion of skin has
its capillaries distended with venous blood, whose return is nearly or quite
suspended.   Some of the serum (writh which the  cellular tissue is already
distended) exudes  under the  cuticle, raising it into a blister.   WThen  this
is removed,  there  is  seen a darkish  layer of sloughing skin.   This, like
the last, may spread with every degree of rapidity; but whether a large 
84
ULCERATION.
tract of skin mortifies at once, or whether the smallest  portion  ulceiates,
the process is one and the same.
   (3.) Combination of the two Forms.—But it most generally happen*
that ulceration consists in a combination of inflammation and congestion ;
that is, in  the  inflammation  of  a  part  already congested, or incapable
through weakness, of supporting inflammation without loss of life.  It ma)
be observed also, that ulcers which have  commenced through  congestion
may be extended by inflammation.
   As this account which we  have given of  the ulcerative process differs
very materially from the doctrines of Hunter, it is necessary to say a few
words in proof of its correctness.
   Now Hunter taught, that  ulcers  are formed by  a variety of absorption,
which he  denominated ulcerative ; the substance of his theory being,  that
the ulcerating tissue feeling  its want  of vitality, causes  itself, as a last act
of life, to  be absorbed by its own lymphatics.
   But to this doctrine it must be objected,  first of all, that it is void of all
proof.   Hunter says that it is so,  and that he  was the first to show it;  but
nowhere does he attempt to  prove it.
   And secondly,  whoever will take the  trouble to watch the first  begin-
nings and progress of a spreading ulcer,  may have ocular evidence  that
the loss of substance is through disintegration.*
   It will be noticed in its proper place, that bone and cartilage sometimes
ulcerate by disintegration, sometimes are removed by a peculiar solvent
power of the textures in contact with them.
   Predisposing  Causes.—The  Tissues most disposed to  ulceration are
the skin, with the mucous and synovial membranes.   From  these  it may
spread to  other subjacent tissues, which yield  to  it with varying degrees
of rapidity.  The cellular tissue ulcerates very easily ;  but muscles, blood-
vessels, and nerves, very slowly; so  that they often  appear to be as  it
were  dissected  out in spreading sores, by the destruction of the cellular
tissue  around them.   Tendons  and ligaments   are  also  very slow to
ulcerate;  but cartilage, bone,  and the cornea,  are in certain constitutions
extremely liable to it.
   The Constitutions  most liable  to ulceration, are those which are debili
tated by intemperance or privations ;—tainted with syphilis or scrofula;—
or broken  down by the excessive use of mercury.
   The parts most disposed  to it  are those wmose circulation is most weak
and languid ;  such as the lower extremities;  and more especially if the
return of  their venous blood  be  in  any way impeded by a  varicose state
of the veins.  On  this  account tall persons are, much  more  frequently
affected with ulcers of the legs than the short.  9ir E. Home shows, on
  • The former editions of this work contained a  copious  array  of arguments on this
question, but it is not necessary to repeat them now, as the  question may be considered
as settled.   For further information, consult Mr. Gaskell's MS. Jacksonian Prize Essay
on Ulceration, in the Library of the College of Surgeons in London, and the preparations
accompanying it; also J. W. Earle, Med.  Gaz., for  1835; C. Aston Key, Med.  Chir.
Trans., vol. xviii. and xix.;  Copland,  Diet. Pract. Med. Art. Inflammation; Pearson's
Principles of Surgery ; and  particularly Wallace on the  Venereal Disease, Lond  1838, p.
4 7.  Writers sometimes confuse the absorption, which they pretend to be the cause of
ulceration, with the absorption of fluids from the surface of an ulcer.  Thus the forma
tion of bubo is sometimes alleged as a  proof that chancre is caused by ulcerative absorp-
tion.  If it  were so, the bubo would come whilst  the chancre is forming; instead of
which, it seldom occurs till it is beginning to heal and to become more capable of im-
bibing its own poisonous secretions, and transmitting them into the veins and lymphatics 
VARIETIES OF  ULCERS.
85
the authority of Dr. Young, that twenty-two out of one hundred and forty-
five tall men, and only twenty-three out of two hundred and seventy-six
short men, were discharged from a regiment  in the West Indies in four
years, on account of ulcers.
   Parts newly formed are, as has been before said, more liable to ulcerate
than those of original formation.   And this is  equally true, whether they
have been produced, first, in consequence  of injury, as  cicatrices and
callus; or, secondly, wrhether they are developed from hypertrophy of a
standard structure ; as  cutaneous tumours, which often remain stationary
for years, and then, from some slight irritation,  will give rise  to the most
destructive and spreading ulceration ;  or, thirdly, whether they consist in
the deposit of a texture alien to the normal  organization.  Thus cancerous
diseases consist in the deposit of a new texture, which, from its low powers
of vitality, yields after a time to disorganization.
   Exciting  Causes. — In constitutions or  parts predisposed to it, the
slightest irritation may  be  sufficient to excite ulceration.  In the healthy it
may be produced by the  continuous  application of some  irritant, so  as
gradually to exhaust the vital  powers  of the part; — such  as continued
pressure ;  the presence of irritating fluids ;  or depraved  secretions.  But
it is not easy to excite genuine spreading ulceration in  the healthy, unless
by some specific cause, such as the venereal poison.


        SECTION II.--O F THE VARIETIES  OF  ULCERS.

   It  is  not easy to give a rigorous definition of the term ulcer,  nor is it
necessary.   For all useful purposes, it will suffice to say, that it  signifies
a chasm on the surface of any organ caused  by the destruction of a portion
of its substance by disease; or by an injury which has not been repaired.
   Ulcers present many varieties, which may be classed  under three heads.
 1.  They may be in a state tending  to  reparation ; as the healthy ulcer.
2. Their surface may have an imperfect form of organization, under which
they may be incapable  of healing, though they are not necessarily spread-
ing ;  the weak and indolent ulcers are examples.   3. They may be under
the influence of the destructive process  which formed them originally, and
which is still causing them to spread ; as the phagedaenic.
   I. The  Healthy Ulcer is nothing more than  a healthy granulating
and cicatrising surface.   The granulations are small, numerous, florid, and
pointed, and  yield a moderate secretion  of healthy pus.  The edges are
smooth,  and  covered  with a  white,  semi-transparent  pellicle, which  is
gradually lost on  the .margin of the  granulations.  It  will be  recollected
that a healthy sore of this  description  will  be greatly  diminished by the
contraction of the surrounding skin, before any cicatrisation has  actually
occurred.
   Treatment.—The only treatment required will be  a  little  dry lint,  if
there  be much discharge,—or the water-dressing, or simple ointment,  if
there  be not.  If there be not much discharge, the dressings should not
be changed more frequently than every second or third  day.   If the gran-
ulations  are  too  luxuriant, they may  be touched with lunar caustic, and
dressed with dry lint; — or the sore  may be exposed to the air for some
hours.  If the granulating surface is very extensive, or if all applications
disagree with it, as sometimes  happens, it  will be  expedient) to  form  a
scab on its surface.   This  may be done by allowing the pus to dry, or by
       8 
86
INFLAMED AND  IRRITABLE  ULCERS.
 sprinkling a little flour, or calamine, or chalk, to absorb it.   But .he be?
 plan  in these cases is to pass a stick of lunar caustic over the surface of
 the sore, as recommended  by Mr.  Higginbottom.   This  .salt  instantlv
 coagulales the fluids on the  sore, and forms a white pellicle, which soon
 becomes dry and black, and  is much less irritating than an ordinary scab.
 If the scab act favourably,  suppuration ceases, and cicatrisation will  be
 found complete when it is   detached.   No  other dressing  is required,
 except  a  piece  of gold-beater's  skin, and a slight bandage, to  prevent
 injury.  If pus continue to be formed, a small hole should be made in the
 middle of the scab to let it out.
   II. The Inflamed Ulcer has already been described.
   Causes. — Ulcers (though  not originally formed by inflammation)  are
 liable to  inflame  from any of the  ordinary local or constitutional causes,
 especially errors in diet.  Sores situated over projecting parts of bones or
 ligaments, as the  outer ankle, or over the bellies of muscles, are  apt to
 assume this character; hence care should  be taken  to avoid making issues
 in such situations.
   Treatment.—In a few instances, when the patient is very plethoric and
 strong,  it  may be expedient to bleed,  and to administer calomel, antimony,
 and opium, till  the mouth is slightly affected.   In all cases, the bowels
 should  be cleared, the secretions kept up, and  the diet be regulated.
 The patient should keep at rest, with the  affected  member in an elevated
 posture.  Leeches may be applied in the  vicinity of the sore ; but not too
 near it, and not to any place where the skin is  much thickened and con-
 gested, lest the leech-bites  themselves take  on  ulceration.   The part
 should be fomented night and morning for half an hour with poppy fomen-
 tations, and  then a poultice or the water-dressing be applied, or the  steam-
 bath  described at  p. 59 may be tried ; — and if the pain be very severe,
 the poultice may  be medicated with opium, F. 78, or conium.   If  the
 ulcer  diminish under these applications, but yet its surface remain foul,
 they may  be continued  till it  is healed ; but if the surface become healthy,
 it may be treated as an ordinary ulcer.   If warm  applications aggravate
 the pain,  cold  evaporating, or saturnine lotions (F. 55) should be  used,
 the sore being protected by a piece of oiled silk or simple dressing.
  If all these soothing measures  prove ineffectual, as they occasionally
 will, even though  aided by  the most judicious constitutional treatment,
 recourse must be had to the measures directed for irritable ulcers.
  III. The  Irritable  Ulcer is a variety of the inflamed.   It is defined
 by Mr. Skey* as having an excess of organising action, with a deficiency
 of organisable material; so  that the  granulations are too small, and  are
 morbidly sensitive  and vascular.
   Treatment.—In  the first place, the  constitution, wThich is generally out
 of order, must  be  corrected  by alteratives  and tonics.  Plummer's pill,
 or F. 31, 32, 33,  at bedtime; and sarsaparilla, soda,  and  hyoscyamus,
 F. 40, 41, during  the  day;  or the extract of conium in  doses of  gx. v.,
 ter die, will be of  great service.
  In the local  treatment, all sources  of irritation must  be removed, and
the  soothing applications directed for  the inflamed ulcer may be tried first.
But the most successful plan, generally speaking,  is the application of a
succession of mild stimulants, so as to alter the actions and exhaust the
  * F.  C. Skey, F. R.  S. A new mode of treatment employed in the cure of various
 fcrms of ulcers.  London, 1837. 
WEAK AND INDOLENT  ULCERS.
87
irritability of the part.   Weak lotions of nitric acid (F. 60), of nitrate of
silver (gr.  i. ad. 3j.),  of arsenic (F. 63), of sulphate  of zinc (gr. i.—- v.
ad. 3j.), of sulphate  of copper (gr. i.—ii.  ad.  3j.),  of acetate  of zinc
(F. 107), of corrosive  sublimate (F. 118), of chloride of soda, of iodine
(F. 46), the linimentum  aeruginis, black  wash  (F.  64), yellow wash
(F. 65), lime water,  solution of sulphate of iron (gr. i. ad. 3j.)> forge
water, that is, water in which red-hot iron has been extinguished, strong
green tea,  powdered chalk or charcoal  mixed with cream, ointments of
Peruvian balsam, of oxide  of zinc, chalk, lead, and calamine; weak mer-
curial  ointment, liniment  of ung. hydr. nitratis;  moderate pressure with
strips of soap plaster, or of  linen spread with soap cerate, or with a smooth
piece of sheet lead; all of these measures will occasionally be of service
in the cure of  obstinate and irritable ulcers.  For it very often happens
that an application which at  first soothes the pain will  soon lose  its good
effects, and then become positively hurtful.
   IV. The Weak Ulcer is the direct reverse  of the preceding.   Its
powers of organisation are  deficient.   The  granulations are large, pale,
flabby, and  insensible, rising above  the margin of the skin, and  showing
no disposition to cicatrise.
   Causes. — This state of  ulcer may be owing to debility of the  system;
but the healthiest granulations, if their healing be  delayed, become weak;
—and conversely, if  any  granulations do  not cicatrise, they should be
considered as weak, and treated accordingly.
   Treatment. — The indications are to augment the  vital forces of the
granulations, and to restrain their exuberant  growth.   A liberal diet and
tonics should be resorted to.  If the  granulations are extremely exube-
rant, they  may be destroyed by escharotics, such as  cupri sulphas; — or
sometimes they may be shaved  off with a thin knife ; — but it is  better to
cause their  removal by over-stimulation than  by actual  destruction.  So
that the best applications are, fine dry lint, which by itself is an  excellent
stimulant;  or lint dipped  in a lotion of sulphate  of zinc, or of sulphate of
 copper, or of nitrate of silver, or the ung. hydr. nit.   The formation of  a
 crust or scab with the lunar  caustic, on Mr. Higginbottom's plan, may be
 often resorted to with  advantage.  At the same  time, pressure by means
 of strips of plaster, or compresses, and bandages, are necessary to prevent
languor of the circulation;—especially if the  muscles are  wasted and
flabby.  In some  cases a scab  may be formed by covering the  sore with
powdered rhubarb, taking care  to oil the edges, so that they may not be
irritated by it.   If the patient  is young and weakly, with great  coldness
and blueness, and tenderness to cedema in the extremities, the limb may
 be immersed in tepid  salt  water for fifteen minutes twice a day;  to which
an equal part of decoction of poppies  may be added, if pimples are pro-
duced.
   V.  The Indolent  Ulcer is  characterised by  a deficiency of  action as
well as of power.   Its surface  is smooth and glassy, and of a pale  ashy
colour,  like a  mucous  membrane.  Sometimes, however, it displays  a
crop of weak fungous granulations.  The edges are raised, thick, white.
and insensible ; the discharge scanty and thin.   The most frequent situa-
tion of these ulcers is  the small  of the leg, and they a;e almost exclusively
met with amongst  the lower orders.  They are often stationary for a great
length of  time ; but,  from any slight cause  of irritation, may enlarge ra-
pidly  by ulceration or sloughing; and even when they  have made consi- 
9R
INDOLENT ULCERS.
derable progress in healing, the granulations and cicatrices that have been
months  in  forming may perish in  a few hours from some  constitutional
disturbance or local injury.
   Treatment.—The general rules are, to promote constitutional vigour by
good diet  and tonics, and to  excite  the local actions by various stimu-
lants.  The patient should take  moderate exercise ; but when he  is at
rest, the affected  limb should  not  be permitted  to  hang  down.   In
treating these  cases, we must  endeavour not only to effect  a  cure, but to
make it permanent; and  this can be  insured  only by attending to the
growth  of  the  granulations, and rendering them as healthy and firm as
possible.
   The following is perhaps the best plan of curing these ulcers.   A num-
ber of pieces of lint, thoroughly soaked  in the nitric acid lotion, should be
laid on the sore, and be covered with  a warm soft poultice.   These ap-
plications should be changed twice a day, and be continued till the dis-
charge becomes healthy, and granulations begin to arise.  If  there is any
degree of inflammation about the parts (which often happens when  these
ulcers first come under treatment), the patient  must be confined to bed
and be  purged.  Afterwards, when the surface is clean,  the following
mode of dressing should be adopted.   First, some pieces of lint, saturated
with the nitric acid lotion, or zinc lotion, or with  some  other stimulating
substance, should be laid on the  sore.  Then strips of adhesive plaster,
about 1^ inch  wide, should be applied two-thirds round the  limb, from an
inch below the ulcer to an inch above it; and in applying each strip, the
edges of the  sore should be  drawn together with a moderate degree of
force.  Next,  a compress  of soft linen must be placed over the plaster,
and finally, the limb must  be well  and  evenly bandaged from the toes to
the knee ; observing that the bandage is to be applied most  tightly below,
and more loosely by degrees as it ascends.
   Baynton's Plan.—If, however, the whole limb is very much thickened,
and  the  edges of the ulcers  are very callous, it will be better to  follow
Mr. Baynton's method ;*—that is, to encircle the whole circumference of
the limb  with strips of plaster, from  an inch below to an inch  above the
ulcers.   Each strip is to be first  applied by its middle to that part of the
limb which is opposite the ulcer, and then the two ends are to be brought
forwards over it, and they should be long enough  to overlap  about two
inches.   A compress  and bandage are to be applied afterwards.   These
modes of dressing almost always cause  severe pain ;—but it ought soon to
subside, and the part  to feel  stronger and more comfortable afterwards.
  • Baynton, T., Descriptive Account of a New Method of Treating Old Ulcers of the
Legs   Bristol, 1797. 
                         INDOLENT ULCERS.                       89

If, however, it continue to be painful and hot, some pure water should be
poured on the bandage from a watering-pot or tea-pot.

                                Fig. 6.
   If the adhesive plaster irritate the skin, it may be diluted with soap-
plaster ;—or the isinglass-plaster may be substituted.  This is made by
dissolving isinglass in spirits of wine, and spreading the solution on silk.
It readily adheres if moistened with a warm sponge.
   But although the plastering and bandaging are adapted for most cases,
the immediate application to the ulcer will require  to be frequently varied.
Sometimes  the strapping may be applied without anything else; or dry
lint may be placed  under it; or lint imbued with  lotions of sulphate of
copper, or alum; or with lotions made by adding half an  ounce of the
tincture of myrrh, or of benzoin (comp.), or aloes (comp.), to four ounces
of water;  or the balsams of copaiba or Peru ;  but metallic preparations
agree better in general  than the vegetable.   Ointments agree better with
the indolent than with the  other varieties of ulcer, because they do no
harm if rancid.   The  ung. hyd. nitric, oxid. is very useful;—and the
ung. hydrarg.  nitrat. dilut.  is praised for its efficacy in reducing thick
callous edges.  Mr. Stafford recommends old deep indolent ulcers to be
treated by filling up their cavity with a mixture  of one part of Venice tui-
pentine,  and four of bees' wax, melted, and poured in warm.
   If a crop of  granulations  threaten to slough,  they should  be  fomented
with hot decoction  of poppies, to which  a little spirit of wine has been
added.   The gastric juice  of animals is  said to  be  a specific for certain
sloughing  ulcers occurring in persons debilitated by the use  of ardent
spirits and  salt provisions, and  by residence in  hot climates.  During
any febrile  disturbance  of  the  system, the local applications must be
mild.
   Mr. Skey has proposed to treat indolent ulcers  in  debilitated constitu-
tions by the administration  of small doses  of opium night and morning,
with the  view of keeping up the capillary circulation.
   Should old, ulcers be healed ?—The propriety of  healing old ulcers will
sometimes be made a question, inasmuch  as certain diseases,  and espe-
cially apoplexy and palsy, are apt to supervene on their suppression.   Sir
E. Home has  specified the following cases in which  a cure ought not to
be attempted.   1. If the ulcer be "evidently affected with  the gout,
having regular attacks  of pain, returning at stated  periods;  and those
attacks similar to what  the  patient  has experienced  from gout in other
       8* 
nO                      FISTULOUS ULCERS.
parts."  2. If an ulcer habitually occur whenever the constitution is dis-
ordered.   3.  If the patient be very infirm and  old;  for under these cir-
cumstances the removal of an habitual source of irritation, or the diversion
of an habitual afflux of blood, may prove fatal;—more especially as very
old  ulcers have been  known to heal spontaneously a short time  before
death.  In the first two cases, however, an issue placed in a convenient
situation might be substituted for an ulcer in an inconvenient one.   But
in other cases, when the ulcer has  not displayed any connexion with con-
stitutional disorder, there  need be no reluctance to heal it, provided that
the secretions of the kidneys  and liver are properly maintained during the
cure, and for some time afterwards.   And if any symptoms of congestion
in the head or other organ should arise, an  issue may be inserted in the
arm.   Whateley* mentions a case in which an ulcer was healed, but some
time afterwards it reappeared of itself, and soon  after that the patient died
suddenly; and, he  observes, if his death had happened before the second
breaking out of the  ulcer, it would infallibly have been attributed to the
healing of it.
   VI. The Fistulous Ulcer (Fistula or Sinus) is  a variety of the indo-
lent, and  consists  of a narrow channel lined by a  pale  pseudo-mucous
membrane, which may or may not lead  to a suppurating cavity.   In old
cases the parietes of the tube are often dense and semi-cartilaginous.
   Causes. — Fistulas are  produced when abscesses  are  not thoroughly
healed from  the bottom, when  there has been a defect in the bandaging,
or in providing proper outlets for the discharge  ; or when there  is some
standing cause of irritation,  as a ligature,  or a piece of dead bone, which
keeps up a discharge of pus.
   Treatment.—The first indication is to remove any source of irritation—
diseased bone, for example—that may happen to exist.  The second, to
prevent the lodgment of matter; for which purpose it may  perhaps be ne-
cessary to make another opening.   The third indication is  to produce the
adhesive inflammation ;—to  which the mucous lining of the fistula is na-
turally indisposed.   The means to be adopted are, stimulating  injections,
tents smeared with irritating ointments;  the caustic bougie; or  a seton
consisting  of a few threads of silk, which may be  passed through the
fistula, and may be  gradually diminished as  the the passage  contracts.
At the same time, the sides of the fistula should be kept constantly pressed
together  with compress and bandage.   If  these means  fail, the  fistula
should be slit up with  a bistoury ;  and then a thin piece of lint be intro-
duced in order to prevent premature union of the cut edges, and make  it
heal from the bottom.
  If there have been a succession of small unhealthy abscesses in a part;
—or if ulceration have spread irregularly in the cellular tissue, so  as to
leave the skin ragged, and extensively undermined with tortuous sinuses,
it will be advisable to destroy the whole of  the  parts so diseased by the
potassa fusa; and this will stimulate the  neighbouring sound parts, so that
when the  slough separates, a healthy surface will be  left,  which may be
healed by the ordinary means.f
  VII.—The Varicose Ulcer occurs in  consequence of a varicose state
of the veins of the lower extremity.  This greatly impedes the  return of
  • Whateley, T., Practical Observations on the  Cure of Wounds and Ulcer3.  Lond.
IS16, p. 144.
  J- Liston, Elements of Surgery. 
PHAGEDENIC  ULCERS.
91
blood, and, by producing habitual venous  congestion, weakens the parts,
and renders them prone  to  ulceration.   The  ulcers are usually three or
four in number; situated above the ankle.   They are oval in shape, in-
dolent in  their progress, and neither  extensive  nor deep; — but they
are attended with considerable pain, which is of a deep-seated,  aching
character.
   The Treatment must be  directed principally to  the veins, and for this,
we must  refer to the chapter on that subject.  We will merely observe
here,  that the applications to the ulcers must be  suited to their condition,
whether irritable or  indolent;—and that great relief to the pain  is  fre-
quently obtained by  opening one of the  enlarged vessels, and abstracting
a  moderate  quantity of blood.   The advantages of proper  support by
bandages or laced stockings need scarcely to  be noticed.  Sometimes
there  is a constant desquamation of the cuticle, writh serous discharge, for
which the best remedies are equal parts  of  limewater and milk, or the
ointment of chalk (F. 102), or of oxide of zinc.
   VIII.  The Sloughing Ulcer is formed whenever either of the other
varieties of ulcer is attacked with sloughing;—which is particularly liable
to  occur  to  the indolent, when subjected to undue irritation.  Or, this
name may be given to ulcers  originally produced by a sloughing of the
skin ;—as on the  legs of the dropsical.
   Treatment.—The  best applications  are warm fomentations of poppy de-
coction, to which a little spirit has been added;  and stimulating poultices
of yeast or carrots;  or the nitric acid lotion on lint,  with a warm poultice
over it.
   IX. Phagedena  is a  peculiar variety of ulceration, extremely rapid in
its progress.   The surface  of the  sore  is  irregular, generally whitish or
yellowish ; the discharge serous, or bloody, and often  extremely profuse ;
and the  pain extreme.  Some cases are attended  with fever and acute
inflammation, the margin of the sore being highly painful, swelled, and
red;—others with  atony and debility, the margin being pale, dusky, or
livid.
   Causes. — This disease  may be  induced either by  extraordinary  local
irritation, or by some peculiar constitutional disorder.  It may attack pri
mary  or secondary venereal sores in  consequence of filth, intemperance,
the abuse of mercury; or of a weakened and vitiated, or scrofulous habit,
or of  some peculiarity in the venereal virus.  Sometimes it appears in the
throat after scarlatina; — it  may attack a blistered  surface when the  con-
stitution  has greatly suffered from  an acute and  exhausting  disease, as
measles,  &c.;—sometimes  it affects  the mouth or  genitals of children,
constituting cancrum oris* noma, &c.
   Treatment.—If the habit is inflammatory, and the pulse full  and strong,
bleeding and the antiphlogistic regimen should be employed, and opiate
lotion be applied to the sore.  If the condition of the  system is  the reverse,
tonics and narcotics (F. 1, 2, 3) should be administered, and the  dis-
eased  surface should be destroyed by nitric acid in the manner to be pre-
sently described.
   X.  Sloughing Phagedena or Hospital Gangrene seems, says Mr.
Lawrence, to be the  state of phagedaena carried to its fullest extent;—or,
as was explained at the commencement of this chapter, it may be described
* V.de Part IV. chap. xiv. 
ii2
PHAGEDiEN C  ULCERS.
as a process intermediate between common ulceration and gangrene.   Its
causes are, (1) great local irritation, combined with a vitiated state ot the
constitution.   (2) Contagion; that is, the application of poisonous matter
to a wound ;  and (3) infection ;  that is, the reception of poisonous mias-
mata into the  blood.   We shall first treat of it as it occurs sporadically in
civil practice, where it bears the  name of sloughing phagedena ; and next,
of those more serious visitations that decimate the patients in  crowded
naval  or  military hospitals, whence it derives its  other name, hospital
gangrene.*
   In the  cases seen in civil practice, the disease is  mostly seated in or
near  the genital organs; in the cleft of the nates,  in the groin, or at the
upper and inner part  of  the thigh.   It  often, but far from  invariably,
supervenes on syphilitic ulcers;  especially in young prostitutes, who have
been exposed to cold and wet, and privation of solid food, and the abuse
of ardent spirits.   It is especially liable to be induced by the too free ad-
ministration of mercury, or by intemperance and  exposure to wet during
a  mercurial  course.   The worst cases,  however,  appear to arise  from
neglected local  irritation, without any specific virus;  as from acrid dis-
charges and defective cleanliness.   Mr. Lawrence mentions the  case of a
young woman who had suffered from severe small-pox, and from diarrhoea
after it.   The continual moisture from  the  rectum, with a mucous dis-
charge from the vagina, irritated and inflamed the skin of the nates, and
caused a large sloughing phagedenic excavation on both sides.
   Symptoms. — "It usually commences as  a highly irritable and  painful
boil, surrounded by a halo of dusky red inflammation, and much  elevated;
the patient also in general having mucous discharges from the vagina, and
a diffused redness of integument in the vicinity of the pudenda."   There
are  severe darting and stinging  pains;  which  are at first intermittent, but
gradually establish themselves as a constant  symptom,  with occasional
exacerbations.   When the pustule is ruptured, the exposed  surface of the
ulcer displays a stratum of adherent straw-coloured flocculi, mottled with
darker points of reddish-brown  and grey.   The  sore thus formed  soon
enlarges in breadth and depth;—the edges become everted, and attended
with a circumscribed thickening, which is surrounded by dusky inflamma-
tion  and  diffused  puffy swelling.   The surface is  composed of grey or
ash-coloured  sloughs, which may become brown, or resemble coagula of
blood.   The  discharge  is reddish-brown, and  peculiarly foetid,  and there
is occasionally severe haemorrhage.  Meanwhile the agonizing  pain, the
haemorrhage,  and  the  absorption of putrid  matters, soon  induce severe
irritative fever, — ushered in by loss of sleep, anxiety,  restlessness, and
thirst; which, with an exhausting diarrhoea, produce death in about three
weeks; and,  as delirium is rare, the patient retains a miserable conscious-
ness of severe suffering till the end.   This disease is highly contagious,

  * In civil hospitals any serious attack of hospital gangrene  is almost unheard of
 5Tet, it occasionally threatens to appear. Thus, Mr. Liston says in 1844, of a  stump*that
was healing kindly in University College  Hospital, that all of a sudden it  assumed a
carious appearance; became enormously swollen, and profuse haemorrhage took  place
"Not many days passed before a number of other wounds  assumed the same appear-
ance;  the parts got puffy around them; the discharge became slimy and tenacious,
very putrid, and bloody foetid gas filled the cellular  tissue around them.  They  ex-
tended rapidly, presenting a circular form."—Lectures in Lancet for 1845, vol. i. p. 57.
 Mr. Arnott witnessed three cases in the Middlesex Hospital in 1835.  Quoted in Souths
Chelius, vol. i. p. 67. 
HOSPITAL GANGRENE.
93
but it appears to be a local disease, and both the constitutional and local
symptoms may be removed by measures which destroy the acrid secretions
of the ulcer.*
  Hospital Gangrene is the name given to this affection when occurring
in military and naval practice.
   Causes.—Like other putrid  maladies,  it is engendered  by crowding
together a number of sick  and wounded  men; — and  by inattention to
cleanliness  and  comfort, and to free ventilation, which is so necessary for
carrying off the  noxious miasmata always generated under those circum-
stances.  It frequently is a concomitant of  dysentery or typhus, originating
in the same sources.  It may affect any  kind of wound, or even a mere
bruise.
   Propagation.—This disease, when once generated, may either spread
by contagion; that is, by the contact  of  its  morbid  secretions; — or by
infection ; that is, through the medium of  its vapour or effluvium.  It may,
although rarely,  occur sporadically; that  is, may be induced  in  isolated
cases by improper and irritating local and constitutional treatment of the
wounded.
   Symptoms.—According  to  Mr. Blackadder, it  begins in the form of a
livid vesicle  at the edge of a wound or sore,  accompanied with an  occa-
sional painful sensation like the sting of a  gnat. Sometimes it first appears
as a small livid spot on the sore, and near its circumference.  In either
case the disease  soon spreads, and converts the whole surface of the ulcer
into an ash-coloured or blackish  slough.  The discharge,  if previously
healthy, is at first diminished in quantity, and sanious ;—but soon becomes
profuse, and dirty-yellowish or Drown.   According to this gentleman, the
hospital gangrene is at first a purely local affection, like  the sloughing
phagedaena ;—and he says that the constitutional symptoms (typhoid fever,
&c.)  do  not make their appearance before the third or fourth, sometimes
not till the  twentieth day.f
   Dr. Hennen's Account. — The  following   quotations, however,  from
Hennen, display a slight variation from Mr. Blackadder's account.   " Let
us  suppose," says Dr. H., "that our w-ounded have  all been going on
well for several days, when suddenly one  of our most promising  patients
complains of severe pain in his head and eyes, a particular tightness about
the forehead, loss of sleep, and want of appetite;  and that these feelings
are accompanied with quickness of pulse, and other symptoms of fever;
his wound,  which had been healthy and granulating,  at once  becomes
tumid, dry,  and  painful, losing its florid  colour, and assuming a  dry and
glossy coat.  This is a description of the first stage of our Bilboa  hospital
gangrene, and if a brisk emetic wrere now  exhibited, a surgeon, not aware
of the disease that was about to form, would be astonished at the ameliora-
tion of the sore,  and the unusual quantity of bile and of indigested matter
evacuated by vomiting." — "If this incipient stage wras overlooked, the
febrile symptoms soon became aggravated;  the skin  around the  sore as-
sumed a higher florid colour, which shortly became darker, then bluish,
and  at last  black, with a disposition to vesicate;  whilst the rest of the
limb betrayed a tendency to cedema.  All these threatening appearances
occurred within twenty-four hours ;—and at this period the  wound, what-
  * Welbank, Med.  Chir. Trans., vol. xi.; Lawrence, Lecture in Med. Gaz., vol. v.
  f Observations on Phagedaena Gangrenosa.  By H.  Home Blackadder.   Edinburgh
1818. 
94
HOSPITAL GANGRENE.
ever might have been its original shape, soon  assumed the circular form.
The sore now acquired  hard prominent ragged edges, giving it a cup-like
appearance, with particular points of the  lip  of a dirt-yellow  hue ;  while
the bottom  of the  cavity was lined with  a flabby, blackish slough.   The
rapid  progress and circular form were highly characteristic of hospital gan-
grene."—"The discharge in this second  stage became dark-coloured and
fetid,  and the pain  extremely  poignant."—"The face  of the sufferer
assumed a ghastly, anxious  appearance;  his  eyes  became haggard, and
deeply tinged with bile  ; his tongue loaded with a brown or blackish fur ;
his appetite  entirely failed  him, and  his  pulse was considerably sunk in
strength, and proportionably accelerated." —  "The third  and last  stage
was now fast approaching.  The surface of the sore was constantly covered
with a bloody oozing;  and  on  lifting up the edge of the flabby slough,
the probe was tinged with dark-coloured  grumous blood, with which also
its track became  immediately filled ; repeated and copious venous bleed-
ings now  came on;"—" at length an artery sprung, which, in  the attempt
to secure it, most probably burst under the ligature."—"Incessant retch-
ings soon came  on, and, with  coma, involuntary stools,  and hiccough,
closed the scene."*
   It thus appears, by  collating the observations of these two military
authorities, that the hospital gangrene may either be  a local disease;  being
produced by local contamination of a wound, and existing for some days
before the system at large is affected by it;—or it may be constitutional
from the first;—that is, may be  introduced by the absorption of poisonous
miasmata into the blood ;  in which latter case  the constitutional symptoms
precede  the  local mischief.f   In fact, the -ordinary constitutional  symp-
toms of hospital  gangrene might be induced in the  nurses and attendants
on the  sick, from washing  the  bandages, and from general exposure  to
noisome effluvia, without  being  followed by any local affection  whatever.
   Treatment.—The  indications  in the treatment of all the forms of slough-
ing phagedaena, are, 1,  to destroy the diseased surface and  its  secretions;
—and, 2, to correct the concomitant contamination  of the system.
   The first  indication is  to be carried into  effect by means of caustics.
The French use the actual cautery; Mr. Blackadder recommends the liq.
arsenicalis ;—but the following mode of using  the concentrated  nitric acid,
as directed  by Mr. Welbank, is preferable to either.  In the  first  place,
the sore must be thoroughly cleansed, and all  its moisture be absorbed by
lint or tow.   If the sloughs are very thick, they may be removed by means
of forceps and scissors.  The surrounding parts must next be defended
with a thick layer of ointment, then a thick pledget of lint, which may be
conveniently fastened to the end of a stick, is  to be imbued with the acid,
and to be pressed steadily on  every part  of the diseased surface till the
latter  is converted into a dry, firm,  and insensible mass.  This  application
of course causes more or less pain for the moment, but, when that  sub-
sides, the patient expresses himself free from  his previous  severer suffer-
ings.   The  part  may then be covered with simple  dressings,  and  cloths
wet with cold water.   " It is  always prudent, often necessary," says Mr.
  * Principles of Military Surgery.  By John Hennen, M. D., F. R. S. E., 3d ed., London
1829, pp. 217 et seq.
  ■f Of the various writers  on Military Surgery,  Pouteau, Rollo, Ollivier, and Copland
Hutchinson, believe the disease to be primarily local;  Thompson and Sir James M'Gri-
gen believe it occasionally constitutional in its origin.   Their opinions are quoted in Sii
G. Ballingall's Military Surgery 
HOsriTAL gan:;rene.
95
Welbank, " to remove  the  eschar at the end of si Kteen or twenty hours;
and then, if the patient be free from pain, and the ulcer healthy and florid,
it is to be treated with  common  stimulating dressings; — such as cerat
calaminae, or solution of argenti nitras;—or a cerate of turpentine, which
may be melted and  poured in warm."  If, however, there be any recur-
rence of pain, or the least reappearance of the  disease, the acid  is again
and again to be applied till a healthy action is restored.
  As for the general treatment;—if the constitution is not affected, opium
may be given to allay the pain caused by the disease, and by the applica-
tion of the escharotic ; the bowels should be opened, and the diet regulated
so as to support the strength without exciting feverishness.
  But if the  disease,  as observed by Hennen, begin with  fever of an
inflammatory type, and  the  patient be robust,  and the  local inflammation
intense, a moderate blood-letting may be performed with advantage; with
an emetic, purgatives, and the antiphlogistic regimen generally. Mercury
is for the most part highly pernicious.*
  If, however, the constitutional affection assume a low or typhoid type,
either from the beginning or subsequently, the principal dependence is to
be placed on opiates, tonic, and wine, in order to allay irritation and sup-
port the strength,  keeping open the bowels by cordial laxatives.  If there
be much diarrhoea, bark will be hurtful.
   Prevention.—It will be most necessary to prevent the spreading of this
dreadful  affection by the freest  ventilation,  by frequent ablution of  the
bodies of the sick and wounded, and changes of their bed-clothes and
linen ;—by the instant  removal  of all excrements or filth;—and  by  the
most scrupulous care to wash the bandages in boiling-water,  if they are to
be  used  again, and to destroy them  immediately if they are not.  The
walls also should be daily white-washed, and the floor perpetually sprinkled
with  a solution of the chlorides.   All the  affected patients should be in-
stantly removed to the greatest possible distance  from the others; every-
thing connected with them should be thoroughly cleansed, and the utmost
care  be taken not to convey the contagion by means of sponges or dress-
ings, or even by  the fingers or instruments of the surgeon ; in fact, tow or
lint might well supersede sponges, as they might be  destroyed after using.
   XI. Malignant Pustule (Charbon) is a contagious and very fatal dis-
ease  common in France, but almost unknown in England. It commences
as a little dark red spot, with a stinging or pricking pain ;  on which there
soon appears a pustule  or vesicle seated on a hard inflamed base.   When
this is opened, it is found to contain a slough, black as charcoal;  and  the
sloughing rapidly spreads, involving skin  and cellular tissue, and some-
times the muscles beneath.
   The account given of this malady by the continental writers is exceed-
ingly confused ; but it appears certain, that  it is caused by infection or
contagion from horned  cattle, which at certain  seasons  are affected with  a
precisely similar disease; and  it further appears that,  like hospital gan-
grene, it may commence  in two ways:—
   1st. By general infection of the system, from respiring air loaded with
miasmata from diseased animals; or from  eating their flesh.   In this case
it commences with constitutional symptoms; and it is  this foim which is
more particularly styled charbon.
  * Babington says, that it may be employed with advantage,  if the surrounding inflam
mation be vivid and intense.  On Sloughing Sores, Lond. Med. Journ. vol. ivii. p. 204.
and vol. lviii. p. 2S8. 
!)C
MALIGNANT  PUSTULE.
  2dly. By inoculation of the diseased fluids;  and in this  case  the local
symptoms begin before the constitutional.  Mr. Lawrence gives an account
of a man  in Leadenhall Market, who  accidentally smeared his  face with
some stinking hides from South America.  The part touched by the putrid
matter  very soon became red, and swelled, and mortified, and the  mortifi-
cation spread over half the cheek.   He has also met with two other cases
affecting persons  in  a horse-hair manufactory.  It is  believed  that flies
which  have alighted on the ulcers  of the  diseased animals, convey the
virus, and infect other animals and human beings.
  The constitutional symptoms and morbid appearances are those of putrid
typhus; the treatment, both constitutional and local, is the same  that we
have directed for hospital gangrene.*
  [In the  Am. Journ. of the Med. Sc, vol. xix., 1836,  is an interesting
paper on the malignant pustule by Dr. Pennock, of this  city,  giving a re-
port of four cases of  this affection.   The following abstract of this essay
will give increased definiteness to Mr. Druitt's account of the disease.
  These four cases  came  under Dr.  Pennock's notice  during the con-
tinuance of an epizootic, which prevailed among the cattle in the  vicinity
of  Philadelphia,  in  the autumn of  1834.   The  persons whose  history
is related had all been engaged in skinning cattle recently dead of the
"murrain," as the  disease was  termed.   One of the  men was stung
by  a musquito on the hand, while he was thus employed, and he care-
lessly rubbed the  bitten part with his bloody hand.   Another " received
a slight wound  on  the ulnar side of the  left hand, which  apparently
soon healed."  A third was not aware of having any abrasion of the skin
at the time, but his hands were covered with blood for two hours.  The
fourth  was equally unconscious of having any scratch upon his arm while
he  was engaged in operating upon the animal,  but "he carried its hide on
the bare and bloody arm for more than an hour."   " At periods,  varying
from three to eight days after contact with the dead bodies of the animals,
a vesicle of the size of a grain of millet appeared on the point  of inocu-
lation, without having been preceded either by heat, prurience, or tension.
This vesicle gradually augmented, was attended by a sensation of  itching,
but no  pain ; its colour was dark brown or livid ;—broke, either spontane-
ously or by rubbing, and discharged a few drops of serosity.  This period
of  the disease occupied from twenty-four to forty-eight  hours."   " The
second period  (of Chaussier) wTas characterized by the  formation, in the
central portion of the ruptured vesicle, of a small, hardened, insensible,
circumscribed tubercle, which was  of a brown or livid colour,  and soon
became surrounded  by a dark purple  areola, in which numerous  vesicles
or small phlyctenae were disseminated.  The  disease had now penetrated
the entire thickness of the skin ; the adjacent tissues became swollen, and
the pruriency was replaced by a feeling of heat, burning, or gnawing in the
contiguous  surface.   This period continued  but  a few days, before the
characters of the third period were perceived."
   " Third period.—This was marked  by the rapid  extension  of the cen-
tral gangrenous portion ; the vesicular areola spread over a greater space,
became raised at the circumference, causing the centre to appear depressed.
  * Lawrence, Med. Gaz. vol. v. p. 392 ;  Die. de  Med. Art. Charbon, Pustule  maligne;
!"'cliwabe, Brit, and For. Rev. vol. vii. p. 550.  A case  of anthrax caused by eating the
flesh of an animal which had died of the disease, is quoted from an Italian journal  in
I<ond. Med. Gaz. 21st Oct. 1*42; and there is a very convenient collection of  the  nio.st
recent information on the subject in South's Chelius, vol. i. p. 65. 
MALIGNANT  PUSTULE.
97
The contiguous parts were hard, swollen, benumbed, and  almost insensi-
ble ; erysipelatous inflammation took place to a considerable  extent, and
was accompanied in three instances, of those mentioned by  Chaussier,
by  intense fever."  " The fourth stage, when  fatal,  is usually of short
continuance, is marked by increased intensity of all the symptoms previ-
ously mentioned, and to these are superadded the worst form of adynamic
fever (Boyer)."
   Of course, the duration of each  of these periods varies very  much.
" Sometimes the progress of the disease is so rapid that the four periods
are confounded and cannot be distinguished.  Under some favourable cir-
cumstances, the  gangrenous progress is limited  to the second or early
stage of the third  period.  When this  occurs, the disease is surrounded
by  a red line of inflammation;  sensation and warmth  are manifested  in
the contiguous surfaces, the pulse becomes fuller,  and all the appearances
assume a favourable aspect."
   The prognosis of the disease, in  its early stages, is singularly various,
according  to the habits, constitution, age, &c, of the patient.   When it
attacks the neck, the danger is increased, in consequence of the liability to
compression of the trachea and oesophagus.  When a considerable extent
of  siuface is involved,  or if there  are several  pustules, a proportionate
degree of danger exists.  If it occurs in a pregnant woman, abortion may
ensue.   Extremes of temperature are unfavourable attendants.
   " In some of the provinces of France, this  disease  is very frequent in
low and marshy districts of  country; it appears  in  hot seasons, after the
meadow lands  have been submerged by inundations ;  when the pasturages
are of bad quality, the  fodder mouldy, mildewed, or charged with  insects
in  a state of putrefaction.  Chabert asserts, that poultry is subject to a
disease which produces the same effect upon man  as the causes previousl)'
mentioned.  The disease  has  also been  contracted by the  dissection of
hares or wolves,  proving that the virus may be produced among the herb-
ivorous and  carnivorous animals, whether domesticated or  wild."
    Treatment.—" The first indication in the treatment of the  malignant
pustule is, to protect the  adjacent parts  from  its action, and to circum-
scribe the original disease  within the smallest possible limits.  Experience
has shown that this is best effected by the combined and judicious  use of
scarifications, and  the  application  of caustic  to  the   diseased surface."
" To be efficacious, the scarifications should be sufficiently deep to pene-
trate through the gangrenous portions, but  not to involve the sound parts
beneath the pustule ; they  allow of the discharge of the morbid secretions.
and permit of  the immediate action of the  remedies upon  the gangrenous
surfaces.
   " The  caustics,  however, are  the  most valuable and truly efficacious
means of treating the disease,  isolating it from the rest of the system, ex-
citing increased vitality in  the adjoining surfaces, and inducing healthy ac-
tion, so that the eschar  is detached by the ordinary process of suppuration
The caustics which are  preferred are the liquid muriate of antimony, caus-
tic potash, and nitrate of silver."   If the morbid  appearances be deep in
the cellular tissue,-the vegetable alkali should be  applied.  After the use
of the caustic, an alkaline, or other stimulating poultice,  should be laid
upon the part,  which should be examined after a  few  hours have passed
 If  a hard tumour be observed around the eschar; — if an areolar  vesicle
should form, or if  the surrounding surfaces  become much  swollen, a
        9                          g 
93
VARIETIES  OF  ULCER*.
second application of the caustic is necessary, previously taking the pre-
caution  to  make  crucial  incisions  through the eschar,  in order that the
escharotic may act upon the contiguous parts.   This treatment is adapted
not only to the early but to the more advanced period of the disease.  In
the vesicular state the serum should be evacuated by opening the vesicle,
and the  bottom of the latter touched with the nitrate of silver, or with the
muriate of antimony.  Sanguine depletion should not be resorted to, even
when the diffuse inflammation is considerable and the accompanying fever
high.  Instead of  this, saline laxatives and cooling draughts should be
employed,  together with saturine lotions to the inflamed  surface.  When,
in the later period, the strength becomes diminished, quinine, camphor,
and the  mineral acids, with broths,  should be freely administered.  Opiates
are also valuable adjuvants.
   Dr. Pennock's paper is illustrated by drawings showing different phases
of the disease.—Ed.]
   XII.  Morbid Ulcers.—Under this term Sir E. Home includes a variety
of ulcers connected with a disordered state of the constitution, and capable
of being removed by particular remedies.   Arsenic is said by Mr. Eccles"
to be highly useful in sores which are dry and little inflamed, and sur-
rounded by much scabbing  and  exfoliation of the  cuticle.   Ulcers  about
the instep and foot, with their edges and the surrounding skin much and
extensively thickened like elephantiasis ;  and often occurring in the lazy
and over-fed  servants of the opulent;—sometimes yield to mercurial fumi-
gations, or the application of mercurial ointment with camphor.
   XIII.  The Cutaneous Ulcer spreads, widely but superficially over the
skin, and  often heals in one  part whilst it  spreads to another.    Some
ulcers of this kind are contagious.
   Treatment. — Any  constitutional  disorder  must  be ascertained and
remedied.  The best local  applications are stimulants, especially  the arg.
nit., employed  in  solution,  or rubbed lightly over  the sore, so as to form
an eschar.
   XIV.  The Ulcer of the Cellular Membrane, — which burrows
under the skin and destroys that tissue, — must be  treated as the fistulous
or weak, according to circumstances.
   XV. Menstrual Ulcer. — This name is given  to ulcers occurring in
chlorotic young women, and exuding a sanguineous fluid at the  time of
their monthly discharge, if that be absent.   Wounds made in operating
will frequently do the same.
   Treatment. — The amenorrhoea must be remedied by steel,  aloes, &c,
and the ulcer be treated on general principles.
   [Too much stress can scarcely be laid  upon the  importance  of perfect
rest of the  part, in the treatment of ulcers.   If the  lower extremity be the
seat of the  disease, a fracture-box will be  found to be the most  convenient
apparatus for the  fulfilment of this indication:  a  pillow, protected by a
piece of oil-cloth, upon which bran  or cotton is spread to imbibe the  secre-
tion from the ulcer, should be placed  in the  box, and the limb laid upon
it and secured by closing the sides of the box, the foot being attached to
the foot-board.   If the arm  be the  part affected, it  should be placed upon
a splint, and  confined by a  bandage so applied as that no undue pressure
sha1! fall upon the ulcer.—Ed.]
* Eccles on the Ulcerative Process and its Treatment.  Lond. 1834. 
MORTIFICATION.
99
                          CHAPTER  X.

                      OF MORTIFICATION.

  SECTION I.--OF THE  PATHOLOGY  OF  MORTIFICATION.

  Definition.—Mortification signifies the death of any part of the body,
in consequence of disease or injury.
  Varieties. — Some persons  use  the terms mortification, gangrene, and
sphacelus, indiscriminately; but it is better to signify by sphacelus an utter
and irrecoverable  loss of life, and to restrict the term gangrene to the state
which precedes, and commonly (but not inevitably) terminates in spha-
celus; a state in which, as Thompson says, "there  is a  diminution, but
not a total destruction, of the powers of life ;—in which the blood appears
to circulate through the larger vessels, — in which  the nerves still retain a
portion of their sensibility, and in which perhaps the part may still be sup-
posed to be capable of recovery."
  Another  distinction is  made between humid and dry gangrene.  The
humid is  a consequence of inflammation, or of obstacle  to  the return  of
the venous blood ; and the mortified part, being  loaded  with  fluid effu-
sions, soon undergoes  decomposition: whilst the  dry gangrene is gene-
rally  a  consequence of deficient supply of  blood, or of  constitutional
causes, and is either preceded by  no inflammation at all, or by one  so
rapid that there is no time  for interstitial  effusions  to  occur,  so that the
mortified  part  becomes dry  and hard — in the former case being called a
slough, in the latter  an eschar.
   Another and a  most important  division is into constitutional and local.
By constitutional mortification is meant that wrhich primarily  originates  in
constitutional disorder; or that which, having begun from a local injury,
is propagated and maintained by constitutional disorder.   By local morti-
fication is  understood that  by  which  the system  is not  implicated, and
with which it does not sympathize in a violent or dangerous degree.*
   Causes.—The  local predisposing  causes are  the same as those of ulcera-
tion ; namely, congestion,  deficient  arterial  circulation, and structural
weakness.
  The constitutional causes of mortification are, — debility from old age,
poverty, starvation, haemorrhage, scurvy,  or long-continued disease of any
kind ;f  disease of the heart with contraction of the aortic orifice, so as  to
impede the arterial circulation ; and the peculiar state induced  by the use
of diseased grain, especially by the ergot  of  rye.   These causes are  in
general predisposing merely; but sometimes they are sufficient of them
selves to  induce  mortification, which  is then mostly seated in the lower
extremities.  The gangrene of the  feet, which was so common amongst
such of the soldiers of the wretched Anglo-Spanish expedition as reco-
vered from the Vittoria fever,  is a good example of mortification from
constitutional causes.
  *  Guthrie, G. J., F. R. S.  A Treatise on Gun-shot Wounds, p. 116.  Third edition
London, 1S27.
  f  Sir B. C. Brodie, in  his Lectures  on Mortification, Med. Gaz., vol. xxvii., give? the
case of a man who caused  himself to be  largely bled when l.itoxicated, and the next
day one of  his feet mortified as high as the instep. 
100
MORTIFICATION.
   [Dr. Flint, the Editor of the last American edition of mis woik, pub-
 ished in that edition the following remarkable case of idiopathic gan-
 grene:— "A very extraordinary instance of mortification, resulting from
 constitutional disturbance, came under my observation last autumn, in the
 case of a little girl about six years old, living in Indiana.  The child was
 well nourished and developed, and in good health, until  about the middle
 of September, when  an  intelligent practitioner of  the neighbourhood,
 visiting another member of her family, was requested to  prescribe for her,
 as she appeared to be  slightly indisposed.   He  examined her, and per-
 ceiving no  symptoms of  serious illness, ordered  some  gentle cathartic
 medicine and departed.  During his visit the next day, he was summoned
 from the room of his patient to another apartment, where  the little girl had
 been  amusing herself, as usual, in the morning, and found her  prostrate,
 unconscious, almost pulseless, and somewhat convulsed.   The symptoms
 of sinking became  more and more urgent, and, while the surface of the
 whole body was rapidly losing its temperature, that of the left half—trunk
 and extremities — became almost uniformly livid.   She was placed in the
 warm  bath, frictions employed, and, as soon  as the power of deglutition
 was restored, diffusible stimuli were carefully administered.   Conscious-
 ness and sensibility were restored in about three-quarters of an  hour, and
 after  the  operation of  some  cathartic medicine, the  next morning she
 seemed to be as well as ever, with the exception of the left foot and ankle,
 which continued to be cold, livid, and insensible, notwithstanding the
 most diligent and assiduous employment of the proper means of restora-
 tion.   No considerable constitutional reaction attended her recovery from
 the sudden prostration, and neither about the foot nor elsewhere was there
 any pain, or any of the usual phenomena of inflammation.  About the
 seventh day from the attack,  a circle of  demarcation began to  form be-
 tween  the dead and  living parts, about two inches above the ankle.   It
 was thought best to  accelerate  the  separation by artificial section, and I
 amputated at the usual point below the knee.   The  vessels and other tex-
 tures at the point of division  appeared to be sound — the wound  healed
 kindly, and  the patient made a good recovery.   The foot was black, dry,
 and wrinkled—no dissection of the wounded part  was permitted.   The
 patient resided in a neighbourhood subject  to epidemics of what is called
 bilious fever, and where,  during this season,  adynamic  symptoms were
 more or less urgent in most of the cases."—Ed.]
   The exciting causes may be divided into— First, mechanical and chemical
 injuries, especially gun-shot wounds and  compound fractures ;—the injec-
 tion of urine or  other stimulant fluids into the cellular tissue ;—the appli-
 cation  of  irritants to  constitutions weakened by previous  disease, as the
 application of blisters to children after measles or scarlatina ;—long-con-
 tinued pressure under the same circumstances; hence the  sloughing of the
 skin over the sacrum,  or trochanters of patients confined to bed with some
 exhausting disease, [or who have suffered an injury  of the spinal cord ; a
man was brought to the Pennsylvania Hospital, four years ago, who, some
weeks  previously, while working  in a  coal-mine, near Pottsville, was
struck  upon  the spinal column, at the upper part of  the dorsal  region, by
a railroad car, which fractured several of the vertebrae, and forced them
upon the spinal cord.   Immediate paralysis of all parts situated below the
 point of injury followed; the man was confined  to  his bed, on his back,
 and when he entered the hospital, large sloughs existed on all those parts 
MORTIFICATION.
101
of the surf-ice below the fracture upon which any pressure had fallen,—on
the  back, the buttocks, the fleshy part of the thighs, the calves of the legs,
the  points of the heels, and even on the posterior surface of the scrotum,
where  it had  rested against the perinaeum.   He  died within forty-eight
hours of his entrance into the ward.—Ed.] — or  the- application of heat
after exposure to cold.
  Secondly, an insufficient supply of arterial blood; whether from ligature
of a main  artery, — from thickening of its parietes so as to contract its
calibre,—from  coagulation  of the  blood within  it, or effusion of fibrine
into it,  as in arteritis, — or from ossification of the  artery, and its  conver-
sion into a ligamentous  cord,  which is  the  cause of senile  gangrene.
Patches of skin often mortify in cedema and cellulo-cutaneous erysipelas,
because its blood-vessels  are obstructed by the distension of the subcuta-
neous tissue with fluid.
   Thirdly, impediments to tfie return of venous blood; whether  from liga-
ture of a venous trunk, — from coagulation of the blood  in  it, — from
tumours (diseased liver for instance) compressing it, or from disease  of the
heart.
  Fourthly, injury  or division  of nerves. — Thus, the  cornea has been
known  to  slough after division of the  fifth nerve.   But, in general, defi-
cient nervous influence operates merely as a predisposing cause.   Besides
diminishing the  vital powers of the  part, it takes away  that  sensibility
which is necessary for its  protection from  injury.
  The  tissue most disposed  to mortification is the cellular; and next to
it, tendinous and ligamentous structures, if the cellular tissue surrounding
them have been destroyed; then bone, if deprived  of its periosteum; next
the skin, especially if the subjacent cellular tissue have mortified, or have
become infiltrated with fluid; and, lastly, parts of higher organisation, as
muscles, blood-vessels, and nerves, resist it most.
   Like ulceration, mortification may either be preceded by  inflammation
or not.   On the one hand, a part which  has  been injured  may mortify,
because it has not strength to support the inflammation which ensues ;  or,
on  the other hand, it may mortify slowly, and the mortification may spread
slowly, without there being energy enough in the system to set up inflam-
mation, which in its adhesive form is necessary to  check the mortification
and repair its ravages.

    SECTION  II. --OF  THE VARIETIES,  SYMPTOMS,  AND
                            TREATMENT.

   Inflammatory Mortification. — Symptoms. — When inflammation is
about to terminate in mortification, its redness gradually assumes a darker
tint, and  becomes purple or blue;—the heat, sensibility, and pain dimi-
nish ; but the  swelling often increases in  consequence of the  continued
effusion of sanguinolent  (or sometimes  of a peculiarly yellow) serum,
which not unfrequently exudes through the skin, and elevates the  cuticle
into blisters.   If the gangrene proceed to sphacelus, the colour becomes
dirty brown or black; the parts  become soft, flaccid, and cold, and they
crepitate when pressed, and emit a cadaverous odour from the  gases that
are evolved by incipient putrefaction.  Whilst gangrene is spreading, the
dark colour is  diffused, and insensibly lost in  the  surrounding  skin ;  out
when its progress is arrested, a healthy circulation is re-established up to
        9* 
102                       MORTIFICATION.
the very margin of the sphacelated portion, and a bright red line of adhe-
sive inflammation (called the line of demarcation)  separates the  living
parts from the dead.   And the appearance of this  line is  most important
as a means of prognosis, because it shows that the mischief has ceased,
and that there is disposition to repair  its ravages.
   Separation of the  Mortified Part.—It is at this  line that the dead part
is separated, which separation is said, according to Hunter's theory, to be
produced by ulcerative absorption; although it is more probably the mere
lesult of the softening of that layer of the living parts which is contiguous
1o the dead.  Be this,  however, as it  may, a narrow white line, consisting
of a narrow circular vesicle, and formed by a separation of the cuticle, first
appears  on the  bright line of adhesive inflammation before mentioned;
and when this  is broken, a chain of minute ulcers is  seen  under it.
These gradually unite  and form a  chink, which widens and  deepens till
the slough is entirely detached ;—and then a granulating and suppurating
surface remains.   In this manner the  whole of  a mortified limb has been
spontaneously amputated;—the  bone  and tendons separating higher up,
and  being more slowly detached than the skin, muscles, and blood-vessels.
When the adhesive inflammation has  duly occurred, this process of sepa-
ration is unattended with haemorrhage, — the vessels being obliterated by
the effusion of lymph, and the  coagulation of the  blood within them.
And this coagulation extends  some  distance from  the  mortified part, so
that a limb has been amputated  in the thigh for mortification of the leg,
without the loss of any blood  from the femoral artery.  Sometimes, how-
ever, as in hospital gangrene, these  vital  processes of adhesion are defi-
cient, and the blood  is found fluid in the vessels, so that the separation of
fhe slough is attended with severe haemorrhage.
   Constitutional Symptoms. — The constitutional symptoms of mortifica-
tion vary with its cause.   If it arise, in a healthy subject, from acute in-
flammation which is  still  progressing, there will be inflammatory fever ;—
  * From a cast in the King's College Museum.  The patient was a destitute girl, and
toe gangrene arose from starvation and  exposure to cold. 
MORTIFICATION.
103
but, on the other hand, if the mortification be very extensive — if the in-
flammation of the subjacent parts be healthy, with no disposition to form
the line of demarcation, but, on the contrary, with a greater tendency to
serous effusion—or if the  mortified part be of great importance, as intes-
tine or lung,  the  constitutional symptoms will be of a low typhoid cast;
there will be  great anxiety,  hiccough, a jaundiced  skin, a soft or rapid,
thready, and jerking pulse ; and frequently profuse perspiration of a cada-
verous odour.
   Diagnosis.—It is important not to  mistake the lividity and vesications
c f bruises, especially when they accompany fractures, for gangrene.  They
may easily be distinguished by their sensibility and  temperature; and by
the  fact, that  in  gangrene the whole  cuticle has lost its adhesion to the
cutis, so that pressure will cause the vesicle to shift its place.
   Treatment.—The general indications are, to  allay inflammation if ex-
cessive ; to support the strength ; and to cause the formation of a line of
healthy adhesion, by  which the mortification may be arrested.
   If gangrene occurs in a healthy, young, robust subject, with great pain,
and a full, hard, strong pulse ; and if it appears  likely to spread from the
violence of inflammation, of which the best  example  is  sloughing of the
penis from inflamed chancre ;  it will be necessary to use bleeding, purging,
and the general antiphlogistic treatment; whilst leeches  and fomentations
may be applied locally.   But care must always be taken to reduce the
strength as little  as possible, whenever a large part is so injured that its
death is probable.
   But  an opposite treatment must be pursued if the pulse is quick and
feeble, and if there are the other signs of deficient vital power that have
been before  mentioned.   The principal  remedies for this state  are wine
and opium,—whose  united  effect should be to render the pulse  slower
and firmer, and to induce a warm, gentle perspiration, and sleep ;—whilst
it will be a sign that they are injudiciously administered,  if they induce or
aggravate delirium and restlessness.  Sir B.  Brodie believes that alcohol
is°by far the best stimulant, and  that  it is better to trust  to  it  in  urgent
cases than to load the stomach with bark.   Fluid nutriment, such as beef-
tea, arrowroot, &c, may be given with it.   Opium is of prodigious utility
from its power of allaying irritability; so that it renders the constitution
insensible as it were  to the local mischief; or, in Hunter's language, " It
does o-ood by not letting the disease  do harm  to the constitution."   It
may either be given  in small doses frequently repeated,  or, if there be at
any time  very great restlessness,  especially towards night, it will be better
to'o-ive a full dose at once ;  such as forty or fifty minims of the tincture,
or Two  grains of the solid opium.   The remedy next in importance is bark,
of which  the most efficacious  preparations  are the quinine, liquor cinchonas
flavae, and decoction of the  cinchona lancifolia.   It may be given in mo-
derate doses  every four or six hours, combined  with  the acids, or with a
small quantity of ammonia;  but Sir B. Brodie believes  that ammonia, if
too long persevered in, depresses the vital energies.— Vide F. 1, 2, 3, 4.
   Local Measures.—If a part be  gangrenous, but not quite dead, its tem-
perature must be carefully maintained, and its actions supported by warm
poultices and fomentations.
   [The proper position  of the part affected  is a matter of some moment
If one of the  limbs be the seat of the  disease, while the inflammatory pro-
cess is still o-oino- on,  it should be retained at rest in  an elevated position 
104
MORTIFICATION.
 which may be gradually depressed as  the  activity of the disorder dimin-
 ishes.—Ed.]
   If sphacelus has  actually occurred, and the powers of the system  are
 languid, and there is little disposition  to form the line of demarcation, or
 throw off the dead parts, stimulating applications are necessary, especially
 the nitric acid lotion, F. 60, on lint under the poultice;—the ung. resinac,
 thinned with turpentine ;—the balsam  of Peru ;—tincture of myrrh,  or of
 benzoin ;—solution  of the  chlorides properly diluted (F. 80);—or  poul-
 tices of  yeast, (F. 76,) or of stale beer  grounds.  • Any locse  portions
 of slough may be  cut away  by scissors, taking care not to tear them  away
 violently.
   Incisions are  of great service in spreading inflammatory mortification,
 attended with extensive  effusion  of serous or purulent fluids; which  not
 only contaminate the blood, and depress the  nervous system by their ab-
 sorption, but also  propagate the  disease by diffusing themselves along  the
 cellular tissue, into parts that are still sound.
   Question of Amputation.—The rule  formerly given on this subject was,
 that we ought to wait till the gangrene is arrested, and a line of demarca-
 tion is formed, otherwise  the stump may become gangrenous.   And this
 rule still  holds good  in mortifications arising from constitutional causes;
 in that caused,  for instance, by arteritis, loss of blood,  and fever.  But
 even after the line of demarcation has  formed, it is necessary to take care
 that the patient has vigour enough to bear the loss of blood which must in
 some degree necessarily ensue.  Sir A. Cooper mentions a case in which
 a mortified leg was separating favourably by itself through the calf, when
 the projecting bones were sawn off, with a view of expediting the  process.
 A few granulations were  accidentally  wounded, and the trivial haemor-
 rhage that ensued  was fatal.*
   But it  will be proper to amputate, without waiting for the line of  sepa-
 ration, if the  mortification  be local as to its  cause ;  as, for instance, in
 mortification of a  limb from severe compound  fracture  or from injury or
 aneurism of the large  arterial trunks.  This practice is sanctioned  by
 Larrey, Guthrie, Brodie, S. Cooper,  Lawrence, James, and  Porter  of
 Dublin.  We may add, that amputation seems to be justifiable as a last
 resource  whenever there  appears little or no disposition to limit gangrene,
 and  whenever it spreads  rapidly.   " Where gangrene," says Mr. Guthrie,
 " is rapidly extending towards the trunk pf  the body, without any  hope
 of its cessation, the operation is to be tried; for it has certainly succeeded,
 where death would in a few hours have ensued."!
  Mortification  from Obstacle to the Return of Venous Blood.—
 This form of mortification mostly affects the lower extremities of persons
who labour under dropsy from diseased heart, and it is  always preceded
by great cedema.   It  may occur without inflammation, or may be a con-
sequence of inflammation, which if it  attack  cedematous parts is  always
liable to terminate in gangrene.   In the former case, the skin of the cede-
matous limb having  become pale, smooth, glossy, and tense, assumes a
mottled aspect of a dull red or purple  colour, from distension of the sub-
cutaneous veins.   " Then at some part where the congestion is greatest,
or where the skin is less yielding, as over the tibia, or above the malleoli,
phlyctenae,  or large bulla?, are formed  by the effusion of serosity, either]
                     * Lectures by Ty-rell, vol. i. p. 237.
                    tOp. cit. p. 132. 
MORTIFICATION.
105
alone or mixed with blood, under the  cuticle.   When  these burst, the
cutis beneath presents a dark red or brown colour, and very soon  is con-
verted into a dirty-yellow or ash-gray slough.*   After the spread of the
mortification to a given extent, inflammation occurs;  and the  slough,
which is mostly an oval patch of skin and cellular tissue,, separates.
   Treatment.—The part should be placed in an elevated position, and the
needle, or a fine lancet, should be used to  let the serum exude.   The
mortified  part, and the ulcer that results, are to be treated by warm poul-
tices of yeast, carrots, or stale beer grounds, and stimulating dressings, of
which the nitric acid lotion is the best.
   Mortification from Pressure.—When a patient is confined to  bed
with some very tedious and debilitating malady, as a fever; and especially
if he has not strength to shift  his posture occasionally, the skin covering
various projecting  bony parts  (as the sacrum, brim of the ilium, or great
trochanter) is apt to inflame  and rapidly ulcerate or  slough; and more
particularly if irritated by neglect of cleanliness, or by the contact of urine.
The first  thing often complained of by the patient is a sense of pricking,
as though there were crumbs or salt  in the bed.  The part, if examined
at first, looks red and rough;  then becomes  excoriated and  ulcerates, or
turns black and mortifies.   This accident is particularly  liable to happen
if the spinal cord has been injured.
   Treatment. — When long confinement to bed is expected, it is a good
plan to apply some stimulant to the skin of the back and  hips,  to  cause it
to secrete a thicker cuticle, and enable it to bear pressure better.  Nothing
can  be better for this purpose than  brandy: but Brodie recommends a
lotion of two grains of corrosive sublimate to an ounce of proof spirit, to
be applied twice or thrice a day.  If the part seems likely to suffer, it  may
be covered with a  broad piece of calico, spread  with  soap plaster;  and
small pillows, or mackintosh cushions, should be  arranged so  as  to  take
off the weight from the part affected ;  and the patient should be  made to
shift his position often,  and occasionally lie  on  his face;  or be placed on
a water bed.  The  soft  poultice (F. 77) will be  found of great service.
After sloughing has commenced, the ung. resinae is the best application.
   Senile  Gangrene. — Symptoms. — This affection  commences by  a
purple or  black spot on the inner sides or extremity of one of the  smaller
toes; from which spot "the cuticle," says Pott, " is always found to be
detached, and the skin under it to be of a dark  red colour."   " In some
few instances, there is little or no pain ; but in  by far the majority, the
patients feel great uneasiness through  the whole  foot or joint of the ankle,
particularly in the night, even  before  these parts  show any mark of  dis-
temper, or before there is any other than a small  discoloured spot at the
end of one of the little toes."f  Its  progress in  some cases is  slow, in
others  rapid  and horribly  painful.  After its first appearance, the actual
gangrene will  generally be preceded by a dark red congestive  inflamma-
tion"   The dead parts become  shrunk, dry, and hard;  and when the  dis-
ease  makes a  temporary pause, which it frequently  does,  they slowly
slouch away ;  but a fresh accession of gangrene mostly supervenes before
any  progress  has  been made  towards cicatrization.   In this way  the
patient  may live several winters,  but  generally sinks  exhausted with the
nocturnal pain before the whole of the foot is destroyed.
                • Carswell, op. cit.
                + Pott's Ohirurgical Works. Svo. Lond. 1771. 
10G
SCROFULA.
   Pathology.—This disease is caused by ossification of the arteries, 01 by
their degeneration  into gristly impervious cords.   Hence the foot is im-
perfectly nourished; it is weak, and liable to pain and numbness, if heated
after being cold ;  and a chilblain, or any other trivial source of inflamma-
tion, is sure to terminate in gangrene.   A similar kind of gangrene some-
times attacks the skin of the leg.
   This affection mostly happens to old persons of the  better class, espe-
cially if they have been  great eaters.  They are generally found  to  have
lost their hair and teeth, and their face and hands betray a languid circu-
lation.  It mostly attacks men.  Mr. James,* however, has  seen it in a
woman  of forty-two, who had disease of the heart;  and Brodie in a man
of thirty-six.
   Treatment. — The patient must be kept in bed; the diet be generous;
opium be given in sufficient doses  to allay pain; and the bowels be kept
open by purgatives.   Then a piece of calamine dressing may be laid on
the part, and the whole foot and limb be loosely wrapped in repeated  folds
of cotton wool, and afterwards sewyed up in a silk handkerchief.   If there
is much discharge, this may be changed every second day;  if not, it may
remain for a week.   Thus the limb will be placed in the most favourable
circumstances for maintaining its circulation,  and the gangrene will pro-
bably cease.   If, however, the inflammation is very acute, and heat great,
this  treatment must be delayed for a few days, and the water  dressing,
with a cooling regimen,  be adopted.   Bark  and stimulating dressings
may be  used afterwards,  to hasten  the separation of the sloughs.  Ampu-
tation is inadmissible.
   White Gangrene of the Skin. — In this curious affection, a circular
portion of the skin, generally of the arm, becomes painful, and suddenly
mortifies;  becoming hard, white,  and  dry, and showing the red streaks
of the vessels with the blood dried up in them.   It sometimes spreads by
the gangrene of a circle of the surrounding skin.  The cause is quite un-
known.    The treatment must depend on  the  circumstances  of the  case;
but tonics will probably be of service.f
                        CHAPTER XI.

                           OF SCROFULA.

                    Syn. — Struma, King's Evil.

  Definition.—Scrofula is a state of constitutional debility, with a ten-
dency to indolent inflammatory and ulcerative diseases, and to the  deposit
of a substance called tubercle, in various tissues and organs.
  General Description.—There are two varieties of scrofulous  habits,
which, although they agree in the main essential of constitutional debility,

  • James on Inflammation, pp. 445 and 552.
  ■f Vide Sir B. Brodie's Lectures on Mortification, Med. Gaz., vol. xxvii., and Mayo's
Pathology, p. 231. 
SCROFULA.
107
are yet totally opposite in many respects. In the first, (oxsanguine variety,)
Ihe skin is remarkably fair and thin, showing the blue veins through it,
and  presenting  the  most brilliant contrast of red and white ; the eyes are
light blue ;  the hair  light or reddish, the forehead ample, and the intellect
lively and  precocious.   Sometimes, however, as Mayo observes, the skin
is dark and transparent, and the eyes  dark,  although there  is  the same
general characteristic of delicacy and vivacity/
   In the second (or  phlegmatic) variety, the whole aspect is dull and un-
promising;— the skin thick and  muddy; the hair dark and coarse; the
eyes greenish or hazel, with  dilated pupils ; the belly tumid, and the dis-
position dull, heavy, and listless to outward appearance ;  although persons
of this  conformation will often be found to possess a clear, vigorous intel-
lect, and  powers of application  far above the average.   The  great  Dr.
Johnson is an example.
   In both varieties the natural functions are liable to be performed irregu-
larly.   Digestion is weak, the tongue often furred, and red on  its tip and
edges; — the upper lip  swelled; — the appetite sometimes deficient, but
more usually excessive, and attended with a craving for indigestible sub-
stances ;—the bowels torpid ;—the blood  thin and watery—its  coagulum
soft and  small;—the  muscles pale and flabby;—and the heart and arte-
ries, as well as the intestines, thin  and weak.f
   In the  sanguine  variety, the growth is  generally rapid, and the  bodily
conformation good, as far as outward form is concerned — the  limbs well
made,  the  stature  tall, and  the  chest  broad.  Puberty also is early,  and
sexual  passion  is often  strongly manifested  before  the  degree of  bodily
strength permits it  to  be indulged in with impunity.  This  is  peculiarly
the  case with the females ; who  are usually remarkable for that early and
 evanescent beauty  which arises from a great development of the adipose
 tissue.   In  the phlegmatic variety, on the other hand, the growth is often
 stunted,  the chest narrow,  and  the  limbs deformed with rickets,  and
 puberty retarded, especially in the females, who are liable to prolonged
 chlorosis.
   Causes.—Scrofula being thus defined to be a peculiar state of the con
 stitution, it may be shown, first, that it may be congenital and hereditary,
 that is to  say, that  scrofulous parents  may transmit  their peculiar organi-
 zation, and predisposition to disease, to  their children.   Not that it fol-
 lows (as  some foolishly quibble),  that all the offspring of all  scrofulous
 parents ought  necessarily to have  scrofulous diseases; nor yet does it fol-
 low that  the parents must necessarily be scrofulous, although the children
 are born so.  For parents may beget scrofulous children, if debilitated by
 privation  or disease;  if  either  of them  is very old or very young;  and
 probably if either of them labours  under a venereal taint, or has been pro-
 fuselv  treated with  mercury, or has a decided tendency to gout.
    Secondly. The  scrofulous habit, if not  congenital, may probably be
 created by any circumstance capable, directly or indirectly, of lowering
 the vital  energies; by poverty and  wretchedness;  meagre, watery, and
 insufficient food ; neglect of exercise ; insufficient clothing; habitual ex-
 posure to  damp and  cold, but most especially by want of fresh  air and

   * Philosophy of Living, 2d edit. 1S38, p. 24.
   t -Mr. Phillips has remarked that the  proportion of saline matter in the blood is con-
 siderably increased in  most cases, and that the albumen aho is in excess.   On Scrofula.
 London, 1S4G, p.  57. 
108
SCROFULA.
solar liglt.  It is exceedingly common in the insular and variable climate
of England, and still more so in Scotland ;  and it is  well  known that
monkeys and parrots, as well as human beings, taken to  that country from
the tropics, not unfrequently die of consumption or other scrofulous
diseases.
   Thirdly. The  scrofulous habit may be  so intense, that the child is
attacked with  some  of the diseases that we shall  presently describe, in
spite of  all care.   Or, on the other hand, actual scrofulous disease may
not appear unless the health is first depressed  by some other disease, such
as scarlatina, measles, the small-pox, or any other acute malady, especially
if treated by too much bleeding and mercury.   Moreover,  everything that
disorders the digestive organs may bring it into action.   Hence it may be
excited in the rich by gross, stimulating, irregular diet,  as well as in  the
poor by habitual  scantiness of food.   It  rarely breaks  out before two or
after thirty years of age ; although it may be called  into active operation
at  any  age by  circumstances which lower the health.
   Pathology of Tubercle.—The most characteristic element of scrofu-
lous disease is  the deposit of a peculiar kind of unhealthy lymph, generally
found in round masses, whence it derives the  name  of tubercle.   Like  the
unhealthy formations that will be  spoken of in the  next chapter, it may be
deposited in three forms, viz.—1st. In distinct masses, rounded or irre-
gular.   2dly.  It  may be  infiltrated generally through  the tissues  of an
organ.   Or, 3dly, It may entirely  usurp the place and form  of some tissue,
which  is then  said to  be converted "nto it.  In the  first form it is most fre-
quently found  in the lungs,  (where it gives rise to pulmonary consumption,)
in the follicles of the intestines, in the  cancelli of bones,  in the brain, in
the pleura or peritonaeum, and in the cellular tissue.   In the  second and
third forms, it is found in  the lymphatic vessels and glands, and in  the
breast, testis, liver, and kidneys;   although it  is also frequently deposited
in these  glands or in their tubes in  distinct nodules.   But wherever it
may be, its course is the same.   In its first stage it is  deposited slowly
and insidiously; causing no pain or  other symptoms, unless it mechani-
cally interfere  with some function.  In this  quiescent state it  may remain
for an  indefinite period, till at  length  the second stage arrives.  Then  the
surrounding tissues inflame,  and form an abscess, which contains  the
tubercle, softened and broken down by the effusion of  serum and pus.
After a time, the abscess bursts, allows the tubercle to escape, and then,
in  favourable   cases, may contract  and  heal.  Sometimes the  tubercle
undergoes a natural cure by being converted into a chalky or earthy sub-
stance, which may be quiescent for  years,*  [" usually surrounded by a
kind of cicatrix,  formed  of thickened fibrous tissue."   " In some  few
cases the softened mass  becomes gradually reabsorbed,  disappears, and
the cavity formed by the destruction of the tissues  is filled by the forma-
tion of a cicatrix;  or else  a portion of the  tubercular matter remains as a
compact,  and  sometimes even as  a quasi-cartilaginous mass, or undergoes
a species of fatty degeneration."   Vogel, Am. ed., p. 258-9.—Ed.]
   With respect to the origin of tubercle, it  appears to depend on a  defect
in the  vitality  of  the fibrine of the blood, which, when effused under cer-
tain circumstances, is incapable of developing within itself the germ-cells
of healthy tissues, and falls into  a state of imperfect organisation.   It is
• Vide Latham's Lectures, xii.; Carswell, op. cit., fasciculus Tubercle. 
SCROFULA.
109
not  necessarily a product of inflammation, although  it is often found
blended with inflammatory exudation of fibrine, and  it is more  liable  to
occur in an organ whose structure and vitality are impaired by inflamma-
tion ; but it is  generally a mere perversion of nutrition.
   There are two states in which it is found : sometimes in minute masses
from the size of a pin's head to  that  of a millet-seed, of a lightish  gray
colour,  and  semi-transparent; — sometimes yellow,  opake, and cheesy
The former variety  is called miliary; and is
also sometimes called crude or unripe, on the           Fig. 8.
supposition  that  it  passes  gradually into  the          ..—■.•.j4,;,-.,
cheesy form;  but it  is more probable  that the
two forms are distinct from the commencement,
 and that the miliary  has a higher degree  of or-
 ganisation, and supports a low kind of vitality.
 The yellow tubercle is  sometimes found soft in
 its  centre ;  but it is doubtful  whether this  is
 through a process of degeneration,  or whether,
 in some cases, it is  not originally depbsited in
 a fluid  state as a kind  of pus, and  solidified  at
 its  circumference by the  absorption of its wa-          ~ '» •''"' '
 tery constituents.*
    Under the microscope the miliary tubercle is  seen to consist of a mass
 of granular matter containing nucleated cells, whose envelopes are either
 wanting, or else blended with the granular matter.  The yellow caseous
 tubercle displays the granular matter with minute spherules and shapeless
 flakes of fragments, and with a few perfect cells only at its periphery; it
 contains also  numerous oil globules.
     Besides tubercular disease, scrofulous patients are liable to  a  variety of
  insidious,  lingering, and  obstinate inflammations and ulcerations.   The
  lymph effused is often  frail  and curdy;—the pus viscid or serous and
  riaky;—and  scrofulous ulcers, weak, with pink surface, flabby, rapidly
  growing granulations,  and loose edges.
     Mr. Phillips and  some other writers are attempting to establish a differ-
  ence between glandular and pulmonary tubercle, or, as they say, between
  scrofula and  consumption ;  on the plea that the  age, and sex, and climate
  most liable to one,  are not so to the  other.   But they use scrofula in the
  sense of an actual disease;  whereas we speak of it as a peculiar kind of
  constitution liable to certain diseases, the relative prevalence of which is
  determined by many circumstances.
     General Treatment.—The indications  are to  strengthen the system
  and prevent local disease, by rendering the blood pure and the circulation
  vigorous,  and by keeping up the secretions.   The means are  both regt-
  nunial and  medicinal.   The former, which  are infinitely the  more  im-
  portant, are food, air,  exercise, and bathing.
     (1.) The  diet of the scrofulous should be  nutritious, digestible,  ana
  abundant, consisting of meat, bread, and farinaceous substances generally,
  with  a sufficient quantity of beer or wine to promote  digestion, without
  creating drowsiness or feverishness.   The  greatest attention  should be
     • Mr Grant  Ca Icier  (Med. Gaz. vol. xxii. p. 280)  and Dr. Kingston (on the Patno-
  |n«v  of Tubercle, in the Med. Chir. Trans,  vol. xx.)  support the idea of  the ongina'
  vitality or tubercle, and of its gradual degeneration and  softening; Andrei  and Grave.,
  comra.  Fig. 8 is taken from Mr. Gulliver's appendix to  translation of  Gerber; see
  aUo Grubv,  Microscop. Jour., lb 12.
          10 
110
SOROITLA.
 paid to the quality of the milk of the mother or nurse;  and  to  feed  the
 child judiciously during the second year.
   (2.)  The clothing should be warm, especially for the neck, chest, and
 feet,—so as to keep up the cutaneous circulation, and prevent congestion
 in the chest or abdomen.   Flannel should be worn next the skin both in
 winter and summer;—in the former for  direct warmth;  in the latter to
 neutralise any accidental changes of temperature.
   (3.)  Free exercise of the  muscles  and  lungs in pure open  air is indis-
 pensable.  The accelerated  venous  circulation which it  causes, and  the
 compression  of the  abdominal viscera by the contraction  of  its muscles,
 are, as Mr. Carmichael has justly shown,  the best means of promoting  the
 action of the liver, and of preventing costiveness with its attendant evils.
 But exercise should be voluntary,—because then it will not be likely to
 be  carried to the pitch of fatigue, than which nothing can be  more inju-
 rious.   Gymnastic exercises should be used with the utmost caution.
   [If the patient can be induced to cultivate some one of the natural sci-
 ences, as botany, mineralogy, &c, his daily walks in  the open air will be
 particularly pleasant  and advantageous to him, since  they will  afford him
 some definite object  other than the acquisition of  health, and thus agree-
 ably relieve his thoughts.  It is a very common  belief that  exercise before
 breakfast is  always beneficial.   This  is a mistake, and one, too, which is
 productive of much mischief to those  who  are feeble,  and habitually defi-
 cient in nervous energy;  none  but the vigorous can with propriety take
 exercise before the morning meal.—Ed.]
  (4.) The best residence  for the scrofulous is one that is  warm, without
 being damp in  the winter, and  cool  and  bracing  in  the  summer.  The
 high lands of the interior, Malvern,  for instance, or Clifton, in the sum-
 mer;—" in the late autumn, when the air loses its freshness, and is tainted
 with the falling leaf and decaying vegetation, the sea-side;"* — in the
 winter and spring, the mild climate of the Isle of  Wight or coast of De-
 von, or a town residence,  are alternations  that are  advisable for those that
 can afford them.   But if the  habit be extremely  delicate, and  disposed to
 phthisis, nothing can be  better than a removal to Madeira, or perhaps
 rather to Egypt, or some tropical country; provided that it be adopted in
 time,  and that the sufferer be not sent away from home and friends (as is
 too often the case) merely to  die.
  (5.) Daily washing and friction of the skin are as beneficial to the scro-
 fulous  as they are to  every one  else; and if the patient be precluded  from
 taking exercise, friction is indispensable.   Cold sea-bathing is, in general,
 so advantageous, that it has  been deemed a specific.  An aperient  dose
 should be given before commencing it, if the habit be gross;  and it is a
 good  plan to  use a  tepid bath or two (90°—80°) first.   The object in
 using the cold bath is  to  produce a vigorous reaction ; consequently, be-
fore taking it,  the nervous  and circulating  systems  should  be in some
 degree of excitement,  and the skin should be warm, although not per-
spiring.  At all events, the  person who bathes should not be  exhausted
by fatigue, nor in a cooling condition  from perspiration.  If the bather be
strong, he may plunge into the  open sea early in the morning on an empty
stomach, not only with impunity, but  with advantage;  but the forenoon is
the  best time for a weakly child, when the air has become warm, and the
system  is invigorated with a breakfast.   Bathing will be injurious if a
                      * Mayo,  Philosophy of Living. 
SCROFULA.
IN
short immersion renders the surface cold, numb, and pinched.  In many
cases,  especially  of scrofulous ulcers, river bathing will  be found more
efficacious.
  Medicinal Treatment. — The medicines of use in scrofula are, first,
aperients, to restore and maintain a proper action of the liver and bowels;
— secondly,  antacids; — and, thirdly,  medicines capable  of  promoting
digestion, and rendering the flesh and blood more sound and healthy.
  (1.) If at any  time the bowels are much confined, or if there is a state
of feverishness, or if there is any  scrofulous disease' going  on that  is
attended  with  pain  and  inflammation,  it will  be advisable to give  an
active  dose of calomel with jalap, or scammony.   And the bowels should
be kept  always regular by some  mild aperient,  such as  rhubarb, mag-
nesia,  or castor  oil;  with a  little aloes, blue pill, or hyd. c. creta occa-
sionally F. 34, if the stools are not  properly tinged with  bile.  But the
patient must not  be weakened by unlimited purging, nor must calomel be
used without consideration.
   [The following judicious remarks, the justice of which was assented  to
by-Mr. Druitt, in the third London edition of this volume, were added  in
a note to the last American edition:—
   " Genuine  tuberculous  scrofula is less common in the Valley of the
Mississippi  than  on the Eastern  coast  of the Union.  But a very large
portion of what is regarded and treated as scrofulous disease in this part
of the country appears to  me to be merely the result of indiscreet mercu-
rialization.   Under the prevalent idea that  biliary derangements either
constitute, or co-exist with, every departure from health, some form  of
mercury  is administered,  in almost every prescription, and  the whole
capillary system  of persons who  happen  to be  occasionally unwell, soon
becomes impregnated and poisoned by this subtile mineral.
   " So, too, if an alterative impression be desired, under any morbid con-
 dition whatever, instead of employing regimen, diet, and  more harmless
 medicaments, it  is common to resort indiscriminately to mercurial agents.
 The consequences of such reckless medication  present themselves to the
 physician in  dyspeptic affections, chronic headaches, pains in  the limbs
 called rheumatic, &c. ; and to the surgeon, in the more striking forms of
 alveolar absorption and adhesions, inveterate ulcerations of the fauces and
 nostrils, where no specific taint  has been suspected, and in various de-
 generations, malignant  and semi-malignant, of glandular organs.
   " Moreover, the evil does not stop with the individual,—for where im-
 portant elementary tissues are so  deteriorated in the  parents, a constitu-
 tional infirmity will be impressed on the offspring, which, if it may not
 properly be  called scrofulous from birth, is the most favourable condition
 possible for the development of the phenomena of that diathesis, whenever
 co-operating influences shall assail the unfortunate subject.
   " The interests of  humanity, no less than the  honour of medicine, de
 mand that those who  observe  and  understand these things should utter, on
 all proper occasions, the most unqualified protestations against such abuses
 of a medicinal agent whose timely and judicious use is so important to the
 healing art, and  thus prevent  it from becoming so detestable, that its em-
 ployment will not be tolerated at all."—Ed.)
   (2.) Alkalis are of great service  in scrofula,  not only  by neutralising
 acrid secretions  in the stomach and bowels, but  (as we may suppose) by
 altering  the constitution of the  blood.   They  are especially indicated if 
112                          SCROFULA.
the patient complains of heartburn or great thirst, or if the tongue is very
red, or if there is a sinking or craving for food  soon after meals.   Car-
michael* recommends a combination of chalk and sesquicarbonate of soda
(gr. x. of the  former, gr. v. of the latter) thrice a day after meals: F. 91
will answer the same purpose.  The liq. potassae is more useful for adult3.
The urine should not be allowed to become alkaline.
   (3.) Before  reviewing the remedies that come under our third head, wc
must warn our junior readers not to be too credulous when they hear of a
new specific.   Scrofula is an imperfect condition of  bodily  health and
strength, generally coeval with the earliest period of embryonic existence;
therefore it is absurd to suppose that this can  be infallibly amended by any
remedy whatever.   If a medicine improves the appetite, and flesh, and
strengtn, it may be persevered  in; but if it  causes feverishness,  emacia-
tion, debility,  no vague idea of its specific virtues ought to  induce  the
practitioner to continue it.
   Bark is of immense service when there is great exhaustion from suppu-
ration, or when ulcers spread rapidly, and when it is necessary to make a
sudden impression on  the system.   The decoction with quinine, or liq.
cinchonee flavae (F. 1.4), are the best forms.
   Iron is better adapted for permanent administration than bark; espe-
cially for thin, pale,  flabby children, whose liver and bowels are  kept in
proper action.   The muriated tincture, F. 8; the amm,onio-chloride, F.  7
(whose advantage  is, that it can  be combined with alkalis, although it is
often  too stimulating for children); the sesqui-oxyde; the  old-fashioned
vinumferri; the ammonio-citrate,  F. 11, the sulphate, F. 13, and a com-
bination  of the protoxide, with aloes and  an alkali, will all be found
useful—F. 37.
   Sarsaparilla often produces the most  unlooked-for benefit, especially N
the alkaline infusions,  F. 40,  41, or  the compound decoction (without
mezereon and guaiacum) given in a concentrated  form, so that the sto-
mach may not be offended by the bulk of fluid in which it  is too much
the fashion to  prescribe it.  This remedy seems to  improve the powers of
nutrition generally, and may always be  given  in cachetic diseases for which
there  is  no palpable cause; in fact, when we are at a loss what to  pre-
scribe.   But it is of most peculiar service when  there  is  great weakness,
with great irritability; when tonics and nutriment cause feverishness, when
the tongue is flabby, coated, and rather sore, and nothing seems to agree.
   Iodine should always  be administered  in  combination  with  a metal, or
alkali, or salt that  renders it soluble — not in the form of simple tincture
dropped on water.   It should,  moreover, be given in small  doses for a
long period;  half a grain per diem,  gradually increased to  a  grain,  is
quite  enough for an  adult.  A slight action on the bowels and  increase of
the urine may be expected; but it should not be permitted to  cause ema-
ciation.   The iodide of iron in doses of gr. \ ter die; or a combination
of tinct. ferri. mur. tt[ xv. with the tinct. iodin. comp. (P. L.) Tr[ v. ter die,
the iodide of potassium in doses of  not more  than gr. iii. ter die, with
decoction of sarsaparilla; and F. 44; are convenient forms of adminis-
tration.!
  * Essay on Scrofula, Lond. 1810.
  f We must warn our junior readers against the vague statements they sometimes meet
with, to tne effect that iodine is good in  scrofula, because it promotes absorption.  Scrofula
i» often said to consist in a peculiarly lymphatic, i.e. watery, flabby temperament, which 
SCROFULOUS  DISEASES.
113
  The oil of cod's liver is a remedy that deserves  a fair trial in the torpid
indolent variety of scrofula.   The dose, to commence with, should be  a
teaspoonful,  taken in water, or milk.  It seems to promote  nutrition, and
is of service  as an embrocation for indolent scrofulous swellings.*
  The  sulphates  of zinc (F. 6) and copper in small doses are sometimes
serviceable as tonics.   The chlorides of calcium and barium were formerly
much praised, but seem to  have fallen into merited oblivion.   A decoction
or extract of walnut leaves  has been used by Dr.  Negrier of Angers, both
internally and externally.   Common salt, especially in the form  of sea-
water, has also been boasted as a specific.
  Pain, when violent, must be relieved by opium  or other anodynes ; and
the extracts of conium and aconite in regular doses thrice a  day, are often
of great service  when there are intractable ulcers.   The aconite requires
caution in its use.
  We  may  add, that F.  34, 91, 43, 12,  are combinations  of  various
tonics,  aperients, antacids, and alteratives, which will  occasionally be
found serviceable ; that of all medicines', steel is the most important, since
it is an ingredient in healthy red blood, and that it ought to be continued
daily in small regular  doses for two  or three years, with occasional inter-
missions of a week; but that wholesome food, pure air, and warm cloth-
ing are more important than any medicines.
            PARTICULAR  SCROFULOUS  DISEASES.

   I.  Of the Skin.—Scrofulous children  are extremely subject to  erup-
tions of small flat pustules about the ears and mouth, and other  parts,
with  extensive excoriations of the skin, and exudation of thin acrid mat-
ter which dries into scabs.  These eruptions  are generally contagious.
   Treatment.—The  general health must be attended to, according to the
foregoing rules; and the local  disease  be treated by the frequent use of
soap  and water, and the application  of the  ointments of oxyde of zinc,
white and red precipitates or nitrate of mercury, or of lead.   This descrip-
tion and treatment may include  almost all the multifarious forms of im-
petigo and porrigo.
   II. Chronic Scrofulous Abscesses (independent of those which  are
caused  by diseased glands  or bone)  may  occur under three  forms.   1st.
They may commence imperceptibly in the cellular tissue.   2dly. A cir-
cular piece of skin, of the size of a shilling or half-crown, with the tissue
immediately beneath, may slowly inflame  and swell, forming a hard, red,
painless tumour,  like  a carbuncle.    After a time it suppurates imper-
fectly, and it  does not get well  till the whole  of the  diseased part is de-

is no doubt partially  true.  Then again, the lymphatic, or, as they are sometimes called,
absorbent glands, are peculiarly liable to become diseased in scrofulous persons.  Hence
some persons, confounding the lymphatic temperament with the lymphatic or absorbent
glands, have asserted iodine to be a good remedy  for scrofula, on the ground of its pro
motirig absorption, which is (quite hypothetically) supposed to be the  function  of the
lymphatic glands.  But  it is better nutrition, not  more absorption, that is wanted iu
scrofula.
  •See some observations by Dr. Tnufflied,  Lond. Med. Gaz.. Feb. 2S. is 10; and an
excellent paper by Mr. Donovan in the Dub. Jour. Med. Se . Sept. IS 13.   The oil should
be pale, and procured from fresh, plump livers at a low heat;  the dark-coloured rank
->i' is not so good.  It contains sometimes a very small quantity of iodine, but this car*.
hardly be the source  of its virtues.
       10*                        H 
114
SCROFULOUS DISEASES.
stroyed by ulceration.  3dly. A small hard tumour of unhealthy  lymph
may form in the cellular tissue, which after a time inflames, causes abscess,
and  then sloughs out.
   The treatment of the first variety is the same as that of chronic abscess
generally.  The two  others should be left to themselves till they suppu-
rate  ; then it  may be  expedient, if there is  a great  piece  of thin  purple
skin, to destroy it by  potassa fusa ;  and the  case afterwards comes  under
the head of scrofulous ulcer.
   III.  Disease of the Lymphatic Glands, especially in the neck, is the
commonest of scrofulous maladies.   It appears from Mr. Phillips's  obser-
vations, that the first  step  is some degree  of inflammatory enlargement,
which, if it  does not  subside, is  succeeded by a deposit of tubercle.
The enlarged glands at first are perfectly indolent  and painless.  Thus
they may remain  for  years  stationary or slowly enlarging, till  at length,
from local irritation or disorder of the  health, they inflame, and chronic
abscesses form between them and the skin.   In some few cases after the
abscess is opened, the cyst contracts and heals, the  glands  remaining
nearly  as before.   But more generally, all the skin covering the abscess
becomes  red and  thin, and ulcerates; and  the ulcer heals with an ugly
puckered cicatrix, but not till the whole  gland has wasted with suppur .-
ration.   These swellings have been known to destroy life by compressing
the  tracheal  or cervical vessels, or by  bursting  into them.   Sometimes
they undergo a cure by the chalky transformation before spoken of.*
   Treatment.—The health  must be amended by the measures  before de-
tailed ;—and an endeavour must be made to cause absorption,  by fomen-
tation with hot salt water, or the zinc lotion, or cold poultices made with
sea-weed,—by an occasional leech when irritated,—and  by iodine oint-
ment or empl. hydrargyri when indolent.   It may  sometimes  be  expe-
dient to extirpate one or more glands.  But if suppuration occurs, and if
the slcin begins to redden, an opening should be made in the manner,  and
with the  precautions,  laid down in the section on chronic abscess.
   IV.  Tabes Mesenterica, or Marasmus, consists in a tubercular dis-
ease of the mesenteric glands,  and  of the follicles of the intestines,  pre-
cisely similar in its course and phenomena to the same disease in the  cer-
vical glands.   The intestines inflame, adhere together,  and ulcerate so
that  openings form between different convolutions; and on examination
the peritonaeum is found as thick as leather,  and the  intestines resembling
a collection of cells rather than  a simple tube.
   Symptoms.—Emaciation and voracity, owing to the obstructed course
of the chyle ;—the belly swelled and hard ;—the skin dry and harsh  ;—the
eyes red;—the tongue strawberry-coloured ;—the breath foul;—the stools
clay-coloured and offensive, sometimes costive, sometimes extremely re-
laxed.   The  patient of course dies hectic, although he often lasts wonder-
fully long.
   Treatment.—Animal food and other nutriment given in small quantities
at short intervals; — mild mercurials to amend the  intestinal secretions,
especially the combination of hydr. bichlorid. with  tinct. cinchonae, F. 43;
—tepid salt bathing;—stimulating  liniments to the abdomen; — change

  •Tubercle in the mesenteric and bronchial glands is more frequently found of the
greyish translucent variety; and it softens and suppurates  less frequently than in the
cervical.   It has moreover a greater  tendency to  the chalky  transformation.—Vide
I'bjll'ps, op. cit. 
u
MALIGNANT DISEASES.
115
of air; — and the cautious administration  of the  antiscrofulous remedies
before mentioned, especially the cod-liver oil.
  V.  Scrofulous Ulcers may be a result of the pustules and excoriations
of the skin that  have been  spoken of; — or they may be formed by the
ulceration  of chronic  abscesses; in which case they sometimes destroy
extensive tracts of skin and cellular tissue, and may kill the patient by
exhaustion, or  render  a limb rigid  and useless, if he recover.   Or they
may be attended with a hardened  base,  thick  everted  edges,  a copious
formation of pale granulations, and deposit of unhealthy lymph  into the
adjoining cellular tissue, wThich, with the granulations, is liable  to  fits of
sloughing, preceded by severe pain.
   Treatment.—We have  nothing to add to the treatment of the weak and
irritable, ulcer,  to which classes these must be referred.   The preparations
of iodine,  F.  44, et seq.,  should have a fair trial.
   Scrofulous  diseases of the bones, joints, eye, breast, and testicle; the
scrofulous  lupus, and ozaena; caries of the vertebrae, and  psoas abscess,
will.be described under the head of the respective tissues or organs which
are affected.
                        CHAPTER XII.

                     OF MALIGNANT  DISEASES.

                 SECTION  I.--INTRODUCTORY.

  Definition. — Malignant diseases are diseases of constitutional origin,
manifested by the formation of one or more of the morbid growths which
will be described in the  following sections.
  These morbid growths possess the following characteristics.   (1.) After
a certain period, they have a tendency to disintegration and decay.   (2.)
They cause the gradual atrophy or transformation  of the organs in which
they are situated.   (3.) They progressively invade  and destroy the tissue."
    • Represents enlargement of the mesenteric glands from a scrofulous patient 
116                    MALIGNANT  DISEASES.                •
in their vicinity.   (4.) They travel  in  the  course  of the  lymphatics, and
attack the  nearest glands.  (5.) They generally affect several organs  in
the same individual;  and (6.)  If mechanically removed from any part,
they mostly reappear in or near the cicatrix.
   Anatomical Characters. — It appears from the researches of Mullcr
and Walshe, that malignant growths are composed of two parts.   1st, of
granules, — of cells  rounded or caudate containing nuclei, younger cells,
and granules (as shown in the  adjoining  figures) ; — with a few fat cells
                         and globules; — and, 2dly, of a fibrous tissue,
          Flg- 10,         or stroma, in which the former parts are im-
                         bedded ; which fibrous tissue sometimes appears
                         to be the natural filamentous tissue;—sometimes
                         is formed of  elongated  cells,  that adhere  by
                         their extremities;  sometimes of the distended
                         parietes of old cells which have become filled
by the  growth of new ones in their  cavity; sometimes of a substance
resembling the buffy coat of the blood.   It  must be added, that malignant
growths are almost entirely composed of albumen;—that they are supplied
with  ordinary blood-vessels, some more and some less; — and that they
scarcely differ from some innocent albuminous growths in their chemical
composition and microscopic elements.*
   Pathology.—The development of malignant disease seems to depend
on a perversion of nutrition.  The lymph or blastema which exudes through
the capillaries, either in the ordinary course of nutrition, or through some
accidental inflammation, appears to have its vitality perverted; so that in-
stead of forming itself into one of the proper tissues of the body, it forms
the irregular abnormal cells depicted above, which  constitute a malignant
tissue.
   Causes.—The cause of this perversion is some ill-understood constitu-
tional diathesis, which  is very frequently congenital,  and inherited,  but
sometimes appears to arise from various causes that impair the vital energy;
of which, mental anxiety and depression are  the best  established.
   Local Ongin.—When this diathesis is strong, malignant disease may
break out spontaneously in one or more tissues or  organs;—when  not so
strong,  its development may be aided by local irritation.   Hence the fre-
quency  of cancer of the lip from the irritation of smoking; of cancer of
the penis in persons  affected with congenital phymosis, and of chimney-
sweeper's cancer from the irritation of soot.
   Contagiousness.—The older writers believed  that  the  discharge from
cancerous ulcers was contagious. All attempts, however, to propagate the
disease  by inoculation have failed of late years, and therefore the modern
opinion is the reverse.   But it is yet a  question whether if some of the
living cancer cells — not the mere discharge, in which these cells are in a
state  of disintegration and  decay—were injected into  the  blood, they
might not take root and vegetate.f
   Mode of Deposit.—Malignant  growths may be deposited in two forms;
viz. either in  one  or more distinct tuberous  masses; or else the morbid
orowth  may be infiltrated through the tissues of an  organ; the  proper sub-
  * Vide Carswell*s Pathology; Miiller on Cancer and Morbid Growths, translated by
C.  West,  M. D., Lond. 1840; Dr. Walshe's article on Cancer in  the Cyclopaedia of Prac-
tical Surgery, and his larger work on Cancer, Lond. 1846.
  t See Walshe, op. cit.,  and an account of an experiment of Langenbeck's in the Micro-
n-apical Journal, vol. ii.  p. 185. 
SCIRRHUS.
117
stance of the organ being gradually replaced by the morbid growth, although
\heform may for a time be little altered.
   Growth.—When malignant growths are once formed,  they increase  in
size by the perpetual development of new cells, either in  the old cells,  or
in their interstices;  and these progressively infiltrate  the  parts adjoining.
They are supplied with fresh  material by blood-vessels, most probably  of
new  and independent formation, which permeate  their interstices in more
or less  abundance.
   Decay.—After a certain time the  older portions of a cancerous growth
lose  their vitality  and soften  down, and  the skin or mucous membrane
covering them ulcerates to allow of their discharge.
   Varieties.—There  are  three varieties  of malignant disease,  viz. scir-
rhus ; medullary sarcoma;  and  gelatiniform cancer.   That  they are very
nearly allied to each other is shown by the circumstance that two or more
of them may affect different organs in the same  individual; or may even
exist together in one  tumour; and that  if one variety be extirpated, an-
 other may make its appearance in the cicatrix.  But it does not seem pro-
' bable that they are identical, or that one can be transformed into another
 by any process of development.   Melanosis, though not strictly perhaps
 a malignant disease, may also be conveniently treated of in this  chapter.
    Semi-malignant Diseases.—There is a  class of diseases which  is termed
 semi-malignant;  which differ from the malignant in the circumstance that
 the morbid changes are purely local;  and that although incurable or de-
 structive to life if left to  themselves, they do not  attack several  organs at
 a time, and  if removed thoroughly  do  not return.   For examples, see
 Part IV. Chapter II.

                   SECTION  II.--OF  SCIRRHUS.

    Symptoms.—Scirrhus begins usually as a rounded  and peculiarly hard
 tumour, subject to occasional fits of severe  lancinating pain.
    Anatomical Characters.—Scirrhus is hard, heavy, and almost carti-
 laginous in consistence.   In  bulk it  is rarely larger than an orange.  It
 cuts crisply, with a creaking sound like a potatoe or unripe pear. The cut
 surface has a peculiar semitransparent glossiness, and its colour varies from
 a bluish-white, if the mass is in a firm condition, to  a pale  dirty fawn or
 o*reyish tint, if softer.   It is unctuous to the touch.  Pressure causes the
 exudation of the cancerous juice, clear and  transparent if the tumour be
 firm, thicker and creamy if of longer growth.  If it have begun to soften
 in spots, from  these pressure may cause  an opake  pultaceous  matter to
 exude, just as the matter does from a  sebaceous  follicle.  When the cut
 surface is carefully examined  with a lens,  the  distinction between the
 stromal (or containing) and the granulo-cellular matter is evident;  but in
 the very earliest stage there is very little of the latter; and in the more ad-
 vanced stages, the  granules and cells accumulate so much as to obscure
 the former.   The peculiar  character of the  stromal portion  of scirrhus is
 its rectilinear arrangement; whereas that of other malignant and of fibn us
 growths is curvilinear.
    Scirrhus is sparingly and irregularly supplied wTith blood-vessels.  It is
 common to say that it contains numerous white  bands intersecting each
 other;—but these are only found in the female breast, and  consist of the
 lactiferous tubes. 
118
SCIRRIIL'S.
11.
   In the progress of decay, it softens into a dirty buff-coloured pulp;  and
 becomes infiltrated  with a creamy liquid.
   Varieties.—Many varieties of scirrhus have been  described  as  distinct
 forms of malignant  disease, to the great perplexity of students.   Such are
 the pancreatic sarcoma, described by Abernethy, and the napiform, chon-
 droid, and lardaceous tumours, designated from their resemblance to turnip,
 cartilage, and boiled bacon-rind respectively.
   Progress  and Termination.—The progress of this disease  is twofold.
 On the  one hand, it spreads and successively invades all the adjoining tis-
 sues ;— and  at the same time the  older portions  of the morbid  growth
 perish by ulceration or sloughing.  At  first the tumour is  indolent  and
                               painless, so  that the patient may be for a
                               long time ignorant of its existence ;  it is
                               also circumscribed  and freely moveable.
                               After  a time it is  affected with fits of
                               severe lancinating pain, which gradually
                               increase in frequency and severity. Then
                               it  slowly enlarges; — loses its distinct-
                               ness, becomes blended with the adjacent
                               parts, and adheres to the skin  and to the
                               parts beneath it.  At  last the  destructive
                               stage   commences.   Portions   of  the
                               tumour soften down, and  form irregular
                               abscesses ;  the  skin ulcerates or sloughs,
                               — and  thus an open cancer is formed.
                               This ulcer enlarges in  every direction;
                               its edges are thick and jagged ; — some-
                               times  undermined and inverted ; some-
                             The  surface is tawny or ashrcoloured,  and
                              The discharge is thin, sanious, fetid,  and
 irritating,—and there is an almost constant burning pain.   Sometimes a
 feeble attempt is  made towards reparation ;—pale,  flabby granulations are
 thrown  out, and a portion of the sore cicatrizes for a time.   In some  few
 cases, the whole  of the diseased growth has sloughed out, and a  perma-
 nent  cure has followed.*   But in  general  the ulceration spreads,  the
 neighbouring glands or viscera become contaminated, and the patient sinks
 from the constant pain and irritation.
   Constitutional  Symptoms.—From the first there is a state of ill health
 which cannot be  solely attributed to the local disease, and which is deno-
 minated the  cancerous cachexia.  The patient is languid, depressed,  and
 emaciated ; — the complexion is leaden and sallow, the appetite bad,  and
 digestion imperfect.  As  the disease  advances, hectic is induced by the
 pain  and exhaustion, — the vital energies are further lowered  by  the ab-
 sorption of deleterious secretions ; — and the patient suffers perhaps from
 the co-existence of the disease in other organs. An extraordinary fragility
 of the bones, so that the femur might be broken  by turning  in  bed, is by
 no  means an uncommon phenomenon; — partly arising  from atrophy
partly from scirrhous disease developed in them.f
  Diagnosis.—The diagnosis of scirrhus from other chronic tumours is at
times most uncertain.  Its principal characteristics are, hardness, lancinaU
        * Travers on Malignant Diseases. Med. Chir. Trans., vol. xv. p. 213.
        (• Salter in Med. Chir. Trans., vol. xv.
times swelled and  everted.
eaten into  irregular hollows. 
SCIRRHUS.
119
ing pain, the co-existence of the cancerous cachexia, the patient's age, and
the situation of the tumour.   But as none of these characteristics may be
well  marked ;  and  as  tumours which have been harmless for years may
ultimately assume  a  malignant  aspect,  the  diagnosis  must   often be
guarded;—that is, hedged in with intimations of its fallibility.
   Prognosis.—Although the destiny of a scirrhous tumour and of the
patient  are pretty certain, still  the  time in which the  disease may prove
destructive is most uncertain.  So that if the patient is old ; — if the dis-
ease has lasted long, and has been slow in its progress; — if the health is
tolerable, and  the cachexia  not well marked; — much  comfort may be
derived from  the assurance, that  although the disease  may be incurable,
yet that life may  be prolonged for many years,  and may perhaps at last be
terminated by some other malady.
   Duration.—Scirrhus is slower in  its progress than any other variety of
 malignant disease ;  for although it has been known to prove fatal in two
 months, yet it may creep on for more than half a century.  But in most
 cases from three  to four years may be  safely assumed as the period within
 which it destroys life.
   Spontaneous Cure.—It appears that  in a very  few well authenticated
 cases  scirrhous tumours have been  removed by absorption; and in many
 more the disease  has become quiescent, lasting for years without making
 progress.
   Causes.—Scirrhus may occur at  any age,  but  it is very  rare indeed
 under thirty; yet it has attacked girls  under twenty. It  most commonly
 attacks  the uterus,  female breast, stomach, lower lip, and skin, especially
 of the face.  Like the other varieties of malignant disease  it is  exceedingly
 uncommon in Africa, and the tropical parts of America, but diffused over
 the rest of the world, especially amongst the  more civilized nations, and
 the higher classes.  Women are more liable to it than males  in  the  ratio
 of nearly three to one ; and the greatest  mortality amongst them occurs
 between the ages of thirty-five and fifty;  at the time when the generative
 function ceases,  and the constitution  undergoes its  most critical change.
 Whether it is more likely to attack the married or the spinster, the barren
 or the fruitful, those who have suckled  or those who have not, are points
 vet undetermined.  The complexion most commonly attacked is the dark
 bilious.  Blows  or other injuries may act as exciting causes, and produce
 it in a  particular part;—but  they cannot do so  unless the constitutional
 tendency exists.
   Treatment. — The first  thing generally spoken of under this head is
 extirpation by the knife.  The  results of this  proceeding, however, have
 been most unsatisfactory.  Although  in some very few cases, doubtless,
 a cure  has been  affected, yet in  by far the majority the  disease returns
 within  a twelvemonth,  and runs a more  rapid  course than it would have
 done if not interfered with.  " Inasmuch," to quote  from Dr. Walshe,
 " as no operation by excision is  performed without the chance of leaving
 some of the diseased structure behind, an accident  that hastens  the  pro-
 gress of the malady; inasmuch  as  absolute certainty of the  freedom of
 internal organs  from disease is  unattainable; inasmuch  as the  dormant
 cancerous diathesis  is often roused into activity by  the  removal of c
 tumour; inasmuch as cancers, in  a  state of  active growth, acquire in-
. creased energy if produced after extirpation ;  and, lastly, inasmuch as the
operation itself has not unfrequently been the cause of death, excision can- 
120
SCIRRHUS.
not be undertaken without imminent risk of putting the patient in a worse
state than he or she was in before the use of the knife."  From these con-
siderations,  (and  especially when the fact is taken  into, account that
patients  have died when operated  on for cancer, in whom no  cancer
existed,) it is evident that the knife should be abstained from as a general
fule.
   The circumstances under which an operation might be performed with
some degree of hope, are:—if there is no cachexia,  nor hereditary taint;
if the disease have begun from  injury; if it be moveable, circumscribed,
and free  from adhesion to the skin or to the parts beneath ;  and especially
if it be in the lip, or in bone, except the skull.
   If, however,  the  skin  is extensively tuberculated and  adherent  to the
scirrhus; — if the  surrounding fat and cellular tissue  are implicated ; — if
the tumour is firmly adherent to the parts beneath; — if it  is extensively
ulcerated; — or if the original disease is  much  less in degree than co-
existent scirrhus of the adjoining lymphatic  glands; — or if the  patient's
health is fast sinking;—or  if there is any palpable internal disease; the
operation should not be attempted.  Yet, even then it may be justifiable
occasionally, in  order  to remove tumours  obstructing the natural  outlets
of the body, or to get rid of a bleeding, offensive mass, and so relieve the
patient temporarily  from  pain.
   Ablation, if determined on, may be effected (1) by the /cnife ; and  in
so doing care ought to be taken  to remove every particle that appears un-
sound ;  (2)  by caustic, especially the chloride  of antimony or zinc, and
arsenic.   These may be resorted to in flat cancerous affections of the skin,
but their utility in glandular scirrhus is doubtful.*  (3.) By ligature, and
other means that require no  comment.
   It must be added that, in the judgment of competent  authorities,  an
operation is more  likely to be  successful after a course  of proper treat-
ment, than if performed at the earliest period ;  and that a  course of altera-
tive remedies is advisable after the  operation,  in order to diminish the
chances of a return.
   Putting aside, then, operative measures, the treatment may consist in
attempts, 1st, by internal and external remedies, to procure  the absorption
of the tumour; or 2dly, if it is in the ulcerated state,  to alleviate the
patient's sufferings.
   Internal Remedies.—The  preparations of iron maybe given with benefit
when the lips are pale, the pulse  weak, and the  patient low and emaciated.
The ammonio-chloride in pills,  in doses of gr. ii. ter die, was a favourite
medicine of the late Mr.  Cline, and often effected the  dispersion of chronic
indolent  tumours.
   Mercury.—Sir A. Cooper recommended five grains of Plummer's pill
at bedtime, and a draught of carbonate of ammonia with a vegetable bitter,
twice in the day, F. 95.  Mercury is also  often  highly useful  in small
nightly doses, with narcotics, F. 32; but  given  in large quantities, cer-
tainly hastens the progress of the disease.   JYarcotics, especially conium,
have been boasted as specifics; but their utility  is  doubtful, except as
adjuvants to tonics, and to  allay the  agony of open cancer.   Iodine, in
various  forms.  (F. 44,) and  arsenic, being most  powerful tonics  and alte-
ratives, deserve  a  fair and  protracted trial; and especially the iodide of
arsenic,  in doses of gr. ^g bis die in a pill, with ext. conii, to be taken
                     * Vide Lupus, in Part IV., Chap. ii. 
SCIRRHUS.
121
two  hours after meals.  F. 10,  50, 53, 94, may be of service  in some
cases.
   Change of air, (especially to countries comparatively exempt from can-
cer, such as Algiers and Egypt,) freedom from  anxiety,  a diet  that will
support the strength without heating the system, wine in moderation, if the
patient is weak and accustomed to it, are other measures that we  need not
do more than allude to.  Vegetable  diet, or low diet, approaching starva-
tion, has been recommended.  But by weakening the system, and increas-
ing the irritability  of the heart and nervous system, it cannot fail to be
mischievous.
   Local Remedies.—Leeches.—If the patient is young and  plethoric,—and
the fits of pain are frequent, and accompanied with heat and throbbing,—
 the diet should be  reduced, the bowels be freely opened,  and leeches be
 applied.   In fact,  occasional leeching is  almost always of service in the
 early stages of any form of malignant disease.   Iodine ointment, and espe-
 cially the ointment of  iodide of lead, F. 54, which is much less irritating
 than the common  ointment, may be smeared on the tumour when indolent.
 Sometimes iodine, calomel, and other remedies, may be applied in sachets;
 that is to say, in little  muslin bags,  filled with cotton wool powdered with
 the remedy in question, and covered with oiled silk on the side that is not
 applied to the skin.
    Pressure.—This was tried some  years ago with partial success, and has
 been  revived by Dr. Walshe, who  entertains rather sanguine expectations
 of its good results.   The manner in which it may be most conveniently
 applied, is by an  instrument that  has  been invented  by Dr. Arnott.   It
 consists of a spring, passing either round the body  or over one shoulder?-
 by means of which the pressure is generated;—of bands, pads, &c, for
 maintaining  the apparatus comfortably in situ; — of a shield or circular
 frame ;—and of a cushion within the shield, partially filled with  air.   The
  diseased part  is  received into this slack air cushion, which adapts  itself
  admirably to  its  surface.   The pressure  should be steadily applied, and
  gradually increased from about two pounds to six or more.   This plan  of
  treatment certainly deserves a fair trial, since, according to Dr. Walshe,
  if it  has no other effect,  it certainly procures an extraordinary alleviation
  of pain.                                  .                          .
     Palliative Measures.—In order to allay pain,  and lessen the  tcetor and
  acrimony of the  discharge, use may be made of many of the applications
  recommended for irritable ulcers.  Dr. Fagan informs the  author that  he
  has found a solution  of tannin produce  cicatrization, and otherwise give
  great relief in  a case,  where the skin was infiltrated with scirrhus and  on
  the point of commencing ulceration, as it  often does, by a wide excoria-
  tion.   Poultices  (not  warm) made of the pulp of carrots;—or  medicated
  with the extracts of conium, hyoscyamus or belladonna;—or with opium,
  or the extract of poppies  ;—ointments or lotions containing the same nar-
  cotics, or the salts of morphia, may be  tried in succession.  Sometimes
   relief is  afforded by alternation with  mild stimulants;  as weak lotions of
   the chlorides of lime  and soda—or of the nitric or  nitro-munatic acid  ;—
   or nitrate of silver.   Affusion with very cold or iced water  is  sometimes
   of use.   Carbonic acid, a powerful narcotic and allayer of irritability, may
   also be often advantageously applied by  means of fermenting poultices  ;-
   or by generating the gas in a bottle, and directing a stream of it  on  the
   surface of the sore through a tube.
          11 
122
MEDULLARY SARCOMA.
SECTION III
OF  MEDULLARY  SARCOMA
12.
Syn. — Encephaloid disease; carcinoma  medullare;  soft cancer ; fungus
                  hematodes; spongy inflammation.
  Symptoms.—Medullary sarcoma usually commences as a soft rounded,
elastic  tumour, growing  rapidly, generally free from pain or tenderness,
and not circumscribed or moveable, but blended with  the surrounding
tissues.
  Anatomical Characters.—On  a  section this tumour appears  to  be
composed of a white opake substance of the colour and consistence  of
                               brain,  streaked with numerous minute
                               blood-vessels.  It very often happens
                               that its delicate blood-vessels are rup-
                               tured, and the tumour, becoming infil-
                               trated  with  blood, resembles a coagu-
                               lum :  in this state it is  called fungus
                               hematodes.    Sometimes  after  rupture
                               of a vessel the effused blood is absorbed,
                               as after apoplexy of the brain, and there
                               is left in  its place a cyst containing a
                               clear or coffee-colouTed serum.
                                  Like that of scirrhus, the cut surface
                               displays  a stromal and an inter stromal
                               substance;  and the spaces inclosed  by
                               the former are more or less spherical,
                               not  rectilinear, as in scirrhus.    Some
                               portions  of  the  mass  are sometimes
                               harder than brain, whilst  other parts
                               have softened into an almost diffluent
                               pulp.
                               -This tumour  enlarges  rapidly; and  its
arterial circulation is  sometimes so  vigorous as to cause pulsation like  an
aneurism.   The skin covering it  soon becomes purple or livid ; and the
subcutaneous veins enlarged and tortuous.  It is now subject to fits  of
aching or throbbing pain, but by no means so severe as that of scirrhus.
At length  one  of the most projecting points  ulcerates  and  discharges a
grumous fluid,—and  a rapidly increasing fungus grows from the aperture.
Sometimes this fungus exudes  an enormous quantity of a thin, colourless
serum ;—sometimes it is covered  with  a slight crust  of coagulum ;—some-
times its blood-vessels give way,  and there is a profuse haemorrhage;—
and sometimes large portions of it soften down or slough.   The constitu-
tion suffers in the same manner as  in scirrhus, but  much more early anc
and severely;  and the patient expires after  a few months, worn out by the
irritation of the external malady, and by  its invasion  of the viscera.
  This form of malignant disease has  a special preference for the testicle,
lungs, kidneys, spleen, and meninges, and is the form  which generally
occurs  in the earlier periods of life ;  moreover, it generally takes the place
of scirrhus, when the latter has been removed by excision.   It occurs more
generally in a  distinct or  tuberiform mass,  than in the form of infiltration
  Varieties.—The mammary sarcoma  of Abernethy, the miltlike turnout
of Munro the youngest;  and the solanoid and nephroid tumours are varie-
Progress and Termination. 
GELATINIFORM CANCER.
123
ties of this disease, deriving their names from their accidental resemblance
to the organs or substances after which they are named.  The disseminated
globose sarcoma, which has been  recently described, consists of tuberous
masses of this disease deposited in the subcutaneous cellular tissue.
   Diagnosis.—This disease is to be  distinguished from  scirrhus by the
absence of hardness and lancinating pain ;—by the  greater rapidity of its
growth ;—by the larger size  it attains, tumours  the size of a  man's head
being not uncommon;—by the  earlier and  more  decided cachexia;—by
its attacking persons of every age, and being more frequent inthe young;
whereas scirrhus is exceedingly rare under  thirty;—and by its disposition
to fungate rather than to ulcerate.
   Prognosis.—This of course  will be highly unfavourable, the patient
sinking much sooner than  in scirrhus.
   Cause.—Some unknown constitutional peculiarity.
   Treatment.—The constitutional treatment is the same as  directed  for
scirrhus.   Leeches  frequently applied at the earliest appearance of the  dis-
ease will  sometimes retard its  progress.   Cold or iced applications,  and
the  ligature of the principal  arteries supplying the tumour have been  re-
commended for the same purpose, but are  not worth trying.  Extirpation
 is hardly to be  thought of, because  the  disease is sure to  return, perhaps
 before the wound has healed.   Hemorrhage in this disease, or in cancer,
may be restrained  by pressure with  a piece of lint.

         SECTION  IV.--OF  GELATINIFORM  CANCER.
   Gelatiniform Cancer.—(Syn. Tumeur
 Colloid, Carcinoma alveolare.)—This  re-
 markable growth  is seen, on a section, to
 be  composed  of  innumerable white inter-
 lacing fibres, forming distinct loculi  or par-
 titions  of a  tolerably regular  spherical
 shape.    These loculi  vary  from the size
 of a grain of sand to  that  of  a  pea, and
 are filled with a soft, viscous  jelly,  of
 greenish  yellow colour, which generally is
 dear and transparent, but occasionally tur-
 bid and  opake.   The jelly-like  matter is
 composed entirely of albumen,  and  retains
 its transparency in alcohol.   This form of
 malignant growth generally infests the sto-
 mach and omentum, as exhibited  in  the
 following drawing (Fig.  14) from a  preparation in the  King's College
 Museum.  Sometimes portions of  it are developed in a scirrhus tumour,
 and have been mistaken for a softened state  of the  latter.   It  is much
 rarer  than  either scirrhus  or  encephaloid, and  as  yet  has  only beeii
 observed in adults.

                   SECTION  V.--OF  MELANOSIS.

    General Description.—Melanosis is a disease consisting in  the  deposit
 of a brown or black matter, composed  of  microscopic cells, containing  a
   » Of the two smaller figures, one  exhibits the circular loculi as they appear on a sec-
 tion ; the other shows the compound spherical character of the malignant growth itself.
 
124                         MELANOSIS.

pigment like that of the choroid coat of the eye.   This black matter maj
either be deposited in a tuberiform mass, or may be infiltrated through the
substance of an organ.   The most common primary  seats of the affection
are the subcutaneous cellular tissue and the eye, but when once the dia-
thesis is established, the liver, lungs, bone, and many other internal organs
may be invaded.  Horses, especially greys, are more liable to melanosis
than man  is.
   Melanosis is not considered  by pathologists a really malignant  disease,
because, though it depends on  a certain diathesis,—is incurable,—returns
l  excised,—affects many organs in the same individual, and produces a
cachexia,—yet it does not form a tissue, but  the cells  continue free like
those of pus or tubercle.   Yet it is convenient to consider it  in this chap-
ter, because it  is not uncommonly found associated with scirrhus or en-
cephaloid.
                                      Progress and Termination.—The
                                    average duration of life in individuals
                                    affected with this  disease, is  pro-
                                    bably under two years. The tumours
                                    after a  time  increase, soften, irritate
                                    the neighbouring  tissues, and ulcer-
                                    ate ; and the irritation  of this  pro-
                                    cess, coupled with the  peculiar ca-
                                    chexia  of  the disease, and the dis-
                                    turbance which its presence in va-
                                    rious internal organs causes to theii
                                    functions,  are very sufficient causes
                                    of exhaustion and death.
   Treatment.—External tumours may be extirpated, if the surgeon thinks
it  advisable, and the health is pretty good.  The general health should be
carefully attended to.f
   * Fig. 14 shows a tuberiform deposit of melanosis in the cutis  vera.
   t Carswell, op. cit.  Fawdington on Melanosis, Lond. 1820; Mackenzie on the Eye,
p.  553; Holmes  Coote in Lancet, Aug. 8, 1846.
 
               PART  III.

OF THE DIFFERENT SPECIES OF INJURIES.
                         CHAPTER I.
                                                    i
                       OF INCISED  WOUNDS.

  Definition.—These  are  wounds  made with  clean-cutting  instru-
ments ;  they generally bleed more  at  first than  the other kinds of
wounds.
  Treatment.—There are four indications:—1, To arrest haemorrhage ;
2, to remove foreign bodies; 3, to bring the divided parts into apposition,
and keep them in union; 4, to promote adhesion.
  (1) To arrest hemorrhage, moderate pressure, a raised position, and the
application of cold, will be sufficient in most cases;—but if an artery have
been wounded, or the  bleeding prove obstinate, the  measures must be
adopted which  will  be  indicated in the Chapter on Wounds of Arteries.
  (2) The removal  of foreign  bodies will be much more easy both for sur
geon and patient if  done at once, than if delayed till inflammation super-
vene.  The best instruments  for this  and every  other surgical purpose
which  they can perform, are the fingers; — but they may be aided by
probes and forceps, if necessary.   Dirt, gravel, &c,  are best got rid of by
affusion with water.  All clots of blood must likewise be removed,  or
they will act as foreign bodies and prevent adhesion.
  (3) In order to bring the sides of the wound into apposition, the part
must be placed in such a position as will relax any muscular fibres that
have been divided,  or that may be subjacent to the divided parts.   Then
the edges  must be made to  meet  as  nicely as they  can without undue
straining, and  must be retained by cross strips of  adhesive  or isinglass
plaster, one end of the  plaster being first applied to that side of the wound
which is loosest, and the other being brought across with a mild degree
of traction.   If the wound, from its severity or situation, compel the pa-
tient to keep his bed, no further application will be needed save a strip
of lint spread with spermaceti  ointment;—otherwise a light compress and
bandage may be applied to keep  on the dressings,  and protect the  parts
from injury.  If the wound is so situated that the plasters cannot be ap-
plied smoothly, a slip of lint may be laid on it first.
  Sutures.—In some  cases it is requisite to have recourse to  sutures ; in
order to get a  better purchase upon the edges of the wound, and  hold
them securely  in contact.   They should be used in  wounds of parts that
are naturally loose  and moveable, or that have no  firm part  underneath
against which  they  can be fixed.   Thus the interrupted suture is used in '
wounds of the  eyelids, scrotum, and  female perinaeum, and when a por-
tion  of the nose or ear has  been detached ; and the twisted suture in
       11*                                              (1M) 
12G
INCISED WOUNDS.
wounds of the lips; in the  cases in fact in which adhesive plaster would
be insufficient.   But adhesive strips should always be placed in the intei-
             vals of the stitches, to prevent any strain upon them.   They
             may be removed in from three to four days ;—sooner if vio-
             lent  irritation comes on ;—but not so soon if there  is no
             great action.   The  surgeon must never employ them  in
             order forcibly to  drag the lips of a gaping wound into con-
             tact, or they will give great pain, and his intentions will be
             frustrated by their  speedily ulcerating.   Five  species are
             enumerated in the older authors.
                1.  The ,Interrupted Suture  is  thus  made.   A  needle
             armed with a single ligature is passed through one lip of
             the wound from without, inwards;—then at a correspond-
             ing part through the other lip from within, outwards.   Then
             the ends of the  ligature (which may  be made  of silk,  or
             stout hempen thread, well waxed and flattened,  that it may
             lie easily in the wound) are to be  drawn together, without,
             however, any great straining, and are to be tied tightly in a
             double reef knot, as represented in the adjoining figure.
   The needle should be carried deeply enough to obtain a firm hold, but
should not include any tendinous part.  As many of these stitches are to be
made as are necessary ; half or three quarters of an inch is a proper interval.
   2.  The Twisted Suture is made thus.   The edges of the wround having
been  placed accurately in  contact, a sufficient number of pins are to be
passed  through both of them  at  convenient distances.   The first pin
should  be placed  at any loose  angle which there may happen  to be.
When all  the  pins have been  introduced, and  the  parts are accurately
adjusted,  the middle of a  long piece of  silk is to be twisted  around the
uppermost, in  the Torm of a figure of 8.  Then the two ends are to be
brought down  and twisted round each of the other pins successively in
like manner;—and, lastly,  are to be secured by  a knot.
   The  pins were formerly made of silver, with steel points, that were
removed after they were inserted ;  but the fine pins used by entomologists
                  for fixing insects, or fine steel needles with lancet points,
                  are excellent substitutes.  They are  so  small  that they
                  excite little irritation ; and a great number of them may
                  be employed, so as to insure  as nice an adaptation  as
                  possible.  But after they are inserted, their points must
                  either be cut off, or else be  guarded with a lump  of
                  wax, in order that they may do no mischief.
                    3.  The  Glover's  or  Continuous Suture  is  nothing
                  more than the  ordinary way of sewing things together
practised  by seamstresses and  housewives.  It is employed in wounds  of
 he intestines and abdominal parietes.
                                         4. The Quilled Suture is per-
                                       formed  by passing  a  sufficient
                                       number of ligatures, as  in  the
                                       interrupted suture.   But instead
                                       of being tied to their opposite
                                       neighbours, all  the  threads  on
                                       each side of the wound are fas-
                                       tened  to  a quill, or  bougie, or
Fig. 16.
Fig. 17.
 
INCISED WOUNDS.
12:
»oll of plaster.  This  suture is now nearly or quite obsolete ; it was for-
merly supposed  to  be  very advantageous in  pressing the deep parts of a
wound together.
  5  The Dry Suture was made  by sticking a strip of adhesive plaster,
or (before that was invented) a strip of linen, smeared with white of egg
and flour, to the skin on each side of the wound.  The adjacent margins
of the plaster  or linen were then sewed together.
   [M. Baudens, chief surgeon to  the " Val de Grace" hospital, recom-
mends the following kind of dry suture, to approximate the edges of the
flap after amputation ;  he surrounds  the limb, above its cut extremity,
with a circular bandage, through which he passes pins in front and behind,
leaving the extremities  of the pins projecting; then, while the flaps are
brought together accurately by an assistant, the surgeon passes from one
pin to the opposite, pieces of thread, wrapping them around the pins with
sufficient tightness to retain the flaps in apposition.
   The bandages used to promote union of incised wounds are the common
roller, the bandage of  Scultetus, and the invaginated  bandage.   The first
two are employed to give support merely to  adhesive strips and  sutures.
The invaginated bandage acts  directly by approximating the edges of the
incision ;  its composition and  mode of application vary, as the wound is
longitudinal or transverse.   These bandages  are applied to the extremities
generally.
   The invaginated bandage for longitudinal wounds is thus prepared:—A
linen  roller is taken,  of a  width corresponding with the  length of the
wound, and sufficiently long to make several turns  around the limb : at
the free extremity of this roller several slits are made, each  about an inch
  road and six or eight inches long; and beyond these, at the distance of
  '  w inches, fenestra? are cut,  in number corresponding with the slits (fig.
 18).   Thus prepared, the centre  of the undivided portion of the  bandage
 is placed  directly opposite the  wound, by the margins of which graduated
 compresses (a,  a, fig. 19) have  been arranged,  one on each side: the
 slits, b, b, b, are passed through the corresponding fenestrae, c, c, c, and
 these  two portions of the roller drawn in opposite  directions  until the

             Fig. 18.                    Fig. 19.
             I I;

edges of the wound  are in apposition (fig. 19).  Then the slits are  laid
flatly upon the surface, and the bandage is completed by circular turns of
the "roller.  The efficacy of this uniting bandage is much increased by the
employment of the compresses, which act very much as the quilled suture,
by pressing together the entire depth of the sides of the wound.   It will
 
123
INCISED WOUNDS.
be found an advantageous mode of approximating the surfaces of deep
incisions of the thighs, particularly.
   The invaginated bandage for transverse ivounds.
   Composition.—A piece of linen from two  to  three feet  long, corre-
sponding in  breadth  with the length of the wround, and divided at one
extremity into two or  more slits, each about an  inch wide and six  inches
or more in length, to  correspond with the same  number of fenestra?  made
in a second piece of linen of the same  dimensions as the first; two rollers,
each six yards long and  two and a half inches wide; together with two
graduated compresses.
   Application.—The limb having been placed in  a position most favour-
able for relaxing the divided  muscles, the  surgeon makes a few turns of
one roller, b, around the limb below the wound, and upon these lays the
fenestrated bandage, so that the divided portion  stretches upon and across
                                     the  incision, while the other part
                                     rests upon   the  limb  below the
                                     wound.   The extremity of this
                                     portion is reflected  upwards over
                                     the turns of  the roller, which is now
                                     resumed  and made  to secure the
                                     bandage  in  position.   The  other
                                     band is  now confined  upon the
                                     limb above  the wound, in the same
                                     manner,  by means of the second
                                     roller,  the   slits corresponding in
position with the wound:  next the compresses, c, c,  are placed parallel
with the edges of the  incision, one above and the other below: then the
slits of one band are passed through the  fenestrae of the other (fig. 20).
The two bands are  drawn in opposite  directions, so as to approximate the
lips of the wound,  and  ar^  firmly fixed  by turns  of the  rollers passing
respectively above and below the seat of the injury.—See Cutler's Treatise
on Bandaging, or Sargent's Minor Surgery.
   Recently it has been ascertained that a solution in ether of the " gun-
cotton," as commonly prepared, is possessed  of very strong adhesive pro-
perties ;  it may be spread upon linen or silk, and  then  applied  to the
surface ; and it offers  this  advantage over other adhesive matter, viz.: that
being insoluble in water, the parts surrounding the  wround may be washed
without disturbing the wound itself, by removing the plaster which covers
it.  To separate the plaster from the surface, it is necessary to moisten the
application with ether.
   Gun-cotton is  made by saturating  carded cotton in a mixture of  equal
parts  of strong nitric and sulphuric  acids, then washing  the  cotton  in
water, and drying it at a temperature of 150°, or less.—Ed.]
   (4.) The fourth  indication  is to keep down  inflammation; that is, to
prevent it from surpassing the degree  necessary for adhesion.   This is  to
be effected by opening the bowels, lowering the  diet, enjoining rest, avoid-
ing tight  bandages and  ever}' other source of irritation and constriction,
and maintaining the  injured part  in  as comfortable a state of  feeling  as
possible;  which, as was before observed, is the surest means of prevent-
ing inflammation.   If, however, much pain and swelling supervene, the
•vater  dressing, or a poultice,  must be resorted to, and plasters, bandages,
and sutures be abandoned till granulation  commences.  Then the parts
 
PUNCTURED WOUNDS.
129
maybe again gently approximated, that they may heal by the second inten-
tion ; that is, by the inosculation of their granulations.
  Cases of complete  Disunion.—If any small portion of the body (a
finger or part of the nose for instance) has been completely cut off, and if
it be reapplied as soon as possible,  and retained by plasters or sutures,
and  wrapped up  so  as  to preserve its temperature, it will very probably
unite again.  And even if such a part have been separated for a consider-
able time, the attempt should not be given up; — but it should be well
washed in warm water to  free it from dirt, and  the stump should also  be
bathed, so  as to  remove  any dry coagulated blood, before they are reap-
plied to each other.  Part of the left fore-finger, an inch  and a half long,
having been cut off for twenty minutes, was replaced and united perfectly
in four days.  The case  is related by Dr. Balfour  of Edinburgh, and is
quoted in Sir A. Cooper's lectures.

                    cure of open  wounds.
   If a part has been abstracted which cannot  be restored  ;—or if any kind
of wound cannot be covered by skin, there are two ways in which it may
heal—either with suppuration, or without it.
   According to the first  process, it inflames and suppurates, then granu-
lates and heals like an ordinary ulcer.
   There are twro ways  in which open wrounds may heal without suppura-
tion ; viz.  (1.) by scabbing, — the  surface  being  dry;  — or (2.) by the
modelling process, if the surface is kept moist.
   The ordinary form of cure without suppuration is that by scabbing;—
the  natural  and simple way in  which most slight accidents heal when not
interfered with by art.   It may be effected by permitting  the blood to dry
on the surface of the wound; under the protection of which the wound
heals without suppuration.  Mr. Wardrop has  seen  the  large surface ex-
posed by the removal of  a diseased  breast heal thus completely under a
crust of blood in thirty  days.   Common experience shows that it is better
to leave slight scratches and abrasions to heal by themselves in this natu-
ral manner, than to interfere with them by plasters or ointments.
   The second  form  of  healing without suppuration, is that first described
by Macartney, under the  term modelling process.   When the water-dress-
inc  is applied, and the part is  kept under the most favourable conditions
of rest and temperature, the  wound fills up by  the gradual exudation  of
lymph, the surface of which continues pale and moist, without  the  least
sign of suppuration, till, having attained the level  of the skin, it forms a
small pliant cicatrix.
                         CHAPTER II.

                 OF  PUNCTURED  WOUNDS.

  General Description.—These are justly esteemed the most dangerou..
of all wounds.  (1.) Because from their depth they are liable to implicate
blood-vessels, nerves, viscera, and other deep-seated parts of importance
                                 I 
130
CONTUSION  AND  ECHYMOSIS.
(2.)  Because the parts which they traverse  are  stretched and torn,  and
consequently are disposed to inflame and suppurate.  (3.) Because matter
when formed has no free exit, and is liable to burrow extensively.   (4 )
Because foreign bodies may be carried into great  depths without  being
suspected,  and create  long-continued irritation.  (5.) Because they are
most liable to be followed by tetanus.
  Treatment.—The first point usually mooted in discussing the treatment
of these wounds is the propriety of dilating them,  and  converting them
into simple incisions, in order to avert the deep-seated suppuration  and
confinement of  matter.   But as those  evils are incident on the inflamma-
tion that supervenes, and as they by no means follow of necessity, an en-
deavour should be made to prevent or mitigate inflammation, so that there
may be no necessity for such a severe measure.
  In the first place, therefore, rest, low diet, purgatives, cold lotions,  and
leeches, must be employed,  to counteract all excess of inflammation,  and
to cause the absorption of any blood that may  be effused in the course of
the wound.   But if, notwithstanding, there should be severe pain,  and
swelling, and fever, a free incision must be made for the relief of tension
and the discharge of matter;—and the case  must be treated in the same
manner as a deep-seated abscess.*
                        CHAPTER  III.

               OF LACERATIONS AND CONTUSIONS.

       SECTION  I.—-OF contusion AND ECCHYMOSIS.

  Definition.—A contusion signifies an injury inflicted by some obtuse,
blunt object, without perforation of the skin.
  Consequences.—The  consequences of contusion are, (1) a degree of
concussion, or benumbing, which  may be pretty severe,  without  much
further mischief; (2)  some  structural injury, which will be  followed by
inflammation.   The degrees of this structural injury are three.
  1.  There may be rupture of the smaller vessels, the blood from which
infiltrates the cellular tissue,  and causes an ordinary ecchymosis.
  2.  A large vessel may be ruptured, so that blood is effused  in consider-
able quantity, ancftears up the cellular tissue, in which it  coagulates;  or
if an artery is ruptured, a false or diffused aneurism may be the result.
  3.  The tissues maybe irretrievably pulpified and disorganised; as hap-
pens from the contact of a spent cannon-ball for instance.
  Ecchymosis.—When ecchymosis has been produced in the  skin or im
mediately beneath it, there appears a swelling of a reddish colour, which
speedily becomes black.   On  the third day it is violet, and  the  margin,
which was at first well defined, is found to be  faint and  diffused.   About
  *  It may be worth knowing for medico-legal purposes that a punctured wound made
with a circular conical weapon is not round but linear, as though it had been made with
a narrow, flat instrument. 
CONTUSION  AND ECCHYMOSIS.
131
the fifth or sixth day the colour becomes green; on the seventh or eighth,
yellow ; and it gradually disappears about the tenth or twelfth—sooner or
later, according to the vigour of the individual  and the quantity of  blood
effused.
   If an ecchymosis be formed in the cellular tissue without injury of the
skin, no discoloration may appear for twenty-four hours;—and  if it be
more deeply seated among the muscles, it will not affect the skin for some
days, and may then appear at a part quite remote from the seat of injury;
—and, in  this last case, will  usually be in the form of irregular yellow
spots, marbled with green and blue.*
   Causes.—Ecchymosis may be produced by many other causes besides
contusions.  It is a symptom of certain diseases, as scurvy, purpura, and
the last stage  of fevers.   It  may be  a consequence  of oblique wounds,
which do not permit  the blood to flow freely out;—of spasms, and other
violent contractions of the  muscles;—it may also be caused by suction,
(as after leech-bites,) especially in a part where  the skin is thin.  It may
further be  simulated  by the application of  colouring matters  to the skin.
Lastly, ecchymosis produced during life may require  to be distinguished
from various appearances arising after death.
   Diagxosis.—Ecchymosis produced by suction maybe distinguished from
that which is the result of injury, by being generally in the form of small
round spots, and situated on the inside of the arms,  or  female breasts; and
the surgeon required  to decide on the  cause of such marks should consider
whether they correspond in their appearance to the date which is assigned
to them.
   Artificial  discoloration of the s/cin may  be distinguished from ecchy-
mosis by its being generally in round or  irregular spots, fringed at  the
edges, f
   Ecchymosis produced during life may be  distinguished  from the livid
discoloration of incipient putrefaction, or that which is caused by the gra-
vitation of blood in a dead body,  by noticing that  in  the first case, blood
is effused into the cellular tissue, and is incorporated with the cutis, which
is thickened; whereas  in the latter two cases, the  blackness will be con-
fined to the surface of the cutis, and if blood is effused  into the cellular
tissue, it will be  only at some depending part, and will  be fluid,  and not
coagulated 4
   Treatment.—The indications are, (l)to cheek extravasation of blood;
(2) to prevent  inflammation;  (3) and  afterwards to produce absorption of
the effused fluids and restore the use of the  parts.
   If the patient be robust, and the bruise seated  on  the head or trunk, and
the swelling increase  rapidly, and  become very tense,  it may be  expedient
to bleed.   The bruised part should, if possible, be placed in a raised po-
sition ;—and cold or  iced water, or a bladder containing a frigorific mix-
ture,  F. 56, should  be applied at once ;—and a sufficient number of
leeches, as soon as there are any signs of inflammatory pain and swelling,
but not before.   These measures, together with purgatives and low diet,
will suffice for  the first two indications;—whilst the third will be  fulfilled
by friction with stimulating liniments ;  by cold affusion ; and passive mo-
tion after inflammation has subsided.   The roots of briony, and Solomon's
  * Devergie, Medicine Legale.  Paris, 1836, tome ii. p.  57.
  t Fallot de la Simulation et de la Dissimulation des Maladies. Bnixelles, 1836. p. 67
  $ Beck's Medical Jurisprudence. 
132
CONTUSED  WOUNDS.
seal, bruised, and  applied as a poultice, appear to have some efficacy in
hastening the disappearance of bruises.
  Sometimes, however, the effusion of blood increases very fast, and  the
tumour becomes tense and  shining, so as to threaten rupture o( the  skin.
It will be well in  this case to imitate the practice  of prize-lighters, and
make a very small aperture with the  point-of a lancet, and  let as much
blood be sucked out  as  can be without difficulty;  although this should
not be done unless absolutely necessary, because the pressure of the blood
already effused tends  to  prevent  the  escape of more.  If, however, thi
cannot be done, because the blood has coagulated,—and if the skin is so
tense that it will inevitably either burst  or  slough,—and if the  pain  and
tension are not adequately relieved by the  free employment of antiphlo-
gistic measures, so that  the clot,  instead of  being  absorbed, will be  re-
moved by suppuration, an incision of sufficient length should be made into
the swelling, and a poultice be applied.  Then the  clot will  most likely
be gradually extruded by the contraction of the cavity, and a simple gran-
ulating wound will be left.   But it is very bad practice to squeeze or scoop
out the coagulum, as the bleeding might be brought on afresh, and severe
inflammation be excited.*
  If an arteiy of considerable size is  lacerated, which  will be  known by
the situation of the contusion, and the great and rapid  swelling, the case
must be treated as a diffused aneurism.
  If the  skin is so injured as to threaten sloughing, tepid  applications are
to  be  preferred, especially the water-dressing, or poppy fomentation with
spirit of wine.
  If the  fingers or toes have been severely bruised, so that  it may seem
impossible to save them,  still they  should not be too hastily amputated, as
they often recover  under unfavourable circumstances.
  If any superficial part  have been killed by injury, the water-dressing or
a poultice will be the best and most convenient application till the slough
separates.
  If any bruise be attended with  severe collapse, the measures  described
in Part L, Chapter I., must be adopted.  In no case should cold be applied
if it make the patient  shiver uncomfortably; nor should it ever be  applied
extensively to the trunk ; extensive superficial extravasation (to counteract
which  it was recommended  above) rarely occurs there ;—and if there, be
extravasation into the cavities, it must be combated by bleeding.

 SECTION II.--OF  LACERATED  AND CONTUSED  WOUNDS.

  General Description.—These wounds are  attended with less  haemor-
rhage than the incised,—both because their surface being irregular, renders
it easy for the blood to adhere and coagulate,—and because arteries, when
torn, do not bleed so much  as when cut.   But  in all  other respects  they
are infinitely more serious.   (1.) They are  liable  to  inflame violently and
slough ; (2.) they are often complicated with foreign bodies;  and (3.) they
are more liable than simple wounds to occasion severe constitutional dis-
turbance and tetanus.
  Treatment.—In the first place, bleeding must be restrained ;—second-
ly, foreign bodies must be removed ;—thirdly, the divided parts must be
brought  into apposition, in case  the whole  or any part of them  may be
                • Hunter on the Blood, part ii. chap. ii. sect. l. 
GUN-SHOT WOUNDS.
133
inclined to unite by adhesion.  But as this is not very likely to occur, and
as the wound mostly inflames highly and suppurates, there should be  no
straining with plasters or tight bandages.  Then the patient must observe
rest, the  diet be moderate, and the bowels be opened; a cloth  dipped in
cold water, or a soft poultice, or the water-dressing, or a poppy fomenta-
tion, may be applied locally.  The tincture of Benzoin on lint is often
highly useful, sealing up the wound as it were from the contact of the air,
and disposing it to heal kindly.   If inflammation  comes on  the patient
must not be reduced too much, or tetanus will be more liable to come on.
Openings are to be made if necessary, in order to  prevent the lodgment
of putrid blood in the  early stages, and of matter subsequently.  When
sloughs  have separated, and suppuration is  kindly established, the parts
should be brought into  apposition, as much as can be done without leaving
sinuses,  and the case must then be treated as an ordinary sore.   [The em-
ployment of cold wrater  by  irrigation, as described on  page 58, will be
found to be one of the  most efficient means  of combating the severe  in-
flammation which  accompanies violent  contused and lacerated wounds,
and contusions unattended by wounds.  It should be borne in mind, how-
ever, that if the feelings of the patient are disagreeably impressed by the
use of cold water thus  applied, warm water must be substituted for it.—
Ed.]
                         CHAPTER IV.

                   OF  GUN-SHOT WOUNDS.

  Definition.—Under the term gun-shot ivounds are included all the in-
juries caused by the discharge or bursting of fire-arms.   They consist of
" severe contusions, with or without solution of continuity."
  Symptoms.—When  a musket or pistol-ball has penetrated an  ordinary
fleshy part, there is seen a hole, perhaps rather smaller than the ball itself,
with its edge livid and inverted;—and if the ball have passed  completely
through, there  will be another larger and more ragged orifice, with its edge
everted.  The  wound will, besides, be attended with more or less pain,
hemorrhage, and constitutional disturbance.
  (a) The pain in these cases is said, by most authors, to  be inconsider-
able at the moment of infliction. Mr. Guthrie, however, both from obser-
vation and  personal experience, affirms that this is by no means the  case,
and  says that  in general the pain  is  severe;—that it is a dead, heavy,
painful  blow ;—although still the injury may not be felt at the moment, if
it is inflicted  while the  patient's  whole attention  is absorbed by  other
objects.
  (b) Most  authors state that  gun-shot  wounds are attended with very
little hemorrhage, unless some considerable blood-vessel has been divided.
But  Mr. Guthrie  asserts  that this  is equally erroneous;—that there is in
general considerable haemorrhage of an arterial colour;—but that a wound
of a large artery is only to be feared if the  blood continue  to  be poured
out in great  quantity and per  saltum, in spite of pressure.
       12 
134
GUN-SHOT  WOUNDS.
  (c) The constitutional disturbance accompanying these wounds is severe
and  peculiar.  The surface is pale, and bedewed with cold perspiration ;
every limb trembles; the patient cannot stand without support; and suf-
fers  from vomiting, faintness, and  peculiar alarm, anxiety, and  confusion
of the mind.   The severity of these symptoms will, in general, be deter-
mined by the extent of the  injury, the importance of the part wounded,
and  the habitual  fortitude of the sufferer; but the anecdote related in the
subjoined note will show that they may  be most  severe under circum-
stances the most  trivial.*
  Course of Balls.—A remarkable  circumstance connected with gun-
shot wounds, is the facility with which the ball may be diverted from its
course by the slightest obstacle.   Any trifling obliquity of surface, or  dif-
ference of density in the parts which it traverses, may cause  it to take a
most circuitous route.    Thus a ball may enter on  one side of  the head,
chest, or abdomen, and may pass  out at a point exactly opposite, just as
if it had gone entirely  through  the cavity, whereas  it may be found to
have travelled round beneath the  skin.   Sometimes it will make a com-
plete circuit, as  in the  case  of a  friend of Dr. Hennen,  who was struck
about the pomum Adami by  a bullet, which  passed completely round the
neck, and was found lying in the  very orifice by which it entered.   The
track of the ball in these cases will often be indicated by a blush, or dusky
red  line, or wheal on the skin, or sometimes by a peculiar emphysematous
crackling;—and  the diagnosis will of course be aided  by the presence or
absence of the symptoms of wounds of the great  cavities.   In a similar
manner  balls will  run  along concave surfaces.  Thus a soldier may be
struck on the wrist when the  arm is bent in the act  of firing, and the  ball
may graze along the arm, and fly off at the shoulder; or a ball may strike
the  outside of the  calf of a  mounted officer, and be thrown  up into the
popliteal space;  or one  may enter  the thorax or abdomen, glide along the
inner surface of the peritonaeum or pleura, and pass out or be  lodged near
the  spine.
   Lodgment of Balls. —It is always important to ascertain whether the
shot has passed out of the body, or whether it is lodged ;—and supposing
that there are two holes, it must be considered whether they are produced
by the entrance and exit of one, or by the entrance of two distinct balls.
If there are  two holes, and they are  distant from  each other, some light
may be  thrown on the question by ascertaining the  position of the  patient
at the  time  he was wrounded, and the posture of  his  assailant.  Thus a
soldier has presented  himself with two  shot-holes, one on the outside of
the  ankle, the other near the trochanter;  but they were both  caused by
the  same ball, which entered at the ankle when the foot was  raised in the
  ■ During a rapid  advance of part of the British army in  Portugal, "one of the skir-
mishers suddenly came upon his adversary, with only a small bank between them;
both parties presented, the  muzzles of the pieces nearly touching;  both  fired, and both
fell.   The British soldier,  after a minute or two, thinking himself  hit, but still finding
himself capable of  moving, got up, and  found his adversary dead on the other side of
the  bank. I saw him," says Mr. Guthrie, "immediately  afterwards in considerable
alarm, being conscious of a blow  somewhere, but which, after a diligent search, proved
to be only a graze from a ball on the ulnar side of.the arm ;  yet the certainty he was in
of being killed, from the respective positions of the parties, had such an effect upon him
at the moment of receiving this trifling injury, as nearly to deprive  him for a short time
of his powers  of volition;  whereas, had the wound  been received  from a concealed or
distant enemy, it would in  all probability have been little noticed."—Guthrie, op. cit
p. 11. 
GUN-SHOT WOUNDS.
135
act of running.*   In another instance, a soldier,  who was ascending a
scaling ladder, was wounded in the  right arm, and  the ball  was  found
under the skin of the opposite thigh.f  But even though there may be but
one opening, it by no means follows that the ball has lodged ; for it may
have escaped by  the very hole at which it entered, after having made the
circuit of the body, as in the case of Dr. Hennen's friend just mentioned.
Or it may have impinged against some part, such as the cartilage of a rib,
which has caused  it to recoil; and a ball has been  known to drive a piece
of bone  into  the  brain, and fall out of the wound afterwards.   In some
instances a ball has been unable to perforate  a fold of linen, but has car-
ried it for the  distance of one, or even three or four inches into the wound;
and on drawing this out, the ball of course comes  out with it.J
   Again, it is very possible that two balls  may enter by the same aper-
ture, one of which may pass out, and the other diverge and wound some
important organ.   So that, in many cases, the prognosis should be guarded,
especially if the  state of constitutional alarm  and  depression, instead of
 diminishing, increase considerably, and disproportionately to the apparent
 extent of the injury.   Sometimes it will happen that a  ball splits, either
from a defect in the casting, or from its striking against  some sharp bony
ridge, as the  vomer or shin.§
    But it frequently happens that large masses of metal are impacted in the
 substance of  a part without much  external indication of their presence, it
 appearing as  though they made room  for themselves by compressing the
 surrounding soft parts. ||
    Foreign Bodies.—Gun-shot wounds may be complicated by the pre-
 sence of other foreign bodies besides the ball;  and these are divided by
 Dr. Hennen  into  two classes;  namely, 1st, pieces of the clothing, or of
 matters contained in the pockets, or portions of the body  of some unfortu-
 nate comrade ;1I 2dly, pieces of bone or muscle belonging to the indivi-
    * Guthrie, op. cit.  p. 17.                  f Hennen, op. cit. p. 35.
    t A silk handkerchief sometimes saves life in the same way; and Mr. Home, in his
 Report on Gun-shot  Wounds in Canada, in 1838, speaks of the great power which the
 canvas lining of soldiers' stocks has in resisting the passage of balls.—Edinburgh Med.
 and Surg. Journ., July, 1840.
    § A Brunswick soidier at Waterloo "was struck by a musket-ball on the tip of the
 nose, which split upon the bony edge where joined  by the cartilage.  A piece of the
 hall was extracted on the spot, and it was supposed that the ball itself had been pur-
 posely cut into pieces, as is sometimes done by foreign riflemen.   The cure went on
 without accident until the tenth day, when the man was seized with a violent haemor-
 rhasje from the nose and mouth, which came on suddenly, and carried him off in the
 course of the night.  On dissection, it appeared that a very minute portion of the ball
 had penetrated along the basis of the skull, and lodged in  the  sinus of the left internal
 jugular vein, forming a sort of  sac for itself, close upon the vein, and having inflamed
 the coats  of the vessel, they at  last ulcerated and burst."—Hennen, op. cit. p. 91.
    j| Hennen relates the case of a young officer who was killed at  the siege of Seringa
 patam by a cannon-ball of thirty-two  pounds, which completely buried itself in the
 muscles of his hip.  A mass of grape-shot, the size of the closed fist, has been extracted
 from under the plantar  aponeurosis.   Guthrie gives a case in which a ball of eight
 pounds' weight lodged in the  thigh without making a large opening, and was not dis-
 covered till it accidentally rolled out on amputating the limb.
    1 A pocket of coarse linen,  containing two five franc pieces and two copper coins
 have been extracted after some days from the vastus externus muscle, in which they
 were deeply imbedded.  Three pieces of coin were extracted on the fifth day after the
 brittle of  Waterloo, from a  wound in  the thigh of a poor Hanoverian soldier.  As he
 possessed neither money nor pocket to put it into, they  evidently came from a comrade
 who stood before him and  who was killed by the same shot.  Part of the cranium has
 been found imbedded in the thigh,—a tooth in tfo? temporal muscle,—and the Olecranon
 of one man in the bend of another man's elbow. 
136
GUN-SHOT WOUNDS.
 dual, but which have become virtually extraneous, in consequence of being
 dead and detached.   These  are infinitely more  mischievous  than  the
 former.   It must be recollected that  although  there  may be no ball in a
 gun or pistol, yet the wadding may act as a ball, if the piece is  discharged
 close to the body.   The surgeon in civil practice who examines a gun-shot
 wound inflicted with intent to murder, should always save the wadding if
 he finds any,  as it may afford a clue to  the detection of the murderer.
    Spent  Balls.—Injuries from spent cannon-balls have at all times at-
 tracted great  attention, from the  extreme  violence of  the injury inflicted
 and the very little external appearance of it.   In some rare cases a cannon-
 ball has passed close to the head, and  has caused death, either immedi-
 ately or within a  few hours, without  leaving any morbid appearance that
 could be  detected by dissection.*  But in the  majority of instances it  is
 found, that although the skin  may be intact, or but trivially grazed, still
 that the parts beneath have been irreparably disorganised;—the muscles
 pulpified, the  bones comminuted, and large vessels and nerves torn across.
 The patient is severely stunned ; and the  part injured  is motionless, and
 senseless, and benumbed  for  some distance.   Swelling  soon comes on,
 but more  from extravasation than inflammation, which, although attempted
 to be set up, never attains  any height.   Gangrene follows speedily, and
 is propagated to  the  neighbouring parts, weakened as  they are by partici-
 pation in the injury,  and by their contact with tissues that have ceased  to
 live.
   These cases were formerly called vrind contusions, being ascribed to a
 compression  and  displacement of the air by the ball;  but the subjoined
 quotation  from Baron Larrey offers the  most probable explanation of the
 phenomenon, f
   Small  Shot, discharged from a fowling-piece or pistol, produce differ-
 ent effects, according to the distance  at which they strike.  If the distance
 is great, they will in all probability be scattered,  and fall singly; peppering
 the victim  smartly, but not penetrating beyond  the  subcutaneous tissue,
 nor doing much harm unless one of them strike  the eye.   But if the dis-
 tance is small, so that they strike en  rnasse, their  effects are  far more
  * A lad was carrying a sand-bag on his head, when it was struck by a  twenty-four
 pound shot from a distant battery.  He  immediately fell, senseless and comatose, with
 a slow, weak pulse,  labouring  respiration without stertor, and  incessant  attempts  to
 vomit  I he pupil of one eye was dilated and motionless, that of the other natural; the
 hair along the sagittal suture was erect, resembling that of a person placed on the insu-
 lating stool and electrified.  In thte state he remained  for twenty-four hours, and then
 expired in convulsions.  No cause of death  was discovered on a minute examination,
 so that it must be attributed to a violent concussion ; but it is remarkable that the ball
 Hennen^ge    & C°nCUSSi°n' wilhout also  musing some more palpable lesion.-
  t"A cannon-ball is propelled  at first with a rectilinear movement: and if, during
 this part of its course, ,t strikes against any part of the human body, it carries it away:
 but the ball, after having traversed a certain distance, undergoes some change in motion
 n consequence of the resistance of the atmosphere, and the attraction of the earth, and
 IT™ "h115 °WTr  ^u' in,add.i1tion to the dire" impulse received from the explosion of
 tne powder.  If lt should strike any part of the  body when the velocity with which the
 ba I is passing is greatly diminished, it does not  carry it away, as in the preceding case ;
 but in consequence of its curvilinear or rolling  motion, it turns round the part, in the
 Tho ,nnft T', 3S &       uPHSSeu °Ver a Iimb' insteafl  of forcinS a PassaS* trough it.
 1,°J"f fe'aS,tlC Pa"s' SUC\as th* skin a"d cellular membrane, yield, whilst the bones,
^™m„VS   T^arKrn S,,&C;',°fferinB a greater degree 0f ^^tance, ™ either bruised
"' \Z           \^U Si10^ld Strike °ne of the cavities of lhe body, the viscera suffer
m like .manner. -Mem. de Chir. Mil. quoted by Guthrie. 
GUN-SHOT WOUNDS.
137
destructive than those of a bullet, for they spread in the flesh, and so cause
greater laceration, besides the mischief arising from their lodgment in the
tissues.
   Progress  and Consequences.—In favourable cases.—Inflammation
generally comes  on  in  from twelve to twenty-four hours after a gun-shot
wound of some common part.   The  wound becomes swelled, stiff, and
painful, and  exudes a  little  reddish  serum.  On  the third or fourth day
pus begins to be formed;  but the suppuration  is  limited by the effusion
of lymph around the wound.  About the fifth day the parts in the imme-
diate track of the ball, which have been killed by the violence of the con-
tusion, begin to  separate, and  change from  a blackish red  to a brownish
yellow colour;—and on the  tenth or fifteenth day, sooner or later, accord-
ing to the vigour of the constitution,  the slough is thrown  off.*  In  the
mean time granulations form, the wound contracts and becomes impervious
at the centre, and generally  heals with a depressed cicatrix by the end of
six weeks or two months,—the lower aperture always healing first.  These
are the symptoms observed  in healthy constitutions, and they will be at-
tended with little constitutional disturbance, and that of no  long duration.
   Inflammatory Complication.—But if the  patient, previously  to the re-
ceipt of his wound, or after it, has committed excesses, or has been exposed
 to vicissitudes of temperature, — or  if the wound has  been irritated by
 want of rest, or improper applications, the local  and constitutional affec-
 tions will be much more formidable.   The pain will be more severe, the
 redness and  swelling  more extensive, the wound dry,  and fever violent.
 When suppuration  is  established, instead of being confined to the track
 of the ball, it is diffused amongst the neighbouring  muscles and under
 fasciae, forming numerous and irregular sinuses;—so that the treatment is
 protracted for many months; and even after the  cure  is completed, the
 limb remains disabled  by contractions and adhesions of the muscles,  and
 is liable to cedematous swellings from the  structural and  vital weakness
 which  a continuance of inflammation  always induces.
    Lodgment of Foreign Bodies.—If  the  ball or any other  foreign  bodies
 remain  lodged, the present inflammation and constitutional disturbance
 will  be proportionably more severe, and  the resulting suppuration more
 profuse and exhausting;  and it will besides be accompanied  with more
 or less pain, till the exciting cause is got  rid of.   But if the constitution
 or parts do hot possess much irritability, if the ball be small and polished,
 and  uf  it press against no  nerves, or vessels, or other sensitive parts, it
 may, and often does, remain for years without creating any  disturbance—
 a cyst being formed for it in the belly of a muscle, or in  the  interstitial
 cellular tissue.   And  this is much more likely to happen if the force with
 which it was propelled was not very great; — because, in that case, the
 wound  is formed rather by penetration than by contusion, — it is a slit,
 rather than a hole,—and it may  close by adhesion, with very little suppu-
 ration or separation or sloughs.
    Rare Complications.—Mr. Guthrie has described two rare  and pecu-
 liarly fatal forms of inflammation occasionally  supervening on gun-shot
 wounds.  The first is a most acute inflammation, attacking the muscles
 and other deep-seated parts, with very little affection of the skin.  In the
   * It is bv no means true, as is  generally stated, that the whole track of the ball mnsi
 slough, for the separated parts are never equal in extent to the depth of the wound.-•
 Gu'hrie.
         12* 
138
GUN-SHOT WOUNDS.
instances related, the wounds  were apparently going on well, when they
became extremely painful towards evening ;  the pain increased during the
night, and  death  occurred  before  morning.   " On dissection," says the
learned author, " the whole limb seemed so  stuffed or gorged with blood,
that  the texture of the parts, muscular as well as cellular, was soft, and
readily giving way to a moderate  pressure with the fingers.  I  can only
compare it  to the appearar.ee of a part just falling into a state of gangrene."
  The second variety made its appearance after the first  two days, and  in
every case  which Mr. G. saw, the  wound was in  the  upper extremity.
The part swelled, and was rather cedematous, and affected with a burning
pain : the skin was bright and glossy.  In fatal cases, the swelling rapidly
extended up  to the axilla,  and then difficulty of breathing came on, and
was soon followed by death.   One  patient only, out of six, was saved, by
the most vigorous antiphlogistic treatment.   The first three cases were not
examined  after  death ; in  the fourth, the great veins were inflamed, and
in the fifth  there was effusion into the chest.
  Mortification supervening on gun-shot wounds  may occur under the
following conditions:—(1) When the injured parts are irrecoverably dis-
organised,  so that they immediately cease to live ; which sometimes hap-
pens to the tissues in the immediate track of a  musket-ball, or to a whole
limb struck by a spent shot.   (2) From  excess of inflammation following
a wound;—especially if the excess is due to a disordered state of the con-
stitution.  (3) From division of the  great arterial and venous trunks. This
is indicated  by its commencing in  the extremity of the limb ; the foot  or
the hand for  instance ; and  it presents a combination of the two forms  of
dry  and humid gangrene. The most distant parts become cold, pale, and
insensible ; this state spreads up the limb ;  then the  patient complains  of
pain and  numbness ; and  the parts above  those which are actually dead
become slightly tumefied and discoloured.   In the course of three or four
days heat  and  redness  supervene, and the  swelling  greatly increases.
The constitution now becomes affected with restlessness, anxiety, and
fever; — the  swelling rapidly increases, with  great  pain, the skin being
yellowish  and streaked with  bluish lines.  The patient mostly sinks;—
there being  but few cases in which, if the first stage has passed by, and
the  constitution has become affected, (as indicated by the rapid  extension
of the  gangrenous swelling,) there will be power to arrest the disease, and
form a line of separation.
   Secondary  Hemorrhage.—This  is the last complication  of gun-shot
wounds that will here require notice.   It may be caused, first, in conse-
 quence of  excessive arterial action,  by which the coagula in the mouths of
 the  divided vessels are displaced.   This may occur at  any time from the
 first day till the fifth.  Secondly, by the separation of a slough from a large
 artery.  This may occur from the fifth  till the twentieth day; and it is
 this peculiar variety of secondary haemorrhage which is generally thought
 to be so frequent in its occurrence, but which as  Mr. Guthrie asserts does
 not happen in more than three or four out of a thousand cases.   Thirdly,
 from ulceration of the coats of an artery; and this may happen at any time
 until the wound  is healed.   The fourth and most common variety is a
 real inflammatory hemorrhage; the blood not being poured  out from any
 particular  trunk, but exuding from the  general surface of a granulating
 wound.   This kind of haemorrhage may be caused by everything capable
 of exciting the circulation ; — by excess in  food, drink,  or muscular exer- 
TREATMENT  OF  GUN-SHOT  WOUNDS.
139
tion, and particularly by venery;* and the same causes will, of course,
tend greatly to induce either of the other varieties.   It  is most  liable to
occur in persons of a sanguine temperament; and especially if they have
been exposed to the close air of a crowded hospital.   The haemorrhage is
preceded in these cases  (and in the other varieties also, if partially induced
by the same causes) by  pain, heat, and throbbing of the wound.


             TREATMENT  OF  GUN-SHOT  WOUNDS.

   Of Simple Cases. — When a ball  has passed completely through some
common  fleshy  part, such as the thigh or buttock, the wound should be
sponged clean:—and when the ordinary haemorrhage is arrested, a piece
of lint  should be applied and  secured by two or  three cross strips of
plaster.   Tremor and mental confusion may be  allayed  by a mouthful of
wine or spirits, and by a few consolatory words  from the surgeon;—or, if
severe, by an opiate.  When they have subsided, a compress, wetted with
cold water, or with some innocent lotion, will  be the only other applica-
tion needed.  If the patient can be  kept at rest in bed, all bandages, at
this stage, will  be unnecessary and  injurious.    In  military  practice, one
or two turns of a roller may be necessary to keep on the  dressings, but
they should not be  applied with  any  degree  of tightness; — and,  as a
general rule, their application on the field of battle  should  be as limited
as possible, lest there be a deficiency of them in the latter stages of treat-
ment, when they can scarcely be dispensed w'ith.
   These  primary dressings need not be removed for the first three or four
days ;  and if they have  become dry and  stiff, they should be well moist-
ened with warm water previously to  their removal.   During the  succeed-
ing inflammatory stage, there is the  choice of  hot  or cold applications,
each of which has its advocates.   Mr. Guthrie  greatly prefers the use of
cold water ;—but if it makes the patient feel chilly or uncomfortable, or if
it augment stiffness and  pain, warm poultices, or the water-dressing should
be substituted.   But it is found  that  the too  frequent use of  poultices
weakens  parts,  and  renders them incapable of the  necessary restorative
actions; whilst they too  often serve as a cloak for negligence, and prevent
the adoption of more active measures;—in fact, the experienced military
surgeon just quoted considers a poultice applied to a compound fracture,
or wounded joint, as the sure precursor of amputation.   When  suppura-
tion is well established,  the  cure is to be  completed  by mild stimulating
lotions  and  bandages.   Particular care must be taken to prevent sinuses,
by pressing  out  all stagnant matter,  and preventing its accumulation by
compresses;  or by free openings, if requisite,  to  ensure  its discharge.
Gentle  frictions and  passive motion, are the best means for preventing or
removing subsequent stiffness.  The  constitutional treatment  must be anti-
phlogistic.   If inflammation be slight, purging, low diet, and rest, may
  * The tendency of the great excitement produced by the venereal orgasm to cause
hrrmorrhage is well known.   Hennen (p. 189) enumerates three cases; in the first of
which, fatal haemorrhage from the lungs took place from this cause ; in the second, "an
officer died from uncontrollable bleeding from  an amputated  arm, from the same;" in
the third, "a young officer with an amputated  thigh, which was healed within half an
inch, had, seven wesks after the amputation, an liEemorrhage so violent from an  excess
i'.'" this nature, and  a subsequent opening up of the stump, to such an extent as detained
him unch'r cure for three months longer."   Instances of death in coitu are mostly to be
assigned to the same cause. 
 140            TREATMENT  OF GUN-SHOT WOUNDS.

 suffice;—but if it be severe, and the patient robust, bleeding may be em-
 ployed freely.*  A combination of sulphate of magnesia and tartar emetic,
 F. 21, is a most convenient form  for the military surgeon.   Leeches may
 be applied to allay inflammation.  Opiates should be given at bedtime, if
 there  be much spasmodic twitching and pain.
   Superficial wounds,  made by musket or cannon-balls, are to  be treated
 in the same way.  It must be recollected that cold lotions are never to be
 extensively applied to the trunk.
   Dilatation. — The same  observations are to be  made  concerning the
 dthtation  of gun-shot, as of punctured  wounds.   Scarifications or  inci-
 sions  are never to be made from routine, nor without some definite object.f
 But if there be a great swelling of muscular parts confined by fasciae, or
 if matter form in the same, there  can be no doubt of the propriety of a
 sufficiently long and deep incision to relieve tension and discharge matter.
 Dilatation  may also be required in compound gun-shot fracture, to remove
 splinters of bone.
   The two peculiarly fatal forms of inflammation specified by Mr. Guthrie
 are to be combated by vigorous antiphlogistic measures and incisions.
   Foreign Bodies.—In every case the surgeon should ascertain whether
 foreign  bodies are lodged  in  the wound; for even  although  it may be
 satisfactorily demonstrated that the ball has passed out,—or although  there
 may be a  mere laceration from grapeshot  or shell, still pieces of the cloth-
 ing or other matters may remain in the wound.  If there is only one open-
 ing, such  an examination is indispensable.   The parts should  be put as
 much as  possible  into  the posture they were  in  when  the injury was
 received ;  and the finger should be passed in as far as it will reach, coun-
 ter-pressure being at the same time made on the opposite side of the  limb.
 In  unimportant parts, the finger may be aided by a long probe  or bougie,
 or a deeply-seated  ball may sometimes be  detected  by a long, fine acu-
 puncture needle.
    If  the foreign body is found lying under  the skin, it should  be imme-
 diately removed  by an incision, which will  require to be larger  than  at
 first would be imagined.   Pressure should  be made to  prevent the ball
 shifting its place during the incision, otherwise the operation will be long
 and vexatious.  If the foreign body is near the wound, it should be re-
 moved  by forceps, — the  simpler  the better.   The  orifice will mostly
 require to  be dilated for'this purpose, because from the natural elasticity
 of  the skin, and the ensuing tumefaction, it will be too much  contracted
 to allow the ball to pass out again.
    It is a well-established rule, that on no  account are incisions to be  made
 for the removal  of foreign  bodies, unless they are certain  of being suc-
 cessful ; both because of the  fruitless pain created,  and because of the
 depressing effects of a failure on the patient's mind.  If a ball  is lodged
 in the middle of the thigh,  or  other  thick fleshy part, and from the direc-
 tion of the wound it cannot be extracted  without a very considerable inci-
f sion,  it should be left to itself; — and it will probably be either brought

   * Soldiers, from  their generous diet, active exercise, and regular discipline, bear de-
 pletions of every kind much  better than  rustic  labourers or mechanics, although, per-
 haps,  the latter may be more ruddy and healthful in appearance.
   t Yet we  read of the orifices of these wounds being scored in a radiated manner by
 foreign surgeons, as though in compliance  with some religious ordinance.  Sir C. Bell's
 Dissertation of Gun-shot Wounds, p. 459. 
TREATMENT OF GUN-SHOT  WOUNDS.
141
within reach by the natural  contraction of the parts, and by the flow of
matter, or it may become encysted, and give no  further trouble.   Bullets
that have become encysted are to be cut out, if they come near the skin,
or if, during any of their extraordinary changes  of position, they impede
the functions of any important part, otherwise they are to be left to them-
selves.   The cyst that envelopes them is frequently so dense, and adheres
so firmly, that a portion of it must be removed at the same time.
   If a ball has lodged in the substance of a bone, it should be removed
by a chisel, or trephine;  otherwise caries,  or necrosis, and so much mis-
chief as to necessitate amputation, may follow.  In a few rare cases, how-
ever, balls have remained imbedded in bone, without mischief.
   Secondary  Hemorrhage. — The  first three varieties of secondary
haemorrhage, described at p. 138, require  the ligature;  the fourth is to be
treated by rest, by the application of cold or iced water, or by ice itself;
—by pressure  on the bleeding surface,  or on the  arterial trunks above;—
and if the blood seem to  ooze  from any particular spot, it may be touched
with nitrate of silver.   If there be fever and plethora, bleeding and purg-
 ing ;—if weakness and irritability,  tonics,  opiates, and the mineral  acids;
 —and, in all cases, removal from a crowded hospital will  be expedient.
   Necessity of Amputation.—It will not be wondered at, that  this ope-
 ration will be frequently  required in gun-shot injuries of the limbs, on ac-
 count of the fracture  and comminution of bones, the exposure of joints,
 the division of blood-vessels,  and the irreparable violence inflicted on the
 skin and soft parts.
    The points for consideration in determining its necessity are two-fold;—
 viz. 1st, Would the preservation of the limb endanger the patient's life?—
 and, 2dly, supposing that it would not, would the limb be of use,  if saved?
 In  deciding on the first point, we must  be guided  by the patient's age;
 for an old person would succumb to an  injury that a young one might
 recover from ; — by his habits,—for temperance, sobriety, and a well-dis-
 ciplined mind, will be greatly in  his  favour; — by previous disease,—for
 (as has already been insisted on*) if there be organic disease of any viscus,
 the patient will be infinitely more liable to sink;—lastly, by the supply of
 ?iecessaiies, and extent of accommodation;—hence, in compound frac-
 tures, and other cases demanding perfect quietude, many  more limbs may
 be saved in  civil  practice  than in the  accidents of naval and military
 warfare.                                             ^
    Primary or Secondary ?—But, supposing amputation to be decidedly
 required, — that  the limb,  if preserved,  could  be but a burden to the
 patient, and that the attempt to preserve  it would endanger his life ;—the
 question next  arises, whether amputation  ought to be piimary; that is,
 performed within the first forty-eight hours, before fever and inflammation
 have set in ; — or whether it  ought to be secondary;  that is, delayed till
 inflammation has subsided,  and suppuration is established,—which is not
 generally the case in less than from three  to six weeks.
    Now this question  is  one which cannot be decided by argument, but
 by experience ; and the general experience of  modern military surgeons
 has decided that amputation,  when necessary, ought to be primary.   We
 may gather from Mr. Guthrie's! works, that the loss after secondary ope
 rations is at least three times as  great as that after primary.

           * Part I. chap. i.                   t G"tnrie> °P-  cit-> P- 224> 
142            TREATMENT OF  GUN-SHOT WOUNDS.

  Hunter, however, and some surgeons before his time, advocated second-
ary amputation; the arguments in favour of their practice being, that per-
sons in a rude state of health do not bear operations so well  as those who
have been  labouring under some  chronic  suppurating  complaint  of the
part to be removed; and that if the patient is not able to support the in-
flammation  arising  from  the  accident, it is more  than  probable that he
would not be able  to support  the amputation and its consequences ;* and
further, that the patient is liable to  sink sooner or later from the shock of
the  amputation speedily  succeeding that of the injury.   Moreover, Mr.
Alcock, surgeon to the  Anglo-Spanish legion, found in  his practice, that
secondary was less fatal than  primary amputation, f
  But it may be seen at a glance, that there is not one reason in favour of
secondary amputation that is worth much.   For, in the first place, it must
be evident that many will die of the inflammation of an extensive lacerated
and contused wound, who would not die of the  minor inflammation aris-
ing from a clean incision ; and that many will die of secondary amputation,
when exhausted by suffering, and weakened by confinement in an hospital,
who might have survived a primary operation.   In the second place, Mr.
Alcock's experience in Spain  is neutralized by another isolated set of
cases, viz. the secondary  amputations  after  the battle of Navarino, all of
which proved fatal.|  And lastly, it must be recollected  that  the question
is,—not whether a hundred men just wounded and requiring amputation
are  more likely to  survive it than a hundred who have gone  through the
ordeal of six  weeks in an hospital;—but whether the first hundred would
live to that period ;  which most probably they would not.
  When amputation is decided upon, it should  then  be primary.   But
'here are two errors as to time, that  even here must be avoided.  The first
is, that of amputating too soon;—of "letting the knife follow the shot,"
before the patient is in any measure  recovered from the immediate  shock
and collapse;  the second is, that of waiting too long, so that  he becomes
exhausted by pain.   Therefore, when the patient is brought to the surgeon
with a limb knocked off, and  with a low pulse, cold skin, hiccup, fainting,
or other symptoms of extreme collapse, the first  endeavour should be to
comfort him ; to explain the nature of his loss; to assure him of his safety,
and to administer small quantities of wine or cordials, and apply warmth;
at the same time jproviding by the tourniquet against immediate peril from
bleeding.   And in this way, by waiting an hour or two, the agitation of
mind and body will be appeased, and the operation may be  performed
without further delay.  But if the pain be  so  intolerable that the patient
eagerly demands to be  relieved from his sufferings, the request should be
immediately complied with; for the shock  of the  operation will be infi-
nitely less detrimental than the endurance of such torments.
  Care should always be taken, before amputating, to ascertain the whole
amount  of injury; for it would be of little use to cut off a leg, if the
patient was shot through the liver.
  If, from  any  unavoidable  circumstances,  the  favourable period has
elapsed, and violent fever and inflammation have set in,  still  the operation
must be done without delay in some few cases, to give the patient a chance
  * Hunter on Gun-shot Wounds.
  -j- Notes on the Medical History of the British Legion in Spain, by Rutherford Alcock.
K. T. S.   London, 183b.
  f Lizaro' Practical Surgery. 
BURNS  AND SCALDS.
143
of surviving.  But, in the majority, free antiphlogistic measures should be
first employed; and then, " On the very day," says Hennen, "that a sub-
sidence of fever is effectually announced  by a free and  healthy suppura-
tion, by the abatement of local inflammation ; by a restoration of the skin
to its functions, demonstrated by returning coolness and elasticity, particu-
larly on the affected limb ;  we should proceed to perform our amputation
on those patients in whom no hope of  an  ultimate recovery without it can
be entertained."*
   Rules for Amputation.—1. When a limb has been completely knocked
off by a cannon-ball, the stump must be amputated ; and if the bones be
splintered and shattered  up to the next joint, or  if the wound  be so near
the joint  that mischief is to be apprehended, the operation must be per-
formed above it.
   2. Gun-shot fracture of the femur always requires amputation, and so
 does division of both femoral artery  and  vein, or of the sciatic nerve.
 But it is not necessary for considerable destruction of the soft parts, pro-
 vided the bone, vessels, and nerves are intact, and that  there are conve-
 niences for the cure.
   3. Injuries of the  knee,  or ankle-joints, or  extensive fracture of the
 tibia, with division of the arteries, require it, but not mere  laceration of
 the calf.
   4. The arm should not be amputated for almost any musket-shot injury.
 If the head of the humerus is shattered, it should if possible be sawn off;
 —if the elbow is shot through, it may be cut out;—and the fore-arm will
 bear so  much  fracturing and cutting, that  it should not be  condemned
 without very great injury both to bones and arteries. But extensive injury
 of the wrist-joint, or of the humerus, with division of the vessels, generally
 requires the operation.
   5. When a main artery is wounded, and gangrene is  commencing and
 spreading beyond the toes or fingers, amputation should  be performed just
 above the level of the wound.
                         CHAPTER  V.

         OF THE EFFECTS OF HEAT, BURNS, AND SCALDS.

  The degree of heat which can be borne without inconvenience or in-
jury, depends very much on the conducting power of the medium through
which it is applied. Thus, Sir C. Blagden and Dr. Fordycef ascertained,
by experiment, that the body may be exposed to air  (whose conducting
power is almost a nullity) of a temperature above  212° without injury;
whereas the  contact of a solid ox fluid of the  same heat would instantly
cause burning.   Again, some parts  of the body will from habit tolerate a
degree of heat that would be extremely painful to others.
  » Hennen. op.  cit. p. 2f>6; Guthrie, Clin. Lect. Med. Gaz., March 10th, 1838.  Sir G
Ballingall's Military Surgery, p. 219, et. seq.
  t They found that they could bear the contact of heated spirits when cooled down to
130 degrees; of oil at 129; water at 123 ;  quicksilver* at 117. Vide Phil. Trans, vol. .xv 
144
BURNS  AND SCALDS.
  Diagnosis.—It  is sometimes important in medico-legal investigations,
lo determine exactly the  manner  in  which burns  have been inflicted.
Those caused by the contact of heated liquids are  generally diffused  in
their extent, and equable in their severity; they are  also generally super-
ficial ; for the heat of boiling water is  not sufficient to cause the death of
the cutis, unless immersed in it for some time ;  although  that effect  may
be  readily  produced by boiling soap or oil, or other liquids whose point
of ebullition is high.   Burns caused by some sudden and intense  heat of
short  duration, — as by the ignition of turpentine or gunpowder, or the
inflammable gases, are more diffused, uniform, and regular than those
occasioned by  the contact of  heated-substances; — and  all the  hair is
burned off smoothly.
   After burns from the explosion of gunpowder, the  injured parts are  said
to be of a  peculiar bluish white.   The irritation of these injuries is often
aggravated by the  numerous grains of gunpowder that escape combustion,
and are projected with such force as to  stick into the skin.   In many
cases, caused by the explosion  of gas in coal mines, particles of the coal-
dust adhere to the skin in the same manner.
   Division.—The most useful  division of burns, for practical purposes, is
the three-fold  one which  has  existed from time immemorial,  into,  1st,
burns producing mere redness;  2dly, those causing vesication ; 3dly, those
causing death of the part burned.
   1.  The first  class  are  attended with mere superficial inflammation, ter-
minating in resolution, with or without desquamation of the cuticle.   The
pain  is philosophically said to  consist of  a perpetuation  of the original
sense of burning.
   2.  In the second class there is a higher degree of inflammation, causing
the cutis to exude  serum and form vesicles. These in trivial cases dry up
and heal;  but if  the injury to the cutis has been sufficient to cause  it to
suppurate,  they will be succeeded  by obstinate ulcers.   The pain of these
burns is much more severe than in the former class, especially if the vesi-
cles have  been torn, and  the surface  of  the true skin exposed to the air
and the contact of foreign bodies.  The formation and increase of vesicles
may  often  be  prevented by proper  treatment.  They generally  appear
immediately after the accident,  although cases are recorded in which  they
did not rise for three days.
   3.  The  third class of  burns is attended with mortification from disor-
ganisation  of  structure.   These are, for  obvious reasons, not attended
with so much pain as the  last  class ; but in every other respect they arr
infinitely more  serious, and the sores which remain after the separation ot
the sloughs are often months or years in healing.
   Constitutional Symptoms.—The  constitutional symptoms  of severe
burns are those of great collapse.   The  surface  is  pale, the extremities
cold, the pulse quick and feeble;—there are violent  and repeated  shiver-
ings,  and  the  patient often complains most urgently of cold.  In some
fatal  cases these symptoms are soon  succeeded  by laborious breathing,
coma, and death ; — in  otherSj  dissolution  is preceded by a period of im-
perfect reaction, with delirium, sharp jerking pulse, and the other symp-
toms  indicative of prostration with excitement.
   Prognosis.—The danger of  burns must be  estimated  by their extent,
their severity, their situation, the age and constitution of the patient, and
by the symptoms actually present.  Extensive burns, even of small seve- 
BURNS  AND  SCALDS.
145
rity, are always dangerous ; and especially if vesication has occurred early,
and the cuticle has been stripped  off.   Burns on the  trunk are  always-
more  dangerous than those of an equal extent  on the extremities; and it
need  not be said that infancy and old age will be alike unfavourable.
With regard to the symptoms actually  present, it  may be noticed, that
although the severe pain, such as is common in burns of the second class,
is in itself a source of great danger, from its tendency to exhaust the  vital
powers, still that it is on the whole a favourable symptom, if the injury is
extensive;  and that the want of it  indicates  urgent peril.   "The early
subsidence  of  complaint," observes  Mr. Travers, " unwillingness to be
disturbed, apathy approaching to stupor, as if the scale  of  sensibility had
shrunk below the point of pain, is invariably a fatal  symptom.   Constant
shivering is an ill omen.  The failure of the pulse  and consequent cold-
ness  of  the extremities, with a livid hue of the  transparent skin  of the
cheeks  and lips from congestion in the capillaries, drowsiness, with occa-
sional muscular twitchings, are sure prognostics of death."  Subsidence
of swelling  is an equally ominous symptom.
   The  periods  of danger in burns  are  three; 1st,  during the first five
days; from collapse or imperfect reaction ; 2dly, during the  sympathetic
fever which follows, in which the patient may sink with an affection of the
head, chest, or abdomen ;  3dly,  during  the  suppurative stage,  in which
he  may die from the profuse discharge, or from  pulmonary consumption
induced by it.   Kentish observes that very many cases  prove fatal on the
ninth day.
   Morbid Anatomy.—A post mortem  examination readily accounts for
the coma and  laborious breathing, which are such constant symptoms of
fatal  burns.  Congestion and serous effusion are found on the surface and
in  the ventricles of the brain  ;—and  the air cells of  the  lungs are  loaded
with  a thin muco-serous fluid, as  in the " suffocative catarrh of the  dyi,ng"
of  Laennec.   Moreover it has been shown by Mr. Curling,* that severe
burns in young people are sometimes followed by an acute ulceration of
the duodenum, commencing probably in Brunner's glands, and liable to
terminate fatally, by perforating the intestine and causing  peritonitis:  or
by opening some large artery and causing effusion of blood, part of which
may  be evacuated by vomiting and purging.  The  cause of these visceral
affections is supposed to be the cessation of the exhalent function of the
injured  portion of  skin; — but this explanation  merely adds  to  the
obscurity.
   Treatment.—The  treatment  of  burns in  their  early stage has been a
matter of great dispute.  Some eminent surgeons! have advocated ice or
other cooling applications; others, the use of turpentine and  other stimu-
lants  ; which latter plan of treatment was ably advocated by  Mr. Kentish
of Newcastle, at the beginning of the present century.
   The  following, however, seem to be the principles of treatment dedu-
cible  from the conflicting theories and practices which have been proposed ;
viz.,  1st., that the first applications  should be of a mildly stimulating na-
ture ; 2dly, after the first two or three days they should  be  soothing; till,
3dly, slight  astringents maybe applied to expedite the healing; and4thly.
the part should throughout be  most carefully preserved from the atmospherit

                   • Med. Chir. Trans, vol.  xxv.
                   \ Earle's Lectures on Burns, Lond. 1832.
       13                         K 
146
BURNS  AND SCALDS.
air and froit cold.  If these principles are held in view, the surgeon will
have no difficulty in finding appropriate remedies.
  Local Treatment of minor cases.—In slight cases of the first and second
degrees, the vesications should be pricked with a needle to take off their
tension, and then the  whole burned  part be wrapped in soft  cotton wool,
which should be kept  constantly wetted with a spirit lotion ; cold or tepid,
according to the patient's choice.  After the first two days  a  lotion  of
zinci sulph. gr. ij;  aquae f. 3j  ; may be applied on lint covered with oil-
silk ; or a bread-and-milk poultice, or the water-dressing if the part is
much inflamed; the  chalk  ointment may be applied afterwards till the
cure is complete.   The part  should be kept thickly wrapped  in cotton
wool during the whole period, to preserve it from the air, and from cold
or injury.
  The surgeon, however, may make his choice from a most  multifarious
list of remedies.  In very slight cases it is a good plan to apply heat, if it
can be done conveniently, either by holding the  part near afire, or by dip-
ping it in  water of 112°, and continuing this until the burning pain begins
to subside;  or it may be bathed with tepid  oil of turpentine, or alcohol,
or aether,  (which may be warmed by putting them into a teacup, immersed
in boiling water,) and then should be warmly wrapped up in lint or cotton.
But if the surgeon prefer the cooling plan, he may apply any evaporating
or refrigerant lotion—cold water is as good as any other: pounded ice
mixed with lard was recommended by  Earle: a poultice  of  potato or
grated turnip is not to be despised ; but whatever is used, it must be re-
newed often enough to  keep up the  sensation of cold.
   The following remedies  also have  acquired popularity in the cure of
burns, and all, as Mr. James  observes, either possess certain stimulating
qualities,  or else exclude the influence of air and temperature.
   The liniment composed of equal parts of linseed oil and lime-water, or
Carron oil, (so  called because in general use  at the iron-works of that
name,) is a good defensative,  but has a most sordid, nauseous odour.  It
is sometimes  applied  after cicatrisation,  to  prevent contraction.  Lime-
water and milk is an  analogous  preparation.   Soap-liniment is a good
stimulant; but it is more expensive than turpentine, and not better.  Com-
mon thick white paint  has, according to Sir C. Bell,* been  used at  the
Middlesex Hospital;  but, from its  containing  white lead, its protracted
application might be hazardous.   Copaiba has  been employed at the Ex-
eter Hospital,  by Mr.  Luscombe, and Treacle by Mr.  Greenhow,f but
neither of the last-named  applications  is to be compared with Kentish's
liniment.   Flour, applied thickly with a common dredger,  and Cotton,
very soft and finely carded, are popular applications.   They  are directed
to be laid on  the  raw surface, and to  be perpetually strewed on in thick
layers, so as to  soak up the discharge ; but without removing any which
is already applied.   The good effects of these two  substances depend on
the same principle.  They exclude the air, and form a soft covering.  But
they are apt to become  dry, hard, and irritating, and not unfrequently are
converted into a noisome mass of putridity and  maggots.   Vinegar.—Mr.
David Cleghorn, an Edinburgh brewer, very strongly recommends the ap-
plication  of warm vinegar  for the first twelve hours,  then  poultices till
suppuration is established, and chalk afterwards.^
      • Institutes of Surgery.  London, 1838.
      f Greenhow, Med. Gaz. Oct. 13; and Leach, Med. Gaz. Nov. 3,  1838.
      \ Med. Facts and Obs. vol. ii. 
BURNS  AND  SCALDS.
147
   Of severe cases.—When a burn is severe or extensive enough to cause
danger to life, Kentish's plan  of first bathing the burnt parts with  tepid
turpentine, then with all possible expedition applying a liniment, composed
of ung. resine  3j;  ol. terebinth. 3ss,  thickly spread on lint,  and lastly,
wrapping them  up warmly in flannel,  seems to be the most judicious.
The dressings should  be allowed to remain as long as possible, and should
not be removed unless there is  a profuse discharge or bad  smell  from the
wound.   Great care should be taken, when  the wound is  first examined,
not to strip off the  cuticle, whilst taking off the patient's clothes.
   Constitutional Treatment.—If there is an urgent degree  of collapse, the
measures  directed in Part  I. chapter I. are to be diligently adopted.  Care
should, however, be taken not  to push the use of  stimulants  too  far,  lest
congestion in the head or chest be induced or aggravated ;—and, on  the
other hand,  not to  abandon them too soon, lest the collapse return, as it is
very apt to do.  Arrow-root, beef-tea, and other forms of mild nutriment,
must be judiciously administered, according to circumstances.
   Use of Opium.—If there be much pain, A good  dose of opium should
be given  without  delay.  For children, nothing can be  better  than  the
compound tincture of camphor, of which 3j—3ij may be given according
to the age.  (Each fluid  drachm contains £ of a grain of opium.)  Yet it
must be added that certain  great  authorities altogether condemn its em-
ployment.   " Opium," says Larrey, " is injurious, whether used externally
or internally.  Externally, it stupifies the parts instead of exciting them to
a salutary inflammation; internally, if used in considerable quantity, it en-
feebles all the organs, after producing a momentary stimulation."*   Travers
objects to it because of its tendency to produce or increase congestion in
the head.  He says that " in small doses it is inefficacious,  and in large
ones injurious."   Notwithstanding these  objections, however, it may be
given in moderation when demanded by urgent pain.  If there be a ten-
dency to  coma, it is of course inadmissible ;  but then the patient will most
probably  perish, whether it be given him or  not.
   During the symptomatic fever, the bowels must be kept open by some
mild laxative, such as castor oil or rhubarb; and the  diet must be unirri-
fating, but not too low.   In the event of any inflammatory or congestive
attack of the head or chest, purgatives, and leeches  or bleeding,  must be
cautiously employed, according to circumstances.   If  there is  any ten-
derness under the  right hypochondrium, or vomiting, or other sign of irri-
tation of  the duodenum, the diet should be  of the blandest  description,
and small doses of hyd. c. creta and henbane be administered.
   Treatment of the remaining Ulcers.—The ulcers  resulting from burns
are often  extremely intractable.  The  granulations are  pale, flabby, and
exuberant;  they secrete pus  profusely; and  many months often elapse
before  they are healed.  The cause  of this  disinclination to heal is  not
well understood;  but one cause  there is which may be  easily detected
and remedied; namely, too full a diet, wThich is often needlessly used on
the plea of supporting the strength under the profuse discharge.   " There
can be no  doubt," says Kentish,  "that full diet  and stimulants, during
the suppurative stage, keep up irritation in the system, and cause the im-
mense  continued  discharge by the  exposed  surfaces of  the wounds."-*

               * Mem. de Chir. Mil., t. i. p.  96.
               t Second Essay on Burns.  Newcastle, 1800, p. 64. 
14S
BURNS  AND SCALDS.
And it is  equally certain that many cases will rapidly get well when th*
diet is lowered and purgatives are administered.
  There should be no hurry in removing the first Dressings, but when they
are  removed, the succeeding applications must be suited to the state  of
the  ulcer.
  If it is irritable and  painful,  or hot and swelled, or seems  inclined to
spread by ulceration, or if small abscesses threaten  to form under th
skin,  poultices, or  the  water dressing, Dover's powder at bedtime, and
aperients, should be resorted to.   If sloughs  are  tardy in separating, the
case must be treated like the sloughing ulcer.
  When  the irritable state  is  removed, a succession of mild stimulants
and astringents will be advisable; especially the zinc lotion ;  chalk, zinc,
or calamine ointment;  simple lint; and pressure  with sheet lead or strips
of plaster.  When the  discharge is very profuse,  the sore should be con-
stantly kept thinly  covered with very finely powdered chalk.  An oint-
ment  of carbonate  of magnesia has  been  used with  good effect by Mr.
Partridge in the King's College  Hospital.
  Treatment of the Cicatrix.—The cicatrix of severe burns is very liable
to become excessively hard, dense, and cartilaginous, and  to  contract in
such a way as to occasion  the most serious deformities.  Thus the eye-
lids or mouth may be rendered incapable of closing ; the chin may be
fixed  to the breast,  or a limb be rigidly and immovably bent.   This con-
traction may, perhaps, be sometimes successfully opposed, by  keeping up
extension wTith  a splint, or, if the neck is the part burned, by  making the
patient wear a stiff collar;  and by frequently moving the part during cica-
trization ; and the cicatrix may be lubricated w7ith  pure oil.   If the fingers
are  severely burned, lint  should be  interposed between  them, and they
should be kept apart as much  as possible, although it will be very diffi-
cult to prevent them from  adhering together.*  In burns of the  head or
face, the edges of the ulcer may be  drawn asunder by strips of adhesive
plaster.   When any of the orifices of  the body are involved they should
be kept ^ilated with canulae, or  plugs of oiled lint.  But if, notwithstand-
ing every precaution, the  cicatrix contracts, and  produces deformity, or
prevents any necessary  motion,  the knife should  be resorted to.   Some-
times the whole cicatrix may be extirpated, the wound being treated  by
water-dressing, and  the parts kept in a proper position during the cure.
Sometimes an incision maybe made in  the  sound  skin on each side of the
cicatrix, so as to form  gaps, which will be filled  up with granulations;—
sometimes it will be useful to divide it transversely by several incisions,
at the same  time  dissecting it up from the parts beneath if it firmly adheres
to them ;—if the  cicatrix is prominent it may be shaved off, and the wound
be  touched frequently with  lunar caustic; — and, lastly, there  is a plan
which has been  adopted with  success by Dr. Mutter,  an American sur-
geon, of dividing the cicatrix, dissecting it up where  adherent, and even
dividing any muscular fibres in order to liberate the parts completely: and
then filling up the gap by  means of a  Taliacotian operation : that is, by
transplanting a portion of sound skin  from some neighbouring part.f
  *  Vide Part iv. chapter xxiv.
  f Vide Earle's Lectures on Burns, Lond. 1832; Dupuytren, Clinique Chirurg.; Mut-
ter on Deformities from Burns,  in the American Journ. M. Sc, July, 1842.  [Also Lis-
ton's "Lectures on  the Operations of Surgery,"  Am. ed. by Mutter.—Ed.]  Several
successful cases by Mr. Parker, of Bridgewater, are quoted in Ranking's Half-yearly
Abs.iact, vol.  iii. p.  106. 
THE EFFECTS OF COLD.
149
                        CHAPTER  VI.

                OP  THE EFFECTS  OF COLD.

