SYSTEM OF 
SURGERY; 
PATHOLOGICAL, DIAGNOSTIC, THERAPEUTIC, 
AND OPERATIVE. 
BY 
SAMUEL D. GROSS, M.D., LL.D., D.C.L. Oxon., LL.D. Cantab., 
EMERITUS PROFESSOR OF SUROERT IN THE JEFFERSON MEDICAL COLLEGE. 
ILLUSTRATED BY 
UPWARDS OF SIXTEEN HUNDRED ENGRAVINGS. 
SIXTH EDITION, 
THOROUGHLY REVISED AND GREATLY IMPROVED. 
IN TWO VOLUMES. 
VOL. I. 
PHILADELPHIA: 
HENIiY C. LEA’S SON & CO. 
1882. Entered according to the Act of Congress, in the year 1882, by 
HENRY C. LEA’S SON & CO., 
in the Office of the Librarian of Congress, at Washington. All rights reserved. 
PHILADELPHIA: 
COLLINS, PRINTER. TO 
THE NUMEROUS PUPILS 
WHO, DURING NEARLY HALF A CENTURY, 
ATTENDED HIS LECTURES, 
AND WHO ARE NOW SETTLED IN EVERY SECTION OF THE UNITED STATES, AS WELL AS 
IN MANY FOREIGN LANDS, 
IN THE 
HONORABLE PURSUIT OF THEIR PROFESSION, 
DESIGNED TO ILLUSTRATE ONE OF THE MOST IMPORTANT AND VALUABLE BRANCHES OF 
THE HEALING ART, 
ARE RESPECTFULLY AND AFFECTIONATELY INSCRIBED 
BY THEIR FRIEND, 
THE AUTHOR. A certis potius et exploratis petendum esse presidium; id est, his quae experientia in ipsis cura- 
tionibus docuerit; sicut in caeteris omnibus artibus; nam ne agricolam quidem aut gubernatorem 
disputatione, sed usu, fieri. Celsus. 
He—the surgeon—should be courteous and condescending, bold in security, cautious in time of 
danger, avoiding impracticabilities, compassionate to the infirm, benevolent to his associates, cir- 
cumspect in his prognostication, chaste, sober, pious, and merciful, not greedy of gain, no extor- 
tioner, but looking to his fee in moderation, according to the extent of his services, the ability of 
his patient, the result of his treatment, and a proper sense of his own dignity. 
Guy de Cuauliac. 
We may not only rank Chirurgery among the Sciences ; but look on it as one of the noblest, most 
certain, and most necessary of them all. Dionis. 
The nobility and dignity of Chirurgery are too well known to want the help of an oratour to set 
them forth. If a panegyrick were necessary, it were best made by running through the particulars 
of the art, and the history of the diseases cured thereby. Wiseman. PREFACE. 
The object of this work, as set forth in the first edition, issued in 1859, is to 
furnish a systematic and comprehensive treatise on the art and science of sur- 
gery, considered in the broadest sense; one that shall serve the practitioner as 
a faithful and available guide in his daily routine of duty. My aim has been 
to embrace the whole domain of surgery, and to allot to every subject its legiti- 
mate claim to.notice in the great family of external diseases and accidents. If 
a larger space than is customary has been devoted to the consideration of 
inflammation and its effects, or the great principles of surgery, it is because of 
my conviction, founded upon long and close observation, that there are no sub- 
jects so little understood by the general practitioner. Special attention has also 
been bestowed upon the discrimination of diseases; and an elaborate chapter 
on general diagnosis has been introduced. 
The work, although presented, as its title indicates, as a formal and system- 
atic treatise, is founded upon the courses of lectures which it devolved upon me 
to deliver during the last forty-two years; first in the University of Louisville, 
for a long time the most flourishing medical school in the Southwest, and during 
the last twenty-six years in the Jefferson Medical College, from which, in 1828, 
I received my degree. During all that period, I was unceasingly devoted 
to the duties of an arduous practice, both private and public; to the study of 
the great masters of the art and science of medicine and surgery; and to the 
composition of various monographs which had a direct bearing upon a number 
of the subjects discussed in these volumes. The work should, therefore, be 
regarded as embodying the results of a large personal, as well as of a ripe, expe- 
rience, of extensive reading, and of much reflection; in a word, as exhibiting 
surgery as I myself understand it, and as I, for so many years, conscientiously 
taught it. 
The favor with which the work has been received is sufficiently attested by 
the exhaustion of five large editions, by its translation into the Dutch language, 
and by the universal commendation bestowed upon it by the periodical press, 
both at home and abroad. This evidence, so gratifying to my feelings as 
an author, instead of abating my ardor, has only served to stimulate me to VI 
PREFACE. 
increased exertion to render the work still more useful as a faithful exponent 
of the existing state of the art and science of surgery. 
Upon the edition now issued much time and labor have been expended, ren- 
dered necessary by the astonishing progress made during the last ten years in 
every branch of surgery. Every chapter has been thoroughly revised, many 
portions have been entirely rewritten, and a large amount of new matter 
has been introduced, in order to place the work fully abreast of the existing 
state of our knowledge. To impart completeness to my labors, in every re- 
spect most arduous and perplexing, I have freely availed myself of the assist- 
ance of Professor S. W. Gross, whose pen and judgment have been of the 
greatest service to me in supplying deficiencies, especially in relation to morbid 
growths, in collecting statistics, and in correcting the press. To I)r. J. Solis 
Cohen, Dr. George C. Harlan, and Dr. Charles H. Burnett my thanks are due 
for aid received in revising, respectively, the chapters on the Respiratory 
Organs, the Eye, and the Ear. The section on Refraction and Accommodation 
of the Eye, written for the fifth edition by Dr. William Thomson, Professor of 
Ophthalmic Surgery in the Jefferson Medical College, is retained nearly in its 
entirety. Professor Edward C. Seguin, of New York, has kindly furnished the 
section on Cranio-Cerebral Topography, the first attempt, as far as I know, to 
introduce matter of this kind into a work on surgery. Dr. Battey has kindly 
supplied me with valuable matter relative to Oophorectomy, and Dr. Lewis 
Hall Sayre relative to the application of the plaster-jacket in the treatment of 
spinal diseases. To Dr. Barnes, late Surgeon-General of the United States 
Army, I am under obligations for many of the cuts which illustrate the sub- 
ject of Gunshot Wounds. The elaborate index has been kindly prepared by 
Dr. Richard J. Dunglison, whose labors in the interests of American medical 
literature are so well known. 
Of the engravings which accompany the volumes upwards of six hundred 
are original. The remainder have been copied from the large collection in the 
possession of the publishers, due credit having been awarded in every instance 
to- the original source when it could be satisfactorily ascertained. Messrs. 
Gemrig and Kolbe, of this city, and Messrs. Tiemann & Co., of New York, have 
supplied me with numerous engravings illustrative of the latest improvements 
in surgical instruments, apparatus, and appliances. 
In taking a retrospect of the last fifteen years one cannot fail to be struck 
with the extraordinary strides which surgery has made during this brief but 
prolific period in the world’s history. Much of this progress is unquestionably 
due to the foundation which Dr. Ephraim McDowell unconsciously laid when, 
in December, 1809, he performed his first operation for the removal of a 
diseased ovary. To that operation, in the bold hands of the two Atlees, Clay, 
Wells, Kimball, Dunlap, Keith, Pean, Schroeder, Ivoeberld, Thomas and others, PREFACE. 
are directly due the brilliant advances which have been made in abdominal 
and pelvic surgery during this time. To Professor Lister must be accorded 
not a little praise for the part he has played in this wonderful work. If 
only one tithe be true of what his admirers claim for him, enough remains to 
entitle him to the credit of being one of the world’s eminent benefactors. It 
was he who first taught surgeons the importance and value of thorough clean- 
liness in their operations and dressings, before his time so little understood 
and so seldom practised. Specialism, too, is entitled to undying praise. It has 
penetrated with its methods and instruments of research the innermost recesses 
of the human body, and has achieved, in a comparatively brief period, triumphs 
which general surgery could not have achieved in half a century, if, indeed, 
ever. Operative surgery is rapidly advancing towards its finality of perfection; 
surgical pathology, under the influence of the cell-doctrine and of the plastic 
genius of Paget, Virchow, Billroth, and others, has been placed upon a perma- 
nent basis; and therapeutic surgery was never in so healthful a condition as it 
is at the present moment. The world abounds in great surgeons, men accom- 
plished in the science, and skilled in the art of healing, capable of interpreting 
the secrets of pathological processes, of diagnosticating disease, and of perform- 
ing with ability and readiness all the great operations, formerly the province of 
a favored few. The time has gone by when any one practitioner can boast of 
a monopoly of skill or of reputation in this or in that field of surgery; all 
have a hand in it, although some are greater and wiser and more competent 
than others. In the marvellous revolution now in progress, it is gratifying to 
find that American surgery is fully abreast of the surgery of other nations. 
S. D. GROSS. 
Jefferson Medical College, 
Philadelphia, October, 1882. CONTENTS OF YOL. I. 
PART FIRST. 
GENERAL SURGERY. 
CHAPTER I. 
PAOK 
IRRITATION, SYMPATHY, AND IDIOSYNCRASY. . . .35 
CHAPTER II. 
CONGESTION. . . . . .45 
CHAPTER III. 
INFLAMMATION. 
Sect. I. General Considerations ........ 48 
1. Causes of inflammation . . . . . . .49 
2. Extension of inflammation . . . . . . .52 
3. Varieties of inflammation . . . . . . .54 
4. Terminations, events, or conditions of inflammation,. . . .55 
II. Acute Inflammation ........ 56 
1. Local symptoms ........ 56 
2. Constitutional symptoms . . . . . . .63 
3. Changes of the blood in inflammation . . . . .66 
4. Intimate nature of inflammation . . . . . .68 
5. Treatment of inflammation . . . . . . .75 
I. Constitutional treatment . . . . . • .76 
II. Local treatment ........ 93 
III. Chronic inflammation ........ 103 
CHAPTER IV. 
TERMINATIONS AND RESULTS OF INFLAMMATION. 
Sect. I. Delitescence and Resolution ....... 106 
II. Deposit of Serum ......... 107 
III. Lymphization or Plastic Exudation . . . . . .109 
1. Uses of plastic matter ....... 113 
2. Injurious effects of plastic matter . . . . . .114 
Treatment . . . . . . • • .116 
IV. Suppuration and Abscess . . . . • • • .116 
Abscesses . . . . . • • • • .121 
1. Phlegmonous abscess . . . . • • • .122 X 
CONTENDS OF VOL. I. 
. • PAGE 
2. Diffused abscess or purulent infiltration . . . . .130 
3. Scrofulous abscess . . . . ' . . . .132 
4. Hectic fever . . . . . . . .136 
Sf.ct. Y. Septicemia and Pyemia ........ 139 
1. Septicemia ......... 140 
2. Pyemia . . . . ... . . . 141 
VI. Hemorrhage . . . . . . . . . 149 
VII. Mortification ......... 150 
1. Acute mortification . . . . . . . 150 
2. Chronic mortification . . . . . . . .157 
VIII. Hospital Gangrene . . . . . . . .162 
IX. Ulceration and ulcers . . . . . . . .168 
Ulcers . . . . . . . . . .170 
1. Acute ulcers . . . . . . . . .171 
2. Chronic ulcers . . . . . . . .174 
X. Granulation ......... 181 
XI. Cicatrization . . . . . . . . .182 
CIIAP TEH V. 
TEXTURAL CHANGES. 
Sect I. Softening .......... 185 
II. Induration . . . . . . . . . .186 
III. Transformations . . . . . . . . .187 
IV. Hypertrophy ......... 190 
V. Atrophy . . . . . . . . . .191 
VI. Contraction and Obliteration . . . . . . .193 
VII. Fistules and Sinuses ........ 194 
CHAPTER VI. 
CONGENITAL malformations. . . . .196 
CHAPTER VII. 
TUMORS OR MORRII) GROWTHS. 
Sect. I. General Observations . . . . . . . .198 
II. Cysts and Cystomas ........ 204 
1. Retention cysts ......... 205 
2. Exudation cysts ........ 206 
3. Dermoid cysts ... . . . . . . 207 
4. Cystomas ......... 207 
5. Extravasation cysts ........ 207 
6. Hydatid cysts . . . . . . . . .207 
III. Neoplasms, -which represent Perfected or Matured Connective Tissue and its Modi- 
fications ......... 210 
1. Lipomatous tumors . . . . . . . .210 
2. Fibrous tumors . . . . . .. . . 213 CONTENTS OF VOL. I. 
XI 
PAGE 
3. Cartilaginous tumors . . . . . . . .215 
4. Osseous tumors . . . . . . . .217 
5. Lymphomatous tumors . . . . . . .218 
IV. Neoplasms, which represent Embryonic, Immature, or Unripe Connective Tissue 219 
1. Sarcomatous tumors . • . . . . . . .219 
Different forms of sarcoma . . . ... . . 223 
2. Myxomatous tumors . . . . . . . .227 
V. Neoplasms derived from and composed of Higher Tissue .... 229 
1. Myomatous tumors ........ 229 
2. Vascular tumors . . . . .. . . 230 
3. Lymphangiomatous tumors ....... 232 
4. Neuromatous tumors ........ 233 
VI. Neoplasms, which proceed from and are composed essentially of Epithelium . 236 
1. Papillary tumors ........ 236 
2. Adenomatous tumors . . . . . . . .237 
3. Carcinomatous tumors ....... 238 
Scirrhus ......... 243 
Encephaloid . . . . . . . . .246 
Epithelioma ......... 248 
Colloid . . . . . . ... . 250 
Melanosis ......... 252 
Diagnosis of Carcinomatous tumors ...... 252 
VII. Treatment of Morbid Growths ....... 253 
1. Benign tumors ........ 253 
2. Malignant tumors ........ 255 
CHAPTER VIII. 
SCROFULA AND TUBERCLE. 
Scrofulous Ulcer . . . . . . . . . .265 
Treatment . . . . . . . . . .266 
CHAPTER IX. 
VENEREAL DISEASES. 
I. Chancroid ........... 270 
Chancroidal bubo ......... 282 
II. Syphilis ........... 285 
Sect. I. General Considerations ........ 285 
II. Primary Syphilis . . . . . . . . .287 
1. Chancre ......... 287 
Syphilization . . . . . . . . .297 
2. Affections of the lymphatic glands and vessels .... 298 
III. Secondary Syphilis ........ 300 
1. General considerations ....... 300 
2. Affections of the skin ........ 301 
3. Alopecia . . . . . . . . 305 
4. Lymphatic adenitis ........ 306 
5. Affections of the mucous membranes ...... 307 
> IV. Tertiary Syphilis ......... 309 
1. General considerations ....... 309 CONTENTS OF VOL. I. 
PAGE 
2. Tertiary Syphilis of particular organs . . . . .311 
nervous system . . . . . .311 
eye and ear ...... 312 
digestive organs and liver . . . .313 
heart and respiratory organs . . . .314 
urinary and genital organs . . . .316 
skin ....... 317 
connective tissue, muscles, and tendons . . . 320 
osseous and fibrous tissues .... 320 
joints ....... 323 
3. Treatment ......... 324 
Syphilis in the infant . . . . . . . .332 
CHAPTER X. 
WOUNDS AND CONTUSIONS. 
Sect. I. General Considerations ........ 337 
1. Mode of dressing and treating wounds ..... 339 
2. Healing of wounds ........ 349 
II. Contusions .......... 351 
III. Incised Wounds ......... 355 
IY. Subcutaneous Wounds ........ 356 
Y. Lacerated Wounds ........ 358 
VI. Contused Wounds ......... 360 
VII. Punctured Wounds ........ 362 
VIII. Tooth Wounds ......... 366 
IX. Gunshot Wounds . . . . . . . . .367 
Question of amputation in wounds . . . . . . 383 
Secondary effects of wounds and contusions ..... 385 
X. Poisoned Wounds ......... 387 
1. Wounds indicted by poisonous insects ..... 387 
2. Wounds inflicted by venomous serpents ..... 388 
3. Wounds inflicted by rabid animals ...... 392 
4. Glanders, farcy, or equinia . . . . . . 398 
5. Wounds inoculated with a peculiar septic poison generated in dead animal bodies 401 
a. Dissection wounds ....... 401 
b. Malignant pustule ....... 405 
CHAPTER XI. 
RAILWAY INJURIES. .... 407 
CHAPTER XII. 
EFFECTS OF INJURIES UPON TIIE NERVOUS SYSTEM. 
Sect. I. Prostration, Collapse, or Shock . . . . . . .411 
II. Traumatic Delirium . . . . . . . 415 CONTENTS OF VOL. I. 
CHAPTER XIII. 
GENERAL DIAGNOSIS. 
PAOB 
Sect. I. Examination of the patient . . . . . . .419 
Examination of the different organs . . . . . .421 
II. Mensuration ......... 424 
III. Attitude of the Patient ........ 425 
IV. External Characters ........ 426 
V. Thermometry ......... 429 
VI. Instrumental Explorations ....... 430 
VII. Examination of the Discharges ....... 434 
CHAPTER XIV. 
MINOR SURGERY. 
Sect. I. Instruments ......... 436 
II. Incisions .......... 442 
III. Avulsion, Enucleation, Ligation, and Crushing ..... 445 
IV. Skin-Grafting . . . . . . . . .447 
V. Sponge-Grafting ......... 448 
VI. Abstraction of Blood ........ 449 
VII. Transfusion of Blood ........ 457 
VIII. Hypodermic Injections ........ 458 
IX. Vaccination ......... 459 
X. Counterirritation ......... 460 
XI. Surgical Applications of Electricity ...... 464 
XII. Antiseptics . . . . . . . . .467 
XIII. Escharotics ......... 469 
XIV. Massage .......... 471 
XV. Dressing .......... 472 
XVI. Bandaging . . . . . . . . . . 477 
CHAPTER XV. 
OPERATIVE SURGERY. 
Qualifications of a surgeon ......... 481 
Preparation of the patient ......... 482 
Assistants ........... 486 
Duty of the surgeon . . . . . . . . .487 
Position of the patient and surgeon . . . . . . . .487 
Operation ........... 488 
Accidents during operation ........ 488 
Dressings and after-treatment ........ 490 
Sources of danger after operations . . . . . . .492 CONTENTS OF VOL. I. 
CHAPTER XVI. 
* PAOE 
PLASTIC SURGERY. .... 497 
CHAPTER XVII. 
SUBCUTANEOUS SURGERY. .... 501 
CHAPTER XVIII. 
AMPUTATIONS IN GENERAL. 
Sect. I. Introductory Considerations ....... 504 
II. Circumstances Demanding Amputations ...... 505 
III. Methods of Amputation . . . . . . . .510 
IV. Operation and After-treatment . . . . . . .516 
Synchronous Amputations ....... 522 
Reamputations ......... 523 
V. Affections of the Stump ........ 524 
1. Primary affections ........ 524 
2. Secondary affections . . . . . . . .527 
VI. Constitutional Effects of Amputations . . . . . .531 
VII. Artificial Limbs ......... 533 
VIII. Mortality after Amputations ....... 536 
CHAPTER XIX. 
EXCISION OF BONES AND JOINTS. 
General Considerations . . . . . . . . .541 
Instruments . . . . . . . . . . .542 
Position of the patient ......... 544 
Incisions ........... 544 
Removal of the bone ......... 544 
Dressing ........... 545 
Statistics ........... 545 
CHAPTER XX. 
ANAESTHETICS. 
General Considerations . . . . . . . . .547 
Chloroform ........... 550 
Mode of administration . . . . . . . . .551 
Effects ........... 553 
Treatment .......... 555 
Ether ........... 556 
Ethyl bromide .......... 557 
Bichloride of methylene ......... 558 
Protoxide of nitrogen ......... 558 
Local anaesthesia .......... 560 CONTENTS OF VOL. I. 
XV 
PART SECOND. 
SPECIAL SURGERY; OR, DISEASES AND INJURIES OF PARTICULAR 
ORGANS, TEXTURES, AND REGIONS. 
CHAPTER I. 
DISEASES AND INJURIES OF THE SKIN AND CONNECTIVE TISSUE. 
PAW K 
Sect. I. Erysipelas . . . . . . . . 566 
II. Furuncle or Boil ......... 576 
III. Anthrax or Carbuncle . . . . . . .578 
IY. Gangrene and Bedsores ........ 581 
V. Burns and Scalds ... . . . . . . . 583 
VI. Frost-bite and Chilblain ........ 590 
VII. Hypertrophies of the skin ........ 593 
1. Dermatolysis ........ 593 
2. Elephantiasis ......... 593 
VIII. Morbid Growths ......... 597 
1. Sebaceous tumors ........ 597 
2. Molluseous tumors ........ 599 
3. Lupus ......... 599 
4. Fibrous tumors ........ 601 
5. Sarcomatous tumors ........ 605 
6. Myomatous and neuromatous tumors ...... 606 
7. Papillary tumors ........ 606 
8. Epithelioma . . . . . . . . .610 
IX. Insects in the Skin and Connective Tissue . . . . . .611 
X. Affections of the Hairs ........ 612 
CHAPTER II. 
DISEASES AND INJURIES OF THE MUSCLES, TENDONS, BURSES, AND APONEUROSES. 
Sect. I. Muscles .......... 613 
II. Tendons . . . . . . . . . .617 
III. Synovial Burses ......... 621 
IV. Aponeuroses . . . . . . . . .624 
CHAPTER III. 
DISEASES AND INJURIES OF THE NERVES. 
Sect. I. Wounds and Contusions ........ 625 
II. Tumors .......... 627 
III. Tetanus .......... 628 XVI 
CONTENTS OF VOL. I. 
PAGE 
Sect. IV. Neuralgia ......... 636 
V. Paralytic Affections . . . . . . . .641 
1. Wasting palsy ........ 641 
2. Infantile palsy ........ 643 
3. Pseudo-hypertrophic muscular paralysis ..... 645 
4. Partial palsy ......•• 645 
CHAPTER IV. 
DISEASES OF THE LYMPHATIC VESSELS AND GLANDS. 
Sect. I. Lymphatic Vessels ......... 646 
II. Lymphatic Glands . . . . . . . . 649 
CHAPTER V. 
DISEASES AND INJURIES OF THE ARTERIES. 
Sect. I. Wounds and Hemorrhage ........ 652 
II. Subcutaneous Hemorrhage . . . . . . .677 
III. Collateral Circulation . . . . . . . .678 
IV. Hemorrhagic Diathesis . . . . . . . .681 
V. Diseases of the Arteries ........ 683 
1. Acute inflammation ........ 683 
2. Chronic affections ........ 685 
3. Dissecting aneurism . . . . . . . .687 
4. Varicose enlargement . . . . . . . .687 
5. Occlusion . . . . . . . . 688 
VI. Aneurism .......... 689 
1. Locality, prevalence, age, sex, and causes ..... 690 
2. Varieties ......... 694 
3. Symptoms ......... 698 
4. Diagnosis ......... 700 
5. Effects and termination ....... 702 
6. Spontaneous cure . . . . . . . .703 
Treatment .......... 706 
a. Deligation of the artery at the cardiac side of the tumor . . . 706 
b. Deligation of the artery at the distal side of the tumor . . .711 
c. Instrumental compression . . . . . . .713 
d. Digital compression . . . . . . . .717 
e. Direct compression of the denuded artery . . . . .718 
f. Forced compression with the elastic bandage ..... 719 
g. Forced flexion ........ 720 
h. Galvano-puncture . . . . . . . .720 
i. Injections ......... 721 
j. Acupuncture, and insertion of foreign materials . . . .723 
k. Manipulation . . . . . . . . .723 
l. Operation of opening the sac . . . . . . .724 
m. Valsalva’s treatment of internal aneurism ..... 725 
n. General medical and surgical treatment ..... 726 
False aneurism ......... 727 CONTENTS OF VOL. I 
XVII 
PAGE 
Sect. VII. Aneurism of Particular Arteries ...... 730 
of the thoracic aorta . . . . . . .730 
of the innominate artery ...... 736 
of the common carotid artery . . . . .742 
of the external carotid and its branches .... 748 
of the internal carotid and its branches . . . .749 
intracranial ........ 750 
of the vertebral artery . . . . . .751 
of the intercostal arteries . . . . . .751 
of the subclavian and its branches . . . . .751 
of the transverse cervical artery . . . . .759 
of the subscapular artery . . . . . .759 
of the axillary artery . . . . . .759 
of the brachial artery and its branches . . . .764 
of the abdominal aorta and its branches . . . .765 
of the common iliac artery . . . . . .767 
of the external iliac . . . . . . .768 
of the internal iliac and its branches . . . . .769 
treatment of . . . . . . . .769 
of the femoral artery ...... 772 
of the deep femoral artery . . . . . .775 
of the popliteal artery . . . . . .775 
of the arteries of the leg and foot . . . . .779 
VIII. Operations on the Arteries ....... 780 
Ligation of the innominate or brachio-cephalic ..... 780 
of the common carotid . . . . . . 780 
of the external carotid and its branches . . . .785 
of the internal carotid artery ...... 788 
of the subclavian and its branches . . . . .789 
of the vertebral . . . . . . .794 
of the internal mammary . . . . . .794 
of the inferior thyroid . . . . . . .795 
of the axillary ....... 795 
of the brachial . . . . . . .796 
of the radial, ulnar, and palmar . . . . .797 
of the abdominal aorta . . . . . .798 
of the common iliac . . . . . . .799 
of the internal iliac ....... 800 
of the gluteal ........ 801 
of the sciatic ........ 802 
of the external iliac ....... 802 
of the epigastric ....... 804 
of the circumflex iliac ...... 804 
of the common femoral ...... 804 
of the superficial femoral ...... 806 
of the deep femoral ....... 808 
of the popliteal ....... 809 
of the anterior tibial ....... 809 
of the posterior tibial . . . . . . .810 
of the peroneal . . . . . . .812 
CHAPTER VI. 
INJURIES AND DISEASES OF THE VEINS. 
Sect. I. Wounds and Hemorrhage ....... 813 CONTENTS OF VOL. I. 
PAGE 
Sect. II. Diseases of the Veins . . . . . . . .815 
1. Acute phlebitis . . . . . . . .815 
2. Chronic alfections . . . . . . . .816 
III. Varix . . . . . . . . . .817 
IV. Introduction of Air ........ 820 
CHAPTER VII. 
AFFECTIONS OF TIIE CAPILLARIES. 
Sect. I. Arterial Tumors ......... 823 
II. Venous Tumors ......... 829 
CHAPTER VIII. 
DISEASES AND INJURIES OF THE BONES AND THEIR APPENDAGES. 
Sect. I. Wounds and Contusions of the Bones, Periosteum, and Endosteum . .831 
II. Periostitis .......... 835 
Acute periostitis . . . . . . . . .835 
Chronic periostitis . . . . . ... .837 
Neuralgia of the periosteum . . . . . . .837 
III. Endosteitis, Medullitis, or Osteomyelitis ...... 838 
IV. Epiphysitis ......... 840 
V. Osteitis . . . . . . . . . .841 
VI. Suppuration and Abscess ........ 844 
VII. Erosion .......... 846 
VIII. Caries or Ulceration ........ 847 
IX. Necrosis or Mortification ........ 853 
X. Softening .......... 864 
XI. Rachitis .......... 866 
XII. Fragility .......... 870 
XIII. Atrophy .......... 872 
XIV. Hypertrophy ......... 873 
XV. Osteophytes ......... 875 
XVI. Tumors . . . . . . . . . .875 
1. Sarcoma ......... 878 
2. Osteoma or Exostosis ........ 882 
3. Chondroma ......... 887 
4. Osteoid chondroma ........ 888 
5. Fibroma ......... 889 
6. Myxoma ......... 889 
7. Angioma ......... 890 
8. Hydatid tumors ........ 890 
XVII. Tubercles ......... 892 
XVIII. Neuralgia ......... 893 
XIX. Fractures .......... 894 
1. General considerations ....... 894 
2. Simple fractures ........ 900 CONTENTS OF VOL. I. 
XIX 
PAGE 
3. Complicated fractures . . . . . . .917 
4. Incomplete fractures or bending of the bones .... 924 
5. Epiphyseal fractures . . . . . . . .927 
6. Ununited fractures . . . . . . . .927 
7. Vicious union of fractures ....... 934 
8. Diseases of the callus . . . . . . .935 
XX. Fractures of Particular Bones . . . . . .937 
1. Head and trunk ........ 937 
Fractures of the nasal bones . . . . . .937 
of the nasal cartilages ...... 938 
of the upper jaw ...... 939 
of the malar bone . . . . . .939 
of the lower jaw ....... 940 
of the hyoid bone ...... 944 
of the clavicle . . . . . . . 944 
of the scapula ....... 950 
of the ribs ....... 952 
of the costal cartilages ...... 955 
of the sternum ....... 956 
of the vertebr* ....... 957 
of the pelvic bones ...... 960 
2. Superior extremity ........ 963 
Fractures of the bones of the hand and fingers .... 963 
of the shafts of the radius and ulna .... 963 
of the ulna ..... . . 964 
of the radius ....... 968 
of the humerus ....... 976 
3. Inferior extremity ........ 985 
Fractures of the foot ....... 985 
of the tibia ....... 986 
of the fibula ....... 988 
of both the tibia and fibula ..... 990 
Complicated fractures of the leg ...... 995 
Fractures of the patella ....... 998 
of the femur ....... 1004 
1. of the shaft ...... 1004 
2. of the inferior extremity .... 1017 
3. of the superior extremity .... 1019 
Intracapsular fractures ..... 1020 
Extracapsular fractures ..... 1029 
Impacted fractures of the neck of the femur . . 1032 
Fractures of the great trochanter .... 1036 
of the thigh in children . . . 1038 
CHAPTER IX. 
DISEASES AND INJURIES OF THE JOINTS. 
Sect. I. Wounds .......... 1039 
II. Concussion ......... 1042 
III. Sprains .......... 1043 
IV. Synovitis .......... 1046 
„ V. Dropsy of the Joints ........ 1049 
VI. Movable and Adherent Bodies within the Joints . . . .1051 CONTENTS OF VOL.I 
XX 
PAGE 
Shct. VII. Tuberculosis of the Joints ....... 1056 
1. General observations ....... 1056 
2. Tuberculosis of the joints of the head and trunk .... 1064 
1. Temporo-maxillary joint ...... 1064 
2. Clavicular joints ....... 1064 
3. Occipito-atloid and atlo-axoid joints ..... 1064 
4. Sacro-iliac joint ....... 1066 
3. Tuberculosis of the joints of the superior extremity . . . 1068 
1. Wrist-joint ........ 1068 
2. Elbow-joint ........ 1068 
3. Shoulder-joint ....... 1069 
4. Tuberculosis of the joints of the inferior extremity . . . 1069 
1. Ankle-joint ........ 1069 
2. Knee-joint ........ 1070 
3. Hip-joint ........ 1071 
VIII. Chronic Rheumatic Arthritis ....... 1085 
of particular joints ..... 1088 
IX. Ankylosis .......... 1091 
X. Neuralgic and Hysterical Affections ...... 1099 
XI. Dislocations . . . . . . . . .1101 
1. General considerations . . . . . . .1101 
2. Simple dislocations ........ 1104 
3. Complicated dislocations . . . . . . .1114 
4. Chronic, old, or neglected dislocations . . . . .1117 
5. Congenital dislocations . . . . . . .1119 
XII. Dislocations of Particular Joints ....... 1121 
1. Head and trunk . . . . . . . .1121 
Dislocations of the hyoid bone . . . . . .1121 
of the jaw . . . . . . . .1121 
of the clavicle . . . . . . . .1124 
of the sternum . . . . . . . .1128 
of the scapula . . . . . . . .1128 
of the spine . . . . . . . .1129 
of the ribs and costal cartilages ..... 1132 
of the pelvis ........ 1132 
2. Superior extremity . . . . . . . . . 1133 
Dislocations of the hand . . . . . . .1133 
of the fingers ........ 1136 
of the carpal bones ....... 1137 
of the wrist ........ 1138 
of the radio-ulnar joints ...... 1139 
of the elbow ........ 1142 
of the shoulder . . . . . . .1148 
3. Inferior extremity . . . . . . . .1162 
Dislocations of the foot . . . . . . .1162 
of the ankle ........ 1166 
of the tibio-fibular joints ...... 1168 
of the patella . . . . . . . .1169 
of the knee . . . . . . . .1171 
of the semilunar cartilages . . . . . .1174 
Dislocations of hip-joint . . . . . . .1175 
Anomalous dislocations of the hip-joint .... 1189 
Partial and complicated dislocations .... 1191 
Chronic dislocations of the hip-joint . . . .1191 
Congenital dislocations of the hip-joint . . . .1193 LIST OF ILLUSTRATIONS TO Y0L I. 
FIG. PAGE 
1. Reticulated Arrangement of the Corpuscles in Inflammatory Blood . . .68 
2. Buffy and Cupped Blood ........ 68 
3. Changes in the Bloodvessels and Tissues in Inflammation . . . .73 
4. Plastic Corpuscles and Filaments in recent Lymph exuded on the Pleura . .111 
5. Recent Lymph, forming False Membrane . . . . . .111 
6. 7. Nuclei and Cells developing themselves into Fibres . . . . .112 
8. Perfect Fibrous Tissue . . . . . . . . .112 
9. Newly formed Vessels in Plastic Lymph . . . . . .112 
10. Vessels in False Membrane of the Pleura . . . . . .112 
11. Fibrinous Exudation in Process of Absorption . . . . . .113 
12. The Lymph of Pleuritis, with new Vessels and Fatty Degeneration . . .113 
13. Various Appearances of Pus Corpuscles . . . . . .119 
14. Abscess opening into the Carotid Artery ...... 127 
15. Abscess Bistoury . . . . . . . . .128 
16. Pus from a Scrofulous Abscess . . . . . . . .133 
17. Formation and Softening of Venous Thrombi ...... 144 
18. Acute Mortification . . . . . . . . .151 
19. Mortification, with an appearance of the Sloughing Process . . . .154 
20. Chronic Gangrene . . . . . . . . .158 
21. Chronic Ulcer . . . . . . . . . .175 
22. Granulating Ulcer, beginning to Cicatrize . . . . . .178 
23. Mode of Strapping an Indolent Ulcer . . . . . . .179 
24. Arrangement of Bloodvessels in Granulations . . . . . .181 
25. Structure of a Cicatrice of the Skin ....... 183 
26. Hydatids inclosed in a common Cyst ....... 208 
27. Cysts of Echinococci ......... 208 
28. Echinococci .......... 208 
29. Hydatid Tumor of the Thigh ........ 209 
30. Liporaatous Tumor . . . . . . . . .211 
31. Minute Structure of a Fatty Tumor ....... 212 
32. Microscopical Characters of Fibrous Tumor ...... 214 
33. Enehondromatous Tumor . . . . . . . .215 
34. Microscopical Characters of Enchomlroma . . . . . .216 
35. Minute Structure of Lymphoma . . . . . . .218 
36-41. Minute Structure of various forms of Sarcoma .... 223-227 
42. Minute Structure of a Myxomatous Tumor ...... 229 
43. Minute Structure of Rhabdomyoma ....... 229 
44. Minute Structure of Leiomyoma . . . . . . 229 
45. Vascular Tumor of the Scalp . . . . . . . .231 
46> 47. Minute Structure of a Simple and Cavernous Angioma . . . .231 
48, 49. Minute Structure of a True Neuroma. ...... 233 
50. Neuromatous Tumor ......... 234 
51. True Plexiform Neuroma ........ 234 XXII 
LIST OF ILLUSTRATIONS TO VOL. I. 
PIG. PAGE 
52. Painful Subcutaneous Tubercle ........ 235 
53. Microscopic Structure of the Subcutaneous Tubercle ..... 235 
54. Minute Structure of Papilloma ....... 236 
55. Minute Structure of Adenoma of the Mammary Gland .... 237 
56. Cells of Carcinoma ......... 239 
57. Stroma of Carcinoma ......... 240 
58. Carcinoma of Mammary Gland ....... 240 
59. Scheme of Development of, and Retrograde Changes in, Carcinoma . . .241 
60. Cellular Infiltration of the Fatty Tissues around a Carcinomatous Lymphatic Gland . 241 
61. Minute Structure of Scirrhus ........ 244 
62. Minute Structure of Encephaloid . . . . . . .247 
63. Epithelial Carcinoma in a State of Ulceration ...... 249 
64. Minute Structure of Pavement-celled Epithelioma ..... 250 
65. Minute Structure of Cvlindrical-celled Epithelioma ..... 250 
66. 67. Colloid Carcinoma, External Appearance and Internal Structure . . . 251 
68. Minute Structure of Colloid ........ 252 
69. Pigmented Cells of Melanosis ........ 252 
70. Serrefine .......... 255 
71. Small Forceps for temporarily checking Hemorrhage ..... 255 
72. Nunneley’s Artery Forceps ........ 255 
73. Minute Structure of Gray Miliary Tubercle ...... 263 
74. Multinucleated Cells of Chronic Phthisis ...... 263 
75. Multiple Chancroids . . . . . . . . .273 
76. Acute Phagedena ......... 274 
77. The Sloughing Sore ......... 275 
78. Indurated Chancre ......... 288 
79. Hunterian Chancre ... ..... 289 
80. Syphilitic Buboes ......... 289 
81. Syphilitic Ulceration of the Larynx . . . . . . .315 
82. Rupial Ulcers of the Skin . . . . . . . .318 
83. Condylomes . . . . . . . . . .319 
84. Nodes of the Skull ......... 321 
85. Syphilitic Caries of the Skull ........ 322 
86. 87. General Syphilitic Hypertrophy, Internal Structure and External Characters . 323 
88. Maury’s Fumigating Apparatus ....... 327 
89. Syphilitic Temporary Teeth ........ 334 
90. Syphilitic Permanent Teeth . . . . . . . .334 
91. Interrupted Suture ......... 341 
92. Old Suture Pin ......... 342 
93. Buck’s Suture Pin-Conductor . ....... 342 
94. 95. Twisted Sutures ......... 342 
96. Pin Pliers .......... 343 
97. India-rubber Sutures ......... 343 
98. The Glover’s or Continued Suture ....... 343 
99. Quilled Suture .......... 343 
100. Price’s Needle for Wire Suture ....... 344 
101. Murray’s Needle ......... 344 
102. Lister’s Needle .......... 344 
103. Tubular Needle ......... 345 
104. 105. Invaginated Bandage for Longitudinal Wounds ..... 345 
106, 107. Contrivances for Extraction of Point of Arrow ..... 365! 
108. Diagram representing effects of Gunshot Wounds ..... 369 
109, 110. Gunshot Probes . . . . . . . . 377, 378 
111. Thomassin’s Forceps ......... 379 
112. Gemrig’s Forceps . . . . . . . . .379 
113. Fenestrated Forceps ......... 379 LIST OF ILLUSTRATIONS TO VOL. I. 
FIG. PAGB 
114. Bullet Extractor . . . . . . • • .379 
115. Thomassin’s Extractor . . . . . . . . .379 
116. Weisse’s Elastic Forceps ........ 380 
117. Head of the Rattlesnake ........ 389 
118. Poison Fang, Magnified ........ 389 
119. Thermometer .......... 429 
120. Surface Thermometer ......... 429 
121. Probe ........... 430 
122. Sayre’s Vertebrated Probe ........ 431 
123. Speculum .......... 432 
124. 125, 126. Exploring Needles ....... 432, 433 
127-133. Different forms of Scalpels . . . . . • .437 
134, 135. Bistouries ......... 438 
136, 137. Dissecting Forceps ........ 438 
138, 139. Scissors ......... 438, 439 
140, 141, 142. Forceps for Morbid Growths ...... 439 
143. Grooved Director ......... 439 
144. Double Director ......... 440 
145. Trocar ........... 440 
146. Potain’s Aspirator ......... 440 
147. Surgical Needles ......... 440 
148. Suture Needle in fixed handle ....... 440 
149. Bonwill’s Surgical Engine . . . . . . . .441 
150. Davidson’s Syringe . . . . . . . . .442 
151. Vaginal Syringe Nozzle ........ 442 
152-155. Different positions of holding the Knife for operative purposes . . . 443 
156-164. Different forms of Incisions ...... 444, 445 
165. Double Canula .......... 446 
166. lllcraseur .......... 446 
167. Wire IScraseur .......... 447 
168. Cutting Skin Grafts . . . . . . . . .447 
169. Skin-grafting .......... 448 
170. Scarificator .......... 451 
171. Cupping Apparatus ......... 451 
172. Cupping Glass with Vulcanized India-rubber top ..... 451 
173. 174. Bleeding at the Bend of the Arm ...... 453 
175. Bleeding at the Jugular Vein ........ 456 
176. Bleeding at the Temporal Artery ....... 456 
177. Author’s Transfusing Apparatus ....... 457 
178. Hypodermic Syringe ......... 459 
179. Vaccine Lancet ......... 459 
180. Corrigan’s Button Cautery ........ 461 
181. Seton Needle .......... 461 
182. Mode of introducing a Seton ........ 462 
183. Porte-Moxa .......... 463 
184. 185, 186. Acupressure Needles ....... 464 
187. Bunsen’s Battery with Cauteries attached ...... 465 
188, 189. Galvanic Cauteries ........ 466 
190. Marshall’s Galvanic Seton . . . . . . . .466 
191. Different forms of Cauteries ........ 469 
192. Thermo-cautery of Paquelin . . . . . . . .470 
193. 194. Maisonneuve’s Plan of Circular and Parallel Cauterization . . . 471 
195. Dressing Forceps . . . . • • • • .473 
196. Drainage-tube and Forked Probe ....... 474 
197. Sponge Tent Holder ......... 476 
198. Greenhalgh’s Sea-tangle Tent ....... 476 XXIV 
LIST OF ILLUSTRATIONS TO VOL. I. 
PIG. 
199. Morton’s Ward Carriage . . paoe 
200. Bandage of Scultetus 
201. Mode of Applying the Roller . 
202. Appearance of the Bandage after its Application . . 
12' 9GoTgr nC fT SAtrangUlati0n °f Injured Limb by un«qual compression of a Bandage .' 480 
204,205. Esmarch’s Apparatus ... b 
206. Tenotome 
207. Circular Amputation, illustrated in the Leg . 
209 In™™™6 b?low the Seat °f AmPutatio«» the Circular Operation ! 512 
209. Appearance of the Stump in the Circular Amputation . . ,, 9 
210. Flap Amputation, illustrated in the Thigh 
211. Corresponding Stump . . . ' * * .513 
212. Teale’s Operation, shown in the Thigh 
213. leale’s Operation, the Flaps being drawn together ' r!! 
214. Petit’s Tourniquet . 
215. Tiemann’s Improved Tourniquet . | ’ ’ * * 517 
216. Artery Compressor ... * 517 
217. Amputating Knife . ’ 517 * 
218. Catlin 
219. Amputating Saw ... ’ 518 
220. Small Amputating Saw 
221. Bone Nippers * ‘ * 518 • 
222. Thigh Stump, with Splint for Extension . ’ ’ ' * 'HI 
223. Necrosis of the Bone after Amputation " 
224. Neuroma of the Stump, after Amputation of the Arm ’ .' ' * * Zl 
225. Aneurismal Varix in a Stump 
226. Appearance of Bony Stump after Amputation ?!? 
227. Artificial Leg . . . 534 
228. Ordinary form of Wooden Leg 
229. Artificial Arm and Hand 
230. Butcher’s Saw ... ' ®3® 
231. Hey’s Saw . . ’ * •••••. 543 
232. Curved Saw for Small Bones . 
233. Chain Saw 543 
234. 235, 236. Bone Forceps * 543 
237. Lente’s Inhaler • 543 
238. Richardson’s Spray Apparatus 
239. Incipient Carbuncle ... * 561 
240. Ulcerated Carbuncle . . ’ ' ’ -579 
241. Vicious Cicatrices of the Face and Neck 
242. Contraction of Elbow from Cicatrice of Burn 
243. Elephantiasis of the Foot and Leg . ’ * -585 
244. Sebaceous Tumors of the Scalp 
245. Fungating Sebaceous Tumor . . " ’ ‘ ' -597 
246. Keloid Tumors . . ' **88 
247. Microscopical Characters of Keloid . ’ * -602 
248. 249. Molluscous Fibroma 
250. Verrucous Sarcoma ... * c°4 
251. Nodule of Melanotic Sarcoma in the True Skin 
252. Common Wart ... ‘ 
253. Structure of a Corn . . ’ 6(16 
254. Horny Excrescence growing from Scalp . * ’ ' 60' 
255. Section of a Horn . . ' 8(^8 
256. Vertical Section of Rodent Ulcer ' * ’ -609 
257. Rodent Ulcer . . . ’ ' ’ * * * • 611 
258. Hydatid . • 611 
. 617 LIST OF ILLUSTRATIONS TO VOL, I. 
XXV 
FI0' ( _ PAGE 
259. Ganglion of the Extensor Tendons of the Hand ..... 620 
260. Fibroid Bodies of Ganglion . . . . . . . .621 
261. Fibroid Bodies of a Synovial Burse ....... 623 
262. Opisthotonos .......... 630 
263. Scrofulous Pus from a Lymphatic Gland ...... 649 
264. Chronic Inflammation of Lymphatic Gland ...... 650 
265. Hypertrophied Lymphatic Glands ....... 650 
266. Cretaceous Degeneration of Lymphatic Gland ...... 652 
267. Plan of Wounded Arteries ........ £54 
268. Contraction of a Divided Artery ....... 034 
269. Plan of Natural Hemostatics in a Cut Artery ...... 654 
270. Change in Artery after Ligation ....... 655 
271. Diagram of Collateral Circulation ....... 655 
272. Toothed Artery-forceps ......... 658 
273. Tenaculum ........ g58 
274. Sliding forceps .......... 659 
275. Prince’s Tenaculum-forceps ........ g59 
276. Mode of Drawing Out and Isolating an Artery ..... 659 
277. Effects of Ligation upon the Inner Coats of the Artery .... 659 
278. Exterior of an Artery after Ligation ....... 660 
279. Reef-knot ......... 660 
280. Surgeon’s Knot ......... g60 
281. Tenaculum-needle, armed with a Ligature ...... 661 
282. Physick’s Artery Forceps . . . . , . . .661 
283. Aneurism-needle, armed with a Ligature ...... 661 
284. Exposure and Opening of the Sheath ....... 661 
285. 286, 287. Effects of Ligation, at the end of Two, Eight, and Fifty Days . . 663 
288. Position of the Artery and Pin in Acupressure ...... 665 
289. Acupressure, showing the manner in which Ends of Pin project across the Skin . 665 
290. Circumclusion .......... 666 
291. First step of Torsoclusion ........ g66 
292. Second step of Torsoclusion ........ 666 
293. First step of Retroclusion ........ g66 
294. Second step of Retroclusion ........ 666 
295. Artery Constrictor . . . . . , # _ .667 
296. Tourniquet applied to the Femoral Artery ...... 668 
297. Field Tourniquet; Handkerchief and Stick ...... 669 
298- Field Tourniquet; Handkerchief and Sword ...... 669 
299. Digital Compression of the Brachial Artery ...... 669 
300. Digital Compression of the Femoral Artery ...... 669 
301. Plan of graduated Compress . . . . . . . .672 
302. Torsion-forceps . . . . . . # # .673 
303. Hewson’s Torsion-forceps ........ g74 
304. Mode of applying Torsion . . . . , _ < .674 
305. I artial Absorption of the Clot in the Femoral Artery, a Fortnight after Amputation . 676 
306. Collateral Circulation Shown in the Thigh ...... 680 
307. Plastic Deposits of the Aorta ........ 684 
308. Plastic Plugs occluding the Axillary Artery ...... 684 
309. Calcareous Deposits ...... 685 
310. Atheromatous Deposits ......... 686 
311. Fatty Granules, with Crystals of Cholesterine . ..... 686 
312. The so-called Dissecting Aneurism ....... g87 
313. Varicose Enlargement of the Arteries of the Hand ..... 688 
314-317. Arrangement of the Arterial Tunics in Spontaneous Aneurism . . . 690 
318. Sacculated Aneurism . . . . . > # .694 
319. Aneurism of the Aorta ......... 694 XXVI 
LIST OF ILLUSTRATIONS TO VOL. I. 
FIG. PAGE 
320. Sacciform Aneurism of the Aorta ready to give way ..... 696 
321. Tubular Aneurism of the Aorta . ....... 697 
322. Aneurism by Dilatation ........ 698 
323. Erosion of the Vertebrae from Aneurism . . . . . .702 
324. Aneurism obliterated by the Deposition and Organization of Fibrin . . . 704 
325. Aneurism of the Descending Aorta, burst ...... 705 
326. 327, 328. Illustrations of Hunter’s, Brasdor’s, and Wardrop’s Operations . . 712 
329. Gibbons’s modification of Charrifcre’s Compressor . . . . .715 
330. Carte’s Compressor . . . . . . . . .715 
331. Hoey’s Clamp .......... 715 
332. Carte’s Circular Compressor . . . . . . . .715 
333. Pravaz’s Syringe ......... 721 
334. Varicose Aneurism, External Appearance ...... 728 
835. Varicose Aneurism, Internal View ....... 728 
336. Aneurismal Varix . . . . , . . . .729 
337. Aneurism of the Arch of the Aorta opening into the Trachea .... 731 
338. Aneurism of the Arch of the Aorta nearly filled with laminated Clots . . . 736 
339. Aneurism of the Innominate Artery, bursting into the Trachea . . . 737 
340. Traumatic Aneurism of External Carotid ...... 748 
341. Traumatic Aneurism of the Brachial Artery . . . . . .764 
342. Aneurism of the Aorta, producing Caries of the Vertebrae . . . .766 
343. Spontaneous Cure of Aneurism of Femoral Artery by Sac being filled with Coagulum 773 
344. Aneurism of the Posterior Tibial Artery ...... 779 
345. Ligation of the Common Carotid and Facial Arteries . . . . .782 
346. Ligation of the Subclavian and Lingual Arteries ..... 786 
347. Ligation of the Occipital Artery . . . . . . .788 
348. Ligation of the Temporal Artery ....... 788 
349. Ligation of the Subclavian Artery, in its outer third ..... 789 
350. Diagram of Left Axillary below Clavicle ...... 795 
351. Ligation of the Axillary Artery ....... 796 
352. 353. Ligation of the Brachial Artery ....... 797 
354. Ligation of Radial Artery . . . . . . . .798 
355. Ligation of the Aorta ......... 799 
356. Ligation of the Common Iliac . . . . . . . .799 
357. Ligation of the External Iliac by Abernethy’s Operation .... 802 
358. Ligation of External Illiac and Superficial Femoral Arteries .... 806 
359. Ligation of the Popliteal at its upper and lower parts ..... 809 
360. Ligation of the Anterior Tibial at various parts ..... 810 
861. Ligation of the Posterior Tibial at various parts . . . . .811 
362. Phlebitis . . . . . . . . • .815 
363. Varix of the Leg . . . . . . • • .818 
364. Anastomotic Aneurism ......... 824 
365. Erectile Tumor .......... 826 
366,367. Erichsen’s Mode of Ligating Vascular Tumors ..... 827 
368. Hypertrophy of the Tibia from Inflammation . . . . . .842 
369. Abscess in the Head of the Tibia ....... 845 
370. Large Chronic Abscess of the Tibia ....... 845 
371. Trephine. .......... 846 
372. Caries of the Head of the Humerus ....... 848 
373. Caries, with Howship’s Lacunae ....... 848 
374. Caries of the Astragalus, with Softening and Incipient Separation of the Cartilage . 848 
375. Caries of the Tibia, with an Ulcer in the Skin ...... 849 
376-380. Instruments for removing Carious Bone ...... 852 
381. Structure of a Granulation in a Bone ....... 853 
382. Sequester of the Tibia ......... 856 
383. Necrosed Tibia, the dead bone lying loose within the new .... 857 no. PAOB 
384. Cloacae in Necrosed Tibia . . . . . . . .857 
385-389. Instruments for removing Dead Bone ...... 862 
390. Hammer .......... 862 
391. Gouge ........... 862 
392. Madame Supiot—case of General Osteomalacia ..... 864 
393. Section of a Softened Femur ........ 864 
394. Rickets ........... 866 
395. Atrophy of Bone ......... 872 
396. Atrophy of Connective Structure of the Thigh-bone ..... 873 
397. Advanced Stage of Senile Atrophy of the Thigh-bone ..... 873 
398. General Hypertrophy, showing the Internal Condition of the Bone . . . 874 
399. Hypertrophy involving both the Thickness and Length of the Bone . . . 874 
400. Osteophytes of the Inferior Extremity of the Femur ..... 875 
401. Periosteal Round-celled Sarcoma of Humerus ...... 876 
402. Central Giant-celled Sarcoma of the Head of Tibia ..... 876 
403. Formation of Bony Capsule in Central Tumor ..... 877 
404. Periosteal Spindle-celled Sarcoma ....... 879 
405. Osteoid Sarcoma of Head of Tibia ....... 882 
406. 407. Exostosis of the Femur ....... 883, 884 
408. Ivory-like Exostosis, showing its Internal Structure ..... 884 
409. Spongy Exostosis of the Femur ....... 884 
410. Cartilaginous Tumors of the Hand ....... 887 
411. Chondromatous Tumor undergoing Ossification ..... 888 
412. Chondromatous Tumor of the Ribs ....... 888 
413. Myxomatous Tumor ......... 889 
414. Anastomotic Aneurism of Bone . . . . . . . 890 
415. Bone Infiltrated with Tubercle ........ 892 
416. Tubercular Excavation of the Cuneiform Bone ..... 893 
417. Oblique Fracture of the Forearm . . . . . . .896 
418. Longitudinal and Oblique Fracture ....... 896 
419. Appearances of the Ends of the Fragments ...... 896 
420. Impacted Fracture of the Neck of the Femur ...... 897 
421. Fracture of the Lower End of the Radius ...... 903 
422. Fractured Tibia, showing the Formation of New Bone .... 905 
423. United Fracture, showing the Condition of the Medullary Canal . . . 906 
424. Appearance of Ends of the Fragments in Ununited Fracture .... 906 
425. Fracture of the Arm-bone of a Turkey ...... 907 
426. Wire Rack for Fracture of the Leg . . . . . . .912 
427. Marcy’s Plaster Bandage Roller . . . . . . .913 
428. Bavarian Splint . . . . . . . . .914 
429. Seutin’s Scissors . . . . . . . . .915 
430. Fracture of the Thigh in Immovable Dressing ...... 915 
431. Dressing in Compound Fracture of the Leg . . . . . .915 
432. Fracture of the Leg, complicated with Wound and Comminution of the Bone . 918 
433. 434. Incomplete Fracture of the Bones of the Forearm .... 924 
435. Case of Green-stick Fracture mentioned by Fergusson .... 925 
436. Hyperostosis after Green-stick Fracture ...... 926 
437. Diastasis of the Femur Reunited ....... 927 
438. Ununited Fracture of Bones of Leg ....... 928 
439. Absorption of the Humerus ........ 929 
440. Gimlet for Piercing Bone ........ 930 
441. Brainard’s Perforator ......... 931 
442. Screw for connecting the Ends of Ununited Fracture ..... 931 
443. Gaillard’s Fracture Pin ........ 931 
444. Smith’s Apparatus for Ununited Fracture, modified by Kolb6 . . . 933 
445. Viciously United Fracture of Leg ....... 934 
LIST OF ILLUSTRATIONS TO VOL. I. LIST OF ILLUSTRATIONS TO VOL. I. 
FIG. 
PAGE 
440. Butcher’s Clamp for Refracturing badly set Bones ..... 935 
44 7. Exuberant Callus after Fracture of the Thigh . . . . . .936 
448. Fracture of the Jaw ....... 940 
449. Felt Mould ........ 941 
450. Gibson’s Jaw Bandage ...... 941 
451. Barton’s Jaw Bandage ....... 941 
452. Hamilton’s Apparatus ........ 942 
453. Thomas’s Mode of Adjusting Fractures of Jaw . . . . .942 
454,455. Hammond’s Wire Splint for Fracture of Jaw . . . . .942 
456. Bean’s Interdental Splint ...... 943 
457. Interdental Splint, applied ..... 943 
458. Fracture of the Clavicle ...... 945 
459. Complete Oblique Fracture of the Clavicle ...... 945 
460. Velpeau’s Clavicle Bandage ....... 947 
461. Fox’s Apparatus for Fracture of the Clavicle ...... 948 
462. Figure-of-8 Bandage for Fracture of the Clavicle . . . . .948 
463. Boyer’s Apparatus for Fracture of the Clavicle . . . . .948 
464,465. Moore’s Apparatus for Fracture of Clavicle ..... 949 
466. Fracture of the Acromion Process ....!. 950 
467. Fracture of the Neck of the Scapula ....... 951 
468. Fracture of the Glenoid Cavity ...... 95I 
469. Fracture of the Coracoid Process . . . . . 951 
470. Ordinary Situations of Fracture of the Body of the Scapula . . . .952 
471. 472. I1 racture of the Ribs, showing Direction of Displacement . . . 954 
473. Fractured Ribs united by Osseous Matter ...... 955 
474. Fracture of the Odontoid Process of the Axis ...... 958 
475. Fracture of the Spinous Process ....... 950 
476. Fracture of the Vertebral Arches . . . . . . 959 
477. Fracture of the Vertebrae ....... 959 
478. Fracture of the Acetabulum ........ 960 
479. Fracture of the Pubic and Ischiatic Bones . . . . • .961 
480. Malapproximation of the Ends of the Fragments in Fracture of the Ulna and Radius 964 
481. Fracture of the Shaft of the Radius, with Vicious Union . . . .964 
482. Fracture of the Shaft of the Ulna ....... 965 
483. 484. Fracture of the Olecranon Process ...... 965 
485. Fracture of the Olecranon Process united by Fibrous Tissue .... 966 
486. Hamilton’s Apparatus for Fracture of the Olecranon Process .... 966 
487. Fracture of the Coronoid Process ....... 966 
488. Apparatus for Fracture of the Coronoid Process ..... 967 
489. Fracture of the Shaft of the Radius ....... 968 
490. Fracture of the Head of the Radius ....... 969 
491. Multiple Fracture of the Lower Extremity of the Radius .... 969 
492. Simple Fracture of the Lower Extremity of the Radius .... 970 
493,494. Fracture of the Lower Extremity of the Radius .... 971,972 
495. Old Fracture of Inferior Extremity of Radius, with Suppuration . . . 972 
496, 497. Levis’s Splint for Fracture of Radius ...... 973 
498. Bond’s Splint for the Back of the Forearm ...... 973 
499. Bond’s Splint for the Front of the Forearm and Hand .... 973 
500. 501. Gordon’s Splint for Colles’s Fracture ...... 974 
502. Moore’s Method of Treatment of Fracture of the Radius . . . .974 
503,504,505. Swinburne’s Apparatus for Fracture of the Radius .... 975 
506. Fracture of the Condyles of the Humerus ...... 977 
507. Fracture of the Internal Condyle . . . . . . .977 
508. Fracture of the External Condyle . . . . . .977 
509. Fracture of the Lower End of the Humerus . . . . . .978 
510. Badly-treated Fracture ol the External Condyle of the Humerus . . . 978 XXIX 
LIST OF ILLUSTRATIONS TO VOL. I. 
FIG. PAGE 
511. Fracture of the Epicondyle ........ 979 
512. Complicated Fracture of the Elbow ....... 980 
513. Stromeyer’s Cushion, with Straps applied ...... 980 
514. Fracture with Detachment of the Head of the Humerus .... 981 
515. 516. Fracture of the Anatomical Neck of the Humerus .... 981 
517. Fracture of the Surgical Neck of the Humerus ..... 982 
518. Badly-united Fracture of Surgical Neck of Humerus .... 982 
519. Welch’s Shoulder Splint ........ 982 
520. Oblique Fracture of the Tibia ....... 986 
521. Tin Case for Fracture of the Tibia ....... 987 
522. Welch’s Splints for Fracture of the Tibia ...... 987 
523. Bauer’s Wire Splints for Fracture of the Tibia ..... 988 
524. Fracture of the Fibula ........ 989 
525. Dupuytren’s Apparatus for Fracture of the Lower Extremity of the Fibula . . 990 
526. Fracture of the Tibia and Fibula at the Ankle-joint ..... 991 
527. Fracture of both Bones of the Leg at the Ankle-joint .... 991 
528. Fracture of the Lower End of the Tibia and Fibula ..... 992 
529. Neill’s Fracture Box ......... 992 
530. Application of the Gaiter . . . . . . . .993 
531. Application of the Handkerchief ....... 993 
532. Application of Adhesive Strips for Making Extension .... 993 
533. Stand and Pulley for Making Extension . . . . . .993 
534. Levis’s Stand and Pulley ........ 993 
535. Perforated One Pound Weights for Extension ..... 993 
536. Swinburne’s Method of Treating Fractures of the Leg .... 994 
537. Salter’s Apparatus for Suspending the Leg ...... 994 
538. Smith’s Suspending Apparatus ....... 994 
539. Complicated Fracture of the Leg ....... 995 
540. Fracture Box for the Leg ........ 996 
541. Compound Fracture of the Leg, dressed ...... 997 
542. Gillingham’s Apparatus for Ununited Fracture of the Leg .... 997 
543. Transverse Fracture of the Patella ....... 998 
544. Oblique Fracture of the Patella . . . . . . .998 
545. Fracture of the Patella ........ 998 
546. Arterial Supply of the Patella ....... 999 
547. Old Fracture of the Patella, showing Separation of the Fragments . . . 999 
548. Hamilton’s Apparatus for Fracture of the Patella ..... 1000 
549,550. Manning’s Splint for Fractured Patella ...... 1001 
551. Malgaigne’s Hooks ......... 1002 
552. Levis’s Hooks, applied ........ 1003 
553. Morton’s Hooks, applied ........ 1003 
554. 555, 556. Fracture of the Shaft of the Femur ..... 1006 
557. Fracture of the Femur at its Inferior Fourth ...... 1007 
558. Jenks’s Fracture Bed ........ 1008 
559. Physick’s Long Splint ........ 1009 
560. Fracture Box with Side Splints ....... 1009 
561. Gilbert’s Fracture Apparatus ....... 1010 
562. Hodge’s Method of Counterextension in Fracture of the Femur . . . 1010 
563. Smith’s Anterior Splint . . . . . . . . .1011 
564. Mode of Application of the Same ....... 1011 
565. Hodgen’s Suspension Apparatus ....... 1012 
566. Levis’s Extending Apparatus ........ 1012 
567. Buck’s Fracture Apparatus . . . . . . . .1013 
568. Swinburne’s Method of Treating Fractures of the Thigh .... 1013 
569. Morton’s Extending Apparatus ....... 1013 
570. Packard’s Fracture Apparatus ....... 1014 XXX 
LIST OF ILLUSTRATIONS TO VOL. I. 
Fin. PAGE 
571. Double Inclined Plane of Sir Charles Bell . .... 1015 
572, 573. McIntyre’s Splint, Simplified and Improved by Liston .... 1016 
574. Fracture of the External Condyle ....... 1017 
575. Comminuted Fracture of the Lower Extremity of the Femur . . . 1018 
576. Separation of Lower Epiphysis of Femur with Fracture , 1019 
577. Natural Appearances of the Head and Neck of the Femur .... 1020 
578. Alterations of the Head and Neck of the Femur from the Effects of Old Age . 1020 
579. 580. Illustrations of Intracapsular Fractures . . . . . .1021 
581. Intracapsular Fracture of the Femur . . . . . . . 1021 
582. Vertical Fracture of the Neck of the Femur ...... 1021 
583. Bryant’s Test Line for Shortening ....... 1024 
584. Senile Atrophy of the Neck of the Femur ...... 1025 
585. Atrophy which might be Mistaken for United Fracture .... 1025 
586. Fracture of the Neck of the Thigh-bone united by Fibrous Tissue . . . 1026 
587. Daniel’s Fracture Bed ........ 1028 
588. Reclining Chair ......... 1029 
589. Extracapsular Fracture of the Femur ...... 1030 
590. Comminuted Fracture of the Upper Extremity of the Femur . . . 1030 
591. Impacted Fracture of the Neck of the Femur ..... 1032 
592. Impacted Fracture through the Trochanters ...... 1032 
593. Fracture of the Great Trochanter ....... 1036 
594. Sir Astley Cooper’s Method of Treating Fractures of the Great Trochanter . . 1037 
595. Epiphyseal Fracture of Great Trochanter ...... 1037 
596. Acute Synovitis ......... 1046 
597. Laced-cap for Dropsical Joints ....... 1051 
598. Loose Articular Concretions ........ 1053 
599. Adherent Articular Concretions ....... 1053 
600. Fimbriated Growths of the Synovial Membrane ..... 1056 
601. Synovial Membrane Studded with Seed-shaped Bodies .... 1056 
602. Section of a Strumous Ulcer of a Cartilage ...... 1058 
603. Section of Strumous Tibia ........ 1058 
604. Tuberculosis of the Wrist-joint ....... 1068 
605. Sayre’s Apparatus for Extension at the Knee-joint ..... 1071 
606. Mode of Applying the Adhesive Plaster for the Same .... 1071 
607. Sayre’s Apparatus Adjusted ........ 1071 
608. Appearance of the Nates and Limbs in the Earlier Stages of Iiip-joint Disease . 1073 
609. Appearance of Parts in Advanced Stages of Hip-joint Disease . . . 1075 
610. Upper Displacement in the Advanced Stage of Coxalgia .... 1076 
611. Extensive Malposition of the Limb in the Advanced Stage of Coxalgia . . 1076 
612. Changes in the Acetabulum and Head of the Thigh-bone in Coxalgia . . 1080 
613. Sayre’s Apparatus for Coxalgia ....... 1082 
614. Adhesive Plaster with Web for the Same ...... 1082 
615. 616. Hutchison’s Shoe ........ 1083 
617. Thomas’s Posterior Splint ........ 1083 
618. Willard’s Splint ......... 1083 
619. Pancoast’s Apparatus for Coxalgia ....... 1085 
620. Pancoast’s Splint, applied ........ 1085 
621. Effects of Chronic Rheumatic Arthritis of the Hip-joint .... 1090 
622. Osseous Ankylosis of the Knee-joint ....... 1092 
623. Kolb6’s Apparatus for the Knee ....... 1093 
624. Modified Stromeyer’s Splint for the Elbow ...... 1093 
625. Lines of Section in Sayre’s Operation for Ankylosis of Iiip-joint . . . 1094 
626. 627. Adams’s Saw for Subcutaneous Division of Neck of Femur . . . 1095 
628. Barton’s Operation for Ankylosis of the Knee ..... 1096 
629. Bone Perforator ......... 1097 
630. Result of Operation for Synostosis of the Knee ..... 1097 LIST OF ILLUSTRATIONS TO VOL. I. 
XXXI 
FIO. PAGE 
631. Dislocation of the Knee from Disease ....... 1103 
632. Clove-hitch Knot . . . . . . . . .1110 
633. Clove-hitch Knot applied . . . . . . . .1110 
634. Compound Pulleys . . . . . . . . .1110 
635. Pulleys applied . . . . . . . . .1111 
636. Staple for Pulleys . . . . . . . . .1111 
637. Levis’s Apparatus for fastening Pulley Rope to Limb .... 1111 
638. Fahnestock’s Method of Extension and Counterextension . . . .1112 
639. Bloxam’s Dislocation Tourniquet ....... 1112 
640. Jarvis’s Adjuster, applied . . . . . . . .1113 
641. Old Dislocation of the Hip, a new Acetabulum being formed . . .1117 
642. Double Dislocation of the Lower Jaw ....... 1122 
643. Dislocation of the Lower Jaw . . . . . . .1122 
644. Dislocation of the Sternal end of the Clavicle . . . . .1125 
645. Dislocation of the Acromial End of the Clavicle . . . . .1126 
646. Dislocation of the Spine between the Fourth and Fifth Cervical Vertebra; . .1129 
647. Dislocation of the Spine seen Laterally ...... 1129 
648. Bilateral Dislocation of the Fifth Cervical Vertebra ..... 1130 
649. Dislocation of the Thumb on the Dorsum of the Metacarpus . . . .1133 
650. Clove-hitch Knot for reduction of Dislocated Thumb . . . .1134 
651. Charrifere’s Forceps for reduction of Dislocated Thumb .... 1135 
652. 653. Levis’s Apparatus for reducing Dislocations of the Thumb and Fingers . 1135 
654. Crosby’s Method of Reducing a Dislocated Thumb ..... 1135 
655. Forward Dislocation of the Thumb . . . . . . .1135 
656. Dislocation of the Finger ........ 1136 
657. Dislocation of the Finger at the Metacarpo-phalangeal Joint .... 1136 
658. Dislocation of the Carpal Bones Forwards ...... 1139 
659. Dislocation of the Head of the Radius Forwards ..... 1140 
660. Dislocation of the Head of the Radius Backwards . . . . .1141 
661. Dislocation of Radius and Ulna Backwards ...... 1142 
662. Dislocation of Radius and Ulna Backwards, showing the manner in which the Mus- 
cles are put on the stretch . . . . . . . .1143 
663. Reduction of the same with the Knee in the Bend of the Elbow . . .1144 
664. Lateral Dislocation of the Elbow-joint Inwards ..... 1146 
665. Lateral Dislocation of the Elbow-joint Outwards ..... 1146 
666. Dislocation of the Ulna Backwards ....... 1147 
667,668. Dislocation of the Humerus into the Axilla ..... 1149 
669. Subcoracoid Dislocation of the Humerus ...... 1150 
670. Thoracic Dislocation of the Humerus . . . . . . .1150 
671. Subspinous Dislocation of the Humerus . . . . . .1151 
672. Reduction of Dislocations of the Humerus with the Heel in the Axilla . . 1152 
673. Reduction of the same with the Knee in the Axilla ..... 1152 
674. Reduction of the same by the Perpendicular Method .... 1153 
675. Extension for the same with the Pulleys . . . . . .1154 
676. N. R. Smith’s Method of Reducing Dislocation of the Shoulder . . . 1154 
677. Anomalous Dislocation of the Shoulder ...... 1157 
678. Dislocation of the Tendon of the Biceps Muscle ..... 1161 
679. Compound Dislocation of the Astragalus Inwards . . . . .1165 
* 680. Dislocation of the Tarsus Inwards . . . . . . .1167 
681. Dislocation of the Tarsus Outwards . . . . . . .1167 
682. Dislocation of the Astragalus Upwards between the Tibia and Fibula . .1168 
683. Compound Dislocation of the Ankle-joint ...... 1168 
684. Dislocation of the Patella Outwards ....... 1169 
685. Dislocation of the Patella Inwards . . . . . . .1169 
686. Dislocation of the Tibia Forwards . . . . . . .1171 
687. Dislocation of the Tibia Backwards . . . . . . .1173 A 
SYSTEM OF SURGERY. 
CHAPTER I. 
IRRITATION, SYMPATHY, AND IDIOSYNCRASY. 
It is very difficult, if not impossible, in the present state of the science, to offer any 
satisfactory definition of irritation, or to assign to this expression its true pathological and 
practical import, without an intimate knowledge of sympathy or of those various and mys- 
terious relations, anatomical and functional, which exist among the different organs and 
tissues of the body, and which thus serve to bind them all up into one harmonious, uni- 
form, and connected system. Irritation and sympathy are not only closely associated 
together, in all the great operations of the economy, but they so constantly run into each 
other as to render it impossible always to draw a precise line of distinction between them, 
or to determine what part they respectively play in the production, propagation, and effect 
of disease. Much of what has been written upon these topics has necessarily been exceed- 
ingly obscure, depending not merely upon the intrinsic difficulties of the subject—great 
and perplexing as they certainly are—but upon the unphilosophical manner in which they 
have, for the most part, been discussed by surgeons, whose authority has not only never 
been disputed, but regarded with a blind devotion as surprising as it has generally been 
unaccountable. To arrive at any other conclusion from an attentive perusal of their writ- 
ings, is impossible. Every page, nay, almost every paragraph, bears testimony to the fact 
that they have constantly confounded together affections of a very different, and even of 
an opposite nature ; that they have, in numberless instances, violated their own definitions 
of disease; and that they have attempted to establish systems of treatment based upon 
principles of the most erroneous and unfounded character. 
What is irritation ? Is it an entity or a mere myth, a certain undefinable something, 
which no one can see, but which every one may recognize by its effects? Perhaps the 
best definition that can be given is that it is a disordered state of the nerves of the affected 
part, attended with more or less pain and functional disturbance, but not with inflamma- 
tion, although it may lead to inflammation, if not timeously arrested: in other words, 
irritation is a disease the predominant symptom of which is nervous derangement. Viewed 
in this light, it may be considered as holding the same relation to the nervous system that 
inflammation bears to the vascular; the one consists essentially in disordered sensation, 
the other in disordered circulation ; in the one there is pain, but it is the pain of per- 
verted sensation ; in the other there is pain also, but it is the pain of inflammation, as is 
evinced by the concomitant vascular injection, discoloration, and tumefaction, which are 
wanting in the former. The differences between irritation and inflammation have some- 
times been defined by stating that the former terminates where the latter begins ; as 
congestion may be said not to be inflammation, but the prelude to that affection. Both 
may be merged in the latter disease, and may, consequently, serve to augment and 
perpetuate it. 
Irritation may be of limited extent, as when it is confined to one particular organ, or 
part of the body, and is then said to be local; on the other hand, it is sometimes widely 
diffused, manifesting itself at numerous points, and constituting what is termed general 36 
IRRITATION AND SYMPATHY. 
irritation, of which one of the most familiar illustrations occurs in nervous shock, conse- 
quent upon severe injury. It is also divided into direct and indirect; in the former case, 
the irritation displays itself at the place of the morbific impression ; in the latter, on the 
contrary, it occurs at a situation more or less remote, sympathy and reflex action being 
the agents of its transmission. An example of direct irritation is afforded in the intole- 
rance of light which results from over-fatigue of the eye ; and of the indirect, in the con- 
vulsions which supervene upon the presence of worms in the alimentary canal, the irrita- 
tion being communicated here from the nerves of the bowels to the spinal cord, or the 
cerebro-spinal axis, and from thence to the nerves of the voluntary muscles, the seat of 
the spasmodic action. 
Local irritation may manifest itself in a great variety of ways and circumstances. It 
is generally excited by the contact of some extraneous substance, or agent, foreign to the 
part, and, therefore, a source of offence to it. Thus a drop of alcohol, falling upon the 
eye, instantly produces pain, and injection of the conjunctiva, with an abundant flow of 
tears ; the organ resents the aggression, and the consequence is a marked perversion both 
of sensation and circulation, which, the exciting cause ceasing to operate, soon passes off, 
the parts regaining their comfort and accustomed action ; or, the cause continuing in play, 
violent and even destructive inflammation may succeed, the minor evil being merged into 
the major. A pinch of snuff will excite sneezing by the irritation which its presence 
induces in the pituitary membrane; on the same principle, some emetics cause vomiting, 
some cathartics purging, and some diuretics an increased secretion of urine. When the 
hand is held near a hot stove, or rubbed with spirits of ammonia, the skin presently shows 
signs of irritation : its sensibility is perverted, it burns and stings, and becomes intensely 
red. All these, and numerous analogous cases that might easily be adduced, if it were 
necessary, are examples of local irritation, or of perverted nervous action, accompanied 
by vascular determination, but not by inflammation, although such an event is certain to 
occur, if the exciting cause of the irritation be not promptly removed. 
Indirect, or reflex irritation, like the direct, also displays itself in different ways, and 
not unfrequently in a manner not less singular than perplexing, defying all effort at expla- 
nation. The subject offers a wide field for contemplation and study. Here I can only 
glance at a few of the more prominent facts which naturally connect themselves with such 
a discussion. To do anything even like partial justice to the subject, it will be proper to 
consider it in relation to the principal organs of the body, a procedure which will neces- 
sarily bring up the question of sympathy, as a knowledge of the latter is indispensable to 
a correct appreciation of the former, and conversely. 
It would be out of place in a work of this kind to inquire into the nature of sympathy. 
All that we know respecting it is that there exists, both in health and in disease, an inti- 
mate relationship between certain organs and tissues, the result either of a continuity of 
structure, similarity of tissue, or of ties, of which anatomy and physiology have failed to 
point out the true character. In health, this action is carried on so imperceptibly as to 
escape attention ; but, whenever there is any serious disorder of the system, it manifests 
itself at every point, serving at once, at least in many cases, to indicate the nature of the 
lesion, and the particular tissues, or set of textures, which it implicates. It is not difficult 
to account for the sympathy that exists between parts that are united together by con- 
tinuity of structure, as, for instance, the eye and nose, or the bladder and urethra; or by 
similarity of structure, as the fibrous membranes, the diseases of which, as gout and rheu- 
matism, are sometimes suddenly transferred from one to another : but in other cases—and 
these constitute some of the most interesting and important exceptions—no connection of 
any kind can be traced, and we are therefore left in doubt in respect to its real character. 
It is only, then, by studying these effects, as they exhibit themselves in different parts of 
the body, and under different circumstances, that our knowledge of them can be made 
practically available. 
1. Nervous System.—The brain, from its elevated position in the scale of organs, and 
its importance to health and life, is subject, in a remarkable degree, to the causes which 
develop and influence irritation. Connected, either directly or indirectly, with every 
other organ and tissue of the body, its functions are liable to be disturbed in every variety 
of way, and in every possible degree, from the most simple and almost imperceptible 
departure from the normal standard to the most complete and thorough perversion, amount- 
ing, at times, to total annihilation of sensation. Hence, it is not surprising that while the 
brain is itself a source of irritation to other parts, it should in its turn, be more or less 
seriously affected by irritation having its seat in remote structures operating upon it through 
CHAP. I. BRAIN—SPINAL CORD. 
37 
CHAP. I. 
sympathy, or reflex action. It is in this manner that are developed many of the most dis- 
tressing diseases of the cerebrum and cerebellum, and also, as a natural consequence, of 
the mind ; and what is remarkable is, some of the most disastrous lesions often have their 
origin in apparently the most trivial cerebral irritation, which, but for neglect or igno- 
rance, might usually be relieved by the most simple treatment. The arachnitis of infancy 
generally begins in reflex irritation, which has its seat in the bowels, stomach, liver, 
skin, or gums, fretted, perhaps, by the pressure of an advancing tooth. Such cases are 
of constant occurrence in this country, during our hot summer months, and there are 
none which are more justly dreaded by the practitioner. The influence of this kind of 
irritation is often forcibly exhibited in traumatic delirium, or that excited state of the 
brain consequent upon accidents and operations, especially in subjects of intemperate 
habits and of a nervous temperament; the brain appears to be in a state of the utmost 
tension from pent-up irritability, which nothing but the most liberal use of anodynes can 
generally control; all the symptoms are such as to preclude the idea of the existence of 
inflammation in the cerebral substance, nor is it by any means certain that there is always 
gastritis, although usually there is marked derangement of the stomach. In disorder of 
the uterus, the brain is often affected by reflex irritation, as is plainly evinced by the 
eccentric phenomena which so generally attend hysterical diseases. 
On the other hand, disease of the brain is often productive of serious irritation, or 
disease in other parts. Thus, after concussion of this organ, it is by no means uncom- 
mon, after the main symptoms of the accident have subsided, to meet with paralysis of 
one side of the face, occasional vomiting, constipation of the bowels, irritability of the 
bladder, or disease of the sphincters, causing involuntary discharges of urine and feces. 
The sympathies existing between the cerebellum and the testes afford a ready explana- 
tion of the occurrence of certain diseases, which, but for a knowledge of this fact, would 
be inexplicable. Military surgeons long ago noticed that wounds of the occiput, even when 
not involving the substance of this portion of the brain, are often followed, at variable periods 
after recovery, by atrophy of the testicles. Injuries of the cerebellum have been known 
to be succeeded, within a short time after their infliction, by the most violent sexual 
excitement. A case of gunshot wound, in a man twenty-five years of age, related to me 
by Dr. Donne, admirably illustrates the nature of such a lesion. The ball, a common 
rifle one, penetrated the skull near the lambdoidal suture, whence it passed obliquely 
downwards and backwards, lodging, there was every reason to believe, in the cerebellum. 
The reaction, which was very slow, was attended with excessive excitement of the 
genital organs. Intense priapism supervened on the fifth day, attended with the most 
extraordinary salacity, which formed the all-absorbing topic of the man’s remarks during 
his semilucid intervals up to the time of his death, nine days after the receipt of the 
injury. Nocturnal pollutions and the habit of onanism, in their most degrading forms, 
are often excited and kept up by a diseased state of the brain operating prejudicially upon 
the testes and seminal vesicles. The effect may be produced simply by inflammation of 
the cerebral tissues, or by the pressure occasioned by some morbid growth, as a sarco- 
matous, scrofulous, or other tumor. 
The study of the sympathies and irritations of the spinal cord naturally follows that of 
the brain. Connected, as this cord is, on the one hand, by the nerves which are detached 
from its substance, with the organs of volition and of special sensation, and, on the other, 
by the anastomoses of these same nerves with those of the great trisplanchnic system, its 
sympathies and relations are as universal as they are close and intricate. Hence what- 
ever has a tendency to derange these consentaneous movements, must necessarily be a 
source of disease, often of a wide-spread, if not of an all-absorbing character. Concus- 
sion, for example, of the spinal cord, when not immediately followed by death, is gene- 
rally productive of excessive prostration of the vital powers, hardly less extensive and 
fatal than that of the brain itself. Life often hangs literally for hours upon a mere 
thread ; the face is ghastly pale, the pulse weak and fluttering, the breathing hardly per- 
ceptible. In the milder forms, the mind is frequently disordered for days, the bladder is 
excessively irritable, the bowels are costive, the eye sees objects confusedly, and the ear 
is incapable of accurately noting sound. There are many diseases which may induce 
spinal irritation ; I shall allude only to inflammation, ulceration, and displacement of the 
uterus, the practice of self-pollution, constipation of the bowels, and chronic gastric dis- 
order. On the other hand, spinal irritation is capable of sending its baneful influence 
through every portion of the system, deranging the functions of every organ, and causing 
a train cf phenomena frequently as distressing as they are enigmatical, or difficult of 
interpretation. Nervous headache, hemicrania, partial paralysis, imperfect sight, partial 38 
IRRITATION AND SYMPATHY. 
chap, i. 
aphonia, embarrassed respiration, palpitation of the heart, gastric irritation, vitiated appe- 
tite, costiveness, and disorder of the menstrual secretion, are often directly traceable to 
disease of the spinal cord and its envelops; and no practitioner can make much progress 
towards a cure in these affections without bearing in mind the sources whence they 
spring. The renal secretion is often greatly deranged by disease and injury of the spinal 
cord, and a very common effect of such lesions is a tendency to various deposits, espe- 
cially the lithic and phosphatic. The bladder is also liable to suffer under such circum- 
stances ; becoming irritable, inflamed, and the seat of calculus, especially when the spinal 
cord has been severely concussed, wounded, or compressed. Many cases of neuralgia, 
gout, and rheumatism owe their origin, there is reason to believe, to disorder of the spinal 
cord, or the spinal cord and brain. 
The nerves, those agents which convey to and from the brain and spinal cord the im- 
pressions made upon the various organs of the body, are themselves not unfrequently the 
seats of serious diseases and injuries, serving to modify and pervert their functions. A 
spicule of bone, a ball, or the point of a needle, pressing ‘upon a nerve, or partially 
imbedded in its substance, has often been productive of epilepsy, partial paralysis, loss of 
sensation, and other unpleasant symptoms, which promptly vanished upon the removal of 
the foreign body. 
2. Heart As the heart is sympathetically connected with every portion of the body, 
so there are few diseases which are not capable of exerting a prejudicial influence upon 
its action, exalting it at one time and depressing it at another. It may be irritated and 
fretted in a thousand different ways ; now by this cause, and now by that; at one time 
by the solids, and at another by the blood, its natural and proper stimulus. Both the 
surgeon and physician daily witness examples of these disturbing agencies, and prepare to 
meet them by the judicious exercise of their clinical knowledge, often sadly tried by the 
perplexing and dangerous features of the case. There is no organ, the brain hardly ex- 
cepted, the action of which varies so much as that of the heart within the limits of health, 
and none which suffers more frequently and profoundly in disease and accident. The 
blood which, on the one hand, serves to animate and rouse it, and which, on the other, it 
is obliged at every moment to propel to every portion of the body, is itself one of the 
greatest sources of irritation to which it is so constantly exposed. At one time the cause 
of the irritation perhaps is plethora, at another anemia ; in one case it may be due to an 
undue proportion of saline matter, in another to the presence of some extraneous substance. 
Among the more prolific sources of cardiac irritation are disorder of the digestive appa- 
ratus, mechanical obstruction to the circulation, however induced, mental emotion, and 
derangement of the liver, uterus, and kidneys. 
In injuries, derangement of the sympathetic relations of the heart is of constant occur- 
rence, exhibiting itself in various forms and degrees, from the slightest disorder of its 
functions to almost complete annihilation of its muscular powers. In shock, the pulsa- 
tions of the heart are weak and fluttering ; in compression of the brain, slow and laboring; 
in hemorrhage, thrilling and vibratory ; in plethora, strong and lull; in anemia, quick, 
jerking, and accompanied with a peculiar systolic murmur. 
Irritation of the heart is often aroused by compression of the cardiac nerves by various 
kinds of tumors, by aneurism of the great vessels, and by diseases resident in its own tis- 
sues, causing them to act in an irregular and imperfect manner. 
As the heart’s action may be disordered by various diseased states of the body, so may 
this organ, in its turn, occasion derangement and irritation in other structures, leading 
not unfrequently to violent inflammations which no remedial measures, however judiciously 
applied, can always arrest and subdue. These disordered states form a wide field of study, 
which it would be out of place to pursue in a work of this kind. The intelligent reader 
will not fail to appreciate their pathological and practical import. 
3. Lungs The action and reaction which are so incessantly going on between the 
lungs and the rest of the system cannot fail to strike the most superficial observer. From 
the importance of their functions, and their extensive sympathetic relations, these organs 
are subject to numerous and diversified changes, the influence of which, upon the gene- 
ral health, can oidy be duly estimated by a profound study of the subject. Whatever 
seriously affects the functions of the more important structures, is sure, sooner or later, to 
exert an unfavorable impression upon the lungs, disordering the respiratory movements, 
and untowardly interfering with the aeration of the blood, or the introduction of oxygen, 
and the elimination of carbonic acid. Hence, a perfectly healthy state of these organs is DIGESTIVE ORGANS. 
39 
CHAP. I. 
a matter of paramount importance in the treatment of every case of injury and disease. 
Among the more common objects of attention, with this view, should be a pure state of 
the atmosphere, the use of wholesome food, and the correction and improvement of the 
secretions, without which our best directed efforts will often fail to avert irritation and 
disease, or to combat them successfully when their development has been unavoidable. 
4. Digestive Organs The stomach, possessing a wide range of sympathy, is often 
the seat, not less than the cause, of severe irritation. Food and drink are the natural 
stimulants of this organ, and, rationally employed, seldom prove unwholesome. But when 
the laws of digestion are contravened by dietetic debauch and indiscretion, or, in other 
words, when the stomach is overloaded with indigestible articles, nausea and vomiting, 
with more or less cerebral and other disturbance, are the necessary and inevitable con- 
sequences. In children and delicate nervous females, such abuse often manifests its 
effects in the most violent convulsions, from the irritation it produces in the cerebro-spi- 
nal axis and the nerves which are distributed to the voluntary muscles. An over-loaded 
stomach frequently brings on a severe attack of asthma, palpitation of the heart, indis- 
tinctness of vision, and distressing noises in the ears. 
Affections of the oesophagus often create excessive irritation of the stomach, manifesting 
itself in nausea and vomiting. Examples of this morbid sympathy occur in carcinoma 
of the oesophagus, as well as in ulceration and in ordinary stricture of that tube. I have 
seen a foreign body, as a common cent, lodged in the oesophagus of a child, keep up nau- 
sea and vomiting until it was extracted. The irritation of the stomach, produced by 
tickling the fauces, is well known to every one. On the other hand, the oesophagus is 
liable to suffer very seriously from disease of other parts of the body. Thus, spasmodic 
stricture of this tube, sometimes of an exceedingly severe and intractable character, may 
be produced by disorder of the stomach, bowels, uterus, or spinal cord, which can only be 
relieved by addressing our remedies to the seat of the primary affection. 
Disorder of the bowels is a prolific source of irritation, exhibiting itself in different 
viscera and tissues; for there are few organs whose sympathetic relations are of a more 
varied and extensive character. Allusion has already been made to the effects occa- 
sioned by the presence of worms in the alimentary canal; the retention of irritating mat- 
ter often produces similar impressions upon the great nervous centres, followed in many 
cases, especially in infants and delicate nervous persons, by violent convulsions, disease 
of the arachnoid membrane, and palpitation of the heart. Itching of the nose, and various 
affections of the lips, tongue, and fauces, are frequently directly chargeable to dyspepsia, 
constipation, and other gastro-enteric derangement. What is called sick headache affords 
a familiar illustration of cerebral irritation dependent upon disorder of the stomach and 
bowels, or of these organs and of the liver. Costiveness never fails, when long continued, 
to oppress the brain, and to produce a sense of general malaise. Excessive itching of 
the pudendum and perineum is sometimes caused by the existence of worms in the ali- 
mentary canal. 
There is an intimate sympathetic connection between the bladder and the rectum; also 
between the urethra and the lower bowel. In dysentery, hemorrhoids and fissure of the 
anus, strangury and spasmodic retention of urine are by no means uncommon, and are 
sometimes productive of great suffering. The ligation of a pile not unfrequently compels 
the surgeon to use the catheter for drawing off the urine; and I have known the vesical 
irritation in such a case to continue for several days. The same affections often cause 
spasmodic stricture of the urethra. 
A very lively sympathy exists between the teeth and some of the other parts of the 
body; more intimate and extensive than would at first sight seem possible. Children, 
from the pressure of the teeth upon the gums, are extremely liable, especially during our 
hot summer months, to vomiting, diarrhoea, fever, and convulsions. Arachnitis occasionally 
supervenes upon difficult dentition; and certain affections of the skin, as eczema and 
porrigo, are frequently directly traceable to its effects, and rendered obstinate, if not 
temporarily incurable, by its persistence. A heated and tumid state of the gums, with 
thirst and redness of the skin, should be promptly met by the free division of these 
structures; otherwise, what is originally a mere irritation of the brain, stomach, or bowels, 
may soon be transformed into a fatal inflammation. 
A decayed tooth, even when it does not itself ache, often causes severe pain in the face, 
temple, neck, throat, or ear; generally, but not by no means always, on the corresponding 
side, doubtless because all these parts are supplied by nerves derived from the same sources. 
When the car is involved, the pain is propagated along the nervous cord of the tympa- 40 
IRRITATION AND SYMPATHY. 
num, a filament of the second branch of the fifth pair of cerebral nerves. A carious tooth 
occasionally creates violent pain in a sound one, though at a distance from it, the suffering 
ceasing the moment the offending tooth is extracted. I have known a severe attack of 
pleurodynia to be kept up by a diseased tooth; the patient was bled and purged, but 
relief came only with the removal of the affected stump. Enlargement of the lymphatic 
glands of the neck, ulcers of the chin and cheek, epilepsy, hysteria, dyspepsia, and various 
other affections, sometimes of a very obstinate and distressing character, may be produced 
by carious teeth. It is difficult to conceive how a diseased tooth could keep up an attack 
of rheumatism of the hip, and yet the possibility of such an occurrence is established by 
some well-authenticated cases. Dysmenorrhaca has been cured by the extraction of seve- 
ral of the large grinders; and attacks of intermittent fever have been relieved in a simi- 
lar manner, after the protracted but fruitless employment of bark and other remedies. 
A decayed tooth has been known to produce neuralgia of the arm, which promptly van- 
ished upon its removal. Amaurosis, temporary and permanent, has occasionally been 
caused by diseased teeth in the upper jaw. In a case related by Hancock, a boy eleven 
years old was rapidly cured of total blindness by the extraction of two permanent bicus- 
pids and four milk molars. Fricard met with a case of severe and obstinate tonsillitis, 
which yielded only after the free division of the indurated and swollen gum over the 
wisdom tooth. 
The sympathetic relations of the liver are at once numerous and diversified, and any 
disturbance in them is generally productive of irritation in a number of the more import- 
ant organs, especially the stomach, bowels, brain, heart, and lungs. The skin also 
frequently suffers in consequence of hepatic derangement, and, conversely, the liver from 
disorder of the cutaneous surface. Various medicines, as well as different kinds of food, 
are capable of seriously disturbing the functions of this organ; and it is well known that 
its secretions are often materially disordered by the direct influence of anxiety or strong 
mental emotion. An attack of jaundice is sometimes instantaneously produced by severe 
fright. The timid duellist and the affrighted soldier often suffer from this kind of irrita- 
tion. Hepatic abscesses not unfreqnently follow upon injury of the skull or brain; and, 
on the other hand, disease of the liver occasionally provokes serious cerebral irritation. 
Dyspnoea, palpitation of the heart, nausea, flatulence, and vomiting, are common effects 
of disease of this viscus. Pain in the top of the right shoulder has long been recognized 
by physicians as a symptom of hepatitis. Violent shock is occasionally followed by total 
suppression of bile; and the passage of a gallstone always causes intense gastric irritation. 
5. Urinary Organs.—The kidneys have important sympathetic relations with different 
parts of the body, manifesting themselves in various forms of irritation. Thus, a renal 
calculus excites pain in the urethra, and a desire to urinate, and as it descends along the 
ureter, it occasions retraction of the testicles, and excessive irritability of the stomach. 
Severe injuries, involving great shock of the system, are often followed by total sup- 
pression of urine; and, on the other hand, there are various affections in which this fluid 
is poured out in enormous quantity. 
The bladder also is variously affected by disturbance of its sympathetic relations. 
After injuries, as compound fractures and severe operations, the organ is often incapable 
of contracting upon its contents, thus necessitating the employment of the catheter; its 
perceptive faculties are suspended, and a few days usually elapse before they are reinstated, 
so as to enable the patient to pass his water without assistance. Stone in the bladder 
causes pain and burning in the head of the penis, and retraction of the testicle. Some- 
times the pain is felt in the knee, heel, and foot; and a curious case has been reported where 
it was seated in the arm. For a long time the professional attendants were unable to 
discover the cause of the suffering ; but at length, the man complaining of vesical trouble, a 
sound was introduced, when he was found to have stone, the removal of which put at 
once a stop to the unpleasant symptom. A very common effect of stone in the bladder is 
spasm of the sphincter muscle of the anus, which is often so great as to interfere with the 
passage of the finger. The introduction of a bougie into the urethra occasionally induces 
swooning, followed by violent rigors and high fever; and cases occur, although they are 
not common, of severe pain being excited in the extremity of the coccyx by such an 
operation. In the female, a papillary tumor at the orifice of the urethra will occasionally 
cause intense pain in the region of the bladder and kidney, with a frequent desire to 
urinate, and excessive scalding in passing water; in short, a train of phenomena closely 
resembling that produced by vesical calculus. A tight and elongated prepuce has been 
known to produce amblyopia and incontinence of urine. 
CHAP. i. CHAP. I. 
GENITAL ORGANS — SKIN. 
41 
6. Genital Organs There is perhaps no class of sympathies of greater interest, in a 
pathological and practical point of view, than those which subsist between the uterus and 
the general system. It was a knowledge of this circumstance which induced Aristotle to 
say that the womb was an animal within an animal. The morning sickness of early 
pregnancy, the hysterical convulsions, the depraved appetite, the rigors which usher in 
labor, and the contraction of the uterus when the cold hand is suddenly applied to the 
abdomen, are all examples of the mysterious relations by which this organ is bound to the 
rest of the body. Nowhere do these effects display themselves more strikingly than be- 
tween the uterus and the mammary gland. During pregnancy, the breasts begin to sym- 
pathize at an early period, as is evinced by their tender and tumid condition ; and the 
effect which the application of the child to these organs has, soon after delivery, in caus- 
ing after-pains, is familiar to every one. A knowledge of this fact has induced obstetric 
practitioners to take advantage of this means as a remedy for inducing contraction of the 
uterus in case of tardy expulsion of the placenta, or tendency to hemorrhage of this organ. 
The derangement of the stomach which accompanies prolapse of the uterus, the pain and 
swelling of the mammary gland from menstrual irritation, and the suppression of the 
lacteal secretion in puerperal fever, may be cited as additional illustrations of the intimate 
connection between the womb and the rest of the system. Excessive and intractable 
pruritus of the pudendum is occasionally produced by congestion of the uterus. Endo- 
metritis and congestion, ulceration, and a granular condition of the neck of the womb, 
especially in young females, occasionally give rise to severe pain in the hip and knee, to 
great distress in the head, to tenderness of the spine, to palpitation of the heart, to suffo- 
cative feelings, and to a host of other anomalous symptoms, generally promptly relieved 
by the removal of the exciting cause. Stone in the bladder has been known to simulate 
ulceration and carcinoma of this organ, causing a most embarrassing train of morbid 
phenomena. 
An intimate sympathy exists between the testicle and the parotid gland. In mumps, 
or inflammation of the latter organ, it is by no means uncommon for the testicle, after the 
lapse of some days, to take on inflammation also, and generally to such an extent as to 
bear nearly the whole brunt of the disease. The translation of the morbid action is usu- 
ally quite sudden, and the suffering of the testicle is often much greater than that of the 
parotid, being not only attended with severe pain and swelling, but occasionally terminat- 
ing in complete atrophy of the seminiferous tubes. In what manner, or in accordance 
with what law of the animal economy, this occurrence takes place, it is impossible to deter- 
mine, as there is no similarity of texture between these parts, or any direct nervous 
connection. The parotid is supplied with filaments from the ascending cervical nerves, 
and with branches from the fifth cranial; the testicle, with filaments from the spermatic 
plexus, formed by the sympathetic. 
7. Skin Remarkable sympathies exist between the skin and the mucous membrane 
of the alimentary canal, as well as between the cutaneous tissues and other parts of the 
body. Irritations, the result of a disturbance of these relationships, are of frequent occur- 
rence, and serve to explain many morbid phenomena which, but for our knowledge of this 
circumstance, would be a complete mystery to us. The sympathy between the skin and 
mucous membrane is particularly close and intimate, arising from their great similarity of 
structure, it being well known that these tissues are convertible the one into the other, 
although there is np direct connection between them, except at the various mucous out- 
lets; here, however, it is inseparable, and this is perhaps one reason, if not the principal, 
why disease of the one is apt to cause disorder of the other. The fact that various sub- 
stances taken into the stomach as food and medicine often produce the most singular cuta- 
neous affections, within a short time after their introduction, is of daily occurrence. 
Everyone’s experience informs him of certain articles which he cannot use with impunity. 
There is no doubt that many diseases of the skin, generally of a very simple character, 
are often greatly aggravated and rendered obstinate, by inattention to the diet and neglect 
of the bowels and secretions; and it will be readily conceded that the practitioner who is 
aware of this possesses a great advantage in the cure of these maladies over one who is 
ignorant of the circumstance, or wilfully disregards it. It is generally supposed that the 
skin suffers more frequently from disorder of the mucous membranes than the latter do 
from derangement of the former; but this is probably a mistake. It must not be forgotten 
that there is a marked difference in respect to the relative frequency of the affections of 
these two classes of structures in different climates, and at different seasons of the year. 
In tropical regions the prejudicial effects of a disordered state of the skin show themselves 42 
IRRITATION AND SYMPATHY. 
chap, i. 
in a great variety of ways in the mucous membranes, especially those of the stomach and 
bowels, as in different forms of gastric irritation, diarrhoea, and dysentery. Erysipelas, 
carbuncle, and furuncle are generally supposed, and very correctly, to be essentially con- 
nected with disease of the chylopoietic viscera ; indeed the more common varieties of 
these affections usually owe their origin to derangement of the stomach and bowels, and 
hence the practitioner rarely makes much progress towards a cure if he loses sight of this 
pathological relation. An unhealthy state of the skin often produces serious disease of 
the eye, brain, lungs, and liver, which is promptly relieved by attention to the cutaneous 
surface. Observation has shown that in bad cases of burns and scalds life is not unfre- 
quently destroyed by ulceration of the duodenum, or the upper portion of the bowel, and 
yet it would puzzle the most profound physiologist to account for such an occurrence by 
a reference to any of the known laws of health and disease. 
8. Eyes—The eyes, like all symmetrical organs, have an important sympathy, not 
only with each other, but also with many other portions of the body, which displays 
itself both in health and disease, and not unfrequently becomes a cause of irritation and 
inflammation. A familiar example of this internuncial action occurs in cataract. When 
one eye suffers from this disease, the other, at no distant period, is very apt to become 
affected also. Even in ordinary ophthalmia a similar liability to the extension of the 
morbid action is exceedingly common. The sound eye either soon takes on inflammation, 
or, if it be so fortunate as to escape this disease, it is sure to become the seat of such an 
amount of morbid sensibility as to render it temporarily unfit for useful vision. A per- 
cussion cap, or other foreign body, lodged in one eye, has not unfrequently been the 
cause of destructive inflammation in the other; and this disposition to the involvement of 
both organs, where one is originally exclusively affected, is nowhere more forcibly and 
painfully exhibited than in amaurosis. It is true, it is not always easy, under these 
circumstances, to determine, in any given case, what share of the disease in the eye 
secondarily affected is due to the influence of consentaneous irritation, or to the operation 
of the same morbific agency which provoked the original malady; but it may reasonably 
be assumed, in the absence of positive information, that much, in the majority of instances, 
is the direct result of deranged sympathy. This liability of the eyes to participate in each 
other’s diseases seems to be due to the intimate connection which exists between the optic 
nerves; and the same circumstance serves to explain the reason why the eyes are so fre- 
quently affected in organic disorders of the brain. 
The eyes and nose are intimately related with each other, first, through the disturbance 
of the ophthalmic branch of the fifth pair of nerves, and, secondly, through the pituitary 
membrane, which is prolonged upwards through the lachrymal passages to form the con- 
junctiva. Hence it is easy to see how catarrhal affections should induce pain and redness 
in this membrane as it is reflected over the eyes; how snuff should excite a flow of tears; 
and how sudden exposure of the eyes to a strong light should cause sneezing. The con- 
nections which the frontal, infraorbital, and other nerves form with the filaments of the 
ophthalmic ganglion enable us to explain the occurrence of amaurosis in consequence of 
blows, wounds, and neuralgia of the face, eyebrows, forehead, and temples. 
The eyes are connected with the abdominal viscera, particularly the stomach and 
bowels, through the medium of the branches of the sixth pair with the great sympathetic. 
The partial blindness consequent upon gastro-enteric irritation is readily accounted for in 
this way; and the same circumstance serves to explain the dilatod state of the pupil 
which occasionally attends the presence of worms in the alimentary canal of children. It 
is probable that the pneumogastric nerves also play an important part in these sympathetic 
relations, otherwise it would be difficult to assign a reason for the excessive nausea and 
vomiting which now and then supervene upon injuries and operations of the eye, as severe 
blows and the depression of the cataract. 
The eyes and teeth sometimes actively sympathize with each other, caries of the latter 
occasionally keeping up violent inflammation of the former, which promptly disappears 
upon the removal of the offending organ. I have several times seen the photophobia 
attendant upon strumous ophthalmia speedily yield in this way, after the failure of nu- 
merous other remedies. 
9. Ears A curious sympathy, noticed by all aural practitioners, exists between the 
ears and the respiratory apparatus, and also between the ears and the stomach. Thus, 
pruritus of the auditory tube sometimes provokes coughing and vomiting; and the former 
of these effects, it is well known, is not unfrequently caused simply by probing or spong- CHAP. I. 
AGE AND EFFECTS — IDIOSYNCRASY. 
43 
ing this passage in the removal of wax, or the extraction of a foreign body. Sir William 
Wilde, in referring to this phenomenon, says that it is by no means unusual, although it 
cannot be produced in all cases. “I never witnessed it,” he continues, in children or 
very young persons; it is most common in males of about middle life, and is in no wise 
connected with any previous disease existing in the respiratory apparatus. In some per- 
sons the slightest touch of the floor of the external auditory passage, about midway be- 
tween its external outlet and the inferior attachment of the membrana tympani, will bring 
on violent irritation and spasmodic action in the larynx. In this case also the patient 
will generally tell us, upon inquiry, that he does not experience pain; but the moment 
we touch this very sensitive spot he feels a tickling sensation in his throat, which imme- 
diately increases to the feeling one has when “a bit is gone astray.” What the nervous 
connection iswhich induces this hasnot been fully determined, but the fact is worthy of note.” 
Arnold has reported a case of chronic vomiting in a child, which long resisted a great 
variety of remedies, but was promptly cured by the extraction of a bean from each ear, 
the foreign substances having been introduced during play. Mr. Toynbee had a patient 
who suffered under a cough which no treatment could subdue, but which promptly and 
permanently disappeared upon the removal of a fragment of dead bone from the auditory 
canal. Numerous instances have been recorded of vertigo, reeling, and vomiting, caused 
by diseases of the ear. Generally, those affections are chronic, and are often erroneously 
imputed to disorder of the stomach, liver, and bowels. 
10. Age and Effects.—All persons are liable to suffer from irritation; but there is, as 
might be supposed, great diversity in this respect, in different individuals. Thus, it is 
well known that persons of a nervous, irritable temperament are more prone to it than the 
sanguine and leucophlegmatic, owing no douht to the fact that they possess a more deli- 
cate nervous system. Women sutler more frequently than men, both from local and 
general irritation; and some of the worst forms of reflex irritation that the practitioner 
meets with occur in hysterical females. Infants and children are extremely liable to the 
disease, the slightest cause often serving to light up the most distressing suffering. Loss 
of sleep, anxiety, grief, hard study, intemperance, inordinate sexual indulgence, impover- 
ished diet, and the enervating effects of a hot climate, all powerfully predispose to the 
occurrence of irritation. The inhalation of impure air is another well-known cause ope- 
rating injuriously upon the system. A student who spends his nights in the foul atmos- 
phere of the dissecting-room will be much more likely to suffer severely from the prick 
of his finger than one who enters it only occasionally. In the one case the constitution 
is deteriorated by exposure, and therefore incapable of resisting the effects of disease ; in 
the other it is healthy, and indisposed to take on morbid action. 
An irritable state of the system often sadly interferes with the reparative process. 
Thus, the healing of a wound is sometimes suddenly arrested by an unhealthy state of 
the system, manifesting itself in a general exaltation of the nervous sensibility, altogether 
incompatible with the development of healthy blastema. An aneurism of the aorta, 
attended with constitutional irritability, has been known to prevent the consolidation of a 
fracture of the femur. These, and other similar facts, are of deep practical interest, as 
they are suggestive of valuable therapeutic measures. 
Another very Common effect of irritation, especially when extensive or seated in an 
important organ, is derangement of the secretions, not only of the parts more immediately 
affected, but of the rest of the system. Thus, irritation of the brain, however induced, 
is very certain to disorder the functions of the stomach, liver, and kidneys, as evinced by 
indigestion, a bilious appearance of the skin, and a high-colored and scanty state of the 
urine. The salivary glands, too, suffer, the mouth becoming dry and viscid ; the head 
aches, the pulse is excited, and the extremities are cold. 
Idiosyncrasy, a subject closely connected with irritation and sympathy, literally signi- 
fies a peculiarity of constitution, or a state of the general system in which certain articles, 
whether taken as food, drink, or medicine, produce an effect altogether different from 
what they do under ordinary circumstances. Thus, lobster and other varieties of shell- 
fish, although they may be used with perfect impunity by most persons, are extremely 
prone in some individuals to induce urticaria, vomiting, and purging. A young lady, 
a patient of mine, married, robust, and of a florid complexion, cannot eat eggs, no matter 
how prepared, without being almost immediately seized with vomiting. A gentleman 
of my acquaintance is always copiously purged after eating soft-boiled eggs; hard- 44 
IRRITATION ANI) SYMPATHY. 
boiled eggs always agree with him. Milk acts on him in a manner similar to that of soft- 
boiled eggs. One of my grandchildren cannot eat strawberries without being instantly 
seized with some pain in the stomach. Some persons are overpowered by a particular 
odor or by the sight of blood. I know a lady who has not been able, for many years, to 
eat watermelon without being very speedily attacked with hoarseness, and soreness of the 
throat and mouth, attended with a burning, pricking sensation, nausea, and colicky pains. 
The use of watermelon-seed tea invariably produces a similar effect. Another lady, for- 
merly a patient of mine, can never take an ordinary dose of laudanum without being 
copiously purged; opium affects her in a similar manner, but morphia does not. Lauda- 
num, administered by the rectum, vomits freely and nauseates tor many hours. These 
articles, however, always afford relief to her suffering. A lady patient of mine always ex- 
periences severe gastric pain after taking a dose of morphia or laudanum, or, in fact, opium 
in any form. In several persons of my acquaintance, among others a physician, the inhala- 
tion or odor of ipecacuanha invariably excites a violent attack of asthma, generally lasting 
for two or three days. In the case of the medical practitioner, the perception of the pres- 
ence of this substance is so keen that, if he be in the third story of a house on the first 
floor of which an ordinary dose of the article is compounded, he is instantly seized with 
spasmodic cough and wheezing. A gentleman, for many years my patient, cannot drink 
a cup of green tea without being promptly and copiously purged; it usually operates on 
the bowels in from fifteen to twenty minutes after it is taken, bringing away thin, watery 
evacuations, accompanied with more or less griping; black tea produces no such effect, 
which he has experienced from the green from his earliest recollection. In two other 
cases, the use of green tea, even in very small quantity, invariably acts as a powerful 
diuretic, causing an abundant secretion of urine, with a frequent desire to void it for a 
number of hours. I lately prescribed for a middle-aged man, who is always copiously 
purged when he takes a glass of milk-punch, the action generally commencing in about 
one hour from the time he swallows it. Dr. Prout knew a man who could not eat mut- 
ton; no matter how it was disguised, he always promptly detected it, and it invariably 
caused violent vomiting and purging. 
A patient of mine, an habitual asthmatic, thirty-five years of age, a tradesman by 
occupation, cannot enter a room where feathers are, without instantly experiencing an 
aggravation of his pulmonary affection. To provoke this effect, it is not necessary that 
he should see or smell the feathers; led blindfold into an apartment thus funished, he is 
at once conscious of their presence, and is immediately compelled to retreat. 
Idiosyncrasy not unfrequently displays itself in the operation of various medicines, 
affording thus useful hints to the practitioner in the selection of his remedies. There 
are many persons who cannot take opium in any form without being kept awake by it 
for hours and even days, besides suffering greatly from nausea, excessive itching, delirium 
and other distressing symptoms. The most minute quantity of mercury will, in some 
persons, cause profuse ptyalism, while in others the article may be given in large doses 
and for a long time without the slightest effect of this kind, the system being absolutely 
proof against the action of the medicine in any of its forms and modes of exhibition. 
Most individuals are freely purged by a drop of croton oil, and yet an instance is occa- 
sionally met with, in which hardly any operation upon the bowels is produced by twenty 
times that quantity. 
The above instances, which might be multiplied to an almost indefinite extent from 
my own experience, will serve to illustrate a class of the most singular affections, the 
influence of which in modifying, if not in inducing disease, is eminently worthy of the 
attention of the practitioner. 
Treatment—In the treatment of irritation there are several leading indications which 
claim special attention. The first is to remove the exciting cause ; the second, to correct 
the secretions ; and the third, to palliate the disease, both primary and consecutive. 
To remove the exciting cause of irritation is not always an easy task. In many cases, 
indeed, it is either wholly inappreciable, or can only be conjectured. The duty of the 
surgeon of course plainly is to get rid of it if he can ; the ball, the calculus, the splinter of 
wood, the dead piece of bone, and the carious tooth, are promptly extracted. Irritating 
ingesta are dislodged by emetics ; offending feces by purgatives ; worms by anthelmintics, 
'fhe mortified toe is amputated ; the compressed gum lanced ; the suppurating felon freely 
laid open. Light is excluded from the inflamed eye ; noise from the suffering ear ; cold 
from the shivering surface. In all such cases the indication is evident, and in genera! 
easily fulfilled. But it is otherwise when the cause is occult. Here the disease must b< 
CHAP. I. 45 
CHAP. II. 
CONGESTION. 
met on general principles; and the judicious practitioner will do well to look into the 
condition of his patient’s secretions, his bowels, and his diet, which are among the most 
common sources of the disease. 
The correction of the secretions is a matter of primary importance in every case of 
irritation, whether local or constitutional. The manner of doing this will necessarily 
depend upon the character of the suffering organ ; but no practitioner will fully discharge 
his duty, if he neglect attention to this point. The viscera whose derangements are most 
liable to provoke reflex irritation, are the stomach, bowels, liver, and uterus, and they 
should, therefore, always be objects of special consideration. Not unfrequently the cause 
of the trouble will be found to exist in irritation of the spine, or of some particular 
portion of the brain, demanding local depletion and counter-irritation, with perfect tran- 
quillity of mind and body. Whatever the cause of the disturbance may be, it will be 
found that purgatives can rarely be dispensed with, while in not a few cases they con- 
stitute the chief anchor of our hopes. The diet, as a general rule, should be mild and 
unirritant, the proportions of its nutritive principles varying with the exigencies of each 
particular case. 
The last indication is to cure the disease, or to palliate it if it be irremediable. To 
point out the methods of doing this in a class of affections of so protean a character as this, 
would be absurd. Every case must necessarily suggest its own treatment. In ordinary 
instances antiphlogisties, properly so called, may usually be dispensed with, and large 
draughts made upon the narcotic class of remedial agents, as their direct influence is to 
allay pain and spasm, and induce tranquillity of the system. The choice of the par- 
ticular articles must be regulated by the circumstances of the case, and will often require 
no little judgment and experience for its successful exercise. 
CHAPTER II. 
CONGESTION. 
It is practically a matter of no little importance that the surgeon should be able to 
discriminate accurately between inflammation and congestion ; or, in other and more 
comprehensive terms, that he should possess clear and definite ideas respecting the more 
essential differences between these two morbid states; for upon their correct appreciation 
must often depend the result of his treatment. The subject, it must be confessed, is one 
of no ordinary difficulty, and a careful examination of what has been written upon it 
will serve to convince any unprejudiced mind that there are no two points in pathology 
concerning which there still prevails a greater amount of confusion ; for what one author 
considers as congestion, another with equal confidence calls inflammation, and con- 
versely ; leaving thus the young and inexperienced practitioner in painful doubt not only 
in respect to the nature of the disease, but, what is far worse, in regard to its proper 
management. As the subject of inflammation will be fully discussed in the ensuing 
chapter, I shall limit myself here to a plain and simple exposition of some of the more 
important facts relative to congestion, preceded by an attempt to assign to this expression 
its legitimate import. 
Congestion signifies an accumulation of blood in a part, the result either of some 
mechanical obstruction, or of disordered innervation, interfering with the onward move- 
ment of the sanguineous fluid. The word is synonymous with hyperemia, which Andral 
has proposed, without any just reason, as a substitute for it. It simply denotes the ex- 
istence of an abnormal quantity of blood in a part, without any of the ordinary phenomena 
and effects of inflammation, which, however, it generally accompanies, if indeed it does 
not form a necessary consequence of the increased quantity of blood sent into the suffering 
structures in that disease. Pathologists usually divide congestion into two varieties, de- 
nominated, respectively, the active and the passive. The first, as the name implies, is 
characterized by inordinate activity of the part, as is evinced by its scarlet complexion, 
its augmented temperature, and its functional disturbance; and soon leads, if allowed to 
progress, to various kinds of deposits, particularly the serous and plastic. Passive con- 
gestion, on the other hand, is distinguished by the dark color of the part, the enlarged 46 
CONGESTION. 
and sluggish condition of the vessels, and the chronic march of the disease. Owing to 
these differences in the action and aspect of the affected structures, these two varieties of 
congestion are often denominated arterial and venous ; terms which are ill chosen, as they 
have a tendency to create erroneous impressions respecting the true nature of the two 
lesions, for it is impossible to conceive of any case of congestion, however slight or severe, 
in which the disease is exclusively confined to one set of vessels. 
It will thus be perceived that active congestion is closely allied to inflammation, although 
it does not, properly speaking, constitute inflammation, except in the opinion of certain 
pathologists, who, it seems to me, are not very felicitous in their attempts at separating 
the two affections from each other, although it is evident that they strive very hard to do 
so. They treat of congestion as a distinct entity, and yet they do not hesitate to ascribe 
to it phenomena and effects which belong exclusively to inflammation, and which conges- 
tion, considered in the proper sense of that term, is utterly incapable of producing. When- 
ever a part, however situated in relation to the amount of blood it contains, is the seat of 
morbid deposits, it has passed the stage of congestion, and gone over into that of inflam- 
mation. If this be not so, then it necessarily follows that active congestion and inflam- 
mation are essentially one and the same disease, and that, consequently, it would be 
absurd to attempt to describe them separately. 
In all acute inflammations, whatever their cause or situation, active congestion is a 
necessary antecedent of the morbid action ; one of the first links in the chain of the 
malady. Hence it would not be improper to say that it is a part of the inflammatory 
process, ushering in the disease, and continuing up to the very point of effusion ; or, in 
other words, ceasing only where effusion commences. But this is strictly true only to a 
certain extent ; for there is in every case of inflammation a circle beyond the process of 
the morbid action, where the blood, playing about in eddies, has accumulated in large 
quantity, distending the bloodvessels, and destined soon to part with some of its constitu- 
ents, if the disease be merged in the inflammation. A veritable fire is lighted up here ; 
the part is hot, abnormally red, and perhaps somewhat painful; nay, it may be, even a 
little tumid, from the dilated state of the vessels ; the blood moves with unwonted force 
and velocity ; the functional disturbance augments more and more ; and presently con- 
gestion ceasing, inflammation takes its place, and goes through its allotted course. Another 
sign of distinction is that, in active congestion, the bloodvessels, although greatly crowded 
with blood, are more easily emptied than in inflammation : during life by pressure, and 
after death by injecting matter. 
But active congestion is not always necessarily followed by inflammation, although 
prone to pass into that state if it continue even for a short time. The cause which induced 
it having been removed, the vessels cease to attract blood in undue quantity, and ridding 
themselves of what is redundant, speedily regain their normal caliber and function. A 
familiar illustration of this occurrence is afforded by the conjunctiva, when, from any 
transient cause, a sudden and violent rush of blood takes place to the affected part; in an 
instant hundreds of vessels, previously invisible, become apparent, being crowded with 
red blood, so as to give the surface almost a scarlet hue. Now, if we analyze these phe- 
nomena, it will be found that they depend simply upon a dilated state of the vessels of 
the eye and the presence of an unusual quantity of blood, containing a large number of 
red globules, which, in the healthy state, are either withheld from these vessels, or which 
are propelled along them in such small numbers as not to permit their coloring matter to 
become visible through their delicate walls. 
Another familiar example of active congestion is furnished by what occurs in the hand 
when plunged into cold water, or exposed to a very low temperature. The skin soon 
becomes remarkably red from an unnatural afflux of blood, the parts are the seat of an 
unpleasant tingling sensation, and the vessels are exceedingly dilated ; still, there is no 
inflammation, or any tendency to morbid deposit; the suffering structures are only irritated 
and preternaturally injected. Cautiously treated, the hand soon regains its natural con- 
dition, the skin recovers its former hue and sensibility, the blood ceases to accumulate, and 
the vessels resume their normal caliber. But it is otherwise when the case is unskilfully 
managed ; the congestion then not only continues, but steadily increases, and is soon 
merged in inflammation, or perverted action and effusion. 
Now, what occurs in the external parts of the body, immediately under the eye of the 
observer, may be supposed to happen, under similar circumstances, in the internal viscera. 
Thus, we know that when there is a sudden repulsion of the cutaneous perspiration, the 
blood is extremely apt to collect in the lungs, causing active congestion of the pulmonary 
tissues, so often the precursor of pneumonia. Poison introduced into the stomach almost 
CHAP. II. CHAP. II . 
CONGESTION. 
47 
instantly induces active congestion of the mucous membrane of that organ, frequently fol- 
lowed, in a few hours, by the most intense and destructive inflammation. A ligature bound 
tightly round a limb affords a good illustration of the manner in which active congestion may 
be supposed to be induced in strangulation of the bowel in hernia and in intussusception. 
A distinction should be made between active congestion in a part, and a determination 
of blood to a part. The former is always the effect of some morbific influence ; the latter, 
on the contrary, may be the result simply of a natural cause. Thus, when the infant is 
applied to the breast, there is an instantaneous determination of blood to the organ, so as 
to enable the vessels to furnish the necessary supply of milk ; during menstruation, there 
is a marked afflux of blood to the uterus, probably accompanied by more or less active 
congestion. In blushing, there is a rush of blood to the cheek ; in erection, to the penis; 
in anger, joy, and other emotions, to the brain. Excessive, sudden, and overwhelming 
determination of blood to the internal organs sometimes takes place during the cold stage 
of intermittent fever, especially in that variety of it to which Alibert and others have 
applied the term malignant. In the congestive fever, as it is termed, of the Southern 
States, death not unfrequently results within a few hours after the commencement of the 
attack, the system never reacting from the effects of the chill. Scarlet fever occasionally 
proves fatal in a similar manner; the surface is pale or slightly livid, the extremities are 
deadly cold, and the internal organs are literally inundated with blood, determination and 
congestion coexisting in their worst forms. 
In passive congestion, the morbid action is distinguished by its peculiarly sluggish char- 
acter ; the vessels are not only dilated, but frequently varicose, tortuous, elongated, and 
incapable of contracting upon their crowding contents; the discoloration is dark, venous, 
or purple, the circulation is tardy and languid, and there is often marked evidence of 
morbid deposits, especially of serum and lymph, in the cells of the areolar tissue. 
Various causes may give rise to passive congestion. The most common are the follow- 
ing; 1st, inflammation; 2dly, mechanical obstruction ; 3dly, debility; and 4thly, depen- 
dent position. 
1st. Inflammation, in whatever form occurring, is almost always' followed by a certain 
degree of passive congestion ; the affected parts, exhausted by severe suffering, are reduced 
in strength and’life-power; the vessels, dilated to their utmost capacity, and perhaps par- 
tially ruptured, are too feeble to contract upon their contents; the crippled structures are 
unusually vascular; and the slightest cause is generally sufficient to rekindle the disease. 
Indeed, as will be stated by and by, an organ that has been once severely inflamed is ever 
after extremely liable to become inflamed again; passive congestion often lasting for months 
and even years. 
2dly. Mechanical obstruction is a prolific source of passive congestion. Examples 
occur almost without number, both in medical and surgical practice. I shall allude only 
to a few, as they will be sufficient for my purpose. 
A good illustration of the effects of mechanical obstruction in producing passive con- 
gestion is seen in organic disease of the valves of the aorta, impeding the passage of the 
blood through the lungs. Compelled to remain here habitually in undue quantity, the 
pulmonary vessels soon fall into a state of passive congestion, which thus acts as a predis- 
posing cause not only of inflammation, to which individuals so affected are extremely 
prone, but also of pulmonary apoplexy. Obstruction of the larger veins, as the femoral 
and iliac, is always followed by passive congestion in the parts below. In varicose 
enlargement of the veins of the leg, attended with disease of their valves, the blood has 
great difficulty in finding its way to the heart, and the consequence is that the distal por- 
tion of the limb is always in a state of passive congestion, with a strong tendency to 
inflammation, and to different deposits, more especially the serous and plastic. Obstruc- 
tion of the artery of the leg, by fibrinous concretions, is always followed by congestion and 
inflammation, if not by gangrene of the foot. 
The structures in the neighborhood of morbid growths are generally habitually con- 
gested ; hence the profuse hemorrhage which so often attends their extirpation. Their 
vessels being compressed by the overlapping tumor, the passage of their contents is seri- 
ously interfered with, and hence they frequently undergo a remarkable dilatation, almost 
amounting to a real varicosity. 
3dly. Debility of a part, however induced, is a frequent source of passive congestion. 
Examples of this form of the affection are seen in the retina and choroid coat of the eye 
from over-exertion of that organ, and in various parts of the body from loss of innerva- 
tion, profuse hemorrhage, or other discharges, and from the natural wear and tear of the 
frame. If, under these circumstances, any particular organ is more feeble or exhausted 48 
INFLAMMATION. 
than the rest, it can scarcely fail to become the seat of passive congestion, or congestion 
and inflammation. 
4thly. Dependent position readily gives rise to passive congestion. It is in this way 
that inflammation of the lungs is so often induced during the progress of lingering dis- 
eases and accidents, as typhoid fever, erysipelas, and compound fractures ; the disease 
usually beginning in the posterior portions of these organs, in passive congestion, and pro- 
ceeding gradually but steadily from bad to worse, until it proves fatal, a result so much 
the more to be dreaded on account of its insidious character. In the so-called bedsores, 
consequent upon long confinement in one posture, during which the pressure of the body 
is concentrated with peculiar force upon the sacrum, the iliac crest, and the great tro- 
chanter, similar effects are produced. There is, both in these and similar instances, in the 
first place a determination of blood to the most dependent portions of the body, then pas- 
sive congestion, and finally, as a natural consequence, inflammation ; often followed, in 
the latter case, by mortification. 
Passive congestion, however induced, is a frequent cause of inflammation ; often of a 
very destructive character, the more so, because the symptoms which attend it are so in- 
distinct, if not so completely disguised, as to prevent the early recognition of their real 
import. It is for these reasons that the practitioner should constantly be on the alert 
whenever he has anything to do with diseases and injuries involving long confinement to 
one particular posture, and an unusual amount of expenditure of the vital forces. 
Inasmuch as congestion may be induced by such a variety of causes, it would be folly to 
attempt to lay down anything like a regular systematic plan of treatment; to do so, would 
be to encroach upon every department of pathology and practice, both medical and surgi- 
cal, of which we have any knowledge. The judicious surgeon, knowing how likely the 
continuance of such a condition is to be followed by inflammation, or to aggravate inflam- 
mation when these two states coexist, will do all in his power to avert the evil, or to com- 
bat it when he finds it has already taken place. The leading indication of cure, in every 
case of congestion, is to equalize the circulation ; but to fulfil this often demands great 
judgment and an amount of pathological and therapeutic knowledge such as comparatively 
few practitioners possess. 
CUAP. III. 
CHAPTER III. 
INFLAMMATION. 
SECT. I GENERAL CONSIDERATIONS. 
A thorough knowledge of inflammation is indispensable to every practitioner of sur- 
gery. It should form the principal subject of his studies during his pupilage, and tlie 
main object of his professional contemplation in after-life. When it is recollected that 
there is hardly any disease which comes within the province of this department of science 
that does not originate in inflammation, or that is not more or less affected by it during 
its progress, the truth and force of these remarks will be sufficiently obvious. The smallest 
pimple upon the nose is, in point of fact, as much an inflammation as an erysipelas that 
covers the face and head. An ulcer of one of the mucous follicles of the mouth does not 
differ, in principle, from an ulcer of one of the glands of Peyer, which are the seat of so 
much disease and danger in typhoid fever. Many of the maladies, vaguely called ner- 
vous, are nothing but forms of inflammation, the nature and seat of which it is often diffi- 
cult, if not impossible, to determine. Their predominant symptoms are of a nervous 
character, and hence the diseases which they accompany are usually considered as ner- 
vous, while in reality the reverse is too frequently the case. 
All accidents, of whatever nature or degree, are, if not immediately fatal, necessarily 
followed by inflammation. The little wound made in cupping, and the bite inflicted in 
leeching, would never heal without the aid of this process; the parts would remain open, 
and be the seat of incessant bleeding, or they would become festering and putrid sores. 
In a word, there would be no repair after any injury, however simple ; and operative 
surgery, instead of being a blessing, would be a positive evil. Thus, it will be perceived, 
that inflammation is capable of playing, as it were, a double game in the animal economy, 49 
CHAP. III. 
CAUSES OF INFLAMMATION. 
being at one time a cause of death, and at another a source of life. It is for this reason 
that it is often designated by the terms healthy and unhealthy, according as the one or 
the other of these states predominates. 
Inflammation may be defined to be a perverted action of the capillary vessels and of 
the perivascular tissues, attended with discoloration, pain, heat, swelling, and disordered 
function, with a tendency to effusion, deposits, or new products. In addition to these 
changes, there is also an altered condition of the blood and nervous fluid as an important 
element of the morbid process. In what inflammation essentially consists, it is as im- 
possible to determine as it is to explain the intimate character of attraction, repulsion, 
gravitation, or cohesion. Hence, the medical philosopher, in studying its history, is 
necessarily obliged to limit himself to an examination of its causes, symptoms, and 
effects, or, in other words, to a rigid analysis of its appreciable phenomena and conse- 
quences. 
1. CAUSES OF INFLAMMATION. 
The causes of inflammation are almost as numerous as the circumstances which sur- 
round us, and are either predisposing or exciting. Whatever has a tendency to affect 
injuriously the mental or physical organization, whether directly or indirectly, is capable 
either of inducing disease, or of laying its foundation. The predisposing causes are 
those which produce in the system, or in some particular part of it, certain changes, 
states, or conditions favorable to the development of inflammation, without actually pro- 
voking it. They are usually tardy in their operation, and are either natural or acquired, 
according as they are inherent in the constitution or dependent upon accidental circum- 
stances. The exciting causes, on the contrary, are those that are directly concerned in 
awakening the disease, or fanning it, as it were, into existence. It is not always, how- 
ever, in our power to ascertain either the predisposing or exciting causes of the morbid 
action, and hence such cases, which are by no means uncommon, are usually known as 
occult cases. 
The natural predisposing causes of disease have reference to peculiarities of constitu- 
tion, and to a tainted state of the economy, in consequence of hereditary transmission. 
To the former class belong plethora, debility, and nervous susceptibility, which prepare 
the system for disease, by the changes which they induce in the fluids and solids. Per- 
sons who have naturally an undue quantity of blood, as indicated by their ruddy com- 
plexion, and the extraordinary functional activity of their organs, are peculiarly prone 
ty inflammation ; their bodies may be compared to a mass of tinder, which the slightest 
spark is capable of kindling into a devouring dame. Those, on the other hand, who are 
naturally feeble, are remarkably prone to local congestions, which, especially when they 
become habitual, are sure to lead to inflammation, often of a very unmanageable char- 
acter, because it cannot be met by the ordinary remedies. Persons of a nervous tempera- 
ment are predisposed to maladies of the brain, spinal cord, and sympathetic nerves, as 
exhibited in derangement of the respiratory, digestive, and genito-urinary apparatus; 
maladies which are generally tardy in their progress, and often so obscurely marked sis to 
be difficult of recognition. 
The fact that some diseases are transmissible from the parent to the offspring is well 
known. There are family diseases, as there are family likenesses, manners, and peculiar- 
ities ; and, what is remarkable, they are more liable to be communicated by the mother 
than the father, as if it were her special prerogative to impress her vices, as well as her vir- 
tues, upon her descendants. Another law is that some of these diseases may skip one 
generation to reappear in another, and that it is not necessary that the parents should be 
actually laboring under an attack of them at the period of conception. The affections 
which maybe transmitted in this way are gout and rheumatism, phthisis, asthma, scrofula, 
carcinoma, and constitutional syphilis, together with some others which it is unnecessary 
here to specify. It is in this wise, apparently, that God visits the sins of the parents to 
the third and fourth generations of their offspring. In what element of the economy the 
germ of the morbid action is locked up, neither reason nor experience has been able to 
determine ; for a time it would seem to be latent in the blood, when it explodes, either 
suddenly, or gradually, with zymotic violence. 
Among the acquired predisposing causes of inflammation are, the effects of previous 
disease, plethora, and debility, however induced. An organ that has once labored under 
inflammation is extremely prone to suffer from it again from the most trivial causes. The 
part, enfeebled by the attack, does not recover completely from its effects for a long time, 50 
INFLAMMATION. 
CHAP. III. 
if ever. Hence, influences which, in the natural state, would not disturb its physiological 
relations, are, under such circumstances, peculiarly prone to excite disease. A familiar 
illustration of this fact is afforded in the tonsillitis of children, in whom a recurrence of 
the malady is generally awakened by the slightest exposure to cold. Organic disease of 
one organ predisposes to organic disease in another, especially if in intimate sympathy 
with it. Albuminuria is a powerful predisposing cause of erysipelas, pyemia, furuncle, 
and carbuncle. It is not necessary here to enlarge upon plethora and debility as predis- 
posing causes of inflammation. If these states of the system are capable of preparing it 
for the development of disease when they are a natural result of the Organization, it may 
readily be supposed that they would be much more likely to produce such an effect when 
they are acquired, in consequence of the mode of life of the individual, or of the influence 
of structural lesion. 
Age, sex, temperament, occupation, food, dress, exercise, climate, and season, are all 
so many predisposing causes of inflammation. Infancy is particularly obnoxious to en- 
teritis, croup, diphtheria, and arachnitis; childhood, to affections of the skin, struma, 
parotitis, and tonsillitis; manhood, to pneumonitis, carditis, and diseases of the genito- 
urinary organs; and the decline of life, to gout and rheumatism, asthma, arteritis, and 
the various forms of malignant maladies. 
The differences in regard to the susceptibility to inflammation in the two sexes arise 
mainly from their anatomical peculiarities, and are much less common than is generally 
imagined. The function of parturition renders the female particularly liable to perito- 
nitis, phlebitis, arachnitis, and carcinoma; while the male,from his occupation and mode 
of life, is more prone to cystitis, urethritis, gout, rheumatism, arteritis, hepatitis, pneu- 
monitis, and pleuritis. 
Of the influence of temperament, as a predisposing cause of disease, loo little is known 
to enable us to speak with any degre of certainty. The sanguine temperament, character- 
ized by plethora with inordinate capillary activity, disposes to inflammation of the internal 
organs ; the nervous, to inflammation of the nervous system ; the lymphatic, to inflam- 
mation of the skin, joints, serous membranes, stomach, bowels, and lymphatic glands. 
Occupation is a powerful predisposing cause of inflammation. Persons who work a 
great deal in the open air, and who are much exposed to cold and wet, are extremely liable 
to suffer from pneumonia, arthritis, tonsillitis, and enteritis. A sedentary life leads to 
chronic disorder of the alimentary canal; and, if conjoined with constant mental exertion, 
is liable to be followed by disease of the brain and arachnoid membrane. Excessive exer- 
cise of an organ, as of the larynx in singing and speaking, is a predisposing cause of 
inflammation. • 
The influence of food in disposing to inflammation is well known. The habitual use of 
stimulating articles of diet, especially when conjoined with want of exercise in the open 
air, is among the most powerful of the causes under notice. On the other hand, an 
impoverished diet, ora privation of nitrogenous food, by inducing a defective blood, leads 
to scurvy, chlorosis, typhoid fever, scrofula, and inflammation of the serous structures, 
terminating in dropsical effusions. Certain articles, as ergot, if employed for any length 
of time, or in any considerable quantity, dispose to arteritis and gangrene of the extrem- 
ities. The habitual indulgence in alcoholic drinks leads to gastro-enteritis, hepatitis, and 
attacks of epidemic diseases, whenever such diseases are prevalent. 
Dress may be an indirect cause of inflammation. It may keep the body too warm or 
too cold, or exert injurious compression ; in either event, local congestion will be apt to 
be induced, which the slightest circumstances may fan into disease. 
A change of climate, whether from hot to cold, or cold to hot, powerfully predisposes 
to inflammation. Hence the period of acclimation is always peculiarly trying, and few 
persons escape without suffering. Season, too, exerts a predisposing influence. Thus, in 
summer, inflammation is most prone to assail the stomach and bowels ; in winter, the 
larynx, lungs, pleura, joints, and throat. 
Mental excitement is a prolific source of inflammation. Fear, grief, anxiety, hard 
study, and loss of sleep, by deranging the secretions, and interfering with the digestive 
process, all dispose to this disease. In short, whatever interrupts, disorders, or arrests 
healthy action, exerts a pernicious influence. This is often the only way in which we can 
account for the occurrence of erysipelas, carbuncle, rheumatism, cerebritis, scrofula, and 
carcinoma. 
The exciting causes of inflammation are extremely numerous, and of the most diversified 
nature ; they act in two ways, either directly noon a part, or indirectly through the sys- 51 
CHAP. III. 
CAUSES OF INFLAMMATION. 
tem. Hence they are said to be local and constitutional; and the former are either of a 
chemical or mechanical character. 
Among the chemical causes are, first, high degree of heat, as hot water and iron ; 
secondly, partial application of cold; thirdly, caustic substances, as the alkalies and acids; 
fourthly, acrid vapors, hartshorn, and gases; fifthly, certain secretions, as urine and bile; 
sixthly, blisters, embrocations, and rubefacients ; and lastly, various septic agents, as 
those of smallpox, syphilis, glanders, and malignant pustule. All these agents act directly 
upon the parts to which they are applied, either destroying them by their immediate 
effects, or combining with them in such a manner as to change completely their structure 
and function. Their operation is always rapid, and the resulting inflammation is usually 
marked by severe symptoms, both local and constitutional. 
The mechanical causes comprise, first, punctures, incisions, contusions, and lacerations; 
secondly, fractures and dislocations ; thirdly, sudden and forcible distensions, as from the 
accumulation of pus, serum, blood, or gas; fourthly, compression, as by bandage, ligature, 
posture, or effused fluids; and fifthly, the presence of foreign bodies, as a stone in the 
bladder, a bean in the air-passages, a bullet in the flesh, a tubercle in the lung, or a 
fibrinous concretion in the brain. Thrombosis, or the formation of clots in the blood- 
vessels, leading to obstruction in the circulation, frequently occasions inflammation. The 
manner in which these various causes act in producing disease is too evident to require 
explanation. 
The constitutional causes of inflammation make their impression either directly upon 
the part, or indirectly through some remote structure. Logically speaking, it would 
perhaps be more proper to say that they all act in the latter way, and not in any case 
immediately upon the part, as it is usually asserted they do. Thus, a morbific impression 
primarily made upon the respiratory passages, as the inhalation of some noxious gas, or 
the contact of malaria, instead of causing disease in the lungs, or in some of its constit- 
uents, often, if not generally, explodes upon some other organ, perhaps very distantly, if 
at all associated with the lungs by sympathy, or similarity of structure and function. A 
septic poison, as, for example, the virus of smallpox, introduced into the system, acts not 
merely upon the blood into which it has been conveyed by the absorbent vessels, but also, 
and mainly, upon the cutaneous tissues, for which it evidently has a greater elective 
affinity than for any other part of the economy; if it produces any action at all upon other 
structures, it is altogether of an indirect character. In the transmission of secondary 
syphilis from the parent to the offspring, the force of the disease is spent, in the first 
instance, upon the skin and the mucous membrane of the throat and mouth ; there is no 
inflammation, so far as we are able to determine, in the connective, fibrous, and serous tis- 
sues, or in the internal organs, properly so called. In tertiary syphilis the bones, peri- 
osteum, and cartilages are particularly prone to suffer, although the disorder has a more 
general tendency, as there is more profound contamination of the system. 
Whatever doubt, however, there may still be respecting the mode of action of the above 
agents, there can be none about the operation of heat and cold, which are such prolific 
causes of inflammation. The influence of a tropical sun, acting upon an impressible 
nervous system, in producing hepatitis, is well known to the practitioners of our Southern 
States, and to those of Africa, Asia, and the West Indies. Gastritis and enteritis, in 
their worst forms, are often developed in a similar manner. The occurrence of tonsillitis, 
croup, pleurisy, pneumonia, enteritis, cystitis, and rheumatism, as an effect of cold feet, 
is familiar to every one. In all these instances the primary impression is made through 
the medium of the skin, by suppressing the perspiration, and throwing the onus of the 
functional disorder upon some internal and remote organ, between which and the cutaneous 
surface there is not the least direct connection. 
Excessive shock, w'hether induced by direct nervous exhaustion, or by loss of blood, is 
a prolific cause of inflammation, often followed by the worst consequences. The inflam- 
mation which succeeds to gunshot, railway, and other severe injuries, is generally 
extremely violent, and is prone, if the patient survive their more immediate effects, to 
give rise to secondary lesions, often more fatal than the primary. The system thus affected 
does not seem to have sufficient vitality to keep the morbid action within proper 
limits : hence its disposition to spread not only over the parts originally implicated, but 
to other structures, more or less remotely situated. 
A part, deprived of nervous fluid, readily falls into inflammation, as is shown in injuries 
of the forearm involving the division of the radial and ulnar nerves, in which the thumb 
and fingers, and sometimes even the entire hand, always suffer more or less severely from 
this cause. Steady and long-continued compression of a nerve, interfering with the 52 
INFLAMMATION". 
CHAP. III. 
transmission of nerve fluid, may lead to similar results, as is witnessed, for example, in 
bedsores. 
Inadequate supply of food is a common cause of inflammation. Animals starved for 
experimental purposes are liable to suffer from inflammation and ulceration of the mucous 
membrane of the intestines; and similar effects have often been observed in persons in 
health deprived of their accustomed supply of aliment. Scurvy and other affections are 
produced by a deficiency of alkaline and neutral salts in tbe blood, especially the salts of 
potassium. Hence the value of the liberal use of lemon-juice in protracted voyages in the 
Arctic regions. 
The blood itself is a frequent source of inflammation ; sometimes, because it is overloaded 
with earthy salts or other irritating materials, as the poison of erysipelas, carbuncle, pye- 
mia, and various eruptive diseases; at other times, because of its impoverished condition, 
rendering it unfit as a supporter of life. There is reason to believe that the latter cause 
lies at the foundation of many of those low and unhealthy forms of inflammation which so 
often eventuate in destructive ulceration of the mucous and cutaneous tissues, as well as 
of some of the worst forms of morbid deposits, as imperfectly vitalized lymph, albumen, 
and tubercle. Deficient secretion, especially of the liver, kidneys, and skin, is a frequent 
cause of disease, various substances being thus retained in the circulation, much to the 
detriment of the general economy, as well as of particular organs, perhaps already pre- 
disposed to morbid action. The non-elimination of the products of tissue-metamorphoses 
is a prolific source of congestion and inflammation. 
From the foregoing considerations it will be perceived that inflammation may be 
traumatic or idiopathic, that is, produced by external injury or by constitutional causes, 
the latter of which are often wholly inappreciable by our senses. 
Inflammation is sometimes caused by sympathy. Thus, the eye occasionally suffers 
from disorder of the stomach, the brain from derangement of the intestines, tbe mamma 
from disease of the uterus, the testicle from lesion of the urethra. A person who habitu- 
ally overtaxes his digestive powers, and takes withal hardly any exercise, will be very 
liable, eventually, to perish from carbuncle or erysipelas ; or, at all events, to have dis- 
ease, in some form or other, of the skin, simply because these parts are intimately 
related to each other by similarity of structure and function. For the same reason 
disease of the skin is very prone to be followed by disorder of the alimentary canal. 
Finally, inflammation may be caused by metastasis, an event, which, as the term im- 
plies, is characterized by a transfer, for the most part gradual, but occasionally very 
sudden, of irritation from the part originally affected to another, perhaps at a consider- 
able distance from it, and in no wise related to it by structure or function. In inflamma- 
tion of tbe parotid gland tbe testis is often involved in this way, but why it is, neither 
our anatomical nor physiological knowledge enables us to explain, as there is no traceable 
connection whatever between them. In rheumatism of the joints the heart often suffers; 
and in erysipelas of the skin the morbid action frequently leaves one part of the surface 
and breaks out upon another. Such occurrences, which are sometimes greatly promoted by 
our local applications, should always be sedulously watched, as they are generally fraught 
with danger, especially when they show themselves in important internal structures. 
2. EXTENSION OF INFLAMMATION. 
All inflammations, of whatever character or grade, are, in the first instance, strictly 
local, beginning in some particular tissue, spot, or point, from which, as from a common 
focus, the morbid action radiates in different directions, until it becomes, so to speak, 
general. Thus, to illustrate, let it be supposed that the malady commences at a certain 
part of the mucous coat of the small bowel, as, for example, in one of tbe glands of 
Peyer. After having remained here for a short time, it gradually spreads to the fibro- 
cellular lamella, then to the muscular fibres, and finally to the peritoneal investment, involv- 
ing thereby the whole in one mass of disease. In erysipelas the same law is observed. 
Here the morbid action, beginning at a little point of skin, gradually extends to the 
deeper structures, until, as in the case of a limb, it invades connective tissue, aponeu- 
rosis, muscle, vessels, nerves, periosteum, and occasionally even bone. A pneumonia, in 
its progress, usually involves the pulmonary pleura and the bronchial mucous membrane. 
The rapidity with which inflammation extends from one texture to another is ex- 
tremely variable ; in some instances the time is very short, perhaps not exceeding a few 
hours or even a few minutes, as, for instance, in cases of snake-poisoning; and such cases 
are, it may be remarked, generally very prone to be characterized by more than usual CHAP. III. 
EXTENSION OF INFLAMMATION. 
53 
violence. It must not, however, be inferred from this statement that the morbid action 
always spreads from the point originally attacked ; for, although there is unquestionably 
a very strong tendency to this, yet there are numerous exceptions to it. In some cases 
this limitation is due to the nature of the disease itself; in others it depends upon the 
deposit of plastic matter; while in a third series of cases it is owing to the structure of 
the overlying tissue, as, for example, in the periosteum, which often serves to protect the 
bone which it surrounds from the encroachment of disease of the soft parts. 
One of the most common modes in which inflammation propagates itself is by conti- 
nuity of structure. The morbid action, once begun, easily passes along the tissues in 
which it originated, often spreading rapidly over a large extent of surface, similarity of 
structure and function favoring its march. By continuity of surface an erysipelas of the 
skin, perhaps not larger at its commencement than half a dime, frequently in a few hours 
diffuses itself over an entire limb, or even the greater portion of the body. In the same 
manner inflammation is liable to be propagated along the mucous canals, as is exemplified 
in the tonsillitis, croup, and other affections of the throat and air-passages, and in the 
various diseases of the stomach, bowels, and genito-urinary apparatus. In duodenitis the 
morbid action may readily extend along the choledoch and hepatic ducts to the liver; 
and in gonorrhma nothing is more common than for the disease to spread along the semi- 
nal passages to the epididymis and testis. 
Secondly, inflammation may be propagated by contiguity of structure. A phlegmo- 
nous erysipelas of the skin has a tendency not merely to spread over the neighboring 
surface, in consequence of its similarity of structure and function, but also in depth, 
thereby involving connective tissue, aponeurosis, muscle, and, in short, every other texture 
within its reach. The tissues maiidy concerned in the enterprise are the vascular and 
connective, the peculiar structure of which renders them highly favorable for the propa- 
gation of the morbid action. An inflammation, beginning in the conjunctiva, often in 
its progress involves the entire eye, simply from the intimate manner in which its differ- 
ent tunics are superimposed upon each other. In the bowel and other mucous canals the 
same effect is frequently witnessed. In pneumonia, especially in the more violent forms, 
the disease is rarely confined to the parenchymatous substance, but is almost sure 
eventually to spread to the pleura and bronchia. In orchitis, although the inflammation 
is primarily seated in the tubular structure of the epididymis and testicle, it is by no 
means uncommon for it to extend to the albugineous and even to the vaginal coat. An 
inflammation of the synovial membrane of a joint often spreads, by virtue of the same 
law, to the articular cartilage and the head of the bone beneath, contiguity and intimate 
connection favoring here, as elsewhere, the propagation of morbid action. 
Thirdly, the extension may be effected through the agency of the veins and lymphatics. 
Of the former a good example is afforded by what occasionally happens in venesection, 
where, apparently from the use of a foul lancet, the inflammation sometimes spreads from 
the little wound in the vessel, at the bend of the arm, as high up as the right auricle of 
the heart; and of the latter by what occurs in chancroid, where the poison, taken up 
by the absorbent vessels of the penis, is conveyed by them to the glands of the groin, 
where it causes a painful swelling, constituting what is termed a bubo. In dissection 
wounds the absorbent vessels always serve as vehicles for the transmission of the peculiar 
poison which gives to these lesions their characteristic features. For a short period after 
the inoculation the poison is apparently latent, when its effects show themselves by one 
or more red lines extending up the limb as far as the axillary glands, whence, as from a 
common centre, its injurious impressions are radiated over the whole system. 
Of the extension of inflammation by nervous agency, or sympathy, a familiar example 
is afforded in parotitis. In this disease, which attacks chiefly young subjects, the inflam- 
mation often suddenly leaves the organ originally involved, and fastens itself upon the 
testicle, which is thus compelled to bear the whole onus of the morbid action. Of the 
precise manner in which this transfer is effected nothing is known. As there is no direct 
nervous connection between these structures, the only plausible conjecture is, that it is 
brought about by the operation of sympathy, although of the nature of this operation it 
is impossible, in the present state of the science, to form any correct idea. A similar 
relationship exists between the mamma and the uterus, the stomach and the lungs, and 
between the stomach and the brain, or, rather, between the former organ and the arach- 
noid membrane. 
Finally, inflammation may be propagated by the blood. This fluid, as will be more 
fully explained by and by, undergoes various changes in this disease, of which the most 
important is an increase of fibrin and colorless globules, with a strong tendency of these 54 
INFLAMMATION. 
chap, in. 
substances to adhere to the sides of the vessels as they are propelled along with the gen- 
eral circulating mass. The blood, thus altered in its properties, leads to obstruction of 
the capillaries in different parts of the body, thereby establishing foci of morbid action. 
It is in this manner that metastatic abscess, or what is now known as pyemia, is occa- 
sionally produced, as is proved by the fact that the aggregation of the colorless corpuscles 
into small masses, and their adhesion to the walls of the vessels, not only diminish the 
rapidity of the circulation, but favor the formation of thrombi and the production of 
embolism. 
3. VARIETIES OE INFLAMMATION. 
With the exception, perhaps, of the epidermis, the hairs, and the nails, there is no 
part of the body which is not susceptible of inflammation and its consequences. The 
reason why these structures are usually considered incapable of this process is our inabil- 
ity to demonstrate in them any bloodvessels, nerves, and lymphatics, the great and 
essential elements of organization in the more elaborate and complex tissues. Notwith- 
standing this, it is extremely difficult to unite in so sweeping a conclusion, when we 
reflect upon the fact, of which daily observation furnishes examples, that these external 
coverings undergo various lesions of forms, size, color, and consistence, which can only 
be explained on the assumption that they are the products of inflammation, modified by 
the nature of the affected parts. There are other structures, as the arachnoid membrane, 
the cornea, and some of the cartilages, in which it is impossible to detect vessels, and 
yet no one would doubt for a moment, on this account, that they are incapable of dis- 
ease. No exception should, therefore, in my opinion, be made, as it respects the 
possibility of the occurrence of inflammation, even in regard to the cuticle, the hair, 
and nails. 
The susceptibility of a part to inflammation is, as a rule, in direct proportion to the 
amount of its vascular and nervous endowments, the importance of its functions, and the 
nature of its exposure. Hence it is found to be most common in the skin, connective 
tissue, mucous and serous membranes, joints, lungs, liver, kidneys, bladder, urethra, 
ovaries, and uterus. The only exceptions to this law are the brain and heart, which 
notwithstanding their incessant labor, the excessive delicacy of their organization, and 
their universal sympathetic relations, are comparatively rarely the subjects of inflammation. 
In the thyroid body, the salivary glands, the pancreas, the prostate, and the spleen, the 
voluntary muscles and their tendons, the nerves, vessels, fibrous membranes, and even the 
bones, the disease is also uncommon, although several of these structures are sufficiently 
prone to inflammation as it manifests itself in certain forms of syphilis, scrofula, and 
rheumatism. It is easy to see why the skin should be so frequently affected, when we 
reflect upon its vast extent, its wonderful vascularity and nervous endowments, its sympa- 
thy with the brain, lungs, stomach, and, in fact, almost every organ in the economy, and 
its constant exposure to all kinds of injurious impressions. For the same reason it is not 
diflicult to account for the frequent occurrence of pneumonia, hepatitis, nephritis, and 
inflammation of some of the other viscera. The connective tissue, although less highly 
organized than the skin, is yet a frequent subject of disease, inasmuch as it is the great 
link by which the various textures are connected together, and the means of transmission 
of the vessels and nerves from one part to another. The functional activity alone of some 
of the organs affords a ready key to their liability to inflammation. Thus, the genital 
organs are almost exempt from disease until the age of puberty, when, their slumbering 
season being over, and their fretful life having begun, they are extremely prone to morbid 
action, both common and specific. 
The progress of inflammation exhibits much diversity, being at one time rapid, at 
another slow; hence the distinction into acute and chronic. An acute attack is one which, 
running its course swiftly, is characterized by well-marked symptoms, as is seen, for 
example, in tonsillitis consequent upon a severe cold, where, in the space of a few days, 
the affected gland acquires a large bulk from vascular engorgement and interstitial 
deposits, attended with great local and constitutional disturbance. Force and rapidity 
of action are its distinguishing features. Chronic inflammation, on the contrary, is 
marked by comparative slowness and feebleness of action; the attendant phenomena are 
also less bold, although there is generally a decided tendency to effusion. It may be the 
sequel of an acute attack, or occur as a primitive affection, existing, perhaps, for a con- 
siderable period without being discovered, owing to the absence of the usual diagnostic 
signs. Once in this condition, it may last almost for an indefinite time, as is exemplified 
in certain cases of gleet, leucorrhoea, tonsillitis, osteitis, arthritis, otorrhoea, and ophthalmia. CHAP. III. 
TERMINATIONS OF INFLAMMATION. 
55 
In addition to the terms acute and chronic, so frequently employed in surgical nomen- 
clature, there are certain expressions in use to designate tlie degree of the morbid action, 
as, for example, acute when the action is very intense, subacute when it is comparatively 
mild, and passive when it is very sluggish, or indisposed, as it were, either to advance 
or to recede, and accompanied, perhaps, by inordinate congestion of the vessels, especially 
of the veins, with little, if any, pain, and no marked constitutional disturbance. 
Inflammation is said to be healthy or unhealthy, according as it manifests a tendency 
to restoration or to mischief. It would be erroneous to regard inflammation always in 
the light of a disease, since it is the means which nature must necessarily employ when- 
ever she repairs an injury that has given rise to it. It is only when the process pro- 
ceeds, as it were, blindly, that it is likely to be productive of harm by overpowering the part 
and system. An incised wound, in a sound constitution, will, if properly managed, heal 
promptly by union by the first intention; whereas, if the reverse be the case, its edges 
will be sure to separate, and, suppuration taking place, a long time may elapse before the 
object is fully attained. In the one case the action is said to be healthy, in the other 
unhealthy; and it will generally be found that the nature of the action is a true index of 
* the condition of the part and system; as the latter is, so will be the former. There are 
of course exceptions to this law, but they are infrequent and unimportant. 
There is a form of inflammation known as the Irritable, but which in reality does not 
differ materially from unhealthy inflammation. The best illustrations of it occur in 
strumous ophthalmia, in ulcers of the extremities, in rupia, and in chronic tonsillitis, 
bronchitis, dysentery, cystitis, urethritis, and orchitis. It evidently depends upon an 
exaltation of the natural sensibility of the affected structures, aggravated by an unsound 
state of the nervous system. 
Inflammation may be common or specific: common, when it proceeds from ordinary 
causes; specific, when it is produced by some peculiar poison, as that of gonorrhoea, 
syphilis, or smallpox. A more important distinction is that certain inflammations are 
capable of appearing only in certain tissues. Thus, erysipelas is generally a disease of 
the skin; in rare instances it involves the mucous membrane of the mouth and throat, 
and, perhaps, also the peritoneum and pelvic veins, as in lying-in females; but it never, 
so far as can be ascertained, fastens itself, as a primary affection, upon the muscles, 
aponeuroses, nerves, arteries, bones, cartilages, or internal viscera. Gout and rheumatism 
have a special fancy for the joints and fibro-serous textures; secondary syphilis, for the 
skin and fauces; tertiary syphilis, for the bones and periosteum ; scrofula, for the lymphatic 
glands; and carcinoma, for the glandular organs, as the mamma, uterus, and liver. 
Finally, there are certain diseases, as smallpox, syphilis, and scarlatina, which occur, as a 
rule, only once in the same person. 
Finally, inflammation may be latent, or fail to reveal itself by the ordinary phenomena. 
Such an inflammation is always to be dreaded, because, owing to its insidious character, 
it is extremely liable to be overlooked. A striking illustration of this form of disease is 
afforded by the glands of Peyer in typhoid fever, the inflammation and ulceration of 
which constitute the anatomical lesions of that formidable malady. Patients thus affected 
seldom complain of pain, or, indeed, of any other suffering directly referable to these 
bodies, even when the morbid action is so extensive as to induce perforation of the bowel. 
Latent pneumonia is sufficiently common; and abscesses of the spine and other parts 
of the body often make great havoc before their true nature is even suspected. 
4. TERMINATIONS, EVENTS, OR CONDITIONS OE INFLAMMATION. 
Although inflammation is generally said to have various terminations, it will be found, 
upon strict inquiry, that these amount only to two, all the rest being so many states, con- 
ditions, or events of the process. This distinction is real, not imaginary, and therefore of 
no little practical value. Philosophically speaking, there are only two terminations of 
the morbid action, the one being in health, the other in the death of the parts. The for- 
mer may occur by delitescence and resolution; the latter, by ulceration and gangrene. 
All deposits, whether serous, plastic, purulent, or sanguineous; and all changes of struc- 
ture, whether they consist in softening, induration, contraction, or thickening, are to be 
viewed simply as so many products, effects, or results of inflammation, without necessarily 
involving a suspension of the process itself. This indeed may still go on, sometimes even 
for an indefinite period, and thus produce additional changes, more serious, perhaps, in 
their consequences than those which attend the act in its earliest stages. In suppuration, 
for example, the inflammation does not generally end the moment matter forms, or as 56 
INFLAMMATION. 
CHAP. III. 
soon as the pyogenic crisis has been fairly attained; instead of this, it proceeds in a 
modified state, accompanied by ulceration, or still further deposits. The same remarks 
are applicable to the exudation of plasma, and even of serum, the latter of which may be 
regarded as one of the processes employed by nature to deplete the inflamed tissues; in 
this, however, she generally succeeds only by degrees, as is shown by the fact that the 
disease often continues for a considerable length of time after the drainage has commenced. 
Blood, either perfectly pure, or variously combined with the secretions of the affected 
surface, may be poured out quite freely, and yet the morbid action continue as vigorously 
as before, as is exemplified in dysentery and other hemorrhagic forms of inflammation. 
is, therefore, really no such thing as a termination of inflammation in effusion of 
serum, deposit of plasma, or the formation of pus. These events occurring, the morbid 
action may still go on, merely modified by the influence exerted upon it by the attendant 
secretion or the nature of the morbid product. 
The nomenclature of inflammation has been much simplified in modern times. As it 
now stands, it is based essentially upon the anatomy of the affected tissue, structure, or 
organ, the term itis being merely added to the name by which the part is generally known, 
as sclerotitis, cystitis, laryngitis. Sometimes, however, the old expressions are retained, 
as quinsy for inflammation of the tonsils, ophthalmia for inflammation of the eye, and 
gonorrhoea for inflammation of the urethra. 
SECT. II ACUTE INFLAMMATION. 
The symptoms of inflammation naturally divide themselves into local and constitutional; 
or those furnished by the part and those afforded by the general system. 
1. LOCAL SYMPTOMS. 
The most prominent external symptoms of inflammation have been known from an early 
period of the profession. They are tersely stated by Celsus as “rubor, calor cum tumore 
et dolore.” The knowledge, however, of the Roman physician of inflammation was 
extremely imperfect, and it was not indeed until some time after the commencement of 
the present century that the subject began to be studied in its relations with the different 
organs and tissues of the body. Bordeu, Carmichael Smith, and Bichat, by laying the 
foundation of general anatomy, paved the way to a more comprehensive acquaintance 
with the nature and seat of morbid action, and were thus instrumental in revealing an 
amount of light, the beneficial effects of which can even yet be hardly foreseen. They 
show what might, a priori, have been anticipated, that the phenomena enumerated by 
Celsus, as characteristic of inflammation, are liable to great and constant variations, ac- 
cording to the nature of the affected structure, and that the most violent morbid action 
may often be present, and yet nearly all of these phenomena be absent. Hence, at the 
present day, too much stress cannot be laid upon disordered function, inasmuch as this is 
frequently the only symptom that is at all appreciable, especially in inflammation of the 
internal organs. Modern research has shed important light upon the condition of the 
capillary vessels and their contents, as well as upon the condition of the cells in inflam- 
mation, and has enabled us to explain many phenomena that were previously obscure and 
mysterious in regard to the more intimate nature of the process. 
1. Discoloration The discoloration of an inflamed part varies from the slightest 
increase of the natural hue to the deepest purple, according to the character of the affected 
tissues and the intensity of the morbid action. It is always, other things being equal, 
most distinctly marked in those structures which are very vascular, while in such as have 
comparatively few vessels it is either entirely wanting, or present only in a faint degree. 
It is a prominent phenomenon in inflammation of the skin and mucous membranes, con- 
nective tissue, lungs, pleura, spleen, kidneys, and peritoneum; structures which are distin- 
guished by their great vascularity, and by the large amount of blood admitted into them in 
disease. On the other hand, there is but little discoloration in inflammation, however intense, 
of the tendons, cartilages, bones, fibrous envelops, brain, nerves, heart, and voluntary mus- 
cles. In inflammation of the arachnoid membrane the only evidence of disease observ- 
able after death is effusion of serum or of serum and plasma ; there is no trace of vascularity, 
and yet the morbid action has been sufficient to destroy life. 
The rapidity with which the discoloration of inflammation advances is greatly influenced 
by the severity of the morbid action, and, above all, by the activity of the circulation of CHAP. IU. 
LOCAL SYMPTOMS. 
57 
the affected structures. In general, however, it proceeds rather slowly, keeping steady 
pace with the gravescent action ; advancing from rose to red, from red to purple, or from 
purple to black, as when the part is about to mortify. It is always most distinct at the 
focus of the inflammation, from which it gradually recedes until, in most cases, it is insen- 
sibly lost in the natural hue of the surrounding healthy structures. Occasionally, as in 
erysipelas of the skin, as well as in some affections of the mucous membranes, the line of 
demarcation is very abrupt, the diseased surface exhibiting a red and well-defined circle. 
The discoloration varies not merely in degree, but also in character, thereby throwing, 
not unfrequently, important light upon the diagnosis of the case. Thus, it may be scar- 
let, as in the skin, throat, and bowels; lilac or bluish, as in the sclerotica and the fibrous 
envelops of the muscles ; brick-colored, grayish, or brownish, as in iritis ; yellowish, as in 
erysipelas, especially when this disease is associated with derangement of the biliary 
secretion ; of a copper hue, as in the eruptions of secondary syphilis; purple, as in the 
edges of a scrofulous ulcer ; livid, as in violent tonsillitis; black, as in mortification. 
These varieties of color, in these and other structures, are dependent, partly upon the 
organization of the affected tissues, partly upon the nature of the inflammation itself, and 
partly upon the amount, degree, or intensity of the morbid action. 
In extent the discoloration varies, from the smallest speck, perhaps not larger than a 
pin’s head, to a surface occupying many inches, if not several feet in diameter, as in ery- 
sipelas, which sometimes involves the greater portion of the body. When this is the case, 
the discoloration is said to be diffuse; it is arborescent, when the vessels upon which it 
depends are arranged in dendritic lines; punctiform, when it occurs in little dots, or 
points, as in some of the inflammations of the serous and mucous membranes; linear, 
when it presents itself in a distinct line, as in phlebitis and angeioleucitis ; maculiform, 
when it assumes the appearance of a blotch or of an ecchymosis. In the latter case, as 
well as in the punctiform variety of discoloration, the morbid hue is due to an actual extra- 
vasation of blood, consequent upon the rupture of some of the capillary vessels of the part. 
To be of value as a diagnostic sign of inflammation, the discoloration must be perma- 
nent, not transient; advancing and receding with the morbid action; disappearing under 
pressure, but reappearing the moment the pressure is taken off'. The blush of shame 
vanishes in an instant, with the excitement that produced it; the hectic flush upon the 
cheek of the consumptive merely denotes the existence of the fever which succeeds the 
afternoon’s rigor; they are very different from the discoloration which marks the rise, 
progress, and termination of inflammation. Besides, the latter is usually associated with 
other symptoms, as heat, pain, swelling, and disordered function ; phenomena sufficiently 
distinctive, in every case, to prevent error of diagnosis. More or less discoloration gen- 
erally remains, in a modified form, for some time after the inflammation has ceased. 
The immediate cause of the changes of color in inflammation is a preternatural afflux 
of blood. In the normal condition of the organs and tissues there are hundreds and thou- 
sands of capillary vessels which are too minute to admit of a sufficiency of red globules to 
render them visible, but which, under the influence of irritation, become distended to such 
a degree as to display themselves in every direction. It is in this manner that the dis- 
coloration of the affected structures is brought about, often in an instant, as is witnessed, 
for example, in the conjunctiva, when a particle of foreign matter lodges upon the cornea; 
and what occurs here unquestionably occurs, under similar circumstances, in other 
structures. It is only in reparative inflammation, or in inflammation concerned in 
rebuilding wasted tissues, that new vessels are formed ; never in ordinary inflammation. 
2. Pain.—Pain, like discoloration, is one of the most constant symptoms of inflamma- 
tion, usually setting in early in the disease, going on steadily increasing until the morbid 
action has attained its maximum, and then gradually abating, as the disease recedes, until 
it is insensibly lost. The subject of pain presents several points of interest, which, as 
they have a practical importance, should be well understood by the surgeon. 
Pain varies in degree from the slightest change in the normal sensibility of the part to 
the most excruciating agony, according to the nature of the affected structure, and the 
intensity of the morbid action. Doubtless idiosyncrasy also exerts an important influence, 
for it is well known that what causes pain in one individual, causes little, if any, in another. 
Few persons suffer much from the application of a blister, but occasionally, although it 
may be retained only for a few hours, it is productive of the most exquisite torture. Such 
a result can only be explained by assuming that there is an idiosyncrasy, or a difference 
in the nervous organization of our patients. The same remark is true in regard to the 
effects of injury. As a rule, the pain is greatest at the focus of the inflammation, and 58 
INFLAMMATION. 
CHAP. III. 
fixed in its situation, but sometimes it darts about in different directions ; is increased by 
pressure, motion, and change of posture; and rarely intermits, although it often remits, 
especially in the morning and in the early part of the forenoon. 
In regard to the character of the pain, there is great diversity, so much so, indeed, 
that it is often possible, from this circumstance alone, to form a tolerably correct idea 
of the seat, and even of the nature, of the inflammation. Thus, in the pleura it is sharp 
and lancinating; in the connective tissue, acute and throbbing, as is exemplified in boil 
and carbuncle; in the liver and lungs, obtuse and heavy ; in the testis, sickening; in the 
skin, prurient, itching, or smarting; in the bones, dull and gnawing, as if insects were 
feeding upon the part; in the urethra, scalding or burning; in the conjunctiva, gritty 
and itching; in the teeth, throbbing, beating, or pulsatile. When inflammation is about 
to terminate in mortification, the pain generally becomes hot and burning. 
Pain is sometimes felt at a point more or less remote from the seat of the morbid 
action, and for this reason does not always serve to denote its existence. In coxalgia, 
the earliest and most prominent symptom usually is severe pain in the knee, and it lias 
often happened, especially in the hands of ignorant and inexperienced practitioners, that 
the latter has been leeched, cupped, and blistered, when all this care should have been 
bestowed upon the hip. In inflammation of the bladder, ureters, and kidneys, a 
prominent symptom is uneasiness in the head of the penis ; and in hepatitis considerable 
suffering is occasionally felt in the right shoulder. In certain cases of carcinoma of the 
uterus, the pain, instead of being located in this organ, is situated in the mamma, the 
sides, the back, groins, or thighs. It is not always easy to explain these occurrences ; but, 
in general, they are dependent either upon continuity of structure, as in the case of the 
urinary passages, or upon reflex action, as in coxalgia and hepatitis. In the latter, some- 
thing may possibly be due to disorder of the intercosto-humeral nerves. 
It is worthy of note that the pain is generally much more violent in inflammation of 
the covering of an organ than in inflammation of its proper substance. A pleuritis is 
always attended with severe local distress, whereas very little, if any, is experienced in 
pneumonitis. In inflammation of the parenchymatous structure of the liver, great dis- 
organization may take place, and yet the patient be entirely ignorant of the fact, as far 
as pain is concerned ; but when the fibro-serous envelop of the organ is mainly impli- 
cated, violent suffering is always a prominent symptom. The same law obtains even in 
inflammation of the brain and its membranes. Pain, especially in chronic inflammation, 
as gout and rheumatism, is greatly influenced by atmospheric vicissitudes, as is evinced 
by the fact that it is always more severe in damp than in dry weather. Nocturnal exa- 
cerbations are very common, if not constant, in inflammation of the bones and joints, 
particularly in syphilitic subjects. 
A correct distinction should be drawn between the pain of inflammation and the pain 
of spasm, as it exercises an important influence upon the treatment of the case. The former, 
as previously stated, is gradual, not sudden, in its attack; persistent, not intermittent ; 
increased by motion, pressure, and posture; and is, moreover, generally accompanied by 
more or less febrile disturbance, and other evidences of indisposition, plainly marking its 
character, to say nothing of the history of the case, which usually furnishes important light 
in regard to the diagnosis. In spasm, the pain comes on suddenly, and, after having con- 
tinued for a short time, intermits, or entirely disappears, only, however, to return again, 
and to pass through the same course; in a word, it is paroxysmal, coming suddenly, and 
going suddenly ; relieved by pressure, and nearly always attended with eructations, and 
rumbling noises in the bowels, supposing the case to be one of colic ; there is no fever— 
indeed, generally no constitutional excitement of any kind—and there is also an absence 
of the other local symptoms of inflammation, as heat, discoloration, and swelling. 
In neuralgia the pain is sharp and lancinating, often darting through the parts with the 
rapidity of lightning, or like an electric shock ; accompanied by a sense of soreness or 
aching, and generally aggravated by pressure. It is usually paroxysmal, coming on per- 
haps once every day, lasting a few hours, and then going off gradually, or even suddenly, 
to reappear about the same time the following day; it is, in fact, generally an intermit- 
tent disease, with a distinct interval of freedom from pain, resembling, in this respect, an 
ordinary intermittent fever, and having often, like it, a miasmatic origin. The pain, 
moreover, is not always fixed, but is at one time here, and at another time there, gene- 
rally in the course of a sentient nerve. 
Severe pain, especially in a nervous, irritable person, is always a formidable occur- 
rence, as it exhausts and depresses the powers of life, and is sure, if not speedily com- 
bated, to occasion serious, if not fatal, mischief. The rule, therefore, is to arrest it CHAP. III. 
LOCAL SYMPTOMS. 
59 
promptly, and at all hazards, before the disease, of which it is a symptom, has committed 
any serious ravages. 
A sudden disappearance of pain, unless occasioned by the use of anodynes, is generally 
denotive of danger, as it implies a termination of the morbid action in the death of the 
affected structures. The occurrence should, at all events, excite suspicion, and lead to 
careful investigation. An individual, for example, has been the subject of strangulated 
hernia; the constriction has lasted for several days, and has been characterized by severe 
suffering, both local and general; suddenly the pain ceases, and the patient flatters him- 
self that he will soon be well. The surgeon, however, comes to a widely different con- 
clusion ; for the sunken features, the clammy skin, the feeble, flickering pulse, the 
incessant hiccough, and the trembling hand, but too plainly foreshadow the approach of 
death from mortification of the bowel. 
Pain is not always present, even although the inflammation may be extremely violent. 
In typhoid fever, a disease attended with inflammation of the glands of Peyer, often 
terminating in extensive ulceration, there is generally an entire absence of this symptom, 
from first to last, uidess the case is followed by perforation of the bowel, and an escape of 
its contents into the peritoneal cavity. In pneumonia there is frequently no pain what- 
ever; and the same is true of inflammation of some of the other viscera. In scrofulous 
affections of the spine, particularly in those forms of it known as Pott’s disease and 
psoas abscess, pain, properly so called, is one of the rarest phenomena, especially in the 
earlier stages of their progress. A painless inflammation is peculiarly dangerous, inas- 
much as it is very liable to be overlooked by the professional attendant, particularly by 
one who is in the habit of placing undue confidence in the ordinary phenomena of the disease. 
The immediate cause of pain is the compression experienced by the nerves at the seat 
of the morbid action by the dilated vessels, but more especially by the inflammatory 
deposits, thereby interrupting the transmission of their peculiar fluid, which thus accu- 
mulates and explodes at the point of obstruction, like the fluid in an electric battery. 
The nerves themselves necessarily participate in the disorder, sharing the same fate as 
the other tissues, and so increasing the suffering. 
Of the intimate nature of pain nothing is known beyond the fact that it consists of a 
peculiar mental perception, dependent upon a healthy state of the brain. There must be 
consciousness, otherwise there cannot be any cognizance of the mischief wrought by dis- 
ease. Of this a convincing proof is afforded in what occurs in apoplexy and paraplegia, 
in which the most violent inflammation may be set up, both in the internal and the 
external structures, and yet the patient be utterly insensible of its presence. The brain 
and nerves being crippled, the latter are unable to convey, and the former to receive, 
painful impressions. 
Although pain is a great evil, it is extremely fortunate that it is so generally present 
in inflammation, inasmuch as it serves to warn the patient of his danger, and usually sup- 
plies the practitioner with important information respecting the nature and seat of the 
morbid action. How many persons formerly perished of typhoid fever simply because 
there was no pain to guide the physician to the true lesions of the disease! 
What is termed throbbing is a peculiar form of pain, generally denotive of the approach 
of suppuration. It is, however, sometimes felt at an early stage of the morbid action, 
especially when it involves the flbrous, fibro-serous, and osseous tissues. It is generally 
dependent, in the first instance, upon an unusually crowded state of the capillary vessels, 
impeding the flow of blood, and afterwards, when the disease is more fully developed, 
also upon the presence of inflammatory deposits. Posture exerts a powerful influence 
upon its production, as is evinced in whitlow, odontalgi,., and common furuncle. In the 
first of these affections the pain is increased a hundredfold, almost in an instant, when 
the hand is lowered ; a decayed tooth that is free from pain in the day, while the patient 
is walking about, aches intensely the moment he lies down at night; and a boil on the 
buttock, which causes hardly any uneasiness during recumbency, throbs violently when 
the body is erect. 
3. Swelling.—Swelling is seldom entirely absent in inflammation of the external parts 
of the body, but very generally in that of certain internal structures, however violent or 
extensive the morbid action. Under the latter head may be enumerated, in particular, 
the fibrous and serous membranes, tendons, cartilages, bones, vessels, and nerves, along 
with most of the different viscera. The mucous membranes also may suffer in this way; 
the principal points where swelling is liable to occur, as a result of inflammation, are the 
conjunctiva, glottis, tonsils, and vulva, for the reason that these parts are largely supplied INFLAMMATION. 
with lax cellular material, which, wherever it exists, readily admits of infiltration of 
serous and other fluids. Hence it is that swelling is generally so conspicuous in inflam- 
mation of the subcutaneous and intermuscular connective tissues, especially in the ex- 
tremities, and sometimes even in the head, as is noticed in the more severe forms of ery- 
sipelas, where the scalp and face are occasionally puffed up to an enormous extent, frightfully 
disfiguring the features. 
The progress of the swelling varies; in general it is gradual, beginning early in the 
inflammation, and increasing steadily until the morbid action has attained its height; 
even then, however, it does not always stop, but often continues until the vessels have 
parted with their more fluid contents, which sometimes occurs only after the disease has 
begun to decline. Occasionally, however, the swelling is most rapid and extensive, 
spreading, in a short time, over an entire limb, or even the greater portion of the body. 
The best examples of this occurrence are witnessed in certain injuries, as compound frac- 
tures and dislocations, phlegmonous erysipelas, and the inflammation consequent upon the 
application of steam, alkalies, acids, and certain animal poisons, as that of the rattle- 
snake. 
The swelling varies in its character; thus it maybe soft or hard, transient or pro- 
tracted, beneficial or injurious. A soft swelling is usually denotive of serous effusion ; 
a hard one, of a deposit of plasma, or of the more solid elements of the blood. A tran- 
sient swelling is generally less prejudicial than a protracted one, as it is less likely to in- 
terfere with the restoration of function. Swelling often proves beneficial, inasmuch as 
the effusion upon which it depends is a means of depletion employed by nature to relieve 
inflammatory action ; it answers, in fact, the same purpose as a blister ora topical bleed- 
ing. When, however, the deposit is very large, or composed essentially of solid material, 
it may produce immense harm by compressing the capillary vessels and thus interfering 
with the transmission of their contents ; in other words, the effusion chokes the parts, 
and thereby causes fatal constriction. In swelling of the conjunctiva, technically called 
chemosis, the matter poured out often compresses the vessels of the cornea in such a 
manner as to induce gangrene of this membrane; and a like result not unfrequently 
follows phlegmonous erysipelas of the limbs and scrotum. Swelling may prove injurious 
in another way; by acting obstructingly, as in oedema of the glottis, which may cause 
death by preventing the ingress of air into the lungs. A similar effect may be produced 
by inordinate tumefaction of the tonsils. A swollen perineum may compress the urethra, 
and thus occasion retention of urine. 
The immediate cause of swelling is twofold: first, engorgement of the capillary ves- 
sels, and secondly, and mainly, effusion of serum and plasma; to which, in the more 
severe forms of inflammation, may be added pus and blood, the latter of which is some- 
times poured out in considerable quantity. 
4. Heat.—An increase of heat is one of the most common effects of inflammation, and 
hence a valuable symptom of the disease. A good illustration of this occurrence is ob- 
served in tonsillitis, gastritis, pneumonia, and the so-called fevers, in which there is often 
a remarkable heat of the breath ; and also in many of the. external varieties of inflamma- 
tion, where the change is rendered apparent both by the sense of touch and by the rapid 
evaporation of our applications. The scalding tear in inflammation of the eye is an evi- 
dence of the same fact. 
The degree of heat, emitted in the act of inflammation, was at one time supposed never 
to exceed that of the blood in the heart and large vessels. The researches of John Hunter 
strikingly countenanced this opinion. In operating upon a man for the radical cure of 
hydrocele, the temperature of the vaginal tunic immediately after the withdrawal of the 
fluid was ascertained to be 9*2°. The cavity was now stuffed with lint, and the next day 
the thermometer stood at 98J°, thus showing an increase of six degrees and three-quar- 
ters, which must have fully equalled the heat, of the blood in the heart and large vessels 
of the patient. In repeating the experiment subsequently upon a muscular wound in the 
side, of a dog, and upon the vagina of an ass, irritated by a solution of bichloride of 
mercury, he found no difference whatever, before or after the occurrence of inflammation 
in the temperature of the parts. Hence, he naturally concluded that the extrication of 
heat during the progress of this morbid process was either very slight or altogether inap- 
preciable. Observations, however, made since the time of the English philosopher, 
conclusively show that there is frequently, if not generally, a decided increase of tem- 
perature in the inflamed structures; and, although this increase may not render the 
temperature of the part equal to that of the heat of the blood in the heart, yet it is none 
CHAP. III. LOCAL SYMPTOMS. 
61 
CHAP. III. 
the less real and positive. It is well known that the outskirts of the body, as the feet, 
hands, and ears, are habitually cooler than the trunk, head, and upper portions of the 
extremities, because they have naturally a more feeble circulation : hence, in inflammation, 
although their temperature may not reach 98° of Fahrenheit, yet if there be any 
elevation of heat over and above what these structures enjoy in the healthy state, it is 
to be considered as an actual augmentation. That this is the fact, in all the more severe 
forms of inflammation, personal observations, many times repeated, fully satisfy me. In 
erysipelas of the skin of the trunk, in urinous infiltration of the scrotum, in acute abscess, 
in tonsillitis, orchitis, bubo, and other affections, I have again and again seen the mer- 
cury arise above 100°, and in some instances even as high as 105°, 106°, and 107°. 
The oviduct of a frog ready to spawn is two degrees warmer than its heart; and Profes- 
sor Dunglison saw the temperature of the uterus during labor rise as high as 10(5°. From 
a consideration of facts such as these it is impossible to avoid the conclusion that there is 
generally an elevation of heat in inflammation, in whatever part of the body situated, 
provided the concomitant action is not too slight, or too limited in extent. A marked 
increase, followed by a decided decrease, of temperature, follows the section of certain 
nerves, notably of those belonging to the sympathetic system, in the structures supplied 
by the wounded cords. 
The nature of animal heat is not sufficiently understood to justify us in expressing any 
decided opinion regarding the cause of its increase in inflammation. It may be supposed, 
however, to be mainly due, first, to the friction which the blood experiences in its passage 
through the vessels, not only in the inflamed parts, but in the system at large; secondly, 
to the oxidation of the carbon and other material introduced into the system in our food ; 
and, thirdly, to the rapid union of the oxygen of the air with the red particles of this 
fluid as it is propelled along in its turbulent course. The influence of an accelerated state 
of the circulation upon the production of animal heat is well exemplified in what occurs 
in ordinary exercise when the feet are cold. A rapid walk under such circumstances in 
the open air soon equalizes the circulation, and sends the blood, loaded with oxygen, to 
every part of the body, warming it as it rushes on. If a horse be rode swiftly round the 
race-track, his whole body becomes intensely heated, and the blood surcharged with fibrin 
and colorless globules; both evidently the result of the increased friction of the blood 
against the coats of the vessels, and the rapid union of the of the air with that 
fluid. Irritating applications, as spirits of ammonia, blisters, sinapisms, and embroca- 
tions, by inviting a preternatural afflux of blood to the affected part, produce an analo- 
gous effect, accelerating the circulation and causing an elevation of temperature. The 
augmented heat of the uterus during parturition can only be explained on the supposition 
of an increased activity‘of its vessels, approximating to a state similar to that which ob- 
tains in inflammation, although not identical with it. During the growth of the antler 
of the deer and of other animals there is always a marked elevation of temperature ; and 
phenomena of a similar kind are often witnessed during the development of malignant 
and other tumors. All these occurrences bear directly upon the question under conside- 
ration, if they do not positively serve to establish its truth. 
5. Tension.—A sense of tension, pressure, weight, or fulness is a prominent symptom 
in inflammation, and often greatly aggravates the local and general distress. It is par- 
ticularly conspicuous in inflammation of the denser structures, as the fibrous membranes, 
tendons,and cartilages, but it is also not unfrequently very severe in the more lax, as in 
the mucous membranes and the connective tissue. The immediate cause of the tension is 
the presence of effused fluids, as serum, lymph, and pus, which thus compress and con- 
strict the affected parts. It is not improbable that mere congestion, or inordinate dis- 
tension of the capillary vessels, may produce a similar effect. In either event, however, 
it is necessary that the parts should be more or less severely inflamed, and abnormally 
sensitive ; otherwise the feeling cannot arise, as is proved by the fact that, mere distension, 
however considerable, will not induce it, as is exemplified in anasarca of the lower ex- 
tremities, the penis, scrotum, and eyelids, where the accumulation is often enormous, and 
yet no sense of tension is experienced during any period of thfe attack. 
Great tension sometimes occurs in inflammation of the viscera, as the liver, spleen, 
kidney, and prostate gland. When combined with throbbing, it is generally denotive of 
incipient suppuration. In orchitis, tension is usually a prominent symptom. It is sel- 
dom, if ever, absent in boils, carbuncles, erysipelas, and paronychia. Occasionally ten- 
sion seems to be a purely nervous phenomenon, as, for example, in what is called sick- 
headache. 62 
INFLAMMATION. 
CHAP. III. 
G. Functional Disorder.—Disorder of tlie functions of the affected part is generally a 
most important symptom, as it is often present when all, or nearly all, the other phe- 
nomena are absent. It manifests itself in various ways, as well as in various degrees; at 
one time in increased sensibility or irritability, at another as a suppression, alteration, or 
augmentation of the natural discharge, and now as an abolition of some special sense; at 
one time as the slightest possible departure from the normal action of the part, and at 
another as a total suspension of it. 
An increase of sensibility is one of the most common effects of inflammation. In peri- 
tonitis, gastritis, and enteritis, the sensibility of the affected structures is often so great as 
to render the slightest pressure of the finger a source of profound distress ; and it is for 
the same reason that, under such circumstances, the weight even of a sheet is sometimes 
almost intolerable. Similar effects are noticed in some of the external diseases, as in boil, 
carbuncle, erysipelas, and in inflamed hemorrhoidal tumors, which are frequently the seat 
of the most exquisite tenderness, hardly exceeded by that which attends an inflamed eye. 
Parts which are devoid of feeling, or nearly so, in the sound state, such as ligaments, ten- 
dons, bone, and fibrous membranes, generally become exceedingly sensitive in inflamma- 
tion. The change in question is diagnostically of great importance, inasmuch as it usually 
enables us to distinguish readily between inflammatory and spasmodic affections, the latter 
of which, as before stated, are often immensely relieved by pressure, which never fails to 
aggravate the former. 
An inert ase of irritability is a very constant phenomenon in all inflammations of mus- 
cular parts. In cystitis, one of the earliest and most prominent symptoms is a frequent 
desire to urinate, arising from involvement of the muscular fibres of the bladder; in gas- 
tritis, the irritability of the stomach is so excessive that the organ is incapable of retain- 
ing the smallest quantity of fluid, however bland ; and in dysentery, the principal suffering 
is due to the incessant peristaltic action of the colon and rectum, the main seats of the 
morbid action. An increase of the contractility of the voluntary muscles is very com- 
mon in fractures and dislocations, in severe sprains, and after amputation, usually mani- 
festing itself in spasmodic twitchings, which can only be relieved by the liberal use of 
anodynes. 
Inflammation produces important changes in the special functions of an organ, some- 
times exalting, at other times diminishing or even completely suspending them. In ophthal- 
mia, the eye cannot look at objects, however dim ; the moment the effort is made, the lids 
contract spasmodically, and the smallest ray of light that impinges upon the retina is pro- 
ductive of the greatest distress. In inflammation of the ear, the slightest noise, which in 
the healthy state would perhaps not be perceived, or which might fall as delightful music 
upon the tympanum, becomes a source of deep distress ; and the sense of hearing is 
almost destroyed by the buzzing and explosive sounds which succeed the morbid action. 
In coryza, the sense of smell is abolished; in inflammation of the skin, the sense of 
touch ; in glossitis, the sense of taste. In laryngitis the voice is at first merely altered in 
its character, but as the disease progresses complete aphonia often ensues. In cerebritis 
there is generally delirium, followed, if the case passes on to suppuration, by convulsions 
and coma, the precursors of speedy dissolution. 
Another prominent symptom of inflammation, one, indeed, which is seldom absent, is 
disorder of the secretions. Thus, in inflammation of the skin, there is suppression of the 
perspiration ; in hepatitis, of the bile ; in nephritis, of the urine. Or, instead of an arrest 
partial or complete, of these and other secretions, important changes are effected in their 
composition, or in their physical, chemical, and microscopical properties. In pneumonia, 1 
the characteristic symptom is a rust-colored sputum ; in dysentery, a discharge of bloody 
mucus. 
The function of absorption is often seriously impeded, if not completely checked, in 
inflammation. The disorder, however, is generally much more conspicuous in the advanced 
than in the early stages of inflammation, in which this process is sometimes executed, 
even with a certain degree of vigor, as is demonstrated by the facility with which morphia 
and other substances are carried into the system when placed upon the skin after vesica- 
tion by cantharides, ammonia, or hot water. In the more violent grades of inflammation, 
the function is usually in a state of abeyance, the action of the absorbent vessels being 
arrested by the morbid deposits. Afterwards, however, as the disease declines, the func- 
tion of absorption is gradually reestablished, and then often proceeds with great vigor, 
rapidly removing the fluids effused during the earlier stages of the inflammation. 
It is worthy of notice that while the absorbent vessels, during the height of inflamma- 
tion, refuse to take up extraneous matter, as, for example, morphia or belladonna, and also CONSTITUTIONAL SYMPTOMS. 
63 
CHAP. III. 
effused fluids, they are often very busy in removing affected textures, even when of a very 
firm and resisting character. A familiar illustration of this occurrence is afforded in 
acute abscesses, the natural evacuation of which is frequently accomplished by the agency 
of the absorbent vessels, where the disease is most intense. In inflammation of the joints, 
cartilage and even bone often suffer extensively from this cause. There is no doubt that 
the pressure of effused fluids always greatly influences and promotes the occurrence. 
2. CONSTITUTIONAL SYMPTOMS. 
Constitutional symptoms do not always attend inflammation. The morbid action may 
be so mild as to prevent its recognition by the system ; it is strictly a local affection, and 
therefore causes no general resentment. But the case is very different when the disease 
is severe, or when, even if comparatively slight, it involves an important structure ; then 
the whole frame feels its irritating and depressing effects, and evinces a strong interest in 
the impending struggle. The group of phenomena thus produced constitutes what is 
termed inflammatory, symptomatic, or sympathetic fever, and deserves consideration as 
expressive of the sum of suffering of each particular organ. The period which intervenes 
between the establishment of the inflammation and the occurrence of fever varies from a 
few hours to several days, depending upon the nature of the exciting cause, the condition 
of the patient, the intensity of the disease, and, above all, the importance of the organ 
attacked. Idiopathic inflammation is generally preceded by depression or a sense of las- 
situde and uneasiness, attended with headache, pain in the back and limbs, bad taste in 
the mouth, vitiated appetite, and slight chilliness, alternating with flushes of heat. Some- 
times the patient is remarkably desponding, or annoyed with disagreeable dreams, and 
unpleasant forebodings respecting his recovery. He feels uncomfortably, both bodily and 
mentally, and is disinclined to exertion. In a word, he is unwell, or in a state interme- 
diate between health and sickness. These phenomena, which are merely the precursors 
of the fever, which is as yet only in a state of incubation, may be compared, not inaptly, 
to the fleeting clouds which precede the outbreak of a storm ; they appear and vanish for 
a time, but gradually coalescing, at length assume their allotted station in the chain of 
morbid changes. When fully established, the fever never intermits so long as the cause 
which has produced it continues in operation ; it, however, generally remits slightly in the 
morning, and sometimes, although rarely, twice in the twenty-four hours. The vesperal 
exacerbation, during which the temperature rises to 102° or 103° Fahr., usually sets in 
late in the afternoon, and persists, with but little alteration, until towards morning, when 
the excitement relaxes its hold, as if in need of temporary repose to meet the gradually 
recurring emergency. During the calm which is now present, the patient often falls into 
a refreshing sleep, his thirst and restlessness subside, and the skin is bedewed with a gentle 
perspiration. Soon, however, the smothered tire is rekindled, and the same suffering has 
to be passed through as before, now, perhaps, augmented by the spread of the morbid 
action, and the development of new sympathies. 
The type of the attendant fever varies. In young and robust subjects, and in the earlier 
stages of the disease, it is generally of a sthenic character, and asthenic under opposite 
circumstances. Very frequently the symptoms are denotive of great debility from the 
very commencement of the attack. In some cases both the sthenic and asthenic types 
are associated with excessive irritability, constituting what is called the nervous form of 
inflammatory fever. 
The nature of inflammatory fever can only be fully comprehended by thoroughly inter- 
rogating, as it were, every organ of the body supposed to evince any sympathy with the 
affected structures. Such an inquiry must, of course, embrace an examination of the 
heart and arteries, the countenance, skin and extremities, lungs, tongue, stomach, bowels, 
liver, kidneys, and bladder, together with the state of the muscles, brain, and assimilative 
powers. 
Derangement of the vascular system is chiefly denoted by the state of the pulse, the 
principal characteristics of which are frequency, hardness, fulness, strength, and quick- 
ness. The number of beats in a minute ranges from seventy, seventy-three, or seventy- 
five, the average standard in the healthy adult, to eighty-five, ninety-five, one hundred, 
or even one hundred and twenty, according to the intensity of the disease and the vigor 
of the constitution. A hard pulse is firm and resisting, rolling under the finger like a 
tense cord, as if the blood were sent into it with extreme power; sometimes the 
thrills or vibrates, owing to a partial displacement synchronous with the contraction o1 
the left ventricle of the heart. When the tension is unusually great, it is difficult, even INFLAMMATION. 
chap. in. 
with forcible pressure, to obliterate the caliber of the vessels. Fulness has reference to 
the volume of the pulse, which feels as if the artery were expanded beyond its normal 
size. Strength implies a sensation of preternatural resistance to the finger; while a 
quick pulse is one in which each beat occurs with great suddenness or abruptness. This 
quality of the pulse is generally associated with frequency, from which, however, it differs 
essentially, as the latter has reference merely to the number of strokes in a given time, 
and not to the rapidity with which the vessel dilates and contracts under the finger. 
Several of these states of the pulse may be absent, and yet the case be one of great dis- 
order of the vascular system. Their entire coexistence, in fact, is uncommon; perhaps 
the nearest approach to it is to be found in gout and rheumatism, hepatitis, pleurisy, 
splenitis, and the commencement of smallpox. 