  Effects of Severe Cold.—When a person is exposed to very severe
cold, especially if it  be accompanied with wind,—or if it be during the
night,—or if he have been exhausted by hunger, watching, and fatigue,
 e feels almost an irresistible impulse to sleep, which, if yielded to, is soon
succeeded by coma and death.   During the state of coma, the  body of
the sufferer is found to be very pale and cold: the respiration and pulse
almost imperceptible, and the pupils dilated; but the limbs are flexible as
long as life remains,  unless the degree of cold be very great indeed.  On
a post mortem examination, the  chief morbid appearances observed are
great venous congestion and serous effusion in the head.
   Frost-bite.—But if the trunk of the body be well protected,  the cold
may affect only some exposed part, such as the nose, ears, or extremities.
The first visible effect is, that the part becomes of a  dull red colour;—an
effect of cold which is notoriously frequent, and which depends on a dimi-
nution of the quantity of blood conveyed by the  arteries, and a stagnation
of it in  the veins.  If the cold continue, the venous blood will be gradually
expelled by a contraction of the tissues, and the part will  become of a livid,
tallowy paleness, perfectly insensible and  motionless, and much reduced
in bulk.  When in this condition, a part is said  to be frost-bitten.   The
patient may be quite unconscious of the  accident that  has befallen him
until he is told of it by some other person ; especially if it be his nose or
ear that is affected, or some other part that he does not move. _
   A frost-bitten part may mortify in two manners;— 1st, by direct sphace-
lus, if  no  reaction whatever is  induced; 2dly,  by gangrenous inflamma-
 tion;  if reaction, when induced, be rendered too violent.
   The decree of cold required  to produce  frost-bite under any ordinary
 circumstances of exposure must be considerably below the freezing point.
 Mr. Guthrie states it at ten degrees below the zero of Fahrenheit.*  The
 natives of warm climates may be severely injured by cold  that would  be
 innocuous to the inhabitants of colder regions.   Thus, during the siege of
 Ciudad Rodrigo, when the troops were obliged  to  sleep  on the ground
 without cover, three of the Portuguese  actually died of the cold  in  one
 night,  whilst the  British escaped without being frost-bitten.   But very
 much depends on the temperament; for according  to Larrey, the phleg-
 matic Dutch, Hanoverians,  and  Prussians,  suffered much more  during
 Napoleon's winter campaigns than the darker and more sanguine soldiers
 of France and Italy.f Those who indulge in spirituous  liquors, exhausted
 as they are by perpetual stimulation, are much more liable to suffer than
 the temperate.                                 .
    It was shown by  Hunter that the ears of rabbits  and combs ot cocks
 may be frozen so as to be quite white, and hard, and brittle, and  yet  re-
 cover with proper care.   And some of the lower order  of animals  may be
 entirely frozen and yet survive.    But it is not credible  that a whole limb
                  * Guthrie, op. cit. p. 141.
                  t Larrey, Mem.  de Chir. Mil. torn. iv. p. 111.
        13* 
150
THE EFFECTS OF COLD.
of a human being, much less that the whole body, could be  frozen with-
out death ensuing;  although stories of such occurrences have long been
current amongst authors.*
   Treatment.—The indications of treatment whenever a part  or the whole
of the body has been exposed to severe cold, are, 1st, To produce mode-
rate reaction, and restore the circulation and sensibility; 2dly, To avoid
excessive  reaction, which would surely lead to violent and  dangerous in-
flammation.
   Of Frost-bite.—The best remedy for a frost-bite is to rub the part well
with snow.  For whilst the friction restores the circulation and sensibility,
the snow prevents any excessive  reaction.  After a time cold water may
be  substituted  for the  snow, and the friction may be rendered  brisker.
These applications must be made in a room without a fire;  and a high, or
even a moderate, temperature must be avoided  for some time.   By these
means no other inconvenience will ensue, save slight swelling and tingling,
with vesication and  desquamation  of the  cuticle; although the part will
remain weak and sensible to cold for some time.
   For the coma induced by cold the treatment must be similar.   At first
the body should be  rubbed with snow ;—afterwards, when its warmth and
sensibility are a little restored,  it should  be wiped quite dry, and be rubbed
with fur or flannel.   Then the patient should be put  into a cold  bed in a
room without a fire, a stimulant enema should be administered, and a little
warm wine and water, very weak, be given as  soon  as  he can swallow.
The enema may be  composed of water and salt, with  a little oil of turpen-
tine ; but tobacco, which was formerly recommended by the profession in
such cases, and is still popularly considered to  be of great service, must
not be thought of;—it would surely be prejudicial—perhaps deadly.  The
after-treatment must be entirely regulated by the state of the patient;—the
strength must  be supported by mild cordials and nutriment; care being
taken not to excite feverishness or headache.
   The contact of any intensely cold body (such  as frozen mercury) causes
severe burning  pain, followed by vesication.   It thus  appears  that the
effects of sudden abstraction may be similar to those of too great  commu-
nication  of heat.  The best application is snow gradually permitted to
thaw.
   Violent Gangrenous Inflammation may be caused, if heat is injudi-
ciously applied to frozen or frost-bitten parts.   It may also ensue if a part
has been exposed for a long period to a low temperature which is suddenly
raised;—although the cold may not have been  sufficient to cause actual
frost-bite, and may have been  tolerated without inconvenience.   A good
example  of this accident is narrated by Baron Larrey,f as  it affected the
French troops during their campaign in Poland in 1807.   During the few
days preceding  and following the battle of Eylau, the cold was  most in-
tense, ranging from ten to fifteen  degrees below the zero of Reaumur.J
But although the troops were day and night exposed to  this inclement
veather,  and the soldiers of the Imperial Guard, in particular, were nearly
motionless for more than twenty-four hours, there were  no complaints of
its effects.  On  the  night of the 9th of February, however, a sudden thaw
  * See an account of some experiments on the revival  of toads after freezing, in the
Lend, and Ed. Journ. Med. Sc. Feb. 1843.
  f Mem.  de Chir. Mil. torn. iii. p. 61.
  t From  20° to 25° below the freezing point of Fahrenheit.
i 
THE EFFECTS OF COLD.
151
commenced, and immediately a great number of soldiers  presented them-
selves at the " ambulances," complaining of severe numbness, weight, and
pricking pain in the feet.   On examination, some were found to  have
slight swelling and redness at the base of the toes and dorsum of the  foot;
whilst the toes of others had  already become black and dry.  And in this
manner, the toes, and sometimes the whole foot, perished ; the mortifica-
tion being so rapid that it was difficult to say whether it was preceded  by
inflammation or not—although it probably was so for a very brief period.
One case, exactly similar, was treated by Mr. Solly in St. Thomas's  Hos-
pital  in  1845.   The patient, not very temperate, had been employed a
whole day in January in handling raw  cow hides.   In the evening, feeling
his left hand excessively cold and stiff, he put it into warm water, and held
it to the fire, which  excited great pain and  inflammation, ending in  gan-
grene, which spread up to the  middle of the fore-arm.*   The  best treat-
ment for such cases  is the application of snow or very cold water, followed
by evaporating lotions.  These, if  employed early enough, may prevent
gangrene ; or even if that have actually occurred, they should be used as
long as it appears to be spreading.   Subsequently, stimulating poultices
and ointments should be employed to hasten the separation of the sloughs,
 and to promote granulation.
   Chilblains consist in an atonic inflammation of the skin, induced by
 sudden  alternations of temperature ; such as warming the feet and hands
 by the fire when cold and damp.   They may present themselves in  three
 degrees.  In the first, the skin is red in  patches, and slightly swelled;
 with more or less itching or tingling, or perhaps  pain and lameness.  In
 the second, there are vesications—the  skin around being bluish or purple.
 In the third degree there is ulceration or sloughing.
    Chilblains are  common in women, children, and weakly persons  gene-
 rally.   In persons whose circulation is very languid,  they are  apt to  affect
 the nose and ears.
    Treatment of the First Degree. — The best treatment consists in a com-
 bination of local stimulants and depletion.  When  there is much heat and
 itchino-, it is an excellent  plan to  apply a leech; —or to make punctures
 with ^ needle or lancet.   It would  be impossible  to name any stimulant
 that has not been recommended by the public or the  profession.  Perhaps
 the best is that proposed by Mr. Wardrop, and consisting of six parts of
 soap liniment, and one of tincture of cantlmrides, F. 73.  But liniments
 of mustard, turpentine, camphorated  spirit, and ammonia;—friction with
 snow -_strono- brine, or, in fact,  any ordinary stimulant, will answer the
 same 'purpose.0  Whichever is chosen, it should be  used cold, with con-
 siderable friction, and should  be  strong  enough to  excite some increase
 of heat and smarting.
    If there are vesications, care must be taken not to  break them;  and cne
 liniment must be applied lightly with a feather.
    If there are ulcers or sloughs, and they are attended with much heat,
 pain, and irritation, poultices are required.  But, as a general rule, poul
 tices are too relaxing, and stimulating ointments or  lotions (such as ung.
 resina, calamine, zinci, &c.) should  be preferred.

                   * Quoted in South's Chel ius, vol. i. p. 12S. 
152     EFFECTS OF MINERAL AND  VEGETABLE  IRRITANTS.
                        CHAPTER  VII.

   OF THE EFFECTS OF MINERAL AND VEGETABLE IRRITANTS.

   General Observations. — These substances, considered with regard
to their local effects, may be divided into two classes:  First, those which
produce inflammation of the  animal  tissues through their  tendency to
decompose them chemically.  Secondly, those which operate by producing
violent irritation, but which  have no  power of causing chemical decom-
position.
   The first class comprehends the strong mineral acids;—the  pure alkalis,
or their carbonates; sundry metallic salts,  such as corrosive sublimate,
nitrate of silver, and butter of antimony;—and the concentrated vegetable
acids, especially the acetic and oxalic.
   The second  class includes arsenic  amongst minerals, — and the whole
list of acrid plants, garlic,  ranunculus,  euphorbium, and  the like,—
amongst vegetables.
   Acids.—The decomposing agency of the concentrated acids appears to
depend mainly on their affinity for water.  The sulphuric acid blackens 01
chars the tissues in destroying  them ; that is, separates the water and othei
constituent elements, and sets free the carbon.   The  nitric turns them
permanently yellow.  The hydrochloric leaves a dead white stain.   The
hydrofluoric  "is, of all known substances," says Turner, "the  most de-
structive.  When a drop of  the  concentrated acid of the size of a pin's-
head comes  in contact with the skin, instantaneous disorganization ensues,
and deep ulceration of a malignant character is produced."*  Phosphorus
seems  to act both by the heat disengaged in its combustion, and by the
acid which is the  result of it.
   Treatment.—After injury from any of these acids, the first thing to be
done is to wash it away, and neutralize it by repeated ablution with warm
soap and water, with a little  carbonate of soda; then to apply poultices or
any simple dressings to the ulcers that remain. The pain of these injuries
is  greatly increased  by cold.
   Alkalis and  Caustic Earths. — These, like the acids, appear to de-
stroy animal matter by combining with its water.  They also form a soap
with the fat.  Caustic potass, in the  form  of liquor potasse, and quick
lime, are the substances of  this  class which most frequently give rise to
accidents.   The liquor ammonie produces almost instant vesication and
great pain when it touches the  skin ;  it is,  therefore, much to  be prized as
a speedy and efficient counter-irritant.
   Treatment.—Ablution with weak warm  vinegar and water, followed by
poultices and simple dressings.
   Metallic Compounds.—The  bichloride of mercury acts by its tendency
to  combine with albumen; and the chloride of zinc and  chloride (or butter)
of antimony, probably produce their cauterant effects in a similar manner.
The nitrate of silver is remarkable for the superficiality of its  effects.  It
may vesicate the  skin, or destroy a film on  the  surface of a sore, but its
action  does  not  spread.   It suffers decomposition at  the moment of its
•Elements of Chemistry, 5th edit. p. 377. 
POISON OF INSECTS.
153
contact with the animal tissue ; its acid appearing to be separated, whilst
the metallic oxide  combines and forms a white crust with the animal
matter: and this soon becomes black, because the silver loses its oxygen,
and is reduced to the metallic state.
   Treatment. — The bichloride of mercury is rendered inert by white of
egg  mixed  with  water; — the chloride  of antimony is decomposed by
water;—the nitrate of silver by common salt; and  the chloride of zinc
by a solution of an alkaline carbonate.   These, therefore, would respec-
tively be  the  proper applications for external injuries caused by these
metallic compounds;  although  such cases  very rarely come under the
surgeon's cognizance.
   Arsenic, if locally applied, produces inflammation, or sphacelus, not by
any chemical  action, but by its influence on  the vital properties of the
part;—it may also be absorbed into the  circulation, and produce its ordi-
nary constitutional  effects  as well.  The surgical treatment of any local
injury from this mineral must consist in  removing it  as much as possible
by ablution or otherwise, and then applying poultices, or whatever other
dressings may be* most appropriate.   Lime-water  might be  useful, if
applied at first. Some  cases, almost too horrible to think of, are recorded.
of the destruction of women by the local application of this poison.
   Acrid Vegetables. — The inflammation excited  by these substances
requires merely  soothing  fomentations  and  emollient dressings.   The
smart from the sting of nettles may, it is said, be allayed by a weak infu-
sion of tobacco, if severe enough to require any remedy at all.
   If an irritating fluid have  been injected into the cellular tissue, free
 incisions  must be  made, both to allow its escape, and to afford  exit to
 pus.   By  this means, sloughing of the  skin may often be  avoided,
 although very likely to occur when the subjacent tissue is extensively dis-
 organized.
                       CHAPTER VIII.

 ON THE EFFECTS OF THE POISON OF HEALTHY ANIMALS, AND
    OF THE TREATMENT OF POISONED WOUNDS GENERALLY.

 SECTION  I.--ON THE EFFECTS  OF  POISONOUS  INSECTS
                        AND  SERPENTS.

  Insects.—The bite or sting of any insects that are met with in England
are not of sufficient importance to need surgical assistance, unless inflicted
in extraordinary numbers, or in peculiar situations.  Mr. Lawrence* men-
tions the case of a French gentleman who was so severely stung  by bees
about the upper part of the chest, that he died in fifteen minutes, with all
the symptoms of mortal collapse usually produced by the bite of venomous
serpents.  Children, if much stung by bees or wasps, may suffer severely
from headache and fever.  But the most common instance of danger from
these  insects is  the  alarming suffocation  produced when their  sting is
                    * Lectures Med. Gaz., vol. v. p. 582. 
154
POISON OF INSECTS.
inflicted  in the pharynx or back part of the mouth; — which  sometimes
happens when they are concealed in fruit, and are incautiously  taken into
the mouth.
   Treatment.—If  a person have been stung sufficiently to cause faintness
or constitutional depression, cordials and opiates must be administered
without delay.  Respecting the local treatment, the  first thing  to be done
is to examine  the parts with a lens, and extract the  stings with a fine for-
ceps, if they  have been left in the wound, as  they very frequently are.
Then the best remedies are those which  are also most useful in burns,
viz. turpentine, hot vinegar, hartshorn, spirit of wine, eau de  cologne, or
other stimulants.   Cold applications give great relief, if used continuously.
Finely-scraped chalk, flour, starch, and  oil, are  favourite remedies with
some people.   Mr. James recommends a combination of ung. hydr. fort.
and  liq. ammoniae.  A weak infusion of tobacco or belladonna might  be
worth trying.   The soap  liniment, or compound camphor liniment, may
be used to remove the cedematous swelling that remains.
  In the case  of a wasp or bee sting in the fauces, with urgent  danger  of
suffocation,  leeches should be  plentifully  applied  both externally and
internally;—and hot stimulating gargles (especially hot  salt  and water)
should be frequently used, in the hope of reducing the  tumefaction,  by
causing a copious  flow of blood and of saliva: but if these measures fail
of affording relief, an opening must be made into the larynx or trachea.
  For the bites of bugs, fleas, gnats, mosquitoes, &c, the best remedy is
eau de cologne, or some other stimulant, so as to convert the itching into
slight smarting.  Any strong perfume will often act as a protective against
these nocturnal visitants.   Sweet oil rubbed over the body is said to have
the same effect;  a little colocynth pulp, powdered,  and sprinkled about,
is also said to  be a sure remedy.
  Spiders.—The  most celebrated of this class is the tarantula, the mira-
culous effects  imputed to the bite of which  are too  well  known to  need
repetition here; and we can feel but little hesitation  in subscribing to the
opinion of Ray, " that the dancing of the Tarantati to certain  tunes and
instruments, and that these fits continue to recur yearly as long as the
tarantula that bites them  lives, and  then  cease, are  no other than acting
fictions, and tricks to get money."   We learn,  however, from the least
romancing of the   old writers,  that it  produces  swelling, lividity, and
cramps, which were cured by scarifications and wine ; and these are just
the symptoms  it might be expected to cause, and the most rational cure.
The effects of  the  scorpion are similar.   There  is one very singular case
on record, of  a gentlemen bitten on the penis by  a spider, in America,
suffering from  violent vomiting, deep-seated abdominal pain, and suffoca-
tive  spasms in consequence.  He was  relieved in thirty-six hours,  by
bleeding, opium, and ammonia.*
  Serpents.—The venom of these animals operates,  as Fontana observed,
on the vital properties of the frame, by " destroying the irritability of the
nerves, and disposing the humours to speedy corruption."   The symptoms
produced vary in their nature and degree, according to the species of ser-
pent, its  degree of vigour, the. frequency with which it may have bitten,
and the strength of the sufferer.   Some serpents  can kill only small ani-
mals ;  the poison of some is very virulent, but soon exhausted by frequent
  * Ray, Phil. Trans.  1698, vol. xxi. p. 47 ;  Boccone, Museo di Fisica; Hulse. Am. Journ.
Med  Sc. May, 1839.  Gozzo, Gaz. Med. 1845, quoted in Ranking, vol. ii. 
POISON OF SERPENTS.
155
biting;  that of others is mild, but not easily exhausted ; some, agair, act
so energetically on the nerves, as to cause death speedily by convulsions;
others produce inflammation of the  lungs;  and others, whose venom is
insufficient to annihilate the nervous functions at once, kill more slowly by
the unhealthy or diffuse inflammation which  they excite at the  bitten  part.
   Viper.—This is the only poisonous snake in the British Isles, but  it is
not often that it kills human beings.  The properties  of  its venom  were
most painfully  investigated, in every possible  point of  view, by the Abbe
Fontana ;* who ascertained that it is a yellow viscous  liquid, not inflam-
mable,  and neither acid nor alkaline ;—that it contains  no salts; and that
it has no taste, except perhaps,  a slight astringent sensation if it is kept in
the mouth for some time.  It is not hurtful to  another viper, nor does it
appear  to affect certain cold-blooded animals, as leeches and frogs. More-
over, it is perfectly harmless if applied to  any natural mucous or cutaneous
surface  ;—so that large quantities of it have been swallowed with impunity.
   Cobra di Capello.—Dr. Russell found that this was capable of killing
a serpent  called Nooni Parogoodo, but not another cobra; and that its
poison  was insipid when taken  into the  mouth, and productive of no ill
consequences when applied to the eyes of chickens.  The symptoms pro-
duced on animals bitten by it are fainting and convulsions, but no swelling;
the lungs were stuffed with blood.f
   Naia Tripudians, hooded snake of Ceylon.   Dr. Davy found that its
poison  tastes acrid, paralyses the iris and  levator palpebrae of  fowls when
applied to their eyes, and is soon exhausted by biting.   It acts chiefly on
the lungs, which are found gorged with blood and serum; the symptoms
being  reduction  of the animal  temperature and prostration  of strength.
According to the same authority, the Trigonocephalus hypnale, or Cara-
willa, has a poison that is mild, but not soon exhausted; that  it produces
local inflammation chiefly, and  can kill frogs, but not large animals.—The
 Vipera Elegans,  or tic polonga, soon causes  death by convulsions; the
blood is much coagulated.^
   Rattlesnake.—This snake, unlike most others, is capable of poisoning
itself.   Capt. Hall made one bite itself, and it died in eight minutes.  Its
effects, according to Sir E. Home, may be divided into two stages, either
of which may prove fatal.   During the first, which may last for sixty-tw^o
hours,  the symptoms are those of  great prostration  of the nervous system,
and contamination of  the blood;—vomiting, deadly  coldness, faltering
pulse, the skin livid or jaundiced, bleeding from  the  nose, fainting fits,
convulsions, and delirium.   Meanwhile the bitten  part swells immensely
from effusion of  acrid serum, and  becomes  mottled with  blood, extrava-
sated under the skin ;  and this  swelling extends to the  trunk.  Sometimes
it is attended with excruciating pain, sometimes with  mere numbness or
coldness.  During the  second stage, large diffused  abscesses form in the
swelled parts,  which contain bloody unhealthy pus and sloughs of cellular
tissue,  and are attended with low  fever.   After death, the body putrefies
very rapidly. §
   * Felix Fontana, Treatise on the Venom of the Viper; translated by loseph Skinner
2d edit.   Lond. 1795.
   f Patrick Russell, M. D.,  F. R. S  An Account of Indian Serpents. 2 vols, folio.  Lond.
179(1.
   t Daw, Physiological Researches.  Lond. 1839.
   § Sir Everard  Home.  Phil. Trans, vol. c.  Case  of T. Soper, who was bitten by a
rattlesnake. Hall on the Poiscn of Rattlesnakes, Phil. Trans, vol. xxx. p. 309. Case of 
156
SNAKE  BITES
    SECTION  II.--TREATMENT  OF  POISONED WOUNDS.

  In the first place, measures must be taken to remove the poison from the
wound, or at all events to prevent it from passing into the blood.
  If no other means are at hand, a ligature should be tightly applied round
the  limb, as near as possible to the wound, and between it and the heart-
so as to prevent the return of venous blood from it.  Then it  should be
thoroughly sucked, taking care that the person who does so, has  no sore
nor recent abrasion in his mouth.
  A. better plan, however, is to cut out the bitten part as freely as may be
necessary, and then to suck the wound, and bathe it thoroughly with warm
water to encourage bleeding—a ligature being also applied, as  in the last
case.
  But the best plan of all is that recommended by Sir David Barry.*   He
directs, first, that an exhausted cupping-glass shall be  applied over the
wound  for a few minutes;—next, the  glass  is to be taken off, and the
wound  freely excised;—and, lastly, the glass is to be  applied again in
order to promote the flow of blood, and cause the re-exudation  of any of
the  poison that may have found its way into the neighbouring blood-vessels.
—The cupping-glass, used in the manner we have just detailed, possesses
all the efficacy, and none of the disadvantages of ligatures;—for without
interrupting the general  circulation of the  limb, it produces a complete
afflux of all  the fluids in the vicinity towards the wounded part, and en-
tirely prevents them from conveying their contaminated  contents towards
the  centre of the circulation.  If the glass is applied in this manner, it is
far from being advantageous (as is generally supposed) to  make incisions
or scarifications near the  wound, whether before or after its excision.  For
the  object is to concentrate the course of the  blood towards the  original
wound itself,—so that it  may carry the venom with it as it escapes;—and
this object would be counteracted by any extraneous incisions.
  The treatment of snake bites during the first stage, consists first in the
administration  of powerful  diffusive  stimulants, such  as hot brandy and
water, ammonia, or the eau de luce,\ to support the nervous system;—and,
secondly, in the use of remedies which may be supposed to eliminate the
poison from the blood.   Thus, if there is  no vomiting, it should be ex-
cited  by a mustard emetic,  to get  rid of the vast  quantity of bile that is
often formed in the blood and  secreted by the liver under these  circum-
stances; if,  however, vomiting is  spontaneous  and too  violent, it  should
be checked by a large dose of solid opium,  and a mustard poultice to the
epigastrium.   But the principal remedy seems to be arsenic, which has
long been popular for these  accidents in  the East Indies.   It is usually ad-
ministered there in the form of a nostrum,  called the Tanjore pills,  each
of which  contains a grain  of  it,  combined with certain  unknown acrid
plants.  The efficacy of this mineral was also  fully established in the West
Indies by Mr.  Ireland, surgeon to the 16th  regiment, who employed it
with perfect success in five cases of the bite of a serpent, which had pre-
Mr.  J  Briental, who was bitten by a rattlesnake, reported by himself, Phil. Trans, vol.
xliv. p. 147. Case of a man bitten by a rattlesnake to cure lepra,  Clarke, Lancet, Dec.
-5, 1838.
  *  David Barry, M. D. Experimental  Researches on the Influence exercised by At-
mospheric Pressure, &c.  Lond.  1826
  j-  Tinct. ammonise comp. P. L. It contains oil of  amber. Dose  mxxx. every half
Lou* 
TREATMENT  OF  SNAKE BITES, ETC.
157
 viously killed several  officers and men, some within  six hours, and all
 within twelve.*   He combined J3ij of the liquor arsenicalis with gtt. x.
 of tinct. opii, (to prevent vomiting,) fsifs of peppermint water,  and f3ss.
 of lime-juice.   This draught, which contains a grain of the arsenious acid,
 was given every half hour for six or eight doses, till it produced copious
 purging, (which was encouraged  by clysters,) or till  the symptoms were
 ameliorated.   The  swelled parts were well rubbed with a liniment of olive
 oil, turpentine, and  liquor ammoniae;—and the patients, although for a
 time greatly debilitated, were soon able to return to their duty.
    Oil has been very warmly recommended, both as an internal and ex-
 ternal remedy in these cases,; and the fat of the viper, a strong nauseous
 substance,  is  said  to  be  a specific for its bite; but its efficacy is very
 questionable.!
   If the local  symptoms are very slight, stimulating embrocations, and hot
 fomentations, with leeches, may be sufficient.   But if the swelling is rapid
 and extensive, or the constitution is much affected by the poison, free  and
 extensive incisions into the swelled parts are indispensable.
   The constitutional treatment of the  second stage must be regulated by
 the symptoms actually present;  it will most likely require a  combination
 of cordials,  opiates, and  tonics.   Senega  and serpentaria  have been in
 great repute in these cases ; and of tonic stimulants they are perhaps the
 most useful.

  SECTION  III.--OF INSECTS WHICH  BURY  THEMSELVES
                         UNDER  THE  SKIN.

   The inhabitants  of  warm  climates are  much  pestered with insects of
' various kinds which burrow and propagate under the skin.  The most
 remarkable of these is  the
   Guinea  Worm,—Dracunculus,  or  Filaria  Medinemis,—a cylindrical
 threadlike worm, but sometimes as^thick as a  crowquill, and several  feet
 long.   It is endemic  in Africa, India, and other hot  countries; whence
 persons often  return to England with  this pest about them.   The worm
 appears, whilst exceedingly small, to penetrate the skin and effect a  lodg-
 ment in the cellular  tissue, where it. remains dormant for some time, and
 gradually increases  in size till it can be felt as a little tumour,  or, perhaps,
 as a cord-like ridge under the skin, feeling like a varicose vein.  At last,
 following the rule of other foreign bodies and parasitic  growths,  it causes
 inflammation, and a very painful boil forms, which breaks, and allows the
 animal's head to protrude.   Often, at this  time, if injured, a considerable
 quantity of milky fluid  exudes from it, which, on examination, is  found to
 be full of small filariae.   If the case is neglected, violent inflammation and
 abscesses ensue ;  to prevent which, the animal must be carefully extracted
 entire.   If the head  does  not protrude, a cut should be made across  the
 track of the animal, which should  be  gently lifted up, and then a small
 roll of plaster be put under it, round which it should be carefully wound,
 day after day, till it is extracted.   Extreme cleanliness, and the application
 of assafcetida, are  said to act as preventives.^:
   * A Letter to T. Chevalier. Esq. on the  effects of arsenic in counteracting the poisca
 of serpents.  Med. Chir. Trans.. 1813, vol. ii. p. 396.
   f Breschet says that the effects of a serpent's bite on birds can be prevented by pas*
ing a current of galvanism through the bitten part.
   $ See a paper by M. Miisonneuve in the Lancet for 1S15, vol. i. p. 152.
        14 
158                     SEPTIC POISONS.

  The Chigoe (Pulex penetrans) is  a minute  insect,  abundant in the
West Indies, which penetrates the skin of the feet, and forms a little cyst
beneath it, in which it deposits its eggs.  When  the cyst is fully formed,
it may be of the size of a pea, and is of a bluish colour.  The symptoms
are  a "violent itching.  The treatment consists in  extracting the bag con-
taining the  creature and its eggs, which  operation is dexterously enough
performed by the  negroes with the point of a needle, and the cavity left is
filled with tobacco ashes.  If the bag is  not extracted entire, so that the
young chigoes escape, violent inflammation is the result.
                        CHAPTER  IX.

 OF THE POISONS CONTAINED IN DEAD HUMAN BODIES, AND OF
                       DISSECTION WOUNDS.

SECTION I.--OF THE POISONS  CONTAINED IN DEAD BODIES,  AND  OF THE
              INFLUENCE OF  DISSECTION  ON THE  HEALTH.

  As soon as life has ceased, a series of  changes  begins in the bodies of
animals, the tendency of which is to reduce them  to the simple materials,
—the water, carbonic acid, ammonia, and earths, which are derived by
vegetables from the atmosphere and the soil, and which, when elaborated
by  vegetables, constitute the food of animals.   During the process  of
change, a number of complex substances are  liable to be formed, which
have a most deleterious  effect if introduced into the blood of living ani-
mals.  These  may be called  septic poisons; and  they appear, according
to Liebig, to produce in the living body the same  state of decomposition
that they are undergoing themselves.   These poisons are peculiarly inte-
resting to surgeons, since they are exposed to their influence in the dis-
secting-room and in performing post mortem examinations.
  One of the  most common of these poisons is a gaseous emanation of a
faint,  sickly,  and  indescribably nauseous odour.   It is most commonly
observed to proceed from the bodies of  those who have died of fever;
and is so abominably nauseous, and so  sedative in its effects, that it often
causes sickness  and  faintness in those that would not be affected by the
most advanced putrefaction.  A second variety is  that which when inocu-
lated into a recent puncture, and sometimes even if applied to  the  un-
broken skin, is capable of producing the most fearful irritative and typhoid
fever, with diffuse inflammation of the cellular tissue.  It is most common
in the bodies of those who have died of inflammation of the  serous mem-
branes, or of  puerperal fever, or some other disease of an  erysipelatous
character.  This poison, however, though  truly  septic in its nature, is
produced during the life of the patient, and, like the preceding variety, it
seems to be decomposed or dissipated as putrefaction advances.
  A third class of poisons consists of the compounds of hydrogen, hydro-
sulnhuric acid, carbureted and phosphoretted hydrogen, carbonic acid,
and ammonia    These gases  are abundantly evolved during putrefaction, 
DISSECTION WOUNDS.
159
but although noxious in  themselves, can hardly be called septic, unless
they carry with them  some small portion of decomposing, but not quite de-
composed, animal matter.
   It the student of anatomy be naturally vigorous, and if he carefully
avoid all other sources of indisposition, he will not find  the practice  of
dissection to be incompatible with even a high state of health.   But if it
be too ardently followed,  to the neglect of regular meals and  sleep, it is
liable  to produce weakness,  indigestion,  and especially  diarrhoea  with
foetid flatulence ;—symptoms that may be easily removed by the fresh  air
of the country;  by aperients and alteratives, with tonics and good living ;
and that may generally be prevented by regular daily exercise, generous
diet, warm clothing, and  strict cleanliness.
   The cause of this indisposition is doubtless the absorption of putrid mi-
asmata.  And the proofs  of this absorption are  so clear,—its effects  on
the system so marked,—and the manner in which the absorbed substances
are eliminated, is so plain, that some light may doubtless  be thrown  on
the modus  operandi of other miasmata,  wrhich cannot be detected so pal-
pably by the senses.
   It not unfrequently happens that deleterious  gases are absorbed in great
quantity;  either because  they are present in  unusual  abundance, or be-
cause  (as we may suppose)  the vital powers  of  resistance  are lowered.
The following  are instances of their effects, and of the manner in which
they are got rid of by the system.  A gentleman, after a hard day's dis-
secting, goes  home;  finds  himself heavy, listless, and indisposed, and
with  the peculiar smell  of the  dissecting-room clinging  to him.   He
changes every particle of  his apparel, and gives himself a thorough ablu-
tion.   But in a very short time the same odour emanates from every part
of him ;—and it is not till after copious  perspirations in the night that  he
is freed from the  annoyance.   Three gentlemen, friends of the  author,
dissected  a fresh subject, from which proceeded the peculiar sickly efflu-
vium that  has been  alluded to.  On their return home, the weakest  of
them vomited;—the  other two  suffered from  nausea and  depression;—
and they all had for several hours a continual sickly taste in their mouths,
similar to the smell which they had been imbibing.   And it is notorious
that dissectors frequently recognise the smell of their subjects in the secre-
tions of their mouths, and in the copious flatus extricated in their stomach
and bowels.
   From these facts it may be concluded that  putrid and other deleterious
gases may be  absorbed into  the blood; — that  the skin  and bronchial
membrane  are the points of ingress ;—that they may be eliminated by the
skin and mucous membranes without any alteration of their sensible qual-
ities ;—and that their elimination by the  gastro-intestinal mucous mem-
brane is the chief  cause of the diarrhoea which is such a frequent  conse-
quence of diligent attendance in the dissecting-room.

           SECTION  II.--OF DISSECTION  WOUNDS.

   The two  most important consequences of wounds inoculated with the
septic poisons we have described are—1. Inflammation of the lymphatics;
and 2. Typhoid fever, with diffuse inflammation of the  cellular tissue.
   Of inflammation of the lymphatics, arising from dissection wounds  as
well as from  other causes, we  shall speak elsewhere.   In  this place we 
160
DISSECTION WOUNDS.
shall describe the symptoms and treatment of the typhoid fever and diffuse
cellular inflammation.
  Symptoms. — The  poison having gained  admission into the blood
through a wound, (which is in most cases so slight  as to pass unheeded,)
at a period varying from  six to  eighteen hours subsequently, the  patient
feels altogether unwell: he is depressed, faint, and chilly, and complains
of lowness of spirits and nausea.  These  symptoms are soon succeeded
by rigors, severe  headache, and vomiting; — the  pulse is  frequent and
sharp,  but weak;—the tongue is coated, and there is the greatest restless-
ness and despondency.  Then theirs* local symptom appears in the  form
of a most excruciating pain and  tenderness of the shoulder, corresponding
to the hand that was wounded.   And in most  cases there soon afterwards
arises  a pustule,  on  or near the wound, which sometimes  resembles the
small-pox pustule, and in  other cases is  a flattened vesicle, containing a
milk-white serum.  But this pustule may be unattended with any pain,
and  the  patient may  be ignorant of its  existence, or may not even  be
aware  that he has received  a wound, till his attention is directed to it  by
his attendants.   As the case proceeds, the pain in the shoulder becomes
more excruciating, and is attended with fulness of the axilla and neck ;—
and a  doughy swelling appears on the side  of the trunk, often extending
from the axilla to the  ilium.  At first it  is pale; but it soon assumes  an
erysipelatous redness, or rather a pinkish tint, like that  of peach-blossoms.
The breathing now becomes difficult; the pulse quicker and weaker ; the
tongue dry, brown, and tremulous ;  the mental distress is truly appalling,
although there is  seldom delirium ; the  countenance is haggard, and the
skin yellow ; and the patient often  expires before the local disease has
made further progress.
   Varieties and Complications.—These symptoms  often present  con-
siderable varieties in  their progress  and  degree of severity, and  may be
complicated  with other maladies arising from  the same, or from some  co-
existent  cause.
   1.  In one small class of cases, the influence of the morbid poison is so
virulent, that the patient actually dies of the precursory fever, before  suffi-
cient time has elapsed for any local disease to  appear—either in the axilla,
or in the wound, or elsewhere.   The most  speedily fatal case on  record,
that of Mr. Elcock, was of this variety.  He died in forty hours from  the
 receipt of the dissection wound; and the nervous commotion and mental
 despondency which he suffered were  even  parallel to those of hydrophobia.
 Dr. Bell, of Plymouth, died in the same manner.
   2. In another  (and by far the  most numerous) class, the general  order
 of symptoms is  the  same as we described in the text;  that is,  there are,
 at first, general depression and fever; — subsequently, diffuse cellular in-
flammation begins in the shoulder and axilla,  and spreads down the side
 of the trunk.
   3. In  a third class, diffuse cellular abscesses  occur in  several remote
 parts — the  knee or elbow, for  instance, as well as in the axilla, as in the
 case of Mr.  Shekelton.*
   4. In other cases the wounded finger inflames violently, and suppurates

   * The  case  of Dr. Bell may be found in Butter on Irritative Fever.  Those  of Mr.
 Eieock and Mr. Shekelton are quoted at length (with many others) in Travers on Con-
 stitutional Irritation. See also  a paper by  Mr. Adam, in the Glasgow Medical Journal,
 August, 1830. 
DISSECTION WOUNDS.
161
or sloughs;—or the diffuse inflammation begins at the wrist, and extends
up the arm.
  5. In a fifth class, inflammation of  the  lymphatic vessels may be com-
bined with the peculiar depressing effects of the absorption of  poison;  as
in the case of Mr. James, narrated in his work on inflammation.
   Termination and Consequences.—If tie case do not terminate fatally
at an early  period, extensive  and foul collections of matter form  in  the
parts  that have swelled; — and  abscesses continue to gather under the
skin, or between the muscles of the trunk and limbs:  and from these  the
patient may slowly sink ;—or, if  he survive,  his existence may be a mere
burden ;  one or more of the fingers may perish by gangrene, the arm may
remain stiff  and  useless, or the seeds of consumption or dropsy may be
left in the system.
   In some cases, severe and  protracted pains of a rheumatic character
have followed the ordinary train of symptoms.   Both Sir A. Cooper and
Mr. Abernethy suffered in this manner, and the same symptoms have been
observed by  Mr. Stafford.*
   Morbid Anatomy.—The morbid appearances  are those of the various
grades of diffuse cellular inflammation.  The following may be quoted as
a fair description of an advanced stage.f  The cuticle covering  the affected
side of the trunk,  vesicated and  wrinkled;—the  cutis mottled and gan-
grenous in patches;—the  subcutaneous cellular tissue, in some parts dis-
tended with serum, in others softened and turgid with pus ;—the tissue  be-
tween the muscles of the trunk, as well as  that which separates the differeut
muscular fasciculi, also  softened  and  purulent;—the muscular fibres, of a
dirty-yellow colour, and softened;—the axillary glands enlarged, but  not
suppurating;—the axillary artery and nei-ves healthy;—but the  veins (espe-
cially the smaller branches) dirty red, and  softened;—the brachial and
median-cephalic veins of the wounded arm, slightly red;—but the fore-
arm healthy, and no connexion whatever to be discovered between the abra-
sion on the finger and the morbid parts in the axilla ;—the pleura of the
affected  side greatly inflamed ;—the lung covered with lymph, and much
serum effused into the cavity of the chest.
   Diagnosis.—1.  From  acute rheumatism  this  disease  may be distin-
guished  by  the suddenness of its invasion; by the precedence of the con-
stitutional symptoms; by their low typhoid type ; by the  depression of the
pulse ; by the pain being confined  at first to  the axilla ; by the characters
of the ensuing tumefaction ;  and by a knowledge of the exciting causes.J
   2.  From  inflammation of the lymphatics,  which is a very frequent con-
sequence of festering scratches and poisoned wounds, whether received in
dissection or not,  this mere serious affection may be distinguished by no-
ticing, that  in inflammation of the lymphatics, the disease begins at  the
wounded part,—which  swells and  becomes  throbbing and painful;—the
inflammation extends in red lines up the arm to the lymphatics above  the
elbow, and  in the axilla;  and the constitutional symptoms are  at first those
of inflammatory fever, although they may become imitative and  typhoid,
if the patient be exhausted by pain, or if matter be confined.   Moreovei,

   * Med. Chir. Trans, vol. xx. 183G.                         ,.„,..   L ,, ,
   t Abridged from the  case of Mr. Young,  in Duncan's paper in the hdmburgn Med
Chir Trans, vol. i.  Quoted also in Travers, op. cit.
   I Dr. Law, in a valuable paper in the Dub. Med. Journal. Nov. 1>39, gives severaj
tnses of glanders and diffuse cellular inflammation mistaken for acute rheumatism.
       14*                      l 
162
DISSECTION WOUNDS.
there are the following  broad features  of distinction:  The constitution*.
symptoms precede the local, in the diffuse cellular inflammation ; but follou:
them in inflammation of the lymphatics.  In the former disease, the local
affection depends  upGn  the constitutional; in the latter it  is the reverse.
Again, the two diseases are most remarkably at variance as regards their
tolerance  of blood-letting; which  remedy is as eminently serviceable  in
cases of pure inflammation of the lymphatics, as it is  positively injurious
in those which arise from the imbibition of poison.
   Prognosis.—Of the  cases on  record,  nearly two-thirds have proved
fatal.  The danger will be proportionate to the violence of the  constitu-
tional symptoms;—the  quickness of pulse, anxiety of  mind, and prostra-
tion of strength.   The  cases in  which inflammation begins at the injured
part are much less dangerous than those in which it appears remote  from
it, or in several places simultaneously.
   Pathology.—Some  persons deny that this disease originates in the .ab-
sorption of poison, and attribute it to mere local irritation acting on an
unhealthy constitution.*   Now it is, on the one hand, perfectly true, that
severe diffuse cellular  inflammation, or inflammation  of the lymphatics,
may be produced by the  slightest conceivable  injury to a vitiated  habit.
And it is equally certain that most medical  students and practitioners are
in a bad state of  health, and  consequently predisposed  to suffer from such
accidents.   But there are reasons which, duly considered, place the ex-
istence and agency of a distinct morbid  poison  beyond all doubts.
   1. It is  a well-established fact, that many individuals  are frequently in-
oculated from one subject.  This  happened in  the well-known  cases of
Professor Dease and Mr. Egan;  and numerous other instances of it are on
record.f
   2. The  disease most frequently arises  from fresh subjects.  Mr. Adam,
in the excellent paper which we have before quoted from, has  collected
forty cases;—and in only two or three  out  of the whole number did the
disease arise from a putrid subject.   The most dangerous poison seems to
be destroyed by putrefaction  ; and the disease caused by inoculation with
putrid matter is in general mild, and consists of mere inflammation of the
lymphatics,—although there are exceptions.
   3. The disease of which a subject  died has a  manifest influence on the
frequency of ill effects from dissecting it.   In two-thirds  of Mr. Adam's
cases the disease  affected a serous membrane :—and the most deadly virus
of all is contained in the bodies of women who die of puerperal fever.
   4. The  disease we have been  describing  begins with  symptoms of con-
stitutional disorder; and, in fact, it may be unattended  with any local dis-
ease whatever.  Consequently it  cannot be said to arise  from local disease,
when there is none.
   Lastly,  it may  be induced  by  immersion of the  fingers in the fluids of a
dead body, although the fingers may be quite free from wound or abrasion.
A.-remarkable instance of this is related  in the third volume of Tyrrel's
edition of Sir A.. Cooper's Lectures.^
  * Abernethy?s Lectures, Renshaw's edition, p. 132.  Lizars' Practical Surgery, Edin
hurgh, 1838, p. 71.  See the section of diffused abscesses in Part ii.
  | Vide Copland's  Diet. p. 304 ; also Nunneley on Erysipelas.
  t Travers gives two analogous cases.  A Mrs. Clifton died of diffused cellular in flam
mation following a prick. Two of her attendants became ill from the contact and efflu-
vium of the discharge, although neither had any wound through  which a poison  might
be inoculated.  One of them buffered from acute fascial inflammation of 'die arm ; the 
DISSECTION WOUNDS.
163
  Treatment.—The indications clearly are, to support the nervous system
in its state of depression ;—to endeavour to eliminate the poison from the
blood ;—and .to relieve  pain  and tension,  and promote the discharge of
pus or sloughs.
  As soon, therefore,  as the  first symptoms  of indisposition make their
appearance  after a wound received during dissection, it will be advisable
that  the patient should take a mild emetic, F. 120, have his feet immersed
tn hot water, and betake himself to a warm bed.   After the vomiting has
ceased, he should take a full dose of calomel, with two or three grains of
camphor, followed  in an hour by a draught of oil  of turpentine, combined
with  castor oil or  senna (F. 19).   These remedies  should be repeated,
and  be aided with turpentine enemata until the  bowels are fully unloaded.
  The medicines subsequently given should be  of a tonic and  narcotic
quality.   If the pulse is moderately firm,  and there  is  much thirst and
headache, effervescing saline  draughts; or liq. am. acet., with the strong
camphor  mixture, (F.  90,)  may be tried.  But in those cases which pre-
sent a more decidedly adynamic  character  from  the beginning,—and in
-all cases towards their termination, it will be necessary to administer wine,
ammonia, aether, and  quinine ;  together with beef-tea and whatever other
articles of nutriment the  patient can take.  It  will  be most urgently neces-
sary to render the  patient  unconscious of  his  severe pain by  narcotics;
and the muriate of morphia  has proved so  beneficial in  Mr. Stafford's
hands, that it is to  be  preferred in similar cases.  It should be given in a
full  dose  (gr. \—j) at bedtime, and in smaller ones  during the day;—and
if the bowels have first  been properly opened,  it  will most probably allay
the  pain, calm the restlessness  and anxiety, and reduce the frequency,
whilst it improves the  tone, of the pulse.
   Local  Treatment.—As soon as pain is first  experienced  in  the axilla,
numerous leeches should be applied, and their bleeding be encouraged by
warm poppy fomentations,  or poultices sprinkled  with laudanum.   But as
soon as any distinct swelling can be detected, an  incision should be made
into it,—in order to relieve pain and tension, and to prevent the diffusion
of serum or pus that may have been formed in the meshes of the cellular
tissue.   Incisions  are the  sine qua non  of the treatment;  the point on
which success  mainly depends; and  it is most truly observed by  Mr.
Stafford,  that in most  of the cases that have hitherto occurred, if  swelling
or abscess formed and were not opened, the result was fatal.
   If the  patient survive, he should as soon  as possible be removed  into
the country, and be put on a course of tonics  and liberal diet.  All the
collections  of matter which sometimes continue to form for months should
be  opened  as soon as  they are detected;  and the ulcers that remain be
dressed with stimulating lotions and bandages.
   Venesection. — With  regard to the propriety of venaesection in this  dis-
ease, there  is but one opinion among the best authorities ;  namely,  that it
is uncalled-for and injurious.   They who recommend it do so on mistaken
principles.   They  imagine  that they have merely a local inflammation to
treat, which,  it need  scarcely be repeated,  is altogether an error.   But
experience, no less than reason,  testifies to  the  impropriety of bleeding.
other from low fever,  and abscess in the axilla. The latter was engaged in unfolding
some sheets from which a most noisome smell proceeded, when she was all at  once
seized with sickness and faintness, and excruciating pain  in  the axilla.—Constitutions.
 Irritation p 373, third edition. 
164
HYDROPHOBIA.
It never relieves the pain, and always aggravates the  nervous dep: ession.
Besides,  the  blood is  never buffed nor cupped,  and the  coagulum is
always small in proportion to the serum.
  Calomel is very strongly recommended by Mr. Adam and Dr. Colles.*
They recommend it to be  given alone in doses of gr. iij. every three or
four hours, so as to salivate in thirty-six or forty-eight hours, and they say
it will  do so more readily if the first few doses act on the bowels;—ai
effect which may be aided by purgative draughts.
  Precautionary Measures.—We need scarcely comment on the expe-
diency of using some precautions in performing post mortem examinations,
especially if the operator be out of health, or if the patient have died of
any disease  of an erysipelatous character.  The wearing  of gloves, or
smearing the hands with  oil or lard, would be of some service, and are
often recommended, but seldom practised.   Sores or scratches on the
finger should be covered with adhesive plaster, or touched with the nitrate
of silver, to  form an eschar.  If the operator should puncture himself, or
should suffer a scratch or abrasion to  come  in contact with the fluids of
the subject, he  should immediately wash  his hands, and thoroughly suck
the wound.  Then a stimulant should be applied to it, in order to decom-
pose the  poison  and excite a slight inflammation,  which  will impede
absorption.   Some  recommend the nitrate of silver  for  this purpose,
others  oil of turpentine;  Macartney speaks highly of  a strong solution of
alum, and Copland of a solution of camphor in concentrated nitric acid.
                        CHAPTER  X.

   OF THE  EFFECTS  OF POISONS GENERATED BY DISEASED
                             ANIMALS.

               SECTION  I.--OF  HYDROPHOBIA.

                  Syn.—Lyssa, Rabies Contagiosa.

  Definition.—Hydrophobia is a disease brought on by inoculation with
the saliva of a rabid animal, and characterised by intermitting spasms of
the muscles of respiration, together with a peculiar irritability of  the body
and disturbance of the mind.
  Symptoms  in the Dog.—Since prevention is better than cure, it is very
desirable that every medical practitioner should know the  symptoms of
rabies in the dog, and most especially the earliest symptoms.  These, ac-
cording to Mr. Youatt, are " unusual sullenness, fidgetting,  and  continual
shifting of posture."   The  dog retreats to his  basket or bed for several
hours,  where  he lies curled up, with his face buried between his paws.
Then he becomes fidgetty, continually changing his resting-place ; appears
clouded and  suspicious in his countenance, and gazes strangely about him
as he lies on his bed.   A peculiar delirium is also an early symptom : the
dog perhaps  springing up and giving an angry bark  at some imaginary
abject.   " I  have again and again," says Mr. Youatt, " seen  the rabid
               • Colles, Dublin Hospital Reports, vol. iii. and iv. 
HYDROPHOBIA.
165
dog start up after a momentary quietude, with unmingled ferocity depicted
on his  countenance,  and plunge with  a  savage howl  to the end  of  his
chain."  But if his master  speaks  to  him every fancied object of terror
disappears, and he crawls towards him with his usual expression of attach-
ment.   Then comes  a moment's pause,—a moment of actual vacuity,—
"the eye slowly closes, the head droops, and he seems as if his fore-feet
would give way and  he would fall; but he  springs up again, every object
of terror once more surrounds him, he  gazes wildly around,  he  snaps, he
barks,  and he rushes again to the end  of his chain to meet his imaginary
foe."
  The amount  of ferocity  displayed by rabid  dogs,  varies  extremely.
Some there are whose  fury knows no bounds, and who if loose rush out,
biting  every man and beast in  their way.   Others, on the  contrary, not
only cannot be made to bite, but in the very earliest stage of the disease,
show an increased fondness, and  are perpetually trying to lick  their owners'
hands and face.  Many cases are on record of persons who  have been
thus infected through some accidental scratch or abrasion, and hence when
rabies has been detected in a dog, it is most important to inquire whether
any persons have scratches which  he  may have licked, and if so they
should be cauterised at once.
  Another early and  constant  symptom of rabies,  is  change of voice.
Every  sound uttered  by a  rabid dog,  says Mr. Youatt,  is  more or less
changed.   But there are two sounds in particular that deserve notice ; one
of which is described as a "hoarse inward bark, with a slight elevation
of tone ;"  and the other a  most peculiar and characteristic combination
of " a perfect bark, ending abruptly and very singularly in a  howl, a fifth,
sixth, or eighth higher than the commencement."
  Other symptoms, observed at the commencement of the  disease, are,
loss of appetite, propensity to lick  cold surfaces, such  as  stones or iron ;
and to devour  straws, litter, and similar rubbish ;  and peculiar eagerness
in scenting at  and licking not only the common urining places, but corners
in rooms that are not usually disgraced by  this evacuation.  This is con-
sidered a highly important  symptom.  There  is no  dread, of water as in
the human being; on the contrary,  an insatiable  thirst,  which the dog en-
deavours to allay by lapping as  long he has power over his jaws.  The
mouth is dry, and the saliva exceedingly  viscid ; at first, perhaps, it is
slightly increased in quantity, but this increase  soon passes off, and the
secretion becomes extremely viscid  and scanty, sticking to the corners of
the mouth, and annoying the poor dog extremely, who  may be seen fight-
ing with his paws at the corners of his mouth, as if trying to dislodge some
bone which had stuck between his teeth.
  Thus, the disease when fully formed  is characterised by delirium, with
more or less ferocity, alteration of the voice, great  thirst, and viscidity of
the  saliva, to which may be added perfect insensibility to pain.   As it ap-
proaches its termination, the eye becomes  dull, the hind legs first, and
then the muscles of the jaws are paralysed, and at  length the poor animal
dies exhausted.
  But  there are some cases in which paralysis of the muscles  of the mouth
and jaws is a very early symptom; the  mouth being open and the tongue
protruding.  A poor  dog  in this condition will plunge his  muzzle into
water up to the very eyes in  order that he may get one drop into the back 
166
HYDROPHOBIA.
part of his mouth to cool his parched throat.  This form of the disease 11
generally called dumb madness.   The usual duration of the disease is from
four to six days.
  The post mortem appearances show merely the effects of the malady, in
various degrees of congestion of the mucous membrane of the respiratory
and alimentary surfaces.  The tongue, often torn and bruised, and covered
with filth; its papillae prominent and reddened, the mucous follicles about
the fraenum  enlarged; in the dumb madness, the  tongue hangs from  the
mouth, and is swelled  and  dark-coloured.   The fauces show a more or
less partial blush, and the epiglottis and larynx are usually much injected.
The  trachea, bronchi, and  lungs are sometimes  much congested,  some-
times the reverse.  The stomach generally shows vivid redness, or some-
times patches of ecchymosis on the summit of its rugae; the brain, intes-
tines, bladder, and heart display no appreciable or constant morbid signs
whatever.  Perhaps one of the most characteristic evidences of rabies that
dissection affords, is the presence of a peculiarly mingled mass of hay, and
hair, and straw, and earth,  and excrement in the stomach ; or perhaps in
the fauces, where it may have lodged from defect in the power of degluti-
tion.*
  Causes.—The cause of this malady in dogs is  most frequently a bite
from another animal already diseased ; yet it must occasionally arise spon-
taneously.   And the most probable sources of its origin are close confine-
ment, rank unwholesome food, want of the couch grass, the natural medi-
cine of the dog, and deprivation of sexual intercourse.
  Besides the dog, it is probable  that hydrophobia  arises spontaneously
in the wolf, jackal, badger,  and perhaps the cat.  But it  may  be commu-
nicated to many other  mammiferous  animals, and there is no doubt but
that  every animal  capable  of taking the disease can also propagate it
This is equally true with regard to human  beings as to animals.   MM. Ma-
gendie and Breschet inoculated two healthy dogs on the 9th of June, 1813,
with the saliva of a man who was  labouring under the disease, and who
died of it the same day at  the Hotel-Dieu.   One of the dogs ran  away;
but the other was affected with decided rabies on the 27th of July follow-
ing, and died of it;—and  some other  dogs, which  it was made to bite,
died also. ' Well-authenticated cases are recorded, in which the  disease
was communicated to man by pigs and horses;—and there is no doubt
but that it would be  so much more frequently, if it  were the instinct of
herbivorous  animals to show their rage by biting.  Breschet, in the  course
of numerous experiments on the subject, repeatedly infected dogs with  the
saliva of rabid horses and asses.   One curious fact demonstrated by these
experiments is, that when rabbits, or other rodentia, and birds, are  inocu-
lated with the saliva of rabid animals, they very soon die, but without ex-
hibiting any of the ordinary symptoms of hydrophobia.f
  In the horse the  disease commences  with great distress  and terror, and
profuse sweating; he soon becomes frantic and outrageous,  stamping,
snorting, and kicking.|  In the sheep, the symptoms are similar.  An in-
stance is  recorded in which eight sheep were bitten, and became  rabid;

  * Vide The Dog, by W. Youatt, Lond. 1845.
  ■j- Breschet sur quelques Recherches experimentales sur la Rage.  L'Experience, Oct
I h, 1840.
  fBlane's Outlines of the Veterinary Art. 2d  edit. Lond. 1816. 
HYDROPHOBIA.
167
they were exceedingly furious, running  and butting  at every person and
thing, but did not bite.  They drank freely.*
   There are several points connected with the propagation of hydropho-
bia, which are still involved in great uncertainty.  It is not known whether
the saliva is the poisonous agent, or whether some poisonous matter may
be secreted by the mouth, fauces, or lungs, and  mixed with it.   This,
however, is not a point of much consequence ; but again, it is uncertain
whether  the whole solids and fluids  of the animal are not poisonous also.
In fact, there is some  reason for believing  that the disease may be com-
municated by the mother's milk.f  Moreover,  it appears that it  may be
communicated by contact of the  dog's saliva with the  skin, or mucous
membrane, without  any wound or abrasion.^   In  a case related by Dr.
Watson,§ the dog's tooth merely indented  the  skin  of the back  of the
hand, but made no wound.  Lastly, a point of more importance and un-
certainty than any is,  whether the bite of an animal in health, or of one
merely enraged, may  not cause the disease ;—it  is  very certain,  at all
events, that the bite of an animal will prove fatal, long before it exhibits
any outward symptoms of rabies.
   Symptoms in Man.—These may  be divided into three  stages.   First,
the stage of incubation, being that which intervenes between the infliction
of the bite and the first appearance of the disease.   This period is exceed-
ingly various.   It is seldom less than  forty days;—generally from five
weeks to three months.   But authors  are by no  means agreed as to its
limits.   Dr. Bardsley  positively  denies  that the  malady ever comes on
after more than two years from the bite  ; and attributes the  cases said to
have  occurred after that time to  "  anomalous causes," or to inoculation
from some unsuspected source.   Other  authors, on the contrary, seem to
think that it  may occur at any indefinite period—even twelve years  after
inoculation.   Dr. Burne||  relates  the  case  of a prisoner in the Milbank
Penitentiary, wrho died of it seven years after he was bitten.   The unfor-
tunate man had indeed kept two cats in his  cell, and it is possible that he
might have received the infection from  one of them.  They were, how-
ever, alive and well at the time of his  decease.   It must be concluded,
therefore, either that hydrophobia may come  on seven years after a bite ;—
or that  it may be communicated  by animals who  are  to all intents and
purposes healthy.  But  if a surgeon is  questioned on the  subject  by a
patient who has been bitten, it will be his duty to allay his apprehensions
as far as possible.   He may very safely  assure him, that  after six months
have elapsed, the chance of  the disease  is very slight indeed.
   Second Stage, or Premonitory Symptoms.—The  first thing that attracts
attention is a peculiar  pain of the wounded part, together with slight heat,
redness,  and swelling.   The pain is  observed to shoot in the  course of the
nervous  trunks, and has in general  a rheumatic character.   Sometimes,
instead of it, there is  a stiffness or numbness, or partial palsy.  In  some
cases it is unattended  with redness  or swelling;—in others, on the con-
   * Lancet, 1829-30, vol. ii. p. 511.
   ■j- Two ewes were bitten by a mad dog, and died hydrophobic. One had two Iambi,
the other  one; all three of which were seized with the disease a week afterwards,
ui though they had  not been bitten by he dog, nor, as was supposed, by the mothers.—
Steele, Med. Gaz.. Oct. 25th, 1839.
   t Hutchinson. Lancet, Dec. 8th,  1838.
   (j Lectures. Med. Gaz., May 7th, 1841.
   | Med. Uaz., April 14th, 1838. 
J6S
HYDROPHOBIA.
trary, the wound has thoroughly inflamed, and has broken out into  sup-
puration afresh, although  healed long  before.  In  some  instances these
premonitory symptoms  have  not  appeared  at all, — or  have been  so
slight as to pass unheeded ;—in a few instances they have not appeared
till after the accession of the  genuine hydrophobic  symptoms; — but in
general they are observed from two to five days previously to them.
   Third Stage.—The first of the  actual symptoms of hydrophobia is a
vague  feeling of uneasiness and  anxiety.   The patient  finds himself
generally unwell; his mind is  irritable, and  his countenance gloomy;—
he experiences a succession of chills and flushes, with transient headache ;
the appetite fails; there is  frequently vomiting, and sometimes a well-
marked accession of fever.  Next, the  sufferer complains  of stiffness of
the neck and soreness of the  throat, with severe  spasmodic pain  at the
epigastrium,—the respiration also  is  embarrassed, and., frequently inter-
rupted by sighing.  But these  symptoms are in most cases attributed  to
cold, and their real nature is not suspected for a day or two, till, all  on a
sudden, on attempting to  drink, the patient is seized with a fit of suffo-
cating spasm, and manifests extreme horror at the sight of fluids.
  The most prominent symptoms  that henceforth present themselves, are
three, viz., difficulty of breathing and swallowing;—extreme irritability of
the body;—and peculiar disorder of the mind.
  (a.) The difficulty of breathing and swallowing depends on spasm of the
muscles of the pharynx and larynx.   Sometimes the patient can swallow
neither solids nor liquids; but more  frequently the  disability extends  to
liquids only;  because they require a  greater exertion of those muscles,
and are consequently more liable to excite spasms.  It is this circumstance
that causes the  aversion to fluids,  and the  alarm  at the sight of  them,
which  so  generally  characterise  the  disease.  At first  the  spasms are
excited only by attempts to swallow fluids;—then they are brought on by
the sight or thought of them ; or by the  motions of spontaneous degluti-
tion ; — but as the malady advances, they recur in frequent paroxysms,—
sometimes  spontaneously, sometimes  excited by  the slightest noise  or
touch.   When the  paroxysms  have become  fully developed, they cause
the most frightful struggles for breath.   All the muscles are convulsed;—
the face is black and turgid, and the eyeballs  protrude from their sockets.
They may come on  either during  inspiration or expiration, but more fre-
quently the latter;—the  patient  struggling most violently to expel the air
that is confined in his chest through the closure of the  larynx.   In this
disease, as in tetanus, the fatal  termination  may ensue from suffocation  in
the middle  of a paroxysm, although it more frequently happens during an
interval, from exhaustion.
  (b.) Next to the spasm,  the astonishing irritability of the surface of the
body is the  most prominent symptom of hydrophobia.   The slightest im-
pressions on the  senses affect  the sufferer most intensely.   A look, or a
sound; — the  opening and  shutting of  the door of his apartment;—the
motions of his attendants; — the reflection of light from a mirror ; — the
least impression on  the skin;  the touch of  a feather, or impulse  of the
gentlest current of air,—are sufficient to bring on the convulsive fits, and
are most earnestly deprecated by the patient.
  (c.) The state of mind is in most cases extremely characteristic.   There
appears to be a most profound despair ; — an utter incapacity for all com-
fort and consolatioa,—corresponding with the patient's haggard physiog- 
HYDROPHOBIA.
J 69
norny and restless movements, and his hurried desponding tone of voice.
He is also  in  general unusually talkative and verbose, as though  he
attempted to relieve or hide his sufferings by ceaseless conversation.  But
in some cases he  is possessed with wild maniacal fury, and is obliged to
be confined in order to prevent injury to himself or others;—whilst, as a
contrary exception, it occasionally happens, that if he be originally of a
strong, resolute mind,  he may preserve his composure throughout, and be
to the last endued with sufficient courage to attempt  drinking,  in spite of
the impending horrors of suffocation.
   Progress and  Termination.—When the disease is fully established,
its torments are aggravated by extreme thirst;  and still more by a peculiar
viscid secretion from the fauces, the irritation of which brings on the con-
vulsive fits, and causes a perpetual haw/cing and spitting—which are very
constant symptoms. Not unfrequently there is vomiting of greenish matter
mixed with blood.  As the disease  advances, the convulsions  increase in
frequency and violence ; there is constant restlessness and tremor; — the
lips and cheeks  become  livid,  and perpetually quiver; till  at length one
fit  lasts long enough to exhaust the remaining strength  and release the
patient from his  misery.   An  entire and remarkable remission (perhaps
from the use of medicine) sometimes occurs;  and the patient enjoys per-
fect ease, or perhaps sleeps for some hours ;—but yet the symptoms return,
after a time, with aggravated violence.  Again, in some  cases there is  a
perfect calm before dissolution ;  " the patient becomes tranquil, and mosl
of his sufferings  subside or vanish;—he can eat, nay, drink or converse
with facility ; and former objects associated with the excruciating torture
of attempting to swallow liquids no longer disturb his feelings.   From this
calm he sinks into repose, and suddenly waking from his sleep, expires."*
   Morbid  Anatomy.—The morbid  appearances most frequently found
 are, congestion of the membranes and substance of  the brain  and spinal
 cord, with  effusion of serum.   Sometimes blood is  extravasated around
 the cervical portion of the cord.   The  lining  membranes of  the fauces,
 oesophagus, trachea, and  bronchi, are mostly highly  vascular;  the papillae
 at the root of the tongue large; and the lungs congested.   The stomach
 often contains  a  darkish fluid, and patches of vascularity of  a dark purple
 colour are found  in it and in  the intestines.   But although  some one  or
 more of these morbid appearances are detected in  most cases, still there
 is not one of them that is present invariably.  The brain,  spinal cord, and
 fauces  have been found  pale, and  the  stomach without spots.  Hydro-
 cyanic  acid has  been detected in the blood after death, but this is not
 peculiar to hydrophobia.!
   Pathology.—It is quite clear, therefore, that no change of structure
 that has yet been discovered, ?an be considered essential to the existence
 of hydrophobia.   It is true that the difficulty of breathing and swallowing
 may be partially accounted for by the inflammation about the fauces; and
 that oreat irritability of the surface is symptomatic of irritation of the spinal
 cord.  But still no mere local changes can explain the mass  of symptoms,
 which must depend on a peculiar change in the blood, or nervous system,
 or both.
   Diagnosis.—The'disease which we read of  under the title  of sponta-
 neous hydrophobia, or hydrophobia not caused by a dog's  bite, consists
                 » Bardsley, Cvcl.  Pract. Med.. Art. Hydrophobia.
                 f Med. Gaz., bth September, 1640.
        15 
170
HYDROPHOBIA.
sometimes  of hysterical symptoms, sometimes of a  state tike  delirium
tremens, and sometimes  of  genuine phrenitis, attended with suffocative
dyspnoea and great irritability of the skin.   It usually  occurs to hysterica.
women or to drunkards.  Now, as we  know that hysteria may stimulate
any disease that can  be named, nothing can be more likely than that if
an hysterical or nervous person  have  been bitten  by any dog or cat;
healthy or otherwise, the fears of the consequences, and knowledge of the
symptoms of hydrophobia, will suffice to bring on a simulated attack.  Or
again, if a person be affected with any form of delirium after an accidental
bite, what can be more likely than  that  hydrophobia will  be  the  leading
subject of his ravings ?
  But a correct diagnosis may generally be formed by attentive  observa-
tion ;—by endeavouring to detect the inconsistencies,  as it were, that are
so frequent in hysteria;—the intervals of perfect  complacency and cheer-
fulness, if the patient can be engaged in conversation, and led to forget
his malady;—and by the sudden  accession  and instant  urgency of the
false hydrophobia, compared with the more gradual accession of the real.
Yet it must be confessed that the diagnosis is by no means always easy.
There was a remarkable case at the Middlesex Hospital in the autumn of
1837, which at first so exactly  resembled hysteria, and afterwards the deli-
rium  of  cerebral irritation, or commencing inflammation,  that few of the
medical attendants could at first persuade themselves that it was real hydro-
phobia, and  even some  of those who  believed  so  at first, altered their
opinions afterwards.    But although there was not much  dysphagia, still
the irritability of the slcin,—the shrinking and convulsions and catching of
the breath induced by the slightest breath of air, and the salivation, enabled
Dr. Hawkins to form a correct diagnosis.*
   Preventive Treatment.—As soon as possible after the bite of a sus-
pected animal, the whole wound should be excised or cauterized, or both.
Mr. Youatt recommends the  nitrate of silver; and he  certainly has a right
to speak in  favour of it,  since he  has  been  bitten  many times, and has
escaped, though he used no other preventive ; and since he gives instances
in which out of several animals bitten by  the same dog,  those who were
cauterized  by the nitrate of silver escaped all further mischief, whilst some
which had the wound excised  or cauterized with a hot iron, were subse-
quently infected with rabies.   These are certainly strong  facts in favour
of using the  nitrate of silver, but it is difficult to account for its superior
efficacy; and cases have occurred in which the immediate and free appli-
cation of it was useless.
   The rule generally given, however, is that the bitten part should be cut
out, care being taken  to carry the knife  wide  of the bite.   After  this,
bleeding should be encouraged by the application of a cupping-glass; or
the wound should be  long and diligently washed in  warm water.  And
then, (especially if the bite  have  been  irregular, so  that it is uncertain
whether the excision has been complete,) the  raw surface  may be cauter-
ised by the nitrate, or by nitric acid, or, as Sir B. Brodie recommends, by
passing a probe which has been dipped into caustic potassa, (melted in an
iron spoon,)  into every nook and corner of the wound.
   When we consider that substances introduced  fairly into the blood may
find their way all over the body in  an inconceivably short  space of time,
  • Lond. Med. Gaz., Nov. 4, 1837.  Several  instructive cases may be found in the
Lancet, especially one by Mr. Hodgson, Lancet, 1838-39, p. 582. 
HYDROPHOBIA.
171
(probably in nine seconds,*) it will be readily seen that excision or cau-
terization, although performed as soon as possible after the bite,- may be of
no avail.  Yet they should never  be omitted, let the interval be what it may.
And one case is recorded, in which it is said that the patient was saved,
although the parts were not cut out till the thirty-first day, and not till the
symptoms had actually made their appearance. This, however, is doubtful.f
  Whether the  wound, after excision  or caustic, should be  allowed to
heal,—or be kept open, and made to suppurate by irritating ointments,—
is a disputed  point.   The weight of authority certainly favours the latter
practice, and  beyond  the inconvenience it can do no harm.
  As for any other preventive treatment, all that can be  done is  to keep
the patient in as good a state of health,  and in as good spirits, as possible.
But there is not one of the innumerable so-called specifics that is worth a
moment's trial.    The Tonquin, Ormskirk, and Burling nostrums;—guaco,
box, belladonna, and broom tops; all kinds of acids, alkalis, earths,  and
vegetables ; half  drowning the patient in the sea ; and stewing him in hot
air and vapour baths,—all these remedies and plans have in turn been re-
puted infallible,  and found to be good for nothing.  At one time it  was
confidently pretended that certain vesicles appear under the tongue during
the premonitory symptoms,  and that if these were cauterised, the  patient
would be safe.   But  unluckily they caii never be found.
   Curative  Treatment.—Here we are met at the outset with the doubt
whether hydrophobia can be cured at  all; whether, like the plague  and
small-pox, it will not run its course,  without the possibility of checking it.
Mr. Youatt says that  he believes he has  occasionally prevented it in the
dog, and that he has occasionally seen a case of spontaneous recovery;
but that he has never cured it.  Dr. Elliotson believes that the premonitory
symptoms may show themselves in men and the  disease go  no further.
But although it cannot be denied that a few rare cases have recovered ;—
still, as the remedies that were supposed to  be successful  in  these cases
have  been used again and again in  others without  benefit, the recoveries
must fairly be considered accidental and spontaneous.
   Bleeding has been frequently  tried to a most enormous extent;  and one
case in the East  Indies  is said  to have been cured  by it: but it rarely
affords even a temporary alleviation, and rather tends, by exhausting the
strength,  to accelerate the fatal issue.   It may, however, be tried as a pal-
liative if the  patient is plethoric, and the face becomes very turgid during
the spasms.
   Warm water.—Magendie and others have proposed, after bleeding,  to
inject large  quantities of warm water into  the veins; and it certainly is
beneficial, although but for a time.
   Opium in  different forms has been  given most profusely, and certainly
with  some success; — for whether administered by the mouth, or rubbed
into the skin, or injected into the veins, it seldom fails to  mitigate the
patient's  sufferings, although it never  averts his death.  This was  most
strikino-ly exemplified in the case of the Milbank prisoner, wrho died seven
years after he was bitten.  A blister was applied along the spine, and ten
grains of the acetate of  morphia  were sprinkled on the denuded cutis
" Scarcely had  one minute elapsed," says Dr. Burne, " when we observed

      * Blake, Ed.  Med. and Surg. Journ., Jan. 1840.
      T Thompson, Med. Chir. Trans, vol. xiii., and Lancet, Sept. 23, 1837. 
172
HYDROPHOBIA.
the stare of the eyes and the dreadful alarm and anxiety of the countenance
to diminish, then the violence of the spasm to abate, and the patchings in
the respiration and the retching to subside ;  and  to  our  astonishment this
general amelioration progressed, till  in  four minutes the countenance had
become placid, and the respiration free ; the retching had ceased, and the
spasms vanished."  This improvement, however, did not last very long;
—the  symptoms returned,—a repetition of the remedy was powerless,—
and  the patient died.   And  this is the  general history of the effects of
opium.
  The whole tribe of sedatives;—belladonna, digitalis, tobacco, Sec, have
been repeatedly tried, but with similar results.  The hot air bath and cold
affusion,—acids and alkalis, especially ammonia ;—every diuretic, purga-
tive, and  sudorific, that can be thought of, has succeeded  no better.  In
one instance, the liquor plumbi diacetatis is said to have  effected a cure.
   In a case which occurred in the King's College Hospital,  the suffocative
spasms were entirely relieved  by letting the Datient eat large quantities of
ice, and applying it externally to the spine and throat ;*  and the last thing
that  has been tried  is  the resin of Indian hemp; but a brief respite from
suffering is the  utmost  good they can produce.
   Mr. Hewitt, surgeon  in the  Bombay Medical Establishment,  has related
a single case in which the patient was saved by violent salivation.  Several
native soldiers and  other persons were bitten  one night by a wild jackal,
which, when killed, was found to be very feeble and apparently starved,
and  its liver rotten and full of abscesses.  A month  afterwards, two of the
persons that had been  bitten were found dead in the fields, and, from the
description which was given of their symptoms, Mr. Hewitt judged that
they had  perished of hydrophobia.  Shortly afterwards, three others were
seized with the  disease, and came under his treatment.  He induced sali-
vation in one of them (a woman) by the most profuse  administration of
mercury,  and she recovered;  but with the other  twro, who  were  men, the
same remedy was  of  no avail.  Strangely enough, the natives of these
parts were entirely ignorant that such a  disease as hydrophobia existed;—
a sufficient refutation of the  perverse error of those who  maintain that it is
entirely an imaginary affection brought  on by fright, f
   In the present state  of our  knowledge, the  principal object in the treat-
ment of this disease is to allay the patient's  sufferings.   This  should be
done by keeping the patient perfectly quiet and in  the  dark;  and by the
external and internal  administration of opium combined with  other seda-
tives.  The strength  should  be  kept up with whatever nutriment can be
taken.  And if the surgeon imagines that he can give  any other remedy
with a chance of benefit, and without adding to his  patient's sufferings, let
him do so.
   There remains, however, one grand experiment  to be made ; that is to
say, the production of asphyxia by the woorali  poison  (as was described
in the chapter on Tetanus), and  the gradual  restoration of the patient to
consciousness by means of artificial respiration.   And there really seems
to be some reason for  hoping that, by thus suspending the functions of the
nervous system, the effects of the poison may gradually cease before the

   * The case is related by Dr. Guy in his edition of Hooper's Physician's Vade Mecum,
p. 277.
   \ Account of the effects of the bite of a wild jackal in  a rabid state, as the same oc-
curred at Kattywar, in the East Indies, in 1822.  Med. Chir. Trans, vol. xiii. 1825 
THE GLANDERS.
173
strength is quite exhausted.   At all  events, to use the words  of Celsus,
" Si nullum appareat aliud auxilium, periturusque  sit qui  laborat, nisi te-
meraria quaque via fuerit adjutus;—satius  est anceps remedium experiri
quam nullum."*

              SECTION  II.--OF THE  GLANDERS.

                      Syn.—Equinia.  (Elliotson.)

   Definition. —The glanders is a disease of the horse tribe, communicable
to man and other animals.  It is chiefly manifested by unhealthy suppura-
tion of the mucous membrane of the nasal cavities, and pustular eruptions
on the skin, and unhealthy abscesses in the lymphatic system.
   Symptoms in the Horse.—It may occur in two forms, which, however,
are merely manifestations of the same disease in different parts.   When
seated in  the lymphatic system,  it is called farcy—when in the nasal cavi-
ties, glanders.  But these two forms  are  essentially identical; the pus of
either of them will reproduce  the  other;  and farcy always terminates in
glanders,  if the animal live long enough, and its progress is not arrested.
   Farcy begins with hard, cord-like swellings of the lymphatic vessels and
glands, called farcy-buds.  These slowly suppurate,  and form unhealthy
fistulous sores, which  discharge a copious thin sanious matter.
   If suffered to proceed unchecked, farcy leads to glanders, although more
frequently the latter arises first.
   Glanders.—Its  symptoms are, a continued flow of discharge from one
or both the nostrils, (generally the left,) which discharge is at first thin and
serous; then thick and glairy, like the white of  egg; but after  a time be-
comes opake, purulent, bloody, and horribly offensive, retaining, however,
its viscidity.  Soon after it  commences, an enlarged gland may be felt
under the lower jaw adhering to the bone.   The next things noticed are
one or more ulcers on the Schneiderian membrane, having the sharp edges
and scooped-out  character of  chancre; these spread widely and  deeply,
and lead  to caries of the bone.   Then the lips and eyelids swell, and the
conjunctivae suppurate; and  the external parts of the face may become
gangrenous, and the  animal  may  die in  a  few days with putrid fever;—
or he may perish  more  slowly;—the disease spreading to the lungs, and
death being induced  by cough, emaciation, hectic, and the formation of
unhealthy abscesses in the lungs and all over the body.f  The  distinctive
symptoms, according to Youatt, are the continuousness of the  discharge,
and the adherence of the enlarged  submaxillary gland.
   Symptoms  in Man.—This  disease may  appear either as glanders or
farcy ; either of which may be acute or chronic.
   (1.) The acute glanders begins with all the symptoms  that indicate the
absorption of a putrid  poison.   There are general feelings of indisposition,
lowness of spirits,  and wandering pains; followed by fever, furred tongue,
great thirst, profuse perspirations at  night, great pain in the  head, back,
  * Formerly it was the custom in decided cases of hydrophobia to smother the patients
between feather  beds; the author knows that about twenty years ago, two respectable
surgeons, one of whom is  still living, purposely bled a woman  to death in  a village in
Lincolnshire; and it appears from the Dublin  Medical Press (26th  Jan. 1841), that a
hydrophobic patient in France was but  out of his  misery by poison, only three years
ago.  Such practices, however, are no  better than murder, and ought not to be thought o£
  j- Blaine,  op. cit.; Youatt on the Horse.
       15* 
174
THE GLANDERS.
and limbs, and tightness of the chest.   After some days  these symptoms
increase ;  Uiere are severe rigors and delirium, often of a phrenitic charac-
ter; die perspirations become more profuse, and sour and offensive,vand
are attended with diarrhoea of a similar character.  Then diffused abscesses
appear in the form of red swellings about  the joints, especially the knees
and elbows—the patient complains of heat and soreness in the throat;  the
tongue becomes dry and brown, the respiration  more oppressed, and  the
fever assumes  a decidedly low  malignant character.  Next (perhaps a
fortnight from the commencement of the illness, sooner or  later in different
cases) a dusky shining swelling appears on the face, especially on one side,
extends over the scalp, and closes the eyes.   Then the characteristic fea-
tures of the  disease appear;—an offensive, viscid,  yellowish  discharge,
streaked with blood, issues from the nostrils;  and a crop  of large and re-
markably  hard pustules (compared by some to those of the small-pox, and
said by others to be about the size of a pea) appears on the face.  In  the
meanwhile the swelling and inflammation increase;—a portion of the nose
or eyelids mortifies;—the discharge becomes more and more profuse and
offensive :—the  pustules spread,  and extend over the neck and body ;
fresh abscesses form and suppurate ; the thirst is most excruciating;  and
low murmuring delirium and tremors usher in death, much to  be wished
for.
   (2.) The chronic glanders is characterised by a viscid  and  peculiarly
foetid discharge from one nostril,  with pain and  swelling  of the nose and
eyes ;—and emaciation, profuse perspiration, and abscesses near the joints,
from which the patient slowly sinks.
   (3.) In the acute farcy, the patient receives the poison through a wound
or abrasion, which inflames violently, together with the lymphatics leading
from it.  These symptoms are attended with  considerable fever, and  are
generally soon followed by the  diffused abscesses, pustular eruption, and
nasal discharge,  that characterise acute glanders.
   (4.) In the chronic farcy, a wound poisoned by glanderous matter de-
generates  into a foul  ulcer; the lymphatic vessels and glands  swell  and
suppurate ; abscesses form  in different parts of the body  ; and if the dis-
ease is  not cured, or  does not destroy the patient first,  it terminates in
acute glanders.*
   Causes.—In the horse this disease may, without doubt, arise spontane-
ously, when the  animal is  subjected to the usual influences that  generate
putrid poisons;—namely, insufficient and  unwholesome  food, and close
confinement, and  ill ventilation,  especially on board  ship.  Mr. Youatt
believes that it may arise if the animal is kept in a poor state of health, as
the climax of constitutional weakness and derangement.   In  man, it is
generally  produced  through inoculation  of the  matter  into  a wound.
Whether it can be  contracted by infection through the miasmata arising
from it, without actual contact of  the matter, is not yet  quite decided.
There  are, however,  some  grounds for  believing that this disease (like
others of a similar character) is occasionally propagated by infection in the
horse; and that the effluvia are capable of communicating some form of
malignant fever, although  not  true  glanders, to the human subject.   But
the matter from the abscesses or nasal cavities of human beings is capable

  * Case of Mr. Turner, Travers, Constitutional Irritation, p. 399 ; Case of Farcy ending
in Acute Glanders in seven months. L'Experience, Jan. 1839. 
THE  GLANDERS.
175
of communicating the disease both to men and animals.   A man died of
glanders in St. Bartholomew's  Hospital, in 1840, and the nurse who at-
tended him inoculated her hand, and died of it also in a very few days;
and two  kittens which were inoculated from the  nurse, became affected
likewise.   Moreover, the blood  of aglandered horse injected into the veins
of a healthy one communicated  the disease, although no abnormal appear-
ance could be detected in  it by the microscope.*   The time at which the
disease appears after inoculation varies from three days to a month.
   Prognosis.—This, in  the acute disease,  is  highly  unfavourable; the
chronic, however, is sometimes, although  rarely, recovered from.
   Morbid Anatomy.—The morbid appearances are the same both in man
and in the horse.   Clusters of white granules, or tubercles, or,  as Dr.
Craigie describes it, of matter like putty or thick pus, are found in what-
ever tissues the disease has invaded ; in the Schneiderian membrane,  in
the antrum and frontal sinuses, and in the vicinity of the  different abscesses.
The nasal cavities mostly contain a thick brown gelatinous secretion, and
are  studded with foul gangrenous ulcers, from which project fungous clus-
ters of tubercular matter.
   Pathology.—The proximate cause of the acute glanders appears to be
a contamination of the blood with the poisonous matter.   This is evident
from the  early depression of strength  and spirits, from  the  profuse and
foetid  perspirations and  purgings, from the  consecutive  or simultaneous
appearance of the  local  suppurations, with their peculiarly offensive and
characteristic discharge, as well as from the black  and thin condition  of
the blood, which has lost the faculty of coagulation.—In the chronic forms,
the disease, like Mr. Blackadder's cases of hospital gangrene, or like pri-
 mary syphilis, appears to be at  first local;  the constitution is affected sub-
 sequently.
   Treatment.—The chief points to be attended  to in the treatment  of
 glanders are, to open all abscesses as soon as they form;—to  syringe the
 nasal cavities with solutions of  creosote ;  and to support  the strength and
 abate the thirst with wine  and  soda water.   Injections  of creosote have
 cured both the acute and chronic glanders ; but almost  any other treatment
 that can  be named has been found of no  service.   Depletion  is inadmis-
 sible.  The  effluvia must be counteracted by fumigations of chlorine and
 aromatics.   In the treatment of farcy likewise, the chief points are to open
 all abscesses early, and  support the  strength. Any swollen glands should
 be extirpated.f
   * Reynault, quoted  in Provincial Medical Journal, 18th Feb.  1843, from the Report
 of the French Academy for Feb. 2, IS 13.
   t Vide Elliotson's papers in the  Med.  Chir.  Trans, vols. xiii. xviii. (with a coloured
plate) and xix.; the Med. Gaz., vol. xix. p. 939 ;  case communicated from father to son,
 Lancet for 1S31-3, vol. i. p. 698; Rayer, de la morve et du farcin chez 1'homme; Mem.
 de l'Acad. de Med. 1837; the cases of the  patient and nurse in St. Bartholomew's Hos
pital above quoted, in the Lond. Med. Gaz., April 18th and 25th, 1S40;  case of acute
glanders cured by injections  of creosote by Mr. Ions, Lancet, April 30th, 1839;  case  of
acute farcy cured by iodide  of potassium with iodine, Arch. Gen. de Med., Jan. 1843 ;
and one similarly treated by Mr. Curtis of Camden Town, and reported in Youatt's book
on the Horse, IS 15; and an excellent chapter on  glanders, embodying almost all that
is known of the disease, with an interesting historical sketch of the progress of know
ledge on the subject, in Dr. Burgess' Translation  of Cazenave on Diseases of the Skin,
Lond. 1S42.  See also a case of acute farcy by  Dr. Craigie, Ed. Med. and  Surg. Jour..
Jan. IS 13.  Many valuable cases may be found  in  the Irish Meatcal Journals, as '.'.,«
disease is far more prevalent in the sister kingdom than it is in England. 
176                  THE VENEREAL  DISEASE.
                         CHAPTER  XI.

                   OF  THE VENEREAL DISEASE.

 SECT.  I.--OF ITS  GENERAL  HISTORY  AND  PATHOLOGY.

   Definition.—The venereal  disease, using the term in its widest accept-
ation, consists  in the effects of certain morbid poisons, generated  and
usually communicated by promiscuous sexual intercourse.
   It includes two distinct diseases, gonorrhoea and  syphilis, which differ
very widely in their nature and effects.
   Both diseases present two classes  of  symptoms;  the primary and the
secondary;—the primary being the effects of the morbid poison on the
parts to which it is actually applied ;  the secondary being the subsequent
results of some general disorder of the constitution.
   Gonorrhoea is an inflammation  of the mucous  membrane of the geni-
tals, which is occasionally, though not  very often, succeeded  by various
rheumatic affections, as secondary symptoms.
   Syphilis consists, first, of ulceration of the parts  to which the  morbid
poison is applied, and inflammation of the neighbouring lymphatics, which
are the  primary symptoms;  and, secondly, of sundry eruptions of the
skin, ulcerations of the throat, inflammations  of the eyes, and inflammation
and  caries of the bones and joints, which are the secondary  symptoms.
   The primary  symptoms of  syphilis are undoubtedly contagious,  and
communicable  by inoculation with  the matter from the  ulcers.   The
secondary symptoms, which depend  on a general  contamination of the
constitution,  are not  communicable  by inoculation, but are capable of
transmission from a mother to the foetus in utero ;  and it is  probable  that
they may also be communicated from the husband to his  wife; from a
nurse to  a suckling infant, and from an infant to its nurse.
   There  is, moreover, a third class  of  symptoms, which may be called
tertiary;  consisting of various eruptions, rheumatic pains, falling off of the
hair, deafness, and all kinds of anomalous cachetic complaints, which are
the sequelae of syphilis when it operates  on an originally bad constitution,
or is aggravated by ill-treatment.  This vitiated  state of constitution  is
doubtless a frequent source of  stunted, sickly, and scrofulous children.
   We must next lay before the reader as brief an  account as possible of
the various disputed opinions with regard to  the history and origin of this
disease.
   The following are the principal  questions  in dispute ;—namely, First,
Was the  venereal disease known  to the  ancients ?  Secondly, Was it im-
ported from America?   Thirdly, Axe there  more  syphilitic  poisons than^
one ? Fourthly, Are the poisons which  produce gonorrhoea and  syphilis
identical?  Fifthly  What is the origin of  syphilis?   And, lastly, what
are the specific virtues  of mercury?—These  questions we will discuss
seriatim.
   I. Was  the Yenepeal Disease known  to  the Ancients?—(a) Ar
guments in favour of its antiquity.—They who believe that it was known
to  the ancients argue thus: They  affirm  that  writers  on medicine from the 
HISTORY AND PATHOLOGY.
177
earliest ages make mention of sundry ulcerous diseases of the genitals and
the fauces, some of which were most probably venereal.   That, in par-
ticular, some of the ulcers of the genitals mentioned by Celsus correspond
exactly with certain ordinary venereal  sores  of the present time.*   That
Rhazes, an Arabian writer, mentions an ulcer of the penis  produced by
the " accensionem mulieris supra virum."  That  sundry foreign authors
who flourished between 1270 and 1470, mention ulcers and pustules of
the penis as contracted by lying with foul women; or with women who
have  ulcers,—or who  have  lately had  connexion with one whose  penis
was ulcerated.   But the strongest arguments  of all  are contained in two
papers presented by Mr. Beckett to the Royal Society in 1717 and 1718,
in which he  contends for the antiquity of the disease  in England.   He
proves that gonorrhoea was well known in 1162 under the terms brenning
or burning;—and that certain  enactments were  extant, which  provided
that any slewholder keeping a woman with the peiilous infirmity of burning
should forfeit the sum  of  one  hundred shillings.  Further, he says, that
John Arden, surgeon to Richard II. (1380), defines the brenning to be an
inward heat  and excoriation of the urethra; and that, besides, he  men-
tions  certain " contumacious ulcers, which we now term chancres."   And,
moreover,  that  a MS.  in Lincoln  College,  Oxford, written by Thomas
Gascoigne,  Chancellor of that  University,  and dated 1430, states that
some men (and amongst them John of Gaunt) had  died of diseases caught
by frequenting women.  Another potent line  of reasoning is founded on
the circumstance, that many ancient authors state the leprosy of their times
as being contagious;—and that ulcers of the penis  and heat of urine were
contracted by men who lay with leprous women.   But it is reasonable to
infer, that what they called leprosy was in  reality venereal disease.  Be-
cause, in the first place, (as Bateman  says,) "there is little doubt that
every species of  cachetic disease accompanied with  ulceration, gangrene,
or  any  superficial  derangement, was formerly termed leprous ;"f—and
because, in the second place, there is  no ground for believing that ele-
phantiasis (the real tubercular leprosy) is contagious  at all;—and because
that disease is never communicated by contact in  modern times, whether
in  carnal conversation  or otherwise ;—a fact which  has been ascertained
by ample experience,  especially at Madeira.^  Mr. Beckett  further men-
tions  the  occurrence  of nodes  on the  bones  at those early periods; and
shows that some  of the so-called leprous diseases were cured by mercury,
whilst real leprosy is not.   Therefore they who believe in  the  antiquity
of  the venereal disease contend,  that  discharges from  the  urethra and
syphilitic ulcers on the genitals were known in the earlier ages; and that
they were known to  proceed from fornication; although the secondary
symptoms which followed them were for the  most part not  known to be
venerea], but were confounded with the leprosy.
   (b) .Irguments against its antiquity.—On the other hand, the opponents
of its antiquity contend, that although  ulcers or pustules on the genital
organs and  sundry discharges were not unknown;—still that neither in
Celsus, nor  in  any other ancient  writer,  do we find mention  that such
maladies were solely, or even frequently, the produce  of sexual commerce ,

  * De Medicinft, lib. vi. cap. 18.
  ■f- Bateman on Cutaneous Diseases, 5th ed. pp. 304 et seq.
  j Mr. Bacot and others who oppose the  antiquity of the venereal disease, assert thai
leprosy is *' undoubtedly conlagiousy
                                  M 
173
THE VENEREAL DISEASE.
 —or that  they were peculiarly difficult to heal;—or that  they were  fre-
 quently, or indeed ever, followed by constitutional diseases.   But the most
 potent  argument  of all is this ;—namely, that  all at once, towards the
 close of the fifteenth century, whilst the French army was besieging  Na-
 ples, a new and terrible  disease sprang up; rebellious to  every  known
 method of treatment;—attacking high  and low, rich and poor ;—sparing
 neither age.nor sex ;—consisting of ulcers on the  parts of generation in
 both sexes;  which were speedily followed by affections of the throat  and
 nose ;—by corroding ulcers  over the whole body; by excruciating noc-
 turnal pains, and frequently by death.  Whereas " not one word that  can
 be construed into  any similar affection, is to be met with distinctly stated
 in any writer before that period."
   They, therefore, who are  in favour of its antiquity, must hold one of
 these three  opinions concerning that virulent disease of the fifteenth cen-
 tury :—viz. 1st, that it was a  new Icind of venereal disease ;—or, 2dly, that
 it was merely an aggravated  variety of  the old disease ;—or, 3dly, that it
 was not the venereal disease at all;  but some  malady (such as sivvens,
 yaws, radesyge,  &c.) resembling it.
   The  most probable supposition is,  that syphilis existed from very early
 ages, and that its increased virulence  in  the  fifteenth century is to be  at-
 tributed to war, famine, and the intercourse of foreigners ;—circumstances,
 which in all times have produced an aggravated type of syphilis ; whilst
 its virulence is invariably diminished under the  influence of peace and
 cleanliness.   But the consideration of the history of this new malady brings
 us to our second question.
   II. Was it imported  from America?—The greatest  weight of evi-
 dence is certainly  opposed to this supposition.   Because no such disease
 is mentioned by the very earliest historians of the discovery of that conti-
 nent;—neither is  it mentioned  by  the  earliest writers  on  America; and
 Peter Martyr, who w^as physician to Ferdinand and  Isabella,  and who
 was  actually at Barcelona when Columbus returned from his first voyage
 in 1493, does not say a word as to its American origin.  But besides—
 of the earliest authors  on the venereal disease, some attribute it  to  the
 divine vengeance, some  to an earthquake, some to  a malignity of the  air
 caused by an overflow of the  Tiber; not a few to a  celestial influx, or ma-
 lignant conjunction of Saturn  and Mars  in tlie sign  Scorpio, or some other
 astrological  nonsense ;—almost all refer  its outbreak to the  siege of Na-
 ples — but not one for the first  thirty  or forty years derives it from  the
 West Indies.
   They who conceive that the new disease was not syphilis, found their
 opinion on  the fact, that the descriptions  given by many of the oldest
 writers  correspond pretty closely with the yaws,  oxframbccsia cr sivvens,
 (a disease frequent  enough in America,) and that  like yaws it often was
 communicated to the very young or old, and to persons who did not catch
 it by carnal  conversation.
   III.  Are  there  more syphilitic poisons  than  one ? — Carmichael
and  others assert, that  there  are various kinds of syphilitic poisons, each
kind causing a peculiar primary ulcer,  and a peculiar train of secondary
symptoms.    They say,  in proof of their opinions, that every other morbid
poison is uniform  and regular in its  effects; and  that it  would be " an
 unreasonable and unwarranted exception to an universal law of  nature,"
if the venereal were  not so also.  But venereal diseases are multiform ar.d 
HISTORY AND  PATHOLOGY.
179
irregular;  consequently they must be caused by more poisons than  one.
For what other single poison can produce  papular, pustular, scaly, and
other kinds of eruptions ?
   But these  arguments are  subverted by the fact, that a prostitute with
one ulcer may cause various kinds of primary ulcers in the men who have
intercourse with her; — that the same kind  of primary sore will give rise
to different eruptions in different persons, and in the same person at dif-
ferent times;—that the  differences of primary sores depend on differences
of situation, constitution,  treatment, and the circumstances of the times,
as was observed in the  last page : — and that if arguments in favour  of
multiplicity of  poisons  be drawn from the  mere appearance of ulcers or
eruptions,  there  may be forty  or fifty instead  of four  or  five venereal
poisons.*
   IV. Are the poisons  of gonorrhoea  and  syphilis identical?  —
Hunter believed that they were identical, for he produced a chancre  by
inoculation with gonorrhceal matter, which was followed  in three months
by sore throat and eruptions.   But the recent researches of Ricord show,
that although the pus of a syphilitic ulcer, like any other morbid secretion,
may irritate a mucous membrane and produce gonorrhoea, still that gonor-
rhceal matter will not  produce  primary syphilitic ulcers,  and that gonor-
rhoea will  not be followed by secondary syphilitic symptoms, unless there
is also a chancre or syphilitic sore in  the urethra; which wras probably the
case with the patient from whom Hunter took the gonorrhceal matter.
   V. What is the  origin of  syphilis? — M. Ricord throws out the
conjecture, that a source foreign to the  human  race may have furnished
the first germ of syphilis,  which once engrafted, has-been propagated  by
inoculation, like the  vaccine  virus ;  and he believes that it never  arises
spontaneously.  Another opinion is,  that it may occasionally be produced
de novo, if a mixture of various foul  and  diseased male and female secre-
tions act upon a breach of surface in an unhealthy constitution.  " I believe
with my  friend Mr. Guthrie,"  says  the  late eminent army-surgeon, W.
Fergusson, " that wherever prostitution is foul and unclean, restricted  to
few women amongst crowds of men, there the infection will be generated;
which afterwards spreads through society at large.   The  irregularities  of
man  are at all times punished by the generation of diseases, and loss  of
the health  ; and it would be difficult  to believe in a superintending provi-
dence if this transgression of divine and human law should be allowed to
pass unpunished."f  This quotation seems to contain the most common
sense  view of the question.  And the  following  facts furnish a kind  of
approximation to a proof of it.   Seventeen  galley-slaves were inoculated
with  gonorrhceal matter.   Slight ulcers were produced,  which in five  of
the cases healed readily enough.  But the remaining twelve patients were
either scrofulous or scorbutic,  or in an  ill  state of health,  and seven  of
these suffered from eruptions and wandering pains.|   Of the causes  of
gonorrhoea we shall speak in the next section.
   Lastly, is Mercury  a  Specific ?—Hunter not only considered that  no
   * Carmiehael  enumerates Jive; Judd nine; which, however, he does not believe to
be all that exist.
  ■f- Notes and  Recollections of a Professional  Life, by the late W. Fergusson, M. D.,
Lond. 184i",.
  $ P. H. Hernandez, quoted by Ricord. Mr. Kingdon, at the Lond. Med. Soc. related
a case of venereal affection  generated by a healthy man and his wife.  Lancet, May  3d
183S.  See also Travers on the Venereal. 
ISO
GONORRHOEA.
really syphilitic disease  could get well without  it, but  gravely upDraids
human nature for doubting it.  " Nothing," says he, " can show more the
ungrateful and unsettled mind of man than his treatment of this medicine.
If there  is such a thing as a specific, mercury is one for the venereal dis-
ease."  The following results, however, of experiments made by the army
surgeons, and  especially by Rose, Guthrie, and  Hennen, will enable th
reader to form a juster estimate  of its capabilities.   It is concluded, (1
That all  kinds of primary and secondary symptoms may get well withou
mercury.  (2) That out "of 1,940 cases treated without it, ninety-six had
secondary  symptoms;  and  out  of 2,827 treated with  it, fifty-one had
secondary  symptoms.  The  average result  of  different  experimenters,
however, show that there are at least  seven times as many cases of second-
ary symptoms, when no mercury has been given, as when it has.  (3)
That the secondary symptoms of cases treated without it are in general
less severe, and that affections  of the bones in  particular are much less
frequent.   (4) That the average  period of cure is much the same in both
cases ; but that relapses are  more frequent when no mercury has been
given.*

                SECTION II.--OF GONORRHOEA.

         Syn.— Gonorrhoea  virulenta; Blenorrhagia ;  Urethritis.

   Definition.—A gonorrhoea signifies a discharge from the mucous mem-
brane of the  male or female genitals; generally produced by contagion
from a similar discharge  during sexual connexion.
   Symptoms.—These may be conveniently divided into three  stages.  In
the first stage, the patient merely notices a little itching at the orifice of the
urethra, with a slight serous, or thin whitish discharge.  If the disease  is
not checked at once, it passes after a few days into the second, or acutely
inflammatory  stage.   The discharge becomes thick  and purulent,  and
when  the disease is at its height  is greenish, or tinged with blood.   The
penis swells;  the  glans  becomes of  a peculiar cherry colour,  is intensely
tender, and often excoriated.  In consequence of the tumefied state of the
urethra, the stream of urine is small  and  forked, and  passed with much
straining and severe pain and scalding.  All the parts in the vicinity of the
genitals, the groin, thighs, perinaeum, and testicles, ache  and feel tender;
and the patient's nightly rest is disturbed  by long-continued and  painful
erections, and by chordee, that is, a highly painful  and  crooked state of the
penis  during  erection.  Hunter says that  there are two  kinds of  it—the
inflammatory and  spasmodic.   The inflammatory arises from a deposit of
lymph in the  corpus spongiosum urethra, which  glues together the  cells,
and prevents  their distension, so that when the penis is turgid  with blood,
it is bent at one part, and horribly painful.   " The  spasmodic chordee,"
says Hunter,  " comes and goes, but at no stated times; at one time there
  * Vide Jphrodisiacus, by Daniel Turner, M. D., London, 1736; (a collection of the
opinions of the early authors;)  Hunter on the Venereal; Hennen's Military Surgery ,
Carmichael on Syphilis; Bacot's Treatise on Syphilis;  Titley on Diseases of the Genitals
of the  Male; Wallace on the Venereal, (plates); Judd's Treatise on Urethritis and
Syphilid, (plates) ; H. J. Johnson, in Med. Chir. Review ; Colles on the Venereal;  Ricord
Traite  des Maladies Veneriennes, Paris,  1839;  Mayo on Syphilis, Lond. 1840; Mr
Lane's  Lectures in the Lancet, 1841 and 1842 ; and Mr. Acton's Treatise on Venereal
Diseases, with an atlas of plates, Lond. 1841. 
GONORRHOEA.
181
will be an erection entirely free from it, at another it will be severely felt
and this will often happen at short intervals."
  Besides the above symptoms, the following complications may occur in
various cases.
  1. There may be severe irritation or actual inflammation of the urinary
organs;—sometimes of the deeper portion of the  urethra, producing great
pain in the perinaeum, and spasm of the  accelerators  and other muscles
during micturition,  so as to interrupt  the stream  of  urine, and cause the
most exquisite agony, or even sometimes complete retention ;—sometimes
of the bladder, causing a very frequent desire  to make water, and great
pain in doing so, which  lasts for some time  afterwards, together with a
white mucous cloud  in the  urine;—or there  may be  pain in the  loins,
scanty urine, tenderness of the abdomen, vomiting, and other signs of
severe irritation of the kidneys.
  2.  Hemorrhage  from  the  urethra;—from  rupture   of  the  distended
capillaries  during violent erection.   The  loss of  blood generally gives
relief.
  3.  Inflammation and obstruction of the mucous follicles of the urethra,
which may suppurate and burst either in the urethra, or externally; or
both.
  4.  Inflammation of the lymphatic glands  of  the groin; constituting
sympathetic bubo.
  5.  Gonorrhoea spuria, vel externa, or balanitis (/3aXavos, glans)—inflam-
mation and suppuration of the mucous investment of the glans and prepuce,
and of the sebaceous follicles around the corona glandis.   This affection
will be treated of in the section on the Diagnosis of Chancre.
  6.  Phymosis, or paraphymosis, may  easily arise, owing to the swelled
condition of the glans  and prepuce.  When  the latter is cedematous, it
presents a  curious semi-transparent appearance called crystalline.
   7.  Inflammation of either testicle.
  8.  Gonorrhceal rheumatism;—pain, swelling,  and   tenderness of the
joints, especially of the knees and ankles, and fever; this generally occurs
towards  the decline of the complaint, and attacks young people of a deli-
cate strumous habit.   The same persons are also liable to rheumatic oph-
thalmia, or inflammation of the fibrous structures of  the  eye; but this,
which is a sympathetic affection, must not be confounded with the gonor-
rhoea! inflammation of the conjunctiva, which  is caused by the  contact of
the discharge.  Bacot says, that the  rheumatism  is sometimes  suddenly
relieved  by the appearance of patches of minute  papulae or pustules.
  In the third stage, the inflammatory symptoms  and  chordee abate, and
a muco-purulent discharge is left, which, when obstinate and thin, is called
a gleet.
  Varieties.—Gonorrhoea varies extremely in its severity.  It is always
most  severe in first  cases, and in patients who are very young, or  who
possess irritable or scrofulous constitutions.  In such cases  it may be at-
tended with extreme  fever and  constitutional  disturbance, and may even
prove dangerous to life by leading to extensive  abscesses in the neigh-
bourhood of the bladder.*
  But, after repeated attacks, the urethra becomes as it were inured to the
disease, and each subsequent  infection is generally (although not always)
attended with fewer of the symptoms  of acute  inflammation.   In some
                     • For cases vide Judd, op. cit. p.  70.
       16 
182
GONORRHOEA.
 rare  instances,  the  constitutional affection is extremely anomalous, and
 characterised by severe and continuous rigors.
   Gonorrhoea sicca.—There is one form of gonorrhoea which is occasion-
 ally met with in the male, and Mr. Acton has often met with it in  the
 female, in which the  mucous membrane is red, swollen, and tender,  but
 free from discharge.  In the male, there are severe  scalding and  pain in
 making water, and the  lips of the urethra are red and swelled. This form
 of disease has the popular name of the dry clap.
   Morbid Appearances.—On dissecting a  urethra affected with recent
 gonorrhoea, the  mucous membrane is found red and swollen, and the folli-
 cles or lacune enlarged and filled with pus, especially the large lacuna in
 the fossa  navicularis, near the orifice.
   Consequences.—1.  Repeated gonorrhoea may lead to stricture of  the
 urethra;  2, to irritability of the bladder;  3, to a hard, dense, semi-carti-
 laginous state of the  corpus spongiosum urethras.
   Causes.—We have shown gonorrhoea to be an inflammation and puru-
 lent discharge from the urethra, and have said that it is generally produced
 by contagion from a similar disease.   But  inflammation and purulent dis-
 charge from the urethra may be produced by  many other causes, some of
 which have no connexion with sexual  matters.  Thus—
   (a) In the first place, discharges resembling gonorrhoea may be caused
 by local irritation.   The author some time ago treated a most obstinate
 case of this description, brought on by galloping several miles on a horse
 without a saddle.   The patient was a married gentleman, with a constitu-
 tional tendency  to irritation of the mucous  membranes; during the treat-
 ment he suffered from a severe  attack of rheumatism.   Immoderate and
 protracted sexual indulgence ;  the introduction of bougies ; blows on the
 perinaeum ;—violent bending of the penis during erection ; and long travel
 in a jolting vehicle over bad roads, are well-authenticated caiises of similar
 cases.*  (b) Urethritis with  discharge  may be produced by various disor-
 ders of the constitution.  It has been a symptom of rheumatism ; and not
 unfrequently it precedes a paroxysm of gout.   It may be caused by sym-
 pathy with irritation of other parts.  Thus it may be occasioned by piles;
 -—and it has been known to accompany the cutting of a tooth several times
 in the same patient,   (c) A discharge is liable to occur in patients affected
 with stricture;— and to  recur in those who  have been long habituated to it,
 upon any neglect of their health, exposure to severe cold, or inordinate
 fatigue, or excess in food,  wine, or  venery.   (d) Lastly, discharges are
 sometimes (although rarely) occasioned by  the use of particular medicines.
 Guaiacum and cayenne pepper have been named as some.
   Again,  a man may contract a pretty severe discharge from a woman who
 is perfectly chaste, and has not been previously infected  by a  third party.
 Thus—(a) The menstrual fluid is capable of causing urethritis with violent
 scalding and chordee, and followed by swelled testicle ;—and a considera-
 ble degree of irritation  may be produced  by the vaginal secretions, just
previous to menstruation.f   (b) Similar consequences sometimes ensue if
the female be affected with leucorrhoea, or with any other discharge of any
sort whatever.
  Diagnosis.—The question next follows, whether there is any means of
distinguishing the simple gonorrhoea,  that is, a discharge which does  not
arise from  sexual connexion, or which a man  contracts from  some acci-
           • Vide Judd, op. cit. p. 32.              -j- J„dd, p. 24. 
GONORRHOEA.
383
dental malady in a clean chaste woman, from the venereal gonorrhoea, 01
clap, caught from an infected prostitute.  The answer is, decidedly not.
The disease of  the urethra, however produced, is the same in its nature,
the same in its  symptoms, and requires the same treatment.
   The grand diagnostic sign laid down by writers,* whereby to distinguish
simple gonorrhoea from venereal gonorrhoea, is the comparative mildness of
the former, and the absence of acute inflammation.  And this is  almost
invariably true.   But yet, the author can testify that in some  of the non-
venereal cases,  the pain, scalding, and other inflammatory symptoms may
be of great severity, and of long continuance, and that they may be fol-
lowed by rheumatism,  which is so frequent a consequence of  genuine ve-
nereal gonorrhoea.  If the patient, however, strongly deny that his malady
can arise from impure  connexion, and if his character place his statement
above suspicion;—if the existence  of some one of the foregoing causes
can be ascertained, and especially if it be known that he has suffered from
it before in like manner; it will be right to  pronounce the case not vene-
real ; and  more especially if the patient be married, or be in circumstances
which would render any imputation on his continence either disgraceful or
ruinous.  Again if, as Mr. Bacot observes, " a discharge come on only  a
few hours after connexion ;  and if it have continued several days without
inflammatory symptoms ; if the patient has been liable to some discharge
after an excess of venery or of wine ;—in all such cases the probability
is, that the patient  labours  under some other diseased  condition of the
urethra, and that although the intercourse of the sexes may have been the
exciting cause, still there may be no  imputation on the  cleanliness of the
female."!
   But it is most important to observe, that although discharges may arise
from many causes besides connexion, and although some discharges may
arise from connexion with chaste women, yet that every one of them is
capable of exciting a similar discharge in a healthy person.
   These observations will go far towards solving another question that is
frequently asked, viz. What is the  danger of conveying infection when the
discharge is very small in quantity, or when it is merely gleety and mucous ?
   The surgeon should inform the patient, that the more virulent the  dis-
ease, the greater is  the danger of  communicating it;  but that, however
slight the discharge, there still will be some risk.  If, however, the  patient
be determined  to run  that risk, he should  cleanse the urethra  first by
making water  and syringing it thoroughly with a mild  astringent lotion.
It is a well-established fact, that the contact of the purulent matter is in-
dispensable to the propagation of the  disease ; consequently by getting rid
of this, the hazard will be diminished.   A person  may have  received the
infection, but cannot communicate it previous to  the appearance  of  dis-
charge.
   The time at which  the disease usually appears after contagion is the
fourth or fifth day.   The later it appears, the  less  severe it  generally is;
but in some very simple cases, produced by simple irritation, the discharge
comes on immediately after connexion.
   Gonorrhoea in the Female.—This, unless the patient is very young
and delicate, is a much more simple disease than it is in the  male  ; since
the parts affected are less  complex  in formation, and  less important in
function.
*Titley, op. cit. p. 186.
f Bacot, op. c't. p. 101. 
184
GONORRHOEA.
  The symptoms are much the same.   Heat and pain in making water
tenderness and soreness, especially in walking, uneasiness in sitting, and
muco-purulent discharge.   On examination, the parts are found swelled
and red, and if the case is severe, there may be excoriations or aphthous
ulcerations.  Sympathetic enlargement of the inguinal glands, and abscesses
in the mucous follicles, are occasional complications.
  Diagnosis.—Acute inflammation of the mucous membrane of the labia,
nymphae, and vagina, is not unfrequent in young girls, as a consequence
of teething; or of costiveness, worms, and other disorders of the aliment-
ary canal;  and it has precisely the same symptoms as gonorrhoea.  It of
course often excites great  uneasiness, and painful suspicions in the minds
of parents;  but the surgeon may very easily remove their alarm by telling
them that it is a common idiopathic disorder of children,  and not a conse-
quence of any improper treatment.
  Leucorrhcea, oxfluor albus, may in general be distinguished from gonor-
rhoea by the absence of heat or pain in micturition;  and by the pain  in
the back, pallid countenance, irregular menstruation, and signs of exhaus-
tion and debility which generally accompany it.  Yet a profuse gonorrhceal
discharge will cause the same appearances.
  As we have recently insisted, all  discharges, however produced, may
be  contagious.  Whether, however, a woman has a discharge, or has
communicated one, the  surgeon  must observe some caution  before he
casts any reflection on her continence.  And  after  all, both in  the male
and female, whatever the cause, the treatment is the same.
  Prophylactic Treatment.—Immediately after a suspicious connexion,
it will be prudent  to make wrater  so  as to cleanse  the urethra, and then
perform a thorough ablution with soap and water.   If the patient is subject
to gonorrhoea, it will be worth while to wash out the front part of the ure-
thra with a syringeful of some astringent lotion ;  and,  if  any fissures or
excoriations are perceived, they should  be touched with lunar caustic, and
a bit of dry lint be applied.
   Curative Treatment.—The remedies for  gonorrhoea are three-fold;
first, antiphlogistic measures, to get rid of inflammation;  secondly, certain
medicines containing a volatile oil, which has a peculiar sanatory influence
on the inflamed mucous membranes; and, thirdly, injections to wash away
the discharge, and alter the action of the inflamed surface.   These different
remedies are to be  combined in various degrees in  different cases, and at
different periods of the disease.
   Of the first stage.—If the patient  applies during the very first stage,
when the discharge is just appearing, and before acute symptoms have come
on, the disease may almost infallibly be cut short, by employing the plan
recommended by  Ricord.   Let him inject the urethra regularly once in
lour hours, with a  solution of two grains of nitrate of silver to eight ounces
of distilled water;  let this be  repeated twelve times:  desisting, however,
sooner, if the discharge is rendered thin and bloody, which is the ordinary
effect of the nitrate.  Then let a weak injection of  sulphate of zinc, or
alum,  be substituted, and be continued till  the discharge ceases.  At the
same  time the patient should take  a mild aperient;  and after it, a dose of
copaiba or cubebs, three times daily;  he should avoid  exercise, fermented
liquors, salt, spice, coffee, and stimulants of every kind  ; he should take
ao supper;  and should continue his  abstemious regimen  for a week or ten 
GONORRHOEA.
185
days after all trace of the discharge has  disappeared.   The  penis should
be wrapped in a piece of rag dipped in lukewarm or cold water.
  The manner of injecting is of no small consequence, as the efficacy of
the lotion depends entirely on its application to the whole of the  diseased
surface;  and, as  Dr. Graves observes, the ordinary opinion that gonor-
rhoea is limited to the anterior extremity of the urethra,  is unfounded and
mischievous.  The patient  should be provided with one of the glass sy-
ringes  with a long, bulbous  extremity, recommended by Mr.  Acton ;* and
having filled it, should introduce it for about an inch with his right hand.
Then,  having encircled the glans penis with his left forefinger and thumb,
so as to compress the urethra against the  syringe, and prevent any of the
fluid from escaping, he  should push down the piston with his right fore-
finger, letting the fluid  pass freely into the urethra; the  syringe should
now be withdrawn, but the orifice should still be compressed, and  the fluid
be  retained for two or three minutes ;  after which, on removing the finger
and thumb, it will be thrown out by the  elasticity of the urethra.
   Of the second stage.—Supposing it to be a first attack  in a young irritable
subject, and  that it has proceeded unchecked to the acute stage, the patient
should be confined to the  house for two or three days, if his avocations
permit it.  Ten or a  dozen leeches  should be applied  to the perinaeum;
but not at bedtime, unless the surgeon wishes to be  called up in the  night
to stop the bleeding.  The penis and scrotum should  be  supported  by a
suspensory bandage,  and be kept constantly wet with  tepid water.   The
glans penis,  if very irritable, should be protected by a piece of lint spread
with spermaceti  ointment.   The diet should be moderate,  to the entire
exclusion of fermented liquors, and the patient should drink  barley water,
linseed tea, gum water,  and other mucilaginous fluids.   But it is far from
advantageous to increase the quantity of urine too much, or to cause the
patient to make water often; because the act of micturition is accompanied
with very great  suffering.   The scalding will be relieved by  combinations
of alkalis and sedatives  (F. 87); and by a hip bath  of  the temperature of
80°; but the bath should not be hot, nor even warm, otherwise it will ex-
cite the  circulation and bring on  erections.  The bowels should be opened
with a dose  of calomel at night,  and some castor oil in  the morning; and
it is advisable to give half a grain or a grain of calomel, with gr. one-eighth
of tartar emetic,  and gr. x.  of  Dover's powder;  or  F. 32, every night
whilst there is  much pain and chordee'.  The mercury is not necessary
as  a specific, but it is highly useful to check the inflammatory symptoms.
As soon as the patient is free from fever, he should take  copaiba or cubebs,
F. 99, 100, in moderate doses.   The best preparation is the capsule, which
should be taken just before a meal, and then it causes no eructations; but
the pills with magnesia, F. 112, or the  emulsion, F. 98, agree very well
with some stomachs.  Young irritable people, with light complexions, can
seldom take these medicines without suffering from  sickness or diarrhoea,
or  sometimes even from fever and a rash; and every combination of aro-
matic  and opiate that  can be devised will  not enable the  stomach to tole
rate them.
   If the patient is very plethoric, and suffers greatly from pain and fever,
and has  a hard pulse and white tongue; and if there be tenderness in the
  * Described in the .Med. Gaz., vol. xxix. p. 42S.  The plan of treatment recommended
by  Dr.  Graves (Clinical Medicine, p. 304) is  highly judicious,  and almost precisely
similar  to that of Ricord and Acton.
       16* 
186
GONORRHOEA.
abdomen, pain  in  the  back,  or other  signs  of  irritation  of the urinary
organs; it may be  right to take blood from the arm, and to administer
calomel, opium, and antimony, pretty freely.
   It is decidedly not safe to use injections with young, delicate, irritable
subjects during the acute stage, and  most especially whilst there is any
tenderness of the glands of the groin, or any aching in the  spermatic cord
or testicles, as they might easily produce swelled testicle,  or great irrita-
tion of the  neck  of the bladder.  And, as a general rule, it is best to
refrain from  them altogether, till the inflammatory symptoms are mitigated
by the antiphlogistic remedies before mentioned.
   Treatment of Complications.—Painful erections and chordee may be
relieved by bathing the parts with tepid or cold water, and the diaphoretic
powder, F. 32, or a small  dose of camphor and extract of  henbane, at
bedtime;  and if the chordee lasts long, a little  mercurial  ointment  and
extract of belladonna should be smeared on the part at bedtime.  Accord-
ing to Hunter, the spasmodic chordee is benefited by  bark.  Haemorrhage
may be checked by cold, and  pressure on the urethra.*   Inflammation of
the mucous glands of the urethra is to be treated by leeches and poultices.
An opening  must be made if the swelling obstructs the flow of urine, but
not otherwise.  Swelling of the glands  in  the groin may generally be
removed by  rest,  and, if necessary, a few leeches.
   [The treatment of gonorrhoea by injection is in  much repute in this city.
Dr. Fox, one of the surgeons to the Pennsylvania Hospital, in whose hands
this mode has been particularly  successful, gives it the preference over all
the internal  remedies which are employed to  exercise  their especial in-
fluence upon the lining  membrane of the urethra.  His plan is,  to inject
a solution of nitrate of silver, containing grs. x. to each fluid-ounce of
water, and to repeat this at the expiration  of twenty-four or forty-eight
hours, unless the  discharge of pus has been arrested or very much dimin-
ished by the first application ;  always preceding each injection of the salt
by one of simple water, in order to cleanse the surface of the urethra.
The use of this  remedy, thus introduced into the urethra, almost always
causes considerable pain at first, with  some swelling of the prepuce,  and
tinges the discharge with blood  ; these effects, however, are  relieved by
injections  of cold water repeated at  intervals of half-an-hour.   Dr. Fox
rarely finds it necessary to use the injections of nitrate of silver more than
twice ; frequently a single injection renders the secretion small in quantity,
and thin, and diminishes the scalding sensation: so soon as such an im-
pression is produced, he resorts  to injections of sulphate of zinc (grs. ij to
each fluid-ounce).   Bubo, swelled testicle, and other ordinary complica-
tions of gonorrhoea, have been much less frequently met with by  Dr. Fox
from this treatment than from any other, and the cure has been much more
speedy.   He considers it applicable to all cases of gonorrhoea of  ordinary
severity, at all periods of the acute stage : if the inflammatory symptoms
are very strongly marked, he precedes this treatment by the antiphlogistic
course ordinarily prescribed.   During the continuance of the disease the
patient should remain  in bed,  if possible;  or, at  least, he should avoid
walking and  standing, and should wear  a suspensory  truss:  at the same
tune, the bowels should be acted upon,  and the diet restricted.
   [f the treatment has not been commenced until the disease has  assumed
• Vii» Part iv. chap. xx. sect. 2. 
GONORRHOEA.
187
the chronic form, it will be found more expedient to use injections of sul-
phate of copper (gr. j to f3iij of water) than the solution  above recom-
mended.
   If, during the  persistence of gonorrhoea, any swelling or tenderness is
observed  in  the  groin, the  part should be kept wetted with a solution of
sugar of lead ; this simple precaution will almost always prevent the form-
ation of a bubo,  more especially if,  as should  always be  enjoined, the
patient be confined to bed.
   In addition  to  the  remedies advised by the  author for  the relief and
prevention of chordee, an  anodyne enema before going  to bed, or the
application  to  the perinaeum of a  cold poultice, or of a  bottle  of cold
water, may be  mentioned as very useful means.—Ed.]
   Of the third stage. — As soon as  the  acute  stage  has  subsided, the
patient  should use the injections of nitrate of silver, followed by  zinc, in
the same  manner  as was recommended for the first stage. If the discharge
does not cease entirely, or if it comes  back again, other injections, F. 107,
10S, 109, 110, 111,  maybe tried;  adapting their strength to the  irrita-
bility of the part, and not permitting them to cause severe pain.
   But a  gleet is often a  very tedious complaint, and requires a judicious
and long-continued course  of  remedies that act  on the urinary organs,
together with most temperate habits of living.  Copaiba,  either alone or
combined  with astringents; — F. 101, 102; oil of  turpentine;  F.  105;
and cantharides,  especially in  combination with zinc, (F.  103,) or steel,
F. 104, are the most useful remedies.   Mr. Acton has seen great benefit
derived from injections of one grain of prot-ioduret of iron and an ounce
of water gradually increased.  The  bowels should be kept properly open,
but saline purgatives should be avoided.   If the  patient wants  to make
water oftener than natural,  and there is an uneasy  sensation in the urethra
afterwards, and the urine deposits  a mucous cloud, buchu and  uva ursi
(F. 106)  will be  advisable.  The  occasional passing of a bougie,  large
enouo-h to  fill the urethra  without  stretching it, will also be of  material
service.  It is also highly useful in these cases to inject the urethra with
cold water from  an elastic bottle, twice a day.   If the urine is preternatu-
rally acid, or loaded with the phosphates; or the digestive organs deranged;
the* case  should  be treated as directed in the section on urinary deposits.
If the health is materially enfeebled by debauchery  or malpractices, affu-
sion of cold water on  the genitals,  cold sea-bathing, blisters to  the  peri-
naeum, bark and steel, good living,  and perfect chastity of body and  mind
are the necessary remedies.   If all other means fail, the porte caustique ot
Lallemand may  be introduced, for the purpose of  slightly touching the
whole of the  canal with the  nitrate  of silver; or a strip of linen, about
eio-ht inches long, may be introduced for a few hours.   This is pushed by
a stilet into  the  canal of a gum-elastic catheter,  which is open at both
ends; the catheter is introduced ;  then it  is withdrawn over the stilet,
which keeps the  linen in the urethra, and lastly,  the stilet itself is with-
drawn, leaving the  linen.   These  two  plans are not applicable if the
urethra is very irritable.
   A scirrhous  or semi-cartilaginous condition of the corpus spongiosum
urethra; is always extremely difficult to get rid of.  The frequent introduc-
tion  of bougies; friction  with ointments of mercury or  iodine, warm
bathing and°the internal  use of Plummer's pill and ioline, afford the best 
188
PRIMARY SYPHILITIC  ULCERS.
chance ol relief.  Cases are recorded in which portions of osseous matter
have been removed from the septum penis by incision.*
   Gonorrhceal rheumatism  must  be treated  on the same principles as
common rheumatism.   The bowels should be  well cleared  by calomel
and black draught,  and then colchicum should be given in doses of Vt^xx,
of the wine with magnesia, every four or five hours, and a  dose of Dover's
powder at bedtime.   In the chronic stage, F. 32, at bedtime ; — sarsapa-
rilla, bark, volatile tinct. of  guaiacum, sea air, tonics, and warm bathing,
are the remedies.  Bleeding can hardly ever be required.
   The Treatment of Gonorrhoea in the Female must be conducted
upon precisely the same principles.  During the acute  stage, rest in the
recumbent posture, leeches, anodyne fomentations, frequent ablution, lu-
brication with lard  or cold  cream—and very frequent sponging with  a
weak solution of alum, a piece of  lint dipped in which should be inserted
between  the labia ;  with laxatives and diaphoretics, are the measures to be
adopted, until heat, pain, and  tenderness subside ;  afterwards injections
may be used with much greater freedom and benefit than in the other sex.
Those of acetate of zinc and nitrate of silver appear to  be the best; and
they should be continued for some  time after all discharge has ceased. But
much greater liberties may be  taken with the vagina than with the male
urethra;  and the disease may often be stopped at once, without risk, by
the application of the solid nitrate of silver, as recommended by Jewel and
others.   It should be  applied, however, either  before  the  inflammatory
symptoms have  attained any height, or after they have  subsided.   Tere-
binthinate medicines (copaiba, &c.) may be given, although they do not do
much good, unless the discharge proceeds from the urethra or its vicinity.
Abscesses or other complications are rare; but  if they occur, they must
be treated on general principles.

    SECTION  III.--OF  PRIMARY  SYPHILITIC  ULCERS.

  General Description.—Primary syphilitic  ulcers or chancres  may be
jcajused by the application  of the syphilitic virus to any surface, mucous or
cutaneous, entire, wounded, or ulcerated.  Their most frequent seat is the
genitals;—and in men they  are more frequently than otherwise found on
the inner surface of the prepuce, or the furrow between  the  prepuce and
corona glandis,  or the angle  by the fraenum;—obviously because  those
spots are most convenient for the lodgment of  filth.   It is notorious that
persons with a long prepuce, whose glans is habitually protected by it, and
covered with a delicate semi-mucous membrane, are  more  liable to suffer
than those whose glans is uncovered, but  clothed with a denser cuticle.
The time at which venereal  sores  appear is  usually  said to be from  the
third to the tenth day  after infection ; but it is more probable, as Ricord
observes, that the syphilitic virus operates progressively from the first mo-
ment of its application, but that the ulcer is fully formed by the fifth day;
although it may not be perceived by a  careless person till  later.   The
average duration of a syphilitic ulcer produced by inoculation is, accord-
ing to Wallace, twenty-five  days.
  Primary syphilitic ulcers  present very many varieties.   These varieties
depend,—1st. On the peculiar sore from which infection was  received;
» Titley, p. 175. 
PRIMARY SYPHILIS.
189
because every kind of sore, and especially the phagedaenic, has a tendency
to reproduce its like.   2dly. On the state  of constitution of the patient,
and the degree of inflammation which is present.   3dly.  On the situation;
and, lastly, on the local treatment.
   It is impossible in this work to collate  and describe the innumerable
varieties of syphilitic ulcers that are spoken of by authors.  For practical
purposes  it will suffice  to  consider them under three  heads.   1st,  the
Ilunterian, or indurated  chancre;  2dly, the non-indurated chancre; and,
3dly, chancres  complicated with sloughing or phagedaena.
   I. The Hunterian  Chancre, or indurated ulcer, is generally found on
the common  integument or on the glans penis.  It may begin  either as a
pimple, or as a patch of excoriation which heals up, leaving  the  centre
ulcerous.   It is nearly  circular ;—deep  and excavated;—the  base and
edges are hard as cartilage, but the hardness is circumscribed ;*—there is
little pain or inflammation ;—its colour is livid or tawny ;—it is never so
hard nor excavated when on the body of  the penis as when on the glans.
   It is this form of ulcer which is ordinarily produced when the pus of a
chancre is inoculated into the sound skin for purposes of diagnosis.   Sup-
posing the inoculation to have been performed with the point of a lancet.
During the first twenty-four hours the puncture reddens.  In the  second
and third days it swells  slightly, and  becomes a pimple, surrounded by a
red areola.   From the third to the fourth  day, the cuticle is raised by a
turbid fluid into a vesicle, which displays  a black spot on its summit, con-
sisting of the dried blood of the puncture.  From the fourth to the fifth
day, the morbid secretion increases and becomes purulent, and the vesicle
becomes a pustule with a depressed  summit.  At this period the areola,
which had increased, begins to fade, but the subjacent tissues become in-
filtrated and  hardened  with lymph. After the sixth day, if the cuticle and
the dried pus which adheres to  it be removed, there is found an  ulcer,
resting on a  hardened  base; its  depth  equal to the whole thickness of  the _ -'
true skin, its edges seeming as if cleanly cut out with a punch—its surface
covered with a greyish pultaceous matter, and  its margin hard, elevated,
and of a reddish brown  or violet colour.t
   2.  The non-indurated chancre, is most frequently found on the inne?
surface of the prepuce.   It may be said to have  four stages.  In the 1st,
it is a small itching pimple, or pustule,  which bursting, displays—2dly, a
foul yellowish or tawny  sore, attended with slight redness and  swelling,
and spreading circularly.  It may or may not  be covered at first  with a
dirty brown scab.  In the third stage it throws out indolent fungous gran-
ulations ;—except it be  situated  on  the glans; (for the substance  of  the
glans penis has  no power of throwing  out granulations,  although its sur-
face may ;) and is usually stationary for a little time after it has ceased to
ulcerate, and before it begins to heal.  In the 4th stage, it slowly heals;
cicatrization  being preceded by a narrow  vascular line.   The  cicatrix is
often red and indurated;—swelled, if on  the  prepuce; but  depressed if
on the glans, from want  of granulations.  It is exceedingly liable to ulcer-
ate afresh.  If  the ulcer be seated near the fraenum,  it is almost sure to
perforate it.
   One sub-variety has  been termed by Mr. H. J. Johnson the multifarious
sore;—because  the discharge is  so infectious that it excites fresh ulcers on
    * So that it has been said to feel like a little cup of cartilage set in the flesh.
    ■(■ Ricord, op.  cit. p. S9. 
190
PRIMARY SYPHILIS.
 the sound skin.   Another sub-variety is described under the term excoria
 tion sore, aphthous sore, or superficial sore;  a circular,  shallowish sore.
 mudi resembling an excoriation, not ulcerating deeply.  Finally, an exco-
 riation or a fissure of the prepuce may be infected, and may be followed
 by secondary  symptoms.   But  if ulceration  does not spread, it will be
 very difficult to say whether it  is a venereal  ulcer, or merely a common
 fissure or excoriation obstinate in healing;  for, in both cases, it may appear
 yellowish and indolent.  Inoculation is the test.
    3.  Chancre complicated with Phagedena or Sloughing.
    (a) Phagedenic chancres are extremely rapid in their progress, and highly
 painful;  their surface yellow and dotted  with  red streaks ;  their shape ir-
 regular ;  their edges ragged or  undermined;  and the  discharge  profuse,
 thin, and sanious.  The surrounding margin  of skin usually looks puffy
 and cedematous, showing a  low grade of arterial action ; but sometimes it
 is firm and of a vivid red.  Sometimes  these ulcers  eat deeply into the
 substance of the penis; sometimes they  undermine the skin extensively;
 but in general they spread widely but not deeply.  Sores of this  last de-
 scription are called serpiginous.
    (b) Sloughing phagedena  affecting chancres requires no observations on
 its symptoms distinct from those made at page 91 et seq.
    Simple or sloughing phagedaena may affect  chancres or open buboes for
 two reasons.  1st, If the constitution be  irritable and broken down by de-
 bauchery, night watching, exposure to cold and damp, or by the profuse
 administration of mercury, or by confinement  in the foul pestiferous air of
 an hospital.  Hence it is liable to occur to soldiers, sailors, prostitutes, and
 bakers;—the last-named class of individuals being obliged  to work in the
 night.   The serpiginous variety is, as Mr. Acton  observes,  extremely apt
 to affect " scrofulous individuals, or old  men who have led a dissipated
 life; or men subject to the diseases of hot  climates, and  persons with
 skin diseases and constitutional  complaints, whose health has been ruined
 by several courses of mercury."  2dly,  They may probably be produced
 by some  peculiar acrimony of the venereal  virus.   There  is reason  for
 believing that intercourse  between foreigners  gives rise to a very destruc-
 tive kind of poison.   The venereal secretions  of the Portuguese women
 appear to have been horribly deleterious  to the British soldiers during the
 Peninsular wrar, who gave the expressive name of The Black Lion to the
 sloughing sores that resulted from connexion with them.*
    (c) Chancres may be affected with simple acute inflammation  leading to
► gangrene, from local irritation, such as horse exercise, and excess in stim-
 ulating liquors.
    Chancre in the Urethra.—Ricord has proved satisfactorily that this
 is the cause of the  secondary syphilitic  symptoms which were formerly
 attributed to gonorrhoea.  The existence of chancre in the urethra may be
 suspected, if in a case of  gonorrhoea the discharge is Aery  capricious,
 sometimes thin,  scanty, and bloody, sometimes thick and profuse ; and if
 there is one painful indurated spot.  But it can only be proved, either by
 the ulcer being visible at the orifice, or by inoculation with the matter.
    Syphilitic Ulcers  in  the Female  require no distinct  observations.
 They do not usually cause so much distress as  in the male, but  they are
 Aery slow in healing, especially if interfered  with by the urine.  When
   • For an account of this investing point in  the history of syphilis,  see  the late In-
 upector-peneral Fergusson, Med. Chir. Trans, vol. iv., and Guthrie, ib. vol. viii. 
DIAGNOSIS OF  CHANCRE.
mi
situated high in the vagina, they may cause no symptoms at all, except
Perhaps a mucous discharge, and can be detected  only by the speculum.

      SECTION IV.--OF  THE  DIAGNOSIS  OF  CHANCRE.

  The ordinary means of distinguishing a syphilitic ulcer are, that  it is
seated on the genitals ; that it has followed a suspicious connexion ; that
it is probably circular, with hardened base and elevated edges ; and above
all, that, if treated with simple applications merely, it is extremely difficult
to heal.   But none of these characteristics are infallible.   The surest test
is that of  inoculation, which has been brought into great repute by Ricord.
If some of the pus of a real chancre, taken while it is extending and before
it begins to heal, be inoculated into the skin of the thigh, it will produce a
regular chancre  there, after the manner we have already described (p. 189).
It may be right to adopt this practice in some few cases when the existence
of chancre in the urethra is suspected; or when the characters of a sore
on the penis are undecided ;  or when there is a sore suspected to be syphi-
litic on the  face, or any  other unusual part; or  when it  is wushed to test
the pus from a bubo ; but the  sore produced by inoculation  must be de-
stroyed by lunar caustic, or by nitric  acid, as soon as  its character is de-
cided, else it may give both surgeon  and patient a great deal of trouble.*
  Affections that may be mistaken for Chancre.—This is the most
convenient place for describing the nature and treatment of  various affec-
tions  that may be mistaken for chancre.
  1.  Gonorrhoea externa, or balanitis, is  an inflammation of the surface
of the glans and inside  of the prepuce, with profuse purulent discharge,
and excoriation of the cuticle.   It generally affects dirty people with long
prepuce, and is caused  either by the acrid secretions of the part, or by
contact with unhealthy secretions in the female.   Sometimes, however, it
occurs to cleanly people whose health is  disordered.  The  thick profuse
discharge, the  peculiar smell, the superficiality of the excoriations, and
their  appearance immediately after connexion, distinguish this complaint
from  chancre ;  and  a little opening medicine, common  soap and water,
and any mild astringent lotion will suffice to  cure it.   Lime-water is the
best lotion if there is much inflammation, and  a grain of corrosive subli-
mate  to an ounce and a half of lime-water if  there is not.    If the cure is
not effected in two or three days, the excoriations should be touched with
nitrate of silver.  Sometimes balanitis is  attended with very great inflam-
mation and fever,  and with phymosis, from the  great swelling of  the pre-
puce  ; and the  pain may be so severe and gnawing, as to make the sur-
geon  uncertain whether there is not a phagedaenic ulcer concealed by the
foreskin.   The thick discharge,  and the pain being  general  and not
confined to one spot, form the chief means  of diagnosis;  and repeated
injection of warm water and astringent lotions under the foreskin are the
remedies.
  2.  Minute aphthous-looking points, sometimes in clusters, sometimes
surrounding the glans;  some of them healing, whilst others break out.
They are totally devoid of  pain ; and  although  they  may last a long
time,  do not lead to ulcers.   They  are  best  treated by  black wash  or
  •  It  must be recollected that inoculation, if performed  from a sore that is healing wil'
produce no pustule ; but yet that sore may be of venereal origin, and would have yielded
an infectious matter at an earlier period. 
192
TREATMENT  OF  PRIMARY SYPHILIS.
  mere lime-water, or lotions of arg. nit.  or cupr. sulph., and alteratives and
  aperients.
     3.  Herpes preputialis* begins with extreme itching and sense of heat.
  The patient examining the part, finds  one or two red patches, about the
  size of a split pea.   On each patch  are clustered five or six minute vesi-
  cles, which, being extremely transparent, appear of the  same red colour
  as the patch on which they are situated.  In  twenty-four or thirty hours
  the vesicles become larger, milky, and opake;  and on the third day they
  are confluent and almost pustular.   If the eruption is seated on the inner
  surface of the prepuce, the vesicles commonly break on the fourth or fifth
  day, and form  a slight ulcer with a white base and rather elevated edges.
  If this ulcer be irritated by caustic or otherwise, its base may become as
  hard as that of a chancre.   If  left to itself, it mostly heals in a fortnight;
  —sooner if situated on the external  skin.  The cause  of  this complaint is
  either some derangement of the digestive  organs, or irritation within the
  urethra, which  should  be ascertained by the bougie.   It is very liable to
  recur in the same individual, which  of course, if known, will greatly aid
  the diagnosis.   Treatment.—A little dry lint,  or  goldbeater's skin, at
, first, and subsequently a very weak  lotion ;  with aperient and alterative
  medicines.
    4.  Psoriasis preputii, painful, irritable, and bleeding cracks or fissures
  around the edge of the prepuce,—best treated by ung. hydr.  nitr. dil.
      section v.—of  the  treatment of  primary
                             syphilis.

   Local Treatment.—It  seems to be pretty well established, that  if a
chancre lasts for a few days only there will be no  fear of secondary symp-
toms, and no need to administer mercury.   If, therefore, a patient applies
as soon as he perceives the chancre, it will be advisable to touch it tho-
roughly with a stick of nitrate of silver, and destroy it;  then give an  ape-
rient, enjoin rest and low diet, and wrap the penis in rag dipped in warm
water, to prevent inflammation.  But if the  sore  has  lasted more than a
week, the  nitrate of silver will  not  act deeply  enough  to destroy it
effectually;  and the  potassa fusa, or strong nitric acid, must be employed
instead.
   But the foregoing plan cannot be adopted with safety if the chancre
presents a well-marked  indurated lump, or  if the penis is swelled  and
inflamed, and the patient feverish, or if there  is any swelling or tenderness
in the groin.   When this is the case, the local applications should consist
of some liquid capable of chemically decomposing the poisonous secre-
tions of the sore, and of a strength proportioned to the existing irritation.
Black wash; a very  weak solution of chloride of  soda,  and  decoction of
oak-bark with a little tincture of catechu, which Mr. Acton uses as a  sub-
stitute for the vin aromatique, the favourite application  of M. Ricord, are
'he most useful.  If there is very much irritation the penis should be  en-
veloped in a  poultice of boiled camomile flowers.   If there is much indu-
ration Ricord recommends an  ointment of calomel.   Afterwards, during
Ihe indolent  and granulating stages, the  sore may be tieated with any

    * Bateman  on C'i'aneous Diseases, 5th ed. p. 238. Burgess's Cazenave, p. 88. 
ILL EFFECTS OF MERCURY.                 193
astringent lotion, and be touched occasionally with nitrate of silver or
sulphate of copper.
   Constitutional Treatment.—If there are none of the contra indications
that will be  mentioned presently, the patient should take  mercury.  Not
because it is absolutely necessary in  all cases, but because it hastens the
cure of the primary  sores,  and affords  a more  decided security against
secondary symptoms,  especially if the chancre is of the Hunterian variety.
But before doing so,  it will be right to open the bowels by blue pill and
black draught;—and to prescribe  low living, rest, and saline medicines,
till local  pain and inflammation  and any general disorder of the system
have been removed.   A warm bath or two may also be useful.  But great
care must be taken not to induce weakness.
   Then the object is  to induce a gentle mercurial action, and to maintain
it long enough ; and the latter point requires to be especially insisted on in
the present day, because surgeons, in order  to avoid giving  too  much
mercury, now seem inclined  to give  too little.   Five grains of blue pill
should be given every night and morning; and if no effect on the mouth
is  produced  by the  fourth  day, the  dose at  night should be doubled.
This will rarely fail, in another day or two, to produce a very slight sore-
ness and  sponginess of the gums with a slight  increase  of the  saliva;
which is all that is wanted ;  for the only use of salivation is  to show that
the system is affected.  The mercurial influence  should be steadily main-
tained for four or five weeks, and until the sore has healed and all hard-
ness of the cicatrix has vanished.  If the mouth become too sore, the dose
should be lessened ;—if the  soreness subside too soon, it may be  increased ;
or two or three doses of calomel may be added.   Meanwhile  the patient
should live regularly, but not too low:—he should avoid all  excess  of
food or wine, and acescent vegetables, and every thing likely to disorder
the bowels ;—his clothing should be rather warm, so as to keep the skin
perspirable ;—and, above all, he  should most sedulously avoid fatigue,
cold, wet, and night air.
   The strong mercurial  ointment is not so likely to disorder the bowels as
the blue pill, but it is more troublesome, and might fatigue a feeble patient
injuriously.   The dose  is from gfs—gj ;—to be rubbed in daily upon the
inside of the thighs or arms till it disappears.   The morning is  the best
time for doing it, as the skin is then softer; it should be rubbed on differ-
ent limbs successively;  the patient wearing the  same drawers  both  by
night and day.  If the skin  becomes irritated, it should  be well washed
and bathed.   If the patient is too weak to rub in the ointment himself, it
must be performed by a  servant, whose hands  should be protected by i<
pi<A bladder, well softened in oil and tied round his wrist.
  If calomel is preferred, two or three grains  may be given every night,
combined with a little opium:  but it  is more apt to purge, and should b"
used only with strong robust people,  who would  be unaffected by milder
means.
   The ill effects of Mercury that require to be guarded against are as
follows :  1. Griping and purging—which are to be obviated by combining
a small quantity of opium or hyoscyamus with the  blue pill, and giving
occasionally a draught with  P.'rhaei 9j, tinct. ejusd. f3J, tinct.  opii TTLxx,
aq. menth. f3x.   It is far from uncommon for a slight attack of dysentery
to  occur, especially about the time that salivation commences ; there beinc
sickness  and severe  griping, with  frequent straining and ineffectual at-
       17                           n 
(94
ILL  EFFECTS  OF  MERCURY.
tempts to go to stool.  This should be treated by the draught just men-
tioned, followed by opiate enemata and the warmth bath,—the mercury
being omitted for the time.
  2. Sore throat; redness of the whole fauces, and sloughing or ulcera-
tion of the tonsils with fever.   In this case the  mercury must  be  discon-
tinued, till leeches,  gargles, and aperients have set the throat to rights ;—
and then it may be  resumed in smaller doses.
  3. Violent salivation.   This may be caused by a too liberal use of the
remedy;  or by a sudden  check to the cutaneous secretion by cold and
damp ; or by loss of blood, or anything that suddenly lowers the system.
It is, however, very common to meet with persons  who  are salivated by
the smallest quantities conceivable ; and every practitioner should make  a
point of  ascertaining  this, before  he  prescribes mercury for any new pa-
tient.   There is  good reason for believing that a great susceptibility of
salivation, and tendency to Bright's disease of the kidney often go toge-
ther.   The symptoms of  severe salivation are, swelling and inflammation
of the  salivary glands, cheeks, tongue, and fauces, with a flow of pecu-
liarly fetid saliva, and ulceration  or  even  sloughing of the gums.  The
best local applications for this state  are, gargles of brandy and water, to
which a little of the solution of chloride of lime may be added, or gargles
of tannin, or of hydrochloric  acid. (*F.  89, et seq.)   The bowels  should
be cleared by mild  aperients ; and as soon as fever has abated, the patient
should have a good diet  and tonics.   Change of air, and  especially re-
moval from the venereal wards of an hospital, are indispensable.   If the
salivation is very obstinate, repeated blisters should  be applied behind the
ears, and to the throat.*
  4. Eczema mercuriale  (Eczema rubrum, Erythema mercuriale, hydrar-
gyria)  consists of patches of redness and inflammation, which appear first
on the groins, axillae, and flexures of the limbs, and then spread over the
trunk.   These patches are covered with minute vesicles, which soon burst,
discharging a thin acrimonious fluid,  and leaving the surface  excoriated,
and exceedingly painful and tender.   The discharge often  becomes pro-
fuse and fetid, and  the affected parts much swollen and fissured.  It gene-
rally lasts for ten days,  but may remain  for many weeks.f   Treatment.
Warm bathing, mild and unctuous  applications, aperients, diaphoretics,
salines, and opiates, during the early stages;—subsequently, bark or sar-,
saparilla, and the mineral acids.  Dr.  Colles  has  described another and
less severe form of  eruption, which resembled the itch, except that the in-
tervals between the fingers are free from  it; the  treatment is the same.
When  a patient who is disposed to these affections reverts to the use of mer-
cury, the doses should be  small, combined  with hyoscyamus, and he should
carefully avoid heat, violent exercise, and  everything else that excites the
cutaneous circulation.
  5. Ercthismus mercurialis consists  in a  tendency  to palsy of the heart.
The symptoms are  great  depression  of strength; anxiety about the prae-
eordia,  dyspnoea, frequent  sighing, weak and  tumultuous  action  of the
heart;—frequent sense of suffocation, disturbed sleep, and faintness upon

  • Di. Macleoa relates two cases of coma following the sudden cessation of salivation;
out fatal ; the other cured by  reproducing it.  Lond. Med. and Phys. Journ. vol. lvi.  p.
•nt.
  \ One variety, hydrargyria  maligna, now almost unknown, is attended with typhoio
fever  Ete;ht out of fourteen cases died.  Alley on Hydrargyria.  Lond.  1810. 
TREATMENT  OF SYPHILIS.
195
any exertion ;  which faintness may prove fatal.   Treatment.  Removal to
a fresh atmosphere;  stimulants; especially the mistura moschi;  tonics;
and good living.*
  If during the mercurial course any febrile or inflammatory attack arise,
it is a  general rule to discontinue it until such a state has been removed.
And if the patient become thin and feeble; losing his appetite and strength ;
complaining of disturbed sleep, night  sweats, cough, or any  other symp-
toms indicative of debility, his diet must be generous, and  sarsaparilla or
cinchona and  other tonics  must be liberally administered; and  if these
symptoms continue, notwithstanding the mercury is given  in  diminished
doses, it must be relinquished altogether.  Vide F. 129.
   If the patient is very easily salivated, the  doses must be very small, and
at distant intervals, and the strength must be well supported by tonics and
good living.    If, on the other hand, as sometimes happens,  the mercury
seems  to make no impression on the system, the patient should  use  the
warm  bath and live low.    If very robust, he may be  bled  and  purged.
But the doses  must not be very much increased, lest they suddenly induce
salivation, or erethismus.
   There are some patients whom it is scarcely advisable to subject to a mer-
 curial course, viz., those actually labouring under consumption ox scrofula;
 or who are extremely debilitated, or who are liable to the erethismus.
   For these and other cases in which mercury is unadvisable, the iodide
 of potassium has been proposed as a substitute ;  in doses of gr. i.—iii. ter
 die.   It produces a great flow of urine.  In over doses, it causes sickness,
 salivation, and emaciation; with  symptoms  of  violent cold  in the head
 and swelling of the  eyes.   Mr. Sm.ee has  published  a valuable paper on
 the use of tartar emetic in doses of gr. £—L every four or five hours, both
 in primary and secondary syphilis.  It may be combined with iron or zinc
 if there is much debility.f
    Sarsuparilla and guaiacum, as combined in the compound decoction of
 sarsaparilla, appear to maintain the secretions, especially those of the  skin
 and kidneys, to increase  nutrition,  and  allay  morbid irritability of the
 nervous and circulating systems.  Hence they are admirable remedies for
 debility during or after a mercurial course ; and for the multifarious variety
 of symptoms that arise when the health is broken down as  well by the dis-
 ease as by its remedy.
    The gangrenous chancre  (when occurring in healthy subjects, with firm
 pulse,) requires to be treated by the  early and  free abstraction of blood;
 and then the  bowels having been  opened, and the pulse  being  reduced,
 opium should be given pretty freely in combination with salines and anti-
 monials.  The poppy fomentation is  the  best application  at  first, and the
 balsam of Peru, or  nitric acid lotion  subsequently, to  assist in  throwing
 off the sloughs.  The ulcer which remains is usually healthy, and is  very
 seldom followed by secondary symptoms;  therefore there is no need of
 mercury unless the sore bzgin to ulcerate, (there being nothing in the gene-
  ral health to account for ft,) or unless secondary symptoms  appear.
    The phagedenic and phageieno-gangrenous chancre must be treated ac-
  cording to the state of the  system.   If there are  fever and  thirst, with a
  full habit and harsh pulse,  and vivid  arterial inflammation, the case should
    • Vide Dr. Bateman's case.  Med. Chir. Trans, vol. ix.  Colles' Lectures on Surjrer*
  rol. ii. p. 242.
    \ Med. Gaz., Sept. 10th, 1S42. 
196
BUBO.
be treated antiphlogistically;  if, however, the constitution is brcken down
and the pulse quick and feeble, bark and opium should be given freely ;—
and if the application of a strong solution of opium does  not stop the pha-
gedaena,  the diseased surface must be destroyed by nitric acid, as directed
at p. 94; and this will probably require to  be done repeatedly, before the
diseased  disposition is got rid of.   Mercury is inadmissible (as a general
rule) when chancres are  affected with  inflammation, sloughing, or phage-
daena.
   Hphymosis is present, and there is a discharge from under the prepuce,
which cannot be turned back, either the case may be one  of mere balanitis,
or there  may  be a chancre under the prepuce.   If  there be  an ulcer, it
may be detected by local hardness and tenderness.   Whilst there  is any
inflammation,  fomentations and water-dressing  must be applied,  and a
mild astringent lotion should be injected frequently between the prepuce
and the glans.   The prepuce should be slit up,  if the   tumefaction is so
great that  it threatens to  slough ;  but not otherwise.    If phymosis  be
caused by small .ulcers at the edge of the prepuce, (which sometimes occur
during the healing of venereal sores,) they should  be touched with arg.
nit., or cupri sulph., or ung. hydr. nitrat.
   As soon as the frenum has been perforated by an ulcer, it should be
completely divided.
   Chancre in  the urethra must be treated by astringent injections;  and by
mercury  if not contra-indicated by any of  the circumstances  above men-
tioned.

                    SECTION  VI.--OF  BUBO.

   Definition.—Bubo signifies  an  inflamed lymphatic  vessel or gland
leading from a venereal ulcer.
   Causes.—Any local irritation will, in certain habits, cause inflammation
of the lymphatics;—in gonorrhoea, for  instance, the glands in the groin are
apt to swell.  But the genuine syphilitic bubo arises from absorption of
the poisonous secretions  of a chancre;  and the ordinary time of its appear-
ance is, just as the ulcerative stage of the chancre is  ceasing.
   Varieties.—(1.) Bubo of the Penis consists of an inflamed lymphatic
vessel on the penis.
   (2.) Acute  bubo at  the groin generally affects  only one  gland, and
pursues the course of an ordinary acute  abscess.  The  cellular tissue be-
tween the gland and the skin is the common seat of suppuration, but there
may also be a small abscess in the centre of the gla»d, arising no doubt
from the absorption and  transmission of poisonous matter, and the pus of
this latter is alone capable of producing a chancre by inoculation.
   (3.) Indolent or chronic bubo very commonly affects more than one
gland.   It  occurs in weak,  scrofulous habits, and  especially in persons
worn out by the improper  administration of mercury.  The glands slowly
enlarge;  suppuration  is slow arid  imperfect, and commences at several
points.  The skin is long before it inflames, but  when it does so, a large
tract of it becomes of  a  dusky bluish  tint; the matter spreads widely;—
and at last  large portions  of the skin perish by  ulceration or sloughing,
leaving an extensive sore that may be  months in healing.
   Diagnosis. — If a bubo at the  groin affect one gland only, and that
above Poupart's ligament, it  is most  probably caused by chancre on  the 
BUBO.
197
penis,  provided there  be, or has been,  one.   But if many glands are
swelled,  and they are below the level of Poupart's ligament, the swelling
is probably caused by some irritation about the foot.   But the  only sure
diagnosis of a syphilitic bubo is, that, if the matter taken from it  be inocu-
lated, it will produce a chancre ;—or that the  sore produced by opening
the bubo presents the  elevated  edges  and copper-coloured margin of a
chancre.  As, however, every bubo is  attended with  suppuration of the
surrounding cellular tissue, the surgeon should recollect that some of the
matter taken when it  is  first opened  may not cause chancre  by inocu-
lation.
   It has been supposed by some surgeons, that the syphilitic virus, if ap-
plied to the skin of the penis, might be taken up by  the absorbents and
produce a bubo in the groin without having first caused a chancre.   Such
supposed cases are called bubon d'emblee by the French.   But though it
is very certain  that the inguinal glands are apt to inflame and suppurate,
if a  person  of bad constitution, who  is  disposed to such  affections,
indulges in immoderate  sexual intercourse (especially if at  the same time
his health  is lowered by fatigue, or irregular living); still there  is not the
slightest proof that  such buboes are syphilitic, unless preceded by  chan-
cre ;  and the  surgeon is not justified in  administering mercury, unless he
can produce chancre by inoculation  with the discharge, or unless decided
secondary  symptoms occur.*
   [The Editor would  call attention to the  fact that  buboes have  .been
confounded with aneurismal and  hernial tumours, and impress upon the
reader the  importance  of making a very thorough examination in each
case, before adopting an opinion as to the nature of the tumour.]
   Treatment.—1. The acute bubo must be treated as an  acute abscess.
The first indication is to produce resolution ;—by rest, aperient and  saline
remedies, low  diet, leeches,  and fomentations.  The  applications to the
chancre must be soothing, and mercury, if being administered,  should be
at once given up.   Sometimes, it is true, a rapid exhibition of it causes a
rapid disappearance of the bubo ;—but more  generally it hastens suppu-
ration, and it certainly predisposes to  subsequent ulceration.   It may be
easily resumed afterwards.   As soon as  the tenderness is relieved, pres-
sure by means of a compress and bandage is useful.  Even if matter does
form, the surgeon should be in  no haste to  evacuate it;—but should en
deavour to procure its absorption by repeated leechings, discutient lotions,
or painting it with a strong tincture  of iodine,  with aperients, attention to
the  health,  and  change of air.   When the  case  becomes chronic,
frictions, bandages, &c, may be used to remove any swelling that remains.
[One of the very best applications to promote  the absorption of an  indo-
lent bubo  is  an ointment recommended by  Mr.  H.  J. Johnson, in the
Cyclop.  Pract.  Surgery: it  is thus compounded:  R unguent,  hydrarg.
fort.  3j;  antimon.  et  potass, tart. 3j; iodini,  grs. x. —  ad.  grs.  xv.;
mft. unguent.   A small portion  of  this ointment should be rubbed upon
the enlarged  gland, every night and morning, until  pustulation is pro-
duced.—Ed.]

   •An officer in the Rifles, young, tall, and eminently  lymphatic in temperament, told
the Author, that whilst serving in Canada in 1841, a large cluster of glands  in the groin
swelled and suppurated after immoderate sexual indulgence.   He  was attended by
one civil and three military surgeons; and this surgical staff was equally divided in
opinion, whether the complaint was sypbilitic or not.
        17* 
198
SECONDARY SYPHILIS.
  But if the matter increases, and the skin becomes inflamed and shining,
a puncture should be  made, and the case be treated  as  any other acute
abscess.
  2. In treating the  indolent bubo, the general health  must be  amended
by every possible means; tonics, the acids, sarsaparilla, change of air,
and especially a sea voyage ;—with occasional leechings and cold lotions,
when demanded by an aggravation of heat and pain.   If  these  measures
fail, and matter forms, and the skin is becoming bluish and  thin, a blister
may be applied;—or the diseased skin may be  rubbed with org.  nit.;
which  measures will either promote absorption, or at  least  stimulate the
parts  to a healthier action.   But if the  matter continue  to increase, the
swelling should be opened either by rubbing it with  potassa fusa, or by
applying the nitrate first, and then opening it with  a lancet;—either plan
having the advantage of causing diminution of the swelled glands, and
preventing the spread of ulceration.  Mercury should not be  given;—
except, perhaps, in alterative doses towards the close of the case.
   In treating the sore formed by opening  a bubo, the first thing is to get
rid of the loose  red skin.   This may be  done (as soon as the part is be-
coming indolent and swelling is abated)  by cutting it away with  scissors,
or by the potassa fusa.  A solution of nitrate of silver is the best dressing
afterwards.
   Sometimes  there remain one or two indolent  enlarged  glands, project-
ing in the  midst of the sore, denuded of skin, and incapable of forming
healthy granulations.   These may be destroyed by caustic  in the follow-
ing way :  An ounce of bread crumbs, two drachms of corrosive sublimate,
and  one  drachm  of red oxide  of lead, mixed into  a paste with a little
water, may be made into conical troches of the shape of bread-seals; and
one of these may be inserted into a puncture  in the diseased gland, which
it will speedily cause to slough.
   Sinuses, if they are  not  soon healed by stimulating injections, may be
slit up.
   If the ulcer become inflamed or irritable, or spread by  ulceration,  or if
it be attacked  by sloughing, or phagedena, (which may destroy the patient
by exhaustion, or by laying open the  femoral artery,) the  same  treatment
must be adopted that has already been directed for similar ulcers in  other       ✓
parts.   Vide p.  91, et seq.

          SECTION  VII.--OF  SECONDARY  SYPHILIS.

   The symptoms of secondary, or constitutional syphilis, generally occur
about six weeks after the  primary symptoms; — sometimes  a  fortnight,
sometimes not for months.   Before their appearance, the patient generally
becomes thin  and wan ;—he looks dispirited ;—his eyes are heavy;—and
he complains  of want of appetite and sleep, and of rheumatic pains.
   The  effects of constitutional  syphilis  are  usually first manifested  upon
the skin and mucous membrane of the throat, and then upon the bones.
We shall first describe these several local  affections, and then  the  treat-
ment of spcondary syphilis generally ; but syphilitic affections of the eye
and testis, which generally accompany those of the throat, will be treated
of in the chapters that are particularly devoted to those organs.
   Syphilitic  Eruptions vary in degree  from the slightest discoloration to
the most inveterate  ulcers.   1.  In the mildest form, the skin is mottled 
SECONDARY SYPHILIS.
199
and  stained in  irregular  patches of a brownish  red  colour;  which are
caused by a slight swelling and vascular injection.  A greater degree of
the same derangement will produce syphilitic psoriasis, in which the skin
is raised in copper-coloured blotches, covered with scales of hypertrophied
cuticle.   Or there may be an eruption of papule or pimples, varying  in
size from  a pin's head to a pea.  These eruptions are succeeded merely
by scabs or exfoliations of the cuticle.
  2.  Scaly Eruption (Lepra Syphilitica) is an  aggravated variety of the
preceding. It begins with an eruption of copper-coloured blotches, which
become covered with scales of enlarged cuticle ;—these are succeeded by
scabs, and, when they fall off,  by shallow  ulcers with copper-coloured
edges.
                                Fig. 21*
  3.  Vesicular Eruption (Rupia).   Large flattened bullae, filled with
serum, which gradually become purulent, and finally dry into scabs, under
which the skin is ulcerated.  The ulcers  spread under the scabs, and the
latter become  remarkably thick from successive additions.
  4.  Pustular Eruption  (Ecthyma).  Large prominent  pustules, with £
copper-coloured base,  leading to  ulcers.
  5.  Tubercular Eruption.  Broad, red,  copper-coloured  tubercles, form-
ing most frequently at  the alas of the nose, or on the cheeks.  They gra-
dually suppurate, and  are succeeded by  deep irregular ulcers, terminating
in puckered cicatrices, and  more properly belong to the class of tertiary
symptoms, in which mercury is  almost inadmissible.  This  form of dis-
ease  is most unfavourable, and usually appears at a considerable distance
of time from the primary symptoms in  persons whose constitution is ori-
ginally weak, or has been shattered by  privation, dissipation, or frequent
unavailing courses of mercury.   A patch of this kind of unhealthy inflam-
mation is apt to form  on the tongue, and after a time an abscess breaks,
disclosino- a ragged excavation,  filled with orange-coloured  sloughs, and
exuding a copious fetid discharge.  If it  occurs on the palate, a probe will
detect bare exfoliating bone ; which rapidly perishes and  leaves a hideous
chasm.
   Condylomata or mucous tubercles are soft red fungous elevations of the
surface of the skin, generally situated  about the  anus,  or between the
scrotum and  thigh, or at other parts where two cutaneous surfaces are  in
contact.   They are covered  with a thin cuticle, like that of mucous mem-
branes, and often exude a copious  thin fetid discharge.   They generally
occur too-ether  with  psoriasis or lepra.  This affection is common  in
Ireland, where it is called button  scurvy, and is believed to be contagious;
which M. Ricord denies, unless  it occurs on the site of a chancre which
has been imperfectly healed.
   Syphilitic Sore Throat.— 1.  The mildest  variety \s  a superficial
  • This cut exhibits the crusts of rupia; from  a cast in the King"s College Museum 
200
SECONDARY SYPHILIS.
excoriation of the  mucous membrane of the tonsils or some other part of
the mouth or fauces, corresponding to psoriasis on the  skin.   The parts
affected are swollen and sore;  sometimes  red  and  raw, and sometimes
covered with a white secretion, or with  a  patch of thickened  epithelium.
This state may be  succeeded by a superficial ulceration.
   2.  The excavated ulcer looks as if a piece had been scooped out of the
tonsil.  Its  surface is foul  and yellow,  its edges raised, and ragged,  and
swelled.   There is remarkably little inconvenience from it, and very little
constitutional affection, unless it be  attended with eruption likewise.
   3.  The sloughing ulcer begins as a small aphthous  spot, which rapidly
ulcerates, and is attended with great pain  and fever.  The surface of the
ulcer  is covered with an ashy slough,  and  the surrounding mucous mem-
brane is dark, livid, and  swollen.   The lingual artery may be opened  by
the spread of the  ulceration, and  the  patient may die  of  haemorrhage,
unless the common carotid  is tied.
   Syphilitic  Ulcerations of the nose and palate commence with ulcer-
ations of the mucous membrane, similar to those of the throat, which may
denude the  periosteum, and then produce exfoliation of the bones, with
profuse fetid discharge  and  odious deformity.  Ulceration  of the nose
generally begins with a sense of heat,  and  dryness, and snuffling.
   Syphilitic ulceration of the larynx is mostly caused by an extension of
ulceration from the palate.   It is characterized by tenderness,  great husk-
iness  of voice (which frequently degenerates into a mere whisper), suffo-
cative  cough,  and  expectoration  of bloody purulent matter; — there is
great loss of flesh and strength, and  life is  often terminated by  suffocation.
   Syphilitic  Disease of  Bone  most frequently attacks the  tibia, ulna,
os frontis, clavicle, and other superficial bones.  It commences with ten-
                                      derness of the affected bone, and
                                      severe pain, which begins in  the
                                      evening,  and  lasts  almost   all
                                      night, but ceases in the daytime.
                                      The pain  is shortly accompanied
                                      with  oblong swellings,  called
                                      nodes, arising from infiltration of
                                      the  periosteum with  lymph and
                                      serum.   These   swellings   are
                                      rather tender; they communicate
                                      a doughy feeling,  or  obscure
                                      sense of fluctuation to the fin in is;
                                      and  the skin over them is at  first
                                      pale and  moveable.  If the  dis-
                                      ease is  arrested at  this  stage, it
                                      causes merely  a superficial  de-
                                      posit of rough porous bone, from
                                      the  organization  of  the lymph
                                      effused ; or else a  consolidation
                                      of the bone itself through the  de-
                                      position of fresh  osseous matter
                                      into  its  cancelli.   If the disease
proceed one step further, a quantity of glairy serum is  effused between the
periosteum and bone, producing an  exquisitely painful fluctuating tumour.

 • This cut shows the  ravages of syphilitic caries.  From the King's College Museum.
 
SECONDARY SYPHILIS.
2Ul
If it advance still further, the bone  becomes  carious; matter forms be-
tween it  and the periosteum;  ex:ensive exfoliations ensue; the patient
suffers severely from the pain and discharge ; and if the disease be seated
on  tne head, (in which situation it is called corona  veneris,) death may
ensue from irritation  of the dura mater, or protrusion of the brain through
apertures in  the  skull.   Such aggravated cases are fortunately, however,
now very rare ; although common enough when mercury was supposed to
be the only means of stopping the ravages of the disease.
   Diagnosis.—There is  often  some difficulty thrown into the  surgeon's
way, by  the denial of patients that they have ever had any primary symp-
toms.  If, however,  the  patient has  a copper-coloured  eruption, a sore
throat, falling off of the hair, and  a  general  faded unhealthy  look, and
these disorders are of recent date, and cannot be attributed to any causes
connected with diet or residence, the probability is that they are syphilitic.
   Treatment.—In the first place, if  a venereal eruption  and sore  throat
are ushered  in with pain in  the chest and other febrile or inflammatory
symptoms, it will be necessary to give aperients, and saline medicines with
antimony, and to restrict the diet, and confine  the  patient to the house.
The warm-bath will also be highly useful.
   When the febrile  state has vanished, if the  patient has never taken a
course of mercury,—or if he has been subjected to an imperfect course
of it for  the primary symptoms,—and  his constitution is  sound, he may
take mercury after the manner directed in the  fifth  section.   If, under its
use, the strength and general appearance are improved, so much the better;
—but if the  patient gets thinner, weaker, and haggard, and  suffers from
chills or feverishness, or if his ulcers become irritable and phagedaenic, it
must be given up.   The corrosive sublimate in very small doses, and not
carried to the extent of affecting the mouth, will often be  of great service
when a full course of the mineral is inapplicable, F. 42.
   The iodide of potassium is the remedy next in efficacy to  mercury, and
should be administered when the former is deemed inexpedient.  F. 50, 51.
Sometimes it is useful to combine it with iodine, F. 44.
   Sarsaparilla, F. 40, 41, is a  remedy that may almost always be used
with  advantage.  It may be combined with  corrosive sublimate  or the
iodide of potassium ;  or may be administered after a course of those reme-
dies, to  restore the flesh and strength.   The mineral  acids,  especially the
nitric ; F. 39 ;—sedatives, especially  hyoscyamus and conium ; F.  50 ;—
tonics' F. 1, 2,  3, 4, 5 ;—and tartar emetic in minute  doses, F. 36, will
be all of service in protracted cases.   In  these the surgeon will find  it
necessary to  change and vary his remedies repeatedly.  The main  object
should be to improve the general look and condition of the patient,—to
treat symptoms,—never to push a remedy, if it does manifest harm, under
the vao-ue idea that it is specific ; and, never attempt to  produce sudden
benefi?by large doses of mercury, or other violent remedies, which may
weaken  or impair the constitution.
   Local  Treatment.—Fox syphilitic  eruptions, the warm,  vapour,  and
sulphur  baths will be often expedient.  Obstinate patches of lepra or
pimples  may sometimes have their removal hastened by ung. hydr. nitratis
diluted,  or  the  ung. hydr. precipitati albi,  or the ung. picis.  Itching
eruptions may often be relieved by a weak lotion of corrosive sublimate.
Ulcers must  be treated  according  to their condition—whether inflamed,
irritable, or indolent.  In general, weak  mercurial applications, such as
black wash,  or weak red precipitate ointment, answer best. 
202
SECONDARY SYPHILIS.
   Condylomata are, according to Ricord, best treated  by washing them
with a solution of chloride of soda, and then sprinkling calomel over them,
and applying dry lint.
   For the common excoriated sore throat, any soothing detergent gargle
will do—F. 80, 81.  When there are ulcers, it is advisable to use gargles
of corrosive sublimate ;—(gr. i. ad. 3iv.;) and when  the ulcers are indo-
lent they may be touched with the linimentum eruginis.  Mercurial fumi-
gation is also occasionally of benefit.   It is effected by putting a scruple
of red sulphuret, or of the common black oxyde, or twice the quantity of
mercury with chalk, on a heated  iron  in a proper apparatus, and  inhaling
the vapour—a heated pennypiece in  a teacup will answer the purpose.
When a foul ulcer is seated on the velum, or roof of the  mouth, or pha-
rynx, or alae nasi, an attempt may be made  to check its ravages, by de-
stroying its surface and edges with nitric acid.
   Ulceration of the larynx is occasionally benefited by similar fumigation ;
but mercury so as to affect the mouth is almost always injurious ;—as it is
in other cases of rapid  ulceration.  Sarsaparilla and sedatives, blisters to
the throat and occasional leechings, and the operation of tracheotomy, if
the breathing becomes much embarrassed, are the necessary measures.
   The pain of nodes is often relieved by blisters, and so  are  rheumatic
pains of venereal origin.  Sometimes it is useful to dress the blistered sur-
faces with strong mercurial ointment and opium.   Acute inflammation of
the periosteum or pericranium, is  sometimes  relieved by a rapid  adminis-
tration of calomel and opium ; although in disease of bone  in general, the
use of mercury requires the greatest caution, and is only admissible if the
patient has a sound constitution, and has never taken a course of it.   It is
peculiarly noxious  when  there is caries of the  bones of the nose.   When
nodes  are very tense and full of fluid, it may be necessary to puncture
them, but this should be  avoided  if possible.   If, during secondary syphi-
lis, the nose becomes tender or painful, the greatest benefit will be derived
from the application of one or two leeches twice or three times  a  week to
the inside of the affected nostril.   At  the same time, the patient should
take  plenty of sarsaparilla, with small  doses  of iodide of potassium, and
should have the benefit of country air, and a nutritious diet.   By these
means, any  further mischief will  sometimes be averted.   If, however, ul-
ceration does occur, it is of  the utmost consequence to remove  any loose
or carious portions of bone, as soon as possible.
   Syphilis of Children.—When a  man  labours  under constitutional
syphilis, it is probable that he may communicate it to  his wrife ;  but, at all
events, if the wife  has it, she may communicate it to the foetus.  The con-
sequence is  sometimes that the infant dies about Ihe fourth  or fifth month,
and the woman miscarries repeatedly.   Sometimes a child is born weakly
and shrivelled, with hoarse voice, discharge from the nostrils, and copper-
coloured blotches or ulcers, especially about the anus and pudenda. Some-
times, again, it is born  healthy, but these symptoms appear a month after-
wards. Lastly, a child may be infected with primary syphilis during its birth.
   The parents in  these  cases should  take  a course of mercury, and be
treated in other respects for secondary syphilis.  And for the children, the
oest pian is to rub  ten grains of mercurial ointment daily into the axilla,
or soles of the feet, or to administer half a grain or a grain  of hyd. c.
creta every night till the symptoms disappear.  The prognosis is always
favourable ; and although the symptoms are apt  to  recur once or twice,
they are in general easily removed by a short repetition of  the remedy. 
PART IV.
OF THE INJURIES AND SURGICAL DISEASES OF VARIOUS TISSUES
                      ORGANS, AND REGIONS.
                          CHAPTER I.

          OF  THE DISEASES  OF THE CELLULAR TISSUE.

             SECTION  I.--CARBUNCLE AND BOIL.

   Definition.—A carbuncle  signifies  an unhealthy inflammation  and
sloughing of a circumscribed portion of the cellular tissue.
   Symptoms.—It begins with  a hard, circumscribed, livid red swelling,
and with severe  burning, smarting pain.  Its  most prominent part soon
becomes soft and quaggy, and numerous small  ulcerated apertures form
on it, which give exit  to  a thin discharge, compared by Sir A. Cooper to
flour and water.   These ulcers  gradually unite, and form  a  considerable
opening, from which a slough of cellular tissue is slowly protruded;  and
wrhen that is separated, the parts may granulate and heal.   The most usual
situations of carbuncle are the  back, the nape of the neck, and the nates.
The tumour may vary in  size from that of a half crown to that of a small
plate.
   Causes.—Carbuncle is always an evidence of a vitiated  state  of the
blood and disorder of the digestive organs; and it usually afflicts  elderly
people, whose health and spirits are impaired by intemperance, or by hard
study, or anxiety  of mind.  It sometimes appears  to be the means by
which some poisonous matter is thrown out of the system ;* in corrobora-
tion of which  idea, Sir B. Brodie mentions a case in which a. carbuncle
disappeared suddenly, and the patient began  to sink and die  at the same
moment.  It is often attended with considerable fever, and almost always
with loss of appetite and  flatulence.   And it  may be attended with great
danger to life, if the patient  is very old or weak—or if  the  carbuncle is
very large, and seated  on or  near the  head, [or on the walls of the  chest,
or of the abdomen, in consequence of the liability to affection  of the brain,
pleura, or peritoneum.—Ed.]
   Treatment.—The  objects of the local treatment are, to afford  a free
exit to slou°ris and discharge, and to excite the diseased tissues to healthy
  * Carbuncles, and unhealthy abscesses, are frequent consequences of what is called
the water cure; and  the Germans  persuade  themselves that they constitute a  critical
evacuation of diseased humours ; but it is far more probable that they are owing to the
exhausted vitality of the skin, which  is so inordinately taxed to relieve the blood of the
immense quantity of water with which it is deluged.
                                                         (203) 
204
CARBUNCLE AND BOIL.
 suppuration and granulation.   In the  first place, therefore, a free incision
 should at once be made completely through the tumour;—and if the tu-
 mour is extensive, it should be scored across by a second incision at right
 angles to  the first.  Then warm poultices should be applied ; and if there
 is much atony about the system,  the yeast poultice, F. 76, or linseed meal
 poultice  mixed  with  a little  port wine, or beer-grounds,  or unguentum
 resinae, will be advisable.   Stimulating ointments and lotions,  especially
 the nitric  acid lotion, F. 60, will complete the cure.  [Dr. Physick strongly
 advised the application of  caustic potass, in order to destroy the skin, so
 soon as any disposition to  the formation of sloughs has become manifest
 He found that the patient's sufferings ceased when the pain caused by the
 action of  the caustic had subsided, and that the cure was  effected much
 more speedily than when the skin was allowed to slough spontaneously,—
 the caustic producing  a  healthy change in the character of the inflamma-
 tion.   It is much better, however, that the skin should be preserved, if
 possible ;  and therefore, when  this seems practicable,  the sloughs should
 be allowed to  escape through  a crucial incision, as recommended by Mr.
 Druitt, rather than by the plan proposed by Dr. Physick.
   The latter distinguished  surgeon also suggested that the  application of
 a blister to the inflamed skin  might  arrest the progress of  the disease, by
 circumscribing the gangrenous inflammation.  This  should not be relied
 upon, however, to the  exclusion of the more certain method above noticed
 See  Chapman's Journal of the Medical and Physical Sciences, vol. ii.,
 1821.   Also Art. "Anthrax," Am. Cyclopaedia of Pract. Med. and Sur-
 gery.—Ed.]
   The indications for the  constitutional treatment are, first, to evacuate
 and correct the secretions of the  alimentary canal.  This is to be effected
 by purgatives, which should be given  in repeated doses, till the motions
 become light yellow and bilious,  instead of dark, grumous, and offensive;
 —or, at all events, as  long as the patient  feels  lighter and better under
 their  use.   If the patient  is  tolerably vigorous, calomel  and the black
 draught will suffice ; but in general it will be better to use a few doses of
 blue pill,  and the warmer  aperients, such as rhubarb, and  decoction of
 aloes, with ammonia, F. 17.  Very often an  emetic, composed of a scruple
 of ipecacuanha, followed by a cupful of warm camomile tea, or F.  120,
 will be of service.  If there  is much  fever and  a pretty good pulse, the
 patient may take the liq. am. acet., or effervescing saline  draughts;—but
 more frequently, bark with  the mineral acids, or ammonia, or camphor, or
 small doses of opium, (F. 1, 2, 3, 4,) will be  necessary to support the
 strength ;  together with wine, beef-tea, &c.
   Boils are miniature  carbuncles.  The best plan is to cut them through
 as soon as possible, poultice for a day or two, and then apply stimulating
 plasters ; such as the empl. galbani, vel ammoniaci.  A few doses of mild
 aperient medicine should be given ; and if they continue to  come out in
successive crops, a course of alteratives, such as Plummer's pill, sarsapa-
rilla, saline, or sulphurous mineral waters, and sea-bathing;—but the liq.
L-otassae, or sodas carb., in  moderate doses, three  times a day, are gene-
rally considered  of  most utility.   " I  was  myself always  troubled  with
 boils," says Hunter, " until I took forty drops  of this lixivium (of soda)
night and  morning in milk  for two months, when all my boils disappeared^
and I have since had no return of them."*
                   * Lecture* in Palmer's Ed., vol. i. p. 610. 
TUMOURS.
205
                    SECTION II.--TUMOURS.

  I. The Common Vascular Sarcoma, ox simple fleshy ox fibrous tumour,
 s a yellowish-white, firm, fleshy, or fibrous mass ;—with few blood-vessels;
—often surrounded with a coat of condensed cellular tissue;—and some-
times containing irregular patches of bone or cartilage.   When examined
microscopically, its structure is seen to be identical with that  of natural
fibrous tissue, and the fibres are arranged concentrically;—not rectilinearly
as in scirrhus.   If boiled, it yields gelatine; scirrhus does not.
  Its formation is supposed to be owing to the organization of lymph. In
external character, it is a firm, lobulated tumour, circumscribed, moveable.
and free from tenderness, unless accidentally  inflamed.  It  is also free
fiom pain, unless it press upon some sensitive part.   It  grows slowly but
steadily, and when it has attained  considerable bulk, the veins on its sur-
face become enlarged and tortuous.   The favourite seats  of this  tumour
are the  subcutaneous  and  submucous cellular tissue, and especially that
of the womb.   As to its consequences, first, it may last  the whole life of
the individual, without any ulterior consequences.   Or (2) it may, by its
enlargement, inflame the skin, or mucous membrane covering it, and cause
obstinate and dangerous ulceration ;  or may even  slough out entirely. (3)
It may produce sundry inconveniences, or even death, by pressure on va-
rious parts.
  Diagnosis.—It is known from  abscess or inflammatory tumour by its
slow, but steady,  and painless enlargement.  To distinguish it from malig-
nant disease, the  points to be attended to are, " the  effect upon the con-
stitution ;" that is, the presence or absence of the cancerous  cachexia;—
and the extent  to which the tumour is connected with the surrounding
parts.*   For the non-malignant  tumour can  generally have  its outline
traced, and  the line of separation between it and  the neighbouring parts
clearly made out; and the  skin or mucous membrane  can be made to
move freely over it.   Not so in the case  of a  malignant tumour.  It  is
often stated that  these tumours may degenerate into scirrhus, or take on
malignant ulceration;  but  Dr. Walshe believes,  that  though the ulcers
arising under the circumstances stated above may  be  dangerous or intract-
able, yet that a real malignant growth is seldom if  ever deposited in fibrous
tumours.  The proper treatment is extirpation with the knife.
  II. The Fatty Tumour consists of lobulated masses of fat, very slightly
vascular, and contained in  a cyst of cellular tissue.  In  external character,
it is a softish, lobulated, painless tumour, feeling  like fat.  Its  growth  is
slow, but progressive ;  and it may attain enormous  bulk, even forty pounds.
Its  terminations may be the same as those  of the  last-named tumour, an 1
its treatment should be also the same.
   Operation.—An incision—rather too long than too  short—should be
made along the tumour, and through its cellular cyst.   If the skin adhere
to it, (but not otherwise,) a portion may be removed by two elliptical inci
sions.   Next, the tumour should be removed as rapidly as possible, partly
by cutting its  cellular  adhesions, partly by tearing them with  the  finger. m
Then the wound  should be examined to ascertain that the extirpation  is
complete ;—and after bleeding has ceased  it should be closed, and healed
by the first intention.   Sometimes fatty tumours may be  removed by pass-
  • See the points of diagnosis instructively stated in Fergusson. op. cit. 2d Ed. p. 144
       18 
206
TUMOURS.
ing a seton through  them, so that  they may waste  away in suppuration
This method  is more tedious and painful than  excision, but it may be
adopted when it is an  object  to avoid  a long  cicatrix,—on the face lor
example.
   III.  Encystkd Tumours, or Wens, occur most frequently under the skin
of the  head.   They consist of a sac, smooth on its internal surface,  and
containing various matters, which,  if examined under the microscope, are
found to consist of epithelial  cells, oil globules, and crystals of stearine.
These  are secreted by the lining membrane of the sac, which is in all pro-
bability an obstructed  sebaceous  follicle of the skin.   The contents  are
sometimes like  curd or rice, (such tumours  being formerly called athe-
roma;)—sometimes like suet, (steatoma;)—sometimes like honey, (rneli-
ceris;)—sometimes  mere water—sometimes hair,  or matter  like  horn.
These  tumours  are  painless, rounded, elastic, circumscribed, moveable,
and they fluctuate indistinctly, according to the greater or less  fluidity of
their contents.   They enlarge slowly and steadily.*
   Treatment.—Extirpation is the only remedy.   Punctures, setons,  injec-
tions, or any means for obliterating  them by  exciting inflammation, are
very hazardous;—because these cysts (like all  new textures) are liable, if
irritated, to give rise to excessive and dangerous inflammation.   Ointments
of iodine, or other substances for creating absorption, are perfectly useless,
and may be mischievous.  If, however, the tumour is  small, its aperture
(a little black  spot) should be looked for, a probe  may be  passed into it,
and the contents  be squeezed out as  often as necessary.   Otherwise,  a
straight, double-edged, pointed bistoury should be  thrust  completely
through the tumour, then the cut edge  of the sac should  be  seized with
forceps, and the whole of it be dissected out.
   IV.  The Painful Subcutaneous Tumour is a small hard body, rarely
larger than a pea or coffee berry, seated immediately under the  skin, liable
to fits of excruciating pain, and supposed  to be formed in  the substance
of a nerve.  It must be extirpated.  The  removal of  such  a tumour from
the breast has cured an obstinate hysteria.f
   V. Malignant Growths.—The subcutaneous cellular  tissue may be
the primary seat of malignant growths, which run the  ordinary course of
such affections.   And in some rare cases nodules of scirrhus or encepha-
loid have been formed in extraordinary numbers  over the  surface of the
body,  giving rise to great diversity of diagnosis.!
  • Vide Erasmus Wilson"s paper in the Med. Chir. Trans., vol. xxvii.
  f Wood in Edinburgh Med. Chir. Trans., vol. iii.  Lond. Med. Gazette, vol. vi. p 59
  j Vide Ancell on a remarkable case of tumours, Med. Chir.  Trans., vol. xxv.;  Dor1
rington, on a case of disseminated globose  carcinoma, Med. Gaz., Feb. 4, 1842 : Harrison,
 6, Feb. 24,  1843; Walshe, op. cit. p. 575. 
SURGICAL DISEASES OF THE SKIN.
207
                         CHAPTER  II.

            OF THE SURGICAL DISEASES OF  THE SKIN.

  I. General Hypertrophy.—The skin may grow into pendulous flaps
or ridges, which,  if inconvenient, are to be removed by incision."
  II.  Warts or vegetations, consist of elongated  papillae of the cutis vera,
clothed with cuticle.  When they are situated on an  exposed part of the
skin, the cuticle is thick, and they are generally dry, hard, and insensible;
but when they are situated at the upper part of the thigh, where two sur-
faces  of the  skin are in contact, their cuticle is thin, and they exude a
serous discharge, which is contagious.
  Causes.—They may be produced  by the  irritation  of diseased secre-
tions ; and hence frequently follow gonorrhoea and syphilis, especially in
women ; but although their secretions are contagious and may cause fresh
crops of warts to  appear, yet they have  nothing of a syphilitic nature, and
require no mercury.  They often come  on the hands of children, and dis-
appear without any assignable cause.
   Treatment.—If their shape permit, they may be snipped off or tied;—
or if  in very inconvenient situations, (as about the finger nails,)  may be
cut out;—but the surface from which they grew  requires some astringent
to be frequently applied, in  order to prevent their reproduction.   If they
cannot be removed in this manner, they may be  destroyed by stimulants,
of which the following are the most generally used: viz. one drachm of
muriatic acid with three  drachms of muriated tincture of iron;—liquor
plumbi  diacetatis ;—liq.  hydrarg.  oxymur.;—liq.  arsenicalis ;—liq. alu-
minis comp.;—nitrate  of silver;—equal parts of powdered savine and
verdigris;—one  drachm  of arsenic dissolved in  half  an ounce of nitric
acid ;—and the juice of garlic, spurge, or sumach.*
  III. Corns are growths  of thick cuticle, and  are  produced when the
skin,  situated over some projecting point of bone,  is irritated by frequent
pressure or friction.   It need scarcely be said that their usual seat is on
the joints of the  toes, and that tight boots or shoes are their usual cause.
They are divided into  two kinds, the  hard  and the  soft.  The hard are
situated on the surface of the foot, where the cuticle can become dry and
hard;—the soft between  the toes, where the cuticle is soft and spongy.
We must observe, however, that what are commonly called soft corns be-
tween the toes, are not corns, but excessively irritable fungous warts, and
consist of a growth from the cutis vera ; not of a mere thickening of the
cuticle.   According to  Sir B. Brodie, when  a corn is completely formed,
a minute bursa is developed between it and the cutis vera.f
   Treatment.—The points to be  attended  to  are, to  have the boots or
shoes properly adapted  to the shape  and size of the foot;—to bathe the
feet frequently in  warm water; to cover the corns constantly with a plaster

  * Brodie, Lecture  on Mortification, Med. Gaz. vol. xxvii.
  f Brodie, Lecture on Corns, Med. Gaz. vol. xvii. p. 775;  Key on Bunion, Guy's Hosp.
Rep. vol. i. p. 416. 
208
TUMOURS  OF  THE SKIN.
 composed of  equal  parts of soap plaster and  oil, spread on kid leather;
 or, if they are very tender, with a bit of linen thickly spread with sperma-
 ceti ointment, so  that they may be kept  soft and pliable, not hard  and
 dry ;—and to remove the growths of cuticle frequently with a blunt knife.
 If these directions are attended to, a cure may be confidently promised in
 ordinary cases.  But some feet are so misshapen originally, or the toes are
 so  crowded  together by wearing small, low, pointed shoes, that it is im-
 possible to contrive  any shoes  that will not press and create corns  some-
 where.   In some of these cases the  application of several plasters of thick
 soft leather, each  having a hole punched in  it to receive the corn and
 relieve it  from pressure, is a very useful device.   But if the corn is on the
 sole of the foot,  it must be covered  wuth a piece of  adhesive  plaster
 spread  on linen, before  the  circular plasters are  applied, otherwise the
 weight of the  body will cause the flesh to bulge  into the  holes, and occa-
 sion much pain in walking.  Sometimes it is useful to put a sole of felt
 into the shoe, with a hole in  it to receive the corn.  If the cuticle is  ex-
 cessively  hard, its exfoliation  may be hastened by rubbing it with nitrate
 of  silver,  or liniment  of ammonia, or by touching  it with a hair pencil
 dipped  in strong nitric  acid, or the chloride  of  antimony.  For the soft
 corns between the toes, the nitrate of silver is the best application.  When
 a corn inflames, and the  bursa between it  and  the skin suppurates, the
 pain is often most excruciating, and only to be relieved by paring it down
 and letting out the fluid.
   IV.  Horny Tumours are formed  by an inspissation of the matter  of the
 sebaceous follicles,  and  by laminated growths  of epithelium  from their
 interior.   They are easily removed by two oval incisions.*
   V.  Cheloid  Tumour. — Under  this name  is described  a peculiar
 tumour, consisting apparently of a thickened reddish patch of skin, partly
 covered with  a thin wrinkled epidermis, and  generally found  in  clusters
 on  the neck and breast.   This disease is rare ; and seldom or never leads
 to ulceration,  although it is occasionally the seat of shooting pains, f
   VI.  Tumours of Cicatrices.—The coloured races of  mankind are oc-
 casionally liable to an  hypertrophy of the skin  at the site of some old
 cicatrix.   Extirpation with the knife is the only remedy.
   There is another  affection, which Mr. Caesar Hawkins has  designated
 the warty tumour of cicatrices, which occasionally appears on old  scars.
 "There appears, in the  first  place,  a little wart, or warty tumour in the
 cicatrix, which is dry and covered with a thin  cuticle, but which soon be-
 comes moist, and partially ulcerated, like the warts of mucous membranes,
 from which a  thin and  semi-purulent fluid is secreted.   In this  stage it
 gives no pain nor inconvenience."   After a time the warts are converted
 into a more solid tumour like fungus haematodes, very vascular, and easily
bleeding when touched.   And this finally ulcerates or sloughs, forming a
foul excavated ulcer, with fresh growths of warts around it, which may de-
stroy the  patient by  its constant irritation and discharge.   This affection
belongs to a class termed  semi-malignant.   The remedy is extirpation with
the knife;  or amputation  of the  affected limb, if the  diseased growth  is
very extensive ;  and the  patient may be confidently assured, that if tho-
roughly extirpated it will not return.:]:
  * Vide Erasmus Wilson, Med. Chir. Trans, vol. xxvii.
  f Warren  on  Tumours, p. 40; Burgess's Translation of Cazenave, p. 305; Mayo'i
Pathology, p. 236.                * Cu-ar Hawkins, Med. Chir. Trans, vol  xix. 
LUPUS.
209
  VTI. Malignant Disease.—When  the  skin is primarily affected with
malignant disease, it is generally found either near one of the natural ori-
fices of the body where there is a great abundance of follicles, (as the lip
or glans penis,) or else on some part of the face or neck.
  It may commence in three forms,—1st, As a  small tubercular deposit
of scirrhus, generally of a reddish or dirty grey hue, which, after continu-
ing perhaps for  years in an indolent or slowly enlarging state, becomes
irritated, and degenerates into  a cancerous ulcer.   2d,  In the form of in-
filtration of a portion of skin with  scirihous matter, producing a darkish
thickened appearance,  something like  a mole.   This generally soon be-
comes covered with a  crust of cuticle, resembling the bark of a tree,
(whence Dr. Warren applied the term lepoides  to  this affection);  under
which, in process of time, ulceration slowly  proceeds.   3d, Sometimes a
chap or fissure, arising apparently from accidental causes, assumes a hard-
ened scirrhous base, and becomes a genuine  cancer.
   Treatment.—The general characteristics of cancer of the skin, are ex-
treme slowness of growth; and less than the  ordinary liability to contami-
nation of the viscera.   Therefore there is  much  to hope for from extirpa-
tion ;—and it seems agreed upon that the best instrument  of  extirpation
for superficial non-adherent cancer  of  the skin is caustic, if  it can be  con-
veniently used;—either the chloride of zinc or arsenic.   The latter mineral
may also be administered internally, with a prospect of benefit.
   The surgeon should deal in the same manner with moles (oblong patches
of imperfectly organised skin with  black matter  in its interstices), warts,
small vascular patches, and other  congenital imperfections of the skin, if
at any time they seem inclined to spread and become irritable;  because it
is possible that they might become  the nidus of malignant growths.
   We have spoken of a class of diseases which may be  called semi-malig-
nant; which, although incurable if left to themselves, destroying the tissues
in  which they are situated, spreading progressively, and destroying the
parts in their vicinity, and finally
fatal to  life from constant irrita-
tion, still are not really malig-
nant ;—because  they do  not at-
tack the lymphatics, do not ap-
pear in  several  remote organs
simultaneously,  and do  not  re-
turn if effectually removed.   To
this class belongs
   VIII.  Lupus — a destructive
ulceration of the skin commenc-
 ing with tubercular inflammation.
 There  are  two  forms; 1st,  the
 genuine lupus, herpes exedens, or
 noli me tangere; and 2dly,  the
 herpes, or lupus  non exedens.
   1. Lupus exedens.—A portion
 of the skin  of the face (mostly on
 or near the alee nasi) inflames,
 swells, and becomes of a bright
 red tint.  The swelling frequently
 occurs in the form of one or more
        18*
Fig. 23.
 
210
LUPUS.
 tubercles; not however indurated  like scirrhus.   The  inflamed surface
 sooner or later becomes excoriated, and secretes an ichorous matter which
 dries into a scab.  After a time, a painful, foul, excavated ulcer forms;—
 variable in its progress, sometimes stationary, or partially cicatrizing;—but,
 in the end, destroying the  flesh of the nose and cheek; and causing caries
 and exfoliation  of the bones:—till  the patient,  a horrid spectacle, dies
 worn  out with pain ;—his eye dropping from  its socket into  the chasm
 made by the destruction of the cheek.   This affection mostly occurs to
 adults;—especially if of weakly scrofulous habits, vitiated by intemperance
 and gross feeding.
   2. The lupus non exedens is a milder form, and attacks scrofulous chil-
 dren.  It begins with shining tubercles, which ulcerate ;  but the ulceration
 has  a tendency to spread widely, rather than deeply;—causing  prodigious
 deformity by the successive  ulceration and puckered cicatrization of the
 face.
   Treatment.—The indications are,  1st. To correct the general health by
 opening the bowels, keeping up the secretions,  promoting  appetite  and
 digestion, and allowing a regular nutritious diet.   A course of Plummer's
 pill, with alkalies and sarsaparilla ; or of the liq. arsenicalis in small doses,
 or in scrofulous cases of the iodide of potassium, will generally  be of great
 service.
   2dly.  To  alter the diseased action by stimulants.  If ulceration has not
 commenced, the part should be rubbed frequently with nitrate of silver,
 so as to keep it constantly covered with a black crust.   If ulceration  has
 commenced, the nitrate may be applied in the  same manner; — or in the
 form of  a lotion.   But the best applications for  ulcerated  lupus are the
 arsenical.  Now, arsenical  applications should be  either very weak or very
 strong;  they should  either produce mild stimulation or sphacelus.  They
 should either be so weak as not to do  any harm  if absorbed into the blood;
 or so strong as immediately to kill the part they are applied to, and so to
 reader it incapable of absorbing them.   The weak may be tried first — in
 the form of F. 63, in order to act as  a mild stimulant and alterative.
   3dly.  But if these  measures do not speedily succeed,  the diseased  sur-
 face must be destroyed by escharotics, of which arsenic and the  chloride
 of zinc are the best.  The arsenic may be applied in the form of ointment
 or solution (3i. ad 3i.)  on  lint, suffered to remain four or five hours.   The
 chloride  of zinc is a highly deliquescent salt, and is therefore ingeniously
 lecommended by Mr. Ure, who  introduced its use into England, to be
 combined  with  two parts of fresh burned plaster of Paris, or it may be
 mixed with flour.   In either case it is to be made  into a paste with a little
 water, and  be spread  accurately with a spatula on the  diseased surface,
 and  allowed to remain for four or five hours.   It causes severe pain for
 eight or  nine hours, which, however, may be relieved by opium.  -When
 a suspicious tubercle  is increasing rapidly, but  not ulcerating, it should
 also  be destroyed with the chloride;  but in this case the cuticle should be
 fiist  removed wTith the liquor ammoniae.
  Caustic  pastes may also be made with two parts of powdered potassa
fusa, and one of soft soap ; — or of three parts  of quick-lime, and two of
 diy soap, moistened at the  time of using with spirits of wine ;—or of three
 pa'-ts of  caustic "potass and two of fresh burned  lime incorporated in a hot
 iron  mortar.  The last is  called the Vienna paste;  the lime is useful in
 correcting the  deliquescent and diffusive power of the potass.  When 
ATROPHY  OF MUSCLES.
211
either of these caustics is used, the neighbouring sound parts should be
protected by, layers of sticking plaster.
  After the sloughs have separated, which generally happens in from six
to twelve days, according to their depth, the surface must be treated with
a weak  solution  of nitrate  of silver; but  as often as there appears any
return  of the  ulcerative orocess, the caustic must be  applied again and
again.*
                        CHAPTER  III.

   OF DISEASES AND INJURIES  OF  MUSCLES, TENDONS, AND
                               BURSiE.

  I.  Atrophy of Muscles.—Two forms of atrophy of muscles may come
under the  surgeon's  observation.  The  first, which may be called rigid
atrophy, is a state in which a muscle becomes short, rigid, and inextensi-
ble;  and it generally, by its shortening, causes various displacements and
deformities of the parts to which it is attached ;—thus club-foot is a conse-
quence of this condition of the muscles of the calf.
   Causes.—This state of rigid atrophy may be a sequel of various circum-
stances.   1st. It may be induced by long inactivity of a muscle ; — thus,
after long-continued disease  of  the knee, the flexor muscles of the1 ham
may become  shortened and  inextensible, keeping the joint permanently
bent, and often  dragging the tibia off from the condyles of  the femur.
2dly. It may be a  sequel of a species of subacute inflammation, which
occasionally affects muscles or their investing fasciae, and which is attended
with pain, tenderness, and spasm.   3dly.  It may be a sequel of habitual
spasm, by  whatever  cause  produced.  4thly. It may arise from defective
innervation ; that is, from  a  want of nervous energy.  It sometimes hap-
pens, that  after a fever, one arm, or one leg, or both legs are deprived of
the power  of motion.   The  affected  member is always chilly ;  its skin is
numb ;  it is imperfectly nourished, and decreases  in bulk; if  the patient
is young, it ceases to grow in proportion with the  other parts of the body;
and  its flexor muscles become affected with this form of rigidity, so that
the joints are immovably bent and contracted.
   Treatment.—In the earlier stages this affection may be relieved in va-
rious ways.  By cupping, fomentations,  or the  steam bath, and subse-
quently blisters over the affected muscles, if there  is any evidence  of local
inflammation.  By purgatives and other constitutional measures, if the
spasm appears to arise from  disordered bowels  or any other  sympathetic
source.   By stimulating frictions, affusion with  cold water, passive  exer-
cise, shampooing, extension  upon splints by bandages, and electricity  or
galvanism, if it arise from want of nervous  energy, or if arising from any
other cause it has become chronic.   But in cases of long standing, the
only remedy that can be relied on is division of the affeqted muscle or its
  * Ure  on  Lupus  and  the Chloride of Zinc, Med. Gaz. vol. xvii. and xviii.; and
Cyclop. Pract. Surg., Art". Cauterants ; Earle, Med.  Chir. Trans, vol. xii.;  Travers,  ib
vol. xv.; Burgess' Trans, of Cazenave, p. 250 ;  Brodie, Surgical Lectures; Walshe, ow
oit p. 548; Liston, Lectures in Lancet, 1844, vol. i. p. 775. 
212                DISEASES  AND INJURIES  OF
tendon ;  by which  means the divided parts will retract; they will  unite
by lymph, and will consequently be  lengthened, and then extension and
the other measures may be pursued with greater vigour and efficacy.  (For
further illustrations  refer to Club-foot .and Wry Neck.)
  II. Acute Atrophy.—In  this affection, one or  more muscles rapidly
waste away, and their wasting is  attended  with severe pain, especially
in the course  of their nerves.  It  appears to depend on a  rheumatic in-
flammation of the muscular nerves, and to be caused by exposure to cold.*
  III.  Rupture of Muscles and  Tendons.—This is an accident which
is frequently caused by violent muscular contraction; especially if,  after
illness or long inactivity, the  muscles are subjected to sudden and severe
exertion.  The muscles which  are most  frequently ruptured are, the gas-
trocnemius and biceps flexor cubiti;  but  more frequently the tendons give
way, especially the tendo Achillis, and flexor tendons of the wrist.   " It
occasionally happens," says Mr. Liston,  "to gentlemen  of  mature years,
who, forgetting these, join in the sports of youth as they were wont to do;
suddenly they suppose that some one has inflicted a blow on the leg from
behind—their dancing  is arrested, the foot cannot be extended, and the
nature of the case is forthwith evident to  the most careless observer."!
  The symptoms of this accident are, sudden pain,  or sometimes an  audi-
ble snap, loss of the motion  peculiar to the muscle, and a depression at
the ruptured part, which may be felt with the fingers.  The  reparation is
effected  by the effusion  and organization of lymph, which forms a callus
like that of broken bone.