The pulse is often materially modified by the nature and seat of the inflammation and 
by the idiosyncrasy of the patient. In cephalic affections, it is slow, full, and laboring, 
in consonance with the oppressed condition of the heart; in peritonitis, it is small, fre- 
quent, and wiry, sometimes, in fact, almost undistinguishable; and in acute inflammation 
attended with internal venous congestion, as in certain forms of fever and injury, it is 
obscure and apparently feeble, but generally rises under the effects of remedies, or the 
powers of the system. Idiosyncrasy often singularly modifies the state of the pulse. A 
middle-aged man, a patient of mine, has a pulse habitually under forty, and other exam- 
ples of this abnormal condition, equally striking, have fallen under my observation. On 
the other hand, it may be unnaturally frequent, beating constantly from eighty to ninety 
in the minute. 
Peculiarities like those here instanced, whether the result of disease or of idiosyncrasy, 
derive a special value from the influence which they must necessarily exert upon our 
diagnosis and treatment. Thus, in peritonitis, the practitioner, if governed solely by the 
state of the pulse, without any knowledge of the condition of the system which causes it, 
would be almost sure to administer stimulants instead of applying leeches and blisters ; 
thereby feeding in place of diminishing the inflammation, and so hurrying on the fatal 
crisis. A pulse, habitually slow, might, in inflammation, hardly attain the normal stand- 
ard of frequency, and yet the system might literally be consumed by symptomatic excite- 
ment. The surgeon, aware of the possibility of such occurrences, is wide awake, never 
allowing himself to be thrown off his guard, whatever may happen. 
The countenance, in inflammatory fever, is generally flushed, and often even unnatu- 
rally full, as if it were slightly tumid. The eyes are reddish, suffused, and frequently 
intolerant of light. The skin is hot and dry, the perspiration being kept in complete abey- 
ance ; and the extremities are usually so warm and uncomfortable as to be unable to bear 
any covering. When the excitement is excessive, the sufferer generally finds it impossi- 
ble to maintain the same posture beyond a few minutes ; he tosses about from side to side, 
and from place to place, in search of a cool spot. 
The respiratory organs actively participate in the general disorder. The inspirations 
are increased in frequency, and are usually performed with a certain degree of labor ; 
various kinds of rales are heard, and cases occur in which there is well-marked evidence 
of venous congestion. 
The digestive organs always suffer more or less severely in inflammation. The tongue 
is variously affected: sometimes it is red and almost clean, but generally it is coated, 
either with a whitish, yellowish, or brownish fur, contracted, and somewhat reddish at the 
tip and edges; nearly always dry, and easily protruded, though often a little tremulous, 
especially when the person is of a nervous temperament. The taste is vitiated, or entirely 
abolished, the salivary secretion is suppressed, a thick, dark-colored mucus adheres to the 
lips, gums, and tongue, and there is a disagreeable arid feeling in the fauces and oesopha- 
gus. The thirst is intense, and can hardly be appeased by the most frequent and abundant 
draughts ; the appetite, on the contrary, is usually destroyed, and hence the patient often 
loathes food, in whatever form presented. Nausea and a sense of gastric oppression, some- 
times accompanied with bilious vomiting, are common attendants. The bowels are gene- 
rally constipated, or alternately constipated and relaxed, distended with gas, and somewhat 
tender under pressure, the alvine evacuations being fetid, and variously altered in color 
and consistence. Along with this condition of the digestive tube there is usually more or 
less disorder of the liver, manifesting itself in excess, deficiency, or vitiation of its special 
secretions. Such a condition is very apt to be present in symptomatic fever consequent 
upon accidents and idiopathic inflammation in malarious districts. In what manner, or 
degree, the functions of the pancreas are affected in this disease, we are ignorant. The CHAP. III. 
CONSTITUTIONAL SYMPTOMS. 
65 
probability, however, is that it suffers very much in the same way as the salivary glands 
of the mouth, which it intimately resembles in its structure and uses. 
The changes produced by inflammation in the renal secretion relate chiefly to the quan- 
tity, color, and consistence of that fluid. In the normal state, the average quantity of 
urine, in the twenty-four hours, is from thirty-five to forty-five ounces, whereas in inflam- 
matory fever it often does not reach one-half, one-third, or even one-fourth of this amount. 
Moreover, instead of being of a clear amber hue, as it naturally is, it is commonly of a 
deep red tint, and surcharged with an unusual quantity of extractive matter, mucus, and 
lithic acid, the latter of which, in a few hours, always falls to the bottom of the receiver, 
in the form of brick-colored sediment. The specific gravity of the secretion, varying from 
1020 to 1024 in health, is also very much increased, and the odor is often more or less 
offensive from the presence of various kinds of animal substances. The chlorides, on the 
contrary, are commonly remarkably diminished, especially when there is much exudation 
with a tendency to cell growth. During the height of very acute inflammation, the fluid 
is often slightly albuminous, and even pervaded by tubular casts. A large quantity of 
urea is occasionally thrown off. Thus, in a case of pyemia, recorded by Vogel, it amounted, 
in the twenty-four hours, in the febrile state, to 1235 grains. The excretion of the fluid 
is seldom much affected, although sometimes it is greatly increased in frequency. In trau- 
matic inflammation, as after fractures, dislocations, and amputations, the bladder is occa- 
sionally so torpid as to require the aid of the catheter for the relief of its contents. 
The muscles are generally the seat of great discomfort in this form of fever. Already 
during the stage of incubation the patient is harassed with a sense of lassitude, stiffness, 
and aching or darting pains, which, gradually augmenting in severity, at length constitute 
a source of great suffering. The pains in the lumbar region are particularly violent; they 
are always worse at night, and are often so intense as to deprive the patient completely of 
sleep. His back feels as if it were bruised, broken, bored, or sawed. Not unfrequently 
every joint is racked with pain, and the whole body is so exquisitely sensitive as to be 
intolerant of the slightest motion, pressure, or manipulation. It is this distress in the 
muscles that causes the patient such weary and painful nights, and which induces him to 
exclaim in the evening, “Oh that it were morning!” and in the morning, “Oh that it 
were evening!” 
The suffering of the brain is evinced by a peevish and irritable state of the mind ; by 
loss of sleep ; by disagreeable dreams; and by occasional fits of delirium. In many cases 
there is more or less perversion of special sensation, as is evidenced by the distracting 
noises in the ears, the intolerance of light, the vitiated taste and smell, and the impairment 
of the sense of touch. 
Finally, the assimilative powers being in abeyance, the body is gradually emaciated, 
and the strength fails in proportion to the impoverished condition of the blood and solids. 
Every tissue wastes, the fat is absorbed, and the countenance presents a shrunken, attenu- 
ated appearance. 
Such is the ordinary course of events in inflammatory fever. If the morbid action do 
not proceed too far, or if the patient be unusually strong and vigorous, recovery is not 
only possible, but probable. The disease, and, along with it, the fever which it has 
induced, will gradually subside, the occurrence being announced by a diminution of rest- 
lessness, anxiety, and thirst, by a restoration of the moisture of the skin and mouth, and, 
in short, by a decided improvement in the condition of all the secretions. The sleep 
becomes more natural and refreshing, the appetite returns, the pulse and temperature 
descend to their normal standard, and the mind regains its accustomed equilibrium. The 
cessation of the fever often declares itself by the occurrence, either sudden or gradual, of 
a profuse sweat, to which the older pathologists applied the term critical, and by a general 
unlocking of all the secretions. In a word, the clouds which had so long obscured the 
horizon are once more succeeded by sunshine ; disease has vanished, and health is regain- 
ing its supremacy. 
If, on the other hand, the disease progresses, a downward tendency is gradually wit- 
nessed of evil, if not fatal, portent. The symptoms, losing their inflammatory type, now 
assume a typhoid character: the pulse becomes weak, soft, tremulous, and frequent, beat- 
ing from one hundred and thirty to one hundred and sixty in a minute ; the countenance 
assumes a peculiar shrunken aspect, denominated Hippocratic; the surface is bedewed 
with clammy perspiration ; the extremities are inclined to be cold ; the tongue is dry 
and covered with a brownish or blackish fur ; sordes collect upon the teeth ; hiccough and 
twitching of the tendons supervene ; and there is rapid emaciation, with corresponding 
failure of the strength, and low muttering delirium. Recovery is still possible, although INFLA M M ATIOX. 
CHAP. III. 
doubtful; a well-directed plan of treatment, or even nature’s unassisted efforts, may be 
sufficient to shake off the oppressive load, and enable the part and system to triumph over 
the ravages of the disease. 
But typhoid fever is not always a necessary consequence of the inflammatory; it may, 
and often does, exist as an independent affection, coming on early in the attack, perhaps 
almost immediately after the commencement of the morbid action, and maintaining 
throughout a well-marked asthenic type. The most common cause of such an event is 
severe shock or loss of blood, occurring in an unhealthy, broken state of the system, or 
actual blood-poisoning, from the absorption of decomposing pus, or the operation of some 
specific virus, as that of malignant pustule, or that generated in the dead human body, 
and received by inoculation in dissection. In the more severe grades of erysipelas and 
carbuncle, the fever soon assumes an asthenic character, whatever may have been its 
original type, the system being speedily overwhelmed by the depressing influence of the 
morbific agent. 
The occurrence of typhoid symptoms early in an idiopathic, specific, or traumatic 
inflammation, always portends evil, as it is denotive of great and rapid waste of life-power, 
which neither medicine nor food can, perhaps, successfully counteract. The nervous sys- 
tem is deeply involved in the morbid process ; the blood is gradually deprived of its plastic 
properties; and, nutrition being at a stand, the body soon becomes pale, emaciated, and 
withered. The mind is early affected, and typhomania is generally a prominent symptom 
throughout. The vital forces diminish more and more, there is incessant muttering, with 
picking at the bedclothes, hiccough, and twitchings of the tendons, and the patient is so 
weak as to be unable to support himself upon his pillow. Exhaustion, in fact, is extreme, 
and a few hours generally suffice to close the scene. 
There is another form of fever which is often seen during the progress of inflammatory 
affections, and to which the term irritative has not inaptly been applied, as it is generally 
met with in persons of a nervous, irritable temperament or habit of body. The best idea 
that can be given of it is that it bears the same relation to the nervous system that in- 
flammatory fever, properly so called, sustains to the vascular; that is, the fever in the one 
case is characterized by irritability, or excess of sensibility, and in the other by plethora, 
or redundancy of vascular action. We find, accordingly, that in irritative fever there is 
a lively perception of pain, and an unusual exaltation of sensibility, both of the part and 
system ; the mind is peevish and fretful, easily dissatisfied, and often filled with despond- 
ency and unpleasant foreboding ; the pulse is quick, jerking, small, and sometimes wiry ; 
the sleep is imperfect and disturbed by frightful dreams ; the skin is hot, dry, and difficult 
of relaxation ; the extremities are inclined to be cold ; and there are frequently nervous 
rigors, followed by marked reaction and great restlessness ; severe suffering is generally 
complained of in the loins and muscles ; the slightest noise and light are annoying ; and the 
head is distracted with severe pain, which often assumes a neuralgic character, and thus 
becomes a cause of great distress. 
There are some low forms of inflammation in which the attendant fever nearly always 
assumes this peculiar type, being present almost from first to last. A good example of it 
is afforded in dissection-wounds, in certain injuries of the skull and brain, in phagedenic 
ulceration, in hospital gangrene, in sloughing chancres and buboes, in carbuncles, and in 
tertiary syphilis, in nervous debilitated subjects. 
3. CHANGES OF THE BLOOD IN INFLAMMATION. 
That the blood, which plays so important a part in the economy in health, should be 
seriously altered in inflammation, is what might naturally be anticipated, and what obser- 
vation fully verifies. Sent with increased force and rapidity through every portion of 
the body, however constituted, or however remote from the heart; subjected to new 
actions and new affinities in the suffering structures, as if it were exposed to the heat of a 
laboratory, and deprived, in great degree, of the stimulus of the oxygen of the air, it is 
not surprising that it should be almost totally changed in its physical, chemical, and vital 
properties. The most important alterations which the fluid experiences relate to the 
fibrin and colorless globules, the quantity and number of which are always materially 
increased in every well-marked case of inflammation. 
In healthy blood the proportion of fibrin to the entire mass is as 3 to 1000 ; in inflam- 
mation, on the contrary, it is generally very much increased, ranging from G to 8, from 8 
to 0, and from 9 even to according to the intensity of the disease and the general 
powers of the system. In what proportion the colorless globules are augmented in inflam- CHAP. III. 
CHANGES OF THE BLOOD IN INFLAMMATION. 
67 
mation is still an unsettled question ; that their number is materially increased is suffi- 
ciently obvious, but whether the change, in this respect, is as great as in the fibrin is not 
ascertained. In addition to this increase in their number, there is a manifest increase of 
their bulk, as well as of their glutinous properties, thereby greatly promoting their tend- 
ency to cohesion to each other and to the sides of the vessels, which forms so striking a 
phenomenon in wrell-established inflammation. 
This excess of fibrin and white globules is generally observable at an early period of 
the inflammation, and gradually increases until the morbid process has attained its maxi- 
mum, when it begins to decline, and finally altogether disappears with the causes that 
induced it. Although it is most conspicuous in the higher grades of inflammation, there 
are few cases in which it is wholly absent, unless the disease is so slight as not to pro- 
duce any serious structural changes, or material embarrassment in the force and rapidity 
of the circulation in the part and system. Gout and rheumatism, pleuritis, pericarditis, 
pneumonitis, hepatitis, splenitis, arteritis, and acute articular affections usually exhibit it 
in the most marked degree. It is also present, but less conspicuously, in inflammation of 
the skin, connective tissue, and mucous membranes. Where or how this change is produced 
is still a mooted question. It is probably mainly effected in the arteries and veins by 
the agitation which the blood experiences in its passage through the different parts of the 
body, its various ingredients being thus forcibly pressed and rubbed against each other, 
and against the sides of the vessels by the increased powers of the heart. A species of 
disintegration is thus established, which doubtless adds very greatly to the already existing 
excitement both of the part and system. The idea that attrition of the blood against the 
walls of the arteries is mainly instrumental in the production of the change in question 
derives additional support from w hat is observed when a horse is subjected to severe exer- 
cise upon the turf. If the animal be bled immediately after having been driven very rap- 
idly, a great increase of fibrin and colorless globules will be found, evidently dependent 
upon the increased momentum of the circulation. Now this is precisely what occurs in 
inflammation ; the greater the excitement of the heart or the more intense the morbid 
action, the greater will be the amount of fibrin and of white globules, and conversely. 
The increase of fibrin and white globules in inflammation is attended with inordinate 
contraction of the crassamentum, and a separation of the red particles, leading to the form- 
ation of what is called the huffy coat of the blood. This consists of a whitish, bluish, or 
tallow-like pellicle upon the top of the crassamentum, which begins to show itself the 
moment the blood commences to coagulate, and attains its greatest height after the con- 
solidation is completed. The thickness and density of the huffy coat are greatly influenced 
by internal and extrinsic circumstances, as the state of the system, the intensity of the 
disease, and the manner in which the blood is drawn. In some instances it is a mere 
delicate film, while in others it forms a firm layer several lines in depth. When the 
blood is much impoverished by protracted disease, long abstinence, or unwholesome food, 
the buffy coat is generally very thin, soft, turbid, and iridescent, forming a striking con- 
trast with the characters exhibited in plethoric states of the system. 
Of the various extraneous circumstances which influence the formation of the buffy 
coat, the most important, in a practical point of view, are the shape and capacity of the 
receiver, the size of the stream, and the motion to which the blood is subjected in its pas- 
sage from the vein. It is most readily produced when the fluid falls into a deep, narrow 
vessel, from a large orifice, at the rate of two to three ounces in the minute. If tiie blood 
runs very slowly, or in a tiny stream, or if the stream, although quite bold, is received 
into a cold or shallow basin, the buffy coat will either not form at all, or so very 
imperfectly as to be scarcely appreciable. Sometimes the blood is merely sizy, the fibrin 
resting upon the top of the cruor like an imperfect bluish film. 
The buffy coat essentially consists of plasma, blood-liquor, or fibrin, in combination 
with albumen and earthy salts. In fact, it is perfectly identical with the plastic matter 
that is poured in inflammation. By a little care it may easily be detached from the 
crassamentum ; and, after being well washed in cold water and immersed in alcohol, it 
assumes not only the peculiar buff-colored aspect, whence it derives its name, but a very 
dense, firm consistence. 
Of the manner in which the buffy coat is formed no very satisfactory explanation can 
be offered. It was formerly supposed to be owing to the more tardy coagulation of the 
blood, thereby permitting the red particles to disengage themselves from the fibrin and to 
sink, by their greater specific gravity, to the bottom of the crassamentum. But this was 
evidently a mistake; for it is now well ascertained that inflammatory blood, instead of 
solidifying more slowly than healthy blood, generally concretes very rapidly and firmly, 68 
INFLAMMATION. 
CHAP. III. 
thus impeding instead of favoring, the development of the huffy coat. The most plausible 
opinion perhaps is that the occurrence is due to the vital repulsion between the fibrin and 
red particles; or, what amounts essentially to the same thing, to the contraction of the 
former by which these little bodies are squeezed out of it, as water is squeezed out of a 
sponge, before the mass of the blood is fully coagulated. However this may be, it is 
impossible for the huffy coat to form unless there is a previous disunion of the principal 
constituents of the fluid, thereby establishing a predisposition to its occurrence. To 
ascertain whether this tendency to the development of the huffy coat exists, it is not neces- 
sary to employ a spoliative bleeding, but simply to draw a few drops of blood, and to look 
at it with the microscope, which will at once detect the slightest deviation from the 
normal standard. The red corpuscles will be observed to run almost immediately into 
clusters of piles or rouleaux, as represented in fig. 1. 
In certain forms of inflammation and conditions of the system the blood is not only 
buffed, but cupped, the upper surface of the crassamentum exhibiting a hollow appearance, 
Fig. 1. 
Fig. 2. 
Reticulated Arangement of the Corpuscles In Inflammatory 
Blood. 
as if it had been scooped out with a knife. Such 
an occurrence usually denotes a higher degree of 
morbid action than the mere presence of naked 
fibrin on the top of the clot, and yet it is 
not unfrequently witnessed under circumstances 
which render it very questionable whether there 
is any inflammation atall, as in anemia, in scurvy, 
in chlorosis, and in profuse evacuations from the 
bowels, skin, and kidneys. To account for such anomalies, is generally not easy, but of 
their practical import every practitioner must be fully aware. In my private collection 
is a beautiful specimen, fig. 2, which I obtained by bleeding a young man laboring under 
pleuro-pneumonia, in which the buffed and cupped appearances coexist in a marked degree 
on both surfaces of the crassamentum. 
It has not been ascertained what changes, if any, the red globules undergo in inflam- 
mation. That they are flattened and otherwise altered in their form is sufficiently obvi- 
ous ; and it is equally certain that they greatly diminish in number as well as in their 
coloring matter, during the progress of the morbid action, especially if at all severe or 
protracted, as is evinced by the pallor of the countenance and of the surface generally. 
4. INTIMATE NATURE OF INFLAMMATION. 
In the definition of inflammation, given in the early part of this chapter, no attempt 
was made to specify its true character or essential nature, as such a step would have been 
premature ; but now that its various local phenomena have been pointed out and its con- 
stitutional effects traced, we are fully prepared to enter upon the subject, and to ask the 
question, What is inflammation ? 
To answer this question intelligibly, it is necessary to consider, 1st, the nature of the 
capillary vessels, in which the morbid action is mainly carried on ; 2dly, the character of 
the blood, which, as already seen, is so singularly changed in this affection ; 3dly, the 
part played by the nervous system, or, perhaps, more properly speaking, by the nerves of 
the affected structures; and 4thly, the condition of the tissues at the seat of the disease. 
The capillaries are those minute canals which are everywhere interposed between the 
arteries and veins, and which are designed not merely as channels for the transmission of 
the blood, but also as organs for the elaboration of various kinds of fluids, as those of 
nutrition and secretion. In structure they differ from the arteries and veins only in the 
Buffy and Cupped Blood. INTIMATE NATURE OF INFLAMMATION. 
69 
CHAP. III. 
fact that the finer ones consist of fiat endothelial cells arranged in a tubular form, to 
which, in the larger, is superadded a tunic composed of a delicate network of fine fibrils, 
formed of the processes of the stellate cells which lie directly upon the vascular wall. 
With regard to their caliber, these vessels are divisible, for the sake of a more thorough 
comprehension of the subject, into two classes. The one embraces those minute tubules 
which, though invisible to the naked eye, carry a continuous stream of blood, so as to 
give the part in which they are situated, when examined with the microscope, a red 
appearance. The other group consists of vessels, the lumen of which is so small as to 
admit only a single globule at a time, and which it is often difficult to detect even with a 
strong magnifier. 
Although the blood, as it circulates through the body, and immediately after it has 
been drawn from a vein of the arm, has the appearance of a homogeneous fluid, a careful 
examination shows it to consist of numerous elements, intended for widely different pur- 
poses in the economy. Coagulation separates it into two parts, one solid, and hence 
called the crassamentum ; the other fluid, and called the serum. The crassamentum 
consists of a pale, whitish, transparent fluid, known as the blood-liquor, plastic matter, 
plasma, or coagulating lymph, and of minute particles, globules, or corpuscles, entangled 
in and suspended by it as the blood circulates through the body. The particles are of 
two kinds, the red and the colorless; the former, which impart to the crassamentum its 
red hue, are exceedingly abundant, and vary in size from the to the gjVg of an inch 
in diameter; they are of a flattened, biconcave, circular shape, and their office seems to 
be to absorb oxygen from the atmosphere and to convey it to the different parts of the 
system, to invigorate the organs and tissues. The colorless or white corpuscles—the leu- 
cocytes of certain authors—are much less numerous, but greatly multiply in inflammation; 
they are round, much larger than the red, and rough or finely granulated on the surface. 
What their precise office is is not determined, but it is certain that, at their expense, the 
red corpuscles can be regenerated ; that they wander from the vessels into the surrounding 
tissues, where they proliferate; and that they play an important part in effecting certain 
plastic changes, if, indeed, they are not intimately concerned in the reproduction of 
impaired or lost structures. 
In the vessels of the living body, the white globules have, apparently, no disposition to 
mingle with the red ; on the contrary, they keep in close contact with the inner surface 
of the vessels, coasting, as it were, slowly along in the blood-liquor, outside of the general 
current. The red particles, on the other hand, pass quietly and gently along the centre 
of the vessels, regardless, so to speak, of the colorless, and in a much more rapid and 
lively manner, without any adhesion to each other, to the white particles, or to the coats 
of the containing vessels. 
The essential elements of the inflammatory process, so far as we are able to compre- 
hend them, are, 1st, slight contraction of the capillaries, with a retardation of the flow 
blood ; 2dly, dilatation of these vessels and an increased rapidity of the circulation ; 3dly, 
exudation of blood-liquor, and emigration of white blood corpuscles; and, 4thly, a 
quiescent state of the capillaries, with complete stagnation of their contents. While 
these changes are going on in the interior of these vessels, important changes are wrought 
in the blood, both in regard to its consistence, its color, the arrangement of its globules, 
and the character of the plasma. Finally, the coats of the vessels themselves are seri- 
ously altered, being rendered abnormally soft and fragile, through fatty infiltration, and 
thereby temporarily incapacitated for the transmission of their contents. These various 
changes are so important as to demand separate consideration. 
If a drop of rectified spirits, or of any mild stimulus, be applied to the web of the foot, 
the tongue, or mesentery of a frog, or the wing of a bat, the effect will be a slight con- 
traction of the arteries, with a partial arrest of the flow of blood through the capillaries, 
the particles of blood moving to and fro for a few seconds, when they will be observed to 
regain their proper course, and to pass on as if nothing had occurred. If the irritation 
be more severe, as when a drop of tincture of capsicum is applied, the vessels, instead of 
diminishing, are instantly dilated, or if there be any contraction, it is so trivial and 
transient as to be inappreciable by the sight. However this may be, the dilatation soon 
becomes marked and decided, as is proved by the fact that the vessels now carry a much 
larger quantity of blood than naturally, the red particles being sent into them in increased 
numbers, as well as with increased force and velocity, evidently in consonance with the 
augmented action of the heart, which, beating perhaps from ninety to one hundred and 
ten in the minute, throws the fluid with extraordinary impetus into the inflamed part. 
The disease advancing, the dilatation steadily augments, until, at length, the artery, 70 
INFLAMMATION. 
chap. in. 
expanded to its utmost, is converted into a mere passive tube, palsied and crippled in its 
action, and therefore not only unfitted for transmitting its contents, but for performing 
any of its more delicate functions as an organ of nutrition and secretion. In otherwords, 
the rate of movement of the blood is again altered, primary acceleration giving way to 
retardation of the circulation. 
In the condition now described, the capillary is not only greatly distended, but dis- 
tinctly elongated and tortuous, sometimes almost knotty, as if affected with aneurismal 
enlargements, or veritable varices. Its coats are also abnormally soft and lacerable, 
from intermolecular changes in their structure. 
The blood, the immediate cause of this dilatation, is literally impacted in the vessel, 
pressing everywhere upon its sides, and thus causing,, by degrees, complete remora, stasis, 
or stagnation. The white and red particles, instead of pursuing an orderly, quiet, and 
independent course, as in the natural state, are now observed to be more or less inter- 
mixed, and so thoroughly crowded together that both are materially changed in their 
shape, being irregularly flattened, elongated, and distorted, as well as adherent to each 
other and to the sides of the vessel. When there is complete stoppage, the distinction 
between the two sets of globules is entirely lost, the blood forming a stagnant pool, of a 
dark homogeneous aspect. 
These various changes, which are brought about gradually, hot suddenly, may be 
studied with great advantage in what occurs in inflammation of the conjunctiva. If this 
membrane be irritated, as, for example, by the contact of a foreign body, there will be an 
immediate rush of blood to the part, with a great seeming increase of its vascularity. In 
a few minutes hundreds of vessels, previously invisible, will be seen shooting out in dif- 
ferent directions, .and connecting themselves with the sides of those that appeared in the 
first instance. These are not new channels, but old ones appertaining to the second class 
of capillaries, rendered evident by the intromission of red particles, which, in the healthy 
state, pass along so sparingly and in so slow and gradual a manner as to elude detection. 
It is not to be supposed that the globules of the blood, as they are sent by the heart 
into the irritated arteries, are able, all at once, to pass through them without some diffi- 
culty. Instead of this, after having proceeded a certain distance, they rebound against 
themselves and against the sides of the vessels, so as to undergo a kind of oscillatory 
movement; but, gradually yielding to the force exerted upon them from behind, they are 
urged onward and onward until they reach the corresponding veins, into which, as their 
caliber is much larger than that of the arteries, they rush as into a vortex, and instantly 
disappear in the current beyond. A similar oscillatory movement of the globules of the 
blood is observed when the circulation is about to be reestablished after it has been com- 
pletely arrested. Some time is required for the detachment of these bodies, and when 
they liave finally succeeded in effecting this, instead of passing on at once into the cor- 
responding veins, they are propelled forward and backward until the diseased arteries are' 
sufficiently dilated to admit of their escape. 
When the morbid action is fully established, and at the same time very intense, with- 
out, however, there being as yet complete cessation of the circulation, the contents of the 
affected vessels not unfrequently break through their softened and lacerable walls, occa- 
sioning thus a veritable extravasation of blood. 
Immediately around the seat of the greatest intensity of the morbid action, marked 
congestion exists, and the blood, consequently, passes along very slowly, and with diffi- 
culty. Beyond this point the phenomena are somewhat different; the excitement is less 
considerable, but still sufficient to cause active vascular determination ; the blood moves 
in a continuous stream, and with extreme velocity, but being unable, as it approaches 
the focus of the inflammation, to make its way through the stagnant tubes, it is sent 
onward through collateral channels, now for the first time fairly opened for its reception. 
Thus it will be seen that, while at the centre of the morbid action stagnation occurs, and 
around this there is a sluggish circulation, an increased activity is going on in its neigh- 
borhood. The arteries leading to the affected part are distended, and pulsate strongly, 
but not with preternatural frequency. 
The part played by the nerves in inflammation is very imperfectly understood. It is 
evident, however, that it is very important, although it is impossible to define its character 
or specify its degree. In traumatic inflammation, as well as in many cases of idiopathic, 
the vascular changes, which, as has been seen, consist essentially in dilatation of the ves- 
sels, with consequent diminution, retardation, and stasis of the circulation, cannot be 
referred to the blood itself, but must be seated in the vascular walls. Decrease of the 
resistance of the vessels to the pressure of the blood is probably due to perverted innerva- INTIMATE NATURE OF INFLAMMATION. 
71 
CHAP. III. 
tion. The irritated sensory or nutrient nerves of the inflamed part impress the ganglionic 
centres in such a way that their action on the walls of the vessels through the vaso-motor 
nerves is diminished or inhibited, thereby producing lessened tone or reflex paralysis of 
their muscular fibres, as evinced by the dilatation of the vessels, and the consequent con- 
gestion of tTTe tissues to which the irritated sensory nerves are distributed. That the dila- 
tation of the vessels and the hyperemia are not, however, necessarily of reflex origin, but 
that they may depend upon the direct influence of the irritating agent upon the walls of 
the vessels is demonstrated by the fact that they may be produced in the tongue of the 
frog after destruction of the nervous centres. 
As the inflammation increases in intensity, the nerves actively participate in the morbid 
process, their substance becoming injected, softened, compressed, and otherwise altered, 
in consonance with the peculiarity of their structure and function. The effect of such a 
change upon the welfare of the affected textures must be extremely pernicious, as it must 
materially diminish, if not entirely arrest, the nervous current, and thus weaken and pros- 
trate their vital powers. 
The joint agency of the nervous and vascular systems, in the production and maintenance 
of inflammation, has been happily illustrated by the researches of modern physiologists. 
Thus, for example, it has been ascertained, that, when the ophthalmic branch of the fifth 
pair of nerves is divided in the cranial cavity of a rabbit at the bridge of Varolius, inflam- 
mation is speedily lighted up in the surface of the eye, eventuating in opacity of the upper 
segment of the cornea. What is still more remarkable is, that, when the nerve is cut on 
the petrous portion of the temporal bone, so as to involve the ganglion of Gasser, the 
resulting irritation is not only more violent, and much more deeply seated, but followed 
by complete disorganization of the organ. 
Analogous effects ensue upon the division of the pneumogastric nerves. When these 
cords are severed high up in the neck, the lining membrane of the air-passages assumes a 
dark color, the lungs are engorged with black blood, and an abundance of serosity is poured 
out into the parenchymatous texture, as well as into the pulmonary vesicles and the minute 
branches of the bronchia?. The pleura generally participates in the irritation, and there 
is almost always more or less inflammation of the stomach, with a suspension ot the secre- 
tion of the gastric juice. 
Animals in which the brachial plexus of nerves has been tied are soon seized with inflam- 
mation of the integuments of the remote parts of the limb, which gradually progresses 
until all the soft structures are invaded by gangrene. A friend of mine removed a section 
of the peroneal nerve on account of a neuroma ; the wound was long in healing, and two 
of the small toes sloughed before the patient recovered. These facts enable us to explain 
certain circumstances that are noticeable in certain morbid states of the system. A part, 
for instance, affected with palsy, is much less capable of withstanding the ordinary impres- 
sions of physical agents than one receiving its customary supply of nervous influence. A 
burn in a paralytic person creates much more serious mischief than in a person in perfect 
health ; and the same is true in regard to blisters and other irritants, the injudicious appli- 
cation of which often leads to the destruction of large portions of the skin and subjacent 
connective tissue. There is little doubt that the inflammation of the bladder, which so fre- 
quently supervenes upon serious injury of the spinal marrow, is caused in a similar man- 
ner; that is, by the interruption of the natural supply of nervous fluid. 
In whatever manner the parts are deprived of nervous fluid, it is presumable that they 
are brought under relations somewhat analogous to those of a frozen limb. The tempera- 
ture is lowered, the sensibility impaired, the process of nutrition perverted; in a word, the 
natural connection between the vessels and nerves is broken up, and hence that series of 
phenomena so characteristic of inflammation. 
The saturation of the affected tissues with fluid exudation, through the escape of blood- 
liquor from the vessels, proceeds step by step with the diminution and retardation of the 
venous and capillary circulation, and forms one of the most essential characteristics of 
inflammation. Although Bennett and Rokitansky had both been aware of the part played 
by the participation of the exudation of blood-liquor in the process of inflammation, it was 
not until recently that its importance in stimulating cell life, or modifying the healthy 
nutrition of local protoplasmic masses, was fully recognized. 
Coincident with the exudation of blood-liquor and the other vascular changes above 
described, the white blood corpuscles, leucocytes, lymph corpuscles, nomadic or wander- 
ing cells, as these protoplasms are variously termed, greatly increase in number, and adhere 
to the inner surface of the vessels, forming upon it an almost motionless layer, while the 
red corpuscles circulate slowly along the centre in their accustomed channel. Thus situ- 72 
INFLAMMATION. 
ated, the white corpuscles begin to wander out or emigrate into the inflamed tissues through 
the softened veins and capillaries, by virtue of the remarkable faculty which they possess 
Df changing spontaneously their form and position, peculiarities which, from their simi- 
larity to those of amoebae, are designated as amoeboid movements. This faculty, as well 
as the diffusion of the white corpuscles in the tissues, was first demonstrated by Von Reck- 
linghausen, without, however, his being aware of their vascular origin. Addison, in 1842, 
enunciated the fact that in inflammation the white corpuscles first pass into and then 
out of the walls of the vessels; and Waller, four years later, by experiments performed 
upon the tongue of the frog, confirmed the statements of his countryman. Although, sub- 
sequently, Strieker, of Vienna, discovered that the walls of the vessels are permeable both 
to the white and red corpuscles, it remained for Cohnheim, in 1867, to establish the cor- 
rectness of these observations, by demonstrating conclusively that white blood corpuscles 
wander from the vessels into the irritated and inflamed tissues, and that, in incipient 
inflammation, all such morphological elements as cannot be distinguished from pus corpus- 
cles, are derived from the blood, and not from the tissues. To Cohnheim, therefore, is 
due the credit of having correctly intrepreted his own observations, and of developing the 
researches of his predecessors. Having once infiltrated the inflamed tissues, these white 
corpuscles germinate, and become either fixed connective tissue cells, forming in conjunc- 
tion with other tissue proliferation, the germ tissue of Rindfleisch, the granulation tissue 
of Virchow, or the plastic infiltration of certain pathologists ; or, they are thrown off by 
the tissue in the form of pus; or, as observed by Ilering, they may enter the lymphatic 
vessels, to be carried to distant points as lymph corpuscles ; or, finally, they may reenter 
the veins and capillaries, as pointed out by Von Recklinghausen, the ultimate disposition 
of the protoplasm being determined by the intensity and duration of the morbid action, 
the texture or organ affected, and the state of the blood. 
Not less important than the vascular changes in inflammation is the succeeding nutri- 
tive disturbance of the cellular elements of the perivascular tissues, due to the stimula- 
ting influence exerted upon them by the exuded blood-liquor, and manifesting itself by 
increase of substance, change of form, and proliferation, either through fission, germi- 
nation, or endogenous generation. Proliferation, multiplication, or germination of local 
protoplasmic masses, accompanies inflammation of all organs and textures, in conse- 
quence of the assimilation by the germinal matter of an excess of new material derived 
from the blood-liquor. This activity of cell life has been observed in nearly all types of 
cells, both of non-vascular and vascular connective tissues. Thus, for example, the in- 
vestigations already alluded to, of Strieker and of W. F. Norris, of this city, have 
demonstrated the proliferation of the germinal matter of the cornea corpuscles; Giiter- 
bock has shown the division of the nucleus of the cells of tendons; and Redfern, as is 
well known, first observed that the germinal matter of the normal cartilage cell is replaced 
by a mass of mobile cells, which are identical with white blood corpuscles. Similar 
hypernutrition of cell elements occurs in the vascular connective tissues. The researches 
of Strieker proved the increase by division of white blood corpuscles, and he has, more- 
over, confirmed the doctrine of Virchow that the fixed connective tissue corpuscles 
multiply in the same manner. Even in the capillary vessels, which are nothing more 
than tubular protoplasms, it has been ascertained by Beale, Strieker, Leidesdorf, and 
Shakespeare that similar growth and division take place; the former distinguished 
observer, moreover, believing, from the likeness of such dropped off bodies to white blood 
corpuscles, that they represent one of the modes of genesis of the latter. Finally, the 
participation of the muscle corpuscles in the process of inflammatory formations has been 
demonstrated by Virchow, Waldeyer, Weber, Weil, Spina, and Tschainski; and the 
nuclei of nerve cells, are said by Jolly, under certain circumstances, to increase in number. 
Local disturbance of nutrition in inflammation is also indicated by the changes which 
occur in epithelial cells. Buhl and Remak discovered the endogenous proliferation of the 
germinal matter of the epithelial cells of suppurating mucous membranes; and the fission 
of the protoplasm of the epithelial cells of the corneal conjunctiva, and of the membrane 
of Descemet, has been observed respectively by Oser and Strieker. Analogous changes 
occur in the cells of the secreting glands, as is exemplified in those of the liver, which 
have been shown by Ilolm and Hiittenbrenner to participate in the formation of inflam- 
matory products. 
To what conclusions do these remarkable discoveries point? Simply, that the process 
of inflammation is attended with local disturbances of circulation and nutrition, the latter 
being dependent upon the former, which manifest themselves, first, by the escape through 
the walls of the thinned, softened, and dilated veins and capillaries of more blood-liquor than 
ciiap. hi. INTIMATE NATURE OF INFLAMMATION. 
chap. in. 
is essential to normal nutritive changes ; and, secondly, under the influence of the assimila- 
tion of an excess of new material derived from that fluid, by increased activity of the cel- 
lular elements of the part, whether they be natural to it, or intruders from the bloodvessels, 
as shown by their enormous multiplication. 
The accumulation of young cells in the tissues thus gives rise to inflammatory new 
formations, or plastic infiltration, which cannot be said, on the one hand, to be due exclu- 
sively to the emigration and migration of white blood corpuscles, as advocated by 
Cohnheim and his followers, or to be derived, on the other hand, exclusively from the con- 
nective tissue corpuscles, as taught by Virchow and his school. On the contrary, both 
elements participate in the process, as do the surface epithelia, gland cells, muscle corpus- 
cles, nerve cells, and, in point of fact, all cells found in the tissue or organ affected. In 
an irritated cornea, for example, it has been established beyond cavil that wandering cells 
intrude into its substance and proliferate ; that the proper corneal cells germinate, and 
that the epithelial cells of the anterior and posterior layers of that structure undergo simi- 
lar changes. What is true of the cornea may be applied to other tissues, so that it may 
be laid down as a general law that the inflammatory process is essentially characterized by 
hypernutrition of the local masses of protoplasm influenced by it. 
The migration theory of Cohnheim has recently been opposed by Strieker, who teaches 
that the inflamed tissue returns to its embryonic condition by the conversion of its cells 
and basis substance into an amoeboid material, which subdivides into the small cells, 
which are regarded by Cohnheim as emigrant white corpuscles, and by Virchow as multi- 
plying connective tissue corpuscles. While I can see no objection to the acceptance of 
the theory of the metamorphosis of the entire tissue into germinal or embryonic tissue, I 
am not prepared to discard the view of the part taken by emigrant cells in plastic infiltra- 
tion, which appears to me to have been settled beyond the possibility of refutation by the 
observations of the most competent authorities. 
Some of the changes which occur in the vessels and tissues in inflammation are admir- 
ably depicted in fig. 3, for whjch I am indebted to Dr. E. O. Shakespeare, representing 
the appearance of the mesentery of a rabbit in a state of acute inflammation of about 
twenty-four hours’ duration, as seen under a magnifying power of three hundred diameters, 
Fig. 3. 
Changes in the Bloodvessels and Tissues in Inflammation. 
after the superficial endothelial covering has been removed. At the lower and right-hand 
portion of the figure the elements and tissues are quite sharply defined, whilst in many 
other places they are considerably out of focus. A portion of a network of capillaries, c, 
crowded with numerous white corpuscles and a few red disks, and possessing swollen 
nuclei, n, in its walls, which are somewhat too sharply delineated, occupies a level in the 
thickness of the mesenteric tissue just beneath the endothelial covering. By focusing 
slightly deeper, a layer becomes apparent, in which a small vein is discovered imme- 
diately beneath a portion of the capillary network. Its axis is found crowded with 
red blood corpuscles, a, whilst the inner surface of the wall, b, of the venule is covered 
with closely-packed and adherent white corpuscles, g, several layers deep, among 
which, scattered at rare intervals, are a few red blood disks. At k, and at similar 
locations, swollen granular nuclei of the endothelial lining of the inner tunic, are plainly 74 
INFLAMMATION. 
CHAP. III. 
visible, and it will be observed that analogous nuclei also cover tbe exterior surface of the 
wall of this minute vein. The venule is surrounded by a perivascular lymph space, e, 
which is filled with great numbers of leucocytes accompanied by a very few red disks. 
The wall of this space also is lined with endothelium, having one or more swollen granular 
nuclei, as seen at i. In one or two places leucocytes can be seen partly in and partly 
outside of the vein wall. The connective tissue, d, is in a condition of decided change. 
Many of the lymph spaces between the bundles of fibres are distended, as at /, with lymph 
rich in leucocytes, and the walls of these spaces can frequently be seen, as at h, to be 
lined with swollen granular endothelium. 
Although Cohnheim demonstrated.the identity of white blood corpuscles with those of 
pus, and showed that in acute inflammation pyogenesis was referrible principally to vas- 
cular origin, the fact must not be lost sight of that white blood corpuscles only are con- 
verted into pus corpuscles under certain circumstances. The question then naturally 
arises, what becomes of the inflammatory new formation—of the tissue infiltrated with 
crowds of young cells ? Without entering into minute morphological details, it will be 
sufficient to say that, if the inflammation be slight, the cells disappear, partly by their 
conversion into connective tissue, partly by atrophy and disintegration, and partly by 
entering the lymphatics or bloodvessels. If the morbid process pass into solid plastic 
infiltration, the cells assume new forms, and are changed into fixed connective tissue cor- 
puscles, while the gelatinous intercellular substance, or the original tissue, softened and 
swollen by exuded blood-liquor, is rendered more and more firm, until its final conversion 
into analogous tissue. If, on the other hand, the inflammation be more active, fluid 
inflammatory infiltration ensues, the cells proliferate and retain their form, the intercellu- 
lar substance liquefies, and suppuration is said to exist. In what manner these different 
results are determined, why one tissue should recover rapidly and without suffering any 
visible signs of injury, while another is disorganized, are points which cannot be answered 
in the present state of our knowledge; but there is no doubt whatever that the process is 
a vital one, and that it is materially influenced by the intensity of the inflammation, by 
the nature of the affected structures, and by the condition of the blood. 
A careful study of the inflammatory process leads to the conviction that, in its earlier 
stages, it is one of increased action, not only of the arteries, veins, and capillaries, but 
also of the tissues through which they pass. It may, therefore, be assumed that it has its 
seat in and around these vessels, no single factor being decisive, since the vascular and 
extravascular characteristics are so inseparably blended and interdependent that all must 
participate in its development. In summing up the essential elements of the process as 
they have here been described, it will be found that they consist, in the order of their 
succession, 1st, of irritation ; 2d, of perverted innervation ; 3d, of deranged circulation, 
as evinced, primarily by .acceleration, consecutively by retardation, with the penetration 
of the vascular walls by blood-liquor and white blood corpuscles, and, finally, stasis ; 4th, 
of textural or nutritive disturbances, due to hypernutrition of local protoplasms ; and, 
5th, of new formations. 
If, when inflammation is in its incipiency, there is augmented action, it follows, as a 
natural consequence, that, when the disease is fully established, there must be correspond- 
ing debility. The capillaries are not only distended to their very utmost with non-oxy- 
genated blood, but partially, if not completely, paralyzed; the tissues, at the seat of the 
disease, are surcharged with inflammatory products; all the normal functions are inter- 
rupted or suspended ; and vitality itself is sadly impaired. At no long interval, the 
affected structures, especially if loaded with plastic deposits, evince a disposition to un- 
dergo the fatty degeneration, the earliest evidence of the occurrence being the confused 
appearance of the parts as revealed by the microscope, and by the presence of minute oil 
globules. If the fibrinous matter is spoiled, or transformed into pus, the quantity of oil 
greatly increases, and the tissues, acted upon by the absorbents and by chemical influences, 
are liquefied and devitalized. If, on the other hand, it becomes organized, the parts are 
in danger of being atrophied, as they are partially robbed of their nourishment, and 
choked as vegetables are choked by weeds. 
Much discrepancy of opinion still exists among surgeons as to what constitutes inflam- 
mation ; some, myself included in the list, believing that only a very slight degree of 
action is necessary, while others maintain that a very wide departure from the normal 
standard is essential. Some, indeed, assert that there is no inflammation, properly so 
called, unless there is suppuration, apparently losing sight of the fact that the disease very 
frequently proves fatal long before it has attained this crisis. Others, again, consider TREATMENT OF INFLAMMATION. 
75 
CHAP. III. 
fibrinous exudation an indispensable condition of the process. As for myself, I am satis- 
fied that it is not necessary that there should be even an effusion of plasma, or fibrinous 
exudation, much less suppuration, inasmuch as there are certain organs and tissues, in 
which, however violent the inflammation may have been, the most careful examination, 
microscopical and chemical, fails to detect after death the existence of fibrin in the affected 
structures. It is only necessary to instance the arachnoid membrane, the aponeuroses, 
bones, cartilages, and nerves, in which this disease is frequently, if not generally, unat- 
tended by a deposit of plasma, especially in its milder forms, and in its earlier stages. 
The quantity of this substance, and the facility with which it is poured out, must neces- 
sarily be very materially influenced by the nature of the affected organs and tissues, some 
furnishing it much more readily, and in much greater abundance, than others. Moreover, 
it requires very nice judgment, particularly in the living subject, to define the boundaries 
between congestion and inflammation, or to determine where the one terminates and the 
other begins. Inflammation, in its incipiency, may be compared to a latent or smothered 
fire, kept in abeyance by a redundancy of surrounding material; exudation cannot occur 
all at once ; some time is necessary to prepare the vessels for their new office : so it is with 
the flame in the furnace, it does not break forth immediately on the application of the 
kindling, and yet no one would thence conclude that fire was not actually present. 
Most of the disputes that has grown out of this question have arisen from a misunder- 
standing as to the amount of disease, or change in the affected part, that is necessary to 
constitute inflammation ; and it is obvious that there never can be any fixed or definite 
views upon the subject so long as this is the case; nor can the question be satisfactorily 
settled, unless it be studied with reference to the nature and functions of the different 
organs and tissues of the body; or, if the expression be allowable, the conduct and habits 
of the organs and tissues in their healthy and morbid relations. 
Another source of difficulty, in the settlement of the question, is the fact that many 
practitioners are seemingly incapable of divesting themselves of the idea that inflamma- 
tion must necessarily be treated by depletion, particularly by the lancet, leeches, purga- 
tives, and starvation. They find it apparently impossible to disconnect the two things, 
and yet it requires very little reflection, and certainly no great amount of experience, to 
show the erroneousness of such a conclusion. Cases of inflammation are of daily occur- 
rence which imperatively demand the use of stimulants from their very commencement; 
and it is not going too far to assert that there is a period in almost every attack of the 
disease, in which, if it be at all severe, the patient will not be greatly benefited by the 
use of brandy, wine, quinine, and nutritious food. 
Attempts have been made from time to time to invent theories of inflammation which 
should satisfactorily explain its character, the philosophers who have thus occupied them- 
selves imagining that, with the aid of the microscope and other ingenious appliances, they 
could penetrate the very secrets of nature, by tracing out her most intricate and hidden 
operations, and the laws by which these operations are governed. How futile all 
such attempts have been, and are likely to be, the history of the subject amply attests. 
Theory has succeeded theory, only to be ridiculed, and to work out, so to speak, its own 
fallacy and insufficiency. The cautious observer contents himself with things as he 
discerns them, unbiassed by prejudice and conjecture, satisfied if he can occasionally 
pick up a pebble at the bottom of the great sea of knowledge. Viewed in this light, and 
measured by this rule, the theories of one man are of no more importance than those of 
another; as guides to clinical observation, and as aids to practice, they are utterly value- 
less. It is fortunate for us in this matter-of-fact age that we are not obliged, as was the 
case in former times, in order to establish our claims as philosophers, to speculate about 
the final causes of things. 
5. TREATMENT OF INFLAMMATION. 
There are two leading indications in every case of inflammation when sufficiently grave 
to demand interference, the first being the removal of the exciting cause of the disease, 
and the second, the establishment of resolution. 
In regard to the first of these points, it is obvious that, although the disease may be 
modified in its character, or rendered comparatively harmless, by treatment, yet it will 
be impossible to arrest it completely so long as the exciting cause is operative. Thus, 
for example, in strangulation of the bowel, it would be folly to expect resolution of the 
inflammation so long as the strangulation which has produced it continues. In such a 
case, one of two things must necessarily happen : either the sufferer must die from the 
effects of the disease, or he must be relieved by the knife, or by nature’s operation, the INFLAMMATION. 
CHAP. III. 
formation of an artificial anus. An inflammation of the lungs from the presence of a 
foreign body in the air-passages cannot be effectually cured so long as the foreign body 
remains, and keeps up the morbid action. A similar remark applies to inflammation of 
the bladder from hypertrophy of the prostate gland. The gland, acting obstructingly to 
the flow of urine, is the cause of the cystitis, and just so long as the enlargement remains 
will the disease continue, although, as stated above, it may be materially modified by 
therapeutic measures. But it does not follow, on the other hand, that the inflammation 
shall at once subside because the exciting cause has been removed. The malady may 
already have made such decided progress as to render the restoration of the part either 
impracticable, or possible only after a long time and after much suffering. In our attempts 
to get rid of the exciting cause by mechanical means, it is hardly possible to exercise too 
much care and gentleness, or to institute them too early. All officious interference, rude 
probing, or rough manipulation, must be avoided, lest we add, as it were, fuel to the 
flame, aggravating and perpetuating the disease. Splinters, nails, needles, pieces of bone, 
are extracted with the finger and forceps; the calculus is cut out of the bladder; the 
speck of steel is picked from the cornea; the aching tooth is lifted from its socket ; all in 
as gentle and easy a manner as possible. 
It is not always, however, that the exciting cause of the malady can be detected, how- 
ever carefully or assiduously it may be searched for. Very frequently, indeed, the cause 
is latent, the morbid action having, to use a very common but unphilosopbical expression, 
sprung up spontaneously. Such an occurrence is, of course, impossible ; there must 
necessarily be a cause for every disease, although it may not be in our power to discover 
it; hence, to wait for its removal before we begin the treatment, might sadly endanger 
both part and patient. 
The second indication is to establish resolution or to disperse the morbid action, with 
the least possible detriment to the structures and functions of the diseased parts. To effect 
this, various remedies may be necessary, some being addressed to the general system, 
others directly to the affected parts ; circumstances which have given rise to the division 
of the treatment of inflammation into constitutional and local, or general and topical. 
I. Constitutional Treatment The constitutional treatment of inflammation 
consists of bloodletting, cathartics, emetics, depressants, mercurials, diaphoretics, diuretics, 
anodynes, tonics, and antiperiodics, with the addition of what is known as the antiphlo- 
gistic regimen. It is not to be supposed, however, that all these means, or even a 
majority of them, are necessary in every case of this disease ; so far from this being true, 
the morbid action often disappears spontaneously, or under the mildest and simplest 
remedies. Whenever constitutional treatment is demanded, it should be employed as 
early as possible, and with a determined hand, with the hope of arresting the inflammation 
before it has made any serious inroads upon the part and system. A few doses of medi- 
cine, judiciously administered at the outbreak of the disease, often do more good than 
twenty administered after it has attained its full development. 
In speaking, as I shall have frequent occasion to do in the following pages, of the 
“antiphlogistic” treatment, I shall employ this expression, sanctioned by long usage, 
wholly in a conventional sense, and not in that of the older pathologists. An antiphlo- 
gistic remedy may, in the modern acceptation of the term, and in the sense in which I 
shall here use it, be mild or harsh, gentle or heroic, soothing or perturbating, according to 
the exigencies of each particular case of inflammation, injury, or disease. To treat all 
patients similarly, or on one uniform plan, would simply be absurd. 
1. Bleeding General bleeding may justly be regarded as standing at the very head 
of the list of the constitutional remedies for inflammation, as it is at once the most speedy 
and the most efficient means of relief. The blood is usually drawn from one of the 
larger veins, and is permitted to flow until a decided impression has been made upon the 
system. When we consider the singular changes which this fluid undergoes in inflamma- 
tion, the fact that it is sent in an unusually large quantity to the affected parts, and the 
circumstance that it is mainly instrumental in supporting the powers of the heart, it will 
not be difficult to form a correct idea of the importance of this operation, or of the influ- 
ence which it exerts in combating morbid action. Its value was not overestimated by 
the older writers when they designated it as the “ great remedy” in the treatment of inflam- 
mation ; yet, strange to say, bloodletting, notwithstanding the high rank which it formerly 
occupied, as an antiphlogistic agent, has, of late, fallen very much into disrepute, not 
only in Europe, but on this side of the Atlantic, where it had at one time so many advo- 77 
CHAP. III. 
CONSTITUTIONAL TREATMENT. 
cates. A great change has come over the profession in tin’s respect, within the last 
thirty years, a change which has so completely subverted all our preconceived notions 
upon the subject, as to render it very questionable, in the opinion of many, whether blood- 
letting is really ever required as an antiphlogistic. To what is this change due ? Is it 
justly attributable, as has been asserted, to a modification of the type of disease, and to a 
gradual diminution of the strength of the American people ? If it be, I have not been 
able to discover it. On the contrary, I am perfectly satisfied that inflammation possesses 
the same characteristics now that it did formerly, and it is equally clear to my mind that 
patients bear depletory remedies quite as well now as they did then. The change has 
been the result of the natural progress of events; of a more thorough and enlightened 
knowledge of pathology, diagnosis, and therapeutics; and, in some degree, of the perni- 
cious influence which a few prominent and distinguished teachers have exerted upon the 
professional mind. Authority never fails to find followers, so much easier is it to be led 
than to think. The result is that bleeding is no longer fashionable; it is denounced by 
nearly every one. For myself, I cannot but regret this change, for it requires no argument 
to show its fallacy. If formerly we bled too much, too frequently, too copiously, and too 
indiscriminately, it is equally certain that the operation is not employed often enough at 
the present day. Many a deformed limb, blind eye, enlarged spleen, and crippled lung 
bear testimony, in every community, to the truth of this remark. 
General bleeding is employed with different views. In the first place, it diminishes 
plethora and reduces the temperature of the body; secondly, it changes the qualities of 
the blood, and thus renders that fluid more healthy; thirdly, it weakens the powers of the 
heart and nervous system, and, consequently, the momentum of the circulation ; and, 
lastly, it promotes the action of other remedies. 
To obtain these effects in the most speedy and thorough manner, the blood should be 
taken from a large orifice in a large vein, the fluid running in a bold, full stream to the 
amount of at least three ounces in the minute, the patient being either in a sitting or 
standing posture at the time. If the operation be performed during recumbency, a much 
larger quantity will be required to be drawn before the part and system become sensible 
of the loss. When the object of the bleeding is merely spoliative, or intended to rob 
the vessels of an unusual amount of their contents, it may be done in this way ; but even 
then the better plan will be to bleed in the semierect posture, reopening the vein a 
second and even a third time, if premature syncope interfere with the requisite abstrac- 
tion. The difference in the effect of these two methods of bleeding is forcibly exempli- 
fied in conjunctivitis. A patient who is bled in the erect posture soon begins to feel 
faint, and to experience relief from pain, the eye at the same time exhibiting a blanched 
appearance, instead of the scarlet hue which it had a moment before; whereas one who 
is bled in the recumbent posture will retain his strength for a much longer time, and 
when, at length, he is rendered unconscious, the inflamed surface will be found to be still 
comparatively red. The impression, moreover, will generally be much more permanent 
in the former than in the latter, and the return, consequently, of the capillary injection 
more slow and less perfect. 
The circumstances which call for this operation are, generally speaking, a hard, strong, 
full, and frequent pulse, a plethoric state of the system, and great intensity of morbid 
action. When such a conjunction exists, the surgeon cannot possibly go amiss in regard 
to the abstraction of blood, constitutionally considered. He may, perhaps, it is true, 
combat the disease without such recourse; by the use of antimony, purgatives, and other 
means, he may gradually bring down inordinate excitement, and thus afford the affected 
structures an opportunity of throwing off the burden with which they are oppressed; but 
if he wishes to make a prompt and decided impression, spoliative and depressive, upon 
the part and system, he can accomplish his object much more readily and effectually with 
the lancet than with any other remedy in the whole catalogue of antiphlogistics. If 
nauseants depress the heart’s action equally with the lancet, they certainly do not pro- 
duce the same effect in unloading the engorged capillaries at the seat of the inflammation, 
in restoring the circulation, and in reclaiming morbid structure. The operation of the 
one is gradual, and, at times, almost imperceptible; of the other, prompt and decisive, 
often cutting down the disease with a single blow ; or, at all events, leaving it in a con- 
dition to be afterwards easily dealt with by other and more simple means. 
When bleeding is required, the earlier it is performed the better. Ten ounces of 
blood taken at the beginning of an attack of inflammation will usually do more good than 
four times that quantity drawn after the disease is firmly rooted. Indeed, when a part 
is once overburdened with deposits, the salutary period for general bleeding may be 78 
INFLAMMATION. 
CHAP. III. 
considered as being passed ; for, although the operation may aid in reducing the force of 
the heart, in lessening temperature, and in promoting the action of other remedies, it 
certainly does not exercise the same happy influence upon the capillary vessels at the seat 
of the disease. 
The quantity of blood drawn at a single operation may vary according to circum- 
stances, the object being effect, and not ounces ; for what would be a large bleeding for 
one person might be a small one for another. From sixteen to twenty ounces is a good 
average loss. Some individuals faint almost as soon as the blood'begins to flow, while 
others can scarcely be made to faint, no matter how they are bled, or how much blood 
is drawn. The best plan, therefore, always is to continue the operation until it has 
made a decided impression both upon the nervous and vascular systems, avoiding actual 
syncope, but inviting an approach to it, and then guarding against the danger of exces- 
sive reaction. 
In former times enormous quantities of blood were occasionally removed for the cure of 
inflammation. The memoirs of the French Academy furnish instances of the abstraction 
of three hundred ounces within a week ; and equally astonishing examples have been 
recorded by British writers. The late Dr. John W. Francis, of New York, while labor- 
ing under a violent attack of croup and tonsillitis, was bled to the extent of nearly two 
gallons and a half in a few days. Such cases are remarkable as showing the wonderful 
power of endurance of the system, but are not to be held up as examples for the imitation 
of the modern practitioner. It must be understood, however, that inflammation often 
engenders a tolerance of bleeding. Thus, a nervous person who in the healthy state will 
faint from the loss of a few ounces of blood, will, when laboring under severe inflamma- 
tion, bear with impunity the loss of perhaps ten times that amount. A similar tolerance 
of remedies is frequently established by disease. In delirium tremens, opium may be 
given in doses that would destroy half a dozen healthy persons; in pneumonitis, the 
stomach acquires an extraordinary degree of tolerance for tartar emetic ; and in croup, 
iritis, synovitis, and in certain forms of syphilis, mercury may be given in large quantities 
without salivation, the system being seemingly insusceptible of its influence. 
The first effect of a loss of blood upon the system is a sense of muscular debility. Pre- 
sently, the individual begins to look pale, to see indistinctly, to be confused, to hear 
unnatural noises, and to feel light and giddy. If the flow be not immediately stopped, he 
will next become deadly sick at the stomach, convulsive tremors will pervade his limbs, 
the pallor of the countenance will increase to a deadly white, the respiration and pulse 
will nearly cease, and, if he is not supported, he will fall down in a state of unconscious- 
ness. He has fainted. Such an effect is sometimes produced by the loss of a few drachms 
of blood ; at other times not until many ounces have been drawn. 
Syncope must be relieved gradually, not too suddenly, lest there should be undue reac- 
tion, by recumbency, by loosing the patient’s clothes, by dashing cold water upon the 
face, or face and chest, and by a free access of air, obtained by throwing 0}>en the doors 
and windows of the apartment, aided, if necessary, by the fan. If consciousness do not 
soon return, the body is raised a little higher than the head, ammonia is rapidly passed 
to and fro under the nose, and sinapisms are applied to the extremities and the precordial 
region. Sometimes a draught of cold water will do more in reviving the patient than 
anything else. If, from idiosyncrasy or excessive loss of blood, the syncope assumes an 
alarming character, a stimulating enema is administered, and mustard is applied to 
the spine and chest, or, what is far more efficacious, the patient is suspended by his legs ; 
but nothing is given by the mouth, unless it is certain that there is still some power of 
deglutition. 
The immediate cause of syncope is an imperfect supply of blood in the brain, and the 
object in placing the patient, while in this condition, in the recumbent posture, is to 
enable the enfeebled heart to force the vital fluid more readily and freely into that organ. 
The reaction succeeding the stage of depression is characterized by a gradual return of 
the various functions of the body to their natural condition. The color reappears upon 
the cheeks, the heart and lungs act more energetically, the limbs regain their warmth, 
the surface often becomes slightly moist, and the mind recovers from its confusion. The 
only treatment necessary, during this stage, is proper vigilance, lest the reaction should 
become too vigorous ; depression being rather favored, when the morbid action is at all 
severe, than rapidly relieved. 
When the loss of blood has been disproportionally great to the powers of the system, the 
stage of depression may be succeeded by dissolution, or reaction may at length occur, the 
struggle for many hours, being, perhaps, one of life and death. This state may be induced CONSTITUTIONAL TREATMENT. 
79 
CHAP. III. 
by one copious bleeding, or by several small ones, establishing an undue strain upon the 
vital current. It is characterized by unusual pallor of the countenance, feeble pulse and 
respiration, coldness of the extremities, clammy perspiration, frequent moaning or sighing, 
great thirst and restlessness, vigilance, and a tendency to delirium. While the system is 
in this condition, local congestion, followed by inflammation, is not uncommon, the struc- 
tures most prone to suffer being the brain, the arachnoid membrane, and the lungs. Some- 
times the symptoms here described are mixed up with those of feeble reaction ; and then 
the countenance, perhaps, is flushed, the eye and ear are intolerant of light and noise, the 
respiration is quickened, the skin is hot and dry, and the pulse is thready, hard, and fre- 
quent. The proper treatment does not vary essentially in the two cases, our main reli- 
ance being upon opiates in full doses, milk punch, quinine, and the bromides, with eleva- 
vation of the head and cold applications, exclusion of light and noise, and blisters, if there 
be marked tendency to local determination. Further bleeding would only cause further 
sinking. 
In the abstraction of blood various circumstances are to be taken into consideration, 
of which the most important are the age, temperament, and habits of the patient, the 
character and progress of the disease, the structure and functions of the affected organ, and 
the peculiar constitution of the atmosphere. Young and robust individuals generally bear 
bleeding much better than children and aged persons, who often experience great exhaus- 
tion from the loss even of a few ounces. Old subjects, in particular, are prone to suffer in 
this way, the system being often a long time in reacting, while in not a few instances the 
operation is followed by sinking. Infants and children are also slow in recovering from 
the effects of bleeding ; but reaction having taken place, there is much less danger of ulti- 
mate exhaustion. Persons of a nervous temperament are less tolerant of the loss of blood 
than the sanguine and bilious. Corpulent persons are bad subjects for the lancet, and the 
habitually intemperate are liable to be thrown into delirium tremens by it. The inhabit- 
ants of densely crowded cities do not bear the loss of blood nearly so well as the residents 
of the country. During the prevalence of epidemics, as erysipelas, scarlatina, diphtheria, 
smallpox, measles, and puerperal fever, bleeding in any form is generally inadmissible. 
Finally, the abstraction of blood must be practised with the greatest circumspection in all 
cases of inflammation likely to be at all protracted, and in all persons suffering under 
grave accidents, as fractures, dislocations, and lacerated wounds, attended with danger of 
excessive drainage and hectic irritation. After severe operations and injuries, excessive 
loss of blood may seriously interfere with the restorative principle. 
The more violent the inflammation is, the more reason will there be, other things being 
equal, for early and active bleeding; so also if the organ affected be one highly essential 
to life. Blood is seldom taken when the inflammation is inconsequential as it respects its 
degree and seat, milder means generally sufficing for its subjugation. 
In regard to the repetition of the bleeding, the practitioner must be governed, first, by 
the intensity and persistence of the morbid action ; secondly, by the importance of the 
organ attacked ; and, lastly, by the state of the blood. The disease continuing with little 
or no mitigation, there will be the same reason for bleeding as in the first instance, and 
the last may now, perhaps, be borne much better, the previous abstraction having, it may 
be, engendered a certain degree of tolerance. Intensity of action will be an additional 
reason for the act. The importance of the organ attacked must not be overlooked. An 
inflamed lung requires more energetic measures than an inflamed skin, and an inflamed 
skin than an inflamed finger. As it respects the huffy coat of the blood, its value as a 
sign of the necessity of a repetition of the operation has already been pointed out, and 
need not, therefore, be again discussed. Associated with a persistence of diseased action, 
and a vigorous state of the circulation along with unusual firmness of the huffy coat, it is 
of some practical ini|>ortance, but much less than was at one time supposed. 
In considering the expediency of’repeating this operation in old, decrepit subjects, the 
action of the heart, as ascertained by the hand and ear applied to the chest, will generally 
be a safer guide than the pulse at the wrist, which, from the force with which the blood 
is impelled into the radial artery, often imparts to the finger a deceptive sense of hardness, 
fullness, and vigor wholly incompatible with the actual condition of the vital powers at 
that period of life. 
It is a matter of great moment, practically speaking, that the use of the lancet is not at 
all incompatible, in the treatment of inflammation, with the employment of beef-tea, beef- 
essence, milk punch, and other concentrated articles of food and drink. On the contrary, 
there is every reason why, in violent attacks of disease, they should go hand in hand, or 
contemporaneously and successively, the lancet relieving the affected structures deluged 80 
INFLAMMATION. 
CHAP. III. 
with blood, while the nutrients supply the necessary pabulum for the support of the sys- 
tem, and the promotion of repair during the struggle between life and death. The 
exhausting effects of a copious bleeding, performed early in the disease, in a strong, robust 
person, before any serious injury has been sustained by the affected structures, are gene- 
rally easily and rapidly recovered from, very much as when a strong, robust, healthy person 
is bled. The globulin which, under such circumstances, suffers more than any of the other 
constituents of the blood, is then speedily reproduced under the influence of a well-regu- 
lated diet and other restoratives. 
2. Cathartics Cathartics constitute a most important class of remedies in the treat- 
ment of inflammation, being even more valuable than bleeding, because of their almost 
universal applicability. Their exhibition, however, should always be premised by the 
abstraction of blood, provided the nature of the case is such as to admit of it. When this 
is contraindicated, they may be given at once, and there are few surgical affections in 
which they will not prove eminently beneficial. Cathartics are usually divided into pur- 
gatives and laxatives, which differ from each other merely in the one being more active 
than the other. The distinction, however, is not without practical importance. 
Cathartics, considered as antiphlogistic agents, are employed for different purposes. In 
the first place, they may be administered simply to evacuate the bowels; secondly, to 
deplete the mucous membrane, and thus diminish the quantity of blood in the system ; 
thirdly, to excite the action of the liver, salivary glands, and mucous follicles; fourthly, 
to produce a revulsive effect, or to set up a new irritation at a distance from the original 
one; and, finally, to stimulate the absorbents, thereby inducing them to remove inflam- 
matory deposits. 
The importance of using cathartics as mere evacuants cannot be too strongly insisted 
upon when it is considered that an overloaded state of the bowels is one of the most fertile 
sources of disease. Many of the so-called idiopathic inflammations evidently owe their 
origin to this cause, as is proved by the fact that a dose of active purgative medicine often 
promptly removes them, especially if administered at the commencement of the attack. 
An incipient ophthalmitis, tonsillitis, or fever, is frequently cut short in a few hours simply 
by clearing out the bowels, and thus ridding them of irritating fecal matter and vitiated 
secretions. Besides, so long as the bowels are constipated, it is impossible for other reme- 
dies to produce their specific effect, or for the various secretions to recover their natural tone. 
Secondly, this class of remedies proves useful in depleting the bowels, by abstracting 
the serous portions of the blood from the vessels of the mucous membrane, and thereby 
diminishing the quantity of fluid in the general system. This practice is often beneficially 
adopted in inflammation of the large intestine, as in diarrhoea and dysentery, and in the 
milder forms of inflammation in various parts of the body, where the loss of the red parti- 
cles of the blood is of questionable propriety. An ounce of Rochelle salt, or half a pint of 
citrate of magnesium, will often carry away from eight to twelve ounces of serum from the 
bowels in a few hours, with the greatest advantage as it respects the morbid action. 
Thirdly, cathartics may be given with a view of stimulating the liver, pancreas, and 
mucous follicles of the bowels. There are few inflammations, or diseases of any kind, in 
which disorder of the liver does not play a conspicuous part, either in exciting or main- 
taining morbid action. The quantity of fluid poured out by this organ, in health, in the 
twenty-four hours, probably amounts to nearly forty ounces, and it is, therefore, not diffi- 
cult to form a tolerably correct idea of the ill effects that must result from the interruption, 
modification, or complete suspension of its functions. The irritating material which it is 
destined to eliminate being retained in the blood, there must arise, as a necessary conse- 
quence, serious derangement of the nervous and vascular systems, as denoted by the exces- 
sive lassitude, headache, excited pulse, and other symptoms, so conspicuous in disordered 
states of the liver. But a diminished supply of bile is not the only difficulty ; on the con- 
trary, the fluid may be secreted in unnatural quantity, and yet, if vitiated in quality, the 
effects will hardly be less serious. The pancreas, too, may have its functions deranged, 
which the well-directed cathartic may readily restore to their normal condition. Of the 
vast influence exercised upon the health by the mucous follicles of the alimentary canal, 
it is hardly possible to form any adequate conception. Existing, as they do, everywhere 
in vast numbers upon the mucous surface, the suppression of their functions, even for a 
short time, cannot fail to be followed by local inflammation in different parts of the body, 
or the material aggravation of it, if already lighted up. Hence, remedies calculated to 
restore, modify, or improve the secretions of these several structures constitute important 
objects of treatment, not only as preventives, but as means of cure. CHAP.. III. 
CONSTITUTIONAL TREATMENT. 
81 
Fourthly, the administration of cathartics proves useful on the principle of revulsion, 
metastasis, or counter-irritation, by establishing a new action in a part more or less remote 
from that originally affected. During the operation of a brisk purgative, as well as for 
some time after, there is an unnatural afflux of blood to the alimentary canal, by which 
the suffering organ is temporarily relieved of vascular turgescence, on the principle that 
two morbid processes cannot go on, to any extent, at the same time. This operation may 
be intermittent or permanent, according to the character of the cathartic and the mode in 
which it is exhibited. In inflammation of the head, throat, eyes, and, in fact, of the 
supradiaphragmatic portions of the body generally, this principle is never, for a moment, 
lost sight of by the practitioner, inasmuch as it constitutes a most important element of 
treatment. 
Finally, cathartics, by clearing out the alimentary canal, and restoring the secretions, 
pave the way for the more successful action of other remedies, as diaphoretics, anodynes, 
diuretics, and sorbefacients. They exert, in this respect, very much the same influence, 
only in a slighter degree, as venesection and leeching, diminishing the volume of the cir- 
culating mass, and diverting the blood from the suffering organ. Relieving obstruction, 
restoring secretion, and establishing new action, they enable the absorbent vessels to 
recover from their torpor, and to render themselves useful in removing inflammatory 
deposits. 
Cathartics are particularly valuable in inflammation of the brain and its membranes, 
the eye and ear, throat, respiratory organs, liver, skin, and joints. In gastritis, enteritis, 
peritonitis, cystitis, wounds of the intestines, and strangulated hernia, they are either 
contraindicated, or exhibited with the greatest possible circumspection, and only in the 
mildest forms. In most, if not in all, of these affections, the best purgative is the lancet, 
aided by large anodynes, either alone or in union with calomel. Tranquillity, not pertur- 
bation, is what is sought, on the principle that whatever excites peristaltic action must 
prove prejudicial to the inflamed surface. 
Cathartic medicines must not be exhibited merely with a view' of correcting disordered 
alvine evacuation. Such a procedure could not fail to prove injurious. The action of 
these remedies is perturbating, and therefore subversive of healthy function; hence, it 
would be unreasonable to expect that the discharges should be entirely natural so long as 
they are exhibited. The more frequently they are administered the more likely will this 
be the case. 
When these medicines act tardily, their operation may be aided by injections; and 
cases occasionally occur where the latter remedies may advantageously, if not entirely, 
take the place of the former. 
The number of purgatives and laxatives is very great, and the surgeon may therefore 
give himself considerable latitude in the choice of his articles. A few, however, either 
alone, or judiciously combined, will answer his purpose in nearly every case. When a 
merely evacuant effect is desired, nothing is better than a dose of castor oil, rhubarb, or 
jalap; the saline cathartics produce watery passages ; calomel, blue mass, and gray pow- 
der act specifically upon the liver; and when an irritating, revulsive, or metastatic effect 
is wished, the proper articles are compound extract of colocynth, scammony, gamboge, 
aloes, and podophyllin. In external inflammations, as well as in inflammations of the 
supradiaphragmatic organs generally, one of the most useful cathartics, as I have found 
from long experience, is an infusion of senna, or of senna and Epsom salt. It operates 
not only promptly and powerfully upon the bowels, but also upon the liver, stimulating 
this organ to increased action, in a manner hardly inferior to calomel and blue mass. The 
only objection to its exhibition is that it is apt to gripe, but this tendency may usually be 
effectually counteracted by combining with it some carminative. Leptandra is also a 
good cholagogue, without so decided a purgative effect as pertains to calomel and senna, 
but this may be increased to any desirable extent by the addition of rhubarb, jalap, or 
podophyllin. Rochelle salt is at once an agreeable, cooling, and efficient laxative. Croton 
oil is rarely used, except to relieve obstinate constipation, and then only with the greatest 
caution. 
Injections, clysters, or enemas, may be prepared of various articles, as gruel and com- 
mon salt, water and mustard, castor oil, spirit of turpentine, infusion of senna, jalap, and 
other substances, according to the intended effect. An excellent enema, prompt and 
efficient in its action, may be made of one quart of soapsuds and two ounces of vinegar. 
Whatever material be used, the important rule is to mix with it a sufficient quantity of 
fluid, warm or cold, to distend the lower bowel. It may be administered with a hard 
rubber or a common pewter syringe, having a long nozzle, and capable of holding at 82 
INFLAMMATION. 
CHAP. III. 
least from sixteen to twenty ounces ; or, when there is obstinate constipation, with an 
ordinary stomach tube. The patient should lie upon his side or belly during the intro- 
duction of the instrument, and care taken that he be properly held, especially if he be 
delirious or otherwise unmanageable. A number of cases of perforation of the rectum 
caused by the reckless use of the syringe are upon record. 
3. Mercury The reputation of mercury, as an antiphlogistic, has long been established. 
Although the precise mode of its action is still imperfectly known, its beneficial effects are 
well understood. Its virtue in controlling inflammation is hardly inferior to that of the 
lancet and of tartar emetic, while, during the decline of the disease, as a powerful sorbe- 
facient, or promoter of the removal of morbid deposits, it is without a rival in the materia 
medica. It may, therefore, be given during the height of the malady with a view of arrest- 
ing its progress, and subsequently, after this object has been accomplished, for the purpose 
of getting rid of effused fluids, or reclaiming oppressed and disorganized structure. The 
efficacy of the remedy, in both these relations, is particularly conspicuous in the phlegina- 
sias of the fibrous and fibro-serous tissues, in gout and rheumatism, synovitis, carditis, 
arteritis, hepatitis, splenitis, pneumonitis, laryngitis, iritis, orchitis, osteitis, and in syphi- 
lis. It is less apparent, although not without its value, in inflammation of the brain, the 
skin, and mucous membranes, bronchitis, nephritis, cystitis, and metritis. 
It is rarely that the treatment of inflammation is commenced with the use of mercury. 
It is only in very urgent or neglected cases that this rule is departed from, the potency 
and activity of the remedy being always augmented by previous depletion. Whenever, 
therefore, there is evidence of plethora, bleeding and purgation should precede its use. 
There is, so to speak, a mercurial point in inflammatory affections, prior to which the em- 
ployment of this remedy either proves positively injurious, or greatly disappoints expecta- 
tion. This point is characterized by softness of the pulse, a relaxed condition of the skin, 
moisture of the tongue, and a general tendency to restoration of the secretions. Admin- 
istered during the height of the morbid action, when the whole system is enveloped, as it 
were, in flame, it can hardly fail to act as an irritant, and to increase the general excite- 
ment. For want of attention to this rule, a great deal of mischief is often done, and a 
remedy, otherwise of inestimable value, permitted to fall into disrepute. 
Of the manner in which mercury acts in relieving inflammation, there is, as already inti- 
mated, no very definite information. That it affords powerful aid in controlling the action 
of the heart and vessels, both large and capillary, is unquestionable ; but how this effect 
is produced, whether by any direct sedative impression it may exert, or by merely cor- 
recting the secretions, is still a mooted point. Nor is there any positive information in 
regard to the changes which mercury induces in the state of the blood. It is well known 
how greatly the properties of this fluid are modified by inflammation, what increase there 
is of fibrin and white globules, and how promptly, in many cases, these changes are cor- 
rected by the judicious use of mercury ; but in what manner this is effected is, in the 
present state of the science, altogether inexplicable. 
When the exhibition of mercury is pushed to the extent of active ptyalism, speedy 
changes are induced both in the solids and fluids. The patient soon becomes thin, hag- 
gard, and enfeebled, and the blood is rapidly changed in its properties, the fibrin being 
diminished, approximately, by one-third of its amount, the globulin by one-sixth, and the 
albumen by one-seventh, at the same time that it is surcharged with heterogeneous and 
irritating matter, the product of decomposition. 
During the decline of inflammation, and, indeed, in many cases long after the morbid 
action has been completely checked, the judicious use of mercury is of the greatest advan- 
tage in effecting riddance of the morbid products. Of the manner in which this is done, 
direct ocular demonstration is occasionally afforded in some of the external phlegmasias. 
Thus, in iritis, if the system be placed under the influence of mercury, the effects of the 
remedy are rendered obvious by the daily progress which the affected structures make in 
freeing themselves of the plastic matter that was effused during the height of the inflam- 
mation, and which frequently proves so destructive to them by the changes which it induces 
in the pupil. Similar effects are witnessed in inflammation of the cornea, attended with 
interstitial deposits. The opacities which result from these deposits often vanish in a 
short time under the influence of slight ptyalism, the effect being frequently apparent before 
the action of the medicine is fairly developed. In orchitis, after the disease lias measura- 
bly subsided, the swelling and induration are, in general, promptly dispersed under the use 
of mercurials, aided by rest, light diet, and purgatives. In all these, and similar cases, 
the beneficial effects of the agent are evidently due to its sorbefacient properties, or to the CHAP. III. 
CONSTITUTIONAL TREATMENT. 
83 
manner in which it stimulates the absorbent vessels, compelling them to remove the pro- 
ducts left by the previous action. 
Administered merely as a sorbefacient, the effects of this remedy are often insensible, 
its action being exerted in a very slow and gradual manner, yet hardly any the less effi- 
ciently. This kind of action is particularly desirable in chronic diseases, attended with 
a crippled condition of the tissues from semiorganized deposits, and an enfeebled state 
of the general system. Under such circumstances, active mercurialization is altogether 
inadmissible, from its irritating and prostrating effects; while a more gentle and persistent 
course is often followed by the greatest benefit, the gums being merely touched, or rendered 
slightly red, tumid, and tender, as an evidence of the silent operation of the remedy. 
The best form of exhibition of the remedy is calomel, blue mass, or mercury with chalk. 
When a prompt and powerful impression is desired, as when there is high inflammatory 
action, likely to prove speedily overwhelming in its effects, not only threatening structure 
but life, the medicine should be given in large and frequently repeated doses, so as to 
keep up a decided and well-sustained influence. For this purpose the best article is cal- 
omel, in does of three to five grains, administered every three, six, or eight hours, until 
we have attained the object of its exhibition. When the case is at all urgent, as, for ex- 
ample, in croup, pneumonitis, or carditis, no time is to be lost; whatever is done must be 
done quickly, with a bold, vigorous hand ; the remedy must be given in full, not in small, 
insufficient quantities, or in a faltering, hesitating manner. There is but a short step 
between the disease and the grave, the struggle is one of life and death, and the victory must 
be accomplished, if accomplished at all, at all hazard, present or future. When the disease 
is less violent, or the organ involved less important to life, the medicine is exhibited in 
smaller doses, and at longer intervals, and then, too, instead of calomel, the milder forms 
may be used, as blue mass, or gray powder. When a chronic or insensible impression is 
desired, the bichloride may be given instead of calomel or blue mass, or the latter may be em- 
ployed in smaller doses. Other forms of mercury, to be mentioned hereafter, as the iodide, 
and cyanide, are often beneficially prescribed in chronic diseases of the skin, in glandular 
enlargements, in chronic affections of the joints, and in tertiary syphilis. Mercury with 
chalk, or gray powder, is a great favorite with some practitioners in inflammatory diseases 
of children and aged persons; but I rarely use it, having frequently found it to nauseate 
and to be unworthy of reliance. 
To prevent the mercurial from running off by the bowels, it is usually necessary to com- 
bine it with a certain quantity of opium, as a fourth of a grain, half a grain, or even more, 
with each dose, according to the particular exigencies. In children, and in all cases affect- 
ing the brain, qpium should be given with great caution, especially during the violence 
of the morbid action. When the skin is hot and dry, the mercurial should either be entirely 
withheld until further depletion has been practised, or it should be united with some 
diaphoretic, as tartar emetic, ipecacuanha, or Dover’s powder. Griping, which is so liable 
to occur during the progress of the treatment, should be counteracted by carminatives and 
laxatives, as oil, salts, or magnesia. 
The administration of so potent a remedy as mercury should be most faithfully watched. 
No judicious practitioner uses it heedlessly or sakelessly. He knows that it is a remedy 
for good or for evil, and he, therefore, employs it wisely and properly; opportunely, not out 
of time. As soon as he discovers, by the fetid state of the breath, the red and tumid ap- 
pearance of the gums, the metallic taste, and the increased flow of saliva, that the object of 
its exhibition has been attained, he either omits it altogether, or gives it only in very small 
quantity, and at long intervals. He does not persist in its administration, as was once 
the custom, until the tongue is too big for the mouth, the teeth drop from their sockets, 
articulation, deglutition, and even breathing are almost impossible, and the countenance 
presents a distorted and hideous aspect; he simply touches the gums, maintaining the im- 
pression thus made, if necessary, on account of the continuance of the morbid action, or 
letting it die out, if the disea.se has been arrested. 
There are certain persons who,from idiosyncrasy, or the former use of mercury, cannot take 
this medicine, even in the smallest quantity, without being violently salivated. To avoid this 
occurrence, so exceedingly disagreeable both to the patient and the practitioner, due inquiry 
should always be made with a view of ascertaining this fact, previously to the administra- 
tion of the remedy. On the other hand, there are persons who cannot, under any circum- 
stances, be constitutionally impressed with mercury, however largely it may be used. They 
are mercury-proof. It apparently fails to enter the system in any form, combination, or 
mode of exhibition. In such cases, and also when the system is not as prompt in respond- 
ing to the effect of the medicine as is desirable, the article should be conjoined with some 84 
INFLAMMATION. 
CHAP. III. 
nauseant, as ipecacuanha or tartar emetic, so as to produce more thorough relaxation of 
the system. The operation of the medicine may also be aided with frictions of oleate of 
mercury upon the groin, the inside of the thighs, the arm, and axilla, thrice in the twenty- 
four hours, for fifteen minutes at a time, the inunction being performed near a fire, with 
the hand well protected with a pair of gloves, otherwise the assistant may salivate himself 
long before be succeeds in affecting tlie patient. One drachm of the oleate will suffice 
at each application. Employed in this way, the effect is sometimes more rapid than 
when the medicine is given internally, although the constitutional impression is more 
mild and evanescent. 
Not unfrequently, especially in persons of very delicate skin, the effect of the remedy 
may readily be obtained by wrapping around each arm a broad piece of flannel, well smeared 
with the oleate, and worn until the gums are slightly tender, a small quantity of the 
preparation being added once a day. 
Rapid ptyalism may be effected by the use of suppositories, composed each of a drachm 
of strong mercurial ointment, rendered stiff with a little tallow, and inserted into the 
rectum every eight hours, the bowels having been well emptied previously, and then locked 
up with a full dose of opium in order to secure retention. The gums under this remedy 
occasionally become quite tender within the first twenty-four hours, and in hardly any case 
does the time required exceed two days. 
There are various circumstances which altogether contraindicate the use of mercury in 
almost any form. Persons of a strumous habit of body, the old, the infirm, the ill-fed, 
the badly-clothed, and the anemic, are particularly prone to suffer from the use of the 
remedy, even when exhibited in very small quantity. It is in subjects of this description, 
more especially, that we witness those frightful ravages of the mouth, teeth, jaws, and 
cheeks, formerly so common in this country from the reckless and indiscriminate use of 
this class of medicines. 
Finally, if salivation should accidentally set in, the best remedies will be astringent 
gargles, cooling laxatives, emollient applications to the face and neck, sulphate of atropia, 
and the liberal use of anodynes, to allay pain and nervous irritation. The lotion which 
I have found most efficacious is a solution of Goulard’s extract, in the proportion of one 
drachm to eight ounces of water, used every hour or two, the only objection to it being 
that it discolors the teeth, an effect which, however, soon disappears of its own accord. 
Gargles of alum, tannic acid, copper, zinc, creasote, and other astringent substances also 
prove beneficial, especially if not employed too strong. When the inflammation runs 
very high, leeches to the throat and jaws are indicated ; and it may even be necessary to 
scarify the tongue, to prevent suffocation. Excessive fetor is allayed with chlorinated 
soda and other suitable means. 
Next to atropia, the best internal corrective of salivation, perhaps, is chlorate of potas- 
sium administered in doses of fifteen to thirty grains three or four times a day, in a large 
quantity of sweetened gum-water, or lemonade, to render it more soluble. This medicine 
seems to act with peculiar efficacy upon the digestive organs, and may often be advan- 
tageously resorted to as a prophylactic during the exhibition of mercury. It may also be 
beneficially employed as a gargle, from one to two drachms being dissolved in a pint of 
water, and the solution used every two or three hours. In very intractable cases of 
pytalism, an emetic of ipecacuanha, morning and evening, often answers when almost 
everything else has failed. 
4. Emetics—Emetics are not as often used now as they were formerly in the treatment 
of inflammation, their employment having been, in great measure, superseded by cathar- 
tics and other evacuants. Their exhibition, at the present day, is limited almost exclu- 
sively to cases in which there is marked gastric and biliary derangement, as denoted by 
the nausea and vomiting, the headache, lassitude, and pain in the back and limbs, which 
sometimes so greatly oppress the patient in the earlier stages of his illness. When these 
symptoms are present, and there is no contraindication, an emetic often acts like a charm, 
not only ridding the stomach of irritating matter, but allaying vascular excitement, pro- 
moting perspiration, and, in fact, unlocking all the secretions. The great Desault and 
his pupils were particularly fond of this mode of treatment in erysipelas, and I have often 
witnessed its beneficial effects in this and similar diseases. Emetics are, of course, not 
used in the phlegmasias of the subdiaphragmatic organs, as gastritis, enteritis, peritonitis, 
hepatitis, and cystitis, inasmuch us the concussion caused by their action would inevita- 
bly prove injurious. For the same reason they are withheld in wounds of the intestines, CHAP. Ill . 
CONSTITUTIONAL TREATMENT. 
85 
in hernia, in fractures, and in dislocations. In cephalic and cardiac diseases they are 
also carefully avoided. 
The best forms of administration are tartar emetic and ipecacuanha; common salt, 
alum, and ground mustard also occasionally answer a good purpose, their eti'ect being 
generally prompt and efficient. Apomorpliia is a direct emetic, and when given even in 
a dose not larger than the one-fifth of a grain often acts with great vigor. Whatever 
substance be employed, it should be followed by large draughts of tepid water, chamomile 
tea, or infusion of valerian, the latter being particularly beneficial in nervous and hys- 
terical subjects. As a general rule, tartar emetic should never be given, on account of 
its sedative and irritating effects, to very young children and to persons enfeebled by age 
and disease. 
5. Depressants Depressants, sedatives, or nauseants, are justly entitled to a high 
position in the scale of antiphlogistic agents. As their name implies, they are remedies 
which, by lowering the action of the heart, lessen the momentum of the circulation, and 
diminish the flow of blood to the affected tissues. This, however, is not the only good 
they are capable of doing; by the impression which they make upon the nervous and 
sanguiferous systems, they are instrumental in reestablishing and in improving the secre- 
tions, and in thus indirectly controlling the morbid action. There is, in fact, not a single 
organ which does not feel, to a greater or less extent, their influence, or which is not 
brought, more or less, under their dominion. The effect of this operation is often wit- 
nessed during the exhibition of tartar emetic in nauseating doses, in the relaxed skin, the 
softened pulse, the moistened tongue, and the pallid countenance, all bearing testimony 
to the universal impression of the remedy. Judiciously employed, depressants are among 
the most valuable and efficient antiphlogistic means we possess, and they have the advan- 
tage that they may often be used without any preliminary depletion. Their beneficial 
effects are particularly conspicuous in inflammation of the respiratory organs, the heart, 
the eye, the joints, and the fibrous structures, as well as in certain forms of inflammation 
of the skin and connective tissue. In many of these affections, if indeed, not in all, they 
have almost entirely superseded the use of the lancet and other evacuants, theft control- 
ling influence over the morbid action being generally very decided. Their efficacy is 
hardly less apparent in many of the diseases of the subdiaphragmatic viscera; but their 
exhibition here demands greater care and vigilance, as their emetic effects could not fail 
to prove prejudicial. Their employment is particularly adapted to the treatment of acute 
inflammation of young, robust subjects, whose systems require to be rapidly impressed 
in order to arrest the progress of their diseases. Infants, and children, the old, infirm, 
and decrepit, do not bear their use well, and often sink under their injudicious adminis- 
tration. 
The most trustworthy depressants are tartar emetic and ipecacuanha, aconite, veratrum 
viride, gelsemium and digitalis, the last of which, however, holds a very subordinate 
rank. Of the depressing etfects of bleeding I have already spoken, and pointed out the 
circumstances under which they may be most readily produced. 
Tartar emetic, as a depressant, may be administered in doses varying from the eighth 
to the fourth of a grain repeated every two, three, or four hours, according to their im- 
pression, which should be steadily maintained until the object of the administration of 
the remedy has been fully attained. It will generally be safest to begin with a small 
quantity, and to increase it gradually if it be found to be well borne by the stomach. 
Sometimes the first few doses, even if small, produce pretty active emesis; but this, so 
far from being injurious, commonly proves highly beneficial, by relaxing the system and 
opening the emunctories. By and by gastric tolerance will be established, and then the 
remedy will often be borne in extraordinary quantities, although it is never employed 
in the enormous doses recommended by Rasori, Thomasoni, and other disciples of the 
Italian school. In this country, indeed, we seldom give as much at a single dose as 
half a grain, the average quantity rarely exceeding one-half or one-third of that amount. 
The Italian practitioners, on the contrary, often gave five, ten, and even fifteen grains at 
a dose. 
When antimony is administered in a proper and persistent manner after the powers of 
the system have been lowered by general bleeding, its effect is to depress the heart’s ac- 
tion still further, to relax the skin, to prevent the tension of the vessels, and to favor the 
passage of the blood at the seat of the disease. A continuance of the remedy increases 
the watery portions of the blood, and diminishes the quantity of solid matter, especially 
the amount of fibrin. 86 
INFLAMMATION. 
CHAP. in. 
The beneficial effects of tartar emetic, as a depressant, may often be greatly enhanced 
by the addition to each dose of a small quantity of the salts of morphia, just enough to 
produce a calming and diaphoretic impression. Such a combination is particularly ser- 
viceable in nervous, irritable persons, and in subjects who have been debilitated by intemper- 
ance and other causes. When the article, given by itself, is productive of vomiting, it 
should never be used in any other way. In children, too, such a mode of exhibition is, 
as a rule, indispensable. Sometimes the medicine may be advantageously administered 
along with the neutral mixture. 
The dose of ipecacuanha, as a depressant, varies from a fourth of a grain to a grain 
and a half, according to the age of the patient, and the article may be used either alone 
or in combination with an anodyne, as, indeed, is usually found to be best. A nauseant 
effect may be kept up in this manner almost as long as may be desired, but the impres- 
sion is less pervasive and far inferior, in every respect, to that of tartar emetic. On 
this account, however, the medicine is peculiarly adapted to the treatment of inflam- 
matory affections of children, who, as already stated, seldom bear the operation of anti- 
mony well. 
Whichever of these two articles be employed, it will be well to withhold all drinks 
from fifteen minutes to half an hour after the exhibition, otherwise they will be very 
liable to cause vomiting. At the end of this time, however, diluents, cool or tepid, 
may be used with the greatest benefit, from their tendency to promote relaxation and 
secretion. 
Aconite is a powerful antiphlogistic. The form in which it is usually exhibited is the 
saturated alcoholic tincture of the root, prepared according to Fleming’s formida, the dose 
of which is from one to five drops, repeated every two, three, or four hours, until it has 
produced its peculiar depressing effect. The best, because the safest, plan is to begin 
with a small quantity, and to increase it gradually and cautiously until it brings down 
the pulse, which, in the course of a few hours, often descends twenty, thirty, forty, and 
even fifty beats in the minute, the surface, at the same time, becoming bathed with per- 
spiration. In large doses, it is powerfully sedative and anodyne, but it should never be 
given in this way, on account of its prostrating influence. It is particularly adapted to 
neuralgic, gouty, and rheumatic affections, and to the higher grades of traumatic fever; 
and my practice generally is to combine it with sulphate of morphia, as this insures a 
more prompt and beneficial action than when given by itself. 
Veratrum viride exerts a powerful influence upon the action of the heart and pulse, 
very similar to that of aconite, only, if possible, still more certainly. The dose of the 
saturated alcoholic tincture of the root, the form of the medicine most generally employed, 
is from five to eight drops, repeated every two, three, or four hours, until it has sensibly 
reduced the force, and frequency of the pulse, when it is either suspended or given in 
smaller quantity. As veratrum viride is an article of great potency, it is impossible to 
be too careful in its use. Carried too far, it causes nausea and vomiting, excessive pros- 
tration, faintness, vertigo, dimness of sight and other dangerous symptoms. It is appli- 
cable to the same class of cases as aconite, and may be given either by itself or in union 
with morphia, or morphia and tartar emetic. The best means for counteracting its de- 
pressing effects are opiates and alcoholic stimulants. 
Gelsemium, like aconite and veratrum viride, is a powerful arterial sedative, lowering 
the heart’s action, relieving congestion, and unlocking the secretions. It is particularly 
applicable to inflammatory disorders attended with neuralgic pains, valvular disease of the 
heart, and the rheumatic or gouty diathesis. It may be administered in the form of fluid 
extract, in doses of five to ten drops, or that of a saturated tincture, in similar quantities, 
repeated every three, five, or eight hours, according to the nature and urgency of the 
case, its effects being carefully watched. 
Of digitalis I have not been led to form a very favorable estimate as a depressant 
or sedative. I was formerly in the habit of employing it a great deal in various forms and 
combinations, as well as in various forms and stages of inflammatory disease, and yet it 
would be difficult for me to recall a solitary case in which I derived any appreciable bene- 
fit from it. I have, therefore, of late years, altogether abandoned its use. 
6. Diaphoretics Diaphoretics, in their mode of action, bear the same relation to the 
skin as cathartics bear to the bowels. They constitute, therefore, a highly important class 
of remedies in inflammation, from the faculty which they possess of restoring and modi- 
fying the cutaneous perspiration, the suppression of which is so frequent a source of disease. CONSTITUTIONAL TREATMENT. 
87 
CHAP. III. 
As the quantity of perspiration daily thrown off by the skin, in the normal state, varies 
from twenty to thirty ounces, the retention of such an amount of material in the system 
must necessarily exert a most prejudicial influence upon the suffering organ. The import- 
ance of a critical sweat, as it was called by the ancient physicians, in arresting disease, 
has long been familiar to the practitioner, and the employment of diaphoretics is only an 
attempt to imitate nature’s efforts, in removing a cause of morbid action, or restoring a 
secretion which has been suppressed by the changes which that action has induced in the 
general system. As in the case of purgatives, depletion should always precede the em- 
ployment of the remedy, so should it in the case of diaphoretics, a relaxed condition of 
the body always powerfully predisposing to a favorable action of the medicine. 
Although the class of diaphoretics is very large, there are only a few articles that are 
really at all reliable, or that are much employed by the experienced practitioner. These 
are tartar emetic, ipecacuanha, and Dover’s powder, aided, if necessary, by tepid drinks, 
and sponging of the surface with tepid water. The spirit of Mindererus, a solution of 
acetate of ammonium, in combination with a small quantity of spirit of nitrous ether, 
forms a mild diaphoretic, often advantageously used in low states of the system. The 
efficacy of antimony, which deserves the highest rank in this class of remedies, will be 
greatly increased if it be given in union with morphia, the two articles thus counteracting 
the bad effects which they are so liable to produce if administered singly, at the same 
time that they subdue the heart’s action, relax the skin, relieve pain, and induoe sleep. 
The best form of exhibition is a watery solution, each dose containing from the eighth to 
the tenth of a grain of antimony, with from one-fourth to one-eighth of a grain of morphia, 
repeated every two, three, or four hours. Ipecacuanha is adapted chiefly to children and 
old persons, and to the latter stages of the disease, and may be given alone, or, what is 
preferable, with some of the preparations of opium. The ordinary dose of Dover’s powder, 
for an adult, is ten grains, to which, especially if there be severe pain or great restlessness, 
I generally add the sixth of a grain of morphia, repeated every eight, ten, or twelve 
hours. The action of these remedies should always be aided by tepid drinks, and, if there be 
much dryness of the surface, by frequent sponging of the body with tepid water. During 
very hot weather, and in high states of inflammation, cool ablutions are often more efficient, 
as well as more grateful, than warm. 
When a speedy and powerful diaphoretic effect is desired, as, for instance, in a severe 
attack of gout, rheumatism, or acute nephritis, in a young robust person, nothing answers 
so well as jaborandi, given either in the form of the fluid extract, or that of the alkaloid 
known as pilocarpin, the dose of the former being one drachm, and of the latter half a 
grain. Copious perspiration, accompanied by a free flow of saliva and an excess of urea, 
generally promptly ensues. The oidy objection to the remedy is its liability to nauseate 
and to cause excessive prostration, on which account it should be administered with great 
caution. 
When nausea exists along with a very arid condition of the skin, excessive thirst, and 
inordinate restlessness, the very best diaphoretic is lemon juice, in tablespoonful doses, 
saturated with bicarbonate of potassium, the salt being added slowly and gradually until 
all effervescence ceases. The addition of a little syrup of orange-peel renders the mixture 
more palatable. If an arterial sedative be required, the object may be readily attained 
by combining with each dose a minute quantity of tartar emetic, as the tenth or twelfth 
of a grain, or a few drops of tincture of aconite. 
Bathing is not often employed in the treatment of acute inflammation, on account, 
chiefly, of the inconvenience and fatigue attending the operation. In the chronic form 
of the disease, however, it is frequently a remedy of great value, especially in affections 
of the skin, joints, and abdominal viscera. The water, which may be simple or medicated, 
is used at various degrees of temperature, the tepid bath ranging from 85° to 92°, the 
warm from 92° to 96°, and the hot from 96° to 112° Fahr. A very excellent and 
convenient mode of conveying moist and heated air to the patient’s body, as he lies in 
bed, consists in attaching one end of a tin tube, from three to four feet in length, to a 
teakettle filled with hot water, the other end being placed under the bedclothes. Copious 
perspiration usually promptly follows the application, which may be maintained for any 
desirable period. The foot-bath is occasionally used with advantage, but to derive full 
benefit from it the patient should be well covered up in bed, his feet hanging in the water 
placed in a suitable vessel upon a chair, the immersion being continued from thirty to sixty 
minutes, and aided by hot drinks. The hip-bath is employed chiefly in affections of the 
genito-urinary organs. 88 
INFLAMMATION. 
C 1IAP. III. 
7. Diuretics Diuretics are medicines intended to restore and modify the renal secre- 
tion, which is invariably more or less changed in all acute inflammatory affections. Their 
employment should, as a general principle, be preceded by depletory measures, and they 
should never be given in inflammation of the kidneys and bladder. Their administration 
is usually accompanied by mucilaginous drinks, but these are not at all necessary to their 
beneficial effects, ordinary fluids answering quite as well. They may be conveniently 
arranged under three distinct heads, the first including those articles which, when received 
into the system, depurate the blood, and increase the quantity of solid matter of the urine, 
as the nitrate, acetate, and bitartrate of potassium. The second class comprises colchicum, 
squills, and other vegetable diuretics, which carry off the watery portions of the blood; 
while the third consists principally of copaiba and cubebs, which not only augment the 
renal secretion, but exert a peculiar influence upon the mucous membrane of the bladder 
and urethra, as is evinced in cystitis and gonorrhoea. Of these various articles, the most 
important, in the treatment of acute inflammation, are nitrate of potassium and colchicum. 
The former may be given in doses of from fifteen to thirty grains every three, four, five, 
or six hours, in a large quantity of water. Instead of the salt, spirit of nitrous ether is 
often employed, especially when a gentle and slightly stimulating diuretic is needed. 
Colchicum is generally given in the form of the vinous tincture of the seed, in doses 
varying from ten to fifty drops, several times in the day and night. My practice usually 
is to employ one drachm along with one-third to one-half a grain of sulphate of morphia 
every evening at bedtime. In this way the medicine produces a much more decided 
impression upon the system, as well as upon the renal secretion, increasing its quantity, 
and freeing it of lithic acid, and probably, also, of other nitrogenized elements. More- 
over, it usually acts upon the bowels, bringing away thin watery evacuations, especially 
when employed by itself; and in large quantities it often vomits. One full dose, admin- 
istered in this manner at bedtime, is far superior to three or four small ones, which often 
only fret and irritate the kidneys and bowels, placing them in a condition ill adapted to 
correct morbid action. 
The alkalies, used as diuretics, combine with the acids in the system, and generally 
pass off as salts. Their value, as remedial agents, consists not only in neutralizing these 
products, always so injurious when in excess, but in retarding the formation of blood, in 
dissolving the fibrin, and in diminishing the quantity of albumen. 
8. Anodynes—There is no class of remedies which requires a greater amount of nice 
judgment and correct discrimination, in respect to their selection, mode of combination, 
and time of administration, than anodynes. The subject, therefore, is one that should be 
carefully studied by every one desirous of acquiring accurate views of their practical 
application in the treatment of inflammatory affections. My conviction is that these 
remedies are not used sufficiently freely, and that they are capable, when properly exhibit- 
ed, of affording immense benefit, not only in allaying pain and inducing sleep, but fre- 
quently also in controlling morbid action, and, consequently, in abridging its course and 
preventing its ravages. 
The same rules, as it respects the premising of depletory measures, are applicable to 
anodynes as to cathartics. Thus, first, whenever there is plethora, fecal distension, or 
disorder of the secretions, their correction should, if possible, precede the exhibition of 
the opiate. Sometimes a full dose of morphia is made to succeed a large bleeding, or an 
active purgative, the medicine then exercising a decidedly sedative and soothing influence. 
Administered before the system has been properly relaxed, the medicine rarely fails to 
increase the vascular action, to arrest the secretions, to produce headache, to prevent 
sleep, and to augment thirst and restlessness. 
Secondly, the medicine should always be exhibited in full doses, as it will thus make 
a much stronger, as well as a much more soothing, impression than when it is taken 
in small, and frequently repeated doses. With the precautions pointed out, an adult 
will bear, when the symptoms are at all urgent, from two to four grains of opium, or its 
equivalent of morphia, every twelve, eighteen, or twenty-four hours. The effects of the 
remedy must be steadily watched, especially if the patient is a child, or if there is any 
undue cerebral excitement. Should the pulse, under its influence, increase in fullness 
and vigor, the skin become more hot and dry, or the vigilance and restlessness augment, 
repetition is temporarily suspended, until, by further depletion, the system is placed in a 
more favorable condition for its reception. 
Thirdly, the best period for the exhibition of the medicine, when there is no immedi- CONSTITUTIONAL TREATMENT. 
89 
CHAP. III. 
ate necessity for its use, is towards bedtime, the patient being thus more likely to obtain 
quiet and refreshing sleep after the removal of light and other external stimulants. 
Fourthly, when there is excessive pain along with great dryness of surface, and the 
depletion has already been carried to a sufficient extent, the anodyne should be combined 
with a diaphoretic, as ipecacuanha, or, what is better, tartar emetic, or, instead of this, a 
full dose of Dover’s powder is given. 
Anodynes are particularly beneficial in inflammation attended with violent pain, which, 
by its persistence, might rapidly wear out the powers of life. Their value cannot be too 
highly appreciated in the phlegmasias of the skin and connective tissue, the joints, the 
subdiaphragmatic viscera, the eye, ear, pleura, heart, and respiratory organs. Within 
the last twenty years enormous doses of opium have been given in peritonitis with the 
most happy results, and the same mode of treatment might, there is reason to believe, be 
advantageously extended to inflammation of many of the other parts of the body. The 
importance of absolute rest to the affected organ is universally conceded, and is daily 
witnessed in the management of external inflammation. Instinct alone is often sufficient 
to secure it, but when this fails, the surgeon endeavors to procure it by means of various 
mechanical appliances. In the internal phlegmasias no such means are applicable, but 
here the object may readily be obtained by opiates, given in full and sustained doses to 
control the movements of the suffering structures. In gastritis nothing so promptly and 
effectually quiets the muscular fibres of the stomach as a suitable quantity of morphia; 
and the same treatment has long been successfully employed in dysentery, or inflammation 
of the lower bowel. In cystitis the most effectual remedy for allaying the excessive 
spasm and the incessant desire to urinate, is a full anodyne. In pleuritis and pneumoni- 
tis, how is it possible to afford rest to the lungs and respiratory muscles, except by the 
same means? The more quietly the parts are kept wdiile laboring under disease, the 
sooner, other things being equal, will the patient recover from its effects, and the less pain 
will he be compelled to endure from the constant and rude contact of the affected surfaces 
upon each other. Even in inflammation of the brain and its meninges, after proper 
depletion has been practised, anodynes are frequently indispensable, not only to allay 
pain and induce sleep, but to control the morbid action. And how do they do this? 
Simply, in the first place, by subduing the action of the heart, and thus preventing it 
from sending to the brain its accustomed quantity of blood; and, secondly, by making a 
direct impression upon the brain itself, thereby, in some degree, controlling its move- 
ments, so injurious both to its own substance and to its coverings, when thus affected. 
Anodynes, in most of these cases, as well as in many others, literally constitute nature’s 
splint. 
The best anodynes are opium and its different preparations, as the salts of morphia, 
codeia, laudanum, and black drop. These may be given either by the mouth or by the 
rectum, double the quantity being usually required to produce the same effect in the latter 
as in the former case. When a person cannot bear opium in any form, a substitute should 
be sought in lupuline, hyoscyamus, aconite, Indian hemp, and kindred articles; or, in what 
I have generally found to answer very well, a union of morphia, tartar emetic, and bicar- 
bonate of potassium, neutralized by lemon-juice. 
Many persons bear codeia better than any other form of opium, as it relieves pain and 
tranquillizes the system, without inducing any cerebral disturbance. The ordinary dose 
is from half a grain to a grain. Battley’s sedative, a watery infusion of opium, some- 
times agrees better with the system than any other preparation of opium, the average 
dose for an adult being about twenty drops. 
Hypodermic injections of morphia are much employed, and very justly so, in sleepless 
and painful conditions of the system, whether the result of inflammation or of other 
causes, the relief thus obtained being almost instantaneous, without any of the unpleasant 
effects of morphia when administered by the mouth or rectum. The quantity of the salt 
should not exceed, at first, on an average, one-fourth of a grain, from which it may be 
gradually increased to one-half, three-fourths, or even an entire grain, according to the 
exigencies of the case, the effects of the remedy being always carefully watched. 
Finally, there is a condition of the system in which a patient is “ too weak to sleep,” 
and in which anodynes, as usually exhibited, instead of being beneficial, are decidedly 
injurious. This species of exhaustion is often witnessed in inflammation consequent upon 
severe shock and loss of blood, and is generally most readily controlled by chloral and 
bromide of potassium, tonics, stimulants, and nutrients, taken as freely as the tolerance 
of the stomach will admit. As soon as the strength has thus been recruited, recourse may 
be had to opiates, and now with a prospect of marked advantage, especially if they be 90 
INFLAMMATION. 
CHAP. III. 
conjoined with some mild diaphoretic, as Dover’s powder, spirit of Mindererus, or mor- 
phia and acetate of ammonium. 
Bromide of potassium is a most valuable remedy in all low forms of inflammation, 
attended with loss of sleep, unusual nervous excitement, and irritability of the stomach. 
It should he given in full doses, as from twenty to thirty grains, every two hours, or even 
more frequently, until the object is attained, when it may be repeated at longer intervals. 
In the excitement consequent upon delirium tremens there is no article which, according 
to my experience, produces such prompt and decided relief as bromide of potassium in large 
and sustained doses. 
As a speedy, trustworthy soporific, there is no medicine at all comparable to hydrate of 
chloral. Its great advantage is that it rapidly induces sleep, without being followed by 
any of the disagreeable effects of opium and its different preparations. The only objec- 
tion to its use is its unpleasant taste, but this is generally easily counteracted by giving 
it in union with syrup of orange-peel. The full dose is thirty grains, repeated every few 
hours, according to the exigencies of the case. One-third of that quantity often pro- 
duces a most decidedly hypnotic effect in low states of the system. When the object is 
to subdue pain, as well as to promote sleep, the chloral may generally be advantageously 
combined with morphia, from ten to fifteen grains of the former to one-sixth of a grain of 
the latter constituting a suitable dose in ordinary cases. 
Sponging the surface of the body and limbs with tepid, cool, or cold water, as may be 
most agreeable to the feelings of the patient, often exercises a most salutary influence in 
cases of insomnia, especially when there is inordinate heat of the skin, tranquillizing the 
system, promoting perspiration, and inducing healthful and refreshing sleep, when every- 
thing else fails. 
9. Tonics There are few cases of acute inflammation, of any severity, in which 
tonics do not, sooner or later, prove indispensable elements of treatment. Very frequently, 
indeed, their exhibition is required at the very outset of the disease. This is especially 
true of persons whose constitution has been exhausted by severe shock, loss of blood, 
habitual intemperance, or the depressing effects of malaria, contagion, or blood-poisoning. 
In all these cases, and others of a similar character, depletory measures are either entirely 
inadmissible, of applicable only in a very limited degree. The general perturbation, in 
fact, is often feigned rather than real, and it not unfrequently vanishes in a few hours 
under the influence of a mild purgative or an anodyne diaphoretic. Active remedies 
would only expedite the downward tendency by still further exhausting the powers of 
life. In all the more violent inflammatory assaults, there is a period when tonics tire indis- 
pensably necessary. The system, enfeebled by the conjoint effects of disease and deple- 
tory measures, must be upheld at all hazard. Tonics, stimulants, and nutritious food and 
drink now come in play, and must be freely administered. The empty bloodvessels and 
the impoverished tissues must be replenished and improved by all suitable means. 
Among the more important tonics are the different preparations of bark, especially 
quinine, cinchonia, and Huxham’s tincture, the various forms of iron, as the sulphate 
and the tincture of the chloride, the bitter infusions, the mineral acids, as the nitric, 
phosphoric, and sulphuric, alcohol and wine. Much judgment is required in the use of 
these articles, both as it regards their doses and the time and mode of their administra- 
tion. They may be given either separately, or in various forms of combination, according 
to the exigencies of the case, or the object which they are intended to fulfil. When there 
is flatulence or nausea, some corrigent, as ginger or capsicum, may often be advanta- 
geously added to the prescription. Of all these articles, by far the most valuable, as a 
general rule, are quinine and the tincture of the chloride of iron, with brandy, whiskey, 
or wine. The dose of the former ranges, on an average, from two to three grains every 
three or four hours; of the latter, from fifteen to twenty drops. The efficacy of these 
two medicines is often greatly enhanced by giving them in union with each other. Of all 
the tonics and stimulants, however, the best and most trustworthy, unquestionably, is 
alcohol, which may frequently be taken in enormous quantities in all low states of the 
system, however induced. The choice of the form may generally, very properly, be left 
to the taste of the patient. A good plan is to vary the prescription occasionally, as one 
article becomes disagreeable another taking its place. The effect must of course ho care- 
fully watched. Wine is frequently preferred to brandy or whiskey. Port, sherry, and 
Madeira are the most eligible articles of this class. Champagne maybe used when there 
is nausea, flatulence, or indigestion. 
Carbonate of ammonium, formerly so much vaunted in all low, asthenic states of the CHAP. III. 
CONSTITUTIONAL TREATMENT. 
91 
system, is now seldom employed as a stimulant, experience having shown that it possesses 
hardly any such property, even when taken in very large quantity. It may, however, 
often be advantageously exhibited, after the violence of the disease has disappeared, for 
the purpose of promoting the absorption and elimination of inflammatory deposits, during 
the progress of their fatty degeneration. The dose should be large, as from ten to fifteen 
grains, freely diluted with water, and repeated every three, four, or five hours. 
10. Antiperiodics—Antiperiodical remedies very justly occupy a high rank in the 
treatment of inflammation ; for there are few cases of the idiopathic form of the disease 
in which malaria is not present, in some stage or other, or in which, if it does not act as a 
predisposing cause, it does not impress its peculiar livery upon the system. Malaria has 
long been known, especially in our Western and Southern States, to play a most important 
part in the causation and maintenance of certain forms of pneumonia, in the treatment of 
which the preparations of bark, in large doses, constitute an essential element, which 
does more in preserving the life of the patient than any other therapeutic agent. In the 
treatment of erysipelas, boils, carbuncles, and kindred affections, antiperiodics are gen- 
erally of immense benefit, and after all serious operations and accidents they are of ines- 
timable value in improving the patient’s strength, and promoting the action of other 
remedies. These remarks are particularly applicable to quinine, the most trustworthy of 
all antiperiodie medicines. Administered in regularly sustained doses, from two to five 
grains every three, four, or six hours, it opens all the emunctories, relieves pain and 
fever, imparts tone to the nervous system, increases the appetite, and lessens the frequency 
of the heart’s action. After severe shock and loss of blood, there is no article of the 
materia medica which renders so much service in preventing pyemia, erysipelas, and 
other low forms of disease, as quinine. Other antiperiodics are sometimes used, but they 
are chiefly adapted to the chronic form of disease, in which they are frequently given 
with marked success. 
11. Combination of Remedies.—There are few acute surgical diseases or severe acci- 
dents in which a combination of several of the remedies now described may not be 
advantageously employed. In nearly every case of the kind the patient w ill be found to 
be oppressed with fever, thirst, pain, and restlessness ; or, in other words, to labor under 
incited action of the heart and arteries, attended with diminished, if not suspended, secre- 
tion, and all the evils consequent upon such a state of the system. To meet the indications 
of treatment, under such circumstances, there is no prescription which, according to my 
experience, is capable of conferring greater benefit than what may be termed the saline 
and antimonial mixture, consisting of the following ingredients :— 
R. Antimonii et potassii tart. gr. ijss. 
Magnesii snlph. §ij. 
Morphi® sulph. gr. j|. 
Acid, sulph. aromat. 3ss. 
Tine, veratr. virid. 3jss. 
Syr. zingiber, 
Aqu® destil. §x. 
M. 
Of this combination the average dose is half an ounce, repeated every two, three, four, 
or six hours, according to the circumstances of the case. If emesis or distressing nau- 
sea ensue, the dose must be diminished. Properly administered, it rarely fails rapidly to 
subdue vascular excitement, to cause copious perspiration, to allay pain, thirst, and rest- 
lessness, to act gently on the bowels, and to induce sleep and general tranquillity. In- 
stead of the veratrum, aconite or gelsemium may be used in similar quantities. Colchi- 
cum may be added when there is a rheumatic or gouty state of the system, quinine when 
there is a tendency to periodicity, and copaiba when there is renal or cystic trouble. The 
quantity of morphia may be increased when there is much pain. 
12. Antiphlogistic Regimen.—Under this head are comprised the patient’s diet, the 
ventilation of his apartment, and various other attentions required during his confine- 
ment. The subject is one which rarely receives the consideration its importance 
demands. 
Few persons, fortunately, have any appetite during the height of an inflammatory 
attack, and hence the surgeon seldom experiences any difficulty in regard to the regula- 
tion of the diet. The stomach, oppressed w ith nausea, or a sense of uneasiness, either 92 
INFLAMMATION. 
loathes food, or rejects it almost the moment it is swallowed. It is well it should be so; 
for any ingesta, however mild, taken at this period, would only become a source of further 
trouble, by increasing the morbid action, perhaps already progressing at a furious rate. 
When the appetite remains, it must be repressed, steadily and courageously, until all 
danger of over-excitement from its indulgence has been safely passed. The mildest and 
least nutritious articles only are admissible in the earlier stages of the disease, such as 
panada, gruel, arrowroot, sago, and tapioca. Not even the lightest animal broth is per- 
missible, unless there is decided tendency to prostration, or an irritable state of the system, 
clearly dependent upon the want of proper nourishment, as occasionally happens in per- 
sons of a nervous, irritable temperament, or who are habitually huge feeders. The drinks 
should be cooling, consisting of iced water, gum-water, linseed tea, or barley-water, either 
simple, or slightly acidulated with lemon-juice, tamarinds, or any of the subacid fruits ; 
care being taken that, while they are used freely, they are employed in such quantity as 
not to produce gastric and intestinal oppression. 
As soon as the violence of the disease has abated, or the vital force begins to flag, a 
more nourishing diet must be employed; and the articles generally best calculated to meet 
this contingency are Liebig’s beef essence, beef-tea, the different kinds of animal broths, 
vegetable soups, eggs, broma, porridge, and corn starch, along with milk, wine, wine 
whey, and milk punch, given at suitable intervals, and in sufficient quantity to supply the 
waste of tissue, blood, and nervous fluid. The return to solid food should be very gradual, 
lest it rekindle morbid action. The starving cells must be fed slowly, not rapidly. When 
gastric irritability exists, along with excessive flatulence, nothing generally affords such 
prompt and effectual relief as small quantities of champagne administered in ice. Acidity, 
or heart-burn, is relieved with subnitrate of bismuth, or bicarbonate of sodium, either 
alone or combined with ginger. Water ices and ice cream are nearly always admissible 
in every stage of inflammation. 
Koumiss, or milk prepared with yeast and sugar, closely bottled, and kept in a cool 
place, is an excellent article of diet, highly nutritious, grateful to the stomach, and well 
suited to dyspeptics in low states of the system. It should be made fresh every day, and 
may be taken at pleasure, either alone or combined with wine, whiskey, maltine, or infu- 
sion of hops, according to the taste or wishes of the patient. 
Concentrated essence of beef, made of four pounds of meat yielding a pint of soup 
without water, is a popular article of diet with English practitioners, in all low states of 
the system, and may be taken more or less frequently in quantities of one to two ounces, 
according to the patient’s wishes and the tolerance of the stomach. Hot toddy is often 
very grateful, especially when the patient is cold or chilly; and its efficacy may occasionally 
be much increased by the addition of an egg and a little spice. 
When food and drink cannot be taken by the mouth, they should be administered by 
the rectum, previously washed out with an enema of warm water, or if there be no con- 
traindications, the bowels should be evacuated by a gentle laxative. In this manner, life 
may often be prolonged for weeks, and even months. The articles most worthy of reliance 
as sustenance are defibrinated blood, beef essence, Liebig’s extract of meat, animal broths, 
milk, cream, and raw egg, either alone or combined with brandy or whiskey, from two to 
five ounces being slowly injected, with a well-warmed syringe, every three, four, or six 
hours. If the bowel is irritable with a tendency to reject the fluid, a little morphia, lauda- 
num, or acetate of opium, may advantageously be added. Thirst is assuaged by gargling 
with cold water, by freely sponging the body, and by injecting, occasionally, if necessary, 
water into the rectum. When the vital powers are greatly exhausted, and all sources of 
nourishment are unavailing, life may occasionally be prolonged, if not actually saved, by 
the transfusion of blood, or even of milk. The effort, at all events, is worthy of trial 
under similar circumstances. The inhalation of oxygen or of the vapor of alcohol is 
sometimes serviceable. 
The promptings of nature should not be disregarded during the progress of recovery ; 
their tendencies are generally wholesome, and they should, therefore, be gratified to at 
least a reasonable extent, unless there are well-marked contraindications. Acid drink3 
and food are particularly apt to be craved, and a moderate use of them is highly beneficial, 
not only in whetting the appetite, but in promoting digestion, by supplying the exhausted 
stomach with substances tending to atone for the want of a due amount of gastric'juice, 
so essential to healthy chymification. Improper indulgence is, of course, avoided, and 
care is also taken that the articles are of such a character as to prevent the occurrence of 
acidity and flatulence. 
Rest of mind and body must be carefully observed. The importance of this is so self- 
CHAP. III. CHAP. III. 
LOCAL TREATMENT. 
93 
evident that it need not be enforced by any labored argument. Whatever has a tendency 
to excite the heart’s action must necessarily increase the momentum of the circulation, 
and, through it, the inflammation. In all severe attacks the patient must keep his bed, 
from which he must not rise even to answer nature’s calls; light and noise are carefully 
excluded from his apartment, especially in inflammation of the eye, brain, and ear; and 
no persons should be permitted to be about him, except his immediate attendants. Many 
a patient is killed by the kindness of his friends and relatives. Sexual intercourse must 
be scrupulously avoided during convalescence. Any excitement of this kind is not only 
exhausting, but has occasionally proved fatal. 
A frequent change of posture is indispensable to the comfort and well-being of a sick 
person, and should be effected with the greatest possible caution, especially when there is 
uncommon debility. Violent pain, loss of sleep, excessive constitutional irritation, and 
dreadful bedsores are sure to follow, in all low states of the system, when this precaution 
is neglected. When the patient is exhausted from shock or hemorrhage, as after a severe 
injury or a capital operation, care must be taken not to raise his head too suddenly, or to 
prop him up with pillows, as he will need all the blood that the enfeebled heart is able to 
propel to the brain. The bed and body clothes should be kept perfectly smooth, otherwise 
the wrinkles will be sure to become a source of annoyance, if not positive suffering. The 
mattress should be soft and elastic, and the sheet pinned fast to the edge of the bed. In 
case of carious disease or injury, a water-bed will be the most comfortable. Frequent 
change of posture is especially demanded in paralytic patients, on account of their liability 
to fatal attacks of bronchitis and pneumonia, from the habitual stasis of blood in the 
posterior parts of the lungs. Bedsores are also exceedingly prone to occur in this class 
of sufferers. When the patient is able to sit up in bed, he will experience great comfort 
from the use of a bed-rest. 
The temperature of the patient’s room should be regulated, not by his feelings, which 
are often deceptive, but by the thermometer. On an average, it should not exceed Go°, 
but in some cases it may range as high as 78°, and in others as low as G0°. The apart- 
ment should be frequently ventilated. When it is recollected how soon the air becomes 
vitiated during sickness, and how necessary a due supply of oxygen is to the proper 
maintenance of the health, importance of attention to this subject will not be doubted. 
Cleanliness of the body and of the bedclothes, is another subject of vital moment in the 
treatment of inflammation, and one upon which few practitioners bestow sufficient consid- 
eration. To medicate the inside of a patient, while the outside is neglected, is one of 
those singular inconsistencies which are daily witnessed in the sick-chamber. I would 
not insist upon too frequent ablutions and changes of this kind, but they should certainly, 
in ordinary cases, be effected at least once in the twenty-four hours; care being taken to 
avoid unnecessary exposure and fatigue during their performance. PAen the arrange- 
ment of the furniture is worthy of attention, on the principle that an agreeable impres- 
sion, of whatever kind, is more conducive to comfort and recovery than one of an opposite 
character. 
In all cases of a severe character the thermometer should be frequently used to ascer- 
tain the temperature of the body. An elevation of heat is a common occurrence in all 
inflammatory as well as typhoid states of the system, and, when sudden, great, or per- 
sistent, is of evil omen. The heart, lungs, and brain cannot hold out long under the 
effects of a temperature of 105° or 10G°, especially if still advancing, and preceded by 
chilly sensations, rigors, or horripilations. For meeting such a condition of the system 
the surface should be freely sponged with tepid water, or, if the patient be strong and 
robust, in the heat of summer with cool water, with the addition, in such case, of a little 
alcohol, vinegar, common salt, or chlorinated soda. 
II. Local Treatment—The local remedies of inflammation consist of rest and ele- 
vation of the affected part, the abstraction of blood, cold and warm applications, compres- 
sion, destructives, and counter-irritation. 
1. Rest and Position Without rest, steady and persistent, of the affected part, little 
progress can be made toward the cure of inflammation. The practitioner who neglects 
attention to this important circumstance, performs only half his duty. The patient, igno- 
rant of its advantages, often continues to exercise the affected organ long after it has 
become unfitted for the discharge of its functions, much to his present discomfort and 
ultimate detriment. A simple conjunctivitis, that might be cured in a few hours, is often 
for the want of a little rest of the eye, urged into a violent and protracted ophthalmia, 94 
INFLAMMATION. 
perliaps, at length, eventuating in a total loss of vision. An inflamed joint is frequently 
for the same reason, rendered permanently stiff and useless. Hence, rest is universally 
regarded as one of the most essential elements of the local treatment of inflammation. 
In general, it is easily procured, simply by the patient’s own efforts ; but when this is 
impracticable, it must be insured by appropriate splints, and other means, applied so as 
not to interfere with the other treatment. In inflammation of some of the internal 
organs, as the heart, stomach, peritoneum, bowels, and urinary bladder, the object is 
attained by the liberal use of anodynes, which, by temporarily paralyzing the muscular 
fibres of the affected structures, effectually prevent peristaltic motion, and thus place 
them in a better condition for speedy recovery. But there is a period when rest must 
not be enforced too rigidly, for, if continued too long, it may be productive of much harm. 
Its great utility is in the earlier stages of inflammation, when morbid action is gravescent, 
and for some time after it has reached its culminating point. As soon as recedence has 
fairly begun, motion, gently and cautiously conducted, is often of great utility. 
Not only should the part be kept at rest, but it should also be maintained in an elevated 
position, the success of the treatment being thereby greatly enhanced. The importance 
of attention to this point is well exemplified in many familiar diseases. The patient 
himself is often conscious of it, and, therefore, resorts to it, as it were, instinctively. 
Who that has ever had an attack of whitlow does not remember the great relief which he 
experienced from carrying his hand in an elevated position? The influence of position 
is nowhere more strikingly evinced than in odontalgia. During the day, the patient, 
while attending to business, is, perhaps, hardly conscious of suffering, but, at night, the 
moment his head touches the pillow the tooth begins to ache and throb, compelling him 
to get up and pace his room. In orchitis, the beneficial effects of our remedies are always 
greatly aided by elevation conjoined with rest of the affected organ. It is quite easy to 
understand why this should be so. In inflammation, the vessels carry an extraordinary 
quantity of blood, which is still further increased when the suffering structures are placed 
in a dependent position, because the flow, not being opposed by gravity, has then free 
scope, thus crowding the already distended capillaries to the very utmost, and propor- 
tionately aggravating the morbid action. 
Finally, the inflamed part should also be maintained in as easy a position as possible, 
mere rest and elevation not sufficing to insure comfort. All restraint must be taken off; 
all muscular contraction counteracted. Thus, in inflammation of the knee-joint, the limb 
should recline upon its outer surface, a pillow being placed in the ham, this being the 
best position for preventing tension. In synovitis of the elbow-joint, the forearm is bent 
at a right angle with the arm; and in hip-joint disease, the thigh is slightly flexed upon 
the pelvis, and turned towards the sound one. 
2. Local Bleeding Blood may be abstracted locally by scarification, incision, punc- 
ture, leeching, and cupping, each being more or less serviceable, in its own way, in par- 
ticular cases and under particular circumstances. 
The manner in which topical bleeding affords relief is sufficiently evident in some of 
these forms of depletion, but not very apparent in others. Thus, in scarifying, incising, 
or puncturing a part, the blood is taken directly from the engorged vessels, which are 
thus drained of their altered and vitiated contents. If the operation be carried to any 
considerable extent, as it often may be, especially in the former of these procedures, we 
may, at the same time, make a powerful impression upon the general system, nearly as 
rapidly and quite as effectually as when blood is drawn from a vein at the bend of the 
arm, although, in general, such an effect is neither aimed at nor desired. A similar 
influence is exerted by leeching or cupping, provided the operation is performed upon the 
inflamed surface, or in its immediate vicinity. Frequently, however, it is performed at 
a remote point, and then its mode of action is less intelligible. Thus, in inflammation of 
the brain, it is difficult to determine how leeches and cups, applied to the nape of the 
neck, temples, or back of the ear, afford relief to the affected organ. It is certainly not 
possible, in such a case, to make any direct impression upon the seat of the disease ; 
whatever influence is exerted must be exerted through the general system. This is a 
self-evident proposition. The vessels of the neck and scalp have no direct coriimunica- 
tion with the vessels of the brain ; hence, in leeching and cupping these parts, we can no 
more drain the cerebral capillaries than we can drain those of the hand, chest, or any 
other distant part. It may be assumed, then, that, when topical bleeding is practised by 
either of the latter methods, its beneficial effects are due, not to any direct drainage of 
the suffering structures, but indirectly to the depressing influence which it exerts upon 
CHAP. III. CHAP. III. 
LOCAL TREATMENT. 
95 
the heart and nervous system, and, through them, upon the morbid action, diminishing 
the momentum ot' the circulation, and, consequently, the flow of blood in the capillaries 
at the seat of inflammation. 
Topical bleeding, to be effective, should, as a rule, be preceded by some form or other 
of general depletion. When the force of the morbid action has thus been broken, the 
rest of the malady is often easily dealt with by the local abstraction of blood. It is only 
when the disease is very mild,.or unaccompanied by marked constitutional disorder, that 
this rule should be disregarded. Under such circumstances, the treatment may occa- 
sionally be very properly commenced with the application of leeches, cups, or scarifica- 
tion, followed or not, as the exigencies of the particular case may seem to require, by 
other measures. The manner of abstracting blood topically will be pointed out in the 
chapter on Minor Surgery. 
3. Cutting off the Supply of Blood.—Cutting off the current of the circulation from 
the inflamed structures by ligating the main artery of a limb, is a procedure which has 
occasionally been employed with advantage, although it is not likely, from its severity, 
ever to come into general use. The credit of suggesting it is due to Dr. Henry U. Onder- 
donk, of New York, who practised it successfully in 1813, in a case of wound of the 
knee-joint. A similar operation was performed in 1824, by Dr. David L. Rogers, upon 
a man thirty years of age, with equally favorable results. These surgeons were led to 
believe, from the results of these examples, that the operation, if performed sufficiently 
early, would often supersede the necessity of amputation, especially in compound frac- 
tures and dislocations, as well as in the more violent forms of spontaneous inflammation. 
The object is to starve the diseased structures by diminishing the activity of the circula- 
tion. In 1866, Professor Henry F. Campbell, of Georgia, recalled the attention of the 
profession to this mode of treatment, in an article in tie Southern Journal of the Medical 
Sciences, in which he adduced a number of cases, chiefly of gunshot injuries of the bones 
and joints, in which it appeared to have yielded the most gratifying results, the pain, 
swelling, and tension being almost immediately relieved, and the character of the dis- 
charges greatly improved. In five cases in the practice of Dr. D. F. Wright, during the 
War of the Rebellion, two of the upper and three of the lower extremity, the beneficial 
effects seem to have been equally striking. In 1867, Mr. C. F. Maunder, of London, 
successfully tied the femoral artery for the cure of acute inflammation of the leg and thigh, 
consequent upon a wound of the knee-joint. The chief objection to the proceeding is the 
grave nature of the operation, which, by cutting off’suddenly so great a quantity of blood, 
might be followed by gangrene of the distal portion of the limb, the very effect which the 
treatment is designed to prevent. It may readily be supposed that cases might arise 
which might justify such an undertaking, and yet it is difficult to point them out in a 
satisfactory manner. How far digital compression, recommended by Professor Yanzetti, 
of Padua, as a substitute for ligation in such cases, may answer the purpose, remains to 
be determined. The practice is very favorably spoken of, not only by its originator, but 
by Neudorfer, Demme, and other military authorities. 
4. Cold and Warm Applications.—These remedies, which are more particularly 
adapted to external inflammations, comprise a great number of articles in the form of 
water dressings and cataplasms, with the character of which every practitioner should be 
perfectly familiar. Both classes of remedies may be simple or medicated, according to 
the tolerance of the part and system, and the nature of the morbid action. 
(1.) Cold water has been employed in the treatment of inflammation from time imme- 
morial ; and it is not difficult to conceive how it operates in subduing morbid action. The 
effect of cold is evidently that of a sedative, lowering the temperature of the part, and 
causing contraction of the vessels, thereby relieving pain, swelling, and tension. It is 
particularly applicable to inflammation in its incipient and gravescent stages, while there 
are, as yet, little effusion, and no serious structural lesion. When the action has reached 
its acme, threatened suppuration, or, what is worse, tending to gangrene, it must be 
promptly discontinued. Besides, it is well known, cold, when intense or protracted, may 
of itself cause gangrene. Young and robust persons usually tolerate such applications 
much better than the aged or feeble; they are .also better borne in summer than in winter. 
As it is impossible always to predetermine their effects, their action should be carefully 
watched, in order that, if they become a source of annoyance, they may either be entirely 
dispensed with, or employed in a modified form. After suppuration has ceased cold 96 
INFLAMMATION. 
CHAP. III. 
may often again be advantageously employed to relieve vascular engorgement, and to 
promote the absorption of inflammatory deposits. 
The water may be rendered anodyne, astringent, or antiseptic, according to circum- 
stances, by the addition of opium, acetate of lead, or some of the chlorides. The best 
way to use it is to cover the affected part with a piece of old porous linen, and to direct 
upon it a constant flow of water in the form of irrigation, from a basin with a stopcock, 
slung to the top of the bedstead, the limb lying on an oil-cloth trough, from which the 
fluid is conducted into another vessel standing near the bed. Or the part may be covered 
with a wide, thin piece of sponge, spongiopiline, or common linen, over which is placed 
a bladder partially filled with pounded ice. Or the water may be conveyed from the 
basin by means of a candle wick to a layer of lint upon the inflamed surface, the wick 
acting on the principle of a syphon. Finally, when ice cannot be obtained, the water 
may be rendered cold by means of alcohol, in the proportion of one to six parts of the 
fluid ; by pyroligneous acid and alcohol ; or, by hydrochlorate of ammonium and nitrate of 
potassium. In whatever manner the fluid be employed, the surface to which it is applied 
should be constantly exposed to the air, to favor evaporation. 
Dry cold is not often used in the treatment of inflammation, although there are cases 
where it is preferable to cold combined with moisture, as when there is high morbid 
action in a part greatly debilitated, and rapidly tending to gangrene. The best mode of 
applying it is in the form of pounded ice, confined in a thin vulcanized India-rubber bag, 
carefully spread over the affected surface. If a bladder be used, the part should be pro- 
tected with a thin piece of flannel, otherwise the ice may produce too depressing an 
influence. The application of pounded ice is particularly valuable in the treatment of 
acute inflammation of the joints, the result of gunshot and other injuries. 
(2.) The use of warm water is also of great antiquity, having been employed by 
Hippocrates and other practitioners in gangrene and various cutaneous affections. It has, 
however, only been within the last thirty years that it has assumed anything like the rank 
to which its importance as an antiphlogistic remedy entitles it. I generally give a 
decided preference to warm water over cold, the impression made by it upon the part and 
system being usually more agreeable and soothing, while there is much less danger of 
metastasis, or of a sudden transfer of disease from the external to the internal parts of the 
body. It is particularly adapted to nervous, irritable individuals, who are easily chilled 
by cold applications, and to cases in which the inflammation has already made consider- 
able progress, where there is much tension and swelling, or where suppuration is impending, 
or has already taken place. A good rule, both in regard to warm and cold applications, 
is to consult the feelings of the patient, using one or the other according to the tolerance 
of the part and system, or simply so long as they seem to be beneficial. When a change 
becomes requisite, care must be taken that it is not made too suddenly, or too rapidly, 
lest it produce harm. Thus, hot applications should be succeeded first by warm, then by 
tepid, afterwards by cool, and finally, if necessary, by cold, the transition being gradual 
and wary, not great and sudden, so as to shock the part and system, and thus cause 
undue reaction. 
In the employment of cold water, the part is exposed ; in the use of warm, it is covered. 
The former does good by constringing the inflamed tissues, and opposing effusion ; the 
latter, by relaxing the tissues, and favoring effusion. 
(3.) Fomentations, which may be considered as a species of local bathing, are often 
very beneficial in inflammation of the joints and some of the internal viscera, from their 
tendency to relieve pain, tension, and spasm. In cystitis, gastritis, enteritis, and peri- 
tonitis, as well as in wounds and other injuries of the pelvic and abdominal organs, their 
employment can rarely be entirely dispensed with. The most simple fomentation consists 
of a large, thick flannel cloth, wrung out of hot water, or water near the boiling point, by 
means of two sticks turned in opposite directions, and applied lightly to the part as hot 
as it can be borne. If a soothing, narcotic, or sedative influence is required, chamomile 
flowers, poppies, hops, or, what is much better, laudanum, or laudanum and alcohol, will 
be found to form valuable additions. In whatever manner they are used, they should be 
frequently renewed, care also being taken that there are two cloths, so that, while one is 
taken off, the other may immediately be applied, all danger of shock or undue reaction 
from exposure to the air being thus avoided. 
(4.) Stuping is a variety of fomentation, particularly serviceable in affections of the eye, 
nose, ear, mouth, and throat. It is conducted with a piece of flannel, rolled into a ball, 
and contained in a small pitcher, which is held at a suitable distance from the affected surface, 
the cloth being wet as often as it becomes cool. The remedy may be medicated, if desired, CHAP. III. 
LOCAL TREATMENT. 
97 
with laudanum, camphor, belladonna, hemlock, or any other article, anodyne, astringent, 
or sorbefacient. 
When it is desirable to apply steam more directly, a funnel may be inverted over the 
hot fluid, and the tube held towards the affected surface at a suitable distance. Steam 
may be conveyed to any part of the patient’s body, under the bedclothes, by means of a 
large rubber tube, attached to a small tin boiler, placed upon a table, over a lighted 
spirit lamp. 
(o.) Poultices, or cataplasms, are an important class of remedies intended for external 
application in inflammation, wounds, ulcers, abscesses, and other affections. They are 
modifications of fomentations, and are made of various substances, either simple or med- 
cated, according to the object intended to be fulfilled. They should not be heavy or 
bulky, and their consistence should be such as to enable them to accommodate themselves 
accurately to the surface to which they are applied, without being so tenacious as to 
adhere firmly to the skin, or so thin as to spread over the neighboring parts. Renewal 
should be effected as often as they become dry and cold, otherwise they will lose their 
good qualities and be converted into irritants. In general, it is sufficient to change them 
thrice a day ; but in warm weather, or when there is much discharge, it may be necessary 
to reapply them every four, five, or six hours. Their temperature should be about the 
same as that of the body, that is, from 85° to 92° Fahr., and they should be placed 
directly upon the affected surface in a uniform layer from three to four lines in thick- 
ness, a piece of bobbinet, gauze, or thin netting being interposed to prevent adhesion and 
facilitate removal. For retaining the heat and moisture of a poultice the most suitable 
appliance is a piece of oiled silk, gutta-percha, or oiled paper. 
The action of a poultice is usually limited to the skin, or to the skin and to the parts 
to which it is immediately applied; it is only when it is composed of very strong materials 
that its influence is more deeply felt. In using medicated cataplasms, it is necessary, 
especially in ulceration or abrasion of the skin, to remember that the active ingredient 
may be absorbed, and thus produce the same effects as when introduced directly into the 
stomach. Poultices differ very much in their mode of action ; thus, some are altogether 
emollient, that is, they soften and relax the parts to which they are applied, at the same 
time that they promote exhalation and absorption ; some are anodyne ; some astringent ; 
some antiseptic; some stimulant. The articles most commonly employed are bread, 
arrowroot, starch, elm bark, and linseed meal. 
The bread poultice is made by pouring boiling water upon the crumbs of stale wheat 
bread, and stirring the mixture in a basin with the back of a spoon until it is of a thick, 
mush-like consistence. It is then spread upon a piece of folded cloth large enough to 
cover not only the affected surface, but also a portion of healthy skin. Milk may be used 
as a substitute for the water, but a poultice, thus prepared, must be more frequently 
changed, as it soon becomes sour and offensive, and possesses, moreover, no special 
advantages. 
The arrowroot poultice is prepared in the same manner as when that article is used for 
food, only that it is rendered more consistent; the powder being mixed at first with cold 
and then with a sufficient quantity of boiling water to convert it into a thick, gelatinous 
paste. Such a poultice is admirably adapted to irritable sores, and deserves to be more 
frequently employed than it is. 
The starch poultice is also a very soothing application, and is prepared in the same 
manner as the arrowroot poultice. 
The slippery-elm poultice is made of the powdered bark of the slippery-elm, mixed 
with hot water. It is very light and demulcent, adapts itself readily to any irregularities 
of surface, and is particularly beneficial in burns. I esteem it as the best poultice that 
can be made. 
The linseed poultice consists of ground linseed mixed with boiling water, and stirred 
until it is converted into a thick, cohesive mass, the vessel in which it is prepared 
being always well scalded previously. This poultice has the advantage of being very 
easily made, retaining its heat and moisture a long time, and of having a sufficiency of 
oil to prevent it from adhering to the surface to which it is applied. 
Excellent emollient poultices may be prepared from apples, okra, carrots, turnips, or, 
indeed, of any of the more tender culinary roots, by boiling them, after having removed 
the skin, and mashing them into a soft pulp. They possess, however, no peculiar vir- 
tues, and are therefore seldom used. 
A poultice may be variously medicated. Thus it may be rendered astringent by the 
admixture of acetate of lead, Goulard’s extract, alum, or a decoction of oak bark ; ano- 98 
INFLAMMATION. 
dyne, by laiidannm, opium, morphia, poppy-heads, hops, or hemlock; stimulating, hy 
chloride of sodium, vinegar, or port wine; absorbent, by iodine and other articles; disin- 
fectant and deodorant, by Labarraque’s solution, permanganate of potassium, thymol, or 
carbolic, and other acids. 
The fermenting poultice, employed in foul, fetid, and painful ulcers, in hospital gan- 
grene, and in mortification, used to be prepared by incorporating a pound of wheat flour 
with half that quantity of yeast,and exposing the mixture to a gentle heat until it swells. 
A better plan is, after the poultice is spread, to pour the yeast upon its surface. The port- 
wine poultice, which belongs to the same class as the fermenting, is made in a similar 
manner, except that it is not boiled. 
The charcoal poultice, also a good antiseptic agent, although now rarely used, is pre- 
pared from recently burned charcoal, reduced to a very fine powder, and mixed with bread, 
oatmeal, elm bark, or ground flaxseed. The objection to this povdtice is its liability to 
discolor the affected parts, thereby concealing their true condition. This may, however, 
be obviated, in great measure, by the interposition of very thin muslin. 
A cataplasm may be rendered refrigerant by means of a freezing mixture, or a bladder 
partly filled with pounded ice and spread over its surface. Such an application, however, 
for reasons already stated, requires great care. 
Poultices, even when quite mild, sometimes act as irritants, causing excoriation and 
tenderness, purulent vesicles, and even minute cutaneous abscesses. Such occurrences 
are most common in anemic systems and in persons of peculiar delicacy of skin. When 
any of these effects arise, the use of the cataplasm should be suspended, and the parts 
covered with warm or cold water, or dusted with oxide of zinc. 
5. Acetate of Lead, Goulard’s Extract, and Chloride of Ammonium -The efficacy 
of water-dressings, and of cataplasms, is generally very materially increased by the addi- 
tion of sugar of lead, Goulard’s extract, or chloride of ammonium, either alone or in 
union with opium. That water alone is a most valuable antiphlogistic agent has been 
abundantly proved both in civil and military practice, but long experience, founded upon 
careful clinical observation, has satisfied me that it is far inferior to water medicated with 
these remedies, all of which possess more or less astringent and sedative, as well as sorbe- 
facient, virtues, and are therefore well adapted to meet the indications that are presented 
in the treatment of inflammation, whether traumatic or idiopathic, slight or extensive, 
superficial or deep, recent or advanced. It would be difficult to say which of these agents 
deserves the preference. They may all be used warm or cold, and in various degrees of 
strength, according to the desired effect. Chloride of ammonium is especially adapted to 
those cases of inflammation in which there is extensive effusion of fibrin, or fibrin and 
blood, and its efficacy is generally materially increased by the addition of a small quan- 
tity of vinegar. A solution of the strength of one ounce to half a gallon of water is 
quite sufficient for ordinary purposes. When combined with an equal quantity of nitrate 
of potassium, it lowers the temperature of the part in a remarkable degree, without losing 
any of its sorbefacient properties. The only objection to it is its liability to cause slight 
pustulation, especially in persons of a very delicate skin ; wdien this arises, its use must 
of course be temporarily suspended. Acetate of lead may be used in similar proportions, 
and is the article I generally prefer as a purely antiphlogistic agent. Goulard’s extract is 
also a very valuable remedy on account of its astringent and sedative properties. The 
average quantity to a pint of water is about two drachms. When the morbid action is 
attended with severe pain, opium, laudanum, or morphia will be a most valuable addition, 
but these preparations must not be employed without great care wdien there is an abraded 
surface or an open sore, lest the medicine, entering the system too freely should produce a 
poisonous effect. When opium is used in substance, it should be well powdered, and dis- 
solved in boiling water to extract its active principles. 
The best medium for applying these solutions is a double layer of old, soft flannel, of 
suitable size and shape, well wrung out, and kept constantly wret by pressing the fluid 
upon it with a sponge; reimmersion, always troublesome, if not painful, being thus obvi- 
ated. Substitution is effected wdienever the cloth becomes soiled and offensive by the 
discharges. When the application is used warm, a covering of oiled paper or oiled 
silk is employed to confine the heat and moisture, otherwise the parts are exposed to the 
air, and the cold may even be increased by means of ice applied in a thin gum-elastic bag. 
6. Nitrate of Silver There is no article which enjoys a higher reputation, as a local 
antiphlogistic agent, than nitrate of silver; certainly none that is more frequently em- 
chap. in. LOCAL TREATMENT. 
99 
CHAP. III. 
ployed. Without understanding its precise mode of action, experience has taught us its 
great value in the treatment of a large number of inflammatory affections, some of which 
it w ould be exceedingly difficult to cure without it, while nearly all are more or less bene- 
fited by it. Ever since its introduction, in 1826, into practice by Mr. Higginbottom, of 
England, as a topical antiphlogistic, it has been employed in almost every form of external 
inflammation, both in a solid and a fluid state. Its beneficial effects in diseases of the 
eye, throat, and genito-urinary organs have long been well known. In cutaneous affec- 
tions, too, it enjoys a high and well-deserved reputation. In erysipelas, it is perhaps 
more frequently used than any other single remedy, iodine alone excepted. Its value in 
the treatment of this disease, so common in this and other countries, is fully established, 
both in a prophylactic and curative point of view. In inflammation of the tonsils and 
fauces, whether the result of ordinary causes, of a strumous diathesis, or a syphilitic taint 
of the system, no article is so generally employed, or enjoys so great a reputation as nitrate 
of silver. In gonorrhoea and gleet, in stricture and morbid sensibility of the urethra, in 
spermatorrhoea, in vaginitis, and metritis, nitrate of silver has become an indispensable 
means of cure. Indeed, it would be difficult to find an accessible disease, attended with 
preternatural vascularity and disordered structure, in which its application would not be 
productive of benefit. 
Nitrate of silver may be used as a vesicant, as when it is applied to the skin, or simply 
as an alterant, or modifier of diseased action ; for, as already stated, nothing definite is 
known of its mode of operation. When employed for blistering purposes, the solid form is 
usually preferred, the stick being passed lightly but efficiently over the surface, previously 
well cleansed and a little moistened with soft waiter, until there is evidence of slight coagu- 
lation of the albuminoid matter of the epidermis. A cloth, pressed out of warm water, 
is then applied, when vesication will soon follow. The same result may easily be pro- 
duced by a saturated solution of nitrate of silver; but, as the remedy is less manageable, 
it is not often employed with that view. Unless applied in a very concentrated form, and 
for an unusual length of time, nitrate of silver never destroys the tissues, or acts as an 
eseharotic. 
Solid nitrate of silver is often used with great advantage in ulceration of the mouth 
and throat, cornea, skin, vagina, and uterus, the application being usually made very 
lightly, and repeated at suitable intervals. Employed too frequently or too abundantly, 
it often does immense harm, not only occasioning severe pain, but sometimes seriously 
aggravating the morbid action. These effects may be produced equally by a strong solu- 
tion as by the solid stick. A strong collyrium of nitrate of silver has destroyed many an 
eye, or urged on an inflammation, perhaps on the very verge of resolution, to a most dis- 
tressing extent. Urethritis is often aggravated, and greatly protracted, by a strong injec- 
tion of this description. Much judgment, then, it will be perceived, is requisite in the 
local use of this remedy, not only as it respects its strength, but also the mode and time 
of its application. Carefully adapted to the exigencies of each particular case, it exerts 
a powerful antiphlogistic impression upon the diseased structures, diminishing vascular 
action, relieving pain, and destroying morbid sensibility, often so conspicuous in inflam- 
mation of the eye and throat, and which nothing else can so well control. 
7. Iodine.—Iodine first introduced to the notice of the profession as an antiphlogistic 
agent by Mr. Davis, of England, is, like nitrate of silver, a most useful topical remedy. 
It is generally employed in the form of the officinal tincture, either pure or diluted with 
alcohol. Its great value consists in its alterant and sorbefacient properties, changing 
the action of the capillary vessels, and promoting the removal of effused fluids. That 
this is the case is sufficiently apparent from what takes place in erysipelas of the skin, 
where the effects of the remedy may always be easily watched. Within a few hours 
alter the application the swelling is usually so much diminished as to cause a marked cor- 
rugation of the surface, attended with a diminution of pain and hardness; circumstances 
plainly denotive of lessened vascular activity, and progressive absorption. Similar effects 
are witnessed when the application is made to an (edematous uvula, scrotum, or eyelid, 
there being not only no further effusion afterwards, but a removal of what was previously 
deposited. From these facts, it may be inferred that iodine, locally employed, is not 
merely a sorbefacient, but also an alterant, or modifier of secernent action. 
As an antiphlogistic, iodine is of very great value. In the treatment of erysipelas, I 
have found no article at all comparable to it as an endermic remedy. It is also of great 
service in boils, carbuncle, whitlow, corns, bunions, and inflamed, irritable ulcers of the 
extremities. Its beneficial effects are hardly less conspicuous in active oedema of the 100 
INFLAMMATION. 
CHAP. III. 
uvula and tonsils, legs, scrotum, prepuce, and pudendum, a single application often 
sufficing to produce the most marked change in the condition of the part. As a colly- 
rium and an injection, the value of iodine has not been sufficiently tested to enable us to 
form any definite opinion, but the trials that have been made with it, in this respect, are 
encouraging, and deserving of repetition. 
For external use, the tincture of iodine should generally be diluted with an equal quan- 
tity of alcohol, the mixture being brushed on with a camel-hair pencil until the skin is of 
a deep yellowish, brownish, or mahogany color. The application may be repeated every 
eight, twelve, or twenty-four hours, according to the exigencies of the case. If the 
remedy be used stronger than this, it will be very apt to produce severe pain and to excite 
capillary action ; two circumstances concerning which it is impossible to exercise too 
much caution. When intended for the tonsils, uvula, and other delicate parts, the 
dilution should, for the reason just mentioned, be still greater. 
8. Compression.—Compression, as an antiphlogistic agent, is too much neglected, nor 
is it always judiciously used. That it is capable of doing an immense deal of good, when 
employed with proper care, and under suitable circumstances, my experience fully justifies 
me in asserting. Why it is so rarely used, it is difficult to determine, unless it is that 
practitioners do not possess the requisite skill in its application and mode of management. 
Although more particularly applicable to the latter stages of inflammation, compression 
is not without its value in the incipient and gravescent forms of the disease. Affording 
support to the affected structures, it is well adapted, when early employed, to give tone 
to the distended capillaries, enabling them to urge on their sluggish contents, and, conse- 
quently, to prevent their effusion into the surrounding tissues. Immense good is often 
done in this way, as every one knows who has ever treated erysipelas, wounds, fractures, 
and dislocations, by compression. If two cases of any one of these affections, of precisely 
the same character, could be treated, one with, and the other without the bandage, simply 
by the ordinary topical remedies, the difference would be found to be most striking. The 
compressed limb would be comparatively free both from pain and swelling, whereas the 
other would be highly sensitive and greatly enlarged, from inflammatory deposits. We 
see, in such circumstances, how, in the one limb, action is controlled, and how, in the 
other, it pursues its wayward course. But this is not the only benefit which systematic 
compression is capable of affording. When judiciously employed, it controls muscular 
action, and thus prevents spasm, both of which are frequently so annoying in fractures, 
dislocations, amputations, and various affections of the joints. Another effect, by no 
means the least striking and important, is the sorbefacient influence which it exerts, rous- 
ing the absorbent vessels, and compelling them to remove the fluids that were deposited 
prior to the employment of the remedy. It is for this reason that compression may 
be so advantageously used in the latter stages of most of the external inflammations, 
attended with effusion of serum and fibrin, there being no means known to the surgeon so 
well calculated to effect this important object, and to assist in restoring the functions of 
the suffering parts. The treatment of orchitis by compression affords a satisfactory illus- 
tration of the mode of action of the remedy under such circumstances. When this 
disease has been shorn of its violence by depletion, the swelling and induration, consequent 
upon the morbid action, often promptly disappear under the influence of systematic com- 
pression ; generally, indeed, in one-tit'th of the time they do under the use of mercury 
and ordinary sorbefacients. The absorption is frequently so rapid as to render it neces- 
sary to change the dressings twice in the twenty-four hours. Similar effects are sometimes 
observed in inflamed and enlarged joints. 
The means of compression are the common roller and adhesive plaster, applied in such 
a manner as to make gentle and equable pressure over the whole of the affected structures. 
When the part admits of it, the bandage deserves the preference, as it is more easily 
managed, and equally efficient ; but there are certain organs, as the testicle and mamma, 
where adhesive strips alone can be used. When an additional sorbefacient effect is 
desired, strips of ammoniac and mercurial plaster may be substituted for the ordinary 
plaster. 
9. Necrotics.—Necrotics are remedies designed, as their name denotes, to destroy the 
germs of certain diseases, as that of chancroid, hydrophobia, and malignant pustule, and to 
neutralize certain poisons, as that of the snake and of the dead subject. Their action is 
either curative or prophylactic ; most generally the latter. 
The most speedy and effectual remedy for an incipient chancroid is the destruction LOCAL THEATMENT. 
101 
CHAP. III. 
of the affected tissues with some escharotie substance, as nitric acid, bichloride of mercury, 
or acid nitrate of mercury. The structures inoculated by the poison of hydrophobia and 
malignant pustule should be treated in a similar manner, or be excised. When the 
knife is n©t admissible, on account of the timidity of the patient, the best remedy, accord- 
ing to my observation, is acid nitrate of mercury, in the form of the officinal solution, 
applied by means of a soft piece of wood, as a common match, or the point of a probe, 
inserted, if possible, into the part, and held there until the tainted tissues are completely 
devitalized. The same remedy, either pure or properly diluted, is admirably adapted to 
the treatment of phagedenic ulcers and spreading gangrene, by whatever cause induced. 
It should not, however, be used without due precaution, as it is an agent of great power, 
and may extend its destructive influence far beyond the diseased limits. The ordinary 
nitric acid is less manageable than the acid nitrate of mercury, from its liability to diffuse 
itself over the adjacent parts, and is therefore seldom used as an escharotie. Bichloride 
of mercury, dissolved in alcohol, in the proportion of two scruples to the ounce, is a most 
efficient caustic, producing a thin, soft, grayish eschar, which separates in a few days. It 
is used chiefly in venereal buboes, and acts most promptly when its application is preceded 
by a blister. A powerful escharotie effect may be produced by a combination of three 
[tarts of bichloride of mercury with one of opium, made into a thick paste with concen- 
trated sulphuric acid. The only objection to these preparations is the excessive pain they 
occasion. 
Similar means may be employed for neutralizing the poison of the rattlesnake and 
other venomous reptiles, and for destroying the virus of wounds received in the dissection 
of dead bodies. In the former case, free excision is practised, followed by the use of the hot 
iron, or some escharotie substance ; in the latter, the part is held for a considerable time 
under a stream of cold water, then well sucked, and next thoroughly cauterized with acid 
nitrate of mercury. 
10. Counter-Irritants Counter-irritants are remedies which, when applied to the sur- 
face of the body, excite a new disease, or a new action, in a part more or less remote from 
the one originally affected. They are never, or at least very seldom, used until after 
pretty thorough depletion has been practised, by which the inflammation has been relieved 
of its violence, as their effects are then always more prompt and decided. The new dis- 
ease is generally established close to the original one, but occasionally at some distance 
from it. Thus, in inflammation of the hip-joint, the counter-irritant is applied as near as 
possible over the acetabulum and head of the thigh-bone, the immediate seat of the mor- 
bid action, and so with the other articulations. In disease of the neck of the bladder and 
prostate gland, it is applied to the perineum ; of the pleura and lungs, over the nearest 
point of the chest. In inflammation of the eye, on the contrary, the irritation is estab- 
lished on the nape of the neck, behind the ear, or on the arm, not in the immediate 
vicinity of the suffering organ. Great judgment is often required to determine the pre- 
cise point where, as well as the precise time when, the new action ought to be instituted. 
If it be too near the original affection, it may run, as it were, into it, and thus aggravate 
instead of mitigating the mischief; if, on the other hand, it be too remote, it may entirely 
fail of the object for which it was employed. Counter-irritation, as already stated, is 
never resorted to until the system has been relieved of plethora, and the morbid action 
weakened by other remedies. Used in the height of the morbid action, it can scarcely 
fail to be productive of local and constitutional disturbance, calculated to exercise a pre- 
judicial influence upon the progress and termination of the case. 
Although the class of counter-irritants comprises a large number of articles of a very 
diversified character, they may with great propriety be arranged under two heads, accord- 
ing to their mode of action, as vesicants, and suppurants. 
(I.) Vesicants are remedies which, when applied to the skin, elevate the epidermis in 
the form of blisters filled with serum. They are of great value in the treatment of inflam- 
mation, both acute and chronic, and are applicable to a great variety of circumstances, 
with which the practitioner should be fully acquainted. The articles commonly used for 
this purpose are cantharides, either in powder or in the form of collodion-liquid, ammonia, 
and hot fluids. In acute disease these means, especially the first, are always preceded by 
active depletory measures, otherwise they are liable to do mischief by increasing the local 
and general excitement. In chronic inflammation, however, they may often be advanta- 
geously used at the very commencement of the treatment. The vesicating agent is gene- 
rally placed as near the affected part as possible ; sometimes, indeed, directly over it. 102 
INFLAMMATION. 
CHAP. III. 
Blisters, properly so called, are prepared with the common fly ointment of the shops, and 
vary in shape and size according to the object they are intended to fulfil, or the region to 
which they are applied. The part, if covered with hair, is previously shaved, and the 
plaster is confined with a compress and roller, or, what is better, with a few' adhesive 
strips. To prevent strangury, an object of great importance, particularly in nervous per- 
sons and young children, the surface of the blister should be sprinkled with afew grains of 
morphia and camphor. The same end may be attained, although less certainly, by the 
interposition of a piece of tissue paper, steeped in spirit of camphor. In addition to these 
precautions, free use should be made of cooling drinks, either alone or in union with spirit 
of nitrous ether. There is no particular advantage in mucilaginous fluids, as flaxseed tea 
and gum arabic water, so generally prescribed during the application of a blister, as they 
do not exert any specific influence upon the renal secretion or the mucous membrane of 
the urinary passages. If strangury occur, prompt relief may usually be afforded by a 
laudanum enema, and hot fomentations to the genitals and hypogastric region, aided, if 
necessary, by a full dose of morphia administered by the mouth, rectum, or skin. 
A blister should, on an average, remain upon the part from six to eight hours, unless the 
skin is very delicate and sensitive, when a shorter period may suffice. In children, in 
whom the desired effect is usually produced in from two to three hours, it is necessary to be 
very careful, otherwise violent inflammation and even gangrene may ensue. I have seen 
horrible suffering, and in two instances, death, follow the application of a small blister in 
children. In the very aged and infirm, similar accidents occasionally happen. Parts 
affected with paralysis often suffer severely from the protracted use of blisters. The plas- 
ter need not, in general, be kept on until there is thorough vesication ; it is sufficient if 
the skin is quite red, or if there be here and there a little vesicle, the process being speedily 
completed by the warm water dressing, or a light emollient poultice. It is of great con- 
sequence to remove every bit of the salve, and also not to break the epidermis, but simply 
to puncture it with a large needle or small bistoury, to admit of the necessary drainage, it 
being a matter of great moment to exclude the air from the raw surface beneath. The 
dressings already mentioned may be continued until new skin has formed. Should the 
surface, however, become red, inflamed, and irritable, bleeding upon the slightest touch, 
and rendering the patient feverish and restless, recourse must be had to the starch, arrow- 
root, or slippery-elm poultice, or, what is more soothing than anything else, a thick layer 
of common white lead paint, covered with cotton, the whole being supported with a roller. 
A powder composed of equal parts of cinchona and prepared calamine dusted upon the 
surface is also an excellent remedy. Pencilling the part with a weak solution of nitrate 
of silver has .sometimes a good effect, as has also the ointment of the oxide of zinc, espe- 
cially when the surface is studded with large irritable granulations. 
Cantharidal collodion is a more elegant preparation than the common fly-plaster, and 
may therefore advantageously take its place, the more especially as its effects are equally 
strong and lasting. It is best applied by means of a camel-hair brush, the surface to be 
vesicated being thoroughly coated with it, and the evaporation of the ether restrained by 
moist patent lint covered with oiled silk. Unless this precaution be used, the article will 
require nearly as long a time to produce its specific influence as an ordinary blister. The 
principal advantages of cantharidal collodion are, that it can be more evenly applied to 
the skin, does not shift its position, is more rapid in its action, and is less liable to pro- 
duce strangury, especially if it contain, as it generally should, an addition of morphia. 
Cantharidine blistering tissue is another elegant preparation for vesicating purposes : 
easily applied and removed, producing its effects promptly without strangury, and leaving 
no sores. 
Ammonia is used only when a strong and immediate effect is desired, as, for example, 
in croup, where the inflammation, if not promptly checked, may speedily destroy life. 
Equal parts of lard and powdered hartshorn produce small vesicles in five or six minutes ; 
and similar effects follow the application of Granville’s lotion or liquid ammonia. Boiling 
water, the concentrated mineral acids, and the heated iron, cause rapid vesication. All 
such applications, however, are very painful, and they can never take the place of cantha- 
rides. Perhaps the least exceptionable article of this class of vesicants is nitrate of 
silver, which often blisters the skin in a few minutes, especially when it is very delicate, 
and has been previously well cleansed. The remedy is particularly adapted to infants and 
children, as it is never followed by sloughing and other ill effects. 
(2.) Suppurants are the most powerful of all counter-irritants. They are much more 
permanent in their character than vesicants, and are therefore more serviceable in eradi- CHAP. III. 
CHRONIC INFLAMMATION. 
103 
eating chronic disease. As their name implies, the discharge which they produce is of a 
purulent nature, and hence they are sometimes described under the name of pyogenic 
counter-irritants. The class comprises permanent blisters, setons, and issues, which will 
receive particular attention in the chapter on Minor Surgery. 
SECT. Ill CHRONIC INFLAMMATION. 
Chronic inflammation is distinguished from acute by a variety of circumstances, which 
it is of the greatest importance to be able thoroughly to appreciate and understand. Its 
study, in fact, is of paramount consequence, and it is not placing too high an estimate 
upon its value when it is asserted that there is much greater merit in being able to diagnos- 
ticate a chronic disease than to determine the nature and seat of an acute one. When a 
lesion declares itself, openly and boldly, by a well-marked train of symptoms, the practi- 
tioner must indeed be ignorant, if not positively stupid, if he cannot discriminate with 
tolerable accuracy between it and other affections which may simulate, or bear some re- 
semblance to it; but it is very different when the malady is of an obscure, chronic char- 
acter, lurking in the system, no one, perhaps, knowing where, even after the closest and 
most patient scrutiny. It is under such circumstances that the intelligent pathologist and 
observant practitioner often appears to the greatest advantage, by turning his knowledge 
to the best account for his patient. 
It does not comport with the design or scope of this work to enter into any of the more 
minute details of this subject; a large volume might be written upon it, and even then 
it would not be exhausted. A mere sketch of its more prominent features is all that I 
shall attempt. 
Chronic inflammation is of great frequency, and is liable to appear in all organs and 
tissues of the body; it is generally a consequence or sequel of the acute form, but cases 
occasionally arise in which it would seem to be a primary affection. Strictly speaking, 
such an occurrence is of course impossible ; all that is meant when the word is used in 
this sense, is that the disease which it serves to designate is of so stealthy and insidious 
a character as to escape, at least for a considerable time, the attention both of the patient 
and his physician ; the person is unwell, perhaps occasionally a little feverish, or the 
subject of headache, want of appetite, or a sallow complexion and constipated bowels ; or, 
it may be, he has a cough, and a pain in his side; or a joint becomes sore and stiff; and 
still he is able to go about and attend to business, although he is soon fatigued, and ren- 
dered uncomfortable by it. Thus a week, a fortnight, or a month may be passed, when, 
a careful examination being instituted, the discovery is made that there is a grave dis- 
ease in some important organ, and that it has perhaps already gone so far as to render 
recovery absolutely impossible, however skilfully the case may now be treated. The dis- 
ease has been latent, or nearly so ; it has failed to make itself known by any distinctive 
train of phenomena, and both patient and practitioner have been lulled into fatal security. 
The morbid action has been lying all this time in ambush, and is now, in the true sense 
of the term, chronic. Such cases are by no means infrequent, and they should serve to 
admonish us never to neglect any symptoms, however trivial, in our clinical investigations. 
A pain, a soreness, a cough, a halt in the gait, may, if properly interpreted, afford useful 
information in regard to the diagnosis of chronic disease, and should teach us the value 
and importance of patience and caution in the examination of the sick. The slightest 
neglect may be fatal; a little spark may kindle a devouring flame. 
Chronic inflammation, however provoked, is generally tardy and sluggish in its move- 
ments, creating little constitutional disturbance, but not, on this account, the less surely 
and effectually undermining the part and system. In the acute variety, the action is 
rapid, bold, daring; suffering is severe; and constitutional response loud and unmis- 
takable. In chronic inflammation, on the other hand, the symptoms are, as already 
stated, often obscure, if not absolutely masked, and the embers of disease never break out 
into open flame. The disease may continue for weeks and months; now stationary, smoth- 
ered, or apparently receding; now advancing, and seemingly almost ready to assume the 
acute type. 
The origin of chronic inflammation is often, if not generally, intimately connected 
with disorder of the digestive apparatus ; seemingly, at all events, the first link in the 
chain of morbid action is frequently referable to the state of the stomach and bowels, 
especially to the effects of dyspepsia or constipation. Idiopathic inflammation of the eye 
and other organs often owes its origin to gastro-intestinal irritation. At other times the 104 
INFLAMMATION . 
cuAP. III. 
disease is awakened by derangement of the menses, defective action of the kidneys, sup- 
pression of the cutaneous perspiration, or disorder of the biliary secretion. Anxiety of 
mind, grief, anger, fatigue, intemperance in eating and drinking, and inordinate sexual 
indulgence, are all so many predisposing and exciting causes of chronic inflammation. 
The effects of this form of disease are various ; if not closely watched and soon checked, 
it may prove fatal by the induction of serious structural changes, which neither nature 
nor art may be able to repair. The most common and important of these changes are 
suppuration, ulceration, softening, adhesion, contraction, induration, and enlargement, 
according to the intensity of the morbid action, the texture and situation of the affected 
organ, and the condition of the general system. The formation of pus and molecular dis- 
integration, whether by softening or ulceration, are exceedingly common attendants upon 
this variety of inflammation, and often proceed to a most destructive extent. Adhesion 
is most liable to occur in the serous tissues; contraction, in the bloodvessels and excretory 
tubes. Induration and enlargement usually coexist, although occasionally they occur 
independently of each other. Examples of these two changes are constantly met with in 
surgical practice, especially in the lymphatic glands of the neck, axilla, and groin, in 
chronic disease in and around the joints, in various affections of the skin, connective tissue, 
and bones, and in inflammatory hypertrophy of the tonsils, testicle, mamma, and prostate 
gland. When existing in a high degree, they lead to serious functional embarrassment 
of the affected parts, growing out of alterations of structure, which the best directed efforts 
of the surgeon often fail to relieve. 
Gangrene, as an effect of chronic inflammation, is rare ; nevertheless, it is occasionally 
met with, as is witnessed, for instance, in the mortification of the toes and feet, so graph- 
ically described by Pott, and dependent upon ossification, inflammation, or embolism of 
the arteries. In most cases, when the disease passes into gangrene, it first assumes the 
acute type, which renders the transition much easier, and, in some degree, a necessary 
preliminary. 
The symptoms of chronic inflammation are generally much less prominent than those 
of the acute variety; the pain is less, and usually also, more dull or obtuse; the discolora- 
tion is dusky, livid, or purple ; the swelling, often considerable, is characterized by un- 
usual hardness, or by hardness and oedema; and the heat is nearly always less than in 
acute inflammation. Functional disturbance is variable, being extensive at one time, and 
slight at another. Symptomatic fever may be entirely wanting, and it is this circum- 
stance which so frequently causes this variety of inflammation to be overlooked, especially 
when it is of idiopathic origin. In time, the fever may assume a hectic type, or it may 
be of this character almost from the commencement. When the disease is extensive, or 
seated in an important organ, adynamic fever generally exists. 
The A’essels of the affected parts are generally very much dilated and distended with 
red and white globules, on which account the blood is propelled through them in a very 
tardy and sluggish manner, strikingly contrasting with the force and rapidity with which 
it is transmitted in the acute form of the disease, where, especially in its earlier stages, 
all is power and activity. When the inflammation is very protracted, many of the 
smaller vessels have a varicose, tortuous appearance, and are so crippled as to be almost 
unable to send on their contents at all. Hence, congestion, often deep and extensive, is 
generally present, both at the focus of the morbid action and for a considerable distance 
around. 
Treatment In the treatment of chronic inflammation, the indications are, first, to 
remove the exciting cause of the disease; secondly, to correct constitutional disorder; 
thirdly, to promote the absorption of effused fluids, and, lastly, to restore the tone of the 
crippled and dilated vessels. 
The removal of the exciting cause of the disease obviously demands the same attention 
here as in the acute variety of inflammation ; whenever it is accessible, it should be 
promptly disposed of. All officious interference must of course be avoided. 
Restoration of the secretions constitutes a most important indication, as it is upon their 
derangement or suppression that the morbid action in chronic inflammation so often 
depends. The remedies that are chiefly to be relied upon, for this purpose, are mercury, 
tartrate of antimony and potassium, iodine, nitromuriatic acid, purgatives, and a judi- 
ciously regulated diet. 
In placing mercury at the head of this list of remedial agents, I simply desire to show 
the high estimate that is so justly attached to it in the treatment of chronic inflammation. 
If its administration is of doubtful propriety in many cases of the acute disease, there 
are few instances of the chronic in which it may not be beneficially exhibited; and yet, CHAP. III. 
CHRONIC INFLAMMATION. 
105 
in making this remark, it must not be understood that it is to be given indiscriminately 
or sakelessly. Its value is unquestionable, but, still, there are cases and circumstances 
in which it is utterly inadmissible ; this is especially true of those cases of chronic inflam- 
mation which are so often met with in scrofulous children, and in persons of enfeebled and 
broken constitution, where mercury, in almost any form, is generally most pernicious, the 
smallest quantity sometimes producing profuse ptyalism, or gangrene of the mouth. 
In administering this remedy for the cure of chronic inflammation, the surgeon has it 
in his power to make choice of a much greater number and variety of articles than in 
acute inflammation, in which he is obliged to restrict himself chiefly to calomel and 
blue mass. In the chronic form of the disease, he has, in addition, the bichloride, the 
protiodide and cyanide, which exert a most salutary influence in changing the capill- 
ary action of the part, and promoting the removal of effused fluids. Whatever sub- 
stance be selected, the dose should be very small, and not repeated oftener, on an 
average, than twice or thrice in the twenty-four hours. The object is to produce a slow 
and gradual effect, and for this purpose it will generally be necessary to continue the 
remedy for several successive weeks. Active pytalism is carefully avoided; it will be 
quite sufficient if we succeed in obtaining slight soreness of the gums. If calomel be 
used, a good average dose will be from one-sixth to one-half of a grain. 
In children, the most suitable mercurials are blue mass, corrosive sublimate, and gray 
powder, or mercury with chalk, given either alone or in union with sodium and columba, 
quinine, or Iluxham’s tincture of bark. 
Iodine and its various preparations, as iodide of potassium, iodide of iron, iodide of cad- 
mium, iodide of ammonium, and Lugol’s solution ; bromide of potassium ; barium ; and 
tartar emetic often exert a most salutary influence over chronic inflammation, and are 
particularly indicated where a slow, alterant effect is required. With the exception of 
mercury, I know of no article of the materia medica which produces so powerful an effect 
as tartar emetic in controlling chronic inflammation, and favoring the absorption of effused 
fluids. The proper plan is to give it in small doses, as the eighth, tenth, or twelfth of a 
grain, in combination with some vegetable bitters and a little morphia, three times in the 
twenty-four hours. 
The different acids are sometimes administered with advantage, especially the dilute 
nitromuriatic, formerly so much employed in the treatment of hepatic affections. They 
are particularly indicated in chronic syphilitic and scrofulous inflammations, attended with 
impaired digestive powers. 
The bowels must be kept in a soluble condition, the nature and dose of the purgative 
being regulated by the exigencies of each particular case. The compound calomel pill, 
which, while it operates on the bowels, and excites the action of the liver and skin, con- 
stitutes one of the most eligible cathartics we possess in the treatment of chronic inflam- 
mation, accompanied with visceral obstruction. 
Particular attention should be paid to the skin. This will appear the more necessary 
when we consider that, in most cases of chronic disease, the perspiration is either entirely 
suppressed, or greatly changed in its properties. Frequent ablutions with cool, tepid, or 
warm water, impregnated with common salt, soap, mustard, or potassa, and followed by 
dry frictions, often prove highly serviceable. In many cases the cold bath will be found 
to be extremely valuable, especially if the surface be well rubbed immediately after with 
a coarse cloth. The renal secretion should also receive proper attention ; sometimes elabo- 
rate chemical and microscopical examinations will be required to determine its character, 
and enable us to direct a suitable plan of treatment. 
Exercise in the open air, either on foot, in a carriage, or on horseback, often effects a 
wonderful improvement in chronic inflammation, especially when of long standing, and 
attended with great debility. At other times, nothing but the most perfect rest will answer 
the purpose; as, for example, in serious disease of the brain, bones, and joints. 
The subject of diet claims special attention in the treatment of chronic inflammation. 
The indiscriminate use of food in this form of disease cannot be too severely reprehended. 
Too great abstinence, however, is often as injurious as too great indulgence. All stimu- 
lating and indigestible articles should, as a rule, be avoided as likely to increase the local 
disease, and exercise a prejudicial influence upon the patient’s recovery. If the system is 
inclined to plethora, the diet should be of a strictly farinaceous character, and be limited 
daily to a few articles, varied from time to time as they become disagreeable to the palate, 
or offensive to the stomach. If, on the other hand, the patient is pale and feeble, it should 
be partly farinaceous, and partly animal, the meat being taken at breakfast and dinner, 
and its effects carefully watched. The different kinds of animal and vegetable broths, 106 
TERMINATIONS OF INFLAMMATION. 
CHAP. IV. 
beef-essence, milk, arrowroot, rice, sago, tapioca, hominy, and grits, are all eligible arti- 
cles in chronic inflammation, and often prove of the greatest service in nourishing and sus- 
taining the system. Their flavor and eflicacy may be improved by the addition of spices, 
wine, or brandy, as may be deemed proper. When the patient is much exhausted, the 
use of whiskey, brandy, wine, ale, or porter will often be indispensable to recovery. Cod- 
liver oil may be employed when there is marked debility along with emaciation; rather, 
however, as an article of nourishment than with a view to the attainment of any alterant 
effect it may be supposed to possess from the presence of iodine and bromine. The dose 
should be as large as may be consistent with gastric tolerance. 
Finally, in the female, proper regard must be had to the state of the menstrual function ; 
prompt measures being adopted for its improvement, or, in the event of its suppression, 
for its restoration. There are numerous complaints which owe their origin, either directly 
or indirectly, to disorder of the uterine functions. 
The local treatmentof chronic inflammation isgenerallya matter of paramount importance. 
It comprises, first, as in acute disease, rest and elevation of the parts ; secondly, leeching, 
scarification, blistering, iodine, and nitrate of silver, especially in the early stages ; thirdly, 
counter-irritation by croton oil, tartar emetic, issues, and the actual cautery ; and, lastly, 
sorbefacients, such as stimulating liniments, embrocations, and unguents, the cold douche, 
compression with the bandage, or adhesive strips, electricity, and massage, the latter of 
which is often of immense service. When the parts are hot and tender, solutions of ace- 
tate of lead, or evaporating lotions, are generally highly beneficial, if not indispensably 
necessary. In obstinate cases, electricity is sometimes useful, although its effects have 
been greatly overrated. 
CHAPTER IV. 
TERMINATIONS AND RESULTS OF INFLAMMATION. 
SECT. I DELITESCENCE AND RESOLUTION. 
These terms are used to denote the restoration of the inflamed structures to their nor- 
mal condition. The word delitescence is of Latin derivation, and literally signifies to 
abscond ; it was introduced into surgical nomenclature by the French writers, and is 
employed to designate the sudden disappearance of inflammation, before it has passed 
through its different stages, and, consequently, before it has occasioned any serious struc- 
tural changes. It is unquestionably the most desirable mode of termination, and may 
occur either spontaneously, or from the slightest treatment. A catarrh, caused by expo- 
sure to cold, and perhaps threatening to be quite severe, often aborts during a profound 
sleep induced by a warm bed, or a hot foot-bath and a little morphia. An inflammation 
of a lymphatic gland of the neck, coming on late in the evening, and attended with great 
tenderness on motion and pressure, together with considerable swelling, often rapidly dis- 
appears under similar measures. An incipient gonorrhoea frequently aborts under the use 
of a mild injection of nitrate of silver or acetate of lead; and who has not seen a bubo 
promptly vanish under steady, systematic compression, aided by the application of iodine? 
Inflammation produced by the presence of a foreign body generally rapidly disappears 
after the removal of the exciting cause of the morbid action. 
The above facts, as well as many others that might be adduced, are pregnant with two 
most important lessons, one of which is to remove as early as possible the exciting cause 
of the inflammation, and the other to lose no time in instituting a proper method of treat- 
ment for the relief of the morbid action. The object should invariably be to save struc- 
ture, and the best way to do this is to compel the disease to abscond, or delitesce. Such 
an event, however, is only desirable when the inflammation can be dislodged more or less 
completely without any risk of throwing it upon some other and, perhaps, more important 
organ. Thus, an attack of gout in the great toe would be a trifling affair in comparison 
with an attack of gout in the heart, brain, or stomach ; and hence it would be far better, 
when there is danger of such a translation of irritation, to let the original disease pursue 
its course, than to attempt to arrest it by means tending to favor such a result. A severe 
injection may suddeidy arrest an incipient gonorrhoea, but it may do inflnite harm by the CHAP. IV. 
DEPOSITION OF SERUM. 
107 
rapid induction of orchitis, which perhaps no treatment, however judiciously conducted, 
may be able to dispel completely under several weeks, or even months. 
The sudden disappearance of inflammation from one structure, or set of structures, and 
its invasion of another, usually known by the term metastasis, suggests the importance of 
proper watchfulness on the part of the surgeon to prevent such an occurrence ; or, if it have 
already taken place, of employing such means as sliall serve to recall the morbid action 
as speedily and effectually as possible to its original situation. For this purpose free use 
should be made of counter-irritation, in the form of stimulating embrocations, sinapisms, or 
blisters, aided, if the organ affected be one of great importance to life, by the abstraction 
of blood and the free use of opiates. If, in this way, the disease cannot be recalled, the 
treatment will go far to put a speedy stop to its violence and its tendency to extension. 
The term resolution denotes the gradual dissipation of inflammation after the disease 
has made some progress and done some mischief, but before it has reached the suppura- 
tive crisis, or committed such ravages as to prevent the affected tissues from regaining 
their original properties. With such an issue effusion of serum and lymph is not at all 
incompatible, as these fluids may be entirely absorbed; a similar remark is applicable to 
pus, provided it exist in small quantity, or not as an abscess, in which there is always 
more or less waste of tissue ; and even to pure blood, which, if not too abundantly effused, 
or deprived of its vitality, is generally readily amenable to the action of the absorbents. 
When resolution is about to occur there is a gradual and steady subsidence of the mor- 
bid action, as denoted by the changes in the local and constitutional symptoms. The 
discoloration, heat, pain, and swelling become less and less through the contraction of the 
vessels and the absorption of the effused fluids ; the febrile disturbance passes off; and 
the part and system, no longer influenced by the effects of the disease, at length regain 
their normal condition. Often many weeks, and even several months, elapse before the 
restoration is finally completed. The absorbent vessels, kept in abeyance by the vascular 
action and the effused fluids, are slow to resume their functions; they act at first hesita- 
tingly, as if afraid to enter upon their labor, but as the work progresses they acquire con- 
fidence, and, at length, setting about it in good earnest, they ere long finish their task, 
drinking in, as it were, all that their oppressors, the secernents, had previously poured 
out, and thus leaving the parts in a condition to regain their primitive characters. The 
bloodvessels usually remain dilated, feeble, and sluggish for some time after the complete 
subsidence of the disease, and there is also frequently more or less perversion of special 
sensation. 
SECT. II DEPOSIT OF SERUM. 
A deposit of serum, or of the watery elements of the blood, is a common attendant upon 
inflammation, and in some cases constitutes, pathologically speaking, the principal, if not 
the only, evidence of its presence. The structures which, when thus affected, supply 
serum in greatest abundance, are the connective and serous, the secernent vessels of which 
are generally extremely active, even when the disease is comparatively mild. Large 
quantities of serum are also occasionally poured out by the mucous membrane of the ali- 
mentary canal, especially by that of the colon and rectum, as in diarrhoea and cholera. 
Inflammation of the skin, unless produced by scalds, blisters, erysipelas, and the various 
bullar diseases, yields this fluid generally sparingly. Very little is also effused in inflam- 
mation of the muscles and fibrous membranes, the nerves and ves.>els; while tendon, car- 
tilage, and bone do not afford any, however severe the morbid action. A similar remark 
is applicable to inflammation of the parenchymatous and glandular organs, as the lung and 
liver. In the connective tissue serous accumulations are particularly liable to occur wherever 
tliis substance is very loose and abundant as in the eyelids, scrotum, prepuce, labia, nymplue, 
legs, and feet, which are often enormously distended in consequence. (Edema of the 
glottis is an example of watery deposit in the submucous connective substance of the edges of 
the larynx. In the splanchnic cavities and the movable joints serum often collects in 
immense quantities ; sometimes as an effect of acute, but more frequently of chronic, 
inflammation. 
Particular epithets are employed to designate certain collections of serum, based either 
upon the appearance of the part, or the anatomical name of the cavity that serves to re- 
ceive the fluid. Thus it is customary to speak of oedema of the glottis, of oedema of the 
eyelids, and of (edema of the legs, simply because these structures, when thus affected, 
have a swollen, glossy aspect. The older writers applied the word anasarca to all aqueous 
accumulations of the inferior extremities, under the supposition that the fluid was diffused 108 
TERMINATIONS OF INFLAMMATION. 
through the muscles. Dropsy of the leg is another familiar expression. The latter term, 
however, is generally restricted to collections of serum in the various cavities of the body, 
as dropsy of the abdomen, chest, head, pericardium, joints, and vaginal tunic of the tes- 
ticle. Or, instead of this term, a Greek one, either simple or compound, is used, as being 
somewhat more classical. In this manner a dropsy of the abdomen becomes an ascites ; 
of the chest, a hydrothorax ; of the head, a hydrocephalus; of the vaginal tunic, a 
hydrocele. 
Although serum is generally limpid in its appearance, cases now and then arise in which, 
from the admixture of hematin, bile, or other extraneous matter, it is reddish, dark, yel- 
lowish, or even milky. A dark appearance, such as is so generally present in the perito- 
neum in strangulated hernia, is to be viewed as an evidence of intense inflammation. A 
similar phenomenon is witnessed in the blebs of incipient gangrene, and in the enormous 
accumulations of serum which occasionally occur in the limbs in consequence of snake 
bite and other severe injuries. 
The fluid, which sometimes contains flakes of fibrin, pus, and even pure Vdood, is unctu- 
ous to the touch, saline in taste, but free from odor, and is readily coagulable by alcohol, 
heat, acids, and corrosive sublimate; circumstances which show that it is composed prin- 
cipally of albumen, in combination with some of the earthy salts, especially the sulphates. 
Its quantity in acute inflammation is usually small, except in the splanchnic cavities, where 
it is sometimes immense, amounting to many quarts, or even several gallons. 
Great diversity of sentiment has been expressed in regard to the kind of action under 
the influence of which this fluid is produced, some declaring that it may be effused inde- 
pendently of inflammation, while others maintain that inflammation is indispensably 
necessary. I have long been of the latter opinion, nor is it possible, it seems to me, to 
arrive at any other conclusion, unless it be assumed that there is no inflammation without 
suppuration, or, at least, without fibririous exudation, a doctrine so utterly at variance with 
the facts of the case as to render its adoption impossible. Inflammation is a very simple 
process; it requires very little disturbance to induce it, and an effusion of serum often 
occurs without any of the ordinary phenomena of the disease, as heat, pain, and discolora- 
tion. In chronic dropsies, for example, the inflammation is frequently so very slight that, 
if it were not for the mechanical inconvenience which the fluid occasions, the patient 
would hardly be conscious of any suffering; and yet, even in such cases, it will generally 
be found, on dissection, that the serous membrane which furnished the water, exhibits 
sufficient indication of the lesion in the opaque and thickened condition of its substance. 
It may be questioned whether mere congestion is capable of producing serous effusion. At 
first sight such an occurrence would seem to be quite probable; but a careful examination 
of the subject soon dispels the illusion. Permanent obstruction of the abdominal cava causes 
ascites, not from mere congestion of the vessels of the peritoneum, but as a consequence of its 
inflammation, the result of the previous vascular engorgement. It is easy to see that ves- 
sels habitually distended must soon take on incited action, followed by abnormal deposits. 
A familiar illustration of this is afforded in the conjunctiva, where, if the vessels are at 
all engorged even for a short time, inflammation is sure to follow, unless the exciting 
cause of the determination is speedily removed. If this mode of reasoning be correct, it 
follows that obstruction of the circulation, however induced, must, if permitted to con- 
tinue, be soon succeeded by inflammation, of a grade and character sufficient to cause at 
least an effusion of serum, if not also of other fluids. 
Of the nature of the morbid action, when serum is rapidly supplied, or when it is asso- 
ciated with other deposits, as lymph or pus, there can be no doubt that it is highly inflam- 
matory. The concomitant symptoms, and dissection after death, clearly establish the 
fact. The rapid and profuse serous exhalations which occur in acute pleuritis, peritonitis, 
and arachnitis admit of explanation in no other way; they are the appropriate products of 
these structures, and hence they generally appear very early in the disease. 
Effusion of serum is often associated with, if not directly dependent upon, an impov- 
erished and watery condition of the blood, accompanied by a marked decrease of fibrin 
and red particles. If, under such circumstances, inflammation be lighted up, especially in 
connective and serous tissues, serum cannot fail to he supplied in large quantities, since, in 
consequence of the diminution of the plastic properties of the blood, there is nothing to 
restrain its exudation. Hence such action is very prone to be followed, externally, by 
anasarca or oedema, and internally by dropsy. 
The symptoms produced by this deposit are such, mainly, as are denotive of mechanical 
obstruction. In the eyelids, glottis, scrotum, prepuce, vulva, and legs, it is marked by a 
soft, inelastic swelling, which pits on pressure, and imparts a peculiar glossy appearance 
CHAP. IV. CHAP. IV. 
LYMPHIZATION. 
109 
to the affected surface ; attended, especially in the inferior extremities, with pain, heat, 
and more or less discoloration, usually of a pale dusky hue. A sense of distention is also 
commonly a prominent symptom. In (Edema of the glottis there is serious impediment in 
the respiratory functions, while in accumulations of water in the splanchnic cavities there 
must necessarily be more or less oppression, with displacement of the contained viscera. 
A large collection of water in the chest may not only cause collapse of the lung on one 
side, but greatly encroach upon the opposite one, and at the same time throw the heart 
completely out of its natural position, depress the diaphragm, and tilt up the intercostal 
spaces so as to give the thorax a vaulted configuration. In infiltration of the connective 
tissue of the leg, feet, scrotum, and vulva, the fluid may, by its pressure upon the capil- 
lary vessels, cut off the supply of blood from the skin, and thus become a cause of morti- 
fication, as is exemplified in certain forms of erysipelas and anasarca. 
In the treatment of internal serous effusions, the leading indication is to promote the 
absorption of the offending fluids by the use of hydragogue cathartics, diuretics, and 
mercurials ; followed, when these means fail, by an operation for their efficient evacuation. 
The most important cathartics, after thorough purgation, are jalap and bitartrate of potas- 
sium, citrate of magnesium, and elaterium, given in doses proportioned to the strength 
of the patient and the tolerance of the stomach and bowels. These remedies, as well as 
others of a kindred nature, produce their beneficial effects by establishing a drain upon 
the serous capillaries of the alimentary canal, which leads indirectly to the absorption of 
the serous accumulation. "When mercurials are required, as in case of obstruction of the 
portal circle, with deficiency of the hepatic secretion, the most eligible articles are calomel, 
blue mass, or corrosive sublimate, either alone or in union with elaterium, squills, digitalis, 
or antimony, according to the nature of the collateral disorder. Deficiency of the renal 
secretion must be corrected by suitable diuretics. 
When the accumulation of serum is very great, as in dropsy of the chest, abdomen, or 
pericardium, all internal treatment will be likely to prove abortive, as it is then generally 
impossible to rouse the absorbents, the pressure of the fluid keeping them in a crippled and 
paralyzed condition, altogether incompatible with the healthy exercise of their functions, 
lienee, instead of wasting time and the strength of the patient, as is unfortunately too 
often done in such cases, early vent should be afforded to the pent-up matter. Serious 
and even fatal errors are constantly committed for the want of early interference with the 
trocar in these accumulations. It must not be forgotten that purgative, diuretic, and 
alterative remedies, if available at all, can prove beneficial only at the expense of much 
distress and exhaustion of the system, which too often leave the sufferer, in the event of 
his recovery, with permanently shattered health. An operation, on the other hand, gen- 
erally promptly remedies the urgent symptoms, and places the part in a much more 
favorable condition for the efficient action of sorbefacient medicines. 