          Fig. 24.
                              Treatment.—The main point is to keep
                           the injured muscle in a state of constant rest
                           and relaxation, so that the severed ends may
                           be in  close  approximation,  and to prevent
                           any violent extension till the union is firmly
                           consolidated.  Pain and inflammation must
                           be counteracted  by leeches, and cold  or
                           warm  lotion.  When  the tendo Achillis, or
                           the gastrocnemius muscle is ruptured, the
                           knee may be kept bent by a string passing
                           from  the  heel of the  slipper to a bandage
                           round the thigh.   For ruptures of the  exten-
                           sors of the thigh, the limb must be placed in
                           the same position as in fracture of the patella.
                           If the biceps is ruptured, the elbow must be
                           kept bent to its utmost;—if the tendons about
                           the wrist or fingers, the forearm must be con-
                           fined oy a  splint.  After three or four  weeks
                           of this rest, the surgeon may use passive mo-
                           tion ; that is, may bend and extend the joints
                           of the injured limb with his hands several
                           times successively.  But the patient must be
                           cautious in using the muscle  for a long time;
                           and (if it be  the  tendo Achillis)  must walk
                           with a high-heeled  shoe for two  or  three
  • Two cases of it are given  in Mayo's Pathology, p. 117.   The author has seen
leveral, which all attempts have failed to cure.
  f Listen's Practical Surgery, 3d ed.  A case  of ruptured rectus femoris is related la
the Med. Gaz., Oct. 10th, 1841.  It did not unite.
 
MUSCLES,  TENDONS, AND BURSjE.
2t3
months;  so that the  recent callus may not be stretched and lengthened,
which would cause permanent weakness.
  IV. Strains.—A strain signifies a violent stretching of tendinous or
ligamentous parts, with or without rupture of some of their fibres.   It pro-
duces instant severe pain, often attended with faintness;  and great tume-
faction and ecchymosis ;  with subsequent weakness and stiffness.  If the
part is not kept at rest, or if the knee or some other large joint is affected,
there will be  great pain, inflammation,  and fever, that may lead to serious
or even fatal  results.
   Treatment.—The most essential measure is perfect rest; and to ensure
this, if the case is at all serious, the  part must be confined by a pasteboard
splint.   Warm fomentations generally  give  more relief than cold lotions;
but in this, as in similar cases, the patient's feelings are the safest criterion.
If inflammation runs high, or a large joint is affected, leeches, or bleeding,
and general antiphlogistic measures, must be adopted.  Subsequently the
indications are to procure absorption of  thickening and extravasation, by
friction with  stimulating liniments,  moderate exercise, and bandages, es-
pecially the flannel bandage.  If the case  is severe, it may be expedient
to  apply a succession  of blisters, and  the other remedies  directed for
chronic inflammation of joints.
  V. Acute Inflammation of Fascle.—Acute inflammation  of fascice
is generally caused by punctured wounds ;—especially by puncture of the
fascia of the biceps during venesection ;—and by punctures of the fingers,
inflammation of the tendinous sheaths of  which is called thecal abscess;
paronychia gravis, or tendinous whitlow.  It is  attended with severe, ten-
sive, throbbing pain ; exquisite tenderness ; slight, but tense and resisting
swelling; and very great constitutional disturbance.  It may lead to sup-
puration ;—the matter extending itself along muscles and tendons—from
the fingers to the forearm—causing sloughing of the tendons—severe irri-
tative fever—life often obliged to be  saved by amputation—or the limb,
if preserved, stiff and useless.
    Treatment.—If the pain and tension increase, notwithstanding the  em-
ployment of leeches, fomentations, and purgatives, free incisions must be
made through the inflamed parts; in order to  give vent to matter, if it
have formed—or by creating a free  discharge  of  blood, to prevent its
formation.*
    VI.  Subacute  Inflammation  of  Fascia.—Subacute  inflammation
sometimes affects the fasciae of the forearm,  hand, or neck; producing
pain and tenderness, with spasm in the subjacent muscles, which may de-
generate into obstinate rigidity, producing one  form of wry-neck, &c.
    Treatment.—Leeches, fomentations,  blisters,  mercurial  camphorated
liniments, F. 66;  vapour bath;  very small doses of colchicum and Dover's
powder at bedtime, with aperients  in  the morning; or blue pill, adminis-
tered so as to cause incipient ptyalism.
   ATI. Tumours on Tendons and Ligaments.—Small tumours about the
size of a pea are apt to form  on the tendons or fasciae.  Sometimes they
follow a strain ; and they have been known to  occur on the palmar fasciae
after a good day's work at the oar; but they often arise without any as-
signable cause.  If indolent, as they often  are, they may be left to them-
selves, and thev will probably disappear.  If painful, leeches, blisters, and
frictions with mercurial ointment or liniment, are the proper remedies.
                     * Vide Whitlow, in  part iv. chap. 24. 
214
TUMOURS  OF BURSiE.
  VIII. Chalkstone Tumours are composed of the lithate (or urate) of
soda; a white insoluble substance, which in gouty subjects is frequently
deposited  into the texture of the bones,  joints, and  cellular tissue;—but
most frequently into the cellular tissue that environs the tendons of the
feet or hands.  The tumours which this  substance forms are not always
inorganic, but may be permeated by exquisitely sensible threads of cellular

                                Fig. 25.
Fig. 26.*
membrane.  After remaining  indolent for a variable time,  they inflame
the superjacent skin, and cause the formation of ulcers that are extremely
obstinate, and discharge vast quantities of the concretion.   They must be
treated with simple dressings.   It is rarely expedient to meddle with these
tumours  with  the knife; but if any one be very  inconveniently situated,
and be perfectly indolent,  it  may  be  extirpated.  The wound must be
expected to heal very slowly.
  IX.  Ganglion and Tumours  of Bursje.—The  simplest affection of
bursa?  and of the  synovial  sheaths of tendons, is excessive secretion of
              synovia, and consequent tumefaction, to which the  name
              of ganglion is given.   A recently formed  ganglion  is an
              indolent fluctuating tumour,  transparent enough to permit
              the light of  a candle to be seen  through it.   It contains a
              clear synovia;  but tumours of those  bursas which may be
              formed by friction—such  as  the  bursa which forms the
              swelling of bunion, do  not contain  synovia, but a viscid,
              semi-fluid substance, like the crystalline lens.  The ordi-
              nary  situation of ganglion is, of  course, that of the various
              bursa?;—on  the patella, or olecranon ;  or on the inner side
              of the head of the tibia;  or the  angle of the  scapula; but
              most frequently about  the wrist and fingers.  When the
              general sheath of the flexor tendons at the wrist is affected
              in this way, it forms a remarkable  tumour, which projects
              in the palm of  the hand, and also  above the wrist, but  is
              bound down in  the middle by the anterior annular ligament
              of the carpus.  When  ganglion has lasted some time, or
              has been subjected to inflammation, the synovial membrane
              becomes thickened, the  contained  fluid turbid and mixed
              with flakes of lymph, and the tumour loses1 its softness and
transparency.   The ordinary cause of ganglion  is  a twist or strain of some
kind, or  irritation from pressure or friction.
   Treatment.—The  best plan of  treating recent non-inflamed ganglion
seems to be, either to puncture it with  a grooved needle,  or else to make
a subcutaneous incision into the sac ; that is, to introduce  a  needle with a
cutting point,  and to turn the  point against the inside of  the sac and di-
vide it;  without, however, making a  larger wound  in the  skin than is
necessary to introduce the needle.   The object of these  operations is  to
  * This cu» displays a ganglion formed by the synovial sheath of the flexor tendon of
a finger   from the King's College Museum.
 
DISEASES  OF THE  LYMPHATICS.
215
empty the sac, and form an aperture by which its contents may henceforth
pass into the cellular tissue and be absorbed.   As soon  as it is  emptied,
constant pressure should be  applied by means of compress and  bandage,
which may be wetted with cold lotion if agreeable.  2. If this plan fails,
recourse may be had to blisters, friction, with mercurial  and other stimu-
lating liniments; or Scott's ointment, F. 66, or the iodine paint,—(i. e.
iodine rubbed up with just  enough rectified spirit to make it liquid, and
painted on the skin)—with a view of exciting absorption.   3. In obstinate
cases it is a good plan to dissect out the cyst of the ganglion—provided
that it is formed of a mere bursa, (as over the patella  or olecranon,) and
has  no  connexion with the sheaths of tendons.  4.  But if the bursa is
large or deeply seated,  as  over the angle of the scapula, it should be
punctured with a lancet, when it may probably inflame and suppurate, and
heal up like an abscess.  5. In  obstinate cases, especially if the  cyst is
much thickened, Mr. Key recommends a puncture to be made, and a few
threads of silk to be passed through the sac as a seton.   This will create
great suppuration and constitutional disturbance for a time, but it will de-
stroy the secreting power  of the sac, and effect a radical cure.  The less,
however,  that the sheaths of the flexors of the wrist are meddled with,
whether by puncture  or seton, the better.  Mr. Wickham strongly recom-
mends the vapour bath, or local steam bath,  as a means of getting rid of
thickness and  stiffness after these operations.  Lastly, any rheumatic or
gouty tendency should be corrected by proper medicines.
   X*. Acute Inflammation of Burs^e is most frequently exemplified in
the  affection called the housemaid's knee,—which is an acute inflammation
of the  bursa,  that intervenes  between the patella and skin,—common
enough in that class of females, from kneeling on hard damp stones.  It
 causes very great pain, swelling, and fever; it may be distinguished from
 acute  inflammation  of the  synovial  membrane of the  knee-joint,  by
 observing that the swelling is very superficial, and in front of the patella,
 which is obscured by it;  whereas in inflammation of the synovial mem-
 brane of the knee, the patella is thrown forwards, and the swelling is most
 prominent at the sides.
    Treatment.—Rest, leeches, fomentations, and purgatives ; by which if
 the pain and swelling are not relieved, it must be punctured, and treated
 as an acute abscess.*
   XI. Loose Cartilages are sometimes formed in the synovial sheaths
 of the hand and foot.   Their  origin, symptoms, and treatment are the
 same as when they are found in joints.
                        CHAPTER  IV.

     OF THE DISEASES AND INJURIES OF THE LYMPHATICS.

  I.  Acute Inflammation of lymphatic glands has already been exem-
plified when speaking  of bubo.  The inflamed gland  enlarges  rapidly,
and forms a hard, tense swelling, with great pain and fever.  If it suppu-
               •Wickham, Cyclopaedia Pract. Snr- Art. Bursae. 
216
DISEASES  OF  THE LYMPHATICS.
rate, the matter is  formed in the cellular tissue around it, or between rt
and the skin, and the case proceeds as an acute abscess.   This affection
may be caused,  (1.)  By constitutional disorder,  like acute  abscesses.
(2.)  By local violence, such as blows or kicks.   (3.) By the irritation or
absorption  of acrid  matter from  ulcers, venereal or otherwise.   (4.) By
simple  injuries,  a clean prick, for instance,  in  persons whose  health is
derano-ed.   (5.) By punctures inoculated with some irritant fluid, perhaps
from a putrid body.
  When the disease arises from ulcers or punctures, the inflammation
generally begins in the absorbent vessels  leading  to  the glands, which
appear as red lines under the skin, and feel hard, cordy, and tender.
  Inflammation  of the lymphatics,  when  a consequence of  dissection
wounds, may be  distinguished  from  the  diffuse  cellular inflammation
arising from the same cause, (Part. iii. chap, ix.) by the simple  inflamma-
tory character of the constitutional  symptoms.   It  begins with swelling
and festering of the original wound, from which red lines extend up the
arm.   In  trivial cases, these  may stop at,  or may not even  reach, the
elbow; and there  may be very little or no febrile  disturbance.  But, in
severe  cases, the glands in the axilla swell and  become exquisitely pain-
ful ;—there is great fever;—the pulse is rapid, full, and hard ;—matter is
formed; and if it be confined by fasciae, and not  evacuated  by art, the
nervous system may sink under the excruciating pain, and  the patient may
die.   If the matter is discharged, he recovers his health without much dif-
ficulty.  A comparison of these symptoms with those of the other affection
will readily show their intrinsic difference,—although, as was before said,
it is very possible that both may be combined.
   Treatment.—Acute  inflammation of  the lymphatics  arising from local
injury, from constitutional causes, or from the irritation of ordinary ulcers,
must be treated by leeches, fomentations, purgatives, and the other local
and general antiphlogistic measures, that require no comment.   If  it be
produced  by slight injuries, whether in  dissection  or otherwise, the  ori-
ginal wound should  be assiduously fomented, and  the  bowels  should be
cleared.  If the axillary glands  are affected, and  the  pulse is full and
hard, venesection should be performed, and even repeated according to
its influence on the pain and on the pulse ;—calomel should be frequently
administered, and the  swelled parts  should be covered with leeches and
fomentations.   Incisions should  be  made early wherever matter is sus-
pected  to exist, or is likely to be formed—and when fever abates, the
patient's health should be recruited by tonics  and change of air, and care
must be taken to prevent the formation of sinuses.
  II. Chronic Glandular Tumours may arise from simple chronic in-
flammation—from sarcomatous transformation—from deposit of scrofulous
tubercle, and from scirrhus or other malignant disease.
  (1.)  Chronic Inflammation causes a tender swelling, with aching pain,
and slight redness of the skin.   It may be caused by any slight irritation
in the course of the lymphatics, but is more frequently constitutional.
  Treatment.—Repeated leechings, cold lotions, and  aperients, followed
by alteratives and tonics, and empl. hydrargyri,  or ung. iodinii.
  ; 2.)  Glandular sarcoma consists in the transformation  of one or more
glands  (especially in the neck) into  sarcomatous or  fibrous  tumours,
whose  characters and treatment have  been  before described  (p.  205).
These  are to be  distinguished from scrofulous tumours  by the  circum- 
DISEASES  OF THE  BONES.
217
stance, that  one or two glands only are enlarged, and  that they grow
slowly but  steadily;—wrhereas  in  scrofula  a whole  cluster  is enlarged,
and they are subject to fits of swelling  and subsidence, from constitu-
tional changes  or  atmospheric  vicissitudes.   From scirrhus and  fungus
raedullaris they may be distinguished by attention to the diagnostic signs
of those maladies.
              CHAPTER V.


OF THE DISEASES AND  INJURIES OF BONE.

    SECTION  I.--OF  THE  DISEASES.
Fig. 27.
  I. Simple Exostosis signifies a tumour formed by the hypertrophy or
irregular growth of bone.  These tumours are hard, indolent, and irregu-
lar, and  mostly situated on  the  upper part of the hu-
merus, or on  the lower part  of the  femur, near  the
insertion of the  adductor magnus.   Their  shape is
Sometimes  broad  and flat; sometimes rounded and
prominent,  with  a narrow neck.   Their structure is
that of ordinary  bone, either  dense like the  cortical
substance, or porous like the cancelli.   They cause no
pain, unless they happen to press on nerves  or arteries ;
but they may by their bulk interfere with the functions
of various  important parts, and give  rise to the most
serious evils.  When  situated on the inner surface  of
the skull, they may cause epilepsy; in  the orbit they
may cause  the eye to protrude on the cheek;—they
may obliterate arteries, and impede  the action of mus-
cles, and the  movements of joints.   Sometimes they
arise without any very obvious cause; although most
probably they  generally originate in a blow, or strain,
or pressure, which produces a slight degree of inflam-
mation.
   Treatment.—In the first place, an  attempt  may be
made to procure  absorption of the tumour by means
of blisters, friction with ointmerit of mercury or iodine,
and  mercurial plasters.  Sometimes (especially  if  the
complaint follow a blow)  a  moderate course  of mer-
cury, so as  barely to affect the  mouth, will be effectual.
If these measures do not succeed, the tumour must be removed by ope-
ration.  If  it is globular, with  a narrowr neck, it  may be cut down upon,
and be sawn or chiseled off, or cut off with a gouge.  But supposing that
its base is broad,  so  that this cannot be done, its periosteum  may be
shaved off;  after which it will probably perish by necrosis, or else wa«:e
away.  Inflammation must be guarded against after these operations ;  to*
       19
 
218
DISEASES OF  THE BONES.
it may possibly affect the whole bone, and the  joints at either extremity,
and lead to very disagreeable consequences.  Exostoses of the  clavicles
of children almost always disappear of themselves.*
                     II. Rickets or Rachitis signifies a feeble state of
                   the system, with atrophy and distortion of the bones ;f
                   it is generally an accompaniment of scrofula.  The
                   cortex of the bones is thin, and their internal structure
                   very spongy:  the cells large and filled with gelatinous
                   fluid ;—sometimes they are  as  soft as  cartilage.  Of
                   course they are unable  to  support the weight  of the
                   body, without bending and producing deformity.  In
                   moderate cases, the  ankles  only may be a little sunk,
                   or the shins bent, or the spine curved ;  but in aggra-
                   vated cases  the physiognomy and general appearance
                   are very peculiar.   The stature is  short; the head
                   large,  with  a protuberant forehead ; the face  pecu-
                   liarly triangular, with  a very sharp-peaked  chin, and
                   projecting teeth ; the  chest  narrow and prominent in
                   front, whence the vulgar term pigeon-breasted;—the
                   spine variously curved; the pelvis distorted  in such
                   a manner that the three points  of  support,  viz. the
                   promontory of the sacrum, and the two acetabula, are
                   pressed together, rendering the cavity perilously small
                   for  child-bearing, and the  limbs  are  crooked, their
                   natural curves being increased.   But after puberty, it
                   is  astonishing how firm the bones  become, and, in
                   particular, how they are strengthened by strong  ridges
developed on their concave sides.
   Treatment.—The  health  must be  invigorated by pure air, wholesome
food, and the other measures prescribed for scrofula.   When a child with
crooked legs is brought to the  surgeon, he should  ascertain whether the
deformity arises from relaxation  of the joints merely—the bones remaining
straight—or from  crookedness of the bones themselves.  For the knees
and  ankles  may be greatly bent inwards from the former cause, but will
become straight of themselves when the health  becomes stronger; espe-
cially if salt bathing and frictions are used  to the legs and back.   But if
the tibia or femur are actually bent, the surgeon must take  care not to tell
the parents that the child will grow out of it; for there is no evidence that
a bone which has once yielded,  can ever recover its primitive shape spon-
taneously.   Therefore some  mechanical contrivances should be  used, in
order both to straighten the bent bones, and to  keep them so till  they are
strong enough to bear the weight of the body; and a pair of simple wooden
splints, well padded, and applied with some degree of tightness, from the
top of the thigh to the foot, seem to answer every useful purpose, and the
child soon learns  to walk about  in them with his knee straight.  They
should of course be taken off once daily for a good washing and rubbing.|
  * Vide Sir A. Cooper on Exostosis, in Cooper and Travers's Surgical Essays.
  t Atrophy of bone  may  be general, as in rickets and mollifies ossitim ; or partial,
when it depends on some local cause, as want of exercise, deficient nervous  influence,
or insufficient supply of arterial blood, or sometimes after inflammation.—Vide T. B,
Curling on Atrophy of Bone, Med. Chir. Trans, vol. xx.
  t See Bishop on Deformities, Lancet for I 840, vol. i.  The author recommends a visi
to the Orthopedic Hospital, Bloomsbury Sqaare.
 
DISEASES  OF  THE BONES.                  219
     III. Mollities Ossium (Malacosteon) is an extraordinary disease, gene-
  rally, but not invariably, affecting elderly females, in which the bones be-
  come softened and brittle, and lose their earthy constituents.   In the very
  first stage, the affected bones are somewhat softened and extremely vascu-
  lar.   As the disease advances they become  somewhat  thickened, and so
  soft as to be easily cut with a knife.  On a section being made, the osse-
  ous  tissue is found nearly absorbed, a mere shell being  left, which in most
  cases is  filled with " a dark grumous matter, varying in colour from that
  of dark blood, to a reddish light liver colour."  Under the microscope the
  Haversian canals are found enormously dilated, and the osseous cells or
  corpuscles greatly  diminished.    As the  disease advances, the affected
  bones seem  to be reduced  to mere thin shells, filled  in some cases with
  serum, in  others with fat;  whilst in some instances all  bony matter what-
  ever has disappeared, and the periosteum has been left as a cylinder filled
  with a dark parenchymatous substance of the consistence of liver.
     The disease  is evidently constitutional, and usually affects almost every
  bone in the skeleton, although two  instances have been  reported to Mr.
  Solly, by Mr. Hodgson, of  Birmingham, in which  it was  confined to the
  lower extremity ; and in one of these amputation was performed.   At the
  commencement of it the patient  is observed to be out of health, emaciated,
  complaining of  violent achings in the bones, and of very great feebleness
  and profuse perspirations.   Then, from a fall or some other slight injury, a
  bone breaks*;—perhaps it unites again—but  afterwards bone  after bone
  breaks from the slightest cause, the  weakness increases, and  the  patient
  becomes bedridden ; and now, as the bones bend or break from the slightest
  influences, the chest and limbs become distorted to an almost inconceivable
  degree, and death at  last  occurs from exhaustion, or from the obstacle
  which the distorted ribs oppose  to the action of the lungs.
     Of the causes of this disease,  nothing is known, and of its real nature,
  just as little.   It is evidently, however, as Mr. Solly justly observes, not
  a  mere  atrophy.  The extreme vascularity of  the bones in  the  earlier
  stages of the affection, and  the  severe pain attending it, sufficiently show
  that their vital condition is seriously, though inexplicably altered.  We
  cannot, however, subscribe  to Mr. Solly's doctrine, " that  it begins with a
  morbid action of the blood-vessels," and that "the absorbent  vessels are
  unnaturally excited;"  because,  as all modern pathology teaches, the ac-
  tions of the vessels are purely subservient to the actions of the parts which
  they supply.*  That the urine is loaded with phosphate of lime, which in
  one  of Mr. Solly's cases formed a renal calculus, is an  interesting and in-
  telligible point  in the  history of this disease.   No available treatment is
  known, beyond the common rules of supporting the strength and allaying
  pain.f
    IV. Acute Inflammation of bone most frequently attacks the femur 01
  tibia in  children, and is usually attributed to cold.  It frequently affects
  more than one  bone, but is generally confined to the shafts, and does not
  often involve the articular extremities.
    Symptoms.—The patient  is seized with violent shivering and fever, and
I  with deep-seated severe pain, and great  swelling of the affected limb, the
  skin of which displays a kind of erysipelatous redness.  Matter soon forms,

    *  See the remarks on this point at p. 52.
    f Vide Mayo's  Pathology; and an interesting paper by Mr.  Solly, containing \\\t>
  lelails of two cases, Med Chir. Trans, vol. xxvii. 
220                 DISEASES  OF THE  BONES.
Fig. 29.
burrows among the muscles, and at last points in several places.   Some-
times the patient is destroyed by the violence of the constitutional derange-
ment, or sinks under the profuse  suppuration  that follows ;  but more fre
quently life  is preserved,  and the bone  left  in  a  state of necrosis.  On
examination of cases that have proved fatal, or that have been subjected
to amputation, the shaft of the bone is generally found separated from the
epiphyses,  and partially or entirely separated from  its periosteum ;  and
patches of newly-formed bone are deposited upon its  surface, and between
the layers of the periosteum.
   Treatment.—Aperient and febrifuge medicines, with leeches and cold
lotions, should be  assiduously employed  at first.   As  soon  as fluctuation
can be detected anywhere, an opening should be made ; and it is better
to do so too soon  than too late.   When a fxee exit is provided for the
matter, a bandage should  be applied to prevent its accumulation.   If the
patient seem likely to sink, in spite of tonics and nutriment, from  the ex-
treme discharge, the affected limb  must be amputated.
   V. Chronic Inflammation of bone  is most frequently the result of
some constitutional disorder,  and  generally attacks several bones simulta-
                  neously.   It is denoted by slow enlargement,  tender-
                  ness, weight, and  pain.   If  caused by injury, it may-
                   lead to necrosis ; but  in general it produces no  organic
                   change, save irregular enlargement.
                    Treatment.—The general health should be improved
                   by  change  of  air, alteratives, and tonics, especially
                   Plummer's  pill, or hyd. c. creta,  in  small  doses every
                   night,  F.  32,  33, and the iodide  of potassium, with
                   sarsaparilla.  F. 40, 41.   The local measures are re-
                   peated leechings and  fomentations, as long as there  is
                   tenderness or much pain ;  with Scott's ointment, F. 66,
                   or blisters or iodine paint subsequently.
                    VI.  Inflammation of  the Periosteum generally
                   occurs on  the  subcutaneous aspect of thinly-covered
                   bones; especially the tibia,  ulna,  clavicles,  and os
                   frontis.  It produces oval  swellings,  called  nodes,
                   through an infiltration of  lymph  and  serum  into the
                   periosteum, or between it  and the bone.   If acute or
                   mismanaged, it may lead to suppuration, and caries or
                   exfoliation of  the bone ; but more frequently it causes
                   merely a  superficial  deposit of rough bone.   It  may
                   sometimes be caused by mechanical injury, or exposure
                   to cold; but far more frequently it is a consequence
of disorder of the  health, especially of a scrofulous or venereal  taint, or
the too free use of mercury.
   Treatment.—For the acute, leeches, fomentations, purgatives,  diapho-
retics, and colchicum in doses  of  rt\ xx.  of the wine every  six hours; or
gr. ii.  of the iodide of potassium at the same  interval.  Calomel  may be
given  in doses  of gr. ii., with half a grain of opium every night, if the
constitution has not been injured by any previous profuse administration
of it; and  sometimes the disease will yield  to nothing but the full influ-
ence of mercury, even although the system has been enfeebled by repeated
courses.  For the chronic, the same treatment as for chronic inflammation
of bone.  The severe nightly pain is, after the application of leeches, best
 
DISEASES  OF THE  BONES.                 221
Fig. 31.
relieved by renewed blisters.  An incision is sometimes necessary if mat-
ter form between the periosteum and bone, and  ho measures  succeed in
producing its absorption and allaying the pain; but it very often happens,
especially in venereal cases, that mercury, (if not previously administered
to excess,) or the iodide of potassium, sarsaparilla, and blisters, will ac-
complish those objects.
  VII. Abscess is a rare consequence of inflammation of bone.  A cavity
lined with a vascular membrane,  and filled  with pus, is formed in the
substance of the bone, generally the tibia, which may or
may not be unusually dense around it.  There may also     Fl&- 30-
be  a small piece of  necrosed bone  confined in the  ^^^r
cavity.  Abscess may be  suspected when, in  addition  |  fii   m
to permanent inflammatory enlargement and tenderness,  y^
(which may have lasted for years,) there is a fixed ten-
sive pain at one particular spot,  aggravated at night,
and unrelieved by any remedy, though perhaps' it  may
have occasional remissions.
   Treatment.—When there is good reason to suspect
the existence of abscess, the bone must be laid bare by
a crucial incision, and an opening be made with a tre-
phine  at  the precise seat of the pain; it may, if neces-
sary, be  deepened  with  a chisel.  After the pus  is
evacuated, the  wound must  be left to granulate and
cicatrize.*
   VIII. — Necrosis. — This  term, although  signifying
 the death or mortification  of bone generically, is yet
 usually restricted  to  one form, — in  which part of the
 shaft of  a cylindrical bone  dies, and is  enclosed in a
 case of new bone. The term exfoliation signifies necro-
 sis of a thin superficial layer, which is not encased in
 any shell of new bone.
    1. Necrosis is a frequent  consequence of inflamma-
 tion of the  shafts of long bones in children, especially
 of the femur and tibia.
    Pathology.—The bone  dies; but its periosteum and
 the surrounding cellular tissue become infiltrated with
 lymph,  which  speedily ossifies,  forming a  new shell
 around  the  dead  portion, and  adhering to the living
 bone  above  and below it.  The dead portion (techni-
 cally called  the sequestrum,) generally consists of the
 circumference of the shaft only,  and  not of the entire
 thickness; for the interior of the shaft seems to be atro-
 phied and absorbed after the death of the exterior.  The
 inside of  the sequestrum  is usually rough, as if worm-
 eaten.   In the majority of cases the epiphyses, or articu-
 lar extremities, are fortunately unaffected.  After a time,
 if  the  sequestrum is  removed by art or accident, the
 newly-formed shell  contracts, its cavity  is  abolished, and  it gradually
 assumes  the shape and function of the  former bone.
    Microscopical Appearances of Diseased Bone.—Healthy bone, when a
 thin section is examined under the microscope, is shown to consist of an
               * Vide Sir B. Brodie*s Lecture, Med. Gaz., Dec. 1845.
        19*
B 
222
DISEASES OF THE  BONES.
obscurely granular substance, arranged in concentric laminae around longi-
tudinal canals (viz. the Haversian canals which contain the nutrient blood-
vessels).  The laminse are separated by circular rows of minute cavities
or  cells,  having fine  canaliculi  running  from  them,  as  shown  in
Fig. 32.   In diseased bone, the  only changes  that have been recog-
nised  are variations  of plus and minus; — that  is to say, in bone  that
is condensed and hardened by inflammation,  the Haversian canals are
small, the laminse wTell defined, and the cells numerous.   In bone, on the
contrary, that is loosened out and rendered spongy, and that has its visible
Fig. 32.                        Fig. 33.
cancelli enlarged under disease, the Haversian canals  are  seen under the
microscope to be greatly enlarged,  and the bone cells  and lamina? disap-
pear.  This is the case in caries, and in that part  of the bone where the
chink  of  separation  is situated in necrosis or exfoliation,  as  shown in
Fig. 33.    In mollifies  ossium the bone  cells  are enlarged,  according
to Mr. Dalrymple.*
   Absorption of Bone.—The mechanism by which dead bone is separated
from living, has afforded materials for ample discussion.   Wrhat is known
positively on  the  subject may perhaps be comprised under these three
heads.   1. All  evidence is against the supposition that dead bone can be
absorbed,  or can be  dissolved by pus.f   The honeycombed appearance
of sequestra does not arise  from  an absorption  of any part of the  bone
after its  death, but from  changes which occurred in  it before  its vitality
ceased.   2. There is no evidence that bone is removed by the lymphatic
or absorbent vessels.   3.  Bone, to be absorbed, must possess vitality, and
must be in contact with a highly vascular structure.^.
  * Vide Dalrymple  on  the Microscopical Characters of Mollifies Ossium, quoted in Lan-
cet, Sept. 19, 1846.
  tFor ample proof of this, see Mr. Gulliver's paper in Med. Chir. Trans, vol. xxi.
  tThus. when the fangs of the milk-teeth are. absorbed before  the descending perma-
nent teeth, the surface in course of absorption is found in contact with a highly vascu-
lar membrane ;  and absorption does not  take place if the tooth is dead.  In the nex<
chapter it will be seen that cartilage is also sometimes absorbed in this manner.  As
to the mechanism of the process by which bone or cartilage are thus absorbed, the
researches of the Goodsirs and Dalrymple appear to prove that the  cells  of the bone
and  cartilage immediately adjacent to the vascular membrane become enlarged and
altered  and that the cells on the surface of the vascular membrane, in immediate con- 
DISEASES OF THE BONES.
223
  And thus the separation of a portion of dead bone is produced by the
absorption of that layer of the  living bone which  is  nearest to it; which
absorption is effected by means of a vascular production resembling ordi-
nary granulations.   Under the  microscope, the Haversian canals are seen
to be enlarged.   And to the naked eye, the cancelli are enlarged (see the
next  figure), so that (to use Miescher's words) " a sort  of diplo'i is pro-
duced, the cells of  which  are filled with  a soft reddish substance.  The
walls of the cells become daily thinner and thinner, till at length the living
and dead bone are  no longer connected by bony substance,"*  and wdien
the  dead part is  removed, the living appears covered  with a layer of
highly vascular granulation, through whose agency the living bone has no
doubt been absorbed, although we cannot believe that it has the power
of absorbing the dead.f
  Symptoms of JYecrosis.—After  acute inflammation,  the bone  remains
permanently swelled; and the apertures  which were  made  for the  dis-
charge of matter remain as sinuses, from which many sensitive, irritable
granulations shoot.  These sinuous apertures in the  skin correspond to holes
in the shell of new  bone (technically called cloace);—and if a probe be
passed into  them, the sequestrum  may be felt loose in the interior;  or at
least the probe will  strike  against dead bone.
  Treatment.—The indication is to  remove the  sequestrum.   Any hope
of its being absorbed or extruded by any, natural process is quite nuga-
tory ; and to permit it to remain, is but to condemn the patient to a per-
petuance of disease and  deformity.   As soon, therefore, as  the shell of
new bone is sufficiently strong, a free  incision  should be made so as to
expose its surface, and it should be made at a part where cloace exist, or
where the bone is nearest  the skin.  Then the new shell  must be perfo-
rated with the trephine,  or with Hey's saw, or with a pair of  strong  bone
forceps; — and the sequestrum must  be  drawn out.  If it cannot be ex-
tracted  entire, it should be divided wTith strong forceps, and each  portion
be  extracted separately.   If the sequestrum be small, or the cloacse large,
the former may perhaps be extracted without any operation; and one way
of enlarging the cloacse is  to  dilate the sinuses in the skin, and keep  them
open with tents of lint.  Necrosis of  the articular extremities of bones, or
of the tarsus or carpus, generally  causes irreparable disease of the neigh-
bouring joints, and  requires amputation.
  2.  Exfoliation  signifies  the mortification and separation of a super-
ficial layer of bone, or of the extremity of a bone — of  a phalanx, or of
the end  of a bone after amputation,  without the formation of a shell of
new bone, for example, as in necrosis.   It  is generally  caused by some
mechanical or chemical injury, or by  stripping off the periosteum.  Not,
tact with the part to be removed, appear to  absorb the latter into their own substance.
See  the notes to the Section on Ulceration of Cartilage in  the next chapter.   Mr. Dal
rymple, speaking of the absorption of bone in mollities ossium, says, "the edges of the
bone appear to be imbedded in a mass of nucleated cells, which adhere to it with great
tenacity.-'  The bone cells are found enlarged, and the canaliculi projecting from them
shortened.  In some places the canaliculi appear as if truncated, and crop out on the
rurface of the bone.
  *  Miescher, quoted in South's Chelius. vol. i. p. 692.
  +  For the fullest information on the structure of healthy bone, refer to Mr. Tomes's
paper on Osseous Tissue in Dr. Todd's Cyclopasdia of Anatomy and Physiology, and to
his Lectures on Dental Physiology and  Surgery in the Lond. Med. Gaz. vol. xxxvii,
The author has to thank Mr. Tomes for the three drawings which illustrate this sub'
ject, as well as for very much  useful information. 
224
TUMOURS  OF  BONE.
Fig. 34.'
Fig. 35.
             however, that stripping off  the  periosteum is invariably fol-
             lowed  bv exfoliation ; for the  bone may remain red and
             moist, and throw out  granulations;  whereas if it be about to
             exfoliate, it becomes white and dry.
               Treatment.—A lotion of weak nitric  acid  may  be useful;
             and the exfoliating portion should be removed as soon as it
             can be  detached.
               IX.  Caries is  an  unhealthy  inflammation of bone which
             first produces softening,  and  then  leads to ulceration and
             suppuration.
               Pathology.—The bone is  soft and red ;  its cells are filled
             with a  red  serous or thick glairy fluid, and with soft granu-
             lations ;—and in scrofulous cases there  is also a deposit  of
more or less tubercular matter.    After a time  suppuration  occurs;  an
abscess breaks, and the  carious  portion of  the  bone, already softened
and spongy,  gradually perishes  in minute scales, which are thrown off
and discharged with the pus.   The bone, when macerated and dried,
               looks soft and  spongy; eaten into  hollows,  and thrown
               into  irregular elevations;  the latter  marking  the site  of
               granulations, and of attempts at reparation.
                  Symptoms. — "The  external character of the limb,"
               says  Mayo,  " is the same in necrosis and caries.   The
               bone appears enlarged, and  one or more sinuses open from
               it  at points  that  are soft, and red,  and sunken."   If a
               probe is passed into these,  it will readily break down the
               softened texture of the carious bone,  which yields a  gritty
               feel.
                  Causes.—Caries  most frequently attacks bones of a soft,
               spongy texture;  such as the vertebrse, the round and flat
               bones, and the articular extremities  of  long  bones.  Its
               genuine cause is  some constitutional disorder, scrofula,
               syphilis, or mercury.
                  Treatment.—The indications are two-fold; — to rectify
               constitutional disorder, and  to remove the  local disease.
               The  former object must be accomplished by change of air,
               tonics, and alteratives, and the measures that have  been
               directed for scrofula and syphilis, supposing the caries to
               be connected with those maladies.
                 If  it can be done, the best local remedy consists in freely
               exposing and removing  the whole  of  the diseased portion
of bone by the saw,  or gouge, or trephine.  If this cannot be done, lotions
of the  dilute  nitric or phosphoric acids may be tried.   Caries  of the  arti-
cular extremities of bones will be considered together with diseases of the
joints.
                       tumours  of  bone.

  Of the various tumours of bone, some depend on an hypertrophy of its
normal structure,  or on  the enlargements incident upon inflammation and
its consequences.   These have been sufficiently described in the preceding
  * This cut shows the extremity of a phalanx in the act of separation by exfoliation.
At the part where the separation is to occur, the cancelli are seen to be enlarged, so as
to form a kind of diploc, and their walls are thin. 
TUMOURS  OF BCNE.
225
paragraphs.   Others, which depend upon the development of adventitious
tissues in or upon  bone, remain yet to be noticed ; and they are of two
orders: the  non-malignant and the malignant; the former of which we
shall treat of first.
   1.  Tumours from extravasated blood.—Mr. Travers* describes a case
in which, after  a  blow, the clavicle  enlarged  into  a firm  oval elastic
tumour; which, when punctured by  a grooved  needle, yielded a few
drops of dark grumous  blood.   The whole bone was  extirpated.   On
examination, it was proved that  the  tumour had evidently originated in a
rupture of the vessels of the bone, and an extravasation of blood into the
cancelli.  By the pressure of this blood, and a continuance of the extra-
vasation, the bony tissue was expanded and  absorbed ; and  the cancelli
were converted into  chambers filled with dark solid coagula.   The tumour
was invested by the  periosteum.
   2. Pulsating tumours are sometimes developed in bone, and may be of
three kinds.   1st, Malignant tumours, the circulation  through which is so
energetic, that they pulsate and  yield a whizzing sound like that heard iii
aneurisms.  2dly, Tumours formed by the development of  erectile tissue
in the substance of a bone;—and, 3dly, Tumours depending on enlarge-
ment of the osseous arteries.f  To the last, the name of osteo-aneurism is
given.  The seat of the tumour is generally the extremity of one of the
long bones, and frequently the tibia just below the knee.   The patient
complains of a  sudden  pain in  the  part.   This is followed by painful
swelling, and all the veins of the leg are  observed to be very tense and
full.  After a time, the whole limb becomes  dark, red, and  painful; and
the tumour becomes distinctly pulsatory.  It is generally moderately firm
to the touch, and perhaps gives a slight crackling sensation, owing to the
thin shell of bone covering some part of it.   On examination, it is found
to be  composed of  a  spongy tissue, containing convoluted vessels and
cells, the latter filled with clots of blood in concentric  layers ; the bone of
course expanded, thinned, and absorbed.   This  disease has also been
observed  in  the humerus, radius, femur, and ilium.  Its diagnosis from
aneurism is  extremely  difficult.   Ligature  of the main arterial trunk of the
limb, or amputation, are the only remedies.
   3.  Cartilaginous exostosis, osteosarcoma, enchondroma (Miiller).  This
growth is described  by Miiller as a firm spheroidal tumour consisting of
masses  of true  cartilage embedded in a fibro-membranous cellular struc-
ture.   On a section it  displays many spherical loculi like those of colloid;
to which disease it bears a strong outward resemblance.   A light arbor-
escent skeleton  of  thin  papery  plates and spiculse of bone, is dispersed
throughout its substance, as is well shown in the following drawing, from
a  preparation in the King's  College Museum.   When boiled, it yields a
variety of gelatine, termed chondrine.   It may be developed in the centre
of a bone,  or on  its surface.   In the former case, it causes the bone to
expand and be absorbed before it, till at last it is covered by a mere shell.
This tumour ordinarily affects only one bone ; and is  occasion .illy found
in the glands, especially the parotid.  It  is not malignant, according to
the strict definition of the term;—for although incurable, and although by

  * Med. Chir. Trans, vol.  xxi.
  ■j- We follow here the division adopted by Mr. Stanley, Mod. Chir. Trans., vol. xxviii.
but the last two kinds of tumour are mere varieties of the same disease.  See the ebap
ter or. Aneurism. Vide Breschet sur des Tumeurs Sanguines.
                                   P 
226
MALIGNANT TUMOURS.
Fig. 36.
its continued  growth it may distend  the  skin, and  cause ulceration, and
wear out the constitution  by the irritation and discharge, still it does not
                          usually return if  thoroughly extirpated,  and
                          does not affect any internal organs.  Yet Mr.
                          Mayo  gives a case in which, after amputation
                          for this disease of the tibia, it attacked the
                          femur and caused death.*
                             4.   A  fibrous  tumour  containing  bony
                          spiculae may be developed  in  the  substance,
                          or on  the surface of bone, especially of the
                          superior or inferior maxillary.   Vide p. 205.
                             5. Hydatids or thin cysts,  containing a clear
                          water, are occasionally developed in the sub-
                          stance of bone ;  causing it to expand and form
                          a tumour, the diagnosis of which must be ex-
                          ceedingly difficult, until the part has been laid
                          open by operation.   One of the best cases on
                          record  was  described  by  Mr.  Keate,  who
                          treated it  successfully by removing as much as
                          possible of the cysts and of the bone containing
                          them, and applying  a solution  of sulphate of
                          copper to the  diseased surface.f

                                  MALIGNANT  TUMOURS.

                             6. Medullary sarcoma (Fungoid  exostosis)
                          is perhaps the most frequent malignant disease
                          of bone.   Its  characters  have  been  already
                          described.  " It generally," says Mr. Mayo,
" arises in the cancellous structure ;  it is therefore generally attended with
considerable pain, for the growth of  the tumour is rapid, and the shell of
'he bone  has to be partly absorbed, partly mechanically forced open from
within."
  7.  Scirrhus in bone  is generally a concomitant  of the  disease in the
breast, or in some other part.  The femur is  the  bone most frequently
affected, and is often fractured in consequence of the scirrhous deposit and
atrophy of its proper texture.
   The  chief points which  distinguish the malignant  from  the  non-
malignant tumours,  are, their greater rapidity of growth ; the greater pain
with which they are accompanied;  their greater softness at some points
than at others;  their tendency to involve and  become blended with the
skin  and  other adjacent tissues,  (a sure  characteristic  of   malignant
growths,) and the existence  of the malignant cachexia.—But as it is often
impossible to distinguish these two classes of tumours from each other, or
Irom  inflammatory enlargements, it is satisfactory to  know that the early
treatment of them all is the  same.  The same measures that will cure the
curable affections will check the  incurable.   They are,  repeated leeching,
mild  mercurial alteratives, sarsaparilla, with  small doses of' the iodide of
  * Vide Miiller on Tumours, translated by West.
  j Vide Mr. Keate's case, Med.  Chir. Trans, vol. x.; quoted also in Mayo's Pathology;
-use of hydatids growing on the  tibia and causing absorption of the bone and fracture,
'i'« Wickham on Diseases of Joints ; and case of hydatids in bones of pelvis, Med. Gaz.
v-'1  xxx. p. WO.
 
FRACTURE.
227
potassium, and change of air and other general tonics.   If these measures
fail, the only course is amputation or extirpation; which may be performed
with confidence of a cure as regards the non-malignant growths.  But the
extirpation of truly malignant growths, to be effectual, should be very
early,  and very complete, a partial removal  being,  to  use Mr. Liston's
words, an " unmeaning and utterly useless cruelty."*

          SECTION  II.--OF  FRACTURE  GENERALLY.

   The term fracture, with its varieties, simple and compound, transverse,
oblique, and comminuted, requires no definition.
   Exciting Causes.—The exciting causes of fracture are twTo: mechan-
ical violence, and  muscular  action.  Mechanical violence may be  direct
or indirect.  It is  said  to be  direct, when it  produces a fracture at the
part to which it is  actually applied; as in the instance of fracture of the
skull  from a violent  blow.   It is  said  to be indirect, when  a force is
applied to two  parts of a bone, which  gives way between.   This is exem-
plified in the case  of  fracture of the  clavicle from a fall on the shoulder.
The sternal end of the bone  is impelled by the weight  of the body, and
the acromial end by the object it falls against; and the bone,  acted upon
by these two forces,, gives way in the  middle.
   The bones most commonly fractured  by muscular action are the patella
and  olecranon ; but the humerus, femur, or any other  bone, may give
way from  this  cause, if  preternaturally weak.
   Predisposing Causes.—There are  certain  circumstances which rendei
the bones  more liable  than usual to be broken.   These are (1.)  Old Age,
which renders the  bones soft  and brittle  ; the earthy matter being deficient
in quantity, and the animal matter having lost its elasticity.   (2.) Disuse.
as in bed-ridden people.  (3.)  Certain diseases, as mol-
lities ossium, and cancer.  (4.)  Original Conformation;
the bones of some people being exceedingly brittle, with-
out any assignable cause.
   Reparation.—The reparation of fractures is produced
by the  effusion and  organisation of lymph.   But  this
process varies considerably  as it occurs in different
bones.
   1.  After fracture of  ordinary  bones,  a quantity  of
lymph is effused into the cellular tissue around the broken
part.   This, in two or three weeks, becomes converted
into a cartilaginous capsule, called a provisional callus,
which completely surrounds  the  fracture, and adheres
firmly to the bone  above and below it.   In two or three
weeks more, the provisional  callus ossifies ; — and then
the use of the bone is restored.   But  at this time the
ends of the fractured bones  are  not directly united ;  and
if  the provisional  callus were removed, they would still
be separable ;—in  the course of five or six months, how-
ever, ossific matter is gradually deposited between them,
and the provisional callus is absorbed.
  There has been  much dispute as to the source of the
  * Vide Wnlshe, op.  cit.; and Liston on Tumours of Mouth and Jaws,  Med. Oar-
i'rans.  vol. xx.
 
228
FRACTURE.
 lymph which  forms the callus.  Some  persons  nave asserted, that it is
 effused by the bone or its medullary membrane, others by the periosteum,
 and others by the cellular or other tissues around.   But the fact is, that ft
 is effused indiscriminately from all the tissues around the fracture; and
 once effused,  its conversion into cartilage and then into bone is the result
 of its own organic forces.  Moreover, if one pf the bones which unite  by
 a  provisional callus when fractured, be extirpated entirely, and its perios-
 teum with it, the lymph which is  effused by the  surrounding  tissues wil
 (especially in  the lower animals) very probably form a new bone.*
   2. But after fracture of the cranium, acromion, olecranon, patella, cervix
 femoris, or of any bone invested with synovial membrane, no provisional
 callus is formed.   If the broken parts are kept in the very strictest appo-
 sition, bony union will certainly occur in  two or three months.  But if a
 portion of the skull be removed, so as to make a gap ;—or if after fracture
 of it, or of the other bones in the same  category, the divided  parts be not
 kept  in the closest  apposition, the lymph effused will be converted into
 ligament, which very slowly ossifies, if at all.
   The reason for the absence of a provisional callus, in these cases, may
 be gathered from a consideration of the situation and function  of the bones
 enumerated ; and from  the evil results  that would  ensue, if a hard lump
 of callus were liable  to be thrown out on the interior of the skull, or into
 the cavities of the joints.   That this is the  true cause  of non-union  is
 plainly shown by an experiment of Sir B. Brodie's.  He broke the tibia
 of a guinea-pig, just above the ankle-joint, where it is entirely covered by
 synovial membrane.  On  examining  the  part sometime afterwards, he
 found that there was no separation of the fragments, and no motion be-
 tween them ; the  synovial membrane was scarcely torn, and the ligaments
 were uninjured;  nevertheless there was no  union, although  there was a
 slight bony deposit into the cancelli.f
   Symptoms.—The essential  symptoms of fracture are three.   (1.) De-
formity,—such as bending, or shortening, or twisting, of the injured limb.
 (2.) Preternatural mobility,—one end of the bone "moving independently
 of the other, or one part of it yielding when pressed upon. °(3.) Crepitus,—
 a grating noise heard and felt when the broken ends are rubbed  against
 each other.  But it  must be recollected that if the broken parts  are dis-
 placed, they must be drawn into their natural position, otherwise no crepi-
 tus will be detected.  In addition to these symptoms, there will be  more
 or less pain, swelling, and helplessness of the injured part.
   It is  important in every  case to know the  causes which produce dis-
placement and deformity after fracture, because it is  necessary to counter-
act them carefully during the treatment.  They are three.  (1.) Muscular
action; which produces various degrees of bending, shortening, or twist-
ing in different cases.  (2.)  The weight of the  parts below, which, foi
instance, causes the  shoulder  to sink  downwards, when  the clavicle  is
broken.  (3.)  The  original violence which  caused the fracture, as when
the ossa nasi are driven  in.
 _  Treatment.—The general indications for the treatment of fracture, are,
first, to procure union, which is accomplished by keeping the parts at rest,

  • Vide a paper by the author, containing  an  account of some experiments  on the
lesiorat.on of bone, by Dr. Heine, Med. Gaz. July 29, 1837;.Troja de novorum ossium
regeneratione, Paris,  1775; Bransby Cooper, Guy's Hospital Rep. 1837.
  j- Med. Gaz. xiii. p. 55. 
FRACTURE.
229
and  in apposition; and, secondly, to  prevent  deformity.  For the latter
purpose certain appliances must be used, which will counteract the various
causes of displacement that were enumerated in the preceding paragraph.
Displacement from muscular contraction must  be obviated by keeping the
part, if possible, in such a position that any offending muscle may be re-
laxed ; and by using mechanical means of extension and support.
   The general  method of treating fractures may be thus described : In the
first place, the limb must, if possible, be  put  in a position that will relax
the principal muscles  that cause displacement.  In fracture of the upper
end of the radius, for instance, the  elbow should be bent to relax the
biceps; and in fracture of  the olecranon  it should be straight, so as to
relax the triceps.
   Secondly, the fracture must be reduced or set: that is to say, the broken
parts must be  adjusted in their natural positions.   For this purpose, the
upper end of the limb must be held steadily, whilst the lower is extended,
or drawn in such a direction as to restore the limb  to its proper length and
shape.   The extension should be  made firmly, but gradually and gently,
otherwise  it will aggravate  the muscular spasm which it is intended to
overcome.
   Thirdly, it is usual to bandage the  whole of the fractured limb from its
extremity.  This  is done for  the double purpose of  preventing cedema,
and of confining the muscles, that they may not contract and  disturb the
fracture.
   Fourthly, it is necessary to use some mechanical  contrivances  to keep
the  limb of its natural  length and shape, and prevent any motion at the
fractured part.  It is usual to  employ for this purpose splints  of wood,
carved to the  shape of the limb.   The surgeon should measure the sound
 limb which corresponds to the injured one, and select splints that are long
 enough to rest against the condyles or other projecting points  at its extre-
 mities.  These must be padded, and  pads are easily made of loose tow or
 horse-hair wrapped up in pieces of old linen.   The splints, when ready,
 should be firmly bound to  the limb with pieces of old bandage; leather
 straps and buckles are  very inconvenient.
   Several substitutes  for wooden splints have been  brought into use of
 late years.  One of the most popular and convenient of these is the gummed,
 ox starched bandage, or appareil  immobile; on which a  Frenchman has
 written  a  large book.   It  consists merely of layers of bandage, lint, or
 linen imbued with a mucilage of starch or gum or arrowroot; which, when
 dry, form  a remarkably light, firm, and unyielding support.  This, how-
ever, should never be applied till  all  chance of swelling is over.   Another
 contrivance of the same nature, invented by Mr. Alfred Smee, and called
 the moulding tablet, will often be  found a very simple  but efficacious aux-
 iliary.   It is composed of two layers  of coarse old sheeting, stuck together
 with a mixture of gum arabic and whiting.  It is easily prepared by rub-
 bino- very finely powdered whiting writh mucilage of gum arabic till it ac-
 quires the consistence of thick paste, and then spreading this on the surface
 of the sheeting, which is to be doubled on itself;  it dries without shrinking,
 and becomes  remarkably hard and  tough; and  may readily be softened
 by sponging it with hot water, so that it may be adapted with the greatest
 accuracy.*  We think it "right also to mention the straw splints, made by

                        * Lond. Med. Gaz. Feb. 1839.
        20 
230
NON-UNION OF FRACTURE.
filling a linen bag of the size of the splint required, with unbroken wheat
straw, such as is used in thatching; the straw being cut  to  the  length of
the limb, and the open end of the bag then sown up.  This is ^oth splint
and pad in one, and may often be of great service in country and military
practice.*
   Some practitioners, instead  of  applying splints immediately,  place tht
limb on a pillow, and merely apply leeches or cold lotion for the first few
days, or perhaps for a week, and resort to splints after the  inflammatory
stage has passed over.   But it appears to be  far better,  in  every case, at
once to use measures, by splints or otherwise, for keeping the fracture im-
movable.   " If," says Mr. Liston, "the limb  is laid loosely on a pillow,
in an easy position, as it is by  some thought or said to be, and no efficient
means are employed to prevent the spasmodic action of  the muscles, the
startings of the limb, the jerkings of the  broken  ends, the  displacement
of the fragments ; then assuredly, in spite of all local and general measures,
there will arise frightful swelling, pain, tension,  and heat;  the  intermus-
cular tissue will be gorged with  blood, and the circulation of the limb
roused to a dangerous and alarming degree."!
   The remaining treatment of simple fracture must be conducted on gene-
ral principles. Cordials to restore the patient from the shock of the injury;
the catheter, if he cannot make water,  which is common after fractures of
the leg; opiates to  allay pain  and muscular twitching; aperients, if they
can be  given without disturbing  the  fracture; cold lotion, if agreeable;
and leeches and bleeding  very rarely indeed, to  allay excessive inflamma-
tion, must be employed at the discretion of the practitioner.
   The apparatus and bandages must be  loosened when  swelling comes
on, and be afterwards tightened sufficiently, to keep the  parts steadily in
their place ; and care must be taken to prevent  painful  pressure on  any
particular spot, and to rectify any displacement as soon as it may occur. *
   If, through mismanagement, a fracture has united crookedly, an attempt
may be  made to bend the  callus, and restore the  right shape. Such a pro-
ceeding may  easily  be  effected before  the fourth week,  and it  has  even
been successful at the sixth month.:}:

    section hi. — of non-union and  false  joint.§

   There are some cases in which fracture  of the shafts of bones does not
unite by bone.   This is liable to happen :—
   1st.  If the  fractured  part is subjected to frequent motion and disturb-
ance ; in which case the effused  lymph, instead of ossifying, will either
be converted  into a ligament which unites the broken  extremities, or else
a false joint will be formed ; the ends of the bones being covered with
synovial membrane, and  surrounded with a  ligamentous capsule, as is
well shown in Fig.  38, from a preparation in the King's College  Museum.
   2dly. The  reparative processes may be deficient if the vital powers are
exhausted by age and debility; or if the system is under the influence of
jjout, syphilis, or cancer;  or if an acute  disease or fever comes  on; or if

  * See some remarks by Mr. Tuffnell,  in Ranking's Abstract, vol. iii. p. 240.
  j Practical Surgery, p. 65.
  * Syme, Ed. Med. and Med.  Surg. Jour., Oct. 1838.
  $ [See a paper by Dr. Norris, " On the Occurrence of Non-Union after Fractures," Am.
Jiur. vol. iii. 1842.—Ed.] 
NON-UNION OF FRACTURE.
23i
the patient becomes pregnant, and all             Fig. 38.
the nutritive energies of the system are
employed  in  the  development of the
fetus ; or if the part be deprived of its
nervous  influence;  thus  Mr.  Travers
relates a case  in which a patient had a
fracture of the arm, and of the leg, and
likewise  an injury of the  back, which
palsied the lower extremities.  The arm
united readily enough, but the  leg did
not.   But  yet  there are some  cases
which it  is as  difficult to account for as
it is to remedy.
   Treatment.—There are three indi-
cations.   1st. To bind up the part in
splints, or the starched bandages, or to
envelope it in  a  mould  of plaster of
Paris, so as to insure  perfect rest, per-
fect  apposition, and  pressure  of the
broken ends against  each other.  But,
as Sir B.  Brodie  very justly observes,
the bandage  should  not  be put  on so tightly as to  impede the general
circulation of the  limb.
   2dly.  Should this  not  succeed after a fair trial of six weeks or two
months,  means  must be adopted to excite the adhesive inflammation around
the fracture.  This may be done by rubbing one end of the bone roughly
 against  the other;—or by making the patient walk on  the limb, which
 must be first well supported with  splints ; and then the apparatus should
 be again firmly applied for six or eight weeks.*  If this also fail, the next
 thing to be tried is a seton; which may be  passed through the limb,  be-
 tween the fractured ends ;—although it is more safe, and quite as effectual
 to pass it through the flesh close to the fracture.   If, however, there is any
 difficulty in doing this, the surgeon may merely cut down on the fracture,
 and pass in a probe or iron wire between the broken extremities.  What-
 ever  is used  for the purpose  should be allowed to remain a week or ten
 days, after wrhich  the  limb should be put up immovably in splints.  If these
 measures also fail, the last resource is to  cut down on  the  fracture, and
 saw or shave off the ends of the bone ;—or sometimes it is found  that a
 little piece of muscle is wedged between them, which must be removed ;
 but this  is a most severe and dangerous operation, and not to be resorted
 to without absolute necessity.
   3dly.  Care should be  taken to detect and remedy any constitutional
vdisorder to which the want of  union can  be attributed.  Debility must be
 counteracted  by tonics, nutritive food, and  stimulants.   Mr. Fergusson
 relates a case of fractured thigh in which no  callus was formed for three
 weeks, until the patient was allowed a reasonable quantity of whiskey, to
 which he had  been  previously accustomed; and Sir B. Brodie relates
 similar  instances.  Mercury may be given if there is a syphilitic  taint:
 and  Mr. B. Cooper  gives a case of non-union, in which,  although  the.

    • Amesbury,  Syllabus of  Lectures on Fractures, &c. with plates of apparatus.
 
232
COMPOUND FRACTURE.
general health appeared perfectly good, mercury given to ptyalism effected
a cure after the seton had failed.*
  A few instances are  known in which the callus, after union was com-
pleted, inflamed and became absorbed, so that the fracture was disunited
again.   Leeches and blisters to the part proved effectual remedies.}  A
recent callus is also sometimes absorbed during fever; and this occurrence
used to be common enough in the sea scurvy.


          SECTION IV.--OF  COMPOUND  FRACTURE.

  Definition.—A simple  fracture may be attended with a wound; but
unless the wound communicates with the fracture, the  latter is not com-
pound.
  Causes.—Fracture may  be rendered  compound.   (1.) By the same
injury which broke the bone.  (2.) By the bone being thrust  through the
skin.  (3.) By subsequent ulceration or sloughing of the integuments.
  Dangers.—These are threefold.   (1.) The shock  and collapse of the
injury, which may prove fatal in  a fewr hours, especially if much blood has
been lost.  (2.) Inflammation, fever, and tetanus.  (3.)  Hectic or typhoid
fever from excessive suppuration.
  Question of Amputation.—In order to decide upon the  necessity of
this operation, the extent of the injury and the  restorative  powers of the
patient must be most carefully examined.   If the bone is very much  shat-
tered and comminuted ;—if the fracture extends into a joint, especially the
knee ;—if the soft parts are extensively torn or bruised ; if, in particulai,
the  skin has been torn away, so that the wound cannot be closed ; or if it
is so injured that a large tract of it must slough ;—if the patient  is very
old; or  much  enfeebled, either  by previous disease, or present  loss  of
blood ;—if the collapse of  the injury is excessive and permanent; ampu-
tation is probably requisite.  Of course  more  may be  hazarded with a
young patient, or with an old person of a spare,  firm habit, who has always
been healthy and temperate, than with one who is bloated  and plethoric,
and in the constant habit of enfeebling his vital powers by over-stimulation
and animal indulgence.
  Laceration of Arteries is  a dangerous complication both  of simple and
compound fracture.  It is detected by the great flow of  blood, if there be
a wound ; and if not, by a  rapid, diffused, and dark-coloured tumefaction
of the limb, with coldness and want of arterial pulsation in the parts below.
If it be the femoral, amputation  will  most  probably be  required,  because
the  vein  may have been injured also ;—if any other, (the anterior or pos-
terior tibial, for instance,) it may be secured ;—provided that  there is no
other valid cause for amputation, and that the  required  incision will not
too  much aggravate the injury to the soft parts.   But, ceteris paribus, this
accident  is always an additional  reason for amputation,  if there be other
circumstances rendering it probably expedient.
  If amputation be decided  on, it  must  be primary; that is, performed
before the  accession of fever and inflammation, as was observed in the
chapter on gun-shot wounds.

  *  v^de Sir A. Cooper on Disloi atnns and Fractures, p. 568 ; Brodie, in Med. Gaz. vol.
xiii ; and  Fergusson's Practical  Surgery, p. 103.
  + James, Address ia Prov. Med. Trans. 1840. 
FRACTURE  OF THE JAW.
233
  Treatment.—If it be determined to  save  the  limb, it  must first  be
placed in a proper position, and then the fracture must be reduced.  If a
sharp end of bone protrude, and it cannot easily be returned or kept in its
place, it should be sawn off.  Any loose fragments or splinters  of bone
should be at once removed ; and if necessary,  the wound may be dilated
for this purpose.   If suffered to remain, they greatly aggravate the inflam-
mation and danger of tetanus, and  may produce long-continued  disease
of the bone.   After reduction, the great object is to produce adhesion of
the external wound, so as to convert the compound fracture into a simple
one, and the best application is a piece of lint dipped in blood, or in com-
pound tincture of  benzoin ;—then bandages and splints  are to be used ;
but, if possible, the  splints  should have apertures corresponding to the
wound, so that it may be dressed without disturbance to  the whole limb.
When inflammation and swelling come on, the bandages must be loosened,
and cold be applied if  agreeable.   Opium,  with antimony and saline
draughts;—laxatives  or  enemata, if they can be  given without disturb-
ance ;—and sometimes,  though very rarely,  bleeding,  are the  general
remedies.  The catheter should be  used if required.  The great object in
the subsequent treatment is to prevent the lodgment of matter, by sponging
and pressing it out carefully at each dressing, and applying compresses to
prevent its accumulation, and, if required, by making openings for its dis-
charge.  But  if, notwithstanding  the employment of tonics,  wine,  and
good diet, the patient seems likely to  sink under the discharge and irrita-
tion, amputation is the last resource.

         SECTION V.--OF PARTICULAR  FRACTURES.

   I. Fractures  of the Ossa Nasi, and of  the Malar and Superior
 Maxillary Bones, may be produced by violent blows or falls on the face,
 or by gun-shot injuries.
    Treatment.—Any displacement of the fractured  portions should be rec-
 tified as soon  as possible, by passing  a strong probe or female catheter up
 the nostril, and by manipulation with the fingers.  A depressed fragment
 may often be  conveniently raised by passing one blade of a dressing for-
 ceps up the nostril, and applying the other externally, so as to grasp the
 fragment between them.   Some practitioners are in the habit of intro-
 ducing tubes or plugs of oiled lint, in order to keep the fragments in their
 places ; but this appears to be unnecessary and is very irritating.   A plug
 of lint may, however, be requisite to check profuse haemorrhage.  If  the
 fracture  is compound, any loose  splinters should  be  carefully removed,
 The great swelling, ecchymosis, bleeding from  the nose, and headache,
 with which this injury is followed, will require to be combated by bleed-
 ing or leeches, purgatives and cold lotions, and spoon diet; and if collec-
tions of matter form, they should be opened without delay.   If there  are
symptoms of  pressure on  the brain, and the  vomer seems depressed, it
should be carefully drawn forwards.
   II. Fracture ov the Lower  Jaw may be caused by violent blows.
Its most usual situation is at the middle of  the horizontal ramus.  Some-
times in  children (though rarely) it occurs at the symphysis, and still more
rarely at the angle, or in the ascending ramus.
   Symptoms.—It  is known by pain, swelling,  inability to move the jaw,
and irregularity of the teeth, because the anterior fragment is generallv
       20* 
234                  FRACTURE  OF  THE JAW.

drawn downwards.   On  moving the  chin, whilst the hand is placed on
the posterior fragment, crepitus will  be felt; and  the gums are lacerated
and bleeding.   The diagnosis of fracture of the ascending ramus will often
be obscured by the great  swelling.   Great pain  and difficulty of motion
are the chief signs.
   Treatment,  1st, By the four-tailed  bandage.—A  piece  of  pasteboard,
softened  in boiling water,  should be accurately fitted to the jaw, and then
                                a four-tailed  bandage should be applied.
                                This is  made  by  taking a  yard  and a
                                half of wide  roller, and tearing each end
                                longitudinally, so as to leave about eight
                                inches in the middle, which  should have
                                a short slit in it.   The chin  is to  be put
                                into this  slit, and then two  of the tails
                                are  to be tied over the crown  of the
                                head, so  as  to fix  the lower jaw against
                                the  upper, and the other two are to be
                                fastened  behind the head.   The teeth
                                on either side  of  the fracture may be
                                fastened together with dentists' silk.   It
                                is useful to  place  a thin wedge-shaped
                                piece of cork between the  molar teeth
                                on each  side, especially if any  of the
                                teeth at the  fractured part are deficient.
                                Sometimes a tooth falls  down between
                                the broken parts ;  a circumstance which
                                should be looked  to,  if there  is  much
                                difficulty in  fitting  them together.
   2dly, By apparatus.—If the above simple means  do not suffice to keep
the fractured parts in contact, Mr. Lonsdale's apparatus should be used;
—and perhaps it would be well to adopt it in all cases, after the primary
swelling and  tenderness  have  subsided.   It  affords perfect support, and
yet allows of free motion.*  The patient for the first fortnight must be fed
entirely with  gruel, broth, arrowroot, &c.  The  cure  generally occupies
five or six weeks.
   [The bandages generally used in this city for the  treatment of fracture
of the lower jaw are those of Dr. Gibson, and Dr. Barton.  The bandage
of  the first-named gentleman is thus described by himself:
   " The surgeon having carefully examined the injured parts, and replaced
such teeth as may have been shaken or loosened, runs his finger along the
margin of the jaw, models the parts to a proper shape, and closes the
mouth firmly, making the  lower teeth press fairly against the upper.  Then
a cotton  or linen compress of moderate thickness,  reaching from the. angle
of the jaw  nearly to the chin, is placed beneath and held  by an assistant,
while the surgeon takes a roller, four or five yards long and an inch and
a half wide, and passes it by several successive turns under  the jaw, up
along the sides of the face and  over the head ; now changing the  course
of the bandage, he causes it to pass  off at a right angle from  the perpen-
dicular cast, and to encircle the  temple, occiput, and forehead horizontally
  * Lonsdale  on Fractures, Lond. 1838.  It consists of a grooved plate of ivory to fit
the teeth, and a wooden plate adapted to the base of the bone.  These two plates are
rnstened together by screws.  See also Fergusson, op. cit. 2d  edit. p. 481.
 
                   FRACTURE OF THE CLAVICLE.              235

Dy several turns;  finally, to  render the whole more secure, several addi
tional horizontal turns are made around the back of the  neck, under the
ear, along the base of the jaw, and over the point of the chin.   To pre-
vent the roller from slipping or changing its position, a short strip may be
secured by a pin  to  the horizontal turn that encircles the forehead, and
passed backwards along the  centre of the head as far as  the neck, where
it must be tacked to the lower horizontal turn,—care being taken to insert
pins at every point at which the roller has  crossed.   This simple method
of securing a fractured  jaw I have practised very successfully for several
years."   (Fig. 40.)
Fig. 40.                            Fig. 41.
   Dr. J. R. Barton's bandage.
   Composition.—A roller five yards long and two inches wide ;  suitable
 compresses.
   Application.—Place the initial extremity of the roller upon the occiput
 just below its protuberance, and conduct the cylinder obliquely over the
 centre of the left parietal bone to the top of the  head; thence descend
 across the right temple and the zygomatic arch, and pass beneath the chin
 to the left side of the face ;  mount over the left zygoma  and temple to the
 summit of the cranium, and regain the starting-point  at the occiput by
 traversing obliquely the right parietal bone; next wind around the  base
 of the lower jaw  on the  left side to  the  chin, and thence return to the
 occiput along the  right  side of the maxilla;  repeat the  same course, step
 by  step, until  the roller is spent,  and then  confine its  terminal  end.
 (Fig. 41.)
  These bandages are easily  applied, and  are very efficacious.   They
 may be made to act upon any particular portion of the jaw, as required by
 the situation of the fracture, by modifying slightly the course of the roller
 in its  successive turns, and by a proper position of the  compresses; a
 little reflection on  the part  of the dresser will enable him  to adapt his
 means of treatment to the ends indicated in each case.—Ed.]
  III. Fracture  of the Clavicle is most  frequently  situated at the
 middle of the bone,  and it is generally caused by falls  on the  arm or
shoulder;  sometimes, however, by direct violence.
  Symptoms.—The patient  complains of inability to lift the affected  arm,
and supports it at the elbow;—the shoulder sinks  downwards, forwards.
and inwards;—the distance from the acromion  to the sternum is less ihan 
236               FRACTURE OF  THE CLAVICLE.
it is on the sound side ;—and the end of the sternal fragment of the bone
projects as though it were  displaced, although it is not so in reality, but
merely appears to be so, in  consequence of the sinking of the  shoulder
and of the outer fragment.
   Treatment.—The shoulder must be raised, and must be supported in a
direction upwards, backwards, and outwards.  The broken parts may be
reduced, either by putting the knee between the scapulae, and drawing the
shoulders backwards ;. or by placing the elbow close to the trunk and a
little forwards, and then pushing it upwards. < To support the parts during
the cure, the most common apparatus is,
   The stellate, or figure of 8  bandage, represented in Fig. 42.  In the
                              first place a  thick  wedge-shaped  pad
                              must be  put  into the axilla, with the
                              large end uppermost.   Then  a long
                              roller must be passed over each shoulder
                              alternately,  and be  made  to  cross on
                              the back.  In the next place, the  arm
                              must be  confined to the side by two or
                              three turns of  the roller; and lastly, the
                              elbow should be well raised by a sling,
                              which is  also to support the forearm. It
                              will be noticed, that the shoulder is kept
                              up  by the sling, out by  the pad,  and
                              back by the bandage.  The same objects
                              may be gained by  means of three hand-
                              kerchiefs, one  to act as the pad in the
                              axilla;  another for a sling;  and the
                              third to keep the arm close to the body
                              —the whole being stitched together.
   Another simple contrivance,  invented  by Mr. James Duncan for the
same  purpose, is a strip  of jean about a yard long, of the shape repre-
Fig. 43.
sented in  Fig. 43.  The elbow is fixed in the hole; the smaller straps
pass back  and front  of the chest  and  are  buckled over the opposite
( 
FRACTURE  OF THE  CLAVICLE.
237
shoulder; and the broad part is buckled round the  chest, confining the
arm to the side.   The whole being  in  one  piece cannot slip, and is very
available for children.  In  ordinary cases the  patient may be allowed to
walk  about in a week  or ten  days, and the cure will be completed in a
month or five wreeks.  The patient should be informed  that some little
irregularity is apt to remain.   If, however,  there is any difficulty in main-
taining  a proper position,  the  psftient must  be  confined to  bed,  and
some  additional  apparatus  be employed.   The  simplest is  a straight
splint across the shoulders, to which they  are to be  bound by the  figure
of 8 bandage ; or a splint shaped like a T,  of which the horizontal part is
bound to the shoulders;  and the vertical part passes  down the back, and
is confined by a belt round the abdomen.
   Besides these there is the clavicle bandage, which consists of twTo loops
for the shoulders, attached  to two pads resting on the scapulae,  which are
drawn together by straps and buckles ; and Amesbury's apparatus, which,
although very complex, seems constructed in a manner that prevents all
possibility of displacement.  If nothing else will do, it should be procured
at an  instrument-maker's.
   [In the year  1828, Dr. Fox, of this city, published an account of an
apparatus which he contrived for the treatment of this fracture, and which
is now very generally employed in this country.
   The apparatus of Dr. Fox consists of a  firmly stuffed  pad of a wedge
shape, and about half as long as the humerus, having a band attached  to
each  extremity of its upper or thickest margin ; a sling to suspend the el-
bow and forearm, made  of strong muslin, with a cord attached  to the hu-
meral extremity, and another to each end of the carpal portion ; and a ring
made of muslin stuffed  with cotton to encircle  the  sound shoulder, and
serve as means  of acting upon and securing the sling.  The  apparatus is
applied thus:—Pass the arm of the  uninjured side through the ring, so
that the latter may surround the shoulder;  press the  thick end of the pad
firmly against the summit of the axilla of the affected side, and carry the
bands which are attached  to it, one in front of, and  the  other behind the
corresponding shoulder, to cross upon the root of the neck and traverse
the chest obliquely, before and behind, and to be tied to the ring;  then
having fixed the elbow and the forearm corresponding with the fractured
clavicle in the sling, conduct its posterior cord behind the thorax,  and the
 two anterior cords  in  front of it, and secure  them  to  the ring.  The
shoulder can-be operated upon very powerfully by means of these co»ds;
it can be thrown  upwards, or backwards  and outwards, to any required
 deo-ree, and  one of  these motions  can be  impressed upon it at pleasure,
until  the surgeon shall be satisfied with the position of the fragments.
   Soft pads of cotton should be interposed between the surface  and the
 apparatus at different points;  and,  from time  to time, when  the surgeon
rearrano-es the dressings, he should endeavour to make the pressure bear
 upon parts  of  the surface which have not previously, or recently, been
 acted upon.   The point of the elbow  will  require protection  in this way,
 frequently it is well to make a circular aperture in the sling, and, having
 covered it with  a flattened mass of cotton,  to allow the point  of the elbow
to sink into it.
   If the fracture is comminuted, a compress may be  placed over the frag
 ments, to assist in the securing of perfect apposition. 
238
FRACTURE  OF  THE  SCAPULA.
                                      Fractures of the clavicle, treated
              FiB- 44-               by this apparatus, are daily dismissed
                                   from the Pennsylvania Hospital, and
                                   by surgeons in private practice, cured
                                   without perceptible deformity; and
                                   no one who has employed it will be
                                   disposed to use any other as a sub-
                                   stitute.
                                      The  annexed  drawing  exhibits
                                   this dressing as applied.  (Fig. 44.)
                                   A mere  inspection of it will  show
                                   the advantages of this apparatus, in
                                   the complete performance of the re-
                                   quisite evolutions of  the shoulder,
                                   the exposure of the injured parts, its
                                   lightness, and the avoidance of im-
                                   pediment  to  respiration,  and  of
                                   pressure upon the mammary glands
                                   when it is applied to females.
  Latterly, an entirely novel method has been  instituted in  France by M.
Guillou; this gentleman reported it to the Academy of Sciences of Paris,
and  the  description of his mode  of treatment was published in full in
" L'Abeille Medicale," for October, 1847; the following summary is taken
from that journal:
  The apparatus consists of five pieces,—1st, of a sling made  of  a hand-
kerchief of proper length; 2d, of a cravat folded in  the middle ; 3d, of a
body-bandage formed  of a towel; 4th, of a square cushion of linen, thicker
in the middle than along the margins ;  5th, of a pad for the axilla, having
a band of about a foot and a half long attached to its base on each side.
  In the adjustment of the apparatus, the pad  is placed in the axilla of
the injured side, and  secured  in this position by crossing its bands upon
the sound shoulder; the forearm fe then thrown behind the back and sup-
ported by the sling, which is passed around the neck, and  made longer
or shorter, according to the degree of force which it may be necessary to
exert upon the external fragment of the clavicle, since  the more the fore-
arm is raised, the more  the external fragment will  be  thrown outwards,
backwards and upwards ; in order  to confine the arm securely  in this po-
sitiQn, the body-bandage is applied, to  compress the lower part of the hu-
merus against the thorax, while the cravat band acts in a similar  manner
upon the upper portion of the arm, being wrapped around this  part of the
humerus, and fastened upon the sound shoulder; to increase the power
of the cravat, the square cushion is inserted between it  and the back, and
the cravat and the body-bandage are pinned to it.
  M. Guillou has employed this method of treatment for some years, and
prefers it to all others.—Ed.]
  IV. Fractures of the Scapula.—The body of  this bone  may be
broken across by great direct violence.   One case is known also in which
it was fractured by muscular action.*   The symptoms  are, great pain in
moving the shoulder, and crepitus;  which  may be detected by placing one
hand on  the acromion or  spinous process, and moving the shoulder or the
inferior angle with the other.
                * Quoted in Ranking" s Abstract, vol. ii. p. 104.
 
FRACTURE  OF THE  SCAPULA.
239
   Treatment.—A roller must be passed round the trunk, and a few turns
oe made round the humerus, so as to fix the arm to the side, and prevent
all motion.  Bleeding, or at  all  events  purging and low diet, will be re-
quired to avert inflammation of the chest.
  Fracture of the Neck of the Scapula, by which is meant an oblique
fracture, detaching the coracoid  process and glenoid cavity from the rest
of the bone, is a  rare  accident,  insomuch that some  surgeons doubt its
existence.*
  The symptoms  described by Sir Astley Cooper are the following:—The
shoulder appears sunk, and the arm lengthened; the acromion is unusually
prominent, and the  deltoid dragged down  and flattened ; the head of  the
humerus can be felt in the axilla; and on  placing one hand or one ear on
the acromion,  and moving the shoulder, crepitus may be detected.  Cre-
pitus  may also be felt on pressing the coracoid process, which  is  situated
deep  below the clavicle,  between the margins of the pectoral and deltoid
muscles.  The accidents with which this fracture is most likely to be con-
founded are fracture of  the neck of the humerus,  and dislocation of  the
shoulder-joint; the  symptoms of which should be carefully studied and
compared.  The  existence of crepitus, and  the fact that the surgeon can
move the shoulder freely, (although with great pain,) are the chief points
of diagnosis between this accident and dislocation.
   Treatment.—The shoulder must be supported by the same sling, band-
age, and pad that are used  for fracture of the  clavicle ;  but a short sling
from  the axilla of the injured side to the opposite shoulder should be used
in addition to  the long sling from the elbow to  the shoulder.   Union may
occur in  seven weeks.  Bleeding, leeches, purgatives,  rest  in  bed, and
warm fomentations, will be necessary for the  contusion with which  this
fracture is accompanied.
   Fracture of the Acromion  is known  by a flattening of the  shoulder,
because the fractured  portion is drawn down by the deltoid ; and by an
evident inequality felt in tracing the spine of the scapula.  It may be dis-
tinguished from  any  dislocation,  by  noticing  that the humerus may be
freely moved  in any direction, and that, on  slightly raising the  shoulder,
the fragment is restored  to its place.   This is also a  rare accident;  and
Mr. Fergusson believes that, in some of the supposed cases of ligamentous
union, the detached portion was never united by ossification to the  rest
of the bone from  birth.
   Treatment.—The same bandages, &c,  are to be applied as for fracture
of the clavicle ; but great care must be taken to raise the elbow thoroughly,
so that the head of the humerus may be lifted up against the acromion  and
keep it in its place.  Moreover, no  pad must be placed in the axilla ;
otherwise the  broken part will be pushed  outwards too much.   Union  is
almost always ligamentous,  owing to the difficulty of keeping the parts in
strict apposition.
   Fracture of the Coracoid Process is a rare accident, caused by sharp
blows on the front of the shoulder.
   Symptoms.—The patient is unable to execute the motions performed by
the biceps and coracobrachial is, that  is,  to bring the arm  upwards  and

  • Mr. May, of Reading, relates a case of this fracture (Med. Gaz. 8th Oct. 1842)  nap.
pening to a young lady, and caused by her throwing her necklace over her shoulder.
He ascertained that  there was no dislocation, and no fracture either of the humerus  oi
clavicle. 
240
FRACTURE  OF THE  HUMERUS.
 forwards;—and motion and crepitus of the detached process may oe felt
 by  pressing with the  finger between  the pectoralis, major and  deltoid,
 whilst the patient coughs or moves his shoulder.
    Treatment.—The humerus must be  brought forwards and inwards, so
 as to relax the biceps and  coracobrachialis, and  must be  confined to the
 trunk.
   V.  Fracture of the Humerus.—Fracture of the shaft will be known
 at a glance by the limb being bent,  shortened, and helpless, and by the
 crepitus felt when it is handled.
    Treatment.—The fracture may be reduced by drawing the elbow down-
 wards, whilst the shoulder is  steadied.  Then the whole limb, from the
 hand  upwards, is to  be evenly bandaged.   Next, a long padded splint
 should be placed on the inner side of the humerus,  one  end of it pressing
 against the axilla, the  other against the  inner condyle;—a similar splint
 on the  outside, resting against the acromion  and external condyle;—one
 in front, and another  behind; and  these are to  be fastened by tapes;
 lastly, the limb may be confined to the side for the sake of greater security,'
 and the hand  and forearm  be supported by a sling; but  the elbow must
 not  be raised up;  otherwise the fracture will be liable to be displaced.
   Fracture of the Neck  of the Humerus is caused by great direct
 violence, and is attended with much swelling.  It may occur either at the
 anatomical neck,—that is, above the tubercles:—or, at the surgical neck,
 or just below them.   The former form occurs  sometimes to children,  but
 the  latter is by far more frequent.
   Symptoms.—The patient  is  unable to raise the  arm.   The shoulders
 seem flattened, but there is no hollow below the acromion,  as  there is in
                   dislocation.  The head of the bone may be felt in its
                   socket,  and the broken end of  the shaft may  be  felt
                   projecting either in  the axilla, or else in front, near the
                   coracoid process of the  scapula.   By grasping  the
                   head of the bone and rotating the elbow, the fractured
                   shaft may be felt to  move  independently of the head.
                   The natural position of the parts is restored when  ex-
                   tension  is  made  by drawing the elbow downwards,
                   but the  deformity returns immediately that the  exten-
                   sion is discontinued; and during these  movements,
                   crepitus may be felt. There is greater mobility in  the
                   fracture below the tubercles, than in that above them.
                      Treatment.—The same  splints, bandages, &c,  are
                   to be used  as in the last case ; and a pad to be placed
                   in the axilla.   The forearm  should be lightly sup-
ported with a  sling,  but neither in  this  nor in the last case  should  the
elbow be forcibly raised.  The great secret in  managing both is to o-et a
good purchase against the axilla and the inner condyle with the innermost
splint.
   It is a good plan in fractures of the upper part of the humerus, as soon
as pain and inflammation are abated and the patient  is able  to leave  his
bed, to  apply  a large  piece of pasteboard, or of Mr. Smee's gummed
sheeting, or of the soft leather sold for splints, all over the  shoulder, and
down the outer side of the arm to the elbow, instead of  the outer splint;
'»!■the inner splint must in no case U dispensed with.
   t racture with Dislocation ~ Sometimes the head of the humerus is
 
FRACTURES  OF  THE  FOREARM.
241
 not only broken off from its neck, but  dislocated  also  from the glenoid
 cavity.  It can be readily felt in  the  axilla, and can also  be felt not to
 move when the elbow is rotated.   The  broken end of the  shaft must  be
 brought into the glenoid cavity, but it will be very difficult, if not impos-
 sible, to restore the head of the bone to its place.   The  arm should  be
 kept  motionless witn a sling and figure of 8 bandage till inflammation has
 abated, and then passive motion be resorted to ; but the patient should  be
 early informed that the power of raising  the arm will be in a great measure
 lost.*
   Fracture  of  the lower extremity of  the Humerus  may present
 many varieties.  (1.) There may be an oblique fracture above the  condyles;
 — which  usually happens to children.   The radius  and ulna,  with the
 lower fragment,  are drawn upwards  and backwards, as  in  dislocation:—
 but the natural  appearance  of the parts is  restored by extension.   (2.)
 Either condyle may be broken off; and the fracture may or may not extend
 into the joint.   (3.) There may be one fracture between the two  condyles,
 and another separating them both from  the shaft.  All these injuries may-
 be distinguished from dislocation of the elbow by noticing that the motions
 of the joint are free, and are attended with crepitus above the elbow; and
 that the length of the fore-arm, measured between  the  condyles of the
 humerus and the lower extremities of the radius and  ulna, is the same as
 on the sound side.
   Treatment.—The fore and upper arm  should be bandaged, and a  piece
 of pasteboard, gummed sheeting, or leather softened  in water, should  be
 cut to a right angle, like the letter L, so  as to  fit the elbow when bent, and
 should be applied on the inner and outer sides, and be retained by another
 bandage.   Besides this, an angular splint may be employed.  It is  com-
 posed of two  pieces joined at a right angle; one of  which is placed be-
 hind  the upper arm, and the  other below7 the  forearm.  But if the injury
 was attended with much violence, the patient must be confined to his bed
 for some days with the arm on a pillow, and  leeches and lotions be em-
 ployed to reduce the inflammation and swelling.  Passive  motion of the
 joint  should be commenced in a fortnight or three weeks ;—but the patient
 should be warned that it is very difficult  to avoid all  deformity  and loss
 of motion.
   [It  will be found more convenient in practice to apply an angular splint
 upon  the inside of the arm and forearm,—the hand being semi-pronated,
 the thumb  directed upwards; or upon the front of the limb,—the  hand
 being supine :  in the former case the splints should be  made flat, in the
 latter  they may be grooved.   A simple joint may be made at the junction
 of the two splints, so that the angle can be altered at pleasure, and adapted
 to the varying positions  in which the arm may be placed from day  to
 day.—Ed.]
   VI. Fracture of the Forearm.   Fracture of the olecranon may be
caused by direct force, or by violent action of  the triceps muscle.
   Symptoms.—The patient easily bends  his limb, but has great pain and
inability in straightening it.  A hollow is felt at the back of the joint, be
cause  the broken part is drawn  from half an inch to two  inches up the
arm;  but sometimes, when the ligaments are  not  torn through, this  dis-
placement may be very trifling,  or altogether absent.
   Treatment.—The limb  should  be placed  in a straight  position,  and
    * For cases, vide Sir A. Cooper on Fractures, and  Fergusson's Pract. Surgery.
       21                        o 
242
FRACTURES  OF THE FOREARM.
 leeches and evaporating lotions be used till swelling and tenderness suo-
 side.  Then the forearm having been bandaged, the olecranon  should De
 drawn down as much as possible, and the roller, continued from the fore-
 arm, should be passed  round above  it, and  then  back again  about the
 elbow in a figure of 8 form.   Then the whole upper arm should  be rolled,
 in order to prevent contraction of the triceps ; and a splint must  be placec
 in front, so as to keep the arm straight.   Passive motion should be com-
 menced in three weeks.  Union will be ligamentous.
   Compound fracture of the olecranon is far from  an uncommon conse-
 quence of violent blows or falls on the elbow; and it is often followed by
 protracted disease of the joint.   The part must be bathed and fomented;
 any loose fragments of bone be extracted ; the wound be closed as it best
 may ; the water-dressing be  applied, and the  elbow be kept straight and
 motionless with a splint;—leeches, &c. must be used to reduce inflamma-
 tion, and when the wound is healed, and the joint free from active disease,
 passive motion must be  employed to restore it to its proper uses.  If the
 bones are so excessively comminuted, as to  render it probable  that the
 process of reparation will be tedious and exhausting, excision of the joint
 should be  performed; unless indeed the injury is so very severe as to
 render amputation indispensable.
  Fracture of the Coronoid Process is very rare.   It is caused by the
 action  of the brachialis muscle.  Mr. Liston gives a case of it which
 occurred to a boy of eight years old, and was caused by his hanging with
 one hand from the top of a high wall.
  Symptoms.—Difficulty of bending  the elbow, and dislocation of the
 ulna,—the olecranon projecting backwards.
   Treatment.—The arm must be bandaged, and kept at rest in the bent
 position.   Union will be ligamentous.
  Fractures of the  shafts of the Radius and Ulna, together or
 singly, are known by the ordinary signs of fracture, especially by the cre-
 pitus felt on fixing the upper  end, and rotating or  moving the other.
 The objects in the treatment are to prevent the fractured ends  of either
 bone from being pressed inwards  towards the interosseous space, and to
 prevent the  upper fragment  of  the  radius from being more supinated or
 everted than the lower.
  Treatment.—The fracture  is easily reduced by extension from  the wrist
 and  elbow.   Then the  elbow being bent, and the forearm placed  in a
 position intermediate between pronation  and supination  (that is to  say,
 with the  thumb uppermost), one splint should be applied  to the flexor
 side, from the  inner condyle  of the humerus to the palm of the hand; and
 another from  the  outer condyle of the humerus  to the  back  of the
wrist.  Both  splints should  be well padded  along their middle, so  that
 they may press the muscles  into the interosseous space, and prevent the
 bones from  coming together.  The hand should be kept in a line with the
forearm.  If both bones be  fractured,  the splints should extend to the
ends of the fingers.
  [The indication mentioned in  the  text,  viz., "to  prevent the upper
 fragment of the radius  from  being  more supinated or everted  than the
lower," cannot always be perfectly accomplished by the plan of treatment
 recommended; hence, as Mr. Lonsdale insists, (Treatise on Fractures,)
the imperfect rotatory movement which often remains to the forearm after
iracture.  The muscles which throw the upper fragment of  the radius in 
FRACTURES  OF THE  FOREARM.
243
supination are the supinator radii brevis and the biceps flexor cubiti; and,
agreeably to Mr. Lonsdale, these muscles  combined  exert  more power
than the pronator muscle which operates  upon the same fragment,—the
pronator radii teres; hence the upper portion of the radius is placed in  a
much more supine position than the lower, if the palm of the hand is
turned towards  the  chest  during the  treatment of the fracture, with the
thumb presenting directly upwards.   To obviate this difficulty, Mr. Lons-
dale advises  that the hand be placed supine, and that it be retained in
this position,  until the union of the fragments has taken place, by splints
bandaged upon the front and back of the forearm.—Ed.]
  After the first week, the splints may be removed and  the starched
bandage be substituted.   A dry roller is to  be first applied from the hand
to a little above the elbow.  This is to be covered with  several layers of
roller imbued with  starch; but the part should still  be supported by a
splint till the starched rollers become dry.   The cure is generally complete
in a month or five weeks.   It must be recollected that the bandage  must
not be applied too tightly, so as to press the fractured extremities towards
the interosseous space.
  Fracture  of the  lower extremity of the Radius,  about half an
inch  or an inch  above the wrist, is often caused by falls on the hand, and
may  be readily mistaken for dislocation of the wrist, as the hand with the
lower fragment is drawn upwards  and backwards by the extensor muscles.

                               Fig. 46.
The distinction is, that if the hand be  moved, the styloid process  of  (he
radius will move with it, if there is  a fracture ;—but not if there is .a dis-
location.  Sometimes the distortion is so great,  that the ulna is dislocated
forwards on the carpus ;—and sometimes  the  fracture is  confined to  the
posterior rim of the articular surface  of the radius, which is  obliquely
broken off, and the hand partially dislocated backwards.*
   Treatment.—These fractures must  be treated  as the  other fractures
of the forearm, but care must be taken to apply pads against the projecting
points of the fractured bone, [one upon the  dorsal aspect  of the forearm,
over the upper extremity of the inferior fragment of the radius,—and  the
other upDn the palmar face, over the inferior extremity of  the upper frag-
ment,—when, as most commonly happens, the hand is drawn upwards on
the back of the forearm; if the lower fragment of the radius rests  upon
the front of the forearm, the position of the compresses must be modified
accordingly,—Ed.] so  as to keep them in  their places.    Passive motion
must be commenced in three weeks or a month, but the  patient should
always be  informed, that many months may elapse before  the use  of  the
wrist  and  fingers  is restored, in consequence  of the irritation which  the
             * Barton, Philadelphia Med. Examiner, No. 7, 1S38. 
244
FRACTURES  OF  THE RIBS.
 lower extremity of the shaft of the radius produces in the sheaths of the
 flexor tendons:  amongst which it is dragged by the pronator quadratus.
   VII. Fracture 01  the Hand.—The carpus is rarely fractured without
 so much other injury as to render amputation necessary.  Fracture of the
 metacarpal bones, or of the phalanges, will be readily recognised.  With
 respect to compound fracture of these parts we may observe, that no  par
 of the hand should be  amputated unless positively necessary, and even
 one finger should be saved if it can be done.
   Treatment.—For fractures of the carpus, middle  metacarpal bones, and
 first phalanges, it is  a good plan to make the patient grasp  a ball of  tow
 or some other soft  substance, and bind his hand over it; for fracture of
 the lateral metacarpal bones, it  is better to support the hand  on a flat
 wooden splint, cut into the shape of the thumb and  fingers.   If one finger
 only be fractured, it may be  confined by a thin lath or pasteboard splint.
 It must be  recollected that  the  palmar surfaces of the metacarpal  and
 digital bones are concave.  They must, therefore, be slightly padded be-
 fore  they are bound to any flat  surface,  or they  will unite crookedly.
 [When the soft parts of the hand  are much injured, as very generally
 occurs in fractures of this portion of the upper extremity, the employment
 of cold water by  irrigation, as before  explained, will be found  to be the
 best means of combating the inflammation.—Ed.]
   VIII.  Fracture  of the  Ribs is  generally situated  in  their anterior
 half, and is commonly caused by direct violence, such as blows; the bone
 giving way  at the point struck.   Sometimes, however, it  is caused  by
 indirect violence ; as for instance, when the chest is violently compressed
 between two points.   In 1837, several people were crushed to death in a
 crowd in the Champ de Mars in Paris, and many of them were found to
 have several ribs broken in this manner.   Sometimes, in old subjects, one
 or more ribs are broken by violent coughing.*
   Symptoms.—Fixed lancinating pain, aggravated  by inspiration, cough-
 ing,  or any other motion.   By  tracing the outline  of the  bone, or by
 placing the hand or the stethoscope  upon  it, crepitus may be felt during
 the act of coughing  or inspiration, and the patient  is sensible of it like-
 wise.   If the fracture be situated near the spine, or if the patient be very
 corpulent, it may  be  difficult to detect it with certainty, but this is of little
 consequence ; for in every case when a patient complains of pain on inspi-
 ration  after a blow on the chest, the treatment is the same.
   Treatment.—The indications are, (1.) To prevent all motion of the ribs,
 by passing a broad flannel  roller, or a towel fastened with tape, round the
 chest,  so tightly  that  respiration  may be  performed  solely by  the dia-
 phragm.  The same end may be obtained by Dr. Hannay's plan of envel-
 oping  the chest tightly with broad strips of diachylon plaster.f   (2.) To
obviate inflammation of the chest,  and diminish the  arterialising duties of
the lungs by bleeding, rest in bed, and low diet; to unload the bowels by
purgatives, so as  to  enable the diaphragm to  descend freely; and to ad-
 minister opiates to prevent  pain and cough.
  If several ribs are broken on each side, it may happen that no bandage
can be borne, and the case becomes highly serious.   Quietude and deple-
tion are the only remedies.

  * See an interesting paper on Fracture of the Ribs, by M. Malgaigne, in the Arch. Gen.
 i» Med. 1838, quoted in Forbes, Rev. vol. vii. p. 554.
  ' D-. Hannay's method of treatment is related in banking's Abstract, vol. iii. p.  116 
FRACTURES  OF  THE  PELVIS.
245
   Emphysema, a swelling  caused by the presence  of  air in the cellular
tissue, is an occasional complication of this fracture.   It is produced in
the following way:  The extremities  of the fractured  rib perforate  both
pleure and wound the lung.  In the act of inspiration, air escapes  from
the lung into the cavity of the pleura, and from thence through the wound
in the pleura costalis into the  cellular tissue of  the trunk.   Emphysema
forms a soft puffy tumour, that crepitates and disperses on pressure.
   Treatment.—Provided the air escapes freely from the cavity of the chest,
little  inconvenience  results, and if the skin  merely be very much dis-
tended, it may be punctured.  But if the air accumulates in the pleura and
compresses the lung, which will be known by great dyspnoea and a  hollow
sound on percussion, — and if the breathing is not relieved by free deple-
tion,  an aperture must be made into the chest to  let the air escape. — See
the Chapter on the Injuries of the Chest.
   IX. Fracture of the  Sternum.    Symptoms.—Crepitus may  be felt
during inspiration or other  movements of the trunk, and displacement (if
any) can be detected by examination.
   Treatment.—The same as for fractured ribs.
   X. Fractures of the Pelvis can be caused only by most tremendous
violence,  and are often attended with some fatal  complication ; — such as
laceration of the bladder or rectum, or of the great arteries or veins.
   Treatment.—The only thing to be done is, to place the patient  at per-
fect rest, and in as easy a position as possible;—to keep a catheter in the
bladder ;  to make incisions if  urine is  extravasated into the perineum, as
it will be  if the urethra is lacerated by fractured portions of the rami of the
ischium and  pubes, and to treat any symptoms that may arise.   If it can
be  borne, a  broad belt  may  be passed round  the pelvis ; and another
under the nates, which might be attached to a pulley over the bed,  so that
the patient may raise the pelvis without exerting any of the muscles
attached to it.
   There are  some cases of  fracture of the os innominatum passing through
the acetabulum, and caused by falls on  the hip,  which might be  mistaken
for fracture of the cervix femoris.  For  instance, in some cases related by
Mr. Earle,* the foot was everted, and there was  loss of prominence of the
trochanter; but there was  no  shortening, and  the limb could be  turned
freely outwards, which motion is highly painful  after fracture of the  neck
of the femur.  The diagnosis will be guided chiefly by  the crepitus felt on
applying the  stethoscope to the ilium, and by examination per anum.  The
patient must be kept  on a fracture-bed.   One of  Mr. Earle's cases was
cured in  eight weeks.
  Fracture of the os coccygis, or of the lower extremity of the sacrum,
may be caused by violent  kicks or falls ; —the former may occur  during
parturition to women who have children after the coccyx is  united  to the
sacrum.   The  loose portions  must be replaced  by introducing the finger
within the rectum, and the bowels must be kept relaxed, so that no dis
turbance  may be occasioned by hard stools.
  XI. Fractures of the  Femur present  many varieties, which must be
carefully  studied;  because, as Pott observes, " they  so often lame the
patient and disgrace  the surgeon."   We must, therefore, treat separately

  * Earle on Fractures of the Pelvis, Med. Chir. Trans, vol. xix.; see also case Uxi. in
the last ed. of Sir A. Cooper on Fractures and Dislocations.
       21* 
246
FRACTURES OF THE  FEMUR.
of fractures of the neck of the femur;  of the shaft just below the trochan
ters ;  of the centre of the shaft, and of the condyles.
  Fracture of the  Neck of  the  Femur  may occur either within the
capsular ligament or external to  it.   The fracture internal to the cap-
sule  is the more common, and  is  generally caused by indirect violence

              Fig. 47.                           Fig. 48.
that is, by a slight force acting on the lower extremity of the limb, as hap-
pens  in  slipping off the curbstone;  sometimes, howTever, it is produced
by falls or blows on  the  hip.   It  is very rare in persons under fifty; but
very common in old  people, especially old women ;  because, in addition
to the changes which all the bones experience in  advanced life, — the
thinness of the cortex, sponginess  of  the cancelli, deficiency of the  bone
earth, and loss of elasticity of the animal matter, — the neck of the  femur
is peculiarly atrophied: it is shortened, and sunk from the oblique to the
horizontal position ; — changes that cannot fail  to  render it  more  easily
fractured.*
  Symptoms.—After a blow or  fall, the patient finds  himself unable to
stand, and complains of  great pain, increased by motion, and principally-
seated at the upper and inner part  of  the thigh.   The leg is from half an
inch to  two inches  shorter than the other;  the foot is  turned outwards;
the  heel  rests in the interval between the ankle and tendo Achillis of the
other leg; crepitus may be detected  if the hand  or the stethoscope  be
placed on the trochanter, whilst the limb is drawn to its proper length and
rotated ; the trochanter generally projects less  than on the other side; and
the  limb may generally be freely moved, although with  great pain, espe-
cially if  it is abducted.

  *  In old bed-ridden persons the neck of the femur is sometimes so shortened that the
nead is brought into contact with the shaft; and at the part  where the capsular liga-
ment is inserted, the bony texture is sometimes completely absorbed, and its place sup
plied with a ligamento-cartilaginous substance ; irregular deposits of bone are formed
also on the top of the shaft of the femur.   These appearances  have been mistaken for
united fracture.  Figs. 47 and 48 exhibit the effects of senile atrophy.
 
FRACTURES OF THE CERVIX FEMORIS.
247
   It may be mentioned, that the shortening very          Fig- 49.
often does not occur till some days after the acci-
dent ;—which may be accounted for by supposing
that a part of the fibro-synovial  investment of the
neck of the bone was not entirely torn through at
first, but gave way afterwards during the patient's
movement in bed ;—sometimes  even  the  whole
diameter of the  bone is not  completely fractured;
and in this latter case the shortening will be alto-
gether absent.   Moreover, in some few cases the
limb is  turned inwards instead of outwards.  The
practical rule, however, is, that when an  old person
has tumbled  down, and complains of pain in the
hip, and is unable  to stand, this fracture should be   -
carefully looked for, although there may be no ap-
parent shortening nor eversion.*
   Fracture of the  neck of the femur, internal to
the capsular ligament, does not unite by bone, ex-
cept in a few rare  instances.   The  reason of this
want of union appears to be, that it is contrary to
the provisions of   nature for the lymph which  is
effused  after fracture within  any joint whatever to
be converted into a bony callus ; because the mo-
tions of the joint would be completely annihilated
by  it.   Besides this,  it may be seen that bony
union is very unlikely to occur:—First. Because of the inadequate nutrition
of the upper fragment, which is supplied only by the small vessels of the
ligamentum teres.   Secondly.  Because the fracture, being separated from
the cellular tissue by the capsular ligament, cannot be assisted by a provi-
sional callus, which is secreted by the tissue surrounding the fracture.  Yet
it is remarkable  that bone is often deposited on the outside of the capsular
ligament, both after this fracture and after disease of the joint; which bone
is equivalent to the callus formed after an ordinary fracture ; but is in this
instance prevented  by the capsular ligament from aiding in  the work of
reparation.!   Thirdly. Because  the  fractured surfaces cannot be easily-
kept in  apposition,  or pressed against each other.   Fourthly. Because the
patients, being old, have neither time  nor  constitutional vigour sufficient
to  effect the cure.   So that in general this  fracture  either unites  by liga-
ment, or, more commonly, does  not  unite  at all; but  the  stump  of the
cervix becomes rounded and covered with a smooth porcellanous deposit,
and plays in a socket formed by the hollowing and absorption of the head.
The capsular ligament becomes excessively thick, and  so does the obtu-
rator externus muscle, so as to support the weight of the body.
  The few instances in which this fracture does unite by bone, are stated
by Sir A. Cooper to be,  1st, those in which the periosteum is not torn
  * Three cases, in which the whole diameter of the cervix was not broken  through,
are narrated by Dr. Colles in the Dublin Hospital Reports, vol. ii. p. 339.  Mr. Guthrie
relates a  case in which the limb was at first turned out  as usual, but afterwards  sud-
denly turned inwards, giving him some annoyance lest he had mistaken the nature of
the injury.  Med. Chir. Trans, vol. xiii.
  + Instances of this may be seen in a  preparation given by Mr. Earle to the Huntenan
Mu««m, and marked  137-294, F.; and also in one in the King's College Museum, re
ferred to  in Mayo's Pathology.
• 
248
FRACTURES OF THE  FEMUR.
through, so that the fractured surfaces are not separated, and the nutrition
of the head of the bone continues; and 2dly, those in which the fracture
is partly internal to the  capsular ligament and partly external to it.  But it
must be evident, that in the former of these cases there will be no short-
ening, crepitus, nor eversion; in  fact, none of the distinctive symptoms
of fracture: and that the real nature of  the injury can  be discovered only
by dissection.*
   Treatment.—It is of  no use to sacrifice the  patient's little  remnant of
health and strength, and run the risk of  producing  sloughing of the nates
by long confinement to  bed, in the hope of procuring union by bone.  But
he should be kept in bed for a fortnight, till pain  and  tenderness abate;
with one pillow under the whole length  of the limb, and another rolled up
and placed under the knee.   Then he may get up and sit in a high chair,
and shortly begin to crawl about with crutches ; and in time he will regain
a tolerable use of the limb, especially if not very corpulent.   The sole of
the shoe must be made  thick enough  to counteract the shortness  of the
limb.
  Fracture external to the capsular ligament resembles the last in
many general  features, but differs  in the  following points ;  1.  It is always
                                  caused by direct violence,  such as se-
                                  vere blows or falls on the hip, by which
                                  the neck of the bone is driven into the
                                  cancelli  of the  trochanter  major.  2.
                                  It  may occur  to persons of any age;
                                  whereas the  fracture  internal to the
                                  capsule  very  rarely  happens  before
                                  fifty.  3.  It is not attended with so
                                  much  shortening  and  eversion.   4.
                                  Crepitus is much more easily felt, be-
                                  cause the shortening is not so great.
                                  5. It is caused by direct violence, and
                                  therefore is attended with  great fever,
                                  pain,ecchymosis, and swelling—some-
                                  times enough  to prove fatal;—where-
                                  as, in fracture' internal to the capsule,
                                  caused by falls on the feet, there  is
                                  very little  local or  constitutional  dis-
                                  turbance after the first week.
                                     Treatment.—This fracture will readi-
                                  ly unite by bone, provided the patient's
age or other circumstances do not prevent it;  and measures should there-
fore be  adopted to ensure a constant and correct adaptation of the broken
parts- and, we may  observe, that in any case  where there  is a doubt
whether the fracture is  internal to the  capsular ligament, or external to it,
the tieatment  of the latter  variety should  be adopted, if the  patient's
strength is sufficient to  enable him to bear the  confinement.
   The indications are, to preserve the length of the limb, and  to keep  the
great trochanter pressed towards the acetabulum.
   The principal method now employed  is that of the long straight splint.
  * Vide the last edition of Sir A. Cooper on Fractures and  Dislocations of the Joints,
 M2, pp. 129 et seq., in which the whole  subject is fully discussed.  [See also R. W.
Smith's Treatise on the same subjects, Dublin, 1847.—Ed.]
 
FRACTURES  OF  THE  FEMUR.
249
The common straight splint of Desault  extends  from the pelvis  to  the
foot, and has a footboard with straps, &c, at the bottom.   But the  simple
splint employed by Mr. Liston, and depicted in the adjoining cut, is much
better.  It is a simple deal board, of a hand's breadth for an adult,  but
narrower and slighter for a young person.  It should reach from opposite
the nipple to four or-five inches  below the foot.  At its upper end it  has
two holes, and at its lower end two deep notches ; with a hollow for the
outer ankle.  " A pad of corresponding length and breadth is attached by
a few pieces of tape;  a roller is split  at  the  end, and having been tied
through the openings in the top part of the splint, is unrolled as far as the
bottom, where it is fixed for a time.   The limb  must now be gently ex-
tended from foot and pelvis to its proper length, and  must be bandaged
from the foot to the hip.   The splint is next applied to the outside of the
limb ; and the roller before sppken of must be repeatedly passed round the
instep and ankle, and through'the notches, so as to secure the foot, and
must then be carried up the  leg.   A perineal band, composed of a large
soft handkerchief padded with tow and covered with  oiled silk, must be
put round the groin, and be fastened firmly to the holes at the top  of the
splint;  and, lastly,  a few turns of broad bandage are  to be  passed round
the trunk."*
   In order to prevent the galling of the perineal band, and  its supposed
tendency  to draw the fractured parts asunder, Mr. Fergusson had adopted
the plan in some cases of making counter-extension from a strong stay of
jean, accurately fitted  to the  upper  third of the opposite  thigh;—from
which a band extends back and front  to the upper end of the splint.  This
is very  comfortable, and obviates the necessity of the band round the belly,
since it draws the splint towards the body.
   Mr. Fergusson has also devised a  modification of the straight  splint,
which has the merits of cheapness and simplicity, and at the same time
seems likely to answer almost every purpose of a splint that can be required
in treating fractures of the lower extremity.f  It  consists of a long iron
bar, of  the length of the ordinary straight splint;  but  the upper half of it
can be  unscrewed and removed, so as to make it a short splint, for frac
tures below the knee.   It has a foot-board, which can be adapted to any
leno-fh of  limb ;  which can be moved to  any distance  from  the splint, so
as to adapt the instrument to the thickness  of the patient's  leg; can be
adapted to any  degree  of flexion  or extension  of the ankle-joint; and
what is of extreme  cons ■■quence, can  be  turned inward or outward, so as
to rotate the limb on its long axis, and prevent inversion or eversion of the
foot. (See fig. 52.)   The advantage of this,  in treating fractures and dis-
locations of the ankle, must be obvious.
                 * Liston, op. cit. p. 88.
                 t It is manufactured by Weiss in the Strand. 
250                FRACTURES OF  THE FEMUR.

                                Fig. 52.
S
  [American surgeons generally prefer the treatment of fractures of th
thio-h in the straight position.  Several kinds of apparatus  have been de
vised in  this country for the cure of this injury, among which those of
Physick, Hartshorne, and Gibson are most used.
            The  chief objection  to Desault's apparatus is, that by it the
         extending and counter-extending forces do not act sufficiently in
         thedine of the axis of the limb.  This difficulty is obviated by
         the very simple modification  which Dr. Physick made of the ap-
         paratus.  This consisted in making the outer splint long enough
         to extend from the axilla to  about four inches beyond the  sole
         of the foot,  and  in attaching  to  its inner side, at  about  two
         inches above its lower end, a block, grooved on its inner margin,
         and broad enough to reach the line of the middle  of the  foot
         (fig. 53); the other component parts of  the  apparatus are the
         same as are used in Desault's.   The counter-extending band is
         best made by filling a narrow bag of muslin, about three-fourths
         of a yard long, firmly with  bran, or oat-chaff, so as to  form a
         cylinder of an  inch in diameter; to  each extremity a piece of
         strong tape should be securely sewed, for the purpose of attach-
         ing  the band to the upper extremity of the splint; when  this is
         applied, a piece of soft buckskin should  be interposed between
         it and the skin,  as a preventive of excoriation and chafing.  Ex-
         tension is best effected by means of a gaiter,  similar in shape to
         that represented in the annexed wood-cut  (see fig. 54): it should
         be made  of strong muslin lined with soft buckskin, both to be
         cut  " bias," so  that the gaiter Will set smoothly to  the ankle;
         stout tapes should be  attached to  its lower edge, one  on  each
          side, to make traction upon  it and to secure it to the splint, and
         three or four shorter tapes should be  sewed to each free margin,
          to tie the gaiter upon the anterior part of the foot.  Previous to
          its application, the ankle should be bathed with whiskey, or soap-
          liniment, or spirits of camphor, and enveloped smoothly in a
          pad of soft carded cotton ; then the gaiter should be fitted nicely
          to the part, and tied.  The following plan may be  pursued in
          arranging and applying this apparatus, or that of Desault:  place
          upon the mattrass, and in a position to correspond with the frac-
          tured limb, the splint-cloth—a piece of muslin  about two yards
          long, and as wide as the length of the inner splint,—and upon
          this arrange the strips of a bandage  of Scultetus; then  lay the
          patient carefully  upon the   mattrass, so  that the broken thigh,
 previously divested of clothing, shall repose upon the strips and the splint-
 cloth ;  next pass the perineal band under the  buttock, and tie the  gaiter 
FRACTURES  OF  THE  FEMUR.
251
around the ankle, as before directed ; the
limb being carefully steadied by an assist-              Fis- 54-
ant,  roll  the  splints  in  the cloth,  com-
mencing  at the  margins, leaving only
space enough between each side  of the
limb and the corresponding splint, thus
enveloped, to admit of the presence of
the junk-bag,—the long pad before spoken
of.   (The proper rolling up of the splints
requires  some time  and  trouble—they
should be  tightly wrapped, so that when
pressure  is used  laterally upon the limb, they may not slip, and thus leave
a larger space between them and  the leg than is compatible with the  ac-
complishment of one of the objects for which they are employed, viz., the
exercise  of an equable and firm compression upon the limb,  by the aid of
the junk-bags.)   The splints being thus  prepared  for use, extension and
counter-extension should be made by assistants, the one grasping the foot
and  ankle, and the other fixing the pelvis—by one hand passed between
the thigh and the pubis and ischium, and the other on  the outside of the
hip—while the surgeon coaptates the fragments and adjusts  the  shape of
the  thigh; he  then arranges  the bandage of Scultetus, and afterwards
presses the junk-bags and the splints firmly against the sides of the limb;
the counter-extending and extending bands should now be tightly secured
to their corresponding extremities of the long splint,—the tapes attached
to the gaiter passing over the  grooved  margin  of the block, before  de-
scribed.   To secure the limb in this  adjustment, three or  four strips of
muslin should be passed underneath the apparatus, at intervals  along the
limb, and tied across, the knot being made upon the edge  of one of the
splints, to prevent it slipping; and a broad band should likewise confine
the  upper part of the long splint to the  side.  It is sometimes advisable to
give additional support to the  foot, by tying  a strip of muslin around it.
and theri pinning the ends to the splint-cloth.   An arched frame of wire,
or of hoop, should be placed over the  foot, to protect it from the pressure
of the bed-clothes.
   The limb should be placed out from the axis  of  the body, particularly
in those  cases where  the fracture is at such a point as that the glutaeus
maximus muscle will draw the upper fragment of bone outwards.
   It is well to use the bandage of Scultetus during the first few" days after
the injury, since it makes gentle and equable pressure  upon the muscles
of the thigh,  and assists somewhat to keep the fragments of the bone in
apposition; after the first week or ten days, however, it is probably as well,
or better, to remove  it, leaving the thigh exposed to the  eye of the surgeon.
   Cold lotions  should be applied at any time, as they may  be called for
by the condition of the  soft parts;  anodyne  liniments  are  sometimes of
service in allaying muscular irritability, and in alleviating pain in the limb.
   Very excellent cures may be effected, undoubtedly,  by the use  of this
apparatus; but it is one which  demands, in its employment, the greatest
care and attention on the part of the attendant.  There are some points to
which  the editor would call particular notice :—the accidents chiefly to be
feared, as directly connected with the use of  this splint, are> excoriations
and  sloughs upon the heel, on the inner side of the knee, at the prominence
of the inner condyle  of the femur and the corresponding point of the tibia,
 
252
FRACTURES  OF  THE  FEMUR.
and in the  perineum.  These are not necessary accompaniments of the
mode  of treatment now under consideration, and with  proper care  they
will  never occur,  but without great  watchfulness they  are  exceedingly
likely to happen ; they may be avoided in this way:—
  The gaiter should be unbound  daily, so long  as it is worn, and the in-
step, ankles and heel carefully examined.  During  the  first week, or ten
days,  the  gaiter should be loosened every  morning and evening, and
these parts bathed with whiskey, or soap-liniment; this may be done with-
out in  the  slightest  degree deranging the fragments of bone, simply by
turning up the lower ends of the junk-bags, so as to give room for the in-
troduction of the hand between the splint and the foot,—the strips which
maintain the lateral pressure being securely tightened.  The inner side of
the knee should be gently rubbed  in the same way, and a little indentation
should be made in the junk-bag, corresponding with the bony prominences
of the  femur and tibia at this  point.  The perineal band  should  be loos-
ened daily,—the limb being supported the while by an assistant,  and the
lateral  compression  maintained, — and  the parts upon  which it presses
bathed, as the others.  Whenever the  apparatus is thus re-adjusted, re-
newed extension and counter-extension should be made, and in ordefthat
this may be persevered in until the end of the treatment, it is highly neces-
sary  that the splints shall be  so closely wrapped in  the cloth, and  shaL
approach the limb, on each side, so nearly, as that firm lateral pressure
may be kept up, and thus the strain upon the foot and perineum rendered
very supportable.
  It is advisable,  oftentimes, to vary the  means by which the extension
and counter-extension are effected.  Thus, after having used a perineal
band of the dimensions and form  above recommended, let one be substi-
tuted flattened in shape and  broader, ,so as to act upon a larger surface,
and thus relieve that part which has been already pressed upon.   So with
regard to  the  gaiter,—it will occasionally, perhaps, be well to substitute
for this a handkerchief folded into the cravat-shape, and  applied  so as to
press upon the instep and the point of the heel, the tails  passing from the
sides of the foot, parallel with the axis of the limb and reaching to the ex-
                                       tremity of the  long splint upon
                                       which they are tied.   (See fig.
                                       55.)  Another  mode of making
                                       extension is by means  of adhe-
                                       sive  plaster, as follows: — Cut
                                       two  very long strips, of  an inch,
                                       or more, in width,  and  apply
                                       them to the leg, commencing at
                                       a point half-way between  the
                                       foot  and  the  knee, descending
spirally to the  side of the foot, one on  each side;  then, when  adhesion
between the strip and the integuments has become firm, attach the strips
to the extremity of the long splint, as by the  other method.  This  plan
was first employed by Dr.  E. Wallace, of this city, while Resident Sur-
geon at the Hospital; he used it as a substitute for  the gaiter, which had
produced excoriation just above the heel; the editor had the pleasure of
witnessing the complete success which attended the operation of this novel
extending: band, both  in the instance  in which it was  first  tried and in
several other cases, and he would  recommend it  highly, as being perfectly
 
FRACTURES  OF  THE FEMUR.
253
secure and efficacious.   It may be proper to make use of a few turns of a
roller, or of a bandage of Scultetus, to compress the adhesive strips against
the leg; but this is scarcely called for, since the junk-bags  exercise suffi-
cient pressure of themselves.
  If there is  any disposition to excoriation or sloughing upon the points
of the malleoli, pressure should be taken off from them, by not allowing
the junk-bags to extend so  low down.   The  same accident may be pre-
vented from occurring upon the point  of  the  heel by placing a cushion
just above it, under the leg, so that the weight of the limb  shall not  fall
upon this  point.  The same simple method may be resorted to when a
similar accident threatens the hips or back,—a judicious arrangement of
pillows will often obviate  much  mischief, aided also by stimulating lini-
ments applied to the parts.   When, in spite  of these precautions, sloughing
does occur—as it sometimes will in old persons, or in those  of lax fibre,—
all pressure should be at once withdrawn from the  affected surface, and
the separation  of the dead tissue aided by the application of poultices;
afterwards stimulating washes should be  used, among the best of which is
Labarraque's solution of the chloride of soda,  diluted with three or four
parts of water, and applied to  the ulcer upon rags,  or, if the slough has
extended beneath the skin, injected from a  syringe.
   There is one objection to the employment of this  apparatus of Desault
and Physick in the treatment of fractures of the thigh, occurring particu-
larly in the upper third of the shaft—(and the same objection is applicable
to the treatment by extension in the straight position, generally):  it is
sometimes impossible to counteract, by it, the deformity which arises from
the powerful contraction of the iliacus internus and psoas magnus muscles,
which tilt up the lower end of the upper fragment.   WThen this  action is
but slight  it may be overcome,  gradually, by  compression with a splint
bound upon the anterior face  of the thigh, or by a  compress, or, finally,
by a  little elevation given  to  the lower fragment by means of a folded
sheet placed beneath the thigh, at this point.   But in very athletic patients
the muscles in question  may contract too powerfully, and then these means
will fail;  if the straight splints are retained, a permanent  deformity will
ensue and the limb will be always weak, in consequence of the imperfect
apposition of the fragments.   In such cases as these, the double inclined
plane should be substituted for the other apparatus.
   The apparatus of  Desault, improved as  above described, is, we think,
the best which has yet been contrived for the treatment of fractures of the
thigh, in the extended position.
   Dr. Gibson, Professor of Surgery in the University of Pennsylvania, has
introduced a modification  of  Hagedorn's  apparatus, which he  thus  de-
scribes (" Institutes and Practice  of Surgery,".vol. i.): — " This method
consists in extending the  patient's limbs upon a mattrass, and confining
both feet,  by gaiters, or a handkerchief,  to a foot-board which  is firmly
supported upon the ends of two splints passed through mortices near its
edges.  These  splints extend from  the  arm-pit, where they are padded
like the head of a  crutch, along each  side  of the  body,  thigh and leg,
beyond the foot, and, being well stuffed on their inner surfaces to prevent
irritation, are confined by six or eight broad  tapes  or  bandages passed
around the limbs, pelvis, chest, &c.  (See fig. 56.)
   " The principle upon which extension and counter-extension are effected
by this contrivance, will instantly be understood.   The  sound limb being
       22 
254
FRACTURES  OF THE  FEMUR.
extended, serves as a splint to the broken one.  Counter-extension then
is made  upon the acetabulum of the sound side, and extension upon the
ankle of  the injured limb, which, so long as the two feet are kept on the
same level, cannot be shortened, provided rotation of the pelvis be pre-

                                  Fig. 56.
vented.  This purpose is answered by extending the splints to the  arm-
pits, and not with a view, as might  be supposed, of producing counter-
extension from these points.  Finding that the patient, in the original
machine of  Hagedorn, (which consists of a single splint merely, and  a
foot-board,  independently of leather straps, &c.) could  incline the pelvis
towards  the affected  side,  and thereby shorten the limb, by causing the
superior fragment to descend and overlap the inferior, the additional splint
was added,  and has been found to answer completely the  end designed."
Vide Sargent*s .Minor Surgery.—Ed.]
   The fracture-bed, a contrivance consisting of four planes, one for the
trunk,  a second for the  thighs, a third for the legs, and a fourth for the
feet, each of which can be adjusted  to any length, and  to  any angle with
the others, is used by some surgeons, and is not without its advantages.
   Oblique  fracture through the Great Trochanter.—This  acci-
dent may occur at any period  of life, and is  attended  with the following
symptoms:—The limb is everted, but very little shortened ; and the  shaft
of the  bone  can be felt widely separated from the trochanter.   This  frac-
ture unites readily by bone; and the treatment required consists of exten-
sion of the  limb by the long  splint,  and a circular girth with a  pad, to
support the upper extremity of the shaft and keep the broken surfaces in
apposition.
   Fracture of  the  Epiphysis  of  the Trochanter  Major. — The
trochanter is sometimes broken off from the femur,  at the part where  it is
united  by cartilage as in epiphysis in youth.  The  diagnosis is  generally
obscure ; but we allude to the accident in order that the surgeon may be
aware  of the possibility of such an  occurrence.  The part will unite by
ligament.
   Fracture of the Femur just below the Trochanters is liable to
be followed  by great  deformity and non-union, because  the  upper  frag-
ment is tilted forwards by the psoas and iliacus muscles.
   Treatment.—If the long splint does not suffice, the best plan is to place
the patient on a fracture-bed, in a half sitting  posture, so  as to relax the
offending muscles.
  The  accompanying figure shows the influence of  the  psoas  and iliacus
in tilting  the upper fragment forwards ; and of the adductor muscles in
drawing the  lower fragment upwards and inwards. 
FRACTURES OF  THE THIGH.                255
  Fracture of the Shaft of the Femur requires no observations as to
its causes or symptoms.
   Treatment.—(1.)  The  first apparatus  that  we  shall     Fig. 57.
notice is  the  long  straight splint  before described,
whose advantages are, that it keeps the foot, knee, hip,
and pelvis immovable.
   (2.) A second plan is that of the double inclined plane.
It consists of two pieces like the letter A ;—one for the
thigh, the other for the leg, with a board to fasten the foot
to.   The whole limb  must  be  bandaged;—the thigh-
piece must be made accurately to correspond to the dis-
tance between the tuber ischii and the  bend of the knee ;
—and then one  splint is  to  be  placed from the great
trochanter to  the  outer  condyle; — a second, from the
ramus of the pubes to the inner condyle; and  a third
on  the anterior surface  of the  limb.    Perhaps it  is a
good plan to apply a fourth  splint, from  the tuber ischii
to the bend of the knee, before placing  the patient on the
plane.  Both legs should be bandaged.   The disadvan-
tage of this plan is, that the patient's bottom, sinks in the
bed,  and thus the upper  fragment is tilted forwards.
   (3.) A third plan  is that of Pott.*   It  consists in lay-
ing the  patient on  the  affected  side, the thigh at right
angles to  the trunk, and the knee  bent—with a many-
tailed bandage and four  splints,  applied between the dif-
ferent points of bone that have just been  mentioned.  The disadvantages
of this plan are, first, that the patient soon turns round on his back, drag-
ging the upper fragment away from  its right place; and, secondly, that
the pressure on the  great trochanter may cause sloughing.   The first evil
may  be prevented simply by watching the patient, and telling him to turn
round on his belly rather than on his back, if he wishes to  shift his posi-
tion.  The second  may be  remedied by placing him on his back, at the
end of a fortnight, with his knees bent up and supported by pillows.
   Every surgeon  must determine for himself what mode  of treatment to
adopt, but must never forget that care and  attention are  requisite for the
success of any plan.
   Supposing a case of veryr oblique fracture of the thigh, with great diffi-
culty in preventing overlapping of the  fragments, it is a good plan to cover
the whole limb from the  foot to the hip with soap-plaster spread on calico ;
then  to extend it to  its proper length with the pulleys, and to cover it with
plaster of Paris;  keeping up the  extension till the plaster has become
hard.f
   If both thighs are broken, a fracture-bed should be employed ;—or, if
the surgeon has not one, the patient should be placed  on his  back, with
four splints to each thigh, and his knees  drawn  up, and  supported by
pillows.
   When the lower end of the femur is fractured obliquely downwards
and forwards, the sharp  end of the  upper fragment is apt  to pierce the ex-
   • Pott, Chirurgical Works, vol.  i., p. 365.
   f A case treated in this way by Mr. Bond, of Glastonbury, will be  found in Sir A
Cooper on Dislocations, p. 191.
 
25G                 FRACTURES OF THE THIGH.
tensoi muscles, and the lower fragment to be dragged down into the ham
by the gastrocnemius.
 *  Treatment.—Firm extension must be kept up with the double inclined
plane and splints;—and  the knee must  be well  bent, to relax  the gas-
trocnemius.
   Fracture of the Condyle into  the knee-joint mostly happens to
old persons, and not unfrequently proves  fatal.   If much comminuted, or
if  compound, amputation  will be  necessary.  Otherwise, the limb should
be placed straight, so that the  head of the  tibia may keep the fractured
parts in their places ;—lotions and leeches should be  used to prevent in-
flammation ;—and afterwards a pasteboard splint.   Passive motion should
be commenced in five weeks.
   [The treatment of compound fractures of  the thigh involves the applica-
tion of much nice  discrimination.   The  question as  to  the necessity or
non-necessity of amputation in any individual case must be discussed with
the utmost care and judgment, assisted  by the  sound principles already
proposed,—the surgeon bearing in mind that many thighs are saved now,
which formerly would have been considered as beyond the reach of sci-
entific skill.                                                     (
   The same general principles of treatment exist as for the simple: the
natural conformation and  length of the  limb should be  preserved, as far
as possible.   It must  be  borne  in mind, however, that  some  degree  of
shortening will occur almost of necessity, in consequence of necrosis of the
broken extremities of the  bone, and because, from the nature of the injury,
the same degree of extension and of  lateral compression cannot be main-
tained as in cases of simple fracture.
   The limb  may be placed in the flexed position on a double  inclined
plane, or it may be  extended by means of any of the different  sorts  of
apparatus already described, or, finally, it may be placed in a long fracture-
box, the sides of which are connected by hinges with the bottom  piece,
and extend,  on the outer  side to the axilla,  and on the inner to the pelvis,
the foot being secured to a perpendicular plane  attached to the lower ex-
tremity of the bottom-piece.  In  this box, the  limb may repose  upon a
bed of bran, which also  affords  the  necessary lateral pressure when the
sides of the box are closed.
   The bandage of Scultetus is, as in other compound fractures, the best
compressing bandage, as  it admits of removal and adjustment without dis-
turbing the limb.   The wound itself should be uncovered, excepting by
a poultice, or some similar dressing, so that the matter may have free escape,
and this should be aided  by moderate pressure upon the  thigh, above and
below the wound, effected by the bandage,  which should be made to act
with particular care on any point or points beneath which the matter may
be disposed to collect: if an abscess should form at any point remote from
the wound, as happens in almost  every compound fracture, it should  be
opened by the knife.
   The dressing for the wound  must  be varied to suit its appearance at
different times.   Great cleanliness of the  parts, and also of the dressings,
should be observed.
   The great length of time during which  it is  necessary to  confine the
patient to  bed renders it  advisable to resort to every expedient to prevent
sloughing; besides  the frictions heretofore  recommended  in  compound
fractures, the position of the patient should be changed, from time to time, 
FRACTURE  OF THE  PATELLA.
257
as far as may be consistent with the security of the  limb; the use of the
inclined plane, for example, may be alternated with that of the straight
splints.
  When the condition of  the wound will rIIow of more direct compres-
sion being exercised about the seat of fracture, this means should be in-
stituted as an aid in securing a proper shape to the  thigh.  For this  pur-
pose,  strips of adhesive plaster, or of soap plaster, may be employed,—
when the roller, or the bandage of Scultetus, cannot be  used,—an interval
being left between the strips, for the ready escape of the pus.—Ed.]
  XII. Fracture of the Patella is  generally transverse, and  is caused
by sudden contraction of the extensor muscles attached to it;—as, for in-
stance, when a person who has his knee much bent under him, and is  in
danger of  falling, tries to save himself by throwing the body forwards.
  Symptoms.—-Inability to straighten the knee, and  separation of the frac-
tured  parts, which can be readily felt, and which is increased by bending
the  knee.
  Treatment.—The limb must be laid straight, with a well-padded splint
behind the thigh and leg, in  order to keep the knee quite motionless;  and
the  patient's body should be raised to  a half-sitting posture, in  order to
relax  the rectus muscle.   Evaporating lotions  and leeches must be used,
till pain and swelling abate ;—then, and not till then, some apparatus may
be employed to keep  the broken surfaces as nearly in contact as possible.
The most common consists of one pad, or strap, or bandage, placed above
the  patella, and a similar one below it;—the two  are then approximated
by longitudinal straps, or bandages, passing between them.  But the best
apparatus  conceivable is that invented by Mr.  Lonsdale ; for it causes no
circular constriction of the limb whatever.    [It consists of a splint  upon
which the limb reposes, and to which a foot-piece is attached in such a
way as to be movable up and down, to  accommodate  the splint to limbs
of different lengths; to the under surface of this  splint two vertical  iron
bars are connected, A B, (see fig. 58,) at about its centre, each one sup-
porting a horizontal arm bent at right angles, G G; these horizontal pieces
slide  upon the upright staffs, but can be arrested at any point by the screws,
C D ; from these arms depend other vertical rods, moveable upon the for-
mer and, like them, fixable by similar screws, E;  finally, to the lower end

                              Fig. 58.
of each of these  second perpendicular rods,  an iron plate, F, F,  of a
horse-shoe form, is attached by means of a hinge-joint. In the application
of this apparatus, the splint should be well padded, and the foot and leg
secured to it by a roller, a bandage having been first passed around these
       22*                        r 
258
FRACTURES  OF  THE LEG.
 parts; then the surgeon places the fragments of the patella in juxtaposition
 the muscles being relaxed as before directed, and applies the upper horse-
 shoe plate to the upper part of the thigh, a soft pad intervening, just above
 the  superior fragment,—not touching the patella itself,—while the other
 plate is applied just below the inferior fragment; the plates are secured in
 these relations by means of the  screws, and a roller is passed around  the
 thigh and the upper part of the  splint.   The  limb is retained  during  the
 treatment in the same position as in the other modes already described.__
 Ed.]  If the parts  can be kept  in complete apposition, the union may be
 bony;—if not, it will be ligamentous; it  is, however, a great object to
 have the ligament as short as possible.   Passive motion should be begun
 in five or six weeks; the patient being made to sit on the edge of a high
 table, and desired to swing his leg backwards and forwards.
   Longitudinal   or comminuted fracture  of this  bone is always caused
 by direct  violence,  and attended with great inflammation,—which being
 subdued, the parts  must be kept in their places by bandages  and paste-
 board splints.   Compound  fracture will generally require amputation
 — unless the wound is  very small—the  skin  not injured  enough  to
 slough  or ulcerate — and  the constitution very good.   [The  indications
 are, to  close the  wound immediately, in  the  hope that  it  will heal
 without  being accompanied by violent constitutional disturbance, and
 to  retain  the fragments  of the  patella  in as close apposition as  the
 condition  of the parts will permit.  The  limb must be placed upon  a
 splint in the same position  as directed for simple fracture, the body being
 well supported in the flexed position on the pelvis, by pillows arranged
 behind the back.   The lips of the wound, after all foreign matter has been
 removed from the opened joint,  should be drawn together by strips of ad-
 hesive plaster, which strips may  be so applied  as to draw  down the upper
 fragment of the patella, and to retain it in apposition with  the lower: then
 a piece  of lint should be dipped in the blood which  flows from the part,
 or in some adhesive or glutinous fluid, and laid upon the wound, where it
 should be retained by a light bandage; all  pressure  being avoided upon
 the joint itself, the muscles of the thigh may be moderately compressed  by
 a roller, the same which confines the splint upon the limb.  Thus arranged.
 the dressing should not be  disturbed so  long as no  unpleasant symptom
 arises ; such as severe inflammation, free suppuration, &c.  In a case re-
 corded by Sir A. Cooper, (op. cit., p. 210,  11) the first applications were
 not removed until a month after  the accident, when the wound  was found
 nearly healed :  the  patient in this  case recovered with a perfectly useful
 limb.  If, however, violent inflammation follows  the injury, with profuse
 discharge  and much constitutional  suffering, the primary dressing must be
 at once removed, and antiphlogistic remedies resorted to, —as  local and
 general depletion, poultices, or water-dressings, &c, &c.  Passive motion
 should be cautiously instituted as  soon  as circumstances will admit of  it.
 1 he introduction of sutures  should be avoided as  much as  possible;  if
 employed, care should be exercised  not to  include  the  ligament in the
 ^vtTt  i   A"  CooPer' °P- cit-> case 137, p. 210.)—Ed.]
 i     i-, *VC.TURES 0F THE Leg.—The ordinary fractures of the leg may
 be readily distinguished by careful examination.   There  are  several me
i hods of treatment.
  (1.) By the tailed bandage and splints.—The  injured leg being laid on
 its outer side, the fracture is reduced by extension from the knee  and ankle. 
FRACTURES OF  THE LEG.
259
Fig. 59.
Then a many tailed bandage is applied after the manner represented in the
cut.   This bandage is easily made thus:—take a  piece  of roller, long
enough to reach from the knee to the foot, and to overlap about one-third
of the leg besides.  Cut another roller into pieces, and lay them across the
first at right angles, in such a manner that each shall overlap one-third of the
preceding one ;  these  transverse pieces (which should be  half as long
again as the circumference of that  part of the  leg which  they are to en-
circle) are to be  stitched to the longitudinal one, and then the bandage is
ready for use.    One splint, well padded,  should be  applied  to the outer
side of the limb ; another to the inner side ; and if there is any projection
of either fragment, it should be kept in its place by a third slight splint
to the shin.   The outer splint  should have a foot-piece,  which should be
carefully padded in such a manner as to  prevent the foot from turning
either inwards or outwards, especially the  latter.  There is a very useful
rule, which should be attended to in all cases of injury below the knee ;  it
is, to  keep the great toe in a line with the inner edge of the patella.
  (2.) By the Macintyre's leg-splint, or some of the numberless varieties
of it in existence, as improved by Mr. Liston  and other surgeons.  The
adjoining cut represents  it as  applied to a patient of Mr. Fergusson's in  •      &
the King's College Hospital, with a compound  fracture, which is left un-

                                Fig. 60.
covered by the bandages.  It is straightened out by means of the screw
under die knee, as Mr. Fergusson prefers  the  straight  position in almost
all cases of fracture of the lower extremity.   Before its application, it must
be made to correspond to the length of the sound limb, and must be we.!
padded. 
2G0
FRACTURES  OF THE  LEG.
  (3.)  By the very convenient side-splint  of Mr. Fergusson's, described
in a preceding page.  This may be applied either on  the  inner or outer
side according to circumstances.

                               Fig. 61.
  (4.)  By the junks.  This very simple but efficient contrivance consists
of a piece of old sheeting, with a bundle of reeds rolled together from .
either end.   But it is more easy to comprehend it from seeing it once than
from a  page  of description.
  (5.)  By the starched bandage.—In simple cases of fracture  of the leg,
the  patient may be permitted to leave his  bed at the end of three weeks,
with the fracture supported by the starched apparatus.   First of all, a dry
bandage should be applied  from the foot half-way up the thigh ; then  a
piece of stout pasteboard, softened in boiling water, should be  accurately
adapted to the limb on each side^,. and the outer piece should be made to
overlap the heel.  In the next place, the hollows  about the ankle and  tendo
Achillis should  be well padded with tow ; and  then four or five layers of
roller must be put on, thoroughly imbued  with mucilage of gum or starch;
and lastly a  dry roller.   When this  has become dry, (which will be in  a
day or two,) the patient may get up, and move to his chair or sofa, but
the foot must be suspended from his neck by a sling;  and he must be
particularly cautioned not to attempt to move it by its own efforts.
  For  FRACTURE OF THE HEAD  OF  THE  TIBIA INTO THE  KNEE-JOINT the
treatment is  the same as for fracture of the condyles of the femur.   The
limb should  be  placed straight, so that the end of the femur may act as  a
splint,  and keep the broken parts in their  places.  The whole limb should
be raised, so as to relax the extensor muscles of the knee ;  and this should
be  done in all cases of fracture of the upper end of the tibia (for which,
consequently, the treatment by splints, with the knee bent, is inapplicable).
Pasteboard splints and starched bandages should be applied, to keep the
joint motionless; but they should not cover the front of the knee so as to
interfere  with the leeches, fomentations, &c, that will be  necessary to re-
duce  the inflammation.  Passive motion should be commenced in  five
weeks.
   Fracture of the lower end of the fibula, about three inches above
♦lie ankle-joint, is  not an uncommon  accident, and may be  caused by
wrists  of the foot, or by jumping on uneven ground.
   Fracture of the internal malleolus may occur in the  same way;
and one  or the  other of these fractures commonly acccompanies dislocation
of the  ankle.
    Treatment.—They may be treated either with  the bandage and two
splints, [or widi the fracture-box.—Ed.] or with Macintyre's splint,  or with 
FRACTURE  OF  THE LEG.
261
Fergusson's side-splint, oi- with Dupuytren's, which is a diminutive of the
long straight splint, represented  at p. 249.  It is to be well padded, and
applied to the side opposite the fracture; but  it is not so easy to keep the
foot in a proper position with this, as with the other apparatus.
Fig. 62.
Fig. 63.
  The surgeon will often find one or more bags of sand most convenient
auxiliaries in keeping fractures of the leg in proper position.   They may
be used both to lay the broken limb  upon, and also to put on  either side
to prevent  the  limb from rolling.   This substance is  so ponderous and
devoid of elasticity that it steadily retains whatever position is given to it.
   Compound fractures of the leg are to be treated on the principles already
laid down for the treatment of compound fracture in general.
  [The simplest and the most convenient  apparatus for the treatment of
fractures of the leg is  the fracture-box.   It is  composed of a horizontal
plane of board extending from a little  above the knee to the  sole of the
foot, where a piece rather longer than the foot, and of the same width as
the other plane, is  firmly secured  to it
at right angles:  side-pieces, also made
of wood, six or seven inches wide, and
of the same length as the bottom-piece,
are connected with the latter by hinges.
(Fig. 63.)   To apply this apparatus  to
the treatment of fractures of the leg,
open the sides of the box, and place  a
pillow upon it, soft enough to adapt it-
self  well to the inequalities of the leg;
then, having reduced  the  fracture, se-
cure the foot to the foot-board by a strip
of bandage and close the sides of the
box, more  or less tightly, according to
the condition of the limb and the degree
of pressure requisite to retain the frag-
ments of the bones in apposition;  the
sides are thus  secured  by strips  of
muslin.  If the pillow alone is  insuffi-
cient to exert  the requisite  pressure,
compresses should be used in addition,
and  these should  be so placed as that
[he pressure may bear upon  those par-
ticular  points  where  they  are  most
needed.  Thus the proper shape of the
limb may  be easily  preserved, being
made more or less curved by the action
of the pillow and compresses.  In this
Fig. 64.
 
262                 FRACTURE OF  THE LEG.
manner some of the most marked deformities may be obviated.  Thus,
for example, in treating the fracture of which the preceding drawing from
Fergusson's Practical Surgery (Am. ed. p. 329) illustrates the appearance,
the leg should be  placed in the fracture-box, as  above directed, and a
compress be applied upon the tibial  side of the limb, just above the pro-
minence of bone, while another is laid on the  fibular side, a little below
the seat of fracture; the compression exercised upon these  points, when
the sides of the box are  closed, will suffice to restore the leg to its proper
shape, and to retain the fragments in complete  apposition.   (Fig. 64.)
   The shape of the sound leg should be compared daily with  that of the
broken one, and any deviation from the proper line in the latter should be
rectified in  the manner  pointed  out.   The  foot should be  kept upright
against the foot-board, the heel supported by  the pillow, and an  additional
pad if necessary.   If there be any signs of excoriation or sloughing on the
heel,  or  malleoli,  pressure should be immediately removed from these
points, and brought to bear  upon others, and the surface  protected by
simple cerate, or stimulated by frictions wTith  spirits of camphor, soap lini-
ment, &c, &c.  Care is  requisite lest the foot fall below its proper line,
as compared with  that of the sound  leg; to obviate this liability to  dis-
placement of the lower fragment, a pad of cotton should be placed under
ihe heel.
   The advantages of the fracture-box are evident:  it is  perfectly secure ;
very simple  in its  construction; fully capable of  retaining  in  place the
fragments of the bones, in the vast majority of  fractures of the  leg, and it
haves the limb always open to inspection, and for the application of local
remedies.  In very many cases of this fracture,  it is necessary or advisable
to employ sedative lotions; one of the best of these is the solution of the
acetate of lead ;  an objection to this, however,  is that in many persons it
irritates the skin too much, and in all it is apt to leave a deposition of the
salt upon the surface, which is sometimes the source of irritation.  When
any liquid application is  made, or any other  dressing which  may soil the
pillow, a piece of soft oil-cloth should be spread upon the latter,  before the
leg is placed in the box.
   The same apparatus is  admirably adapted to the treatment of compound
fractures of the leg, particularly when, as was  first recommended by Dr.
J. R.  Barton, of this city, bran is used as a  substitute for the pillow em-
ployed in  case of simple fractures.   The fracture-box has a sufficient
quantity of the bran laid upon the bottom of  it, to afford a soft resting-
place for the leg; the leg is placed upon it, the form of the limb adjusted as
well as possible, the foot  is properly attached to the foot-board; then the
sides of the box are closed, and the box itself  filled with bran.   The requi-
site degree of lateral pressure can generally be gained by packing the bran
pretty firmly opposite particular parts of the  leg; and in addition, a few-
strips of adhesive plaster may be drawn around the limb at the point  of
fracture, without closing the wound entirely, or materially interfering with
the ready exit of the pus.  Thus the leg is imbedded in the midst of a
substance which absorbs at once the discharged matters; which diminishes
the unpleasant fcetor, by secluding the pus  from  the action of the air;
which is itself clean,  light, and  cool, and which  is  easily renewed.  It
will be found, moreover,  to be the most effectual mode of preventing the
deposition of the  ova of  flies and other insects which, in our warm sum- 
             DISEASES  OF THE  SYNOVIAL  MEMBRANE.          263

mers, become developed in the wound and are the source of great incon-
venience and annoyance.
  The disposition to the formation of  abscesses at points remote from the
wound is often met with in compound  fractures of the leg.   WThen formed,
they should be opened as soon as possible, and the matter  confined be-
tween the point of incision and the original wound by a few strips of the
bandage of Scultetus laid above the seat  of abscess,  or below it, as the
case may be.—Ed.]
  XIV. Fractures  of the Foot will often  be attended with so much
other mischief as renders amputation expedient.  But  an attempt should
be made to save part of it;—especially the ball of the great  toe.  Paste-
board splints and other contrivances must be used to  preserve the proper
position ; — and if matter forms, there should be no delay  in freely divid-
ing the  dense fasciae of the foot, to let it escape.  '
  The tuberosity of  the  os  calcis  may  be broken  by the action of the
muscles attached to it, in the same manner as the patella and olecranon,
and will unite only by ligament.   The treatment must be the same as that
of ruptured tendo Achillis.
                        CHAPTER  VI.

       OF THE DISEASES  AND INJURIES  OF  THE JOINTS.
                                    t

    SECTION  I.--OF THE DISEASES OF  THE  SYNOVIAL
                           MEMBRANE.

   I. Acute  inflammation of the synovial membrane (or synovitis) may
be produced by local or by constitutional causes.   The former are blows,
strains, mechanical injuries, and especially penetrating wounds, and cold.
The latter are, the rheumatic  and gouty diatheses, and the morbid state
of the constitution produced by syphilis or the  abuse of mercury;—some-
times,  also, this  disease is a sequel of gonorrhoea.   It very seldom attacks
young  children.   The joint most frequently affected is the knee.
   Symptoms.—In the most acute form, the symptoms are severe aching
pain in the joint, aggravated by the slightest motion ; great swelling occur-
ring very soon after the pain; redness and tenderness of the skin;  and
fever, which is often violent and alarming.
  The swelling  is peculiar, and is distinctive of the disease.   It is occa-
sioned  by a rapid effusion of fluid into the synovial cavity;  and,  conse-
quently, if the joint is superficial, it fluctuates  freely.  It is always most
prominent at the points where the joint is least covered by ligament, and,
consequently,  the shape of the joint is always altered.  When the knee is
affected, the patella is protruded forwards, and there is a great fulness at
each side of it, and at the lower and front part  of the thigh.  In the elbow,
the swelling  is  most distinct above  the olecranon, and in the hip  and
shoulder there is a general fulness of the surrounding muscles.
   Prognosis.—This disease is much more serious when it affects one joint
solely,  and more particularly when it arises from local injury, (especially 
264
DISEASES  OF  THE
 a penetrating wound,) than when it affects many joints, and arises  from
 constitutional disorder.  The danger to life in  any case, will be propor-
 tionate to the severity of the febrile symptoms, and the rapidity and sharp-
 ness of the pulse; delirium, or typhoid symptoms,  show great peril.
   Morbid Anatomy.—In slight cases the synovial membrane is reddened,
 and the joint  contains a quantity of turbid serum.   In  very severe casts
 the membrane suppurates rapidly, and the cartilage entirely ulcerates (see
 paragraph III).  In other severe but more protracted cases, the membrane
 becomes  thickened, pulpy, and highly vascular; granulations form on its
 surface and project like fringes into the cavity of the joint, and at the same
 time the cartilage wastes or is absorbed.
   Treatment.—In all  cases arising from  injury, the joint,  or rather the
 whole limb, should be  confined  by a splint, so as to keep it  perfectly
 motionless.   This is indispensable ;  for the joint cannot  be kept motion-
 less  without it.   The best  splint for the purpose is made of very thick
 leather, which  admits of being easily adapted to the surface of the  joint
 when softened in warm water.   If the knee is the part affected,  it should
 not  be allowed  to become  bent on the thigh, or if it is already bent,  it
 should be brought as nearly straight as possible.  The other measures are,
 bleeding from the arm, if the patient is robust, and the joint important; if
 not,  leeches in abundance to the joint, or cupping near it; ice, evaporat-
 ing lotions, or warm poppy fomentations, according to the patient's choice;
 purgatives in moderation, and not given so as to disturb the part by fre-
 quent motions ; tartar emetic in saline  draughts ; or calomel, with opium
 and  antimony, in moderate doses  every four hours, till the mouth begins
 to suffer; and  opiates at night to relieve pain.   A warm poultice of cam-
 momile flowers, boiled till they are quite soft, will generally be found more
 soothing than  cold applications.  Blisters, it need scarcely be said, are
 inapplicable during the acute stage.
   When the disease is manifestly connected with rheumatism—when  it is
 attended with red sediment in the urine and acid perspirations, and affects
 several joints, and extends to the synovial  sheaths of tendons, colchicum
 should be administered, F. 121, or the iodide of potassium with alkalis.
 But when only two or three joints are affected,  or when  there has been  a
 manifest translation of the disease from some internal part, or from  one
 joint to another,  Sir B. Brodie prefers the use of calomel  and opium in
 moderate doses, till the mouth is affected.  When there is a tendency to
 gout, and the patient complains of grinding,  excruciating pain, as if the
 joint were torn  asunder, the colchicum is also the main remedy.  In syphi-
 litic cases, (which will be known  by the patient's general history, by his
 wan  peculiar appearance, and most likely by the existence of papular or
 other eruptions, tide p.  199,) mercury may be tried, if it  has never beftre
 been given to excess; but if it has, or if the constitution  is broken down,
 recourse may be had to the iodide of potassium in doses of gr. iii, ter die,
 with a small dose of colchicum and  opium  at night;  and sarsaparilla
 should be given in  abundance.   F. 40, 41.   In all these cases, warm
 baths, in which a quantity of carbonate of soda  or potass has been  dis-
 solved, will probably be of service.
   II. Chrontc Inflammation of the synovial membrane is characterized
by sioelling of the joint, of the same nature that attends  the acute form,
and by a dull  aching pain, accompanied with a sense of weakness  and
relaxatioi., and not usually aggravated by pressing the articular surfaces 
SYNOVIAL MEMBRANE.
265
against each other.  The swelling always comes on in a few days  aftei
the pain ; and sometimes, in cases of  an indolent character, it is the only-
symptom present; these  cases  are  called hydrops articuli or hydrarthus.
If the disease proceed, the synovial membrane and surrounding  tissues
become thickened and gristly, and the swelling loses its softness and fluc-
tuation ; and, in neglected cases, the inflammation may lead to ulceration
of the cartilages and destruction of the joint.   The causes  are the same
as those of the acute form, of which it may be a sequel.
   Treatment.—The indications are,  first, to correct  constitutional dis-
order ;  secondly,  to reduce inflammation ; and thirdly,  to  produce  ab-
sorption of  the  effusion  and thickening, and  restore the part to its  proper
uses.
   In the first  place,  therefore, if  the  complaint is  constitutional, and
depends on gout, it must be treated  by colchicum and warm aperients,
especially the decoction of aloes and alkalis.   F. 121, 122,124,  52, 132.
If the habit is rheumatic, colchicum, or the iodide of potassium, must be
resorted to; and  in most  cases,  especially  those  following  syphilis or
gonorrhoea, warm-bathing, change of air, sarsaparilla, and a most carefully
regulated diet,  avoiding  all heavy, innutritious, acescent, or indigestible
substances, will be indispensable.
   Secondly, in  cases arising from local injury; whilst there is any activity
about the inflammation, (especially an increase  of aching pain at  night,)
the part should  be confined by  a splint or starched bandage, and  should
be bathed with  cold  lotions, and  blood  should be  repeatedly taken by
leeches or cupping.  Mild alteratives should also be administered,  F. 32,
33, &c.
   The  third indication  is to be  fulfilled by counter-irritants, beginning
with blisters;  which are  as  serviceable in the chronic as they are  detri-
mental in the  acute disease.  They should be applied in succession, and
be quickly healed up ;  and  should not be put  too near the joint,  if it is
superficial, as  the knee.  The  strong acetum  cantharidis  will often be
found a very convenient substitute.   After the blistering, when the activity
of the  disease has  subsided, the tartar-emetic ointment,  F.  67 ;  the lini-
mentum hydrargyri; or  liniments  of  cantharides, ammonia, and turpen-
tine, F. 71; or  of  croton oil, F. 130; the douche, or affusion with hot
water;  and  the vapour bath will complete the cure.   But all stimulating
applications must be at once abandoned, if they cause an aggravation of
heat and pain.   The ointment  of Scott, F. 66, the  ceratum hydrargyri
comp. of the pharmacopoeia, is one  of  the most useful applications for the
convalescent stage of this and other chronic diseases of joints.  It is ap-
plied thus:  the  surface of the joint, having first been washed with cam-
phorated spirit,  should be covered with the ointment  thickly spread on
lint; next, adhesive plaster should be evenly applied in  strips, so as to
form a complete casing for the  joint; and lastly a bandage.  When the
knee is bandaged in this  way, the adhesive straps should be arranged so
as not to press too  tightly on the patella.   Supposing, after inflammation
has subsided, the joint is  left stiff,—the knee, for example, in a half-bent
state—a process of very gradual extension  may be set about  by means of
splints  with  a screw attached; but  the greatest care must be taken not to
light up a fresh inflammation.
  III.  Abscess in Joints.—If, after acute or chronic inflammation,  ajoim
becomes very mmth distended,  and there is constant pain unmitigated bj
       23 
266                     DISEASES  OF  THE

remedies, and considerable  constitutional excitement, suppuration of the
synovial membrane may be fairly suspected.  The first thing to be done
under these circumstances is  to make a puncture with a grooved needle,
and  examine the fluid that exudes.   If  it is serum, two or three more
punctures may be made,  and an exhausted cupping-glass be applied over
them ;  and by these means the part may be very safely and expeditiously
relieved of a considerable quantity of fluid.  If it is pus, a free opening
should be made with a lancet, in a depending position, so that the matter
may run out easily ; the joint  should be  placed on  a' splint  in the most
easy and convenient posture: the  general  health should be amended by
tonics, alteratives, and proper diet; and then, in favourable cases, a cure
will be effected by anchylosis.  But if the suppuration and constitutional
disturbance increase, the limb must be amputated.
   Purulent depots in Joints.—It has been mentioned in  several previous
chapters, that a rapid  effusion of pus  into the joints and other parts is  a
frequent occurrence in phlebitis,  puerperal  fever,  erysipelas, dissection
wounds, and other cases in which  the blood is contaminated  by a morbid
poison.  The part becomes red and painful, and very soon afterwards is
found to be filled  with pus.  The only local treatment consists  of a free
incision in a depending position, and a splint, with  a bandage to prevent
accumulation of matter.
   IV.  Pulpy Degkneration.—Under the influence probably of chronic
inflammation, the  synovial membrane (generally of  the knee) sometimes
is converted into  a thick pulpy substance of a light brown or reddish
brown colour,  intersected  by white  membranous lines.   This peculiar
fungous growth gradually projects  into the joint and causes ulceration of
the cartilages, caries of the bones, wasting of the ligaments, and abscesses
in various places.
   Symptoms.—Gradually increasing  stiffness and swelling of the joint,
without pain; — the swelling less regular than that of chronic  inflam-
mation ;—and not fluctuating,  although  so soft and elastic that it seems
so to do.
   Treatment.—The progress of the  disease may be retarded by rest and
antiphlogistic measures ;  but, after a longer or shorter duration of the in-
dolent stage, ulceration  of the  cartilage  and hectic come on, and the
patient can only be saved by amputation.*
                   V. Loose Cartilages commence  as little pendulous
                 growths upon  the  synovial  membrane, which  become
                 accidentally detached.   They form  in any joint,  but
                 most frequently in the knee.
                   Symptoms.—They  can  be  felt  when  they present
                 themselves at the surface of the joint;—and when they
                 get between the ends of the bones, which they are very
                 apt  to  do  during  exercise, they cause sudden  excru-
                 ciating pain and  faintness, followed by  inflammation.
                   Treatment.—If possible, the cartilage should be fixed
                 by bandages,  so  as  to prevent it from  getting between
                 the bones;—otherwise  it must be removed; — taking

  ■ Brodie on Diseases of the Joints, 4th edit. p. 72.
  fTlns cut exhibits a parasitic cartilage, shaped like a melon seed—in its original
ufuation.  From the Museum of the Middlesex Hospital.
 
SYNOVIAL MEMBRANE.
267
care to prepare the patient by rest, low diet, and purgatives, and to use
every precaution against inflammation afterwards.
  The ordinary way of operating consists, first, in pushing the cartilage
to the upper part  of the joint on one side of the patella, and steadying it
there against the condyle of the femur; then the  skin having been drawn
slightly upwards, an incision is  made  down to the cartilage of sufficient
length to let it escape.  But there is a plan of operating by subcutaneous
incision,  which seems to  have been proposed almost  simultaneously by
Mr. Syme of Edinburgh,  and M. Goyraud, and which  avoids the danger
of a direct wound  into the joint.   According to  this  plan, the cartilage
having been pushed up as high as possible into one of the synovial pouches
by the side  of  the  patella, a long narrow knife is passed down  upon it
through the skin two or three inches above, and made to divide the syno-
vial  membrane to  such  an extent, that the cartilage may be  squeezed
through it into the subcutaneous cellular tissue, but without enlarging the
wound in the skin.  There the cartilage must remain till the wound in the
synovial  membrane has had time to heal;  and then  it may, if desired, be
easily removed by an incision through the skin; but if it causes no incon-
nience it may be  allowed  to remain.*
  VI.  Pendulous Fleshy or Gristly  Tumours may produce many of
the symptoms of  loose  cartilages.  They may, perhaps, be distinguished
by being less hard, and by being stationary.  They have been extirpated
from the  knee,  but of course with very great hazard to life.

SECTION II.--INFLAMMATION  OF THE CELLULAR TISSUE.

  Inflammation of the cellular tissue around a joint is a peculiar affection,
particularly described by Mr. Wickham, an author of great experience on
the  joints.   It  commences with a  tolerably firm  swelling, various in ex-
tent ;—attended with  slight obtuse pain, and  caused by a deposition of
lymph, which  renders the tissue  hard  and brawny.   As it increases, the
skin becomes distended, white,  and shining, and  the pain and constitu-
tional distress extreme.  After this adhesive stage has lasted an  uncertain
number of months, suppuration  occurs at one or more points;  and the
abscesses burst through the synovial membrane, and  cause irreparable dis-
organization of the joint.
  Treatment.—Leeches or cupping, and cold lotions, followed after a time
by Scott's ointment (F. 66).  Mr. Wickham deems  counter-irritants and
friction injurious.!

               SECTION III.—THE  LIGAMENTS.

  I.  Inflammation.—Authors have described a form of inflammation of
the  ligaments  of  joints characterized by great pain from motions  that
shake,  or twist them.J   It must be  treated like  the subacute  fascial
inflammation.
  * Vide B. & F. Mod. Review, vol.  xi. p.  526, and Fergusson's Practical  Surgery,
p. o-2i.
  f Wickham  on  the Joints, p. 84,  Winchester, 1833.  See  also Nicolai, quoted in
Coulson on the Hip Joint, p. 85.  Mr. South gives two cases of this rare disease in his
Trans, of Clielius, vol. i. p. 210.  What used to be called white swelling of the knee joint
seems really to hate consisted of a similar degeneration of the cellular tissue aroun I
the joint.
  * Mayo's Pathology, p. 79. 
268
ULCERATION  OF CARTILAGE.
  II. Relaxatidn.—If any joint have been long disused, and especially
if its innervation is impaired, its ligaments are liable  to become relaxed
and  elongated, so as even to permit  the dislocation of the  bones to which
they are attached.   Thus in a case related by Mr. Stanley, which followed
an attack of hemiplegia, the  ligamentum teres  and  capsular ligament of
the hip were so  elongated as  to permit the head of the femur to slip out
of the  acetabulum.    A  similar result may  ensue  from  long-continued
chronic  synovitis or  rheumatism.   Mechanical support, blisters, friction,
cold affusion or  sea-bathing, and electricity, are the  only available  reme-
dies.*   Slighter degrees of relaxation occurring  to weakly children,  may
be cured by good diet, tonics, and friction.

                 SECTION  IV.--THE CARTILAGE.

  The  affections of cartilage  in which the  surgeon  is  interested,  are its
absorption or atrophy, and ulceration.
  I.  Senile Atrophy.—The cartilage of the joints of  elderly persons is
sometimes partially absorbed, so as even to denude  the  bone;—but both
the cartilage itself  and the  exposed surface  of  bone are quite  healthy.
This state may exist without producing any symptoms, except, perhaps, a
slight grating.    Sometimes before its  disappearance the cartilage  is con-
verted into  a soft fibrous or villous  structure ;  and its  place  is afterwards
supplied by a crust of a dense bony deposit, as smooth and hard as ivory
or porcelain.f
  II. Ulceration of cartilage is the climax of all severe affections  of the
structures entering into the  composition of joints.  It is a very common
consequence of inflammation of the synovial membrane,  acute or chronic:
—it is a constant consequence of caries of the joint-ends of the bones ;—
but whether it ever commences as a primary independent  affection  of the
cartilage itself is a matter of dispute.
  Pathology.—(1.)  There seems no  doubt but  that  ulceration of carti-
lage may be effected, as  Mr. Key pointed out,f by the instrumentality of
those highly vascular  fungous granulations which  project like  fringes from
the synovial membrane over the cartilage after severe acute or chronic in-
flammation ; just as we showed  in the last chapter that the absorption of
bone may be caused by contact with a highly vascular membrane (p. 222).§

  * Vide six  cases  of Dislocation from this source, narrated  by Mr. Stanley in Med.
Chir. Trans, vol. xxiv.
  f This change is said to occur  in the astragali of old draught horses, without  occa-
sioning any inconvenience to the animals.  Richet, quoted in Brit, and For. Med. Rev.
Jan.  1846.
  i Med. Chir. Trans, vol. xviii. and xix.
  § Mr. Goodsir's observations on the process of ulceration  in cartilaare through the
agency of the inflammatory exudation  that covers it, are as follows :—•' If a thin section
at right angles be made through the articular cartilage of a joint,  at any part where it is
covered  by gelatinous membrane in scrofulous disease, or by false  membrane in simple
inflammatory condition of the joint, it will be found  to present the  following  appear-
ances : on one edge of the section  is the cartilage unaltered, with  its corpuscles (cells)
natural in position  and size.  On the opposite edge is the gelatinous or false membrane,
both  consisting of  nucleated particles, intermixed, especially in the  latter, with fihres
and blood-vessels, and in the former with tubercular granular matter.  In the immediate
vicinity, and  on both sides of the irregular edge of the section  of cartilage where it is
connected to the membrane, is a remarkable change in the shape and size of the carti-
lage corpuscles.  They become larger, rounded, or oviform, and  instead of two or three
nucleated cells in. their interior, contain a mass of them. At the  very edge of the ulcer- 
ULCERATION OF CARTILAGE.
269
  (2.) It seems equally well established that ulceration of the cartilage—
beginning on that surface which is attached to the bone — may be caused
in the same way by the red fungous granulations which arise in the can-
celli of the joint-ends of the bones when carious (see the next section).
  (3.) Some  foreign  pathologists entirely deny, and  some  English ones
doubt whether ulceration  ever  begins primarily in the cartilage itself, inde-
pendently of anterior  changes in the bone  or in the synovial membrane.
Sir B. Brodie, however, believes that  it can; and certainly, since  every
organized part must be allowed to have some degree of auto-plastic power,
it is difficult to conceive why cartilage should not occasionally degenerate
in its structure, as well as tooth or bone.
   We have before spoken of that rapid ulceration of cartilage which is a
consequence of unchecked synovitis; but  now we have to treat of that
very common disease, chronic ulceration; and we  may observe that if  it
does commence by a change  in the synovial membrane, it is with a par-
tial, insidious, and  limited change,  not with that diffused  inflammation
which occurs in ordinary synovitis, and not with effusion.
   III. Chronic Ulceration of cartilage  commonly affects persons of
bad, scrofulous constitutions, between the age of puberty and thirty-five;
—and is usually ascribed to cold, or to neglected injury.
   Symptoms.—For the first few weeks (or perhaps  months) of this disease,
the  patient complains only of slight  occasional  rheumatic pains, perhaps
flying about and affecting  several joints, but at length settling decidedly
in one.  After a time, the pain increases in  severity, especially at night,
and it is generally referred to one small spot, deep in the joint, and is  com-
pared by the patient to the gnawing of an animal.  Moreover, it is usually
accompanied  by an aching of some other part of the  limb ; — thus, when
the hip or  elbow is  affected, there is an aching of the knee or wrist;—but
it is important to notice, that both the pain  in  the affected joint, and the
sympathetic remote pain, are  always aggravated by motion of the joint,
and by pressure of the articular surfaces against each other.  As the dis-
ease proceeds, the suffering becomes  most excruciating, and is attended
with  painful spasms and  starting  of  the limb during sleep; so  that the
patient's rest is broken, his spirits exhausted, and his appetite and general
health rapidly impaired.   At first the pain  is  unaccompanied with any
swelling;  in fact, this symptom never appears in less  than four or five
weeks, and often not  for as many months;  and when it does appear, it is
slight; and as it depends on an infiltration of the tissues around the joint,
and not on effusion  into it, the shape of the joint is unaltered.
   Terminations.—In fortunate cases,  that are subjected to judicious treat-
ment at an early stage, the ulceration may be  arrested,  and the  diseased
surfaces  will  throw out  lymph and  heal;  or  very probably the lymph
effused by two opposite  ulcerated surfaces will unite, and anchylosis will

ated cartilage, the cellular contents of the enlarged cartilage corpuscles communicate
with the diseased  membrane by openings more or less extended.  If a portion of the
fnl«e membrane be gradually torn  off the cartilage,  the latter  will appear rough and
noney-combed.  Into each depression on its surface, a nipple-like projection of the false
membrane penetrates.''—Anat. and  Pathol. Obs., Edin. 1845.
  These observations of  Mr. Goodsir are confirmed by Mr. Rainey, who believes the
peculiar change  which takes place  in the cartilage before its absorption to be a fatty
degeneration; for the cartilage cells  become  filled with minute globules of oil, and the
hyaline substance between them partakes of this conversion. — V'de South's Cheljns
voi. i. p. 274.
       23* 
270
ULCERATION  OF  CARTILAGE.
  be  produced.*   But, in unfavourable cases, the  ulceration proceeds and
  lays bare the bone, which becomes carious,  and can be heard to orate on
  the least motion ;—suppuration occurs into the joint, and numerous tortu-
  ous abscesses form around it, so that the surrounding soft  parts are disor-
  ganized ;—the ligaments  are destroyed, so that the flexor muscles   which
  have long kept the joint immovably  bent, at last dislocate it;—if the knee
  is affected, for instance, the head of the  tibia is drawn  backwards into the
  ham ;—and at last the patient, unless amputation is performed  dies ex-
  hausted with hectic.
    The prognosis, in the first stage, that is, before  swelling has occurred
  may be  favourable;  but after swelling  has  existed for  some time the
  patient will be fortunate in recovering with  anchylosis; and after suppu-
  ration, he will (especially if an  adult) be almost  certainly compelled to
  suffer amputation.
    Treatment.—The first and most indispensable measure is perfect rest •
  which  must be  insured by confining the joint with a starched  banda°e
  (not too tight) or leather splint.   The splint or bandage should have aper-
  tures in it to allow the  application of counter-irritants.   (2.)  Occasional
  leechings,  or small  cuppings, in the early stages, when  the pain is severe
  But loss of blood is merely a palliative of accidental fits of inflammation
  and must not be  carried too far.   (3.) Counter-irritation either by a  seton'
  or caustic issue, or the  actual cautery.   If the knee  is  affected,  an issue
  may be established on each side  of the head of the tibia.   Sir B  Brodie
  recommends, in these cases, that the issue should be kept open by  rubbing
  the sore occasionally with caustic potass,  or the sulphate of copper, rather
  than  by peas  _ The  actual cautery  is exceedingly efficacious,  and not
  half so painfu  m reality as might be imagined.  The manner of applying
  it is described  elsewhere.f  For children, blisters answer very well; and
  it is better to keep  one blister open  than  to  apply  a succession of them.
  Mr a Brodie  has  shown  that  issues, when  long established, sometimes
  rSiJ   .   f fiC0+nstltut10"-' ^^  on a  return of th« pain which  they
  relieved at first, and which will again depart if they are healed up.  It is
  a practical rule therefore  to give them up for a time, before condemning
 orerZ    amPutatl°n-   1};e °mtment of Scott, applied as  described in a
 preceding page will often be found a useful auxiliary to time and quietude.
 £il™T7rt?  U}d be glVen S°  as  t0 affect the Wm;  Sir B  Brodie
 of he art?  ^ admmistratlon of mercury in ulceration of cartilage is one
 unahlegtnT  imProvements in modern  surgery.*  (5.) If the patient is
 of  ootassitirn Fm/nCU1?ut0 ^ ab°Ve extent, sarsaparilla and the iodide
 be Wl T\    f' Wlt\sma11 Native doses of mercury, F. 33,  may
 change  "f^  *    °T ^ Fneral health must be maintained by tonic"
 formf there ne^'h     I™ b-e ^^ b? °Piates-   (6«) When abscess
 much' ^tended  I" U° ^ "* ^^ k '  but if the ^ becoraes  ve?
 much distended,  it may be punctured, and  the part be wrapped  in a
  * The ulcerated portion of rartila<rQ  •
 Lt I cannot," says Brodie "as^rt^  T    sometlmes supplied by a dense membrane.
 the true cartilaginous s\r„c.t„T  f   u membrane is "ever ultimately converted into
 on the carious surface "  In o.W }u 0ther/.cases. a compact layer of bone is generated
 substance of a arav <-oln„r  ,7'     ,S fo"nd " a thin layer of hard semi-transparent
 "r.ies. lastly, the heacl of tL K  presentlnS an irregularly granulated surface."  Some-
•exture, of a white 'colour JL^? 'S °??.?Kd  " with a crust of bonv matter, ofcompact
,d:t. p. 163.           ' Sm°°th' and like Polished marble."  Brodie on the Joints, 4*
  f Rofer to the Inde.c
                                          i Lectures, Med.  Gaz. vol. xxxvii. 
ARTICULAR  CARIES.
271
fomentation cloth,  so that the matter  may  gently  exude.   No rough
squeezing  is admissible.   If the puncture  heals, another may be made
when necessary—if it remains open it should be made large enough to let
the matter flow out freely as soon  as it is secreted.   The  case must then
be treated according to the directions for abscess in joints.
section  v,
ARTICULAR CARIES.
Fig. 6G.
Fis
   Caries of the head of a bone is not an uncommon cause of ulcera-
tion of the adjacent cartilage and  disorganization  of the joint.   The
affected bone is found to be soft, red, and vascular, and deficient in earthy
matter, so that it is easily cut or crushed; its  cancelli are filled with  a
reddish fluid, and  in scrofulous cases a
cheesy  matter is  deposited  in  them.
Owing to this softened state of the bone,
the  cartilage  peels  off from it  readily.
When peeled off, its under surface is pro-
bably found  ulcerated;  and  between  it
and the bone there is a small  quantity of
highly vascular lymph growing out of the
carious cancelli, which probably is the in-
strument in removing the  cartilage,  after
the manner already  detailed.   Whpn the
cartilage is perforated, inflammation  and suppuration ensue in the  joint,
and the case then pursues the  same course  as the ulceration of cartilage,
although a slower one.    In  some few cases, from  the
rapidity of the  caries,  the   cartilage  is  detached  en
masse; and sometimes necrosis of a small portion of the
bone ensues.
   This disease most frequently affects the knee, elbow,
and small bones  of the  carpus and  tarsus;—it is very
common in  scrofulous  children,  but rare  after thirty.
An  advanced stage  gives rise to what was  formerly
called spina ventosa ;—that is, the extremity of the bone
becomes greatly enlarged by superficial deposits,  but is
hollowed out into a mere  shell by  caries in its interior.
   The symptoms are nearly the same  as those of ulcera-
tion of cartilage ;—that is, fixed pain, extending to dif-
ferent parts of the limb ;—aggravated by  motion, and
unaccompanied at  first  by swelling.   But in scrofulous
cases theie is a  remarkable  absence  of pain, except
during the formation and  bursting of abscesses.
   Treatment.—This is  also nearly the  same that is  re-
quired for ulceration of cartilage.   The chief dependence
is to be placed on perfect rest, by means of the leather
splint; on  pure  air, good diet, steel,  sarsaparilla, and
other anti-scrofulous  remedies, by the use of which a
better state of nutrition may be induced, and  the con-
stitution be enabled to repair  the local  disease ; and on
the various measures that have  been  directed for the
  * This cut exhibits caries of the astragalus, with incipient separation of the cartila°
From the King's College Museum.  The next (Fig. 67)  shows a state approach'r.g
spina ventosa.
I  \l 
2T2
ANCHYLOSIS.
constitutional treatment of scrofula.   Issues are not advisable in  genuine
scrofulous  cases, as a general  rule;  but they are  of great  service when
the pain  is  severe  and continuous.   Small leechings may be also occa-
sionally expedient to relieve accidental fits of inflammation.  Abscesses
should in general be left to burst  of  themselves.   Amputation need not
be so hastily performed in  general in  this disease as in the last—both be-
cause the patient has a greater  chance of recovery with anchylosis;—and
because it seems probable  that  disease of the lungs or mesentery is some-
times suspended or averted by  the continuance of a (not very severe) dis-
ease in the extremity.   If, however, the pain is so serious that it exhausts
the strength and spirits, the part must  be amputated; because the  con-
tinuance of so severe an outward disease might induce the very same dis-
ease in the lungs  or mesentery, which a more moderate degree might
avert.   Recovery without  amputation is far more probable  when  one of
the larger articulations is affected, than when the complicated joints of the
tarsus  or carpus are involved.   Excision of the extremities of the diseased
bones  should be resorted to, when practicable, instead of  amputation.
   General Diagnosis.—It may be  useful to present a concise view of
the differences of the three principal chronic diseases of joints, as regards
their  two principal symptoms — viz. pain and swelling.  The pain  in
chronic synovitis is not very severe ; it usually increases for ten or fourteen
days, and  then declines;—and it is  not immediately aggravated by mo-
tion, or by pressure of the articular surfaces against each other.  In ulcer-
ation  of the cartilage, the  pain  is very severe,  continuous  and exhausting,
and increases as the disease advances, becoming greater after the occur-
rence of swelling; moreover, it is attended with sympathetic pain of  some
other part of the limb, and is always aggravated by motion.   " In articular
caries  in scrofulous children,"  says Brodie, " there is not that severe pain
which exhausts the powers and spirits of the patient," as in ulceration of
the cartilage;—but it must be confessed, that in cases occurring to adults,
there  is very little difference in this respect.
   The swelling in chronic synovitis comes on  in the course of a few days;
it fluctuates freely,  and alters  the form of the joint.  In the other two
affections it does not come on  till after  some weeks or months, and it does
not alter the shape of the joint; but as  it depends on a general infiltration
of the  tissues around the articular extremities,  it seems as  if it were caused
by enlargement of  the  bones; the skin moreover is free from redness;
hence  the  term white swelling, by which these two  affections are  com-
monly designated.*

                  section  vi.—anchylosis.

   Anchylosis, or  immobility,  is  a  frequent consequence of  serious
injuries and diseases of joints; therefore, whenever it is likely to happen,
the affected joint should be placed in the position which will be the least
inconvenient  for it to preserve.  The  elbow should  be placed at a right
angle; the wrist straight; the hip and knee  a very little bent; and the
ankle  at a  right angle to the leg.  There are three varieties of anchylosis.
   (1.) The spurious ox false anchylosis, which depends on thickening and
   * ''■ Llceration may be suspected," says Mr. Mayo, "when with  little  or no fluid  in
•Jie synovial membrane, there is pain of the joint, accompanied with  acute sensibility
U"> pressure or morion of the articular cartilages on each other. 
ANCHYLOSIS.
273
deposits into the synovial  membrane and ligaments, and rigidity of the
muscles.  The extensor muscles are  apt, in almost all  cases where the
joint is diseased, to become paralysed and wasted; and the flexor mus-
cles to fall into the state of rigid  atrophy, becoming short, inextensible,
and very probably dislocating the joint, by their continued traction.   The
form of anchylosis is very common after synovitis.
   Treatment.—Daily vigorous friction with stimulating liniments over the
extensor muscles ;—vapour baths or the local steam bath—shampooing—
and passive motion—that is to  say, the joint to be every day bent and
extended with a gentle degree of force, not sufficient to cause much pain.
[For this purpose  an instrument such as  that advised by Dr. Mutter, of
this city (Liston and Mutter's " Lectures on the Operations  of Surgery,"
Am. Ed. p. 433), is recommended.   It consists of steel splints curved to
the shape of the arm and fore-                      gg
arm, and well padded, two  for                    lg>    •         .
the upper arm and two for the                          (/L*^^N\
forearm, for the  anterior  and                                   "W
posterior surfaces of the limb.
The  anterior  splints are con-
nected  by a steel or iron  bar,
which is firmly secured to them
on each side,  and jointed by a
pivot at the  centre, so as to
move freely like  a  hinge.  A
" Strsmeyer's  screw"  is fast-
ened to the centre of the  same
splints  in  front,  by  moving
which the apparatus may be made straight or angular, at pleasure,  lhe
splints are now applied to the limb, those for each division of the member
being secured to  each other by means of  straps and buckles, and thus
 made to surround the arm  above and below its bend, care being had that
the joint of the side bars is opposite the centre  of motion  of the elbow.
When the apparatus is thus properly  applied, the  screw  should be turned
until the patient commences to  experience  slight uneasiness in the joint;
 this process should be repeated  daily, now extending and now flexing the
 limb,—avoiding the infliction of pain in the joint,—until an adequate
 degree  of motion is restored:  the action of the apparatus will  be very
 much aided by frequently soaking the joint in warm water.
   When  so elegant a splint  as that employed by Dr. Mutter cannot be
 obtained, the  same effect may be had by attaching the screw to simple
 splints of wood.  The apparatus may be adapted to the knee as well as
 to the elbow,  and with equally good  results.—Ed.]  If one or more rigid
 muscles seem to be the main  obstacles, their tendons may be  divided, by
 subcutaneous section.
   (2.)  Ligamentous anchylosis  signifies the union of two articular surfaces
 by ligament and  is an occasional consequence  of compound dislocation,
 and of ulceration of cartilage.   It admits  of only very gentle  treatment
 by passive motion, especially if it follow disease, and by gentle endeavours
 to straighten the joint, if necessary, with  a screw.
   (3.)  Bony  anchylosis is produced when  the lymph that is effused after
 destruction of cartilage  ossifies.   It  is incurable,  except by sawing
 
274
DISEASE  OF  THE HIP-JOINT.
ihrough  the bone,  or cutting  out  a  wedge-shaped portion, ana then
                              employing frequent motion so as to \ire-
                              vent  the consolidation  of a  callus  and
                              establish  a false  joint.   This operation
                              was successfully  performed  by Dr. Rhea
                              Barton,  of Philadelphia, on  the hip, in
                              1827, and on the knee  in 1838.  It was
                              also successfully  performed  by Dr.  Gib-
                              son, of Philadelphia, in a case of complete
                              anchylosis of the  knee, with  not  a vestige
                              of ligament,  cartilage, or  synovial  mem-
                              brane remaining.    Having laid  bare the
                              front of the  joint by a V  incision  above
                              the patella, he sawed out a wedge-shaped
                              portion  of the   bone,  and  gently  bent
                              the  rest  so   as   not to  endanger  the
                              popliteal  vessels.f    But  of course  this
                              is so serious  an   operation,  that it must
                              not be undertaken inconsiderately.

                             DISEASE  OF THE  HIP-JOINT.

  This joint is exceedingly liable to chronic disease, and there are certain
peculiarities in the symptoms which render it expedient to devote a section ,
to it in particular.  The usual forms of  disease are the  chronic ulceration
of cartilage in the adult, and scrofulous caries of the  head of the femur in
children.   The symptoms and consequences of both are nearly the  same.
  Symptoms.—The disease begins with slight occasional pain, and more
or less lameness  in the gait.  As it advances, the pain becomes very ex-
cruciating in the  cases of ulceration of cartilage, whilst in those of scrofu-
lous caries it is comparatively trifling; but in both forms it is  felt  chiefly
in the  knee; and in the scrofulous  caries, this pain in the knee may be
the  only  symptom complained of; nay, there may be even some swelling
there.  The criterion, however, is, that if the surgeon moves  the hip-joint,
or if he jerks  the femur upwards against the  acetabulum, great  pain will
be  felt in  the hip, and the pain in the knee will be greatly aggravated.
There  is  also tenderness in the groin, and behind  the  great trochanter, and
sometimes swelling of the inguinal glands;  and the nates of the affected
side soon becomes wasted and flabby.
  But the chief characteristics of hip disease are certain  alterations  that
occur in  the length of the limb.   In the first  stage the limb acquires an
apparent increase of length, which  is accounted for in  different ways by
different  authors.  (1.) One opinion is, that it is produced  by effusion into
the  cavity of the  joint, and consequent protrusion of the  limb  outwards
and downwards.^  (2.) Mr. Wickham explains it by supposing that  in the
  *  This cut shows the results of long-continued disease of the ankle-joint.  The bones
are  completely welded together by bony anchylosis.
  t  Vide American  Journ. Med. Sc. July, 1842, and a case by Dr. Buck, Ranking's Ab-
stract, vol. iii.  For further information consult Liston and Fergusson.
  t  This opinion is corroborated by the experiments of M. Paris on the  influence of
artificial injections into the hip-joint after death, in separating the bones and  dislocating
the  femur. Arch. Gen. de Med. Mai et Juin, 1842.  See also an account of M. Bonnct'l
experiments on the  injection of joints,  quoted in B. and F. Med. Rev., Jan. 1846.
Fig. 69.»
 
DISEASE  OF  THE HIP-JOINT.
275
first stage of the disease there is a spasmodic  action of the glutaei and ro-
tator muscles,  by which the limb  is drawn a little away from its fellow.
The surgeon, in comparing their lengths, naturally approximates the sound
limb to the diseased one, instead of disturbing the latter; and thus, as the
sound limb is carried  over the  median line, it seems to  become a little
shorter, and the diseased one seems, by comparison, apparently lengthened.
(3.) Sir B. Brodie explains it by showing that when the patient stands up-
right he rests his whole weight on the  sound  limb, and  stretches  out the
other in advance  merely to  steady himself; and  that, in consequence  of
this repeated attitude, the pelvis on the diseased  side  becomes  habitually
depressed. But whatever explanation  be adopted, it must be  remembered
that the lengthening is apparent, and not real; because the distance  from
the spine of the  ilium to the patella is  the same on both sides.
   In a subsequent  stage of the  complaint, the limb  becomes apparently
shortened, as shown in fig. 70, which gives a bird's-eye view  of a child, a
patient of Mr. Partridge's, in  the King's College Hospital, in the second
stage  of hip disease.   This shortening is attributed by Mr. Wickham to a
preponderating action of the psoas and iliacus which  draw the limb  up
across the other.   And this explanation  is rendered  probable by the fact
that spasmodic action of those muscles is  capable of stimulating  disloca-
tion of the hip.*   But it is  sometimes caused by the patient's attitude.!
Fig. 70.                        Fig. 71.
  » Kluyskien's " TExperience," Oct. 28, 1840.  Case of spasmodic affection stimulating
dislocation of the hip.
  \ " In a few cases," says Sir B. Brodie, "where the parent is in the erect  position, <:
may be observed that the foot which belongs to the affected limb is not inclined more 
276
DISEASE  OF THE  HIP-JOINT.
This shortening is  functional, and is easily removed, if the disease  is
checked.
  But if the disease proceed, it is succeeded by another kind of shortening,
caused either by the destruction of the neck of the femur by caries, or (as
is more  commonly the case) by the destruction of the acetabulum and  cap-
sular ligament, and dislocation of the bone upwards by the muscles.  Th
deformed  appearance caused by this dislocation is well  exhibited in the
preceding sketch (fig. 71), taken from a patient under the care of Mr.  Fer-
gusson,  in the King's College Hospital; it also shows the apparently broad
and large, but really wasted and flattened, form of the nates.   The effect
of the altered length of the limb in distorting the spine is also seen. Some-
times the limb is turned inwards, as in dislocation on the dorsum ilii; or
outwards, as  in fracture  of the neck  of the  femur; this  is accidental.
This organic shortening is  usually soon followed by abscess, which  may
burst on the thigh or the groin ; or the  acetabulum may be perforated so
that the  matter passes into the pelvis and bursts into the rectum ; and from
this stage  it  is exceedingly  rare for an adult to recover, although, in the
case of  children, the prognosis is not unfavourable, if the strength is pretty
good.
  Diagnosis.—The ulceration of cartilage may be  known from caries of
bone by various distinctions, which have been  before pointed out.   The
great pain caused by pressing the femur against the acetabulum will  dis-
tinguish either disease from sciatica;  and they may be distinguished from
inflammation of the  synovial membrane of the hip by the fact, that the
pain in  the latter complaint is referred to the upper and inner part of the
thigh, and that it is not aggravated by standing on the limb.
   Treatment.—This must of course be the  same in principle as the treat-
ment of other diseased joints.   If the  patient  comes under treatment in
the earliest  stage, the limb should be  maintained at perfect rest in the
straight posture, by means  of a straight splint reaching from the  axilla to
the foot, [or by a carved splint of wood, or one made of " papier-mache',"
corresponding to the shape of the limb, extending along its outer side from
the ankle  to the lower ribs, and embracing at least one-half of its  circum-
ference.—Ed.]  If distortion has already commenced, a leather or starched
bandage should be applied ; and the patient should  not  be permitted to
lie constantly on the sound side, else  the distortion  of the  spine and the
chance  of dislocation will be enhanced. Cupping will be of great service
in the early stages.  But the  principal dependence is to  be placed on
proper  constitutional treatment, and  on counter-irritation by means of an
issue behind the great trochanter, or at the anterior edge of the tensor va-
ginas femoris,  or by a seton in  the  groin ;  and these measures should not
be neglected,  even though suppuration has  commenced.   When  abscess
forms, it should not be opened too soon, and when it is opened it should
be done in the manner described in the section on chronic abscess, although
it must  be added that this is a plan of treatment which Sir B.  Brodie  does
not believe to possess any particular advantage.   Excision of the  head of
the femur was successfully performed by Mr. White in 1818, and by Mr.
Fergusson in 1845, in cases that would no doubt have otherwise terminated
fatally; but as the latter surgeon  confesses, the  bones of the pelvis are

forward  than the other, but that the  toes only are in contact with the ground, and the
heel raised, at the same time that the hip and knee are a little bent."  Op. cit. p.  134. 
DISLOCATION  GENERALLY.
277
often so extensively diseased as to preclude a possibility of a cure by this
operation.*

             SECTION VIII. — WOUNDS OF  JOINTS.
   Symptoms.—A wound may often, but not invariably, be known to have
penetrated a joint, by the escape of synovia, in  the form  of small oily
globules.
   Treatment.—The object is to avert acute inflammation of the  synovial
membrane, which might prove fatal.   If, therefore, the part wounded be
 he knee, and if the skin be torn  or injured so that the  wound  cannot be
closed, or so that it is certain not to unite by adhesion, and if the  patient's
constitution be bad, amputation should be performed at once.  Otherwise,
the wound should be carefully closed with a piece  of lint dipped in blood ;
—the joint should be kept quite  motionless on a splint;—and every local
and constitutional measure be adopted, to avert or subdue inflammation.

        SECTION IX.--OF  DISLOCATION  GENERALLY.

   Symptoms. — The symptoms of dislocation are  two:—(1.) Deformity;
there being an alteration in the form of the  joint;  — an unnatural promi-
nence at one part and a depression at another ;  together with lengthening
or shortening of the limb.  (2.)  Loss of the proper motions of the joint,
which is most frequently rendered stiff and motionless.
   Causes.—Dislocation may be caused by external violence, or  by mus-
cular action.   And the circumstances that enable muscular action to pro-
duce it are,—a peculiar position (as when the jaw is very much depressed);
—paralysis of an antagonist set of muscles ;—elongation of ligaments;—
or fracture or ulceration of some process of bone.  Thus ulceration of the
acetabulum permits the head of the  femur to be dislocated upwards, and
fracture of the  coronoid process  permits the  ulna to be dislocated back-
wards.
  Morbid  Anatomy. — Dislocation is  almost of necessity attended with
some rupture of ligaments, which, however, readily unite  and  heal by the
adhesive inflammation.   If the dislocation  be  left unreduced, the lymph
thrown out around the  head of the bone in its new situation becomes con-
verted into new ligaments, and a new socket, which is lined with a smooth
ivory substance,  and  not with cartilage; and  a  very  useful degree of
motion is often acquired.   Meanwhile  the old  socket gradually becomes
filled up.
  Diagnosis.—Dislocation may be distinguished from  fracture, 1. by the
absence of crepitus.  For although a  slight crackling is  often perceptible,
owing to an effusion of serum into the cellular tissue, it can hardly be mis-
taken for the grating of fracture.  2. By the circumstance, that mobility  is
increased in fracture, diminished in dislocation.   3. By measurement of the
bone  supposed to be broken, which,  if broken, will be  most probably
shortened.  4.  By the  patient'rage;—for fractures near joints are  most
common in the  very young, and the aged—dislocations  in the adult.f
  Treatment. — The reduction of dislocations may be effected by fixing
the part from  which the  bone has been dislodged, and extending  the dis-
located  limb  in such a manner as to draw the head of  the bone  into its
   • Vide Fergusson's Practical Surgery, 2d edit. p. 380.
   \ Dislocations of the elbow-joint are quite as common in children as fractures
       24 
278
DISLOCATION  OF  THE JAW.
socket, and in such a position as to relax as many of the opposing muscles
as possible.   After reduction, leeches, cold, and purging, must be used to
prevent inflammation, and  the joint should be kept at rest till any lacera-
tion of its ligaments may have healed, otherwise the dislocation may be
perpetually recurring.   But it will be necessary, before attempting reduc-
tion, to diminish the resistance offered by the muscles,  if those which sur-
round the affected joint be large, or if the patient be robust and plethoric.
Bleeding to  faintness;  immersion in a hot bath (100 to 106° F.) for half
an hour, and the exhibition of half-grain doses of tartar emetic,  are the
requisite measures.   But they may be often avoided, if the reduction can
be effected before the patient has recovered from the faintness consequent
on the injury.*
   Compound Dislocation is a dangerous accident, because of the acute
synovial inflammation, rapid ulceration of cartilage, and violent constitu-
tional disturbance, with which it is  liable to be followed.   The necessity
of amputation will depend on precisely the same contingencies as in com-
pound fracture;—old age;—bad  constitution ;—shattering of the bone ;—
extensive  bruising  or laceration  of the integuments,  so that the wound
cannot be closed;—laceration of large blood-vessels;—or if it be the knee
joint.   If the limb is to be saved, the dislocation  must be reduced;—if
the end of the bone protrude through the  skin, and render reduction diffi-
cult, it must be sawed off, or the aperture must be slightly dilated ;—the
wound  must then  be closed, and covered with a piece of lint dipped  in
blood;  and the case be treated as a wounded joint.
  Dislocation and Fracture. — Supposing the femur or humerus to be
dislocated, and fractured also, Sir A. Cooper directs the fractured part to
be first well secured in splints and bandages, and then the dislocation to
be reduced without delay.   Because, if the  dislocation is not attended to
till after the fracture has united,  the difficulty of reducing it will be very
much increased  through the lapse of time; and, perhaps, the  bone may
be broken again during the forcible extension that will be necessary.


      SECTION  X.--OF PARTICULAR  DISLOCATIONS.