Local remedies are available chiefly in serous effusions i 11 the external parts of the 
body. In oedema of the extremities great benefit is often derived from steady and per- 
sistent elevation, and regular, equable compression with the bandage, extending upwards 
from the distal portion of the limb. In this way support is given to the weakened 
capillaries, while a salutary stimulus is imparted to the absorbents, increasing their 
action and thus favoring the removal of effused fluid. This treatment often derives 
important aid from frictions with sorbefacient unguents, liniments, and embrocations, and 
the application of dilute tincture of iodine. When the distention is inordinate, or 
threatens to pass into gangrene, early punctures and even free incisions are called for, 
although, generally speaking, they are objectionable, as they often bring about the very 
disease they are designed to prevent. In oedema of the glottis nothing short of prompt 
and decisive scarification can save the patient from suflocation. 
SEC. Ill LYMPHIZATION OR PLASTIC EXUDATION. 
Lymphization is the act of separating lymph or plasma from the blood and depositing 
it in the organs and tissues, or upon their free surfaces. The term bears the same rela- 
tion to the substance which it serves to designate that the word suppuration bears to pus, 
the product of that act. As signifying the same thing, the phrase “ fibrinous exudation,” 
or “ inflammatory exudation,” is often used. 
There is seldom any inflammation, however slight, without some deposit of lymph. 
Indeed, in many cases, and in certain situations, it constitutes almost the only product of 
the morbid action. Thus, in croup and peritonitis, the chief evidence of the existence of 
these diseases, after death, is the presence of lymph ; in general, however, it is associated 110 
TERMINATIONS OF INFLAMMATION. 
CHAP. IV. 
with other deposits, especially serum, which is often poured out along with it in large 
quantities. When the inflammation is at all severe, and particularly if it have already 
made considerable progress, there may be, in addition, puriform matter, pus, and even 
pure blood. Its presence, whether occurring singly or combinedly, is generally denotive 
of a higher grade of action than the mere effusion of serum. 
The capacity of furnishing lymph, in inflammation, is possessed in different degrees by 
different organs and textures, depending upon the peculiar nature of their structure and 
organization. The serous membranes, especially the pleura and peritoneum, the connective 
tissue, and certain portions of the mucous system, as the faucial, laryngeal, intestinal, 
and uterine, yield it very freely. Very little is effused, under any circumstances, by the 
fibrous membranes, the muscles and their tendons, the vessels, nerves, cartilages, and 
bones, except in fractures and other injuries, in which it is sometimes thrown out in great 
abundance. In some of the parenchymatous organs, as the brain, liver, and kidneys, it 
is usually supplied very sparingly, whereas in inflammation of the lungs and spleen it is 
often effused very freely, leading to rapid solidification of their proper structure. Large 
quantities of lymph are sometimes exhaled during the progress of abscesses, many of 
which it serves to inclose in a distinct cyst, known as the pyogenic membrane. 
Lymph is generally poured out very early in the inflammatory process, and often con- 
tinues for an indefinite period, increasing and declining with the disease. It is surprising 
how soon it sometimes shows itself. From experiments that 1 have performed upon the 
inferior animals, as well as from observations upon the human subject, I am convinced 
that it begins much earlier than is usually supposed. In 1841, I had repeated proofs of 
this fact, while engaged in an elaborate series of experiments upon dogs, with a view of 
elucidating the nature and treatment of wounds of the intestines. 1 found, in many of 
these animals, that the bowels had become extensively adherent, not only to each other, 
but likewise to the walls of the abdomen, within a very few hours after the operation. In 
the case of a gentleman whose abdomen I opened, on account of a twist in the small in- 
testine, although death occurred at the end of four hours, nearly the whole peritoneum, 
visceral and parietal, was coated with a thin film of fibrin, of which hardly any traces 
existed anywhere at the time of the operation. In another case, that of a young lad, 
who died within nine hours after he had been shot in the side, the ball wounding the 
abdomen, diaphragm, and chest, large quantities of lymph were seen both upon the peri- 
toneum and the pleura. The flaps made in an amputation become speedily glazed with 
fibrin, and the edges of an incised wound frequently adhere quite firmly within a very 
short time after their approximation. 
From the preceding facts, it is evident that the exudation of lymph generally begins 
at an early period of the inflammation, and that, under favorable circumstances, it proceeds 
with great vigor. When the reverse, however, is the case, it advances comparatively 
slowly, or it may even fail entirely. Such an event will be most likely to occur in low 
and depraved states of the system, attended with anemia and lesion of the innervation. 
Plasma, considered as an effect of disease, is a direct product of the vessels of tlie 
affected structures, the process by which it is elaborated being one of a vital character, analo- 
gous to, if not actually identical with, secretion. Virchow maintains that it has an extra- 
vascular origin ; or, in other words, that it is a local product of the tissues, on and in 
which it is found, being essentially composed of the material generated in the inflamed 
part itself through the changes in its condition. lie denies that there is, in the ordinary 
acceptation of the term, any inflammatory exudation whatever; or, what is the same 
thing, that there is any actual transudation of the blood-liquor. However this may be, 
lymph is a vital, organizable, proliferous fluid, susceptible of great changes in its compo- 
sition, and capable of playing a most important part in injury and disease. 
Recently effused lymph is of a whitish, pale straw, or opaline appearance, although now 
and then it is somewhat reddish, from the admixture of hematin. In cases of protracted 
jaundice, it is occasionally of a pale orange hue. It is of a soft, unctuous consistence, 
like hot glue, or a thin solution of starch, is destitute of odor, has a faint saline taste, and 
is essentially composed of fibrin in union with albumen and serum. Immersion in alco- 
hol renders it tough, and changes its color from white to buff 
Lymph is a vital, organizable fluid, identical in its composition with the huffy coat of 
the blood. Under the microscope it is found to consist of numerous globules, analogous 
to colorless blood corpuscles, of a spherical shape, nearly homogeneous, and about the 2 
of an inch in diameter. Delicate fibrils, straight, parallel, and interspersed with 
innumerable granules, are also visible in it. Although lymph is always poured out in a 
fluid state, it soon arranges itself in various forms; now as an amorphous mass; now as LYMPHIZ ATION. 
CHAP. IV. 
a tube, as in the larynx and bowel; at one time as a lamella, and at another as a distinct 
band ; its conformation being materially influenced by that of the organ, tissue, or cavity 
in which it is effused. 
Plasma does not always exhibit the same appearances either under the microscope or 
to the naked eye. In this respect it shares the same fate as other morbid products. 
Any differences that it may present are entirely due to differences in the state of the 
blood, the part and the system in different individuals, localities, and grades of the morbid 
action. Corpuscular lymph, as it has been termed by Rokitansky, differs from ordinary only, 
or chiefly, in having a greater number of exudation globules, and less of healthy fibrin. 
It is generally met with in persons of deficient vital powers, with an impoverished state 
of the blood, and soon manifests a disposition to break down and become effete. In 
young, robust persons the lymph poured out in inflammation is generally very firm and 
abundant, with a strong cell-force, and a tendency to rapid organization. In scrofulous 
subjects it is almost wholly corpuscular. Its constitution is also materially influenced by 
the nature of the affected structures and the character and intensity of the morbid action. 
Fig. 4 represents a portion of recently effused corpuscular lymph, opaque, white, friable, 
and magnified about 380 diameters, from an inflamed pleura. It is composed of colorless 
corpuscles, and granular matter in a hyaline matrix. In the lower part of the figure the 
corpuscles are shown as floating in serous fluid. In fig. 5, magnified 800 diameters, the 
structure of the effused matter is somewhat different. It forms, in fact, a sort of false 
Fig. 4. 
Fig. 5. 
Fig. 4. Plastic Corpnscles and Filaments in recent Lymph exuded on the Pleura, a The Corpuscles, unchanged by 
Acetic Acid. 
Fig. 5. Recent Lymph, forming False Membrane. 
membrane, the croupous exudation of the German authors. Numerous corpuscles, more 
or less globular, a few epithelial cells, and granular matter, are seen to be interspersed 
through filaments of fibrin. 
The period at which the organization of this substance takes place varies with a number 
of circumstances,'of which the most important are, the plasticity of the effused matter, 
the nature of the affected tissues, and the state of the general system. To enable it to 
attain this point at all, it must have a strong cell-life, formative power, or cell-force; if 
this be wanting the development of cytoblasts will either be impracticable, or so 
imperfect as to be soon arrested, or, at all events, very much impaired. When everything 
is favorable, the development proceeds very rapidly; cells and nuclei are formed in great 
numbers, and these, connecting themselves with each other, are gradually spread out into 
fibres, lying, for the most part, in straight, parallel lines, and profusely inlaid with 
granules, as in fig. 6. Soon after this process has begun, vessels appear in the new 
product, either as a result of the canalization of branched cells, or as an extension from 
the neighboring structures, the latter being by far the more common source of the supply. 
The walls of the vessels are, at first, very frail and yielding, so that the least pressure is 
sufficient to rupture them and cause extravasation of their contents. Gradually, how- 
ever, as they grow older, they become better qualified for the discharge of their functions, 
and in time acquire all the properties of the natural vessels. When fully developed, 
they can easily be discovered with the naked eye, and readily admit fine injecting matter. 
The veins are usually disproportionately large to the arteries, but this defect also ultimately 
disappears. Nerves and absorbents likewise exist, but whether they are supplied by the 
surrounding tissues, or by the inherent powers of the effused matter, is undetermined. 
The arrangement of the newly-formed vessels is represented in the annexed sketches. 
Fig. 9 is a portion of plasma attached by a narrow neck to the peritoneal coat of an 112 
TERMINATIONS OF INFLAMMATION. 
CHAP. IV. 
inflamed intestine. The vessels have a ramiform disposition, and freely anastomose with 
each other. Fig. 10 is a piece of false membrane of the pleura. The vessels are large, 
numerous, and further advanced than in the other sketch. 
Fig. 6". 
Fig. 7. 
Fig. 8. 
Figs. 6 and 7, from Bennett, show Nuclei and Cells developing themselves into Fibres : while Fig. 8 exhibits a Perfect 
Fibrous Tissue. 
When the process of organization is unusually rapid, the new vessels, in consequence 
of their very tender and brittle condition, occasionally give way, either under the influence 
of external violence, or the force with which the blood is impelled into them by the 
heart’s action. Such an occurrence may be productive of considerable hemorrhage. 
Fig. 9. 
Fig. 10. 
Newly-formed Vessels in Plastic Lymph. 
Vessels in False Membrane of the Pleura. 
The organization of plasma is sometimes completely prevented by the contact of 
extraneous matter, as feces or urine. Hence, we seldom meet with a false membrane in 
the bowel and bladder. The very moment the plasma is poured out it is devitalized and 
converted into an effete substance. The state of the blood and solids also exercises an 
important influence upon the process; the more impoverished and exhausted these are, 
the less likely will the effused matter be to form cells and nuclei, vessels, nerves, and 
absorbents. 
Plasma is susceptible of absorption both in its fluid state and after it has been changed 
into connective tissue. This, however, does not occur, at least not to any considerable 
extent, during the height of the inflammation by which it has been produced ; on the 
contrary, there must always be a marked reduction of the morbid action before the absorb- 
ent vessels can be induced to take hold of it; but this point having once been attained, 
the process often goes on very rapidly, as is witnessed in fractures, dislocations, wounds, 
and other injuries, in which the swelling, chiefly caused by fibrinous deposits, occasionally 
completely vanishes in a few days. The absorption will necessarily be more difficult 
when the plasma has become organized, when, in fact, it often effectually resists all the 
efforts that can be employed to get rid of it. The opaque spot on the cornea, for example, 
often remains despite the most protracted treatment. It is probable that plasma, before 
it can undergo absorption, even in its liquid state, is broken up and dissolved in the fluids 
of the affected parts, being thus brought more readily under the influence of the vessels. 
In fig. 11 the fibrous matter is undergoing absorption, some parts of the layer being 
completely removed, while others are becoming softened and attenuated. 
Moreover, this substance is liable to various kinds of degeneration, both in its early 
and in its more matured stages. When recently effused, it may be converted into pus, 
especially if it be aplastic and exposed to the air; and it then also frequently becomes 
hard, dry, shrivelled, devitalized, and effete. It likewise undergoes the fatty transforma- CHAP. IV. 
USES OF PLASTIC MATTER. 
113 
tion, both before and after vascularization, as exhibited in Fig. 12 ; and, lastly, it is occa- 
sionally infiltrated with pigmentary matter. 
Finally, organized plasma forms the basis of what are called the analogous tissues, 
and may, therefore, like the original structures with which it is in contact, become the 
seat of inflammation, sarcoma, tubercle, and other formations. 
Fig. 11. 
Fig. 12. 
Fig. 11. Fibrinous Exudation in Process of Absorption ; Areola; form in it, and reduce it to Filamentous Bauds, 
Fig. 12. The Lymph of Pleuritis, with New Vessels aud Fatty Degeneration. 
Uses of Plastic Matter.—The great value of this substance is strikingly illustrated in 
numerous diseases, injuries, and operations. As a reparative agent, as a living animal 
glue, as it may very properly be termed, it is impossible to overestimate its importance. 
If it were not for its interposition, no wound, sore, or ulcer, however insignificant, could 
ever heal. In the treatment of an incised wound the duty of the surgeon is strictly me- 
chanical, consisting simply in the approximation of the raw surfaces, and in their reten- 
tion by suitable dressings. Nature does the rest by the effusion and organization of 
plasma, generally well and quickly, provided the parts are kept perfectly cool and quiet. 
Very little inflammation is required. The great danger is in overaction, thereby thwart- 
ing the efforts at repair. Under proper management the wound generally heals in a few 
days, the bond of union becoming hourly more and more firm by the gradual conversion 
of the plasma into connective tissue, of which, however, very little ordinarily remains 
when the process is perfected. 
Parts completely severed, and immediately replaced, will often, if judiciously man- 
aged, reunite, and be nearly, if not quite, as useful as before. Numerous well-authenti- 
cated cases are upon record of bits of fingers, the nose, and the ear having been success- 
fully treated in this wise. 
It was upon a knowledge of the peculiar plastic properties of lymph that Tagliacozzio 
founded his world-renowned operation, now universally known by his name, of repairing 
mutilated noses, lips, and ears. His attention was originally directed to the subject by 
watching the effects of the grafting of trees ; he observed that the transplanted portion 
not only contracted firm adhesions in its new situation, but that it generally grew with 
great vigor, and ere long produced most excellent fruit, altogether superior to, and differ- 
ent from, that of the parent stock. Possessed of a profoundly inventive genius, he was 
led to believe that a similar operation might be performed upon man, and it was not long 
before he put his reasoning to the test of experiment. His success was so complete that 
he became the great rhinoplastic surgeon of his day. 11 is method consisted, first, in rais- 
ing a suitable flap of integument from the arm ; secondly, in thoroughly paring the muti- 
lated organ ; and lastly, in sewing the raw edges accurately together, care being after- 
wards taken to put the parts in the closest relation until they were firmly and inseparably 
united. The Indian method, as it is termed, differs from that of Tagliacozzio mainly in 
this, that the flap of skin is generally borrowed from the immediate vicinity of the de- 
formed organ, its pedicle being twisted upon itself in such a manner as not to interfere 
injuriously with its circulation. 
Some very curious experiments, illustrative of the surgical uses of this substance, were 
performed towards the middle of the last century by Du Hamel ; one of these experi- 
ments consisted in ingrafting the spur of a cock upon the comb of the same bird, where 
it speedily contracted adhesions, and gradually attained a large size. Hunter, who re- 
peated the experiments of the Dutch physiologist, went a step further, transplanting the 114 
TERMINATIONS OF INFLAMMATION. 
CHAP. IV. 
testis of a cock into the abdomen of a hen, where the union became so perfect that he 
could readily pass injecting matter from the vessels of the one into those of the other. 
The fact that a healthy tooth, extracted by mistake, will, if immediately replaced in its 
socket, speedily reunite, and ultimately regain its original hold, has long been familiar to 
dentists. Hunter found that if a fresh human tooth be inserted into the comb of a cock, 
it will soon become firmly fixed in its new situation, vessels extending up into the cavity 
of the fang, so as to establish an active circulation between the two bodies. 
Curious and instructive as these experiments are, they hardly equal, in point of inter- 
est, many of those that have been performed by the modern surgeon upon the human 
subject for the relief of mutilated structures. One of the most recent additions to our 
knowledge is the transplantation of bits of skin for the cure of wounds and ulcers, sug- 
gested by Reverdin, and so successfully employed in numerous instances both in Europe 
and in this country. 
The good effects of plasma are exhibited in various other processes, as in the suppres- 
sion of hemorrhage, and the radical cure of hernia. In the former, the patient would 
inevitably bleed to death if it were not for the agency of this substance in sealing the 
mouth of the vessel by attaching the internal clot firmly to its surface. In hernia a rad- 
ical cure can only be effected through the intervention of plastic matter, thrown out as a 
consequence either of the pressure of a well-adjusted truss, or of the injection of some 
irritating fluid, causing inflammatory action of the parts around. 
Plastic matter is often useful in circumscribing morbid action, and in inclosing foreign 
bodies. In abscess a wall of this substance is generally formed around the pus, effectually 
preventing its diffusion among the surrounding tissues. Occasionally the fluid is inclosed 
by a distinct membrane, derived from the fibrin of the blood, and possessed of a high de- 
gree of organization. In carbuncle and erysipelas the matter is usually of an aplastic 
nature, and therefore unable to prevent the extension of the disease. Balls, needles, 
pins, and various other foreign bodies are occasionally surrounded by a cyst, and, in con- 
sequence, often remain harmless tenants of the body for many years. 
Plasma may be of service in obviating accidents. Thus, in abscess of the lung, if 
it were not for the intervention of fibrin, the matter would often break into the chest, 
and rapidly destroy life. As the disease advances, the pulmonary pleura becomes in- 
flamed and pours out lymph, which thus serves as a bond of union between this mem- 
brane and the costal pleura; so that by the time the matter reaches the surface an effec- 
tual barrier is opposed to its effusion, and the consequence is that it generally discharges 
itself through a contiguous bronchial tube. A similar occurrence takes place in abscess 
of the liver in relation to the peritoneum and the intestinal tube. In typhoid fever the 
glands of Peyer are often perforated, and yet the contents of the bowel seldom escape 
into the abdominal cavity, simply because, as the disease progresses, the contiguous serous 
structures are firmly glued together by plasma. 
Finally, lymph is of use in obliterating serous cavities. In the radical cure of hydro- 
cele, a disease of the vaginal tunic of the testicle, an operation is performed for the pur- 
pose of provoking a deposit of fibrin, barely sufficient to cover the opposing surfaces, and 
to insure their permanent agglutination. Serous cysts are treated upon similar princi- 
ples ; and modern surgery has been emboldened to inject even some of the movable joints, 
the abdomen, and ovarian tumors with irritating fluids, for the radical cure of dropsical 
diseases of these parts. 
Injurious Effects of Plastic Matter Lymph is capable of producing injurious effects 
as well as beneficial; nature’s operations cannot always be controlled by art, and it is, 
therefore, not surprising that she should often overleap the bounds of discretion when 
engaged in depleting inflamed structures by the effusion of plastic matter. Immense mis- 
chief is frequently done in this manner within a few hours after the commencement of the 
morbid action ; mischief which it may require months of the most judicious and perse- 
vering efforts of the surgeon to eradicate. 
Among the more common and obvious effects of this description are the following: 1. 
Mechanical obstruction of the natural outlets of the body. 2. Change of structure by 
interstitial deposits. 3. Abnormal adhesions. 4. Strangulation. 5. Loss of transpa- 
rency. 6. Induration and enlargement. 
a. An example of mechanical obstruction from a deposit of lymph is afforded by what 
occurs in the windpipe in plastic croup, the principal anatomical character of which is 
the formation of a false membrane, which often moulds itself accurately to the shape of 
the tube, and which, especially if it extend high up into the larynx, may cause suffocation 
by impeding the entrance of air into the lungs. In rare cases the membrane is detached INJURIOUS EFFECTS OF PLASTIC MATTER. 
115 
CHAP. IV. 
and expectorated ; but generally it remains despite our remedies, and speedily destroys 
the patient, even tracheotomy seldom averting death. 
In some of the mucous canals this matter is poured out beneath the lining membrane 
instead of upon its free surface, where, becoming organized, it leads to permanent contrac- 
tion of the tube. It is in this manner that stricture is formed; when the case is a very 
bad one, lymph may also be effused into the substance of the lining membrane, and even 
upon its free surface, as, for example, in what is called the bridle-stricture of the urethra. 
4. Change of structure from interstitial deposit of lymph occurs in almost all cases of 
inflammation, however slight or however situated. In pneumonitis, it closes up the air- 
cells and minute bronchial tubes, as well as the cells of the connective tissue, producing 
what is called hepatization of the lungs. Opacity of the cornea, acting obstructingly to 
the rays of light, is the invariable result of a deposit of plastic matter either beneath its 
conjunctival covering or in its interlamellar structure. 
y. All abnormal adhesions are effected by this substance, and are necessarily more or 
less prejudicial. In the thoracic cavity, they confine and restrain the movements of the 
heart and lungs; in the abdomen, they often become a source of internal strangulation ; 
in the mucous outlets, as in the vagina and uterus, they may produce complete occlusion 
of their orifices; and in the vessels, especially the arteries, they have been known to 
induce obliteration of the largest trunks. Abnormal adhesions between the bowel and the 
sac in hernia are sometimes a cause of its irreducibility. 
Great mischief is often done by the lymph that is effused within a joint. The matter, 
if not promptly removed by the absorbents, is organized and converted into an adven- 
titious structure, which, undergoing various transformations, at length assumes the prop- 
erties of the osseous tissue, and effectually destroys the motions of the articulation. The 
case, in fact, is one of bony ankylosis, which it is often difficult, if indeed not impossible, 
to cure. 
5. When this substance is arranged in the form of a cord or band, it may act as a com- 
pressing agent, by arresting the circulation, and thus give rise to all the symptoms of fatal 
obstruction. A band or cord of lymph, for example, extending from one organ to another, 
may as effectually strangulate the bowel as when the tube is girted by the rings of a her- 
nia at one of the natural outlets of the abdomen. Dr. Montgomery, of Dublin, has shown 
that the amputations of the limbs which occasionally occur spontaneously during utero- 
gestalion are due to the constriction caused by cords of this kind accidentally thrown around 
the affected member, and acting on the principle of a gradually tightened ligature. The 
constant tendency of such bands to contract affords a ready explanation of an event which, 
until recently, was universally regarded as a result of gangrene. 
*. Loss of transparency in structures that are naturally transparent, as the cornea, or 
translucent, as the serous membranes, is a common consequence of a deposit of plasma. 
This has been supposed by some to be due, in part at least, to a change in the nutrition 
of the affected tissues ; but, in general, it will be found to depend solely upon the presence 
of inflammatory material. 
£. Among the more frequent evils of plastic deposits are induration and enlargement, 
or hardening and thickening of the affected organs and tissues. Such occurrences are 
generally exceedingly annoying, often severely taxing the patience of the sufferer and the 
skill of the professional attendant. They are the direct result of interstitial effusions, 
which often manifest an early tendency to organization and transformation, and which 
none but the most determined perseverance in the use of remedies can ultimately over- 
come. The stiff and thickened joint, the indurated and enlarged testicle, the hypertro- 
phied spleen, liver, and lymphatic gland, the hardened and enlarged tonsil, so frequently 
seen in practice, are sad illustrations of the truth of this statement. 
When lymph is effused upon an open surface, as a wound or an ulcer, its appearance 
may generally be taken as a true index of the precise character of the action that is going 
on in the affected part, as to whether that action is healthy or unhealthy; and it is, there- 
fore, capable of affording valuable therapeutic indications. When it has the requisite 
degree of vitality, it is promptly converted into healthy granulations and new tissue ; 
whereas, when the reverse is the case, it rapidly perishes, and is finally thrown off as an 
effete substance or as a species of slough, the surface beneath exhibiting an irritable, in- 
flamed, phagedenic, or gangrenous aspect, and discharging a thin, serous, or bloody fluid, 
more or less fetid, and entirely destitute of the properties of laudable pus. This local 
action of the part is generally associated with a depraved, vitiated, scorbutic, or typhoid 
state of the system, and is liable to run into the very worst forms of pyemia and erysipelas, 
especially during the prevalence of epidemics, among the inmates of crowded, ill-venti- 116 
TERMINATIONS OF INFLAMMATION. 
CHAP. IV. 
lilted hospitals, and other establishments for the accommodation of the sick and wounded. 
Under such circumstances the lymph is nearly always aplastic, so much so, indeed, that the 
patient may be said to be laboring under a veritable aplastic diathesis. 
Treatment The treatment of lymphization is conducted upon general antiphlogistic 
principles; undue action is repressed, and the absorption of effused matter promoted. To 
accomplish the first of these objects, the ordinary local and constitutional measures are 
employed; for the second, sorbefacients are necessary, as mercury and iodide of potassium 
internally, and the tincture of iodine, liniments, and embrocations externally. In the 
acute stage of the disease, while secretion is still active, purgatives and antimonials, with 
the judicious exhibition of calomel, constitute the chief means of relief; but, the tendency 
to deposit having ceased, their use is dispensed with, all except the mercury, which is now 
given in minute doses, and with a view strictly to its alterative effect; it is often carried 
to slight ptyalism, the mouth and gums being maintained in a tender condition for, per- 
haps, several weeks consecutively ; or, with an occasional interval, for even a much longer 
period. In the latter event, the bichloride frequently, if not generally, forms a valuable 
substitute for the calomel; less likely to act hurtfully, and yet, at the same time, very 
effectually stimulating the absorbents. In such cases, too, small doses of tartar emetic 
often produce a most salutary influence, its action being hardly inferior to that of mercury 
itself, witli which it may frequently be advantageously combined. When the inflamma- 
tion has measurably subsided, its products, especially the serous and plastic, are generally 
easily disposed of by chloride of ammonium, or iodide of potassium, administered in doses 
varying from three to twenty grains, thrice in the twenty-four hours; strict attention 
being meanwhile paid to the diet and bowels. When the case is obstinate, an occasional 
mercurial constitutes a valuable addition. 
Among the more beneficial topical means are, the dilute tincture of iodine, applied twice 
in the twenty-four hours; inunctions witli mercurial and other unguents, particularly 
t.iat of the iodide of lead ; stimulating embrocations; and steady, uniform support with 
the bandage. Various kinds of plasters, as the common mercurial, the compound galba- 
num, and others of a kindred nature, are also frequently serviceable. Washing the part 
well, when accessible, twice a day with hot water and Castile soap, followed by dry fric- 
tion, often does more good than anything else. In some cases, again, cold, especially in 
the form of the douche, acts very beneficially, affording relief when other treatment fails. 
In the joints passive motion must be carefully performed, at first once, and then twice a 
day, to prevent ankylosis from the organization of the fibrinous bands which are so liable 
to form during the progress of synovitis. 
When the object is simply to assist nature in her efforts to repair an injury, as a wound 
or fracture, care should be taken, on the one hand, that the attendant action is not too 
low, and, on the other, that it does not transcend the fibrinizing limits. By overotfi- 
ciousness the system may be so exhausted as to render it impossible for the part to furnish 
an adequate amount of lymph, and a similar condition is often induced by debility, the 
result of previous disease, intemperance, or imperfect nutrition from want of proper food. 
Whatever the cause may be, it should be promptly counteracted by the use of tonics, 
especially quinine and iron, alcoholic stimulants, and other invigorating measures, to sup- 
ply the blood with the requisite material for the deposition of fibrin ; all enfeebling 
topical applications being at the same time discontinued. Overaction, on the contrary, is 
met by the usual antiphlogistic means, carefully and warily applied, lest harm should 
arise from the too rapid reduction of the vital powers. The management of the repara- 
tive process always demands great judgment and vigilance. 
SECT. IV SUPPURATION AND ABSCESS. 
Suppuration, the process by which pus is formed, is one of the most frequent, as it 
certainly is one of the most important, of the results, events, or conditions of inflamma- 
tion. Its presence, as a rule, is denotive of a higher grade of excitement than a mere 
deposition of serum and plastic matter, which, however, are nearly always associated 
with it. But it must not be supposed that the reverse of this proposition is true; for 
inflammation often exists in a severe degree, with an abundant effusion of the watery 
and fibrinous elements of the blood, and yet there is not the slightest evidence of sup- 
puration. 
It was formerly supposed that suppuration might occur independently of inflammation, 
an opinion which, doubtless, had its origin in the fact that there are occasionally cases in CHAP. IV. 
SUPPURATION AND ABSCESS. 
117 
which large quantities of pus are thrown off, without any evidence of the ordinary phe- 
nomena of inflammation, such, especially, as pain, heat, and discoloration of the struc- 
tures in which the matter is formed, or any constitutional disorder ; the whole process 
being apparently conducted as if both the part and system were unconscious of what is 
going on. Such cases are by no means infrequent, and yet, if they be carefully investi- 
gated, or traced through the various stages of their progress up to the dissection of the 
affected tissues, the most satisfactory proof will be afforded of their phlogistic nature. In 
a cold, strumous, or scrofulous abscess, for example, which has so often served as the basis 
for this now exploded idea, and the formation of which is sometimes the work of several 
months, inflammation is just as much concerned in the production of its contents, as in a 
phlegmonous boil that is developed in three or four days. The only difference is that in 
the one the morbid process advances very slowly, indeed almost imperceptibly, while in 
the other it proceeds very rapidly, and is accompanied by such well-marked symptoms as 
to render it impossible to mistake their character. 
Matter may form without any breach of continuity of the affected parts. This mode 
of suppuration is, in fact, very common, not only in the serous cavities, but throughout 
the greater portion of the mucous system. It is not, however, confined to these tex- 
tures. In the connective tissue, lungs, brain, liver, and other viscera, nothing is more 
frequent than suppuration without any ulceration whatever in the incipient stages of the 
morbid action. 
Suppuration does not take place equally readily in all the organs and textures. Of the 
viscera, those most prone to it are the liver, lungs, and brain ; of the tissues, the connec- 
tive, cutaneous, mucous, and serous. In the fibrous, cartilaginous, tendinous, and osseous 
textures, pus not only forms with difficulty, but is seldom of a thick, consistent character. 
Of the mucous system some portions are more liable to suppuration than others. Thus, 
it is much more common in the colon than in the stomach or ileum, in the vagina than 
in the uterus, in the urethra than in the urinary bladder, in the nose than in the month, 
in the fauces than in the oesophagus, in the bronchia than in the larynx. So, likewise, 
in the serous system, suppuration is more frequent in some situations than in others, as 
for example, in the pleura, the vaginal tunic of the testicle, and the lining membrane of 
the larger joints. In the subcutaneous connective tissue, pus forms most rapidly in parts 
remote from the heart. The bloodvessels do not often suppurate, except when wounded; 
and the same, so far as can be ascertained, is the case with the absorbents. The lym- 
phatic glands, however, suffer very frequently, especially those of the axilla, groin, neck, 
and base of the lower jaw, particularly in persons of a scrofulous taint. Nervous tissue 
seldom suppurates; muscular still more rarely. From all these facts we may deduce the 
axiom that those structures are most prone to form matter which contain the largest 
amount of loose connective substance, and, conversely, that those which possess this tissue 
sparingly always suppurate with difficulty, requiring, generally, a much longer period, 
and elaborating a less perfect fluid. 
The period at which suppuration occurs after the establishment of inflammation varies, 
on an average, from twenty-four hours to three or four days, depending upon the nature 
and situation of the affected tissues, the intensity of the morbid action, and also, in a 
very material manner, upon the condition of the system, and the character of the exciting 
cause. Mucous membranes, especially if exposed to the air, generally suppurate very 
readily, having, seemingly, a predisposition to take on this kind of action ; serous mem- 
branes, on the contrary, as they are arranged in the form of shut sacs, do not feel the 
stimulus of the atmosphere, and, therefore, suppurate with difficulty; another reason, 
doubtless, is the fact that such structures, when irritated, are naturally inclined to furnish 
lymph rather than pus, their organization peculiarly fitting them for that office. The same 
difference exists between the veins and arteries, and it is practically fortunate that it does ; 
otherwise the danger of wounds, whether the result of accident or design, requiring liga- 
tion of the principal arteries, would be much greater than it is. In some of the internal 
viscera, as the brain and liver, pus occasionally forms with great rapidity, as is seen in 
cases of injuries of these organs. Matter, other things being equal, forms most readily 
when the inflammation is very intense. A wound in an unhealthy or intemperate person 
is more likely to run speedily into suppuration than a similar one in an individual of 
sound constitution and regular habits. A phlegmonous boil usually pours out pus in from 
twenty-four to thirty-six hours, whereas a chancroid does not furnish any until about the 
beginning of the fourth day. In variola, the suppurative process is seldom fully estab- 
lished before the ninth day. 
Exposure of an inflamed surface to the air greatly promotes suppurative action, and 118 
TERMINATIONS OF INFLAMMATION. 
CHAP. IV. 
is, therefore, directly hostile to adhesion. The more nicely the edges of a wound are 
approximated, the greater, other things being equal, will he the probability of speedy 
and permanent reunion, and conversely. Serous membranes, as already stated, have 
naturally a disposition, when inflamed, to pour out lymph, and to contract adhesions; 
hut whenever they lose the character of closed sacs, as they necessarily do when they 
are accidentally opened, the morbid action, consequent upon the injury, is certain to 
be followed by the formation of pus, especially if the air have free access to them for any 
length of time. 
When suppuration is fully established, it is impossible to predict when it may termi- 
nate. In many situations, as, for example, the bowels and the bronchial tubes, it occa- 
sionally lasts for years, the discharge literally usurping the place of the natural secretions. 
Suppuration, when very profuse, as in a lacerated wound, an inflamed joint, ora large, 
irritable ulcer, leads to rapid exhaustion by the abstraction of the more important ele- 
ments of the blood, and by the induction of hectic fever, pyemia, or purulent infection, 
generally attended by severe rigors and copious sweats, rapidly draining the system. The 
appearance of thick, yellow, cream-like pus, under such circumstances, is always hailed 
by the surgeon as a gratifying omen, indicating, as it does, a decided improvement both 
in the part and system. Pus serves as a protective to granulating surfaces, preserving 
moisture and promoting growth ; assists in detaching foreign bodies impacted in the soft, 
structures and is probably instrumental, at least at times, in eliminating noxious matter 
from the blood, or so changing its character as to render it harmless. 
Pus, the product of suppuration, originally appears in the form of distinct globules, dis- 
persed through the affected structures, where they may be easily recognized by their pale 
yellowish color. As the particles increase in number, they gradually become confluent by 
the removal of the diseased tissues, the matter being thus collected into an abscess. 
The symptoms which characterize the suppurative process will claim special attention 
under the head of abscesses. Here it will suffice to observe, in general terms, that they 
are such as denote the existence of ordinary inflammation, with an increase, more or less 
considerable, of the local and constitutional disturbance. 
Pure pus, such, for example, as is found in a w'ell-matured phlegmonous abscess, is an 
opaque, homogeneous fluid, of a yellowish-white color verging on greenish, of a sweetish 
taste, without any particular odor, of a cream-like consistence, slightly viscid, and of an 
average specific gravity of 1030 to 1033. It has a faint alkaline reaction, is imperfectly 
soluble in water, does not readily putrefy, and is coagulated by heat, acids, and chloride 
of ammonium. Freezing destroys its normal properties. 
The specific gravity of pus is liable to considerable variation, depending mainly upon 
the quantity of its solid ingredients and the density of the pus-liquor. Thus, in seven 
examinations of this fluid, taken from abscesses in different situations—as the thigh, arm, 
axilla, back, pleura,and the lung in pulmonary phthisis—Dr. John Davy found the specific 
gravity as low in one as 1021, and in another as high as 1042. 
Pus essentially consists of the elements of the hlood, in an altered state, water consti- 
tuting about eighty-five per cent., the remainder being made up of albumen, fatty matter, 
osmazone, and salts, as chloride of sodium, and phosphate of calcium and magnesium. 
Lehmann, who has carefully examined this fluid, found the quantity of fatty matter to vary 
from 2 to 6 per cent., and the quantity of albumen in the serum from 1-2 to 3-7 percent. 
Casein and hematin do not exist in normal pus. A peculiar principle, termed pyine, has 
been detected in it by Giiterbock, supposed by some to be an oxide of protein, by others 
a form of fibrin. It is soluble in water, but insoluble in alcohol. Recent examinations 
have shown myosin, paraglobulin, protozen, leucin,and tyrosin to be constant constituents. 
Pyocyanine, the substance which imparts the bluish or greenish color to the contents of 
certain abscesses, and to the discharges of certain ulcers, is occasionally present. Pus of 
an orange color is sometimes met with, but all attempts to trace its origin, or to decipher 
its significance, have thus far failed. 
Pus is composed of numerous corpuscles, suspended in a'thin, transparent fluid, called 
pus-liquor. These little bodies, known as pus corpuscles, are spherical, finely granular 
masses of germinal matter or protoplasm from the to the °f an inch in diameter, 
and identical with lymph and colorless blood corpuscles. They are not vesicular in 
structure, for what w'as formerly considered to be a distinct cell-wall, is now known 
to be simply a peripheral, limiting layer of non-germinal or formed material. They are 
provided with nuclei, which are rendered visible on the addition of water or acetic acid, 
and are deeply stained by ammoniacal solutions of carmine. Some contain one well 
defined nucleus, others two, three, or more small nuclear bodies, their size depending upon 119 
CHAP. IV. 
their number. Fig. 13, from Rindfleisch, exhibits pus corpuscles in their different forms : 
a represents globules containing a single, large nucleus, from the pus of a healthy, granu- 
lating sore ; at b and c are seen cells from an abscess, before 
and after the action of acetic acid ; broken-down globules, 
from the pus of carious bone, are delineated at d; while at 
e are shown the forms which the living cells assume, by vir- 
tue of their softness and elasticity, in their amceboid move- 
ments. 
The pus corpuscles float in the pus-liquor, and are inter- 
mixed with various solid elements, as granules, shreds of 
fibrin, epithelial matter, and also, at times, with small 
homogeneous, non-nucleated corpuscles, termed pyoid. 
Pus is liable to be modified in its properties by the pres- 
ence of extraneous substances, as grumous blood, fibrin, 
cholesterine, and the debris of the organs and textures in which it is formed. In com- 
mon phlegmon, it often contains shreds of connective tissue, of a dirty grayish color, not 
unlike wet tow. The brownish matter found in certain abscesses of the liver probably 
derives its color and consistence from the intermixture of softened, disintegrated, hepatic 
parenchyma. In suppuration of the different glands, the pus is not unfrequently mingled 
with the product of their peculiar secretions, as urine in the kidney, bile in the liver, 
milk in the mamma, and semen in the testis. Purulent matter is sometimes very fetid, 
apparently from the extrication of sulphuretted hydrogen. 
The different varieties of pus have received different names. When the fluid is of a 
whitish, or pale yellowish color,creamy in consistence, and composed of numerous globules, 
it is said to be healthy, pure, or laudable, in reference to the process by which it is pro- 
duced, this being of a healthy, sanative, or restorative nature. It is usually met with in 
suppurating wounds, in healing ulcers, and in phlegmonous abscesses. 
Samoa s, serous, ichorous, or sanguinolent pus is thin, almost transparent, of a yellowish, 
amber, or reddish color, and generally so acrid as to erode the parts with which it comes 
in contact. It is a product of unhealthy inflammation, and is principally observed in caries 
of the bones, irritable ulcers, and open carcinoma. This variety of pus is often intermixed 
with grumous blood,flakes of fibrin, and the debris of the affected tissues. The thin, sani- 
ous pus furnished in abscess, ulceration, and necrosis of the osseous tissue, not unfrequently 
contains a considerable quantity of phosphate of lime. 
Fibrinous pus consists of common pus in combination with plasma. It is of a whitish, 
grayish, or cineritious color, and of a semiliquid, concrete, or lardaceous consistence. 
Under the microscope, it displays the globules of healthy pus, with numerous other cells 
and fibres, of irregular shape. It is usually found in the joints, in the splanchnic cavities, 
in metastatic abscesses, and in carbuncular inflammation. Its presence denotes a high 
degree of morbid action. 
Scrofulous pus is chiefly met with in pulmonary caverns, cold abscesses, scrofulous dis- 
ease of the joints, and chronic inflammation of the lymphatic glands. After standing a 
while, it usually separates into two parts, of which one is thick, straw-colored, and inodor- 
ous; the other, which rests on the surface, is oily in appearance, thin, ropy, and mixed 
with small, opaque, curdy flakes. When scrofulous pus is long retained, it may acquire a 
disagreeable, nauseous smell, not unlike the pollen of the chestnut; at other times it is 
excessively fetid. The attendant action is usually very languid. The term curdy is often 
applied to this variety of pus. 
Gummy pus, as it is termed, is a product of syphilitic affections of the bones, muscles, 
connective tissue, and internal organs. In its appearance it bears a strong resemblance 
to a thin solution of isinglass, arrowroot, or gum arabic, is of a pale whitish color, more 
or less ropy in consistence, and in great degree destitute of the properties of ordinary pus. 
It is composed mainly of albumen, and contains only a few well-formed pus corpuscles : 
oil globules and fatty matter are usually present in it. 
There is a variety of pus to which, from its admixture with mucus, the term muco-pu- 
rulent is applied. It is usually a product of a high degree of inflammation of the various 
outlets of the body, particularly of the nose, eye, bronchial tubes, and genito-urinary 
apparatus. The mucus supplied by these surfaces in the healthy state is composed of a 
transparent fluid, and of abraded epithelial cells, flat, and irregularly sided, with a central 
nucleus. In addition to these, the microscope detects numerous granular masses and 
spherical globules, similar to those of pus, suspended in a viscid, transparent, ductile fluid. 
SUPPURATION AND ABSCESS. 
Fig. 13. 
Various Appearances of Pus 
Corpuscles. 120 
TERMINATIONS OF INFLAMMATION. 
CHAP. IV. 
Under inflammation, the epithelial cells are cast off so quickly that they do not have time 
to be flattened out, and the globules are not only greatly augmented in number, but they 
acquire somewhat the character of those of pus. 
Finally, what is calledpuriform matter, is, as the name implies, not genuine pus, but an 
imperfect liquid bearing some resemblance to it. It occurs chiefly in bad forms of inflam- 
mation, as erysipelas, carbuncle, and pyemia, and consists essentially of broken-down 
lymph and shreds of tissue, interspersed with fatty substance, granules, abortive cells, and 
a few globules, smaller than those of pus, and not affording the usual reaction under acetic 
acid. The puriform matter, so abundantly thrown off in inflammation of the serous mem- 
branes, is generally nothing but turbid serum. 
Certain kinds of pus, as those, for example, of smallpox, varioloid, farcinia, gonorrhoea, 
and venereal ulcers, are contagious. In what particular element of the fluid the virus or 
specific secretion is contained, or whether it exists as an entity, is undetermined. The 
vitality of the organ by which it is elaborated is not necessary for the preservation of its 
peculiar effects. Once formed, it becomes independent of its source, and retains, for a 
considerable period, the power of contaminating the parts to which it is applied, producing 
a disease of the same character. Various chemical reagents, however, as the alkalies and 
acids, effectually neutralize, if they do not completely destroy, its specific properties. The 
pus of a chancroid often contains animalcules, particularly the vibrio lineola. 
Pus is a substance that is easily altered in its properties, the causes which mainly con- 
tribute to this result being its age, or the length of time during which it is retained in 
the body, and the contact of various fluids, especially air, gas, and water. The globules 
of the pus of an old abscess always contain fine fatty granules, generally from five to ten 
in number, which, when the development is unusually perfect, present a large, swollen 
appearance. The caseous transformation is observed chiefly in old scrofulous abscesses, 
the pus-liquor of which is absorbed, while the pus globules, assuming an angular con- 
figuration, shrink, atrophy, and form, by their agglomeration, a dryish caseous mass, of a 
whitish or slightly yellowish color. In abscesses of the cancellous structure of the bones, 
especially in those communicating with the joints, the fluid is generally very thin and 
watery, and not unf'requently contains lactic acid, under the influence of which the pus 
cells are distended, the protoplasm dissolved, and the nuclei set free. In suppuration of 
the joints of the fingers in gouty persons the fluid usually contains a large quantity of 
urate of soda. The pus globules always experience great alterations in their size and 
shape when pus contains an unusual quantity of water. The presence of gas in pus has a 
tendency to decompose it, to render it fetid, and to change its color. Pigmentary infil- 
tration of the pus globules occurs whenever the suppuration is attended with any consid- 
erable effusion of blood. 
The distinction between pus and mucus is of practical importance. The microscope is 
the most certain means of discrimination ; but, in its absence, other measures may be 
resorted to. Pus sinks in water; mucus floats. A glairy, viscid, gelationus mass is 
formed by the addition to pus of about half its quantity of the officinal solution of potassa, 
no such effect resulting from the action of the alkali on mucus, which becomes more fluid 
and limpid. The serum of pus is highly albuminous ; mucus is not. Mucus treated with 
acetic acid coagulates into a thin, membranous substance; pus does not. Under the ap- 
plication of ether, mucus yields the merest trace of fat, while pus always furnishes this 
material in considerable quantity. Pus diffused through blood can only be satisfactorily 
detected with the microscope, but in many cases the examination is very difficult on ac- 
count of the very close resemblance of the globules of the two fluids to one another. 
The differences between pus and milk, as in mammary abscesses, are generally easily 
distinguished by the relative size of the globules, those of the former being a good deal 
larger than those of the latter fluid. Purulent urine always contains albumen, and ex- 
hibits the characteristic pus globules. Softened and broken-down fibrin, as in clots in the 
bloodvessels, connective tissue, old aneurisms, and the splanchnic cavities, sometimes bears 
a considerable resemblance to pus, but differs from it in being destitute of exudation cells. 
Softened atheromatous matter is distinguished by the presence of cholesterine and the 
absence of pus corpuscles. 
By far the most ready, delicate, and trustworthy differential test of pus, however, is 
the color test, discovered by Dr. John Day, of Victoria. It is founded on the property 
possessed by oxygenated tincture of guaiacum of turning a clear blue color when brought 
in contact with pus, no such effect being produced on mucus, except on the addition of 
carbolic acid diluted with alcohol. CHAP. IV. 
ABSCESSES. 
121 
Pus was formerly supposed to be a product of broken-down fibrin ; but the observations 
of Virchow, Cohnheim, and other German pathologists, show that pyogenesis is due to 
the disturbances of the circulation and nutrition of the affected structures, through which 
the activity of local protoplasmic masses is increased, as evinced by their enormous mul- 
tiplication. It has been demonstrated by Virchow that, under the influence of the 
assimilation of an excess of blood-liquor, which has escaped from the dilated vessels at 
the focus of the inflammation, the connective-tissue corpuscles proliferate and assume the 
characters of pus globules. This theory of the formation of pus, however, is too exclu- 
sive, and has been placed in doubt bv the discovery of Cohnheim, who has shown by a 
series of well-contrived experiments that pus is in a great degree the product of the color- 
less blood corpuscles, which have wandered out of the vessels into the tissues. The 
results of these experiments have been confirmed by the researches of Koster, Vulpian, 
and other observers, and they carry the mind back to the days of Gendrin, who, in 1824, 
in his great work on the Anatomical History of Inflammation, enunciated almost pre- 
cisely similar views, based upon his own investigations. It has, moreover, been demon- 
strated that other cell elements enter into the formation of pus, as, for example, those ot 
the cornea, muscles, glands, mucous and serous membranes, which by their germination 
aid in the process. These points have been fully discussed in studying the intimate na- 
ture of inflammation, and need only be thus briefly referred to here. They, however, 
clearly point to the fact that pus is a fluid inflammatory new formation, due to the accu- 
mulation of young cells, which are derived partly from the blood, and partly from the 
cell elements normal to the tissue or organ affected. 
Pus corpuscles are originally alive, and in a state of active amoeboid movement, pro- 
liferating and sending out offshoots which form new corpuscles. Their transition from 
lymph and blood corpuscles may in many cases be distinctly traced with the aid of a 
magnifying glass; but how, or in what manner, they obtain their peculiar color and 
other physical properties, is undetermined. The probability is that the process is partly 
of a vital, partly of a chemical nature. All that is certainly known is that the pus 
corpuscles, in their size, shape, and structure, closely resemble lymph or colorless blood 
corpuscles, and that the fluid in which they are suspended always contains more or less 
oily matter, which, formed during their metamorphosis, constitutes one of its character- 
istic attributes. 
Pus is susceptible of absorption, probably in all its varieties, as well as in almost every 
locality. Of this fact satisfactory proof is afforded by what occurs in abscesses in the 
different external parts of the body; and it is, therefore, analogically reasonable to infer 
that it may also take place in the internal organs and cavities. Great doubt has been 
expressed by some pathologists respecting the possibility of pus being taken up in this 
manner, on the ground, chiefly, that the accumulations which occasionally disappear, both 
spontaneously and under treatment, are really not abscesses, but collections of plastic 
matter. Every surgeon of experience, however, knows that pus, or puriform fluid, is 
sometimes removed by the agency of the absorbents, after its existence lias been satisfac- 
torily tested by the exploring needle. Particular remedies are often employed for the 
attainment of this object, and our efforts are certainly not unfrequently crowned with suc- 
cess, although probably not so often as is generally supposed. 
When pus disappears spontaneously, it is highly probable that the more fluid elements 
enter the system readily, and without any previous change ; indeed, recent observation 
has shown that even the pus corpuscles may do this, although it is reasonable to suppose 
that, as a rule, the absorbent vessels do not admit them unless they have been more or 
less disintegrated and broken down. Whether the fatty matter remains, or whether it, 
also, is removed, has not been determined. How pus is disposed of, after it has reached 
the circulation, is likewise unknown ; the most reasonable conclusion is that it undergoes 
oxidation, and that it is excreted by the liver and kidneys, if not, also, by some of the 
other emunctories. 
ABSCESSES. 
An abscess is a circumscribed cavity of abnormal formation, containing pus. When 
the matter is poured into a natural cavity, as the chest, or into a joint, the collection con- 
stitutes what is called a purulent effusion. An abscess may be superficial or deep, acute 
or chronic, common or specific. It is said to be superficial when it lies immediately 
beneath the common integuments or in the connective tissue among the superficial muscles. 
The word deep, on the contrary, is used when the matter is lodged in an internal organ, 122 
TERMINATIONS OF INFLAMMATION. 
CHAP. IV. 
in a bone, or among muscles. The terms acute and chronic have reference merely to the 
time occupied in the formation of the abscess. A common abscess is one produced by 
ordinary inflammation; while the specific abscess is the result of the operation of some 
particular poison, as the virus of chancroid, smallpox, or glanders. Finally, an abscess is 
circumscribed, as when it is bounded by plastic matter ; or diffused, as when its contents 
are sent abroad through the connective tissue. 
The most natural division of abscesses is into phlegmonous, scrofulous and metastatic, 
the first being incident to all persons, while the second occurs only in certain classes of 
individuals, or such as are affected with a strumous taint of the system. The term “ me- 
tastatic,” formerly so much in vogue, is employed to designate those collections of pus 
which supervene upon severe injuries, operations, and diseases, and might advantageously 
be abolished, as it is calculated to convey false impressions respecting a form of suppura- 
tion which properly comes within the definition of phlegmonous, although, as will be 
shown by and by, it is generally supposed to have its origin in a septic condition of the 
blood. It has also been described under the term “ multiple,” and will claim particular 
attention under the head of pyemia. It is not easy, in the present state of the science, 
to assign an appropriate place to the diffuse abscess, as it is often impossible to determine 
its true character. The specific abscess does not require any special consideration, since, 
apart from its exciting cause, its mode of formation does not, so far as we are able to com- 
prehend it, differ at all from that of the common phlegmonous abscesses. 
Sir James Paget, in 1809, described what he calls the “residual abscess,” formed out 
of the debris of former structures of this kind, often at the distance of many years, from 
a recurrence of inflammation, especially after the system has become exhausted by the 
influence of disease or accident. The occurrence is most common in connection with 
scrofulous abscesses, the walls of which, left in an unsound condition, are very suscepti- 
ble to fresh attacks of inflammation, the predisposition to disease being augmented, often 
very greatly, by the retained, withered, half dry, and degenerated pus. Instead of call- 
ing such abscesses residual, it would be more appropriate to denominate them “ recurrent,” 
as the name is more expressive of their peculiar character. 
1. PHLEGMONOUS ABSCESS. 
A phlegmonous abscess is one which, running its course with unusual rapidity, is always 
accompanied by well-marked inflammatory symptoms. The part feels, as the name im- 
plies, as if it were on fire, being hot, tender, and exquisitely painful. A tensive, throb- 
bing sensation is usually present, synchronous with the pulse at the wrist, and greatly 
aggravated by dependent position ; it is particularly severe at the focus of the morbid 
action, and is a valuable diagnostic symptom, as it is generally denotive of suppuration. 
Its immediate cause, as explained elsewhere, is obstructed circulation, with consequent 
pressure upon the nerves of the affected structures. 
The mode of development of a phlegmonous abscess is an interesting study. In the 
first place, the matter is obliged to have a receptacle for its accommodation. This is usu- 
ally furnished by the cells of the connective or areolar tissue of the part; but as the ac- 
cumulation, at first drop-like, progresses, this substance is destroyed by ulcerative action, 
or by the action of the absorbents, and a cavity is thus gradually formed, often capable, 
in the end, of holding an immense quantity of fluid. While the process of deposition is 
going on, plastic matter is poured out at the periphery of the cavity, gluing up the connec- 
tive tissue, and thereby forming a kind of boundary line around the pus, which effectually 
prevents its diffusion among the surrounding structures. No distinct cyst is constructed, 
for nature has not time for such an enterprise, nor is she at all in need of it, although the 
occurrence is not impossible even in acute abscesses, especially in one of the liver. The 
next phenomenon to be observed is the effort which the matter makes to reach the nearest 
surface, for this is one of the laws of interstitial suppuration. To this end the matter 
itself is eminently contributary, the pressure which it exerts upon the superimposed parts 
greatly promoting and expediting the ulcerative action, by the agency of which evacua- 
tion is finally attained. Thus, at least three separate and distinct processes are going on 
during the formation of an abscess ; a deposit of pus, an effusion of plasma, and ulcerative 
absorption. The importance of an effusion of plasma is shown by the fact that, when 
this substance fails to be poured out, the contents of the abscess ai'e widely diffused 
among the surrounding structures, committing extensive havoc in the connective tissues, 
and causing frightful separation of the muscles. These evil effects are often witnessed PHLEGMONOUS ABSCESS. 
123 
CHAP. IV. 
in phlegmonous erysipelas, where, from the cacoplastic character of the lymph, the matter 
occasionally burrows to a great distance, destroying everything within its reach. 
The great law which presides over the spontaneous evacuation of abscesses, by which 
their contents are enabled to reach the nearest surface, is attended with the most fortu- 
nate results, for it not only abridges suffering, but saves structure. Thus, in abscess of 
the liver, a long time would elapse, and an immense amount of pain and constitutional dis- 
order would be caused, if the matter, instead of emptying itself, as it usually does, into an 
adjoining coil of intestine, were compelled to travel across the walls of the abdomen. 
The contents of the phlegmonous abscess usually partake strongly of the nature of 
well-elaborated pus, being of a whitish, or pale straw color, and of a thick, cream-like 
consistence, with an abundance of large and well-matured pus corpuscles. Intermixed 
with them are often flakes of lymph, and the debris of the affected structures. Thus, in 
abscess of the external parts of the body, it is not uncommon to meet with shreds of con- 
nective tissue ; in abscess of the liver, with broken-down hepatic substance. Occasion- 
ally, again, the pus is blended with the peculiar secretion of the part, as semen in abscess 
of the testicle, bile in that of the liver, and milk in abscess of the mamma. As a means 
of diagnosis, a knowledge of these facts is of great practical value, the nature of the ad- 
ventitious matter often pointing directly to the seat of the disease. Some forms of acute 
abscess, as those more particularly which follow upon severe accidents and capital opera- 
tions, and to which the term metastatic is sometimes applied, are made up almost en- 
tirely of fibrinous matter, the quantity of pus corpuscles being extremely small. When 
pus is long retained, the corpuscles may degenerate, breaking down and assuming an 
amorphous form ; while the serum undergoes various chemical changes, often of a putre- 
factive character, attended, in most cases, with the fatty transformation, and sometimes 
even with the liberation of calcareous salts. 
The contents of certain abscesses are excessively fetid. This is especially true of ab- 
scesses around the anus, from the proximity of the pus to the bowel, or from the actual 
intermixture of fecal matter. The same circumstance occasionally obtains, although 
generally in a less degree, in abscesses in some other situations, as the tonsils, bones, and 
lymphatic glands. 
An abscess sometimes contains air, the fluid resting upon the top of the matter, as in 
inflammation of the perineum, about the sacrum, in the ileo-lumbar region, and in front 
of the abdomen, from a communication with the intestinal tube. A similar occurrence is 
occasionally witnessed in suppuration of the chest, when the matter contained in that 
cavity makes an effort to escape externally through one of the intercostal spaces, after 
an opening has been made into a bronchial tube. In general, the pus, when thus ad- 
mixed, is excessively fetid, and the abscess is distinctly emphysematous, crepitating under 
pressure, and often emitting a peculiar gurgling noise. 
Phlegmonous abscesses occur at all periods of life, as well as in all classes of individuals. 
They are occasionally observed within a few weeks after birth, especially in the mamma 
and in the lymphatic glands of the neck and of the axilla. They may be traumatic, or 
idiopathic ; or, in other words, dependent upon external injury, or constitutional causes, 
as a depraved condition of the blood, derangement of the digestive organs, or the sup- 
pression of some important secretion, as that of the liver, kidney, or uterus. Abscesses 
of this kind are sometimes of a secondary character, one forming after another, as if there 
existed a species of pyogenic diathesis. Such an occurrence often proves exceedingly 
untoward, sadly interfering with recovery, especially during convalescence after protracted 
fevers and severe injuries. 
Although phlegmonous abscesses may form in any part of the body, they are most 
common in the connective tissue beneath the skin, among the muscles, and around the 
lymphatic glands, as well as in the substance of these bodies, especially in those of the 
neck, axilla, and groin. Among the internal organs, those that are most liable to suffer 
are the liver, lungs, and brain, but even here phlegmonous abscesses, except as a result 
of external injury, are extremely rare. 
The number of abscesses varies from one to a great many, and is generally in an inverse 
•ratio to their size. Two or three large ones occasionally exist simultaneously in different 
parts of the body; and, on the other hand, the whole surface is sometimes, as in variola, 
literally covered with small ones. The size of a phlegmonous abscess ranges from that of 
a mustard-seed up to that of an adult’s head. 
The symptoms which precede and accompany the formation of a phlegmonous abscess 
are very variable. In general, they are such as characterize ordinary inflammation. The 124 
TERMINATIONS OF INFLAMMATION. 
CHAP. IV. 
part, if open to inspection, is found to be red, hot, swollen, and painful, beating and 
throbbing synchronously with the left ventricle of the heart. As the matter accumulates, 
all these symptoms augment in severity, especially if the fluid is bound down by hard, 
unyielding structures, interfering with its exit or extension. Under opposite circum- 
stances, however, the pain often diminishes, the part feeling relieved almost as soon as the 
deposition of pus has fairly begun. However this may be, the discoloration of the skin 
always increases as the matter approaches the surface, and generally assumes a dusky, 
purple, or livid aspect, particularly at the focus of the abscess. The swelling also aug- 
ments, and the part often pits on pressure, more or less serum being effused into the 
subcutaneous connective tissue. The heat is much greater than it is in the surrounding 
structures, and there is always serious functional disor ler. 
The morbid action continuing, the centre of the abscess becomes acuminated, and the 
matter, in surgical language, is said to point. The skin here is not only greatly discol- 
ored, but thin and impoverished; and giving way at the most prominent part of the tumor, 
allows its contents to escape, generally by a small orifice, which is often entirely inade- 
quate to thorough clearance. The period which intervenes between the commencement 
of the inflammation that leads to the formation of the abscess, and the evacuation of the 
pus, varies from a few days to several weeks. 
When the abscess is small, or situated in a comparatively unimportant part, the con- 
stitution may fail to take cognizance of it, but this is the exception rather than the rule ; 
for, in the majority of cases, the system warmly sympathizes with the local trouble, and 
manifests the interest it feels in it by well-marked inflammatory symptoms. When an 
abscess is about to form in an internal organ, the patient is seized with rigors, often vio- 
lent and long continued, alternating with flushes of heat, and generally followed by copious 
sweats. This frequently happens even when the abscess is of a very trivial size; the 
importance of the affected structures giving proportionate force to the morbid action, 
liigors also generally occur in abscess of the bones and joints, but comparatively seldom 
when the disease is seated in the subcutaneous connective tissue. An abscess of the ear, 
parotid gland, tonsil, anus, and perineum is nearly always attended with high constitu- 
tional excitement, along with cold, chilly sensations, and what are called muscular pains. 
If the case is at all severe, delirium will be likely to be present, lasting either until the 
part is relieved, or until the disease proves fatal. The countenance is generally flushed, 
the eyes are suffused, and there is often a hectic spot upon the cheek, especially in internal 
suppuration. The pulse is full, strong, and frequent; the skin hot and dry; the urine 
scanty, high-colored, and loaded with uric acid. Great thirst and restlessness usually 
exist. When the abscess is fully formed, the constitutional symptoms, as well, indeed, as 
the local, often greatly abate, comparative comfort succeeding the violent perturbation. 
The pulse becomes soft and calm, the surface is bathed with perspiration, the renal secre- 
tion increases in quantity and improves in quality, and the patient, grateful for the happy 
change, falls into a tranquil sleep. 
Diagnosis Notwithstanding that the symptoms of phlegmonous abscess are usually 
well marked, cases now and then arise where the diagnosis is so obscure as to cause seri- 
ous doubt respecting their true character. Indeed, there is probably no department of 
surgery where so many mistakes are constantly committed as in this. If the records of 
the science could be thoroughly explored, they would be found to abound in blunders of 
this kind. As it is, we frequently hear of carcinomatous and sarcomatous tumors, aneu- 
risms, and hernias being opened for abscesses, and life either instantly destroyed, or 
placed in great ultimate jeopardy, by the operation. Such mistakes, which are more fre- 
quent in chronic than in acute abscess, are hardly less injurious to the surgeon than to 
the poor patient; for they but too certainly ruin his prospects and reputation as a practi- 
tioner. Attention to the following circumstances will materially assist in clearing up 
difficulty: 1. The history of the case; 2. Pointing; 3. Fluctuation; 4. (Edema; 5. 
The use of the exploring needle. 
1. The flrst object that should claim attention is the history of the case. Upon inquiry, 
it will usually be found that the disease has been of short duration ; having commenced 
with the ordinary symptoms of inflammation, and gradually increased until the suppura- 
tive point was attained, the fever being high, and the local distress often extreme, liigors 
are looked for if the abscess be deep seated, extensive, or among important structures. 
The pain is tensive and throbbing, steady and persistent, not intermittent, or severe atone 
time, and absent at another. The countenance is expressive of great suffering, and, with 
a surgeon of experience, this symptom alone is sometimes sufficient to establish the diag- PHLEGMONOUS ABSCESS. 
125 
CHAP. IV. 
nosis of the case. If the abscess is lodged externally, the swelling is observed to be 
gravescent, unnaturally hot, excessively tender, intolerant of manipulation, and of a dusky 
reddish color, especially at its most prominent point. Its career is comparatively brief, a 
few days, a week, or, at most, a fortnight, sufficing to reach its acme. Then comes the 
period of dissidence, if the matter is not evacuated ; the symptoms abating in severity, 
the pulse and skin becoming soft, and the pain losing its throbbing character. 
2. Pointing is a symptom of great importance in the diagnosis of a phlegmonous abscess. 
It is always most conspicuous where there are, or were, most pain and discoloration, and 
naturally the least amount of resistance in the overlying structures. The skin looks 
dusky, purple, or livid, and feels thin and attenuated, as if it were ready to give way, as, 
in fact, it generally is. A tumor, benign or malignant, may also point, but a careful con- 
sideration of the history of the case commonly suffices to show the difference. 
3. Fluctuation in an abscess necessarily implies the existence of mobility. If the 
matter lies near the surface, it may readily be displaced on one side, and rendered corre- 
spondingly prominent on the opposite. Two methods may be adopted in conducting the 
examination. In one, alternate pressure is made with the hands or lingers resting upon 
opposite points of the abscess. As one hand or finger sinks in, the other is elevated, a 
circumstance clearly denotive of the existence of fluid, although the fluid may not be 
purulent. The other method consists in percussing the tumor with one hand, the other 
band being placed upon the opposite side. If matter be present, an undulatory motion 
will be imparted, one of the surest signs of suppuration. This method, however, is less 
delicate than the other, and is applicable only to abscesses of unusual volume. When the 
matter is seated superficially, its presence may often be detected by passing the finger over 
the most prominent part of the swelling, when, if there be pus, it will generally sink in a 
little, in consequence of the skin at that part offering less resistance than at the periphery 
of the tumor. This method of examination is particularly adapted to small abscesses of 
the scalp, perineum, tibia, clavicle, fingers, and other superficial portions of the skeleton. 
Finally, one may often readily satisfy himself of the existence of pus by grasping the 
suspected swelling, especially if it be very small, with the thumb and forefinger, and then, 
while the skin is thus stretched or rendered tense, pressing upon the top of the swelling 
with the index finger of the other hand. Such a mode of exploration is particularly valu- 
able in abscesses of the mamma, testicle, subcutaneous connective tissue, and lymphatic 
glands of the neck, groin, and axilla. 
There are certain parts of the body, which, under the influence of disease and injury, impart 
a deceptive sensation of fluctuation, as the dorsal surface of the hand, the forearm on a 
level with the head of the radius, the calf of the leg, the upper and outer aspect of the 
thigh, and the inner and upper portion of the thigh on a level with the iliac and psoas 
muscles. A similar condition occasionally exists in the temple. Without a knowledge of 
these facts, the occurrence of swelling in these regions might readily induce the surgeon 
to use his bistoury when there is no matter. 
4. Valuable information is often afforded by the appearance of the swelling. Thus, 
when the matter is very deep seated, as in an abscess of the thigh, the existence of oedema 
is nearly always decisive of the nature of the case, especially when it is conjoined with a 
hard, brawny state of the parts. The fluid cannot, from the manner in which it is bound 
down, reach the surface, but its presence causes inflammation in the skin and connective 
tissue, leading to an effusion of serum, and consequently to more or less pitting under the 
pressure of the finger. In empyema, or purulent collections in the pleura, oedema of the 
chest, directly over the seat of the fluid, is usually a prominent, and, indeed, in many 
instances, a characteristic symptom. A puffy, oedematous state of the scalp is often 
denotive of abscess of the brain and dura mater, in injury of the skull. 
Although oedema is in general a valuable sign in suppuration, it occasionally exists in 
a very high degree without any pus. A few years ago I saw a case of acute sarcoma 
of the hip and thigh in a young lady of twenty-six, where the quantity of serum in the 
subcutaneous conneetive tissue was so great as to produce the most decided fluctuation at 
various points of the swelling, and yet not a particle of matter followed the insertion of the 
bistoury. 
5. The affections most liable to be mistaken for abscess are sarcoma, aneurism, 
hernia, cystic tumors, and local oedema. From the first of these the history alone of the 
case will generally suffice for a correct diagnosis. Sarcoma is a chronic affection ; a 
phlegmonous abscess an acute one the first is attended with little or no pain until ulcera- 
tion sets in ; the latter with a great deal, generally from the moment it begins until it is 
evacuated. 126 
TERMINATIONS OF INFLAMMATION. 
CHAP. IV. 
An abscess may be mistaken for an aneurism,'especially if it be seated over a large 
artery, which communicates to it its impulse. Errors of this kind are most likely to hap- 
pen when the disease occupies the axilla, neck, groin, or ham, where the tumor receives 
an impulse from the vessel below. An aneurism of the thoracic aorta, perforating the 
chest, has occasionally been opened under the supposition of its being an acute abscess. 
The history of the case, the discoloration of the skin, the imperfect outline of the swell- 
ing, and the conical projection on the surface, will generally suffice to differentiate the 
two affections. An aneurism is usually of slow formation, and does not for a long time 
manifest any disposition to approach the surface. The disease, moreover, is most com- 
mon in elderly subjects, whereas abscesses occur at all periods of life. 
A strangulated hernia of the groin, abdomen, or upper part of the thigh might be mis- 
taken for an abscess, but such an accident could hardly happen in the hands of an expe- 
rienced surgeon. The history of the case, the peculiar character of the swelling, and the 
existence of symptons of strangulation will always be sufficient to clear up any doubt that 
may arise respecting the nature of the affection. 
A serous cyst has occasionally been mistaken for an abscess. Such an error can only 
occur when the cyst takes on inflammation, attended with discoloration, pain, and fluctua- 
tion. The mere site of the tumor is generally sufficient to indicate its true nature, inde- 
pendently of its history. 
An acute abscess maybe confounded with local oedema of the connective tissue, circum- 
scribed, elevated, puffy, discolored, and more or less painful. The occurrence is most com- 
mon in the hand and foot, and in the neighborhood of some of the joints, especially in 
cases accompanied by a considerable effusion of synovial fluid. 
6. When, notwithstanding the most thorough scrutiny of the case, the diagnosis remains 
uncertain, the exploring needle will often decide the question in a moment. The instru- 
ment which I usually prefer is an ordinary cataract needle, introduced at the most promi- 
nent part of the swelling down to its very centre, and freely rotated upon its axis, in 
order to condense the walls of the puncture, and thereby facilitate the flow of fluid. If 
the contents be purulent, the circumstance will be revealed by the appearance of a drop of 
pus at the orifice; whereas, if the swelling be an aneurism, the discharge will be san- 
guineous. If the tumor be sarcomatous simply a little blood will probably escape. 
Sometimes the diagnosis of a suspected abscess may readily be determined by the aspi- 
rator. A small canula having been introduced into the swelling any fluid that may be 
present rushes at once into the exhausted receiver, and thus reveals the true nature of the 
affection. 
Prognosis The prognosis of this disease is influenced by a variety of circumstances, 
of which the most important are the size, number, and seat of the abscesses, and the age, 
habits, and constitution of the patient. 
A large accumulation of pus is, other things being equal, more dangerous than a small 
one, because it not only produces more havoc among the tissues, but it exerts more severe 
pressure upon the surrounding parts, and establishes a greater drain upon the system. 
Number has an important bearing upon the prognosis. A man may struggle through 
several abscesses, even when of considerable bulk, but when he is laboring under a great 
many he will be extremely fortunate if he do not sink under them. Smallpox is always 
a dangerous disease, chiefly on account of the immense number of abscesses which attend 
its progress, few patients being able to withstand the irritation and consequent prostration 
occasioned by their development. The situation of the matter is an object of import- 
ance. Thus a small abscess of the perineum may cause fatal retention of urine, as one 
of the fauces may induce death by compression of the glottis. Importance of struc- 
ture also influences the issue of the case. An abscess of an internal organ, as the liver, 
is more dangerous, and more likely to prove fatal, than an abscess of an external part of 
the body, as a lymphatic gland. 
The recovery of a person laboring under phlegmonous abscess is often materially influ- 
enced by his age, habits, and state of constitution. Young adults and middle-aged subjects 
usually get on better than children and very old persons, who often meet such attacks very 
poorly, making a very feeble show at resistance. The intemperate man has a worse 
chance than one of good habits, and the man of bad previous health than one who has 
always had an excellent constitution. 
Treatment The treatment of phlegmonous abscess is conducted upon general anti- 
phlogistic principles ; at first, by depletion, purgatives, antimonials, and the ordinary 
topical means, to limit deposit and save structure ; and afterwards, by the lancet, to pro- CHAP. IV. 
PHLEGMONOUS ABSCESS. 
127 
mote evacuation and repair. Sometimes spontaneous removal is permitted, as when the 
abscess is seated immediately beneath the periosteum as an effect of tertiary syphilis, or 
when it occupies a lymphatic gland, and has as yet made little progress; favored, if 
necessary, by the administration of mercury and iodide of potassium, and the application 
of iodine, blisters, and other sorbefacients. But such cases are exceptional, and do not 
affect the general rule of practice, which always seeks an early outlet for the pent-up fluid. 
In some situations we do not even wait for well-marked pointing, much less distinct fluc- 
tuation ; but assured that matter is present, make an early and free incision, thus abridg- 
ing suffering and saving structure. The beneficial 
effects of this practice are strikingly illustrated in ab- 
scesses in various parts of the body. Thus, in puru- 
lent collections around the anus, an early outlet is 
indispensable, otherwise the matter will be sure to 
burrow along the side of the rectum and to perforate 
its walls, thereby forming an anal fistule. An ab- 
scess of the perineum requires prompt interference to 
prevent retention of urine and the establishment of 
urethral fistule ; of the fingers, lest the matter should 
travel along the sheaths of the tendons and so pro- 
duce extensive sloughing and necrosis ; of the fauces 
and tonsils, to prevent suffocation by the pressure of 
the swelling upon the glottis. The torturing pain of 
a gum-boil, an abscess of the jaw, is often instantly 
relieved by an early and free incision. The same 
procedure in deep-seated abscess of the extremities 
not only moderates pain and constitutional irritation, 
but prevents the pus from burrowing among the mus- 
cles, and so causing extensive destruction of the con- 
nective tissues. 
An abscess should be opened early when, from its 
proximity to a large vessel, there is danger that a 
communication may be established between them, 
thus leading to fatal hemorrhage. Such an event 
will be more particularly liable to occur in delicate 
children, laboring under the effects of scarlatina, mea- 
sles, or smallpox, and in elderly subjects worn out by 
long suffering and an impoverished state of the blood. 
The vessels most subject to this danger are those about the neck. In Mr. Liston’s cele- 
brated case, the abscess opened into the common carotid ; it was punctured and the patient 
perished from hemorrhage. The parts are represented in fig. 14. In an abscess of the 
neck, involving the thyroid artery, asphyxia has been suddenly induced by the escape of 
blood into the windpipe. Billroth met with an abscess at the base of the skull, in which, 
in consequence of disease of the internal carotid artery, death finally resulted from profuse 
hemorrhage of the right ear, nose, and mouth despite the ligation of both common carotids. 
Artificial evacuation may be effected with the knife or with caustic. The latter, atone 
time so much in vogue, is now seldom employed, and it would be difficult to conceive 
what possible advantage it could possess over the former, which is incomparably more 
expeditious, less painful, and more certain. A surgeon should not so far humor a patient 
as to use caustic wdien his judgment plainly condemns it, simply because he is foolishly 
timid, especially now that all apprehension and suffering may be so readily prevented by 
the administration of amesthetics ; nor should he, on the other hand, resort to caustic 
with the view of promoting suppurative action, since there are always at our command 
articles far more desirable and efficacious. If, however, such a remedy should be called 
for, the best one is Vienna paste, applied as in making an ordinary issue, the eschar 
being afterwards penetrated, if need be, by the bistoury, now no longer dreaded by the 
patient. 
Various instruments are employed for opening abscesses. The awkward, clumsy thumb 
lancet, which formerly figured so conspicuously in every pocket-case, is now seldom used, 
having been advantageously superseded by the scalpel and bistoury. The scalpel is, how- 
ever, rarely employed, except in very large abscesses, when it is necessary to make a very 
free division of the overlying structures. By far the neatest contrivance for the purpose 
is the little bistoury, represented in fig. 15, which I have used almost exclusively for 
Fig. 14. 
Mr. Liston’s Case. b. The External Opening 
of what was an Abscess a. The Ulcerated 
Communication between the Cyst and the 
Carotid Artery: the latter has been sliced 
open. c. The Pneumogastric Nerve. 128 
TERMINATIONS OF INFLAMMATION 
CHAP. IV. 
many years. It consists of two very narrow, sharp-point- 
ed blades, one straight, and the other slightly curved, short, 
yet long enough to reach to the desired depth in almost any 
conceivable case. Selecting the most prominent, and, if 
possible, also the most dependent, portion of the abscess, 
the instrument is plunged perpendicularly through the skin, 
into the very midst of the matter, its arrival there being 
indicated by a want of resistance and probably also by an 
escape of a few drops of fluid, especially if this be thin. 
The puncture thus made is then converted into an incision, 
by depressing the handle of the bistoury, and cutting from 
within outwards, the length of the opening varying, on an 
average, from a third of an inch to an inch, according to the 
volume of the abscess. In general, it is better that the 
opening should be too large than too small, as the object 
always is to afford free vent to the pent up fluid. Care, 
of course, is taken, in introducing the bistoury, not to in- 
terfere with any important vessels and nerves, or to perfo- 
rate any important cavity. 
In large abscesses, attended with great destruction of the 
connective tissue, and extensive separation of the muscles, 
the course of the arteries is sometimes completely changed 
by the pressure of the accumulating fluid ; and hence the 
surgeon, if not fully upon his guard, may, in making this 
puncture or incision, cause very serious, if not fatal hemor- 
rhage. The best way to avoid such an accident is to ascertain carefully, beforehand, the 
situation of the vessel, as may usually be done by its pulsation. 
When the abscess is very deep seated, as, for instance, when it occupies the muscles of 
the thigh, the walls of the abdomen, the groin or axilla, the safest plan is to divide the 
skin and fascia freely with the knife and grooved director, employed in the same cautious 
manner as in the removal of a deep-seated tumor. 
Penetration having been effected, the matter usually escapes of its own accord, simply 
by the pressure of the atmosphere; but the evacuation may be aided, if necessary, by 
the hand or finger, used, however, with the greatest gentleness, otherwise it may occasion 
not only severe pain, but an aggravation of the inflammatory action. Too much caution, 
indeed, cannot be observed in this particular. Nothing can be more reprehensible than 
the rude manipulations that are so often practised after this operation, even by surgeons 
otherwise well educated. To prevent the incision from healing by the first intention, and 
the necessity of the repeated use of a knife, a small, well oiled tent, made of old linen, is 
interposed between the edges, one extremity being carried a short distance into the now- 
empty sac, and the other left slightly pendant externally, substitution being effected once 
in the twenty-four hours. Or, instead of a tent, a drainage tube maybe used to carry off 
the matter as fast as it is formed ; the caliber of the tube should be of good size, and the 
side openings should be large, otherwise they will soon become clogged, and thus be- 
come a source of mischief. The best application for the surface of the abscess is an emol- 
lient cataplasm or a cloth wrung out of tepid lead water; but this should not be made 
until bleeding has ceased, otherwise troublesome hemorrhage might ensue. As soon as 
the parts have become perfectly comfortable, the warm dressing is discontinued, on ac- 
count of its relaxing tendency, a piece of lint, spread with simple cerate, or wet with 
olive oil, being used in its stead. 
When the matter is seated in a bone, evacuation must be sought with the trephine; but 
the operation is not always successful, owing to the difficulty of the diagnosis. 
When the abscess is of large size, or when it has occasioned extensive separation of 
the muscles, its sides should be approximated, after evacuation, by means of a thick and 
well-adjusted compress, secured by adhesive strips, or, in the event of the matter being 
seated in an extremity, by the common roller, extending upwards from the distal part of 
the limb, care being taken not to interfere with the artificial opening. In this way a 
cavity that might otherwise not close under several weeks, will often be effectually oblite- 
rated in a few days. 
Large abscesses are often immensely benefited, especially if slow in healing, by being 
thoroughly washed out several times daily with weak solutions of carbolic acid, chloride 
Fig. 15 
Abscess Bistoury. CHAP. IV. 
PHLEGMONOUS ABSCESS. 
129 
of zinc, or chlorinated sodium. These fluids, judiciously used, allay fetor, arouse healthy 
action, promote repair, and lessen the danger of purulent infection. 
An abscess is sometimes prevented from healing by the unfavorable position of*its open- 
ing, whether natural or artificial, the matter accumulating in a kind of pouch, situated 
between the orifice and the bottom of the swelling. Such a condition calls for what is 
termed a counter-opening, which is easily established by making an incision at the most 
dependent part of the sac, upon the end of a grooved director, introduced through the 
previous and now useless aperture. Counter-puncture is often necessary in abscess of the 
neck and parotid region, from the gravitating tendency of the matter in these situations. 
Sometimes, again, an opening of this kind is called for on account of a change in the po- 
sition of the part after the first operation, performed perhaps well enough at the time. 
Whatever may be the causes demanding it, patency is maintained with more care, if 
possible, than under ordinary circumstances. 
Again, repair may be rendered tedious, if not impracticable, by the existence of a 
sinus, extending, perhaps, deeply among the surrounding parts, or, if may be, communi- 
cating with some natural cavity. The most speedy and effectual remedy is incision with 
a bistoury upon a grooved director, inserted into the bottom of the track, the parts being 
thus laid into one, and permitted to heal by granulation, readhesion being prevented by 
the constant interposition of a piece of lint. In the milder cases, steady and systematic 
compression sometimes succeeds in obliterating the abnormal channel; sometimes, again, 
gently stimulating injections are useful; and, finally, there is a class of cases in which 
the seton is worthy of trial. In general, however, these means only serve to amuse the 
patient and annoy the surgeon, who is at last compelled to have recourse to a remedy 
which he should have employed in the first instance. • 
Hemorrhage from extension of ulcerative action into a neighboring artery or vein may 
be so profuse as to endanger if not destroy life, either speedily or more or less remotely. 
In most cases it will be found to be very troublesome from the difficulty that is experienced 
in ascertaining its source. The proper remedy is the ligature, the vessel being seized and 
drawn out with the forceps or tenaculum, or compressed with a needle confined with a 
stout thread, after the manner of a twisted suture. Gentle compression sometimes answers 
the purpose, especially if the bleeding be venous, or if it proceed from a number of small 
points. If an artery of considerable size has been opened, and cannot be easily reached, 
the incision should be enlarged to effect the necessary exposure. 
When the bleeding is capillary or when the blood escapes from numerous points, as it 
sometimes does when the vessels have lost their support, from their inability to contract 
and retract, in consequence of the destruction of the connective tissue and the effusion 
of plasma, the best plan generally is to lay open the abscess freely, and to cover the raw 
surface with lint, wet with a solution of subsulphate of iron, and confined with a com- 
press and bandage. In a case recently under my care, in which a chronic phlegmonous 
abscess of the nates had been the seat of repeated copious hemorrhages, I exposed the 
entire cavity, turned out the clotted blood, and scraped away all the unhealthy granula- 
tions, thus placing the parts in a proper condition for rapid repair. No bleeding occurred 
afterwards. The coagula which had been confined in the abscess had evidently contri- 
buted to keep up the hemorrhage. 
When an artery or vein of considerable size has been accidentally opened, the treat- 
ment must be conducted upon the same general principles as when the hemorrhage is 
produced by ulcerative action. If direct means fail, the main trunk of the vessel, espe- 
cially if it be an artery, must be exposed and ligatured. In such a case no delay should 
be permitted in applying the proper remedy. 
The healing of an abscess, whatever may be the manner of its evacuation, is effected 
by the contraction and approximation of its walls, which generally begin the moment the 
matter has escaped, and steadily progress until the sac is completely obliterated. The 
raw state of the opposed surfaces strongly predisposes them to unite with each other, an 
occurrence which is always favored by an effusion of plasma. If the cavity of the abscess 
were obliterated, as was formerly supposed, by granulations, the part would remain hard 
and prominent fora long time ; but this is not the case. On the contrary, it soon shrinks, 
becomes soft, and drops down to a level with the surrounding surface. The opening 
alone unites in this way; but even this is not always so, for examples constantly occur of 
closure by the first intention. 
Although the outer wall of the abscess generally soon recovers its pristine softness and 
pliancy, occasionally the reverse is true, the parts remaining hard, tender, enlarged, and 
seemingly reluctant to throw off their inflammatory burden. To expedite resolution, the 130 
TERMINATIONS OF INFLAMMATION. 
affected surface may be covered with an ammoniac and mercurial plaster, commonly the 
very best remedy that can be used for the purpose ; or it may be rubbed several times a 
day with some sorbefacient liniment, unguent, or embrocation, aided, perhaps, by the 
bandage and a few alterative doses of mercury. A bran poultice, prepared with salt 
water, is often a most efficient application. 
Constitutional treatment must not be neglected. Indeed, there are few cases in which 
this is not absolutely necessary. This is especially true in all severe cases of phlegmo- 
nous abscesses, in which the copious discharge of pus, the high fever, and profuse sweats 
so generally present, always establish a serious drain upon the system. The remedies 
mainly to be relied upon are quinine and iron, particularly when there is marked anemia, 
quinine and the mineral acids, milk punch, beef essence, and, above all, opium and fresh 
air. When convalescence is unusually slow, a residence at the seaside often proves 
beneficial; and when digestion and assimilation are seriously at fault, cod-liver oil will 
be worthy of trial. For the relief of night-sweats the best remedies are aromatic sulphuric 
acid, atropia, or oxide of zinc, either alone or in union with opium. 
2. DIFFUSED ABSCESS OR PURULENT INFILTRATION. 
The above is one variety of phlegmonous abscess; the circumscribed, in which, united 
with rapidity and severity of action, the matter is bounded by a distinct wall of fibrin, 
serving the purpose of a cyst, although in reality there is no such formation. In the 
present variety, already incidentally adverted to, there is no connective exudation, and 
the consequence is that the pus is widely diffused among the surrounding structures, 
dissecting and separating them from each other in the most frightful manner. Such 
collections, which are generally attended with intense suffering, are often described under 
the appropriate and expressive appellation of purulent infiltrations, the result always of 
cellulitis. 
The diffused form of abscess is met with under a great variety of circumstances, both 
as it respects the nature of the exciting cause and the condition of the general system. It 
is most common in persons whose constitution has been dilapidated by intemperance in 
eating and drinking, by want and exposure, and by organic affections of the heart, lungs, 
liver, bowels, and kidneys, leading to anemia, obstructed circulation, and exhaustion of 
the vital pow'ers. AVhen such persons meet with a serious accident, or suffer from a pro- 
longed attack of fever, suppuration is extremely prone to take on this kind of action, 
often sadly complicating the original disease. Diffused abscesses are also sufficiently 
common after severe injuries, as compound fractures and dislocations, lacerated, railway, 
gunshot, and dissection w'ounds, and capital operations, especially amputations of the 
larger limbs and resections of the bones and joints. Persons of a scrofulous constitution 
are, on the w'hole, more liable to suffer from diffused suppuration than any other class of 
individuals, their vital powers being too feeble to furnish a sufficiency of fibrin to limit the 
purulent matter. 
Diffused abscesses may occur independently of any other appreciable disease, or they 
may arise in conjunction with erysipelas, pyemia, or phlebitis, which they resemble very 
much both in their mode of origin and in the character of their symptoms. Their 
presence, in fact, is alw'ays denotive of a bad, depraved, or degraded state of the system ; 
in some cases the fault apparently lies in the blood, either in a defect of some of its more 
important constituents, or in the ingress of some morbid poison ; in others, again, it seems 
to be due to imperfect action of the skin and kidneys, excess of food and drink, the respi- 
ration of impure air, overaction of the brain, or exhaustion of the nervous system. 
The symptoms of this variety of abscess are ordinarily bold and well defined. In gen- 
eral, the disease is ushered in by considerable shivering, if not by a severe rigor, followed 
by heat and perspiration ; the pulse soon becomes small, quick, frequent, and irritable ; 
the extremities are cold, the urine is scanty and high-colored, the appetite is destroyed, 
the tongue is covered with a brownish fur, the strength rapidly declines, and the patient 
soon sinks into a state of delirium. Great irritability of the system exists; the pain is 
often excessive, sleep is interrupted, and the mind is peevish and fretful. Frequently 
the symptoms are of a typhoid character from the beginning; if not, they are sure soon 
to become so ; and yet not merely typhoid, but typhoid and irritative, the two classes 
being generally well balanced throughout. 
The local symptoms are those of ordinary inflammation, only that they are more severe, 
especially when the matter is deep seated. The discoloration is of an erysipelatous na- 
ture, the parts are swollen and pit on pressure, the pain is smarting and pulsatile, and 
CHAP. IV. CHAP. IV. 
DIFFUSED ABSCESS. 
131 
the skin feels hot, stiff, anil numb. If the matter lies immediately beneath the surface, 
or among the more superficial muscles, a boggy sensation will-be imparted to the hand of 
the examiner, and a little pressure will be sufficient to push the fluid about from one place 
to another, sometimes to a distance of many inches. When, on the contrary, the pus lies 
far below the surface, bound down by muscles and aponeuroses, its early detection will 
generally be very difficult; under such circumstances, the best guide to its situation will 
be the history of the case, the deep-seated pain, the presence of oedema of the skin and 
connective tissue, and the character of the constitutional phenomena. If any wounds or 
sores exist, they speedily dry up, and assume an unhealthy appearance. 
Although any part of the body may become the seat of diffused abscesses, their most 
common sites are the limbs, in which the matter often burrows to a great extent, both 
beneath the integuments and among the muscles ; in some of the worst forms that I have 
ever seen, it lay in immediate contact with the bones, separating them from the soft 
structures, and even from the periosteum. In one case under my observation, the fluid 
had spread along the posterior surface of the lower extremity, in close contact with the 
femur and the bones of the leg, from the hip as far down nearly as the heel. The matter 
is generally thin, sanious, irritating, acrid, and excessively offensive, often tainting the 
atmosphere of the apartment for many feet around, and fastening itself upon the hands 
and clothes so as to be perceptible for hours afterwards, notwithstanding, perhaps, the 
liberal use of deodorizers. In fact, the stench is usually most disgusting. In some cases 
the fluid approaches more nearly to the properties of ordinary pus, but this is uncommon. 
Occasionally extensive sloughs form, especially in the connective tissues, so that the 
disease may be said to partake of the character both of suppuration and of gangrene. 
The prognosis of this form of abscess is generally very unfavorable, few constitutions 
being able to withstand its depressing effects. The very fact that such a disease is in 
operation shows, as already stated, that the system is in a depraved condition; and when 
it is recollected that some of this foul matter must necessarily find its way into the circu- 
lation, contaminating everything with which it comes in contact, it is not difficult to 
anticipate what the result will be likely to be, even when the purulent collection is not 
very extensive, especially in persons already exhausted by shock, loss of blood, or lesion 
of some important organ. 
The treatment of diffused abscess is sufficiently obvious. The leading indications are 
to evacuate the matter, and to support the system. The first is fulfilled by early and free 
incisions, practised at the most favorable site for ready drainage, with the precaution of 
avoiding hemorrhage, the smallest quantity of which is sometimes sufficient, in such an 
event, when life is, as it were, quivering in the balance, to bring on fatal exhaustion. 
Counter-openings are often necessary. After the abscess has been thoroughly evacuated 
and cleansed, its sides are gently approximated with the bandage, a means of support of 
the greatest value, not only in preventing the extension of the matter, but in promoting 
the healing of the parts. So long as the fluid is offensive, the abnormal cavity should be 
well syringed several times a day with tepid water, charged with a suitable quantity of 
chlorinated sodium and permanganate of potassium, or creasote, chloride of zinc, acid 
nitrate of mercury, or carbolic acid, to correct fetor, and to impart tone to the disabled 
structures. Any sloughs that may form should be speedily removed, the knife being 
used, if necessary, to effect their separation. The parts are placed in a proper position 
for facilitating drainage, and are enveloped in warm-water dressing, or an emollient 
medicated poultice, with acetate of lead and opium. Compression is steadily employed 
until the sac is obliterated. 
Among the more valuable internal remedies are anodynes, quinine, iron, and brandy, 
with animal broths and soups, and a pure atmosphere, which is of paramount importance 
to recovery. The windows and doors of the apartment should be frequently thrown open, 
the dressings changed, and disinfecting agents used. Anodynes are indispensable to allay 
pain and induce sleep, and should be administered in full doses, in the form of morphia, 
opium, or black drop. The best tonics are quinine and brandy, given in the same man- 
ner as in typhoid fever; the tincture of chloride of iron, in doses of fifteen to twenty 
drops, every three or four hours, will also be of service ; and, in many cases, ammonia, in 
camphor mixture, will meet the exigencies of the case better than almost any other remedy, 
especially if there be hiccough with twitching of the tendons. 132 
TERMINATIONS OF INFLAMMATION. 
CHAP. IV. 
3. SCROFULOUS ABSCESS. 
The scrofulous abscess is known by various names, some of which have reference to its 
progress, some to its symptoms, some to the nature of its contents, or to the state of the 
constitution preceding and accompanying its formation. Thus, it is often described as 
the chronic abscess, tardy development being one of its characteristic features; the word 
cold is frequently employed on account of the absence of inflammatory symptoms ; but 
scrofulous is the appellation by which it is generally distinguished at the present day. As 
implying the same thing, the terms strumous and tubercular are much in vogue. There 
is a form of this abscess to which the name congestive has been applied, from its tendency 
to change its position, although it is impossible to discover any etymological fitness in it. 
The scrofulous abscess is altogether a singular affection; singular in its origin and prog- 
ress, its termination and its treatment. It is never met with, except in the strumous 
constitution. The phlegmonous abscess is common to all persons, of every age, grade, 
and condition in life ; the scrofulous, on the contrary, can only occur in persons who have 
a predisposition to scrofulous affections, whom nature has stamped, so to speak, with a 
peculiar diathesis, or state of the system, rendering them prone to phthisis, coxalgia, 
caries of the spine, and kindred maladies. Its sphere of action is, therefore, compara- 
tively limited, a hundred cases of phlegmonous abscess occurring to one of a scrofulous 
character. 
The progress of the scrofulous abscess is always slow, weeks and months usually elaps- 
ing before it acquires any considerable bulk : hence the term chronic, by which it is so 
frequently designated. A phlegmonous abscess, on the contrary, is always rapid in its 
progress, generally attaining its full development in a very short time. Another peculiar 
feature of the strumous abscess is the absence of the ordinary inflammatory symptoms. 
The skin, instead of being hot and red, is cold and blanched, the part feeling and looking 
as if there were great deficiency in its circulation. Hence this variety of abscess used to 
be termed cold, especially by the German surgeons, who were the first to describe it. 
Pain, too, is absent, or, if it exist, it is so trivial as hardly to attract attention. Func- 
tional disorder also is very slight, especially in the earlier stages of the disease. Looking 
at the constitution, the same uncommon train of phenomena is observed. The general 
health may be somewhat impaired ; the strength may slowly and almost imperceptibly 
decline, and the countenance may have a pale, sallow appearance; but there are none of 
the open and well-marked inflammatory symptoms which attend the march of a phleg- 
monous abscess, and which, especially when the disease is located in an important internal 
organ, suggest the idea of great and immediate danger. Thus, as far as appearances are 
concerned, the affection is one seemingly of little moment; its discovery is often purely 
accidental, and, tor a while, both patient and surgeon may be wholly unconscious of its 
true character. It is, indeed, as completely different from an ordinary abscess as it is 
possible for one disease to be from another. Scarlatina and measles are not more unlike 
each other. 
The strumous abscess is very frequent in the lymphatic glands, subcutaneous connec- 
tive tissue, and in the dorso-lumbar region. The testicle, breast, and liver are also 
sometimes its seat. It is, however, more common in the lungs than anywhere else, for 
there it is the immediate product of the softening of tubercular matter, eventuating 
generally in the formation of what are termed vomicae or pulmonary caverns. In the 
external parts of the body it is usually situated in the neck, on the chest, in the axilla, 
on the loins, in the groin, or upon the superior portion of the thigh. Large strumous 
accumulations sometimes occur in the movable joints. 
As to the size and number of these abscesses, considerable diversity obtains. In cer- 
tain situations, as in the lungs, they are always small, but at the same time often very 
numerous; while in others, as in the cervical glands, on the chest, in the groin, and on 
the back, they are usually single, and from the volume of an orange to that of a foetal 
head. 
The strumous abscess is nearly always furnished with a distinct cyst, called the pyo- 
genic membrane, which, while it serves to individualize it, separates it effectually from 
the surrounding parts. At what period of the suppurative process the membrane appears 
is not determined, but that it is developed at an early stage is unquestionable. It has 
been supposed that its formation, at times, precedes the formation of the pus. The sub- 
ject, however, does not admit of easy demonstration; for it is seldom that an opportunity 
is afforded of inspecting such an abscess until after it has attained considerable bulk, and 
the membrane has acquired some degree of development. The most plausible conjecture, 133 
CHAP. IV. 
perhaps, is, that the membrane is formed as a matter of necessity, nature intending it as 
a means of limiting the diffusion of the pus, as would otherwise inevitably happen in 
consequence of its tardy but steady deposition. To accomplish this object, she sets up 
around the purulent depot, at an early period of the morbid action, a species of adhesive 
inflammation, by which, in the first place, the cells of the neighboring tissues are effect- 
ually occluded, the process being precisely similar to that which occurs in an ordinary 
phlegmonous abscess. Thus, the fluid is temporarily circumscribed, but, as may readily 
be perceived, the barrier thus opposed would soon yield before the accumulating burden, 
and thus thwart nature’s intentions, if it were not that a wall of plastic matter is next 
constructed, which no amount of pus, however great, can, for a time, break down or de- 
stroy. The thickness of this wall varies from the eighth of a line to the eighth of an 
inch ; its density steadily increases with its age, and hence it is often found to be of a 
fibrous consistence, with here and there a semi-cartilaginous patch. Its outer surface is 
rough and intimately united with the surrounding structures; the inner, on the contrary, 
is either perfectly smooth, or studded with minute granulations, not unlike the villi of the 
small intestine, only not so regular and numerous. Its vascularity, which is always con- 
siderable, is easily distinguishable by the naked eye, as well as by minute injection. It 
also, no doubt, contains nerves and absorbents, although they are not demonstrable. 
No one can reflect upon the structure of this membrane without being impressed with 
the conviction that it is invested with important functions. In the first place, as already 
stated, it protects the tissues in the immediate, neighborhood of the abscess from the dif- 
fusion of its contents ; a circumstance which could not fail to be productive of great 
injury, inasmuch as the matter, burrowing about in different directions, might occasion 
extensive separation of the muscles, which it would afterwards be extremely difficult to 
remedy. Secondly, the membrane is an important secreting structure, since it furnishes 
the matter which it incloses, either directly, or indirectly through the agency of lymph, 
speedily transformed into pus. Thirdly, it is also an absorbing structure, as is proved by 
the fact that the matter which it contains occasionally disappears, either spontaneously, or 
under the influence of treatment. Finally, the membrane possesses important sympathies 
with the rest of the system. Left to itself, it causes no general disturbance, but the 
moment it is opened so as to admit the entrance of air, it resents the aggression, and is 
sure to occasion severe constitutional derangement. 
The pus of a strumous abscess is generally of a whitish or yellowish cast, slightly inclin- 
ing to greenish, of a tolerably thick consistence, free from odor, and intermixed with 
caseous particles, looking and feeling very much like pieces of soft-boiled rice. Instances 
occur, especially in scrofulous disease of the lymphatic glands of the neck, where it is very 
thin, pale, and full of curdy substance, consisting apparently of imperfectly broken-down 
tubercular matter. When long retained, or situated near the anus and rectum, scrofulous 
pus is sometimes excessively fetid, either from actual decomposition or from the presence 
of sulphuretted hydrogen. Permitted to stand for some time, it separates into two parts, 
one of which is thin, whey-like, or sero-oleaginous in its appearance, the other thick and 
curdy, the former being always upon the top of the latter. Like the pus of a phleg- 
monous abscess, it occasionally contains the debris of the organs in which it is formed, and 
also some of their peculiar secretion. Thus, a strumous abscess of the liver may contain 
bile; of the breast, milk; of the spine, osseous particles. The microscopic characters of 
scrofulous pus are well illustrated in tig. 19, from Jones & Sieveking. 
In regard to quantity, there is much variety in the pus of this form of abscess. In 
psoas abscess, one of the best examples of the disease, the accumulation is sometimes 
enormous, reaching several quarts, or, perhaps, even a gallon. 
In scrofulous abscess in the glands of the neck, there is also 
occasionally a good deal of pus, although, in general, it is small. 
Large collections of strumous matter are sometimes seen in 
chronic abscess beneath the skin, especially in the lower ex- 
tremity. A young woman, a patient at the College Clinic, 
had an abscess of this kind on the left thigh, containing nearly 
a gallon of pus. 
The contents of a chronic abscess are sometimes remarkably 
thin and pale, or almost watery, being composed essentially of 
the serum of the blood, with few, if any, well-developed pus 
globules. Flakes of fibrin and broken-down connective tissue 
are occasional ingredients of such fluids, which sometimes exist 
in enormous quantities, especially in young, scrofulous subjects, 
SCROFULOUS ABSCESS. 
Fig. 16. 
Pus from a Scrofulous Abscess. 134 
TERMINATIONS OF INFLAMMATION. 
of an anemic appearance and dilapidated constitution. The pyogenic membrane, also, is 
generally uncommonly thin and imperfectly organized. Abscesses of this kind, formerly 
known as lymph abscesses, are most common about the hips and nates, and in the upper 
part of the thigh. 
The diagnosis of the strumous abscess may be gathered from the remarks already made 
respecting that of phlegmonous abscess. The principal affections with which it is at all 
likely to be confounded are aneurism, and various kinds of tumors, as the cystic and 
sarcomatous. In the groin and upper part of the thigh such an abscess might be mistaken 
for hernia. From these affections, however, it may usually be easily distinguished by 
the history of the case, the fluctuating character of the swelling, and, if necessary the 
use of the exploring needle, the latter of which seldom, if ever, fails to furnish the 
requisite light. 
When a cure takes place in a strumous abscess, whether spontaneously or by art, the 
cyst gradually shrinks, and is ultimately completely obliterated, the wall itself finally dis- 
appearing. In exceptional cases, however, a portion of the structure remains, generally 
in an unsound condition, and, therefore, liable to fresh attacks of inflammation, years, 
perhaps, after the apparent obliteration of the sac. Such an event will be the more likely 
to occur when, as not unfrequently happens, some of the contents of the abscess are re- 
tained in the form of half-dried, shrivelled, and disintegrated matter, which may thus, at 
any time, become a source of irritation, provoking not only inflammation, but more or 
less profuse suppuration, the development of abscesses, and constitutional disturbance. 
These residual or recurring abscesses are most prone to form in connection with Pott’s 
disease of the spine, and other portions of the skeleton, generally as a consequence of 
external injury, or protracted disease, seriously undermining the vital powers. 
Treatment—The treatment of this abscess differs essentially from that of the phleg- 
monous. In the latter, the system often bears energetic measures ; in the former, seldom, 
if ever; in the one, the surgeon does not hesitate to make an early and free incision into 
the swelling, with a view to the early evacuation of its contents; in the other, he waits 
and hesitates, well knowing that such an operation is often the prelude to serious consti- 
tutional disturbance, if not death. The one is the work of a few days, or, at most, of a 
few weeks, taking the part and system, as it were, by surprise, and, therefore, requiring 
prompt interference; the other is the work of time, affording the part and system an 
opportunity of accommodating themselves to its presence, and, therefore, often intolerant 
of interference. When the quantity of matter is small, removal is occasionally effected 
by absorption, the process being sometimes advantageously aided by internal and external 
remedies, especially the iodide of potassium and the bichloride of mercury, together with 
sorbefacient plasters, unguents, and embrocations. These means are more particularly 
available in chronic abscesses of the glands of the neck, groin, and axilla, and in those 
of the mamma and subcutaneous connective tissue. In psoas and lumbar abscesses, on the 
contrary, little or no benefit usually results from their employment, beyond the influence 
which they may exert in improving the general health, and in eradicating the strumous 
diathesis. When general debility exists, relief should be attempted with tonics, as quinine 
and iron, along with cod-liver oil, milk punch, and change of air. 
When a scrofulous abscess is seated in an external part of the body, as the mamma, a 
lymphatic gland of the neck, or the subcutaneous connective tissue, the only rational 
treatment is the evacuation of its contents. In such cases, indeed, it is hardly possible 
to make too early or too free an incision ; for, not only is there, generally, no danger of 
causing constitutional disturbance, but the procedure is eminently calculated to save 
structure and promote recovery. The matter being thus disposed of, the cavity usually 
at once contracts, and, the tendency to secretion gradually diminishing, the part finally 
heals by granulation or adhesion. Besides, such a procedure always enables the surgeon 
to watch the morbid action, and to apply his remedies directly to the affected surface. 
The best local applications, after the abscess has been punctured, are emollient poultices, 
rendered slightly stimulating by the addition of a little common salt; or tincture of iodine, 
spirituous lotions, or some sorbefacient plaster, as the ammoniac and mercurial, soap, com- 
pound galbanum, or iodine plaster, care being taken to leave an appropriate opening for the 
discharge of matter. I can speak with great confidence of the beneficial effects of these 
agents, especially the first, from my experience of them in the treatment of strumous 
abscess of the neck, mamma, and subcutaneous connective tissue. When the cavity of the 
abscess is slow in healing, on account of the torpor of its vessels, or the existence of a 
strong pyogenic membrane, nitrate of silver, carbolic acid, acid nitrate of mercury, or 
chloride of zinc, may be employed, in the form of weak injections, as local stimulants, 
CHAP. IV. CHAP. IV. 
SCROFULOUS ABSCESS. 
135 
until there is a disposition to the formation of healthy granulations. Sometimes, as in the 
case of a subcutaneous abscess, a seton may advantageously be introduced, retention being 
maintained until the sac is obliterated by inflammation. Or, instead of this, a counter- 
opening may be made, and a tent inserted. Or, if the sac is small, it may be dissected 
out. As a rule, when the abscess is small, the best plan is to lay it freely open, and to 
scrape away all unhealthy and disintegrated matter, a step which wonderfully promotes the 
cure. 
When the abscess is connected with disease of the bones, as it generally, if not always, 
is when it takes the name of psoas or lumbar abscess, the treatment formerly in vogue 
was that originally suggested by Abernethy, which consists in making a valve-like open- 
ing into the most prominent or most dependent part of the swelling, and drawing off only 
a portion, as one-half or two-thirds of its contents at a time, the operation being repeated 
every fourth or fifth day according to its effect. Educated in a school in which this 
practice was strongly inculcated, and warmly prepossessed in its favor, I followed it 
until the accumulated experience of many years satisfied me of its utter uselessness, and 
I therefore abandoned it. The treatment which I now pursue, is simply to evacuate the 
matter at the earliest possible period by a moderately free incision, and to wash out the 
sac most thoroughly with warm water, charged with chlorinated sodium, carbolic acid, or 
permanganate of potassium,and introduced with a gum elastic syringe. A full anodyne is 
administered either a short time before or immediately after the operation, and is repeated 
twice daily for at least one week. The object in giving the anodyne in this way is to 
prevent undue reaction after the evacuation of the matter, which will otherwise be sure 
to occur, and to lead to hectic irritation, and great prostration of the vital powers. I was 
induced to adopt this practice many years ago from observing its beneficial effects in cases 
of this kind, and can, therefore, warmly recommend it. The medicated in jections should 
be repeated at least twice in the twenty-four hours, the fluid being always thrown into 
the sac in such a manner as to distend its walls, and thereby promote the thorough cleans- 
ing of their free surface; in other words, every effort should be made to prevent the 
accumulation and retention of decomposed and offensive secretions. A drainage tube, of 
some kind or other, should be retained in the abscess. The best local application, for 
some time at least, is an emollient poultice or warm-water dressing, medicated with lauda- 
num and acetate of lead. The patient is kept at rest and supported by tonics, such as 
quinine and iron, with nutritious food and drink. As the strength improves, exercise is 
employed in the open air, and advantage taken of a change of air, with, if possible, a 
residence at the seaside, always so beneficial in exhausted states of the system. 
The antiseptic treatment of a scrofulous abscess, through which it is asserted that putre- 
factive changes in the pyogenic membrane may be prevented, is conducted in the following 
manner: The skin having been thoroughly washed with a one-to-twenty solution of 
carbolic acid, a one-to-thirty carbolic spray is directed upon and around it by a steam 
atomizer, when the abscess is opened freely with a bistoury which has been dipped in a 
solution of the former strength. When the pus has discharged itself, the lightest pressure 
alone being permissible to favor its escape, a carbolized drainage tube is inserted, the 
incision is covered with a bit of oiled-silk protective, and the dressing is completed by 
retaining upon the part antiseptic gauze, between the seventh and eighth layers of which 
a piece of mackintosh has been inserted. The first six layers of the gauze, as well as 
the protective, should be moistened with a one-to-forty carbolic solution before they are 
applied. The dressing need not be changed for several days unless the occurrence of 
fever or of profuse discharge demands it. Oil of eucalyptus may be substituted for the 
carbolic acid, as it is said to be equally as effective as that agent. This method of 
treatment is still employed by many surgeons, but I regard it as utterly useless. 
It has been proposed to open these abscesses while the patient’s body is immersed in 
water, on the ground that there would thus be less likelihood of the introduction of air; 
but it may well be asked whether the ingress of the former fluid would not be quite as 
injurious as that of the latter? The truth is, it is hardly possible to perform the opera- 
tion without some risk of this kind, although, if proper care be taken, the quantity will 
not be so large as to produce any serious mischief. 
As to iodine injections, recommended for the radical cure of this form of abscess, the 
experience of the profession offers nothing in their favor. The practice, considered in a 
purely theoretical point of view, is sufficiently plausible, inasmuch as its object is to 
change the character of the secerning surface of the pyogenic membrane, by inviting an 
effusion of plastic matter, with the hope of effecting the obliteration of its cavity. It was 
evidently suggested by the beneficial effects which are known to follow the use of iodine 136 
TERMINATIONS OF INFLAMMATION. 
CHAP. IV. 
injections in hydrocele and kindred affections, but to insist upon a similarity of structure 
of the sac of a chronic abscess and of the vaginal tunic of the testicle certainly evinces a 
very imperfect knowledge of morbid anatomy. It is not surprising, therefore, that the 
practice should have failed, and that its employment should have been attended, in most 
cases, with considerable risk, from its tendency to create undue irritation both in the part 
and system. 
4. HECTIC FEVER. 
Hectic fever, although not necessarily dependent upon suppuration, is yet so closely 
connected with it, as a common result of that process, that it may very properly be de- 
scribed under the same head. Its existence is nearly always indicative of serious organic 
lesion, of which it, therefore, constitutes merely the general expression. The word hectic, 
literally signifying a bad habit of body, was originally employed to designate the peculiar 
train of phenomena attendant upon pulmonary phthisis, of which it forms so remarkable 
an attribute as to have attracted the attention of practitioners in all ages. It is, how- 
ever, no longer restricted to such narrow limits ; for the group of symptoms which 
it serves to characterize follows upon a great number of diseases, accidents, and ope- 
rations, and, therefore, claims the special consideration alike of the surgeon and the 
physician. 
Hectic fever never occurs as an idiopathic affection ; on the contrary, it is always 
symptomatic of some particular disease, generally of the presence of profuse discharge, 
as of pus or blood, or the existence of an abscess.in some important structure, as the 
brain, lung, or liver. One of the most remarkable circumstances connected with its his- 
tory is, that it rarely, if ever, appears until the malady which it serves to represent has 
made considerable progress, or induced serious structural changes, along with grave in- 
roads upon the constitution. Thus, in phthisis, it is seldom witnessed until softening of 
the tubercular matter is about to take place, sometimes, indeed, not until large cavities 
have formed ; on the other hand, there are cases, as in psoas abscess, where pus frequently 
exists in large quantity, perhaps for several months, and yet none of the ordinary signs 
of hectic fever arise. Serious as the local disease apparently is, the general system does 
not seem to be disposed to take any particular notice of it ; the pulse, sleep, appetite, 
bowels, and secretions all go on nearly in their accustomed manner; and, if there be any 
loss of flesh and strength, the alteration is so gradual and imperceptible as almost to elude 
the attention even of the patient himself. But sudden and often most alarming changes 
occur in the constitution if, in consequence of a large opening, air is freely admitted into 
the cavity of such an abscess, causing decomposition of its contents. The shock is vio- 
lent, and resentment of the injury is close at hand; soon a severe rigor comes on, last- 
ing, it may be, several hours, when it is succeeded by violent fever, as this, in its turn, 
may be followed by copious sweat. Such is not unfrequently the commencement of an 
attack of hectic fever, a bad habit of body, which often ceases only with the patient’s life. 
Thus, it will be perceived that hectic fever, like every other form of fever, at least so 
far as we can comprehend its nature and type, is not a disease, but a symptom of disease, 
an expression of general suffering, dependent upon some special local lesion, not always, 
perhaps, appreciable by our senses, yet, nevertheless, in active operation, and effectually 
accomplishing its work. 
In traumatic affections, hectic fever often sets in at an early period after the accident ; 
perhaps there may have been grave shock and profuse hemorrhage, and the two are soon 
followed by copious suppuration, which thus still further undermines and exhausts the 
vital powers ; or it may be that more or less of the pus has been carried into the circula- 
tion, and that the whole system has become poisoned by the unfortunate admixture, every 
blood globule and every fibre and atom of solid matter feeling the baneful influence. The 
brief struggle which ensues may be characterized by the inflammatory type ; but this is 
evanescent, hectic soon taking its place, and thence on steadily maintaining the ascend- 
ency, no intercurrent circumstances ever changing its true character, although they may 
temporarily disguise it, or for a time keep it in abeyance. 
Hectic, then, is a continued, remittent fever, persisting generally so long as the cause 
which induced it lasts; subject to distinct paroxysms of exacerbation and remission, but 
at no period, perhaps, completely absent, although apparently it may be. Its outbreak is 
often sudden and violent, sweeping over the system with the fury of a hurricane ; at 
other times, and more generally, it creeps on gradually and stealthily ; in the former case 
it is marked by severe rigors, in the latter merely by a sense of chilliness, or slight hor- HECTIC FEVER. 
137 
CHAP. IV. 
ripilations. Whatever may be its mode of attack, its actual invasion is always preceded 
by more or less indisposition, amounting ordinarily to a mere state of malaise, or a feeling 
of lassitude and discomfort, which the patient struggles in vain to throw off. Ilis appe- 
tite and sleep are impaired ; his tongue is inclined to be dry, perhaps somewhat coated ; 
more or less thirst exists ; and there is often considerable fever, either of the inflammatory, 
irritative, or typhoid type. In short, hectic, like every other fever, passes through a stage 
of incubation, brief in one case, protracted in another. The crisis being attained, the 
chill appears, and thus the disease is fairly inaugurated; taking its position in the system, 
which, as already stated, it never abandons until the removal of the exciting cause, and 
often not then. 
The febrile exacerbation is usually vesperal, coming on late in the afternoon, or early 
in the evening; lasting, on an average, from six to nine hours, and then gradually going 
off, to reappear, in a similar manner, about the same time the “next day, thus giving the 
disease a distinct periodical character, not unlike that of an ordinary intermittent. Not 
unfrequently there are two paroxysms in the twenty-four hours ; one in the evening, and 
the other, perhaps, late at night, or during the course of the morning; the latter being 
generally much the milder of the two. The chill ushering in the fever is often very long 
and severe, the patient occasionally shivering for several hours, his teeth chattering vio- 
lently, and the whole body feeling as if it were wrapped in ice ; at other times, as already 
intimated, the sensation of cold is very slight, and, perhaps, perceived chiefly along the 
spine, shoulders, and lower extremities, its duration being variable, now short, now quite 
protracted. The chill passing off, reaction succeeds, usually violent in proportion to the 
previous depression, the temperature,' however, rarely exceeding 103.5° Fahr., and grad- 
ually, sometimes suddenly, merging into a profuse sweat, the harbinger of returning ease 
and comfort. All the secretions are again unlocked; the mouth regains its moisture; 
the urine is poured out in increased quantity ; the thirst rapidly subsides ; the pulse be- 
comes soft and comparatively calm ; and ere long the poor patient, tortured and racked 
with suffering, falls into a tranquil and refreshing sleep. 
In the interval of the paroxysms, the patient, although comparatively comfortable, is 
by no means entirely free from excitement. The pulse, in particular, is always preter- 
naturally frequent, often even quick and small ; seldom entirely normal in any case or at 
anytime; easily disturbed by exercise and mental emotion. The countenance exhibits 
well-marked evidence of the inward trouble ; in the morning it is pale, shrunk, and care- 
worn ; in the afternoon, on the contrary, it has generally a somewhat full appearance, and 
a circumscribed blush, too plainly denotive of the vital decay, rests upon the cheeks in 
striking and often mournful contrast with the surrounding pallor. The eyes have a pecu- 
liarly lustrous expression, and gradually retreat more and more within their sockets. 
Emaciation begins early, and is steadily progressive, proceeding from bad to worse, until 
the body is literally wasted away to a skeleton. Amidst all these evidences of decay, it 
is remarkable how well the appetite frequently sustains itself; the patient often eats vora- 
ciously in the intervals of his paroxysms, and digestion goes on with little or no inter- 
ruption, assimilation alone being at fault. The tongue is variously affected ; in general, 
however, it is clean, or nearly clean, but, perhaps, a little too red at the tip and edges. 
At times it is very smooth and glossy ; and cases occur in which it appears to be glazed, 
as if it were coated with a thin layer of mucus. A foul tongue is a rare phenomenon in 
this form of fever. Hectic patients are usually easily impressed by atmospheric vicissi- 
tudes ; the slightest exposure produces chilliness, and hence they always require an unusual 
amount of clothing. The feet and legs, in particular, are nearly incessantly cold ; the 
hands on the contrary are generally dry, hot, and burning. 
As the disease occasioning the hectic progresses, the symptoms gradually manifest more 
and more of a downward tendency ; the appetite fails, the sleep is interrupted, the perspi- 
ration is more profuse and exhausting, aphtha; appear upon the tongue and fauces, and the 
bowels are constantly harassed with diarrhoea, the discharges being thin, watery, and ex- 
cessively fetid. Thus, the case goes on, steadily but almost imperceptibly, from bad to 
worse, until the patient dies literally exhausted, by the want of nourishment, and, per- 
haps, also by the severity of his bodily pains. During all this struggle, it is aston- 
ishing, to see how the mind, rising above the mortal decay around, maintains its 
supremacy, being not only clear and strong, but hopeful and often even sanguine to the last. 
The progress of hectic fever is influenced by such a variety of circumstances as to defy 
anything like a definite statement. In general, it promptly disappears with the removal 
of the existing cause, provided the inroads made by it have not been productive of any 
serious disorganization; should this have happened, the case will probably have an un- 138 
TERMINATIONS OF INFLAMMATION. 
CHAP. IV. 
favorable issue, the hectic continuing in a modified form down to the fatal crisis. Ope- 
rative interference often exercises a wonderful influence under such circumstances. I 
have repeatedly seen a severe and protracted hectic, consequent upon the destruction of a 
tuberculosed joint, completely vanish in less than twenty-four hours after amputation, and 
the system rapidly recover from the effects of the previous disturbance. 
The indications in the treatment of hectic fever plainly are, first, to remove the exciting 
cause, and, secondly, to support the system until it has an opportunity of shaking off the 
effects of the morbid action. 
The first of these objects is frequently best accomplished by the knife, as when, for ex- 
ample, the disease depends upon, and has been kept up by, a tuberculosed joint, or a sup- 
purating compound fracture, the removal of which often promptly restores health and 
tone to the prostrate system. If the cause.be inaccessible, the case must be treated upon 
general principles, in the hope that, by and by, as the strength improves, the patient will 
have sufficient recuperative power to dislodge the source of irritation, and so get rid of 
his malady. 
The second indication is fulfilled by tonics, nutritious food, anodynes, the suppression 
of unnatural discharges, change of air, and attention to cleanliness. 
The use of tonics is generally indispensable in almost every case of hectic, however 
induced, particularly in its more advanced stages, when there is a wretchedly impover- 
ished condition both of the blood and solids. The articles most to be relied upon are 
quinine, aromatic tincture of bark, and the different preparations of iron, of which, ac- 
cording to my experience, the sulphate and the tincture of the chloride deserve the pre- 
ference. Whatever substance be selected, its operation should be aided by a nutritious 
diet, consisting of the richer kinds of animal broths, beef-essence, beefsteak, milk-punch, 
tapioca, ai’rowroot, and milk, whine whey, ale, or porter. When the emaciation is steadily 
progressive, and dependent upon a tubercular diathesis, cod-liver oil will be of service, 
and should be given in as large doses as the stomach may be able to bear. 
Anodynes are among the most valuable agents in the treatment of hectic, as they serve 
to allay the inordinate action of the heart, to relieve pain and irritation, and to procure 
sleep, which is generally so much impaired in cases of this kind. They should be given 
in full doses, not too often repeated, the best period for their exhibition being usually 
towards bedtime, so that their appropriate effects may be realized during the night in re- 
freshing tranquility. Morphia is generally better borne than opium, but when there is 
much sweat or diarrhoea, it may often be advantageously replaced by the latter, as more 
likely to produce an astringent influence. 
The exhausting effects of diarrhoea and perspiration, especially when they are of a col- 
liquative character, must be promptly counteracted by suitable remedies, of which opium, 
as just stated, is one of the best. When the diarrhoea is dependent upon vitiated fecal 
matter, a mild laxative should be given, and blue mass, or calomel, in minute doses, if it 
has been caused by derangement of the biliary secretion. Sometimes it is most readily 
checked by astringents, as rhatany, prepared clialk, or tannic acid, in union with an 
anodyne. 
Night sweats, often a source of so much prostration, are best controlled by the free use 
of aromatic sulphuric acid, tannate of iron, oxide of zinc, or atropia, with frequent ablu- 
tions of the surface with tepid alum water. Atropia is especially valuable in controlling 
night sweats. It may be given by the mouth, in the dose of the fiftieth to the sixtieth part 
of a grain, or, what is preferable, in the form of a hypodermic injection, the average 
being the one-hundredth part of a grain. The injection need rarely be repeated oftener 
than once in twenty-four hours. Sometimes the sweats may be effectually prevented by a 
full opiate administered a short time before the expected rigors. 
When the local disease, inducing the hectic, admits of it, exercise should be taken in 
the open air, which frequently conduces more to the restoration of the patient’s appetite 
and strength, and the relief of the colliquative diarrhoea and sweats, than all other means 
combined. Children may be carried about in their nurses’ arms, or in the hand car, 
while adults may ride about in a carriage, or walk, as may be most agreeable and conve- 
nient. Occasionally a residence at the seaside will be found to be eminently beneficial. 
Finally, cleanliness is of the greatest possible importance; the body must be frequently 
washed and rubbed ; the excretions carefully and promptly removed ; and the apartment 
thoroughly ventilated at least twice a day, the windows being lowered in the mean time to 
admit of a constant supply of fresh air. CHAP. IV. 
SEPTICEMIA AND PYEMIA. 
139 
SECT, y SEPTICEMIA AND PYEMIA. 
By septicemia is meant a febrile affection which is produced hy the absorption of putrid 
material into the blood, and which is not accompanied by the development of metastatic 
abscesses. The term pyemia, on the other hand, is restricted to the fever which is caused 
by the entrance of septic material into the circulation, where it multiplies and gives rise 
to embolic abscesses. Both affections are frequently associated with each other, and 
pyemia is merely septicemia with the addition of certain inflammatory lesions. 
Before entering into the separate consideration of these septic fevers, a brief sketch of 
the nature of the septic poison, which is the same in both affections, and of its mode of 
absorption affords an interesting field of inquiry. Gaspard, of St. Etienne, in France, 
as early as 1808, performed an elaborate series of experiments with putrefying fluids, 
with a view of ascertaining their effects upon the system when introduced under the skin 
or into the veins of animals. He found that, when the quantity was considerable, it 
invariably induced violent constitutional symptoms, attended with great gastric distress, 
and copious fetid and bloody alvine evacuations, rapidly followed by exhaustion and 
death. These researches were published in 1822, in Magendie’s Journal of Physiology, 
but attracted little or no attention on the part of scientific men. During the past twenty 
years, however, the experiments of Weber, Billroth, Burdon-Sanderson, Koch, Hueter, 
Savory, Davaine, and others, have fully verified the results established by Gaspard 
three-quarters of a century ago, and have supplied us with a few additional facts, chiefly 
in reference to the existence of certain microscopic organisms in the blood and tissues 
during the progress of septicemia and pyemia, of which the French observer was igno- 
rant. The septic poison, upon the introduction of which into the circulating blood these 
specific fevers depend, usually originates in connection with the putrefying secretions of 
surgical wounds and injuries, in which minute rod-like and spherical organisms, known 
respectively as bacteria and micrococci, are always present, and which are considered by 
many observers as being essential for the production of the infective material. Some 
writers assert that the bacteria are the active agents in the pathogenesis of septicemia, 
pyemia, puerperal peritonitis, and allied affections; while others, again, maintain that the 
micrococci are the important factors. Billroth and Hallier deny that these organisms 
are distinct; Klebs doubts it; but Cohn, Rindfieisch, and Cheyne affirm that specific 
differences exist between them. During the past seventeen years, mainly through the 
exertions of Mr. Lister, the attention of surgeons has been directed to the prevention of the 
entrance of these schizomycetes into wounds from the surrounding atmosphere, with a view 
of avoiding decomposition of the discharges, and thereby averting local and general in- 
flammatory processes. That the introduction of these low organisms into the system from 
putrefying surfaces occasions the septic fevers is strenuously asserted by Pasteur, Lister, 
Sanderson, Birch-IIirschfeld, Hueter, Koch, and other distinguished observers; but that 
they are essential to their development is by no means proved. If it be true that micro- 
scopic organisms are the cause of the evils that have been ascribed to them, the micro- 
cocci must be regarded as being utterly harmless, since numerous examinations of the 
discharges of wounds treated antiseptically, conducted by Ranke, Volkmann, Cheyne, 
and others, demonstrate that they almost invariably contain these bodies, and that they 
multiply rapidly in weak solutions of carbolic acid. Then, again, if the septic poison is a 
product of the growth of bacteria, and if the septic fevers arise from the direct action of 
the bacteria on the system, those affections should not be produced by the injection of 
putrid fluids from which the bacteria have been removed by filtration through porcelain. 
Numerous experiments of this nature have conclusively shown, however, that the effects 
of the poison are not due to the organisms themselves. Hence, other investigators have 
looked for some other infective material, and have concluded with Panum, Bergmann, and 
Billroth, that there exists in decomposing fluids a soluble chemical product termed sepsin, 
to the absorption of which septicemia and pyemia may be attributed. 
The intimate nature of the poison of septicemia and pyemia is entirely unknown. The 
probability is that it is similar to, if not absolutely identical with, the poison of traumatic 
or surgical fever, erysipelas, hospital gangrene, puerperal fever, and kindred affections. 
Obstetric physicians long ago noticed that a bad form of septicemia is often produced 
during pregnancy by the presence in the womb of a dead foetus. The juices of a decom- 
posing child being absorbed by the uterus, and carried into the system, give rise to the 
very worst form of the affection, characterized by great gastric irritability, high tempera- 
ture, great restlessness, offensive alvine evacuations, delirium, and excessive prostration, 
followed, in a few days, by death. It has been remarked, in such cases, that the amni- 140 
TERMINATIONS OF INFLAMMATION. 
CHAP. IV. 
otic liquor anti the vaginal discharges are often almost insupportably offensive. When such 
fluids are permitted to enter the system, whether they contain bacteria and micrococci, or 
are free from these organisms, they must invariably give rise to a septic fever of the very 
worst form, and this is precisely what the results of obstetric practice have fully estab- 
lished. 
To sum up my own views of the nature of the septic poison, I may state that I believe 
that the infective material is sepsin, or the chemical product of the decomposition of the 
tissues, and that the schizomycetes, which have been shown to be present in the blood 
and organs of septicemic and pyemic animals and men, as well as the corpuscles of putre- 
fying blood and pus, act merely as carriers and disseminators of the poison. 
Whatever the nature of the poison may be, one thing is perfectly certain, and this is 
that it is frequently, if not generally, highly inoculable. Of this fact the results of the 
experiments above referred to, and of surgical experience, private and hospital, afford 
indubitable evidence. Many lives have been lost from the effects of wounds and punctures 
in examining the bodies of persons dead of septic affections; and every obstetrician is 
painfully familiar with the inoculable character of the secretions furnished during the 
progress of puerperal fever. The poison in such cases often adheres to the fingers and 
even to the clothing, despite the utmost attention to cleanliness, and is thus readily carried 
from one person to another. 
The poison gains admission into the system through the lymphatics and the veins, but 
more especially through the former vessels, and its absorption is effected most readily 
when the putrid fluid is in contact with a fresh wound, or with a serous or synovial 
cavity. A point of great practical interest is that healthy granulations, in which most 
careful examinations have failed to discover the presence of lymphatics, afford a decided 
protection against septic absorption ; but if they are unhealthy or are destroyed they 
present a surface which readily admits decomposing fluids. 
1. SEPTICEMIA. 
From the experiments, principally of German observers, which have been carefully 
considered by the committee appointed by the Pathological Society of London to inves- 
tigate the nature and causes of pyemia, septicemia, and purulent infection, and whose 
report may be found in the thirtieth volume of its Transactions, it appears probable that 
septicemia includes two distinct conditions, which are known, respectively, as septic or 
putrid intoxication, and septic or putrid infection. 
In regard to the former condition, which may be termed toxemia, experiments upon 
animals demonstrate that if a lethal quantity of putrefying material is injected under the 
skin death rapidly follows simply from the effects of the chemical poison termed sepsin. 
The blood injected into another animal does not set up a similar affection, thereby show- 
ing that the poison does not multiply in that fluid ; nor does the blood, according to the 
observations of Koch, contain minute organisms, although it undergoes certain changes, 
of which the most important are, first, the tendency of the red corpuscles to aggregate into 
small masses instead of rouleaux, and, secondly, the commencing disintegration of the 
corpuscles, as shown by the staining of the serum with the blood pigment, and the occur- 
rence of petechia? beneath the serous membranes. The other post-mortem appearances 
indicate intense congestion of the gastro-intestinal mucous membrane, and engorgement 
and softening of the spleen. The clinical phenomena which accompany these morbid 
changes are elevation of the temperature to 104° Fahr., and upwards, with corresponding 
increase in the frequency of the pulse, unrest, muscular twitching, gravescent muscular 
debility, oppressed breathing, vomiting, profuse diarrhoea, somnolence, and coma. 
In the human subject a mild form of septic intoxication is of very common occurrence 
in connection with severe surgical injuries and wounds, to which the term traumatic or 
surgical fever is usually applied. The committee already alluded to consider that the 
conditions under which acute septic intoxication can occur in man comprise the admission 
of a considerable quantity of putrid matter, as from one to two ounces, rapidly absorbed 
from large, irregular recent wounds, from serous or synovial cavities, from large abscesses 
opening externally by an insufficient aperture, and from the raw surface of the uterus 
left by the separation of the placenta. After the operation of ovariotomy the conditions 
most favorable to septic intoxication are all present, and many deaths occurring in the 
first two days are doubtless referable to it. The conclusions of the committee in regard 
to the evidence to be looked for as indications of acute putrid intoxication in man are, 
first, “ the presence of a sufficient quantity of septic matter to yield the necessary dose of CHAP. IV. 
PYEMIA. 
141 
the septic poison ; secondly, the invasion of the symptoms at a time when decomposition 
of the discharges has commenced, and before the surface of the wound has become covered 
by granulations; thirdly, high fever rapidly followed by great depression ; fourthly, post- 
mortem appearances indicative of a tendency to congestion and capillary hemorrhage; 
and, lastly, the absence of organisms from the blood during life, or immediately after 
death.” 
In the second form of septicemia, or septic infection, which may be termed ichorrhemia, 
the poison multiplies in the system, and a drop of the blood or of the inflammatory dis- 
charges sets up a similar process in another animal. The blood, moreover, in addition to 
changes which are met with in septic intoxication, contains large numbers of bacteria; 
and the lungs, spleen, and liver are congested. The disease develops more slowly and 
pursues a more chronic course than acute putrid intoxication, and the symptoms are fever 
with progressive emaciation and exhaustion. The distinction between the two affections 
is obscure ; but infective septicemia may be suspected to exist when from the small size 
of a wound it is impossible for a lethal dose of septic matter to be formed in it; and the 
evidence of infection from one patient to another is conclusive when it exists, as it cannot 
occur in cases of pure septic intoxication. As the clinical distinction between these two 
forms of blood-poisoning cannot, in the present state of our knowledge, be accurately 
made, the remaining remarks will refer simply to septicemia as distinguished from pyemia. 
In the majority of cases the signs of septicemia begin on the second day, the disease 
being ushered in by a marked chill, which is followed by febrile excitement, during which 
the temperature varies from 103° to 108°Fahr., but rapidly subsides during the succeed- 
ing sweating. When the affection assumes a severe type, the more prominent symptoms, 
in the order of their frequency, in addition to muscular weakness, are delirium, an icteric 
tint of the skin, dyspnoea, vomiting, diarrhoea, and ecchymoses of the integument. In 
the milder cases the temperature reaches its maximum of 103° or 104° Fahr., in from 
two to four days, and then sinks with the development of suppuration, and gradually dis- 
appears with the formation of healthy granulations. 
Attempts have been made to draw a distinction between septicemia and pyemia by the 
chills, which are said, as a rule, to be limited to the initial rigor in the former, and to 
succeed one another in a few hours or days in the latter atfection. In septicemia they 
are repeated, however, more than once in four-fifths of all cases, so that this feature is of 
no diagnostic value. A high temperature is more characteristic of septicemia, and it 
does not appear to be the subject of the irregular variations of pyemia, which range as 
high as 10° or even over 10° or 11° Fahr. 
The principal lesions found in patients dead of septicemia are congestion of the lungs, 
parenchymatous swelling and softness of the spleen and liver, extreme congestion and 
ecchymoses of the gastro-intestinal mucous membrane, subserous petechiae, and post- 
mortem staining of the tissues. The blood is not uncommonly very fluid, and early 
decomposition is occasionally witnessed. The prognosis of the affection is most unpromis- 
ing. In the fatal cases, although life is now and then prolonged tor three weeks, one-half 
perish in four days from the commencement of the invasion, and four-fifths in the first 
eight days. The treatment does not differ from that of pyemia. 
2. PYEMIA. 
The fact that certain injuries and operations are occasionally followed by the develop- 
ment of abscesses in some of the internal organs of the body, did not escape the attention 
of some of the older surgeons. Ambrose Pare makes distinct mention of the occurrence ; 
and Pigrai, about the same period, noticed that, during one particular year, nearly every 
person who was so unfortunate as to have a wound of the head, died of suppuration of the 
liver. These observations were afterward confirmed by Morgagni, Bertrandi, and An- 
douille, and, more recently, by Schmucker, lvern, Klein, Hennen, Larrey, Guthrie, and 
other military surgeons, as well as by many hospital and private practitioners. Velpeau, 
however, was the first to investigate the lesion in a really scientific manner, and to institute 
a thorough and elaborate examination into its etiology, pathology, and treatment. 
Although the exciting causes of pyemia are of a very diversifled character, the most 
important, by far, are shock, loss of blood, or depression of the vital powers. As follow- 
ing severe injuries of the head, it was, as already stated, long ago noticed by many of 
the older pathologists and surgeons, although they failed to other any correct or even 
plausible theory of its occurrence. Since attention was first prominently called to it, in 142 
TERMINATIONS OF INFLAMMATION. 
CHAP. IV. 
1823, by Velpeau, it has been much oftener observed after compound fractures and dis- 
locations, lacerated, contused, railway, and gunshot wounds, and amputations of the larger 
limbs, than after any other accidents. In lying-in females it is also sufficiently frequent, 
and is, in fact, a considerable source of the mortality consequent upon the puerperal state. It 
has been known to supervene upon erysipelas, carbuncle, periostitis, necrosis, diseases of 
the joints, injury of the big toe, gumboil, abscess of the throat and middle ear, smallpox, scar- 
latina, typhoid fever, ulcerative endocarditis, suppurative myositis, and even gonorrhoea. 
One of the first cases of the disease I ever saw occurred in a young woman laboring under 
a slight attack of erysipelas of the leg. On dissection, I found the cause of death to have 
been a pyemic abscess in the left lung, about the volume of a large almond, filled with aplastic 
matter, and surrounded by highly inflamed and softened tissue. No appreciable disease 
existed in any other part of the body. The secondary purulent collections so often met 
with in glanders and dissection wounds evidently belong to this class of affections. Pyemia 
occasionally succeeds to the use of the trephine, the extirpation of tumors, and operations 
on the bones, joints, urinary organs, and bloodvessels. Sometimes, indeed, apparently 
the most trifling operation is followed by it. Many years ago I attended, in consultation, 
a man who lost his life by blood-poisoning consequent upon bleeding at the bend of 
the arm; and a similar case afterwards occurred in my own practice at the Louisville 
Marine Hospital. The patient, a colored woman, the subject of chronic disease of the 
wrist-joint, was bled at the median basilic vein. In a few days violent phlebitis super- 
vened, followed by large purulent collections in nearly all the. principal articulations, as 
well as among the muscles of the arm and shoulder, terminating fatally in less than a 
week. The injury inflicted in the removal of a small piece of dead bone has been known 
to cause death by embolic abscesses. In 1848, I lost a young man, twenty-eight years 
of age, from pyemia, induced by tying three hemorrhoidal tumors. Death occurred on 
the eighth day; and, on dissection, the connective tissue of the mesorectum was found 
to be studded with hundreds of abscesses, from the size of a currant to that of a small pea. 
Pyemia occasionally follows the suppurative inflammation consequent upon a badly- 
healed stump, weeks, if not months, it may be, after the amputation, and long after the 
patient is apparently out of danger. The discharge, perhaps never entirely arrested, 
suddenly increases in quantity, the parts become tender and irritable, the constitution is 
seriously affected, rigors soon set in, and, in short, all the symptoms of blood-poisoning are 
fully declared. 
The disease, now and then, assumes an endemic type. Thus, in the military hospital at 
Stanton, during the late war, fifty-nine cases, all, excepting two, the result of gunshot 
injuries and surgical operations, occurred within a period of twelve months. 
No period of life is entirely exempt from this disease. It has been met with even in 
children at the breast; and a case has been reported of an infant, only ten days old, in 
whose body, the subject of erysipelas, not less than nine large abscesses of this kind had 
formed, causing death in a short time. On the other hand, it occasionally occurs at a 
very advanced age. Young and robust subjects, however, have appeared to me to be 
most liable to it, especially after severe railway, gunshot, and other accidents, attended 
with severe shock and excessive loss of blood. Wounds of, and operations upon, the 
veins are very prone to be followed by blood-poisoning. Pyemia is more common among 
the inhabitants of crowded cities than among those who enjoy the benefit of pure country 
air, good wholesome food, and an abundance of exercise and sleep ; it is likewise more 
frequent in hospitals, almshouses, and other receptacles for the poor, than in private 
practice; circumstances of no little interest, both in an etiological and therapeutic point 
of view. 
Unhealthy occupations, exposure, fatigue, loss of sleep, and mental anxiety are powerful 
predisposing causes of pyemia. It is asserted by Mounier that during the war in the 
Crimea not a single case of this disease occurred among the first two thousand amputations, 
while it was afterward very common in association with gangrene, scurvy, typhoid fever, 
and other low states of the system. 
With regard to the immediate cause of pyemia, the old notion that it is the product 
of metastasis, or, in other words, that it is due to the absorption of pus from the part 
originally affected, and to the transportation of this fluid to some other, more or less 
remote, situation, where it is collected into a focus, and thus becomes a source of new 
irritation and disease, has still its advocates and adherents. It rests upon the supposition 
that the pus corpuscles are admitted, unchanged, into the open mouths of the veins at the 
seat of the wound, as, for example, the surface of a stump after amputation, and that, 
being so introduced into the circulation, and pushed onward by the blood, they are finally CHAP. IV. 
PYEMIA 
143 
arrested in the minute capillaries, which are unable to transmit them, as they do the red 
particles of the blood, in consequence of their lager size. The mechanical obstruction 
thus occasioned forms, it is alleged, a new cause of morbid action, which is soon followed 
by the development of an abscess, or a deposition of pus, and, if the new depots be numer- 
ous, by purulent infection. In opposition to this doctrine, it has been contended that pus 
corpuscles never gain access in this way into the circulation, and that those who profess 
to have seen them there were deceived by the resemblance which these corpuscles bear to 
the colorless globules of the blood. Moreover, it has been clearly shown that the injection 
of laudable pus does not induce symptoms which resemble those of pyemia in any respect, 
but merely gives rise to a transient fever. 
The doctrine that pus, as such, cannot enter the circulation has been completely over*- 
turned by the observations of modern pathologists, who have demonstrated the permea- 
bility of the walls of the veins and capillaries to colorless blood corpuscles, or their 
equivalents, pus corpuscles, which would render the view of the direct introduction of 
pus into the blood as a factor in the production of pyemia, at least plausible. In the event of 
pus corpuscles—pathologically altered colorless blood corpuscles—finding their way into 
the blood through the softened walls of the vessels of the inflamed part, it is, however, 
scarcely probable that they would give rise to the formation of abscesses in the manner 
described in the preceding paragraph, since the tendency of the commingling of the two 
fluids would be to the production of a clot or thrombus, which would form, as will be 
pointed out below, the first link in the chain of morbid action. I have myself no doubt 
whatever that pus, as pus, may enter the blood, and give rise to septic changes in that 
fluid, and, further that, under certain circumstances, it may lead to the formation of an 
initial thrombus, to the retrograde changes in which the phenomenaof pyemia are partly due. 
Passing over other theories which have been advanced from time to time as to the 
causation of pyemia, it is evident that under the term pyemia should be included three 
distinct and dissimilar processes, changes in the blood, the formation of septic thrombi 
and emboli with metastatic deposits, and the absorption of ichorous or putrid fluids, 
which may coexist in the majority of cases, and are possibly interdependent. The 
modifications of the blood consist of an increase in the number of colorless corpuscles, 
with simultaneous increase of the fibrin. The tendency of these elements is to cohere 
and to form adherent layers upon the inner walls of the vessels, points which not only 
favor the occurrence of stasis, but also, by presenting centres of roughness, invite more or 
less extensive coagulation of the blood. It is in this way that the changes in the blood 
become one of the causes of thrombosis. 
The connection of thrombosis and embolism with the formation of metastatic, or 
embolic, abscesses is one of the most interesting, as well as one of the most firmly 
established, facts in pathology. A thrombus or clot may form, in a vein, 1st, in conse- 
quence of the retardation or interruption of the current of blood, due commonly either to 
constriction of the vessel, from the compression exerted upon it by the products of the 
inflamed perivascular tissues, or to the division of the vessel, as, for example, in an am- 
putation, whereby the flow of blood is completely cut off; 2dly, to inflammation of the 
coats of the veins themselves, the result of very acute inflammation of the connective 
tissues around them ; and, 3rdly, to projections into the lumen of the vessels caused by 
small abscesses in their walls, or adherent layers of fibrin and white blood corpuscles, due 
to leucocytosis, or small offsets of fibrin, which are merely the central ends of thrombi 
formed in the smaller veins, where they communicate with the branch or trunk affected, 
or colonies of schizomycetes, which line the larger vessels and project into them in the 
form of papilla}. All of these conditions form starting points for larger coagula, which 
afterwards increase by the deposition of successive layers of fibrin. 
The disposition of a fully formed thrombus will depend upon the quality of the fibrin 
and the nature of the inflammation. If the fibrin be organizable and the inflammation 
tend to resolution, the thrombus will be converted into connective tissue and cause simple 
obstruction ; but if the morbid action proceed to suppuration and gangrene, the clot will 
soften, disintegrate, and break down into a puriform fluid, which, mingling with the 
fibrinous detritus, excites phlebitis, as shown by thickening of, and the occurrence of 
purulent deposits in, the walls of the vessel, and the partial destruction of its coats. 
The central end of the thrombus generally extends to the nearest collateral branch, 
where it projects into the main trunk, by the addition to it of layers of fibrin, as exhibited 
at a, fig. 17, from Callender. Under the influence of predisposing causes, most probably 
the septic condition of the blood, the clot softens, particles, fragments, or emboli are 
loosened and detached by the current of blood, as at b, and carried into the circulation, 144 
TERMINATIONS OF INFLAMMATION. 
CHAP. iv. 
until the right side of the heart is reached, whence they pass into the pulmonary arteries, 
in the smaller ramifications of which, and usually at a bifurcation, they are arrested. At 
the points of lodgement (hey excite inflammation, which terminates in suppuration and 
sloughing of the walls of the vessels and of the parenchymatous perivascular tissues, and, 
in this way, give rise to the so-called metastatic abscesses. In 
other cases, the embolus is so large as to deprive a portion of the 
lungs of their due supply of blood, causing in this event gangrene 
of the points involved. From these primary pulmonary abscesses 
venous thrombi form, which, in their turn, reach the left side of the 
heart; and through the systemic circulation develop similar phenomena 
in the liver, spleen, kidneys, subcutaneous tissue, and other struc- 
tures. The explanation of those rare cases of secondary abscesses 
in organs, when the capillaries of the lungs have escaped, is pro- 
bably to be found in the hypothesis that thrombi disintegrate into 
particles or granules, which are so minute as to enable them to slip 
by the pulmonic system of vessels into the left side of the heart. 
The third process concerned in the development of pyemia, and 
that which, in all probability, occasions the disintegration of the 
thrombi, is a poisoned state of the blood, systemic infection, ichor- 
rhemia, or septicemia, consequent upon the absorption of the ichorous, 
septic, or putrescent material present in suppurating and gangrenous 
wounds and in stumps after amputation. Not only may the more 
watery portion of the noxious secretions enter the circulation, tho- 
roughly contaminating both solids and fluids, and, consequently, 
effectually undermining the constitution ; but, as I previously stated, 
the corpuscular elements may permeate the walls of the vessels, and by their mechanical 
action upon the blood, excite the formation of thrombi. 
The researches of the committee appointed by the Pathological Society of London, to 
whose labors allusion is made in the preceding section, render it highly probable that 
pyemia frequently depends upon a general infective process, which is rapidly followed 
by the development of abscesses without the formation of thrombi. Thus, of 150 fatal 
cases, in 58, or 37 per cent., there was no evidence whatever that the abscesses and sup- 
purations discovered in the viscera and elsewhere were due to thrombo-embolic processes. 
In the remaining 98 cases, on the other hand, the disease could be traced to putrid embo- 
lisms. In the latter class the poison does not multiply in the system, and it has not been 
shown experimentally that the affection is communicable by means of the blood from one 
animal to another. In view of these facts the committee are disposed to separate pyemia, 
as they did septicemia, into a non-infective and an infective form, the latter being a specific 
and a communicable disease, whereas the former does not possess those attributes, but is 
merely a condition of blood-poisoning from the absorption of septic material from putre- 
fying wounds. The first link in the chain of pyemia from traumatism thus appears to be 
an altered condition of the blood, attributable to a depressed and enfeebled state of the 
constitution engendered principally by loss of blood, severe shock, or a tainted state of 
the atmosphere ; the second, the formation of abscesses, which are usually found in con- 
nection with thrombosis and embolism ; the third, systemic infection due to the absorption 
of noxious matter. 
These views of the causes of pyemia derive the strongest possible confirmation from the 
experiments of Polli and other observers upon animals, proving, as they incontestably do, 
that unhealthy pus thrown into the blood produces septicemia with multiple abscesses ; 
and, secondly, that the injection of putrid substances gives rise to a bad form of suppura- 
tion characterized by symptoms of typhoid gastro-enteritis. Virchow had previously in- 
duced all the conditions of pyemia by the introduction of a piece of putrid fibrin into the 
jugular vein of a dog. 
The prejudicial effects that are exerted by the emanations from the wounds of pyemic 
patients upon the wounds and constitutions of healthy subjects confined in the same 
apartments, as, for instance, in the crowded wards of a hospital, are well known to military 
as well as civil practitioners, and they necessitate the greatest possible care in the man- 
agement of such cases, in order to prevent the extension of disease. A poison of the 
most subtle and virulent character is engendered in the foul air thus produced, probably 
similar to that of hospital gangrene, and exceedingly destructive to all those who are 
brought under its baneful influence. Under these circumstances schizomycetes are gene- 
Fig. 17. 
Formation and Softening 
of Venous Thrombi. CHAP. IV. 
PYEMIA. 
145 
rally developed in great numbers upon wounds and sores, and, in hospitals, may sometimes 
be discovered upon the floor, walls, and ceilings. 
Is pyemia, as the name denotes, always a result of the admission of vitiated secretions, 
or of putrescent matter into the circulation ? Instances occur, as when the disease com- 
plicates typhoid fever, scarlatina, and various other asthenic affections, where the reverse 
would seem to be the case, and yet, it must be confessed, it is not alwTays possible, even 
here, to determine whether the individual is entirely free from antecedent suppurative 
action. It is probable that, under such circumstances, mere disorder of the blood, such 
as undoubtedly attends the worst forms of these maladies, may be quite adequate to the 
production of secondary abscesses of a very bad character. 
The period of latency of pyemia is commonly very short, not exceeding a few days 
from the time of the accident or operation giving rise to it. There are cases, however, 
although they are infrequent, in which a much longer time elapses. In every 100 cases 
the symptoms appear in the first week in 57, in the .second week in 19, and after a fort- 
night in 24. As a general rule, it may be assumed that the briefness of the period of 
latency will be in proportion to the shock of the system, the amount of hemorrhage, and 
the ill state of the patient’s health prior to the injury. The time is usually shorter in 
traumatic than in idiopathic affections, in the latter of which the secondary lesion occa- 
sionally does not come on until near the period of apparent convalescence. 
The approaches of pyemia are generally very stealthy and insidious ; hence the young 
and inexperienced practitioner is often thrown completely off his guard in respect to the 
nature of the formidable disease with which he has to grapple. If, for instance, the 
attack is one consequent upon an amputation, he probably feels concerned to find that the 
stump gives evidence of being in an unhealthy condition, that it is unusually tender and 
painful, that it manifests no disposition to heal, and that the discharge is not only profuse, 
but foul, thin, sanious, bloody, or ichorous. The patient, although not inclined to com- 
plain much, is restless and ill at ease, looking pale, sallow, and anxious, as if some serious 
evil were impending. Ilis pulse is irritable and too frequent, the cheek is marked by a 
sinister flush, the appetite is impaired, the secretions are deranged, and there is a remark- 
able increase in the temperature of the body. This prodroma is of short duration, often 
hardly lasting twenty-four hours. Rigors, more or less violent, now set in, and having 
continued from fifteen minutes to several hours, are succeeded by excessive reaction, and 
this, in turn, by profuse sweats, often completely drenching the surface and even the body 
clothes. These rigors may return twice or even thrice in-the twenty-four hours, or they 
may come on at regular periods, not unlike the paroxysms of an intermittent fever, for 
which the unwary sometimes mistake them. Their severity is not always the same ; 
cases occur in which they are replaced, as it were, by chilly sensations, alternating with 
flushes of heat, and not unfrequently lasting for several days together. In 27 per cent, of 
all instances they are absent altogether, and when this happens they are replaced by pro- 
fuse sweating. In whatever manner this outbreak displays itself, the disease at once 
assumes a more bold and decisive character. The skin and conjunctiva exhibit a well- 
marked icterode appearance ; the features are shrunken and withered, the nose being 
pinched and the eye sunk in its socket ; the pulse is small, feeble, and frequent, usually 
ranging from 100 to 120, although it may reach nearly 200 ; the breathing is accelerated, 
ranging from 40 to 50 in the minute, and performed with unusual effort; the tongue is hard, 
dry, and brown; the thirst is urgent; the sleep and appetite are interrupted; the bowels 
are irregular, being at one time relaxed, and at another constipated ; the stomach is irri- 
table and nauseated ; the urine is high-colored and scanty ; the extremities are cold ; the 
mind wanders; and the body is often racked with excruciating pain, especially in the 
joints and muscles, whigh are not unfrequently exquisitely sensitive to the slightest touch. 
Occasionally the patient complains of severe pain in some internal organ, to which he 
refers all his principal suffering. Cough is sometimes present, and is then generally 
dependent upon more or less serious lesion of the pulmonary tissues, or of the lung and 
pleura. As the disease progresses, red blotches, swollen, and excessively painful, appear 
upon the larger joints, and serve as the forerunners of approaching suppuration in their 
interior, as well as in the tissues immediately around them. Similar marks occasionally 
occur in the course of the principal veins and in the situation of some of the muscles, 
particularly the deltoid and pectoral. In some of the more obscure forms of pyemia,.the 
chief evidence of the disease is an eruption of the skin, as the erythematous, vesicular or 
pustular, or an erysipelatous condition of certain portions of the surface, very liable to be 
mistaken for some other affection. 
There is always in pyemia a notable increase in the temperature of the body which, at 146 
TERMINATIONS OF INFLAMMATION. 
CHAP. IV. 
the commencement of the chill, rapidly and constantly rises, and attains its highest point 
at its termination, when it may reach even 108° Fahr. It is, however, subject to irregu- 
lar variations, which range over 10° or 11° Fahr. During the sweating stage the 
temperature again falls to its former level. 
The symptoms, long before the disease has reached this crisis, are of a typhoid charac- 
ter, the whole system seemingly laboring under the depressing influence of a deadly 
poison. The downward tendency is rapidly progressive; the machinery of life moves 
alternately to and fro ; the pulse becomes more and more feeble ; the respiration is fright- 
fully oppressed ; the body is remarkably emaciated ; and the patient lies in a comatose 
condition, from which he is destined never to awake. This, however, is not uniformly 
the case; for the instances are not infrequent, where the mind retains its consciousness 
almost to the last. The average period at which death occurs, after the disease has fairly 
commenced, varies from ten days to a fortnight, the minimum being a few days, and the 
maximum, as nearly as can be determined, about three months. In every 100 cases, 42 
die in the first week, 30 in the second week, 20 in the third week, and 8 after the 
thirtieth day. Of the more prominent symptoms the most common, in the order of their 
frequency, are rigors, delirium, vomiting, diarrhoea, rapid emaciation, and jaundice. 
Although there are, strictly speaking, no pathognomonic symptoms of pyemia, it is 
seldom that any one who has ever seen a case of this disease, or who has made himself 
thoroughly familiar with its history and progress, can possibly confound it with any other 
complaint. Its very mode of invasion generally sufficiently stamps its true character. 
The sudden, violent, and unexpected rigor, usually followed by copious sweats ; the ex- 
traordinary increase of temperature ; the unhealthy character of the suppurating sore or 
wound, if any exist; the icterode and shrunken state of the features; the rapid super- 
vention of typhoid symptoms; the great mental anxiety and excessive restlessness; the 
horrible aching pains in the joints, limbs, and other regions ; and, lastly, the rapid abduc- 
tion of the fat, leaving the body in a wasted and emaciated condition, far beyond what 
occurs in almost any other affection, excepting, perhaps, cholera ; are signs which, if they 
do not unerringly mark the nature of pyemia, will always excite the serious suspicion of 
the attendant, and induce him to scrutinize the case in the most careful and thorough man- 
ner. Almost the only disease with which blood-poisoning is liable to be confounded is 
intermittent fever; but here the distinction is so easily drawn as to render error impos- 
sible. Pyemia of the joints has sometimes been mistaken, especially in its earlier stages, 
for acute articular rheumatism, rheumatic gout, or rheumatoid arthritis. The diagnosis 
of traumatic pyemia is generally less difficult than that of the idiopathic variety, or that 
arising from internal causes, the violent rigor, the icterode countenance, and the rapid 
prostration and emaciation being usually sufficiently characteristic of the nature of the 
complaint. 
The dissection of patients dead of pyemia reveals important and interesting changes 
both in the solids and fluids. Of those affecting the solids, the most constant are abscesses 
and purulent depots in various organs, cavities, and tissues. The former, generally 
known under the name of metastatic, embolic, or multiple abscesses, are most common in 
the lungs, next in the liver and spleen, and, lastly, in the kidneys, brain, and heart. They 
sometimes 6ccur in the subcutaneous connective substance, and beneath the peritoneum. 
In one instance, previously referred to, I found an immense number in the connective 
tissue of the mesorectum. Their presence has also been detected in the prostate and 
parotid glands. 
Professor Sedillot, of Strasbourg, who has studied this disease with great care, remarks 
that in 100 cases the lungs would be likely to be affected in 99 ; the liver and spleen in 
1 of 12 ; the muscles in 1 of 15 ; and the heart and peripheric connective tissues in 1 of 20. 
Of 131 cases analyzed by the committee of the Pathological Society, abscesses were found 
in the lungs in 104, in the liver in 14, in the spleen in 11, in the kidneys in 9, in the 
brain in 6, in the heart in 3, and in the subcutaneous connective tissue in 6. 
Metastatic abscesses vary in number in different instances from one to twenty, thirty, 
fifty, or even several hundreds. Occasionally, indeed, the surface of the affected organ is 
completely studded with them, more than a thousand having been observed in a single 
case, principally in the deep-seated viscera. Their size ranges from a hemp-seed or a pea 
to a hazelnut, a marble, a pigeon’s egg, or even an orange. When very numerous, they 
are usually proportionately small. In their form they are oval, spherical, or angular. 
When seated near each other, they are occasionally confluent, like the pustules of smallpox. 
The contents of metastatic abscesses seldom consist of well-formed pus; on the con- 
trary, the matter is usually of a semi-concrete consistence, of a dirty grayish, cineritious, 147 
CHAP. IV. 
PYEMIA. 
or drab color, and largely intermixed with spoiled lymph. It further differs from genuine 
or healthy pus in the abscence of the true nucleated pus corpuscles, and in the existence 
of an unusual quantity of oily matter and immense numbers of granular cells, and low 
organisms. When the abscess is more matured, or when it is of long standing, the 
contents are more decidedly purulent, but even then there is frequently a very consider- 
able amount of foreign substance, as flakes of fibrin, grumous blood, and the debris of the 
affected tissues. In pyemic suppuration of the serous membranes, the fluid that is so 
abundantly secreted by these structures consists mainly of turbid serum, or puriform 
matter; while in the joints it is of an oily or greasy character, of a pale yellowish hue, 
and destitute of well-formed pus corpuscles and nucleated cells. 
The textures immediately around the abscess may be natural, or variously altered in 
appearance and consistence. In most cases they are engorged with blood, heightened in 
color, and more or less softened, if not completely pulpified. The coats of the vessels are 
inflamed, thickened, and infiltrated with serosity, while their canals are filled with pus, 
semifluid blood, emboli or fibrinous concretions. The capillary veins and arteries 
usually participate in the inflammation. The blood always contains an unusually large 
quantity of fibrin and white corpuscles. 
Purulent collections, as a consequence of pyemia, are most common in the chest, being 
rare in the peritoneum, the arachnoid, and pericardium. The reason of this difference 
seems to be that the lungs nearly always suffer when there is serious involvement of the 
system, whereas the abdominal viscera, heart, and brain usually escape. 
The joints often suffer very severely. In some of the cases that I have had an oppor- 
tunity of examining after death, matter was found in nearly all the larger ones, and also 
in quite a number of the smaller. Very frequently the pus is situated on the outside of 
the joints, as well as within. 
Large collections of purulent fluid sometimes occur in the subcutaneous and intermus- 
cular connective tissue, the result evidently of cellulitis ; the veins also occasionally contain 
a considerable quantity, either lying free in their cavities, or, as is more common, inter- 
mixed with the blood in the interior of fibrinous concretions. 
The pus that is found in these various localities is of the same nature as the fluid con- 
tained in metastatic abscesses, properly so termed, that is, it is imperfectly elaborated, and 
intermixed with a large proportion of aplastic material. Both in the veins and in the in- 
termuscular connective tissue, it is generally, as just stated, interspersed through fibrinous 
concretions, coagula, or blood-clots, giving the latter a peculiar appearance, as if they 
were infiltrated with small specks of lymph, or lymph and pus. 
In addition to abscesses and purulent collections, the most common lesions met with in 
pyemia are parenchymatous swelling of the spleen, kidneys, and liver, congestion of the 
lungs, and subserous petechia;. Internal congestions are, however, less frequent than in 
septicemia. 
The prognosis of pyemia is most unfavorable; few patients recover, and these, for the 
most part, remain for a long time in a debilitated and crippled condition, liable to out- 
breaks of other diseases from the slightest causes. Of forty cases, mostly gunshot fractures, 
treated at the Lettterman Hospital after the battle of Gettysburg, not one was saved. Of 
150 cases analyzed by Dr. William S. Savory, of London, 26 recovered, but this is an 
unusual percentage. The fatal character of the disease is well illustrated in the cases 
that occurred in the Stanton Hospital, fifty-nine in number, of which, according to the 
statement of Dr. Lidell, only three recovered, affording thus a ratio of mortality of nearly 
95 per cent. Most of the patients died before the tenth day, and two in less than forty- 
eight hours, only one surviving a month. As already stated, death usually occurs within 
the first fortnight of the attack, apparently from the severe exhaustion consequent upon 
the excessive pain and obstructed circulation, so conspicuous in this affection. A return 
to health is generally announced by the presence in the urine of an unusual quantity of 
lithic acid and by the gradual subsidence of the graver symptoms. 
Treatment In the treatment of pyemia the leading objects should be, first to remove 
the exciting cause of the disease; secondly, to eliminate the poison from the system ; and, 
thirdly, to support the constitution, in order to enable it, if possible, to shake off the 
toxical influence under which it is so plainly laboring. 
If the disease has been induced by an accident or operation, attended with an open, 
suppurating surface, much may be done, in many cases, by the promotion of cleanliness 
and the use of antiseptics, to prevent further mischief from the ingress of purulent fluid. 
This object is best attained by diligent, almost incessant, attention to the dressings and to 
the position of the part, the former being frequently changed, and the latter so arranged 148 
TERMINATIONS OF INFLAMMATION. 
as to favor the escape of the secretions as fast as they are poured out. Detergent lotions 
are often serviceable, especially if they contain chlorinated sodium, carbolic acid, or chloride 
of zinc, but care must be taken that they are not so strong as to irritate; and it will be 
well, particularly if the surgeon has to deal with a foul stump, to throw them freely upon 
the parts with a large syringe, as this exerts a much better and wider influence than the 
less efficient irrigation with a sponge. Jt will also be advantageous to keep the dressings 
constantly sprinkled with the chlorides, both with a view of allaying fetor and of purifying 
the air of the apartment, which must be frequently renewed by opening the doors and 
windows. 
To prevent the further ingress of purulent fluid into the system is not so easily accom- 
plished. If the surface is not too extensive, the best remedy will be the officinal solution 
of acid nitrate of mercury diluted with four to ten parts of water, applied rapidly and freely 
with a mop, the intention being not so much to produce an escharotic as an alterant effect, 
thereby inviting a rapid change in the action of the capillary vessels and an abundance of 
exudation matter, so as to close up the mouths of the vessels, and cause consolidation of 
the affected tissues generally. When the vessels are large and patulous, they may some- 
times be closed by well-regulated methodical compression. The actual cautery, recom- 
mended by the French surgeons for sealing the suppurating surface, should never be 
employed, unless it be drawn over the parts, previously well wiped, in the most careful 
and considerate manner. 
To neutralize the poison of pyemia, or to render it inoperative, is an object of vital 
importance in the treatment of the disease, and yet, if such a remedy exist, it remains to 
be pointed out. The hyposulphites of sodium, potassium, and ammonium seem to have 
yielded good results in some cases, in the hands of Polli, T. Spencer Wells, Dr. Walter 
F. Atlee and others, and they are worthy of further trial, as they exert a direct influence 
upon the blood and the tissues during the time that it is necessary to convert them into 
sulphates, the form in which they are eliminated from the system. To produce the desired 
effect, the medicines should be given in large and sustained doses. 
The third and last indication is best fulfilled by stimulants and tonics, as brandy, wine, 
ammonia, camphor, iron, and quinine, with animal broths, and other suitable means of 
support. Opiates should be given freely to allay pain and induce sleep. The recurrence 
of rigors, or chilly sensations, is most readily prevented by quinine and morphia, the dose 
of the former being not less than ten grains to one-third of a grain of the latter, every 
four or six hours, until a decided impression has been made upon the system. No benefit 
can accrue, under such desperate circumstances, from administering these articles in 
smaller quantity, as they only serve to tease the system, and to permit the play of morbid 
affinities. The irritability of the stomach, so often present in pyemia, is generally best 
controlled by sinapisms, abstinence from drink, the use of ice, and the exhibition of 
aromatic spirits of ammonia, champagne, or lemon-juice neutralized by bicarbonate of 
potassium. Bromide of potassium, either alone or in union with hydrate of chloral, often 
acts very beneficially under such circumstances. When dependent upon the lodgement 
of bile, or vitiated ingesta, a gentle emetic may be of service, as ground mustard and 
common salt. Active purging must be avoided. 
Inflammation of the joints and muscles must be treated with soothing measures, as warm 
medicated lotions and cataplasms, aided by the frequent application of iodine. If absces- 
ses form, evacuation must be afforded by early and free incisions, the opening being made 
in such a manner as to prevent accumulation and bagging of fluids. Determination to 
internal organs, as the lungs, heart, spleen, and liver, must be counteracted- by dry cupping 
and blistering. The secretions, generally so much disordered in pyemia, should be corrected 
with blue mass or calomel, not carried so far as to provoke ptyalism, as this could not tail 
to prove prejudicial. 
Bleeding, both local and general, is invariably inadmissible in all diseases attended 
with blood-poisoning. The system, oppressed and borne down by the toxical influence, 
needs all the support it can derive from this fluid ; the whole current, it is true, is vitiated, 
and its vitality greatly impaired, but, although this is the case, no sensible practitioner 
would attempt to improve the condition of the affected part by such a procedure. Good 
nourishing food and drink, with invigorating medicines, alone can be confided in under 
such circumstances, when the loss of even a small quantity of blood would inevitably 
hasten the fatal crisis. 
When a marked tendency to hemorrhage exists, in consequence of a dissolved and 
broken-down state of the blood, the most suitable remedies will be some of the prepara- 
tions of iron, especially the tannate and tincture of the chloride, the former in doses of 
CHAP. IV. HEMORRHAGE. 
149 
CHAP. IV. 
five to ten grains, and the latter of twenty to twenty-five drops, every three or four hours. 
The same remedies, either alone or combined with ergot and atropia, will generally answer 
for arresting the copious sweats so often present in the different stages of pyemia. Some 
times acids, as the nitric and sulphuric, may advantageously be exhibited, with a view 
both to their tonic and to their antidiaphoretic effects. 
Throughout the whole treatment, great attention must be paid to cleanliness; the bed 
and body clothes should be frequently changed, the surface of the patient sponged with 
tepid salt water, or weak chlorinated washes, and the apartment constantly ventilated, 
fresh air being more essential to recovery than all other means combined. In all cases 
the most rigid observance of hygienic measures will be required to insure ultimate restora- 
tion. Convalescence will always be tardy, and the slightest exposure, fatigue, or irregu- 
larity of diet will be certain to endanger life. 
SECT. VI HEMORRHAGE. 
A discharge of blood, as an effect of inflammation, is an uncommon occurrence. It 
may take place in the interstices of the organs and tissues, or upon their free surfaces, 
and is generally a result of the rupture of some of the vessels of the part, in consequence 
of the manner in which the blood is sent into them by the heart, at a time when their 
walls, weakened by the morbid action, are incapable of offering much resistance. It is 
probable that, when the blood is in a dissolved condition, as occasionally happens in 
scurvy, typhoid fever, and other low states of the system, the hemorrhage may occur as 
a product of secretion, or, rather, perhaps as a mechanical transudation, the fluid perco- 
lating through the coats of the vessels as water oozes through a bladder, the globules 
passing off in an altered and disintegrated form. 
The fluid may present itself in a pure state ; or, as is more generally the case, be mixed 
with other morbid products, as serum, lymph, pus, and mucus, which may thus essentially 
modify its properties, if not, in a great degree, mask its character. The quantity of the 
effused blood varies, in different cases and under different circumstances, from a few drops 
to a number of ounces. The largest hemorrhages of this kind commonly occur in con- 
nection with the serous and mucous surfaces, and the subcutaneous and intermuscular con- 
nective tissue, especially in diffuse erysipelas, and in inflammation consequent upon snake- 
bite, in the latter of which the dissolved state of the blood powerfully predisposes to the 
extravasation. In scorbutic affections, where a somewhat similar condition of the fluid 
exists, inflammatory hemorrhages are by no means infrequent. Considerable effusions of 
blood occasionally take place in the air-cells of the lungs and the minute bronchial tubes 
in pneumonitis. In dysentery, a discharge of blood and mucus is one of the character- 
istic symptoms of that disease. 
Inflammatory hemorrhage rarely comes on until the action of which it is a product has 
made considerable progress; hence its appearance may generally be regarded as denotive 
of a higher grade of excitement than a mere deposit of serum, plasma, or even pus. 
When the discharge is copious, it may, if it do not go too far, prove serviceable in the 
way of depletion, answering much the same purpose as local bleeding by leeching, scari- 
fication, or puncture. In general, however, it is too small to confer any substantial bene- 
fit in this way ; while, on the other hand, if it be very copious, it may speedily lead if not 
to fatal exhaustion, at all events to such a degree of depression as to interfere materially 
with recovery. Besides, it may cause serious mechanical obstruction, as when it is effused 
into the interstices of organs, thus sadly impeding their functions. 
In the treatment of inflammatory hemorrhage reliance is to be placed mainly upon the 
ordinary antiphlogistic measures, employed more or less vigorously according to the exi- 
gencies of each particular case. If the discharge be at all copious, so as to threaten ex- 
haustion, recourse may be had to the administration of acetate of lead in union with 
opium, and injections of the same article, or, what will be better, of the subsulphate of 
iron, a substance which possesses a remarkably controlling influence over all kinds of 
capillary bleeding, whether inflammatory or otherwise. They must, however, be used 
with great caution, that they may not excite undue irritation. Sometimes the discharge 
may readily be arrested by cold applications, as cloths wrung out of iced water, and fre- 
quently renewed, or by the steady employment of a bladder partially filled with pounded 
ice, or some refrigerating lotion. When the blood has been poured out into the connective 
tissue beneath the skin, or among the muscles, and acts injuriously by compressing the 
capillary vessels, nothing short of early and free incisions will be likely to avail. When 
the hemorrhage is internal, proceeding from a serous membrane, as the pleura or perito- 150 
TERMINATIONS OF INFLAMMATION. 
CHAP. IV. 
neum, the use of sorbefacient remedies is indicated ; but these failing, as they will be 
likely to do, when the deposit is uncommonly large, evacuation must be attempted w’ith 
the trocar, although such an operation will generally be extremely hazardous, not to say 
anything of its inefficacy when the effused biood has undergone coagulation, thus render- 
ing its escape impracticable. 
SECT. YII MORTIFICATION. 
Mortification may be defined to be the death of a part, the rest of the organism retain- 
ing its vitality. The word, as now usually employed, is synonymous with gangrene, 
which was formerly used to denote that state of a part which immediately precedes its 
dissolution, while sphacelus was employed to signify the complete extinction of life, with- 
out any possibility of its recovery. In speaking of the death of a bone, necrosis is the 
expression generally adopted. 
Mortification may be acute or chronic, moist or dry, common or specific, according to 
the rapidity of its progress, the condition of the dead part, or the nature of the exciting 
cause. There is really no material difference between acute and moist mortification, or 
between dry and chronic, and hence these terms may very properly be employed in a 
convertible sense. The word specific implies the operation of a peculiar virus in the pro- 
duction of the death of a part, as the poison of the rattle-snake, of chancroid, or of malignant 
pustule. 
1. ACUTE MORTIFICATION. 
Acute mortification, whether the result of traumatic or idiopathic causes, may occur in 
all parts of the body, with, perhaps, the sole exception of the heart. There are some 
organs and tissues, however, which possess this tendency in a much greater degree than 
others, or which, more properly speaking, are better adapted to withstand its assaults. It 
may be stated, as a rule, that those textures are most prone to perish, which stand lowest 
in the scale of organization, or which have naturally a feeble life. Hence the fibrous 
membranes, tendons, ligaments, cartilages, and bones commonly perish very readily, and 
often to a great extent. The connective tissue is also very liable to suffer, its areolar struc- 
ture fitting it in a very special manner for the reception of morbid products, the pressure 
of which, inducing mechanical obstruction in its vessels, is a frequent cause of mortifica- 
tion in erysipelatous and other forms of inflammation. When the supply of blood is cut 
off from the skin, by the infiltration of the cellular substance beneath, this structure also 
dies very readily, notwithstanding its wonderful nervous and vascular endowments. Next 
in order come the mucous and serous membranes, the lymphatic glands, muscles, nerves, 
and bloodvessels, the latter of which, especially the larger trunks and branches, generally 
perish very reluctantly, as is proved by the fact that they often retain their vitality in the 
midst of the sphacelated parts, as, for example, occasionally happens in malignant scar- 
latina, attended with mortification of the glands and connective tissue of the neck. 
Mortification of the internal organs is very uncommon. In the lungs it is occasionally 
a consequence of pneumonitis. It is likewise noticed, but still more rarely, in the liver, 
spleen, kidneys, uterus, and ovaries. The testicle, mamma, tonsils, and salivary glands 
sometimes perish from the effects of erysipelas, and the prostate from urinary infiltration. 
Of mortification of the heart no well-authenticated instance is upon record. Gangrene 
of the brain, from wounds of its substance, although infrequent, is occasionally witnessed. 
The causes of acute mortification are the same as those of acute inflammation ; what- 
ever has a tendency to produce the one may occasion the other. It is not necessary, 
therefore, to enter into any minute discussion respecting them. They may be divided, in 
reference to their character, into five distinct classes: 1. Intensity of inflammatory action. 
2. Mechanical obstruction of the circulation. 3. Chemical agents. 4. Defect of nervous 
energy. 5. Constitutional debility. 
I. It has already been seen how intensity of inflammation acts in producing obstruction 
in the capillary vessels of the affected part; how the blood, rendered adhesive by the 
increase of fibrin and wdiite globules, attaches itself to their walls, and how these walls, 
softened and dilated, at length yield under the pressure of their contents, which are often, 
in consequence, extensively effused into the surrounding tissues, thus materially aggra- 
vating the local trouble. As the disease progresses, the capillary engorgement rapidly 
augments, the blood becoming more and more stagnant, and there is also almost complete 
suspension of the nervous fluid. In short, the greatest perversion of structure and func CHAP. IV. 
ACUTE MORTIFICATION. 
151 
tion exists, the part is in an utterly helpless condition, circulation and innervation are 
entirely at a stand, and death, already actively engaged at the focus of the inflammation, 
soon accomplishes its work. 
Mortification from intensity of action generally advances at an alarming rate, a large 
amount of tissue, and sometimes even an entire limb, perishing in the course of twenty- 
four hours from the commencement of the process. Some of the most characteristic 
forms of this species of gangrene are met with in compound fractures and dislocations, in 
lacerated, contused, railway, gunshot, and poisoned wounds, in burns and scalds, in car- 
buncle, and erysipelas, in which the tissues often succumb under the resulting inflamma- 
tion with amazing rapidity. Hence, such cases, of which fig. 18 affords an excellent 
illustration, are generally said to be acute; and, as the parts are always inundated with 
fluids, the term “ moist” is also often used to designate them. 
Fig. 18. 
Acute Mortification, Rapid in its Progress, and attended with much Swelling and Moisture. 
II. Mortification from mechanical obstruction of the circulation may be caused by 
direct injuries to the arteries, or indirectly through disease of the heart, interrupting the 
flow of blood to the part. Ligation of the femoral artery for the cure of aneurism of the 
popliteal, is occasionally followed by mortification of the toot and leg; and a similar acci- 
dent sometimes happens from the pressure which a tumor of this kind exerts upon the 
terminal branches of this vessel. The circulation being thus impeded, inflammation, gen- 
erally of a very active kind, is liable to be awakened, which soon overpowers the affected 
tissues. Laceration of the principal artery of a limb often results in the death of the 
structures which it supplied with blood. Disease of the valves of the heart, leading to 
vascular engorgement of the feet and legs, along with oedema of the subcutaneous connec- 
tive tissue, not unfrequently produces similar effects. Tight bandaging, pressure of the 
body from protracted decubitus; and inordinate constriction of the bowel, in strangulated 
hernia, are so many causes of mortification from interruption of the circulation. 
Gangrene is sometimes produced by obstruction of the arteries by emboli, either de- 
tached or adherent, or detached clots. Instances of cerebral gangrene, from this cause, 
have been witnessed by different observers; and Paget has collected the particulars of 
seventeen cases in which it gave rise to mortification of the lungs. The influence of the 
puerperal state in favoring the formation of fibrinous concretions has long been familiar 
to pathologists. Gangrene of the extremities from detached cardiac clots, or emboli, is 
sufficiently common. A very interesting case of this form of mortification was kindly 
shown to me some time ago by Dr. James H. Hutchinson, of this city, in a girl, eleven 
years of age, who had long been affected with disease of the heart, attended latterly with 
considerable anemia. Gangrene of the foot and leg set in early in March, and terminated 
fatally on the 13th of April following, a line of demarcation having previously formed 
two inches below the knee, and the foot dropped off near the ankle. The limb, at first 
of a mottled, livid aspect, ultimately became perfectly dark, and was all along the seat of 
the most intense pain. The heart was found to be dilated and hypertrophied, the mitral 
valve greatly contracted, the left auricle distended with an old grumous clot, and the right 
common and external iliac arteries completely obstructed by a firm concretion. 
Embolism occasionally induces mortification with astonishing rapidity, as in a case, 
communicated to me by Dr. Leonard, of a child six years old, who, while seemingly in 
good health, was suddenly seized with excessive prostration, accompanied with delirium, 
unconsciousness, and great depression of the temperature of the whole body. In a short 
time the left leg became livid, and the next morning the foot was found to be dead as hjgh 
up as the ankle, the surface being black, dry, cold, and insensible. At the end of a week 152 
TERMINATIONS OF INFLAMMATION. 
CHAP. IV. 
a line of demarcation began to appear, and, amputation being performed below the knee, 
the case resulted in a good recovery. 
Gangrene from embolism sometimes arises during the progress of typbbid and other 
fevers. In a case reported to be by Dr. Edward North, the patient, a lad, twelve years 
of age, while convalescing from an attack of the former of these diseases, was suddenly 
seized with mortification of the foot, which gradually extended to the leg, along the course 
of the anterior tihial artery to within four inches of the knee. After amputation of the 
limb, the cause of the mischief was found to he a clot completely occluding the popliteal 
artery. A similar case has been communicated to me by Dr. T. H. Andrews. Dr. 
Walter F. Atlee attended a woman, forty-eight years of age, who, while apparently in 
sound health, was seized with thrombosis of the femoral artery, ending in gangrene of the 
leg, followed by death on the sixth day from the attack. 
Mortification occasionally arises from obstacle to the return of venous blood. The oc- 
currence is most common in the lower extremities as an effect of valvular disease of the 
heart, and is generally preceded as well as accompanied by great oedema. When the 
morbid action is unusually severe, the skin is of a dull red, purple, or livid aspect, from 
congestion of the subcutaneous vessels, pits freely on pressure, and is the seat of a burn- 
ing, throbbing pain. Vesicles, of variable size and shape, filled with turbid serosity, form 
upon the inflamed parts, and, upon bursting, the exposed surface is found to he of a dark 
red or brownish hue, partially, if not completely, devitalized, cold, and insensible. The 
mortification usually occurs in small, superficial patches, particularly over the tibia and 
about the ankle, the skin eventually dropping off in pale, grayish, or ash-colored sloughs. 
The sudden loss of a large quantity of blood, in a person of intemperate habits or de- 
praved constitution, sometimes induces mortification. A drunken man, whose case has 
been reported by Sir B. C. Brodie, was seized, soon after having been bled to an inordi- 
nate extent, with gangrene of both feet, doubtless due to embolism. 
III. The influence of chemical agents in producing inflammation and mortification is 
exemplified in various ways. The contact of the alkalies and acids, if very slight, will 
generally cause merely a rubefacient effect ; if more severe, it will induce vesication ; 
while in its worst form it will occasion instantaneous destruction of the tissues. Ileat 
and cold act very much in the same manner. In all these cases life is destroyed, either 
by the primary impression of the chemical agent, or by the violence of the resulting in- 
flammation. In persons of feeble organization, especially, in young children impover- 
ished by starvation and disease, the application of a common blister is often followed by 
extensive sloughing; and a similar effect is occasionally witnessed as a consequence 
simply of the protracted retention of a mustard plaster. The infiltration of urine in the 
connective tissue of the perineum often produces wide-spread gangrene of the scrotum ; 
and portions of peritoneum sometimes perish from the contact of bile and feces. 
Although nothing definitely is known of the nature of animal poisons, it is highly pro- 
bable that they induce inflammation and gangrene much in the same way as the acids and 
alkalies. Some of these poisons are the product of a peculiar secretion with which the 
animal is provided as a means of defence ; others, on the contrary, appear to be developed 
by a peculiar septic action, which is particularly strong during the last moments of life, 
and for a short time afterwards, before the tissues have undergone much decomposition. 
However generated, their entrance into the circulation usually awakens a peculiar form 
of inflammation, which not unfrequently terminates in the death of the affected structures ; 
often with extreme rapidity, as, for instance, in snake-bite, chancroid, and malignant 
pustule. 
IV. Defective nervous power is an occasional cause of mortification. A palsied limb, 
for example, is much less capable of resisting the influence of ordinary physical agents 
than a sound one, and, when inflamed, the morbid action is much more liable than usual 
to terminate in mortification. In apoplexy and injury of the spinal cord, attended with 
lesion of innervation, the most trifling puncture, nay, even the application of a blister, is 
sometimes followed by the death of the part. The occurrence of bad bed-sores, from the 
same cause, is a matter of daily observation. The division of the peroneal nerve, in the 
removal of a tumor of the leg, has been succeeded by mortification of the small toes ; and 
Magendie, long ago, ascertained that, if the ophthalmic branch of the fifth pair of nerves 
be cut within the cranium, the resulting inflammation will end in sloughing of the cornea. 
V. The occurrence of mortification from general debility is well illustrated in typhoid 
fever, scarlatina, measles, smallpox, and scurvy, as well as in other states of the system, 
attended with loss of innervation, and an impoverished condition of the blood. During 
the progress of these diseases, local inflammation, however induced, is extremely liable 153 
CHAP. IV. 
ACUTE MORTIFICATION. 
to assume a bad type, and to terminate finally in mortification. In typhoid fever, exten- 
sive sloughs often form upon the hips and the sacrum, despite all the attention that can be 
bestowed upon the patient in warding off pressure ; and in scarlatina and other eruptive 
maladies, mortification of the neck and throat is by no means uncommon from an inflam- 
mation, which, ordinarily, would readily resolve itself in a few days, but which, now that 
the system is exhausted by the operation of the peculiar poison of these affections, is 
promptly followed by the death of the part. Inflammation of an organ, set up immedi- 
ately after the occurrence of profuse and debilitating hemorrhages, is very liable to even- 
tuate in the same disastrous manner. Mercury given in low states of the system, to the 
induction of ptyalism, often leads to violent sloughing of the gums and cheeks, and to 
necrosis of the jaw and teeth, followed by the most horrible disfigurement of the features. 
A form of mortification of the jaws has long been known among operatives engaged in 
the manufacture of lucifer matches, from the pernicious effects of phosphorus. How this 
substance produces this result is still a mystery. It is supposed by some that it makes its 
impression locally; by others, that it acts through the constitution, in the same manner 
very much as mercury. 
When acute inflammation is about to terminate in mortification, there is generally a 
sudden aggravation of all the previous symptoms, both local and constitutional. The pain 
and sensibility become more keen and intolerable, the redness assumes a more vivid as- 
pect, the swelling and tension materially increase, effusion is unusually active, and func- 
tional disorder is at its maximum. If sores or wounds exist, all discharge generally 
ceases. Along with these local phenomena, there is marked augmentation of the consti- 
tutional trouble ; the fever is excessive, the pulse is frequent and often quite strong, the 
thirst is intense, and there is great restlessness, commonly with more or less delirium. 
The type of the constitutional symptoms exhibits much diversity. In young and robust 
individuals it is generally of a sthenic character, or denotive of strength ; but, when the 
disease has been unusually violent, or the system has sustained a serious shock, whether 
from the present attack, or from previous suffering, it is commonly indicative of prostra- 
tion, the tongue and mouth being dry, the pulse frequent and feeble, the stomach irrita- 
ble, and the surface bathed with cold, clammy perspiration. 
The complete cessation of vitality, in mortification of an external part of the body, is 
denoted by the livid, black, or mottled discoloration of the skin ; by all absence of heat 
and sensibility ; by a peculiar fetid or cadaverous odor; and by more or less crepitation, 
from incipient decomposition. Immediately beyond the seat of the mortification the ordi- 
nary phenomena of inflammation are notably visible ; the surface is of a scarlet or pur- 
plish hue, hot, dry, tumid, and painful, and the dead and suffering structures are usually 
insensibly blended, or separated merely by a faint, indistinct line. 
The part having actually died, the general symptoms are no longer of an equivocal 
character, whatever they may have been during the previous struggle. They are now 
clearly of a typhoid nature, and, consequently, fully denotive of the exhausted condition 
of the system. The pulse is small, feeble, and one hundred and forty to one hundred and 
sixty in a minute; the surface, bathed with cold, clammy sweat, has a yellowish, withered 
appearance, and exhales a peculiarly disagreeable odor, not unlike that of moist earth ; 
the respiration is short, hurried, and difficult ; the countenance is pale and shrunken ; the 
eyes are devoid of lustre and sunk in their sockets; the nose is thin and pinched ; the 
lips are incrusted with dark scabs ; the tongue is dry, contracted, and covered with a thick 
blackish fur; the abdomen is tympanitic; and there are frequent twitchings of the tendons, 
with hiccough and low, muttering delirium. The strength is so much exhausted that the 
patient, unable to sustain himself upon his pillow, constantly sinks down in the bed; the 
stomach is harassed with nausea, or nausea and bilious vomiting ; and towards the last 
there are often involuntary discharges from the bowels, with retention of urine. 
The cause of this depressed condition of the system is probably twofold. In the first 
place, it may be supposed to depend upon the shock which such an occurrence must neces- 
sarily inflict upon the great nervous centres; and, secondly, upon the absorption of viti- 
ated matter, which, by its union with the blood, contaminates both solids and fluids, 
thereby incapacitating them for the discharge of their appropriate functions, in short, a 
poison is developed similar to that in septicemia. 
The color of the mortified parts varies in the different organs and tissues. The skin, 
as already remarked, is usually purple, black, or mottled, while the connective tissue beneath 
it, in great measure, retains its normal complexion, unless, as sometimes happens, it has 
been infiltrated with bloody matter, when it will, of course, be of a dark, reddish, or 
modena color. The aponeuroses, muscles, tendons, nerves, vessels, cartilages, and bones 154 
TERMINATIONS OF INFLAMMATION. 
CHAP. IV. 
undergo very little change in this respect. In mortification of the lungs, the color is 
black ; of the brain, grayish or ashy ; of the liver, reddish or yellowish. The serous 
membranes are commonly of a lilac or purplish tint; the mucous, of a black, brownish, 
or claret, with almost every possible intermediate shade. As a general rule, it may be 
assumed that the depth of color of the sphacelated structures is in direct ratio to their 
vascularity and the violence of the antecedent action. 
The consistence of the dead part is also variable; in general, it is quite soft, and, as it 
were, broken down, from the infiltrated condition of the connective tissue and of the inter- 
molecular spaces of the proper structures of the affected organ. In mortification of the 
limbs, involving all the compound tissues, the part feels swollen, soft, and crepitant, 
because it contains both gas and different kinds of fluids, as serum, pus, and blood ; but, 
if the textures be examined individually, it will be found that all, with the exception 
of the connective, are very nearly of their normal consistence, particularly if there is as yet 
but little decomposition. In the parenchymatous organs, as the brain and lungs, the loss 
of cohesion is always very great, the mortified mass being of a soft, pultaeeous consistence. 
The fetor in mortification is peculiar and characteristic. It evidently depends upon the 
extrication of sulphuretted hydrogen gas, and is sometimes, as in mortification of the lungs, 
almost insupportable. 
The effects of mortification upon the general system vary with many circumstances; 
they may be so severe as to destroy life in a few days, or even in a few hours,as occasion- 
ally happens in the traumatic form of the lesion ; or, on the other hand, so slight as to be 
hardly felt even as a serious inconvenience. In the latter case, an attempt is generally 
made, after some time, to detach the dead parts from the living, by the establishment of ulcer- 
ative action, the first evidence of which is theformation of a circle of vesicles, usually filled with 
a sero-sanguinolent, ichorous, or turbid 
fluid. Presently these vesicles burst, 
and then a faint reddish line is observ- 
able, known as the line of demarcation, 
which, as it is denotive of the cessation 
of the gangrene, is always looked for 
with great anxiety by the attendant. 
The process, which constitutes a species 
of natural amputation, seen in fig. 19, 
often proceeds with considerable rapid- 
ity, one part separating after another, 
generally skin and connective tissue first, 
then muscle, next tendon and aponeuro- 
sis, then vessel and nerve, and lastly 
cartilage and bone; the latter being 
always detached with extreme difficulty, 
on account of the large quantity of 
earthy substance which it contains. Owing to this circumstance, several months commonly 
elapse before the connection is finally severed, and even then the proceeding is anything 
but surgical, the stump thus made being always badly shaped and but rarely covered with 
an adequate amount of integument. 
The separation of the dead parts is always accompanied with more or less pain, dis- 
charge, and fetor, adding thus still further to the prostration of the system, and the danger 
of constitutional contamination. The pain is sometimes excessive, while at other times 
it is very trivial, depending upon the extent of -the morbid action, and the state of the 
constitution. In general, it is sharp, stinging, smarting, or burning. The discharge, 
which is often very profuse, is always, at first, unhealthy, ichorous, or sanguinolent, and 
irritating; by degrees, however, it assumes a more favorable character, and at length 
acquires all the properties of laudable pus. The fetor is generally sickening, and over- 
powering; tainting the atmosphere of the apartment, and unless speedily corrected, ex- 
erting a most prejudicial effect upon the patient. The emanation is, of course, rather 
from the dead parts, now called a slough, than from the gap, or trough, which lies between 
them and the living. As the separation progresses, granulations gradually spring up 
along the raw border, exhibiting the usual appearances of healthy bodies of this kind in 
other situations, and furnishing an abundance of thick, yellowish pus, which, while it 
serves to shield them from the rude contact of the air, affords the surgeon excellent oppor- 
tunity of judging of the nature of the ulcerative action, or, in other words, of the state of 
the part and system. 
Fig. 19. 
Mortification of the Foot and Leg with an Appearance of the 
Sloughing Process, the Soft Parts being Extensively Separated 
from the Bone. CHAP. IV. 
ACUTE MORTIFICATION. 
155 
While these changes are going on between the dead and living parts, for the riddance 
of the former, and the benefit of the latter, all the ordinary phenomena of inflammation 
are plainly visible in the structures above or around the breach, being busy in 
throwing up her walls of defence by pouring out a liberal supply of plastic, matter into the 
meshes of the connective tissue. In this way the surviving structures are solidified and 
fortified against the ingress of air, and also, at least in some degree, against the absorption 
of pus and ichorous fluid. • 
The manner in which the vessels are closed in mortification, so as to prevent hemor- 
rhage during sloughing, is worthy of passing notice. As was before stated, both the 
arteries and veins possess an astonishing conservative power, by which, at least in many 
cases, they are enabled to maintain their vitality in the midst of the dead and perishing 
structures. At length, however, they also yield to the devastating influence, but not be- 
fore their contents have become thoroughly coagulated and firmly adherent to their inner 
walls, thereby hermetically sealing their orifices. Hence, no bleeding can occur; and 
for the same reason there is often no hemorrhage whatever during the artificial section of 
the part, inasmuch as the clots of blood frequently extend a considerable distance beyond 
the line of demarcation. 
Treatment The treatment of acute mortification is conducted upon the general prin- 
ciples applicable to that of inflammation. When this event is about to occur in a person 
of strong, robust habit, with a vigorous pulse, and a red, fiery, and painful condition of 
part, the indication is to draw blood by leeching, if not also by venesection, to make free use 
of depressants, along with a sufficiency of opium to allay pain and quiet the heart’s action, 
and to cover the affected surface with a large blister, to paint it with iodine, or to keep 
it constantly wet with saturnine and anodyne lotions, either tepid, cool, or cold, as may 
be most agreeable. When the local action is accompanied with inordinate swelling, 
punctures, scarifications, or incisions should be made, freely and early, in order to afford 
vent to effused fluids, to relieve congestion, and to moderate pain and tension. The 
approach of gangrene may often be averted, certainly materially checked, by the timely 
use of a blister, large enough to cover in not only the whole of the inflamed part, but also 
a portion of the healthy skin, and retained sufficiently long to effect thorough vesication. 
I am satisfied, from observation, that there is generally no more efficient remedy. It is 
particularly valuable in the idiopathic form of the disease, although it is not without its 
benefit in the traumatic. I was first led to use it from its great efficacy in erysipelas, 
where it unquestionably very frequently averts the occurrence of gangrene altogether ; and 
it is well known to the American surgeon that it was a favorite means, in this affection, 
in the hands of Physiek. Cantharidal collodion is a valuable substitute for the blister, as 
it accommodates itself better to the parts, and is much more prompt in its action. 