  I.  Dislocation of the Jaw  may be  caused by a blow on the chin,
when the mouth is wide open, or by spasm  of  the pterygoid muscles, by
which  the  articular  condyles are drawn  over the transverse root of the
zygomatic process.
  Symptoms.—The mouth fixedly open ;—the chin protruding forwards;
—and  a prominence felt under the zygomatic process.   If one  side only
is dislocated, the chin will be turned towards the opposite.
   Treatment. — The surgeon should wrap a napkin  around his thumbs,
and place them at the roots of the  coronoid processes behind  the molar
teeth ;-—then he should  press them downwards and backwards, elevating
the chin at the same time with his fingers.   Or he may place the handle
of a  fork  on the last molar teeth, and  depress them with it,  using the
upper teeth as a fulcrum.  Or a piece of cork may be put between the
  * We feel  bound to  notice in this place the  instrument invented byDr.Jarvis.au
American surgeon, and called the Surgical Adjuster.  It contains within very small
compass the  means of making most efficient extension, witho.ut violence, or inconve-
nience of any kind ; and it appears likely to be of great service in the reduction of dis-
locations.  It may be procured at Weiss's, in the Strand. 
DISLOCATIONS  OF THE  SHOULDER.
279
molar teetn, in order to act as a fulcrum, whilst the chin  is elevated.
After reduction, the chin must be confined for a week or two by a four-
tailed bandage.
  II. Dislocations  of the Clavicle.—The sternal extremity of this
bone may be dislocated forwards by blows on the shoulder.  It can readily
be felt on the anterior surface of the sternum.  The treatment is  in all re-
spects the same as for fractured clavicle.   Dislocation of this end  of the
bone backwards has been caused by curvature of the spine.   It produced
so much pressure on the  oesophagus as to threaten  starvation, and was in
consequence extirpated by Mr.  Davie of Bungay.  There are also a few
cases on record of dislocation of this  end of the clavicle backwards by
violence.   Pain and difficulty of breathing are the  consequences; the re-
duction and subsequent treatment the same as for the dislocation forwards.*
  The outer extremity of the clavicle  may be dislocated upwards on  the
acromion.  The shoulder is sunken and flattened, and on tracing the spine
of the scapula, the end of the clavicle can  be felt upon the acromion.  The
outer extremity of the clavicle has also been known to be dislocated under
the acromion by a kick from a horse on the shoulder.f  The  treatment is
the same as for fracture of the clavicle.
   III. Dislocation of the Shoulder-Joint may occur in three  principal
directions.   The  head of the humerus may be  thrown downwards, for-
wards, and backwards ; besides which it  may be partially dislocated for-
wards and upwards.
   (1.) In the dislocation downwards ox into the axilla, (fig. 72,)  which is
the most common, the head of  the bone  rests on  the axillary plexus of
nerves,  between the subscapularis muscles and the  ribs.
  Symptoms.—The arm  is lengthened ;—a hollow may be felt under the
acromion, where the head of the bone ought to be;—the shoulder seems
flattened ;—the elbow sticks out from the  side;—and the  head  of the
Fig. 72.                           Fig. 73.
  • Vide a case by M. Pellieux in the Revue Medicate, Aug. 1834, p. 151, and anothe
hy Mr. Brown of Callington, Med. Gaz., Aug 1, 1845.
  j- Forbes Rev. vol. vi. 
280
DISLOCATIONS  OF  THE SHOULDER.
 bone can be felt  in  the  axilla, if  the limb  be raised; although such an
 attempt causes great pain and numbness.
   Diagnosis.—There are three fractures liable to be  mistaken for disloca-
 tion : viz. fracture of the acromion;—of the neck of the scapula;—and of
 the neck of the humerus.   The first two  may be known by the facility with
 which the form  of  the joint is restored by raising the limb, and  by the
 crepitus felt  on doing so.   In fracture  of the cervix humeri, the limb is
 shortened, instead of being lengthened as it is in dislocation ;—there is not
 so much vacuity under the acromion;—and the rough angular end  of the
 shaft may be felt in  the axilla, instead of the  natural smooth head of the
 bone.
   (2.) In the dislocation forwards, (fig.  73,) the head of the humerus is
 thrown on the inner  side of the coracoid process, and may be felt  under
 the clavicle.
   Symptoms.—The  arm is shortened;—the elbow projects backwards ;—
 the acromion seems pointed, and the  head of the bone cannot be felt
 under it.
   (3.) In the dislocation backwards, the  head  of the bone may be felt on
 the dorsum scapulae  ; and the elbow projects forwards.
   (4.) In  the partial dislocation forwards, the head of the bone is thrown
 partly off from the  glenoid  cavity  against the coracoid process.   The
 symptoms are, projection of the  acromion  and a hollow under it at the
 back  of the joint; whilst the head of the bone is prominent in front, and
 may be felt to move  on rotating the elbow ;  cramps of the hand, and diffi-
 culty of raising the elbow, because the head of the bone strikes against
 the coracoid process.
   (3.) The partial dislocation upwards is attended with a displacement of
 the biceps tendon from its groove,  as we shall mention more particularly
 presently.
  Treatment.—There are five methods of reducing the first  or down-
 wards form of dislocation.
   (1.) By simple extension.  A jack-towel is  to be passed round the chest,
 both above and below the shoulder, so  as  to fix the scapula well; this
should be held firmly.   Another should be fastened round the arm, above
the elbow, by means of the knot called  the clove hitch, represented in the
next figure.   Extension should then be made by the  latter;—the patient
sitting on the floor, his elbow being bent, and the humerus  being raised
and earn d forwards, so as to relax the deltoid, supra-spinatus, and biceps
                             muscles.   When extension has been made
                             for some  minutes, the  surgeon should lift
                             the head of the bone, and it will frequently
                             return with a  snap.
                               (2.)  The extension  may be performed
                             in the same direction with the aid of the
                             pulleys;—recollecting always that they are
                             not  to be  used in  order to exert greater
                             force, but to exert  it more  equably.  A
                             damp bandage should be  applied round
                             the  elbow to protect the  skin before the
                             strap of the pulleys is attached.
 \ {                            (3.)  By the  heel  in the axilla.  The
                            patient lies down on a bed, and  the  sur-
 
DISLOCATIONS  OF THE  SHOULDER.
281
geon sits  on the edge.  He puts his heel  (without  his boot)* into the
axilla, to press  the head of the bone upwards and outwards, and at the
same time pulls the limb downwards by means of a towel fastened round
the elbow.
   [The surgeon may very  much increase his  power  over the dislocated
shoulder, by securing one  end of  a common  double roller-towel  to the
wrist, or to the arm just above the elbow, and slipping the other end over
his own neck, so that one portion of the towel shall rest upon his shoulder,
and the other pass under .the axilla of the other side.  Then, fixing the
patient's position by the heel in the axilla, the surgeon  can exert the power
of the muscles of his back as well as of the  arms in operating upon the
dislocation.—Ed.]
   (4.) According to the method invented by Mr. White, of Manchestei
revived by Malgaigne, the patient lies down, and the surgeon sits behind
him.   The scapula is well fixed, by placing one hand upon the shoulder,
or by passing a jack-towel over the shoulder and fixing it to the opposite
corner of the bed;—then the arm is raised from the side, and drawn straight
up by the head, till the bone is thus elevated into its socket.
  (5.) By the knee in the axilla.  The patient being seated in a chair, the
surgeon places one  of his knees in the axilla, resting the foot on the  chair.
He then puts one hand on  the shoulder to  fix the  scapula, and with the
other depresses the  elbow over his knee.
  The  dislocation forwards may be reduced by the heel in the axilla, or
by extension with the jack-towel or pulley.   But the extension must be
made in a  direction  downwards and backwards.   For the dislocation
backwards, extension should be  made forwards.  The partial dislocation
forwards may be reduced by simple extension.
  After reduction a pad should  be placed in the axilla, and the arm and
shoulder be  supported  for some days with a figure of 8 bandage,  a few
turns of which should confine the arm to the trunk.   Warm fomentations
—perhaps leeches—and "subsequently frictions, will relieve  the pain and
swelling.  The^more weak and flabby the patient, or the oftener the dis-
location has occurred, the longer will  confinement be necessary, in order

  * A case is  related by Dr. Warren, of Boston, in which a person made a violent at-
tempt to reduce a dislocation by puttinsr the heel of his boot in the axilla. The resuij
kvas a rupture of the axillary artery.  Vide Ranking's Abstract, vol. iii. p. 43.
       24* 
282
DISLOCATIONS  OF  THE SHOULDER.
to allow of a complete  consolidation of the ruptured ligament.  In fact,
when the dislocation has occurred more than twice, an  apparatus consist-
ing of a clavicle bandage, with a broad band round the head of the  hume-
rus, should be worn for some months, so as to restrain the motions  of  the
joint.                                                        .
   It has been before  directed  that this and all other dislocations should
be reduced as soon as possible after the injury.   If the reduction has been
delayed till the muscles have fixed the part, and  the  patient is robust, it
will be necessary to bleed or administer tartar emetic, and to make a long,
slow, and gentle, but unremitting extension by the pulleys.   When  the
extension has been continued  some time, the surgeon  may gently rotate
the limb by the fore-arm, or lift the  head  of the  bone;  and  during  the
whole operation the patient's attention should be diverted as much as pos-
sible to other objects.   If the dislocation has lasted some time, there will
be still greater necessity for a preparatory bleeding, purging, and the warm
bath, and for a tedious  operation.   Sir A.  Cooper's opinion  is, that a  re-
duction ought not to be attempted after three months.  But the criterion
which Mr. B. Cooper has proposed is abetter one; and that is, the degree
in which the arm has been  exercised, and the  amount of useful motion
which it has acquired in its new situation; for, in proportion as the head
of the bone has formed  for itself a new socket, so most likely will the old
socket have become  unfit for  its reception again.  There are numerous
instances on record, of the most disastrous  and even fatal results that have
ensued from attempts at reduction at a later period; the integuments and
muscles have been lacerated ;  abscess has  formed, and  been followed  by
anchylosis of the joint;  nay, even the whole side has been palsied from
injury to the cervical vertebras, and the axillary artery has been torn across.
   Injuries of the shoulder-joint are liable to be followed by various obsti-
nate and intractable  affections.  Sometimes the  deltoid  muscle wastes
away, owing probably to injury of the circumflex nerve.   Violent spasms
and neuralgic pains of the arms sometimes occur from injury to the other
nerves ; and there are some cases in  which rupture or displacement of the
long tendon of the biceps is the source of continued impairment  of motion;
and, together with displacement of this tendon, the head of the humerus
has been known to be partially dislocated upwards.*
   IV.  Dislocation of  the Elbow  presents six varieties.  Both radius
and  ulna may be dislocated,  (1) simply backwards ; or, (2)  backwards

                               Fig. 76.
  ♦See a paper by Mr. Stanley on Rupture of the Biceps Tendon, in the Lond, Mm
Caz. vol. iii.; and case of partial dislocation of the humerus upwards, by Mr. Soden, in
M?d  Chir. Trans, for 1841. 
DISLOCATIONS  OF THE ELBOW.
283
and inwards;  or (3) backwards and  outwards.   (4) The ulna by itself
may be dislocated backwards; — and the radius by itself either (5) back-
wards, or (6) forwards.
  (1.) When both radius and ulna are dislocated backwards, the elbow is
bent at a right angle, and  is immovable;—the olecranon projects much
behind; — a hollow can  be felt  at each side of it, corresponding to the
greater sigmoid cavity ; — and the trochlea of the humerus forms a. hard
protuberance in front.   The coronoid process rests  in  that fossa of the
humerus which naturally contains the olecranon.
  (2.) In dislocation of both bones backwards and outwards, the coronoid
process is  thrown behind the external  condyle; and in addition to the
preceding  symptoms,  the head  of the radius can be very plainly felt on
the outer side of ihe joint.
  (3.) The dislocation backwards and inwards is  known by a great pro-
jection of the  outer condyle, in addition  to the symptoms of the first
variety.
  (4.) In dislocation backwards of the ulna  solely, the olecranon is much
projected backwards ;—the elbow is immovably bent at  right angles, and
the fore-arm is  much twisted and pronated.
  The treatment  of these four varieties is the same.   Reduction may be
effected, first,  by fixing the lower end of the humerus whilst the fore-arm
is drawn forwards; or  secondly, the surgeon may bend the elbow forcibly
over his  knee; or thirdly, (if the case be quite recent,) he may forcibly
straighten the arm, so as to make the tendon  of the biceps pull the trochlea
of the humerus back into  its place.
  (5.) The head of the  radius  alone maybe dislocated forwards, being
thrown against the external condyle.   The elbow  is slightly bent, and, in

                               Fig. 77.
bending it more, the  head of the radius can be felt to strike against the
front of the humerus.
   Treatment.—Simple extension from the hand, the elbow being straight.
   (6.)  Dislocation of the radius baclcwards is very rare.  The head of the
bone can be felt  behind the outer condyle.  Reduced by simply bending
the arm, which should be kept bent for three weeks.
   Diagnosis.—These dislocations of the elbow maybe distinguished from
fractures  of the  lower extremity of  the humerus,  (1) by the  impaired
mobility of the joint, and by the absence of crepitus;  (2) by measuring
the length of the humerus from its condyles to the shoulder; — which, in
dislocation, will be equal to that of the sound limb, but will be diminished
in fracture of the lower extremity of the humerus.   But when  it is con-
sidered that these six dislocations may be combined  with various fractures 
284
DISLOCATIONS OF THE HAND.
of the condyles of the humerus and of the bones of the fore-arm, it will d«
aaraitted that the injuries of the elbow present  a  sufficiently wide and
complicated field of study.
  V.  Dislocations of the Wrist  may readily be distinguished  by the
altered position of the hand, which is thrown either backwards or forwards
if both bones be dislocated, or twisted if only one be displaced,—and by
the alteration of the natural relative position of the styloid processes of the
radius and  ulna with the bones of  the carpus.  They are  reduced by
simple extension.*
  VI.  Dislocations of the Hand.—The os magnum  and os cuneiforme
are sometimes partially dislocated  through relaxation  of their ligaments,
and form projections at the back of the hand, which must not be mistaken
for ganglia.  Mr. Fergusson has also known the  os pisiforme dislocated by
the action of the flexor carpi ulnaris muscle.
   Treatment.—Cold affusion, friction, and mechanical  support.
   Dislocations of the thumb, fingers, and toes, are  difficult of reduction, in
consequence of the strength and tightness of their lateral ligaments,  and
the small size of the part from which  extension can be made.  A. firm hold
                                Fig. 78.
may be obtained by means of a piece of tape fastened with the knot called
the clove hitch, represented in this figure.   But it is a good plan to place
a part of the tape round the head of the dislocated bone, so as to  pull it
straight forwards into its place.   Extension should  be made towards the
palm, so as to relax the flexor muscles.  But " before the  reduction has
been effected," says  Mr. Liston, " it has been in some  cases  even found
necessary to divide  one  of the  ligaments;  the external is  most easily
reached ; it is cut across by introducing a narrow-bladed and  lancet-pointed
knife through the skin at some distance, and  directing its edge against the
resisting part."
   [A very firm grasp may be secured upon the fingers,  or toes, when lax-
ated, by using the sort of tube  made of bark plaited as basket-work by
the Indians of our northern borders.   This  should be  slipped upon the
part,—a finger for example,—and its construction is such, that when it is
drawn upon its  cavity becomes smaller and  smaller in  proportion to its
elongations, so that the greater the power employed to reduce the disloca-
tion the more  unyieldingly the instrument clasps the finger.—Ed.]
   In compound dislocation of the first phalanx of the thumb on the meta-
carpal bone, the head of the phalanx should be sawn off, before attempting

  » Dupuytren taught that these dislocations are extremely rare,  or, in fact, almost im-
possible; and that fractures of the lower extremity of the  radius were generally mis-
taken for them.  But the experience of English surgeons shows  that real dislocation,
without any fracture, is not  by any means uncommon.   See a very carefully reported
case in the Loud. Med. Gaz., June 17th, 1843. 
DISLOCATIONS OF THE HIP.
285
reduction ; and in compound dislocation of the second phalanx, it is better
to saw off the head of the first.
   VII.  Dislocations of the Ribs.—The costal cartilages  may be  torn
from the extremity of the ribs, or from  the  sternum;—and  the  posterior
extremity of the rib  may be  dislocated from the spine by falls on the
back ;  but these accidents  are very rare.  A  case is related  in which the
heads of the last two ribs were driven forwards from  the spine, in a boy
of eleven, by a violent blow on the back; abscess  formed, and the  case
terminated fatally.*   The body of the sternum has also been  dislocated in
liont of the manubrium, and the ensiform cartilage is sometimes separated.
In all these cases, the same local and constitutional  treatment must  be
adopted that was prescribed for fracture.
   VIII. Dislocations of the Hip-Joint.—There
are four  principal  varieties of this  dislocation.
1st. The dislocation upwards ;  in which the  head
of the bone is  thrown on the dorsum ilii.  2dly,
The dislocation backwards on the  sciatic notch ;
3dly,  downwards,  on  the  obturator externus
muscle ; and 4thly,  forwards, on the os pubis.
Besides which  there  are two or three  others that
are exceedingly rare.
   1. Dislocation upioards on the dorsum ilii is  the
most frequent.
   Symptoms.—The limb is from an  inch and a
half to  two  inches  and a  half shorter than  the
other;—the toes rest on the opposite instep ;—the
knee is turned  inwards, and is a little advanced
upon the  other;—the limb  can  be slightly bent
across the other, but cannot be moved outwards ;
—the trochanter is less prominent than the other,
and nearer the  spine  of the ilium ;—and if  the
patient is thin,  and there is no swelling, the  head
of the bone can be felt in its new situation.
   Diagnosis.—Fracture of the cervix femoris may
be distinguished from this dislocation by the cir-
cumstance that the  limb can be freely moved in
any direction, although with some pain ; that it
is turned outwards instead of inwards ;—and that it can be drawn to its
proper length  by moderate  extension, but  becomes shortened  again as
soon as the extension is discontinued: whereas in dislocation, it requires
orcible extension to restore the limb to its proper length and shape ;  but
when once the  head of the bone is replaced  in its socket, it remains there.f
   Treatment.—In the first place, it will most likely be requisite to diminish
he force of the muscles by a moderate bleeding; by  immersion in a hot
  ' Dublin Med. Press, 3d Feb. 1841.
  + There are a few cases on record of fracture of the upper extremity of the femur,
in which a portion of the great trochanter was broken off, and  drawn by the muscles
bnel< wards on the dorsum ilii, into the position usually occupied  by the head of the bone
when dislocated ;  so that the nature of the accident was obscure.   It suffices to  notice
the possibility of such cases, in order to put surgeons on their guard.  Vide a paper by
M.  Stanley,  Med. Chir. Trans, vol. xiii.  When one  leg also has been shortened bv
previous disease or injury, the surgeon is puzzled if the other is dislocated, as he ha*
no criterion by which to estimate its proper length. 
236
DISLOCATIONS  OF THE  HIP.
bath of 100° to 110°; and  by the exhibition of half a graL of tartar
emetic every ten minutes, continued till the patient  feels nauseated and
powerless. * Then he should be wrapped in a blanket, and placed  on his
back on a table; a leathern girth or strong  towel should be passed round

                               Fig. 80.
die upper part of the thigh, so as to bear firmly against the perinaeum and
cristi ilii, as represented in Fig. 80, which was sketched from nature by
Mr. W. Bagg; and  this should be attached  to a ring or hook securely
fastened into the wall or floor.  A linen roller should next be applied to
the lower part of the thigh, and over it the strap belonging to the pulleys;
—which last are to be fixed to the wall or some other firm object.   Then
extension is to be made in such a direction as  to draw the thigh across the
opposite, a little  above the knee.  After a little time, the surgeon should
gently rotate the limb, or lift the upper part of it, and the head of the bone
will probably return to the acetabulum.   The patient should then be care-
fully moved to bed with his  thighs tied together.
   2. The dislocation backwards, Fig. 81, (in which the head of the femur
is thrown into the sciatic notch, or on the pyriformis) is known by the fol-
lowing symptoms.   The limb is shortened  from half an inch to an  inch;
—the toes rest on the ball of the great toe of the other foot;—the knee is
advanced and turned inwards, but not so much as in the last case;—the
trochanter is rather behind its natural position, and the  head  of the  bone
can scarcely be felt.
   Treatment.—Pulleys  are required, as in the  last case ; but  the patient
should be placed on  his side, and the  limb be  drawn across the middle of
the opposite thigh.   After a little while the upper part of the limb should
be lifted by means of a  napkin, so as to raise the head of the bone over
the edge of the acetabulum.
   3. In  the dislocation downwards,  (fig. 82,) the head of the bone  is
thrown into the thyroid foramen, or on the obturator externus.  The symp-
toms are as follows:—the  limb is  lengthened  one or two inches;—it  is
drawn  away from the other;—the toes point downwards and directly for-
wards ;—and the body is bent forwards, because the psoas  muscle is on
the stretch.
   Treatment.—The object is to draw the head of  the bone outwards, and
rather upwards.  There are  two methods of effecting  this.   In the first
place, the patient may be laid on his back on a bed, with one of the bed-
posts between his thighs, and close up to the perinaeum.   Then the foot
may be carried inwards, across  the  median line ;—so  that  the bed-post,
acting as a fidcrum, may throw the head  of the femur outwards.  But the 
DISLOCATIONS  OF  THE HIP.
287
loot must not be raised, otherwise the head  of the  femur may slip  round
under the acetabulum into the sciatic notch.  (2.)  Or the  pelvis may be

             Fig. 81.                              Fig- 82-
fixed by straps, and the pulleys be applied to the upper part of the  thigh,
to draw it outwards:  whilst the knee is at the same time pulled down-
wards and inwards.   (See fig. 83.)
   Sir Astley Cooper has decided that eight weeks is the latest period after
which it is justifiable to attempt the  reduction of a dislocated hip, except
in persons of extremely relaxed fibre or of advanced age ; and numerous
instances are on record of death  from abscesses or phlebitis, occasioned
by violent extension at a later period.
   4. In the dislocation upwards and forwards, (on the pubes,) see fig. 84,
the limb is shortened about an inch ;—it is drawn away from  the  other,
and the foot points directly outwards; the head of the bone may be plainly
felt below Poupart's ligament; and by this circumstance  this  dislocation
may be distinguished  from fracture of the cervix femoris.
   Treatment. — The  patient is to be laid on the sound  side; — extension
should be made with  the pulleys in a direction backwards and  outwards;
—and  after it has been continued a little time, the head of the bone should
be lifted over the edge of  the acetabulum  by  means of a napkin.
   With respect to  the relative  frequency of these  dislocations,  Sir  A.
Cooper believed that out of twenty cases, twelve would be on the dorsum
ilii, five in the ischiatic notch, two in the foramen ovale, and one  on the
pubes.*
  • These dislocations generally happen to adults. In very old people it is more com
mon for the cervix femoris to  give way.  They are also rarely met with  in children
 
288
DISLOCATIONS OF THE  HIP.
  It may be added, that in elderly weakly persons these dislocations may-
be conveniently reduced by means of the surgeon's foot pressing on the

                 Fig. 83.                              Fig. 84.
perineum,  whilst  extension and rotation  of the  limb  are  effected  by
assistants.*
   [Dr. Gilbert, Professor of Surgery in the Pennsylvania Medical College,
of this city, has recommended a very convenient and attainable substitute
for the pulleys in  the reduction of dislocations of the  head of the thigh-
bone.   He says: — "Place the patient and adjust the extending  and
counter-extending  bands as for the  pulleys;  then procure  an ordinary
bed-cord, or wash-line, tie the  ends together, and again  double  it upon
itself; then pass it  through the extending tapes or towel, doubling the
whole  once more, and fasten  the distal end, consisting of four loops of
rope, to a window-sill,  door-sill, or staple, so that the ropes shall be
drawn moderately tight; finally, pass a stick  through the centre  of the
doubled rope, dividing the strands equally by  it; then,  by revolving the
stick as  an axis or  double-lever, the power is produced precisely as it
should oe in such cases:  viz.  slowly, steadily, and continuously."   Am

ahnough  Sir A.  Cooper relates one case which happened to a boy of seven; Mr. Tra
vers, jun., one to a boy of five; and the late Mr. Place, of Wimborne, was good  enougli
to communicate  to the author the particulars of a case of dislocation on the dorsum iii.
happening to a boy of ten.
  • South's Clielius, vol. i p. 801.
 
                   DISLOCATIONS  OF THE  KNEE.                289

Journal, vol. ix. N. S.  The accompanying drawing illustrates the appli-
cation of this means.—Ed.]

                               Fig. 85.
  Unusual  Dislocations.—Besides the above  four varieties, a disloca-
tion  directly downwards on the tuberosity of the  ischium ;  one directly
backwards on the spine  of the ischium ; and one directly upwards on the
space between  the  anterior spinous  processes of  the  ilium, have  been
known to occur, although very rarely.   In a case  of dislocation directly
downwards, recorded by Mr. Keate, the limb was lengthened three inches
and a half, and was fixed and everted ; the trochanter was sunk ; and the
head of the bone close to and on a level with the tuberosity of the ischium,
where it was capable of being moved under the finger.!  In a case of dis-
location on the  spine of the  ischium, which happened in the practice of
Mr. Earle, at St. Bartholomew's, the limb was lengthened about half an
inch ; it was neither everted nor inverted, but if anything the latter; there
seemed to be a great vacuity in front of the  hip ;  the  edges of the sar-
torius and tensor vaginse femoris could be plainly felt, and a cavity behind
them; and the trochanter was further back, and not  so prominent as usual.
But the dislocation directly upwards is the most common of these unusual
forms.   In a case that  was examined  by Mr. Travers, jun., some time
after the accident, the limb was completely everted and slightly movable;
and  the neck of the bone lay between the two anterior spinous processes
of the  ilium; so that when  the  patient was erect, the limb seemed  to be
slung or suspended  from this point.   The diagnosis must in such cases be
guided by an attentive examination of  the  deformity that is present, and
by the absence of any  symptoms of fracture.   The reduction  must be
effected by extension, made in such a direction  as seems most  likely to
bring the head of the bone into its socket.*
  IX.  Dislocations of the Knee. — Dislocation of the tibia from  the
femur is not very common; and, when it does occur, is rarely complete.
In most cases the tibia is thrown backwards towards the ham.   The de

  • Vide a paper on Rare Dislocations of the  Hip-Joint, in the Med. Chir. Trans., vol
xx.. hv .Mr. Travers. jun.  Sir A. Cooper, op. cit. and Guys  Hosp. Rep., vol. i.;  Keate
Med. (.Jaz., vol. x.; a case of dislocation directly upwards, in the Lancet,  May 15tli
IS 11 ; and Mr. Earle's case, Lancet, vol. xi. p. 159.
       25                        t 
290
DISLOCATION  OF THE  ANKLE.
 formity and  impediment  to motion will enable the practitioner to distin-
 guish the accident;—and if there be no complication requiring amputation,
 the displacement must be rectified  by  simple extension, and  the  knee be
 kept at rest till inflammatory symptoms have subsided.
   Dislocation of the Patella may occur either inwards or outwards;
 more frequently in the latter direction.   The symptoms are, that the knee
 cannot  be bent, and  that the  bone can be felt  in its new situation.  This
 dislocation may be caused either by mechanical violence, or  by a  sudden
 contraction of the extensors of the thigh.   It generally happens to knock
 kneed, flabby people.   There is, in general, no  difficulty in reducing it by
 means of the finger and thumb, if  the knee is straight and the leg raised.
 There is one variety of this dislocation, however, in which the patella is
 turned round on its  long axis,  so  that its inner edge rests on the  outside
 of the trochlea of the femur, and its outer edge lies immediately under the
 skin.   In one instance, the surgeon was unable to reduce it by any means,
 even  although  he  divided the ligamentum patellae, and cut through the
 quadriceps at its insertion into the patella ; and the patient died in eleven
 months,  in consequence of his wounding the joint.  Mr. Mayo relates a
 similar case,  in which he succeeded in  overcoming the difficulty by bend-
 ing the knee  to the utmost, so that the patella was drawn out of the groove
 in which it was lodged.*
   The patella is dislocated upwards after  rupture of its tendon  by the
 extensor muscles.  This must be treated as fracture of the patella ; but it
 is very rare.
   Partial Dislocation of the Semilunar Cartilages. — During sud-
 den twists of the knee-joint, the  semilunar cartilages may slip out of  theii
 proper position, and  become  wedged in between the tibia  and  femur.
 The symptoms are sudden extreme  sickening pain, and inability to stand,
 or to straighten the limb.  This accident generally happens to people of
 relaxed habits, and when it has once happened is very liable to recur.  In
 a case dissected by Mr. Fergusson, the external semilunar cartilage was
 found to be  torn from its connexion  with the tibia, except just at its
 extremities.   The best way of restoring the part to its place, is to bend
 the joint to the utmost, and then extend it:  and the patient should wear
 an elastic knee-cap.
  Dislocation of the Head of the Fibula is of very unfrequent occur-
rence ; except as a consequence of relaxation of the ligaments from weak-
ness, which must be treated by blisters  and bandages, with a pad to press
on the head of the bone.  There are two cases  of it, caused by violence,
in Sir Astley  Cooper's work ; the head  of  the bone could be felt to  pass
more  backwards than  natural,  and could  be moved by the fino-er.   The
pad of a tourniquet was employed to keep it in  its place.
  X.  Dislocation of the Ankle may occur in four directions.  (1).
Dislocation of the tibia inwards is the most common.  It is attended  with
fracture of the lower third of the fibula, and may be easily known by the
sole of the foot turning outwards ;—its  inner edge turning  downwards ;—
and great projection  of the internal malleolus.   (2.) Dislocation  of the
tibia and fibula outwards is attended with fracture of the internal malleolus,
and may be known by the sole of the  foot turning inwards.  (3.) In the
dislocation forwards, the foot appears shortened, and the heel  lengthens.,
  •These cases are related in Sir A. Cooper; and a similar  one in  Sir G. Ballingail'8
AlUlta.1V >nrrjf>rv                                                    ° 
DISLOCATIONS  OF THE  FOOT.                291
and the toes pointed downwards.  There is also a partial dislocation for-
wards, in which the tibia is only half displaced from  its articulation with
the astragalus, the fibula being also  broken; the  foot appears shortened,
and  immovable, and  the  heel cannot be brought to the ground.  (4.) A
dislocation backwards has been described  ; but it must be  excessively
rare,  as  Sir A. Cooper never  saw it.   There is a case of it  described by
Mr. Colles, which, however, was probably one of transverse fracture of the
tibia and fibula  just above the joint, wTith displacement  backwards.  The
fracture of the  fibula about three inches above the outer malleolus, which
accompanies the dislocation inwrards, is commonly called Pott's fracture.
   Treatment. — The  patient  must be laid  on the  affected  side, and the
knee  must be bent, (to relax the gastrocnemius,) and be firmly held by
an assistant.  The surgeon must then grasp  the instep with one hand, and
the heel  with the other, and make  extension, (aided  by pressure on the
head  of  the tibia,) till he  has restored the natural shape and  mobility of
the parts.  Then the limb must be put up with a  splint on each side, in
the same manner as a fracture of the  lowrer part of  the leg, taking care to
keep  the great toe in  its proper line with the patella.
   Compound Dislocation of the ankle-joint is  by far the most frequent
example of that kind  of injury.  If the wound in  the integument, does not
heal by the first intention, the joint inflames; suppuration occurs in about
five days; much of the cartilage is  destroyed by  ulceration ; at last the
wound  is filled  with granulations,  and  the patient recovers  a  tolerably
good  use of the foot in from two to  twelve months.   The first thing to be
done  is, to wash away all  dirt with warm water; to remove any shattered
pieces of bone  gently with the fingers, and then to  reduce the bone to its
place  ; slightly enlarging the wound  in the skin,  if necessary, in  order to
effect  this without violence.   If  it is very difficult to return the end of the
tibia,  or if it  is fractured  obliquely,  or much shattered,  it is better to saw
it off; as the patient will have quite as good use of the  limb  afterwards.
Then  the external wound should be closed with a bit of lint dipped in the
patient's blood, and the leg be secured with  a tailed bandage and splints,
and be wetted by an evaporating lotion.   Care must  be taken not to let
the foot  be  pointed, nor be turned  to either side.  The remaining treat-
ment  is  the same as that of compound fracture;  and the rules which are
given  as  to the necessity of amputation, are the same in  both cases.
  XI. Dislocations of the Foot.—The most important of these are the
dislocations of the astragalus,  which  may be separated from its connexion
with the os  naviculare and  os calcis in  various ways.   Sometimes it is
thrown inwards,  so as to rest  on the inner surface of the  os calcis; and in
this case, there appears an unusual projection below the inner ankle, and
a corresponding depression below  the outer one, and the whole foot
seems displaced outwards.   Sometimes it is thrown outwards;  and then
the foot seems to be displaced inwards.   If  these dislocations  are simple,
reduction should be immediately attempted by extension, and  the pulleys
and tartar emetic will be needed ;  although  the attempt  will  often be
unsuccessful.   If the  dislocation is compound, and the bone cannot be
replaced, or if it is  much  shattered, it may  be dissected out.   In these
two dislocations, the astragalus is separated from  the  other tarsal  bones.
but preserves its connexions with the tibia  and  fibula, so that they may
be regarded merely as varieties of dislocation of the ankle-joint, in which
the tibia and fibula carry the astragalus with  them in  their displacement 
292                   WOUNDS OF ARTERIES.
It may, however, be completely shot out from under  the  tibia, and lie
under  the skin of the outer side of the  foot.   And lastly, it may in the
same way be dislocated backwards; projecting behind  the ankle-joint
and  pushing the  tendo Achillis backwards.   This displacement, if only
partial, will  be extremely difficult to rectify, and, if complete, it will most
likely be impossible.*
   Besides these, the five anterior tarsal bones may be dislocated from the
os calcis and astragalus.  The cuneiform bones may  be  dislocated up-
wards from  the navicular; the  metatarsal bones from the tarsal, and the
toes from the metatarsal.  In any of these cases, the proper position of the
parts must be restored as much as possible by pressure and extension and
be preserved  by bandages;  but reduction will  often be very difficult, if
not impossible.
                        CHAPTER  VII.

            OF INJURIES AND DISEASES OF ARTERIES.

                 SECTION I.--OF WOUNDS OF ARTERIES.

   Symptoms.—An artery may be known to be wounded by the flow of
 blood,—which is profuse;—of a  florid colour,—and ejected per solium;—
 that is to say, in repeated jets, corresponding to each beat of the pulse.
   Pathology.—It must be evident that the bleeding from wounded arte-
 ries must necessarily be profuse  and dangerous, because from the nature
 of their coats they remain open and patulous, and do not collapse as the
 veins do; and  because of the perpetual current of blood impelled by the
 heart.   Hence  it is important to  study the  means by which arterial hemor-
 rhage is at first arrested, and those by which the wound is afterwards per-
 manently closed;  as well  as the different effects of different kinds of
 wounds.
   There are four  processes employed by nature  for the temporary sup-
 pression of haemorrhage.   In  the first place, the divided  orifice contracts
 more or less ; and secondly, it retracts into its cellular sheath;  3dly, the
 blood coagulates in the sheath of the artery and in the wound  and  thus
 obstructs the further exit of it; and 4thly, the faintness  induced by hemor-
 3' b°^ diecks the current  of blood from  the heart, and gives it an
 increased  disposition to coagulate.                           5
 J] 7^ S ^ Urge a.rter^ such as Ae femoral or subclavian, is wounded,
 on ol 1  t^l  ""f Li1* ?  langLe' and  the flow of blo°d  is in no manner
 opposed, the loss of blood will be so rapid as to occasion death almost in-
 san.-.neously   But if the wound in the  artery is very small, it maybe
 ••losed^firmly by coagulated blood  during syncope, and  the  patient may




i*LV:rUnd rraseenrrge2rvoL vii-p- 254>in -^ * ^ ™ * *- 
WOUNDS  OF ARTERIES.
293
  If the artery is of the second order, as  the  humeral or tibial, the bleed-
 ng will most probably cease for a time through the influence of the four
processes that we have just spoken of.   But in the course of some hours,
when the faintness has passed off, and the heart beats strongly again, the
coagula in  the orifice of the vessel will most probably be dislodged, and
the bleeding will recur again and again, so that the patient will very likely
die of it, unless it be checked by art.   In some cases, however, the orifice
of the vessel may become  permanently closed in  the wTay that  we shall
mention directly.
  If the wounded artery is small, as the digital or temporal, the haemor-
rhage, though pretty brisk for a time, will generally soon  cease spontane-
ously and permanently in the following manner:
  Supposing the  artery to have been completely divided; its orifices will
contract, and will retract into the sheath, which also will be  plugged with
coagula.   Thus then the bleeding is checked for a time.   But shortly the
adhesive inflammation is  set up ;—a yellowish green, tough lymph is ef-
fused, and  fills up the contracted  orifice  of the vessel;—that  part of the
artery which intervenes between the wround and the nearest branch, gra-
dually contracts in the shape of the neck of a champagne bottle;—the
blood coagulates within  it, adheres to its internal surface,  and  becomes
organized into a cellulo-fibrous  tissue ;—and, finally, the impervious por-
tion  of the artery degenerates  into a  fibrous cord, and  is gradually
absorbed.
  It must be evident that  a  puncture or partial division  of an  artery is
much more dangerous than complete division ;—because the two principal
natural means of arresting haemorrhage,—namely, the contraction and re-
traction, are prevented ;—and the bleeding can only be  obstructed by the
coagulated blood in the wound.   Under these circumstances, three things
may happen.  In the first place, the aperture, if longitudinal or very small,
may in favourable  cases be closed by the adhesive inflammation, the artery
remaining  pervious.  The uniting lymph, however, is very liable to be
dilated into a false aneurism.  Or, secondly, the channel of the artery may
be obliterated by lymph  or coagulated blood.  Or, thirdly,  bleeding may
recur perpetually,  till the undivided part of the vessel ulcerates, or is di-
vided by art.   From these details may easily be gathered  the reason why,
when a small artery has been partially divided, (as the temporal in arteri-
otomy,) it is judicious to divide it completely.
  When an artery is torn across, it contracts  almost immediately, and be-
comes quite impervious,  so that an arm  or leg may be torn off  by a shot
or by machinery, without any loss of blood from the axillary or  tibial ar-
teries.  For this reason, there is no haemorrhage from the umbilical cord
of young animals, which is either torn or bitten through by the mother.
Lastly, it will be readily  seen that division of arteries which are  diseased,
or which are situated in condensed and inflamed tissues, so that  they can-
not contract or retract, will be followed by profuse bleeding.
  Treatment.—The first indication is to stop the flow of blood, until
measures can be adopted for arresting it permanently.  This may be done
by placing  a finger on the orifice of the bleeding vessel, or by grasping it
between the finger and thumb,  if the wound  is large and open;—or, by
making pressure  on the wound itself;—or by pressing the  trunk of the
artery above, against  a bone ;—or by applying the tourniquet ;*  or in de-
          * The touriiquet is described in the chapter on Amputations.
      25* 
294
WOUNDS  OF  ARTERIES.
Fia. 86.
 fault of that, a handkerchief maybe passed round the limb, and be twisted
 tightly with  a  stick.   The permanent  measures  are ligature—torsion-
 pressure—cold, and styptics.
                      Ligature.—When a ligature is tied tightly upon an
                   artery, it divides the  middle and internal coats, leavinc
                   the  external  or cellular  coat enclosed  in  the  knot.
                   Then the following series of phenomena occurs.   The
                   cut edges of the internal coats unite by adhesion ;—
                   the blood between the point tied and the nearest col-
                   lateral branch coagulates  and adheres to the lining
                   membrane ;—the ring of the cellular coat enclosed in
                   the ligature  ulcerates;—the ligature comes away in
                   from five to twenty-one days, (sooner or later,  accord-
                   ing to the size of the vessel;)—and, finally, that portion
                   of the artery which is filled with coagulum shrinks into
                   a fibrous cord.
                      Now it must be observed that the  efficacy of the li-
                   gature depends  on two things.  (1st) On the adhesion
                   of the cut surfaces of the internal coat of the artery;—
                   and in order to promote this, the ligature should be small
                   and round, so as to divide them smoothly and evenly.*
   (2dly)  On the adhesion and  organization  of the blood in the artery be-
 tween  the part tied and the nearest branch.
   Hence the rule is generally given, not to tie an artery immediately below
 a branch,  if  it can be avoided ;f  and in tying it, to disturb it as little an
 possible;—in order not to tear through the vessels which it receives  from
 its  sheath, and  on which the nutrition of its coats, and their  capacity for
 adhesion, depend.
   When the artery is diseased and brittle, the ligature should be large, and
 not tied so tightly;—otherwise it may cut through entirely.
   The manner of tying an artery is simple enough.   If the wound  is  large
 and open,  as after an amputation, the orifice will generally be readily  seen,
 and very  likely will project  a little.  It should be taken hold of with a
 forceps, and be gently drawn out, and  then an  assistant  should  tie the
 ligature round it as tightly and  smoothly as possible  in a double or treble
 knot.  If the bleeding orifice cannot be drawn out with the forceps, it may
 be transfixed with the tenaculum;—but in  some cases, where it is deeply
 seated or cannot be found, or is  contained in a dense consolidated tissue,
 it is necessary to pass a  curved needle and ligature through a considerable
 thickness of the flesh, and tie  it up altogether.   This,  however, should
 never be done if it can be avoided.   In  all cases where it is possible, the
 artery  alone should be included  in the ligature.   After tying, one end of
the ligature should be cut off, and the other be made to hang out of the
wound.
  When an artery is completely divided, it  is necessary to tie both ori-
 fices ;—and if it is wounded, but not  divided, a ligature must be placed
by an  aneurism needle  both above  and below the wounded  part.  It is
  * J. F. D. Jones, M. D., Treatise on Haemorrhage and the Ligature.  Lond. 1805.
  T The author Hoes not believe this circumstance to be of such great importance as it
is sometimes thought; and agrees with Mr. Porter,  that when secondary haemorrhage
occurs, it is  more frequently owing to some morbid state of the  artery or of the system,
which has prevented the  healthy process of obliteration, than to the place or mode of
application of the ligature.  Vide Porter on Aneurism. 
             GENERAL  TREATMENT OF  HEMORRHAGE.          293

necessary to  observe,  that in all  cases, .when  it is possible, a wounded
artery must be tied  at  the wounded part;—and not in the  trunk above.
When the wound is not  large enough to  expose the artery, it should be
lemrthened by an incision upwards and downwards; and it is better, as
Mx°Guthrie insists, to cut even through  thick muscles, than to tie the
trunk of the artery above the  wound.*
   2.  Torsion is performed by drawing out the vessel, fixing it by a pair
of forceps a quarter of an inch  from  the  end, and then twisting the end
round and round till it will  not untwist itself.   There  is no English au-
thority for applying this method to  large arteries, but it may be useful
enough when many minor vessels bleed after the extirpation of a tumour.
   3.  Pressure is a means of suppressing haemorrhage that may be resorted
to either when the  ligature is deemed unnecessary, or when it cannot be
applied.  Thus it is applicable to wounded arteries of small size situated
immediately over bones ; as  the temporal;—or to arteries that cannot be
tied because they lie very deeply;  as the external carotid in the parotid
gland;—or to arteries that are so diseased that a ligature will not  hold.
The pressure must be confined as much as possible to the bleeding orifice,
and should be effected by a  graduated compress;  i. e. one composed of
several pieces gradually decreasing  in  size, the smallest  being on the
wound.   It is  also a good  plan to apply pressure  to  the course of the
trunk, above the wound.  Moreover, when pressure is  to be relied upon,
the whole limb should be securely bandaged from  its extremity,  in  order
to diminish its entire circulation, and it should  be placed in a raised posi-
tion.  When the palmar arch is wounded, one compress may be placed
on the wound, and another  on  the back of  the hand;—a paper knife or
strong slip of wood may then be laid  on each compress transversely across
the hand, and their ends be  firmly tied together.
   4. Cold is applicable to cases of bleeding from numerous small vessels.
 If there is a general oozing from a stump after amputation, a cloth dipped
 in cold water may be twisted over the face of it.   Haemorrhages from the
 vagina and rectum may  sometimes be checked by dilating them  with  the
 speculum and exposing  them to the cold air, [or by introducing into them
 a portion of a bladder or intestine filled with pounded  ice.—Ed.]
   5. Styptics are of various kinds.   1. Some of them check haemorrhage
 by opposing a mechanical obstacle to the exit  of blood ;—as the agaric,
 and other porous  substances which entangle it;—2, others  act by coagu-
 lating the blood ;—3, or by causing contraction of the bleeding vessels ;—
4, or by exciting the adhesive inflammation and formation of granulations.
 The tinct. ferri mur.;—a saturated solution of alum ;—turpentine, creosote,
the nitrate of silver, and the matico leaf, are the best.   They are applica-
 ble to the same cases as cold and  pressure ;—that is,  when  the  bleeding
 vessels are very numerous and  small.  The  actual cautery, which  is  the
 most potent styptic of all, has two operations.  If the iron be red hot,  it
 stops bleeding mechanically  by burning up the orifices of the vessels,  but
 the bleeding is liable to return  when  the  eschar separates.   It is better,
 therefore, to use the iron at a black heat, for it  then excites  the  adhesive
 inflammation ;  and is very efficacious for arteries that either cannot be tied,
 or that are too diseased to hold  the ligature.  A pinch with the forceps will
 often cause small vessels to cease bleeding.
   Medical  Treatment.—In cases of  arterial  haemorrhage, which there  l>
 any difficulty in restraining by ligature or otherwise, it will be necessary
        i Guthrie on Diseases and Injuries of Arteries, p. 254.  Lond. 18-30. 
29G         GENERAL  TREATMENT  OF HAEMORRHAGE.
to keep the patient in the recumbent posture, and on  low diet; and to
keep down the heart's action by lead, F. 128, henbane, or opium.
  Secondary Hemorrhage may occur under the following seven circum-
stances: 1. It often happens that in  a few hours after a wound has been
oound up, and the patient put to bed and become warm, sundry small ar-
teries bleed.   This case is easily managed.  The wound must be opened;
any vessels must be tied that require it;—the surface sponged with  cold
water, and then be exposed to the air for a few hours.   2.  There may be
a general exudation of blood from a wound, owing to some disorder of the
circulation.  Its causes and treatment  axe described  in the chapters on  Hae-
morrhage, and on  Gun-shot Wounds.  The surgeon must recollect its lia-
bility to occur in the female from the menstrual nisus.   3.  Haemorrhage
may occur from sloughing of an artery; and, 4, From ulceration spreading
through the arterial tunics.  5. It may occur from  imperfect closure of an
artery when a ligature separates;—through the influence  of a diseased
state of the artery, or of the constitution, which  prevents the healthy pro-
cess of adhesion ;—and this form  of haemorrhage will  be more likely to
occur, if the ligature  was  coarse, thick, and ill-applied, so as to bruise the
internal coats  instead  of cutting them evenly;—or if the artery was much
disturbed in its sheath during the operation.   In the  last three cases the
only remedy is to  cut down upon and tie the bleeding orifice ;—or if that
cannot be done, or the vessel  be too diseased to  hold the ligature, and
pressure and styptics  fail,  the trunk must be tied  above.  6. Haemorrhage
is apt to come from the lower orifice  of a divided artery, if only the upper
one has been tied. In this case the  blood wells out in a continuous stream,
but not with the arterial saltus;—and it is not quite so florid as that which
comes from the other end.  7. Haemorrhage is very likely to occur if the
operation for aneurism is applied to a wound of an artery ;—that is, if the
vessel be tied  at a distance above instead of at the  wounded parts.*  For
these two cases the ligature is the remedy.
  The Hemorrhagic Diathesis is a peculiar constitutional defect, which
seems to consist in a  want of contractility of the arteries, and of coagula-
bility of the blood ; so that the slightest wound bleeds  almost uncontrol-
lably, and life may be lost through the most trifling injury  or surgical
operation.   If the existence of  this  diathesis  be ascertained,  surgeons
would do well to refrain from operations with the knife on the  individual
possessing it.   In  a case of congenital phymosis, in a person of this kind,
which fell under Mr. Liston's care,  he very judiciously employed the liga-
ture instead of the knife.  This  diathesis often runs in families.  Thus the
history is  recorded of  four children who were  born of healthy parents;
their skins were white and  complexions fair ;—they were very subject to
fever with ecchymosis; their blood was very fluid, but coagulated in the
usual manner; violent coughing easily produced haemoptysis or epistaxis,
and any slight injury  caused ecchymosis of the skin.  One  died at twenty
months from biting his tongue ;  another at eight years from general mucous
haemorrhage,  and  a third  at twelve  from epistaxis.   In a case of obstinate
bleeding of this kind, pressure and the nitrate of silver  locally, and a nu-
tritious diet with iron or the acetate of lead and opium, seem to  be the
most hopeful remedies.f
  * Guthrie, op.  cit. p. 248.
  f Vi<]e B. and F. Med. R., Jan. 1840; and two  valuable papers by Dr. Allan of the
Haslai Hospital,  and  Mr. Miller  of Edinburgh, in Dr. Cormack's Journal for June and
July, 1842. 
INFLAMMATION  OF ARTERIES.
297
     SECTION  II.--OF  INFLAMMATION OF ARTERIES.*

   This is rather an  uncommon and obscure disease.   There are  three
 forms of it:  1. Subacute Arteritis (Phlegmonous Arteritis, Guthrie) is a
 local form of inflammation, not extending any great distance.  It produces
 redness and thickening of the artery, with effusion of lymph into its cavity,
 and coagulation of the  blood within it.   The  symptoms are, tenderness
 and swelling of the affected artery, with violent pain, numbness,  absence
 of arterial pulsation,  and tendency to gangrene, in the parts  supplied  by
 it.  The author lately treated a case  in which, during convalescence from
 acute dysentery, a small portion of the axillary artery  suddenly inflamed
 and became impervious.  The arm  and hand  were cold and benumbed.
 The circulation through  the  affected vessel was restored in  about three
 weeks.  Mercury and other antiphlogistic remedies are most likely to  be
 of use.
   2. Acute Arteritis  (Erysipelatous or diffused Arteritis) has a tendency
 to spread, and involve the arterial system generally, and to produce rapid
 suppuration, and it is almost invariably fatal.   It may be idiopathic^ or it
 may be caused by a wound.   It is known by very violent fever, and great
 throbbing of the arteries ; succeeded  by symptoms  of irritative or  typhoid
 fever; with livid vesications on different parts of the body.  If the disease
 originate in a  wound, there will probably be gangrene.    Treatment must
 be antiphlogistic, without reducing the patient too low.
   In a case of severe and rapidly fatal inflammation of the chest, the aorta
 was found to  participate in the inflammation, and there was an effusion  of
 adherent lymph on  its inner surface, nearly blocking up  the left subclavian
 artery.   This is believed to  be not an uncommon cause of embarrassed
 circulation towards the close of acute inflammation  in the chest.
   A curious  case  is recorded  by Mr. Crisp, (Lancet,  1835-6, vol. i.  p.
 534,) of what seems to be rheumatic arteritis.   A  girl, aged  22, suffered
 from violent fever, fainting,  profuse perspirations, great pain  in the limbs,
 and tenderness in  the course of the arteries.  After some days, no pulse
 could  be felt in the axillary from an inch below the  clavicle, or in the
 popliteal.  Both feet became  gangrenous, especially the left, which was
 amputated below the knee  eight  months  afterwards ; at the time of the
 operation no  pulse  could be  felt  in any of the extremities.   Very little
 blood  came from the larger  arteries, and that  not per  saltum,  but the
 smaller vessels bled  profusely.   On examination of the leg, the  arteries
 seemed smaller than natural, but not  otherwise diseased.   In  a somewhat
 similar case, recorded in the Provincial Medical Journal, 23d April, 1842,
 sudden obliteration of the left axillary artery j with intense  pain and numb-
 ness of* the arm, and sloughing of the end  of one finger, followed the
 haemorrhage of abortion in a young lady of 24. f
   The practical  point to be derived from our knowledge of this  complaint
 is, that, in any case oi spontaneous gangrene, we  should not be  too  hasty
 in treating it as a case of debility, by local and general  stimulants, till the
 condition of the  arteries has been well examined.
  * Guthrie, op. cit. Mayo, Pathol, p. 447.  Copland, Diet. art. Arteries ; and  Hodgson
on Diseases and Injuries of Arteries, Lond. 1815, p. 5.
  f See also Sir B. Brodie's Lecture on Gangrene, Med. Gaz. vol. xvii. for two cases  o*
dry gangrene from arteritis. 
298
ANEURISM.
   3. Chronic Arteritis may be supposed to be  an occasional cause or
 accompaniment of thickening, softening, ossification, occlusion and other
 forms of degeneration of arteries.*

                 SECTION  III.--OF  ANEURISM.

   Definition.—An aneurism is a sac filled with blood, and communicat-
 ing with an artery, by the rupture  or dilatation of which it has  been pro-
 duced.
   Varieties.—In the first place, a distinction must be made between
 aneurism, which  consists of a dilatation  of an artery, for a part only of its
 circumference; and the general dilatation, which consists of  a bulbous
 expansion  of all the  arterial tunics for  the whole  of their circumference,
 and  which differs from true aneurism in containing no laminated coagula.
   Then there are  three  kinds  of aneurism.   First, the true  aneurism,
 which consists of  a sac formed  by one or more of the  arterial tunics.f
 Secondly, the false aneurism, which is formed after a puncture of an  artery,
 by a dilatation of the  adhesive  lymph by  which the puncture was united.
 Thirdly, the diffused aneurism ; which is formed when an artery is lacer-
 ated by a fractured bone, or ruptured by a blow, wuthout a wound in the
 skin; or when an artery is punctured, and the wound in the skin heals
 up speedily.  In either of these cases, the blood escapes into the cellular
 tissue, which forms the sac of the  aneurism.  Besides these kinds, authors
 speak of a sacculated aneurism ;  that is,  one which is formed into pouches
 by an unequal dilatation of its parietes; — and of a dissecting  aneurism,
 that  is  to say, one in which the blood finds  its way between the arterial
 tunics,  and  may even  open into the artery at another part.
   Pathology.—The formation of aneurism is preceded by some disease
 of the artery.   Sometimes the middle or fibrous coat becomes opake, yel-
 low, and as thin as paper; — sometimes  it degenerates into a fatty sub-
 stance; and a soft, pultaceous, or as it  is called, aetheromatous matter is
 deposited upon it; this, according to  Mr. Gulliver, displays  under the
 microscope  earthy and albuminous particles, oily globules, and crystalline
 plates and scales;  and is  principally composed of cholesterine.  At the
 same time the lining membrane often acquires considerable  thickness and
 hardness; in  consequence apparently of an effort  to compensate for the
 weakness of the middle coat; and Dr. Davy believes that these changes
 must terminate either in aneurism, or in obliteration of the  artery.J Or,
 lastly, there may  be a  deposit of a brittle calcareous substance (composed
 of phosphate of lime) in the substance or on the outer surface  of the inner
 tunic.   This earthy matter may be deposited in spots, or  scales, or rings,
 or projecting spiculae ; and in the  arteries of elderly people it is very com-
 mon.   But  the earthy degeneration of  old age does not  appear to be so
 common a cause  of aneurism as the soft aetheromatous deposit.
   Aneurism generally  commences by a giving way of the internal and
 middle  coats  of  the  artery at the  site of some  aetheromatous spot, after
which the pressure  of the blood  dilates the external or cellular coat into a
  * An  abstract of  a  learned paper by Tiedemann on Arteritis and its consequences
may oc found  in Rankings Abstract, vol. iii. and Ed. Med. and Surg. Journ., Jan. 1846.
  f It may be remarked  that some  authorities call all aneurisms  false which do  noi
consist of all three arterial tunics.
  t Vide Davys Researches, and Gulliver on Fatty Degeneration of the Arteries, Prov
Med.  Jour., Marco 18th, 1843. 
ANEURISM.
299
 pouch.  This mode of origin is evident from the distinct rounded circum-
 scribed opening by which  most aneurisms communicate with  the  artery.
 But it may also commence by a dilatation of all three of the tunics at some
 diseased spot.   The latter is the opinion of Hodgson.  Scarpa, however,
 asserts " that there is only one form of this  disease ;—that, namely, caused
 by a rupture of the proper coats of the  artery,  and  an  effusion of arterial
 blood into  the  cellular  sheath  which  surrounds  the  ruptured artery."*
 Sometimes  it commences  by  the blood
 finding its  way into  small  cysts or ab-             Fig- 87-t
 scesses that are developed between the
 coats of the artery.   Sometimes again,  as
 in a case that happened to Mr. Liston, an
 aneurism  commences by an artery ulcer-
 ating  and opening into  a contiguous ab-
 scess, the sac of  which becomes  the sac
 of the aneurism.   Let the aneurism, how-
 ever,  commence  as  it may, it gradually
 dilates under the  constant pressure of the
 heart's impulse.   It  soon becomes  lined
 with coagula, deposited  in distinct con-
 centric laminae, of which  the  outer ones
 are the palest  and  firmest;—and whether
 it was originally formed or not of all the
 three tunics, certain it is, that the two in-
 ternal  ones soon waste and disappear.
   Svmptoms.—If an aneurism be seated
 in the  neck or limbs, it  appears as  a tu-
 mour in the course of an artery, and pul-
 sating with it.  If it be small,  and not
 filled  with  coagulum, pressure on the
 artery  above will render  it flaccid, so that
 it may be emptied by pressure ;—and the
 blood  returns into  it afterwards  with  a
 peculiar  vibratory  thrill  or bruissement.
 The patient will  very often say  that  it
 commenced  after  some violent  strain,
 when  something appeared to give way.   In the chest, aneurism will be
 principally known by an unnatural pulsation felt by the patient, and de-
 tectable by the stethoscope ;—together with symptoms  of  disordered cir-
 culation and respiration.   In the abdomen, an  aneurismal tumour may be
 felt through  the parietes.
  Diagnosis.—Tumours  situated over  arteries, and receiving pulsation
 from them,  may be distinguished from aneurism  by noticing, 1st,  that
 they do not  pulsate at first, when they are small;—whereas aneurisms dc
 so from their earliest  formation.  2dly,  that  a tumour may often be lifted
 up from the artery, and that then it will cease to pulsate.  3dly, That aneu-
 risms are generally soft at first,  and become hard subsequently;—tumours

  •Scarpa on  Aneurism, by Wishart, Eiin. 1808, p.  113.
  tThis drawing exhibits an aneurisrr  of the common femoral artery, for which the
external iliac was tied by Sir B. Brodie.  The  ligature  is seen, imbedded in lymph
the  coagulum  in the  artery above and below it; and the laminated coagula in the
aneurism.  From the museum of St. George's Hospital.
 
300
ANEURISM.
are generally the reverse.   4thly, That tumours cannot be emptied by pres-
sure .—and that no alteration is made in their consistence by compressing
the artery above.  5thly,  Enlarged lobes of the thyroid gland may be dis-
tinguished from aneurism of the carotid by their slipping up out of the
fingers, along with the larynx, in the  act of deglutition.   6thly, Psoas
abscess may be known from  aneurism by the precursory pain and weak-
ness in the back; and by its disappearance when  the patient lies down.
7thly, Pulsating tumours, composed oi erectile or of malignant growths—
especially those connected with bone—are  sometimes mistaken for aneu-
risms ; from which, in fact, it is  hardly possible to distinguish them during
Hfe, since they have the same kind of pulsation, attended with  the same
whizzing  noise, and checked like  that  of aneurism, by pressure on  the
artery above.   The mistake, however, is of no very serious consequence,
because the ligature  of the main  artery, which would cure an aneurism,
might also check the growth of a tumour.
   Progress.—As an aneurism  enlarges, its coats become thinner, but are
strengthened by the  adhesion of the parts  around.   As the enlargement
Fig. 88»                          Fig. 89.
proce* ds, these  are gradually absorbed ;—bone offers no  resistance, but
is absoibed as well;—and at last the tumour reaches the skin and distends
it.  Inflammation succeeds ;—the skin becomes red, then livid and vesi-
cated ;—and sloughs.  When the edge  of the slough  separates a fatal
bleeding ensues ;—sometimes in  a gush  enough to destroy life at once,
although more frequently the blood oozes away slowly.   But an aneurism
may burst into a mucous canal;—or into a serous cavity ;—or into a vein,
with, of course,  a fatal disturbance of  the  circulation if the vein is large;
—or into the cellular tissue of a limb ;—or it may cause  death through its
pressure on the trachea or oesophagus  ;—or through the pain and irritation
r,reated by its compressing  nerves or  interfering with the  abdominal vis-
cera, without bursting.   We may observe, that when an aneurism opens
into a mucous canal (as shown in Fig. 89), it is usually  by a small round

  * Figure 88 exhibits a front, and the succeeding one a back view of an aneurism of
the arch of the aorta, which burst into the  trachea.  The opening into the aneurism
fom tLe artery, and the aetheromatous  patches between the coats of the latter, are wel
•hown  From Mr. Lane's Museum. 
ANEURISM.
301
ulcerated spot, not by a slough, as in the skin ; and when it bursts into a
serous cavity, it is generally by a crack or fissure.
   Spontaneous Cure.—The cure of aneurism depends on the cessation
or diminution of the circulation through it;  for when this is the case, the
blood within it  coagulates,  forming  a solid  tumour, which gradually
wastes.   In some few fortunate cases a spontaneous cure occurs.   1st, If
the circulation is languid, the blood in the  sac may coagulate of its own
accord, and  the  aneurism be  converted into a  firm tumour.  In some
cases, however, the sac does not become quite obliterated, but the coagula
become  thick and  firm  enough to  resist  further  distension.   Nature
generally endeavours to aid this process by enlarging the  collateral circu-
lation, and by setting up the adhesive inflammation so as to  thicken the
artery and obstruct  its  current.  It has happened, in a few lucky cases,
that a portion of clot has been  detached from  the interior of the sac by
some accidental violence, and has  effected  a cure by blocking up the
opening into the aneurism.   2dly, The aneurism has sometimes sloughed,
or has been involved in  a large abscess;  and  the artery participating in
the inflammation has become obstructed by effusion of lymph, or by co-
agulation of the blood in  it.   3dly,  The artery has become obliterated by
an accidental pressure of  the  aneurism upon it;—or by the  pressure  of
blood escaping from it on its bursting into the cellular tissue.
   Causes.—The predisposing cause of aneurism is some constitutional
tendency to  arterial  disease,  which may perhaps be created by intemper-
ance, syphilis, or the abuse of mercury.  The exciting cause may be, strong
emotion of the mind,—violent exertion of the body, or local injury.
Men are very much more subject to it than women ;—and it is a disease
of middle life, being most frequent  between  the  ages of  thirty and  fifty,
although it has occasionally been met with even in children.
   Situation.—The most favourite situation of aneurisms is in the aorta,
near the heart;  but if aneurisms of the aorta are excluded from our  con-
sideration, (since they are not to be  relieved by any surgical interference,)
we shall find that of all the arteries of the limbs, the popliteal is the  most
frequently affected.   Thus, out of 179 cases of spontaneous aneurism col-
lected by Lisfranc, (not including any of the aorta,) there were 59 of the
popliteal  artery; 26 of the femoral in the groin,  and 18 in the femoral at
other parts ;  17 of the carotid; 16 of the subclavian; 14 of the axillary;
5 of the external iliac ; 4 of the innominata ; 3 of the brachial, common
iliac, and anterior tibial, respectively;  2 of the gluteal, internal iliac, and
temporal, respectively; and 1 of the  ulnar, perineal, internal  carotid,
radial, and palmar arch, respectively.
  Treatment.—The indications are  to stop, or at  least to check, the
circulation through the aneurism, and to produce coagulation of the blood
within it.   The means  are, compression,  or ligature of the  diseased
mtery, which means  may be aided by internal remedies.
  Surgical  Treatment. — 1st, By  Compression.   This  very  simple  and
obvious mode of arresting the circulation through arteries, was employed
long since by Guattani and others, and with some degree of success; but
from the  imperfect  and often violent manner in which it was applied, it
more frequently failed than  succeeded, and often caused  considerable
mischief.  During the last six years, however, it has been  revived by the
Dublin surgeons, Hutton, Cusack, and  Bellingham,  and  has been  ren-
dered so  safe, painless, and speedy  a remedy, that it ought to supersede 
302
ANEURISM.
the ligature  in  popliteal aneurism, and in fact  in  any case whatever in
which it can be applied.   It has been proved that it is not necessary com-
pletely to obstruct  the  circulation of the artery at the point compressed,
still less to excite the adhesive inflammation  there so as  to  obliterate it,
in fact, that a very  feeble circulation through the aneurismal sac is advan-
tageous.  It is found on  dissection of cases treated in this  manner, that
the artery is obliterated at the site of the aneurism.
   The instrument employed to cause the pressure, may  be either Signo-
roni's  tourniquet, (shown in the adjoining sketch,) an arc of steel, with a
                                         joint in the middle, and a screw
                                         by which the extremities of the
                                         instrument  are pressed  toge-
                                         ther;—or else  a solid clamp of
                                         steel, having  a wooden splint
                                         at one  end,  and a pad with a
                                         screw at the other.  By means
                                         of either of these instruments it
                                         is evident that the pressure is
                                         confined to two points only  of
                                         the circumference of the limb.
                                         As soon as it becomes irksome
                                         to the patient, it can easily  be
                                         shifted to a spot higher or lower
                                         down in the course of the artery;
and it  seems advisable to have either two or three instruments, or else two
or three pads on the same instrument, which  the  patient may tighten and
loosen by turns.
   The pressure, as before said, need never be very severe; nor is it ne-
cessary entirely to  stop the circulation ; but if applied with sufficient force
to render the current very  feeble, the aneurism is, after a time, found  to
have lost its pulsation, and to have become solid.  This happy event may
occur in three or six days, or perhaps may require as many weeks; after
which  the tumour is slowly  absorbed, and the limb  may  be brought into
use again.
   In cases which do not admit of pressure  being applied on the  artery
leading to the aneurism, it may be tried cautiously on the tumour itself,  or
upon the artery below it.   Cases are recorded which give room for hope
from such a measure.*
   2d,  By Ligature. — In  cases in which the  above plan is inapplicable  or
unavailing, the artery must be tied between  the aneurism and the heart.
The operation  should be performed neither too near the  aneurism, so  as
to place the ligature on a portion  of the vessel that is diseased ;—nor too
far from it, lest the circulation through it be kept up by means of collateral
branches.  After the operation, the temperature of the limb  falls  two  or
three  degrees;—but in a few hours it rises  rather higher  than that of the
opposite limb, because the  blood is forced to circulate through the super-
ficial capillaries.   Subsequently  it sinks again rather below  the  natural
Mandard.  Therefore the patient should  be  placed in bed, with his limb

  • Vide cases  by Dr. O. B. Bellingham, Dublin  Journal, May, 1845; Messrs. Greatrex
nnd Robinson,  M. C. T., vol. xxviii.; and a notice of cases by Liston,  Robert Storks,
Oartnell, and  other surgeons, in Ranking's Abstract, vol.  iii.; and a case of axillary
aneurism cured by compression on  the distal side, by Dr. M. Goldsmith, of America, ib
 
VARIETIES OF  ANEURISM.
303
in an easy position ; wrapped up, to preserve its circulation; and  though
it become rather swelled, (which is not unl_kely,) cold must on no account
be applied.
  When a ligature cannot be applied between the aneurism and the heart,
it has been proposed to tie the vessel on the distal side; and this operation
has been performed with success in cases of carotid aneurism,  by Mr.
Wardrop and others.   But Mr.  Guthrie  shows that this operation does not
act as  the (Hunterian,  or) ligature between the aneurism  and the heart
does, by stopping  the  circulation through the aneurism ; but by " giving
rise to inflammation in the aneurism, and in the artery both above and
below it, and that unless it does this, it fails."  It is therefore a dangerous
and uncertain operation,  and should  be performed only where  the  tumour
increases rapidly, and cannot be checked by any other means.
  After the operation  the limb may become  gangrenous, in the same
manner as described  at  p. 104.   If the  gangrene  spread  beyond the
fingers or toes,  amputation should be performed above  the level of the
ligature.
  3dly, Medical Treatment.—In all cases that are submitted to operation,
it will  be advisable to use various  auxiliary measures for reducing the
energy of the circulation; and in cases  in which no operation can  be per-
formed, it is by these only that  we can hope to lengthen out the patient's
existence.  Thus, before using either compression or the ligature, it will
be expedient to bleed  moderately once  or twice, to confine the patient to
his bed, and to administer some of the sedative medicines to be presently
mentioned.
  Bleeding may be performed occasionally, if the patient is plethoric, and
the tumour increases rapidly, with violent pulsation;—but it should never
be carried to faintness.   The  diet  should be  light.  Bodily or  mental
exertion and fermented liquors  should be rigidly abstained from.  Much
benefit  may be derived from digitalis, F. 131, or tartar emetic, F. 36, in
moderate doses.   But  the most useful remedy is the acetate of lead, given
in doses of gr. £—i ter die, with half that quantity of opium, and a draught
containing acetic  acid, F. 128.   This medicine seems to have the faculty
of rendering the blood coagulable, and of diminishing the calibre of the
arteries.   It  used to  be  mentioned in terms of commendation  by  Mr.
Green  in his lectures  at  King's College, who gave some instances of its
efficacy.*  But it must be recollected that frequent bleeding and too  rigid
starvation will increase the irritability of the heart and arteries, and render
the system incapable  of forming healthy lymph;  and that consequently
they will prevent the desired changes in the aneurismal sac.   Particular
care should  be taken  not to administer drastic purgatives; because they
invariably cause a great excitement and throbbing of  the arteries.

   SECTION  IV.--OF OTHER VARIETIES  OF ANEURISM.

  I.—The Diffused Aneurism is caused, when an artery is lacerated—
by a broken bone for instance—without any wound of the  skin ; or when
an artery has been stabbed, and the wound in the skin has healed quickly,
that  in  the  artery remaining open ;—in either of which cases the blood
escapes into  the  cellular  tissue.   It is known by a  rapid dark-coloured
  • See also a case of aneurism of aorta caused by acetate of lead in large doses. Area.
(Jen. de Med., Sept. 1839. 
304
ANEURISM BY ANASTOMOSIS.
swelling of a limb soon succeeding an  injury;  perhaps fluctuating, and
sometimes pulsating,—together with coldness, numbness, and absence of
pulsation in the parts below.
   II.—The False or Traumatic Aneurism is  formed by a  dilatation
of the lymph which  forms the cicatrix, after a wound in  an  artery has
healed.  For this, and the preceding variety, the operation for ordinary
aneurism is inadmissible;  but the wounded part must be exposed, and a
ligature be placed above and below it, as was directed when speaking of
wounds of arteries.
   III.—Aneurismal Varix is produced when  an  artery is  punctured
through a vein,—the brachial artery through the median basilic vein at the
bend of the elbow for instance ;—and they adhere together, the commu-
nication between them remaining permanent.  The  consequence is, that
blood passes from the artery into the vein at each beat of the pulse ; caus-
ing it to become enlarged  and tortuous, and to present a vibrating thrill at
each pulse.
   IV.—Varicose Aneurism is said to exist when an artery has  also been
punctured through a vein,  and  a false aneurism has formed between them,
opening into both, and formed of lymph that was effused between them.
The difference between aneurismal varix and  varicose aneurism,  (which is
a cause of perplexity to young students)  is  this: aneurismal  varix is  a
swelling of a vein, caused  by the admission of arterial blood into it.  Va-
ricose aneurism  is the same thing, but with the addition of a false aneurism,
situated between the  artery and vein.   These two cases need not be in-
terfered with unless they enlarge rapidly, or cause inconvenience.   If they
do, a ligature must be placed both above and below the wounded part of
the artery.
  V.—Dissecting Aneurism.   This variety of aneurism begins with ul-
ceration of the  lining membrane of an  artery at  some diseased spot, in
such a way that the blood  penetrates between the  arterial tunics, splitting
them  up,  and making false passages between them.  In  this  way very
anomalous symptoms may be produced, of which no better example can
be desired than  is  afforded by a case of Dr.  Todd's, related in the 27th
volume of  the  Med. Chir. Transactions.   In this  case, ulceration had
taken place in the aorta, and this  was the  starting point of  a splitting up
of the middle arterial tunic, which extended upwards through the innomi-
nata into the right carotid,  and  partly into the  left, and downwards nearly
as low as the kidneys.  Of course the getting in of the blood between the
coats of the arteries must have materially impeded the circulation through
them;  and, in fact, in this case caused  softening of the anterior portion
of the right hemisphere of the brain, by depriving it of its supply of blood,
suppression of urine, and  other symptoms that would  have been almost
inexplicable, unless a post mortem examination had been performed.
SECTION V.--OF ANEURISM BY ANASTOMOSIS  AND NJETU8.

  I-—Aneurism by Anastomosis is a pulsating tumour, generally situated
in the subcutaneous tissue of the head or  neck, or sometimes in the ex-
tremities.   It is  formed of several enlarged and tortuous arteries whose
?oats are excessively thin ; and which are accompanied with many dilated
veins, which feel like a bundle of worms.  (See fig. 91.) 
N^EVUS.
305
  II.—Njevus  is  a similar
affection,  consisting  appa-
rently in an enlargement of
very  many  small vessels,
which form  a kind of erec-
tile tissue.  It may either be
seated  in  the skin itself, or
under it in  the cellular tis-
sue ; and occasionally is de-
veloped  in  bone.   It   is
doubtful whether it is always
a  congenital affection,  or
whether it may be developed
in after life.
   When in  the skin it ap-
pears soon  after  birth as a
small shining red  spot, dusky, or scarlet, according as arterial or venous
capillaries predominate in its composition.   In many  cases it remains
stationary, and  gives no further trouble ;  but more  commonly it enlarges,
and forms a soft pulsatory tumour, the skin covering which is so exceed-
ingly thin, that  profuse bleeding may occur from the slightest abrasion.
   The symptoms of large neevi, and of aneurism by anastomosis,  are the
same.   "Some of these tumours," says Mr.  Liston, "communicate  a
thrill to the fingers; they can be emptied to a  certain  extent by uniform
and continued pressure, or by interrupting the circulation, and are instantly
filled on permitting the blood again to flow into  or towards  them.  The
large ones pulsate synchronous with the  heart's action.  They are much
increased  in size by anything that increases the  activity of the circulation ;
as the  cries of children, and the violent exertion of adults.  On the appli-
cation  of the stethoscope, pulsation is  heard as in common aneurismal
tumours, and a sound  which differs from that of the common aneurism,
being loud, rough, and whizzing, and which being once heard can never
be  mistaken."
   Their course and termination are also the same.  Sometimes they re-
main  for a long time  stationary;  but  in general, gradually  enlarge, and
distend the  skin, and at last ulcerate  or slough, and cause the patient's
death by repeated  haemorrhage.
   Treatment.—The cure of these diseases may be effected  either by ex-
citing the  adhesive inflammation in the diseased structure, so as to  obliter-
ate the distended vessels, or by extirpation with the ligature or knife : the
former class of  remedies being best adapted for naevi under the  skin, the
latter for those which implicate the skin itself.
   Of the former class, the best remedy is the seton; and the  best way of
using it, is to pass two or three threads, with a common sewing needle, in
different directions across the tumour, withdraw them as soon  as they have
excited suppuration, and then pass others through  other parts of the tu-
mour.  If a larger needle is used, it should be straight and flat, with sharp
edges, and should be made to drag as much  silk as it can possibly carry,
so as to fill the wound, and prevent haemorrhage.   Some  surgeons  dip the
threads in croton oil or in a solution of lunar caustic, but this  seems unne
  • From a preparation in  the King's College  Museum,  showing an enlarged  and toi
nious iirtery.
       26*                        o
Fig. 91.»
 
306                            NiEVUS.
cessary.   On a similar  principle the nsvus  may be  punctured with the
uoint of a lancet, and a fine probe which has been dipped in melted nitrate
of silver, or a needle heated to a black heat,  may be passed  through it in
various directions ; or its substance may be simply broken  up with a cata-
ract needle.   Pressure by means of a smooth surface of ivory or sheet-
lead, confined by strips of plaster and a bandage, is a good remedy, if the
naevus is small, and situated over a bone,  so that it can be  applied uni-
formly and effectually.   The injection of an astringent fluid by means of
Anel's syringe, has been proposed, but has caused the death  of a child  by
convulsions.   Vaccination has  also been used for this disease ; but it re-
quires that the whole surface of the tumour and some of the  skin around
should be inoculated, so as to  cover  it with a confluent vesicle, which ex-
cites great fever,  and the  opportunity of doing so must be rare.  A very
small naevus may also  be destroyed  by puncturing it, and  inserting into
the puncture a glass pen  dipped in nitric acid; this is also a good method
of removing little red spots on  the fi*ce, formed by a distended vessel with
radiating branches;  but immediately  after applying  the  acid, the part
should be  sponged with a solution of carbonate  of soda, to  prevent any
scar on the  skin.   Mr. Fergusson  sometimes passes a needle under a
small nsevus, and twists a thread over it, so as to  cause considerable pres-
sure, allowing it to remain for forty-eight hours or longer.
   Extirpation of these tumours is practicable only when they  are of the
cutaneous variety, or when they can be lifted up  from  the  parts beneath,
so that their whole extent can be ascertained.  If it is done  with  the knife,
two elliptical incisions should be made, to include the whole of the dis-
eased growth, and a little of the sound tissues around.  For, to use Mr.
Guthrie's words,  " it cannot be too forcibly impressed  on the mind of the
surgeon, that if the  diseased part  be  cut into, the  bleeding will  be terrific
and difficult to stop."
   But it is generally considered that the  ligature is  the safest and best
method.   The most convenient form of using it  is to pass  two or three
needles crucially  through the base of the tumour, and  then twist a strong
silk ligature firmly round beneath them.   Or instead of this, two or more
doubled ligatures may be passed through the  base of the tumour, with a
curved needle which has its eye at its pointed extremity, and then the tu-
mour may be strangulated by tying the  adjacent  threads together.  The
tumour may be punctured before the  threads  are  finally tightened, but  in
every case the constriction should be made as tight as possible.  If the
skin is not implicated, it may be dissected back in flaps before  the liga-
tures are passed.
   Another method analogous to extirpation, is the division  of all the soft
parts around the tumour.  This was  once  done successfully by Mr. Law-
rence, in an aneurism by anastomosis on the finger.   He divided all the
soft parts, except the tendons and thecae.   But in other cases it has been
unavailing.
   If the disease is inaccessible to any of these means, (as in the orbit,)
!ind increases rapidly, ligature of the  common carotid (or of all  the large
trunks supplying  it) is the only  resource ; but it is  dangerous and not often
successful.*
  • Vide Curling's Pathological Lectures in  Med. Gazette, July 1838.  Lawrence, Med.
Chir. Trans, ix. 216.  A fatal case of convulsion during the operation for naevus by in-
jection, Med. Gaz. vol. xxi. p. 529.   J. Adair Laurie on Cricoid Aneurism, Med. Gaz 
INJURIES AND  DISEASES  OF VEINS.
307
                       CHAPTER  VIII.

             OF INJURIES  AND  DISEASES  OF VEINS.

  I. Wounds.—The haemorrhage from wounded veins is not, in general,
dangerous, unless from some  large and deep-seated trunk, or from a large
varicose vein on the leg.   It may in ordinary cases be restrained by pres-
sure and a raised position.  But if  there  is any difficulty in the matter, it
will be  necessary  either to apply  a  ligature,  (which,  however, should
always be  avoided, if possible,) or to keep up unremitting pressure on the
bleeding point with the finger.  The latter practice was resorted to " in
the  case of his Excellency William Prince of Orange, who, in his hurt by
the  Spanish boy, as my Lord  Bacon relates, when the internal jugular was
opened, could find no way to stop the flux of blood, till the orifice of the
wound wTas hard compressed by men's thumbs, succeeding for their ease
one after the other, for the space of forty-eight hours, when it  was hereby
stanched."*
  II.  Inflammation of Veins, or Phlebitis, is a very important disease,
of which there are two forms, the subacute, (or, as it  might more properly
be called,  the circumscribed,)  and the acute, or diffused.
  The Subacute Phlebitis  is  not a very serious disease, and generally
affects the  veins of the  legs, especially if varicose.   The  symptoms  are
tenderness and hardness of the affected vein, more or less swelling around
it, cedema of the  parts  below, and  painfulness of the limb generally.
After  it has subsided,  the vein is usually felt hard as a cord ; because, as
was explained in a previous  page,  inflammation of a blood-vessel  causes
the  blood within to coagulate, which, with the lymph that is effused,
renders  it impervious.  It sometimes, although rarely, causes a circum-
scribed abscess in the vein, or in the cellular tissue around it.
  Treatment. — Rest, with the limb in an elevated position ;—leeches ;—
fomentations, or cold lotions,  according to the  patient's  choice; — and
purgatives;—subsequently, friction  with camphorated oil, and bandages.
  III. Acute Phlebitis is a most dangerous, and  generally a fatal  dis-
ease.   It  may  be  caused  by wounds of veins, — as in venesection, for
example,—if irritated and  not permitted  to heal; or by tying veins;—or
even by bruises and other injuries unattended with an open wound, if the
patient be subjected to  the influences that produce erysipelatous disease.
It is  a frequent concomitant of malignant puerperal fever, phlegmonous
erysipelas,  and  diffused cellular inflammation;  with  which  diseases it
appears  to be identical in its type, and in the form of constitutional  affec-
tion which attends it.
  Symptoms.—The symptoms are, repeated shiverings, or perhaps fainting
fits; rapidity of the pulse, anxiety of the countenance, depression of spirits,
catching pains  about  the heart, and more or less swelling and tenderness
over the course of the affected veins.  In many cases the tongue soon be-
comes furred, brown,  and dry,  or black; the pulse exceedingly rapid  and
weak ; the prostration of strength and spirits extreme ;  the skin sallow ,—-
21st Oct, 1812. The author has also borrowed from a lecture which he heard delivered
by Sir B.  Brodie, at St. Georges  Hospital, in ~Sov. 1842.
  •  Turner, op. cit, vol. i. p. 346. 
308                     ACUTE  PHLEBITIS.
then bilious vomiting and low delirium come on, and are  followed by
death, perhaps in two or three days from the commencement of the attack.
In other more protracted cases, great swelling and redness occur over the
inflamed veins, and abscesses form, which, if punctured, are found to con-
tain clots of blood mixed with pus.  But the most characteristic termina-
tion of this disease is the formation of consecutive or secondary abscesses.
The patient  remains low, with  an anxious  sallow  countenance, rapid
pulse, and yellow tongue; and suddenly complains of excruciating pain
in the shoulder,  knee, or some other joint, which is rapidly succeeded by
a copious formation of pus ;—and this abscess is followed by others in the
other joints, or in the lungs or liver, which ultimately cause death.
   Pathology.—At an early period of the disease, the lining membrane of
the affected  vein is found deeply<red, and a little lymph is effused at the
seat of injury.   Subsequently, the vein is plugged with coagulated blood
and lymph,  mixed either with real pus, or with a pus-like fluid formed of
softened  coagulum.  In cases which do not terminate very early, some
portion of the vein  is formed  into  an  abscess, by the effusion of lymph
above and below the inflamed part; and this abscess soon communicates
with the cellular tissue by ulceration.  The  extreme malignity of the con-
stitutional affection which accompanies this  disease, used to be accounted
for by supposing that the inflammation travelled along the great veins to
the heart.   Mr. Arnott, however, has shown  that this  is a mistake; be-
cause the inflammation is generally found to stop abruptly at the juncture
of some  collateral  branch with  the inflamed  vein.   The  more probable
supposition  is, that the whole of the blood  is contaminated by the secre-
tions of the  inflamed part; and that this contaminated state of the blood
is the source of  the great constitutional depression, as well as of the con-
secutive abscesses that are so often formed.
   Secondary Abscesses.—There is no tissue  or part of the body which may
not be the seat of inflammation  and abscess,  in this disease.   When the
lungs are affected, the  earliest morbid  appearance is a small well-defined
ecchymosed spot, of very dark colour, which soon is surrounded by a
hard spherical patch of purple  congestion ; though sometimes the colour
is brighter, and  the diseased spot resembles lobular inflammation.   In the
centre of this discoloured spot a small  portion of light coloured lymph, or
a globule of pus, may be detected, which probably is the materies morbi,
and has been deposited there from the blood.  In the next stage, the dis-
eased patch becomes indurated by effusion of lymph, and afterwards it be-
comes entirely softened and broken down.   In the liver similar abscesses
may form, and  the hepatic veins are  sometimes filled with lymph.  The
spleen is often found infiltrated and softened down ;  and the kidneys mot-
tled with recently effused lymph.   Diffuse suppurations are common in
the cellular tissue and in the muscles.  The slcin sometimes presents small
 deposits of matter resembling small-pox pustules ; and sometimes circular
 patches of it first  become congested, and  then  slough.  The brain may
 be pink and softened, and the arachnoid covered with a layer of puriform
 lymph.  The serous membranes and the joints often inflame violently and
 suppurate;  although, when the pleura  is the seat of disease, the morbid
 fluids found are usually bloody lymph or serum, and not pus.  The blood,
 loo, may present visible alterations; the coagula  found in the heart and
 great vessels, often loose in  consistence, and brown  in  colour, mottled
 with patches of a dirty yellow. 
VARICOSE VEINS.                      309
  That these consecutive inflammations and suppurations are really caused
by the admixture of poisonous  secretions with the blood, will be further
evident when it is considered that they are liable to occur not only after
phlebitis, but also after diffused abscess,  after suppuration in the cancelli
of bone, and  in cases  where an imperfectly contracted womb  becomes
filled,  after delivery, with half-putrid  secretions; in  all of which cases
there is a ready access for poisonous matter to enter the blood.*
   Treatment.—The  principal things to be done in this almost hopeless
malady are—to apply numerous relays  of leeches and fomentations  to the
part affected—to open all abscesses early—to open the bowels moderately
-—to allay restlessness  and pain;—and to support the strength  by nutri-
ment, such  as  beef-tea  and arrowroot.   Relief is also generally afforded
by a flannel bandage.   As to any other measures stimulating or lowering,
they must be employed  according to the exigencies of each particular case.
Bleeding may  occasionally be of service when the patient  has  a robust,
unimpaired constitution ; but in  many cases it would only accelerate the
fatal issue ;  nay, excessive bleeding seems occasionally to be a main cause
of the disease.  Mercury may be  resorted to in general, unless there is
very great depression indeed.   Wine and bark should be used, if the pulse
is very feeble.
  IV.  Varix signifies an enlarged and tortuous state of the veins,  which
are generally  thickened, rigid,  and divided into irregular pouches, with
their valves incapable of preventing the reflux of blood.   This state may
be caused by any thing  that retards the  venous circulation;—such as occu-
pations that require  a  standing  posture;  or pressure from loaded bowels
or the gravid uterus.  But there must be  an original weakness of structure
besides; because varix often occurs when there is no pressure on the veins
to  account for it;  and  if produced  by temporary pressure in healthy
people, always subsides of itself when that pressure is removed;  a  fact
that is familiar to practitioners in midwifery.   It is most frequently seated
in the lower extremities, scrotum, and  rectum.
   Varicose veins on the leg produce several troublesome  consequences.
(1.) In the first place, they occasion great pain,  weight, and fatigue upon
taking much exercise, or remaining long in an erect posture.  (2.) They
frequently  cause ulcers or excoriation of the skin.   (3.) Sometimes  a vein
becomes exceedingly thin, and bursts;  causing a profuse  or  even fatal
haemorrhage, inasmuch as there might  be no valves between the part rup-
tured and the  heart.  (4.) Occasional  inflammation occurs, with clotting
of the  blood in the affected vein;—which  may perhaps give rise to abscess.
   Treatment.—This may either be palliative or radical.   The  palliative
consists of measures adapted to prevent  further  enlargement, and induce
contraction of the distended veins.   If one or two trunks only are affected,
it may be  sufficient to apply pieces of  leather  spread with soap plaster
firmly over them ; but if many smaller veins are  enlarged, the whole limb
should be well  supported with  a calico or  caoutchouc bandage, or laced
stocking, which should be applied in the  morning, before the patient rises.
Friction with lin. hydrargyri;—or with iodine  ointment;—the application
of tincture  of iodine, repeated blisters, and electric sparks, have been sup
posed to accelerate  the cure.  Constipation should always be  provider1
  * The above particulars are gathered from a very interesting paper by Mr. Henry Lee,
in which he gives the  details of twenty-three fatal cases of secondary inflammation,
which occurred in St. George's Hospital in 1845.  Vide Med. Gaz., vol. xxxviii. 
310
VARICOSE VEINS.
 against; and when  the patient  is not taking exercise, the leg should do
 placed in a raised position.
   But if these means fail, and the patient is subject to urgent inconveni
 ence, the radical cure  must be resorted to; that is to say, the  diseased
 veins must  be obliterated ;—a proceeding which will have some  prospect
 of success if only one or two large trunks are affected ;  but not if all the
 minor cutaneous veins  are enlarged also.   There are several ways  of ef-
 fecting this.   1st.  Some years ago, Sir B. Brodie recommended division
 of the vein by subcutaneous section, in the following way.   A long curved
 narrow-pointed knife, like a bistoury, but cutting on the convex edge, was
 introduced by the  side of the vein, and carried horizontally with its  flat
 surface between it and  the skin.   Then the  convex edge was turned  to-
 wards the vein, in order to  cut  through it, as the  knife  was withdrawn.
 2dly. Mr. Watson, of New York, recommends, in some cases, excision of
 a portion of the affected vein.  Then, 3dly, there is a  method which was
introduced by Mr. Cartwright, and improved by Mr. Mayo, of destroying
a narrow' slip of skin across the vein by a paste oi potassa fusa and quick-
lime, in order to cause  slight inflammation of the vein, with coagulation
of the blood in it, and obliteration of its cavity.  4thly.  Pressure by means
of a firm pad and bandage has been used for  the same  purpose.
                                Fig. 92.
   5thly. But  the newest  and  safest treatment is that by means of the
twisted suture.  The surgeon pinches up the vein between his left  fore-
finger and thumb, and passes a  needle behind it; it is a good plan also to
pass another at right angles, which should  be made to  transfix  the vein
twice, and should go behind the first; a thread is then to be twisted around
them tightly enough to stop the  circulation ; and this may be  done at as
many places as the surgeon  thinks requisite.   The points  of the needles
should be cut  off.  They should be allowed to remain till they have begun
to create slight ulceration ; and  it is better, unless the irritation is too great,
to permit one  or two of them to separate by ulceration quite through the
vein ; because if they only remain long enough to cause coagulation of the
blood between the needles, the coagulum will soon be absorbed again, and
the circulation be re-established, as has been  conclusively shown by M.
Bonnet.                                                J         J
   Both before and  after these  operations,  care  must be taken to  avoid
every cause of inflammation; because any  of them—even  the  last-may
be foflowed by abscess or diffused phlebitis, if precaution be neglected.*

oth*erV'inMTri,lMTeC!-ChTJran8-'Vol-XV- Lee, ibid. Mayo. Pathol.; Copland and
Jan Iwn  £' MaVU,Vnd iUgUSt 1838- Bonnet' W°ted in Brit- and F°r' Med. Rev,
Dr Wato'  £°2d'     ' t2-' 8(S DeC" 18395  a"d valuable papers by Dr. Norris, and
L»r. Watson in American Joum. Med. Sec, Jan. 1843. 
INJURIES AND DISEASES  OF  THH  NERVES.         311
                         CHAPTER IX.

           OF INJURIES AND DISEASES OF THE NERVES.   .

   I.  Complete division of a nerve produces palsy and loss of sensibility
 in the parts to which it is distributed.   The nerve, however, will readily
 unite in the same  manner as bone or tendon, and sensibility and motion
 will return.  Sensibility has been known to return in three weeks, and the
 power of motion in four weeks after division.   A nerve may also recover
 its functions after a small piece of it has been removed.  Sometimes, how-
 ever, the  divided ends, instead of uniting, shrink and become bulbous, as
 they do in a stump after amputation.*
   II.  Partial division.—If a nerve is partly divided, leaving some fibres
 on the stretch, as sometimes happens  in venesection, very disagreeable
 consequences may ensue;  such as immediate  severe pain,  recurring in
 paroxysms, and snooting in the course of the nerves;—violent spasms, or
 palsy of the  limb; fits of  epilepsy; and great  disorder of the  digestive
 organs.  The  same symptoms may also ensue if a nerve has been bruised,
 or compressed, or stretched ; or if it has been  divided, and its extremity
 has become  implicated and compressed in a cicatrix.  This not unfre-
 quently happens  after amputation, and produces excruciating pain, with
 spasm and retraction of the muscles of the stump, causing it to become
Conical.
   Treatment.—If these symptoms come on immediately after  a wound, so
 that it is probable that a nerve has been  partly divided, an incision-may be
 made so as to divide it completely.   If, however, they appeared whilst a
 wound was healing, it is the best plan to remove the cicatrix entirely. But
 it unfortunately happens, that neuralgic pains, when once established, do
 not always cease, even when the  cause which produced them  at first is
 removed.   Very disagreeable  consequences,  in the  shape of palsy,  or
 numbness, or spasm,  are sometimes caused if a nerve is subjected to pres-
 sure ;  as for instance, the pressure of crutches  on the axillary nerves;  or
 from a blow, such as  people often meet with on the ulnar nerve above the
 elbow; or from a violent stretch.  Leeches, blisters, and the application
 of mercurial or tartar emetic ointment, or of opiate or belladonna plasters,
 or inoculation of a concentrated solution  of morphia under the cuticle, are
 the chief remedies.
  III.  Inflammation of Nerves is known by pain  and tenderness, with
 fever if acute.   Sciatica is an example of rheumatic  inflammation of the
 sciatic  nerve.   Purgatives,  alkalis,  colchicum, the iodide  of potassium,
 guaiacum, and other anti-rheumatic remedies, must be used according to
 circumstances.
  IV.  Tumours in Nerves may produce every local and general symp-
 tom  of nervous  irritation.   The painful subcutaneous tumour is  one
 instance.!  Iodine, counter-irritation, and the  other  means  of exciting
 absorption, may be  tried; but  if they fail, as they most likely will, the
tumour must be extirpated, provided that it be not intimately embedded
  * The bulbous ends of a nerve which had not united have been cut out, but withom
avail.  Vide Sir G. Ballingall's Mil. Surg. p. 249.
  f Vide p. 206. 
312
NEURALGIA.
in the substance of a large nerve, such as the sciatic, the division of which
would paralyse a limb.
  V.  Neuralgia, or Tic-Douloureux.—This  affection  may be  defined
to be  severe pain affecting the nerves, not necessarily produced by organic
lesion.  It occurs in paroxysms of very severe pain, mostly of a plunging,
lancinating character, shooting in the course of the nerves.  It  most fre-
quently attacks persons of middle age, female sex, and comfortable cir-
cumstances.
  Causes.—The  exciting causes may be of two orders.  (1.) There are
some  which act upon the nerve that is the seat of pain.   Thus neuralgia
maybe produced by wounds and  other injuries,  as  before  related;  by
tumours;  by spiculae of bone pressing  on  the nerve (which  is a frequent
cause of facial neuralgia); or by some disease in the brain or spinal cord
at its  origin.
  (2.) It may be caused sympathetically by influences that act  upon dis-
tant parts, or on  the system at large; as, for instance, by loss  of blood
and debility ;  by wet and cold; by irritation of the skin from eruptions or
wounds ;  by carious teeth ; by disorders of the  alimentary canal; some-
times by diseases of the urinary or other internal organs; lastly, by malaria.
When arising from malaria, it is generally intermittent, like other diseases
arising from  the  same  source, and occurs  at regular intervals.   But all
intermittent neuralgia is not necessarily  caused by  malaria ;  because this,
as well as other nervous  affections, may occur only  at  stated periods,
although caused by a local source of irritation that is permanent.
  The  nature  of the  complaint is  apparently functional derangement!
The suddenness of its accession  and departure, and the  absence of organic
change in  nerves that  have  been affected  for years, prove that  it is not
essentially inflammatory;  although inflammation  of a  nerve, when exist-
ing, may doubtless be an exciting cause.
  The most common forms of neuralgia are—the Supraorbital JVeuralgia,
Brow Ague or Hemicrania, which is usually caused by malaria; neuralgia
of the superior and inferior maxillary nerves, which is often caused by
diseased teeth, or disease of the bony canals through which  those nerves
pass ; and neuralgia of the ear, mamma, and testicle, which will be treated
of elsewhere ; it may also attack the extremities,  or any internal organ.
  Treatment.—The  indications  are three.   First, to remove all sources
of irritation which may affect the painful nerve, either at  its origin or in
any part of  its course ; remembering  always that the painful spot is very
seldom the  real  seat of the disease ; secondly, to amend  any disorder of
the  constitution that  can be detected; thirdly, to alleviate  pain.
  In  the first place, therefore, the whole  course of the affected nerve
should be thoroughly examined; and  if there is a  cicatrix, or tumour, or
wound, or a carious tooth, or an abscess, or ulcer, or hernia,  or aneurism,
to which the  pain can be  attributed, measures  should be taken for their
removal.  In cases of neuralgia of the extremities, if there is any tender-
ness, or other reason for suspecting inflammation of the nerve or its sheath,
leeches and  blisters, followed by liniments,  (especially F.  72,  130,) or
tartar  emetic ointment applied in the course of the nerve, combined with
proper constitutional  remedies, may effect a cure, (vide Spinal Irritation,
chap,  xi.)  The  head, and particularly the spine, should be  well scrutin-
ised.   The  condition  of the  great  secreting organs,  as  well  as of the
stomach, uterus, and rectum, should also be ascertained, in order to make 
NEURALGIA.
313
sure that a morbid condition of one of these parts is not the real source of
the evil; and  if any pain or tenderness, or other genuine sign of conges-
tion or disease, is detected, it  should be removed by cupping, the warm
bath and blisters, or the tartar emetic ointment.
   Secondly. The state of  the  constitution  must be regulated in the same
manner as was directed in the  treatment of chronic inflammation.  If there
are paleness of the lips,  emaciation, and debility, iron,  bark, and other
tonics, may be given with advantage.  Inquiry should  always be made in
these cases, for piles,  menorrhagia,  or other weakening ailments.   On the
other hand, bleeding  and low diet have cured cases attended with hard
full pulse and  plethora.  In all cases, the appetite, the tongue, the biliary
and alvine  secretions, and the  state of the uterine system, should  be inves-
tigated.  In the  brow ague and other cases arising from malaria, quinine
should be  freely administered ; and if it fails, the liq. arsenicalis, or the
extract of nux vomica, in doses of gr. \ ter die, may be tried.   In cases
of a rheumatic or  gouty  character, colchicum, F. 121, 122, may be of
service.  Asafoetida with aloetic purgatives and valerian may be given if
there are hysterical symptoms, and sarsaparilla with iodide of potassium,
and perhaps with small doses of mercury if the malady has followed syphi-
lis, or if there is any reason to suspect thickening of the bones of the skull.
But all lowering remedies, and especially mercury, should be used with
the utmost  care and hesitation.
   Thirdly; but if  no cause whatever can be detected; — or if when de-
tected it cannot be  removed ; — or if, as frequently happens, even  though
removed, its removal  fail  to cure the disease, an empirical and palliative
plan of treatment is the only resource.   A course oi purgatives, especially
the croton oil, in  doses of lfj \ ter die ;  tonics, especially the  carbonate
of  iron, and oxide or sulphate, or valerianate of zinc  ; any remedies, in
fact, that have been known to  do good, may be tried in succession ; taking
care, however, not  to impair the constitution by giving them at random.
Opiuiu, morphia, hyoscyamus, belladonna, conium, stramonium, or  prussic
acid, given internally; friction with ointments, or alcoholic solutions  of
veratria, strychnia,  or aconitina (3ss ad 3i) — sprinkling gr. \—| of mor-
phia or strychnia, on  a newly  blistered surface; or making a dozen punc-
tures in the course of the nerve and inoculating a concentrated solution of
these alkaloids under the cuticle—galvanism, acupuncture, issues, and the
moxa,  generally afford some relief, and sometimes  completely cure.
Division of the nerve, with or without excision of a portion, is the  last
resource.   It produces instant ease, — which, however, lasts but a short
time; and  the  oftener it is  repeated, the more transient are  its effects.
Sometimes, after repeated divisions, the pain is as severe as ever, although
the part may become quite numb  and insensible.  The infraorbital and
mental nerves, (which may be divided from within the  mouth just as they
escape from their foramina,) the frontal, the radial, just after it has passed
between the  supinator tendon and  the bone, and the digital, are those
which have been  most frequently operated upon.
  VI.  Anomalous  Nervous Affections.—The same local and constitu-
tional causes that give rise  to neuralgia, may also occasion every other
symptom that can be  produced  by functional nervous  disorder; such as
rigid ind permanent spasm, (as in wry neck,) or twitching and convulsion
of modes;—difficulty of swallowing and performing evacuations, owing
to spasm of the oesophagus, of the  sphincter ani, or of the perineal mus- 
314
NEURALGIA.
 cles ;—sneezing, dumbness, stammering, thirst, and affections of the sight
 and hearing.   The treatment must be conducted on the same principles.
   VII. Hysterical  Neuralgia.—Hysterical females are liable to  suffer
 from various  obstinate maladies  which simulate  serious organic diseases.
 In particular they are exceedingly subject to severe and  permanent pain
 and tenderness of the joints ;  (especially the knee or hip ;) with weakness
 of the  limb,  and inability to use it;—or  to pain and tenderness of  the
 spine, with perhaps spasms, or weakness  of the  legs, tympanites of  the
 belly, and palsy of the bladder;—symptoms, in fact, of ulcerative disease
 of the joints or spine, that might mislead careless practitioners ; more  es-
 pecially as they are often attributed to some injury.   In fact, they present
 the sensations of organic  disease, with none of the reality.  These  cases
 may be known by observing that the patients are  young females, (or effe-
 minate  males;)—generally the spoiled children  of the rich; or, at  all
 events, persons in whom the feelings have been allowed to get the mastery,
 whilst self-control,  abstinence, and firmness of mind and body have never
 been inculcated.   The patients have generally some cause of wretchedness,
 real or imaginary;—perhaps  their affections have  been blighted ; or per-
 haps when their lover has become their husband, they may have found
 themselves unable to  settle down to the duties  and dull realities  of life.
 Most likely (but not invariably) they are subject to irregular menstruation,
 torpid bowels, and coldness of the extremities:—or perhaps to well marked
 fits of hysterical sobbing and  choking.   Not uncommonly some intimate
 friend has laboured under a similar complaint just previously.   The pain
 is greatly aggravated by motion or pressure ;—but it  seems to be princi-
 pally seated in the  skin ;  and the patient shrinks from the least touch ;—
 whilst, if her  attention be engaged elsewhere, a somewhat rude examina-
 tion may be made without complaint.   The pain often prevents  the patient
 from sleeping, but  once asleep, she may continue so for hours.  There
 may be some degree of swelling,  but it is puffy and diffused,—and comes
 and goes capriciously.  These complaints may last many years in defiance
 of all treatment, and then may vanish suddenly without assignable cause;
 —or perhaps from some strong impression on the nerves,—or perhaps the
 patient may seek relief in religious fanaticism,—or in a runaway marriage.
 Sometimes the patient  labours under  an obstinate  contraction of some
 joint;  perhaps the hip, or the finger; which  very likely goes off quite
 suddenly, and transfers itself to another joint.
   A more disastrous  thing can hardly happen  to a patient than to  have
 one of these hysterical affections  treated as a genuine disease, by issues,
 leeches, and confinement to bed; but the surgeon must be equally careful
 not to make the opposite mistake, and not to treat an ulcerated joint as if
 it were mere hysteria; and the author would urge young surgeons to  be
 most careful in their  diagnosis, as he  knows that mistakes of  both these
 kinds have occurred even to very experienced practitioners.
   Treatment.—Any detectable disorder of the digestive or uterine systems
should be removed.   The patient  should have  fresh air, generous  living,
and plenty  of  occupation  for  body and mind; she should be encouraged
to take exercise, notwithstanding pain  and weakness;  and to resume  as
far as possible the habits of a healthy person.   Friction of the surface;
the shower bath;  the  mistura  ferri, or  the ammonio-chloride in doses  of
gr. ii.; the sulphate of zinc in small doses  with ext. anthemidis—or the
ammonio-sulphate of  copper in doses of gr. £ ter die, may be given with 
CONCUSSION  OF  THE  BRAIN.
315
benefit if the circulation is languid ; and quinine may be of use if the pain
is  periodic.  The bowels should be kept open  by nightly doses of the
warmer aperients, such as aloes, or colocynth, with asafcetida, cajuput oil,
or the compound galbanum  pill.   Acidity of the  stomach must be  coun-
teracted by soda or magnesia;  and inaction of  the liver by occasional
doses of the  blue pill.  Deficiency or excess in  menstruation should be
properly looked  after.   " Sometimes,"  observes Sir B.  Brodie, " the
symptoms have abated under the use of active purgatives: or of valerian
combined with bark and ammonia, or of injections of asafcetida."   F.  10
is one  of his prescriptions for these cases.   He  also recommends warm
fomentations,  especially  one  composed of  sp. rosmarin. 3iss and mist.
camph. 3viss, or  of lin. camph.  3iv, with ext. belladon. 3ii.   Occasional
leeching may be  of service, but counter-irritants  should be avoided.   If
the limb at any  time become very hot, it should  be sponged with tepid
lotions ;—but if cold, it should be wrapped up warmly in flannel and oiled
silk.  Amputation in these cases is useless and cruel.*
                          CHAPTER X.

                     OF INJURIES OP THE HEAD.

            SECTION  I.--WOUNDS  of  the  scalp.

   Wounds and contusions of the scalp, be they ever so slight, are not to
be neglected.   For they may be followed by erysipelas;—or by inflam-
mation and suppuration under the occipito-frontalis, or within the cranium
that might easily prove fatal.  It may be observed, that sutures  are gene-
rally inexpedient;—that although there be considerable arterial haemorrhage,
ligatures should be avoided, if it can be restrained by pressure ;—that if a
flap of the scalp is nearly or even quite  detached, it  should be  carefully
washed,  and returned to its place, avoiding sutures and pressure by band-
ages and plasters; that if a blow on the head causes an extensive and in-
creasing  extravasation of blood  under the scalp, rendering it evident that
an artery has been divided by the blow, the exact situation of the injured
vessel  should, if possible, be ascertained, and  pressure be applied there;
that early and free incision must be made in the event  of suppuration, and
that punctures must be made if  there is great effusion of serum under the
occipito-frontalis ;—but that if blood is extravasated there, its absorption
is  to be promoted by bleeding,  cold, and low diet;  and no incision is to
be made, unless positively necessary.

         SECTION  II.--CONCUSSION OF THE  BRAIN.
   Definition.—Concussion (commonly called stunning) signifies sudden
interruption of the functions of the brain, caused by a blow, or other me-
chanical injury to the head, and not necessarily attended with visible  or-
ganic lesion of the brain.
  • Vide Brodie on the Joints, 4th ed. p. 311.  Brodie on Local Nervous Affection j
Lond. 1S37.  Rowland on Neuralgia,  Lond. 1838. 
316
CONCUSSION OF THE BRAIN.
   Symptoms.—There are two degrees of it.  (1.) In ordinary cases, \ht
 patient lies for a time motionless, unconscious, and insensible; if roused
 and questioned, he answers hastily, and instantly relapses into insensibility;
 after a  time, he moves  his limbs as  if in uneasy sleep, and vomits, and
 frequently recovers his  senses instantly afterwards ;  remaining, however,
 giddy,  confused, and sleepy for some hours.   (2.)  In the  more  severe
 degree  the patient  is profoundly insensible, the surface pale and cold, the
 features ghastly, the pulse feeble, and intermittent, or perhaps insensible,
 and  die breathing slow, or performed only by a feeble sigh, drawn at
 intervals.
   Vomiting is  an  important  symptom.  It is  not present in very slight
 cases, nor in very severe ones ;—and its occurrence is mostly an indication
 of approaching  recovery.
   Consequences.—(1.)  In cases not attended with fracture or lesion of
 the brain, the patient suffers from some degree of headache  and feverish-
 ness for a few days, which might easily be  aggravated into a fatal inflam-
 mation  of the  brain.   (2.) If  the concussion  be very severe, it may be
 followed by death; although  this is  not  often  the case, unless there is
 also a fracture of the skull, or extravasation  of blood within the  brain.
 The degree of danger in any case may be estimated by the degree in which
 the spinal and ganglionic systems appear to be  implicated.   If, therefore,
 the pulse and respiration  continue feeble for many hours; if the eyelids
 do not  move when  irritated, and the legs are not drawn up when the soles
 of the feet are tickled, the prognosis will be serious.   (3.) Concussion is
 occasionally succeeded by a peculiar state of insensibility, which may last
 some days.  The patient lies as if in a tranquil sleep ;  his pulse is regular;
 but on the slightest exertion it rises to 130 or 140, and  the carotids beat
 vehemently;—when roused he answers questions, but  immediately relapses
 into unconsciousness.  Some patients in this state resemble somnambulists;
 they may get out of bed, bolt the door, shave, or make water, but still are
 insensible to what passes around.   (4.) It  may leave a very infirm  state
 of the health and intellect;—impairment of the memory, or of the senses,
 especially of smell and hearing;  and a constant tendency to inflammation,
 and  to extravagant  actions after drink or any other excitement.
   Pathology.—The brain is  often found bruised,  or ecchymosed, or
 lacerated ;  but still concussion may be fatal, without any injury that can be
 detected by dissection.
   Treatment.—The indications are : (1)  to recover the patient from in-
 sensibility and collapse ; (2) to prevent inflammation ; (3) to restore any
 faculties that may remain impaired.
   1.  In order to fulfil the first indication,  friction of the surface with the
 hand, and the application of warmth to the feet, may be resorted to, if the
 depression is very great, and the pulse very low ;  but it is better in most
 cases to leave the patient to  recover by himself, than to be  officious in
 administering stimulants,  as they would increase the effusion of  blood,
 supposing the brain to  be lacerated.  Mr. Guthrie's sentiments on this
point are very decisive.   " It is useless to  open the  patient's veins," he
observes, " for they cannot bleed until he begins to recover, and then the
ioss of blood would probably kill him.  It  is as  improper to put strong
 dnnks into his mouth, for he cannot swallow ;  and if he should be so fat
 recovered as to  make the  attempt, they might probably enter the larynx
 and destroy him.  If he  be  made to  inhale strong stimulating salts, thei 
            COMPRESSION  FROM EXTRAVASATED  BLOOD.        3J7

will probably give rise to inflammation of the inside of his nose and throat,
to his subsequent great distress."*
   2. After reaction has  taken  place,  the  patient  (unless too  young  or
feeble)  should be bled ;f at all events the bowels  should be  freely acted
on,  and perfect rest and low diet should be observed.  If the pulse be-
comes hard and frequent, and if the patient complains of pain or tightness
in the head,  the bleeding and  purgatives should be repeated as often  as
may be necessary,  with  saline and antimonial draughts  in the  intervals;
and the head should be  shaved  and kept wet with  evaporating  lotions.
As a general rule, after any  severe blow on the head, the patient should
observe a cautious antiphlogistic regimen for a month or six weeks—care-
fully keeping himself free from all fatigue, intemperance, and excitement.
If violent delirium  or convulsions come on after an injury to the head
which has been treated by copious venaesection, and if they are not relieved
by further  depletion, or if that seems inexpedient, they will probably yield
to acetate  of  morphia.
   3. In order to  remove headache, deafness,  giddiness, squinting, loss
of memory,  tinnitus aurium, and other remote  consequences  of  concus-
sion, a course of mild alterative mercurials ;—repeated blisters, or an issue
or seton ;—the shower-bath, change of air, general friction of the  surface,
and a most regular diet, are the remedies.


   SECTION  III.--COMPRESSION  FROM  EXTRAVASATED
                               BLOOD.

   Symptoms.—The symptoms of compression of  the brain are those of
apoplexy.   They are insensibility; general palsy,, (sometimes, but rarely,
confined  to  one  side ;)  dilated  and  insensible pupil; slow,  labouring
pulse;  skin often hot and perspiring; retention  of the urine, through
palsy of the detrusor urine; involuntary discharge of faeces, through palsy
Of the sphincter ani ; and stertorous breathing, owing to palsy of the velum
pendulum  palali.   Sometimes, however, the pupils  are contracted, and
sometimes one is contracted and  the other dilated.
   Causks.—Compression (surgically considered)  may be produced by
three causes.  (1.) By extravasation of blood.   (2.) By fracture of the
skull, with depression.   (3.) By  suppuration within its  cavity.
   The symptoms of compression from extravasated blood generally show
themselves in  the  following manner: The patient receives  a blow, and
becomes stunned and  insensible from  the concussion, with  extremely
feeble pulse  and cold skin.  After a while he recovers his  senses;—but
a^ain in an  hour or two he becomes sleepy,  confused and insensible;
with slow  stertorous breathing, slow pulse, and dilated  pupils.   These
symptoms closely correspond with those of one  form of apoplexy called
the ingravescent; in which the patient suddenly feels an acute pain in the
head, caused by the  bursting of  a blood-vessel, and becomes sick and
  * Guthrie, G.  J., on Injuries of the Head affecting the Brain.  Lond. 1842, p. II.
  | Whether the patient has recovered his consciousness or not, he should be bled if
the pulse become hard, and the skin hot. But bleeding is not a r^»edy for concussion
itself:—it merely removes its consequences;  and if employed during a depressed state
of the circulation, may induce epileptic convulsion, or perhaps death.  In every case
r>f sudden insensibility, whether from  disease or accident, the  vulgar clamorously de-
mand that the patient should be bled ; but the surgeon must be very ignorant or very
weak if he yields to their wishes.
      27 * 
 318        COMPRESSION  FROM EXTRA\ ~SATF.D BLOOD.

 faint—in fact, suffers from concussion.  Then he  recovers his  senses-
 but shortly  afterwards, as  the  extravasation from  the  ruptured vessel
 increases, becomes quite comatose.*
    On the other hand, if a large quantity of blood is extravasated rapidly
 the symptoms of compression may immediately succeed  the insensibility
 of concussion, without any interval of  consciousness.
    The blood may be situated, (1) between the dura mater and  skull; and
 if in large quantity, it proceeds from laceration of a branch of the middle
 meningeal artery ; (2) between the membranes;  (3) in the substance of
 the brain.
    Diagnosis.—The insensibility  arising from  compression may be distin-
 guished from that which arises from concussion of the brain by observing,
 1st. That the symptoms of concussion  always follow the  accident imme-
 diately ; those of compression from  effusion of blood may come  on after an
 interval.  " The first stunning or deprivation  of sense," says Pott, " may
 be from either;  no man can tell from which ; but when these  first symp-
 toms have been removed, or have spontaneously disappeared, if such pa-
 tient is  again  oppressed with drowsiness  or stupidity, it then becomes
 most probable that the first complaints were from concussion, and that the
 latter are from extravasation."  2dly.  In concussion, the pulse is feeble,
 and the  skin pale ;  and the  greater the insensibility the  feebler will the
 pulse be.  In compression, on the contrary, when reaction is thoroughly
 established, the pulse will be slow and full, and the skin hot and  perspir-
 ing.   3dly.  Stertorous  breathing and muscular palsy  are  rare  in mere
 concussion,  common in compression.   4thly. The  pupil in  concussion
 is  variable :  sometimes contracted, sometimes dilated, and not  always
 insensible to light;  in compression,  it is  almost always  dilated and
 insensible.
   Treatment.—The head should be shaved and examined, and  if there
 is no sign of fracture, the case must be treated as  one  of apoplexy;  the
 indications being to avert  inflammation, and procure absorption of the
 olood  oy bleeding, cold applications to  the head, purgatives, and  calomel
 :n repeated doses.  Frequently a  puffy swelling arises after a day or two,
 and points out the seat  of the blow.  If, in spite of the above  measures
 the  insensibility continues,  and the lungs become clogged with  mucus
 and the breath escapes from the corner of the mouth with a peculiar whiff
 during expiration, which are very perilous symptoms, the  last reso«-<ee—
 and, under these circumstances, it must be confessed, a very desperate
 one—is trephining,—which operation should be performed at the seat of
 the injury, if that is known,—or if  that  is not known, it should be  done
 where any puffy swelling arises ;—or lastly, if  there is no  puffy swelling,
 it should be done over the middle meningeal artery;—and if one side is
 more palsied  than the other, it should be done on  the  other, because, as
 is well known, injury of one side of the  brain  produces  palsy of the
opposite  side of the body.  The trephine should be rather large, because
the blood is  almost always  found coagulated.  Perhaps the inner table
may be found extensively fractured, with only  a mere fissure of the outer
table.  The skull is  said always to bleed very little when  scraped at the
seat of effusion between it and the  dura mater, because it is deprived of
its supply of blood from  that membrane.  This, therefore, is an  important
diagnostic sign ; and  in a  desperate case it might be  advisable to cul
                     * Copland. Diet. Art. Apoplexy. 
FRACTURE  OF  THE  SKULL.
319
through the scalp,, and examine the bone  at  any part where  mischief is
suspected to exist.
  When a piece of bone has been removed, the dura mater, in its normal
state, is found to be level, and of a reddish silvery colour, and it rises and
falls synchronously with the motions  of  respiration;  but if there is fluid
underneath, it bulges up  tightly into the aperture made by the trephine,
and its motions are very indistinct or entirely lost.  In  this  latter case a
puncture should be made to let the fluid  escape; and numerous instances
are on record in which, after the  surgeon  has  punctured the distended
dura  mater, and some ounces of  blood  have  escaped, the patient has re-
covered his consciousness immediately.*
Fig. 93.
          SECTION  IV.--FRACTURE OF  THE  SKULL.
   Fractures  of  the skull are divided, (1) into those which consist of a
 mere crack or fissure  without displacement;  (2) into fractures with extra-
 vasation of blood, which generally accompanies fracture of the anterior
 inferior angle of the parietal bone,  and which was  spoken of in the last
 chapter;  and (3) into fractures with depression.  Fracture of the base of
 the s/cull is the most dangerous kind.  It is caused when the patient falls
 from a height, and pitches on his head ; the basilar  process being snapped
 through by the weight of the whole body, which tells upon it through the
 spinal column.   In  these  cases there is  frequently a  copious venous
 haemorrhage  from the ears, in consequence of laceration of the sinuses  at
 the base of the brain.   This is a  most unfavourable symptom ; although a
 slight  haemorrhage from  the ears, or nose, or mouth, may depend  on an
 insignificant  rupture  of  the membrana tympani, or of the mucous mem-
 brane of those parts.  These cases mostly terminate fatally, although there
 is one instance of recovery on record.
   A copious discharge  of  thin watery
 fluid from the ear is an indication of
 imminent  peril.f   It evidently filters
 through  a crack in the petrous portion,
 into  the  tympanum, and thence  out-
 wardly through  a rupture in the mem-
 brana tympani; but  whether  it  comes
 from the sac of  the arachnoid, or from
 the vei  us sinuses, is uncertain ; most
 probably from the former, because  it is
 uncoagulable, and,  like the  cerebro-
 spinal  fluid,  contains very  little or no
 albumen  or  salts.   In  a case  under
 Mr.  Tatum's care in St.  George's Hos-
 pital, the  membrana tympani was rup-
 tured, and the saliva flowed copiously from the ear; of course through the
 Eustachian tube.
   1.  Simple fissure requires no  treatment apart from that of the concus-
 sion, compression, or  scalp wound, with which it may be accompanied.
   2. Fracture with depression may be simple or compound ; the compound
being that which is attended with a scalp wound exposing the fracture.
  * Guthrie, op. cit. pp. 39, 125.  Brodie, Med. Chir. Trans, vol. xiv.
  T For observations on this point see Guthrie op. cit.; and a notice of papers by MM
Langien, Robert, and Chassaignac, in Ranking'* Abstract, vols. ii. and iii.
 
320
FRACTURE  OF  THE SKULL.
  (a.)  Simple fracture  with depression may be ascertained  by a careful
examination  of  the  shaved  scalp, when, if it exist, there will be felt a
depression at one part, with a corresponding edge or projecting ridge near
it.  Sometimes  a  coagulum of blood under the scalp conveys the feeling
of a sharp elevated ridge of bone ; — it may be known, however, by its
yielding to firm  pressure with the finger, and by observing that no part of
the bone  is below its  natural  level.   But  although  there  may be a real
fracture with depression, still  there may be no compression of the brain;
because the  outer table may merely have been driven into the diploe, or
the outer wall of the frontal sinus may have been broken in.   The former
accident (i. e. fracture of the outer table only) can only happen to a pa-
tient of middle age, because the diploe neither exists in infancy nor in old
age ; — the latter will  be known  by the  escape  of air, when the nose is
blown forcibly, either into the cellular tissue of the  forehead, or out of the
  ound, if there be one.
   Treatment.—In a case of simple depressed fracture, if there are symp-
toms of compression of the brain, the scalp  should be divided, and the
bone be raised by trephining.  But if there are no  symptoms of compres-
sion (and there sometimes are none),  and if the patient is conscious  and
rational, there is a difference of opinion as to the plan to be pursued.  Sir
A. Cooper and Abernethy direct that no incision should be made through
the scalp,  nor should the trephine be  immediately resorted to, which they
contend must necessarily aggravate the amount of the injury, and the pa-
tient's danger; but that the patient should be bled, purged, and kept under
the strictest antiphlogistic regimen ;  and  then, perhaps, recovery may be
completed without the slightest appearance of compression, and inflamma-
tion be averted.   Even if there be slight  symptoms of compression, the
same plan is  to be adopted, in the hope that they may be removed by free
depletion.
  The practice,  however, of Pott and his predecessors was to trephine in
every case of depression ; alleging that the operation should be performed
in order to prevent ill symptoms, and that if it were delayed till they came
on, it would be too late.   And this latter doctrine  is  supported in some
degree by Mr. Guthrie, who says,  that if fracture with marked depression
exists, in an adult, it is the best plan to divide the scalp, and ascertain the
nature and extent of the depression.   If it is probable that  portions of
bone are sticking into and irritating the dura mater, it is better to trephine
at once, even  although no symptoms of compression should  be present*
In children, whose bones are soft and thin, great indentations and depres-
sions may be produced without fracture. They are to be treated antiphlo-
gistically; and if the bowels are kept well open, they may not cause any
bad symptom whatever, and the bone may rise in time to its proper level.
  (b) In the  case of compound fracture of the skull, with  depression of
none, whether there are symptoms of compression of the brain or not, the
bone must be elevated.   If possible,  it should be done with the elevator;
but if one piece of bone  is wedged  in under another, a sniall aperture
should be  made  with the trephine, in order to make room  for employing
ihe  elevator.   If any pieces of bone are  perfectly loose  and  detached,
they must  be removed ; but not if they have a pretty good adhesion to the
pericranium and dura mater.
  * This question is admirable discussed in  Sharp's Practical Treatise on Injuries of tlie
Hoad.  Lond. 1641. 
WOUNDS  OF  THE  BRAIN.
321
  Sabre Cuts.—Cuts inflicted by a sword or sabre, if they do not quite
penetrate the skull, are to be treated as simple fissures; but if  produced
by a blow which  descended perpendicularly, the inner table of the skull
is apt  to be extensively splintered ; and if on  examination with a blunt
probe this is found to be the case, recourse should be had to the trephine.

            SECTION V.--WOUNDS  OF THE BRAIN.

   Wounds of the dura mater add very considerably to the danger of com-
pound fractures of the skull, both  from  the risk  that inflammation may
spread over the surface of the arachnoid, and from the greater chance of
hernia cerebri.  Hence this membrane should never be punctured in search
of fluid, without  due consideration.
   Wounds of tlie sinuses are of no great  consequence, provided the blood
does not accumulate within the skull; haemorrhage from them is easily
restrained by pressure.
   Wounds of the brain, whether incised  or lacerated, are not of necessity
attended with any mental or bodily disorder, besides that which arises from
the concussion, compression,  or inflammation  that  may accidentally be
present.  Instances are numerous in which portions of the brain have been
lost, without any  ill consequences at the  time or afterwards.  But yet Sir
B. Brodie has observed in some cases a greater degree of mental confusion
than usually attends concussion, and in others spasmodic twitchings of the
muscles.
  It' foreign bodies are imbedded in the  brain, the danger will  be mate-
rially augmented.  Sir B. Brodie says, that no  foreign  body, whether  a
portion of the skull or not, is to be removed, if  the  removal will  add in
die least to the irritation or injury; but the practice of most surgeons is, to
remove them without delay, but with as little disturbance as possible.
   The treatment of these cases  consists in the preventing of inflammation ;
and in causing the wound  to  cicatrise  without the  formation  of hernia
cerebri.

   SECTION  VI.--HERNIA  CEREBRI,  AND  MALIGNANT
       UROWTHS  OF  THE  CRANIUM  AND MENINGES.
  When a portion of the skull  has been  removed, the brain is liable to
protrude through  the  aperture in  the  form  of a rounded tumour, styled
hernia  ox fungus cerebri.   Mr. Guthrie describes two varieties  of it.  In
the  first, which occurs within two days, the tumour is  composed of coagu-
lated blood, and is caused by haemorrhage into the brain, near its surface.
It is accompanied with delirium and phrenitis, and is  generally fatal/ The
best treatment is,  to shave it off level with the surface, so as to permit a
free discharge of blood.   The  other kind of tumour  consists of brain it-
self, infiltrated with lymph from inflammation ; which, if the dura mater is
still entire, causes it to slough by its constant pressure, and then protrudes
through the aperture in the skull.   As it increases  in  size, it suffers con-
striction from the  aperture through  which it passes,  and sloughs;  but is
speedily succeeded by a fresh growth of brain and of fungous granulation,
which undergoes the  same processes, till  the patient dies of the irritation.
  Treatment.—In order to prevent this tumour, a well-regulated  pressure,
just sufficient to afford a natural support,  should be made upon the brain
jy means of compresses of soft lint oiled, ia all cases when the skull
                                  V 
322
INFLAMMATION  OF THE  BRAIN.
perforated.  If the fungus has already protruded, the best application u
liq. calcis, with which the lint may be wetted.   If this fail, and the degree
of pressure requisite, to prevent increase cause  symptoms of  cerebral
oppression, the part should be shaved off level with  the  scalp,  and any
further growth  be  prevented by ihe liq. calcis  and lint, and pressure, as
before.
   Malignant  Growths occasionally spring from the dura mater, and in
their earlier stages produce various symptoms, whose  intensity is  the less
in proportion as the increase of the tumour is slow.   Sometimes the irrita-
tion of the surface of the brain  gives rise to epileptic convulsions, which
may be accompanied with intense headache, limited to the seat of the dis-
ease.  Sometimes there  are the signs of compression, in the form of gradu-
ally increasing  mental imbecility, and palsy of the limbs.   Sometimes the
patient is cut off with a sudden attack of  hemiplegia.  But if he  survives
long enough, the  growth  (which is usually of the  encephaloid  variety)
makes its  way outwardly, perforates the skull,  and appears as  a soft
lobular tumour.  Attentive examination may perhaps detect two kinds of
pulsation in it: one synchronous with the  arterial pulse, the  other  with the
rise and  fall of the  brain  in respiration.   The tumour cannot be moved
laterally, but in its earlier stages may perhaps be returned  into the skull,
giving rise to  symptoms of compression.  If the patient  survives long
enough,  the disease  follows the ordinary course of encephaloid.   Mode-
rate compression is the  only feasible treatment; any interference  with the
knife can only  lead to speedy death.

    SECTION  VII.--OF INFLAMMATION OF  THE BRAIN,
                    ARISING  FROM  INJURY.

   General  Description. — Inflammation of the brain rarely makes  its
appearance till a week  after an injury, frequently not till three weeks, or
even later.   Its symptoms and progress are very various; sometimes sud-
den, violent, and soon terminating in destructive suppuration; sometimes
slow, insidious, and unsuspected, till suddenly manifested by fatal coma
or palsy.
   Symptoms.—First stage.—The patient complains of pain in the head,
aggravated by  heat, motion, and anything that causes excitement of mind
or body, together  with a disagreeable sense of  languor or weakness, con-
fusion of ideas, quick pulse, disturbed sleep, nausea, and want of  appetite,
and alternate  flushing  and  paleness.   Second stage. — The  symptoms
having lasted  a day or two, there  comes on a violent rigor, followed  by
burning heat of the skin ; the pulse is hard and frequent; the carotid and
temporal arteries  pulsate  vehemently; the headache becomes  most  in-
tolerable and throbbing; the pupils are contracted ;  light is insupportable
to the eyes, and sound to the ears; the tongue is dry, the bowels obsti-
nately costive,  and the  stomach rejects everything with frequent retching.
Besides these symptoms, violent  delirium or convulsions come on at  in-
tervals, or perhaps coma.   If they  are unrelieved,  the third stage soon
follows.  The pulse loses,its force, and*becomes either slow and oppressed,
or excessively  rapid ; and squinting, low delirium, convulsions,  or palsy,
soon usher in death.   Rigors, followed by squinting, dilated pupil, ster-
torous breathing, coma, and palsy, are indications of suppuration.
   Certain changes on  the outside of the head also  accompany the mis- 
INFLAMMATION OF THE  BRAIN.
323
chief that is  going on within.   Supposing the injury which is the cause
of the inflammation to have been accompanied with a wound which up to
the occurrence of the  inflammation has been g»ing on well, — to use the
words of Pott, " the sore loses its  florid complexion and granulated sur-
face, and becomes pale, flabby, glassy,  and painful;  instead of good
matter, a thin gleet is discharged from it; the lint with which it is dressed
sticks to all  parts of it; and the pericranium, instead of adhering firmly
to the bone, separates all round from it to some distance from its edges.''
The bone, moreover,  becomes white,  dry,  and bloodless; because the
nutrient vessels  that naturally pass from the  dura mater to the skull are
cut off,  in consequence  of the inflammation  or incipient suppuration of
that membrane.   If there be no wound, the scalp will  present  a puffy,
circumscribed, indolent  tumour at the  seat of injury, on incising which,
the pericranium is found detached.  If the  dura mater is exposed, it at
first appears of " a dull, sloughy cast, and smeared  over with something
glutinous," and subsequently is covered with matter.
  Pathology. — It is believed that if the membranes and surface of the
brain be inflamed, there  will  be greater pain, and a greater disposition to
delirium and convulsions ;*—but that in inflammation of the cerebral sub-
stance, there wrill be an early tendency to coma and palsy.
  Prognosis will be unfavourable, if the  malady have  advanced to  its
second stage, and is not promptly relieved by depletion.
  Treatment.—Upon  the  first appearance  of the  symptoms, bleeding
should be performed (perhaps from the temporal artery  or jugular vein,)
to the approach of faintness; the bowels  should be most freely opened,
and the head be  shaved and  kept cool  and elevated.   If they do not
yield, the bleeding should be repeated as often  as  may be necessary;
leeches should be freely employed,  and from two to six grains of calomel,
with a quarter of a grain of tartar emetic (not enough to  cause vomiting),
should be given every two or three hours.   The  remedies for  the  third
stage are  blisters  to the head or its vicinity; mustard cataplasms to the
feet; terebinth in ate or stimulant enemata;  and trephining, if  suppuration
is indicated  by symptoms of compression,  or by the  above-mentioned
state of the wound.   The trephine  should  be large, and if the matter be
seated  between the dura mater and skull, it may afford relief, although it
rarely does.
  Abscess in the brain, or that form  of disorganisation which is called soft-
ening or ramollissement,\ may be very remote consequences of injury, not
occurring perhaps for years.   Their symptoms are  very obscure  and insi-
dious.  Occasional headache ; general loss of health and strength ;  impair-
ment of the  memory or other mental faculties ; quick pulse, and furred
tongue; disorder of the eyes  or ears ; sense of constriction, or of coldness
in the scalp, or of creeping in the limbs, with  numbness,  are the most fre-
quent.   But  these  are  succeeded  by  sudden convulsions,  or  palsy, or
coma, from which the patient soon  dies, although he may perhaps recover
for  a time.
  *  Dr. Marshall Hall ascertained  that lacerations of the dura mater of frogs gave rise
to spasmodic motions of the eye, eyelids,  and head:  probably through tne reflex influ
ence of the small branches of the  fifth nerve which supply that membrane.
  t  Softening of the brain may arise from two opposite causes; viz., from atrophy, ot
Insufficient supply of arterial blood ; or from inflammation ; in  the  latter case, as men-
tioned at p. 09, the nerve tubes are broken up and mixed with  pus and exudation cot
puscles. 
324
TREPHINING  AND PARACENTESIS.
   Treatment.— Blisters, issues, setons, or the tartar emetic ointment; mei-
curial  alteratives;  purgatives;  occasional  depletion ;  shower-baths; the
most regular diet, and avoidance of every kind of excitement of mind or
body,  are the remedies in  case  mischief is suspected.  After the occur-
rence of palsy, or other decided symptoms, blisters; leeches, if the pulse
is strong enough, and  there  is pain or heat in the head ;  purgatives, and
enemata.   But if the  patient is low and feeble, he must be supported by
mild nutriment and stimulants of the diffusive kind, especially the prepa
rations of ammonia.

    SECTION VIII.--TREPHINING  AND  PARACENTESIS.

   I. Trephining.—The  apparatus requisite for this operation  comprises
a large and small trephine, a straight  and  curved Hey's saw, and an ele-
vator—besides a good scalpel, and the other instruments which every sur-
geon is supposed to have in his pocket.
   There are four cases  which may  require this operation.   1. Fracture of
the skull with depression of bone.  2.  Extravasation of blood under the
skull.  3. Suppuration of the dura mater.  And lastly, occasional cases
of epilepsy arising from the irritation  of a diseased spot of the skull. For
the first and last cases, the trephine should be quite small, so  as not to
sacrifice more bone than is absolutely necessary ; but when the operation
is intended for  the relief of suppuration or  extravasation, the trephine
should be large, so as to afford a free exit to the  fluid.
   Supposing it to be a  case of depressed fracture.   In the first place, the
bone, if not already laid bare by a  scalp wound, must  be exposed by an
incision in the shape of a V, or T.   Then perhaps  some  loose  fragment
may be picked out, or a projecting point may be sawn off with a Hey's
saw, that will enable the surgeon to raise the  depressed portion with the
elevator.   But if this cannot be  done, a circular piece, consisting of the
edge of the depressed bone, and of the adjoining bone under which it has
been wedged, must be removed.   The pericranium  being shaved off from
the part which is to be  perforated, the surgeon applies the trephine, and
works  it with an alternate pronation and supination of the wrist, and when
it has made a circular groove deep enough to work in steadily, he takes
care to withdraw the centre pin.   He saws on  steadily and  cautiously,
pausing frequently and examining the groove with  a probe, to  ascertain
whether it has reached the dura mater, and when it has, he introduces the
elevator to raise the circular piece of bone.  He must be particularly care-
ful to fix the centre pin, and the  greater part of the circumference of the
instrument on firm bone,—and by no means to press heavily, whilst saw-
ing, on any piece that is loose  or yielding.  The saw will be  known to
have reached the  diploe by the escape of blood with the bone-dust;—but
it must b/» recollected that the diploe exists neither in children  nor in the
aged.  The trephine should not be applied in the course  of the sutures,
nor over the lower part of the frontal  or  occipital bones, if  it can be
avoided ;  but if necessary there is no objection.
  II. Paracentesis Capitis, or puncture of the  head, is an operation that
sometimes is resorted to in hopeless cases of hydrocephalus in  children,
when all  meduine fails  of checking the effusion of water, or of causing it
to be aosorbed.   It has been particularly recommended by Dr.  Conquest,
wno has performed it in nineteen  cases, out  of which he succeeded in 
DISEASES  OF THE  SPINE.
325
saving ten.  The operation consists merely in introducing a very fine *ro-
car or grooved needle perpendicularly to the surface, through the anterior
fontanel, as far as possible  from the longitudinal sinus.   When  two or
three ounces of fluid have escaped, the puncture should be carefully closed,
and moderate support be applied to the head by bandages.   If the child
becomes faint, it must be kept in the recumbent posture,  and have a few
drops of sal volatile.  The operation may  be repeated at intervals of two
or three weeks.*

                                                          0
                         CHAPTER XI.

         OF  THE DISEASES AND  INJURIES OF THE SPINE.

    SECTION  I.—OF THE  DISEASES  AND  DEFORMITIES.

   I. Lateral Curvature.—Curvature of the spine presents many varie-
 ties, some of which arise from  mere debility, whilst others are caused by
 the destruction of portions of  the spinal  column  by disease.  We  shall
 first describe that distortion which arises from  debility of the bones,  liga-
 ments, and muscles, and which is so exceedingly common in this country
 in young females from about the age of ten to sixteen.
   Symptoms.—The first thing that attracts attention is a projection of one
 scapula, or of one  side of the bosom, or an elevation of one shoulder,
 (most commonly the right,) which are popularly, but erroneously supposed
 to be growing out.   On examination the spine is found to be curved like
 an  italic f.  The right shoulder and the right side of the chest are unna-
 turally high and rounded, whilst the opposite is depressed and  concave.
 In the  same way the left hip projects, whilst the loins on the right  side are
 curved inwards.
   Causes.—This affection is readily caused  by occupations or postures
 that tax one  side of the body more  than  the  other.  We shall  mention
 under the head of treatment such as are most common in children, but we
 may add, that there are some circumstances which almost infallibly cause
 distortion even in the healthiest adult;  such as one leg being  shorter than
 the other, or walking wyith  a wooden leg.   Why one-sided postures should
 cause distortion must be evident, when it is considered that the interverte-
 bral substance is compressible to  such an extent, that an  adult  man of
 middle stature loses about an inch of his height after having  been in the
 erect posture during the day, and does not regain it till after some hours
 of rest.   "Since the united thickness of the intervertebral substance in an
 adult man is about 3-875 inches," we see  that they lose nearly one-fourth
 by compression, which they do  not  recover till  after some hours  of  rest.
But if the weight of the body falls unequally on the spine  day after  day,
it must be evident that they will become  compressed on one side more
ihan on the other; and that if their elasticity be impaired, and the  muscles
and ligaments be weak, and the bones soft, as they are in  young  persons

         • Vide Dr. Watson's Lectures in the Med. Gaz. for March 1841
       28 
326
DISEASES OF THE  SPINE.
who have not a sufficiency of fresh air, wholesome food, and active exer-
cise, this lateral distortion will become permanent.*
   Treatment.—Attention must be paid to the following  circumstances:—
viz. position, exercise, and rest.   (1)  In  the  first  place, the patient must
be watched, in order to find  out from what particular attitude or habit the
distortion takes its rise.  Standing on the right leg is  the most frequent,
for in this posture the left side of the  loins is thrown upwards, and the
patient is obliged to raise the right shoulder to keep the body perpendicu-
lar.   A habit of  raising the  right shoulder whilst writing, or drawing, or
playing the  harp, or riding on horseback,—or of sleeping  constantly on
one side with too high  a pillow,—the stupid custom of letting girls' dresses
be made low on  the  chest, so  that the patient  is perpetually inclined to
hitch up the shoulder-strap on one side and let it fall  off the other, are also
occasional  causes.  And all these, and every one-sided posture, should be
vigilantly prohibited.!   (2) The patient should take free exercise in the
open air, whether walking or riding, or indulging in  any games or sports,
such as the dumb-bells, the skipping-rope, drawing a light  garden roller,
hopping, or carrying  weight? in the  hands.  The  club exercise, intro-
duced by Mr. Angelo into the regular cavalry training, is  extremely advan-
tageous.^   It consists in a series of exercises for the  arms, whilst a club
or loaded stick about two  feet long, and from  two to  seven pounds  in
weight, is held in each hand.  In this, as well  as in using the dumb-bells,
or other exercises performed in a standing posture, the patient should stand
with the heels close together, the feet at an angle of 60°, the knees straight,
the belly thrown  back, (so that it may not be strained,) the chest forwards,
and the shoulders square; and whilst both sides  are  duly exercised, the
weaker one should be principally brought into play.  Climbing a rope, and
swinging by the hands from a cross piece of wood attached  to a rope, are
also  useful.   (3)  These exercises should  never be carried  so far as  to
fatigue;  and after using them the  patient  should lie down on her back on
a flat  inclined plane,  although any easy posture on a bed or sofa, or on the
floor,  will do as well.   She should never be forced to stand  longer than is
perfectly agreeable, and when sitting should rest herself  well  against the
back of the chair.  Her seat should be wide enough to reach to the knees,
and the feet should be well supported.   These  measures, combined with
tonics, especially steel, F. 8, good diet, country air, shower bathing, fric-
tion of the back  with horsehair gloves, and attention to the health, may be
sufficient to cure incipient cases,  and to mitigate severer ones.
  Curvature from Rickets.—There is another form of curvature from de-
bility, which chiefly affects young children  of the lower orders, and arises
from rickets.  It is readily distinguished  by the  general  rickety aspect of
the patient, (vide p. 218,) and by the distortion of the limbs that is also

  * See some judicious observations on this point by Mr. Bishop, in the  Lancet for 184G,
vol. i. p. 215.
  f Jackson, the pugilist, used to say that he knew an  infallible plan for making any
child crooked ; viz., Let it bolt its victuals and stand on one leg. (Vide Mayo's Philoso-
phy of Living.) Whilst on the subject of bolting food, the author may hint to his junior
readers, that there is generally some cause for this habit. Either the appetite is morbidly
ravenous, through an unhealthy state of the secretions of the stomach, or else the gum!
are tender, or the teeth carious, so that mastication gives pain.  These states may easil)
be relieved,  and then the bad habit may be attacked with some chance of success.
  * Vide  proposed Regulations  for the instruction &c. of the Cavalry.  Part I. Pub
lish*d by Authority.  Lond. 1832, page 11. 
pott's curvature.
327
 present, as well as by the circumstance that the spine is not simply curved
 laterally as described above, but is often  curved directly forwards;—the
 seat of this curvature  being  the  upper part of the back ;—or perhaps it
 may be curved backwards.
   There are four other measures which are occasionally resorted to for the
 cure of these and the  other severer degrees of spinal  distortion, viz. the
 recumbent  position — mechanical support—mechanical  extension—and
 division of some of the spinal muscles.
   1.  The recumbent position, continued for a length of time, is a measure
 which has been most disgracefully abused by certain spine-quacks; inso-
 much that poor wretches who have applied to them to be cured of a mere
 distortion of the back, have, after many months of confinement, been sent
 away broken in health, and incapable almost of moving a limb.   In slight
 cases the patient need lie down only  for a short time^fter taking exercise,
 in order to relieve the spine from the weight of the body whilst its muscles
 are fatigued.   In severe cases the patient should never be permitted to
 sit or stand upright; she should, however, walk out daily in the open air;
 but when not walking, should lie down.  She  should, moreover, be  pro-
 vided with  some exercises for the arms, which may be used whilst lying
 down.   But a continuance in the recumbent position, without rising  at
 all, is only necessary under one circumstance—and  that is, when the
 curvature increases very fast, and is so abrupt at one point that it begins
 to compress and irritate the spinal cord, and produce spasms or palsy of
 the legs.                         A -,
   2.  Mechanical support is of: great seance in  many cases ; and the  best
 way of applying it seems  to be by a circular well padded iron girdle,  to
 be buckled round the pelvis, to which is attached a crutch, by which the
 axilla of the depressed side can be supported and gradually raised, whilst
 a broad  band passes over the convex side of the chest, and forces it back
 into its proper  position.  But all circular constriction of the body, as with
 the common female stays, is an evil.
   3.  Extension oi the spine longitudinally may be effected by fixing the
 pelvis or feet to the bottom of an inclined plane or couch, and the armpits
 to the upper part of it; then there must be some contrivance by which
 the couch  may be very gently lengthened.  Or something may be done
 by pulling at the arm on the convex  side of the chest, whilst one foot of
 the operator is  pressed against that side of the chest, and the other against
 the pelvis.   These measures may do good if not abused.
   4. Division  of spinal muscles.—This operation was practised  a  few
 years  ago,  but  the author believes it is  now  almost, if not  quite,  dis-
 continued.
  II.  Angular Curvature  (PoWs  curvature) is produced,  as  fig.  94
 shows, by caries of the  bodies of the vertebras, or ulceration of the inter-
 vertebral substance—a disease which generally affects scrofulous children
 or adults.  It begins with  symptoms that indicate irritation of the spinal
cord; the patient complains of weakness, coldness, and numbness of the
legs, and incapability of taking exertion ; and these symptoms are followed
by twitchings  and spasms of the  legs, and  afterwards  by palsy.  The
bowels are costive;  and there is difficulty sometimes of passing, some-
times  of retaining the  urine,  which  is generally pale  and alkalescent.
Children rarely complain of much pain in the back;  but if the patient is
an adult, there  is generally a heavy dull  aching pain, aggravated by mo- 
328
diseases  of  the spine.
tion,  together with great tenderness on  pressure ;  and a  peculiar dead
sickening sensation like that of a carious  tooth, if a smart blow be siruck
                              on the diseased  part with  the knuckles.
                              If the disease is situated in the dorsal ver-
                             tebrae,  it  will  moreover be  accompanied
                             with  tightness of  the  chest, and difficulty
                             of breathing;  and if in the  cervical, one
                             or both arms  may  be palsied, and there
                             will be a difficulty of supporting the head.
                             As the disease advances, the back becomes
                             curved forwards, and  the  spinous  pro-
                             cesses  of  the  diseased vertebras  project
                             backwards, so  as  to  cause  great  de-
                             formity ; abscesses form, and the patient
                             exhibits great constitutional  derangement
                             and hectic.
                                Consequences.—1. In favourable cases,
abscesses, if they form, are healed, or their matter is absorbed ; the diseased
bones collapse, and are anchylosed, as after ulceration of the cartilages of
joints;  and the patient recovers with more or less deformity, which is of
course incurable.  2.  In some fatal cases the patient dies suddenly from
two or three of the diseased vertebrae giving way, and crushing the spinal
cord ; or from dislocation of the odontoid process, owing to ulceration of
its ligament; or from the bursting of aSscesses into the spinal cord;  or from
their bursting into the pleura or peritoneum; but more frequently death is
caused by slow irritation and exhaustion, consequent on the formation and
bursting of psoas or lumbar abscesses.
   Diagnosis.—This  affection must not be confounded with  its hysterical
counterfeit spoken of in the'ninth chapter.  It may readily be distinguished
from the distortion which arises from debility by noticing that the curvature
is abrupt and angular, whereas in  the latter affection  it is gradual  and
rounded, and implicates nearly the whole spine.  It  may be distinguished
also by the tenderness  and  pain;  and by the symptoms of  irritation of the
spinal cord ;  which latter symptoms are present in cases of vertebral caries
from their very commencement, but  exist only in very severe  degrees of
curvature from debility.
   Treatment.—(1.) Rest in the horizontal posture is absolutely necessary.
A  water-bed  or fracture-bed may be  used, if easy or convenient.   But the
patient must not be taught  to lie on his back, nor must any means be used
with a view of straightening the spine, as they would  merely impede the
natural process of recovery, by preventing the remains of the diseased ver-
tebras from falling together.  A bandage  containing strips of whalebone,
and reaching from the  head to the hips, is of use in  keeping the trunk  at
perfect rest.  (2.) Issues should be made  and  kept  open with  caustic on
each side of the  spinous processes of the  diseased vertebras.   (3.) At the
same time, the constitution must  be  thoroughly supported by good diet,
and by sarsaparilla and steel, and other tonics and alteratives, as directed
for scrofula.
   III.  Lumbar and Psoas Abscess.—These are abscesses arising from
that diseased condition of the  spine which has just been described. When
*ne connections of the various muscles and fasciae to the  spine are  con-
sidered, the variety of course? which these abscesses take are very intelli-
 
spinal irritation.
329
gible.   Sometimes they point in the back (constituting  lumbar abscess if
low down); sometimes the matter makes its way between the abdominal
muscles, and may point at any part of the abdominal parietes ; sometimes
it enters the sheath of the psoas muscle, passes downwards in its sheath,
causes absorption of that muscle, and points below Poupart's ligament,
forming a  tumour which diminishes or disappears when the patient lies
down, and receives an impulse on coughing.  This is called psoas abscess.
Its diagnosis is alluded to in the  chapters on Aneurism and Hernia.   If
these abscesses enlarge in spite of the issues and other measures directed
against the vertebral disease, they must be treated in the manner directed
for large chronic abscess, p. 76.
  IV.  Spinal  Irritation.—The practitioner ought to be aware that por-
tions of the spinal column are liable to fall into a peculiar state of irrita-
tion and congestion, and to give rise to various trains of symptoms, which
cause immense perplexity and trouble, unless traced to their proper source.
Thus,  for example, patients may complain (1) of all kinds  of disordered
sensation in the skin, varying between the limits of the most exquisite sen-
sibility, and the most utter numbness and insensibility, and including every
variety of creeping, shooting, coldness, formication, tingling,  and so forth ;
or (2)  they may complain of genuine neuralgic pains, shooting accurately
in the  course  of the nerves, and intermittent or continuous ; or (3) they
may suffer  from spasm, or tremor, or cramp, or palsy of any of the volun-
tary muscles of the limbs;  or, (4) from fixed pain  and tenderness, with
perhaps some  little swelling of a joint, or of the mamma, or testicle ;  or,
(5) they may suffer from the same kind and amount of irritation and dis-
ordered sensation in any  internal organ; such as vertigo, nervous asthma,
palpitation   of the  heart, great  flatulence  and pain in the stomach  or
bowels, &c.
  Now, as we observed before, when treating oi neuralgia, (p. 313,) since
the great object is to get  at the source oi these symptoms, the spine should
always be examined to ascertain whether it is there ; and more  especially
since it is very seldom that the patient in these cases makes any complaint
of the  back.   The best method of examination is, to make a  firm pressure
on each of the spinous processes, or to pass a sponge wrung out  of hot
water over  them ; and then the  patient will piobably complain  of severe
pain .over one  vertebra.   Should this be the case, all the symptoms will
probably vanish like magic if leeches be applied to the tender spot, and
be followed by a blister, or a stimulating liniment, or a plaster containing
tartarised antimony.
  These symptoms  may be present along with  lateral  curvature  of the
spine ;  but  it does not appear that the two affections have any connexion,
and one may be relieved  without relieving the other.   Mere  spinal irrita-
tion may be distinguished from incipient caries, by attention to the general
signs which distinguish functional from organic  disease; in  particular by
noticing that the patient seldom complains of any pain in the back, and
by the  length of time the symptoms last without the occurrence of abscess
or angular deformity.*
  V.  Rheumatic Inflammation  of the spinal cord is apt to  occur to per-
sons who are greatly exposed to cold and wet, such as labourers and pros-
titutes.  Fever, violent pain in the  back, and complete paraplegia, with
loss of power over the rectum and bladder,  are the symptoms. The treat-
           * Vide Teale's Treatise on Neuralgic diseases, Lond. 1829.
       28* 
330
DISEASES  OF  THE SPINE.
rncnt must consist of bleeding or cupping; calomel  to  affect the mouth,
and subsequently blisters and warm baths.
  VI.  Si'ina Bifida, or hydrorachitis, is an affection in which the spinous
processes and laminas of some of the vertebra are cleft or deficient.  The
spinal membranes, deprived of their ordinary support, yield to the pressure
of the  fluid which they contain,  (which  also is secreted in unusual quan-
tity,) and bulge out, forming a fluctuating tumour in the middle line of the
back.
  Pathology.—This affection evidently has its origin in the earliest stage
of foetal existence, and depends on an arrest of development of the lamina;
of the  vertebrae,  and generally of the lumbar and sacral.   It is found, on
dissection, that not merely the spinal  membranes are distended, but that
the nerves or the  cord itself may have very important connexions with the
sac.  "If the tumour," to use Mr. Prescott Hewett's words, "corresponds
to the two or three upper lumbar  vertebras only, the  cord itself rarely de-
viates from  its course, and  the posterior spinal  nerves are generally the
only branches which have any connexion with the sac.  But if the tumour
occupies partly the lumbar and partly the sacral region, then generally the
cord itself and its nerves will be found intimately connected with the sac.
Mr.  Cruveilhier  believes from his  dissections  that this connection is
constant."
  This is well illustrated by the accompanying  sketch  (fig. 95) of a pre-
paration in the St. George's Hospital Museum, made by Mr. Hewett, who
kindly  obtained permission for the author to have the drawing made.  The
Fig. 95.                              Fig. 96.»
patient was five months old, and  died  under Mr. Tatum's care.  The
cavity of the tumour is seen to be intersected by the cord,  and by the
serves emanating  from it.  The cord and  its nerves passing out of the
spinal canal at the  upper part of the opening run across the cavity of the
* Represents the tumour formed in spina bifida.  From the King's College collection. 
SPINA BIFIDA.
331
tumour to its posterior wall, where they are firmly fixed, the nerves being
here flattened and spread out upon a fine membrane.   From the sac, the
anterior branches of the first four  sacral nerves return in distinct bundles,
forming large  loops, to the anterior  sacral foramina, through which  they
pass as  usual to form the sacral plexuses.  The fluid had evidently been
effused between the visceral arachnoid and pia mater; and the walls of
the sac were formed by the visceral and parietal arachnoid and by the skin,
all of which were much thickened, and firmly united to each other.
   In cases like this, in which  the cord  and  its nerves pass through the
cavity of the tumour, it is probable that the fluid was originally effused in
the subarachnoid cellular tissue, after partial adhesions had formed between
the cord with its nerves, and the two layers of arachnoid covering its  pos-
terior surface.   But in some cases  the cord and  its nerves are  found
spread out upon the  posterior wall of the sac, without passing through its
cavity;  and in these most probably the fluid was effused into the  sub-
arachnoid cellular tissue, after extensive adhesions had united the cord and
its  nerves to the two layers of arachnoid covering its posterior surface.
Whereas, if the fluid be effused into the cavity of the arachnoid before any
adhesions form between the two layers of that membrane, no nerves  will,
in Mr. Hewett's opinion, be connected with the sac.
   Terminations.—The tumour formed by a spina bifida, (see fig. 96,)  may
vary in size from that of a turkey's egg, to that of an adult head;  and its
integuments may be  thick and  covered with  a dense cuticle, or may be
thin and transparent.   In some cases the tumour bursts during the act of
birth ; in most others, after  the  patient has lived some months or years, it
becomes enormously distended, and  ulcerates, the  patient speedily dying
of the irritation: in  one case, of a  young woman, aged 27, which came
under the author's observation some  time ago, and  which has since been
under the care of Mr. Walsh, the tumour relieves itself when distended by
the exudation  of a watery fluid through a minute aperture; and in some
few cases the patient lives to the ordinary span of life, without being much
troubled with the deformity.  There is further, a  great  variety  in  the
amount of inconvenience attending  it.   Sometimes it is combined  with
congenital  hydrocephalus;   sometimes with  club-foot;   sometimes  with
more or less palsy of the legs, or incontinence of urine, (which symptoms
are easily accounted  for by  the wasted and compressed condition in which
the cord and its nerves are often found,) whilst in other cases there are
none of these inconveniences, unless the tumour is compressed or inflamed.
   Treatment.—We have been thus minute in describing the real nature
of this disease, in order to deter the surgeon from mischievous attempts at
curing what must almost inevitably be  an  incurable malady.  We read
of cases in which the tumour has been cut off, and the  edges  united by
twisted suture ; or, in which it has been included in a ligature and tightly
tied; but  these plans will not be  readily adopted by any one who would
rather not  open the  spinal membranes, or injure  the cauda equina.   The
operation of puncture, too,  is generally followed by speedily fatal results.
Therefore,  we  think the  surgeon's wisest  p^an  is,  merely  to  apply
moderate support by means of a hollow truss, or some such contrivance,
so as to  counteract that tendency  to effusion which there always is when
the natural pressure  on any part of the body is taken  away.*   If the
  • See a successful case treated by Sir A. Cooper  in this  way.  Med. Chir. Trans.
voL ii. 
332
INJURIES OF THE SPINE.
swelling increase very fast, and the surgeon is inclined to try the effect of
a puncture, he should, at  all events, strictly observe  the following rules
laid down by Mr. P. Hewett.
   1st. " The tumour should never be punctured along the mesial line.
especially in  the sacral region; for it is  generally at  this point that the
cord and its nerves are connected with the sac.   The puncture is to be
made at one side of the sac, and at its lowest part, so as to diminish the
risk of wounding any of the nervous branches.
   2d. " The instrument ought to be a needle or a small trocar; for if a
lancet is used, there will be a greater risk of wounding some important
part contained in the cavity of  the tumour."*
   After puncture very great attention should be paid to proper support
by bandages.
   VII.  Malignant Disease of the Spinal Column.   When severe and
continued pain in some part of the  spine, with more or less derangement
of the nervous functions, and perhaps some perceptible tumour, occur in
a patient afflicted with malignant disease, the probability is, that some of
the same morbid growth is deposited in or near the vertebras.f


           section ii. — injuries  of  the spine.

   I. Concussion.—Violent blows or bendings of the  spine  are liable to
produce very serious injury to the spinal cord.  Sometimes they cause an
immediate  paralysis of the parts  below  the seat  of the injury, which
gradually passes off, and thus  resembles the effects of concussion of the
brain; sometimes they are followed by inflammation,  which requires
o.ompt  antiphlogistic measures, in order to avert  permanent paraplegia
>r death.
   II. Extravasation of Blood.—A severe blow on the back sometimes
,auses an  extravasation of blood  into  the  spinal canal,  which, as it
increases,  causes compression of the cord, and paraplegia.
   III. Dislocation and Fracture.—Dislocation of the spine is rare, ex-
cept in the cervical region; but it occasionally does  occur even  in the
lumbar  and dorsal without any accompanying fracture.   When fracture
occurs, it generally passes transversely across the body and arch  of the
vertebras.   The  ill consequences of these  accidents  will of course be pro-
portioned to the  amount of injury inflicted on the  spinal cord ; and if that
escapes compression, the consequences may not be serious.  Thus it may
happen  that one or more  spinous  processes  may be broken off;  or that
the cervical vertebras may be twisted round ; and the last dorsal and first
lumbar vertebras have been displaced backwards, the  patient recovering
with permanent deformity, but nothing worse.:{:
   But it more  frequently happens in fracture  and   dislocation  of the
vertebras, that the spinal cord  is compressed or lacerated, and the parts
below the seat ef injury deprived of their nervous influence ; and in these
cases the symptoms vary, according to the level of the injury.
   If the injury affect one of the lumbar or lower dorsal vertebre, the legs
and lower part of the trunk are palsied and insensible, the penis is erect,
  • Vide  cases of spina bifida, with remarks by Prescott Hewett.  Lond. Med. Gaz„

  t Caesar Hawkins. Med. Chir. Trans., vol. xxiv.
  tGuerin, L'Exp6rience. Dec. 3, 1840; Shaw, Med. Gaz.  vol. xvii. p. 936. 
INJURIES OF THE SPINE.
333
the fa:ces are discharged involuntarily, owing to palsy of the sphincter ani;
but the urine cannot be voided voluntarily, owing to palsy of the muscular
coat of the bladder.  Immediately after the injury, the secretion of urine
Fig. 97.                       Fig. 98.
is diminished, but in a few days it becomes copious, ammoniacal, and
offensive, and the mucous coat of the bladder inflames, and secretes  a
quantity of viscid adhesive mucus.  The bowels are distended with wind,
and  obstinately costive;—in  protracted cases the evacuations  become
olack, treacly, and extremely offensive.   The temperature of the palsied
parts at first rises—in one  case so high as 1110 F.—but afterwards sinks
to the natural level, or below it.   In some few cases, in which the spinal
cord is not entirely compressed or lacerated, the  patient  may retain some
degree of sensation  or motion, or may suffer from painful spasms of the
legs; but in  general the loss of feeling and motion is complete.
   If the fracture or dislocation be high in the back, or at the lower part of
tlie neck, there will, in addition to the above  symptoms, be palsy of one or
both arms, and  great difficulty of breathing, especially of expiration, be-
cause the intercostal and abdominal muscles are palsied, and the diaphragm
has no  antagonist.
   If the injury be above the origin of the phrenic nerve (fourth or fifth cer-
vical), the diaphragm will  be palsied, and death instantaneous. The most
frequent example of  this is the dislocation of the odontoid process, which
is sometimes  caused by ulceration of its transverse ligament, sometimes
by blows on the  back of the head, or by lifting a child up by the head.
   IV. Softening is a frequent consequence of  concussion  or laceration
of the spinal  cord.   The affected part becomes pulpy  and diffluent, with-
out, however, any traces of inflammation.
   V. Acute Inflammation  of the spinal cord is a very rare consequence
of injuries, except penetrating wounds, which generally prove  speedily
fatal in consequence.  It is known by rigors, delirium, and opisthotonos,
or general convulsions, followed by palsy and coma.
   Prognosis.—If a fracture is situated high up, so as to affect the respira
tion, the patient rarely survives more than a day or two.  If it is  situated
in the lower part of the back, or loins, he may live two or three weeks, or
a month; and in some rate cases, recovery has even occurred, of course
with permanent paraplegia.  The manner in which death occurs after these 
334
INJURIES OF THE EYE.
injuries, is from general exhaustion and debility.  The appetite and diges-
tion fail; a weakening diarrhoea comes on, and then the nates slough, and
the patient  soon sinks.   The  prognosis is  very uncertain  after severe
blows; sometimes the patient has recovered the use of his limbs even after
complete paraplegia; sometimes  recovery occurs with permanent para-
plegia ; sometimes, on the other hand, the patient having appeared to re-
cover from the ill effects  of the injury, most  unexpectedly becomes para-
lytic, and dies from slow disorganization of the cord.
   Treatment.—1. If there be any displacement, an attempt may be made
to reduce it by extension.  In partial dislocations of the  neck, however,
the attempt should be very cautious indeed, since although it has succeeded
(in the case of M. Guerin for instance), it has  also been known to produce
instant death.  2. The patient must be kept at perfect rest in the horizontal
posture, and the greatest care must be taken to prevent or delay gangrene
of the nates, by arranging pillows or Macintosh's air-cushions, half filled
with water.   3.  The  urine must  be  drawn  off by the  catheter, and the
bowels be kept open by clysters  and  purgatives, to which Sir B. Brodie
recommends ammonia to be added.   Tonics  and the  muriatic  acid may
be given  to  support the strength, and obviate the derangement of the urine.
The tympanitic state of the  belly may be relieved by rubbing it with the
compound camphor liniment.   4. Bleeding or cupping may occasionally
be employed if there are inflammatory symptoms, and the pulse  is firm.
But in the majority of cases, if fracture has occurred, and the cord is in-
jured, loss  of blood is contra-indicated by the pulse, and would hasten a
fatal issue.   5.  If the patient recover with his life, any remaining weak-
ness or palsy may perhaps be attempted to be  removed by the cautious use
of blisters or issues, friction, warm-bathing, and the internal use of strych-
nine ; but they will very rarely do any good.*
                        CHAPTER XII.

           OF THE INJURIES AND DISEASES  OF THE EYE.

     SECTION I.--OF WOUNDS AND  FOREIGN BODIES.

  I. Wounds of the eyelids or eyebrow's should be most carefully adjusted
oy means of small sutures, introduced with a very fine sewing needle. A
linen rag wetted with cold water should then be laid on the part,—inflam-
mation should be counteracted,  and the  patient  be  kept at rest till the
wounds are healed.  Wounds of the forehead are sometimes  liable to be
followed by amaurosis, in consequence of injury to the frontal nerve.
  II. Blows on the eye  are generally followed by a disreputable looking
ecchymosis, which  is inconvenient enough.   But sometimes a blow on the
naked eyeball causes permanent blindness from concussion  of the retina.
Antiphlogistic measures are the only resource.

  • Vide Cooper on Dislocations, and Brodie on Injuries  of the Spinal Cord, in Med
Chir  Trans., vol. xxi. 
DISEASES  OF THE  EYELIDS.
335
  III.  Foreign Bodies.—When  a  patient complains of a foreign body
in the eye, the surgeon should first examine the inside of the lower eyelid
and lower part of the globe, telling the patient to look up.  If nothing is
discovered there, the patient should turn the eye downwards, so as  to
expose the upper part of the globe, and the surgeon should turn the upper
eyelid  inside out, which  may easily be done by  taking  the eyelashes
between the finger and thumb, and  turning them  upwards  over a probe.
If any substance stick  in  the  cornea, so that it cannot be removed by a
probe, or silver toothpick, or fine forceps, the point of a cataract needle  or
lancet should be  carefully passed under it so as to  lift it out.  If, how-
ever, the removal cannot be effected without considerable difficulty,  it is
better to  leave it  to be detached by ulceration.  Every  means must be
taken to obviate inflammation, and if the wound in  the cornea is painful
or irritable,  it should  be touched  with nitrate of  silver.   To   remove
particles  of  lime  or mortar, the eye should be well syringed or sponged
with weak vinegar and water, or with oil, or with pure water if neither  be
at hand.
  IV.  Prolapse of the Iris, in  consequence of penetrating wounds of
the cornea, may be attempted to be reduced (provided the pupillary margin
is not  prolapsed)  by  closing  the eye,  and very  gently  rubbing  the lid
against the cornea, so as to press on the prolapsed portion, and by exposing
it to a strong light, so as  to cause the pupil to contract.   But if the pupil
is prolapsed, belladonna should be applied to cause  dilatation.  If, how-
ever, the prolapsed part cannot be returned, it should be snipped off,  in
order to avoid the irritation which it would  otherwise cause;  and if the
wound does not soon  heal, it should be touched with a pencil of lunar
caustic.

         SECTION  II. — diseases  of  the  eyelids.

  I.  Hordeolum, or sty, is a  small  painful boil  at  the  edge  of the
eyelid.
   Treatment. — Poultices and early puncture, subsequently ung. hydr.
nitrat.  dilut., to remove any remaining hardness.  Aperients, tonics, and
alteratives, are always necessary.
  II. Ophthalmia Tarsi is an inflammation of the edge of the eyelids,
with disordered secretion of the Meibomian  glands—so that the  eyelids
stick together and become encrusted with inspissated mucus during sleep.
It may be acute — attended with great  pain  and soreness, and requiring
leeches—but in  general  it is chronic  and obstinate, and attended with
violent itching.   It occurs to weakly persons with  disordered digestive
organs.   It may lead to ulceration of the eyelids, loss of the lashes,  and
subsequent thickening or inversion of the edge of  the lids.
  Treatment.—In the first place, the health, wilich is always out of order,
must be remedied by aperients, alteratives, tonics, change of air, bathing,
and whatever other measures  may  be  suitable for  each particular case
Whilst there  is much heat and swelling, the  eyes should be bathed with
an anodyne  collyrium, F. 119, and  the lids be  smeared with lard at bed
time to prevent them from sticking  together.   But as soon as the bowels
have been well cleared, an  astringent  collyrium  (F.  117,  118)  may be
used during the day, and  the undiluted unguentum  hydrargyri nitratis be
applied in very small quantity to the edges of  the lids at  bed time  or 
33G
DISEASES OF  THE EYELIDS.
thiee nights  successively.   A weaker ointment of the same sort may fa
used habitually afterwards if necessary, F. 116.   The  lashes should bci
plucked out  if there is any ulceration about their roots.
   Svphilitic Ulcers of the eyelids, if primary, will be known by their
sudden appearance and rapid progress in a patient otherwise healthy, ami
by their not having been preceded by a wart  or tubercle, like malignant
ulcers.   Secondary ulcers will be known by their coppery colour and the
general cachectic look of the patient.
   Treatment.—Mercury, and the treatment of syphilis generally.
   IV. Trichiasis signifies  a growing  inwards  of the  eyelashes.—Dis-
trichiasis,  a double  row  of eyelashes, one  of which grows inwards.
The misplaced hairs  must  be perpetually plucked out, or if that do not
suffice, their bulbs must be extirpated with a fine knife ;  or each bulb may
be punctured, and destroyed by introducing a very fine probe dipped in
melted nitrate of silver.
   V. Entropion, permanent inversion of the eyelid, may (l)be caused
by contraction of the ciliary margin of the lid, after protracted ophthalmia
tarsi—the remedies for which are, either to  make two perpendicular cuts
with scissors  quite through the  lid, near each  angle—or rather to dissect
off the edge of the lid with the lashes and their bulbs.   (2)  Sometimes it
is caused by a thickening  of the conjunctiva  at the line of its reflection
from the lid to the globe, so that the orbitar margin of the  lid is pushed
outwards, and the tarsal margin consequently turned inwards.  This must
be counteracted by leeches, and astringent applications.  (3) If there is
no disease of the margin of the lid, and the patient is old, with the skin
of the cheek loose and flabby, a transverse flap of the loose skin, and of
the orbicularis beneath, should be cut out of the eyelid, and the edges of
the wound be brought together with fine  sutures, in order that the inver-
sion  may be counteracted by the contraction of the cicatrix.   Sometimes
for the same purpose a portion of the skin is destroyed by drawing trans-
verse lines on it with  a  wooden point,  dipped in the concentrated sul-
phuric acid ;  but this method is more painful and uncertain.   Care must
be taken not  to remove too  much, else this disease will be converted into
ectropion, which is still worse.
  VI. Ectropion,  or eversion  of the  eyelid,  may be  caused (1) by a
fleshy thickening of the conjunctiva, owing to long-continued inflamma-
tion    Ihe weak ung. hydr. nitric, oxyd., or lotion of arg. nit. (gr. ii. ad
 
DISEASES  OF  THE  EYELIDS.                337
31) may be tried first in order to bring the conjunctiva into a healthy state
—but if they do not succeed, a portion of the thickened conjunctiva must
be removed by scissors.   This  failing, it may be necessary to cut  out  a
triangular slip from the  tarsus.*  (2) It may be caused by a cicatrix on
the  cheek, — that resulting from a burn for instance.   In this  case the
cicatrix may be  divided ; or may be dissected out, and its place may be
supplied by a patch of skin  transplanted from the neighbouring part  of the
cheek, after the  manner described in the observations  on restoring lost
noses.
   VII. Lagophthalmos (hare eye) signifies an inability to close the pal-
 pebral.  Sometimes it arises from the contraction of cicatrices, and requires
 the same treatment as ectropion when arising from the same cause.  But
 it sometimes  depends  upon inaction  of the  orbicularis  muscle, through
 palsy of the portio  dura.  This  may  be caused by exposure to cold ; on
 the  outside  of a coach for  instance ; in which case  it  is  attended with
 numbness of the cheek, and generally subsides in a  few days with ape-
 rients, nursing,  and perhaps a  blister  behind  the ear.  But it may be
 caused by a tumour in the course of the  nerve ; by disease of the  temporal
 bone ;—or by congestion within the head, like the following disease.
   VIII.  Ptosis  signifies a falling  of  the upper eyelid from palsy of the
 third nerve.   Sometimes it  is a precursor of apoplexy, and  is  attended
 with headache,  giddiness, and  other signs of congestion in the head,
 which  should  be treated  by bleeding, purgatives,  mercury, and blisters.
 Sometimes it is an accompaniment  of that form of amaurosis which arises
 from organic cerebral disease ; and is  attended with dimness  of  sight; a
 sluggish dilated pupil;  and more or less  strabismus  : the  eye being turned
 outwards and downwards, because the  external rectus and superior oblique
 are the only muscles unparalyzed.   If  it occurs without any assignable
 cause, and persists notwithstanding the employment of every measure cal-
 culated to improve the  health, a portion  of skin must be snipped  out from
 the eyebrow, so that the lid may be brought into contact with the occipito-
 frontalis muscle, and be elevated by it.
   IX.  Ancvloblf.pharon.—Union of the edges of the  lids, when  com-
 plete and congenital, (which  is very rare,) may be removed by an incision;
 when partial, and consisting of a junction of the lids near one angle, which
 is sometimes caused by cicatrizing ulcers, it is incurable.
   X.  Svmblepharon signifies an union  of the lid to the globe, following
 some  accident that  has caused ulceration of both—the introduction of
 lime, for instance.  It is irremediable,  if the adhering  surfaces are exten-
 sive.   Very slight adhesions  (frasna)  may be  divided; but the  raw sur-
 faces are too apt to adhere again.
   XI.  Tumours, consisting of nevi or wens, when  occurring on  the eye-
 lids, are to be treated the same as  elsewhere.  Sometimes  thin cysts, or
 hydatids, containing a watery fluid, grow beneath the  loose fold of con-
 junctiva which passes from the inside  of the eyelid to the surface of the
 eyeball.  If that fold be divided longitudinally, they may be extracted by
 a hook or forceps.  A  small encysted tumour, containing a gelatinous
 fluid, sometimes grows  within the substance of the  tarsal cartilage,  about
 its centre.  It feels at first like a small  pin's head under the skin ; and on
everting the lid it may be seen to cause  a slight prominence.   It should
  ' The first of the accompanying cuts represents an  ectropion  caused by a cicatrix
and the  other shows the successful results of the operation spoken of in the text
       29                        w 
338        DISEASES OF THE LACHRYMAL  APPARATUS.

be punctured from within  when it has acquired  some little size, and when
it begins to look bluish about its centre;  and the cyst should be lacerated
with the pointed end of a probe.
  XII.  Pediculi.—These loathsome insects  sometimes  lodge about the
roots of the eyelashes, and produce an obstinate itching.   They are easily
killed by anv mercurial preparation ;  but the surgeon ought to be aware
of their existence, as they might be mistaken for crusts of dried mucus.

      SECTION III. — DISEASES  OF THE LACHRYMAL
                           APPARATUS.
  I. The Lachrymal Gland is very rarely the seat of disease.  It  is,
nevertheless, occasionally  subject to acute and chronic inflammation—the
symptoms and'treatmeht  of which will  be obvious.  It  is  also liable to
morbid growths, for which it has occasionally been extirpated.
  II.■ •X*:Rophthamia'signifies a dryness of the  eye  from  deficiency of the
tears, or rather of the mucous secretion  of the conjunctiva.  It may be
palliated by-frequently bathing the eye with tepid water  by means of  an
eye-cup.               ''.'
  III.  Epiphora signifies a redundancy or over-secretion  of tears,  so
that they run over the cheeks.   It should be distinguished from the stilli-
cidium lachrymamm, or overflow of tears in consequence of an obstruction
in the channels that convey them to the nose.  It may depend  on general
irritability of the  eye, and is not unfrequent in scrofulous children.  When
arising from this cause it  should be  treated by aperients  and  alteratives,
with tonics  and antacids  (F.  37, or quinine, with  small  doses  of soda?
Carb.)   An emetic may  be given if the stomach is foul.   The  same local
applications may be used as are prescribed for scrofulous ophthalmia.
Search should be made for foreign bodies or inverted eyelashes.
  IV.  Closure  of the  Puncta Lachrymalia  may be congenital, in
which case it is quite incurable, or it may be a consequence of inflamma-
tion of the lachrymal sac and its appendages.  Of  course it produces  a
stillicidium lachrymamm.   When a  consequence  of inflammation, the
openings must first be restored by a fine gold pin, and then one of Anel's
gold probes should be frequently passed through them into the  sac.  The
probe must be introduced, first  perpendicularly upwards  for the superior,
punctum,  and downwards for the inferior; then horizontally inwards to-
wards the nose.
  V.  Obstruction of the Nasal Duct is most probably a consequence
of thickening of the mucous membrane that lines it, and is not uncommon
in delicate young persons.  The patient complains of weakness of one
eye, which is perpetually watering; and of dryness of the corresponding
nostril.  The lachrymal sac distended with tears forms a small  tumour by
the  side of the nose, from  which tears can be squeezed upwards through
the  puncta, or downwards into the nose, if the  obstruction  be not quite
complete.*  This affection mostly leads to
  \I. Chronic  Inflammation of the Lachrymal Sac—tenderness  of
the  sac, perhaps  redness of the superjacent skin ; irritability and constant
tendency to inflammation of the conjunctiva;—and if the sac be squeezed,
glairy mucus escapes with the tears.

  *A case is related in Forbes"? Rev. xii. 641, of congenital absence of the nasal duel
»n which M. Berard succeeded  in establishing a communication with the nose. 
FISTULA  LACHRYMALIS.
330
  VII.  Acute Inflammation of the sac is known by great redness, swell-
ing, pain, and tenderness at the side of the nose, implicating the eye, and
attended with fever and headache.  If it be not soon relieved, the sac will
suppurate and burst.
  VIII.  Fistula Lachrymalis signifies an ugly fistulous aperture at  the
inner corner of the eye, communicating with the lachrymal sac.  It is the
ordinary consequence of the three preceding affections if unrelieved, and
may be said to have five stages.   First, it begins with obstruction of the
nasal duct;  the most prominent symptom of which is a perpetual watering
of the eye.   Secondly,  this is followed by inflammation;  which, thirdly,
gives rise to abscess; and this, fourthly, by its bursting causes the fistulous
aperture from which the name of the affection  is  derived;  whilst, fifthly,
in old neglected  cases,  the lachrymal or inferior turbinated  bone may be-
come carious; but  this is  not very common.   The fistulous aperture is
generally crowded with fungous granulations, and the  skin around is  red
and  thickened from the  perpetual irritation of the tears that escape from it.
   T/eatment.—Acute inflammation  of the  sac must  be treated by leeches,
purgatives, and cold lotions or poultices.   If the pain increase in severity,
and  become throbbing,  the sac should be opened in the manner to be pre-
sently described.
  Chronic  inflammation of the  sac should be treated bp an occasional
leech, and by the  strictest attention to the general health, and' especially to
the functions of the skin and  of the digestive organs.   When the sac be-
comes distended, the patient should endeavour to press its contents down
into the nose ; and  he should also frequently draw in  his breath strongly
whilst his mouth and nostrils  are closed, so as  to draw the ^ears down the
duct by the pressure of the atmosphere.   The secretions, of the eyelids
should  be  corrected with  citrine ointment (F. 116),  and a/few drops  of
some astringent collyrium (F. 117) should be put twice a day into the in-
ner angle of the eye, so that  it may be absorbed by the puncta, and car-
ried into the sac.  By these means the thickening of the duct may perhaps
be removed, or at all events the patient may go on pretty comfortably.
   Treatment by the style.—But  if the  re-
tention of the tears in the sac  causes a con-
stant irritability of the eye, or if there is a
fistulous orifice between the sac and  the
cheek, measures  should be adopted to re-
store the obstructed duct.   Supposing that
there is  a  fistulous aperture,  the fungou?
granulations, or  thickening  of   the  skin
about it, should be first  removed by nitrate
of silver and poultices.   If there  is no
aperture, the sac should be  opened by a
narrow knife ; introducing it just below the
tendo oculi, and carrying it downwards and
outwards for one-fifth  of  an  inch.  The
place of the tendo  oculi  may  easily be
found by gently drawing the eyelids out-
wards, when it is seen as a small rounded  cord, passing inwards from the
inner canthus of  the eye.   The escape of tears  and mucus shows when
the sac is opened.   Then a common probe should be  pushed through the
duct mto the nose.  In  order to make sure of getting it into  the sac, it
 
340
INFLAMMATION  OF THE  EYE.
 may as well be introduced by the side of the bistoury before that is with-
 drawn.   It should be pushed downwards,  but a little backwards and in-
 wards.  When in the right direction, its upper part lies in the situation of
 Fig. 102.  the supra-orbital notch.   It will be known  to have reached the
         nose by the  escape  of a little  blood.   When  inflammation has
 !g&     subsided, a style should be introduced, i. e. a  silver-gilt probe
 *%    about an inch or an inch and a  quarter long, solid or hollow, with
         a head like a nail, which lies on the cheek, where it passes unno-
         ticed like a black patch.   The  constant presence  of this  instru-
         ment causes the  duct to dilate,  so that the tears  flow by its side.
         It should be occasionally cleaned,  and then be replaced;  and it
         causes so much comfort, and the duct is so likely to close if it be
         left off, that it generally is worn for life.   The above is the  plan
         of treatment which the author has generally seen  adopted ; and
         the results have been on the whole satisfactory;  but it follows of
         necessity that in so common  a complaint many other plans of
 treatment  are  followed  by different surgeons.  Short  pieces  of  catgut
 bougie, or silver tubes, are sometimes employed instead of the style.  Some-
 times attempts are made to restore the nasal duct to its proper calibre, b\
 introducing instruments from below ; either a common silver probe, with
 its  blunt end bent at a right angle, or else a steel probe made for the pur-
 pose ;  whichever is employed, should be passed along the inferior meatui
 of  the nostril till its point is under the   anterior  extremity of the inferioi
 turbinated bone, and  then by a little manipulation it will pass into th?
 duct.

 SECT.  IV.--OF  INFLAMMATIO'N  OF THE  EYE  GENERALLY,
        AND OF  THE DISEASES OF THE CONJUNCTIVA.

   I. Common acute Ophthalmia consists of inflammation of the conjunc-
 tiva.   Symptoms.—Smarting, heat,  stiffness, and dryness of the eye, with
 a feeling as if dust had got into it; the conjunctiva  of a bright scarlet red-
 ness ; the redness superficial, so that the enlarged  vessels can be moved
 by  pulling the eyelids; slight intolerance of light and flow of tears on ex-
 posure of the eye, and more or less headache and fever.   Causes.—Slight
 local irritation, disorder of the digestive  organs, or cold and damp.
   Catarrhal Ophthalmia is a variety of  this inflammation, caused by cold
 and damp, and attended with a thin mucous  discharge, which in severe
 cases becomes thick, purulent, and doubtless contagious.
   Treatment.—A dose of calomel followed by black draught,  preceded
 by  an emetic if the stomach is very foul; the eye to be frequently bathed
 with poppy decoction, or F. 119, or the weaker forms of F. 118, lukewarm
 or cold, according to the patient's choice ;  the edges of the eyelids to be
 smeared  at night with fresh lard, and with weak ung. hydr. nit. ox. after
 the first day or two ; a green shade to be worn over both eyes, whilst there
 is much intolerance of light; but the patient  not to be confined to the house
too long, unless the case is very severe, or the weather  bad.   In the ca-
tarrhal  variety, a large drop of solution of arg. nit. (gr. ij.—iv. ad 3i.) ma)
be put  into the eye twice or thrice a day.   If there is much pain, leeches
may be applied to the  temples;  and if the  patient is  plethoric, and then:
is much headache and  fever, bleeding and calomel in repeated doses will
be required.  But it is a great mistake to treat common  inflammation of 
INFLAMMATION OF THE CONJUNCTIVA.           341
the eye, when it occurs to delicate subjects, by lowering measures.  After
the bowels are cleared, a good  diet, and exposure to moderate light and
cool air, and an astringent lotion, will do more good than black draughts,
leeches, and green shades.
   II.  Inflammation  of the whole Eye is  a rare  disease.  It may be
caused by severe injuries, or  may be a consequence of the common oph-
thalmia, if neglected.   The symptoms are, great redness  and swelling of
the conjunctiva;  pain, both burning, aching, and throbbing; intolerance of
light,  dimness of vision, and  severe headache and fever.  It may lead to
suppuration of the whole globe; or  to opacity of the cornea and lens, ad-
hesions of the iris, insensibility of  the  retina,  and  atrophy  of  the whole
globe.  The treatment must be decidedly antiphlogistic ; and if it be clear
that suppuration  within the eyeball has occurred—there being rigors—the
cornea yellow and distended, and excruciating pain unrelieved  by further
depletion, a free incision should be  made into the cornea to let the  matter
escape.
   III. Chronic  inflammation of the  Conjunctiva may be a sequel of
the acute; or may be caused by some local irritation,  such as inverted
eyelashes ; or by some derangement of the health.
   Treatment.—(1.) All local sources of irritation should be removed.  (2.)
The general health  should be amended, in the  same manner as directed
for chronic inflammation generally.    (Vide p.  59.)   (3.) The  distended
capillaries  must  be unloaded by occasional leechings, and be  excited to
contract by stimulants and astringents, such  as the various collyria in F.
117 and 118, which should be  used with an  eye-cup; or the vinum opii,
of which a few drops may be put into the eye daily.   The  edges of the
eyelids should be  smeared  every  night with weak ung. hydr. nit.; and
blisters should be applied behind the ears, if the case is obstinate.
   IV. Purulent Ophthalmia, or purulent conjunctivitis, is the most vio-
lent form of inflammation of  the conjunctiva, and is attended with a thick
purulent  discharge, which supervenes in from twenty-four to forty-eight
hours after the  commencement of the disease.   There are  three varieties
of it:—(1) the purulent ophthalmia  of children ; (2) the common purulent
ophthalmia of adults ;  and (3) the gonorrhceal ophthalmia.
   The Purulent Ophthalmia of  Children, or ophthalmia neonatorum,
always begins to  appear a  few days after birth; generally, on the third
day.
   Symptoms.—At first the edges of the lids appear red, and glued together;
their  internal surface is red and villous, and the eye is kept closed.   Then
the conjunctiva of the globe  becomes intensely scarlet and much swelled,
often  so much so as to cause eversion of the lids; it  secretes a thick pu-
rulent discharge, and the child is very restless and feverish.   If neglected,
this disease may occasion opacity or ulceration, or  perhaps sloughing of
the cornea; but  it generally yields to early and proper treatment.
   Causes.—The contact of gonorrhceal  or leucorrhceal secretions from the
vagina during birth;  neglect in washing the natural cheesy secretion of the
skin away from the eyes; together with exposure to cold, and damp, and
bad nursing.
   Treatment.—The eye should be  very frequently but gently washed out
with  a weak astringent collyrium (F. 117); and a large drop of a solution
of two grains of nitrate of silver to  an ounce of distilled water should be
put  between the lids once a day with  a camel's hair pencil.   When 'he
        29* 
342
PURULENT  OPHTHALMIA.
discharge is  on the wane, the  lids may be smeared at night with weak
citrine ointment.  The eye should be opened with very great delicacy ;
because if the cornea is beginning to  suppurate, it might easily be buiM.
and the lens be squeezed out.   Moreover, it is better to wash out the eye
by everting  the lids and  using a bit  of sponge, than by injecting with a
syringe, which  would create a risk of splashing some of the discharge  into
the operator's eyes.  The bowels should  be cleared with a grain of calo-
mel or gray powder, followed by a little castor oil or rhubarb ; and if the
disease has been  neglected, and there is  great tumefaction, a leech may
be applied to the upper eyelid, and half a grain of calomel be  given every
eight  hours.   If the insides of the lids become thickened, they must be
scarified, and touched afterwards with  sulphate  of copper; and a  few
threads of cotton, spread with blistering plaster, may be laid  between the
external  ear and  the head, so  as to  create a discharge.  If the cornea
ulcerate or slough, or if the discharge be obstinate, tonics are required
(quin. sulph. gr. fs.—vel ext. cinchon.  gr. iii. ex lacte), and the astringent
collyria should  be persevered in.
  V.  Purulent  Ophthalmia  in Adults (Contagious or Egyptian Oph-
thalmia).  Symptoms. — This  disease begins with  stiffness, itching,  and
watering of the eye, with a sense of dust in it, and slight swelling of the
lids, which stick together during sleep ; and on examination of their inter-
nal surface, the palpebral conjunctiva is found to be intensely red, thick,
and villous, like a foetal stomach injected.   As  the  disease advances, the
conjunctiva covering the  globe becomes also intensely red, swollen, and
villous, and discharges a copious secretion of  pus.  The  swelling of the
ocular conjunctiva is called chemosis.   It is  produced by a secretion of
blood, lymph, and  serum into  the cellular tissue which connects the con-
junctiva to  the  sclerotic;  and it elevates the conjunctiva into a kind of
roll around the margin of the cornea, which sometimes overlaps it entirely.
These symptoms are accompanied with severe burning pain, extending to
the cheek and temple,  and great headache and fever; the palpebras also
are swollen, tense, and shining, so that the patient cannot open the eye.
   Consequences.—This affection  may  lead to ulceration, or opacity, or
perhaps sloughing of the cornea ; or to adhesion of the iris ; or to impair-
ment  of vision, from extension  of inflammation to the internal parts of the
globe.
   Causes.—It  may be produced  by severe local irritation, as the intro-
duction of lime, for instance.  It is  endemic in Egypt, owing to  the
glaring sunshine and  the  particles of sand with which the air is loaded.
It may also  be produced  by  the close  damp atmosphere loaded with
animal vapour that results from crowding many persons together in a con-
fined  space, and from the neglect of cleanliness and ventilation; hence
its prevalence amongst the  military in barracks; in schools ;  and on board
ship ;  especially amongst the wretched inmates of slave-ships.   But when
once produced  by any cause whatever, it is most probably both contagious
and infectious ; that is, capable of being propagated both  by contact with
the purulent secretion, and by exposure to its vapour, if many persons
affected with the disease are crowded  together.
  VI.  Gonorrhceal Ophthalmia is  the  most violent  form of purulent
conjunctivitis.  The symptoms are essentially the same as those of the  last
species;  but the chemosis is  greater, the discharge thicker and more 
GONORRHCEAL  OPHTHALMIA.
343
 abundant, the constitutional disturbance  more  severe,  and the  cornea
 much more apt to slough.
   Cause.—This  disease arises without doubt from the application of gon-
 orrheal matter from the urethra to the eye.
   Prognosis.—This is very unfavourable.  The sight of the affected eye
 will either be lost, or excessively  impaired, unless treatment be very  early
 and efficacious.
   Consequences.—The most frequent  and detrimental is  sloughing of the
 cornea, which is  said to be caused by the constriction of its vessels by the
 chemosis.   The  sloughing generally occurs quite suddenly; the cornea
 may be clear in the morning—cloudy and flaccid in the evening—and by
 the next morning it may have burst;—and this change may supervene at
 any time from the second  day of  the  disease till  the last.  After this has
 occurred, the swelling of the lids subsides, the discharge diminishes and
 becomes thinner, and the pain greatly abates.  If the slough is very small,
 the iris may  protrude, and close  the aperture, imperfect sight remaining,
 —but generally the greater part of the cornea perishes, and all useful  sight
 is lost.
   Treatment.—There are  three sets of measures which may be adopted in
 this very hazardous disease;  viz., antiphlogistic  remedies, scarifications,
 and stimulants.
   Experience has shown that it is  not possible to  check this disease
 entirely by antiphlogistic measures, such as bleeding, purgatives, calomel
 and antimony, &c.;—and that although these ought to be used in propor-
 tion to the violence of the fever with which the local disease is attended,
 yet they cannot be trusted to  entirely.
   If  the patient applies, at  the very commencement, the use of  a nitrate
 of silver lotion twice  a day, and fomentations of poppy, with one  grain of
 alum  to the ounce,  together  with low diet, antimony, and confinement to
 bed, it may suffice to check the disease.
   But if the disease has reached its height, and there is great fever and
 headache,  with full  bounding pulse, it will  be right to  bleed freely, to
 purge, and  to administer calomel  and  antimony in regular doses,  with
 Dover's powder, at bed-time, to  allay pain.   The patient must be kept in
 bed  in a darkened room, with the head  elevated, and on low diet.   But
 if these  measures, combined with the local applications  to  be mentioned
 presently, do not arrest the disease, and the chemosis is evidently extend-
 ing round the cornea, and the cornea  is becoming hazy, six or eight  inci
 sions  should  be made completely  through the swollen conjunctiva, begin
 ning at the margin of the cornea,  and  radiating towards the  circumference
 of the eye.*  The incisions  should be  fomented with warm water, that
 they may bleed.   If  there comes on,  as frequently happens, an exacerba-
 tion  of pain  towards evening, it may be prevented by applying a few
 leeches in the afternoon, or by putting blisters behind the ears.

  * Tliis practice was revived  by  Mr. Tyrrell;  (Vide Med. Chir. Trans., vol. xxi. part
 II.. and Tyrrell on the Eye, vol. i. p. 73.)  It is  mentioned by Astruc in the following
 terms:  '■ It was thought proper some time ago to try the same remedy in the eye  tend-
 int: to a mortification, as is made use of in other parts of  the body when they are
 threatened with the  same disease;  viz.. to scarify the swelled conjunctiva thick and deep,
 so that the globe of the eye, and especially the cornea, might be less compressed by if
 fortlnu sudden  destruction of the eye seemed to be chiefly owing to its being  too tisditly
embraced by the swelled cenjunenva."  Astruc  on the Venereal  Disease,  translated.
from the Latin, Lond. 1754. 
344
SCROFULOUS  OPHTHALMIA.
  The eye  should  be frequently but gently washed  out, oy means of n
piece of fine sponge, or syringe, with warm water or poppy decoction,
containing a grain of alum to an ounce, in order to get rid oi the purulent
secretion; and  once or twice daily, a few drops of a freshly-made clear
solution of two grains of nitrate of silver in an  ounce of  distilled water
should be dropped into the eye by means of a camel's hair pencil.  As
soon  as  the chemosis begins to lessen, the proportion  of alum  in  the
poppy-water may t)e increased ;  or F. 118, or the weaker preparations of
F. 117, may be used instead.  The diet also should be improved, and
the edges of the lids should be smeared at night with  weak ung. hyd.
nit. ox.   If the  strength becomes  impaired, and the cornea has  given
way,  tonics (especially  F.  1)  or sarsaparilla  should be  administered,
which, with repeated blisters, and a continuance  of the astringent applica-
tions, are the measures for removing the reliques of  the disease.
  We must add,  that a great variety of stimulating applications have been
recommended at  various times  for the cure of this disease, such  as  liq.
plumbi acet. undiluted,  and the ol. terebinth.  Mr. Guthrie, in particular,
recommended an  ointment of arg. nit. gr. x. liq.  plumbi n;  xv. adipis 3i.,
the nitrate to be very finely powdered,  and the lard well washed.   A
 {)iece of  ointment the size  of a pea, or a large drop of the  solution on a
 lair pencil,  to be  thoroughly diffused between the lids and globe twice a
day at least.  The ointment should turn the  membrane white.
  VII.   Scrofulous  Ophthalmia  (phlyctenular ophthalmia)  generally
attacks children under eight years of age.
  Symptoms. — Extreme intolerance of light;   the  lids  spasmodically
closed ; the  head  turned  obstinately away from the light; no general vas-
cularity of the  conjunctiva,  but  one  or  two enlarged  vessels running
towards the  cornea, and terminating at one or more  phlyctenule, or small
opake  pimples  (or  sometimes pustules) on the cornea.  This, like other
scrofulous diseases,  is extremely obstinate, and liable to recur perpetually.
Its most frequent  consequences are ulceration of  the cornea at the seat of
the  phlyctenule,  and  opacity from  the  effusion of  lymph between  its
layers.
  Treatment.—The first and chief point is to look after the general health.
The alimentary canal, therefore, should be cleared by  an emetic and dose
of calomel and jalap, and, after feverishness has subsided,  recourse must
be had to steel, sarsaparilla, and alkalis, and  to the various combinations
of tonics, aperients, and antacids, and  to  the  other general remedies
directed for scrofula.  Quinine is particularly recommended by Mackenzie.
Secondly, the distressing  intolerance of light  must be relieved.   This is
sometimes effected  by cold lotions applied to the outside of the eye, and
to the forehead  and  temples ; such as poppy decoction with a little spirit;
or water to which  a little vinegar or spirit, or nitric asther, has been  added ;
or the white of egg curdled with alum.   But  warm poultices,  or dec.
papav. vel anthemid., or exposing  the  eye to the vapour of warm water,
or to the vapour of laudanum or sp. camph., which  may be  put into a
teacup and be held  in warm water;  or warm lotions of ext. belladon. vel
hyoscyami (di. ad 3j.  aquas), or those extracts smeared on  the brow, are
of more  efficacy.   Small doses of extract of conium  are also  of service.
Moreover, both eyes  should be protected by a  shade.  Thirdly,  if the
insides of the lids are turgid, they may be scarified ; any  enlarged vessels
running from the conjunctiva to the cornea  may  also  be scarified across; 
DISEASES  OF THE  CORNEA.
345
 and blisters or the tartar emetic ointment may be applied behind the ears,
 or to the nape of the neck.  Lastly, in the advanced stage of the disease,
 benefit will be derived from dropping in a few drops of vin. oph or lotion
 of nitrate of silver (gr. i. ad rSi.) once a day.
    VIII.  Granular Conjunctiva signifies a thick, rough, fleshy, state of
 that membrane (especially of that part of it  which lines the eyelids), and
 is a frequent consequence of severe and long-continued ophthalmia.   It
 does not depend, as its name would seem to  imply, ori*the formation of
 granulations, but on an hypertrophy of the villous surface of the mucous
 membrane.  It causes great pain and disturbance to the motions of the
 eye, and, if it  continues, will render the cornea opake by its friction.
    Treatment. — In the first place, the thickened part should  be scarified ;
 then, after one or two days, it should be touched  with  lunar  caustic or
 sulphate of copper, and the scarification and caustic should be repeated
 alternately at intervals of two or three days.   The dilute citrine ointment
 should be smeared at night  on the edges of the lids, blisters should be
 applied  behind the ears, and the general health be  attended  to.  But if
 these measures prove fruitless, the thinnest possible layer of the granular
 surface must be shaved off with a fine knife or scissors.
   IX. Pterygium is a peculiar alteration of  the conjunctiva, a triangular
 portion of which, with the apex towards the cornea, becomes thickened
 and elevated, sometimes transparent, sometimes red and fleshy.  It may
 spread over the cornea and obstruct vision ;  but it  does not give much in-
 convenience besides, and is not essentially an  inflammatory affection, al-
 though it sometimes follows protracted ophthalmia.
    Treatment.—If it  does not disappear under the. use of vin. opii  or
 caustic lotion,  it must be  completely scarified across; and if that fail, it
 must be seized with a hook and be extirpated with curved scissors.

     section v. — of  the  diseases  of  the cornea.

   I. Acute Inflammation of the Cornea, or acute corneitis, is generally
 a  consequence  of neglected injury.  The part becomes red and opake, the
 sclerotic around highly vascular; and ulceration of the  cornea, or suppu-
 ration  between its layers, or abscess of the anterior  chamber,  may ensue.
 Local  and general bleeding, mercury and antimony, or turpentine in the
 dose of one drachm three times a day, in an  emulsion with carbonate of'
 soda and mucilage, F. 133, and fomentations, are  the remedies.  Stimu-
 lating applications are prejudicial.
   II. Scrofulous Corneitis most frequently occurs  between the ao-es of
 eight and eighteen.
   Symptoms.—The cornea opake, rough, and red, and unusually promi-
 nent; the surrounding sclerotic also red;  pain and intolerance of light are
 generally trivial;  tjfiexe is considerable tendency to inflammation of the iris
 and retina; the pulse  is frequent, and the  skindry.
   Treatment.—For the acute, leeches, emetics, purgatives, calomel, and
 antimony, fomentations, and belladonna smeared  on the eyebrow.   For
 the chronic, quinine should be perseveringly administered ; blisters should
 be repeatedly applied to the nape of the neck, and behind the ears, and
the health should  be treated after the manner  directed for scrofula.  The
vin. opii, and ung. hydr. nit. ox. to the eyelids, are almost the onlv local
applications admissible. 
346
DISEASES  OF  THE CORNEA.
  III.  Opacity of the cornea may be divided  into two kinds.   1st. The
opacity which results from the Adhesive Inflammation, and effusion of
fibrine between its layers, or between it and  the  conjunctiva, which is a
very common consequence of inflammation of the cornea, and of scrofu-
lous ulcers during their healing stage ;—and, 2dly, the opacity, or leucoma,
which  is produced by a loss of substance  and its resulting cicatrix,—that
which  follows a pustule of the small-pox for example.  The. former kind
is in most cases curable : the latter not so.
  When an opacity of the former kind is slight and  diffused,  it is called
nebula; when  denser and of a  firmer aspect, albugo.   Sometimes the
lymph forming an albugo becomes vascular, and one or more vessels run
to it from the circumference of the eye, and the cornea becomes red and
fleshy:  this state of things is called pannus.
  Treatment.—(1) All sorts of irritation about the eye or lids (inverted
hairs, granular conjunctiva, &c.) must be  removed, and any existing de-
gree of inflammation be counteracted by proper measures.   Then (2) ab-
sorption of the lymph may be promoted by counter-irritants, such  as blis-
ters and the tartar emetic ointment; by alteratives and measures calculated
to improve the health ; and by the application  of stimulants to the eye.
The ordinary applications are, caustic lotion (gr. ii.—x. ad 3j.), or hydr.
bichlor. gr. i.—ii. ad aq. 3j.; vin. opii; ung. hydr. nit. ox.; or a  powder
composed of hydr. nit.  ox. 3j. sacchari 3j. very finely powdered,  a little
of it to blown  into  the  eye.   Whichever is selected  should be  applied
regularly, and should not excite long-continued pain or active inflamma-
tion.   Any enlarged vessels running from the circumference  of die eye to
the  opacity should be divided.  Gooch used to cure opacity of the  cornea,
even of long standing,  and,  in fact, other forms of chronic  inflammation
of the eye, by the administration of corrosive sublimate, in  doses that
would now be  considered hazardous.  He gave gr. \ twice a day; and in
a few days' time increased the dose to gr. -|, and then to gr.  i.  It caused
feverishness, purging, slight sweating, and headache.
  IV.  Leucoma signifies an  opake cicatrix of the cornea.  If recent, it
may be partially removed  by the measures just indicated for the  cure  of
the  opacity arising from adhesive inflammation.   If of long standing, it is
irremediable.   Should both eyes be affected with leucoma, and should the
opacity be exactly in front of the pupil, it will be  right to make an artifi-
cial opening in the iris opposite some part of the cornea that is transparent.
  V. Onyx signifies a suppuration between the layers of  the cornea, and
is  an  occasional result of acute  ophthalmia, especially of  the catarrho-
rheumatic.  It derives its name from its resemblance in shape to the white
spot at the root of the finger-nail.   It mostly disappears with proper anti-
phlogistic treatment.  If it extend very fast, it may be necessary to punc
ture the external layers  of the cornea, to  relieve the great  pain,  but the
sight will be lost
  VI. Ulcers of the cornea are most frequently the results  of the phlyc-
tenule of scrofulous ophthalmia, but  they may arise  from mechanical in-
jury, or from  any form of conjunctival inflammation.  When a conse-
quence of the scrofulous phlyctenule, they are  generally deep, and tend
to perforate the cornea, and  leave an opake cicatrix;  when  arising from
other  causes, they are  often  superficial, and  heal with a semitransparent
cicatrix, which gradually becomes clear.                           •
  These ulcers may, as Mr. Tyrrell observes, exist in three states.  " First, 
                     DISEASES  OF THE  CORNEA.                 347

that which we may^erm healthy, when the surface and circumference ex-
hibit a degree of haziness or opacity of a whitish or gray aspect, which is
owing to the effusion of adhesive matter on  the  surface, and  in the sur-
rounding texture, which is essential to the healing of the  part."  In  this
state, the case merely requires to be watched, to prevent injurious increase
of action.
   Secondly, an ulcer may be inflamed, when its hazy circumference will
be observed to be highly vascular.  Leeches and counter-irritation, with
soothing applications, are the remedies.                   ^
   Thirdly, an ulcer may be indolent; clear, and transparent, looking as
if a little bit  had been  cut  out of the cornea; without any vascularity or
effusion of lymph.  This state requires stimulating applications, (arg. nit.
gr. i.  ad aq. 3i.)
   Again,  ulcers  may form  on a surface that is
already rendered opake and nebulous by scrofu-
lous inflammation.   However, in any case, coun-
ter-irritation ; and measures to improve the health,
together with weak  caustic lotion or vin. opii  used
twice a day,  are  the chief  remedies.   The pupil
should be dilated with belladonna, if the ulcer is
near the centre of the cornea.
   When an ulcer is very irritable, keeping up constant pain and intolerance
of light, in spite of soothing applications, the best plan is to touch its sur-
face with a finely pointed pencil of nitrate of silver, so as to  produce an in-
sensible film  on the surface ; this is to be repeated at intervals of three or
four days.
  VII.  Staphyloma is  a term employed to  signify any protrusion on the
anterior surface of the eye.    There are  several varieties of it.   1. Staphy-
loma  iridis signifies a protrusion  of the iris, which occurs when the cornea
is perforated by  ulcers  or wounds.   The protruded part should be punc-
tured, or be  snipped off if  large, and  be subsequently touched with arg.
nit.   The term myocephalon is applied to  the protrusion  of a very  small
piece of the iris through an  ulcerated opening in  the cornea.

               Fig. I04.f                         Pig. 101
  2.  Staphyloma of the cornea is said to exist when a portion or the whoie
of the cornea  is prominent, opake and white, the iris adhering to it—a
  • This figure exhibits the healing stage of an ulcer of the cornea.  It is copied by
Mr. W. Bagg from a drawing for which the author has to thank Mr. Partridge.
  | These two drawings (figs. 104, 105) represent partial and complete staphyloma.
 
348
DISEASES  OF THE  SCLEROTIC.
consequence of severe inflammation.  If partial, the'hitrate of silver 01
butter of antimony may be applied to the apex of the staphyloma, so that
the inflammation excited may thicken the cornea, and enable it to resist
further protrusion.   The caustic should be well washed off with milk be-
fore the lids are closed.   Ii general, the staphyloma should be shaved off,
for, as it is not covered by the eyelids, it is a source of constant irritation
and pain.
   VIII.  Hernia Corner. When the cornea is nearly or quite perforated
by an ulcer, a thin transparent vesicle is apt to protrude from the aperture,
consisting either of the  membrane  of  the aqueous humour or of a thin
lamella of the cornea;  or else of an imperfectly organized cicatrix pro-
truded by the aqueous humour.   It may be snipped off if large, and the
place be touched with caustic ; but it is apt to be reproduced very rapidly.
   IX. Conical Cornea.  In this curious affection, the cornea seems to
become weak in  its structure, so as to bulge out under an increased secre-
tion of aqueous humour.  It gradually becomes thin and exceeding con-
vex, but remains transparent, and it often gives a peculiarly brilliant ap-
pearance to the eye.   As it increases, it causes almost total deprivation of
vision;  which, however, can be partially remedied  by looking  through a
minute aperture in a  piece of blackened wood.   It  is incurable, although
it's progress may  be retarded by tonics, counter-irritants, and mild stimu-
lating applications.   Vide Artificial Pupil, p. 352.
   Caution.—If the  acetate of lead is used as  a collyrium when there is
any abrasion of the conjunctiva or cornea, a white  precipitate is formed,
which is liable to become fixed in the cicatrix as a dense white spot.  The
film may, however, sometimes be removed by a needle.   The  nitrate of
silver, if applied  too long, is apt to turn the conjunctiva to a deep olive
hue.

       section vi. — diseases of the sclerotic.

   I. Acute Inflammation of the Sclerotic is commonly called Rheu-
matic Ophthalmia ;  because the structure affected is similar to that which
is attacked by rheumatism; but it is not certain that  the kind of inflamma-
tion present is always the genuine rheumatic.
   Symp oms.—It is  known by redness of the sclerotic,—no great intole-
rance of light,—severe stinging pain of the eye, and aching of the bones
around,  which  is greatly aggravated at night,—and  fever.   It may be
caused by cold, and  sometimes, like other rheumatic inflammations, is a
sequel of gonorrhoea; but it is a rare disease.   It may lead to opacity of
the cornea, or to iritis.
   Diagnosis.—This  form of ophthalmia may be distinguished from in-
flammation of the conjunctiva, 1st, by the character  of the pain; which is
a severe aching, principally felt in the eyebrow, temple, and  cheek; and
is greatly aggravated every evening; being excessively severe during the
night,  but  remitting towards morning.  Whereas  in  conjunctivitis, the
pain is of a scalding nature, and accompanied with  a sensation as if sand
was in the eye.   2dly, By the character  of the redness; which is deep-
seated, and of a pale pink;  and by the vessels running in  straight lines
from the circumference of the eye towards the cornea; whereas in conjunc-
tivitis the redness is scarlet and superficial and more vivid ; the vessels are
rorv.uous, and freely anastomose, and can be moved  about with the finder. 
DISEASES  OF THE  IRIS.
349
   Treatment.—In~severe cases, it will be necessary to  bleed  and purge,
and administer colchicum, F. 122 ;  or perhaps calomel and opium till the
gums begin to suffer.   The other measures are, friction of the  forehead
every afternoon, with extract of belladonna dissolved in warm laudanum
(3J ad oj), or with mercurial ointment and opium; — warm pediluvia, or
warm bath,—blisters behind the  ears,—and Dover's powder at bed-time
Subsequently tonics will be useful, especially F. 134, or a combination of
dried carbonate of soda and powdered bark, five grains of each of which
may be given every four hours.  Dry warmth, by means of muslin bags,
filled  with chamomile  flowers and  heated on a  hot  plate,  is the most
soothing local application.
   II.  Catarrho-rheumatic Ophthalmia is a combination of inflamma-
tion of the sclerotic with that of the conjunctiva.   The symptoms of con-
junctivitis, that is to say, roughness and sense  of dust in the eye,—muco-
purulent discharge and superficial scarlet redness,—are  combined with the
deeper-seated,  straight-lined redness, and with  the zone around the cornea,
and fits of nocturnal aching, that characterize inflammation of the  scle-
rotic.   This disease is very apt to lead to onyx, and to ulceration of the
cornea, and suppuration in the anterior chamber.
   Treatment.—Nitrate of silver,  astringent collyria, scarifications, weak
citrine ointment, and the other topical applications for conjunctival inflam-
mation, must be used in addition to bleeding, calomel and opium, and the
other remedies  prescribed for simple inflammation of the sclerotic.

    SECTION VII.--INFLAMMATION OF  THE  ANTERIOR
              CHAMBER, OR  AQUO-CAPS U L I T I S .

   This affection is generally the consequence of some other form of oph
thalmia, but it  may occur by itself.
   Symptoms.—The iris dull, the  cornea mottled, the eye very tense  and
painful, and fever. The most peculiar consequence of this disease, whether
primary or consecutive  of some  other inflammation of the eye, is hypo-
pyon ; i. e. an effusion of an albuminous (or perhaps purulent) fluid  into
the anterior chamber.   It is distinguished  from onyx  by the white fluid
moving in different positions of the  head, and by its upper margin being
straight, not convex.
   Treatment.—Calomel  and opium, and belladonna, and  the genera]
treatment of iritis, will remove the inflammation, and cause  absorption of
the hypopyon.

    SECTION VIII.--OF  THE  DISEASES  OF  THE  IRIS.

   I. Inflammation of the Iris, or Iritis.   The  iris being muscular in
its structure, and  covered with a serous membrane, is  exceedingly liable
to inflammation of an adhesive character, which frequently involves  also
the sclerotic, the anterior capsule of the lens, and the deeper structures in
the eyeball.
   Symptoms.—In the first stage, the  fibrous  texture of the iris appears
confused, and it loses its colour; if dark, it becomes reddish; if blue, it
becomes greenish.   The pupil, also, is contracted and irregular.   In the
next stage, lymph begins to be effused ; sometimes in the form of a  thin
layer, causing the surface to appear rusty and villous,—sometimes in smaL
       30 
350
DISEASES OF  THE IRIS.
nodules;—sometimes the pupil is filled with a film of it,—sometimes it iS
poured out in such abundance as to fill the whole  cavity of the aqueous
humour.  The eye displays that kind  of redness which arises from vascu-
larity of the sclerotic ; that is to say, a pink redness, with vessels  running
in straight lines from the  circumference of the eye, and  terminating in a
vascular zone around the cornea; but in very acute cases the conjunctiva
becomes injected likewise.   The patient complains of intolerance of light
and dimness of vision, and of more or less burning, stinging pain in  die
eye;  but  besides this,  there is also a severe  aching of the brow and parts
around the opbit, coming on  in nocturnal paroxysms, as in the rheumatic
ophthalmia, and depending probably on an affection of the orbitar perios-
teum and surrounding fascia1.
   Causes.—Iritis  may be caused by injuries, or  by over-exertion of the
eye;  but  it more frequently  depends  on  constitutional taint, syphilis, or
Sout-
   Prognosis.—Favourable, if the disease is recent and confined to the iris,
although the  impairment of vision may be  considerable;—but doubtful, if
it be  of long duration (i. e.  more  than a  fortnight);—if there  be much
deep-seated pain, and  especially if there be great effusion of lymph behind
the iris.
   Varieties.—Iritis may vary in the degree  of acute  inflammation which
attends it; being  active  and  rapid, attended with bright redness, great
pain and fever if it occurs in a robust plethoric subject;  but in other cases,
slow and  insidious.  It is also divided into  several species,  according to
the nature of the cause  producing it.  Thus, 1.  The traumatic iritis is
that which arises from  penetrating wounds of the e\e.   2. The rheumatic
iritis arises from cold ;  although, like the rheumatic sclerotitis, it does not
necessarily occur in persons who have suffered from rheumatism previously.
3. Syphilitic iritis.—This is  the most  frequent variety.  It is said to  be
distinguished by the pupil being displaced upwards and inwards, and by
the effusion of lymph in little nodules  of a reddish or dirty brown colour,
which cause the pupil to become angular.   There  is  great pain at night,
and but little by day, and secondary venereal affections of the throat and
skin are usually present  at the  time.   4.  The arthritic, or gouty iritis, is
                                an asthenic form, generally occurring to
                                elderly dyspeptics and sots.  It is said
                                to be distinguished by the atonic dusky
                                hue  of  the  redness,  and  the  varicose
                                state of the blood-vessels;  and  there is
                                also sometimes a  narrow white  ring or
                                interval  of sclerotica between the red
                                vascular  zone  and  the  cornea;  but
                                Mackenzie  says  that  the same  is seen
                                also  in the other varieties of iritis if oc-
                                curring to  old people.  There is great
                                pain  around the  eye ; and the patient
will generally be found to have laboured under irregular gout, and various
forms of asthenic dyspepsia.    5. Scrofulous iritis.—This  is  generally an
extension of  disease from the external tunics in neglected cases  of stru-

  • From a drawing in the possession of Mr. Partridge.  It represents the nodules of
lymph effused in syphilitic iritis.
 
DISEASES  OF THE  IRIS.
351
 mous ophthalmia; but iritis sometimes, although rarely, occurs  in  young
 scrofulous subjects as a primary affection.
   Treatment. — The  indications are,  1, to subdue inflammation; 2, to
 arrest  the effusion of lymph,  and cause  absorption of what  is already
 effused ;  3, to preserve the pupil entire ; 4, to allay pain.
   1. If the  patient be strong, and the disease acute, with much pain and
 fever,  bleeding should  be performed, and be repeated  according  to the
 pulse.   In  chronic cases, cupping  from the temple will  be preferable.
 The bowels must be  well  cleared,  the antiphlogistic regimen  generally
 be observed, and blisters be  applied  after the most  acute  stage  has
 subsided.
   2.  To fulfil  the second indication, the  principal remedy is  mercury;
 given in such a manner as to affect the mouth speedily; — such as gr. i—
 iii of calomel with gr. \—^ of opium at intervals of from  four to eight
 hours.   And when the mouth becomes sore, the lymph will generally be
 found to break up and gradually disappear, leaving the pupil clear.   If it
 is judged inexpedient to  administer mercury because the patient's consti-
 tution  has been broken down by repeated  salivations, the next remedy to
 be tried  is turpentine, in a dose  of a  drachm thrice daily, F. 133.   When
 given in these small doses, it enters the circulation, and often acts severely
 on the  kidneys, without opening the  bowels; but it may also  be  given
 sometimes in a larger dose, F. 19, during the exhibition of mercury, so as
 to purge copiously.
   3. The pupil should be kept well  dilated by means of extract of bella-
 donna,  a thick  solution of which should  be painted on the eyelids during
 the acute stage;  and  a filtered solution of one scruple in an ounce of dis-
 tilled water may be dropped into the  eye  afterwards.   But the  most  ele-
 gant means of  obtaining the effect of belladonna is to drop into  the eye a
 solution of the sulphate of atrophine,  (gr.  i ad Si aquas distill.)   Stramo-
 nium or hyoscyamus may be substituted, if preferred.
   4.  The pain must be relieved by nightly doses of opium, and the  appli-
 cation of poppy fomentation to the eye.
   In gouty iritis, calomel  is only to  be used in order to  evacuate  the
 bowels and amend the secretions, and  it is  highly injurious if given  to the
 extent of affecting the  system.   But colchicum  in doses of TT[ xx.  of the
 wine (F.  121),  or turpentine (F. 133), must be used instead.   Bleeding,
 local and general, must be employed  as the strength permits, and  pedi-
 luvia containing mustard should be used every night.
   II. Synechia Posterior, adhesion  of the uvea to the capsule of the
 lens; Synechia  Anterior, adhesion  of  the  iris to  the  cornea;  and
 Atrksia Iridis, or closure of the pupil,—three consequences of organiza-
 tion of lymph from protracted iritis,—may be partially removed by mer-
 cury if recent, but are irremedial, except by operation, if of long standing.
 But belladonna  should always be applied; because if a very  small portion
 of the  pupil  is  by chance unadherent, it may be dilated so  as to afford a
 very useful degree of  vision.
  III.  Myosis—a preternaturaily contracted pupil — is sometimes mel
 with in persons accustomed to  look at minute  objects,  and is  attended
 with great obscurity of vision, especially in a feeble light, because the ins
is unable to dilate.  To give repose to the eyes,  and attend to the health,
are the only available indications of treatment; Mackenzie says that  bella
donna is hurtful. 
352
DISEASES  OF  THE IRJS
  IV.  Mydbiasis signifies  a preternatural dilation of the pupil,  whit I
does not contract on exposure to light.  This state, as is well known,  is
readily produced by belladonna and many other narcotico-acrid poisons;
it is caused also by any injury of the brain affecting the tubercula quadri-
gemina, as in apoplexy  and  congestion of  the brain; and is an attendant
of confirmed amaurosis.   But sometimes it depends simply on a derange-
ment of the nerves supplying the iris, without any diminution of the sen-
sibility of the retina; and this form of it may also be attended with ptosis;
as a further evidence  of paralysis of the  third nerve.   If the retina  is
sound, which will be known by the perception of light, and by  vision
being improved by looking through a small round  aperture in a piece of
blackened  card, the best remedy is the application  of lunar caustic to the
margin  of the  cornea;  this was proposed by M.  Serres, and  has been
found useful in England  by Mr. Ure.*  Electric sparks and other  stimu-
lants have also been used with benefit; and one case is recorded f  which
was cured by ergot of rye, in scruple doses four times a day.
  V.  Tumours or Cysts  growing upon the iris must be removed if they
become large, so as to interfere with vision, or to inflame  the eye by their
pressure.   A section of the  cornea  must  be  made as for extraction of
cataract, and the diseased part of the iris, having  been  drawn out, must
be snipped off.
  VI. Artificial Pupil.—There are certain cases in which it becomes
expedient to alter the  shape and position of  the pupil, or to form  a new
pupillary aperture in the iris.
  1st.  In cases of conical cornea, or of permanent opacity of  the  centre
of the cornea, it is advisable  to bring the pupil opposite  to a transparent
part of it;  and  Mr. Tyrrell observes, that if the position and extent of the
opacity do not forbid, the pupil should always  be brought  downwards and
outwards.  This is done in the following way: a broad needle is carefully
passed  through  the cornea,  close  to its junction with the  sclerotic.
Through the puncture thus made, Tyrrell's hook, a fine blunt hook  with a
long bend, is passed into the  anterior chamber, with the  bent  limb for-
wards.  As soon as it has  reached the pupillary margin, the hook is turned
backwards so as to catch  it:  and then the  hook  is withdrawn through the
corneal puncture, bringing out the iris with it, and of course rendering the
pupil oblong.   The piece of  the iris that protrudes should be snipped off
with a fine pair of scissors.
  2dly. In cases where the pupil has been  nearly or altogether lost in
consequence of prolapse of the iris through wounds or ulcers, or slough
of the cornea;  or where vision is obscured by opacity of the cornea, with
adhesion of the  iris to it;  or by partial staphyloma of the cornea, with
adhesion of the iris ;—a new pupillary aperture may be made ;  or the old
pupil (if not quite abolished)  may be extended opposite to  that part of the
cornea which remains transparent, by the same  operation  which we have
just described.   But if the  old pupil is quite lost,  it will be necessary to
make a little puncture  of the iris with  the needle which  is employed to
puncture the cornea; — into which puncture of the iris the hook is to be
inserted.  Supposing, moreover, that after either of these operations the
new pupil  degenerates  into  a  mere  slit, this slit  must  be enlarged, by
another operation of the same kind—that is, by making another puncture
                  • Vide Lond. Med. Gaz., 19th May, 1843
                  t  L'Experience, Sept. 1839. 
CATARACT.
353
 of the cornea at a little distance above the first, and dragging up the upper
 margin of the slit with the hook.
   3dly. In cases where the pupil has closed after the removal of a cata-
 ract, whether in consequence of prolapse of the iris, or of inflammation
 and organization of lymph, an artificial pupil may be made  by making an
 opening at the margin of the cornea, about a quarter of an inch in extent.
 Through this, a small  pair of scissors (Maunoir's) is introduced, and a V
 shaped cut is  made in the iris.   Or in  cases where part of the cornea is
 opake, a new pupil may be made  with  the needle and  hook as above
 described.*
   But before resorting to any of these  operations, it must be ascertained,
 1st, whether the  adhesions of the iris cannot be removed by mercury or
 belladonna, or opacity of the cornea by  external applications; 2dly, that
 the  retina is perfectly sound;  3dly, that  all tendency to  inflammation
 (syphilitic or otherwise)  has ceased.  It is not advisable to operate if one
 eye  beguile sound ; and supposing one  eye to be irrecoverably lost, it is
 not advisable to form an artificial pupil in the other, provided the patient
 find his way about with it.   Moreover,  the  new pupil should be made
 large, because  it  will always contract somewhat afterwards.

 SECTION  IX.--INFLAMMATION OF  THE CAPSULE  OF  THE
                       CRYSTALLINE LENS.

  This is a very  rare affection, and  always chronic.  Vision is  confused,
 — objects looking as if they were seen through a fine gauze.   On exam-
 ining the eye with a strong lens in a good light, and the pupil  being well
 dilated with belladonna, a number of minute red vessels are seen in  the
 pupil.  If the anterior  capsule  be  affected, the vessels form a circular
 wreath of vascular arches with the centre clear;  if it be the posterior cap-
 sule, they are  central  and arborescent.  The iris is always slightly dis-
 coloured and sluggish.
   Treatment.—Local  or  general bleeding; mercury,  counter-irritation,
 change of air,  and alteratives.

                  SECTION X.--OF  CATARACT.

  Definition.—An opacity of the crystalline lens or its capsule.
  Svmptoms.—Before examining any patient with suspected cataract,  the
 pupil should be  dilated with belladonna, and then,  if there be  cataract,
 there will be seen an opake body of a gray, bluish-white, or amber-colour,
 behind the pupil.   The  patient usually gives as his history, that his vision
 has become gradually impaired;  that objects appear as if surrounded with
 a mist, or as if a  cloud was interposed  between  them and the eye ;  and
 that  the sight is better in the evening, or when the back is turned to the
 window;  or after the application of belladonna, — obviously because  the
 pupil, being dilated under those circumstances, permits more light to pass
 through that part of the lens which is yet transparent.   In the most con-
 firmed cases, the  patient is able to distinguish day from night.
  * This operation, when performed by means of an incision in the iris, is t-ehnically
 •tailed coretomia ; when performed l>y the excision of a little piece, it is called corectomia ,
and  when effected by detaching the iris from the ciliary ligament, it is called coredia-
lysis.   (Kiori, pupilla.)  The last operation is too violent.
       30*                        x 
354
CATARACT.
   There is also the catoptric test, — that is, the mode of examining the
eye by the reflection of light, which was proposed by M. Sanson.  When
a lighted  taper is moved before the eye of a  healthy person, three images
of it may be observed.  1st. An  erect image, that moves upwards when
the candle is moved upwards, and that is produced by reflection from the
.surface of the cornea.   2dly. Another erect image, produced by reflection
from the anterior surface of the crystalline lens, which also moves upwards
when  the  candle is  moved upwards; and,  3dly. A very small inverted
image, that is reflected from the  posterior surface of  the crystalline lens,
and that moves  downwards when the candle is raised upwards.  Now, in
cataract, this inverted  image is from the first rendered  indistinct, and soon
abolished; and  the deep erect one is soon afterwards abolished also.
   Diagnosis will be spoken of under Amaurosis and Glaucoma.
   Causes.—Cataract (especially of the capsule) is sometimes attributable
to inflammation, and may be caused in a  short space of time by wounds
or other injuries of the lens.   But the ordinary cataract of the  oldr seems
to be a mere effect of impaired nutrition.
   Varieties.— 1. Hard cataract.   This is the form that is generally me
with in elderly people.   The lens is shrunk and hard, amber-yellow in the
centre, grey towards the circumference.   There is  an  appreciable interval
between the lens and iris.  2.  Radiated cataract.  In this form, the opa-
city commences in  streaks at the circumference,  which, as the disease
advances, slowly converge towards the centre.  In this variety there is of
course some little  diversity from the  ordinary symptoms.  For instance,
the patient sees  best in a bright light, when the pupil is  contracted ; and,
moreover, he is  apt to see objects double, or distorted, in consequence of
irregular reflections of light from the opake streaks.  3. Soft cataract,—
the lens of the consistence of soft cheese or cream, and of a grey or bluish,
or pure white colour without any amber  tint.   This variety is generally
met with in congenital cases, and, in fact, in. all persons under forty; it
causes a greater degree of blindness than the  hard variety;  moreover, the
lens, being swelled, projects against the iris, and interferes with  its  mo-
tions.  4.  Capsular cataract.   Opacity of the capsule is said to occur in
spots  or streaks, with less  opake intervals.  It is not unfrequently the re-
sult of a slow inflammation, which may be  accompanied with pain in the
eye, and signs of congestion in the head; it may be produced also by in-
flammation extending from the iris or conjunctiva.   Opacity of the anterior
portion may be  seen immediately  behind  the iris, and  has  a glistening,
chalky, or pearly white appearance.  That of the posterior appears at some
little distance behind  the pupil, and presents  a concave  striated surface,
of a dull yellowish appearance.   5.  Capsulo-lenticular cataract is very
common,—in fact, opacity of the capsule is always followed by opacity of
the lens.
  Treatment.—The cataract must be removed by operation.  No other
Jeatment  is  of  any avail to get rid of the disease, although perhaps its
progress  may be retarded by counter-irritation, and stimulating applica-
tions to increase the flow of tears,  and sternutatories, and measures calcu-
lated  to lower vascular  action.  It is, however, a general  rule  not  to
operate till the cataract is mature,—that is, not whilst the degree of vision
is sufficient for ordinary purposes;  more particularly if the patient  is very
old and feeble, or if one eye is already lost;—because under these circum-
stances a failure  of the operation would entail utter blindness    Therefore 
CATARACT.
355
the patient should assist his vision by dropping into  the  eye one or two
drops of a carefully filtered solution of extract of belladonna (di. ad 3i.) in
distilled water, night and morning, so as to dilate, the  pupil, and defer the
operation till, despite of that aid, his blindness is complete.
   Prognosis.—This will be favourable if the patient is in good health, of
a spare frame  and temperate  habits;  if the iris  moves freely, and if  the
retina  seems perfectly sensible  to light.   On  the other hand, it will be
doubtful if there are signs of vascular disturbance in the eye or head—if
the iris is motionless or altered in colour, or if it is adherent to the capsule;
—or if the  cataract is complicated with amaurosis, synchysis, or glaucoma.
   Preparation.—Before operating, the patient should be put into as perfect
a state of health as possible.   The bowels should be cleared, the secretions
be regulated, and bleeding and  low diet be enjoined if the habit is inflam-
matory.  Moreover,  the  operation should always  be  performed  in  mild
weather.
   There are three methods of operating;—1, extraction, 2, depression,
(or couching,) and, 3, the operation for causing absorption.
   1. Extraction.—The object of this operation is, to make an incision
through rather more  than one  half of the circumference of  the cornea,
almost close to the sclerotic ;  to lacerate the  capsule of the lens ;  and then
to extract the cataract  entire,  through  the pupil.   Its  advantage is, that it
effectually removes the cataract;—its  disadvantage, that in the event of a
failure sight is almost irretrievably lost.   It is best adapted for hard cata-
racts in elderly people.  But  it  should not be attempted, 1st, if the patient
is very old and feeble, in  case the wound of the cornea might not unite.
2dly. If the anterior chamber is very small and the  cornea very flat, so
that  a sufficiently large opening cannot be  made in it.  3dly. If the  iris
adheres much to the  cornea, or if the cataract is large and pushes it for-
wards, or if the pupil is habitually contracted.  4thly.  If the eye is sunken,
or if the fissure of the lids is preternaturally small.   5thly. If the  eyes are
very unsteady, or if the patient is subject to habitual  cough or asthma, or
is unmanageable in consequence of infancy or idiocy.   Some practitioners
direct that  one eye only should  be operated on  at a time, the other being
kept as a reserve, whilst others  are not afraid to  operate on both together.
   Preliminaries.—The patient should be seated  in a low chair with a high
back, opposite a window that admits a good clear light, but no sunshine*,  ■.,
and the eye to be operated  upon should be  turned somewhat  obliquely-to:^
the window, so that the operator may not see the  image of it on the cornea.'
The surgeon should sit immediately before the patient on a higher chair j
and should have a stool, so as  to raise one knee  to  a proper height  for
steadying the elbow of the operating hand upon it.  Behind the patient an
assistant should stand, whose  duties are, 1st,  to steady  the head against the
back of the chair, or against his oWn breast.   2dly. To elevate the upper
eyelid, and fix  it against  the margin of  the  orbit, with one forefinger.
3dly.  To drop it at a preconcerted signal from the surgeon.
   Operation.—The surgeon,  1st, depresses the lowrer  eyelid, and steadies
the globe with the fore and  middle fingers of one hand, but without exert-
ing any pressure on  it.  He  particularly endeavours  to prevent it  from
rolling inwards during the operation.  2dly, holding the  cornea-lcnife*
  •The knife called  Beer's is most used.  It has a  triangular blade,—*the point sharp
—the back straight and blunt, the edge slanting obliquely, and the blade increasing in
breadth and thickness as it approaches the handle.  The advantages of this shape  are, 
356
CATARACT.
 like a pen, (in the right hand for the left eye, and vice versa,) and resting
 the  other fingers  on the patient's cheek, he touches  the  cornea once or
 twice with the flat part of the blade, in order to take off the patient's alarm.
 3dly. He punctures  the cornea close to  its outer margin, pushing the  point
 of the blade  perpendicularly towards  the  iris, and not obliquely; other-
 wise it would  pass  between the laminae of the cornea instead of entering
 the anterior chamber.   4thly. He  must push it steadily across parallel to
 the  iris, till  it cuts  its way out, making a semicircular flap of the  lower
 half of the cornea; immediately upon which the eyelid should be dropped.
 5thly. Waiting a few seconds,  the surgeon takes a curette, — introduces
 the pointed end with the convexity upwards, and freely lacerates the cap-
 sule with it; — and then withdraws it with  the  convexity  downwards.
 Gthly. He makes very gentle pressure on the under part of  the globe, and
 on  the upper  eyelid, till the lens rises  through  the  pupil and  escapes.
 Lastly, the eye should be opened after a minute or two, to see that the
 flap  of the cornea is  rightly adjusted, and that the iris is not prolapsed:—
 if it is, the eyes should  be  exposed to  a bright light, so  as to make the
 pupil contract, and the  prolapsed portion should  be gently pressed upon
 with the spoon of the curette.   Then the operation is finished.
  It follows, as a matter of necessity, that  there  must be  many varieties
 in the manner of performing an operation comprising so many minute and
 delicate manoeuvres  as the one under consideration.  Thus, if the surgeon
 be  ambidexter, he may sit  before  his  patient, when  operating  on either
 eye; but, if he can use  his right hand only, he must sit behind his patient
 when operating on  the right eye.   Many  surgeons make a flap of the *
 upper half of the cornea,  as represented in Fig. 107, instead of the lower
                             half.   " The  advantages  of this opera-
                             tion," says  Mr. Lawrence, " are, that the
                              operator has a more complete control over
                             the  globe;  he can fix it very  perfectly;
                              that the aqueous humour does not escape
                              so readily, and consequently that  the sec-
                             tion of  the cornea  is  more readily accom-
                             plished  ; that there is  less chance of pro-
                             lapsus iridis ; and that the upper lid keeps
                             the  flap  of the cornea in exact apposition."
                             Some operators,  again, dispense entirely
 with an  assistant, and fix the globe with the left hand.  Mr. Guthrie also
 objects to making the puncture of the cornea with the knife perpendicular
 to the eye.  Some operators use belladonna  to dilate the pupil; others
 are  averse to it.
  Complications. — (1.) Sometimes,  in  consequence  of the premature
 escape of the  aqueous humour, the iris falls  forwards under the edge of
 the  knife.  The best way of inducing  it to retract, is  to press on the cor-
 nea with the forefinger over the protruding part of the  iris.   If this fails,
ihe  knife must be  withdrawn,   and the  operation  be  completed  with
 Guthrie's double knife, which has  a sharp  blade  sliding on a blunt one;
the sharp blade being pushed out when the knife  has  reached  the  inner
side  of the cornea.   But sometimes the  point of the knife is so completely
 that it fills up the  incision which it  makes, and prevents  the  escape of the aqueous
humour; and that the flap of the cornea is  made by one simple motion; that  is, by
pushing the knife inwards.
 
CATARACT.
357
  entangled in the iris, that it is necessary to withdraw the instrument, heal
  the wound, and repeat the operation afterwards.   If, however, a little bit
  of it should get under the edge of the  knife, when  the section is  nearly
  complete, the  operator may push on boldly, since if a little  piece of it be
  cut, it will be of no great consequence.   (2.) If the opening of the cornea
  is not large enough, it  must be enlarged with a  small knife.   (3.)  If a
  portion of the  lens remain behind, it should be left to be absorbed—unless
  it has passed  into the anterior  chamber, and can be removed very easily
  indeed.  (4.)  If the vitreous humour seem disposed to escape, the cataract
  should be hooked out with the curette.   But the escape of a little is of no
  consequence.
    After Treatment.—The patient should be put to bed, with the shoul-
  ders raised, the room darkened, and with a very soft dry linen rag over
  both  eyes.  No  food should be  allowed which requires mastication, the
  bowels should be kept  open, and everything be avoided which  is likely
  to provoke coughing, sneezing,  or  vomiting.  If he goes on comfortably,
  the eyelid may be raised on the  fifth day, and then if there  be no prolapse
  of the iris, and the cornea be united, he may get up occasionally, wearing
  a shade, sitting in a darkened room, and walking about a  little.   After a
  fortnight, the eye  may  be opened in  a weak light, and  be  gradually
  brought into  use.  But  inasmuch as it remains weak and irritable, the
  patient must  take the greatest  care to avoid exposure to cold, excess in
  diet, over exertion of the. eye, or exposure of it to too strong  a light.   Grey
  spectacles are the best protectors against wind, or too glaring a light.  The
  patient will require convex spectacles  for exact vision, but they must be
  used very sparingly at first.  He should have two pairs, one with a short
  focus for near objects, and another of long focus for distant objects.
    The inflammation which may come  on after the operation may be of
  two kinds.   If the eyelids are  swollen, and florid, and tender, and there
  is a thick yellow  secretion about  the lids, and  the conjunctiva  is  red,
  swollen, and  chemosed, the  inflammation  is acute, and  requires to be
  treated by bleeding  and purging.  But if, as Mr/Tyrrell shows, the pal-
  pebras are not much  discoloured, and are rather cedematous than  tinged
  with blood;—and if the secretion is light-coloured, and the conjunctiva
  oedematous, the patient will be benefited by good  broth, carbonate of am-
  monia, and opium.
    II.  Depression, or  Couching.—The object  of this  operation is to
  remove the  cataract from the axis  of vision.  It is a clumsy and violent
  operation, and adapted only to those cases of hard cataract, of which the
% extraction would be  unadvisable,  for reasons  mentioned in a preceding
  page (355).  The disadvantages  of it are, that the pressure of the lens
  on the ciliary processes and retina is liable to be  followed by  protracted
  inflammation or amaurosis ; and that the lens may rise  again  to its old
  place, and  obstruct vision as before.   The preparation of the patient,
  his position  during the operation, as well as that of the surgeon, and the
  duties of the assistant, are the same as required for the operation of extrac-
  tion.   The pupil should  be dilated with belladonna.   There are four ways
  of operating.
    Operations.—(1.)  A couching-needle is passed  through  the  outer side
  of the sclerotic, about two lines behind the margin of the  cornea,  and a.
  little below the transverse  diameter of the eye, so as to  avoid the long
  ciliary artery.   It is carried upwards and forwards behind the iris, and in 
358
CATARACT.
front of the cataract, and then is steadily and gently pressed upon it till it
has carried it downwards and backwards out of sight. It should be held for
a few moments to fix it, then should be lifted up, and if the lens rise also,
it must be a°-ain depressed for a short time.  Then the needle is withdrawn.
  (2.) According to Scarpa's plan, a curved needle is used instead of a
straight one.    It is to be introduced with its convexity forwards, and the
lens is  to be  depressed in  the manner just described—but before with-
drawing the  needle,  its point is  to be turned  forwards, and made  to
lacerate the capsule freely.
  (3.) King's  Operation.—A curved needle  is passed  perpendicularly
through the sclerotic, as low down as possible;  and if the patient's eye
is directed upwards and inwards,  it can be made to enter almost perpen-
dicularly below the centre of the  cornea,  and one-eighth of an inch from
its margin.  It should then be passed onwards with a slight rotatory mo-
tion to the pupil, having its  convexity forwards, i. e. towards the back of
the iris.   When it reaches the pupil, these rotations are to be  increased,
so that the  point  may  cut  the anterior capsule  into small pieces.  The
needle is then  slowly withdrawn, and the lens  follows it,  so  that it is left
at the bottom of the eye close to the puncture made by the needle.  If the
lens should not immediately follow the needle downwards, the  latter is to
be stuck into it again.*
   (4.) The  method of reclination, which  consists of turning the lens
backwards from an upright to an horizontal position, is not much  in
vogue,  although some surgeons  recline  the cataract before  they  de-
press it.
  III. The Operation for producing Absorption is very easily per-
formed, and excites very little inflammation.   Its disadvantages  are, that
it requires to  be repeated several  times, and that  the  cure is  very slow,
occupying several weeks or  months.  It is well adapted for soft cataracts,
especially the congenital, but very seldom if ever answers with the hard
cataracts of old people.
   Operations.—(1.) The needle may be introduced behind the iris in the
same manner as for depression.   Then the  anterior layer of the  capsule
is to be freely divided,  and'  the needle, having been passed once or twice
through the  substance  of the lens, is  to  be withdrawn.  Care must be
taken not to  dislocate the lens in  this first operation.   The  cataract will
be  more  or  less dissolved  by the  aqueous humour, and be  absorbed.
After the lapse of a few weeks, the operation  may be repeated, the capsule
may be lacerated more extensively, and the lens be  cut up into  fragments,
which, if perfectly soft, may be pushed through the pupil into the anterior t
chamber, where absorption is more brisk.  This operation may be repeated
again and again if necessary.  But if a hard fragment be pushed into the
anterior chamber, it may probably excite great inflammation, and require
to  be  removed by operation; so that  the surgeon  had better avoid
attempting to do too much at once.
   (2.)  Some  recommend the needle to be  introduced through the cornea;
an operation  styled keratonyxis.   The pupil must be well dilated.  Then
the needle is passed through the cornea about an eighth  of an inch from
its margin, and is made to lacerate the capsule to the extent of the pupil.
It should be  of such a shape as  to prevent  the escape  of  the aqueous
1-umou."  This method is liable to induce iritis, and does not enable the
                • Lond. Med. Gaz., vol. xiii. pp. 701 and 1009. 
GLAUCOMA.
359
 surgeon to act upon the body of the  lens.  It should therefore be merely
 employed as a first operation, to divide the capsule.
   (3,) There is a third  modification of this operation, which Mr. Tyrrell
 terms the  operation by drilling.  It  is particularly adapted for cases of
 capsular or capsulo-lenticular cataract wThich have been caused by exten-
 sion of inflammation from the iris.  It is performed by introducing a fine
 straight needle through the cornea near its margin, and passing it through
 the pupil to the lens.  It is then to be made to enter the substance of the
 lens to the depth of about  one-sixteenth of an inch, and to be freely ro-
 tated.  This operation may be repeated at intervals of three, four, or five
 weeks; and if the  puncture be  made in a fresh place at each operation,
 that portion of the capsule which is behind the pupil will become loosened
 and detached, and the lens absorbed.  This operation may also be occa-
 sionally resorted to in order to diminish the size of the lens, previously to
 depression or extraction.
   Operations on Infants.—Congenital cataracts should be operated on
 early—within four months if possible, lest the  eye, which when born blind
 habitually oscillates  from  side  to  side, may never acquire  the power of
 being  directed  to one particular  object.  The pupil being well dilated, the
 child should be placed on a table—the head on a pillow, and rather hang-
 ing over it—one assistant holding the legs and trunk, a second the  arms
 and chest, a third fixing the head between his two hands, and a fourth, de-
 pressing the lower eyelid with one hand,  and steadying the  chin with the
 other.   The operator then, seated  behind the patient, performs the opera-
 tion for absorption as before described;  at the  same time  elevates the
 upper lid, and fixes the globe with an  elevator.   Care must be  taken
 not to dislocate the lens, and not to wound the posterior capsule or vitre-
 ous humour.  This operation on children, and in  fact on persons under
 twenty, generally excites so  little inflammation,  that both  eyes  may be
 operated  on  at once; but the  bowels must  be  kept open, and leeches
 should be applied if there be pain.
   Capsular Cataract.—When congenital cataract is left to itself, the lens
 becomes absorbed, and the  capsule remains tough  and opake.   And  it
 sometimes happens that an opake capsule  is left, or that it becomes opake
 after one of the operations for cataract.   There are three plans of treat-
 ment.   (1.) A  needle with cutting edges  maybe  introduced, as for de-
 pression ;  and then may be made to cut crucially through the  opake cap-
 sule, which then may shrink and leave the pupil clear.  (2.)  The upper
 part of the capsule, for four-fifths of its circumference, may be detached
 by the needle from the ciliary processes, and then be pushed down below
 the pupil.  (3.) If no other plan  succeed in removing a detached piece of
 capsule, an opening may be made in the cornea, through which it may be
 extracted  by means  of  a small  hook or  forceps.   Mr. Middlemore has
 proposed a plan for removing such bodies  through the sclerotic*

                SECTION  XI.--OF GLAUCOMA.

  Glaucoma signifies a state of  impaired vision,  accompanied with  a
greenish discoloration of the pupil.   It was formerly supposed to be de-
pendent on a turbidity of the vitreous  humour; dissection, however, has
shown  that this  opinion is not correct;  but that the  organization of all the
                       * Med. Gaz., April 7, 1838. 
360
DISEASE  OF  THE CHOROID.
 central portions of the eye is impaired.  The lens is found still transparent,
 or nearly so, but yellowish or reddish  in  colour;—the  vitreous humour
 yellowish, but nearly pellucid and quite  fluid, owing to an  atrophy of the
 hyaloid membrane ;—the choroid membrane of a light brown colour, from
 a deficiency of the black pigment;—and no remains of the central spot
 in the  retina.   The greenish discoloration which appears  deep in the eye,
 is owing partly to the deficiency of black pigment, partly to the change of
 colour in the lens which reflects the light of a greenish colour, and absorbs
 the other rays.
   Symptoms and Diagnosis.—The  patient complains of gradually increas-
ing dimness of sight, attended with more or less  rheumatic  pain over the
 eyebrow, and visions of black spots, and flashes of  light.   The pupil  is
 dilated, and moves sluggishly ; the eye feels hard ;  and its  blood-vessels
 often appear dilated  and varicose.  The patient is generally from forty to
 sixty years of age, and the disease appears to partake of  the nature of
 senile  degeneration.  It may be distinguished from cataract, by the green-
ish colour, and indistinct nature of the opacity; which resembles, as Mr.
Tyrrell observes, the reflection of the sun's rays from a muddy pool; and
by its being seen deep in the eye;  whereas  in  cataract, a definite whitish
opake  body is  seen  immediately behind the pupil.  The  opacity disap-
 pears,  moreover, in glaucoma when looked  at sideways, which is not the
case in cataract.  Vision is assisted by a strong  light in glaucoma; but
the reverse in cataract.   If the eye be examined by means of the reflec-
tion of a lighted candle, as was shown in the section on  cataract, the in-
verted image, which is soon obliterated in cataract, is distinctly perceptible
in the  earlier stages of glaucoma; although not in the latter stages; yet
it continues to be formed by the circumference of the lens  after it is im-
perceptible  at  the centre.*  The  deep  erect  image, however, continues
more distinct even than in the healthy eye ;  whereas it is absent in cataract.
   Treatment.—It is  of no use  to adopt any other treatment for the  ordi-
nary chronic glaucomatous degeneration  of  age, beyond  abstinence  from
exertion  of the  eye ;  and from anything likely to disorder the health.  But
if the affection  begin suddenly with acute symptoms  of a  gouty character,
as it does sometimes, they must be combated  by cupping, counter-irrita-
tion, and the other remedies proposed  for the arthritic iritis.

SECTION  XII.--OF THE DISEASES  OF THE CHOROID;  AND
          OF  SYNCHYSIS  AND  H Y D R O P H T H A L M I A .

  I. Inflammation  of the Choroid, or Choroiditis, is not a  common
disease, and is apt to be overlooked in  its early stages; Dr. Mackenzie has
generally met with it in strumous females.
  Symptoms.—It commences with more or less  intolerance of light, and
 dimness  of vision, together with pain in  the eye, eyebrow,  and  forehead,
and lachrymation.   The conjunctiva is not uniformly red,  but one or more
enlarged vessels are  seen  to proceed from the back of the eye, and to ter-
minate in a vascular zone partially  surrounding the cornea.   The pupil is
often displaced, and  brought towards the affected side of the choroid.   If
it proceed,  the sclerotic becomes thin  and blue,  showing the choroid
  * When the candle is  held in the axis of the eye, the inverted image is obscure, both
in incipient cataract and in incipient glaucoma : but when it  is moved to one side, it
becomes distinct in glaucoma, but remains obscure in cataract. 
RETINITIS.
361
through it—a watery fluid is effused  between the  choroid  and  retina
causing the thinned part of the sclerotic to bulge out (staphyloma sclerotice,)
and finally the cornea may become opake, the eye protrude from the socket,
and the whole globe suppurate.   The digestive organs are generally much
deranged  from the first, and hectic and emaciation come on when the eye
becomes much distended and painful.
   Treatment.—I.  Repeated  and profuse local bleeding, by  cupping on
the temples, and afterwards by many leeches to the  eye;—purgatives of
calomel and black draught, followed by daily doses  of blue  pill (gr. v.)
and aloes  (gr.  iv.), the tartar emetic ointment to the nape of the neck, and
the vapour bath to excite the secretion of the skin,  are the remedies for
the first stage.  Ptyalism is  not considered useful.   Afterwards tonics,
such as the oxyde of iron and quinine,  but especially the liq. arsenicalis,
in doses of TTJ, iv. ter die, are of service.   When the sclerotic becomes
much distended, it should be punctured with a needle—the instrument
being introduced for one-eighth of an inch towards the centre of the eye,
so as not to wound the lens.
   II. Weakness  of Sight ;  Muscle Volitantes.   Persons of delicate
constitutions and sedentary habits,  especially if they are in the habit of
writing much, or otherwise exerting their eyes on minute objects, are liable
to suffer from dimness of sight; uneasiness on exposure to a strong light;
and the vision of floating black specks or streaks, which from  their re-
semblance to flies, have  acquired the name of musce volitantes.   These
symptoms evidently depend on weakness  of organization, either original
or produced by over exertion; and the  principal measures to be adopted
are tonics, aperients, shower-bathing; and care  never to use  the eyes too
long at a time.  Weakness of sight, with  intolerance of light,  is very com-
monly an  accompaniment of short sight;  it may always be recognized by
an uneasy bashful look about  the patient's eyes, the lids of which are half-
closed, and perpetually winking, and the  brow7 contracted.    The muscas
volitantes  are  supposed to depend  on  a  distension of the vessels  of the
choroid ;—if there is  a permanent black  spot,  it  probably  depends on a
permanent varicosity of some  branch.
   III.  Synchysis is an unnatural fluidity of the vitreous humour, which
may or may not be also  discoloured.  The eye feels  soft and flaccid, the
iris is peculiarly tremulous, shaking backwards and forwards like a rag in
a bottle of water, the retina becomes insensible,  and the lens opake. This
affection  is  sometimes the result of wounds, and sometimes comes  on
without obvious cause.   It is  supposed to depend on  a slow inflammation.
It is irremediable.
   IV.  Dropsy of  the vitreous  humour,  or Hydrophthalmia, probably
depends on a slow inflammation  of the inner tissues of the eye.  It causes
enlargement of the globe, with loss of sight and constant excruciating pain,
only to be relieved by puncturing the sclerotic with a needle.

               SECTION XIII.--OF  RETINITIS.

   The Retina must of necessity be more or less  involved in  any inflam-
matory process which  affects  the  deeper  structures of the  eve-ball; but
sometimes it appears to be the  original  seat of inflammation, of which
authors describe three forms; the acute, subacute, and  chronic.  1.  In the
acute form the symptoms  are—severe, deep-seated and throbbino- pain in 
362
AMAUROSIS.
the eye, extending to the temples and  head ; vision rapidly impaired, or
even  altogether lost;  frequent sensations of flashes of  light, with great
fever  and delirium.   The pupil gradually closes—the  iris loses  its  bril-
liancy, and the sclerotic is highly vascular and rose-red.  If unrelieved,
the whole globe may suppurate.   2. Subacute.—Dimness of sight, head-
ache or giddiness, flushed countenance and fever, the pupil soon becoming
motionless, and the iris  turbid.  3. Chronic.—Gradually increasing dim-
ness of sight—visions of black spots or flashes of light—irritability of the
eye, and intolerance of light—tenderness of the eyeball, and of the parts
around;—but the  patient, though he may shade the eye,  does  not always
shut it.   These affections are  distinguished by the circumstance that dim-
ness of sight  and  intolerance of light occur before redness, or any external
sign of inflammation.   Causes.—Exposure to vivid light, flashes of light-
ning,  strong fires, the reflection of the  sun from  snow, and the like—or
habitual exertion of the eye on minute  objects, together with neglect of
exercise,  confinement of the  bowels, and over-indulgence in  food  and
spirituous liquors.
   Prognosis.—If, in the acute or subacute form, vision  is not much im-
paired, nor the iris altered, nor the pupil much contracted, the prognosis
may be favourable.
   Treatment.—General and local  bleeding, purgatives, mercury adminis-
tered  so as to affect the mouth — belladonna, and the antiphlogistic treat-
ment  generally, according  to the  urgency  of  the symptoms  and  the
strength of the patient.

                SECTIONXIV.— OF  AMAUROSIS.

   Definition. — Imperfection of  vision, depending on some change in
the retina, optic nerve, or brain.
   Symptoms.—1. Of course the first and most prominent symptom is im-
pairment of vision; the mode and degree of which are, however, subject
to very great  variety.   Sometimes the sight becomes suddenly dim, and
is soon extinguished altogether; more frequently it becomes impaired by
slow degrees; and at first is only so at intervals; after the eyes have been
fatigued, for  instance, or when the spirits are low, or the  stomach  dis-
ordered.   Sometimes it commences as indistinct vision, or amblyopia,—
or as diplopia, objects appearing double, — or as hemiopia, one half only
of the objects looked at being seen; — or objects may appear crooked,
disfigured, or discoloured;—or they may be seen covered with patches;—
or the affection  may commence as near-sightedness or far-sightedness.
The patient finds  himself unable to estimate distances, and misses  his aim
when  trying to snuff a candle, or pour beer into a glass.  The flame of a
candle generally appears split, lengthened, or broken into  an iridescent
halo.
   2. Ocular spectra, sometimes in the form of floating black spots, (musca
volitantes,) sometimes as flashes of light, or as a coloured  cloud  or  net-
work.*
   3. Sometimes incipient amaurosis is attended with great intolerance of
light—sometimes,  on the contrary, with a constant thirst for light, or feel-
ing as if objects were not illuminated enough.
  * The student will do well to read Milton's account of his own  blindness, as given
ui Dr. Johnson's Lives of the Poets. 
AMAUROSIS.
363
  4. The patient walks with a peculiar uncertain gait, and his eyes have
a vacant stare ; — the eyelids move imperfectly and seldom — the pupil is
generally dilated (unless it be an incipient case, attended with  intolerance
of light); — the iris moves sluggishly, and in confirmed  cases is  totally
motionless.  But if one eye be sound, and be exposed to light during the
examination, the iris of the affected eye will often move  in sympathy with
that of the sound one.
  Diagnosis.—Amaurosis may be distinguished from cataract by noticing,
1. That in cataract, an opake body can  be  seen  behind the  pupil, and
that the impairment of vision is in proportion to the extent of that opacity;
whereas, in pure amaurosis, the pupil either shows its natural colour, or
else a deep-seated greenish discoloration.  2. That, in cataract, (with the
exception of the radiating variety,)  vision is simply clouded, and that a
lighted candle appears as if enveloped in a mist;  whereas, in amaurosis,
objects  are  seen discoloured or  perverted in shape; and that a lighted
candle seems split, or  lengthened, or iridescent; and  that muscce voli-
tantes, and flashes  of fire when the eyes are shut, are not present in pure
cataract.  3. That in cataract vision is better in a dull light, whereas it is
generally the reverse in amaurosis.   4.  That a patient with  cataract is
always able  to discern  light  from darkness, and that he looks about him
and moves his eyes as though conscious that vision still exists, although
he may be  unable  to  discern particular  objects;  whereas in confirmed
amaurosis there  is a peculiar fixed vacant stare, and  the  eyeball is pro-
truded and motionless.  5. That in pure amaurosis the  three images of a
candle are as  distinct as  in  the healthy  eye, which is not the  case in
cataract.
  Prognosis.—This  is generally unfavourable — unless the disease  de-
pends on some  palpable  cause which admits of removal, and unless the
remedial measures employed  very soon produce good effects.
   Varieties.—Amaurosis  has  been divided into the functional  and
organic: the former depending on  some sympathetic  or  other disorder •
wdiich does  not primarily affect the structure of the nervous apparatus of
the eye—the latter on organic disease.
  Causes. — The usual causes of amaurosis are circumstances that over-
stimulate and exhaust the  retina ;—such as long-continued  exertion of the
eye on minute objects ; — or exposure to glaring light,  especially if com-
bined with heat — and  these exciting causes are  particularly aided by in-
temperance, stooping, tight neckcloths, too much sleep in bed, and  any
other  circumstances capable of producing determination of blood to  the
head.    Amaurosis may also be a consequence of organic  change, inflam-
mation, concussion, compression from extravasated blood, fractured bone,
morbid  effusions, tumours or aneurisms — whether affecting the brain,
optic nerves, or eye.
  Treatment. — The  indications in every  case are, 1. To  rectify  any
palpable disorder,  inflammation or plethora, by depletion;—debility by
tonics.  2. To neutralise  determination of blood  to  the  eye  or head  by
counter-irritation.  3.  To stimulate and  restore the excitability of the
retina.  For practical  purposes,  it will be convenient to  classify the  dis-
ease under the five following heads: viz. 1. Inflammatory;  2. Atonic;
3. Sympathetic cases; 4. Those produced by poisons; and 5.  By organic
disease. 
364                         AMAUROSIS.
   1. Inflammatory.—(a.) If amaurosis be attended with any of the symp
toms of retinitis that have been before enumerated ;
   (b.)  Or if it suddenly follow some injury to the eye, such as a puncturec
wound, or  blow on the naked eyeball, or exposure to a flash of lightning
or if the patient has been engaged in occupations that necessarily tax th*
eye severely, such  as reading and writing much  by candle-light; expo
sure to the  intense light reflected  from snow ; staring at an eclipse of th»
sun, and so forth ;
   (c.)  Or if there are plethora, headache, giddiness, red turgid counte
nance, with a hot skin and a hard pulse,—and if there are frequent flashes
of light, or streams of red-hot balls seen  before the eyes, (especially when
stooping, or undergoing some active exertion);
   (d.)  Or if the complaint has followed a suppression of any accustomec
evacuation, such  as bleeding from piles; or the translation of erysipelas
or gout; or the suppression of the menses from exposure to cold; or the
sudden suppression of perspiration ;  or the drying up of an habitual ulcei
or eruption;  or if it accompanies the inflammatory hydrocephalus tha'
sometimes  follows scarlatina; in all these cases  the antiphlogistic treat
ment must  be adopted, and should be pursued with  vigour.
   Bleeding, or cupping,  from the temple or mastoid process, should be
performed  at intervals.   The bowels should  be well  cleared,  the diet
should be low,  and all employment of the  affected  organ and all violent
bodily exertion should be desisted  from.  Mercury should be  adminis-
tered—rapidly  if the  case  be sudden in its attack, and present urgent
inflammatory symptoms — but more slowly  if  it present a more chronic
aspect—but in  either case it should be given so  as to  bring the system
under its influence, and its effect should be kept up for some time.  Small
doses  of tartarized antimony may sometimes be  conveniently combined
with the mercury (calomel gr. ii. ant. tart. gr. }), or may be given accord-
ing to  F. 31, 35, 36.  Counter-irritants  of all sorts are  beneficial; blis-
ters, or the tartar-emetic  ointment applied behind the ears, or to  the nape
of the neck—immersion of the feet in hot water and  mustard—or an issue
in the arms in chronic cases.
   2. Atonic amaurosis may come on  at the close of some long and ex-
hausting illness, or may be produced by  great loss of blood, menorrhagia,
immoderate suckling, leucorrhcea, excessive venery, or  other debilitating
circumstances.   It may  be  distinguished  by its  being attended  with
general debility, pallid lips, frequent trembling pulse, dilated pupils, and
despondency of mind ;—and  the patient generally sees  best after a meal
or a few glasses of wine, and in  a strong light.  The  practitioner must
carefully examine into the  causes of debility—whether they consist in
some disorder of the  system,  or in depraved and unhealthy habits of life.
The treatment  consists,  first, in  suppressing any habitual discharge, or
other  source  of exhaustion.   Secondly, in  strengthening the  system by
change of  air,  tonics, quinine,  steel and zinc, and especially by good
living.   At the same  time the abdominal secretions should be well regu-
lated by aperients, (such  as aloes and rhubarb,) that act copiously, but
not drastically;  and  the cutaneous  and  general  circulation  be  pro-
moted  by exercise  and bathing, especially  the shower-bath.   Camphor,
or arnica, asafcetida, and  other fetid stimulants, or strychnine in very small
doses  (gr. TVf) may be of service.   It is in this form, if in any, that local
stimulants  are  applicable—sucl as exposing  the  eye  to the vapour of 
AMAUROSIS.
365
Fig. 108.f
asther, or sal volatile, (a teaspoonful of either being held in the  hand,)—
taking electnc sparks from the eye; stimulating snuff, (F.  113, 114,)
cataplasms of capsicum to the temples; strychnine applied to  the temples
after the skin has been  denuded by a blister, beginning with gr. -|, and
gradually increasing it to  gr. i. ;  friction  of the  forehead with cajeput or
croton oil, or with an alcoholic solution of veratria.*
   3.  Sympathetic. — (a)  Amaurosis  not  unfrequently supervenes on an
attack of jaundice.    If there  be evidence  of congestion in the head, as
there frequently will  be, blood  should be  taken by  cupping, whilst  the
abdominal disorder should be removed by appropriate measures.
   (b) li there be headache, vertigo, foul tongue, disagreeable eructations,
tumid belly, and other evidence  of abdominal  congestion and  disorder,
emetics,  repeated once or twice a week, blue pill or  hyd.  c.  creta, in
small doses every night;  and purgatives, such  as senna, aloes,  and rhu-
barb, with  soda, magnesia, and ipecacuanha, till the secretions are set to
rights, followed by tonics and  counter-irritants, are the requisite measures.
In similar cases, some foreign  authors recommend the  use of Schmucker's
or Richter's resolvent pills, F. 115.   Turpentine should be given both as
a purgative and  enema, if there be  signs of worms.
   (c) Amaurosis sometimes arises from irritation of the fifth pair of nerves.
If it follow a wound  on the forehead, the latter  should be dilated, or if it
have healed, the  cicatrix  should be cut out.  Tumours of all sorts near
the eye, and carious teeth, should be removed.
   4.  From  Poisons. — Amaurosis  is  liable to be induced  by  certain
narcotico-acrid  poisons,  such  as  bella-
donna, and especially by tobacco, whether
administered  in poisonously large  doses
by accident, or used  slowly and frequently
in  the form of snuff or smoke.    If the
amaurosis  persists after the ordinary effects
of the poison have been  got rid of by the
usual  measures; the cold  shower  bath,
counter-irritation, electricity,  and  small
doses of mercury are the remedies most
likely to be of service.   Amaurosis is also
one of the set of paralytic affections winch
lead may induce.   The treatment must be
conducted on the same principles.
   5.  Organic.—These cases  are the most
hopeless.   If the disease has followed an
injury of the head, or fit  of  apoplexy, or
syphilis,  or if there be reason to suspect a
tumour in the brain, or in  the course of the
optic  nerve,—a moderate course  of mer-
cury,  with  alkalis and sarsaparilla,  and with counter-irritants, and atten-
tion to the general health, should  be tried, and sometimes may effect a
cure.   For other cases of amaurosis arising from organic  disease, espe-
cially if there be fixed pain in the head, palsy, or epilepsy, or idiocy,  the

  • The dose of arnica is, f 3 i of an infusion, made with 5 ss of the dried leaves, to Oj
of hailing  water.  It should be combined  with aromatics.
  t This cut  exhibits atrophy of the left optic nerve and right tractus opticus consequent
on amaurosis.—From the  Middlesex Hospital Museum.
       31*
 
366
SHORT  AND LONG SIGHT.
best thing that the surgeon can do will be to prevent congestion in the
head by occasional  depletion, and  counter-irritation; — to  maintain the
secretions of  the liver and bowels ;—to keep up the strength by a nutri-
tious but not stimulating diet, and to guard the patient from  every excess
or exertion, mental or bodily, that is capable  of  accelerating the cerebral
circulation.

        SECTION  XV.--OF  SHORT AND  LONG  SIGHT.

   I. Short Sight or Myopia.—This  affection appears to depend either
on an increase in the refractive power of the eye, or else  on an elongation
of its axis, so that in either case the  rays of light  are  brought to a focus
before they reach the retina. The cornea is generally exceedingly convex,
and  the  secretion of aqueous humour abundant;  and the  crystalline lens
is  also probably too convex, all of which circumstances would cause the
refractive power of the eye to be increased. It is most frequently congen-
ital,  and  is perceived in early childhood  ; but doubtless,  if  not congenital,
it may be brought on during youth by too close  attention to study and by
habits of looking at minute objects,  which irritate the eye, and cause the
secretion of aqueous humour to be increased,  and render the cornea more
convex.  It is a popular error to imagine that the sight  improves as the
individual grows older.
   Treatment.—The  eyes should  be  exercised and accustomed to look at
distant objects.   When children display any tendency to  short sight, their
studies should be abridged, and  they should  have plenty of exercise in
the open air.   Shooting, archery,  cricket, and field sports  in general, are
highly beneficial.  It is worth while also to try  a plan of treatment invented
by Berthold, and consisting in the  use of an instrument which has received
the sesquipedalian title of myopodiorthoticon.   This is really nothing more
than a support for the chin,  to  prevent the  patient stooping forwards,
whilst he reads from a book with large print.   And the book is every day
to  be placed  at a slightly greater distance from the eyes,  till the patient
has acquired the faculty of reading at the»ordinary focal  distance—that is
to  say, at about fifteen inches.   The glasses which are adapted  for short-
ness of sight  are  concave ; since they tend to disperse the rays of light,
and  prevent their coming to  a focus so soon.  They need not  to be
resorted to, however, if the patient can  go on pretty comfortably without
them; or. at all events should only be worn when required  to prevent him

                               Fig. 109.
Irom  stooping  awkwardly whilst  reading or playing music.   But  if the
myopia is very  decided, or if the eyes feel fatigued after any ordinary use
of them,  it will  be better  to  wear  the  glasses continually.   Spectacles
should always be used in  preference to a single glass.  The patient should
choose a pair that enables him  to see objects within forty feet as distinctly 
SQUINTING.
367
as other people,—the names on the corners of the street for instance; but
should not have them so concave as to make objects appear dazzling, or
smaller than usual.
   II. Presbyopia, or longsightedness, depends apparently on a diminished
quantity  and  density  of the humours of' the eyeball,  through  which  it
becomes  flatter, and   its refractive  powers  are  diminished.   It  needs
scarcely be said that it is one of the earliest signs of impaired nutrition in

                                Fig.  110*
 old age.  The  patient's sight  must  be remedied by convex glasses;  but
 he should not resort  to them  at first, nor change those first selected for
 stronger ones before he is absolutely compelled ;  and the sight should be
 spared by candle-light as much  as possible.  The  glasses should  cause
 minute objects near the  eye  to  appear bright and distinct,  but not larger
 than natural.  If they  do, they are too convex, f

                 SECTION  XVI.—OF SQUINTING.

   Squinting, or Strabismus, may be defined to  be a want of parallelism
 in the position and motion of the eyes.
   The essential  cause  of the affection appears, in most  instances, to be
 some weakness of sight, or some want of adjustment in the visual axis of
 one eye, in  consequence of which it is involuntarily turned  aside, in  order
 to avoid the double or distorted vision that would result  from looking at
 objects with two eyes of different  powers.  The immediate mechanism by
 which the squint is produced, is most probably a relaxed or inactive state
 of the external rectus  muscle, so  that  its antagonist  muscle, the  internal
 rectus, preponderates in force, and draws the eye inwards.J  Sometimes,
 although more rarely, it may be supposed that the affection  commences by
 an original spasm of the internal rectus.
   The ordinary form of squint is the convergent,  or that in  wilich the  eye
 is turned inwards ;  the divergent, or that in which the eye  is turned  out-
 wards, is more rare.   It occasionally happens that both eyes squint;  but

  * The former of these cuts is intended to explain the nature of myopia, and the  effects
 of concave glasses;  which disperse the rays and prevent their coming to a focus  before
 they reach the retina.  The  latter is  intended to show the reverse state of things in
 presbyopia.
  f An elderly gentleman, who had been some time presbyopic, met with a violent fall
 and contusion of the eyes ;  which doubtless produced an increased secretion of aqueous
 humour, and restored his power of seeing at  the ordinary focal  distance.  Presbyopia
 occurring  in young persons generally arises from intestinal irritation, and may be  a pre-
 cursor of amaurosis.
  t This is shown by the results of the operation of dividing the internal rectus, aAei
 which the eye  is merely drawn by the external rectus into its natural position ; whereas
 when (in various accidents)  one of the  recti of a sound eye has been  severed, its anta
gonist has drawn it completely over to its own side.  Vide Sir C. Bell. Practical E»
says, 1841. 
368
SQUINTING.
it must be remarked that they do  not both squint at the same  time, but
alternately.   When one eye is distorted and fixed, the affection  is called
luscitas.
  Causes.—1. Squinting may be caused by congenital  malformation.
  2. It may be induced  by bad habits ; such as the imitation of parents,
nurses, or schoolfellows,  if they happen to squint;  or by constantly look-
ing at spots and pimples on the nose ; or it may follow affections (such as
hordeolum) which render motion of the eye painful; and  during which
the patient turns the eye  inwards  and keeps it motionless.   3. It may be
caused by using one eye constantly to the neglect of the other.  It  may
be observed that all shortsighted persons  have  more or less tendency to
squint, for the following reason.  They never use both eyes whilst they are
reading or  examining small objects near the eye ; but sometimes use the
right eye, and sometimes the left.   If, however, they were by accident to
persist in using one only, it would become stronger by use,  and the other
weaker by  disuse ; and the weaker might  squint.   In this manner, squint-
ing has been  known to occur after one eye has been for along time shaded
in consequence of an inflammatory attack; which  shows the  expediency
of alwrays covering both eyes when a shade is necessary.   4. If there  hap-
pens to be  an opacity on the cornea of one eye, and that eye is the better
one, the  patient will sometimes continue to  use it for ordinary vision, but
for that purpose is obliged to  distort it so as to remove the corneal opacity
from the visual axis.   5. Squinting, like almost every other  conceivable
consequence  of defect of nervous  influence, is sometimes a relique  of
fevers and  the exanthemata.  6. It may be induced by  irritation or disor-
der of the stomach and bowels, teething,  wrorms,  constipation, and  so
forth;  it may, moreover, be caused by fright or violent fits of passion;
and in some children  it always appears when the health is  out  of order,
and disappears when  it  is  restored.  Lastly, it  may be caused  by some
disorder of the circulation in the  brain.   Thus it  is  pretty  frequently the
precursor of  acute hydrocephalus or convulsions in  children  ; and when it
is associated  wirh  dropping of one or both eyelids,  and with unusual
sleepiness, or torpor of the intellect, or faltering in the gait, some mischief
within the  head may fairly be anticipated.
   Treatment.—If the affection be recent, it may perhaps be removed by
judicious medical treatment.  The  patient  should be secluded  from the
society of  every squinting person who might be imitated.   Any disorder
in the  stomach or bowels should be removed by purgatives, antacids, and
tonics; and if the patient is a weakly child, and if the  squinting has fol-
lowed a severe illness, a course of steel wine, or small  doses of sulphate
of zinc, may be of service. An endeavour should  be made to strengthen
and exercise the squinting eye, by covering the  sound one with a light
shade for one or two  hours every day; but this must be done with mode-
ration ; because it has happened, that whilst a squinting eye has been cured
by this means, the sound one has  been weakened  by seclusion, and has
been made to squint instead.  It is a useful plan to make the patient  exer-
cise his eye before a glass in the following manner.  He should be told
to close  the sound eye, and look  at a particular point with  the  squinting
one.   Then let him open the  sound eye.   Upon  this,  the  squinting eve
will immediately diverge ;  but by perseverance the patient may educate it,
till he  can  command it, and keep it parallel with the other.   If a child is
beginning to squint, it should be  carefully watched, and be  told to en 
SQUINTING.
369
 deavour to correct it;  close  application to study should be interdicted ;
 plenty of exercise should be taken in the open air;  and if the sight is
 short, a pair of shallow concave spectacles should be used.   Lastly, cases
 are related of recent squinting cured by very small doses of strychnia, and
 ny taking electric sparks from the eye, or by passing slight galvanic cur-
 lents between the frontal and infraorbital nerves.
   But if the squint  is  of long standing and is habitual, very little  good
 can be done unless the internal  rectus muscle is divided ;  or the external
 rectus, if the squint  is  divergent.  This operation (the rationale of which
 will be alluded to in the chapter on Club Foot) will be  of equal efficacy,
 whether the  squint is produced  by spasm of one  muscle, or by weakness
 of its antagonist.  It is easily performed in the following manner.   The
 patient,  if an adult, and  manageable, sits  in a low chair;  if an unruly
 child, he should be  rolled  up in a sheet, and be  placed on a table, with
 the head supported by a pillow.   The sound  eye should of course be
 bandaged, and an assistant should place two fingers on it to keep it steady
 during the operation.  Then the upper lid of the squinting eye being held
 up by the assistant's  finger, or by a  wire speculum, and the  lower lid
 being held down by another assistant's finger, or by a  small catch or bull-
 dog forceps (which may be made to seize the conjunctiva  inside the lid,
 and will hold it down  by its weight):  these preliminaries being  arranged,
 the surgeon introduces the fine double
 hook into the conjunctiva just inside the              Fig. ill.
 cornea, and having drawn  the  eye out-
 wards, gives it to  an  assistant to hold
 steadily.  Then he  raises  the conjunc-
 tiva on  the  inner  side  of the  eyeball
 with  a forceps, and divides  it  perpen-
 dicularly with the curved scissors.  Next
 he raises some  reddish  cellular tissue,
 and cuts through it in the same manner;
 and, thirdly, he cuts through the muscle;
 which being divided,  will expose the
 clear  white  sclerotic.   He should  be
 careful to divide perpendicularly  every
 fibre which covers the  sclerotic for the extent of half an  inch;  and  if he
 does so, he will find that the patient can move the eye  more freely than
 before in all  other directions, but  that he cannot move  it  directly inwards.
 This is a sign that the  operation is complete.
   After the  operation  the  eye should be  protected from cold and light,
 and  any inflammatory symptoms  be  checked  by appropriate measures.
 But  it is very rarely  succeeded  by  any untoward  symptoms,  although
 the author knows more than  one case in which  the  eyeball suppurated
 and burst.
   This  operation may be performed for two purposes.   The first is, to
 get rid of the deformity of the squint.   And  this purpose  is  generally
 answered effectually; although it  must be confessed  that the inner side
 of the eyeball is apt to project somewhat,  and  the  eye to look large
 and goggled.  But the patient must make his  own choice between this
 and the squint.
   The second purpose  is that of strengthening  the eye, and enabling the
patient to bring it into use.   And  this purpose  is  no doubt  answered in
                                 Y
 
370
MALIGNANT DISEASES OF THE  EVE.
some measure, so that both eyes are used for the vision of remote objects
and the patient says that the eye feels  stronger  and clearer; but it is not
likely to be useful in  near vision till after a long time, if at all.   More-
over, after the  operation,, it is  very common for some  degree of double
vision to be complained of.  This will be  perfectly intelligible when it is
considered that objects  are viewed by two  eyes of different powers and
adjustments.  But this inconvenience soon passes  off, because the patient
learns to neglect the image presented by the weaker eye.


SECTION  XVII.--OF  MALIGNANT  DISEASES  OF  THE  EYE.

   I.  Scirrhus.—After years of supposed inflammation, the eye becomes
shrunk  and hard, and  the conjunctiva tuberculated, thickened, and red.
The eye is exquisitely tender;  there is much burning or lancinating pain,
and severe hemicrania.  After a time, ulceration occurs, and spreads to
the neighbouring parts, and the patient sinks.
   Treatment. — Extirpation,  if  it can be  adopted  before  the lids are
affected;  if not, the local  and  general employment of narcotics.
   II. Medullary Sarcoma  is  not unfrequent, especially  in  children.
                                  Its most frequent seat is  the termina-
                                  tion of the  optic nerve.   The  eye is
                                  accidentally  discovered to be  blind,
                                  and a small  tumour of a peculiar me-
                                  tallic lustre can be detected very deep
                                  behind  the pupil.  This gradually ad-
                                  vances, and  generally appears whitish
                                  or yellowish, and lobulated, and more
                                  or  less  streaked with blood-vessels.
                                  In a space of time, varying from a few
                                  months to two or three years, the cor-
                                  nea bursts before the enlarging tumour,
                                  a bleeding fungus protrudes, the cer-
vical  glands enlarge, and the patient perishes.   There is not usually much
pain before the cornea begins to be distended.
   III. Melanosis. — This substance  is  occasionally  deposited  in the
eyeball,  or in  the orbit,  either  alone or  in  connexion with cancer.
There is more to hope for  from extirpation of this  disease than from that
of cancer.f
   Treatment.—Much may be hoped from a light nutritious diet, fresh air,
occasional leechings, and  a gentle course of mercury, which should be
kept up for some weeks.   By these means the disease, if malignant, may
be checked ; if not malignant, may be cured.   Extirpation is scarcely ever
deemed advisable in children, (1) because the disease, if really malignant,
is sure to return; (2) because there are sundry scrofulous tumours which can-
not be distinguished from the malignant, and which either disappear or give
no trouble.  The  diagnosis may be considered doubtful, if such tumours
follow an  evident wound or injury; if there be scrofulous disease in other
parts, and if the eye shrink and become atrophic.
  •From a drawing of a preparation in  King's College  Museum, with  whHi the
author was favoured by Mr. Partridge.  The eyeball is seen to be  filled with a medul-
ary growth.
  t fee a paper by Dr. Robertson, Northern Journal of Medicine, Nov. 1S44.
 
DISEASES  AND INJURIES  OF  THE EAR.           371
  IV.  Extirpation of the Eye.—The  operator first passes a ligature
through the anterior part of the globe in order to  steady it, or else seizes
it with a hook or vulsellum, and  slits  up the  external  commissure of the
lids.   Then he raises the upper eyelid, cuts through the fold of conjunctiva
reflected from it to the eye, and dissects  backwards, so as to separate all
the soft parts from the roof of the orbit.  The same process is repeated
below  and on the sides—taking care to cut loose to the bone, and to re-
move the lachrymal gland.   Then a  curved knife  is  introduced  on the
outer side  to cut through the optic nerve and origin of the muscles, and
so the  eye  is detached.   The patient must then be put to bed, with a cloth
dipped in cold water laid over the face.  If there is a  very great haemor-
rhage from the ophthalmic  artery, it  may be restrained by pressure with a
piece of lint,—which should be removed as soon as it  is suppressed; but
it is better not to stuff the orbit with lint if it can be avoided.
  After staphyloma or any other  disease which has  rendered the eye-ball
sunken and sightless, if the patient objects to the trouble  and expense of
an artificial eye, it may be  convenient  to divide  the levator  palpebras, in
order that the lids may remain permanently closed.  This may be effected
by  making a transverse incision in the upper eyelid just below the orbit,
and seizing the belly of the muscle as far back as possible.   Then  a piece
should be snipped out of it with scissors.
  V.  Excanthis is an  enlargement of  the  caruncula lachrymalis,  and
semilunar fold of the conjunctiva, which may be easily extirpated by curved
scissors.   Sometimes, however, it is the seat of a malignant growth, be-
coming dull  red, very hard, and subject  to lancinating pain ; and finally
degenerates into a cancerous ulcer.  Sir A. Cooper thinks that in this case
extirpation is inadmissible.*
                        CHAPTER  XIII.

           OF THE DISEASES AND INJURIES OF THE  EAR.

                SECTION  I.--EXAMINATION OF THE EAR.

  I. Deafness is so common and so distressing an  infirmity, and when
of long standing is so incurable, that we cannot  too strongly uro-e all
medical practitioners to  make themselves familiar with the treatment of
diseases of the ear.   They should also encourage their patient to  apply
to them for the relief of slight and incipient ailments in this organ, instead
of allowing them to go on till they become permanently deaf,  and then
letting them fruitlessly seek relief from ignorant and mercenary quacks.

  *  Yule Lectures by Professor Green, in  Sir A. Cooper's Lectures, Renshaw's edit •
Lawrence on Diseases and on Yenereal  Diseases of the Eye; Copland Diet., Art. Eye,'
Amaurosis, &c.; Middlemore  on Diseases of the Eye; Guthrie on  the Operative Sur-
gery of the  Eye, and in Lond. Med. and Surg. Journal: Littell's Compendium: Foot's
Ophthalmic Memoranda: Morgan on the Eye, Lond. 1839; Tyrrell  on the Eye, Lond
LMii;  nnd  especially Mackenzie on Diseases of the Eye, 3d ed., Lond.  1840  a work
of the greatest erudition  and practical utility. Much information and amusement mav
also be derived from Hull on the Morbid Eye, Lond. 1840, which contains much  sterling
sense under a vein of pleasantry and affectation of pedantry. 
372                EXAMINATION OF THE  EAR.
  II. Examination of the Meatus.—Every surgeon ought to accustom
himself to examine the external meatus, and to become familiar with  its
appearances, both in  health  and in disease.   We may premise that this
canal is about an inch long; that its course is forwards and inwards, but
that it presents a slight curve with the convexity upwards, and is narrow-
est about its middle.   It may be said  to have three divisions, which  differ
from one another in structure and appearance.   In the first or outermost
part of the tube, the passage is  " formed almost entirely of pure fibro-car-
tilage covered with its perichondrium," and lined by the same fine dermal
structure that invests the auricle.*   " Here the  skin is studded over with
fine white hairs pointing inwards, and also with numerous sebaceous glands
or follicles; it is here also more loosely connected to  the cartilage than at
any other part of the tube, and this accounts for the fact that small circum-
scribed abscesses occur in this part of the canal more frequently than in
any other.   The next portion  of the  tube may be  called  the glandular
division, because  in it  are seated  the  ceruminous glands that secrete the
ear-wax ; this is about three-eighths of an inch long,  and is the narrowest
portion of the tube."  Its  walls have less of  cartilage, and more of dense
fibrous membrane in their  composition, and its dermal lining is  finer.
When in a  healthy state it  is  generally coated with  wax, which forms a
ring coating this part of the meatus.  This part of the passage is, accord-
ing to Mr.  Wilde, the usual seat of polypous excrescences, which proba-
bly have their origin in the ceruminous glands.   The third and last portion
of the passage is slightly dilated, and contained principally within the bony
                             part of the meatus.  It can only be seen satis-
            Fig. 113.           factorilyby means of a speculum, of which in-
                              strument several sorts are sold, and some of
                              them intended to dilate the ear.   But since
                              it is only the outer extremity of the meatus
                              that can be  dilated, these dilators are  of no
                              great use, and the most convenient one will
                              probably be found to  be a simple conical
 silver tube  of the size and shape  depicted in the adjoining cut, and  in-
 tended  solely to transmit light.
    For the  examination, it is advisable to  have a good stream of  direct
 sunshine ;  but if this cannot be had, the best substitute is a  gas or Argand
 lamp.f   The patient, according to his height,  should sit, kneel, or stand
 sideways before the surgeon ; who should take the auricle  with one hand
 and gently draw it  outwards  and backwards, whilst with the other he
 inserts  the speculum as far as  it will go without pain.  Then, by placing
 the patient's head at the proper angle, and by gently moving the large
 end of  the speculum from side to side, a stream of light  may be made to
 play on the  innermost portion of the meatus, and  on the membrana
 tympani.   But the operator must take care not to put his own head  in the

    WThen the innermost portion of the meatus  is thus examined, its lining
 exhibits, if healthy,  a  " fine,  smooth, dry,  pearly-white shining appear-

   • The quotations are from Mr. Wilde's excellent  paper on  Otorrhoea, in the  Duhhn
 Journ. Med.  Sc, Jan. 1844.
   T A description of an instrument for examining the ear was published by Dr. Warden,
 of Edinburgh, in the Edin. Phil. Journ., Oct. 1844.  Mr. Avery, of the Charing Grow
 Hospital, has also constructed an auriscope, with a powerful reflecting lamp.
 
              AFFECTIONS  OF THE  EXTERNAL  EAR.            373

ance " and in a perfectly healthy state, it is not coated with wax.   The
membrana tympani  also'is seen closing the  passage obliquely;  greyish
white dry, and semi-transparent.   " Within it, is seen  the  handle of the
malleus,  proceeding from  above  downwards, and slightly forwards.
This bone, which runs  about half-way across the membrane, divides it
into an anterior superior, and posterior inferior portion, the former of which
is flat or slightly concave, whilst that part " which  is below  and  behind
the malleus is, in a perfectly healthy living human ear, convex towards the
external aperture.   This lower portion is also more glistening in  appear-
ance than  the upper or  anterior part, and when viewed through the spec-
ulum, a bright spot  of light shines upon its most convex portion, which is
a little below and behind the point of the malleus."   Under inflammation
this innermost division of the meatus becomes  thickened, highly vascular,
and  villous or granular,  like the granular conjunctiva, and secretes a
purulent matter; but, according to Mr. Wilde, never gives origin to poly-
pus or fungus.

   SECTION II.--AFFECTIONS OF THE  EXTERNAL EAR.

   I. Foreign substances in the ear.   Children not unfrequently poke
bits of slate  pencil, peas, glass beads,  &c, into  the passage of the ear,
which, if  allowed to remain, would give rise to  violent inflammation and
deafness.   Any such body should therefore be removed as quickly and as
gently as  possible,   either  by syringing  the ear with warm water,  or by
means of a small forceps, or a curette or scoop, or bent wire or probe.
   II. Otorrhoga, or inflammation of the external meatus, with muco-
purulent discharge,  is  a very  common complaint in delicate children.
Sometimes it occurs after scarlatina or some other fever, and sometimes
appears to be excited by currents of cold air,  or the irritation of decayed
teeth, especially if the stomach and bowels are in an unhealthy condition.
   It may occur in connexion with porrigo larvalis; and we may observe,
that if the discharge from the ear of an unhealthy child comes in  contact
with any abraded surface, it  is very liable to induce a widely-spreading
porrigo.   It  may be caused also by the bursting  into the meatus of ab-
scesses which are connected with enlarged glands, or with caries of the
temporal bone, as will be mentioned presently.
   Symptoms.—This disease begins with fever, headache, intense  pain in
the ear, and  swelling of the glands of the neck.   Soon afterwards  a red-
dish serous discharge appears, which gradually becomes thicker and puru-
lent ; and  as this increases, the febrile symptoms disappear. The discharge,
which is often excessively copious, and excessively fetid, unless the strictest
attention be  paid  to cleanliness, is generally  tedious in its duration, like
most other maladies occurring in scrofulous habits ; and if neglected, this
disease is  liable to produce fungous  granulations, ulceration of the mem-
brana tympani, suppuration of the tympanic  cavity and of the  mastoid
cells, loss of  the ossicula, and caries of the temporal bone.   On examina-
tion with the  speculum, the whole meatus is seen to be swelled, and vas-
cular, and covered with a slimy secretion.
   Treatment.—During the acute stage, the bowels should be opened, and
the diet be restricted to liquids (which, in fact, from the pain caused  by
mastication,  are the only things the patient is inclined for).    The affected
ear should be very  gently syringed ouc with warm water or poppy decoc-
       32 
371
DISEASES  OF  THE  EAR.
 tion, and be constantly covered with a warm poultice ; for which purpose
 nothing can be better than a bag of soft linen filled with bran, and dipped
 into hot water.   If the pain and headache are very severe, leeches may be
 applied to the mastoid process.
   When the  pain and fever are removed, and the chronic  stage has set
 in, the treatment  must  be conducted in the same manner as that  of any
 other  chronic mucous  inflammation  in  scrofulous  constitutions.  The
 general health must be improved by tonics, alteratives, and aperients; and
 by warm baths (cold bathing  is almost sure to be injurious); — and  the
 local disease must be treated  by the cautious use of stimulants and astrin
 gents.  The ear should be twice daily very gently syringed  out with white
 soap and water; and immediately afterwards a weak  solution of alum or
 sulphate of zinc (gr. j, ad 3i.), or a lotion containing two drachms of liq.
 plumbi diacet. to  half a  pint of distilled water, may be dropped into the
 meatus till it is filled, and after remaining there  two or three minutes, be
 allowed to run out.   The lotions should be used tepid.
   The best instrument for syringing  the ear in these  cases is  an elastic
 bottle  ; and we may observe, that this operation should always be done as
 delicately as possible, without hurting the  meatus with the nozzle of the
 pipe, and without forcing in bubbles  of air.
   If the discharge is very fetid, a lotion  of two drachms of solution of
 chloride of lime to half a pint of water may be used ; and  if the case is
 obstinate, the  whole  interior of the meatus may be pencilled twice a week
 with a solution  of nitrate of silver (gr. v. ad 3i.), by  means of a camel's
 hair pencil.  If the discharge, as sometimes happens, causes excoriation
 of the auricle  or of the neck,  these parts must be first  fomented, and then
 smeared with  an  ointment of hyd. prsecip. alb.  But  it  seems advisable
 not—as a general  rule—to insert ointments into the meatus.
   If at any time during the treatment, an attack of acute pain  and fever
 should come on, and the discharge should stop suddenly, leeches, purga-
 tives, and fomentations must be resorted to, and all astringent applications
 be abandoned till  these acute symptoms have subsided.
   We may observe in this place that  the surgeon should be constantly on
 his guard against the  dangerous practice of plugging the meatus with cot-
 ton, which many persons do from a belief  in its virtues, whilst some lazy
 parents do it in order to save trouble, and prevent the discharge from soil-
 ing the child's clothes.   It is never justifiable, however, to put cotton into
 the meatus; but if it be desirable to protect  the ear from cold,  a little bit
 may be put loosely into the concha.
  III.  Accumulations  of Wax.—In  persons of dark  oily complexion,
 1 he ear is apt to become completely filled  with wax mixed with  flakes  of
 cuticle and innumerable hairs.  This should be removed from time to time
 by gently syringing with warm  soap and water.  We may observe that the
 ear bears water  that is rather hot;  and  that a little  cotton should be put
 into the concha after the operation.
  IV.  A thickened state of the cuticle lining the meatus  is not an un-
 common sequel of otorrhcea.   The accumulations must be removed by the
 syringe, and then the  surface  be touched with a weak  solution  of  nitrate
 of silver, and  afterwards  with  dilute citrine ointment (F. 116) melted and
 applied warm  with a brush.
  V. Polypus.—Genuine polypus excrescences, " fleshy  pedunculated
growths, nearly colourless, having a  thin cuticular covering, unattended 
FUNGOUS GRANULATIONS.
375
with pain, not appearing as the result of inflammation, and not accompa-
nied with discharge," Mr. Wilde believes not to be very common ;  and
when they are present, they generally grow from the middle or cerumino-
glandular portion of the  meatus.
   Treatment.—The point of attachment of any such growth having been
ascertained, it  may be  snipped  off,  if possible, by means of very  fine
curved  scissors, and the place from which  it grew should be regularly
touched with nitrate of silver, to  prevent its  reproduction.   If it cannot
conveniently be excised, it may perhaps be cut off by means of a loop of
fine platina wire, carried through a hole in the end of a little  silver rod,
and slipped  over the excrescence.*
   VI.  Fungous Granulations are exceedingly common consequences of
otorrhcea, and often pass for polypi; although, as has just been observed,
the genuine polypus is  exceedingly rare.  They generally  occur  at the
very bottom of the meatus, or grow from the  membrana tympani, or from
the cavity of the tympanum  after the membrane  has been  perforated by
ulceration.  Sometimes the membrane is covered with florid vascular gran-
ulations so as to resemble the granular conjunctiva.
   Treatment.—The nitrate of silver  should  be  regularly applied to the
diseased surface, and astringent washes  should be injected.  The nitrate
should be applied  as  before  directed only to  the diseased  part itself, by
means of a probe, or some similar contrivance coated with it;  and  it  cer-
tainly is not justifiable to thrust a great stick of it, or a great piece of  sul-
phate of copper into the ear,  and  roll it round, thus cauterizing the healthy
as well as the diseased parts, and occasioning intense irritation.
   VII.  Caries of the Temporal Bone, especially of the mastoid process,
may be a consequence  of extension  of inflammation  from  the  mucous
membrane of the ear, particularly if the  cavity of the tympanum has sup-
purated.  There is constant  otorrhcea, and the. discharge is sanious  and
fetid, and stains silver probes.  Perhaps the meatus is  choked with fun-
gous granulations.  This is a most serious disease.  Death may be caused
by extension of the caries to the cranial  cavity, and suppuration on the
dura  mater, or by inflammation of the  brain  or its  membranes,  through
contiguous irritation,—or the side of the  face may be palsied through com-
pression of the portio dura.  Sometimes an abscess bursts behind the  ear,
or burrows amongst the muscles of  the neck and  points low down.
   Treatment.—Tonics, alteratives, counter-irritants,  and astringent injec-
tions  (or F. 60), frequently repeated, to wash away the fetid  discharge.
Any portions of loose bone should be cautiously extracted.  Sir P. Cramp-
ton drew from  the  meatus of a young lady, a piece of bone comprising
the entire internal ear—vestibule, cochlea, and semicircular canals, with a
small portion of the inner wall of the tympanum.  The patient had urgent
symptoms of inflammation of the brain, with hemiplegia,  and total deaf-
ness of  one ear, but ultimately recovered.  Abscesses near the  ear should
be opened as soon as possible.   If the patient be labouring  under secon-
dary venereal symptoms, sarsaparilla  may be  given with  advantage.   If
inflammation, or symptoms of compression of the brain supervene, they
must be treated as  was detailed in Chapter X., recollecting that depletion

  * For a description of a very neat instrument of this kind, refer to Mr. Wilde's Paper
in the Dublin Journal, Jan. 1811.  The  lunar caustic should be applied by means of a
probe, the blunt end of which should  be dipped in nitrate of silver that has been melted
in a platinum spoon over a spirit lamp, and is ,'ui'. beginning to cool. 
376                   DISEASES  OF THE  EAR.

and mercury must be used with  the  greatest moderation, as  they cannot
remove the exciting cause.
  VIII. Earache—(otalgia).    This term  ought to be restricted to sig-
nify neuralgia oi the ear.  Genuine neuralgia of the ear,—occurring m
fits' of  excruciating  pain, shooting over the  head and face,—may be dis-
tinguished from otitis by the sudden intensity of the pain,,—which is not
throbbing,—does not increase  in severity,—is not attended with fever,—
and comes and goes capriciously.   Its causes axe the same  as  those of
neuralgia generally, but particularly caries of the teeth;  and its treatment
principally  consists in  removing carious  teeth, or  stopping  them, and
giving large doses of carbonate of iron.   What is popularly called ear-
ache is an inflammatory pain,—perhaps the precursor of otorrhcea,—to be
treated by fomentations  and purgatives.   Carious teeth, if any, should be
extracted, and gum-boils be opened.
   IX. Hypertrophy of the External Ear.—Dr. Graves mentions a
case in which  the pendant lobes of the  ears became thickened and elon-
gated through a deposit of fat into their cellular tissue;  in a patient who
died of fatty degeneration of the liver.  The author has seen one or two
cases in which the whole external ear was excessively enlarged and thick-
ened ; but he would not have included them in this  chapter, had not Dr.
Graves appeared to consider the affection an uncommon one.*

SECTION  III.--OF  AFFECTIONS  OF THE  TYMPANUM  AND
   INTERNAL  EAR,  AND  OF THE  CAUSES  OF  DEAFNESS.

   I. Acute Inflammation of the tympanum and internal ear (otitis) no
doubt generally accompanies the severer forms of otorrhcea, and may be
caused by cold, or mechanical injury.  Violent pain, ringing noises in the
ear, and delirium, are the symptoms, which must be combated by vigorous
antiphlogistic measures.  Suppuration in the tympanic cavity will probably
be denoted by rigors and an increase of pain, with a heavy tensive sensa-
tion; and by the membrana  tympani appearing  white  and tense; and
there are  some few cases in which it might  be necessary to puncture this
part with a long slender knife or needle.
   II.  Chronic Inflammation.—The researches  of Mr. Toynbee have
shown most conclusively, that by far the majority of cases of deafness de-
pend on changes wrought in the tympanic cavity by chronic inflammation.
Mr.  Toynbee  divides the diseased  appearances  in  the tympanic cavity
into  three stages.  In the first stage, the lining membrane retains its na-
tural  delicacy of structure, but  its vessels are enlarged and tortuous;
blood is sometimes effused into  its substance, or on its attached surface,
or sometimes between it and the membrane  of the fenestra rotunda; and
sometimes lymph is effused on its free surface.   In the second stage, the
membrane  is  thickened and flocculent; and occasionally covered with
cheesy, tuberculous,  or fibro-calcareous  concretions;  but  the morbid
change most frequently observed consists  of fibrous bands, which  are
sometimes numerous enough  to occupy nearly the whole  of the cavity.
In some instances they connect the inner surface of the membrana tym-
pani to the inner wall of the tympanic cavity ; or to the incus and stapes,
but by far most frequently they extend from the crura of the stapes  to the
adjoining wall of the tympanum, so that this  bone is, as it were, com*
                    * Gravp's Clinical Medicine, p. 581. 
DEAFNESS.
377
pletely enveloped in a fog of adhesions.  In the third stage, the  mem-
brana tympani is ulcerated, the ossicles discharged, and the whole mid-
dle ear disorganised.*
   Causes.—This diseased state may be caused by any of the circumstances
that either predispose  to, or actually produce, congestion  and inflamma-
tion of mucous membranes.  Thus it is  a very frequent sequel of the  ex-
anthemata, and especially of scarlatina ;—it may, like cachectic diseases of
the eye, be caused by  unwholesome  diet,  and residence in close unventi-
lated apartments; it may further be the  result of local irritation, such as
inflammations in the throat, currents of cold air, or previous disease, or
improper surgical applications  to  the meatus.  Besides  these, there are
two sources of deafness which are  so  common, that they ought to be espe-
cially noticed.   One is cold-bathing; and the other, the habit of blowing
the nose violently, which often causes a  most painful strain on all parts in
the middle ear, and sometimes bursts the membrana tympani.
   Symptoms.—These  unfortunately are generally so slight, that the patient
gives no heed to them, till in process of time he finds himself altogether
deaf in one or both ears.   A slight woolly sensation, or occasional  noises
or ringing, with variable obtuseness of hearing, and slight aching, are the
most frequent.
   Treatment.—Mr. Toynbee's  researches show that  very few  cases of
deafness can be  considered as  nervous, since by far the majority depend
on a thickened condition of the tympanic membrane;  and that, therefore,
instead of empirically  resorting to stimulants, the most rational plan is to
use those local and  constitutional  remedies which are  known  to give
relief in other cases  of chronic  inflammation.   Pure air, exercise, warm-
bathing, regular diet, remedies  calculated to  improve the general health,
and the  condition  of the digestive organs,  should always be  used.
Minute doses of corrosive sublimate, with bark, or sarsaparilla,  might be
of service; or mercury in some  other  form in small regularly-repeated
doses.  Any diseased state of the  meatus  should be remedied by the
measures  spoken of in the preceding section.   If there is any uneasiness
about the  ear, from two  to four  leeches should be applied repeatedly to
the mastoid process; and afterwards a succession of blisters, each the size
of a shilling.   If the membrana tympani looks opake, it may be brushed
once a week with a solution of nitrate of silver.  In fact, the remedies for
deafness must be the  same in kind as would be used for a granular con-
junctiva,  or opacity of the cornea, only varied and adapted as the inge-
nuity of the surgeon  may suggest.   By such means,  if the case  is of no
very  long standing, it will probably be relieved, and may possibly be
cured; but it must be  confessed that there  is  not  much to be hoped for
if the case has been of long duration.!
   III. Deafness sometimes  depends primarily on a morbid state  of the
throat and Eustachian tubes:—such as obstruction of the tubes by en-

   * As a proof of the  small number of persons whose hearing is  quite perfect, Mr.
Toynbee found in 1'20 dissections, 29 healthy; 20 in the first stage of tympanic dis-
ease ; 65 in the second stage, and 6 in the third stage.  Mr. Toynbee has since (October
1846) dissected nearly 1000 ears.  The author has  to thank  him  for much valuable
information.
   + The author treated a case a short time since, in which deafness of recent occurrence
was manifestly connected with rheumatism. There were achings in the head and neck
and beating noises in both ears, and scanty red urine.  The deafness subsided undei
ihc u*f of mercurial and alkaline remedies.
       32* 
378
DISEASES  OF  THE EAR.
larged tonsils, or by the cicatrices following the ulcerated sore throat of
syphilis or scarlatina;  or  by thick  mucus,  or  by granulations.  Some-
times these tubes are extremely dilated.   They  may be known to be per-
vious if the shock of air can be heard against the membrana tympani, by
means of the stethoscope applied to the mastoid process, whilst the patient
closes his mouth and  nostrils, and makes a strong  expiration; and they
may be  known to be clogged with mucus, when loud crackling or gur-
gling noises are heard by the patient, (or by the surgeon with the stetho-
scope,)  when he expires strongly with the mouth and nose  closed.  If the
membrana tympani is perforated, air may often be made to whistle through
the aperture.
   Treatment. — Chronic sore throat, or swelling of the  tonsils,  must be
removed by stimulating and astringent gargles, or by  touching  the parts
with a hair pencil dipped into a strong solution of nitrate of silver, as well
as by the use of tonics, counter-irritants, and  attention  to  the general
health.  If these  measures fail, and  the tonsils  are  much  enlarged, they
should be abridged with the knife.  In other respects the treatment should
be the  same as  is detailed in the preceding paragraph.  These are the
cases in which  it has  been  recommended  to  introduce catheters  and
bougies into  the  Eustachian tubes,  and to inject warm water, or air, or
medicated  liquids or vapours into the cavity of the tympanum.   But the
author cannot recommend these  operations  for  general adoption;  first,
because they are painful, and because he believes they very seldom, if
ever, do any real good ; and secondly, because they are dangerous,  and
have  proved fatal in  more  instances than one.   When it is considered
that  in  some cases the bony partition between the  Eustachian tube  and
the carotid canal  is  almost entirely  absorbed ; and that in others there is
but the  thinnest shell of bone, or perhaps only a mere membrane between
the tympanic cavity, or mastoid cells, and the cavity  of the  cranium, or
jugular fossa, (all of which morbid changes the  author has  seen in  Mr.
Toynbee's collection,) it will be very readily understood  how7 the pokings
in the dark at the Eustachian tube,  and forcible injections of the tympa-
num that we read of, may have very easily produced fatal results.   Per-
foration  of the membrana tympani, which has been proposed to be done,
so as to allow the access of air to the tympanum  when the natural  open-
ings in  the  throat are obliterated, is another operation  of very doubtful
utility.
   IV. Deafness  is often caused by blows on the head, which either pro-
duce concussion or rupture of the auditory nerve, or else extravasation of
blood into  the tympanum  or labyrinth.   Depletion, if any inflammatory
symptoms are present, with alteratives and counter-irritants afterwards, are
the only remedies; but  if deafness immediately succeed the injury, they
will scarcely relieve it.
   V. It may be produced by organic alterations in the brain, tumours, or
the like, and  may be attended with epilepsy or idiocy, or may be a con-
sequence of apoplexy or convulsions.  The treatment  must be  the same
as for amaurosis arising from similar causes (p. 364).
   \ I. Deafness is said  to be nervous, when it depends on  general torpor
and  debility, and is  better at some times than at others,  especially in fine
weather, and when the  patient is  cheerful or excited, and  the stomach in
good order.  It is a form of deafness common in the very  aged.
   Treatment.—Aperients and alteratives, with diffusible  stimulants, espe 
DISEASES  OF  THE FACE AND  NOSE.            379
cially ammonia, aether, and valerian, taken occasionally, and the employ-
ment of excitants locally;  such as stimulating  gargles (tinct. capsici f3fs
ad inf. rosu) Ofs), masticatories of pellitory, &c.  In many of these  cases
the meatus is dry, and altogether deficient in cerumen;  and great benefit
may be derived from the introduction of a few drops of fish-oil, or of ox-
gall, or turpentine, or the vapour of aether or of sp. am. ar. into the meatus,
and the application  of garlic, mustard, and  other counter-irritants behind
the ear.  Electricity may be mischievous.*
                        CHAPTER XIV.

  OF THE  DISEASES  AND INJURIES OF THE  FACE AND NOSE.

  I. Salivary Fistula is said to exist when the stenonian duct has been
perforated by a wound or ulcer,  so  that the saliva  dribbles out on  the
cheek.
  Treatment.—In the first place, a good passage must be established from
the  duct into the mouth.   This may be done by puncturing  the mouth
through the fistula  in  two places, passing a small skein of silk, or, still
better, a piece of very flexible wire, through  the  apertures, and  securing
the  two ends in the mouth by a knot.   After a few days, the edges of the
fistula must be pared, and  be  brought into contact by sutures, in order
that they may unite by adhesion.  When there has been  a loss  of sub-
stance, it may be necessary to apply the actual  cautery to the margin of
the  aperture, in order that the fungous granulations succeeding the burn
may supply the deficiency;  or to  cover it with a flap of skin  raised from
the  adjoining parts.
  II. Lipoma is a term employed to  signify an hypertrophy,  or sarcoma-
tous tumour, of the cellular tissue and skin of the nose, which is particu-
larly liable to affect persons who have  been  addicted to the pleasures of
the  table.   Such tumours  are  very inconvenient and  unsightly, but  not
malignant.  They grow slowly—are indolent and painless—the sebaceous
follicles are  much enlarged, and secrete profusely, and the skin is more or
less mottled with  veins.
  Treatment.—If the patient desires it, the tumour may be removed with
the  knife; but he must observe  rigid abstemiousness,  and have his bowels
well cleared for a fortnight previously.  An incision  may be made in  the
median line nearly down to the cartilage.   Then an assistant distends  the
nostrils with his fore-finger, whilst the surgeon seizes the morbid growth,
and shaves  it  clean off, close to the cartilage.  After the operation, there
will be considerable haemorrhage from numerous vessels.   Some of these
may be tied, some may be pinched with a forceps, some may be secured
with a very  fine cambric needle and thread; and any general  oozing may

  • Vide Copland Diet., Art. Ear and Hearing; Kramer on Diseases of the Ear, trans-
lated by Bennet; Pilcher on the Structure and Diseases of the Ear, Lond. 1838; Essay
on the Ear, by Joseph Williams, M. D., Lond. 1840; a paper by Mr. Toynbee in Med.
Chir. Trans., vol. xxiv.; and a notice of another paper, read before the Med. Chir.
Society, in Med. Gaz., 7th July, 1843. 
380
EPISTAXIS.
be restrained by the application of a cloth dipped  in cold water, or, if it
be obstinate, by plugging the nostrils,  and making pressure with strips of
plaster.
  III.  Foreign Bodies may be removed from the nose by a small curette,
or scoop, or bent probe.  If they cannot be brought through the nostrils,
they may be pushed back into the throat.  The removal should be effected
as early as possible.
  IV  Epistaxis, or hemorrhage from the nose, may, like other haemor-
rhages, be produced,— 1st, by injury ; 2dly, it may be an active haemor-
rhage of arterial  blood caused by general excitement and plethora, or by
determination of blood to the  head, or by the suppression of some other
discharge ; 3dly, it may be  a passive draining of venous blood,  owing to
obstruction of the circulation by disease of the heart or liver,  or to a mor-
bidly thin state of the  blood,  together with relaxation of the vessels, as
happens in scurvy, purpura, and the last stage of fevers.
   Treatment.—(1.) If the  patient be  red-faced,  plethoric, and subject to
headache and giddiness, the haemorrhage  should  be regarded  as  salutary,
and should not be  restrained  too suddenly.  If it be very profuse, and
attended with  much headache, venesection may be performed, and at all
events purgatives and  low diet should  be  prescribed.  Epsom salts in
small  doses, with  the  dilute  sulphuric  acid,  form an useful medicine.
(2.) But the haemorrhage requires to be stopped, either if it have continued
so long that the patient, will be  injuriously weakened, — or if  it arise from
injury, — or if  it be a passive haemorrhage depending on visceral  disease,
or general cachexy.  If an upright posture, cold  applied to the head, and
a piece of cold metal to the back, with a  draught of any cold liquid, and
compression  of the nostril do not stop it, the patient may snuff  up pow-
dered  gum, or gall-nuts,  or powered matico; and, these failing, the nos-
tril must be plugged with  lint, or with putty.   In very urgent cases, the
posterior orifice of the nostril must be plugged also.   This is easily done
by passing a bougie, with a long piece of silk fastened  to its end, through
the nostril into the pharynx.  The  end of the silk in the pharynx is  then
brought .through the mouth with a pair  of forceps, and a piece of soft
sponge, less than an inch in diameter,  is tied to it.   Then by pulling' the
silk  back through the nose,  the sponge is drawn  into  the posterior open-
ing of  the nostril.  [Belloc's instrument is the most complete contrivance
for arresting haemorrhage  from  the nose; the accompanying  figure illus-
trates it.  It is a canula of  silver, A, curved like a catheter,  but smaller.

                               Fig. 114.

          j—2—r~
Through this  canal a straight rod o(  silver, B, is introduced, to which is
attached a piece  of  watch-spring,  C, terminating in a  rounded  head,
which has a hole drilled in it for the insertion of a ligature.  The free ex-
 
NASAL  POLYPUS.
381
 tremity of the stem, B, has a button attached to it to prevent it from being
 drawn out of the canal;  a ring  is soldered to the inferior surface of the
 canula, to  aid in holding the instrument.   In introducing this, draw the
 watch-spring entirely within the  tube, so that the head shall form a smooth
 convex extremity to the canula; then pass the latter along the floor of the
 nostril, the concavity presenting downwards, until its head reaches the
 extremity of the  naso-palatine septum, when the spring is pushed out, its
 curved form causing it to find its way directly into the mouth ;  ihe  head
 is now drawn  forwards, and a  ligature, with a  plug of  lint attached,  is
 passed through the eye ;  the  remaining part of the  operation is  managed
 as in the other case.—Ed.]   The plugs or coagula, in  severe cases, should
 not be disturbed for three days.   Nitre, or other salines; or pills of plumbi
 acet., with draughts containing  vinegar, F. 128, may be  given with ad-
 vantage in inflammatory cases;  and the nitric or sulphuric acids, opium,
 alum, quinine, small doses of turpentine (Tr[ xv.),  and the ergot of rye, in
 those of atony and  debility.
  V. Nasal Polypus. — There  are four varieties of  this affection.   (1.)
 The common gelatinous polypus is a tumour of the  consistence of jelly,
 pear-shaped,  yellowish, slightly streaked  with blood-vessels, attached by
 a narrow neck to the mucous membrane, especially that on the turbinated
 bones,  and apparently consisting of organized lymph.   The patient has a
 constant feeling of stuffing and  cold in the head, which  is increased in
 damp weather.   If  he  force  his  breath strongly through the affected nos-
 tril, while he closes the  other,  the polypus may  be  brought into view.
 There are very often more than  one of these  tumours, and they are very
 liable to return when removed.   If polypus  be  permitted to remain,  it
 continually increases in size, blocks up the nostril, displaces the septum,
 and obstructs the other nostril, causes prodigious deformity of the  cheek,
 prevents the  passage of the tears, and may even cause death by pressure
on the  brain.
  Treatment.—A probe should be introduced  to feel  for the neck of the
polypus, which should then be seized with forceps, and be gently  twisted
off.   If, as sometimes happens, it projects backwards  into the pharynx,  it
must be extracted through the mouth with curved forceps.  After the  ope
ration,  the nostril should be plugged to restrain bleeding.   [The last edi-
tion  of Fergusson's " Practical Surgery" contains the following valuable
remarks on this subject:—" In general, such an instrument as that repre-
sented  in fig.  115, will enable the surgeon to effect his intentions, thus:—

                               Fig. 115.
The patient being seated, the blades of the forceps  must be  passed into
the nostril, one on each side of the growth, if possible, when they should
be closed over its roots, and withdrawn by a twisting, pulling motion, se-
as to separate the disease from the mucous membrane above.  In some in- 
382                      NASAL  POLYPUS.

stances this can be done readily, and with one  application of the instix-
ment; at other times it must  be  introduced again and  again, when the
substance is removed piecemeal; and the best criterion of the operation beinu'
complete is, that the patient can breathe freely through the passage. Some-
times it is necessary to repeat the  proceedings in the course of a few weeks
or months, as  the  ordinary simple  gelatinous  polypus, unless it  be tho-
roughly removed, is almost sure to grow  again.
  In certain instances when the tumour is  of considerable size a ligature
may be most advisable: this being drawn tight round the root of the mass
will cause its strangulation, when  it will separate in the form of a slough.
Whipcord, catgut, or silver wire, may be used on  these occasions ;  perhaps
the two latter are best from their elasticity, and either may be applied thus:
A portion twelve or eighteen inches long should be doubled, taking care
not to injure its elasticity at the bend ; this  part should  then be  pushed
along the floor of the nostril until it reaches  the pharynx, where it will be
allowed to expand ; and now the point of the forefinger or forceps of con-
venient length should be passed along the mouth into the  throat, and so
managed as  to push the gut or wire behind and above the growth ;  when
this is accomplished the ends must be introduced through a small double
canula, such as that here represented, (figure 116), which  should be slid

                               Fig. 116.
along upon them as high up as the root of the disease seems  to  extend,
and thus the noose will befurther up than the finger can push it: one end
of the ligature may then be fastened to the ring at the side of the canula, and
the other must be drawn so tight as to obstruct all circulation in the part:
it may then, if allowed to remain, be fixed to the ring of the tube, and
tightened from  day to day, until  the separation  is effected.   I have fre-
quently used the  ligature as thus directed; but have  almost invariably
drawn it through the mass, which has, therefore, been removed at once,
and I have never seen reason to dread  the haemorrhage which  some seem
to apprehend on these occasions.  Sometimes I have found the  part  so
compressible, that  it came readily through the nostril in front; but occa-
sionally I have withdrawn it by the mouth, and when the projection behind
is large it is well to be careful in case of  its  dropping into the  lower part
of the pharynx, or possibly covering the  orifice of the larynx.   If it could
be effected with safety, I should on all occasions separate the part  at once,
instead of leaving  it to slough ; but if  the latter were deemed most eligi-
ble, I should prefer a silver wire to any other ligature, and choose it, too,
before the forceps, which have been recommended by Sir Charles Bell and
others for the purpose.
  When a polypus is very large in front, so as to have caused absorption
oi the nasal process of the superior maxilla, the nostril may be slit open,
and the disease extracted through the  aperture by means of the  forceps.
I have known a growth  six ounces in weight successfully removed in this
way , and were it necessary, the upper  lip also might be divided.  In some 
DISEASES  OF THE ANTRUM.
383
 instances it may be deemed advisable and  necessary to remove a portion
 of the superior maxilla, turbinated and nasal bones, to permit the complete
 separation of growths in the nasal fossae.   Such operations have been per-
 fonned by Mr. Syme, Mr. Flaubert of Rouen, and Dr. Mott—the latter
 of whom has published an  interesting case  of this kind  in the January
 numbers  of  the "American Journal of Medical Sciences," for 1842 aad
 18-13.  The external edges of all such wounds must afterwards  be care-
 fully approximated, and immediate union encouraged."—Ed.]
   2. The hydatid polypus is a rare species, consisting of a number of thin
 vesicles filled with a watery fluid, and attached by a peduncle.  The vesi-
 cles burst upon the slightest pressure, and their reproduction may be pre-
 vented by touching the peduncle frequently with a hair-pencil dipped  in
 butter of  antimony.
   3. The carcinomatous polypus is nothing more  than a scirrhous tumour
 in the nose.   It may be known by its occurring to elderly persons; by the
 cancerous cachexia, the hardness of the tumour, and lancinating pain.
   4. The fungoid  polypus is a soft red  tumour, growing with great  ra-
 pidity, frequently bleeding,  and pursuing the ordinary course  of fungus
 haematodes.   This, like the last, admits only of palliative  treatment, and
 should not be meddled with by the knife.
   VI. Chronic Inflammation, and tumefaction of the Schneiderian mem-
 brane, produces a constant feeling of weight and stuffing, as from a bad
 cold in the head, and more or less discharge, which is very apt to be fetid.
 It is very common in young persons of scrofulous constitutions, and if neg-
 lected may lead to a very obstinate ozsena.   It is  to be treated by apply-
 ing one or two leeches to the inside of the nostrils, once or twice a week ;
 by keeping the bowels open with mild purgatives, and occasional doses
 of hyd. c. creta; and by administering sarsaparilla with alkalis, F. 40, 41.
 Sometimes, in young children, the membrane swells into  little red fleshy
 eminences, which may be touched with nitrate of  silver, but  must not  be
 mistaken for  polypi, nor be meddled with by the forceps.
   VII. Oz^na signifies an obstinate fetid discharge from one or both nos-
 trils.   It is, of course, a mere symptom, and may depend  either on  scro-
 fulous inflammation of the Schneiderian membrane ; or on ulceration ; or
 on disease of the bones, venereal  or scrofulous.  Sometimes it  depends
 on the formation of large clots of mucus  mixed with false membrane,
 which adhere and putrefy.
   Treatment.—Copious daily injections of warm  water, and of astringent
 lotions of nitrate of silver, sulphate of copper, or  of the chlorides of soda
 and lime,  the citrine ointment applied by means of a camel's hair pencil,
 and attention to the health, are the only remedies.
   VIII. The nostrils are sometimes imperforate, owing to  congenital mal-
 formation.  The passage  may (if the parents wish it) be restored by a
 cautious incision,  and must be kept  open  with  bougies.  If, however, the
 obstruction be seated far back, it ought not to be meddled with.

                 DISEASES  OF  THE ANTRUM.

  IX. Abscess of the Antrum may be caused by blows  on the cheek
but it more frequently results from the irritation of decayed  teeth.  The
symptoms are permanent aching and uneasiness of the cheek, preceded
probably by acute throbbing  pain and fever,  and rigors, and  followed, if 
384
DISEASES  OF  THE  ANTRUM.
an opening is not made soon, by a slow, general enlargement,—which, if
permitted to increase, causes bulging of the cheek, extrusion of tne eye,
obstruction of the lachrymal duct, depression of the hard palate, loosening
and dropping out of the teeth, and  closure  of  the  nostril.   The  parietes
of the cavity sometimes becomes so thin from distension, that they crackle
on pressure like parchment. Sometimes (though rarely) the matter makes
its way into the nostril; and sometimes the abscess points  externally, or
bursts into the mouth.
   Treatment.—A free  aperture must be made into the cavity.   If  either
of the molar teeth is loose or carious, it should be extracted, and  a  trocar
be pushed through the empty socket into the antrum.   But if all the teeth
are sound, or if they have been all extracted before, an incision should be
                                       made through the  membrane of
                Fi>. 117.                the mouth above the  alveoli of
                                       the molar teeth, and the  bone be
                                       pierced by a  strong pair of scis-
                                       sors or trocar, as represented in
                                       fig. 117.  The instruments should
                                       not be made  of too highly tem-
                                       pered  steel,  lest  they might
                                       break.  The cavity should be
                                       frequently syringed with  warm
                                       water, in order to clear away the
                                       matter, which is sometimes thick
                                       like putty. If the discharge con-
                                       tinues profuse and  fetid, search
                                       should be made with a probe for
                                       loose  pieces of  bone, which
                                       should be removed without de-
                                       lay, the aperture being enlarged
                                       if necessary.
                                         X.  Dropsy of the Antrum.
                                       — The   antrum  may  become
                                       enormously  distended,  and its
                                       parietes  thin  and  crackling on
                                       pressure, in  consequence  of an
accumulation of its natural clear mucous secretion, if the aperture  into the
nostril has become obliterated.  An opening must  be made in the manner
just described.
   XT. Fungus  Medullaris may commence in the lining membrane  of the
antrum, or in the sockets of the adjoining teeth. In its  first stage it causes
a sense of weight and stuffing, with perhaps epistaxis, which usually gives
relief to the symptoms  for a time.  Then the cheek bulges out, in the form
of a hard tumour.  After a time, some portion  of  it feels soft and pulpy,
and then bleeding fungous tumours project from the cheek, or  into the
mouth, or into the orbit, causing horrid pain and  deformity, with  profuse
fetid discharge: protruding the eye from its socket, and leading to the in-
evitably fatal results of fungus haematodes.
   Treatment.—The only remedy is extirpation of the superior maxillary
bone; but, to be of any use, it  must be performed before the diseased
growth has burst from the cavity, and before the skin and lymphatic glands
have become implicated.
 
              NON-MALIGNANT  OR  FIBROUS TUMOURS.          385

  XII.  A Non-Malignant or Fibrous Tumour is not unfrequently de-
veloped in the antrum, or on the external surface of the superior maxillary
bone.   On  a  section, it appears  a dense, homogeneous, fibrinous mass,
containing spicula of bone.   Its origin is generally ascribed  to  external
injury, or to disease of  the  teeth.  It may be distinguished  from malig
nant disease by noticing that its growth is slow, that its surface is lobulated,
that it feels hard and elastic, like brawn interspersed with bony particles;
that although the superjacent skin may become turgid and purple with dis-
tended veins, still that it does not become incorporated with the tumour;
and that although  ulceration  may accidentally occur on its  surface, still
that the ulcers are superficial, furnish  no fetid discharge nor haemorrhage,
and may heal on the removal of the exciting cause.*  These tumours may,
if suffered to remain, entirely obstruct the nose and mouth, and  so caust:
suffocation or starvation.
   Treatment.—The tumour must be extirpated entirely.   If  of moderate
size, and situated towards the front of the bone, the aperture of the mouth
may be  enlarged by an  incision from  the ala of the nose to the margin of
the  lip;  if  very small, this may not  be necessary.  At all events,  "the
mucous membrane  and  cheek must be dissected off the tumour as far up-
wards and backwards as its bulk renders necessary; then an incisor  tooth
and bicuspid or molar must be  extracted, and the  point  of the  knife  be
carried through the mucous membrane of the hard  palate, and every soft
texture which  it can reach, where it is intended to effect the separation:"
then the bone  on either  side of, and above the tumour, must be  grooved
with small saws,  of various sizes, after which its separation must be  com-
pleted with the cutting forceps.
  If,  however, the tumour is of larger dimensions, so  that it not only pro-
trudes in front, but also encroaches on the nostril, and pushes  the  eyeball
upwards, it will be necessary to remove  the whole of  the  superior maxil-
lary, and perhaps the malar bone  also.   To effect this, an incision  must
be made with  a straight  bistoury from the  nasal process  of  the  superior
maxillary bone to the mouth.   It must go quite down to  the bone, must
detach the nasal cartilages, and cut through the lip in  the median line. A
second incision must be made  from  the external angular  process of the
frontal bone to the corner of the mouth;  and  if the malar bone  is to be
removed, a third, at right angles to the  second, must  be made along and
down to the zygoma. The flap is then dissected up, the infraorbital nerve
divided, the inferior oblique muscle  and other parts  separated  from the
floor of  the  orbit, and supported with a narrow bent  copper spatula; the
nasal  process of the superior maxilla, and its junction with the malar, are
divided  with strong bone forceps (or, if the malar is  to  be  removed, its
junction with the frontal and zygoma must be divided instead)—a notch
must be made with strong scissors in the  alveolar process  of the middle
incisor tooth, (which should be extracted  before the operation,)—then the
anterior half of the roof of the mouth must be divided with a pair of strong
  •  -'Softness and rapidity of growth are," says Mr. Fergusson, "most indicative of ma-
lignancy in such  cases; and if combined with these, the limits  are  indistinctly defined.
and  there are constitutional  indications of such a growth, the disease is evidently one
of a serious character.  If. on the other hand, the swelling is hard and  slow of increase :
if the distinctions between it and the surrounding parts  are apparent; if the person
fcems otherwise  in good health, and in nowise disturbed by the swelling excepting by
the inconvenience resulting from its bulk, then there may be every reason to suppose
that it is benign in its character''—Practical Surgery, p. 483.
       33                         ?, 
386                RHINO-PLASTIC OPERATIONS.
cutting forceps, one blade being put into  the nostrils, the other into the
mouth.   The tumour, being thus loosened, is then to be  forcibly moved,
and its remaining attachments are to  be divided with the knife, carefully
preserving the velum  palati.   If the floor of the orbit is not implicated, it
should be permitted to remain;  and for this purpose, instead  of cutting
through the nasal process of the superior maxilla, the bone must be sawn
horizontally just  below the orbit.    During  the  operation, the common
carotid is to be compressed, to prevent haemorrhage.  After it,  the facial,
and any other arteries that require it, are to be tied, the chasm to be filled
with lint,  and the wound closed with sutures.*
   XIII.  Rhino-plastic, or Taliacotian Operations.—When a portion
or the whole of the nose has been  destroyed by disease  or accident, the
deficiency may be restored by a transplantation of skin from an adjoining
part,  the operation  being varied according to the extent of the  deformity.
   (1.) When the whole or greater part of the nose has perished, a triangular
piece of  leather should be cut into the  shape which it formerly  presented,
and be spread out  flat on  the forehead, with its base uppermost, and its
boundaries should be marked out on the skin with ink.   Then the remains
of the old nose (if any) are to be pared, and  the margins of the  nasal aper-
ture are to be cut into deep narrow  grooves.   When the bleeding from
these  wounds has ceased, the flap of skin marked out on the forehead is
to be  dissected up, and all the cellular  tissue down to the periosteum with
it, so  that it may hang attached  merely  by a narrow strip of skin between
the eyebrows.  When all bleeding has ceased, the  flap is to  be twisted
on itself, and its edges are to be fitted into the grooves made for their re-
ception, and to be  fastened with sutures.   The nose thus made is to be
supported, but not stuffed, with oiled lint; it should be wrapped in flan-
nel to support its temperature, and if it become black and turgid, owing

  * Vide Liston on Tumours of the Face, Med. Chir. Trans, vol. xx.; and Fergusson'l
Practical Surg'.ry, 2d edit. p. 507; also Lancet, Feb. and March, 1842. 
%
                   RHINO-PLASTIC OPERATIONS.                387

to a deficiency in the  return  of blood from it, a leech  may be applied.
When adhesion has thoroughly taken place, the  twisted  strip of skin, by
which  its connexion with the forehead was maintained, maybe cut through,
or a little strip may be cut out  of it, so that it may be laid down smoothly.
   (2.) The septum oxcolumna nasi is often restored by the same operation
with the nose itself, by means of a flap from the forehead; but it is better,
as  Mr. liston proposes, to form it out of the upper lip  at a subsequent
operation.  A strip is cut out  of the centre of the upper lip, a quarter of
an inch in breadth, and  of its whole thickness.  The fraenulum having
been divided, this strip  is turned up, but not twisted;  and its labial sur-
face having been  pared  off, and the inside of the apex  having been made
raw, the two latter surfaces are united by the twisted suture, and the wound
of the lip is also united  by the same.   During the  cure,  the nostrils must
be kept of their proper size by introducing silver tubes  occasionally.
   (3.) When one ala nasi alone is destroyed, a portion  of integument may
be measured  out  on the cheek,  and be  raised to  supply the  deficiency.
But if  both alae are lost, or if  the cheek be spare and thin, it is better to
supply their place with skin  brought from the  forehead.   The slip which
connects the  engrafted  portion with the forehead will of course be long
and thin; and in  order to maintain its vitality, a groove may be made to
receive it on the dorsum of the nose.  But when union has occurred, this
connecting  slip may be raised and cut off, and the groove which contained
it be united by sutures.
   (4.)  Depression of the apex of the nose is to be remedied by raising the
parts, dividing any adhesions that may have formed, making, if necessary,
a new  columna, in the manner described above,  and  supporting the parts
carefully with plugs of lint, till they have acquired  firmness.  But it may
be done still more completely by a method which was proposed by Diffen-
bach, and a modification of which has been practised with great success by
Mr. W. Fergusson.  " The point of a small scalpel," says Mr. Fergusson,
" was introduced under  the apex,  and the  alae were  separated from the
parts underneath; next the  knife  was carried on  each side between the
skin and the bones, as far as  the  infraorbital foramen, taking care not to
interfere with the nerves, when by passing the point of  my finger below
the nose, I caused the latter organ to be as prominent as could  be wished.
I now passed a couple of long silver needles, wilich had been prepared
for the purpose, with round heads and steel points, across from one cheek
to the other, having previously applied on each side a small piece of sole
leather, perforated with holes at a proper distance ;  then I cut off the steel
points, and  with tweezers so  twisted the end of each needle, as to cause
the cheeks to  come close to  each other, and thus to render the  nose pro-
minent.  Thus by bringing  the  cheeks more into the  mesial line, a new
foundation,  as it were, was given  to the organ. _ Adhesion occurred in
some places, granulations  in others, in the lapse  of ten days the  needles
were withdrawn, and in the course of a few weeks, when cicatrization was
complete, the  nose presented as favourable an appearance as could reason-
ably have been desired."*
  (5.)  Depression of the ridge,  owing to the loss of the  ossa nasi,  may be
remedied by paring the  surface,  and covering it with a flap of  skin from
the forehead ;  or by making a longitudinal incision, and engrafting a smaL
• Op. ci* ;  454. 
388                 FISSURE  OF  THE PALATE.
portion of skin from the forehead into it;  or, if the case is slight, by cut-
ting out one or two transverse slips, and bringing the cut edges together
by sutures, so that thus the surface may be stretched to its proper level.
  XIV. Hare-Lip signifies  a congenital fissure  of the upper lip.  Its
usual place is just on one side of the mesial line ; and it may exist on one
side only, or there may be a double fissure with a small flap of skin between.
Sometimes there  is also  a fissure in the  bony palate,—sometimes in the
soft palate  also,—and  the  upper incisor  teeth  and  their alveoli  project
through the fissure,—all which conditions give rise to considerable de-
formity and impediment in speaking and feeding.
   Treatment.—The edges of the fissure, which are red like the lip, are to
be pared, and then  made to unite by adhesion.   Sir A. Cooper  recora
mended that the operation should not be undertaken till the child is about
two years old, and has cut its teeth ; because of the liability of young in-
fants to be carried off by diarrhoea or convulsions ;  Mr. Fergusson believes
this risk  to be exaggerated,  and prefers operating shortly after  the child
has ceased to suck; provided, however, it is in good health, and not suf-
fering from its teeth at the time.  If the patient is a child, his body should
be entirely wrapped in a cloth, to prevent struggles ;  and the surgeon sits
behind him, taking the head between his knees.   Then  seizing the lip by
the corner of the fissure with his left forefinger and  thumb, he pierces it
with a bistoury at the top of the fissure  just under the nose, and carries the
instrument downwards, so as to shave  off the edge of the fissure, and the
rounded  corner at the  bottom; and it  is better to remove too much than
too little.   This process is repeated on the other side, and the two strips
are next  detached from the upper angle.  When bleeding is checked, the
edges are to  be  brought into  most exact union, and to be transfixed by
two or more hare-lip pins, or long slender needles, over which  a twisted
suture is to be made.   The first pin should be inserted near the angles of
the fissure ; and if the  labial  artery bleed, another should be placed so as
to transfix and compress it.   The pins should penetrate full two-thirds of
the thickness of the lip.  They may be removed on the fourth or fifth day;
and a slip of adhesive  plaster may be drawn from one  cheek to the other
instead.
  If the hare-lip  is double, both  sides  should be operated on at once, the
middle flap being transfixed  by the pins.   But care  should  be taken to
push  up the middle flap towards  the nose so as to render the latter organ
more prominent,  as it is in general very flat in cases of hare-lip.
  If one or more teeth project in the fissure, so as to offer any impediment
to its union, they should be  extracted ; and if the bone project much, il
may be necessary to remove a small  portion of it with the cutting  pliers,
the soft  parts on it having  been first divided with the knife;  but some-
times (as in a case related in  Cooper's Dictionary)  the  projecting  bones
may be pushed so far backwards by means of a kind of spring truss worn
daily for several  hours, that  the soft  parts may  be brought over them
without difficulty; and when  this can be  done  it is  far  better not  to
sacrifice any of the teeth.
  XV. Fissure  of the  Palate.—As the upper  lip  may be fissured
through defective development, so also may the various  parts constituting
the hard and soft palate.   Sometimes  the  uvula  merely is fissured; but
the cleft may extend forwards as far as the lips, and be combined  with a
hare-lip.   The fissure  in  the hard and soft palates is invariably  in the 
FISSURE  OF THE  PALATE.
389
mesial  line, but when it extends forwards  through the alveoli, it diverges
somewhat to one side.   In a few cases the fissure is double in front, so
that it may, as a whole,  be compared to the letter Y, the two lines in front
having the intermaxillary bone between them.
  This affection, when  extensive,  necessarily causes very great  difficulty
in sucking and swallowing;  and  if the child grows up, it causes a" very-
serious impediment to articulation.
   Treatment.—When the fissure  extends from  back to front,  entirely
through the hard and soft palate and lip, the lip should be operated upon
early ,°in the manner described when speaking of hare-lip.   The fissure in
the soft palate may at puberty be united by a somewhat similar operation,
which is known by the name of Staphyloraphy, and which has lately been
very greatly  improved  by Mr. W. Fergusson,
who for the first time has submitted  the  mal-
formed  parts to  dissection, and thus has ena-
bled us clearly  to  understand  the  operation,
and to  overcome the  difficulties which attend it.
  It had been often  remarked  that the action
of the  muscles upon  the edges of the fissure in
the soft palate was difficult of explanation.  If
the deformed part  is examined whilst perfectly
quiescent,  the gap is seen conspicuously, the
lateral flaps are distinct, and the posterior nares,
with the  upper  end  of  the pharynx, are ob-
served  above  and behind them.  If now the
flaps are  touched, they will in  all probability
be jerked upwards;  and if they be still further
irritated, each flap will  be still more forcibly
drawn  upwards  and  outwards, so as hardly to
be  distinguishable from the  rest  of  the  parts
forming the  sides of the nostrils  and throat.
But, on the other hand, if the pharynx be irritated, and made to  perform
the act of deglutition, the margins  of  the fissure  will be brought together.
  Now it  is easy to understand both that  the separation of the flaps must
be produced by the action of the palatine muscles, and also that this must
occasion a very serious  impediment to any operation for uniting them by
adhesion;  but the  muscular action by which the flaps are brought together
was a mystery till Mr. Fergusson showed  that it was caused by the upper
semicircular border of the superior constrictor muscle of the  pharynx,—
and to  him is due the credit of proposing that the muscles which tend to
separate the flaps should be divided, instead of endeavouring to counteract
them by random  incisions in the  soft palate, as had been the practice of
surgeons previously ;—and of showing what thy  muscles are, which really
need to be divided ;—viz., the levator palati, and palato-pharyngeus.
  The operation is thus described by Mr. Fergusson: — " With a knife
whose blade is somewhat like the point of a lancet, the  cutting edge being
about a quarter of  an inch in extent, and the flat surface being bent semi-
circularly,  (Fig. 120,) I make an incision, about half an inch long, on
each side  of the posterior nares, a little above and parallel to the palatine
flaps, and  across a line straight downw-ards from the  lower opening of the

    * From a preparation of Mr. W. Fergusson's in the  King's College Museum.
       33*
 
390
CANCER OF THE LIP.
Eustachian tube, by which I divide the levator palati on  both sides, jusl
above  its attachment to the palate.  Next I pare the edges of the fissure
Fig. 120.
L.
with a straight, blunt-pointed bistoury, removing little more than the rau-
cous  membrane;  then, with a pair of long blunt-pointed curved scissors,
I divide the posterior pillars of the fauces, immediately behind the tonsil,
and if it seems necessary, cut across the anterior pillar too ;  the wound in
each part being about a quarter of an inch in extent.  Lastly, stitches are
introduced by means of a curved needle set in a handle ;  and the threads
being tied, so as to keep the cut edges of the fissure accurately in contact,
the operation is completed."
   The knot is a thing of some importance, both because it is exceedingly
                         difficult to keep the edges of the cleft in contact
                         after the first noose is cast and before the second
                         is  made;  and  likewise,  because  if the knot
                         itself lies in the trunk of the wound, it causes
                         slight ulceration, and  prevents it from healing.
                         The  author believes that the simple and inge-
                         nious knot  depicted  in  the adjoining woodcut
                         will  be found  to  obviate both  difficulties, and
                         prevent the  necessity of  having  recourse to
                         leaden  wires  and the other  contrivances  pre-
                         viously in use.
                           Fissures in the anterior part of the bony palate
                         may  be diminished by lateral compression  dur-
                         ing  growth;  and, after puberty may either be
                         palliated by means  of an obturator of gold or
                         caoutchouc,  or relief may be  attempted by
                         means of an operation first proposed by Dr. J.
                         This consists in paring off the  tissues from  the
bones on each  side of the  fissure, in two lateral flaps, and stitching the^e
together in the mesial line.*
   The patient should abstain from talking or swallowing for  the first eight
and forty hours after  the operation, and may be nourished by enemata of
beef soup.
   XVI.   Cancer of the  Lip  may commence  in  either  of the forms
described under the head  of cancer of the skin, p. 209, but most fre-
quently as a small fissure, (usually attributed to the irritation  of smoking,)

  * For further information, vide Fergusson's Practic*! Surgery, 2d edition, and his pa-
per in Med. Chir. Trans, vol. xxviii.; also Listo^'s Practical Surgery, and South's Che-
lius.  The author has to  thank Mr. Fergusson for his kindness in communicating many
interesting particulars concerning this  operation, and in particular for  leave to have  •
drawing made  of the above knot, before it was published  elsewhere.   [See  also the
Am. ed. of Liston, by Dr. Mutter, in which these operations are  very  fully described.
-"Ed.'
Warren, of Boston. 
CANCRUM  ORIS.
391
which gradually degenerates  into a ft-ill ulcer, with hardened base and
ragged surface.
   Treatment.—The disease must be extirpated by a V incision—taking
care to include the whole of it—and uniting the wound  afterwards like
that made in the operation for hare-
lip.   If, however,  the  whole  or
greater part of the lip be implicated,
the diseased parts should be freely
removed without any attempt  to
unite  the edges of the  incision.
The extirpation cannot be expected
to  be effectual  unless  performed
before the glands are implicated—
but it is justifiable at any stage—in
order to avoid for a time the horri-
ble pain and fetor of the ulcerative
process.   It has been very clearly
shown   by Mr.  Earle,   that  any
ulcers,  if subjected to  perpetual
irritation,  (and  especially  ulcers
near the outlets  of the body,) may
assume  a  malignant  appearance,
which ceases on  the removal of the
source of irritation.   When there-
fore there are foul ulcers on the
lips, cheeks, or tongue, the  teeth
should be well examined in order to remove any roughness, or collection
of tartar, and the secretions of the skin, bowels, and kidneys  should be
carefully attended to.
   XVII. Cancrum Oris—(Phagedena  oris, gangrenous erosion  of the
cheek)  is  a phagedceno-gangrenous  affection  of  the  lips  and cheeks,
occurring almost exclusively amongst  the ill-fed squalid children of large
towns.  It appears to be a disease of debility, and  to be induced by want
of proper food and of fresh air, and by neglect of cleanliness.   Like other
disorders of a similar character, it is very liable to follow the measles or
scarlatina, or any other severe and weakening illness.
   Symptoms.—In the instances which have fallen under the author's  ob-
servation, it has commenced as a shallow ulcer on the lip,  or inside of the
cheek;  with  a peculiar  dirty gray or  ash-coloured surface, and black
edges.   Sometimes it is  said to  commence with an  exudation of  a pale
yellow fibrinous matter,  like that which is exuded  in croup and some
forms of putrid  sore throat.  At the  same time the face is  swollen, the
breath  exceedingly  fetid, and there  is  a dribbling of fetid saliva  mixed
with blood.   If  the disease proceeds,  the ulcer  becomes gangrenous, and
destroys the  cheek and gums ; the teeth  drop out, typhoid symptoms
supervene, and the patient  dies  exhausted.   The swelling which accom
panies this disease shows nothing like active or healthy inflammation.   It
is moderately firm, or what may be called semi-cedematous, and is either
pale, or else of faint pink colour.   In  the most rapid form of the disease,
it commences at once as a black spot of gangrene, which  slowly spreads,
and is  not  accompanied by any inflammation whatever; all  the parts
around being quite pale  and wax-like.   The constitutional symptoms  an»
Fig. 122.


 
392                 DISEASES  OF  THE TONGUE.

at first those of weakness, and disorder of the stomach and bowels, and
afterwards the rapid feeble pulse, and stupor of typhus.
   Diagnosis.—The diagnosis of this affection is of some importance, be-
cause when a child has died of it, the parents, through ignorance or malice,
are liable to bring  the surgeon into  trouble, by accusing him of havino
caused death through profuse  mercurial salivation.  The chief points of
distinction are, that in this disease the ulceration or gangrene is circum-
scribed, and is generally confined to one  side;  and that it  commences
usually in the cheek, and that it only affects  that part of the gums which
is in close  contiguity, and that  the  tongue  is untouched.   Whereas in
severe  mercurial salivation, the ulceration  is  diffused ;  the  whole of the
gums, and the lining membrane  of the cheeks, and the tongue, as well as
the palate, being affected from the first.
   Treatment.—The indications are threefold.   1st. To evacuate and cor-
rect the secretions of the stomach and bowels by  mild but efficient purga-
tives—especially rhubarb  and magnesia, which  should be  administered
daily.   The author believes that one  or two grains of calomel  may he ad-
vantageously added to the first dose, although the practitioner may deem
it prudent to avoid the risk of being accused of causing the disease by this
remedy.  2dly. To keep  up  the  strength by wine, beef-tea, and other
nutritious articles, and by bark or quinine in sufficient doses.   The chlo-
rate of potassa  has been  strongly recommended, and  maybe given in
doses of gr. xx.—xl. in  the twenty-four hours.  3d. To excite a healthy
action in the  diseased part by stimulating  lotions, especially  solution  of
nitrate of silver, alum, sulphate of copper, or the chloride of  lime;  and,
lastly, if these means  fail to arrest the  disease, the  strong nitric  acid should
be applied so  as to destroy the whole of the  diseased part, in the same
manner as was directed for hospital gangrene.*
  XVIII. Small Tumours, semitransparent and  fluctuating, containing a
glairy matter,  and probably consisting of obstructed mucous follicles, are
often met with on the inner surface of the cheeks and lips.
  XIX. Ranula is  a tumour of the same  nature, situated under the
tongue.  It may consist  either of one  of the Whartonian ducts, or of a
follicle obstructed.   This and the foregoing  tumours are best treated by
snipping out a small piece of  the sac, and rubbing the interior with lunar
caustic ; or by passing a small seton  through the sac.
  XX.  Tongue-tie  signifies  a prolongation of the fraenum linguae, con-
fining the apex of the organ to the lower jaw.  It is usually detected by
the difficulty which the infant  has in sucking; and may easily  be  relieved
by dividing the fraenum with a blunt-pointed pair of scissors,—taking care
to direct their points downwards, and to keep as close to the lower jaw as
possible, so as to avoid the lingual artery.
  XXI.  Wounds of  the tongue  are liable to  be attended with severe he-
morrhage from the  lingual artery.  If the bleeding orifice cannot be tied,
one or more ligatures must be introduced with curved  needles, so as to
include and constrict  the bleeding parts;  or a heated iron may be applied
through a tube.

  * Vide James on Inflammation, p. 527 ; Marshall Hall in Lancet for 1839-40, p. 409,
P. H. Green, ibid.; and also  in Cycl.  Pract. Surg.  Art. C antrum  Oris; Willis on  Cu-
taneous Disease; Hunt, Med. Chir. Trans,  vol. xxvi.  [See also  the works of Rilliet
and Barthez;  Yalleix; and J. F. Meigs, » On the Diseases oi Children,"  Philad U»-l*.
—En.'; 
DISEASES OF  THE TEETH.
393
   XXII.  Inflammation  of  the  tongue, known  by  great  swelling,
tenderness,  and difficulty  of speaking and deglutition, must be treated
by bleeding and leeches, purgatives,  slight incisions,  and the antiphlo-
gistic regimen  generally.  Inquiry should be made whether the patient
has been taking mercury.  If abscess form, the fluctuating part should be
opened.*
   XXIII.  Hypertrophy. — Slow enlargement,  without tenderness  or
structural disease, sometimes  affects  the tongue, causing it  to protrude
permanently from the mouth.   The superfluous portion may be removed
by ligature, — a needle armed  with a  strong  double  ligature being
passed through the  centre  of the tongue, and one thread being then tied
very tightly round  each half.  But if it be not  very  considerable, a \
shaped portion  may be cut out from its anterior extremity, the cut surfaces
being united by suture  after the bleeding vessels are tied, and oozing has
ceased.
   XXIV. Cancer.—A foul excavated ulcer, with  extremely hardened
base, and prominent edges, with burning and lancinating pain, and pre-
ceded by nodular scirrhous enlargement.  The  constitutional symptoms
are those of the cancerous cachexia.
   Treatment. — The  diseased  part should be early extirpated with the
knife ; or, if extensive, with ligatures, in the manner before described.
   XXV. Ulcers on  the Tongue, presenting very formidable characters,
are often  attributable to local irritation  (from  diseased teeth, &c), or to
some derangement  of the health—perhaps a venereal taint.   The  obvious
indications  are, to  remove irritation  from rough teeth,  to  keep up the
secretions of the liver and bowels, to  regulate the diet, and  support the
strength.   Plummer's pill, sarsaparilla, or F. 39,  42, hyoscyamus and
conium—perhaps iodine—and the local and general treatment of irritable
ulcers, will  be of service.
   XXVI.  Stammering.—This affection requires to be noticed here, be-
cause two operations, within  the last few years, have been  proposed for
the cure of it.    They consisted in making deep gashes  in the tongue, and
in extirpation of the uvula and  tonsils,—proceedings  so barbarous and
irrational, that it is  surprising that surgeons could be found  to do, or pa-
tients to submit  to them.
   XXVII. Lancing  of the Gums.—If at any time during dentition  a
child is feverish  and restless, with its stools slimy and day-coloured,  or if
there are any symptoms of disorder in the head or chest, the gums should
be examined; and  if any part, especially where a tooth is soon expected,
appears red  and swollen, a free incision should be made with a sharp gum
lancet quite down to the tooth.   This  affords  instant relief by removing
the tension and pain.
   XXVIII.  Irregularity of the Permanent Teeth is a frequent  con-
sequence of injudicious haste in extracting the temporary set—an opera-
tion wdiich not only permits the arch of the jaw to  become contracted, but
disturbs the  nutrition of the permanent teeth, hurries their appearance, and
  * Sometin.es the tongue enlarges suddenly to an immense size, so as almost to cause
suffocation, but without any symptoms of inflammation  properly so called.  A case
which proved fatal in spite  of  bleeding, leeching, calomel, and incisions, is related by
Mr. Lyford, of Winchester, in the Lancet for 18-28, p. 16; a similar case, cured by pur
galives and incision, by Mr. Taynton, Med. Gaz. vol. xxii.; who speaks of it as the
only case he had seen in a practice of forty years; and one by Mr. Collins (ib. p. 643",
in a pregnant woman, cured by an incision in the raphe on the under surface.
\ 
391
CARIES  OF THE  TEETH.
 ensures their early decay.  The temporary set should, therefore, always be
 suffered to remain as long as possible.   The only ones that there need be
 any haste in extracting  are the  upper incisors, in order to  prevent their
 successors from growing behind their natural position, which would render
 the mouth under-hung.   If either of the canine  teeth, or of the  incisors
 of either jaw, project much, the  patient should be  taught perpetually to
 endeavour to push it back into its proper situation with his  fingers.  But
 if at the age of fourteen or fifteen this method has not succeeded, and the
 teeth are much crowded, the projecting  tooth may be removed, although
 in many cases it is better to sacrifice  one of the bicuspides to make room
 for it.   If a growing child is under-hung, so that the under incisors come
 in front of the  upper ones when the  mouth is shut, or so  that the teeth
 meet at the cutting edges, instead of the lower teeth being received within
 the upper, it should  be encouraged daily to push the upper teeth forwards
 with its tongue and fingers ; and should frequently put the end of a spoon-
 handle  behind the upper incisors, and  then  close  the mouth, using the
 spoon as a lever to  press  the upper teeth forwards  and  the lower ones
 backwards.   But if  these simple means do not  succeed,  recourse should
 be had to the appliances used by professional dentists.*
   XXIX. Fracture and Dislocation of Teeth.—If a  portion of a
 tooth is broken off, without exposing the pulp cavity, the exposed surface
 should be filed smooth, and then  no inconvenience will  probably follow.
 If it is snapped off at the neck, and the pulp cavity is exposed  and very
 painful, it should be touched with  lunar caustic, and the mouth  be  fre-
 quently bathed with  strong poppy decoction; and when pain and tender-
 ness have ceased, an artificial  tooth  may be  fastened by a pivot to the
 stump.   If, however, the root of the tooth is loosened,  it had better be
 extracted at once.  If a tooth is loosened by a blow, it should be fastened
 by silk to its neighbours.   If a tooth is  entirely driven out, it  should be
 replaced as soon as bleeding has  ceased, and  be fastened in by silk; no
 food should be allowed that requires mastication, and inflammation should
 be combated by repeatedly leeching the gum.
   XXX. Caries of Teeth signifies a successive  softening and decay. It
 generally begins at the surface of the bone of the tooth, and appears as a
 dark spot underneath the enamel, which after a time gives  way and ex-
 poses a  cavity.   The decay gradually  spreads and reaches the central
 cavity of the tooth, which from that time is subject to fits of toothache.
 This disease seems to depend generally on original weakness of the teeth,
 which is often hereditary, and appears to be connected with the strumous
 diathesis.  The profuse administration of mercury during early childhood
 is conceived to be a predisposing cause.   The use of very hot  or very
 cold drinks—and especially of ices and sweatmeats, are  supposed to  be
 exciting causes.
   Treatment.—If the caries be slight and recent, the whole of the decayed
 portion should be removed by proper instruments, and the cavity be fil'ed
 up with gold,  or an amalgam  of silver and mercury.   But if the  de-
 cay has advanced far towards the pulp cavity, or has laid that open, it may
 be necessary first, to  use  some applications to deaden the sensibility of the
tooth, so as to enable it to bear the stopping,  and to protect it meanwhile
from contact with food and saliva.  For these purposes the best plan is to
  • A good a-xount of which will oe found in Mr. Tomes's Lectures on Dental Surgery,
 in the Lond Med. Gaz  vols, xxxvii. and xxxviii. 
TOOTHACHE.
395
fill  the  cavity with a composition  of powdered chalk, with  a very little
tannin,  mixed up into a paste with a solution of mastic in alcohol; or else
with a little bit of cotton wool dipped in a solution of one scruple of tan-
nin, and the same quantity of  mastic, in half an ounce  of aether, F. 126 ;
or frequently to introduce a drop of some narcotic or stimulating solution
—such  as a solution of  acetate of morphia, or of  nitrate of silver (gr. x.
ad 3i), or alcohol, or sp.  camph.  By these  means the tooth  may very
probably be brought into a state to bear stopping with gold.   The patient
should avoid exposure to cold, or drinking very hot, or cold, or sweet, or
acid fluids, and should be careful not to  induce feverishness by any errors
in diet.
  A pecuMax fungous excrescence occasionally grows from the lining mem-
brane when  exposed by caries.  Sometimes  it  is indolent,  sometimes
acutely  sensible ;  but it  always gives more or less  annoyance  in  mastica-
tion.  A strong solution of nitrate of silver is the  best  application.  The
lining membrane, when exposed or irritated  by caries, is also  liable to
ulcerate and suppurate.
  XXXI. Toothache.—This  disagreeable infliction has several varieties,
which depend  on different circumstances.  Thus  it may depend (1.) on
caries and exposure of the central nervous pulp.   This form of toothache
is generally very intense ; a shooting, agonizing pain, not inflammatory in
i:self, though  if it continues, it gives rise to an inflammatory condition of
the  parts around.  It is exceedingly liable to be induced by anything that
irritates the tooth, or disorders  the general health.
  Treatment.—We may arrange the  multifarious  remedies for this form
of toothache in the following order,   (a) Purgatives and low diet are  in-
dicated if die pain followed exposure to cold or excess at table, and if it
is attended with foul tongue, hot skin, and headache,  (b) Scarification of
the gums, or leeches to  them are useful, if the tooth has become tendei
and the gums swollen,   (c) Rubefacients to the cheeks—especially ammo-
nia and aether applied in the palm of the hand, or  mustard poultices, may
be sometimes  of service ;  and (d) Sialagogues, especially, ginger, cloves,
and pellitory,  or steaming the  mouth with hot water, may be so likewise;
but it is a most barbarous custom to treat toothache by  the indiscriminate
use of  heating substances; which, in  fact, inflame the interior of the
mouth,  and can do no good to the tooth,  (e) Anodynes.—A small quan-
tity of laudanum, or of  a solution of morphia, or a paste made with  opii
gr. j. camph. gr.  iv.—or of morphia, chalk, and solution of mastic ;—or a
drop of tincture  of  aconite—inserted into the tooth, are  often of great
benefit;  but it is  not generally  of use to administer large doses of opium
internally—they disorder the system without adequately relieving the pain.
A drop  of the hydrocyanic acid inserted into the hollow of the tooth,
and two minims of the  same,  given  every four hours in a saline  draught,
are  the best remedies of this class,   (f)  Stimulants—such as the essential
oils of cinnamon, origanum, cloves, and  the like,—creosote,—solution of '
the  nitrate of silver,—alcohol,—diluted hydrochloric acid (3fs ad 3ii aquae)
—are popular  remedies, whose efficacy is supposed to  depend  on their
exhausting the sensibility  of the nerve.   But, be  it observed, that they
should be applied in very small quantity, and solely to  the cavity of the
tooth ; and that it is barbarous  and useless to apply them to the  *ums as
many persons  do.  When the  lining membrane  is exposed, and there is
severe toothache,  some dentists introduce either a  drop of a strouij  solu- 
39C
TOOTHACHE.
lion  of nitrate  of silver, or else a little fragment  of it, and stop up the
cavity  with wax,  or diachylon plaster, softened between  the fingers,  (g)
Astringents.—A  solution of half a drachm of alum  in half an ounce  of
nitric aether is one of the popular remedies that sometimes succeeds; but
of all anti-odontalgic remedies .whatever, the audior believes the best to be
tannin, in the form of an aetherial solution, F. 126 ;  the use of which  he
gratefully acknowledges to  have learned from his friend Mr. Tomes. This
is  particularly beneficial if the tooth  looks soft, or the gum swollen and
flabby; and especially if, as frequently happens, a bit of  the gum  grows
into  the cavity of the carious tooth,  (h) Alkalis.—It sometimes  happens
that  toothache arises from disorder of the  stomach, and an  acid  state  of
the secretions of  the mouth;  and may be  relieved  almost immediately  by
rinsing the mouth with a solution  of carbonate  of soda,   (i)  Cauterants.
—It  has  been proposed to introduce the concentrated sulphuric  or nitric
acid, or a red hot wire, into the carious cavity, in order to disorganise the
nervous pulp.  But these  remedies can scarcely ever be applied with  a
certainty of accomplishing their object—if they do  not cure the toothache,
they  will be sure  to aggravate it,—and in  the  hands of a bungler they
might be productive of very great mischief.   The  chloride of zinc  is the
most useful of this class  of substances.  It was  recommended by Mr.
James, and has  been  extensively used by  Mr. Tomes, in  the following
manner: He dilutes it with ten parts  of  powdered  plaster of Paris, and
then  dips the end of a little roll of softened wax in this powder, and stops
it  into  the cavity.
   We  may sum up the treatment of this form of toothache as follows: —
let the  patient have an aperient dose;  let him wash  out the mouth  with a
solution of carbonate of soda in water ; let the gum around the tooth, and
between  it and its neighbours,  if tumid, or tender, be deeply  scarified
with a  fine lancet;  then let the cavity be  filled loosely with a little bit of
cotton  dipped into the  solution of tannin; and if the toothache is curable
at all,  this plan, with a little patience, will be almost sure  to succeed.  If
the pain  is very violent, half a grain of powdered acetate  of morphia may
be taken up with the cotton  imbued with the tannin ; which should  be
warmed  before  it is put into the cavity.   As soon  as the  pain is relieved,
the  tooth, if of use, should be  stopped with gold or amalgam;  if of  no
use,  it  should be extracted.
   (2.)  It may  be remarked that the  gum in  the  interstice between a
decayed tooth and its neighbour often  becomes spongy, and swelled, and
excessively sensitive;  giving  rise to  a very wearing kind  of toothache;
and  causing excruciating  pain if a  portion of the  food happens to  be
pressed down upon it.  This  may be relieved by  a deep  incision through
the swollen gum, and the application of tannin, F. 126, and by such ape-
rients as tend to unload a congested mucous membrane.
   (3.)  Inflammation of the central pulp sometimes affects a tooth  that is
apparently sound.  It  occasions severe, heavy throbbing  pain, extending
to the  head, and considerable  tenderness  of the tooth and of the gum
around.   It  may lead to  suppuration of the pulp, or to abscess  in the
alveolus, and death of the tooth in consequence.
   Treatment.—Leeches, low diet, and purgatives.
   (4.)  When a tooth is partially decayed, it very frequently causes inflam-
mation of the periosteum of its socket, which swells  and so  causes the tooth
to feel  looser, and larger than natural.   The gum around the neck of  the 
EXTRACTION  OF  TEETH.
397
tooth  is generally highly vascular.  This state of  things often ends in a
gum.-boil, or alveolar abscess.  A leech, or a deep incision in the gum
between the diseased tooth and its neighbours, and fomentations of poppy
to the interior of the mouth are the remedies.
   (5.) JVeuralgic toothache, whether it occurs in  teeth that  are  entirely
sound, or partially carious, is to be distinguished by its occurring  in  par-
oxysms which come  and go suddenly, in more or less regular intervals.
It is very common in the earlier months of pregnancy.
   Treatment.—Quinine or the carbonate of iron in large doses, together
with aperients and alteratives, are the most successful remedies.
   (6.) Toothache sometimes  has the characters of chronic rheumatism; —
flying about the jaw, affecting no tooth in particular, and not  relieved by
extraction,  so much as by blue pill and aperients, with  small doses of col-
chicum.
   (7.) It sometimes happens that the fang of the  tooth is thickened by a
deposit of  bone;  in which  case the tooth becomes affected with severe
pain that can  hardly be distinguished from that of neuralgia.  It some-
times occurs on teeth that  are perfectly sound,  but  more generally  on
carious teeth, or  stumps.  The excessive pain of this affection is in general
only to be relieved by extraction.
   XXXII. Necrosis of Teeth.—A tooth is said  to be necrosed when it
has become black  and unsightly, and loose in its  socket.  This affection
may be caused by blows which have torn across the nutrient vessel^—or
by inflammation  of the pulp (perhaps from the abuse of mercury).  Ex-
traction must be  performed, if the tooth cause  inflammation  or other
inconvenience.
   XXXIII. Extraction of  Teeth.— The  instruments  for extracting
teeth are the forceps, the elevator, and the key-

                 Fig. 123.
  (1.)  The forceps is  the  instrument that is
now generally employed by dentists.  It should
be made with sharp edges,  so  that it  may be
pushed  up between  the  tooth and  the  gum,
and should  seize the tooth by its neck, close
to the  alveolus.  For  this  purpose also,  the
jaws of the  instrument should be made  to in-
cline towards  each other in such a way, that
they may slip up and embrace  the neck of the
tooth accurately when the handles are  pressed
together;  and they should  be  ground in such
a manner that they may be adapted  accurately to the shape of each tooth
For this purpose,  the  surgeon will require  several  sets of instruments.
Two are required for the  upper molars—one for each side, because of the
third fang which projects  inwards.   The above figures  show the manner
       34
Fig. 124.
 
398                  EXTRACTION  OF  TEETH.
in which they should fit the depressions and elevations of the tooth   One
will  suffice for the lower molars, both  right and  left,  because they  have
only two fangs.   One instrument will be necessary for the bicuspides and
canines of the upper jaw, and another for those of the lower jaw ;  and two
sets will  be necessary for the incisors of either jaw.
   In  extracting teeth  by the forceps, there are  two  things to be done;
first to loosen the tooth, and then  to  pull  it straight  out.   In extracting
the incisors and canines of the upper jaw, ihey may first be loosened by
giving them  a  gentle  twist, combined with a slight rocking motion, and
then  may be pulled perpendicularly downwards with a slight inclination
backwards.   The incisors and canines of the lower jaw are to be loosened
by giving them a firm but gentle motion  backwards and forwards, and
then  may be pulled straight up.   The bicuspides and  molars are to be
loosened by moving them from side to side, so  as to  make the  alveolar
process yield a little, and then they may  be  pulled perpendicularly, up-
wards or downwards, as the case may be.   The  operator should grasp the
forceps firmly, in such  a  manner  that  it  may move  altogether  with his
hand; but yet not  so forcibly as  to run the risk of  crushing the tooth.
The two preceding figures were sketched by Mr.  W. Bagg from the hand
of Mr. Tomes.
   (2.) The elevator is highly  useful for stumps,  and for old  straggling
teeth.  The point is to be thrust firmly down  between the tooth  and its
socket, and  then  by bringing  the  instrument  into a  horizontal position,
and making a fulcrum of the eAge of the alveolar process, or of the adjoin-
ing tooth, or of the operator's fingers, the tooth may be lifted out.
   (3.) The key is an  instrument that  is very generally employed for the
extraction of the bicuspides and  molares ;  but it is more painful than the
forceps, and every one must know instances of laceration of the gum, and
splintering of the alveoli, followed  perhaps  by tedious exfoliation, that
have been produced by the clumsy use of this  instrument; not to  mention
the risk of the claw slipping from  the decayed  tooth and dragging out a
sound neighbour instead.   If, however, it is preferred, care should be
                  taken to select an  instrument  of  proper size, and to
    Fig. 125.       place the fulcrum in a proper position.  If the key is
                  too small, and the fulcrum  too high, very probably the
                  crown of the tooth will be snapped off.   If the key is
                  too large, and  the fulcrum  too  low, either the  claw of
                  the  instrument  may be snapped across, or the  alveolar
                  process be  extensively splintered.   The  adjoining
                  figure is intended  to show the right  position, which
                  will draw the  tooth more or less perpendicularly  from
                  its socket.  The fulcrum ought to be placed on the
                  inner side for the  bicuspides of the lower jaw, and
                  molars  of the  upper; and on the outer  side for the
                  molars  of the lower jaw.   The denies sapientie oi the
upper jaw should never, according to Bell, be  extracted with the  key,
because of the  delicate texture of the bone  on which the fulcrum must
rest.
  Before extracting teeth with  the key, it is usual to  cut away the  gum
from their necks  by means of a gum  lancet; — a practice which some
authorities consider unnecessary.  It certainly is unnecessary in the ma-
jority of eases, especially foi the  extraction of the temporary teeth, and of
 
INFLAMMATORY  ABSORPTION.
399
the teeth of old persons which have separated from the gum, and become
loose  in their  sockets; —yet it may be performed either if the  gum  has
been subject to repeated inflammation, which renders  it adherent to  the
tooth, and liable to be lacerated on its removal;  or secondly, in order to
afford room  for the claw, if the tooth has decayed  down to the gum.
Some persons, instead of using a lancet, separate the gum by means of a
small tenaculum.
  Hemorrhage after Extraction of Teeth. — This operation  may be  fol-
lowed by very severe and dangerous  haemorrhage,  which sometimes
appears to come from the dental artery at the bottom of the socket; some-
times from the gums,  when they have been  long  diseased.  A strong
solution of nitrate of silver may be tried first, or a  piece of matico leaf may
be put  into  the socket;  but if neither  of these  remedies succeeds,  the
alveolus must be plugged in the following way:  It is first to be cleansed
from coagulum; then one end of a long thin strip of lint  is  to be firmly
pressed into it, so as to come  into contact with  its very bottom, and the
remainder in successive  portions is to be forced in till the socket is filled
up to the level of the gum.  A compress should then be placed  on  the
part, thick enough to be pressed  upon  by the antagonist teeth, and  the
mouth should  be kept firmly closed by a bandage passing from under the
chin to the  vertex.  Some persons plug the  alveolus with putty ; or by
inserting again the tooth which has been extracted.
  XXXIV.  Tartar, or salivary calculus, is an  earthy matter deposited
on the teeth  from the saliva.  It is found  most  abundantly on the superior
molares and inferior incisors, — obviously because  those teeth are  the
nearest  the orifices of the  salivary ducts. If suffered to accumulate,  it
causes inflammation and absorption of the gums, and gradual loosening
of the teeth.
   Treatment.—The deposit of this substance is to be prevented by taking
care not to  disorder the stomach, and  by the strictest cleanliness.  The
teeth  should  be cleaned at least  twice  a day, with a soft  tooth-powder
(camphorated  chalk is the beet) and a  little soap.   The hairs of the tooth-
brush should be soft, and not too closely set;—so that they may penetrate
the better into the  interstices of  the  teeth.   When any quantity of the
tartar has accumulated, it should be removed  by the scaling instruments.
The edge  or point of the instrument is to be  introduced between the con-
cretion and the gum, so as to detach the former in flakes; — in the mean-
while a finger  or thumb, guarded with a towel, should be  pressed firmly
on the cutting edges of the teeth, so that they may not be loosened by the
force  necessarily employed.  Sometimes a small  portion of this substance
is found sticking in the orifice of one of the salivary ducts, and creating
great discomfort by its irritation.   It may be  easily removed.
  XXXV. Inflammatory  Absorption, vulgarly called  scurvy of the
gums, generally affects middle-aged or elderly people,  and may  be a con-
sequence of  the accumulation of tartar, but more  frequently depends on a
congested state of the liver and bowels.   The gums are swollen, spongy,
exceedingly  tender, and subject to constant  aching  pain, and they bleed
on the slightest touch.   If the disease  proceeds, they separate from the
teeth; the alveoli gradually become absorbed, and the  teeth loosen,  anu
at last fall out.  These  consequences  are  sometimes speedy, and  are
attended with suppuration  in the alveoli, but more fiequently they are
slow,—the teeth dropping out one by  one in  the  course of years. 
400
TUMOURS  OF THE  LOWER JAW.
   Treatment.—The gums should be unloaded by deep and free scarifica-
tions  and repeated leechings; the bowels  should be well cleared  by a
course of purgatives and mercurials;  and gargles  should be employed tc
correct the  secretions of the mouth, and excite the vessels to contract.
Whilst there is much pain  and* soreness, dec. papav. vel  anthemid., oi
three  drachms of nitre dissolved in a pint of barley-water, will answer best.
Subsequently, recourse may be had to F. 80, or to gargles of dec. ciuchon.
with  alum or dilute  sulphuric acid and tinct. myrrhae, or of liq. calcis
chlorid. f3j. to  half a pint of  brandy and water.
   XXXVI.  Gum Boil (alveolar abscess, parulis) is a small abscess com-
mencing in the  socket of a tooth, and bursting through the gum, or some-
times through the cheek.  It. is usually caused by the irritation  of a dead
or carious tooth.
   Treatment. — Leeches  and  fomentations;  removal  of the tooth, if
much  decayed  ; and a  puncture  as  soon  as  matter can  be detected.
If the tooth is  extracted soon, the sac  of the abscess very often comes
away  with it.    t
   XXXVII.  Epulis  signifies a tumour formed by an hypertrophy of the
gum,  without any apparent  alteration in  its  structure.   It generally com-
mences between two teeth, which it gradually separates, then loosens, and
finally displaces,—and may spread so as to involve several of them.   This
tumour is indolent,  painless, and of slow growth;  but it ought always to
be extirpated without delay, because it is sure to increase, and might be-
come the  seat of offensive ulceration, or even of malignant disease.
   Treatment. — The  tooth on either  side  must be  extracted, and the
tumour entirely cut out.  A  portion of the alveolar process  must be
removed  likewise,  if necessary,  in  order  to  render  the  extirpation
complete.
   A similar tumour is sometimes formed  when a dead portion of the  root
of a tooth remains  in its socket, and the gum has healed over it.  The
tumour should  be  entirely removed with the knife, and  the  extraneous
body  should be sought  for, and be  extracted  if possible.   Malignant
tummirs of the gums are exceedingly rare ; they will, however, be recog-
nised  by their rapid growth, and tendency to haemorrhage.
   XXXVIII. Tumours of the Lower Jaw may, like those of the upper,
be either  simple or malignant.   Their distinctive characters  have  been
before alluded to.   Free extirpation is the only remedy.   If the tumour
is large, and situated  near the middle of  the bone, it must be exposed by
making an incision from each  angle of the mouth down to the bottom of
the chin ;—a tooth must be extracted  on each side of the tumour;—next
the bone  may be sawn half through  perpendicularly on  each side, and
then be  divided completely  by the straight cutting  forceps,  one  blade
being passed up on  the inner side  of the bone, and  the  other placed in
the groove made by the saw;—and, lastly, the parts attached to the inner
side of the bone must be cautiously divided,—namely, the digastric, mylo-
hyoid, genio-hyoid, and  genio-hyo-glossus muscles.   When the attach-
ments  of  these muscles  are  divided, care must be  taken  not to let the
tongue  retract into  the throat, which  might push back the epiglottis  and
cause  suffocation.   To prevent this, a ligature may be passed through the
tip of the tongue, by which it may be held forwards during the operation,
and which may be  fastened to the  twisted suture by  which the wound is
afterwards to be closed. 
CLOSURE OF THE  JAWS.
401
  If, however, the  disease is not so very extensive, it may not be neces-
sary to sacrifice the wiiole thickness of the  bone, but a horizontal portion
of the base of the bone may be  saved,  which will prevent the chin from
falling  in after the operation.  In  order to effect  this, the bone may be
sawn downwards  for half its depth on each  side  of the  tumour, and a
horizontal cut be made below it;  and then  the diseased portion  be sepa-
rated completely with the cutting pliers.
  If a lateral portion is to be removed,  an  incision  should be made from
the lower lip  to the chin, and along the basis of the bone,  to its posterior
angle.   Thus a flap is formed, which may  be  turned up so as to furnish
a good view  of the tumour, and then the bone is to be divided as before
described.
  If the extent of the disease renders  it necessary to remove the entire
side of the bone, and to separate it from its  articulation with the temporal,
—the operator must begin by making a curved incision from  beneath the
ear, along the basis of the jaw, to the chin.   The flap so formed is to be
dissected up, and  the masseter with it; an incisor tooth is to be removed,
and the bone to be sawn  vertically through;—the end is next seized and
depressed, and the temporal  muscle dissected  from  the coronoid  process;
the pterygoid  muscles and  other  internal attachments are  then  to  be
divided, and finally the ligaments of the joint.  Whilst effecting the dis-
articulation of the condyle, the point of the knife should be kept close to
the bone* so  as to  avoid all risk of wounding  the external carotid artery.
After bleeding has been restrained, the wound is to  be closed by sutures,
excepting at  the middle, where an aperture  should be left for the ligatures,
and to  permit the  escape of discharge.*
  XXXIX.  Closure  of the Jaws, with  more or less inability to  open
the mouth, and to masticate solid food,  may be a result of disease of the
bone implicating  the joint;  or of rigid cicatrices within the  mouth pro-
duced after sloughing,—whether caused by drinking  boiling water, or by
the profuse administration of mercury.   The  division of any  rigid bands
of cicatrices,—the division of the masseter muscle  by subcutaneous sec-
tion, a  narrow knife being thrust from the mouth between the  muscle and
the skin,—an operation which has been successfully performed by Mr.
\V. Fergusson,—and the use of a  screw dilator,—are the only available*
remedies.

  *  Vide Liston's Elements of Surgery, and Practical  Surgery, 2d edition;  Copland's
Diet. art. Haemorrhage; Sir A. Cooper's  and Lawrence's Lectures;  Guthrie in Med.
Gaz. vol. xvii.; Brodie, ibid. vol. xv.;  Liston on Tumours of the Face, in Med. Chir.
Trans, vol. xx.; Bell  on the Teeth; Jobson on the Teeth; and Fergusson's Practical
Surgery.   Disease of  the lower jaw requiring amputation has been caused by a projec-
tion anteriorly of the coronoid process, which hindered the  evolution of the wisdom
tooth.  Forbes's Rev.  vol. viii.
34 •
Si 
402
DISEASES  OF THE  TONSILS.
Fig. 126.
                        CHAPTER XV.

  OF  THE SURGICAL  DISEASES  AND  INJURIES OF THE  NECK.

    section  i.,—surgical diseases  of  the fauces.

  I. Acute Inflammation  of the Tonsil is known by rapid swelling
of the part, great pain in deglutition, and fever.   It must be treated by-
leeches or bleeding, purgatives, gargles calculated to produce the secre-
tion of saliva (F. 80),  and the ordinary antiphlogistic  routine.  If the
tdand continue to swell, or if it occasion any embarrassment to the breath-
ing, an incision should be made  into it to unload the  vessels, and give
            exit to  matter.   The tongue should  be depressed with one
            fore-finger, whilst a straight bistoury  wrapped round with
            lint except an inch and a half of its point, is plunged directly
            into the tumour,  and made to cut its way out towards the
            median line.
               II.  Chronic Enlargement of  the Tonsil is  a frequent
            sequel  of  repeated  inflammation,  especially  in  scrofulous
            children.   It causes sundry inconveniences.  The parts are
            liable to frequent attacks of acute inflammation ; deglutition
            is impeded; the  voice is  rendered  hoarse;  respiration is
            noisy  and  laborious, especially during sleep; there  is more
             or less deafness from the obstruction of the  Eustachian tubes;
             and suffocation  has  even been  caused   by  viscid mucus
             entangled between the swollen glands.  The tonsil has been,
             in rare cases, the seat of malignant disease.
               Treatment.—In the first place, the system must be strength-
             ened,  and the secretions kept up by proper tonics and altera-
             tives.   The iodide of iron, the combination of corrosive sub-
             limate with tinct. cinchonae, and  other remedies  mentioned
             at p. 60,  may often be administered with benefit.  At  the
             same time, absorption of  the tumour must be promoted by
             astringent gargles (of  dec. cinchon. with  alum, or F. 83)—
             by washing it once a day with  strong lotions of arg. nit., or
             cupri  sulph. on  a hair pencil,—by applying  stimulating, or
             mercurial, or ioduretted liniments and ointments  to the skin,
             —and by lancing the  gums over the wisdom  teeth if tumid,
             and removing any decayed teeth  that cause irritation.  But
             if these measures fail, part of the gland should be removed
             with the knife—a much more expeditious and cleanly method
             than  the  ligature.  The   surgeon seizes the tumour with a
             hook  or vulsellum (depressing  the  tongue with  its  handle),
             then introduces  a blunt-pointed curved bistoury, and shaves
              it off, cutting upwards, rrrallel to  the isthmus faucium.  The
              nearest half of the blact  of the bistoury should be  wrapped
              in lint, to prevent the lips from being cut; and in operating
              on the right side, the  surgeon will find it  most convenient to
              cross his hands;' the left, holding the vulsellum, being under-
              most.  There are certain other instruments occasionally used
 
                  DISEASES OF  THE  OESOPHAGUS.              403

 for this operation, such as a kind of guillotine instrument, consisting of a
 ring with which the  tonsil  is encircled,  and a blade  moving in a groove ;
 but the simple knife and forceps answer  every purpose.  [The neatest and
 best instrument for  the removal of the tonsil  is one contrived by Dr.
 Fahnestock, of Pennsylvania ; fig. 126 illustrates it.—Ed.]
   III. Enlargement of the Uvula produces tickling cough and expec-
 toration  by irritating the  larynx.   If it does not yield to the treatment
 directed for enlarged tonsil, it should be stretched and steadied with for-
 ceps, and be cut through in the middle  with a pair of long scissors.

 SECT.  II.--SURGICAL  AFFECTIONS OF THE CESOPHAGUS.

   I.  Spasm  of the CEsophagus  (spasmodic stricture) is known  by its
 generally occurring in sudden fits—the  patient  at a  meal finding himself
 altogether incapable of swallowing, and the attempt to do so producing
 spasmodic pain and a sense of choking.   The diagnosis between this and
 the organic ox permanent stricture is founded on  the suddenness of  its ac-
 cession ; it being much better at some times than at others; and the fact
 that the bougie, if  passed, either meets  with  no  obstruction, or with one
 that very easily yields.
   Treatment.—This affection always depends on a weakened or hysterical
 state of the system, or on the presence of some other disorder, as has been
 mentioned whilst treating of neuralgia.   Brodie relates a case that ceased
 on the removal of bleeding piles; and Mayo, another that was  cured by
 relieving chronic disease of the liver.  Tonics, antispasmodics, and altera-
 tives—especially the carbonate of iron thrice a day, with pills of aloes and
 galbanum at  bed-time—exercise  in  the open air, the shower-bath, and
 other forms of warm and cold bathing—great attention to the diet—care
 not to  swallow anything imperfectly masticated or too hot, and  the occa-
 sional passage of a bougie,—are the remedies.
   II.  Palsy  of the  (Esophagus  occasions  inability of swallowing, but
 without pain or other symptoms of spasm, and a bougie, when passed,
 meets with no obstruction.   It generally depends on organic disease of the
 brain or spinal cord, which must be examined into and cured if possible.
 The patient should be fed by the stomach-pump,  by nutrient enemata, and
 by pushing soft  food  occasionally down the oesophagus with  a probang.
 The palsy has sometimes been temporarily relieved by electrifying the pa-
 tient on an insulating stool.  Nutrient  enemata  should be composed of
 very strong beef or mutton broth, without salt or  spice.  The quantity in-
 jected  at one time should not exceed four ounces ; and if the rectum does
 not retain it, a few  drops of laudanum should be  added.
   III.  Dilatation and  Sacculation.—The oesophagus has  been  found
 after death exceedingly dilated.   The symptoms during life  were, great
 dysphagia,—food, when  swallowed, never seemed to  reach the stomach,
 and was vomited in a few minutes.   If this condition should be ascertained
 during life, the patient should  be fed  as in palsy.   Sometimes a blind
 pouch is  connected with the  oesophagus, and occasions great distress in
 swallowing, by intercepting the  food.  It may be formed either by a pro-
 trusion of the  mucous membrane through the muscular fibres,  or by the
 sac of an abscess which has burst into the tube.   The only remedy is, to
feed the patient constantly with the stomach-pump, so that the pouch may-
be allowed to close. 
404              DISEASES OF THE  CESOPHAC.IS.
  IV.  Permanent Stricture  of the oesophagus  signifies a  narrow.ng
produced by an inflammatory thickening of  its mucous and  submucous
coats, which form  a firm ring encroaching on the  canal.   It is generally
found just below the termination of the pharynx ; that is, opposite the cri-
coid cartilage,—and  is most frequent in  females.   The  symptoms  are,
difficulty of swallowing,—noticed  probably for years—gradually increasing
—never absent—and occasionally aggravated by fits of spasm.   The act
of swallowing frequently produces pain in the chest, which shoots between
the shoulders, and  up to the head.   When a bougie  is passed, it meets
with an obstruction, and displays  the impression of the stricture on its ex-
tremity.   The causes of this affection are generally unknown:  sometimes,
however, it appears to be a sequel of repeated quinsy,  or to be caused by
swallowing boiling or corrosive liquids; in one case it appeared to be in-
duced by violent retching in  sea-sickness.   The prognosis  is  always
serious, especially if the complaint is of long duration.   If unrelieved, its
consequences will be ulceration of the oesophagus, either  above or below the
stricture, with salivation,  vomiting  of purulent matter, and impossibility
of  deglutition, which in no long time will  be followed by death.  The
fatal termination may be owing  either  to sheer starvation, or to  the irrita-
tion of the local disease, or the  extension of ulceration to the lungs.
                             Treatment.—A mild  course  of mercury, so
                           as just to affect  the gums,—occasional leech-
                           ing, to relieve exacerbations of pain or spasm,
                           —combined  with hyoscyamus or conium, if
                           there  be much  irritability—a  seton between
                           the  scapulae,—and the occasional passage of a
                           bougie, or of a  ball probang—an  ivory ball
                           attached to a piece of whalebone or flexible
                           wire—or of a piece of sponge  moistened with
                           a wreak solution of nitrate of silver, and attached
                           to a stout  copper wire, as recommended by
                           Sir  C. Bell, are  the remedies.  The  method
                           of introducing the bougie is as follows:  The
                           patient sits upright, with the head  thrown as
                           far  back as possible, and the mouth wide open.
                           The  bougie, which  should  be  previously
                           warmed in the   hand and  oiled, and gently
                           curved, is passed  down into  the pharynx in
                           such  a manner that its point may slide along
                           the vertebrae.   In order that it may not excite
                           cough by interfering with  the epiglottis, the
                           patient  should  be directed to protrude the
                           tongue from the  mouth as  far as possible; or
                           to perform the act of deglutition just when the
 bougie is entering  the pharynx.   If it meets with an  obstruction to its
 descent, the surgeon should slightly withdraw it, then again press it gently
 against the obstruction, increasing the pressure for a few minutes if it gives
 no pain.   If it fail to pass, it should be taken  out and its  point be exam-
 ined ; and if it bear the  impress of a stricture, a smaller one should be
 iried.
  * This cut exhibits a stricture of the oesophagus.  From the Museum of the Middlesex
 Hosoital.
 
DISEASES  OF  THE CESOPHAGUS.
405
   V. Ulceration of the oesophagus is generally situated at its upper part,
 and on its posterior surface.   It causes great dysphagia, and burning pain
 on the passage of food.  If a bougie is passed, it meets with one obstruc-
 tion just  above the ulcer,  and with another just below it, and its point
 returns marked with bloody pus, and presenting the ragged impression of
 the ulcer.
   Treatment.—Alteratives, counter-irritants, and nutrient enemata.   The
 burning pain is sometimes  relieved by swallowing small quantities of iced
 cream.
   VI.  Malignant Disease.—" Infiltrated  scirrhus, deposited in a strati-
 form manner, encircling the walls of the tube more or less completely, and
 causing gradual diminution of its calibre," is the  most common form of
 malignant disease in this  part.*   It produces at  its commencement the
 same symptoms as stricture, and must be treated in the  same manner, by
 cautious dilatation.
   VII.  Tumours pressing  on the oesophagus,—whether  abscesses,  aneur-
 isms, bronchocele, or enlargement of the bronchial  lymphatic glands, will
 produce all the symptoms of organic stricture.   Aneurisms and abscesses
 have been burst by the passage of bougies—with, of course, instant death
 in the former case, and relief in the latter.   Before  performing this  opera-
 tion, therefore, the chest ought  to be well scrutinized by auscultation, to
 detect  any unnatural pulsation or bruit; and any signs of embarrassed cir-
 culation or respiration should  not be overlooked.!
   VIII.  Foreign Bodies,  wiien fixed in the pharynx, or about the aper-
 ture of the larynx, or in the oesophagus, produce  a sense of choking, and
 fits of suffocative cough.   This accident, if unrelieved, may prove fatal in
 two manners.   The patient  may either be  suffocated at once, by spasm
 of the  glottis; or, if the foreign substance remains  impacted, it may pro-
 duce a  fatal ulceration of  the parts, attended with  exhausting cough and
 dyspnoea, and  profuse fetid expectoration.
   Treatment.—The  patient should be seated  in a chair, with the head
 thrown back, and the mouth wide open.   The  surgeon  should then intro-
 duce his  finger—regardless of attempts  to vomit—and should pass it
 swiftly into the pharynx, and  search the whole of  it thoroughly.   When
 the substance is felt, it may perhaps be entangled in the point of the nail,
 or curved forceps may be guided to it by the finger.  Pins  or fish-bones
 are often entangled about the velum, or in the folds of mucous membrane
 between the epiglottis and  tongue.
   If the body has passed into the oesophagus, and it is small and sharp (a
 fish-bone for instance), it may be got rid of by making the patient swallow
 a good mouthful of bread.   If large and soft (as a lump of meat), it may-
 be  pushed down into the stomach with  the probang.   But large hard
 bodies, especially if rough  and angular, (such as  pieces of bone or glass,
 &c.) should be brought up  if possible.   A pair of long curved forceps,  or
 a piece  of whalebone armed with a flat blunt hook, or with a skein of
 thread, so as to form an infinite number of nooses,  are convenient instru-
 ments.   If the stomach is full, a dose of tartar emetic dissolved in  a verv
  * Walshe, op. cit. p. 271.
  f \ ide  Sir E. Home, on Strictures, vols. i. and ii.; Monro on the  Morbid Anatomy oi
die Gullet, &c.; Brodie on  Local Nervous Affections (spasmodic stricture;)  Mayo's Pa
thology;  Stokes in Cyclop. Pract. Med. vol. ii.; and Sir C. Bell's Institutes of Surgery
vol. L 
406
(ESOPHAGOTOMY.
small quantity of water  may be administered, in  the hope that when the
contents of the stomach are  vomited, they may  bring up the offending
substance with them.   One case is on record in  which a  chicken  bone
lodging in the oesophagus was  dissolved by making the patient swallow
large quantities of dilute  acid.  If all means fail, however, and the sub-
stance can neither  be brought up  nor down, and if it be lodged in the
cervical portion of the tube, it must be extracted by the operation of oeso-
phagotomy in the following manner.
   IX. (Esophagotomy.—This  operation  should  be performed on  the
side towards which the foreign substance projects.  Its situation  having
been  ascertained, an incision of  sufficient length must be  made through
the skin and  platysma between  the  sternomastoid  muscle and trachea.
The cervical fascia  must next  be  divided on a director.   The surgeon
must  then  divide  the cellular membrane with a blunt knife, or lacerate it
with his fingers, avoiding the carotid and thyroid  arteries and  the recur-
rent nerve.   A common silver catheter may then be  passed down the
throat, and be made to project in the wound, so that the oesophagus may
be opened by cutting on it.   This small wound in the oesophagus should
be dilated with forceps, in order to  avoid  haemorrhage, and  the foreign
body should then  be extracted.  This  operation has  occasionally been
performed for the purpose of conveying food into the stomach in cases of
stricture of the cesophagus, but with no very satisfactory results.*
   X. Use  of the  Stomach-pump.—The tube of this instrument is to be
introduced in the same manner as the cesophagus bougie.   It  is usual to
place a gag  in  the  patient's  mouth, having  a hole for the tube to pass
through, in order that  it may not be compressed by the  teeth.  Before
pumping out the contents of the stomach, one or two pints of water should
be  injected  into  it, and  care should  be taken not to  withdraw quite ai
much as was  injected.  More water should then  be thrown in, and the
process should be repeated till it returns colourless.
   The stomach-pump is by no means so universally efficacious as is popu-
larly supposed.  It ought only to be employed in those cases of poisoning
by  opium, or alcohol, or other  narcotics, in which  the  stomach and
nervous system are  rendered so insensible that vomiting cannot be excited.
For, in the first place, the operation is not free from danger.  It is a well-
established fact, that a tube may sometimes  be passed into the trachea of
a sensible  person without  creating any peculiar sensation, or exciting
cough ; but if the patient, be insensible, that accident will be much more
liable to happen.   In fact, a case is  on record in which a meddling sur-
geon, with more zeal than knowledge, did actually pass the tube down
the trachea, and  inject  the  lungs  with chalk mixture, which he had far
better have permitted his luckless patient to have swallowed quietly; and
Sir C. Bell tells us that he has seen, on dissection, both lungs filled with
broth, which was intended to have been injected into the stomach.  Again,
it  is known that in one  case the mucous  membrane of the stomach was
sucked into the holes of the tube, and torn into strips, — a thing likely to
happen if the  stomach  is pumped too empty.  Besides, this artificial
evacuation of the stomach is by no means so efficacious as free vomiting,

  * Vide Arnott on CEsophagotomy, Med. Chir. Trans, vol. xx.;  Report of a case in
which it was performed unsuccessfully for the relief of stricture, by Mr. Watson of New
york, and of two cases in which it was performed for the removal of a foreign body
in  -'-i's. ii. and til of Ranking s Abstract. 
        FOREIGN BODIES  IN  THE LARYNX AND  TRACHEA.     407

assisted by plenty of diluents.  Lumps of arsenic were left in the stomach,
in the very case just cited, in which the mucous membrane was torn.  But
yet  surgeons have been reprimanded by attorney coroners and " respect-
able" juries  for not using this instrument,  even in cases where it  must
have been either useless or injurious.  These are  the fruits of permitting
the  office of coroner to be filled by men who have no  knowledge of the
subjects that they are required to sit in judgment on.*

SECTION  III.--SURGICAL  AFFECTIONS  OF  THE  LARYNX
                         AND  TRACHEA.

  I. Foreign bodies  in the  Larynx and Trachea. — It  sometimes
happens that a person who is busily laughing and  talking during a meal,
suddenly rises from table, attempts to put his finger into his throat, spee-
dily turns blue in the face, and then drops down dead.   This arises from
a piece of food getting into the rima glottidis; a thing liable to happen if
a sudden  inspiration be made through the mouth, as in laughing, when
the mouth is filled with food.  It  rarely happens that the  surgeon arrives
in time to do any good; but  if he should be promptly on the spot, he
ought  to search the pharynx with his  fingers, to ascertain whether the
obstruction can be removed ; — and  if  not, he ought to perform laryngo-
tomy immediately; — and to pass a probe up into the larynx through the
wound, so as to push the foreign substance up into the  mouth.
  When a foreign substance has passed the rima glottidis, and has got
into the trachea, it will produce different symptoms according to different
circumstances.   For, in the first place,  it  may become impacted in the
ventricles  of the larynx or upper part of the trachea ;  in which case it will
probably produce violent spasmodic cough and difficulty of breathing, to-
gether with  a fixed pain referred to one  particular spot — a croupy sound
during respiration, whjch may be heard  by the stethoscope most distinctly
at the seat of that pain ; and loss of voice.
  In the second place, the foreign substance may be loose in the trachea.
In this case, the violent coughing and sense of suffocation produced by its
first introduction generally subside for a time ; — but every now and then
there are violent fits of coughing, and of spasmodic difficulty of breathing,
during which the substance may be heard  by means of the stethoscope, or
perhaps may be  felt by the finger to be forcibly impelled against the upper
part of the larynx.
  Thirdly, the foreign substance may have passed into one of the bronchi,
(generally the right,) where  perhaps it may  be  detected by  causing  a
whistling  or murmuring sound ;  and it will very probably be dislodged
and driven upwards when the patient coughs.
  It is sometimes difficult to distinguish the symptoms produced by a fo-
reign body in the larynx or trachea from those of croup or laryngitis.  But
the surgeon  may generally pretty confidently decide that a foreign body is
present, if the symptoms came on suddenly during a  meal; or perhaps
the history will be that  the patient was  playing with  a button, or cherry-
stone, or some similar  body in his mouth, and that he chanced  to  fal.
down,  when the button disappeared, and the symptoms came on directly
  *  Vide an amusing Clinical Lecture on the abuse of the Stomach-pump, by Professor
Watson, in Lond. Med. Gazette, vol. xvii.; and Roupell's Illustrations of the Effects of
Poisons. 
408
LARYNGOTOMY  AND TRACHEOTOMY'.
afterwards.   Moreover, in these cases, expiration is generally more diffi-
cult than inspiration, whereas it is usually the reverse in croup.  Besides,
when there suddenly occurs a fixed pain, and a fixed whistling sound in
the larynx or  bronchi, without any other symptoms  of croup, the  case
must almost  of necessity  arise from a foreign body.*
   Treatment.—For the  removal  of any foreign  substance from  the  air-
passage, recourse must be had to one of the two operations next described.
   II.  Laryngotomy and Tracheotomy.—The former of these operations
is most quickly and easily performed, and is to  be preferred in sudden
emergencies, but the latter most readily admits of the  removal of foreign
bodies, and is generally chosen in cases of suffocation from disease.
   Laryngotomy is performed by cutting at once, through the crico-thyroid
membrane, which may be  felt as  a  soft  depression, an inch below the
pomum Adami.
   Tracheotomy is thus performed: The head being thrown back, an inci-
sion, an inch and a half to two inches long, must  be made  exactly in the
median line from the cricoid cartilage to the top of the sternum.   The
skin, superficial fascia, and fat, are  then  divided; the  sterno-hyoid mus-
cles are separated with the point of the knife ;  the loose cellular tissue and
veins are cleared from the front of the trachea with the  fingers or handle
of the  scalpel; the thyroid gland, if in the way, is pushed up ;  then  the
patient being told to swallow, the surgeon seizes the moment, and whilst
the trachea is stretched, sticks in his knife, with a slight jerk,f at  the bot-
tom of  the wound, and carries it upwards, so as  to divide three or four
of its rings.  The operator must take great care to keep in the middle
line, and must  be very cautious not to cut downwards at the bottom of the
wound, for fear of the large veins.   Haemorrhage may be arrested, if arte-
rial, by the ligature ; if venous, by nicely adapted pressure ;  which must
be kept up with the point of the fingers if nothing else  suffices.  As soon
as an opening is made, the foreign body is usually expelled with a strong
gust of air; but if  not, it must  be  searched  for with a probe, and be re-
moved by forceps or by a blunt hook.  If there is any  difficulty, the plan
may be tried, which has  recently been practised with  success, of turning
the patient with his head  downwards, in order to let the foreign substance
fall through the rima glottidis; and  it may be remarked that as soon as an
artificial passage is  made  for the patient to breathe through, the great irri-
tability of the  natural aperture  subsides,  so  that  it permits  the  body to
                 pass. The wound may be closed by plaster when bleed-
    Fig. 128.      ing has  ceased, but not before.
                    If the  operation  were performed  for  the relief of
                 dyspnoea, a conical curved tube  should be introduced
                 for the  patient  to breathe through.   From its shape, it
                 fits tightly into the aperture, and prevents the entrance
                 of blood into the trachea.  It should be of  such a size,

  * Vide an interesting paper  by Mr. C. Hawkins, and another by Mr. Travers, jun., on
this subject, Mpd. Chir. Trans, vol. xxiii., and a notice of a paper  read by Sir B. Brodie
on Mr. Brunei's case, Med. Gaz. July 7th,  1843.
  ■j- The trocar is, as Mr. Fergusson justly observes, a most clumsy and  inefficient in-
strument for opening the trachea ; which being an elastic tube, yields and bends before
the pressure necessary to introduce  the  point of it.  The author once  saw a surgeon
fruitlessly endeavour to use it;  and he seemed  in great danger either of running it
through both trachea and oesophagus into the vertebrae, or else of letting it slip sidewayi
into the jugular ve/iv
 
*
                LARYNGOTOMY  AND TRACHEOTOMY             409

as Trousseau has remarked, that the air may pass through it in respiration
without any  whistling  noise.*  When  the  patient  wishes to cough or
speak, he must be  taught to close  its orifice with his finger.   It should be
frequently cleared  of any mucus that may lodge in it.
  The operation of opening the  larynx  or trachea may be required for
various diseases and injuries  which  cause  mechanical  impediments to
respiration ; such as acute  laryngitis, croup,  chronic  laryngitis with ulcer-
ation, cedema glottidis,  tumours, and  some injuries  which have  crushed
the larynx.   We  have  space  for a very few observations only on  these
cases.                   ♦
  III. In acute laryngitis  and in croup,f where bleeding and other anti-
phlogistic remedies fail  to make any  impression
on the disease, it is generally agreed upon that
tracheotomy  should  be performed,  without
waiting till the  patient  is exhausted by strug-
gling for breath,  and  his  case   has  become
hopeless in consequence.   In the state called
cedema glottidis, in which  the  submucous tis^
sue about the  glottis becomes infiltrated  with
serum in consequence  of  a low degree of in-
flammation, or  of  a general dropsical diathe-
sis, a glance  at the adjoining figure will show
that an artificial aperture must  be  often  neces-
sary to  preserve life.   This state may be sus-
pected when intense dyspnoea, not referable to
disease in the chest, arises  during sore throat,
or erysipelas  ; or when  it occurs spontaneously in unhealthy constitutions,
without any acute  inflammatory symptoms.
   IV. In chronic  inflammation and  ulceration of the larynx, the operation
should  also  be performed  before the disease  has  lasted  long enough to
exhaust  die  patient  by the  spasmodic cough, dyspnoea, and  purulent
expectoration which attend it.  This disease is an occasional consequence
of secondary syphilis, as mentioned  at p. 200, and more frequently of con-
firmed phthisis; but the operation should always be performed if there is
imminent danger  of suffocation,  even though the  patient's ultimate re-
covery may be quite hopeless.
   V. The operation  is sometimes  required for tumours or w/arty excres-
cences growing within the  larynx; — cases that will  generally be obscure,
inasmuch as  their  symptoms must be  nearly the same as those of chronic
inflammation, viz., spasmodic cough,  dyspnoea, and  wheezing respiration.
   VI. A  Polypus growing  from  the  Epiglottis has  been known to
produce fits of suffocative spasm of  the muscles of the glottis, which have
proved fatal.J  Any such  tumour,  if ascertained  to exist by examining
with the finger, must be removed  if possible.   A case is on  record also
  * Trousseau  de la Traefceotomie, L'Experience, Nov. 5, 1840.
  | In a case  of croup which came under the writer's observation some years since,
the patient being manifestly in articulo mortis, tracheotomy was performed by Mr. Mayo,
and a large piece of false  membrane was extracted ; after which the child lived  foui
days, and had every prospect of recovery,  but was suddenly carried off by convulsions
This case is mentioned to justify the recommendation to perform tracheotomy ia croup
a thing which some surgeons altogether  condemn
  * \'ide cn.se published by  Mr. Stallard, Med. Gaz.  19th Ma)', 1843.
       35
» 
                                                                 f

410                 SCALDS OF THE  GLOTTIS.

                 Fig. 130*                    Fig- 131.f
of a polypous tumour growing in the trachea ;  the diagnosis of such a case,
from chronic inflammation or thickening, must be very difficult.^
  VII.  Cases that stimulate Laryngeal Disease.—Some years since
tne  medical journals made  themselves merry  at the expense of the house
surgeon to one of the largest hospitals in London, who being summoned
in the night to a patient apparently dying of dyspnoea, immediately per-
formed  tracheotomy, but without  avail; for the man  expired very soon
afterwards; and on a post  mortem  examination it was found  that  there
was nothing the matter with the larynx, but that a  large aneurism existed
on the arch of the aorta.  What was the use, it was justly said, of cutting
the throat  of a man wiio was dying of aneurism ?   The  house surgeon,
however,  was not  so entirely to blame  as  he was  then considered, be-
cause, as  is now very well known, tumours about  the  aortic arch  may
produce spasm of the glottis, by irritating the recurrent nerves.   But now
that this fact is known, every surgeon should  carefully scrutinise the chest
in obscure cases of  dyspnoea, to  see whether it  arise from  this cause,
because if it does, no good can be gained  by any operation.   The same
may be said of that spasm of the glottis which often affects children during
their  teething; and  of cases  in which the  symptoms of laryngitis are
mimicked by hysteria.§
  VIII. Scalds of the Glottis, through swallowing boiling water or
corrosive fluids, produce the ordinary symptoms of laryngitis—suffocative
cough,  and dyspnoea.                            •

  • Warty excrescences within the larynx.   Laryngotomy had been performed.   From
the  Middlesex Hospital Museum.
  •J- Ulceration of the larynx.
  i There is a preparation exhibiting this in the King's College Museum, from Mr,
Mayo's Collection.
  ^ Many very valuable observations  on these  points will be found in Dr. Watsou's
Lectures on  the Practice of Physic.
I 
WOUNDS  OF THE  THROAT.
411
   Treatment.—Leeches, ice to the throat, calomel in large  doses, so as
rapidly to affect the system, and tracheotomy if required.
  IX.  Hanging may destroy life in three ways.   (1.) By dislocating the
neck.   (2.) By compressing the trachea, and suspending respiration.  (3.)
By compressing the jugular veins, and inducing apoplexy.
   Treatment.—Artificial respiration, bleeding  from the jugular vein if the
face be turgid, dashing cold water on the face and chest, and  a current of
galvanism passed from the nape of the  neck to the pit of the  stomach, so
as to excite the diaphragm.*
  X.  Drowning,  Treatment of.—If respiration has ceased, it should in-
stantly be commenced  artificially; at the  same time  the body should be
wiped  dry, and be  assiduously rubbed with hot cloths.   Hot bricks and
bottles of hot water should be put into the  axillae,  between the thighs, and
to the feet; the head should be raised,  the nostrils irritated with a feather,
or with the fumes of hartshorn, and  a warm enema of turpentine may be
thrown up.  Galvanism should be resorted to,  if respiration is not quickly
restored.   It need  scarcely be said that enemata  of  that filthy narcotic,
tobacco,  must not  be thought  of.  As  soon as the patient can  swallow,
he should have  some  weak wine and water; and  soon  afterwards an
emetic of mustard,  to clear the stomach of the water  which he has swal-
lowed, and to  restore the  circulation by the impetus of vomiting.  After
some hours he  will suffer from severe headache and fever, which must be
relieved by bleeding or leeching, purgatives, and  other remedies, accord-
ing to the exigencies of the case.   A case is related in which life was re-
stored by the most persevering friction, which was kept up for eight hours
before the humanity of the surgeon, Dr. Douglass  of Havre, was rewarded
by a return of respiration.f     .
  XI.  Artificial Respiration is required in all cases of suspended ani-
mation,—whether from external injury, noxious gases, or narcotic poisons,
including alcohol.  It  may be performed by passing  a pipe through the
mouth, or a male catheter through the nostril, into the glottis;  or by simply
putting a pipe into one nostril, and  closing the mouth and the other nos-
tril, and blowing through it.   But it is a better plan to use a small pair of
bellows,  putting its muzzle  into one  nostril.  The  operator should be
careful to force the air into the lungs with very great gentleness, and to
press the  larynx  against the spine, so that  it may not go down the oeso-
phagus.  If the  larynx has been crushed by a  rope, or by a violent blow,
it may be necessary to perform tracheotomy, so as to impel a current of
air directly into the trachea—but not otherwise.

SECTION IV.--SURGICAL AFFECTIONS OF  THE EXTERNAL
             PARTS  OF  THE 'NECK  AND THROAT.

  I.  Wounds of the Throat are generally made with intention  of sui-
cide, and are extremely dangerous, no  less from  the importance of the
parts injured, than from the despondency of the patient.
  Treatment.—The general indications are, 1st,  to arrest haemorrhage;
2dly, to obviate difficulty of breathing;  3dly, to prevent  inflammation of
the trachea or chest.
  In the  first  place, any arteries that are wounded  must be tied, and
ha-morrhage from large veins must be restrained by pressure with the finger
  * For the munner of applying galvanism in these cases refer to Part v. chap. ii.
  f Med. Gaz., «>3d  December,  1S42. 
412
WOUNDS  OF THE  THROAT.
kept up as long as may be necessary.  The patient should be put to bed
in rather a warm room ; and as soon as all oozing has ceased, but not be-
fore, his shoulders should  be raised by pillows, and  the head be bent for-
wards, and be confined by a bandage passing from each side of the  night-
cap to the shoulders.   Plasters are inadmissible, and so are sutures, except
in the cases  that will  be alluded to presently.  If the wound penetrates
the trachea or larynx,  it should be covered with a loose woollen comforter,
or, after the  first week, with one of Jeffrey's respirators, if it can be  nicely
adapted.  The patient should not be kept too low; and if the pharynx or
cesophagus is wounded, a common,  large-sized,  elastic catheter may be
passed, through which  nutritive fluids  can be injected by  means  of  an
elastic bottle.  But if during the  inflammatory stage  the attempt causes
great irritation, it  may be  necessary to  employ nutrient enemata merely.
At all events, no tubes should be passed through the wound for that pur-
pose.  The  great thirst and dryness of the fauces, experienced  in these
cases, may in some measure be mitigated by sucking a wet rag.   If the
patient finds great difficulty in expectorating through  the wound, he must
be taught to close  it partially by leaning his  head forwards, and placing
his fingers on it, whilst he makes an expiratory effort, so that he may expel
die air with  a sudden gust.
   In every stage of the cure, difficulty of breathing should be viewed with
suspicion.   It may arise from several causes.   (1) If the wound is above
the larynx,  it may be caused by the epiglottis being detached from the
tongue, and  hanging  down upon  or  irritating the rima  glottidis,—or by
clots of blood collecting in the pharynx.  (2) It  may be caused by an ir-
regular and  jagged division of the larynx or trachea, so that some  pieces
of the cartilage hang into the tube; or supposing the trachea to have been
completely cut through, it  may be caused by the aperture of the lower
portion being overlapped by the upper.  In these cases it may be requisite
to employ suture, but  they should be passed merely through  the cellulai
tissue around the cartilage, and neither  through the cartilage nor the skin.
(3) It may be caused  by swelling of the mucous membrane of the  larynx
and trachea in the acute inflammatory stage  immediately after the injury;
-^or by chronic thickening of that membrane from the continued irritation
of cold air,  if the wound is very slow in closing.  In  the former of these
cases, free antiphlogistic measures  must be used;—the latter must be pre-
vented by using a proper position, so as to promote the approximation of
the wound whilst it is healing.  In either  case  it may be necessary to
make a longitudinal division of the trachea to relieve the dyspnoea.  (4)
Another frequent cause of dyspnoea is the passage of blood into the trachea,
if the wound is prematurely closed,  and  especially if it is sewn  up or
covered with plasters.  Even supposing  the  trachea  not to  be opened,
great danger may result from closing a wound of the throat before bleeding
has ceased,  for the blood may accumulate in the  cellular tissue, and co-
agulate, and compress the  trachea.
   II. Bronchocele  (Goitre, Derbyshire neck) signifies  an hypertrophy
of the thyroid gland.
   Symptoms.—A soft, projecting,  elastic tumour occupies the front of the
neck, in the situation and of the shape of the thyroid gland.   It is rarely
tender, and the skin is not discoloured.   Frequently one  lateral lobe  is
larger than the otr_r;—and occasionally the middle lobe  or isthmus is
solely or principally affected. 
BRONCHOCELE.
413
132*
   Consequences.—When  of moderate bulk, it rarely causes  any inconve-
nience, except occasional headache, and  difficulty of breathing in a stoop-
ing posture.  But when very large, it may produce a most dangerous diffi-
culty  of swallowing  and  breathing, and
congestion in the head by its  pressure on
the trachea, cesophagus, and jugular veins ;|
or it may induce thickening and disease of
the trachea,  with  most  obstinate  cough,
which may end  in consumption.
   Diagnosis. — It  is  to  be  distinguished
from encysted   and other  tumours  by its
shape, by  its want  of fluctuation, and  by
its mostly affecting  both sides.
   Prognosis.—If it be soft and recent, and
occur in a  young patient, it will most likely
be  cured ; but  probably  not if it be old,
hard, and the patient advanced in life.
   .finatornical  Characters.—The  cells  of
the gland are found enlarged ;—of various
sizes, from that  of a pea  downwards;  and
filled  with a viscid fluid, which  becomes
gelatinous  if  immersed in alcohol.  Hence
it has been presumed that the disease consists essentially of an increased
secretion of the matter contained  in  the  cells of the gland.   Sometimes
they are filled with blood.  In old  cases, the tumour becomes  hard, re-
sembling a sarcomatous formation, and may contain earthly deposits, as
shown in Fig. 1334
   Causes. — Bronchocele is what  is
termed  an endemic disease: that is,
one extremely prevalent in certain lo-
calities; amongst which may be men-
tioned  Derbyshire,  Nottingham,  and
the chalky parts  of England generally ;
and various Alpine  and  mountainous
districts, especially the Tyrol and val-
ley of the  Rhone.  The use of melted
snow or of  water impregnated  with
calcareous  or earthy particles, to which
the inhabitants of all those  places are
more or less habituated, although not perhaps the invariable cause, is  the
most probable   that can  be assigned.§   In  England it most frequently
affects females about the age  of puberty, and in many cases  is obviously
connected  with  uterine derangement.  Patients  so often refer its origin to
  * From the King's College collection.  The oesophagus is seen  to be  pushed to the
right side by the tumour.
  j-JMr. Howship gives a case of bronchocele with the jugular vein passing Mi rough its
substance.  The patient suffered greatly from congestion  in the head.
  t Vide Baillie's  Morbid Anatomy, by Wardrop, 2d ed. p. 84.  and Turner's Art of
 nrgery, vol. i. p.  198.   The cut exhibits a preparation in the Middlesex Hospital  Mu-
Fig. 133.
S
setini
  § Cnpt. Alexander Gerard, in his account of Korrawur in the Himmalayas, says, that
"although the Korrawurrees can get nothing but snow for some months in the year, they
ire not so subject to goitres as the people that live in the damp grounds in the forest »'
the foot of the hills, where there can never be any snow water."
       35* 
414
BRONCHOCELE.
some twist or strain of the neck, that there is  some  reason  for believing
that such an accident may be an exciting cause.  There are some persons
who always have more or less enlargement of the thyroid gland, and who
invariably find  it increase in  bulk when  their  health is out of order, or
their strength lowered.
   Treatment.—The  best  remedy for this disease  is iodine.  The dose
should not be large enough to cause pain or disorder of the stomach, or
any diminution of the general health.   The tincture of pure iodine is ob-
jectionable, because it is not miscible with water, and is apt to  cause pain
in the side.  But the iodine should be  combined with  an alkali, or with
the iodide  of potassium, or with iron ; and an aromatic or a little hyoscya-
mus often makes it sit more lightly on  the stomach, (F. 44.)   Before ad-
ministering the iodine, however, it is useful, if  the  complaint is of  recent
origin, to apply leeches, and purge the patient freely.  An ointment or
liniment of iodine, or of the iodide of potassium, may also be rubbe I  into
the tumour; but it must be remembered  that  the  swelling generally en-
larges, instead  of decreasing, if the skin be irritated.  The patient,  if pos-
sible, should remove from a district in which the malady is prevalent,  and
should  drink boiled  or distilled water.   A  residence  on the  coast,  and
warm sea-bathing, are mostly  advantageous.   If the iodine does not suc-
ceed, the burnt sponge, in doses of 3fs. ter die, is the best substitute. Any
disorder in the  digestive  or uterine organs should  be  carefully removed.
Pills composed of aloes, soap, and assafeetida (aa gr. ii.—iii.) may be given
at bed-time with advantage.   Other remedies which were in vogue  before
the discovery of iodine, and which may be resorted to  if that fails,  are as
follows: mercury, iron ;—potass and soda ;—chlorides  of barium and cal-
cium ;—digitalis, hyoscyamus, and belladonna ;—and sea-water.
   If medicines prove ineffectual, and the  tumour enlarges rapidly, so as
to threaten suffocation or apoplexy, surgical  operations must be resorted
to   There are three  which have been proposed and  practised :—viz. the
introduction of setons;—ligature of the arteries which  supply the gland;
and extirpation.   The general results  of  these  operations may be  stated
thus: All three of them have at different times succeeded ; all of them
are hazardous to life, and have  proved fatal;  and  the  first  two have, in
some instances, failed to remove the disease, although  the patient has re-
covered with his life.
   If a  seton be passed, it should be of silk,  and large  enough to fill the
wound made by the needle, so that there may be no fear of bleeding.  The
needle  should be long and narrow.  The utmost precaution must be taken,
both before and  after the operation, to avoid  inflammation.  If after the
seton has remained for some time, it ceases to produce a diminution of the
gland,  it should be withdrawn, and be re-introduced in another place.
   Extirpation  of the gland  is performed by making  an  incision  in the
mesial line of the neck ;  the skin and muscles must  then be dissected from
the tumour; and every artery be tied as  soon  as it is divided.   Then (as
it is mostly enlargement of the isthmus, or middle lobe, that requires this
operation) a strong double ligature should be passed through it, and  should
be firmly tied on each side of it, before it is cut out.
   Encysted Tumours.—Sometimes cysts axe formed  in this  gland, which
contain a glairy matter or blood.   If necessary, they may be punctured,—
when they will most likely inflame, suppurate,  and contract.  If bleeding
Drove troublesome, the wound must be filled with lint.  Similar cysts are 
PAROTID TUMOURS.
415
liable to form in other parts of the neck, and not connected with the thy-
roid gland.  Their treatment is the same.*
  *This gland may further 1-e affected with acute ana chronic inflammation,
and  tubercular deposit;  either  of which may lead to abscess.   Their
treatment must be conducted on general principles.
  It  has also been effected with scirrhus, although rarely.  Some cases of
it are recorded in  the Med. Chir. Trans, vol. xxvii. by Mr. Caesar Haw-
kins, and by Mr. Brown of Bath.  The patients presented  solid tumours
in the situation of the gland, not having the characters  of ordinary bron-
chocele, and one distinctive feature was the fixity of the parts.
  III. Hernia Bronchalis (Bronchocele vera, Goitre aerien) is a very rare
tumour, formed by a protrusion of the  mucous membrane through the
cartilages of the larynx, or the rings of the trachea, and  caused by violent
exertions of the voice.  Larrey met with sundry instances of it in French
officers, and in the muezzin  or priests  that call the  people  to prayer from
the top of the  minarets in Mohammedan countries.  The tumour is soft
and elastic,—can often be made to disappear by pressure, and is increased
by any exertion.  The only available  treatment is moderate support.f
  IV.  Parotid Tumours.—The parotid gland is  occasionally, although
rarely, the seat of malignant disease, and perhaps of sarcomatous enlarge-
ment.   But the tumours behind the  ramus  of the jaw, commonly called
parotid tumours, generally  depend on  disease of the  lymphatic glands,
which are embedded  in the  parotid.   These, by their increase, may cause
the natural texture of the latter to be  absorbed, and may extend inwards
to the pterygoid and styloid processes, and  be intimately connected with
the branches of the portio dura.   " If there be  reason  to  suspect," says
Mr.  Liston, "that the disease is of malignant  nature, and  not thoroughly
limited by a cellular cyst, no interference is admissible.  If, on the con-
trary, it be at all moveable, has advanced slowly, possesses a smooth sur-
face, and  is firm (neither of stony harshness, nor pulpy), then an  opera-
tion  may be contemplated."
   V. TuxMours in the side of the Neck, arising from  enlargement of the
lymphatic glands, if subjacent to the skin merely, and freely moveable on
the subjacent tissues, may be readily removed,—but if  they lie deep, and
are bound down by the platysma and fascia, they require some considera-
tion.   If a tumour be of slow growth, defined in its outline, and movea-
ble,  so that it is probably not malignant,—or if it  interferes with degluti-
tion or respiration,  its extirpation may be attempted.  The patient should
always  be warned  of the  probability of fascial palsy after removal of a
parotid tumour.  See the remarks on the removal of tumours in Part V.
   VI. Wryneck is a peculiar  distortion in which the  head is bent down
towards one shoulder (generally the  right), and the face is turned to the
opposite.   The right eyebrow and right corner of the mouth generally be-
come elevated, so as to preserve their horizontal position, notwithstanding
the distortion of the neck.
   Varieties.—This affection presents many varieties.   It may perhaps be
only a part  of general lateral curvature of the spine.   Or (2) it may de-
pend on caries of  the cervical  vertebra.  (3) It may be  caused by con-
traction of the  cicatrix of a burn or ulcer.   Or (4) by  glandular enlarge-
  • Vide a paper by Mr. B.  Phillips in Med. Chir. Trans, vol. xxv., on Tumours in the
N'eck not involving the Thyroid Gland.
  -j- Larrey, Clinique Chirurgicale, torn. ii. p. 81.  Paris, 1829. 
416
VVRYINECK.
ment on one side of the neck;—the treatment of which cases requires no
observation in this place.
  But  the genuine wryneck is produced by permanent contraction of oV
sterno-mastoid muscle, which may depend (1) on inflammatory spasm of
that  muscle, with or without sub-acute inflammation of the cervical fascia.
This form  generally  occurs  somewhat suddenly to weakly children with
disordered digestive organs.   The skin over  the muscle is  often hot ana
tender, and any motion causes pain.
   Treatment.—Perfect rest in a horizontal  posture,—leeches,—and poul-
tices, or hot fomentations, so as to keep  the skin constantly moist and
perspirable,—with purgatives and alteratives.*
  (2.)  It may depend on rigid  atrophy oi the  muscle, which may be a
sequel  of the*  state of inflammatory spasm  last described, or may be con-
genital.
   Treatment. — Long-continued friction  with mercurial ointment, or with
lin. hydrargyri, — or Scott's  ointment (F.  66) worn as  a  plaster, — with
blisters behind the ears, and to  the nape of  the neck,—and the use of a
machine to keep up extension,! — may be  of service in cases that are of
no very long duration.  If they  fail, or if the case is congenital, division
of the  sternal origin of  the  muscles (or perhaps of the clavicular also) is
the last resource.   It  is  best performed thus: — The  skin  covering the
muscle at about an inch  from the sternum  is to be  pinched up  between
the left fore-finger and  thumb.   A narrow curved bistoury is then to be
thrust  under the muscle, and is  to be made to  divide it as it  is being
withdrawn ; but  the wound  in  the  skin must only be large enough to
admit  the instrument.  The aperture may  be made at the anterior border
of the  right muscle, and  between the sternal and clavicular portions of the
left.   As soon as the division is  complete,  the ends of the muscle retract
with a  dull snap, and the thumb  should be  pressed on the part, to prevent
effusion of blood under the skin.  When the wound has healed, but not
before, an apparatus should be  applied to elongate the callus, and restore
the neck to its proper  position.   A stiff collar to the diseased side is the
simplest and best apparatus.
  (3.)  Lastly, this  distortion may be caused  by palsy oi one sterno-mas-
toid  muscle, in consequence of which, the  other  muscle,  being uncon-
trolled, drags  the  neck  permanently to its  own side.  If the administra-
tion  of remedies calculated to remove any  existing disease in the head or
back, and to improve  the health,—and if strychnine, blisters, issues, and
electricity fail,—division of the  sound muscle has been  recommended.^
  * For further information  respecting this form of  wryneck, consult Abernethy, Lec-
ture xxxii., Renshaw's ed.; James on  Inflammation, 2d ed. p. 484; and Brodie on Local
Nervous Affections.
  t See  a plate in Cooper's First Lines.
  t Vide Cases of Wryneck, &c, by DiefTenbach, in the Lancet for Sept. 1838. Gooch
f.ives a  case of wryneck and distortion of the jaw caused by contraction of the platysma
mvoides, and cured by division of that muscle, in the year 1759. 
HYDROTHORAX.
417
                       CHAPTER  XVI.