When mortification has actually occurred, our line of conduct must of course be different 
from what it is when we are watching its approaches. The symptoms may still be of a 
sthenic nature, as will probably be the case when the patient is young and robust, and the 
part invaded is of trifling importance to life. Nevertheless, it will hardly be proper, even 
then, to indulge in further depletion, certainly not in venesection; leeching may be ad- 
missible, and we may perhaps continue, in a moderate degree, the internal use of anti- 
phlogistics ; cautiously and warily, however, lest they be instrumental in bringing on pre- 
mature exhaustion, and thus placing life in jeopardy. When, on the contrary, the patient 
is feeble, the pulse small and frequent, and the tongue already covered with a brownish 
fur, clearly denotive of an asthenic state of the system, stimulants and tonics must be 
employed, and, in fact, every effort made to husband the remaining powers of the consti- 
tution. The best remedies then are quinine, tincture of iron, camphor, and opium, alone 
or variously combined, together with wine whey, pure wine, or what is far better than 
either, brandy, gin, or whiskey. The diet must be as nourishing and concentrated as 
possible, so that, while it affords the greatest amount of sustenance in the smallest space, 
it may not oppress by its weight and bulk. The most reliable articles are beef essence 
and the different kinds of animal broths, aided, as the appetite and the digestion improve, 
by tapioca, sago, broma, corn starch, oysters, beefsteak, and poultry, which are then 
commonly well borne by the stomach. The most potent internal remedies, properly so 
called, are quinine and iron ; full doses of opium, to allay pain and procure sleep ; and 
brandy, in the form of milk-punch. Little, if any, confidence is to be placed in the 
carbonate of ammonium, musk, castor, and valerian, so much vaunted by some of the 
older writers, and still occasionally exhibited by modern practitioners; these articles pos- 
sess no blood-generating power, and rarely do much good even as nervines. The system, 156 
TERMINATIONS OF INFLAMMATION. 
CHAP. IV. 
in such a state,requires something more active and permanent, and there are no means so 
well calculated to fulfil this indication as those just mentioned. 
Whatever measures, of a general nature, be adopted, the utmost attention must he paid 
to cleanliness and ventilation. Sponging the surface several times a day with tepid salt 
water, or, if there be much perspiration, with a strong solution of alum, will be highly 
beneficial, if not carried to fatigue ; the body and bedclothes must be frequently changed; 
and the windows should either be kept constantly.open, or be often raised, in order to 
secure the admission of pure air, so essential to the healthful reaction of the system in 
disease. 
The object of the local treatment is to allay fetor, which is generally so excessive in 
acute gangrene, and to promote the rapid separation of the sloughs. The first of these 
measures is best accomplished by the liberal use of permanganate of potassium, the chlo- 
rides, or Labarraque’s disinfecting liquid, sprinkled freely upon the parts, as well as upon 
the body and bedclothes; the second, by the steady application of fermenting cataplasms, 
or the warm-water dressing, simple or medicated. The charcoal poultice, formerly so 
much in vogue in such cases, is now seldom employed, as it discolors and obscures the in- 
flamed surface, and thus conceals its true condition. The ordinary yeast poultice is, on 
the whole, as eligible an application as can well be made ; where an additional stimulant 
is required, recourse may be had to camphor water, chlorinated sodium, chloride of zinc, 
or some of the acids, as the nitric, pyroligneous, and, above all, the carbolic, diluted with 
from twenty to forty parts of water; pieces of lint wet with any of these fluids being laid 
in the gap, and kept in place by the cataplasm. 
When the sloughs are tardy in separating, the knife and scissors are employed, with 
care, of course, in making the dissection, not to interfere with the living tissues, much 
less with any important vessels. For want of due precaution in performing this little 
operation, much suffering is sometimes entailed, and I have witnessed several cases in 
which the patient was absolutely destroyed by it ; for, when the powers of life are greatly 
reduced by the effects of the gangrene, the most insignificant bleeding and the most 
trifling shock may prove fatal. 
Clearance having been effected of the dead and putrid mass, the next object is to pro- 
mote the granulating process, by the steady use of emollient and soothing dressings ; aided, 
if necessary, by weak lotions of acid nitrate of mercury, nitric acid, nitrate of silver, 
or acetate of zinc, of balsam of Peru, tincture of benzoin, creasote, and similar articles. 
The system must be supported by suitable tonics, nourishing food, and change of air. 
As soon as the granulations begin to assume a healthy aspect, as indicated by their florid 
color, and the thick, yellowish character of the discharges, the healing process will gene- 
rally progress best under the most simple dressings, serving merely as protectives against 
friction and rude exposure ; as, opiate cerate, or a light emollient poultice. If the sore 
be large, cicatrization may be promoted by touching its edges lightly once a day with 
solid nitrate of silver, and drawing them gently together with adhesive strips. Skin- 
grafting will often greatly expedite the cure. 
In connection with this subject the question of amputation necessarily arises. Under 
what circumstances is this operation necessary or proper ? Should it be performed while 
the mortification is still progressing, or postponed until it is completely arrested, and a 
line of demarcation is formed ? These are important points, and they should, therefore, 
always be duly considered ; for it is the solemn duty of the surgeon to save not only the 
life, but also, if possible, the limb of his patient. To preserve, not to mutilate, should be 
the object; since it is a thousand times more creditable to his skill and judgment to save 
one extremity than to lop off a hundred, however adroitly this may be done. 
In attempting to settle this question, special reference must be had to the nature of the 
mortification, or the causes under the influence of which it is developed ; for experience 
has shown that the two forms of the disease generally require different treatment. Thus, 
in idiopathic gangrene the rule is never to amputate until the surgeon is assured, by the 
establishment of a circle of demarcation, that both the part and system are in a condi- 
tion to bear the shock of the operation, and that death has been completely arrested. 
Even further delay may be demanded, if, upon careful investigation, it be found that the 
patient is still feeble from the effects of the mortification ; that he looks pale and wan ; 
that he has a weak and shattered pulse; in short, that everything is denotive of an ex- 
hausted state of his constitution. To amputate under such circumstances would greatly 
endanger the result, if not positively destroy the patient ; proper allowance must also be 
made for the loss of blood and the shock which must of necessity follow the use of the 
knife, both of which, even when the greatest care is taken in performing the operation, 157 
CHAP. IV. 
CHRONIC MORTIFICATION. 
are often most serious. If, on the other hand, the powers of the system are sufficiently 
active, if there is no apparent contamination of the fluids and solids, and, above all, if 
nature is making a vigorous effort to arrest the extension of the malady, there is no 
reason for delay, and therefore the sooner the offensive parts are removed the more likely 
will the case be to have a favorable termination ; the system is prepared for the emer- 
gency, and will soon react from any depression that may ensue from the employment of 
the knife. Longer delay, in truth, should not be thought of, seeing what pernicious in- 
fluence the retention of the dead structures must by their putrid and fetid condition exer- 
cise upon the system, already weakened to a sad extent by the disease before the tissues 
were fully deprived of vitality. 
From this treatment that of traumatic gangrene is altogether different ; here the 
extinction of vitality is usually more rapid and extensive, and hence to wait always, or 
even generally, for the appearance of a line of demarcation, would be virtually, in many 
cases, to consign the patient to the grave without making an effort to rescue him from the 
impending danger.. When injury of an important artery, nerve, or joint is the cause of 
the mortification, amputation can hardly be performed too soon ; nothing, certainly, can be 
gained by delay, which, even in a few hours, may put the case beyond our reach, such, 
not unfrequeritly, is the swiftness with which death travels along the affected limb. 
This is particularly liable to happen in railway, factory, and steamboat accidents, which 
are so common in this country, and which are often of the most frightful nature, pulpify- 
ing the soft parts, laying open large vessels and joints, and literally crushing the bones 
into atoms. Under such circumstances the judicious surgeon will of course amputate at 
once, the very moment sufficient reaction has taken place to enable the system to bear 
the operation ; but instances often occur where the case has been neglected, or ill man- 
aged, and where death of the parts has already set in before we are consulted. Now it 
is precisely in such cases as these that the question will arise in regard to the propriety of 
immediate action, and much judgment and experience are frequently required to enable 
us to come to a correct decision. The proper procedure is not to hesitate, if the state of 
the system is such as to warrant the belief that it will be able to bear the shock of the 
operation ; but I should certainly refrain if the patient was so far exhausted as to render 
it probable that he would sink under it. In that event, I should endeavor to rally him 
by the free use of cordials, as wines, brandy, and quinine, and employ the knife only so 
soon as a favorable change occurred. 
The question of amputation in gangrene from embolism is an important one, but, in 
the existing state of the science, undecidable. It may be stated, however, in general 
terms, that the operation should be performed without delay when the destructive action 
is rapidly advancing, provided the patient is free from serious organic disease, and is 
otherwise in a condition to bear the shock and loss of blood. When the reverse is the 
case, the proper plan is to wait for a line of demarcation ; and a similar course should be 
adopted when the mortification is more chronic and is evidently dependent upon the 
presence of a clot in the principal artery of a limb near the trunk. 
2. CHRONIC MORTIFICATION. 
There is a form of mortification, in many respects, the very opposite to the one just 
described, to which, therefore, the term chronic, or dry, may very properly be applied. 
It is characterized by the remarkable tardiness of its progress, by the absence of humidity, 
and by the deep color of the skin, which, when the loss of vitality is complete, is sis black 
as charcoal. Mortification from embolism consequent upon ossification of the arteries, 
the most common cause of the disease, proceeds slowly; mortification from ordinary 
embolism rapidly, death frequently doing its work in a few hours, or, at furthest, in a few 
days. 
One of the best types of this variety of mortification is wdiat is now generally known as 
senile gangrene, from the fact that it is most common in elderly subjects. It is the same 
disease which was so admirably portrayed, for the first time, by Percivall Pott, of Lon- 
don, under the appellation of mortification of the “ toes and feet,” and which, for this 
reason, is still frequently called by his name. It generally begins upon the inside of one 
of the small toes as a little dark, bluish, or purple speck, not larger, perhaps, than a mus- 
tard-seed, which is soon succeeded by a m nute vesicle filled with a serous, ichorous, or 
sanguinolent fluid, and which, bursting, exposes a black surface beneath, perfectly cold 
and insensible. This spot gradually spreads in different directions until it involves the 
whole foot, as in fig. 20, as high up, in many instances, as the ankle, or even the middle 158 
TERMINATIONS OF INFLAMMATION. 
of the leg, although, in general, the patient (lies long before it reaches that situation. 
Occasionally, the mortification begins on several toes simultaneously, or in pretty rapid 
succession; and I have met with 
examples in which it first showed 
itself upon the heel and instep. 
Dr. Charles Marr has communi- 
cated to me the particulars of a 
case in which the disease was 
confined to the lower and back 
part of the leg; and in an elderly 
female under my charge at the 
Philadelphia Hospital, the gan- 
grene never extended beyond the 
big toe. However this may be, 
the part always exhibits a charac- 
teristic appearance; it is perfectly 
dry and withered, cold, insensible, 
odorless, or nearly so, and as black 
as charcoal, the limb looking as 
if it were unnaturally small, as, 
in fact, it generally is. During the progress of the mortification, especially if this is 
somewhat rapid, the skin has occasionally a mottled, purplish aspect, owing to the coagu- 
lation of the blood in the superficial veins. 
Symmetrical gangrene, as it is denominated, is closely akin to senile gangrene, and is 
evidently due to embolism of the capillary vessels. It is most common in women between 
the ages of eighteen and thirty, and originally appears in the tips of the lingers and toes, 
sometimes in the former, at other times in the latter. It is also liable to occur in the 
nose and ear. It is generally preceded by a pale and shrunken condition of the affected 
parts, which gradually change their color to a light blue or purple, and at length become 
the seat of severe pain. Sometimes the parts feel very cold and numb; vesicles filled 
with turbid serum usually form. The march of the disease is generally chronic ; the 
bones rarely suffer, and the prognosis, as a rule, is favorable. When the eschars drop off, 
a clear, healthy sore is exposed, which gradually heals by granulations. The symmetrical 
development of the disease, in the two halves of the body, its liability to affect both the 
upper and lower extremities, the comparative youth of the patient, the severe pain, and 
the remarkable numbness of the affected structures, readily distinguish it from chilblain 
and senile gangrene. The general health is usually more or less impaired. In a case 
reported to me by Dr. A. M. Vedder, of Schenectady, in a lady fifty-three years of age, 
the tips of the index, middle, and ring fingers of the right hand had mortified as the 
result of embolism of the brachial artery. A similar case has been communicated to me 
by Dr. P. K. Graybill, of Virginia, the patient being a child, two years and a half old, 
the subject of a slight attack of scarlet fever, during which both legs and the lower por- 
tions of the thighs were seized with symmetrical gangrene. 
Whatever its site may be, the disease is usually preceded and accompanied by pain in 
the toes and foot, darting about in different directions, and liable to nocturnal exacerba- 
tions, preventing sleep, and rapidly undermining the general health. The pain, which is 
of a burning, scalding, or stinging character, is often referred by the patient to the effects 
of gout or rheumatism, particularly if he was formerly subject to attacks of that nature; 
it steadily increases with the spread of the disease, and can only be relieved by the free 
use of anodynes. The dependent posture commonly aggravates it, but, in a case of gan- 
grene of the foot, which I saw along with Dr. Mahlon M. Levis, of this city, in a man 
eighty-three years of age, the suffering was immensely augmented whenever the limb was 
elevated even for a few moments. In some instances, the attendant pain is extremely 
slight. Considerable swelling is occasionally present above the site of the mortification; 
and cases occur in which the whole of the affected extremity is very oedematous, exqui- 
sitely sore, and of a pale rose-color, or marked by an erysipelatous blush. 
Although in general this form of gangrene is strictly chronic, an instance is occasion- 
ally witnessed in which it spreads with such rapidity as to entitle it to the term acute. 
The most remarkable case of this kind that I have ever seen, happened in a stout, fat 
female, sixty-four years of age, a patient of Dr. Coad, of this city, long subject to attacks 
of gout. The gangrene commenced in the big toe, from which, in less than a fortnight, 
it spread over the entire foot and lower half of the leg. The parts were as black as char- 
coal, shrivelled, horribly fetid, and excessively painful. 
CHAP. IV. 
Fig. 20. 
Chronic Gangrene of the Feet, the Disease being Arrested, and the 
Parts Undergoing Separation. CHAP. IV. 
CHRONIC MORTIFICATION. 
159 
Well-marked constitutional symptoms attend this complaint, usually from the very first, 
and sometimes even before there is any local evidence of its presence. They are of an 
asthenic type either from the beginning, or they soon become so. The pulse is feeble 
and upwards of one hundred and twenty in the minute, quick, sharp, and irritable. The 
tongue is coated with a brownish fur, dry, and more or less tremulous ; the appetite is 
impaired; the bowels are costive; the alvine evacuations are fetid ; the urine is scanty 
and high-colored; the sleep is interrupted by pain and frightful dreams; the strength 
rapidly declines ; and the patient gradually dies from sheer exhaustion, the period between 
this event and the commencement of the attack varying from six weeks to three or four 
months. 
This form of gangrene occurs in both sexes, probably with nearly equal frequency, 
although it was formerly supposed to be more common in men than in women. It attacks 
all classes of individuals, the rich and the poor, the idle and the industrious, the temperate 
and the dissipated. Nearly all the cases, probably altogether a hundred, that have come 
under my notice, occurred among the middle and poorer orders of the community. It 
has been conjectured that a gouty and rheumatic temperament predisposes to its develop- 
ment, and cases occasionally occur which would seem to countenance such an idea. 
Again, it has been asserted that particular modes of life, as indolence and huge feeding, 
powerfully contribute to its production. 
From this variety of chronic mortification few patients recover. In most instances, the 
disease proceeds steadily, or with an occasional temporary intermission, to a fatal termina- 
tion from sheer exhaustion of the system. In a case of senile gangrene, in a man sixty- 
two years of age, recently under my care, the immediate cause of death was opisthotonos. 
Now and then, as when the powers of life are not too much undermined, the morbid action 
is arrested, and spontaneous amputation takes place, followed, after long suffering, by 
recovery. The event is denoted by the establishment of a line of demarcation, immedi- 
ately above which the surface exhibits a dusky, erysipelatous blush, very different from 
what usually occurs in ordinary gangrene. The sloughing process is generally attended 
with severe pain and the most offensive odor. 
The cause of senile mortification, as originally suggested by Cowper, an English anato- 
mist, is calcification of the arteries, followed by the formation of fibrinous clots or emboli 
closing up the caliber of the vessels, and thus mechanically intercepting the passage of the 
blood. The principal obstruction, as I have ascertained by repeated dissections, occasion- 
ally exists at a considerable distance from the seat of the disease. Thus, I have found 
the occlusion limited altogether to the femoral artery, the popliteal, or the commencement 
of the tibial and fibular. In most cases, however, it affects also the smaller branches. 
The concretions generally exist in various degrees of development, from recent coagula- 
tion of the blood to complete organization; hence, while some may be easily detached, 
others are firmly adherent to the sides of the vessels. 
The immediate cause of these clot formations is doubtless the interception of the fibrin 
of the blood by the roughened walls of the arteries consequent upon their calcification, 
aided by an effusion of plasma, the result of chronic inflammation of the serous mem- 
brane, thereby favoring the coagulation and adhesion of the blood. 
A form of chronic gangrene of a very remarkable character is sometimes caused by the 
inordinate use of ergot, spurred rye, or secale cornutum. The affection, which has occa- 
sionally prevailed endemically, has hitherto been observed chiefly in France, Germany, 
and Switzerland, in certain districts of which rye bread forms a principal article of diet. 
When ergot enters largely into the composition of the flour, as it is apt to do in very wet 
seasons, and is employed for any length of time, it is liable to cause mortification in the 
remote parts of the body. The attention of the profession was first prominently directed 
to the subject in 1676, by Dodard, a French physician, and since then it has frequently 
been noticed by other writers. For a long time doubts were entertained respecting the 
power of ergot to produce this effect, doubts which were finally solved by Tessier, at the 
instance of the Royal Academy of Medicine of Paris. lie selected for his experiments 
various animals, especially pigs, ducks, and turkeys, which he fed exclusively upon ergot; 
he found that most of them died from the tenth to the twenty-fourth day, and that distinct 
marks of mortification existed in the bodies of all, both externally and internally. Since 
the poisonous effects of this substance have become so well understood the disease has 
almost entirely disappeared, and in this country I am not aware that it has ever been 
noticed in the human subject. It is said, however, to have prevailed extensively 
among the horned cattle of Chester County, in this State, in 1819, and in the following 
year in Orange County, New York, from the free use, as was supposed, of a species ot 
green grass, the poa viridis, the seeds of which were affected with ergot. TERMINATIONS OF INFLAMMATION. 
The manner in which ergot acts in producing this disastrous effect has not been ex- 
plained. It is very singular that its virulence should explode upon those parts of the 
body which are most remote from the heart, as the feet and legs, and the corresponding 
portions of the upper extremities, along with the nose, chin, and ears. I am myself in- 
clined to believe that the primary impression of the poison is made upon the blood, ren- 
dering it abnormally stimulant and plastic; and the secondary upon the inner coat of the 
arteries, which, becoming inflamed, thereby intercepts the liquid, and thus leads to the 
formation of thrombi or fibrinous clots. In a word, there can be no doubt that mechanical 
obstruction of the vessels is the direct and immediate cause of the gangrene, and, if this 
idea be correct, wre cannot fail to discover the closest analogy between this form of the 
disease and ordinary senile mortification. It is much to be regretted that Dodard, Noel, 
Bossau, Gassoud, and others, wdio have left such admirable descriptions of the external 
characters of this strange affection, should not have given us any account of its patholo- 
gical anatomy. 
Mortification from ergotism has been observed at all periods of life; it is usually pre- 
ceded by discoloration, pain, and burning heat, which, subsiding in the course of four or 
five days, leave the parts cold, dry, hard, insensible, of a uniform black color, and free 
from fetor. It generally begins in the toes, whence it gradually extends over the foot 
and leg, until, in some cases, it reaches as high up as the hip. Occasionally it appears 
simultaneously both in the lower and upper extremities, as well as in the nose and ears. 
Sometimes the disease is accompanied by considerable swelling and by the most excru- 
ciating pain, allowing the patient no rest day or night. The constitutional symptoms 
vary, being at one time very slight, at another excessive; in general, however, the pa- 
tient is tormented with fever, thirst, restlessness, and high delirium. Under favorable 
circumstances ulcerative action is set up, and this, gradually progressing, at length 
eventuates in spontaneous amputation of the sphacelated structures. 
Chronic gangrene is occasionally associated with, if not directly dependent upon, or- 
ganic disease of the kidneys, especially that form of it which is attended with saccharine 
diabetes. Cases of this description have been reported by different observers, among 
others by Marshal de Calvi and Verneuil, who drew special attention to the subject in 
elaborate memoirs, published, respectively, in 1864 and 1866. The parts generally 
affected are the lower extremities of old persons; the malady occurring mostly in patch- 
like spots, and nearly always terminating fatally within a short time of the outbreak of 
the local trouble. The urine is sometimes both saccharine and albuminous. 
Anomalous cases of chronic mortification occasionally occur, of so obscure a character 
as to render it impossible to x*efer them to any particular division of the disease, as in the 
extraordinary instance, recorded in the Philadelphia Medical Examiner, by Dr. Bernard 
Henry, of this city, the patient, a female, forty-two years of age, having gangrene of 
all the extremities, from the effects of which she finally died. She was the mother of 
nine children, was of intemperate habits, and had formerly had syphilis. The disease 
was preceded by stinging and burning pains in the hands and feet, which, together with 
the tip of the nose and the skin of the knees, gradually assumed a black, dry, and shrivelled 
appearance, the gangrene eventually extending beyond the middle of the arms and legs. 
The oidy lesion revealed on dissection was some contraction of the left aurieulo-ventricu- 
lar orifice, slightly obstructing the flow of blood into the aorta. The arteries were free 
from calcification and atheromatous deposits. 
Treatment Much diversity of opinion still exists among authors respecting the proper 
method of treatment in chronic mortification; some favoring stimulating measures, while 
others are the warm and avowed advocates of depletion, as if it were possible in a disease 
which exhibits such a protean character to lay down any one plan that shall be applicable 
to all cases. Every case here as every where else, must be managed according to its 
own peculiar needs. Nevertheless, long experience has convinced me that the stimulant 
method of treatment is generally the only one that can safely be adopted. I have seen 
instances where, from the robust state of the individual, and the character of the pulse, no 
doubt could be entertained about the propriety of the employment, at least to a moderate 
extent, of antiphlogistic measures, where, indeed, even the lancet and antimony were 
admissible ; but I am quite sure that the instances are comparatively rare, and that, even in 
them, too much caution cannot be used in their adoption. Nine patients out of ten would 
be injured by such a course. The symptoms are generally of a typhoid character from 
the very beginning of the malady, and not only so, but the disease nearly always occurs 
in old, worn-out subjects, or in persons who have long labored under depression of the 
nervous, vascular, and muscular powers, and who are therefore ill able to bear such a plan 
CHAP. iv. CHAP. IV. 
CHRONIC MORTIFICATION. 
161 
of treatment. Tonics and stimulants, judiciously administered, and aided by appropriate 
local measures, constitute the proper means in such cases. Sometimes a “masterly 
inactivity” is more effective than anything else, the surgeon doing little more than watch- 
ing the patient, and attending to his diet, bowels, and secretions. But, in general, it will 
be found that a supporting plan of treatment is absolutely necessary to prevent the system 
from falling into a hopeless state of exhaustion. Quinine, carbonate of ammonium, and 
tincture of chloride of iron, with wine, wine whey, or milk punch, and opium, are the most 
important arid trustworthy articles. Anodynes are especially necessary to allay pain, induce 
sleep, and tranquillize the heart’s action, and should be administered in full doses. 
Locally, the best remedies are the dilute tincture of iodine, brushed very thoroughly 
twice a day over the whole of the affected surface, and the use of the bandage, applied 
with moderate force, and kept constantly wet with a strong solution of opium and acetate 
of lead, Goulard’s extract, or chloride of ammonium. Leeches are usually objectionable, 
as their bites are sometimes provocative of gangrene, and the same remark is applicable 
to punctures and incisions. Wrapping the affected parts up in dry cotton is often very 
grateful, especially as there is generally a feeling of cold in them. By these means the 
inflammation in the obstructed vessels may now and then be gradually or even promptly 
arrested, and the further extension of the mortification prevented. 
When sloughing has commenced, the same general principles of treatment are applica- 
ble as in the acute form of the disease, only that the local applications should, if possible, 
be still more mild and soothing. The most eligible remedies, according to my experience, 
are the nitric acid lotion, in the proportion of two to six drops of the acid to the ounce of 
mucilage of gum arabic, or the opiate cerate, for the ulcerated surface, and cloths con- 
stantly wet with a solution of chlorinated sodium for the dead, especially if there be much 
fetor. As the parts become detached they may be removed with the scissors, but this 
must be done with the greatest gentleness, as the slightest injury inflicted upon the living 
tissues is sure to be productive of mischief. 
In regard to the question of amputation, it is extremely difficult to offer any satisfactory 
opinion. My belief, founded upon considerable experience, is that we ought scrupulously 
to follow the practice long ago laid down by surgeons, not to interfere until there is a 
well-marked line of demarcation ; and, indeed, not even then, unless it is evident that 
there is sufficient strength of the system to bear the shock of the operation. I have, 
however, seen several cases where amputation was succeeded by the most happy results 
before nature had made any attempt to cast off the slough, and that, too, under circum- 
stances apparently not at all promising as it respected the powers of the constitution. 
Whenever surgical interference is deemed advisable, no means should be spared to sup- 
port the patient with tonics and stimulants, as upon their judicious use the chances of 
his recovery will, in great degree, depend. When the operation is performed prematurely, 
or before the system has sufficiently recovered from the exhausted condition consequent 
upon the gangrenous action, the disease will generally reappear within a few days upon 
the stump, or death will follow from sheer exhaustion. 
At what point should the limb be removed in this form of mortification? Should it 
be cut off, as is so generally done, close to the line of demarcation ? Such a proceeding 
would only lead to a speedy recurrence of the disease. Instead of this, a remote point 
should be selected, one, if possible, some distance above the seat of the greatest degene- 
ration of the principal artery of the limb. Thus, it seems to me, as I have long taught, 
that, when the gangrene is limited to the toes and lower part of the foot, amputation 
should be performed high up in the leg, and when it affects the upper part of the foot, or 
foot and ankle, at the inferior third of the thigh. The only objection to such a proceeding 
would be the greater risk from the operation on account of its closer proximity to the 
trunk; but this would be more than counterbalanced by the greater safety on account of 
its distance from the seat of the disease. Some of the cases treated upon this principle 
by different surgeons within the last ten years have done well; but the number is not 
sufficiently large to justify us in deducing from them any rule of practice. 
The treatment of chronic mortification from ergotism is involved in mystery. There is 
no remedy, so far as is at present known, the employment of which exerts the slightest 
counteracting influence upon the deleterious effects of this substance upon the system. 
Hence the only proper plan of procedure is to manage all such cases upon the general 
principles just laid down in respect to the treatment of the ordinary forms of the disease. 
In the symmetrical variety of gangrene, our chief reliance must be upon iron and quinine, 
with opium and good diet, and the application of slightly stimulating lotions and cata- 
plasms. 162 
TERMINATIONS OF INFLAMMATION. 
CHAP. IV. 
SECT. VIII HOSPITAL GANGRENE. 
Under this name may be described a variety of mortification, or of mortification and 
ulceration, which often commits great ravages among the wounded in crowded hospitals, 
in camps, and on board of vessels of war. The disease appears to he much more common 
in Europe and in the East than in this country, where it is exceedingly infrequent, even 
in our larger eleemosynary institutions, while in private practice it is almost unheard of. 
During the late war, however, it was sufficiently prevalent among our wounded soldiers. 
I place this affection between mortification and ulceration, as it evidently, in many cases, 
if not in all, strongly partakes of the nature of both. 
Although it is extremely probable that hospital gangrene has existed from time imme- 
morial, no distinct and satisfactory account of it appeared until 1783, when an admirable 
description of it was published in the posthumous wrorks of Pouteau, of Lyons, who had 
himself suffered from a severe attack of it while resident pupil of the IIotel-Dieu of that 
city. Soon afterwards attention was directed to it by Dussassoy, whose treatise was 
rapidly followed by the tracts of Moreau, Burdin, Gillespie, Leslie, Blackadder, Brauer, and 
Boggie, to whose joint labors we are mainly indebted for our present knowledge of the affection. 
Various names, all more or less expressive of the nature of this disease, have been 
employed to designate it by different authors. Thus, by Pouteau and some of the earlier 
writers upon the subject, it was denominated hospital gangrene, evidently in reference to 
the frequency of its occurrence in this class of public institutions, of which it was at one 
time the great scourge, both in military and civil practice, particularly the former. Sub- 
sequently it was described under the appellations of contagious gangrene, gangrenous 
phagedena, putrid degeneration, malignant sloughing, or putrid ulcer, camp gangrene, and 
humid hospital gangrene. 
Sporadic cases of this variety of gangrene, more or less severe, are occasionally met 
with in all large hospitals and other places crowded with sick and wounded, but we no 
longer hear of that frightful devastation which used to characterize its existence in former 
times. This happy change is no doubt due to the great attention which the modern 
practitioner bestows upon ventilation and cleanliness, and the prompt segregation of his 
patients on the appearance of the malady. According to Mr. Macleod, hospital gangrene 
was not at all common among the English during the war in the Crimea; it prevailed 
during the first winter in a mild form at Scutari, but it never became either general or 
severe, although the barrack hospital of that city was, during the early occupation of the 
troops, in a very filthy and uncomfortable condition. Whenever any cases broke out, the 
patients were at once isolated, and sent into wards specially set apart for the treatment of 
the disease. The French, on the other hand, suffered most severely, owing, as was sup- 
posed, to the injury which they sustained during their removal immediately after being 
wounded to the hospitals on the Bosphorus, and to the manner in which they were 
crowded together in the wards of those institutions. 
Formerly hospital gangrene often prevailed as an endemic, attacking almost every one 
that was brought within its baneful influence, and thus causing the most horrible mortality. 
In the IIotel-Dieu, at Lyons, in the time of Pouteau, several frightful outbreaks of this 
sort appeared, and such were their ravages that this distinguished surgeon was induced to 
ask the question, whether hospitals were not an evil instead of a blessing. In 1780, the 
disease prevailed extensively among the inmates of the naval hospital at New- York, some 
of whom had been sent thither from the West Indies, others from the American squadron, 
then in port on account of stress of weather. Upwards of two hundred cases occurred, 
and of these many died; quite a number from the recurrence of gangrene upon the stump 
after they had suffered amputation. In 1781, the malady committed terrible ravages at 
the naval hospital on Pigeon Island, St. Lucia. In 1800, it prevailed extensively on 
board the Prince of Wales, on her homeward passage from Martinique to England ; the 
suffering w'as excessive, and every little scratch or injury, in whatever manner inflicted, 
speedily degenerated into a bad gangrenous ulcer. A short time before this, the disease 
existed in a very severe form at the Cape of Good Hope. Of the horrible ravages, w'hich 
it occasionally commits at sea, an idea may be formed when it is stated that sixty bodies 
were thrown overboard by one vessel in thirty-eight hours in her passage from the Bos- 
phorus to the south of France. At Bilbao, after the battle of Yittoria, the mortality 
from this source was excessive. In the Parisian hospitals, the disease has prevailed, off 
and on, for many years, often sadly interfering with the results of surgical accidents and 
operations. In 1847, it appeared in some of the London hospitals, and nearly at the 
same time in some of those at Edinburgh; in both cities, however, in a mild and transient CHAP. IV. 
HOSPITAL GANGRENE. 
163 
manner. In the Philadelphia Hospital I saw cases of the disease, in a more or less severe 
form, every winter during my connection with that institution, chietly in old worn-out 
persons, the subjects of chronic ulcers of the extremities, accompanied with a scorbutic 
state of the system, brought on apparently by an insufficient supply of vegetables and 
subacid fruits. 
During the late war the disease prevailed more or less extensively in many of our 
military hospitals. It was particularly troublesome, for a time, at Annapolis, Washington, 
Baltimore, New York, Louisville, and Frederick, Maryland, after the engagements at 
South Mountain and Antietam, in September, 1862. At the latter place, it manifested, 
as has been asserted by Dr. Alfred North, a very decided preference for ulcers of the 
lower extremities in an advanced state of cicatrization ; with a single exception, no recent 
wounds were attacked, although numerous operations were performed. In the military 
hospitals in and around this city comparatively few persons suffered from it, and of these 
most recovered. 
These references are interesting, as showing the occasional epidemic tendency of this 
disease, and the consequent absolute importance of avoiding the huddling and crowding 
together indiscriminately of the sick and wounded in large hospitals, camps, and other 
places, often selected with little judgment, for the accommodation of the poor. There 
can be no doubt whatever that much, if not the whole, of the immunity enjoyed by the 
hospitals, infirmaries, and almshouses of this country, is due to the vigilance that is 
exercised in the sequestration of their inmates, and the great attention that is paid to the 
cleanliness and ventilation of these establishments; circumstances which never fail to exert 
a powerful prophylactic influence upon this and other diseases whose origin and propagation 
are so closely connected with a vitiated state of the atmosphere and a disordered condition 
of the blood. 
Hospital grangrene shows itself in one of two ways, either as an original affection upon 
an unbroken surface, or in connection with an abrasion, open wound, ulcer, or amputated 
stump; more frequently in the latter than in the former. When the tendency to the 
disease is very strong, the slightest scratch, sore, or wound may become the means of 
propagating it, and of producing the most frightful ravages. Several instances have been 
recorded of the most horrible sloughing occasioned by the accidental inoculation of the 
bite of the mosquito. When the disease prevails endemically, or even when there is 
merely such a tendency, no operation, however insignificant, can be performed with any 
certainty that it may not be followed by hospital gangrene. The stripes inflicted in 
flogging soldiers have frequently been known to become the seat of the disease in its very 
worst form. Boils, abscesses, sinuses, fistules, and cicatrices generally, under such cir- 
cumstances, share a similar fate. It has been noticed that, when hospital gangrene exists 
as an endemic, it manifests but little disposition to seize upon ulcers of a specific nature, 
as chancres, venereal buboes, and malignant sores. In its sporadic form, on the contrary, 
these are the parts which seem to be particularly liable to suffer, the disease often attacking 
them, apparently, in preference to simple ulcers. 
The distinction which has been made by some authorities, of this disease into sloughing 
and phagedenic, seems to me to be improper, since it is evident that the two affections are 
merely different grades of the same disorder, the one destroying the tissues in large 
masses, the other on a small scale, the action by which this is done being strictly identi- 
cal in both cases. A much more important division is that into idiopathic and traumatic, 
the origin of the former depending upon constitutional causes, that of the latter upon ex- 
ternal injury. In many cases the disease is strictly chronic ; at all events, a disposition 
to its occurrence sometimes manifests itself for weeks and even months together. 
With respect to the causes of this variety of gangrene, while some regard it as a strictly 
local affection, others consider it as having a constitutional origin ; and in this opinion I 
am strongly inclined to concur, from a careful study of the history of the disease, both 
from what I have seen of it myself, and from the accounts given of it by different writers. 
Possessing many features in common with erysipelas and septicemia, it is highly probable 
that, like these diseases, it owes its origin to a species of blood-poisoning, depending upon 
a foul, infected atmosphere, operating upon a depraved and enfeebled constitution. It is 
very certain that the strong and robust are much less liable to suffer from it than those 
of an opposite state of the system, or who have become exhausted by intemperance, 
disease, exposure, or want of proper food ; and it is often easy to determine, beforehand, 
when a great many persons are crowded together in the wards of an infected hospital, 
which will be likely to be attacked and which to escape, simply from the differences in 
their appearances. Whether the subjects of hospital gangrene are capable ot generating 164 
TERMINATIONS OF INFLAMMATION. 
CHAP. IV. 
a poison which, in its turn, can impart the disease to others, by its operation upon the 
system, is still a mooted point, although an extremely probable one. However this may 
be, the fact that the malady may be communicated by actual contact of the secretions of 
a gangrenous sore with a sore of a healthy character, is well established. A very striking 
circumstance, bearing strongly upon the question of the existence of a distinct poison 
elaborated during the progress of this malady, has been recorded by Sir George Ballingall, 
in his Outlines of Military Surgery. Speaking of the disease as it prevailed in a regi- 
mental hospital at Feversham, in 1806, he states that, after the endemic had been going on 
for some time, it was discovered that all the ulcers in the establishment had been washed 
with one sponge. A different mode of cleansing the sores was immediately adopted, and 
not a single case of gangrene appeared afterwards. When to this circumstance is added 
the result of the experiment of Ollivier, who produced the disease in his own person, by 
inserting matter, taken from an ulcer of the very worst description, into the arm just 
below the attachment of the deltoid muscle, it is impossible to withhold our belief in the 
contagious property of traumatic hospital gangrene. The case of Illackadder, who suffered 
severely from a puncture accidentally inflicted upon one of his fingers in dissecting the 
stump of a man dead of this affection, is equally strong and convincing. 
A scorbutic state of the system, severe shock, loss of blood, and, in short, all depressing 
influences whatever, probably act as so many predisposing causes of this disease, by low- 
ering the powers of the heart and nervous system, and thereby favoring the operation of 
the septic poison. Protracted courses of mercury, or exposure to wet and cold during 
salivation, have often been follow'ed by the disease during its endemic prevalence. In 
private as well as in hospital practice, it is particularly liable to be induced in young, 
unhealthy, scrofulous persons, affected with syphilitic ulcers, and weakened by all kinds 
of privation, especially the effects of cold, and the excessive use of ardent spirits. In the 
army and naval service of Europe, it formerly often supervened upon severe and exhaust- 
ing attacks of dysentery, scurvy, and typhoid fever. 
When many persons are crowded together, the air of the apartment soon becomes 
contaminated by the elimination of carbonic acid gas from the lungs, and by the various 
emanations from the body, the urine, and the feces, so as to render the atmosphere 
entirely unfit for the purposes of respiration. The deleterious impression is much in- 
creased if the patients are laboring under extensive wounds or ulcers, the exhalations 
from which are often, of themselves, sufficient to poison the system of the stoutest 
individual. 
The period of latency of the poison of hospital gangrene is undetermined. It probably 
varies in different persons and in different cases, depending upon the previous state of the 
general health, and the peculiar mode of the infection. In most cases it is short, not 
exceeding thirty-six or forty-eight hours before it shows its specific effect. When the 
infection is indirect, a longer time is probably required for the development of the disease 
than when it is direct, or effected by actual contact of the secretions. 
The disease occurs at all periods of life in both sexes, and at all seasons of the year, 
although it is most common, as well as most virulent, in hot weather. 
The symptoms are partly of a local, partly of a constitutional nature, the order of their 
priority being not always easily determined. When it supervenes upon a wound, an 
ulcer, or the stump of an amputated limb, the appearance of the preexisting affection 
undergoes at once a series of the most important changes, completely modifying its whole 
aspect. The discharge is sensibly diminished, or, perhaps, entirely dried up ; the granu- 
lations, if any exist, assume a dark, foul appearance, and are rapidly destroyed ; a large 
quantity of aplastic lymph, of a dirty grayish color, soon covers the bottom of the sore, 
the edges of which at the same time become jagged and everted ; the adjacent parts are 
of a deep purple or livid hue, and the seat of numerous vesicles, filled with sanious or 
bloody serum ; the pain is constant and excessive, being sharp, biting, or stinging ; the 
affected structures exhale a horrible odor ; and swelling is both great and threatening. 
Sloughing now takes place, skin, connective tissue, fascia, and muscle often dropping off in 
large, livid, putrescent masses, thoroughly impregnated with the most horribly offensive 
secretions. In the more severe forms of the lesion, the ravages are not limited to the 
soft parts, but extend to the bones and even to the joints ; the affection, perhaps, rapidly 
travelling up a limb until it is completely destroyed. Long before this crisis has been 
attained, indeed generally at an early period, glandular swellings are observed in the 
groin or axilla, possessing many of the features of pestilential buboes : they usually in- 
volve a number of glands, and are always exquisitely tender and painful, thus greatly 
aggravating the local and constitutional distress. When suppuration occurs, which, how- HOSPITAL GANGRENE. 
CHAP. IV. 
ever, is not invariably the case, the discharge is generally abundant and highly fetid, and 
the resulting ulcer speedily exhibits all the characteristics of the parent sore. 
When the disease appears on an unbroken surface, its advent is announced by the 
formation of little vesicles, or blebs, tilled with ichorous fluid, and surrounded by a reddish 
areola ; both gradually extending, the former soon burst, and thus reveal a dirty, foul 
slough, which, dropping otf, exposes a filthy-looking, excavated cavity, incrusted with a 
thick layer of adherent, grayish, unorganizable lymph. The parts feel hot and stinging, 
and there is great swelling, with livid discoloration of the adjacent surface, and a tendency 
to rapid extension and destruction, the different tissues dying either together or succes- 
sively, in the same manner as when the disease is ingrafted upon an ulcer or open sore. 
As it respects the appearances of the affected structures, hospital gangrene presents 
three tolerably distinct varieties of form. In one the parts perish, as it were, in mass, 
and are of a dark red color, very moist, fetid, and infiltrated with putrescent, sanious 
matter. In a second class of cases, the tissues are converted into a pulpy, diffluent putri- 
lage, or into a dark, brownish, dirty-looking substance, of the consistence of starch, pap, 
soft cheese, or currant jelly. Finally, there are cases, and these are by no means uncom- 
mon, in which, the action being purely ulcerative, the death is molecular, the affected 
structure melting away, as it were, in an almost imperceptible manner. 
The constitutional symptoms are generally well marked, their severity being usually in 
proportion to the violence of the local disturbance. If the patient, prior to the attack, 
was tolerably strong and robust, they will probably be of a strictly inflammatory nature, 
but in any event they will soon lose this type, and assume the asthenic form, which will 
become more and more distinct as the disease pursues its downward tendency. The pulse 
will be found to be unusually frequent, quick, and irritable ; the mind peevish, fretful, 
and desponding ; the tongue dry, and covered with a brownish fur; the strength much 
impaired ; and the pain so excessive as to deprive the patient completely both of appetite 
and sleep. Delirium often sets in at an early period, forming one of the most prominent 
symptoms. 
The diagnosis of hospital gangrene is generally not difficult, for there are but few dis- 
eases with which it can be confounded. Almost the only affection, indeed, for which it 
is in danger of being mistaken is scurvy, but a little attention will usually serve to render 
the distinction between them very evident. The scorbutic ulcer, as it has been named 
by Lynd and other writers, is remarkable for its fungous, livid, bloody, and fetid character, 
and the granulations are of enormous size, very soft and spongy, growing with great rapid- 
ity, and bleeding copiously upon the slightest touch. The discharge is profuse, and the 
blood often lies in cakes upon the surface of the sore, from which it is wiped with diffi- 
culty; the pain is trivial, and the granulations, if cut away, are speedily reproduced, 
generally in the course of a single night. Ulcers of this kind are nearly always 
attended by serious disease of the gums, which are fungous and extremely vascular, and 
by hemorrhagic spots in different regions of the body. There is, also, as another striking 
diagnostic circumstance, an absence of fever, and, generally, also, of vesication. In hos- 
pital gangrene, on the contrary, there is always grave constitutional disorder, while the 
local phenomena are deriotive of high vascular action. The ulcer is foul, exquisitely 
painful, deeply incrusted with lymph, and surrounded by a livid, vesicated surface. The 
granulating process is speedily arrested, and the sloughing extends in every direction. 
The prognosis varies with many circumstances. Thus, it is always, other things being 
equal, more unfavorable when the attack is of an epidemic character than when it is spo- 
radic, and in persons who have been exhausted by previous suffering, privation, or intem- 
perance, than in the young and robust. The extent of the disease must also necessarily 
exert a material influence upon the progress of the case, the danger being less when this 
is slight than when it is considerable, and conversely. Serious involvement of the brain, 
the early occurrence of delirium, or the development of secondary disease in some internal 
organ, as the lung or liver, always portends evil, and should induce a guarded prognosis. 
Formerly, hospital gangrene was an extremely fatal disease, the mortality being often in 
the proportion of one to three of those attacked. In some instances, indeed, nearly one- 
half perished. Since the pathology of the disorder, however, has come to be better under- 
stood, comparatively few cases prevail. 
Death may be caused by mere exhaustion of the vital powers from the extreme violence 
of the morbid action, or from the occurrence of repeated hemorrhages, as when an impor- 
tant vessel is laid open during the sloughing process. In general, the arteries and veins 
are among the last structures that yield to the devastating influence of the disease, and it, 
therefore, seldom happens that they are not protected by a provisional clot; occasionally, TERMINATIONS OF INFLAMMATION. 
CHAP. IV. 
however, nature fails in her efforts, and the bleeding may then not only be profuse but 
fatal. Finally, there is a class of cases, by no means uncommon, in which, although the 
suffering is very great, death is apparently caused by an empoisoned state of the system, 
induced by purulent infection, or the formation of secondary abscesses. The time at 
which death occurs varies from a few days to several weeks from the commencement of 
the attack. 
Treatment—The treatment of hospital gangrene was, until lately, very little under- 
stood, and the consequence was that an immense number of persons were lost by it. The 
indiscriminate use of bark and other stimulants, so much in vogue among the army and 
naval surgeons of Europe, especially those of Great Britain, even down to the time of the 
late Mr. Hennen and his colleagues in the Peninsular wars, exercised a most destructive 
influence upon the subjects of this (jisease. No judgment seems to have been employed 
by these practitioners, in adapting their remedies to the exigencies of their cases ; all were 
treated alike, and the result was an amount of mortality that was often truly appalling. 
Dr. Boggie did much to reform this vicious system, by substituting the use of the lancet; 
but it is questionable whether he did not err by carrying his measures to the opposite 
extreme. However this may be, it is certain that neither plan is applicable to all cases; 
but that the management of each must depend upon its own contingencies. The abstrac- 
tion of blood can, as a general rule, be required only in persons of a comparatively robust 
constitution, and in the earlier stages of the disease; but even then it should be practised 
with much caution, lest it lead to fatal exhaustion, or so far damage the system as to pre- 
vent it from shaking off, without great difficulty, the morbific influence. The disease, it 
must be recollected, has an asthenic tendency, often from the very start, especially when 
it is of an endemic character; and, therefore, any measures calculated to favor this ten- 
dency must necessarily exercise a pernicious influence. 
Purging and attention to the diet and the secretions constitute important elements in 
the treatment, and must on no account be neglected. A good dose of calomel and rhu- 
barb, or of equal parts of blue mass, jalap, and compound extract of colocynth, given at 
the outset of the disease so as to induce two or three large, consistent, alvine evacuations, 
will often be more beneficial in arresting the morbid action than almost everything else. 
Subsequently the bowels should be maintained in a soluble condition, without establishing 
any decided drain upon them, and the utmost care should be taken to restore the secre- 
tions, which are always so much disordered in hospital gangrene. Mercury, as a salivant, 
is to be avoided as a poison. 
When the system begins to flag, whether from the overwhelming influence of the attack, 
or from the neglect of proper treatment, prompt recourse must be had to quinine, iron, 
wine, brandy, beef-essence, and nutritious broths. The best preparation of iron is the 
tincture of the chloride, given in doses of fifteen to twenty-five drops, every three or four 
hours, in some mucilaginous fluid. Quinine is extremely serviceable, and there are few 
cases, when thjs stage has been attained, which will not be immensely benefited by brandy, 
or some other form of alcohol, especially if combined with milk. 
But the great constitutional remedy in hospital gangrene is opium, either in substance, 
or in the form of morphia. It should be given in large doses, generally not less than from 
two to four grains, every six or eight hours, in union with a diaphoretic, as ipecacuanha, 
or the neutral mixture. When we reflect upon the excessive pain, irritability, and sleep- 
lessness which so generally attend the severer grades of this disease, it is impossible to 
place too high an estimate upon the value of anodynes as means not only of insuring com- 
fort to the patient, but of arresting the morbid action. 
The diet, especially in the more advanced stages of the disease, should be highly nutri- 
tious, and as concentrated as possible. The patient’s room should be constantly ventilated, 
the bed and body clothes daily changed, and the cutaneous surface frequently sponged 
with tepid salt water, or weak alkaline solutions. The chlorides, bromine, or permanga- 
nate of potassium should be freely used. When the disease manifests an endemic tendency, 
as when it breaks out on board ship, or in the crowded wards of a hospital, the sick should 
be promptly sequestered, and the apartments thoroughly cleansed. 
When the disease is obviously connected with a scorbutic state of the system, the best 
internal remedies are potassa, in union with lemon-juice, potatoes, water-cresses, oranges, 
onions, tomatoes, and other fresh fruits and vegetables. 
The local treatment should be as gentle and soothing as possible; not rough, irritating, 
or perturbating. Any vesicles that may exist should be promptly opened either with a 
needle or with the point of a bistoury, and the whole of the affected surface pencilled over 
with dilute tincture of iodine, followed by a strong solution of acetate of lead and opium, CHAP. IV. 
HOSPITAL GANGRENE. 
167 
either cold or tepid, a cloth wet with it being constantly kept upon the part. If mortifi- 
cation has taken place, the dead substance should be removed without delay, and the 
exposed surface, thoroughly cleansed and dried, should be freely mopped with a weak 
solution of acid nitrate of mercury, carbolic acid, nitric acid, sulphate of copper, or per- 
chloride of iron, with a view of changing capillary action and allaying fetor. All strong 
applications should, in my opinion, be avoided, as they are not only extremely painful, 
but generally productive of mischief by their tendency to depress the vital powers. If the 
disease manifests a disposition to spread, and there is, at the same time, excessive suffer- 
ing, with a marked feeling of tension, scarifications and incisions must be practised, in the 
same manner and with the same object as in erysipelas. 
Attention to cleanliness is of paramount importance. The best mode of effecting this 
is to cut away carefully all dead substance as fast as it forms with the knife or scissors, to 
wash the raw surface thoroughly with a weak solution of chloride of zinc, permanganate 
of potassium, or chlorinated sodium, and, finally, to soak up with cotton or lint every 
particle of moisture. Unless this be done, no application will be likely to be of any 
material service in arresting the morbid action. 
During the late war extensive use was made, chiefly on the recommendation of Dr. 
Goldsmith, of pure bromine in the treatment of this affection. It was generally applied 
by means of a glass test-tube to the whole of the raw surface, previously divested of slough, 
and thoroughly dried. The parts were then covered with a yeast, cinchona, or port-wine 
poultice. One application usually sufficed ; if a second was necessary, it was not made 
under several days. 
Dr. Hinkle found a favorite remedy in permanganate of potassium well known for its 
powerful deodorizing, disinfecting, and oxygenating properties. lie used it both inter- 
nally and externally ; internally, in doses of one or two grains several times in the twenty- 
four hours, and externally, as an escharotic, in concentrated solution, applied by means 
of a camel-hair pencil to the surface of the wound and also to the cuticle for some distance 
around. The parts were first thoroughly cleansed with Castile soap and water, and after- 
wards covered with lint soaked in a weak solution of the medicine, the dressing being 
renewed every three hours. When the wound was deep seated or inaccessible, medication 
was effected with the syringe. The sloughs usually separated in from four to six days, 
leaving a healthy sore which soon healed under simple treatment. 
Dr. John S. Packard derived great benefit from the employment of powdered white 
sugar, thickly dusted upon the raw surface, which was then covered with wet lint, con- 
fined by adhesive strips and a bandage. The application, which was always preceded by 
the thorough removal of slough and matter, was found to be extremely useful in check- 
ing the morbid action, and was relied upon almost exclusively in the treatment of this 
affection in several of the military hospitals in and around this city. Buttermilk yielded 
excellent results, in one of these institutions, in the hands of Dr. Walter F. Atlee; and 
Professor L. A. Dugas, of Georgia, found nothing so beneficial as tar-water. The appli- 
cation of lactic acid, as suggested by the late Professor Samuel Jackson, of this city, on 
pledgets saturated with the fluid, and frequently renewed, is worthy of trial. Subsul- 
phate of iron—Monsel’s salt—is also an excellent remedy, at once mild and efficient, 
promptly neutralizing fetor, and rapidly changing the action of the sore. It is a powerful 
deodorizer and desiccant. 
The hot iron, formerly so much vaunted as a remedy in the treatment of this affection 
by the French and German surgeons, will not be likely to have many advocates at the 
present day. That the application, especially if it embraces the whole of the diseased 
surface, may occasionally be beneficial, is unquestionable ; but there are so many more 
efficient and agreeable measures that it may well be abandoned. 
Personal experience fully satisfies me that, if care be taken to cleanse the wound prop- 
erly of slough and sanious matter, which is always poured out in such great abundance in 
this affection, it is of little consequence whether the application be carbolic acid, acid 
nitrate of mercury, nitric acid, sulphate of copper, creasote, tar-water, bromine, nitrate of 
silver, permanganate of potassium, sugar, or buttermilk. A port-wine poultice, or a poul- 
tice made of elm bark or flaxseed meal, sprinkled with quinine or cinchona, often answers 
an excellent purpose, and there are few, if any, articles more likely to prove serviceable 
than pyroligneous acid. The remedy, however, which I have found most useful is acid 
nitrate of* mercury, freely diluted with water, and carefully applied with a soft mop. 
When the mortification is arrested, amputation must not be thought of until there is a 
decided line of demarcation, with sufficient power in the constitution to bear the shock 
of the operation. The tendency to recurrence of the gangrene, after removal of a limb, TERMINATIONS OF INFLAMMATION. 
CHAP. IV. 
is sometimes astonishingly great. Salleron, of Lyons, (luring his attendance upon the 
hospitals at Constantinople, (luring the Crimean war, witnessed cases in which the 
disease relapsed four, five, and even six times, owing apparently to the foul atmosphere of 
those institutions. As soon as the men were able to bear the voyage, they were sent to 
France. During convalescence, change of air always proves an important auxiliary to 
recovery. 
SECT. IX ULCERATION AND ULCEUS. 
Ulceration is the molecular death of a part, as mortification is the destruction of a part 
upon a large scale : in a word, it is death in miniature. At least three distinct acts are 
concerned in its production : softening, disintegration, and, lastly, removal of the affected 
tissues as effete and extraneous matter. Antecedently, however, to these acts there is 
another paving the way for their advent, namely, inflammation, which is always an indis- 
pensable accompaniment of the process, whatever its site, stage, or degree. It was 
formerly supposed, chiefly in conseqence of the influence of the writings of John Hunter, 
that ulceration consisted essentially in the disintegration and absorption of the suffering 
textures ; hence the general use of the phrase “ulcerative absorption.” According to this 
doctrine, the diseased substance, after having been devitalized, is taken up by the absorbent 
vessels, and thrown into the blood, to go the rounds of the circulation, and be finally cast 
off as exerementitious matter. There are numerous circumstances which, at first sight, 
would seem to favor such a view. Thus, large ulcers sometimes form in a very short 
time, and yet it is quite impossible, so far as can be ascertained by the most careful scru- 
tiny, to determine what has become of the tissues concerned in their development. If 
search be made for them in the discharges, they cannot be discovered, since their quantity, 
however great, is frequently insufficient to account for the loss of solid material. Similar 
phenomena are witnessed in abscesses of the brain, lung, liver, and spleen, where enormous 
destruction of the proper substance of these organs often occurs from the accumulating 
pus, without our being able to explain what has become of it. It might naturally be sup- 
posed that the lost tissues were contained, in an altered and disintegrated condition, in the 
pus, but such a conclusion is disproved by the fact that it is impossible to detect their 
presence by the most careful examination. 
The disease appears under two varieties of form, the open and occult or, as it may not 
inaptly be termed, the subcutaneous. The first is by far the more common. Of the latter, 
examples are seen in various kinds of abscesses, sinuses, fistules, Pott’s disease of the 
spine, coxalgia, and other affections, in which the morbid action is carried on beneath the 
skin, out of sight, instead of upon an open surface. 
Ulceration has a remarkable disposition to invade some structures and to shun others. 
Those which are most liable to its inroads are the dermoid and mucous tissues, the car- 
tilages, bones, lymphatic glands, tonsils, uterus, lungs, and kidneys. The fibrous and 
serous membranes, muscles, tendons, vessels, nerves, brain, heart, liver, and spleen, 
together with the salivary, prostate, and thyroid glands, seldom suffer from it. Newly 
formed parts, as cicatrices and the callus of broken bones, are easily affected by ulcera- 
tion, especially when, from any cause, there is a depraved and impoverished condition of the 
system. It is worthy of remark, both in a pathological and practical sense, that this action 
is much more prone to occur in certain portions of the same structure than in others. Thus, 
ordinary ulceration of the skin is by far most frequent in the legs and feet, whether because 
these parts are in a state of habitual congestion, or because they are more exposed to 
fatigue and accident, is not determined. The disease is extremely rare in the oesophagus, 
but very common in the pharynx, tonsils, tongue, cheeks, and lips. The same remark is 
true of ulceration of the stomach and small intestine as compared with ulceration of the 
colon and rectum. In the genito-urinary division of the mucous system a similar law 
obtains. Thus, the affection is extremely rare in the urethra and bladder of the female, 
but very common in the vulva, vagina, and uterus. The male, on the contrary, seldom 
suffers from ulceration in any portion of the genito-urinary apparatus, except as a result 
of venereal diseases. 
Ulceration is common or specific; common, when it is the result of ordinary inflamma- 
tion, specific when it is caused by a special poison, as, for example, that of syphilis. In 
the latter case, the disease runs a peculiar course, and, during its progress, furnishes a 
specific secretion, capable, by inoculation, of producing a similar action. The ulceration 
that attends carcinoma is also specific, but the matter yielded is not communicable by 
actual contact 169 
CHAP. IV. 
ULCERATION A X 1) ULCERS. 
Ulceration varies in its progress, being sometimes very rapid, at other times very tardy. 
The circumstances which determine this result are not always appreciable, hut, in general, 
they depend upon the nature of’ the exciting cause, the amount of the attending inflam- 
mation, and, above all, the state of the system. When the action is very rapid, an extent 
ot surface may be destroyed in a few days which cannot, perhaps, be repaired under 
several months. The process often goes on simultaneously at several points in the same 
organ or tissue, and not unfrequently in structures of an entirely opposite character. 
The causes of ulceration do not differ from those of inflammation, more or less of 
which, as previously stated, always accompanies the process. They may very properly 
be divided into predisposing and exciting. The former comprise an impoverished state 
of the blood, however induced, and, in short, whatever has a tendency to impair the 
powers of the system. Experiments, performed long ago, by Magendie and others, have 
established the fact that the protracted and exclusive use of starch, sugar, and other non- 
azotized articles of food, is capable of producing ulceration of the cornea; and it is well 
known that the poorer and more ill-fed classes of people are peculiarly subject to ulceration 
of the skin and mucous membranes. Ulceration of a severe nature often follows upon 
scurvy and the various kinds of fever, especially typhoid, scarlet, and morbillous, from 
the exhausting influence which they exert upon the solids and fluids. 
The exciting causes may be common or specific, the latter being such as act primarily 
upon a particular part, as, for example, the head of the penis in chancre, or, secondarily, 
in the same disease, upon the constitution, in consequence of the absorption of the specific 
poison. Tubercular, scirrhous, encephaloid, melanotic, and sarcomatous tissue, after 
having undergone softening, always creates ulceration by its pressure upon the adjacent 
soft textures, thereby favoring its elimination from the part and system. 
The inflammation which precedes and accompanies ulceration varies much in degree, 
as well as in character. When acute, it is usually marked by the phenomena which ordi- 
narily distinguish it under other circumstances, as discoloration, heat, swelling, pain, and 
disordered function, and then often spreads with great rapidity, laying waste a large 
amount of tissue in an almost incredibly short time. When this is the case, the mole- 
cular structures perish, as it were, in mass, and not in the slow and gradual manner 
which characterizes the disease when the inflammation is of a more mild and simple 
grade. It is to this form of ulceration that the term phagedenic is commonly applied, 
from a Greek compound literally signifying to eat, feed upon, or erode, the parts around 
the breach made by the morbid action being rapidly disintegrated, melted down, and cast 
off, as if they had been consumed by fire, their ashes alone being left as the evidence of 
their former existence. When the concomitant inflammation is chronic, the ulceration 
generally advances more tardily, and is also marked by milder symptoms; this rule, how- 
ever, has many exceptions. 
The pain of ulceration is sometimes peculiar, affording thus valuable diagnostic infor- 
mation. Thus, in ulceration of the joints and bones, it is usually heavy, aching, or gnaw- 
ing ; in rupia, hot and burning; in scirrhus, sharp and lancinating, or like the pricking 
of a needle. Sometimes, again, there is a complete absence of pain, as in common ulcera- 
tion of the skin, in ulceration of the glands of Peyer in typhoid fever, and in ulceration 
in tubercular disease of the large bowel. The pain, as a rule, is more severe in the acute 
than in the chronic form of the disease, and it is then also more steady and persistent. 
In syphilitic ulceration of the skin and bones, the suffering is often intermittent, the par- 
oxysm usually coming on at night, and gradually disappearing towards morning. Finally, 
the pain may be of a neuralgic nature, although this is rare. 
Ulceration is always attended with more or less discharge of matter, the quality of which 
is greatly influenced by the nature of the case. Thus, when the attendant inflammation 
is unusually high, the matter is generally sanious, bloody, ichorous, corrosive, and pro- 
fuse ; a similar fluid is always present in ulceration of carcinomatous growths. When the 
action is less severe, or tending to restoration, the discharge is commonly somewhat con- 
sistent and of a yellowish color, like laudable pus. 
The tendency in ulceration is usually towards the nearest surface, an occurrence which 
is often of great service in the evacuation of abscesses and the discharge of foreign matter. 
It would seem as if nature availed herself of the operation of this law to economize time, 
save structure, and prevent pain. If it were otherwise, abscesses would often, if indeed 
not generally, be emptied in the most tedious and circuitous manner, and at the expense 
of vast suffering, both local and constitutional. Of the beneficial effects of this law, an 
illustration is afforded in collections of pus in the liver, which, as a rule, discharge them- 
selves, not through the walls of the abdomen, which are thick, muscular, and I’esistant, 170 
TERMINATIONS OF INFLAMMATION. 
CHAP. IV. 
but through a contiguous coil of intestine, which is thin, proximal, and yielding. In 
abscess of the lung, the matter usually escapes through a neighboring bronchial tube ; 
when it makes an effort to empty itself externally, it either pours the fluid into the 
pleural cavity, thus speedily causing fatal inflammation, or it attains its object only after 
a long and tedious process of ulceration, generally accompanied with great pain and 
hectic irritation. 
When ulceration has continued for some time, it manifests a disposition either to remain 
stationary, to cease altogether, or to progress in a modified form. Its conduct, in these 
various particulars, is greatly influenced by internal and external circumstances, as the 
state of the constitution, the amount of the local inflammation, the nature of the exciting 
cause, and the effects of remedies. In the skin of the lower extremities, in syphilitic 
rupia, in the spongy structure of the hones, in the movable joints, and in malignant 
growths, it often continues for an almost indefinite period, being better at one time and 
worse at another. When it is about to cease, the accompanying inflammation gradually 
subsides, the discharges disappear, and, plastic matter being poured out, granulations are 
formed, by which the breach is finally closed, the process of cicatrization generally, if not 
always, proceeding from the circumference toward the centre. 
In the treatment of ulceration, the great and leading indication is to combat the con- 
comitant inflammation, so as to place the part in a condition for the efficient development 
of granulations, as it is through their agency that the lost substance must finally be re- 
paired. For this purpose the ordinary antiphlogistic appliances are to be put in requisi- 
tion and continued until the morbid action has been completely arrested, as will be de- 
noted by the subsidence of the pain, heat, swelling, and redness by which it is usually 
characterized. When granulations begin to form, only the most mild and soothing mea- 
sures must be employed, and the sore carefully watched to keep it in a healthy condition 
until it is perfectly cicatrized. In specific disease, as chancroid and malignant pustule, the 
most efficient treatment, provided the case is seen in time, before the matter has gained 
entrance into the veins and lymphatics, is to cut out the part, or destroy it with the actual 
cautery, Vienna paste, or acid nitrate of mercury. 
In ulceration under the skin, or skin and mucous membrane, such as is witnessed in 
sinuses, fistules, and other diseases, a cure can seldom be effected without the free division 
of the affected structures; injections, simple and medicated, and systematic compression, 
however long continued, generally fail ; the knife is the most effectual remedy, and its 
early employment often prevents an immense amount of suffering. General treatment is, 
of course, not neglected. In most cases tonics and other supportants are required to 
invigorate the exhausted constitution. 
ULCERS. 
An ulcer is a breach in continuity of a surface, organ, or tissue, attended with inflam- 
mation, and a discharge of pus, ichor, or sanies. The disease, which is of frequent occur- 
rence, is met with at all periods of life, in both sexes, and in all classes of persons, and is 
often a source of great suffering to the patient, as well of immense trouble and vexation 
to the surgeon. Its very name carries with it an idea of loathsomeness, and it may well 
be imagined how much this feeling is increased when, as so often happens, the sore is the 
seat of foul and offensive discharges, rendering the patient disagreeable alike to himself 
and to all around him. 
There is not, it may confidently be asserted, in the whole domain of surgery, a class of 
maladies, the pathology and treatment of which are so little understood by the profession 
generally as those of ulcers. It is surprising what an immense amount of confusion still 
exists upon the subject even among many of the best and most experienced authors. In 
examining the various treatises on surgery, in the principal languages of Europe, the 
reader has little cause to congratulate himself upon the progress that has been effected in 
this department of the healing art. He looks almost in vain for any positive additions to 
his stock of knowledge since the latter part of the last century, when Mr. Benjamin Bell 
published his Treatise on the Theory and Management of Ulcers. The minute divisions 
and subdivisions, the refinements and absurdities, respecting the nature of these lesions, 
are, with little variation, substantially reproduced by most of the practical writers of the 
present day. In studying the literature upon the subject, one is almost forced to con- 
clude that, while every other branch of surgery has experienced the salutary influence of 
progress, this one alone has remained unimproved and uncared-for. I am, indeed, ready 
to admit that the nosography of ulcers is much more perfect now than it was formerly ; CHAP. IV. 
ACUTE ULCERS. 
171 
but who can read their classification, as it appears in most of our modern treatises, and 
not be struck with its many absurdities and inconsistencies ? The catalogue is absolutely 
appalling, and it must be apparent to the most superficial observer that it comprehends, 
under different names, diseases which are absolutely and positively identical in their na- 
ture ; not even constituting, strictly speaking, so many varieties, much less distinct spe- 
cies. Sir Astley Cooper, in his Lectures on the Principles and Practice of Surgery, 
describes not less than ten forms of ulcers, under the names, respectively, of healthy, 
languid, inflamed, gangrenous, irritable, sinuous, menstrual, varicose, ungual, and cuta- 
neous, the latter including noli me tangere, and ulcers with thickened, inverted, and 
everted edges. A more recent foreign author, whose works were at one time extensively 
circulated in this country, adopts a somewhat similar arrangement. Thus, he treats, 
under so many separate heads, of the simple purulent or healthy, the weak, scrofulous, 
cachectic, indolent, irritable, inflamed, sloughing, phagedenic, and sloughing-phagedenic 
ulcer. The same spirit of classification pervades the works of more recent writers. Why, 
then, should it be deemed strange that the student should take up the investigation of the 
subject with doubt and misgiving as to his ability to comprehend it, even in the most 
superficial manner? No one, however industrious and intelligent, can possibly unravel 
the mysteries of divisions so minute and so utterly unphilosophical. It would puzzle the 
most profound pathological anatomist to discriminate between some of these classes of 
ulcers, as, for instance, between the irritable and inflamed, the sloughing and sloughing- 
phagedenic. To describe every sore that appears upon the body as a distinct ulcer be- 
cause it happens to possess slight shades of differences in its external characters, would 
be as absurd as to describe, in a work on anthropology, every human being as a separate 
variety of the race because he happens to be a little unlike his neighbor. All inflamma- 
tory affections resemble each other, some closely, others remotely, but yet always suffi- 
ciently so to enable us to trace out their relations and affinities. The same is strictly true 
of ulcers ; no two cases are ever precisely alike, and yet the most superficial observer may 
see that they exhibit many traits in common ; one may be undermined, incrusted with 
aplastic matter, and the seat of severe pain, with a foul, sanious discharge, and great dis- 
coloration, heat, and swelling of the surrounding integuments; another may have hard 
and elevated edges, and a glossy, granulated surface, with, perhaps, scarcely any secre- 
tion at all, and none of the ordinary evidences of inflammation ; in a third ease the ulcer 
may be disposed to spread, its tendency being essentially destructive ; in another series, 
by no means uncommon, the sore has thickened and everted edges, with profuse ichorous 
discharge, and an inability to furnish reparative material; finally, there may be a vari- 
cose state of the veins of the part, a sinus, disease of the adjacent bone, or disorder of 
the general system, modifying the action of the ulcer, and interfering with its cure. 
These are, it is true, contrarieties, but contrarieties which are solely dependent upon 
local and constitutional causes, and which, consequently, are not entitled to be con- 
sidered as distinct diseases. We might as well say that the varieties of color in ordi- 
nary inflammation constituted so many reasons for founding new species of morbid action, 
when it is obvious that in this, as in the former case, the circumstance is purely acci- 
dental. 
Assuming that all ulcers are merely so many forms of inflammation with breach of 
texture and more or less discharge, the most rational classification, it seems to me, that 
can be adopted, is that of ulcers into acute and chronic, according to the intensity and 
rapidity of the morbid action. Such an arrangement certainly greatly simplifies the 
subject, and divests it of much of the mystery and perplexity that have hitherto en- 
shrouded it. 
There are two genera of ulcers, just as there are two genera of inflammations, the 
common and the specific. Common ulcers are such as are produced by ordinary causes, 
as common inflammations, abrasions, and wounds; specific ulcers, on the contrary, owe 
their origin to the operation of some peculiar virus, as the poison of syphilis, smallpox, 
glanders, or malignant pustule. Although the ensuing remarks are more particularly 
intended to illustrate the various forms of common ulcers, they are also, at least in some 
degree, applicable to the specific, which, however, will receive special attention in their 
proper place. 
1. ACUTE ULCERS. 
The acute ulcer is distinguished by the rapidity of its progress, and the severity of its 
symptoms, which are those very much of ordinary acute inflammation. The sore usually 172 
TERMINATIONS OF INFLAMMATION. 
CHAP. IV. 
begins at a small point of skin, or skin and connective tissue, from which it speedily spreads 
in different directions until it often covers a large extent of surface. In its form it is 
generally somewhat oval or circular, but it is frequently very irregular, and instances are 
met with in which it is of a serpiginous, creeping, or angular shape. When the ulcerative 
action commences simultaneously at several spots, as occasionally happens, the sore may 
have a peculiar, sieve-like, or worm-eaten appearance, similar to that of the cover of an 
old book, or the bark of a tree. Its surface is red and angry-looking, either uniformly, 
or red at one point, and white at another, owing to the presence of aplastic matter, which 
occasionally overspreads it completely. When the action is unusually severe, the bottom 
of the ulcer generally exhibits a foul, greenish, brownish, or blackish appearance, and if, 
under such circumstances, any plasma is poured out, it is immediately spoiled or washed 
away by the discharges, which are always thin, sero-sanguinolent, and irritating, possessing 
none of the properties of laudable pus, such as is furnished by a granulating wound. In 
regard to the edges of this class of ulcers, they present the greatest possible variety ; in 
general, however, they are thin, rather sharp, and somewhat undermined, or undermined 
at one place, straight at another, and perhaps everted at a third ; in some cases they 
are very steep and ragged, notched or serrated. Extending from the sore in different 
directions are occasionally small sinuses or fistulous passages, which thus greatly compli- 
cate its character and protract the cure. The parts immediately around the ulcer exhibit 
all the phenomena of high inflammation, being of a deep red, livid, or purple color, preter- 
naturally hot, painful, and more or less (edematous, from sero-plastic effusions. 
The pain of the acute ulcer is frequently a prominent and absorbing symptom ; it varies 
not oidy in degree but in character, being at one time throbbing or pulsatile, at another 
sharp or pricking, at another dull, heavy, and gnawing. Its violence is often altogether 
disproportionate to the extent of the morbid action. Cases have often been under my 
observation in which, although the ulcer was scarcely as large as a twenty-five cent 
piece, the pain was so excruciating as to deprive the patient of sleep for days and nights 
together, and bring on rapid emaciation and hectic irritation. It may be limited to the 
sore, but in general it is felt over the whole of the inflamed surface, and is usually worst 
at night and in damp states of the atmosphere. Posture also commonly aggravates it, 
being more severe when the part is dependent than when it is elevated, although occa- 
sionally the reverse is true, even when the sore is quite large. 
Along with these phenomena there is generally considerable constitutional derangement, 
manifesting itself, not so much in febrile commotion, as in an irritable state of the system, 
and in disorder of the digestive organs. The patient feels unwell rather than sick ; his 
head troubles him ; his appetite is vitiated, or temporarily arrested ; the tongue is coated, 
and there is a bad taste in the mouth, especially in the morning; the bowels are inclined 
to be constipated ; and the urine is scanty and high-colored. When the ulcerative action 
is rapid and extensive, there is frequently more or less fever, with thirst, restlessness, loss 
of sleep, and excitement of the pulse. Disorder of the secretions is generally a prominent 
symptom in these cases, especially of the liver, uterus, and mucous follicles. 
An impoverished state of the blood, however induced, habitual intemperance, excessive 
indulgence at table, mental anxiety, exposure to cold, and the various eruptive diseases, 
may be enumerated as so many predisposing causes of the acute ulcer. Nervous, irritable, 
and plethoric persons, especially old dram drinkers, are its most frequent subjects. Both 
sexes are liable to it; but men, from their greater exposure and hardships, suffer much 
more frequently than women. It is rarely met with in the higher circles of society, and 
in very early life. 
An ulcer may be acute from the beginning, or it may suddenly become so after having 
been, perhaps, for months or even years in a dormant condition with, it may be, little 
disposition either to advance or to recede. However this may be, the disease often spreads 
with astonishing rapidity, eating away everything within its reach—skin, connective 
tissue, fibrous membrane, muscle, and sometimes even bone—and often laying waste in a 
few days an extent of surface which it may take months, aided by the best skill, to repair. 
When this is the case, the action may be said to be truly phagedenic, or to consist of 
rapid mortification of the molecular structure of the suffering part, which is hot, oedema- 
tous, fiery red, exquisitely painful, and bathed with profuse, fetid discharges. Constitu- 
tional disturbance is great, and the tendency is usually decidedly typhoid, especially if the 
patient has been worn out by intemperance and other causes of depression. This form of 
ulcer is very prone to occur upon new and imperfectly organized skin, where it often com- 
mits the most terrible ravages, which, for a time, hardly anything can successfully resist. CHAP. IV- 
ACUTE ULCERS. 
173 
Treatment—The treatment of the acute ulcer must be strictly antiphlogistic, modified, 
of course, by the peculiar exigencies of the case. When the symptoms are urgent, as 
denoted by the severity of the local and constitutional disorder, the indication obviously 
is to take blood from the arm, provided the patient is at all plethoric; or, this not being 
permissible, at all events to open his bowels freely with an active cathartic, containing 
from five to ten grains of calomel, and followed up, if necessary, in six or eight hours, by 
infusion of senna and sulphate of magnesium. Recourse is then had to the antimonial and 
saline mixture to subdue vascular action ; while opium is administered in large doses to 
allay pain and induce sleep. The diet must be mild and not too nutritious, and the patient 
must observe the most perfect rest in the recumbent posture. Active purgation will be 
found to be of the greatest value in this form of ulcer; in fact, it is difficult to imagine a 
case in which it could be entirely dispensed with. To render it promptly effective, how- 
ever, I have long been in the habit of combining with it a certain quantity of mercury, 
either in the form of calomel, or blue mass, with a view of making a strong and rapid 
impression upon the secretions, which, as before stated, are usually notably deranged, and 
which thus keep up a spreading tendency in the disease. Of the beneficial effects of 
anodynes in arresting acute ulceration no one, who has witnessed them, can form any just 
conception. Their salutary impression is evidently due to the influence which they exert 
in tranquillizing the heart’s action, and in allaying nervous irritability, which is generally 
so prominent a symptom in this affection ; hence they should always be given in large and 
sustained doses from the very commencement of the malady. 
It is not to be inferred from these remarks that active depletion is suited to all cases of 
this disease; on the contrary, we are often obliged to use tonics and stimulants at the very 
beginning of the treatment, and to continue their exhibition until we have succeeded in 
building up the system, so as to enable it to oppose a successful barrier to the encroachment 
of the morbid action. The state of the pulse, skin, digestive organs, and muscular system 
will generally serve as a correct guide to the kind of treatment best adapted to meet the 
exigencies of this class of cases. Quinine, iron, and milk-punch, with opium, or the 
salts of morphia, will usually constitute the most reliable means. 
The local treatment does not differ, in its general principles, from that already described 
as applicable to acute inflammation, except as it respects the modifications arising from 
the presence of a broken surface. The part, as a primary and essential step, must be 
placed perfectly at rest in an easy, elevated position, to prevent arterial ingress and favor 
venous return ; it will even be well, in many cases, to lay the limb upon an inclined plane, 
so that the sore shall be higher than the rest of the body, and to confine it, if necessary, 
in this situation by means of a light roller, applied in such a manner as not to obstruct 
discharge or make undue compression. If the part be filthy from want of cleanliness, or 
adherent dressings, ablution by immersion should precede direct medication. The use of 
leeches is commonly objectionable, however high the inflammation, for the reason that 
the bites of these animals are liable to occasion excessive pain, and sometimes even an 
aggravation of the disease. A much better plan is to draw blood by scarification with 
the lancet, the limb, firmly encircled with a cord a tew inches below the knee, the while 
standing in a tub of warm water. From six to a dozen vertical incisions, not quite skin 
deep, being made over the inflamed surface around the sore, the blood is permitted to flow 
until the patient shows signs of approaching syncope, if he be at all plethoric, or, at all 
events, until the engorged vessels have been thoroughly unloaded, as denoted by the com- 
parative pallor of the part. There is no method so well adapted as this to make a prompt 
and decided impression upon an acute ulcer; it is a most potent alterant, and I rarely 
omit its employment in any case of the slighest urgency. For the sore itself the best 
remedy is the officinal solution of acid nitrate of mercury, diluted with eight, ten, or 
fifteen parts of water, according to the foulness of the affected surface. The application 
should be made lightly with a soft sponge or a cloth mop, and may, if necessary, be 
repeated once in the twenty-four hours until there is a manifest improvement in the con- 
dition of the ulcer, when it should be entirely dispensed with, or used much weaker and 
more sparingly. Another valuable agent is carbolic acid ; and now and then great benefit 
accrues from the use of chloride of zinc. As a constant cowering for the parts, the most 
suitable one is a light emollient cataplasm, or warm water-dressing medicated with acetate 
of lead and laudanam, the latter being used warily, especially if the exposed surface be 
uncommonly large. Fetor is allayed with the chlorides. In some instances yeast may 
advantageously be added to the poultice. Under this treatment rapid improvement may 
usually be looked for; the ulceration soon assumes a more healthy character; the dis- 
charges become thicker and less profuse; the surrounding parts lose their fiery red and 174 
TERMINATIONS OF INFLAMMATION. 
ocdematous aspect; and as the reparative process advances granulations spring up, and 
new skin forms along the margin of the old. When that point has been attained none 
but the mildest applications will be needed. 
Such, in a few words, is an outline of the treatment which, when a choice of remedies 
is allowed, will generally be found to be most serviceable in this class of ulcers. But the 
patient will not always submit to scarification, nor is this always proper, owing to the 
exhausted condition of his system. Under such circumstances, the object may often be 
promptly attained by the free application of the dilute tincture of iodine to the parts 
around the sore, while the sore itself is lightly touched with the acid nitrate of mercury, 
as in the previous case, or with a strong solution of nitrate of silver or this article in 
substance, although both are decidedly inferior to the former remedy. In some instances 
a speedy and permanent check may be put to the ulcerative action by covering the sore 
and the inflamed surface with a blister, retained until thorough vesication is induced, 
followed by the ordinary dressings. Few cases of acute ulcers can resist this remedy. 
Its beneficial effects are no doubt due to the drainage which it establishes, and the conse- 
quent change in the action of the capillary vessels. The progress of the cure is sometimes 
embarrassed by dead matter, as shreds of connective tissue and fibrous membrane, the 
removal of which should receive prompt attention. 
2. CHRONIC ULCEUS. 
While it is not always easy to determine when an ulcer becomes chronic, it is to be 
borne in mind, as was previously stated, that a chronic ulcer may, in consequence of local 
and constitutional causes, occasionally assume an acute character. In this respect the 
present disease does not differ from ordinary inflammation, unattended by breach of tex 
ture. Thus, an inflammation of the conjunctiva, after having pursued a chronic march, 
with but little pain and discoloration, perhaps suddenly, at the end of several months, 
breaks out with renewed vigor, characterized by all its primitive intensity, and now rapidly 
urging on the affected structures to permanent disorganization, rendered the more prone 
to this occurrence by their protracted suffering. Ulcers are not unfrequently subjected to 
similar hardships ; not once only, but, perhaps, many times during their progress, and 
thus their career often becomes a most checkered one, defying alike our powers of diagnosis 
and treatment, and constituting at least one of the causes, previously adverted to, of the 
unscientific nomenclature which disfigures this branch of surgery. 
When does an ulcer become chronic ? or, in other words, what time must elapse before 
it can be said to assume this character? To this question it.is impossible to give any- 
thing like a definite reply: in some instances the disease is chronic almost from the 
beginning ; in others, it becomes so in a few weeks ; and in others, again, perhaps several 
months intervene. The term chronic, as every one knows, has reference to time, and is 
employed to designate a class of affections which, having passed through their acute stages, 
are deprived of their primitive characteristics; their action has been modified by treat- 
ment, or by treatment and the operation of time. The inflammation now generally exists 
in a much milder form ; there is less functional disturbance, while the constitutional 
derangement often entirely ceases, and the local phenomena of heat, redness, pain, and 
swelling are materially diminished in intensity. The part, however, is oppressed, if not 
overpowered, by effused fluids; its vessels are sluggish, dilated, and engorged with dark 
blood; nervous sensibility is perverted, and the restorative tendency is either much em- 
barrased or completely at a stand. Ulceration still goes on, and, perhaps, commits even 
serious havoc, but the action is tardy, and exhibits few, if any, of the phenomena which 
originally characterized it. It would seem, at first sight, as if it were a paradox to say 
that a disease was chronic from its commencement, and yet such is, nevertheless, the 
fact; rather, however, in reference to its symptoms than to the true and legitimate mean- 
ing of the term. 
Chronic ulcers often exist for many months and years together; at one time stationary, 
now receding, now advancing; in one case exhibiting too much action, in another too 
little, but rarely in a condition to furnish the requisite amount and quality of reparative 
material. Even if granulations occasionally do form, they are seldom healthy, or, if 
healthy, they seldom long remain so ; on the contrary, they soon languish for the want of 
proper support, or they perish from the violence of the attendant inflammation. These 
effects may be the result purely of local causes or of causes exerting their influence indi- 
rectly through the constitution ; generally, perhaps, of both. If this statement be true, 
as multiplied observation proves, wc cannot fail to deduce from it imnortant principles of 
CHAP. IV. CHAP. IV. 
CHRONIC ULCERS. 
175 
practice. It plainly suggests the necessity, in every instance, of a careful inquiry into the 
nature of the exciting cause and the condition of the system, as well as the state of the 
part itself. To treat a chronic ulcer upon any other plan is a palpable absurdity ; and yet 
that this is generally the case, daily experience amply attests. Few practitioners look 
upon this class of diseases in their true light; their ideas of their pathology are vague and 
indistinct; and it is, therefore, not surprising that they find themselves so often and so 
completely baffled in their efforts to cure them. It is for this reason that chronic ulcers 
of the legs have so long been regarded as an opprobrium of surgery, and that so many 
patients are obliged to carry their malady with them to the grave, notwithstanding the 
numerous attempts that may have been made to get rid of it; all arising from the fact 
that its true nature was never properly understood. 
The chronic ulcer is capable of assuming every possible variety of seat, number, form, 
size, color, condition of surface, and complication. In general, it occupies the inner sur- 
face of the leg, a few inches above the ankle; but it is often situated higher up, and in 
rare cases it lies directly over the joint itself. The outer surface of the limb is also liable 
to suffer, and occasionally both sides are affected simultaneously. In fact, no part of the 
leg is wholly exempt from the disease, unless it be that just below the knee. The remark- 
able liability of the inner and lower part of the leg to the occurrence of ulcers seems to be 
due, in a great degree, if not wholly to the delicacy of the skin in this situation, and the 
very liberal supply of veins, thus rendering the tissues prone to congestion, a condition 
still further favored by the erect posture and by the artificial constriction of the limb, from 
the habitual use of the garter. 
The form of the ulcer is variable, being at one time circular, now oval, and then 
angular, or so irregular as to defy all attempts at accuracy of description. In some cases, 
it extends round the limb in the form of a belt nearly of equal width. In size it ranges 
from a five-cent piece to that of the palm of the hand, or even the entire hand, the des- 
truction of substance being truly frightful. In its depth, it rarely reaches beyond the sub- 
cutaneous connective tissue ; in some cases, 
howrever, it involves the aponeuroses, the 
muscles, and even the bones and cartilages. 
Such ravages generally imply an unusual 
amount of antecedent inflammation, or the 
repeated intervention of acute action, al- 
though they are often produced by the 
steady progress of the chronic disease itself. 
Although the chronic ulcer is often soli- 
tary, it is not uncommon to meet with two, 
three, or even a larger number, situated 
either in close proximity with each other, 
or at different, and perhaps rather remote, 
points of the limb. When the number is 
considerable, their size is usually propor- 
tionately small. 
The color of the ulcer varies from light 
rose to deep purple, according to the inten- 
sity of the concomitant action and the 
congested condition of the cutaneous capil- 
laries. The most common shades of color 
are the dusky, brownish, and light livid, 
but it i3 worthy of note that an ulcer which is of a rosy hue to-day may be of a deep pur- 
ple to-morrow, simply from the change in its inflammatory condition. The parts around 
the sore are often as high-colored as the sore itself; sometimes, indeed, much more so. 
In general, the discoloration, of whatever character, is lost by insensible gradations in the 
surrounding healthy hue, not abruptly, as in erysipelas and erythema. 
In regard to the edges of the chronic ulcer, nothing can be more diversified ; hence, 
some of those singular distinctions of Home, Astley Cooper, and others who have followed 
so closely in each other’s footsteps. In general, the edges are hard or callous, elevated, 
rather broad, and so insensible as to admit of the rudest manipulation : in some cases, 
they are thin, ragged, almost serrated, and either everted or inverted, and perhaps ex- 
quisitely sensitive. In another class of cases, by no means infrequent, they are consider- 
bly undermined, or shelving at one point and everted at another. In fact, there is no 
end to the diversities nresented by the boundaries of such a sore. 
Fig. 21. 
Chronic Ulcer with Deep Edges, partially undermined) 
and a Foul, Unhealthy Bottom, studded with Fungous 
Granulations. 176 
TERMINATIONS OF INFLAMMATION. 
Tlie surface of the ulcer is generally more or less irregular, being deeper at one part 
than at another, although, as was before stated, it rarely extends beneath the subcutaneous 
connective tissue. Its actual condition usually varies with the amount of inflammatory 
action. When this is considerable, there is often an entire absence of granulations, and 
then the bottom of the sore will generally be found to be in a foul, bloody, or phagedenic 
condition, or incrusted with a stratum of lymph too feeble to admit of organization ; or, 
finally, granulations, sloughy matter, and vitiated plasma may all be present, in varying 
degrees, upon different parts of the exposed surface. The concomitant discharge is pro- 
fuse, sanious, fetid, and irritating, possessing none of the properties of laudable pus. The 
sore, as well as the surface immediately around it, is usually sensitive, and often the seat 
of severe pain. It is to this form of ulcer that writers usually apply the term inflamed, 
or irritable, from its excess of vascular and nervous activity. It is most common in ner- 
vous, irritable subjects, and in the habitually intemperate. 
When the inflammation is more moderate, granulations are seldom wholly absent, and 
they may exist even in great abundance, although they may be altogether unhealthy. 
When the action is somewhat less, but not too languid, they commonly exhibit a pale, 
reddish, flabby appearance; their surface is irregular or tubereulated, and they are much 
too large ; in fact, they look as if they had been reared in a hot-bed and had been too 
freely watered. Their reparative power is so very feeble that the surgeon is often obliged 
to get rid of them entirely before a cure can be effected. This state of granulation con- 
stitutes what is vulgarly called “ proud flesh,”‘and is often difficult to manage. 
Again, the circulation may be inordinately languid, and then the granulations may be 
still larger, totally insensible, and perhaps quite cedematous, readily pitting under pressure, 
and, if punctured, freely exuding a serous, sanious, or ichorous fluid. Cacoplastic lymph 
is generally interspersed through the granulations, or adherent to the surface of the sore, 
the edges of which are hard and very prominent, so that the raw surface appears as if it 
were much below the level of the surrounding parts, which, however, it seldom is. The 
accompanying discharge is slight, thin, and sero-sanguinolent; while the adjoining skin is 
cedematous and of a dusky-brownish hue. 
Finally, cases occur in which the granulations are very small, or apparently stunted in 
their growth, irregular in shape, of a fiery red color, and so exquisitely sensitive as to be 
a source of great suffering, the ulcer being intolerant of the slightest pressure, motion, or 
manipulation ; the discharge is sanious and irritating, although seldom very fetid or profuse; 
the edges of the sore are thin, irregular, everted, or inverted; and the surrounding skin 
is actively inflamed. 
The chronic ulcer is often complicated with other diseases, which tend to modify its 
action, and impede, if not entirely prevent, its restoration. Of these affections some are 
of a local, others of a general character. The former consists mainly in the involvement of 
the deep-seated structures, as the fibrous membranes, tendons, muscles, and bones; in the 
formation of sinuses ; in a varicose state of the veins; and in the presence of foreign mat- 
ter, under the influence of which the ulcer was, perhaps, originally induced. Eczema of 
the skin around the ulcer is of ten met with, especially in cases of long standing in elderly 
subjects, addicted to intemperance, overfeeding, or habitual constipation of the bowels, 
and is generally a source of great discomfort, if not actual suffering. The eruption usually 
appears in patches, studded with little vesicles, resting upon a reddish, bluish, or bronze 
colored base, and attended with more or less itching. 
Old ulcers, especially if habitually irritated, occasionally, although rarely, become the 
seat of carcinomatous disease, the most common form being the epithelial. Such a change 
may occur in almost any part of the body, but is most frequently met with in the legs of 
old, dilapidated subjects. 
Spots, of variable form, size, and color, often exist upon the skin in the neighborhood 
of chronic ulcers, and are generally an index of a degraded, depressed, or impaired action 
occurring most commonly on the inner side of the leg ; they are of a dark purple, gray- 
ish, black, bronze, or brownish hue, are longer in the perpendicular than in the transverse 
direction, and are obviously dependent upon some change in the pigmentary structure of 
the skin. In some instances the color is pretty uniform, and involves nearly the entire 
circumference of the limb, forming a belt perhaps several inches in height. It is worthy 
of note that this pigmentary change is very often associated with a varicose condition of 
the veins. 
Among the constitutional complications, the most common are, disorder of the secre- 
tions, especially of the liver and alimentary canal, anemia, dyspepsia, plethora, and 
habitual intemperance in eating and drinking. I have never seen what writers have 
CHAP. IV. CHAP. IV. 
CHRONIC ULCERS. 
177 
called the menstrual ulcer, although it is not to be doubted that great uterine derange- 
ment, showing itself in deficiency of discharge, might seriously interfere with the healing 
of a sore on the leg, or, indeed, on any other part of the body. An ulcer is sometimes 
rendered exceedingly sensitive and irritable by a gouty or rheumatic state of the system. 
Treatment.—In the management of chronic ulcers the leading indications are, first, to 
remove any complications that may exist; secondly, to regulate the inflammatory action ; 
and, lastly, to produce healthy granulations. If these cardinal points be kept in view, 
the practitioner cannot fail to settle down upon a rational and philosophical plan of treat- 
ment, destined to be crowned with success. It is only necessary to treat the disease as 
one of ordinary inflammation, modified by accidental circumstances. The great object in 
every case is to bring the ulcer into a simple granulating condition, so as to afford nature 
an opportunity of beginning and carrying on the healing process without impediment. 
Ulcers sometimes refuse to heal in consequence of the partial destruction of aponeurotic, 
tendinous, or muscular tissue, or the manner in which the parts are compressed by over- 
lying structures ; in the former case, the dead substance is removed with the knife or 
scissors; in the latter, relief is afforded by adequate incisions, after which the malady is 
treated upon general principles. Necrosed bone is extracted with the forceps, while 
carious bone is scraped away, or removed with the chisel, gouge, saw, or scalpel. 
Varicose veins are dealt with according to the rules laid down for the management of 
that disease in a subsequent chapter; the complication is often a serious one, and nothing 
short of the ligation of the affected vessels, or their destruction with Vienna paste, 
answers the purpose. When the malady is comparatively slight, amelioration may be 
afforded by wearing an elastic stocking to give uniform support to the limb, and by the free 
use of spirituous lotions, with the occasional application along the track of the enlarged 
vessels of dilute tincture of iodine. Hemorrhage sometimes attends this complication, from 
extension of the ulceration into a contiguous vein : I have seen cases where more than a 
quart of blood was thus lost in a few' minutes, and I am cognizant of two instances in 
which the bleeding was so copious as to prove fatal. The proper remedy is compression, 
followed, if need be, by a Vienna paste issue to produce permanent obliteration of the 
vessel at the seat of the ulceration. 
Sinuses are laid open with the director and bistoury, their course being completely 
traced out, as no cure is to be expected so long as any portion remains concealed. Re- 
union of the incision is opposed by the tent and by careful dressing. 
Ulcers, consequent upon wounds, are frequently prevented from closing by the presence 
of foreign matter, as a pellet of paper, a piece of cloth, a ball, nail, or fragment of bone. 
In such an event, a careful search is made with the probe, and the substance, if detected, 
is extracted in the usual manner. 
In an ulcer attended with undermined, inverted, ragged, or very callous edges, the 
proper plan is to use the knife, cutting otf all that is spoiled, redundant, or irreclaimable. 
Exuberant granulations are similarly dealt with, excision here being far preferable to 
escharotics, the action of which is always painful, tedious, and uncertain. 
Ulcers complicated with hemorrhage are treated upon general principles. The blood 
may proceed from an artery or vein, laid open by the morbid action, or it may ooze from 
numerous points, as when there is a dissolved state of the blood, or a hemorrhagic dia- 
thesis. In what English surgeons call the menstrual ulcer, the discharge is generally 
vicarious of, and consequently coincident with, the menstrual flux, and usually readily 
disappears under tonic treatment, as iron and quinine, with exercise in the open air, salt- 
bathing, and other invigorating measures. 
The second object is to reduce the concomitant inflammation, in order to enable the 
sore to form healthy granulations, which it cannot do so long as the morbid action is either 
very high or very low. One step towards accomplishing this end is the removal of com- 
plications, which, indeed, is frequently of itself suflicient to effect a cure. When this 
fails, the rest of the inflammation is often readily relieved by the application of dilute 
tincture of iodine to the parts immediately around the ulcer, preceded, when the con- 
gestion and discoloration are unusually great, by free scarification ; and by touching the 
sore itself very gently, once a day, with solid nitrate of silver, or, what is better, the offi- 
cinal solution of acid nitrate of mercury, variously weakened, according to the exigencies 
of the case. One such application in the twenty-four hours usually suffices, and in many 
instances the cure will progress more rapidly and satisfactorily if it be made less fre- 
quently. Other topical remedies may often be advantageously used, especially the nitric 
acid lotion, and solutions of acetate of lead and opium. As a constant protection for the 
parts, nothing is more suitable than an elm or a linseed cataplasm, which, notwithstanding 178 
the abuse that lias been heaped upon it, is still, in most cases, one of the neatest and most 
trustworthy remedies. Or, instead of a poultice, warm water-dressing may be used, 
medicated, when the pain is very great, with solutions of morphia, or morphia may be 
cautiously sprinkled directly upon the surface of the ulcer. 
When the healing process is impeded by the indurated, disorganized, and contracted 
condition of the tissues immediately around the ulcer, there is no method of treatment so 
likely to be beneficial as the one originally suggested by Mr. John Gay, of London, con- 
sisting in the thorough division of the parts by drawing the knife elliptically through the 
skin, connective tissue, and aponeurosis a short distance from the sore, thus severing 
their adhesions, and changing their action ; in other words, placing them under entirely 
new relations. The operation is often quite bloody, especially when it involves, as it 
occasionally does, large veins ; but the flow, which is usually productive of great benefit 
by relieving the engorged vessels, is always easily controlled by means of styptics and 
compression. 
Whatever local measures be adopted, strict attention must be paid to the state of the 
system; the bowels must occasionally be relieved with mild aperients, and care must be 
taken that the diet is perfectly mild and not too nutritious. If the general health is 
much disordered, recourse is had to more active purgation, and to the free use of antimo- 
nial and saline medicines, with a full opiate at night, especially if there be much pain, or 
inability to sleep. Bleeding at the arm will be required only in very plethoric subjects, 
in urgent cases. When an ulcer is associated with a gouty or rheumatic state of the 
system, the use of colchieum, salicylic acid, and other suitable remedies is indicated. 
Absolute recumbency is observed, at least until the morbid action has been measurably 
subdued.; and the affected part is placed at rest in an easy, elevated position, precisely as 
in ordinary inflammation. 
If the general health is much reduced by protracted suffering, or if the system is in 
an anemic condition, or, finally, if typhoid symptoms are present, stimulants and tonics 
will be indicated,especially quinine and iron, with milk-punch, nutritious food, and change 
of air. 
If the measures now detailed be judiciously employed, the ulcer will soon be placed in 
a suitable condition for the development of healthy granulations, fig. 22, after which little 
else will be necessary than to watch the parts, with a view to the prevention of overaction. 
The mildest and most soothing applications 
will now generally suffice, the object being 
rather to protect the surface of the sore from 
the injurious contact of the atmosphere than 
to promote its welfare by direct medication. 
Among the best of these remedies are oint- 
ments prepared with opium, acetate of lead, 
balsam of Peru, oxide of zinc, and above all, 
the ointment of the acid nitrate of mercury, 
diluted with ten to twelve times its weight 
of cosmoline. Its cicatrizing properties are 
far greater than those of any other substance 
I am acquainted with. When the ulcer is 
very sensitive or irritable, iodoform or chloral 
may be used, either in a solution or in the 
form of unguent. Iodoform rendered odor- 
less by admixture with oil of aniseed is 
sometimes highly serviceable in the treat- 
ment of the more obstinate form of old ulcers. 
It should be applied in a thick layer, the sore 
being previously well cleansed and dried, and 
afterwards carefully strapped with soap and 
mercurial plaster, daily renewed. Any dis- 
organized matter should be thoroughly 
scraped away, as a preliminary step, to promote the development of healthy granulations. 
The scabbing process may often be expedited by touching the granulations very lightly, 
once a day, along the edge of the sore, for the space of a line, with solid nitrate of silver. 
Rest in the treatment of ulcers is indispensable to a rapid cure, and yet instances 
constantly occur where, either on account of the patient’s condition in life, or the ex- 
hausted state of his health, exercise in the open air is absolutely necessary ; under these 
TERMINATIONS OF INFLAMMATION. 
CHAP. iv. 
Fig. 22. 
Granulating Ulcer, beginning to Cicatrize ; the Process 
extending from the Periphery towards the Centre. 179 
CHAP. IV. 
circumstances, the part should be as carefully protected as the exigencies of the case will 
permit, fatigue and protracted dependency being especially guarded against. The bandage 
in particular will usually be found to be a powerful adjuvant both to comfort and cure ; 
but it must be applied equably from the distal portion of the limb upwards, and not in 
folds or creases, otherwise it will do infinite harm. It must be changed at least once a 
day, being replaced as soon as the limb has been thoroughly cleansed and the sore pro- 
perly dressed. In hot weather, it may occasionally be kept constantly wet, with good 
effect, with cold water, spirituous lotions, or weak solutions of lead and opium. In 
winter the “ domette” flannel bandage is preferable to the ordinary roller, as it is both 
warmer and more elastic. 
A most important step was made a few years ago, in the treatment of chronic ulcers 
by the yse of the elastic bandage, originally recommended by Dr. Henry A. Martin, of 
Boston. It is particularly applicable to the treatment of old ulcers attended with varicose 
enlargement of the veins, or an eczematous condition of the skin, and is far Superior to 
the treatment by the ordinary roller and Baynton’s dressing, so long in vogue in such 
cases in this and other countries. The plan consists in enveloping the affected limb in 
what is known as the solid rubber bandage, applied spirally from near the toes upwards 
in such a manner as to afford firm and equable support to the parts. The bandage, which 
should be about two inches and a quarter in width by ten to twelve feet in length, 
and furnished at the upper end with two tapes for fastening, is removed every night, 
washed, and reapplied in the morning, the sore and the surrounding surface having been 
previously well cleansed with soap atul water. No protective is placed upon the ulcer, unless, 
as occasionally happens, the bandage acts for a while as an irritant, when the interposition 
of a piece of gauze or of thin patent lint may become necessary. The bandage during the 
first few days is generally productive of some inconvenience, caused by the increased heat 
and the confinement of the secretions ; but this soon subsides, and is followed by so much 
relief that the patient would be unwilling to go without it even for a day. In some cases, 
especially in persons of delicate skin, a few vesicles or even pustules are liable to form, 
and the epidermis is apt to become so much softened and macerated as to give rise to dis- 
agreeable feelings. The same bandage can often be worn for months, and even years, 
and is therefore a great desideratum with poor patients, who are thus enabled to perform 
their daily labor with entire comfort. If, at any time, the sore becomes inflamed, it may 
be covered with a poultice at night. The bandage should always, if possible, be reapplied 
before the patient leaves his bed, and, consequently, before the veins become distended 
with blood. 
The method of Baynton sometimes furnishes very good results, especially in small 
ulcers attended with great thickening and induration of the skin. It consists in strapping 
the sore and adjacent parts with adhesive plaster cut into strips, varing from an inch to 
an inch and a quarter in width, and long 
enough to extend about three-fourths around 
the limb, each one being so arranged as to 
overlap that which is below it, and drawn so 
firmly as to afford uniform support to the 
affected surface, as in fig. 23. The dressing, 
which is completed by enveloping the limb 
in a bandage from the toes as high up as the 
knee, should not be changed, on an average, 
oftener than twice a week. Occasionally, as 
when the ulcer is associated with a varicose 
state of the veins of the extremity, the entire 
foot and leg may be beneficially enveloped 
with adhesive plaster for some distance above 
the sore, as originally suggested by Mr. Crit- 
chett. In my own practice I have often found 
that the mere covering of old, granulating 
ulcers with adhesive plaster, by protecting 
them from the air and the friction of the 
clothing, is highly favorable to their cicatri- 
zation. 
In cases of long standing, the surface of the ulcer may sometimes be advantageously 
protected with an artificial crust, consisting of an ointment composed of three parts of 
prepared chalk and two of fresh lard, the former being previously reduced to a very fine 
CHRONIC ULCERS. 
Fig. 23. 
Mode of Strapping of an Indolent Ulcer. 180 
TERMINATIONS OF INFLAMMATION. 
CHAP. IV. 
powder, and then gradually stirred into the latter, melted in a vessel over a slow tire. The 
ointment is applied once a day upon a piece ot' lint, and the limb is supported either with 
Baynton’s dressing, or a flannel bandage, as suggested by Mr. J. K. Spender, the author 
of this mode of treatment. 
A powerful impression may generally be made upon an atonic or indolent ulcer even in 
a few days by the use of galvanism. The current is transmitted through a copper wire 
from six to eight inches in length to a thin silver plate, of suitable size and shape, applied 
to the sore, and connected wit!) a small zinc plate placed upon the sound skin a short dis- 
tance off, a piece of chamois leather, soft sponge, or paper lint, moistened with vinegar, 
intervening. The apparatus is held in position by a bandage or by adhesive strips. 
Under the stimulus thus produced, healthy granulations are rapidly developed, with a 
strong tendency to cicatrization. 
There is great art in dressing an ulcer. Everything like rude manipulation and pro- 
tracted exposure must be avoided ; the sore is never wiped, or even touched with the 
finger, and, while the necessary ablutions are going on, the limb is carefully supported 
over a basin or small tub, the water, which may be cither cold or tepid, being gently 
squeezed upon it from a sponge held at a distance of several inches. The secretions being 
thus disposed of, the surrounding surface is properly dried, and the dressing reapplied. 
If fetor be present, a little permanganate of potassium, chlorinated sodium, or carbolic acid 
is mixed with the water employed in cleansing the sore, as well as sprinkled from time to 
time upon the poultice and bandage. When the discharge is unusally abundant, oakum 
may be advantageously used to absorb the matter. The eczema so liable to complicate 
old ulcers of the leg is generally promptly relieved by a brisk laxative, a cooling diet, and 
the application of benzoated zinc ointment, or dilute ointment of acid nitrate of mercury. 
If much inflammation be present, a weak solution of actetate of lead will be the most 
suitable remedy. 
The cicatrization of ulcers, as will be shown in another chapter, is often greatly pro- 
moted by skin-grafting, or by the insertion of little bits of integument into different parts of 
the affected surface. To insure the success of the operation, it is essential that the sore, 
as well as the adjacent skin, should be as free as possible from inflammation, that the gran- 
ulations should be of a healthy, florid complexion, and that the discharge should possess all 
the properties of what is called laudable pus. When these characteristics are present, it 
is an evidence that both the part and the system are in a good, sound condition, and that 
skin-grafting may be performed with every prospect of expediting the healing of the sore 
by establishing more or less numerous centres for the formation of a new skin. 
Whatever mode of treatment be employed, it is essential, as it respects the prevention 
of relapse, that the patient should observe great care in regard to his exercise and diet, 
for a number of weeks after the ulcer has completely healed. If he indulges his appetite 
too soon, neglects his bowels, or allows his secretions to become disordered, he can hardly 
escape a new outbreak of the disease, especially if, at the same time, he fatigues his leg 
much, lets it hang down constantly, constricts it improperly with his garter, rubs it with 
his boot, or permits it to become covered with filth. Cleanliness, indeed, cannot be too 
rigidly enforced as a means of promoting healthy action. The parts should be thoroughly 
washed at least once a day with soap and water, and then sponged with some alcoholic 
lotion, to revive and invigorate their exhausted powers. 
In inveterate cases, extensively involving the osseous tissue, greatly impairing the gen- 
eral health, and resisting the best efforts of the surgeon for their relief, the only resource 
is amputation, performed through a sound portion of the limb. Such a procedure, how- 
ever, will, I am sure, be rarely demanded in these days of conservative surgery; for, 
unless the bone is almost entirely destroyed, it will be easy, in the majority of instances, 
to dispose of the diseased structures with the knife, gouge, and mallet, or by resection. 
Finally, the question may be asked, is it always safe and proper to heal old ulcers? 
Upon this subject, various opinions have been expressed by writers on surgery. Those 
who assert that it is not, assume that such sores act as issues, which serve as safety-valves 
to the system, by ridding it of redundant, if not positively peccant, humors. They allege 
that cerebral apoplexy and other serious diseases have occasionally occurred as the direct 
and speedy consequences of the drying up of old ulcers. Those, on the contrary, who 
espouse the opposite side of the question, declare that such attacks are mere accidental 
circumstances, readily explicable by the laws of coincidence; a view which I have myself 
always adopted. It is questionable, indeed, whether surgical science possesses any well-authen- 
ticated facts by which this opinion can be sustained. I have often cured ulcers of five, 
ten, and even fifteen years’ standing, constantly attended with more or less discharge and GRANULATION. 
181 
CHAP. IV. 
irritation, and yet no instance to which such an event could justly be ascribed has ever 
fallen under my notice. Besides, the constitutional treatment that is usually necessary in 
these cases to effect relief, is, in itself, almost a guarantee against attacks of grave disease 
in other parts of the body. If, however, such an occurrence should be dreaded, it would 
be easy, while the sore is drying up, to protect the system by a continuance of the consti- 
tutional remedies, especially a spare diet, and the occasional use of a purgative, conjoined 
with the employment of an issue in a remote region of the body, as the arm, chest, or neck. 
SEC. X GRANULATION. 
Granulation is the means by which lost tissues are replaced and wounds healed when 
they fail to unite by the first intention, or by adhesive action. The process is one of great 
interest, whether it be viewed merely as a physiological phenomenon, or as an operation 
employed by the system to restore injured and mutilated structures. An intimate knowl- 
edge of its nature and habits is, therefore, of great importance to the surgeon. 
It is chiefly upon the external surface of the body that an opportunity is afforded of 
examining this process with any degree of satisfaction. In the various mucous outlets it 
is more difficult to watch and to trace it through its different stages; while in the internal 
organs it either does not occur at all, or is observable only after death. 
It may be assumed, as a law, that high vascular excitement and repair are incompatible 
with each other. Hence, before the process in question can fairly begin, there must be a 
material abatement of the inflammation. As soon as the balance of action has thus been 
reestablished, the breach is covered with red, Heshy-looking bodies, technically denomi- 
nated granulations. By a continuance of this action the developmental process steadily 
progresses until the gap is finally filled up and scabbed bver. 
A granulation is a highly organized body, capable of executing highly important func- 
tions. It consists essentially of capillary vessels, the interstices of which are occupied 
by small, soft, round, nucleated, embryonic cells, heaped upon each other without any 
particular order, and connected together by a minute quantity of amorphous, mucous in- 
tercellular substance. It is usually of a florid color, very vascular, extremely sensitive, 
and of a conical, rounded, or oval shape, its vol- 
ume varying from a mustard-seed to that of a 
large shot. Its vessels, which are remarkably 
numerous, are evidently, for the most part, out- 
growths of those of the adjacent parts, and are 
arranged, as seen in fig. 24, from Billroth, in 
the form of beautiful loops and arches, closely 
interwoven with each other. As they are de- 
veloped with great rapidity, their walls are at 
first so extremely delicate as to yield to the 
slightest pressure; hence there is generally 
more or less hemorrhage whenever anything is 
rudely brought in contact with them. The 
veins are very large, tortuous, and convoluted. 
Although no nerves are demonstrable in granulations, they are unquestionably abundantly 
supplied with them, as is shown by the fact that they are often very sensitive, especially 
when diseased. The existence of lymphatic vessels also is a matter of inference rather 
than of positive proof. Observation shows that certain articles, placed in contact with a 
granulating ulcer, are promptly taken up, and carried into the system, producing a similar 
effect, nearly in as short a time, as when introduced in the ordinary manner. Thus, mor- 
phia readily allays pain and induces sleep; atropia dilates the pupil; arsenic irritates and 
inflames the stomach ; strychnia convulses the muscles. Moreover, a granulation is a 
secreting body, a kind of compound gland, capable of pouring out plasma and providing 
the elements of pus; the former for enlarging its own dimensions and multiplying itself; 
the latter as a means of defence from the atmosphere and the surgeon’s dressings. 
Granulations form with various degrees of facility, depending mainly upon the nature 
of the part and the amount of inflammatory action. Ulcers of the skin and connective 
tissue always, other things being equal, furnish them most readily, as well as in greatest 
abundance; a circumstance evidently due to their extreme vascularity and high nervous 
endowment. Bone, cartilage, tendon, and fibrous membrane, on the contrary, granulate 
more slowly, and hence injuries of these structures are always repaired with more difficulty. 
The same rank applies, only more pointedly, to scirrhous and other malignant ulcers. 
Fig. 24. 
Bloodvessels in Granulations. 182 
TERMINATIONS OF INFLAMMATION. 
CHAP. IV. 
The bodies are sometimes developed subcutaneously. Paget states that be has seen a 
mass of tlorid granulations in a case of simple fracture, in which the ends of the bones 
had remained long ununited, and a similar phenomenon is occasionally witnessed in Pott’s 
disease of the spine. In a case of caries of the ribs and costal cartilages in a young man, 
I found the bottom of the ulcer studded with numerous fine, florid granulations, although 
the opening in the skin, hardly the size of a common probe, was nearly three inches dis- 
tant; and in a case of hematoma of the burse of the patella in a young woman, a patient 
at the College clinic, I found, after the semiorganized clots were scraped away, numerous 
well-formed bodies of a similar kind upon the walls of the cyst, the overlying integument 
being perfectly healthy. 
In examining a cluster of granulations, a great difference may generally be observed in 
their character. The deep-seated ones are comparatively firm, more or less elongated, 
and of a fibroplastic structure, if not actually filamentous. The superficial, on the con- 
trary, are in a rudimentary state, very soft, lacerable, and extremely vascular. At the 
edges of the surface, near the junction of the new and the old tissues, they possess the 
properties of incipient epithelial cells. 
Granulations are liable to disease. This often occurs from causes apparently the most 
insignificant; depending, perhaps, at one time upon the state of the part, at another upon 
the state of the constitution, or upon both combined, but more frequently upon the nature 
of the dressing, and the indiscretion of the patient, lienee, the appearance of these 
bodies usually serves as an index of the concomitant action, local and general, and affords 
useful indications of treatment. The most important alterations which they undergo are 
such as relate to their size, color, consistence, and sensibility. Ilealtby granulations are 
generally small, not exceeding the volume of a mustard seed, but cases occur in which 
they are many times larger. Trfeir natural color is a beautiful florid ; when congested or 
inflamed they assume a purple, livid, or brownish aspect, while under opposite states they 
are occasionally pale, or even blanched. In their consistence these bodies may, on the 
one hand, be very soft and lacerable, and, on the other, very firm, inelastic, and almost 
callous. Occasionally they have an infiltrated, cedematous, or dropsical appearance, serum 
escaping freely upbn the slightest puncture. Their sensibility is usually very feeble, 
except in very nervous, irritable persons, in whom they are sometimes exquisitely painful, 
particularly if they are much inflamed. In ulcers from burns the granulations are always 
distinguished by their excessive tenderness and by the rapidity of their growth. 
The discharge furnished by these bodies varies very greatly. When they are in a 
perfectly normal condition, as indicated by their florid aspect, small size, and steady 
development, it is usually of a thick, cream-like consistence, and of a pale yellowish 
color, or, in other words, of the nature of laudable pus; if, on the other hand, they are 
inflamed and irritable, it will generally be thin and sanious, with an inordinate quantity 
of earthy salts ; when the excitement is very high, the matter is usually mixed with 
aplastic lymph ; hard, callous granulations are often free from all discharge, being appa- 
rently incapable of furnishing any matter whatever. In dropsical granulations the fluid 
is usually serous. 
The management of the granulating process must be conducted upon the same general 
principles as the ulcerative. The leading indication is to favor its development by pro- 
tecting the raw surface from the atmosphere and whatever else has a tendency to embarrass 
its progress. The most suitable applications, as a general rule, are water-dressings and 
emollient poultices, employed in such a manner as, on the one band, not to excite exuberant 
action by their warmth, and, on the other, not to repress growth by their refrigerant effect. 
Rude contact, protracted exposure to the air, and irritating applications must be carefully 
avoided. 
SECT. XI CICATRIZATION. 
Cicatrization is the completion of the granulating process, the last act in the operation 
of repair, the hermetic sealing, as it were, of the breach left by the destruction of the 
tissues of the affected part. 
Cicatrization must always necessarily be preceded by a subsidence of the inflammation 
of the part, just as is the development of granulations, only to a still greater extent. This 
is an essential preliminary. The granulations having attained the level of the skin, their 
growth is arrested, and their vessels coalesce so as to form a continuous gelatinous tissue. 
The next step is a deposit of plasma at the edges of the breach, followed by its rapid 
organization and conversion into a thin, bluish, or whitish pellicle, abounding in epithelial CHAP. IV. 
CICATRIZATION. 
183 
scales, and strikingly contrasting, by its peculiar appearance, with the granulations and 
the adjoining skin. The new substance is always easily detached with the sponge or 
finger, for as yet its consistence is very slight. Gradually, however, it becomes more 
thick and firm, assimilating itself more and more closely to the preexisting integument, 
whose place it is intended to supply. The process, thus begun, continuing, the plastic, 
organizable film extends steadily onward until the exposed surface is finally completely 
covered in, the length of time necessary for this varying according to the size and shape 
of the breach, the absence or presence of complications, and the state of the system. The 
majority of the cells of the granulation tissue now disappear by disintegration and absorp- 
tion, and the gelatinous intercellular substance is converted into fibrillar connective tissue, 
while the remaining cells assume the characters of connective tissue corpuscles. The 
superfluous capillaries become obliterated, and the new tissue contracts more and more, 
until a perfect cicatrice is formed. Ovoidal ulcers or wounds heal, other things being 
equal, more rapidly than circular, superficial than deep, common than specific. Cicatri- 
zation is usually more easily accomplished in the upper extremities than in the inferior, 
and in the skin and connective tissue than in the other structures. In the organs, properly 
so called, it generally takes place with difficulty, and only after a long interval. 
Cicatrization, as a general principle, always begins at the edges of the breach which it 
is designed to repair, whence it proceeds towards the centre, which is, consequently, the 
last to heal. So constant and uniform is this occurrence, that it may be regarded as the 
great law of cicatrization. It would seem as if the aid of the natural tissues were neces- 
sary to enable the new substance to obtain a secure foothold. If, occasionally, an example 
of an opposite character presents itself, it is simply exceptional, and it cannot, even then, 
always be determined whether the starting point of the process was not a small fragment 
of the old structures, which, standing like a little island in the midst of the ulcer, serves 
as a nucleus to the new. Obviously, in such an event, there is no new law in operation. 
Some time necessarily elapses, after the cicatrization is completed, before the new struc- 
ture, now called a cicatrice, acquires much solidity and strength. It is only by degrees 
that it loses its bluish appearance and assumes the properties of the preexisting substance. 
Even then it is at best only a very imperfect copy of the original, whose place it is 
designed to supply, being destitute alike of hair, sebaceous follicles, and sweat glands. 
Its vessels, at first remarkably large and tortuous, gradully dwindle down to the size ol 
the natural ones, in the adjacent sound parts, and, when fully developed, 
generally exhibit a beautiful retiform arrangement, as in fig. 25. The 
scar always remains tender for some time after its formation, is very 
liable to break, crack, or ulcerate from the slightest causes, and has a 
remarkable tendency to contract or diminish. 
What is true of the imperfect reproduction of the skin is equally true 
of all the textures with the exception of the nerves and muscles in 
which perfect regeneration both as regards form and function occurs. 
Of the other tissues new bone comes, perhaps, nearer to the original 
structure than any other; but even this presents many peculiarities, and 
it is certain that it often acquires a degree of hardness and solidity far 
greater than that of the primitive substance. There are, moreover, some pieces of the 
skeleton which, when broken, unite, not by osseous matter, but by fibrous tissue, fibro- 
cartilage, or cartilage. Fractures of the patella, the olecranon process, the acromion 
process of the scapula, and the neck of the thigh-bone within the capsular ligament, are 
generally, if not invariably, repaired after this fashion, because the ends of the fragments, 
deprived of their natural supply of blood and nerve-fluid, are unable to pour out the 
requisite quantity of phosphate and carbonate of lime, to insure their solidification. Car- 
tilage is imperfectly reproduced after injuries; the new substitute is always very thin, 
hard, and of an unnaturally bluish tint. In fracture of the costal cartilages the consoli- 
dation is effected by bone. Tendon is renewed only in the case of subcutaneous section ; 
never when lost by disease. Bloodvessels are never regenerated ; their continuity cannot 
be reestablished after complete division, on account of the retraction of their extremities. 
The cerebral, pulmonary, hepatic, splenic, salivary, renal, and seminiferous structures are 
incapable of reproduction, the new substitute being always of a cellulo-fibrous, fibrous, 
or fibro-eartilaginous nature. Serous, mucous, and fibrous membranes are repaired in a 
similar manner. Thus, it will be seen that a tissue, when seriously mutilated, is seldom 
perfectly reproduced, whatever pains may be taken to assist its efforts. 
It is not surprising that a substance so imperfectly organized as a cicatrice should be 
liable to inflammation and its consequences, as well as to some of the new formations. 
Fig. 25. 
Structure of a Cica- 
trice of the Skiu. 184 
TERMINATIONS OF INFLAMMATION. 
CHAP. IV. 
Its powers of resistance being naturally feeble, it generally yields more readily to disease, 
whether simple or malignant, than the original structures. It is for this reason that 
inflammation of the substitute-tissue is prone to pass into ulceration, or if the morbid 
action is at all severe, even into mortification. In suppuration, the matter furnished by 
the part is nearly always of a thin, ichorous nature, a development of genuine pus being 
almost impossible under any circumstances. 
When a cicatrice is habitually exposed to pressure, it has a great tendency to change 
into a species of corn, not unlike a corn upon a toe, both in color, shape, and consistence. 
In other cases, again, it may be transformed into a bunion, burse, or synovial cyst, as 
upon the extremity of an old stump, especially af ter amputation of the thigh and leg. A 
genuine horny growth sometimes occurs upon a cicatrice ; and occasionally the new tissue, 
from the effects of long-continued pressure, undergoes the cartilaginous, fibro-cartilagi- 
nous, or even the osseous degeneration. 
A true neuroma is sometimes developed in such a structure, as in a case recently under 
my charge, in a man, thirty-five years of age, who, twelve months previously, received a 
lacerated wound in the left middle finger. The parts were long in healing; and at le ngth 
an exceedingly hard, ugly scar formed, exquisitely sensitive on the slightest touch, consider- 
ably elevated above the surrounding level, and habitually of a red-purplish hue. The ten- 
derness was always worse in cold, damp states of the atmosphere, and, under such circum- 
stances, the pain not unfrequently extended along the forepart of the arm, as high up as 
the elbow. The principal mass of the growth consisted of an expansion of the digital 
nerves, incased by dense, fibroid tissue. 
The most common form of malignant disease to which cicatricial tissue is liable is epi- 
thelial carcinoma; it may occur upon any part of the body, but is most frequently met 
with upon the face, hands, and feet, parts which are habitually exposed, or constantly 
subjected to pressure and friction. The diseased structure, almost of4 stone-like hardness, 
and the seat of sharp, pricking, or burning pains, soon ulcerates, and pours out a thin, 
sanious, and fetid fluid, highly irritating to the neighboring healthy surface. The edges 
of the sore are hard, steep, everted, or partially undermined, while the bottom is foul and 
slightly covered with spoiled lymph : occasionally the part has a worm-eaten appearance. 
The ulcer is always intractable, and, steadily proceeding from bad to worse, is eventually 
followed by the most serious consequences. 
Keloid is another form of disease liable to appear in cicatrices ; this, as will be seen 
elsewhere, is a peculiar fibroplastic growth, which often forms after burns and scalds, and 
which derives its name from the supposed resemblance which it bears, in its configuration, 
to the claws of a crab. 
There are certain cicatrices which are habitually dry, painful, and the seat of more or 
less itching, with a tendency to ulceration and discharge. Old stumps of the leg and 
thigh, imperfectly covered with integument, with the raw substance firmly adhering to 
the ends of the bones, are very apt to suffer in this way, and to be a source of perpetual 
annoyance. Not unfrequently the pain is of a neuralgic character, especially when it is 
dependent upon the presence of a neuroma, ora bulbous expansion of the nerves. Lastly, 
the pain, of whatever nature, is often materially influenced and aggravated by hygrometric 
conditions of the atmosphere, the part and system being conscious of the slightest change 
of the weather. 
Finally, cicatricial tissue sometimes manifests a remarkable disposition to contract, even 
long after it has apparently attained its f ull development. This tendency is nowhere more 
conspicuous than in burns and scalds, where it is occasionally so great as to give rise to 
the most hideous deformity. Thus, a vicious scar may pinion the arms to the side, retract 
the hand upon the wrist, and pull down the chin upon the chest. The new tissue, conse- 
quent upon the loss of substance caused by salivation, generally contracts in such a manner 
as to produce firm adhesion of the jaw, sadly interfering with eating, mastication, and even 
articulation. 
In order to prevent the degeneration of a cicatrice, especially if large, it should be pro- 
tected for a long time from rude manipulation, pressure, friction, and irritating applica- 
tions. Any tendency to undue contraction should promptly be counteracted, otherwise it 
may lead to great deformity and impairment of function. A vicious cicatrice may occa- 
sionally be advantageously extirpated. 185 
CHAP. V. 
SOFTENING. 
CHAPTER V. 
TEXTURAL CHANGES. 
Under this head may be described those organic changes which are effected in the 
substance of the organs and tissues, as the result either of inflammation or of defective 
nutrition, consequent upon lesions in the circulatory and nervous systems. The most 
important of these alterations of texture are softening, induration, transformations, hyper- 
trophy, atrophy, contraction, and fistule. 
SECT. I SOFTENING. 
Inflammation not unfrequently passes into softening, or what the French pathologists 
have denominated ramollissement. The event is characterized by a loss of cohesion of the 
affected textures, varying in degree from the slightest change of the natural consistence to 
almost complete pulpifaction. All parts of the body are liable to this occurrence, but 
those which are most apt to suffer are the lungs, brain, spleen, liver, and heart, together 
with the mucous membrane of the stomach and bowels, the articular cartilages, and the 
spongy structure of the bones. The subcutaneous and intermuscular connective tissue is 
occasionally softened to a great extent in rapidly progressive forms of inflammation, particu- 
larly in diffuse erysipelas. On the other hand, the vessels, nerves, muscles, and tendons, 
the fibrous and serous membranes, the lymphatic and salivary glands, the kidneys, the 
thyroid body, uterus, ovaries, testes, and prostate rarely experience this alteration, how- 
ever violent the attendant action. 
Softening sometimes occurs rapidly, at other times slowly; hence the distinction into 
acute and chronic. In the former case the affected tissues may be almost completely de- 
prived of their natural consistence within the space of a very few days. Thus, in acute 
pneumonia the lungs are often so much softened at the end of this time as to be incapable 
of resisting the slightest pressure of the finger. In the brain and spleen the loss of cohe- 
sion sometimes proceeds even more rapidly than in the lungs. Chronic softening is most 
common in the cerebral substance and in the mucous membrane of the ileum and colon, 
where it is generally a most insidious disease, often involving a large extent of tissue, and 
yet unaccompanied by any characteristic symptoms. 
The true nature of softening has not been explained. We can, however, hardly divest 
ourselves of the idea that it is a species of molecular mortification, especially in its more 
advanced stages. Be this as it may, it is unquestionable that the loss of cohesion, under 
such circumstances, is entirely incompatible with the exercise of the functions of the part, 
or its restoration to health. Many of its smaller vessels are completely obliterated, while 
the remainder are so crippled and paralyzed as to be scarcely able to propel their contents. 
Changes not less conspicuous are observable in the proper parenchymatous structure, which 
not only loses its natural consistence, but also its natural color; its cells are infiltrated 
with serosity, or serosity, lymph, pus, and blood, and its minute texture is no longer dis- 
tinguishable by the aid of the most powerful microscope. If this is not death, or a con- 
dition closely approximating to it, what is it? In the milder forms of mollescence the 
structure may still retain some vitality, and may, consequently, be able, in time, to regain 
its original characters ; or, what is more probable, may be rebuilt by plastic matter, after 
the manner of other broken-down and mutilated tissues, the first step in the process being 
the removal of the effete substance. 
There is a species of softening which is intimately connected with, if not actually depen- 
dent upon, obliteration of the vessels of the affected structures, with consequent deficiency 
of blood and impairment of nutrition. It is most frequently met with in the brain and 
spinal cord of old persons, and is generally supposed, although perhaps erroneously, to be 
of a non-inflammatory character. If this opinion were correct, it is not probable that we 
should find, as we always do in this disease, more or less effusion of serum, plasma, and 
even pus. Wherever these fluids are deposited, they afford indubitable evidence of incited TEXTURAL CHANGES. 
chap. v. 
action ; and it would, therefore, be absurd to conclude that they could be poured out here 
without the agency of inflammation. 
This event of inflammation is interesting chiefly in a pathological point of view ; for, 
as it is met with almost exclusively in the internal organs, and presents no characteristic 
symptoms, it is evident that treatment holds out little prospect of relief. When the true 
nature of the lesion is suspected, the proper remedies, in the*acute form, will be such as 
are calculated to reduce inflammatory action and to favor the removal of deposits; in the 
chronic variety a mildly alterative course, with tonics, embracing cod-liver oil, quinine, 
and iron, is indicated. 
SECT. II INDURATION. 
A deposit of lymph, plasma, or fibrin is common to nearly all inflammations, whatever 
may be their cause, site, or degree. When occurring upon the free surfaces of the organs, 
it usually presents itself in the form of a layer, which, escaping the influence of the ab- 
sorbents, is ultimately converted into an analogous tissue, which often remains during the 
rest of the individual’s life, subject, in the meanwhile, to all the diseases and accidents 
incident to preexisting structures. When the deposit takes place in the substance ot 
the organs, it fills up their cells, interstices, or molecular spaces, and thus increases their 
consistence, as well as their weight, the matter assuming the shape of the cavities in which 
it is lodged, and being liable, as in the former case, either to be absorbed or to become 
organized, according to the condition of the part and the vitality of the morbid product. 
A similar arrangement occurs when plasma is effused into the connective tissue beneath 
the skin, among the muscles, and in other situations. 
Induration is extremely common, and may occur in any organ and tissue of the body. 
It is most frequently met with, however, in the lungs, spleen, liver, thyroid gland, testicle, 
lymphatic and prostate glands, mamma, ovaries, uterus, bones, and subcutaneous connec- 
tive tissue. 
Age exerts considerable influence upon the production of induration. In the great 
majority of the organs it may occur at any period of life, but in some, as in the thyroid 
gland, for example, it rarely appears before the fourteenth year, while in the genital ap- 
paratus it is hardly even observed until after puberty. Induration of the prostate gland, 
of the vessels, and of the brain and spinal cord is an affection of advanced life, as is also 
induration of the crystalline lens and its capsule. 
The degree of induration varies from the slightest alteration of the natural consistence 
of the part to the solidity and density of concrete albumen, old cheese, fibro-cartilage, 
cartilage, or bone. Much, in this respect, will depend upon the nature of the affected tis- 
sue, and the date of the lesion, or the degree of change which the deposit upon which the 
induration depends may have undergone. The color of the affected part may be normal, 
or variously altered, according to the amount of its vascularity and the presence or absence 
of effused blood. Much diversity also exists in regard to its volume, although in most 
cases this is considerably augmented, and sometimes even quite enormously, the bulk 
many times exceeding that which is natural to the organ in health. The weight of the 
part, too, is usually increased, and there is commonly some dryness, with a marked loss 
of elasticity. 
The period required for the production of induration ranges from a few hours to several 
days, weeks, or months, depending upon the nature of the exciting cause and of the af- 
fected structures. In the testicle it often occurs in a very marked degree in less than 
twenty-four hours, and at the end of forty-eight hours the organ may be so hard as to be 
entirely incompressible. The induration accompanying the development of tonsillitis, 
adenitis, furuncle, carbuncle, and erysipelas generally occurs with extraordinary rapidity, 
and the same thing is frequently witnessed in the connective tissue around the joints, especi- 
ally in inflammation of a gouty or rheumatic character. In pneumonia the parenchymatous 
substance of the lungs is often extensively solidified within a few days from the commence- 
ment of the morbid action. On the other hand, the induration may proceed very slowly, 
as in goitre, chronic arteritis, hepatitis, and splenitis, and in certain affections of the 
uterus and prostate gland, where months, if not years, may elapse before it attains its full 
development. 
The effect of induration upon the tissues in which it occurs is of the most prejudicial 
character, sadly impairing their structure and functions and frequently leading to the 
worst results. Thus, when it exists in both testicles it may become a cause of impotence; 
in the liver it may interfere with the secretion of bile; and in the lung it may produce 
death by offering a mechanical obstruction to the ingress of the air. In the arteries in- CHAP. V. 
TRANSFORMATIONS. 
187 
duration is frequently followed by rupture of their coats, leading to aneurism; while in the 
connective tissue around the joints it always impedes the exercise of the articular surfaces. 
The immediate cause of induration is a deposit of plastic matter in the cells of the 
affected structures, which it thus obliterates while it condenses the adjoining substance, 
and so renders it unfit, either temporarily or permanently, for the proper exercise of its 
functions. The fluid is generally associated with more or less serum, and not unfrequently 
also with pus and even pure blood. When the circumstances under which it is deposited 
are favorable, it soon becomes organized, and may finally be converted into an analogous 
tissue, which often retains its parasitic connection during the remainder of life, although 
in most cases it ultimately disappears. 
In the treatment of induration the leading object is to excite the absorbent vessels so 
as to induce them to remove the deposits upon the presence of which the lesion depends. 
The sooner this is always done the better. The longer we wait, the greater will be the 
danger of a permanent change of structure, or, when the organ is one of great importance 
to life, of the death of the patient. When the deposit is recent, and action still high, our 
reliance is mainly upon the vigorous employment of antiphlogistics, as bleeding, purging, 
and diaphoretics, writh antimonials, light diet, and rest in the recumbent posture. In- 
flammation having thus been moderated, the induration, already greatly reduced by the 
previous measures, may usually be promptly disposed of by alterative doses of mercury, 
carried, perhaps, to slight ptyalism ; and, when the part is accessible, by sorbefaeient 
liniments, embrocations, and unguents, aided by pressure with the bandage. In the more 
chronic forms of the affection the different preparations of iodine must be brought into 
play, particularly Lugol’s solution, Donovan’s liquor, and the various forms of mercury, 
as the bichloride and biniodide; along with the topical applications just mentioned, if the 
induration be external. Friction and the cold douche will also prove serviceable under 
such circumstances. 
SECT. Ill TRANSFORMATIONS. 
The human body is in a state of constant mutation, decay and renovation, commenc- 
ing before birth, and continuing down to the last moments of existence. The Wolffian 
bodies and the gubernaculm of the testicle disappear druring intra-uterine life; then 
thymus gland is gradually effaced during childhood ; the arteries calcify in elderly persons; 
and at every period of life various states of the system, dependent upon disease or acci- 
dent, arise, in which there is a strong tendency to the deposition of oil globules, or the 
transformation of different organs and tissues into fatty matter. 
The most important of these changes, surgically considered, are the cellular, mucous, 
cutaneous, fibrous, calcareous, and fatty; they are all connected with defective vitality, 
and with atrophy of some, if not all, of the constituent elements of the affected structures. 
The cellular transformation is met with chiefly in parts that have been rendered useless, 
either by the natural cessation of their functions, or by accidental circumstances. Thus, 
the thymus gland, which is evidently connected with some important office in the foetus, 
gradually decays during childhood, and is ultimately converted into shreddy cellular sub- 
stance, of which hardly any trace remains after the thirtieth year. The gubernaculum 
undergoes a similar change; the gall-bladder, occluded by biliary concretions, is occa- 
sionally completely transformed into this tissue; and the cellular adhesions so often seen 
between the costal and pulmonary pleurae, consequent upon the degeneration of old, 
adventitious membranes, are familiar to every pathologist. Various ligaments, especially 
the capsular, sometimes degenerate in this way, the metamorphosis being most marked in 
young subjects affected with unreduced dislocations of the hip and shoulder. 
When skin is inverted for any length of time into one of the natural outlets of the 
body, as, for instance, the anal, it gradually undergoes a species of metamorphosis into 
mucous membrane. The first indication of the change is a softened condition of the 
cuticle and the disappearance of the hair ; the epidermis scaling off, the surface beneath 
assumes a reddish, velvety aspect, becomes extremely vascular, and soon begins to secrete 
a thin, ropy, whitish fluid, not unlike mucus. 
A change from mucous membrane to skin is sometimes observed, although the occur- 
rence is uncommon. It is noticed chiefly in prolapse of the rectum, vagina, and uterus, 
the mucous investment of which, from long exposure to the atmosphere, becomes dry, 
rough, and insensible, and is ultimately converted into a tissue bearing a more close re- 
semblance to the cutaneous than to the mucous. The transformation, however, as in the 
case of the skin, is at best extremely imperfect, and it remains to be shown whether, in 188 
TEXTURAL CHANGES. 
chap. v. 
either instance, the old structures are so completely deprived of their identity as to justify 
the idea of a genuine transformation. 
The fibrous transformation is most commonly met with in those parts of the body that 
have been deprived, either accidentally or otherwise, of their natural functions. Thus, 
in an artery that has been tied for the cure of aneurism or the arrest of hemorrhage, the 
portion of the vessel included between the ligature and the fifst large collateral branch is 
gradually converted into a solid cylinder, which, in its turn, is changed into a dense 
tibrous structure, in which it is impossible to discern any trace whatever of the primitive 
tissues. Ligaments, serous membrane, and adventitious textures occasionally undergo 
similar changes. The cornea, in the withered and atrophied eye, the victim of destruc- 
tive inflammation, is, at times, almost completely transformed into a substance bearing 
the closest resemblance to the sclerotica, one of the best examples of the fibrous tissue. 
In some of these cases, as in the one just mentioned, the change is accompanied by a de- 
posit of oil globules. The whitish opaque bodies, so common in the coats of the spleen, 
in the placenta, and in the arteries of elderly subjects, are apparently essentially com- 
posed of fibrous substance, although in theif outward characters they strikingly resemble 
fibro-cartilage. 
The calcareous degeneration is most common in the arteries, but is also occasionally 
seen in other parts of the body, as in fibrous tumors, especially those of the uterus, in the 
articular cartilages, and in the concretions that are sometimes found in the larger joints, 
particularly that of the knee. In the arteries it generally begins in the form of little 
opaque patches in the middle tunic, which, as they advance in age, assume a firm, solid 
consistence, and ultimately convert the vessels into rigid earthy cylinders. The deposit— 
for such it is, rather than a genuine degeneration—was formerly supposed to be of an 
osseous character, but that this is not the case is shown both by its chemical and physical 
properties. In the more matured specimens it is essentially composed of carbonate and 
phosphate of lime, in union with a minute portion of albumen ; in recent cases, on the 
contrary, the animal matter exists in much greater quantity. It differs still further from 
bone in having no areolar structure, and in being destitute of vitality. In fibrous tumors 
of the uterus large calcareous masses, weighing several pounds, are occasionally found. 
Th a fatty degeneration, if not the most common of all, is the most universally distri- 
buted, since there is hardly any organ or tissue of the body in which, under favorable 
circumstances, it may not occur. Observation has shown that it may take place even in 
the lungs, in cartilage, in bone, in the placenta, in the cornea, and in the crystalline lens. 
It is also met with in plastic exudations, tubercle, morbid growths, and in pus globules. 
It is of frequent occurrence in the muscles, and in the coats of the arteries, in connection 
with the atheromatous deposit. In short, it may take place both in natural and in ad- 
ventitious formations, in the hard as well as in the soft, in the most humble as well as in 
the most exalted in point of organization and life-power. Of all the various structures, 
however, which are liable to suffer from it, the liver and the arteries are the most fre- 
quently affected. Fatty degeneration may occur in the former at any period of life, 
even in young children, and is a very common consequence of habitual alcoholic stimula- 
tion ; in the latter, on the contrary, it is usually restricted to elderly subjects. The senile 
arc of the cornea is most common in advanced life, and is supposed by some observers, 
amongst others by Mr. Canton, to be almost always coincident with fatty degeneration of 
the heart and other organs. Fatty degeneration of the muscles occurs both in the volun- 
tary and involuntary classes, although it is by no means so common in the latter as in 
the former. 
Tiie fat in this degeneration occurs either in the form of a drop of oil or of small gran- 
ules in the cells of the tissues, their protoplasm being converted by chemical decomposition 
into fat. Such an infiltration is often observed in the liver, brain, pancreas, and arteries. 
An organ that has undergone the fatty degeneration is generally a few shades lighter 
than in the natural state, diminished rather than increased in consistence, easily torn, 
greasy to the touch, and of less specific gravity than in health. The amount of oil which 
it contains often ranges from one-third to one-half of its own weight. 
What is the essential cause of the fatty degeneration ? In some cases it is evidently 
connected with a general hypertrophy of the adipose tissue, accompanied by a redundancy 
of oily matter dependent upon the use of an inordinate quantity of hydrocarbonaceous 
food and imperfect assimilative power. In the liver of some of the inferior animals the 
fatty degeneration may often be produced at will, simply by subjecting them to rest, and 
constantly cramming the stomach with food, which, by creating obstruction in the portal 
circle, probably induces congestion and inflammation of the hepatic tissues, which thus CHAP. V. 
TRANSFORMATIONS. 
189 
favor the deposition of oily matter. The fatty transformation of the liver of drunkards 
is doubtless occasioned in a similar manner. In other cases the lesion appears to be es- 
sentially due to a want of exercise of the affected parts, conjoined with deficient nervous 
and vascular supply, as is so often witnessed in the muscles of the leg in paralysis of the 
inferior extremity. Under such circumstances, especially when the case is of long stand- 
ing, the muscles generally assume a pale, yellowish, or brownish aspect, are remarkably 
soft and flaccid, and yield a clear oily fluid on pressure, their libres, however, remaining 
perfectly distinct. 
The treatment-of the fatty transformation is unsatisfactory. When the patient’s habits 
are at fault, they must of course be corrected ; alcoholic stimulation must be abandoned, 
the diet must be changed, and a system of exercise must be instituted, to improve the 
state of the blood and the assimilative powers. Local treatment should not be neglected 
when the degeneration is suspected to be going on externally, as when the muscles of a 
limb begin to waste in case of paralysis, disease, or injury. 
The lardaceous degeneration has been described under various names, as amyloid, 
waxy, and albuminoid. Its clinical history is still imperfectly understood, although its 
origin, as is well known, is usually associated with a depraved condition of the system, of 
which pulmonary phthisis, Bright’s disease, syphilis, carcinoma, chronic alcoholism, and 
affections attended with profuse suppuration, are among the most common and prolific 
causes. The degeneration is generally widely diffused, but the structures which are 
more particularly liable to suffer are the liver, spleen, kidneys, lymphatic glands, blood- 
vessels, muscles, and cartilages. The muscular tissue of the smaller arteries is, apparently, 
its primary seat. Virchow has seen cases in which the minute arteries of the alimentary 
canal from the mouth to the anus were literally loaded with amyloid matter. It has also 
been noticed in false membranes, in recent fibrinous exudations, in tubercle, and in car- 
cinomatous formations of the liver. 
An organ affected with the amyloid degeneration is deficient in potassa and phosphoric 
acid, while it contains an unusual quantity of soda, chlorine, and cholesterine ; is increased 
in volume, consistence, and weight, absolute and specific; feels like a piece of soft wax, 
or wax and lard combined ; and exhibits upon its cut surface a semitransparent appear- 
ance, the more delicate sections being perfectly translucent. The coats of the arteries, 
at first opaque, thickened, and granular, eventually become pellucid, transparent, and 
hyaline, at the same time that they are diminished in caliber, and so much increased in 
firmness as to remain patulous when divided. 
Lardaceous matter, regarded by some as dealkalized fibrin, has a strong resemblance 
to albumen, but differs from it in its insolubility in acids containing pepsin. Water, 
alcohol, and alkalies produce no change in it. The contact of iodine causes a reddish- 
brown color, characteristic of its nitrogenous nature. The matter seems to pass from 
the vessels in a fluid state, coagulates firmly in the living structures after it is effused, 
and is entirely destitute of cell properties. The only form in which it occurs is that of 
an infiltration, which is often so great as to inundate the tissues in which it is deposited. 
The lardaceous degeneration is characterized by a pale waxy appearance of the skin, 
by anemia, and by progressive emaciation and debility. Its immediate effect is to dimin- 
ish the lumen of the minute vessels, and thus to interfere with the process of nutrition 
and repair. Of the immediate cause of the degeneration nothing whatever is known, and 
of its treatment we are equally ignorant. 
The pigmentary degeneration occurs principally in the skin, lungs, and lymphatic 
glands, in certain morbid growths, especially warts and nevoid tumors, and in melanotic 
carcinoma and sarcoma. The scars of old ulcers of the legs are frequently of a bluish, 
pink, bronze, or brownish tint, evidently the effect of some abnormal deposit. The lungs 
in spurious melanosis, as it is termed, so common among colliers, often become remarkably 
black from the inhalation of carbonaceous matter in an extremely finely pulverized state, 
and the bronchial lymphatic glands not unfrequently suffer in a similar manner. In Ad- 
dison’s disease of the suprarenal capsules, a bronzed appearance of the skin was at one 
time regarded as a diagnostic sign of that affection. In melanosis the black color is char- 
acteristic of that peculiar formation. Sarcomatous growths are often stained with pig- 
mentary matter; and the so-called analogous tissues occasionally experience similar 
changes. The pigmentary degeneration is generally denotive of diminished vitality, and 
no treatment, so far as is at present known, exercises any influence over it. 190 
TEXTURAL CHANGES. 
CHAP. V. 
SECT. IV HYPERTROPHY. 
Tlie word hypertrophy is employed to designate the increased size and weight which 
an organ acquires in consequence of an augmentation of its nutrition or of chronic irrita- 
tion. The hypertrophy may be general or local, and the latter may affect either an entire 
organ, or be limited to particular portions of it, or even to some of its component elements. 
It may exist alone or in association with other lesions, and is liable to occur at all periods 
of life; sometimes, as in the thymus gland and capillary vessels, apparently even before 
birth. No organ or structure is probably entirely exempt from it; but among those which 
most frequently suffer are the lymphatic glands, mamma, thyroid body, spleen, liver, 
heart, prostate gland, tonsils, bones, vessels, adipose tissue, and skin. The best example 
of hypertrophy of the cutaneous textures is elephantiasis, in which the increase of weight 
and bulk is sometimes enormous. 
The causes of hypertrophy are, first, inordinate exercise of the organ ; secondly, me- 
chanical obstruction; and, thirdly, chronic inflammation. 
The most simple manner, apparently, in which hypertrophy of an organ occurs is from 
an increase of its functional activity. Examples of this variety of the affection are found 
in various textures, particularly the muscles, lungs, and kidneys. The muscles, voluntary 
and involuntary, are always developed in proportion to the amount of their exercise. 
Kept at rest, they soon lose their firmness and healthy color, and become comparatively 
feeble and useless. The blacksmith, who constantly plies his hammer, has much larger 
and stronger arms than the dancing-master, who merely employs his legs. The same law 
obtains with regard to the lungs and kidneys. When one of these organs is imperfectly 
developed, compressed by effused fluid, or destroyed by some morbid growth, the other is 
sure to become preternaturally expanded, thereby compensating for the deficiency. There 
are certain viscera, as the uterus and breast, which are subject to temporary hypertrophy. 
During pregnancy and lactation these organs increase very much in bulk, but again 
diminish soon after parturition and weaning. 
Hypertrophy may be caused, secondly, by some mechanical impediment interfering 
with the due performance of the functions of an organ. This is frequently seen in the 
heart, where, from disease of the valves, preventing the easy passage of the blood, the 
viscus is obliged to perform increased labor, and so becomes more or less enlarged. In 
the muscular fibres of the stomach, a similar change is often witnessed from obstruction 
at the pylorus, and in those of the urinary bladder, from stricture of the urethra, or hyper- 
trophy of the prostate gland. 
Hypertrophy from chronic irritation is of frequent occurrence, and is met with under 
a great variety of circumstances. Some of the best examples of this species of hyper- 
trophy are seen in the lymphatic glands of the groin from chronic irritation of the head 
of the penis, of the mesentery from ulceration of the ileum, and of the bronchi* from 
disease of the lungs. Enlargement of the liver and spleen, sometimes of enormous size, 
is unquestionably due to a similar cause. In chronic dysentery, not only the mucous 
and submucous connective textures become hypertrophied, but the affection often extends 
to the muscular tunic, which occasionally attains an extraordinary degree of development. 
The follicles and villosities, which, in the healthy state, are hardly perceptible to the 
naked eye, are also rendered extremely prominent, the former being sometimes of the 
size of a mustard-seed, while the latter are more than a line in length. A similar devel- 
opment is frequently observed in the coats of the urinary bladder, as a consequence of 
chronic inflammation. 
The color of the affected organ is generally much heightened, especially when the 
hypertrophy is wholly physiological; on the other hand, it is occasionally greatly dimin- 
ished, and instances are observed in which it is apparently perfectly natural. The con- 
sistence may likewise be normal, diminished, or increased. These three conditions do 
not, however, occur with equal frequency. An increase of density is by far the most 
common, and is particularly conspicuous in hypertrophy of the heart, the mammary gland, 
the muscular fibres of the bladder, the lymphatic glands, connective tissue, hones, liver, 
spleen, and kidneys. A diminution of consistence is extremely rare, and cannot be viewed 
as a necessary consequence of the lesion. 
An increase of weight of the affected organ follows, as a natural effect, when the lesion 
is not conjoined with atrophy. An augmentation of volume is by no means constant. 
Thus, in hypertrophy of the heart and bladder, there may be great development of the 
muscular fibres, with marked diminution of the size of their cavities. A change of form 191 
CHAP. V. 
ATROPHY. 
always arises when hypertrophy is circumscribed, or limited to a particular point, as in 
the bones, skin, heart, bronchial tubes, and bloodvessels. 
Hypertrophy essentially consists in an augmentation of the nutritive function. When- 
ever an organ is unusually active for any length of time, a much greater quantity of blood 
is sent into it than in the natural state, and it assumes a deeper color in consequence, at 
the same time that its structure is rendered more dense, and its cells multiply and increase 
in size. It is in this manner that the alteration under consideration is brought about. In 
that variety of it which results from chronic irritation, it is not unlikely that there is 
often superadded to the alteration just mentioned a deposit of new substance in the con- 
nective tissue, thus leading to an actual change of structure. The effects of hypertrophy 
on surrounding parts will be considered in connection with the different organs and tex- 
tures of the body. 
In regard to the treatment of hypertrophy, no definite rule can be laid down, as it must 
be regulated, in great degree, by the nature of the exciting cause, which should, there- 
fore, always be a prominent object of inquiry. Much benefit may generally be anticipated 
from the steady and persistent use of sorbefacients, locally and constitutionally applied, 
such as iodine, blisters, compression, mercury, iodide of potassium, and tartar emetic, 
aided by purgatives and attention to diet. In some cases, nothing short of the removal, 
partial or complete, of the affected organ holds out any prospect of relief. 
SECT. V ATROPHY. 
Atrophy, the reverse of hypertrophy, consists in a wasting of the substance of an organ, 
accompanied by a diminution of its weight and bulk. Occurring at all periods of life, 
it may affect an entire organ, or a part of an organ, or be limited to some of its constitu- 
ent elements. 
Remarkable examples of general atrophy are occasionally met with, but as such an 
occurrence is of no special surgical interest, it does not demand any particular notice 
here. Cases of this kind are sometimes apparently of a congenital character; at other 
times they are the result of disease, and are either curable or otherwise, according to their 
extent and the nature of their exciting causes. 
Local atrophy may be produced by a variety of causes, of which the principal are, first, 
cessation of the natural function of an organ ; secondly, loss of nervous influence ; thirdly, 
deficient supply of blood or nutritive matter ; and, lastly, inflammatory irritation. 
It is a law of the animal economy that an organ, deprived of its natural functions, 
gradually falls into a state of decay. Of this class of structure are the umbilical vesicle 
and the pupillary membrane of the foetus, the former of which, after having subserved its 
purpose, disappears at the close of the third month ; the latter between the seventh and 
eighth. The development of the genito-urinary organs is preceded by the formation of 
two small jelly-like glands, known as the Wolffian bodies, which acquire their greatest 
bulk about the middle of utero-gestation, after which they gradually shrink, and at length 
entirely disappear. The gubernaculum, first visible in the tenth week of embryonic life, 
is a thin, membranous process, which guides the testicle to the internal ring, and is 
eventually converted into cellular substance. All these are instances of atrophy from the 
cessation of the functions of an organ in the foetus. After birth, changes not less remark- 
able are observed ; such, for example, as the wasting of the thyroid body, the suprarenal 
capsules, and the thymus gland. From the same cause the alveolar processes of the jaws 
disappear after the removal of the teeth. The ovaries shrink after the decline of the menses; 
and, in conformity with a similar law, the testicles often diminish remarkably in size in 
monks, who lead a life of celibacy, in the strict observance of their vows. 
Atrophy may, secondly, result from a diminution of nervous influence ; a circumstance 
not surprising when it is recollected how much the action of the capillaries is under the 
control of the cerebro-spinal axis. Whole limbs sometimes waste from this cause; in 
other cases the lesion is more limited, and implies only a very partial disorder of the 
nerves. Atrophy caused by disease of the brain occurs much more slowly than when it is 
.occasioned by an affection of the nerves of the part. 
This variety of atrophy is very common in young children during dentition, from the 
sudden suspension of nervous influence, causing a species of local paralysis, which often 
terminates in complete wasting of the affected parts. It is most frequently observed in 
the lower extremities, sometimes in one, at other times in both ; but it also occurs in the 
upper extremities, particularly in the deltoid muscle, which is occasionally transformed 
into a pale, flabby, membranous layer, hardly a few lines in thickness. 192 
TEXTURAL CHANGES. 
chap. v. 
Great atrophy of the upper extremities occasionally occurs from pressure of the head of 
the humerus, as in dislocations, on the axillary plexus of nerves, thereby interrupting the 
nervous influx. When such an accident arises in a very young subject, the growth of the 
limb, if not positively arrested, is imperfectly executed, and not only the muscles, but 
even the bones, become singularly stunted in their development, their shafts being very 
thin, and their prominences unnaturally small and indistinct. 
A mere perversion of the nervous function of an organ is capable of producing atrophy. 
In neuralgia of the testicle that organ is sometimes remarkably diminished both in size 
and consistence, not so much, apparently, from an actual loss of nervous influx, as from a 
change in its character. What corroborates this view is that the testicle, during the 
wasting process, is often so exquisitely sensitive as to be intolerant, of the slightest 
manipulation. 
The effects of a deficient supply of blood in producing atrophy are well known. When 
any part is deprived of the usual quantity of this fluid, it very soon becomes enfeebled, 
its substance is rendered pale and flabby, and it at last loses its functions, although every 
other condition for their performance may remain unimpaired. Thus, the testicle wastes 
after tying the spermatic artery ; and, for the same reason, the muscles of the lower ex- 
tremity occasionally shrink after ligation of the principal vascular trunk of the thigh. 
Atrophy of the heart is sometimes produced by ossification of the coronary vessels ; and a 
case is recorded in which the spleen, from the obstructed condition of its artery, was not 
larger than a filbert. In old age, many of the capillaries are obliterated ; and it is not 
improbable to this circumstance is owing that diminution of the size of the organs which 
constitutes senile atrophy. To the same cause is to be attributed the wasting of the lung 
and heart, from the accumulation of fluids in the pleural and pericardiac cavities. 
Atrophy attendant upon mere want of exercise is probably essentially due to deficient 
nervous and vascular supply, in conformity with a law, mentioned under the head of hyper- 
trophy, that the development of an organ is usually in proportion to the amount of its use. 
The wasted and attenuated condition of the legs in club-foot and other affections depriv- 
ing the muscles of their functions, or interfering with their proper exercise, is probably 
owing entirely to this cause, as is shown by the fact that, when the disability is removed, 
the individual gradually recovers the functions of his limbs, the calves often becoming 
strong and plump, as if there never had been any arrest of growth. The only, or chief, 
exception to this is where the muscles have undergone the fatty degeneration, when they 
never regain their original development, but always remain weak and puny. 
Atrophy from the effects of inflammation is very common. A good example of this is 
seen in the wasting which occurs in the gall-bladder from the presence of biliary concre- 
tions, in which this organ is sometimes reduced to a mere little fibrous mass, with hardly 
any trace of the original reservoir. Hepatitis often gives rise to atrophy of the parenchy- 
matous structure of the liver, and orchitis, especially when the result of mumps, is not 
unfrequently succeeded by impotence. Ilow the lesion, in these and other cases, is pro- 
duced, is not easily determined. It is probable that the inflammatory deposits may so 
choke up the capillary vessels of the parts as to deprive them of their customary and 
necessary supply of nutritive material; or, if this conjecture be untenable, that the pres- 
sure exerted by these effusions causes the absorption of some of the anatomical elements 
of the affected structures, thus reducing them, as it were, to their primitive condition. 
Atrophied structures are prone to undergo the fatty transformation, and it is not im- 
probable that this transformation itself occasionally acts as an exciting cause of the wasting 
process. However this may be, it is certain that the two lesions are sometimes so inti- 
mately associated together as to render it impossible to determine which preceded the 
other, or what part they played as cause and effect. 
The change of color experienced by an atrophied organ is necessarily greatly influenced 
by the natural complexion of the part, but does not possess any special surgical interest. 
The weight of the affected structures is generally considerably diminished, but their bulk 
often remains unaltered, and it is not uncommon to meet with cases where it is even 
greater than natural. 
The treatment of atrophy, occurring in an external or accessible part of the body, as a 
muscle, resolves itself into the use of the warm and cold douche, frictions, either dry or 
through the medium of stimulating embrocations, shampooing, massage, and the applica- 
tion of electricity, as described uuder the head of wasting palsy. The general health 
must be amended, strychnia and tonics being given when there is marked evidence of 
debility. The affected part must be gradually and steadily exercised, or, as it were, re- CHAP. V. 
CONTRACTION AND OBLITERATION. 
193 
educated : the influences of a strong will frequently directed upon it being often of 
essential service in rousing its latent faculties. 
SECT. VI.—CONTRACTION AND OBLITERATION. 
By the word contraction is meant the diminution of a canal, tube, or passage to an ex- 
tent incompatible with the due performance of its functions. It is strictly synonymous with 
the term stricture, the signification of which is so well understood by the surgeon. The 
lesion is liable to occur in various degrees, from the slightest possible change in the size 
of a canal to the complete obliteration of its caliber. 
The chief interest of this subject, surgically considered, relates to the contractions that 
occur in the mucous canals, or excretory ducts, as they are called, and the bloodvessels, in 
both of which the lesion is frequently productive of the most disastrous consequences ; 
attended, in the former, by retention of the secretions of these tubes and of the contents 
of the reservoirs with which they communicate, and in the latter by an impediment to 
the circulation which, in one cast*, may lead to atrophy, and, in another, to softening, 
ulceration, or gangrene. 
Contractions of the mucous passages, to which the ensuing remarks are more particu- 
larly designed to apply, are deserving of great attention, both from the frequency of their 
occurrence, and from the great suffering which they so often entail upon those who are 
the subjects of them. They are met with in nearly every mucous outlet of the body, but 
are more common in the male urethra and in the nasal canal than anywhere else. Doubt- 
less stricture often exists in the smaller excretory ducts, as those of the prostate and sali- 
vary glands, without our knowledge, or without awakening any serious functional distur- 
bance ; in the larger passages, on the contrary, the slightest coarctation is generally a 
source of more or less annoyance, if not of great pain and inconvenience. 
The causes of contraction are mainly two ; inflammation with plastic deposit, and me- 
chanical compression, the former being by far the more common. 
The inflammation giving rise to this lesion may be either acute or chronic ; in the 
former case generally doing its work rapidly, with bold and well-marked symptoms; in 
the latter, on the contrary, the injury is often inflicted in a slow and stealthy manner, 
without perhaps exciting any suspicion as to what is impending. The plastic matter, 
the real cause of the contraction, is generally deposited in the submucous connective tis- 
sue, either exclusively, or partly there and partly in the interstices of the mucous mem- 
brane itself. However this may be, it soon becomes organized, and is ultimately transformed 
into cellulo-fibrous, fibrous, or flbro-cartilaginous tissue, which, gradually contracting upon 
itself and upon the neighboring structures, thus diminishes, in a proportionate degree, the 
caliber of the tube in which it is situated. It is in this manner that all organic strictures, 
properly so termed, of the mucous outlets of the body are formed. 
The second cause of contraction is of a purely mechanical character, although in most 
cases, if not in all, the lesion is attended with inflammation and plastic deposit, secondary, 
however, in their character. It is thus that stricture of the nasal canal may be produced 
by the pressure of a tumor in the sinus of the upper jaw ; of the bronchia, by the pres- 
sure of an aortic aneurism ; and of the Fallopian tubes, the biliary ducts, and the uterus, 
by the pressure of an enlarged viscus or a morbid growth in their immediate vicinity. 
The same cause often induces constriction and even complete obliteration of the blood- 
vessels. A tumor, compressing the aorta, has been known to give rise to permanent 
closure of that vessel as effectually as if it had been surrounded by a ligature. 
The extent of the contraction varies, both in length and diameter, in such a manner 
as to render it impossible to specify it in a general manner. In some cases it may not 
exceed the fraction of a line, while in others it may involve the whole length of the af- 
fected tube. 
The effects of such a lesion upon the parts concerned are often extremely distressing. 
Thus, in the urethra, the obstruction is attended with difficulty of micturition ; in the 
nasal canal, with impediment to the passage of the tears into the nose ; in the oesophagus, 
with difficulty of deglutition. 
The prognosis is, ordinarily, not at all serious, as the obstruction generally admits of 
relief, except when it has been induced by the compression of some internal tumor of an 
enlarged viscus, when it will almost necessarily be irremediable. 
The treatment of the inflammatory form of contraction must be conducted according 
to the general principles laid down in the chapter on the exudation of plasma; by anti- 
phlogistic remedies in the earlier stages of the disease, and afterwards by alterants, rest, 194 
TEXTURAL CHANGES. 
light diet, purgatives, leeches, and a regular, systematic course of dilatation by means of 
bougies, either alone or aided by incision, scarification, or free division of the affected 
structures. Great care must be taken, in the employment of dilatation, to conduct it in 
the most gentle and cautious manner, as the object is to excite the absorbent vessels, and 
at the same time to keep the capillaries, if possible, in a perfectly passive condition. In 
this way riddance is eventually effected of the effused matter, upon the presence of which 
the constriction essentially depends, without the risk of provoking further inflammatory 
deposits. 
SECT. VII FISTUI.ES AND SINUSES. 
A fistula is a narrow track, straight or tortuous, of variable depth, having generally 
two distinct orifices, lined by an adventitious membrane, and bathed with a thin, gleety 
fluid, intermixed with the natural contents of the part, organ, canal, or cavity affected. 
The disease, which is always of a consecutive nature, occurs in different regions of the 
body, and is developed under the influence of various causes. 
Although the abnormal track has usually two openings, one of which is superficial and 
the other deep-seated, yet this is by no means constantly the case. Hence the distinction 
of fistules into complete and partial. The terms recent and old, often used by writers, 
refer merely to the duration of the disease. 
The lesion may occur in almost any situation, but originates most frequently about the 
anus, perineum, face, groin, and mammary gland. Fistule of the neck, thoracic cavity, 
the biliary apparatus, the stomach, colon, and small bowel, kidney, pancreas, and urinary 
bladder, is comparatively rare. It takes place in both sexes and at every period of life; 
but children and young persons suffer much less frequently than the old and middle-aged. 
The nomenclature of fistule is quite extensive. The names are derived either from 
the parts in which the abnormal passage is situated, as anal, perineal, broncho-pleural, 
and recto-vaginal, or from the nature of the discharge, as salivary, urinary, and sterco- 
raceous. 
Fistules vary much in their extent. The longest tracks occur along the spinal column 
in connection with psoas abscess. In this affection, the matter generally escapes at the 
groin, just above Poupart’s ligament, in the upper part of the thigh, or, lastly, in the ileo- 
lumbar region, the channel which is thus established varying in length from six to twelve 
inches, and being always lined by a well-organized, adventitious membrane. Passages of 
considerable length are sometimes met with in the internal organs, as between the kidney 
and lung, between one coil of intestine and another, or between the urinary bladder and 
the cutaneous surface. In other situations, on the contrary, the track is remarkably 
short, being hardly two or three lines from the surface, or from the cavity with which it 
communicates. 
The diameter of these abnormal tracks is also very variable. Sometimes they are so 
small as scarcely to admit the finest bristle; while at other times they are sufficiently 
capacious to receive a goose-quill or the end of the finger. The narrowest tracks usually 
occur in the lachrymal passages, salivary glands, anus, and perineum. It is not often 
that a fistule is of the same uniform diameter throughout; on the contrary, it is almost 
always larger at one point than at another. 
The external orifice, generally of a rounded or oval shape, may be so narrow, on the 
one hand, as to be hardly perceptible; or, on the other, so large as to admit the end of a 
probe, a goose-quill, or a finger. It may have sharp and well-defined margins; be sur- 
rounded by a soft, spongy, florid rim ; or be depressed, inverted, or infundibuliform. The 
number of external orifices varies in different cases, from one to as many as six, ten, or even 
a dozen ; when it is very considerable, the affected surface commonly presents a cribriform 
appearance. 
The internal orifice may be of the same size as the external, or it may be smaller or 
larger. In its shape it is usually irregularly rounded, and it is seldom that it is found 
multiple, even when the number of external openings is considerable. 
Although the direction of the passage may be perfectly straight, yet, in general, it is 
more or less flexuous, serpentine, oblique, or winding. Occasionally it forms nearly a 
right angle with the surface upon which it opens. When several tracks exist, they often 
run together, and terminate, by one common orifice, upon the reservoir with which they 
communicate. 
A fistule, in its recent state, is simply a raw surface bathed with purulent matter. 
It is, in fact, an ulcer, an open sore, a solution of continuity, which must undergo a pro- 
chap. v. 195 
CHAP. V. 
FISTULES AND SINUSES. 
cess of repair before it can justly be entitled to its distinctive appellation. The track, 
however, soon becomes smooth, and is speedily coated with an adventitious membrane, 
varying in thickness from a mere film to half a line, a line, or even the sixth of an inch. 
The new layer, at first soft and easily detached, gradually augments in density, and is at 
length inseparably united to the parts which it serves to line. Its color, like its consist- 
ence, is very much influenced by its age, and by the nature of the secretion or excre- 
tion which passes over it. In its earlier stages it is red, pink, or rose ; in cases of long 
standing, white, gray, or slightly bluish. The free surface of the membrane is smooth 
and polished ; or it is rough, mammillated, or studded with villi of various shapes and 
sizes. The other surface is attached by means of dense connective tissue to the parts 
upon which it lies. Bands of lymph sometimes extend from one side of the abnormal 
channel to the other, very much as in the bridle stricture of the urethra. 
The membrane here described is formed out of the blood-liquor, and is of the same 
nature as the pyogenic membrane of a chronic abscess. Around the anus, in the peri- 
neum, and in some other regions, it bears no little resemblance to mucous tissue, but dif- 
fers from it in having no follicles and no distinct epithelial layer. It is liberally supplied 
with vessels, nerves, and, probably, also with absorbents, is the seat of a constant secre- 
tion of gleety or other matter, and is liable, like all new textures, to inflammation and its 
consequences. In ancient cases it occasionally acquires a dense, fibrous, or fibro-earti- 
laginous consistence. 
The nature of the discharge in this disease varies with the situation of the abnormal 
passage. In general, it is thin and gleety, as in chronic gonorrhoea, and mingled with 
the natural secretions or excretions of the reservoir with which the fistule communicates. 
When, however, the lining membrane labors under inflammatory irritation, the discharge 
is either entirely suspended, or it is bloody, purulent, or muco-purulent. 
The parts in which the abnormal track is situated are variously affected, being some- 
times nearly natural, but more generally firm and callous, from the effusion and organiza- 
tion of plasma, which, when present in large quantity, often completely obliterates the 
meshes of the connective tissue. Owing to this condition, many of the smaller vessels 
are choked up, while those which remain are, when divided, unable to retract, thus be- 
coming not unfrequently a source of considerable hemorrhage. 
The causes of fistules are either mechanical or vital. To the first class belong wounds, 
contusions, and lacerations; to the second, ulceration, gangrene, and abscesses. There is 
a variety of the affection which may be regarded as a remnant of embryonic organiza- 
tion. Its most frequent situation is the antero-lateral part of the neck. Like the ordi- 
nary fistule, it may terminate in a cul-de-sac, or it may have two orifices, of which the 
external is sometimes scarcely visible. The abnormal passage itself is usually very nar- 
row, and seldom extends beyond two or three lines in depth. 
The treatment of fistule must be regulated by circumstances. In recent cases, before 
the passage has become lined by an adventitious membrane, a cure will sometimes follow 
the use of stimulating injections, as a weak solution of nitrate of silver, sulphate of cop- 
per, tincture of iodine, or acetate of lead, repeated twice in the twenty-four hours ; or 
by touching the parts lightly once a day, or once every other day, with solid lunar caustic, 
or with the end of a probe dipped in a solution of acid nitrate of mercury. Strict atten- 
tion should be paid to cleanliness, and the parts should be maintained in a state of abso- 
lute rest. It is seldom, however, that a permanent cure can be effected in this way, espe- 
cially if the fistule be of any extent, or situated where it is influenced by the contraction 
of muscular fibres, as, for example, when it involves the anus. The best plan, in fact, 
nearly always is not to lose any time in vain experiments with these remedies, but at 
once to lay open the abnormal passage in its entire length, so as to afford the parts an 
opportunity of healing from the bottom by the granulating process, a tent being inter- 
posed between the edges to prevent their readhesion. Occasionally a seton may be passed 
through the track, and retained until it ulcerates out. In some forms of fistule, as in the 
vesico-vaginal and urethral, a very delicate operation is generally required in order to ef- 
fect a cure, consisting in paring the margins of the opening and in bringing them together 
by the interrupted suture. 
The healing of a fistule is often materially retarded, if not effectually prevented, by the 
presence of foreign matter, as a mass of dead connective tissue, a loose piece of bone, a 
bullet, or a portion of wadding, or, by the contact of some irritating substance, as urine 
or feces. The indication, of course, is to remove the extraneous matter, whatever it may 
be, and then to manage the case upon the principles just laid down. 196 
CONGENITAL MALFORMATIONS. 
CHAP. VI. 
Occasionally, again, the reparative process may be opposed, at least in part, by deficient 
tone of the system, or by some disorder of the general health. The patient, for example, 
may be anemic from organic disease, intemperance, or want of wholesome air and food. 
Such cases, which are not uncommon in large cities, and in the wards of crowded, ill- 
ventilated hospitals readily suggest their ow n treatment. 
The practitioner is sometimes sorely perplexed in this disease as to whether he should 
attempt a radical cure, or limit his efforts to palliative measures. In general, it will be 
best to let each case be governed by its own rules. When the fistule has been of long 
standing, and has acted all along as a drain upon the system, serving perhaps to counter- 
act some other affection, such as phthisis or a tendency to apoplexy, no operation should 
be practised, since it could hardly fail to provoke mischief. In fact, serious organic dis- 
ease of any kind is a contraindication to an operation. The only exception to this is 
where the fistule is a cause of excessive local distress, completely depriving the patient of 
sleep, appetite, and comfort. Under such circumstances, the surgeon could hardly refuse 
his aid ; but, before doing this, he would be sure to open a newT source of counter-irrita- 
tion, in the form of an issue or seton, in some other and more eligible portion of the 
body, thus establishing a drain at least equal to that which he is about to suppress, as a 
means of temporary mitigation. In ordinary cases there is of course no reason for delay ; 
the operation is promptly performed, and a rapid recovery is reasonably anticipated. 
CHAPTER VI. 
CONGENITAL MALFORMATIONS. 
Congenital malformations, surgically considered, constitute a subject of the deepest 
interest, both because they are of frequent occurrence, and because they generally require 
an extraordinary amount of knowledge and skill for their successful management. Pre- 
senting themselves under different forms or characters, they exhibit every variety of 
grade, from the most simple departure from the normal standard to the most pitiable and 
disgusting deformity, well calculated to elicit the sympathy and aid of the considerate and 
humane surgeon. With a view to a more full appreciation of the nature of these malfor- 
mations, they may conveniently be arranged under the following heads : 1st, deficiency of 
parts; 2dly, redundancy of parts; 3dly, displacements; 4thly, occlusions ; 5thly, devia- 
tions of positions; Gthly, adhesions of contiguous surfaces; 7thly, vascular tumors. 
1st. The first class, consisting of a deficiency of parts, may be subdivided into two 
orders; the one comprehending fissures, or clefts, and the other an entire absence of cer- 
tain structures, as a finger, hand, or ear. 
The most common, and, in a surgical point of view, the most interesting, fissures are 
harelip, cleft palate, bifid uvula, exstrophy of the bladder, epispadias, hypospadias, and 
bifid spine, together with extraordinary patency of the fontanelles. Of these malforma- 
tions some admit of relief by operation, whereas others are hopelessly irremediable; at all 
events, every attempt hitherto made to cure them has either signally failed, or eventually 
destroyed the patient. The operation for harelip is of daily occurrence, and, when pro- 
perly executed, rarely disappoints expectation ; besides, if it fail, it admits of repetition. 
Staphylorraphy has also become a common procedure, which is frequently, if not generally, 
crowned with success. Exstrophy of the bladder, consisting in a deficiency of the ante- 
rior wall of that viscus and of its protrusion at the linea alba, has hitherto, for the most 
part, resisted every means directed for its relief. Epispadias and hypospadias are difficult 
of cure ; and a cleft of the vertebra, with protrusion of the envelops of the spinal cord 
and of the cephalo-spinal liquid is nearly always a fatal affection. The closure of these 
fissures is effected by paring their edges, and approximating them by suture, ultimate 
union being accomplished through the intervention of plastic matter. The tumor in bifid 
spine is emptied with the trocar, and then injected with some slightly stimulating fluid, 
with the hope of exciting obliterative inflammation. In general, the operation is speedily 
followed by convulsions, coma, and death. 
In the second order of cases the deficiency consists in the absence of certain structures, 
as a finger, a hand, or even an entire arm. The,genital organs suffer perhaps more fre- CHAP. VI. 
CONGENITAL MALFORMATIONS. 
197 
quently in this way than any other parts of the body. Tims it is by no means uncom- 
mon to find the vagina absent, or the vagina and uterus, or these organs along with the 
ovaries and Fallopian tubes. Sometimes the testes are wanting, or, if present, they exist 
only in a rudimentary form, perhaps hardly equalling the volume of an ordinary bean. 
The penis, too, may be absent; or, instead of being large and well grown, it may, at the 
age of puberty, be less than that of a child at the eighth or tenth year. 
2dly. A congenital redundancy of structures is sometimes met with, consisting, chiefly, 
in hypertrophy of the integuments of various regions of the body, or in the addition of a 
supernumerary finger, toe, tooth, or ear. To the same category belong the anomalous 
divisions of certain arteries, as the brachial and femoral, high up in their respective limbs. 
A redundancy of skin and connective tissue is most common about the neck, hands, feet, 
and genital organs, as the prepuce and vulva, where the superfluous structures sometimes 
occur in large, pendulous masses. A supernumerary toe, thumb, or finger is no unusual 
occurrence; occasionally each hand and each foot are provided with such an appendage. 
I have seen one well-marked example of four ears. An increase of the natural number of 
teeth is not uncommon. In some of these cases the supernumerary organ is buried in the 
alveolar process of the jaw, where I have known it to be productive of such an amount of 
disease as to require a serious operation for its removal. Most of these malformations 
admit of cure by retrenchment with the knife, and the operation may generally be safely 
executed at an early age. 
3dly. Congenital displacements occur in various parts of the body, but principally in 
the articulations and in the abdominal viscera. The joints which are most liable to this 
form of dislocation are the hip, shoulder, and wrist; but it has also, although very seldom, 
been met with in those of the jaw, clavicle, elbow, and knee. The deformity thus pro- 
duced is often very great, and what aggravates the case is the circumstance that it rarely 
admits of relief, however skilfully and perseveringly it maybe treated. The malformation, 
as will be shown elsewhere, probably begins at an early period of foetal life, and goes on 
gradually increasing until it attains an irremediable stage. 
The most common form of displacement of the abdominal viscera occurs in what is called 
congenital hernia, caused by a want of closure of the inguinal canal during the descent of 
the testis. The consequence is that, soon after the child has begun to breathe, the dia- 
phragm, pressing the bowels against the walls of the abdomen, forces them down into the 
scrotum. The portion of tube thus displaced is generally a loop of small intestine, but 
now and then other organs are pushed down along with it. The most suitable remedy for 
such a defect is steady compression upon the neck of the hernia by means of a well- 
adjusted truss, which generally eventuates in an effusion of lymph, and the obliteration of 
the sac of the tumor. 
4thly. Congenital occlusion may occur in any of the mucous outlets of the body, but is 
much more frequent at the anus and genital organs than anywhere else. Closure, pro- 
perly so called, of the anus may be produced by a continuation of the integument across 
from one buttock to the other; or it may depend upon the existence of a fold of mucous 
membrane situated just within the anus, an arrangement not unlike a hymen. In either 
case, relief may easily be effected by the knife, patency being afterwards maintained by 
the frequent insertion of the finger. The prepuce is sometimes completely impervious, or, 
if an opening be present, it answers very imperfectly the purjKise of an outlet for the urine. 
The vagina is occasionally imperforate, being closed by what is termed the hymen ; and 
there is reason to believe that certain forms of sterility are due to occlusion of the uterus, 
or of the Fallopian tubes. 
5thly. Congenital deviations of position are infrequent. The most interesting, in a sur- 
gical point of view, is the deformity of the nasal septum, which is occasionally so great as 
to interfere materially with the functions of the nose, one of the anterior nares being 
sometimes completely occluded by the projection of the partition towards the correspond- 
ing side. A simple operation, consisting in the removal of the incurvated portion of the 
septum, generally effectually relieves the difficulty. 
There is occasionally a remarkable congenital incurvation of the penis, disqualifying the 
organ for the easy and full discharge of its functions. The defect is always associated 
with hypospadias, and consequent shortening, or imperfect development, of the spongy 
structure of the urethra. An admirable operation for the cure of this deformity, devised 
by Dr. Physick, and successfully performed by Professor Pancoast, myself, and others, 
will be described in the chapter on the genital organs. 
Deviation of position is often associated with permanent contraction or shortening of the 
muscles and tendons, as is seen in club-foot, wry-neck, and analogous distortions. This 198 
TUMORS OR MORBID GROWTHS. 
CHAP. VII. 
class of lesions is one of great practical interest, having opened to the modern practitioner 
a wide field for the exercise of his ingenuity and skill, as well as of his patience. Taken 
in hand soon after birth, they may frequently be promptly remedied by the use of the 
most simple appliances, whereas under opposite circumstances the treatment will gener- 
rally be very tedious, even if aided by the free division of the affected structures. The 
rectification of these malformations forms one of the most interesting chapters in the his- 
tory of subcutaneous surgery, one of the great inventions of modern times. 
fithly. Congenital adhesions most commonly occur between the fingers and toes ; more 
rarely between other parts, as the lids and ball of the eye, the ear, and scalp. The unit- 
ing medium is generally merely a fold of common integument, the severance of which often 
effectually releases the parts from their restraint, and restores them to usefulness. 
7tlily. There is a class of congenital affections, consisting of peculiar vascular tumors 
known as ncevi, or mothers' marks, occurring in different regions of the body, especially the 
head and face, and constituting a very interesting and important form of morbid growths. 
Their composition is variable; sometimes they are essentially composed of dilated and 
tortuous capillary veins, connected by areolar tissue ; at other times they are made up 
mainly of enlarged and diseased capillary arteries; lastly, there is a third species which 
seems to partake of the character of both the others, the two sets of vessels being so inti- 
mately blended as to render it impossible to determine which predominates. 
These vascular growths, however constituted, almost always begin in the substance of 
the skin, from which, as they augment in size, they gradually extend to the connective 
tissue beneath ; they are of a soft, spongy consistence, readily receding under pressure, and 
expanding under mental emotion. Their color is variable; the venous varieties being 
usually of a dark purple, and the arterial of a red scarlet hue. The latter are of a truly 
erectile character, and hence they commonly pulsate, heaving and throbbing synchro- 
nously with the contraction of the left ventricle of the heart. The growth of both varie- 
ties is generally steadily progressive, and the consequence is that they often acquire a 
considerable bulk. 
Most of these morbid growths readily admit of cure, especially if timeously begun. 
This may be effected, 1st, by ligation ; 2dly, by incision ; and, 3dly, by escharotics. 
In regard to the causes of these various malformations, it would be out of place to insti- 
tute any special inquiry into them here. Some of them are doubtless owing to an arrest 
of development, dependent upon defective organization of the germ ; others are probably 
occasioned by irritation of the nervous centres; while others, again, are perhaps due to 
faulty position of the fcetus in the uterus, or violence inflicted upon it during gestation. 
CHAPTER VII. 
TUMORS OR MORBID GROWTHS. 
SECT. I GENERAL OBSERVATIONS. 
Tumors may be arranged under two great classes, neoplasms and cysts. The former, 
which constitute permanent additions, either circumscribed or diffused, to the natural 
tissues or organs in which they take their rise, are simply pathological new formations, 
representing an excess of physiological development and growth under perverted functional 
or nutritive disturbances. Cysts, on the other hand, may be new formations, although 
they usually originate in other ways. 
Morbid growths are now almost universally classified, for the sake of histological 
uniformity, according to their likeness to, or derivation from, the physiological tissues. 
Although this classification has been variously modified by different authors, 1 have, after 
careful consideration, adopted the following arrangement, which has, at least, the merit 
of designating the origin of the neoplasms and the tissues of which they are composed :— 
I. Cystic tumors in general. 
II. Neoplasms in the strict acceptation of the term. 
A. Of these, certain ones are derived from and composed of connective tissue and its 
equivalents, of which two divisions may be made, namely:— 
a. Those which represent perfected or matured connective tissues, and which may, GENERAL OBSERVATIONS. 
199 
CHAP. VII. 
therefore, be termed typical. These comprise lipoma, or fatty tumor; fibroma, or fibrous 
tumor; chondroma, or cartilaginous tumor; osteoma, or osseous tumor; and lymphoma, 
or lymphatic gland-like tumor. 
0. Those which represent embryonic, immature, or unripe connective tissue, and which 
may be termed atypical, as they do not find their analogues in the adult organism. They 
are limited to sarcoma and myxoma. 
B. The second division of neoplasms includes those which are derived from and are 
composed of higher tissues. These are, first, myoma, or muscular tumor; secondly, 
angioma, or a tumor composed of bloodvessels ; thirdly, lymphangioma, or a tumor made 
up of lymph vessels; and, fourthly, neuroma, or a tumor composed of nerve tissue. 
C. The third and last division of neoplasms comprise those which proceed from, and 
are formed essentially of, epithelium. Like the connective tissue growths, they may be 
separated into those that are typical and those which are atypical. 
a. The typical epithelial formations embrace, first, papilloma, or papillary tumor, 
which has its physiological representative in the papillae of the cutaneous, mucous, and 
serous surfaces; and, secondly, adenoma, or glandular tumor, which has its physiological 
type in the secreting glandular organs. 
*3. The atypical epithelial new formations are confined to the genus carcinoma, super- 
ficial and deep-seated, with its various divisions. 
All neoplastic formations, considered in a general point of view, are governed by two 
great fundamental laws. The first, originally enunciated by J. Muller, of Berlin, teaches 
that the constituents of all morbid growths have their types, representatives, or analogues 
in the normal tissues of the organism, either in their embryonic state, or in a state of 
complete development. The other, enunciated by Virchow, declares that the cellular 
elements of all neoplasms have their origin in preexisting cellular structures. That these 
doctrines are strictly true, all modern pathologists admit ; but it is not true, as Virchow 
asserts, that the cells of the majority of the neoplastic formations are invariably derived 
from those of the connective tissue. Carcinomatous tumors, for example, owe their 
origin to abnormal multiplication and extension of epithelial cells, and, as is well known, 
wandering cells play an important part in the development of morbid growths. 
If these doctrines be accepted, it follows, as a necessary corollary, that all tumors must 
be in great degree, if not entirely, homologous, and, therefore, that the term heterologous 
is inapplicable. If, however, the entire structure, and not the individual elements, be 
regarded as the criterion of heterology, the term should be retained, as there are not a 
few neoplasms which have no analogues among the normal textures. In point of fact, 
the so-called homologous growths are for the most part so unlike the physiological tissues 
that the similarity merely amounts to mimicry. Nothing could deviate more from the 
normal glandular type than carcinoma, the cells of which extend into the surrounding 
parts in such a way that the picture is entirely unlike that of the tissue from which it is 
derived. Through the excessive preponderance and peculiarities of form and grouping 
of the cells of sarcoma a structure is constituted which is not similar to any matured tissue. 
Hence the carcinomas and sarcomas must be regarded as heterologous growths. It 
should, however, be stated that the term heterology is employed by Virchow in an 
entirely different sense, and that his views have met with general acceptance. lie teaches 
that heterology may be applied to the homologous formations in the sense of misplace- 
ment, as a fibroma, for example, in a bone; and he says, “ Heterologous structures, when 
considered in reference to their points of origin, may easily be separated from the homo- 
logous ones by their deviating from the type of the part in which they arise. When a 
fatty tumor is met with in adipose tissue, or a fibrous tumor in connective tissue, the type 
followed in the formation of the new structure is homologous to the type followed in the 
formation of the old one. All such new growths are included under the term hyper- 
plasia ;” and it is a law that hyperplasia produces a tissue similar to that of the original 
part. “ Ileteroplasia engenders histological elements which correspond, indeed, to natural 
forms, but these elements do not arise in consequence of the proliferation of such as pre- 
viously existed, but in consequence of a change in the original type of the parent tissue.” 
Thus, chondroma of the testicle or of the parotid gland, and osteoma of the connective 
tissue, are heteorologous tumors, since neither cartilage nor bone are normal to these 
structures. The original unity of all the tissues emanating from the middle leaflet of the 
blastoderm explains how tumors derived from the connective tissue can transform them- 
selves one into the other; but in such cases we have to deal with a change in the local 
histological type, which may be expressed by the term metaplasia. From these state- 
ments it follows that the same variety of tumor may be homologous or heterologous. A 200 
TUMORS OK MORBID GROWTHS. 
CHAP. VII. 
chondroma, for example, arising from cartilage is homologous, from bone heterologous ; 
an osteoma of a bone is homologous, but heterologous when met with in the brain. In 
considering, therefore, the question of tlie homologous or the heterologous nature of 
neoplasms, attention is not paid to the “composition of the structure as such, but only to 
the relations which subsist between it and the parent soil from which it springs.” Hence 
the term heterologous may be applied to a tumour when it differs from the tissue in which 
it is situated ; and the terms homologous and heterologous as formerly employed may be 
substituted by the terms typical and atypical, which I have already used in the classifi- 
cation of neoplasms. By a typical growth is meant one in which a determined model is 
followed, so that there is a tumor-like reproduction of apparently normal tissues. In the 
atypical growths the elements are not arranged upon the physiological type, but they 
deviate in form, size, and grouping from the normal structures, and represent irregular 
proliferations. 
The development and growth of neoplasms depend essentially upon the proliferation of 
preexisting cells and their descendants, either through direct hyperplasia and the primary 
production of the typical forms of the mother tissue, or after the model of embryonic 
tissue-formation, and their final conversion into the tissue of which the tumor is composed. 
Having once started, the tendency of the new growth is to persist and increase, either by 
central growth, that is, by fresh additions through the progressive multiplication of its 
own cells, as occurs in the perfected histoid tumors, or by peripheral extension or the 
formation of fresh foci in the contiguous structures, as is witnessed in carcinoma. In the 
first mode of increase the neoplasm is circumscribed and frequently encapsuled ; in the 
second it infiltrates and destroys the adjacent tissues. 
Although the tendency of most neoplasms is to persist unchanged, they are liable to 
the same diseases as the normal textures, as is evinced by their inflaming, suppurating, 
ulcerating, and even dying. They are likewise subject to various degenerations and 
transformations, as the fatty, caseous, mucoid, colloid, cystoid, pigmentary, telangiectatic, 
calcareous, and osseous. These changes give rise to certain subdivisions, and are often 
employed as prefixes to indicate the nature of the transformations or degenerations which 
have occurred, or designate the existence of certain subordinate tissues. 
Neoplasms occasionally change their anatomical character, or are converted into tissues 
of a different kind. Thus, a simple melanoma, or pigmented nan us, may form the start- 
ing point for a sarcoma or a carcinoma; a lipoma may pass into a myxoma, or a myxoma 
into a lipoma, and a fibroma, particularly of the breast, is frequently transformed into a 
sarcoma. 
A morbid growth may be benign or malignant, that is, it may simply incommode by 
its situation, weight, or bulk, or it may, after a certain period, as the result of its infec- 
tious nature, destroy not only the part in which it appears, but also the patient. The 
neoplasms wdiich evince malignant attributes are carcinoma, sarcoma, myxoma, and 
certain kinds of lymphoma. 
Occurring at nearly all periods of life, and in nearly all the organs and tissues, the 
malignant and benign formations possess certain features in common with each other ; a 
circumstance which renders it necessary to study them in a general point of view. Such 
a proceeding, indeed, is indispensable to a correct appreciation of the structure, diagnosis, 
and treatment of these affections. The principal points to be considered, in connection 
with these topics are, first, the physical properties of the morbid growth ; secondly, its 
relations to the surrounding parts ; and, thirdly, its history. 
1. It would be difficult to point out any situation in which tumors may not occur. 
Glandular carcinoma is most common in the mamma, liver, and mucous follicles. Epithe- 
lial carcinoma has a peculiar predilection for the cutaneous and mucous textures at the vari- 
ous outlets of the body. Sarcoma is most frequent in the subcutaneous and intermuscular 
connective tissue, the periosteum, bones, and the salivary and mammary glands. Benign 
tumors are usually met with in the skin, connective tissue, ovary, uterus, prostate, and 
nose. Hydatid formations occur chiefly in the liver, breast, testicle, ovary, and bones. 
Tumors affect various forms, depending upon the nature and amount of resistance 
offered to their development, and also, in some degree, upon the shape of the parts wherein 
they originate. A sebaceous tumor is generally globular ; a fatty, either flat or pendulous; 
a polypoid fibroma or myoma, pyriform, conical, or pedunculated. Malignant growths 
are commonly distinguished by the irregularity of their surface, which is often lobulated, 
or marked off into ridges and depressions. Certain tumors occur in the form of excre- 
scences, as the warts on the hands of children, the venereal growths on the penis and 
vulva, and the so-called cauliflower cancer of the uterus. GENERAL OBSERVATIONS. 
201 
CHAP. VII . 
In their volume, tumors range, in every possible gradation, from a millet seed, as in 
the little granule on the eyelid, to that of the patient’s body, as in ovarian cysts and 
elephantiasis of the scrotum, those enormous masses which are sometimes absolutely more 
bulky and heavy than the subject in whom they are developed. Fatty, fibrous, cartila- 
ginous, and osseous tumors occasionally acquire a large size, but they are almost the 
only ones of their class that do. Among the malignant tumors, those which attain the 
greatest volume are the encephaloid sarcoma and colloid carcinoma ; scirrhous, mela- 
notic, and other formations of this description are usually comparatively small. 
Tumors vary in number ; generally they are solitary, but they may be multiple, de- 
pending upon their character and the nature of the organ in which they are developed. 
Osseous, fatty, and sebaceous tumors occasionally exist in large numbers, whereas most 
of the other innocent growths are commonly solitary. Sarcomatous and carcinomatous 
tumors are seldom multiple, except in their secondary forms. Tumors that are multiple 
from their outset are seldom malignant. 
With respect to their consistence, some tumors are soft, some solid, some semisolid. 
Tumors containing serous fluid, as hygromatous cysts of the neck and ovary, are always 
soft and fluctuating, unless they are overlaid by a large quantity of solid substance, when 
they may partake of the latter character even more than of the former. Fibrous, carti- 
laginous, and osseous tumors are known by their great hardness, which equals that of the 
natural structures. Scirrhus is the most firm of the malignant formations, its name 
being derived from that circumstance. Occasionally one portion of a tumor is soft, 
another hard, and a third, perhaps, semiliquid. Ovarian growths exhibit these varieties 
of consistence more frequently, and in a more perplexing degree, than any other, whether 
benign or malignant. 
The color of a tumor is generally a matter of secondary consideration, as the morbid 
growth is seldom sufficiently exposed to admit of direct inspection, except in some of the 
mucous outlets. In the early stage of all formations of this kind that take place beneath 
the external surface of the body, there is usually an absence of discoloration, and it is 
only when the growth bears too heavily upon the integument, pushing it out and stretch- 
ing it in every direction, or when it manifests a disposition to ulcerate and evacuate its 
contents, that it renders the skin red, livid, or purple. In tumors of the nose, mouth, 
throat, vagina, uterus, and anus, color often affords great assistance in the discrimina- 
tion of the case. A gelatinoid polyp can never be mistaken for a fibrous one, as its 
complexion is always diagnostic of its character. It may be assumed, as a law, that 
the lighter a tumor is externally the greater is the probability of its being benign, and 
conversely. 
Mobility is an important quality in a tumor, its amount varying according to the nature 
of the affected organ and the degree of resistance offered by the surrounding parts. Some 
morbid growths are never movable, others always are, whatever their age, volume, or 
situation. A sebaceous tumor never contracts such firm adhesions that it cannot be pushed 
about; while an exostosis is always immovable from first to last. 
Tumors are endowed with various degrees of sensibility, depending upon the peculiarity 
of their structure and the amount of compression exerted upon them by the parts in which 
they are developed. Most of them, whether innocent or malignant, are free from pain 
during their earlier stages; but, as they increase in size, they encroach upon the neigh- 
boring tissues in such a manner as to interfere with their movements, and thus seriously 
compress their nerves, whilst the tissues, in their turn, more or less compress the nerves 
of the advancing mass. Occasionally the pain is characteristic,as,for example, in scirrtius 
of the mammary gland. Fatty tumors and cystic tumors of the skin are usually entirely 
free from pain ; or, if pain attend their progress, it is the result purely of accidental cir- 
cumstances. The subcutaneous tubercle is essentially a painful growth from first to last; 
occasionally the suffering is of a neuralgic character, and extremely distressing by its 
constancy and severity. 
2dly. In regard to the relations which tumors bear to the surrounding structures, 
several circumstances deserve to be noticed. The first is the manner in which they are 
bound down, or inclosed in their habitation. Every tumor must necessarily have an 
appropriate residence, but like a settler in a new country, it is seldom content with 
the spot originally assigned to it. On the contrary, soon lacking room, it encroaches 
upon, frets, and worries the parts around it, which are not slow to resent the invasion. 
Mutual oppression and discomfort must be the necessary result of such invasion. For a 
while the healthy structures successfully resist the intrusion, but as they yield, the enlarg- 
ing mass often converts the muscles into mere ribbons and the bones into mere shells. 202 
TUMORS OR MORBID GROWTHS. 
Function, too, may be seriously interfered with ; the ranula filling the mouth, the goitre 
compressing the neck, the myoma occluding the womb. 
In the second place, the tumor, as it progresses, is liable, either by its continued pressure 
upon the overlying parts, or by the gradual decay of its own structures, to produce ulcera- 
tion, followed by more or less discharge. This tendency, although most conspicuous in the 
malignant formations, is also witnessed in some of the benign, as the encysted and adipose. 
Large vessels are sometimes laid open during the progress of the affection, thereby in- 
ducing copious hemorrhage. 
Tumors often occasion serious disease in the surrounding lymphatic glands. This is 
particularly true of carcinomatous tumors, in some of which it forms a very conspicuous, if 
not an unmistakable, feature. Thus, in carcinoma of the tongue, breast and testicie, 
especially when the disease is fully developed, there is always marked enlargement of the 
glands, respectively, of the neck, axilla, and groin, either from actual invasion by epithe- 
lial cells, or from the effects of sympathetic irritation. 
Finally, an intimate sympathy exists between tumors and the constitution, operating at 
one time beneficially, at another prejudicially. The progress of malignant growths is 
frequently stayed for months and even years, simply by attention to the general health ; 
on the other hand, it is often astonishingly hastened by disorder of the system, and, in 
fact, by whatever has a tendency to produce derangement of the secretions, especially 
those of the liver, uterus, and kidneys. 
3dly. The history of the case often furnishes important points of comparison. Tumors 
occur at all periods of life, in all classes of persons, and in all varieties of temperament. 
Certain forms of malignant disease, however, are most common at one period, and others 
at another. Thus, carcinoma is almost peculiar to elderly subjects, while sarcoma is most 
frequent between the ages of twenty and forty. The lymphomatous tumor is most common 
in childhood and adolescence. Benign growths of every description are often observed in 
early life, some, indeed, being even congenital; but the greatest number by far occur in 
young adults. 
The distinction between innocent and malignant tumors, and between different tumors 
of the same class, is often extremely difficult, and occasionally, for a time at least, imprac- 
ticable. For this reason great care and patience are frequently required in order to 
prevent mistake. Rapidity of growth, great bulk, increase of temperature, a pulpy consist- 
ence, firm and extensive adhesions, and early lymphatic involvement, imply inordinate 
vascularity, and lead to a suspicion of malignancy. There is no tumor, except, perhaps, 
the round-celled sarcoma, that acquires so large a bulk in so short a time as the encepha- 
loid carcinoma, and there is certainly none that is more surely fatal. Ovarian cysts, of the 
non-malignant type, often grow very rapidly, and are capable of attaining an enormous 
size. Sebaceous, fatty, and osseous tumors, on the contrary, usually advance slowly, and 
occasionally enjoy even a considerable period of repose or inactivity. 
Tumors situated immediately over or around an artery generally receive a distinct im- 
pulse from the shock imparted to them by the blood. Such tumors, which are very liable 
to be mistaken for aneurisms, are called pulsating tumors, and are most common in the 
neck, abdomen, groin, and ham. 
The phantom tumor, as it is termed, is only met with in the abdomen, chiefly in ner- 
vous, hysterical women, although it is not peculiar to the female sex; and depends, in 
most cases, partly upon the contraction of the muscles and upon a fat, plump state of the 
belly, but mainly, and often almost exclusively, upon an accumulation of gas and feces in 
soitie particular portion of the bowel, especially the large. The best and surest diagnostic 
of such a tumor is chloroform, under the relaxing influence of which it always speedily 
vanishes, the muscles becoming soft and flaccid, and the spine distinctly traceable under- 
neath. 
The structures immediately around morbid growths, especially the malignant, and the 
larger and more rapidly developing innocent, are habitually congested; and hence such 
tumors are usually a source of great pain and inconvenience. For the same reason 
operations undertaken for their removal are often unavoidably attended with copious 
hemorrhage. 
It is not often that a tumor disappears spontaneously, although such an occurrence is 
not impossible; and there are several ways in which it may be effected, as by absorption, 
enucleation, ulceration, and gangrene. The first of these modes of cure is the most com- 
mon ; and one of the best examples of it is witnessed in the lymphmatous tumor, so fre- 
quent in the neck and about the angle of the jaw in strumous children, from exposure to cold 
and derangement of the digestive organs. The disease essentially consists in an inflam- 
CHAP. VII. 203 
CHAP. VII. 
GENERAL OBSERVATIONS. 
matory enlargement of one or more lymphatic glands, which, after having perhaps existed 
for years, tinally disappear without any assignable cause, merely, as it would seem, in 
consequence of an improved state of the general health, and of a change in the nutrition 
of the part. 
Sometimes a tumor is enucleated, and drops off, leaving perhaps merely its inclosing 
cyst. It is thus that the fibrous tumor of the uterus is occasionally detached ; and a 
similar accident may happen to an exostosis, particularly if it be large and situated upon 
the skull. In such cases the vascular connection between the morbid growth and the 
circumjacent structures is probably, as a preliminary step, in great degree, destroyed, so 
that the tumor, gradually dying and acting as a foreign body, is at length cast off by the 
living tissues. 
A cure is occasionly effected by profuse suppuration, or, more correctly speaking, by 
suppuration and ulceration. The kind of tumor most easily influenced in this way is the 
lymphomatous, which is completely disintegrated and broken down, or it is dissected off by 
ulcerative action, and is finally detached as an effete substance. 
Lastly, gangrene seizing upon a tumor, may so interfere with its circulation as effectu- 
ally to destroy its vitality. Such an occurrence, although very rare, may take place in a 
malignant as well as in a benign growth. An elderly lady, a patient of mine, had scirrhus 
of the mammary gland, which, after having gone on for upwards of a year, was suddenly 
attacked by gangrene, and in less than a week it dropped off in the form of a black slough, 
leaving in its stead a large excavated cavity. 
It is still a mooted question whether there is a class of tumors intermediate between 
those so frequently referred to above, to which, scientifically considered, the term semi- 
malignant is properly applicable. I am not myself inclined to accept such a division ; 
for the reason that, while it is difficult, if not impracticable, in many cases, clearly to 
define the boundaries between innocent and malignant formations, it is impossible to form 
any conception of such an occurrence. A tumor must be one thing or another, either 
innocent or malignant; it cannot be semiinnocent or semimalignant, although, as it 
respects portions of the same growth, one may be of this structure and another of that, as 
is occasionally witnessed in what is termed a combination tumor. A tumor may appa- 
rently be innocent so far as its autological phenomena are concerned, and yet be found, 
upon microscopic examination, to be malignant. A sarcoma is often as malignant as the 
worst form of carcinoma; and it must not be forgotten that a tumor originally benign 
may, in the course of time, assume the most destructive type. 
Certain tumors, as, for example, the fatty, are composed chiefly, if not wholly, of a 
single tissue, and are hence designated as histoid. When the number of structures is 
greater, the term organoid is employed ; while teratoid is the expression used when the 
formation is unusually complex, as when it represents the highest type of organization 
and development. The combination tumor, consisting of a union of several morbid 
growths, ingrafted, as it were, upon one another, is sufficiently common. Formations of 
an entirely different character, as the naevoid, cystic, fatty, fibrous, calcareous, and osseous, 
are thus occasionally associated in the same morbid mass, especially in the old, retro- 
gressive forms. 
The distinction between acute and chronic tumors is well founded. Most of the so- 
called innocent tumors are characterized by slowness of growth ; now and then, however, 
a case is met with in which the development is very rapid, the morbid mass acquiring, 
perhaps in the course of a few months, a very extraordinary weight and bulk. To such 
a growth the term acute is applied, in contradistinction to the more ordinary chronic 
forms. Malignant tumors, as the different varieties of carcinoma and the worst types of 
sarcoma, generally possess a remarkable proliferating power, often advancing with fright- 
ful celerity. 
The etiology of tumors is not well understood. That inflammation is frequently con- 
cerned in their production is unquestionable, a view which I have long entertained, and 
which is also held by Virchow, Samuel, Wagner, Birch-Hirschfeld, Cornil and Ranvier, 
Woodward, Formad, and others. In many cases, indeed, both of innocent and malig- 
nant tumors, their origin is directly traceable to the effects of injury, as a bruise or con- 
tusion. Keloid tumors often supervene upon burns, scalds, and other lesions ; epithelial 
growths are very common at those parts of the skin and mucous membranes which are 
habitually exposed to irritation ; and the influence of long-continued pressure in pro- 
ducing carcinoma is well exemplified in the undescended testicle compressed by the 
walls of the abdomen. In the great majority of cases, however, tumors of every descrip- 204 
TUMORS OR MORBID GROWTHS. 
CHAP. VII. 
(ion arise without any assignable cause. Examples of hereditary neoplastic formations 
are uncommon. 
All forms of tumors occasionally manifest a disposition to return after extirpation, the 
secondary growths constituting what are called recurrent tumors. This tendency is not, 
as was formerly supposed, by any means peculiar to malignant growths, as the different 
varieties of carcinoma and sarcoma; innocent tumors also occasionally exhibit it. With 
respect, however, to the latter, there is good reason to believe that recurrence is generally 
due to imperfect removal. Every surgeon has witnessed examples of recurrence after 
the excision of an ordinary sebaceous tumor of the face and scalp. The smallest fragment 
that is left behind in such a case must necessarily serve as the nucleus of a new growth, 
which may eventually attain the same bulk as the original. Proliferous cysts, chon- 
dromas, nrevoid angeiomas, and myxomas, all, at times, manifest this disposition. In 
none of the morbid growths, however, is it so frequent, or so conspicuous, as in carcinoma 
and sarcoma, in the former of which it is always malignant, with a certainty of the early 
destruction of the patient, whereas, in the latter, the tumor may recur again and again, 
perhaps as often as three, five, or even six times, at intervals of several years, and death 
at last be produced by some other disease. 
The recurrent growth may, in structure, be essentially like its predecessor, or it may 
exhibit typical variations ; not, however, so striking as to constitute material departures. 
The likeness to the parent still exists, at all events in certain parts, even when the new 
tumor assumes the character of malignancy. The new growth may appear at the site of 
the primary one, as, indeed, it most generally does, the cicatricial tissues seemingly 
serving as the starting-point. Not unfrequently, as in carcinoma, it selects the lymphatic 
glands. Occasionally an internal organ is involved, entirely unlike the original both in 
structure and function. Properly speaking, however, this is not a recurrence, conse- 
quent upon the removal of the primitive growth, for the same causes that may produce a 
tumor in one organ may produce a similar tumor in another, either simultaneously or 
consecutively. In strictness of language, the term recurrent should be limited to the 
new growth that occurs at the seat of the parent one. All other formations should be 
regarded as coincident or accidental, uninfluenced, so far as their exciting causes are con- 
cerned, by the one removed. 
The secondary formations so often witnessed in the lymphatic glands, and in some of 
the internal organs, as the lung and liver, after the removal of carcinomatous and sarco- 
matous tumors, have their origin in cells that are detached from the original growth, and 
that wander about, as it were, in search of new homes, their transmission being effected by 
the lymphatic vessels, and probably, also, at least in many cases, by the veins. Such for- 
mations are now generally known by the somewhat equivocal name of metastatic tumors, 
and the state of the system, under the influence of which they are developed or general- 
ized, as the infectious dyscrasia. 
When a tumor that is originally innocent assumes a malignant character, the occur- 
rence usually manifests itself by a rapid increase of bulk, by more or less serious encroach- 
ment upon the adjacent structures, especially the lymphatic glands, by a tendency to 
ulceration, by an impoverished condition of the blood, and by a constitutional dyscrasia, 
which becomes more and more conspicuous as the disease progresses. 
Death from tumors may be occasioned by sheer malignancy, by the injurious effects 
exerted by the morbid growth upon important structures in its neighborhood, by second- 
ary formations, by profuse hemorrhage, and by various other causes, as excessive suppu- 
ration, hectic irritation, pyemia, and erysipelas. 
SECT. II. CYSTS AND CYSTOMAS. 
Cysts are sacs filled with more or less fluid contents. They may be classified in ac- 
cordance with their mode of development, first, as retention cysts, or those which arise 
from the retention and accumulation of the normal secretion of glands ; secondly, as exu- 
dation cysts, or those which result from the distension of closed cavities; thirdly, as der- 
moid cysts, or those which arise from foetal inclusions; fourthly, as cystomas, properly so 
called, or cysts of new formation, which are possibly due to cystic degeneration of the 
cells of the connective tissue; fifthly, as extravasation cysts, or those which form around 
effused blood; and sixthly, as hydatid cysts. It will be seen that I have excluded from 
this nomenclature the so-called softening cysts, which represent the fatty, mucous, and 
colloid degenerations of the tissues of the various neoplasms, thereby constituting the 
cystoid neoplasms. The proliferous cysts are also discarded, since, as for example, in the CYSTS AND CYSTOMAS. 
205 
CHAP. VII. 
mammary gland, they are merely solid projections of variously shaped masses into the 
deformed and enlarged duets from the tissues which compose the original growth. As 
they are secondary changes, the neoplasms in which they are found are distinguished by 
the prefix cystic. 
The cystic formations are not only of very frequent occurrence, but they are capable of 
acquiring an extraordinary bulk. Their contents, which are of a singularly diversified 
character, may be either solid, semisolid, or liquid. Occurring in nearly every organ and 
tissue of the body, they are particularly liable to arise in the skin and mucous membranes, 
the glandular organs, as the breast, testicle, liver, and the ovaries, and in the subcuta- 
neous connective tissue. While no period of life is exempt from them, they are most 
common between the ages of twenty and forty-five, especially in females, who are also 
more subject to them than males, and in whom they frequently attain an enormous vol- 
ume. Occasionally they have an intra-uterine origin, and in many cases they arise soon 
after birth. 
1. Retention Cysts Retention cysts consist merely of a thin cyst, sac, or bag, 
occupied by the natural secretion of the affected part, more or less altered by its protracted 
retention. An excellent type of this variety of morbid product is afforded by the so- 
called sebaceous tumor, which, in reality, is nothing more than a sebaceous follicle of the 
skin, in a state of hypertrophy from the occlusion of its orifice, and the consequent reten- 
tion of the sebaceous matter. The immediate cause of the obstruction is inflammation, 
causing obliteration of the outlet of the follicle, and thus constituting the first link in the 
chain of morbid action. The second is the retention of the normal secretion of the follicle, 
which, being tightly pent up, undergoes important changes, both in its physical and 
chemical properties, leading to irritation, and sometimes even to inflammation of the sac, 
which, gradually enlarging before the accumulating and burdensome mass, at length 
forms a tumor perhaps as large as a medium-sized orange. The cystic tumor that is 
sometimes found upon the lower lip and upon the vulva arises in a similar manner. Ranula 
owes its origin to a like cause. Obstruction of a lactiferous duct may give rise to the 
cystic milk tumor of the breast. In the cysts which occur in the liver and kidney, the 
mode of formation is extremely simple, the hepatic and renal ducts being at first con- 
stricted, and finally, in many cases, obliterated by interstitial inflammation. 
The contents of retention cysts must necessarily vary, as may be gathered from what 
precedes, according to the structure and functions of the affected part. Thus, in the 
mamma it contains milk, in the ranula saliva, and in a sebaceous formation sebaceous 
matter; altered, in every instance, in its physical and chemical properties. The cyst 
itself may be either solitary or multiple, and is generally composed of a single layer of 
connective tissue, its external surface, which is rough and fiocculent, being more or less 
firmly adherent to the surrounding tissues, while the internal one, lined by epithelium, 
is usually smooth, shining, or glossy, without septa, and in immediate but loose contact 
with the proper contents of the tumor. It varies in thickness from the merest film up to 
that of a stratum several lines in depth. In cases of long standing it is occasionally par- 
tially converted into a substance resembling fibro-cartilage, cartilage, bone, or earthy 
matter. 
Retention cysts are most appropriately described according to the nature of their con- 
tents, as serous, mucous, salivary, oily, milky, seminal, and sebaceous. 
a. Serous cysts, the most common of all, are met with in all situations and at all periods 
of life, in their most simple as well as in their most complex form. Many of them are 
congenital, especially the more simple varieties, and not a few make their appearance 
soon after birth. Their most common seat is in the mammary gland, the liver, the kid- 
ney, the ovary, and the testicle. 
The contents of these cysts are, as their name implies, generally of a thin, watery 
character, slightly saline in taste, and coagulable, in whole or in part, by heat and acids, 
thus showing that they are composed largely of albuminous material. The color is not 
always uniform. In the smaller and younger cysts the fluid is usually transparent, or 
clear and limpid, like well water; under opposite circumstances, on the contrary, it is 
often quite turbid, muddy, greenish, milky, or snnguinolent. In protracted jaundice I 
have occasionally found it to be of a pale lemon tint, evidently caused by the presence of 
bile; and in suppuration, to which, in certain situations, the cyst is very prone, the fluid 
is always intermixed with pus and lymph. The contents of certain serous cysts sometimes 
coagulate spontaneously on exposure to the air. Their walls are commonly thin, and 
originally translucent, if not actually transparent; but as they grow older they increase 
in thickness and density, and present an opaque appearance. Connective tissue, lined by 206 
TUMORS OR MORBID GROWTHS. 
CHAP. VII. 
pavement epithelium, forms the essential basis of their structure, which, in cases of long 
standing, is often partially transformed into fibroid substance, with, here and there, per- 
haps, a minute calcified patch. 
/3. Mucous cysts occur chiefly in connection with the glands of the mucous membranes, 
those more particularly of the lips, the cheeks, the vulva, the vagina, and the uterus. 
Mucous cysts are occasionally developed in the maxillary sinus, in different portions of 
the alimentary canal, and in the glands situated in the posterior wall of the trachea, form- 
ing small projections between that tube and the cesophagus. They have also been 
observed in the. larynx and upon the epiglottis. 
The contents of mucous cysts are nearly always of a thick, ropy, glutinous consistence, 
intermixed with epithelial matter, and numerous corpuscles closely resembling white blood 
corpuscles. In the more recent cases the contents are thin and clear, like normal mucus 
or the white of an egg. Occasionally they bear a strong resemblance to the fluid of a 
synovial burse; Paget has seen it of the color of the ink of the cuttle-fish ; and in some 
cases, as those observed by Hawkins and Lebert, it has the aspect and consistence of thin 
fecal matter. 
The cyst-wall is generally thin and composed of a single layer, smooth internally, lined 
by epithelium, and intimately adherent to the parts around by dense connective tissue. 
In shape, such tumors are usually spherical or pyriform, and in volume they range from 
a pea to a large fist or even a foetal head, as is occasionally seen in the vulva and the 
vagina. Old mucous cysts of the genital organs are prone to inflammation and suppuration. 
y. Salivary cysts are peculiar to the salivary glands, being most frequent in the sub- 
lingual gland, constituting there what is known, surgically speaking, as ranula. A tumor 
of this kind, of considerable size, occasionally forms in the duct of Steno, from the occlu- 
sion of its orifice. The contents of these cysts are thick and ropy, like the white of egs, 
and consist essentially of saliva, mixed with a large quantity of mucous and epithelial 
matter. 
a. Cysts containing milk, sometimes of considerable bulk, are liable to form in the 
mammary gland during the process of lactation. At least half a dozen such cases have 
fallen under my observation, mostly in young females, within the first six or eight months 
after parturition. Obstruction of one or more of the lacteal ducts, from inflammatory 
deposits or inspissated milk, is the immediate cause of the formation. The size of the 
cyst is variable. In a case recorded by Scarpa, it was enormous, the contents amounting 
to upwards of one gallon. The fluid may be pure and perfectly liquid, or it may be com- 
bined with caseous and epithelial matter. 
s. Oil cysts are uncommon. They are usually quite small, and are generally due to 
advanced fatty degeneration of the epithelium of sebaceous cysts and of milk globules. 
Hence they are generally seated in the skin and breast. In one case, that of a young 
woman, I met with a cyst of this kind in the mammary gland partially filled with oil and 
a material strongly resembling curds, the result evidently of altered and disintegrated 
milk. The oil, on exposure to the air, sometimes congeals into a substance not unlike 
lard, containing acicular crystals of palmitine and stearine. 
£. Seminal cysts are frequently confounded with hydrocele of the cord. The fluid from 
which they derive their name is chiefly composed of turbid serum, holding the character- 
istic spermatozoa, which can only be distinguished by the aid of the microscope, as it 
were, in suspension. Such bodies are occasionally contained in the fluid of ordinary 
hydroceles, but the only true spermatoceles, or seminal cysts, originate in dilatation of the 
seminal tubes in the vicinity Of the head of the epididymis. 
rj. Sebaceous cysts comprise milium and comedones, which arise in the hair -follicles 
and contain epidermis; and steatoma or atheroma, which consists of an accumulation of 
sebum and epidermis in a sebaceous gland. As these formations are fully discussed 
among the tumors of the skin, their further consideration here need not detain us. A 
substance of a whitish pearly aspect is sometimes found in these cysts, described by 
some authors under the name of pearly tumor or cholesteatoma. The contents consist 
essentially of a white, dry, fatty substance, composed partly of epithelial cells and partly 
of cholesterine and palmitine and stearine, the whole being inclosed in a cyst of variable 
size and form. The growth, hitherto observed chiefly in the temporal bone, cerebellum, 
testicle, and ovary, is very uncommon. 
II. Exudation Cysts Cysts which result from the accumulation of the contents of 
preexisting closed cavities or cavities which are not provided with an excretory duct are 
known as exudation cysts. Among the most characteristic types of these formations are 
the synovial cysts, ordinarily known as ganglions and burses, which are so common in the 207 
CHAP. VII. 
CYSTS AND CYSTOMAS. 
synovial sheatlis of the tendons of the wrist and on the front of the patella, the latter 
constituting the so-called housemaid’s knee. In the sheaths of the tendons and the 
natural burses the abnormal development is caused by the transformation of the cells in- 
closed in the fringe-like processes of the synovial membrane. 
The volume of these cysts is generally small, and in their form they are, for the most 
part, rounded, globular, or hemispherical. In the sheaths of the tendons cysts of this 
kind have occasionally a tuberculated, knobby, or constricted appearance, as if they were 
divided, as, indeed, they not unfrequently are, into several compartments. The structure 
of the cyst-wall varies from simple connective tissue to fibroid, or even fibro-cartilagi- 
nous tissue, age and pressure being the principal modifying circumstances. Their con- 
tents may be serous, mucous, glutinous, colloid, or of jelly-like consistence, and of a 
whitish-opaque appearance. The so-called ganglionic cysts of the sheaths of the tendons, 
especially those of the wrist, often contain great numbers of small, free bodies, resembling 
cucumber seeds in shape, composed of compact connective tissue, and developed evidently 
under the influence of long-continued pressure and friction. Bursal cysts are very prone 
to inflame and suppurate; their walls are often very thick, and their inner surface occa- 
sionally exhibits a peculiar retiform appearance, the effect of inflammatory deposits. 
III. Dermoid Cysts—Cutaneous or dermoid cysts differ from sebaceous cysts in not 
being originally provided with an excretory duct, and in the composition of their walls, 
which contain all the elements of the cutis. They are always congenital, and are usually 
seated in the connective tissue around the orbit, root of the nose, floor of the mouth, near 
the angle of the jaw, along the sheath of the carotid vessels, in the vicinity of the anus, 
and in the sacrococcygeal region. In these situations, as well as in the anterior fonta- 
nelle, they evidently arise from the imperfect closure of the branchial clefts, and the clefts 
along the median line. Their contents are commonly composed of sebaceous matter and 
short, white hairs. In the ovary, the testicle, the brain and its meninges, the eye, the 
anterior mediastinum, the thymus, the lungs, the mesentery, and the omentum, in which 
they are also found, dermoid cysts may also contain teeth and rudimentary cartilage and 
bone, showing that they are probably the remains of foetal inclusions. 
IV. Cystomas—Cysts of new formation, lined by endothelium, and containing serous 
contents, are of frequent occurrence, as is witnessed in the so-called congenital cystic 
hygroma of the neck, perineum, and axilla. Their mode of development is a matter of 
conjecture, but it is probable that they arise from cystic degeneration of the corpuscles of 
the connective tissue. A good example of the neoplastic cyst is the accidental burse 
which is developed under the influence of protracted pressure. 
V. Extravasation Cysts—Cysts occasionally form around extra vasated blood, constitut- 
ing what are known as hematomas or as sanguineous cysts. They have their seat most 
commonly in the neck, groin, and trunk. Their contents consist either of pure blood or 
of blood mingled with serum and other substances. The cyst-wall is usually very thin 
and smooth, but in some cases the inner surface has a peculiar fasciculated appearance, 
not unlike that of the right auricle of the heart. The cyst is commonly small, of a 
rounded or hemispherical shape, and fluctuates on pressure, especially in its earlier 
stages. 
VI. Hydatid Cysts.—The hydatid cyst differs from the ordinary cyst in one essential 
particular, that is, it contains an entozoon, parasite, or vesicular worm, inclosed in a dis- 
tinct, separate sac, originally described by Laennec under the name of acephalocyst, a 
term signifying headless bladder. The organs in which it is most commonly found are 
the liver, ovary, and uterus. It is also met with, although much less frequently, in the 
mamma,, brain, testicle, kidneys, lungs, bones, serous cavities, and subcutaneous connec- 
tive tissue. In my cabinet is a beautiful specimen of hydatid tumor which I removed 
from the deltoid muscle of a young man, a patient at the College Clinic. 
Varying in volume between a mustard seed and a small orange, the entozoon is of a 
globular figure, of a whitish, semiopaque appearance, and composed of a vesicle, or 
bladder, filled with serous fluid, and surrounded by a fibrous capsule, which thus isolates 
and protects it from the circumjacent structures. It is usually gregarious, numbers of 
them inhabiting a common cyst, as in fig. 26; sometimes, however, there is only a solitary 
one, which is then commonly proportionately large. The contents of the animal are of a 
clear limpid character, remarkably saline to the taste, but destitute of odor and coagula- 
bility. The inclosing cyst is fibrous, more or less vascular, and possessed of considerable 
strength. Between this cyst and the parasite there is commonly a soft, pulpy, dirty- 
looking substance, the precise nature of which is undetermined. Owing to its endogenous 208 
mode of generation, a large hydatid sometimes contains several smaller, one within 
another, like so many pill-boxes. 
Although the hydatid itself" consists of two distinct layers, it is generally so weak and 
delicate as to break under its own weight when removed from its inclosing cyst, shrinking 
into a soft, pulpy mass, not unlike the 
white of a hard-boiled egg, both in ap- 
pearance and chemical composition. 
The inner surface of the parasite is 
studded with numerous little bodies, 
seen in fig. 27, resembling diminutive 
fish-spawn, hardly as large as a grain 
of sand, of a spherical shape, and of a 
grayish color, each consisting of a deli- 
cate cyst, filled with echinococci. The 
echinococci, deriving their origin and 
support from the hydatid, soon lose 
their connection, and thus acquire an 
independent existence, great numbers 
being often seen floating about in the 
parent liquor when they are yet hardly 
the two-hundreth part of an inch in 
diameter. 
Each echinococcus consists of a body 
and a head, the latter being encircled by 
a row of teeth naturally concealed in a narrow cleft, but capable of projecting itself. The 
body, composed of solid, granular matter, has a curiously speckled appearance, due to 
the presence of numerous ovoid spots immediately beneath its outer coat. The teeth, or 
booklets, are spinous, sharp, and perfectly characteristic. They are not easily decom- 
posed, and are, therefore, capable of affording important diagnostic information. The 
various appearances here described are well illustrated in fig. 28. 
TUMORS OR MORBID GROWTHS. 
CHAP. VII . 
Fig. 26. 
Hydatids inclosed in a common Cyst. 
Fig. 27. 
Fig. 28. 
Cysts of Echinococci. 
Echinococci. 
Hydatids are much less common in this country than in England and the continent of 
Europe. Nowhere, however, are they so prevalent as in Iceland, where, according to 
Eschricht, a sixth part of the population is infested with them. Men are more subject 
to them than women ; and it is obvious that the ova of the parasite, derived for the most 
part from the dog, are introduced into the stomach with the food, from which they after- 
wards find their way into the different tissues and organs of the body. In one.district, 
where the disease is most common, and where the inhabitants are accustomed to eat raw, 
smoked mutton, Dr. Hjaltelin reports that nearly every adult sheep and every third person 
are affected with the disease. 
Hydatids are usually short-lived, rarely lasting beyond a few years. Various causes 
may destroy them, as suppuration, gangrene, the gradual desiccation of their contents, 
and the pressure of their young. Under such circumstances, the inclosing cyst is often 
remarkably thickened, and even partially transformed into fibrous, fibro-cartilaginous, or 
calcareous matter. 1 have seen instances where it had assumed an appearance similar to 
the interior of an aneurismal sac. Great mischief eventually arises from their presence, 
especially during their decay, from the violent irritation which they excite. A hydatid of 
the liver occasionally induces fatal peritonitis; and the hardest structures, the osseous not 
excepted, are not always capable of withstanding its progress. In one case a parasite of 
this kind perforated the scapula. In the lungs acephaloeysts sometimes find their way CHAP. VII. 
CYSTS AND CYSTOMAS. 
209 
into the bronchial tubes, from which they are afterwards ejected by expectoration. In 
the kidneys they are commonly voided with the urine, either whole or piecemeal. 
Under the term “ multilocular echinococcus tumor,” or “alveolar hydatid tumor,” 
Virchow, Carriere, and other authors have described a form of this affection which differs 
from the ordinary variety of hydatid cyst, particularly in its structure. Instead of a cavity 
inclosing more or less rounded vesicles, it consists of a mass of solid tissue, strewed over 
with small, transparent bodies, resembling jelly. Scattered throughout the membrane are 
a great number of small cavities, or alveoli, which give it a worm-eaten or spongy appear- 
ance, and which vary in size from microscopic proportions to those of a hemp seed. They 
are tilled with gelatinous bodies, which, on minute examination, are found to be composed 
of shrivelled hydatid membranes, echinococci, and booklets. The tissue possesses a great 
tendency to ulcerate, as is evinced by one or more excavations of various sizes with ulcerated 
walls. 
A very striking example of this form of tumor, the external appearances of which are 
delineated in tig. 29, came under my observation in 1869, in a German, fifty-four years of 
age, who had long been in the habit of eating pork. 
Eight years previously, he noticed a swelling on the 
lower and inner side of the thigh, which, in a few 
weeks, attained the size of a fist, after which it re- 
mained stationary until four months before he con- 
sulted me, when it began to increase, and soon ex- 
tended from the popliteal space to the pubes, occupying 
chiefly the inner aspect of the thigh, where it formed 
a soft, fluctuating tumor, from which 1 drew otf thirty- 
five ounces of a dirty-brownish fluid, looking very 
much like ordinary yeast. One month subsequently, 
I laid it open by an incision twelve inches long, and 
dissected away the exterior adventitious sac or lining 
membrane. It contained many cysts, each invested 
by an adventitious membrane, and occupied by pus, 
the largest being about the size of a goose-egg. The 
adventitious sac was subcutaneous, two lines in thick- 
ness, and studded with small gelatinous bodies and 
alveoli, the former of which presented all the charac- 
teristics of ordinary hydatid membrane, and the para- 
site with its booklets. The fluid in the adventitious 
cyst consisted of pus in a state of advanced fatty de- 
generation. 
There are no signs by which a hydatid tumor can 
be satisfactorily diagnosticated. The only positive 
evidence of its existence, when it is seated in an 
internal organ, is the presence of the vesicle, or of 
some of its constituents, in the discharges, as the 
urine, sputa, or feces. It is not often that an acepha- 
locyst is voided entire ; most generally it comes away 
in broken pieces, or in shrivelled fragments, consisting 
of booklets, laminated shreds, milky-looking detritus, and oily particles, discoverable with 
the microscope. When the tumor is situated superficially, or when it is developed among 
muscles, in a broad bone, the liver, kidney, or mammary gland, it fluctuates more or less 
distinctly on pressure, and yields the peculiar characteristic thrill, known as the hydatid 
fremitus. In order to elicit this sign, the fingers of one hand should be laid upon the 
tumor, and tapped sharply with the fingers of the other. The sensation thus communi- 
cated has been compared by Davaine to the vibrations of a repeater watch held in the 
hand. In some cases it closely resembles the peculiar crepitating feel produced by pressure 
applied to a burse of the knee or to a ganglion of the hand. A similar sensation is com- 
municated to the ear when the stethoscope is used, and the tumor is percussed with the 
fingers. Not unfrequently all attempts, however patiently or skilfully conducted, utterly 
fail in throwing any satisfactory light upon the nature of the affection. 
The diseases with which hydatid tumors are most liable to be confounded are abscesses, 
especially the strumous variety, hypertrophy of the liver and spleen, accumulations of 
bile in the gall-bladder and of fecal matter in the large bowel, aneurism of the aorta, en- 
Fig. 29. 
Hydatid Tumor of the Thigh. 210 
TUMOBS OK MORBID GROWTHS. 
CHAP. VII. 
largement of the ovary and uterus, and various kinds of tumors of the abdominal and 
pelvic viscera, particularly the cystic, fibrous, and carcinomatous. 
Treatment.—Cysts are never benefited by constitutional medication, except in so far as 
it may have a tendency to improve the general health, and thus retard their development. 
Their contents do not seem to be amenable to the action of the absorbents. When they 
are situated superficially and are of small size, their growth is sometimes retarded, although 
they are seldom cured, by compression, and by sorbefacient applications, particularly the 
dilute tincture of iodine. A more certain plan is to break the cysts or incise them subcu- 
taneously, so that, their contents having escaped into the surrounding connective tissue, 
their walls may collapse, and ultimately unite by adhesive inflammation. When the 
tumor is deep-seated, iodine injections may sometimes be advantageously employed, the 
operation being performed in the same manner as in hydrocele of the vaginal tunic of the 
testicle. A seton, too, is an eligible procedure. When the cysts are large or numerous, 
and, above all, when the primitive textures are, in a great measure, if not entirely anni- 
hilated, the only course likely to succeed is excision of the entire mass, care being taken 
not to leave the slightest particle, for fear of reproduction. Too much stress cannot be 
laid upon this injunction. For want of this precaution, I have known a patient to be 
obliged to submit to not less than three distinct operations for the cure of a tumor origin- 
ally not larger than a pigeon’s egg. A secreting surface, hardly the size of a pin’s head, 
is capable of reawakening growth. Removal may sometimes be effected by enucleation ; 
at other times, and more generally, a minute dissection is necessary. The proceeding 
need not be at all bloody, unless the tumor is seated among very vascular parts, or the 
knife is carried too far away from the encysted mass. 
The treatment of hydatid cysts varies according to their site. When the tumor is sit- 
uated externally, as, for example, when it occupies the mammary gland, a muscle, or a 
bone, the only remedy is excision. When, on the contrary, it occupies an internal organ, 
as the liver or kidney, the proper plan is to evacuate its contents with the trocar, and 
provoke obliterative inflammation by the injection of a weak solution of iodine or the 
insertion of a tent. When no contraindication exists, a free incision may sometimes be 
advantageously made. Electrolysis has occasionally been successfully practised. The 
treatment is especially adapted to hydatids of the breast and liver. When the hydatids 
infest the kidney, the best internal remedies are oil of turpentine and nitrate of potassium, 
in moderate doses, repeated several times in the twenty-four hours. 
SECT. III.—NEOPLASMS WHICH REPRESENT PERFECTED OR MATURED CONNECTIVE 
TISSUE AND ITS MODIFICATIONS. 
1. LII'OMATOUS TUMORS. 
The lipomatous or fatty tumor is not only very common, but may occur in any part of 
the body, not even excepting the hand, foot, fingers, and toes. It is seen, however, more 
frequently about the nucha, back, shoulder, and arm than in any other regions. The 
upper eyelid is also a common seat of it. Sometimes, but more rarely, it is developed in 
the orbit of the eye, the v-alls of the abdomen, perineum, labium, and underneath and 
even in the substance of the tongue. Recently I removed a small tumor of this kind 
from the forehead of a woman, forty-three years of age ; and on another occasion one, the 
size of an orange, from the left temple of a man of thirty-five. Dr. Hatfield, also, met 
with an adipose tumor on the forehead, and Dr. S. W. Gross removed one in a middle- 
aged person from the occipital region. Large masses of fat occasionally form in the 
internal cavities of the body, as in the omentum and mesentery, and around the kidneys. 
The number of fatty tumors varies, in different cases, from one to several hundred. 
In general, they are solitary, or, at most, there are only two or three, occupying different 
regions of the body, or grouped more or less closely together. In a physician, a former 
member of my class, thirty-eight years of age, I counted upwards of two hundred, from 
the volume of a small pea to that of a large marble. They all had a doughy, inelastic 
feel, and most of them were of a globular shape, a few being slightly flattened or com- 
pressed. They w’ere situated principally on the forearms, inside of the thighs, loins, 
abdomen, and pectoral regions, the latter of which were literally covered with them. 
None existed on the head' neck, and upper part of the back. The general health was 
good, and the tumors had been first observed about sixteen years previously. During 
two severe attacks of acute disease, accompanied with great emaciation, many of them CHAP. VII. 
LIPOMATOUS TUMORS. 
211 
entirely disappeared. The late Dr. Nott, of New York, mentioned to me the particulars 
of a similar case. 
In their volume, these growths range from a small pea to that of an adult head. Some- 
times, indeed, they are much larger, measuring many inches in diameter, and projecting 
a great distance beyond the surface. I am indebted to Professor Leidy for a section of a 
fatty tumor which weighed upwards of seventy pounds ; it was removed, after death, from 
the abdomen of an elderly person, and contained large masses of bony matter. Dr. Bray, 
of Evansville, Indiana, extirpated a growth of this kind which weighed nearly forty 
pounds, the patient making a good recovery. 
In their form, fatty tumors are generally somewhat globular, with a lobulated surface, as 
in tig. 30, from a specimen in my collection ; 
as they augment in volume, however, they 
are liable to become elongated, and to assume 
a pyriform, gourd-like, or pedunculated con- 
figuration. These changes, no doubt, depend 
upon their weight, by which they are grad- 
ually dragged out of their original shape, as 
well as position. For the same reason they 
sometimes shift their seat, descending from 
the point where they originally appeared to 
one below it, perhaps several inches distant. 
Thus, a fatty tumor developed in the groin 
has been known, in time, to pass down be- 
tween the scrotum and the thigh. This mi- 
gratory tendency, which is of special interest 
in a diagnostic point of view, is most common 
in those parts of the body which are most 
abundantly supplied with loose connective tis- 
sue, and in those cases in wdiich the tumor 
has a large bulk and a pedunculated attach- 
ment. Occasionally their edges, have a den- 
tated arrangement, due to subordinate out- 
growths of variable size and forms. 
The fatty growth is always surrounded by 
a fibrous capsule, by which it is connected 
more or less firmly to the parts around, the 
strength of the adhesions being generally in 
proportion to the age and bulk of the tumor, and the amount of pressure exerted upon it 
during its development. Attached to the inner surface of this covering are numerous 
processes, which, dipping into the interior of the growth, separate it into lobes, lobules, 
and granules, until the component tissues are resolved into their ultimate elements. 
These processes, which are usually very delicate, are occasionally, as when there is a 
hypertrophic condition of the connective tissue partitions, very dense and tough, forming 
distinct bands, of a whitish or grayish color, between the different structures. 
When a fatty tumor contains an unusual quantity of fibrous matter, as when its capsule 
and intersecting processes are very thick and dense, it constitutes that form of morbid 
growth to which Muller, Rokitansky, Gluge, and other German histologists, have applied 
the terms mixed lipoma, steatoma, and lardaceous tumor. The name fibro-fatty would be 
more appropriate, although the distinction is of no practical value. 
A growth in which the adipose element is intimately combined with the vascular, 
although not in an equal degree, is sometimes met with, chiefly upon the back, thigh, and 
buttock, and is known as the naevoid lipoma. It has a soft, doughy, inelastic feel, is free 
from pulsation, pursues a slow, indolent course, is generally congenital, is essentially com- 
posed of a cellulo-adipose basis, interspersed with enlarged veins, and occasionally mani- 
fests a recurring tendency after extirpation. 
Fatty growths generally receive very little blood, and they therefore seldom bleed much 
when they are extirpated. It is only when they are of large size, or of very rapid develop- 
ment, that they are likely to be very vascular. The capsule and its processes serve to con- 
duct the vessels into the interior of the morbid mass, and to direct, as it were, the distribution 
of their branches and ramifications. As the tumor is always free from pain, and tolerant of 
the rudest manipulation, it may be concluded that it does not receive many nerves. Absorb- 
ent vessels also exist sparingly. It may, furthermore, be inferred that, as the general health 
Fig. 30. 
Lipomatons Tumor. 212 
TUMORS OR MORHII) GROWTHS 
CHAP. VII. 
is usually unimpaired throughout the whole progress of the 
affection, however protracted, it does not possess any impor- 
tant sympathetic relations with the general economy. 
The minute structure of this form of tumor is well dis- 
played in fig. 31. It is made up of cells, exactly similar to, 
but larger than, those of natural fat, interspersed through 
connective tissue, as seen in the larger drawing: the small 
figure a represents isolated cells, showing the crystalline 
nucleus of margaric acid. Various other substances, of an 
adventitious character, are generally perceived under the 
microscope, more especially in the older growths. 
The fatty tumor often sends prolongations around the mus- 
cles, tendons, fasciae, vessels, and other structures. Thus 
in the neck it occasionally extends deeply between the trachea 
and oesophagus, dips in between the carotid artery and jugular vein, or passes down behind 
the sternum and clavicle into the chest. A fatty growth of the wall of the abdomen is 
sometimes prolonged into its cavity ; and,on the other hand,such a tumor occasionally be- 
gins in the subperitoneal connective tissue, and ultimately descends through the inguinal 
canal, or through some abnormal outlet, down into the scrotum, thus simulating hernia of 
the groin. All such arrangements must necessarily greatly embarrass both the diagnosis 
and the attempts to remove the morbid mass. 
Fatty tumors are generally easily recognized by their soft, doughy, semielastic feel, 
their mobility, their well-defined outline, their uniform consistence, their lobulated surface, 
their tardy progress, and their indolent disposition. Some are pedunculated, some pen- 
dulous, some pyriform, or gourd-like, some flattened, as if compressed, and some ramiform, 
processes extending in different directions among the muscles, vessels, and other structures. 
There is no pain, no tenderness on pressure, no impairment of the health, no enlargement 
of the subcutaneous veins, and no inconvenience, except what is occasioned by the situa- 
tion, bulk, and weight of the growth. 
Inflammation, suppuration, ulceration, and even gangrene may occur in these growths, 
usually induced by mechanical pressure, caustic applications, or inefficient nourishment, 
in consequence of a loss of their vascular and nervous supply from the pendulous or 
overgrown character of the morbid mass. In a tumor of this kind, about the volume 
of an orange, which I removed from the top of the left shoulder of a girl eighteen years 
of age, the ulcer had a remarkably foul, unhealthy aspect, with thin, everted edges ; the 
pain was, at times, very severe, and the discharge was of a sanious nature, intermixed 
with globules of fat. Various attempts had been made, but without success, to heal 
it up, and no cause could be assigned for its formation. The general health had been 
a good deal impaired, and there had latterly been some irregularity of the menstrual 
function. The ulcer was included in two incisions, and speedy recovery was the result. 
Again, such tumors now and then undergo the fibrous, cartilaginous, calcareous, or 
osseous degeneration, not uniformly, but at certain points of their extent. Nodules, 
varying in size from a hazel-nut to a pullet’s egg, may thus be formed, having a firm, 
characteristic consistence, more or less movable, and contrasting singularly with the other 
structures. Finally, they occasionally contain cysts filled with various kinds of substances, 
as oily, serous, mucous, or gelatinous. The walls of the cysts may be very thin and 
transparent, or thick, opaque, and perhaps even partially calcified. 
Fatty growths generally arise without any assignable cause. Sometimes, though very 
rarely, their development is apparently due to external injury, as a blow, contusion, or 
persistent mechanical compression. It is most common in young adults and middle-aged 
persons. Occasionally it is congenital, as in the interesting cases reported by Johnson, 
Gay, and others. 
The medical treatment of this class of morbid growths is most unsatisfactory, as there 
is no remedy which seems to be capable of arresting their progress, or of causing their 
removal. The instance of Sir Benjamin C. Brodie, in which he succeeded in dispersing 
a large mass of fat from a man’s chin and neck, by the free and persistent use of the ofii- 
cinal solution of potassa, may be regarded as a remarkable example of good luck. All 
local means, as systematic compression, and sorbefacient lotions, liniments, and unguents, 
are equally useless, the absorbent vessels being seemingly incapable of responding to 
their action. 
'I’lie manner of excising such tumors is generally sufficiently simple. Any diseased skin 
that may exist should be removed along with the morbid mass, which should be enucleated 
Fig. 31. 
Minute Structure of a Fatty Tumor. CHAP. VII. 
FIBROUS TUMORS. 
213 
by a rapid dissection, care being taken that not a particle of the tissue is left behind ; 
otherwise reproduction may take place. When the tumor is superficial, the operation is 
easily performed and soon over; but when it is deep-seated, or when it sends processes 
among the surrounding structures, it may be one of great difficulty and perplexity, requir- 
ing consummate skill and a most thorough knowledge of the anatomy of the parts. A 
fatty tumor that has long been compressed, as when it occupies the nape of the neck, 
shoulder, or buttock, is often removed with difficulty, owing to its firm and extensive 
adhesions. For the reasons already mentioned, the operation is sometimes nearly blood- 
less. I have, indeed, seldom found it necessary to apply more than two or three ligatures, 
whatever may have been the volume of the tumor. 
When a fatty tumor is completely extirpated, there can be no recurrence of it. In a 
case of lipoma of the scrotum, recorded by Mr. Curling, in which there was a reproduction 
five times, the new product was evidently merely an outgrowth of a part of the pedicle 
which in each instance had been left behind. 
2. FIRROUS TUMORS. 
The fibrous tumor owes its name to its peculiar structure, which strongly resembles 
normal fibroys tissue. One of the best examples of this variety of morbid growth is to be 
found in the uterus of elderly females, where it sometimes attains a weight and magnitude 
equal to those of the body of the patient. It also occurs in the connective tissue, both 
subcutaneous and intermuscular, in the mammary gland, testicle, ovary, periosteum, 
bones, nerves, and other parts of the body. In my cabinet is a large fibrous tumor, weigh- 
ing nearly five pounds, which I removed from the interior of the scrotum of a young 
man of twenty-five, but which had no connection whatever with the testicle. A remark- 
able fibrous tumor sometimes grows pendulously from the lobe of the ear. Certain keloid 
formations of the skin obviously belong to the present class of morbid products, although 
they usually contain an inordinate quantity of fibroplastic tissue. Fibrous growths occa- 
sionally occur in the interior of the joints, especially the elbow and knee, in the latter 
of which they sometimes attain the volume of a pullet’s egg. The dura mater, periosteum, 
and fibrous envelop of the muscles are all liable to such formations, although the occur- 
rence is unusual. Finally, fibrous tumors are often met with in the neck, either imme- 
diately beneath the skin or deep among the muscles and lymphatic glands. Not long ago 
I removed from a lady, forty-three years of age, a small nodule of this kind from the site 
of the lachrymal sac, which was almost completely obliterated by its pressure. Certain 
polyps, as they are called, are of a purely fibrous structure. 
This growtli is not peculiar to any period of life. The greatest number of cases, per- 
haps, occur in young adults. In the uterus and ovary it is most common in elderly sub- 
jects. It is sometimes congenital, and I have met with it also in several members of the 
same family. 
The fibrous tumor, although of slow growth, may eventually acquire an enormous bulk, 
as is exemplified in the immense masses which are occasionally found in the neck, the 
uterus, and other parts of the body. It feels heavy and incompressible, is globular, 
ovoidal, or pyriform in shape, and has generally a smooth, even surface, although not 
unfrequently it is remarkably lobulated, or marked by numerous elevations and depres- 
sions. In the uterus and the joints it is often attached by a narrow neck, while almost 
everywhere else it is in immediate contact, on all sides, with the structures in which it is 
developed, its adhesions being effected by connective tissue. Generally solitary, it occa- 
sionally occurs in considerable numbers, more particularly in the uterus, which is some- 
times completely crammed with it. In the case of a woman, sixty-six years old, Lebert 
found several hundred fibrous tumors scattered through the subcutaneous connective tissue 
in different parts of the body. In the nerves upwards of one thousand have been observed 
in the same person. 
The structure of this tumor is characteristic. As its name indicates, it is composed of 
fibrous tissue, the filaments of which cross each other in every conceivable manner, form- 
ing thus an intricate network, which the most careful dissection fails to unravel. These 
filaments are of variable size and shape, and are so intimately compacted together in the 
firm variety as to form a dense, hard, inelastic substance, so characteristic of this kind of 
product. It is only in rare cases that their passage across each other leaves any inter- 
spaces for the lodgment of fluid or solid matter. They are of a grayish or pale drab color 
after maceration, but in their natural state rosaceous, reddish, or even purple, their com- 
plexion depending upon the amount of blood they contain. Occasionally they have a 214 
TUMORS OR MORBID GROWTHS ciiap. vii. 
whitish, silvery, glistening appearance, like the sclerotic coat of the eye. The soft va- 
riety, as, for example, the molluscous fibroma, possesses a looser and a less dense texture, 
resembling that of the subcutaneous connective tissue, and its color is usually white, red- 
dish, or yellowish. 
The fibrous tumor has seldom any distinct capsule; the tissues around it are, it is true, 
usually a good deal condensed and thickened, but the covering thus derived is altogether 
adventitious and secondary, forming none of the essential elements of its growth. Few 
vessels can be traced into its substance, and these are rarely of any considerable size; a 
circumstance the more surprising when it is recollected what immense bulk it sometimes 
acquires. No reliable chemical examination has been made of this variety of tumor, but 
it is probable that it consists essentially of gelatine, as this substance is largely furnished 
by protracted boiling. Under the microscope it exhibits hypertrophied fibres, between 
which are interspersed, sometimes in great numbers, small 
ovoidal or fusiform cells, containing bright nuclei, which are 
always rendered very conspicuous if the part be previously 
treated with acetic acid, as in fig. 32, from a drawing of one 
of my specimens by Dr. Packard. 
A fibroma sometimes contains mucus, the result of softening, 
lodged in distinct cells or cavities, and giving rise to a mixed 
form of tumor, known as the myxomatous fibroma. The pres- 
ence of the mucus probably serves to give additional impulse to 
the development of the tumor, which occasionally increases 
with remarkable rapidity, and soon acquires a large bulk in 
consequence. 
The general tendency of the fibrous tumor is gradually to 
increase, to impair function, and ultimately to wear out life by 
its secondary effects. The older formations of this kind nearly 
always contain adventitious deposits, especially the calcareous, 
which often exist in considerable quantity. The cartilaginous 
is also not uncommon, while the osseous is rare. Sometimes 
large cavities, containing serum, pus, and other substances, are 
found in them. In a case observed by Paget, a fibrous tumor 
of the uterus contained a mass of fat the size of a large walnut. 
Their progress is usually painless, except when they, compress important parts, the incon- 
venience which they occasion being dependent mainly upon their weight, bulk, and site. 
A growth of this kind sometimes takes on malignant action, its tissues serving as a 
nidus tor sarcoma. Although it is impossible to determine what are the circumstances 
which predispose to, or influence, such an occurrence, there can be no doubt that it is 
governed by the same laws as those which preside over the development of sarcoma in 
the connective tissue generally, and that the change does not consist in a degeneration, 
properly so termed, of the fibrous substance, but in an entirely new formation. The neo- 
plasms, which were described in former editions as fibroplastic and recurring fibroid 
tumors, will be discussed in the section on sarcoma. 
The diagnosis of the fibrous tumor must mainly be deduced from its history and its 
consistence. Its growth is generally very tardy, there being a marked difference, in this 
respect, between it and the carcinomatous formations. Usually beginning in a little hard 
nodule, or lump, several years commonly elapse before it attains any considerable bulk, 
especially when it is developed among the external tissues; its progress is comparatively 
painless, the chief inconvenience occasioned by it being of a mechanical nature. The 
tumor usually feels hard, firm,'and inelastic, being more dense than encephaloid, but not 
so solid and dense as scirrhus. Its consistence is usually uniform; not hard at one point 
and soft at another. Its surface, too, is commonly smooth ; and there is nearly always, 
unless the growth is very large, an absence of enlargement of the subcutaneous veins. 
In its earlier stages it is somewhat movable, except when it springs from the periosteum ; 
by degrees, however, it contracts adhesions, and is thus firmly fixed in its position. 
The fibrous tumor is rarely amenable to local or constitutional treatment. When favor- 
ably situated, pressure, steadily and systematically applied, is sometimes serviceable ; but 
this is so seldom the case that hardly any calculations of a curative character are to be 
based upon it. In the early stage of the development, before any great firmness and 
density of structure are attained, a mild course of mercury may be tried, its constitutional 
impression being persistently but very gently maintained for several successive months, or 
alternated with that of iodide of potassium, also an agent of some consequence in the 
Fig. 32. 
Microscopical Characters of 
Fibrous Tumor from the Sub- 
maxillary Region. X472 Diam- 
eters. CARTILAGINOUS TUMORS. 
215 
CHAP. VII. 
softer forms of fibrous growths, although rarely of any benefit in those of maturer devel- 
opment. But the surest remedy, when the tumor is accessible, is removal, performed 
early and efficiently, by dissection and enucleation. Hemorrhage is usually slight, and 
recurrence not probable, unless, as sometimes happens, the morbid mass has become the 
nidus of sarcomatous deposit. As this cannot always be certainly predicted, the prognosis 
should not be too sanguine. 
3. CARTILAGINOUS TUMORS. 
The cartilaginous tumor, first accurately described by Professor J. Muller, under the 
name of enchondroma, or chondroma, holds, histologically, a position intermediate be- 
tween the fibrous and osseous, and is harder than the former and softer than the latter. 
It is divided by Virchow, primarily, into ecchondroses, which spring from the permanent 
cartilages, and enchondromas, which are developed from a non-cartilaginous basis. The 
former, which do not differ from the latter in their clinical history and minute structure, 
have a predilection for the costal, pelvic, laryngeal, and tracheal cartilages, and they also 
form the movable bodies of the articulations. 
Enchondroma occurs in various parts of the body, as the parotid and submaxillary 
glands, the testicle, and ovary, as well as in the subcutaneous and intermuscular connec- 
tive tissue, but is most frequent in the skeleton, as the metacarpal bones and the pha- 
langes of the fingers, where it may be central or periosteal. I have seen large and 
numerous growths of this kind form simultaneously upon both hands and both feet, causing 
hideous deformity and almost complete loss of function of the affected parts. The most 
formidable tumors of this kind are generally met with in the scapula. Although they 
occasionally occur in elderly subjects, they are by tar most common in young persons be- 
fore the twentieth year, especially in such as are of a weak, rickety constitution; and they 
are often associated with a remarkably stunted state 
of the body. The annexed sketch, fig. 33, from a 
specimen in my possession, conveys a good idea of 
the external characters of an enchondroma of a 
finger. 
The enormous size which a cartilaginous tumor 
is capable of attaining is well illustrated in a case 
which came under my observation in a young man, 
twenty-six years of age. The tumor, which occu- 
pied the right shoulder, had appeared about six 
years previously, and involved the scapula, hu- 
merus, and clavicle, forming an immense mass, of 
very irregular outline, excessively hard, forty-five 
inches in circumference at the base, and weighing, after death, as was ascertained by Dr. 
II. J. Bigelow, thirty-one pounds. In another instance, one which I saw with Dr. Davi- 
son, of Illinois, in a man forty-five years of age, an enormous mass of this kind, having 
its origin in the scapula, and occupying the left side of the trunk, weighed ninety pounds. 
In a case of enchondroma of the femur, related by Sir Philip Crampton, the tumor 
measured six feet and a half in circumference. Mr. Gamgee, in 1862, amputated suc- 
cessfully at the hip-joint, in a case in which a growth of this kind, along with the thigh- 
bone, weighed ninety-nine pounds. 
The structure of enchondroma corresponds with the type of permanent cartilage, con- 
sisting either of hyaline, fibrous, or reticular tissue alone, or, as is nearly always the case, 
of all those varieties variously intermingled, so that, in reality, most tumors of this kind 
are of a mixed character. Portions of it undergo different transformations, and in cases 
of long standing, or of extraordinary bulk, mucous, fatty, fibrous, cartilaginous, calca- 
reous, osseous, and sarcomatous changes are almost always met with. It also not unfre- 
quently contains large cysts filled with various kinds of substances, either solid or fluid. 
To the hand it imparts the sensation of unusual firmness and solidity; it is destitute of 
elasticity, is generally distinctly circumscribed, and is nearly always strongly adherent to 
the tissues from which it springs. Its surface, which is sometimes smooth, is commonly 
lobulated, or marked by irregular prominences and depressions. No pain usually exists, 
or, if there be any, it is owing rather to the pressure which the tumor exerts upon the 
neighboring parts than to any disorder of its own sensibility. When the growth is very 
old and bulky, there is generally great enlargement of the subcutaneous veins, with a 
tendency to softening and disintegration of its more feebly organized portions. 
Fig. 33. 
Enchondromatous Tumor. 216 
The cartilaginous tumor varies in consistence, not only in the different stages of its life, 
but in different portions of its extent. The older sections are generally hard, firm, dense, 
cutting with difficulty, and creaking under the knife ; the younger, on the contrary, are 
soft, almost gum-like, or of the consistence of honey, warm glue, isinglass, or synovia. 
Sometimes almost the entire tumor is semiliquid ; at other times the fluid matter is con- 
tained in distinct cysts or cavities, and in some cases, again, the fluid parts are intermixed 
with fibrous, cartilaginous, or osseous nodules. The softer portions may be present as an 
original product, or they may be the result of secondary formation, consequent upon defi- 
cient nutrition, or retrograde, degenerative changes. 
On section, it is of a whitish, grayish, or bluish as- 
pect, and is characterized by a peculiar linear or lobu- 
lar arrangement. 
Under the microscope this tumor presents numer- 
ous cells, as in fig. 34, of an oval or rounded shape, 
from the to an inch in diameter, pro- 
vided with one or two nucleolated nuceli, and lodged 
in cavities of various sizes and forms, distributed 
through an amorphous hyaline, mucous, dimly fibril- 
liated, or coarsely fibrous, intercellular substance. In 
the older growths, some of the cells are cloudy and 
shrivelled, others are in a state of fatty degeneration, 
while others, again, are marked by projections similar to those of cartilage in process of 
ossification. Its principal constituent is chondrin in union with phosphate of lime. The 
animal matter, readily extracted by boiling, solidifies on cooling like gelatine, but does 
not contain any of the latter substance, as is shown by the fact that it does not expand 
by contact with fluids. 
'Die cartilaginous tumor is sometimes inclosed by a distinct cyst of condensed connect- 
ive tissue; at other times it is in immediate contact with the structures in which it is 
developed. Its vascularity is often very great, a circumstance which readily explains 
the astonishing rapidity which occasionally marks its progress, cases having been observed 
in which, in the course of a few months, the tumor attained the size of an adult’s head, 
or even of the patient’s chest. Such an occurrence, however, is extremely uncommon ; 
for the development of enchondroma is usually singularly tardy, and now and then, it 
apparently enjoys even a period of repose. 
Enchondroma is generally painless and indolent, causing little or no inconvenience, 
save what results from its weight and pressure ; sometimes, however, it inflames and ulcer- 
ates, and in this way a large cavity may be formed, attended with copious discharge and 
excessive constitutional disturbance, rapidly followed by hectic fever. Portions of it may, 
as already stated, undergo various transformations, as the cystic, fatty, fibrous, calcareous, 
and osseous; and segments occasionally degenerate into malignant disease, nodulefc of 
cartilage, of various shapes and sizes, being interspersed through the sarcomatous tissue, 
each invested by connective tissue. 
Although the cartilaginous tumour is generally an innocent growth, it sometimes as- 
sumes a malignant form, and numerous instances have been reported in which it recurred 
after extirpation, not only once but repeatedly. The recurring tendency is well exem- 
plified in the remarkable case observed by the late Dr. Reuben D. Mussey, in which the 
disease successively invaded the hand, arm, and shoulder, the second operation being 
performed thirteen years after the first, and the last, in which the entire scapula and 
clavicle were successfully removed, five years after the second. Syme performed ampu- 
tation at the shoulder-joint, in a girl, fourteen years of age, on account of a cartilaginous 
tumor which reappeared in the stump and in the axilla. In two cases, recorded by Gluge, 
the disease returned and destroyed life, respectively, at eighteen months and two years 
and a half. Virchow relates an instance in which an enchondroma of the scapula re- 
curred seven times, and finally proved fatal. Under such circumstances similar growths 
are frequently found in other organs, as the lungs, liver, spleen, and testicle. The ex- 
tension of cartilaginous tumors, by the lymphatic vessels, has been repeatedly observed, 
the vessels being remarkably tortuous and dilated, and tilled with cartilaginous matter. 
It is not, however, at all certain that in the recorded cases of malignity of enchrondroma 
the tumor was constituted by cartilage alone ; and I am of the opinion that the car- 
tilaginous tumor never occasions secondary deposits, unless it is combined with sarcoma, 
myxoma, or carcinoma. 
The only remedy for this tumor is early and efficient extirpation. The operation, 
TUMORS OR MORBID GROWTHS. 
CHAP. VII. 
Fig. 34. 
Microscopical Characters of Enchondroma. OSSEOUS TUMORS. 
217 
CHAP. VII. 
however, as already stated, is not always successful, for now and then repullulation occurs, 
either causing death, or demanding further surgical interference. This is especially lia- 
ble to happen when the tumor sends out small processes into the surrounding structures, 
or is not distinctly incapsuldted, and when sarcomatous elements are intermingled with 
the cartilaginous. When the new growth is closely connected with bone, amputation will 
always be required. 
4. OSSEOUS TUMORS. 
Osseous tumors, or osteomas, usually known as exostoses, are met with chiefly as out- 
growths of the skeleton, especially of the skull and thigh-bone, the superior jaw, the orbit 
of the eye, and the distal phalanx of the big toe, occurring in various forms and sizes, 
from a pea up to a fcetal head; hard and compact, like normal bone, which they closely 
resemble in structure and composition; slow and painless in their progress; seldom, if 
ever, degenerating into malignancy; unamenable to ordinary medication; and demanding 
removal only when they seriously interfere with the exercise of important functions. 
Osteomas, not directly connected with bone, or continuous with bone, occasionally occur 
as the result of ossification of the cartilaginous, muscular, tendinous, and aponeurotic tis- 
sues, but their consideration does not properly belong to the present subject; and a 
similar remark is applicable to those peculiar osseous formations which are sometimes 
met with as isolated bodies, of varying forms and sizes, in the substance of different 
organs, as the brain, lung, ovary and testicle, and in connection with different kinds of 
soft tumors. A well-marked exostosis, constituting what is called an odontoma, occa- 
sionally forms on the root of a tooth, especially of the large grinders. 
Osseous tumors, properly so called, are, in reference to their structure and mode of 
growth, divisible into two classes, the soft, spongy, or cancellous, and the compact, hard, 
or ivory-like. The former, which is by far the more common, has usually a cartilaginous 
origin, and is often, especially in its earlier stages, invested by a layer of this substance, 
from one to several lines in thickness, of a grayish, whitish, slightly bluish, or pearly 
aspect, and of a hyaline character. Sometimes it is inclosed by a thin fibrous capsule, a 
form of synovial burse, lubricated by serous or sero-oleaginous fluid. Such an arrange- 
ment is most common in osteomas near the larger joints, in connection with the epiphyses 
of the long bones, and is evidently designed to facilitate the movements of the soft parts 
immediately around the morbid growth. 
In its shape the cancellous osteoma is generally more or less rounded, with a nodulated 
surface, and a broad base; occasionally it is very irregular, spiculated, or angular ; and 
now and then it has a distinctly pedunculated form. It is of a dense, firm, bony con- 
sistence, and is only movable while it retains its fibrous, periosteal, or cartilaginous at- 
tachment. Its volume usually ranges between a pea and an adult fist, although it is 
capable of acquiring much larger dimensions. The structure and chemical composition 
are as nearly as possible like those of normal bone, both in its compact and medullary 
substances. Cancellous osteomas sometimes arise in the medullary canal and within the 
frontal sinus, forming thus what, in strictness of language, may be called enostoses, which, 
however, in no wise differ in structure and composition from exostoses, or external bony 
outgrowths. The most frequent seats of the cancellous exostosis are the femur, tibia, 
fibula, and humerus. 
The ivory-like tumor is destitute of cancellous substance, and is so firm and dense as 
to be severed with great difficulty, the section admitting of a fine polish, very much like 
the substance to which it owes its name. Phosphate and carbonate of lime are present in 
unusual quantity, although it is not improbable that its hardness depends more upon the 
mode of aggregation of its several constituents than on chemical differences. The Haver- 
sian canals and lamellar arrangement are always well marked. Of a rounded, globular, 
or hemispherical shape, the morbid growth is generally smooth, or slightly nodulated, of 
small size, and attached by a narrow base, often of a cartilaginous character. Its most 
common site is the skull, and it may grow either from the outer or the inner table; more 
generally the former. 
Osteomas are generally of slow growth, and the principle inconvenience occasioned by 
them arises from their situation, bulk, weight, and pressure. Severe pain, mostly of a 
dull, heavy, aching character, may be produced by them when they overly, inclose, or 
compress important nerves. The general health is usually unaffected. The diagnosis 
is easily established by the history of the case, and by the firmness, density, and immo- 
bility of the tumor, which are greater than those of any other morbid growth. The can- 218 
TUMORS OR MORBID GROWTHS. 
CHAP. VII. 
cellous osteoma is most common in young subjects, before the twenty-fifth year; the ivory- 
like in advanced age. Of the nature of their exciting causes nothing definite is known. 
Their origin, in many cases, is directly traceable to external injury; and instances occur 
in which there is a veritable exostotic diathesis, exostoses, sometimes of a symmetrical 
character, existing, perhaps, upon almost every bone in the body. A hereditary tendency 
to these outgrowths is occasionally witnessed ; and I have met with examples of them in 
several members of the same family. 
It is possible, I presume, for an osteoma, under the influence of injury, protracted 
pressure, and general ill-health, to assume malignancy ; but such an event is extremely 
uncommon. The occurrence of caries and necrosis is also very infrequent. A sponta- 
neous cure sometimes takes place, the growth, from the interruption of its circulation, 
losing its vitality, and finally dropping off as an extraneous substance. Such an event is 
most common in osteomas of the head and face. Medication is of no avail in arresting 
the progress of the disease, except when the tumor is very small and young, when sorbe- 
facient applications, judiciously employed, are occasionally of use. As long as the growths 
cause no serious inconvenience they should not be subjected to operative interference, as 
the patient might perish from erysipelas, pyemia, or profuse suppuration. The bursal 
covering of an exostosis seated on the epiphyses of the long bones sometimes opens into 
a neighboring joint, rendering such interference doubly perilous. 
5. LYMP1IOMATOUS TUMORS. 
A lymphoma is a neoplasm composed of a tissue similar to that of the follicles of the 
lymphatic glands, or the adenoid tissue of His, which, as is now well known, is widely 
distributed throughout the body, being found not only in the lymphatic glands, but in the 
parenchyma of the various organs, the medulla of the bones, the tonsils, the pharynx, 
and the mucous membrane of the intestinal tract. In France the growth is called lym-. 
phadenoma; but as that term is also applied to the affection which in England is styled 
Hodgkin’s disease, it should be discarded. By other writers the term lymphosarcoma is 
loosely employed as the equivalent of lymphoma, which is altogether improper, as the 
two affections differ widely from each other in their minute structure and in their clinical 
features. In the following description the term lymphoma will be employed as signifying 
progressive hyperplasia of preexisting lym- 
phatic tissue, and has, therefore, nothing in 
common with sarcoma, or the enlargements due 
to ordinary inflammation, struma, syphilis, tu- 
bercle, Hodgkin’s disease, or lymphatic leu- 
kaemia. 
Viewed in the sense here indicated, the lym- 
phomatous tumor is most frequently met with 
in the neck and axilla, the glands of which 
usually enlarge with great rapidity, and finally 
constitute bulky growths. The tumor itself is 
free from attachments, and the individual glands 
of which it is composed remain encapsulated 
and thoroughly independent of each other, ex- 
cept through their union by loose connective 
tissue, are generally kidney-shaped, or long- 
oval, and of a soft, semielastic consistence, 
movable under the skin, free from pain, or 
nearly so, and tolerant of rude manipulation. 
Their sectional surface is of a grayish, light- 
pink, or reddish-yellow color, sometimes mottled 
with minute points of extravasated blood, and yield on pressure a whitish, lactescent juice, 
not unlike that of encephaloid carcinoma. 
The minute appearances are well exhibited in fig. 35, from O. Weber, representing a 
fine section of an enormous tumor of this description removed from the axilla of a boy. 
At c, the delicate meshes of the reticulated struma are seen, freed from the corpuscles by 
pencilling; while at a and 5, the alveoli are crowded with lymph corpuscles, which at e 
and f are undergoing active proliferation by division and endogenous germination. In 
the soft form of lymphoma the lymph cells predominate, and the connective tissue of the 
Fig. 35. 
Minute Structure of Lymphoma. SARCOMATOUS TUMORS. 
219 
CHAP. VII. 
follicles exists as a very delicate reticulum, while in the firm variety the reticulated stroma 
is much increased in thickness and the cells are diminished in number. 
These tumors are most common in adults between the ages of twenty and thirty- 
five, but they are sometimes observed in children. Their ordinary course may be thus 
described : Commencing on one side of the neck, for example, usually below the angle of 
the jaw, all the glands are successively invaded until the great anterior and posterior 
triangles and the supra-clavicular fossa are filled by the growth. After a period, which 
varies from four to eighteen months, the glands of the axilla and the opposite side of the 
neck become involved, followed by those of the mediastinum, bronchia?, and mesentery, as 
is indicated by chest troubles and impairment of the general nutrition. The patient is 
pale, weak, anemic, has a poor appetite, sleeps badly, becomes dropsical, and finally dies 
utterly exhausted. 
The diagnosis of the disease in its earlier stages from simple inflammatory or scrofulous 
enlargement of the glands is impossible; but its signs are so characteristic after it has 
made some progress that its nature is unmistakable. Its distinctive features are, its 
occurrence in young and vigorous subjects; its limitation to one side of the body; its 
progressive, rapid, and indolent growth, without any tendency to suppurate or extend 
beyond its capsule and to infiltrate the adjacent tissues; the mobility of the glands under 
the skin; the natural condition of the skin in regard to color and freedom from adhesions; 
the successive involvement of the contiguous glands; its elastic consistence and lobulated 
outline; and, finally, the absence, in its early stage, of a cachectic state of the system. 
Lymphosarcoma, on the other hand, occurs later in life; is painful ; usually commences 
in a single gland ; soon extends beyond the limits of its capsule to infiltrate the adjacent 
tissues, and convert them into a fixed, confused, and inseparable mass, and the overlying 
integument rapidly becomes adherent and discolored, and finally ulcerates. 
Lymphomatous tumors, considered in the restricted sense in which they are here de- 
scribed, are of evil import. The firm form frequently recurs after extirpation, and progresses 
more tardily to a fatal termination than the soft variety. The latter, which is the more fre- 
quent, is excessively liable to occasion secondary deposits in the lungs, liver, spleen, kid- 
neys, mediastinal, bronchial, mesenteric, and retroperitoneal glands, the intestinal tract, 
the osseous system, and the brain, and in point of malignity is not surpassed by carcinoma. 
The most important remedies are chalybeate tonics, quinine, cod-liver oil, nutritious food 
and drinks, and a change of air. Mercury is generally hurtful, and friction with stimulating 
liniments and unguents should be avoided. From the arsenical treatment, so much 
lauded by some German surgeons, which consists in the exhibition of Fowler’s solution in 
gradually increasing doses, and the injection of that remedy into the tumor, I have not 
met with decided results, nor have I been more successful from extirpation. The disease 
is very liable to go on from bad to worse despite all our attempts to arrest its progress, 
death finally taking place from sheer exhaustion. 
SECT. IV NEOPLASMS WHICH REPRESENT EMBRYONIC, IMMATURE,'OR UNRIPE 
CONNECTIVE TISSUE. 
1. SARCOMATOUS TUMORS. 
Sarcoma embraces an entirely distinct class of tumors, which hold an intermediate posi- 
tion between benign and malignant growths, inasmuch as they have a local, innocent 
period, during which they are amenable to the knife, while later they may assume a malignant 
form, as exhibited by their constant tendency to recurrence after removal, and the devel- 
opment of metastatic or secondary deposits in distant tissues and organs. It is by far the 
most interesting of the histoid neoplasms, presenting, as it does, in its clinical history, 
features similar to and yet dissimilar from those of carcinoma, and differing widely from 
the latter in its histological construction, the distinction between them being that carci- 
noma is characterized by a marked alveolar formation of its stroma, the loculi being 
crowded with cells of an epithelial type, while in sarcoma the cells are of the type of the 
developmental series of the connective tissues, and mingled with the intercellular sub- 
stance. In its pure form, no tumor can be more simple in its character, as it consists of 
imperfectly elaborated elements, which have no similarity to any normal structure of adult 
life, and which never advance to higher development. A sarcoma may, therefore, be de- 
fined to be a tumor composed almost entirely of cells, which have their origin in those of 
the connective tissues, and persist as such, although greatly enlarged and increased in 
number. The structure of such a growth is, then, only distinguishable from that of the 220 
TUMORS OR MORBID GROWTHS. 
CHAP. VII. 
connective-tissue series, by the excessive preponderance, development, and arrangement 
of its cellular elements, which constitute its peculiar features. 
The connective tissues proper, whether subcutaneous, submucous, subserous, intermus- 
cular, or fascial, are always the starting-points of sarcoma. It often, however, arises from 
other structures of this series, as, for example, the delicate, supporting, retiform tissues of 
the nervous centres and the lymphatic glands, the periosteum and osseous marrow, when 
the histological peculiarities of the matrix are usually propagated to it. Thus, sarcomas 
of the choroid and skin produce pigment cells; spindle cells predominate in those which 
originate in aponeuroses ; while periosteal sarcomas evince a disposition to osseous forma- 
tions, so that they are distinguished by the similarity of their structure to one or another 
of the group of connective tissues, as fibrous, mucous, glious, lymphoid, cartilaginous, 
osseous, or pigmented. They may, moreover, spring from the connective tissue of other 
neoplasms, as is frequently seen in carcinoma, some segments of which present sarcoma- 
tous characters, and they possess, in a remarkable degree, the power of combining among 
themselves, several different tissues existing in the same growth, thereby giving rise to 
mixed tumors. 
The cell elements of sarcoma, like those of the tissues from which they are developed, 
are round, spindle-shaped, or stellate, existing either separately or in conjunction in the 
same tumor. In the latter event, the most common of all, one form always predominates, 
and it is in accordance with the preponderance of one or the other kind of cell that three 
principal forms of sarcoma are recognized, namely, round-celled, spindle-celled, and giant- 
celled. In all of these the cells, as a rule, are hypertrophied ; the nuclei and nucleoli are 
especially enlarged and increased in number, the former often attaining the size of the 
largest normal cells. Hound cells are found in all sarcomas, and are often very small, as 
is seen particularly in the glious variety. They are extremely friable, thereby producing 
the appearance of free nuclei in recent preparations, and, for the most part, resemble 
lymph corpuscles, colorless blood corpuscles, and granulation cells, from which they can- 
not be distinguished, unless it be by the relatively large dimensions of the nucleus, and, 
occasionally, of the cell itself. Spindle cells are very easily recognized. They consist of 
a dimly granular, pale, fusiform body, which terminates at each end in a long, delicate, 
perhaps subdivided, filamentary process. The nucleus, which contains one or more 
nucleoli, is usually single and well defined, and of an ovoid or elliptical form. Giant 
cells, which are commonly associated with the round and fusiform elements, are very 
characteristic, and are similar to the flat protoplasms that are found in the marrow of 
foetal bones. They are the largest of human cells, and often attain extraordinary dimen- 
sions. Their substance is finely granular, and contains very numerous, not unfrequently 
even hundreds of oval, nucleolated nuclei. Their form, which is very variable, is gener- 
ally irregularly ovoidal or polygonal; and rounded or filamentous processes not unfre- 
quently shoot out from their bodies. 
The form and number of the cells are so varied that they cannot alone be considered as 
decisive of the variety of the sarcoma, but it is their arrangement and development that 
are characteristic, as will be seen when the structure of the different tumors of this group 
is considered. They are placed side by side, either in contact with each other, or only 
separated by a minimum quantity of intercellular substance, the nature of which deter- 
mines, in great measure, the subdivisions of sarcoma, but not of the sarcoma itself. 
The matrix, or intercellular substance, is rarely collageneous or pure connective tissue 
capable of yielding gelatine on boiling, but generally of an albuminous, mucous, or glious 
nature. It is always present to a greater or less extent, and may be homogeneous, granu- 
lar, or fibrillated. It occurs in small proportion in spindle-celled and giant-celled tumors, 
but is very abundant in the soft, rapidly-growing, small-celled sarcomas, imparting to 
them a sensation of fluctuation. In fibrous sarcomas it is distinctly fibrillated ; in the 
lymphoid variety it forms a delicate network ; in glious and some mucous sarcomas, it is 
usually amorphous and granular ; while in some again of the latter it is frequently hyaline 
and homogeneous. Finally, one variety of cell may form the matrix of a tumor composed 
of an entirely different cell, and it is not at all uncommon for spindle cells to play this 
role in gaint-celled sarcomas of the bones. 
Bloodvessels exist in great abundance in all sarcomas, pervading them in every direc- 
tion, and forming more or less loose capillary networks, in the meshes of which the cells 
are contained. When the vessels are large, they are surrounded by a supporting connec- 
tive tissue, which assists in giving a retiform appearance to some tumors, but when they 
are minute the cells, like those of granulation tissue, lie directly in contact with their 
walls, from which it is difficult to isolate them. In soft sarcomas, the capillaries are CHAP. VII. 
SARCOMATOUS TUMORS. 
221 
rarely seen to consist of proper walls, but their lumen appears to be limited by round or 
spindle cells, and this disposition of their constituent elements, or vascularization of an 
almost purely cellular tissue, serves as a point of distinction between these and other neo- 
plasms. In some cases the vessels are greatly enlarged, and are so numerous as to con- 
stitute telangiectatic or erectile sarcomas, which, from their great tendency to hemorrhage, 
represent one of the forms of fungus hematodes of former writers. In other cases they 
give rise to pulsating tumors, containing collections of blood, which include, in part, those 
formations known as aneurism of bone. 
Of the causes of sarcoma little is known ; for, although it sometimes shows itself soon 
after birth, it is doubtful whether it is ever of an hereditary character; it is often spon- 
taneous in its origin, but is most frequently traceable to local irritation and external 
injury. 
It appears in both sexes with about equal frequency, and, although it may occur at 
any period of life, is generally met with between the twentieth and the fortieth year, being 
rare before the second decade and uncommon after the latter period. The age of the 
patient, however, influences the liability of the affection in different organs. Thus, 
medullary sarcoma of the genital organs, particularly of the testicle, is more frequent 
about the age of puberty ; retinal glious sarcoma is almost peculiar to infancy ; osseous 
sarcoma is most common in young persons, while pigmented sarcoma usually occurs late in 
adult life. No reliable data exist as to the relative frequency of the seat of the disease. 
It is most common in the skin and subcutaneous and intermuscular connective tissues of 
the extremities. Periosteum and bone, particularly the epiphyses of the long bones and 
the maxillie, are highly obnoxious to it. It is more rarely met with in the lymphatic 
glands and the secreting glandular organs; among the latter, the female breast and the 
testicle are its favorite seats. The eye is not unfrequently affected ; while the serous and 
mucous membranes occasionally are its primary seats. 
Sarcomas usually arise in the form of nodules, single or multiple ; they may be firm or 
soft, and are distinguished from all other neoplasms by the rapidity of their growth, 
through which they often, in a short time, attain enormous dimensions, as is seen particu- 
larly in those connected with the periosteum and lymphatic glands. This increase in 
volume is, in part, central, through proliferation of preexisting cell elements, and, in part, 
peripheral, by extension to the continuous tissues. If the former process predominate, the 
tumor is incapsulated, as is exemplified in fibrous sarcomas; whereas if the growth be due 
to extension by local infection, it is diffused, as is witnessed in soft, small-celled sarcomas. 
Their tendency is progressive. Although there may be a temporary arrest of develop- 
ment, extending even through a number of years, during which they are stationary, they 
usually, under the influence of some exciting agent, external or constitutional, awaken 
into activity and proceed regularly to their termination. Retrogression, through fatty 
metamorphosis of the cells, is almost constant in old, voluminous tumors, but it is rarely 
observed to affect the entire mass. The central part may recede, but, at the same time, 
the remainder increases more luxuriantly, and there is probably not a well-authenticated 
case on record of a spontaneous cure through absorption of the emulsified fatty detritus. 
Fatty degeneration occurs generally in those forms which are very soft, rich in cells, and 
increase rapidly, as the glious and mucous medullary sarcomas, converting them into a 
caseous material, resembling broken-down gummy substance. Through the same change, 
the harder, fibrous forms are converted into dense cicatricial tissue, poor in cells, not 
unlike that of atrophic scirrhus ; but cicatricial shrinkage is uncommon. Calcareous and 
osseous transformations take place in portions of those tumors which are connected with 
bone, as is evinced by the production of irregular, radiating, delicate spicules or plates. 
At other times, and especially in large, medullary growths, softening ensues, which may 
end in ulceration ; or the detritus may be absorbed, leaving cavities, which become filled 
with a serous fluid, thereby forming species of cysts. In some cases, during the process of 
softening, the bloodvessels are eroded, causing extensive parenchymatous hemorrhage, in 
which event the sarcoma, nowr and then, is converted into a species of blood cyst, obscur- 
ing the original characteristic elements, which can then be discovered with difficulty, and 
only at the periphery. Sarcomas of the skin ulcerate early, but the destruction is not great. 
In general, these tumors exhibit little tendency to ulcerate, particularly the firmer forms, 
for which reason the fibrous sarcomas may attain an enormous size. The soft, rich-celled 
sarcomas are more disposed to this change, but it appears later than in carcinoma. When 
it has once occurred, the ulcer rapidly increases, has a foul, fungous appearance, and the 
accompanying discharge, often bloody, sometimes putrid, is very abundant. If the hemor- 
rhage and suppuration are profuse, symptoms of anemia rapidly supervene. Coincidently 222 
TUMORS OR MORBID GROWTHS. 
CHAP. VII. 
with, but seldom before, the ulceration, pain sets in, the general strength fails, the internal 
organs become affected with secondary deposits, and the patient finally succumbs either 
from complications or accidents due to metastatic infection, septicemia, or exhaustion, 
induced by the combined effects of anemia, prolonged suffering, and profuse discharges of 
blood and pus. 
Malignity is a very decided attribute of sarcomas, exhibiting itself not only in a con- 
stant tendency to local recurrence, after extirpation, but also in its power of metastatic 
diffusion. Locally, the infection extends, first, to the neighboring homologous tissues, 
often far beyond the apparent limits of the tumor, a circumstance which explains its dis- 
position to repullulation; and, subsequently, it advances, by continuity, to the heterologous 
tissues. Secondary nodules, often in enormous numbers, and almost invariably present- 
ing the same type as that of the original affection, also develop in distant organs, as the 
lungs, liver, kidneys, brain, bones, pleura, and peritoneum. This dissemination of sarcoma 
takes place, as a rule, through the blood, either by the passage of infecting juices, germs, 
or cells into the vessels, or by embolism, and very rarely by the lymphatics. The lym- 
phatic glands are either not affected at all, or they become involved very late in the 
disease; and the lymphatic vessels themselves are seldom occupied by sarcomatous cells. 
This immunity of the lymphatic system is peculiar, and serves to distinguish this class of 
tumors from carcinoma. The most distant organs, as, for example, the lungs, in osseous 
sarcoma of the extremities, are frequently involved, without the intervening lymphatic 
glands being at all affected. 
From the preceding general description of the clinical progress of sarcomas it is evident 
that they bear a certain resemblance to carcinomas, but differ from them in the following 
particulars. After extirpation, they almost certainly return, representing the peculiari- 
ties of the original tumor, in or near the cicatrice, and this local recurrence is constantly 
repeated. In carcinomas, on the other hand, continuous recurrence usually is the rule. 
Sarcomas evince little disposition to open ; they rarely give rise to a true cachexia; are 
almost painless before ulceration sets in ; and the neighboring lymphatic glands are sin- 
gularly free from implication. These distinctive features are reversed in carcinoma. To 
the naked eye, the only differential characteristics, so far as we are aware, are that the for- 
mer are frequently incapsuled, fat is never seen in their interior, and they do not contain 
a juice like that of carcinoma, which can be expressed from an alveolar structure. The 
anatomical distinctions are not less marked, the relation borne by the cell to the intercel- 
lular substance being decisive of the nature of the mass. In carcinoma, alveoli are formed 
between the trabeculae of the fibrous stroma, which are crowded by cells of an epithelial 
type. In sarcoma, on the other hand, the cells are arranged as parenchymatous cells, 
forming component parts of a continuous tissue; and the structure is never, in the true 
sense of the term, alveolar, in such a way that the cell elements, which always preserve 
the type of connective-tissue cells, are loosely grouped in the particular meshes of a stroma. 
The tendency exhibited by sarcomas to local recurrence and general diffusion warrants 
the surgeon in regarding them as malignant formations, thereby rendering the prognosis 
in the highest degree unfavorable. This is particularly true of the soft varieties which 
are rich in small cells, whether round, fusiform, or stellate, with an abundant intercellular 
substance, and they include the greater number of those tumors known as medullary and 
hematoid fungus. They soften, and ulcerate early, bleed easily, and rapidly disseminate 
themselves throughout the organism. As a rule, local and general infection commence 
soon, and exist, although inappreciable to the eye and touch, at the time of operative 
interference, on which account rapid repullulation is witnessed. In these cases the prog- 
nosis, before operation, must, of necessity, be guarded, inasmuch as an important element, 
which guides the surgeon in carcinoma, namely, involvement of the lymphatic glands, is 
generally absent. The diffused forms are more infectious than those which are isolated 
or incapsulated, and the firm sarcomas are more benign and pursue a less rapid course than 
the soft. It is, moreover, important to remember that, at an early period of their devel- 
opment, particularly if their growth has been tardy, they are local, relatively benign affec- 
tions, attended neither with pain, inconvenience, nor detriment to the general health, and 
amenable to operation, good results being occasionally obtained after amputation even in 
large osseous sarcomas of the extremities. 
The degree of malignity of sarcomas differs, although it is not easy to establish the gra- 
dation. In general, however, it may be stated that soft tumors which are rich in small 
cells are more destructive to the part, as well as to life, than those with large cells, medul- 
lary giant-celled and colossal spindle-celled sarcomas even affording a comparatively 
favorable prognosis. Fibrous sarcomas are usually solitary, and, hence, are more benign CHAP. VII. 
DIFFERENT FORMS OF SARCOMA. 
223 
than the former. Glious, myxomatous, and pigmented tumors, with small cells, on the other 
hand, do not yield to carcinoma in respect to malignity. In other words, the greater the 
tendency to the production of more highly developed structures, as connective tissue and 
bone, as seen in the spindle and giant-celled sarcomas, the less grave is the prognosis ; 
while it becomes more serious the more the tumor is formed entirely, or nearly so, of 
rudimental or persistent developmental tissue. In the order of malignity, the sarcomas 
may, therefore, be classed as follows—medullary round-celled, pigmented, alveolar, osteoid, 
myxomatous, lipomatous, spindle-celled, fibrous, and giant-celled. It may, however, be 
remarked that the prognosis is influenced by the organ or tissue affected, as well as by 
the structure of the tumor itself. Thus a sarcoma of the testicle is more malignant tnan 
the same variety affecting the ovary. Sarcoma of the aponeuroses gives a favorable prog- 
nosis, while in some of the mucous membranes local and distant infection rapidly supervenes. 
DIFFERENT FORMS OF SARCOMA. 
1. Round-celled Sarcoma—Round-celled sarcoma, known also as the embryoplastic 
tumor, or soft, medullary, granulation, glious, lymphadenoid, or encephaloid sarcoma, is 
most frequently met with in young persons, and during infancy, in connection with the 
periosteum and the neuroglia, or delicate supporting reticulum of the retina and nervous 
centres. It is, however, not uncommonly observed in the skin, subcutaneous and deep 
connective tissues, bones, muscles, testicles, and 
glands, especially the lymphatic and mammary, 
and must be regarded as the most malignant of all 
growths, not carcinomatous, as it runs a very rapid 
course, attains huge proportions, soon ulcerates, 
bleeds easily, almost always, if not invariably, re- 
turns after extirpation, and possesses great powers 
of general dissemination, the lungs being then, ap- 
parently, its favorite seat. 
On section, the cut surfaces are occasionally so 
soft and white as to resemble brain matter; but 
they usually have a translucent, light-grayish ap- 
pearance, which may be tinted of a pinkish or yel- 
lowish hue, or be variously mottled by extravasated 
blood and injected vessels, which are very nume- 
rous and of a large size. They also furnish, on 
pressure or scraping, a transparent fluid, altogether 
different from the so-called cancer-juice. This is a 
peculiarity not met with in the other varieties of sar- 
coma, excepting the soft spindle-celled. From their 
naked-eye appearances, as well as from their clinical 
history, these growths are constantly mistaken for 
encephaloid carcinoma, and the difficulty of distinction between them is sometimes very 
great, if not insurmountable, without the aid of the microscope. In its minute structure, 
round-celled sarcoma is composed essentially of delicate bloodvessels and spherical, fragile 
cells, provided with a round or oval nucleus, and of the dimensions of lymph corpuscles, 
and contained in a homogeneous, dimly granular, or amorphous matrix, thereby bearing a 
great resemblance to granulation tissue. There are several varieties of round-celled sar- 
coma, which are based upon the nature of the intercellular substance, and upon certain 
degenerations. 
a. Lymphadenoid sarcoma—The lymphatic gland-like round-celled sarcoma is distin- 
guished by a delicate reticulum similar to that of adenoid tissue, pervaded by large, thin- 
walled capillaries, which are formed of only one cell layer, as is shown at a, fig. 3(5, from 
Rindfleisch. The spaces between the vessels are occupied by the reticulum, the meshes 
of which contain lymphoid cells, with relatively large nuclei, each of which includes from 
one to three nucleoli, as shown at b. This variety of tumor is very soft, and is found 
more particularly in the superficial and deep-seated connective tissue of the thigh, and the 
periosteum and medulla of bones. 
j3. Glioma.—Glious sarcoma proceeds from the neuroglia, or cementing substance of the 
central nervous system, and is essentially composed of small round cells imbedded in a 
granular matrix. It differs from all other tumors of this class in being seated only in the 
brain, spinal cord, and the soft nerves which proceed from the brain, as the optic and its 
Fig. 36. 
Minute Structure of Lymphadenoid Sarcoma. 224 
TUMORS OR MORBID GROWTHS. 
CHAP. VII. 
retinal expansion, the trigeminal, and the auditory. Virchow teaches that the nervous 
elements which normally exist in the neuroglia, disappear in these growths, but Klebs has 
conclusively shown that in their earlier stages they contain ganglion cells and medullated 
nerve fibres, on which account he terms them neurogliomas. However this may be, glioma 
frequently has a soft cerebriform section, infiltrates the adjacent tissues, and occasionally 
reproduces itself in the internal organs. It is most frequent in infancy and early child- 
hood in the retina. 
y. Alveolar sarcoma A still wider departure from the ordinary type is observed in the 
tumors originally described by 
Billroth as alveolar sarcoma, 
an illustration of the minute 
appearances of which is af- 
forded by fig. 37, copied from 
that author. Roundish heaps 
of comparatively large cells, 
which look not unlike giant 
cells, are contained in the 
spaces of a connective-tissue 
meshwork, the coarser tra- 
beculae of which give off deli- 
cate bands that intersect the 
masses of cells and divide the 
larger clusters into smaller 
ones. It is this peculiar ar- 
rangement of the intercellular 
substance, along with the lym- 
phoid character of the cells, 
which serves to distinguish this neoplasm from carcinoma, as well as to exclude the term 
sarcomatous carcinoma, which Rindfleisch has applied to it. 
Alveolar sarcoma is an uncommon, but a highly vascular growth, and constitutes a 
certain proportion of the so-called aneurisms of bone. It is met with in the bones, mus- 
cles, and skin ; and it is as malignant as carcinoma. 
5. Lipomatous sarcoma The lipomatous sarcoma is not a rare form of the medullary 
round-celled sarcoma, in which a limited number of the cells are distended with drops of 
oil without being destroyed, thereby giving rise to an irregular infiltration of the mass. 
Its favorite sent is the subcutaneous connective tissue of the extremities, where it forms 
large tumors, which may be confounded with encephaloid carcinoma, but from which they 
may be easily distinguished with the aid of the microscope. Lipomatous sarcoma returns, 
as such, alter extirpation, rapidly infects the neighboring lymphatic glands, and dis- 
seminates itself throughout the organism ; the secondary deposits, however, retaining the 
type of the medullary round-celled sarcoma. 
s. Myxomatous sarcoma The myxomatous sarcoma is an outgrowth of early and ex- 
tensive mucous transformation of the round-celled sarcoma, and derives its name from the 
peculiar tremulous, gelatinous appearance presented on section. It is very decidedly 
malignant, grows rapidly, and acquires a large volume, particularly when fatty infiltration 
is combined with the mucous change. These cha-acters, when considered in connection 
with its infecting powers and its minute structure, serve to distinguish it from the ordi- 
nary myxomatous tumor. It has been observed in the omentum, the back, the skin, and 
the connective tissue of the extremities. 
2. SpiniUe-celled Sarcoma.—Spindle-celled sarcoma has various synonvmes, of which 
the most common are fibroplastic tumor and recurring fibroid, although it is also desig- 
nated as fasciculated sarcoma, albuminoid sarcoma, and plasmoma. It is met with chiefly 
in certain growths of cicatrices and of the skin, known as keloid, and seems to have a 
predilection for aponeuroses, the sheaths of bloodvessels and nerves, and the subcutaneous 
and intermuscular connective tissues of the extremities and the neck. It is also found in 
periosteum, bone, the testicle, female breast, and uterus, and differs from the preceding 
variety in exhibiting rather a proneness to local recurrence than to general infection. In 
one of my cases, the growth was removed four times in ten years, and instances are on 
record, in which the disease, appearing primarily in young adults, has returned and been 
extirpated, at or near the site of the first operation, as often as five or six times, at consid- 
erable intervals, and yet the patient attained a good old age. 
The most interesting and extraordinary example of recurrence, probably, ever recorded, 
Fig. 37. 
Minute Structure of Alveolar Sarcoma. CHAP. VII. 
DIFFERENT FORMS OF SARCOMA. 
225 
is one which has been for upwards of ten years under my personal observation, and which 
was described in former editions as encephaloid carcinoma. Reexamination, however, 
proved it to be composed of sarcomatous cells, in which the small spindle forms prepon- 
derated. The patient, an unmarried woman, aged forty-four, in March, 1857, perceived in 
the left breast a small tumor, which was excised the following October. During the next 
sixteen months two more operations were performed, but as the mammary gland had only 
been partially removed, I extirpated the whole of it, along with a fourth tumor, in May, 
1859, when the case was placed under my charge by Dr. Russell, of this city. The disease 
soon reappeared in the cicatrice, and in three months and a half again required the use of 
the knife. After four operations by myself, the case fell into the hands of one of my former 
clinical assistants, Dr. Asch, who attended her until May, 1861, when she was again put 
under my care. In September of that year, I performed the twenty-third and last operation. 
The number of tumors removed, from first to last, was fifty-two, varying in size from a 
small almond to a pullet’s egg. They generally recurred at or near the cicatrice within a 
few weeks after extirpation, and speedily assumed a fungating appearance. They were of 
a soft, vascular, brain-like structure, and the seat of a thin, fetid discharge, with little or 
no disposition to bleed. Occasionally the woman complained of sharp, shooting pains in 
the tumors, extending to the shoulder, but the local suffering was commonly very slight. 
Her general health was all along excellent; there was no lymphatic involvement in the 
axilla or elsewhere; menstruation was going on well; and she always rapidly recovered 
from the effects of the use of the knife. 
Ten years have now elapsed since the last operation. The cicatrices are all in a 
sound condition, very soft, and of a whitish 
aspect. Large portions of the pectoral and also 
of the external and internal intercostal mus- 
cles, were cut away, so that during a deep in- 
spiration there is a slight protrusion of the 
pleura. The apex of the heart is likewise par- 
tially uncovered. It is proper to add that eleven 
of the operations were performed in 1860, and 
six in 1861. 
In its earlier stages, when cut, the spindle- 
celled sarcoma grates under the knife, and the 
surface exhibts a firm, tough, grayish, or pale 
yellowish appearance, similar to that of an ordi- 
nary fibrous growth. After repeated repullulation 
and removal, however, it becomes softer, more 
succulent and brain-like, and it may be accepted 
as a rule that entirely medullary, glistening-white 
tumors are composed of spindle-cells, which, how- 
ever, rarely attain great size. Its texture is 
sometimes remarkably brittle, the slightest trac- 
Fig. 39. 
Fig. 38. 
Minute Structure of Small Spindle-celled Sarcoma. 
Minute Structure of Large Spindle-celled Sarcoma 
tion separating it into numerous fragments, some of which are apt to be left behind dur- 
ing extirpation, unless great care is used in tracing them out. 
Spindle-celled sarcoma, as seen in fig. 38, from Green, and in fig. 39, from Virchow, 
consists essentially of fusiform cells, with well-marked nuclei, and thin processes, some- 
times split at the end, and often many times the length of the body of the cell. They may 
be closely aggregated, forming long bands, which give a trabeculated appearance to certain 
portions of the growth, or they may be arranged loosely in a radiating manner. The 
cells are imbedded in a granular, hyaline, or fibrillated intercellular material, which 
usually exists in small quantity. 226 
TUMORS OR MORBID GROWTHS. 
The varieties of spindle-celled sarcoma are the fibrous and melanotic or pigmented. 
a. Fibrous sarcoma The fibrous sarcoma is a variety of the fibrous tumor, from 
which, however, it differs in the relatively greater richness and development of its cell 
elements, and it includes those cases of so-called fibroma, which manifest a peculiar 
tendency to local return, and are occasionally followed by secondary deposits, particularly 
in the lungs and pleura. Tumors which possess these clinical features, and show, on 
minute examination, segments of pure sarcomatous cells, and segments of pure fibrous 
tissue, should be classed under this head. In such cases, either an old fibrous tumor 
takes on active growth through increase of its cell elements, or a fibroma with relatively 
less cell development recedes and approaches more and more the type of pure sarcoma. 
These growths arise chiefly from the fascia; and periosteum, and are most frequently 
observed in connection with the nares and base of the skull and the superior maxillary 
sinus. 
J3. Pigmented sarcoma Pigmented or melanotic sarcoma, although pigmentation of 
the cells may be met with in any of the forms of sarcoma, is usually a variety of the 
spindle-celled tumor, in which the cells are more or less highly impregnated with melanin, 
as in fig. 40, from Green. To the naked eye, it has either a 
uniformly dark-brown or black appearance, or it may be mottled, 
or present limited zones of pigmentation, the intermediate portions 
being white, gray, or translucent. From the cut surfaces a dark, 
creamy juice can be scraped, which, under the microscope, ex- 
hibits round and fusiform cells in different stages of infiltration, 
the structure of the tumor itself being composed generally of 
round cells lying in the interstices of a spindle-celled network, 
although a pure round-celled, or a pure spindle-celled, growth is 
occasionally met with. The most frequent seats of pigmented 
sarcoma are the skin and choroid coat of the eye, but it sometimes arises primarily in 
the lymphatic glands. Its great malignity is shown by its tendency to rapid and almost 
universal dissemination, every organ and tissue being liable to be invaded by it. In this 
respect, it bears a striking similarity to melanotic carcinoma, from which, indeed, it is 
almost impossible to distinguish it. Both are of a medullary nature ; the latter contains, 
as a rule, few large cells of an epithelial type, and its alveolar structure disappears very 
early, the cell development soon predominating over the formation of a fibrous stroma. 
When the structure is spindle-celled, the distinction is readily made ; but when the tumor 
is round-celled, it is extremely difficult to discriminate between them. The occurrence 
of lymphatic involvement, however, may be of some value in forming a differential diag- 
nosis. This, as has already been pointed out, is comparatively rare in sarcoma, and very 
common in carcinoma. Of 83 cases of melanosis, collected by Eiselt and Pemberton, in 
only 33 was there contamination of the lymphatic system, a circumstance rather in favor 
of the majority not being carcinomatous. These facts, however, show that pigmented 
sarcoma is probably of more frequent occurrence than has generally been supposed, and 
they entitle it to a place in the varieties of sarcoma. 
3. Giant-celled Sarcoma.—This term is applied by Virchow7 to that variety of sarcoma 
in which giant or multinucleated cells form a regular and constant element, although it 
had previously been described by Lebert and Nelaton as the myeloplaxic tumor, and by 
Paget as the myeloid or marrow-like tumor. It has been noticed in the different parts 
of the body, but in particular in or upon bones, the jaw-bones and the epiphyses of the long 
bones being its favorite seats. It has also been observed in the mammary gland, uterus, 
cerebral membranes, the subcutaneous connective tissue, in the muscles, and in the eye- 
lids and conjunctiva, occurring in various sized masses, generally of a rounded or ovoidal 
shape, and of a consistence varying from that of tallow or suet to that of fibrous tissue. 
The cut surface has a smooth, compact, shining, grayish-white or greenish appearance, 
with blotches of a dark crimson, brownish, pink, or modena hue, either uniformly, or in 
various degrees of combination, all these tints being sometimes commingled. Much stress 
is laid upon these colors by pathologists as diagnostic characters of giant-celled sarcomas, 
affording, as they do, the most ready external means of discrimination between them and 
analogous growths. When the disease is developed in the cancellous tissue of the bones, 
in which its occurrence is more frequent than anywhere else, the tumor disparts the com- 
pact layers, forming a kind of cyst-like expansion, in which the new matter is lodged, and 
which, under such circumstances, often contains a large amount of osseous substance, 
soft, cellulated, of a reddish or pale yellowish tint, and easily recognized by sight and touch. 
CHAP. VII. 
Fig. 40. 
Minute Structure of Pig- 
mented Sarcoma. MYXOMATOUS TUMORS 
227 
CHAP. VII. 
The giant-celled sarcoma is 
generally rapid in its growth, 
and is not always a benign affec- 
tion. It destroys effectually the 
structures in which it is devel- 
oped, recurs locally after extir- 
pation, and sometimes gives rise 
to metastatic nodules in the in- 
ternal organs. It is, however, 
the least malignant of the sarco- 
mas, and the prognosis is, as a 
rule, favorable. 
The most characteristic minute 
feature of this tumor, as seen in 
fig. 41, from Liicke, is the pre- 
ponderance of multinucleated, 
myeloplaxic, or giant cells,which 
never, however, exist alone, but 
are variously intermingled with round or spindle forms, and contained in a sparse, gener- 
ally amorphous, sometimes fibrillated, intercellular substance. 
In addition to the foregoing three principal forms of sarcoma and its varieties, there are 
certain other varieties, which will be described in their appropriate places under the heads 
of lymphatic, cartilaginous, and osseous tumors. 
The diagnosis of sarcomas during life is by no means always easy. Their form is 
usually well defined, round, oval, or spherical, and their surface is more or less lobulated. 
Periosteal tumors of this description, however, may be distinguished by their smooth snr- 
face and fusiform outline. In consistence, they may be firm, tense, and elastic, but are 
generally soft and apparently fluctuating, so much so, indeed, that they may be mistaken 
for abscesses and the softer varieties of fatty and mucous tumors. The overlying integu- 
ment may be unchanged, or it may be tense, florid, or livid, and, in some parts, ulcerated, 
the sore, in the latter event, being usually superficial and covered with healthy-looking 
granulations. The subcutaneous veins rarely attain any considerable volume. Their 
origin is commonly traceable to external injury. They sometimes grow slowly, at other 
times rapidly. In the case of a lady, thirty-five years of age, whom I saw with Dr. 
Addinell Ilewson, a small, round-celled tumor of this kind in the mammary gland at- 
tained, in the course of four months from the time of its first appearance, a weight of 
nearly six pounds and a volume equal to an ordinary adult head. No pain attends these 
neoplasms until ulceration sets in, and even then it is often very insignificant. They are 
most frequent between the twentieth and fortieth years, rare before and after these periods, 
and very uncommon in young children. In a word, a very rapidly growing, large, pain- 
less, apparently fluctuating tumor, occurring before the fortieth year, not marked by lym- 
phatic involvement, disposition to ulcerate, or impairment of the general health, may be 
pronounced to be sarcomatous. 
In the treatment of these tumors nothing need to be expected from general measures, 
the only remedy that holds out the slightest prospect for a cure being early and complete 
excision, with, perhaps, destructive cauterization of the surrounding parts. For the very 
large, soft sarcomas which originate deep in the extremities, whether from the interstitial 
muscular tissue, lymphatic glands, aponeuroses, sheaths of vessels and nerves, periosteum, 
or bone, amputation, if possible, in the contiguity of the limb, is the proper resource, 
while resection may be practised when the shorter bones, such as the phalanges of the 
fingers, clavicle, radius, and ulna, are affected. When the jaws are the seat of the dis- 
ease, total extirpation is preferable to partial excision. 
2. MYXOMATOUS TUMORS. 
The morbid product, originally described by J. Muller under the name of collonema, is 
now generally known as the mucous tumor, or myxoma, from the fact that it is essentially 
composed of mucous material, which thus imparts to it its distinctive features. In some 
pathological treatises it figures as a variety of sarcoma with the prefix “ gelatinous” or 
“net-celled.” Its characteristic mucous constituent is represented in the normal state by 
the jelly-like matter of the umbilical cord, by the subcutaneous connective tissue of the 
foetus, and to a slight extent by the vitreous humor of the adult eye. A young myxoma 
Fig. 41. 
Minute Structure of Giant-celled Sarcoma. 228 
closely resembles, in its physical properties, a mass of fat; and cases are met with in 
which the one is directly convertible into the other by an increase or decrease of the 
respective constituent elements. 
The characteristic features of the myxoma are elasticity and softness. Its consistence, 
however, is by means uniform. Occasionally the whole mass has a tremulous, jelly-like 
look and feel; sometimes it has an infiltrated, oedematous appearance, and readily pits on 
pressure; and nowand then it fluctuates like a cyst. In rare cases these various proper- 
ties are associated in the same specimen. The older growths are always harder than 
the recent, the former generally containing more solid matter and the latter more mucous. 
Two essential elements enter into the composition of a myxoma, a fibrous basement 
structure and an intercellular substance, pervaded by bloodvessels, generally so distinct 
as to be easily recognized by the naked eye. The basement structure, the proper stroma 
of the tumor, belongs essentially to the developmental series of connective tissues, and 
yields on pressure, when cut, an intercellular substance of a glutinous, tenacious consist- 
ence, like the white of an egg, or a solution of gum arabic, perfectly free from milky 
juice. The fluid thus obtained exhibits under the microscope numerous cells, of varying 
forms and sizes, for the most part round, angular, stellate, spindle-shaped, or net-like. 
Many of the cells are of great length, as if they were beaten out, with very thin, tapering 
extremities. Some of the cells have several nuclei, others only one, and many of them 
are connected in such a manner as to present an appearance as if they were fused together. 
In the young myxomatous growths, abound- 
ing in mucous material, the round and 
angular cells are most conspicuous, whereas 
in the old there is a preponderance of the 
stellate and spindle-shaped, which not un- 
frequently exhibit an anastomotic and 
areolar arrangement, rendered very dis- 
tinct on the addition of a solution of iodine 
or carmine, as in fig. 42, from Liicke. 
Besides these elements, the morbid mass 
often contains fat cells, fibrous tissue, both 
white and elastic, cartilage and bloodves- 
sels in varying proportions, thus giving 
rise to certain subdivisions, as the lipoma- 
tous, fibrous, cartilaginous, and telangice- 
tatic. 
Among the more perfect types of the mu- 
cous growths are the gelatinoid polyps of the 
nose, ear, and uterus,and the non-malignant 
colloid tumors, especially those developed 
in the parotid region, in the nerves, and in 
the mammary gland. They occur chiefly in young subjects, in the subcutaneous and 
intermuscular connective tissues, particularly upon the thigh, back, shoulder, neck, labia, 
and trunk, in the mucous cavities, in the hilus of the kidney, and in the nerves and bones, 
in the latter of which they usually take their starting-point in the medulla. More or less 
mucous matter, such as distinguishes the myxoma, is often found in goitrous and other 
cysts, serving to impart a mixed character to the morbid growth. 
The myxoma has only a very feeble circulation, and is, therefore, usually of slow growth 
and of small size, although occasionally the tumor advances very rapidly, and acquires a 
large bulk. Such an occurrence will be most likely to happen when the morbid mass 
abounds in embryonic material and in round cells with several nuclei. Although gene- 
rally essentially benign, mucous tumors may, by tbeir active proliferation, and their 
remarkable power of combining with other tumors, occasionally assume a decidedly ma- 
lignant character, as evidenced by their frequent recurrence, and the formation of second- 
ary deposits in the viscera. The latter occurrence is most frequently witnessed in the 
lipomatous variety, since of seven cases of which 1 am cognizant in only two was the 
tumor of a hyaline nature, while it was lipomatous in the remainder. 
The myxoma is liable to hemorrhage from the accidental rupture of its vessels, bdt it 
rarely, if ever, ulcerates or mortifies. The older portions often undergo the fatty degene- 
ration, and such portions are occasionally occupied by cartilaginous, or osseous matter, as 
the result of a retrogressive movement. 
The diagnosis of such a growth cannot be easily solved before extirpation, except when 
TUMORS OR MORBID GROWTHS. 
CHAP. vix. 
Fig. 42. 
Minute Structure of a Myxomatous Tumor. 229 
CHAP. VII. 
MYOMATOUS TUMORS. 
it occupies a mucous canal. When situated under the skin or among the muscles, its 
slow development, its soft, elastic consistence, its mobility, the integrity of the general 
health, and the absence of pain, discoloration of the skin, and involvement of the neigh- 
boring lymphatic glands may assist, but cannot positively determine, the diagnosis. 
No remedies, local or general, exert any control over this variety of morbid growth. 
Removal is effected, according to the situation and volume of the mass, with the forceps, 
ligature, ecraseur, or knife. Recurrence will not be likely to happen if the operation be 
well performed. 
SECT, y NEOPLASMS DERIVED FROM AND COMPOSED OF HIGHER TISSUES. 
1. MYOMATOUS TUMORS. 
Under the term myoma may be described a tumor which is composed of muscular 
tissue. It embraces two varieties of growths, namely, a neoplasm containing striated 
muscular fibres, and a neoplasm containing smooth muscular fibres. 
Fig. 43. 
Minute Structure of Rhabdomyoma. 
1. Myoma composed of striated or voluntary muscular fibres, or the rhabdomyoma of 
Zenker, is very rare, but it has been observed in the kidney, heart, uterus, testicle, in the 
muscles of the arm and chest, the vagina, and 
at the root of the nose. It consists, as is seen 
in fig. 43, from Rudnewa, of striated fusiform 
cells, with a varying amount of connective tis- 
sue. It is frequently congenital ; may attain 
the volume of an adult head ; is now and then 
combined with sarcoma or myxoma ; and is 
liable to recur after extirpation. 
2. Myoma composed of smooth muscular fi- 
bres, or the leiomyoma of Zenker, finds its char- 
acteristic type in the uterus. In structure, as 
seen in the adjoining sketch, fig. 44, from Ar- 
nott, it is made up of parallel or interlacing bun- 
dles of unstriped muscular fibres, or of elongated 
spindle cells with rod-shaped nuclei united by 
connective tissue. A few fat cells are shown 
in the illustration. 
Leiomyoma occurs almost exclusively in the 
involuntary muscles, those of animal life being 
in great degree exempt from it. Although it 
is occasionally met with in the oesophagus, pros- 
tate, vagina, bladder, testicle, stomach, intes- 
tine, skin of the scrotum and mammary region, 
its favorite seat is the uterus, especially the body of that organ, for the reason, apparently, 
that this part is much more abundantly supplied with muscular fibres than the cervix. In 
the organ in question it occurs in three distinct situations, as an intramural, intraparietal, 
Fig. 44. 
Minute Structure of Leiomyoma. 230 
TUMORS OR MORBID GROWTHS. 
CHAT. VII. 
or extramural growth, capable in all of attaining an enormous bulk, cases having been 
observed in which the weight nearly equalled that of the body of the patient. When 
such a growth is developed in the cavity of the uterus, it is generally described as a polyp, 
although its structure does not differ from that of a myoma in the other situations referred 
to. In shape the tumor is, for the most part, globular, conical, or pyriform, its attach- 
ment being either by a broad base, or, as is most commonly the case, by a comparatively 
narrow pedicle, especially when the growth is of the polypoid variety. 
The number of muscular tumors is variable. In the uterus it is often considerable, 
especially in the extramural variety, in which there are occasionally as many as half a 
dozen, or even more. In their color they are light-grayish, pale-reddish, or almost white. 
Their consistence varies with their age and other circumstances. Young growths of this 
kind are often quite soft, succulent, and even slightly elastic, whereas the older ones are 
very firm and dense, creaking under the knife, and tearing with great difficulty. Many, 
especially the older ones, contain a large proportion of fibrous matter, and, hence, such 
growths are usually called fibro-myomas, or fibro-muscular tumors. Calcareous matter 
and cysts, fdled with different kinds of fluids, are also occasionally found in them ; and 
many, as they advance in age, undergo the fatty degeneration. 
A myoma is occasionally met with in the prostate gland, chiefly of elderly subjects, as 
an outgrowth of the normal muscular fibres, which are prolonged upon the organ from the 
muscular coat of the bladder. A very large proportion of the structure of this gland is, 
as is well known, made up of these prolongations, interspersed with the peculiar glandu- 
lar substance from which the organ derives its distinctive features. The part of the gland 
most liable to this growth is the posterior and middle, where it occurs in various forms 
and degrees, constituting what is called the middle lobe, a structure which has no exist- 
ence in the normal state. Small nodules of this kind are occasionally imbedded in the 
main body of the gland, inclosed in a distinct capsule, and easily enucleated. 
The myomatous tumor is most common in advanced age. In the uterus it seldom 
appears before middle life, and is most frequent in elderly subjects. It is never congenital. 
It is generally tardy in its development, has a very scanty supply of bloodvessels, and 
incommodes chiefly by its weight and bulk, and by its encroachment upon the surround- 
ing parts. In the cavity of the uterus it usually gives rise to hemorrhage, and in the 
prostate gland to serious obstacle to the passage of the urine. 
Of the causes of these formations nothing whatever is known. Inflammatory irritation 
may possibly have some agency in their production, but in what manner or degree, is 
wholly conjectural. That they are merely so many benign outgrowths or hyperplasias of 
the normal tissues of the organs in which they are developed, is sufficiently evident. 
Medication exerts no influence upon the progress and ultimate fate of this morbid 
growth. When seated in the cavity of the uterus, it is often susceptible of removal, 
particularly when it has a narrow pedicle, with the forceps, ligature, or ecraseur. Occa- 
sionally a tumor of this kind may be enucleated; and now and then a case occurs of 
spontaneous expulsion, especially when the growth has undergone calcification, or when 
it has been partially devitalized by incisions and the injection of irritating fluids. Myomas 
of the prostate are irremediable. 
2. VASCULAR TUMORS. 
The vascular tumor, angioma, or erectile tumor, essentially consists, as the name 
implies, of a network of small vessels, mostly of new formation, and held together by a 
minute quantity of connective tissue. Its characteristic type is found in what is called 
a mother’s mark, naevus maternus, capillary angioma, or telangiectasis, a term much em- 
ployed by German pathologists, and literally signifying a dilatation of the capillary vessels. 
Aneurism by anastomosis, so graphically described by John Bell, early in the present 
century, is a not uncommon form of vascular tumor. The term erectile, as applied to 
these morbid growths, is, in the main, well chosen, as their structure bears, in many in- 
stances, if not generally, a very close resemblance to the cavernous body of the penis and 
similar erectile textures, expanding under mental emotion and whatever has a tendency 
to cause a temporary influx of blood. 
The vascular tumor is generally met with as a congenital affection, its foundation being 
laid during foetal life, and it is not uncommon for it to acquire a considerable bulk before 
birth. Most generally, however, it is very diminutive when first noticed, not exceeding, 
it may be, the volume of a pin’s head, a millet seed, or a currant, and it often continues 
so until some time after, when, perhaps suddenly, and without any assignable cause, it VASCULAR TUMORS 
231 
takes a new start, growing with remarkable 
rapidity, and encroaching more or less seriously 
upon the surrounding structures. The ordinary 
sites of angioma are the skin and mucous mem- 
branes, especially about the head, face, eyelids, 
lips, cheeks, and tongue. An internal hemor- 
rhoidal tumor is essentially an erectile angioma. 
Vascular tumors vary much in their color, 
the chief influencing causes being their structure 
and situation. The venous are usually of a 
bluish, deep lilac, claret, or purple hue, whereas 
the arterial are generally of a bright rose or 
scarlet color, in consonance with the nature of 
their contents. The color, however, is not 
always uniform, but often varies in different 
portions of the same growth. In their consis- 
tence they are soft and spongy, easily com- 
pressed, and often notably elastic, especially 
when of large bulk, of long standing, or deeply 
seated. An arterial angioma—the true anas- 
tomotic aneurism—always pulsates synchro- 
nously with the heart, and, as already stated, 
greatly augments in bulk under mental excite- 
ment ; but it rarely has any of the sounds so 
characteristic of a common aneurism. 
There is generally only one such tumor; but we often meet with several in the same 
patient, and in some of my cases the number was so great as to lead to a belief in the 
existence of a kind of angeiomatous diathesis. 
Although most vascular tumors are congenital, they occasionally do not make their ap- 
pearance until a long time after birth. How far external injury, as a blow or bruise, may 
be instrumental in giving rise to such formations is undetermined. There are, however, 
numerous instances upon record which go to show that it may act as an exciting cause. 
In a case related by the late Dr. J. Mason Warren, a man, thirty-six years old, had a 
large aneurism by anastomosis on the lobe of one of his ears, consequent, apparently, 
upon a severe frost-bite, received at the age of sixteen. 
CHAP. VII. 
Fig. 45. 
Vascular Tumor of the Scalp. 
Fig. 46. 
Fig. 47. 
The vascular tumor exhibits considerable variety of structure, being at one time essen- 
tially composed of veins, at another of arteries, and occasionally, again, of both arte- 
Minute Structure of Simple Angioma. 
Minute Structure of Cavernous Angioma. 232 
TUMOUS OR MORBID GROWTHS. 
CHAP. VII. 
ries and veins, so equally balanced, in number and calibre, as to render it difficult, if not 
impossible, to determine which predominate. In the simple angioma, which embraces 
the various forms of telangiectasis and mevi, the vessels, arterial, venous, or capillary, 
are greatly enlarged, tortuous, and anastomose, as in fig. 40, from Billroth. In the cavern- 
ous angioma, or cavernous venous tumor, which comprises erectile tumors and aneurism 
by anastomosis, the structure, as displayed in fig. 47, from Rindfieisch, is very similar to 
the cavernous body of the penis, being composed of a reticulated meslnvork of dense and 
elastic connective tissue, lined by endothelium, and distended with blood. The meshes 
or alveoli freely intercommunicate, and constitute a system of cavities in which the blood 
carried to them by numerous vessels circulates. Old angiomas sometimes contain phle- 
bolites and organized clots. Numerous instances are recorded in which the patient bled 
to death in attempts to extirpate such tumors. 
The diagnosis of angiomas is deduced from their situation, color, and consistence, and 
from a careful consideration of the history of the case. The prognosis varies. The 
venous tumor is always less dangerous than the arterial, which, as it enlarges, is liable, 
especially under the influence of injury, ill-health, or exhausting disease, to ulcerate, to 
bleed, and to cause absorption of the surrounding structures, the osseous and cartilagi- 
nous not excepted. Some growths of this kind, arterial as well as venous, occasionally 
enjoy a period of repose, apparently neither advancing nor receding ; generally, however, 
the reverse is the case, there being a disposition to rapid development, the more espe- 
cially when there is a marked predominance of the arterial element, or when the tumor 
is almost exclusively composed of this structure. A spontaneous cure occasionally 
occurs, the vessels becoming obliterated, probably as an effect of inflammation leading to 
the coagulation of their contents and the gradual closure of their calibre. Recurrence 
has been witnessed after excision, probably due to the imperfect use of the knife rather 
than to any inherent tendency to repullulation. Carcinomatous or sarcomatous degene- 
ration is possible, but very uncommon. The treatment of angiomas will be fully dis- 
cussed in the chapter on the affections of the capillary vessels. 
3. LYMPH ANGIOMATOUS TUMORS. 
Tumors composed of newly-formed and of dilated preexisting lymph vessels are un- 
common, but their existence is confirmed by a number of examples which have been re- 
corded during the past fifteen years, and which have been carefully studied by Wegner in 
an elaborate paper published in the Archiv fur Klinische Chirurgie for 1877. 
Lymphangioma may be simple, cavernous, or cystoid. The simple variety consists of 
an anastomosing network of lymphatics supported by a slight quantity of connective 
tissue, so that it resembles simple or plexiform angioma. Cavernous lymphangioma is 
composed of a trabecular cavernous tissue, the meshes of which are filled with fluid or 
thrombosed lymph. Hence it has the same anatomical construction as cavernous angioma 
or venous tumor, the only difference being that its meshes contain lymph instead of blood. 
The cystoid variety, as the term implies, is characterized by the presence of one or more 
cysts, which usually arise from the occlusion of the openings of communication between 
the meshes of the cavernous variety and the efferent lymph vessels. Of the three divi- 
sions, the cavernous is the one usually met with. 
The most common sites of lymphangioma are the neck, where it forms a certain 
proportion of the congenital cystic hygromas, the tongue, the lips, and the cheeks, in 
which it is known, respectively, as macroglossia, macrochilia, and macromelia, the groin, 
and the perineum. It has also been observed on the forehead, in the axilla, the mammary 
region, the shoulder, the buttocks, the penis, the adrenal, the kidney, the liver, and the 
mesentery. In all of these situations its point of departure is the superficial or deep con- 
nective tissue. The tumor may be diffused, as when it occurs in the tongue, the lips, or 
the cheeks, or it may be distinctly circumscribed, and even be surrounded by a well- 
formed capsule. 
The etiology of lymphangioma is obscure. Although it may be acquired, and is occa- 
sionally ascribable to injury, it is nearly always congenital. Its growth is constant, but, 
as a rule, very gradual, so that many years may elapse before it attains the volume of a 
walnut. Now and then its increase is so very rapid that it may attain the size of a fist 
in six or eight weeks, or, in the course of fifteen or eighteen months, even of a child’s 
head. 
When it involves the tongue or the lip, the neoplasm is of a fibro-elastic consistence, 
but in other situations it is soft and compressible like myxoma, or even fluctuating, as when 233 
CHAP. VII. 
NEUROMATOUS TUMORS. 
it is of the cystoid variety. It is rarely painful, and it evinces no tendency to ulcerate; 
but it is liable to attacks of inflammation, during which it increases in volume, becomes 
hot, red, and tender, and gives rise to constitutional disturbance. The integument covering 
the growth is now and then the seat of small, transparent vesicles, which, on bursting, 
admit of the escape of its contents. 
In the absence of lymphorrhoea and periodical attacks of inflammation, these tumors 
so closely resemble the soft fibromas, lipomas, myxomas, and simple angiomas, that 
their discrimination is most difficult before removal. The cavernous and cystic varieties 
may, however, be readily recognized by the exploring needle, the withdrawal of which is 
attended by the escape of colorless fluid presenting the chemical and physical properties 
of lymph. 
Lymphangiomas are benign formations. The proper treatment is by excision ; but 
the knife should be replaced by irritating injections when the cystoid variety is situated 
in the midst of important structures, as, for example, in the neck. 
4. NEUROMATOUS TUMORS. 
The nerves of animal life, especially the radial, ulnar, median, tibial, and peroneal, are 
subject to two forms of tumors, known, respectively, as the true and spurious neuroma, 
the former being composed principally of nerve substance, while the latter is seated on 
and in the nerve trunks, and includes fibromas, sarcomas, and myxomas, as well as the 
painful tubercle, incidentally noticed by Petit, Cheselden, Dupuytren, and other observers, 
and first accurately described, in 1812, by Mr. William Wood, of England. The neuro- 
matous tumor, properly so termed, has been particularly studied and delineated by Mr. 
liobert W. Smith, of Dublin, who published a splendid monograph upon it in 1849. 
A true neuroma may arise in the gray centres of the brain and spinal cord, but it is 
very uncommon in these situations, and is of no clinical importance. The form which 
chiefly interests the surgeon proceeds from the peripheral nerves, and is composed of 
nerve fibres, partly of new formation, and partly of preexisting hypertrophied fibres, 
separated by connective tissue. It may contain medullated fibres, when it is denominated 
Fig. 48. 
Fig. 49. 
Minute Structure of a True Neuroma seen 
in Transverse Section. 
Miuute Structure of a True Neuroma seen iu 
Longitudinal Section. 
myelinic by Virchow, or non-medullated fibres, when it is known as amyelinic neuroma ; 
but the latter variety is difficult of determination, since it is scarcely possible to distin- 
guish the fibres of Iiemak from fibrous tissue. Both sets of fibres generally exist in 
conjunction in the same tumor, as may be perceived by a reference to figs. 48 and 49, 
magnified 450 diameters, after Dr. Paul Bruns, of Tubingen. The former, copied from 
a transverse section of a plexiform neuroma of the posterior auricular region, shows the 
relation of the nerve fibres to their sheaths and to the interstitial connective tissue. In 
the largest fibres, the concentric arrangement of the myelin around the axis cylinder is 
very apparent, while it is missing in others. The smallest filaments are composed of 
naked axis cylinder alone. The latter figure represents a longitudinal section of the same 
tumor, with its double-contoured or myelinic nerves, and fibrillated and wavy connective 
tissue. In this particular specimen, therefore, the nervous substance constitutes the 
greater part of the growth ; but other formations are met with in which the interstitial TUMORS OK MORBID GROWTHS. 
tissue preponderates, thereby giving rise, in accordance with the nature of the latter, to 
the fibrous, glious, or myxomatous varieties of neuroma. 
The neuromatous tumor is commonly solitary, but there may be a considerable num- 
ber, varying in size from a pea to that of an almond, an egg, or even an adult head. It 
is solid to the touch, firm, inelastic, and of an oblong, ovoidal, or irregularly compressed 
form. When small, it has generally a distinct cyst, of fibrous structure, filled with a 
transparent jelly-like substance, and developed within the neurilemma of the affected 
nerve, the filaments of which are separated from each other, and spread out over the 
surface of the tumor. In cases of long standing, or when the tumor is of unusual bulk, 
the morbid mass is remarkably dense, white or nearly so, homogeneous, and destitute of 
a cyst, properly so called. 
The neuromatous tumor occurs in both sexes, and at various periods of life, although 
it is most common in males and in middle age. Its progress is usually slow, and it sel- 
dom attains any great volume. The exciting causes are generally very obscure, but in 
some cases it is plainly traceable to the effects of external injury, as a wound, blow, or 
bruise; while in other instances there is a congenital or hereditary tendency to its forma- 
tion. Now and then, a veritable neuromatous diathesis exists. In such an event, nearly 
all the nerves of the body, central, spinal, and sympathetic, may be affected. Smith, in 
one instance, counted as many as eight hundred enlargements, and in another upwards of 
two thousand. Occasionally it follows upon amputation, the nerves of the stump becom- 
ing enlarged and bulbous. The pain which attends the disease is very variable, both in 
degree and in character. In most cases it is neuralgic, exceedingly severe, sharp, darting, 
pungent, or stinging, and liable to periodical exacerbations, dependent, apparently, upon 
atmospheric vicissitudes, and disorder of the digestive functions. The slightest pressure, 
friction, or manipulation increases the suffering, which then, not unfrequently, amounts 
to great agony. The parts beyond the tumor, especially those supplied by the affected 
nerve, are cold, numb, and almost powerless. The pain is sometimes seated in the neigh- 
borhood of the tumor rather than in the tumor itself; and occasionally again there is no 
local distress whatever. Although the 
general health may remain good, or- 
dinarily it is more or less impaired; 
and the system, constantly tortured by 
the excessive suffering, is gradually 
reduced to the utmost prostration. 
The accompanying sketch, fig. 50, 
affords an excellent illustration of the 
gross characters of a myxomatous 
neuroma of the peroneal nerve. It 
had existed for nearly twenty years, 
during the last three of which it was 
exquisitely tender and painful. It 
was extirpated by Dr. Dalton and Dr. 
Hoffman, of Ohio, who kindly sent 
me the specimen. The operation was 
followed by sloughing of the fourth 
and fifth toes. 
Under the term plexiform or cir- 
soid neuroma, Verneuil, Billroth, 
Bruns, and others, have described a 
peculiar form of this affection, which 
the last author, from whom the ac- 
companying sketch, fig. 51, is taken, 
includes among the true neuromas. It consists of nodular, convoluted, or varicose cords, 
and may be mistaken for cirsoid aneurism, from which, however, it differs in its incom- 
pressibility and freedom from pulsation. It has been observed only in seventeen instances, 
in all of which it was congenital, and it appears to have a predilection for the subcutaneous 
connective tissue of the upper lid, and temporal and cervical regions. It is singularly 
free from pain, but is occasionally tender on firm pressure. The affection is generally 
attended with hypertrophy of the overlying integument and very marked enlargement of 
the sebaceous follicles. 
The only effectual treatment is excision. As long, however, as the tumor is painless, 
or causes no inconvenience, it is best to let it alone. The operation is usually very sim- 
CHAP. VII. 
Fig. 50. 
Neuromatous Tumor with the Nerve passing to and from it. 235 
CHAP. VII. 
NEUROMATOUS TUMORS. 
pie, and devoid of danger. An attempt should generally be made to enucleate the tumor, 
by pushing aside the nervous filaments, or separating them from the parts in which they 
are embedded. When this is impracticable, from the manner in which the structures are 
fused together, the mass should be exposed by a free incision, and lifted out of its bed by 
Fig. 51. 
True Plexiform Neuroma. 
dividing the affected nerve immediately above and below, over a grooved director. The 
loss of motion occasioned by this proceeding, even when it involves a comparatively large 
nerve, is usually restored in a very short time. Indeed, the chief inconvenience to which 
it gives rise is a sensation of coldness in the distal part of the limb, which may, however, 
remain for years. Amputation has been resorted to for the cure of this complaint; but 
it is difficult to conceive of a case in which it would really be necessary. 
The painful subcutaneous tubercle, fig. 52, is generally situated, as the name implies, 
immediately beneath the skin, in the connective tissue, or in this tissue and in the skin. 
Fig. 52. 
Painful Subcutaneous Tubercle. 
Microscopic Structure of the 
Subcutaneous Tubercle. 
In its minute structure, as seen in fig. 53, it appears to belong to the connective tissue 
series, being composed of fibrous tissue either in a rudimental or perfect state. The pain 
which attends it would seem to establish some relation between it and the superficial 
nerves, and it is highly probable that amyelinic nerve fibres are involved in it. This 
point is, however, difficult of demonstration, as it is almost impossible to distinguish such 
fibres from those of fibrous tissue. In one instance, Virchow found that the tubercle was 
composed of gray nerve fibres. On being cut out it looks very much like a small mass of 
adipose substance, the section having a bright yellowish, grayish, or whitish aspect. Few 
vessels can be discerned in it. It is always remarkably small, seldom exceeding the volume 
of a pea ; very movable ; exquisitely tender to the touch ; and the seat of frequent pain, 
often of a neuralgic character, and subject to constant exacerbations from the most trivial 
causes. It is generally represented as being most common in the lower extremities, but 
this does not accord with my experience, most of the cases that have come under my 
observation having occurred in the arm, forearm, and shoulder. 236 
The painful tubercle is generally single, or, if multiple, more than two or three rarely 
exist in the same person. It occurs in both sexes, but much more frequently in women 
than in men, the reverse being the case in regard to the neuromatous tumor. Its develop- 
ment is usually tardy, and several years often elapse before it becomes very tender and 
painful. Women of a nervous, hysterical temperament appear to be most prone to its 
occurrence. During its development it always involves the skin. 
The situation of this tumor just beneath the skin, or in the skin and connective tissue, 
the absence of discoloration of the surface, the peculiar character of the pain, the intol- 
erance of manipulation, and the history of the case, generally suffice to determine the 
diagnosis. 
The only remedy is free excision, including a small portion of the surrounding healthy 
integument. The disease never returns at the cicatrice, although it may occur afterwards 
in other parts of the body. 
SECT. VI NEOPLASMS WHICH PROCEED FROM AND ARE COMPOSED 
ESSENTIALLY OF EPITHELIUM. 
The epithelial neoplasms may be typical or atypical. The former embrace papilloma 
and adenoma, and the latter are confined to the carcinomatous formations. 
1. PAPILLARY TUMORS. 
The morbid growths comprised under this appellation have their physiological prototypes 
in the papillaB and villi of the cutaneous and mucous membranes from which they are 
generally derived ; and they are composed, as is seen in fig. 54, from Rindfleisch, of vas- 
cular connective tissue, covered by epithelium, 
which varies in character in accordance with the 
origin of the formation. In some of these hyper- 
plastic tumors, as in the ordinary wart, corn, and 
born, the epithelial elements predominate; while, 
in others, as in the condylomas, and the villous 
or papillary growths of the mucous surfaces, the 
connective tissue forms the essential constituent. 
Two varieties of papillomas naturally fall under 
this arrangement, the corneous or hard, and the 
mucous or soft: the former consisting of warts, 
corns, horns; and the latter of condylomas, certain 
outgrowths from the nose, larynx, the gastroin- 
testinal tract, the neck of the uterus, and the 
bladder, and the formations met with in the 
serous surface of the dura mater. The corneous 
variety is most common in the hands, fingers, 
toes, forehead, face, and trunk. The soft variety, 
on the other hand, is generally met with in the 
mucous canals, as the vagina, the rectum, and the 
nose. The excrescences which form around the 
anus and on the head of the penis, perineum, and 
vulva, as a consequence of inoculation with the 
venereal virus, belong to this category of morbid formations. The bladder, colon, rectum, 
and inside of the cheek, palate, and pharynx are occasionally the seat of villous growths, 
the papillary structure of which is generally recognizable by the naked eye. The very 
vascular, florid, sensitive tumor met with at the orifice of the female urethra, and the 
vascular excrescences occasionally seen in the interior of the larynx in and around the 
vocal cords, are well-marked examples of a similar kind. Certain tumors which occasion- 
ally project from the serous surface of the dura mater belong to the same group ; and the 
researches of Professor Yon Luschka into the minute structure of the Pacchionian bodies 
render it highly probable that these structures are merely enlarged villi which naturally 
exist upon the adherent surface of the arachnoid membrane. 
Papillary tumors are frequently very vascular, and those of the mucous surfaces are not 
uncommonly attended with ulceration and exhausting hemorrhage. They are benign 
formations, but they may degenerate into carcinoma or sarcoma. Concerning their treat- 
TUMORS OR MORBID GROWTHS. 
chap. vri. 
Fig. 54. 
Minute Structure of Papilloma. CHAP. VII. 
ADENOMATOUS TUMORS. 
237 
ment, no definite plan need be laid down here, as the subject will be fully discussed in 
connection with the different organs and structures in which they are developed. 
2. ADENOMATOUS TUMORS. 
The glandular tumor, or adenoma, owes its name to the peculiarity of its structure, 
which is a close imitation of the normal glandular tissue, whether acinous or tubular. 
It is essentially a hyperplastic growth, consisting of newly-formed gland tissue, corre- 
sponding in its main features with what Lebert has described under the name of “partial 
glandular hypertrophy,” and is frequently, but incorrectly, described as adenoid tumor. 
Its principal seats are the parotid, thyroid, mammary, prostate, and sweat glands, and 
the mucous follicles of the lip, cheek, palate, nose, vulva, vagina, uterus, and rectum. 
In the breast the new product is either imbedded in the substance of the organ, or it 
projects from its surface as a peripheral outgrowth, continuous with the parent tissues by 
a distinct pedicle. In adenomas of the parotid and prostate glands a similar law obtains 
in regard to the site of the new growth. 
An adenoma is, for the most part, a solitary tumor, of a firm, dense, inelastic consist- 
ence, especially in its earlier stages, of a whitish, grayish, or pale straw color, surrounded 
by a capsule, or limitary membrane, easily enucleated, and seldom larger than a hickory- 
nut, an almond, or a pullet’s egg. The sectional surface has often a glistening appearance, 
and, in recent growths, yields no fluid on pressure. Few bloodvessels enter into this 
tumor. The epithelial cells which naturally line the ducts and acini of the glands com- 
monly consist of a single layer. 
Under the microscope the newly-formed glands are arranged as acini, or as tubes, as in 
fig. 55, from Green, separated 
usually by a small amount of con- 
nective tissue. The cells which 
line the lobules or ducts rest upon 
a limiting membrane, which 
serves to distinguish the growth 
from carcinoma. The best type 
of the acinous or lobular adenoma 
is that which occurs in the mam- 
mary gland. The tubular or duct 
adenoma proceeds from the mu- 
cous membranes, and frequently 
constitutes one of the varieties of 
mucous polyp. 
In the mucous follicles, the 
tumor, rarely larger than a cherry, 
or small nut, is always, as in the 
mammary and prostate glands, 
distinctly encapsulated, while in 
the thyroid body, belonging to 
the ductless order of glands, the 
new glandular structure, usually 
even in its earlier stages, exhibits 
a remarkable tendency to cystic 
transformation, so characteristic of goitre. All adenomas exhibit, indeed, the same ten- 
dency, which is due to mucoid softening of the proliferating epithelial cells and dilatation of 
the ducts. In some cases, the epithelium gives rise to vegetations or papillae which more 
or less completely fill the cysts. 
The period of life at which adenoma is developed varies in the different organs. In 
the breast it is most frequent from the age of puberty to that of thirty-five, young prolific 
females being its most common subjects. In the thyroid body it generally begins before 
the fifteenth year, especially in those parts of the world in which goitre is endemic. In 
the labial, buccal, vaginal, and uterine glands the occurrence is most frequent in young 
and middle-aged persons. In the prostate gland it is usually associated with, or a con- 
sequence of, senile hypertrophy of that organ, occurring either in its substance, or as a 
pedunculated, polypoid outgrowth. 
In the mammary gland adenoma is frequently quite tender on pressure, and occasionally 
even very painful, especially in young females, the subjects of dysmenorrhoea, the suffer- 
Fig. 55. 
Minute Structure of Adenoma of the Mamma. 238 
TUMORS OR MORBID GROWTHS. 
in" being then very liable to assume a neuralgic character. In most of the other organs 
the tumor incommodes simply by its bulk and situation, or mechanical inconvenience. 
Adenoma usually arises without any assignable cause. Its progress is generally very 
slow, and it seldom attains any considerable volume, although when it invades an entire 
gland, as the mammary or parotid, it may reach a great bulk. In its character the tumor 
is essentially benign, but, in exceptional cases, it is no doubt, like other benign growths, 
capable of assuming malignancy. When thoroughly extirpated, no relapse will be likely 
to occur, although examples have been recorded in which as many as three, four, and even 
five operations were performed upon the same tumor. 
Adenoma is distinguished by its locality, by its tardy and equable growth, by its circum- 
scribed, ovoid, and bossed outline, by its firm, inelastic consistence, by its hard and heavy 
feel, by the absence of lymphatic involvement, and by the integrity of the general health. 
In the treatment of adenomas very little is to be expected from medication, and a 
spontaneous cure is very uncommon. Occasionally, under favorable circumstances, dilute 
tincture of iodine and a weak ointment of the biniodide of mercury prove useful in pro- 
moting the absorption of the tumor. Iodide of potassium and bichloride of mercury 
administered internally, have sometimes been beneficial. The efficacy of such treatment 
is most evident in cases of recent standing and in growths of small size. Some surgeons 
speak favorably of methodical compression, but as this is difficult, and in many cases 
impossible, little advantage is to be anticipated from its employment. When the tumor 
is painful, as when it is the seat of neuralgia, or of large size, causing inconvenience by 
its weight or pressure, or when it is partially softened, the only rational remedy is extir- 
pation. A single incision often suffices to expose the tumor and to effect its enucleation. 
The whole organ in which it is situated must be sacrificed when the disease pervades its 
entire substance; but such a procedure, for reasons previously mentioned, will seldom be 
necessary. 
3. CARCINOMATOUS TUMORS. 
Under the term carcinomatous are comprised certain morbid growths, which have the 
effect, within a variable period after their formation, of destroying not only the tissues in 
which they are located, but also the life of the patient. The formations commonly 
embraced under the present head are scirrhus, enceplialoid, colloid, melanosis, and 
epithelioma. It would greatly simplify the study of these affections if the term “ cancer,” 
by which some of them continue to be designated, were altogether discarded from surgical 
nomenclature. This expression, introduced in the infancy of the science, is commonly 
employed as the substantial equivalent of malignant, and is, therefore, calculated to mislead 
the mind of the inquirer. 
Of the extensive prevalence of carcinomatous disease some idea may be formed when 
it is stated that, in the five years from 1838 to 1842, inclusive, 11,062 persons died of it 
in England alone, independently of the cases which occurred in London. Of these cases, 
8746 occurred among women, and 2916 among men, or in the ratio almost of three to 
one. Mr. S. W. Sibley, in 1869, analyzed 522 cases of carcinoma, collected from the 
records of the Middlesex Hospital, of which 419 related to females, and 103 to males. 
This disparity of the disease in the two sexes is due to the extraordinary frequency of 
carcinoma of the uterus and mamma, particularly the former, which suffers nearly as 
often as all the other organs together. 
These various morbid formations, although widely differing in many of their characters, 
possess certain features in common with each other, which may be briefly enumerated 
before they are individually described. 
1st. Microscopically considered, they are distinguished from all other neoplasms by the 
marked alveolar structure of their fibrous stroma, the alveoli being disorderly crowded 
with unadherent polymorphous cells of an epithelial type, without the intervention of 
formed intercellular substance. 
2dly. They are always derived primarily from the epithelium of the glands, or of 
the skin, and mucous membranes. Instead of being confined by a limiting membrane, 
as occurs, for example, in adenoma of the mamma, the epithelial cells infiltrate, grow, 
or thrust themselves into the surrounding connective tissue, thereby giving rise to 
an atypical epithelial formation, or one which is entirely unlike the normal glandular 
structures. 
3dly. They are all at the outset of a purely local character, but after a variable period 
of their existence they evince malignant attributes, as is indicated by their infiltrating the 
CHAP. VII. CHAP. VII. 
CARCINOMATOUS TUMORS. 
239 
adjoining tissues, by the production of similar tumors in the associated lymphatic glands, 
and by the formation of metastatic deposits in the various textures and organs. 
4thly. They occur only, as primary affections, in the epithelial organs and tissues of 
the body, particularly during middle age, in persons of all temperaments, occupations, and 
social conditions. They occasionally display a marked hereditary tendency, and also a 
disposition to appear in several members of the same family. 
5thly. Their progress is generally rapid, most of them causing death in from nine 
months to two years and a half from their commencement. 
The so-called cancer cells, which, along with the creamy, homogeneous, or granular 
intercellular substance, form what is termed the cancer-juice, have been, and still are, a 
prolific source of disputation. Apart from the peculiar arrangement of the stroma, these 
protoplasms cannot be said to be characteristic of carcinoma, and yet the practised micro- 
scopist would not hesitate to pronounce a tumor to be of that nature, if it were composed 
principally or entirely of such nucleated cells as are delineated in fig. 56, from Green, 
Rindfleisch, and Paget, representing typical forms derived from different carcinomatous 
formations. At a are exhibited the multiform cells of scirrhus and encephaloid, which 
Fig. 56. 
Cells of Carcinoma. 
range from T|r11TTT to 7 Jtt °f an ’ diameter. In shape they vary greatly. Commonly 
oval or nearly spherical, some are pyriform, some fusiform, some angular, others reniform, 
and they are provided with one, and occasionally even with several large, oval, well-de- 
fined, eccentric, nucleolated nuclei. At b are represented the most common types of 
cells of epithelioma. They are generally round-oval, singly nucleated, flattened, and 
scale-like, and vary from to of an inch in their chief diameter. At c are de- 
lineated the cells of colloid carcinoma, which consist of the vacuolated and the seal-ring 
forms, from 5J jy to of an inch in diameter. The origin of the so-called cancer cells, 
the distinctive feature of which is their epithelial character, is still involved in mystery. 
According to Virchow, Rindfleisch, Volkmann, Cornil and Ranvier, Tripier, Coyne, and 
Moxon, they are developed by proliferation of the connective tissue corpuscles, a theory 
of formation which has been placed in doubt by the results of embryological inquiry. 
His, Aeby, Thiersch, Waldeyer, Billroth, Samuel, Klebs, Liicke, Langlians, and other 
pathologists, contend that histological researches have failed to demonstrate the derivation 
of the epithelial cells from corpuscles of connective tissue. Thiersch maintains that epi- 
thelioma originates from increase and multiplication of preexisting epithelial cells alone ; 
while Waldeyer and Billroth extend this view to all carcinomas. That epithelium must 
be produced from its like, and that carcinoma can only arise as a primary growth in the 
epithelial structures which are derived from the outer and inner layer of the embryo, are 
statements which I fully indorse, and I believe that the continuous proliferation and 
transplantation of the epithelium are sufficient to account for all the changes met with in 
the development and extension of carcinoma, without invoking the aid of other theories. 
The stroma, or basement structure, the second essential constituent of carcinoma, con- 
sists of succulent, preexisting connective or fibrous tissue, although it is, now and 
then, partly a new formation. The trabecuke of the stroma form elongated ovoidal 
spaces or meshes, which freely communicate with each other, and impart to it an alveolar 
or cavernous appearance. The cells are packed in the alveoli, and a few lymphoid cells 
are usually intercalated between the fibres of the stroma itself. These appearances are 
well shown in fig. 57, from Rindfleisch, which exhibits a partially pencilled-out section of 
encephaloid, magnified 300 diameters. The stroma is variously supplied, according to 
the variety of the neoplasm, with bloodvessels, some of which are normal to the part, TUMORS OR MORBID GROWTHS. 
chap, vii. 
while others are of new formation. Lymphatic vessels have been demonstrated to com- 
municate with, or to open into, the alveoli, as in tig. 58, from Cornil and Ranvier, a fact 
which explains the almost constant involvement of the lymphatic glands. 
Carcinoma is always derived from the epithelial elements of the glands, or of the 
skin and mucous membranes. Its evolution 
in a glandular organ, as the mamma, can be 
readily traced. Thus, the acini and ducts be- 
come enlarged and deformed, and more or less 
completely tilled with proliferating epithelium. 
The periglandular connective tissue is, at the 
same time, infiltrated with lymphoid cells, out of 
which the newly formed stroma is produced. Dur- 
ing the second stage, the basement or limiting 
membrane of the acini and ducts is broken 
through, and the cells extend into the new con- 
nective tissue and the preexisting lymph spaces 
as solid, branching cylinders, or plugs, whereby 
the normal appearance of the mamma is com- 
pletely destroyed. Some of these changes, as 
well as the relation borne by the cells to the 
stroma, are represented in the adjoining sketch, 
fig. 59, from Rindfleisch, magnified 300 diame- 
ters. At a the connective tissue is infiltrated 
with corpuscles, the nuclei of which at first di- 
vide, followed by fission of the cells and their accu- 
mulation in rows. The young cells finally enlarge and assume various shapes, until, as 
depicted at b, they have collected in groups in the meshes of the tissue, the fibres and 
lymph spaces of which they have disparted to form elongated ovoidal spaces or alveoli. 
Carcinomatous tumors are at the outset local degenerations of the tissues or organs in 
which they are situated. The marked tendency to recurrence after extirpation, to con- 
tamination of the lymphatic 
glands, and to the development 
of secondary nodules in the 
viscera, so far from being a 
sign of a constitutional taint 
or dyscrasia, merely shows that 
the original tumor acts as a 
focus of infection of adjacent 
and distant parts. As they are 
not surrounded by a capsule, 
their growth is generally rapid, 
and the increase in volume is, 
for the most part, peripheral, 
their constant tendency being 
to infiltrate the surrounding 
structures by the penetration 
of young epithelial cells into 
the continuous, loose connec- 
tive tissue spaces. This very 
interesting fact has a direct 
and most important bearing 
upon the results of surgical 
operations performed for the 
removal of malignant forma- 
tions. Schroeder Van der 
Kolk, to whose researches we 
are mainly indebted tor this knowledge, states that the tissues immediately around the 
morbid mass, although perfectly healthy in appearance when viewed with the naked eye, 
are, if examined with the microscope, found to be infiltrated with young cells, which 
gradually increase in size and number in proportion as the periphery of the tumor is ap- 
proached. This fact affords a ready reason why carcinomatous growths so frequently 
recur after extirpation at the site of the original disease. Fig. 60, from Billroth, magni- 
Fig. 57. 
Stroma of Carcinoma. 
Fig 58. 
Carcinoma of Mammary Gland—the ground substance of the section 
stained with nitrate of silver, a. Alveoli of the carcinoma filled with 
cells, b. Lymph spaces shown in the fibrous tissue after treatment by ni- 
trate of silver, c. Lymphatics showing silver staining of the endothelium. CHAP. VII. 
CARCINOMATOUS TUMORS. 
241 
fied 350 diameters, and representing cell infiltration of the fatty tissues around a carcino- 
matous lymphatic gland, serves to convey a good idea of these appearances. 
A characteristic feature of carcinomatous growths consists in their tendency to multiply 
Fig. 59. 
Scheme of Development of, and Retrograde changes In, Carcinoma. 
and disseminate themselves, until, in many cases, a considerable number pf tissues and 
organs are successively affected with analogous deposits. This infecting power is due to 
the transference of’ germs or 
juices by the veins or lympha- 
tics, particularly the latter, as is 
evinced by the early and fre- 
quent invasion of the lymphatic 
glands and the blocking up of 
the vessels themselves with car- 
cinomatous material. It is very 
rare to witness secondary no- 
dules in distant organs without 
involvement of the intervening 
glands, and in this respect car- 
cinoma, as has already been 
pointed out, bears a striking 
contrast to sarcoma. 
It would be of great practi- 
cal utility if we knew the origin 
of carcinoma, or the causes, local and constitutional, under the influence of which it is 
developed; but upon this subject we are, unfortunately, entirely ignorant, nor is it likely 
that our inquiries concerning it will lead to a satisfactory solution of a question which has 
occupied so much attention. 
Among the predisposing causes may be mentioned age and sex. Carcinoma never 
occurs before puberty, and is most common between forty and sixty, or during the period 
of functional decline of the various secreting organs. It is far more prevalent in females 
than in males in consequence of the extraordinary frequency of its occurrence in the uterus 
and mammary gland, but its evolution does not appear to be influenced by pregnancy or 
lactation. It is sometimes inherited; that is, it manifests a tendency to descend from 
parent to child; and this factor in its production is due to the transmission of a pecu- 
liarity of tissues, which renders them more prone to take on carcinomatous degeneration 
in some persons than in others not similarly predisposed. This tendency, however, is 
much less frequent than is generally supposed, since of 389 examples of carcinoma of the 
female breast, analyzed by Dr. S. W. Gross, only 10.30 per cent, could be assigned 
to hereditary influence. Besides, it should be remembered that there is a difference, 
and that a very wide one, between the transmissibility of this disease from the parent to 
the offspring, and its coexistence, or successive development, in different members of th§ 
Fig. 60. 
Cellular Infiltration of the Fatty Tissues around a Carcinomatous Lym- 
phatic Gland. 242 
TUMORS OK MOKBII) GROWTHS. 
CHAP. VII. 
same family. The latter occurrence, although also very uncommon, is much more fre- 
quent than the former, of which my own experience has supplied me only with a few 
examples. Lately, I saw a well-marked carcinoma of the mammary gland in a lady 
whose mother and maternal aunt had died of a similar disease. In 1855,1 prescribed for 
an aged female with a carcinoma of the lip, whose mother had perished from carcinoma 
of the breast, and the father from carcinoma of the tongue. One of the most remarkable 
and instructive instance of this kind upon record, is that related by Dr. Warren, in his 
work on 'rumors. A man died of carcinoma of the lip ; his son had a similar disease in 
the breast, from which, after having undergone an operation at the age of sixty, he finally 
lost his life. Two of his sisters had carcinoma of the mammary gland ; they were 
operated upon, but ultimately died from a relapse of the malady. A daughter of one of 
the ladies had a carcinoma of the breast, which was removed at an early period ; she 
recovered, but perished some years after, from disease of the uterus. A daughter of the 
gentleman had a carcinoma of the breast, and there was reason to believe that other 
members of the family were affected by the same malady. 
A case, almost equally remarkable, of this hereditary tendency to carcinoma, was com- 
municated to me by the late Dr. J. M. Warren. In this instance, a man who died of 
carcinoma of the penis, had lost his father, grandfather, and great-grandfather from similar 
disease. In a case, recorded by Broca, out of a family of twenty-six, in three successive 
generations, fifteen died of carcinoma. 
More frequently, as has already been stated, the disease occurs, either simultaneously 
or successively, in several members of the same family. My own practice has afforded 
me a number of instances of this kind, and all writers on carcinoma narrate examples of 
it. In one remarkable case, four out of six members of one family have died of the dis- 
ease ; one from carcinoma of the uterus ; another from carcinoma of the mammary gland; 
a third from a malignant polyp of the nose ; and the fourth from carcinoma of the thoracic 
viscera. Professor Gibson gives an instance of carcinoma of the breast in four sisters. 
Of 322 cases of carcinoma, analyzed by Paget, the disease occurred in other members of 
the family in 78, or very nearly in one-fourth. In 305 cases collected from the records of 
the Middlesex Hospital, London, by Mr. S. W. Sibley, the disease was traced to the rela- 
tives of the patients in 8f per cent, of the entire number of cases. Most of these cases 
occurred in females. 
The opinion, once so prevalent, that carcinomatous affections owe their origin to a pecu- 
liar virus, either generated within the system, or introduced from without, has long been 
obsolete. It is, at all events, perfectly certain that if there be such a poison, its existence 
has never been demonstrated. The juice of carcinoma, even when the disease is in a 
state of ulceration, is not inoculable, or communicable by immediate contact, as the matter 
of smallpox, vaccinia, chancre, or gonorrhoea. If it were, the disease would often spread 
indefinitely over patients affected with it, from mere contact with the discharges; nurses 
would become infected from handling the dressings, and surgeons would not be safe in 
performing any operations; and yet there is not upon record a solitary instance, of a reli- 
able character, from the eaidiest periods of the profession down to the present time, in 
which the malady was imparted in this manner. Carcinoma of the penis lias never been 
transmitted during coition. Carcinoma may, however, be inoculated by injecting the 
juice of infected animals into the veins or tissues of sound animals; and small fragments 
of carcinoma removed from man have been successfully transplanted in animals. 
Of the direct exciting causes of carcinoma the most frequent are injury and chronic 
inflammatory or irritative processes. Thus, epithelioma of the lip may be caused by jagged 
teeth, or smoking foul clay pipes; epithelioma of the tongue may result from icthyosis of 
that organ ; psoriasis and eczema of the nipple are occasional precursors of carcinoma of 
the mamma ; epithelioma of the penis is frequently traceable to phimosis ; and carcinoma 
of the uterus and stomach is notoriously the outcome of catarrhal inflammation of those 
organs. The incompatibility of carcinoma and tubercle, in a state of active growth, is 
well established. There are, of course, exceptional cases, but they are very uncommon ; 
and yet it not unfrequently happens that the relatives of persons affected with carcinoma 
die of phthisis. When active phthisis exists in a patient affected with carcinoma, the 
former malady may so completely obtain the ascendency over the latter as to cause the 
morbid growth to shrink and wither. Organic affections of the kidneys, liver, bones, 
skin, nerves, and bloodvessels neither prevent the occurrence of carcinomatous disease nor 
materially alter its course after its development. The absence of organic degeneration of 
the heart in those who die of carcinoma has been placed in a very clear light by the 
observations of Mr. Sibley and Mr. Moore, of the Middlesex Hospital, London, an insti- 
tution largely devoted to the treatment of this class of subjects. CHAP. VII. 
CARCINOMATOUS TUMORS. 
After carcinoma has made considerable progress, it impresses itself upon the constitu- 
tion, as is indicated by the worn and haggard features, the sallow complexion, and the 
emaciated and exsanguineous condition of the system, characters which it is impossible 
to mistake. The countenance bears the impress of the disease, looking as if it had been 
stamped with the seal of malignity. 
The so-called cancerous cachexia is present chiefly in carcinoma attended wdth serious 
involvement of the nutritive functions and imperfect sanguification. In external carci- 
noma it is frequently entirely absent until internal complications arise, or until the system 
has been weakened by profuse discharges, or repeated hemorrhages. In carcinoma of the 
liver, stomach, and other important organs, on the contrary, cachexia often occurs at an 
early stage of the disease. It generally manifests itself in its worst forms in encephaloid. 
Its principal characteristics are a sallow, shrunken condition of the features ; a soft, flabby 
state of the muscles; rapid absorption of the fat; and an impoverished condition of the 
blood, accompanied with abnormal frequency of pulse, night sweats, and general debility. 
The immediate causes of death in carcinomatous diseases are various. Most commonly 
life is worn out by anemia, inanition, and hectic irritation. In many cases the vital 
powers are seriously undermined, if not completely exhausted, by the violence of the 
hemorrhage, after the establishment of ulceration. The excessive fetor, the copious icho- 
rous discharges, and the severity and constancy of the pain, always greatly expedite the 
downward tendency. Sometimes carcinoma destroys life by mechanically impeding the 
functions of an organ, as w hen the disease affects the oesophagus, stomach, or bowel. In 
open carcinoma, attended with a profuse secretion of ichorous, sanious, or sanguinolent 
matter, death may be occasioned by septicemia, from the absorption of some of the un- 
healthy fluid into the system. 
A spontaneous cure of carcinoma, in any of its forms, is an extremely rare occurrence. 
Of the causes which may give rise to it, the most frequent is inflammation, followed by 
gangrene, by which the morbid mass is sometimes lifted bodily out of its natural bed, as 
neatly, in fact, as if it had been removed w ith the knife. Rokitansky speaks of the saponi- 
fication of carcinoma—a conversion of its protein-compounds into fat—as one of the modes 
of cure, especially of encephaloid ; and he also imagines that such an event may be 
brought about by the gradual condensation of the stroma of these growths, thus depriving 
their cells of proper nourishment. The shrunken, shrivelled appearance occasionally seen 
in scirrhus of the breast of very elderly females, is probably, in great measure, if not solely, 
due to this circumstance. 
Carcinomatous tumors, like other neoplasms, are liable to undergo inflammation and 
various transformations. Inflammation, softening, and consequent ulceration, are not un- 
common, particularly in the advanced stage of the growth. The ulcer shows no disposition 
to heal, and new carcinomatous nodules are constantly being formed around it, which go 
through similar changes. Fatty metamorphosis of the cells occurs in all the varieties of 
carcinoma, and is never entirely absent. It sometimes proceeds to such an extent that 
the fibrous stroma contracts and shrinks, and the alveoli contain only a few cells and 
granular debris. This cicatricial tendency is met with in scirrhus, giving rise to what is 
knowrn as withering or atrophying scirrhus. These retrograde changes are represented at c 
and d, fig. 60. The calcareous degeneration has occasionally been noticed in epithelioma 
and scirrhus. Pigmentation and colloid transformation of the cells, and mucoid degenera- 
tion of the stroma are also met with. 
The histological varieties of carcinoma are determined by structural peculiarities, or 
by the relative proportion of the stroma and cells, by the type of the cells, and by certain 
degenerations and transformations. The clinical divisions are scirrhus, encephaloid, col- 
loid, melanosis, and epithelioma. Of these, scirrhus, fibrous, hard, or chronic carcinoma, 
is composed of small cells, and a relatively large amount of firm, contractile fibrous 
tissue. Encephaloid, medullary, soft, or acute carcinoma is characterized by the large size 
of its cells, and the small proportion of delicate stroma. Colloid or gelatinous carcinoma 
differs from the preceding varieties only in the fact that the protoplasm of its cells has under- 
gone colloid degeneration. Melanotic or pigmented carcinoma is distinguished by the fact 
that its cells are infiltrated with granules of melanin. Epithelioma, or epithelial carcinoma, 
is the variety in which the cells are analogous to those of squamous epithelium ; and it 
differs from the other varieties in always proceeding from a mucous or cutaneous surface. 
1. SCIRRHUS. 
Scirrhus, so called on account of its great density and firmness, is rare until after the 
age of forty, when it is sufficiently common. The period of its greatest frequency is 244 
TUMORS OR MORBID GROWTHS. 
chap. vri. 
from the forty-fifth to the fifty-fifth year. Women suffer mueli oftener than men, but in 
what proportion has not been ascertained. The influence of habit, temperament, and 
occupation upon the production of the disease is also undetermined. Of the exciting 
causes of the disease also very little is known. It generally arises spontaneously, and 
makes perhaps considerable progress before any suspicion is aroused as to its true character. 
Occasionally, although seldom, its development is manifestly due to the influence of some 
external injury, as a blow, fall, or bruise ; and it is not unfrequently the result of catarrhal 
inflammation, as when it occurs in the mucous surfaces. 
Certain organs are more prone to scirrhus than others. Thus the mamma, the pylorus, 
the rectum, the oesophagus, and uterus are particularly liable to suffer, and it is occasion- 
ally met with in the skin, vagina, and jaws. The testicle is singularly exempt from it. 
Scirrhus appears under several varieties of form, as the tuberoid, stratiform, and infil- 
trated, of which the first is the one, surgically speaking, of the greatest interest. The 
other two occur chiefly in the internal organs, particularly the oesophagus, stomach, colon, 
and rectum, the submucous connective tissue of which they often so completely transform 
as not to leave a vestige of the original structure, at the same time that they encroach 
very seriously, if not fatally, upon the caliber of the tube. The affected part, dense and 
crisp, cuts almost like fibrous cartilage, and is of a pale yellowish or grayish hue, with 
white fibrinous intersections. The stratiform variety is occasionally met with in the skin, 
but the occurrence is uncommon. Scirrhus of the uterus generally presents itself as an 
infiltration. 
The best example of the tuberoid variety occurs in the mamma. Sometimes the tumor 
consists of one single mass, but more generally it is made up of several, which together 
may form a growth as large as an orange, or even of a fist, hard, dense, inelastic, and 
almost incompressible, grating under the knife, of variable shape, but generally globular 
or ovoidal, movable with, and deeply inlaid in the tissues among which it is situated. The 
fibrous intersections which pervade the interior of the morbid mass are generally of a 
dense, firm consistence, and of a grayish, bluish, or rosaceous color. It is questionable 
whether the fibrous bands, as they are commonly called, are ever entirely of new formation. 
A section of a scirrhous tumor, especially in its more matured stages, exhibits a 
whitish, homogeneous aspect, and yields, upon being scraped, a peculiar fluid, sometimes 
of a whitish, creamy hue, but more generally of a pale, grayish, turbid appearance, not 
unlike thick gruel, which contains great numbers of cells, and is known as the cancer 
juice. It is slightly unctuous to the touch, readily mixes with water, and often contains 
a considerable quantity of free oil. It exists very sparingly in recent specimens, and is 
evidently caused by the softening and disintegration of the mass, preparatory to ulceration. 
Scirrhus has a very feeble circulation, its vessels being remarkably small, and probably 
wholly derived from the surrounding parts. The paucity of vessels affords a satisfactory 
clue to the slow growth, and comparatively small size of the morbid product, and a 
reason, also, why there is so seldom any considerable hemorrhage after ulceration. 
Scirrhus is composed, as is represented in fig. 61, from Arnott, of a stroma of dense, 
inelastic, fibrous tissue, arranged so as to form alveoli, in which comparatively small and 
multiform epithelial cells are contained. In the withering or 
atrophying variety the alveoli are merely represented by a few 
elongated or fusiform clefts, which contain fatty detritus, or one 
or more rows of unchanged cells. 
The progress of this disease is generally more slow than that ot 
the other carcinomatous growths, both as it respects its tendency 
to ulceration and to the destruction of life. It is seldom that 
a scirrhous tumor of the breast becomes an open sore under nine, 
twelve, fifteen, or eighteen months ; not unfrequently, indeed, 
several years elapse before it takes on this kind of action. In 
1857, I had at my Clinic an elderly lady, once a patient of Sir 
Astley Cooper, in whom the disease had existed for more than 
twenty years before there was any disposition to ulceration. 
Several other cases of somewhat less duration have been under 
my observation. In general, however, the tendency to ulceration 
shows itself towards the end of the first or the second year, 
commencing usually in a superficial portion of the tumor, some- 
times at one, and at other times at several points, the process 
being preceded and accompanied by more or less discoloration of the surface, and by the 
adhesion of the skin to the subjacent structures. The color is always dark, purple, or 
Fig. 61. 
Minute Structureof Scirrlius CHAP. VII. 
SCIRRHUS. 
245 
livid, the vessels immediately concerned in its production being enlarged and deeply con- 
gested, frequently presenting an appearance as if they were inlaid in the cutaneous 
tissues. The part at length giving way, an unsightly ulcer is exposed, having hard, 
steep, rounded edges, and a foul-looking bottom, generally incrusted with spoiled lymph. 
The discharge is always sanious, ichorous, or sanguinolent, more or less fetid, irritating, 
ami often remarkably profuse. It tarnishes silver, imparts a green color to syrup of violets, 
and, on admixture with sulphuric acid, evolves a peculiar gas. having many of the pro- 
perties of sulphuretted hydrogen. No healthy granulations ever form upon such an ulcer; 
hence it never heals, the plastic matter which it secretes being always speedily devitalized. 
There are, of course, exceptions to this rule; but they are very uncommon, and I have 
met with very few. Sometimes the scirrhous ulcer has a remarkably excavated appear- 
ance, as if it had been dug out with a punch. The parts immediately round the ulcer are 
always very hard, tender, discolored, and oedematous. 
Another tendency of the scirrhous tumor is to contract adhesions to the structures in 
and among which it is situated. This disposition, which often manifests itself at a com- 
paratively early period, is always very conspicuous during the later stages of the malady. 
The immediate cause of the adhesions is the extension or growth of the epithelial cells 
into the skin, connective tissue, muscles, glands, and even bones, involving all in one 
common mass. 
A tumor of this kind not only affects the parts with which it lies in more immediate 
contact, but it often extends its influence to others farther off. The structures that are 
most liable to suffer in this way are the lymphatic glands, which frequently take on the 
same kind of action, becoming enlarged and indurated, and exhibiting, on section, pre- 
cisely the same appearances as the original tumor. Sometimes, again, parts still more 
remote become involved in the morbid action. Thus, in scirrhus of the mamma there is 
often not only great contamination of the axillary lymphatic glands, but serious swelling 
of the corresponding arm, either from an extension of the primitive affection, or from 
obstacle to the return of the blood in the veins. 
Thus the tendency of this disease is to spread and to contaminate the surrounding 
structures, making itself deeply felt not only locally, but constitutionally. In exceptional 
cases, the morbid influence is closely circumscribed, limited, perhaps for years, to the spot 
in which it originally appeared ; even then, however, it eventually breaks through its 
barriers, and spreads among the adjoining tissues. Finally, after having remained in the 
part for a time, nature occasionally makes an effort at extrusion, the tumor being invaded 
by gangrene, and at length cast off as a slough. Such an occurrence, however, is extremely 
rare, and I have witnessed only one instance of it. The patient, an elderly lady, fat, and 
otherwise healthy, had had a medium-sized scirrhous tumor in one of the mammary glands 
for several years. Suddenly, without any assignable cause, inflammation set in, and in a 
few weeks the whole mass was lifted from its bed as neatly as if it had been done with 
the scalpel. Some time afterwards the disease broke out in the axillary lymphatic glands, 
and made rapid strides towards a fatal termination. 
The symptoms of scirrhus necessarily resolve themselves into local and constitutional. 
The former can only be satisfactorily studied as they appear in an external tumor, 
as, for example, the mamma. In taking hold of such a growth, one is struck with its 
extraordinary hardness and density; it is firm, incompressible, and inelastic. If it be of 
recent origin, it will be found to be perfectly circumscribed and movable, the examiner 
being able to grasp it with the fingers, and to push it about beneath the skin ; at a later 
period, however, it contracts adhesions to the surrounding parts, and becomes more or less 
firmly fixed in its situation. The morbid product may occur as a solitary tumor, or several 
little lumps may appear simultaneously or successively, and, gradually coalescing, a mass 
of considerable size may thus be formed. 
The pain of scirrhus is peculiar. It is sharp, lancinating, or stabbing, darting through 
the parts like an electric spark, or causing a sensation as if needles were thrust into 
them. It makes its appearance at an early date, gradually increasing in severity, and 
becoming at length a source of intense suffering. It may be steady and persistent, but 
more commonly it is intermittent. It is always aggravated by damp states of the atmos- 
phere, by derangement of the digestive organs, and by whatever has a tendency to impair 
the general health. In some cases it is of a neuralgic character, and then, instead of 
being limited to the morbid mass, it often shoots about in different directions among the 
neighboring structures. During the later stages of the disease it is usually so constant and 
violent as to deprive the patient of appetite and sleep, thus rapidly urging on the fatal 
issue. 246 
TUMORS OR MORBID GROWTHS. 
CHAP. VII. 
As the disease advances, the skin is gradually tied down to the morbid mass, and soon 
becomes hard and livid, its vessels being at the same time very much enlarged and con- 
gested. Eventually erosive action sets in, and thus a steep, excavated ulcer is formed, 
the seat of a foul, ichorous discharge, and incapable of furnishing healthy granulations, 
or laudable pus, or of undergoing repair. The tumor is now firmly adherent to the sur- 
rounding structures, and there is generally, although not invariably, lymphatic involve- 
ment. The ulcer sometimes bleeds, but seldom more than a few drachms, or, at most, a 
few ounces. The flow may be purely capillary, or it may proceed from a tolerably large 
vessel, arterial or venous, laid open by the morbid action, and unable to retract in conse- 
quence of the condensed condition of the circumjacent tissues. 
Scirrhus occasionally assumes an atrophic form, causing more or less wasting of the 
affected organ, and a consequent reduction of its natural size. This form of carcinoma 
is almost peculiar to the mammary gland of elderly females, after the age of sixty, in 
whom the disease sometimes remains stationary for a number of years, the morbid growth 
being characterized by extraordinary hardness, with little, if any tendency, to ulceration 
and constitutional involvement. On the other hand, a tumor of this kind sometimes 
attains an unusual bulk, caused by the infiltration of the normal tissues by the carcino- 
matous matter, the resulting mass being of a dense, compact structure, freely interspersed 
with fatty and fibrous substance, in an altered condition. In what is called acute scirrhus, 
the disease advances with extraordinary rapidity, the case often terminating fatally within 
a few months of its first appearance, from extensive constitutional implication. 
Scirrhus, in its earlier stages, produces little or no constitutional disturbance. It is 
strictly a local affection, annoying and fretting the parts directly involved in it, but not 
awakening any general sympathies. A little mental disquietude, the result of the con- 
sciousness that there is a suspicious tumor or lump, is the only thing that excites attention. 
By and by, however, the health begins to fail; the appetite is impaired; the sleep is 
interrupted by the severity and frequency of the pain ; the secretions are sadly disordered ; 
the bowels are irregular; the assimilative functions suffer; occasional attacks of fever take 
place ; the flesh and strength gradually decline ; the mind is depressed ; and life is beset 
on every side by the treacherous and unrelenting foe. During the latter stages of the 
malady, sometimes even before there is any serious lymphatic involvement, the countenance 
assumes a peculiar sallow, cadaverous expression, so denotive of the carcinomatous cachexia; 
diarrluea and sweats set in ; the limbs become anasarcous; and at length the patient dies 
utterly exhausted, being literally fretted to death by the disease. 
During the progress of this malady secondary scirrhous deposits often appear in other 
parts of the body especially the liver, lungs, and pleura; the blood is thin and colorless ; 
and the solids are pale, flabby, and wasted. Even the bones often experience important 
changes, particularly those of the extremities, which are sometimes rendered so fragile as 
to give way from the slightest cause. Many years ago I had under my charge, on account 
of scirrhus of the mamma, a lady of seventy-three, who broke her right femur a few days 
before she died, simply by turning over in bed. 
2. ENCEPIIALOID. 
Encephaloid has various synonyms, of which the most common are soft, acute, medul- 
lary, and cerebriform carcinoma, and fungus hematodes. All these various appellations 
have reference either to the appearance, consistence, or progress of the morbid product, 
and are, therefore, more or less appropriate. That of encephaloid, however, is, on the 
whole, the least objectionable, and is the only one that ought to be retained. 
Encephaloid generally comes on spontaneously, although, now and then, it is directly 
traceable to the effects of external injury, as I have witnessed in a number of instances. 
Thus, in 1861, I attended a medical gentleman, sixty-eight years of age, on account of 
an encephaloid tumor of the maxillary sinus, the result of an accidental blow received 
several months previously. A young man hurt his testicle in riding on horseback. The 
organ soon began to increase in bulk, the lymphatic glands of the groin became involved, 
and in less than six months death occurred from soft carcinoma. In both of these cases 
the disease was of unusually rapid development, and, such, I believe, will generally be 
found to be the fact when it is caused by violence. 
The affection is most common in the liver, kidney, ovary, testicle, mamma, prostate, 
and salivary glands. Both sexes are liable to it, but the greatest number of cases occur in 
females between the fortieth and sixtieth years. Encephaloid carcinoma, like scirrhus, 
consists of an alveolar stroma with inclosed epithelial cells; but it differs from the latter 247 
CHAP. VII . 
growth in that the stroma is more delicate and the cells 
are more numerous and of larger dimensions, as is well 
represented in fig. G2, from Green. 
In regard to its arrangement, encephaloid occurs 
under three varieties of form, as a tumor, a stratum, 
and an infiltration, the first being the most common, 
and surgically considered the only one of any particu- 
lar interest. It varies in volume from a pea to that of 
an adult’s head, its shape being generally somewhat 
ovoidal, and its surface more or less lobulated. 
On section an encephaloid tumor presents a white 
or grayish pulpy appearance like that of the foetal brain. 
In not a few specimens the grayish-white basis is 
mottled with pink, red, or brown areas, which are in- 
dicative of increased vascularity, and slight effusions of 
blood. When the tissue resembles a recent coagulum, or contains spaces filled with blood, 
the tumor is termed hematoid or telangiectatic carcinoma, which is synonymous with 
fungus hematodes. This variety of tumor is met with principally in the mamma, the 
testicle, and the ovary. 
Encephaloid, being an extremely vascular structure, is endowed with a high degree of 
vitality, growing generally with great rapidity, and often attaining a very extraordinary 
bulk within a few months from its first appearance. Its vessels, which are unusually 
large, are arranged in a close, intricate, and retiform manner, and its circulation is always 
remarkably active, thus strikingly contrasting with that of scirrhus, and affording a ready 
explanation of the differences in the rapidity and size of the two formations. The walls 
of the vessels are unusually brittle, and they are, therefore, liable to give way under the 
most trifling causes, producing those apoplectic depots which are so often seen in their 
interior, and those frightful hemorrhages which occasionally attend their open condition. 
It is not unusual for encephaloid tumors to contain serous cysts, thus complicating their 
structure, and occasionally throwing a doubt over their diagnosis. In general, the cysts 
are small; but in one instance, within my observation, a cavity of this kind contained 
fully a pint of serum, its walls having a peculiar honey-combed appearance. Apoplectic 
depots are, as already stated, most common in the hematoid variety of encephaloid growths. 
It is seldom that an encephaloid tumor, after having taken a fair start, remains even 
temporarily stationary ; on the contrary, its tendency is to proceed, steadily and regularly, 
in its work of disorganization, until it destroys life either by hemorrhage, by irritation, or 
by visceral complications, the period at which this takes place varying, on an average, 
from nine to twelve months. Death sometimes occurs in an almost incredibly short period. 
Great softness of texture, bulk, and rapidity of growth are the circumstances which par- 
ticularly predispose to an early unfavorable issue. 
The period at which an encephaloid tumor becomes an open ulcer is indefinite; some- 
times this takes place within a few months, at other times not under a year, or a year and 
a half from the first appearance of the disease, although this is uncommon. The imme- 
diate cause of the ulceration is the pressure of the morbid mass upon the skin, the forma- 
tion of an abscess, or the occurrence of a slough, leaving a sore, the edges of which are 
thin, undermined, jagged, or irregular, while the bottom, which is sometimes of consider- 
able depth, has a foul, bloody, fungous aspect. The parts immediately around are of a 
deep red, livid, or purple color. The discharge is usually profuse, and of a sanious, 
ichorous, bloody, or sanguinolent character, pure laudable pus being rarely, if ever, met 
with. Copious hemorrhage occasionally takes place, especially in the hematoid variety 
of the disease, and by its frequent repetition rapidly undermines the general health, urging 
on the fatal crisis. The occurrence is particularly common in encephaloid of the uterus 
and mamma. Of the many cases that I have seen of the encephaloid ulcer, not one ever 
healed even temporarily. Intractability is one of its distinguishing features. 
Lymphatic involvement often occurs at an early stage of the disease, sometimes, indeed, 
long before ulceration sets in ; at other times, however, not until the tumor has become an 
open sore. The general law is that the more rapid the growth is the earlier will there be 
disease in the neighboring lymphatic glands, and conversely. The constitutional cachexia 
is always well marked in the more advanced stages of the affection, and the patient’s doom 
is often depicted in legible characters upon his countenance several months before it is 
finally sealed in death. 
ENCEPHALOID. 
Fig. 62. 
Minute Structure of Encephaloid. 248 
TUMORS OR MORBID GROWTHS. 
CHAP. VII. 
An encephaloid tumor is distinguished by its comparative softness, by the rapidity of 
its growth, by its great bulk, and by its lobulated surface. The pain is generally slight, 
at least until the occurrence of ulceration ; and there is occasionally considerable, some- 
times, indeed, enormous, enlargement of the subcutaneous veins with more or less involv- 
rnent of the neighboring lymphatic glands. In its earlier stages, the tumor is movable, 
as in scirrhus, but as it advances it contracts adhesions, and at length becomes per- 
manently fixed. 
3. EPITHELIOMA. 
There is a class of affections which was formerly known under the name of scirrhus, 
from its supposed identity with that disease, but which modern research has shown to be 
so different from it as to entitle it to be regarded as a separate formation. The affec- 
tions comprised under this head are the various forms of malignant disease of the cutaneous 
and mucous tissues, more particularly carcinoma of the lip, gums, tongue, face, anus, 
rectum, uterus, vagina, and penis. They are not, however, limited to these parts; for 
they sometimes invade, secondarily, the deeper structures, as the bones, muscles, lym- 
phatic glands, liver, and lungs, although their occurrence here is very uncommon. The 
name by which these formations are now generally designated is epithelioma, or epithelial 
carcinoma. 
Epithelioma is more common in men than in women, the latter being more liable to 
scirrhus. Of 1407 persons admitted into the Cancer Hospital in London, on account of 
this disease, 1022, according to the statement of Dr. Marsden, were males. In men the 
lip and penis are most frequently attacked. What is called chimney-sweeper’s cancer is 
merely a form of epithelial disease of the scrotum. Rodent ulcer, or the noli me tangere 
of the older writers, is nothing but epithelioma of the skin of the face and other parts of 
the body, an affection sufficiently common in both sexes, and often committing the most 
frightful ravages. Epithelioma occurs also in the tongue, at the anus, in the rectum, 
in the uterus, in old scars, and in chronic ulcers. The cauliflower excrescence of the 
uterus, first described by John Clark, of London, belongs to this variety of carcinoma. 
Whatever the form may be, the disease seldom shows itself before the age of thirty-five or 
forty, and then usually only in one part of the body. 
The causes of this disease are generally inappreciable. Sometimes it is directly trace- 
able to external injury, as a blow, long-continued pressure, or some particular irritation. 
Thus, Dr. Da Costa has mentioned to me the case of a shoemaker, where it was clearly 
attributable to the effects of a small board worn habitually upon the abdomen while the 
man was working at his trade. A man, aged fifty-nine, consulted me on account of a 
carcinoma of the lip and cheek, induced by a Mound received five months previously from 
the prong of a fork in eating. Epithelioma of the lip is often charged to the irritation 
produced by the pipe in smoking. Chimney-sM'eeper’s cancer is generally supposed to be 
occasioned by the lodgment of soot in the folds of the scrotum. Sometimes the disease 
originates in a wart, mole, or cicatrice. Epithelioma of the penis has been very com- 
monly referred to the irritation arising from want of cleanliness due to the existence of a 
long and tight prepuce. A sharp tooth, constantly brought in contact with the tongue, 
may, it is believed, serve as an exciting cause of carcinoma of that organ. In 1806, I 
excised from the bridge of the nose of a lady, seventy-five years of age, an open epithelial 
tumor, fully half an inch in thickness and diameter, induced six weeks previously by the 
accidental prick of a needle. In 1877, a man, upwards of forty years of age, was brought 
to the College Clinic on account of a small epithelial growth on the right cheek caused by 
a slight Mound inflicted with the razor in the act of shaving less than two months before. 
The disease sometimes originates in the scar of an old burn, as in the case of a middle- 
aged man, a patient at the College Clinic, whose arm I amputated at the shoulder, in 
1864, on account of an enormous epithelial ulcer consequent upon an injury of this kind 
received ten years previously. Many years ago I attended a young man for an epithelial 
ulcer of the anus, which had its rise, apparently, in a protracted eczematous affection of 
the skin and mucous membrane. Air. Sliaw, of London, has published the particulars of 
a case in which the disease suddenly broke out in an issue which had been kept open for 
thirty-five years ; and Mr. Clark successively amputated both legs of a man whose bun- 
ions, long in a state of ulceration, had been invaded by epithelial carcinoma. Mr. P. C. 
Delagarde, of the Devon and Exeter Hospital, England, has reported two cases of epithe- 
lioma of the cicatrice of a burn, coming on, respectively, forty and sixty years after the 
accident. 
Cases have been collected which tend to prove that the disease occasionally manifests a CHAP. VII. 
EPITHELIOMA. 
249 
hereditary predisposition. Dr. Foster, of Terre Coupee, Indiana, has communicated to 
me the particulars of three cases which occurred in three members of the same family, 
two having died of epithelioma of the face, and one of epithelioma of the foot. 
The form which epithelial carcinoma assumes is greatly influenced by that of the struc- 
tures in which it is situated. Its outlines are, as a general rule, so ill-defined and irregu- 
lar as to defy accuracy of description. The most common varieties are the tuberculated, 
manunillated, and cauliflower-like. Now and then they present a lobulated, conical, disk- 
shaped, pedunculated, or even a pendulous appearance. 
Epithelioma generally begins as a tubercle, crack, or wart-like excrescence, hard to the 
touch, movable, and somewhat tender on pressure. As the disease advances, it extends 
in different directions, and assumes a more distinctive character. By and by ulceration 
sets in, sometimes almost simultaneously at several points, the exposed surface having a 
foul, unhealthy, fungating appearance, with irregular granulated edges, and a hard, rough 
base. The discharge is generally abundant, and of a thin, sanious, acrid description, often 
eroding the skin in the neighborhood. The ulcer is intractable, manifesting no disposi- 
tion to heal, or, if granulations form, they speedily degenerate and lose their vitality, their 
recuperative powers being too feeble to carry on the work of repair. Once begun, the disin- 
tegrating action never stops, and hence its ravages are 
of ten most frightful, as, for example, in the case from 
which the adjoining cut, fig. 63, was copied, where 
the disease successively involved skin, muscle, bone, 
cartilage, and fibrous membrane, sparing nothing that 
came in its way. The pain, like that of scirrhus, is 
of a sharp, darting, or pricking nature, and often ex- 
tends through the surrounding parts. Hemorrhage 
occasionally occurs, chiefly in the fungating form of 
the epithelial ulcer, and may be sufficiently copious 
to cause serious debility, especially when an artery 
or a vein of considerable size is laid open. 
During the progress of the disease, lymphatic in- 
volvement occurs; sometimes early, but generally not 
until after the eighth, twelfth, or fifteenth month. 
The constitutional suffering, also severe, usually sets 
in later than in ordinary carcinoma, although ulti- 
mately it is not less fatal. 
Occasionally the disease shows itself successively 
in a great number of organs. In a case observed by Virchow, in a man, seventy-three 
years of age, it affected both lips, lymphatic glands, clavicle, ribs, lungs, heart, liver, and 
kidneys. In the cylindrical-celled variety of the disease secondary growths in the lymph- 
atic glands are not uncommon, and the viscera are occasionally affected. 
Epithelioma consists essentially of an ingrowth of epithelial cells into the deeper tissues. 
Its stroma is not like that of the alveolar connective-tissue matrix of scirrhus or encepha- 
loid, although it is analogous to it, and the cells retain the type of those of the surface 
from which the growth originates. When the skin is affected the cells resemble epider- 
mis cells; when the tubular glands of the intestine are the source of origin of the tumor, 
the cells, on the other hand, are cylindrical. Hence, epithelioma is anatomically divided 
into the pavement-celled, and the cylindrical-celled varieties. In the former variety, 
which is so common about the face, penis, labia, and uterus, the squamous epithelial cells 
are arranged in simple or branched cylinders or plugs, which grow into the stroma of the 
cutis or connective-tissue framework of the mucous membrane. These appearances are 
well represented in fig. 64, from Green. As the cells grow older they are very frequently 
closely packed together, forming nests, and assuming a concentric arrangement, like the 
layers of an onion. They are often visible to the naked eye, and are very characteristic 
of, although not entirely peculiar to, epithelioma. In the cylindrical-celled tumor, which 
is found in connection with mucous membranes with columnar epithelium, as those of the 
stomach, rectum, and uterus, the cells are arranged on the walls of the connective-tissue 
stroma after the normal type. These growths have a soft consistence, readily ulcerate, 
and are disposed to bleed. 
Epithelioma is generally comparatively tardy in its growth. In a case of epithelioma of 
the tongue, reported by Dr. Da Costa, twenty-two years elapsed from the appearance of the 
disease to the time of its removal by operation. In the lip the disease often lasts a number 
of years before it terminates fatally, although this is not its ordinary tendency, for most 
Fig. 63. 
Epithelial Carcinoma in a state of Ulceration. 250 
TUMORS OR MORBID GROWTHS. 
CHAP. VII. 
Fig. 64. 
Minute Structure of Pavement-celled Epithelioma. 
persons die in from eighteen months to two years. I have seen rodent ulcer of the face 
continue its ravages for nine, fifteen, and even twenty-five years before it finally caused 
death. Under such circumstances, 
the ulceration occasionally ceases for 
a time, and then recurs, perhaps now 
with increased vigor. 
No experiments that have yet been 
performed to test the inoculability of 
epithelioma have been successful. A 
clinical observation, however, pub- 
lished by Mr. Nunn, of London, seems 
to countenance such a view. A wo- 
man, thirty-four years of age, had a 
carcinoma of the rectum, which perfo- 
rated the posterior wall of the vagina, 
forming a fistulous opening the size of 
a goose-quill. On the anterior wall of 
the vagina, exactly opposite this open- 
ing, and in immediate contact with it, 
was a small, inflamed circular patch, 
superficially ulcerated, studded with 
little red granulations, presenting, 
under the microscope, all the characteristic features of carcinoma. Here the mere contact 
of a healthy with a diseased surface was, apparently, sufficient to propagate the growth. 
4. COLLOID. 
Colloid is one of the most uncommon of the carcinomatous formations. The name by 
which it is now usually known has reference to the peculiar jelly-like appearance of one 
Fig. 65. 
Minute Structure of Cylindrical-celled Epithelioma. CHAP. VII. 
COLLOID. 
251 
of its principal constituents, and is therefore quite appropriate. It lias also been described 
under the terms gelatiniform, alveolar, cystic, and gum cancer. 
The favorite seats of this morbid product are the liver, stomach, rectum, ovary, and 
mamma. 
Although colloid may appear, simultaneously or successively, in a considerable number 
of organs, it manifests less tendency to general diffusion than any of the other carcinoma- 
tous formations, except the epithelial. It is rarely met with before the fortieth year, and 
is most common between forty-five and fifty-five years. 
Colloid appears under two varieties of form, as a tumor and as an infiltration, the latter 
being most common in the alimentary canal, particularly the stomach and rectum ; the 
former, in the mammary gland and ovary. In the infiltrated variety, the new matter 
occupies the meshes of the connective tissue, forming cysts, from the size of a mustard 
seed to that of a hazel-nut, which are filled with the characteristic jelly-like matter, and 
which, as they increase in volume and number, so completely subvert tlie primitive struc- 
tures as ultimately to leave no trace of them. In the other variety of colloid, there is 
a distinct tumor, from the volume of a marble to that of an adult head, of a globular, 
rounded, or irregular shape, and of a firm, dense consistence. 
The surface of the colloid tumor is generally rough, knobby, or distinctly lobulated, 
according to the volume and arrangement of the component cysts. Occasionally it bears 
a strong resemblance to the exterior of a pudding stone. In the larger masses, vessels of 
considerable size may be seen running over the surface, and penetrating the walls of the 
principal cysts, without, however, passing through their contents. 
Colloid consists of two component elements, a stroma, and the peculiar cell-containing, 
jelly-like matter from which the neoplasm derives its distinctive features. The former is 
of a fibrous character, and is arranged in such a 
manner as to form cells, loculi, or cavities, from 
the size of a pin-head up to that of a small mar- 
ble, rounded, ovoidal, or angular, and commu- 
nicating with each other. The stroma generally 
possesses great firmness and density; it creaks 
under the knife, and is of a dull, whitish, gray- 
ish, or pale yellowish color. It receives an 
abundant supply of vessels, as I have satisfied 
myself by dissection, and as is evinced also by 
the rapid development of the morbid growth, 
and the great bulk which it occasionally attains. 
In one case, in particular, I had no difficulty 
in tracing several large, straggling arteries into 
a tumor of this kind, showing that it had a very active circulation. The cystiform struc- 
ture of colloid is easily recognized, as it constitutes one of the most remarkable features 
of the morbid growth. It is well illustrated in the annexed cuts from a preparation in my 
collection; fig. 66 showing the external arrangement, and fig. 67 the internal. 