  OF  THE SURGICAL DISEASES  AND INJURIES  OF  THE CHEST.

  I. Pneumothorax signifies a distention of the cavity of the pleura with
air, and collapse of the lung.   It is known by the following symptoms:
On the affected side there  is an absence  of the respiratory murmur, with
an exceedingly clear sound on percussion, and immobility of the ribs ;—
and diere  is puerile respiration on the other side.   It may be caused (1.)
by a fractured  rib which has lacerated the lung — and in this case it is
attended with  emphysema, — as has been detailed at  page 245.  (2.)  It
may be caused by the bursting of an abscess of the lung into the  cavity
of the pleura.   This case will be indicated by succussion, and by metallic
tinkling, in  addition to the signs mentioned above.   Succussion simply
consists in making the patient shake himself, when (inasmuch as both air
and fluid have escaped from the lung into the pleural cavity) the fluid will
be heard to splash, if the ear is applied to the chest.   The metallic tink-
ling is a clear sound, like  the dropping of water into  a cask.  It  is pro-
duced when the  patient coughs, — by which  means a drop  of fluid  is
shaken  from the  orifice into the lung, and made to fall to the bottom of
the chest.
   Treatment. — As far as the mere surgical treatment of pneumothorax is
concerned, if the breathing become very difficult, a grooved needle, or
small  exploring trocar, may be introduced  between  the fifth and-sixth
ribs, to let the air escape.
  II.  Hemothorax, which signifies the presence of blood in  the pleural
cavity,  may be suspected if great  dyspnoea and dulness on  percussion
follow a fractured  rib.   The blood may proceed either from the intercostal
artery, or from the lung.
   Treatment. — If die  difficulty of  breathing be very urgent, paracentesis
must be performed, to let the blood  escape.
  III. Hydrothorax, or water on  the chest,  is indicated by great diffi-
culty  of breathing, especially when  lying  dowTn—livid countenance—dis-
turbed sleep—dulness on percussion—and if the effusion be confined  to
one side of the chest, there is very great difficulty in lying upon the other.
   Treatment.—If the hydrothorax were merely an inflammatory effusion
from pleurisy,—a local affection,—paracentesis might be advisable for the
dyspnoea ;  but if (as it is generally)  it is an effect of organic  disease of the
heart  or lungs, the operation would do no  good.   At all events, both sides
of the chest must not be punctured.
  It has been  suggested to the  author by Dr. Fergusson, that it might be
advantageous to employ the needle  for the cure  of serous  effusion into
the  pleura, in the same manner as it  is employed for the cure of hydrocele
and ganglion.   That is to say, half a dozen  punctures  might be made
with an acupuncture needle or grooved needle through one of the inter-
costal spaces;  and thus the serum might pass through the punctures into
the  cellular tissue outside  the pleura,  whence  it might  be absorbed.
The same  plan might also be adopted in  cases of hydrops pericardii and
ascites.
                                2b 
418
WOUNDS  OF THE  CHEST.
   IV.  Empyema signifies abscess of the chest,  or suppuration  of the
 p eura.   It  is an  effect of acute  inflammation,  whether idiopathic or
 caused by injury.   It is  known by  dulness  on percussion — gradually
 increasing enlargement of  the side of the chest—separation of the ribs—
 dyspnoea—difficulty of lying on the sound side—and more or less cedema
 of the parietes of the  chest.  If left to itself, the abscess may point and
 burst between the ribs.  Paracentesis is decidedly required, if the case be
 clear; if it be not, two or three punctures may be made with a grooved
 needle, or a small exploring trocar, and a cupping-glass  be applied over
 diem to extract some fluid.
   V. Paracentesis Thoracis,  or puncture of the chest, is an operation
 sometimes  required   for  the  foregoing  affections,  and  especially for
 empyema, and may be performed by making an incision an inch  and a
 half long, between the  fourth and fifth or fifth and sixth ribs, at or  a little
 behind their middle.   The  intercostal muscles  are then to be  cautiously
 divided, and the  point of the bistoury to be passed  through the pleura.
 If fluid escapes from this  puncture, it may be slightly enlarged.    When
 performed for the relief of empyema, this operation is liable to be followed
 by many of  the mischiefs  that result from  the opening of large chronic
 abscesses.   The  pleural cavity  is incapable of contracting as  the  pus
 escapes;—air consequently enters to supply its  place, and causes irritation
 of the cyst, and putrefaction of its contents.   The discharge becomes pro-
 fuse and fetid,  and the patient suffers severely from irritative fever,  under
 which he may sink.  It is, therefore, advisable to place the patient on the
 diseased side immediately after the  puncture, so  that the matter may flow
 out without the ingress of  air,—to  close the wound  with lint and plaster
 before too much  has escaped,—to press  the  abdominal viscera upwards
 whilst the fluid is escaping,—to bandage  the chest afterwards,—and to
 repeat the  operation in a  few days, if necessary, instead  of leaving the
 wound open.
  VI.  Hydrops Pericardii may occur under the same pathological con-
 ditions  as hydrothorax, and may be  combined with it.   Its diagnosis is
 obscure.  It may be suspected to exist if the patient complain of constant
 weight  in the  praecordia,  great  dyspnoea, especially when lying on the
 back, and faintness upon exertion ;—if there is great dulness on percussion,
and  manifest  fulness over the region of the heart—if its pulsations are
tremulous—and the circulation  embarrassed.   The operation  of para-
centesis pericardii has  been practised, although it can rarely be of much
benefit.  It  has been  attempted in sundry cases of hydrothorax,  which
 were mistaken  for hydrops pericardii; but by a second lucky mistake the
pleura was opened  instead.  It  may (if thought advisable) be performed,
either by making  an incision opposite the heart's apex, and dividing the
 muscles and pericardium with the same precautions as in paracentesis
thoracis—or by first making an opening into the pleura, opposite the junc-
tion  of the fifth or sixth rib with its cartilage—and then  introducing the
finger, feeling  for the  distended pericardium,  and cutting  into it with
curved scissors.
  VII.  Wounds and Contusions of the Parietes of the chest require
the same treatment, whether the ribs are fractured or not.   A firm bandage
(having an aperture to  admit of the  dressing of  any wounds) must be ap-
 plied to prevent motion of the ribs.   Free venaesection must be employed 
WOUNDS  OF THE CHEST.
419
to prevent inflammation ;  the bowels  must be opened, the  diet low, and
cough and irritation be allayed by opiates.
  VIII. Penetrating Wounds of the thorax, unattended with wound of
the  lungs, are  exceedingly rare.   In some cases when the chest is laid
open, the lung collapses, just  as it would in a dead body; in others, on
the  contrary, it does not  recede from, or it even may protrude out of the
wound.
  Treatment.—Bleeding  must  be restrained ; foreign bodies and splinters
of bone must  be removed, and the wound be closed ; then the surgeon
must employ free  bleeding, and  the other measures spoken of above.
The intercostal artery, if wounded, must, if possible, be tied,  with a
curved needle or tenaculum, the wound  being enlarged for that purpose
if necessary.   If this  cannot be  done, pressure must be kept up  on the
bleeding orifice by the finger.   If the  lung protrudes, the rule generally
given is, to return  it as quickly as possible, unless it is injured or begin-
ning to mortify; but Mr.  Guthrie recommends that it should be permitted
to remain, as it closes the aperture into the pleura, and  speedily granu-
lates and heals over.
  IX.  Wounds of the  Lung are  known by the following  symptoms:
Great dyspnoea and sense  of suffocation ; the countenance pallid and ex-
tremely anxious—and expectoration of blood,—which is coughed up in
florid arterial mouthfuls,  mixed with occasional clots.  The  dangers  of
these wounds  are  threefold.  1st.  The  great hemorrhage,  which may
destroy the patient by exhaustion, or may fill up the  air passages and in-
duce suffocation.   2dly.  Inflammation, which is  sure to  supervene from
the injury, and may be aggravated by the irritation of clots of blood, or
of other extraneous bodies.   3dly.  Profuse and exhausting suppuration,
with cough, debility, hectic, and all the symptoms of phthisis.
  Prognosis. — This of course must be  extremely guarded.   But there
may be good hopes of recovery after the third day is passed.  Death  is
seldom caused after the first forty hours.
   Treatment.—The first indication is to check the haemorrhage.  This can
only be done by abstracting a large quantity of blood  from the arm, pro-
vided the patient be not  already faint.  Then the wround  should be exa-
mined, and if it be of large size, or a gunshot wound, the finger should be
introduced  into it, to remove clots of blood, splinters of bone,  or any other
foreign substances that it  may find.  If it is not  sufficiently large for this
purpose, it may be dilated  by a probe-pointed  bistoury.  At the same
time, an intercostal artery, if wounded, should be  secured.   The wound
should then be accurately closed with lint and  plaster, and  the patient
should be suffered to lie as quiet as possible.  He should  have  plenty of
cool air, and a very light  covering.   It is a general rule, in all injuries of
the thorax  and abdomen, to place him  on the  wounded  side.  In the
course of a few hours the pulse will  probably rise,  and the pain,  and
cough, and spitting of blood return.  Upon the first appearance of sucn
symptoms, vensesection must be repeated; and it must, without hesitation,
be resorted to again and again  if they recur.  The diet must be rigorously
low; nothing but cold acidulated drinks—lemonade,  or barley-water with
lemon-juice—can be allowed for several days; the bowels must be opened,
and opiates be given to allay cough and pain.
  Secondary hemorrhage, after wounds of the lung, may (1) be caused
by  inflammatory excitement;  or  (2) (if  the wound be gunshot) by the ' 
420        DISEASES AND  INJURIES OF  THE ABDOMEN.

separation of sloughs from the lung; or (3)  by the sloughing of an inter-
costal artery that may  have been  brushed by the ball.  Vemc.scction is
the remedy for the first two cases, and  the ligature, or pressure, for the
third.
   If,  after the  primary dangers of haemorrhage and inflammation  have
ceased,  and the wound has  closed, there  are  rigors, dyspnoea, and outer
signs  oi empyema, paracentesis is requisite.   And if these symptoms come
on soon after the  injury, the paracentesis  should be performed at the site
of the wround ;  but if they  come on at a distant  period, the  paracentesis
should be  done  at the usual place, in order to avoid the adhesions that
are sure to be formed near the wound.
   Foreign bodies  in the chest add greatly to the danger of exhausting sup-
puration, although patients have recovered for years with balls, or pieces
of cloth, encysted in the lung  or  pleural cavity.  In some cases, a ball
has remained rolling loosely about in the  pleural cavity.  If any foreign
body  is  detected, it should, if possible,  be removed, and part of the upper
border of a rib  may be sawn awTay with Hey's saw, if necessary, in order
to get at it.
   Some surgeons direct penetrating wounds  of the chest not to be closed;
or they even recommend tents or canulse to be inserted, to provide for the
escape of blood  or matter.  But  it must be evident that there will be
much less liability to severe  inflammation if the wound is closed,—just as
in wounds of joints and compound fractures.  Besides,  " if the patient,"
says Hennen, "is placed with the wound in  a dependent posture, the exit
of effused fluids is not  necessarily impeded.   If they exist in large quan-
tity, the wound is effectually prevented  from closing;  if the flow is  so
minute  as  to admit of the  union of the wound, the quantity effused is
within the power  of the absorbents to remove."
   After wounds of the chest, there is a constant susceptibility of inflam-
mation from slight causes, so that the patient should be  cautious to avoid
over-fatigue, intemperance, and atmospheric vicissitudes.
   X. Wounds of  the Heart generally prove fatal from hajmorrhage.
Numerous instances, however, are  on  record, in which  stabs or musket
wdunds of this organ  healed, both in man and animals, without any ill
effects remaining.  The  diagnosis  and prognosis will of course be ex-
tremely doubtful.  The  only available treatment is  free depletion and
opiates, in order to prevent haemorrhage, and keep the circulation as quiet
as possible, so that the blood may coagulate  in the wound, and the coagu-
lum become adherent and organized.
                       CHAPTER  XVII.

 OF THE SURGICAL DISEASES AND INJURIES OF THE ABDOMEN.

  I. Paracentesis Abdominis  is an  operation performed  in ascites and
(Marian dropsy,  when  the  abdomen has become so  distended  that the
breathing  and  the circulatipn  of  the  lower extremities  are  seriously
impeded 
OVARIOTOMY.
421
   Diagnosis. — Ascites is known by the abdomen being equably enlarged
and fluctuating—not feeling harder at one part than at another,—whilst in
ovarian dropsy, the swelling fluctuates less  distinctly,—and  is evidently
composed of distinct cysts, some of which feel more distended than others.
A second means of distinguishing the  twTo affections is afforded by percus-
sion.   In ascites,  the bowels,  as they contain air, float up  through the
serum; and, in whatever position the patient may be placed, they tend
to occupy the  uppermost part, and the serum  the  lowest;  and a  clear
sound may be  elicited by percussion over the bowels, but a dull sound
over  the serum.   Thus, if the patient be placed on his back, a  clear
sound will be produced over the anterior surface of the  abdominal pa-
rietes, but a dull sound towards the sides and back.   In  ovarian dropsy,
on the  contrary, the abdomen  is  distended by a tumour which occupies
its front part, the bowrels being  behind and on either side of it.  Conse-
quently, when the  patient lies on her back, percussion of the  anterior sur-
face  produces  a  dull  sound ;  whilst  a  clear sound may be  produced
towards the back  part  and sides.  In doubtful cases a puncture may be
made with a small trocar, to examine the  fluid that issues;  which, in
ascites, is a clear serum, but in ovarian dropsy displays under the micro-
scope numerous small granules  and cells.*
   Operation.—The  patient must be  seated  in  a chair.   A  broad towel
must  then be passed round the lower part of the abdomen,  and its ends
be crossed behind  and entrusted to two assistants, who are to be  instructed
to draw it tight and  support the belly as the fluid escapes; otherwise, the
removal of the compression  to which the  abdominal veins have  been
habituated would cause  the blood to  gravitate into them from the heart,
and  induce syncope — or perhaps they might burst, and occasion a fatal
haemorrhage.  A piece of flannel broad enough to cover the whole abdo-
men,  and having a notch cut out of it above and below (and the edges
sewn  together afterwards), is  a  good  substitute for the towel.  The sur-
geon  then holding  a  trocar in a  canula in his right hand, with the end of
his forefinger about two  inches from the point of  the instrument, plunges
it through the linea alba, two inches below the umbilicus,—then steadying
the canula with his left  hand, he  pulls out the trocar with his right; the
fluid,  of course, is  to be received into a proper vessel—and the  assistants
to draw the towTel tight as it escapes.  If the trocar is a large one, it will
be as  well to puncture the skin with a common lancet before introducing
it.  The aperture  is afterwards to be closed with lint and plaster, — and
the patient to be put  to bed, with  the towel fastened round  the  loins.  A
broad flannel roller should  be  substituted for it  before she  rises.   If a
patient with ascites happens also  to have an  old irreducible hernia, and
the sac is  much distended, and preserves a free communication with the
abdomen, it is a good plan to puncture the sac instead of the  linea  alba.
   II.  Ovariotomy.—Ovarian dropsy consists apparently  in  the conver-
sion of the ovary into a large tumour,  containing one  or many cysts, filled
with a serous or glairy fluid,  and mixed with more or less solid matter.
The cysts  may vary in number,  from one to a great  many;  and in size
from that of a pea to  that of the  biggest pumpkin.   They may be thin and
flexible like  bladder,  or thick and semicartilaginous.  The contained  fluid
is  generally glairy  like white of egg, and contains about  eighteen  grains

              • Bennett, Ed. Med  and Surg. Journal, April, 1846.
       3f» 
422
INJURIES OF THE  ABDOMEN.
of albumen to the ounce ; but it may be clear and transparent  as pure
water, or thick and almost semisolid.  The ovarian tumour not uncom-
monly contains more or less of malignant growth.
  The ordinary course of this disease is, that it continues to increase; it
fills up the abdomen;  interferes with the  breathing, makes the patient's
existence  a misery,  and  at last wears her out from pain and irritation.
The question then is, what can our art do to cure the  patient, or to miti-
gate her sufferings ; and there are three things  that  require mention, viz.,
tapping, medicine, and  ovariotomy.
  (1.) Paracentesis.—This is the most obvious mode of procuring relief;
but this is by no  means complete, nor unattended  with risk.   Cases  are
extant, it is true, in one of which the patient lived to be tapped sixty-six
times  at intervals of about a month; and in  another one hundred and
twenty-eight times at intervals of six weeks ; but taken  as a general  rule
it may be affirmed that few patients survive more than four years after the
first tapping, — a period passed in the  greatest misery and suffering ; so
that this operation cannot be said to be worth  much even as a palliative.
We may  add, that in  order to relieve  the  patient effectually, it may be
necessary to use a very  long trocar, and  to plunge  it quite deeply, so as
to reach the more deeply-seated cysts; and that the puncture had better
be made wherever fluctuation  is most evident.
  (2.) Medicines.—We believe it  to be quite contrary to reason and  ex-
perience to expect that any medicines whatever can cause the absorption
of the enormous  bulk of an  ovarian tumour.  We have read lately of
cases  in which excessive pressure,  effected by binding  heavy books as
tightly as possible on  the  patient's  stomach, and combined with the most
profuse administration of mercury, has been employed for this purpose;
and the ovarian  cyst  having  suppurated  and  discharged, a few patients
have  escaped with life.  But it is to be hoped that  this kind of  practice
will meet  with but few imitators;  and we believe it  to  be  the general
opinion of the profession, and a sound  opinion too, that cccteris paribus,
the less a patient with ovarian dropsy is tampered  with by medicine, the
greater her chance of life.
  (3.)  Ovariotomy.—The remaining remedy then is the extirpation of the
tumour through the abdominal parietes—an operation so tremendous that
there are not wanting  some  who condemn it  under any circumstances;
although the general feeling of the profession seems to be in  favour of it,
if performed in cases only that are favourable for it.  Against the opera-
tion may be adduced, 1st, the extreme difficulty of diagnosis; insomuch
that out of eighty-one cases collected by Mr. B. Phillips in 1844, in which
it had been attempted, no  tumour whatever was found in  five, and in six
others the  tumour was not ovarian ;  2dly, the fact that in fifteen out of the
eighty-one cases, after the abdomen was opened, extirpation of the tumour
was found impracticable, in consequence of the numerous adhesions which
bound it to neighbouring parts ;* 3dly, the mortality.   Of the eighty-one
cases, forty-nine recovered, thirty-two died.  Of the sixty-one  in which
the tumour was extracted, thirty-five recovered, twenty-six died.   Of the
  *  Out of four patients operated on by Mr. Lizars some years ago, one died ; one re-
covered ; in one, after the abdomen was  laid open, there was found to be no tumour
at all;  and in the fourth there was discovered an enormous mass of convoluted vessels
looking like a placenta, which proceeded  from  the omentum to the tumour, and of
course  rendered extirpation quite  out of the question, so that the incision was quietly
elosed again 
OVARIOTOMY.
423
fifteen in which the tumour could not be extracted, nine  recovered, and
six died.  On the other hand, in favour of the operation it may be argued,
1st, that increase of experience must tend to clear up difficulties of diag-
nosis ;  2dly, that  the  mortality arising from  this is not larger than that
from many other surgical operations ;* 3dly, that no other plan of treat-
ment can effect a radical cure;  and 4thly, we may state what cannot be
doubted  by any reasonable  men, viz. that  if favourable cases only were
submitted to operation, the mortality would be very small.   Dr. F. Bird
we believe has operated seven times without one death.
   The surgeon, therefore, who  determines to extirpate a diseased ovary,
would  do well to run  no risks ; to check his own desire for a capital ope-
ration,  and not to be  prevailed on  by the patient against his better judg-
ment ;  since not unfrequently patients are importunate  to be relieved at
once, and at any risk, of their miserable  burden.   He should  ascertain
that the general health is  such as  would be desired in any patient who
was to  undergo a capital operation ; he  should carefully estimate the size
of the  tumour; the amount of solid  matter it contains, as indicated by
more or  less perfect fluctuation over its surface ;  and in particular should
endeavour to estimate whether  it adheres to the abdominal parietes or
viscera.  This he may do in some measure by noticing whether it shifts
its place as the patient rolls herself  from side to side;  and also by a very
ingenious test which the author  has seen  used by Dr. F. Bird;  namely,
by putting the  abdominal  muscles in action, and noticing whether they
rise much from  the surface of the tumour.   Thus, if the patient whilst
lying on her back  be told to  raise herself up  in  bed without using her
arms, the recti muscles will start up into a prominent band if their sheath
is not bound down by adhesions on its peritoneal surface, but not if it is.
   There are  two modes  of operating.   The first  is by means of a long
incision from sternum to  pubes; which was practised some years ago by
Mc. Dowall,  of Kentucky, and  by Mr. Lizars, and of late by Dr. Clay,
of Manchester.   The manner of operating, and the previous and subse-
quent treatment which Dr. Clay adopted, were  as  follows: — The night
before the operation he gave ten grains of inspissated ox-gall,  and repeated
it in the morning, believing it to have the power of evacuating the aliment-
ary canal  and of dispelling flatulence with the  least possible amount of
irritation.   The patient being  placed comfortably on a table, he severed
the integuments from  sternum to pubes with  one stroke — an incision 24
inches long; — then having carefully cut through  the  peritonaeum  at the
upper part, sufficiently to introduce two fingers of his left hand, he passed
in a probe-pointed bistoury, and, under the protection of his fingers, divided
the peritonaeum to the extent of the first incision.  The pedicle of the
tumour, one of the broad ligaments, was then firmly tied and  cut through;
but as it was excessively thick, some of the vessels in it continued to bleed
and required separate ligatures.  The hands were now/ passed round the
tumour in search of adhesions;  some that  were soft and recent gave way
readily to the slightest touch; but an extensive  omental adhesion required
to be  divided by the scalpel, and a vessel that bled freely was  secured.
The tumour was  then  lifted up and  removed.   When all bleeding  had
ceased, the integuments were brought together with nine stitches,  and
straps of adhesive plaster; and a broad bandage was passed round the
  • Mr. Solly, in a Lecture  in the Med. Gaz. vol. xxxviii, states that the deaths frorr
orariotomy up to 1840  wera only one in three and a h'Uf 
424
INJURIES OF THE  ABDOMEN.
body.   The subsequent treatment consisted in giving small doses of hen-
bane and morphia,  when  necessary;  opening  the  bowels by  clysters;
relieving flatulence by introducing a gum elastic tube; and nourishing the
parient with as simple a diet as possible.   The incision should be  made
to di'erge a little, so as not to  cut through the umbilicus; — and if, on
examining  the tumour, it is found either to be of a different nature from
what was anticipated, or to have  contracted  excessively numerous and
wide adhesions, it is better to close the wound quietly, without attempting
to extirpate it.   In order to bring the sides of the  abdomen evenly toge-
ther, a number of lines  may be marked across the linea alba with nitrate
of silver before the operation.
   The second mode of operating is by means of an  incision through the
linea alba, below the umbilicus, of from two to four inches in length. As
soon as the ovarian  cyst is  exposed, it is to be punctured,  and the edges
of the puncture being seized with a hook or forceps, the whole of the cyst
is to be dragged  out of the wound, as it gradually collapses on the fluid
escaping; — then  the pedicle of the cyst having  been transfixed with a
needle armed with  a strong  ligature,  is to be  tied tightly and  cut off.
Whilst  the cyst is protruding, an assistant should keep his hands on the
margins of the wound, to prevent any escape of the bowels.  An estimate
may be formed whether the tumour consists of one cyst or many, by the
quantity of  fluid which  escapes when the puncture is made; and if a
second cyst is discovered, it may be punctured and dragged out  as well.
This operation was suggested many years ago, although never performed,
by Dr. W. Hunter.   It was revived in 1838 by Mr. Jeaffreson, and has
since been adopted by Mr. B. Phillips, Dr. F. Bird,  Mr. Lane, and other
operators.  It may be remarked that the temperature of the apartment in
which any such operation is performed, ought to be raised to 70°.*
   III.  Violent Blows on the Abdomen from obtuse substances,—the
passage of cartwheels;  spent shot,  and so forth, — may produce various
results.   (1) They may cause severe concussion and  collapse, which may
either speedily prove fatal, — or may pass off without  further ill conse-
quences, or may be  succeeded by inflammation.
   (2) They may produce laceration oi the bowels, or of the solid viscera;
—with effusion  of blood or of their secretions into the  peritonseal cavity.
This may be suspected if the patient complains of  excruciating pain radi-
ating over the whole belly ;—if the features  are pinched, the belly soon
swells, and the pulse is very small and tremulous.
   Treatment.—The patient must  be suffered to  lie quietly  during the
stage of collapse, without any officious  administration of stimulants: and
as soon as pain or vomiting comes on, he should be bled.   Subsequently
bleeding, leeches, and fomentations to  the belly, to  abate  inflammation;
and large  doses of opium to  support the system  under the irritation,
are the  only available remedies.  The  bowels should  not  be disturbed
either with  purgatives  or enemata  for the first  three days,—nor should
   * Vide Lizars on the  Extirpation of Diseased Ovaria, Edinburgh, 1825; account of
Di. Clay's operations in Braithwaite"s Retrospect, vol. vii.; and of two successful ope-
rations by Mr. Walne, Lond. Med. Gaz., 2.3d Dec. 1812, and 7th July,  1813;  Jeaffreson,
Lancet, 7th January, 1839; King. Lancet, 21st January, 1837; West,  Lancet, 25th No
vember,  1S37; also Med. Gaz., November 24(h,  1838; and case by .Mr. B. Phillips,
which proved fatal, Med. Gaz., October 10th, 18-10; also B. Phillips, Med. Chir. Ttans.,
vol. xxvii., and Ranking's Abstract, vol. iii. 
WOUNDS  OF THE  ABDOMEN.
425
any nutriment be taken, save very small quantities of the mildest fluids  at
intervals.
   IV.  Abscesses between the abdominal parietes occasionally result from
contusions or punctured wounds,  and sometimes occur idiopathically.
According to the principles  laid down in the chapter on abscess, they
should be  opened early, both because  of the  tendinous  structures  by
which  they are covered, and of the possibility that they might  burst into
the peritonaeum.
   V.  Penetrating Wounds of the abdomen may be divided into four
species:  namely, 1st, simple wounds of the  parietes; 2dly, wounds  of
the viscera; 3dly, wounds of the parietes with protrusion of  the viscera;
and, 4thly, wounds  in which  some  of the  viscera  are protruded and
wounded likewise.
   (1.)  In the case oi a simple wound of the parietes, the surgeon must first
(if it be large enough) gently introduce his finger, to ascertain that no part
of the intestines is  beginning to protrude; — then the wound must  be
closed by  sticking-plaster;  or by suture, if it is extensive.   If the epi-
gastric artery is divided, it must be cut down  upon and tied.  The sur-
geon must recollect that when any part of the abdominal parietes has been
wounded or severely bruised, it  is almost  certain  afterwards to become
the seat of hernial protrusion.
   (2.)  Wounds of the viscera.—In the case of small wounds of  the abdo-
men without protrusion, it will  be often  impossible  to say whether the
bowels are wounded  or not, but  the  treatment must be altogether the
same, whether they are or not.
   (a) Wounds of the stomach may be known by the situation and depth
of the wound,—by vomiting of blood,—by the very great depression and
collapse,—and by the nature of the matters (if any) that escape from the
wound.
   (b) Wounds of the boioels may perhaps be  known by the passage  of
blood with the  stools,—or by faecal matter escaping from the wound,—or
by the  symptoms of extravasation of their contents into the abdominal
cavity—that is  to say, excruciating pain, radiating over the whole belly
from the seat of the injury, and attended with  signs of great collapse.
Fortunately, however, as Mr. Travers has shown, wounds of the stomach
and intestines, unless very large, are not so liable to be attended with ex-
travasation as was formerly thought.   For, in the first place,  the mucous
membrane protrudes  through the muscular, so as to fill  up  a small aper-
ture ;  and, secondly, any tendency to extravasation is counteracted by the
constant equable pressure of all the abdominal  viscera against each other.
Moreover, lymph is soon effused, and glues the neighbouring parts toge-
ther, and thus the aperture is circumscribed, and any future extravasation
is prevented.
   (c)  Wounds of the liver, if extensive, are, from its great vascularity,
nearly as fatal as those  of the heart.   Small wounds may be recovered
from.   There will at  first be symptoms of great collapse,  which, if the
patient survive, will be succeeded  by severe sickness, pain in the liver,
yellowness of the skin and urine, great itching, and a glairy,  bilious dis-
charge from the wound.
  (d)  Wounds or rupture of the gall bladder are almost invariably fatal.
although there are one or two instances of recovery on record.
  [c) Wounds of the spleen, if deep, are also fatal, from the great haemoi-
       36* 
426
WOUNDS  OF THE  ABDOMEN.
rhage that follows; although the whole organ has been removed from ani-
mals (and, it is said, from man) without much consequent evil.
  (/) Wounds of the kidneys axe attended with bloody urine.  They are
exceedingly dangerous, first from haemorrhage, next from violent inflam-
mation with  excessive vomiting; and, lastly, from profuse suppuration,
kept up by the passage of urine through  the wound.   Venisection, very-
mild laxatives, the warm bath, avoidance of too much drink, very light
dressings, so as to admit  of  the flow of urine through the wound, and
some unctuous application to prevent excoriation of the surrounding skin,
are the necessary  measures.
  (g) Wounds of the bladder, if communicating with the peritonaeum, are
extremely  dangerous, owing  to extravasation of urine.  In fact, unless
there is an external wound through which it can escape, they are almost
uniformly mortal.  The catheter must be worn constantly.
  (3.) If the intestines protrude, and are neither wounded nor gangrenous,
they should first be freed from any foreign particles that stick to them, and
then be returned as soon as possible.  The patient should be placed on
his back, with  his shoulders raised, and his knees drawn  up.  If  abso-
lutely necessary, the wound must be  a little dilated with a probe-pointed
bistoury.   Then the surgeon  should return the bowel portion by portion,
passing it back with his right  fore-finger  and thumb, and keeping his left
fore-finger on that which is  already replaced, to prevent it from protruding
again.  He should be careful to replace  intestine before  omentum, and
the part that  protruded last should be returned first.
  (4.) If the stomach and intestines, when protruded, are found  to be
wounded,  the wound should be sewn carefully up with  a fine needle and
silk, by the continuous ox glover''s suture (p. 126), in  such  a manner as
to bring the  edges into  apposition,  and prevent all extravasation between
them.   Then the  part  should be replaced, and the  external wound be
closed.   The aperture in  the bowel will be united, as in other cases, by
the adhesion of contiguous  surfaces; and the silk employed in the suture
will be detached by ulceration, and fall into its cavity.  If, however, any
part of the bowel that  is protruded be  bruised  or lacerated, or be gan-
grenous, it should not be returned, but be left hanging out, that an  artifi-
cial anus may be  formed.
  The symptoms oi inflammation of the peritoneum or abdominal viscera,
which is of course exceedingly likely to follow these wounds and injuries,
may readtfy be recognised.  The patient lies on his back, with his  knees
drawn up ; he breathes solely with the thorax, and not with  the diaphragm
or abdominal muscles ; the countenance is anxious ; the pulse small, wiry,
and resisting, but becomes fuller after bleeding; there is severe throbbing
pain, with great tenderness, more or less widely diffused ;  a dry tongue,
constant nausea,  or vomiting, and  obstinate constipation, complete the
catalogue.  If the case proceeds to a fatal termination, the belly swells,
partly from serous effusion,  partly from tympanites; and the  pulse becomes
more frequent and weak, the patient retaining his senses to the last.
  The after treatment of all these cases is the same.  The patient must be
kept at perfect rest, and should lie on the wounded part, if such a posture
be easy.   Vensesection and leeches must be sedulously employed to avert
haemorrhage  and  inflammation, and the  indication for bleeding must be
taken rather from the stomach than from  the pulse.  The pulse will, from
the nature of the parts inflamed, be  small, and perhaps weak;  but if there 
WOUNDS  OF THE  ABDOMEN'.
421
be vomiting, bleeding may be performed without fear.   After the bleeding,
large  doses of opium should be given, and should be  repeated, so as to
keep the system under its influence.  Nothing but water, or thin arrowroot,
should be  given for three dayrs, when the stomach or intestines are probably
wounded.
   The author hopes that it is  unnecessary to warn his readers against the
fatal and abominable custom of giving purgatives in cases of inflammation
of the bowels arising from wounds of the abdomen.   It is  quite true that
the bowels will  be obstinately costive;  but this  costiveness  arises from
their being inflamed, and unable to propel their contents onwards; and the
proper remedies  for it, are such  as will relieve the inflammation—that is,
bleeding, leeches, fomentations,  and calomel and opium.  But if, in spite
of common  sense, the surgeon  attempts to overcome the costiveness by
colocynth  pills and  black  draughts, he  will soon  induce  an obstinate
vomiting, that will render all his other remedies  nugatory.   If in any case
of inflammation of the bowels it is probable that they are loaded with  feces,
the proper remedy is the repeated injection of warm water as an enema.*
   VI. Artificial Anus signifies a preternatural communication between
the intestine and skin.   It may be a consequence of penetrating wounds,—
of abscess or ulceration of the intestines,—or of mortification of intestine
in strangulated hernia;  and it is  sometimes purposely made by the surgeon
in cases of imperforate anus, in order to afford an exit for the feces.  The
external opening is irregular, everted, and red, and the surrounding skin
excoriated.  The  aperture  in the intestine adheres by its  margin  to the
peritonaeum, so that  extravasation  into the abdomen is prevented.   That
portion of intestine which  is immediately above the aperture, and that por-
tion which is immediately below it, meet at the artificial anus at a more
or less acute angle, and present two orifices,—one by which  matters de-
scend from the stomach,  and another which leads dowrn to the rectum.
These two orifices are separated  by a sort of  crescent-shaped septum,
formed by a projection of the mesenteric side of the bowel opposite to the
aperture.  Now it may readily be understood that  the greater the aperture
in the bowel, the more  acute  will  be the angle at which the  upper and
lower portions meet, and the greater will the septum also be; and that, if
the septum is large, it will act as a valve, and close up the orifice  of the
lower portion of bowel, causing any matters that come down through the
upper portion to escape externally, instead of passing into the lower, f
   The consequences oi  this affection may be, 1st, that the patient may die
of starvation, from the escape  of the chyle, if the aperture is near the duo-
denum.  2dly, that  a portion of the  intestine may protrude and form a
hernia;—besides the constant  disgusting annoyance  occasioned  by the
escape of fecal matter and flatus.
   Treatment.—If the affection  is  of recent origin, and especially if it is
consequent upon strangulated hernia, the patient  should remain in bed,
and great care should be taken to keep the parts clean; and then, perhaps,
the external aperture may  contract and  cicatrize.  If the latter  is very
small, and if the  passage  between it  and the bowel is of some length (a

  * Vide Travers on Wounds of the Intestines, Lond. 1812;  Hennen's Military Sur-
gery; the observations on the treatment of Enteritis in Ferguson on Puerperal  Fever;
Griffin's Medical Problems;  and  Dr. Holland's Notes and Reflections.
  •{■ Vide the chapter on Artificial  Anus in Lawrence on  Hernia, and Dupuytren. in
Diet, de Med. torn. iii.
• 
428
HERNIA.
state of parts termed fecal fistula), something may perhaps be done by
compression, or by engrafting a piece of skin over the aperture;  or by
making an oval incision in  the  skin on each  side of the  aperture, and
bringing the outer edges of the incision together by means of needles and
the twisted suture; or by applying the actual cautery to the margin  of the
wound.
  But  if the  loss of substance in the bowel is considerable, and the pro-
jecting septum large, the chance of recovery is not great.  A pad of simple
linen or lint may be worn to compress the aperture, and prevent discharge
from it, or sometimes a hollow truss with  a  leathern or horn receptacle,
may be used with  advantage.   Enemata are useful in  all  cases.   More-
over, a tent may be thrust into both  internal  orifices, in  order to  enlarge
the lower one, and repress the septum, as proposed by Dessault.   As a
last resource, a small portion of the septum may be nipped and strangulated
by the  forceps invented  by Dupuytren for that purpose.
  VII.  Gastrotomy.—There are not a few cases on record in which
patients have died of  obstructed bowels, and in which it was found after
death that the obstruction was caused by a small band  of adhesion which
might  easily  have  been severed with one touch of the  bistoury, and the
patient, in all probability, have been  relieved.   The author does not wish
his  readers  rashly to  lay open the  abdominal cavities of their patients,
more especially when it is  considered how  uncertain  are our means of
diagnosis as to the nature and seat of the obstruction.   He merely wishes
to hint at a possible and desperate means of relief  that might be adopted
in some desperate  case ; and the case would appear to be, when all reme-
dies have proved  useless, and when complaint is made  of some  local
uneasiness, that would seem to point to the seat of the obstruction.*
                      CHAPTER  XVIII.

                            OF HERNIA.

SECTION  I. --OF   THE NATURE AND CAUSES  OF  HERNIA
                           GENERALLY.


  Definition.—Hernia signifies a protrusion of any viscus from its natural
cavity.  But the term, employed singly, is restricted to signify protrusion
of the abdominal viscera.
 _ Causes.—The formation  of hernia may be readily understood by con
sidering that the abdominal viscera  are 'subject to frequent  and violent
pressure from the diaphragm and the other muscles by whfth they are sur-
rounded,—a  pressure which tends to force them  outwardly against the
parietes of the  abdomen.   Consequently, if any point of the parietes be
not  strong enough to resist this  pressure; some portion of  the viscera may
je forced through it, and form a hernial tumour externally.

       » Vide Lancet, December 19th, 184G ; South's Clielius, vol. ii., p. 94.
I 
HERNIA.
429
  The predisposing cause of hernia, therefore, is a weakness of the parie-
tes  of the  abdomen, which may be produced by various circumstances.
Thus (1)  some  parts of the parietes  are  naturally weaker than others;
especially the  inguinal and crural  rings, and the umbilicus;  and it is at
these parts that hernia  most  frequently occurs.  (2.)  The  abdominal
parietes may be weak from  malformation, or congenital deficiency.  (3.)
They may be weakened by injury or diseases, such  as abscesses, wounds,
and bruises ;  or  by distention by the pregnant uterus, or by dropsy.
  The exciting cause is  compression of the viscera, by the action of the
muscles that surround them.  Hence hernia is so  frequent a result of vio-
lent bodily exertion—lifting heavy weights  and the like—especially if the
patient have  been previously weakened by illness.  Moreover, it is not
uncommon in persons afflicted with stone or stricture, from the immoderate
straining that they employ in passing their urine.
  The viscera most  liable to hernial protrusion are the  small intestines,
omentum, and arch of the colon.  But  every one of them has occasionally-
been found protruded, partially or entirely — especially in  cases of  con-
genital deficiency of the abdominal parietes.
  The Sac of a  hernia is a portion of the parietal  or reflected layer of peri-
tonaeum which the protruding viscera  push before  them in their escape,
and which  forms a pouch containing them.   It very soon contracts adhe-
sion to the surrounding cellular tissue, and consequently does not return
into  the abdomen when the viscera  are  replaced.  Although  it must be
observed, that a hernia may be pushed back en masse, sac and all, when
great force is used  in reducing  a  strangulated hernia.   As  the  hernia
increases in size, the sac  also increases ; — partly by growth ; partly by
distention,  and slight laceration or unravelling; partly by fresh protrusion
of peritonaeum.   Sometimes it  diminishes  in thickness whilst increasing
in capacity; sometimes, on the  contrary, it  becomes thick, indurated, and
divisible into layers.   Its neck (the  narrow  part which communicates with
the abdomen) always becomes thickened, rigid, and more or less puckered,
in consequence of the pressure of the muscular or ligamentous fibres which
surround it.  Sometimes the sac has two constricted portions, or necks—
either because (as in oblique inguinal hernia) it passes through twro tendi-
nous apertures—(the external and internal  abdominal rings)—or because
the  original neck has been pushed down by a fresh protrusion.  Some
herniae, however, are destitute  of a sac, or at least of a complete  one.
This may happen,—(1.) If the protruded viscus is  not naturally covered
by peritonaeum ;  as the caecum.   (2.)  If the hernia occur in consequence
of a penetrating wound.   (3.) In  some  cases  of congenital umbilical
hernia.  (4.) Hernia may be considered virtually without a sac, if the sac
has  been burst by a blow, or if it has become entirely adherent to its con-
tents.  Instances, again, are known in which two  peritoneal sacs  have
protruded through one  and  the same aperture in  the abdominal  parietes;
and in which one sac has come down within a previously existing  one.
  Division.—Hernia is divided into several species (1st) according to its
situation—as fhe inguinal, femoral, and so  forth;  (2dly) according to the
condition of the  protruded  viscera ; — which may be (a) reducible, or re-
turnable into the abdomen ; (b) irreducible, that is, not returnable  into
the abdomen ; or (c) strangulated;  that is, subject to some constriction
which not only prevents their return  into the abdomen, but also interferes
with the passage of their contents, and  with their circulation.
i 
430
REDUCIBLE  HERNIA.
        SECTION  II.--OF THE  REDUCIBLE  HERNIA.

   Symptoms. — A soft compressible swelling appears at some part jf the
abdominal parietes.   It increases in size when the patient stand up; — if
grasped, it is found to dilate when he coughs or makes  any exertion; and
it diminishes or disappears when he lies down, or when properly directed
pressure is made upon it.   If the  sac  contains  intestine (entero-cele), the
tumour is  smooth, rounded, and elastic; borborygmi (or flatulent croak-
ings)  are occasionally heard in  it, — and when  pressed upon, the bowel
returns into  the abdomen with  a  sudden jerk  and gurgling noise.   If,
however,  it contains  omentum (epiplo-cele), the  tumour is flattened, ine-
lastic, flabby, and  unequal to the touch, and when pressed, it returns with-
out noise, and very slowly,—the pressure requiring to be continued till it
has nearly disappeared.  But very  often one hernial  sac contains both
intestine and omentum (enter o-epiplo-cele);  and very frequently it is per-
fectly impossible to ascertain which it contains, by any external  exami-
nation.*
   Treatment.—The indications for the treatment of reducible hernia are,
(1st) to replace the hernia, and (2dly) to  prevent its return.  The replace-
ment  of the  hernia  is to be  effected by the  taxis;  that is, by properly
directed pressure  used in the manner to be described in the subsequent
sections.   The second object is to be accomplished by  the use of a truss,
—an instrument consisting of a pad placed on the seat of protrusion, and
of a steel spring which passes round the body, and causes the pad to press
with the requisite  degree  of force.   In order to take the measure for a
truss, the patient should  lie down, and the hernia should be replaced;
then he should stand up, and be told to  cough,  whilst the surgeon ascer-
tains with  his fingers the exact  spot at which the protrusion commences.
The distance from this spot round the hip to an  inch on the other side  of
the spine gives the required admeasurement.   If the hips  are very flat, or
peculiarly formed, the measure should be taken with a piece of wire, stiff
enough to keep its  shape,  so that it  can be taken to the  instrument-
maker's for a pattern.  The pad should not be too large, nor the spring
too weak, or the instrument will  be loose and inefficient; nor should the
spring be  too  forcible, or the pad too small, otherwise  it will cause pain.
But the patient must expect to find it rather irksome for the first week.
The truss should be constantly worn by day; and if the patient will sub-
mit to  wear it at night also, so much the  better.   If he will  not  do this,
he should, at all events, apply it  in the morning, before he rises  from  the
recumbent posture.   Thousands of trusses, with every possible complica-
tion and variety of spring  and pad, are daily  advertised by their inventors;
but any one who has had much practical knowledge of the subject, will
not fail to agree with  Mr.  Liston, that "the simple truss, well constructed,
made for, and  fitted to the particular individual, with or without a thigh-
strap, is to be  preferred," in most cases; yet it must  be  acknowledged
that there are instances in which  the trusses of Coles, Salmon, Williams,
and other patentees, are found to answer when the common ones fail.
  •From xjjXi; tumour; tvT'jpov, intestinum;  and irttrttoov, omentum.  The  word xr^i)
is frequently used in  the older surgical terminololy; ex. gr. hydrocele, a tumour contain-
ing water j hamatoctle, a tumour containing blood; bubonocele, a hernial tumour in  tha
^roin. 
IRREDUCIBLE  HERNIA.
431
   Radical Cure.—If the patient is below the age of puberty, or not much
nbove it, and if the hernia has not existed very long, it is probable that
the truss, if constantly worn, may effect a permanent cure.  The herniary
aperture, no longer subject to distension, may become firmly closed, and
the neck of the sac obliterated.   This cure may perhaps occur in two or
three years, but, as a measure of precaution, the truss should  be worn for
two or three years more.   As for the old-fashioned attempts to obtain a
radical cure by cutting out the sac,—or by including its neck  in a wire or
other ligature,—or by making a large slough of the superjacent skin, by
means of red-hot iron,—or M. Belmas's scheme of poking little bladders
of gold-beater's skin upon sticks of gelatin into the neck of the sac for the
same purpose,*—the  less  that is said about them the better.   One or two
measures for the radical cure of inguinal hernia will be mentioned in their
proper place.


      SECTION III.--OF  THE  IRREDUCIBLE  HERNIA.

   Definition.—Hernia is said to be irreducible wiien the protruded  viscera
jannot be returned into the abdomen, although there is no impediment to
.he passage of their contents, or to their circulation.
   Causes.—Hernia may be rendered irreducible  (1) by an  adhesion of the
sac to its contents, or of the latter  to each other, or by membranous bands
formed across the sac.  (2.) By enlargement of the omentum or mesentery
— whether from simple deposition  of fat, or  from  sarcomatous or other
organic change.   (3.) Omental hernia may be rendered irreducible by a
contraction of that portion which  lies in  the neck of the sac, so that it is
not stiff enough to stand against the pressure intended to push it back into
the abdomen, but doubles up under it.
   Consequences.—Irreducible hernia may produce sundry inconveniences.
In the first place,  the patient is often liable to dragging pains in the abdo-
men, or perhaps attacks of vomiting, which  come on after food, or when
he assumes the erect posture; because the protruded omentum  or intes
tines, being fixed, resist all distension or upward movement of the sto-
mach.   These inconveniences will  be greatly aggravated, if  the  patient
increase in corpulency, or become pregnant.   Moreover, the protruded
bowels,  being deprived of  the support naturally afforded them  by  the
abdominal muscles, their feculent contents are apt to lodge in them, and
frequently cause colic or  constipation.   Lastly, the bowel is  greatly ex-
posed to external injury, and in constant hazard  of strangulation.
   Treatment.—This  may  be either palliative or radical.  (1.)  The palli-
ative treatment consists in  applying a hollow bag truss, or else a truss with
a hollow pad  that shall firmly embrace the hernia, and prevent any addi-
tional protrusion.   The patient should avoid all violent exertion or excess
in diet, and should never let his bowels be confined.
  (2.) Radical Cure.—It has occasionally happened, after confinement to
bed for several weeks  with fever or some other emaciating ailment, that a
hernia,  irreducible before,  has been replaced with ease, owing to  an ab-
sorption of the fat of the  omentum  or mesentery, and relaxation  of the
abdominal apertures.   The  same result has  also  in  some  cases been
effected by art—by keeping the patient in the  recumbent posture and on
« Vide Lancet, 1829-30, vol. ii. p. 390. 
432
STRANGULATED HERNIA.
very low  diet for six weeks or two months, and by the frequent use of
glysters and laxatives, and at the same time by keeping up  a constant
equable pressure on the tumour by means of a bag truss made to lace ovei
it.  This  plan  is very uncertain  as  to its results, and will be  effectually
defeated  if there  are  any adhesions;  and,  besides, there are  not  many
patients who will  submit to it.   It will be more likely to succeed  if the
hernia is omental, than if it contains intestine.  But several instances are
known, in which, after the contents of old herniae had been replaced, they
produced so much irritation  in  the abdomen, that the patients were glad
to compound for their life by keeping the hernia.  Any surgical operation
with the view of opening the sac, dividing  adhesions, and returning the
parts  into the  abdomen, is scarcely justifiable, as it would be exposing
life to too great  a hazard for the removal of a mere inconvenience.*


        SECTION IV.--OF  STRANGULATED  HERNIA.

   Definition.—Hernia is said to be strangulated, when it is constricted in
such a way, that the contents of the protruded bowel cannot be propelled
onwards,  and the return of its venous blood is impeded.
   The causes of strangulation may be (1.) A sudden protrusion of bowel
or omentum through  a narrow aperture, in consequence  of violent  exer-
tion,—(a  thing not unlikely to happen if a truss has been worn for some
time,  and  then  is carelessly left off.)   (2.)  Distention  of the  protruded
intestines  by flatus or feces,—or tumefaction and congestion of the omen-
tum or mesentery.f  (3.) Swelling of the neck of the sac, or spasm of the
muscular  fibres around it.
   The seat of stricture is generally at the neck of  the  sac, but in  some
rare cases  the bowel has  been constricted by membranous  bands,  or by
fissures in the omentum, or in the sac itself.
   The symptoms of strangulated hernia axe, first, those of obstruction of
the bowels;—secondly, those of  inflammation.   The patient first  com-
plains  of  flatulence, colicky pains, a sense of tightness  across  the belly,
desire to go to  stool, and inability to evacuate.  (It is  true  that stools
may be passed if there be any fecal matter in the bowel below the hernia,
or if the hernia be entirely omental, but with very  transient  relief.)  To
these  symptoms succeed vomiting of the contents of the stomach,—then
of mucus  and bile,—and  lastly, of matters which have acquired a stereo-
raceous appearance by being delayed  in the small intestines.  Meanwhile
the tumour is uneasy, tense, and incompressible.   If this state of things
continue, the inflammatory stage comes on.   The neck of the sac becomes
tender, and tenderness diffuses itself  over the tumour and over the abdo-
men, both of which become very painful and much  more swelled.   The
countenance is anxious ;—the vomiting constant;—the patient restless and
despondent; — and the pulse small, hard,  and wiry.  After a variable
time, the  constricted parts begin to mortify.   The skin becomes cold,—
the pulse very rapid and tremulous,—and the tumour dusky red and em-

  * A case  in which Velpeau practised subcutaneous incisions for the relief of an irre-
ducible hernia, is related in Bull. Gpn. de Therap. 15 and 30  Aug. 1840.
  f Mr. 1. Wilkin="" King, Med. Gaz. 5 May, 1843, shows that the duration of hrrnia
befoie  strangulation, in above half the number of cases, is from 15 to 25 years; and
attributes the production of strangulation in old cases to tumefaction of the bowel from
infective circulation. 
STRANGULATED HERNIA.
433
physematous;  but the pain ceases, and the patient, having perhaps  ex-
pressed himself altogether relieved, soon afterwards dies.
   Varieties.— There  is often considerable  diversity in the rapidity and
violence  of these symptoms.   If  the patient is a  strong  adult, and the
strangulation  has commenced  suddenly with a fresh protrusion  during
some  forcible  exertion, the  inflammatory  stage  may  come on instantly,
and be followed by death in a very few  hours.   On the other hand, if the
patient is old,—if the hernia has  been  long irreducible, and has  a large
nec]<)—arul if the strangulation is produced by distention of the  pro-
truded bowel with flatus  or feces —the symptoms of mere obstruction
may last many  days before  those of inflammation come on.  To this
latter class  of cases the term incarcerated is applicable.*   Again, if the
hernia be omental, the symptoms will probably be less acute than if it be
intestinal.
   Diagnosis.—If a patient with irreducible hernia be attacked by colic, or
enteritis,  or peritonitis, the case  will present many of the features  of
strangulation.   Yet it may perhaps be distinguished by noticing  that the
pain and  tenderness  did  not begin at the  neck of the sac, and are  not
more intense  than elsewhere.   The diagnosis will be very obscure if the
inflammation commences  on the omentum  or intestine in  the  sac.  But
the general rule is, when in doubt,  operate.
   In  every case of sudden and violent vomiting and colic, the surgeon
should make it a rule to examine the bend of the thigh, the scrotum, and
the other ordinary seats  of hernia,  and to  make strict enquiry for any
tumours about the abdomen—because the patient may have been labouring
under hernia for years, and yet from ignorance or mauvaise honte may not
mention  it.
   Morbid Appearances.—After death from strangulated hernia, the bowels
are found reddened,—the upper portion of  them much distended,—and
there are effusions of turbid serum and lymph.   Around the  sac the tis-
sues are  oedeinatous  or  emphysematous.    The strangulated intestine is
dark,  claret-coloured, and turgid with blood,—roughened in patches by a
coating of lymph,—and displaying patches of gangrene, in the  form of
greenish  or ash-coloured  spots, which break down under the finger.  The
omentum is dark red—if gangrenous, it feels crispy and emphysematous,
and the blood in  its veins is  coagulated.  The sac also contains bloody
turbid serum.
   Treatment.—The  indications are, 1st, to  return the intestine,  or  any
portion of it that may not be irreducible; 2dly, to divide any constricting
part, if necessary; 3dly, to obviate inflammation.
   The Taxis.—In the first place, an attempt should be made to return the
protrusion by a manual operation—technically called taxis.\  The bladder
having been  emptied, the patient should  lie  down, with  his shoulders
raised ; and both his  thighs  should be bent towards the belly  and  be
placed close to  each other, so that every muscle  and ligament connected
with the  abdomen may be relaxed.  He should be engaged in conversa-
tion to prevent  him from straining with his respiratory muscles.  Then
(he surgeon,  if  the tumour be large, grasps it with  the  palms of both
hands,—gently compresses it in order if possible to squeeze a little of the
   • There  is great confusion in the  use  of these term?, ns some surgeons employ the
term incarcerated, to signify what is generally known as irreducible hernia.
  f From rdaaia, I set in order.
       37                         2 c 
434
STRANGULATED HERNIA.
flatus into the abdomen,—pushes it in the axis of the neck of the sac, and
at the same time with his fingers gently kneads and sways the parts at the
neck of the tumour, or perhaps tries to pull them very gently downwards,
in order if possible to dislodge them.   This operation may be continued
for a quarter  or half an hour or longer  if the  tumour is indolent, but not
so long if it is tender,—and at last, perhaps, the surgeon will be  delighted
to hear a gurgling sound accompanying the return  of a portion  of intes-
tine.   The operator should  recollect that too  much force  may  bruise or
rupture the viscera,—or drive  sac  and all  into the  abdomen,—or push
them between the layers of abdominal muscles,—and that he must not be
satisfied with a  partial  reduction of  the  volume  and  tension  of  the
tumour, if the  vomiting remains  unrelieved, because, as Mr. Mayo has
shown, such  a diminution  might be  caused by merely forcing the serum
contained in  the  sac  into the  abdominal cavity.  It sometimes happens
that  the  taxis  succeeds  better when  the  abdominal  parietes  are  not
so much relaxed; at all  events this plan might be tried  if the ordinary
one fails.
  If the taxis do not succeed, certain auxiliary measures  are commonly
resorted to,  in order to  relax the  muscles,  reduce the heart's  action,
and  diminish the size  of the tumour.   These we must  treat of in
succession.
  (a)  Bleeding to the  approach of syncope should be tried if the patient
is robust, the hernia small and of recent date, and if there is much  ten-
derness of the  sac or the abdomen, in  which latter case it should be em-
ployed before trying the taxis.
  (b)  The hot bath (96°—100° F.)  continued long enough to produce
great relaxation is useful in similar cases ; but it must be recollected that
a delicate person will not be very likely to bear the shock of an operation,
if bled or boiled  to death's door first of all.
   (c)  A large dose of opium or morphia, is a remedy that is now much in
vogue  in cases of acute strangulation, after  bleeding; especially if the
pain and vomiting are violent.
   (d)  The tobacco enema (3j ad Oj aq.  ferv. allowed to stand ten minutes,
and half to be used at a time)  has certainly been successful in many cases,
especially of inguinal hernia, but it is a most dangerous remedy, and one
that is not to be  recommended, unless  in some desperate case in which
the patient refuses to be  operated on.   It has proved immediately fatal to
some patients,  and has rendered others incapable  of surviving  the shock
of the  operation.
   (e)  Cold,  applied to the tumour by means of pounded  ice or  a freezing
mixture (F.  56)  in a bladder, is useful  by reducing inflammation, con-
densing flatus, and constringing the  skin.  It is most applicable to large
scrotal herniae.   It, too, is  not without its hazards, for it may cause gan-
grene of the  skin if applied too long, or if hot applications are incautiously
used after it.
   (/) Tartar emetic, given as in dislocation, is said to have  been em-
ployed with  benefit, but it might cause a very troublesome vomiting.
   (g)  Purgatives and enemata are  irritating  and mischievous  in sudden
acute strangulation, but vastly beneficial if the patient is aged,  the hernia
large and long irreducible, and if the attack has been preceded and caused
 by constipation.   Large doses of calomel and colocynth are the best pur-
 gatives, and the  enemata should consist of as much  salt and water as can 
STRANGULATED HERNIA.
435
be injected without  causing very much  pain or distention.  They should
lie injected with a pumping syringe, and not with those filthy, inefficient,
and now obsolete instruments,  the  bladder  and  pipe, or  old-fashioned
pewter syringe.   Moreover,  Dr. O'Beirne has  fully shown that  greater
benefit is to be derived in cases  of incarcerated hernia and obstinate con-
stipation from passing up a long tube—(the tube of a stomach-pump an-
swers very  well)—into the  colon, than from the use of the ordinary short
enema pipe.  The long tube relieves the  bowels of their flatus ;  and of
course, by  diminishing the bulk  of the contents of the abdomen, renders
the return of the hernia more easy.*
   In old standing cases, occurring to aged people with large herniae, the
surgeon may be  justified in waiting some time to try the effect of his
remedies;  but in acute cases, occurring to young  people, it may be laid
down as a  general rule that, if the taxis—aided perhaps by bleeding, the
warm-bath, and  opium — do not  succeed, it is the safest plan,  on the
average, to perform an operation for  dividing the stricture without further
delay,—using the  other remedies only if the  patient will not consent to
the operation.
   The operation generally performed consists in opening the sac, dividing
the stricture, and returning the  intestine.  The manner of doing which,
for each variety of hernia, will be found  in the following sections.   When
the sac is  opened, the intestine  should  be well  examined, and especially
that part of it which has  been  actually compressed by the stricture, and
which should be gently drawn  down for that purpose.   If it be  merely-
dark claret-coloured, from congestion,—or slightly roughened with lymph,
—or if it exhibit a few black patches of ecchymosis, it should be returned
—the  operator  being careful to replace  it bit by  bit—intestine  before
omentum—and those parts first which protruded last.  The wround may-
then be closed with one or  two sutures, and a firm compress be placed
upon  it.
   If the hernia were irreducible  long before it was strangulated,  and if its
contents are united  to the sac by firm broad adhesions, they should not be
disturbed.   But if the  adhesions are recent, or very thin  and slight, they
may be divided and the bowel be returned.
   If the intestine is mortified, which will be known by the softened green
or ashy spots,  the  mortified part should  be slit open,  the stricture  be
divided, and the patient left to recover with an artificial anus.  Again, if
a large portion  of the  intestine, which  has been long irreducible in  an
elderly person, appear extremely dark and advanced towards sphacelus,
so as to render it doubtful whether it would be capable of performing its
functions when returned,—the safest plan  is  to make an opening into it,
and so afford an outlet for its contents;  although the inconvenience of an
artificial anus must of course be considered.
   If the  omentum  is gangrenous, or if it is thickened and indurated, it
would, if returned, excite dangerous  irritation of the peritonaeum.  In this
case some surgeons advise it to be left to granulate  in the sac,—or to cut
it off  close to the neck of the sac, and  leave it there as a plug to prevent
further protrusion.  Macfarlane  and others, on the  contrary, recommend
it to be cut cleanly off, and all the vessels to  be tied with  fine  silk liga-
tures, and the end to be then passed quite into  the  abdomen,—breaking
  *Vide Lancet, July 6 and 27, 1S39;  also James's Retrospective Address, in Prov
Med. Trans.  1S40; and O'Bcirno on Defamation. 
43C
STRANGULATED  HERNIA.
up any adhesions about the neck of the sac, if necessary;—thus avoiding
the dragging pains  and colic which are liable to occur if a portion of the
omentum or intestine is fixed.
   Division of the Stricture external to the Sac. — Some surgeons recom-
mend that the stricture should  be released by dividing the parts surround-
ing the neck of the sac, without opening the sac itself.  - The argument in
favour of this proceeding is, that the danger of inflammation of the perito-
naeum is greatly diminished ;—the arguments against it are, that the stric-
ture may be  in  the sac  itself, or at its thickened  neck, being caused  by
peritoneal bands or thickened omentum, and that it is desirable to exa-
mine the state of the intestine  before returning it into the abdomen.  The
circumstances under which this mode of operating seems most advisable,
are when the hernia is of very great size, and has been long irreducible,
so that the idea of  returning its contents could  not be entertained; and
when the hernia is small, and of quite recent  date, so that there  is  no
chance of gangrene, or of great thickening of  the neck of the sac.  In a
similar case, M. Guerin has divided the stricture by means of a subcuta-
neous incision.*
   But it may  happen that there may be a portion of intestine  concealed
within the omentum, and completely enveloped in a kind of sac formed
by it.   This is especially liable to be  the  case  in  the umbilical hernia.
Therefore, to use the words of Mr. Prescott  Hewett, "when  the hernial
sac appears to  contain thickened omentum only, the omentum ought to he.
drawn out and carefully examined, to see that  it does not form a sac con-
taining a portion of the  intestine." f  If it is thickened and firmly united
to the neck of the hernial sac throughout its whole circumference, an inci-
sion should be  carefully made through it; bearing in mind that it is often
extremely thick, and that the intestine may  be firmly adherent to its inner
surface.   In fact,  as  Mr.  Hewett  says, the  surgeon ought  carefully to
" examine every portion of omentum  which  is  in a hernial  sac, so as to
ascertain that no knuckle of intestine is contained within its folds, before it
is returned into the abdomen, left in the sac, or removed altogether."
   Hernia reduced  en  masse. — When the taxis is used  forcibly for the
reduction of a  strangulated hernia, the tumour, sac and all, may be forced
through the herniary aperture,  and  lie between  the abdominal muscles and
the peritonaeum; or, rather, between  the muscles and the fascia transver-
salis.  In such a case, all the symptoms of strangulation continue, although
the tumour disappears.   The first thing to be done is to make the patient
stand up and cough, in order, if possible, to bring the hernia  down again,
when it should be operated on without delay;  but if this does not suc-
ceed, a cautious incision should be made through the abdominal parietes,
over the suspected seat  of  the  disease; and if found,  the  sac  should be
opened, the stricture divided, and the  case be then treated  according to
the ordinary rules.J
   After Treatment.—After the hernia has been  returned, a compress,—a

   * Mr. Luke informed Mr. Fergusson  that  lie had  lost only two out of nearly forty
patients since he had operated without opening the sac; although previously he had
Lost about one in three.  Vide Fergusson's Practical Surgery, p. 526.  Guerin, Gaz.
Med. de Paris, 7th Aug. 1841, and Mr. Key's Memoir, on dividing the Stricture external
to the sac.
   ■J-Med. Chir. Trans., vol. xxvii.
   ;■ See a report of a paper read  by Mr. Luke, at  the  Roy. Med. Chir. Soc, in Med.
Gaz., 5th May, 1843. 
INGUINAL HERNIA.
437
towel, for instance,—should be put on the site of the tumour, and be re-
tained with a bandage, so  as  to  prevent any protrusion from coughing,
sneezing, or any other accidental exertion.   If the bowels do not act in
six or eight hours, they may be solicited by injections; but salts and othei
purgatives administered by the mouth can scarcely fail to be mischievous;
for as the intestine that was constricted  remains for some  time inflamed,
weakened, and incapable of propelling its contents, they will  but irritate
it  uselessly.    Mr. Travers has very satisfactorily  shown, that the  great
dano-er after the return of the  hernia arises from palsy, and not from in-
flammation of the bowels.*   Castor oil, or  rhubarb  and  magnesia, may
be resorted to after twelve hours.  Tenderness, pain, and other inflamma-
tory symptoms, may be allayed by bleeding, leeching, calomel and opium,
and fomentations.  A truss should be  applied before the patient gets up
again.
             SECTION V.--OF INGUINAL  HERNIA.

   Dkfinition.—Inguinal hernia is that which protrudes through one  or
both abdominal rings.
   Varieties.—There are four varieties.  The oblique,—direct,—conge-
nital,—and encysted.
   (1.) The oblique inguinal hernia is the  most common.  It takes precisely
the same route as the testicle takes in its passage  from the abdomen into
the scrotum.   It commences as a fulness or swelling at the situation of the
internal abdominal ring, that is to say, a little above the centre of Poupart's
ligament,—next passes into the inguinal canal (and in this stage is called
bubonocele)—and  if the protrusion increase, it projects through the external
ring, and descends into the scrotum  of the male, or labium of  the female.
The coverings of  this hernia are, 1, Skin. 2, A strong layer of condensed
cellular tissue, derived from the superficial fascia of the abdomen, in which
the external  epigastric artery ramifies.   With this is mostly incorporated,
3,  the fascia spermatica,—a  tendinous  layer, derived from the interco-
lumnar bands, a set of semicircular fibres which connect the two margins
Fig. 134.f
of the external ring.   Under th;s lies, 4, the cremaster muscle,—sometimes
called tunica communis.  5. Next comes the  fascia propria,—a cellular
layer continuous with the fascia transversalis of the abdomen ; and lastly,
6, the sac.   The internal epigastric artery is  always internal to the  neck
  * Travers, case of Hernia, &.c. Med. Chir. Trans., vol. xxiii.
  f This  diagram, copied from Tiedemann. gives an internal view of the  parts coi ■
corned in the foimation of hernia; and on the left side shows the usual place at whicn
direct inguinal hernia protrudes.
       37* 
438
INGUINAL HERNIA.
of the sac.   The spermatic cord is generally behind  the sac; but, in old
cases, the parts which compose the spermatic cord  are separated by the
tumour, so  that the vas deferens and spermatic artery lie sometimes  in
front, sometimes on either side of it.
  2.  The direct inguinal hernia bursts through the conjoined tendon of the
internal oblique and transversalis muscles, just behind  the external ring.
Its coverings are the same as those of the oblique variety, except the cre-
master, for it has no connexion with the cord.   The  epigastric artery runs
external to the neck of the sac. This hernia may, however, push the  con-
joined tendon "before it, instead of bursting through it.   The  spermatic
cord generally lies  on its outer side.
  3.  The congenital hernia  is a variety of the oblique, and is so called
because that state of parts which permits of it only exists  at or soon  after
birth.   A portion of omentum or intestine  accompanies the testicle in its
descent, and passes down with it into the very pouch  of peritonaeum which
forms the tunica vaginalis reflexa, before  its  communication with the ge-
neral  peritonaeal cavity has become obliterated.   The sac of this hemia is
consequently formed by the tunica vaginalis ;—its  coverings in  other re-
spects are the same as of the oblique variety, and the  protruded bowel lies
in immediate contact with the testicle, and if not replaced, generally ad-
heres to it.
            Fig. 135.*                           Fig. 136.
  4. The encysted (or hernia infantilis) is a sub-variety of the congenital.
The protruding bowTel pushes before it a sac of peritonaeum either into or
close behind the tunica vaginalis, and this tunic and  the  sac  adhere very
closely together.   This hernia, therefore, has, as it  were, two  sacs: viz.
one  proper sac, and another anterior, composed of  the  tunica vaginalis,
which in these cases is very liable to be the seat of hydrocele.!  Fig. 136,

  * This figure exhibits a congenital omental hernia of the right side.
  t This kind of hernia was  first described by Hey of Leeds, in a letter to  Gooch 
INGUINAL HERNIA.                      439
which, like  the  preceding, was copied from a preparation in the King's
College Museum, shows another variety of this hernia, in which the sac is
apparently formed of tunica vaginalis, but its communication with the tes-
ticle is closed.
  Diagnosis.—(1.) The difference between the oblique and direct inguinal
hernie, and  their relations to the epigastric artery, are shown in fig. 137,
which is taken from Tiedemann.  In the oblique, the neck of the tumour
inclines upwards and outwards, and causes a fulness extending up  to the
middle of Poupart's ligament.  In the direct, it inclines (if at all) rather
inwards;  and when the hernia is reduced, the finger, carrying integument
before it, can be passed straight back into the abdominal cavity.   But in
old cases of oblique hernia, the neck of the sac is dragged down towards
the mesial line, so that all distinction is lost.

                                Fig. 137.
  (2.) Hydrocele may be distinguished from hernia by its beginning at the
bottom of the scrotum ; by its being semi-transparent and fluctuating, and
preventing the testicle from being clearly felt (whilst the  cord can be dis-
tinctly felt above it);  and by not  dilating on coughing.   Whereas hernia
begins at the top of the scrotum ;  it is not transparent; does not fluctuate ;
does not prevent the testicle from being  clearly felt, although it obscures
the cord ;  and dilates on coughing.   But hernia may and  does often co-
exist with hydrocele:  the  former beginning from above, the latter from
below\  Moreover, a hernia consisting of intestine greatly distended with
flatus, has been known to be as transparent as a hydrocele.
  (3.) Hydrocele  of the Cord, if low down, may  be distinguished by its
transparency and fluctuation ; but if high up, it may extend into the abdo-
minal ring, and receive an  impulse on coughing, and the diagnosis be very
difficult.   But as a hernia may be concealed behind  this  kind of tumour,
(Vide Gooch's Chir. Works, vol. ii. p. 217.)  He says, "The intestine in this case had
forced its way into the the scrotum before the tunica vaginalis had formed  its adhesion
to the cord, but after its  abdominal orifice was  closed; under which circumstance it
brought the peritona-um  down with it, forming the hernial sac : contrary to what hap
pens in the hernia congenita, where the intestine descends before  the  orifice in  tha
•unica vaginalis has closed, and consequently has no hernial sac but that tunic." 
140
INGUINAL  HERNIA.
the rule, when in doubt, operate, should be acted upon in case of symptoms
of strangulation.
   (4.) Varicocele (or cirsocele), which signifies a varicose enlargement ol
the spermatic veins, resembles hernia, inasmuch as it increases in the erect
posture, and perhaps dilates on  coughing;  but it may be distinguished
from hernia by its feeling like a bag of worms ; and although, like hernia,
it  disappears when the patient lies down, and the scrotum is raised, still it
quickly appears again, if pressure be made upon the external ring, though
that pressure would effectually prevent a hernia from coming down again.
   (5.) Lastly,  a testicle that has  not come  down  through the external
abdominal ring into the  scrotum, has been frequently confounded with a
bubonocele, or small hernia in the  inguinal canal; and has been compressed
with a truss, to the gTeat pain and detriment of the patient.  A  little  care
and attention will prevent this mistake.
   Treatment.—(\.) Inguinal hernia, if reducible, must be kept  up with a
truss, of which the pad generally requires to press on the internal abdomi-
nal ring, and the spring should pass round midway between the  trochanter
and crest of the ilium.   Care must be taken not to let the pad slip down,
and bear  against fhe  spinous process of the pubes.   In fact, it  should be
made to  press accurately against the internal  ring, where the  protrusion
begins, and not be permitted to  slip down so as to bear against the sper-
matic cord.  Malgaigne found that out of two hundred cases in which a
common  truss was applied, there was disease of the cord  or  testicle  in
sixty-five.*
   Various plans have been  proposed for the  radical cure of this  hernia.
One (which is useless) consists in transfixing the root of the scrotum with
a number of  pins, and  making pressure  at  the  same  time  with corks
(through  which the pins are passed), so as to create the adhesive inflamma-
tion in the sac.
   A  second  plan, which  is more feasible, consists in  pushing a fold ot
integument up as far as possible into the neck of the sac, securing it in
this inverted or invaginated position by means of two  sutures (both ends
 of a ligature being passed from within the invaginated skin), and then de-
nuding the pouch of invaginated skin of its cuticle by means of liquor am-
 moniae, so that the surfaces of skin and peritonaeum thus  opposed to each
 other may adhere, and the  neck  of the  sac be  effectually plugged.
   This operation, which was proposed  by M. Gerdy, has been practised
 by Mr. Bransby Cooper, and with some benefit.   For the  herniary aper-
 ture  in Mr. Cooper's patient was so large  before the operation,  that the
 bowel could  not be kept  up by a truss; whereas,  after the operation, a
 common truss enabled the patient to  pursue  a laborious  occupation with
 safety and comfort.f
   Another plan, which has been proposed by M. Gue'rin, consists m sca-
 rifying the neck of  the sac with a convex blunt-pointed  knife, rather less
 than an inch in the length of its blade, such as is used in the division of ten-
 dons.  This is introduced through a mere puncture, so that the incisions
 are subcutaneous.!
   Lastly, we  may mention  the  plan proposed by Dr. Pancoast of Phila-
 delphia,  who  first  returns the contents of the hernia into  the abdominal
            « Malgaigne, Bull. Gen. de Therap. 1839.
            j- Bransby Cooper, Guy's Hosp. Rep., Oct. 1840.
             t See a case in Provincial Med. Journ.,  10th Oct. 1841. 
INGUINAL  HERNIA.
441
cavity, and makes firm pressure with the finger on the external ring; then
introduces a very fine trocar and canula; and having made the point strike
against the  horizontal portion  of  the pubes, just to the inner side of the
spine of that bone, turns it either  upwards or downwards, so as to get the
instrument fairly into the cavity of the sac.   Then the inner surface of the
neck  of the sac  is freely scratched and  scarified with the point of the
trocar; and next, the surgeon having withdrawn the  trocar, and having
made certain that the canula is  in the  sac,  cautiously injects through it
half a drachm of tincture of iodine or of cantharides, lodging the liquid as
near as possible to the external ring.  The canula being now removed, a
compress is to be  placed on the external ring,  and a well-fitting truss over
it, which must be worn unremittingly for eight or  ten days,—the patient
being in bed all this time, and measures being adopted to prevent inflam-
mation.
   Respecting these operations, it seems to be  the prevalent opinion, that
though they might be useful, if (as  in Mr. Cooper's case) the hernia can-
not be kept up with a truss, yet that if a truss  answers, they should not be
resorted to.*
   (2.) The irreducible must be supported with a bag truss.  If it contain
only omentum, a common truss may perhaps be applied in the usual man-
ner, so as to make it  adhere to  and  plug the neck of the sac.   But this
cannot often be borne, and is liable to induce  swelled testicle.
   (3.) In performing the taxis for the relief of strangulated oblique inguinal
hernia, the patient should  be placed in the position  described in a forego-
ing page (433), with his thighs as close together as  possible (although the
surgeon must put one arm between  them), and the pressure  must  be made
upwards and outwards.
   The operation  for  this hernia is performed  thus:—The parts being
shaved, and the  skin made tense, an incision  three or four inches long
must be made through the skin, along the axis of the tumour, beginning
from above its neck.  This will be  quite long  enough, even  for the largest
hernia; because the object is to bring the seat of stricture fully into view,
without exposing  too  much of the  sac.   Then  the successive coverings
before enumerated are to be divided in the following manner:—a little bit
of each is to be pinched up with forceps, and to  be cut into  with the knife
held horizontally; a director is to be passed  into this little aperture, and
the layer is then to  be divided on it to the extent  of the  incision in the
skin.   Cautious operators will find (or make) many more layers than those
usually enumerated, which are,  in  fact, easily subdivisible, especially in
old herniae.  When at last the sac is reached,  which will be known by its
bluish transparency, it is to be opened to the  like extent, a little bit of it
being first pinched up and cut through, so as to admit the director.  If
possible, it should be  done at a part where there is some serum, or omen-
tum, between it and the bowel.   Then the left forefinger should be passed
up into the neck of the  sac to seek for the stricture, which will generally
be at the internal  ring.  It may be  at the external ring (or at both); but
wherever it may be, it must be dilated  so as to allow the  finger to pass
into the abdomen.  A curved blunt-pointed bistoury  or hernia knife—not
cutting quite up to the  point—should be passed up flat on the  finger through
the stricture, and its  edge be then turned up  so as to divide it;  and in
  • For an account  of Pancoast's operation, see Brit, and For. Med. Rev., July 184V
sue also Souths Clielius;  Christophers in  Lancet for Feb. '21, 1846. 
442
FEMORAL OR CRURAL HERNIA.
every case the division should be made directly upwards, parallel to the
linea alba; and then, whether the hernia be direct or oblique, the epigas-
tric  artery will not  be wounded.   If no stricture  be discovered  in  the
neck, it must be sought for in the body of the sac.
   The  subsequent proceedings, — the return or otherwise of the intestine,
and  the after-treatment—are detailed in the preceding section.

     SECTION  VI.--OF  FEMORAL OR  CRURAL  HERNIA.

   Definition.—Femoral  hernia  is  that which  escapes behind Poupart's
ligament.
   It passes first through  the crural ring—an aperture bounded internally
by Gimbernafs ligament, — externally by the  femoral vein — before, by
Poupart's ligament—and behind by the bone.   It next descends behind
the falciform process of  the fascia lata—thirdly, it comes forward through
the saphenic opening of that fascia—and lastly, as its size increases, it does
not descend down on the thigh, but turns up  over the falciform  process,
and  lies on the anterior surface  of Poupart's ligament.  The coverings of
this hernia are—1.  Skin.   2. The superficial fascia of the thigh, loaded
with  fat, and  divisible into  an uncertain number of layers.  3. Fascia
propria, a layer of cellular tissue derived from  the  sheath of the femoral
vessels, or, according to  others, from the fascia cribriformis which closes
the saphenic aperture.   It is in  general pretty dense about the neck of the
                                      hernia,  but thin, or even deficient,
             Fig.  138.*                °o its fundus.  4.  The sac.   Be-
                                      tween  the  last two  there  is  often
                                      found a  considerable layer of fat,
                                      which might be mistaken for omen-
                                      tum.   This hernia rarely attains a
                                      very large size.  It  is much  more
                                      frequent  in the female  than  in the
                                      male, — obviously from the greater
                                      breadth of the pelvis, f
                                        Diagnosis.—(1.) Femoral hernia
                                      may be  distinguished from  the  in-
                                      guinal by observing  that Poupart's
                                      ligament  can  be traced  over the
                                      neck of the sac, and that the spinous
                                      process of the pubes  lies internal to
                                      it; whereas it is the  reverse in the
                                      inguinal hernia.  Besides, the fem-
                                      oral  is generally much smaller and
                                      is more frequent in women.
  • The  cut, taken from a preparation of Mr. Fergusson's in the King's College Museum,
shows a  femoral  hernia with its relation to the other parts which pass under Poupart's
ligament.  Externally are seen  sections  of the iliacus  and  psoas muscles, with the
crural nerve between them: then the femoral artery and vein; next the hernia, which
passes through a  small aperture occupied by an absorbent gland in the  normal state,
<tnd is bounded by Gimbernat's ligament on its inner side.  The hernia passes down-
wards in the sheath of the femoral vessels;  separated, however, from  the vein, us that
is from the artery, by a process of cellular tissue.  The sheath of the vessels is contin-
uous above with  the  fascia transversalis.
  f Mr.  Partridge informed the author that  he had met with a case of femoral  hernia,
protruding below Poupart's ligament,  external to the vessels.
 
FEMORAL OR CRURAL HERNIA.
443
  2. Psoas abscess resembles this hernia in  its situation — in dilating on
coughing, and diminishing when the patient lies down.  The  points of
distinction are, that it is generally more external, that it fluctuates, but
does not feel tympanitic, and that it is attended with symptoms  of disease
of the spine.
  3. Varix of the femoral vein also resembles this hernia, inasmuch as it
dilates somewhat on coughing, and diminishes when the patient lies down;
but then,  if pressure  be made below  Poupart's  ligament, the swelling
quickly reappears,  although it  must be  evident that under such circum-
stances a hernia could not come down.
  4. Bubo and other tumours of the groin may in most cases  be recog-
nised by their general character and history, and by their being unattended
with abdominal disorder.  But  if there be any such swelling, and symp-
toms of strangulation as well,  an  incision  should certainly be made to
examine  it.   The  very best surgeons  have been known  to fail in the
diagnosis of these cases.
  Treatment.—(1.)  The reducible femoral hernia should be  supported
by a truss ; the pad of which requires to be bent  downwards at an  angle
with the spring.   Its  pressure should tell against the hollow which is just
inferior and external to the spinous process of the pubes.  This hernia is
very seldom, if ever, cured radically.
  (2.)  The irreducible should  be  supported by  a  truss with  a hollow
pad; or perhaps (if it be omental) the pressure of  a  common pad may be
borne.
  (3.)  The femoral hernia, when strangulated, gives rise to  much severer
symptoms than  the  inguinal  does,  because  of  the  denser  and  more
unyielding nature of the parts  which surround the neck of the sac.  In
performing the taxis, the patient should be placed in the usual position,
with the thigh  of the  affected side much rolled inwards, and crossed over
towards the other  side.  The  tumour should first be drawn downwards,
from the anterior part  of Poupart's ligament, and then be pressed with the
points  of  the  fingers  backwards and upwards.   If, however,  the  taxis
(with bleeding and the warm-bath if  the tumour is tender)  does not soon
succeed, the operation should be resorted to.  No good will be done by
any other  measures.
   Operation.—In the first place, the skin must be  divided.   Some sur-
geons make one  simple perpendicular incision.  Sir A. Cooper directs
one like an  inverted j,; Mr. Liston prefers making one incision  along
Poupart's  ligament, and another falling perpendicularly from  its centre
over the tumour, thus, \^^    The skin may be very safely and  expe-
ditiously   divided  by    |\ pinching it  up into a fold, and running
the  knife  through  it         with its back  towards the  sac.   Mr.
Fergusson  sometimes         makes  one like  an  inverted ^, so that
the skin can be turned back in three flaps; after which the succeeding
layers may be divided by a simple longitudinal incision.  Then the dif-
ferent cellular layers down to the sac  must be divided by the bistoury and
director, as in  the inguinal hernia, and the sac must be opened with veiv
great care, because it  is generally very small, and  embraces  the bowel
tightly, and seldom contains any serum or omentum.   Then  the  finger
should  be  passed up to  seek for the stricture, which, according to Sir A.
Cooper and Mr. Liston, will be generally found to be the  inner edge of
the falciform process.   This must be  gently divided  for a line or two, the 
444
UMBILICAL HERNIA.
incision  being  directed upwards and a little inwards, towards the
spinous process of the pubes.   It must be recollected, that if this incision
were carried too far, the  spermatic cord in the  male, or round ligament
in  the  female, would be injured.    If, however,  the  stricture is not
released  by that incision,  a few fibres  of Gimbernat's ligament must be
divided;  although it must be  recollected that the  obturatrix artery not
unfrequently runs round behind that ligament, and would be infallibly
wounded.

SECTION VII.--OF THE UMBILICAL, VENTRAL, AND OTHER
               REMAINING  SPECIES OF  HERNIA.

   I. Umbilical Hernia—(exomphalos)—is, for obvious  reasons,  most
frequent in children soon after birth.   It is also not uncommon in women
who have  been frequently pregnant, although, in  many  of the so-called
umbilical herniae in "adults, the hernial aperture, is really not at the umbi-
licus, but a little on one side of it.   The  coverings of this hernia are  skin,
superficial  fascia, and sac ;  they are always  very thin, and not unfre-
quently the sac is adherent to its contents.
   Treatment.—If reducible, and the patient  an infant, the best plan is to
place a hemisphere of ivory with its convex surface on the aperture, and
retain it there  with cross strips of plaster, and  a bandage round the belly.
A pad of linen, covered with sheet lead, will  do as well.   But the  belly
should by no  means  be bound up  too tightly, otherwise  there will be
danger of producing  inguinal  hernia.  An adult should wear a truss or
broad belt, with some contrivance to  prevent it from  slipping down below
its proper level.   For the irreducible umbilical hernia, a large hollow pad
should be worn.   The  reduction of this hernia is to be effected by the
ordinary manual taxis ;  but if it be very large,  Sir A. Cooper recommends
it to be compressed by a wooden platter.   If it becomes strangulated, and
the patient is  aged, and the strangulation was  preceded by constipation,
purgatives and copious enemata should have a fair trial.  If the operation
is necessary, an incision three inches in length should be made at the upper
part of the tumour through the skin, fascia, and sac, in succession.   The
stricture  should then be  dilated directly upwards in the linea alba with
the knife recommended in other cases.  But perhaps it is better to make
the incision so as to divide the under side of the  neck of the sac, as ad-
vised by Mr. Liston.
   II. Ventral Hernia is that which protrudes through the linea alba, or
through the linee semilunares  or transverse, or in fact through any other
parts of the abdominal  parietes, save  those which are the ordinary  seats
of hernia.  It may be a consequence of wounds or bruises.   Its treatment
requires no distinct observations; but if it should  ever be  necessary to
operate for the relief of strangulation, care must be taken to avoid the epi-
gastric artery.*
   III.  Perinjeal Hernia descends between  the bladder  and  rectum,
forcing its way through the pelvic  fascia  and levator ani, and  forming a
tumour in the  perinaeum.
  • Mention is made in the Lond. Med. Gaz., 21st Oct. 18-12, of an adipose tumour,
situated between the peritonuum and abdominal muscles, and projecting through an
aperture, in the linea alba, through which it could be pushed back, so that it completely
simulated a  hernia.  Such a  case,  if complicated with peritonitis, might remler '.M
'liagnosis very obscure; but an incision would clear up the mystery. 
DISEASES  OF THE RECTUM  AND ANUS.           445
  IV. Vaginal Hernia  is a variety  of the preceding;—in  which the
tumour projects into and blocks up the vagina, instead of descending to
ihe perinaeum.
  V. Labial or Pudendal Hernia descends between  the vagina  and
ramus of the ischium, and forms a tumour in one of the labia.  It is to be
distinguished from inguinal hernia
by the  absence of swelling at the              Fis- 139-*
abdominal rings.  These  three her-
niae must be replaced  by pressure
with the fingers, and be kept up by
pads made to bear against the peri-
naeum, and  by hollow caoutchouc
pessaries worn  in the vagina.
  VI.   Obturator  or  Thyroid
Hernia projects through  that aper-
ture in the obturator ligament which
gives exit to the  artery and nerve.
In a fatal case related by Mr. How-
ship, in which  a  very  small  piece
of  intestine was strangulated   in
this  opening,   the  patient  com-
plained  of  great pain down  the
leg in  the course of the obturator nerve.   This might  be an aid in the
diagnosis.
  VII. Ischiatic Hernia protrudes through the sciatic notch.   This and
the preceding are exceedingly rare ; — and  the tumours  are of necessity
small.   If discovered to exist during life, they must be returned and  sup-
ported by proper apparatus  — and if strangulated, the stricture must be
divided by operation.
  VIII. Diaphragmatic  Hernia is generally a result of congenital defi-
ciency, or accidental separation  of the fibres of the diaphragm.  But it
may also be  caused  by violent falls on the  abdomen, or by violent  pres-
sure of any kind,  capable of lacerating the  diaphragm, and driving some
of the bowels into the thorax.!  This form of hernia, if strangulated, will
produce the ordinary symptoms — vomiting, constipation, and pain; —
which are not  in  any manner to be  distinguished from the symptoms of
ileus or intus-susception—or from those produced when a fold  of bowel is
entangled in a  rent in the omentum,  or mesentery; or when the bowel is
constricted  by membranous bands resulting from  previous inflammation
of the peritonaeum.
CHAPTER XIX,
OF THE SURGICAL DISEASES AND INJURIES OF THE RECTUM
                          AND ANUS.
  I.  Foreign  Bodies in the rectum sometimes require to be removed by
surgical art.   They may consist either of small bones or the like that have
  ' From n preparation of .Mr. Fergusson's in the King's College Museum.
  y Rt id on Diaphragmatic Hernia, Ed. Mod. and burg. Journ., Jan. and July, 1840.
       38 
440
DISEASES  OF  THE RECTUM  AND  ANUS.
 descended from above, or of pins,  glyster-pipes, or other  bodies  intro
 duced from  below.   Substances  of very  extraordinary dimensions  (a
 blacking-bottle, for instance) have been forced into the anus.   The grand
 point is first to dilate the bowel well, by passing in several fingers (oiled).
 or by means of a speculum ; — and then a proper forceps, or a lithotomy
 scoop, may generally be used with success.
   II. Imperforate Anus (atresia ani) signifies a congenital  closure of
 the rectum, and may occur in various degrees.   The anus may be merely
 closed by thin, fine skin, which soon  becomes distended with meconium;
 or the gut may terminate in a blind pouch at any point from the sigmoid
 flexure downwards, the anal  aperture being altogether wanting — or the
 anus may be open for an inch or two, with an obstruction beyond.
   Treatment.—If the end of the intestine can be felt protruding when the
 child cries, a crucial  incision may be made into it without  delay — if it
 cannot be felt,  a day  or two should be waited, so that it may become dis-
 tended with meconium, and then a cautious incision should be made with
 a double-edged bistoury, in the direction  of the curve of the sacrum.  If
 it succeed  in reaching the bowel, the aperture should be kept open by
 tents.
   But if this operation should fail in  reaching the bowel,  or if  the rectum
 appears to be  altogether deficient, so that  it is  useless to attempt it, the
 only resource is  the formation  of an artificial anus ; a measure which it
 is  the surgeon's duty to propose to the  parents, and  to  perform  if they
 wish it; although it really appears  more  humane to let  the child die
 quietly, than to subject it to the pain of the  operation, and the perpetual
 misery and filth of an artificial anus if it survives.  The best  operation for
 this purpose is  one that has  been performed successfully by Amussat in
 cases of obstruction  of the  rectum by disease.   A transverse incision is
 made in the left lumbar region, just above the crista of the ilium, so as to
 come upon the descending colon at the outer edge of the sacro-lumbalis
 and  longissimus dorsi muscles, where  it  is not covered by peritonaeum.
 As soon as the  gut is reached, a loop of thread should be passed through
 it to fix it, and then it may be opened with  a bistoury.  The constant pro-
 lapsus which is such a source of distress when artificial anus is situated in
 the groin,  is not so likely to occur when an aperture is made in this
 situation.*
   This operation has been  successfully performed on adults, in whom the
 large intestine was obstructed by scirrhus  or other disease.
   III. Spasm of the Sphincter Ani is known by violent pain of the
 anus, with difficulty of evacuating the faeces.   On examination, the mus-
 cle feels hard, and resists the  introduction  of the finger.   This affection
 may be caused  by constipation  of the bowels, or disorder of the health.
 It may occur in sudden  paroxysms which  soon go off,—or may last per-
 manently, and lead to organic thickening and stricture of  the anus.
   Treatment.—In recent cases, a dose  of calomel and Dover's powder,
 followed by castor oil, and by enemata of warm water with a little lauda-
 num, will  relieve the paroxysm.  In more obstinate  cases, a bougie or
 mould candle should  be passed  daily—alteratives and enemata of warm
water should also be administered daily ; but if they fail, the sphincter must
be divided and made to heal by granulation.  Division of the Sphincter
  • Vide Brit, and For. Rev.. Jan. 1840, and cases in the Prov. Med. Journ., by Mr
leaJo of Leeds, and others;  also Evans, Med. Chir. Trans  vol. xxviii. 
HAEMORRHOIDS.
447
w  easily performed by introducing the  fore-finger into the anus, and  a
straight, narrow, blunt-pointed bistoury by its side—and then  making an
incision of sufficient extent towards the  tuberosity of the ischium.
  IV.  Haemorrhoids, or Piles, are small tumours situated near the anus.
  Pathology.—They commence as varicose
enlargements of some of the haemorrhoidal
veins;  the irritation  of  which causes vari-
ous morbid changes  in  the mucous  mem-
brane and cellular tissue adjoining.  Some-
times there is a little varicose knot with the
cellular tissue around  thickened.  Some-
times the blood in a  dilated vein  coagulates, forming a solid tumour with
the thickened cellular tissue around.  Again, if piles are situated within
the rectum, the mucous membrane covering them is liable to become ex-
cessively vascular and sensitive, resembling an  erectile tissue.  They are
divided into twro  species, the internal and external, according  as they are
situated within the rectum, or external to the anus.
   Internal Piles are generally firm tumours, varying in size from that of a
pea to that of  a walnut, of a pale or red dish-brown colour when indolent,
but dark or bright red when congested or inflamed. They generally cause
great inconvenience  by  protruding at each motion, and the hypertrophied
vascular mucous  membrane covering them is exceedingly liable to bleed
from the straining and pressure.
   External Piles may be met with (1) in the form of round hard tumours
just at the margin of the anus, and covered half  with skin and half with
mucous membrane ;  or  (2) of oblong ridges of skin external to the sphinc-
ter.  These are commonly called marisce, or blind piles, because they do
not bleed.
   Symptoms.—Piles maybe  met  with in two states—indolent ox inflamed.
When indolent, they merely produce the inconveniences  that necessarily
result from their bulk and  situation.  When inflamed, they occasion the
following symptoms: Pain, heat, itching, fulness, and tension about the
anus—a sensation as if  there  were a  foreign body in the rectum—pain and
straining  in passing evacuations—with  perhaps more  or less bleeding.
These symaptoms  may, in violent  cases,  be complicated with  irritation of
the bladder, frequency of micturition, pain in the back, pain and  aching
down  the thighs.   The young surgeon should  remember, that a patient
with piles may not be aware of the  nature  of his  complaint, or through
delicacy may abstain from mentioning it.  Whenever, therefore, a patient
complains of unusual irritation of the bladder, or of symptoms of dysen-
tery—that is to  say, frequent, painful,  and  unsatisfactory efforts  to pass
motions, the surgeon should always make inquiries after piles.  In women,
piles may cause  aching of the back, uterine  irritation, with mucous dis-
charge, and many anomalous symptoms, which the surgeon  will in vain
endeavour to cure until  he finds out the real cause. The haemorrhage from
piles will be treated of more  particularly at page  450.
   Causes.—The predisposing causes are any circumstances that produce
fulness of the abdominal vessels,  or that impede the return of  blood from
the rectum—such as luxurious and  sedentary habits  of life—pregnancy,
constipation, disease of the liver  or lungs retarding the passage of blood
  * Piles after excision, showing the dilated veins, of which they are in a great mea-
sure composed.
 
448          DISEASES OF THE RECTUM AND ANUS.

through them, and tight stays.   The exciting causes may be anything thai
irritates the lower bowels,—particularly large doses of aloes — ascarides—
horse exercise, or the application of cold  and damp  to  the  posteriors.
Piles are most frequent in women, and are rare under puberty.
   General Treatment.—The  grand objects are to remove the predisposing
and exciting causes.  The patient, if stout, plethoric, and  of sedentary-
habits,  ought to live abstemiously, and take  plenty of exercise.   The
bowels should be regulated by some mild aperient, capable of producing
daily copious soft  evacuations without straining  or griping.   Senna, sul-
phur, cream  of  tartar, and magnesia, in  the form of electuaries, and F.
20, are  frequently used for this purpose; or pills of rhubarb and  soap,
with ipecacuanha, taken twice a day, F. 25; or small doses of blue pill,
followed by F. 27;  or by a small dose of castor oil or Rochelle salts the
following morning.  It is worth knowing that the nauseous greasy taste of
castor oil is pretty effectually  disguised by mixing it with milk, and adding
a little nitric aether and oil of cinnamon.  It is a good plan to inject the
rectum with cold, or nearly cold water after the motions, and to use a hip-
bath at 85—70° at  bed-time.  In cases of long standing, in which the
mucous  lining of the rectum is relaxed, Ward's paste, or the confect.
piperis comp. may be given with great benefit in doses of 3j ter die.  In
similar cases, especially if the patient is advanced in years, and the piles
are attended with a flow of mucus, copaiba may be given in the dose of
thirty or forty drops every morning  in  milk; and a scruple  of common
pitch may be taken in pills every night  at bed-time.   Old people  rarely
dislike the taste  of copaiba.   The bowels should act once daily—and Dr.
Burne says, that the evening  is a much  better time for that purpose than
the morning.  The seat of the water-closet should shelve inwards  at its
margin.
   If the piles are inflamed, leeches to the anus, or cupping on the sacrum,
a  dose  of calomel and opium at  bed-time, followed by castor oil  in the
morning; low diet,  rest in bed, warm fomentations and  poultices; and
enemata of warm water, if the anus is not too tender to bear the introduc-
tion of the pipe, are the requisite measures.  Cold lotions of lead (with a
little laudanum) may be substituted for the warm applications, if more
comfortable.  If there is a tense bluish solid tumour, evidently containing
coagulated  blood, it maybe punctured; but  perhaps it  is better not to
do so.
   Local treatment.—(1.) The first and most essential  measure is perfect
cleanliness.   Mr. Mayo directs the anus to be well washed with yellow soap
and water after each  motion—and if the piles are internal, and protrude
during evacuations,  they should be washed before they are returned.   (2.)
Astringents—the zinc lotion  (F. 58)—or unguentum gallae, to which latter
a  little  of the liq. plumbi diac. may be  advantageously added, (F. 68,)
are generally of benefit.   Dr. Burne recommends an  ointment composed
of pulv.  hellebori nigri 3j adipis 3J, which he says never fails of affording
great relief, although exceedingly painful for  a time.   (3.)  Pressure by
means of a bougie  introduced  occasionally—or  a pad of ivory with or
without a spring, made to bear against  the anus with a T bandage, are
often of service.   There is an instrument consisting of a short egir-shaped
ivory bougie, which is introduced  into the anus, and which is attached by
a slender neck to an ivory pad—so that  pressure is thus made both inter-
nally and externally, that is extremely useful in cases of internal piles with
prolapse. 
Haemorrhoids.
449
  Extirpation.—If the preceding constitutional and local measures fail to
afford the patient the requisite degree of relief, extirpation must be resorted
to.   But the  surgeon  must  bear in mind that it  is highly dangerous  to
operate upon internal piles if the health is broken, or if there is any organic
disease of the liver or  kidneys; and the operation  must be both preceded
and followed by a course of the most regular diet, and medicines to main-
tain the secretions, and remedy any disorder in the health.
  The piles, if  external,  may be  removed by excision with the knife  or
scissors; if  internal, they should be removed by ligature, for excision of
them might  occasion a fatal haemorrhage.*
  The operation is performed as  follows: The bowels having been previ-
ously well cleared, the patient must be told to protrude the piles; and if
he cannot do it easily,  he should sit over a vessel of warm water,  or have
an enema of warm water.   Then  the  piles should be  drawn out with a
tenaculum, and a ligature (not too fine) be tied as tightly as possible round
the base of each.   If  one of the tumours is large,  a double ligature  may
be passed through its base with a needle, and either half be tied separately.
Before finally tightening the ligatures, the piles should be slightly punctured.
After the operation, the ends of the thread should be  cut short, and be
returned into  the  rectum.   The patient should remain in bed, and the
bowels should not be  disturbed for forty-eight hours after the operation.
Pain is to be relieved  by  an opiate, or by leeches; and if it persist, the
piles should be examined to  see  whether the  ligatures remain as  tight as
possible, and if not, they should be reapplied.
  We  must also mention the use of nitric
acid, which  has  been recommended by Dr.
Houston,  in order to  destroy the tender,
tumid, and  bleeding  surface of  mucous
membrane which covers internal  piles, and
which  is the source of their  excessive irri-
tability and haemorrhage.   The pile having
been protruded, its surface is to be smeared
with a smooth  wooden  stick dipped into
the concentrated acid; and then  pure olive
oil is to be applied in  order to prevent the
caustic being too  widely diffused.   The
subsequent treatment  is  the  same as  after
extirpation by the ligature;  and  when the
slough caused by  the acid  separates,  the
surface generally  cicatrizes  speedily, and
leaves  the part braced  up by its contraction.
We may add, that Mr. Fergusson has in-
vented  a speculum ani,   made  of glass,
silvered, and covered  with a smooth pre-
paration of India rubber, and having a hole in  one  side, through which the
acid  can be  very conveniently applied (fig.  141 ).f
  * If the surgeon  is determined to excise internal piles, the only  safe way of doing so
(9 as follows:  When the tumour is protruded, the base of it should be transfixed by a
long needle, which will prevent it from  returning into the  anus.  Then it  may be cu!
jff; and the cut  surface being exposed to the air, will not  bleed so profusely; or if it
does, it is easy to apply cold, astringents, or ligatures.
  f See  an account of Dr.  Houston's method in Dublin Med. Journ., March 1S43: Fer
gtisRon, Tract. Surg. 2d Ed. p. 095.
       38*                        2d
 
450          DISEASES OF THE  RECTUM AND ANUS.
   V. Warts, Condylomata, and other excrescences  around the anus,
that arise from local irritation, are to be removed with the knife, and the
surface from which they grew should,   during  the  granulating stage, be
treated with astringent lotions.
   VI. Haemorrhage from the rectum   is  a very frequent concomitant of
piles, and  may be  of two kinds.   In the first place it  may be caused by
the bursting of a varicose vein; in which  case  the  blood is venous; and
the haemorrhage in general  occurs  only at  unfrequent intervals.   But far
more frequently it  proceeds from  the vascular surface  of internal piles;
which gives way under the  straining which  accompanies defiecation.  In
the latter case the blood is  arterial: it  is squirted from the anus in jets,
when the patient is straining at the water-closet, and the bleeding occurs
very frequently, especially when the body is feverish, or the piles inflamed.
Haemorrhage from the rectum may be distinguished from that which has
its source higher  up, by noticing that the blood is generally of a florid hue,
and  that it covers the faeces, but is not intimately mixed with them.
   Treatment.—(1.) If the haemorrhage  is  moderate in quantity—if it has
been of habitual or periodic  occurrence—if it induces no weakness—and if
it brings relief to  pain in the head, or any other feeling of disorder—before
suppressing it the patient must be made  to adopt  a  course  of exercise,
temperance, and  alterative  and aperient medicines, with the view of  re-
moving the state of plethora that occasions it.   (2.) But if the patient is
weak and emaciated ; if the lips are pale, and the pulse  feeble, the bleed-
ing should be  at once suppressed.  (We may observe here, that whenever
a patient applies for relief in consequence of violent palpitations and  short-
ness of breathing, or giddiness and swimming in the head ; if the lips are
pale, and the extremities tend to swell,  the  surgeon  should always inquire
for piles;  because, as we before observed, some patients, through false
delicacy, will  not mention them.)   Or if the bleeding, as sometimes hap-
pens, instead of relieving symptoms  of  heat and fulness in  the  rectum,
aggravates  them,  the  bleeding  should also be stopped, whatever the
patient's complexion  may be ;  and if he is of a full habit, he should live
abstemiously,  and  keep the bowels  open  with Seidlitz powders.  The
means of checking haemorrhage from the  rectum are, (1.) That piles, if
any exist, should be tied, or be cauterized  as before directed.   (2.) As-
tringent applications, such as injections  of dec. quercus,  or infus. catechu,
used cold.   (3.)  The internal remedies most likely to  be of service are
salts of iron, or bark with  sulphuric  acid,  or the balsams of copaiba and
Peru, or oil of turpentine (in the dose of njxx in mucilage), F. 9, 128.
   VII.  Discharge of  Mucus—clear and  viscid—without faecal  odour,
may be caused by piles, ascarides, the use of aloes, or  any other causes
of irritation to  the  rectum.   To be treated by  mild aperients, astringent
injections,  and copaiba.   F. 17, 18, 20, 98.
   VIII.  Abscesses near  the  rectum may be caused by the  irritation  of
foreign bodies, or by caries of  an adjacent bone, but they are much more
frequently the  result of the various causes of disordered circulation in the
haemorrhoidal  vessels that were mentioned as producing piles, and espe-
cially of that morbid state of mucous membrane which accompanies pul-
monary tubercle.   They may  either  be large and  deep-seated, or  small
and  superficial.   (1.) Deep-seated  abscesses  are  attended with  great
aching and throbbing,—difficulty and pain  in evacuating the fauces,—and
fever,—and on internal  examination a  fulness  or fluctuation  may be felt. 
FISTULA  IN ANO.
451
If these abscesses are left to themselves, a vast quantity of matter may ac-
cumulate in the  loose  cellular tissue of the pelvis, and severe  irritative
fever result from its confinement.   (2.)  Superficial abscesses are attended
with more or less  pain, tenderness,  and throbbing, and swelling around
the anus.   They are often chronic, and often occur in  the consumptive.
   Treatment.—Leeches and fomentations maybe tried  at first—but if they
do not very soon remove the pain and tenderness,  or  if there is the least
suspicion that  matter is forming,  a bistoury should  be pushed home into
the inflamed part,—and if  it be at all extensive, two  or three punctures
should be made.
   IX.  Fistula  in Ano signifies a  fistulous track by  the side of the
sphincter ani.  It is extremely difficult to heal, both because the constant
contractions of the sphincter and levator ani interfere with the union of its
sides, and because of the passage of faecal matter into  it from the bowel.
There are three kinds spoken of in books.   (1.) The complete fistula, which
has one external opening near the anus, and another into the bowel above
the sphincter.   (2.) The blind external fistula, which has no opening into
the bowel, although it mostly reaches its outer coat.   (3.) The blind inter-
nal fistula, which opens into  the bowel,  but  not externally, although its
situation  is indicated by a redness and hardness  near the anus.
   This affection is a common result  of abscess by the  side of the rectum.
Sir B.  Brodie's opinion is, that it always  commences with an ulceration
of the  mucous membrane  of the rectum, and an escape of faecal matter
into the cellular tissue ; which gives rise to abscess, and  the abscess to
fistula.   This  opinion  is corroborated by the  circumstance, that fistula  is
so common in consumptive persons, who  are  also very subject to ulcera-
tion of the  bowels.   It also accounts for the fetor of the discharge.*
   Treatment.—The grand remedy  for this affection  is  division of the
sphincter ani,  so  as to prevent contraction of that muscle for a time, and
cause the fistula to  heal from  the bottom.   The digestive organs  and se-
cretions must first be put in good order, and the bowels be well cleared
by castor-oil and an injection, so  that they may not want to be  disturbed
for two or three days.  Operation.—The patient  being  placed on his
knees and elbows on a bed, or being made to kneel on a  chair and lean
over the  back  of it, and the nates being kept asunder  by an  assistant, the
surgeon introduces his left forefinger into the anus, and at the same time
explores with  a  probe  the whole extent  and ramifications of the fistula.
If it is of the blind internal kind, its situation must be ascertained, and a
puncture be made into  it by the side of the anus.   Perhaps  a probe bent
at an acute angle may be passed into it  from the bowel, and serve as a
guide for the puncture.  Then, one  forefinger being still in the  anus, the
surgeon passes a  strong curved probe-pointed bistoury up to the further
end of the  fistula.   Next  (if the internal  opening  cannot  be found) he
pushes it through the coats of the bowel, so  that its  point  may come in
contact with his forefinger.  Then he puts the end of his forefinger on the
point of the bistoury, and draws it down out of  the anus; and as  soon as
it is fairly emerged, he pushes the handle towards the orifice  of the fistula,
so as to divide skin, sphincter, and  bowel, at one sweep.   Sir B. Brodie
recommends that the bistoury should always be passed through  the inter
nal opening of the fistula, and says that the affection will very likely return
  * This was also the opinion of M. Ribes, who held that the  internal orifice  of th«
stricture might always be found at about an inch and a quarter from the anus. 
w
452          DISEASES OF THE  RECTUM AND ANUS.

if this is not divided ;—he ako condemns  the practice of cutting through
the bowel higher up than this opening.  A few threads  of oiled lint are
then to be placed in the wound, and  the patient to be kept in bed for three
days.   The subsequent treatment consists in the use of perfect cleanliness,
and the daily introduction of a very little slip of lint (which may be dipped
in some stimulating lotion if necessary) between the  edges of the wound
for the first few days, so as to prevent its edges from uniting, and to cause
it to granulate from the  bottom.   If haemorrhage prove  violent  after this
operation, and does not yield to the  application  of cold,  the anus must be
well dilated with a speculum, so as  to expose the bleeding surface to the
air, and any artery discernible may be tied ;  or else  it may  be firmly
plugged with lint, which is to be secured by a T bandage.
   If  the patient will not submit to  this operation, or if he is  labouring
under disease of the lungs, or liver, or kidneys, in an advanced stage, so
that it would be unsafe, the  treatment  must be palliative  merely.  The
confect. piperis, or copaiba  and tonics,  may be administered internally,
and stimulating injections and ointments  be  applied to the  fistula; but
they will rarely be of any avail.
   [A peculiar abnormal condition of the mucous membrane of the rectum
was pointed out by Dr. Physick  (see Am. Cyclop. Pract. Medicine and
Surgery, vol. ii.)  It consists  in  the  formation of praenatural  pouches.
The symptoms are variously  described by different patients, — sometimes
as an intolerable and unappeasable itching  about the  anus; sometimes as
violent, heavy pain,  or sense of weight:  these sensations  are  generally
most  marked after an evacuation, and at night.  If the finger is introduced
within the rectum no tumour can be felt, nor, with the aid of a speculum
even, can any evidence of other diseased condition be detected,  as a  gen-
eral rule.  There is not always a discharge of any kind apparent externally
to indicate irritation of the mucous membrane ; sometimes, however, the
margin of the anus is seen to be  lubricated with serum  or  mucus: these
secretions are liable to be increased  by an inflammatory condition of the
membrane, and  pus is occasionally engendered from the  same cause.
   The method pursued by Dr. Physick to determine the existence of these
pouches was, to introduce a probe slightly  curved at  one extremity, and
to make the instrument advance and  retreat alternately all around the cir-
cumference  of the gut;  if pouches  really  existed, the end of the probe
would enter their open  mouths, so that the sacs could then be drawn
down  towards the orifice of  the anus and be removed by excision with a
pair of scissors: the operation must be repeated, if  necessary, until the
symptoms are relieved and the pouches removed.—Ed.]
  X. Rhagades—fissures and excoriations about  the anus—produce the
utmost pain during the passage of evacuations, and if neglected,  may lead
to spasm and permanent stricture of the sphincter.
   Treatment.—Aperients and alteratives,—regular diet,—astringent appli-
cations, such as  decoction of rhatany, zinc  lotion,  borax  and honey, — or
mercurial ointment, or ung. hydr. nitrat. dilut.,  to which a little ext. bel-
ladon. should be added  if there be much pain or spasm  of  the sphincter,
—and the strictest cleanliness.   But  if a fair trial of these measures is un-
availing, the sphincter must be divided.         **
  XI. Prolapsus Ani consists in an eversion of the lower portion of the
rectum, and its protrusion through the anus.  Sometimes a  little fold of
d.c  mucous membrane  only protrudes; but in ordinary cases the muscu- 
INTERNAL PROLAPSUS.
453
far coat, and whole thickness of the bowel, come down.   This affection
is most common  in  infancy and old age.  It may depend on a natural
laxity and delicacy of structure, or be caused by violent straining,  in con-
sequence of costiveness, or of the existence of piles, or stone, or stricture.
  Treatment.—Whenever the protrusion occurs, the parts should be care-
fully waslied, and then  be replaced by pressure with the hand.  If there
is any difficulty in doing so, the fore-finger oiled should be pushed  up into
the  anus, and it will carry the protruded
part with it.  If, however,  as sometimes              Fis- 142-*
happens, a larger  portion than usual has
come down,  and it is  so swelled  and
tender from the constriction of the sphinc-
ter,  and  from being irritated by the
clothes, that   it  cannot  be  returned,
leeches, fomentations, a dose  of opium,
and rest  in the  horizontal posture for
some hours, will  remove  the  difficulty;
but plain iced water is perhaps the best
application.  To cure this affection radi-
cally, the  bowels should be regulated by
gentle aperients,  (F.  20, 25, 27,) so as
to prevent costiveness and straining,—
injections  of dec.  quercus,  or of a lotion
composed of a  drachm of muriated tinc-
ture of iron to  a pint  of water;—sponging with cold  water—tonics, espe-
cially steel wine— the occasional passage of  a  bougie, and support by
pads and  T bandages, may be used to give tone  and firmness to the parts
—and piles, or any other source of irritation,  must be removed  by appro-
priate remedies.  Dr. MacCormac of Dublin  recommends  that when the
stools are  passed, the skin  near the anus  should be drawn to one side with
the  hand,  so as to tighten  the orifice ; this the author believes to be a very
valuable suggestion.   But  if the diligent  employment of these measures is
of no avail, certain operations may be resorted to.  (1.)  The mildest con-
sists in pinching up two or three folds of mucous membrane on the  pro-
truded bowel  with  forceps, and tying them tightly with ligatures.  (2.)
Or  ligatures may be  passed by needles through several folds of skin just
at the margin  of the anus, which are then  to be tied up  tightly.   Or a
small patch of relaxed mucous membrane  may be destroyed by acid.
Either of these  operations  may be  repeated as often as necessary.   Their
effect in producing adhesion and consolidation of the relaxed tissues must
be obvious.  There  is a  French operation, which consists  in  excising  a
portion of the sphincter ani; but when this operation used to be performed
(as  it commonly  was sixty years ago) for fistula, it wyas often followed by
inability to retain  the faeces.
  XII.  Internal Prolapsus.—Sometimes the upper part  of the   rectum
becomes prolapsed and invaginated within the lower, giving rise  to most
of the symptoms of stricture.   On examination with  the finger, the canal

  *  This cut, from a preparation in the  King's  College Museum, shows a  section of a
prolapsed rectum—the whole circumference of the lower part  of the bowel  being
everted and extruded.   The mucous membrane is excessively thickened from the irr
latiou of exposure.
 
454           DISEASES  OF THE  RECTUM AND  ANUS.

of the rectum is fo^ind obstructed by a tumour with  a capacious ml de sac
around it, and with the natural passage of the bowel in its centre.
   Treatment.—Aperients,  mild  astringent injections, and the bougie, the
point of which should be carefully guided into the orifice in the centre of
the prolapsed portion.
           Fig. 143.               XIII.  Spasmodic Stricture of the rec-
                               tum—known by great difficulty in  evac-
                               uating the bowels, with spasmodic pain
                               on  doing so—is an affection about which
                               but little is known.  " It generally  de-
                               pends,"  says Mr. Mayo, " on  a  vitiated
                               state of the secretions;  and is  more  fre-
                               quently relieved by a regulated diet and
                               alterative medicines, and the  use of in-
                               jections, than by the employment of  the
                               bougie."
                                 XIV. Permanent Stricture.—In this
                               affection (here is a chronic thickening and
                               contraction of  the mucous coat of  the
                               rectum, so as to form a ring encroaching
                               on its canal.   It  is generally situated at
                               from two inches and a half to four inches
                               from the anus.   More rarely  it is met
with higher up, or even in  various parts of the colon.  The symptoms  are
great pain, straining and difficulty in voiding the faeces, which are passed
in small, narrow, flattened  fragments;—and on  examination the stricture
may in  ordinary cases be readily felt. Irritation  of the bladder and uterus,
and pains or cramps in the leg, with headache  and  dyspepsia, are occa-
sional additional symptoms.  If this affection be unrelieved, it leads to
ulceration of the rectum above the stricture, with a consequent aggravation
of all the symptoms,  and death from irritation.
   Treatment.—The remedies are aperients and injections so as to produce
daily soft unirritating stools,—and  the bougie.   A soft  bougie, capable
of being passed with  moderate facility through the stricture, should be  in-
troduced once in three or four days,  and be allowed to remain  fifteen or
twenty minutes;  and its size should  be gradually increased  when a larger
one  admits of being passed.  The best bougie is a short one, made  of
India rubber, which may be received altogether  within the sphincter; and
it may be withdrawn  by means of a  ribbon  at one end.   Instruments  of
every sort introduced into the rectum should be  handled  with the  utmost
gentleness.   Nothing is gained by forcing a large  bougie through a stric-
ture.   The cure is to be effected by  the repeated and gentle stimulus  of
pressure,—so as to excite absorption,—not by mere mechanical dilatation.
There are numerous fatal instances on record in which the bowel has been
torn by bougies, and  by that most dangerous and loathsome instrument,
the common  clyster syringe, in the hands of careless or  ignorant people.
For the administration of enemata, the pipe should be only an inch and a
half in length, with a large bulbous extremity.   Or if in cases of stricture,
or of obstinate costiveness  with great accumulation of faeces, or of incar-
cerated  hernia, it is desirable to introduce a tube farther, it should be quite
flexible  like that of a  stomach pump.  But the natural sharp fold at the
junction of the rectum with the  sigmoid flexure, and the fact shown  by
 
              MALIGNANT  DISEASE OF THE RECTUM.           455

Mr. Ear.e that the bowel not unfrequently makes a horizontal curve to the
right before descending into the pelvis, render the introduction of bougies
into the sigmoid flexure a very blind, hazardous proceeding, and one that
is not often to be justified.   Moreover, the surgeon must be on his guard
lest he fall by inadvertence into an error, which some vile mercenary men
daily commit on purpose.   That is to say, he must not pronounce his pa-
tient to have a stricture merely because the point of the bougie catches in
the fold of the mucous membrane, or is obstructed by the  promontory of
the sacrum.
  XV. Simple Ulcer of the rectum is generally situated  on its posterior
surface, just above the sphincter, where  it may be felt with a slightly in-
durated edge.   It generally begins as a small crack or fissure of the mu-
cous membrane, caused by straining to  get  rid of hardened  faeces.   It
produces great pain and difficulty of defsecation;—more or less discharge,
occasionally tinged with blood, and irritation of the bladder.
   Treatment.—Laxatives, enemata of warm water, to which a little lauda-
num may be added when there is much pain,—and the application  of a
solution of arg. nit. to  the  ulcer, or the  introduction of  tents of  lint
smeared with mercurial ointment,—which failing,  the sphincter must be
divided and made to heal by granulation.
  XVI. Malignant Disease of the  rectum is usually of the scirrhous
variety, and situated at first about two or three inches above the anus.   It
may either commence as a distinct tumour, or as an  infiltration of some
part of the walls of the  bowel.   The earliest symptoms are  uneasiness in
the rectum, with a sense as if some faecal matter had lodged there;  aching
and pain in the back, hips and thighs, and irritation of the bladder.  As
the disease advances, the bowel  becomes more or less obstructed; there
is frequent discharge of a fetid muco-purulent matter streaked with  blood;
and there is a most obstinate constipation, attended with enormous swell-
ing of the abdomen, and sometimes with all the symptoms of strangulated
hernia; but this  may alternate  with the most profuse and exhausting
diarrhoea.   Abscesses about the rectum, opening perhaps into the bladder
or vagina,  aggravate  the patient's misery, and death  ensues  from  ex-
haustion, or from  peritonitis, or perhaps from rupture of the  distended
bowels.  This  disease is  to  be  distinguished  by examination  with the
finger, or with the speculum ; which will detect hardening and ulceration,
or perhaps fungating tun. ours blocking up the gut.
   Treatment.—The first object is, to keep up the action of the bowels by
enemata of warm water, and by the mildest laxatives;  and to allay irrita-
tion  by  occasionally leeching  the sacrum;  by  belladonna and  opiate
plasters;  or occasional enemata, or suppositaries of opium, or large doses
of henbane or conium ; and by the tepid hip-bath.   Sir B. Brodie recom-
mends injections of linseed oil, either pure or mixed with lime water, and
balsam of copaiba with alkalis internally.  When the obstruction threatens
to become considerable, it will be expedient  to use bougies, very gently,
of the softest materials,  and not more frequently than is absolutely neces-
sary.   When these fail, it may be expedient, as a temporary resource, to
cut through, or to excise some  portion of the obstructing growth; some
surgeons  have even extirpated the lower extremity  of the rectum ;  but all
these  operations can  only be regarded  in the light of palliatives.  As a
last resource, an artificial  anus  may be  formed in the left groin, as de-
scribed in a preceding page.*
                        * Walshe, op. cit., p. 297. 
456           DISEASES OF  THE URINARV ORGANS.

  XVII. Pruritus Ani,  a very violent itching of the anus, is a  very
troublesome affection.   The best plan is, to keep the bowels open  with
sulphur, seidlitz powders,  or castor oil, with occasional doses of blue  pill;
—to put the stomach  in proper order;—to bathe the part very frequently
with water as hot as can  be  bome; and  to  apply some stimulating or
astringent substance—such as nitrate of silver, weak solution of corrosive
sublimate, the citrine ointment, or lemon juice.
                        CHAPTER  XX.

          OF THE DISEASES OF THE  URINARY  ORGANS.

SECTION  I.--OF RETENTION OF URINE FROM  SPASMODIC
            STRICTURE  OF  THE  MALE  URETHRA.

   Retention of Urine. — This term signifies want of power to pass the
urine from the bladder.   The student must make himself aware of the dis-
tinction between this  and the suppression  of urine ; in which latter case,
there is no urine secreted by the kidneys, and the bladder is consequently
empty.   He should notice also  the  important fact  that an involuntary
dribbling of urine often occurs when the bladder is full almost to bursting,
and that it is no sign that there is no retention.
   Causes. — Retention of urine  may be caused by morbid  conditions of
the urethra—including spasmodic and permanent  stricture; contraction of
its orifice; the impaction of stones or other foreign bodies in it; and the
presence of cicatrices, abscesses, tumours, and fractured bones external to
it;  by disease of the prostate ; and by palsy of the bladder.
   Of stricture there are three varieties: (1.)  the permanent or organic stric-
ture, in which the urethra is contracted  and condensed from chronic in-
flammation ; (2.) the spasmodic stricture arising from  spasm of  the mus-
cular fibres which  surround  the  membranous  portion ;  and (3.) this in
certain cases is combined with some degree of acute inflammation, whence
the term inflammatory stricture.
  Spasmodic Stricture depends on spasm of the muscular fibres* which
surround the  membranous portion of the urethra.   It  generally affects
persons who are labouring under some degree of permanent stricture,—
or whose urethra has been rendered irritable by repeated attacks of gonor-
rhoea, or by a  diseased  condition of the  urine (especially a tendency to
phosphatic deposits); — these therefore are the predisposing causes,   'fhe
usual exciting causes are, exposure to  cold  and wet,—and  indulgence in
punch or champagne, or  similar acid liquors, which disorder the stomach
and render the urine unusually irritating.   Hence an attack of spasmodic
stricture generally comes on about four hours after dinner.  It  may also
be caused by cantharides, whether taken by the mouth, or absorbed from
blisters applied to the skin.

  • Particularly described by Mr. Guthrie in  his work on the  Urinary and Sexual
Organs, 3d ed. Lond. 1S43. 
SPASMODIC STRICTURE.
457
  The symptoms are,—sudden Retention of Urine; that is to say, the
patient finds himself suddenly unable to pass his water, although he has a
great desire  and makes repeated straining efforts to do so.   The bladder
soon becomes  distended, and can be  felt as a tense round  tumour above
the pubes, and unless relief is given, the countenance becomes anxious,
the pulse quick, and the  skin hot.   'fhe straining  efforts  at  micturition
also become more frequent and violent, and the distress  and restlessness
are extreme.   In this way,  if unrelieved, the patient  may perhaps  go on
for three or four  days; a little urine passing occasionally when the  spasm
is less urgent, but the bladder still remaining loaded ;  till  at last either the
bladder bursts into the peritonaeum;—or, as more frequently happens, the
urethra behind the stricture, (which of course becomes dilated and weak-
ened under the pressure of the urine impelled  by the whole force  of the
abdominal muscles,)  bursts into the perinaeum, and gives rise to extrava-
sation of urine, as will be described in the third section.
  The inflammatory stricture is a variety of the preceding, in which great
pain and tenderness of the perinaeum, and fever, are combined with spasm.
It is generally caused by abuse of injections, or by exposure  and  intem-
perance during acute gonorrhoea.   The treatment of this and of the spas-
modic variety must be the same.
   Treatment.—In the first place the bladder must be relieved if possible.
A silver catheter may first  be introduced.  But if that fails  to pass, the
surgeon may try a  gum catheter of the smallest size, which has been kept
for some time on a curved  wire, so  that it retains its curve  when the wire
is withdrawn.   If  that also fail, a  catgut bougie, or a common bougie,
may be tried in succession, the  surgeon endeavouring to get them within
the gripe of the stricture ;  after which, if they are withdrawn, a stream of
urine will  generally  follow.  In introducing either  of these  instruments,
the surgeon should be careful, 1st, to draw the penis  well forwards on it,
so as to stretch  the  urethra, and prevent  the  instrument from becoming
entangled.   2dly. To make the point slide along the  upper surface of the
urethra.   3dly.  On meeting  with the obstruction,  to  press against it
steadily, but very gently.   And by one or other of these means, used with
delicacy and perseverance for five or ten minutes, the stricture will in most
cases be made to yield.   The  size  of the instruments employed should
vary according to the duration  of  the disease; being small if that is of
long standing; but larger if it is only of recent formation.
   If, however, they  all fail, certain remedies for relaxing the spasm  must
next be resorted to.                                .         .   .  „
   (a) Venaesection,  or cupping from the perinaeum—if the patient is of an
inflammatory habit, or complains  of much pain ;  (b)  An enema, or some
purgative of speedy  operation—if the attack is  caused by excess at table ;
—followed  by (c) an enema of solution of starch f 3iii with tinct. opii f 3i,
—or by repeated doses of  opium or Dover's powder;—together with (d)
immersion  of the whole body in a hot bath (104° F.) till faintness super-
venes,—are the  most useful.  But there are many others that are often of
very great service ; especially (e) the tinct. ferri sesquichloridi in doses of
 Ttlx every ten minutes—(/) affusion of cold water on the genitals—(g) large
draughts of lime water—(h) and  belladonna smeared on  the perinaeum.
(i)  A slight touch with the caustic bougie sometimes produces immediate
relief, when there is some degree of permanent stricture, which is exceed-
       39 
458          DISEASES OF THE URINARY ORGANS.
mgly irritable, and liable to frequent spasm,   (k) Quinine has cured cases
in which spasmodic stricture occurred periodically.
   But the most generally useful remedy of  all, is  opium ;  which allays
the extreme anxiety of the patient, and stops his repeated strainings; for
the stricture generally relaxes when it is  relieved from the constant pres-
sure of the urine against it.
   Puncture of the bladder.—If none of these  means  succeed,  and the
bladder has become  exceedingly distended, it must be punctured.  But
this  operation, although sometimes  necessary to save life, is not very fre-
quently performed,   'fhe time at which it must be done must be decided
by the surgeon's judgment; sometimes,  as Sir B. Brodie observes, it is
necessary within thirty-six hours, sometimes  not for three  or four days.
The puncture  may be made in three places, viz. 1, by the  rectum,—2,
above  the  pubes,—or 3, the  urethra  may be opened  in the perinaeum.
'fhe first  operation is preferred by some surgeons in  cases of retention of
urine by  stricture, but is very seldom performed ;—the second is needful
when the prostate is enlarged so  as to render  puncture  by the rectum im-
possible;—and the third when urine is extravasated, and in most cases of
impassable stricture.
  Puncture of the Bladder by the Rectum is performed by placing
the patient on his hands and knees, or placing him  on his back with his

                               Fig. 144.
knees drawn up, and bringing him close to the edge of the bed,—intro-
ducing the right fore-finger into the anus, and a long curved trocar and
canula, by its side,—then feeling for the  distended bladder just  behind
the prostate, and exactly in the  middle line, and plunging the trocar into
it—leaving the canula for four-and-twenty hours.  The point of the trocai
should be withdrawn slightly within  the canula as it is being introduced
into the anus.

          section  ii.—permanent  stricture.

  Permanent Stricture signifies  a contraction of the urethra, caused
by chronic  inflammation.  At first, a small portion of the  mucous mem-
brane, perhaps only a line or two  in extent, is found  thickened and
deprived  of its  natural elasticity; and perhaps contracted  so as to form a
sharp fold,  as if it  had been  tied with a thread   But in  old neglected 
PERMANENT  STRICTURE.
459
cases, the canal with the corpus spongiosum around may become converted
into a thick, gristly, cartilaginous mass several inches in extent.   Its most
frequent situation  is just at the commencement
of the membranous portion  of the urethra ; but it
is also very commonly found in the anterior por-
tion of  the canal,  especially at the  distance  of
four inches from the orifice.  The causes are re-
peated  gonorrhoea, intemperance, and unhealthy
conditions of the urine.
  Symptoms.—In what may be called  the first
stage, the  patient finds  that he wants  to make
water oftener than usual,  and that he has  more
or less  uneasy sensation  in the perinaeum after
doing so ; he also notices that a few drops hang
in the urethra, and dribble from him after he has
buttoned up.   Then he observes that the stream
of wTater is smaller than usual, and  forked,  or
scattered, or twisted, and that he requires a longer
time and  greater effort than  usual to  pass  it.
Itching  of the  end of  the  penis and  gleety dis-
charge  are  not unfrequent concomitants if the
stricture is  near the  anterior  extremity of the
urethra.
  If the disease proceeds to its second stage, the
bladder becomes irritable, — obliging  the patient
to rise  in the night to void his urine.   He is liable to attacks of spasm
with complete retention, as  was described in the  preceding section.   In
one of these, the  urethra may ulcerate or burst, — giving  rise to urinary
abscess, or to extravasation of urine, as  will be described in the next sec-
tion.  Rigors occurring in paroxysms like ague fits are not uncommon.
  Finally, if the complaint is  permitted to continue, the health suffers
from the constant irritation and want of sleep ; the bladder and kidneys
become  diseased;  the  complexion becomes wan; the appetite fails; the
patient  complains  of chills and flushes, of  aching and weakness in the
back, and of great languor and depression of spirits ; and the urine is con-
stantly loaded  with fetid mucus.   After death, the urethra  behind the
stricture is found greatly dilated;  the prostate, with its ducts dilated, and
in a state of suppuration, or  perhaps containing small  circumscribed
abscesses;  the bladder, sometimes dilated, but more frequently contracted
and having its muscular coat enormously thickened ; sometimes sacculated
from a protrusion of its mucous coat between  the fibres of the muscular;
the  ureters dilated,  and converted into subsidiary receptacles,for the urine,
and  the kidneys  either greatly dilated  or  disorganized.   An engraving
illustrative  of  this will be  found  in the seventh section of  the present
chapter.
  Treatment.—In the first place, any disorder  of the general health, or of
the digestive organs, and any derangement of the urine, must be corrected
by proper remedies.  (Vide* Gleet, Chronic Inflammation of the Bladder,
and  Urinary Deposits.)  The  patient also  must  avoid violent  exercise,
  • This  dmvins. from a,  preparation in the Kind's College Museum, shows the nre^
thru  laid  open, and a stricture in the membranous portion just in front of  the veruinou
t'inuin.
 
460
DISEASES OF  THE URINARY  ORGANS.
 especially on horseback.   But the stricture can only be cured by mechan-
 ical means.   And these are five: 1, the bougie,—2, the catheter kept in
 the urethra,—3, the caustic bougie,—4, puncturation with the stilettc,—
 and, 5, division from the perinaeum.
    1. The bougie.—In  order to ascertain with  precision  the  existence of
 stricture, the urethra should  be examined widi a common plaster bougie
 of full size, i. e.  one that will readily enter the orifice, and that will fill i|ie
 urethra without  stretching  it.  The surgeon takes  the corona glandis in
 his left hand, and  introduces the bougie (previously oiled and bent to the
 shape of the urethra)  with his right—holding it loosely like a pen.  If it
► meets with an obstruction,  it should  be  slightly withdrawn, — then  tried
 again.   If it now  seem to  pass, the surgeon should relinquish his hold,—
 and  then if it recoils, it is a sign that it has bent against the stricture ;—
 whereas  if it  has  entered  the stricture  it will be held, and will require a
 gentle force to dislodge it.   If after all it does not pass, a metallic sound
 or catheter may  be tried, because a slight obstacle to the instrument  at its
 first introduction must  not  be set down at once as stricture.   The  patient
 generally suffers somewhat from sickness and faintness on the first  trial.
 When  the stricture is  clearly made out, the surgeon should mark and lay
 by a bougie that will just pass through it.   In three or four day's time he
 introduces the same bougie again, — lets it remain a few minutes, — then
 withdraws it, and  introduces another of a size larger, which he suffers to
 remain for ten or fifteen  minutes.   After three more  days the  process is
 repeated,—first  using  the  instrument that was passed on the former occa-
 sion,— then one of a  size  larger; and this  process  repeated a sufficient
 number of times affords in most cases an easy, painless cure.
   Metallic bougies or sounds made of silver, or steel plated, are to  be pre-
 ferred to those of the  ordinary soft materials, 1st, if the stricture is old
 and very hard and gristly;  2dly, in cases of very irritable urethrae, because
 their smooth polished surface is not so apt to cause spasm; 3dly, in  cases
 where a false passage has been formed, which these instruments, as they
 can be directed  with greater precision, can be made better to avoid.  They
 should be eight or  nine inches long, not smaller than No. 4, slightly curved,
 and mounted on a firm w7ooden handle,  and their point  should be made
 to slide along the upper surface of the urethra, as it is at the bottom that
 false passages generally exist, and are most easily made.  These  instru-
 ments may also  be used for the cure of old impassable strictures in the
 following way:—A sound  of moderate size, about  one-fifth or one-sixth
 of an inch in diameter, may  be introduced once  in three or four days, and
 be firmly pressed against the stricture for from five to fifteen minutes, tak-
 ing care to keep its point against the  upper part of the urethra.   This will
 cause the anj^rior  part of the stricture to relax a little;  and if the  process
 is repeated often enough it will at last clear the way to the bladder.*
    2. If a small  catheter is  retained in the bladder for two or three days, the
 passage suppurates and dilates remarkably; just  as the lachrymal duct
 does from the presence of a  style.  This method of cure  is extremely
 speedy and efficient.   It may therefore be employed,  1st, when time is of
 much value ;  2dly, when  the  stricture  is very gristly and  cartilaginous,
 3dly, when the  urethra is irregular, or has had a false passage made in it;
 4thly, when the urethra is  so irritable that severe rigors  and  fever are oc-
 casioned by the  passage of the urine after the use of the common bougie
             * Vide Sir B. Brodie  on the Urinary Organs, 3d ed. 1S42. 
PERMANENT STRICTURE.
461
__a circumstance common enough with patients who have  lived in hot
climates.  The  catheter should  be retained  by  means  of  two  strings,
which may either be fastened to the penis with sticking-plaster, or may be
tied to the thighs, or may be passed backwards between  the thighs, and
be fastened to a band round the waist.  It should be removed in three or
four days, and a larger catheter should be passed four-and-twenty hours
afterwards, and should be introduced often enough  subsequently to  keep
up the dilatation.  In cases of stricture which will  not suffer any instru-
ment to pass, Mr. Guthrie recommends a  bougie to be kept in the urethra,
and to be made to press constantly against the anterior surface of the stric-
ture.   He says that this plan " has never failed in his hands to clear the
urethra, and to effect a passage into the bladder."   Mr. Liston, however,
describes it as " a very  futile and  unsurgical proceeding," and  one  " not
likely to be called for in the practice of a man with hands to act and  a
head to guide them."
  3. 'fhe caustic bougie is a powerful agent in diminishing the irritability
of strictures, and is advisable in cases where there is a perpetual tendency
to spasm.  The modus operandi  is  that of a stimulant, not  of an escha-
rotic;  it is employed to take away the irritability of the urethra; not me-
chanically to burn a fresh passage through an old stricture.  Yet it may
sometimes be employed to destroy very  firm strictures of small extent.
But it  should never be used till other means have  failed, and never should
be repeated more than three or four times about the same  period,—for it  is
liable, if misused, to induce  inflammation, abscess, spasm,  haemorrhage,
or false passage.  The  manner of using  it is this:—the distance of the
stricture is measured by a common  bougie,—then the caustic  bougie  is
passed down to the same distance, and is to be pressed firmly and heavily
against the  stricture for a quarter or half  a minute.   The process should
not be repeated in less  than three days.
   4.  Puncturation, or division of the stricture  by means of the  lanceted
stilettes  invented by Mr. Stafford, may be resorted  to with  advantage  in
some cases of old stricture,  especially if at the anterior part of the urethra.
 But if the  stricture is far back, it is a blind,  dangerous proceeding;  and,
 if any instrument whatever  can be passed, it  is unnecessary.
   5.  The  operation  of Opening the Urethra from the  Perinaeum  is
 absolutely requisite in all cases of rupture of the urethra with  extravasa-
 tion of urine,—and it may also be expedient  in cases of very old stricture
 with  extensive urinary fistulae.   It is performed  thus:—the  patient  is
 placed in the lithotomy position ;  a grooved staff is passed  down to the
 stricture, and the left forefinger, introduced into the rectum, is to feel for
 the urethra, and serve as a  guide to the  incisions.   Then a straight bis-
 toury is to be plunged in just above the anus to the depth of an inch, and
 made  to cut its way out upwards in  the middle  line of the perinaeum.
 The end of the sound  should next be felt  for and cut  upon,—and the
 knife is then to  be carried backwards through the stricture into the urethra
 bevond it, which is always more or less dilated and prominent, especially
 if the patient is told to strain  and  try to pass urine.   A  gum  catheter
 should then be passed into the bladder, and  be retained there, so that the
 wound may heal over it, and form a new passage. It should, however,  be
 changed once in three or four days.*
  • "The operation of opening the membranous part of the urethra and introducing a
 catheter into the  bladder,  is,"'says Mr. South, " the  most  effectual. If there be stnc
        39* 
462                      URINARY  ABSCESS.
   There is a modification of this operation which Sir B. Brodie adopted
in a case of old stricture, so hard, narrow, and extensive, that no  instru-
ment could be passed through  it,  and  complicated  with urinary fistula.'.
He cut down through  the perinaeum into  the  dilated  part of the urethra
behind the  stricture.  Then,  having introduced the  finger, he  pressed
with it against the back part of the stricture, and  having  passed  down an
instrument similar  in  principle  to  Mr.  Stafford's, made the  lancet cut
through the stricture.  A catheter was then passed into the  bladder, and
retained there; the wound  in the perinaeum healed, and the patient reco-
vered the facility  of  making -water in a tolerable stream.   The  advantage
of this method is, that the free opening  in  the perinaeum  prevents *11 risk
of extravasation of urine.
   In whatever manner a stricture has been cured, the bougie should still
be used  at intervals, to prevent a fresh contraction.
   Contraction of the Orifice of the urethra may be a congenital affec-
tion, or may be caused by the cicatrization of ulcers.   It must be coun-
teracted by  the daily passage of  a short bougie, otherwise it may  produce
all the evil consequences of stricture further back.  If the  contraction is
very great, and causes retention of urine, one of Anel's probes, a common
probe, and  a  director, may be introduced  in  succession, and then when
the bladder is emptied, the  orifice  must  be dilated  by  a slight incision
downwards  ; any subsequent contraction being obviated by  the bougie.


 SECTION III.--OF  URINARY  ABSCESS,  EXTRAVASATION
            OF  URINE,  AND  FISTULA  IN  PERIN^O,

   I. Urinary Abscess is a  frequent consequence of stricture. It  signifies
an abscess in the  cellular tissue of the perinaeum, and  is caused in the fol-
lowing way:  One or two drops  of urine escape into the cellular tissue, in
consequence of a slight  ulceration  or  laceration  of  the weakened  and
dilated part  of the urethra behind the stricture ; and this small quantity of
urine produces inflammation, so that an abscess  forms, filled with dark-
coloured putrid pus.*
   Symptoms.—A patient with old stricture complains  of rather more diffi-
culty of  micturition  than  usual—he is seized with shivering, the  skin be-
comes hot, the tongue brown, and the pulse faltering;—and on examina-
tion, a deep, hard, and painful but not prominent swelling will be detected
in the perinaeum.   Perhaps  the scrotum is  cedematous.
   Treatment.—The abscess should be opened immediately, and the patient
will  soon  be brought  from the gates of  death to comparative health.  It

ture, it is the surgeon's own fault if the stricture and the retention be not cured at one
and the same time ; and to a certainty it prevents  the possibility of mischief from ex-
travasation, as the urine speedily flows by the wound, and is never pent up."  "If the
urethra  cannot be found, as occasionally happens with young operators, who cut righl
through it before they are aware of it. then, if the cut be continued more deeply, and be
carried up  in  the axis of the pelvis,  the  bladder must be opened ; and if  it be not
opened, it is not a matter of great consequence, provided there be a free external open
ing, as in the course of a few hours the urine will find its way  into  the wound and be
readily discharged."—South"s Clielius, vol. ii. p. 436.
  * In the same manner, a little urine  may escape from a minute aperture in the blad
der, and give rise to abscess behind the pubes, or between the  bladder and rectum;
which may point above the pubes; or in the groins, or may burrow amongst the muscles
of the thigh. 
EXTRAVASATION  OF  URINE.
463
will  also be  expedient 'to  cut through the stricture as directed in the last
section, and pass a catheter into the bladder.
   II. Rupture  of the  Urethra and Extravasation of Urine.—This
is another consequence of  old  stricture, and it  generally happens in the
following way:—The patient, who has  long been labouring under diffi-
culty of micturition, has a fit of spasmodic retention  more obstinate than
usual.   He  is repeatedly getting out of bed, and
straining with all his might to pass his water.  At
last, during one  violent effort, he plainly feels that
something has given way ; — his  painful sense of
distention becomes immediately less, and  he  is
very well pleased, and thinks himself better.  And
perhaps he is now able  to make a little water by
the natural passage, because the stricture  generally
relaxes, when, by any means whatever, it is re-
lieved  from  the  former pressure.   But at the time
when  something  seemed  to yield,  the urethra
burst; — the urine was forced by the whole power
of the  abdominal muscles  into the cellular tissue
of the  scrotum, perinaeum,  and groins ; — the pa-
tient soon  complains  of a  smarting or tingling
about the anus and perinaeum ;—the urine, which
has become putrid and concentrated  by long con-
finement in the bladder, speedily causes inflamma-
tion  and sloughing ;—the skin over the infiltrated
parts displays a reddish blush, which  is soon suc-
ceeded by black spots of gangrene ;—low typhoid
symptoms appear; the tongue  is black,  the pulse
begins to falter,  the skin is clammy; low mutter-
ing delirium and hiccup come on;—and the patient soon departs this life,
unless  proper measures are  taken for his relief.   A black spot on the
glans penis, indicating that the urine has penetrated the  corpus spongio-
sum, is a very fatal sign.
   Treatment. — A staff or catheter must be passed as far as possible, and
it may sometimes be passed  quite into  the bladder,  because, as was ob-
served above, the stricture generally relaxes after the bladder is unloaded,
be it how it may.   Then the urethra must be opened and the stricture be
divided in the manner described in the last section, and  a catheter be
passed through the wound into the  bladder, and be allowed  to remain
several days.   At the same time free incisions must be made  into any parts
that are sw-elled or emphysematous—showing that they have been pervaded
by the  urine.
  The urethra may also be ruptured  by blo-vvs or kicks on the perinaeum,
or by accidents that fracture the bones of the pelvis.   The symptoms will
be pretty evident.  The patient will be  unable  to  make  water ; or if he
attempts it, the urine will be extravasated into the perinaeum and scrotum.
'fhe  treatment consists in retaining a catheter in the urethra, and incising
(he perinaeum if urine has been extravasated.
  III.  Fistula  in Perin-eo, or  Urinary Fistula, signifies an  opening
  * This cut exhibits the urethra laid open; a stricture at the commencement of  the
oulbous  portion ; and false passages, one of which leads into an abscess that surround*
the membranous portion.
 
404
CONTRACTION OF THE  URETHRA.
from the perinaeum  into the urethra,  through which  the urine  dribbles
when the patient makes water.   It is  a frequent consequence  of urinary
abscess and extravasation.
   Treatment. — The first and most essential measure is, to restore the
urethra to a healthy state, and to dilate any strictures that may happen to
exist, by the bougie.   When this has been  done, the fistula  should  be
stimulated  to  granulate by injection  of arg. nit., or by passing a heated
wire into it;-—and  the  external orifice should  be  occasionally touched
with potass, so as not to allow it to heal before the whole track  is closed
—otherwise fresh  abscesses will  form.  Sir B. Brodie thinks it is not a
good plan  either to introduce  the catheter every time the patient makes
water, nor  yet to keep a catheter in  the urethra, as  some have recom-
mended, with the view of preventing the urine from passing through the
stricture, as the irritation does more harm than good.  The patient should
be directed to make firm pressure with his fingers on  the fistulous orifice
when he makes water.  This will sometimes prevent the escape of urine.
   Sometimes  there is a blind fistula  in  perinaeo; that is, a small narrow
fistula, opening into the urethra, but  not externally.   It is occasionally
inflamed and tender; and may be felt as a small tumour in the perinaeum;
perhaps  the size of  a  horse-bean.  It  is attended with more or less dis-
charge from the urethra.   The  treatment consists in  laying the tumour
open, and  dilating any strictures  that exist.
   Sometimes a fistulous communication  forms between the urethra and
rectum.  This may  be known by air passing through  the urethra.   It is
to be treated by dilating the urethra, and then perhaps a heated wire may
be introduced into tfrj fistula from the rectum, in order to close it by the
adhesive inflammation.

   SECTION IV.--OF  SOME OTHER AFFECTIONS  OF  THE
                        MALE URETHRA.

   I. Contraction of the Urethra following injuries, such as blows
on the perinaeum, must be treated  in the same way as permanent stric-
ture : that is, bougies should be regularly passed to keep the canal dilated;
but if it has become contracted and impenetrable, Sir  B. Brodie's plan of
opening the canal, described at the end of the  second section, should be
adopted, and a catheter be passed into the bladder and be kept there till
the wound heals over  it.
   II.  False  Passage. — This  may be produced by using too small a
sound, and pushing  it out of the urethra, or by the misuse of caustic
bougies.   There is nothing to be done for the false passage; but the  stric-
ture which was the  origin of it  must  be treated either with the metallic
sound, or  by keeping  in a small catheter.  WThen  the  surgeon suspects
that he  has pushed an  instrument out of the right passage, he ought to
leave the urethra untouched for  at least a week.
   III. Hemorrhage from the Urethra may be caused by the rude in-
troduction of bougies, or by injuries from without, or  by the separation of
a slough formed by the caustic bougie ;—or, lastly, by a rupture of blood-
vessels during acute chordee.  If the application of cold does not check it,
pressure may be tried.  A flat  piece  of cork  should  be pressed by the
patient against the perinaeum far back, and  be gradually moved forward
till it lights on the right spot, and the  dripping of blood ceases. 
ENLARGED  PROSTATE.
465
  IV. Solid Tumours in the course of the urethra, composed of indurated
follicles, torment the patient by keeping up a perpetual gleet and chordee.
The  mercurial ointment with camphor externally;  and the passing of a
bougie ; or keeping a small catheter in the bladder for  a few days at a
time, are the chief remedies.
  V.  Acute and Chronic Inflammation of the urethra, from whatever
cause arising, differ in no  respect,  in their symptoms, consequences, or
treatment, from gonorrhoea and gleet.
  VI. Foreign Bodies in the urethra may consist  of calculi, or of small
bodies introduced from without;  of clots of blood, of mucus, or, in rare
cases, of portions of faecal matter,  or worms that  have passed into the
bladder from the intestines by means of an ulcerated opening.  They may
perhaps be pushed forwards by the fingers, aided  by the patient's strain-
ings,—and then may be brought out through the orifice, (which must be
slightly  dilated, if necessary,)  by  forceps, or a bent probe.  Or, it is a
very good plan to press the thumb on the urethra behind the foreign body,
antl  then  to inject a good  stream of water from a large syringe, so as to
dilate the passage.  But if these means fail, the substance must be pushed
back into the membranous portion, (if not there already,) and be extracted
by an incision in the perinaeum.   Incisions into the front of the urethra
should be avoided, for they are apt to  leave  irremediable fistulae;  or if
near the scrotum, may occasion infiltration  of urine into its loose cellular
tissue.

    section  v. — of  the  diseases  of  the  prostate
                              GLAND.

  I. Acute Inflammation of the prostate is generally a consequence of
acute gonorrhoea.  The Symptoms are, great weight, pain, and  throbbing
at the neck of the bladder—and tenderness of the  perinaeum;—the gland
feels swelled  and tender on examination by the rectum—and there  are
frequent, violent,  and exceedingly painful efforts to make water.
   Treatment.—Rest in bed—cupping or leeches to the perinaeum—or ge-
neral bleeding if the patient is strong—hip-baths  and enemata of starch
3ii, laudanum 3ss every night.  If the urine  cannot be passed without it,
a very small gum catheter may be introduced ;—but it should be avoided
if possible.
  II. Abscess of the prostate  may be  suspected  if rigors, and obscure
swelling in the perinaeum, follow the symptoms of acute inflammation.  In
any such case, the swelling should at once be freely punctured with a bis-
toury.  If left to itself, the abscess may burst into  the rectum  or the ure-
thra, which latter circumstance will be  indicated by a sudden  discharge
of pus with the urine.   If the abscess should burst into  the urethra,  the
catheter should be used every time the patient passes his urine, in order to
prevent  it from entering and irritating the cyst.  If the case is chronic and
the  habit scrofulous, quinine and tonics, and small doses of cubebs, to  act
as a gentle stimulus on the  parts,  will  be of service.
  III. Chronic Enlargement of the prostate is  extremely frequent in
advanced life, and seems to depend on  the decay of age rather than  on
any disease ; or perhaps it may be said to resemble  the enlargement of the
thyroid gland in bronchocele.  It  generally commences,  as Sir. B. Brodie
observes, about the time that the hair turns  gray, and when earthy specks
                                 2e 
466
ENLARGED  PROSTATE.
Tig. 147.
begin to be deposited in the coats of the arteries.   The  gland increases
from two to fourteen times its natural bulk, and becomes hardened.  The in-
crease in its size is readily detected by examination with the finger by  the
rectum.  The middle lobe generally forms a projecting tumour at the neck
of the bladder, and, in  consequence  of the  alteration of the  shape  and
size of the gland, the prostatic portion of the urethra becomes lengthened.
and curved abruptly upwards.
   The first symptoms are slowness  and  difficulty in making water, sense
of weight in the perinaeum, and tenesmus. In the next place, the bladder
becomes irritable, and the  calls to make water  are oftener than before.
Then, as the patient cannot empty the organ completely, in consequence
of the projection formed  by the tumour, a portion of urine always remains
behind, and decomposes, and becomes ammoniacal.   Sometimes a fit of
complete retention ensues,  and it may be brought on by exposure to cold
or excess in venery.  Next, the mucous  coat of the bladder, irritated by
the frequent strainings, and by the alkaline urine, inflames and  secretes a
viscid mucus.  Finally, the obstacle continuing to increase, the bladder is
constantly  distended—the  urine  perpetually dribbles away—the ureters
                      become dilated  into subsidiary  receptacles;  the
                      kidneys become  disorganized, the  patient's little
                      remaining strength is exhausted, and  he  dies. Ab-
                      scess  in the  gland, or ulceration of that surface
                      which projects into the bladder, sometimes add to
                      the patient's misery, and hasten his death.
                        Treatment.—Medicines are  of  no avail  to  re-
                      move senile enlargement  of the prostate, although
                      they may very likely be required for accompanying
                      disease of the bladder or kidneys.*  The only thing
                      to be  done is to introduce  the  catheter once or
                      twice a day, so that the bladder may be completely
                      emptied.  The instrument will meet with an ob-
                      struction just at the entrance of the bladder, occa-
                      sioned partly by irregularity of the urethra, partly
                      by the projection of the third lobe.   To avoid  the
                      latter,  the instrument (commonly called prostate
                      catheter) should be long, and  have its  point well
                      turned up.  In introducing it, the point should be
                      made to glide as close as possible round the pubes,
and the handle should be well depressed as it is entering the bladder, in
order that the point may ride over the projection.  The finger also should
be introduced into the rectum to  guide it.  The  best catheter, if it can be
used, is  a small gum, which has  been kept a long while  on an iron wire
of considerable curve; but a silver one of proper shape is more  easy of
introduction.                               "
   If  the bladder has been long distended to the  utmost,  and the kidneys
have  become organically diseased in consequence, the sudden withdrawal
of all the urine will be liable to be followed by irretrievable sinking. The
urine should therefore be drawn off in small  quantities at a time, and  the
strength  be w7ell supported with tonics, wine, and plenty of nutriment.
  * Sir B. Brodie gives  a case  in which  enlargement of the prostate in a man aged
thirty-one. following gonorrhcea, was cured by the iodide  of potassium ; and the same
remedy has been used as a local application in the senile form.
 
DISEASES  OF THE  BLADDER.
467
  IV. Complete Retention of Urine from enlargement of th«. prostate
In this case, if there are inflammatory symptoms, cupping  from the peri
naeura and the hip-bath are indicated.  The catheter should be passed if
possible, and when passed, it should be retained, because the bladder does
not regain its contractility for two or three days, and the frequent introduc-
tion of the instrument would be irritating.   If, however, the catheter can-
not be passed by the natural route, it should be thrust through the projecting
part of the gland, so as to make a new passage into the bladder—(or perhaps
one of Statibrd's  lanceted  stilettes  may be  advantageously employed  for
that purpose).   But if this cannot be done, the last resource is
  Puncture of the  Bladder  above the Pubes.—This is  easily per-
formed by making a small incision through the linea alba  just above  the
pubes, and then thrusting a long trocar and canula downwards and back-
wards into  the  bladder, wiiere it  is not  covered by  the peritonaeum.
The canula must be retained, and the patient be kept  on his back to pre-
vent extravasation;—and no  time should be lost in restoring the  natural
passage.
  V.  Calculi  of the prostate  are  small  reddish-brown  concretions of
phosphate of lime formed in the ducts of the
gland.  They cause obscure  irritation of the
neck of the bladder, and difficulty of  micturi-
tion.  They may perhaps be felt by the finger
in the rectum.  Sometimes it may be possible
to remove  some of them with the  urethral
forceps — or if there  are  many  contained  in
one cyst,  to cut upon  them from the peri-
naeum ;  but in general  the only thing to  be
done  is, to keep the urethra well dilated with
bougies,  so as  to favour their spontaneous
escape.
   VI. Scirrhus  of the prostate is a disease
of very rare occurrence.  In one or two cases
which occurred in Sir  B.  Brodie's  practice,
the gland was enlarged, and  of  a stony hard-
ness; there was  great  pain  referred to  the
groins and perinaeum, and irritability of the bladder, and  the real  nature
of the disease  was shown by  the  cancerous  cachexia manifest  in  the
patient's whole appearance.

   SECTION  VI.--OF  THE  DISEASES  OF  THE BLADDER.

   I. Acute Inflammation of the bladder (or cystitis) is rarely a primary
idiopathic affection.   Most frequently it is a consequence of neglected or
ill-treated gonorrhoea,  or else  an  aggravation of the chronic inflammation.
The symptoms are pain, referred to the perinaeum and sacrum—tenderness
of the lower part of the abdomen — micturition exceedingly frequent,
attended with great straining, and followed by an aggravation of the pain
—a mucous or muco-purulent sediment in the urine, and fever.
   Treatment.—Bleeding—leeches  or cupping on the lower part  of  the
abdomen or perinaeum—hip-baths and warm fomentations—castor oil, so
  * The engraving  shows  a cyst of the  prostate gland, from  the King's  College
Ccllectior.
 
468
DISEASES  OF  THE  BLADDER.
as to keep  the  bowels open without  much straining—opiate glyster.-i at
night.   If, moreover, the urine  is acid, (turning blue litmus paper red,)
and if the sediment in  it is yellowish and  not  adhesive, F. 31 may be
given three or four times a day, with saline draughts containing excess of
alkali,  (or F. 97,) in the intervals.  But if the urine be alkaline, (turning
red litmus paper blue,) and if it  deposit a dark-coloured adhesive mucus,
vin. colchici TT[xx—xxx should be given three or four times a day instead
of the  calomel and alkalis.
  II.   Chronic  Inflammation  of the bladder (catarrhus vesice) is a
very frequent consequence of irritation from stricture, diseased prostate,
or stone.
  Symptoms.—The bladder irritable—micturition very frequent and pain-
ful— the urine loaded  with mucus—which is  sometimes  tinged with
blood,  sometimes yellowish  and puriform, but more generally grayish,
streaked with white, highly alkaline, and excessively viscid, so as to stick
to the  bottom of the chamber-pot when turned upside down.  In  the
early stages there is but  little mucus, and the urine may remain  acid ;  but
as the  disease advances, the quantity of mucus becomes  enormous, and
the urine  is voided of a brownish hue, and of a most offensive ammo-
niacal odour.  Moreover, it may clog the urethra, and cause retention of
urine ;—a kind of retention difficult to manage, because the mucus clogs
up the  eyes of the catheter.   In  this stage there is very frequent desire to
make water, and  constant pain above the pubes.   In general, the  mucus
contains phosphate of lime, which may be seen in it in white streaks, and
which  is apt to collect and form  a stone in the bladder.  Perhaps the mu-
cous membrane of the  bladder  may ulcerate, and  after death  it may be
found as cleanly dissected from the muscular coat, as if it had been done
with a  knife.   This will be  attended with an intense aggravation  of  the
pain in micturition,  and with a dark colour of the urine;—owing  to  the
admixture of a little blood which exudes from the ulcerating surface, and
which, after the  urine is passed,  sinks to the bottom like coffee grounds.
But more  frequently the  bladder throws out flakes of lymph, which  be-
come encrusted with patches of  phosphate  of lime.  Moreover, the blad-
der, by the constant exercise of  its muscles in straining, becomes  hyper-
trophied and exceedingly thick ;—and portions of its mucous membrane
are apt to  be forced between the intervals of its muscular fibres, and form
pouches which  are soon filled  with  mucus, or with phosphatic calculi.
Finally the mucus becomes purulent, disease of the kidneys ensues, and
the patient dies.  Dr. Prout says that, in the  last stage of all kinds of
bladder disease, the urine not unfrequently becomes acid  suddenly, and
the mucus and pus disappear, immediately before death.
   Treatment.—In the first place, if there is  a stricture, or enlarged prostate
or stone in the bladder,  proper measures should be taken for their removal
or relief.  In the next place, if the symptoms are at all severe, the  patient
should keep himself in the recumbent position  as much as possible, with
the pelvis  elevated.  Thirdly, if there is at any time a great aggravatior
of pain, and the strength is pretty good, a  few ounces of blood may be
taken  by cupping on the sacrum or perinaeum;  but, as a general rule, all
lowering measures  are  injurious.  Stimulating or  opiate  plasters  to  the
sacrum are sometimes of use.  Pain and irritation are to be allayed by the
hip-bath, and by enemata or suppositories of opium—(F.  85), or  by the
internal administration  of opium.  The.bowels  should be kept properly 
DISEASES  OF THE  BLADDER.
469
open by mild aperients, such as castor oil or rhubarb ;  but griping or
purging are inexpedient.   The diet should consist of boiled mutton, white
fish, rice, arrowroot and other substances that are nutritious, easily diges-
tible, and not apt to turn sour;—with cold weak brandy and water, or gin
and water, or sound  sherry.  Mercury and alkalis are  of course,  as a
general ruie, inexpedient;  yet, if the urine is still acid (not being yet made
alkaline by the mucus) and the strength is good, small doses may be given,
\i required for the state of  the stomach ;—as will be  shown when  treating
of the phosphatic diathesis.
  Besides these remedies, the bladder may  be acted on by certain medi-
cines, and by injections.   Of medicines, the most useful, according to
Brodie, is the root of the pareira  brava, an ounce of which should be boiled
in three pints of water down to a pint, and the decoction be administered
in doses of giv ter die—or the extract of pareira in doses of gr. xxx ter
die may be substituted.   Uva ursi,  or buchu, in doses of an ounce or two
of a strong infusion or decoction, F. 106; or oil of turpentine, (fllxv.) or
chian turpentine, (gr. ii.) or  cubebs, (gr. xv.) or copaiba, (ttjxx.) or tinct.
ferri mur. (\xv.)—in  small doses  three times a day, are also  remedies
of similar virtues.   Hyoscyamus or opium, and small doses of mineral
acids, if the urine is highly alkaline, may be added to any of them.   The
sulphate of zinc  may also be highly useful, F.  123,  6.
  Injections into the bladder are  not to be thought of when there  is acute
inflammation of the bladder  and blood mixed with the  mucus, but they
are highly serviceable in chronic cases, by relieving the irritability of the
bladder, and washing out  the organ, getting rid of the decomposed stink-
ing urine and mucus.   Injections of simple warm water are very useful;
the best way of effecting them is that employed by Mr. W. Fergusson; it
is, to have a catheter with a double passage, and to throw in  the  water in
a continuous stream by means of a small syringe like that of a  stomach
pump.  Three or four pints of water may thus be passed through the
bladder daily.   Decoction of poppies or laudanum may be added in some
cases.   Moreover, injections of very dilute nitric acid (Tl[i—ii—ad 3iss aq.
destil.) thrown into the bladder not oftener than  once a day, through a
double gold  catheter, and allowed to remain  thirty seconds, are  of great
service when the urine is highly  ammoniacal.
  III.  Irritable  Bladder.—Many cases described under  this  title are
cases  of chronic inflammation.   Simple irritability,—that is, a  frequent
disposition to pass the urine without any disease,—may be caused by an
irritating state of the urine ; or it may be the  effect of mere  nervousness,
which is not uncommon in  elderly people ;  or it may be sympathetic of
disease  of the kidneys, as will be described in the next section ; or of irri-
tation of the rectum.
  IV. Paralysis of the bladder may occur under many circumstances. It
may be  caused by injury or disease of the head or spine,—it is often pre-
sent in  typhus fever—it may be caused for  a time by any severe injury,
especially of the legs—it generally remains for a few days after the bladder
has been long distended, whether from prostatic disease or stricture—and
it sometimes occurs suddenly to nervous sedentary people,  who, if they
let their bladder get filled beyond  a certain point, find that they cannol
empty it.  The symptoms of it  are, either retention of urine ;—i. e. that
die patient cannot make water ;—or else incontinence of urine ; that is, the
water dribbles away without his  being able to hold  it.  The  diagnosis of
       40 
470
DISEASES  OF THE  BLADDER.
retention through palsy, from  retention through stricture, is easy.   Th«
retention from palsy comes on suddenly, and  there is no obstacle to the
introduction of a catheter.
  A strong  decoction of parietaria officinalis; cantharides, ergot of rye,
and tinct. ferri mur., are the remedies for simple palsy.
  V.  Incontinence and Dribbling of Urine.—This is a symptom that
requires particular notice ;  because in nine cases out of ten it happens, not
because the  patient cannot hold his water, but because he has retention of
urine, either from stricture  or  enlarged prostate, or palsy of the bladder.
For it must be noticed, that, in either of these  cases, as  soon as the blad-
der becomes full, a little urine begins to dribble away through the urethra
—and besides, the patient  may perhaps be able to squeeze out a little by
straining with  his abdominal muscles, and  may believe  his bladder to be
empty, although all  the while it  is enormously distended.   No surgeon
will fail to put his hand  on the pubes when he sees  the urine dribbling
away.   The obvious remedy is the catheter.
  VI.  Hysterical Retention of Urine.—There  is one  form of palsy
of the bladder which is  not unfrequent  in hysterical women, and which
consists in a deficiency of volition rather than of power.   They are  not
unable to empty  the bladder if they try—but they are unable to try.  These
cases must be  treated with purgatives, and fetid medicines both internally
and as enemata,  F.  23, 86.  If the catheter is  not employed, the patient
will generally begin to make water as soon as  she suffers much from dis-
tension ;  but the bladder  must not be allowed to go unrelieved too long.
  Puerile  Incontinence. — Incontinence of urine  during the night is
common enough in  delicate children ; but the  surgeon  may be consulted
on account of its continuing to an age at which such an  infirmity becomes
very troublesome and degrading.   The best plan of treatment is, to ad-
minister quinine  or steel, and other tonics; F.  1, 11, 13, &c.;  to prevent
the patient from  sleeping on his back;  to have him awakened at a certain
hour, so that he  may empty the bladder of his  own accord;  and to adopt
some means of rendering the habit so disagreeable to him, that  he maybe
induced to correct it by exercising that degree  of volition which remain j
during sleep.  Assafcetida glysters; nauseous  medicines;  and in  the fe-
male, cauterizing the  orifice of the urethra with nitrate of silver, so thai
the flow of urine may cause  severe  smarting,  are  among  the remedies
worth adopting.   Small doses of tincture of cantharides aie  also  recom-
mended.
  VIII.  Fungus Hematodes.—This form of malignant disease sometimes
affects the bladder, and generally commences  in the mucous membrane
near its neck.  The ordinary symptoms,  are frequent desire to make wa-
ter ;  and uneasiness in the region of the bladder, aggravated after  mictu-
rition, and often  extending to the glans penis, perinaeum, and groins.  The
urine is generally turbid,  and deposits  an adhesive  mucus, and it is very
frequently mixed with blood, in  irregular clots; and with  these, portions
of medullary substance are sometimes intermingled.  These symptoms,
combined with the absence of a calculus, and  the possibility perhaps of
detecting a tumour with the sound, are the chief means  of diagnosis.
   Treatment can only be palliative. 
DISEASES OF THE KIDNEYS.
471
  SECTION VII.--OF  DISEASE  OF  THE  KIDNEYS,  HEMA-
            TURIA, AND  SUPPRESSION  OF  URINE.

  I. Acute Inflammation of  the  Kidney (Acute Nephritis)  is  some-
times caused by blows  on the loins, or by the irritation  of renal calculi,
but is very  rarely an idiopathic primary affection.  The symptoms  axe,
burning pain and tenderness in the loins; colicky pains in the belly;  the
urine scanty and high coloured, and the bladder irritable, so that there  are
constant attempts at micturition  ;—fever and  great thirst, and violent  vo-
miting.  The remedies are—bleeding, cupping, and leeches—castor oil—
repeated doses of calomel, opium, and antimony, with colchicum  if  the
habit is  gouty;—warm baths, or warm fomentations to the loins,  and
barley water and other demulcent drinks.
                                Fig. 149.*
  II. Chronic Disease of the Kidneys, when  it comes under the sur-
geon's care, is generally a  consequence of long standing  disease  of the
urethra or bladder.  When the bladder has  been subject to frequent dis-
tention through stricture or enlarged prostate, and its mucous  membrane
inflamed, the ureters are liable to become distended  and converted as it
were into subsidiary receptacles for the urine, so  that all the  violent strain-
ings to  evacuate it tell upon the  kidneys;  and these become diseased,
  *  This engraving, from a preparation in the Middlesex Hospital Museum, represents
the  beginning, middle, and end of a fatal case of disease of the urinary organs.  It
shows a tight stricture about three inches from the extremity of the pen-'s; the urethra
dilated behind it; another stricture in the membranous portion;  false passages and ab-
scess around ; the bladder contracted in size but enormously thickened ; the ureter di-
lated and tortuous, looking like an intestine ; and the kidney expanded and atrophied,
With scarce any of its secreting substance remaining. 
472
FATTY  DEGENERATION.
partly from the mechanical irritation, partly from sympathy, partly from an
extension of inflammation from  the bladder, and partly through  partici-
pating in that general degeneration of the functions and  structures of the
body, which  is sure to ensue when any one  important function is long and
seriously impeded.
  Symptoms.—A person, who has long  been labouring under some chro-
nic  affection  of the bladder,  begins to complain of general weakness and
languor, both bodily and mental.   The sleep is unrefreshing, and the ap-
petite impaired.  There is frequent pain of a weak aching character in one
or both loins ; occasionally shooting down to the testicles or groins.  The
urine is  almost invariably albuminous ; it is generally pale-coloured and
opakish when passed;  sometimes it is tinged with blood, and sometimes
it displays shreds or flakes of lymph, moulded probably into the shape  of
the  ureters.   As  the disease proceeds, it becomes yellowish and purulent,
and deposits a quantity of pus after standing, the globules of which  may
be detected  by examination with the microscope.  These cases are almost
sure to end fatally.  Sometimes the patient dies of exhaustion and obsti-
nate vomiting; sometimes of suppression of urine and coma; sometimes
in a sudden fit of severe shivering;  and sometimes of a rapid attack  of
acute inflammation.   The kidneys are found after death  to  be soft and
disorganised; readily  separating  from their capsule, which  however ad-
heres firmly to the fat and cellular tissue of the  loins; and most likely
they are dilated into cysts ; the secreting tissue being  spread out over the
dilated pelvis and infundibula.
  III. Fatty, or Glandular Degeneration.—This state of the kidneys,
which, from  its original discoverer, is familiarly knowrn  as Bright's dis-
ease, and which has recently been elucidated by the discoveries of Dr.  G.
Johnson, of  King's College, is of peculiar  interest to the surgeon,  both
because irritability of the bladder is one of the first symptoms complained

                               Fig. 150.*
of, and one for which medical advice is first sought;  and also because the
existence of this disease contra-indicates the performance of serious opera-
tions, as well as great loss of blood, and  other severe lowering measures.
It is generally observed that patients labouring under it are easily salivated
by minute  doses of mercury.
  * 1. Epitl elium cells from the tubuli uriniferi, loaded with oil globules magnified 400
diameters; 2. fibrinous shreds from their interior having blood corpuscles and oil glo-
bules entangled in them magnified 200 diameters; 3. one of the tubuli from a kidney
affected with Bright's  disease.  Oil globules are  seen through  its walls.  From Dr.
Johnson's paper, M. C. T. vol.  xxix. 
ALBUMINOUS  urine.
473
  Symptoms.—The patient, who is generally of a pasty scrofulous appear-
ance, weak and dyspeptic, and deficient in red blood, complains of drow-
siness and  nausea; palpitation  of the  heart and great indigestion ;  says
that he is obliged to rise once or twice in the night  to make water; and
sometimes  complains of very great pain and  scalding at  the  neck of the
bladder.   Swelling and pain of the testicles, and  irritation of  the orifice
of the urethra, with gleety discharge, are also occasional symptoms.
  Pathology.—The real nature  of the disease is a slow degeneration of
structure, commencing with an  abnormal deposit of  fat in the epithelium
cells lining the tubuli uriniferi.   As this increases, the circulation in the
venous plexuses surrounding the tubuli becomes impeded; the Malpighian
capillaries consequently become distended with blood, and so either allow
the serum  of the blood to exude from them and  mix with the urine, or
else burst and allow of the escape of fibrine and red  particles likewise.
  State of the Urine.—In the earliest stages, if examined with the micro-
scope,  it is found  to contain particles of epithelium, loaded with fat glo-
bules ;  as  the disease  advances, it is albuminous, and often contains red
particles of the blood, and little fibrinous shreds, moulds of the  interior of
the tubuli uriniferi  from which  they have  escaped; these  often have en-
tangled within them either blood particles, or else epithelium  cells, gorged
with oil globules.
   The end of this disease is, that the kidney becomes more and more in-
capable of separating the urea and other noxious matters from  the blood,
and the patient dies dropsical and comatose, poisoned by impure blood,
or is cut off by acute inflammation.
   The practical point to be noticed as regards the detection of this disease
by the surgeon is this.   Supposing a  patient to  complain of  extreme irri-
tability of  the bladder; and the urine to be  free from the ropy mucus of
cystitis, but albuminous,  the disease  is probably  seated in the kidneys.
   IV.  Albuminous Urine.—The presence  of  albumen  in  the urine  is
valuable as a sign that blood, or the serum  of blood,  or  pus, or some
other albuminous fluid, is mixed with the urine.   This may happen—1st,
through that degeneration of the kidneys commonly known  as Bright's
disease;—2dly, through  congestion of the kidneys, induced by cold and
suppression of the perspiration, or by the presence of a morbid poison,  as
when dropsy and albuminous urine occur after scarlatina ; or by the pres-
sure of the gravid  uterus, or of other tumours on  the renal veins;—3dly,
through an intermixture of pus with the urine.
   (1.)  Urine  may be known  to  contain  albumen,  by  heating a small
quantity in a test-tube over a spirit lamp, when the albumen will coagulate,
and, according to its quantity, may either produce a  mere opacity, or may
even solidify the  entire specimen heated.   If the urine be alkaline, this
test will fail,  because  then heat alone will not coagulate the  albumen;
and,  moreover, heat alone may  cause  a deposit of white phosphates;
therefore a drop  of nitric acid  should be added, which will prevent mis-
take.  Search should be made with  the microscope  for the little shreddy
 particles of the albumen before spoken of.   They generally  fall to the
 bottom of  the vessel, and form  a dirty-white cloud, like mucus.
   (2.)  When urine contains a very small  quantity of blood,  which has
 drained from the tubuli uriniferi, it has a dingy, smoky hue, like port wine
 and water; the  albumen coagulates by heat; and  blood corpuscles and
 minute fibrinous shreds may be  discovered by means of the microscope.
        40* 
474
CHRONIC KIDNEY DISEASE.
  (3.) Pus  may be present in the urine, through suppuration of any part
of the mucous lining of the urinary passages, or from an abscess in  some
contiguous part which has burst into them.   It  generally falls to the bol-
'om of the vessel containing the urine, " forming a dense  homogeneous
layer of a pale-greenish,  cream  colour, seldom  hanging in  ropes in the
fluid like mucus, and  becoming, by agitation, completely diffused through
it.  The addition of acetic  acid neither prevents this diffusion, nor dis-
solves the deposit.  If a  portion of the deposited pus be agitated with an
equal quantity of liquor potassae, it forms a dense, translucent, gelatinous
mass.   On  decanting some  urine from  the deposited pus,  the presence
of albumen may  be detected by heat  and nitric acid."*  The pus glo-
bules may be recognised under the microscope.
  (4.) Mucus, when  present in  urine, may be1 distinguished from pus,
by the addition of  acetic acid, which  corrugates the viscid  liquor of the
mucus, but  exerts  no  such  action  on the  liquor puris.   Moreover,
mucus contains no albumen  in a state  capable  of coagulation by heat or
nitric acid.                                           •
  Pyelitis.—This is the  name  given by M. Rayer to inflammation of the
mucous lining of the  pelvis and infundibula of  the kidneys.  It may ac-
company  the  catarrhus  vesica;,  or mismanaged gonorrhoea, or may  be
caused by renal calculus.   The symptoms are, low fever, heat and pain in
the  back, irritation of the stomach and  testicles,  and the presence offtakes
of epithelium, and  of mucus in the urine.
  Abscess in the Kidney.—This may be suspected if dull pain in the loins
and repeated shivering follow fhe symptoms of nephritis.   Sometimes the
abscess bursts  into the  ureter, and  an immense quantity of pus is dis-
charged with the  urine.  Abscess of the  kidney also sometimes bursts  on
the loins,  and the patient has been known to recover.
  V.  Treatment of Chronic Kidney Disease.—On this subject we can
but give a few general hints.  We  must observe, that the  granular de-
generation is not  essentially an inflammatory disease, although it may be
occasionally accompanied and accelerated in its progress by congestion or
actual inflammation.  When this is the case, as evinced by pain and ten-
derness in  the loins, a moderate quantity of blood may be taken by cup-
ping.   Blisters or issues, or plasters of the  emp. ammoniaci c. hydrarg.,
or of belladonna, may also be of service.   The  skin should be excited by
warm baths and friction ; and flannel should be constantly worn.  It will
be necessary te provide for the  free action of the liver and  bowels, and to
keep  up the secretion of the kidneys,  if deficient, by the milder sorts  of
diuretics ; such as small  doses  of neutral salts;—the infusions of buchu,
and uva ursi, of carrot-seed, or  of the root of parsley.  If there is no fever,
small doses of tartrate or  citrate  of iron will  often be  of great service.
Lastly, the  diet should be  strictly attended to.  It should be plain and
nutritious, and every superabundance  of saccharine  or  fatty matters, or
hard  water or acid wines,—in fact, all acescent  and indigestible sub-
stances should be carefully avoided.
  VI. Hematuria, or Bloody Urine.—The seat of the haemorrhage may
be either the kidneys, or the prostate or bladder.  (1.) Haemorrhage from
ihe kidney is  generally  caused by the irritation of  renal  calculi,  or by-
blows on the loins;  but it may also depend on  a diseased state of the
  • Quoted from Golding Bird on Urinary Deposits, 2d edit. p. 273; a work containing
most ample and valuable information on the  subject it treats of. 
URINARY diseases.
47fi
whole system, as in typhus  fever or scurvy.   The blood is rarely in large
quantity, and it is equally diffused through the urine; although perhaps
there may be some long shreds of coagulum formed in the ureter.  If the
mine is boiled, the blood will coagulate, and  leave the fluid of its natural
colour.
   (2.) Haemorrhage from the prostate or bladder may be  caused by the
rude introduction of instruments, or by the irritation of stone ;  or by the
existence  of an ulcer or fungoid tumour, of  which in fact it is  often  the
earliest  manifestation.   When  the blood is  derived from  the  bladder,
some portion of it often flows pure after the urine is discharged, and it is
in much greater quantity, and often in larger and more irregular clots than
when derived  from  the kidneys;  moreover,  the  pain in the back, and
other signs  of renal irritation that accompany bleeding from the kidney,
will not be present.
   Treatment.—When haemorrhage from the kidneys is attended with in-
flammatory  symptoms, bleeding and the acetate of lead are indicated;—
when with symptoms  of debility, the dilute  sulphuric acid, alum, tinct.
r'erri muriatis, or gallic acid, in doses of gr. v. in a draught with mucilage
and a  little henbane ;  and when  with symptoms of gout, alkalis  and
colchicum  are  indicated.   Cold may be applied to the loins and hips by
means of  bladders of  ice.  In haemorrhage from  the bladder, a catheter
should be passed and be retained,  in order to prevent both accumulation
of blood  in the bladder,  and  straining efforts at micturition.   If  the
haemorrhage is  obstinate, the bladder may be  injected with cold water
containing a scruple of alum to  each pint;—and if much blood  have  co- *
agulated in  the bladder, it will be necessary to break it down by repeated
injections  of water.
   VI. Suppression of Urine, ischuria renalis.—When the kidneys have
been long abused by inordinate indulgence in  strong drink, and are falling
into disease,—or when they have become  diseased  through fatty degene-
ration, or  through the irritation of stricture  or enlarged prostate, they are
liable suddenly to lose their function of  secreting  the urine.   The conse-
quence  of this  is, that the urea  and other elements of the urine  accumu-
late in the blood ; the patient complains of great  uneasiness in  the head
and loins; he becomes first drowsy, and then comatose,  and dies in four
or five days of effusion into the  brain.   This  affection is  alluded to here,
in order to hint at the diagnosis between it and  retention of urine.  In
suppression, if  the  catheter  is  introduced,  the  bladder will  be found
empty; whereas in  retention, whether from  stricture, or from  diseased
prostate, or from palsy  of the bladder, it may be felt full and  distended
above the pubes.*

 SECTION VIII.--OF  URINARY  DEPOSITS  AND   GRAVEL;
   AND  OF   THE  DIATHESIS, OR  STATES OF  CONSTITU-
   TION  WHICH  GIVES  RISE  TO  THEM.f
   Under particular diseased conditions of the system, certain substances
are precipitated from the urine.   If they are not precipitated from it till  it
  » See retention  from stricture, p. 458 ;  retention from enlarged prostate, p. 465, and
retention from palsy of the bladder, p. 469.
  ■j For information on the subject of  this an 1 the following sections, consult Prout on
Stomach  and  Urinary Disease;  Dr. Bence Jones on  Gravel, Calculus, and Gout; Dr
Willis on Urinary Diseases, and  on Stone in the Bladder;  Sir B. Brodie's  Lectures on 
476
LITHIC  DEPOSITS.
has cooled, they are commonly called sediments ;—if they are precipitated
whilst the urine is yet in the bladder, they constitute  gravel;—and lastly,
they mav lodge in some part of the urinary apparatus, and  concrete into
stone.   They may be  divided into  three classes: the lithic; the o\;ilic ;
and the phosphatic.
   I. Lithic Deposits. — The lithic or uric acid, is an animal substance,
containing  much  nitrogen.   It is  insoluble, unless  combined with an
alkali, or alkaline salt; and  in the  urine it is combined with  ammonia,
with which it forms a salt, the superlithate of  ammonia, the acid being in
excess.    This  salt is held  in perfect solution in normal urine ; but if it is
secreted in unnatural quantity, or if the quantity of water in the urine is
too small to dissolve it, it will be thrown down in the form  of  an  impal-
pable powder,  constituting the amorphous  lithic sediment; — and if there
is any free  acid existing abnormally in the urine, the lithic  acid will be
separated from its  ammonia, and will be  thrown  down in a  crystalline
form, constituting lithic or red gravel.
   1. Amorphous Lithic Sediments may appear  in  two forms,  (a) The
first is that  yellowish sediment, which appears in the  urine of almost every
person,  when the digestive  organs  are out of order.  It consists almost
entirely of the  lithate  of ammonia combined with the colouring matter of
the urine.   This form of sediment is  so common  and  well known, that
little more  need be said  about it.  The urine is  always acid, and clear
when passed.   The sediment is deposited when it cools; but it may be
dissolved again by heating a little of it  in  a  watch-glass.   The addition
of a drop of nitric  acid causes  the  deposit of numerous little crystals of
lithic acid.
   (b) A second variety consists of the lithate of ammonia, deeply coloured
by the presence of an excess of highly carbonized  pigment  in  the  urine.
This colouring matter,  which has received from Dr. Golding Bird the
name of purpurine, is always present in the urine when there is  an excess
of carbonaceous matter in the blood, such as is caused by too gross a
diet, as well as in fever, and in diseases of the organs whose office it is to
free the blood  from excess of carbon ; viz. the liver and lungs.  It has a
great affinity for the lithate of ammonia, and when that salt  is  in excess,
and is precipitated, much of the purpurine is precipitated with it.   This
form of  deposit varies in tint in different  instances;  the  most notable
varieties  being the lateritious or brick-dust sediment of fever,  gout, and
rheumatism; and the pink  sediment,  which  is indicative of organic dis-
ease of the lungs or liver, or of exhausting suppuration.
   2. Crystallized Lithic Deposits. — The  most common form of these is
the red gravel; which  consists of minute  crystals of lithic  acid, like
cayenne  pepper.   They do  not dissolve by the application of heat, like
the lithate  of ammonia.*   The urine  from which they are precipitated is
generally acid, high-coloured, and  scanty, consequently of high specific
gravity, but clear.   If turbid from the presence  of  an amorphous deposit
of lithate of ammonia, the  latter may be  dissolved by heat.   When the
Diseases of the Urinary  Organs,  3d edition ; Dr. Rigby's work on Dysmenorrhea, in
connection with  Malassimilation, contains much useful information on  the examination
of the urine.  Golding Bird, op.  cit.
   * The lithic acid when pure is white; and it is white  in the urine  of serpents and
birds; but when  deposited from the urine of man, it is tinted reddi>h or yellow, by the
colouring matter  always present in that fluid.  The chemical tests for  this acid urc de-
scribed in the section on  Calculus 
LITHIC DIATHESIS.
477
crystals  of  this acid are examined  under the microscope,  they present
various  appearances,  most of which,  however, are modifications of the
ihombic prism, as shown  in  the  adjoining cut.  The symp-
toms attending the deposit of a  large quantity of this acid,
constitute  what  is  called  a  fit  of the  gravel.  They are,
feverishness; pain in the loins, shooting down to the bladder;
aching of the  testicles and hips; and  exceedingly frequent
micturition, attended with severe  scalding.
  Causes. — The diathesis or state  of constitution in which
lithic acid, gravel, and stone are  formed from the urine, is
very frequently hereditary.   It is intimately connected with
the  gout, (of which it will be recollected that deposits of  the
lithate of soda are highly  characteristic,) and with the san-
guine variety of  scrofula.   It may also be induced  by errors
in diet,  and especially  by inordinate  indulgence in animal
food, wine, and malt liquors.  It is therefore, generally speaking, a sign
of an inflammatory habit.   The ages at which it is most strongly marked,
are  before puberty, and  between  forty and sixty.
  Pathology.—In former editions of this work we  gave  a  tolerably full
account of the theories proposed by Prout and Liebig respecting the form-
ation of lithic deposits.   In the  present we shall confine ourselves to the
most practical  and  best ascertained  facts solely.  We may safely assume
.it as proved, that the lithic  or uric acid is one of the forms into which the
albumen and fibrine and other nitrogeneous elements of the body, and of
the food,  are  converted by oxydation, in order to their elimination from
the system.  If this substance exist  in preternatural quantity in the urine,
it will probably be, as stated by  Dr. Golding Bird, from one or other of
these five causes, viz.—either, 1st, from fever, rheumatism, or some other
state producing excessive oxydation of the animal tissues ; 2dly,  from too
great a supply  of food ; more being taken than is required for the purposes
of the economy, and part of  the  surplus being oxydized and drained off
by the kidneys;  3dly, from  inability of the  digestive  organs to  dispose
properly of the food introduced into them, though of wholesome quantity
and quality; 4thly, from neglect  of exercise, imperfect supply of oxygen
to the blood, and defective action of the skin, by which  means  not  only
is much of the lithic  acid  not oxydized and  converted into  urea as it
ought to be, but  the natural  outlets for much effete and  acid  matter are
closed;  5thly, from local congestion or irritation of the kidneys.
  Whether the lithic acid shall be deposited in the form of lithate of am
monia,  or in the uncombined crystalline form,  evidently must depend
partly on the  quantity of lithic acid formed, partly on  the presence oi
otherwise  of some  stronger acid, such as the hydrochloric or butyric, a
very minute quantity of which would suffice to precipitate all the  lithic
acid contained in a large quantity of urine.
  Treatment.—The treatment of  the lithic acid diathesis will  be seen from
the  foregoing  statement  to comprise  the following objects—1st,  strict
attention to the quantity and quality  of the food, which requires to be pro-
portioned in every case both to the  wants of the system, and  also to the
capabilities of the stomach.   We  can only give as general rules, that it
should be plain and unstimulating; consisting of a moderate quantity of
meat, with bread, especially  brown bread,  and fresh vegetables or fruit,
but  to the exclusion of an undue  proportion of oily, saccharine, and alco- 
478
LITHIC DIATHESIS.
holic substances.   Much fat and  alcohol  in  any shape are objectionable,
because they load the blood with  hydro-carbonaceous matters, which pre-
vent the due action of the  oxygen  on the uric  acid, and its conversion
into urea.   Saccharine substances are objectionable for the same reason,
and also because they are liable to the acetous fermentation.   Ripe fruits,
green vegetables, especially peas and the eruciferae, water-cresses, &,c,
we consider decidedly wholesome, provided always, that the stomach  is
in a condition capable of digesting them.   If they can be digested, they
not only do good by  filling out the stomach, and preventing the patient
from  indulging so largely in meat and other more stimulating articles of
diet,  but they keep the  bowels open, and supply a valuable quantity of
alkaline matter to the  urine, and so serve to keep the uric acid in solution.
In all cases, however, the golden  rule must be observed, so forcibly stated
by Dr.  Prout, that moderation in the quantity is  of quite as much conse-
quence as  attention  to the quality of food.   Of alcoholic liquors, sound
sherry of the dryer kinds, or small quantities of brandy or Hollands and
water, are the best.
   2dly. The action of the slcin, and  aeration of the blood, must be pro-
moted by exercise  in the open air, proportioned to the  strength of the
patient, and the amount  of  nitrogeneous matters he is able to assimilate;
recollecting always,  that over-fatigue causes the oxydation of a large
quantity of  the living muscular tissue, and the consequent appearance of
copious lithic deposits in  the urine.  Warm clothing; friction of the skin ;
frequent warm  or tepid baths,  or vapour or sulphur baths if there is  any
difficulty in inducing perspiration, or if the skin is diseased, are of great
service.  Baths also containing carbonate of potass in solution, are useful
means of conveying alkali into the blood, if used before a meal,  when the
veins are empty.
   3dly. The system must be relieved of any excess of carbonaceous mat-
ter, and the portal system be well  unloaded by such aperients as will pro-
duce a  proper discharge  of bile.  Mercurials, colchicum, aloes, colocynth,
and saline purgatives, in such combinations as F. 18,  121, 124, 125, 28,
will all be found useful.
   4thly. It  will be necessary to  give alkalis, for two purposes.   One  is
to neutralise acid matters liable to be formed in the stomach at the close
of digestion ; if, therefore, an  hour or two after  a meal, the  patient com-
plains of heartburn, flushed  face, or distension/of the stomach, some such
prescriptions as'F. 91, 92, 93, should be  resorted to.   The second pur-
pose  is to  hold  the  lithic acid in solution ;  by  supplying alkaline matter
and plenty of water.   For this purpose copious  draughts of soda, potass,
Seltzer,  or Vichy water; or effervescent draughts  containing excess  of
alkali, may  be prescribed;  and it  may be observed, that neutral  alkaline
salts, if combined with a  vegetable acid, will appear in the urine in the
shape of carbonates.   Drs. Barlow and Golding Bird  have shown very
satisfactorily that it is impossible for any medicines to act as diuretics, so
long as the abdominal veins and liver are congested, and hence the reason
that mercury and colchicum and purgatives are such necessary precursors
of a course of diuretics. Saline matters intended  to act as diuretics should
be taken in  very diluted  solutions; and pure water itself, such as that of
Malvern, or distilled water,  is, as a mere diuretic, one of the  best.  We
will  only reiterate our recommendation of a vegetable diet, provided the
«omach can digest it, as an antidote to lithic sediments  in the urine. 
                         OXALIC  DEPOSITS.                     479

  Whilst on this head, we ought to mention the good effects that may be
probably derived from the administration of small doses of the phosphate
of soda, or of borax, salts which have a material influence  in  dissolving
the lithic acid; though the stimulant action of borax on the womb must
be remembered when it is administered to females.  Benzoic acid too,
when taken in'o the system, has the property of abstracting from the blood
a quantity of nitrogeneous matter sufficient for  its conversion into hippuric
acid, and in this very soluble  form is  readily excreted from  the kidneys.
It may therefore be administered in doses of gr. x bis die, with much con-
fidence that it will limit  the quantity of lithic acid.  F. 135, 136, 137.
  5thly. In  cases in which there is a want of tone in  the  system, as in
those forms of gout popularly called poor gout, and in which the stomach
seems unable to effect the proper changes in a moderate quantity of whole-
some food, recourse may be had to tonics, such as bitter infusions, acidi-
fied with the mineral acids, F. 1, 14, 15, or sulphate of zinc, or ammonio-
chloride of iron,  in small doses.   And we may observe that it is  an
admiiable practice to give  bitters, and  tonics, and mineral acids before
meals, to invigorate  the  stomach, and  a  moderate dose of alkali an hour
or two after the meal, in  order to  tranquillize  an irritable stomach,  and
neutralize any acids generated during  digestion.
  II. Oxalic Deposits.—These may occur in the form of    Fig  15?
minute  crystals  diffused  through  the  urine, and only to be   w
 detected by the  microscope; or more rarely, in the form of    <\* ^
 small calculous  concretions  resembling hemp  seed, one of          W
 which may lodge in the bladder and increase till it forms a   ^   n
 mulberry calculus.  The urine  containing them is generally    a     %
 of darkish colour, and rather high  specific  gravity; it very
 often contains slight traces of lithic or of phosphatic sedi-
 ments likewise.   If a portion of the urine be kept at rest for
 some hours, and the upper part be decanted off, a drop  taken
 from the bottom, examined under the microscope, displays
 myriads of crystals, of the  shape depicted in the cut, fig. 1.
 If any of them be allowed to dry on  a slip of glass, they exhibit the ap
 pearance of fig.  2,  and in  a very few cases  they are met with  having the
 remarkable dumb-bell shape, fig. 3.
   Pathology.—Oxalic acid is readily formed during the oxydation of lithic
 acid; and its  presence in  the  urine  must  be attributed to  some defect
 either in the assimilation of the  food, or in the changes which the nitroge-
 neous tissues undergo when  they have become effete.  It may occasion-
 ally be derived from articles of food in which it may exist, such as rhubarb
 stalks, or sorrel;  but it does not appear to be derived from mere saccha-
 rine  matter, nor is there any connexion ascertained, as might  have been
 supposed, between  the oxalic diathesis and diabetes.   The presence of
 this substance in the urine should always be suspected, when  there is dys-
 pepsia, with emaciation, and  great loss of spirits, and nervous depression,
 whether the patient makes complaint or not of any pains in the loins or ir-
 ritation of the bladder.  Irregular  habits of life, unwholesome food and
 exposure to lowering agencies of any kind, are supposed to be the exciting
 causes.   Boils and  other skin diseases, dyspepsia, flatulence, and palpita-
 tions, are frequent accompaniments.
  This must be directed to the  restoration of the general health, by plain
nourishing digestible food,  warm clothing, baths, exercise, and pure air;
 
480
PHOSPIIATIC GRAVEL.
with remedies calculated to keep up  the  secretions and  restore the ton«?
of the digestive organs.   We have seen great benefit derived from tonics,
especially the sulphate of zinc in grain doses, with dilute  nitro-muriatie
acid taken before meals, F. 14, 15 ; whilst an alkaline  carminative, F. 91,
92, 93, was given after meals.
   III.  Phosphatic Deposits, white gravel.  Of these there are three va-
rieties ;  viz. 1, the triple phosphate, or phosphate of ammonia and magne-
sia, or ammoniaco-magnesian phosphate;  2, the phosphate of lime;  and,
3, the mixed or fusible phosphates,  consisting  of  the first two  varieties
combined.
                 1.  Triple Phosphate.—The source of phosphatic salts  in
   Fig. 153.    ^e ur|ne js part]y from tne food,  partly from  the oxydation
              of the phosphorus contained in the  tissues, partly from the
              mucus of the bladder.  When in excess, they are not only
              abundantly present in the urine, but are  also thrown out by
              the mucous membranes, of the mouth, for example.   They
              are naturally held in solution by the  acid of the urine; but
              if, through debility, or some other cause,  the urine is in-
              sufficiently acid:  or if it  becomes alkaline  through decom-
              position  of its urea,f the triple phosphate will be  deposited.
              The urine in these cases is pale, more copious than natural,
              and of low specific gravity;—sometimes it  is  slightly opake
when passed; it is very feebly acid, and scarcely, if at all, reddens litmus-
paper ;J — it has a faint nauseous smell,  which soon becomes ammoniacal
and offensive ;—and it exhibits the peculiar minute  white  brilliant crystals
of the triple phosphate, which often float on the  surface, and look like an
iridescent film of grease.
   2. Phosphate of Lime.—This salt  is  deposited  from the urine in the
form of an impalpable powder, which is generally white, but is occasion-
ally tinged with the colouring matter of the urine.  The general characters
of the urine  are the same as those of the last variety.   This  salt is not,
strictly speaking, deposited from the urine, but is secreted by the mucous
membrane of the kidneys and bladder when chronically inflamed or other-
wise degenerated.   We have shown in  a preceding section,  that  it  is
contained in the viscid  mucus of cystirrhaea (p. 468); in fact, it is sure  to
be secreted if the urinary organs are subjected to long-continued irritation,
whether from the too long retention of a catheter, or from  a  stone or other
foreign body in the bladder, or from diseased urine.
   3. Mixed Phosphates.—The phosphate of lime is very seldom deposited
alone, but in by far the greater number  of cases  is associated with the
triple phosphate ; — an association that is  easily  accounted for; for if the
triple phosphate is secreted by  the kidneys, the mucous membrane will
also throw out phosphate of lime; or, on the other hand,  if the phosphate
of lime  is secreted with mucus  in unusual abundance, through irritation
of the mucous membrane, the presence of the mucus soon causes the urea
to be decomposed, and ammonia to be  evolved, which precipitates the triple
  * Crystals of triple phosphate under the  microscope.  This and  the two preceding
figures, are  taken from Dr. Golding Bird.
  j- fjrea is a cyanate of ammonia ;  and by a  transposition of  its elements is convertible
into carbonate of ammonia.
  $ It is yet doubtful whether urine is ever secreted alkaline, or whether it derives  its
nlkalinity subsequently from decomposition  of its own urea, or from contact with de-
'•or^posing mucus in the bladder. 
PHOSPHATIC GRAVEL.
481
 phosphate from the urine.  The urine in these cases is copious, pale, and
 stinking, and deposits a thick mortar-like sediment, mixed with more or
 less of the crystallized triple phosphate.
   Causes. — The phosphatic diathesis offers a remarkable contrast to the
 lithic, both in the qualities of the urine, and in the characters of the con-
 stitution, and in the causes which engender it.  Persons whose urine  de-
 posits the triple phosphate are of a pale, bloodless appearance, and  com-
 plain of exhaustion and debility, and of an aching weak  pain in the loins;
 —and Dr. Prout has  very ingeniously attempted  to show that the  great
 consumption of phosphorus, which is an essential constituent of all  the
 nervous  tissues, may be a cause of the  great  nervous  irritability and ex-
 haustion  which  accompany phosphatic deposits  from  the  urine.  The
 diathesis may be induced by inordinate  bodily fatigue, or mental anxiety;
 hard study; night watching ;  insufficient and unwholesome food, and by
 lowering medicines, and in particular by mercury, alkalis, and saline pur-
 gatives (especially seidlitz powders, and others containing vegetable acid),
 given  in excess.   Injuries of the  spine  also produce alkaline phosphatic
 urine (vide p. 333); and we need  not again mention stricture, cystirrhaea,
 and other local causes.
   Treatment.—The indications are, to strengthen the system, and acidify
 the urine.  The  diet should  be generous, but plain, and should include
 sound malt liquor, or port, or sherry.*   The  importance of good air and
 exercise  needs  scarcely be hinted at.   Nothing can be more injurious,
 however, than fatigue, bodily or mental.   The other remedies are tonics,
 acids, and opium.  Bark, quinine, or steel, may be given in combination
 with the  mineral acids, F. 1, 3, 124,  14,  15,  and  with opium; which, in
 confirmed  cases  of phosphatic deposits  in adults agrees remarkably well;
 allaying  pain  and  nervous  irritation without impairing the appetite or  in-
 ducing costiveness.  In obstinate  cases, strychnine in  doses of gr. -V  ter
 die, acts as an  energetic tonic, F. 138.   Benzoic acid in doses of gr. x.
 twice  daily,f  appears,  from the observations  of Mr. Ure, to be  of great
 value.  Buchu  and uva  ursi, F. 91, are also of service.  If the mucous
 membrane of the bladder is diseased, recourse  must be had to the remedies
 mentioned at p. 469.   All diuretics are, as a general rule, injurious; and
 mercury  and alkalis are unadvisable, except perhaps in  small occasional
 doses when required by the state of the stomach.   It must be observed,
 in conclusion,  that, although  phosphatic deposits are attended  with  an
 alkalescent state of the urine, and although they are, as a general rule, to
 be treated  by acids, still that acescent substances, sugar, pastry, hard beer,
 or cider, and especially the  thin  acid  French  wines which are sometimes
 recommended, are highly injurious.  The author has had constant oppor-
 tunities of observing the urine loaded with the triple phosphate, and highly
 amraoniacal, w/hen the stomach has abounded  in acidity; the simple fact
 being, that when the health is disordered by any  means whatever, whether
 acidity in the stomach or not, the phosphates will be deposited if the dia
 thesis exists.   On this account, small doses of  alkalis, F.  91, 92, 93, may
 occasionally be given in these cases with the greatest benefit after meals,

  * Soda water is  injurious if it contains soda, which, as a mere  article of Iuxu.y, ii
 Wglit not to do.  But simple water impregnated with carbonic acid is grateful tr thu
■tomach, and wholesome.
  j-See an interesting case by Mr. Ure, Prov. Med. Journ., Feb. 11, 1843.
       41                         2f 
482
VARIOUS  KINDS OF CALCULI.
if the stomach is  disordered;  whilst tonics  and acids may be given an
hour or two before meals.
  Excess of Urea. — Before quitting this subject, we ought to advert to
this, as  a frequent  and most serious, though unseen, source and indication
of loss of flesh and strength.  Urea being, as it were, the ash of the living
tissues, if it be present in preternatural abundance, there is direct evidence
that they, probably from  some defect in their vitality, are being subject to
a morbidly rapid oxydation; in fact, a  superabundance of it, and of the
solid contents of the  urine generally, indicates a rapid waste of tissue, and
not unfrequently is combined with phosphatic or oxalic  deposits.  The
restoration of the health is the only  indication of treatment.  For full par-
ticulars  as  to the  diagnosis, and  as to the  chemical and  microscopical
examination of the urine in  this and other cases, — a subject which the
author's limits barely allow him to allude to, — the practitioner may be
referred to the  works of Dr. Prout, as well as to the able and  useful
volume of Dr. Golding Bird.