'The other element of colloid is an unrecognizable product, of a whitish, greenish, or 
yellowish color, and of the consistence of ordinary jelly, whence the name by which the 
disease is usually known. In the older spaces the matter is sometimes as firm as moist 
cheese, or the albumen of a hard-boiled egg, opaque, and of a white, pearly, or yellowish 
hue, interspersed with minute dark points. Sometimes, again, it resembles currant jelly, 
halt-dissolved glue, or a solution of gum shellac. However this may be, it never adheres 
to the walls of the alveoli, and is, therefore, easily enucleated, or pressed out. When 
perfect clearance has been effected of the loculi of a mass of colloid, the fibrous structure 
exhibits very much the appearance of a piece of sponge, the alveolar arrangement being 
then particularly conspicuous, hundreds of cavities being often visible upon a surface less 
than an inch in diameter. 
Under the microscope colloid differs from scirrhus and encephaloid mainly in the large 
size of the alveoli and in the contained gelatinous material, within which are included the 
so-called colloid corpuscles, or large, refractory, vacuolated cells, which are sometimes 
marked by several delicate concentric lines, giving them an oyster-shell appearance. 
With the advance of the metamorphosis, the cells disappear almost entirely, and nothing 
remains except large laminated spaces, from the to the of an inch in diameter, 
usually oval and grouped, nearly transparent, and interspersed with elongated nuclei, 
small, nucleated cells, and brood cells. The annexed sketch, fig. 68, from Kindfleisch, 
magnified 300 diameters, shows the alveolar formation of the stroma, and concentric cir- 
Fig. 66. 
Fig. 67. 
Colloid Carcinoma. Fig. 66 exhibits the External 
Appearance, and Fig. 67 the Internal Structure. TUMORS OR MORBID GROWTHS 
CHAP. VII. 
cles interspersed with granular matter 
and slender nuclei, and inclosing oval, 
well-defined, nucleated cells. This ar- 
rangement is very common, and most 
characteristic of colloid carcinoma. 
From the fact that colloid was until a 
comparatively recent date confounded 
with myxoma, it is impossible, in the 
existing state of our knowledge, to as- 
sign to it a proper position in the scale 
of the carcinomatous formations. In 
the mammary gland, in which organ 
he has carefully studied its clinical 
features, Dr. S. W. Gross finds that, 
when compared with scirrhus, its pro- 
gress is slow, that the lymphatic glands 
are affected late in the disease and in 
only one-fourth of all cases, and that 
metastatic tumors form only after it has existed for several years. The comparative 
immunity of colloid from local and general dissemination is ascribed by Dr. Gross to the 
fact that the migration of the cells along the lymphatics to the associated glands and 
the viscera is delayed or prevented by the colloid degeneration, a change which acts the 
part of a cementing substance and renders the cells immobile. 
5. MELANOSIS. 
Melanotic or pigmented carcinoma is a variety of encephaloid carcinoma, the oidy 
difference being that the cells of the former are impregnated with melanin, the appear- 
ances of which are represented in fig. 69, from Bennett. 
It has been observed in the breast, ovary, rectum, and 
parotid gland, but the history of its life is so mixed up 
with that of melanotic sarcoma that scarcely anything 
is known of its clinical features. 
After having remained stationary for an indefinite 
period, the tumor manifests a disposition to disintegra- 
tion, the softening process generally beginning at some 
superficial point, and thence gradually leading to the 
establishment of a foul, non-granulating, unhealthy 
ulcer, which no skill can cure. The discharge is gene- 
rally of a sanious character, mixed with and discolored 
by the pigment. Its progress is usually more tardy than 
that of scirrhus; but the general health often suffers 
long before ulceration sets in, the patient becoming thin, 
haggard, sallow, and exhausted. 
DIAGNOSIS OF CARCINOMATOUS TUMORS. 
Epithelioma is usually sufficiently easy of recognition. Its situation at the junction of 
the skin and mucous membranes, or upon either of these structures; its origin in a crack, 
fissure, or wart-like excrescence; its extraordinary firmness, the part feeling like a mass 
of fibro-cartilage; its slow growth; its small size; and the absence, for a long time, of 
severe pain and constitutional taint, are features that cannot deceive. 
The only characteristic sign of melanosis is the peculiarity of the color of the tumor; 
hence, when it is situated superficially, as when it occupies the parotid region, it is quite 
impossible to mistake the nature of the disease. 
Colloid tumors are liable to be confounded with fibrous, cartilaginous, myxomatous, 
and sarcomatous formations; but a careful consideration of the history of the case, and a 
thorough examination of the morbid growth, will generally serve to clear up any doubt 
that may arise in regard to the diagnosis. Colloid tumors are tardy in their progress, 
smooth or rough on the surface, of uniform consistence, and free from pain, their bulk 
being usually small, and the general health greatly disordered. Fibrous tumors enlarge 
slowly, seldom attain a great bulk, and do not usually seriously undermine the constitution. 
The cartilaginous growth is harder and less elastic than the colloid; its progress is rather 
Fig. 68. 
Miuute Structure of Colloid. 
Fig. 69. 
Pigmented Cells of Melanosis. CHAP. VII. 
TREATMENT OF MORBID GROWTHS. 
253 
rapid, and its outlines are always well defined, which is seldom the case with alveolar car- 
cinoma. A sarcoma often attains an immense size in a few months, especially in the 
bones, jaw, and the mammary gland, is generally of a globular shape and uniform con- 
sistence, and seldom contaminates the neighboring lymphatic glands. Myxoma is softer, 
grows more rapidly, and attains a far greater volume than colloid ; the former is not 
characterized by adhesions or lymphatic involvement; and metastatic tumors are infinitely 
less common than in colloid. 
Almost the only diseases with which encephaloid is liable to be confounded are scirrhus 
and sarcoma, and it will be therefore necessary to point out their differential diagnosis. 
For this purpose 1 give the subjoined table of the characteristics of the three affections. 
ENCEPHALOID. 
SCIRRHUS. 
SARCOMA. 
1. The tumor is soft and elastic, 
but not uniformly. 
1. Uniformly hard and inelastic, 
feeling like a marble beneath 
the skin. 
1. May be firm, tense, and elas- 
tic ; generally uniformly soft, 
and apparently fluctuating. 
2. It grows rapidly and soon 
acquires a large bulk, per- 
haps ultimately attaining the 
volume of an adult’s head. 
2. Growth is slow, and bulk 
comparatively small; the tu- 
mor rarely, even in the worst 
cases, exceeding the volume 
of a large fist. 
2. May remain stationary, or 
nearly so, for many years; 
awakened into activity, it 
progresses more rapidly than 
enceplialoid, and may attain 
an enormous volume in a 
short time. 
3. The pain is slight, and erra- 
tic, until ulceration begins, 
when it becomes more severe 
and fixed. 
3. The pain begins early, is 
distinctly localized, and is of 
a sharp, darting, burning, or 
lancinating character. 
3. Rarely pain until ulceration 
sets in, and even then usually 
insignificant. 
4. There is nearly always 
marked enlargement of the 
subcutaneous veins. 
4. In scirrlius these vessels re- 
tain their natural size, or are 
only slightly enlarged. 
4. The subcutaneous veins only 
slightly, if at all, enlarged. 
5. The ulcer is foul, deep, and 
excavated, with thin, under- 
mined, and livid edges, and 
is subject to frequent and co- 
pious hemorrhage. 
5. The ulcer is incrusted with 
spoiled lymph, and has steep, 
abrupt edges, looking as if it 
had been scooped out of the 
part; bleeding little, and sel- 
dom. 
5. The ulcer is fungous, and 
subject to frequent and copi- 
ous hemorrhage. 
6. There is generally early lym- 
phatic involvement. 
6. Usually not until late, or 
shortly before ulceration oc- 
curs. 
6. Singularly free from lym- 
phatic involvement, or, if the 
glands are affected at all, they 
become so quite late. 
7. More frequent before the age 
of forty-five than scirrlius. 
7. Seldom before the age of 
forty-five. 
7. Generally before the age of 
forty, and most commonly 
between that age and twenty. 
8. Is most frequent in the mam- 
ma, testicle, ovary, prostate, 
and salivary glands. 
8. Rarely occurs in the testicle, 
ovary, and prostate. 
8. Always begins in the con- 
nective tissues, particularly 
sarcoma of the extremities ; 
most common in periosteum, 
bones, and the mamma. 
9. The disease usually termi- 
nates fatally in from nine to 
twelve months. 
9. Seldom sooner than eighteen 
months or two years. 
9. No reliable data ; patients, 
however, often survive many 
years, even after repeated ex- 
tirpation. 
It is not improbable that an encephaloid carcinoma might be confounded with a chronic 
abscess, or an aneurism, especially when it is so situated as to receive an impulse from a 
neighboring artery. The very mention of the possibility of such an occurrence will be 
sufficient to put the practitioner upon his guard, and serve to point out to him the absolute 
necessity of the most profound caution in every case of a suspicious character. 
SECT. VII TREATMENT OF MORBID GROWTHS. 
In their management, tumors may, for the sake of convenience of description, be di- 
vided into the benign and malignant. The former comprise the cystic, fatty, fibrous, 
cartilaginous, osseous, muscular, vascular, lymphangiomatous, neuromatous, adenomatous, 
and papillary formations. The latter include myxoma, sarcoma, lymphoma, and carcinoma. 
1. Treatment of Benign Tumors.—The treatment, medical as well as surgical, of 
innocent tumors, having been succinctly discussed under each respective variety, it is only 
necessary here, in order to place the whole subject in a more tangible form, that I should 
briefly recapitulate the more prominent points of what has already been said. 254 
TUMORS OR MORBID GROWTHS. 
CHAP. VII. 
Few, if any, of the innocent formations are in the slightest degree amenable to reme- 
dies, whether locally applied or internally administered. The more simple forms of cystic 
tumors, and certain forms of goitre, occasionally disappear under topical and constitu- 
tional treatment; but even in these, in many cases, we find ourselves completely baffled, 
however perseveringly or judiciously the curative plan may be carried out. The most 
trustworthy local remedies, unquestionably, are tincture of iodine and the ointment of 
biniodide of mercury, variously diluted, and applied once or twice in moderation in the 
twenty-four hours. Chloride of ammonium also possesses powerful solvent properties. A 
poultice made of bran and salt water is an excellent sorbefacient. Leeches and blisters 
are useful when the morbid growth is hot and congested, or actually inflamed ; and, under 
similar circumstances, great benefit occasionally accrues from lotions of acetate of lead 
and Goulard’s extract. Systematic compression with adhesive strips, the roller, or the 
air-cushion, is sometimes serviceable, as is shown in certain tumors of the mammary 
gland, the testicle, and other parts of the body. 
The only internal remedies at all worthy of consideration, in the treatment of benign 
tumors, are iodine, either in substance, tincture, or Lugol’s solution, iodide of iron, iodide 
of potassium, mercury, chloride of ammonium, and tartar emetic. These articles may 
be given by themselves, or in various forms of combination, care being taken that the 
dose is not so large as to oppress the stomach, and that the prescription be occasionally 
pretermitted for a short time, as the effects are thus greatly enhanced. The diet must, of 
course, be properly regulated, being light, non-stimulant, and at the same time not too 
nutritious; the bowels are kept gently open, and the utmost attention is paid to the main- 
tenance of the secretions. 
How far electrolysis is to be trusted in the treatment of innocent tumors is a problem 
which further experience alone can solve. The chief affections in which it has been em- 
ployed are, hydrocele, hydatid tumors of the liver, nasvoid growths, and certain forms of 
goitre, in which it has occasionally been beneficial, having been followed, in some of the 
cases, by a permanent and rapid cure. The manner in which electrolysis acts is probably 
by the induction of inflammation, the perturbating effects of which put a stop to further 
growth at the same time that they promote the absorption of its various constituents, 
fluid as well as solid. To the harder varieties of innocent tumors, as the fibrous, cartila- 
ginous, and osseous, this method of treatment does not seem to be adapted ; at all events, 
I am not aware that any successful cases of it have been reported. A similar remark is 
applicable to the.various forms of ordinary cysts and lipomas. Papillary growths, as 
warts on the skin and genital organs, have occasionally been cured by it. 
With respect to the removal of innocent tumors, a few precepts may here be introduced 
for the guidance of the surgeon. The knife, of course, always claims preference in every 
operation of this kind ; but now and then a case occurs in which, on account of the 
danger of hemorrhage, or the difficulty of access, the ecraseur is used. The practice of 
removing innocent tumors with caustics has long been obsolete. 
1st. Interference should, as a rule, be avoided when the tumor is stationary, or nearly 
so, painless, and not inconvenient by its size, weight, or situation. 
2dly. If an operation be determined upon, the system should always be subjected to a 
certain degree of preliminary treatment, even when the tumor is comparatively small, 
experience having shown that extirpation is often followed by erysipelas. 
3dly. While the object should be to effect the most thorough removal, care should be 
taken not to interfere unnecessarily with the surrounding tissues, but to respect them as 
much as possible by keeping the knife in close contact with the morbid growth. 
4thly. When the tumor is of unusual bulk, it will generally be necessary to remove a 
portion of skin by including it in an elliptical incision, otherwise it should be retained, 
due allowance being made for its astonishing contractile powers. If this precaution be 
neglected, there may be a deficiency of flap wrhen the surgeon comes to approximate the 
edges of the wound. 
5thly. Diseased integument should always be removed along with the morbid growth, 
the knife being carried around it elliptically. 
fithly. Extirpation may generally be readily effected by a single incision carried across 
the centre of the tumor, either vertically, horizontally, or curvilinearly. It is only when, 
as already stated, the morbid growth is very large, or when there is diseased integument, 
that an elliptical incision will be required. 
7thly. The incisions should be directed in such a manner as to favor drainage, and to 
prevent bagging. Hence, one of the extremities should always correspond with the most 
dependent portion of the tumor. In operating upon parts that are habitually exposed, as CHAP. VII. 
TREATMENT. 
255 
the face, head, neck, hand, and arm, it is a matter of great importance to avoid the 
occurrence of unseemly scars. To facilitate this object, the skin should, as originally sug- 
gested by Dr. John H. Packard, be divided obliquely, the knife being held edgewise in 
making the incisions, so as to impart to the borders of the wound a bevelled appearance. 
A wound thus made, heals, Dr. Packard thinks, more readily than one made with a 
straight cut, and hardly leaves a perceptible cicatrix. 
8thly. When the morbid growth is very vascular, uncommonly soft, or very firmly ad- 
herent to the integument, the removal will be greatly facilitated if the skin be divided, as 
a preliminary step, upon the grooved director, the knife being thus prevented from pene- 
trating the proper substance of the tumor. 
9thly. By keeping the knife in close contact with the tumor, the whole mass may some- 
times be speedily and effectually enucleated with the hand, finger, scalpel, scissors, or 
scraper. Another advantage of such a precaution is the avoidance of hemorrhage. 
lOthly. When the mass is very large, pendulous, and vascular, as, for example, in those 
enormous growths constituting what is called elephantiasis of the scrotum, the bleeding 
may be essentially diminished by elevating the tumor and pressing the blood out of its 
veins immediately prior to the operation either with the hands or with the elastic bandage. 
llthly. There are certain kinds of morbid growths, as, for example, polypoid myomas 
of the uterus and naevoid tumors, that are more easily and safely removed with theecraseur 
than with the knife, on account of their peculiar situation, and the danger of hemorrhage. 
In using this instrument, the part, as a preliminary step, is thoroughly isolated by transfix- 
ing its base with pins, and then gradually divided by linear crushing, the chain with which 
it is provided being well adapted to such an object. The stump must not be disturbed after 
the operation is completed, as this might excite bleeding and interfere with the healing 
process. 
12thly. Any large arteries that may be divided should either be compressed by an 
assistant until the extirpation is completed, or they should immediately be tied, loss of 
blood being carefully guarded against in all proceedings of this kind. When the surgeon 
is operating alone, or when he has no good aids, the bleeding may be temporarily checked 
with the serrefine, fig. 70, a kind of wire forceps, the contrivance depicted in fig. 71, or 
Nunneley’s forceps, fig. 72. These instruments maintain their hold by their own elas- 
ticity, and will be found to be of great service in extensive and tedious dissections, espe- 
cially when the same artery is obliged to be cut several times. 
Fig. 70. 
Fig. 71. 
Fig. 72. 
Serreflne. 
Small Forceps for Temporarily Check- 
ing Hemorrhage. 
Nunneley’s Artery Forceps. 
1 Bthly. When all oozing of blood has ceased, the edges of the wound are accurately 
approximated by suture and adhesive strips, aided, if necessary, by a light compress and 
bandage, to keep the Haps in close contact with the raw surface beneath, as the object is 
to secure union by the first intention. 
Lastly. The part is to be kept perfectly at rest until the wound is healed, and the case 
treated, in every respect, upon ordinary antiphlogistic principles, the greatest attention 
being paid to drainage and cleanliness. In general, the dressings should not be disturbed 
before the end of the second day, especially if the absence of fetor and discharge indicates 
favorable progress. 
2. Treatment of Malignant Tumors In the treatment of the various forms of 
malignant growths all internal remedies, of whatever kind and character, have proved 
unavailing in arresting their march, or in modifying their action so as to render the 
surrounding structures tolerant of their presence. The vaunted specific of the empiric, 
and the enchanted draught of the honest but misguided enthusiast, have alike failed in 
performing a solitary cure ; and the science of the nineteenth century must confess, with 
shame and confusion, its utter inability to offer even any rational suggestions for the relief 
of this class of affections. But, although this is the case, yet it by no means follows that 
the subjects of these complaints may not be benefited by general treatment, if it be directed 
by common sense and sound judgment. Every practitioner of experience knows how 256 
TUMORS OR MORBID GROWTHS. 
CIIAP. VII. 
much ordinary local diseases are influenced by constitutional measures; and if this be 
true of these lesions, how much more true must it be of tbe malignant, in the production 
of which both the solids and fluids play such an important part. Hence, when surgical 
interference is inappropriate, the attention of the surgeon should be particularly directed 
to the patient’s diet, bowels, and secretions, and to the avoidance of all sources of local 
irritation, calculated to favor the morbid growth, and hasten the fatal issue. 
The diet should generally be of a bland and unirritant character, and yet at the same 
time sufficiently nutritious to preserve a sound condition of the blood, and to maintain the 
tone of the muscular system. All condiments, coffee, strong tea, pastry, hot bread, and 
the coarser kinds of vegetables and meats, should be abstained from. Eggs, fish, oysters, 
and the white kinds of meat, may be moderately used once a day, but not oftener, unless 
there is some special reason for it, founded upon the state of the general health. Fre- 
quently a purely farinaceous and milk diet will be found to answer better than any other, 
the patient not only thriving under it, but the disease being apparently kept in check by it. 
The bowels should be maintained in a soluble condition, but all active purgation must 
be carefully avoided. The most suitable aperient, when a tendency to constipation exists, 
is a blue pill, with one grain of ipecacuanha, or equal parts of blue mass and jalap, at bed- 
time, followed, if necessary, by a Seidlitz powder in the morning. If gastro-intestinal 
irritation arise, the blue mass may advantageously be replaced by a small portion of calo- 
mel. In this way, while the bowels are maintained in an open state, the secretions are 
also duly preserved ; a matter of no little moment in the treatment of all malignant dis- 
eases without exception, especially when they are attended with marked constitutional 
disturbance. 
Sleep is procured and pain allayed by morphia given, if possible, hypodermically once 
or twice in the twenty-four hours. When the suffering is of a neuralgic character, the 
anodyne may be administered by the mouth in union with arsenic or arsenic and strychnia. 
When marked debility exists, tonics, as quinine and iron, a generous diet, and the use 
of brandy, wine, ale, or porter, are imperatively demanded. Night sweats are best con- 
trolled by sulphate of atropia, aromatic sulphuric acid, oxide of zinc, or acetate of lead 
and tannic acid. 
Perfect rest of the affected part, and entire freedom from pressure and excitement, are 
of paramount moment. Thus, in carcinoma or sarcoma of the breast or testicle, the organ 
must be well suspended, the dress worn loose, and all rude manipulation scrupulously 
abstained from. If the part be tender, hot, and swollen, or (edematous, some mildly astrin- 
gent and anodyne lotion will be of service, or the surface may be painted several times a 
day with a weak solution of iodine. When the local inflammation is unusually severe, as 
evinced by the discoloration and pain, nothing, according to my observation, affords such 
prompt and decided relief as the application of a few leeches, unless it be a small blister, 
retained until free vesication is produced. Some cases are greatly benefited by the use of 
an opium, belladonna, or cicuta plaster, renewed every eight, ten, or twelve days. All 
caustic applications should be carefully avoided, inasmuch as they can never do any good, 
but may do a great deal of harm by establishing sores which it will afterwards be impos- 
sible to heal. 
In open malignant growths, the sore must be kept constantly clean by frequent ablu- 
tions; while the excessive fetor which so generally attends must be allayed by the free use 
of permanganate of potassium and other articles. The best dressing is an emollient poultice, 
particularly one made of powdered elm bark, sprinkled, if there is much pain, with a little 
morphia, pulverized opium, or laudanum. If the ulcer is very sensitive, it should occa- 
sionally be very lightly touched with solid nitrate of silver, or kept constantly covered with 
very dilute ointment of acid nitrate of mercury. When the discharge is very profuse, 
sanious, and offensive, a lotion composed of two to four drops of nitric acid to the ounce 
of mucilage of gum arabic, or of five grains of chloral to the ounce of water or cosmoline, 
will be found exceedingly beneficial in diminishing its quantity and changing its character. 
Carbolic acid is also an excellent remedy, the only objection to it being its offensive odor. 
The affected glands in the neighborhood of the diseased organs often require attention, 
especially when they are very painful and bulky. The remedies should be of an anodyne 
and antiphlogistic character, especially leeches, iodine, and saturnine lotions in union with 
laudanum. 
The hemorrhage attendant upon open carcinoma is generally easily controlled with 
Monsel’s salt, or a thick coating of Richardson’s styptic, consisting of collodion with the 
addition of three grains of tannic acid to each ounce of fluid. Acupressure may be required 
when a small artery or vein has been laid open. TREATMENT. 
257 
CHAP. VII. 
The electrolytic treatment of malignant growths has, on the whole, been very unsatis- 
factory. The details of the reported cases are obscure, and the tumors said to have been 
malignant, and removed by this measure, have rarely exceeded the volume of a nutmeg, 
so that errors in diagnosis were not out of the question. In the majority of instances the 
sole results appear to have been amelioration of the suffering, and, in a very few, tempo- 
rary arrest of growth. 
The treatment of carcinomatous diseases by compression, introduced early in the present 
century by Sir Charles Bell, has, after having been alternately eulogized and condemned, 
at length fallen into merited disrepute. Many years ago, Mr. Arnott, of London, made 
an attempt to revive this mode of treatment, especially in carcinoma of the mammary 
gland, by the invention of a cup-shaped apparatus furnished with an elastic air-cushion, in 
order to apply the pressure in a more gentle and equable manner. The suggestion, ema- 
nating from so eminent an authority, attracted much attention at the time, and led to 
numerous trials, both in Europe and in this country, but with results so discouraging as 
to have caused its entire abandonment. 
In 1866, Dr. Broadbent, of London, called attention to the treatment of carcinoma by 
means of the hypodermic injection of acetic amd diluted with two to five parts of water, 
the quantity introduced at each operation varying from twenty to thirty minims. Cases 
are cited in which its use is said to have been followed by marked diminution of the 
volume of the tumor, but as no examples of permanent cure have been reported the 
practice has been abandoned. I have myself, in the few trials I have made with it, ob- 
tained no benefit. In several of the cases the operation was followed by a smart attack 
of erysipelas and by a good deal of ulceration. The treatment of lymphoma by parenchy- 
matous injections of Fowler’s solution is not only attended with depression, restlessness, 
sleeplessness, and fever, but its employment holds forth no prospect of ultimate recovery. 
In regard to extirpation, if it be done early and in a thorough manner, so as to remove 
all diseased tissues, recent experience has demonstrated that it may be relied upon in a 
certain proportion of cases as a means of permanent cure. In other cases, the results are 
not so striking ; but there are hundreds of examples of carcinoma, sarcoma, lymphoma, and 
myxoma on record, which prove conclusively that life maybe extended many months and 
even years by timely interference, and by the removal of recurrent growths as fast as they 
make their appearance. Hence my conviction is that the knife should be resorted to as 
early as possible, and that no time should be wasted in the employment of the measures 
indicated in the preceding paragraphs. 
When a scarcoma, or myxoma, is seated in one of the long bones, or deeply among the 
muscles of an extremity, the only resource is amputation of the limb, performed at the 
nearest articulation. To remove a limb in its continuity, in such a condition, is worse 
than useless, conferring neither benefit upon the sufferer, nor reflecting any credit upon 
the judgment of the surgeon. 
Epithelioma is less liable to recur after extirpation than scirrhus, encephaloid, or me- 
lanosis. Removed in its earlier stages, there is occasionally a strong probability that there 
will be either no relapse at all, or only after a considerable period. One reason perhaps 
of this is that the disease is commonly more localized than the ordinary forms of carcinoma. 
General Rules for conducting Excision of Malignant Tumors.—When excision is 
determined upon, it is very essential that it should be performed in the most thorough and 
complete manner, in order that the parts may be effectually protected from relapse. The 
slightest atom of the new tissue, the most minute cell, nay, possibly, the smallest particle 
of juice, may, if left behind, endanger reproduction. 
1st. To accomplish this object, it is necessary that the incisions should be carried 
through the healthy tissues some distance beyond the morbid growth. If any part has 
escaped the knife in the first instance, it should be traced out immediately after the ex- 
tirpation of the main mass, and be excised with the most scrupulous exactness. Free use 
should be made, in this stage of the operation, of the sponge and finger; of the former 
for clearing away the blood, of the latter for ascertaining the consistence of the surface of 
the wound. The sight alone should never be trusted, inasmuch as it is a great deal more 
deceptive than the sense of touch. Not a particle of the least suspicious substance should 
be left behind. Nay, the very atmosphere of the disease should be destroyed. Skin, 
muscle, glands, vessels, nerves, and bone should all be sacrificed, if necessary to success. 
2dly. When only a portion of an organ is involved by a malignant growth, the rule is 
to remove, not a part, but the whole of it. Thus, in carcinoma or sarcoma of the mam- 
mary gland, the practice invariably is to extirpate the entire organ, however small the 
part implicated. 258 
TUMORS OR MORBID GROWTHS. 
CHAP. VII. 
3dly. It is equally important to remove the associated contaminated lymphatic glands, 
and even search for them if they were not palpable previous to the operation. In car- 
cinoma of the breasts of fat women, laying open the axilla will frequently bring to light 
infected glands which could not be felt from the surface. If permitted to remain the 
object of the operation will be defeated. 
4thly. The utmost care must be taken to guard against hemorrhage, even when the 
patient is tolerably plethoric, especially if the operation is at all severe. Lean and fat 
subjects generally bear the loss of blood badly. A copious hemorrhage, besides seriously 
endangering adhesive action, is often followed by erysipelas, and I am fully satisfied that 
it predisposes to early relapse. 
Sthly. As a preventive against local reproduction the wound left by the operation 
should be mopped with a strong solution of chloride of zinc, or even seared with the 
cautery at a red heat. The latter agent is always indicated after the extirpation of second- 
ary nodules in the adjacent muscles. 
Gtlily. The edges of the large wound should be as closely approximated as possible by 
a few sutures inserted at least an inch from the edges and by adhesive strips. The most 
suitable dressings are an oiled compress and a bandage. When the parts are slow in 
healing, skin grafting may be employed. 
7thly. When the skin is defective, it is sometimes practicable to borrow the requisite 
amount from the surrounding structures; an operation first suggested, I believe, by 
Martinet, who imagined that a return of the disease could thereby generally, if not always, 
be effectually prevented. lie thought the functions of the parts might thus be changed in 
such a manner as to restore their healthy nutrition, and so counteract the tendency to 
the reproduction of carcinoma. 
I have had recourse to this procedure in a number of instances, in different regions of 
the body, especially in epithelioma of the lips and eyelids ; but in very few with any 
permanent or even protracted benefit. For a time the transplanted parts retained their 
healthy character; but at the end of a few months they gradually became hard and rigid, 
and soon thereafter exhibited all the evidences of carcinomatous disease. 
8thly. When the morbid growth is seated in an extremity, and is of large bulk, or involves 
important structures, amputation takes the place of excision. Whenever the operation is 
performed for sarcoma of the long bones, experience has shown that there will be no 
return of the disease in the stump, provided care has been taken to remove the limb above 
the limits of the tumor. Death, however, commonly occurs, except when the sarcoma 
is of the myeloid variety, at no distant date from a development of similar disease in some 
of the internal organs, especially the lungs. 
Finally, it is well to bear in mind that the surgeon, in the removal of a malignant 
tumor, may incur great personal risk as it respects his own health and life. Professor 
Puldley suffered for many months from the inoculation of his hand in amputating the 
forearm of a person affected with encephaloid sarcoma; and, in 1869, Dr. Maurice II. 
Collis, of Dublin, lost his life from the effects of a slight puncture of one of his fingers, 
received during the excision of a carcinomatous tumor of the upper jaw. Other examples 
of a similar nature are upon record. The symptoms are usually those of blood poisoning. 
Thorough ablutions, first with simple water and soap, and then with water impregnated 
with chlorinated sodium, are the best preventives. 
Treatment ajter Operation.—The treatment after removal of the affected structures 
must be conducted upon general principles. When the patient has recovered from the 
immediate effects of the operation; he should be put upon a general course of treatment 
intended to maintain his health as near as possible at the normal standard. Above all, 
strict and constant attention should be bestowed upon his diet. 
Of the propriety and importance of attention to the patient’s diet, after excision, no 
one can entertain any doubt. The force of this remark will appear the more evident when 
it is recollected that the progress of carcinoma has occasionally been stayed for months, 
and even years, by a regular and persistent system of starvation, barely allowing a suffi- 
cient quantity of food, of the most bland and unirritant character, to maintain the due 
play of the vital functions, without too great a reduction of the heart’s action. 
The kind of diet is a matter of no little moment. Meats, soups, and the coarser varie- 
ties of vegetables should generally be proscribed, on account of their heating and indigesti- 
ble character. For the same reason, condiments, wines, spirits, coffee, and fermented 
liquors are to be eschewed. Among the more suitable articles are stale bread, toast, and 
soda biscuit, hominy, grits, rice, sweet and Irish potatoes, mush, macaroni, baked apples, 
figs, and ripe fruits. Oysters and fresh fish may be used in moderation. Not only CHAP. VII. 
TREATMENT. 
259 
should the food be perfectly simple, and easy of digestion, hut it should be well masticated, 
and taken in such quantity at each meal as not to crowd and oppress the stomach. As 
drinks, the best articles are water, milk, and weak tea. 
Of late years an almost exclusive milk diet has been used in several remarkable cases 
after this operation, with effects so encouraging as to deserve further trial. The facts 
published upon this subject by Dr. Pierce, Dr. Bowditch, and others, are exceedingly 
interesting and instructive, and worthy of attentive consideration. 
As there are no remedies which will eradicate the malignant structure from the 
system before the operation, so are there none which will prevent its reproduction after. 
Of the numerous articles that have been employed for this purpose there is not one which 
can be viewed in the light of a specific, or as a counter agent to the morbid action. 
Some of the older surgeons, and, indeed, quite a number also of the modern, strongly 
insist upon the establishment of a kind of perpetual drain in the neighborhood of the 
original disease, as a means of preventing relapse after extirpation. The principal 
measures that have been suggested for this purpose are the issue and seton ; modes of 
treatment with which I have no experience, and in which, on principle, I should have no 
confidence. 
If relapse ensues, and the patient becomes debilitated, supporting measures must be 
adopted, as quinine, iron, brandy, and nutritious food, along with gentle exercise in the 
open air. Pain must be allayed by the free use of anodynes, and night sweats by sulphate 
of atropia, elixir of vitriol, or oxide of zinc, given in as large doses as the stomach will 
tolerate. Constant attention must be paid to cleanliness; fetor must be corrected by 
chlorinated sodium, permanganate of potassium, and other means ; and the utmost care must 
be taken to protect the parts from the pressure of the clothes and from all kinds of rude 
contact. The most suitable local remedies are leeches, dilute tincture of iodine, opiate 
plasters, and emollient cataplasms, medicated with anodynes. 
Contraindications to Surgical Interference The following circumstances may be 
enumerated as contraindicating the removal of malignant tumors:— 
1st. Interference should be avoided when the disease coexists in several parts of the 
body, as, for instance, in the mamma and uterus, or the testicle and eye, as it would be 
almost certain to hasten the patient’s destruction. 
2dly. No operation is ever resorted to, at least not as a curative agent, when there is 
serious local involvement; or when there is marked evidence of the carcinomatous cachexia. 
Thus, in carcinoma of the mamma, no surgeon who values his reputation, or who has any 
regard for the welfare of his patient, interferes when the tumor is firmly adherent to the 
surrounding parts, when the skin is changed in structure, ulcerated, indurated, or dimpled, 
when there is enlargement of the axillary, subclavicular, or supraclavicular lymphatic 
glands, when there is oedema, with numbness and loss of function in the corresponding 
limb, and, finally, when, in addition to these symptoms, the countenance exhibits all the 
evidences of the carcinomatous cachexia. The same circumstances guide the surgeon in 
carcinoma of the testicle, lip, penis, and extremities. If the knife is ever employed 
when the malady has made such progress and such inroads, it is with a view solely to 
palliation, not to cure. Of the propriety of such a course every surgeon must be his own judge. 
3dly. When the disease advances very rapidly, as it not unfrequently does in encepha- 
loid sarcoma, carcinoma, and myxoma, breaking through its original barriers, and leap- 
ing, as it were, suddenly into the surrounding tissues, ablation will either be improper, 
or, if had recourse to, speedy repullulation maybe expected. Rapid growth, constituting 
what has sometimes been denominated the acute form of malignant action, always implies 
a bad state of the constitution and extensive infiltration of the surrounding tissues, and 
imperatively forbids surgical interference. An oedematous appearance of the parts imme- 
diately around the morbid deposit, or at a distance more or less remote from it, is another 
unfavorable occurrence. This condition, which is seldom absent in external carcinoma in 
its later stages, is not unfrequently present at an early period in encephaloid, especially in 
the hematoid variety, and is always indicative of the very worst state of things, both local 
and constitutional. The immediate cause of this symptom is obstruction of the lymphatic 
vessels and glands. Observation shows that nothing but mischief is to be expected from 
interference when the malady has attained this crisis. 
4thly. A quickened state of the pulse, occasioned by the local irritation, augurs unfavor- 
ably. Excision, performed under such circumstances, is nearly always speedily followed 
by relapse. 
5thly. Latent carcinomas should not be tampered with. Cases constantly occur in 
which, from neglect of this precaution, the patient loses his life, within a very short period 260 
TUMOliS OR MORBID GROWTHS. 
CHAP. VII. 
after operation, from a return of the disease in its worst form. The reproductive powers 
of the part, if not of the system generally, usually manifest an astonishing activity under 
such circumstances, and the consequence is that the malady soon accomplishes its work of 
destruction. 
Gthly. It is not necessary to insist upon the propriety of refraining from operation when 
there is serious disease of an important internal organ. Such a complication could hardly 
fail to predispose to relapse, if not to the speedy destruction of the patient. 
7thly. I was formerly greatly opposed, in malignant affections, to operative interfer- 
ence merely as a palliative measure, believing that the pain and risk consequent upon 
its employment, would not counterbalance the beneficial effects. After more mature 
experience, however, 1 came to a different conclusion, and for years past I have, in 
numerous instances, used the knife where there was not the slightest prospect of a per- 
manent cure. The class of cases to which this procedure is more especially adapted are 
those in which there are excessive pain, loss of appetite and sleep, and great discharge of 
foul, offensive matter, contaminating the air of the patient’s apartment, and rapidly under- 
mining the vital powers. With the aid of anaesthetics, an operation is no longer a source 
of suffering, and may, in such a condition, if properly performed, be followed by much 
good, not only freeing the patient from local and constitutional distress, but, perhaps, 
materially prolonging life by getting rid of a burden which has weighed down both mind 
and body. Moreover, the recurring disease is not always as bad as the original, although 
such an event can seldom be foretold with any degree of certainty. 
Reproductive Tendency of Malignant Diseases after Operation—Of the reproductive 
tendency of malignant diseases, after extirpation, or destruction by the actual or potential 
cautery, writers have made mention from the earliest periods of medical science to the 
present time. Hippocrates was fully aware of the fact; and he entered his protest against 
all operative proceedings, under the conviction that, however early or well executed, they 
could not possibly afford any permanent relief, or protect the patient against a return of 
this malady. Similar views have been advanced by nearly all succeeding writers; but a 
different sentiment is now entertained in regard to removal as a final measure in many 
cases, provided early and adequate operations are performed. 
The period at which relapse occurs varies from a few w eeks to several years, the average 
period being from four to six months. Occasionally it is astonishingly short. In one of 
my cases relapse appeared in less than three weeks. The original disease, a genuine 
scirrhus of eight months’ standing, occupied nearly the whole of the left breast; the nipple 
was somewhat retracted, and there was a slight enlargement of one of the lymphatic glands 
of the axilla, which was removed in the operation. The dissection was performed with 
the utmost care, and the w'ound united by the first intention, excepting a little spot at 
the centre, which remained open and became the starting-point of the new growth. The 
woman, who was forty-six years of age, died three months after the operation, having 
endured the most horrible suffering. • 
When relapse is unusually tardy, the probability is that the original disease was more 
than ordinarily localized, and that there is no disposition after extirpation to involvement 
of the general system. 
All malignant diseases possess a tendency to relapse after ablation, although not in an 
equal degree. Encephaloid undoubtedly has it in a far greater degree than scirrhus, and 
scirrhus than colloid. Melanosis also recurs with great frequency and promptness, and 
may be placed next to encephaloid in this respect. Even epithelioma often relapses after 
extirpation, but now and then the part and system continue to be remarkably exempt for 
years, if not during the remainder of life. Sarcoma, myxoma, and lymphoma also evince 
a great tendency to local reproduction, the last, indeed, being scarcely inferior in that 
respect to encephaloid carcinoma. 
The reproductive tendency of malignant disease, after operation, is well illustrated in 
the case of a man, aged thirty-two, who consulted me in April, 1851, on account of a 
sarcomatous epulis of the lower jaw', first noticed three months previously. The growth 
was firm, elastic, free from pain, of a pale red color, and attached to the gum and jaw, 
extending from the ramus to the first bicuspid tooth. Two operations had already been 
performed upon it, each being followed by rapid relapse. On the 27th of April, I excised 
the parts, along with the corresponding portion of the jaw. On the 24th of September 
the patient came again under my care, and I now removed the whole of the new growth, 
about the size of a pullet’s egg, and also about three-quarters of an inch of the anterior 
extremity of the ramus of the bone, from which the diseased structure seemed to spring. 
On the 31st of August, 1852, I excised the ramus at the articulation, the disease having SCROFULA AND TUBERCLE. 
261 
CHAP. VIII. 
attacked its inferior extremity. The man remained well until the winter of 1853, when 
the disease broke out in front of the ear, where it soon formed a tumor as large as a small 
fist, under the effects of which he rapidly sank. It is worthy of remark that the general 
health had all along been pretty good, and that the wound always healed well after each 
operation. 
Epithelioma affords a greater number of non-recurring examples after operation than 
any other carcinomatous formation. I have myself had a number of instances of 
epithelioma of the lip in which there was an entire freedom from disease for years— 
in some as many as seven, eight, and even ten—and similar good luck has followed 
some of my excisions of the penis for carcinoma of the head of that organ. In a case of 
epithelioma of the lower lip, communicated to me by Dr. Barclay, of New York, the patient 
survived the first operation seven years, the knife having been employed altogether five times. 
In a case of encephaloid sarcoma of the thigh, reported to me by Dr. C. S. Tripler, of 
the Army, the man did not die until five years after the first operation. In 1853, I 
amputated the arm of a gentleman, thirty-five years of age, on account of soft sarcoma of 
the upper portion of the forearm ; the disease had been in progress for nearly twelve 
months; the tumor was large and well-marked; the wound healed kindly, and life was 
prolonged for nearly six years, when death occurred from some affection of the lungs and 
pleura;, the precise nature of which I have not been able to ascertain. I am acquainted 
with the history of a number of other examples nearly equally remarkable. 
The recurring tendency of melanotic sarcoma is familiar to every surgeon of experience. 
II ardly an example of permanent cure by operation is upon record. A remakable instance 
of this recurring action came under my notice many years ago, in the practice of the 
late Professor McClellan, of this city. The disease had, seemingly, begun in several 
small subcutaneous tubercles of the abdomen, about the size and color of so many shot, 
which soon became exquisitely painful, and, gradually bursting through the skin, w'ere 
at length converted into foul, fungous sores, attended with a highly fetid, sanious dis- 
charge. Many of these tumors were extirpated, some in their crude, others in their 
open state; but, although the w'ounds generally readily healed, they were alw’ays rapidly 
succeeded by a new growth in the immediate vicinity of the original. The man became 
much emaciated, and finally died completely exhausted, with all the evidences of the 
melanotic diathesis. 
CHAPTER VIII. 
SCROFULA AND TUBERCLE. 
The term scrofula had formerly a far more limited application than is at present 
accorded to it. It was originally employed to designate a glandular swelling of the neck, 
strikingly resembling the neck of the swine, whence its derivation. At present, how- 
ever, it has a much wider signification, including within its range a variety of affections 
apparently of the most opposite character, and yet in reality essentially alike in every 
particular. As meaning the same thing, the words struma and tubercular disease are 
frequently used. 
The affections which may be comprised under this term are pulmonary phthisis, chronic 
enlargement of the glands of the neck and other parts of the body, hip-joint disease, 
psoas, lumbar, and chronic abscesses, Pott’s disease of the spine, certain forms of folli- 
cular ulceration of the mucous membranes, arachnitis, otorrhoca, ozaena, ophthalmia, 
eczema, and ulceration of the bones. The fact is, the class of scrofulous maladies is almost 
endless; for they affect almost every part of the body, and assume almost every form of 
morbid action. 
Scrofula consists essentially of a peculiar state of the system, in which there is a 
marked tendency to the formation of an inflammatory product known by the name of 
tubercle. Attempts have been made from time to time to draw a distinction between 
tubercle and the state of the system which predisposes to its occurrence. It is difficult 
altogether to deny the propriety of this distinction ; for there are unquestionably cases 
which we are in the habit of designating as strumous, where, nevertheless, there is not, 
so far as can be determined, the slightest tubercular deposit. There would seem to be SCROFULA AND TUBERCLE. 
merely a strumous irritation in the part, without the part being in a condition to furnish 
any product capable of giving rise to tubercles. 
‘There is another distinction, which, however, is fast losing ground, which it is more 
difficult to reconcile than that just mentioned, the alleged difference between phthisis and 
scrofula. It would be easy, if a work on surgery were the proper place to discuss the 
subject, to show the fallacy of this opinion. I have long been convinced of the identity 
of these diseases, and of the fact that the only actual difference between them depends, 
not upon any difference in the morbid action, but solely upon the difference of structure, 
tubercular disease sharing the same fate, in this respect, as ordinary inflammation and as 
the other atypical formations. A tubercle in the lung is essentially the same disease as 
a tubercle in a bone or a lymphatic gland, having a similar origin, running a similar 
course, and producing similar results. 
Tubercular disease is of an infectious nature, and is due to the absorption of the softened 
caseous products of scrofulous inflammation, which excite irritation and proliferation of 
the cellular elements with which they come in contact, and in that way result in the 
formation of the tubercle granule. Once formed, submiliary tubercles increase by aggre- 
gation, and by their caseous degeneration and softening may act as foci for secondary 
infection. 
The transmissibility of tubercle by inoculation has been confirmed by the experiments 
of Villemin, Cohnheim, Burdon-Sanderson, and other investigators, and there is reason 
to believe that tuberculosis may be communicated in the human subject in other ways. 
Thus Reich has recorded some interesting observations which show that the disease was 
transmitted by a phthisical nurse to a number of children ; and the risk of contracting 
the affection by occupying the same bed with a subject of pulmonary consumption, is 
insisted upon by several authors. Tuberculosis has been produced by feeding the lower 
animals on tuberculous material; and Epstein believes that the disease may be transmitted 
to children by the ingestion of the milk of tuberculous nurses and cows. 
Tubercular disease occurs at all periods of life. Sometimes, indeed, it exists as an 
intra-uterine affection, thus leading to the conviction that it is occasionally hereditary, or 
that it is transmitted in the very act of impregnation. When it occurs as phthisis, it is 
most common between the twentieth and fortieth year, and it is remarkable that after the 
age of puberty it rarely exists in any part of the body without involving the lungs. In 
children, the disease, considered in a general point of view, is most frequent between the 
third and tenth year. A vast majority of the cases of scrofulous disease that are met 
with in the form of coxalgia, Pott’s disease, caries of the short bones of the extremities, 
arachnitis, ophthalmia, otorrhcea, tonsillitis, and chronic enlargement of the lymphatic 
glands, occur at this period of life, and constitute an immense source of mortality. It is 
a remarkable fact that adults seldom suffer from external scrofula ; and, on the other hand, 
it is equally remarkable that children suffer comparatively seldom from consumption, so 
common among persons after the twentieth year. In old age the disease is rarely wit- 
nessed in any form. 
Struma is frequently hereditary. The children of consumptive parents are often cut 
off by the same disease, or they suffer in various parts of the body, as the bones and 
joints, lymphatic glands, eye, ear, and serous membranes. Whole families are sometimes 
swept off by it. Occasionally the disease skips one generation, and reappears in another, 
owing, doubtless, to some temporary improvement in the intermediate offspring. 
Tubercle has been observed in nearly all the organs and tissues of the body, the only 
ones, perhaps, that are exempt from it being the skin, nerves, ligaments, aponeuroses, 
tendons, and voluntary muscles. The lungs, particularly their summits, are, of all the 
structures, the most prone to suffer; then, next in the order of frequency, come the 
lymphatic glands, then the spleen, serous membranes, and mucous follicles of the alimen- 
tary canal, then the bones and joints, and finally the brain, liver, kidneys, testes, and false 
membranes of the serous cavities. In the lungs and some of the other more vascular 
organs the external coat of the smaller bloodvessels seems to be the favorite seat of the 
deposit. Its coexistence in various parts of the body, or its almost universal diffusion, is 
sufficiently common, and constitutes the so-called strumous diathesis. 
The deposit being the result of an infectious inflammatory process, and due to the proli- 
feration of the endothelial cells of the bloodvessels, lymphatics, and of the serous mem- 
branes, of the fixed connective-tissue corpuscles, and of the wandering cells, occurs both 
in the parenchyma and upon the free surfaces of the organs. Hence it exhibits itself in 
various forms, of which the nodular is by far the most common, the stratiform and infil- 
trated being, indeed, exceedingly rare. The nodular variety occurs in little masses, from 
chap. vm. CHAP. VIII. 
SCROFULA AND TUBERCLE. 
263 
the size of a millet-seed to that of a pea, of a pale yellowish or grayish color, and of a 
consistence ranging from that of curds or soft putty to fibro-cartilage, hundreds and even 
thousands often existing in a very small compass. When very numerous and closely 
grouped, they sometimes coalesce, so as to form a tumor of considerable size. The strati- 
form variety of the deposit is most common upon the mucous surfaces, while the infiltrated 
is met with chiefly in the lungs, around tubercular excavations, and in the lymphatic 
glands. Whatever shape it may assume, it is always deposited in a soft state, from which 
however, it passes speedily into the solid form, which it retains for a certain period, 
generally from six to twelve months, when, becoming softened and disintegrated, the 
part makes an effort to rid itself of it. These changes are followed by the formation of 
a cavity, named a strumous abscess, of which the best examples occur in the lungs, bones, 
and lymphatic glands. The matter is peculiar, being generally of a yellowish, dirty, 
turbid color, thin, oleaginous, and intermixed with small whitish flakes, very similar to 
broken-down grains of boiled rice. 
Tubercles present certain peculiarities in their histological characters in accordance with 
their age and the structure of the organ in which they originate. They are, however, 
usually composed, as is well represented in fig. 73, from Green, of a small-celled lymphoid 
tissue surrounding giant or multinucleated cells, the branched processes of which are 
continuous with the adenoid reticulum. The cells contained within the reticulum are 
round or ovoid, and vary in size from 25W to 35W an inch in diameter. An isolated 
giant cell with its long processes is shown in fig. 74, copied from the same author. 
Fig. 73. 
Fig. 74. 
Minute Structure of a firm Gray Miliary Tubercle of the 
Lung in a Case of Acute Tuberculosis. 
A Multinucleated Cell from the Lung in a 
Case of Chronic Phthisis. 
Tubercular material, in its crude state, consists almost entirely of albumen, with a 
small quantity of earthy salts, particularly phosphate and carbonate of lime. Some 
specimens also contain a little fibrin, casein, extractive matter, and pyine ; but the great 
and pervading substance is albumen, or protein matter. 
The microscopical and chemical examinations of tubercle are extremely valuable, 
inasmuch as they go to show the low grade of its vitality, and its consequent inability to 
maintain, for any length of time, its existence. The vessels of the tissues in which the 
new formation originates gradually become obliterated, and, as a result, the nodule under- 
goes caseous degeneration, which ends in softening and the production of a cavity or an 
ulcer. Now and then, and particularly when the fatty degeneration is not so marked, 
the adenoid reticulum is converted in a firm fibroid mass; and dessication and calcifica- 
tion of the caseous material are occasionally met with. 
Of the exciting causes of tubercular disease our knowledge is rather conjectural than 
positive. It may fairly be inferred, however, from the numerous observations that have 
been made upon the subject, that, when the tendency to the disease exists, anything that 
produces excessive debility, or an impoverished condition of the blood and solids, may 
provoke the morbid deposit. The causes which are most likely to bring about this effect 
are: 1. Meagre and unwholesome food, deficient in fibrinous, albuminous, gelatinous, and 
fatty qualities. 2. Protracted disorder of the digestive organs, particularly the various SCROFULA AND TURK RULE. 
CHAP. VIII. 
forms of dyspepsia. 3. Exposure to cold, and confinement in damp, ill-ventilated, ill- 
lighted apartments. 4. Exhausting fevers. 5. Excessive and long-continued evacuations 
of blood. 6. Severe courses of mercury. 7. Stoppage of habitual discharges, as the 
menstrual and hemorrhoidal. 8. Protracted mental depression. 9. Syphilis, whether 
original or inherited. 10. Inordinate sexual indulgence. All these causes act by lower- 
ing the vital principle, and diminishing the plastic properties of the blood. 
The immediate cause of the disease is inflammation, which regulates not only the 
quantity, but also the quality, of the deposit. The action is generally of a low grade, 
and is therefore not characterized by the ordinary phenomena, although it is not the less 
effective on that account. The reasons which may be adduced in support of this view 
are the following :— 
1. Irritation of the lung, mechanically excited, frequently gives rise to tubercle in that 
organ, as is occasionally seen in cases of foreign bodies, accidentally introduced through 
the larynx. In the inferior animals, as the dog and the rabbit, mercury dropped into the 
trachea often rapidly induces the disease. Miners, needle-grinders, and weavers, habitu- 
ally exposed to the inhalation of gritty and irritating matter, are particularly prone to 
phthisis. 
2. This view of the origin of the disease is countenanced by the composition of the 
deposit; for we know of no substance which contains so much albumen, or albumen and 
fibrin, that is not the product of inflammation. 
3. Tubercle bears a great resemblance to lymph, especially the more degraded forms 
of that substance, and this, as every pathologist is aware, is always the result of infinm- 
matory action. 
4. The disease is often developed under the immediate effects of cold, and various other 
causes which have a tendency to produce congestion of the internal viscera. Indeed, it 
is well known that dyspeptics, and persons who live upon unwholesome food or in damp 
and ill-ventilated apartments are peculiarly liable to suffer from this disease. 
A close and careful study of scrofula during a half of a century in public and private 
practice has forced upon my mind the strongest conviction that many of the so-called 
cases of the disease, as they are brought under our observation, are simply examples of a 
syphilitic taint of the system in its more remote forms. The influence of the syphilitic 
poison in establishing a cachectic state of the constitution, and thus deteriorating the 
blood and solids, has long been recognized, if, indeed, not universally acknowledged, by 
professional men. A poison like this, so potent, so subtile, so diffusive in its action, and 
so difficult to eradicate, is well calculated to make the most fearful inroads upon the 
system, pervading every atom of living matter, weakening the vital powers, and estab- 
lishing a predisposition to disease, which the slightest causes may readily fan into an open 
flame. What adds still further to this deterioration of the blood and solids is the harsh 
and unscientific treatment still so frequently employed, even at the present day, in the 
different forms of syphilis. Mercury, especially calomel, it is true, is no longer used in the 
copious and reckless manner so characteristic of the practice of former times. Syphilitic 
patients are no longer salivated until the tongue protrudes from the mouth, the teeth shake 
in their sockets, and quarts of saliva are discharged in the twenty-four hours, week after 
week, draining and exhausting the system, and producing a state of debility often only 
ending with life itself. The effect of this improved method of treatment has been a 
marked diminution of the so-called scrofulous affections. Forty years ago strumous disease 
of the neck was much more common than it is now. At present we seldom meet with 
those large, hideous glandular swellings, the flattened nose, the deformed palate, and the 
cadaverous-looking countenance, at that time so frequent, especially among the lower 
orders of persons, the victims of the joint agency of the syphilitic poison and of injudi- 
cious mercurial medication. Such cases have become comparatively rare, at least in this 
country; and still further improvement may reasonably be anticipated from steady per- 
severance in the present system of treatment, especially from the use of the iodides in the 
tertiary form of the disease. 
The duration of strumous diseases is too variable to admit of any accurate general 
statement. Phthisis usually destroys life in from nine to eighteen months ; tubercular 
arachnitis often terminates fatally in a few days; while external scrofula may last for 
years, and finally eventuate in recovery. 
The symptoms vary, of course, according to the nature of the affected structure ; but, 
whatever this may be, there are certain appearances which are hardly ever absent in any 
case. Thus, whether the disease be seated in the lungs, in a bone, in a joint, or simply 
in the connective tissue, in the form of a cold abscess, there is always, during its progress, CHAP. VIII. 
SCROFULA AND TUBERCLE. 
265 
excessive emaciation ; for, with the exception of the glandular viscera, the brain, nerves, 
and a few other parts, there is hardly any organ in the body that does not, in some degree, 
participate in the general atrophy. The fat gradually but surely disappears; the muscles 
are pale, flabby, and attenuated ; the connective tissue is deprived of its moisture ; the skin 
is soft and blanched ; the hairs grow slowly, and many drop out; the nails are thin, and 
frequently incurvated; and the bones, although they retain their size, are usually light, 
and saturated with sero-oleaginous fluid. The blood also is altered. It is impoverished, 
thin, pale, and deficient in red globules. The clot is unnaturally small and dense, and when 
the disease is fully established, with a tendency to suppuration, is almost always covered 
with a huffy coat. The fibrin is not materially changed until softening sets in, when it 
increases disproportionately in quantity, and so continues until suppuration begins, when 
it attains its maximum. These alterations are generally very conspicuous in phthisis, 
psoas abscess, and extensive disease of the lymphatic glands. 
Persons who are affected with scrofula, or who are laboring under what is termed the 
strumous diathesis, exhibit certain peculiarities which may be considered as almost charac- 
teristic. These refer mainly to the state of the complexion, the digestive apparatus, and 
the circulation. 
The complexion is generally brunette, and the hair, for the most part, dark, although 
in both these respects the greatest possible diversity exists. The eyelashes are drooping 
and of extraordinary length ; the pupils are habitually dilated; the upper lip is tumid; 
the face is pale and puffy; the hands and feet are nearly always cold ; the body is un- 
usually impressible by atmospheric vicissitudes ; the abdomen is hard and distended ; there 
is a deficiency of muscular strength; and the intellect is dull and sluggish, instead of 
being sprightly and precocious, as is usually represented. The digestive organs are sub- 
ject to frequent derangement ; the appetite is irregular and capricious ; the bowels are 
either constipated or relaxed, seldom entirely natural; digestion is feeble and imperfect; 
great annoyance is experienced from flatulence and acidity; and the individual is often a 
martyr to dyspepsia. Children predisposed to struma are particularly prone to cutaneous 
eruptions about the scalp, to purulent discharges from the ears, and to chronic enlargement 
of the tonsils and lymphatic glands. 
' There is another class of strumous subjects of a state of mind and body almost the 
opposite of that just described. The complexion is light ami florid, the eye blue, the 
mind unusually active, and the cutaneous circulation very vigorous. The parts of the 
body which are most liable to suffer, in this form of constitution, are the bones and joints, 
the eye, skin, and lymphatic glands, particularly those of the neck, consumption being 
much more rare than in the dark variety. 
Scrofulous Ulcer Various scrofulous affections of the skin give rise to ulceration, but, 
perhaps, the most characteristic ulcer of this kind is that consequent upon suppuration of 
the lymphatic glands of the neck, groin, and axilla. Be this as it may, the features of 
the scrofulous ulcer are so peculiar as to require distinct notice. 
The surface of the scrofulous ulcer is always unhealthy, being coated with rough, aplastic 
matter, of a pale yellowish or grayish color, hard, and firmly adherent to the subjacent 
structures. This matter, which possesses none of the characteristics of laudable pus, is 
often intermixed with disintegrated tubercular substance. In many cases the bottom of 
the ulcer is formed by altered lymphatic glands, of a reddish appearance, and so much 
softened as to break down under the slightest pressure ; sometimes, however, they are 
hard, almost of a fibrous consistence, and as if they had been partially dissected from the 
surrounding parts. In some cases, in fact, they separate, or slough, several perhaps 
coining away at the same time, or in more or less rapid succession. No healthy granula- 
tions exist upon such a sore, unless it is in a healing condition, and even then they form 
and maintain themselves with great difficulty. 
The edges of the ulcer are characteristic. They are of a bluish, purplish, or reddish 
hue, undermined, hard, jagged, thin and sharp at some points, thick and obtuse at others. 
Occasionally they are bent in towards the bottom of the ulcer. They are generally re- 
markably insensible, deeply congested, and incapable of forming healthy granulations. 
In fact, the skin, having lost its support, is excessively impoverished, and has great diffi- 
culty in maintaining its vitality. 
The structures around the scrofulous ulcer are generally hard, either from the presence 
of indurated and diseased glands, or from interstitial deposits ; usually, in fact, from both. 
The skin is red and congested, and not unfrequently also somewhat oedematous, pitting 
on pressure. The swelling is often great and disfiguring ; in short, characteristic of that 
peculiar appearance from which the disease originally derived its name; the neck, when 
that is the part affected, strikingly resembling that of the swine. 266 
SCROFULA AND TUBERCLE. 
CHAP. VIII. 
The scrofulous ulcer maybe single, or multiple; variable in shape and extent, and 
frequently communicating with considerable sinuses. The discharge is ichorous, or thin 
and whey-like; sometimes thick and yellowish; in either case, apt to be intermixed with 
the debris of distintegrated glands, flakes of lymph, and broken-down tubercular matter. 
The cicatrice left by the healing of a scrofulous ulcer is peculiar. It is of a fibroid 
texture, very hard, dense, almost crisp, and tightly adherent to the subjacent structures. 
Its surface is of a purplish hue, more or less depressed, traversed by large veins, and 
marked by prominent radiating ridges. The surrounding skin is hard and contracted, 
very much as in the scar of a burn. A long time generally elapses before the new skin 
becomes soft and pliant, and divested of its unnatural complexion. 
Treatment.—The treatment of scrofula, like that of carcinoma, has been exceedingly 
diversified and empirical, for there is hardly a solitary article of the materia medica that 
has not, at one time or another, been called into requisition. Even at the present day, 
when the pathology of the disease is so much better understood, the greatest uncertainty 
prevails in regard to our therapeutic measures, and the consequence is that few practi- 
tioners approach the disease without doubt and misgiving as to the benefit they may be 
able to confer by their treatment. Strumous affections have always afforded a vast field 
for the charlatan, and his pretensions have never been more impudently paraded before 
the public than in our own day. One, if not the chief, reason of this is that so few 
practitioners really understand the nature of this class of diseases ; they seem to forget, or 
not to know, that they occur in every possible form and under every variety of circum- 
stances, and, that, in order to meet them successfully, it is necessary constantly to vary 
our remedies according to the exigencies of every particular case. I am certain, from no 
little experience upon the subject, that the results of our treatment hinge most materially 
upon a just discrimination of the different states of the system under which these affec- 
tions occur. To treat every case of scrofula alike, without regard to the condition of the 
constitution which attends it, is, to say the least, absurd. The disease has no specifics; 
and 1 do not hesitate to declare it as my opinion that the indiscriminate use of iodine and 
cod-liver oil, still so common, has done an immense amount of harm, in so often taking 
the place of other and more suitable remedies. 
It will be sufficient, for practical purposes, to consider scrofulous subjects as being divi- 
sible into two great classes, the weak and the vigorous ; that is, those who have but little 
constitutional stamina, and those who, although affected with a strumous taint, are com- 
paratively strong and robust, possessing a ruddy complexion, and an active cutaneous 
circulation. The latter, undoubtedly, constitute the minority of the cases that come 
under our observation, but they are, nevertheless, sufficiently common, and so well 
marked as to be easily recognized by the most superficial observer. Now, to treat these 
two classes of subjects on the same principle, as is so generally done, is contrary to the 
dictates both of sound sense and daily experience. While cod-liver oil, iodine, and tonics 
will perform wonders in the naturally weak, they will be of little avail in dislodging and 
curing the disease in the naturally robust; and, conversely, while the lancet and tartar 
emetic will be of immense service in the latter, their employment can scarcely fail to be 
highly prejudicial in the former. It must not be imagined, however, that one mode of 
treatment is applicable to every instance of this or of that form of the disease; on the con- 
trary, circumstances constantly arise during the progress of each particular case which 
imperatively demand a change of remedies, and it is in the knowledge of this fact that the 
great art of curing the malady lies. 
It is well, as a general rule, to begin the treatment with some mild but efficient aperient, 
to clear out the bowels, and improve the secretions. The course must then be shaped by 
the peculiarities of the case. If the patient be naturally very feeble, or has become so by 
protracted suffering, an alterative and tonic course must at once be instituted, as the most 
likely to meet the indications ; but if, on the other hand, he is strong and plethoric, as 
denoted by the state of his pulse and complexion, much time will be gained, and the 
structure saved, by the use of antiphlogistics, especially tartar emetic and Epsom salt in 
the form of the saline and antimonial mixture, properly guarded with tincture of opium. 
The lancet must be employed with the greatest care ; but I am satisfied that it is often 
of immense benefit in arresting the morbid action, and that it has fallen into too much 
neglect in the treatment of scrofulous affections. In scrofulous inflammation of the eye, 
throat, and lymphatic glands, its effects are often marked and permanent. But there is a 
time when the employment of active measures ceases to be proper, and when they must 
be superseded by other remedies, similar to those generally applicable in the more com- 
mon form of the disease. If the depletory system of treatment be carried too far, it CHAP. VIII. 
TREATMENT. 
exhausts the vital powers, and thus creates a disposition, in different parts of the body, to 
deposition of tubercular matter. 
Among the various remedies that are employed for the cure of scrofula, iodine may be 
regarded, in many respects, as the most important. It may be administered alone, or in 
union with other articles, as potassium, iron, mercury, lead, quinine, barium, and ammo- 
nium ; and hence much judgment is often required to determine what particular form of 
it is best adapted to a particular case or form of the malady. As a general rule, it may 
be stated that, when a purely alterative effect is desired, it may be exhibited by itself, in 
substance, in tincture, or in the form of Lugol’s concentrated solution, consisting of one 
scruple of iodine and double that quantity of iodide of potassium, dissolved in seven 
drachms of water. Of this from five to ten drops may be taken every eight hours, in a 
wineglassful of sweetened water, the dose being gradually increased to fifteen, twenty, 
twenty-five, or even thirty drops, according to the tolerance of the system. 
With the same view', iodide of potassium is not unfrequently administered alone ; and, 
when scrofula is associated with constitutional syphilis, rheumatism, or mercurial disease, 
it certainly constitutes one of the best forms in which iodine can be exhibited. With 
whatever intention it be employed, it is proper always to begin with small doses, as four 
or five grains, if the patient be an adult, gradually increased to ten, fifteen, and even 
twenty, three or four times a day. The most eligible mode of giving it is in union with 
some aromatic syrup. Some patients take it very well in hop tea, and when there is much 
restlessness at night, or nervous irritation, this is perhaps the best form in which it can 
be exhibited. 
When the liver is at fault, when there is a syphilitic taint of the system, or when there is 
much disorder of the secretions, protiodide of mercury may advantageously be prescribed, 
in doses varying from the fourth to half a grain, three times a day. The biniodide may be 
employed with a similar view, but, as it is much more potent, greater caution is necessary 
in its administration. The dose, which, at first, should not exceed the twelfth or six- 
teenth of a grain, may be gradually augmented to a fourth or even half a grain, given in 
the form of pill, or in alcoholic solution. 
When an alterant and tonic effect is indicated, nothing can be better than iodide of 
iron, or iodide of quinia. The former of these articles is one of the most valuable anti- 
scrofulous remedies that we possess, rarely disappointing expectation. In my own prac- 
tice it has been particularly beneficial in disease of the cervical glands, upper lip, eyes, 
and joints. I often give it in solution, but more commonly in the form of pill, in union 
with quinine and opium. If undue vascular action be present, a minute portion of tar- 
trate of antimony and potassium may be added to each dose. In children, who cannot take 
pills, the best vehicle is syrup of orange peel, or syrup of sarsaparilla. 
Iodide of quinia has been advantageously employed in the treatment of scrofulous 
tumors, in cases where iodine and tonics are indicated, in doses of one to two grains every 
six or eight hours. 
In whatever form iodine is used, whether as a simple or compound, it must be borne in 
mind that the system should be free from all vascular excitement, and that, after it has 
been exhibited for a fortnight, it should be pretermitted for several days, when it may be 
resumed, and given as before. Employed in this manner, it exerts a much happier influ- 
ence upon the progress of the complaint, and is much less likely to disagree with the 
stomach and bowels, then when given uninterruptedly. If it acts as an irritant, it must 
be administered in smaller doses, or in union with opium or hyoscyamus. Great mischief 
often results from neglect of this precaution. 
Barium is another remedy of great value in the treatment of scrofulous disease. It has 
repeatedly succeeded in my hands when other means have proved inefficient or entirely 
unavailing; it is particularly serviceable in chronic enlargement of the cervical glands, 
both before and after the establishment of suppuration. It is chiefly adapted to patients 
with a languid circulation, a pale, tallow-like complexion, a flabby tongue, indigestion, 
and cold extremities. Its use is contraindicated when there is inflammatory excitement, 
or congestion of any important organ. The best mode of administration is the officinal 
solution of the United States Uharmaropceia, beginning with six or eight drops, and 
gradually but cautiously increasing the dose to ten, twelve, or fifteen, three times a day, 
in a wineglassful of hop tea, or half an ounce of syrup of orange peel. Exhibited in large 
quantities, it is liable to cause nausea, heartburn, diarrhoea, griping, headache, rigors, 
profuse sweats, and symptoms of mineral poisoning. 
Iodide of barium, from its great alterative properties, is worthy of trial in scrofulous 
affections. The dose is one-eighth of a grain thrice daily, gradually increased to four, five, 
or even six times that quantity. SCROFULA AND TUBERCLE. 
Calcium is sometimes employed with advantage, either in the form of iodide or the solu- 
tion of the chloride, the dose of the former being half a grain, and of the latter from fifteen 
to thirty drops, three times a day. The medicine is particularly valuable in the treatment 
of scrofulous affections of the skin and lymphatic glands. 
Bromide of iron occasionally answers a good purpose, although, in general, it is very 
decidedly inferior to the iodide. The best formula is that of Parrish, the average dose of 
which, for an adult, is twenty drops every eight hours, gradually increased according to 
the tolerance of the stomach. 
There is no medicine which has been more frequently or more extensively employed in 
the treatment of strumous diseases than mercury. The preparations most commonly 
selected are calomel, blue mass, corrosive sublimate, and the black sulphuret, or Ethiops 
mineral. Of these the bichloride is the best. It should be given in minute alterative 
doses, as the tenth, sixteenth, or twentieth of a grain, three times a day, either in the 
form of pill, or solution. Thus administered, it yields hardly in efficacy to iodine, and is 
probably superior to barium. In employing mercury, in any form, care should be taken 
that the system is properly prepared for its reception, and that it is not carried so far as 
to induce salivation. If it be found to act as an irritant or excitant in any way, it must 
at once be discontinued, or exhibited in smaller quantity. Whether mercury produces 
its beneficial effects merely by correcting the secretions, and thereby improving the 
general health, or by suspending or modifying the tubercular action, is still a mooted 
question. 
When the disease has existed for a considerable length, and especially when it is 
accompanied by marked emaciation, great [tailor of the countenance, cold extremities, 
and a small, frequent pulse, great benefit may be expected from the use of cod-liver oil, 
given in doses of one drachm to half an ounce thrice in the twenty-four hours, in good 
ale, or along with a little brandy. The value of this remedy is fully borne out by the 
general testimony of the profession. Although it contains a minute quantity of iodine 
and bromine, its good effects probably depend chiefly upon its nutritive qualities. How- 
ever this may be, it unquestionably improves the condition of the digestive organs, and 
acts slightly upon the urinary and cutaneous secretions. To derive full benefit from it, 
its use must be continued for a long time, with an occasional intermission, to afford the 
stomach a short respite, and to prevent the disgust which must necessarily arise from such 
a remedy when too persistently administered. Experience has shown that cod-liver oil 
is of no benefit whatever, in this affection, when there is no decided waste of the system, 
and when the pulse is rather retarded than accelerated. 
Whatever remedies may be employed, the closest attention should be paid to the bowels, 
diet, exercise, and dress. Constipation is counteracted by mild aperients, as blue mass 
and rhubarb, or, when there is much disorder of the secretions, by a few grains of calomel, 
followed by a little oil. Active purgation, however, must be studiously avoided, as it will 
inevitably do mischief by inducing debility. Torpor of the liver must be promptly met 
by mild mercurials, and acidity by alkalies, of which bicarbonate of sodium, either alone, 
or in union with a little ginger, is the most valuable. The alkalies were at one time 
much in vogue in the treatment of scrofula, in the belief that they possessed a kind of 
specific power, but their influence was evidently much overrated. Emetics are occasion- 
ally of service, especially when there is much nausea, depraved appetite, flatulence, and 
headache. 
The diet of a scrofulous patient should be light, unirritant, and nutritious. It should 
consist principally of the farinaceous articles, with milk or weak tea at breakfast and 
supper, the latter of which should always be very light, and taken at least three hours 
before retiring to bed. Coffee, fresh bread, pastry, and, in short, everything of an 
indigestible nature, must be proscribed. The food should be well masticated, and never 
used in such quantity as to oppress the stomach. When the strength is much impaired, 
some of the lighter meats, a little fresh fish, or a few oysters may be taken twice a day, 
along with a glass of porter, ale, sherry, port or madeira, or, what is better than all, 
brandy and milk. Sometimes an almost purely animal diet agrees best with the stomach. 
Many patients are greatly benefited by the free use of whiskey, rapidly becoming strong 
and fat under its influence. It should be taken repeatedly in the twenty-four hours, in 
quantities suited to the state of the stomach and system. 
As an important auxiliary, exercise claims particular attention. It may be taken on foot, 
in a carriage, or on horseback, as may be most convenient or agreeable to the sufferer, 
and should be indulged in whenever the weather admits of it, without being carried to 
fatigue. In bad weather, the patient may use dumb-bells, or amuse himself in sawing 
CHAP. VIII. CHAP. VIII. 
TREATMENT. 
269 
wood, planing, or anything else to which he may have access. Children should be carried 
about in their nurses’ arms, or in handcarts. 
The patient’s clothing is worthy of special consideration. He must be warmly clad. 
Flannel should be worn next the surface, both in summer and winter, the feet should be 
protected with thick shoes and stockings, and the skin should be maintained in a healthy, 
perspirable condition by frequent ablutions with tepid water, impregnated with common 
salt, ground mustard, strong soap, or any other exciting substance. 
A change of air is sometimes of vast service, and has been known to be of itself almost 
sufficient to effect a cure in this disease. The locality selected should be as healthy as 
possible, and not liable to great or sudden variations of temperature. If the atmosphere 
be dry, it matters little whether it be cold or warm, provided it do not run into either 
extreme. A residence near the sea-shore is often of immense benefit ; and daily sea- 
bathing, in the hot summer months, has occasionally produced the most astonishing im- 
provement in the general health. 
In the latter stages of the disease, when the patient is harassed with hectic fever 
and diarrhoea, the treatment must be of a tonic and stimulant character. The diet must 
be highly nutritious; porter, ale, wine, and milk-punch must be freely used; the bowels 
must be restrained with astringents; the excessive sweats must be controlled with quinine, 
elixir of vitriol, or atropia ; and sleep must be procured and pain allayed with anodynes. 
There is no doubt that the state of the mind is capable of exercising a powerful influ- 
ence upon the cure of scrofula, especially when seated in the external parts of the body. 
This may be assumed to be a fact from the astonishing benefit which so often followed the 
royal touch, a practice which originated in the time of Edward the Confessor, near the 
middle of the eleventh century, and which continued down to the reign of Queen Anne. 
The belief in the efficacy of the royal touch seems to have been for a long time almost 
universal in Britain. It was particularly prevalent in the reign of Charles II., who, in 
one single year, touched nearly 100,000 persons, who flocked to him from all parts of 
England, Ireland, Scotland, Jersey, and Guernsey. The practice was generally accom- 
panied by prayers and other religious ceremonies, and particular days and seasons were 
set apart for its observance. The effect of this singular remedy w'as variable; in some 
of the patients a cure followed almost immediately after they were touched; in others, 
the relief was more tardy, but in the end not the less effectual; occasionally the process 
was obliged to be repeated; and in some cases the treatment was entirely useless. 
Richard Wiseman, who was surgeon to Charles II., and a most sagacious observer, must 
have had great confidence in the efficacy of the royal touch ; for he expressly declares 
that “ His Majesty cured more persons of scrofula in one year than all the chirurgeons of 
London in an age.” 
The local treatment of scrofula merits great attention, although here it can be alluded 
to only in a very general manner, as each affection comprised under this denomination 
requires a mode of management in some respects peculiar to itself. The most important 
topical remedies are leeches, blisters, issues, pustulation with croton oil, tincture of iodine, 
embrocations, and sorbefacient unguents, especially such as have iodine for their bases, 
as the iodides of mercury, lead, potassium, iron, barium, cadmium, and zinc. Leeches 
are often of immense service ; and, as to counterirritants, they can rarely ever be entirely 
dispensed with. Of the various sorbefacient applications none is entitled to a higher 
rank than the tincture of iodine, either pure, or as I generally prefer, considerably diluted 
with alcohol. It is used as in ordinary inflammation, and often exerts a powerful influ- 
ence upon the progress of external scrofula, especially of the joints and cervical glands. 
Blisters, too, are a valuable means for relieving local congestion, modifying capillary 
action, and removing morbid deposit. If the part affected be a joint, rest, long and faith- 
fully continued, will be necessary, if, indeed, not indispensable. If abscesses form, they 
must be opened, with the precaution, if possible, of excluding the air, unless they are 
situated very superficially, experience having shown that such ingress is highly prejudicial, 
not on account of anything noxious in the air itself, but because of its tendency to cause 
decomposition of the contents of the sac, and, consequently, violent reaction, or hectic 
irritation. The swelling is attacked in its most depending part, the knife being introduced 
in a valve-like manner, and the opening immediately closed with adhesive strips, supported 
by a compress and roller. The practice of permitting such accumulations to continue 
until they have seriously impaired structure, or caused intense suffering, cannot be too 
pointedly condemned. 
When the enlarged glands obstinately resist treatment, they should be excised, pro- 
vided they are sufficiently accessible, and there is no serious internal disease forbidding 270 
VENEREAL DISEASES. 
C1IAP. IX. 
interference. An operation is particularly indicated when the morbid growths press upon 
important neighboring structures, or when they are a source of great deformity, as when 
they are situated in the neck, under the chin, or about the angle of the jaw. The dissec- 
tion is often tedious and bloody, especially when a large chain of glands has to be removed, 
and is then very liable to be followed by erysipelas and other bad consequences. When 
the glands have undergone caseous transformation they should always be removed with 
the view of preventing tubercular infection of other organs and tissues. 
The scrofulous ulcer must be treated rudely at first, and gently afterwards. The 
undermined edges are cut away with the knife or scissors, and the surface is thoroughly 
touched with the dilute acid nitrate of mercury, the solid nitrate of silver, or sulphate of 
copper, the application being repeated every other day until there is an appearance 
of healthy granulations, when milder means, such as opiate cerate, or the dilute ointment 
of nitrate of mercury, take its place. If disintegrated glands are present, they are re- 
moved with the knife, or destroyed with the Vienna paste; for so long as they remain, no 
substantial progress can be made towards a cure. Sinuses are traced out with the bistoury, 
unless they involve important structures, when stimulating injections, or the seton, must 
be used instead. Valuable aid will often accrue in these cases from the daily application 
of the dilute tincture of iodine to the surface immediately around the ulcer. 
CHAPTER IX. 
VENEREAL DISEASES. 
Three distinct affections are included under the term venereal. They all arise pri- 
marily from impure connection ; they are all contagious ; they all produce only their like ; 
and they may all coexist in the same person. Of these maladies, gonorrhoea is a catarrhal 
inflammation of the mucous membrane of the urethra or of the vagina ; chancroid is the 
local contagious venereal ulcer ; while syphilis is a specific disease, the initial lesion of which 
is chancre, or the constitutional contagious ulcer. The first of these affections will be 
considered in the chapter on the diseases of the male genital organs. 
1. CHANCROID. 
By the word chancroid is understood a disease which, in some of its features, resembles 
chancre, but differs from it in the fact that it is essentially a local contagious venereal 
ulcer; whereas chancre is always the first manifestation of contamination of the system 
by the syphilitic virus. This distinction, which was for a long time held in doubt, is now 
generally, if not universally, admitted by the most distinguished and reliable syphilo- 
graphers. It had, as will be seen, by a reference to the previous editions of this work, 
disturbed my own mind during nearly the whole of my professional life; and it has only 
been within the last few years that, in consequence of the accumulating light of modern 
observation by men of the greatest opportunity, and the most reliable skill and judgment, 
in different parts of the world, my doubts have been finally removed. This perplexity 
was shared by many writers, and was caused, in some degree at least, by the fact that 
there are two kinds of chancres, a hard and a soft; the latter, although very uncommon, 
being equally infecting with the former. Chancroid is supposed to have existed from the 
earliest ages of society, whereas chancre or true syphilis is said to be of comparatively 
modern origin, our first knowledge of it, as is alleged, being coeval with the discovery of 
this continent by Columbus in 1492. How erroneous this assertion is, it would be easy 
to show by an abundant array of facts gathered from the history of the various nations 
of the earth ; but as this is not the place to discuss the subject, it will be sufficient here 
to state that the first scientific and truly trustworthy attempt to separate the two diseases, 
or, in other words, to establish the doctrine of dualism, now so generally held, was first 
distinctly enunciated, in 1852, by Bassereau, of Paris. It is not surprising that this 
doctrine should have met with much opposition ; many of the best minds in the profes- 
sion arrayed themselves against it; but this opposition has gradually disappeared, and it 
may be boldly asserted that the number of unicists at the present day is as small as it is CHAP. IX. 
CHANCROID. 
271 
uninfluential. It should not be forgotten, in this connection, that hardly one hundred 
years have elapsed since the doctrine of the identity of gonorrhoea and syphilis was suc- 
cessfully controverted. 
What the precise nature of the poison of chancroid is is still an enigma. That its viru- 
lence resides mainly, if, indeed, not exclusively, in the pus globules of the secretion of 
the ulcer or sore whence it is derived, seems to be sufficiently established by clinical ob- 
servations, as well by arguments derived from analogy. Rollet ascertained experimentally 
that, if the secretion of chancroid be freed from its globules by filtration, the remaining 
substance is innocuous. It is apparently owing to this fact that the virus, instead of enter- 
ing the system and thus making an impression upon the constitution, is arrested in the 
lymphatic glands of the groin, where, sooner or later, it is capable of provoking suppura- 
tion and ulceration, the pus of which is, in its turn, highly inoculable. In fact, the sore 
thus produced is, in all essential particulars, a chancroid. Beyond this the matter does 
not travel; it is here that its action is arrested, and, however frequently it may affect the 
genital organs, it never infects the system, or occasion what are called secondary symp- 
toms, such as are so constantly witnessed in syphilis. There may be, and indeed fre- 
quently is, irritative or inflammatory fever, but such excitement is entirely independent of 
the absorption of poisonous matter into the general system, as is invariably the case with 
the virus of syphilis; and the same is true of the pus that is furnished by the inflamed 
connective tissue around a suppurating gland, the product of the pus of chancroid. How- 
ever abundant the fluid may be, it does not poison the constitution, so as to give rise to 
secondary phenomena, even supposing, as is undoubtedly the case, that some of the secre- 
tion occasionally enters the system ; in other words, the secretion is# devoid of contami- 
nating power; its effects are purely local. Another peculiarity of this matter is that an 
individual who has once been the subject of it is at any time, if exposed to its contact 
again, liable to its influence; the virus of syphilis, on the contrary, rarely affects the same 
person twice, the impression made by it upon the system being, like that of smallpox, 
scarlatina, and kindred maladies, generally permanent or inerradicable. 
It has been conjectured that the virulence of chancroidal matter is due to the presence of 
low animal or vegetable organisms, but if such parasites exist, they have never been satis- 
factorily demonstrated. The fact is, no mode of examination hitherto employed has 
succeeded in revealing its intimate nature. Its admixture with vaccine, gonorrhoeal, 
or syphilitic matter does not necessarily impair its power ; frozen and then thawed, it is still 
inoculable. Inclosed in a hermetically sealed tube, Ricord inserted it successfully at the 
end of seventeen days. Its potency, says Bumstead, is not destroyed by dilution with 
six to ten times its quantity of water. It is rendered innocuous, however, by exposure 
to a high temperature, and by admixture with alcohol, alkalies, and acids. 
It has been supposed that the matter of chancroid may, under certain circumstances, 
arise spontaneously, and subsequently retain, for an indefinite period, its inoculable 
qualities. In support of this view, writers have cited the experiments of Pick, in which 
he inoculated simple, non-venereal matter of inflammatory origin, as that, for example, 
of acne, scabies, or pemphigus, upon syphilitic persons, and obtained well-formed pus- 
tules, the contents of which retained their nocuous properties through several generations. 
These results have since been verified by other observers ; and Dr. Edward Wigglesworth, 
of Boston, has gone a step further by showing that the matter of acne and scabies, inoc- 
ulated upon a perfectly healthy individual, will produce similar effects. Interesting as 
these experiments undoubtedly are, they fail, in my opinion, to prove that such fluids are 
capable of causing a true chancroidal disease; we might as well assume that simple, non- 
venereal pus could give rise to smallpox and other zymotic diseases. The only philosoph- 
ical conclusion is that the secretion of chancroid is the invariable product of a specific 
inoculation. 
It is still a mooted question whether chancroid can be transmitted from man to the 
lower animals. Hunter and Ricord performed numerous experiments upon dogs, asses, 
cats, rabbits, guinea-pigs* and pigeons, without propagating the disease in a solitary in- 
stance. On the other hand, Auzias Turenne, Diday, and other observers declare that 
they have succeeded in inducing the disease with matter of this kind in a number of the 
inferior animals. Fortunately, the solution of this question, one way or another, is of no 
practical moment. 
The relative frequency of chancroid and chancre is worthy of brief notice, although, in 
a practical point of view, it is of little or no value. Of 10,000 cases of these affections 
observed by Puche at the Hopital du Midi, 8045 were chancroids, and 1955 were 
chancres. Le Fort, on the other hand, finds that of 1789 cases, 951 belonged to the 272 
VENEREAL DISEASES. 
former class, and 838 to the latter. Dr. Hardie, of the British army, ascertained that the 
proportion of chancroids to chancres in 303 cases was about two to one. it is highly 
probable that the relative frequency of the two affections is modified by local and consti- 
tional causes, as the peculiar character of the exposures, and the condition of the system 
at the time of the inoculation. Military surgeons have noticed that chancroids prevail in 
one garrison, and chancres in another; and it is not unlikely that similar occurrences take 
place among the residents of towns and cities. 
The most common sites of chancroid are the genital organs, not that they possess any 
special aptitude over certain other parts, but because these structures from their peculiar 
situation are most frequently exposed to the contact of its peculiar secretion. All the 
mucous outlets of the body are more or less obnoxious to it; and, if matter of this kind 
be inserted underneath the epidermis in any region of the body, a specific pustule and 
ulcer will be certain to arise. Fournier has constructed a table of 445 cases of chancroid, 
in 347 of which the gland or prepuce was involved ; various parts of the penis suffered in 
70, the meatus in 11, and the interior of the urethra in 5. Debauge has published the 
statistics of 200 cases of this disease as occurring in women. In 78 of the cases the 
fourchette or navicular fossa was affected, the labia in 19, the nymphae in 10, the urethra 
in 21, the lower part of the vagina in 24, the neck of the uterus in 1, the margin of the 
anus in 23, and the perineum and the groove between the nates each in 5. 
A chancroidal ulcer may gradually wear itself out, or continue variously modified for 
an almost indefinite period, now stationary, now better or worse. As healthy granula- 
tions spring up the discharge sensibly lessens, the areola of inflammation, if there was any, 
disappears, and although the ulcer contracts under the influence of new tissue extending 
from the edges towards the centre, unless there has been uncommon destruction of tissue, 
such an ulcer seldom, if ever, leaves any trace to mark its former existence. 
The rarity of chancroid on and within the uterus is worthy of special notice, as it 
is in singular contrast with the occurrence of chancre in those sites. A similar remark 
applies to the lips, tongue, and mouth, structures in which chancroid is exceedingly 
uncommon, while chancre is by no means infrequent, and may generally be readily in- 
duced by auto-inoculation, or by the insertion of matter into the affected person himself, 
or by hetero-inoculation, as when the secretion is transferred from one individual to 
another. 
If the secretion of a chancroid be inserted just beneath the epidermis, a reddish blush 
will form around the {juncture in twenty-four hours, which is converted into an inflamed 
areola on the second day, at the centre of which a vesicle forms, and is soon converted into 
a pustule. In the course of a few days the latter breaks, and discloses a circular ulcer 
with abrupt, sharply cut, and undermined edges, and a non-indurated, grayish, uneven 
floor, which secretes a tolerably abundant purulent fluid. 
The chancroid, whether it results from inoculation or contagion, has no period of incu- 
bation properly so called, as is always the case with chancre. Indeed, well-marked 
symptoms often appear within the first twenty-four hours. Of GG6 examples of the dis- 
ease observed by Le Fort, 510 attained their full development by the end of the first week. 
Early development is especially to be looked for when the virus during an impure inter- 
course is brought in immediate contact with an abraded or idcerated surface. Then the 
fire is at once kindled into full activity. It is different when the offending matter has to 
work its way through a sound mucous crypt or an unbroken surface, inasmuch as this 
always retards its progress. 
The chancroidal ulcer is generally more or less rounded in form, especially when it 
takes its rise in a mucous or sebaceous gland ; when it begins in an abrasion, it is often 
very irregular, and not unfrequently exhibits the appearance of a fissure or groove. In 
the male it is most common at the free margin of the prepuce, or at, or just behind, the 
corona of the penis. Several chancroids often spring up simultaneously, as in fig. 75, from 
Cullerier, and others are liable to form during the progress from fresh inoculation, or the 
mere contact of their own secretions with the surrounding In one case under my 
charge, in a woman, upwards of fifty years of age, I counted not fewer than forty sores of 
this kind, from the size of a mustard-seed to that of a three-cent piece, on the vulva and 
perineum. The surface of the chancroidal ulcer is generally superficial, flat, uneven, and 
coated with a grayish, whitish, or dirty, drab-colored deposit, evidently spoiled lymph. 
It has frequently a ragged, worm-eaten appearance. When the sore is seated on the 
head of the penis, its edges are steep and rather abrupt, as if it had been punched out, or 
sharply defined with a knife ; but on the prepuce they are usually overhanging, sloping, 
or shelving, more or less ragged, and less closely identified than in chancre with the sur- 
CHAP. IX. CHAP. IX. 
CHANCROID. 
rounding structures. The base of a chancroid is entirely free from 
induration, except in very rare cases in which irritating applica- 
tions have been used, followed by an increase of morbid action 
and a deposit of plasma. It is worthy of note that every ulcer of 
this kind is an inflammatory ulcer. 
A chancroidal ulcer generally manifests a disposition to spread, 
or to enlarge its area; and hence, especially in persons of a dilap- 
idated constitution, occasionally runs into phagedenic action. It 
furnishes an abundance of purulent fluid, which is highly con- 
tagious, and, therefore, readily inoculable, thus accounting, as 
already stated, for the multiplication of sores during the progress 
of the disease, one ulcer being superadded to another simply by 
the dissemination of the secretion over the contiguous surface. 
The sores are followed, in about one-third of the cases, by bubo, 
the disease being usually limited to one of the superficial glands 
of the groin, which, becoming gradually inflamed and swollen, 
suppurates, and eventually forms an ulcer, the matter of which, 
like that of the original sore, is of a highly inoculable character, 
and capable, in turn, of producing a chancroid if implanted into 
skin or mucous membrane. Finally, a chancroid never contaminates 
the system, or gives rise to secondary and tertiary symptoms. 
W ell-marked febrile commotion sometimes attends this disease, but this, as a rule, is 
the case only when it is followed by more or less serious complications, when the inocu- 
lation has occurred during serious impairment of the general health, or when the attack 
is of an unusually virulent nature. Ordinarily the constitution takes little or no cogni- 
zance of the local affection, any more than it does of a boil or common sore. The pain is 
generally insignificant, except when the sores are very numerous or unusually large, or 
accompanied by severe swelling and other evidences of high inflammation. 
Chancroid as now described is liable to be modified in its appearances, progress, and 
modes of termination by local and constitutional circumstances, among which the most 
important are the want of cleanliness and the degree of the concomitant inflammation, 
the habits of the individual, the state of the general health at the time of the inoculation, 
and the supervention of intercurrent diseases. The influence which these several causes 
rtre capable of exerting is, in many cases, so great as to change the whole outward features 
of the existing ulcer; hence those numerous divisions and subdivisions of chancroid 
which have tended so much to embarrass the progress of our knowledge. It is impossible 
for this disease to observe the same uniform course in every instance; alterations are 
inevitable, and must often occur despite the utmost caution both of the patient and his 
attendant. In this respect, a chancroid holds the same relation as an ordinary ulcer, 
presenting one appearance to-day and another to-morrow ; now highly inflamed, and now 
almost free from irritation ; at one time in a healing condition, and at another ready to 
commit the most destructive ravages. Out of these appearances, or varieties of appear- 
ances, have sprung the so-called inflammatory, diphtheritic, phagedenic, and sloughing 
chancroids, with several others which it is unnecessary here to mention. Such occurrences 
constitute complications of disease rather than species and varieties, for they are liable 
to take place in all sores, whatever their character, whether simple or malignant, specific 
or common. There is reason to believe that the specific poison may sometimes undergo 
such a radical change as to adapt it, in an especial manner, for the production of these 
differences in the appearances of the local affection. Promiscuous intercourse with badly 
diseased women, particularly if they are foreigners, and receive the embraces of a consid- 
erable number of men in rapid succession, would seem to be a powerful predisposing cause 
of these accidents. It was observed by the surgeons who accompanied the British army 
into Portugal that many of the soldiers who had connection with the native prostitutes 
suffered severely from phagedenic and gangrenous ulcers, while the residents of the coun- 
try experienced very little trouble, and usually soon recovered from the effects of the 
disease. The French soldiers, during Bonaparte’s campaign in Egypt, suffered in the 
same manner. Similar phenomena are frequently witnessed in the inmates of the houses 
of ill-fame in crowded cities. Thus, in London, in Swan Alley, a narrow lane, cele- 
brated as the residence of the humblest class of prostitutes, half starved, badly clothed, 
nearly constantly intoxicated, and having frequent intercourse every day with filthy 
lascars and other vagabonds, many of the cases of chancroid assumed the worst possible 
type, running rapidly into phagedenic action, and often causing frightful ravages and 
Fig. 75. 
Multiple Chancroids. 274 
VENEREAL DISEASES. 
CHAP. IX. 
even loss of life. Examples of a like kind came under my observation in this city, in 
1827, 8, and 9, in the Philadelphia Almshouse, and in the numerous brothels which 
then existed among the low blacks and whites south of Pine Street. What may be 
termed international chancroid, the result of sexual intercourse between civilized people 
and the low, degraded Indians of Mexico and South America, is, in every sense of the 
term, one of the very worst types of this disease, the poison acting with much greater 
virulence than under ordinary circumstances. 
All chancroids are inflammatory affections, and it is, therefore, only when the concomi- 
tant action assumes a grave type that it can be regarded as unnatural. Under such cir- 
cumstances, the characteristic symptoms consist of inordinate pain and swelling of the 
parts more directly involved in the disease, accompanied by an increase of discoloration, 
and an unhealthy aspect of the ulcer, which is the seat of a thin, ichorous discharge, more 
or less abundant, and generally a good deal irritating. Morbid erections are frequent, 
the prepuce is disposed to be (edematous, and the whole organ, especially the anterior 
extremity, appears to be enlarged. When the inflammatory action transcends certain 
limits, it may pass into gangrene or destructive ulceration, as occasionally happens in 
common ulcers of the leg, and from similar causes, especially from the excessive use of 
ardent spirits, loss of sleep, bad air, an impoverished diet, and improper courses of mer- 
cury. Or, the overaction may be brought on by a plethoric state of the system, and a 
neglect of the requisite depletion. 1 have seen gangrene and phagedenic ulceration of 
the genital organs of both sexes occur at a very early period, in consequence, apparently, 
merely of too active a course of treatment soon after the establishment of the disease, and 
such cases are sometimes characterized by extraordinary rapidity of progress, the suffering 
parts being, as it were, overwhelmed by the disease. 
Phagedena is a rare complication of chancroid, especially in the better classes of subjects; 
it is analogous, in its worst forms, to hospital gangrene, and is most liable to show itself 
in persons whose constitution has been ruined by intemperance and other debilitating 
influences. As already stated, it sometimes occurs as an endemic, and is then probably 
induced by a foul state of the atmosphere, as when the disease breaks out in the crowded 
wards of public institutions ; or by some peculiar modification of the chancroidal poison, 
greatly heightening its virulence, as when it takes place in soldiers after having cohab- 
ited with foreign prostitutes. The morbid action deports itself variously ; in general it 
extends rather slowly, but continuously, gradually but effectually eroding the parts, and 
thus widening the breach as well as deepening it. Or, it may be that, as one portion of 
the chancroid heals, another spreads. Or, the action may be very acute, extending with 
extraordinary rapidity, and committing excessive ravages in an almost incredibly short 
time. Or, lastly, the erosion may be conjoined with gangrene, the 
textures dying both molecularly and in mass. The phagedena may 
begin soon after the appearance of the chancroid, or it may manifest 
itself, as is most generally the case, at various periods of its progress. 
It may occur upon any portion of the genital organs, but is most com- 
mon upon those parts of the mucous surfaces which are most plentifully 
supplied with follicles. In the male it is most liable to appear in the 
gutter behind the head of the penis, or at the point of reflection of the 
prepuce. The under surface of the penis, at the side of the frenum, is 
another favorite site, and when chancroid occurs here it is almost certain 
to destroy this fold of mucous membrane. The appearances of phage- 
denic chancroid are illustrated in fig. 7G. 
The phagedenic complication is sometimes followed by grave hemor- 
rhage, the erosive action laying open, it may be, an artery of consider- 
able size, as the dorsal artery of the penis, from which blood may issue 
in such quantities as to induce severe, if not fatal, exhaustion. The scarlet hue of the 
fluid and the saltatory character of the stream will at once indicate its source. In some 
cases it oozes from the ulcerated surface at many points, as water from a sponge. 
Gangrene, as a consequence of chancroid, is more common on the prepuce than on the 
head of the penis, and, what is remarkable, the upper portion is more frequently affected 
than the lower or lateral. Occasionally both the head and foreskin are attacked simul- 
taneously, or, if one suffer first, the other is soon attacked also, and in this manner the 
w'hole organ may gradually be involved, dropping oft" perhaps ultimately near the scrotum, 
or at its attachments to the pubic bones. The occurrence of gangrene is announced by a 
blackish spot, preceded and accompanied by burning, smarting pain, and by an aggra- 
vation of all the other inflammatory symptoms. The system is extremely feverish, the 
Fig. 76. 
Acute Phagedena, 
burrowing beneath 
the Integuments of 
the Penis. CHANCROID. 
275 
CHAP. IX. 
pulse is frequent and irritable, sleep and appetite are impaired, or, more commonly, en- 
tirely destroyed, and the patient is often slightly delirious. When the prepuce alone 
suffers, the whole of it may slough off, or, what is not unusual, it may 
be perforated at one or more points, the largest opening perhaps ad- 
mitting the head of the penis, as in fig. 77. A common effect of gan- 
grene, consequent upon chancroid, no matter where situated, is the 
destruction of the specific poison, thus effectually preventing inocula- 
tion of the lymphatic glands of the groin, provided that had not pre- 
viously taken place. 
Chancroids sometimes assume a serpiginous form, the erosive pro- 
cess, as the term implies, creeping about in different directions, gen- 
erally in circles or semicircles, one portion of the sore being perhaps 
cicatrized or partially healed while another is steadily advancing at 
the opposite point. The ulcer, although generally superficial, occa- 
sionally penetrates to a considerable depth, and, as its course is usually 
chronic, it often results in serious mutilation. Its surface, incrusted 
with grayish, greenish, or drab-colored lymph, is bathed with ichorous 
fluid, its edges being steep, ragged, and more or less everted. The 
serpiginous form of chancroid is most common in persons of a strumous 
constitution, especially if they are predisposed to phthisis, and her- 
petic affections. It is generally remarkably obstinate, and sometinns undermines almost 
the entire skin of the penis nearly as far as the pubes, from which it may extend into the 
groin, abdomen, perineum, or thigh, forming narrow, superficial tracks, which retain 
their specific character during the whole period of their existence, however protracted. 
When the sore is incrusted with lymph, it constitutes what the French syphilographers 
have called the diphtheritic chancroid; such an occurrence is very common in all ill- 
conditioned specific ulcers upon the genital organs, and is always denotive of an unusually 
irritable and inflamed condition of the part, the action of which altogether transcends the 
healthy limits, nature being incapable of converting the deposit into granulations, and so 
throwing it off in the form of a slough, or as an effete substance. 
Diagnosis—The diagnosis of chancroid is often difficult and sometimes impracticable, 
particularly in its earlier stages, before the disease has assumed its more distinctive features. 
The affections with which it is most liable to be confounded are chancre, herpes, eczema, 
balanitis, and simple excoriations, fissures, or abrasions, the result of friction and other 
accidents. 
The diagnosis between chancroid and chancre will be fully discussed in the section 
devoted to the consideration of the latter. Here it will suffice to state, in general terms, 
that chancroid is characterized, in contradistinction to chancre, by its rapid development, 
its abundant secretion, the absence of induration, and its tendency to multiplicity, one sore 
being frequently followed by another simply from the inoculable nature of the discharges. 
Herpes is an eruption on the prepuce and head of the penis of little vesicles, hardly as 
large as the head of a pin, occurring in groups, closely set together, of a whitish color, 
and resting upon a florid base, with which they form a striking contrast. They are most 
frequent on the inner surface of the prepuce, in persons of red hair and tender skin, and 
often appear in successive crops, none of which, however, last longer than six or eight 
days. Characterized by a sense of itching and a slight serous discharge, they manifest 
little disposition to extend, and usually promptly yield to very simple treatment. The 
resulting ulcer is always free from induration. 
Chancroids rarely put on the appearance of herpes. The only approach to it is where 
the ulcers are seated in the mucous follicles, but even then their circular form and exca- 
vated character will always serve to distinguish them from common sores. 
Eczema is also an eruptive disease, but the little vesicles are more minute and diffused 
than in herpes, and there is also usually a greater amount of local irritation, the parts 
being swollen, hot, red, and itchy. When the vesicles burst, a thin, watery fluid 
escapes, succeeded by the development of small, delicate scales. The affection is apt to 
become chronic, and then little crevices generally form, increasing the irritation, and 
furnishing an acrid, sero-purulent, sanious, or ichorous discharge. Eczema is most 
common on the prepuce, and is often particularly conspicuous at its free border. A 
careful examination of the affected structures, the history of the case, and the existence 
of eczema in other parts of the body, will always lead to a correct distinction between 
this disease and chancroid. 
An inexperienced practitioner might possibly mistake an incipient balanitis for a 
Fig. 77. 
The Sloughing Sore, 
the Prepuce being al- 
most destroyed, and 
the Head going. VENEREAL DISEASES. 
CHAP. IX. 
chancroid, but no one who lias ever seen the two diseases could commit such an error. 
In balanitis the inflammation is generally widely diffused, often, indeed, over the whole 
surface of the prepuce and head of the penis, and the discharge is not only profuse, but 
of a thick, muco-purulent nature from the very commencement. There is no circum- 
scribed ulceration as in chancroid, and, indeed, little or no tendency whatever to destruc- 
tion of tissue. These characters will always serve to prevent the disease from being 
confounded with chancroid, which invariably presents itself as a distinct and well-defined 
ulcer. 
Simple ulcers, abrasions, or excoriations are liable to appear upon the prepuce and head 
of the penis, and may, unless great caution is exercised, be mistaken for chancroids. They 
may proceed from a great variety of causes, as want of cleanliness, friction of the panta- 
loons, injury received during copulation, and intercourse with filthy females, especially 
such as are habitually the subjects of profuse and acrid discharges. However induced, 
such ulcers are always very superficial, and display no disposition to extend in depth, 
although they may spread considerably in diameter. The secretions which attend them 
are of an ichorous character, and they are usually surrounded by an inflammatory border, 
which is seldom the case in chancroid. The most important diagnostic feature, however, 
by far, is that such ulcers always very promptly disappear under the most simple remedies, 
attention to cleanliness, with cooling lotions and a mild aperient, generally sullicing to 
effect a cure in a few days. 
Epithelioma is sometimes, but rarely, mistaken for chancroid. The absence of ulcera- 
tion and discharge in the earlier stages of the disease, and the tuberculated, warty, or 
cauliflower-like appearance of the sore after the occurrence of ulceration, together with 
the peculiar quality and quantity of the'secretion, the fluid being always of a thin ichorous 
or sero-purulent character and much more copious and fetid than in chancroid, are the 
most trustworthy diagnostic phenomena. The history of the case usually affords addi- 
tional light. Most of the epithelial growths in fact, occurring upon the prepuce and head 
of the penis, reveal their own secrets. 
The site, size, shape, appearance, and course of chancroid, considered separately, afford 
no reliable diagnostic evidence; but, collectively, are of great importance as means of 
discrimination. Thus, mere site and size are of no consequence, because a chancroid 
may, like a common sore, occur on any portion of the penis and be very diminutive, as 
when, for instance, it occupies a mucous follicle; but if, in addition to this, the ulcer is 
found to be excavated, to have afoul, diphtheritic bottom, to pursue a chronic course, and 
to resist the ordinary means of cure, it is quite impossible to mistake its character; we 
conclude that it is chancroidal, and nothing else. 
The history of the case often affords valuable information. If the patient is a married 
man, or if he has any other motive for concealment, he will be likely to deny that he has 
had impure connection, and even insist upon it that the sore on the penis is non-specific. 
Under such circumstances, it is not necessary to try to convict him of falsehood ; the 
surgeon examines the parts, and if he finds any suspicious-looking ulcers, he will very 
naturally conclude that they are venereal, and this opinion will be strengthened by the 
very denials of the patient, especially if he is noted for his gallantries. Young unmarried 
men usually treat their attendants with entire candor, generally specifying with great 
particularity the time of the impure connection, and evincing no little anxiety to afford 
them all the light they can, with a view of settling the diagnosis. We must not, there- 
fore, on the one hand, believe that a man has not been exposed to infection simply because 
he says so; or, on the other, take it for granted that every sore that may be found upon 
the penis is of a specific nature. 
Finally, in all cases of doubt the groins should be examined with reference to the ex- 
istence or non-existence of bubo. In the ordinary non-specific affections, above described, 
glandular enlargement is extremely rare, and it usually appears early in the attack, the 
bubo being small and always comparatively transient. In chancroid swelling of the groin 
occurs only once in every third or fourth case, and is invariably attended with more or 
less pain, aggravated by exercise and pressure, and tending to suppuration. In chancre, 
the swelling is indolent, non-infiammatory, and persistent; it rarely appears before the 
twelfth or fifteenth day from the impure contact, and very seldom passes into suppuration 
or ulceration. 
When the above means of diagnosis fail, as they seldom will, if proper care be used, 
the only other resource is inoculation, a small quantity of the suspected matter being 
inserted, upon the point of a lancet, into the skin on the inside of the thigh. If the oper- CHANCROID. 
CHAP. IX. 
ation is gradually followed by a vesicle, and this, in turn, by a pustule, with a well-marked 
areola, there can be no doubt whatever respecting the true nature of the disease. Inocu- 
lation, if properly executed, cannot deceive, and is, therefore, after all, the only true and 
reliable test, although there are few surgeons of experience who will not, as a general rule, 
be able to determine the diagnosis without its aid. 
The prognosis of chancroid is always favorable in the milder forms of the disease occur- 
ring in persons of sound constitution. In neglected cases, however, or cases complicated 
with high inflammation, the disease often assumes a very serious character, causing great 
suffering, local and constitutional, and, perhaps, more or less extensive loss of substance. 
In former times when chancroid was a much more severe affection than it is at the present 
day, it was not uncommon, especially in persons of depraved constitution, rendered so by 
intemperance, debility, exposure, or the use of mercury, to witness gangrene of the affected 
organs, large portions of which occasionally sloughed off. Gangrene of the prepuce is a 
possible occurrence in phimosis attended with great oedema. In chancroid of the urethra 
stricture is almost inevitable under any circumstances. In chronic or neglected cases the 
disease may continue for months, or even years, causing more or less suffering and more 
or less mutilation. 
Prophylaxis.■—If the old adage, “ an ounce of prevention is worth a pound of cure,” 
is any where applicable to diseases, it is emphatically so in the venereal affections. The 
susceptibility to the disease varies, as is well known, very greatly in different persons, 
some being remarkably prone to suffer from the slightest contact of the specific matter, 
while others, less delicately organized, escape with impunity. When a man has exposed 
himself to suspicious intercourse, the penis should immediately be washed with soap and 
water, special care being taken to cleanse the margin of the prepuce, the groove at the 
neck of the penis, and the parts around the frenum ; for it is at these points, more par- 
ticularly, that the virulent matter is most liable to effect a lodgment. Women should use 
a large syringe, charged with a strong solution of alum, common salt, chlorinated sodium, 
or permanganate of potassium, with which the vagina should be thoroughly cleansed, the 
fluid being thrown up with considerable force against the uterus with a Davidson’s 
syringe. The nymphaj, labia, and perineum must be washed with a sponge. A very 
excellent lotion for preventive purposes, much used by the prostitutes of Bordeaux, is 
composed of half an ounce of alum, and of fifteen grains each of sulphate of copper and 
sulphate of protoxide of iron, dissolved in a quart of distilled water, with the addition of 
one drachm and a half of compound aromatic alcohol. 
In some of the larger cities of Europe, especially on the continent, the occupants of 
houses of prostitution are regularly inspected once, if not twice, a week, with a view to 
the prevention of the spread of these diseases, and it is to he regretted that the practice 
has not been introduced in this country, considering the immense benefit which, if it were 
properly carried out, it would confer upon the public, by the insurance of greater cleanli- 
ness, and the consequent diminution of the frequency of the miseries entailed by these 
maladies. It is a fact of not a little diagnostic value that, while a chancroid is, as a rule, 
always easy of detection with the speculum, a chancre, owing to its small size and ill- 
developed character, is readily overlooked. 
Treatment—The treatment of chancroid in its early stages, or before the lapse of ten 
days, if there are no decided contraindications, growing out of the existence of severe 
inflammation, must be conducted with the threefold object of shortening the duration of 
the disease, destroying the contagious principle of the secretion, and preventing the forma- 
tion of a bubo. As excision of the sore is rarely of any avail, an attempt to accomplish 
these objects should be made by means of escharotics. The one most generally selected is 
nitrate of silver, cut to a very delicate point, and inserted into the ulcer, or broken vesicle, 
where it is held until the infected tissues are brought thoroughly under its influence. 
The objection to this substance is its insufficiency ; for, whether it act simply as a 
neutralizer of the poison or as an escharotic, it is equally certain that it is generally 
unreliable, and it should, therefore, never be used in a disease of such a serious nature. 
The article to which I have long given the preference, on account of its superior efficacy, 
is the officinal solution of the acid nitrate of mercury, applied either pure or variously 
diluted, according to the exigencies of each particular case. A good average strength is 
one part of the acid to double the quantity of water, applied with a piece of soft wood, 
the end of which is smooth and well rounded off. Such a contrivance is much better 
than a probe wrapped with lint and cotton, as the fluid can thus be brought in contact 
with the infected surface in a more concentrated and efficient manner. In order to 
prevent the solution from diffusing itself too widely, the part should previously be well 278 
VENEREAL DISEASES. 
wiped, and immediately after bathed in pure water, or some weak alkaline lotion. The 
most suitable dressing is an emollient poultice. One free application of tbe acid generally 
suffices. 
When acid nitrate of mercury is not at hand, almost any of the acids may be em- 
ployed, especially the carbolic, nitric, or hydrochloric. Some surgeons use caustic potassa, 
while others give a preference to the Vienna paste. Iticord recommends a power- 
ful caustic, composed of sulphuric acid and powdered charcoal, united in the proper 
proportions to form a semisolid mass. Of this earbo-sulphuric paste, as it is called, a thin 
layer is applied to the chancroid and the parts immediately adjacent, upon which it soon 
dries, forming a black, adherent crust, which, on dropping off, as it usually does in eight 
or ten days, leaves a healthy, granulating sore, rapidly followed by cicatrization. The 
objections to the carbo-sulphuric paste are the extreme pain which it produces, and its 
tendency to spread too widely over the sound tissues. Of late years I have found that 
pure carbolic acid is the least painful and one of the most valuable of tbe escharotics. 
Abortive measures are justifiable only in the very earliest stages of the disease, before 
the supervention of marked inflammatory action. When this stage has been passed such 
treatment cannot fail to do harm by increasing the local irritation. Mild measures alone 
are proper in such a condition. From neglect of this precaution, which cannot be enforced 
with too much emphasis, many a sore on the genital organs that would, if properly 
managed, disappear in a few days, is often protracted for weeks, if not months, to the 
great detriment both of the part and system. Young and inexperienced practitioners are 
very prone to fall into this error; they think they cannot do too much, and the conse- 
quence is that they fret and worry the sore until it places itself, so to speak, in a state of 
open rebellion, resisting all measures, local and constitutional, that may l>e adopted under 
the delusive hope of effecting its cure. Rest and attention to diet are of inestimable value 
in every case. Strict confinement to the house is not always necessary by any means, 
but any thing like excitement, physical or mental, should be scrupulously guarded 
against; the bowels should be moved from time to time with cooling laxatives, and no 
animal food, unless absolutely called for by the exhausted condition of the patient, should 
be permitted. This kind of indulgence never fails to retard the cure, and often leads to 
serious complications, and yet, strange as it may seem, it rarely engages the surgeon’s 
attention. If the secretions are disordered, as evinced by the coated tongue, the depraved 
appetite, bad taste in the mouth, or distressing headache, an active mercurial cathartic 
may be administered ; but for no other reason should mercury ever be employed in the 
treatment of an affection which, as is now well known, never contaminates the constitu- 
tion in the sense that syphilis does. Febrile excitement is kept in abeyance with the 
neutral mixture, or antimonial and saline preparations, with the addition to each dose of a 
few drops of tincture of aconite. Anodynes are given to relieve pain, induce sleep, and 
prevent reaction ; in a word, the whole treatment is conducted upon strictly antiphlogistic 
and soothing principles. 
Cleanliness is of the utmost importance in every case of the disease, and is best secured 
by frequent immersion of the penis in warm water, containing a little common salt, acetate 
of lead, or chlorinated sodium. If the chancroid is concealed by a tight and irritated pre- 
puce, the syringe is freely used, as it will be impossible to effect retraction to an extent 
sufficient for ordinary ablution. In the intervals of these local baths, which, while 
they favor cleanliness and comfort, contribute materially to the reduction of the inflam- 
mation, the ulcer should be kept constantly covered with lint, wet with a weak solution of 
tannic acid and opium in compound spirit of lavender, yellow wash, sulphate of copper, 
or acetate of lead. Tannic acid and opium are most excellent remedies, exerting at once 
an astringent and soothing influence, greatly promotive of healthy action. They form 
the principal ingredients of the aromatic wine, so much used in the French hospitals, and 
their efficacy has been well attested both in public and private practice everywhere. The 
yellow wash is also a very valuable agent, but to obtain all the good which it is capable 
of yielding, it should be employed very weak, as one-eighth of a grain of the mercury to 
the ounce of lime-water, the strength being increased if necessary on account of the slow 
progress of the case. The officinal preparation is much too strong and irritating. I have 
frequently derived great benefit from the ointment of nitrate of mercury, diluted with eight, 
ten, or twelve parts of simple cerate, and applied either alone or in union with tannic acid 
and opium. In fact, there is no remedy which has done better or more efficient service in 
my hands than this in the treatment of simple chancroid. Powdered iodoform, sprinkled 
on the sore, is highly praised by many practitioners as an excitant to healthy granula- 
tions; but its odor is so penetrating and disagreeable as to make it objectionable in 
CHAP. IX. CHANCROID. 
279 
CHAP. IX. 
private practice. This disagreeable feature may be overcome by employing the remedy 
in the form of an ointment composed of one drachm of iodoform, two drachms of balsam of 
Peru, six drops of oil of peppermint, and five drachms of cosmoline. Employed in this 
way it constitutes an excellent application, especially when the sore is seated upon the 
integument. 
There is one important rule which applies here with as much force as in the case of 
common ulcers, and that is to vary the dressings whenever they are found to become a 
source of irritation, or cease to be beneficial, making them now weaker, now stronger, 
adding new ingredients, omitting old ones, or changing the remedy altogether. Much of 
the success, in every case, will depend upon the care with which this rule of practice is 
carried out. 
When the parts begin to granulate, the simplest dressings generally suffice, such as 
opiate cerate, or ointment of red oxide of mercury, diluted with eight, ten, or twelve 
times its bulk of cosmoline, or merely a bit of dry lint carefully interposed between the 
contiguous surfaces. The latter application often promotes cicatrization with remarkable 
rapidity. 
When the head of the penis is swollen and painful, it must be kept constantly buried 
in an emollient poultice, made of powdered elm bark or ground linseed, and frequently 
changed. Or, instead of this, warm water-dressing may be used, its efficacy being in- 
creased by the addition of laudanum and acetate of lead. The best vehicle for such 
dressing is cotton wool, in which the organ, properly elevated, and maintained at rest, 
should be completely buried. 
Constitutional treatment is too important to be overlooked, however simple the sore. 
Perfect quietude of mind and body is indispensable. The effects of any disturbance of 
this kind always manifest themselves promptly in the aspect of the sore and the character 
of the secretions. The diet must be plain and simple, animal food and stimulants being 
carefully avoided ; the bowels are kept open by cooling purgatives; and, if need be, free 
use must be made of saline and antimonial preparations. Venesection will rarely be 
required, and then only in very plethoric subjects. If the local trouble is considerable, 
leeches may be applied to the groins or to the inner surface of the thighs, the bites 
being well covered, when the flow of blood has ceased, with collodion, in order to 
prevent their inoculation from the accidental contact of chancroidal matter. Leeches 
should never be applied to the penis itself, much less to the parts immediately affected, as 
their secretions could hardly fail to come in contact with the little wounds, and so propa- 
.gate the disease. 
When chancroid is accompanied by severe inflammation, as denoted by the swollen, 
discolored, and painful condition of the parts, and the feverish state of the system, anti- 
phlogistic means should at once be vigorously employed. Active purgation, light diet, the 
neutral mixture, and the use of antimonials, with absolute rest in the recumbent posture, 
cooling, anodyne, and mildly astringent lotions to the ulcer, and an emollient poultice or 
warm water-dressing for the head of the penis, constitute the chief remedies in such an 
emergency, and must be carried to an extent compatible with the powers of the system. 
Pain and morbid erections are relieved with opiates and bromide of potassium, adminis- 
tered in full doses. By these means the disease is soon brought under subjection, when it 
is to be managed in the same gentle manner as the milder forms of chancroid already 
described. 
Chancroid of the frenum is almost invariably followed by perforation of that fold, and, 
in such a case, the cure is always greatly expedited by its prompt division, the raw surface 
being immediately cauterized with carbolic acid. 
When the ulcer assumes a phagedenic character, with a tendency to spread more or 
less rapidly both in depth and diameter, the principal addition to the treatment, required 
in chancroid complicated with undue inflammation, consists in the increased amount of 
opium employed to soothe the part and system, which are generally excessively irritable 
in this variety of morbid action, and can only be successfully quieted by the most liberal 
use of this article. If the skin be hot and arid, the pulse excited, and the face flushed, 
the opium should be combined with antimony, or some cooling diaphoretic, so as to pro- 
duce a decided determination to the surface. The diet and bowels must receive due 
attention ; all stimulants must be avoided ; and the mind and body must be maintained in 
the most tranquil condition. 
The local applications should all be of the blandest kind, consisting of warm water- 
dressing or emollient poultices, and of lint steeped in mucilage of gum arabic, or an 
infusion of elm bark, with the addition, to each ounce of fluid, of two or three drops of 280 
VENEREAL DISEASES. 
CIIAP. IX. 
nitric acid and one drachm of the vinous tincture of opium. If the disintegrating action 
is very rapid, the ulcer should be covered with iodoform, or be freely mopped with a 
weak solution of acid nitrate of mercury, or, touched with solid nitrate of silver, its 
surface being kept constantly covered in the interval with the medicated lotion just 
mentioned. In some cases nothing arrests the erosive tendency so speedily as a weak 
solution of sulphate of copper, in the proportion of about one grain to the ounce of water, 
with the addition of four to six times that rpiantity each of tannic acid and opium. 
When the action, is obstinate, immersion of the parts in hot water is very efficient in 
arresting its progress and in relieving pain. 
The phagedenic form of chancroid, however, does not always occur in the strong and 
robust; the system may be, and often is, in an adynamic condition, requiring tonics and 
stimulants instead of depressants. The constitution, degraded perhaps by long suffering, 
by starvation, and by all kinds of intemperance, must be brought up with quinine and 
iron, porter, ale, or milk punch, a generous diet, and change of air, particularly if the 
patient is the inmate of a crowded and ill-ventilated hospital. The dissipated and ener- 
vated residents of large cities are particularly prone to suffer from phagedena during the 
progress of chancroid, and it is, therefore, impossible to be too cautious in regard to the 
employment of depletory measures. What is needed in such a state of the system is 
perfect tranquillity of mind and body, as secured by the liberal exhibition of anodynes, 
and a better condition of the blood, to enable the part to institute a more salutary action. 
If gangrene set in, th.e treatment must vary according to the concomitant state of the 
system, independently of any consideration growing out of the presence of the specific 
virus. The question should simply be, is the action of the system too high or too low ? 
If the former, antiphlogisties will be indicated, and should be promptly employed, 
although not without a certain degree of reserve, lest the powers of the constitution 
should suffer from the effect, and thus encourage the spread of the disease. Depletory 
measures, if used at all, must be used warily. The excitement may only be apparent, 
not real; and may, consequently, shortly subside, either spontaneously, or under very 
simple remedies. Most likely the action is typhoid from the beginning, or, if not, it soon 
will be; hence, instead of a depletory,a corroborative course will be necessary,similar 
to that in ordinary gangrene in other parts of the body, the chief reliance, so far as con- 
stitutional means are concerned, being upon quinine, iron, ammonia, brandy, camphor, 
and opium, with milk and rich animal broths. The use of pot assio- tart rate of iron, in 
doses of ten to twenty grains, repeated four or five times in the twenty-four hours, has 
been greatly lauded in this form of the disease ; but, judging from the results of my own 
experience, it possesses no advantages whatever over the sulphate and tincture of the 
chloride, so much employed in all anemic states of the system. 
To arrest the gangrenous action, and promote the separation of the eschars, the affected 
structures should be freely painted with dilute tincture of iodine, and wrapped up in an 
emollient poultice, medicated with laudanum and acetate of lead, Goulard’s extract, or 
what is superior to either, a saturated solution of potassio-tartrate of iron, while the dying 
tissues are well mopped with the acid nitrate of mercury, or brought under the full influ- 
ence of carbolic acid. If any constriction exist, as that produced by a tightened and 
retracted prepuce, it must promptly be relieved with the knife. The detachment of the 
sloughs may be promoted artificially, or, if not too large, be intrusted entirely to nature’s 
efforts ; at all events, all harsh interference must be carefully avoided. Fetor is allayed 
with chlorinated sodium, permanganate of potassium, or other means. 
The sloughs having separated, the next object is to favor the development of healthy 
granulations ; for which the most available remedies will be found to be the nitric acid 
lotion, with tincture of opium, the ointment of the balsam of Peru, the aromatic wine, or 
the dilute ointment of acid nitrate of mercury, with warm water-dressing or an emollient 
cataplasm, as a general covering to the affected structures. A lotion composed of five to 
ten grains of potassio-tartrate of iron to the ounce of water is often very beneficial in im- 
proving the condition of the sore. 
The serpiginous chancroid is generally an obstinate and troublesome sore, for the cure 
of which one of the most efficient local remedies is a saturated solution of potassio-tartrate 
of iron, applied upon lint. In very rebellious cases it is sometimes necessary to use strong 
lotions of nitric, carbolic, or hydrochloric acid, or even to sear the surface of the ulcer 
with the actual cautery, with a view of changing its condition. The undermined and 
partially devitalized edges must be removed with the scissors. Constitutional treatment 
is indispensable. Chalybeate tonics, cod-liver oil, a generous diet, exercise in the open 
air, or a residence at the seaside, will greatly assist recovery. CHAP. IX. 
CHANCROID. 
281 
In the diphtheritic chancroid the most efficient remedy for reducing the inflammation 
is the warm water-dressing, or an emollient cataplasm, medicated with opium and sugar 
of lead, the sore being touched once a day with solid nitrate of silver, or brushed 
over with a weak solution of acid nitrate of mercury. Under this management, aided 
by suitable constitutional means, the sore soon assumes a more healthy action, followed 
by the development of florid granulations, and a gradual tendency to cicatrization and 
a final cure. 
The indolent chancroid, or chancroid attended with deficient action, generally depends 
upon some defect of the system, by correcting which the ulcer will speedily assume a 
healthy appearance, throwing out florid granulations, furnishing thick, laudable pus, and 
cicatrizing along its margins. Or it may be that the obstacle is of a strictly local nature, 
occasioned by want of cleanliness, by an undermined condition of the sore, or, by the 
presence of a thick, semiorganized, and firmly adherent layer of lymph. Whatever the 
cause may be, it should, if possible, be promptly rectified; the constitution, if at fault, is 
suitably improved, and every effort is made to promote the granulating process. Particular 
attention is given to cleanliness, the thickened and shelving edges are trimmed off with 
the scissors, and the incrusted surface, freely cauterized with nitrate of silver, nitric acid, 
or acid nitrate of mercury, is kept constantly covered with blue ointment or some stimu- 
lating lotion. The best internal remedy generally is the tincture of chloride of iron in 
doses of twenty drops four times a day, in union with quinine. The potassio-tartrate of 
iron is also a valuable agent, and may be given in doses of ten to fifteen grains every 
eight hours, dissolved in water and syrup of orange peel. 
Any hemorrhage that may arise during the progress of chancroid must promptly be 
arrested ; the patient may already be much exhausted by previous suffering, and a slight 
drainage of this kind might, therefore, prove exceedingly prejudicial. When the blood 
issues from an open orifice, the vessel should at once be secured by ligature, acupressure, 
or compressing forceps, a sufficiency of tissue being included in their bite to insure safe 
maintenance. If, on the contrary, it proceeds from numerous points, the ordinary styptics, 
as alum, or, what is better, Monsel’s salt, with a full dose of opium and aconite to con- 
trol the heart’s action, will generally suffice for its speedy arrest. 
The morbid erections which so often accompany chancroid, and which generally so 
much impede the reparative process, must be treated in the same manner as in gonorrhoea; 
by the liberal use of anodynes by the skin, mouth, or rectum, and by soothing topical 
applications, either warm or cold, as may be most grateful to the part and system. If 
hemorrhage be present, they must be controlled at all hazards, on account of their tend- 
ency to tear open the bleeding vessels. 
“ Phimosis, complicating chancroid, must not be interfered with, unless it act constrict- 
ingly, threatening destruction of the prepuce and of the glans by mortification. In this 
event, the parts must be freely divided upon the grooved director, the edges of the inci- 
sion being immediately cauterized with carbolic acid or acid nitrate of mercury, and 
coated with a layer of collodion to prevent inoculation. In ordinary cases, the tightened 
foreskin is permitted to retain its place, cleanliness and medication of the ulcer being 
effected, as already stated, by means of the syringe. 
Paraphimosis is occasionally present, perhaps to a perplexing and even dangerous ex- 
tent. The constriction produced by it may be such as to cause excessive oedema of the 
prepuce, and great engorgement, if not severe swelling of the head of the penis, inducing 
a condition which, if not speedily relieved, may eventuate in extensive gangrene. These 
effects may occur whether the chancre be situated on the head or on the retracted pre- 
puce, and, for the reason just mentioned, always demand prompt attention. An attempt 
should be made to restore the parts by manual effort, aided by anaesthesia, to give the 
surgeon more perfect command over his movements. This failing, the only alternative 
is to divide the stricture, and to keep the wound well coated with collodion, to prevent 
further inoculation. 
Chancroids in women The structures which are most liable to suffer from chancroids 
in woman are the vulva, labia, nymphas, vagina, urethra, and the vicinity of the clitoris. 
The inferior third of the vagina is more frequently affected than the middle or upper 
third, and the uterus suffers least of all. A very common site of chancroids is the t'our- 
chette, its dependent position favoring the contact of the contagious secretions, no matter 
what parts of the genital organs may be involved in the specific disease. For a similar 
reason, the perineum, the anus, and even the buttocks are occasionally covered with chan- 
croids. In the case of an elderly woman, previously alluded to, I counted forty chan- 
croids upon the perineum. 282 
VENEREAL DISEASES. 
CHAP. IX. 
Chancroids upon the female genitals affect almost every variety of number, size, and 
shape. Generally they are multiple, from autoinoculation of the secretions; of small 
dimensions, and of an irregularly rounded or ovoidal shape; sometimes they occur in the 
form of fissures, and at other times they coalesce or run into eacli other, forming thus 
ulcers of large size. However this may be, they seldom, except in women of dilapidated 
constitution, reach to any great depth, but are usually superficial, although they always 
furnish an abundance of thick, purulent, and highly inoculable matter. Great pain and 
swelling are often present, especially when the chancroids occupy the labia, the lower 
part of the vagina, or the anus and perineum. Chancroids of the urethra often cause 
excessive suffering and extensive destruction of tissue. Occasionally the vesico-vaginal 
septum gives way, and stricture of the anus, and even of the rectum is by no means an 
uncommon occurrence. Chancroids in the female genitals are liable to be followed by 
phagedena, gangrene, and other serious effects, precisely as in the male ; buboes, are, how- 
ever, less frequent. Ulcers of the uterus are generally difficult to cure, and are more apt 
to take on phagedenic action, often destroying large portions of the neck of the organ, 
and even extending some distance up the canal. 
The diagnosis can only be determined by the history of the case and by careful ocular 
inspection. The rapid development of the sores, their multiple character, and the pro- 
fuse, inoculable secretion, and the existence of more or less pain, form important 
elements in the discrimination of the disease. In case of doubt, inoculation may be 
practised. 
In the treatment of chancroids of the female genitals, the same general rules are ap- 
plicable as in the corresponding affections in men. Absolute rest in the recumbent 
posture, active purgation, saline and antimonial preparations, opiates, diaphoretics, the 
warm bath, and light diet, constitute the most appropriate remedies in ordinary cases. 
The most important topical means are frequent injections of hot water, or of hot water medi- 
cated with alum, chlorinated sodium, or carbolic acid; the application, especially if there 
be overaction threatening the occurrence of phagedena or gangrene, of weak solutions of 
acid nitrate of mercury ; and, above all, isolation of the affected surfaces with plugs of 
lint or cotton, medicated with aromatic wine, lotions of tannic acid and opium, yellow 
wash, or some slightly stimulating ointment. Pain is allayed, and rest secured with 
anodynes in full doses, repealed as often as may be necessary. Tonics and other sup- 
porting measures are of course necessary in exhausted states of the system. 
CHANCROIDAL BUBO. 
• Bubo essentially consists of an enlargement of the lymphatic glands of the groin, and is 
the result of the transference of the virus of the original sore to the latter situation. Hence 
it is capable of furnishing a secretion similar to that by which it was itself produced. An 
open chancroidal bubo is, in fact, nothing more or less than a chancroidal ulcer, resembling 
in every essential particular a chancroidal ulcer of the genital organs. Like the latter, 
it is wholly of a local nature, or, in other words, incapable of contaminating the system. 
The chancroidal bubo is present only in about one-third of the cases of chancroidal disease, 
whereas the true syphilitic bubo, or glandular enlargement, is a universal sequence of 
inoculation with the syphilitic virus ; the latter never tends to suppuration, is strictly 
indolent, and is characterized by a remarkable degree of induration, seldom noticeable, as 
a prominent feature, before the end of the tenth to the fifteenth day from the time of the 
impure contact. Moreover, the syphilitic bubo is always followed by constitutional dis- 
ease, or, more correctly speaking, is an evidence that the system has already been invaded. 
The chancroidal bubo is usually limited to one or at most two glands, although others 
may become involved during the progress of the disease, not by direct inoculation but by 
an extension of the inflammation which always accompanies the inoculation. The rela- 
tive proportion of bubo to chancroid has not been definitely settled ; but it will be sulli- 
ciently near the truth if it be put down at one case in every three, three and a half, or 
four. An active, open state of the primary ulcer, and the smallest conceiveable amount 
of inflammation in the structures immediately around are, other things being equal, the 
conditions most favorable to the development of the disease. Large or numerous sores 
attended with an abundant discharge of pus also materially contribute to the occurrence. 
On the other hand, the absorption of the specific virus and its transmission by the lym- 
phatic vessels to the groin are accomplished with great difficulty when the parts are over- 
powered by disease. The occurrence of phagedena or gangrene early during the progress 
of the primary ulcer is sure to act as a preventive. CHAP. IX. 
CHANCROIDAL BUBO. 
283 
The bubo generally occurs on the same side as the primary sore. Thus, if the ulcer 
exist on the right side of the penis, the right groin will be the one to suffer, and conver- 
sely. Occasionally an exception to this rule is met with, depending, probably, upon an 
interlacement of the lymphatic vessels, those of the right side passing over to the left, and 
the reverse. A bad form of bubo sometimes occurs at the root of the penis, or upon the 
pubes, caused by the presence of an infected gland. Now and then a bubo is developed 
in each groin, especially when the chancroid is situated upon some part of the middle line, 
as the frenum or the upper surface of the penis. 
The chancroidal bubo is much more frequent in men than in women, owing to the differ- 
ences in the arrangement of the lymphatic vessels, those of the former passing in a much 
more direct manner than those of the latter from the seat of the disease. In chancroid of 
the uterus and the upper part of the vagina bubo is uncommon, and the same law obtains 
in regard to chancroid of the urethra in the male. 
An opinion was at one time extensively prevalent that a bubo may form in the groin 
without the intervention or antecedence of chancroid, from the direct absorption of the 
specific poison from a mucous or cutaneous surface. It was and still is maintained by 
some that such an effect is possible, because, as is alleged, virulent bubo occasionally 
occurs without any evidence whatever of having been preceded by primary ulcers. It is 
assumed that the matter in which the poison is entangled, or held, as it were, in solution, 
may be absorbed by the mucous or even the cutaneous surface of the penis in the same 
manner as morphia, atropia, and other articles of the materia medica, and that, being sub- 
sequently conveyed by the lymphatic vessels to the groin, it is capable of infecting its 
glands in such a way as to form a true chancroidal bubo. Hence, the disease has been called 
the primary non-consecutive bubo, or, to use a French phrase, bubon d’einblee. The 
existence of this variety of bubo was admitted by several of the older writers on venereal 
diseases, especially by Astruc and Swediaur; Hunter also believed in it, and it was at 
one time dwelt upon at much length by Ricord and his disciples. Many of the most 
experienced practitioners, however, in all parts of the world, positively assert that they 
have never met with it, and, as for myself, I am sure that no instance of the kind has 
ever fallen under my observation. 
Varieties Bubo, like chancroid, is susceptible of a great variety of forms. Thus, it 
may, after having made a certain amount of progress, remain stationary, perhaps even for 
several months, manifesting no decided disposition either to advance or to recede. In 
another class of cases the enlarged glands, taking on inordinate inffammatory action, pass 
into suppuration, the matter usually collecting in a solitary abscess, of an ovoidal shape, 
from the volume of an almond up to that of a goose’s egg. When the disease assumes this 
form, it generally runs its course with considerable rapidity, being characterized by severe 
constitutional disturbance, such as rigors, fever, and headache, and by intense local suffer- 
ing, the pain being of an aching, throbbing character, the swelling great, the heat exces- 
sive, and the discoloration of a dusky livid red. If the matter, which is generally of a 
thick, yellowish appearance, intermingled with blood and cellular sloughs, is not promptly 
evacuated, it is apt to burrow among the neighboring tissues, causing extensive sinuses, 
which it is often extremely difficult to heal, and which occasionally lay open most impor- 
tant structures. In neglected cases, such an abscess may, on the one hand, pass high up 
over the abdomen, and, on the other, low down upon the front of the thigh. Dr. Lente 
has reported a case of virulent bubo in which the matter perforated the abdomen, and 
induced fatal peritonitis. In a case mentioned to me by Dr. J. M. Barton, upwards of a 
quart of pus was discharged through the rectum, the patient, notwithstanding the most 
extensive suppuration of the groin, thigh, and abdomen, making eventually a good 
recovery. Whenever the quantity of matter is unusually large, it may be assumed that it is 
mainly furnished by the connective tissue in which the affected glands are wrapt up, and 
not by these bodies themselves. 
When the contents of the abscess have been discharged, whether spontaneously or 
otherwise, the disease assumes the name of an open, ulcerating bubo, a state in which it 
may remain, with very little change, for an almost indefinite period. The discharge from 
such a sore, which is always situated above Poupart’s ligament, or partly above and partly 
below, and which inclines from above downwards and inwards, may partake more or less 
of the character of laudable pus, or it may, as is most common, be thin, ichorous, and 
irritating, the quantity varying from several drachms to upwards of an ounce in the 
twenty-four hours. It retains its specific properties until cicitrization is completed. The 
edges of the sore exhibit very much the same appearances as those of a common ulcer ; 
thus, they may be very steep, and ragged ; everted, inverted, or undermined; thick or 284 
VENEREAL DISEASES. 
CHAP. IX. 
thin; pale, reddish, dusky, or purple. The bottom is usually incrusted with a dirty, 
greenish, or yellowish pultaceous substance, with here and there a small, fiery-looking, 
exquistely sensitive granulation. Sinuses often extend from the main ulcer in different 
directions, and it is not uncommon, when the destruction has been at all extensive, to see 
some of the affected glands lying in a partially detached state at the bottom of the sore, 
perhaps adhering merely by a few shreds of connective tissue. 
An ulcerated bubo may take on phagedenic action, extending more or less rapidly in 
different directions, especially in persons of an unhealthy constitution. This epiphenome- 
non may show itself soon after the swelling has been laid open, or not until after the lapse 
of several weeks or months. It is usually characterized by severe pain, by a thin, pro- 
fuse, sanious discharge, and by a foul, pultaceous state of the sore, along with an irritable 
condition of the system, want of appetite and sleep, and disorder of the alimentary canal. 
Finally, a virulent bubo may run into gangrene; sometimes before ulceration sets in, 
but usually not until afterwards. Such a termination is most liable to occur in the lower 
classes of patients, the inmates of cellars, prisons, almshouses, and other filthy places, and 
often produces the most frightful ravages, causing extensive destruction of the skin and 
connective tissue, as well as, in some cases, of the muscles of the abdomen. The symp- 
toms are generally very severe and the disease often proves fatal, the sufferer, meanwhile, 
forming a most loathsome and disgusting object. 
Diagnosis Chancroidal bubo is liable to be confounded with bubo from other causes, 
and hence it is by no means always easy to determine the diagnosis, desirable as it is that 
there should be no mistake upon a subject of such practical moment. There are a few 
points in connection with these classes of swelling which are deserving of attention as 
means of discrimination. In the first place, the surgeon must carefully consider the 
history of the case. A chancroidal bubo seldom comes on before the end of the second 
week from the primary disease, and in many instances, indeed, not until a much later 
period. In the common bubo, the swelling ordinarily supervenes within a short time 
after the application of the exciting cause. Thus, a boil upon the nates, or a corn, 
bruise, or other injury of the toe, is usually followed by a bubo during the first three or 
four days after the commencement of the local affection. Secondly, useful information 
may be obtained from a consideration of the duration of the swelling. A chancroidal 
bubo usually lasts a number of weeks, often, indeed, several months; an ordinary bubo, 
on the other hand, generally promptly disappears with the cause that induced it. Thirdly, 
the chancroidal bubo often suppurates and ulcerates; the common bubo seldom, and then 
only or chiefly in persons of a scrofulous and broken constitution. Fourthly, the mat- 
ter of the chancroidal bubo is always inoculable ; of the common, never. Finally, the chan- 
croidal swelling is always situated above Poupart’s ligament, or partly below and partly 
above ; the non-specific usually below, and generally affects a greater number of glands. 
The syphilitic buho generally appears at the same time as the induration of the base of 
the initial lesion, and involves a number of glands, which are distinct, freely movable 
upon one another and the surrounding tissues, and densely hard. It rarely suppurates, 
and its secretion is not autoinoculable. 
The scrofulous bubo occurs only in persons of a scrofulous diathesis, mostly in children, 
prior to the age of puberty. It commonly affects a considerable number of glands simul- 
taneously, and they remain enlarged for a long time, being very hard and lobulated, and 
slowly tending to suppuration. The matter is of a yellow-greenish hue, and collects in 
several little abscesses, which, bursting, leave ill-conditioned ulcers, with thin, bluish, 
undermined edges, and a thin, sanious, irritating discharge, destitute of inoculable proper- 
ties. The bulk of the swelling is usually situated below Poupart’s ligament, at the upper 
and inner part of the thigh ; and traces of strumous disease generally occur in other 
parts of the body. 
Treatment The treatment of bubo must be conducted upon the same general princi- 
ples as that of the primary sore, of which, as already stated, it is simply another form. 
If the disease be seen early, before there is much inflammatory action or any decided 
tendency to suppuration, the abortive treatment will come into play, consisting of the free 
application of tincture of iodine, and of concentrated compression, either with a truss, a 
piece of lead, a bag of fine shot, a series of linen pads, or, what is better than anything 
else, layers of wet sponge frequently renewed, and secured with the spica bandage. There 
are few cases of incipient bubo which can resist the combined influence of these remedies, 
if properly managed. If the compression prove painful, it must be moderated, or tem- 
porarily pretermitted. Occasionally the treatment is advantageously preceded by the appli- 
cation of leeches placed around the periphery of the affected glands. CHAP. IX. 
SYTHILIS. 
285 
If the disease has already made considerable progress, iodine and compression will 
probably prove insufficient, and then more active measures will be required. Of these, 
the most efficient is the formation of an eschar upon the most prominent portion of the 
swelling by means of the Vienna paste, applied as in making an ordinary issue, or a 
solution of bichloride of mercury, in the proportion of twenty grains to the ounce of alco- 
hol. The skin having previously been elevated by a small blister, a compress, wet with 
the lotion, is firmly bound upon the raw surface, and retained for two hours, when it is 
replaced by an emollient poultice or warm-water dressing. The pain produced by this 
aplication is excessive, and hence the paste usually deserves the preference, especially as 
the mercury does not possess any special therapeutic advantages. The new action created 
by the caustic neutralizes or overwhelms the preexisting, and rapidly destroys the specific 
disease. 
When suppuration is threatened, or inevitable, it should be expedited by the usual 
means, especially emollient poultices, aided by recumbency and a relaxed position of the 
lower extremity. As soon as fluctuation is observed, the parts must be freely divided, 
even if the matter be deep-seated, in order to give full vent to the confined fluid. A 
tent is kept in the opening to prevent closure of the edges. Two incisions should always 
be made, one in the direction of Poupart’s ligament, and the other perpendicularly, or in 
the direction of the linea’alba, to afford thorough drainage. The operation is sometimes 
attended with considerable hemorrhage, chiefly, however, of a venous nature, and, conse- 
quently, easily arrested by pressure and quietude. If troublesome, the cavity should be 
packed with lint, wet with Monsel’s solution. When the suppurative process is very slow 
and imperfect, the most appropriate application is a large blister, retained sufficiently 
long to produce thorough vesication, and dressed with an emollient poultice. When the 
accumulation of pus is very large, it has been proposed to effect its evacuation, not by 
incision, but by the aspirator, or by numerous punctures, on the ground that it would be less 
destructive to the integument than the more common operation. I have not, however, 
found this to be so in my own practice. On the contrary, the skin and connective tissue 
are generally so much detached and impoverished as to render it impossible to preserve 
them with any reasonable prospect of ultimate reunion. Hence, I am always in favor of 
a free division; nor do I hesitate afterwards to remove such portions of integument as 
may seem to act obstructingly to the reparative process by overhanging the surface of the 
ulcer, and thus interfering with its medication. If sinuses form, they must be laid open, 
early and freely, in the usual manner; or, if they are very deep and tortuous, injected with 
some stimulating lotion, tented, and compressed. Fungous granulations are repressed 
with escharotics, as sulphate of copper or acid nitrate of mercury, or, what is better, the 
scissors. Loose glands are removed with the scoop or the knife. If the constitution is im- 
paired by protracted suffering and confinement, tonics and change of air will be required; 
and in all cases proper attention must be paid to the diet, bowels, and secretions. If 
phagedena or gangrene supervene, the same line of treatment will be demanded as under 
similar circumstances in the primary disease. 
II. SYPHILIS. 
SECT. I.—GENERAL CONSIDERATIONS. 
The term syphilis is applied to a disease which, commencing in the genital organs in 
the form of a sore of a specific character, invades the lymphatic glands of the groin, the 
cutaneous and mucous tissues, and finally also the bones, cartilages, fibrous membranes, 
and viscera, leaving upon each and all of them, as well as upon the system at large, a 
peculiar and distinctive impress. These different parts, however, do not all suffer at one 
and the same time; on the contrary, it would seem to be necessary that the poison upon 
which the infection depends should lie for a certain period in the tissues in which it has 
been deposited, in order to enable it to prepare itself for further action. Thus, in the 
first instance, the operation of the poison is limited to the genital organs and the lym- 
phatic glands of the groin. After having lingered here for some time, varying, on an 
average, from six to seven weeks, the cutaneous and mucous surfaces begin to suffer ; and 
at a still later period, generally from six to eighteen months, the bones, cartilages, fibrous 
membranes, and viscera are attacked. In this manner are produced three distinct groups 
of syphilis, known, respectively, as primary, secondary, and tertiary. To these has lately 
been added another, the quaternary, in which the disease is seated, mainly, in the nervous 286 
VENEREAL DISEASES. 
system and the viscera, as the brain, lungs, heart, liver, spleen, kidneys, and testicles, the 
latter of which may be regarded as external viscera. 
It is not my intention here to enter into an account of the history of the origin of 
syphilis; such an undertaking, besides involving an immense amount of research, ethno- 
logical, literary, and biblical, would be entirely out of place in a treatise of this descrip- 
tion, limited as it is to the practical details of surgery. I may remark, however, that, in 
my opinion, it is great folly to regard the disease as of modern origin. If the records of 
antiquity could be fully explored, it cannot be doubted that we should discover the most 
satisfactory and irrefragable evidence of the existence of syphilis in the most remote pe- 
riods of society, now aggravated and now kept in abeyance, according to the habits and 
morals of the various races of mankind, and the nature of the climate of the countries in 
which they dwelt. If the history of the inner life of Sodom and Gomorrah could be laid 
open to our scrutiny, it would furnish a page to the history of prostitution as loathsome 
and disgusting as any afforded by the vilest and most depraved cities of the present day, 
either in the Old World or in the Newr. 
Experiments performed by Turenne, Diday, and others, conclusively show that while 
chancroid may be propagated from man to the inferior animals, as the monkey, cat, rab- 
bit, and horse, and from these back again to man, in no instance has inoculation with 
the virus of a chancre succeeded in producing a similar local affection or constitutional 
involvement. 
The disease invariably arises from inoculation with a peculiar poison, known as the 
poison of syphilis or chancre. Of the precise nature of this poison all that is known is, 
that, when inserted into the tissues, it engenders a disease similar to itself, the resulting 
sore yielding a virus, in every respect, identical with that which furnished it in the first 
instance. Like the poison of smallpox, it is a peculiar poison, capable of reproducing 
itself, and of multiplying itself by zymosis. The smallest inconceivable atom, brought 
in contact with an appropriate surface, speedily develops a disease which, if permitted to 
progress, may occasion the most horrible consequences, both local and constitutional, and 
so contaminate the solids and fluids as to render it transmissible from the parent to the off- 
spring. As a little yeast may impregnate a large mass of dough, and cause a ferment 
that shall affect every particle of gluten entering into its composition, so a little syphilitic 
virus, so minute as to be utterly inappreciable by our senses, may affect the whole system, 
and poison every avenue of life and health. Zymosis having fairly commenced, it is im- 
possible, in any case, unless proper means be adopted to counteract it, to say when it may 
cease, or what may be its ultimate effects. 
The specific property of the syphilitic virus is not destroyed for a number of weeks, if 
the secretion with which it is combined is preserved in a well-corked vial; resembling, in 
this respect, the virus of vaccinia and variola. Sperino relates a case where the matter, 
dried upon the point of a lancet, was successfully inoculated at the expiration of seven 
months. It is rendered inert by chemical agents, and also by gangrene of the tissues in- 
fected with it. 
The virus does not seem to have any particular predilection for age, sex, temperament, 
or occupation ; all are alike liable to be affected by it. Previous disease does not prevent 
its action. It produces its peculiar impression most readily when applied to a clean ulcer- 
ated surface, an abrasion, or a recent wound ; but inoculation may take place independ- 
ently of these circumstances, simply from the introduction of the virus into a mucous 
follicle, which thus serves to entangle and retain it until its structure is brought thoroughly 
under its influence. When the part to which the virus is applied is perfectly healthy, 
several days may elapse before it is impregnated ; or it may even escape entirely, the mat- 
ter which contains it either not being able to penetrate its surface, or being wiped off 
before the occurrence of absorption. For the same reason a person thus situated may 
communicate the poison to another so as to give rise to a chancre, while he himself ex- 
periences no ill effects. Such a result not unfrequently occurs in women, from the entan- 
glement of syphilitic matter in the folds of the mucous membrane of the vagina, from 
which it is afterwards transferred to the virile organ in the act of copulation. 
The syphilitic virus may be communicated in various ways; first, and most commonly, 
by sexual intercourse; secondly, by kissing or sucking, through the agency of a mucous 
tubercle on the lip, tongue, or nipple ; thirdly, by tatooing, as in the cases recorded by 
Josias and Maury, the pigments having been mixed with the saliva from a person affected 
with mucous patches of the mouth ; fourthly, by unnatural connection, giving rise to 
chancre of the anus and perineum ; fifthly, by linen, towels, pipes, spoons, toys, tumblers, 
pencils, bank-notes, and other articles; sixthly, by surgical instruments, sponges, and 
CHAP. IX. 287 
CHAP. IX. 
PRIMARY SYPHILIS. 
dressings; seventhly, by chamber-pots and water-closets; and, lastly, by the fingers 
of the affected individual. In this manner a person may inoculate his own lips, nose, 
eyelids, or any abraded, raw, or open surface upon any portion of the body. In this way, 
too, accoucheurs sometimes inoculate their fingers in examining womem laboring under 
chancre of the vulva, vagina, or uterus. Syphilis has been contracted by chewing the 
stumps of segars ; and during the late war numerous cases occurred in which it was com- 
municated by vaccinating soldiers with lymph from infected persons. In the valley of 
Rivalta, in Piedmont, in 1861, forty-six out of sixty-three children suffered almost simul- 
taneously from this form of inoculation, several of them having died before the true na- 
ture of the disease was suspected. In these cases the real agent of contagion is the blood 
of persons in the secondary stage of the affection, which is mixed with the lymph ; and 
the blood corpuscles of the menstrual discharge of syphilitic women, is declared by Dr. 
Hyde, of Chicago, to be not an unfrequent source of contagion. 
The fact that the semen of a man laboring under constitutional syphilis is capable 
of communicating the disease, has long been familiar to practitioners. It is also a well 
ascertained fact that there are certain urethral discharges, occurring in persons affected 
with syphilis, which are of a contagious character, and therefore capable of imparting the 
disease to a healthy female, or to one who has never suffered from syphilis Such fluids, 
mixing with the semen in its passage along the urethra, are supposed by Mr. Henry Lee, 
of London, to be a not unfrequent cause of hereditary syphilis. 
SECT. II PRIMARY SYPHILIS. 
Primary syphilis consists, as already stated, of chancre and bubo, that is, of the initial 
lesion, and of an induration of the lymphatic glands in anatomical relation with the 
former. The disease is not, as was formerly supposed, strictly local when it is limited to 
these phenomena, but it is an evidence that the system is already contaminated by the 
syphilitic virus. 
1. CHANCRE. 
If what is said under the head of chancroid be true, it follows, as a logical sequence, 
that there is only one truly syphilitic sore, the most appropriate name for which is chancre. 
The phrase, “initial lesion,” introduced by the German writers, is also quite expressive, 
and is much in vogue in this and other countries. Hunter described a form of chancre 
which has long been known by his name, the characteristic feature of which is great 
hardness with an excavated condition of the resulting ulcer. This form of chancre 
mentioned with special emphasis by many of the earlier writers on venereal diseases, 
must have been much more common formerly than it is at present; for experience has 
shown that, while induration exists in almost every case of the disease, the form of sore 
here referred to is comparatively infrequent. Thus, of 170 cases tabulated by Basserean, 
superficial erosions existed in 146, and circumscribed sores with abrupt edges, or sores 
falling under Hunter’s distinction, only in 2 4. 
Syphilis occurs, as a primary disease, under two varieties of form, the acquired and 
the inherited ; the former, as the name implies, is the effect of direct contact in which 
infected tissue is brought in relation with souixl tissue, whereas the latter is the result of 
the contamination of the ovum either in the act of copulation or at a variable period after 
that act. In either case, the cause of the disease is a peculiar virus, known as the syphi- 
litic virus, the precise nature of which has never been satisfactorily unravelled either by 
chemical analysis or microscopical observation. All that is really known respecting it is 
that it is a zymotic virus, similar, in this respect, to the virus of measles, scarlatina, or 
variola, and capable of producing a constitutional impression which, as a rule, secures 
immunity to the system from future attacks. It differs, however, from the ordinary zymotic 
diseases in the fact that it passes through distinct stages of development, and that its 
germs may forever remain in the system, liable to be called at any time into activity, if, 
from any cause, the person experiences great impairment of his health. It is, moreover, 
transmissible from the parent to the child. 
The site of chancre is very extensive, more so, indeed, than that of chancroid. In the 
male the parts most frequently involved are the head and prepuce of the penis. Of 476 
cases of this disease observed at the Hopital du Midi in 1856, 314 occurred in these situa- 
tions. The skin of the penis was affected in 60 cases, and various parts of this organ in 
11 more; the meatus in 32 cases, the interior of the urethra in 17, the peno-scrotal angle 
in 11, the anus in 6, the lips in 12, and the tongue in 8; the nose, pituitary membrane, 288 
VENEREAL DISEASES. 
eyelids, fingers and leg each in 1. I have repeatedly seen chancres on the fingers in 
medical men, and chancre of the lips is by no means uncommon in the women treated 
for venereal diseases at the Jefferson Medical College Hospital. In the female sex 
chancre is most frequently witnessed upon the labia and nymph®, the entrance of the 
vagina, meatus, fourchette, and anus. In suckling women the nipple is occasionally 
inoculated by an infecting infant. The uterus rarely suffers from chancre. 
The question, whether chancre has a period of incubation lias been so often answered 
affirmatively that it would be idle to discuss it in a work on surgery. All zymotic diseases 
have a period of this kind, and syphilis forms no exception to the general law. In syphilis 
it averages from two to three weeks, but it often extends to a much later date, and as remotely 
even as fourteen weeks ; on the other hand, in exceptional cases, the period is only ten 
days. It is not to be inferred from the word “ incubation” as here used that the virus of 
syphilis lies perfectly latent in the inoculated part from the time of exposure to the 
appearance of the sore; on the contrary, it begins its zymotic operation within a very 
brief period, and rapidly penetrates the system, the entering wedges being the lymphatic 
vessels. This effect is always, other things being equal, produced more promptly when 
the infecting matter is brought into contact with an open, ulcerated, or abraded surface 
than when it is entangled in the orifice of a mucous crypt or sebaceous gland, in either 
of which it may lie literally in a state of latency for several days, if not several weeks. • 
Chancre, as already stated, appears under no exclusive form, but is susceptible of great 
variation, assuming at one time this feature and at another that. The superficial form is 
most common on the mucous membranes, especially in those situations which are free 
from friction and exposure to the air and other sources of irritation ; it is generally of a 
rounded or oval shape; the base is slightly depressed, seldom excavated, smooth or even 
partially polished, and of a reddish, livid, or grayish color. Its size varies from that of 
a split pea to that of a five-cent piece. It is generally solitary, has no areola and, unless 
irritated, does not furnish any pus globules, but only a thin, serous secretion, small in 
quantity and destitute of autoinoculating properties. On the skin the ulcer is generally 
more depressed, and its edges more defined ; it is also more liable to be covered with 
scabs, and to give rise to appearances closely simulating certain forms of secondary 
eruptions, as the pustular and ecthymatous. In both structures, the mucous and cutane- 
ous, induration constitutes a conspicuous if not an invariable concomitant of the ulcer, as 
is well shown in fig. 78, from a hospital patient. 
The number of chancres offers a remarkable contrast to that of chancroids ; while the 
latter are generally multiple the former are most frequently solitary, certainly in three 
cases out of every four. Such, at all events, must be our conclusion if we may credit the 
statistics of 1J84 cases compiled by Fournier, Clerc, 
Hammond, and Le Fort, of which 4GJ only were 
multiple. Occasionally the number ranges from tw o, 
three, five, or even six, and in one remarkable in- 
stance, observed by Fournier, there were as many as 
nineteen. 
Chancre, as might be supposed, is liable to certain 
modifications in its appearances, depending upon 
various causes, local and constitutional, individual 
peculiarity, and, no doubt, also upon the character 
of the poison itself; for there can be no question that 
it is much more virulent in some cases than in others. 
In the so-called Hunterian chancre, fig. 79, the 
ulcer is hollow' as if it had been scooped out of the 
tissues, and incrusted with a layer of very fiimly 
adherent fibrin, of a dirty-grayish color. The edges 
are hard, slightly elevated, and inclined somewhat 
slopingly from within outwards. The base is well 
defined and remarkably hard, feeling, if pressed be- 
tween the thumb and finger, like a button of fibro- 
eartilage, or, to employ the comparison of Benjamin Bell, like a split pea set in the 
structures immediately around the chancre. This form of sore is, as already stated, most 
common on the skin, but is also sometimes met with on the head of the penis, the inner 
surface of the prepuce, the labia, uterus, and lips. 
A diphtheritic condition is very common in chancres, and is especially liable to occur 
when there is, from any cause, overaction in the sore ; the plastic matter which gives 
CHAP. IX. 
Fig. 78. 
Indurated Chancre. CHANCRE. 
289 
CHAP. IX. 
rise to this appearance is usually deposited in a thin, firmly adherent 
layer, more or less moist, and of' a dirty, grayish, or greenish color. 
The neighboring structures are more or less inflamed, and often 
highly sensitive, if not actually painful. 
A chancre occasionally appears as a hard knot or tubercle, of an 
indolent character, free from pain, and indisposed to take on ulcera- 
tive action. The frenum and edges of the prepuce are its most 
common seats. 
A chancre never suppurates except when it is irritated by fric- 
tion, exposure, want of cleanliness, or improper applications. When 
this is the case it pours out pus, in greater or less quantity, precisely 
as any ordinary sore, and the fluid thus furnished may, by admix- 
ture with the natural secretion of the chancre, become inoculable. It is a fact worthy 
of notice that chancre and chancroid may coexist, or be ingrafted, so to speak, the one 
upon the other. In such an event, one sore will be hard and the other soft, or, if the 
ulcers run together, one part will present this feature, and the other that. This form of 
chancre is probably of more frequent occurrence than it is generally supposed to be. 
Professor Sigmund, of Vienna, who has made it a special study, inoculated the pus of 
a chancroid upon the infiltrated tissues of a hard papule with an unbroken surface, and 
in less than two days an open sore was established, one part of which was soft, while the 
other, or deep portion, exhibited all the characteristic features of a Hunterian chancre, and 
was the seat of the true syphilitic virus. 
The natural color of a chancre is reddish or grayish, but this is liable to be changed by 
overaction of the part, however induced. A muddy, darkish, or blackish appearance is 
by no means uncommon, especially in persons of dilapidated constitution or intemperate 
habits, and is always denotive of the existence of molecular gangrene. Phagedena or 
gangrene in mass, as it may be termed, is occasionally witnessed under similar circum- 
stances, and may, if not speedily arrested, be productive of great havoc. Nevertheless, 
such occurrences are far less common in chancre than in chancroid; and the serpiginous 
ulcers, so often witnessed in chancroid in persons of deteriorated health, are rarely seen in 
similar conditions in chancre. 
What is known as the multiple herpetiform chancre, originally described by Dubuc, is 
a rare form of ulcer occasionally met with on the head and foreskin of the penis and on 
the labia and vulva, occurring in the form of superficial erosions, of a rounded shape, of 
a deep red or coppery hue, and originally hardly the size of a millet-seed, but liable to 
enlarge as they progress, and finally to coalesce or run into each other. They are very 
sensitive, bleed readily under rude contact, and generally, as their name denotes, exist in 
considerable numbers, as many as a dozen, fifteen, or even twenty, coexisting or forming 
in more or less rapid succession. From ordinary herpes with which they are liable to be 
confounded they are distinguished by their smooth and shining surface, by their slightly 
indurated base, by their persistency, which is seldom less than four or five weeks, by the 
absence of itching, and by the induration of the lymphatic glands of the groin. 
Under the name of infecting balano-posthitis Mauriac has given an account of a rare 
form of chancre, which consists essentially in a thickened, reddened, and excoriated con- 
dition of the mucous membrane of the prepuce and head of the penis, attended with more 
or less induration, tumefaction, and cell-infiltration. '1 he disease is characterized by its 
chronicity, and by more or less involvement of the neighboring lymphatic glands ; circum- 
stances which readily distinguish it from ordinary balano-posthitis. 
Finally, there is what Lancereaux, Bumstead, and others have described as the dry 
chancre, an extremely rare form of the disease, in which the head of the penis is incrusted 
with patches, of a round or oval shape, of variable size, and of a whitish or grayish color, 
beneath which the superficial structures are more or less thickened, indurated, and filled 
with cells. Dr. P. A. Morrow has published the particulars of a rare case of chancre, 
in which the head of the penis was covered with a membranous hood; but in this instance 
the deposit was moist and glistening, and, although firmly attached, unaccompanied by 
hardness or ulceration. The disease pursued an indolent course, and was followed by 
secondary symptoms. 
Induration forms a prominent feature in chancre, and hence is of great diagnostic value ; 
indeed, it is the most characteristic sign of the disease. It is seldom observable before the 
eighth or tenth day from the exposure, and never, as a rule, attains its maximum develop- 
ment under a fortnight. Of 261 cases of chancre treated by Sigmund, the induration 
occurred on the ninth day in 71, on the tenth in 84, on the fourteenth in 76, on the seven- 
Fig. 79. 
Hunterian Chancre. 290 
VENEREAL DISEASES. 
CHAP. IX. 
teenth in 15, on the nineteenth in 12, and on the twenty-first in 3. In 438 cases reported 
by Le Fort, the average period was nineteen days; in 5 cases the induration was noticed 
between the second and fourth days, and in 60 between the fifth and eighth days. Diday, 
in 19 cases, found the mean duration to be fourteen days, while Chabalier, in 96 cases, was 
induced to place it at eighteen days. Similar testimony in regard to the tardy develop- 
ment of chancre has been furnished by Castelnau, Gibert, Rollet, Bumstead, Bellehomme, 
Martin, and many other syphilographers. The fact, indeed, is familiar to every experienced 
practitioner. In rare examples the period of its appearance has been known to exceed one 
month. Occasionally the induration precedes the ulceration ; and it is not uncommon for 
it to persist long after the primary sore is healed ; or it may disappear, and then recur, 
perhaps a second, third, or even a fourth time, with or without reopening of the old sore. 
In exceptional cases the induration constitutes the only evidence of the initial lesion of 
syphilis. Its approaches are usually very insidious, and unaccompanied by any of the 
evidences of ordinary inflammation. Its boundaries are always well defined, but its con- 
sistence is generally more or less influenced by the seat of the chancre, or the nature of 
the affected structures. Thus, on the skin, it always, as a rule, in the fully-developed 
chancre, imparts the sensation, if pressed between the thumb and finger, of a hard lump or 
piece of fibro-cartilage. This form of induration is especially conspicuous in the so-called 
Hunterian chancre, striking illustrations of which are so constantly met with in chancre of 
the lips, and, occasionally also, upon the head of the penis, as well as in other localities. 
In chancres, on the other hand, seated in the mucous membranes, and presenting them- 
selves as superficial erosions, the induration is commonly of the parchment-like variety, 
the affected structures feeling as if they rested upon a layer of that substance. In excep- 
tional cases, as rare as they are generally difficult of accurate discrimination, there is an 
entire absence of induration; or, in other words, the chancre is soft, and yet not any the 
less infecting. 
The cause of the induration is the new growth of connective tissue, which surrounds the 
chancre evenly and completely, forming around it a distinct and well-defined wall, without 
any blending into the neighboring parts, differing thus from an ordinary inflammatory 
deposit which is always lost insensibly in the circumjacent structures. 
The duration of chancre varies in different cases and under different circumstances, but, 
as a general rule, it is somewhat less than that of chancroid. If the person is in sound 
health at the time of the exposure, and guards himself well afterwards, he will be likely 
to fare much better than one in an opposite condition. Mow far the mercurial treatment, 
to be discussed by-and-by, may influence the duration of chancre is still an open question. 
As a rule, no patient is safe so long as the ulcer is not in a healthy granulating condition. 
It is now fully established that one attack of chancre effectually protects both the part 
and system against a second attack, the poison of syphilis thus resembling, in its habits, 
the poison of variola and similar diseases; chancroid, on the contrary, exercises no such 
influence, one attack affording no immunity against another. Artificial inoculation per- 
formed upon persons previously effected with syphilis produces no positive effects, con- 
clusively showing that there is no susceptibility to future invasion. 
Does a chancre ever leave any cicatrice or scar? This question is one of great interest 
both in a diagnostic, therapeutic, and juridical point of view, and should therefore always 
be carefully considered. In the more simple forms of the disease, in which there never is 
any appreciable loss of substance, the process of cicatrization effectually obliterates all 
traces of the chancre, save, perhaps, in the skin, in which there is occasionally a slightly 
bronze-colored hue; but it is far different when such a sore has been assailed by phage- 
denic, gangrenous, or sloughing action. Here, as there is always more or less destruction 
of tissue, a scar, more or less depressed, indelible, and a few shades lighter than the 
adjacent surface, is inevitable, and always, at least as a rule, easily detectable. No patient 
can be said to be entirely well so long as the cicatrice of such a sore remains hard; the 
induration is an evidence that some of the virus still lurks in the affected structures, where 
it may at any moment be fanned into activity. 
The complications of chancre are inflammation, phagedena, and gangrene, but these 
affections are not so common as they are in chancroid, under which head they are fully 
described. The affections of the lymphatic glands and vessels will be considered in the 
succeeding section. 
Diagnosis—The subjoined table shows at a glance the typical differences between 
chancre and chancroid. The most reliable signs of the former are the period of incuba- 
tion, induration of the associated lymphatic glands, and induration of the base of the 
sore. CHAP. IX. 
CHANCRE. 
291 
CHANCRE. 
1. A constitutional disease, dependent upon the 
inoculation of a peculiar poison the product of 
a chancre, a mucous patch, or of contaminated 
blood. 
2. Generally seated on the genital organs, but 
may also occur on the lips, nipples, fingers, 
and other structures. 
3. Has a distinct period of incubation, varying 
on an average from eleven to twenty-one days. ■ 
4. Begins as an excoriation, or induration, gen- 
erally in the form of a papule, or a tubercle 
which, in time, undergoes ulceration. 
5. Advances slowly and heals rather rapidly. 
6. Is generally single ; multiple, if at all, usu- 
ally so from the start from primary inoculation. 
7. Form ; round, or oval, generally as a super- 
ficial erosion ; flat or slightly elevated ; rarely 
deep, or excavated. 
8. The floor of the ulcer smooth, red, and of a 
livid, or copper color; often grayish, muddy, 
or slightly greenish, especially if incrusted 
with plasma. 
9. Edges sloping, as if the sore had been scooped 
out; flat, and adherent. 
10. Discharge scanty and serous, and autoin- 
oculation either impossible or effected with 
great difficulty. 
11. Induration almost invariable, especially in 
men ; sometimes absent in women ; cartilagin- 
ous or parchment-like in its feel ; circum- 
scribed, movable, indolent, and persistent. 
12. Generally insensible ; hence often over- 
looked. 
13. Occurs seldom, if ever, more than once in the 
same individual. 
14. Seldom invaded by phagedena or gangrene. 
15. Induration of the lymphatic vessels, common, 
especially in those of the penis. 
16. Neighboring lymphatic glands indurated, 
painless, and freely movable; suppuration 
uncommon, and pus never autoinoculable. 
17. Difficult of eradication, but may be improved 
by mercury and other remedies. 
18. Is peculiar to the human race ; at least the re- 
sults thus far obtained tend to this conclusion. 
CHANCROID. 
1. A purely local affection, due to the inocula- 
tion of a contagious matter, wholly different 
from that of chancre. 
2. Most common on the genital organs, whence 
it may extend to the groins, perineum, and 
the anus, especially in women. 
3. The action of the poison begins at once, the 
ulcer usually attaining its full development 
and specific character by the end of the third 
to the fifth day. 
4. Appears originally as a pustule, sore, or 
ulcer, and retains the character of an open 
surface throughout. 
5. Progresses vapidly but heals slowly. 
6. Frequently multiple, if not from the start, 
soon rendered so by autoinoculation from 
diffusion of the secretion. 
7. Irregularly rounded, oval, or fissured, the 
sores often running into each other, and accom- 
panied by a tendency to burrow. ’• 
8. Dirty-yellowish white, grayish, or pale pink; 
ragged, or worm-eaten. 
9. Edges abrupt or perpendicular ; eroded, and 
often undermined. 
10. Abundant, thick, purulent, and readily 
autoinoculable. 
11. Always wanting, except when the sores 
have been irritated by caustic or other harsh 
applications. 
12. Always more or less painful. 
13. May occur an indefinite number of times. 
14. Inflammation often runs high, and may then 
end in destructive action, especially in broken- 
down persons. 
15. Very uncommon, but may attend when the 
sore has been unduly inflamed by local irritants 
or a bad state of the system. 
16. Bubo exists in about one-third or one-fonrtli 
of the cases ; disease always inflammatory, and 
tending to suppuration ; the pus frequently 
autoinoculable. 
17. More or less amenable to simple local and 
general remedies. 
18. May, it is believed, be transmitted by in- 
oculation to some of the lower animals. 
Chancre of the Urethra—Chancre occasionally attacks the urethra; probably much 
oftener than is generally supposed, although its relative frequency to chancre of the pre- 
puce and head of the penis has not been satisfactorily determined. Of 471 cases of 
chancre in males observed at. the Hopital du Midi at Paris in 1856, 17 involved the urethra 
and 32 the meatus. The fact that chancre is liable to occur here was not known, even to 
the most enlightened syphilographers, until within a comparatively recent period, and it 
is, therefore, not surprising that many of them should have considered gonorrhoea as capa- 
ble, in some cases, of giving rise to secondary symptoms. The sore being concealed in 
the urethra, the discharge which attended it was regarded as being exclusively the pro- 
duct of gonorrhoea, and the ignorance which existed upon the subject would probably 
never have been removed if it had not been for the practice of inoculation. The nume- 
rous experiments which have been performed upon the subject have proved, beyond the 
possibility of doubt or cavil, that gonorrhoea is a merely local affection, and that, whenever 
any constitutional syphilitic phenomena occur as the consequence of a urethral profluvium 
these phenomena are due, not to the effects of gonorrhoea, but to those of urethral chancre. 
Chancre of the urethra is generally situated immediately behind the meatus, or in that 292 
VENEREAL DISEASES. 
CHAP. ix. 
portion of the canal which corresponds with the glans ; I have, however, repeatedly met 
with it on the lips of the external orifice, and in a young gentleman, recently under my 
care, there was a well-marked indurated chancre at least two inches behind the anterior 
extremity of the tube. The disease occasionally, although very rarely, extends over 
nearly the whole of the urethra, as far back as the neck of the bladder. 
The period of latency of chancre of the urethra is much longer than in the ordinary 
form of the disease, being seldom less than three and a half or four weeks. The reason 
of this would seem to be that the specific virus, entangled in some of the lacunae of the 
canal, is incapable of exerting the same rapid influence as when it is brought in contact 
with an abraded surface upon the head of the penis. Moreover, it is extremely probable 
that only a very small quantity of the poison generally finds its way into the urethra, and 
that, consequently, it has great difficulty, not merely in effecting a secure lodgment, but 
in so multiplying itself as to enable it to produce ultimately an explosive effect upon the 
mucous and submucous tissues. The urine, passing along the tube soon after the intro- 
mission of the specific fluid, generally either washes it entirely away, or, combining with 
it, effectually neutralizes its active properties. 
The discharge attendant upon chancre of the urethra is always much less copious than 
in ordinary gonorrhoea; it is also more thin, and of a lighter color, unless the accompany- 
ing inflammation is unusually severe, when it may be both profuse and of a thick, bloody 
character, or thick and yellow with a greenish tinge. There is generally some degree of 
scalding in micturition, though hardly ever so much as in gonorrhoea, and the site of the 
chancre is nearly always indicated by a sense of hardness, or a kind of lump easily dis- 
tinguished by the thumb and finger. When the disease affects the anterior extremity of 
the tube, it is not uncommon to find great induration of the whole head of the penis, with 
a red and phlogosed appearance of its mucous covering, and considerable tumefaction of 
the prepuce. Morbid erections are not only frequent, but often very painful and trouble- 
some. The disease is usually chronic, rarely gives rise to fever, and is always followed 
by constitutional symptoms. Bubo is seldom so distinctly marked as in chancre of the 
penis. More or less contraction of the urethra, especially in neglected or protracted cases, 
is an invariable sequence. 
The diagnosis of chancre of the urethra is often difficult. It is easy enough when the 
ulcer is situated at the lips of the meatus, or just behind the orifice, the mere separation 
of the edges of which will then be sufficient to bring it fully into view. When located 
farther back, its existence becomes a matter of doubt; for, although the accompanying 
induration may be very distinct, yet as a similar condition may be present in gonorrhoea, 
or stricture, as a consequence of a deposit of lymph into the submucous connective tissue, no 
useful deduction can be drawn from it. The most valuable rational symptoms are, the 
unusual latency of the poison, or the extraordinary length of time which intervenes be- 
tween the impure connection and the outbreak of the disease, the remarkable obstinacy of 
the attack, resisting, as it generally does, all the various methods of treatment commonly 
directed for the cure of gonorrhoea, the slight scalding in micturition, and lastly, the 
frequent variation in the nature of the discharge, which is now scanty, thin, and serous, 
now profuse, thick, and yellow. 
Chancre of the Fingers, Lips, Tongue, and Anus Chancre of a finger may be con- 
tracted by surgeons and accoucheurs in examining, dressing, or delivering diseased women, 
from the accidental inoculation with the syphilitic poison. It commonly begins as a little 
sore or vesicle at the side of the nail, from which it gradually extends until it eventually 
involves its entire structure, as well as the surrounding parts. The attack is attended 
with great pain, discoloration, and swelling of the finger, which soon becomes bulbous and 
distorted, very much as in the worst forms of onyxitis ; and the ulcer itself presents a foul 
phagedenic or sloughing aspect, lied lines frequently extend up the arm, the axillary 
lymphatic glands are enlarged either alone or conjointly with that tit the elbow, as well as 
exquisitely tender, and the general health is seriously impaired ; often, indeed, totally 
wrecked. 
A chancre sometimes forms upon the lips; more frequently upon the lower than the 
upper, as a result either of the contact of chancrous matter or of inoculation with the 
secretion of a mucous tubercle, as in tlie act of kissing, smoking, drinking, or glass-blow- 
ing. The sore is solitary, more or less oval, and characterized by a remarkably indurated 
base, the part feeling like a mass of fibro-cartilage. The discharge is scanty and ichorous. 
The whole lip is stiff, painful, and everted. Lymphatic involvement of the chin and side 
of the jaw is an invariable sequence. CHANCRE. 
293 
CHAP. IX. 
In chancre of the tongue, it is usually the tip of the organ that is affected. The sore 
is very hard and indolent, but possesses no distinctive features. 
In chancre of the anus the sores, which may be solitary or multiple, may be seated just 
at the verge of the anus, or immediately above the sphincter muscle, and are distinguished 
by their hardness, their rosaceous color, and their slow and painless development. 
Defecation is exquisitely painful, the parts are excoriated and inflamed, the discharge is 
thin and fetid, and, if the morbid action be not speedily arrested, abscesses are liable to 
form, although they seldom open into the bowel. Buboes rarely follow. 
Chancres are liable to form in other parts of the body, as the nose, cheeks, eyelids, 
scalp, trunk, and extremities, and it is remarkable that in all these situations the sores 
invariably belong to the indurated variety of the disease. 
The diagnosis of chancre of the lingers, lips, tongue, anus, and other portions of the 
cutaneous, mucous, or muco-cutaneous surface must be deduced from the history of the 
case, and from a careful examination of the affected structures. It should be borne in 
mind that a chancre of the lip may be mistaken for an epithelioma; and no surgeon should 
ever be in haste to amputate a syphilitic finger, when the ulcer presents a foul or sloughy 
asf>ect, inasmuch as a judicious course of treatment may promptly cure the disease. 
Is syphilis a curable disease? Does it ever disappear spontaneously, or eventually lose 
its hold upon the system, so that a patient may be said to be perfectly well? These are 
grave questions, and it is much to be regretted that we cannot, in the existing state of 
the science, return satisfactory answers. From all the light that at present exists upon 
the subject, I think it may fairly be assumed that, as a rule, when a man has once been 
syphilitic, he will always be syphilitic; in other words, that the germs of the disease re- 
main forever in the system, liable, under adverse circumstances, to be at any time, how- 
ever remote from the primary inoculation, fanned into activity, or, figuratively speaking, 
to rise, like a phoenix, from its ashes. That the virus is, in exceptional cases, as rare as 
they are difficult of detection, completely eliminated from the constitution, is unquestion- 
able; at all events, such is the conclusion arrived at after a thorough study of the subject 
in all its phases by some of the ablest and most experienced syphilographers of the present 
day, men who are not easily led astray by speculation or conjecture, lint, although 
syphilis is generally an ineradicable disease, it is consolatory to know that it is no longer 
endowed with the virulence which characterized it in former times, and that, under proper 
treatment and hygienic precautions, the disease may be kept indefinitely in a state of 
abeyance, without danger to the jMitient or to his offspring. 
Can syphilis give rise to pulmonary phthisis and carcinoma? Here, again, are two im- 
portant questions, for the solution of which facts are still wanting. 1 have, myself, long 
been satisfied that syphilis, in persons of depraved constitution, often acts as an exciting 
cause of tubercular disease of the lungs and other organs, but only in cases in which 
there is a well-marked or deeply ingrafted predisposition to that affection. When no such 
state of the constitution exists, I do not believe it possible for the poison ever to produce 
such an effect. As to carcinoma, there are at present no facts before the profession to 
warrant the assertion that syphilis, in any of its forms, is capable of engendering it. 
Treatment—Much stress w'as formerly laid upon what was called the abortive treat- 
ment of chancre, on the supposition not yet entirely abandoned, that, if the inoculated 
structures could be effectually destroyed before the end of the fifth or sixth day, or the 
supervention of induration, which forms so characteristic a feature of the disease, till 
danger of the entrance of the virus into the system could thereby be averted. This doc- 
trine is, however, no longer tenable, for, as was previously stated, there is reason to be- 
lieve that the virus begins to act the moment it is brought into contact with an abraded 
surface, or the interior of a mucous follicle, and that, consequently, it does not, except in 
very rare cases, have, as was so long conjectured, any period of latency, properly so 
termed, however short. If we assume that this supj>osition is true, and few syphilogra- 
phers of the present day doubt or deny it, then all abortive measures must necessarily be 
futile. The opinion of Ricord upon this subject is positive, and emphatic. lie has 
entirely abandoned the practice of cauterizing and excising chancres. He considers all 
such procedures perfectly useless, experience having shown that even before there is any 
appearance of a sore or tubercle, constitutional syphilis already exists. “ If,” says he, 
“ the penis were amputated on the appearance of an infecting chancre, syphilis would none 
the less be produced.” I have, myself, repeatedly destroyed incipient chancres with the 
knife, acids, or escharotics, and yet in no solitary instance which I can now recall was 
the operation successful in preventing the development of constitutional symptoms. When VENEREAL DISEASES. 
CHAP. IX. 
a man applies for advice, with a suspicious looking sore or abrasion, within a few hours 
after impure connection, the surgeon should not hesitate to employ means for the destruc- 
tion of its specific properties ; the treatment might, and probably would, fail ; but if pro- 
perly conducted, it could do no harm, and would, certainly, for a time at least, calm the 
patient’s mind, an object, frequently, of the greatest importance, especially if, as so often 
happens, he is very nervous or excitable. If, on the other hand, several days have 
elapsed, or induration already exists, all such interference will be perfectly useless so far 
as the development of constitutional symptoms is concerned. But, although this is un- 
doubtedly true, the operation, if early and thoroughly performed, will materially modify 
and abridge the local disease, and for this reason, always deserves serious consideration. 
When the work is decided upon, it should be done effectually, by including, if possible, 
some of the surrounding healthy structures. The best, safest, and least painful operation 
is excision, but, as few patients will submit to this, the next best thing is some acid or 
alkali, as the acid nitrate of mercury, nitric acid, or Vienna paste, cautiously applied, 
otherwise serious mischief may result. Ricord was in the habit of using carbo-sulphuric 
paste ; but the pain arising from it is so excessive as to render its employment highly 
objectionable, not to mention its tendency to spread too widely over the sound tissues. 
Nitrate of silver, whether in substance or solution, possesses no value as a neutralizer of 
the syphilitic virus. The treatment after the use of any of these agents should be con- 
ducted upon strictly soothing and antiphlogistic principles, conjoined with perfect rest 
until the more severe symptoms have disappeared. 
Assuming, what is undoubtedly true, that, when a patient has once been thoroughly in- 
oculated, constitutional syphilis is inevitable, the question arises, what is best to be done 
to render the outbreak as harmless as possible ; or, in other words, to eliminate the spe- 
cific virus in the shortest time, and in the most thorough manner, from the system? It 
has been seen that this poison is, among other properties, possessed of zymotic qualities, 
by reason of which it induces rapid cell-proliferation, the effect of which is to taint 
alike the solids and fluids, as is shown by the various affections that manifest themselves, 
first, in the dermoid and mucous tissues, and, subsequently, if the disease be not timeously 
arrested, in all parts of the body. To prevent the germination of this poison becomes, 
therefore, an object of the deepest possible interest. But is it possible to do this? Upon 
this subject, again, as, indeed, upon every other growing out of this disease, there exists 
more or less divergence of opinion ; but, I think, I state the matter fairly when I assert 
that much may be done in every case if taken in hand at an early period after inocula- 
tion, not in preventing the occurrence of secondary symptoms, but in retarding their 
access, in moderating their severity, and in abridging their duration. If this can be 
done, a great point will be gained, a point which it is the solemn duty of every practi- 
tioner to aim at. Medicine alone will not accomplish the object. To succeed, the patient 
must place himself unreservedly in the hands of his professional attendant. Every 
hygienic measure must be called into requisition ; the diet, if plethora be present, must 
be abridged, the bowels freely moved, and the mind and body kept at rest. These are 
points upon which it is impossible to lay too much stress, or without the due observance 
of which it will be possible to make any efficient progress. It is worse than useless to let 
the patient have his own way, or to permit him to follow his accustomed mode of living. 
The most reliable remedy, undoubtedly, for neutralizing the poison or eliminating it from 
the system, is mercury, in the form of calomel, administered thrice a day, in doses varying 
from the third to half a grain, a short time before eating. If the patient be plethoric, 
it will be well to combine with each dose of the medicine a few drops of aconite, or the 
tenth or twelfth of a grain of tartar emetic. The effect should, of course, be carefully 
watched, ptyalism being sedulously guarded against, and griping and purging prevented 
by the use of opium and an occasional dose of oil. To prove beneficial, the treatment 
should be steadily maintained for at least five or six weeks. Protiodide of mercury, blue 
mass, or gray powder may be used as substitutes for calomel, but, as a rule, the latter 
deserves the preference on account of its greater certainty and more manageable character. 
If mercury is the only or principal remedy capable of neutralizing, eliminating, or de- 
stroying the syphilitic virus, how long should it be persisted in to insure this desirable 
result ? Can this question be determined in any given case, or must every case be gov- 
erned by its own laws? Manifestly, the practitioner must be guided here, as in the treat- 
ment of every other disease, by general principles ; but, as a rule, founded upon long 
experience, and acted upon by many of the most enlightened syphilographers, it may be 
assumed that the use of the remedy must be continued, more or less steadily, for at least 
from twelve to eighteen months. Some practitioners insist upon its exhibition for a much CHAP. IX. 
CHANCRE. 
295 
longer period, as two or even three years, but if such a practice is at all justifiable, it can 
be so only in exceptional cases, cases in which the poison has taken more than an ordi- 
narily firm hold of the the system. When the treatment is prolonged over such a length 
of time, there must always be great danger of inflicting serious injury upon the system, 
unless the mercury is administered in the smallest possible quantity compatible with its 
therapeutic effects, and with the greatest possible care and judgment. 
Another excellent remedy, as an eliminator of the poison of syphilis in its incubative 
stage, is tartar emetic, in doses varying from the eighth to the tenth or twelfth of a grain, 
according to the tolerance of the stomach, thrice a day. It may be given by itself, or in 
union with aconite and sulphate of magnesia, in the form of the antimonial and saline 
mixture, with the positive assurance that it will rarely, if ever, disappoint expectation. It is 
certainly only less potent as a neutralizer or eliminator of the syphilitic virus than mercury. 
As to the iodides in the treatment of primary syphilis, experience showed long ago 
that they possess no curative power, whether they are employed singly or in combination 
with other remedies, in small or in large doses. Practitioners, ignorant of the true action 
of these remedies, alone employ them in this stage of the disease, and hence much valu- 
able time is often lost, time that should have been spent in the employment of other and 
more appropriate remedies. 
Diday, who is regarded the world over as a great authority in syphilis, and who be- 
lieves that, under certain circumstances, this disease tends to self-limitation, has published 
the results of forty-three cases treated by the non-mercurial plan, in twenty-six of which 
there was never any serious constitutional disturbance, the principal phenomena consist- 
ing of a mild form of fever, acne of the scalp, roseola, and mucous patches. Although 
these symptoms reappeared several times in most of the cases, each successive attack was 
milder than the preceding one, showing plainly, as he declares, that the disease was 
gradually dying out or losing its hold upon the system. No tertiary symptoms were de- 
veloped, and all the patients gradually regained their health and vigor. The disease, 
according to this writer, will be most likely to be comparatively mild when to a protracted 
period of incubation there is superadded a gradual diminution of the engorged lymphatic 
glands, followed, perhaps, only by superficial blotches of the skin, or skin and mucous 
membranes, separated by long intervals. When the opposite conditions exist, the prog- 
nosis will necessarily be of a more grave character, inasmuch as they go to show that the 
disease is more deeply rooted, or more thoroughly inlaid in the general system, the blood 
and solids being alike contaminated by the operation of the virus. Although there may 
occasionally be cases of syphilis falling under the first of these divisions, no conscientious 
surgeon would be likely to adopt the expectant method of treatment in a matter which so 
seriously concerns the happiness of his patient. An error here would not only be a blun- 
der, but might be followed by the most lamentable consequences. 
The non-mercurial treatment of venereal diseases, formerly so much lauded, is com- 
pletely divested of any value that was at one time attached to it, by the fact that the 
distinction which is now known to exist between chancroid and chancre had not been 
recognized ; consequently both these affections were treated on the same principles. The 
British surgeons, during the Peninsular wars, furnished, as they supposed, the most irre- 
fragable proof that primary syphilis could generally be effectually cured by ordinary anti- 
phlogistic means; and similar testimony was supplied by the hospitals of Sweden, Ham- 
burg, Strasbourg, and other continental cities of Europe. These reports, which at one 
time attracted universal attention, and were accepted by many practitioners with implicit 
confidence in their reliablility, are now only fit for the waste basket. 
IIow mercury acts in curing syphilis, whether as a neutralizer, or as an eliminator, is 
still a mooted question. In all probability it acts in both ways; certain it is that its pre- 
sence has been detected again and again within a short time after its exhibition, in the 
urine, the perspiration, the saliva, and even in the alvine evacuations. Administered 
in small quantities, after the system has been properly prepared for its reception, it in- 
creases the number of red globules, while it decreases the number of white, and improves 
the general health by augmenting the appetite and the assimilative functions. In large 
doses, on the other hand, or when the system is brought under its prolonged influence, it 
produces directly opposite effects. These facts, which accord fully with the clinical ob- 
servations of every enlightened practitioner, have been placed in the strongest possible 
light by the researches of Liegeois, Wilbouchewitch, and I)r. E. L. Keyes, whose excel- 
lent paper on the effects of small doses of mercury in modifying the number of red blood 
corpuscles in syphilis is replete with interest, and worthy of the attentive study. 
During this mercurial treatment, complications must be looked for and properly met as 296 
VENEREAL DISEASES. 
CH AP. ix. 
they arise. Thus, if the secretions he at fault, they must be promptly corrected; and 
until this be accomplished, it will be well to suspend the use of the specific remedy, as it 
could hardly fail to [trove mischievous by acting as an irritant. If febrile disturb- 
ance arise, accompanied with a strong bounding pulse and a hot, dry skin, blood may be 
abstracted from the arm, or, what will usually answer quite well, recourse may be had to 
the neutral mixture, with the addition to each dose of two or three drops of the tincture 
of aconite. Opium in large doses, repeated more or less frequently, and conjoined with a 
suitable diet and perfect rest, will be absolutely necessary if phagedena or gangrene occurs. 
Ricord, in such an emergency, has unbounded faith in the utility of potassio-tartrate of 
iron, administered every five or six hours in syrup of orange peel, or some other suitable 
vehicle. The exhibition of mercury is at once suspended, and every effort made to tran- 
quillize the part and system. If the patient is anemic or greatly debilitated, the use of 
tonics, as quinine and iron, milk punch, and other supporting measures will be impera- 
tively demanded, perhaps at the very outset of the treatment. 
In regard to the local treatment, little, if anything, needs to be added to what is said 
upon this subject under the head of chancroids. Local baths, either simple or medicated, 
are of paramount importance ; they serve not only to cleanse and soothe the affected parts, 
but afford material aid in moderating inflammation. The frequency with which these 
baths are repeated, and the time during which they should be continued, must depend 
upon the amount of pain, swelling, discharge, and other circumstances. I am disposed 
to lay much stress upon them, for it is impossible to overestimate their value in a curative 
point of view. The best local application, in the intervals, is a moderately strong solution 
of acetate of lead, or lead and opium, applied upon soft lint, or, what is much better, cot- 
ton-wool, covered with oiled silk, and renewed as often as it becomes dry or soiled. An elm 
poultice, simple or medicated, is another most grateful application. Blood may be taken 
by leeches from the groins and inside of the thighs, if the local irritation is uncommonly 
severe, but these animals should not, for obvious reasons, be applied to the affected organ 
itself. Weak lotions of acid nitrate of mercury will be found to be the most suitable 
remedies for arresting phagedenic or gangrenous action ; and occasionally nothing answers 
so well as weak solutions of subsulphate of iron, combining, as this article does, the pro- 
perties at once of a detergent, an alterant, and a powerful antiseptic. Languid action 
demands the use of stimulants, of which, according to my experience, nitrate of silver is 
the very best. It may be applied in substance passed lightly over the affected surface 
once a day, or, what I generally prefer, in solution, as five, ten, or fifteen grains to the 
ounce of water. A tight, unretractable prepuce should never be incised, unless it acts 
as a tense cord imperilling the occurrence of gangrene, when it should be freely divided 
at all hazard, the raw surfaces being immediately cauterized with crystallized carbolic 
acid, nitrate of silver, or acid nitrate of mercury. Any oedema that may be present may 
be treated with dilute tincture of iodine; or, this failing, with a few small punctures, 
hermetically sealed with collodion as soon as thorough drainage has been effected. Morbid 
erections are controlled with anodynes, either in the form of suppositories or hypodermic 
injections. When the prepuce cannot be retracted, the syringe must be freely used ; 
first, with simple warm water to wash away the secretions, and, immediately afterward, 
with weak solutions of lead, alum, chlorinated sodium, or some other suitable fluid, to pro- 
mote the healing of the sores. When the foreskin is sufficiently soft and yielding, it 
should be kept constantly separated from the head of the penis, either with dry lint, 
which is often the very best application that can be made, especially when the first flush 
of inflammation is over, or lint wet with some mild lotion, as water containing two or 
three drops of acid nitrate of mercury to the ounce. Dry calomel is also sometimes bene- 
ficial ; and now and then weak yellow wash answers a good purpose. Ointments are, as 
a rule, from their liability to become rancid and offensive, less kindly borne than fluids. 
Here, as in the case of chancroid, it is very important to watch closely the effects of our 
local remedies, making such changes from time to time as the exigencies of the case may 
demand. He who expects to treat successfully any case of chancre, of the least severity, 
with any one particular remedy, will generally find himself egregiously at fault. Finally, 
let it be borne in mind, as a solemn warning, that all harsh applications in the treatment 
of this affection, as in that of chancroid, will inevitably be productive of harm, provok- 
ing irritation, increasingpain, keeping up constitutional excitement, and protracting the cure. 
The indolent form of chancre is always accompanied by great induration, which often 
continues long after the ulcer is completely cicatrized, and constitutes a variety of syphilis 
peculiarly dangerous on account of its liability to be followed by unusually severe and 
protracted constitutional symptoms. Indeed, no patient is safe so long as the part re- SYPHILIZATION. 
297 
CHAP. IX. 
mains in this condition. It is an incontestable evidence that the virus still lingers at the 
original seat ot‘ the infection, and that, like a smothered fire, it may spring up at any moment 
into a full blaze, reexciting ulceration, and endangering the system. It is to this form of 
chancre that mercurialization is so emphatically applicable : no delay should be permitted, 
and it will generally be necessary to carry the treatment to the extent of slight ptyalism. 
When the desired effect is unusually tardy, the treatment may be aided by mercurial 
inunctions, from one to two drachms of the ointment being rubbed on the inside of the 
arms and thighs morning and evening ; or, what is better, a mercurial suppository may be 
inserted every eight, ten, or twelve hours, the effect of the remedy being carefully watched, 
lest overaction should be induced. The best local remedies are very dilute tincture of 
iodine, lead lotions, and inunctions of mild mercurial ointment. 
The treatment of chancre of the urethra is conducted upon general antisyphilitic princi- 
cles. The remedies which prove so serviceable in gonorrhoea are entirely inert here, ex- 
cept in so far as they may be instrumental in diluting the urine and depriving it of its 
acrimony. When within reach, gentle cauterization with nitrate of silver will be benefi- 
cial; indeed, in obstinate cases, hardly any other direct application will be of much avail. 
In the intervals of the cauterization, or, in the more intractable forms of the disease, 
throughout the treatment, different kinds of injections must be used, especially weak lotions 
of sulphate of copper, tannic acid and opium, acetate of lead, bichloride of mercury, and 
iodide of iron. If the sore be seated near the meatus, the opposite surfaces should be kept 
apart with a tent medicated with dilute ointment of nitrate of mercury; or a small bougie 
smeared with this substance may occasionally be introduced. If marked induration exists, 
early but gentle mercurialization must be employed. Chancres of the fingers, lips, tongue, 
anus, and other portions of the cutaneous, mucous, or muco-cutaneous surface must be 
treated on general principles. Nearly all of these affections will be materially benefited 
by a mild course of mercury. 
SYPHILIZATION. 
It was supposed at one time that syphilis could be effectually eradicated from the sys- 
tem, after the failure of all other means, by successive inoculations with the virus of this 
disease. To this treatment the term syphilization, first used by Dr. Auzias Turenne, was 
applied. As early as 1844, this physician, in attempting to transfer syphilis from man 
to the monkey, was struck with the fact that, when the operation was repeated a number 
of times, the tissues into which the matter was inserted were at length rendered completely 
insusceptible to its further influence. Believing that the treatment might be advantageously 
applied to the human subject, he instituted some experiments in this direction, but the 
results were not given to the profession until after the publication of the memoir of Dr. 
Sperino, of Turin, in 1851. In this memoir numerous experiments are detailed apparently 
confirmatory of those of Auzias Turenne. Subsequently the matter was very thoroughly 
investigated by the late Professor Boeck, of Christiania, the results of whose labors were 
widely disseminated through the medical press of Europe and America. 
The value of the observations of these and other experimentalists is rendered completely 
nugatory when it is remembered that they were unicists, or believers in only one venereal 
poison. Ilence, since it has been determined that chancre and chancroid are essentially 
distinct diseases, syphilization has lost all its scientific interest and practical value : it is an 
exploded myth which had its origin in misconception and the grossest absurdity. As 
stated in a former paragraph, it is now well ascertained that the inferior animals are in- 
susceptible of contracting syphilis, and it is equally certain that chancroid is a strictly local 
affection, and therefore incapable of contaminating the system ; moreover, when a person 
has once had syphilis, he is, as a rule, as perfectly proof against future attacks as one who 
has had measles, scarlatina, or smallpox. 
According to Boeck, whose name is indelibly associated with the history of this opera- 
tion, syphilization is justifiable at all periods of life, but should only be resorted to after 
the development of secondary symptoms; for, so long as the disease is in its primary stage, 
inoculation would be improper, as it cannot positively be determined beforehand whether 
the constitution will become tainted or not. The earlier the treatment is commenced the 
better, and the effect will always be the more prompt and decisive, when the patient has 
not been subjected to any previous mercurial course, as this renders the system more 
stubborn to its influence, and more prone to relapses. 
In performing the operation, it is immaterial whether the virus is taken from a chan- 
croid or an irritated chancre. The parts selected for the operation are the trunk and the 
inside of the thighs and arms. In a few days pustules form, the matter of which is in- VENEREAL DISEASES. 
CHAP. IX. 
serted into the skin until no further effects result, when the virus of the primary sore 
must again be employed, and the same course pursued as before, until the system is ren- 
dered completely unimpressible. It will sometimes require, says Boeck, the use of a 
new virus live or six times, before thorough constitutional immunity is secured. The 
symptoms generally begin to abate in from four to six weeks, but it may take many months 
or even an entire year before the disease is perfectly eradicated; the average period being 
about 134 days. It will be found, upon every repetition of the inoculation, that the pus- 
tules and ulcers become less and less, and, also, that they gradually lose their specific ap- 
pearance and character. 
Dr. Boeck furnished the statistics of 502 cases, treated in the hospital at Christiania, of 
which 429 took no mercury. Of the latter, 384 were completely cured. In the remainder 
the disease relapsed. He declares that the success in his private practice was still more 
flattering. 
One cannot but regret in reading the contributions of Dr. Boeck and his followers that 
so much time was misspent and so much labor wasted in an investigation that has been 
productive of so little, if, indeed, any good. The treatment to which they devoted so 
many years of fruitless toil, was not only very tedious and painful to their patients, but 
so exceedingly filthy and disgusting that, even if it had had truth on its side, it could never 
have been extensively, much less generally, adopted. Men would have shrunk from such 
an infliction. Besides several surgeons who pursued this treatment were not only severely 
censured, but prosecuted and heavily mulcted. Long before the downfall of syphilization 
as a practical matter, it was shown by Mr. Lee, of London, and Dr. Lindwurm, of Munich, 
that the alleged beneficial effects of the operation were due, not to any specific influence of 
the inoculation, but to the depurating effects of the resulting ulcers upon the system, the 
continuous suppuration serving as a salutary drain. For much interesting and valuable 
information on this and other subjects of syphilization, the reader is referred to an exhaust- 
ive paper of Dr. Owre in the London Medical Times and Gazette for 1868. 
2. AFFECTIONS OF THE LYMPHATIC GLANDS AND VESSELS. 
These affections consist mainly in induration of these structures, liable of course to be 
modified during their progress by various inflammatory accidents. More or less indura- 
tion of these bodies is present in almost every case of chancre. Ricord lays it down as a 
pathological law that a chancre cannot exist without induration of the associated lym- 
phatic glands ; “ induration,” he says, “ follows a chancre as a shadow follows a substance.” 
In this opinion most syphilographers of the present day fully concur, and yet it would be 
wrong to assert that this law has not an occasional exception. Bumstead, who affirms 
that he has never met with a chancre which was not attended by induration of the neigh- 
boring lymphatic glands, regards it as a far more reliable symptom of a chancre than 
induration of the base of the ulcer itself, inasmuch, he adds, as it is more constant and 
persistent, and less likely to be counterfeited by extraneous influences. The frequency of 
this condition of the lymphatic glands may be inferred from the statistics of some of the 
French syphilographers. Thus Bassereau found it in 355 out of 380 cases of chancre, 
the diagnosis of which was confirmed by the evolution of well-marked secondary symptoms. 
Of 265 examples reported by Fournier the lymphatic glands were affected in 260. Rollet 
collated 26 cases of artificial inoculation with the virus of syphilis performed upon persons 
previously free from this disease, in only 20 of whom induration was detected. A number 
of cases have been furnished of inoculation performed upon persons previously infected 
with syphilis, in every one of whom the operation afforded none but negative results. It 
may reasonably be supposed that gangrene or phagedena occurring very early in the pro- 
gress of chancre might oppose the development of induration, although even this admits 
of doubt; and it is also very probable that cases may arise in which the induration of the 
lymphatic glands of the groin and other regions of the body is so thoroughly masked by 
fatty matter or diseased structure as to render its detection utterly impossible. 
The glands most liable to suffer from induration are, as a rule, those in closest prox- 
imity with the seat of the original infection. Thus in chancre of the penis, urethra, 
scrotum, vulva, vagina, uterus, perineum, anus, nates, inferior parts of the abdomen, and 
the lower extremities, the glands of the groin are involved ; chancre of the lips, tongue, 
mouth, and chin, is followed by induration of the submaxillary glands; chancre of the 
eyelids affects the anteaurieular gland ; and the axillary glands suffer in chancre of the 
breast and of the upper extremity. In a case of chancre of the forefinger, Bumstead 
found a well-marked induration in the web between it and the thumb; and Sigmund long 
7 O O AFFECTIONS OF LYMPHATIC GLANDS AND VESSELS. 
299 
CHAP. IX. 
ago showed that the epitrochlear gland generally becomes enlarged and indurated when 
the disease breaks out on the hand or forearm. 
The induration of the inguinal glands usually appears as early, or nearly as early as the 
induration of the base of the sore, that is, from the seventh to the eleventh day, when it 
may be said to have attained its maximum development. In exceptional eases, it occurs 
later, but rarely, if ever, earlier. It may affect both groins, as when the chancre is multi- 
ple or situated on the middle line of the genital organs ; but in ordinary cases it is limited 
to one side. Now and then, as in chancroid, the situation is reversed, owing to the pecu- 
liar arrangement of the lymphatic vessels, those of the right side, for instance, crossing 
over to the left, and conversely. In the groin, as in most other localities, where the glands 
occur in groups, nearly all are implicated in the induration, as in fig. 80, from Cullerier, 
Fig. 80. 
the smaller, varying in size from that of a bean to that of an olive, being closely agregated 
around a larger central one. The tumor thus formed is of a hard, dense, gristly consistence, 
of an irregularly rounded or oval shape, freely movable, devoid of pain and even tender- 
ness, and without any attachment to the overlying integument, which always retains its 
normal color. The tumor, in fact, is an indolent, insensible mass, which retains its pecu- 
liar features from several weeks to several months, without, as a general rule, manifesting 
any tendency to suppuration, differing thus widely and characteristically from the course 
of a chancroidal bubo. Suppuration is not impossible, but in such an event the matter is 
small in quantity, of a thin, serous or sero-sanguinolent appearance, and insusceptible of 
autoinoculation. Of 968 cases of induration of the inguinal lymphatic glands, consequent 
upon chancre, recorded by Bassereau, Rollet, and Fournier, suppuration occurred in 
only 35. Hence, it may be laid down, as a rule, that, when an abscess forms in the groin, 
it is not the product of chancre, but of chancroid or struma, or of a non-specific inflam- 
mation. The diagnosis of this form of induration may usually be readily determined by 
the history of the case and by a careful examination of the affected region. 
Induration of the lymphatic vessels is most frequently observed upon the penis, although 
it is not peculiar to this organ. It manifests itself in the form of dense, firm, whip-like 
cords, extending from the chancre towards the root of the penis, which, however, it seldom 
reaches. Sometimes a knotty or tubereulated appearance is present. The change which 
evidently depends upon interstitial deposits in the cavity of the affected vessels, is usually 
contemporaneous with the induration of the chancre and of the lymphatic glands, and is 
characterized by its persistency, freedom from pain, and indisposition to inflammation. 
No treatment is generally necessary in these affections. Any tenderness that may arise 
during their progress will promptly yield to rest and to the application of tincture of 
iodine or of a few leeches, followed by a cooling laxative. Inflammatory irritation must be 
relieved by the ordinary antiphlogistic measures, and matter evacuated with the lancet. 
In general, the induration gradually subsides under the mercurial treatment, employed to 
cure the primary and constitutional disease, whether occurring in the lymphatic glands or 
vessels, of which it is simply one of the most constant and most persistent phenomena. 
Syphilitic Buboes. VENEREAL DISEASES. 
CHAP. IX . 
SECT. Ill SECONDARY SYI'IIILIS. 
1. GENERAL CONSIDERATIONS. 
The term secondary is employed to designate that group of’ morbid phenomena which 
manifest themselves after the occurrence of primary syphilis, the period of their evolution 
varying, on an average, from six to seven weeks from the first outbreak of the disease. 
The structures which are most liable to suffer are the cutaneous and mucous, and these 
may be attacked either simultaneously or consecutively, or one may suffer and the other 
escape, according to the condition in which they maybe at the time of the contamination. 
Secondary syphilis is always preceded by chancre. It often comes on before the 
initial lesion has disappeared ; a chancre, indeed, may, to use a figurative expression, be 
in full bloom, and continue to furnish an abundance of specific virus, and yet the consti- 
tutional disease have already made considerable, if not very serious, progress, the skin being 
perhaps covered with numerous eruptions, the throat inflamed or ulcerated, and the tongue 
affected with tubercles, thus showing thorough contamination both of the solids and fluids. 
Or, the chancre may be cicatrized, but remain hard and tender, more or less of the specific 
poison lurking in the affected tissues, ready to ferment and break out anew from the most 
trivial causes. Or, the original sore may have got entirely well, but the bubo be still 
active, either as an indurated swelling, or as an ulcer with more or less discharge. Or, 
lastly, and as is, perhaps, most commonly the case, the secondary complaint does not appear 
until some time after the primary has completely vanished, the patient having, perhaps, in 
the meanwhile, imagined himself perfectly well. 
It is generally impossible to determine, in advance, what effect a chancre may exert 
upon the system ; or, in other words, whether it will be likely to lead to mild or severe 
constitutional contamination. We are, however, warranted in assuming that a mild attack 
will follow a long incubation and a superficial chancre, and that the symptoms will be 
severe when the incubation is short and the initial lesion is deeply ulcerated. If the patient 
be stQut and robust, and, in every respect, well-conditioned, both as concerns his fluids 
and solids, at the time of the inoculation, the poison will be much less likely to do great 
harm than if he be feeble and exhausted by disease, or be laboring under the strumous or 
scorbutic cachexia. 
Secondary syphilis is, under certain circumstances, an inoculable disease. It has been 
shown, for example, that matter taken from a mucous tubercle, a condylomatous excres- 
cence, a pustular eruption, or a superficial ulcer of the mucous membrane, and, in fact, 
even the blood will, if carefully inserted into the skin of the arm or thigh, produce a 
chancre essentially similar to a primary one. The period of incubation, however, is much 
longer than ordinary, ranging, on an average, from twenty to thirty days, and the resulting 
ulcer, which is always indurated, is invariably followed by indolent enlargement of the 
neighboring lymphatic glands. 
A remarkable feature of this secondary matter is that it will not generate a chancre in 
the person furnishing it, or even in another infected individual. To be capable of receiv- 
ing the disease the subject must be free from all syphilitic taint. 
That the blood of a person affected with constitutional syphilis is inoculable is clearly 
established by the fact that the disease has been repeatedly propagated from an infected 
to a sound person by vaccination, through the agency, not of the vaccine matter, but of 
the blood ; for Viennois has ascertained that there is not the slightest danger of infection 
when care is taken to keep the lancet free from this fluid in performing the operation, or 
when the operation is done with vaccine matter destitute of blood. 
Numerous cases of this form of infection occurred during our late war; and the out- 
growth of the disease, vaccinio-syphilitic inoculation, has been made the subject of an 
elaborate and exhaustive essay by Professor Jones, of New Orleans. The sad effects of 
this mode of propagating syphilis are well illustrated in the cases that occurred at Rivalta 
in Piedmont, where an infant that had been vaccinated with infected matter communicated 
this malady to his mother and to forty-six children. One of the children thus contami- 
nated imparted the contagion to his wet-nurse and to seven children. The fact that a 
tooth transplanted from the mouth of an infected person into that of a healthy one is 
capable of communicating syphilis was established long ago by the observations of John 
Hunter and other practitioners. Even the precaution of rubbing the surface of the tooth 
previously to its insertion did not always prevent contamination. The infecting character 
of the mucous tubercle of the tongue and lip is universally admitted. Indeed, not to CHAP. IX. 
AFFECTIONS OF THE SKIN. 
301 
carry these illustrations any further, there is every reason to believe that many of the 
natural and abnormal secretions of every organ, tissue, or structure affected with syphilis 
are capable of propagating the disease, although it nmy be difficult to establish the fact by 
artitical inoculation. From some experiments performed by Mireur it appears that 
the semen of a person affected with chancre and secondary symptoms is not inoculable. 
In four persons thus treated no specific disease followed. 
In 1877 a large number of cases of syphilis occurred in this city and at Reading from 
tattooing the arms on different persons, the operator, who was affected with mucous tubercles 
of the tongue, using his saliva for mixing his materials. An account of these cases from 
the pen of the late Dr. F. F. Maury and Dr. Dulles, will be found in the American 
Journal of the Medical Sciences for January, 1878. 
Secondary syphilis is not only inoculable, but also transmissible from the parent to the 
offspring, the result declaring itself in a great variety of affections, more or less destruc- 
tive to the new being, sometimes before, at other times not until after, birth. The very 
stream of life is thus poisoned, so that all those who are affected by it are destined to suffer 
from its effects, this being at least one of the ways in which “God visits the iniquity of 
the fathers on their children down to the third and fourth generation.” The fact that the 
disease is transmissible shows that the whole system of the individual is impregnated with 
the specific poison, every globule of blood and every particle of solid matter being im- 
pressed by it. It is this pervasive, universal influence that has led to the opinion, now 
very general among syphilographers and practitioners, that constitutional syphilis is 
seldom, if ever, completely eradicable. Once implanted in the system, its germ is prob- 
ably indestructible. 
Secondary syphilis is usually ushered in by well-marked constitutional phenomena. 
From eight to fifteen days before there is any evident disease, the patient feels uncom- 
fortable and unwell; he is irritable, gloomy, desponding, and unable to apply himself to 
business; his countenance has a dull, muddy aspect; his hair is dry and rough; his 
limbs and joints are sore and stiff; his appetite is impaired; the bowels are costive, or 
alternatively costive and relaxed ; the urine is scanty and high-colored ; exercise soon 
fatigues; headache is often present; and the sleep, disturbed by frequent dreams, is un- 
refreshing. Gradually, after the lapse of a few days, or, it maybe, suddenly, he is seized 
with chilly sensations, or actual rigors, followed by high fever, or by fever and profuse 
sweats. When the disease is fully established, an increase of temperature of several de- 
grees is often noticeable, especially in the afternoon and evening; and cases occur, 
although rarely, in which the fever assumes an indistinct periodical type. The attack, 
constituting what is called syphilitic fever, is manifestly an effort of the system to elimi- 
nate the specific poison, and the tissues upon which it usually expends itself are, as was 
previously stated, the cutaneous and mucous, together with the posterior cervical glands, 
the morbid phenomena of the former exhibiting themselves in various eruptions, and of 
the latter in ulcers of the throat and in mucous tubercles of the tongue and mouth. The 
iris also frequently sutlers from secondary involvement. The blood is always more or less 
affected. As a rule, syphilis diminishes the number of red corpuscles below the normal 
standard, while the white are, in very severe forms of the malady, greatly increased. 
2. AFFECTIONS OF THE SKIN. 
The syphilitic affections of the skin, the syphilides, as they have been termed by A1 i- 
bert, and the syphilodermata of more recent authors, occur under at least six varieties of 
form, the exanthematous, scaly, vesicular, papular, pustular, and tubercular. Of these, 
however, the last three, from their severity and late appearance, may be regarded as 
appertaining rather to the tertiary order of phenomena than to the secondary. Of the 
other three, two are not unfrequently coincident with the primary disease, although, in 
general, they do not come on until some time afterwards. To these syphilides may be 
added certain pigmentary changes originally described by Hardy, and more recently by 
Fournier, Pillon, Drysdale, Fox, Atkinson, and others. The syphilitic eruptions nearly 
alwTays pursue a chronic course, are more or less circular in their form, and usually exhibit 
a characteristic copper color, especially in their earlier stages ; for, after they have existed 
for some time, they are very apt to assume a grayish, muddy, or bronze appearance, 
owing to some modification in the pigmentary matter of the skin. Although occurring 
upon all parts of the cutaneous surface, they are usually most conspicuous upon the fore- 
head, nose, cheek, back, and shoulder, together with the inside of the arm and thigh, and 302 
VENEREAL DISEASES. 
are attended or followed by thin, grayish scales, hard, thick, greenish scabs, narrow, 
superficial cracks, or well defined ulcers. 
Syphilitic cutaneous diseases are generally easily distinguished from ordinary skin dis- 
eases by, first, the history of the case, especially the presence or absence of chancre, or 
chancre and bubo ; secondly, by the concurrence of lesions of the cutaneous and mucous 
textures ; thirdly, by the pinkish-red, yellow-brownish, or faint copper color of the affected 
surface, dissipated by pressure in their earlier stages, but gradually shading off into a 
darker permanent hue ; fourthly, by the total absence of itching, or of itching in a much 
milder and more evanescent form than in common skin affections ; fifthly, by their ten- 
dency, at least in many cases, especially when they appear as papular and erythematous 
rashes, to assume a circular, rounded, or ring-like form ; sixthly, by their polymorphism ; 
and, lastly, by the fact that syphilitic eruptions are often found in regions of the body in 
which ordinary cutaneous diseases rarely, if ever, occur. Stress has been laid by certain 
authors upon the odors arising during the progress of some of the syphilides, especially 
the ulcerating; but, although the smell may occasionally be offensive, especially if clean- 
liness be neglected, it is never characteristic. All these affections are, as is now well 
known, liable to be modified in their evolution, course, and termination by various inter- 
current acute diseases, as gout, rheumatism, pneumonia, and pleurisy; and also by the 
use of mercury and other remedies given for the relief of the primary maladies. 
1. In the exanthematous form, the spots are of a reddish, pinkish, or pale copper color, 
circular in shape, and from the size of a dime to that of a twenty-five cent piece, the 
intervening surface being of a muddy, dusky aspect. Although they sometimes cover 
nearly the whole body, they are generally most prominent on the trunk and extremities; 
they are rarely confluent, do not disappear under pressure, and usually pass off with a 
slight desquamation of the cuticle. There is a variety of this eruption in which the spots 
are much smaller, more irregular in shape, and of a brighter red, the color resembling 
that of a new copper coin. From this circumstance, and from the eruption being often 
somewhat confluent, like measles, it is generally known by the name of roseola. In nei- 
ther of these forms is there any actual elevation of the skin. 
The syphilitic exanthem may be looked for in from six to twelve weeks after the ap- 
pearance of the initial lesion. It often comes on before the disappearance of the primaiy 
disease, sometimes suddenly, and without any decided premonitory symptoms; at other 
times gradually, and with considerable pyrexial disturbance. As the eruption fades it 
loses its reddish tint, and assumes a dingy, dirty, dusky, or grayish aspect. Its duration 
varies from ten days to six weeks. Its gradual disappearance, and its coincidence with 
chancre, bubo, cervical adenitis, and other marks of syphilis, either primary or secondary, 
together with the absence of local distress, as itching and smarting, readily distinguish it 
from measles and other cutaneous affections. Syphilitic fever is absent in at least one- 
fourth to one-third of the cases in this form of the disease. On the other hand, there are 
few cases in which there is not marked enlargement of the lymphatic glands in different 
parts of the body, especially of those of the posterior cervical region. 
2. The scaly variety of syphilis, or psoriasis, generally appears without any febrile dis- 
turbance, from two to six months after the primary disease; it is always remarkably 
chronic, lasting frequently for months together, and is commonly associated with ulcera- 
tion of the throat and palate, iritis, and affections of the bones and joints; forming, in 
this event, a kind of connecting link between the secondary and tertiary stages of the 
constitutional infection. 
The eruption, as the name implies, manifests itself in distinct scales, or thick, hardened 
portions of epidermis, of a dull, opaque, grayish appearance, resting upon a copper-colored 
base. It generally appears in separate patches, which, although liable to occur on all 
parts of the cutaneous surface, are most common on the forehead, scalp, face, forearms, 
palm of the hand, and sole of the foot, in the latter of which they often acquire a remark- 
able thickness. Each individual spot is from three to six lines in diameter, of a rounded 
shape, ordinarily isolated, rough, and somewhat elevated beyond the adjoining level. 
The scale is hard, whitish or grayish, and slightly adherent ; the skin underneath has a 
tendency to ulcerate, or to form cracks and fissures, and when, by this means, its integ- 
rity is destroyed, the affected surface becomes covered with a thick, dry, brownish crust. 
When the part has cicatrized, a whitish spot, somewhat depressed at the centre, marks 
the original site of the disease. 
3. The vesicular variety of syphilitic disease is very uncommon ; it is, in fact, by far 
the rarest of all the syphilides. It usually begins coincidently with the latter stages of 
the primary sore, or soon afterwards, in minute, circumscribed pimples, scattered over 
CHAP. IX. AFFECTIONS OF THE SKIN. 
303 
CHAP. IX. 
different parts of the body, to which soon succeed small vesicles, occupied by a trans- 
parent, serous fluid, and surrounded by a reddish, copper-colored areola. From the 
fact that many of these are traversed by a hair, it is not improbable that they have 
their origin in the hair follicles. Their progress is slow, and their contents are either 
absorbed, or transformed into thin scales, or scabs, which, falling off at different inter- 
vals, leave the skin of a dingy, yellowish hue, with small, depressed, temporary cica- 
trices. The vesicles, which may be small and pointed, large and globular, isolated or 
grouped, are occasionally so numerous as to cover nearly the whole surface of the body. In 
general, they are most common on the neck, chest, and extremities, especially the supe- 
rior, their occurrence on the face and head being very infrequent. They usually coincide 
with syphilitic disease of the throat and nomadic pains in the bones and joints; a cir- 
cumstance which, together with their copper-colored base, readily distinguishes them 
from ordinary vesicles. 
4. Syphilitic pustules are circumscribed elevations of the skin, occupied by pus, or 
sero-purulent matter, and possessing a strong tendency to ulcerate. Although they occa- 
sionally coexist with the primary disease, they seldom appear until a long time after, 
and, therefore, generally appertain to the third order of symptoms, their presence being 
always denotive of profound constitutional contamination. Their size ranges from a pea 
to that of a small hazel-nut. In their shape they are conical, oval, pyriform, rounded, or 
flattened, with a minute central depression ; and there are few instances in which these 
different varieties do not coexist. Their number is often immense, hundreds being scat- 
tered over a small extent of surface; and, as they form successively, they may be seen 
and studied in every stage of their development. Each pustule reposes upon a hard, 
copper-colored base, and occupies the deep layer of the dermis around the hair and seba- 
ceous follicles. 
After remaining for a short time, the contents of the pustule escape, concrete, and 
form hard, thick scabs, of a dark brownish, or olive-brown color, pretty firmly adherent, 
and sometimes circularly furrowed. In the more simple cases, the scabs soon fall off, 
leaving merely a chronic induration, a livid, dusky, or grayish stain, or a small cica- 
trice ; but, in the more severe, deep, circular, characteristic ulcers are exposed, with a 
foul, grayish bottom, and a hard, purple, and well-defined margin. In cases of the 
latter description, the scabs are frequently renewed, and are finally succeeded by round, 
indelible scars. 
The pustular syphilide comprises acne, impetigo, and superficial ecthyma, and the 
pustules themselves may occur in groups, or be disposed separately, without any tendency, 
as is sometimes the case with the other, to become confluent. The matter of these pustules 
is capable of producing chancre by inoculation. 
The pustular form of syphilis is not unfrequently associated with the tubercular and 
papular, but rarely with the roseolar and squamous. Severe constitutional disturbance 
is generally present, and, indeed, the suffering may be so great as to destroy life, the 
health being gradually undermined by the excessive pain and irritation of the eruption 
and its sequela;. 
fi. Papular syphilis, or lichen, is characterized by the occurrence of small, hard, solid 
elevations, containing no fluid, and terminating nearly always in desquamation, seldom in 
ulceration, or in the formation of scabs. There are two varieties of the affection, one of 
which is acute and primary, the other chronic and secondary. 
In the first variety, the eruption appears simultaneously on different regions of the 
body, and is completed in about forty-eight hours from the time of its invasion. The 
papules are extremely small, disjointed, or grouped, of a red copper color, and of a 
slightly conical shape, being surrounded, here and there, by violet areolae, which are often 
confluent, and give the surface a characteristic tinge. Ulceration rarely attacks these pa- 
pules; they soon disappear, and are followed by a furfuraceous desquamation of the cuticle. 
In the other variety, the eruption is developed in a slow, successive manner, being 
announced by small yellow spots, which are particularly numerous on the forehead, scalp, 
and extremities. The papules are of a light copper color, larger than the preceding, flat, 
of the size of small beans, grouped, and devoid of an areola. In time, the summit of each 
elevation is covered with a dry, grayish pellicle, which is regenerated as fast as it desqua- 
mates until the disease finally entirely subsides. Meanwhile, the skin between the agglo- 
merated papules undergoes important changes; it assumes a dingy yellowish color, has a 
dry, shrivelled aspect, and is the seat of a constant exfoliation of the cuticle. 
The papular eruption is often complicated with other syphilitic affections, as inflamma- 
tion and ulceration of the throat, iritis, and nocturnal pains in the larger joints. VENEREAL DISEASES. 
CHAP. IX. 
Occasionally it coexists with an imperfectly healed chancre or bubo, or with the scaly, 
pustular, or tubercular form of the disease. Iritis, in particular, is an exceedingly common 
accompaniment. 
6. Of the tubercular ibrm of syphilis, the most formidable of all, there are two varieties, in 
the milder of which the eruption consists of small, red, copper-colored eminences, varying, 
ordinarily, in size between that of a mustard seed and a pea. Of a rounded, flattened, or 
conoidal shape, they are either isolated, assembled in groups, or arranged in more or less 
perfect circles; they are smooth and polished, cause little or no pain, and soon become 
covered with a dry, scaly crust, which is generally reproduced as fast as it falls off. 
In the more aggravated form, the tubercles are inordinately large, of a deep violet hue, 
and encircled each by a well-marked, copper-colored areola. After continuing thus for 
some time, varying from a few weeks, to several months, they inflame, suppurate, and are 
finally replaced by deep, foul, painful, irregular ulcers, reposing upon a hard, purple base. 
The thick scab which usually covers these erosions is repeatedly renewed, showing, when- 
ever it is detached, an extension of the ravages of the sore. When the tubercles are 
numerous, the ulcers, running together, often acquire a frightful size, and, on healing, 
leave white, disfiguring cicatrices. 
Pigmentary changes of the skin are most frequent on the side of the neck, but no region 
is entirely exempt from them. Fournier met with them in the former situation in twenty- 
nine out of thirty cases. The color is usually more or less brownish, or dirty, milk-like, 
unacompanied by any elevation or depression of the affected surfaces, coming on gradually 
in patches from the size of a split pea to that ot-a twenty-five cent piece, circular, ovoidal, 
or more or less irregular in shape, discrete or confluent, generally supervening late in the 
disease, pursuing essentially a chronic course, uninfluenced by antisyphilitic treatment, 
and finally disappearing, after months or evdn years, without any appreciable alteration 
in the skin. In some cases the spots have a festooned appearance, and Dr. Fox, of New 
York, has given a drawing in which the discoloration presented itself in the form of a 
distinct ring with a dark central speck. The lesion, which is most common in women of 
a light complexion, is liable to be confounded with leucoderma, chloasma, and several 
other affections of the skin, from which it may, however, in general be easily distinguished 
by its deeper hue, its situation, and by the history of the case. 
Syphilitic ulcers of the skin are characterized by their rounded shape and excavated 
appearance, the bottom having a foul, grayish aspect, while the edges are red, ragged, 
and inflamed. Their tendency is to spread and undermine the surface, several not 
untrequently running into each other. The discharge is thin, sanious, or ichorous, fetid, 
and more or less profuse and irritating. These ulcers usually have a copper-colored 
base, and they arc nearly always sequelae of pustules, or tubercles. They occasionally 
exist in great numbers. The scars left by these ulcers are permanent, of a whitish 
color, and extremely liable to break out into open sores on the application of the 
slightest irritant. 
Treatment The treatment of secondary cutaneous syphilis may be divided into common 
and specific, the first being of a general antiphlogistic character, while the second has for 
its object the neutralization or destruction of the virus upon the action of which the affec- 
tion more particularly depends, and which, so long as it continues, exposes the system 
constantly to new outbreaks of the disease. In most cases it will be found to be advan- 
tageous to begin the treatment with antiphlogistic remedies ; for, although they may not 
always, or perhaps even very generally,eradicate the poison, the salutary impression which 
they make upon the system, by ridding it of its impurities, and restoring the secretions, 
greatly paves the way for the more prompt and efficient operation of any specific 
measures that may afterwards be deemed advisable. A disregard of this rule is 
probably one of the chief reasons why the mercurial treatment of syphilis is so often 
followed by severe tertiary symptoms, the system not being properly prepared, by a course 
of diet, baths, purgatives, and other remedies, for the reception and beneficial action of 
the mineral. 
Syphilitic fever should be combated upon the same general principles as any other 
sympathetic fever. If the symptoms run high, as indicated by the state of the pulse and 
skin, and the patient is young and plethoric, blood may advantageously be taken from 
the arm, followed by saline, and antimonial preparations, the bowels having previously 
been opened by a brisk cathartic. The action of the medicines should be promoted with 
tepid drinks, and, if there be much pain and aching in the back and limbs, a Dover’s 
powder, or an anodyne and diaphoretic draught will be beneficial. The duration of the 
fever is usually very short, the disease often yielding to very simple measures. CHAP. IX. 
ALOPECIA. 
305 
When eruptions appear upon the skin, the most efficient treatment, according to my 
experience, is the antimonial, or antimonial and saline. The quantity of tartar emetic 
given at each dose must vary from the fourth to the eighth of a grain, repeated every three, 
four, or five hours, with the precaution of avoiding decided nausea, which is hardly ever 
desired. The object simply is to produce a sedative and alterant effect. It may be 
administered by itself, as in the milder forms of secondary cutaneous affections, or be 
variously combined with other articles, as sulphate of magnesium when there is constipa- 
tion, aconite when there is much arterial excitement, or morphia when an anodyne and 
diaphoretic action is indicated. The salutary operation of the medicine will be greatly 
promoted by the daily use of the tepid bath, by diluent drinks, and by a strict observance 
of the antiphlogistic regimen. 
IIow tartrate of antimony and potassium operates in producing its salutary effects in 
secondary syphilis of the skin has not been determined. It is not improbable that it may, 
as mercury is supposed to do, neutralize the poison of the disease by divesting it of its 
zymotic qualities; or it may act simply as an eliminator, by furnishing an outlet for the 
poison through the various emunctories, upon all of which this medicine is known to exert 
more or less influence. 
Tartarized antimony is particularly worthy of confidence in the treatment of secondary 
syphilis of the skin, but it may also be advantageously exhibited in the various affections 
of the mucous membranes, although its effects here are generally less apparent. The remedy, 
however, is not infallible, and hence, when the disease is unusually rebellious, it should 
be replaced by mercury, given in the same manner, and with the same restrictions as in 
the primary form of the disease. Without being disposed, then, to discard mercury 
altogether, I am satisfied, from ample experience, that its use may very properly be 
limited to an exceedingly narrow circle of cases of secondary syphilis, and that, whenever 
it is rendered necessary, its action will be greatly promoted by the previous employment 
of tartar emetic. Calomel is, according to my experience, the best form in which it can 
be exhibited ; the dose should vary from the fourth to half a grain, repeated twice or thrice 
in the twenty-four hours, properly guarded with opium, and carefully watched. Bichloride 
may be used when the system has been seriously damaged by intemperance and other 
debilitating influences. 
With respect to the topical treatment, in the event of ulceration and discharge, cleanli- 
ness is of paramount importance, and is best effected by frequent ablutions with simple 
water or slightly medicated fluids, care being taken that they do not fret or irritate the 
skin. Cataplasms and warm-water dressings are among the more soothing local remedies. 
Various lotions are of service, as weak yellow-wash, and solutions of nitrate of silver, 
sulphate of copper, tannic acid, and glycerine. When the ulcers are obstinate, mercurial 
fumigations may be advantageously used. Ecthymatous pustules should be opened, and, 
after their contents are discharged, the cavity should be gently stimulated with acid 
nitrate of mercury or solid nitrate of silver. When a papular eruption is seated upon 
exposed parts, as the face and hands, its disappearance may be hastened by the local 
application of a weak ointment of ammoniated mercury, or the five-per-cent, oleate of 
mercury. 
3. ALOPECIA. 
During the progress of syphilis the hair of the scalp occasionally falls off, generally 
within the first six, eight, or ten weeks from the appearance of the primary sore, with 
which, consequently, it is not unfrequently coincident. The affection, which is known 
as alopecia, usually occurs in circular disks, of variable size, and of a well-marked copper 
color. It is commonly partial, showing itself in distinct patches, of which several may 
exist simultaneously, or as fast as one gets well another may succeed, and thus the 
malady may proceed until it has travelled over the greater portion of the scalp ; or, 
instead of this, nearly all the bulbs may suffer at once, and the hair drop off in great 
numbers, leaving the head ultimately nearly completely bare. When the system is 
saturated with the specific virus, not only the hair of the scalp, but also the beard, the 
eyebrows, and the hair of the rest of the body may disappear. Two well-marked cases of 
this universal alopecia, both in young men who had suffered from indurated chancre 
upon the head of the penis, have fallen under my observation. In one the desquamation 
was associated with roseola and sore throat, and was never followed by a reproduction of 
hair anywhere ; the patient, after having lingered for several years under the exhausting 
effects of rupia and nodes, died in a state of marasmus. In the second case, the alopecia VENEREAL DISEASES. 
was succeeded by syphilitic sarcocele, and the hair was eventually regenerated upon the 
scalp, although it remained always stunted, and was remarkably coarse, stiff, and sparse. 
The first sign of baldness is usually a loss of the soft and glossy state of the hair, which 
becomes dry, stiff, and brittle, breaking off very readily under the use of the comb. After 
a little while it is observed to fall off in great abundance; and the scalp is not only remark- 
ably harsh and scurfy, but covered with muddy, dingy, or dusky, copper-colored blotches, 
generally of a circular shape, and apparently, although not in reality, somewhat elevated 
above the adjoining surface. Fever occasionally accompanies the affection ; and pains in 
the bones and joints, seemingly of a rheumatic nature, ordinarily characterize the progress 
of the case. Regeneration of the hair, partial or complete, may generally be expected, 
even under apparently the most adverse circumstances. 
Baldness, as an effect of syphilis, is a grave occurrence, and should, if possible, be 
promptly arrested. The first thing to be done is to cut off the hair, not closely, but suffi- 
ciently to admit of the requisite attention to cleanliness and medication. Shaving of the 
scalp is seldom necessary. The treatment, directed more especially to the relief of the 
diseased hair bulbs, must be essentially of a stimulating character, as the object is to 
impart tone and vigor to the whole of the affected surface. In the more simple cases 
mild lotions of alcohol and spirit of hartshorn, eau de Cologne and compound spirit of 
lavender, or alcohol, glycerine, and tincture of cantharides, either in equal, or in different 
proportions, may be advantageously used. Another excellent wash is a solution of tannic 
acid and sulphate of copper in equal parts of bay-rum and water, six grains of the former, 
and half a grain of the latter being added to the ounce of fluid. The application should 
be made twice in the twenty-four hours, the friction being performed with the hand and 
fingers, and steadily continued until there is a glow upon the surface. The scalp should 
be washed every morning with warm water and Castile soap, and well combed imme- 
diately after to promote cleanliness and the dislodgment of dandriff. 
If soreness of the scalp exist, or if there be eruptions, papules, tubercles, or numerous 
dry and adherent scales, the most eligible application is a pomade made of ointment of 
nitrate of mercury, diluted with from seven to ten parts of simple cerate, mixed with a 
few drops of oil of jasmine and a little Cologne water, and thoroughly rubbed into the 
roots of the hair night and morning. Along with these means special attention should be 
paid to the state of the system, and, if the case threaten to be obstinate, or if the alopecia 
coexist with an indurated, indolent, or badly-healed chancre, the patient should be brought 
as promptly as possible under the gentle influence of mercury. 
4. LYMPHATIC ADENITIS. 
The posterior cervical glands generally suffer at an early period of the constitutional 
involvement, becoming enlarged and somewhat tender, although never very painful, and 
rolling, when pressed with the finger, like so many little elastic balls under the integu- 
ment. The swelling is generally most conspicuous in the glands along the upper two- 
thirds of the posterior border of the sterno-cleido-mastoid muscle, and along the root of 
the hairy scalp, extending frequently as far outwards as the mastoid process on each side. 
It is essentially of a chronic nature, often lingering for many weeks, and never terminating 
in suppuration. Diagnostically considered, this species of adenitis, from the constancy of 
its presence, is of great value, but from the want of practical tact to detect it, it is extremely 
liable to be overlooked. The number of glands involved seldom exceeds two or three, and 
in many cases the disease is apparently limited to a single one. Its occurrence is most 
common in young subjects, and it occasionally manifests itself at so late a period of the 
disease that it may then be considered as belonging to the tertiary rather than to the 
secondary order of symptoms. 
In syphilis of the lips, tongue, chin, throat, palate, and tonsils, there is not unfrequently 
an enlarged and engorged condition of the glands at the base and angle of the jaw ; and 
a similar affection of the gland of the arm immediately above the internal condyle of the 
humerus, between the biceps and triceps muscles is occasionally met with. Marked 
disease of the axillary glands, as an effect of constitutional syphilis, is very uncommon. 
Syphilitic adenitis generally disappears under the treatmeat directed for the relief of 
other secondary affections. The enlarged glands may be rubbed twice a day with mild 
mercurial ointment or ammoniated liniment, or painted with dilute tincture of iodine. If 
much induration exist, the most eligible remedy will be gentle mercurial inunction. 
CHAP. IX. AFFECTIONS OF THE MUCOUS MEMBRANES. 
307 
CHAP. IX. 
5. AFFECTIONS OF THE MUCOUS MEMBRANES. 
Secondary syphilis of the mucous membranes generally declares itself within a short 
time after the cure of- the primary sore, and sometimes even before this has completely 
disappeared; existing at one time in association with secondary affections of the skin, and 
at another, and perhaps more commonly, independently of them. From four to eight 
weeks is the average period of the evolution of the disease when it attacks these struc- 
tures. What is very remarkable is the extent of surface over which it may spread, there 
being no visible portion of the mucous membranes upon which it has not been observed. 
The parts, however, which are most prone to suffer are the tonsils, palate, pharynx, tongue, 
cheeks, and lips. It rarely extends into the windpipe. No dissections of a satisfactory 
nature have been made tending to show that the lining of the stomach and bowels ever 
participates in the morbid action, but it is certain that well-marked signs of the malady 
have been repeatedly witnessed at the anus, and in the lower part of the rectum within 
the first inch or inch and a half of that tube. In the male secondary phenomena sometimes 
appear upon the foreskin and head of the penis, while in the other sex they are liable to 
occur upon the vulva, vagina, and uterus. Their presence has not been detected in the 
respiratory and urinary organs, and is, therefore, altogether a matter of conjecture, to be 
settled by future observation. From the remarkable relations existing between the skin 
and mucous membranes, and the fact that syphilitic affections of the former are liable to 
occur in all parts of its extent, it is not improbable that the latter may suffer in a similar 
manner, although perhaps not in an equal degree, some portions almost entirely escaping, 
while others are peculiarly prone to receive and harbor the specific virus. 
Secondary affections of the mucous tissue occur in various forms; at one time, or in one 
place, as an erythematous disease, at another as an elevation or tubercle, and, again, as 
a distinct ulcer, crack, or fissure; depending, doubtless, upon some peculiar modification 
of the structure of the suffering part, some change in the action of the poison, or some 
idiosyncrasy of the individual. In the mouth and throat, where these affections are most 
common, it is not unusual to notice their coexistence, mere inflammatory redness with or 
without plastic deposit going on at one point, ulceration at another, and the formation of 
a tubercle or mucous patch at a third. 
Syphilitic erythema is observed chiefly in the throat, affecting the arches of the palate, 
tonsils, uvula, pharynx, and perhaps the root of the tongue. In rare cases it extends to 
the roof of the mouth. It may present itself as a diffused inflammation, or in the form of 
distinct patches, generally of a circular or oval figure, from the size of a gold dollar to that 
of a twenty-five cent piece, the intervening surface being apparently quite healthy. The 
color, in the early stage of the disease, resembles that of a new copper coin, but it gradu- 
ally loses its bright, fiery hue, shading off into dark bronze, as the morbid action declines. 
In cases of long standing and unusual severity, the discoloration is of a deep flesh-color 
and conjoined with marked thickening of the mucous membrane, along with a tendency 
to ulceration. Deposits of lymph are not uncommon upon the inflamed surface, even 
when the disease is not at all active; occurring in small aphthous-looking specks, in 
patches of considerable size, or in circular rings, more or less firmly adherent, and of a 
pale orange tint. 
This affection which bears the closest resemblance to erythema of the skin, generally 
exists without the consciousness of the patient, as there is no soreness of the throat, diffi- 
culty of deglutition, or constitutional disturbance. All is quiet and passive, the discovery 
of the disease being perhaps purely accidental. . It of course denotes only a very slight 
taint of the system. It is liable to appear within the first four or five weeks after the 
primary sore, and, consequently, not unfrequently before this is healed. 
Ulcers of the throat assume various appearances, and involve different structures, but 
more particularly the uvula and tonsils, arches of the palate and back of the pharynx, 
affecting these parts either separately or conjointly. They occur principally in two varie- 
ties of form, the superficial and excavated. 
The superficial ulcer is frequently multiple, several occurring together, either in close 
proximity, or scattered over the inflamed surface. Its appearance is either that of an 
erosion, or of a cavity writh well-defined, ragged edges, rather sharp, and often somewhat 
undermined: its surface is covered with a white, yellowish, or greenish, tenacious and 
adherent lymph : the parts around, although red and irritated, are free from induration. 
The most common sites of this variety of sore, which now and then assumes a serpiginous 
character, are the arches of the palate, uvula, and pharynx. It generally comes on early 
after the appearance of the primary sore, and often coexists with it. VENEREAL DISEASES. 
CHAP. IX. 
The excavated ulcer looks, as the name denotes, as if it had been made with a punch, 
or dug out of the tissues with a sharp instrument. J ts edges are steep, everted, or ragged, 
like those of the Hunterian chancre, and they are surrounded by a hard, inflammatory, 
copper-colored base. The surface is usually encrusted with a greenish, muddy, or yellow- 
ish lymph, which gives it a foul, unhealthy aspect. The discharge is thin and ichorous. 
The excavated sore is always most distinctly marked on the tonsils, where it sometimes 
acquires an immense size, and is generally accompanied by extensive inflammation of 
the surrounding parts. It is often seen during the progress of the primary disease, and is 
liable to be associated with some of the earlier forms of cutaneous eruptions, particularly 
the exanthematous and scaly. 
Secondary syphilitic ulcers of the throat are liable to phagedenic and gangrenous action, 
in the same manner as primary sores, and apparently from similar causes, the state of 
the system and mode of life of the patient mainly contributing to change their character. 
From the superaddition of this action, extensive destruction of the soft palate may result, 
followed by difficulty of deglutition and important alterations of the voice. Ordinary 
syphilitic ulceration of the throat, even when considerable, is not always attended by well- 
marked local and constitutional symptoms; the disease, in fact, is often remarkably insidi- 
ous in its approaches, and may, therefore, have made great progress before its presence 
is even suspected. The excavated form of the affection is generally accompanied with 
extensive swelling, pain, and difficulty in swallowing, enlargement of the cervical lym- 
phatic glands, and more or less febrile disturbance. When the tonsils are the seat of the 
lesion the tumefaction may be so great as to cause serious obstruction to respiration. 
Small ulcers, crevices, and fissures, of a secondary nature, are sometimes met with on 
the lips, especially at the corners of the mouth, the insides of the cheeks, and on the 
tongue; generally superficial, indisposed to spread, and attended with but little uneasi- 
ness sind dischsirge. Occasionally they have abrupt edges and a hardened base. Their 
diagnosis must necessarily be difficult, the only reliable sign being their coexistence with 
other marks of syphilis, either primary or secondary. 
Mucous tubercles occur most commonly upon the tongue, lips, inside of the cheek, ton- 
sils and palate, as slight elevations of the mucous surface, generally of an irregular oval 
or elongated shape, and of a whitish hue, as if the secretion of the part had been discolored 
with nitrate of silver or partially coagulated albumen. Upon taking hold of them 
with the thumb and finger they are found to be more or less hard, not unlike indurated 
chancres, and remarkably tolerant of manipulation, even firm pressure rarely causing any 
decided pain. The size of the spots is variable, ranging from a pea up to that of a twenty- 
five cent piece ; they sometimes exist in considerable number, and then they occasionally 
become confluent. If unrestrained, they may give rise to ulceration, either superficial, 
or of a deep, excavated character, with steep, callous edges. 
This variety of syphilitic affection finds its analogy in the condylomatous excrescences 
which are so liable to form about the anus, perineum, and vulva, from the action of the 
syphilitic virus. As it usually comes on without any pain, its discovery is often purely 
accidental. The most reliable diagnostics are the peculiar color and feel of the affected 
part above referred to, and the coexistence of syphilis in other localities, particularly the 
throat and skin. Not unfrequently traces of the primary disease will be found either in 
an open sore, or in the indurated cicatrice of a recently healed chancre. 
In the female mucous tubercles are frequently met with on the inner surface of the labia 
and nymplne, the vagina and uterus, forming whitish, grayish, or opaline spots, of an 
elongated, ovoidal shape, coming on soon after the appearance of the initial sore, and 
often terminating in ulceration, sometimes superficial, at other times deep. Fully one- 
half of the women who suffer from constitutional syphilis are affected with mucous tuber- 
cles of the genital organs. Patches of this kind are occasionally found between the toes, 
behind the ears, on the perineum, on the scrotum, and, above all, around the anus. Of 
130 cases of this disease in men, reported by Bassereau, 110 occurred in this situation. 
In women it is most common on the vulva. The infectious character of these bodies has 
been clearly established by experiments and clinical observation. 
Treatment These mucous affections being all of a kindred character, their treatment 
must be conducted upon the same general principles. If the patient be at all plethoric, 
antiphlogistics will probably be necessary, blood being taken either by the lancet or by 
leeches from the vicinity of the inflamed parts, and the depletion followed by active 
purgation and the use of antimonial and saline preparations, rendered anodyne and dia- 
phoretic by the addition, to each dose, of a small quantity of morphia. Light diet and 309 
CHAP. IX. 
TERTIARY SYPHILIS. 
perfect quietude are enjoyed. In the milder cases of these diseases the most simple con- 
stitutional means will generally suflice, no drain upon the system of any kind being necessary. 
The most suitable local remedies are nitrate of silver in substance, or acid nitrate of 
mercury, variously diluted, and applied at longer or shorter intervals, according to the 
exigencies of each particular case. The first of these articles generally answers best in 
my hands when there is no breach of continuity, the affected surface being carefully 
touched once every forty-eight hours, some mildly astringent gargle, or simple mucilaginous 
fluid, being employed in the intervals. When the part is ulcerated the caustic must be 
used more boldly, as well as oftener; although, under such circumstances, I usually give 
a decided preference to the acid nitrate of mercury, diluted with eight or ten times its 
bulk of water, and applied very gently by means of a large camel-hair pencil, or a very 
soft linen mop. Not only the sore, but also the inflamed surface around, should be treated 
in this way, regularly every twenty-four hours, until there is a decided improvement in 
the disease. Hardly any secondary ulcer of the throat, or tongue, can withstand such a 
remedy beyond six or eight days, while in many cases it yields in a much shorter time. 
As soon as the reparative process begins, the acid is used less frequently and in a much 
more diluted state. When the acid nitrate of mercury is not accessible, a good substitute 
will be found in nitric, carbolic, or hydrochloric acid. Sulphurous acid, one drachm to 
the ounce of water, used in the form of a spray, is also a valuable local application. 
The gargle which 1 usually prefer in ulcerated sore throat is a mixture of pyroligenous 
acid and water, from one to two drachms of the former to half a pint of the latter, well 
sweetened with honey, and used five or six times in the twenty-four hours. Weak solu- 
tions of subacetate of copper and tannic acid, of tannic acid and glycerine, of nitric acid, 
and of chlorinated sodium also answer an excellent purpose. 
Mucous tubercles generally yield to a few applications of solid nitrate of silver, aided 
by astringent gargles, suitable purgation and light diet. Similar means usually suflice 
for the cure of superficial abrasions, excoriations, and fissures of the lips, cheek, anus, 
vagina and anus. 
Mercurialization is necessary only in particular cases. The remedy is generally called 
for when there is an excavated ulcer, or an ulcer possessing an extraordinary degree of 
indolence, or indolence and induration. The simple, superficial sore rarely requires such 
a remedy; and it is of course withheld when there is a tendency to phagedena or gan- 
grene in a broken, anemic state of the system. Under such circumstances tonics, a 
generous diet, and nutritious drinks, with change of air, take the place of mineral. 
SECT. IV TERTIARY SYPHILIS. 
1. GENERAL CONSIDERATIONS. 
When the specific poison has deeply penetrated the system, and is, as it were, inlaid in 
its different structures, as well as thoroughly commingled with the blood, the effects which 
it produces constitute what is denominated tertiary syphilis. The boundary line, how- 
ever, between the secondary and tertiary groups of phenomena is not always well defined, 
the former affections often running, by gradual and insensible gradations, into the latter; 
an occurrence which cannot be too strongly weighed, on account of its great practical 
importance. It is generally understood that those symptoms of the disease which show 
themselves before the fifth or sixth month from the commencement of the primary sore 
should be classed under the head of “ secondary syphilis,” while those which come on 
subsequently, or after this period, are considered as appertaining to the third order of 
phenomena, or “ tertiary syphilis,” the average period of their evolution ranging from six 
to eighteen months, although in very many instances they do not occur until a number of 
years after the appearance of chancre, or chancre and bubo. Thus, I have repeatedly 
seen tertiary symptoms manifest themselves, for the first time, from twelve to eighteen 
years after the primary disease, the poison having lain all this time, like a hidden spark, 
in the economy. In one of my cases as many as forty years had elapsed front the primary 
inoculation. Once fairly roused, however, into activity, it rapidly extends through the 
system, completely overwhelming it in its progress, and exploding, with peculiar force, upon 
certain tissues, textures, or organs, as if it possessed a kind of elective affinity for them. 
A fourth order of symptoms—the quartenary—has of late been recognized by certain 
syphilographers, consisting of certain morbid changes caused by disease of the viscera, 
as the brain, heart, lungs, and liver, and coming on long after the initial sore. The dis- 310 
VENEREAL DISEASES. 
CHAP. IX. 
tinction, however, is not well founded, inasmuch as this tardy appearance is not peculiar 
to the viscera, but common to them and other structures, particularly the skin, bones, 
cartilages, and fibrous membranes. 
The textures most prone to suffer in tertiary syphilis are the connective tissue, mucous 
membranes, periosteum, bones, fibro-cartilages, aponeuroses, tendons, and testicles. All 
parts of the economy, however, may be involved in the contamination, and it is extremely 
probable that, in the worst cases, hardly any entirely escape. The affections of the internal 
viscera, although alluded to by many of the older syphilographers, have been especially 
investigated by Virchow, Dittrich, Lebert, Gubler, IVilks, Bristowe, Budd, and Moxon, 
who have ascertained that the changes in the lungs, brain, heart, liver, and other organs 
are generally of a very grave character, liable to be followed by the worst results, the 
more so because their approaches and progress are usually so insidious that even their 
existence is frequently not suspected during life, to say nothing of the impossibility of 
arresting them by any known treatment, or combination of remedies. The most common 
of these internal lesions are gummy tumors, foul, ragged-looking abscesses, with imper- 
fectly elaborated contents, softening and pulpy degeneration, and tubercular deposits. 
Attention has not yet been sufficiently directed to the alterations of the ovaries of women 
dead of tertiary syphilis; but from the resemblance which exists between these organs 
and the testes, both in structure and function, and from tlie fact that the latter are so 
often involved in the disease, it is extremely probable that it will be found, as our patho- 
logical researches are extended, that they frequently seriously participate in the morbid 
action. The uterus rarely suffers, and the Fallopian tubes have never been found involved 
in this disease. 
The gummy tumor, so common in the more advanced stages of syphilis in the internal 
viscera, as well as in some other parts of the body, is worthy of special attention, par- 
ticularly in relation to the progressive changes effected in the inflammatory deposits and 
in the structures at the seat of the morbid action. The earliest noticeable alteration 
which it experiences is hyperplasia of the interstitial connective tissue, the cells of which 
increase in size and number ; the new substance next becomes soft and gelatinous, melting 
down as it were; unhealthy pus is thrown out, and, finally, ulceration sets in. In a 
second form of the deposit, there is no unusual development of the connective tissue ; the 
cells retain their normal features or they assume the rounded shape of granulation cells, 
and by degrees undergo fatty degeneration, the original mass being eventually transformed 
into yellow tubercles, so characteristic of syphilis in deep seated organs. 
A section of a recent gummy tumor exhibits under the microscope three distinct zones, 
the outer of which consists of highly vascular granulation tissue ; the second is composed of 
fibrillated connective tissue ; the third, of a yellowish color and firm consistence, is consti- 
tuted by a mass of cells undergoing fatty transformation. The gummy tumor is some- 
times known as the fibronucleated tumor, in reference to its peculiar structure. The term 
fibroplastic is also applied to it. Its essential features are alike in the different organs 
and tissues. 
Tertiary syphilis is not invariably preceded by secondary symptoms ; on the contrary, 
there are many cases where the disease passes directly from the first to the third order of 
phenomena, the structures usually implicated in the secondary attack escaping entirely. 
It is well known, too, that tertiary syphilis is not always preceded by bubo, or appreciable 
induration of the glands of the groin. 
Tertiary symptoms are most liable to occur in persons of intemperate habits, and of a 
dilapidated constitution, with an impoverished state of the blood. A scrofulous or scor- 
butic condition of the system also acts as a predisposing cause. 
The immediate development of tertiary syphilis is often remarkably influenced by the 
habits and state of health of the individual. It is impossible to say how long the specific 
virus might lie dormant in the system if the subject of it were entirely free from the pre- 
judicial influences of surrounding agents. Exposure to cold is usually accused as being 
one of the most common exciting causes of the complaint, and yet it is notorious that the 
inhabitants of the South Sea Islands and other tropical regions are extraordinarily prone 
to all kinds of constitutional syphilis. There can be no doubt, however, that the poison 
is often fanned into activity by the hardships of our northern winters and by a residence 
in damp cellars, or moist, ill-ventilated, underground apartments, especially when this 
mode of life is conjoined with all kinds of dissipation and intemperance, loss of sleep, and 
an impoverished diet. Although it is extremely probable that no state of the system, 
however nearly it may approach to the normal standard, can ever entirely prevent the CHAP. IX. 
TERTIARY SYPHILIS OF PARTICULAR ORGANS. 
311 
development of’ tertiary syphilis, when once the poison has taken full possession of it, yet 
there can be no doubt that an individual so circumstanced will, other things being equal, 
be much less likely to suffer than one who is differently situated, or who gives himself up 
to the unbridled indulgences of his passions. 
It is an interesting fact, a fact now generally accepted by syphilographers, that the 
matter furnished by ulcers, abscesses, and suppurating surfaces, during the progress of 
tertiary syphilis, is not heteroinoculable, or, in other words, communicable from one person 
to another. Any doubts that formerly existed upon this subject have been completely 
dispelled by recent observations. That the matter, however, is autoinoculable is an equally 
well attested fact. I have myself seen two cases which unerringly point in this direction, 
and testimony of a similar nature has been repeatedly furnished by other observers. In 
one of these cases—that of a man, upwards of sixty years of age, long the subject of 
tertiary syphilis—matter taken from an intractable ulcer of the skin of one thigh, and 
inserted into the skin of the other, produced, in a short time, all the characteristic features 
of a syphilitic chancre, which, in its turn, yielded inoculable fluid, and was a longtime in 
healing. The other instance was equally remarkable. A gentleman, forty years of age, 
in 1851, had a chancre upon the penis, which was cured at the end of five months, leaving 
merely an indurated cicatrice. In August, 1862, without there having been any consti 
tutional symptoms in the interval, an abscess formed in the left groin, and at length opened 
spontaneously. The sore not only never closed, but extended in a serpiginous manner 
round the thigh towards the anus. In April, 1867, his medical attendant inoculated the 
sound limb with the secretions of this sore, with the effect of a formation of a pustule, 
which gradually degenerated into a large ulcer, with hard, elevated edges, very painful, 
and for a number of years utterly indisposed to heal. 
It is believed that tertiary syphilis is rarely hereditarily transmissible; but although 
this may be true in the ordinary sense of the term, it is extremely probable that the oil- 
spring of such an individual are, if not actually imperfectly developed, naturally predis- 
posed to various kinds of cachectic affections, particularly scrofula, scurvy, and rickets, 
by which life is rendered miserable and often cut off prematurely, the constitution being 
unable to endure the hardships incident to ordinary pursuits. 
The diagnosis of tertiary syphilis hardly admits of general description. Every case 
must stand, as it were, for itself. Very frequently one of the first evidences of the disease 
is the existence of nocturnal pains, a node upon the tibia, a gummy tumor in the sub- 
cutaneous connective tissue, an eruption upon the skin, an ulcer in the throat, a fetid dis- 
charge from the nose, or an enlarged and indurated condition of the testicle. Most 
commonly, however, the patient is conscious of declining health ; his appetite and strength 
sensibly fail; the secretions are disordered; the countenance is pallid ; the spirits are 
dejected ; and there is occasional febrile disturbance. After these symptoms have con- 
tinued for an indefinite period, various local affections appear, generally so well marked 
as to render it impossible to mistake their character. The history of the case will also 
commonly furnish important light; and in some instances the diagnosis is readily deter- 
mined by the nature of our remedies, especially the use of the iodides, which, when the 
malady is syphilitic, never fail to afford prompt relief of the more severe suffering. 
The prognosis of tertiary syphilis is always grave. Whatever form it may assume, it 
is extremely difficult to dislodge it effectually from the system, or to effect a radical cure. 
Relapses are of constant occurrence from the most trivial exposure, or the least disorder 
of the digestive organs, and few patients, however skilfully they may have been treated, 
are afterwards ever entirely free from rheumatoid pains, proneness to cold, and stiffness of 
the joints. In fact, although recovery undoubtedly does occasionally take place, yet in 
most cases the constitution remains in an enfeebled and crippled condition, remarkably 
predisposed to attacks of other diseases. 
Tertiary syphilis often proves fatal, although not nearly as frequently as prior to the 
discovery of the use of the iodides, death generally occurring from local irritation and 
constitutional exhaustion. Many of those who recover are horribly disfigured by pock 
marks, the partial or complete destruction of the nose and palate, loss of hair, anchylosis 
of the joints, and other affections. 
2. TERTIARY SYPHILIS OP PARTICULAR ORGANS. 
Nervous System Syphilis of the brain and spinal cord is more frequent than it was 
formerly supposed to be. I have myself witnessed a number of well-marked examples of 
it. It manifests itself in different ways, but the forms in which it most commonly appears 312 
VENEREAL DISEASES. 
CHAP. IX. 
are mental imbecility, epilepsy, paralysis, and muscular twitches. The paralysis is usually 
of the kind known as paraplegia; sometimes, however, it affects also the superior extre- 
mities. I lately had under my care a gentleman, twenty-seven years old, who, in con- 
sequence of a chancre contracted three years previously, was suffering from palsy of 
both legs and of the right arm. In 1876, I prescribed for a lady, aged thirty-two, who 
was affected with hemiplegia and aphasia, from an attack of syphilis two years before. 
The paralysis is generally preceded by numbness and various anomalous sensations, but 
sometimes its advent is sudden and unexpected. 
These tertiary affections of the brain and spinal cord seldom come on until several 
years after the primary sore, and the worst examples that I have seen appeared to have 
been induced by the joint effects of the syphilitic poison and the inordinate use of mercury, 
eventuating in a deposit of fibrin, the formation of gummy tumors, or the development of 
tubercles. Occasionally considerable serous effusions occur. 
The cerebral lesions in tertiary syphilis are either direct or indirect, depending, in the 
former case, upon the presence of gummy tumors or gummy exudations, and in the latter 
upon obliterative endarteritis, especially of the circle of Willis, and upon caries, necrosis, 
or exostosis of the cranial bones, more frequently the frontal than any other. Gros and 
Lancereaux have collected the statistics of 31 autopsies of direct cerebral disease, in 7 of 
which softening of the brain existed, and in 12 true gummy tumors. The anterior lobes are 
especially liable to suffer from these lesions. Cicatricial furrows, similar to those observed 
in syphilis of the liver, are sometimes seen upon the surface of the brain. Among the 
more remote effects of syphilis of this organ, are epilepsy and neuralgia, both commonly 
of a very intractable character. Symptoms of hysteria and chorea are also of occasional 
occurrence. 
The diagnosis is in general readily determined by the history of the case, the existence 
of syphilis in other parts of the body, as nodes, sores, eruptions, papules, or tubercles, 
and the dilapidated state of the system. In paralysis, the attack is occasionally ushered 
in by symptoms closely simulating those of cerebral apoplexy ; the stupor, however, soon 
disappears, and the concomitant phenomena are of shorter duration. In every one of my 
cases, the paralysis was associated with exquisite tenderness of the dorso-lumbar portion 
of the spine, and a want of power in the sphincter muscles of the anus and bladder. It 
is a noteworthy fact that most of the cases of hemiplegia occurring in early life are due 
to a syphilitic taint of the system. 
The prognosis of this class of affections is generally very grave. They are always 
difficult of cure, and not a few of the patients perish from their effects; some suddenly, 
others gradually, apparently from sheer exhaustion. 
Syphilitic affections of individual nerves, eventuating in disturbances of the special 
senses, anaesthesia, hyperaisthesia, analgesia, paralysis, or neuralgia, are by no means in- 
frequent, although they cannot always be readily traced to their true source. They may 
depend either upon disease of the nerves themselves, as when they are infiltrated with 
gummy matter, upon lesion of the brain at the roots of these cords, or upon disease, as 
caries, necrosis, or exostosis, of the openings in the bones through which the nerves pass 
to reach their destination. In all these conditions it is easy to perceive how effectually 
the transmission of the nervous fluid might be interfered with, causing either neuralgia or 
paralysis of the most inveterate, if not incurable, description. Many of the more obscure 
cases of these affections are referable to these morbid alterations, which are by far most 
common in the cerebral nerves, although the spinal are by no means exempt from them. 
The syphilitic character of these lesions may be suspected when they coexist with a 
syphilitic taint of the system. 
Syphilis of the Eye and Ear Iritis belongs to the more advanced stages of syphilis, 
being usually associated with papular, tubercular, or pustular eruptions, rupial sores, nodes, 
and rheumatism of the bones, and ulceration of the throat, palate, and nose. Its coexist- 
ence with the papular form of the disease is exceedingly common. Of eleven cases, 
observed by Dr. F. F. Maury at the Philadelphia Hospital, in 1866, iritis and papules 
were present in every one. The affection is characterized by a fixed and contracted state 
of the pupil, which is generally filled with lymph and displaced upward and inward; by 
the appearance, upon the anterior surface of the iris, of reddish-brown tubercles, or min- 
ute yellowish abscesses ; and by severe nocturnal pains, situated deep in the eye, forehead, 
and temple. The disease commonly attacks both organs, either simultaneously or suc- 
cessively, and always rapidly extends to the other structures, as the cornea, choroid, and 
retina, involving them in its ruinous consequences, few persons recovering without loss of 313 
CHAP. IX. 
TERTIARY SYPHILIS OF PARTICULAR ORGANS. 
sight. As allusion will again be made to this affection, and also to syphilitic keratitis, in 
the chapter on the eye, no further notice need here be taken of them. 
Retinitis as an effect of syphilis is uncommon ; it generally makes its appearance within 
the first eighteen months after the primary sore, and as it is usually unaccompanied by 
other constitutional symptoms it is exceedingly liable to be overlooked. The most promi- 
nent phenomena are pain in the eye and temple, indistinctness of vision, and a sluggish 
condition of the pupil. The retina is seen to be abnormally vascular, more or less hazy, 
and dotted with little whitish, yellowish, or reddish points, of a globular outline, and 
closely resembling the condylomes observable in iritis. Considerable oedema is often pre- 
sent, and the optic nerve is seldom free from involvement. 
Syphilitic choroiditis is also infrequent; it rarely exists by itself, but is usually asso- 
ciated with iritis or retinitis, and is characterized by impairment of sight, more or less 
pain, and other symptoms denotive of inflammation of the deeper structures of the eye. 
The pathological changes are variable, but the most prominent are an injected and vari- 
cose state of the bloodvessels, plastic deposits, and serous infiltrations. The vitreous 
humor, retina, and optic nerve are always involved in the more severe forms of choroiditis. 
Both choroiditis and retinitis are occasionally met with as inherited affections. 
The eyelids, especially the upper, not unfrequently suffer in tertiary syphilis. The dis- 
ease generally occurs as an indurated ulcer, somewhat of an oval shape, commencing at 
the tarsal edge, and thence gradually extending to the other structures. The borders are 
inflamed and thickened, the conjunctival lining is more or less oedematous, and there is 
considerable muco-purulent discharge. The diagnosis is founded upon the history of the 
case, the rebellious character of the sore, the indurated and enlarged condition of the 
glands behind the corresponding ear, and the coexistence of syphilitic disease in other 
parts of the body. The only ulcer with which it is liable to be confounded is the epithe- 
lial ; but from this it is usually readily distinguished by the fact that the latter never 
heals, whereas the former often undergoes repair at one point while it spreads at 
another. The diagnosis is often promptly decided by the use of antisyphilitic remedies. 
Syphilis of the ear is uncommon. Patients of a broken constitution and of intempe- 
rate habits are most likely to suffer from it. The disease generally comes on in the form 
of sudden deafness, attended with aching pain, and evidently consists of inflammation of 
the tympanal membrane, which, upon inspection, is found to be red and abnormally vas- 
cular, and, in time, to become more or less opaque. If the morbid action be not soon 
arrested it may eventuate in ulceration, followed by complete destruction of the mem- 
brane, and by permanent deafness. In the worst forms of the disease, the Eustachian 
tube, the middle ear, and even the petrous portion of the temporal bone become involved. 
The diagnosis is usually sufficiently easy, the most reliable points being the coexistence 
of syphilis in other parts of the body, the comparative slightness of the pain, which is 
much less than in ordinary myringitis, and the amenability of the disease to specific treat- 
ment. The affection evidently appertains to the earlier tertiary group. 
Digestive Organs and Liver—Tertiary affections of the throat and mouth are by no 
means uncommon; they supervene at an indefinite period after chancre, and manifest 
themselves in characteristic ulcers, which, if permitted to go on, gradually spread to the 
palate and maxillary bones, which, together with the soft parts, are sometimes destroyed 
to a most frightful extent, the buccal and nasal cavities being perhaps laid into one im- 
mense cavern. In some of these cases large portions of the alveolar process of the max- 
illary bone are necrosed, followed by the loss of many of the teeth, and a similar fate 
may be experienced by the ascending process and ungual bone, thus implicating and en- 
dangering the lachrymal sac and its canal. The nature of the disease is readily ascer- 
tained by inspection and by the altered state of the voice and breath. 
Tertiary syphilis of the tongue generally appears in the form of ulcers, or fissures, the 
latter of which are sometimes of enormous extent and depth, reaching far into the sub- 
stance of the organ. Specific ulcers are usually situated upon the side of the tongue, at 
or near its middle, and exhibit the characteristic features of venereal sores in other struc- 
tures, having a deep, excavated form and a foul surface, with marked induration of the 
base, the parts feeling, on being pinched, like a mass of fibro-cartilage. Only one such 
cavity generally exists, and this, when large and irritable, may give rise to a swelling of 
the lymphatic glands at the base of the jaw. The history of the case, the foul, excavated 
character of the sore, and the existence of syphilitic disease in the throat, nose, or other 
parts of the body, will always distinguish the lesion from other affections. 
Mucous tubercles are occasionally met with, and gummy tumors are not uncommon ; 
they are generally situated near the base of the organ, deep among the muscular fibres, VENEREAL DISEASES. 
CHAP. IX. 
and usually rapidly disappear under specific treatment. The more superficial sometimes 
ulcerate, forming foul, ill-conditioned sores,with a tendency to spread in different direc- 
tions, and often difficult to heal. 
The following case, that of a man twenty-eight years of age, a patient at the College 
Clinic, affords an excellent type of the tertiary form of this disease in this situation. The 
tongue, which was of the natural length and breadth but much increased in thickness, 
and excessively hard at the sides, especially the left, was covered with numerous fissures, 
of varying size and depth, overhung by steep, indurated edges, which at first sight con- 
cealed them almost completely from view. The largest groove, which resembled a deep 
furrow, extended along the centre of the organ, from a short distance in front of the root 
to within a few lines of the tip, its depth being nearly half an inch. The bottom of each 
fissure had a clean, smooth appearance ; and there was an entire absence of pain and 
even of soreness under rough manipulation, although the mucous membrane of the tongue 
generally was somewhat redder than naturally. The starting-point of the disease seemed 
to have been the throat, which had been inflamed for a long time ; the uvula had become 
elongated, and had been cut off weeks before. The arches of the palate and the tonsils 
were still a good deal discolored and congested. The tongue had been in its present con- 
dition for three months, having resisted various kinds of treatment, without the disease 
apparently manifesting any tendency to spread. A small, painful node existed on the 
right tibia, and there was a vesicular eruption with some itching on the lace. Under the 
internal use of iodide of potassium with bichloride of mercury, and the local application, 
every other day, of solid nitrate of silver, the man rapidly recovered. 
Serious disease of the teeth sometimes occurs in tertiary syphilis. It generally mani- 
fests itself in the form of a black spot, in the upper incisors, upon the anterior surface of 
the enamel, close to the gum, and gradually extends until the crown separates from the 
fang. In time, the lower incisors suffer in a similar manner. 
Gummy deposits have been found in the oesophagus, terminating in a bad form of ulcer; 
in other cases the syphilitic disease excites stricture of this tube, as I have myself wit- 
nessed in three remarkable instances. These affections always come on long after the 
primary sore. The history of the case is generally the best interpreter of its nature. 
Syphilitic ulceration of the intestines is an occasional cause of long-continued dysentery, 
attended with bloody, mucous discharges, more or less pain, and excessive emaciation. 
The parts most commonly involved are the colon and the small bowel near the ileo- 
caecal valve. Syphilitic stricture of the rectum and anus will be described in a future 
chapter. 
The liver is, perhaps, more frequently affected in tertiary syphilis than any other organ, 
the lung not excepted. The most important anatomical alterations are gummy tumors, 
or gummy and fibrinous infiltrations, and cicatricial furrows, grooves, or scars upon the 
surface of the organ. The gummy tumors are of variable size and form, and generally 
most numerous at the periphery of the liver. They usually coexist with evidence of 
syphilis in other parts of the body, and generally come on at a very remote period, at 
ten, fif teen, or even twenty years after the primary affection. There are no symptoms by 
which they can be distinguished during life from the more ordinary diseases of the liver. 
Syphilis of the Heart and Respiratory Organs—The lesions of the heart and large 
vessels, consequent upon tertiary syphilis, are imperfectly understood. The subject has 
been studied with much attention by Virchow, and interesting cases have been reported 
by Rieord, Lebert, Robert, Gubler, and others. The most important anatomical changes, 
in the earlier stages of the disease, are fibrinous, albuminoid, or fatty infiltration of the 
muscular fibres of the heart, interspersed with numerous molecular granules; and, in the 
more advanced periods, gummy deposits either in the substance of the organ or upon its 
free surface. Whitish, yellowish, or drab-colored spots, the result of inflammatory action, 
are occasionally seen upon the endocardium and pericardium. Syphilitic disease of the 
heart is generally associated with similar affections in other parts of the body, especially 
of the lungs and liver. The specific degeneration has been noticed in various parts of the 
arterial system, and is now universally regarded as a predisposing cause to aneurism. 
Disease of the heart will probably eventually be found to be more common in inherited 
than in ordinary syphilis. 
Syphilitic disease of the nose, or syphilitic ozrena, as it is occasionally called, manifests 
iteslf in inflammation and ulceration of the pituitary membrane and of the different bones 
of the nasal fosste. In the more severe forms of the affection the proper bones of the 
nose not unfrequently suffer. The morbid action, which is generally associated with 
marks of a constitutional taint in other situations, usually sets in at a very remote period 315 
CHAP. IX. 
TERTIARY SYPHILIS OF PARTICULAR ORGANS. 
after the primary sore, and lingers on obstinately for many years, notwithstanding the 
best directed efforts to arrest it, until it has caused the most extensive havoc, piece after 
piece dying and dropping off until every one has disappeared. When the proper nasal 
bones are involved, the whole organ, bridge, cartilage, and skin may be destroyed. The 
disease is attended with an abundant fetid and bloody discharge, and the voice has a 
peculiarly characteristic, muffled twang. The septum often suffers in this form of syphilis, 
giving way, first, at the cartilaginous structure, and afterwards at the osseous. Openings, 
of variable size and shape, are thus formed, with sharp, irregular edges, which have a 
constant tendency to enlarge until the greater portion of the septum is destroyed. 
Syphilis of the larynx seldom comes on until a long time after the primary sore, and 
may, therefore, very properly be classed among the tertiary phenomena. Although it may 
occasionally be simply an extension of disease from the palate, tonsils, or pharynx, it 
usually occurs as an independent affection, commencing in the larynx, and thence some- 
times passing up into the throat. Its coincidence with syphilis in other parts of the body, 
particularly of the skin, bones, and fibrous membranes, sufficiently stamps its character, 
and renders it easy of diagnosis. 
The relative frequency of the localization of syphilis in the larynx is undetermined. 
Gerliardt and lloth detected it in this situation in 18 cases out of 56. One-half of the 
cases occurred in the third deeennium of life. The malady appears to be equally com- 
mon in both sexes, but is very rare in children. 
The disease, beginning in inflammation, soon terminates in ulceration, which often 
continues for months and even years together, the erosive action being at one time sta- 
tionary, or on the very verge of healing, and at another 
steadily advancing. Confined originally to the mucous 
membrane, it at length invades the arytenoid cartilages, 
the vocal cords, and even some of the muscles of the larynx. 
Portions of the thyroid cartilage occasionally perish, and a 
not uncommon occurrence is the partial destruction of the 
epiglottis. In some of the cases of this disease that have 
come under my observation, nearly the whole of the epi- 
glottis was eaten away, nothing but a thick, narrow, stump- 
like remnant being left, as seen in fig. 81, from a prepara- 
tion in my private collection. The cricoid cartilage rarely 
participates in the disease. 
The ulcers are seldom numerous, unless they are follicu- 
lar, when the affected surface is occasionally literally stud- 
ded with them ; generally there are not more than one or 
two, which are then pretty large, both as it respects their 
depth and superficial area. They are of a circular or oval 
shape, with indurated edges and a foul bottom, and, in the 
more severe and protracted cases, they sometimes penetrate 
very deeply, opening, perhaps, externally. Such an occur- 
rence is most probable when there is extensive destruction 
of the thyroid cartilage. 
Occasionally the mucous membrane, instead of being 
ulcerated, is covered with granulations, warts, or excres- 
cences, of a red, fleshy color, from the size of a small pin- 
head to that of a mustard seed, their number varying from 
half a dozen to fifteen or twenty; they are usually most 
conspicuous around the vocal cords, and apparently consist in a hypertrophied condi- 
tion of the mucous crypts which naturally exist in the interior of the vocal tube. Some- 
times the disease manifest itself in the form of distinct nodules, gummy tubercles, or 
condylomatous excrescences with a broad base. In a case which I recently examined, 
one of the sinuses of the larynx was completely annihilated, while the other was closed 
up by a fibroid tumor. The patient, a man fifty-three years of age, had not been able to 
speak above a whisper for several weeks before his death. 
The symptoms are generally well marked, particularly when the disease has made 
considerable progress, or when it presents itself in the form of ulceration. Besides the 
wan, emaciated, and cachectic appearance of the patient, which is itself almost sufficient 
to point out the nature of the affection, there is a hoarse, husky characteristic state of 
the voice, which is gradually reduced to a mere whisper, and eventually completely lost. 
The larynx feels tender on motion and pressure ; deglutition is difficult and painful; and 
Fig. 81. 
Syphilitic Ulceration of the Larynx. 316 
VENEREAL DISEASES. 
CU AP. ix. 
the slightest vocal exertion is productive of severe suffering. Cough is always present, 
frequently to a most harassing extent; and in attempting to swallow fluids the patient 
is frequently seized with paroxysms of impending suffocation. The expectorated matter 
is excessively fetid, often bloody, and occasionally mixed with fragments of cartilage, its 
quantity being frequently very copious. As the disease progresses, the local and consti- 
tutional irritation increases ; the emaciation becomes extreme ; the sweats are copious ; 
and the patient finally dies completely exhausted, the immediate cause of death being, 
perhaps, inanition, suffocation, or hemorrhage from the sudden giving way of an import- 
ant artery. The precise seat and extent of the morbid action can only be determined by 
laryngoscopic inspection. 
The prognosis is variable. The milder cases often yield to treatment, whereas the 
more severe are generally incurable, especially when attended with a dilapidated state of 
the system. Syphilitic ulcers are always followed by permanent loss of substance, and 
by radiating cicatrices, hard, dense, and firm, with a disposition to contract and to cause 
constriction of the tube. In the vocal cords and arytenoid cartilages they invariably 
lead to irremediable alterations of the voice, not unfrequently amounting to complete 
aphonia. 
Syphilitic involvement of the lungs is uncommon. The disease generally occurs in 
the form of gummy tubercles, either single or grouped, of variable size and shape, of a 
dirty grayish color, and, in their earlier stages, of a tolerably firm consistence. The 
tubercles sometimes exist in large numbers, and are then not always easily distinguish- 
able from ordinary scrofulous tubercles. The matter which is formed during their disin- 
tegration is of an unhealthy character, and often remarkably fetid and putrilaginous. 
The trachea and bronchial tubes are sometimes inflamed, ulcerated, and even seriously, 
strictured in this disease; the bronchial lymphatic glands are also liable to suffer, and 
the pleura is occasionally studded with tubercles and covered with sero-purulent effusion. 
The diagnosis is deduced from the history of the case, the presence of cough, the 
gradual decline of the general health, and the existence of syphilis in other parts of the 
body. 
Urinary and Genital Organs.—The precise character of the syphilitic lesions of the 
urinary organs is still undetermined. In the kidneys, the most common alteration is 
interstitial inflammation, attended with gummy deposits, fatty degeneration, and atrophy 
of the uriniferous tubes, followed by induration of the renal tissue, and deep cicatricial 
depressions upon the surface of these organs. Occasionally there is amyloid degenera- 
tion ; and cases are met with in which the kidneys are tumefied, softened, and of a re- 
markably pale grayish color, interspersed with little yellowish streaks, dots, or points. 
The suprarenal capsules are sometimes greatly enlarged, and transformed into fatty 
matter. 
The bladder and ureters are occasionally inflamed, and the seat of plastic deposits. 
When the disease is chronic, it is very liable to pass into suppuration, especially if it be 
associated with paralysis of the lower extremities. I lately attended a case of this kind 
in which the quantity of pus and mucus thrown off in the twenty-four hours was abso- 
lutely enormous ; the urine was of a very dark color, and contained, in addition to these 
ingredients, a large amount of albumen. It was free from odor, and for a long time 
dribbled off involuntarily, owing to the loss of power in the sphincter muscle of the 
bladder. Renal casts are often present. 
Syphilis of the testicle is generally one of the remote effects of this disease. The 
average period, in the numerous cases that have fallen under my notice, was from two to 
four years; but frequently the enlargement does not come on until after the lapse of 
eight, ten, or even twelve years. It is usually associated with syphilis of other parts of 
the body, particularly the bones, joints, throat, nose, and skin, the last of which is often 
extensively ulcerated and otherwise disordered. 
The disease almost always involves both testicles, either simultaneously or successively, 
although seldom in an equal degree ; and, as it proceeds, it is sure to extend to the epidi- 
dymis, the two structures thus forming eventually one inseparable mass. The swelling 
is characterized by extraordinary weight and hardness, the affected organ resting upon 
the hand like a heavy, solid body, and requiring constant support to prevent it from 
causing a sense of dragging. When the disease has reached its maximum, the testicle 
is often six to ten times the normal bulk. The surface of the tumor is variable, although 
generally it is rather smooth, or but slightly knobby. The induration is uniform, except 
when there is, as not unfrequently happens, an accumulation of water in the vaginal tunic, 
when the corresponding portion may be soft and fluctuating. The spermatic cord usually CHAP. IX. 
TERTIARY SYPHILIS OF PARTICULAR ORGANS. 
317 
participates in the morbid action, being unnaturally bard and thickened, feeling like a 
whip-cord when pressed between the thumb and finger. When the disease is of long 
standing, the affected structures lose their normal characters completely, either at particu- 
lar points, or throughout, the seminiferous substance being replaced by fibrous tissue. In 
its worst forms gummy deposits occur, which, breaking down and disintegrating, lead to 
the formation of unhealthy abscesses and fungous growths. 
Syphilitic sarcocele is always a remarkably tardy and painless disease. It is only, as 
a rule, when there is much water in the vaginal tunic, constituting the complication called 
hydrosarcocele, and causing constant pressure upon the inflamed and degenerating tissues, 
that the patient will be likely to sutler much, and then chiefly at night and in damp 
weather. When the swelling is very large, considerable inconvenience is usually experi- 
enced from its weight and bulk. The subjects of this form of syphilis are nearly always 
thin, pale, and anemic, the appetite is greatly impaired, the strength is wasted, and the 
sleep is interrupted by nocturnal rheumatism. Their whole appearance, in fact, is indi- 
cative of a worn-out, miserable state of the system. When both organs are extensively 
diseased, the individual must necessarily be impotent. A remarkable feature of this form 
of syphilis is its tendency to recur, perhaps again and again, after being apparently 
relieved by treatment. 
Syphilitic orchitis is always easily distinguishable from common orchitis, first, by the 
tardy, indolent, and persistent character of the swelling ; secondly, by the simultaneous or 
successive involvement of both organs ; thirdly, by the coexistence of syphilitic disease in 
other parts of the body, especially of nodes, and ulcers of the skin, nose, and throat; 
fourthly, by the gradual but certain destruction of the textures and functions of the testi- 
cle ; and, lastly, by a careful consideration of the history of the case, particularly the 
character of the patient. When there is unusual obscurity, it is well that the surgeon, 
before resorting to extirpation, should make a faithful trial of antisyphilitic remedies, 
otherwise he may have occasion to lament his rashness. 
The subjoined case, treated at the College Clinic, affords an excellent illustration of the 
nature, progress, and termination of syphilitic orchitis, with the changes experienced by 
the affected organ. The man, aged 29, had, on admission, a fungus of the right testicle, 
which had commenced, four months previously, as a small pustule on the scrotum. Nine 
years before he had had a chancre and bubo, and was now laboring under syphilitic rheuma- 
tism, ulceration of the tibia, and a slight eruption upon the face. The right testicle had been 
enlarged, hard, and painful for the last three years; the left one was also diseased, but in 
a less degree. The general health was much impaired. The fungus was about the size 
of a half dollar, and the seat of a fetid, ichorous, and profuse discharge, as well as of 
severe suffering, especially at night. As the organ was hopelessly destroyed, I at once 
removed it. The tubular structure was completely annihilated, a fibrous substance, of a 
pale yellowish color and dense consistence, occupying its place. At the posterior part of 
the epididymis was an abscess, about the volume of a small hickory-nut, filled with a 
tough, yellowish, cheesy-looking matter, bearing a close resemblance to tubercular deposit. 
The wound soon healed, and under the use of iodide of potassium and bichloride of mer- 
cury, aided by a generous diet, the patient rapidly improved in health and spirits. 
Whenever syphilitic orchitis is of long standing, whether it be accompanied or not by 
fungus, the tubular substance will generally be found to be irretrievably destroyed. 
The seminal vesicles and prostate gland rarely suffer from syphilis. The deferent tubes, 
on the contrary, participate in the morbid action, for the most part in conjunction with 
disease of the epididymis and testes, feeling like hard, firm cords under the skin. In the 
cavernous bodies of the penis gummy nodes sometimes form, commencing as small, pain- 
less lumps, nearly always situated in the posterior third of the organ, where, as they 
increase in volume, they occasion more or less deformity, and may so completely inter- 
fere with the circulation of the blood as to render intercourse impracticable. 
Tertiary syphilis is sometimes met with in the breast, either in the form of distinct 
gummy tumors, or as a diffused indurated condition of the entire gland. The ovaries, 
uterus, and vagina are occasionally affected, but no disease of this kind has, I believe, 
ever been noticed in the Fallopian tubes. 
Skin Ulcers of the skin, which may commence as ecthyma, rupia, or softened 
gummy tumors, are usually among the more remote effects of the tertiary form of the 
disease, coming on, in most cases, several years after the primary affection. They usually 
coexist with nodes and rheumatic pains, or with ulcers of the throat, nose, and larynx, or 
with all these ailments combined, and are nearly always preceded by scaly eruptions, pus- 318 
VENEREAL DISEASES. 
CHAP. IX. 
tides, papules, or tubercles. Persons of a broken, infirm, and cachectic constitution are 
their most common subjects, and those in whom they commit the greatest ravages. 
Much diversity exists in regard to the situation and character of these cutaneous ulcers. 
They are most frequently found on the extremities, especially the inferior; they are also 
sufficiently common on the forearm and elbow, and on the scalp, forehead, and temple. 
Their size ranges from a split pea to that of the crown of a hat, their shape being usually 
circular or oval, although sometimes it is extremely irregular from two adjoining sores 
being connected or running into each other. The edges are nearly always callous, everted, 
and more or less ragged ; the surface is excavated, covered with a greenish, pultaceous 
matter, and exquisitely sensitive; while the discharge, which is often very profuse, is 
thin, ichorous, and offensive, frequently excessively so. In other cases the sore is covered 
with a brownish-black or greenish-black crust, which may be flattened and depressed, or 
conical and laminated. It is not often that there is anything like a distinct, well-defined 
areola; such an occurrence is very rare, but in most instances there is marked inflam- 
mation with redness and induration in the parts immediately around. The largest of 
these ulcers generally occur on the shoulder, side, and buttock, and it is amazing what 
an immense size they may attain. Numerous small ulcers of this kind occasionally exist 
in groups, giving the surface a peculiar worm-eaten appearance. In some cases, again, 
the ulcers have a serpiginous arrangement; in another class of cases they are, perhaps, 
very much undermined ; and now and then two large ulcers are connected together by 
a kind of cutaneous bridge. In fact, there is no end to the diversities of their configura- 
tion. Finally, they may be quite superficial, or so deep as to involve the subjacent con- 
nective tissue, and even the fascia?, muscles, tendons, and bones. Rupial ulcers of the 
skin are admirably illustrated in fig. 82. The diagnosis is unmistakable. 
Fig. 82. 
Syphilitic ulcers often continue for an indefinite period, sometimes partially cicatrizing, 
now spreading, now indolent, or stationary. From local causes, as well as constitutional, 
they may take on almost any kind of action : when the patient is in an exhausted, irri- 
table condition, they are very apt to become severely inflamed, and to assume a phagede- 
nic, sloughing character, often spreading with immense rapidity, both in diameter and in 
depth. The system generally actively sympathizes with these sores, the skin being hot and 
dry, the pulse small, quick, and frequent, the appetite impaired, the sleep destroyed, and 
the loss of flesh and strength excessive. The patient has an old, superannuated, care- 
worn look, with all the signs of a deep-laid syphilitic cachexia. The scars left by the 
healing of these ulcers are abnormally white, and retain for a long time a remarkable 
hardness, with a tendency to constant furfuraceous desquamation. They are sometimes 
very rough, and prone to reopen from the slightest causes. 
The diagnosis of a syphilitic ulcer of the skin is generally sufficiently easy, the only 
affection with which it is liable to be confounded being the common non-specific sore. 
Its very appearance, in fact, usually at once stamps its character. In the first place, it 
is ordinarily circular or oval, and of an excavated shape, with hard, everted edges, and a 
foul surface, destitute of granulations and of healthy discharge; the surrounding surface 
is indurated, and nearly always somewhat of a copper, bronze, or brownish color. 
Secondly, the sore is often multiple, occurring in groups, and also on different parts of the 
surface, a circumstance which is generally of itself sufficient to denote its nature ; for 
the ordinary ulcer is usually solitary, and is most common on the lower extremity. 
Thirdly, the disease of the skin nearly always coexists with syphilitic disease in other 
structures, especially of the periosteum and bones. Finally, the effects of the treatment 
afford important aid in doubtful cases ; ordinary ulcers disappearing, or soon assuming a 
healthy, granulating condition, under simple antiphlogistics, rest, and light diet, whereas 
specific ulcers always require the use of the iodides and of mercury, the latter often both 
internally and externally. 
Rupial Ulcers of the Skin. CHAP. IX. 
TERTIARY SYPHILIS OF PARTICULAR ORGAN'S. 
319 
Syphilitic eruptions are sometimes attended with onychia, or inflammation of the 
matrix of the nails, the latter of which gradually become dry and black, and eventually 
drop off, leaving a foul, excavated, painful ulcer, with hard, steep edges, and a very fetid, 
ichorous discharge. If the morbid action be very severe, or not soon checked, the matrix 
will be completely destroyed; most commonly, however, a part of its substance survives, 
and afterwards makes a feeble effort at the formation of a new nail, generally an ill-shaped, 
stumpy, horn-like excrescence, wholly different from the original structure. The diag- 
nostic signs of the disease are the copper-colored appearance of the surface immediately 
around the ulcer, and marks of syphilis in other regions of the body. The lesion 
occasionally does not appear until many months after the primary sore, thus bringing it, 
properly speaking, under the head of tertiary symptoms. It is most common in children, 
as a result of inherited syphilis. 
In what is called friable onychia, the nail gradually loses its natural lustre, assumes a 
dull, yellowish color, becomes thickened at the edges, and readily breaks or cracks, large 
portions often dropping off on the slightest exposure. The skin under and around the 
nail is generally much thickened. Hypertrophy of the end of the finger, or even of the 
entire finger or toe, is a sufficiently common occurrence, especially in inherited syphilis. 
Condylomes of the skin, or of the skin and mucous membrane, usually described by 
the French syphilographers under the name of mucous tubercles, consist of various sized 
excrescences, of a flat and rather broad appearance, occurring either in groups or as 
isolated growths, dependent essentially upon a hypertrophied condition of the integument. 
It is difficult to assign to this disease its precise rank in the order of syphilitic phenomena, 
or even to affirm, with certainty, that it is always plainly of a syphilitic character. 
Surgeons of great experience do not hesitate to assert that condylomes may be produced 
by the contact of gonorrhoeal matter, or by acrid vaginal and other non-specific secretions. 
On the other hand, it has been alleged that they pertain, not to one form of syphilis, but 
to all three, now following chancre, now secondary syphilis, and now tertiary. As for 
myself, I am inclined to regard them as belonging rather to the third order of phenomena 
than to the second, and under no circumstances whatever to the first. 
These excrescences are sometimes the result of hereditary syphilis, as I have witnessed 
in a number of instances. In one remarkable case—that of a lad eight years old—the 
father had had a similar affection several years previously, in consequence of tertiary 
syphilis, attended with nodes and scaly eruptions. The tubercles occupied the margin of 
the anus and the lower part of the perineum, the child being pale and thin, but there was 
no other evidence of constitutional 
contamination. The mother had 
given birth to three infected in- 
fants, two before, and the other 
at the full period; the former 
were cast off dead, in a putrid 
condition, and the latter died at 
the age of three months from 
marasmus, the whole body having 
been covered with scaly erup- 
tions, which were particularly 
conspicuous on the forehead, 
hands and feet. All the other 
cases were equally well marked. 
The most common sites of con- 
dylomes, fig. 83, are the scrotum, 
perineum, anus, buttocks, and 
vulva. They also occur, although 
rarely on the penis, and in the 
folds of the thigh, in the axilla, 
and in and around the ear, and 
between the toes. They have a 
particular predilection for parts 
which are habitually hot and moist ; for it is there that they are not only most frequently 
found, but that they acquire their greatest and most rapid development. Their size and 
shape are very various. Thus, they may, on the one hand, not be larger than a pin-head, 
or a mustard seed; while on the other, they often acquire the volume of a filbert, and 
Fig. 83. 
Condylomes. 320 
VENEREAL DISEASES. 
CHAP. IX. 
even of a small almond. In shape, the}r are usually flat, with a broad base, although not 
unfrequently the free portion is much larger than the adherent, a circumstance which 
gives the growths a pedunculated aspect. When they occur in groups, as is very apt to 
be the case, they often coalesce, forming thus considerable masses, tuberculated on the 
surface, irregular in shape, of a reddish color, and of a firm, fibrous consistence. The 
largest and worst of these tumors always occur at the margin of the anus, and on the 
perineum, vulva, and other parts which, from the contact of the opposing surfaces, are 
habitually subjected to friction, heat, and moisture, which, as already stated, are greatly 
conducive to their development. In these localities, the tumors are always humid, ex- 
haling a thin, muco-purulent fluid, often very abundant, and always excessively fetid. In 
those parts, on the contrary, where they are more exposed to the air, they are dry, in- 
sensible, of a darkish color, and partially incrusted with scabs. 
Condylomes often coexist with other evidences of a syphilitic taint, especially nodes, 
ulcers, tubercles, and scaly eruptions of the skin. Their course is variable; sometimes 
steadily onward, at other times stationary, and now and then even retrogressive. Exercise 
and friction always irritate them, rendering them sore, and more or less sensitive, if not 
actually painful. When they are large and numerous, the discharge is generally copious, 
almost insupportably offensive, contagious, and consequently inoculable. They are rarely 
accompanied by febrile symptoms. 
The diagnosis cannot be mistaken. The situation of the excrescences, their peculiar 
shape, their chronic character, and their fetid secretions all serve to impart to them a dis- 
tinctive character. Corroborative testimony is often furnished by the history of the case 
and by the presence of syphilis in other parts of the body. 
Connective Tissue, Muscles, and Tendons Gummy tumors, of variable size and shape, 
are liable to form in the subcutaneous connective tissue during the progress of this dis- 
ease, especially in persons of feeble constitution or broken health. They evidently apper- 
tain to the third group of phenomena, are usually very indolent, and seldom, in their 
earlier stages, encroach upon the skin. In volume they range between that of a pea and 
a pullet’s egg ; they are of a firm, semielastic consistence, and they not unfrequently occur 
in considerable numbers, several being occasionally seen side by side. Commonly, how- 
ever, there are not more than three or four, situated perhaps at remote points. In a case 
under my charge at the Philadelphia Hospital there were two on the chest, one on 
the clavicle, and one in the hyoid region, the rest of the body being entirely free from 
them. Perfectly movable at first, they gradually contract adhesions to the surrounding 
skin, and ultimately suppurate and ulcerate, discharging a thick, gummy matter, whence 
their name. 
Sometimes successive crops of these tumors occur, one disappearing as another arises, 
and thus the disease is occasionally kept up for months and even years. The resulting 
abscesses may be very small, and then they are generally proportionately numerous. I 
have witnessed cases in which hundreds, not larger than a pea, were scattered over the 
chest, arms, and shoulders. 
Gummy tumors occasionally form in the muscles and tendons, generally in connection 
with syphilitic affections in other parts of the body, as ulcers of the skin or fauces, nodes, 
exostoses, and tumors of the connective tissue. They range in volume from a pea to that 
of a pullet’s egg, are of a firm, dense consistence, and are seldom attended with severe 
pain, except when they are breaking down and becoming disintegrated. They are most 
easily detected by their peculiar feel when the muscles and tendons are relaxed. 
The diagnosis of gummy tumors is usually easily determined by their situation, by 
their semielastic feel, by their coexistence with syphilis in other parts of the body, by 
their tardy progress, by their tendency to disintegration, and by their history. 
Osseous and Fibrous Tissues Affections of the pei’iosteum and bones belong to the 
later order of tertiary syphilis, and they may declare themselves in various forms, of which 
the most important are nodes, or gummy tumors, inflammatory hypertrophy, exostosis, caries, 
and necrosis. These affections may come on at any time after the eighteenth month from 
the date of the initial sore, but in the great majority of cases they do not arise until after 
the lapse of at least twice that period. They are most liable to occur in persons of a 
scrofulous and cachectic constitution, and in those whose health has been destroyed by 
habitual intemperance, constant exposure, and deficient alimentation, leading to an im- 
poverished state of the blood and protracted derangement of the secretions. The idea is 
now generally prevalent that diseases of the periosteum and bones, especially in their 
more severe forms, are, in great measure, limited to those persons who have undergone CHAP. IX. 
TERTIARY SYPHILIS OF PARTICULAR ORGANS. 
321 
severe courses of mercury for their cure ; and in this opinion the results of my experience 
fully concur. Of the many cases of tertiary syphilis of the osseous tissue which have 
fallen under my observation nearly all had taken mercury in large quantity, and the few 
who had been treated without that remedy had suffered comparatively little, except where 
there w'as a marked strumous diathesis, which never fails to aggravate the effects of the 
ingrafted disease. It would thus appear, at first sight, that this mineral, by combining 
with the specific poison, was capable of essentially modifying its action, if not of forming 
a new virus, more potent and destructive than the original. However this may be, it is 
certain that the action of mercury, when carried to excess, is a most powerful depressant, 
the effect of which is felt, for a long time, by the whole system, by the blood not less than 
by the solids. A species of physical degradation of the entire organism is thus engend- 
ered, which strongly predisposes it to the injurious operation of morbific agents, whether 
acting within the system, or impressing it from without, through the medium of the cuta- 
neous and mucous surfaces. Instead, therefore, of supposing that a new poison, or a sort 
of a syphilitico-mercurial virus, is formed under these circumstances, it will be found to 
be more in accordance with the established facts of pathology to conclude that the fright- 
ful ravages so often committed in tertiary syphilis, after the inordinate use of mercury, in 
the osseous tissue, are the result, exclusively, of the deteriorating influence of this mineral 
upon the general system, wdiereby the more feebly organized structures, as the bones and 
their investing membrane, are rendered peculiarly prone to the occurrence of a bad form 
of inflammation, which, if not early checked, often leads to the most disastrous conse- 
quences. 
Tertiary syphilis is met with only in certain bones, chiefly in the superficial, or in those 
least protected by soft parts, as the tibia and fibula, ulna, clavicle, and bones of the skull, 
nose, palate, and upper jaw. In rare cases, almost 
every piece of the skeleton is involved, either 
simultaneously or successively; some in nodes, 
some in caries, some in necrosis, and some in ex- 
ostosis. 
Nodes occur principally upon the tibia, the ulna, 
the clavicle, and the skull, particularly the frontal 
and parietal bones, as in fig. 84, from Jullien. 
Apppearing as circumscribed, semisolid swellings, 
they are of an ovoidal shape, somewhat elastic to 
the touch, and from half an inch to an inch and a 
half in diameter. So far as we are able to deter- 
mine, they always begin beneath the periosteum, 
upon the surface of the bone, in the form of a 
gummy tumor. The periosteum and bone at the 
seat of the node, are inflamed, softened, and ulce- 
rated ; and, as the tumor extends, the superincum- 
bent structures, participating in the morbid action, 
become red and painful, and ultimately yield at the 
most prominent point, thus allowing the pent-up 
fluid an opportunity of escaping, although generally 
in a very imperfect manner, and not without severe 
suffering. 
A node is essentially a broken-down gumma. 
Its course is always chronic, and the attendant pain 
is peculiar, being of an intermittent, neuralgic 
character, subject to violent nocturnal exacerba- 
tions. The general health is usually disordered, 
and, if the swelling is large, there is apt to be considerable constitutional disturbance. 
Nodes often coexist in different pieces of the skeleton, the skull, for example, being some- 
times literally studded with them. 
An ulcerated node may take on an almost endless variety of morbid actions, incident to 
syphilis in other structures. Thus, it may be excessively irritable, be invaded by phage- 
dena or gangrene, burrow extensively among the surrounding tissues, be complicated with 
serious disease of the bones, or, lastly, be indolent and indisposed to heal. 
Syphilitic abscess of the bones is uncommon. It may occur in almost any portion of 
the skeleton, and is characterized by long-continued pain, usually deep-seated, circum- 
scribed, and of a dull, heavy, gnawing character, liable to serious aggravation from 
Fig. 84. 
Nodes of the Skull. 322 
VENEREAL DISEASES. 
chap, i x. 
exposure, fatigue, or any disorder of the general health. The diagnosis is determined by 
the history of the case, by the enlargement of the affected bone, and by the peculiar 
obstinacy of the pain. When the disease is chronic it may persist for an almost indefinite 
period, as in the case of a man, thirty-three years of age, a patient of mine, who had 
a deep-seated abscess of this kind in the upper extremity of the tibia for upwards of nine 
years. In another case the disease had been in progress for sixteen years. 
Caries is most common in the long bones of the extremities, as the tibia and ulna, in 
the skull, and in the palate, maxillary, nasal, turbinated, and ethmoid bones, together 
with the vomer; it may exist by itself, or be conjoined with necrosis, whole pieces often 
dying and sloughing away, so as to cause the most frightful mutilation and disfigurement. 
These ravages are generally most conspicuous about the countenance, especially when the 
disease attacks and destroys the proper bones of the nose, which then cave in, and cause 
that remarkable flattening of the face so characteristic of the effects of tertiary syphilis. 
In many cases the turbinated bones, the ethmoid, and vomer are separated, so as to 
convert the nasal fossae into one immense cavity; and instances occur where, from the 
destruction of the palate and maxillary bones, the mouth and nose communicate with 
each other. In the long bones of the extremities, the caries and necrosis are generally 
superficial, the dead portions coming away in the form of exfoliations, the central parts 
of' these pieces seldom participating in the morbid action to an extent sufficient to cause 
their destruction. The sequester in syphilitic necrosis is characterized by its peculiar 
porous, cribriform or worm-eaten appearance, 
dependent upon the peculiar arrangement of 
the gummy matter that accompanies the process 
of osteomyelitis. The cicatrice which is left 
by the healing of the parts is remarkably hard, 
compact, poorly supplied with vessels, depressed, 
and of a uniform, whitish appearance. 
Virchow has described what he calls “ dry 
caries” of the osseous tissue, as an effect of 
syphilis; it is most common in the bones of the 
skull, and is characterized by the entire absence 
of suppuration, conjoined with rarefaction of 
the affected part and hypertrophy of the ad- 
jacent textures. It may affect both tables of 
the skull, and, when the depressions accom- 
panying it correspond, it may cause complete 
perforation. 
The adjoining cut, fig. 85, from Druitt, 
affords a graphic illustration of caries of the 
bones of the skull, which, as in a case under 
my observation many years ago, are sometimes 
so completely riddled as to give them a peculiar 
cribriform appearance. 
Syphilitic hypertrophy of the osseous tissue 
is extremely common, and sometimes involves the greater number of pieces of the skeleton; 
the bones, however, which are most liable to be attacked are the tibia, fibula, femur, ulna, 
radius, and cranium. The lesion occurs either as an exostosis, or as a diffused swelling, 
which, when it affects the whole length and thickness of a bone, assumes the. name of 
general hypertrophy. The mode of formation of a syphilitic exostosis presents nothing 
peculiar; it evidently takes its rise in a deposit of plasma, which serves as a nidus for the 
future growth, theossific process passing through the same phases as in the natural skeleton. 
The tumor is usually knobby and irregular, with a broad base, and a rough, scabrous 
surface. In cases of long standing, it is nearly always of a hard, ivory consistence. 
The more common variety of hypertrophy is the diffused or general, of which the best 
specimens are usually seen in the bones of the leg, thigh, and forearm, which are often 
nearly twice the natural thickness and of extraordinary weight and firmness. A section 
of such a piece, seen in fig. 86, from a preparation in my cabinet, shows that the spongy 
substance has been completely, or almost completely, replaced by solid osseous matter, 
that the medullary canal has been obliterated, and that the compact structure has acquired 
a closeness of texture almost equal to that of ivory. The Haversian canals are for the 
most part obliterated, or greatly changed in size and shape, while the outer surface of the 
bone, as sketched in fig. 87, is remarkable for its roughness, its appearance bearing a 
Fig. 85. 
Syphilitic Caries of the Skull. CHAP. IX. 
TERTIARY SYPHILIS OF PARTICULAR ORGANS. 
323 
striking resemblance to that of worm-eaten bark. The skulls of persons laboring under 
tertiary syphilis are sometimes astonishingly hypertrophied. In a specimen presented to 
Fig. 86. 
General Syphilitic Hypertrophy of the Femur ; Internal Structure. 
me by Dr. Cochran, of Louisiana, the cranial bones are throughout at least half an inch 
in thickness; the different pieces are completely fused together without any trace of suture 
or of diploe, and their consistence and density are almost equal to those of ivory. 
Fig. 87. 
General Syphilitic Hypertrophy ; External Characters. 
Syphilitic osteophytes occur, both in the long and the flat bones, in various forms ; some- 
times as thin, sharp, thorn-like excrescences, and, at other times, as flat, irregular, trian- 
gular, or knobby prominences. They are apparently composed of the same material as 
the bones from which they spring, and often exist in great numbers, especially in the 
neighborhood of the larger joints. 
Extreme fragility of the osseous tissue sometimes arises from the effects of the syphi- 
litic poison. A young man, a patient of mine, fractured his humerus, near its middle, in 
the act of throwing a chip at a person. He was in feeble health at the time, but, under 
the influence of tonics and iodide of potassium, union occurred within the usual limits. 
The periosteum is variously affected in syphilitic diseases of the bones; in the more 
inflammatory lesions it is generally very vascular, soft, and spongy, at the same time that 
it is considerably thickened, and easily detached from the subjacent surface. In hyper- 
trophy, especially the diffused form, the principal alterations are thickening and indura- 
tion, with a tendency, here and there, to ossification. Instead of being easily separated 
from the affected bone, as it is in the more acute affections, the membrane always adheres 
to it with extraordinary firmness. 
The various syphilitic affections of the bones, but especially diffused hypertrophy, are 
all attended with more or less disturbance of the general health, and deep-seated, excru- 
ciating pains. These pains, from being always worse at night, have earned for themselves 
the title of nocturnal, although they are rarely entirely absent even in the day; they are 
also frequently called osteocopic pains, and syphilitic rheumatic pains. They are generally 
of a dull, heavy, aching, or gnawing character, and begin to increase in severity the 
moment the patient becomes warm in bed ; they may continue all night, or go off in a few 
hours, but while they last the patient is in great suffering, and is unable to sleep. Not 
unfrequently they are of a neuralgic nature, excessively keen, darting, and paroxysmal. 
While they exist, the affected bones are generally exquisitely tender and intolerant of 
manipulation. 
Joints.—A mild form of synovitis is by no means uncommon in tertiary syphilis, espe- 
cially in persons of a dilapidated constitution, ill-clothed, and ill-fed. The attack generally 
comes on stealthily, and may last almost for an indefinite period. The joints most liable 
to suffer are the knees, elbows, and wrists, though hardly any are entirely exempt from 
it. The accompanying pain is usually of a dull, aching character, and is always aggra- 
vated at night and in wet weather. The affected parts feel sore and tender, and are 
intolerant of the slightest motion and pressure. The synovial membrane generally becomes 
thickened and incrusted with gummy matter, while its cavity is partially filled with a 324 
VENEREAL DISEASES. 
CHAP. IX. 
turbid, viscid fluid, sometimes spontaneously coagulable. This fluid, which seldom exists 
in any considerable quantity, occasionally temporarily disappears, and then recurs from 
the slightest causes, now perhaps more rapidly and abundantly than in the first instance. 
The structures around the diseased joint are stiff and indurated from plastic deposits, but 
the integuments are free from disease. The general health is usually more or less 
deranged. 
In the more severe forms of syphilitic synovitis, the disease extends not only to the 
articular cartilages, but also to the extremities of the bones; the pain and general disturb- 
ance are excessive; the swelling and effusion are great; and the morbid action either ends 
in permanent anchylosis, or in destructive suppuration and ulceration of the joint. 
The diagnosis is determined by the history of the case, by the insidious character of the 
attack, by the peculiarity of the concomitant pain, and by the coexistence of syphilis in 
other parts of the body. 
3. TREATMENT. 
The treatment of tertiary syphilis reposes upon broad, scientific, and philosophical 
principles, and may, therefore, generally be pursued with a positive certainty of affording 
great relief, if not ultimate eradication. Even the worst cases may usually be immensely 
benefited in a very short time under the modern system of treatment; and I have repeat- 
edly seen patients, apparently on the verge of the grave, who had not enjoyed a comfort- 
able night’s sleep for years, and whose bodies had been sadly deformed and racked by 
pains, raised to health and usefulness by a few doses of medicine. The remedy to which 
we are indebted for these wonderful effects is the iodide of potassium, first employed in 
this class of affections by Dr. Wallace, of Dublin, a remedy, which, if there be such a 
thing as a specific, is unquestionably entitled to that distinction. Experience has shown 
that it exercises the same happy influence in tertiary syphilis as quinine in intermittent 
fever, or arsenic in neuralgia. It is the remedy par excellence in tertiary syphilis; a 
modern discovery of stupendous consequence to the human race ; a remedy without which 
it would be impossible to treat this disease with any prospect whatever of success in almost 
any case, however simple. Nevertheless, it must not be supposed that iodide of potassium 
is absolutely infallible; like quinine and other agents, it occasionally disappoints expecta- 
tion; but we may safely claim for it a degree of certainty which no other article of the 
materia medica, except, perhaps, iodide of sodium or iodide of ammonium, possesses as an 
antisyphilitic in the tertiary stage of the affection. 
The exhibition of iodide of potassium may usually be commenced without any pre- 
liminary treatment; it is only when the patient is anemic, or when there is great disorder 
of the secretions that any preparation of the system will be necessary, and then it need 
generally not extend beyond a few days. The proper mode of exhibition is that of solu- 
tion in distilled water, either alone, or with some bitter infusion or tincture, as hop, gen- 
tian, or quassia, such a combination being particularly desirable when a gentle tonic is 
required. The dose of potassium has been a prolific source of dispute. Long experience 
has taught me that, while less than eight or ten grains rarely do much good, there are 
few cases in which more than this quantity is rarely ever needed, repeated three times a 
day, at intervals of eight hours, the most favorable period for the administration being 
about one hour after eating. When a rapid effect is required, as when there is unusual 
urgency of the symptoms, an additional dose maybe given, but this will seldom be neces- 
sary. I have occasionally exhibited twenty, twenty-five, and even thirty grains at a dose 
thrice daily, but the effect, instead of being gratifying, has generally disappointed me, 
the medicine seemingly acting as an irritant rather than as a calmative, as it does when 
it agrees perfectly with the system. I have never given the article in drachm doses, as 
it sometimes is by others, and I should regard such practice as altogether unmeaning, if 
not positively prejudicial. The disease cannot be taken by storm ; the treatment must 
be chronic, in conformity with the course of the malady which it is intended to cure ; hence 
it requires patience, regularity, and perseverance, rather than a display of vigor and 
heroism. The object should be to accomplish a certain amount of good every day, 
until the implacable foe is effectually expelled from the system. If the treatment be con- 
ducted upon this plan, a most rapid and decided amendment generally occurs; the sleep, 
appetite, and strength steadily improve; the countenance loses its wan, cachectic appear- 
ance; and in less than a fortnight, often indeed in less than a week, the patient looks and 
acts as if he were a new being, his whole condition, physical and mental, evincing the 
astonishing change wrought by the medicine. 
Iodide of potassium, especially if given in large doses, occasionally signally disagrees CHAP. IX. 
TREATMENT OF TERTIARY SYPHILIS. 
325 
with the system, rendering it necessary either to suspend its use altogether, or to admin- 
ister it in a modified form, or in smaller quantity. The most common effects ot‘ it are 
an irritable condition of the air-passages, with a sense of fulness in the head and frontal 
sinuses, a thin, watery discharge from the nose, more or less sneezing, vascular injection 
of the conjunctiva, and a general feeling of discomfort, the symptoms strongly resembling 
those of a severe coryza. These effects sometimes declare themselves after the exhibi- 
tion of a few doses only of the medicine ; at other times they do not appear until after 
the lapse of eight or ten days, or until the system has been pretty well saturated with it. 
In some cases, depending evidently upon a strong idiosyncrasy, almost the smallest quan- 
tity is sufficient to produce excessive discomfort, and an invincible repugnance to the fur- 
ther use of the remedy. Among the more uncommon effects to which the iodide of 
potassium may give rise are, gastric irritation, diarrhoea, salivation, glossitis, vesicular 
eruptions of the skin, excessive diuresis, hemorrhagic discharges from the urethra and 
vagina, and cerebral excitement not unlike that occasioned by alcoholic stimulants. 
The best mode of counteracting these disagreeable effects is to combine with each dose of 
the medicine an anodyne, as a small quantity of morphia, or a few drops of acetated tinc- 
ture of opium. In some cases I have found the free use of strong hop tea to answer the 
purpose, while in others a mere diminution of the dose was sufficient. I remember but 
few instances in which I was compelled, on this account, to abandon the exhibition of 
the article altogether. 
The length of time during which the potassium should be continued must, of course, 
vary in different cases and under different circumstances. In the great majority of in- 
stances it should be exhibited for many weeks and even for a number of months, with an 
occasional intermission of three or four days, in order to afford the system a short respite, 
which is always found to be highly beneficial whenever a medicine is employed chroni- 
cally. An invariable rule with me is to continue the remedy for several weeks after all 
disease has apparently vanished ; and afterwards to give it for eight or ten days at a time 
at intervals of a month, on the same principle that quinine is administered periodically 
for the radical cure of intermittent fever. 
Iodide of potassium is sometimes advantageously combined with carbonate or muriate 
of ammonium, the two articles being given in solution, in equal proportions, thrice a day. 
As a substitute for this article, I often prescribe iodide of sodium or iodide of ammonium 
Both preparations are, I am satisfied, fully equal, as antisyphilitics, to the iodide of potas- 
sium. During my connection with the Philadelphia Hospital ample opportunity was 
afforded me of testing their efficacy in numerous instances ot‘ tertiary syphilis in all parts 
of the body; and for the last fifteen years I have rarely employed anything else in pri- 
vate practice for the relief of this disease. The iodide of sodium is preferable to the 
iodide of ammonium, as the latter is not only offensive to the taste, but liable, unless com- 
bined with some corrigent, to nauseate. The average dose of either should not exceed 
eight or ten grains, and the best time for their administration is from half an hour to an 
hour after meals. Their action should be aided, when there is much emaciation, by cod- 
liver oil, iodide of iron, a generous diet, and alcoholic stimulants. 
How the iodides act in affording relief in the treatment of tertiary syphilis, whether 
by neutralizing the poison, or by eliminating it from the system through the emunc- 
tories, is still a mooted question. One thing is very certain, and that is, that it passes off 
largely by the kidneys, generally within a very short time after it is swallowed. 
Although iodide of potassium and its kindred articles alone will often rapidly relieve 
tertiary syphilis, their efficacy is generally very materially enhanced by the addition of a 
small quantity of mercury. Indeed, so thoroughly am I convinced of the decided supe- 
riority of this course, that I have for many years almost invariably employed it, thus 
greatly abridging the treatment, and much more completely eradicating the disease. The 
plan is particularly beneficial when the affection is of long standing, when it has deeply 
penetrated the system, as shown by the existence of nodes, nocturnal pains, and ulcers 
of the skin, and when the patient has been fruitlessly subjected to frequent courses of 
the iodides alone. An infirm, broken state of the system is no bar to the use of mercury 
in this mode of combination ; on the contrary, it often affords the medicine an opportunity 
for its best display, especially if it be used along with tincture of chloride of iron. 
The form of mercury which I prefer is the bichloride ; it is readily dissolved by the 
potassium, sodium, or ammonium, and may be given in doses varying from the eighth to 
the sixteenth of a grain, three times a day. The best plan usually is to begin with the tenth 
of a grain, gradually increasing the quantity if necessary, on account of the obstinacy of the 
case, to the eighth or sixth of a grain, which should rarely, if ever, be exceeded. The 326 
VENEREAL DISEASES. 
CHAP. IX. 
effects of the remedy are, of course, carefully watched, the slightest tendency to ptyalism 
being a sign for its suspension, or, at all events, its more guarded use. It will generally 
be found beneficial to continue the mineral until there is slight tenderness of the gums, 
with a metallic taste in the mouth, and to keep up this action afterwards for several 
weeks by repeating the dose occasionally as the effects begin to hag. In short, chronic mer- 
curialization is aimed at, not acute, which never fails to do harm, sometimes immense and 
irreparable. After the mercurial course has been sufficiently prolonged, the cure may be 
completed by the use of one of the iodides, now given by itself, perhaps in reduced doses, 
simply to maintain a slight constitutional impression. 
When the bichloride disagrees, which, however, is seldom the case, a good substitute, 
will be found in the biniodide, which, indeed, sometimes yields better results than the bi- 
chloride. The ordinary dose is one-sixteenth of a grain, gradually increased to one-eighth 
or even one-fourth, thrice a day. The protiodide occasionally answers well, but is more 
apt to gripe and nauseate. Donovan’s solution, a compound of mercury, iodine, and 
arsenic, is sometimes advantageously exhibited, the dose being from five to eight drops. 
It often proves serviceable in relieving rheumatic pains and swellings of the bones and 
periosteum, but it must be given cautiously, as it is very liable to nauseate. 
Instead of giving mercury by the mouth, it may sometimes be beneficially administered 
by the rectum in the form of suppository, consisting of half a drachm of strong mercurial 
ointment, rendered stiff with a little tallow, and repeated twice or thrice in the twenty- 
four hours, until the gums are slightly affected, as they often will be in a very few days. 
The bowels should be well cleared out previously, after which a little morphia should oc- 
casionally be exhibited in order to secure the retention of the suppository. This method 
of treatment is particularly applicable to constitutional syphilis, as it is at once efficient 
and harmless. 
The hypodermic use of bichloride of mercury, in quantities varying from the eighth to 
the fourth of a grain every twenty-four hours, has been warmly advocated during the 
last ten years, especially by Max-Van-Moss, Lewin, Kobn, Muller, and Dr. R. W. Tay- 
lor. The chief objections to it are that it is inconvenient, that it is liable to produce 
abscesses and severe salivation, and that patients are often unwilling to submit to it on 
account of the pain caused by the prick of the syringe, and the contact of the salt with 
the tissues. To moderate this, the salt should be combined with the eighth or tenth of a 
grain of morphia. The most eligible points for the injection are the outer sides of the 
extremities, the chest, shoulders, loins, and nates. Slight ptyalism usually supervenes in 
a few days. With a view of overcoming its irritating effects, the remedy may be combined 
with peptone, by rubbing together one drachm of the bichloride, two drachms of chloride 
of sodium, and one drachm of peptone, dissolving the product in the smallest possible quan- 
tity of water, filtering the solution, and evaporating it in vacuo. When perfectly dry, the 
mercuric peptone is again reduced to powder, and one drachm to three ounces of distilled 
water forms a one-per-cent, solution of the corrosive sublimate, of which about twelve 
minims may be used at each injection. The full value of this species of medication re- 
mains to be tested. 
When the system is much dilapidated, mercurialization is best attained by inunction, 
fumigation, or the vapor bath, the remedy, when thus introduced, acting often much more 
beneficially and kindly than when administered by the mouth, which, indeed, it rarely, if 
ever, should be in such a condition. 
The topical application of mercury is particularly to be commended when the syphilitic 
disease is of unusually long standing; when the surface is covered with irritable, painful, 
and intractable sores ; when there is deep involvement of the bones, as declared by the 
existence of nodes, diffused swellings, or caries and necrosis ; or when the system is 
greatly exhausted by protracted suffering, want, and exposure, or long and injudicious 
courses of mercury by the mouth. Thus employed, its effects frequently display them- 
selves in the most striking and efficient manner, in the rapid and extraordinary improve- 
ment that follows in the character of the several local affections and the condition of the 
general system. 
The article commonly employed for inunction is the mild mercurial ointment, from a 
drachm to a drachm and a half being rubbed upon the inside of the thighs and arms, 
once a day, until the constitutional effects of the medicine become apparent by the state 
of the gums, breath, and saliva. I usually add a small quantity of powdered camphor, 
with a view of rendering the ointment more soluble, and thereby facilitating its introduc- 
tion into the skin. The friction should be very thorough, and continued until the oint- 
ment has nearly disappeared from the surface. A more cleanly mode of inunction is to CHAP. IX. 
TREATMENT OF TERTIARY SYPHILIS. 
327 
rub the ointment into the soles of the feet, the action of the remedy being greatly pro- 
moted by walking. The same stockings should be worn continuously for a week, when 
the feet are thoroughly washed with hot water and soap, and the frictions are resumed 
after an intermission of two or three days. The mercurial ointment may be replaced by 
the twenty-per-cent, oleate of mercury, diluted with an equal quantity of cosmoline. 
Mercurial fumigations may be conducted in a very cheap and simple manner. All 
that is necessary is a large comfort, long enough to extend from the floor to the patient’s 
neck, to which it is carefully secured with a piece of tape, to prevent the fumes from 
escaping into the room and injuriously entering the sufferer’s lungs. Or, instead of this, 
the body may be surrounded with a cloak of oil- or gum-cloth. The patient, completely 
stripped, is seated in a large arm-chair, or upon a stool, beneath which is placed the fumi- 
gating apparatus, consisting of a tin framework with a thin iron plate, and a small spirit 
lamp, so situated as not to endanger 
the safety of the person. The most 
suitable mercurial preparations are the 
protiodide, bichloride, and biniodide, as 
they admit of ready volatilization at a 
comparatively low temperature, and 
furnish an abundant vapor. The ope- 
ration, repeated once a day, lasts from 
ten to twenty minutes, at the end of 
which the patient is put to bed, well 
covered, in order to maintain perspira- 
tion. Great prostration, however, may 
follow this sweating process, if it be 
carried too far, or renewed too frequently. 
The duration of the treatment must de- 
pend upon circumstances, the average 
period being from two to three weeks. 
Mercurial fumigation may sometimes 
be advantageously combined with steam 
in the form of the mercurial vapor-bath. 
A very simple mode of applying it is to 
volatilize the mercury, and to convey 
the steam by means of a tube from a 
boiler to the patient’s body as he sits in 
his chair. The most unexceptionable 
plan, however, is the employment of a 
tin vessel, with two compartments on 
the top, one containing a pint of hot 
water, and the other, the central one, 
the requisite quantity of mercury. The heat is applied with a spirit lamp, the patient 
being wrapped up in the usual manner. Instead of this contrivance, the more elaborate 
apparatus represented in tig. 88, and devised by the late Dr. Thomas F. Maury, of Wash- 
ington, which may be attached by means of a flexible tube to an ordinary gas fixture, 
may be employed. The best articles are the protiodide, bichloride, and biniodide of 
mercury, their volatility, as I have ascertained by experiment, being in the order here 
enumerated. Calomel requires a much higher temperature for volatilization than these 
preparations, while the red sulphuret, formerly so much employed, is altogether unfit for 
the purpose. Whatever substance be used, the vapor should be brought as thoroughly as 
possible in contact with the syphilitic sores. 
More or less of the mercury is usually deposited upon the surface of the body, where 
it must be left to undergo partial absorption. Hence special care must be taken not to 
wipe the skin. A little vapor, freely diluted with air, may also be inhaled, especially if 
the principal disease is in the nose and mouth. The operation should be repeated once a 
day, from ten to twenty minutes at a time, when the patient is put to bed, well covered, 
to favor gentle perspiration. 
When there is much disorder of the secretions, derangement of the alimentary canal, or 
a feverish state of the system, a short course of preliminary treatment will generally be 
necessary, as this will greatly augment the efficacy of the fumigation. 
Simple and medicated baths often prove serviceable in tertiary syphilis, not only as 
means of cleanliness, but by the direct soothing and healing influence which they exert 
Fig. 88. 
Maury’s Fumigating Apparatus. 328 
VENEREAL DISEASES. 
CHAP. IX. 
upon the part and system. They are particularly beneficial in ulcers of the skin and in 
rheumatic pains of the bones and joints. An emollient bath, prepared with starch or 
wheat bran, generally proves most grateful. The common salt-water bath, or a bath con- 
taining a small quantity of carbonate of potassium or chlorinated sodium, is an excellent 
detergent and stimulant in the foul ulcers of the skin and bones so common in the ad- 
vanced stages of syphilis. Occasionally the water may be advantageously impregnated 
with bichloride of mercury, from three to ten grains of the salt being added to the gallon 
of fluid, and the immersion continued for twenty, twenty-five, or thirty minutes. Much 
caution, however, is required, especially when the surface is considerably denuded, other- 
wise severe ptyalism may arise. Baths containing nitric, hydrochloric, carbolic, or acetic 
acid, are sometimes beneficial. 
Besides mercury and the other articles above mentioned, there are certain remedies 
which, although usually considered as being merely auxiliary, are, nevertheless, of great 
consequence in a curative point of view in the treatment of syphilis. At the head of 
these may be placed a properly regulated diet, tonics, sudorifics, and anodynes, which de- 
serve the greatest attention in every case of the disease. 
It is impossible to insist too strongly upon a wrell-regulated diet in the treatment of this 
affection, when it is recollected how much its progress and virulence are influenced by the 
exhausted and impoverished condition of the system which so generally attends it in its 
more advanced stages. No medicine can possibly produce its full effects under such cir- 
cumstances, without the aid of good, wholesome, and easily digestible food, stimulating 
drinks, especially brandy or whiskey, and an abundance of milk and fresh air. The blood 
must be enriched and the solids rebuilt before it will be possible to neutralize the specific 
virus, or to eliminate it from the system. 
Tonics are nearly alwayrs indicated ; and quinine and iron usually answer better than 
any other combination. The bitter extracts, as gentian and quassia, are generally useless, 
except in so far as they may tend to improve the appetite. Occasionally benefit accrues 
from the use of some of the mineral acids, particularly the nitric and phosphoric, largely 
diluted with water. Formerly, powerful antisyphilitic properties were ascribed to these 
articles, but it is probable that their good effects are solely due to their tonic virtues, and 
not to any agency in neutralizing the syphilitic poison. When much emaciation exists, 
with want of assimilative power, or a feeble digestion, there is no more useful article than 
cod-liver oil, given in doses suited to the state of the stomach and the general condition 
of the system. 
Sudorifics have long held a high rank in the treatment of syphilitic affections, under a 
supposition that they aid in eliminating the venereal poison, thus ridding the system of 
its noxious influence. Whether they possess such property or not, there is no question 
as to their general usefulness in all states of the economy attended with obstructed per- 
spiration, so often present in the advanced stages of syphilis, particularly when there is 
serious involvement of the skin. The object for which such medicines are usually pre- 
scribed may readily be obtained by the warm, hot, or steam bath, assisted by tepid drinks, 
and various kinds of diaphoretics, as Dover’s powder, antimony and morphia, and similar 
articles. Some caution is necessary in the use of sudorifics, lest injurious debility be 
induced. 
But of all the auxiliary remedies now described, the most important, in every respect, 
are anodynes; their employment is absolutely indispensable, and it is, therefore, impos- 
sible to assign to them too high a rank. They are, up to a certain stage of the treatment, 
of more consequence even than food and drink. The patient is not only unable to sleep, 
but his body is literally racked with pain and irritability. To look, under such circum- 
stances, for any substantial improvement from ordinary remedies, would simply be absurd. 
The first thing to be done is to quiet the system and induce sleep; and to accomplish 
this, anodynes must be exhibited in large and sustained doses, a quarter of a grain of mor- 
phia, or its equivalent of solid opium, laudanum, or black drop, being given every eight, 
ten, or twelve hours, according to the effects of the article. The manner in which ano- 
dynes are often borne, in the worst forms of tertiary syphilis, is astonishing, and can only 
be explained by the tolerance established by the irritable condition of the nervous system. 
When the insomnia depends upon exhaustion, the morphia may generally be advanta- 
geously combined with chloral, or chloral may be freely given by itself. 
As to sarsaparilla, formerly so much vaunted in the treatment of this disease its 
employment in my hands has never been productive of any appreciable benefit. Whether 
this has arisen from ill luck, or from the use of an inferior article, it is not in my power 
to affirm ; I may state, however, that I have exhibited it in every form and mode of CHAP. IX. 
TREATMENT OF TERTIARY SYPHILIS. 
329 
combination in which it is given in this and other countries, and am, therefore, inclined 
to believe that it has been invested with virtues which do not belong to it, or which are 
due mainly, if not solely, to its associate ingredients. 
Finally, persons laboring under tertiary syphilis should have the benefit of a pure, dry 
atmosphere, and be well protected from cold by flannel worn next to the skin both summer 
and winter. When it is remembered how easily the disease is provoked by suppression of 
the cutaneous perspiration, and by living in damp, underground, and ill-ventilated apart- 
ments, the importance of attention to this injunction cannot fail to be fully appreciated. 
Sea bathing and a residence at the seaside are often of advantage in syphilitic persons 
of deteriorated constitution ; and the Hot Springs of Arkansas have become a sort of 
El Dorado for this class of patients, thousands annually flocking to them from different 
sections of the United States. It is questionable, however, whether the use of these 
waters is of any real benefit. The good which results from the visits is probably due, in 
great measure, if not entirely to the change of air, food, and scene, and to the liberal 
employment of the iodides and of mercury to which this class of patients are invariably 
subjected by the resident physicians. The use of sulphur water, in the form of drink and 
baths, bas also been greatly extolled, but the praises lavished upon it have never been 
realized. In France, Germany, and other European countries there are a number of 
resorts celebrated for their supposed antisyphilitic virtues. 
Syphilitic affections of the nervous system must be treated with the iodides in very 
large doses, experience having shown that the doses administered in syphilis as it occurs 
in other parts of the body are worse than useless. Not less than twenty, twenty-five, or 
thirty grains should be given thrice a day an hour and a half after meals, and this quan- 
tity should be gradually increased, with an occasional intermission, to the full extent of 
tolerance of the stomach. The efficacy of the prescription will be materially increased by 
the addition to each dose of the eighth or tenth of a grain of bichloride of mercury and 
an occasional large dose of quinine. An issue made with the hot iron when the seat of 
the disease can be localized, will be found to be a powerful adjuvant. When, from idio- 
syncrasy, or any other cause, the iodides are inadmissible, our main reliance must be upon 
mercury, carried, if the system is not too much impaired, to slight but persistent pytalism. 
The treatment of tertiary syphilis of the heart and bloodvessels, the lungs, liver, and 
spleen, differs in no respect from those just mentioned in connection with the treatment of 
syphilitic affections of the nervous system. The great point is to push the remedies to the 
utmost before the gummy or specific matter has undergone the softening process. 
In regard to the topical treatment there are certain rules which are applicable to all 
local affections, whatever their nature, site, or extent. Thus, there can be no hesitation 
about the removal of dead bone, opening abscesses, tracing out sinuses, dividing fasciae or 
aponeuroses, and trimming off the ragged, undermined, and impoverished edges of cuta- 
neous ulcers, so as to place them in a more suitable condition for speedy repair. All this 
is self-evident, and only requires mention to secure attention. Cleanliness is of para- 
mount importance, as it contributes not merely to personal comfort, but also, in a powerful 
degree, to recovery. Fetor is allayed by the free use of deodorizers, as chlorinated sodium 
and permanganate of potassium. 
Ulcers, fissures, eruptions, papules, and tubercles of the skin often recover under very 
simple topical treatment, as weak solutions of nitrate of silver, or acid nitrate of mercury, 
aided by the use'of iodide of potassium, or potassium and mercury, with attention to 
cleanliness and other hygienic observances. When much inflammation is present, with a 
foul appearance of the part and a tendency to spread, acetate of lead and opium will come 
in play, with emollient cataplasms, or warm water-dressing, simple or medicated. Touch- 
ing the sores lightly once a day, or every other day, with dilute acid nitrate of mercury or 
a weak solution of nitrate of silver, generally singularly promotes the cure. Unguents 
are not always as bad as they have been represented to be in these cases. I have often 
employed them with excellent effect, especially opiate cerate, balsam of Peru ointment, 
and ointment of nitrate of mercury, weakened with six, eight, or ten times its bulk of 
simple cerate or cosmoline. Mercurial ointment, diluted, and mixed with opium, fre- 
quently makes a most useful dressing in the indolent form of rupial ulcer. Sprinkling 
the surface of the sore with calomel, iodoform, or nitrate of lead, and keeping it covered 
with dry lint, sometimes rapidly promotes cicatrization. 
The bronze and copper-colored stains of the skin which follow certain forms of syphilis 
are often very unseemly, and, therefore, a source of annoyance to the patient. The best 
remedies are minute doses of mercury and the frequent use of the sulphur vapor-bath. 330 
VENEREAL DISEASES. 
CHAP. IX. 
Syphilitic onychia is, strictly speaking, a rupial ulcer, to be treated in the same manner 
as similar sores elsewhere. One of the most valuable applications is nitrate of lead, sprinkled 
upon the sore several times a day, and kept in [dace with dry lint. Iodoform is also a useful 
remedy. Unhealthy granulations must be repressed with caustics or the scissors. If 
abscesses form under the nail, they must be punctured; and if the nail die, it must be 
removed, or trimmed, especially if it overhang and injuriously compress the diseased 
structures. Friable onychia demands no special treatment beyond trimming of the nails, 
and the application of lead water, if the soft parts around are inflamed. 
The topical treatment of tertiary ulcers of the throat, mouth, and tongue is restricted 
principally to applications of acid nitrate of mercury and solid nitrate of silver, at first 
once a day, and subsequently every third or fourth day, according to the condition and 
progress of the soi’e. Weak gargles, or washes of acetic acid, tannic acid, and sulphate of 
copper, chlorinated sodium, or cyanuret of mercury, from ten to sixteen grains of the salt 
to a pint of some bland, mucilaginous fluid, as linseed tea or infusion of elm bark, may 
be employed in the intervals. 
In the treatment of syphilis of the nose, the chief reliance must be upon injections of 
weak lotions of iodide of iron, sulphate of copper, and tannic acid, tincture of myrrh, 
permanganate of potassium, and chloride of zinc, particularly the latter, as they impart not 
only a healthy stimulus to the affected surfaces, but effectually allay fetor, so distressing 
in this class of complaints. Mercurial preparations are generally improper, from their 
liability to pass into the stomach, and thus occasion salivation. In using injections for 
the nose, a large syringe with a long, perforated nozzle is required, to bring the fluid fully 
in contact with every portion of diseased structure. They should be repeated at least 
thrice a day, with special care not to distress by their severity. The hydrostatic mode of 
cleansing and medicating the nose, with Thudichum’s apparatus, is now generally, and, 
indeed, very justly preferred to the more ordinary procedure, as it is far more thorough 
and effective. 
If the affected parts are within reach, regular and steady medication may be effected 
with lint smeared with some suitable ointment, as glycerine and tannic acid, or wet with 
some slightly stimulating lotion, as Goulard’s extract, nitrate of silver, sulphate of copper, 
or chlorinated sodium. In all cases the nasal cavities should be frequently inspected, with 
a view to the early detection and removal of dead bone. 
In syphilis of the larynx direct medication may be attempted by means of the mop wet 
with a weak solution—from ten to twenty grains to the ounce—of nitrate of silver, intro- 
duced once every third or fourth day, the patient being at the moment partially under the 
influence of chloroform, so as to render the parts more passive, and, consequently, more 
tolerant of the operation, which is otherwise very apt to prove abortive. When the dis- 
ease is extensive or the case urgent, as when there is deep ulceration with excessive 
difficulty of deglutition, frequent spasm of the muscles, or oedema of the glottis, the only 
resource is tracheotomy. Direct medication may then be made with acid nitrate of mer- 
cury or with any other article that may seem expedient. If warty excrescences exist, 
they may be clipped off with the scissors, repullulation being prevented by escharoties or 
sorbefacients. Dead cartilage is removed in the usual way. 
The great remedy for syphilitic iritis is mercury pushed to rapid but general ptyalism. 
If the patient is young or plethoric, blood is freely taken from the arm, or by leeches and 
cups from the temple. Opium is given to allay pain and to restrain the action of the 
mercury upon the bowels. If, on the other hand, there is evidence of exhaustion, or of an 
anemic, shattered state of the constitution, stimulants and tonics, as iron and quinine, 
with a generous diet, and gentle exercise in the open air are at once employed. Mercury 
is either entirely omitted, or administered very sparingly. In general, the most suitable 
article, in this condition of the system, is corrosive sublimate in union with iodide of 
potassium. Turpentine, so strongly recommended by Carmichael and others in such 
cases, as a substitute for mercury, is seldom of any use, and is certaidly not reliable as a 
curative agent. In addition to these general measures it is of the first importance to 
keep the pupil constantly dilated by instillations of four grains of sulphate of atropia to 
the ounce of distilled water. 
Syphilitic ulcers of the eyelids generally promptly yield under the influence of iodide 
of potassium and the application of very dilute citrine ointment. 
Syphilis of the ear is managed upon the same general principles as syphilis of other 
organs. The great remedies ai'e mercury and potassium, aided by leeches, blisters, and 
mildly astringent injections. CHAP. IX. 
TREATMENT OF TERTIARY SYPHILIS. 
331 
The local treatment of affections of the bones and periosteum must be strictly anti- 
phlogistic. The pain and swelling are often immensely benefited by tincture of iodine, 
leeches, and blisters, although in very many instances they readily yield to the exhibition 
of iodide of potassium and mercury. A node, as a rule, should not be opened so long as 
it is very small, and free from serious annoyance; when the reverse is the case, it should 
be freely incised, and so also if it be the seat of distinct fluctuation, denotive of the exist- 
ence of matter. A good rule, under such circumstances, is to make the knife graze the 
bone, imperfect division of the parts being generally worse than useless. If the resulting 
ulcer is slow in healing, it should be well blistered, or dressed with mercurial ointment, 
or some stimulating and anodyne lotion. Sometimes the pain and tension of a node may 
speedily be relieved by subcutaneous incision, effected by means of a delicate bistoury, 
carried about in different directions and in such a manner as also to divide the periosteum. 
Necrosed bone must be removed as soon as it is sufficiently loose to admit of easy separa- 
tion ; while carious bone must be scraped and otherwise managed to put it in a suitable 
condition for repair. Diffused hypertrophy rarely requires any other than constitutional 
remedies. When the affection is circumscribed or not too widely extended, great and 
prompt relief sometimes follows the use of the trephine, several small, circular disks being 
removed by carrying the instrument nearly through the entire thickness of the affected 
bone. When the disease is caused by an abscess, nothing short of such an operation will 
be of the slightest benefit. Evacuation must be effected without delay. An exostosis, 
acting obstructingly, must be removed with the saw or pliers. 
The most suitable means in syphilitic synovitis are iodide of potassium and mercury 
internally, and locally acetate of lead and opium, leeches, blisters, and tincure of iodide, 
with perfect rest of the affected joint. 
Syphilitic sarcocele is treated, topically, upon the same principles as swelling of the 
testicle from gonorrhoea; by rest of the body and elevation of the parts, leeches, astringent 
and anodyne fomentations, and mild mercurial inunctions. When the enlargement is 
indolent and rebellious, strapping may be employed, either with common adhesive plaster, 
mercurial and ammoniac plaster, or the plaster of Vigo. The cure is often retarded in 
these cases by the presence of a considerable quantity of serum in the vaginal tunic, com- 
pressing and irritating the diseased organ; an effect generally promptly relieved by a free 
incision, or by numerous punctures. Abscesses are treated in the ordinary manner. 
Internally free use is made of the iodides. 
When the testicle is fungous, ulcerated, and completely disorganized, the only resource 
is removal, no treatment, either general or local, proving of any service in such a case. 
Before, however, so serious an operation is ventured upon, it should always be ascertained 
by exploratory incisions that the organ is really, and not merely apparently, past recovery. 
The treatment of condylomatous growths must be general and local. Topical applica- 
tions alone will, it is true, often effect riddance without difficulty; but to cure the disease 
permanently constitutional medication is usually indispensable. The most efficacious 
remedy, undoubtedly, is iodide of potassium in union with bichloride of mercury, admin- 
istered as in ordinary cases of tertiary syphilis, the diet, bowels, and secretions being at 
the same time suitably regulated. The specific treatment should be prolonged, in a modi- 
fied manner, for several weeks after all disease has apparently vanished, in order to break 
up the tendency to recurrence. 
In regard to the topical treatment, cleanliness is of primary importance, hardly less on 
account of the attendants than the patient himself. Free use must be made of tepid water, 
impregnated with chlorinated sodium, and applied by means of a sponge or syringe, the 
dressings and the bedclothes being frequently sprinkled with the solution, especially if 
there be much discharge. Another important element of treatment is perfect rest with 
isolation of the affected parts, their contents, as previously stated, having a tendency to 
foster growth and secretion. To repress the tumors, various articles may be used, one 
of the best of which is chromic acid, brushed on once in the twenty-four hours, until they 
are shrivelled and dried up, as they generally will be in a few days. A lotion of bichloride 
of mercury, in the proportion of twenty grains to the ounce of water, is also an excellent 
remedy. Nitrate of silver, nitric acid, and acid nitrate of mercury, so commonly recom- 
mended, are all extremely severe, besides being very uncertain. In the intervals of the 
applications, the excrescences should occasionally be sprinkled with some desiccating sub- 
stance, as calomel, prepared chalk, or carbonate of zinc, and protected with a large roll of 
dry lint, retained with a T-bandage. Under this management, the tubercles soon lose 
their sensibility, and rapidly disappear. Perfect cleanliness must be observed for a long VENEREAL DISEASES. 
CHAP. IX. 
time after the cure is completed, otherwise relapse may occur. When unusually large 
and rebellious, the growth is more easily disposed of with the scissors, the hemorrhage, 
which is often copious, being repressed, if necessary, with Monsel’s salt. 
SYPHILIS IN THE INFANT. 
There are two modes in which infants may become infected with syphilis. First, they 
may suffer from direct inoculation, and, secondly, the disease may be communicated by 
either parent ; by the father in the act of copulation, or by the mother during the progress 
of pregnancy. It has also been supposed that a child may be contaminated by the milk of an 
unsound nurse ; and there are numerous cases upon record, going to show that the poison 
may be communicated in suckling by a sore or mucous tubercle on the nipple. Direct 
primary syphilis, however, is most generally contracted during parturition, as the child 
passes through the soft parts of the mother, from inoculation of the body with the secre- 
tions of a chancre of the uterus, vagina, or vulva. The idea that the specific matter may 
enter the system through a sound surface, by the agency of the absorbent vessels, is 
untenable. 
In whatever manner the infection is communicated, the disease pursues the same course 
as when it occurs in the adult, whether from sexual intercourse or artificial inoculation. The 
child may perish from the local irritation, or, if it survive the primary affection, it may 
afterwards suffer from constitutional syphilis, the impression manifesting itself in cuta- 
neous eruptions, mucous tubercles, sore throat, ulceration of the nose, gummy tumors in 
different parts of the body, and rheumatic pains in the bones and joints. 
In the great majority of cases of infantile syphilis, however, the disease is communicated 
either through the seminal fluid of the father in the act of procreation, or by the mother 
through her blood after the ovum has taken up its residence in the uterus. That the 
contamination may occur in both of these ways is a fact that has long been incontestably 
established. The semen is a living fluid, and in a man laboring under constitutional 
syphilis the probability is that every spermatozoon is completely impregnated with the 
specific poison; hence it is only necessary that it should come in contact with the ovum of 
the mother in order to produce thorough vitiation of the new being. Thus, the very 
fountain of life is poisoned in the very act of conception, and it is, therefore, not surprising 
that all rts sources should participate in the evil thus entailed. 
The time at which a female with secondary symptoms may communicate the poison to 
her offspring cannot be accurately stated. The probability is that it is very short. This 
is proved by the circumstance that such a woman frequently aborts within a few months 
after conception, evidently from the deleterious effects of the virus upon the foetus. It is 
supposed that syphilis may be communicated to the child through the amniotic fluid, but 
if this be so, the question is still an open one. 
It has been alleged that a healthy child, or child born of healthy parents, may be in- 
fected by a nurse affected with secondary syphilis; the milk being tainted, and capable of 
communicating the disease. Of the possibility of such an occurrence I entertain great 
doubt; my own practice has certainly not afforded me any examples of it, while it lias 
fallen to my lot to see several cases where the converse was the fact, healthy children 
having sucked infected women, and yet remained perfectly sound. 
As an infected mother may communicate syphilis to her child in the womb, so, on the 
other hand, may a child, contaminated by its father, impart the disease to the mother, 
although she may herself have been perfectly sound at the moment of conception. The 
occurrence, however, is by no means constant. Dr. Victor De Meric, for example, has 
collected not less than thirteen cases in which the mother gave birth to a syphilitic child, 
and yet she hei’self never exhibited any signs of the malady in her own system. 
The question, whether an infected infant can communicate the disease to its nurse in 
the act of suckling, is well settled. The secretion from a mucous tubercle of the tongue, 
cheek, or lip may thus be brought in immediate contact wflth the nipple, which it will be 
almost sure, eventually, to inoculate, especially if it be the seat of any cracks, fissures, 
ulcers, or abrasions. It has been alleged, with a good deal of plausibility, that a woman 
affected in this manner may, in turn, infect her own offspring. In a case related by Mr. 
Hunter, and upon which great stress has usually been laid by authors, it is asserted that 
the diseased infant thus successively inoculated three wet-nurses, two of-whom afterwards 
conceived, and were delivered of syphilitic children. Although a wet-nurse may contract 
the disease in this manner, there is not, so far as is at present known, a reliable instance CHAP. IX. 
SYPHILIS IN THE INFANT. 
upon record in which a mother has ever been infected from suckling her own offspring. 
This apparent anomaly is readily explained by the fact that when the system has once suf- 
fered from a taint of this kind, it is not susceptible of a second attack. It proves the 
unicity of the poison, and shows that, under such circumstances, either both mother and 
child are equally affected, or that the mother is from some constitutional inaptitude inca- 
pable of contracting the disease. 
The question whether a husband laboring under secondary syphilis may communicate 
the disease to his wife through the agency of the semen, unaccompanied by impregnation, 
is no longer a mooted one. It is absurd to suppose that this fluid, when injected into the 
vagina and uterus, is ever absorbed, no matter how long it may be retained, so as to make 
a prejudicial impression upon her system. Of such an occurrence there is certainly no 
satisfactory proof. It is different when conception occurs. Here, as already seen, the 
semen mixes directly with the ovum of the female, to which it at once imparts its dele- 
terious properties, thereby effectually tainting the new being in the very act of its creation. 
Hereditary syphilis is generally a grave disease ; for, unless it is judiciously treated, it 
nearly always proves fatal. A great majority of the neglected cases terminate in abortion, 
the fuetus often perishing as early as the end of the third month, and from thence on death 
may occur at any period up to the full term of gestation, the child being usually thrown 
off in a putrid and more or less offensive condition. 
The immediate cause of abortion in a syphilitic mother is a diseased state of the pla- 
centa, commencing, apparently, at an early stage of pregnancy, in inflammation of the 
decidua, by which its substance is indurated and thickened, followed by obstruction in 
the maternal circulation, and consequent atrophy and arrest of development of the foetus. 
In addition to this there is always a greatly deteriorated state of the mother’s blood, render- 
ing it unfit as a source of nourishment. When the disease is communicated by the father, 
the placenta generally suffers secondarily, the syphilitic affection beginning in the foetus. 
The number of abortions is sometimes remarkable; in one instance, under my own 
observation, it amounted to thirteen, the woman never having brought forth a healthy infant; 
and in another there were fifteen abortions and miscarriages, with two healthy births between 
the seventh and ninth mishaps. Cases of three or four successive accidents of this kind 
are by no means uncommon. Now and then a woman will abort several times consecu- 
tively, and then be delivered of an apparently healthy child ; I say apparently healthy, for, 
although the new being may he perfectly plump and fat, and exhibit all the outward signs 
of the most perfect integrity, yet generally, in a very few weeks, it will be found to present 
unmistakable marks of decay and disease. The first thing that is usually noticed in a syphi- 
litic child is that it loses flesh and strength, becoming gradually thin and puling, and looking 
as if it had been withered by the sudden drying up of its juices. The skin, of a dingy, muddy 
shrivelled appearance, hangs about in loose, soft folds. The countenance, shrunken, wan, 
and ghastly, resembles that of a man of seventy-five or eighty, instead of an infant a few 
weeks old. The voice is husky; the respiration is snuffling; the throat is sore; the gums 
are red and spongy; the lips and anus are fissured ; and the body is covered with copper- 
colored eruptions, usually of the scaly kind, and intermixed with tubercles. Purulent 
ophthalmia is not uncommon, the inflammation coming on within two or three days after 
birth, and generally ending in total blindness. In some cases numerous superficial ulcers 
are found upon the surface, attended with a thick, tenacious, discharge, and a hard, red- 
dish, characteristic base. The hair often drops off in large quantity, both on the scalp, the 
eyebrows, and on the rest of the body. The well-developed node and orchitis are of rare 
occurrence in infantile syphilis. Death, under such circumstances, usually occurs within 
the first three or four weeks after birth. Occasionally, the patient may reach the end of 
the second or third year, and in exceptional instances life may even be prolonged until 
after the period of puberty, the individual having a stunted, sickly growth, accompanied, 
perhaps, with deep ulcerations of the throat, palate, nose, and skin, disease of the teeth, 
especially of the upper central incisors, caries of the bones of the extremities, and stiff- 
ness of some of the principal joints. Few children recover, and those who do are doomed 
to drag out a miserable existence, generally amidst the most loathsome and disgusting 
deformities. 
Under proper treatment, especially the judicious use of mercury, the specific virus in a 
syphilitic woman, may in time, be so completely neutralized as to enable her to bear healthy 
children. Bumstead thinks that, as a rule, after the lapse of six years, the influence of 
the disease is so far exhausted as to render the risk of transmission very slight. Such a 
statement must have many exceptions. 
Infantile syphilitic eruptions are liable to be mistaken for some of the more common VENEREAL DISEASES. 
CHAP. IX. 
affections of the skin incident to early childhood, and the diagnosis is, therefore, not tin- 
frequently environed with great difficulty. In obscure cases, the chief reliance is to be 
placed upon the history of the attack, and other concomitant circumstances. From three 
to four weeks after birth is the average period of the appearance of the cutaneous affec- 
tions, the sole of the foot, the buttock, scrotum, face, chest, and inside of the thigh and 
arm being the parts originally involved. The surface immediately around the eruptions 
is of a coppery, reddish-brown, or bronze color, a condition very different from what is 
observed in ordinary diseases, especially eczema, lichen, prurigo, and lepra, with which 
they are most liable to be confounded. Besides this, which is always a most important 
symptom, diagnostically considered, the general appearance of the infant shows that it has 
received a severe shock ; it is thin and emaciated, and progressively fails to an extent 
and in a manner altogether unusual in common cutaneous maladies. The old, withered, 
and shrivelled look of the child is, of itself, almost characteristic of the disease; the 
snuffling is another important element in the discrimination of the case, and too much 
stress cannot be laid upon the mottled, dingy, or muddy state of the skin. The history of 
the case will usually show that the parents have been the subjects of syphilis, or that they 
are actually suffering from its effects. 
Much stress is very properly laid upon the condition of the teeth as a diagnostic sign in 
hereditary infantile syphilis, attention having first been directed to the subject by Mr. 
Hutchinson, of London. The disease occurs chiefly in connection with, or as a result of, 
specific stomatitis, and displays itself more particularly in the upper incisors, although the 
lower incisors and even the canine teeth occasionally participate in the morbid action. 
The first evidence of the disease generally is a dirty, dingy, or light brownish appearance 
of the enamel of the central and afterwards of the lateral incisors, which soon begin to soften 
and crumble away, the child ultimately becoming edentulous. Both sets of teeth are cut 
prematurely, as well as very irregularly, as it respects their position in the jaw ; and, unless 
the constitutional taint is early eradicated, the permanent are doomed to share the same 
fate as the temporary, although they are destroyed less rapidly. 
Mr. Hutchinson considers the upper central incisors as the test teeth of hereditary 
syphilis. “ When first cut,” he remarks, “ these teeth are uncommonly short, narrow 
from side to side at their edges, and very thin. After a while a crescentic portion from 
their edge breaks away, leaving a broad, shallow, vertical notch, which is permanent for 
some years, but between twenty and thirty usually becomes obliterated by the premature 
wearing down of the tooth. The two teeth often converge, and sometimes they stand 
widely apart. In certain instances, in which the notching is either wholly absent or but 
slightly marked, there is still a peculiar color, and a narrow squareness of form, which 
are easily recognized by the practised eye.” The characteristic appearances of infantile 
syphilitic teeth are well illustrated in figs. 89 and 90. 
Fig. 89. 
Fig. 90. 
Syphilitic Temporary Teeth. 
Syphilitic Permanent Teeth. 
The eye also frequently suffers in inherited syphilis, iritis, and corneitis being the affec- 
tions most commonly met with ; they are more frequent in female than in male children, 
and occur alike in the well-fed and in the half-starved. Iritis seldom appears before the 
fifth month, and is usually attended with an abundant effusion of lymph, with great danger 
of occlusion of the pupil. Corneitis is most frequent from the eighth to the fifteenth year, 
and is almost invariably associated with a dwarfed and notched condition of the perma- 
nent central incisor teeth of the upper jaw. It generally gives rise to marked opacity of 
the cornea. 
Deafness is a not infrequent result of inherited syphilis. It may come on soon after 
birth, but it is most common from the tenth to the twentieth year; and, although it is gen- 
erally accompanied by more or less otorrhoea, it is essentially due to organic changes in 
the delicate structures of the internal ear; mainly, in all probability, to disease of the CHAP. IX. 
SYPHILIS IN' THE INFANT. 
auditory nerves. Inherited syphilis is a fruitful source of deaf-muteism. The loss of 
hearing nearly always atfects botli ears. 
Ulcers of the tonsils, uvula, palate, and pharynx are not infrequent; they usually come 
on before the eighth or tenth year, exhibit an excavated appearance, and, if not carefully 
watched, are apt to produce great havoc in the affected structures. The diagnosis is 
always easily determined by the peculiar character of the ulcers and their coexistence 
with syphilitic disease in other parts of the body. 
Nodes, enlargement at the junction of the epiphyses with the shafts, hypertrophy, 
and other affections of the bones of the extremities are very uncommon in infants ; but 
sufficiently frequent in children, especially in the humerus, radius, and ulna, which 
occasionally suffer simultaneously. Nodes of the phalanges of the fingers—the dactylitis 
of authors—are sometimes observed. A number of such cases have been under my care 
at the College Clinic, as well as in private practice. In a few of the cases the affection 
was congenital. The gummy matter is generally deposited, either simultaneously or 
successively, in the areolar osseous tissue and between the bone and periosteum, leading 
to great enlargement and deformity, attended with livid discoloration of the skin, and 
more or less pain, followed, at length, by suppuration and a bad form of ulcer, often 
involving several of the phalanges and even the contiguous joints. Nodes in children 
are occasionally multiple. It is a curious fact that the bones of the lower extremities, 
which so frequently suffer from syphilis in the adult, are seldom involved in this disease 
in very young subjects. Marked prominence, with more or less tenderness on percussion, 
of the frontal protuberance and cranial sutures is often met with, the affected part some- 
times presenting the appearances of slight exostoses. Syphilitic onychia is most common 
in very young children. 
Inherited syphilitic hypertrophy of the osseous tissue occasionally exists in a remarkable 
degree, as in a case at the College Clinic, in 1867, in a lad, fourteen years of age, in 
which the disease was, apparently, entirely limited to the radius, which was enlarged in 
a most extraordinary degree, both in length and thickness, from one end to the other. 
The wrist and elbow joints were normal. The right arm had been amputated at. the 
shoulder some months previously, on account of necrosis of the head and shaft of the 
humerus, attended with destruction of the articular cartilage, and great exhaustion from pain 
and suppuration. Treatment failed to make any impression upon the hypertrophied bone. 
Parrot has recently described an atrophic lesion of the cranial bones in inherited 
syphilis, in which there is gelatiniform transformation of the osseous tissue. The bones 
present a worm-eaten appearance, and the metamorphosis begins beneath the periosteum. 
The change cannot be recognized during life. 
The large joints, especially the elbow, knee, and ankle, are liable to suffer during the pro- 
gress of hereditary syphilis ; the attacks are uncommon in early childhood, but are not infre- 
quent after the fourth year, and are then generally attended with considerable pain, heat, 
and swelling, attended with more or less effusion of synovial fluid and disorder of 
the general health. In badly healed or neglected cases, the disease may terminate in 
abscess, anchylosis, or even complete destruction of the component structures of the 
affected joints. 
Syphilitic periostitis is very uncommon in infants, for the reason that in them all kinds 
of syphilitic affections are secondary, whereas in children they ai'e tertiary. Nocturnal 
pains are also of rare occurrence as an effect of inherited syphilis. Syphilis of the testis 
in infants is uncommon. It is characterized by great hardness of the organ, caused by 
interstitial hypertrophy of the connective tissue, and is occasionally noticed within a few 
months after birth, although it is most frequent after the second year. 
The gummy tumor of the heart is probably much more frequent in hereditary syphilis 
than is generally supposed. The disease has been studied with great care by Professor 
Virchow, who, in 1868 showed me numerous preparations illustrative of its nature and 
history. The liver also occasionally suffers in a similar manner. 
Hemorrhage is an occasional occurrence in hereditary syphilis, manifesting itself at 
various periods after birth, in some of the numerous outlets, as the mouth, anus, rectum, 
or vagina; in blotches under the skin, as in purpura ; in effusions into the serous sacs ; 
or in deposits in the substance of the brain, lungs, liver, or spleen. I have met with two 
cases in which fatal hemorrhage proceeded from the stump of the umbilicus of syphilitic 
children less than ten days old. In whatever form appearing, it is always denotive of a 
profoundly syphilitic condition of the system, and admits of no relief from treatment. 
Affections of the nervous system are not uncommon in inherited syphilis, appearing in 
various forms, sometimes soon after birth, at other times not until the age of ten, twelve, 336 
VENEREAL DISEASES. 
C1IAP. IX. 
or even fifteen years. The most frequent developments are chorea and epilepsy with 
paralysis of some of the cranial nerves, and affections of the retina, or of this membrane 
and of the choroid. Hemiplegia, with or without aphasia, is another occasional occurrence. 
Death in this condition of the system is often sudden and unexpected. Dissection gener- 
ally reveals the presence of gummy tumors, softened cerebral substance, arterio-capillary 
constriction, and various albuminoid or protoplasmic nutritive changes. 
The development of hereditary syphilis is occasionally postponed until a very late 
period, as the fifteenth, eighteenth, or twentieth year; and there is reason to believe that 
the poison may remain latent in the system even for a much longer time. It is an 
interesting fact that the subjects of hereditary syphilis are either insusceptible of primary 
syphilis, or, if they contract the malady, that they suffer from it in a modified form. 
Finally, hereditary syphilis, by impairing the general health, or, in other words, gradu- 
ally undermining thq powers of life, predisposes to scrofula, rickets, and phthisis. How 
far it may act as a cause of certain malformations, as harelip, cleft palate, or bifid spine, 
is still an open question. 
Treatment—The treatment of infantile syphilis is prophylactic and curative. If the 
mother be suspected to be laboring under a constitutional taint, as she justly may be if 
she has had several consecutive abortions or miscarriages, or if she is in infirm health, 
with eruptions upon the skin, a plentiful discharge from the vagina, or an ulcerated con- 
dition of the neck of the uterus, she should be promptly put upon a course of mercury 
and a properly regulated diet, in order to prevent the ill effects of the contaminated state 
of her blood upon the foetus, and thus enable the latter to attain its full growth, and the 
full period of gestation. The mercurial course should be chronic, not acute, and as gentle 
as possible, lest it should excite abortion ; and in most cases it will be beneficial to 
associate the mineral with the iodide of potassium and some preparation of iron, with a 
view to a tonic effect upon the general system, which, as already stated, is usually in an 
impaired and cachectic condition, and, therefore, in need of great attention to raise it to 
its normal level. The diet should be mild and nutritious, the clothing warm, and the 
patient well supplied with fresh air. 
As soon as the child is born it should be taken from its infected mother, and confided 
to a sound wet-nurse, as an appropriate diet is absolutely essential to its preservation. If 
no suitable wet-nurse can be obtained, it should be furnished with an abundant supply of 
fresh cow’s milk, or, what is better, of the milk of the ass, which approaches nearer to 
human milk, in some of its more important properties, than that of any other animal. 
The body and limbs should be well protected with flannel, and frequently bathed with 
tepid water, impregnated with bran, starch, or mucilage, especially if there be eruptions, 
fissures, or ulcers upon the skin. The child should breathe none but the purest air. The 
fact is, too much attention cannot be paid to hygienic measures. Cod-liver oil will prove 
a valuable adjuvant in all cases in which it agrees with the stomach. When the disease 
is associated with anemia and coldness of the extremities, quinine and iodide of iron must 
be employed, in combination with brandy, whiskey, or milk punch. 
The most important internal remedy is mercury, and it is here that this article often 
displays its effects to the greatest advantage in neutralizing the specific virus. If any 
one should be inclined to doubt the efficacy of this medicine, as an antisyphilitic agent, 
his skepticism will soon vanish if he will take the trouble to watch the progress of the 
treatment and the good results that will be sure to follow it. If it is not positively a 
specific, it approaches as nearly to this property in this disease as anything well can, 
quinine in intermittent fever hardly excepted. The form of exhibition is the bichloride, 
in doses varying from the fortieth to the fiftieth of a grain three times in twenty-four 
hours, dissolved in distilled water, or, when there is need of a tonic, in a few drops 
of Huxham’s tincture of bark. This should be steadily continued, with, now and then, 
a few days’ intermission, for a number of weeks, not only until all disease is apparently 
gone, but for a considerable period after; and it will be well, for the sake of the more 
complete eradication of the poison, occasionally to recur to the remedy until the child 
is several years of age. When the disease proves obstinate, the bichloride may generally 
be advantageously conjoined with the iodide of potassium, from the fourth to the 
eighth of a grain of the latter being given with each dose of the salt, according to the 
age of the child. 
When the disease appears at a late period of life, as after the eighth, tenth, or fifteenth 
year, the best plan is to use at once liberal doses of iodide of potassium, as from three to 
five grains, in combination with the tenth of a grain of bichloride of mercury, thrice in 
the twenty-four hours. This treatment is particularly indicated in affections of the eye, CHAP. X. 
GENERAL CONSIDERATIONS. 
337 
ear, throat, nose, and bones. When corrosive sublimate disagrees, or does not seem to 
reach the case, the most suitable substitute is calomel. 
When the body is covered with sores, pustules, or tubercles, a gentle course of mercurial 
fumigation will be advisable, great care being taken not to carry it to such an extent as 
to induce debility. Mild dressings may be used in the intervals, of which the best are 
nitrate of lead, iodoform, or acid nitrate of mercury, properly diluted. 
When bichloride of mercury is inefficient or prejudicial, the gray powder may be 
employed, or, what is preferable, because not liable to cause gastro-intestinal irritation, 
inunctions with mild mercurial ointment, from half a drachm to a drachm being rubbed 
upon the inside of the thighs once a day, or a flannel bandage smeared with the ointment, 
or the twenty per cent, oleate of mercury may be steadily worn around the abdomen. 
The treatment should be persistently continued until all evidence of the disease has 
disappeared. 
CHAPTER X. 
WOUNDS AND CONTUSIONS. 
SECT. 1 GENERAL CONSIDERATIONS. 
The term wound is a generic one, employed to designate all injuries attended with a 
division of tissue, inflicted by sharp, pointed, or blunt instruments and weapons of every 
description. The breach, or solution of continuity, may be apparent or concealed ; that 
is, upon and in the skin, as well as the more deep-seated structures, or the skin may retain 
its integrity, and the wound be strictly subcutaneous. 
Wounds are constantly made by the surgeon in the legitimate exercise of his profes- 
sional duties, as in the removal of limbs, tumors, and urinary calculi, and in the restora- 
tion of lost or mutilated parts. In general, however, they are inflicted accidentally, and 
hence, as this may happen in a great variety of ways, they are very properly arranged 
under different heads, according to the manner in which they are produced. Thus, a 
wound is said to be incised when it is caused by a sharp instrument; lacerated, contused, or 
bruised, when it is made by a blunt body; punctured, when the weapon i.s narrow and pointed. 
A gunshot wound is a breach inflicted by a ball. In a poisoned wound the tissues are inocu- 
lated with some peculiar virus, either secreted by an appropriate apparatus in the bodies of 
certain animals, as the bee or snake; contained in the salivary fluid, as in the dog in 
hydrophobia; or developed after death, as in the human subject in the dead-house. The 
term penetrating is employed when the wound communicates with a cavity, as a joint, 
the chest, or the abdomen. 
Wounds are also named according to the region of the body which they occupy, or 
the particular tissues, organ, or cavity which they affect and interest. Thus it is customary 
to speak of wounds of the head, neck, chest, abdomen, and extremities ; of wounds of the 
skin, muscles, tendons, vessels, and nerves ; of wounds of the stomach, heart, lungs, liver, 
and brain ; and of wounds of the joints, pleura, pericardium, and peritoneum. Finally, 
wounds may be superficial or deep; recent or old ; simple or complicated ; oblique, trans- 
verse, or longitudinal. The most common complications which attend wounds, or which 
arise during their progress, are, hemorrhage, the presence of foreign matter, abscesses, 
mortification, erysipelas, septicemia, pyemia, and tetanus. Such accidents, whether occur- 
rin gsingly or in combination, often completely change the character of a wound, rendering 
complex what was originally perhaps perfectly simple, and dangerous what was, in the first 
instance, perhaps so insignificant as hardly to attract serious attention. 
The characteristic features of wounds will be pointed out in connection with the differ- 
ent classes of injuries to which they relate. The prognosis and treatment will also receive 
due attention. It will, therefore, be sufficient here to state, in general terms, that they 
ajre all productive, each in its own peculiar way, of more or less pain and hemorrhage, 
and that, in most cases, there is marked retraction of their edges, caused either by their 
natural resiliency, or by the vulnerating body. The principal exceptions to this rule are 
in punctured and gunshot wounds, in which, from the peculiarity of their shape, and the 
manner in which they are inflicted, the latter phenomenon is very uncommon. 338 
WOUNDS AND CONTUSIONS. 
ciiap. x. 
Wounds are absorbing surfaces, a fact which should not be lost sight of during their 
treatment, as through them poisonous substances may readily find their way into the system, 
and thus either seriously complicate them, or destroy the patient. Recent skin wounds 
especially possess this quality, but it is hardly less conspicuous in muscular wounds. In 
granulating wounds the danger is less. The experiments of Renaulton on the virus of 
glanders and those of Dolin on that of anthrax go to show that the absorption is so rapid that 
cauterization performed more than ten or fifteen minutes after the inoculation is useless 
as a means of protecting the system. Davaine finds that punctured wounds are by far the 
most dangerous of all, as it respects the ingress of poisonous material, and that cauteriza- 
tion to be effective must be very prompt. These facts are of the greatest practical signifi- 
cance, as they point unerringly to the indispensable necessity of the employment of 
cleanliness and of free drainage in every case of this class of affections. 
A not unfrequent occurrence after wounds, especially in nervous, irritable subjects, is 
spasm of the muscles, often accompanied with violent pain and twitching. Such an effect 
may follow upon almost any injury of this kind, however insignificant, but is most com- 
mon in punctured, lacerated, and gunshot wounds, in which it not unfrequently entails 
the most frightful suffering. The stump, after amputation of the leg and thigh, sometimes 
jerks and twitches in the most distressing manner for hours and even days together; and 
spasm of the muscles, in compound fractures, is one of the most common causes of dis- 
placement of the ends of the fragments, as well as, in many cases, a source of great pain 
and annoyance. The spasm generally occurs in paroxysms, coming on during sleep, and 
suddenly waking up the patient, very much as in coxalgia and disease of other joints. 
The muscular movements are occasionally very slight, amounting to a mere quivering of 
very transient duration, and unattended with any starting or jerking. 
Emphysema is occasionally noticed in and around wounds. It comes on at a variable 
period after the receipt of the lesion, and manifestly depends upon different causes. Thus, 
in wounds of the neck, chest, and abdomen it is usually owing to an escape of air, respec- 
tively, from the windpipe, lungs, and intestines. In another class of cases, it is probably 
due to the accidental introduction of the air at the moment of the injury, or to the 
entanglement of the external air among the tissues from the peculiar valve-like shape of 
the wound. Sometimes, again, it is apparently caused by the decomposition of effused 
fluids; and cases arise in which it is evidently dependent upon the gas generated during 
the progress of traumatic gangrene. 
However induced, the exciting cause of the emphysema should always be diligently 
inquired into, as this must necessarily exercise an important influence upon the prognosis 
and treatment of the case. When present immediately after the receipt of the wound, it 
is evident that it cannot be due to gangrene or to the decomposition of effused fluids, but 
that the air must have found its way in, either from the exterior or through some natural 
cavity. The emphysema is generally more or less circumscribed, occurring as an irregu- 
lar tumor, of a soft, crepitating character; but cases occur, as in wounds of the neck and 
chest, in which it may occupy almost an entire limb, if not the greater portion of the body. 
The scars left by wounds, even by the most simple incision, are sometimes followed by 
great disfigurement; and now and then they are transformed into keloid growths, with a 
remarkable recurring tendency after extirpation. A cicatrice occasionally presents an 
unhealthy aspect from the constant irritation to which it is subjected by the friction of the 
patient’s clothes. A morbid condition of the system, especially scurvy and anemia, may 
also materially influence the nature of such a product. Wounds made by glass, splinters 
of wood, nails, and similar bodies, are exceedingly prone to be followed by unseemly, 
indurated, rough, and troublesome scars. 
Foreign bodies, containing coloring matter, may, if retained, leave a cicatrice perma- 
nently in a dark, unseemly condition. The principal substances likely to cause such an 
appearance are gunpowder and coal, both of which are often so firmly imbedded in the 
skin as to render it extremely difficult to dislodge them. 
The nature of the cicatrice is generally materially influenced by the character of the 
granulations which precede its development. If these are firm and healthy, the cicatrice 
will be likely to be so too : but if they are large, sodden, and oedematous, it will inevita- 
bly be soft and thin, abnormally vascular, of a bluish color, and prone to ulceration and 
even gangrene. An imperfectly organized cicatrice of the abdomen occasionally gives 
way under the pressure of the contained viscera, and thus becomes a cause of ventral 
hernia, and the cicatrice of the large wound in certain amputations, as in those of the 
thigh, sometimes gives way long after the parts are apparently firmly united. Scars, to CHAP. X. 
MODE OF DRESSING AND TREATING WOUNDS. 
339 
which this description applies, are most common in feeble, anemic, or scorbutic subjects, 
and are evidently due to a defective state of the vital powers interfering with nutrition 
and the process of repair. 
Painful scars are very common after amputations, owing to some peculiar change 
wrought in the terminal portions of the nerves after such operations. Lacerated, con- 
tused, punctured, and gunshot wounds are not unfrequently followed by similar effects. 
The pain, which often assumes a neuralgic character, is liable to serious exacerbations 
from the most trivial causes, especially exposure to cold, atmospheric vicissitudes, and 
disorder of the general health, and, from its persistency and obstinacy, may become a 
source of great suffering and annoyance, rendering life perhaps almost insupportable. 
Keloid tumors, of the spurious variety, originally described by Alibert, often form 
upon scars without any assignable cause, even after a wound has healed apparently in 
the most kindly manner. The degeneration usually appears within the first few months 
after the closure of the wound, forming a hard, firm, irregular cicatrice of a fibrous or 
fibroplastic character, more or less unseemly, the seat of frequent itching and annoyance, 
and liable to repullulation after extirpation. 
Finally, scars left after the healing of wounds sometimes take on carcinomatous action, 
the most common form in which it appears being the epithelial. Such an occurrence is 
most frequent in old scars, and especially in the scars left by burns and scalds constantly 
irritated by pressure, friction, and other causes of disease. 
1. MODE OF DRESSING AND TREATING WOUNDS. 
The most important retentive means in the treatment of wounds are adhesive plaster 
and sutures, aided, if necessary, by the bandage and attention to the position of the injured 
parts. 
There are various substances which are endowed with adhesive properties, and which 
are therefore well adapted to retain the edges of a wound in contact with each other. 
Those, however, which are usually employed for this purpose are the common adhesive 
plaster, collodion, and isinglass plaster. 
The old adhesive plaster, so long used in this and other countries, has been entirely 
superseded by the plaster invented by Dr. Henry A. Martin, of Boston, by whom it was 
formally introduced to the notice of the profession in 1877. It is essentially composed 
of the very best Para rubber, Burgundy pitch, and balsam of Tolu, spread upon strongly 
woven cloth, thoroughly shrunken and freed from every trace of dressing by treating it 
antiseptically. The advantages of this plaster are indisputable. It is applied without 
heat or moisture, adheres with extraordinary firmness, is flexible, waterproof, and devoid 
of irritating properties, is unimpaired by age, light, air, or temperature, and can be re- 
moved without leaving any of the adhesive matter on the skin. Mead’s plaster also 
adheres without warming, and possesses highly adhesive properties. 
The plaster is cut, as occasion requires, into suitable strips with scissors, carried in the 
direction of the length of the cloth, not in that of its breadth, as it is much more yielding 
in the latter than in the former, and therefore liable, when it becomes heated by the 
skin, to let the edges of the wound gape more or less. Trifling as this precept may ap- 
pear, it is of great practical importance, and can, therefore, hardly be too strongly insisted 
upon. When the wound occupies a limb, each strip should be long enough to embrace 
about three-fourths of its circumference; on no account should it completely encircle it, 
lest it impede the return of venous blood, and cause pain and tension. The width of 
each strip should be uniform, and vary, on an average, from half an inch to an inch, 
according to the exigencies of the case. 
Previously to applying the plaster, the surface of the skin should be divested of hair, 
and well dried with a soft cloth, as the least moisture prevents it from adhering. The 
shaving of the parts is necessary to facilitate the removal of the plaster, which would 
otherwise be difficult and painful, and which might, by its traction, even seriously com- 
promise the safety of the adhesive process. These important preliminaries being disposed 
of, all bleeding having ceased, and the edges of the wound being carefully held together 
by an assistant, each strip is applied in such a manner that its centre shall correspond 
with the wound, while each extremity firmly grasps the opposite side. If the wound is 
very long and deep, the first strip should be stretched across the middle, which thus 
becomes the starting point of all the rest. The interval between each two strips should 
not, on an average, exceed the eighth or fourth of an inch, as this will afford ample 
space for the drainage of blood, serum, and lymph, of which there will generally be more WOUNDS AND CONTUSIONS. 
chap. x. 
or less after every injury of this description, especially if it be of considerable extent. 
Care must be taken that the adhesive strips are laid down in as smooth and even a man- 
ner as possible ; hence, the parts should always be put in the position in which it is in- 
tended to keep them during the treatment. If the strips rise up in folds, or are partially 
detached, they should immediately be replaced by others, more skilfully applied. Finally, 
it is very necessary, on the one hand, not to invert the edges of the wound or to draw 
them together too firmly, and, on the other, not to approximate them so loosely as to en- 
danger their partial separation. In short, everything should be done in the most neat, 
accurate, workmanlike manner. 
Isinglass plaster is not used so much now as formerly. It is said to be less irritating 
than the common plaster, and equally as adhesive. Moreover, it is alleged that insinglass, 
if spread upon gauze, will, by its transparency, admit of complete surveillance of the 
wound, the surgeon being able to witness the changes going on in and around it. Not- 
withstanding these supposed advantages over common adhesive plaster, my conviction is 
that the latter, as prepared by the modern pharmaceutist, is decidedly superior to it, in 
every particular. The idea that common adhesive plaster is apt to provoke erysipelas 
and ulceration of the skin is in great measure, if not wholly, chimerical; at all events, 
I have seldom met with such an occurrence. In the next place, it is much stronger than 
isinglass plaster, and therefore affords better support to the parts. Thirdly, it is less 
liable to be prematurely detached ; and, lastly, although it is opaque, yet as there is 
always an interval left between each two strips for drainage, it is obvious that it cannot 
in the slightest degree interfere with the examination of the wound and its vicinity. I, 
therefore, generally limit the use of isinglass plaster to the dressing of small wounds or 
little cuts, and employ the common plaster for wounds of large size. The principles 
regulating its application do not differ from those already laid down. The strips should 
be of appropriate length and width, and moistened on the glazed surface with a sponge 
pressed out of cold water. 
Glycerine adhesive plaster, employed by some of our surgeons, is liable to the same 
objections as isinglass plaster; it makes, however, a very neat dressing, and is well 
adapted to the more simple forms of wounds. 
Court plaster, as it is called, is seldom used by the scientific surgeon, as, from its irri- 
tating nature, it is very apt to inflame the parts, and thus occasion overaction. It is 
composed of gum benzoin and isinglass, dissolved in rectified spirit, and brushed over 
silk, with a coating of Chian turpentine, to prevent it from cracking. 
The substance known as skin plaster is well adapted as a dressing for very small, super- 
ficial wounds, as it is perfectly transparent, very smooth, and non-irritant, but is not strong 
enough for large ones. It is composed of sheep’s omentum, coated with a solution of 
isinglass, and is applied to the parts previously wet with a sponge. 
Collodion, first used for surgical purposes by Dr. J. P. Maynard, of Boston, in 1847, 
consists of a solution of gun cotton in ether, with the addition of a little alcohol. It is a 
transparent, colorless fluid, of a syrupy consistence, which, when applied to a dry surface, 
allows of the rapid escape of the ether, leaving a thin, bluish film, possessed of remark- 
ably adhesive and contractile properties. As it is impervious to water, it is less liable to 
be prematurely detached than the isinglass or common plaster. Put upon wounds or 
abraded surfaces, it causes sharp pain, which, however, always speedily subsides. It may 
be applied by means of a camel-hair pencil, or a small brush, directly to the affected parts, 
as in the case of small, superficial cuts; or upon strips of linen, muslin, patent lint, or 
Tarlton gauze, of suitable width and length, when the wound is so large and deep as to 
require firm support. As the ether evaporates very rapidly, the dressing should be applied 
with as much celerity as possible, everything being thoroughly arranged beforehand, and 
the edges of the wound well dried and supported by an assistant. Collodion makes an 
excellent dressing in wounds of the neck and face, as well as in other movable regions of 
the body, and in all cases where it is particularly desirable to exclude the air. 
Styptic colloid, introduced to the notice of the profession by Dr. B. W. Richardson, 
of London, is a styptic, antiseptic, and deodorizer, and affords a complete means of exclud- 
ing air from wounded or ulcerated surfaces. It is composed of xyloidine, a substance 
resembling gun cotton, dissolved in ether and saturated with tannic acid. Applied in a 
similar manner to collodion, the blood and secretions permeate the cotton as the ether 
vaporizes, and the albumen is coagulated by the tannic acid, forming a leathery mem- 
brane, while the cotton imparts substance and adhesive qualities to the mass. To remove 
the dressing, it is only necessary to moisten it with a mixture of alcohol and ether, or 
with alcohol and water warmed a little above the temperature of the body. CHAP. X. 
MODE OF DRESSING AND TREATING WOUNDS. 
341 
India-rubber possesses strong adhesive qualities, and an excellent plaster may be pre- 
pared from it by spreading a solution of it, with a stiff brush, upon gauze, silk, or thin 
muslin, after the fashion of collodion. One great advantage which it possesses over most 
other material is that it is completely impermeable by water. 
The substance, whatever it may be, should be retained until it ceases to answer the 
object for which it was applied. The moment it becomes a source of irritation, loses its 
hold, or obstructs drainage, it should be removed, the substitute material being always 
properly arranged beforehand, lest the parts should be unduly exposed to the air, or insuffi- 
ciently supported. Surgeons often err in being too anxious to meddle with the adhesive 
plaster; too early interference has a tendency to interrupt the adhesive process, and may, 
in persons of a bad, irritable constitution, give rise to erysipelas and other accidents. I 
have, more than once, after severe operations, retained all the original strips for upwards 
of a fortnight; until, in fact, complete cicatrization had taken place. Such good luck, 
however, is rare; and it more generally happens that the dressings, plaster and all, have 
to be changed at the end of the second, or, at furthest, the third day.. Much, of course, 
will depend, in every case, upon the state of the weather, the size and situation of the 
wound, and the amount and character of the discharges. 
When the wound is extensive, only a few strips should be taken off at a time, otherwise 
there will be danger of separating its edges. Before the dressing is readjusted, the parts 
should be thoroughly cleansed with tepid water, pressed from a sponge held at some dis- 
tance or applied with a syringe; no wiping must be done, nor must the wound be rudely 
squeezed. Any matter that may be at the bottom or between its edges should be pressed 
out in the most gentle and careful manner, rough manipulation being not only painful, but 
injurious to reparative action. Sometimes the necessary cleanliness may readily be 
effected with a moist sponge or soft cloth passed lightly over the surface. Great skill is 
required in removing the plaster to the best advantage of the parts. Each strip should 
be raised by taking hold of one extremity with the thumb and finger of one hand, while 
the other hand is engaged in supporting the wound ; the other end being treated in a 
similar manner, the portion corresponding with the wound is lifted off last, and thus all 
danger of injury is effectually obviated. 
The principal sutures employed in surgery are the interrupted, twisted, continued, and 
quilled. There are several others which will be described in their proper place. 
The interrupted suture, which is more frequently employed than any other, is made 
with a needle, either straight or slightly curved, and armed with a single, well-waxed 
ligature, either of silk or of linen, as may be found most convenient; for, in a practical 
point of view, it is really altogether immaterial which it is. The instrument, which should 
always be very sharp, and in the best possible order, is introduced through the edge of 
the wound, from without inwards, at a suitable distance from its surface, and then pushed 
from within outwards at precisely the same point at the opposite side, leaving the thread 
in its track. A second stitch is then to be taken in a similar manner, and thus the 
operation is continued until a sufficient number has been introduced, when the ends of 
each ligature are to be tied with a reef-knot, and cut off close. The distance at which 
the needle should be inserted from the wound must of course vary in different cases and 
in different regions of the body; but, in general, it should 
not be less than a line, nor more than a quarter of an inch. 
The depth at which it is passed should be such as to admit 
of accurate approximation of the wound, about one-third of 
the thickness of the edge being behind and the rest in front 
of the needle. In no case of superficial wound should the 
instrument embrace muscular or aponeurotic substance. The 
interval between each two stitches must also necessarily vary, 
according to circumstances, from a few lines to an inch or 
more, and should be supported, after the sutures have been 
tied, with adhesive plaster, as in fig. 91. If the wound is 
very small, it may be sewed up with a common cambric 
needle, and a proportionately delicate thread. 
The needles for sewing up wounds are of various forms 
and sizes, straight or curved, short or long, according to the 
object to be fulfilled, or the nature of the parts affected. 
For sewing up any wound of considerable size, the instrument 
should, as a rule, be perfectly straight, and not less than two and a half to three inches in 
length, with a sharp rounded point, or a point slightly curved and spear-shaped. In 
Fig. 91. 
Interrupted Suture. 342 
WOUNDS ANT) CONTUSIONS. 
chap. x. 
certain situations, as in wounds of the face, a curved needle will be found to be most 
convenient. Very short curved instruments are necessary when we wish to sew up a 
fissure of the palate, or a ruptured vesico-vaginal septum. A needle with an immovable 
handle, such a one as is generally put up in our pocket cases, is a very useful instrument. 
The twisted suture is made by introducing a pin through the edges of the wound, and 
passing a thread round it, so as to confine it in its place. It makes an admirable retentive 
apparatus, but is of more limited application than the interrupted suture. From the fact 
that it is generally employed in the treatment of harelip, it is often called the harelip suture. 
Various instruments are employed for making the twisted suture. What is called the 
lady’s toilet pin, a round steel pin, very sharp-pointed, and furnished with a glass head, 
is in the main the best; it readily penetrates the tissues, and creates less irritation than 
the common sewing-needle, formerly so much employed for this purpose. Fifty years ago 
surgeons were in the habit of using a silver needle, with a movable steel point, as seen in 
fig. 92 ; a cumbersome, awkward instrument, now happily discarded. Dieffenbach x’ecom- 
Fig. 92. 
Old Suture Pin. 
mended what is called the insect pin, which, however, has never come into general vogue, 
at least not on this side of the Atlantic. In small wounds of the forehead, face, and 
neck, in which it is of so much importance to prevent the occurrence of a scar, I have 
been in the habit, ever since I entered the profession, of employing a very delicate gold 
pin, with a head of sealing wax, and there is not, I am sure, any article better suited to 
fulfil such an indication. Insusceptible of oxidation, it causes no irritation, and may 
therefore be retained for almost any length of time without detriment to the parts. 
Whatever kind of pin be employed, transfixion is effected in the same manner as in the 
common interrupted suture, the thumb and finger being generally quite sufficient for the 
purpose. In some situations, however, as, for example, in certain parts of the face, the 
operation will be greatly facilitated by the use of a special pair of forceps, or the pin- 
conductor, fig. 93, of Dr. Gurdon Buck, an instrument easily obtained at any of the cutler 
shops. The wrapping material, consisting of ordinary thread or silk, smooth and well 
waxed, to prevent the imbibition of the secretions, is wound around the pin elliptically, 
as in fig. 94, as it arranges itself much more evenly and efficiently when thus applied 
than when it is carried around the pin in the form of an 8, as in fig. 95, and as is so gene- 
Fig. 93. 
Fig. 95. 
Buck’s Suture Pin-Conductor. 
Twisted Suture. 
rally done in this and other countries. As many pins or needles having been inserted as 
may be deemed advisable, the threads are passed from one to the other diagonally across 
the gap, so as to effect complete apposition there also, and so obviate the necessity for 
using adhesive plaster. Finally, the threads being tied, the operation is completed by 
cutting off the points of the pins with a pair of pliers, hg. 96, otherwise they may hurt 
the patient, or be caught in his clothes. 
Instead of confining the pin with a thread, Rigal uses a thin narrow ring of gum elastic, 
which answers the purpose most admirably, as it draws the parts firmly and evenly to- 
gether. The only objection to it is that it may cause too much pressure xvhen there is 
an unusual amount of swelling in the lips of the wound. The late Dr. Washington L. 
Atlee employed this form of suture in many of his ovariotomy cases, under the impres- 
sion that it possessed decided advantages over the more ordinary contrivances. The 
annexed cut, fig. 97, exhibits the shape and mode of application of the ring. chap. x. 
MODE OF DRESSING AND TREATING WOUNDS. 
343 
The period during which the pins are retained varies from two to three or four days, 
according to the circumstances of the case. Their removal should be effected with great 
Fig. 96. 
Fig. 97. 
care, in a direction contrary to that of their introduction, the parts 
being well supported at the time. As the threads are generally firmly 
glued to the surface and edges of the wound, it is well to let them 
remain until they drop off of their own accord, as they usually do in 
a day or two after the withdrawal of the pins. The support thus 
afforded is often of great service to the imperfectly organized bond 
of union, and its premature removal sometimes necessitates the em- 
ployment of adhesive plaster, or the insertion of a new pin. 
The continued suture, fig. 98, is similar to that used by the glover, on which account it 
is generally known as the glover’s suture. It is made with a needle armed with a suitable 
thread, which is passed diagonally from one side of the wound to the other, on the same 
principle as in the interrupted suture. Its use is almost exclusively restricted to the treat- 
ment of wounds of the intestines, in connection with which it will again be noticed. 
Piu Pliers. 
India-rubber Sutures. 
Fig. 98. 
Fig. 99 
The Glover’s or Continued Suture 
Quilled Suture 
The quilled suture, fig. 99, so called from the fact that it was originally made with the 
assistance of two quills, is employed chiefly in the treatment of lacerations of the peri- 
neum, with a view of effecting more even and accurate contact of the opposed surfaces. 
The older surgeons were in the habit of using it in sewing up deep muscular wounds, as 
those of the thigh and abdomen. No one, however, thinks of resorting to it for such a 
purpose at the present day ; for in the latter case the object can be attained much more 
easily by the ordinary interrupted suture, extending down nearly to the peritoneum, and 
in the former by methodical support with the compress and bandage. The quilled suture 
is made by passing a stout double thread through the. sides of the wound, at intervals of 
an inch or an inch and a half, and tying its ends over a piece of bougie, quill, wood, or 
whalebone, lying parallel with the cut, bpt about half an inch from it. 
Although sutures undoubtedly act as foreign bodies, necessarily exciting a certain de- 
gree of irritation in the tissues into which they are inserted, I have by no means that WOUNDS AND CONTUSIONS. 
chap. x. 
dread of them which they seem to have inspired in the minds of many practitioners. I 
have rarely witnessed any ill effects from their employment, and when anything of the 
kind did occur, the fault was generally due more to the indiscretion of the surgeon, or to 
the want of stamina on the part of the patient, than to any untoward operation of the 
sutures themselves. Provided the threads, or needles and threads, are clean, of suitable 
size, and properly inserted, the constitution of the patient in good condition, and the 
wounded structures in a tolerably sound state, it is difficult to understand how they could 
become a source of serious irritation, much less of erysipelas or severe ulceration, effects 
which have all been charged to their action. It is, therefore, I conceive, a good plan to 
use them freely, and to allow them to remain so long as they seem to answer the purpose 
for which they were introduced. The moment this object is attained, or they are found 
to be productive of injury, they should be withdrawn. 
The best material for sutures unquestionably is metal, and it matters not, according to 
my experience, whether this is silver or iron, provided it is properly tempered, perfectly 
smooth, and sufficiently thin and pliant. This substance, although noticed in connection 
with this subject by different writers, was first introduced into regular practice by Dr. J. 