    SECT.  IX.--OF  THE VARIOUS  KINDS  OF CALCULI.

  The various deposits  spoken of in the  preceding section  may, as we
observed, lodge in some part  of  the urinary organs, and  concrete into
stone.   There are altogether fourteen species, many of which are exces-
sively rare.   The principal ones are, the lithic, phosphatic, and mulberry.
  I. Lithic Acid calculi are generally oval, flattened, fawn, or mahogany-
coloured, and on a section are seen to be composed of concentric laminae.
Tests.—This acid  may be dissolved by  boiling in liquor potasse; it burns
away almost entirely before the blowpipe, and if digested in a  small quan-
tity of nitric  acid,  and evaporated  at a very gentle heat, it leaves a scarlet
residue, which becomes  purple on the addition of ammonia.
  II. Lithate of Ammonia rarely forms a calculus, because  it  is tolera-
bly soluble in warm  urine.   Tests.—It  may be known by the same tests
as the  preceding,—and  besides, it evolves ammonia when treated by liq.
potassae.
  III. Phosphate of Lime or bone earth calculi are rare.   They aie pale
brown,  friable, and laminated.  Tests.—Soluble in nitric or muriatic rtcids,
and precipitated by liq. ammoniae ; infusible except at a very intense heat.
  IV.  Triple Phosphate (of ammonia and magnesia) forms white or pale
grey  calculi,  composed of small  brilliant crystals.   Tests.—Soiuole in
acetic or muriatic acid ;  evolves ammonia when treated with liq.  potassae.
  V.  The  Fusible  Calculus is  formed of the phosphate of  lime  and
triple phosphate mixed.   It forms  a white friable mass like mortar, and is
very fusible.
  VI.  The Mulberry Calculus is composed of oxalate of lime.   It is
dark red, rough, and tuberculated.   Tests.—Soluble in nitric acid,  and
if exposed to the blowpipe, the acid is  burned off, and quick  hme is  left.
which if moistened,  reddens turmeric paper.
  VII.  Besides the above, calculi  are sometimes composed of  carbonate
of lime, cystic oxide (a peculiar animal  substance, soluble both in alkalis
and dilute  mineral acids, and  containing  much sulphur), fibrine of the
blood, and xanthic or uric oxyde, a peculiar animal  matter allied to  uric
acid.   The  lithate of soda, the lithate  and  carbonate of magnesia, and
silica, are also rare ingredients in calculi. 
STONE  IN THE KIDNEY AND  URETER.           483
  Alternating Calculi.  Sometimes stones are composed of alternate lay-
ers of lithic acid and oxalate of lime ;  and very commonly the outer lay-
ers of a stone are phosphatic, the nucleus lithic or mulberry.   The phos-
phates commonly succeed the other deposits, being surely produced after
a time by the irritation of the mucous membrane ;  but the lithic and mul-
berry never coat the phosphates.

 SECTION  X.—OF STONE IN  THE KIDNEY  AND  URETER.

  Symptoms.—The symptoms  of stone in the  kidney are, pain in one or
both loins ;—irritation and retraction of the  testicles ;—the  urine  bloody
after violent jolting exercise ;—and occasional fits  of inflammation of the
kidney.  Stones in the kidney are most frequently composed of lithic acid,
which will be known by the  deposit of red  sand from  the  urine.  The
mulberry calculus  is more rare  ; it may be suspected if the urine is free
from sediment, either lithic or phosphatic, and  if dark-coloured blood  is
frequently mixed with it.   Crystals both of this substance and  of lithic
acid have been detected in the  tubuli  uriniferi.   Phosphatic  stone in the
kidney is still more  rare.   When it does exist, it  is  generally composed
of the phosphate of lime, and indicates incipient disease  of  the organ.
   Treatment.—When a stone is ascertained or suspected to exist in  the
kidney, the indications axe, first, to determine the  peculiar diathesis, and
take measures to counteract it,  as detailed in the last section;  secondly, to
endeavour to expedite its  expulsion  through the ureter, by diluents and
diuretics; and by the cautious use of exercise so as  to dislodge it; and,
thirdly, to remove  inflammation and pain by cupping on  the loins (if the
nabit is  inflammatory), by mild  aperients  and  copious enemata of warm
water, by opium or henbane, and by warm baths or fomentations. Pounded
ice applied to  the loins gives  great relief when much burning pain is com-
plained  of;  but it must be used with caution.
  The ordinary and most  favourable event of renal calculus is, that it de-
scends through the ureter  into  the bladder.   In some cases, however,  it
remains in the kidney, increases in size, completely fills up the pelvis and
infundibula, and causes the organ either to waste away or to suppurate ;—
the  abscess bursting either into  the colon, or on the loins.
  The Passage of a Stone  through the Ureter causes the following
symptoms:—The patient complains of sudden and most  severe pain, first
in the loins and groin, subsequently in the testicle and  inside of the thigh.
The testicle is also retracted spasmodically.   At the same time, there are
violent sickness, faintness, and collapse, which may last two or three days,
and are  only relieved when the  stone reaches the bladder.
  Treatment.—'fhe warm bath, large doses of opium,  emollient enemata,
and plenty of  diluents, are the obvious remedies,—and an active  purga-
tive may perhaps be tried  if the process is slow.
  Sir B. Brodie  has shown that  there  is a set of symptoms which fre-
quently affect gouty people—consisting  of pain in the loins reaching to
groin and neck of  the bladder ; and  scanty, high-coloured urine—which
very much resemble those caused by the passing of a stone  through thr
ureter.   They may be distinguished by the absence of faintness and vo-
miting, and readily yield to purgatives and colchicum. 
484
STONE  IN THE BLADDER.
       SECTION   XI.--OF STONE IN  THE  BLADDER.

  Stone in the Bladder produces the following symptoms:  1.  Iirita-
bility of the bladder,—frequent irresistible desire to make water.   2. Oc-
casional sudden stoppage of the stream of water during micturition, from
the  stone falling on the orifice of the urethra;—the  stream probably flow-
ing again if the patient throws himself on his hands and  knees.   3. Oc-
casional pain at the neck of the bladder, always severest after micturition.
4. Pain in  the glans penis.  If the patient be  a  child, he is always at-
tempting to alleviate this pain by pulling at the fraenum,  which becomes
extremely elongated.   5.  Sounding.   But none of the above  symptoms
must be depended on alone.   The existence of the stone must  be made
sensible to  the ear and fingers by means of a sound, a solid iron rod like
a catheter,  but not  so  curved, and with a polished  handle.   This should
be introduced—the patient lying on his back, the  pelvis  raised on a pil-
low, and the  bladder nearly,  but  not  quite, full.   It  should  be carefully
moved about, to  examine every part of the  bladder, and if  there is  a
stone of any  size it will most probably be heard to  strike  and felt to grate
upon it.  If  nothing, however, is discovered, the patient may be made to
turn on one side, or to sit  upright, or the finger may be  passed* into  the
rectum ;  or a catheter may be introduced, and the stone  may perhaps be
felt to strike  against it as the  urine flows away.   But if the symptoms are
well marked, the  surgeon must  not be contented with one  unsuccessful
examination.  On the  other hand, the rubbing of the sound  on the blad-
der, or on  gravel entangled in mucus, must not be too hastily set down
as signs of stone.
  The symptoms of stone vary in their severity,—1. according to its size
and roughness; 2.  according to the state of the urine;  3. according to
the condition of the bladder, wiiether healthy or inflamed. They may be
very slight for years, — in fact, a little pain  in  micturition  and bloody
urine after riding may be the only inconveniences.   But after a certain
period the  bladder suffers just as  it does  from any other cause of irrita-
tion,—the  urine deposits a slight cloud of mucus,—the bladder becomes
more and  more irritable and finally inflamed,—the urine becomes alka-
line, and loaded with viscid mucus, and of course with  the  triple phos-
phate and  phosphate of lime,—the strength fails, and finally,  after years
of suffering,  the patient sinks under the  irritation.   Sir B. Brodie, how-
ever, has observed, that if the prostate become enlarged, the sufferings
from stone are  often  mitigated;  because it is prevented from  falling on
the neck of the bladder.
   The sources of vesical calculi are two:—1. From the urine;  2. from
the mucus  of the  bladder;  and calculi are exceedingly liable to form from
the latter source,  if the prostate is  diseased, or if foreign bodies are intro-
duced into the bladder, so as to  serve for nuclei.  In  these  cases, the
stone is  invariably phosphatic.   And  all  calculi, whatever their original
composition, are sure to become coated with the phosphates if they remain
till the patient becomes old and the bladder diseased.
   The composition of a calculus will be determined by  the  state  of the
urine.   Its size may be appreciated, 1. by its  composition—for the phos-
phatic are  a.ways  the largest; 2. by the  time it has  existed ; 3. by ob-
rerving the force  required to  dislodge it from its situation ;  4. it may be 
STONE  IN THE BLADDER.
485
 measured by passing the sound across  its surface, or by the urethra for-
 ceps.   Calculi have been known to vary in weight from a few grains to
 forty-four ounces, and in number from one to one hundred and forty-two.
 The  largest  that was  ever extracted entire weighed sixteen ounces, but
ihe patient died ;  Sir A. Cooper was the operator.   Gooch tells us that
 Mr. Harmer,  of Norwich, in the year 1746, extracted one entire which
 weighed nearly fifteen ounces, and the patient lived  five years.  And Mr.
 C. Mayo, of Winchester, extracted  one weighing fourteen  ounces and  a
 half,  but it was broken, and  the patient lived several years.
   Treatment.—The indications are, 1. to get rid of the diseased state of
 the urine ; 2. to  allay pain  and irritation; 3. to remove the stone.   The
 first and second are to be  accomplished by measures which  have been
 already spoken of when treating of gravel and of chronic inflammation of
 the bladder.   The third may be executed in four ways, viz. by  extraction
 of the stone through the  urethra,—solution of it by injections,—lithotrity,
 —and lithotomy,—to which  we may add the new operation of lithectasy.
   1.  Extraction  by  the Urethra.—When a stone is known to have re-
 cently escaped from  the ureter into the bladder, the first point is to remove
 all irritability of the  bladder by sedatives, and by restoring the proper con-
 dition of the urine, so that there may be no spasm to obstruct its passage
 into the urethra.  The patient  also should drink plentifully, so that the
 bladder may be quite filled.   Then, when he is going  to make water, he
 should be instructed to lie on his face, and to grasp the penis so that the
 urethra  may become distended with urine ; and thus,  very probably, the
 sudden  gush that will come,  when he relinquishes his grasp of the penis,
 will bring the stone with it.   In some  cases the urethra may be dilated
 by passing bougies.   But should this plan not  succeed after some  days,
 Weiss's urethral forceps should  be  tried.  The patient being placed on
 his back with his pelvis raised, a catheter is to be introduced to draw off
 the urine, and five or six ounces of  tepid water are  to be  injected  after-
 wards.  Next the forceps, being introduced, is to be made to feel for the
 stone, and  the blades  are to be cautiously opened  over it and made to
 seize  it.  An index  on the handle  of the forceps will now show the size
 of the stone.  If small, i'" may  be  extracted at once,—if very large, it
 must  be left where it is,—if of a doubtful size, it may perhaps be brought
 into the membranous portion of the urethra,  whence it can be  extracted
 by incision.
   2.  Solution by injections.—Sir B.  Brodie has satisfactorily shown  that
 phosphatic calculi may sometimes be dissolved altogether, and sometimes
 be so disintegrated or reduced in size  that they may escape through the
 urethra, by means of injections of very dilute nitric acid passed through  a
 double gold catheter in the manner directed for chronic cystitis.  At the
same  time, these injections diminish  the  secretion of mucus, which is the
source of the phosphate of lime.   Oxalic calculi appear to resist the action
of all  solvents.   The disintegration of lithic calculi by solutions of alkalis,
or of  borax, and  other alkaline  salts, has been the subject of numerous
experiments ; but the results  cannot yet be spoken of as certain.   It is to
be hoped  that the labours of Hoskins,  Petit,  and Dr.  Willis, will be
seconded  by other practical  men who possess the  opportunity, and thai
this much to be desired object may at last be accomplished.  The waters
of Vichy, or a solution of from 3 to 5 grains of bicarbonate  of soda to an
ounce of water, passed in a  slow continued current  through the bladdei
      41* 
486
L1TH0TRITV.
by means of a double catheter, and used  internally likewise, have been
supposed to effect the solution of calculus in  the  bladder, and hold out
the strongest encouragement for further trials.*

               SECTION XII.--OF LITHOTRITY.

  It  need scarcely be said, that the object of this  operation .s  to reduce
stones in the bladder  into fragments of so small a size, that  they may be
readily expelled through the urethra.
  The apparatus by which this object was  first accomplished by Civiale
and Leroy was, as Sir C. Bell rightly called it, villanous  and dangerous
enough.   A straight cylindrical canula was introduced into  the bladder,
containing three or four branches which could be protruded from  its ex-
tremity.   These were made to grasp the stone and hold it tightly, whilst
it was bored, and scooped, and excavated by drills and other contrivances
contained in the centre of the canula, and worked by a bow.  When the
stone was sufficiently excavated, its shell was crushed by a most complex
piece of  mechanism called the brise coque,  or shell-breaker.   "  For some
time," says Mr. Liston, " it was  maintained,  that almost every case of
stone could be satisfactorily disposed of by this boring and grinding pro-
cess.   It was  tried extensively," but,  " after many miserable  and painful
failures,  utterly disappointed the hopes of its advocates."  Nor  will these
failures be  wondered at, when we  consider the difficulty sometimes of
seizing the stone, sometimes of disentangling the instrument from itf—the
extremely slow and inefficient  means  of disintegrating  it, and  the great
number of times the operation was  consequently obliged to be repeated;—
not to mention the pain caused by the stretching of the urethra with a large
straight instrument—the  risk of entangling the coats of  the bladder, and
of seriously bruising the parts about the neck—rand the most incomprehen-
sible perplexity of the instruments employed—the nomenclature, structure,
and use  of which require not a little study.
  The next method which was employed, and which was first practised
by Heurteloup,J consisted in hammering the stone to pieces.   The patient
was confined to a bed of peculiar construction, called the  lit rectangulaire,
and  the  percuteur  courbe a  marteau—an  instrument composed  of two
blades sliding on each  other—was made to seize the stone.   (See figs.
154, 156.)  It was then broken by repeated blows with  a hammer on the
other extremity of the  instrument, which  was fixed  securely to  a vice.
But  this plan  was  fraught with many inconveniences.   The instrument
was liable to be bent or broken; its blades were apt to become so clogged
with pulverised fragments,  that they were withdrawn with difficulty, or
perhaps not until the orifice  of the urethra had been slit up ;—and the
bladder was exposed to injury from percussion  communicated from the
instrument, and from the violent splitting of the calculus.
   The instrument which has now superseded the foregoing, is  the screw
lithotrite of Mr. Weiss ; which is composed of two sliding blades, between
which the stone is seized, and then is  crushed by gradual pressure  with' a
  » Vide the case of D. B. Jacob, at p. 29 of Dr. Willis's work on Stone.
  f In fact, in one case, the branches could not be returned into the canula;  and th?
instrument was  obliged to be dragged out open through the neck of the bladder and
urethra.
  * In the vear 1 &V) 
LITHOTRITY.
487
screw.  This instrument was, in fact, originally invented in 1824 (although
it was laid ^side at the recommendation of Sir B. Brodie, who thought it
liable to some objections, and was  superseded for a time by the straight
Fig. 154.
Fig. 155.                          Fig. 156.
3K3
arills of Civiale and the percuteur of Heurteloup);—and it was from this
that Heurteloup took the idea of the percuteur; disimproving it,  however,
by substituting the hammer for the screw.   Mr. Fergusson prefers a kind
of hand-rack and pinion, as a more convenient mechanical power than the
screw.   In order to prevent any clogging of the blades by the lodgment
of fragments, the anterior blade'is made open  to receive the other within
it.  The operation is performed as follows.  The patient is  placed on  a
couch with his pelvis well raised, and his shoulders comfortably supported;
—the bladder is then  emptied, and five or six ounces of tepid water in-
jected  with a proper catheter and  syringe.  The instrument, previously
warmed and oiled, is slowly introduced and placed upon  the stone—its
blades  are  opened  and made to grasp it between  them—the  handle  is
moved  from side to side, to ascertain that  no  part of the bladder is en-
tangled—and then it is depressed so as to lift the stone towards the neck
of the bladder.   The screw or handle is then slowly and cautiously turned
backwards and forwards till the stone is crushed by its repeated  impulses.
Then the instrument should be withdrawn.  When the irritation has sub-
sided, the fragments must be seized and comminuted with the same in-
strument, or with a  smaller one,  or with one that has not the aperture in
the anterior blade.  Sometimes they may be removed with sundry scoops.
But whether this can be done at  one sitting or at many, must depend on
the  size of the stone, and  the degree of inconvenience suffered by the
patient.
  No fair numerical estimate can yet be made  of the proportion of casej,
in which lithotrity has been successful  or otherwise.   In its present im-
proved  form, and practised on patients calculated for it,  it  may be con-
sidered easy, safe, and effectual.   But  practised on cases not adapted to
it, no operation can be compared to it for the misery and fatality of ils
results.  We may gather from D»-. Willis, who has been at much pains to 
488
LITHOTRITY.
collect what  M. Souberbielle calls the martyrology of lithotrity, that the
mortality has been  in  all probability at least one  in four.  Whereas the
statistics of lithotomy give only one unfavourable case in seven or eight.
Of twelve  cases narrated by Mr. Key, three were cured by it—in three it
was either  inapplicable or unavailing, and lithotomy was resorted to—and
the remaining six perished — one with abscess in the prostate  soon after
the operation—four with protracted sufferings from irritation of the bladder
by the fragments which were retained—and one with disease of the bladder
brought on or aggravated by the operation.   Mr. W. Fergusson gave the
results of eighteen cases; of which six were cured ; seven were  not cured,
(and four of these underwent lithotomy afterwards,) and five died.*   The
sources of  danger are, the irritability of the urethra and bladder, the great
pain and inflammation  often produced by the introduction of  the instru-
ments, and aggravated by the substitution of many irregular fragments for
one smooth stone, and the frequent repetition of the operation.  The pre-
paratory treatment  consists in the use of measures for removing the dis-
eased condition of  the urine, and any irritability of the  bladder, [and in
the frequent  introduction of bougies  or sounds  gradually increasing  in
size, in order to accustom the bladder and urethra to the presence of the
instrument, and to  dilate the urethra sufficiently to admit of the easy in-
troduction  of a lithotrite large  enough to crush the stone.—Ed.]   In the
after treatment, diluents should  be employed to increase the secretion of
urine, and  injections of warm water to accelerate the passage of the frag-
ments— and hip-baths, opiate suppositories or enemata, and  leeches,  or
cupping on the perinaeum, for the relief of pain or inflammation.   Some-
times the fragments stick in the urethra, and require to be removed by in-
cision in the perinaeum, and sometimes it is requisite, after all, to extract
them from  the bladder by a regular lithotomy operation.
   [M. Civiale, who may be considered the highest authority on the sub-
ject of lithotrity, published  last year a treatise, in which the history and
practice of the operation  are fully discussed.   A very interesting review
of this book  appeared in the " British and Foreign Medico-Chirurgical
Review" for January, 1848, from which  paper  the following remarks are
briefly condensed:—
   The operation is  practised  by many of the Parisian surgeons, but with
less success than by M. Civiale.  Thus, from 1832 to 1838,124 patients
were operated upon in the principal  hospitals in Paris ;  78 cures and 27
deaths alone are recorded, the result in 22  not being stated, or the cure
being incomplete;  again, of  38 cases operated upon, 22 cures  and 11
deaths resulted.  "The practice of M. Civiale  may be divided into two
periods: in the first, from 1823 to 1836, he had used his three-branched
instrument; crushing  the  stone, when it was not too large or  too  hard,
between the branches and the head of the perforator, and if this did not
answer, having recourse to perforations to facilitate the crushing process.
In the second period, from 1836 to 1845, he used  the  screw and percus-
sion instruments, either alone or combined with his older ones.
   "In the  first period, 506 patients were attended; 199 were not operated
on; of 307 operated upon, 7 died and 3 obtained only an imperfect  cure;
m 1 the result was unknown.
   " In the second  period, 332 new cases were attended.  Of  this num-
ber 241  wrere lithotrized.  1o these operations 25 must be added, pn>-
                   • Ed. Med. and Surg. Journ., Oct., 1838. 
LITHOTOMY.
489
ceeding from the return of the stone in 26 cases, which gives 266 opera-
tions, of which 259 were cured, some  incompletely ;  the patients having,
besides the stone, serious  lesions of the  bladder  or  prostate,  have con-
tinued, after the operations, to suffer some functional  derangement due to
these lesions."
  M. Civiale admits, that during the first period he was more careful in
the selection of patients for the operation than during  the second, because
he felt that the reputation of the new method was then unsettled; but its
excellence having been at length conceded, and the instruments hairing
been more perfected, he felt more at liberty to test it in cases less pro-
mising ; hence, he concludes, the comparatively greater number of unsuc-
cessful results in the second  period.   The  want of  success which has
attended the operations of other surgeons, he attributes to a variety of
causes,—chiefly to an imperfect acquaintance with the instruments, result-
ing from not having frequently operated upon the  dead body; to an im-
perfect knowledge of the character and  dimensions of the  stone, and of
the condition of the urinary organs;  to inadequate preparatory treatment;
to too long and tedious sittings.
  The directions which M. Civiale gives as to the preparatory treatment,
and the mode of operating, agree very well with those expressed  by Mr.
Druitt.  He advises  that the bladder should be emptied of urine, and that
tepid water to the amount of ten  or  twelve  ounces, in most cases, should
be injected without violence.  The duration  of the sittings is a matter of
much moment.   M.  Civiale used formerly to occupy from twenty to thirty-
minutes ;  now he occupies only five or ten, and often less, particularly in
the first sittings, before the bladder has become thoroughly accustomed to
the presence of the instrument.  " It is a  most important precept  to make
the sittings very short, and to operate very slowly and gently."
   The lamented death of Dr. Randolph, of this  city, has deprived the
profession of the results of his experience in this operation ;—an experience
vastly  greater,  and more favourable to the operation, than that of any
American surgeon.—Ed.]

               SECTION XIII.--OF  LITHOTOMY.

   Choice of operation.—Supposing that a patient with stone in the bladder
is an adult, that the stone is  under the size of a chestnut, aad that the
bladder and  urethra  are healthy, as is shown by the power of retaining
the water, and making it in a good stream, the operation of lithotrity may
be recommended.  But if the stone is very large or very hard—or if there
are more than one, or if the urethra  is strictured, or the prostate enlarged
(which would prevent the debris oi the stone  from coming away)—or the
coats of the  bladder diseased — or  the stone adherent, or contained in
pouches or sacculi of the bladder—or if,  as Mr. Fergusson justly insists,
the parts are so irritable that the introduction of the instrument occasions
more pain in  the urethra than is ordinarily caused by the passing of a
catheter; if the bladder rebels against the instrument,  and contracts spas
modically, causing a painful and irresistible effort to micturate ;—or if the
patient is very old or very young, it will be safer to  extract the stone by
lithotomy.
  Contraindications.—The  surgeon must,  however, in the first place,
ascertain that  the patient is  free from  serious organic disease — which 
490
LITHOTOMY.
would render him liable  to sink under either operation.   Languor, de
pression, loss of strength and flesh and  appetite, irregular shiverings, pain
and tenderness  in  the loins, purulent or highly albuminous or bloody
urine, indicating organic disease of the kidneys; — excessively frequent
and painful  micturition, with  the  urine constantly bloody and purulent,
indicating serious organic disease or ulceration of the prostate or bladder
—the existence of hectic or pulmonary consumption, or of any other ex-
tensive disease, require the surgeon to  decline the operation — or at least
to perform it only at the urgent ana repeated request of the patient, who
should be informed of its probable result.
   Preparatory Treatment.—In the second place, the patient must be well
prepared by measures calculated to improve the general health, and to
remove all disorder of the urine and irritability or congestion of the bladder.
He should not even be sounded whilst labouring under any local or general
vascular excitement.
   There are four methods in which lithotomy may be performed, viz. the
lateral operation  in  the perinaeum—the bilateral—the recto-vesical—and
the high operation.   The  lateral is that which common consent has de-
cided to be  the best, except in a few rare instances.  There are an infinity
of minute variations in the manner of performing it, and  in the  instruments
employed by different surgeons.  In the following description the author
avails  himself principally of the directions  given  by Sir B. Brodie, Mr.
Liston, and  Mr. Fergusson.
   Lateral  Operation.—It is advisable that the bowels should be cleared
on  the morning  of  the  operation with a  simple enema.   The bladder
should  be moderately full, and  if the  patient  has recently emptied it, a
few ounces of water may  be injected.   It is also desirable that the exist-
ence of the  stone should be clearly demonstrated with  the sound or staff,
immediately before the operation.  Then the proceedings may commence
by  introducing the staff"— a  solid steel rod like a sound, with a deep
groove either on its convex border, or, as some surgeons  prefer it,  a
little  on its  left  side.  It should be  as large as can be conveniently
introduced.
   The  next point is to  place  the  patient in a convenient posture.  He
should  be placed on  his back, on a table two feet a half high, with his
shoulders resting in the lap of an assistant, who sits astride behind  him.
Then, in order to expose the  perinaeum thoroughly, he must be made to
raise and separate his thighs: and  to grasp the outside of each foot with
the hand of  the same side;  and the hand and foot are to be firmly bound
together by a broad garter;—meanwhile, if not done before, the perinaeum
should  be shaved.   The  surgeon may, says Mr. Fergusson, pass his left
fore-finger well oiled into the rectum, to ascertain the size of the prostate,
and  its depth from  the surface; he should also explore with his fingers
the surface of the perinaeum, and the position of the rami and tuberosities
of the ischia.
  Everything being now prepared,—an assistant on each side  holding the
thighs firmly asunder—another being at hand to give the surgeon his in-
struments—and a third stationed on the left side holding the staff perpen-
dicularly,  and well hooked against the symphysis pubis—in which position
he is to hold it steadily from first to  last; — the surgeon  commences by
passing in his knife to the depth of  an  inch on the left side of the raphe'
ybout  an  inch before the anus, and cuts downwards and outwards to the 
LATERAL OPERATION.                   491
bottom of the perinaeum, midway between the anus and tubei.tsity of the
ischium.   " The forefinger of the left hand," says Mr. Liston, " is then
placed in the bottom of the wound about its middle, and directed upwards

                               Fig. 157.
and forwards; any fibres of the transverse muscle, or of the levator of the
anus, that offer resistance, are divided by the knife, its edge turned down-
ward : — the finger passes readily through the  loose cellular tissue, but is
resisted by the deep fascia, immediately anterior to which, the groove of
the staff can be felt not thickly covered.  The point of the instrument is
slipped  along the nail of the finger, and, guided  by it, is entered, the back
still directed upwards, into the groove, at this  point.  The finger all along
is placed so as to depress and protect as much as possible the coats of the
rectum, and the same knife, pushed forwards,  is made to divide the deep
fascia, the muscular fibres within its layers," and to perforate  the urethra
about two lines in front of  the prostate.  Then it must be pushed gently
into the bladder, slitting up the urethra and notching the margin  of the
prostate in  its course.  The knife, being withdrawn, the left forefinger is
gently insinuated  into the bladder, dilating the  parts as it enters ; then the
assistant having removed the staff, the forceps are cautiously introduced
over the finger into the bladder; the finger being gradually withdrawn as
the instrument enters.   And, at this moment Mr. Fergusson,  with admir-
able  dexterity, opens the blades, and  catches  the stone as it is brought
wiihin their jaws by the  gush of urine that  escapes.   If, however, the
stone is not  caught  in  this ready way, the forceps must be closed and
brought into contact with it — then  the  blades  are opened  over  it and
made to grasp it;—if the stone is seized awkwardly, it is relinquished and
seized again — then it  is extracted  by slow,  cautious, undulating move-
ments.  The  forceps should be held with the convexity of one blade
upwards and of  the other downwards;  and  the endeavour should be to
make the parts gradually yield and dilate, not to tear them.
  The general maxims  to be borne in mind  during the performance of
this operation are, (1) to make a free external incision, and to bring it
low enough down, so that the urine may subsequently escape freely with
out infiltrating the cellular tissue ; (2) not to cut too high up, or to opeu 
'192                         LITHOTOMY.
 the urethra too much in front, for fear of wounding the bulb or its artery;
 (3) not  to  wound the rectum, or pudic artery, by carrying  the  incisions
 too much inwards or outwards;  (4) and above all, not to  cut completely
 through the prostate, beyond its fibrous envelope, otherwise the urine will
 find a ready passage into the loose cellular tissue of the pelvis, and  the
 patient will almost surely die.*   The incision into the prostate should  not
 be of greater extent than six or seven lines; its direction downwards and
 outwards, like the rest of the wound.
   The varieties of this operation before  alluded to are as follow.   Most
 surgeons direct the assistant to hold the  staff so that it may project in  the
 perineum, and incline a little to the left side of it, — and when they have
 opened the urethra, and are about to incise the neck of the bladder, they
 take its handle  in their own left hand, and bring it  down horizontally.
 Mr. Key prefers a straight staff.   Again, there are great diversities in the
 manner of cutting into the bladder.  Some persons use a bistouri cache,
 an instrument containing a  blade  that  protrudes to a certain extent  on
                                 touching  a  spring.   Sir B. Brodie pre-
            Fig. I58.f             fers a beaked knife;  or, if the  stone  is
                                 very large, a double-edged knife with a
                                 beak in the centre, so as to divide  both
                                 sides of the prostate.   When the  blad-
                                 der is opened he  directs the wound to
                                 be dilated by means of the  blunt gorget,
                                 which  distends the neck of the  bladder,
                                 and  splits cleanly  through the prostate,
                                 without any risk of haemorrhage or mis-
                                 chief.  Many surgeons open the bladder
                                 by  means of the cutting  gorget; the
                                 beak of which being put into the groove
                                 of the  staff, held  horizontally  in the
                                 operator's left hand, it is  pushed cau-
tiously on, and made to cut its way into the bladder.   If this instrument
is  employed, every precaution must be used to keep it in contact with the
staff, and not to let it slip between the bladder and rectum,—an accident
that has been the death of not a few.   In the case of a very large stone,
it  will be expedient to divide both sides of  the  prostate.    This may be
done, either by cutting into the bladder with a double-edged beaked  knife
— or after one side  is incised in the ordinary way, by cutting through a
little of the other with a probe-pointed  bistoury, the edge of which should
be directed  towards the right  tuber  ischii.   Lastly, there  is a  method
which was occasionally employed by Cheselden, and which is  still prac-
tised by a very experienced  and successful lithotomist, Mr. C. Mayo of
Winchester.  In this method, the operator,  after making the usual exter-
nal incisions,  " cuts into the side of the  prostate  as far back  as he can
reach, and  brings  out the knife, along the groove of  the  staff", into the
membranous part of the urethra;" thus making the incision  into the  neck
  • We should not omit  to mention that some great authorities, for instance. Cheselden,
Martineau, S.  Cooper, advocate a rather free incision of the neck  of the bladder.  For
an interesting  collection of opinions on this point, see Mr. Brittan's excellent translutiuu
nf  Malgaigne's Operative Surgery.
  f This diagram, copied from a paper by Mr. Bryan. Lancet, Feb. 11th, 1813, is use-
ful is exhibiting an internal view of the parts at the neck of the  bladder concerned in
Lithotomv :  o  vasa deferentia ; b, vesiculae seminales ; c, prostate ;  d, ureters.
 
LATERAL OPERATION.                    493
of the bladder from behind forwards, instead of from before backwards,
as in the other varieties.*
   [Dr. Flint added to the former edition of this book the following valu-
able note, which we take pleasure in reproducing:—
   " Most operators  at the present day, in  performing lithotomy, employ
the knife in some one of its modifications for the prostatic section—indeed,
I know but a single exception to this practice,  among distinguished litho-
tomists.   My neighbour  and friend, Prof. Dudley, of Lexington, who has
cut more frequently than any living surgeon, and with better success than
any man who ever lived, and has furnished authentic reports of his opera-
tions, invariably uses the gorget, and all who  have witnessed this gentle-
man's operations, admire the dexterity, precision and dispatch with which
he opens the bladder with this instrument, which,  in most other hands,
seems clumsy and unsafe beyond any that has been invented, for the same
purposes.  Dr. Dudley's extraordinary success is  principally  due to his
judicious management of his cases previous and subsequent to the opera-
tion—an attribute which should entitle him to more credit, as a good sur-
geon, than the most imposing use of the best constructed apparatus, in the
performance of it.
   " Prof. Dudley has now operated for stone in the bladder one hundred and
seventy-five times, and he is confident  that a fatal  termination, occurring
as the effect of the operation, has taken place in a single instance only.   A
few years ago, when  the number of  his cases amounted to one hundred
and thirty-five, he  published a statement which exhibited such unprece-
dented success as  to excite the astonishment of surgeons in all countries,
and in some quarters to provoke expressions of incredulity and even sus-
picion of misrepresentation,  injurious towards Dr. Dudley and unworthy
of those  who  promulgated them.   Yielding  even  the four  unsuccessful
cases  which M. Civiale has  inferred from Dr. D.'s  own  account of his
operations, a triumphant success must still  be conceded to him in this de-
partment of our art, which should rebuke the spirit of envy, and will secure
from all magnanimous cotemporaries an acknowledgment of his title to be
regarded as the greatest Lithotomist of his day.
   " In ray own operations I  have  used the knife recommended, and I be-
lieve, invented by Mr. Liston—an  elongated scalpel  with  a  cutting edge
extending from the point to about midway of the blade.  With this instru-
ment, having  a long and stout handle, the surgeon may accomplish all his
incisions from the  integument through, with the utmost convenience and
precision, and, if sufficiently sure  of his anatomy to  justify an attempt at
such an operation, may avoid all parts which should  remain  intact, with
more  certainty than  in the employment of any one of the various instru-
ments and apparatus  which ancient or modern  invention has supplied.
   " The directions in the text, respecting the staff, are pertinent and impor-
tant.  It should be held  perpendicularly, and firmly in one position until
the incisions are completed as our  author directs.  Nothing savours more
  » There has been very much dispute about this operation of. Cheselden's; because
he had two manners  of performing it; the first, which was described in the fourth
edition of his Anatomy, Lond. 1730, is that in  which  the prostate is divided  in the
manner commonly used at present, and  which is now generally known  as Cheselden't
operation; — the second, which  is  spoken of in the text, is described in the fifth editio-.
of CheseldenV  Anatomy. Lond. 1740; and  the sixth edition, 1741, p. 330. This it is
which  was described by Dr. Donglas ; and which was performed by Mr. C. Mayc, as
detailed bv i im in Med Chir. Trans vol. xi.
       42 
494
LITHOTOMY.
of discomfort or embarrassment in such proceedings, than to hear the ope-
 'ator calling to his staff holder to " bulge the staff into the perineum."
If he cannot find the staff", when he has approached the membranous por-
tion of the urethra, it is either because his anatomy fails him  at the most
critical point in his undertaking, or because he is bewildered by his devi-
ous and unskilful progress through the textures already divided.
  In observing the direction  to have  the staff well hooked against the
symphysis pubis, the operator  should be careful not  to  drag upwards the
portions of urethra which are to be divided, so that when suffered to resume
their natural relations upon  the  withdrawal of the staff, the continuity of
the external and internal incisions shall be interrupted."
  The following statement of  the results of the operation, as practised by
American surgeons, is taken from the report of the Committee on Surgery
of  the  American  Medical Association,  read  at  their  recent  annual
meeting:—
  " In the last account* of the practice of Dr. Dudley which has reached
us,  it is stated that up to the beginning of 1846 he had operated upon 185
cases of stone, of which number 180 are reported as successful.  This re-
markable result, according to Dr. Bush, cannot be attributed to any selec-
tion of cases on the part of the  operator, since out of 188 subjects presented
to him,  185 were cut.   Dr. B., who furnishes this report, ascribes these
results to the  thorough  preparation of the general  system made by Dr.
Dudley, preparatory to  the  operation, an account of which was  detailed
some years since, in a paper published by him in the Transylvania Jour-
nal, and which we can only here refer to.
  " From communications that have been made to the committee, it appears
that Dr. Marsh, of Albany, has operated by the lateral method seven times,
all of which were successful.
  "Dr. Mettauer, of Virginia, states that he has operated by lithotomy on
seventy-three  cases of  calculus, two  of which proved fatal.  One from
prostatic hemorrhage, and the  other from the occurrence of spasm of the
ileum.
  " Dr. John C. Warren has operated upon thirty cases, of whom two died;
one of these lost his life by an error in diet, the other had a purulent effu-
sion, owing to the great size of the stone, and the force required to extract
it.  The mode of operating in his fifteen first cases, was by the lateral in-
cision and the gorget.   In the thirteen following, by the  knife, and in the
three last by the bilateral method.
  " Dr. Eve, of Georgia, has  operated  eight times, including one female,
all oi which were successful.   Dr. Mussey, of Cincinnati, informs  us that
he has cut thirty-two patients for stone, all of which cases have been suc-
cessful but two.
  " From the Pennsylvania Hospital your committee have procured a ta-
bular statement of all the patients cut in that Institution from its founda-
tion in 1752 to  the  1st of  May,  1848, which, though  in  some respects
imperfect, is nevertheless valuable, as exhibiting the largest mass of experi-
ence in calculus, which has yet  been furnished  by any American Institution.
  " From this table, it appears that during the period mentioned, 83 cases
underwent the operation of lithotomy, which, it is believed, was invariably
by the lateral method, and except in a few instances of very young chil-
* Western Lancet, 1846. 
BILATERAL OPERATION.
495
dren, by means of the gorget.  Of this number, 72 were cured, 10 died,
and 1 set down as relieved.
  " A tew among us have resorted to  the bilateral method, and within  a
few years the profession have been favoured with valuable papers on
modifications of it by Drs. Warren and Stevens.  So far as your commit-
tee can  ascertain, the first operation in our country by this  method was
performed by Dr. Wm. Ashmead, of Philadelphia,  in 1832, nearly eight
years after it was brought prominently into notice by Dupuytren at the
Hotel Dieu of Paris.  The case proved successful, and in that  and the
succeeding years, the same gentlemen  operated upon three other patients.
Dr.  Ogier  of Charleston  repeated  the operation  in 1835,  without  any
knowledge of its having been  previously done in the country, and since
that period it is known to your committee to have been  practised by Dr.
Stevens, Eve, the Warrens, Mussey, May, Watson, Hoffman, Post  and
Pancoast."—Ed.]
  After Treatment.—When every fragment of the stone has been removed,
and  the bladder has been syringed with warm water, the patient should be
put to bed.   Dr. Nott, an American surgeon,  is in the habit  of passing a
large catheter, and injecting a stream of wTarm water  through it into the
bladder, whilst the patient sits over a chamber-pot.   Every fragment is
thus washed through the wound.  The patient should lie on his back with
his shoulders elevated;  a napkin should be applied' to the  perinaeum  to
soak up the urine, and the bed be protected by oilcloth.   It is a good plan
to introduce a large gum elastic canula through the wound into the bladder
for it to flow through.  If not, the surgeon should introduce his finger
after a few hours, to  clear the wound of  coagula.   Pain must be  allayed
by anodynes—the bowels be kept open without purging—the wound be
kept perfectly clean,  and then, in favourable cases, the urine begins to flow
by the  urethra in about one week, and the wound heals completely  in
four or five.
   Complications.—-(1.)  Severe  haemorrhage  may proceed from  the
 pudic or bulbous arteries if wounded.   If the bleeding orifice cannot
be secured, it must be compressed as  long as may be necessary with the
finger.   A general venous or arterial oozing  must be checked by filling
 the wound firmly with lint or sponge—the tube being then indispensable.
 (2.) Tenderness of  the  belly and  other inflammatory symptoms must
 be combated by leeches, fomentations, and, if necessary, venisection.
 (3.) Chronic inflammation of the bladder, with continued secretion of
 the  phosphates, by the measures directed at p. 468.  (4.) Sloughing
 of  the cellular tissue from urinous infiltration, a frequent result of a
 hasty operation, and of too freely incising the neck  of the bladder,  is
 indicated by heat of the skin and  sleepiness, followed by a rapid jerk-
 ing  intermittent pulse—hiccup,—the belly tympanitic, the countenance
 anxious,  and  the other signs of irritative  or typhoid fever.  To be
 treated by  wine,  bark, and ammonia, by thoroughly  opening  the
 wound with  the  finger, and,  if necessary, laying the wound into the
 rectum, so that the urine and fetid discharge may escape.
   The Bilateral  Operation is  performed by  making  a curved in-
 cision, with  the convexity upwards, from one side of the  perinaeum  to
 the  other—carrying it  between the anus  and bulb of the urethra—
 opeding the membranous portion of the  urethra—and then pushing a
 double bistouri  cache  into the bladder, by which  both  sides of the
 prostate may be divided. 
496
LITHOTOMY.
  The Rectovesical Operation consists in cutting into the bladder from
the rectum, in the middle line behind the prostate.
  The  High  Operation is performed by making an incision through the
linea alba, and opening  the  bladder, (which is projected upwards on the
point of a catheter,) at its fore and upper part, where it  is not covered by
peritonaeum.   This  operation may be occasionally resorted  to  when  the
stone  is of great  size, and the prostate  much enlarged, or the space be-
tween the tuberosities of the ischia contracted.
   Lithectasy* or  Cystectasy. — The object of this operation  is to
remove the stone by a slow and gentle dilatation of the  parts at the neck
of  the bladder, without  any incision or laceration of the  prostate.   The
idea of the operation is not a new one;  it was performed successfully by
Sir A. Cooper, at Dr. Arnott's suggestion,  in the year 1819; but its
recent revival is due to the exertions of Dr. Willis.   The following is the
way in which it was performed by Mr. Fergusson: — The patient having
been placed  in the  usual lithotomy position, an incision was made  in the
raphe about  an inch and a half long, terminating half an inch in front of
the anus; from which point, twTo incisions, each about three-fourths of an
inch in length, were carried  downwards  and outwards.   The  superficial
cellular tissue, having been similarly divided, the  point of the knife  was
thrust into the groove of the staff a  little in front of the triangular ligament.
This ligament having been slightly divided on both sides, in the direction
downwards and  outwards, the metal  point  of an ArnoWs dilator  was
carefully guided along the groove of the staff into the bladder.  The dila-
tor, which is composed of a cylindrical bag of oiled silk, was then injected
with a little warm mucilage of gum arabic, till the patient complained of
some pain from the distention.   The object now is, to increase the dila-
tation  at  short intervals, till at  the end of from thirty to forty hours a for-
ceps can  be introduced,  and the stone extracted without difficulty.f
   The few cases in  which this operation  has been performed give hardly
sufficient materials  for a judgment on  its safety  and efficiency.   What
may be  called one  variety of  it has been very largely  performed by Dr.
Bresciani de  Borsa, an  eminent surgeon of Verona; who, after opening
the membranous portion of the urethra,  passes in his left fore-finger along
the staff into the bladder, then having withdrawn the staff, and dilated the
neck of the bladder by rotating his finger, he  at  once introduces the for-
ceps, and seizes the stone.J
   Stone in  women is  much  less frequent than it is in  men, and when a
renal calculus reaches the bladder, it  is much more easily voided.   If,
however, there is a  calculus  too large to  escape, it must be  removed by
dilating the orifice of the urethra, or by incision, or both.   The great evil
is  the almost certainty that more or less  incontinence of urine will  follow
either operation.  To lessen the chance  of which, Mr.  Fergusson recom-
mends that the  dilatation, should  be effected very slowly, by means of a
metallic or some other dilator, till it is capable of admitting the forefinger,
when a forceps may be introduced to seize the stone.  If this should not
answer, and   it seems necessary' to make an incision, he recommends that
   • Aifloj, calculus, and cKraais, extensio.
   ■f Vide Dr. Willis, op cit.; case (fatal) by  Mr. Fergusson, recorded in Prov.  Med
.ourn., 5th August, IS 13; one  (successful) by Mr. Elliott, in Braithwaite's Retrospect,
vol. vii.; another (successful) by Dr. Wright of Malton, Lond. Med.  Gaz. vol. xxxiv.; ard
n paper by Dr. Anion. Lancet, August 5th, 1S43.
   t Hee an account of this operation in Ranking's Abstract, vol. iii. p. 119. 
DISEASES OF THE  PENIS.
497
the anterior half of the urethra—not its whole length into the bladder—
should be divided to the extent of half an inch with a probe-pointed bis-
toury ; after which sufficient dilatation  might be  effected with  the fore-
finger oiled.  The outer part of the urethra, which is the most undilatable
part of it, would be alone divided by this operation, and the neck  of the
bladder, unless very roughly used, would  speedily  acquire  its tone  and
use.  In this way the eminent surgeon just quoted  has  extracted a stone
three inches in circumference, and the patient had the power of  retaining
her urine immediately  afterwards.*
                        CHAPTER  XXI.

            OF THE DISEASES OF THE MALE GENITALS.

      SECTION  I.--OF  THE  DISEASES  OF THE  PENIS.

  I. Phymosis signifies a preternatural  constriction  of the orifice of the
urethra, so that the glans cannot be uncovered without difficulty, if at all.
It may be  a congenital affection, or  may be caused by the contracted
cicatrices of ulcers.   Besides  the obstruction which it  occasions  to the
functions of the organ, it prevents  the washing away of the  secretions from
the corona glandis, and thus renders the patient liable to frequent balanitis
and gleets, and in advanced age to cancer of the penis ; and it is a source
of great trouble if he happens to be affected with the venereal disease.f
   Treatment.—A director should  be introduced about  half an inch be-
tween the glans and  prepuce, and a curved, narrow-pointed bistoury be
passed along its groove, by which the prepuce should be slit up.   At the
same time, if the edge of the prepuce  is  thickened,  it should be  seized
between the blades of a forceps,  and be shaved  off.  Then four or five
fine sutures should be passed through the margin of the incision, so  as to
draw together the edge of the skin and  that of the mucous  lining of the
prepuce, that they mayr unite by adhesion.  If this is not  done, the skin
and mucous membrane  will be separated by the  swelling that follows the
operation, and  the wound, instead of being a mere line, will  be  half an
inch wide.
  [In phymosis the stricture is caused  by contraction  and rigidity of the
internal membrane of the prepuce, the external portion, consisting of cellu-
  * Practical Surgery, second edition, p. 135.
  ■f- il In the Jewish circumcision, the child is wrapped in a cloth and  laid across the
thighs of a sitting man. by whom he  is properly held.  The circumcisor grasps the pre-
puce with the thumb and forefinger of his left hand, draws it forwards and inserts it
in the cleft of an instrument similar to a silver spatula.  Then holding the  prepuce
and raising the penis upright he cuts  off the former close to the plate with a  single
stroke of a button-ended knife.  The circumei^or as quickly as possible seizes the inner
fold of the prepuce with his thumb-nails, which have been specially cut for that pur-
pose, and tears it immediately up to the corona  glandis.   He  then  spirts some  water
from his  mouth upon the wound, takes the penis in his mouth,  and sucks the blood out
of it a few times.  A strip of fine linen is then wound round the corona and the cut
surfaces as a dressing, and the penis laid upon the pubes in a ring, to prevent its beinjj
touched."—South's Chelius, vol. ii. p. 345.
       42*                        2g 
498
DISEASES  OF  THE  PEMS.
lar  tissue and skin, remaining generally  sufficiently  loose and yielding.
Hence the  constriction  may be  relieved  by dividing merely the internal
lamina of the foreskin.  The operation may be effected, in cases in which
the phymosis is not very complete and rigid, by drawing back the external
portion of the prepuce as far as practicable, until the tense ring of the in-
ner prepuce, which forms the stricture, is  exposed, and then dividing this
latter with  a  bistoury or a  pair of scissors, at  one or more points,  suffi-
ciently to permit of the free motion of the prepuce over the  glans  penis.
(South's  Chelius.)
  Dr. Peace, one of the surgeons to the Pennsylvania Hospital, has  been
accustomed,  for some  years past, to relieve  phymosis, even when  most
complete, in the following  very simple manner, the instrument  employed
being a pair of small straight scissors, of  which one  of the blades is ter-
minated  by a little  button,  like a probe-pointed  bistoury.   He  glides  the
point of  this blade along the glans penis beneath the  prepuce,  and  forces
the sharp point of  the other bfade through the  substance  of the prepuce,
between  the inner membrane and the external  skin, beyond the seat of the
stricture  ; then by closing the blades the  inner portion is divided to  the
requisite  distance,  thus  relieving the phymosis.  After the division the  cut
edges are spontaneously separated from each  other, and  cicatrization fol-
lows.  The bleeding which follows the  incision is very trifling.   The
great advantage of this operation is that no deformity ensues.—Ed.]
                        II.  Paraphymosis is said to exist when a tight
                      prepuce is pulled back over the glans, constricting
                      it, and causing it to swell.
                        Treatment.—The surgeon first compresses  the
                      glans with the fingers of one hand, so as to squeeze
                      the  blood out of it,—then pushes it back with that
                      hand, whilst he draws  the prepuce forwards with
                      the  other.   If this  fails, the constricting part of the
                      prepuce must be  divided with  a curved-pointed
                      bistoury.
                        III.  Cancer of the Penis is  generally of  the
                      scirrhous, very rarely  of the encephaloid variety.
                      It generally begins as a warty excrescence or small
pimple on the prepuce; but sometimes by an  infiltration  of the  substance
of the glans, which is converted into an indurated mass.  It almost inva-
riably occurs to elderly persons, who have had phymosis.  The disease
follows  the ordinary course of  cancer.   After a time   ulceration com-
mences ;  or fungous growths sprout up; the  discharge is fetid and  irri-
tating; the glans in the groin become  affected,  and  the  patient dies mi-
serably.
   Treatment.—As a prophylactic, the above-described operation for phy-
mosis should always be performed, if required.   As a curative measure,
amputation of the affected organ is the only resource, though, to use Dr
Walshe's words, " a singularly sorry one;" since all experience shows that
the disease generally soon returns in the stump, or in  the inguinal glands.
   Operation.—The surgeon stretches out the  penis with one  hand, and
cuts it off with one sweep  of a bistoury ;  bleeding vessels are  then to be
tied, and cold to be applied,—and after three  or four days a piece of bou-
2^e is to  be introduced into the orifice of  the urethra, and to be retained
I heir during the cicatrization.
 
DISEASES  OF THE  TESTIS.
499
  IV. Epispadias is a congenital malformation, consisting of an imperfect
closure of the urethra on its upper surface.   Hypospadias is a similar de-
ficiency of the under surface. They sometimes may be relieved by paring
the edges of the skin on each side  of the fissure, and uniting it by suture,
—provided that the urethra is pervious to the  end of the penis.   An
American surgeon has proposed to unite the edges of the fissure by cau-
terizing them with nitrate of silver, and then scraping off the black eschar;
by which means the surfaces are made  raw without haemorrhage or loss
of substance.
  V. Tumours.—The natives of warm climates  are  liable to a sarcomat-
ous growth of the  cellular tissue  of the  penis and scrotum, forming an
immense tumour in  which those parts are completely buried.  Poor Hoo
Loo, the Chinese, had a tumour of this sort.  Extirpation is the only cure,
—and if the tumour is very large,  no attempt  can be made to  save  the
penis and testicles.
    SECTION  II.--OF  THE  DISEASES  OF  THE  TESTIS.

   I. Acute Inflammation of the testis (acute testitis, orchitis, hernia hu-
moralis) may be caused by local violence, but more frequently occurs in
conjunction with gonorrhoea, through  an  extension  of inflammation  from
the urethra.  It is very liable to be induced if the patient indulges in vio-
lent exercise and  fermented liquors, or neglects to use a suspensory band-
age while employing injections.
   Symptoms.—The discharge from the urethra diminishes, and the patient
soon complains of aching pain in the  testis and cord, extending up to the
loins, and soon followed by great swelling, excruciating tenderness, fever,
and.vomiting.  The epididymis is the part chiefly affected.  The swelling
depends upon an  effusion of" lymph and serum into  the tunica vaginalis.
   Treatment.—Bleeding if the habit is very plethoric,—the application
of numerous leeches, or the abstraction of blood  from some  of the veins
of the scrotum; purgatives, especially F. 21, followed by the exhibition
of tartar emetic in  doses of  a quarter of a grain (F.
36), so as  to keep down  the pulse,  and  of mercury
with opium, so as barely to affect the gums, if the dis-
ease does not readily yield  to the  tartar emetic alone ;
—cold lotions or warm fomentations,  according to the
patient's  feelings,—a suspensory bandage to elevate
the part.   After the acute stage  has subsided, strong
astringent lotions, F. 16, may be  employed, and  sub-
sequently friction with mercurial ointment,  in order  to
remove the hardness and swelling which (as the patient
should always be informed) remain after the acute at-
tack.   As soon as the very acute  stage has subsided,
compression will be found a useful means  of reducing
the swelling, and  supporting the dilated vessels.   The
affected testicle is grasped  and separated  from its fel-
low, and then is encircled with strips of adhesive plas-
ter, which are to be applied regularly  and as tightly as
the patient can  bear ;  the first  strap being applied
round the spermatic  cord immediately above the tes-
 
f>00
DISEASES  OF  THE TESTIS.
 ricle, and the other downwards in succession, slightly- overlapping  each
 other.*
   II.  Chronic Inflammation (sarcocele) is known by more or less hard-
 ness, swelling, tenderness, and occasional pain.  Very often it commences
 in the epididymis.  It may be a sequel of acute inflammation,—or may
 be caused by disease in the  urethra, or disorder of the heahh.   It some-
 times depends on a syphilitic taint,—which will be probable, if the patient
 has the aspect of secondary syphilis, if the pain  is principally severe al
 night, and  if there  are secondary venereal affections of other parts.  Ii
 very often,  in its latter  stages,  is accompanied with some  degree of  effu-
 sion into  the tunica vaginalis (hydro-sarcocele).   It may be distinguished
 from  malignant disease, by the greater uniformity and smoothness  of the
 swelling, its slower  progress,  and the absence of glandular enlargement in
 the groin ;  but the diagnosis is often obscure  in  the  earlier stages.   On
 examination, the testicle is found to contain  more or less yellow, solid
 lymph, which is interspersed  in  its substance, and,  according to  Sir B.
 Brodie and Mr. Curling, is deposited into the lubuli seminiferi, and  may
 be found extending  into the vas deferens.
   Treatment.—The patient must be confined to his bed or sofa,—mercury
 be administered till  it begins to touch the gums,—the bowels be kept open,
 the diet nutritious but not stimulating, and  the part be suspended.  If an
 ordinary course of mercury seems inexpedient, the iodide  of potassium,
 or corrosive sublimate,  with sarsaparilla, F. 39, 40, 41, 42, will probably
 be  of service.  The part may be frequently  bathed  with F.  55, 58, 59;
 or F. 66 may be applied with moderate pressure, as directed at p. 265.
   III. Abscess of the testis  may be a result  of chronic  or scrofulous in-
 flammation—very rarely of the acute.   A  puncture should be made as
 soon as fluctuation is  clearly felt, and the  skin is adherent.    When an
 aperture is formed spontaneously or by art,  part of the tubular texture of
 the gland is apt to protrude in  the form of a pink, fungous, irregular mass,
 to which the name fungus ox hernia testis has  been given.  This should
 be returned to its place by pressure with strips of plaster;  and stimulating
 applications should be used in  order to excite granulation.   Sir B. Brodie
 recommends the red precipitate, and Mr.  Curling a strong  solution of
 lunar  caustic.  It is  not right to shave off the protruding  substa- ce, as it
 would be almost  equivalent to castration.
  IV.  Scrofulous Inflammation commences with a deposit  of tubercle
into some part of the testis or epididymis, either into  or between the  tu-
buli.   A  nodular swelling appears externally, attended  with very  little
pain or tenderness, which after a time inflames and bursts, and gives  exit
to the fungous protrusion just mentioned.   It  generally happens that the
lungs  are tubercular  as well.
   Treatment.—The  health must be invigorated by tonics, alteratives,  and
change  of air, and  the  local actions be excited  by stimulating lotions.
When all the tubercular matter has been evacuated, the abscess heals of
itself;  but, before this occurs, the whole organ is often disorganised  and

  •  This practice, which was first recommended by Fricke of Hamburg, was adopted
ny Ricord, and introduced into this  country by Mr. Acton and Mr. Langston Parker , it
seems to be generally approved of. and  is recommended by Mr. T. Blizard  Curling in
his Practical Treatise on the Diseases of the Testis, &c,  Lond. 1843; a work ol the
highest character, and greatest utility. 
DISEASES  OF THE  TESTIS.
501
rendered useless, and sometimes it is necessary to remove  it, on account
of the irritation and drain on the system.
  V. Atrophy of the testicle  may be a result  of excessive venereal  in-
dulgence, or of inflammation ; the part becoming filled with lymph, which
first annihilates the tubular structure, and  then is  itself absorbed.  The
gland dwindles to the size  of a pea.  There is no cure.
  VI.  Neuralgia of the  testis and cord  produces fits  of excruciating
pain, which leave the parts tender and  slightly swollen.   The treatment
must be that of neuralgia generally.  All the secreting  and excreting  or-
gans must be set in order.   Violent purgatives in general do mischief.  A
few leeches,—the application of intense cold, (F. 56,)—counter-irritants,
and opiate or belladonna plasters,—sometimes afford relief.  The internal
remedies  most likely to do good are sarsaparilla, quinine, arsenic, and
other tonics.   Extreme sensitiveness of the testis, so that  it cannot bear
the slightest touch, is another form of this disorder sometimes met with in
nervous hypochondriacal subjects ;  especially in persons who labour under
a  diseased condition of the urethra, or excessive spermatic discharges.
Tonics and cold  applications may be tried,  and the cause of the affection
should be ascertained, and if possible  removed.  In  these  cases, the  pa-
tients often desire to be castrated.   Before doing so, the surgeon ought to
convince himself that the pain  originates in a diseased  state of the  testis
itself, as it sometimes does.  If it  depends on disorder of the viscera or
general health, it might return in the cord,  after the removal of the testis.
   VII. The Hydatid or Cystic Disease is a rare  affection, and occurs
almost exclusively to adults.  The testicle swells exceedingly, and its  in-
terior is filled with a number of cysts containing a watery fluid.  They are
supposed to be developed  from dilated tubuli seminiferi;  and  their inter-
stices are filled with a solid fibrinous substance.  This  affection is incura-
ble, but not malignant.   When the  part becomes of unsightly magnitude,
it must be removed.
   VIII. Malignant Disease of the testis is  almost  invariably medullary
sarcoma, very rarely scirrhus.   At  first the  gland  swells, and becomes
very hard and  heavy ;  it is  scarcely, if  at  all, painful or tender, and
merely causes slight aching in the loins by its weight.  After a time it  en-
larges rapidly and feels soft,—the cord swells,—diere are occasional dart-
ing pains,—a fungus protrudes, the lumbar glands become affected, and
cachexia  and death  soon  follow  in the  ordinary course (pp. 115—-121).
This  disease  is  to be  distinguished from hydrocele by  its opacity and
weight,—and from  chronic inflammation  or the hydatid  disease by  the
darting pains, swelling of the cord,  and  cancerous cachexia.   It may  fui-
ther be distinguished from chronic  inflammation by the fact, that neither
mercury nor any other remedy produces any permanent benefit.
   Treatment.—Dr. Walshe, as in all  other cases of cancer, recommends
a fair trial of the iodide of  arsenic, and of pressure.   He believes that cas-
tration as a remedy is almost  utterly unavailing, since  there is hardly an
instance on record of permanent recovery after it, whilst  in not a few cases,
the patient's life  has been brought to a speedy close from the effects of the
operation.
   IX. Castration  is performed thus:—the  scrotum  being shaved, the
surgeon grasps it behind to stretch  the skin, and then makes an incision
from the external abdominal ring to the very bottom of the scrotum.   If
die skin is adherent, or diseased, or if the  tumour is very large, two ellip- 
502
HYDROCELE.
tical incisions may be made, so as to remove a portion of skin between
them.   If there is any doubt as to the nature of the disease, he may next
open the tunica vaginalis to examine  the  testis.  Then he separates the
cord from its attachments, and an assistant holds it between his finger and
thumb, to prevent it  from retracting  when  divided.   The operator now
passes his bistoury behind the cord, and divides it—and seizing the lower
portion draws it forwards  and dissects out the testicle,  'fhe arteries of
the cord, and any  others requiring it,  are then to be tied;  and the  wound
must not  be closed  till all the bleeding has ceased,  as this  operation is
often followed by secondary haemorrhage.
   [We add the following observation of Dr. Flint, which was  appended
to the former edition of this book:—" It is often more convenient to ter-
minate the operation by the  section of the cord, having previously separated
the testis from the  integuments.   The retraction of the cord leading to ir-
repressible haemorrhage, so  much feared by some surgeons,  may  always
be prevented by dissecting its cremaster envelop from the duct and vessels
well up towards the abdominal ring, and dividing the essential  elements
of the cord by themselves."—Ed.]
   X. Hematocele  signifies an  extravasation of blood into the  tunica
vaginalis, in  consequence  of injury.   It is sometimes combined with ec-
                   chymosis of the  scrotum.  If the quantity extravasa-
                   ted is small,  bleeding and cold lotions may cause it
                   to be absorbed.  If large, a puncture should be made,
                   and a poultice be applied, for the blood to ooze into
                   gradually.  Blood may also be extravasated into the
                   spermatic cord from local injury or strains.
                     XI.  Hydrocele signifies a collection  of  serum in
                   the tunica vaginalis.
                      Symptoms. — It forms  a  pear-shaped  swelling,
                   smooth on its surface, fluctuating if pressed, free  from
                   pain and tenderness, and causing merely a little un-
                   easiness by its weight.  The epididymis can  be felt
                   on the posterior surface of the tumour near the bottom.
                   On placing a lighted candle on one side  of  the scro-
                   tum, the light can be discerned through it.
                     Causes.—Hydrocele may be a sequel of inflamma-
                   tion of the testis, but more frequently arises without
                   any local cause.   It is often supposed to follow strains
                   of the loins or belly.
                     Diagnosis.—Solid enlargements of the testis  may
                   be  distinguished  from  hydrocele by  their weight,
                   solidity, and  greater painfulness, and by  the absence
                   of fluctuation or  transparency.  The  diagnosis from
hernia will be found at p. 439.
   Varieties.—It sometimes happens that the tunica vaginalis preserves its
communication with  the abdomen,  and then becomes filled with serum,
forming a cylindrical tumour extending up to the abdominal ring, to which
the name congenital hydrocele is  applied.   On  raising and compressing
it, the fluid is slowly squeezed into the abdomen, and slowly trickles down
again afterwards.  This case is liable to be complicated with  a congenital
or encysted hernia,  to prevent which, and to close the communication with
               * Hydrocele.  From  the King's College Museum.
 
HYDROCELE.
503
the cavity of the peritonaeum, a  truss should be worn.   Sometimes the
transparency and fluctuation of hydrocele are absent in  consequence of a
thickening  of the  tunica vaginalis, which  may  be  known,  according to
Brodie, by noticing that the thickened membrane forms a projection along
the epididymis,—whereas in solid enlargements  of the testicle the projec-
tion of the epididymis is lost.   Sometimes  the tunica vaginalis is  partially
adherent to the testicle.   Sometimes loose  cartilages are found in the sac,
—they are easily removed by a slight incision.
   Treatment.—The remedies for hydrocele  are threefold.   (1.) Strong
discutient lotions (F. 59), which  sometimes  assist  the  cure  in children,
but cannot be depended on for adults.   (2.)  Evacuation of the serum, or
the palliative  cure.   This  may be accomplished  by a  puncture with a
common lancet, or trocar;  but the method  most commonly adopted at
present, consists in  making a number of punctures with a large needle, so
that the fluid may escape from the tunica vaginalis into  the cellular tissue
of the scrotum, wiience it is readily absorbed.  This palliative treatment is
always sufficient for children, but very rarely  so  in the case of adults.
   (3.) Radical Cure.—This, which is generally necessary for adults, is
performed by injecting certain stimulating fluids, or by introducing setons,
or other foreign substances into the tunica  vaginalis, in order to  excite a
degree of inflammation sufficient to destroy its secreting faculty.   It must
not be forgotten, however,  that this radical cure is  totally inadmissible if
the testis is diseased, or  if the hydrocele is complicated with an irreducible
hernia, or if the tunica vaginalis preserves its communication with the ab-
domen.  Mere thickening from previous disease  is, however, no objection.
   Operation.—The surgeon grasps the tumour behind,  and introduces a
trocar and canula into the sac—pointing the  instrument  upwards, so that
it may not wound the testicle.  He next withdraws the trocar, at the  same
time pushing the canula well into the sac, so  that none of the fluid that is
to be injected may  pass into the cellular tissue of the scrotum.  When all
the serum has escaped, he injects from two to four ounces of some stimu-
lating fluid through the  canula, by means of an  elastic bottle fitted with a
stop-cock.   Equal  parts of port wine and water  of zinc lotion  (F. 58) are
commonly used.   Mr. Curling prefers common lime water.  When the
fluid has remained from three to five minutes, according to the degree of
pain which it causes, it is suffered to flow out, and the canula is withdrawn.
Some degree of inflammation follows, and more effusion into the sac—but
the latter generally  disappears in  a fortnight or three weeks.   If  the  cure
is not quite perfect, the operation may be repeated after a few weeks.  But
the remedy most in favour  at present is the tincture of iodine, which was
used with very great success at Calcutta, by Mr. Martin.  The disease is
so common  in the East, that Mr. Martin can refer to thousands of success-
ful cases.   The sac having been punctured with a small trocar and canula,
about one or two drachms of a mixture of one part tincture of iodine, and
two of water are injected and allowed to remain  in the sac.  Mr.  Fergus-
son uses for this purpose a small  glass syringe, with a silver or platinum
nozzle made to fit the canula.   One advantage this method certainly has;
namely, that there  is much less chance of extravasation  into the  scrotum,
than when the sac  is filled with many ounces of  fluid.
   XII.  Varieties  of Hydrocele.—(1.)  Encysted Hydrocele.  Sometimes
a serous cyst  is developed on or near the testis.   Most frequently it is
situated between the tunica vaginalis and epididymis; very rarely  between 
504
VARICOCELE.
the tunica vaginalis and testis, and more rarely still within  the  simstance
of the external layer of that tunic.  These cysts contain a clear water, and
                        not serum.   They  may  be  punctured with a
        Fig. 16.2.*         grooved  or cataract needle, to  let  the fluid
                        escape, if  they  have become of inconvenient
                        bulk;  and  if it is necessary to adopt some radi-
                        cal method of cure,  the best plan seems to be
                        to pass a common silk ligature through the  sac
                        with a curved needle, and retain it  till it  has
                        caused some inflammation.  (2.) Hydrocele of
                        the spermatic cord may consist either  of an  en-
                        cysted tumour, such as has just been described,
                        or else of a collection  of serum  in the cellular
                        tissue of the  cord.   In either case, the  needle
                        must be employed if the  swelling becomes trou-
                        blesome from its bulk.
                           XIII. Varicocele (Cirsocele or Spermatocele)
                        signifies  a  varicose  state  of  the veins  of  the
                        spermatic cord.  It  is caused by the ordinary
causes of varix;  that  is to say, by obstruction to  the return  of blood,
through corpulence, constipation, tight belts round the abdomen, and the
like.  It is much more common on the left side  than  on the right;
obviously because the left  spermatic vein is  more  liable  to be pressed
upon by faecal accumulations in  the sigmoid flexure of the colon, and be-
cause its course is longer and less direct than that  of the right vein.
   Treatment. — In ordinary cases, sufficient  relief may be  obtained by
keeping the bowels thoroughly open ;—by frequently washing the scrotum
with cold water or astringent lotions, so as to constringe the skin ; — and
by supporting it with a suspensory sling made of open silk net, and fas-
tened up with two tapes, which  are to be attached  in front, to a band
passing round the abdomen;—but it should have no tapes passing behind
between the legs.  But there are some cases in  which this disease pro-
duces very serious inconvenience—pain in the- scrotum and loins—sense
of dragging at the stomach—loss of appetite—flatulence—and despond-
ency of mind—and for these cases, something more must be done.  Mr.
Wormald recommends the  loose skin of the  scrotum to be pinched up
and  confined with a steel ring.  Blisters and counter-irritants, so as to in-
flame and  condense  the scrotum ; — division  of the veins by the knife or
caustic, and passing setons of thread through them, have had thtir advo-
cates ; — and  even the barbarous  operation of passing a ligature through
the scrotum, and  tying up the skin of half the scrotum, with all the vessels
except the artery and vas deferens, so that they may be divided by ulcer-
ation, has been practised in some cases with success;  in others with fatal
results;  but certainly always with  a risk of causing atrophy of  the testes.
Sir A. Cooper proposed the operation of cutting away a good piece of the
loose relaxed skin.  " The  manner of performing it is as follows: — The
patient  being placed  in the recumbent posture, the relaxed scrotum is
drawn between the fingers; the testis is to be  raised to  the ring  by an
assistant;  and  then the portion of the  scrotum is  to  be removed by the
knife."  Any artery requiring it must be tied ; and cold must be applied

   • En^ysred hydrocele.  From a preparation in the  Middlesex Hospital Museum.
 
VARICOCELE.
>05
to check bleeding; and then the lower flap of the scrotum must be brought
upwards and  forwards, and be attached by sutures to the fore and upper
part; — and a suspensory bag should be  applied to press the testis up-
wards, and glue the scrotum to its surface.  It is of no use to remove too
little of the skin.
   [Dr. Pancoast describes in the Medical Examiner (March 4, 1843) the
following modification of Ricord's operation, which he states he has em-
ployed with success:—
   Previous to the operation, the patient is to be directed  to walk about
for an hour or two with the scrotum unsupported, so as  to cause an accu-
mulation of blood in  the enlarged veins.   He is to be seated on the side
of his bed, with the legs separated.  The thumb and forefinger of the left
hand are then to be  pressed in, so as to lift up the enlarged veins, and
thus separate  them from the vas  deferens.   This  duct is  readily distin-
guished by its hard and wiry feel,  and is  to  be  pressed off with the nail
of the left forefinger towards the os pubis.  A long,  round,  lancet-pointed
needle,  curved near the point  like that of the sail-makers, and threaded
with a piece of fine but  strong hempen twine passed double through the
cye, is then  carried between the bundle of veins and the vas deferens;
entering it on the side of the thumb, and  bringing out the point against
the pulpy portion of the  finger.   " The loop of the  double ligature is  to
be  detached  from the needle; the ligature being left in the track of the
wound.   The  needle, without being  threaded, is  again to  be entered
through the same orifice of the  skin as before, but  carried this  time be-
tween the skin of the scrotum and the veins of the cord, and  its point
brought out through the other puncture  made in the skin on the side next
the pubis.   To  facilitate  this step, the skin should  be  lightly raised up
from above the veins  with the  thumb  and finger."  If there is any en-
largement of the subcutaneous veins of the front part of the scrotum, the
point of the needle is to be so carried  as  to  scrape the under surface of
the skin, and passed in  front of these veins.  The  needle is now to be
left in the wound.  The place  of  entry of the needle is to be lower than
its place of exit; " so that the point of the instrument,  which should be
pushed well through, may lie undisturbed without pressing  over the  root
of the penis.  The course of the instrument across the cord  will be, there-
fore, rather  diagonal  than transverse.   The  loop of the ligature (which
lies next the pubis) is now to be thrown  over the  point of the needle.
Traction is next to be made upon the other side, upon the loose  ends of the
ligature, so as to draw the loop along  the  needle, through the orifice  in
the skin.  One tail of the ligature  is now to be drawn out for four inches,
so as to ishift the portion of the thread  forming the loop over the needle,
for fear that this might have been cut by the point or edge of the needle,
so as to break when subsequently knotted.  The loose ends of the ligature
are then to be tied with a single knot over the shank of the needle;  this
is  to be drawn  as tightly as possible,  so as to completely strangulate the
veins of the  cord, which will be thus inclosed by the double ligature on
its back part, and the needle in front.   To make the strangulation more
effectual, the two ends of the loop  thus formed  over the needle may be
slid towards each other, by pressure through the skin, and the knot again
tightened.  This step  is followed by severe  pain, which gradually dimi-
nishes, and at the end of half  an  hour ceases almost entirely."  To be
able to tighten the ligature at the end of two or three  days, when it will
       43 
506
DISEASES  OF THE  SCROTUM.
be found  foosened by having partially cut through the compressed mass
ot veins, an oblong piece of sole leather pierced in the centre and notched
at the  ends,  is slid  over the heel of the needle, and a firm double bow
knot made of the  ligature above it.  " The point of the  needle is  to  be
sheathed in  a small cork,  and  a compress placed below it to prevent its
worrying the  skin.  A piece of thick tape is to be passed through the eye
of the  needle and knotted, in order to prevent the  needle, when  it  be-
comes  loosened by suppuration, from  being pressed through the hole in
the  leather by  the movements  of the thigh,  so as  to detach the loop.
The  scrotum  is to  be slightly supported by a couple of silk  handkerchiefs,
folded  and placed below it.  No dressing is required.  If neuralgic pains
arise, they are to be soothed by hot fomentations, and the administration
of anodynes."   The ligature over the leather is to be untied  every third
day for three successive  periods, tightening it again as much  as possible
at each time.   On the eleventh the needle is removed; the loop, which
is then left  detached, and  will  be  found but small from  the successive
tightenings, is at the same time withdrawn.  Above the place  of the liga-
ture, the condition of the cord will  be found perfectly natural; below, it
will be found a hardened mass of the size of a walnut, formed by the effu-
sion  of lymph between,  and in  all probability in the cavities of the veins,
causing their complete obliteration.  After the  withdrawal  of the  needle,
a light poultice may be laid for a few days over the part, to promote sup-
puration from the points of puncture, and to facilitate the resolution of the
tumour left.—Ed.]*
  The method  which appears most promising at present,  consists  in the
application of moderate pressure to the dilated veins at the  external abdo-
minal ring, by means of  Evans's patent lever truss; so as to release them
from the  pressure of the superincumbent  column of blood,  and  afford
them a moderate degree of support.*

        SECTION III.--DISEASES  OF THE SCROTUM.
  I.  Acute  CEdema of  the Scrotum.—The loose  cellular tissue of this
part  is exceedingly liable  to serous  infiltration,  from  inflammation  or
dropsy.  But there is one form  of acute cedema, which has been particu-
larly described  by Mr. Liston,f and which is liable to supervene on exco-
riations of the  parts in  unhealthy persons.   The scrotum  becomes enor-
mously swollen and tense, and soon sloughs unless a free incision is made
in the  mesial line.   The  case very much resembles extravasation of urine,
but may be distinguished by the absence of swelling in the perinaeum, and
of obstruction in micturition.
  II. Cancer  Scroti.—This disease  is commonly  called the Chimney-
sweepers  Cancer, because it is very seldom met with except amongst that
class of men, and because the irritation of soot lodging in the ridges of the
scrotum is believed to be the cause of  it.  It may be  remarked, however,
that some other irritants  are believed to have the same effect on the scro-
tum.   Thus, it is stated  on the authority of Dr. Paris, that smelters are
liable to a similar disease.   And, on  the other hand, soot may produce
this disease on  other parts besides the scrotum.
  * Vide Sir A. Cooper, Guy's Hosp. Rep., vol. iii.; Reynaud, Journ. des Connaissances
Med., Feb.  1839;  James, in  Prov. Med.  Trans, for 1840;  and Curling,  op. cit.  The
diagnosis of Varicocele has been spoken of at p. 417.
  J Med. Chir. Trans., vol. xxii. 
IMPOTENCE.
507
  It usually commences as a florid vascular wart, called the soot-wart.  It
admits of doubt whether this, in all  cases, is of a truly cancerous  nature
at the  commencement, although when the disease is far advanced, there
is unquestionably a deposit of genuine scirrhus in the base of the ulcer,
and  in the parts around.   Ulceration, the sprouting of fungous growths,
and the contamination  of the inguinal glands, are the regular course of this
disease ;  and the only remedy is the early and  free excision of the whole
of the diseased portion  of skin.  We may add that this operation has a
far better chance of ultimate success than  most other attempts at the extir-
pation of cancer ;  and that some successful  cases are  known in which it
was done even  after the inguinal glands had swelled.*

                SECTION  IV.--OF IMPOTENCE.

  Impotence in  the male may depend on a variety of conditions.  (1.)
It may be  caused by absence,  or mutilation, or malformation, or original
weakness and want of development  of the  genital organs.   (2.)  After a
severe and tedious illness, the genitals may remain incapable of perform-
ing their functions, long after the restoration of the health and strength in
other respects.   Steel  and other tonics, with cantharides, musk,  extract
of nux vomica, resin of Indian hemp, galvanism cautiously applied to the
spine, spices, eggs, and oysters, are  the remedies.   Phosphorus in doses
of gr. ^ dissolved in oil, is said to be a potent aphrodisiac in these cases.
(3.)  Blows  on  the head, or spine, are apt  to  be followed by impotence ;
which sometimes is relieved, but more frequently is  permanent.  A cau-
tious  course of mercury, followed  by the stimulating  aphrodisiacs just
mentioned,  are the remedies most likely to be  of use.  A similar result
sometimes  follows a fit of apoplexy.  (4.) Certain  diseases  are always
attended with a diminution, and sometimes with a complete loss, of sexual
power;  especially diabetes, diseases  of the kidneys, some forms of dys-
pepsia ; and the  latter stage of most chronic organic  diseases.  (5.) It
often happens that a young man, the first time he yields to carnal temp-
tation— or that  a newly married man on the night of his nuptials, finds
himself incapable of accomplishing his wishes — through awkwardness, or
timidity,  or over-anxiety  on his own part, or, perhaps, from something
disagreeable in his bed-fellow.  He straightway fancies himself impotent
— and if he applies to one of the advertising Jewish scoundrels, will no
doubt  be told  that  he is so.  The surgeon should cheer the patient's
spirits, and  should inform him that his case is by no means uncommon —
that most other men feel  the same incapability at times; and he  should
give him a little nitric aether and cinnamon water, and  make him promise
to sleep with the lady three nights without touching her, which will seldom
fail to prove  an effectual cure.  These are  difficult  cases  to manage;
because the disease is in  the mind and not in the body.   It is most diffi-
cult  to persuade the patient that he has  not more than an imaginary dis-
ease ; and he is far too ready to accuse the surgeon of inhumanly ridicul-
ing him.   (6.) Lastly, impotence may be  produced by premature and
excessive venery,  or by  the practice of self-pollution.   Such cases  fre-
quently come under the observation of the London surgeon, who  has  no
difficulty in distinguishing them from the  last variety.   The sexual  organs
have  been  rendered in  these cases  so weak and irritable, that the  least
* Vide Walshe, op. cit. 
508           DISEASES OF THE FEMALE GENITALS.

excitement from a lascivious idea or from the mere friction of the cl<>tli-'>,
brings on an imperfect erection followed immediately by the discharge of
a thin fluid.  The erection is so imperfect, and followed so soon  by the
discharge, that the patient is quite incompetent for sexual connexion ; and
the frequent and abundant losses of seminal fluid, (whence the term sper-
matorrhea is given to this malady,) together with the patient's conscious-
ness of  his own imperfection, bring on a most  miserable state  of  bodily
weakness and mental despondency.   General tonics, and  cold  shower
bathing will do something to relieve  this  state; but the most essential
thing is, the observance of perfect chastity  oi idea,  so that all excitement
may be avoided.   The prostatic  portion of the urethra in these cases, is
almost  always preternaturally irritable and sensitive ; and this condition
of the parts at the orifice of the seminal ducts tends  greatly to keep up the
excessive secretion, and to promote the action by which it is expelled.  It
is a very important  indication, therefore, to attack  this  irritable surface,
destroy its sensitiveness, and so interrupt the chain of morbid phenomena.
This may be effected by the use of nitrate  of silver according to the  plan
proposed by M. Lallemand.  The porte caustique is passed down the ure-
thra, and as soon as it arrives at the painful part, the caustic is protruded
for an inch, and passed backwards and forwards rapidly once or twice,—
then the instrument is withdrawn.  This is  followed by more or less pain,
and thin  bloody discharge — sometimes by severe inflammation : but the
spermatorrhoea  is almost invariably benefited at once.  Injections  of thin
mucilage, containing one grain of opium and three  of acetate of lead  to
the ounce, have been recommended by Mr. Douglas, of Glasgow, as less
painful, and equally efficacious; the author can  confirm this  statement.
Enemata of cold water, and small doses of cubebs with henbane, are use-
ful adjuncts to the treatment.*
                       CHAPTER XXII.

    OF  THE SURGICAL  DISEASES OF THE FEMALE GENITALS.

  I. Blennorrhea.—Young  female  children are sometimes subject  to
mucous or purulent discharges from the parts at the entrance of the va-
gina ; which may also perhaps be  excoriated.  Purgatives and  tonics—
perfect cleanliness, and F. 58, or any mild astringent lotion, are the  re-
medies.
  II. Noma signifies a phagedaenic affection of the labia pudendi  of young
female children,  precisely resembling the cancrum  oris, p. 391,  in  its
causes and nature, and symptoms.   After two or three days of low fever,
the little patient is observed to  suffer considerably whilst making water,
and on examination, the  labia present a livid erysipelatous  redness and
vesications, that are rapidly followed by phagedaenic ulcers.  This disease
is very frequently fatal.   The treatment is the same as  directed for can-
crum oris.   The surgeon must be very careful not  to mistake this  oi  the
  • Vide B. Phillips, Med. Gaz., 23d Dec, 1843;  Curling, op. cit.  Douglas,  Med. Gaz,
29th Sept., 1843. 
DISEASES  OF THE  FEMALE GENITALS.
509
preceding affection for the venereal  disease;—an error common enough
among parents.*
  III.  Vesico-Vaginal Fistula signifies a communication between the
bladder and the vagina.   It generally results from sloughing of the  parts
after a tedious labour.   As soon as it is discovered, the patient should be
made to lie on her face—a catheter should be constantly worn in the ure-
thra, and an oiled sponge in the vagina, and the  bowels should  be kept
moderately loose.   By these  means  the  natural contraction  of the  parts
will be aided.  After some weeks, it will be expedient to pare  the  edges
of the fissure, and unite them by suture, by means of Mr. Beaumont's
treatment;—or if this fails, to touch them frequently with nitrate of silver,
or to apply the actual cautery at intervals for a  few months.   To perform
these operations, the vagina  must be  dilated with a speculum.   If  these
means fail, or if the patient will not submit to  them, Dr. Reid's  plan  of
plugging the vagina with  an  India rubber bottle, appears to be  the best
means of preventing the constant dribbling of urine.
   IV.  Recto-Vaginal Fistula must  be treated by constantly wearing a
sponge in the vagina, so as to prevent the passage  of faeces through it, and
by mild laxatives.  If after a time the aperture does not close, it must be
treated as in  the last case.   Complete laceration of the perineum into  the
anus is attended with distressing incontinence  of  faeces, and is prevented
from healing by the action of the sphincter.  Hence it is necessary to di-
vide the sphincter on each side of the laceration, and to prevent these new
wounds from uniting, by placing a few threads  of lint in them, until  the
laceration has united.
   V. A Vascular Excrescence, varying in size from that of a large pin's
head to that of a horse-bean, is liable to grow from the female  urethra. It
causes great distress through its exquisite sensibility.  It should be cut  off,
and the potassa fusa be applied to the  surface to prevent its reproduction.
But, immediately after the caustic,  a  sponge  dipped  in diluted vinegar
should be applied, in  order to prevent injury  to  the  surrounding  sound
parts;—and if it is necessary to introduce the caustic within the urethra,
it must be by means of a tube which has an aperture  in  it corresponding
to the  diseased surface.
   VI. Uterine Polypus is  a pear-shaped tumour covered by mucous
membrane, and attached by a narrow, neck to some part of the uterus.
The symptoms that  it produces are those  of  uterine irritation—bearing
down  pains—menorrhagia—and, after a time,  fetid  discharges.  On ex-
amination, an insensible  tumour is  found partially or entirely protruding
through the os uteri.  If it projects much into the vagina, the surgeon must
carefully feel for the os uteri, and ascertain that the neck of the polypus is
either  attached to some part  of it, or that it passes clear into the womb.
Inversion, or prolapsus of the womb, must not  be  mistaken for it.
   Treatment.—A ligature should be twisted tightly round  its neck, but
not too near the womb, by means of the double canula  invented for that
purpose by the late Dr. Gooch.
   VII. Imperforate Hymen.—Sometimes this membrane'completely ob-
structs the vagina, and causes the menstrual fluid  to accumulate  and dis-
tend the uterus.  The impediment  is easily got rid of by a crucial inci-

  • Kinder Wood, on a fatal affection of the pudenda of female children.   Med. Chir
Trans,  vol. vii. p. 84.
        43* 
510
DISEASES  OF THE  BREAST.
sion.   Then all the black treacly fluid that has accumulated  should be
immediately syringed out with warm water,  otherwise it might putrefy, and
cause typhoid fever and death.
   \ III. The labia may be the seat of acute  inflammation, and of encysted
tumours, and sarcomatous or fatty enlargements.  The treatment of these
cases requires no  distinct comments.  The  clitoris  and nymphae, if they
grow to an inconvenient  size, should be curtailed by an incision—and  if
they are affected with scirrhus, should be entirely extirpated at an  early
period.
                      CHAPTER  XXIII.

                OF THE DISEASES OF THE BREAST.

   I. Acute Inflammation of the breast is known by great swelling,
tenderness and pain, and fever.  These symptoms are soon succeeded by
shivering, and  formation of matter.   The abscess is very slow to point.
This  affection  may  occur  at  any  period during lactation.   It may be
caused by cold—by too stimulating a diet—or by neglect in  suckling.
   Treatment.—The  bowels should be  freely kept  open by saline purga-
tives, plenty of leeches should be  applied  as soon as possible, and tepid
fomentations or poultices after them ; the milk  should be drawn off, if it
can be  done without very much  pain,  and  Dover's powder should  be
given to allay restlessness.  As soon as fluctuation is well established, a
puncture should be made.  The aperture after a time discharges a milky
fluid.    If  it is long in healing,  astringent  lotions  should be injected
into it.
   II.  Chronic Inflammation generally attacks one or twTo  lobules only,
causing them to swell into  firm tumours, which, on  examination with the
finger, are felt to be composed of  numerous little  granules.  The whole
gland may however be affected.   There is very little  tenderness or pain,
except at the time  of menstruation.  This affection is distinguished from
malignant disease, by the circumstance  that the patient is generally young,
without the leaden look  of cancer, that the tumour is more  diffused and
not so hard, and  that the skin, nipple and lymphatic  glands are un-
affected.
   Treatment.—The  appetite  and  digestion — the  state of the liver and
bowels, and, above all, of the uterine system, must be regulated by Plum-
mer's pills, aloes, steel, and other alteratives, aperients, and  tonics.   Oc-
casional leeches'—cold lotions—issues  in the back—mercurial  plasters,
containing a little belladonna — and, in indolent cases, friction with weak
mercurial  ointment—are the  requisite  local  remedies.   Marriage  is in
some cases almost  a  specific.
   III.  Irritable Breast is a neuralgic  affection resembling the irritable
testis.—Extreme pain and tenderness, aggravated at the menstrual period,
with occasional heat and slight swelling, are the symptoms.  This, like
the other affections of its  class, (p.  314,) is extremely  unmanageable, and
may remain for years.
   Treatment.—Steel, aloes, and other tonics—emmenagogues—especially
the ferri ammonio-chloridum  in  doses  of gr. ii. ter die—with change of 
DISEASES  OF THE  BREAST.                511
air, marriage, and  other means for the improvement of the health,--are
the chief remedies.   Leeches, cold and  warm  applications—mercurial,
belladonna, and other plasters—issues, blisters, and other local measures,
sometimes  do good, but as often the reverse.
   IV.  Lacteal Tumour.—Sometimes a lacteal  duct becomes oblite-
rated,  and the  milk  accumulates in it, forming  an oblong  fluctuating
tumour near the nipple.   If  this  is  punctured, milk will  continue to be
discharged during lactation, and,  after the child is weaned, it will dry up
and heal.   In a few very rare instances there has been  formed a
   V.  Lacteal Calculus.—The  fluid part of the  milk in an  obstructed
lacteal duct having been absorbed, whilst its more solid and  earthy ingre-
dients  remained, and concreted into a calculous mass.
   VI.  Abscess in the Lacteal Tubes.—An elderly woman  applied to
the author  some time since with  a painful, elongated swelling, stretching
from the nipple to the circumference of the breast.   It  evidently con-
sisted of a  lacteal tube which had suppurated ; and, after being punctured
and yielding half an ounce  of pus, it soon got well.
   VII. Sore Nipples.—Excoriations and chaps about the nipples not
only cause great pain and inconvenience  in  suckling, but are a frequent
cause  of acute inflammation, by deterring the mother from  allowing the
child to suckle so freely as it ought.   A solution of gr. v.  of tannin in an
ounce  of water ; F. 127 ;  or a touch with lunar caustic, if there is a very
deep irritable  fissure, are the  best remedies; lotions of borax, alum, or
sulphate of zinc, and arrowrroot and cream, are also  common applications.
The 'nipple should be defended from the clothes,  and from the child's
mouth, by  a wooden or caoutchouc shield.   Women who are subject to
this affection  should  frequently wash the parts with salt and water, or
solution of alum,  during pregnancy; or should  apply every night a lini-
ment composed of equal parts of rectified spirit and olive oil.
   VIII. The  Hydatid Disease consists in the development of a  number
of cysts in the gland, filled with clear water.   Sometimes  the cysts are
developed  by the gland—being lined with a vascular membrane, and con-
taining a yellow serum.   Sometimes they consist  of hydatids—parasitic
animalculae, composed of  thin bladders  filled with a  clear  water, which
are developed in the gland by their own vital powers, and are  capable of
engendering other smaller hydatids within themselves.  The diagnosis of
this affection is obscure.   At first it occasions a hard tumour resembling
that of chronic inflammation,  and unattended with pain, except at the
menstrual period.   Subsequently  fluctuation is felt at different parts—and
when  any cyst  has acquired a considerable  magnitude, it ulcerates, dis-
charges its fluid, suppurates, and  contracts.
   Treatment.—If there are but one or two cysts, they may be punctured,
and then they will suppurate and contract.   But  if the whole  gland is
involved,  it should  be removed.   The  inconvenience  arising  from its
bulk, and the  irritation caused by the ulceration of the  cysts, will thus be
got rid of.   At the same time, the chance that this, like other new struc-
tures,  may become the  nidus of malignant disease, is an additional rea-
son for the operation.
   IX.  The Serocystic Disease is a peculiar affection  of the  breast, de
scribed by Sir B. Brodie in a clinical lecture  at St. George's Hospital, in
1840.   It  chiefly affects the upper classes, and  is rarely met with in hos-
pitals,   It  consists in the development of numerous cysts, formed proba- 
512                         SCIRRHUS.
bly by a dilatation of  the lactiferous tubes, and containing serum, whicli
often exudes from, or may be squeezed  out of, the  nipple.   It generally
occurs to women under the age of thirty, who  are  unmarried, or barren.
In its first stage, it appears as one or more globular tumours—the size
perhaps of a marble—which seem to  be moveable,  because the whole
breast moves with them, but are not so in reality.   This  disease does not
affect the  axillary glands, and may remain  stationary for years.  But in
time a  second stage  arrives.   Fibrinous matter  is effused between the
cysts, gluing them together; and tumours  are  developed on their inner
walls.   As the disease advances, the  skin  ulcerates, the serum escapes,
and in  a  few  days  a fungus protrudes, which ultimately  causes  death
through bleeding and sloughing.
   Treatment.—In the early stages Sir  B. Brodie recommends counter-
irritation by  means of blisters, or tincture  of iodine,  or by flannel clothd
soaked  in a combination of sp.  camphorae, sp. tenuioris aa f 3 iiiss; liq.
plumbi f 3i;  intermitting these applications when the  skin becomes  sore.
Punctures are not on the whole advisable.   In the later stages the breast
must  be amputated, and if the whole  of it is  removed, the disease will
not return.
   X. Scirrhus generally commences  as a hard, circumscribed, moveable
swelling in some part of the  breast.  In its early stages, it  is not  often
tender or painful, and perhaps is only discovered  by accident.  After a
few weeks or months, however, it increases in size, and becomes tubercu-
lar in its outline; and now becomes  affected with  paroxysms of violent
lancinating pain,  which are said to be most apt to occur about the period
of menstruation.  Not unfrequently a little bloody fluid is discharged from
the nipple.   The cellular tissue and  fat about the gland often  become
atrophied, so that the  diseased breast is smaller than the sound one, and
the nipple is  generally drawn in, and  the skin  around it puckered  like a
cicatrix.  The disease  may, however, commence, not as a distinct tube-
rous deposit  forming  a tumour in the breast, but as a general  infiltration
of the whole organ,  which becomes  a  hard, heavy,  tuberculated  mass.
But in either case the progress and termination of this disease are such as
have been already described (p.  118).   The tumour after a time  invades
the entire gland,  and  adheres to the skin, and to  the  muscle  beneath, so
as to become fixed and immoveable. Then it ulcerates and forms a cancer.
The glands in the axilla, and sometimes those  in the  neck,  enlarge, and
compress  the axillary veins, and the arm swells and becomes cedematous
from the obstruction to its circulation.   The ribs and pleura become scir-
rhous—water is effused into the  chest—the breathing  becomes difficult—
the patient suffers from rheumatic pains in the bones, and  at last  dies.
The rapidity of this disease is most uncertain.   But Sir A. Cooper used
to say that it was generally from two  to three  years  in  attaining its full
growth; and from six months to two years afterwards in destroying life.
   Diagnosis.—In well marked cases this disease cannot be mistaken. The
stony-hard, moveable swelling in its early stage, or the shrunken  gland
and retracted nipple subsequently,—the age about forty,—the leaden, sal-
low complexion,—the weakness and  cachexia,—the  lancinating pain,—
and the circumstance (which  very often happens) that the patient's mother
or sisters have suffered from cancer,  all  distinguish it.  But there are
several circumstances which may render the diagnosis doubtful.  (1.) In
rhe first place  the scirrhous  deposit  may be attended with more or less 
EXTIRPATION'  OF  THE  BREAST.
513
common inflammatory pain, tenderness, and swelling, so that it loses its
characteristic hardness, and becomes blended in its outline with the sur-
rounding tissues, and exactly resembles the swelling arising from chronic
inflammation.   (2.) It may occur in a young female between twenty and
thirty.   (3.) The effect of  remedies  may be  deceitful, for they  may, per-
haps, diminish the inflammatory swelling around, and  so  cause a tempo-
rary decrease of the  tumour, though not of its scirrhous portion.
   Treatment.—The local and  general treatment of  scirrhus of  the breast
must be conducted on the principles laid down in the section of Scirrhus
generally.  We can  only reiterate the opinion there given of the  almost
hopelessness of remedial measures of any kind ; and the judgment of Dr.
Walshe, that " treatment in the early periods, plus operation (if  necessary)
in the later, gives greater chance of the suspension of the  disease, and of
prolongation of life,  than early operation minus treatment."
   The cedema of the arm,  which is often such a distressing complication
of the later stages of this disease, may be somewhat retarded by  bandages,
and by keeping the limb in an elevated posture.  Blisters near the shoulder,
and punctures of the skin may be tried when it becomes excessive.
   XI.  Medullary Sarcoma  of the  breast is generally  combined  with
more or less scirrhus, and  rarely exists  alone.   It forms a large rapidly
increasing tumour ; lobulated on its surface ; and the projecting  parts yield
an elastic sensation.  This affection may be  distinguished from scirrhus
by its more rapid growth and greater softness.  It is often  difficult in its
early stage  to distinguish it  from innocent chronic tumours, more especially
as the latter may after a time become the seat of malignant growths.  Me-
lanosis and gelatiniform sarcoma are sometimes, though rarely, found  in
the breast.
   XII.  Extirpation of the Breast  is thus performed:  The patient
being placed in  a convenient position, sitting or reclining, an assistant
takes the arm of the  affected side and holds it out, so as to put  the pecto-
ralis on the stretch.  The  surgeon then makes a semi-elliptical incision
below the nipple  along the lower border of the pectoralis  major, and an-
other on the upper and inner side of the nipple, so as to include that part
between them.  He next  dissects out the lower and outer part of  the gland,
quite down to the pectoralis, (taking care not to get behind that muscle,)
and then, cutting from  below upwards, he separates the remainder.   If an
adjacent gland is enlarged, the incisions should be managed so  as to in-
clude it also.   When the mass is removed, its  surface should  be wiped
and examined,  and the wound should also be well examined, to ascertain
that no part of  the gland, and that no  hardened or discoloured portions
of cellular  tissue or of  muscular fibre, are left behind.  Arteries are  then
to be tied,  and  the patient to be  put  to bed,—and when  all oozing has
ceased, a few strips of adhesive plaster may be applied.
   XIII. Boys and girls about the age of puberty are  subject to slight swell-
ing and tenderness of the breast, which soon disappears  of  itself if not
interfered with.
   XIV.  Men occasionally  suffer from  malignant  disease of the breast,
which manifests itself in the same  manner, and requires  the same treat-
ment, as it does in the  female.
                                 2h 
514
CLUB-FOOT.
                      CHAPTER  XXIV.

OF THE  DISEASES  OF THE HANDS AND FEET,  CLUB-FOOT,  AND
              OTHER DEFORMITIES  OF  THE LIMBS.

  I. Club-Foot (Talipes) signifies a peculiar deformity  of the foot, pro-
duced by rigidity and contraction of the muscles of the leg.   (1.) In the
most simple variety, which is called talipes equinus,  the heel merely  is
Fig. 163.                           Fig. 164.
raised, so that the patient walks on the ball of the foot.  (2.) In the talipes
varus, which is far more common, the distortion is much  more complex.
In the first place the heel is raised;—secondly,  the inner edge of the foot
is drawn upwards;—and  thirdly, the whole foot is twisted  inwards; so
that  the patient walks on the  outer edge, and in  confirmed cases, on the
dorsum of the foot, and outer ankle.  Figure 164 shows the talipes varus.
(3.)  In the talipes valgus the  outer edge of the  foot is  raised up, and the
patient walks on the inner ankle.
   Causes.—This affection consists essentially in  that state of shortening
and rigidity of the muscles of the calf,  which we have described as rigid
atrophy (vide p. 211).  The exciting causes  are various circumstances
that interfere with the supply  of nervous influence, or with the proper nu-
trition of the muscles.  Thus it may be a consequence of  fevers ;—of in-
juries of the spine;—*of division of the sciatic nerve;—of long confinement
and inactivity';1—pf repeated attacks of rheumatic or other kinds of inflam-
mation of the muscles of the calf;—or it  may be a sympathetic consequence
of irritation of the bowels, or of some other part  of the system—and lastly,
it may be  congenital, or produced during uterine life.   As a proof of the
imperfect nutrition and innervation of the distorted limb, it is always  cold
and feeble;  the bones are  small, and the muscles wasted. 
WEAK ANCLES.
515
   Treatment.—If this  distortion  is congenital,  or commences  in  early-
childhood, it may sometimes be  rectified by constantly wearing  a proper
apparatus.   Slight cases in particular, occurring  to children after fevers,
may generally be  remedied, if taken at their very commencement, by
daily extension with the hands, and friction of emollient embrocations on
the muscles, together with tonics, galvanism,  change  of air, and  sea-
bathing.   But in confirmed  cases, it  is better at once to  resort to Stro-
meyer's operation of dividing the tendo Achillis.   The rationale of this
operation  may  readily  be comprehended.  The tendon being  divided,
heals by a callus, which renders it longer, and which, while recent,  may
be stretched to any desired length.  Thus  the mechanical shortening of
the muscle  is neutralized.   At the same  time,  the antagonist  muscles,
which are always wasted  and inert, are  relieved  from a constant state of
tension, and are enabled to resume their natural functions, so that  the limb
rapidly increases in strength and bulk.   The operation is easily performed
thus:  The tendon is put on the stretch ; and a narrow sharp-pointed knife
is thrust through the skin on one side of it;  then its edge is turned against
the tendon, and made to divide it as it  is being withdrawn.  If the tendons
of the tibialis posticus,  or flexor pollicis; or in fact if any  others offer an
obstacle to bringing down the heel, they may be divided  as well.  It is
often expedient to divide  a portion of the plantar fascia, or of the muscles
of the  sole of the foot.   As soon after the operation as it can  be done
without causing too  much pain, some  apparatus should be applied to ex-.
tend the callus and bring the  foot into its proper shape.   Stromeyer's font-
board is  recommended by Dr. Little, but  Scarpa's shoe, as improved by
Weiss, seems to be neater and  more efficient.  It is admirably adapted
for counteracting the threefold distortion! of talipes varus.
   II.  Weak Ankles. — In this  affection the foot is flattened, its arch is
sunk, and the astragalus  forms a projection below  the internal  malleolus,
rendering the internal border of the foot convex  instead of concave.  In
ba*d cases  the inner ankle almost touches  the  ground, and  the patient
walks with great pain and lameness.   This  affection depends on a weak-
ness and relaxation of the bones and ligaments.  It is sure to be brought
on, if weakly children are put upon their legs too soon.  It is more com-
mon amongst girls than  boys—partly from their greater delicacy—partly
because they are taught at an early age by ignorant governesses and dancing
masters, that it is necessary for them to turn their  feet out as much as  pos-
sible, as the very first step towards elegance in  dancing or walking. Thirty
years ago it was a common practice to make  school girls sit for an hour
every day in a kind of stocks, with their feet turned outwards, so as to be
almost in a straight line  with  each other.   Children, however,  if left to
nature, stand with their  toes slightly turned inwards—the position, in fact,
which is the firmest, and most calculated  to prevent this distortion whils'
the bones are yet soft and yielding.
   Treatment. — The patient should wear shoes or boots  with high heels,
and with the inner edge  of the sole much thicker than  the outer.   He
should also be directed to turn the foot  out very little, if at all.   Benefit
may also be  derived from a well-applied bandage, such as is represented
at  p. 88.   It should always be applied so as to be carried round the ankle
from the inner side of the  foot.   In severe cases the patient should wear r
tightly  fitting boot with  a piece of steel or whalebone fastened to  the sole 
516
CONTRACTION OF THE FINGERS.
 and passing perpendicularly upwards to  the  middle of the inner side «\f
 the leg.
   III. Coxtraction of the Toes.—It often happens that one of the toes
 is permrnently elevated, and rides over its neighbours,  from  the habitual
 use of narrow boots; and  the upper surface of this toe being peculiarly
 exposed to friction, is generally covered with corns so painful, that many
 persons have  been compelled  to  have the part amputated.  Division of
 the extensor tendon may,  however,  enable  the toe to  be  brought down
 into its place, and prevent  the necessity of its removal.
   IV. Bunion.—A bunion signifies  a distortion of the metatarsal joint of
 the great toe; which is thrown outwards, so that the head of the meta
 tarsal bone projects, and  forms a  swelling on the inner side of the foot.
 The skin covering it is generally very thin;  sometimes, however, thick-
 ened  from inflammation, or from the development of a  bursa underneath.
 This affection is  produced, partly  by the use of tight boots, which cramp
 the toes together, and force the great toe outwards, in  order to  make the
 foot fashionably pointed ; — and it is  partly a consequence,  as  Mr. Key
 has shown, of a weak, flattened state of the foot, which throws the extre-
 mity of that  metatarsal  bone forward, and the toe  outwards.   The liga-
 ments of the joint are thus stretched and thickened, the joint is rendered
 unnaturally prominent,  and subjected to  pressure  and  friction, a bursa
 forms over it, and there is a constant state of tenderness and pain, subject
 to fits of inflammation.
   Treatment.—The patient must  wear proper shoes, so arranged  as not
 to press  on the tender part.  Mr. Key recommends the great toe to  be
 kept in its proper place  by means  of a partition in  the  stocking, like the
 finger of a glove, and a partition of strong cow's leather fixed in the sole
 of the shoe.   But it is almost an impossibility for a  person who walks
 about to  use such contrivances.  A mercurial  plaster on soft leather often
 gives great comfort.   If the bursa  inflame, it must be treated by rest,
 leeches  and poultices, in order to  avoid suppuration and the  necessity flf
 a puncture, which is sure to lead to  an inveterate fistula; for which, Mr.
 Key says that a weak solution of creosote is the best application.*
   V.  Contraction of the Fingers generally depends on shortening and
 rigidity of  the palmar  aponeuroses and tendinous  sheaths, or on a liga-
 mentous degeneration of the cellular tissue on the palmar aspect of the
 fingers.
   Treatment.—Friction with oily  liniments, and extension upon splints,
 may be of some service.  But the following operation will be of more:—
 a longitudinal incision may be made through the skin on the palmar sur-
 face of the  first phalanx, then the edges  of the wound being held asunder,
 a curved bistoury may  be  passed under  the  contracted tissues, so as to
 divide them.  If any of the muscles of the  fore-arm  are rigid, their ten-
 dons may be divided by a  narrow  knife, as in the operation for club-foot.
   VI.  Webbed Fingers.—This is a deformity consisting of  an union of
the fingers to each other.   It  may  be congenital, or may be caused  by
 burns.  It is a most intractable affection.  Mere division of the  connect-
 ing skin is not  often of any avail, for the fingers almost inevitably grow
together again when the wround heals.  In  order to counteract their union,
 a flap of skin may either be brought from the dorsum of the hand,  and be
  * Vide Key on Bunion, Guy's  Hosp. Rep., vol. i.; and Fergusson's Practical Surgery,
 p. Vo-i. 
ULCERS ABOUT  THE NAILS.
517
 engrafted  between the fingers,—or, as Mr. Liston proposes, a perforation
 may  first  of all  be made in the connecting skin near the roots of the
 fingers, and be prevented from closing by keeping a piece of cord in it
 till the edges have healed, and then the remainder of the connexion may-
 be divided.
   VII.  Ulcers about the Nails.—1. A very common and troublesome
 affection is that  which is popularly termed " the growth of the nail into
 the flesh,"  and which most usually occurs by the side of the great toe.  It
 does not, however, arise from any alteration in the nail, as its name would
 unply, but the  contiguous soft parts  are first swelled and inflamed by con-
 stant pressure against its edge, from the use of tight shoes.  If this  state
 be permitted to increase,  suppuration  occurs,  and an ulcer is formed with
 fungous  and exquisitively sensible granulations, in which the edge of the
 nail is embedded, and which often  produces  so much pain as  totally to
 prevent walking.
    Treatment. — The objects are, to remove the irritation caused by the
 nail,  and reduce the swelling of the  soft parts.   In most cases, if the nail,
 having been well softened by soaking in warm water, is shaved as thin as
 possible  with a knife, or file, or bit of glass,  the pain and  irritation  may
 easily be allayed by rest for a day or  two, with fomentations and poultices;
 and then any ulcer that has  formed will soon heal, with the aid of  black
 wash on lint, or a touch of lunar caustic, or a lotion of a grain  of sulphate
 of copper  to an ounce of distilled water.   But if the case  is more obsti-
 nate, the edge  of the nail must be removed.   This frightfully painful ope-
 ration may be done by passing the  sharp blade  of a pair of scissors reso-
 lutely under the  nail,  cutting it  through, and then quickly tearing  away
 the offending portion with forceps.  If the complaint return after this, the
 whole nail had  better be  dissected  out, together with the  gland that
 secretes it.   Persons disposed to this  affection should always wear loose
 shoes, and keep  their nails  scraped rather  thin, so that they may be
 flexible.
   2.  Onychia Maligna is  a  peculiarly un-         Fis- 165-*
 healthy ulcer occurring at the root of the nail,
 either of the fingers or toes, but more frequently
 of the latter.   It  commences with a deep red
 swelling, and an  oozing  of a thin  ichor from
 under the fold  of skin at the root of the nail;
 and lastly, an  ulcer is formed,  with a smooth
 tawny or brawmy surface, a very fetid sanious
 discharge,  and  swelled jagged edges of a pecu-
 liar vivid  dusky  hue.   It is in  general extremely painful, especially  at
 night.
   Treatment.—Mr. Wardrop recommends mercury to be employed, so  as
 to affect the gums in about a fortnight;  and says that then the swelling
*vill generally subside, and the ulcer become clean.  The mercurial effect
 should be  continued gently till  the sore is healed, and  for a short time
 afterwards.  The best local applications are solution of arsenic,  (liq. arsei:
 3ij. ad aq.  sij.) as recommended by Mr. Abernethy, which will generally
 be found to succeed ;  solution of corrosive sublimate, (P. L.,) of nitrate
of silver, black and yellow wash, and  other compounds of  the  same de
                 * From a cast in the King's College  Museum.
44 
518                   SPURIOUS  ANCHYLOSIS.
scription.   Fumigation by means of a candle made with a drachm of ver
milion to an ounce of wax, is also useful."
  VIII. Whitlow,  or  Paronychia, signifies an abscess of the fingers
There  are three kinds: the cutaneous, the subcutaneous, and the tendinous.
The cutaneous whitlow  consists of inflammation of the surface of the skin
of the last phalanx, with burning pain and effusion of a serous or bloody
fluid which elevates the  cuticle into  a bladder.  The subcutaneous  is
attended with greater pain  and throbbing, and suppuration  under the
skin at the root of the nail, which may come off.
   Treatment.—Search should be made for foreign particles sticking in the
skin :   a leech  may be applied, and  the  part be fomented in hot water;
but if  these measures do not speedily cause resolution, a pretty free inci-
sion should be  made into the inflamed  part.   If the tip of the finger is
long painful and tender without suppurating, it should be well pencilled
with  lunar  caustic.   Aperients,  tonics,  and alteratives are  always of
service.
   The tendinous  whitlow,  or thecal abscess,  affects the  deeper  seated
tissues, and was  described at p. 213.   We may observe here, however,
that the finger should be  freely laid open with a scalpel.  If matter have
extended into the palm, the incision should be continued along the  meta-
carpal bone till it freely gushes out.  It is better not to cut into the spaces
between the metacarpal bones, (unless matter points there  very decidedly
indeed,) for fear of wounding the digital artery.   If it be necessary  to slit
up the palmar fascia, a cut should be made over the head of a  metacarpal
bone,  in order that a director may be passed under it.
   IX. Spurious Anchylosis.—In cases of spurious anchylosis,  (p. 272)—
that is to say, stiffness of joints  depending on rigidity of the surrounding
tissues,—or on permanent contraction of the flexor muscles, owing to their
having been long kept in a fixed position,—division of the tendons of the
contracted muscles  will do  much towards  restoring the  mobility of the
joint.  The tendons of the hamstring muscles have been divided by Mr.
Phillips with  great success in a case of stiffened  knee from rheumatism.
The pectoralis major, latissimus dorsi, teres major and teres minor muscles,
have   been  divided  by Dieffenbach  in  order to effect the reduction of  an
old dislocation  of the  shoulder; and the pectinaeus and  sartorius by  an
American surgeon, in a case of contracted hip.   All these operations are,
of course, to be performed by what is called subcutaneous section; that  is,
in the same manner in which the tendo Achillis  is divided.   The  muscle
or tendon must be put on  the  stretch, and a puncture be  made  on one
side of it.   Then a curved blunt-pointed bistoury may be passed under it,
and be  made to divide  it.   In many  cases it  is  necessary to divide the
fasciae under the knee,  or in the sole of the foot, as well as the tendons.
A few days after either of these operations some  apparatus must be applied
 by which gradual extension may be made.
   •Vide Lawrence, Lectures in Med. Gaz.; James Wardrop, F. R. S. E., on Diseasei
'A the Toes and Fingers, Med. Chir. Trans., vol. v. 
            PART  V.

OF THE OPERATIONS OF SURGERY.
                         CHAPTER  I.

  OF OPERATIONS IN GENERAL,  AND OF THE EXTIRPATION OF
                             TUMOURS.

  I. The Apparatus necessary for operations in  general comprises one
or more  bistouries, scalpels, or other specific cutting  instruments; — a
dissecting forceps, a tenaculum, and small  forceps (which should have a
spring or catch)  to  take  up arteries;—plenty of well-waxed ligatures,
curved needles threaded, fine  sponge, water both warm and cold, and
wine and hartshorn in case of faintness.   There should also be a sufficient
number of assistants to restrain the patient's  struggles, to administer cor-
dials, to hand the different instruments to the surgeon, or to assist him in
other respects,—besides a good light, and  a  bed or table, with pillows or
cushions  to make the patient's position as easy as possible.   Mr. W. Fer-
gusson gives the useful hint that it is desirable to have delicate  instru-
ments made  to shut in  a handle like a pocket clasp-knife; so that they
may be kept  in the  surgeon's waistcoat-pocket till they are wanted, and
that their edge or point may not be injured  through the carelessness of the
assistants.
  " The  temperature of cutting  instruments should be raised," says M.
Mulgaigne, " to that of the body; since cold metallic sounds pass with
more difficulty into  the  urethra,  and the  razor cuts  better  after  being
warmed."*
  II. Incisions.—In making incisions, there  are several points that  de-
mand attention.   First of all, the  manner of handling the knife,—which,
as systematic writers say,  may be held either  like a common dinner knife,
—or like a pen,—or like a fiddle-stick.   The first two positions are those
which are employed commonly; the third is resorted to in cutting into the
different layers over a hernial sac, and in sundry other delicate operations.
Secondly,  before  commencing an  incision, the  skin must be  gently
stretched and steadied with  the points of the  fingers, otherwise it will be
dragged  along by the knife, and the  incision will be  ragged,  and  shorter
than was intended.   Thirdly, in cutting through the skin, the knife should
be passed in  at right angles to the surface, and should be at once carried
down  to  the  subcutaneous tissue—then  the blade  should  be inclined
downwards, and be made to cut through the skin to the requisite extent,—
       ■ Malgaigne's Operative Surgery, translated by F. Brittan, Lond.  1846.
                                                        (519) 
520
avoidance  of  pain.
and lastly, as the incision is finished, the instrument must be again brought
to a right angle with the surface.  By these means the whole thickness of
the  skin will be divided,  both  at die beginning and end of the incision ;
for nothing can be more painful than a partial division  of  it.   Moreover,
the operator should always cut the skin as speedily as possible, for it is the
most painful part of every operation.   He should  also take care to make
the incision quite as long as will be required—and  rather too long than too
short.   To pause in the middle of an  operation, and cut a little more of
the skin, is most  awkward on  the surgeon's part, and  most cruel to the
sufferer.   The author has not  sufficient space to detail all  the tedious va-
rieties of incisions that are enumerated in systematic treatises.  It is of
little use to say that they may be made by cutting from without inwards,—
or by first plunging in  the  instrument, and then cutting outwards (as in
bleeding),—or  that they may be  simple or  compound—straight, curved,
or angular.   It may be noticed, however, that when two incisions  are to
be made to  meet near their extremities, (as, for example, the two semi-
elliptical incisions in amputation of the breast,)  the second should fall into
the first nearly, but not quite at its extremity, so that there may be no little
isthmus of skin left undivided between them.   Again, in making a V in-
cision, the second cut should not be begun where the first terminated, but
at its other end ; \.at  is to say, it should  be made towards the first, and
not from it.  In making a T incision  likewise, the transverse cut should
be made first, and the other be directed towards it.  Lastly, the angle of
a V incision should, if possible, be always dependent.
  III.  The Preparation of a patient for  an operation is a  most important
element  in  its  success.   The  object is  to  have every organ  and  every
function in as healthy a state as possible,  and vascular action  a little, but
not too  much below par.  For the full-blooded and inflammatory, bleed-
ing will be requisite, and in all cases recourse should be  had to abstinence,
aperients, and gentle alteratives, with or without small doses of sedatives,
till the pulse has become quiet, the  tongue clean,  the bowels  regular, the
liver, kidneys, and skin in good order, and the mind cheerful.   Moreover,
it is  best not to perform  an operation in very cold weather, if it can be
avoided, especially upon the eye.«  It  has also been recommended, and
the recommendation seems  rational, that  the patient should be made to
keep his bed for two or three days  before an  operation, in order that he
may become accustomed to  the confinement.*
  IV.  The Avoidance of Pain.—This, -we need scarcely say, is an ob-
ject  of  the highest importance ; not  merely in  order to  lessen the amount
of physical suffering attending operations,  but also because severe pain has
a most serious tendency to depress the nervous system, and induce death
from exhaustion ; and because  many patients have so great a dread of the
knife that they  put off applying to the surgeon till their case has become
almost hopeless.  Up to the end of 1846  we knew of no means for effect-
ing this very desirable object save the previous administration of narcotics,
and long-continued compression of the  nerves supplying  the part to be
operated on; means, both of which are  so  uncertain and  inefficient that
scarcely any one  ever  thought of employing them.   We do  not include
Mesmerism in the list, because  this  so-called science is  so intimately con-
  • Dr. Norman Chevers, and  Mr. T. Wilkinson  King, have shown that in most cases
->t death  after operaiions, one of the great depurating organs of the  blood—either  the
liver cr kidneys—is diseased. 
INHALATION OF ETHER.
521
nected with quackery, obscenity, and imposture, that very few respectable
persons would consent to meddle with it, even for a good purpose.
   Whilst, however, this work was being printed, there arrived from Bos-
ton, in America, the account of a method of rendering patients insensible
tc oain  during operations by means of the vapour of ether.   This method,
whi,-h was invented by Drs. Jackson and  Morton,  of Boston, was  first
promelgated in England in January  1847, by Dr. Boott of Gower Street;
and some trials having been  made,  with favourable  results, it has, in the
short space of time which has elapsed since its introduction, been used by
almost every surgeon in the kingdom, in every possible variety of case,
and with very favourable effects.
   The operation consists in  making the patient inhale the vapour of ether,
mixed with  more or less atmospheric air.   To effect this, already a legion
of instruments have been devised, as may be seen by referring to the me-
dical periodicals for January, 1847.  They consist, for the most  part, of a
vessel containing sponges saturated with ether;—having one aperture for
the admission of air, and  another communicating with an  inhaling tube,
through which the patient inspires the  air mixed with the vapour.  The
inhaling tube should be provided with a  valve to prevent any of the air
expired  from the patient's lungs from  being breathed back again into the
vessel, and with an aperture to  admit of its escape.   It wrould be impossi-
ble to describe all, and invidious to  describe a few of the various appara-
tus that have been devised.   A pickle-jar, provided with a good cork,
through which pass two glass tubes,—one  straight, and going down to the
bottom of the jar,  for the ingress of  air,—and another curved, for the in-
haling pipe;  this,  having a piece of lint  at the bottom  soaked in ether,
would serve  to make the experiment.   Mr. Alfred Smee has shown the
author one wiiich  is very compendious and portable; and which has a
compartment holding hot water, for the purpose of  vaporizing the ether
more quickly.   Other  forms have  been devised by Mr.  Squires, Mr.
Hooper, and Dr. Snow, and they are multiplying daily.
   Whatever apparatus  be used, it  is  desirable  to administer the vapour
rather slowly at first; and to  encourage the patient to make deep inspira-
tions through the  tube, in  spite of the cough and  feeling of suffocation
which are often occasioned on  the first trial.   Then,  if the operation suc-
ceeds nicely,  the  patient may generally be observed to become a little
flushed in the face; the veins of the forehead turgid; the eyes  suffused,
and staring open,—the pupils dilated;  and,* at the same time there is more
or less perfect insensibility to external  impressions, so that any operation
may be  performed without being felt.
   Dr. Plomley, of Maidstone,  who has made  many experiments with the
ether, both on human patients and on animals, and has also  several times
inhaled  the vapour himself, divides the  effects into  three stages.   " The
first is merely a pleasurable feeling of half-intoxication; .the second is one
of extreme pleasure ; being similar to the sensation produced by breathing
nitrous oxide or laughing gas.   There  exists in this  stage a perfect con-
sciousness of everything said  or done, but generally an impossibility of
motion; in this stage, also, there is  not exactly an insensibility to pain,
but  rather  an indifference, a ' care-for-nothing' sort of feeling; and, if
surgical operations are done in  this stage,  the  patients almost always re-
cover before the operations are complete, and the results are unsatisfactory
__'Phe third stage  is one of profound intoxication and insensibility.  The
       44* 
522
INHALATION  OF ETHER.
 individual is completely lost  to  pain  and  to  external impressions ; the
 muscles become  prostrate, the circulation  lessens,  and the temperature
 falls;  but the mind is often revelling in the most pleasurable regions, as in
 a dream."*
   There can be no doubt but that the etherial vapour is received into the
 blood, circulates in the brain, suspends  sensation and voluntary motion,
 and, in fact, produces a very profound, but very transient state of intoxica-
 tion.    The pulse (which  is generally rather excited  in persons who are
 screwing up their courage to undergo an operation) becomes first quick-
 ened,  but sinks as  soon as the state of insensibility is produced.  The
 time in wiiich the stupor comes on varies, according to the nicety of the
 arrangements for the inhalation,  from  three minutes to a quarter of an
 hour;  and  generally lasts about  five minutes; and when  it departs the
 patient awakes as from a dream, and usually suffers no other ill  effect than
 slight  confusion and giddiness.
   The cases in which the  etherization has been effected, and for which it
 is adapted, comprise, of course, all surgical manipulations, from the  ex-
 traction of a tooth or the  operation  for strabismus  to amputation at the
 hip-joint, or the Caesarian  section.  It  is available,' moreover,  under any
 circumstances in which  any surgical  proceeding is liable to be frustrated
 through the irritability or restlessness of patients;  such as the introduction
 of the  catheter throifgh painful  strictures,  the reduction of dislocations, the
 obstetric operation of turning,  and all  examinations attended with pain.
 It probably will be found useful, likewise, in several  nervous and  painful
 diseases, but it has no effect on the involuntary contraction  of the bladder
 and womb.  We are rather disposed to recommend it to be carried to the
 second degree only for most purposes, or at least so as  only just to touch
 the third degree; since  surely a state of  delicious insouciance  is quite a
 sufficient substitute for  the horrors of tooth-drawing, without  going the
 length of inducing absolute coma.   If the effect  passes off, it  is  easy to
 administer a little more of the vapour.   On the  other hand, should the
 pulse become too low (and some one ought  to  keep his finger on it  the
 whole  time,) a little wine  should  be given.  The operator may generally
 begin as soon as the pulse sinks and the patient can be pinched sharply
 without complaining.
   Some cases there have been in which this  operation has failed.  In
 these,  probably, there was some defect in the way of applying the vapour.
 In others there have been sundry untoward  occurrences.  One  of the
 slightest of these is the production of a kind of noisy and  furious  intoxi-
 cation  ; which generally happens when  the patient is scarcely etherized in
 the second degree,  and soon passes off without  any harm.   Another, and
 a more serious one, is the occurrence of a deep and obstinate state  of nar-
 cotism ; with  feeble pulse, slow respiration, and  cold skin, caused by a
 too protracted inhalation.  This must be treated by friction, cold affusion.
 sinapisms to the feet, and removing the  patient into fresh air.  The  authoi
 has heard of haemoptysis as an  unfavourable  result, that happened in  one
 instance; which is not much to be wondered at,  considering the  highly
 irritating effects of the vapour in  the lungs: and, of one  other case, in
which  death was  decidedly caused.   No  doubt some  such  cases will be
heard of; but somehow unlucky cases are  seldom put forward  with very
great promptitude
                       • Lancet, January 30th, 1847. 
EXTIRPATION  OF  TUMOURS.
523
  In conclision, the author would advise that this experiment should not
be tried on young children, or on persons disposed to organic diseases of
the brain, or heart, or lungs ; and it is as well to hint at the disastrous re-
sults that might ensue if the ether or its vapour came in  contact with the
flame of a candle.
  It does not seem advisable, on the whole, that the etherization should be
tried in any case in which the amount of pain or irritability is not likely to
cause any obstacle to the operator, or danger to the patient.
   [Since the employment of ether as an anaesthetic  agent, several  other
substances have been found productive of similar effects;—such as ben-
zoin, the  nitrate  of ethyle, aldehyde, ohloroform.  Of these the last is
most used, as being more manageable, though perhaps not more powerful,
than the others.
   Professor Simpson of  Edinburgh is the first who employed chloroform
as  an anaesthetic  agent: his paper on the subject was read before the
Medico-Chirurgical  Society of Edinburgh, Dec. 1st, 1847.  It has now
been  extensively resorted to both in this country and in Europe.   As to
the capability of this agent  to annul pain caused by surgical operations
and by disease, there can be no question ; indeed it is generally conceded
to be more powerful than the ether, in the ratio of 8 to 1; the former pro-
ducing a condition of insensibility to pain in from 30 to 40 seconds, while
the latter operates in an average period of 4 minutes; from 30  drops to
3i of chloroform are in general sufficient to produce the  desired  effect.
The greater activity of  the chloroform, as compared with ether, would
very naturally suggest increased caution in  using it, and the inference is
strengthened by the knowledge that death  has  been caused by its incau-
tious  employment.  It is inhaled in the same  manner, and the  same or
greater care should be taken  during its  administration, as when ether is
exhibited.   The best antidotes to the poisonous  effects of  both  are fresh
air, the dashing of cold  water upon the  face, and artificial  respiration if
necessary.
   For some interesting and valuable  statements  on  the use of anaesthetic
agents, the  reader is referred to the report of the Committee on Surgery of
the Am. Med. Association.—Ed.]
   V. Extirpation of Tumours.—A different proceeding is to be adopted
in the case of malignant and of simple growths.   In the former  it may be
necessary to remove a portion of skin by two semi-elliptical incisions, if it
appears to be contaminated by the diseased growth.   But in extirpating
wens of fatty or sarcomatous tumours, however large, it  is a general  rule
not to remove any of the skin, unless it is much  inflamed or ulcerated, or
so entirely adherent to the tumour that its separation would  be very tedious
and difficult.  Again, in the former case it is necessary to  cut quite wide
of the diseased mass, and remove plenty of the  surrounding tissues,—in
the latter case the incisions should be carried through the cellular cyst of
the tumour.  In all cases it is a better plan (unless the tumour is exceed-
ino-lv large) to carry the dissection at  once boldly  to the deepest  part
where the largest vessels enter the tumour, than to tie the different branches
as they are  divided,—by which means some vessels may perhaps be tied
more than once.   Again, it is requisite  in every case that the extirpation
be  complete, because if the smallest portion is left, it may become the nu-
cleus of a fresh growth.   If, therefore, it is found that there is any portion
of a tumour which cannot be cut out without  fear of ''angerous haemor- 
524
VENISECTION.
rhage, a double ligature should be passed through  its base, and be tied
tightly on each side of it.
  The following very ingenious knot for strangulated tumours with broad
bases was communicated to the author by  Mr. Fergusson.   A needle,
                     armed with a double thread, is thrust transversely
                     under the centre of the tumour.   The centre of the
                     thread, which has  the  needle in it, is then divided.
                     Next, one end of the thread  is passed through the
                     eye of the needle, which eye should be  near  its
                     point, and,  having been  brought one-fourth  round
                     the  circumference  of  the tumour, is thrust  trans-
                     versely through its base.   Then it is to be  disen-
                     gaged from  the  eye  of the needle,  and the other
                     thread  to be put  into  the eye, and to  be  carried
                     back with h>  Lastly, the adjoining ends of the two
                     threads are to be  tied tightly ; so that each of the
two threads shall include an 8-shaped portion of the tumour.
  VI. Air in Veins.—The entrance of air into  a vein is a most  dangerous
accident, that has sometimes occurred  during the extirpation of tumours
from the  neck or axilla.  A large vein being cut across, whose coats ad-
here to some firm  textures around, so that they cannot collapse, a sort  of
bubbling,  sucking noise is  suddenly heard,  the patient instantly faints,
and  generally dies soon afterwards.  On examination, the heart is found
distended with air.   If any such sound  should be  perceived  during  an
operation, the surgeon  should  instantly  put  his finger on the spot  that it
proceeds from,—and the patient, if faint, should be kept in  the recumbent
position, with the head low; and should be well supplied with stimulants.*
[In operating  in the  neighbourhood of large veins, as  in  the  neck, it is
advisable to press with the finger upon the course of the vein between the
intended incision and the heart:  this simple precaution may prevent the
ingress of air entirely.—Ed.]
                         CHAPTER  II.

                   OF THE MINOR OPERATIONS.

   I. Venisection at the bend of the arm should always, if possible, be
performed  in the median-cephalic vein.   A ligature being placed a little
above the elbow, (but not tight enough to stop the pulse at the wrist,) the
operator takes the fore-arm in his hand, places his thumb on the vein a
little below the  intended puncture,—and  then (using the right  hand for
the right arm,  and vice versa)  pushes the lancet obliquely into  the vein,
and  makes it cut its way directly outwards.  When sufficient blood has
been taken, the surgeon should untie the ligature above  the elbow, and
place his thumb on the bleeding aperture.  Next he should put a little bit
of lint on the wound, and secure that with a strip of plaster, only removing
  * For the best account of these curious cases,  refer to Sir C. Bell's Practical Essays,
Lond. 1841.
 
VENISECTION.
525
his thumb sufficiently to admit of the application.  Then he removes his
thumb enough to  put on a little square compress of linen, over which he
Fig. 167«
Fig. 168.f
places the middle of a bandage.  This is to be passed round the elbow
in the form of a figure of 8, and the two ends are to be crossed and turned
backwards over the compress.  Fig.  169  is intended to show the way
in which the surgeon should  grasp the arm, and keep his thumb over the
bleeding aperture till the bandage is secured.
  The jugular vein is sometimes opened in  cases of apoplexy in adults,
and in children, if the veins at the elbow are hidden by fat.   The patient,
if a child, being laid in a nurse's lap, with his head towards the surgeon,
the latter puts  his left thumb  on the vein a little above the clavicle, and
then opens it with a lancet, cutting towards the thumb, and in a direction
downwards  and  inwards, so  that the incision may cross the  fibres of the
platysma.   When blood enough  has been taken, the wound should be
closed  with lint and plaster,  and not  till then should the  thumb be
removed.

  * [The veins of the forearm and bend of the elbow.  1. The radial vein.  2. The
cephalic vein.  3.  Anterior ulnar  vein.  4. The posterior  ulnar vein.   5. The trunu
formed by their union.  6. The basilic vein, piercing the deep fascia at 7. 8. I he me-
dian vein  9. A communicating branch  between  the deep veins of the forearm and
the upper part of the median vein.  10.  The median cephalic vein.  11. The median
basilic  V> A slight convexity of the deep fascia, formed by the brachial artery.  1 his
fa^ia is divided  and turned aside  in fig. 168, to show the brachial artery.  13. Ihe
process of fascia, derived from the  tendon of the biceps, and separating the median
basilic vein from the brachial artery.  14. The external cutaneous nerve piercing the
leen fa«cia, and dividing into two branches, which pass behind the median cephalic
,-ein    15  The internal" cutaneous nerve, dividing into branches, which  pass in front
of the median basilic vein.  10.  The intercosto-humeral cutaneous nerve.  17. The-
spiral cutaneous nerve, a branch of the musculo-spiral.]
  + This cut shows the veins of the bend of the elbow, together with the relation of tho
 ,ia-Hal artery to the median basilic vein. 
52b
CUPPING.
  The veins in the leg, scrotum, or neighbourhood of the eye or ear, can
readily be opened  in the same  manner, instead of the ordinary ventesec-
tion, or leeching, or cupping.

                               Fig. 169.
  Abscess  in  the cellular tissue,  inflammation  of the fascia,  phlebitis,
neuralgia, varicose aneurism, and aneurismal varix, are occasional ill con-
sequences of venisection.
  II. Arteriotomy. — The temporal artery should be  opened above the
outer angle of the eyebrow—not just above the zygoma.  The surgeon
feels for the largest branch, steadies it with two fingers,  one placed above,
and the other below the intended puncture — then pushes in the lancet in
the  same manner as in venaesection.  The incision should be  directed
across the vessel, and should cut it about half  through.  When sufficient
blood has flowed, the  best plan is to introduce the  lancet, and cut the
vessel  completely across, so that its ends may  retract.   A firm graduated
compress should then be applied, and be confined with  a bandage passing
round  the head; and some degree of pressure should  be kept up on the
wound for a week  or  ten  days.   Any subsequent bleeding or  spurious
aneurism must be treated by completely dividing the artery, if  it has not
been done already, and  by pressure,—but if the wound is much inflamed
or ulcerated, so  as not to admit  of pressure, a transverse incision should
be made on each side of it, and  the artery be tied in both places.
  III.  Cupping.—The  patient being placed  in a comfortable position,
with fowels arranged so that  his clothes may not be soiled  by the blood,
and being moreover protected from cold, so that the flow of blood to the
surface  may not be checked, and the  operator having his scarificator,
glasses, torch,  spirits of wine,  lighted candle, hot water, and sponge, con-
veniently arranged on a table  close by, — the  first  thing is to sponge the
skin well with  hot water, so as to make it somewhat vascular.   The ope-
rator next dries it with a warm towel, and adapts his  glasses to the part.
Their number  must depend on the  quantity of  blood to be  taken — from
three to five ounces is a fair calculation for each glass.   In the next  place,
he dips the torch in the  spirit, sets it on fire, introduces it for half a second
into one of the glasses, and immediately claps  the latter on the  skin—and
the same with  the other  glasses in succession.  As soon as the skin has
become red and swollen, he charges the scarificator, and takes it between
nis  right forefinger and thumb, at the same time holding the lighted torch
between  the little and ring fingets of the same hand.   He then detaches 
                ACUPUNCTURE--ISSUES--CAUTERY.            527

one glass by insinuating the nail of his left forefinger under its edge — in-
stantly discharges the scarificator on the swollen skin, and as expeditiously
as possible introduces the torch into the glass, and applies it again,  'fhe
same process is repeated with the other glasses.  When they become
tolerably full,  or the blood begins to coagulate in them, they must be  de-
tached  in  succession and re-applied, if blood enough has not been taken
— and when  the operation is finished, the wounds should be closed with
lint  and plaster.  There are several points connected with this operation
that require notice.   In the first place, the glasses must not be exhausted
too much ;  if they are,  the pressure of their rims  will occasion severe pain
— the blood will not flow — and the operations will very probably be  fol-
lowed  by a  considerable ecchymosis.   Secondly,  the position of  the
glasses must  be slightly varied each time they are applied, so  that their
edo-es may not again press on the  same circle of skin.   Thirdly, the expe-
diency of not burning  the patient needs scarcely be hinted  at.   Fourthly,
in taking off  the glasses, the upper part of each should be detached first,
so that the blood may  not escape.  Lastly,  the length of the scarificators
 must  be adjusted to the thickness of the skin; for if the incisions are too
 deep, the fat  will  protrude  through them, and prevent the flow of blood.
 The direction of the incisions should correspond  to the course of the mus-
 cular fibres beneath ; but this is  of no great consequence.  For cupping
 on the temples smaller glasses  and scarificators are employed.   A branch
 of the temporal artery  is generally wounded, and the flow Qf blood  may
 be expedited by slightly lifting the lower  part of  the  rim of the glass.
 Pressure  should be  kept up  on the wounds for some days afterwards, in
 order to prevent secondary haemorrhage or false  aneurism.
   IV.  Acupuncture is easily performed by running in five or six needles
 with a rotary motion.   It is certainly very efficacious in  some cases of
 neuralgia, but it is by no means easy  to explain  its operation.   Acupunc-
 ture is also resorted to in anasarca, when the skin is much distended; —
 and we have spoken  of its  utility in ganglion,  hydrothorax, and ascites,
 for the purpose of permitting the  serum to exude into the cellular tissue.
   V.  Issues  may be made by caustic or by  incision, or by the actual cau-
 tery.   The first may be  made either by rubbing a  portion of skin of the
 requisite  extent with the potassa fusa, or by making a paste with equal
 parts  of the potass and soft soap,  and laying it on the skin  till the latter is
 converted  into a black slough.   The parts  immediately around the issue
 should be protected with several  layers of sticking plaster.  After the ap-
 plication of the caustic, the part should be  poulticed till the slough sepa
 rates, and then the  sore may be prevented from  healing, either by binding
 several peas firmly on its surface, or by touching it occasionally with the
 caustic.   The  second  species of issue is made  by pinching up the skin,
 and slitting it up with  a lancet, and then introducing some peas to prevent
 it from healinc,  It may be remarked, that  issues should  never be made
 over projecting points  of bones, nor over the bellies of muscles ; for  they
 might degenerate into  most obstinate  sores.   Thus, for diseased vertebra;,
 the issues should be made between the spinous  and transverse processes ;
 __for diseased hip, behind the great trochanter,  and not over it, — for dis
 eased knee, just below the inner  tuberosity  of the tibia.
   VI. The  Actual Cautery is certainly a very efficient, and it is  very
 far  from  being the most painful,  manner  of effecting  counter-irritation.
 On the contrary, its effects  are  more speedy, and  attended with far less 
528
VACCINATION--GALVANISM.
suffering.   It is easily effected by means of an iron rod with a knob of the
size  and shape of an olive at one end of it, and a wooden handle at the
other.   The knob being heated  red hot, is rubbed on the skin so as to
make two or three blackened lines about half an inch wide, and  an  inch
asunder.  Then the cold water dressing or a poultice may be applied till
the shallow eschars separate ; — and it appears to be better to keep the
sores open by  touching them  occasionally with the cautery, than by the
ordinary irritating dressings.
   VII.  Setons are  introduced by pinching up a fold  of the skin, and
pushing a needle  through it armed with a skein of silk or cotton, or a long
flat piece  of India-rubber.   As  soon as one or two inches of the thread
are brought through, the needle is cut off.   A fresh portion of the thread
is to be pulled through the wound every day, so as to keep up a constant
irritation and  discharge.   If the discharge is insufficient,  the thread  may-
be covered with some irritating ointment before it is drawn under the skin.
   VIII. The  Moxa is a peculiar method of counter-irritation long prac-
tised in the east,  and occasionally employed in Europe, for the relief of
chronic nervous and rheumatic pains, or for chronic diseases of the joints.
One or more small cones, formed of the fine fibres  of  the artemisia chi-
nensis,  or of some other porous vegetable  substance — such as  German
tinder, or linen impregnated with nitre, are placed on  the skin  over the
affected part, and then are set on fire, and allowed to burn away so  as to
form a superficial eschar.   The surrounding skin must  be protected by a
piece of wet rag,  with a hole in it for the moxa.
   It is convenient sometimes to use the moxa as a rubefacient or vesicant,
and  not as a  cauterant.  A roll  of German tinder  ignited may be  held
with dressing forceps at a little distance  from the skin, the surgeon at the
same time blowing upon it with a blow-pipe, till the skin becomes red.
   IX. Vaccination.—The success  of this operation will depend partly
on the state of the health of the patient—for it  will most probably be de-
feated if there is any cutaneous disease or disorder of the system generally
—and partly on the quality of the matter which is inoculated.  The mat-
ter should be taken on the  eighth day, before an inflamed  areola is spread
around the vesicle,  and it should be lymph, clear and transparent, not
purulent.   The operator should make three punctures on  one arm with a
fine  lancet, carrying the point of the instrument  obliquely under the cuticle
for about  one-eighth  of an inch,  and, if possible, without drawing blood.
Then, if he has a patient to take the matter from, he ruptures a portion of
the vesicle, dips the lancet in the lymph, and inserts it into each puncture.
If he has the matter on points, he should breathe on them  so as to liquefy
it, and then insert one into each puncture,  and  allow it to remain three or
four minutes.
   X.  Electricity  and Galvanism.—Although  these powerful agents
have been by turns overrated and decried, and have lost much of their
therapeutical reputation, through having been resorted to  as the  last des-
perate remedy in  cases where it was irrational to expect benefit from them,
still  no one who knows how to  use them  can doubt their efficacy.   In
certain cases of  defective  circulation and  nervous influence ;—when the
(high is weakened  and  benumbed after  sciatica ;—in cases of atrophy of
!he extremities after fever;—when the extensors are paralyzed from long
disuse, as after disease of the joints;—in deficient menstruation ;—in dysp-
noea from weakness of the stomach ;—in loss of voice from relaxation of 
BANDAGES.
529
the mucous membrane of the fauces;—in hysterical neuralgia, and in other
causes of nervous pain  unattended with increased  vascularity, they may
be  resorted  to with  every prospect of benefit.   But the cases to which
they are most applicable, are those of asphyxia, from poisoning, or hang-
ing, when the affusion of cold water, and other stimulants, fail to excite
the action of respiration.  The best method in these cases is, to place one
wire at the nape of the neck, and the other at the pit of the stomach;  or,
if  the sensibility is so feeble that this fails to take effect, a needle may be
inserted deeply between the eighth and ninth ribs on either side, so as to
reach the diaphragm, and the current be passed between them.   The most
convenient apparatus seems to be a single battery on Smee's or DanielPs
principle, with a coil wound around a piece of soft iron, which is thereby
converted into  a temporary magnet, and with a contrivance for interrupting
the circuit, and giving a stream of gentle shocks.
   XL Galvano-puncture.—In obstinate neuralgia it  is a good plan to
insert two needles deeply, at two points  in the course of the nerve, and to
pass a galvanic current through them.
                        CHAPTER  III.

                          ON BANDAGING.

   T. The Art of Bandaging is so easily learned from practice, and so
impossible to teach merely from books, that in former editions of this work
we dismissed  it with as  few words as possible.   In the present edition,
however, in deference to the judgment of some of our friends, we shall
say rather more upon it; yet we  shall endeavour to avoid that  strange
complexity  which some  modern writers delight  in, who have invented
bandages with such names as " Compound-Bis-Axillo-Scapulary," " Com-
pound-Metatarso-Rotular," &c, and who seem to assume a knowledge of
millinery as well as of surgery on the part of their readers.
   II. Bandages usually consist of a strip of linen,  calico, or flannel, vary-
ing in breadth from one to three, five, or more inches, and in length from
one to six, eight, or  twelve yards.  Sometimes they are made of  India-
rubber web, or of a substance like stockings ; but, for most purposes, good
stout unbleached calico will answer.  They are generally rolled up longi-
tudinally for use, and hence have received the name of rollers.  Besides
the simple roller, there are  many compound bandages, as the T bandage,
and the many-tailed  bandage (described at  p. 259); but the latter are not
now much in use, and, like  other special bandages, are generally prepared
by professed bandage-makers.  Lastly, bandages  may often be made out
of handkerchiefs, or square pieces of linen.
   III.  Uses.—Innumerable are the properties  assigned to  various forms
of bandages by  the older writers;  hence  such names as the retentive, ex-
pulsive, uniting, dividing, recurrent, &c.   We  believe, however, that we
shall not be far from the truth if we state the chief uses of bandaging to be
       45                       21 
530
BANDAGES.
these two, viz., 1st. To keep on dressings, to protect a diseased part from
injury, and put some little restraint upon its motions; 2dly, To afford  a
support to relaxed muscles, ligaments, and vessels.  Deprive any part of
its normal support, and varicose veins and dropsical effusions are sure to
occur; and  conversely many cedematous and other chronic swellings of
the limbs and joints may often be  cured by the  proper application of
bandages alone.
  IV.  The Roller.—In applying this to any limb, the surgeon should
hold it  as represented in fig.  171, and should pass it from one hand to the
other as he encircles the limb with it.  He should begin at the  extremity
of the  limb,  applying it most tightly there, and a very little  more loosely
as it ascends.  He should unfold very little  of  it at  a time, and should
make each fold overlap about a third of the previous one.  When the
limb increases in size, he must turn the bandage on itself after the  man-
ner depicted in the cuts.
                              Fig. 170.
  V. Bandage for the Finger.—This is  a simple strip of linen, that
may be wound round the finger a few times with the requisite tightness.
We introduce the figure in order to show how to fasten it neatly without
pins or stitches, by merely splitting up the end of the bandage  into two
tails, which may be turned opposite ways round the finger, and be tied in
a bow.  This is a most convenient way of keeping dressings on the penis.

                              Fig. 171.
  VI. For the Hand.—A bandage about two inches wide may be passed
in a figure of 8 around the hand and wrist, excluding the thumb, and may
be finished by one or two circular turns round the wrist.
  VII. For the Forearm.—After applying it about the hand  and wrist
as just described, carry it up the forearm, and in every turn fold the band- 
BANDAGES.
531
age sharply and smoothly back upon itself, in such a way that  it may lie
smoothly on the limb.

                               Fig. 172.
  VIII. For the Foot.—Let the roller be first  passed round the meta-
tarsus, and then be carried u.p round the ankle, and back again round the
foot exactly as  depicted  at page 88.  The bandage  should always be
brought up on  the inner side  of the  instep, as there shown, in order to
support the arch of the foot.

                               Fig. 173.
  IX. For the Leg.—After the foot and ankle have been well enveloped
let the bandage be carried up the leg, and be turned sharp on itself on the
calf, in order that it may lie closely, and the fold not be separated.
  X. For the  Knee. — To support the knee, in ordinary cases,  a band-
age may be passed round it in a figure of 8 form, excluding the  patella.

                              Fig. 174.
If that bone  is to be covered, the bandage must be passed lightly ovei
it afterwards several times,  making  turns when  necessary to  procurr
smoothness. 
532        .                BANDAGES.
  XL  Four-tailed Knee Bandage.—When it is merely wished to keep
on dressings, or to give slight support, the four-tailed  bandage may be
used, as depicted and invented by that accomplished surgical artist, Dr.
Westmacott.   A piece of linen a yard and a half long, and eight or nine

                              Fig. 175.
inches wide, is split up in the middle at each end to within a few inches
of the centre.  The centre being then placed on the patella, the four tails
are brought under the knee, crossed, and tied two and two.
  XII. For the Groin. — Having passed a'roller round the lower part
of the abdomen, and secured it  with a stitch, bring  it in front of the
affected groin, then round the back of the thighs, next round the  abdo-
men ; and so on in a figure of 8 form, with the folds crossing each other
over the groin.
Fig. 176.
  [Or the  triangular bandage of Velpeau makes a very neat and simple
dressing for the groin.   It consists of a triangular piece of muslin, having
a band attached to its  base, for the purpose of securing it  around the
waist, and another strip secured to  its apex, which  passes  around the
upper part of the thigh,—as in the accompanying figure.—Ed.]
  XIII. For the Axilla. — In order to keep on dressings or poultices,
&c, put the centre of a common handkerchief folded cornerwise under 
BANDAGES.
533
the axilla, cross it over the shoulder, and carry the ends one before, the
other behind the chest, to tie under the opposite axilla.*

                               Fig. 177.
  XIV. For the Head.—A roller having been carried horizontally round
the forehead and occiput, and secured by a stitch, let it be  carried verti-
cally over the head  and under the  chin.  At the  point of crossing on
either side let it be secured by a stitch.  [See  Gibson's bandage for frac-
ture of the lower jaw.—Ed.]
  XV. Four-tailed Head  Bandage.—A  four-tailed  bandage  having
oeen prepared as directed for the patella, and the centre of it having been
placed on the top of the head, inclining either to the front or the back as
circumstances may require, two  of the tails may be carried back round
under the occiput, and be either tied there or be brought round the neck;
and the other two be tied under the chin.
  In bandaging  the head care should always be taken to comb the hair so
that it may lie smoothly and comfortably; and likewise to arrange  the
bandages so that the pressure may tell exactly where it is required. Fig.
178 will show what is meant.
Fig. 178.                        Fig. 179.
  XVI. Bandage for the Perinjeum.—This consists of a circular girth
for the loins; and of a piece that descends perpendicularly, and  that is
provided with a pad, covered with oiled silk; this is  divided to  enclose
            * Copied from Smith's Minor Surgery, Philadelphia, 1843.
       45* 
534
AMPUTATION OF  THE THIGH.
the scrotum or labia, and, lastly, is brought up in  two portions to be  at-
tached to the circular girth in front.  The  circular girth may be kept up in
its proper place by means of a pair of braces passing over the shoulders
This bandage is highly useful in prolapsus ani; and in prolapsus uteri from
relaxation of  the vagina; firm pressure on  the perinaeum being the great
secret of the utero-abdominal supporters that are so frequently advertised.
CHAPTER IV.
                      OF THE AMPUTATIONS.

  I. Amputation of the Thigh.—This amputation being  probably the
most important, and one  that is very frequently practised, it will  be con-
venient to describe it first; and to  embody in  the  description  of it such
general precepts as are applicable to the other amputations.
  In the first place, the surgeon should have his tourniquets, amputating
knives, saws, forceps and tenacula, ligatures, bone-nippers, sponges, and
                                       curved needles threaded, close
                 Fie-18°-                at hand on a tray, arranged in
                                       due order; and he should see
                                       with his own eyes that every re-
                                       quisite  is at  hand  before  he
                                       begins.
                                         The  next point is, to place
                                       the patient in a convenient pos-
                                       ture.    For amputation  of the
                                       thigh, the patient may be placed
                                       on a bed, or on a  table covered
                                       with a folded blanket;—the dis-
                                       eased leg should  project suffi-
                                       ciently  over the edge, and should
                                       be supported at the knee by an
                                       assistant, who sits  on  a low stool
                                       in front;—and the sound limb
                                       should  be secured to one of the
                                       legs  of the table  with  a  hand-
                                       kerchief.
                                         Then measures must be adopt-
                                       ed for compressing the  main
                                       artery,  and preventing too great
loss of blood.  This may be  done, either by pressure with the hand, or
with the tourniquet.  Pressure with the hand on  the main  arterial  trunk,
if effected by a steady assistant who  can be trusted, is sufficient  in most
cases;  and if the limb is amputated so high up that the tourniquet cannot
be applied, there is  of course no choice ;—the femoral artery must  be
compressed against the ramus of the  pubes.
  The common tourniquet consists of three parts ;—a pad, to compress
the  artery, which should be  firm, narrow, and flattish;—a  strong  band
 
AMPUTATION OF THE THIGH.
535
w/hich is buckled round the limb ;—and a bridge-like contrivance, over
which the band passes, with a screw, by turning which the bridge is raised
and the band tightened.   The pad should always be  placed so as to com-
press the artery against the bone.   The advantage of this instrument is,
that it compresses the smaller arteries as well as the principal trunk;—its
disadvantage is, that it arrests the venous circulation, and causes a greater
loss of venous blood;—wherefore, it should  never be constricted  tightly
until the incisions are just commencing.
  This, like other amputations, may be performed in two ways—either by
the circular incision—that is, by cutting round the limb  from without to-
wards the bone ;  or by the flap operation—that is, by transfixing the limb
and then cutting outwards.   The flap operation is the favourite with the
rising generation of surgeons; it certainly can be performed with much
more facility; and it enables the surgeon to select a flap where he pleases,
so that when the  flesh on one side of the limb is  destroyed by disease or
injury, the end of the stump may be covered with a flap taken almost en-
tirely from the sound side, and  a greater length of limb may be preserved.
It affords too a  greater certainty of preserving a sufficiency of flesh to
cover the  bone; and it enables  the  muscles  to be more  easily retracted,
and the bone exposed for the application of the  saw.  It entirely  avoids
the difficulty, also, which sometimes occurs  in the circular operation, of
retracting the skin when it has become adherent to the parts beneath. But,
as Sir C. Bell observes, the grand rule in all cases is, to save integument
enough  to cover the muscle, and muscle  enough  to  cover the  bone, and
not to scrape off the periosteum.  And if these things are done, it requires
ingenuity  to make a bad stump.
  (1.) Circular Method.—The  surgeon stands on the outer side  for the
left leg, and on the inner for the right;  so that he may use his left hand to
grasp and steady the part which he is to amputate.  The artery must be
compressed by  one  of the methods  before  described,  and  an assistant
must grasp the limb with both hands, so as to draw up the skin as high as
possible.   Then  the surgeon commences by putting his arm  under the
thigh, and makes an incision at one  sweep  completely round  the limb,
through the skin and fat down to the fascia.  The assistant is now to draw
the skin further up, the  retraction being  aided by a few touches with the
knife;  and then the knife, being put close to the edge  of the  retracted
skin, is  to be made divide everything down to the bone by another clean
circular sweep.   The next thing is, to separate the muscles from the bone
for another inch or two with the point of the knife, especially those con-
nected with the linea aspera ; and then the periosteum having been divided
by one more  sweep—the retractor,—a piece of linen with a longitudinal
slit in it,—is put  over the face of  the stump,  and the muscles  are to be
drawn up  with it.  Now the bone must be sawn through.  The heel of
the saw should first be  put on the bone, and it should be  drawn up so as
to make a groove, before working it downwards; it should be  used very
lio-htly,  and the last few strokes should  be excessively short and gentle,
that the bone may not be splintered.  If  it is, the  irregular part must be
removed by nippers.   The femoral  artery should  now be tied,  its  orifice
being seized and slightly drawn out by forceps;  and afterwards any large
branches that appear in  the  muscular interstices.   Then  all  compression
should be suddenly ceased, so that any arteries that are liable to bleed may
do so, and be tied at once.   Haemorrhage from large veins  may  be re 
536
AMPUTATION OF THE THIGH.
strained by elevating the stump, and making compression for a short time
with the finger.  If,  however, nothing else will do, they must be  tied.
Any obstinate oozing from small vessels should be restrained by sponging
with cold water, or perhaps by a touch with  arg. nitras.  Then  a  light
bandage may be passed round the limb above  the stump, and  the edges
of the wound should be approximated with a few strips of plaster,  with or
without sutures.  The edges are to  be brought together in a straight line,
which may be made either perpendicular or horizontal, the latter however
being probably the better plan.   The ligature  should be  left  hanging out
in the interstices of the adhesive straps.  The  patient should then be re-
moved to  bed, and  the stump be  supported on a pillow covered with oil-
cloth.   No other application will be needed save a cloth  dipped in  cold
water.   Pain may be allayed by an  opiate.  The stump  may remain as it
is for some days, the discharge  being merely wiped  occasionally from  its
surface.   But after from  four to six  days, sooner or later, according to the
quantity of the discharge and  the  feelings of the patient, the  dressings
should be changed, the straps being taken off and replaced  one by one,
with care  not to disturb the  ligatures, and the  hands of  an assistant being
employed to support the edges, and prevent their falling asunder.  At the
subsequent dressings, the points to be  attended to are, to renew the  light
bandage occasionally, which was passed round the stump soon after the
operation, in order to support the muscles, and prevent  their retraction—
to bring together the edges of the wound with  adhesive straps—to  remove
the ligatures when loose—(that on the femoral artery should not be dis-
turbed for a fortnight)—and to accelerate  cicatrization  by the nitrate  of
silver, or other stimulants, if the granulations  appear languid.
  There are a few varieties  in the manner of performing this circular ope-
ration that require a brief notice.  Some surgeons, after having cut through
the skin, dissect it from the  fascia, and turn it  back—a proceeding neces-
sary enough if this operation is performed (which it never should be) when
the cellular tissue is condensed and adherent.   Again, if the patient  is
very emaciated, the circular  incision may be carried down to the bone  at
once without  ceremony, because  in  such patients the  muscles  always
retract greatly.  Sir C. Bell recommends  the skin not to be divided  quite
circularly, but the knife to be inclined a little, first to one side then to the
other,  so  as to make two  oval  flaps.  The  same may be done  also  in
dividing the muscles.  He  further recommends that the limb should be
raised perpendicularly whilst the  bone is being sawn, so  that the saw may
be worked horizontally, by which means, he says, the bone may be  divided
more evenly, and much shorter, so that its end will be no more seen when
the stump is depressed.
   (2.) Flop  Operation.—The flaps  may be made, either from  the  inner
and outer, or from  the anterior and posterior aspects of the limb.  The
latter way is the most convenient if  the amputation is low down ;  but the
former, if it is in the middle or upper third; because the end of the bone
is liable to  be tilted forwards by the iliacus  and psoas muscles, and  to
project  between the lips  of the  wound.   In performing this operation, the
surgeon, standing  as before,* grasps the  flesh on the anterior surface of
the limb with his left hand, and  lifts it from  the bone; then passes his
  • Mr. Fergusson thinks it more convenient that  the surgeon should stand on  the outer
fide in amputating the right thigh, as it is awkward  to stoop over the sound limb;
which, moreover, is in the way of the surgeon's hand. 
AMPUTATION AT THE HIP-JOINT.
537
knife horizontally through it — carries the point over the bone,—pushes it
through the other side of the limb, as low as possible;  then makes it cut

                               Fig. 181.
its way out upwards and forwards, so  as  to make the anterior flap.  In
amputating the right leg, the knife should be passed in behind the saphena
vein.   It  is again entered on the inner side a little below the top of the
first incision, passed behind the bone, brought  out at the wound on the
outside, and directed so as to make a posterior flap in the  direction of the
dotted line.  This should be a very little longer than the anterior, because
the flexor  muscles  retract  more than the extensors, which  are adherent to
the bone.   Both flaps are  now drawn back ; the knife is swept round the
bone  to divide  any remaining muscular fibres,  and the  bone is  sawn
through.  In the same manner flaps may be made  from  the inner and
outer sides of the limb, the surgeon first grasping the flesh,  and transfixing
it, and cutting a flap on one side of the bone, then passing the knife close
to the bone  on the other side,  (without again piercing  the  skin,) and
making another flap.
  II.  Amputation  at the Hip-joint is  performed by Mr. Liston after
precisely the same manner in which he amputates the thigh. The femoral
artery being compressed, the knife is entered about midway between the
anterior superior spinous process  of the  ilium  and  the  trochanter and is
carried  across the front of the articulation, so as to form the anterior flap.
Then  the  anterior part of the capsular ligament  being cut into, and the
ligamentum teres and posterior part of the capsular ligament being divided,
the blade of the knife is put behind the neck and trochanters of the femur,
and the posterior flap is  formed.   The vessels on  the  posterior flap are
tied fast.  But this method can hardly be preferable to that of making two
lateral flaps ; — first, passing the knife completely  through  the limb on the
inner  side of the joint, and carrying it forwards and inwards, so  as to
form a flap of the adductor muscles; then cutting into the joint, and sev-
ering  the ligamentum teres, and the  muscles attached to the digital fossa
with a short strong curved knife;  and lastly, putting in the knife over the
trochanter, and  cutting downwards and  outwards,  so as  to make the
external flap.  In this manner Mr. Mayo performed this operation in less
than half a minute.  He previously tied the femoral artery below Poupart's 
538
AMPUTATION OF THE LEG.
ligament; but most authorities prefer compressing it during the operation,
and tying its cut orifice afterwards.
   III. Amputation  of the  Leg.—The rule  generally given is, that this
operation should  be performed  as near the  knee as possible, unless the
patient can  afford  an artificial foot; because a labouring man would find
it very inconvenient  to  have  a long stump trailing after him ;  as it would
if  he  rested  on the bent knee  with  the ordinary wooden  leg.   But a
wooden leg may be  procured, which is light and inexpensive, and which
enables the patient to rest on the stump and to have the use of the knee ;
and therefore it is  better not  to  sacrifice more of the  limb than can be
avoided.
   (1.) Circular Method.—The artery being under command, as in ampu-
tations of the thigh, and the  leg being placed horizontally, one assistant
supporting it at the ankle, and another holding it at the knee  and drawing
up the skin, — the surgeon (standing on the  inner side for the right leg,
and vice versa) makes a circular incision through the  skin, four inches
below the tuberosity of the tibia.   The  integuments are  next to be dis-
sected up for two  inches, and turned  back;  and the muscles are to be
divided  down to  the  bone by a second circular incision.  Then a  long
slender double-edged knife, called a catline,  is passed  between the bones
to  divide the interosseous ligament and muscles, and both  bones are sawn
through  together,  the  flesh being protected by a retractor, which should
have three tails.   The spine of the tibia, if it  projects  much, may be re-
moved with a fine  saw or bone nippers, and care should be  taken not to
leave  the fibula longer than the tibia, or it will  give much trouble.   The
anterior and posterior tibial and  peronaeal arteries, and any others requir-
ing it, being tied, the stump is to  be  treated  as directed after amputation
of the thigh.  The integuments should be put together, so as to make a
perpendicular line  of junction.

                               Fig. 182.
  (2.) But it is agreed  on all sides that the flap operation is by far the
best for this situation, and the easiest way of  performing  it is as follows.
— The  surgeon passes his  knife horizontally behind both bones  at the
level of an inch below the head  of the fibula, and cuts downwards and
forwards, so  as to make  a flap of the posterior muscles about four or five
iuches long.   A semilunar  incision,  with the  convexity  downwards,  is 
AMPUTATION OF  THE ARM.
539
hen made across the front of the limb, the skin is slightly turned back,
the parts between the bones are divided, and the bones are sawn as before.
But the manner in which Mr. Fergusson performs this amputation renders
it  by far the most elegant and expeditious operation which the author
ever witnessed.  He first places the heel  of the knife on the side of the
limb farthest from him, and draws  it across the front of the limb, cutting
a semi-lunar flap of skin ; when its point has arrived at the opposite side,
it  is at once made to transfix the limb; — this stage of the operation is
represented in the preceding cut; — and then the flap is  cut, as above
directed.  When transfixing the right limb, the surgeon must take great
care not to get his knife between the two bones.   When the operation is
performed high up, the popliteal artery will be  divided instead of the two
tibials.  The tibia, however, should never be sawn higher than  its tuber-
osity, or the joint will  be laid open.  The amputation may be performed
near the ankle in the same manner.  If  low down, the tendo Achillis will
require to be shortened after the flap is made.   The flap is to be brought
forwards, and confined by a stitch or two, the line  of junction  being  of
course horizontal.
   IV.  Amputation of the Arm.—In amputation of the upper extremity,
the flow of blood may be  sufficiently  commanded  by compressing the
artery above the clavicle, or in the arm.  If it is thought proper, however,
the tourniquet may be  applied so as to compress  the artery against the
humerus.
                               Fig. 183.
  (1.)  Circular.—The arm  being held out, and an assistant drawing up
the skin, one circular incision is made through the skin, which being forci-
bly retracted, another is made down to the bone.  These incisions should
be made with two slight divergences, so  as  to  cut the skin  and muscles
rather longer in front and behind than at the sides.  The subsequent steps
are precisely similar to those in amputating the thigh.
  (2.)  Flaps.—The knife is entered at one side, carried down to the bone,
turned over it, brought out at a point opposite (the vessels being left behind'
for the second flap), and then made to cut a neat rounded anterior flap two
or three inches long.  It is next carried behind the bone, to make a pos-
terior one  of equal length ;  and  is lastly swept round  the bone, to divide
any remaining fibres.   The division of the bone, ligature of the arteries,
and treatment of the  stump as before. 
540
AMPUTATION OF  THE FOREARM.
  V.  Amputation at the Shoulder may be performed in  several man-
ners.   (1.) The patient being seated in a chair and well supported,—or,
which is better, being placed on a firm table, with  the  shoulder elevated,
and projecting beyond its  edge,—and the  subclavian artery being com-
pressed, the surgeon enters a long straight knife at  the  anterior margin of
the  deltoid muscle, an  inch below the acromion.  From this point, he
thrusts it through the muscle, across the outside of the joint, and brings
out the knife at the  posterior margin of the axilla.   If the left side is ope-
rated on, the knife must be  entered at  the posterior margin  of the axilla,
and be brought out  at the anterior margin of the deltoid muscle.  Then, by
cutting downwards  and outwards, the external flap is made.   The origins
of the biceps and triceps, and insertions of the infra and supra spinatus,
are  next cut through, and the joint is laid open.  Finally, the blade of the
knife, being placed  on the inner  side of the head of the bone, must be
made to cut the  inner flap.
  (2.) The covering for the exposed part of the scapula, in the preceding
operation, was obtained from the deltoid.   But it may also be obtained
from the muscles in front or behind, supposing the deltoid to be implicated
in the disease or injury which demands the  operation.   One elliptical in-
cision may be carried from beneath the middle of the acromion to the pos-
terior border of the  axilla, and another to the anterior border.  These flaps
being dissected up,  the head of the bone may be turned out of the socket,
and the remaining soft parts be divided; or the bone may be sawn through
just beneath its neck.  An assistant  should  be directed to grasp the flap
which contains the  axillary artery as soon as it is divided; because the
pressure above the clavicle is generally not sufficient to stop the circulation.
  VI.  Amputation at the Elrow is performed by passing the  knife
through the muscles in front of the joint, and cutting upwards and forwards,
so as to make a flap of them.  Then the operator (who stands on the inner
side for the right arm, and vice  versa) makes a transverse incision behind
                                   the joint.  He next cuts through the
              Fig. 184               external lateral ligament, and enters
                                   the joint between the head of the ra-
                                   dius  and  external condyle, then
                                   divides the internal lateral ligament,
                                   and, lastly, saws through the olecra-
                                   non, the  apex  of which, with the
                                   triceps  attached to it,  is  of course
                                   left in  the stump.
                                     VII. Amputation of the Fore-
                                   arm should  always be  performed
                                   as near the wrist as possible.
                                     (1.)  Circular.—The limb being
                                   supported with  the  thumb upper-
                                   most, and an assistant drawing up
                                   the skin, a circular incision is  made
                                   through it down to the fascia.  When
                                   the skin has again been retracted as
                                   much  as possible, the muscles are
                                   divided by a second circular inci-
                                   sion ; the interosseous parts and the
remaining fibres  are next cut through  with  a catline ;  the flesh is  drawn
 
                    AMPUTATION  OF  THE  HAND.               541

up with a  three-tailed retractor,  one tail of which is put  between the
bones, and the bones are then to be sawn through together, the saw being
worked perpendicularly.   The radial, ulnar, and two interosseous arteries
require Mgature.
  (2.) Flaps.—The limb being placed in a state of pronation, the surgeon
makes a flap from the  extensor side, just  as  is represented  in Fig.  184;
and  he  then  transfixes  the flexor  side, and  makes  the other flap;—
taking care not  to pass  the  knife between the bones,  whilst performing
either transfixion.   The  interosseous parts are  next divided,  the  flesh
drawn upwards, and the bones sawn through.   If the tendons project,
they must  be shortened.
  VIII.  Amputation of the Wrist.—(1.)  Circular.—The skin  being
pulled back, a circular  incision is  made a little below the level of the line
that  separates  the forearm from  the palm of the hand,  'fhe external
lateral ligament is then  cut through, and the knife carried across Ihe joint,
to divide the remaining attachments.
  (2.) Flaps.—A semi-lunar incision is  made  across  the  back of the
wrist, its extremities being at the styloid processes, and its centre reaching
down as far as the second row of carpal bones.  This flap being  dissected
up,  the joint is opened behind, the lateral ligaments are cut through, and
the knife, being  placed between the  carpus and bones of  the forearm, is
made to cut out a flap from the anterior surface of the palm, as represented
in the next figure.

                              Fig.  185.
  This operation is scarcely to be preferred to amputation of the forearm
low down, as the flaps with their numerous tendons may not unite readily,
and there may be a difficulty in preserving flesh enough to cover the ends
of the bones.
  IX. Amputation of the Hand.—(1.) Amputation  of the fingers oi
thumb at their last joint may be performed thus:  The  surgeon holds the
phalanx firmly between his finger and thumb, and bends  it, so as  to give
prominence to the head of the middle phalanx.  He then  makes a straight
incision across the head of the middle phalanx, so as to cut into the joint,
and takes care to carry it deeply enough  at the sides to divide the lateral
lio-aments.   The joint being then thoroughly opened, the bistoury is cai-
ricd through it, and made to cut a flap from the palmar surface of the lust
       46 
542              AMPUTATION OF  THE FINGERS.

phalanx, sufficient to cover the head of the bone; and it is better to leave
too much than too little.

                              Fig. 186.
  If, however, the joint cannot be bent, this operation may be performed
thus:  The  surgeon holding the phalanx firmly, with its palmar surface
upwards, first passes his knife horizontally across the  front  of the joint,
the  flat surface towards it, and cuts  out the  anterior flap;  then divides
the  lateral ligaments and the remaining attachments with one sweep of the
knife.
  (2.) Amputation at the second joint of the fingers or thumb maybe per-
formed in the same manner.
  (3.) It is always expedient to save  as much as possible of the forefinger
and thumb ; consequently, in cases admitting of it,  a  flap may be made
from  the soft  parts  in front;  those  behind  may be divided by a semi-
lunar  incision, and then  the bone may be sawn through, or be cut  with
bone  nippers.
  (4.) Amputation of a finger at the metacarpal joint may be effected by
making a semi-lunar incision  on one  side  of the prominence of the
knuckle, from a quarter of an inch beyond the joint, to the middle of
the  digital  commissure  on the other side of it.  The finger being then
drawn to the other side, the extensor  tendon is cut through, and the point
of the bistoury is passed into the joint, and made to divide its ligaments.
This will allow the head of the bone to be turned out,  so that the bistoury
being placed behind  it may cut through  the  remaining attachments, and
make another flap.   This operation may also be performed by making an
incision on  one side of the joint, (as in the method just described,) and
then  bringing it across the palmar surface, and round the other side, to
terminate where it began.  The  tendons and ligaments are now to be
divided,  and the head of the bone turned out.  The digital arteries  must
be tied, and, after bleeding has ceased, the wound may be closed by con-
fining the adjoining fingers together.   It must  be recollected, that the 
AMPUTATION OF  THE FINGERS.
543
situation of this joint is full half an inch above the lines that divide the
fingers from the palm.
  (5.) Amputation of the  metacarpal bone of the thumb is performed thus:
The thumb being  separated from the  fingers, an incision must be carried
from the centre of the commissure between it and the forefinger,  down to
the  articulation with  the  trapezium.   The incision should be  inclined
rather towards the metacarpal  bone of  the thumb.  The  thumb being
then forcibly abducted, the blade of the bistoury is to be carried through
the  joint (which, it must be recollected, lies obliquely in a line extending
to the root of the little finger);  the head of the bone is to be forcibly dis-
located  towards  the palm  ; the  knife is then made to cut its way out, so
as to form a flap of the skin and muscles which constitute the  ball of the
thumb.
  When the  metacarpal bone of the  thumb alone is diseased, it should,
as Mr. Fergusson  advises, be extirpated alone, and its phalanges should
be preserved.   The  bone should  be  exposed by means of an incision
along its radial margin ; then its articulation with the phalanges should be
divided;  and lastly,  it may be  turned out  and separated from  the trape-
zium ;—taking care  not to wound the radial artery where it  passes  be-
tween the first and second metacarpal bones.
  (6.) Amputation of the metacarpal bone  of the little finger, at  the joint
between it and the unciform, is performed thus: The flesh and the in-
teguments being grasped, and  drawn away from the ulnar side of the
bone, a bistoury is passed perpendicularly through them close to the joint,
and made to cut its way downwards to a little beyond the  articulation
with the first phalanx.   The  skin of the  hand being next strongly drawn
towards the  thumb  side, the bistoury is placed on  the  other side of the
bone, (without again piercing the skin,) and carried along so as to divide
everything down to the  digital  commissure.  Then the ligaments of the
joint are to be divided,  first on  the inner, and next on the  dorsal aspect.
It is,  however, a much  better plan, if it can be  effected, to cut through
the bone by means of the saw or bone-nippers, than to  remove it at the
articulation.
  (7.)  Amputation of the head  of a metacarpal bone is effected by making
an  incision on each side of it, (as in amputation of the fingers at the joint,
but extending rather higher up,) and then
cutting through the  bone with the cut-
ting-forceps.   Mr. Fergusson recommends
the head of the metacarpal bone to be re-
moved  in almost every  instance  where
the  entire finger  is  abstracted, because
the deformity is much less.   But the part
need  not be removed high enough up to
divide  the  transverse  ligament.   Care
must be taken during  the cure, to keep
the  fingers  parallel, and prevent their
crossing at their tips.
  If  a  part  or the whole of the shaft of
one  of these  bones is  to  be removed
also,  an  incision  should  be made along
its  dorsum, to the point where  the two  former ones meet; and then the
 
544
AMPUTATIONS OF THE  FOOT.
flesh being  dissected away on  either side, the bone may he cut through
or disarticulated according to circumstances.
   X. Amputations of the Foot.—(1.)  Amputation  of the  toes at any
of their joints is performed in precisely fhe same manner as amputation
of the fingers.  In  removing a single toe from  its metatarsal  bone, the
surgeon should take care first of all to ascertain the exact situation of the
joint, which lies rather deeply.   Moreover he should not remove the head
of the metatarsal bone, as he  may of the metacarpal, because it is im-
portant to preserve the entire breadth  of the foot.
  (2.) Amputation of all the toes at their metatarsal joints — an operation
which may be requisite in cases of frost-bite—is performed by first making
a transverse incision along  the dorsal aspect of the  metatarsal  bones—
dividing  the tendons and  lateral  ligaments of each joint in succession ;
and  then, the phalanges  being dislocated upwards,  the knife  is placed
beneath their metatarsal extremities, and  made to cut  out a flap  from the
skin  on the plantar surface, sufficient to cover the heads of the  metatarsal
bones.  The arteries are to be tied, and the foot  laid on its outer side, so
that the discharge may escape more readily.
  (3.) Amputation of the metatarsal  bone of the great  toe is  performed
precisely like the operation for the  removal of the metacarpal bone of the
little finger.   It is better, if circumstances  permit, to cut through the bone,
than  to  disarticulate it from the internal  cuneiform bone, and  it may be
observed that, in dividing the metatarsal  bones of the  great or little toes,
or the metacarpal bones of the  fore or little finger, the forceps should be
held  obliquely, so as not to leave any prominent angle.
  (4.) Amputation of all  the metatarsal bones is  performed in the follow-
ing manner:  The exact situation of the articulation of  the great toe to the
inner cuneiform  bone  (to which the  tendon of  the tibialis anticus may
serve as a guide) being ascertained, a semi-lunar incision, with the con-
vexity forwards,  is made down to the bone, across the instep, from a point
just  in front of it, to the outside of the tuberosity of the fifth  metatarsal
bone.  The flap of skin thus formed being turned back, the bistoury is to
be passed round behind the projection of  the  fifth metatarsal  bone, so as
to divide the  external ligaments which connect it with the cuboid.   The
dorsal ligaments are  next to be  cut through,  and then the remaining ones,
the bone being depressed.   The fourth and third metatarsal  bones  are to
be disarticulated in  a similar manner, dividing  their  ligaments with the
point of the knife, and taking care not  to let the instrument become locked
between the bones.   The first metatarsal is next to be attacked, and lastly
the second, the  extremity of which,  being  locked in  between  the three
cuneiform, will be more difficult to dislodge.  Perhaps it may be conve-
nient to saw it across.  When all the five bones are detached, the surgeon
completes the division  of their plantar ligaments,  and  slightly separates
the textures which adhere to their under surface with the point of the knife,
and then, the foot being  placed horizontally, he  puts the blade under the
five bones,  and  carries it  forwards along their  inferior surface, so as to
form a flap from the  sole of the foot sufficient to  cover the denuded tarsal
bones.  The flap should be about two inches wide on the inner side and
one on the outer.
  (5.) Amputation may be performed through the tarsus, so as to remove
the navicular and cuboid bones, with  all the parts in front of them.   This
i.c commonly called  Choparfs operation.   In the first  place, the articula- 
AMPUTATION AT THE  ANKLE-JOINT.
545
lion of the cuboid with the os calcis, (which lies  about midway between
the external malleolus and the tuberosity of the fifth metatarsal bone,) and
that of the navicular with the astragalus—(which will be found just behind
the prominence of the navicular bone  in front of  the inner ankle)—must
oe sought for, and a semilunar incision be made from one to the other, as
in the last described operation.   The flap of skin  being turned  back, the

                               Fig. 188.
internal and  dorsal ligaments that connect the navicular to the astragalus
are to be divided with the point of the bistoury—recollecting the convex
shape of the  head of the latter bone.   The  ligaments  connecting the os
calcis and  cuboid are next divided—and lastly, a flap is to be procured
from the sole of the foot, as in the last operation.
   XI. Amputation at the Ankle-joint.—Syme's Operation.—This ope-
ration is proposed by Mr. Syme to be substituted for amputation above
the ankle, in cases where disease or injury of the tarsal bones  implicates
the astragalus and os  calcis, and for which, therefore, Chopart's operation
is inadmissible.   The principle of the operation is, that the whole of the
oones of the foot are taken  away;  and the  articular surface of the tibia,
with both malleoli, are cut off smoothly;  but the skin of the heel is pre-
served, as the best and  most natural cushion for the stump to rest upon.
Mr. Syme makes one curved incision across the instep, from one malleolus
to the other; and carries a second across  the sole of the foot.   The flaps
are dissected from the subjacent parts, which  is easily effected, except
just  at the heel;  the astragalus and os calcis, with the rest of the foot, are
-emoved, and the projections of the malleolar processes cut off with for-
ceps.  If the ankle-joint itself is diseased, a  thin slice of the lower extre-
mities of the tibia and  fibula may be removed with a saw.   The  thick
skin of the heel is then brought up to cover the  ends of the bones, and is
retained by  sutures.  It appears useful  sometimes  to  make a puncture
through the  integuments of the  heel, to  let  the discharge escape freely.
This operation has been performed very many times in Edinburgh by Mr.
Syme, and once in London by Mr. Fergusson, with very good results.
   Stumps, Affections of—I.  Secondary hemorrhage may occur under the
same circumstances  as after other  wounds, and requires no  observations
distinct from those made at pages 141 and 296
   (2.) Erysipelas and phlebitis have also  been fully treated of elsewhere.
   * Vide Lond. and Ed. Journ. Med. Science, Feb. and April, 1343; and several papers
in vhe same ably  conducted periodical for 1840.
        46*                       2k 
546
AFFECTIONS OF STUMPS.
—one of them may be suspected to be  coming  on if the patient, a few
days after amputation, is seized with a  violent shivering.
  (3.) It sometimes happens that the flesh shrinks away from the end oi
the  bone, which becomes white and  dry,  and  finally exfoliates.   The
nitric acid lotion is the best application.
  (4.) Protrusion of the bone is a  very  awkward circumstance.   It not
only greatly retards the healing of the stump, but the cicatrix when formed
is thin, red, constantly liable to  ulcerate, and  unable to bear the  least
pressure or friction.  The cause of the conical  stump, as  it is technically
called, is generally a want of skin and muscle  sufficient to cover the end
of the bone".   Sometimes, however, it arises from  spasmodic retraction of
the  muscles — especially  if they have not  been  properly supported by
bandages  during the  cure.   The remedy is simple ; the bone  must be
shortened.  This may be done  in slight cases  by making a longitudinal
incision over the  bone on the side opposite  the vessels, and sawing off a
sufficient portion of it — removing at the same time any diseased  portion
of the  cicatrix.  But if the  projection  is considerable, a second amputa-
tion is necessary.
  (5.) J\"euralgia of the stump is another very untoward event.   It some-
times arises, because the truncated  extremities  of the nerves (which after
amputation always swell and become  bulbous) adhere to  the cicatrix, so
as to be subject to constant  compression  and tension.  Sometimes, how-
ever, it is entirely independent of any morbid state  of the extremities of
the nerves, but arises  from some irritation in their  course, or from  some
irritation, centric or excentric, of the spinal cord.    Sometimes, again, no
local cause whatever is detectable;  and  the  pain is evidently connected
with an hysterical state of the system.  In any case  the symptoms are ex-
treme irritability and tenderness — paroxysms of violent neuralgic pain—
and spasms and twitchings of the muscles—which  not unfrequently retract,
and cause the  bone to protrude,  and the stump to  become  conical.
  Treatment. — (1.) Gentle friction with strong mercurial ointment — to
which a little powdered camphor or extract of belladonna  may be advan-
tageously added—or Scott's ointment, F. 66, spread on lint, and worn as
a plaster,  or  the emplastrum saponis  or plurnbi, combined with a little
belladonna or  opium—together with  change  of air, and the administration
of remedies calculated  to restore the  strength, maintain  the secretions,
and allay irritability, such as sarsaparilla with henbane;—steel in various
forms; — and  aloetic pills with galbanum — sometimes suffice to  remove
the  extreme sensitiveness of these as well as of other irregular cicatrices.
(2.)  If the pain and  tenderness  are referred to one or two  nerves  only,
their bulbous extremities  should  be  cut  down  upon and removed.   (3.)
If, however, the whole surface of the stump is implicated, or if the bone
protrudes, a second amputation  should be  resorted to.  But in the case
of young hysterical women, the propriety of a second operation  is ex-
tremely doubtful.  The cases on  record in which this practice was adopted
present no satisfactory results;  the pain was removed for  a time, but
returned when the wound healed.   It can  therefore be justifiable  only
when performed  at  the  patient's urgent request, after every local and
general remedy likely to be  of service  has been  tried perseveringly, out
in vain. 
EXCISION  OF JOINTS.
547
                         CHAPTER V.

                       EXCISION OF JOINTS.

  In  3ertain  cases  of chronic disease or gun-shot injuries of joints, an
attempt may be made to save the limb, by cutting out the joint, instead
of performing amputation.  This  operation has now been performed on
most of the joints;  and the results cannot be stated  better  than  in the
words of Mr. Blackburn,  who  says,  " that  excision  is advisable  in the
shoulder and elbow ; — that it is admissible, though of doubtful utility, in
the ankle; — and that it  is  inadmissible, except under very peculiar cir-
cumstances, in the wrist, hip, and knee."*
   Excision of the Elbow-joint is effected  in the following manner:—
The patient  sits in a chair; the  limb is held out and  well supported.
The joint is laid open by cutting through the coverings of its dorsal aspect.
If the disease is not very extensive, it will be sufficient to make  a crucial
incision — a perpendicular cut three or four inches long,  and a transverse
one at the level of the interval between the external condyle and head of
the radius.   If the  disease is more extensive, an H incision should be
made, so that two flaps can be turned up.   The ulnar nerve should be
carefully preserved, and held aside; the insertion of the triceps should be
divided, and then, says Mr. Liston, " the ends of the bones, but slightly
retained by  their ligaments, are  turned out of the  wound by flexing  the
forearm ; the soft parts are detached, as much as is necessary, by cutting
upon and  close to the bones; the extent of ulceration  or necrosis is then
well ascertained, and by the application of the saw the unsound parts may
be removed."  A copper spatula may be used to  protect the nerve and
soft parts whilst the bones are sawed.  The cutting bone forceps may be
substituted for the  saw with young patients;  and Mr. Fergusson recom-
mends the gouge to be used for the purpose of scooping away small spots
of the carious bone, which cannot be removed by either forceps or saw.
Any arteries  that require it having been tied,  the wound is  closed by two
or three sutures  and slips of plaster, and placed half-bent  on  a pillow.
The ends of the  bones will unite by  ligament, and in many cases a very
useful degree of motion will be  acquired.
   The shoulder-joint may be exposed by making a perpendicular incision
through the deltoid, three or four inches downwards from the acromion;
and another  from the extremity of the first incision upwards and  back-
wards to  the posterior border of the  deltoid.   The  triangular flap, thus
formed, is reflected upwards and backwards; the joint may be laid open ;
the head of the humerus be exposed  and  turned out, and sawn  off; and
the  glenoid  cavity of the scapula, if diseased, may  be  removed  by  the
bone nippers or gouge.   But as this operation is most frequently required
in cases of gun-shot wound, the surgeon may vary his incisions, according
to the extent and situation of the wound ; and may make them  of a V or
T shape,  or  may make a simple curved flap,  by cutting from near the co-
racoid process to an inch behind and below the root of the acromion.j
   * Guy's Hosp. Rep,  vol. i.                                 .      ,
   + The entire scapula was removed by Mr. Fergusson from a patient in King s College
 Hospital in February 1847.  The arm had previously been removed at the shoulder 
548
LIGATURE OF ARTERIES.
  These operations must of course be well considered before they are set
about.  They must neither be performed unnecessarily, in cases that  might
get well with proper local  and constitutional treatment;—nor, on the other
hand, should  they be resorted to when the  constitution has  become  ex
hausted, and the limb disorganised by long suppuration ; nor yet in cases
of injury so complicated,  that the patient would be liable to sink from th
ensuing irritation and discharge.*
                         CHAPTER  VI.

                 OF THE LIGATURE OF ARTERIES.

  It may be as well to remind the reader, that when an artery is wounded,
the wounded part  should always, if possible, be  exposed, and a ligature
be  placed both above  and below it.   If the  wound  in the superjacent
parts pass directly to the vessel, it may be enlarged in the proper direc-
tion and to the requisite extent.  If, however, the wound pass indirectly,
(from the back of the thigh, for instance, to the femoral  artery,) the part
of the vessel supposed to be wounded should be  cut  down upon in the
ordinary Way.  In both cases  the introduction  of  a probe will be a useful
guide to the seat of injury.  If the wounded part of the  artery cannot be
tied, a ligature must be placed on the main  trunk above, at the nearest
practicable point;—and perhaps it may be expedient to  place another
below to prevent regurgitation.
  I. The Common  Carotid  Artery is  generally tied  below  the spot
where it is crossed by the omo-hyoideus muscle.  The patient being placed
on his back, with the shoulders raised, and with the head  thrown back and
slightly turned towards the opposite side, an incision three inches in length
is made along the inner margin of the sterno-mastoid muscle.  This inci-
sion should be carried through skin, platysma,  and superficial  fascia, and
should terminate about an inch above the sternum. The head should now
be brought a little forwards, so as to relax  the sterno-mastoid muscle, and
the cellular tissue beneath is to be raised with  forceps  and divided ; but
any veins that are found are  to be turned aside  with  the  handle of the
scalpel, and are not to be wounded if it can be avoided.  Next comes the
thin strong deep fascia and the omo-hyoideus muscle, to  the margins of
which it adheres.  It should be pinched up slightly  with  the forceps, just
below that muscle, and  be divided by cautious  touches with the  knife,
which should be held with its flat surface towards the artery ;  and this di-
vision of the fascia should be made immediately over the  artery, the situa-
tion of  which is to be carefully ascertained with the finger.   Then  about
half an  inch of the sheath is to be opened  in the same manner,—avoiding
 joint, and a portion of the glenoid cavity and adjacent bone had been removed with it.
The patient is doing well.—March  2d, 1847.
  * For every further information concerning amputations, and  excision of joints, the
author must refer his readers to Mr. Liston's  frequently quoted Practical Surgery, to Mr.
Fergusson's Practical Surgery, and to Malgaigne's Manuel de  Medecine Operatoire,
translated by Mr. Brittan. 
CAROTID.--LINGUAL.
549
the descendens noni nerve, which ramifies upon it.  It should be opened
rather to the inner side of the artery, so that the jugular vein may not  be
interfered with.   Then an aneurism needle, armed with a single ligature,

                               Fig. 189.
is to be carried round the vessel.   It is to be passed from the outer side.
and to be kept close to the  vessel, within its sheath.   When its point ap-
pears  on the inner side, the surgeon seizes the ligature with forceps, and
withdraws the needle,—ascertains that the nervous vagus is not included
in the ligature,—and then ties it tightly in the double knot represented at
page 294.   One end of the ligature may then be cut off close to the knot,
and the other be left hanging out of the wound, wiiich is to be closed with
plaster when bleeding has ceased.  The patient  must be kept at perfect
rest in bed till the ligature separates.
  This artery  may also be  tied above the omo-hyoideus, by making  an
incision through  the skin  and platysma three inches in  length, and termi-
nating at the level of the cricoid  cartilage.   The fascia should next  be
divided on a director, in  the same manner as the layers over a hernial sac
(p. 441).   The surgeon then separates  the  cellular tissue and veins from
the  sheath, and opens the sheath and passes the ligature in the  manner
described above.
  II.  The External Carotid  may, if wounded, require a ligature; or
if many  of its branches are wounded, and  cannot be tied; but such an
operation  is  very rarely, if  ever, practised.   An incision  of the same
len<rth and direction as in the two preceding  operations should be  made
through the skin, platysma, and sheath, so as to  tie the vessel near its ori-
gin, that  is, at the level of  the os hyoides, and below the part where  it is
crossed by the digastric muscle and ninth nerve.
  III. The Lingual Artery may be tied by making a transverse inci-
sion along the os hyoides, from a Tittle below the symphysis of the jaw to
near the  border  of the sterno-mastoid muscle.   The skin, platysma, and
fascia being divided, the  artery must  be looked  for where it lies upon the 
550
LIGATURE OF ARTERIES.
 greater cornu of the os hyoides, below the digastric muscle and  ninth
 nerve.  This artery  has been tied in cases  of tumours and wounds of the
 tongue; but, considering the depth at which it lies from  the surface, the
 irregularity of its origin, and the important parts in its vicinity, it is much
 better, as  a general rule, to tie the external or common carotid.
   IV. The Facial Artery  may easily be tied  by cutting through  the
 skin and  cellular tissue that cover it where it  turns over the jaw, at the
 anterior border of the masseter; but such an operation can hardly ever be
 requisite.
   V. The Arteria Innominata has been tied in cases  of aneurism of
 the right subclavian, extending inwards as far as the scalenus.   The  pa-
 tient being placed on his back,  with the shoulders raised  and  the head
 thrown back, one incision, two inches in length, is to be made along  the
 inner margin of the  sterno-mastoid muscle, terminating at the clavicle,—
 and another across the origin of that muscle, meeting the former at a right
 angle.  The flap of integument thus formed is to#  be  turned up, and  the
 sternal  and part of the clavicular origin of the sterno-mastoid are to be
 divided on a director, which is to be passed behind the muscle, and kept
 as close to it as possible.   The cellular tissue and fat which now appear
 being  turned aside, the sterno-hyoideus, and  sterno-tbyroideus muscles
 must  be separately  divided on  a director.  A strong fascia, which next
 appears, must be cautiously scratched through, and the carotid be traced
 with the finger down to  its origin.   Then  the vena innominata being  de-
 pressed, a ligature may be carried from without inwards, round the artery,
 close to its bifurcation, taking care to avoid the vagus, recurrent, and car-
 diac nerves.
   VI.  The Right Subclavian  Artery,  in the first part of its course,
 that is  to say, between its origin from the innominata and the  scalenus
 muscle, may  be tied by an operation almost precisely similar to the latter;
 but it is the most difficult operation in surgery, and the most unsuccessful.
 This artery and  the  innominata have each been tied four or five times in
 cases of aneurism of the subclavian, reaching inwards as  far as the scale-
 nus, but with no very happy results.*
   VII.  The  Subclavian Artery of either side may be  readily tied  ex-
 ternal to the  scalenus muscle.  The patient should be laid  on a table, with
 the shoulder  of the  affected side drawn down as far as possible, and  the
 head slightly turned to the other side.  An incision must  then  be made
 above and parallel with the clavicle, th^ee or four inches in length.  It
 should  cut through  the skin and platysma, and. should extend  from  the
 margin of the sterno-mastoid to that of the trapezius.  This preliminary
 incision may be conveniently made by drawing down the skin, and cut-
 ting through  it while it is steadied on the clavicle.  The superficial fascia
 must next be divided to the same extent,  taking care not  to wround  the
 external jugular vein.   If the sterno-mastoid muscle has rather  a wide
 attachment to the clavicle, some of its fibres may be divided, to give more
room.  The succeeding steps of the operation consist in cutting cautiously
through the cellular tissue and fascia down to the outer edge of the scale-
 nus muscle.  Many surgeons tear through them with a director or blunt
silver knife.  The point of the  finger  must next be passed  along  the
  * The right subclavian was tied in the first part  of its course by Mr. Partridge, in the
King's College  Hospital, in February,  1841.  The patient died four days afterwards,
apparently from irritation of the pneumogastric nerve. 
AXILLARY--BRACHIAL--RADIAL.
551
scalenus down to the rib,—and in the angle between that  muscle and the
rib, the artery will be found.   The needle  must be passed round it from
below upwards.   If there is much difficulty with the common needle, that
of Dr. Mott  or Mr.  Weiss, with  a contrivance for separating the point,
and bringing it and the ligature round on the other side of the vessel, may
be used instead.
  VIII.  The Axillary Artery below the  clavicle maybe tied by making
a semilunar  incision, with its convexity upwards, from  near the sternal
end of the clavicle to the anterior  margin of the deltoid muscle.   The skin,
superficial fascia, and clavicular  fibres of the pectoralis major muscle, are
to be divided in succession,—avoiding the  cephalic vein and  thoracica
acromialis  artery, where  they pass between the pectoralis and  deltoid.
'fhe flap being turned  down, a strong fascia which intervenes between the
pectoralis minor and subclavian muscles is  next to be divided on a direc-
tor ;—the cellular tissue  and veins covering the vessels  are to be turned
aside;—then the axillary vein being pressed downwards, a ligature is car-
ried round the artery from below upwards.   This operation is exceedingly
difficult, and only to be performed in case of wounds.
   It is much more easy to tie this artery in  the  axilla.   The  arm  being
widely separated from  the  trunk, and the  fore-arm supinated, an incision
three inches in length is made over the head  of the humerus, between the
margins of the  pectoralis major  and latissimus dorsi muscles,  but rather
nearer the latter.  The cellular  tissue  having been dissected through so
as to expose the vessel, and the vein and nerves drawn  aside, the aneurism
needle should be passed from the inner side.
   IX. The Brachial Artery is superficial in the whole of its course,
and may be tied by making an incision  two inches in length  on the inner
border of the coraco-brachialis muscle in the upper part, and of the biceps
in the lower part of the limb.   The incisions  must be directed towards
the centre of the limb, and the cellular tissue must be divided with caution
so as not to injure  the internal cutaneous  nerve, which lies superficial to
the artery in the upper part of its course.   At the lower part of the limb,
the basilic vein must be avoided.'  It must be recollected that the median
nerve lies over the artery  in the middle  of its course,—and that the  vessel
has two venae comites, both of which must be carefully excluded from the
ligature.   Before tying the ligature, it should be ascertained whether or
not there is a high division of the artery, and whether the trunk that is ex-
posed commands the circulation  at the wounded or aneurismal  part.
   In the cases of a small  puncture of this artery at the bend of the elbow,
 from carelessness in bleeding, the surgeon  may either close the wound,
and attempt the cure  by compression—placing a  graduated  compress on
 the wound—bandaging the whole  limb—and keeping the patient in  bed
and on low diet, so as to  maintain a tranquil state of the circulation ;—or
 may at once enlarge the wound upwards and downwards to the extent of
three inches,—divide  the fascia  to the same  extent, and  tie the  vessel
above and below the wound—recollecting that the median nerve lies to its
inner  side.   There are  authorities for both  practices.   Supposing an
aneurism to follow  such  an  accident, it is better to cut into the tumour,
and tie the vessel above and below it, than to trust to one ligature at the
lower part of the arm.
   X.  The Radial Artery in  the upper third of the  fore-arm may be
 tied by making an  incision three inches in length, in a line from the bend 
552
LIGATURE OF  ARTERIES.
                     of the elbow to the thumb, through the skin ant
                     superficial  fascia,  avoiding  the  veins.  The su-
                     pinator longus  and pronator teres  being  drawn
                     asunder, and the deep fascia being divided to the
                     same  extent,  the  artery will  be  exposed, with
                     its  accompanying veins, which are to  be carefully
                     separated  before  the  ligature is passed.    The
                     aneurism needle should be introduced from with«
                     out, in order to avoid the radial  nerve, which lies
                     at a distance on the radial side.
                       The vessel  can  be  readily  tied in its  middle
                     third by making a similar  incision  through the
                     same parts on  the  ulnar border  of the supinator
                     longus, and in the lower third, by making  an in-
                     cision on the radial side of the flexor carpi radialis.
                     It may also be  tied at the back of the carpus, just
                     before it dips into the  palm between  the first and
                     second metacarpal  bones, by making an incision
                     between the tendons of the  extensor  secundi and
                     primi  internodii pollicis.  But  it  is easier to tie it
                     at the lower part of the fore-arm.
                       XI.  Ulnar  Artery. — When this  vessel  is
                     wounded in its upper third, where  it is  covered
                     deeply by  muscles,  it  is  an   undecided  point
                     whether the wound should  be dilated, — cutting
                     through or across the muscles to reach the bleeding
                     point,—or whether the lower end of the brachial
                     should be tied.  In the middle and inferior thirds
                     of the fore-arm, this vessel may be readily exposed
by cutting through the integuments and superficial fascia along the outer
margin of the flexor  carpi ulnaris for the extent of three inches.   That
muscle is then to be  drawn  inwards, the  deep fascia to be divided, the
veins to be separated  from the artery, and the needle to be passed from
within, so as to avoid the ulnar nerve which lies on the uinar side.
  In wounds of the palm of the hand, with great haemorrhage, the wound
should be  dilated, and  the bleeding vessels  be tied, unless  they  lie too
deeply.   If that is the case, methodical pressure should be resorted to—
the wound  being cleared of coagula, and  filled with lint, (which  may  or
may not be dipped in oil  of turpentine,)  and firm  pressure  being made
upon it, before and behind, in  the manner described at p. 295.   But if
haemorrhage has recurred again and again, and the  parts are inflamed  or
infiltrated with blood, the brachial artery should be tied just above the el-
bow.   If an operation  is  required at  all, it is better at once to do this,
since the anastomoses are  so numerous, that after tying both radial and
ulnar above the wrist, the  haemorrhage may still continue through the in-
terosseal arteries.
  XII. The Aorta, the Common Iliac, and the Internal Iliac arteries,
may be tied by a similar operation.  An incision from four  to six inches
in length must be made on the anterior surface of the abdomen.   It may
either be made parallel to the outer border of the rectus, or to the epigas-
tric artery—and  it should  terminate an inch  above Poupart's ligament.
The three layers of abdominal muscles are to be cautiously divided to the
 
EXTERNAL  ILIAC—FEMORAL.
553
same extent—and the fascia transversalis likewise—it being first scratched
through, so that the finger may be introduced  between it and the perito-
naeum—to divide it  upon.  The peritonaeum must now be detached by
the fingers from the iliac fossa, as far as  the brim of the pelvis, where the
external iliac  artery will be found beating—and by following this vessel
upwards, the operator will  come upon the internal or common iliac, or the
aorta.   The edges of the wound being now held asunder by copper spa-
tulae, the  artery to be tied must be separated from its vein with the  nail
of the forefinger or  the flat end of  a  probe, and the aneurism-needle be
passed  round between  it  and the vein.  It will be  recollected  that the
common iliac veins lie behind and to the right  of their respective arteries—
that the left internal  iliac vein is behind its  artery—and that the right is a
little external  as  well as posterior.  The internal iliac may require to be
tied for disease  or  injury of the glutaeal or  other branches outside the
pelvis.
   XIII. The External  Iliac artery may be  tied,  according to Sir A.
Cooper's method, by making  a semi-lunar incision  (with  the convexity
looking downwards  and outwards) from near the anterior superior spinous
process of the ilium to  the superior  angle of the external abdominal ring.
This  incision will be nearly parallel with Poupart's ligament,  and about
an inch above it. The skin,  superficial fascia, and
tendon of the external oblique having been divided,
the lower margin of the internal oblique and trans-
versalis muscles  must be  raised on the finger and
be detached  from Poupart's  ligament,—the fascia
transversalis must be carefully scratched through,
—and  then, if the finger  is passed  back under the
spermatic cord,  it will come in  contact with  the
 artery.   The dense  cellular  tissue  connecting the
 artery with the vein (which lies on  its internal and
 posterior aspect) must be scratched through, and
 the needle be passed between them.*
   XIV.  The Femoral artery may be tied in  any
 part of its course from Poupart's ligament down-
 wards,—but  the best  spot for the ligature,  when
 performed for popliteal aneurism, is just above the
 part where the vessel is overlapped  by the sartorius
 some little distance below the origin of the  pro-
 funda.    The  patient being  placed on  his  back,
 with the knee slightly bent, and the  limb turned
 outwards, an  incision  must be made  through  the
 skin in the course of the  vessel—which, it will be
 recollected, corresponds to a line  drawn from the
 middle of Poupart's ligament to the inner  edge of
 the patella.   The  incision  may commence  two
 inches below the groin, but its length must depend
 on the thickness of the parts to be  divided.   It is
 better  to make  it  too long than too  short.   The
 cellular tissue must next be  dissected down  to the fascia lata—avoiding
   * This artery was tied by Mr. Partridge, in the  King's College Hospital,  in Novem
 ber, 1846, for aneurism of the common femoral.  The patient, only 23 years old. madti
 it -ood recovery.
        47
 
554
ligature of arteries.
the saphenic vein.   If any glands  are  in the way, they should be turned
aside.   The fascia lata is now to be divided for about two inches, and the
sartorius to be gently  drawn onwards.   The artery may  now be felt, and
wiien the sheath and the  cellular tissue  over it have been raised with the
forceps and divided by cautious touches with the knife, (held with its flat
surface  towards the  artery,)—the point of the aneurism-needle is to be
gently insinuated between  the artery and the vein (which lies behind it)
The  needle should be passed from the inner side.  Before finally tight-
ening the ligature, the artery should be compressed, to  see whether the
pulsation in the aneurism  ceases, as there  might be  a double artery, or
some other irregularity in the course and distribution of the vessel.
   The Femoral artery may also be tied in the middle third of the thigh,
where it is covered by the  sartorius, by cutting on  the inner edge of that
muscle and turning it aside, and then slitting up the strong fibrous sheath
which envelopes the artery at that part; but this is a  much more difficult
operation, and it has no commensurate advantages.*
   XV.  The Gluteal artery may be tied by placing  the patient  on his
face, with the  toes turned inwards, and making an incision from an inch
below the posterior spinous process  of the  ilium, and an  inch  from the
sacrum, towards the great trochanter.  This incision should be about four
inches long.   The fibres of the glutaeus maximus having  been cut through
or separated to the like  extent, and a strong  fascia beneath having been
cut through, the vessel will be found emerging from the upper part of the
sciatic notch.   The Sciatic artery may be  found  by making an incision
through the same parts and for the  same  extent, but  an inch  and a half
lower  down.   Both  these operations are  extremely  difficult,  from the
great depth to which the  dissection must be  carried, the unyielding nature
of the surrounding parts, and the haemorrhage from the  numerous blood-
vessels  that must  necessarily be wounded.   They should  be  attempted,
however, in case  of  wounds — but for aneurisms of  these arteries, it  is
necessary to tie the internal or common iliac.
   XVI.  The  Poplitjeal artery may be tied by cutting  through the skin
and  fascia lata for  the extent of three  inches  on  the  outer border of the
tendon  of the  semi-membranosus muscle—the patient  being placed  on his
face, with his  knee straight.  On pressing that tendon  inwards, the artery
may be felt.   Its  vein, which  lies superficial and rather  external to it,
must be cautiously separated and drawn outwards,  and  the needle  be
passed between them.  This operation is very seldom performed.
   XVII.  Posterior Tibial Artery.—The operation usually  recom-
mended for tying this artery in the upper  part of the leg is performed
thus: The limb being placed on its outer side, with  the  knee bent and
the foot extended, an incision four inches in length must  be made through
the  skin and  fascia over the inner margin  of the tibia,  avoiding the sa-
phena vein.   The edge of the gastrocnemius thus exposed is to  be turned
back.   A director must  then be insinuated beneath the inner head of the
solaeus, and this muscle  must be divided from its  attachment to the tibia
The  strong and tense fascia beneath it must next be  divided in the same

   • :< When the skin and fascia have  been divided," says Mr. Fergusson,  "and some
muscular fibres  exposed, it may be doubtful to which muscle they  belong—whether to
the sartorius or  the vastus.  If to the latter, they will seem to run towards the inner
side  of the thigh ; if the former, they will pass nearly in its long axis."'—Practical
Surgery, p. 312. 
PERONEAL ARTERY.
555
manner.   Then the muscles being relaxed as much as possible by bend-
ing the knee and extending the foot, the artery may be felt about an inch
from the  edge of the tibia.   The veins are to be separated from it, and an
aneurism-needle passed  round it  from without, inwards, so as  to  avoid
the nerve.
   This operation, however, is considered by Mr. Guthrie to be so " pain-
ful, difficult, bloody, tedious, and  dangerous," that he proposes  to  reach
the artery  by making a perpendicular incision six or  seven inches  in
length, at the back of the leg, through the skin, gastrocnemius, plantaris,
and solaeus—then the fascia  will be exposed with the artery beneath it,
and the nerve  to the outer side.  Perhaps this operation cannot be spoken
of in much more complimentary terms than  the preceding one.

                               Fig. 192.
  The posterior tibial artery may be easiby exposed, in the lower third of
the  leg, by cutting parallel to the tendo Achillis, and on its inner side, for
the  extent of two or three inches, through the skin and two layers of fascia.
The cellular tissue  and  sheath of  the  vessel must next be cautiously
divided, and the venae comites having been separated from it, the needle
must be passed round the vessel from the outer side.
  This artery may also be tied behind the inner ankle.   A semilunar in-
cision, two or three inches long, is made in  the hollow between the heel
and the  ankle,  but rather nearer to the latter.   The  integuments,  the
superficial  fascia, and a  very strong tendinous aponeurosis, continuous
with the  deep fascia of the leg, must be  successively divided to the same
extent.   The sheath  of the vessels  which will be  thus  exposed must be
opened—the venae comites  separated, and  the needle  passed from  the
heel towards the ankle in order to  avoid the nerve, which lies a little
nearer to the heel.
  XVII. The Peronjeal artery may be  exposed in the upper part of the
leg  by an incision similar  to that which Mr. Guthrie proposes for the liga-
ture of the posterior tibial, only rather more  external.   For the  first few
inches of its course,  this vessel lies underneath the deep fascia—after-
wards  it lies concealed under the inner edge  oi the flexor  longus  pol- 
556                  LIGATURE OF ARTERIES.

licis, which must be turned aside to  expose it.   But this is an operation
which is enumerated rather from form than because it is of real utility.
                          The Anterior Tibial artery in the first third
       Fig 193.          of its course, where it is covered by the extensoi
                        muscles, is very difficult to reach.   If, however,
                        it is expedient to place a ligature  on it,  an inci-
                        sion four or five inches in length  must be made
                        down to the fascia, in  the  direction of a line
                        drawn from  the head of the fibula  to the  base of
                        the great toe.   The intermuscular septum,  be-
                        tween the tibialis anticus and extensor digitorum
                        muscles  must then be cut into, and the  muscles
                        be separated down to the interosseous ligament,
                        where  the  artery  will  be  found.   The  foot
                        should be moved backwards  and forwards at the
                        ankle, in  order  to  ascertain  with  exactness  the
                        junction of  the muscles.
                          Below the middle of the leg, at any point to
                        the termination of its course, this  artery may be
                        found on the fibular side of the extensor proprius
                        pollicis tendon, which must be the guide for the
                        incision.  But it lies much more  deeply in  the
                        living subject than would be  surmised from a
                        mere  dissection  of the  dead.  The coverings
                        must be divided with the usual precautions, and
                        neither the peronaeal nerve nor the venae  comites
                        should be wounded with the knife,  or be included
                        in the ligature.
                          In wounds of the arteries in the  sole of  the
                        foot, (except perhaps  of the external   plantar,
                        opposite  the base of the  little toe,) it is scarcely
judicious to enlarge the wound with the view of  securing the bleeding
point.   But methodical pressure  should be applied after the  manner
recommended at page 294; and if  that fails, the posterior tibial artery
should be tied  behind the inner ankle—and the anterior tibial on  the
dorsum of the foot likewise, if necessary.*

  * For further information on these operations, vide Manec on the Arteries ; the works
of Harrison, Liston, and Fergusson, and Brittan's Translation of  Malgaigne.
 
APPENDIX  OF  FORMULA.
                                  § I.  Tonics.

                           F. 1.  Tonic Draught with Acid.
  R. Acidi su.phurici  diluti nj v.—xv.;  syrupi aurantii f3j- i  infusi cascarillae (vel decocti
cinchonae), f3x.   Misce, fiat haustus, ter vel quater die sumendus.

                                    For Children.
  J$. Decocti cinchonae  lancifoliae  f giijfs.;  syrupi  zinziberis  f 3fs. acidi sulphurici diluti
Tf| xv.   Misce; sumatur pars quarta ter die.

                         2.  Quinine Draught with Ammonia.
  JJ. Quinae disulphatis gr. ij.—v.; tincturae opii m ij.—v.; spiritiis aetheris compositi, spi-
ritiis ammoniae aromatici, aa f3fs.; decocti cinchonae f 3*-   Misce, fiat haustus, ter vel
quater die sumendus.   In cases of great Debility, with Restlessness or law Delirium.

                           3. Quinine  Draughts, with Acid.
  R. Quinae disulphatis gr. ij.—v.;  acidi sulphurici  diluti  m v.—xv.; tincturae  aurantii,
syrupi ejusdem, aa f3j.;  aquae fgj.   Misce, fiat haustus, ter die sumendus.

  R. Quinae disulphatis gr. ij.—v.; acidi hydrochloric! TT[*-—xv.; camphorse gr. ij.; spiri-
tiis aetheris  nitrici f 3j.; tincturae cardamomi  composite  f 3j.; aquae menthae viridis  f3*.
Misce, fiat haustus, sext£i quaque hora sumendus.

                           4. Batttefs Liquor Cinchonx.*
  R. Liquoris cinchonae  flavae  flixx.; aquce  pimentae f3j.  Misce, fiat haustus quater die
sumendus.  In atonic erysipelatous diseases.

                               5.  Bark and Guaiacum.
  Ti. Tincturae  guaiaci  ammoniatee,  tincturae  humuli aa f 3fs.; decocti cinchonae lanct
foliae fgij.   Misce, fiat haustus, ter die sumendus.

  R. Tincturae  guaiaci ammoniatae f3iv.; mucilaginis  f 3f«.; tere simul  et adde decocti
cinchonae f3vi.; tinct. serpentariae f3ij.   Misce.   Dosis f3ij. bis die.

   ]5. Tincturae  guaiaci ammoniatae, tincturae cinchonae compositae singulorum fjj.  Misce.
Dosis f 3ij.  bis die e cyatho lactis.

                                   6.  Zinc Mixture.
   a Zinci sulphatis gr. vj.;  acidi sulphurici  diluti  TT| *xx.;  syrupi aurantii f3fs.: infus'
«uratitii f 3vfs.  Misce, sumantur cochlearia duo ter die.
             * O-ie fluid drnchm of tliis solution is equal to an ounce of the finest bark.
         47 *                                                         (557) 
558                       appendix of  formulae

                                  7.  Ammoniated Iron.

   R.  Ferri  ammonio-chloridi gr. xij.—xx.; sodae  sesquicarbonatis gr. xij. ;  ammoniae ses-
quicarbonatis 9j.;  syrupi  f 3fs.;  aquae destillatce  f3vfs.  Misce.  Dosis  13j,  ter die.  In
debility, with acidity and flatulence.

                                8. Chalybeate Mixtures.

   R.  Tincturae ferri sesquichloridi f 3'j-» spiritus aetheris nitrici f3ij.; sacchari 3j.;  aqusa
f3v.   Misce.  Sumantur cochlearia duo magna bis die.

   R.  Yini ferri  f 3vj.;  tincturae  ferri  sesquichloridi Tfixx.; aquae destillatce f 3vj-  Misce.
Sumantur cochlearia duo bis vel ter die.

                               9.  Steel and Acid Mixture.
   R.  Ferri  sulphatis  gr. xij.; acidi sulphurici  diluti f3j.;  tincturae  cardamomi composite
f 3ts.; infusi rosae compositi f 3vfs.   Misce ;  sumantur cochlearia duo magna bis vel ter die.


                                   10.  Steel and Bitters.

   R.  Infusi quassiae f 3fs.; tincturae  ferri ammoniati f3fs.; ammoniae  sesquicarbonatis gr.
vj.; syrupi aurantii f3j.;  aqua destillatae f3vij.   Misce;  fiat haustus, bis vel  ter quotidie
sumendus.   For hysterical women.  (Brodie.)

                             11. Citrate of Iron for Children.

   R.  Ferri  citratis gr. xij.; syrupi f3''j- i  aquae  destillatae f 3iij.   Misce.  Dosis  f3fs. ter
die.

                              12.  Solution of Iodide of Iron.

   R.  Ferri  ramentorum 3'j*' iodinii 3vj-; aquae destillatae f3xvj.   Put the iodine and
iron into a bottle, then add the water,  and having shaken them well  together, keep  the hot-
tie in a warm place for  three days.  Lastly, pour off the clear solution, and keep a coil of
iron wire suspended in it.   Dose, m xv.—f 3j- thrice daily in a little aromatic water with
syrup.

                            13. Sulphate of Iron for Children.

   R.  Ferri  sulphatis  gr. vj.; acidi sulphurici  diluti fflxij.; syrupi zinziberis f3'>j- i  aquae
florum aurantii f3nj- '■> aquae destillatae  f'3',Ks'   Misce.    Dosis t'3fs. ter die.

                              14.  Nitro-Muriatic Acid.

   R.  Acidi Nitromuriatici diluti*  f3'j>; spiritus  aetheris nitrici f3ij.;  syrupi  f 3fs.;  aquae
f 3v'j^s-   Misce.   Sumatur pars sexta ter die.   In Dyspepsia, with nasty tongue, and in-
active liver.
   ( With a dose of this it is often useful to give a pill containing half a  grain  of sulphate.
of zinc with a little bitter extract.)

   R.  Acidi Nitromuriatici diluti  f 3'j-; infusi  chirettae f3vijfs.  Misce.   Dosis, f 3jfs. ter
die.  A bitter that is  very grateful to irritable bowels.


                              15.  Sulphuric Acid Mixtures.

   R.  Acidi  sulphurici diluti foj-; syrupi aurantii f 3vj-; aquae  f3vijfs.   Misce.  Sumatur
pars sexta ter die.  A grateful refrigerant and tonic in  Debility with profuse perspiration,
in hot weather, S(C.

                               Sulphuric Acid and JEther.

   R.  Acidi sulphurici diluti  m *'•;  spiritus aetheris sulphurici compositi  f3ij-;  sacchari
albi  3fs.;  aquae  menthae viridis f3vj.   Misce.  Sumatur pars quarta, quater  die.   An ad'
mirab/e restorative after illness.

               * Cmnuosi'ii of one part of dilute nitric, and two of dilute muriatic acid. 
APPENDIX  OF  FORMULAE.
5o9
                                    § II. Aperients


                                    16.  Black  Draughts.

   R.  Sennae foliorum 3vj.;  zinziberis concisi 3fs. ;  extracti glycyrrhizae 3ij.; aquas ferven-
 lis f3'ix.   Post  horas Ires cola, et adde spiritus ammoniae aromatici f3ij. ;  tincturae sennae,
 tincturae cardamomi composite aa  f3fs.  Dosis f3jfs*


                              17.  Cordial Aperient Draughts.

   R.  Pulveris rhei,  potassae sulphatis  aa 9j.; decocti aloes compositi,  aquae menthae viridis
 aa I'ovi.;  spiritus ammoniae compositi f3fs.   Misce, fiat haustus.


   R.  Pulveris rhei 9j.;  bismuthi trisnitratis 9j.; confectionis aromaticae 9j.; aquce months
 piperita? f 3iv.; Misce.   Sumatur  pars quarta  bis die.  In habitual constipation and flatu-
 lence.

                               18.  Mild Aperient  Draughts.

   R.  Sodae potassio-tartratis 3iv.; syrupi  zinziberis f 3j-;  spiritus  myristicae  f3fs.;  aquae
 f3jfs.   Misce, fiat haustus.


   R.  Sodae potassio-tartratis 3'j-;  magnesiae calcinatae 9j.; syrupi aurantii f3j.;  aquae f3jfs.
 Misce.


   R.  Sodae potassio-tartratis 3'j- ? sodae sesquicarbonatis  9j.; sacchari albi 3j.; fiat pulvis,
 e cyatho aquae sumendus, cum cochlear!  magno succi limonis.


                        19.  Castor Oil  and  Turpentine  Draught.

   R.  Olei terebinthinae, olei ricini aa f3vj.; tincturae  sennae f3ij. mucilaginis acaciae f3ij.;
 aquae menthae quantum satis sit ut  fiat haustus.


                                 20. Aperient  Electuaries.

   R.  Pulveris potassae supertartratis, 3fs.; sulphuris prascipitati 3ij-—iv.; confectionis sennae
 3j.; syrupi zinziberis, quantum sutis sit.


   R.  Magnesiae  ustae, potassae supertartratis,  pulveris rhei, aa 3j-i  pulveris  zinziberis 3fs.;
 Iheriacae,  quantum satis est.


   R.  Mannae, confectionis sennae, aa 3j.; sulphuris 3iij.; syrupi quantum satis sit  Dosis,
 3j.—iv., onini nocte horal  somni.


                          21. Epsom Salts and Tartar Emetic.

   R.  Magnesiae  sulphatis 3j-; antimonii  tartarizati gr. j.; sp. sctht'ris nitrici  3'j-» aqu®
 menthae f3x.  Misce ; sumantur cochlearia  magna tria,  quarui  quaque hora.   An active
 nauseating aperient, fit for robust persons.


                               22. Rhubarb and Magnesia.

   R.  Pulveris rhei gr. x.; magnesiae  ustae gr. v.; pulveris zinziberis gr. ij.   Misce, fiat pul-

 vis, omni mane sumendus.


                             23. Sulphate of Iron with A toes.

   R.  Ferri  sulphatis, aloes  Barliadensis aa 3'j-! pulveris rhei 3j-   Misce et divide in  pilu
 las Ix.   Dosis,  una  vel duae hora  somni.   An  admirable  aperient for weak  constipatea

persons.^

  * This draught is greatly improved,  both in flavour and  efficacy, by the addition of a  few caraway
seeds, one ounce of buckthorn juice, one of tincture of jalap, and six  of moist sugar.
  t When the common dose of an aperient dots not act, it should he combined with a depressant, such as
antimony or ipecacuanha, if the patient is of an inflammatory habit, and with a tonic if there is a want
ol  vigour in the system. For the former state of things F. 21, or combinations of colocynth with ipeca-
cuanha will be serviceable.  For the latter, the above pills of iron  with aloes, or of compound rhubarb
r-ill with grain doses of sulphate of zinc, or of sulphate of quina with Epsom "alts and dilute sulphuric
acid, or of rhubarb with  bismuth, or of extract of colocynth with gr. l-12th of strychnia. 
oou                      APPENDIX OF  FORMl.'LiE.

                               24. Pilulae Aloes Dilutee.

  R. Aloes  Barbadensis, saponis, theriacas, extract! glycyrrhizae aa 3j.   Solve Icni calore
in balneo; dein divide in pilulas xlviij.   Dosis, una  hora somni.   A capital eccoprotic ape-
rient, unloading the colon of scybala, but rather irritating to the rectum.  The aloes should
be of the best Barbadoes kind.

                         25. Ipecacuanha and Rhubarb Pills.
  R. Pulveris ipecacuanhae gr. xxiv.; pulveris rhei  9iv.; saponis 9fs.  Misce et  divide in
pilulas xxiv.: quarum sumatur una ter die.  A gentle aperient in Piles and other congested
conditions of the intestines.

                             26.  Blue Pill and Colocynth.

  R. Pilulae hydrargyri Bj.;  extract! colocynthidis compositi 9ij.   Misce, fiant pilulae du<>-
decim.

                       27. Haustus Magnesix Sulphatis Acidus.

  R. Magnesiae  sulphatis 3j-—3'v-» syrupi aurantii  f3'j-;  acidi sulphurici diluti rrix.;
nquae anethi f3j.   Misce, fiat haustus.   To  this draught may be added, one  grain  of sul-
phate of zinc, or of sulphate of iron, or two grains of quinine, in cases of debility.

                            28.  Haustus Magnesix A/bus.

  R. Magnesiae  sulphatis 3ij.;  magnesiae  carbonatis   9j.; syrupi  zinziberis f3j.; aqusa
anethi f'3xj.  Misce, fiat haustus.  This draught will often be retained by the stomach when
almost every other form is rejected.

                         29.  Pills of Aloes and  Sulphuric Acid.

  R. Aloes Barbadensis gr.  xxiv.;  acidi sulphurici  fortissimi guttas vj.   Misce et divide in
pilulas vj. ; quarum sumantur duo, quarta quaque hora.   A  very  powerful aperient, thai
often succeeds when almost, every thing else fails.  The author is indebted for the pres •**>
*ion to his friend Dr. Dickson.
                § III.  Alterative  and  Febrifuge  Medicines.

                                 30. Saline Draughts.
   R. Potassae nitratis 9ij.; sodae  sesquicarbonatis 9fs.;  vini antimonii f3ij.;  syrup  roci,
spiritus aetheris nitrici, aa f3j-; aquee f3v.  Misce.   Dosis f3jfs. quarta quaque horfr

   R. Liquoris ammoniae acetatis f3'j-i  Misturae camphorae f 3*v-  Misce.  Dosis f3j.  joarta
quaque  hora\.

   R. Potassae bicarbonatis  9iv.;  syrupi  zinziberis f3'j-i aquae fgvfs.   Dosis fgifs. quirta
quatque  hora, cum f3fs. succi limonum recentis.

   R. Ammoniae sesquicarbonatis Bijfs.;  spiritus aetheris nitrici f3fs.; tincturae cardamomi
composilae f3fs.;  aquae anethi f3v. Misce.  Dosis f3jfs. quarta quaque hor&, cum cochleari
magno succi limonum, vel gr. xv. acidi citrici.

   R. Potassae nitratis gr. x.; sacchari  9j.   Misce, fiat pulvis, sumendus e cyatho vinario
aqua? menthae  viridis.   Green  mint water and nitre form a very agreeable mixture, ana
produce a pungent cooling sensation  on the tongue and palate.  But the salt should only
be dissolved at the moment of administration, and the mint water should be  quite cool
Attention to these trifles makes a great difference to a patient who is parched with fever.

                                  31.  Calomel  Pill.
   R. Calomelanos gr. j.—iij.;  antimonii potassio-tartratis gr. |—£; extracti  hyoscyami
\vel  conii) gr. iij. (t>e/ pulveris opii gr. £.)   Misce, fiat pilula, tertia — sexta quaque horf
sumenda. 
                            APPENDIX  OF  FORMULAE.                       561

                                   32.  Alterative Pill.
   R. Pilulae  hydrargyri gr. iij.; extracti hyoscyami (vel pulveris Doveri) gr. iij.; pulveris
^•ecacuanhae gr. j.   Misce, riant pilulae duae omni nocti sumenda?.

                                 33. Alterative  Powder.
   R. Hydrargyri cum creta gr. iij—vi.; pulveris Doveri gr. j.—v.  Misce, fiat pulvis omni
nocte sumendus.
                                 34. Alterative  Powder.

   R. Hydrargyri  cum creta  gr. ij.;  pulveris rhei gr.  v.   Misce, fiat pulvis, omni nocte
sumendus.
                           35.  Tartar Emetic with Mercury.

   R. Antimonii potassio-tartratis gr. j.; hydrargyri cum creta gr. viij.; extracti conii gr
viij.  Misce, et divide in pilulas octo ; quarum sumatur  una bis vel ter die.

                              36. Tartar Emetic  Mixtures.

   R. Antimonii potassio-tartratis gr. j.—ij.;  syrupi papaveris f3fs.; aquae destillatae fgvijfs
Misce ;  sumantur cochlearia duo magna ter die.

   R. Antimonii  potassio-tartratis gr. iij.; tincturae opii f3fs.;  aquae f3vj.  Misce.  Dosis,
cochleare unum omnisemihoral, vel  majori intervallo donee delirium cessaverit.  In Delirium
Tremens and other cases of nervous excitement in which depletion is inadmissible.—<See Dr.
Graves's Clinical Medicine.

                             37. Steel and Aloes  Mixtures.
   R. Ferri sulphatis 9j.; sodae subcarbonatis gr. xxv.;  ammoniae  sesquicarbonatis 9j.;  vini
aloes f3fs.; spiritus myristicae f3iij.; aquae destillatae f3vij.  Misce.  Dosis f3fs. ter die.

   R. Misturae ferri compositae, decocti aloes compositi partes equales.  Dosis f 3j. ter die.

                       38. Tonic Aperient and Antacid  Powders.
   R. Sodae carbonatis exsiccataa gr. v.; pulveris calumbae gr. x.; pulveris rhei  gr. ij. Misce;
fiat pulvis  quotidie, ante prandium sumendus.

   R. Ferri sesquioxydi 9j.;  sodae sesquicarbonatis gr. iij.;  pulveris rhei  gr. iij.   Misce, fiat
pulvis,  ter die sumendus.

   R. Pulveris  cinchonae  9j.;  sodae sesquicarbonatis  gr. iij.  Misce, fiat pulvis, ter die su-
mendus.
                            39. Sarsaparilla  and  Nitric Acid.
   R. Decocti sarsae compositi f3iv.;  acidi nitrici diluti  U|xx.—lx.;  tincturae  hyoscyami
f3fa.   Misce, fiat haustus ter die sumendus.

                         40. Alkaline  Infusion  of Sarsaparilla.

   R. Sarsaparillae Jamaicensis radicis, consisae et contusae 3'j-» radicis  glycyrrhizae concisae
3ij.; liquoris potassae fll xl.—lx.; aquae destillatae ferventis f3x.;  tincturae cardamomi com-
positae f 3'ij-  Macera per horas viginti  quatuor, et  cola.   Sumatur totum quotidie.

                           41. Sarsaparilla and Lime  Water.

   R. Sarsaparillae  3ij.; glycyrrhizae 3'j-5  liquoris calcis  f3x.   Macera per horas viginti
quatuor et cola.  Sumatur totum indies.

                             42. Corrosive  Sublimate  Pills.
   R. Hydrargyri sublimati corrosivi, ammoniae hydrochloratis aa gr. j.-^ij.; aquae destillata
guttam  ; micae panis quantum satis est, ut fiant pilulae xij., quarum sumatur una ter die.

                    43  Corrosine Sublimate  and  Bark for Children.

   R. Hydrargyri sublimati corrosivi gr. j.;  tincturae cinchonae (vel  tincturae rhei) 3ij.; soivc
Dosis f3j. ter die ex aqua.  To be  taken after meats.
                                          2l 
562                        APPENDIX  OF  FORMUL.E.

                                  44.  Iodine Mixture.*
   R.  Iodinii gr. £ ; potassii iodidi gr. j.; aquae destillatae f 3vj.
   Vel. R. Tincturae iodinii compositi (p. l.) m  xx.;  aquae  destillatao f3vj-
   Vel. R. Liquoris potassii  iodidi  compositi (p. i>.) f 3fs.;  aquae  destillatae  f 3vfs.   Miste.
Sumatur totum indies divisis dosibus.

                                  45.  Iodine Ointment.
   R.  Iodinii gr. vij.; potassii iodidi 9ij.; adipis 3j-   Misce.

                                      Iodine Paint
   Is composed of iodine rubbed with  enough spirits of wine to make it of the consistence ol
paint.   Used as a strong discutient for bubo, diseased joints,  Sfc.

                                    46. Iodine Lotion.
   R.  Liquoris potassii iodidi compositi f3j.; aquae destillatae f3x.  Misce.   For Scrofulou$
Ulcers, Fistulx, Ophthalmia, tyc.

                            47.  Rubefacient Solution of Iodine.
   R.  Iodinii 3'v-i  potassii iodidi 3j-»  aquae destillatae f 3vj.  Misce.   To touch very indo-
lent sores, the edges of the eyelids, ozxna, #c.

                             48. Caustic Solution of Iodine.

   R.  Iodinii, potassii iodidi aa 3j- >  aquae destillatae f3ij.  Misee.   To destroy weak granu-
lations, ragged edges of sores, 4"C
                                     49.  Iodine Bath.
   Should contain, for children, half  a grain  of iodine to each  quart of warm water;—and,
for adults, one drachm to twenty-five gallons.  The body may  be immersed ten minutes.-}-

                                    50. Warm Emetic.
   R.  Pulveris ipecacuanhae, ammoniae sesquicarbonatis aa 9j.; spiritus lavandute compositi
fljx.; aquae f 3j-  Misce;  fiat haustus.   Bibat aeger postea infusi anthemidis  tepidi octarium
In the incipient stage of Erysipelas, Fever, <fc.

                      51.  Iodide of Potassium with Bitter Extract.
   R.  Potassii iodidi gr. xij.; extracti gentianae B'lj.   Misce et  divide in pilulas duodecim.

                           52.  Iodide of Potassium with Alkali.
   R.  Potassii iodidi gr. xij.; potassae bicarbonatis 3j- ; (vel liquoris potassae f3'j.) ;  syrupi
f 3fs.; aquae f3vfs.   Misce.  Dosis  f3j. bis die.

                           53. Iodide of Potassium with Steel.
   R  Potassii iodidi  gr. xij.;  ferri sulphatis gr. vj.;  syrupi f3fe.; aquae destillatae f3vfe.
Misce.   Dosis f 3j. bis die.
                                   54. Iodide of Lead.

   R.  Plumbi iodidi gr. iij.;  extracti gentianae gr.  ij.   Misce, fiat pilula bis die sumenda.

                                     $  IV.   Lotions.

                                     55.  Lead Lotion.

   R.  Liquoris plumbi diacetatis  f 3j->  acidi  acetici diluti, spiritus rectificati aa f 3&.; aquae
(3ix    Misce, fiat lotio.

  » Tliese three formulae are of the same strength.  The dose of iodine  may be gradually increased to gr
4-5tns, or gr. i. daily.
  f Vide Essays on the Effects  of Iodine in scrofulous diseases, Vy iL.ugoi, translated by O'Shaughnesey
Iji»n<lon, 3831. 
                            APPENDIX OF  FORMULA.                       563
                                 56.  Frigorific Mixture.
  R. Sodii chloridi, potassae nitratis, ammoniae hydrochloratis, partes aequales ;  aquae quan-
tum satis sit ad solvendas.
                                   57.  Spirit Lotion.
  R. Spiritils vini rectificati f3j-; aquae f 3xv.   Misce, fiat lotio.
                                    58.  Zinc Lotion.
  R. Zinci sulphatis 3j.;  aquae octarium.   Misce, fiat lotio.
                                  59.  Discutient Lotion.
   R. Ammoniae hydrochloratis 3fs.;  acidi acetici diluti, spiritus rectificati aa f 3fs-; misturse
 camphorae f 3xv.   Misce, fiat lotio.
                                 60.  Nitric Acid Lotion.
   R.  Rosae petalorum 9j.; aquae ferventis f 3viij.; acidi nitrici diluti f3'ijfs.   Misce, et cola
 post horam, ut fiat lotio.
                                   61.  Opiate Lotion.
   R  Pulveris opii 3fs.; aquae  destillatae ferventis f3viij.; macera per horas duas, et cola.
                                   62. Conium Lotion.
   R. Extracti conii 3j.; aquae destillatae f3iij.; tere simul, et macera per  horas duas; deiu
 cola.
                                  63. Arsenical Lotion.
    R.  Liquoris arsenicalis  f3j.—ij.;  aquae destillatae f 3j.    Misce.
                                     64. Black  Wash.
    R.  Calomelanos 3j.; mucilaginis acaciae f 3fs.;  liquoris calcis f3vfs.   Misce.
                                    65.  Yellow  Wash.
    R.  Hydrargyri sublimati corrosivi gr. vj.—xij. ; liquoris calcis f 3vj.  Misce.

                                  §  V.  Ointments.
                                   66. Scotfs  Ointment.
    R.  Unguenti hydrargyri fortioris, cerati saponis aa 3j-? camphors pulverizatae 3j.  Misce
                               67. Tartar  Emetic  Ointment.
    R.  Antimonii potassio-tartratis 3j.;  adipis 3j-  Misce.
                                  68. Ointment for  Piles.
    R.  Pulveris gallae 3j.;  liquoris plumbi diacetatis TT[xv.; adipis 3j.  Misce.
                              69. Peruvian  Balsam Ointment.
    R. Balsami Peruvian!  3j-;  unguenti cetacei 3j-   Misce.
                                   70.  Chalk  Ointment.
    R. Cretae, subtillissime pulverizatae 3j.;  olei olivae 3'j.;  adipis 3fs.   Misce.  For Bums,
  excoriations with acrid discharge, fyc.
                                   §  VI.   Ltnimexts.
                                 71.  Stimulating Liniment.
    R.  Liquoris ammonite f3'j-; linimenti  saponis (vel linimenti camphorae compositi) f3l
  Misce, fiat linimentum. 
564
APPENDIX  OF  FORMULAE.
                               72. Pearson's  Liniment.
  R. Olei olivae f3jfs.;  olei terebinthinae  f 3fs.;  acidi sulphurici fortissimi f3j"»-  Misce
gradatim.
                               73. Chilblain  Liniment.

  R. Tincturae cantharidis foi'j- ; linimenti saponis f3ix.   Misce, fiat linimentum

                                §  VJI.  Poultices.

                                 74.  Mustard Poultice.
  R. Lini seminum,  sinapis,  singulorum contritorum  libram  dimidiam;  aceti  fervefacti,
quantum satis sit; ut fiat cataplasmatis crassitudo.  Misce.   (Pharm. Lond.)
  A far belter poultice is made by merely mixing flour of mustard with warm (not boiling)
water.
                               75. Linseed Meal  Poultice.
  The highest authority  on poultices was  Mr. Abernethy, who seemed to revel in  the idea
of them.   " Scald  your basin," he says, " by  pouring a little hot water into it, then put a
small quantity of finely-ground  linseed meal into the  basin, pour a little hot water  on it, and
stir it round  briskly until you  have well incorporated them ; add a little more meal and a
little more water, then  stir it again.  Do not let  any lumps remain in  the basin, but stir the
poultice weil, and do not  be sparing of your trouble.  If properly made, it is so well worked
together, that you  might throw it  up to the ceiling, and  it would come down  again without
falling in pieces ; it is, in  fact, like a pancake.   What you  do next, is  to take as much of it
out of the basin as you may require, lay it on  a  piece of soft linen, let  it be about a quarter
of an inch thick, and so wide that  it may cover the whole of the inflamed part."

                                  76. Yeast Poultice.
  R. Farinae lb. j.; cerevisiae fermenti f 3j.   Misce,  et  calorem lenem  adhibe donee intu-
mescant.   (Pharm. Lond.)
                                  77. Bread Poultice.
  « I shall now speak," says Mr. Abernethy,  " of the bread and water poultice.  The way
in which I direct it to be made is the following:—Put half a pint of hot water into a pint
basin, add to  this as much of the crumb of  bread as the water will cover; then place a plate
over the basin, and let  it remain about ten  minutes;  stir the bread about in the water, or, if
necessary, chop it a little  with  the edge of the knife,  and drain off the water by holding the
knife on the top of the basin, but do not press  the bread, as is usually done; then take it out
lightly, and spread it about one-third of an inch  thick on some soft linen, and lay it upon the
part."
  A very admirable soft poultice for parts that are excoriated, or that threaten to slough from
pressure, during long illnesses, may be made by  mixing equal parts of  bread  crumbs and of
mutton suet grated very fine, with  a little boiling water, and stirring them in a saucepan over
the fire till they are well incorporated.

                                 78.  Opiate  Poultice.
  R. Micae panis, et lotionis opiatx suprapraescriptae  (F. 61), singulorum, quantum  satis sit

                                 79.  Conium  Poultice.
  R. Cataplasmatis panis (F. 77) quantum satis sit; extracti conii 9j.  Misce.


                                 § VIII. Gargles.

                                 80.  Detergent Gargle.
  R. Liquoris calcis chlorinatae f3iv.;  mellis 3j-;  aquae destillatae f3iij.   Misce.    A fable
ipoonful to be mixed with a glass of warm brandy and water, and to be used as a  gargle.

                                 81.  Cooling Gargle.
   R. Mellis, confectionis rnsoe canincc- aa  3ij.;  aceti destillali f3fs.;  acidi  hydrochloric!
 m xxx.- aquae rosae f3j-i aquas purse f3vj-   Misce. 
                          APPENDIX OF  FORMULAE.                      565
  R.  Potassae nitratis 3j-;  infusi rosae compositi f 3viij.   Misce.
                               62. Astringent Gargle.
  R.  Aluminis 3j.; acidi sulphurici diluti lt]xx.;  tincturae myrrhse f3'j-» decocti cinchonse
f3vj.   Misce.
                                 83. Tannin  Gargle.
  R.  Tannin  9j.;  Brandy  f3fs.;  misturae  camphorae  f3vfs.  Misce.   For  salivation,
ipongy gums, relaxed throat,  <f-c.
                           84. Corrosive Sublimate  Gargle.
  R. Hydrargyri sublimati corrosivi gr. ij.; acidi hydrochlorici 1tl xx.; mellis 3j.; aquas
iestillaUe f3vij.   Misce.

                                 "^ IX. Enemata.
                                 85. Opiate  Enema.
  R. Decocti amyli f3iv.; tincturae opii  f^fs—3j.  Misce.  (Pharm. Lond.)
                                 Opiate Suppository.
  R. Pulveris opii gr. j.—iv.; saponis (vel cetacei) gr. x.; contunde simul.
                               86. Turpentine Enema.
   R. Olei  terebinthinae f3j.;  vitelli ovi (vel mucilaginis  acaciae), quantum  satis  sit; tere
oimul et adde, decocti hordei, vel decocti avenae  f 3xix.
                                 87. Tobacco Enema.
   R. Tabaci foliorurn 3fs.; aquae octarium dimidiuin ; macera  per horae quartatn partem, et
 iX)la.
                               88.  Castor Oil  Enema.
   R.  Olei  ricini f3iij.; potassae carbonatis gr. xv.; saponis 3j.; aquae ferventis octarium;
 (ere simul donee bene misceantur.
                               89. Purgative Enemata.
   R.  Magnesiae sulphatis 3ij-5 decocti avenae octarium.   Misce.
   R.  Salis vulgaris 3j.; decocti anthemidis octarium.   Misce.
   R.  Fellis bovini inspissati  3fs-; saponis 3j.; aquae ferventis octarium.
   R.  Extracti colocynthydis 3j-;  aquae  ferventis octarium.

   § X. Miscellaneous  Prescriptions for various  surgical diseases.
                             90.  Strong Camphor Mixture.
   R.  Camphorae gr. xxv.; amygdalas dulces deeorticatas sex ;  sacchari purificati 3iij.; op-
 time contere, dein adde gradatim, aquae menthae viridis f3vijfs. ut fiat mistura, cujus suman-
 tur cochlearia tria magna,  quarta quaque hora.  (Hooper.)   In Hysteric, and various Ner-
 vous and Spasmodic affections.
                        91.  Antacid and  Carminative Mixtures.
   R.  Magnesiae carbonatis  9j.;  spiritus ammoniac aromatici f3fs.; syrupi  aurantii f3iij.
 aquae calcis, aquae destillatae aa f3iij-  Misce, sumantur cochlearia duo magna ter die.  After
 meals.
   j^. Crete prepnratae 3fs.; liquoris calcis f 3iij.; aquae  anethi f3iij.  Misce, sumantur
 cochlearia duo magna ter die.
          48 
566                       APPENDIX  OF  FORMLI..E.

  R.  Potassae bicarbonatis  9j.;  infusi  rhei f3'j->  syrupi zinziberis f 3>j-i aquas menth«
piperita? f3ij.  Misce.   Dosis f3j. bis die.
  The above prescriptions are intended for children with  voracious appetites, red tongues,
thirst, and loaded urine.

  R.  Infusi caryophylorum  f 3vijfs.; sodae  sesquicarbonatis 3j-; spiritOs ammonia? aromatici
f3'j-i tincturae cardamomi composite f'3fs.   Misce.   Dosis, t'3jls. bis die.

  R.  Ammonia? sesquicarbonatis, potassae bicarbonatis aa 3fs.;  aquae anethi f 3 vijfs.   Dosis,
f3jfs. bis die.  For adults labouring  under Dyspepsia, acidity, and turbid urine.  To be
taken after breakfast and at bed-time.      .

                                 92.  Bismuth Mixtures.

  R.  Bismuthi trisnitratis 3j-> pulveris acaciae 3'j.; soda?  sesquicarbonatis 9j. ;  syrupi zin-
ziberis f3iv-;  aquae anethi  f'3vijfs.   Misce.   Dosis, f3jfs. bis die.    To be taken an hour
after breakfast and dinner in  cases of Gastrodynia and Pyrosis, with disordered urine.

  R.  Bismuthi trisnitratis 5j.; magnesias carbonatis 3jf"s. ? pulveris  acaciae 3'j»;  syrupi zin-
ziberis, tincturae cardamomi composite aa f3'<j' a0,uffi  f 3 vijfs.   Misce.   Dosis, l"3jfs. bis die.

                            93.  Prussic Acid Mixtures.

  R.  Acidi hydrocyanici diluti (Pharm. Lond.)  fji iv.; potassae bicarbonatis gr. v.;  syrupi
zinziberis f3fs.;  aquae anethi f3jfs.   Misce, fiat haustus bis die sumendus.  This acid should
always be sent out in single draughts; then an overdose cannot be taken.  In  cases of irri-
table acid stomach.

  R.  Acidi hydrocyanici dilut (Pharm. Lond.) fli iv.;  mistura? crete f3jfs.;  soda? sesqui-
carbonatis gr. v.   Misce, fiat haustus.  In the same class of cases, with irritable bowels.

                                 94.  Arsenical Mixture.

  R.  Liquoris arsenicalis 711 xx.—xxx.; syrupi  f3"j'» tincturae cardamomi f 3'ij-; aqn«
destillate f 3vfs.   Misce.  Dosis, f 3j. ter die.*

                     95.  Sir  A. Cooper's  Prescription for  Cancer.
  R.  Ammoniae sesquicarbonatis gr. v. ; soda? sesquicarbonatis 5fs.; tincturae calumba? f3j.;
infusi gentianae compositi f3j's-   Misce, fiat haustus bis die sumendus.

                             96. Tincture of Indian Hemp.

  R.  Resinae cannabis Indicie 3j-5  spiritus  rectificati  f3xx.;  macera per dies  quatuordecim
et cola.

  R.  Tincturae  supra-prescripte TTlxv.;  spiritus rectificati  ftjxlv.   Misce,  fiat  haustus.
This draught should be swallowed out of the bottle, or if mixed with water, should be drank
instantly, otherwise the resin will separate.

                        97. Demulcent Mixtures for  Gonorrhoea.

  R.  Mucilaginis acacia? f 3'j-? sodae sesquicarbonatis 3fs-;  vini antimonii  tartarizati /3'Jm
tincturae opii m xx.; aquae anethi f3vijfs.    Misce.  Dosis f3jfs. quater die.

  R.  Liquoris potassae f 3ij-; liquoris opii  sedativi f 3fs.;  mistura? amygdala? f 3vj.   Misce.
bumantur  cochlearia duo quarta quaque  hora.

  * Mr. Hunt, of Heme Bay, who has had probably greater experience in  the  use of arsenic  than  any
oilier man living, gives the followine rules for its administration.  " It should never ba given when there
is any feverishness; never on an empty stomach; never in increasing dosas, the largest dose ever required
being m v. of Fowlor's solution three times a day.  The first effuct to be looked for is an itching or smart-
ing of the conjunctiva, and swelling and puffiiiess of the lower eyelid ; upon which the  dose should be
reduced to three minims.  If the conjunctiva continues much inflamed, the dose should be  again reduced,
but it should be kept in a tender state throughout the course.  The arsenical cours" should  he continued
for  as many months after the disappearance of the skin  disease, as it had existed years  before."  Vide
papers by Mr. Hunt, in Lancet for 1846.  The medicine, to ensure  genuineness, should be procured from
Apothecaries' Hall. 
                             APPENDIX  OF  FORMULAE.                       567

   R.  Liquoris potassae, tincturae hyoscyami, aa f3'j. J  aquae  f3iv.;  Misce.  Sumatur pars
quarta ter die.
                                  98. Copaiba Mixture.
   R.  Copaibte f3ij.—iv.; mucilaginis acacia? fgiv.; spiritus a?theris nitrici, spiritus lavan-
dula? aa f3ij. 5  olei cinnamomi guttas vj.;  aquae f 3v.  Misce.   Dosis f3j. ter die.

                             99.  Copaiba and Oil of  Cubebs.
   R.  Copaibae f 3"j.; olei cubebae ftj xx.;  liquoris potassae f 3ij.; sp. myristica? f 3»j.; mis-
tura? camphora? f3v'j-   Misce.  Sumantur  cochlearia duo magna ter die.

                                 100.  Cubebs and Soda.
   R.  Pulveris cubebae  9ij.;  soda? sesquicarbonatis, potassae bitartratis  aa 9fs.  Misce;  fiat
pulvis, ter die  sumendus.

                                 101. Copaiba and Kino.
   R.  Copaiba? f 3fs.;  pulveris kino 3j-;  mucilaginis acacia? f3iij.;  spiritus lavandulffl
compositi f 3iij.;  aqua? f 3v.   Misce.   Sumantur cochlearia duo magna ter die.

                                102.  Copaiba and Catechu.
   R.  Copaiba? f 3fs.; tincturae catechu f3vj.; olei juniperiguttas duas; mucilaginis f3iij.;
•quae  f 3v.  Misce.   Sumantur cochlearia duo ter die.

                               103.  Cantharides  and  Zinc.
   R.  Zinci sulphatis gr. xxiv.; pulveris cantharidis gr. vj.; pulveris rhei 3j.; terebinthinae
venetiensis quantum satis sit, ut fiant pilulae viginti quatuor, quarum sumantur duo ter die.

                                104.  Cantharides  and  Steel.
   R.  Tinctura? ferri sesquichloridi, tincturae cantharidis,  aa  f3'j-;  tincturae  capsici f3j
syrupi croci f3iij.»  aqu33  pimentae f3vj-   Misce ;  sumantur cochlearia duo ter die.

                               105.  Turpentine and Copaiba.
   R.  Olei terebinthinae f3ij.;  copaiba? f3vj-  Misce ;  sumantur gutte quadraginta  ter  di«,
ex cyatho aqua?.
                                106.  For  Chronic Cystitis.
   R.  Foliorurn buchu, et uvae ursi, aa 3'j-?  aquae ferventis f3vj.   Macera per horas duas;
dein cola, et adde liquoris potassae f3j-;  tinctura? cinnamoni, tinctura? hyoscyami aa f3iij.
 Misce;  sumantur cochlearia  duo ter  die.*

   R.  Pareira? 3)-;  aqua? destillatae octarium; decoque ad  dimidium ;  dein adde  decocti
cinchona? flavae f3vj.; tinctura? hyoscyami f3»j-; scdae sesquicarbonatis  3fs.  Dosis f3iij.
bis die.

   R.  Decocti chimaphila? f3j.; syrupi zinziberis fJ5j.; spiritus aetheris nitrici f3j.;  Misce,
flat haustus bis in die sumendus.

                              107. Acetate of Zinc Injection.
   R.  Zinci sulphatis gr  t"  'liquoris plumbi  diacetatis f3fs.; aqua? rosa? f3iv.  Misce, fiat
injectio.
                             108. Acetate of  Copper  Injection.
   R.  Oupri sulphatis gr. v.; liquoris plumbi  diacHatis f3fs-» aqua? rosa? f3iv.  Misce, fiat
injecti;.
                          109. Ammoniuret  of Copper Injection.
   R.  Liquoris cupri ammonio-sulphatis -rr[ xx.; tinctura? opii f3fs.;  iqua?  rosa? f3iv.  Misce,
fiat lotio.
   * lir. Ootding Ri d, in speaking of the remedies most useful in chronic inflammation of the bladder, says,
 the una ur.<i is"a simple astringent, but slightly diuretic; the chimaphila a less active astringent, but freely
 stimulating the kidneys; the bur/in, a stimulating tonic, diuretic, and diaphoretic, whose active principle
(volatile oil is excreted by the kidneys; Pareira, a narcotic, (?) tonic diuretic. 
503                       APPENDIX of  formula:.

                            110. Sulphate of Zinc  Injection.

   R.  Zinci sulphatis gr. viij.; aqua? destillate f3v'ij.  Misce.

                          111. Sulphate of Zinc  with Opium.
   R.  Pulveris opii 9fs.; aqua?  ferventis octarium dimidium; macera per horas duas, tiffin
cola, ct adde zinci sulphatis 9fs.

                           112.  Copaiba and Magnesia Pills.
   R.  Copail«e f3fs.; magnesia? carbonatis quantum satis sit ut  fiat massa in pilulas divi-
denda*
                                    113. Eye Snuff.
   R.  Pulveris asari partes tres; pulveris riorum  lavandula?  partes duas.   Misce.  Vel. R
Pulveris euphorbii partem unam, pulveris amyli partes septem.  Misce.

                               114. Mercurial Eye  Snuff.
   R.  Hydrargyri sub-sulphatis flavi 3fs-?  pulveris glycyrrhiza? 3U-  Misce intime.

                           115. Schmucker's Resolvent  Pills.

   R.  Sagapeni, galbani,  saponis aa 3j- > rne' 3j^s- > antimonii  potassio-tartratis gr. xv.;
succi glycyrrhiza? 3j-  Misce.   Dosis gr. xv. bis die.

                                     Richter's Pills.

   R.  Ammoniaci, asafostidae, saponis, Valeriana?, arnica?, aa 3'j-;  antimonii potassio-tartra-
tis gr.  xviij.; syrupi quantum satis est ut fiat massa.  Dosis gr. xx.—xxx. ter die.

                           116. Ointments for the  Eye-lids.-\
   R.  Unguenti hydrargyri nitratis 3fe;  olei  amygdala?  f3fs.  Solve  leni calore.
   R.  Unguenti  hydrargyri nitratis 3fs.;  hydrargyri nitrico-oxydi  in pulverem  subtilissi-
mum redacti gr. v.; adipis 3j.   Misce bene.
   R.  Liquoris plumbi diacetatis guttas x.; morphia? acetatis gr. iv.; calomelanos  gr. x.;
adipis  3fs.  Misce.
                                     117. Collyria.
   R.  Zinci sulphatis gr.  j.—iv.; vel aluminis gr. j.—iv.;  vel cupri sulphatis gr. $—ij.; vet
argenti nitratis gr. j.—iv.; vel zinci acetatis gr. j.-—iv.; vel iiq. plumbi diacetatis mx.; aquae
destillate f 3j.   Misce.
   One part of good brandy to six of water makes an admirable collyrium  for most cases.

                          118.  Corrosive Sublimate  Collyrium.
   R.  Hydrargyri  sublimati corrosivi gr. j.;  aquae destillate  fSviij.  Misce.   (Mackenzie.)

                                119.  Opiate Collyrium.

   R.  Zinci sulphatis gr. xij. (vel liquoris plumbi diacetatis f 3fs.) ;  tincturae opii f 3ij.; aqua?
destillate f 3xij.   Misce.
                                     120.  Emetics.
   R.  Pulveris ipecacuanha? 9j.;  ammonia?  sesquicarbonatis 9j.; aqua? f3j.  Misce, fiat
haustus.  Bibat a?ger postea, infusi  anthemidis tepidi, octarium.   In the cold stage of Ery-
sipelas and Fevers.
   R.  Zinci sulphatis 3j.; aqua? f 3j.   Misce.

                             121.  Colchicum and Magnesia.

   R.  Vim  colchici f3'j* '■> solutionis  magnesia?^  f 3j*s.;  syrupi croci f3'j- j  misturae cam-
phorae  f 3ivfs.   Misce ; sumantur cochlearia duo quarta. quaque hora.
  * One plan is to boil the balsam with one-fourth of its weight of calcined magnesia, over a water bath,
i ir 12 or 15 hours ; but the essential oil would most likely be dissipated.
  f Singleton's Golden Ointment, is said to bo composed of equal parts of orpiment and lard.
  1 Made by Mirray or Dinneford. 
                            APPENDIX OF  FORMULAE.                       569

   R.  Magnesia? carbonatis, soda; sesquicarbonatis aa 9fs.; vini  seminum colchici fl] xv.;
aqua? pimenta? f3jfs.   Misce, fiat haustus ter die sumendus.

                    122. White  Purgative Draught with  Colchicum.
   R.  Magnesia? sulphatis 3ij.;  magnesia?  carbonatis 3fs.;  aceti colchici f 3j.; syrupi zinzi
beris f3j-; aqua? anethi f3jfs.  Misce.

                             123. Anti-Phosphatic Mixture.
   R.  Acidi nitrici diluti, acidi muriatici diluti aa f 3ijfs.;  syrupi aurantii f3j.; aquae riorum
aurantii f 3j.;  aquae destillate f3xiijfs.  Misce; sumatur cyathus vinarius ter vel quater die.
(Brodie.)

                                  124. Anti-Lithic Pill.
   R.  Extracti colchici acetici, pilulae hydrargyri aa gr. j.;  extracti colocynthidis compositi
gr. ij.   Misce ; fiat pilula omni nocte sumenda.

                                125.  Anti-Lithic Powder.
   R.  Magnesia? gr. vj.; potassa? bicarbonatis gr. xij.; potassae tartratis gr. xv.  Misce; fiat
pulvis, omni vespere sumendus e cyatho parvo aquae.  (Brodie.)

                          126.  Mlherial  Tincture of Tannin.

   R.  Tannin 9j.; mastiches 9fs.; spiritus aetheris sulphurici f3rs.  Solve.

                                  12.^.  Tannin Lotion.

   R.  Tannin 9j.; aquae destillatae f 31V»   Misce,  fiat  lotio.   For sore Nipples, Excoria-
tions, <Vc.
                                  128. Lead Draught.

   R.  Plumbi acetatis gr. iij.; aceti destillati f3'j-i tinct. opii ftjj.—x.; syrupi rha?ados f3j.;
aquae destillatae f 3yij.  Misce ;  fiat haustus quarta quaque hora. sumendus, ad sex  vices.

                                 129.  Sarsaparilla Soup.

   "To three ounces of sarsaparilla, sliced, add three pints of water; let them simmer on  a
slow fire until reduced to two pints; take  out the root, bruise it, and return it  into the water
with half a chicken,  or half a pound  of beef without fat;  boil them for an hour slowly, and
pour off the soup for use."—Dr. Colles's  Lectures, vol. ii. p. 346.

                             130. Croton  Oil  Embrocation.

   R.  Olei tiglii guttas xx.;  linimenti saponis f 3j.   Misce.

                    131. Digitalis Draught, for Aneurism or Hectic.

   R.  Tinct. digitalis it]  xv.;  aceti destillati f 3j. i  syrupi f3j-;  aqua?  f3jfa.  Misce, fiat
haustus ter die sumendus, ad duodecim vices.

         132. Sir A.  Cooper's  Prescription for  Chronic  Gout or Rheumatism.

   R.  Potassae  bicarbonatis 3fs.;  tinctura?  aurantii f 3'j* >  decocti aloes compositi f 3viij.
Misce, sumatur cyathus vinarius omni mane.

                      133.  Turpentine  in small Alterative  doses.

   R   Mucilaginis f3fs.; soda? sesquicarbonatis  9fs.; olei  terebinthinae  m xv.—xl.; aquas
destillatae f 3j.  Misce, fiat haustus. In Rheumatism, rheumatic Ophthalmia,  Iritis, passive
Haemorrhage, <5fC.
                              134. Guaiacum Electuaries.

   R.  Pulveris guaiaci, pulveris cinchona? aa 9j.;  pulveris cinnamomi compositi 9fs.  Misce,
fiat pulvis bis die sumendus.
   R.  Pulveris guaiaci 3'j- >  pulveris rhei  3fs.; sulphuris  3j-! pulveris myristicae 3fs.; the-
riiisaj quantum  satis  est  ut  fiat electuarium.  Dosis, pars sexta omni nocte.   In chronic
Rheumatic diseases.
         48* 
570
APPENDIX  OF  FORMULAE.
                                   13"). Benzoic  Acid.
    R. Acidi  benzoici, ammonia? sesquicarbonatis aa 3j.; syrupi tolutani f3'j- >  aquae destii
 lata? f3vj.   Misce.   Dosis, f3j. ter die.

    R. Acidi benzoici, extracti  papaveris  aa 3fs.  Misce, et divide in pilulas xij.; quarum
 sumantur duo ter die.

    R. Acidi benzoici, sacchari albi aa. gr. viij.   Fiat pulvis, ter die sumendus.   In Urinary
 disorders, Chronic Bronchitis and Cystitis.

                                      136. Borax.
    R. Soda? biboratis 3j- i soda? sesquicarbonatis 3^- ?, potassa? nitratis 3f8»  Misce, et divide
 in pulveres sex ; quorum sumatur unus ter die e cyatho aqua?.  In Lithic deposits.

                                137. Phosphate of Soda.
    R. Soda? phosphatis 3iij.  Fiat  pulvis, mane sumendus e cyatho aqua?.   As  an aperient
 in the Lithic diathesis.

    R. Soda?  phosphatis  9j.;  infusi gentiana? compositi f 3j.  Misce, fiat  haustus  bis die
 sumendus.
                                138. Strychnia Mixture.
   R. Strychnia? gr.  j.;  acidi nitrici diluti f3j.; aqua? destillate fjxij.   Misce; sumatur
 f3j. ter die.   In obstinate Debility, Diabetes insipidus, the Phosphatic diathesis, $c.  (Dr.
 Go/ding Bird.)
                              139.  Sulphate of Manganese.
   R. Manganesii sulphatis 9j.; maganesia? sulphatis 3ij.;  syrupi  zinziberis  f3j-> aqua?
 f3'fs. Misce, fiat haustus mane sumendus.  In Gouty cases, to produce a copious discharge
 of bile.

   R. Manganesii sulphatis, pulveris rhei aa. 9j.; spiritus lavandula?  compositi  f3j.; aqua)
 f3,ls-  Misce, fiat haustus.

                             140. Colchicum  and Rhubarb.
   R. Infusi rhei fox.;  vini colchici  m xx.;  potassa? bicarbonatis  9j.; tinctura? cardamomi
 compositi f3j.  Misce ;  fiat haustus, hoiis somni sumendus.

          141.  To make a Metallic Amalgam or Cement, to Jill Decayed Teeth.
   Rub together in a  mortar some silver, reduced to  a fine  powder by filing or by precipita-
 tion,  with a few globules of mercury.  When  well  mixed into a  paste,  knead it well with
 the fingers, and squeeze  out any superfluous mercury.  Then the cavity of  the tooth  having
 heen  properly scraped out and dried, fill it with the amalgam, making the surface of the metal
 smooth, and even with that of the tooth.   The  patient must  be desired not to use the teeth
 for some hours, till the amalgam has become hard.

       142.  To melt  Nitrate of Silver for the purpose of coating a Probe, or Sound.
   "Some powdered  lunar caustic, from six to  twenty grains, is to be moistened with water
 in  a  little porphyry dish, boiled up over a spirit lamp, and constantly stirred with a silver
 knife till the water have evaporated,  and the caustic  remain  fluid in its water of crystalliza-
 tion alone, which may be ascertained by its thin  pap-like appearance, and the formation of
 the crystallization-film.   This paste is  now to be spread with the spatula  on  the slightly-
 heated groove of the  caustic-holder, and, when it has cooled, any projection  is to be removed
 with the spatula or with  pumice-stone.  Whilst boiling, the caustic flies about  smartly, and
 therefore it  is  necessary to put  on a glove, so that  the hand  be not spotted with black."—
 South's Chelius.
                           143.  To make common Bougies.
   "A piece of fine linen, which has been already used, nine inches long and to an inch in
 width, according to the thickness of  the bougie to be made,  is to be dipped into melted plas-
ter, and when a little cooled,  spread flat and even  with a spatula; it  is  then  to be rolled
together between the fingers, and afterwards between two plates of marble till it is quite firm
and smooth.   The bougie must be  equally thick throughout its whole length  to about one
inch from its  point, from whence  it should gradually taper, and terminate in a  firm round
point.  Bougies are  also made  by dipping cotton-threads in  melted wax till they have ac-
quired sufficient size,  after which they are rolled  between marble plates."—South's Chelius
 This formula  may be useful to surgeons on foreign stations. 
INDEX.
Abdomen, affections of, 120
Abscess, acute, 70
   "    alveolar, 400
   "    of abdominal parietes, 425
         in bone, 221
   "    in the brain, 323
   "    in the chest, 418
   "    chronic, 74
   "    consecutive, 70, 174, 308
         diffused, 82, 161
   "    in joints, 265
   "    in kidney, 474
         lumbar, 328
   "    metastatic, 70
   "    from phlebitis. 308
   "    of prostate, 465
   "    psoas, 328
   "    psoas, diagnosis of, from hernia, 443
   '*    near rectum,  450
   "    scrofulous, 113
   "    in  testis, 500
   "    urinary, 462
Acids, injuries from, 152
Acupuncture, 527
Adhesion, 62
Air in veins, 524
Albugo, 346
Alkalis, injuries from,  152
Alterative medicines, 60
Amaurosis,  362
Amputation for fracture, 232
      "      for gangrene,  104
      "      for gunshot wounds, 141
      "      for diseased joints, 272
      "      primary or secondary,  141
Amputations described, 534
Ana?mia, death from, 26
Anchylosis,  272           .
     "      spurious,  division  of  muscles
               for, 518
Anryloblepharon, 337
Aneurism, 298
     "     by anastomosis, 304
           diffused, 132, 301, 303
     "     dissecting,  304
           false,  304
     "     in bone, 225
     "     varicose, 304
Ankles, weak, 515
Antimony,  chloride of, 1)2
Antrum, diseases of,  383
Anus, artificial, 427
          "     as a remedy for imperiorate
                  anus, 446
       diseases of, 445
Apnaea, death from,  26
Aquo-capsulitis, 349
Arsenic, injuries from, 152
   "    for snake-bites,  156
   "    as a caustic, 210
   "    for onychia, 517
Arteries, wounds of, 292
   "     inflammation of, 237
   "     laceration of, by fracture, 238
   "     operations for tying, 548
Arteriotomy, 526
Artery, intercostal wounds of, 419
   "    palmar wounds of, 295
Ascites, 421
Asthenia,  death from, 26
Atresia ani, 446
   "    iridis, 351

Balanitis,  181, 191
Bandages, 529
           for ankle, 88
           four-tailed, 234
    "     clavicle, 236
    "     many-tailed, 25S
    "     starched, 229
    "     stellate, 236
Bathing, rules for, 110
Bees, sting of, 153
Belladonna,  351
Biceps tendon, rupture of, 282
Bladder, diseases of,  467
    "     puncture of, by rectum, 458
    "          "       by perinseum, 461
    "          "       above pubes,  467
    "     wounds of, 426
Blennorrhcea, ISO
Blood, buffed and cupped, 33
   "   organizable ? 64
Bloodletting for inflammation, 54
      "      operation of,  524
Boils, 204
Bone, atrophy of, 218
   "   diseases of, 217
   "   venereal diseases of, 200
   "   inflammation  of, 219
   "   tumours of, 224
   "   malignant tumours of, 226
Bowels, wounds of,  425
    "     inflammation of, 426
    "    rupture of,  by blows, 424
Brain, compression of, 317
   "   concussion of, 315
   "   inflammaiion of, 322
   "   softening of,  69, 323
   "   wounds of, 321
                             (571) 
572

Breast, diseases of, 510
   "    extirpation of, 513
Bronchocele, 412
Brow ague, 312
Bubo, 196
Bubonocele, 437
Bunions, 516
Burns,  143
Bursa?,  affections of, 214

Calculus, salivary,  399
    "    vide  Stone
Callus,  formation of, 227
Cancer,  117
   *'    gelatiniform, 123
   "    chimney-sweepers',  506
   "    of breast,  512
   "    of lip, 390
        of eye, 370
   ■«    of nose, 383
   "    of penis, 498
   "    of scrotum, 506
   "    of skin, 209
   "    of tongue, 393
Cancrum oris, 391
Cannon balls, spent, 136
Carbuncle, 203                '
Carcinoma, vide Cancer
Caries, articular, 271
   "   of bone, 224
   "   of temporal bone,  375
   "   of vertebra?, 327
Cartilage, ulceration of,  268
Cartilages, loose, in joints,  266
    "       "   in bursa?, 215
    "       "   in tunica vaginalis,  503
Castration, 501
Cataract, 353
   "     capsular,  354
   "        "    operation for,  354
   "     in infants, 359
   "     diagnosis from amaurosis, 363
Catarrhus vesicae, 468
Caustics, 210
Cautery, actual, 527
Cellular tissue, suppuration in, 70
   "     "    diffuse inflammation of, 1
   "     "    diseases and tumours of, 203
   "     "    ulcer of, 98
Cellular tissue,  around joints, inflammation
    of,  267
Chalkstone, 214
Chancre, 188
   "     diagnosis of,  191
Charbon, 95
Chemosis, 342
Chest, wounds and affections of, 417
Chigoe, 158
Chilblain, 151
Chloroform, 523
Chordee, 180
Choroid, diseases of, 360
Cicatrices from burns, 148
    "    nerves implicated in, 311
    "    irritable,  546
    "    tumours of, 208
Cicatrization, 71
Circumcision,  497
Cirsocele, 504
Club-foot, 514
Cold, effects of,  149
Collapse, 25
Colloid disease,  123
Coma, death from,  27
INDEX.

     Condylomata, 199, 450
     Congestion, 51
     Conjunctiva, diseases of,  340
          "      granular, 345
     Contusion, 130
     Convulsions,  46
     Copaiba, 185
     Coredialysis,  353
     Coretomia, correctomia, 353
     Cornea, diseases of, 345
        "    conical, 348
     Corus, 207
     Couching, 357
     Crisis, 31
     Crystalline lens, diseases of, 353
     Cubebs,  185
     Cupping, 526
     Cystitis, cystirrhoea, 467
     Cytoblast, 63

     Deafness, 377
     Death, forms of, 26
     Delirium traumaticum,  28
     Derbyshire neck, 412
     Diarrhoea, 36
     Diplopia, 362
     Dislocations,  277
     Dissection, efi'ects of, on health, liS
         "      wounds, 159
     Districhiasis,  336
     Dropsy, acute, 61
        "     of abdomen, 421
        "     of antrum,  383
        "     of chest, 417
        "     of pericardium,  418
        "     ovarian, 421
        "     vitreous humour, 361
        "     gangrene from,  104
     Drowning, 411
     Dura mater, wounds of,  321

     Ear, affections of, 371
     Ecchymosis, 130
     Ecthyma, 199
     Ectropion, 336
     Eczema mercuriale, 194
     Elbow-joint, excision of,  547
     Electricity, 528
     Emphysema, from broken rib,  245
     Empyema,  418
     Encanthis, 371
     Enchondroma, 225
     Entropion, 336*
     Epiphora, 338
     Epispadias, 499
     Epistaxis, 380
     Epulis, 400
     Erethismus mercurialis,  194
     Eruptions, venereal, 198
     Erysipelas, 78
     Ether, inhalation of, 520
     Excoriation, nature of, 83
         "     of penis, 190
     Exfoliation of bone,  223
     Exostosis, 217
         "     cartilaginous,  225
     Eye, affections ofT 334
      "   malignant diseases of,  370
     Eyelids, diseases of, 335
        "     operation for closing, 336

     Face, affections of, 379
      "  cancerous ulcer of, 209
     Farcy,  173 
INDEX.
573
Fascia?, diseases of, 213
Fever, 30
   "   hectic, 35
   "   inflammatory, 30
   "   intermittent, 30
   "   irritative,  34
   "   typhoid, 37
Fibrinc,  62
Fingers, contracted, 516
   "     webbed, 516
Fistula,  90
   "     in ano, 451
   "     faecal,  428
   "     lachrymal, 339
   "     in perinaeo, 463
   "     recto-vaginal, 509
   "     salivary, 379
   "     vesico-vaginal, 509
Fracture, 227
    "    compound, 232
    "    non-union of, 230
          of skull, 319
    "    of spine, 332
Frostbite,  150
Fumigation, mercurial, 202
Fungus medullaris, ha?matodes, 122
   "    pulpy, of synovial membrane, 266

Gall bladder, wounds of, 425
Galvanism,  528
Galvano-puncture, 529
Ganglion, 214
Gangrene,  99
     "    from aneurism, 300
     "    from cold,  150
     "    from wound of artery,  143
     "    from gun-shot wound,  138
     "    hospital, 93
     "     from oedema, 104
     "     from pressure,  105
     "     senile,  105
     "     white, of skin,  106
 Genitals, male affections of,  497
          female,  508
 Glanders, 173
 Glands, vide Lymphatics.
 Glaucoma,  359
 Gleet, 178
 Glottis, scalds of,  410
    "    foreign bodies in, 407
 Goitre, 412
    "    aerienne,  415
 Gonorrhoea,  180
 Gonorrhoeal rheumatism.  181, 188, 264
 Granulation, 71
 Gravel, red, 476
    "    white, 480
 Guinea worm,  157
 Gums, affections of, 399
    "    lancing, 393
 Gunpowder, burns from, 144
 Gun-shot wounds, 133

 Haematocele,  502
 Haematuria, 474
 Haen-orrhage, active, 66
        "      passive, 66
        "      from wounds of artery, 292
        "      from wound of vein, 307
               from bladder, 475
        "      from kidneys, 475
        "      from urethra. 464
        "      from nose, 380
        "      from rectum, 450
Haemorrhage,  after extracting teeth, 399
              secondary, from wound of ar-
                          tery, 296
      "           "     from gun-shot
                         wound, 138, 141
      "           "     from wound of
                          chest, 419
Haemorrhagic diathesis,  296
Haemorrhoids, 447
Haemothorax,  417
Hanging,  411
Hare-lip,  388
Head, injuries of, 315
Heart, wounds of,  420
Hectic,  35
Hemicrania, 312
Hemiopia, 362
Hernia, 428
   "    bronchalis, 415
   "    cerebri, 321
   "    congenital, 438
   "    cornea?, 348
   "    diaphragmatic,  445
   "    encysted, 438
   "    femoral, 442
   "    inguinal, 437
   "    irreducible,  431
   "    ischiatic, 445
   "    obturator, 445
   "    omental, 430
   "    pudendal, 444
   "    perinaeal,  444
   "    reducible, 430
   "    strangulated, 432
   "    umbilical, 444
   "    vaginal, 444
   "    ventral, 444
 Herpes exedens,  209
   "    praeputialis, 192
 Hiccup, 28
 Hip-joint  disease, 274
    "    dislocation of, 285
 Hordeolum,  335
 Hospital  gangrene,  93
 Housemaid's knee,  215
 Hydatid disease of breast, 511
    "      "    of testicle, 501
 Hydatids in bone, 226
 Hydrargyria,  193
 Hydrarthus, 264
 Hydrocele, 502
      "     diagnosis from hernia, 439
 Hydrophobia,  164
       "      spontaneous, 166
 Hydrops pericardii,  418
 Hydrorachitis, 330
 Hydrothorax, 417
 Hymen,  imperforate, 509
 Hypopyon, 349
 Hypospadias, 449
 Hysteria, diagnosis of, from hydrophobia, 1/0
 Hysterical neuralgia, 314

 Impotence, 507
 Incisions, 519
 Inflammation, 47
       "       acute, 54
               adhesive, 62
       "       chronic, 59
       "       diffused, 82
       "       erysipelatous, 77
        "       cedematous,  62
       "       theory of,  52
 Injections for gonorrhoea, 184 
574
INDEX.
 Injections of bladder, 469
 Inoculation for diagnosis of chancre, 191
 Insects, poison of, 153
 Iodide of potassium, 61, 195,201
 Iodine for scrofula, 112
   "   for bronchocele,  414
   "   vide  Appendix
 Iris, prolapse of, 352
  "  diseases of, 349
 [ssues, 527

 Jaw, lower, tumours of, 400
  "   upper, tumours of, 385
 Joints, diseases of, 263
   "   excision of, 547
   "   false, 230
   "   wounds of, 277

 Keloides,  208
 Keratonyxis, 358
 Kidneys, diseases of, 471
    "    wounds of, 426

 Labia pudendi, affections of, 510
 Lachrymal apparatus, affections of, 338
 Lagophthalmos, 337
 Laryngotomy, 408
 Larynx, foreign bodies in,  407
   "   venereal disease of, 200
 Lateritious sediment,  31, 476
 Lead, remedy for aneurism, 303
 Leech bites, 58
 Lepoides,  209
 Lepra syphilitica, 199
 Leucoma, 346
 Leucorrhoea, 184
 Ligaments,  affections of, 213, 267
 Ligature, effects of, 294
 Lip,  diseases of, 390
 Lipoma of  nose, 379
 Lithectasy,  496
 Lithic acid,  476, 482
 Lithotomy,  489
 Lithotrity,  496
 Liver, wounds of, 425
 Lung, wound of, 419
 Lupus, 209
 Luscitas, 368
 Lymph, 62
 Lymphatics, affections of, 215

 Malignant disease, 115
 Marasmus,  114
 Maxilla, superior, tumours  of, 385
 Medullary sarcoma, 122
 Melanosis,  1.23
 Mercury in primary syphilis, 193
   "   in secondary syphilis,  201
   "   ill effects of,  193
   "   bichloride of,  153
 Metallic tinkling, 417
 Modelling process, 72, 129
 Moles, 209
Mollnies ossium,  219
Mortification, 99, vide Gangrene
 Moxa, 528
Mucus, relation of, to pus,  68
Musca? voliiantes, 361
Muscles, affections of. 211
Musket balls, course 0^134
Mydriasis,  352
Myocephalon, 347
 Myopia, 366
Mvosis, 351
 Naevus, 304
    "    ligature for, 524
 Nails, ulcers near,  517
 Nebula, 346
 Neck, affections of, 411
   "   scrofulous abscess in, 114
   "   tumours of,  415
 Necrosis, 221
 Nephritis, 471
 Nerves, affections of, 311
 Neuralgia, 312
     "     hysterical,  314
     "     of stumps, 546
 Nipples, sore, 511
 Nodes, 202
 Noli me tangere, 209
 Noma, 508
 Nose, affections of, 379
   "   venereal disease of, 200
 Nostrils, imperforate, 383

 CEdema,  61
    "     acute, of scrotum, 506
 CEsophagotomy, 406
 CEsophagus, affections of, 403
 Onychia maligna, 517
 Onyx, 346
 Operations, 519
 Ophthalmia,  340
      "      catarrhal, 340
      "      catarrho-rheumatic, 349
      "      gonorrhoeal, 348
      "      purulent, 341
      "      rheumatic,  348
      "      scrofulous,  344
      "      tarsi,  335
 Orchitis,  499
 Osteo-aneurism, 225
 Osteo-sarcoma, 225
 Otalgia, 376
 Otitis, 376
 Otorrhcea, 373
 Ovarian dropsy,  421
 Oxalic acid diathesis,  479
   "   stone, 482
 Ozaena, 383

 Palate, fissure of, 388
 Palm of the hand, wounds of,  295
 Pannus,  346
 Paracentesis abdominis, 422
      "     capitis, 324
      "     pericardii, 418
      "     thoracis, 418
Paraphymosis, 498
Paronychia, 518
Parotid, tumours of, 416
Parulis, 400
Pediculi palpebrarum,  338
Penis, affeciions  of, ,497
Pericardium,  dropsy of, 418
Perinaeum, abscess in,  462
     "     laceration of, 509
Periosteum, inflammation of, 200
Phagedena, 93
      "     sloughing, 93
      "     venereal,  190
Phlebitis, 307
Phlegmon, 71
Phosphaiic gravel, 480
Phymosis, 497
     "     with chancre,  191
Piles, 447
 Pneumothorax, 417 
INDEX.
575
Poisons of healthy animals, 153
   "    of diseased animals, 158
   "    mineral and vegetable, 152
   "    putrid or septic,  158
Polypus of epiglottis, 409
   "     nasal,  381
   "     uterine,  509
Presbyopia, 367
Prolapsus ani, 453
Prosiate, affections of, 465
Prostration, 25
            with excitement,  28
Pruritus ani,  456
Psoriasis prasputii, 192
         syphilitic,  199
Pterygium, 345
Ptosis,  337
Pulse, theory of,  31
Pupil, artificial,  352
Pus, formation of, 69
  "  in the blood, 70
  "  varieties of,  67
Pustule, malignant,  95
Pyelitis, 477

Ramollissement,  69
Ranula,  392
Rattlesnake,  155
Reaction after bleeding, 55
Rectum, affections of, 445
Respiration, artificial, 411
Retention, vide Urine
Retina, diseases of, 361
Rhagades, 452
Rheumatism, gonorrhceal, 181, 264
     "      of joints, 263
Rhino-plastic operation, 386
Rickets, 218
Rupia, syphilitic, 199

Salivation, 194
Sarcoma, fleshy, 205
   "      mammary, 122
    '      medullary, 122
Sarsaparilla  112, 201
Scabbing,  85, 129
Scalds, 143
   "     of the glottis, 410
Scalp, wounds of, 315
SchneiJerian membrane, inflammation of, 383
Scirrhus, 117
   "     of breast,  512
   "     of oesophagus,  405
   "     vide Cancer
Scott's ointment, 265
Scrofula, 106
Scrofulous diseases of bone, 218
    "       "     of eye,  344
    "       "    of joints, 271
    '•       "     of kidneys, 472
    "        "    of lymphatics, 114
    "       "    of skin,  113
    "       "    of testicle, 500
Scrofulous ulcers, 115
Scurvy of the gums, 399
Sea scurvy, effects of, 64, 232
Sero-cystic disease,  511
Serpents, poison of,  155
Serum, effusion of, 61
Seton, 528
Short sight, 366
Shoulder joint, excision of, 547
Silver, niirate of, for ulcers, 86
   "       "      injuries from, 152
Silver, nitrate of, discolours the  conjunctiva
                   348
Skin, diseases of, 207
  "   scrofulous disease of,  113
  "   ulcers of,  98, 207
  "   tumours of, 207
Skull, fracture of, 319
Snake bites, 153
Softening of brain,  323
   "     of spinal cord,  333
Spermatocele, 504
Spermatorrhoea,  508
Sphacelus,  99
Sphincter ani,  division of,  451
    "     "   spasm, 446
Spiders, bite of,  154
Spina bifida, 330
  "   ventosa, 271
Spine, affections of, 325
  "   malignant disease of, 332
Spleen,  wounds of, 425
Splints,  229
Sprains,  213
Squinting,  367
Stammering, 393
Staphyloma cornea?, 347
           iridis, 347
     "     sclerotica?, 361
Staphyloraphe, 389
Steam bath, 59
Stillicidium lachrymarum, 328
Stomach, wounds of, 425
Stomach-pump,  406
Stone, 482
  "   in the kidney, 483
  "   in bladder, 484
  "   in prostate, 467
  "   in ureter,  483
  "   in urethra, 465
  "   in woman, 496
Stricture of oesophagus, 404
   "     of rectum, 454
   "     of urethra, spasmodic, 456
   "          "     permanent,  458
Struma,  106
Stumps,  affections of, 546
Styptics, 295
Suppuration,  66
Sutures,  125
Symblepharon, 337
Synchysis,  361
Synechia, 351
Synovial membrane, diseases of, 263
Syphilis, primary, 188
   "     secondary,  198
   "     in children, 202

Tabes mesenterica, 114
Talipes,  514
Tarantula,  bite of, 154
Tartar on the  teeth, 399
Taxis, 433
Teeth, affections of, 393
Tendons, affections of, 211
Testis, diseases of, 499
Tetanus, 38
   "     chronic, 45
   "     hysterical, 45
Throat,  venereal sores  in, 199
   "    wounds  of, 411
Thyroid gland, affections of, 412
Tic douloureux,  312
Toes, distortion of,  516
Tolerance of bleeding, 55 
576
INDEX.
Tongue, affections of, 392
Tonsils, affections of, 402
Toothache,  395
Torsion, 295
Tourniquet, 534
Tracheotomy, 408
Trephining, 324
Trichiasis,  336
Trismus infantum, 45
Trusses, 430
Tubercle, pathology of, 108
Tumours, of bone,  224
    "     of bursa?,  214
    "     of cellular tissue,  205
    "     chalk stone, 214
    "     of cicatrices,  208
    "     encysted,  206
    "    in eye-lids, 337
    "     extirpation of, 214, 519
          fatty, 205
          fleshy,  205
    "     glandular, 216
          horny,  208
    "     of synovial membrane in joints, 267
    "     lacteal, 511
          of lips, 390
    "     malignant,  116
     '     of male genitals, 497
     '     of female genitals, 508
     '     of maxilla superior, 385
    "     of maxilla inferior, 400
    "     in the neck, 415
    "     of nerves, 311
     '     on oesophagus, 405
    "     parotid, 416
    "     painful  subcutaneous, 206, 311
    "     of the skin,  207
    "     cheloid, 208
    "     of tendons, 213
    "     in urethra, 465
Turpentine, for burns, 147
     "      as a purge, 163
     "      in iritis, 351

Ulceration, pathology of, 83
Ulcers,  85
   "    from burns,  14
   "    cancerous,  117
   "    cutaneous, 98
   "    cancerous, of skin, 209
   "    weak, 87
   "    of cellulSr membrane, 98
   "    of cornea, 346
   "    of eyelids, 336
   "    fistulous,  90
   "    healthy, 85
   "    indolent,  87
   "    inflamed, 86
   "    irritable,  86
   "    on lips, 390
   "    malignant,  115
   "    menstrual,  98
   "    morbid, 98
   "    about  the nails, 517
   "    about  the nose, 209
   "    of oesophagus, 405
   "    phagedaenic, 91
   "    of rectum, 455
   "    semi-malignant, 117, 209
   "    sloughing, 91
Ulcers, scrofulous, 115
    "   on tongue, 393
    "   varicose, 90
    "   venereal, primary, 188
Urethra, male affections of,  1^0, 456
    "    contraction of orifice ot,  462
    "    rupture of, 463
    "    discharges from,  180
    "    chancre^in,  190
    "    female.'affections of,  508
Urinary abscesses, 462
Urine, albuminous, 473
   "   extravasation of, 463
   "   incontinence of, 470
   '    retention of, from stricture, 456
    '       "      from  diseased  prostate,
                     465
   "       "      from  palsy  of  bladder,
                     469
   "       "      hysterical, 470
   "   sediments in, 475
   "   serous, 474
   "   suppression of, 475
Uvula, enlargement of, 403

Vaccination,  528
Valgus, 514
Varicocele, 504
     "     diagnosis of, from hernia, 439
Varicose ulcers,  90
Varix, 309
   "   aneurismal, 304
Varus, 512
Veins, affections of, 307
Vegetable irritants, 152
Vehaesection, 524
Venereal disease,  176
Vertebrae, diseases of,  325
Viper, 155
Vitreous humour, diseases of,  360
Vomiting, 27

Warts,  207
Wasps, sting of,  154
Wens,  206
Whitlow, 518
Wind-contusions, 136
Wounds, contused and lacerated, 1?2
    "    gun-shot, 133
    "    incised,  125
    "    poisoned, 155
    "    punctured,  129
    "    of  abdomen, 425
    "    of  arteries, 292
    "    of  chest, 417
    "    of joints, 277
    "    of  scalp, 315
    "    of  throat, 411
    "    of  brain, 321
    "    of  veins, 307
    "     nerves,  311
    "    eyelids, 334
    "    tongue, 392
Wourali, 45, 172
Wry-neck,  415

Xerophthalmia,  338

Zinc, chloride of,  210
THE  END. 
                    CATALOGUE
                                OF
               BLANCHARD  &  LEA'S
MEDICAL  AND  SURGICAL  PUBLICATIONS.
                  TO THE MEDICAL PROFESSION.
  In submitting the  following catalogue of our publications in medicine and the
collateral sciences, we beg to remark that no exertions are spared to render the issues
of our press worthy a continuance of the confidence which they have thus far enjoyed,
both as regards the high character of the works themselves, and in respect to every
point of typographical accuracy, and mechanical and artistical execution.  G-entlemen
desirous of adding to their libraries from our list, can in almost all cases procure the
works they wish from the nearest bookseller, who can readily  order  any which
may not be on hand; and who, as well as ourselves, will be happy to answer any
inquiries as to price, &c.
                                                BLANCHARD &  LEA.
  Philadelphia, August, 1855.
TWO  MEDICAL  PERIODICALS,  FREE OF POSTAGE,
       FOR FIVE  DOLLARS PER AAWTUM.
THE AMERICAN  JOURNAL OF THE MEDICAL SCIENCES, subject to
  postage, when not paid for in advance,.......$5 00
THE MEDICAL NEWS AND LIBRARY, invariably in advance,   -    -   1 00
  or, both periodicals furnished, free op postage, for Five Dollars remitted
  in advance.
  THE AMERICAN  JOURNAL  OF THE MEDICAL SCIENCES,
                  Edited by  ISAAC HAYS,  M. D.,
is published Quarterly, on the first of January, April, July, and October.  Each number contains
at least two hundred and eighty large  octavo pages,  handsomely and appropriately illustrated,
wherever necessary.  It has now been issued regularly for more than thirty-five years, and it has
been under the control of the present editor for more  than a quarter of a century.  Throughout
this lon^ period, it has maintained its position in the highest rank of medical periodicals both at home
and abroad, and has received the cordial support of the entire profession in this country.  Its list of
Collaborators will be found to contain a large number of the most distinguished names of the pro-
fession in every section of the United States, rendering  the department devoted to
                ORIGINAL  COMMUNICATIONS
full of varied and important matter,   great interest to all practitioners.
 As the aim of the Journal, however, is to combine the advantages presented by all the different
varieties of periodicals, in its
                     REVIEW  DEPARTMENT
will be found extended and impartial reviews of all important new works, presenting subjects of
novelty and interest, together with very numerous
                BIBLIOGRAPHICAL NOTICES,
 eluding nearly all the medical publications of the day, both in this country and Great Britain, with
"Choice; selection of the more important continental works. This is followed by the 
'2
BLANCHARD or LEA'S  MEDICAL
                           QUARTERLY SUM MARY,
being a very full and complete abstract, methodically arranged, of the

           IMPROVEMENTS  AND DISCOVERIES IN THE MEDICAL  SCIENCES.

  This department of ihe Journal, so important to the practising physician, is the object of especial
care on the part of the editor.  It is classified and arranged under different heads, thus faciliiating
ihe researches of  the reader in pursuit of particular subjects, and will be found to present n very
full and accurate digest of all observations, discoveries, and inventions recorded in every branch ol
medical science.   The very extensive arrangements of* the publishers are such as to afford to the
editor complete materials for this purpose, as he  not only regularly receives

     ALL THE  AMERICAN  MEDICAL AND SCIENTIFIC  PERIODICALS,
but also twenty or thirty of the  more important Journals issued in Great Britain and on the Conti-
nent, ihus enabling him to present  in a convenient compass a thorough  and complete abstract of
everything interesting or important  to the physician occurring in any part of the civilized world.
  An evidence of the success which has  attended these  efforts may be found in the constant and
steady increase in the  subscription list, which renders  it advisable for  gentlemen desiring  the
Journal, to make known their wishes at an early day, in order to secure a year's set with certainty,
the publishers having frequently been unable to supply copies when ordered late in  the year.  To
their old Mibscribers, many of whom have been on their list for twenty or thirty years, the publish-
ers feel that no promises are necessary; but those who may desire for the first time  to subscribe,
can rest assured that no exertion wilfbe spared to maintain the Journal in the high position which
it has occupied for so long a period.
  By reference to the terms it  will be seen that, in addition to this large amount of valuable and
practical information on every  branch of medical science,  the subscriber, by paying in advance,
becomes entitled, without further charge, to

            THE  MEDICAL  NEWS  AND  LIBRARY,

a monthly  periodical of thirty-two large octavo pages.  Its "News Department" presents the
current information of the day, while the "Library Department" is devoted to presenting stand-
ard works on various branches of medicine.  Within a few years, subscribers have thus received,
without expense, the following works which have passed through its columns:—

WATSON'S LECTURES ON THE PRACTICE OF PHYSIC.
BRODIE'S CLINICAL LECTURES ON SURGERY.
TODD AND BOWMAN'S PHYSIOLOGICAL ANATOMY AND PHYSIOLOGY OF MAN.
  724 pages, with numerous wood-cuts, being all that has yet appeared in England.
WEST'S  LECTURES ON THE DISEASES OF INFANCY  AND CHILDHOOD.
MALGAIGNE'S OPERATIVE  SURGERY,  with wood-cuts.
SIMON'S LECTURES ON  GENERAL  PATHOLOGY.
BENNETT ON PULMONARY TUBERCULOSIS, with wood-cuts, and
WEST ON ULCERATION OF THE OS UTERI.
                               While the year 1855, presents
        BROWN ON THE SURGICAL  DISEASES OF  FEMALES.
                           HANDSOMELY ILLUSTRATED ON WOOD.
  The diseases  treated  in this volume have  hitherto not received from writers  of systematic
works the attention to which their importance entitles them.  In treatises on female diseases they
have been but little noticed, as belonging more properly to the surgeon, while our surgical text-hooks
have in like manner referred them to the writer on midwifery and female affections.   In supplying
this palpable vacancy in medical  literature,  Mr. Brown has brought to his subject the  result of
many years of observation and experience, and his labors  will prove of much value to all practi-
tioners.  The publishers therefore flatter themselves that in securing this volume for the " Library
Department" of the " Medical News" they  will meet the  wishes of their numerous  subscri-
bers,  who will thus receive this highly important work free of all expense.
  It will thus be seen that for the small sum of FIVE DOLLARS, paid in advance, the subscriber
will obtain a Quarterly and a Monthly periodical,

            EMBRACING  ABOUT FIFTEEN HUNDRED  LARGE OCTAVO  PAGES,

mailed to any part of the United States, free of postage.
  These very favorable terms are now presented by the publishers with the view of removing all
difficulties and objections to a full and extended circulation of the Medical  Journal to the office of
every member of the profession throughout the United Slates.  The rapid extension of mail facili-
ties, will now place the numbers before subscribers with a certainty and dispatch not heretofore
attainable; while by the system now  proposed, every subscriber throughout the Union is placed
upon an equal footing, at the very reasonable price of Five Dollars for two periodicals, without
further expense.
  Those subscribers who do not pay  in advance will bear in  mind that their subscription of Five
Dollars will entitle them to the Journal only, without the News, and that they will be at the expense
of their own postage on the receipt of each number. The advantage of a remittance when order-
ing the Journal will thus be apparent.
  As the Medical News and Library is in no case sent without advance  payment, its subscribers
will always receive it free of postage.
  It should also be borne in mind that the publishers will now take the risk of remittances by mail,
when the letter inclosing the amount is registered under the  new Postage Act, going  into effect
July 1, 1855.
                                   Address       BLANCHARD &  LEA,  Philadelphia. 
AND SCIENTIFIC PUBLICATIONS.
3
                              ALLEN  (J.  M.),  M. D.,
                  Professor of Anatomy in the Pennsylvania Medical College, &.C.

THE PRACTICAL  ANATOMIST; or, The  Student's  Guide in  the Dissecting-
  ROOM.  With numerous illustrations.   In one handsome royal 12mo. volume.  {In Press.)
  In the arrangement of this work the author has endeavored to present a complete and thorough
course of dissections in a clearer and more available form for practical use in the dissecting-room,
than has as yet been accomplished.  His long experience as  a teacher of anatomy has given him a
familiarity with the wants of students, and has  shown him the best modes of obviating or relieving
the difficulties which present themselves in the progress of dissection.  As adapted  to the course
pursued in our colleges, and containing ample practical directions and  instructions, in addition to
the anatomical details  presented, it possesses  claims to the immediate attention of teachers and
students.  It will appear in time for the Fall session of the present year.
                         ANALYTICAL  COMPENDIUM
OF  MEDICAL  SCIENCE, containing Anatomy, Physiology, Surgery, Midwifery,
  Chemistry, Materia Medica, Therapeutics, and Practice of Medicine.  By John  Neill, M. D.,
  and F. G Smith, M. D.  Second  and enlarged edition, one thick volume royal 12mo. of over
  1000 pages, with 350 illustrations.   I5P See Neill.
                               ABEL (F.  A.),  F. C. S.
                Professor of Chemistry in the Royal Military Academy, Woolwich.
                                           AND
                                  C. L.  BLOXAM,
                   Formerly First Assistant at the Royal College of Chemistry.

HANDBOOK OF CHEMISTRY, Theoretical, Practical, and Technical, with a
  Recommendatorv Preface by Dr.  Hofmann.  In one large octavo volume of 662 pages, with
  illustrations.  (Just Issued.)
  It, must be understood that this is a work fitted for
the earnest student, who resolves to pursue for him-
self a steady search into the chemical  mysteries  of
creation.  For such a student the  ' Handbook' will
prove an excellent guide, since he will find  in it,
not merely the approved modes of analytical investi-
gation, but most descriptions of the apparatus ne-
cessary, with such manipulatory details as rendered
Faraday's ' Chemical Manipulations' so valuable at
the time of its publication. Beyond  this, the im-
portance of the work is  increased by the introduc-
tion of much of the technical chemistry of the manu-
factory."—Dr. Hofmann's Preface.
                          ASH WELL  (SAMUEL), M. D.,
                   Obstetric Physician and Lecturer to Guy's Hospital, London.

A PRACTICAL TREATISE ON THE DISEASES PECULIAR TO WOMEN.
  Illustrated by Cases derived from  Hospital and Private Practice. Third American, from the Third
  and revised "London edition.  In one octavo volume, of 528 pages.  (Now Ready.)
  The most useful practical work on the subject in
the English language. — Boston  Med. and Surg.
Journal.
  The most able, and certainly the most standard
and practical, work on female diseases that we have
yet seen.— Medico-Chirurgical Review.
  We commend it to our readers as the best practi-
tical treatise on the subject which has yet appeared.
—London Lancet.
  The young practitioner  will find it  invaluable,
while those who have had most experience will yet
find something to learn, and much to commend, in a
book which  shows so much  patient observation,
practical skill, and sound sense.—British and Fo-
reign Med. Revieio.
  With no work are we acquainted, in which the
pleasant and the useful are more happily blended. It
combines the greatest elegance of style with the
most sound and  valuable practical  information.
We feel justified in recommending it, in unqualified
terms, to our readers,  as a book from which they
can scarcely fail to derive both pleasure and im-
provement.  It is truly a model for medical compo-
sitions.—Southern Med. and Surg. Journal.
                             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,
  M. D.  Complete in one octavo volume, of 484 pages, with about two hundred illustrations.

                            BENNETT (HENRY),  M. D.

A PRACTICAL  TREATISE   ON INFLAMMATION  OF  THE  UTERUS,
  ITS  CERVIX AND  APPENDAGES, and  on its connection with Uterine Disease.  Fourth
  American, from the third and revised London edition.  In one neat octavo volume, of 430 pages,
  with wood-cuts.   Just Issued.)
  This edition will be found materially improved over its predecessors, the author having carefully
revised it, and made considerable additions,  amounting to about seventy-five pages.
  This edition has been carefully revised and altered,,   When, a few years back, the first edition of the
and various additions have been made, which render j  present work was published, the subject was oneal-
it more complete, and, if possible, more worthy of j  most entirely unknown to the obstetrical celebrities
the hio'h  appreciation in which it is held by the j  of the day ; and even now we have reason to know
medicifl profession throughout  the world.  A copy j  that the bulk of  the profession are not fully alive to
should  he in the possession  of every physician.— ;  the importance and frequency of the disease of which
Charleston Mid. Journal and Review.             it takes cognizance.  The present edition is so much
  We are firmly of opinion that in proportion as a  enlarged, altered, and improved, that it ean  scarcely
knowledge of uterine diseases becomes more appre- . be considered  the same work.—Dr. hanking's Ab-
ciated, this work will be proportionably established , s(ra«'-
as a text-book in the profession.—The Lancet. 
4
BLANCHARD &  LEA'S MEDICAL
                           BROWN  (ISAAC  BAKER),
                       Surgeon-Accoucheur toS;. Mary's Hospital. &c.

 ON  SOME DISEASES OF WOMEN ADMITTING OF SURGICAL TREAT-
   MENT.  With handsome illustrations.  One vol. 8vo.  (At Press.)
         Publishing in the "Medical News and Library" for 1855.  See preceding pnse.
   Mr. Brown has earned for himself a high reputa-
 tion in the operative treatment of sundry diseases
 and injuries to which females are peculiarly subject.
 We can truly say of his work that it is an important
. addition to obstetrical literature. The operative
 suggestions and contrivances which Mr. Brown de-
 scribes, exhibit much practical sagacity  and skill,
and merit the careful attention  of every sur.'ron-
nccoucheur.—Association Journal.

  We have  no hesitation in recommending this book
to the careful attention of all surgeons who make
female complaints a part of their study nnd practice
—Dublin Quarterly Journal.
               BENNETT  (J.  HUGHES),  M, D.,  F. R. S. E.,
               Professor of Clinical Medicine in the University of Edinburgh, &.c.
THE  PATHOLOGY AND TREATMENT  OF  PULMONARY  TUBERCU-
  LOSIS, and on the Local Medication of Pharyngeal and Laryngeal Diseases frequently mistaken
  for or a^sociated with,  Phthisis.  In  one handsome octavo volume, with beautiful wood-culs.
  pp. 130.   (Lately Isstted.)

                        BILLING (ARCHIBALD), M. D.
THE  PRINCIPLES OF  MEDICINE.  Second American, from the Fifth and
  Improved London edition.  In one handsome octavo volume, extra cloth, 250 pages.
               BLAKISTON  (PEYTON), M. D.,  F. R. S., &.C.
PRACTICAL  OBSERVATIONS  ON   CERTAIN   DISEASES  OF  THE
  CHEST, and on the Principles of Auscultation.  In one volume, 8vo., pp. 384.
                         BURROWS (GEORGE),  M.D.
ON  DISORDERS  OF THE  CEREBRAL CIRCULATION, and on  the Con-
  nection between the Affections of the Brain and Diseases of the Heart.  In one 8vo. vol., with
  colored plates, pp. 216.

                       BUDD (GEORGE),  M.  D.,  F. R. S.,
                     Professor of Medicine in King's College, London.

ON  DISEASES   OF  THE LIVER.   Second American, from the second and
  enlarged London edition.  In one very handsome octavo volume, with four beautifully colored
  plates, and numerous wood-cuts. pp. 468.  New edition.  (Lately Issued.)
  The full digest we have given of the new matter
introduced into the present volume, is evidence of
the value we place on it. The fact that the profes
sion has required a second edition of a monograph
such as that before us, hears honorable testimony
to  its  usefulness. For many years, Dr. Budd's
work must be the authority of the great mass of
British practitioners on the hepatic diseases ; and it
is satisfactory that the subject has been taken up by
so able and experienced a physician.—British and
Foreign Medico-Chirurgical Review.
                            BUSHNAN (J. S.),  M.  D.
THE  PHYSIOLOGY OF  ANIMAL AND VEGETABLE LIFE;  a Popular
  Treatise on the Functions and Phenomena of Organic Life.   To which is prefixed a Brief Expo-
  sition of the great departments of Human Knowledge.   In one handsome royal 12mo. volume,
  with over one hundred illustrations,  pp. 234.
  Though cast  in a popular form and manner, this work Is the production of a man of science, and
presents its  subject in its latest  development, based on truly scientific  and accurate principles.
It may therefore be consulted with interest by those who wish to obtain in a concise  form, and at
a very low price, a resume of the present state of animal "and vegetable physiology.

                     BIRD (GOLDING), A. M., M. D., &c.
URINARY   DEPOSITS:    THEIR   DIAGNOSIS,  PATHOLOGY,  AND
  THERAPEUTICAL INDICATIONS.  A new and enlarged American, from the last improved
  London edition.  With over sixty illustrations.  In one royal 12mo. volume, extra cloth, pp. 372.
  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
Etudent, 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 research**
regarding the physiology and pathology of the uri-
nary secretion, which have contributed so much W>
the  increase of our diagnostic powers, nnd  to 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.— 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 oae neat volume, royal 12mo.  pp.402. 
AND SCIENTIFIC PUBLICATIONS.
5
                       BARTLETT (ELISHA), M. D..
      Professor of Materia Medica and Medical Jurisprudence in the College of Physicians and
                               Surgeons, New York.

THE  HISTORY,  DIAGNOSIS,  AND  TREATMENT  OF  THE  FEVERS
  OF THE UNITED STATES.  Third edition, revised and improved.  In one octavo volume,
  of six hundred pages, beautifully printed, and strongly bound.
  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 language,
and as such cordially recommend it to the medical
public.—St. Loui$*Medicaland 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.
  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
Review.
                          BUCKLER (T.  H.), M. D.,
                Formerly Physician to the Baltimore Almshouse Infirmary, &c.
ON  THE  ETIOLOGY,  PATHOLOGY,  AND  TREATMENT  OF FIBRO-
  BRONCHITIS AND RHEUMATIC PNEUMONIA.  In one handsome octavo volume, extra
  cloth,  pp. 150.

                        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.)

               BEALE (LIONEL JOHN), M. R. C. S., &.C.

THE  LAWS  OF  HEALTH  IN  RELATION TO  MIND AND BODY.
  A Series of Letters from an old Practitioner to a Patient. In one handsome volume, royal 12mo.,
  extra cloth,  pp. 296.

                  BLOOD AND  URINE (MANUALS  ON).
BY  JOHN  WILLIAM  GRIFFITH,  G. OWEN REESE, AND  ALFRED
  MARKWICK.  One thick volume, royal 12mo., extra cloth, with plates, pp. 460.

                 BRODIE  (SIR BENJAMIN  C), M. D., &c.
CLINICAL LECTURES ON SURGERY.   1 vol. 8vo., cloth.  850 pp.


                         COLOMBAT DE LMSERE.
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.
                        CURLING (T.   B.),  F. R.S.,
                          Surgeon to .the London Hospital, &c.

A PRACTICAL TREATISE ON  DISEASES OF THE TESTIS, SPERMA-
  TIC CORD, AND SCROTUM.  Second American, from the second and enlarged English edi-
  tion.  In one handsome octavo volume, with numerous illustrations.  (At Press.)
  The additions of the author will be found to bring this work on a level with the improvements ot
the day, and to maintain its reputation as  the standard practical treatise on the subject.


                 COPLAND  (JAMES),  M.  D., F. R. S., &c.

OF  THE  CAUSES,  NATURE,  AND  TREATxMENT  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. 
6
BLANCHARD  &  LEA'S MEDICAL
             CARPENTER (WILLIAM B.)f  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, Hvgiene, and Forensic Medicine. A new American, from
  the last and revised London edition.  With about three hundred illustrations.  Edited, with addi-
  tions, by Francis Gurney Smith, M. D., Professor of the Institutes of Medicine in the Pennsyl-
  vania Medical College, &c. In one very large and beautiful octavo volume, of about one thousand
  large pages, handsomely printed and strongly bound in leather, with raised bands. (Lately Issued.)

                                                 The best  text-book in the language on this ex-
                                               tensive subject.—London Med.  Times.
                                                 A complete cyclopaedia of this branch of science.
                                               —JV. Y. Med. Times.
  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
                                        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,
These will be found, however, very far to  added to, or entirely remodelled to adapt  it to the
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
subject within the reach of the American  reader ;
and while, for availability as a text-book, we may
perhaps regret its growth in hulk, 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
lunguage.—Stethoscope.

  The most complete work now extunt in our lan-
guage.—iV. 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 harmonious
system.—Southern Med. and Surg. Journal.
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.  (Now Ready.)

PRINCIPLES OF COMPARATIVE  PHYSIOLOGY.   New American,  from
  the Fourth and Revised London edition.  In one large and handsome octavo volume, with over
  three hundred beautiful illustrations,  pp. 752.
  The delay which has existed in the appearance of this work has been caused by the very thorough
revision and remodelling which  it has undergone at the hands of the author, and the large number
of new illustrations which have been prepared for it.   It will, therefore, be found almost a new
work, and fully up to the day in every department of the subject, rendering it a reliable text-book
for all students engaged in this branch of science.  Every effort has been made to render its typo-
graphical finish and mechanical execution worthy of its exalted reputation, and creditable to the
mechanical arts of this country.
  This book should not only be read but thoroughly
studied by every member of the profession. None
are too wise or old, to be benefited thereby.  But
especially to the younger class would we cordially
commend it as best fitted of any work in the  English
language to qualify them for the reception and com-
prehension of those truths which are daily being de-
veloped in physiology.—Medical Counsellor.
  Without pretending to it, it is an Encyclopedia of
the subject, accurate and complete in all respects—
a truthful reflection of the advanced state at which
the science  has  now  arrived.—Dublin Quarterly
Journal of Medical Science.
  A truly magnificent work—in itpelf a perfect phy-
siological study .—Ranking's Abstract.
  This work stands without its fellow. It is one
few men in Europe could have undertaken;  it is one
no man, we believe, could have brought to so suc-
cessful an issue as Dr. Carpenter.  It required for
its production a physiologist at once deeply read in
the labors of others, capable of taking a general,
critical, and unprejudiced view of those labors and
of combining the varied, heterogeneous materials at
his disposal, so as to form an harmonious whole.
We feel that this abstract can give the reader a very
imperfect idea of the fulness of  this work, and no
idea of its unity, of the admirable manner in which
material has  been brought, from the most various
sources, to conduce to its completeness, of the lucid-
ity of the reasoning it contains, or of the  clearness
of language in which the whole is clothed.  Not the
profession only, but the scientific world  at large,
must feel deeply indebted to Dr.  Carpenter for this
 treat work.   It must, indeed, add  largely even to
 is high reputation.—Medical Times.
                             by the same author.  (Preparing.)

PRINCIPLES  OF  GENERAL  PHYSIOLOGY,  INCLUDING  ORGANIC
  CHEMISTRY AND HISTOLOGY.   With  a General  Sketch of the Vegetable and Animal
  Kingdom.  In one large and very handsome octavo volume, with several hundred illustrations.
  The subject of general physiology having been omitted in the last edition of the author's " Com-
parative Physiology," he  has undertaken to prepare a volume which  shall present it more  tho-
roughly and "fully than has yet been attempted,  and  which may be regarded as an introduction to
his other works. 
AND  SCIENTIFIC  PUBLICATIONS.
7
                CARPENTER (WILLIAM  B.>, M. D.,  F. R. S.,
          Examiner in Physiology and Comparative Anatomy in the University of London.

ELEMENTS  (OR  MANUAL)  OF  PHYSIOLOGY, INCLUDING  PHYSIO-
  LOGICAL ANATOMY.   Second American, from a new and revised London edition.  With
  one hundred and ninety illustrations.  In one very handsome octavo volume,  pp. 566.

  In publishing the first edition of this work, its title was altered from that of the  London volume,
by the substitution of (he word "Elements" for that of " Manual," and with the author's sanction
the title of " Elements" is still retained as being more expressive of  the scope of the treatise.
  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 subject of 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 expose^ 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.  (Preparing.)

THE  MICROSCOPE AND ITS  REVELATIONS.   In one handsome volume,
  with several hundred beautiful illustrations.
  Various literary engagements have  delayed the author's progress with this long expected work.
It is now, however, in an advanced  state of preparation, and may be expected in a few months.
The importance which  the microscope has assumed within the last few years, both as a guide to
the practising physician who wishes to avail himself of the progress of his science, and as an  indis-
pensable assistant to the physiological and pathological observer, has caused the want to be severely
lelt of a volume which should  serve as a guide to the learner and a book of reference to the more
advanced student.  This want Dr. Carpenter has endeavored to supply in the present volume. His
great practical familiarity with the instrument and all  its uses, and his acknowledged  ability as a
teacher, are a sufficient  guarantee ihat the work will prove in every way admirably adapted  to its
purpose, and superior to any as yet presented to the scientific world.

                                  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,  pp. 178.  (Just Issued.)


                             CHELIUS (J. M.), M. D.,
                    Professor of Surgery in the University of Heidelberg, &e.

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.

  The most learned and complete systematic treatise
now extant.— Edinburgh Medical Journal.
                      CLYMER (MEREDITH), M. D., &.C.
FEVERS;   THEIR  DIAGNOSIS,  PATHOLOGY,   AND   TREATMENT.
  Prepared and Edited, with large Additions, from the Essays on Fever in Tweedie's Library ol
  Practical Medicine.  In one octavo volume, of 600 pages.
            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-
  tions, Uses, 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.
                                              There is not in any language a more complete and
                                             perfect Treatise.—N. Y. Annalist.
                                              In conclusion, we need scarcely say that we
                                             strongly recommend this work to all classes of our
                                             readers.  As a Dispensatory and commentary on the
                                             Pharmacopoeias, it is unrivalled  in the English or
  It is not needful that W". should compare it with
the other pharmacopoeias extant, which enjoy and
merit the confidence of the profession : it is enough
to say that it uppears to us as perfect as a Dispensa-
tory, in the present state of pharmaceutical science,
could be made.  If it omits any details pertaining to
this branch of knowledge which the  student has a
right to expect in such a work, we confess the omis-
Bion has escaped our scrutiny. We cordially recom-
mend this work to such of our readers as are in need
of a Dispensatory.  They cannot make choice of a
better.—Western Journ. of Medicine and Surgery.
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. 
8
BLANCHARD & 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. (Lately Issued.)

                             From the Author's Prepack.
  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 the several
diseases of which it treats.
  In the preparation of the present edition, as in those which have preceded, while the auihor 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, nevertheless, 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 work 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.—If. Y. Journal of Medicine.

  A veritable pediatric encyclopsedia, and an honor
to Americammedical 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 t>een
published, we still regard it in that light.—Medical
Examiner.
                       COOPER (BRANSBY  B.),  F. R-.-S.,
                           Senior Surgeon to Guy's Hospital, See.

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
been  surgeon  to Guy's Hospital; and the volume
before us may be said to consist of an account of
the results of his surgical experience during that
long period. We cordially recommend Mr. Bransby
Cooper's Lectures as a most valuable addition to
our surgical literature, and one which cannot fail
to be of service both to students and to those who
are actively engaged in the practice of their profes-
sion.—The Lancet.
                    COOPER (SIR  ASTLEY P.),  F. R. S., &c.

A TREATISE ON DISLOCATIONS  AND FRACTURES OF THE JOINTS.
  Edited Jay Bransby B. Cooper, F. R.  S., &c.  With additional Observations by Prof. J. C.
  Warren.  A new American edition. In one handsome octavo volume, of about 500 pages, with
  numerous illustrations on wood.

                                 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.

ON THE  STRUCTURE  AND   DISEASES   OF  THE  TESTIS, AND ON
  THE  THYMUS GLAND.  One vol. imperial 8vo., with 177 figures, on 29 plates.

                                 BY THE SAME ATJTHOR.

ON THE  ANATOMY AND DISEASES   OF  THE BREAST, with  twenty-
  five Miscellaneous and Surgical Papers.  One large volume, imperial 8vo., with 252 figures, on
  36 plates.
  These last three volumes complete  the surgical writings of Sir Astley Cooper.  They are very
handsomely printed, with a large number of lithographic plates, executed in the best style, and are
presented at exceedingly low prices.
                          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. 
AND  SCIENTIFIC  PUBLICATIONS.
9
                CHURCHILL (FLEETWOOD), M.  D., M.  R. I. A.

ON  THE  THEORY AND PRACTICE OF  MIDWIFERY.  A new American,
  from the last and improved English  edition.   Edited, with Notes and Additions bv D  Francis
  Condie, 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.—If. 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.
— N. 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.
  handsome volume of over 600 pages.
In  one large and
  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 American
authors  on this  subject.   The  names of Dewees,
Eberle, Condie, and Stewart, occur on nearly every
page, and these authors are constantly referred to by
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.  We 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
 knowledgeas this.—JV. 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,
embodying whatever information has been laid be-
fore the profession since their authors' time.  He has
also  prefixed to the  Essays on Puerperal Fever,
which  occupy the larger portion of the volume, an
interesting historical sketch of the  principal epi-
demics 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, l>v 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. 681.   (Just Issued.)
  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, wc 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
nigh 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.—JV. 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 the subject;
and it may lie 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.—Tht
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 foT 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 liritish press.—The Dublin Quarterly
Journal.
                             DICKSON (S.  H.), M. D.,
Professor of Institutes and Practice of Medicine in  the Medical College of South Carolina; late Professor
         of the Institutes and Practice of Medicine in the University of New York, Sec. &c.

ELEMENTS  OF  MEDICINE;  A Treatise on Pathology and  Therapeutics.   In
  one large and handsome octavo volume of nearly S00 pages.  (Nearly Ready.)
  As a text-book on the Practice of Medicine for the student, and as a condensed work of reference
for the practitioner, this volume will have strong claimson the attention of the American  profession.
Few physicians have had wider opportunities, than the author, for observation and experience, and
few perhaps have used them better.  As the result of a life of study and practice, therefore,  the
present volume will doubtless be received with the welcome it deserves.
                                    From the Preface.
  The present volume is intended as an aid to young men who have engaged in the study of medi-
cine, to physicians who have recently assumed the responsibilities of practice, and to my fellow
professors of the Institutes of Medicine, and private instructors who have felt the difficulty of com-
municating to  the two first classes the  knowledge which they are earnestly seeking  to acquire.
Having been a teacher of medicine for thirty years, and a student more than forty, I  must have
accumulated some experience in both characters.   I have prepared and printed for those in attend-
ance on my lectures many successive manuals or text-books. I have also written and published
several volumes  on medical subjects in general.  The following  pages  are the  result of a careful
collation of all that has been esteemed valuable in both, with such matter as continued study and
enlarged experience has enabled me to add.
                          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 Isstied.)                       ,

                                  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.
  one volume, octavo, 532 pages, with plates.  (Just Issued.)
Tenth  edition.   In
                                 DANA  (JAMES   D).
ZOOPHYTES AND  CORALS.   In  one  volume, imperial  quarto, extra cloth,
  with wood-cuts.  Also, AN ATLAS, in one volume, imperial  folio, with sixty-one magnificent
  plates, colored after nature.  Bound in half morocco.
               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.   (Lately Issued.) 
AND SCIENTIFIC  PUBLICATIONS.                   11
                      DRUITT  (ROBERT),  M.R. C.S.,  &c.

THE  PRINCIPLES  AND PRACTICE  OF  MODERN  SURGERY.   A new
  American, from  the  improved London edition.  Edited by F. W. Sargent, M. D., author of
  " Minor Surgery," &c.   Illustrated  with one hundred and ninety-three wood-en°-ravin°-s.  In
  one very handsomely printed octavo volume, of 576 large pages.
  Dr. Druitt's researches into the literature of his
subject have been not only extensive, but well di-
rected ; the most discordant authors are fairly and
impartially quoted, and, while due credit is given
to each, their respective merits  are weighed with
an unprejudiced hand.  The grain of wheat is pre-
served, and the chaff is unmercifully stripped off.
The arrangement is simple and philosophical, and
the style, though clear and interesting, is so precise,
that the book contains more information condensed
into a few words than any other surgical work with
which we  are acquainted.—London  Medical Times
and Gazette, February 18, 1S54.

  No work, in  our opinion, equals it in presenting
bo 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 to 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 editor, Dr. F. W.
Sargent, has contributed much to enhance the value
of the work, by su«h 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 consideration. Every medical man frequently
needs just such a work as this, for immediate refe-
rence in moments of sudden emergency,  when he has
not time to consult more elaborate treatises.—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, nnd 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
Western Journal of Medicine and Surgery.

  The most accurate and ample resume 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 maybe 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 M 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
Btx-ty-eight distinguished physicians.

                                               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.
  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
                          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, <fcc. &c, on Healthy Man;
  constituting Elements of Hygiene.  Second edition, with many modifications and additions.  In
  one octavo volume, of 404 pages. 
12
BLANCHARD &  LEA'S  MEDICAL
                         TJUNGLISON  (ROBLEY),  M.D.,
          Professor of Institutes of Medicine in the Jefferson Medical College, Philadelphia.

MEDICAL  LEXICON;  a Dictionary of Medical Science, continuing 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;  Formula? for various Officinal, Empirical,
  and  Dietetic Preparations, etc.  Twelfth edition, revised. In one very  thick octavo volume, ol
  over nine  hundred large double-columned pages, strongly b.ound in leather, with raised bands.
  (Just Issued.)
  Every successive edition of this work bears the marks of the industry of the author,  and of hn
determination to keep it fully on a level with the  most advanced stale of medical science.  Thus
nearly fifteen thousand words  have been added to it within the last lew years.   As a complete
Medical Dictionary, therefore, embracing over FIFTY  THOUSAND  DEFINITIONS,  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 twelfth edition.
  Every 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 bnt exceedingly clear type, cast  for this purpo:~e.  The
press has been  watched with  great care, and every effort used to insure the verbal accuracy so ne-
cessary 1o 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.

  We welcome it cordially; it is an admirable work,
and indispensable to all literary medical men.   The
labor which has been bestowed  upon it is something
prodigious.  The work,  however,  has now  been
done, nnd we are happy in the thought that no hu-
man being will  have again  to  undertake the  same
gigantic task.  Revised and corrected from time to
time, Dr. Dunglison's " Medical Lexicon" will last
for centuries.—British and Foreign Med. Chirurg.
Review.
  The fact that this excellent and  learned work has
passed  through  eight editions, and that a ninth is
rendered necessary by the demands of the public,
affords a sufficient evidence of the general apprecia-
tion of Dr. Dunglison's labors by the  medical pro-
fession in England and America. It  is a book which
will be of great service to the student, in teaching
him the meaning of all the technical terms used in
medicine, and will be of no  less use to the practi-
tioner who desires to keep himself on a level with
the advance of  medical science.—London Medical
Times  and Gazette.
  In taking leave of our author, we feel compelled
to confess that  his work bears evidence of almost
incredible labor having been bestowed upon its com-
position.— Edinburgh Journal of  Med. Sciences.
  A miracle of labor and industry in  one who has
written able and voluminous works  on nearly every
branch of medical science.  There could be no more
useful  hw>k  to the student  or  practitioner, in the
present advancing age, than  one in which would be
found,  in addition to the ordinary meaning arid 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 almostasindispensableto 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 thedateof publication ; the author states
in his preface that hehasadded 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;  andwt
can only confirm their judgment, by recommending
this most useful volume  to the notice of our cisat-
lantic readers. No medical library will be 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
better 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.

  The most comprehensive and best English Dic-
tionary  of medical terms extant.—Buffalo Medital
Journal.
                                    BY THE SAME AUTHOR.

THE PRACTICE  OF MEDICINE.   A Treatise on  Special Pathology and The-
  rapeutics.  Third Edition.  In two large octavo volumes, of fifteen hundred pages.         '
  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 neive him  with courage,  and  faithfully
direct him in his efforts to relieve the physical suf-
ferings of the race.-
Journal.
-Boston Medical and Surgical
  It is certainly the most complete treatise of which
we have any knowledge.— Western Journal of Medi-
tine and Surgery.

  One of the most elaborate treatises of the kind
we have.—Southern Med. and Surg. Journal. 
AND SCIENTIFIC PUBLICATIONS.
13
                         DUNGLISON  (ROBLEY),  M.D.,
          Professor of Institutes of Medicine in the Jefferson Medical College, Philadelphia.

HUMAN   PHYSIOLOGY.  Seventh  edition.   Thoroughly revised  and exten-
  sively  modified and enlarged, with  nearly five  hundred illustrations.  In two lar°-e and hand-
  somely printed octavo volumes, containing nearly 1450 pages.
  It has long since taken rank as one of the medi-
cal classics of our language.  To say that it is by
fur the best text-book of physiology .ever published
in this country,  is but echoing the" general testi-
mony of the profession.—iV. 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 completest work on
Physiology in the English  language, and is highly
creditable to the author and publishers.—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.  (Just Issued.)

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.
  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 this the author 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-
provement will be found in every department of its mechanical execution.  As a convenient text-
book for the student, therefore, containing within a moderate compass a satisfactory resume of its
important subject, it is again presented as even more worthy than heretofore of the very great favor
which it has received.
  In this work of Dr. Dunglison,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.

  It may be said to be the work now upon the sub-
jects upon which it treats.— Western Lancet.
  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
onesi on account of  its increased  merit. — Ar. Y.
Journal of Medicine.

  We consider this work unequalled.—Boston Med.
and Surg. Journal.
                                  BY THE SAME AUTHOR.

NEW  REMEDIES, WITH  FORMULA 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.—  diseases and for remedies, will be found greatly to
Southern Medical and Surgical Journal.            enhance its value.—New York Med. Gazette.
  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 physicians, it is  unsurpassed by any
other work in existence, and the double index for
  The great learning of the author, and his remark-
able industry in pushing his researches into every
source whence information is derivable, has enabled
him to throw together  an extensive mass of facta
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 Amer icdn Journal
of Pharmacy.
                          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,
  octavo, 226 pages.
                             FRICK (CHARLES),  M. D.
RENAL   AFFECTIONS;  their  Diagnosis and Pathology.
  One volume, royal 12mo., extra cloth.
With  illustrations. 
14                      BLANCHARD &  LEAS MEDICAL
                                  ERICHSEN  (JOHN),
                     Professor of Surgery in University College, London, Ac.
THE SCIENCE  AXD ART OF SUUGERV; bkixo aTrkatise on Surgical
  Injuries, Diseases,  and Operations.   Edited  by Johx H. Bkinton, M. D.   illustrated with
  three hundred and  eleven engravings on wood.  In one large and handsome octuvo volume, of
  over nine hundred closely printed pages.  (Just Issued.)
  It is. in our humble judgment, decidedly  the best
book of ihe kind in the Kntrlish language.  Strang.-
that just such books are noloftener produced by pui>
lie teacher-' of surgery  in this  counlry  and  (in-ai
Britain.  Indeed, il is a matterof great astonishment.
but no less true than astonishing,  that of the many
works on surgery republished in this country within
the last fifteen or  twenty years as text-books for
medical students, this is the only one, that even ap-
proximates to ihe fulfilment of the  peculiar wants of
young men just entering upon the study of this branch
of the profession.— Western Jour.of Med. and Surgery.
  Embracing, as will be perceived, the whole surgi-
cal domain, and each division of itself almost com-
plete and perfect, each chapter full  and explicit, each
subject faithfully exhibited, we can only express our
extimate of it in the aggregate.  We consider it an
excellent contribution  to surgery, as  probably the
best single volume  now exiaril on the subject, and
with great pleasure we  add  it to  our textbooks —
Nu.iiville Journal of Medicine and Surgery.
  Its value  is  greatly  enhanced by a very copious
well-arranged index.  We regard  this as one of the
most valuable contributions to modern surgery. To
one entering his novitiate of practice, we  regard it
the most serviceable guide which he can consult.  Ho
will find a fulness of detail leading him through every
step of the operation, and not deserting him until the
final issue of the case is deeided.  For the siiuie reu-
son we recommend il to those whose routine of prac-
tice lies in such parts of the country that tliey must
rarely encounter cases requiring buryical  manage-
ment.—Stethoscope.
  Prof. Erichsen's work, for its  size, has  not been
surpassed; his nine hundred and eight pages,  pro-
fusely tllustraled, are rich in physiological, patholo-
gical,  and operative suggestions, doctrines, details,
and processes; and will prove a rt liable  resource
for information, both to physician  and surgeon, in the
hour of peril.— N. 0. Med. and Sutl; Journal.
  We are  acquainted  with  no  other work wherein
so much good sense, sound principle, and practio.ri
inferences, stamp every page.  To say more of the
volume would be useless; to say  less would be doing
injustice to a production which  we consider above
all others at the present day, and superior and more
complete than the many excellent treatises of the
Knglish and Scotch  surgeons, and tins is no small
encomium.—American Lancet.
                             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.  (Lately Issued.)
  After an examination of the new matter and the
alterations, we believe the reputation of the work
built up by the author, and the late distinguished
editor, will continue to flourish under the auspices
of the present editor, who has the industry nnd accu-
racy,  and, we would say, conscientiousness requi-
site for the responsible task.—American Journal of
Pharmacy, March, 1S54.
  It will  prove particularly useful to students and
young practitioners, as the most important prescrip-
tions employed in  modern practice, which  lie scat-
tered through our  medical literature, are here col-
lected and conveniently arranged  for reference.—
Charleston Med. Journal and Review.
                         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.   (Now 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. Hofmann, 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.
  We know of no better text-book, especially in the
difficult department of organic  chemistry, upon
which it is particularly full and  satisfactory.  We
would  recommend it  to  preceptors as a  capital
" office book" for  their students who are beginners
in Chemistry.  It  is copiously illustrated with ex-
cellent wood-cuts, and altogether admirably "got
up."—JV. J. Medical Reporter, March, 1854.

  A standard manual, which  has long enjoyed the
reputation of embodying much knowledge in a small
space.  The author has achieved  the difficult task of
condensation with masterly tact. His book is con-
cise without being dry, and brief without being too
dogmatical or general.— Virginia Med. and Surgical
Journal.
  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 Gmelin, 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 doctrinea
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 charge*
very properly urged against most manuals termed
popular.—Edinburgh Monthly Journal of Medical
Science. 
AND SCIENTIFIC  PUBLICATIONS.
15
                       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.   (Just Issued.)
  The most important subjects in connection with
Cradical surg&ry which have been  more recently
 rought under the notice of, and discussed by, the
surgeons of Great Britain, are fully and dispassion-
ately considered by Mr. Fergusson, and that whicl
was before wanting has now been supplied; so that
we can now lodk upon it as a work on practical sur-
gery instead of one on operative surgery  alone.
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 pur-
poses of the practitioner, whether he confines him-
self 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 singlepurpose than this.—If. Y. Med', and Surg.
Journal.
  The addition of many new pages makes this work
more than ever indispensable to the student and prac-
titioner.—Ranking's Abstract.

  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.
                          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.
                      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.   Second Edition, thoroughly revised, with numerous additions,  by Robert P. Thomas,
  M. D., Professor of Materia Medica in the Philadelphia College of Pharmacy.   In one large and
  handsome octavo volume, of over six hundred pages, double columns.  (Just Issued.)
  It was a work requiring much perseverance, and
when published was looked upon as by far the best
work of its kind that had issued from the American
press, being free of much of the trashy, and embrac-
ing most of the non-officinal formulae used or known
in American, English, or French practice, arranged
under the heads of the several conslituentdrugs, plac-
ing the  receipt under its more important constituent.
Prof Thomas has certainly "improved," as well as
added to this Formulary, and has rendered it addition-
ally deserving of the confidence  of pharmaceutists
and physicians.—American Journal of Pharmacy.
  We are happy to announce a new and improved
edition of this, one of the  most valuable and useful
works that have emanated from  an American pen.
It would do credit to any country, and will be found
of daily usefulness to practitioners of medicine; it is
better adapted to their purposes than the  dispensato-
ries.— Southern Med. and Surg. Journal.
  A new edition of this well-known work, edited by
R. P. Thomas. M. D.,  affords  occasion for renewing
our commendation of so useful a handbook, which
ought to be universally studied by medical men  of
every class, and made use of by way of reference by
office pupils, as a standard  authority.  It has been
much enlarged, a>id now condenses  a vast amount
of needful and necessary  knowledge in  small com-
pass.  The more of such books the better for the pro-
fession  and the public— N. Y. Med. Gazette.
  It is one of the most nsefil books a country practi-
tioner can possibly have in his possession.—Medical
Chronicle.
  The amount of useful, every-day matter, for a prac-
ticing physician,  is really immense.—Boston Med.
and Surg. Journal.
  This is a work of six hundred and fifty one pages,
embracing all on the subject of preparing and admi-
nistering medicines that can be desired by the physi-
cian and pharmaceutist.— Western Lancet.

  In short, it is a full and complete work of the kind,
and should be in the hands of every physician and
apothecary.— O. Med. and Surg. Journal

  We predict a great sale for this work, and we espe-
cially recommend it to  all medical teachers.—Rich-
mond Stethoscope.

  This edition of Dr. Griffith's work has been greatly
improved by the revision and ample additions of Dr.
Thomas, and is now, we believe, onfe of the most
complete works  of its kind in  any language.  The
additions amount to  about seventy pages, and no
effort has been spared to include in them all ihe re-
cent improvements which have  been published in
medical journals, and systematic treatises.  A. work
of this kind appears to us indispensable to the physi-
cian, and there is none we can more cordially recom-
mend.— N. Y. Journal of Medicine.
                                   BY THE SAME AUTHOR.
MEDICAL  ROT ANY;  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.

                        GREGORY (WILLIAM), F. R. S. E.,
LETTERS   TO A  CANDID  INQUIRER   ON  ANIMAL  MAGNETISM.
  In one neat  volume, royal 12mo., extra cloth,   pp. 384. 
16
BLANCHARD &  LEA'S  MEDICAL
                           GROSS  (SAMUEL  D.),  M.  D.,
                     Professor of Surgery in the University of Louisville, Ac.

A  PRACTICAL   TREATISE  ON  THE  DISEASES,   1NJUIJLKS,  AND
  MALFORMATIONS OF THE UKINARV  BLADDER, THE PROSTATE  GLAND, AM)
  THE URETHRA.   Second Edition, revised  and much enlarged, with one hundred and eighty-
  four illustrations.  In one large and very handsome octavo volume, of over nine hundred pages.
  [Noio Ready.)
  The author has availed  himself of the opportunity afforded by a call for  a new edition of this
work, to thoroughly revise and render it in every respect worthy, so far as in his power, of the very
flattering reception which has been accorded  to  it by the profession.  The new matter thus added
amounts to almost one-third of the original work, while the number of illustrations has been nearly
doubted.  These additions pervade every portion of the work, which thus has rather  the aspect of
a new treatise than a new edition.  In its present improved form, therefore, it may confidently be
presented as a complete and reliable storehouse of information on this important class of diseases.
and as in every way fitted  to  maintain  the position-which it has acquired  in Europe and in  this
country, as the standard of authority on the subjects treated of.
  On the appearance of the first edition of this work,
 the leading English medical review predicted that it
 would have a " permanent place in the literature of
 surgery worthy to rank with the best works of the
 present age."  This prediction has been amply ful-
/filled. Dr. Gross's treatise has  been found to sup-
 ply completely  the want which  has been felt ever
 since the elevation of surgery to the rank of science,
 of a  good practical treatise on  the diseases of the
 bladder and its  accessory organs. Philosophical in
 its design, methodical in its arrangement, ample and
 sound in its practical details, it may in truth be said
 to leave  scarcely anything to  be desired on  so im-
 portant a subject, and with the additions and modi-
 fications resulting from future discoveries and im-
 provements, it will probably remain one of the most
 valuable works on this subject so long as the science
 of medicine shall exist.—Boston Med.  and Surg.
 Journal, June 7, 1655.
  A volume replete with truths and principles of the
 utmost value in the investigation of these diseases.—
 American Medical Journal.
  Dr. Gross  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.—Western Journal of Med. and Surg.
  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-cut? which illustrate it, de-
monstrate that America is tnakimr 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 what animates a long-
expectant husbandman, who, oftentimes disappointed
by the produce of  a favorite field, is at last agree-
ably surprised by  a stately crop which may  bear
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.
  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.—JV. Y. Journal of Medicine.
                            BY THE same author.  (Just Issued).

A PRACTICAL TREATISE  ON  FOREIGN BODIES  IN  THE  AIR-PAS-
  SAGES.  In one handsome octavo volume, with illustrations,  pp. 468.
                                               a most interesting and hitherto a most neglected de-
                                               partment of surgical pathology and practice.—St.
Louis Med. and Surg. Journal, May, 1855.
  Surgical authors, isolated reports in medical pe-
riodicals and modern surgeons ' blend their common
toil" to make a book which exhausts the subject,
and must forever remain the standard work on the
management of this accident.—Buffalo Mud. Journ.
  We consider this work one of the most important
of the recent additions to practical surgery.  Con-
taining all  that has been recorded relating  to the
class of accidents of which it  treats,  admirably
arranged and systematized, it should find a place in
  A very elaborate work. It is a complete summary
of the whole subject, and will be a useful book of
reference.—British and  Foreign  Medico-Chirurg.
Review.
  A highly valuable book of reference on a most im-
portant  subject in  the practice of medicine.  We
conclude by recommending it to our readers, fully
persuaded  that its perusal  will afford them much
practi"al information well conveyed, evidently de-
rived from considerable experience and deduced from
an ample  collection of facts. — Dublin Quarterly
Journal, May, 1855.
  In this valuable monograph Dr. Gross has cer-
tainly struck a new lead in Surgery, and is entitled  everymedical library.—Montreal Med. Chronicle
to the credit of having  illustrated and systematized I

                             BY the same author.  (Preparing.)

A SYSTEM  OF  SURGERY;  Diagnostic, Pathological, Therapeutic, and Opera-
  tive.  With very numerous engravings on wood.

                                   BY  THE SAME AUTHOR.

ELEMENTS OF  PATHOLOGICAL  ANATOMY;  illustrated by colored En-
  gravings, and two hundred and fifty wood-cuts.  Second edition, thoroughly revised and greatly
  enlarged,   In one very large and handsome imperial octavo volume,  pp. 822.
  We recommend it as the most complete, and,  on | The colored engravings and wood-cuts are exceed
the whole, the least  defective compilation on tli
subject in the English  language.—Brit. and. For.
Med. Journal.
  It is altogether the most complete exposition of
Pathological Anatomy in our language.—American
Journal of Medical Sciences.
  It is the most complete and useful systematic work
on Pathological Anatomy in the English language.
ingly well executed, and the entire getting up of the
work does much credit to the enterprising publishers.
We regard it as one of the  most  valuable works
ever issued from the American press, and it does
great honor alike to the author, and the country of
his birth.—N. Y. Journal of Medicine.
  We commend it to the attention of the profession
as one of the best extant upon the subject on which
it irente.—Southern Journal Med. and Pharmacy. 
AND  SCIENTIFIC  PUBLICATIONS.
L7
                         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!
  This being, as far as we know, the only work in
which pathological histology is separately  treated
of in a comprehensive manner, it will, we think, for
this reason, be of infinite service to those who desire
to investigate the subject systematically, and who
have  felt the difficulty 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 phy-
siology.—American Med. Journal.
                       GARDNER  (D. PEREIRA),  M. D.
MEDICAL CHEMISTRY, for the use of  Students  and the  Profession: heing a
  Manual of the Science, with its Applications to Toxicology, Physiology,  Therapeutics, Hygiene,
  &c.  In one handsome royal 12mo. volume, of about 400 pages, 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
  SYSTEM.  In one octavo volume, 292 pages.

                                HUNTER (JOHN).
TREATISE ON THE  VENEREAL DISEASE.   With copious Additions, hy
  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.) ISF See Ricord.
Also, HUNTER'S COMPLETE WORKS, with Memoir, Notes, &c. &c.  In four neat octavo
  volumes, with plates.

                            HUGHES  (H.  M.), M. D.,
                         Assistant Physician to Guy's Hospital, See.
A  CLINICAL  INTRODUCTION  TO  THE  PRACTICE OF  AUSCULTA-
  TION, and other Modes of Physical Diagnosis, in Diseases of the  Lungs and Heart. Second
  American from the Second and Improved London Edition. In one royal 12mo. vol. pp. 304.
  It has been carefully revised throughout.  Some small  portions have been erased;  much has
been, I trust, amended;  and a great deal of new matter has been added;  so that, though funda-
mentally it is the same book, it is in many respects a new work.—Preface.

                       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.  New and  much improved American Edition.  Revised, with
  numerous  Additions, from  the last London edition, by Isaac Hays, M. D., &c.  In one  large
  royal 12mo. volume, of over four hundred pages, double columns.  (Nearly Ready.)
  In passing this work a second time through the press, the editor has subjected it to a very tho-
rough revision, making such additions  as the  progress of science has rendered desirable, and sup-
plying any omissions that  may have previously existed.  As a concise and convenient Dictionary
of Medical Terms, at an exceedingly low price, it will therefore be found of great value  to the stu-
dent and practitioner.

                    JONES (T.  WHARTON),  F. R. S.,  &.C.
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.
                                            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
  The work amply sustains, in every point the al-
ready high reputation of the author as an ophthalmic
Burgeon 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
oare and attention. We eatertain  little doubt that
this hnok will  become  wkat its author hoped it
all the productions of the learned author.—British
and Foreign Medical Review. 
18
BLANCHARD k  LEA'S  MEDICAL
JONES (C. HANDFIELD), F.  R. S.,  &. EDWARD  H.  SIEVEKING, M.D.,
                Assistant Physicians and Lecturers in St. Mary's Hospital, London.

A  MANUAL OF  PATHOLOGICAL  ANATOMY.   First  American  Edition,
  Revised.  With three hundred and ninety-seven handsome wood engravings.   In one large and
  beautiful octavo volume of nearly seven hundred and fifty pages.   (Just Issued.)

  In a work like the present, intended as a text-book for the student of pathology, accurate engrav-
ings of the various results of morbid action  are of the greatest assistance.   The American pub-
lishers have, therefore, considered that the value of the work might be enhanced by increasing the
number of illustrations,  and, with this object,  many wood-cuts, from the best authorities, have been
introduced, increasing the number from one  hundred and  sixty-seven, in the London Ldilion, to
three hundred  and ninety-seven in this.   The selection of these  wood-cuts  has been made by a
competent member of the profession,  who has  supervised  the progress  of the work through the
press, with the view of securing an accurate reprint, and of correcting such errors as had escaped
the attention of the authors.
  With these improvements,  the  volume  is  therefore presented  in the  hope of supplying the ac-
knowledged want of a work which, within a  moderate compass,  should embody a condensed and
accurate digest of the present state of pathological science, as extended by recent microscopical,
chemical, and  physiological researches.
  Asa concise text-book, containing, in a condensed I authors have not attempted to intrude new views on
                                               their professional brethren, but simply to lay before
                                               them, what has long been wanted, an outline of the
                                               present condition ot pathological anatomy.  In this
                                               they have been completely successful.  The work is
                                               one of the best compilations which we have ever
                                               perused.  The opinions and  discoveries of all the
                                               lending pathologists and physiologists are engrossed,
                                               so that by reading any subject  treated in the book
                                               you have a synopsis of the views of  the most ap-
                                               proved  authors.—Charleston Medical Journal and
                                               Review.
                                                 We have no  hesitation in recommending it ns
                                               worthy of careful and thorough study by every mem-
                                               ber of the profession, old, or young.—JV. W. Med.
                                               and Surg. Journal.
                                                 From  the casual examination we have given we
                                               are inclined to regard it ns  a text-book, plain, ra-
                                               tional, and intelligible, such a book as the practical
                                               man needs for daily reference.  For this reason it
                                               will be likely to be largely useful, as it suits itself
                                               to those busy men who have  little  time for minute
                                               investigation, and prefer a summary to an elaborate
                                               treatise.—Buffalo Medical Journal.
form, a complete outline of what is known in the
domain of Pathological Anatomy, it is perhaps the
best work in the English language.  Its great merit
consists in its completeness and brevity, and in this
respect il supplies  a great desideratum in our lite-
rature.  Heretofore the student of pathology was
obliged to glean from a great number of monographs,
and the field was so extensive that but few cultivated
it with sny decree of success. The authors of the
present work have sought to corrrct this defect by
placing before the reader a summary of ascertained
facts, together with the opinions of the most eminent
pathologists both of the Old and New World.  As a
simple work of  reference, therefore,  it is of great
value to the student of pathological  anatomy, and
should be in every physician's  library.— Western
Lancet.

  We urge upon our readers and the  profession gene-
rally the importance of informing themselves in re-
gard to modern views of pathology, and recommend
to them to procure the work  before us as the best
means of obtaining this information.—Stethoscope.
  In  offering the above titled work to the public, the
                    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 and 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.—• 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-
«tl 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.

  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.
  First American edition, with Notes and Additions, by Prof. Walter R. Johnson.   In two hand-
  some octavo volumes, printed and illustrated in the highest style of art, with about five hundred
  wood-engravings.
                                   LONGET  (F. A.)

TREATISE  ON  PHYSIOLOGY.   With  numerous  Illustrations.   Translated
  from the French by F. G. Smith, M. D., Professor of Institutes of Medicine in the Pennsylvania
  Medical College.   (Preparing.) 
AND  SCIENTIFIC PUBLICATIONS.
19
                                LEHMANN  (G. C.)

PHYSIOLOGICAL  CHEMISTRY.   Translated by George E. Day, M. D.,
  and edited  by Prof. R.  E.  Rogers, of the University of Pennsylvania.  In  two large octavo
  volumes, with handsome illustrations.  (Nearly Ready.)
  This great work, universally recognized as the most complete and authoritative exposition of its
intricate and  important subject in its most  advanced condition, will receive every care during its
passage through the press, under the superintendence of Prof. Rogers, to insure the entire accuracy
indispensable to a work  of this character.  It will  be further improved by the distribution in the
appropriate places throughout the text of the numerous additions and corrections embodied in the
Appendix, while a number of illustrations will be introduced from " Funke's Atlas of Physiological
Chemistry."  The publishers, therefore, trust that  it will be found a complete and accurate edition,
and in every respect worthy of the reputation of the work.
  The progress of research in this department is so
rapid, that Prof. Lelimann's treatise must be re-
garded  as  having completely superseded  that of
Simon; and all who desire to possess a systematic
work on Physiological Chemistry by a man who is
thoroughly qualified, both by his physiological and
and exact view of its present aspect, should lose no
time in attaching themselves to the Society by whieh
it is in course of publication.—British and Foreign
Medico-Chirurgical Review.
  The work of Lehmann stands unrivalled as the
most comprehensive book of reference and informa-
chemical acquirements, by his own eminence as an | tion extant on every branch of the subject on which
experimentalist, and by the philosophic impartiality j u treats.—Edinburg Monthly Journal of Medical
of his habits of thought, to afford a comprehensive I scjencg#
                         LAWRENCE (W.),  F. R. S., &c.

A TREATISE  ON  DISEASES  OF  THE   EYE.   A   new edition,  edited,
  with numerous additions, and 243 illustrations, by Isaac Hays, M. D., Surgeon to Wills Hospi-
  tal, &c.  In one very large and handsome octavo volume, of 950 pages, strongly bound in leather
  with raised bands.   (Lately Issued.)
  This work is so universally  recognized  as the standard authority on the subject, that the pub-
lishers in presenting this new edition have only to remark that in  its  preparation the editor has
carefully revised every portion, introducing  additions and illustrations wherever the advance of
science has rendered them necessary or desirable.  In this  manner  it will be found to con-
tain  over one hundred pages more  than the last edition, while the list of wood-engravings
has been  increased by sixty-seven  figures, besides numerous improved illustrations substituted
for such as were  deemed imperfect or unsatisfactory.   The various important contributions to
ophthalmological science,  recently made by  Dalrymple, Jacob, Walton, Wilde, Cooper, &c,
both in the form of  separate treatises  and contributions to periodicals,  have been carefully
examined by the editor,  and, combined with the  results of his own experience, have been
freely  introduced throughout the volume, rendering it a complete and thorough exponent of
the most advanced state of the subject.
                                              octavo pages—has enabled both author and editor to
                                              do justice to all the details of this subject, and con-
                                              dense in this single volume the present state of our
  In a future number we Khali notice more at length
this admirable treatise —the safest guide and most
comprehensive work of reference, which is within
the reach of all classes of the profession.—Stetho-
scope, March, lb54.

  This standard text-book on the department of
whieh it treats, has not been superseded, by any or
all of the numerous publications  on the subject
heretofore issued.  Nor with the multiplied improve-
ments of Dr. Hays, the American editor, is  it  at all
likely that this great work will cease to merit the
confidence and preference of students  or practition-
ers.  Its ample extent—nearly one thousand  large
knowledge of the whole science in this department,
whereby its practical value cannot be excelled. We
heartily commend it, especially as a book of refe-
rence, indispensable in every medical library.  The
additions  of the American editor very greatly  en-
hance the value of the work, exhibiting the learning
and experience of Dr. Hays, in the light in which he
ought to be held, as a standard authority on all sub-
jects appertaining to this specialty, to which he  has
rendered  so many valuable contributions.—N. Y.
Medical Gazette.
                      LEE (ROBERT),  M. D.,  F. R. S.,  &.C.

CLINICAL  MIDWIFERY;  comprising  the  Histories of  Five  Hundred  and
  Forty-five Cases of Difficult, Preternatural, and Complicated Labor, with Commentaries.  From
  the second London edition.  In one royal 12mo. volume, extra cloth, of 238 pages.

                             LUDLOW  (J.  L.),  M. D.,
                 Lecturer on Clinical Medicine at the Philadelphia Almshouse, &c.
A MANUAL  OF  EXAMINATIONS  upon Anatomy and  Physiology, Surgery,
  Practice  of Medicine, Chemistry, Obstetrics, Materia Medica, Pharmacy, and  Therapeutics.
  Designed for Students of Medicine throughout the United States.  A new edition, revised and
  extensively improved.  In one large royal 12mo. volume, with several hundred illustrations.
  (Preparing.)

                        LISTON (ROBERT), F. R. S., &c.
LECTURES  ON  THE  OPERATIONS  OF  SURGERY, and on Diseases and
  Accidents requiring Operations.   Edited, with numerous Additi6ns and Alterations, by T. D.
  Mutter, M. D.  In one large and handsome octavo volume, of 566 pages, with 216 wood-cuts.

                                  LALLEMAND (M.).
THE  CAUSES,  SYMPTOMS,  AND  TREATMENT  OF   SPERMATOR-
  RHOEA.  Translated and edited by Henry J. McDougal.  In  one volume, octavo, 320 pages.
  Second American edition.  (Just Issued.) 
20
BLANCHARD  & LEA'S  MEDICAL
                            LA ROCHE (R.),  M. D., &c.

PNEUMONIA ;  its  Supposed Connection, Pathological  and  Etiological, with  Au-
  tumnal Fever>, including an Inquiry into the  Existence arid  Morbid Agency of Maluria.  In one
  handsome octavo volume, extra cloth, of 500 pages.

                                              the periodical press, and yet in the work before ui
                                              he has exhibited an amount of industry and learning,
                                              research and ability, beyond what we are accustomed
                                              to discover in  modern medical writers;  while bis
                                              own  extensive opportunities for  observation and
                                              experience have been improved by the most laudable
                                              diligence,  and  display n familiarity with  the whole
                                              subject in  every aspect, which commands both our
                                              respect and confidence. As a corrective of prevalent
  A more simple, clear, and forcible exposition of
the groundless nature and dangerous tendency of
certain pathological and  etiological heresies,  has
seldom been presented to our notice.—A'. Y. Journal
of Medicine and Collateral Science.

  This work should be carefully studied by Southern
physicians, embodying as it does the reflections of
an original thinker and close observer on a subject
peculiarly their own.— Virginia Med. and Surgical
Journal.
  The author had prepared us to expect a treatise
from him, by his brief papers on kindred topics in
and mischievous error, sought to be propagated by
novices and innovators, we could wish that Dr. Ea
Roche's book could be widely read.—Ar. Y. Medical
Gazette.
                            by the same author.  (Just Ready.)

YELLOW FEVER,  considered  in  its Historical,  Pathological, Etiological,  and
  Therapeutical Relations.  Including a Sketch of the Disease as it has occurred  in Philadelphia
  from 1699 to 1854, with an examination of the connections between it and the fevers known under
  the same name in other parts of temperate  as  well as in tropical regions.  In two large and
  handsome octavo volumes.
  The publishers are happy in being able to announce the speedy appearance of this great work.
As the result of many years of study and observation, and as a complete resume of all that has been
written on the subject, it will at orice lake its place as the standard authority and work of reference
on the important questions brought under consideration.
                    LARDNER (DIONYS1US), D. C. L., &c.

HANDROOKS   OF   NATURAL   PHILOSOPHY   AND   ASTRONOMY.
  Revised, with numerous Additions, by the American editor.  First Course, containing Mecha-
  nics, Hydrostatics, Hydraulics,  Pneumatics, Sound,  and Optics.  In  one  large royal 12mo.
  volume, of 750 pages, with 42-1 wood-cuts.  Second Course, containing Heat, Electricity, Mag-
  netism,  and Galvanism, one volume, large royal 12mo.,  of 450  pages,  with 250 illustrations.
  Third Course ( now ready), containing Meteorology and Astronomy, in one large volume, royal
  12mo. of nearly eight hundred pages, with thirty-seven plates and two hundred wood-cuts.  The
  whole complete in three volumes, of about two  thousand large  pages, with over one thousand
  figures on steel and wood.  Any volume sold separate.
  The various sciences treated in this work will be found  brought thoroughly up to the latest period.
                             MACKENZIE  (W.),  M.D.,
                 Surgeon Oculist in Scotland in ordinary to Her Majesty, &c. &c.

A PRACTICAL  TREATISE ON  DISEASES   AND  INJURIES OF  THE
  EYE.  To which is prefixed an Anatomical Introduction explanatory of a Horizontal Section of
  the Human Eyeball, by Thomas Wharton Jones, F. R. S.  From the Fourth Revised and En-
  larged London Edition.  With Notes and Additions by Addinell  Hewson, M. D.,  Surgeon to
  Wills Hospital, &c. &c. In one very large and handsome octavo volume, with plates and numerous
  wood-cuts.  (Nearly Ready.)
  The reputation which this work has universally attained will be enhanced by the present edition.
Besides the  thorough revision by the author which it has enjoyed in  recently passing through the
press in London, the additions by the editor will embrace whatever is necessary to adapt it com-
pletely to the wants of  the American practitioner, constituting it a library of Ophthalmic Medicine
and Surgery.
  The treatise of Dr. Mackenzie indisputably holds
the first place, and forms, in respect o( learning and
research, an Encyclopcedia unequalled in extent by
any other work of the kind, either English or foreign.
—Dixon on Diseases of the Eye.

  Few modern books on any department of medicine
or surgery have met with such extended circulation,
or have procured  for their  authors a like amount of
European celebrity.  The immense research which
it displayed, the  thorough  acquaintance with the
subject, practically as well as theoretically, and the
able manner in which the author's stores of learning
and experience were rendered available for general
use, at once procured for the first edition, as well on
the continent as in  this country, that high position
as a standard work which each successive edition
has more firmly established, in spite of the attrac-
tions of several rivals of no mean ability.  This, the
fourth edition, has been in a great measure re-writ-
ten ;  new matter, to the extent of one hundred and
fifty pages, has been added, and in several instances
formerly expressed  opinions have  been modified in
accordance with the advances in the science which
have been made of late years.  Nothing worthy of
repetition upon any branch of the subject appears to
have escaped the author's notice.   AVe consider it
the duty of every one who has the love of his profes-
sion and the welfare of his patient ut heart, to make
himself familiar with  this the most complete work
in the English language upon the diseases of the eye.
—Med. Times and Gazette.
  The fourth edition of this standard work will no
doubt be as fully appreciated as the three former edi-
tions. It is unnecessary to say a word in its praise,
for the verdict  has already been passed upon it by
the most competent judges, and " Mackenzie on the
Eye" has justly obtained a reputation which it is
no figure of speech to call world-wide.—British and
Foreign Medico-Chirurgical Review.
  This new edition of Dr. Mackenzie's celebrated
treatise on diseases of  the eye, is truly a miracle of
industry and learning.  We need scarcely day that
he hag entirely exhausted the subject of his specialty.
—Dublin Quarterly Journal. 
AND  SCIENTIFIC PUBLICATIONS.                   21
                          MEIGS (CHARLES  D.), M. D.,
             Professor of Obstetrics, &c. in the Jefferson Medical College, Philadelphia.

ON   THE   NATURE,   SIGNS,   AND   TREATMENT  OF  CHILDBED
  FEVER.  In  a Series of Letters addressed to the Students of his Class.  In  one handsome
  octavo volume, of three hundred and sixty-five pages.  (Now Ready.)
  The  instructive and interesting author of thjs
work, whose previous labors in the  department of
medicine which he so sedulously cultivates, have
placed his countrymen under deep and abiding obli-
gations, again challenges  their admiration in  the
fresh and vigorous, attractive and racy pages before
us.  It is a delectable book. *  #  * This treatise
  This book will add more to his fame than either
of those which bear his name.  Indeed we doubt
whether any material improvement will be made on
the teachings of this volume for a century  to come,
Bince it is so eminently practical, and based on pro-
found knowledge of  the science and consummate
skill in the art of healing, and ratified by an ample
and extensive experience, such as few men have the
industry or good  fortune to acquire.—N.  Y. Med.
Gazette.
upon child-bed fevers will have an extensive sale,
being destined, as it deserves, to find a place in the
library of every practitioner who scorns to lag in the
rear  of his brethren.—Nashville Journal of Medi-
cine and Surgery.

                                  BY  THE SAME AUTHOR.

WOMAN: HER  DISEASES  AND  THEIR  REMEDIES.   A Series of Lee-
  tures  to his Class.  Third  and Improved edition.  In one large and beautifully printed  octavo
  volume.  (Just Issued. Revised and enlarged to 1854.)   pp. 672.

  The gratifying appreciation of his labors, as evinced by the exhaustion of two large impressions
of this work within a few years, has not been  lost upon the author, who has endeavored in every
way to render  it worthy of the  favor with which it has  been received.  The opportunity thus
afforded for a second revision has been improved, and the work is now presented as in every way
superior to its predecessors, additions  and alterations  having beefl made whenever the advance of
science has rendered them desirable.  The typographical execution of the  work will also be found
to have undergone a similar improvement and the work is now confidently presented as in every
way worthy the position it has acquired as the standard American text-book on the Diseases of
Females.
                                              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.—JV. Y. Med. Gazette.
  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 OfT-hand fervor, a glow,  and a warm-
heartedness infecting the efTort 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  ability, 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 und made to stand  out in
                                  BY THE SAME AUTHOR.

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.

                           BY THE SAME AUTHOR.   (Now Ready.)

A  TREATISE  ON  ACUTE AND  CHRONIC  DISEASES  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, extra cloth.

  The object of the  author in this work has been to present in a  small compass the practical results
of his long experience in this important and distressing class of diseases.   The great changes intro-
duced into practice, and the accessions to our knowledge on the subject, within the last few years,
resulting from the use of the metroscope, brings within the ordinary practice  of every physician
numerous cases which were formerly regarded  as incurable, and renders of great value a work like
the present combining practical  directions for diagnosis and treatment with an ample series of illus-
trations, copied accurately from colored drawings made by the author, after nature.
BY THE SAME AUTHOR.
OBSERVATIONS  ON  CERTAIN  OF   THE   DISEASES   OF   YOUNG
  CHILDREN.  In one handsome octavo volume, of 214 pages. 
22                     BLANCHARD &  LEA'S  MEDICAL
                       MACLISE  (JOSEPH),  SURGEON.

SURGICAL  ANATOMY.   Forming  one  volume,  very  large  imperial  ouarto.
  With sixty-eight large and splendid Plates, drawn in the best style and beautifully colored.  Con-
  taining one hundred and  ninety Figures, many of them the size of life.  Together with copious
  and explanatory letter-press.   Strongly and  handsomely bound in i^tra cloth, being one of the
  cheapest and best executed Surgica 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 ol
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 a work 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.
  One of the greatest artistic triumphs of the age
in Surgical Anatomy.—British American Medical
Journal.
  Too much cwinot  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 offered 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.—JV. 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-
valled, both for accuracy of drawing, beauty of
coloring,  and all the requisite explanations of the
subject in hand.—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.  In  those sudden emergencies that so often
arise, and which require the instantaneous command
of minute anatomical knowledge, a work of this kind
keeps the details of the diBsecting-room perpetually
fresh in the memory.—The Western Journal of Medi-
cine and Surgery.
  ggjp" 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.
                        MULLER (PROFESSOR  J.),  M.D.

PRINCIPLES  OF  PHYSICS  AND  METEOROLOGY.   Edited, with  Addi-
  tions, by R. Eglesfeld Griffith, M. D.  In one large and handsome octavo volume, extra
  cloth, with 550 wood-cuts, and two colored plates, pp. 636.

  The Physics of Mailer is a work superb, complete, j tion to the scientific records of this country may be
unique : the greatest want known to English Science j duly estimated by the fact that the cost of the origi-
could not have been better supplied.  The work is I nal drawings and engravings alone has exceeded the
of surpassing interest.  The value of this contrihu- | 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 Pharmacopeia, 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 J. Pereira, M. D.  In one neat royal 12mo. volume, extra cloth, with cuts, 388 pages. 
AND SCIENTIFIC  PUBLICATIONS.
23
                          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, byF. 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.
  This edition is far superior, both in the abundance
nnd quality of its material, to any of the preceding.
We hope it will be extensively read, and the sound
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.—JV. Y. Journal  of
Medicine.
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 nnd 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
Bound and philosophical views developed in the fore-
going book.—New Orleans Med. and Surg. Journal.
  Without doubt the ablest exposition of the prin-
ciples of that branch of the  healing art in any lan-

                          by  the  same author.  (Lately Published.)

THE  PRACTICE OF  SURGERY.   Third  American  from  the second  Edin-
   burgh edition.  Edited, with Additions, by F. W. Sargent, M. D , one of the Surgeons to Will's
   Hospital, &c.  Illustrated by three hundred and  nineteen engravings on wood.  In one  large
   octavo volume, of over seven hundred pages.
  No encomium of ours  could add to the popularity
of Miller's Surgery.  Its reputation in this country
is unsurpassed by that of any other work, and, when
taken in connection with the author's Principles of
Surgery, constitutes a whole, without reference to
which  no conscientious surgeon would  be willing
to practice his art.  The additions, by Dr. Sargent,
have materially  enhanced the value of the work.—
Southern Medical and Surgical  Journal.
   It is seldom that two volumes have ever made so
profound an impression in  so short  a time as the
"Principles" and the  "Practice" of Surgery  by
Mr. Miller—or so richly merited the reputation they
have acquired.   The author is an eminently sensi-
ble, practical, and well-informed man, who knows
exactly what he  is talking about and exactly how to
talk it.—Kentucky Medical Recorder.
   The two volumes together form a complete expose
of the present state of Surgery, and they ought to be
on the shelves of every surgeon.—JV. J. Med. Re-
 porter.
  By the almost unanimous voice of the profession,
his works, both on the  principles and practice of
surgery have been assigned the highest rank.  If we
were limited to but one work on surgery, that one
should be Miller's, as we regard it as superior to all
others.—St. Louis Med.  and Surg. Journal.

  The author distinguished alike as a practitioner
and writer, has in this and his "Principles," pre-
sented to the profession one of the most complete and
reliable  systems of Surgery extant.  His style of
writing is original, impressive, and engaging, ener-
getic, concise, and lucid. Few have the faculty of
condensing so much in small space, and at the same
time so  persistently holding the attention;  indeed,
he appears to make the very process of condensation
a means of eliminating  attractions.  Whether  as a
text-book for students or  a  book  of  reference for
practitioners, it cannot be too strongly recommend-
ed.— Southern  Journal of the Medical and Physical
Sciences.
                                MALGAIGNE  (J.  F.L
OPERATIVE  SURGERY, hased on Normal and Pathological Anatomy.   Trans-
  lated from the French, by Frederick Brittan, A. B., M. D.  With numerous illustrations on
  wood.   In one handsome octavo volume, of nearly six hundred pages.

      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.

                               NEILL  (JOHN),  M. D.,
                  Professor of Surgery in the Pennsylvania Medical College, &c.
OUTLINES OF THE ARTERIES.   With short  Descriptions.   Designed  for
  the Use of Medical Students.  With  handsome colored plates.  Second and improved edition.
  In one octavo volume, extra  cloth.
OUTLINES OF THE NERVES.   With short Descriptions.   Designed  for  the
  Use of Medical Students. With handsome plates.  Second and improved edition.  In one octavo
  volume, extra cloth.
OUTLINES  OF  THE  VEINS AND  LYMPHATICS.  With  short Descrip-
  tions.   Designed for the  Use of Medical Students. With handsome colored plates. In one octavo
  volume, extra cloth.                                                             ,      __
ALSO—The three works done up in one handsome volume, half bound, with numerous plates, pre-
  senting a complete view  of the Circulatory, Nervous, and Lymphatic Systems
  This book should be in the hand of every medical
student.  It is cheap, portable, and  precisely the
thing needed in studying an  important, though  diffi
cult"part of Anatomy. — Boston Med. and Surg.
Journal.
  We recommend every student of medicine to pur-
chase a copy of this work, as a labor-saving ma-
chine,  ndmirablv adapted to refresh the memory,
with knowledge gained  by lectures,  dissections,
and the reading of larger works.—JV". Y. Journal of
Medicine.
  This work is from the pen of a Philadelphia ana-
tomist, whose familiar knowledge of the subject has
been aided by the press, the result of which is a vo-
lume of great  beauty and excellence.  Its fine exe-
cution commends  it to the student of Anatomy.  It
requires no other recommendations.—Western Journ.
of Medicine and Surgery. 
»4                     BLANCHARD  &  LEA'S  MEDICAL
                              NEILL  (JOHN), M. D.,
                         Surgeon to the Pennsylvania Hospital, A c; and
                      FRANCIS  GURNEY  SMITH, M.D.,
             Professor of Institutes of Medicine in the Pennsylvania Medicul 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 l'Jmo. volume, of over one
  thousand pages, with three hundred and fifty illustrations on wood. Strongly bound  in leather,
  with raised bands.
  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 to 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.
  Notwithstanding the enlarged size and improved execution of this worlr,  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 nnd 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
Bincerely 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 hlimit
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.
               NELIGAN  (J.  MOORE), M. D., M. R. I. A., &.C.

A  PRACTICAL  TREATISE  ON  DISEASES  OF  THE  SKIN.   In one
  neat royal 12mo. volume, of 334 pages.

                               OWEN (PROF.  R.),
         Author of" Lectures on Comparative Anatomy," " Archetype of the Skeleton," &c.
ON THE  DIFFERENT  FORMS  OF  THE SKELETON,  AND OF THE
  TEETH.  One vol.  royal 12mo., with numerous illustrations.  (Just Issued.)
  The name of the distinguished author is a sufficient guarantee that this little volume will prove
a satisfactory manual and guide to all students of Comparative Anatomy and Osteology.   The im-
portance of this subject in geological investigations will also  render  this  work a most  valuable
assistant to those interested in that science.
                     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,  pp. 350.

                              PANCOAST  (J.),  M. D.,
              Professor of Anatomy in  the Jefferson Medical College, Philadelphia, &c.

OPERATIVE  SURGERY; or, A Description  and Demonstration of  the various
  Processes of the Art; ^including all  the  New Operations, and exhibiting the State of Surgical
  Science in its present advanced condition.  Complete  in one roval 4to. volume, of 380 pages of
  letter-press description and eighty large 4to. plates, comprising 486 illustrations. Second edition,
  improved.
  This excellent work is constructed on the mode]
of the French Surgical Works by Velpeau and Mal-
gaigne; and, so far as the English language is con-
cerned, we are proud as an American to say that,
of its kind it has no supEfiioR.—JV. Y. Journal of
Medicine.
                             PARKER  (LANGSTON),
                        Surgeon to the Queen's Hospital, Birmingham.

THE MODERN TREATMENT  OF  SYPHILITIC DISEASES, BOTH PRI
  MARY  AND SECONDARY;  comprising the Treatment of Constitutional and Confirmed Syphi-
  lis, by a safe and successful method.  With  numerous Cases, Formula;, and Clinical Observa-
  tions. From the  Third and entirely rewritten London  edition.  In one neat octavo volume,
  of 316 pages.  (Just Issued.)
  Few of our readers can require  to be informed  and in some parts has heen rewritten, it is incum-
that Mr. Langston Parker has for some years held bent on us to describe a few of its more salient fea-
one of the highest positions as an authority on the tures. * * * We can heartily recommend Mr. Par-
treatment of "syphilis.  He cannot, therefore, be in ker's Modern Treatment of Syphilitic Diseases as
the position of one who requires the aid of the re- an admirable exposition of the subject of which it
viewer to enable him to bring to light a  first work ; ■ treats.—Association Medical Journal.
bat as  hia  book has undergone  an entire revision, I 
AND SCIENTIFIC  PUBLICATIONS.
25
                                      (Now Complete.)
             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 Encyclopaedia of Materia
  Medica.  Edited, with Additions, by Joseph Carson, M. D., Professor of Materia Medica and
  Pharmacy in the University of Pennsylvania.   In two very large octavo volumes of 2100 pages,
  on small type, with over four hundred and fifty illustrations.
Volume I.—Lately issued,  containing the Inorganic  Materia Medica, over 800  pages, with 145
  illustrations.
Volume II.—Now ready, embraces the Organic Materia Medica,  and forms a very large  octavo
  'volume of 1250 pages, with  two plates and three  hundred handsome  wood-cuts.
  The present  edition of this valuable and standard work Will enhance in  every respect its well-
deserved reputation.  The care bestowed upon its revision by the author may be estimated by the
fact that its size has been increased by about five hundred  pages.  These additions have extended
to every portion of the work, and embrace riot only  the materials afforded by the recent editions of
the pharmacopoeias, but also all the important information  accessible  to the care and industry of
the author  in treatises, essays, memoirs, monographs, and from correspondents in various parts  of
the globe.  In this manner the work comprises the most recent and  reliable information respecting
all the articles of the  Materia Medica, their natural and commercial history, chemical and thera-
peutical properties, preparation,  uses, doses, and modes of administration, brought up to the present
time, with a completeness  not to be met with  elsewhere.  A considerable  portion of the work
which preceded the remainder in London, has also  enjoyed the advantage of a further revision by
the author expressly for this country,  and in addition to this the editor,  Professor Carson, has made
whatever additions appeared  desirable to adapt  it  thoroughly to the U. S. Pharmacopoeia, and to
the wants of the American profession.  An equal  improvement will likewise be observable in every
department of its mechanical execution. It is printed from new type, on good white paper, with a
greatly extended and  improved series of illustrations.
  Gentlemen who have the first volume are recommended to complete their copies without delay.
The first volume will no longer be sold separate.
  When we remember that Philology, Natural His-
tory, Botany, Chemistry, Physics, and  the Micro-
scope, are all brought forward to elucidate the sub-
ject, one cannot fail to see that the reader hasl here
a work worthy of the name of an encyclopedia of
Materia Medica.  Our own opinion of its merits is
that of its editors, and also that of the whole profes-
sion, both of this and foreign countries—namely,
" that  in copiousness of details, in extent, variety,
and accuracy of information, and in lucid explana-
tion of difficult and recondite subjects, it surpasses
all  other works on Materia Medica hitherto pub-
lished." We cannot close this notice without allud-
ing to the special additions of the American editor,
which  pertain  to the prominent vegetable produc-
tions of this country, and to the  directions of the
United States Pharmacopoeia, in connection with all
the articles contained in the volume which are re-
ferred to by it. The illustrations have been increased,
and this edition by Dr.  Carson cannot well be re-
garded in any other light  than that of a treasure
which  should be found in the library of every physi-
cian.—New York Journal of Medical and Collateral
Science, March, 1854.

  The  third edition  of his "Elements  of Materia
Medica, although completed under the supervision of
others, is by far the most  elaborate treatise in the
English language, and will, while medical literature
is cherished, continue a monument alike honorable
to  his  genius, as  to his learning and industry.—
American Journal of Pharmacy, March, 1854.

 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  at 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.
                             PEASELEE  (E. R.),  M. D.,
                  Professor of Anatomy and Physiology in Dartmouth College, &c.
HUMAN HISTOLOGY, in its applications to Physiology and General Pathology;
  designed as a Text-Book for Medical Students.  With numerous illustrations.  In one handsome
  royal 12mo. volume.  (Preparing.)
  The subject of this work is one, the growing  importance of which, as the basis of Anatomy and
Physiology, demands for  it a separate volume.   The book will therefore supply an acknowledged
deficiency in medical text-books, while the name of the author, and his experience as a teacher for
the last thirteen years, is a guarantee that it will be thoroughly adapted to the use of the student.

                          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., Professor of Surgery in the Penna. Medical College, Surgeon to the Pennsylvania
  Hospital, &c.  In one very handsome octavo volume, of 780 pages, with 316 illustrations.
  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 ns, 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.
  One of the best treatises on surgery in the English
language.—Canada Med. Journal.
  Our impression  is, that, as a manual for students,
Pirrie's is the best work extant.—Western Med. and
Surg. Journal. 
26                     BLANCHARD  &  LEA'S  MEDICAL
                               PARRISH  (EDWARD),
  Lecturer on Practical Pharmacy nnd Materia Medica in the Pennsylvania Academy of Medicine, Ac.
A PRACTICAL  INTRODUCTION  TO PHARMACY.  Desigued  as a Tv.xt-
  Book for the  Student, and  as a Guide to the  Physician  and Pharmaceutist.   With numerous
  Formulae and Illustrations.   In  one handsome octavo volume.  (Nearly Ri'.ady.)
  The want of an elementary textbook on  this subject has  long been felt and acknowledged
While vast stores of information on all the collateral  branches of pharmacy are contained in such
works as Mohr and Redwood, the U. S. Dispensatory, the Pharmacopeia,  Percira, and other«,
there has been no compendious manual presenting within a moderate compass, and  in  systematic
order, the innumerable minor details which make up the everyday business of those  who dispells*
medicines.  It has been the object of the author to supply this want, and while to the pharmaceutist
such a work is  manifestly indispensable, its utility will hardly be less to the country pructilioner,
residing at a distance from drug stores, and obliged to dispense the remedies which  he prescribes.
Familiarized with the elements of therapeutics and  the  essentials of materia medica, by his at-
tendance at lectures, he has  hitherto been obliged to learn  for himself  the details of prescribing,
compounding, and preparing  medicines.  The volume commences with a chapter on the "outfit
of the country physician, describing the different articles, their various kinds and comparative ad-
vantages ; the  Pharmacopoeia is described, explained, and commented upon, its contents classified
and arranged so as to  be easily comprehended and referred  to; all the operations  of pharmacy are
given in minute detail, and under each  head  the various preparations are  specified to which it i*
applicable, with directions for making them, giving in this  manner a comprehensive and  practical
view of the materia medica,  with much valuable information regarding all  the more  important ar-
ticles.  All the officinal formula; are thus presented, with directions for their preparation and use,
together with many empirical ones of interest, and numerous new ones derived from the practice
of distinguished physicians.   Especial  attention  has been  bestowed on the new kemkdies, tlie
more important of which are minutely described, particularly  those derived  from our indigenous
plants, which  have of late  attracted  so much  attention, and which the  author has thoroughly
investigated.  The chapters on extemporaneous  pharmacy contain clear and  accurate instructions
for writing prescriptions, selecting, combining, dispensing,  and compounding medicines, making
powders, pills, mixtures, ointments, &c. &c,  with formulae ; and the work concludes with an ap-
pendix of valuable  hints and  advice to those  purchasing  articles connected with  their  profession.
Numerous tables  interspersed throughout elucidate the various subjects, which  are  rendered still
clearer by a large  number of engravings.   Care  has been taken in  all  instances to indicate and
describe the simplest apparatus and procedures affording satisfactory results.  The long experience
of the author, both as a teacher of pharmacy, and as a practical pharmaceutist, is sufficient guarantee
of his familiarity with the wants and necessities of the student, and of his ability to satisfy them.
                         ROKITANSKY  (CARU,  M.D.,
    Curator of the Imperial Pathological Museum, and Professor at the University of Vienna, tee.
A  MANUAL  OF   PATHOLOGICAL  ANATOMY.  Four volumes  octavo,
  bound in two.  (Nearly Ready.)
Vol. I.—Manual of General Pathological Anatomy.  Translated by W. E. Swaine.
Vol. II.—Pathological Anatomy of the Abdominal Viscera.  Translated by Edward Sieveking,
    M.D.
Vol. III.—Pathological Anatomy of the Bones, Cartilages, Muscles, and  Skin, Cellular and Fibrous
    Tissue, Serous and Mucous Membrane, and Nervous System.  Translated by C. H. Moore.
Vol. IV.—Pathological Anatomy of the Organs of Respiration and Circulation.   Translated by G.
    E. Day.
To render this large and  important work more easy of reference, and at the same time  less cum-
  brous and costly, the publishers have arranged the four volumes in two, retaining, however, the
  separate paging, &c.
  The publishers feel much pleasure in presenting to the profession of the United States ihe great
work  of Prof. Rokitansky, which is universally referred to as the standard of authority by the pa-
thologists of all nations.  Under the auspices of the Sydenham Society of London, the  combined
labor of four translators has  at  length overcome the almost insuperable difficulties, which have so
long prevented the appearance  of the work  in an English dres», while the  additions made from
various papers and essays of the author present his views on all the topies embraced, in their latest
published form.  To  a work so widely  known, eulogy is  unnecessary,  and the publishers would
merely state that it contains the results  of not less than thirty thousand post-mortem examina-
tions  made by the author, diligently compared, generalized,  and wrought into  one complete  and
harmonious system.
                            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.
                            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 I ductions on the other extreme,  which are neces-
will fill  up an important vacancy that existed be- | sarily imperfect from  their small extent.—British
tween Dr. Pereira's  most  learned and complete I and Foreign Medical Review.
system of Materia Medica,  and  the class  of pro- | 
AND  SCIENTIFIC PUBLICATIONS.
27
                      RAMSBOTHAM  (FRANCIS H.),  M.D.

THE PRINCIPLES AND  PRACTICE OF OBSTETRIC  MEDICINE  AND
  SURGERY, in reference to the Process of Parturition. A new and enlarged edition, thoroughly
  revised by the Author.  With Additions by W. V. Keating, M. D.  In one large and handsome
  imperial octavo volume, of 650 pages, with sixty-four beautiful Plates, and numerous Wood-cuts
  in the  text, containing in all nearly two hundred large and beautiful figures. (Now Ready.)
  In calling the attention of the profession to the new edition of this standard work, the publishers
would remark that no efforts have been spared to secure for it a continuance and extension of the
remarkable favor with which it has been  received.  The last London issue, which was considera-
bly enlarged, has received a further revision from the author, especially for this country.   Its pas-
sage through the press here has been supervised by Dr. Keating, who has made numerous addi-
tions with a view of presenting more fully whatever was necessary to  adapt it thoroughly to
American modes of practice.  In its mechanical execution, n like superiority over former editions
will be found.   The plates have all been re-engraved in a new and beautiful style ; many additional
illustrations have been introduced, and in every point of typographical finish it will be  found one of
the handsomest issues of the American press.  In its present improved and enlarged form the pub-
lishers therefore confidently ask for it a place in every medical library, as a text-book for the student,
or a manual for daily reference by the practitioner.

                           From Prof. Hodge, of the University of Pa.
  To the American public, it  is most valuable, from its intrinsic undoubted excellence,  and as being
the best authorized exponent of British Midwifery. Its circulation will, I trust, be extensive throughout
our country.
  The publishers have shown their appreciation of
the merits of this work and secured its success by
Ihe truly eleuant style in,which they have brought
•tout, excelling themselves in its production, espe-
cially in its plates.  It is dedicated to Prof. Meigs,
and  has the emphatic endorsement of  Prof. Hodge,
as the best exponent of British Midwifery.  We
kno\y of no text-book which deserves in all respects
to be more highly recommended to studeuts, and we
could wish to see it in the hands of every practitioner,
for they will find it invaluable for reference.—Med.
Gazette.
  But once in a long time some brilliant genius rears
his head above the  horizon of science, and illumi-
nates and purifies every department that he investi-
gates ; and his works become types, by which innu-
merable imitators model their feeble  productions.
Such a genius we rind in the younger Ramsbotham,
nnd such a type we find in the work now before us.
The binding, paper, type, the engravings and wood-
cuts are all so excellent as to make this book one of
the finest specimens of the art of printing that have
given such a world-wide reputation to its enterpri-
sing  and liberal publishers.   We welcome Rams-
botham's Principles and Practice of Obstetric Medi-
cine and  Surgery  to our library, and confidently
recommend  it to our readers, with the assurance
that it will  not disappoint their most  sanguine ex-
pectations.—Western Lancet.
  It is unnecessary to say anything in regard to the
utility of this work. It is already appreciated in our
country for the value of the matter, the clearness of
its style, and the fulness of its illustrations. To the
physician's library it is indispensable,  while to the
student as a text-book, from which to extract the
material for laying the foundation of an education on
obstetrical science, it  has no superior.—Ohio Med.
and Surg. Journal.

  We will only add that the student will learn from
it all he need to know, and the practitioner will find
it, as a book of reference, surpassed by none other.—
Stethoscope.
  The character and merits of Dr. Ramsbotham's
work are so well known and thoroughly established,
that comment is unnecessary and praise superfluous.
The illustrations, which are numerous and accurate,
are executed in the highest style of art. We cannot
too highly recommend the work to our  readers.—St.
Louis Med. and Surg. Journal.
                                RICORD (P.), M. D.,
                           Surgeon to the Hopital du Midi, Paris, &c.

ILLUSTRATIONS OF SYPHILITIC DISEASE.   Translated from  the French,
  by Thomas F. Betton, M. D.  With the addition of a History of Syphilis, and a complete Bib-
  liography and Formulary of Remedies, collated and arranged,  by Paul B. Goddard, M. D. With
  fifty large quarto plates, comprising one hundred  and  seventeen beautifully colored illustrations.
  In one large and handsome quarto volume.

                        BY the same author.  (Lately Published.)

A TREATISE  ON THE VENEREAL DISEASE.    By John Hunter, F. R. S.
  With copious Additions, by Ph. Ricord, M. D.  Edited, with Notes, by Freeman J. Bumstead,
  M. D.  In one handsome octavo volume, of 520 pages, with plates.
                                                In the notes  tq Hunter, the master substitutes him-
                                              self for his interpreters, and gives his original thoughts
                                              to the world, in a summary  form it is true, but in a
                                              lucid and perfectly intelligible manner.  In conclu-
                                              ?ioii we can say that  this is incontestably the best
                                              treatise on syphilis with which we are acquainted,
                                              and, as we do  not often employ the phrase, we  may
                                              be excused for expressing the hope that it may find
                                              a place in the library of every physician—Virginia
                                              Med. and Surg. Journal.
  Every one will recognize the attractiveness and
value which this work derives from thus preseniirg
the opinions of these two masters side by side.  But,
it must be admitted, what has made  the fortune of
the book, is ihe fact that it contains the "most com-
plete embodiment of the veritable doctrines of the
Hopital du Midi," which has ever been made public.
The doctrinal ideas of M. Ricord, ideas which, if not
universally adopted, are incontestably dominant, have
heretofore only been interpreted by more or less skilful
secretaries, sometimes accredited and sometimes not.
BY THE SAME AUTHOR.
LETTERS  ON SYPHILIS, addressed to  the Chief Editor of the Union Medicale.
  With an Introduction, by Amedee Latour.  Translated by W. P. Lattimore, M. D.  In one neat
  octavo volume of 270 pages.
BY THE SAME  AUTHOR.
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 pa^os. 
23                     BLANCHARD  &  LEA'S  MEDICAL
                           SMITH  (HENRY  H.), M.D.,
                    Professor of Surgery in the University of Pennsylvania, Ac.

MINOR  SURGERY; or, Hints on  the Every-day Duties of the Surgeon.   Illus-
  trated by two hundred and forty-seven illustrations.   Third and enlarged edition.  In one hand-
  some royal 12mo. volume,  pp. 456.
  And a capital little book it is. .  . Minor Surgery,
we repeat, is really Major Surgery, and anything
which teaches it is worth having.  So we cordially
recommend this little book of l)r. Smith's.—Med.-
Chir. Review.
  This beautiful little work has been compiled with
a view to the wants of the profession in  the matter
of bandaging, &c.,and well and ably has the author
performed his  labors.  Well  adapted to give  the
requisite  information on the subjects of which it
treats.—Medical Examiner.
  The directions are plain, and illustrated through-
out with clear engravings,—London Lancet.
  One of the best works they can consult on  the
subject of which it treats.—Southern Journal of
Medicine and Pharmacy.
  A work such as the  present is therefore highly
useful to t|e student, and we commend  this one
to their attention.—American Journal of Medital
Sciences.
  No operator, however eminent, need hesitate to
consult this unpretending yet excellent book. Thoue
who are young in the business would find Dr. Smith's
treatise  a necessary companion, after once under-
standing its true character.—Boston Med. and Surg.
Journal.

  No young practitioner should be without this little
volume; and we  venture to assert, that it may b«
consulted by the  senior members of the profession
with more real benefit, than the more volumnnui
works.— Western  Lancet.
                                BY THE SAME AUTHOR, AND
                         HORNER (WILLIAM  E.),  M. D.,
                   Late Professor of Anatomy in the University of Pennsylvania.

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.
  These figures are  well  selected, and  present  a  late the student upon  the completion_of this Atlas
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.  VVe must congratu-
as it is tlie most convenient work of the kind that
has yet appeared ; and we must add, the very beau-
tiful manner in which it is " got up" is so creditable
to the country as to he flattering to our national
pride.—American Medical Journal.
In
                             SARGENT (F. W.),  M. D.
ON BANDAGING  AND  OTHER  POINTS  OF  MINOR  SURGERY.
  one handsome royal 12mo. volume of nearly 400 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 thesubjects 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-
celleut.work on this,subject,nnd his publishers havs
illustrated,and printed it in  most beautiful style.—
The Charleston Medical Journal.
  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 he
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.

                     SKEY (FREDERICK  C), F. R. S.,  &c.
OPERATIVE  SURGERY.   In on« very handsome  octavo volume of over 650
  pages, with about one hundred wood-cuts.

       SHARPEY  (WILLIAM),  M.D.,  JONES QUAIN,  M.D.,  AND
                         RICHARD  QUAIN,  F. R. S., &c.

HUMAN ANATOMY.   Revised, with Notes and Additions, by Joseph Leidy,
  M.D.  Complete in two large octavo volumes,  of about thirteen  hundred pages.  Beautifully
  illustrated with over five hundred engravings on wood.
  It is indeed a work calculated to make nn era in
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.
  We have no hesitation in recommending this trea-
tise on anatomy as the most complete on that  sub-
ject in the English language; arid the only  one,
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.
In  one volume,  octavo,
                               STANLEY (EDWARD).
A TREATISE  ON  DISEASES  OF  THE  BONES.
  extra cloth, 286 pages.

                            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 of 500 pages, with 120 wood-cuts. 
AND  SCIENTIFIC  PUBLICATIONS.
29
                            STILLE (ALFRED),  M. D.
PRINCIPLES   OF  GENERAL  AND   SPECIAL   THERAPEUTICS.   In
  handsome octavo.  (Preparing.)
                            SIMON (JOHN), F. R. S.

GENERAL  PATHOLOGY,  as  conducive  to the  Establishment  of Rational
  Principles fcr 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, of 212
  pages.
                          SMITH  <W.  TYLER), M. D.,
                      Physician Accoucheur to St. Mary's Hospital, &c.
ON  PARTURITION,  AND  THE  PRINCIPLES  AND  PRACTICE  OF
  OBSTETRICS.   In one large duodecimo volume, of 400 pages.

                          BY THE SAME AUTHOR.—(Now Ready.)

A PRACTICAL TREATISE ON THE  PATHOLOGY AND TREATMENT
  OF LEUCORRHXEA.  With numerous illustrations.  In one very handsome octavo volume ol
  edxiut 250 pages.
 The investigation of the pathology and treatment
of leucorrhcea is a task that may Well engage the
time  and energies of the most philosophical and
skilled physician;  and there are few men more capa-
ble of conducting and deducing important observa-
tions from such a study than the author of the pre-
sent treatise. Dr. Tyler Smith's previous researches,
not less than his devotion to physiology and scientific
medicine, point him out as one eminently calculated
to throw light on many subjects, which less able
men might fail to elucidate.  We consequently take
his work in hand with high expectations  and we
have not been in the least disappointed.  The fore-
going cursory examination  of Dr. Tyler  Smith's
work will be sufficient to prove its value, and we
hope more than enough to induce every practitioner
to study it for himself.—The Lancet.
 The above list contains simply the general head-
ings of the different chapters;  to have enumerated
all the subjects discussed, or to have  made further
extracts, would have compelled us  much to exceed
our limits.  This, however,  we scarcely regret;
because we think a perusal of the extracts given
will induce the reader to examine the work for him-
self; and we would advise all who are anxious for
correct ideas respecting  these  discharges, and their
sources, to possess themselves of it.—Dublin Med.
Press.
                          SIBSON  (FRANCIS),  M.D.,
                             Physician to St. Mary's Hospital.
MEDICAL ANATOMY.  Illustrating the  Form, Structure, and Position of  the
  Internal  Organs  in Health and Disease.  In large imperial quarto, with spleridid colored plates.
  To match "Maclise's Surgical Anatomy." Part I.   (Nearly Ready.)
                     SCHOEDLER (FRIEDRICH),  PH.D.,
                       Professor of the Natural Sciences at Worms, &c.

THE  BOOK  OF NATURE;  an Elementary  Introduction  to the  Sciences of
  Physics, Astronomy, Chemistry, Mineralogy, 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 Medlock, 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, and embodies a vast amount of informa-  mentary knowledge, with so full illustrations, at so
Won for instruction. No other work that we have | cheap a rate.—Silliman's Journal, Nov. 1853.
                            TOMES (JOHN),  F. R. S.
A MANUAL OF  DENTAL PRACTICE.   Illustrated by numerous engravings
  on wood.   In one handsome volume.   (Preparing.)
  TRANSACTIONS  OF  THE AMERICAN  MEDICAL ASSOCIATION.

VOLUME  VIII,  for 1855, 8vo., extra cloth.   (Nearly Ready.)
A few complete sets can still  be had, in eight volumes, price $38.  Applications and remittances
  to be made to Caspar Wister, M. D., Treasurer, Philadelphia.
*** These volumes are published by and sold for account of the Association.               «


        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  fir*t portion of Part IV, with numerous original illustrations, was published in the Medical
New* aud Library for 1853, and the completion will be issued immediately on its appearance in
London.   Those who have subscribed since the appearance of the preceding portion of the work
can have the three parts by mail, on remittance of $£ 50 to the publishers. 
30
BLANCHARD & LEA'S  MEDICAL
                            TANNER (T.  H.), M.  D.,
                          Physician to the Hospital for Women, Stc.

A  MANUAL  OF CLINICAL  MEDICINE  AND  PHYSICAL DIAGNOSIS.
  To which is added  The Code of Ethics of the American Medical Association.  In one ncut
  volume, small 12mo., extra cloth. (Just Ready.)
  The object of this little work is to furnish the practitioner, in a condensed and convenient com-
pass, and at a trifling cost, with a guide for the daily exigencies of his practice.  A large portion of
the volume is occupied with details of diagnostic symptoms, classified under the dillerenl seats of
disease.  This, in itself, is well worth the price of the book, but in addition,  there will be found an
immense amount of information, not usually touched upon in  the systematic works, or scattered
throughout many different volumes—such as general rules for conduct, taking notes, clinical exami-
nation of children and of the insane, post-mortem examinations, medico-legal examinations, exami-
nations for life insurance, instruments employed in diagnosis, such as the  microscope, tests, the
spirometer, dynamometer, stethometer, stethoscope, pleximeter, ophthalmoscope, speculum, uterine
sound, Arc.; directions for the chemical and microscopical  examination of the blood, urine, sputa,
&:c. &c.; with many other subjects of equal importance which hitherto the young practitioner has
had to learn in a great measure from experience alone. Although necessarily treated in a condensed
manner, the topics will be found to embrace the latest and most approved modes of procedure, while
the addition of the admirable " Code of Ethics" of the American Medical Association  renders it
complete as a guide for the student and as a manual of daily reference for the younger practitioner.
  Those who desire to use it as a vade-mecum ibr the pocket, can obtain copies neatly done up in
flexible cloth.
                    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.  (Just Issued.)
  We know of no work on  Medical Jurisprudence
which contains in the same  space anything like the
same amount of valuable matter.—N. Y. Journal of
Medicine.
  No work  upon the subject can be put into the
hands of students either of  law or medicine which
will engage them more closely or profitably; and

                                 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.
none could be offered to the busy practitioner of
either calling, for the purpose of casual or hasty
reference, that would be more likely to afford the aid
desired.  We therefore recommend it as the best and
safest manual for daily use.—American Journal of
Medical Sciences.
  The most elaborate work on the subject that our
literature possesses.—British and Foreign Medico-
Chirurgical Review.
  One of the most practical and trustworthy works
on Poisons in our language.—Western Journal oj
Medicine.
                    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

                       WATSON (THOMAS),  M.D.,  &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 hut to echo the sentiment of the
medical  press  throughout the country. — JV. 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.
  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.
Journal.
                               WHAT  TO  OBSERVE
AT  THE  BEDSIDE  AND  AFTER  DEATH,  IN  MEDICAL  CASES.
  Published under the authority of the London Society for Medical Observation.  A new American,
  from the second and revised London edition.   In one very handsome volume, royal 12mo., extra
  cloth.  (Now Ready.)
  The demand which has so rapidly exhausted the first edition of this little work, shows that the
advantages it offers to the profession have been duly appreciated, and has stimulated the authors to
render it more worthy of its  reputation.  It  has therefore been thoroughly revised, and such im-
provements (among which is a section on Treatment) have been made as further experience in
its use has shown to be desirable.
  To the observer who prefers accuracy to blunders I  One of the finest aids to a young practitioner we
and precision to carelessness, this little book is in-  have ever seen.—Peninsular Journal of Medicine.
valuable.—N. II. Journal of Meditine.            \ 
AND  SCIENTIFIC PUBLICATIONS.
31
                    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 Engl^h 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 SAME 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., of 458 pages, with 115 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 "Diseases of the Skin," by Mr. Erasmus I nothing to be desired, sofaras excellence of delinea-
Wilson, may now be regarded as the standard work | tion and perfect accuracy of illustration are con-
in  that  department of  medical literature.   The  cerned.—Medico-Chirurgical Review.
plates by which this edition is accompanied leave |

                                 BY THE SAME AUTHOR.

ON  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.

                          BY  THE same author.   (Now Ready.)

HEALTHY SKIN; A Popular  Treatise on  the Skin and Hair, their Preserva-
  tion and Management.  Second American, from the  fourth London edition.   One neat volume,
  royal 12mo., of about 300 pages, with numerous illustrations.
              Copies can be had done up in paper covers for mailing, price 75 cents.

                    WHITEHEAD  (JAMES),  F. R. C. S.,  &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.   Second American Edition.  In one volume, octavo, 368 pages.  (Now Ready.)
                                             the works which must be studied by  those who
                                             would know what the present state of our knowledge
                                             is respecting the causes and treatment of abortion
                                             and sterility.—The Western Journal of Medicine and
  Such are the advances made from year to year in
this department of our profession, that the practi-
tioner who does not consult the recent works on the
complaints of females, will soon find himself in the
rear of his more studious brethren.  This  is one of
Surgery.
                             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 12mo., 512 pages.
  We consider this as the ablest work in the En- I the author being the first stethoscopist of the day.—
giish language, on the subject of which it treats; | Charleston Medical Journal.

                                  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 of 476 pages, with illustrations.
  Thisworl.  certainly contains more information on  laws, and amenable to the same general  methods of
the  subjec!  o which it is  devoted than any  other  treatment as oiher morbid processes.  The work is
with which we are acquainted.   VVe feel grateful to  not written to supply the cravings of popular patro-
ihe author for his manful effort to rescue this depart-  nage, but it is wholly addressed  to the  profession,
ment of surgery from the hands of the empirics who  and bears on every page the impress of the reflections
nearly monopolize it.  We think  he has successfully  of a sagacious and practical surgeon.— Va. Surg, and
shown that  aural diseases are not beyond ihe re-  Med. Journal.
sources of art; that they are governed by the same 
32       BLANCHARD & LEA'S SCIENTIFIC PUHLICATIONS.
                           WEST (CHARLES),  M.  D.,
                       Physician to the Hospital for Sick Children, &c.

LECTURES  ON  THE DISEASES  OF  INFANCY AND  CHILDHOOD.
  Second American, from the Second and Enlarged London edition.  In one volume, octavo, of
  nearly five hundred pages.  (Just Issued.)
  We take leave of Dr. West With great respect foT
his attainments,  a due appreciation of his  acute
powers of observation, and a  deep sense of obliga-
tion for  this valuable contribution to  our profes-
sional literature.   His book is undoubtedly in many
respects  the best we possess on diseases of children.
The extracts we  have given will, we hope, satisfy
our readers of its value; and  yet in all candor we
must say that they are even inferior to Bome other
parts, the length  of which prohibited our  entering
upon them.  That the book will shortly be in the
hands of  most of our readers we do not doubt, and it
will give us much pleasure if our strong recommend-
ation of it may contribute towards the  result.—The
Dublin Quarterly Journal of Medical Science.

  Dr. West has placed the profession under deep ob-
ligation by this able, thorough, and finished work
upon a subject which almost daily taxes to the ut-
most the Fkill of the general practitioner.  He has
with singular felicity threaded his way through all
the tortuous labyrinths of the difficult subject he has
undertaken to elucidate, and has in many of the
darkest corners  left a light, for the benefit of suc-
ceeding travellers, which will never be extinguished.
Not the least captivating feature in  this admirable
performance is its easy, conversational style, which
acquires force from its very simplicity, and leaves
an impression upon the memory, of the truths it
conveys, as clear and refreshing as its own purity.
The author's position secured him  extraordinary fa-
cilities for the investigation of children's diseases,
and his powers of observation and discrimination
have enabled him to make  the most of  these great
advantages.—Nashville Medical Journal.
                          BY THE SAME AUTHOR.  (Just Issued)

AN ENQUIRY INTO THE  PATHOLOGICAL  IMPORTANCE OF ULCER-
  ATION OF  THE OS UTERI.  Being the Croonian Lectures for the year 1854.  In one neat
  octavo volume, extra cloth.
                    WILLIAMS  (C. J.  B.),  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 476 pages.  (Lately Issued.)

  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.—ErrrroR'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 Essay 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 beautifnl
  illustrations.  In one very handsome volume, crown Svb., crimson cloth, gilt.


              ILLUSTRATED  MEDICAL  CATALOGUE.

  BLANCHARD &  LEA have now ready a Catalogue of their Medical, Surgical, and Scien-
tific  Publications, containing descriptions  of the works, with Notices of  the  Press,  and
specimens of the Illustrations, making a pamphlet of sixty-four large octavo pages.  It has
been prepared with great care, and without regard to expense, forming one of the most beau-
tiful specimens of typographical  execution  as yet issued in this  country.  Qopies  will be
sent by mail, and the postage paid, on application to the Publishers, by inclosing two three
cent postage stamps.
  Catalogues of  Blanchard & Lea's numerous Miscellaneous and  Educational Publications
will be forwarded free by mail,  on application. 
 
V
^ 
 
" , •..■?>v*J
^M
W§- r
«£
*&?■#■
^j
.'■*..,*?<&*&■
W
%m
M
•:&
j/wi
»
r--k
A7&**
.v*
1/ ^fih*
Vf : «u *•• i- "