Marion Sims, and is one of the greatest additions to the armamentarium of the present day. 
The advantages of the metallic suture over every other are that it is entirely free from 
all irritating properties, and that it may be retained for weeks or even months, as I have 
repeatedly known it to be, without provoking suppurative action, so common when silk 
or thread is employed. 
In England, at the suggestion of Mr. Clover, a very thin copper wire covered with 
gutta percha—in fact, a miniature telegraph wire—is occasionally employed for closing 
wounds. It does not cause any irritation, is easily introduced with a fine sewing-needle, 
and is so soft as to be readily cut and tied into a knot, like ordinary thread. 
Wire is introduced in the same manner as thread, the short end being firmly twisted 
round the long one; or, instead of this, it is tied with a double knot, as may also be 
readily done when the wire is very thin and flexible. Numerous needles have been de- 
vised for facilitating the insertion of the wire, but it is questionable whether they possess 
any particular advantage over the one in common use. Perhaps the most unexceptionable 
one is one with two holes, with a vertical groove on each side. 
The annexed engravings will serve to convey an idea of some of the best forms of this 
kind of needles. Fig. 100 represents Mr. Price’s instrument; it is grooved on both sur- 
Fig. 100. 
Price’s Needle for Wire Suture. 
faces, and is pierced with two holes, nearly half an inch apart, the wire being passed from 
the lower to the upper, and then doubled and twisted at the end to hold it. Mr. Murray’s 
needle, fig. 101, has a groove and open box end, while Mr. Lister’s, fig. 102, has a single 
Fig. 101. 
Fig. 102. 
Murray’s Needle. 
Lister’s Needle. 
eye and a groove on the side. Ingenious contrivances of a similar kind have been con- 
structed by Dr. Levis and Dr. Goddard, of this city. 
For introducing wire, both in superficial and deep-seated wounds, the tubular needle, 
represented in fig. 103, will be found a convenient instrument. 
In removing the wire suture, care must be taken that the edges of the wound be not 
forcibly separated. To prevent this, the loop should be cut on one side very close to the 
border of the wound, when the twist may be seized with the forceps, and the wire gently CHAP. X. 
MODE OF DRESSING AND TREATING WOUNDS. 
345 
drawn out. The length of time during which the suture is retained must depend upon 
circumstances. From three to five days is a good average period. 
Fig. 103. 
Tubular Needle. 
Horsehair prepared by boiling for a short time in a weak solution of sodium, is occa- 
sionally employed as a material for the interrupted suture, and answers excellently well, 
as it is sufficiently strong for any wound, however large or deep, and does not absorb 
fluids or cause irritation. It may, likewise, be retained indefinitely. To prevent the 
ends from untying themselves, the reef-knot must be used. 
Carbolized catgut is now being employed as a material for stitures in connection with 
the antiseptic treatment of wounds; but it should be prepared with chromic acid in order 
that it may resist the solvent action of the tissues until the process of union is completed. 
Rest and easy position are essential elements in the treatment of wounds. If the part 
be exercised, or moved, it will be difficult, if not impossible, to preserve apposition, and 
to limit inflammatory action. If the wound be transverse, and seated in an extremity, 
it will inevitably be torn open, if the muscles which pass along it are not maintained in a 
relaxed condition. Thus, if the wound involve the front of the thigh, the limb is ex- 
tended, and flexed if it affect the posterior aspect; the muscles immediately concerned in 
the lesion being thus in each case put in a state of perfect repose. 
In very large and deep wounds, it is hardly possible to keep the edges in contact, in 
their entire extent, without the aid of compresses and bandages, more especially when 
they involve large and numerous muscles, as, for example, in wounds of the thigh. In 
such a case, adhesive plasters and sutures, however skilfully applied, would scarcely be 
sufficient to afford the parts the support which is necessary to maintain them in perfect 
apposition. More or less separation would almost be inevitable. To fulfil this indication, 
so important to the adhesive process, it is indispensably necessary to lay a stout compress 
or piece of sponge along each side of the limb, opposite the deep portion of the wound, and 
to confine it with a roller, extending from the toes upwards as far nearly as the groin. 
In all lesions of this description, whether the result of accident or of operation, great care 
must be taken to prevent the retention of fluids, otherwise suppuration will take place 
instead of union by the first intention. Large intervals should be left between the adhesive 
strips, and holes should be cut in the bandage where it lies over the affected part: in 
some cases, indeed, it will even be necessary 
to leave a small tent or tube at the bottom 
of the wound, at the most dependent point, 
to drain off the discharges. 
The most suitable bandage for support- 
ing wounded parts is the common roller, 
carried upwards from the distal portion of 
the limb to a short distance beyond the 
seat of the injury. The invaginated band- 
age, represented in figs. 104 and 105, and 
formerly so much in vogue, is a dangerous 
contrivance, unworthy of scientific surgery. 
When all foreign substances have been 
removed, when hemorrhage has been 
checked, and when its surfaces have been 
accurately approximated without tension, and are properly supported, due provision 
having been made for the escape of the secretions, a wound is placed in the best possi- 
ble condition for repair, and the less it is interfered with the more likely will it be, all 
other things being equal, to do well. Meddlesome surgery cannot be too pointedly con- 
demned, for it is hardly less pernicious than the slovenly surgery still so common at the 
present day, especially in private practice. The modern treatment of wounds has been 
carried to the very verge of simplicity, and it is difficult to see how it could possibly be 
improved, although it is doubtless still susceptible of important modifications. When the 
Fig. 104. 
Fig. 105. 
Invaginated. Bandage for Longitudinal Wounds. 346 
WOUNDS AND CONTUSIONS. 
chap. x. 
parts are merely divided, all that is generally necessary is to put them in accurate con- 
tact, and to maintain them for a certain period in an easy, elevated, quiet, and relaxed 
condition. When the wound is very large, as after the amputation of a limb, or the 
extirpation of the mammary gland, I generally cover the surface with a pledget of lint 
wet with olive oil or cosmoline, to prevent the contact of the air and thus diminish the 
chances of profuse suppuration. 
I have never found any appreciable benefit in such a case from the use of antiseptic 
dressings, although they are regarded by many surgeons as most valuable accessories. 
The antiseptic method, when strictly adhered to, demands rigid attention to minute 
details, so that it has been modified in various ways, of which the most popular appears 
to consist in irrigating or washing the wound with a solution of carbolic acid, boracic 
acid, salicylic acid, benzoic acid, thymol, oil of eucalyptus, chloride of zinc, or pure 
alcohol, and afterwards enveloping the part in cotton-wool or absorbent cotton. The 
merits of ordinary cotton-wool in preventing the ingress of microscopic organisms from 
the surrounding atmosphere are justly praised by Guerin, Gamgee, Little, of New York, 
and the late Dr. Green, of Portland, and it is also certainly useful for affording gentle 
and systematic compression. At the present day, carbolic acid is falling into desuetude. 
As I have pointed out in the section on septicemia and pyemia, it does not prevent the 
development of micrococci and bacteria in the pus of wounds, and its employment has 
not only frequently given rise to serious symptoms of poisoning, but it has been followed 
by death in a number of instances. 
Cold water-dressing may be required, with a proper regulation of the diet and a mild 
aperient when there is danger of overaction. In contused, lacerated, punctured, and 
gunshot wounds, cold water-dressing, either alone or in union with opium, arnica, lauda- 
num, or laudanum and acetate of lead,* may generally be advantageously employed from 
the beginning; or, instead of this, warm water or a cataplasm may be used, especially 
when there is a tendency to suppuration or sloughing. Leeching and more active general 
means, with opium to allay pain and to induce sleep, may be required when high in- 
flammation with violent traumatic fever arises, provided there has not been any severe 
shock or great loss of blood. The dressings must not be allowed to become hard and dry 
over the wound, nor should they oppress by their weight, otherwise they will be sure to 
prove hurtful and offensive. The discharges should be frequently removed with the 
sponge or syringe, the sickly odor exhaled from the raw surfaces being neutralized by the 
proper use of the chlorides, Labarraque’s solution, or weak lotions of permanganate of 
potassium. The atmosphere of the patient’s apartment should be kept in as sweet and 
pure a condition as possible by attention to ventilation; in short, everything should be 
done to promote nature’s efforts at restoration. 
If the action in the wound be languid, some mildly stimulating wash must be employed, 
as a drachm of tincture of myrrh to a pint of water, a weak solution of nitric acid or 
nitrate of silver, or the red lotion, as it is termed, consisting of two grains of sulphate of 
zinc to the ounce of water, with a sufficiency of spirit of lavender to give it color and 
fragrance. Creasote water is also a very efficient application, and occasionally nothing 
answers so well as water and alcohol, water and spirit of camphor, Labarraque’s solution, 
or a solution of chloride of zinc, in the proportion of two to five grains to the ounce of 
water. Most of these lotions are highly detergent and antiseptic, exciting new action, 
allaying fetor, and promoting the granulating process. Conjoined with these remedies must 
be proper constitutional means, as a generous diet, wine, porter, or brandy, and quinine, 
either alone, or, what is better, combined with tincture of chloride of iron. Such treat- 
ment, which will often be demanded even in the more simple cases of wounds, is impera- 
tively required when there has been excessive shock or great loss of blood, causing a 
severe drain upon the nervous and vascular systems, with a tendency to a low form of 
fever, erysipelas, septicemia or pyemia. 
A wound sometimes assumes a diphtheritic aspect, becoming incrusted, either uniformly 
or in patches, with unorganizable lymph, of variable thickness and consistence, and of a 
yellowish, whitish, or greenish color. The occurrence is commonly associated with the 
diphtheritic diathesis, and is most frequently met with in persons of a dilapidated consti- 
tution, especially among the inmates of crowded, ill-ventilated hospitals, in which it 
occasionally exhibits an epidemic tendency, so that hardly any open surface, whether 
recent or chronic, or however induced, escapes. Blisters, leech-bites, and the little wound 
made in venesection, have all been known to be promptly invaded by it during the pre- 
valence of this tendency. 
When a wound is thus attacked, it at once puts on an unhealthy appearance; the pro- CHAP. X. 
MODE OF DRESSING AND TREATING WOUNDS. 
347 
cess of repair is effectually checked ; and the discharge either dries up, or assumes a serous, 
bloody, or ichorous character, at the same time that it exhales a mawkish, sickening odor. 
Any granulations that may have existed are speedily destroyed, or transformed into pale, 
flabby bodies, enfeebled and partially devitalized. The edges of the wound are swollen 
and oedematous, while the surrounding surface is inflamed and not unfrequently erysipela- 
tous. In the more severe forms of this complication, the parts run into phagedena, if not 
into actual gangrene ; the pain is unusually severe; and the system soon falls into a low, 
typhoid condition, either eventuating in death, or in ultimate but tardy convalescence. 
The treatment consists in isolation of the wounded, the employment of supporting 
measures, especially iron and quinine, the application of local stimulants, as nitrate of 
silver and lotions of permanganate of potassium, acid nitrate of mercury, or chloride of 
zinc, and free ventilation of the infected apartments. 
Erysipelas, as a consequence of a wound, usually sets in within the first forty-eight 
hours after the accident, in the form of a reddish blush of the skin accompanied by the 
formation of delicate vesicles, a slight burning, itching pain, and more or less swelling, 
the point of the finger readily leaving its impression upon the affected surface. The wound 
soon assumes an unhealthy aspect, the discharge seemingly decreases or altogether disap- 
pears, and the plasma that is poured out is speedily devitalized. The constitutional symp- 
toms are denotive of a depraved condition of the bloodvessels, and, in the more severe 
cases, typhomania often makes its appearance early in the attack. Occasionally the 
erysipelas breaks out upon the body of the patient without invading the wound, and such 
cases, of which a considerable number have fallen under my immediate observation, are 
generally peculiarly dangerous, as they are indicative of an uncommonly disordered and 
depraved state of the system. The chief remedies in the treatment of traumatic erysipelas 
are quinine and iron with milk punch, beef essence, and fresh air, and the application of 
iodine with emollient cataplasms and solutions of acetate of lead, frequently renewed. 
If the wound be assailed by gangrene or phagedena, the topical remedies most likely 
to prove useful are nitric acid, carbolic acid, nitrate of silver, bromine, iodoform, per- 
manganate of potassium, and acid nitrate of mercury, the latter being especially entitled 
to our confidence for its well-known efficacy in arresting morbid action. Sometimes these 
substances may be advantageously employed in a pure state ; in general, however, they 
should be very greatly diluted, otherwise they will be productive of severe suffering, if 
not also of positive injury. 
The cicatrization of a granulating wound may generally be very materially expedited 
by skin-grafting, performed after the manner described in the chapter on Minor Surgery. 
The operation is especially adapted to cases attended with great destruction of integu- 
ment. As many as a dozen, fifteen, or even twenty grafts may be inserted at one time, 
at a distance of eight or ten lines from one another; repetition being occasionally effected 
if the cicatrization do not advance sufficiently rapidly. 
The spasm and jerking consequent upon wounds, whether accidental or inflicted by the 
surgeon’s knife, are best controlled by anodynes, especially hypodermic injections of mor- 
phia, the bromides, chloral, valerian, and choloroform, with the addition of the bandage 
and lotions of aconite and laudanum. Attention to posture is generally of great moment ; 
and in many cases, especially in the treatment of wounds after resections of the joints, in 
compound fractures, and dislocations, ease and perfect rest can only be secured by means 
of splints. 
The emphysema which occasionally follows upon such injuries must be treated accord- 
ing to the nature of the exciting cause. In general the air gradually disappears sponta- 
neously ; when it does not, and the symptoms are at all urgent, relief must be sought by a 
few punctures or small incisions. 
Unhealthy scars, the result of unsound granulations, and other causes, must be treated 
with solid nitrate of silver, or some slightly stimulating unguent, as the dilute ointment of 
nitrate of mercury, aided by multiple punctures or scarifications and gentle compression. 
Hard, elevated, unseemly scars must be removed with the knife, the wound being after- 
wards treated upon general principles. Before doing this, however, great care should be 
taken to prepare the system properly, otherwise the parts may be seized with erysipelas, 
or a bad cicatrice may be succeeded by a worse one. 
Scars left by incised wounds inflicted in early life, whether accidentally or designedly, 
generally completely disappear with the progress of age. The inodular tissue, unless very 
abundant, gradually assumes the properties of the native structures in its vicinity, and 
eventually resembles them so closely as to render it impossible to detect any difference. 
When a vessel of considerable size is divided, the only plan is to secure it at once with WOUNDS AND CONTUSIONS. 
chap. x. 
a suitable ligature. If some time, however, has elapsed since the occurrence of the injury, 
the artery will not only be inflamed and more or less softened in its texture, but materi- 
ally changed in its relations by deposits of lymph, and, perhaps, even by the presence of 
pus. A ligature, applied to a vessel in such a condition, will be almost sure to be detached 
before the natural process of repair ha3 advanced sufficiently far to form a firm internal 
clot. Besides, the difficulty of finding such a vessel is generally very great. A tedious 
dissection, often painful and bloody, is required to expose it; and when, at length, the 
object is attained, the surgeon has the mortification to discover that it does not answer 
the purpose. The parts slough or ulcerate, the ligature is cast off prematurely, and a 
copious hemorrhage again ensues; and thus the case is apt to continue until the patient is 
completely exhausted. Instead of pursuing such a useless and dangerous course as this, 
no time should be lost in securing the affected vessel by acupressure, the needle being 
passed underneath it in such a manner as to include a large quantity of the neighboring 
tissues. This may occasionally be done, as when the vessel is comparatively superficial, 
without any previous dissection, by pushing the needle through the skin. It is just in 
such a case as this that acupressure, I conceive, finds its chief advantage; effectually 
arresting the flow of blood, and yet not, like the ligature, irritating the artery. 
When the case does not admit either of ligation or of acupressure, the only resource is 
the employment of styptics and systematic compression, which often answer the purpose 
very satisfactorily, even when the hemorrhage proceeds from an artery of considerable 
magnitude, as, for example, the axillary or brachial. Dr. James M. Holloway, formerly 
of the army, has adduced a number of instances of consecutive and indeterminate hem- 
orrhage, consequent upon gunshot wounds, treated successfully in this way, and my own 
experience fully corroborates the propriety of the practice. His paper upon the subject 
may be found in the American Journal of the Medical Sciences for October, 1865, and is 
well worthy of an attentive perusal. 
The development of maggots in wounds occurs chiefly in hot weather, but I have also 
seen it in the autumn and early part of winter, in consequence of the artificial heat of the 
patient’s apartment. In tropical climates the formation of maggots in wounds and ulcers 
is almost unavoidable, despite the best directed efforts to prevent it. The soldiers in 
Egypt and Syria, under Larrey, and our troops during the war with Mexico, suffered 
greatly from this cause. Dr. Proctor informed me that wounds, however carefully 
cleansed in the morning, were found, in the evening, to contain large numbers of these 
worms, and, if the slightest neglect took place, they speedily collected in incredible 
quantities, and of prodigious size, their diameter equalling that of a small goose-quill, 
while their length ranged from three to nine lines. The soldiers had a great horror of 
them, and, from the disposition which they evinced to burrow deeply among the muscles, 
they were productive of no little pain and distress. 
The best preventive of this occurrence is cleanliness, with a frequent change of dress- 
ing, and burying the affected parts in light bran, or carbolized dry earth, so as to place 
them beyond the reach of flies, which, under almost any other mode of management, are 
sure to find their way to the wounded surface, the slightest crevice affording them access 
to the much coveted spot. Moisture and a high temperature are the causes which most 
rapidly conduce to the formation of maggots. The means that prove most destructive to 
them are olive oil, spirit of turpentine, creasote, and alkaline solutions, particularly chlori- 
nated sodium. Dr. Atkinson, of the British army, has found no remedy so efficacious as 
calomel, sprinkled upon the wound, or blown into it from a quill. Dr. Neudorfer, form- 
erly Surgeon-in-chief of the Austrian army in Mexico, informs me that the most speedily 
destructive remedy he has ever tried is petroleum. Olive oil would probably be quite as 
effective. 
Wounded persons should never be crowded together in the same apartment, as the 
effluvia ai'ising from their sores, their persons, and their excretions cannot fail to contami- 
nate the atmosphere, and thus become a prolific source of disease and death. Much of 
the mortality attendant upon gunshot wounds, in times of war, when segregation of the 
wounded is impracticable, is doubtless due to this cause. Wounds in syphilitic persons 
are occasionally slow in healing, and may, if irritated, assume the characteristics of syph- 
ilitic ulcers. The proper remedy, in such an event, would be a mild mercurial one. 
The fever which follows upon these lesions, usually called traumatic, wound, or surgical 
fever, is greatly influenced in its character by the violence of the injury, the amount of 
shock and loss of blood, the nature of the parts involved, the constitution of the patient, 
the condition of the atmosphere, and the nature of the after-treatment. Arising generally 
within the first six or eight hours after the accident, it is commonly ushered in by slight CHAP. X. 
HEALING OF WOUNDS. 
349 
chilly sensations, alternating with flushes of heat, and succeeded by disturbance of the 
pulse, headache, anxiety, thirst, restlessness, heat of skin, loss of appetite, and scanty, 
high-colored urine. The pulse is usually strong and full, except when there is great de- 
pression of the vital powers, when it is generally very feeble, small, frequent, jerking, or 
even somewhat wiry. The bowels are constipated, the sleep is disordered, and the mind 
often wanders. Such a fever is well designated as sthenic, in contradistinction to the 
asthenic, so commonly met with in all low states of the system, whether induced by 
violent contusions and lacerations, suppurative inflammation, erysipelas, pyemia, the 
penetration of a large joint, the extravasation of some irritating fluid, as bile or urine, or 
the coexistence of serious internal disease. 
Typhoid traumatic fever, always an occurrence of evil import, is essentially character- 
ized by delirium, frequently of a low-muttering character, dryness of the tongue, sordes 
on the gums and teeth, tympanites, excessive thirst, nausea, want of appetite, great 
feebleness and frequency of the pulse, and coldness of the extremities, with a sense of 
excessive exhaustion. The wound in such a condition of the system has always an un- 
healthy appearance; the granulations, if there be any, are pale, flabby, and cedematous, 
while the attendant discharge is thin, sanious, watery, and offensive, exhaling an odor 
not unlike that of a macerating tub. 
2. HEALING OF WOUNDS. 
The parts having been properly adjusted, the duty of the surgeon, as far as manipula- 
tion is concerned, is temporarily at an end. Nature, the physician of wounds, as she was 
called by Paracelsus, must do the rest. “ Warily,” says this eccentric man, in his 
“ Great Surgery,” published in ld36, “ warily must the surgeon take heed not to remove 
or interfere with Nature’s balsam, but protect and defend it in its working and virtue. It 
is the nature of flesh to possess in itself an innate balsam which healeth wounds. Every 
limb has its own healing in itself; Nature has her own doctor in every limb; wherefore 
every chirurgeon should know that it is not he, but Nature, who heals. What do wounds 
need? Nothing. Inasmuch as the flesh grows from within outwards, and not from with- 
out inwards, so the surgery of wounds is a mere defensive, to prevent Nature from suf- 
fering any accident from without, in order that she may proceed unchecked in her opera- 
tions.” If these sentiments, uttered more than three centuries ago, could only be firmly 
impressed upon the mind of the modern surgeon, there would be much less meddlesome 
practice of every kind than there is now, notwithstanding our boasted knowledge, and 
our contempt for the fathers of the profession. 
Modern surgeons have described five distinct modes in which wounds are supposed to 
heal. The first is by immediate union, or the direct growing together of the raw surfaces ; 
the second, by scabbing, or the formation of a crust of blood upon the wound ; the third, 
by the effusion of lymph, and the conversion of this substance into connective tissue; the 
fourth, by granulation, and the development of epithelial matter; and the last, by the 
junction, coalescence, or inosculation of granulation with granulation. The old doctrine, 
so ably advocated by Hunter, and so long entertained by practitioners generally, assumes 
that there are only two modes of cure ; the one consisting in union by the first intention, 
primary adhesion, or adhesive inflammation, and the second in the formation of granula- 
tions, filling up the gap, and thus repairing the injury, the last stage of the process being 
the development of new skin. This latter mode of repair constitutes what was so long 
known in the schools as union by the second intention, or union by granulation. 
The idea that immediate union of a wound may occur was first advanced by Dr. James 
Macartney, of Dublin. It assumes that two raw surfaces, laid closely and evenly together, 
will promptly coalesce with each other, independently of inflammation and effusion of 
plasma, vessel inosculating, as it were, with vessel, muscular fibre uniting with muscular 
fibre, skin adhering to skin, and nerve becoming again continuous with nerve. It is 
alleged, it is true, that this occurrence is uncommon, and that it requires for its produc- 
tion complete homogeneity of tissue, a good constitution, an entire absence of local inflamma- 
tion, and the greatest possible caution in the management of the parts. When these 
conditions are present, it is asserted that even large wounds, such, for example, as are 
made in the extirpation of the mammary gland, or the amputation of the thigh, are 
capable of this kind of union, an assertion which is contrary alike to sound reasoning and 
correct observation. In discussing this question, it must be borne in mind that different tex- 
tures possess, as is well known, different faculties of furnishing plastic matter, as well as of 
removing it after it has been deposited. Thus, in amputation of the leg, when the flap is 350 
WOUNDS AND CONTUSIONS. 
chap. x. 
exposed to the air, the muscles, fibrous membranes, skin, and connective tissue are much 
more rapidly glazed with lymph tlmn adipose substance, vessels, or bone, the latter of which, 
in fact, rarely exhibits any evidence of its presence under several days. 
If we take into consideration all the circumstances that can be brought to bear upon 
this question; the fact that all injuries whatever are followed by inflammation, if the 
patient survive their effects long enough, as well as by more or less effusion of lymph ; 
that some structures take on this action more readily than others; that inflammation is 
often slight in one part and severe in another; and that lymph, when no longer of any 
use, is invariably absorbed, nature abhorring a substance which she does not need, as in 
the case of a wound after the completion of the solidifying process; I conceive it to be im- 
possible for any wound, however induced, situated, or treated, to heal by immediate union, 
or without the intervention of a certain degree of inflammation and more or less deposit 
of lymph. 
The only case, it appears to me, in which such a mode of union would be at all likely to 
occur, is where the edges of the wound, as, for instance, one of the hand, are carefully 
approximated immediately after the receipt of the injury, thus affording the vessels and 
other structures an opportunity of promptly regaining by their homogeneity their natural 
relations. But even here it is more rational to conclude that the vessels, irritated and 
fretted by the injury which they have sustained, would furnish a thin film of lymph, serv- 
ing as a bond of union between the divided parts. 
The second mode in which a wound is supposed to be capable of healing is by scabbing, 
and here, also, the cure, it is alleged, is effected without the intervention of inflamma- 
tion, or a deposit of plastic matter. The blood, coagulating upon the surface of the wound, 
soon forms a hard, solid crust, which thus protects it from the contact of the air and 
other injurious influences until it is covered with new skin, when nature’s shield, now no 
longer required, is cast off as an effete substance. This mode of healing is rare in man, 
but sufficiently common in the inferior animals, as the horse and cow, which are so much 
less liable to active inflammation and its consequences. It is occasionally imitated by the 
surgeon’s dressing, consisting of lint dipped in blood, or smeared over with collodion, so 
as to protect the raw surface from the contact of air and dirt. The principal proof of 
this mode of cure rests upon the assumption that any inflammatory deposits occurring in a 
case of this kind would effectually destroy the process by prematurely detaching the scab, 
and so leading to the development of granulations, or union by the second intention. 
There is, however, no positive evidence that this is the fact, and to my mind the whole 
theory is a mere speculation, unsupported by a single proof. The difference between such 
a wound and an ordinary open one is simply this, that, while in the former there is very 
little inflammation, in the latter there is a good deal, but in neither is it wholly absent. 
With regard to the third mode of cure, or union by adhesive inflammation, all pathol- 
ogists are agreed. The only conditions which it demands for its speedy and successful 
accomplishment are, first, that no coagulated blood shall intervene between the contiguous 
surfaces, and, secondly, that the part and system shall be maintained in such a state as to 
keep the inflammation strictly within the limits of healthy lymphization. According to 
this doctrine, union cannot take place without more or less inflammation and the effusion 
of a certain amount of plastic matter, serving as a bond of connection between the opposed 
surfaces, glazing and gluing them together, and ultimately, after having enjoyed the prop- 
erties of nucleated blastema, assuming the character of connective tissue. Now, if the 
above views be correct, it follows that all union is the result of adhesive action ; that is, of 
a certain degree of inflammation just sufficient, and no more, to supply the requisite 
amount of lymph for effecting the cohesion of the raw surfaces. If the quantity of this 
substance is very small, or its vitality is greatly impaired, no union can occur; nor will 
such an event take place if the effusion be attended with high excitement; for then the 
material that is poured out will either be aplastic or it will be converted into pus, thus 
causing the parts to gape and compelling them to heal by granulation, or union by the 
second intention. In the more favorable cases of adhesive inflammation, the intervening 
substance is soon removed by absorption, without being transformed into fibrous tissue, 
which can only be needed when the union is tardy, or when it is effected through the 
medium of an inordinate quantity of plastic material; when, in short, the apposition has 
been somewhat imperfect, and yet not so unfavorable as to offer any serious obstacle to 
cohesion, or to cause suppuration. When the process of reunion goes on kindly, the 
merest conceivable film of lymph is generally sufficient; the vessels, nerves, and absorb- 
ents rapidly extend from one side to the other across the intervening substance, and as 
soon as coalescence has occurred, and complete interchange has been established, the new CHAP. X. 
CONTUSIONS. 
351 
matter, now no longer needed, is speedily removed in the same manner and for the same 
reason that the callus is removed after the union of a broken bone; nature, as already 
stated, being averse to the retention of anything that is useless. 
The fourth mode according to which wounds may heal is by the granulating process, or 
union by the second intention. This occurs in all cases where the adhesive inflammation 
is thwarted, whether from defective action, mismanagement, or any other cause whatso- 
ever. The surface of the gaping wound is gradually covered with granulations, by which 
the cavity is ultimately filled up, cicatrization constituting the last act of the process. 
Finally, it is contended that a wound may heal by secondary adhesion, as when the 
granulations covering its surface are closely approximated and held together by appropriate 
dressings. In this way, as is alleged, an opportunity is afforded these bodies of growing, 
as it were, into each other, by an interchange of their respective constituents. To my 
mind, however, this mode of union does not differ, in any respect, from the process which 
occurs during the development, aggregation, and cohesion of the granulations upon the 
surface of a suppurating wound or of an ulcer treated in the ordinary manner. In neither 
case is the coalescence direct, but intermediate, the connecting bond being a thin film of 
lymph, similar to that interposed between the raw edges of a recent wound. 
If what has now been said be true, it necessarily follows that there are only two modes 
in which wounds unite, long recognized by surgeons, easily comprehended, and in perfect 
accord with the results of observation and experience. These two modes are, as was 
previously stated, adhesive inflammation, or union by the first intention, and repair by 
granulations, or union by the second intention ; in other words, there is no form of union 
without inflammation and lymph; and the only difference in the two processes here men- 
tioned is that in the one the plastic matter serves as a direct bond of connection between 
the opposed surfaces, while in the other it is converted into a series of elaborately organ- 
ized bodies which, by their coalescence, ultimately fill up the gap left by the retracted 
edges of the wound. 
A subcutaneous wound heals in the same manner as an open one, only that, as the air 
is excluded, there is less inflammation and more rapid cell-growth and repair. Suppura- 
tion and sloughing are seldom looked for in any of the more simple forms of such a lesion. 
SECT. II CONTUSIONS. 
A contusion is an injury produced by the sudden and forcible contact of a body, as a 
club or bludgeon, with a blunt surface, attended with an effusion of blood, but not with 
any wound of the skin, or, if a wound exist, it is so slight as to be hardly appreciable. 
Whon the skin is divided, the lesion constitutes what is called a contused wound, or a 
contused and lacerated one. A contusion may affect any of the structures, superficial as 
well as deep, hard as well as soft, cutaneous and connective tissues, muscles, nerves, blood- 
vessels, fibrous membranes, bones, and viscera, presenting itself in various forms and 
degrees, at one time slight and at another severe, according to circumstances, more espe- 
cially the violence of the blow and the amount of resistance offered by the parts struck. 
The causes of contusions are of a very numerous and diversified character. Among the 
most common are blows and falls, and machinery in rapid motion. A pinch with the 
thumb and finger, or a light stroke with a hammer, affords a good illustration of a slight 
injury of this kind. The effect of long-continued pressure in the production of contusions 
is well exemplified in what so often occurs in the child’s head in laborious parturition, by 
which the scalp is severely bruised, and more or less blood is extravasated underneath the 
tendon of the occipito-frontal muscles. From the same cause the vagina often suffers, 
the bruised structures taking on inflammation, which, in some of the worst cases, termi- 
nates in sloughing, and in the establishment of vesico-vaginal fistule. The prostate gland, 
as every lithotomist knows, is sometimes badly bruised in the extraction of a urinary cal- 
culus, either because of its large size, or from the maladroit use of the forceps. A severe 
contusion may be produced by the mere concussion of an organ, as, for instance, the brain 
in injuries of the skull, or the testicle in riding on horseback, from the forcible contact of 
the organ with the saddle 
Contusions vary much in degree. In the milder forms there is simply a little discolora- 
tion of the surface, or the subcutaneous connective tissue is slightly infiltrated with blood, or 
a small quantity of blood is collected at a particular spot, all of the unnatural appearances 
subsiding in a few days, either spontaneously or under the influence of some gently stimu- 
lating lotion. In the second degree, as it may be regarded, the lesion is more serious and 
extensive, there is greater change of texture, a larger quantity of blood is poured out, or WOUNDS AND CONTUSIONS. 
chap. x. 
an artery of considerable size is laid open and a diffused aneurism is formed, contusion 
and laceration of tissue coexisting. In the worst degree, the soft structures are completely 
disorganized, mashed, or pulpified, and, if life is not speedily destroyed by shock, or shock 
and hemorrhage, they are soon assailed by mortification. Injuries like these are most 
commonly produced by falls from a great height, by the passage of the wheel of a carriage, 
or by the contact of a partially spent cannon ball. The skin in these frightful accidents 
generally participates in the lesion ; but now and then an instance occurs in which, owing 
to its elasticity, it remains intact, although the underlying structures may be irretrievably 
damaged. The internal organs, as the liver and spleen, are not unfrequently fatally con- 
tused by a blow or a kick, without the faintest trace of injury of the skin where the 
violence was inflicted. The lungs and the brain occasionally suffer in a similar manner. 
Some persons are so peculiarly constituted as to suffer from contusions from the most 
trivial causes, as the slightest blow, pinch, or pressure, as in sitting on a hard chair, or 
lying on a hard, uneven mattress. Old, fat, anemic women, with a very lax and delicate 
skin, are peculiarly liable to sutler in this way, some indeed almost habitually, more espe- 
cially on the back, arms and thighs. Scurvy, wasting diseases, the hemorrhagic diathesis, 
and, in fact, all affections attended with an impoverished condition of the blood, may be 
enumerated as so many predisposing causes of these occurrences. 
The shock in contusion is not always in proportion to the gravity of the accident, the 
degree generally depending more upon constitutional peculiarity than any thing else. In 
violent cases, as when an important viscus or a large joint has been crushed, it may be so 
great as to prove fatal, either speedily or after a feeble attempt at reaction. 
The effects of contusions are primary and secondary, and in both cases they may be 
slight or more or less severe, if not fatal. Contusions involving the skin, or the skin and 
subcutaneous connective tissue, are always attended with a certain degree of discoloration, 
purplish, black, or reddish at first, but gradually, as the blood causing it disappears, shad- 
ing off into bluish, olive, greenish, or brownish yellow, until it finally vanishes. When 
the blood is situated among the muscles, the discoloration may not show itself for several 
days, and even then it does not always appear at the part hurt, but perhaps at a con- 
siderable distance from it, the fluid gravitating along the easiest route towards the surface. 
In nearly all contusions there is more or less swelling, the degree being usually in pro- 
portion to the degree of violence, the nature of the affected structures, as their laxity or 
density, and the amount of extravasated blood. Its advent, as well as its departure, may 
be sudden or gradual. In the former case it may be due solely to effusion of blood, but 
generally there is, in addition to the blood, a rapid exudation of serum, or of serum and 
fibrin, and also great distension of the vessels, the whole contributing to the formation of 
what is vulgarly called a bump, so common about children’s heads as an effect of blows 
and falls. When the swelling is slow, it is usually attributable, especially in the absence 
of inflammation, to the gradual accumulation of blood, in consequence of the rupture of 
the injured vessels under the pressure of their contents. There is no doubt, however, in 
all such cases more or less exudation. 
The contused structures have generally a feeling of numbness, especially if largely sup- 
plied with nerves. When the injury is slight, the sensation is commonly very transient; 
but now and then it lasts indefinitely, and is a source of intense suffering, as is so often 
witnessed in contusions of the scalp, tibia, knee-joint, spine, and shoulder. Partial and 
even complete paralysis and loss of sensation may exist when a large nervous trunk is 
severely contused. 
The pain consequent upon contusions is usually very slight and evanescent, passing off 
soon after the receipt of the injury. It is only in exceptional cases that it is at all severe 
in the first instance. As a secondary effect it is sometimes very troublesome, especially 
in contusions of the back of the head, often assuming a neuralgic character, increased by 
pressure, atmospheric vicissitudes, and disorder of the general system, and liable to peri- 
odical exacerbations. A contused joint, eyeball, and bone are frequently the seat of severe 
local distress long after the occurrence of the primary lesion. 
The amount of blood effused in this accident may be very slight, on the one hand, or 
very copious, on the other, depending as already stated, upon the extent of the vascular 
involvement and the laxity or firmness of the connective tissue. In the milder forms of 
contusion the blood stagnates in the capillary vessels of the skin, or is effused into the 
connective tissue below, so as to cause merely a little discoloration of the surface, discol- 
oration as is witnessed, for example, in a bruise of the scalp or in the “ black eye” of the 
pugilist, from a blow of the fist. The effused blood generally occurs as an infiltration 
being more or less widely diffused through the connective tissue, where it is speedily brought chap. x. 
CONTUSIONS. 
353 
under the influence of the absorbents, and in a very short time completely removed, a few 
days often sufficing for the purpose. What is called an ecchymosis so often found in con- 
tusions, consists essentially in a slight extravasation of blood, caused generally by the 
rupture of the smaller vessels, situated in the connective tissue, immediately beneath the 
skin, and presenting itself in the form of a livid, black, deep blue, or purple spot, of 
irregular shape and variable size. It generally comes on immediately or within a short 
time after the infliction of the injury, and is usually superficial, although it may be deep- 
seated, affecting the interior of a muscle, a bone, or a viscus. Numerous ecchymoses are 
occasionally found in the brain, lung, spleen, and liver, after accidents, in which the 
parenchymatous structure of these organs has been more or less severely bruised. When, 
in consequence of an injury, the blood is collected in a small circumscribed spot, the 
affection takes the name of “ thrombus,” while the term “ depot” is employed to designate 
it when it is large and concentrated. The accumulations of blood which occur on the 
child’s head, and in the labium of the mother, during severe and protracted labor, are 
good illustrations of a sanguineous depot, so often met with upon a large scale in severe 
contusions, both with and without any external wound. When the extravasation is copi- 
ous, it is presumable, whatever may be its form, that it has been caused by the rupture 
of some of the larger vessels, and such an occurrence should, therefore, always be regarded 
as one of a serious character, often placing limb and life in jeopardy. 
The presence of blood in the contused structures, whether occurring as an ecchymosis, 
a thrombus, or a depot, is denoted by discoloration of the skin, and by a marked sense of 
fluctuation, some parts of the swelling, however, generally feeling harder than others, 
depending upon the manner in which the blood is bound down by the overlying tissues. 
When an artery of considerable size has been laid open, there will be, in addition to 
these phenomena, more or less pulsation and murmur, or that peculiar whirring sound so 
characteristic of aneurism. 
The extravasated blood, in contusions, may be perfectly fluid, semifluid, or solid, the 
consistence depending upon the amount of injury sustained by the parts. When the 
injury has been very severe, the blood may be completely devitalized, and then it will of 
course be perfectly fluid, as, for example, not unfrequently happens in the accumulations 
that occur upon the child’s head in ditlicult and protracted labor ; very generally, however, 
it is partially, if not completely, coagulated, and it need hardly be added, what indeed is 
self-evident, that the condition of the blood greatly influences its own ultimate disposition, 
as well as the effects induced by it upon the tissues in which it is located. When it re- 
tains its vitality, and the quantity is inconsiderable, it is usually speedily absorbed, or, 
even if it remain for some time, it is not likely to excite any mischief. When, on the 
contrary, the blood is necrosed, it is either not absorbed, or it is soon decomposed and 
thus becomes a source of irritation and inflammation, leading, not unfrequently, to suppu- 
ration, ulceration, or even mortification, the more especially if the soft parts have been 
much contused, or if they are severely compressed by the extravasated fluid. When the 
blood is very abundant, it may, even if it retain its vitality, so oppress and choke the 
absorbent vessels as to incapacitate them for its removal, just as sometimes happens in 
large dropsical effusions. Occasionally the blood separates into its two constituent ele- 
ments of serum and crassamentum. The opinion that this fluid, in favorable conditions 
of the part and system, may become vascularized, and gradually transformed into con- 
nective tissue, is generally admitted by pathologists, although such an occurrence must 
necessarily be uncommon and exceptional. Whether the new growth, as it may under 
such circumstances be regarded, occasionally forms the starting-point of various kinds of 
tumors, innocent and malignant, is not determined, greatly as the question has been 
agitated. 
The more severe forms of contusion are occasionally followed by more or less effusion 
of pure serum, unaccompanied, apparently, by any fibrin and hematin. The occurrence 
is most common in injuries in which the skin is forcibly torn from the subcutaneous con- 
nective tissue, especially when it is detached obliquely, as when the wheel of a carriage 
passes over a limb, severely bruising the soft structures without causing an open wound. 
The ruptured capillary vessels in such a condition readily part with their serous contents, 
while the more solid portions of the blood are retained, the quantity poured out varying 
from a few drachms to several ounces. The ordinary site of the effusion is the subcuta- 
neous connective tissue, but, at times, it is also found in the intermuscular. The fluid 
appears either as a circumscribed, globular tumor, soft and fluctuating, or, as is more com- 
monly the case, as a veritable extravasation, vague, undefined, and undistinguishable from 
an ordinary accumulation of blood under the skin, excepting that there is, perhaps, less 354 
WOUNDS AND CONTUSIONS. 
chap. x. 
discoloration of the surface. In chronic cases, the fluid is sometimes distinctly encysted. 
In its color the fluid, at first, is generally somewhat reddish, but it gradually assumes a 
pale amber hue, and eventually becomes perfectly clear and limpid; it is viscid to the 
touch, saline in taste, and coagulable by heat and acids. 
A contusion may be dangerous or otherwise, according to its extent, the nature of the 
parts involved, and the state of the constitution. A slight bruise in a person in ill health 
at the time of its occurrence, may become a source of great suffering, even when the 
structures affected are not at all important to life, from the supervention of suppurative 
inflammation, ulceration, or gangrene. A severe contusion of an internal organ, as the 
spleen or liver, may prove speedily, if not instantly, fatal. A contusion of the scalp may 
cause erysipelas, phlebitis, abscess of the brain, pyemia, and death. Old men not un- 
frequently perish from injuries of this kind inflicted upon the prostate gland in lithotomy 
and lithotrity. A contusion complicated with the laceration of important vessels and 
nerves, the crushing of bones, and the perforation of the larger joints, is always a danger- 
ous occurrence. Limb and life are sometimes imperilled secondarily, as when there is a 
large accumulation of blood, rapidly undergoing devitalization and putrefactive decompo- 
sition, poisoning the system by the imbibition of noxious gases and ichorous matter. The 
prognosis is unfavorable in severe contusions occurring in persons exhausted by scurvy, 
anemia, typhoid fever, and long-continued and profuse discharges. 
In the treatment of contusions the leading indications are, to prevent further effusion, 
to limit inflammation, and to promote the removal of the accumulated blood. 
In the lighter forms of injury the application of cold water, simple or medicated, will 
generally be all that is required for a speedy cure. Lotions of arnica, vinegar, and 
common salt, lead, Goulard’s extract, chloride of ammonium, alum, and spirit of camphor 
are among the most important agents in this class of injuries, most of them acting 
as powerful sorbefacients, at the same time that they tend to repress excitement and 
prevent effusion. Pounded ice, inclosed in a bladder or rubber bag, spread out over 
the affected surface, is often a very valuable remedy, but is not to be used without 
proper vigilance, lest it should harm by depressing the vital powers of the part. 
Leeches may be scattered over the affected surface when there is much local disorder. 
Cataplasms and warm water-dressing are sometimes serviceable. The most trustworthy 
sorbefacient is a strong solution of chloride of ammonium, with the addition of a small 
quantity of vinegar, applied upon folded flannel, covered with oiled silk, and renewed six 
or eight times in the twenty-four hours. Parts excessively contused generally require 
stimulating applications, as alcohol and water, or lotions of spirit of camphor, not, of 
course, too long continued. 
When the blood is devitalized, or in a decomposed condition, whether fluid or coagu- 
lated, it should be promptly evacuated by a free incision, the abnormal cavity being well 
washed out immediately after with tepid water, impregnated with permanganate of potas- 
sium, or, with a few drops of any of the acids. Undue reaction is controlled with morphia, 
while the treatment, in other respects, is managed upon general principles. When the 
cavity left by the discharge of the effused blood is very large, reunion will be promoted by 
the use of the compress and roller. Diffused aneurism is treated by exposure of the 
wound, and by the ligation of both ends of the affected artery. Amputation may become 
necessary when the contusion occupies an extremity, and is attended with extensive puri- 
fication of the soft tissues, crushing of the bones, laceration of important vessels and 
nerves, and the penetration of the larger joints. The treatment of the secondary effects 
of contusions will receive proper attention in connection with the diseases and injuries of 
the different organs and textures. 
Cavalry-men and grooms are exposed to a severe form of contusion of the tibia, from 
the kick of the horse. The accident is liable to be followed by violent inflammation, 
with a tendency to erysipelas and diffused abscess. Recovery is often slow, and suffering 
great, especially if there has been much concussion of the bone, or extensive injury of 
the periosteum. The treatment is conducted upon general principles, with the addition of 
free incisions to liberate the soft parts, the knife grating against the surface of the bone, 
as in the operation for whitlow. 
Tissues that are firmly compressed, constricted, or strangulated are placed very much 
in the condition of contused structures, and are liable, if not promptly rescued, to become 
severely, if not fatally, constricted. A bandage tightly wound around an inflamed limb 
may give rise to gangrene ; a ring slipped over the wrong finger, to violent inflammation; 
and the narrow aperture through which the intestine descends in a recent hernia, to 
mortification of the protruded structures. Paraphiniosis affords a good illustration of the CHAP. X. 
INCISED WOUNDS. 
355 
compression and contusion of a part by the action of tlie common integument, the effect 
being similar to that produced by the pressure of a tight ligature. The first effect of 
such an occurrence is an impediment in the vessels and nerves, interfering with the cir- 
culation of the blood and the transmission of nerve lluid, speedily followed by an effusion 
of serum, giving rise to a soft, glossy, oedematous condition. If prompt relief be not 
afforded, the obstruction increases, inflammation is set up, lymph is poured out, the 
circulation is completely suspended, and the parts, assuming a dark, mottled, purplish, or 
blackish hue, are irretrievably lost. These effects often ensue in an almost incredibly 
short time, as, for example, is so often witnessed in strangulated hernia, especially in 
cases of recent standing accompanied with an unusually small aperture of descent. 
The treatment of these and similar affections is sufficiently obvious, the first and most 
important point being the removal of the exciting cause, after which an attempt must 
be made to repair any damage that may have been don£ by the constriction, special pains 
being taken to restore the circulation and to promote the absorption of inflammatory 
deposits. 
SECT. Ill INCISED WOUNDS. 
Incised wounds are simple cuts made with any sharp instrument, as a knife, a sword, 
or an axe, and vary in extent from the slighest possible incision to a gap of frightful length' 
and depth. The largest incised wounds are usually made designedly by the surgeon in 
the extirpation of tumors, in the amputation of the limbs, and in the resection of the 
joints. In general, they are open, and therefore in contact with the air; sometimes, 
however, they are subcutaneous, and therefore exempt from such exposure. All incised 
wounds, however simple, are characterized by three phenomena, deserving of special con- 
sideration : 1st, hemorrhage; 2dly, more or less pain ; and 3dly, retraction of the edges 
of the divided structures. 
1st. The hemorrhage varies in quantity, from a few drops to several ounces, or even 
quarts, according to the extent of the injury, and, above all, the vascularity of the affected 
tissues. When the capillaries alone are involved, the blood oozes rather than flows away, 
the reverse being the case when a tolerably large vessel is divided. The hemorrhage 
may be strictly arterial, but generally it is both arterial and venous. In the former case 
the fluid is of a scarlet color, and spirts out in jets, synchronously with the contraction of 
the heart; in the latter, on the contrary, it is of a dark modena, or purple complexion, 
and issues in a continuous stream, as in bleeding at the arm. Some structures are natur- 
ally more vascular than others, and, therefore, yield more blood when divided. Thus, a 
wound of the lip bleeds more freely than one of the cheek, and of the cheek than one of 
the leg. Again, a part that is habitually irritated bleeds, when divided, much more 
copiously than when it is in a healthy state. A familiar example of this occurrence is 
afforded in excision of the tonsils, an operation which is sometimes attended with profuse 
hemorrhage, in consequence simply of the enlargement of the vessels, and their inability 
to retract on account of inflammatory effusions. 
2dly. The pain, like the hemorrhage, attendant on an incised wound, is influenced in 
its extent by the size of the lesion, the nature of the affected textures, and the tempera- 
ment of the individual. In general, it very soon subsides, and does not afterwards return, 
unless there is undue inflammatory action. When a large nerve is implicated in the injury, 
there is usually, in addition, some degree of numbness in the surrounding tissues, and 
occasionally, also, partial paralysis in the distal parts. 
3dly. The retraction of the edges of the wound is dependent upon the natural resiliency 
of the cutaneous and muscular tissues. It is very materially influenced, however, in its 
degree, by the depth of the wound, by its situation, and also by the amount of motion to 
which it may be subjected immediately after the receipt of the injury. Thus, a wound 
of the hairy scalp, extending down to the bone, will hardly gape any, while one on the 
forehead, arm, or leg will exhibit a frightful cavity ; in the one in consequence simply of 
the muscular contraction of the part, and in the other of the change of posture. 
The treatment of such an injury is perfectly simple. The first object is to arrest the 
hemorrhage, provided this has not been already done by the natural efforts. When it 
is strictly capillary, it will either soon cease spontaneously, or it may readily be checked 
by exposing the wound to the air, or by pressing upon it a sponge wet with hot water. 
When, on the other hand, it proceeds from a vessel of considerable size, the more prudent 
course will be at once to apply a ligature; for, although it may be temporarily arrested, 
it will be very liable to break out again, if not upon the slightest exertion, at all events, 356 
WOUNDS AND CONTUSIONS. 
chap. x. 
so soon as reaction is fully established, and it may then become a source of great annoy- 
ance both to the patient and to the surgeon. 
The hemorrhage having been arrested, all foreign substances, however delicate or 
minute, must be carefully picked away with the forceps, removed with the fingers, or dis- 
lodged with a stream of water, squeezed from a sponge, or thrown upon it from a syringe. 
The finest hair, if allowed to remain, would act as an irritant, and impede the adhesive 
process. The same remark is applicable to any blood that may cover the wound or 
incrust its edges. It is just as necessary to remove this as dirt or any extraneous sub- 
stance whatever. Even the slightest possible layer of blood is likely to prove a barrier 
to immediate reunion ; for, although this fluid sometimes is unquestionably susceptible of 
organization, such an event is never expected or wished for under such circumstances. 
Hence the whole surface of the wound should be thoroughly freed of it, not roughly, of 
course, but as gently as possible, before an attempt is made to approximate its edges. If 
the blood is coagulated and adherent, it may readily be detached with the fingers, forceps, 
or handle of the scalpel. Finally, the circumjacent parts, if covered with hair, are care- 
fully shaved and washed. 
The object of these preliminaries is to place the wound in the most favorable condition 
for union by the first intention, or the establishment of the adhesive process. To insure 
this, the edges must be carefully approximated in their entire extent, and retained in con- 
tact for a certain period, by appropriate means, aided by rest and proper position of the 
part. If the wound is of small extent, nothing will be required beyond a strip or two 
of adhesive plaster. If, on the other hand, it is long and deep, it will probably be neces- 
sary to use, in addition, a few sutures, if not, also, a compress and bandage. 
The wound being dressed, and the parts concerned placed at rest in a relaxed, and, if 
possible, also, in an elevated position, little remains to be done by the surgeon, except to 
watch and assist nature in her reparative efforts. Within a short time after the edges of 
the wound have been approximated, inflammation is set up, speedily followed by an effu- 
sion of plasma, not only upon their surface, but also into the surrounding tissues. The 
interposed layer, perhaps hardly as thick as the most delicate spider’s web, soon becomes 
organized, by an interchange of vessels and nerves between the opposite sides, is con- 
verted into connective tissue, and thus forms a bond of union between the divided struc- 
tures. In the meanwhile the inflammation gradually subsides, the surrounding tissues 
regain their accustomed functions, and the consolidation is completely established. The 
resulting cicatrice remains rough for some time, but by degrees it becomes polished, and 
finally assimilates itself to the natural skin, except that it is whiter, destitute of hair, 
sebaceous follicles, and sweat glands, and less capable of resisting the effects of disease 
and injury. 
But it is not always that the healing process advances so favorably as it is here described. 
Very frequently, indeed, it is materially retarded, interrupted, or even entirely subverted. 
Of the various causes which may contribute to bring about this untoward result, the most 
common are the presence of foreign matter in the wound, want of accurate apposition, 
too much motion, improper applications, or undue inflammation, however induced. It is, 
therefore, the duty of the practitioner not only to attend well to every case of this kind in 
the first instance, but to watch it most sedulously throughout its entire progress, inciting 
action when it is deficient, and repressing it when it is too high. 
If the symptoms assume an untoward tendency, the adhesive action threatening to pass 
into the suppurative, the sutures and plasters should immediately be slackened, and water- 
dressing, either warm or cold, simple or medicated, applied, according to the tolerance of 
the part and system. In general, simple water will be found to answer better than any- 
thing else, and may often be advantageously employed from the very commencement, 
especially if the wound is very large, in anticipation of inordinate action. The diet, 
bowels, and secretions must be properly regulated; and, if suppuration be inevitable, the 
most agreeable and soothing remedy will commonly be a light, emollient cataplasm. 
Gaping of the wound should be counteracted by the use of adhesive strips, aided by posi- 
tion, and, if necessary, by a few loose stitches and the bandage. 
SECT. IV SUBCUTANEOUS WOUNDS. 
Subcutaneous wounds differ from all other wounds in three important particulars: first, 
they do not have an exposed surface, or, in other words, the tissues that are involved in 
them are not laid bare ; secondly, they are generally followed by very slight inflammatory 
action ; and, lastly, they heal, for the most part, promptly, by union by the first intention, CHAP. X. 
SUBCUTANEOUS WOUNDS. 
357 
the whole process of repair being one of unusual rapidity, evidently due to the fact that 
no air is admitted into them to embarrass the cure. It is upon a knowledge of these prin- 
ciples that Stromeyer and his followers founded what is now known as subcutaneous sur- 
gery, a branch of practice which is of such signal service in the treatment of malforma- 
tions and deformities. 
There are, properly speaking, two varieties of subcutaneous wounds, sufficiently dis- 
tinct in their character to entitle them to separate consideration. In one, that to which 
the above remarks are chiefly applicable, the wound communicates with the exterior, the 
aperture by which this is effected being usually a mere puncture, such, for example, as is 
made in tenotomy, or in the subcutaneous division of a tendon ; in the other, which is 
often a formidable lesion, the skin is not perforated, and, consequently, there is no admis- 
sion of air, not even transiently. Such wounds are essentially contused and lacerated 
wounds, in which, even occasionally when the lesion is of the most formidable character, 
the integument either retains its integrity, or, as more commonly happens, it is somewhat 
bruised, cut, or torn, but not completely divided. A simple fracture is essentially a sub- 
cutaneous wound of a bone and of the adjacent soft structures. A wound made by the 
tearing away of a tendon from a muscle, leaving behind its sheath, is a lesion of a similar 
kind. Thus, it will be perceived that, although in one of these wounds air is admitted, 
and in the other excluded, yet the former is by far the more simple of the two, seldom 
much inflamed, and generally easjly healed. 
The subcutaneous wound most commonly met with is that so often made in tenotomy 
and in kindred operations practised for the rectification of various affections of the mus- 
cles, aponeuroses, ligaments, and other structures, and which, in its character, combines 
the puncture with the cut. Lesions of this kind have been studied chiefly in connection 
with tenotomy, and I shall, therefore, limit myself, in great measure, in what I intend to 
say upon the subject of subcutaneous wounds, to what occurs in a divided tendon. 
In tenotomy, the skin, generally pierced somewhat obliquely, is opened just sufficiently 
to admit of the easy introduction of the knife used for the division of the tendon. The 
moment this is effected, the ends of the cord acted upon by the muscle with which it is 
connected retract, thus leaving a gap of variable extent between them. The little punc- 
ture in the skin being immediately closed with adhesive plaster, the parts are placed pre- 
cisely in the same condition as in a wound originally without an external opening. The 
air that always enters such a wound is speedily absorbed; the effused blood, too, soon 
disappears, and nature, ever on the alert in such a case, rapidly fills up the gap with 
plasma. Some inflammation necessarily ensues, but the action is slight, and in no wise 
hostile to repair, or to the development of new tissue. The plasma, at first soft and 
jelly-like, and of a ruddy tinge from the intermingling of hematin, the result of the knife’s 
work, gradually augments in firmness, and presently assumes a grayish or whitish appear- 
ance. Proliferation and growth are active, but the cells rarely advance beyond the fusi- 
form, and often, at an early period, manifest a retrograde movement, degenerating and 
atrophying. The surrounding tissues always participate in the inflammatory action, be- 
coming red, injected, slightly swollen, more or less tender, and infiltrated with blood- 
liquor. The new piece of tendon, when fully developed, is found to bear so close a 
resemblance to the primitive as to be with difficulty distinguished from it; it fills exactly 
the original gap, and thus forms a continuous structure, slightly overlapping and ensheath- 
ing the retracted extremities, and soldering them firmly together, much after the fashion 
of the ensheathing callus in a broken bone. As the process approaches completion, the 
neighboring structures gradually return to their normal condition, their vascularity dis- 
appearing, the inflammatory material being cleared away, and eventually function being 
completely restored. 
What occurs in a subcutaneous wound after the division of a tendon happens, under 
similar circumstances, in other structures; the new connecting bond, however, is not 
always precisely like the original, especially in muscle and cartilage ; and the retraction 
of the divided ends is generally much less than in tendon. Thus, in the connective and 
adipose tissues, in nerves, ligaments, and fibrous membranes, it is hardly perceptible unless 
the parts are forcibly stretched during or immediately after the division. 
In the second class of subcutaneous wounds, the risk to limb and life forms in many 
cases a most important element; for, although there is originally no external opening 
admitting air, yet the injury inflicted upon the affected tissues is frequently so severe and 
extensive as to be followed, perhaps, in a very short time, by the most disastrous conse- 
quences, death being often caused by shock, gangrene, or diffused suppurative inflammar 
tion, blood and solids being alike depressed, if not more or less devitalized. The skin, WOUNDS AND CONTUSIONS. 
chap. x. 
without being cut or pierced, is often extensively detached from the connective tissue be- 
neath, and is, therefore, in imminent danger of sloughing from the arrest of its circulation. 
In their character such wounds are essentially bad forms of contused and lacerated wounds. 
The more simple forms frequently admit of cure, although the structures concerned in 
them generally remain long in a weak and crippled condition. The reparative process is 
similar to that of an incised subcutaneous wound, that is, the effused blood is generally 
carried away, and the plasma that is poured out serves to connect the ends of the divided 
structures ; all redundant substance eventually disappearing, and the parts, if not too much 
injured, resuming their normal functions. The reason why a simple fracture heals so 
much more readily than a compound one is that in the one the air is excluded, and in the 
other admitted. The treatment of open wounds, of whatever character, is often greatly 
expedited by the employment of protective measures, not too frequently changed. The 
much vaunted antiseptic treatment owes, I have no doubt, more of its efficacy to this cir- 
cumstance than to any special virtue of the antiseptic agents themselves. 
The treatment of a subcutaneous wound is generally of the most simple kind, perfect 
rest and elevation of the affected parts constituting the most important elements of success. 
If the inflammation threatens to transcend the limit of fibrinous exudation, the case must 
be met by the application of leeches, medicated lotions, the cold water-dressing, or emol- 
lient cataplasms, along with appropriate internal remedies. The treatment of contused 
and lacerated subcutaneous wounds does not differ from that necessaiy in open wounds of 
this character, described in a previous section. 
SECT, y LACERATED WOUNDS. 
A lacerated wound is a lesion in which the tissues, instead of being smoothly divided 
with a sharp, cutting instrument, are torn rudely and forcibly asunder. The edges are 
ragged and irregular, there is little pain or hemorrhage, and the surrounding parts, fre- 
quently bruised and discolored, are cold and numb. The injury most commonly occurs 
in factories, grist-mills, and steamboats, from the clothes and limbs being accidentally 
caught in the machinery. Extensive lacerations are often caused by weapons of war; by 
the teeth of the inferior animals, as the shark, dog, and bear; by the passage of the 
wheel of a cart or carriage; and by falls from a considerable height, in which the body 
strikes against a hard and projecting object, as a stone, post, or railing. 
A lacerated wound differs from an incised one, 1st, in the slightness of the attendant 
pain ; 2dly, in its indisposition to bleed ; 3dly, in its tendency to suppurate and slough ; 
and, 4thly, in its liability to be followed by erysipelas, septicemia, pyemia, tetanus, and 
other nervous symptoms. 
The pain in lacerated wounds is generally very trifling ; indeed, instances are frequently 
met with in which there is no pain at all, the patient being unconscious not only at the 
moment, but for some time afterwards, of having received any serious injury. Thus in 
the case of Wood, the miller, as detailed by Cheselden, the arm was torn off at the 
shoulder, and yet so slight was the pain that the man was not aware of what had occurred 
until he observed the limb moving round on the wheel. I have seen instances in which 
the tendons of the fingers, along with portions of their muscular bellies, were pulled out 
with such velocity that the patient not only experienced no pain, but was for some time 
utterly unconscious of the injury. When the lesion is very grave and extensive, as when 
a limb is suddenly severed from the trunk, the attendant shock must necessarily be so 
severe as, in great measure, to obliterate all local sensation. Upon the occurrence of 
reaction, however, the pain is frequently intense. 
The absence of hemorrhage in a lacerated wound forms a very striking feature, and is 
the direct consequence of injury done to the vessels. In an incised wound there is no 
impediment to the flow of blood, because the vessels are divided evenly; in a lacerated 
one, on the contrary, they are torn into shreds and fragments, which readily intercept the 
fluid as it sweeps over them, and thus promote the formation of a coagulum, often extend- 
ing high up into the tube. The vessels, moreover, are partially paralyzed, from the injury 
sustained by the nervous filaments of the affected parts; hence they are incapable of con- 
tracting upon and propelling their contents. In addition to these circumstances, there is 
frequently, especially in severe lacerations, excessive prostration of the system, which 
powerfully contributes to the coagulation of the blood, and to the formation of an internal 
clot. This indisposition to hemorrhage is often present even when very large vessels are 
wounded. In the celebrated case of Wood, above alluded to, the arm was torn off along 
with the scapula, and yet there was no hemorrhage. A number of instances of a similar CHAP. X . 
LACERATED WOUNDS. 
359 
kind have been published, among the more remarkable of which are those related by La 
Motte, Morand, Clough, Mussey, Scarnell, Lizars, Braithwaite, Cooper, King, and Lowe. 
Lacerated wounds are frequently deceptive in their appearance, the amount of injury 
being much greater than the surgeon is at first sight led to suppose. The skin, for exam- 
ple, may be affected very slightly, perhaps, indeed, hardly at all, while the muscles, 
aponeuroses, vessels, and even the nerves, may be extensively severed, or torn up. In 
many cases the bones are crushed, large joints laid open, and the soft structures completely 
pulpified. Hence too much caution cannot be observed in our examinations, as well as in 
our prognosis. 
The treatment of a lacerated wound is conducted upon the same general principles as 
that of an incised one. All extraneous matter is removed, the vessels, if necessary, 
are tied, the parts are neatly approximated, and every precaution is used to moderate the 
resulting inflammation. In applying the ligature, a sound portion of artery is selected, 
otherwise secondary hemorrhage will almost with certainty follow the sloughing process. 
When the hemorrhage is venous, it may generally be promptly and effectually arrested by 
a compress and roller, so arranged as not to impede the return of the blood to the heart. 
All undue constriction must be avoided. Ligation is rarely called for, even when the 
largest veins are torn across. Although it is not probable, from the ragged character of 
the wound, that much of it will heal by the adhesive process, it is always best to treat the 
case with reference to this object. For this purpose the edges, after having been neatly 
trimmed, are lightly approximated, and maintained by adhesive strips, supported by a 
bandage; all tension is carefully avoided; and large interspaces are left between the 
plasters for easy drainage. Sutures may usually be dispensed with, although I have not 
the same dread of them that some surgeons have; for while I have, in many cases, derived 
the most signal benefit from their employment, I have never seen them do any harm. 
Any parts that are completely devitalized may at once be cut away, but as there must 
generally be some doubt on the subject, it is a good rule to let them alone, and intrust 
their separation to the efforts of nature ; or, at any rate, to wait until it is perfectly certain 
that they are dead. 
To moderate the inflammation, water-dressing is used, either warm or cold, as may best 
comport with the comfort of the patient. On the appearance of suppuration it may, 
unless it is acting very kindly, give way to an emollient cataplasm, which, in its turn, is 
superseded as soon as the granulating process is fairly established, by opiate cerate, or the 
dilute ointment of nitrate of mercury. If the inflammation run very high, threatening to 
terminate in gangrene, purgatives and nauseants are freely used, and leeches are applied to 
the parts immediately abound the wound. The lancet is rarely required, except in very 
robust and plethoric subjects, in whom, under such circumstances, it cannot be resorted to 
too early or hardly too vigorously. The mercury is frequently indicated at the very com- 
mencement of the treatment, on account of the concomitant derangement of the biliary 
and digestive apparatus, produced by the shock of the injury. It should be administered 
in moderate doses, either alone or conjointly with opium, Dover’s powder, or morphia and 
antimony. Anodynes must be freely given to allay pain and insure sleep. Much judg- 
ment is required not to carry the depletion too far. Due allowance must always be made 
for the waste which must necessarily attend a wound of this description, as well as for the 
depression which the system experiences in the first instance, and which often continues to 
exert its baneful influence for days and weeks together. 
Attention w'as called, in 1874, by Dr. F. II. Hamilton, to the treatment of wounds by 
immersion in simple warm water; and Dr. David Prince, of Illinois, had previously em- 
ployed what he calls “ perpetual irrigation” with warm water impregnated with so- 
lution of carbolic acid and of salicylic acid. The treatment is especially commended 
in lacerated wounds and in wounds attendant upon compound fractures and dislocations ; 
it is generally very soothing in its effects, lessens suppuration, promotes cleanliness, and 
conduces in many cases, cases even of an apparently desperate nature, to recovery. I 
have no personal experience with this method of treatment, but have great faith in the 
judgment of the two able surgeons who so highly recommend it. 
Secondary hemorrhage in such a wound may arise as soon as reaction takes place, or it 
may be postponed until the sloughs begin to separate. In the latter case it will not be 
likely to occur before the fifth or sixth day. When there is reason to expect such an 
event, as when an artery of considerable size is implicated, the patient should be most 
sedulously watched until the crisis is past, a tourniquet being placed loosely around the 
limb, and the nurse instructed in its use, so as to be fully prepared to meet the emergency 360 
WOUNDS AND CONTUSIONS. 
chap. x. 
the moment it arises. For the want of such precaution, life might be destroyed in a few 
minutes, before it is possible for the attendant to reach the bedside. 
Tetanus, as the result of a lacerated wound, is most frequently met with in nervous, 
irritable subjects, during the prevalence of hot, or damp, chilly weather, and often arises 
without any obvious cause, either as it respects the injured part or the system. Anodynes, 
especially morphia and chloral in large doses, will sometimes promptly arrest it in its 
earlier stages, but when fully developed it almost always proves fatal, whatever may be 
the nature of the treatment. 
When the laceration is seated in an extremity and involves important vessels and 
nerves, or when it is accompanied by a comminuted fracture, a compound dislocation, or 
a disorganized state of the soft parts, amputation will probably be required, the proper 
period for its performance being the moment reaction is fully established. If it be under- 
taken while the patient is pale, faint, and exhausted, he will almost certainly die from 
the shock of the operation, either immediately, or, at most, within a few hours after. On 
the other hand, amputation must not be postponed until the system has been assailed by 
inflammation, since this would equally compromise the result. The time, then, for inter- 
fering is when the heart has, in some degree, resumed its wonted action, the pulse reap- 
peared at the wrist, the color returned to the face, and the warmth been reestablished in 
the extremities; then, but not until then, is the use of the knife proper. 
SECT. VI CONTUSED WOUNDS. 
A contused wound derives its chief characteristics from the compressed and disorganized 
condition of the tissues, and occurs in two varieties of form, the open and the subcuta- 
neous, the integument in the latter retaining its integrity, whereas in the former it is more 
or less cut or lacerated. The injury, in either event, may arise in a great many ways, as 
from a blow with a heavy bludgeon, the kick of a horse, the passage of the wheel of a 
carriage, the contact of a partially spent ball, or the explosion of a gun, shell, or rocket. 
An ugly contused wound is occasionally received in a high fall, in which the person 
alights among sharp and disjointed stones, upon a pile of timber, or upon a mass of rub- 
bish. The most severe accident, however, of this kind, is that which follows the passage 
of the wheel of a railway car, in which the body is most frightfully mangled, the soft 
parts being literally pulpified and the bones ground in pieces. The contusion and lacera- 
tion which occur under the scalp during the descent of the child’s head in parturition 
afford a good illustration of a subcutaneous contused wound. 
The effects of a contused wound are various. When the injury is very severe, life 
may be destroyed on the spot, precisely as in a gunshot wound, from shock or loss of 
blood, without any attempt whatever at reaction. In the milder forms, however, the con- 
sequences may be very trifling. From the manner in which the structures are bruised, 
there is generally but little pain both in the first instance and for some time afterwards; 
the part feels merely stiff and numb, perhaps somewhat sore and tender ; by and by, 
however, when inflammation arises, the pain is often considerable, and in some instances 
it is even extremely severe. When the injury is extensive, there is always violent shock ; 
the patient is deadly pale and almost bereft of consciousness, the pulse is hardly percep- 
tible, and there is great coldness'of the extremities. When he recovers from this state, 
he is apt to suffer from vomiting and various nervous disorders. If the weather be hot, 
or the constitution unusually irritable, he may be seized with locked jaw. Neuralgia is 
also liable to occur as a sequel of such accidents. 
Another peculiarity of the contused wound is the trivial hemorrhage which usually at- 
tends it; resembling, in this particular, the lacerated and punctured wound. The vessels 
being bruised and paralyzed, are unable to propel their contents, which, consequently* al- 
most instantly coagulate, thus opposing an effectual barrier to the effusion of blood, which 
is also, at the same time, in many cases, if not generally, deprived of its vitality in the 
midst of the injured and perhaps pulpified tissues. When, however, the lesion is very 
slight, the vessel always throws out more or less blood, although the flow is never copious, 
except when an artery of considerable size has been laid open, when it may be so great 
as to prove speedily fatal. Much, then, will depend, in every instance, so far as bleed- 
ing is concerned, upon the extent and the particular character of the lesion sustained by 
the coats of the vessels, and also, but in a minor degree, upon the injury inflicted upon 
the blood itself. 
Although there frequently is little or no bleeding in such a wound immediately after its 
occurrence, there is generally, if the injury be at all extensive, great danger of secondary CHAP. X. 
CONTUSED WOUNDS. 
361 
hemorrhage. The period at which this will be most likely to arise is when the sloughs 
begin to separate, which, on an average, will be from the fifth to the tenth day, according 
to the size of the breach and the amount of the concomitant contusion. Hence, as in 
lacerated and gunshot lesions, the patient should always be diligently watched during this 
time, lest, hemorrhage coming on unexpectedly, he should perish before proper assistance 
can be obtained. 
Contused wounds seldom heal, even in any considerable degree, by union by the first 
intention ; the vessels are too much crippled to furnish healthy plasma; and the inflam- 
mation is often so violent that the surgeon is extremely fortunate if he can restrain it 
within suppurative limits. Gangrene is by no means uncommon, the more especially if 
the lesion be at all severe; for there are few cases in which more or less tissue is not de- 
vitalized during the infliction of the injury, and, under such circumstances, more or less 
sloughing is of course inevitable. Large abscesses often follow, particularly in contusions 
of the scalp, the hands and feet, the walls of the abdomen, the perineum, and the mus- 
cles of the thigh, back, and shoulders, the matter being not unfrequently extensively dif- 
fused among the surrounding structures, and preceded in its development by erysipelatous 
inflammation, a nervous, irritable, and exhausted state of the system generally powerfully 
predisposing to the untoward occurrence. 
Serious injury is occasionally inflicted upon the trunk or upon a limb, without any out- 
ward evidence whatever of the fact, perhaps not even the slightest bruise, scratch, or 
discoloration of the surface. Such accidents are most frequently caused by the passage 
of the wheel of a carriage, the kick of a horse, machinery in rapid motion, or the blow 
of a cannon ball, and are easily accounted for by the elasticity of the skin, which enables 
it to glide out of the way of the vulnerating body, while the other and deeper-seated 
structures, destitute of this property, are sometimes completely destroyed by its contact, 
the vessels and nerves being cut to pieces, the muscles torn into shreds, the bones crushed, 
and the largest joints laid open. The scalp is sometimes extensively detached from the. 
cranium by a fall upon the head, without any external wound, and a partially spent can- 
non ball, striking the belly obliquely, has been known to tear open the bowels, spleen, and 
liver, without leaving any mark or trace whatever upon the skin. Such injuries, which 
are essentially subcutaneous wounds, are peculiarly severe, and are liable to be followed 
by the worst consequences; often proving fatal on the instant, or, subsequently, from the 
effects of inflammation. 
A contused wound occasionally exhibits the appearance of an incised wound. Such 
an occurrence may readily arise when the soft parts are struck by a blow, kick, or fall, by 
which they are brought forcibly in contact with the osseous surface beneath, which thus 
acts as a resisting, vulnerating agent. The effect will be more likely to arise if the tis- 
sues overlie a sharp ledge or bone. The rent thus produced may be transverse, oblique, 
or longitudinal, and of variable width and depth. The most common sites of such inju- 
ries are the face and head ; and an accident as simple as a blow with the fist has been 
known to occasion them in these regions. A kick on the vulva, violently compressing 
this part against the pubic bone, may cause a similar lesion. A rent, closely resembling 
an ordinary cut, is sometimes inflicted upon the lip by a front tooth in a blow, fall, or 
kick upon the mouth. 
What is vulgarly called a brush-burn is a peculiar form of contused wound, the con- 
sideration of which properly falls under the present class of lesions. It is most com- 
monly met in manufacturing districts, and is generally caused by machinery in rapid 
motion, or revolving belts and similar contrivances. It may also be produced by sliding 
rapidly down a bill or on rough ice. The immediate effect of such contact is an abrasion 
of the cutaneous surface, in which the superficial structures of the skin are ground to 
pieces, at the same time that they are partially burned, while the underlying tissues 
are more or less bruised and disorganized. The accident, unless very slight, is generally 
followed by severe pain and inflammation, occasionally terminating in gangrene. 
In the treatment of contused wounds the leading indications are to arrest hemorrhage, 
to limit inflammation, and to promote the absorption of effused fluids. 
Hemorrhage is controlled in the usual manner; by compression, styptics, and hot 
water, if it be slight or venous; by ligature, if it be copious and arterial. When the 
bleeding vessel is concealed, as when the wound is subcutaneous, it may be extremely 
difficult to find it, owing to the bruised and infiltrated state of the parts, which often 
renders the search one of gruat labor and annoyance ; still, it is the only resource, and, 
therefore, the sooner the operation is performed the better, for it will certainly not at all 362 
WOUNDS AND CONTUSIONS. 
chap. x. 
facilitate the undertaking if it be postponed until the supervention of inflammation. If 
the obstacles are unusually great, or if, in the attempt to tie the artery at the seat of 
injury, important structures are found to be in the way, it will be well to secure the vessel 
at some distance above the wound ; trusting that any recurrent bleeding that may arise 
will either cease spontaneously, or yield to systematic and persistent compression. 
Although we can hardly expect to obtain much, if any, union by the first intention in 
a contused wound, no harm can result from trying, as the effort cannot possibly make 
matters any worse. With this view, the edges of the wound should be as nicely approxi- 
mated as possible, care being taken, of course, not to draw them together at all tightly ; 
for due allowance must be made for swelling and drainage, which will always be more or 
less considerable in this class of lesions. No fear need be entertained respecting the use 
of sutures, provided they are introduced loosely, and not too numerously. I never hesi- 
tate to employ them in such cases, for I have never known them to be followed by any 
ill effects. It is only when they produce tension, or when they are made to embrace im- 
proper tissues, that they are likely to prove prejudicial. The same remarks are applica- 
ble to adhesive strips ; they cannot be dispensed with, but they must be applied with great 
care, and in such a manner as to leave free room for the escape of fluids. Some authors 
advise that the edges of the wound should be neatly trimmed prior to their approxima- 
tion, but such a procedure is never justifiable, unless it is perfectly clear that the tissues 
are dead, or so ragged and irregular as to render it impossible to effect accurate apposi- 
tion. It will generally be well to intrust this matter, in great degree, if not entirely, to 
the operation of nature. 
A few sutures and adhesive strips are usually the only dressings required. The parts, 
having been properly adjusted, are kept constantly wet with evaporating lotions, of which 
alcohol, largely diluted with water, is generally the best. Weak solutions of acetate of 
lead or Goulard’s extract are also serviceable. Such cases are usually benefited by 
slightly stimulating applications, as they impart tone to the enfeebled vessels, and thus 
ward off erysipelas, so frequent in this class of lesions when treated in the ordinary 
manner. Leeches and iodine may become necessary when the inflammation is very 
active, and then a poultice will also generally be found to be more grateful than cold 
water or astringent lotions. The bowels and secretions must receive due attention, but 
severe purgation, and, in fact, all active depletion must be studiously guarded against. 
Proper allowance must be made, in every case, for the profuse discharges which are so 
liable to follow contused wounds. If mortification should occur, the treatment will not 
differ from that consequent upon ordinary inflammation. Pain and nervous symptoms 
are controlled by anodynes and antispasmodics. When granulations begin to spring up, 
the milder ointments will advantageously supersede the warm and cold applications ; the 
former proving nowr too relaxing, and the latter too repressing. 
The removal of extravasated blood is best effected by the tincture of arnica, in the 
proportion of three ounces to the pint of water, diligently applied with patent lint; 
and by cold, astringent lotions, such as acetate of lead, Goulard’s extract, alum, and 
chloride of ammonium. After the lapse of a few days, the part may be frequently bathed 
with spirit of camphor, or soap liniment; painted with dilute tincture of iodine; or 
covered with a poultice made of crumbs of bread and common salt, or of the bruised roots 
of briony. Under this treatment an ordinary ecchymosis will often vanish in a few days; 
in the more severe cases a much longer time may be required. 
When the extravasated blood appears as a distinct depot, or as a concentrated collec- 
tion, attended with marked tension of the integument, the speediest way of getting rid of 
it is to make a small opening, barely sufficient to permit the blood to drain off, if it be 
fluid, or to be pressed out, if it be coagulated. The walls of the sac are then approxi- 
mated by a compress and bandage, and irritation is kept down by the ordinary antiphlo- 
gistic means. 
The treatment of brush burn is conducted upon general principles ; the most soothing 
application, in the first instance, is a solution of acetate of lead in glycerine, and after- 
w'ards, especially if gangrene is threatened, weak lotions of nitric or carbolic acid and a 
yeast poultice. 
SECT. VII PUNCTURED AVOUNDS. 
A punctured wound is a peculiar injury, deriving its name from the nature of the in- 
strument with which it is inflicted, and the manner in which the tissues are divided. It 
comprehends all those lesions which are produced by nails, splinters of wood, thorns, pins, CHAP. X. 
PUNCTURED WOUNDS. 
363 
needles, pieces of bone, or fragments of glass; or by the thrust of a dirk, bayonet, lance, 
sword, or any other sharp-pointed weapon. The operation of tapping affords a familiar 
instance of such a wound. The sting of the bee, wasp, and other insects, and the bite of 
the snake, dog, rat, and other animals, are all examples of this class of injuries, with 
this difference, however, that most of them are inoculated with the peculiar poison se- 
creted by these creatures, and hence they naturally come to be considered separately. In 
common, every-day life, punctured wounds are most frequently met with in the hands and 
feet of the working classes. In dissecting and sewing up dead bodies the physician often 
punctures his fingers, and sometimes suffers severely in consequence, apparently, from the 
introduction of a peculiar septic virus, generated either during the act of dying or shortly 
after dissolution. 
Punctured wounds vary much in extent, direction, and character; thus, they may be 
superficial or deep, narrow or wide, straight or crooked, simple or complicated ; circum- 
stances which must necessarily exert more or less influence upon their prognosis, treat- 
ment, and termination. Their depth is usually much greater than their width, and for 
this reason it is often extremely difficult to determine the amount of injury done to the 
parts in which they are situated. 
A punctured wound is peculiar, not only as it respects the mode of its production, but also 
in regard to its effects. The tissues are forcibly pressed asunder, and, consequently, more 
or less contused, if not also a good deal lacerated. The wound made by the bite of a 
man and the inferior animals is usually both a punctured and a lacerated wound ; so also 
when a splinter of wood, or a similar body, is violently driven into the flesh during an 
engagement on shipboard, or wrhen a person is suspended by a hook or impaled upon a 
railing. A needle, nail, or a piece of bone, on the contrary, usually makes a purely 
punctured wound. 
The pain attendant upon such a wound is frequently very excruciating, depending, evi- 
dently, not so much upon its extent as upon the injury sustained by the nerves of the 
part, and the bruised and condensed state of the tissues. Hence the suffering, which is 
often immediate, is sure to be immensely increased if the resulting inflammation is at-all 
severe. It is always greatest, other things being equal, in persons of a nervous, irritable 
temperament. Much also will depend, in this respect, upon the nature of the vulnerating 
body. The puncture, for example, made in the operation of tapping the abdomen with a 
trocar generally causes very little uneasiness, while that of a nail, penetrating the sole of 
the foot, deep down among the muscles, usually produces the most intense agony. Vio- 
lent nervous symptoms often supervene upon such accidents, and in hot climates, as well 
as in the hot seasons in the colder latitudes, they are liable to be followed by tetanus, 
especially among negroes and the more intemperate classes of whites. The disastrous 
effects which even the slightest puncture may occasionally produce, in a person of great 
susceptibility, is strikingly illustrated in the remarkable case, related by Sir Astley Cooper, 
of a young lady, who, on being pricked with a sewing needle, screamed, fainted, and died. 
Punctured wounds are rarely attended with much hemorrhage, indeed frequently hardly 
any at all; if a large artery, however, has been penetrated, then the bleeding may not 
only be copious, but, perhaps, almost instantaneously .fatal. The thrust of a sword, lance, 
dirk, or bayonet into the chest, abdomen, neck, or thigh, often literally taps the vessels, 
destroying the patient in a few minutes. The shock of such a lesion, too, may prove to 
be of consequence ; even a slight puncture is sometimes followed by excessive prostration, 
and it has been found that soldiers, during engagements, are seldom able to continue the 
fight beyond a few minutes after they have been deeply pricked by the point of any of 
these weapons. The shock is excessive, and the patient soon falls into a fatal syncope. 
Another peculiarity of punctured wounds is their liability to be followed by erysipelas, 
angeioleucitis, abscess, contraction of the limbs, and wasting of the muscles. Mortifica- 
tion will not be likely to ensue unless the main artery or nerve of an extremity has been 
severed, or the system at the time of the injury is in a bad condition. Punctured wounds 
of the scalp, hands, feet, and joints, especially the larger, as the knee, ankle, elbow, and 
wrist, are particularly prone to be followed by severe nervous and inflammatory symp- 
toms, and also by erysipelas, the latter generally coming on within less than thirty hours 
after the infliction of the injury. When the lymphatic vessels become involved, as they 
often do, the disease is indicated by red lines, extending from the seat of the injury to- 
wards the nearest lymphatic glands. A similar phenomenon, along with more or less 
induration, is witnessed when the veins participate in the mischief; an occurrence by no 
means uncommon. WOUNDS AND CONTUSIONS. 
chap. x. 
The secondary effects of punctured wounds are often very serious, entailing much suffer- 
ing, with occasional deformity and loss of limb, and demanding much care on the part of 
the practitioner. Needles, pins, fragments of glass, and pieces of bone sometimes enter 
the tendons, ligaments, and aponeuroses, and, causing severe and protracted irritation, 
ultimately lead to irremediable contraction. 
Much of the local distress in punctured wounds arises from the injury done to the 
nerves, by the partial division of their filaments. The gap thus left is nearly always filled 
up with hard, callous matter, of a fibrous, or fibroplastic structure, ill adapted for the 
transmission of nerve fluid, and almost invariably the seat for a long time afterwards of 
more or less pain and tenderness. Neuralgia is also a common occurrence; and not un- 
frequently all the muscles in the neighborhood of the affected part are eventually com- 
pletely atrophied and rendered useless. 
The treatment of punctured wounds consists, first, in the extraction of the foreign sub- 
stance, in case it has not been already dislodged ; secondly, in checking hemorrhage ; and, 
thirdly, in moderating inflammation and preventing the development of nervous symptoms. 
To determine whether any extraneous matter remains in the wound, all that is neces- 
sary, in most cases, is simply to inspect the vulnerating body. If this exhibit marks of 
fracture, the probability is that a part of it has been left behind ; if so, the probe and 
finger will assist in detecting it. Should the wound, however, be very deep and narrow, 
it may be necessary, before this can be done, to make an incision, the extent of which 
must depend upon the circumstances of each particular case, the only care to be observed 
being the avoidance of important structures, especially vessels, nerves, and tendons. 
When a needle or other slender substance is imbedded in the flesh, or buried in the con- 
nective tissue, its presence may often be detected by folding up the skin over it, or making 
gentle and systematic pressure with the ends of the forefingers at its supposed site, which 
is generally indicated, at least in recent cases, by a little puncture, perhaps not as large as 
a flea-bite, upon the surface. Sometimes the local pain or tenderness affords valuable 
information as to the precise spot where the needle is lodged. The surgeon should not 
hesitate, when there is reason to believe that the foreign body is retained, to make a free 
incision for the purpose of extracting it; it is much better to do this at once than to tem- 
porize with the case, or to wait until serious symptoms arise, when such a procedure 
becomes inevitable, although it may now be too late to prevent altogether its bad effects. 
I have found after long experience that the best forceps for extracting needles and other 
sharp-pointed bodies are such as are rather long and slender in the blades, with deeply ser- 
rated surfaces. The ordinary dissecting forceps are generally worse than useless, especially 
when, as often happens, the substance is firmly imbedded. Mr. Marshall, of London, has 
suggested a very ingenious mode of detecting the fragment of a needle imbedded at some 
depth. It consists in holding a powerful magnet upon the suspected spot for a quarter of 
an hour, in order to influence the fragment, when, a finely hung polarized needle being 
suspended over it, deflection will ensue if iron be present. 
In the sole of the foot, pieces of bone, glass, and other small bodies are sometimes 
buried deeply beneath the plantar aponeurosis, where it is often impossible to determine 
their presence, however carefully searched for. A case which forcibly illustrates this fact 
fell under my observation, many years ago, in a boy, nine years old, who was wounded by 
a piece of chicken bone, nearly an inch long, which entered the sole of the foot, and lodged 
deeply in the substance of the flexor muscles, in contact with the metatarsal bones. Pain 
and swelling soon followed, but the boy, despite his suffering, continued to walk about, 
limping, of course, for upwards of a fortnight ; the weather, in the mean time, being ex- 
cessively hot. Suddenly symptoms of tetanus came on ; Professor Willard Parker, then 
my colleague, and I now saw the case, and, although every effort was made to discover the 
foreign body, it could not be detected, such was the depth at which it was situated. Death 
followed in a few days, when the bone was found to be so completely buried as to require 
a very elaborate dissection to remove it. 
Removal of foreign bodies, deeply imbedded in the flesh, will be greatly facilitated if 
the limb be previously constricted with the elastic roller. All barbed instruments, hooks, 
and similar substances, should be extracted either by counteropenings, or by pushing them 
across the part in which they are imbedded. Any attempt to extricate them by pulling 
at them in the direction in which they entered would only increase the difficulty, unless a 
very free incision be made over them. 
The bleeding in punctured wounds generally ceases spontaneously. If a large artery 
has been laid open, or divided, it must be exposed, and tied at each extremity, in the usual 
manner. If this cannot be done, compression may be tried, as in the treatment of aneu- chap. x. 
PUNCTURED WOUNDS. 
365 
rism ; or, this failing, or not being deemed admissible, the main trunk of the vessel is tied 
at some distance from the injury. 
To prevent the occurrence of severe pain and nervous distress, a full anodyne should 
always be given, if the case is at all severe, immediately after the accident, and the part 
wrapped up in flannel, wrung out of warm water and laudanum and frequently renewed. 
If the general health suffer, a dose of calomel should be administered, followed by oil 
or senna. If fever arise, antimonial and saline preparations with morphia may be re- 
quired, to act on the skin and bowels, to allay pain, and to induce sleep. If matter form, 
as indicated by the tension and throbbing of the part, free incisions must be made; ery- 
sipelas, angeioleucitis, and phlebitis being treated in the usual manner. Nervous symptoms 
are combated with the liberal use of anodynes, bromide of potassium, chloral, and other 
means. 
Along our Indian borders very severe wounds, of a punctured character, or partly 
punctured and partly incised, are often inflicted with the arrow, which, as is well known, 
is capable of being projected, with extraordinary precision, to a great distance. Being 
usually made of the young willow, or other suitable wood, it varies in length from two feet 
to two feet and a half, and is feathered in the greater part of its extent, in order to facili- 
tate its movements and increase its speed through the air. The head is generally furnished 
with a spear-shaped piece of flint, obsidian, or iron. This, which is technically termed 
the point of the weapon, is of a flattened conical figure, its length from base to apex rang- 
ing from three-quarters of an inch to an inch and a half; the corners, or angles, project 
in a line with the side of the free extremity, and are usually upwards of an inch in width, 
the whole arrangement being such as to enable the instrument to operate on the principle 
of the barb of a fish-hook. Thus constructed, the point is securely fixed in a notch on 
the head of the arrow by means of the tendinous shreds of the deer, coated with the resin 
of the fir-tree. 
It is supposed that many of our Indian tribes poison their arrows, so as to inflict a 
more deadly wound; but I am told by a former pupil, Dr. William F. Edgar, that this 
practice is peculiar to the savages inhabiting the mountainous regions watered by Pitt 
River, one of the northern branches of the Sacramento. These people, it is said, use the 
poison of the rattlesnake, by grinding the dried head of that reptile into an impalpable 
powder, which is then applied by means of the putrid blood and flesh of the dog to the 
point of the weapon, the wound made by it proving speedily mortal. 
Wounds made by arrows often, Dr. T. C. Henry, U. S. A., informs me, partake of the 
nature of incised wounds, or those inflicted by the thrust of the small sword; and a simi- 
lar remark has been made by Dr, J. H. Bill, in an elaborate paper on this class of injuries 
in the American Journal of the Medical Sciences for October, 1«62. The iron heads ot 
these weapons are exceedingly thin, and, when propelled with great force, make a clean 
cut, a portion of which not unfrequently unites by the first intention. Arrow wounds are 
often attended with great shock, especially when inflicted upon internal organs, resembl- 
ing, in this respect, gunshot and similar lesions. 
Arrow wounds are frequently complicated with copious hemorrhage, and they are also 
extremely liable to be followed by profuse suppuration, the matter often burrowing exten- 
sively among the muscles and other structures. Erysipelas and pyemia are not uncommon. 
Arrow wounds of the internal organs, as the lungs, liver, spleen, and intestines, almost 
invariably prove fatal, especially if the point of the missile, detached from its shaft, is 
retained among the tissues or lodged in a splanchnic cavity. 
Fig. 106. 
Fig. 107. 
Contrivances for the Extraction of the Point of the Arrow. 
In the treatment of arrow wounds, the first indication is to extract the extraneous sub- 
stance, and then, bleeding having been arrested, to limit the resulting inflammation by 
appropriate antiphlogistic measures. Long and deep incisions will often be required to 
effect dislodgment, especially if the arrow is impacted in the head of a bone, or buried at 
a considerable depth among the muscles and aponeuroses. The best probe for determining WOUNDS AND CONTUSIONS. 
chap. x. 
its situation is the finger. Rotating the shaft of the arrow upon its axis, or twisting it 
between the thumb and forefinger, is a good method for ascertaining whether the point of 
the weapon lies loosely among the soft structures, or is imbedded more or less firmly in 
bone. Stout forceps, with long and well-serrated blades, should be employed, and the 
success of the operation will be greatly increased if care be taken during the manipulation 
not to detach the shaft from the point of the arrow. The extraction, as stated by Dr. 
Bill, is sometimes greatly facilitated by means of a noose made of stout annealed wire, 
passed through a double canula, a Coghill’s suture twister, fig. 106, or the contrivance 
represented in fig. 107, carried around the point of the weapon. If abscesses form, they 
should be promptly opened, to prevent infiltration and destruction of tissue. 
SECT. YIII TOOTH WOUNDS. 
Wounds inflicted by the bite of the human subject and of the inferior animals, as the 
dog, cat, or rat, partake of the nature of contused, lacerated, and punctured wounds. 
Such lesions are by no means uncommon, and, from the danger which so often attends 
them, are worthy of special consideration. I have met with a number of cases of severe 
suffering from wounds of the fingers received in the act of striking persons upon the 
mouth. The inflammation consequent upon such injuries is prone to run into erysipelas, 
especially if, at the time of the accident, the constitution is in a deranged state, and it is 
sometimes so violent as to be followed by mortification. In 1851, a distinguished jurist 
struck a man upon the mouth, wounding his finger slightly against his teeth. Erysipelas 
speedily supervened, and the hand was obliged to be amputated; subsequently the disease 
reappeared in the stump, and necessitated the removal of the arm. 
A woman, forty-seven years of age, always in good health, scratched the skin slightly 
over the knuckle of the right index-finger in a blow in which she struck the front tootb 
of a servant girl; only a few drops of blood were lost, and there was hardly any pain. 
Within two hours afterwards, however, the part began to ache and throb; the finger 
swelled rapidly to an enormous degree; the whole limb became enlarged and exquisitely 
sensitive ; and a deep red line extended as high up as the axilla, the lymphatic glands of 
which were very tumid and tender to the touch. Great constitutional disturbance, 
attended with loss of sleep and appetite, supervened ; and a large abscess formed in the 
theca of the finger, followed by necrosis of the last phalanx and ankylosis of the other 
joints. The whole limb remained for a long time sore, tender, and swollen, and upwards 
of a year elapsed before the reestablishment of the general health. 
A farmer, thirty-six years of age, struck a man upon the mouth, receiving a superficial 
abrasion over the knuckle of the little finger of the right hand. Violent erysipelas of the 
whole limb followed ; the finger became enormously swollen, and a large abscess formed 
in it, eventuating in necrosis of the phalanges. The general health suffered greatly, and 
a fresh attack of erysipelas broke out after the amputation of the finger. Many months 
elapsed before final recovery occurred. 
A physician, upwards of seventy-two years of age, received a small wound upon the 
left index-finger, in striking a lad upon the front teeth. Erysipelas soon showed itself, 
attended with exquisite pain, and extending up the limb beyond the elbow. After much 
suffering, in which the constitution seriously participated, the inflammation, at length, 
disappeared, leaving the finger stiff, crooked, withered, cold, and benumbed. 
A farmer, forty-seven years of age, in good health, in December, 1851, struck a man 
on his mouth in such a manner as to bring the knuckle of the metacarpal bone of the 
right ring-finger forcibly in contact with the incisor teeth ; the skin was slightly broken, 
but he experienced no particular inconvenience at the time. The same evening, however, 
the hand and finger became painful and stiff", and the next day they began to swell and 
to present an erysipelatous appearance. Excessive suffering ensued, producing profound 
constitutional disturbance ; and finally, in about three weeks, a large abscess formed in 
the hand, requiring the lancet. When I first saw the case, at the end of this time, the 
thumb and all the fingers were stiff" and immovable; the wrist-joint was also much 
affected, and, in fact, the whole limb was sore and painful. In August, 1852, the thumb 
and fingers were still rigid and useless, much colder than natural, numb, and considerably 
attenuated. Every attempt to bend the fingers was attended with severe suffering. The 
right ring-finger was ankylosed at the metacarpo-phalangeal joint. There was still much 
uneasiness in the palm of the hand, and the whole limb was atrophied. 
The bite of the human subject is often followed by violent symptoms, coming on soon 
after the infliction of the injury. A considerable number of such cases have fallen under CHAP. X. 
GUNSHOT WOUNDS. 
367 
my observation, and in several I have experienced much difficulty in saving limb and life. 
I do not presume that the saliva in this class of wounds has anything to do with the pro- 
duction of the bad effects by which they are so liable to be succeeded ; the parts are badly 
bruised, or bruised, lacerated, and punctured, and it is well known how prone such injuries, 
however induced, always are to be followed by erysipelas and other serious consequences, 
especially in persons of intemperate habits or disordered health. 
The bite of the inferior animals, particularly if they are much enraged at the time, is 
often succeeded by a very bad form of erysipelas. Many years ago I attended, along with 
Dr. Trimble, a child, three years of age, who, a few days previously, had been bitten by 
a rat in one of his fingers. A severe attack of erysipelas soon came on, involving the 
whole hand and forearm, and causing most violent local and constitutional suffering. The 
injured part was converted into a large unhealthy ulcer, discharging a thin, sanious fluid, 
and was a long time in healing. Recovery finally took place, but not without permanent 
ankylosis of the finger, and partial atrophy of the hand and forearm. The bite of the 
dog, cat, horse, mule, ass, and camel frequently occasions violent inflammation and great 
general disturbance. Prescott Hewett has reported a case in which the bite of a ferret 
caused pyemia and death. Severe wounds, combining all the unfavorable conditions of 
punctured, lacerated, and contused wounds, may be inflicted by the claws of the feline 
races of animals, as the cat, lion, and tiger. The inflammation that follows upon the 
injury inflicted by the bill of certain birds, as the turkey and duck, is often extremely 
severe, and even dangerous, cases of gangrene and death having been witnessed from its 
effects. A fatal wound has sometimes been inflicted by the spur of a cock, and the peck 
of a hen. 
The treatment of tooth wounds and abrasions must be conducted upon the same general 
principles as that of ordinary contused and punctured wounds. The part, however, should 
always, as a preliminary measure, be well cleansed and bathed with warm salt water, to 
rid it of any saliva and any other matter that may have been deposited by the teeth ; after 
this, the best application will be an emollient poultice wet with a solution of acetate of lead 
and laudanum, followed, if necessary, by leeches, and, if matter form, by early and free 
incisions. Dilute tincture of iodine, pencilled over the inflamed surface around the wound, 
will also be useful. The best internal remedies are calomel and opium, with an active 
purge at the commencement of the treatment. When the ease is obstinate, alteratives 
and tonics with change of air may be required. 
SECT. IX GUNSHOT WOUNDS. 
Gunshot wounds are injuries inflicted by fire-arms, as pistols, muskets, rifles, carbines, 
cannon, shells, and rockets; and are dangerous or otherwise according to their extent, the 
nature of the affected structures, and the state of the system at the time of their receipt. 
Occurring in all parts of the body, they may, in one case, be so slight as hardly to attract 
serious attention, while in another they may be §p severe as to cause death upon the spot, 
either from shock or loss of blood, or, secondarily, from the violence of the resulting 
inflammation. Even when the person is so fortunate as to escape with his life, he often 
remains miserable ever afterwards on account of his mutilated condition, the repeated 
formation of abscesses, or the occurrence of neuralgic pains, which, hardly leaving, him 
any respite from suffering, keep his mind and body in a state of constant irritation, and 
thus utterly incapacitate him for enjoyment and usefulness. 
The missiles generally employed in civil life, in this country, are pistol, rifle, and 
musket balls, varying in volume from that of swanshot to that of a small marble. The 
round bullet, formerly used in our army, has been entirely superseded by what is called 
the new rifle-musket bullet, on account of its greater efficiency. It is of a cylindro- 
conoidal shape, with a hollow base and three circular grooves, weighs 500 grains, and 
penetrates, when impelled by a charge of sixty grains of powder, at a distance of 200 
yards, eleven one inch pine planks, placed one inch and a half a part. At the distance 
of 1000 yards it penetrates three and one-fourth of such planks. 
The British, French, and Russians employ a considerable variety of bullets adapted to 
the peculiarities of their respective services. The Enfield ball, used by the English since 
1853, has superseded nearly all other missiles of that description. It is a long conical 
ball, hollow in the base, and weighs %j and 9ij. The Martini-Henry ball weighs about 
428 grains. The French Minie ball weighs 3j, 3'j and 9>j» and the Russian ball, also 
conical, weighs |j and 3yj. The Chassepot ball is nearly cylindrical, and weighs 380 368 
WOUNDS AND CONTUSIONS. 
chap. x. 
grains. The Prussian hall is somewhat egg-shaped, weighs 530 grains, inflicts an ugly 
wound, and frightfully shivers the bones. The ball of the mitrailleuse weighs one ounce 
and three-quarters; the Austrian ball 400 grains. 
It has been found in military operations that the cylindro-conoidal ball, meeting with 
less resistance from the atmosphere than the round, passes, consequently, to a much greater 
distance, and does more terrific execution upon entering the body, generally proceeding 
in a straight line, and fracturing and comminuting the bones in a most frightful manner; 
thus causing a much greater mortality, as well as a more frequent necessity for amputa- 
tion. The conical ball, moreover, is less liable to be flattened and divided than the 
round ball, and the aperture of exit is nearly always opposite to that of entrance, which 
was not so often the case formerly. Much of the gravity of gunshot wounds of late years 
has arisen from the substitution of the conical bullet. To show with what force a Minie 
ball occasionally acts, it may be stated that it has been known to pass through the bodies 
of two men and to lodge in that of a third standing some distance behind. 
Sometimes two balls are united by a bar or chain of iron, and put in a cartridge, thus 
producing, when fired, a terrible wound, as often happened in the Schleswig-Holstein 
war. In the naval action off Camperdown, in 1797, great destination was wrought by 
the Dutch, by the discharge of bags of nails and pieces of old iron. During the war in 
the Crimea, the Russians occasionally employed an incendiary ball, consisting of a small 
cylinder of copper filled with a detonating substance, made up in the form of an ordinary 
cartridge, and discharged from a musket, the projectile, on striking an object, exploding 
with violence. 
Cannon balls are solid bodies, made of cast-iron, and ranging in caliber from one to 
many pounds, according to the object which they are designed to accomplish. They are 
either round, or of a cylindro-conoidal shape, the latter of which possesses the same 
advantage over the former as the cylindro-conoidal bullet over the spherical. A grape-shot 
is composed of nine cast-iron balls, disposed in three layers of three balls each. Formerly 
the shot were confined in a canvas bag, fastened to a wooden spindel with a strong cord, 
the whole bearing a faint resemblance to a bunch of grapes, whence the name. From 
this the canister shot differs principally in being contained in a tin cylinder closed at the 
top and bottom. The balls, arranged in four layers, are packed in sawdust. “ Shells 
are large hollow spheres of iron loaded with gunpowder, which may act either in their 
entire form as solid balls, or subsequently by the explosion of their contents, and their 
subdivision into numerous splinters, by which their ravages are greatly extended. 
Shrapnell shells, so named from their inventor, are hollow spheres, loaded partly with 
gunpowder, partly with balls.” 
Slugs and fragments of cannon balls often occasion frightful wounds, lacerating the soft 
parts, crushing bones, laying open joints, penetrating splanchnic cavities and committing 
other ravages, either fatal at the moment or proving so by secondary involvement. 
A pistol ball, if fired near, inflicts quite as deadly a wound as a musket, carbine, or rifle 
ball. This missile is now generally of conical shape, and operates with great effect, 
both upon the soft and hard structures. 
Serious injury, extremely liable to be followed by tetanus, is often inflicted with the 
toy pistol, as it is termed, in such common use in this country on the fourth of July and 
during our Christmas holidays. The hands and fingers are the parts usually wounded, 
and the lesions, even when superficial, are very liable to cause severe nervous symptoms, 
especially during our hot summer months. 
A buck-shot wound is at present of rare occurrence. During our last war with Great 
Britain it was sufficiently common. Buck-shot are sometimes inclosed in wire cartridges, 
and are then very effective, carrying close for twenty yards, diverging somewhat at fifty, 
and entering separately at one hundred and fifty, readily penetrating a yellow pine board 
an inch thick. 
Small shot, striking the body in a concentrated form, produce effects similar to those 
of a large bullet; if they are scattered, the injury will be less grave, unless they happen 
to hit an important organ, as the heart, brain, or spinal cord, when death may ensue in 
a few minutes, or, more remotely, from the resulting inflammation, as in several instances 
that have fallen under my own observation. Lachese ascertained by numerous experi- 
ments that a load of small shot discharged at a dead body, at a distance of ten inches, 
will make a clean, round opening; at from twelve to eighteen inches the opening will be 
very ragged and irregular; while at thirty-six inches each shot will enter separately. 
Grave injury sometimes follows the explosion of a percussion-cap. Such accidents are 
sufficiently common among sportsmen, whose pleasures of the chase are often requited by chap. x. 
GUNSHOT WOUNDS. 
the loss of an eye, and by the most excruciating suffering, from the lodgment of a piece of 
the foreign body in one of the chambers of that organ, or in the substance of the iris, lens, 
or vitreous humor. 
Wadding discharged from an ordinary fowling-piece may occasion a fatal wound, as in 
an instance which occurred, many years ago, at a Philadelphia theatre where, from 
this cause, a man lost his life in a sham-fight upon the stage. The wadding—a common 
cartridge—struck the side of the head, fracturing the temporal bone, and, passing aci’oss 
the brain, lodged against the falx of the dura mater, from which it was extracted after 
death by Dr. John Rhea Barton. In 1838, a girl was killed in England by the discharge 
of a gun loaded with paper pellets, some of which penetrated the body and lodged in the lungs 
and liver. In two other instances life was destroyed by a single pellet; in one, by laying 
open the fifth intercostal artery, and in the other by breaking the orbital plate of the 
frontal bone, and injuring the brain. A case is recorded of a man being fatally wounded 
by a kid-glove with a button attached to it; it was discharged from a blunderbuss loaded 
with powder, and struck the person, who was standing ten feet off, upon his abdomen, in 
the cavity of which it was found on dissection. 
Powder alone, without any wadding, may, when discharged near the body from a gun, 
pistol, or fowling-piece, occasion fatal injury. From the experiments of Lachese it 
appears that, when the distance does not exceed six inches, and the weapon is large and 
strongly charged, the wound thus made will bear some resemblance to that produced by 
a small shot, each particle that escapes combustion acting like a pellet. The fact that 
the mere explosion of powder near the body is capable of causing severe bruises, contu- 
sions, lacerations, and even death, has long been familiar to observers. A remarkable 
case of the latter occurred in this city in 1847, in a lad, a patient of Dr. Paul Swift. 
The charge, fired from a pistol, entered the left hip, inflicting a wound four inches in 
depth by one inch in diameter, blackened throughout by the powder, grains of which 
adhered to its surface. The integument and muscles were severely torn and discolored. 
Death occurred on the seventh day from tetanus. The instances are quite numerous of 
great suffering, mutilation, and disfigurement from the lodgment of grains of powder in 
the eyes, face, neck, and other parts of the body. Stone-quarriers are particularly liable 
to such accidents. 
In its character, a gunshot wound is a punctured wound, with more or less of the nature 
of a contused and lacerated wound; at the opening of entrance, and for some distance 
around, the tissues are bruised, but as the ball passes onward it tears 
the parts, and at the opening of exit they often look as if they had been 
cut with a sharp knife. The effects of the transit of the missile upon 
the soft textures may be explained, as was first suggested by Sir Charles 
Bell, by a reference to a diagram consisting of three concentric rings, 
as in fig. 108. The first, including the tubular wound, is bounded by 
tissues which are so compacted, condensed, or contused as to deprive 
them partially of their vitality, or, at any rate, to place them in such a 
condition as inevitably to lead to suppuration; consequently this por- 
tion of the wound seldom unites by the first intention. The structures between the first 
and the second rings, having sustained less injury, will also inflame, but only, as a rule, 
in such a manner as to give rise to a deposit of lymph and pus; while those between the 
second and third circles will either retain their natural properties, or, becoming excited, 
w’ill merely experience some slight serous infiltration. 
The above phenomena may generally be studied to the greatest advantage in deep flesh 
wrounds, as those of the thigh. In such cases there is often a considerable slough of the 
bruised tissues, upon the separation of which the parts are seen to suppurate and to form 
granulations, while farther on they are hard, next oedematous, and beyond this natural. 
These phenomena, however, do not generally pervade the entire length of the wound; 
for frequently a considerable portion of the track unites by adhesive action, the tissues 
being lacerated instead of contused, as they are in the early stage of the passage, and, 
consequently, favorable to restoration. The precise point where the tubular w’ound loses 
the character of a contusion and assumes that of a laceration cannot usually be ascertained, 
as it must necessarily vary very much in different cases, and under different circumstances. 
The preceding remarks in regard to the injury inflicted by the projectile are chiefly 
applicable to the smaller kinds of balls, such as the pistol and rifle ; the larger ones are 
generally productive of more serious mischief, and hence it often happens that the wound 
sloughs in its entire length, from the opening of entrance to that of exit; there being 
afterw'ards, wdien the dead parts have separated, extensive and tedious suppuration, the 
Fig. 108. 370 
WOUNDS AND CONTUSIONS. 
chap. x. 
matter, perhaps, burrowing deeply among the soft structures, and thus greatly retarding 
the process of repair. 
Disposition of the Projectile.—The manner in which the projectile is disposed of 
varies ; sometimes it lodges, and then, of coui’se, it makes but one opening ; at other times 
it passes completely through the part, and so leaves two apertures, one of entrance, the 
other of exit. Cases occur where one ball may make three, four, or even more holes. 
Thus, if it encounter a sharp edge of bone, as the crest of the tibia, it may be cut into 
two or more pieces, each of which may afterwards issue at a separate point. Dupuytren 
met with an instance in which a ball of this kind made five orifices; and at Antwerp the 
younger Larrey saw six holes made in a similar manner. Again, a ball piercing the sur- 
face, just above the wrist, may be unable to penetrate the aponeurosis of the forearm, but, 
travelling along for some distance under the integument, may emerge below the elbow'; 
then, the limb being considerably flexed at the moment, it may reenter the skin a second 
time at the inferior part of the arm, and finally escape near the shoulder-joint; thus 
leaving four apertures, two of entrance, and two of exit. Such an occurrence is, of 
course, very rare ; but its possibility is worthy of remembrance, as it is of great interest 
in a medico-legal point of view. A man, for example, might be shot in a duel, and his 
friends seeing the number of openings in the limb, might accuse his adversary of foul 
play, on the ground that he had used more than one ball. 
A curious case has been related, by Hunter, of a young man who was shot in the abdo- 
men by three bullets discharged simultaneously from the same weapon, with the effect of 
making only two openings of entrance and twro of exit, one of the missiles following closely 
in the track of one of the others, as was proved by the fact that they all lodged by sepa- 
rate orifices in the wainscot of the apartment where the accident occurred. During the 
French wrar in Algeria, a grenadier was pierced in five places, all w'ounds of entrance, by 
a single ball, divided into five pieces by first striking a rock, the fragments rebounding at 
various angles. 
A ball striking an extremity may pass not only completely through it, but also through 
its fellow, thus making four openings; or it may perforate the upper part of the thigh and 
then pass through the head of the penis, leaving two orifices in the former and two in the 
latter, as in a case which I saw in the Hospital at Alexandria, under the care of Dr. 
Sheldon, after the engagement near Centerville, Virginia, in July, 1861 ; or, finally, it 
may traverse both buttocks, or it may perforate one and lodge under the integument on 
the outer side of the other, as in a man who was wounded in the battle of Bull Run. 
When there is only one opening, it is natural to conclude that the ball has lodged, and 
this, as already stated, is usually the fact. Instances, however, occur, although rarely, 
where the reverse is the case. Thus, a ball has been known to pass some distance into 
the pectoral muscle, and to be immediately ejected by the recoil of a rib. The knee- 
joint has occasionally been opened, the ball being supposed to have lodged in the head of 
the tibia, but upon amputating the limb none was found, although there was but one open- 
ing. Lastly, a ball may enter the body, perhaps rather deeply, along with a piece of 
cloth, upon extracting which the missile may drop out. 
Large balls, fragments of shell, pieces of iron, and other substances, occasionally bury 
themselves deeply among the muscles, where, from the small size of the opening of entrance, 
they may long remain undiscovered. Larrey extracted a ball, weighing five pounds, from 
the thigh of a soldier, who had suffered so little inconvenience from it that it had been 
entirely overlooked by the surgical attendant; and Hennen refers to a still more remark- 
able instance as having occurred at Seringapatam. At the battle of Fort Donelson, Dr. 
Henry W. Davis, of Chicago, amputated a thigh, in the muscles of which a shell, weigh- 
ing twelve pounds, and measuring four inches and a half in diameter, was buried. In a 
case referred to by Longmore, a grape-shot, weighing one pound and two ounces, remained 
in the back of the pharynx for three weeks without exciting any suspicion of its presence. 
Considerable difference generally exists between the openings of entrance and exit. 
The former is usually rounded with even or slightly inverted edges, as if the skin had 
been tucked in a little, and there is frequently more or less of a bluish or blackish dis- 
coloration of the adjacent surface, from the contact of burnt powder, deposited upon the 
ball at the moment of the explosion, and rubbed off' as the ball strikes the body. When 
the discharge takes place within a few feet of the surface, scorched grains of powder often 
adhere to the skin, or may even be imbedded in its substance. Occasionally the margins 
of the orifice have a pale, dead-like aspect, or they may be simply of a livid hue, from 
the effects of contusion. The opening of exit, on the contrary, has generally a slit- 
like appearance, looking as if it had been made with a sharp knife rather than an obtuse CHAP. X. 
GUNSHOT WOUNDS. 
371 
body; it is free from discoloration, and its edges, instead of being inverted, are turned 
out. I have met with cases where both openings had an incised appearance, but such a 
condition is uncommon. 
The size of the two openings is variable. The round ball generally makes a larger 
orifice of entrance than of exit, the reverse being the case with the conical ball. These 
peculiarities were remarkably apparent in the wounds of the troops after the battle of Bull 
Run, in July, 1861. I had occasion also to notice the immense size of the openings in 
gunshot wounds of the integuments, made by the conical ball, especially when the two 
apertures were close together. In nearly all the cases of this class of lesions that I 
observed during the war, the holes, particularly that of exit, were disproportionately 
large, as well as remarkably irregular and ragged. 
Experiments performed by Dr. Sarazin, of Strasbourg, upon the dead subject, with the 
Chassepot rifle, show that the size of the orifice of entrance is essentially the same as that 
of the projectile itself, whereas the diameter of the orifice of exit is enormous, being from 
seven to thirteen times larger than that of the ball. 
Shell wounds, and wounds inflicted with stones, nails, splinters, and similar missiles, 
always exhibit a lacerated appearance, owing to the irregular shape of the vulnerating 
body. A similar character is often imparted by flattened bullets, and by bullets entering 
the surface flatwise, as occasionally happens when their course is changed by some inter- 
vening object. 
When any doubt exists in regard to the nature of the two holes, it may often be 
promptly dispelled by a careful examination of the openings in the patient’s clothing, as 
here the aperture of exit is invariably the larger and more ragged of the two. 
Wounds inflicted by the explosion of torpedoes are usually attended with excessive 
laceration and contusion of the soft parts. Dr. S. W. Gross, who saw a number of 
wounds of this kind during our late war, found that grave and deep-seated injuries occa- 
sionally occurred without any apparent lesion of the skin, and that very generally they 
caused complicated fractures, or even cai’ried away portions of a limb; in either event 
demanding amputation. 
A ball in rapid motion, under the impulse of a strong charge of powder, flies like an 
arrow ; it does not revolve on its axis, and, consequently, on reaching the body, it passes 
through in a straight line, dividing everything before it, and perhaps issuing at a point 
directly opposite to that of its entrance. If, on the other hand, its force is partially spent, 
it will either not enter at all, or, if it enter, it will be turned out of its course, the slightest 
resistance, as that offered by a tendon, ligament, or aponeurosis, serving to change its 
direction. The circumstances which tend to weaken the force of a ball are two, the 
attraction of the earth and the resistance of the atmosphere. A strong wind blowing 
perpendicularly to the direction of the American rifle-musket ball, will deflect it from its 
course twelve feet in 1000 yards, about one-fourth that distance in 500 yards, and about 
six inches in 200 yards. Besides, its impulse may receive a serious check by coming in 
contact with the person’s accoutrements or some article of dress, as a button, buckle, or 
breast-plate, or any substance that may, at the moment, happen to be in his pocket, as a 
key, pencil, knife, watch, or coin. If, from these, or any other causes, the force of the 
projectile is partially spent, it may, on reaching the surface, either glance off, or, if it 
enter, it will be likely to be deflected, the course which it then sometimes pursues being 
very remarkable. Thus, a ball has been known to pierce the forehead, but instead of 
penetrating the frontal bone, it passed round the skull, underneath the scalp, and lodged 
upon the occiput, at a point nearly opposite to that of entrance; or, what is still more 
extraordinary, it travelled nearly completely round the head, issuing only a short distance 
from the place where it struck. In the same manner a ball has been found to describe 
the circumference of the chest, its course being marked by a reddish weal or zone. Cases 
are mentioned by military surgeons in which the missile, piercing the wall of the chest by 
the side of the sternum, made the circuit of the thoracic cavity by passing between the 
costal and pulmonary pleura, and either falling down upon the diaphragm, or lodging in 
the wall of the chest behind, without inflicting the slightest injury upon the lung. Exam- 
ples of a similar kind occasionally occur in the abdomen, the ball, after piercing the 
skin, being deflected by the tendon of the external oblique muscle, so as to cause it to 
course round the belly beneath the integument, and effect a lodgment near the spine, or, 
perhaps, emerge somewhere upon the back. Finally, cases are not wanting, although 
they are rare, where the missile entered the abdomen in front, and issued behind, in a 
straight line, without wounding any of the viscera. Such occurrences find their counter- 372 
WOUNDS AND CONTUSIONS. 
chap. x. 
part in sword, bayonet, and dagger wounds of the abdomen, in which the walls of that 
cavity are sometimes completely transfixed, and yet its contents escape unharmed. 
A case has been related by Dr. William H. Herring, in which a musket ball, entering 
the upper and back part of the neck, was discharged at the end of five months by the 
anus, having, as was supposed, passed by ulceration into the pharynx and thence into 
the stomach. 
When soldiers lie on the abdomen with the head towards the enemy, the ball may pass 
vertically through the skull, and either lodge or emerge at a distant part of the body. 
An instance occurred during the war in the Crimea, in which a ball, entering the top of 
the cranium, traversed the neck, back, buttock, and thigh, and escaped near the knee. 
A long bone is occasionally terribly shattered and comminuted by a bullet without the 
destruction of its continuity, some of the splinters being forcibly driven into the medul- 
lary canal, where they are retained, and act as foreign bodies, keeping up inflammation 
and discharge for an indefinite period. Hennen long ago called attention to this lesion, 
of which numerous cases occurred during our late war. 
Different tissues possess the faculty of deflecting balls in different degrees. Thus bone 
offers a greater amount of resistance than cartilage, cartilage than tendon, tendon than 
aponeurosis, and aponeurosis than muscle. Arteries often escape in a remarkable man- 
ner, their astonishing elasticity enabling them to glide away from the flying projectile. 
Common integument, too, readily throws a partially spent ball out of the straight line. 
Deflection of every description, however, is much less frequent now than formerly, owing 
to the substitution of the conical for the round ball, the former readily penetrating every- 
thing, even when fired at a great distance, whereas the latter is easily spent, and arrested 
on coming in contact with the more resisting tissues. 
A ball, upon meeting a sharp bone, as the crest of the tibia, is sometimes cut in two 
as smoothly and evenly as if it had been divided with a knife. A gentleman wTas shot 
in a street rencontre, the ball striking the clavicle, which split it into two nearly equal 
portions, one bounding off and escaping, the other lodging in the lower part of the neck, 
from which I removed it several months afterwards. Cases have occurred in which, as 
before stated, bullets have been cut into a number of pieces, each perhaps making a sepa- 
rate orifice in the skin. The conical ball suffers much less frequently in this manner 
than the round. 
When a ball strikes a bone, it may be arrested in its substance, or it may perforate it, 
lodge in the soft parts, or make its escape. In the latter event, the opening of entrance 
in the bone will generally be somewhat round, and comparatively small, whereas that of 
egress will be large, ragged, and irregular, with everted edges. The old round ball, in 
its transit through a bone, often made a hole much bigger than itself, especially if its 
force was partially spent. Indeed, cases were occasionally observed in which the opening 
was so capacious as to admit not only the ball, but also the barrel of the weapon from 
which it was discharged. The conical ball, although it makes a comparatively small 
aperture of entrance, commits much greater havoc than the round, owing to the manner 
in which it breaks and comminutes the osseous tissue, the loose splinters themselves thus 
often becoming a source of severe injury to the soft structures, contusing and lacerating 
them in every direction. 
Grave injury is sometimes inflicted upon a bone, even without the occurrence of frac- 
ture, simply from the violence of the shock which it experiences. The bullet strikes its 
surface with great force, bruising the periosteum, and causing dreadful concussion of the 
osseous tissue, but the force with which it is impelled is not sufficient to enable it to 
effect penetration. In such a case erysipelatous inflammation is very liable to be followed 
by exhausting suppuration, and, perhaps, sloughing and death. 
Immense damage is sometimes sustained by the soft parts, by fragments of bone being 
forcibly driven into their substance, sometimes at a great distance from the site of the 
original injury. A case occurred in the Crimea, in which a piece of the lower jaw was 
detected behind the right clavicle; and Professor Hamilton mentions an instance in 
which, during the late war, a ball and four incisor teeth were removed from beneath the 
skin at the top of the sternum. In gunshot wounds of the extremities, splinters of bone 
often do more mischief than the missile by which they are inflicted. 
The older writers on military surgery speculated a great deal respecting what used to 
be called the windage of a ball. It is well known that the most horrible injuries may be 
inflicted upon the body by shell and round shot, completely pulpifying the muscles, lacer- 
ating the vessels and nerves, laying open large joints, and literally crushing the bones, 
and yet, perhaps, hardly bruise the skin, much less produce any serious wound. The chap. x. 
GUNSHOT WOUNDS. 
373 
true cause of these injuries is the manner in which the projectile strikes the surface. As 
before stated, a ball in rapid motion will, on reaching the body, pass through it in a 
straight line; or, instead of this, it will, if large, as in the case of a cannon ball, carry 
away the part completely. But it is very different when the missile is projected lazily, or 
when, from the great distance over which it has travelled, its force is measurably exhausted. 
Then the slightest resistance will tend to deflect it, or change its course ; it no longer 
passes in a straight line, but rolls or turns upon its axis after the manner of a billiard 
ball; and hence if, while in this condition, it strikes the body, it may inflict the most 
frightful injury upon the muscles, bones, and even the viscera, and yet not perhaps leave 
a trace of its effects upon the skin, the elasticity of which enables it to slide out of harm’s 
way,While the other and deeper structures, which possess this property in a less degree 
or not at all, readily yield to its influence, and suffer severely in consequence. In such 
an event, the patient may instantly perish from the violence of the shock ; or, if he sur- 
vive the immediate effects of the injury, his life will be likely to be assailed by wide- 
spread sloughing of the soft parts. 
During naval and military engagements, soldiers often have pieces of their dress, 
accoutrements, and even of their persons, carried away by balls in rapid motion, without 
sustaining any serious injury in the bones and muscles. The faculty possessed by the 
integuments of gliding out of the way of mischief is well exemplified in railway acci- 
dents, which strongly resemble those inflicted by partially spent round shot, and in 
which they frequently escape in the most astonishing manner, while the deeper parts, 
soft as well as hard, are frightfully torn and pulpified. These gunshot lesions are much 
less frequent now than formerly, owing to the general use of the conical ball, which does 
its work more neatly and effectually, as well as at a much greater distance, than the old 
round ball. 
The distribution of wounds during a battle will necessarily vary with circumstances. 
In an engagement in the open field, the chances are that nearly all parts will suffer alike. 
In nearly four hundred cases of gunshot injury which I saw after the battle of Bull Run, 
in July, 1861, almost all the wounds were situated in the extremities, and in nearly 
equal proportion in the upper and lower. A few only of the patients had been struck on 
the head, chest, back, or abdomen. This cannot, however, be taken as a fair criterion 
of the result of the engagement, since those that were most severely wounded fell into 
the hands of the enemy. At the capture of Fort Donaldson, in February, 1861, accord- 
ing to the estimate of Dr. Andrews, seventeen per cent, of those wounded were shot in 
the head and face. At the battle of Pittsburg Landing, at Fair Oaks, and several other 
places, the majority of the injuries in the Federal troops were situated in the lower ex- 
tremities. According to Hennen, of the wounds received in battle, ten will be in the 
upper extremity, seven in the lower extremity, seven in the head, four in the neck and 
chest, and two in the abdomen. Scrive, from his observations in the Crimean war, con- 
cludes that, in the open field, one-tenth of the wounds will be in the head, one-twentieth 
in the chest, and one-fortieth in the abdomen. Men fired at behind breastworks are 
most liable to suffer in the head, neck, chest, shoulders, and arms, the lower parts being 
protected by the defences. 
Symptoms The symptoms of gunshot wounds necessarily resolve themselves into local 
and general, or into such as are peculiar to the part and to the system; and, it need hardly 
be added, vary greatly in their character, according to the extent of the lesion, the 
importance of the tissues involved, and the idiosyncrasy and other circumstances of the 
individual. 
The pain in a wound of this kind is often very insignificant, the person, although 
perhaps severely hurt, not being conscious of having received any injury until some 
minutes after it has been inflicted. It is generally of a dead, heavy character, 
altogether different from the pain of an incised or punctured wound; it is only when a 
large nerve has been partially cut across that it is likely to be at all severe, and then it is 
usually very sharp, pricking, or burning. In this case, too, there will also be more or less 
numbness in the part below the wound, and sometimes, as when the principal nerve has 
been entirely severed, complete paralysis. Thus, in gunshot wounds of the thigh, involv- 
ing the division of the sciatic nerve, there is always loss of motion, and often, also, of 
sensation of the knee, leg, and foot, which feel as if they were cold and dead. The suf- 
fering is generally great when a bone is broken, a large joint penetrated, or a visceral 
cavity laid open, and the shock is then also much more severe and protracted. The pain, 
however slight at the moment of the injury, is always more or less aggravated upon the 
supervention of inflammation. 374 
WOUNDS AND CONTUSIONS. 
chap. x. 
The hemorrhage in gunshot wounds is generally not at all in proportion to the severity 
of the injury, owing to the contused and lacerated nature of the lesion. The structures 
immediately around the track of the ball are usually so much condensed that, unless the 
divided vessels are large, or numerous, the bleeding will, in the majority of instances, be 
so slight as to excite little, if any, alarm for the patient’s safety. Very frequently, indeed, 
it amounts to the merest oozing, which soon ceases spontaneously, or under the application 
of cold water. If a large artery, however, has been laid open, the hemorrhage may not 
only be copious, but so great as to prove speedily fatal, perhaps, indeed, in a few minutes 
at furthest. Such an event will be more likely to occur if, as so often happens in this 
class of injuries, the vessel is only partially divided, so as to prevent its retraction; when 
this is the case the blood will flow most freely, and, although it may be temporarily 
arrested by syncope, the clot will be washed away the moment reaction takes place, the 
fainting recurring again and again until the patient has bled to death. If, on the other 
hand, the artery is completely severed, there may hardly be any hemorrhage whatever 
until the occurrence of reaction; perhaps not even until the separation of the sloughs. 
During a battle it often happens that an extremity, torn off by a shell or round shot, is 
left hanging merely by the integuments, and yet the patient is in no immediate danger 
from hemorrhage, the vessels, from their lacerated and contused condition, being instantly 
closed by coagula. 
A ball may pass directly in the course of a large artery, perhaps the main trunk of a 
limb, and yet the vessel escape injury, or, at most, be merely grazed. The reason of 
this is the resilient power of the vessel, which enables it to jump, as it were, out of the 
way of the projectile. Such an artery, however, will be particularly liable to gangrene, 
and, therefore, to secondary hemorrhage during the separation of the sloughs. 
The hemorrhage is generally external, the blood issuing at both orifices of the wound. 
The reverse, however, may be the case, especially if the injured parts have been thrown 
out of their relative positions, or if, as sometimes happens, there has been extensive sepa- 
iation of the muscles; in such an event a large quantity of blood may be effused among 
the deep-seated structures, with hardly any outward bleeding. In wounds of the chest, 
abdomen, and pelvis, the hemorrhage is usually internal, and therefore the more dangerous, 
because concealed. 
Gunshot wounds are, for the reasons already mentioned, extremely liable to secondary 
hemorrhage. A large artery may have been merely grazed, and, inflaming, a slough may 
form, which, separating, may, in a few minutes, give rise to severe, if not fatal, bleeding. 
Or an artery, of considerable size, may have been completely severed, but its ends, as 
well as the surrounding parts, having been violently contused, a clot is instantly formed, 
which thus affords a temporary barrier to the escape of blood; by and by, however, reac- 
tion takes place, and then perhaps the artery is reopened, its contents now gushing out in 
a full stream; or the event may not take place for some days, perhaps not until after the 
establishment of suppuration, ulceration, or gangrene and sloughing. Sometimes the 
injured vessel is completely blocked up by the ball or other foreign substance, upon the 
removal of which copious hemorrhage ensues. 
Secondary hemorrhage, the result of sloughing, usually arises from the tenth to the 
fifteenth day; much, however, will depend, in this respect, upon the size of the ball and 
the amount of injury sustained by the soft parts around the wound, as well as by the ves- 
sel itself. In some instances it does not appear before the twentieth, twenty-fifth, or 
thirtieth day; and, on the other hand, it occasionally occurs as early as the fifth, sixth, or 
seventh. 
The occurrence of aneurism, as an effect of gunshot wounds, is uncommon, especially 
the circumscribed variety. The diffused form is more frequent, and is generally a very 
grave affection, liable to be followed by violent local and constitutional suffering. Some- 
times the passage of a ball leads to the formation of an arterio-venous aneurism, as in a 
number of instances under my observation, one, among others, of which was kindly brought 
to my Clinic by Dr. W. B. Atkinson, of this city. 
The constitutional symptoms are subject to much diversity. The shock is sometimes 
severe in a degree altogether disproportionate to the violence of the injury; the stoutest 
and most courageous individual will often swoon from the most insignificant wround, and, 
on the other hand, a man may have his limb completely shattered, and yet not evince any 
serious alarm; his mind is perfectly calm and collected, and he is, perhaps, able to give 
the word of command or cheer on his comrades up to the very moment of his dissolution. 
Temperament and idiosyncrasy have much to do in the production of these phenomena, 
and should have due weight in the prognosis of the case. It is said that veterans upon CH AP. X. 
GUNSHOT WOUNDS. 
375 
the field of battle generally, other things being equal, suffer much less apprehension and 
alarm from their injuries than raw and inexperienced troops, 
The subjoined case affords a good example of the manner in which shock occasionally 
causes death in gunshot wounds in civil life:—An army officer in 1851 fell in a duel, the 
ball, a very large, round one, fired from a rifle at a distance of forty yards, entered the left 
thigh a little above its upper third, lacerating the soft parts in the most horrible manner, 
laying open the femoral vein, and crushing the bone into numberless fragments. The 
missile then passed into the right thigh, where it lodged, producing, however, but little 
mischief. Although hardly a pint of blood was lost, the system never rallied, notwith- 
standing the free use of brandy and other stimulants, up to the moment of the patient’s 
death, two hours after the rencontre. 
The shock in gunshot injuries is generally most intense when the ball traverses the 
head, chest, abdomen, or pelvis, when it splits, breaks, and comminutes a large bone, or 
when it lays open an important joint, as that of the knee or hip. A wound inflicted with 
a conical ball is, other things being equal, attended with more collapse than one made 
with the common round ball. During the Crimean war upwards of two hundred soldiers 
perished from shock alone within forty-eight hours after the receipt of their injuries. 
Great mental agitation, sometimes followed by furious delirium, and even by insanity, 
has been known to ensue, within a short time after a severe battle, in soldiers who escaped 
all bodily injury, but experienced excessive alarm and shock the moment they reflected 
upon the dangers through which they had passed. A number of such cases occurred 
during the war in the Crimea. 
It has generally been supposed that gunshot wounds are peculiarly liable to be followed 
by tetanus, but this is the case only when the sufferers are neglected, or permitted to lie 
upon damp, cold ground, or in currents of cold air, after an engagement. When they are 
properly cared for, the danger from this source is very trifling. Thus, after the affair in 
Paris, in July, 1830, of three hundred and ninety wounded received into the IIotel-Dieu, 
of that city, only one was attacked with tetanus. In the Peninsular war the pi’oportion 
was estimated at about one in two hundred; and in the Schleswig-Holstein campaigns, 
according to Stromeyer, at one in three hundred and fifty. In the English army in the 
Crimea, the number was exceedingly small, being only 0.2 per cent, of the wounded; and 
the French loss, during the same period, did not exceed altogether thirty cases. After 
the battle of Solferino, three deaths occurred from this disease, caused chiefly, as is sup- 
posed by Bertherand, by the damp, chilly air of the churches in which the wounded were 
temporarily accommodated. Baron Larrey was struck with the great frequency of tetanus 
in Egypt, especially in the neighborhood of the Nile and the sea. The mortality from 
tetanus after naval engagements is sometimes very great. Thus, after Admiral Kodney’s 
action, twenty out of eight hundred and ten wounded were attacked with this disease; and 
during our war with Great Britain the proportion was still more frightful. Injuries 
inflicted upon the hand and fingers by the toy pistol are a frequent source of tetanus. In 
Baltimore, in 1881, nearly twenty persons, chiefly boys, died from lesions of this kind 
inflicted during the Fourth of July celebration. 
Prognosis The prognosis of gunshot wounds varies with so many circumstances as 
to admit of being pointed out only in a very general manner. Some of the milder cases 
of this class of injuries often recover promptly, without a solitary untoward symptom, the 
parts occasionally uniting, as I have myself seen in several instances, by the first inten- 
tion. In other cases, on the contrary, apparently of a mild character, severe nervous 
symptoms may arise, or the wound may take on erysipelas, or a bad form of inflamma- 
tion, and the patient lose his life. In 1857, I attended a young man who had been shot 
with a pistol, the ball, a small one, having entered the outer and back part of the arm, 
just above the middle, grazing the humerus, and lodging immediately under the integu- 
ment, from which I removed it an hour afterwards. The ordinary treatment was em- 
ployed ; but in thirty-six hours violent erysipelas set in, and death occurred in less than 
eight days from the time of the injury. On the other hand, apparently the most despe- 
rate cases will sometimes recover. Much will, of course, depend, in every instance, upon 
the size and situation of the wound, the presence or absence of complications, the state of 
the patient’s constitution, the condition of the atmosphere, and the nature of the treat- 
ment. Wounds inflicted in battle are generally more fatal than those received in civil 
life, especially if treated in crowded, ill-ventilated hospitals. Death then often occurs 
from sheer neglect, or the want of good nursing and suitable surgical treatment. 
Some gunshot wounds must necessarily be fatal, either instantaneously, as when they 
involve a large vessel, or an important organ, or, more or less remotely, as a consequence 376 
WOUNDS AND CONTUSIONS. 
chap. x. 
of inflammation, gangrene, pyemia, or profuse and exhausting discharge. The danger to 
limb, if not to life, will be great when a large joint has been laid open, the main artery, 
vein, or nerve severed, the bone crushed, or the integument extensively stripped off; or 
when all, or nearly all, of these parts suffer together. Gunshot wounds of the lower ex- 
tremity are, other things being equal, more dangerous than those of the upper, sharing, 
in this respect, the same fate as ordinary lacerated and contused wounds. 
The causes of death in gunshot wounds are, shock, hemorrhage, pyemia, erysipelas, 
gangrene, tetanus, profuse suppuration, and hectic irritation. 
Remote Effects—The remote effects of gunshot wounds are often very troublesome, 
entailing much suffering, and being occasionally followed by loss of life at the distance 
of many years. In a case of gunshot injury of the chest, related by Dr. M. H. Hous- 
ton, of Virginia, a thick linen patch, with which the ball had been enveloped, remained 
in the left lung for twenty years, when the patient died in a state of extreme marasmus, 
his general health having never been good since the occurrence of the accident. Some- 
times a bullet lodges in the head of a bone, where, although it may for a while be com- 
paratively harmless, it ultimately causes necrosis, with inflammation and discharge in the 
soft parts, thus necessitating the removal of both substances, if not of the limb itself. 
Marshal Moncey died from the effects of a gunshot wound forty years after its receipt. 
In 1861, I removed from the lower part of the leg of a man seventy-nine years of age, 
shot at the battle of Moscow, a hall weighing six drachms and a half; it was incased in a 
mass of calcareous matter, and, although it was somewhat rough on the surface, it had 
remained in a quiet state for forty-nine years, when it gave rise to inflammation, followed 
bv some pain and profuse discharge, necessitating surgical interference. An old soldier, 
wounded at the battle of Chippawa, carried a half ounce bullet in the upper part of his 
thigh for sixty-one years. During all this time, however, he suffered more or less from 
pain and suppuration. 
On the other hand, a ball may occasionally remain in the body for a long time, 
perhaps even in an organ of vital importance, without inducing any particular mis- 
chief. Thus, in a case reported by Dr. Henry Wurtz, of New York, an ounce bullet 
was found, on dissection, in the middle lobe of the right lung, of an old soldier, forty-five 
years after its introduction at the siege of Badajos. It was inclosed in a distinct cyst, an 
inch below the surface of the organ, having entered between the fourth and fifth ribs, as 
was proved by the existence there of an old cicatrice. An Englishman lived, without 
any inconvenience, with a ball in his back between his shoulders for fifty-six years. Dr. 
S. W. Gross has recorded the case of a soldier, struck at the battle of Shiloh, in which a 
cylindro-conoidal ball was encysted in the right cavernous body of the penis. 
In gunshot injuries, attended with fracture, it is not uncommon for the wound, after hav- 
ingbecomeapparentlyperf‘ectlysolidified,toreopen,and takeon unhealthyaction. The cause 
of this occurrence is usually some foreign substance, generally a piece of dead bone, im- 
prisoned by callus, which, for a time, masks its presence, but does not ultimately pre- 
vent it from exciting inflammation and suppuration. More frequently the wound, under 
such circumstances, remains fistulous until the source of the irritation is completely re- 
moved. 
Among the more serious remote effects of this class of injuries are, atrophy of the af- 
fected limbs, paralysis, either partial or complete, permanent ankylosis, and contraction 
of the tendons, muscles, and aponeuroses, leading to deformity and loss of function. 
Treatment In the treatment of gunshot wounds six distinct indications are presented: 
1st. To revive the patient, or promote reaction ; 2dly. To arrest hemorrhage; 3dly. To 
ascertain the precise condition of the soft parts and bones ; 4thly. To extract the ball and 
any other foreign matter that may have entered along with it; othly. To remove any loose 
pieces of bone; and Gthly. To circumscribe the resulting inflammation. 
1st. Shock is relieved by the employment of the ordinary restoratives. If the patient 
be faint, he must at once be placed in the recumbent posture, with his head as low as the 
rest of his body; cold water must be dashed upon the face, the fan freely used, and the 
smelling-bottle passed under the nose. If the symptoms are urgent, sinapisms are applied to 
the chest, spine, and extremities, a stimulating injection is thrown into the bowel, and, if 
the power of deglutition is not gone, brandy, wine, or ammonia is given by the mouth. 
If, however, there is internal hemorrhage, care is taken to bring up the pulse slowly and 
gently, allowing time for the formation of coagula, and guarding against the occurrence 
of violent inflammation. A kind look, or a soothing expression, will often do more to re- 
vive the patient and encourage recovery than anything else. 
2dly. If the hemorrhage be capillary, or caused by the division of very small vessels, CHAP. X. 
GUNSHOT WOUNDS. 
377 
it will probably soon cease of its own accord, or simply by exposure of the part to the 
cold air, or under the application of cold water, pounded ice, or some astringent lotion. 
If it be venous, compression may perhaps suffice; whereas if it proceed from a lai’ge artery, 
such as the radial or tibial, the only reliable remedy is the ligature. The case is very 
simple when the vessel is superficial, and the wound capacious; but, under opposite cir- 
cumstances, the duty of the surgeon is often exceedingly embarrassing. Here it becomes 
necessary either to dilate the wound, so as to expose the artery and tie it at both ends, 
which is by far the best plan; or, when this is impracticable on account of the depth of 
the vessel, its proximity to important structures, or the great swelling and infiltration of 
the parts, as may happen when some time has elapsed since the receipt of the injury, to 
cut down upon the main trunk of the vessel, and to secure it as in the Hunterian opera- 
tion for aneurism. The latter procedure, however, will rarely succeed, inasmuch as the 
bleeding is extremely liable to be kept up by the recurrent circulation ; for this reason it 
is always best, if practicable, to expose the injured artery at once, and to apply a ligature 
to each extremity, which cannot fail to put an effectual stop to the flow of 
blood. The more promptly the operation is performed the better; if the 
surgeon wait till inflammation has supervened, great difficulty will be experi- 
enced, not only in securing the artery, but also in inducing the ligature to 
maintain its hold upon its softened and partially disorganized tissues. When 
the hemorrhage has been very profuse, but has gradually or suddenly stopped, 
it will hardly be safe to intrust the case to the efforts of nature, because, 
when reaction occurs, the vessel will almost be sure to be reopened, and thus 
the bleeding may progress until the system is completely exhausted; whereas, 
if the surgeon has done his duty, the parts will be placed in the best possible 
condition for speedy recovery. The proper plan in such cases is to do what- 
ever may be necessary without temporizing. 
When secondary hemorrhage is expected, as when a ball has passed in 
the direction of a large artery, the patient should be most sedulously watched 
until all danger is over. A tourniquet should be placed loosely round the 
affected limb, and instructions given to tighten it the moment bleeding ap- 
pears. Meanwhile the patient should be kept perfectly quiet, and everything 
done to control vascular excitement. If the wound is not too large, it may, 
as an additional precaution, be plugged with lint soaked in Pagliari’s styptic 
or in a strong solution of subsulphate of iron. 
Aneurism caused by gunshot injury must be treated in the same manner 
as in ordinary cases of this disease; if possible, by ligation of the affected 
vessel; if this fail, and the symptoms are urgent, by amputation. 
3dly. To ascertain the condition of the wound is a matter of the first im- 
portance, and yet it is one which, I am convinced from much personal ob- 
servation, is often most grossly neglected. The object should be not only to 
determine whether there is any foreign substance, but what the actual condi- 
tion of the soft parts and bones is ; whether, in a word, excessive and irrepara- 
ble injury has been inflicted, forbidding all attempts at surgical interference, 
whether primary amputation is demanded, or whether the treatment should 
be wholly conservative. For the want of this precaution many limbs and 
lives are lost, simply because what should be done at once, at the earliest 
possible moment, is postponed until it is too late to be of any benefit. Many 
of the men that are sent from the battle-field to the hospital fall victims to 
erysipelas, pyemia, gangrene, and secondary hemorrhage in consequence of 
the irritation produced by retained splinters of bone, shreds of clothing, or 
other hurtful matter that should have been extracted on the spot. Such 
neglect, whether caused by ignorance, carelessness, or timidity, cannot be too 
pointedly condemned, or too severely censured. It need hardly be added 
that, inasmuch as all explorations of this kind must be painful, the patient 
should always be thoroughly anaesthetized. Moreover, they should be insti- 
tuted at the earliest possible moment, before the parts are invaded by inflam- 
mation and swelling, as they may then be conducted with comparative ease, 
and without any serious ulterior harm. 
4thly. The fourth indication is the extraction of the ball; but to do this it is necessary, 
in the first place, to ascertain where it is ; to grope about in the wound without any defi- 
nite idea as to its precise location, would only be to inflict additional pain and injury. In 
order to conduct the examination with the greatest advantage, the part should be put as 
Fig. 109. 
Author’s Bul- 
let Probe. 378 
WOUNDS AND CONTUSIONS. 
chap. x. 
nearly as possible in the position in which it was at the time of the accident. This is the 
more necessary, because, as was before stated, the missile often pursues a very different 
route from what might be supposed from merely looking at the orifice of entrance or exit; 
the slightest resistance may change its direction, and cause it to lodge at a point far beyond 
what it would have sought, had it been permitted to pass in a straight line. Hence atten- 
tion to the position of the part is, in all cases, a matter of the greatest importance. 
Fig. 110. 
Sir Charles Bell’s Bullet Probe. 
In searching for the ball, care must be taken not to mistake for it some osseous pro- 
minence. Stromeyer refers to two cases in which he saw this blunder committed: in one 
the surgeon cut down upon the head of the fibula, in the other upon a metatarsal hone. 
The assertion of a patient that the ball has dropped out is seldom reliable, unless the mis- 
sile is found in his pocket. 
The course of a ball is sometimes indicated by the impression made by it upon the nerves 
of the part. Thus, as observed by Sir Charles Bell, when the missile has traversed the 
pelvis or shoulder, the defect of feeling in the extremity, studied anatomically, will afford 
useful information in regard to its passage; whether, for example, it has cut, or is press- 
ing upon, a particular trunk. The color of the blood will indicate whether an artery or 
vein has been wounded, and the size of the stream whether the vessel is small or large. 
The best probe for conducting the examination is the finger, provided it is sufficiently 
long and slender; it possesses the same value, in such cases, as direct auscultation in the 
exploration of the chest, or the finger in the examination of the uterus and rectum, and 
should, therefore, always be used when practicable. If the digit is inadequate, recourse 
is had to a stout probe, fig. 109, or fig. 110, from ten to twelve inches in length, as thick 
as a medium-sized bougie, slightly flexible, blunt-pointed, and composed either of silver 
or brass. The ordinary pocket probe is much too small. When a suitable instrument is 
not at hand, the necessary exploration may be performed with a female sound or catheter, 
or even with a long, slender pair of bullet forceps. The instrument, whatever it may be, 
is passed along the track of the wound with all possible care and gentleness, otherwise it 
will be very likely to make a false passage in the surrounding connective tissue, or become 
entangled among the muscles, tendons, nerves, or vessels. The contact of the probe with 
the ball usually produces a sensation of roughness and resistance, together with a dull noise 
if the instrument be struck against the foreign body by short jerks. 
When it is doubtful whether the missile has really lodged, or when the missile is 
retained, but cannot be distinguished from bone, Nelaton’s probe, consisting of a metallic 
rod, the extremity of which is tipped with a small olive-shaped piece of white, un- 
polished porcelain, capable, when rubbed against a bullet, of receiving a stain from it, will 
afford the most satisfactory result. The instrument being withdrawn, any blood or pus 
that may have collected upon its bulb should be washed off with a stream of wTater, in 
order that the stain, if any exist, may be brought into full view. When such a probe is 
not at hand, a good substitute will be found, as suggested by Dr. Gelisch, of California, 
in one constructed of white pine wood, the extremity of which readily receives the stain 
of the lead. 
Attempts have been made from time to time to detect the presence of bullets by the 
use of the electric bell-probe, but in hardly a solitary instance with satisfactory results. 
What future investigations may accomplish in this direction remains to be determined. 
Finally, the missile may sometimes be detected with the exploring needle, after all the 
more ordinary means have failed. The instrument, which should be long, straight, and 
slender, should be inserted at the supposed situation of the foreign body, and moved about 
in different directions until the diagnosis is clearly established. The peculiar shape of 
the missile, and the facility with which it may be displaced, provided it is not firmly 
imbedded, may be regarded almost as certain indications of its presence. 
The bullet being found, the forceps take the place of the probe, the blades being firmly 
closed as they pass along the track until the point comes in contact with the extraneous 
substance, which is then seized and extracted in such a manner as not to include any of 
the surrounding tissues. Occasionally the operator will derive important aid in his 
manipulations from counter-pressure, the hand or the thumb and a few fingers being 
applied to the opposite side of the wounded parts. chap. x. 
GUNSHOT WOUNDS. 
379 
Bullet-forceps and extractors, of various forms and sizes, are in use. The most impor- 
tant qualities of such instruments are lightness, strength, and slenderness, with length of 
blade, which should not be less than four inches. The extremity should be well rounded 
Fig. 111. 
Fig. 112. 
Fig. 113. 
Fig. 114. 
Fig. 115. 
Thomassin’s 
Extractor. 
Thomassin’s Forceps 
Gemrig’s Forceps. 
Fenestrated Forceps. Bullet Extractor. 
off, and fashioned in such a manner as to adapt itself readily to the shape of the foreign 
body, and at the same time grasp it with great firmness, without the risk of including any 
of the adjacent structures. The old forceps did good service during the reign of the round 
ball, but will hardly answer for the extraction of the conical. For the latter purpose, Mr. 
Tiemann, of New York, has reintroduced to the notice of the profession the ingenious 
instrument, fig. Ill, devised by Thomassin in the latter part of the last century. It is 
quite slender in the blade, and is provided with short, stout teeth, projecting somewhat 
like the incisors of a mouse, their object being to take a firm hold upon any part of the 
bullet by partially burying themselves in its substance. 
Thomassin’s instrument has been greatly improved by Mr. Gemrig, by making the end of 
one blade cup-shaped, with two curved prongs, separated in front by a narrow interval, and 
terminating each in a point. The other blade has only one prong, also curved, but central, 
and terminating in a point, which, when the forceps are shut, is received in the interval 
here alluded to, thus rendering its extremity perfectly blunt. The instrument, represented 
in fig. 112, answers for the round as well as the conical ball, and possesses the great ad- 
vantage of facility of application with firmness of grasp. 
The forceps delineated in fig. 113 were made in 1861 at my suggestion, by Mr. Gemrig. 
They are about nine inches and a half in length, light, slender and fenestrated at the ex- 
tremity, which is scooped out in such a manner as to embrace the ball with great facility, 
while its inner surface, roughened like that of a stirrup, maintains its hold with extra- 
ordinary firmness. 
When the wound is unusually large, and the ball not deeply seated, the extraction may 
sometimes be effected with a small lithotomy scoop, the common dressing or polyp forceps, or an instrument like that sketched in fig. 114, made for me by Mr. Kolbe. It consists 
of a silver tube, inclosing a steel stylet, terminating in two blades, cup-shaped on the 
inside, and movable by a hinge. The extremity of the instru- 
ment is seen grasping the ball. Fig. 115 represents a similar 
instrument, devised by Thomassin, and used by the French 
and British surgeons. When the course of the ball is very 
circuitous, or when the missile is imbedded among swollen and 
infiltrated tissues, advantage may be derived from the elastic 
forceps of Dr. Weisse, delineated in fig. 116. 
The gimlet-like instrument, so much extolled by the older 
surgeons, is now almost obsolete, although it might still occasion- 
ally be employed with advantage when the extraneous substance 
is lodged in a bone thickly covered by muscles. The trephine, 
however, is generally preferi’ed under this and similar circum- 
stances. 
The extraction of a ball and other foreign matter is sometimes 
greatly facilitated by the elastic roller, or the ordinary bandage, 
tightly applied. It is especially valuable when the wound is 
situated among very vascular structures, or when deep incisions 
are required for the detection or removal of the missile. 
A ball, after having traversed the thickness of a limb, or 
of the body, occasionally lodges immediately beneath the skin 
or among the superficial muscles, where its presence may 
readily be detected by the probe or finger. In such a case it 
should be removed by a counter-opening, made by cutting 
down upon it at the nearest point; a procedure which often 
saves an immense amount of pain and trouble. 
When the ball cannot be found without much probing, and 
the risk of inflicting serious additional mischief, the best plan 
is to let it alone, in the hope that it may either become en- 
cysted, or that it may be detached and washed away by the 
discharges. In general, however, every justifiable effort should 
be made to remove it, on the ground that, if left, it will be 
almost sure to excite violent inflammation, followed by profuse 
suppuration and extensive separation of the tissues. Such an 
event will be more likely to occur when the ball has become 
rough, jagged, or flattened by striking against a bone ; for then 
it must necessarily keep up irritation so long as it remains, as 
there is no possibility of its being isolated by an adventitious 
membrane. 
The great importance of not permitting balls to remain un- 
extracted has been placed in a very forcible light by the obser- 
vations of Hutin, chief surgeon of the Hotel des Invalides of 
Paris. Of 4000 soldiers whom he examined, within a space 
of five years, only 12 had experienced no inconvenience from 
the retention of foreign bodies, while the rest, 200 in number, 
had all suffered more or less severely until they were relieved 
by operation. 
Another reason for the early extraction of the missile is 
that persons soon after the receipt of the injury, generally, 
submit much more readily to the necessary operation than after 
they have partially recovered from its effects; their dread usually increases in proportion 
as they get well, and thus pass beyond the reach of immediate danger. 
When a ball lies loose in a movable joint, it should always be promptly extracted ; if, 
on the other hand, it is lodged in an adjoining bone, the proper plan is to let it remain, in 
the hope that it may soon be covered with plastic matter, and thus become comparatively 
harmless. The only exception to this rule is where the ball projects into the cavity of 
the articulation, when it should be removed at all hazards, inasmuch as its retention 
would inevitably lead to violent, if not fatal, inflammation, and utter uselessness of the part. 
No sensible surgeon ever thinks of searching for a ball in any of the great cavities of 
the body ; such a procedure would be sure greatly to increase the dangers of the accident, 
and cannot, therefore, be too pointedly condemned. 
380 
WOUN’DS AND CONTUSIONS. 
chap. x. 
Fig. 116. 
p 
S' 
> 
2] 
2 
S°! 
o! 
o 
Weisse’s Elastic Forceps. CHAP. X. 
GUNSHOT WOUNDS. 
381 
If it be necessary to the welfare of the part and systerp to remove a ball, which is a 
comparatively innocuous substance, it is much more important to extract the various 
foreign bodies which so often enter along with it, and the presence of which, however 
protracted, must be a source of incessant irritation and annoyance. The rule here is im- 
perative, and applies to the smallest as well as to the largest substance ; to the little piece 
of wadding and the stoutest splinter, the linen shred and the brass button ; in short, to 
every description of extraneous matter. Wherever it may be, it must be sought for, and, 
if possible, extracted without delay. There is no chance here for the formation of a cyst, 
as sometimes happens with a ball; nature admits of no such liberty. In naval and mili- 
tary engagements large pieces of wood, metal, and other substances are liable to be 
impelled into the body, in which they are often buried at a great depth, or lodged among 
the muscles, which sometimes close over them in a sort of valve-like manner, rendering 
it extremely difficult not merely to extract but even to find them. Much may be done 
in such cases by the gentle use of the finger and probe, aided by counter-pressure. 
5thly. Any detached splinters of bone, or pieces of bone so much loosened as to render 
it improbable that, if left, they will reunite, should be removed as early as possible after 
the occurrence of the accident, experience having shown that their retention is always 
productive of extensive and protracted suppuration, if not of worse results. By the timely 
extraction of such bodies, immense suffering may be prevented, and ultimate recovery 
greatly expedited. It is surprising that surgeons should ever hesitate in such a case, and 
yet the instances are not uncommon of the most culpable neglect. A remarkable example 
of this kind fell under my notice in 1847, in Lieut. George Adams, of the United States 
Marine Corps, who was desperately wounded in the right thigh by a large musket ball, 
at the battle of the National Bridge, during our war with Mexico. The soft parts were 
extensively injured, and the bone shattered into numerous fragments, not less than twenty- 
four of which, some of them upwards of an inch and a half in length, I removed nine 
months afterwards, from the enormous callus that had formed around the seat of the frac- 
ture : most of them were completely imprisoned in the new osseous matter, and, therefore, 
very difficult of extraction. The incisions healed kindly, except at one point, which 
refused to close, owing to the presence of a small piece of bone, which was subsequently 
removed by the late Professor Warren, of Boston. 
WThen powder is imbedded in the skin, every particle should immediately be picked out 
with a cataract needle, or a delicate bistoury, entirely regardless of pain. Unless this be 
done, the powder will speedily excite inflammation, besides causing disagreeable and per- 
manent disfigurement by the bluish spots which it will leave. The operation is not only 
tedious, but always attended with severe suffering. The resulting inflammation is to be 
combated in the usual manner; cold water, or cold saturnine lotions, being generally the 
best local remedies. 
6thly. The last indication is to circumscribe and moderate inflammation. To fulfil 
this, attention to various points is necessary. In the first place, the parts must be pro- 
perly dressed. The rule formerly laid down was that the orifices of the wound should be 
lightly covered with lint and adhesive plaster. Such a procedure is exceedingly ir- 
rational, inasmuch as its direct effect must inevitably be to aggravate the local mischief 
by interfering with the discharges, of which there will necessarily always be more or less. 
Instead of this, the orifices should be left open, while, by means of a light compress and 
bandage, an attempt is made to approximate the sides of the wound in order to promote 
their reunion. The roller, extending from the distal portion of the limb beyond the seat 
of injury, must be applied in such a manner as not to impede drainage. By such treat- 
ment the cure will often be immensely expedited; the resulting inflammation will be 
comparatively slight, infiltration of fluids will, in great degree, be avoided, and suffering 
will be vastly abridged. The bandage, however, must be used with great caution,for there 
is danger, especially when there is much swelling, of its producing injurious compression, 
and thus becoming a cause of gangrene. In gunshot wounds of the extremities, involving 
the deep muscles and aponeuroses, great advantage will accrue, during the progress of the 
treatment, from the use of the bandage in preventing the formation of sinuses and in 
favoring the escape of pus. 
The part having been dressed, and placed at rest in an easy, elevated position, cold 
water is applied, provided there is no contraindication to its use, on account of the state 
of the weather or the intolerance of the part and system. If the weather be mild, and 
the patient young and robust, cold will usually be borne better than warmth, and the 
most eligible form is that of water, either simple, or medicated with opium and acetate of 
lead. The use of cold water in the treatment of this class of lesions dates as far back as 382 
WOUNDS AND CONTUSIONS. 
chap. x. 
tlie time of Biondo, towards the middle of the sixteenth century, and its beneficial effects, 
although lost sight of for a long time, were again brought prominently before the notice 
of the profession by Kern, Larrey, Guthrie, and other army surgeons, during the con- 
tinental wars of Europe early in the present century. Cold water, however, is not 
tolerated equally well by all patients, and the rule, therefore, is, when it disagrees, to 
substitute warm applications, either in the form simply of tepid water, or in that of a 
light, emollient cataplasm, which, after all, makes, in many cases, an admirable dressing, 
soothing pain, and promoting discharge. 
Although water-dressing usually answers a most excellent purpose in this and other 
classes of wounds, I am certain, from long experience, that its efficacy may generally be 
very greatly increased by the addition of acetate of lead and opium, the astringent and 
anodyne effects of which are thus directly imparted to the affected structures. An ounce 
of the former of these articles with a drachm of the latter to a half gallon of boiling 
water are the proportions which I commonly employ. The application is made either 
tepid, cool, or cold, as may be most agreeable to the patient. During my connection with 
the George Street Military Hospital of this city I had ample opportunities of testing this 
mode of practice, and of satisfying myself of its superiority. 
When much contusion exists, as is so often the case in shell and cannon wounds, 
the best local remedy is some spirituous lotion, as, for example, two parts of alcohol 
or tincture of arnica to ten of water, with the addition, if there be any offensive discharge 
of a small quantity of chlorinated sodium. The tissues, deprived of nervous power, must 
be slightly stimulated, to prevent them from running into profuse suppuration, if not 
gangrene. 
If the inflammation assumes a threatening aspect, ap when it is of an erysipelatous 
character, and is attended with great pain, tension, and swelling, free incisions, and some- 
times counter-openings, must be made, otherwise extensive mischief may result from the 
burrowing of fluids, and the consequent destruction of the connective tissues. Besides, 
the parts, if not promptly relieved, might mortify. The older surgeons made it a rule to 
dilate all wounds of this kind as soon as possible after their infliction, with a view of 
preventing these and other untoward results, but this procedure has become obsolete, the 
modern practitioner resorting to it only when the necessity arises on account of the 
severity of the inflamation; assuming that a man ought not to be cut merely because he 
has been shot. 
When there is profuse suppuration, with extensive separation of the tissues, the wound 
should be freely syringed several times daily with tepid water, slightly medicated with 
chlorinated sodium, permanganate of potassium, bromine, carbolic acid, nitric acid, or sub- 
sulphate of iron, the latter being particularly serviceable when there is a disposition to bleed- 
ing. Much may frequently be done in this manner, not only in preventing the lodgment 
and burrowing of pus, but in getting rid of any clots of blood, shreds of cloth, or detached 
splinters of bone that may be present. 
The orifices of the wound will usually begin to granulate in from four to eight days, 
even when there is slight gangrene of their edges, and the whole track will often close in 
an almost incredibly short time. Much of it, especially if it be long, will be in the con- 
dition of a subcutaneous wrnund, and, therefore, highly favorable to repair. When thes, 
passage is slow in filling up, the healing process may be expedited by the use of slightly 
stimulating injections, thrown in twice in the twenty-four hours ; few cases, however, will 
demand such interference. The wound of exit generally heals first, provided it is not 
ragged, contused, or interfered with by the discharges. 
Conjoined with these local measures must be perfect rest of mind and body, along with 
a generous diet, gentle laxatives, and anodynes, the latter being given for the double pur- 
pose of allaying pain and spasm, and inducing sleep. Opiates are generally borne in large 
doses, and can rarely be dispensed with in any case, however mild. If the wound is 
severe, and especially if it be attended with serious hemorrhage, antimonials and active 
purgation must be scrupulously abstained from, on account of their depressing effects, 
and their tendency to provoke pyemia and erysipelas. Due allowance must be made, in 
every instance, for the discharges which are likely to attend such injuries. Hence much 
judgment is often required to steer clear of difficulty and danger. Bleeding by the lancet 
is hardly to be thought of under any circumstances; in young and plethoric subjects, 
however, blood may occasionally be advantageously taken by leeches. In ordinary cases, 
the diet should be plain and simple, rigid abstinence not being required, except when 
there is unusual fulness of habit. Marked exhaustion, whether from shock, loss of blood, CHAP. X. 
QUESTION OF AMPUTATION IN WOUNDS. 
383 
inflammatory disturbance, or profuse suppuration, must be met by the use of milk punch, 
quinine, iron, cod-liver oil, and nutritious food. 
If any tendency to erysipelas, pyemia, or hospital gangrene arises, the patient in addi- 
tion to the means already indicated, should be promptly placed under the influence of iron 
and quinine along with brandy and nutritious food ; and if large numbers of wounded are 
crowded together, no time should be lost in effecting their sequestration. 
The progress of gunshot wounds is often seriously interrupted by the occurrence of 
diarrhoea and dysentery, especially in tropical regions or in the heat of summer, among 
troops that have been exposed to malarious influences. The discharges rapidly reduce 
the strength, and often, in the course of a very few houx-s, completely arrest the granulat- 
ing process. The best remedies are quinine and iron in union with opium and arsenic. 
Powdered charcoal and permanganate of potassium are also valuable remedies, either 
alone or variously combined with other articles, particularly anodynes. A scorbutic state 
of the system is best rectified with subacid fruits and vegetables, tonics, beef essence, and 
milk punch. In all cases the patient should have the full benefit of fresh air, frequent 
ablutions, and change of clothing. 
When the cicatrization of a gunshot wound is fully completed, there is commonly 
a marked difference between the scar at the opening of entrance and that of exit. The 
former is generally somewhat depressed, whereas the latter is either on a level with the 
adjacent surface or projects very slightly beyond it. 
QUESTION OF AMPUTATION IN WOUNDS. 
The most horrible wounds are generally those which are inflicted by machinery in 
rapid motion, the passage of a railway car or the wheel of a heavy wagon, and the ex- 
plosion of fire-arms, violently lacerating and contusing the soft parts, extensively crushing 
the bones, and perhaps opening one or more of the larger joints. In many cases, the 
character and extent of the mischief are apparent at first sight; in others, as when it is 
principally subcutaneous, it becomes so only after a most patient and thorough examina- 
tion. The latter class of injuries is particularly to be dreaded, as it is often impossible, 
even with the greatest care, to determine the extent of the lesion. When the examina- 
tion necessary to ascertain the condition of the parts is likely to be painful or protracted, 
commiseration for the sufferer always dictates the propriety of administering chloroform, 
although the anaesthesia will rarely be required to be carried to the extent of complete un- 
consciousness, a few full and prolonged whiffs being generally sufficient to effect the 
desired tolerance. 
In attempting to determine the question as to whether an effort should be made to cut 
off or save a limb, not a little stress should be laid upon the age, habits, and previous 
health of the patient, the manner in which the injury was inflicted, and the number, 
variety, and importance of the structures involved. 
Young adults bear severe accidents much better, other things being equal, than the 
two extremes of life, childhood and decrepitude, in both of which, but especially the latter, 
th.e power of reaction is generally very feeble, and the effect of shock and hemorrhage felt 
for a long time. Nevertheless, there is not a practitioner of any experience who has not 
occasionally witnessed striking exceptions even under these circumstances. A temperate 
man usually bears up under a severe wound much better than a dissipated one, and the 
resident of the country than the inhabitant of the crowded city; a person in ill health at 
the time of the accident will be likely to suffer more than one in an opposite condition. 
The worst class of accidents in civil practice are those inflicted by railway cars, steam- 
boats, and steam factories, and these are often of such a nature as to require the prompt 
removal of the mangled and mutilated structures. 
But of all the circumstances influencing the recovery of the patient, and the ability 
of the surgeon to save the mutilated parts, the most important, by far, is the extent of 
the injury, or the number and nature of the tissues involved. To place this subject in a 
clear and tangible light, it must be considered somewhat in detail; but, before doing so, 
it is proper to observe that amputation should never be performed in wounds of any kind 
until reaction has taken place, for, if this precaution be neglected, the additional shock 
which the operation would necessarily impart to the system might prove fatal, either 
before the patient is removed from the table, or soon after. As long as he is deadly pale, 
the pulse small and thready, the surface cold, and the thirst, restlessness, and jactitation WOUNDS AND CONTUSIONS. 
chap. x. 
excessive, the employment of the knife is wholly out of the question. The proper treat- 
ment is recumbency, with mild stimulants, sinapisms to the extremities, and other means 
suited to reexcite the action of the heart and brain. Power being restored, the operation 
is at once proceeded with, due regard being had to the prevention of shock and hemor- 
rhage, the two things now mainly to be dreaded. 
The advantages of primary over secondary amputation, in all severe wounds, are too 
obvious to require comment. Mr. Guthrie long ago ascertained that the loss after 
secondary operations, in gunshot injuries, was at least three times as great as after 
primary, and the results of his observations have been amply confirmed by the more 
recent experience of military surgeons. In the Crimean war, where the wounds were, 
for the most part, inflicted with the conical ball instead of the round, as in the cases seen 
by Mr. Guthrie, the difference was less marked, but still strikingly in favor of primary 
interference. Thus, the mortality in 690 primary amputations was 175, or in the ratio 
of 25.3 per cent., and 38 in 89 secondary, or in the ratio of 42.7. Intermediary ampu- 
tations are, as will be explained in the chapter on amputations, of all operations of this 
kind the very worst. 
The following circumstances may be enumerated as justifying, if not imperatively 
demanding, amputation in cases of wounds, of whatever nature:— 
1st. When a limb has been run over by a heavy cart, crushing the bones, and tearing 
open the soft parts, amputation should, as a general rule, be performed, even when the 
injury done to the skin and vessels is apparently very slight, experience having shown 
that such accidents seldom do well if an attempt is made to save the limb, the patient 
soon dying of erysipelas, gangrene, pyemia, or typhoid irritation. The danger of an 
unfavorable termination is always greater in the lower than in the superior extremity. 
2d. No attempt should be made to save a limb when, in addition to serious injury 
inflicted upon the integument, muscles, or bones, its principal artery, vein, or nerve has 
been extensively lacerated, or violently contused, as the result will be likely to be gan- 
grene, followed by death. 
3d. A lacerated, punctured, or gunshot wound penetrating a large joint, as that of the 
knee or ankle, and accompanied by comminuted fracture, or extensive mischief of the 
ligaments, will, if left to itself, be extremely liable to terminate in tetanus, mortification, 
or pyemia, and is, therefore, as a rule, a proper case for early amputation. 
4th. Gunshot wounds attended with severe comminution of the bones, the fragments 
being sent widely around among the soft parts, lacerating and bruising them severely, 
generally require amputation, especially in naval and military practice. Gunshot fracture 
of the thigh-bone is generally considered by military surgeons as a sufficient cause for 
primary amputation. The rule, however, admits of many exceptions. 
5th. Extensive laceration, contusion, and stripping off of the integument, conjoined 
with fracture, dislocation, or compression and purification of the muscles, generally 
demand the removal of a limb. 
In all severe lacerated and contused wmunds, whether induced by cannon shot, falls, 
blows, machinery in rapid motion, or the passage of the wheel of a wagon, the limb 
should generally be amputated at a considerable distance above the apparent seat of the 
injury. If this precaution be neglected, mortification will be liable to seize upon the 
stump, owing to the fact that, in such cases, the injury, both of the soft and hard parts, 
usually extends much further than the naked eye can discover. 
Should amputation be performed when a limb, the subject of a severe wound, lacera- 
tion, or contusion, has been suddenly seized with mortification, manifesting a rapidly 
spreading tendency, extending, perhaps in a few hours, up as far as the middle of the leg, 
or even as high as the knee ? Such cases are generally desperate; no local or internal 
remedies can arrest the morbid action ; the system has sustained a profound shock, and 
the affected parts perish, not by inches, but literally by feet. I have repeatedly seen this 
variety of gangrene extend from the toes, instep, or ankle as far as the hip-joint in less 
than thirty-six hours, in cases where there was but. little visible injury, the mischief being 
evidently deep-seated, involving muscle, nerve, vessel, and bone. If amputation is not 
performed, the disease, the march of which is indicated by a bluish, purple, or livid, 
crepitating, and tender streak along the limb, will be sure to terminate fatally in a few 
days, and the operation should, therefore, be resorted to at the earliest possible moment, 
the surgeon not waiting for a line of demarcation, which cannot take place, since neither 
the part nor the system has the power of arresting the morbid action. The event, it is 
true, will generally be unfavorable, but as it is the only chance the patient has, he should, CHAP. X. 
SECONDARY EFFECTS OF WOUNDS AND CONTUSIONS. 
385 
slender though it be, undoubtedly have the benefit of it. In the cases in which I have 
amputated under these unpropitious circumstances, the result in all except three was fatal. 
Lacerated, contused, and gunshot wounds are often of so frightful a nature as to render 
it certain, even at a glance, that the limb will be obliged to be sacrificed in order to afford 
the patient a better chance for preserving his life. At other times, the injury, although 
severe, may yet, apparently, not be so desperate as to preclude, in the opinion of the 
practitioner, the possibility of saving the parts, or, at all events, the propriety of making 
an attempt to that effect. The cases which may reasonably require and those which may 
not require interference with the knife are not always so clearly and distinctly defined as 
not to give rise, in very many instances, to the most serious and unpleasant apprehension, 
lest we should be guilty, on the one hand, of the sin of commission, and, on the other, of 
that of omission; or, in other and more comprehensive terms, that, while the surgeon 
endeavors to avoid Scylla, he may not unwittingly run into Charybdis, mutilating a limb 
that might have been saved, and endangering life by the retention of one that should have 
been promptly amputated. It is not every man, however large his skill and experience, 
that is always able to satisfy himself, even after the most profound deliberation, what line 
of conduct should be pursued in these trying circumstances ; hence the safest plan for him 
generally is to procure the best counsel that the emergencies of the case may admit of. 
But, in doing this, he must be careful to guard against procrastination ; the case must be 
met promptly and courageously ; delay even of a few hours may be fatal, or, at all events, 
place limb and life in imminent jeopardy. Above all, proper caution must be used if the 
patient is obliged to be transported to some hospital, or to a distant home, that he may 
not be subjected to unnecessary pain, exposed to loss of blood, or carried in a position 
incompatible with his exhausted condition. Vast injury is often done in this way, by 
ignorant persons having charge of the case, and occasionally even by practitioners whose 
good sense should be a sufficient guarantee against such conduct. The transportation of 
a patient to a distance of perhaps hundreds of miles upon a railway car, after he has been 
desperately wounded, in the hope, it may be, bf obtaining better aid, cannot be too severely 
reprehended, as involving not only the loss of precious time, but often also the infliction 
of additional injury upon a part and system already overwhelmed by shock and hemorrhage. 
Excision in gunshot and other injuries involving the articulations is, as will be more 
fully explained elsewhere, applicable chiefly to the shoulder and elbow joints, in cases 
unattended w ith serious lesion of the soft parts. In the former, a portion of the humerus, 
embracing, if necessary, from three to five inches in length, together with a part or even 
the whole of the glenoid cavity of the scapula, may be safely and expeditiously removed 
under such circumstances, and yet the patient have an excellent use of his arm. Experi- 
ence shows that primary excision of the other joints, excepting, of course, the smaller 
ones, as those of the hand and foot, is generally very unfavorable. 
Further observations upon this subject will appear in the chapters on amputation, frac- 
tures, dislocations, and excisions. 
SECONDARY EFFECTS OF WOUNDS AND CONTUSIONS. 
Every practitioner occasionally meets with cases of wounds and bruises in which the 
patient, happily escaping from the primary effects of the injury, suffers severely from what 
may be termed the secondary effects, coming on several weeks or months afterwards. 
These lesions have not received sufficient attention from systematic writers. It has fallen 
to my lot to see a very large number of such cases, of which the following are selected in 
illustration of the subject:— 
A farmer, thirty years of age, twisted and bruised his left foot in a fall from his horse. 
The accident was instantly followed by severe pain, and next day by excessive swelling, 
which, however, gradually subsided under the usual antiphlogistic remedies. In the 
course of a few weeks the man was able to exercise on crutches, but the foot was now 
observed to be very sore and tender, cold, clammy, withered, benumbed, and completely 
destitute of power. There was also frequent twitching of the three small toes, particu- 
larly at night, so as to interfere with sleep. These symptoms were aggravated in damp, 
cold states of the atmosphere, when there were also occasionally neuralgic pains in the 
part. The general health likewise materially suffered, the appetite being bad, the bowels 
irregular, and the mind much dejected. When I saw the patient, nearly a year after the 
accident, he had been subjected to various plans of treatment, with hardly even any WOUNDS AND CONTUSIONS. 
chap. x. 
temporary relief. Notwithstanding that he was placed upon tonics, alterants, and the hot 
and cold douches, with frictions with veratria liniment and the use of the bandage, many 
months elapsed before he experienced much benefit, and he has never entirely recovered 
the functions of his foot and ankle. 
A man, twenty-five years of age, cut himself with an axe on the instep of the left foot, 
directly over the internal cuneiform bone. The weapon penetrated the bone, and evidently 
severed the extensor tendon of the great toe, as the toe could no longer be moved by the 
effort of the will. The wound healed completely in a few days, but shortly afterwards 
the parts became tender and remained so for several months. Meanwhile, the foot and 
leg grew sensibly thinner, and were habitually cold and clammy; a condition which has 
continued for several years. Whenever exercise is taken, the parts swell, and become 
tender. The muscles of the whole limb are flabby and wasted. The general health is 
much disordered ; the man has lost thirty pounds of flesh, and he has been unable to 
attend to any business since the accident. His tongue is habitually coated, he sleeps 
badly at night, and he is subject to frequent fits of despondency. 
A man, thirty-five years of age, consulted me on account of an accident similar to the 
above. He was a bricklayer by occupation, and had always been in good health until 
eight months previously, when he cut himself with a hatchet in the left instep, immedi- 
ately over the internal cuneiform bone, as nearly as possible in the same situation as in 
the preceding case. The wound healed rapidly, but the patient soon began to experience 
exquisite pain and tenderness in the parts, extending up the leg, and subject to severe 
exacerbations from damp states of the atmosphere, exposure to cold, and derangement of 
the digestive organs. The suffering, which was irregular in its recurrence, was generally 
worse at night. The limb was cold and clammy, as well as much emaciated, and the 
parts immediately around the scar were hard, as if from the presence of organized lymph. 
The general health was much impaired, the tongue was coated, and the sleep was usually 
much interrupted, by spasm of the limb. A prominent symptom in the case was great 
soreness in the hollow of the foot, in front of the heel. When the man attempted to walk, 
the foot became very tender, and immediately began to swell. In this, as in the preced- 
ing case, the patient was obliged to use crutches. 
A young lady, who had long suffered from dyspepsia and great nervousness, punctured 
the forepart of her right wrist, towards the ulnar margin of the forearm, with a small, 
slender sewing-needle, which entered the skin directly over the ulnar artery ; and passed, 
apparently, obliquely inwards and outwards towards the centre of the joint, without, howr- 
ever, penetrating it. The needle was immediately withdrawn, but not examined, and 
the patient, consequently, was uncertain whether a portion had not broken off and re- 
mained behind. The accident was followed by most excruciating pain, pervading the 
entire extremity from one end to the other, but particularly severe at the seat of the injury 
and in the thumb and first two fingers. A violent rigor soon succeeded, and for ten days 
the patient suffered the most horrible torture, being frequently threatened with tetanus, 
and constantly annoyed with spasmodic twitches of the muscles of the hand and arm. 
Considerable swelling arose shortly after the receipt of the injury in the forearm, wrist, 
hand, thumb, and the fingers above named. At the end of the tenth day a small, circum- 
scribed abscess formed at the site of the puncture, which, upon being opened, discharged 
about a drachm and a half of thick pus, much to the relief of the patient. In a -week the 
matter had reaccumulated, and the part was again lanced, followed by the same relief as 
before. Subsequently the skin was scarified several times, the cuts bleeding profusely, but 
not yielding any pus. During the following summer she experienced severe and constant 
pain, especially in the anterior part of the arm, between the elbowr and the insertion of 
the deltoid muscle ; it was always more violent in the evening, and was of a dead, heavy, 
aching character. The limb was stiff’ and numb. Her hand and thumb, together with 
the fore and middle fingers, swelled every evening, becoming stiff and sore, so that she 
could with difficulty flex or extend them. During the day the parts always felt much 
more comfortable. Pressure at the seat of the puncture caused a sense of uneasiness 
rather than of pain, but was always followed soon after by so much distress as to prevent 
sleep during the succeeding night. The ring and little fingers were free from swelling, 
and easily moved. The whole limb was cold and considerably wasted. The probability 
is that, in this case, the needle pricked the ulnar nerve at the wrist, producing a condi- 
tion, in her bad state of health, similar to that which occasionally results from the punc- 
ture of a nerve in bleeding at the arm. Under the use of an alterative and tonic course 
of treatment, with strychnia and arsenious acid, the hot and cold douches, frictions 
with vei’atria ointment, a nutritious diet, and exercise in the open air, the general CHAP. X. 
WOUNDS BY POISONOUS INSECTS. 
387 
health rapidly improved, and the local slithering finally disappeared, although the limb 
never recovered its original powers. 
Bad effects not unirequently follow upon gunshot wounds; they present themselves in 
different forms and degrees, and often entail great suffering along with partial loss of 
function. Among the more common and annoying of these secondary effects are, as 
before stated, neuralgic pains and a sense of numbness in the parts, progressive atrophy 
of the muscles, contraction of the aponeuroses and tendons, and ankylosis of the joints. 
In regard to the treatment of these secondary lesions, it is impossible to lay down any 
definite plan; every case must be managed according to the peculiarities of its symptoms. 
Much benefit may generally be expected from attention to the state of the general health, 
which is nearly always more or less seriously disordered. Neuralgic pains, altered sensi- 
bility, and atrophy usually require a course of tonics and arsenic, purgatives, the hot and 
cold douches, massage, or dry frictions, the use of the fringed towel, electricity, and other 
means to excite the vasomotor nerves. Rigidity of the joints must be counteracted by 
passive motion and sorbefaeients; contraction of the tendons and aponeuroses by the use 
of splints and the bandage, aided, if necessary, by the knife. Change of air and sea 
bathing are often of signal benefit. 
SECT. X POISONED WOUNDS. 
Under this head are included four distinct classes of wounds: first, those inflicted by 
venomous insects and snakes ; secondly, those caused by the bite of rabid animals ; thirdly, 
those produced by inoculation with the poison of glanders ; and, lastly, wounds received 
in the examination of dead bodies, constituting what are called dissection wounds. 
1. WOUNDS INFLICTED BY POISONOUS INSECTS. 
There are various genera of insects which naturally secrete a poison, which, when in- 
stilled into the living tissues, is capable of producing serious and even fatal consequences. 
Of these the most common, at least in this country, are the humble-bee, honey-bee, wasp, 
hornet, and yellow-jacket. The poison of these insects is contained in a small vesicle in 
the abdomen, and is under the control of a peculiar muscular apparatus by which it is 
injected into the puncture made by the barbed sting of these little creatures. It is highly 
acrid, especially in the honey-bee, hornet, and yellow-jacket, transparent, of a sweetish 
taste at first, but afterwards hot and disagreeable, and particularly active during the heat 
of summer. When angry, these insects sting with great fury, producing a wound which 
is instantly followed by a sharp, pungent, itching pain, and in a few moments after by a 
pale, circumscribed, inflammatory swelling. In some persons, owing to idiosyncrasy and 
other causes, the symptoms are exceedingly severe and even alarming, the patient having 
dimness of sight, vertigo, nausea, palpitation, and a feeling of indescribable oppression, 
with a disposition to syncope. Instances have occurred of persons having been stung to 
death by a single honey-bee; one such case, of which I have the particulars, occurred, 
many years ago, in Kentucky, in a man upwards of thirty years of age. He was wounded 
in the face, and died in a few hours. A young man, an acquaintance of mine, always 
suffers from severe sickness of the stomach and great nervous depression when stung by a 
bee. Violent effects sometimes proceed from the sting of a bee, wasp, or yellow-jacket 
in the fauces, oesophagus, or stomach, as when these insects are accidentally swallowed in 
cider and other drinks. 
As the sting is often left in the skin, in the infliction of this class of wounds, the 
part should be carefully examined, in order that, if present, it may at once be extracted. 
The most promptly efficacious applications are generally salt water, alcohol, laudanum, 
vinegar, hartshorn, spirit of camphor, Cologne water, soap liniment, solutions of acetate 
of lead, dilute tincture of iodine, and tobacco-juice. Turpentine is also a very valuable 
remedy. Whether these and similar articles act by neutralizing the poison, or merely by 
relieving inflammation, is not ascertained. When the system becomes affected, internal 
stimulants, of which the best are brandy and ammonia, should immediately be used. 
If the insect has passed into the throat, a mustard and salt emetic will be the proper 
remedy, followed, if urgent swelling and impending suffocation ensue, by leeches to the 
neck, and, perhaps, by laryngotomy. 
Various species of the mosquito tribes are poisonous, and, therefore, capable of inocu- 
lating the wounds made by their bite. In the Southern States, as well, indeed, as in 
some of the Western, and along many parts of the Atlantic coast, the mosquito exists in 388 
WOUNDS AND CONTUSIONS. 
chap. x. 
vast numbers, and often inflicts serious injury, both upon man and animals. I have met 
with a number of instances in which the bite of this insect was productive of severe in- 
flammation, and several in which it was followed by considerable ulceration. The late 
Professor Dorsey, of this city, observed a case of gangrene and death from a wound of 
this kind in a lady, previously in good health. So serious an effect as this is probably 
always dependent upon some idiosyncrasy, or upon the occurrence of erysipelas, conse- 
quent upon the bite. The stinging sensation and swelling which attend the application of 
the poison of the mosquito usually soon subside of their own accord, or under the use of 
some mild stimulant, as Cologne water, alcohol, vinegar, or laudanum. When the effect 
is more serious, tincture of iodine and warm water-dressing may be necessary. 
The poison of the scorpion has many of the properties of that of the bee and wasp, 
although it is much more active. It is of a whitish color and oleaginous consistence, and 
is contained in a small reservoir near the end of the tail, whence it is ejected through two 
little pores on each side of the sting. In North America and Europe the wound inflicted 
by the insect is comparatively harmless, the only effect generally being a slight, transient 
inflammation ; but in Africa and Asia it is often followed by great suffering and even loss 
of life, death sometimes occurring in a few hours. In those countries the scorpion fre- 
quently attains an enormous size, having a huge body, and a length of six to ten inches. 
Several species of this insect, of large size, are found in Cuba, Texas, Mexico, and South 
America, but I am not aware that their sting is particularly venomous. The great 
Eastern remedy in this variety of wound is olive oil, and an idea prevails that its virtues 
are greatly enhanced by infusing in it the bodies of some of these animals previous to its 
application. Spirit of hartshorn would doubtless be a more valuable addition. Such a 
wound should always be immediately well washed with salt water, then scarified, next 
thoroughly rubbed with volatile liniment, and then covered with an emollient poultice. 
If constitutional symptoms arise, they must be combated with anodynes, brandy, and 
ammonia, the treatment being very similar to that adopted for the sting of the bee and wasp. 
Bad effects sometimes supervene upon the bite of the spider ; and the fabulous stories 
about the poisonous qualities of the tarantula are known to every reader of history. The 
most prominent of these effects is a sense of itching at the wound soon followed by vio- 
lent pain, difficulty of breathing, frequency and weakness of the pulse, nausea, copious 
perspiration, and general prostration. The symptoms of the bite of the tarantula are 
very similar to those produced by the sting of the common scorpion. The chief remedies 
in both cases are alcoholic and ammoniated stimulants, with opium, to relieve pain and to 
assist in sustaining the heart’s action. 
The bite of the centiped, which, in some countries, as the East and West Indies, Africa, 
South America, and the Southern regions of the United States, often attains a length of 
five to seven inches, is occasionally followed by severe symptoms, and even death, as in a 
case related by Dr. Linceicum, in the American Journal of the Medical Sciences for 
October, 1866. The poison bag, lodged near the base of the jaw of the insect, is of an 
oblong shape, and has a long, narrow, excretory canal, with a small opening at the ex- 
tremity of the hooklet. The bite is exceedingly painful, and is frequently followed by 
considerable swelling and discoloration, along with more or less fever and even delirium. 
In the case observed by Dr. Linceicum, the patient survived the bite only about six hours. 
The prominent symptoms were, great general uneasiness, coming on immediately after the 
injury, excessive nausea, and frequent vomiting, which gradually increased in violence 
until the child, in a convulsive struggle, ceased to breathe. The whole surface was 
dappled with livid spots, from the size of a five-cent piece up to that of a dollar, and 
there was an elastic pufliness, giving the whole person a singularly tumid appearance. 
The treatment of such a wound must obviously be conducted upon the same general prin- 
ciples as the sting of the bee and other insects, the most reliable antidotes being ammo- 
nia and alcohol, along with anodynes. The immediate application of a cupping glass 
materially lessens the danger by preventing the ingress of the venom. 
2. WOUNDS INFLICTED BY VENOMOUS SERPENTS. 
The number of poisonous serpents in different parts of the world is very considerable; 
but in this country there are, so far as is at present known, only three genera that are at 
all dangerous on account of their bite. These are the crotalus, trigonocephalus, and 
elaps. Of the crotalus, or rattlesnake, so called from the peculiar appendage to its tail, 
Professor Holbrook, in his Herpetology of North America, has described not less than 
six species, of which the banded, striped, and miliary are the most common ; all are CHAP. X. 
WOUNDS BY VENOMOUS SERPENTS. 
389 
venomous, and, consequently, capable of inflicting deadly wounds. These reptiles for- 
merly abounded in almost every section of the United States, especially in the swampy 
and mountainous regions, but are now very seldom met with in our denser settlements. 
All the different species of rattlesnakes are provided with two small sacs, each of which 
contains a minute quantity of poison, and communicates, by means of a short excretory 
duct, with the canal in the fang on each side of the upper jaw. It is inclosed in a bony 
framework, situated external to the proper jaw, and is under the control of appropriate 
muscles, the action of which aids materially in expelling its contents. The fangs, situated 
just at the verge of the mouth, are very long, sharp, and crooked, like the claws of a cat, 
and are naturally retracted and concealed in a fold of integument; but, when the animal 
is irritated, are capable of being instantly raised, and darted forward with great force into 
the skin, followed by an emission of poison. The snake, then, does not bite, but strikes, 
making a punctured wound. 
The annexed illustrations represent the head of the rattlesnake, and one of the poison 
fangs, with the canal along which the venom flows when the animal is in the act of 
inflicting its wound. 
Fig. 117 
Fig. 118. 
Fig. 117. Head of the Rattlesnake, a, a. Poison Gland, and its Excretory Duct; the latter cut open at its extrem- 
ity. e. Anterior Temporal Muscle. /. Posterior Temporal Muscle, g. Digastric, h. External Pterygoid, i. Middle 
Temporal, q. Articulo-Maxillary Ligament, which joins the Aponeurotic Capsule of the Poison Gland, r. The 
Cervical Angular Muscle, t. Vertebro-Mandibular Muscle, u. Costo-Mandibular Muscle. 
Fig. 118. Poison Fang, magnified. p,p. The Pulp Cavity of the Tooth, v, v. The Canal along which the Venom 
flows, truly on the outside of the Tooth. 
The poison of the rattlesnake is a thin, semitransparent, albuminous fluid, of a yellow- 
ish color, with, occasionally, a tinge of green. According to Dr. S. Weir Mitchell, of 
this city, who has carefully studied its qualities, it is of a glutinous consistence, devoid of 
smell and taste, distinctly acid, of the specific gravity of 1044, and coagulable at a tem- 
perature of 143° to 160°. Its toxic activity is not materially, if at all, impaired by 
boiling and freezing, and alcohol, acids, alkalies, iodine, and chlorides do not destroy its 
virulence. When dried, it retains its noxious properties for an indefinite period. In an 
experiment performed by Dr. A. G. Taylor, two grains of the powder, which had been kept 
for twelve years, mixed with water, and injected under the skin of a rabbit, caused death 
in forty-five minutes. It contains, besides coloring matter, and an undetermined sub- 
stance, both soluble in alcohol, a trace of fatty matter, chlorides and phosphates, and two 
albuminoid principles, one coagulable at 212°, the other, termed crotoline, not coagulable 
at this temperature, neutral in its action, freely soluble in water, and of a nitrogenous 
nature. 
The quantity of venom contained in the poison-bag does not generally exceed a few 
drops; but it accumulates when the animal is inactive, and Dr. Mitchell had a snake 
which, on one occasion, ejected fifteen drops, its fang not having been used for several 
weeks. It is peculiarly acrid and deadly in hot weather and during the procreating sea- 
son. In winter and early spring the reptile is in a torpid condition, and the poison is 
then diminished in quantity, and unusually thick, although not less virulent. 
The effects of the wound of the rattlesnake vary with many circumstances, as the situa- 
tion of the part, the acrid character of the poison, and the age of the patient. Experience 
has shown, as in the case of the bite of rabid animals, that most of those hurt in this way WOUNDS AND CONTUSIONS. 
chap. x. 
escape either entirely or suffer only in a very slight degree ; the poison either failing to 
reach the tissues, or being too inert to make any decided impression upon the system. It 
is also known that adults are less liable to suffer than children, simply because they pos- 
sess, as may be supposed, greater vigor of constitution, and, consequently, greater power 
of withstanding the influence of the venom. The deleterious effects of the poison seem 
to be much weakened, if not actually exhausted, by a rapid succession of bites. The 
experiments of Captain Hall, of Carolina, and of Professor B. S. Barton, of this city, 
place this matter in a very clear light. Of three dogs bitten in succession by a rattle- 
snake four feet long, the former gentleman found that the first died in less than a quarter 
of a minute, the second in two hours, and the third in three hours. The subjects of Bar- 
ton’s experiments were chickens, and the results were almost identical with those of Hall. 
Of three fowls, bitten on three consecutive days, the first perished in a few hours, the 
second lived for some time, and the third finally recovered, although not without consid- 
erable suffering. Instances are occasionally met with in the human subject of almost 
instant destruction from the bite of the rattlesnake, as in a remarkable case which occurred 
at Baltimore, in which a man, bitten at two places on the cheek, died in twenty-eight 
minutes. In a case related by Dr. Shapleigh, of this city, death occurred in three-quar- 
ters of an hour, the man being struck on the forefinger, directly over the second joint. At 
other times the case proceeds more slowly, the patient surviving several hours, or, perhaps, 
even several weeks. Dr. Wainwright, of New York, lost his life in less than six hours 
from the time he was wounded. The reptile, an uncommonly large one, had lain in a 
torpid state for some time, when, unexpectedly becoming warmed, he struck his victim 
furiously on the last phalanx of the middle finger of the left hand. Although the wound 
was immediately sucked, and soon afterwards excised and cauterized, a ligature being also 
tied firmly round the wrist, the hand soon became enormously swollen, the tumefaction 
speedily extending up the limb nearly as far as the axilla, and the surface, in the greater 
part of its extent, exhibiting a mottled bluish and greenish-yellow hue. The pulse was 
very small and frequent, unconsciousness rapidly supervened, and the patient expired in a 
completely comatose state, preceded by nausea and excessive restlessness. Finally, in 
another series of cases, the patient, after having been near death’s door for several weeks, 
eventually perishes or recovers. When death occurs almost instantaneously, the prob- 
ability is that the poison is injected directly into the blood, the fang having penetrated 
some tolerably large vessel. Under such circumstances, the fluid is found to be thin, 
black, and uncoagulable on exposure to the atmosphere. 
When this poison is freely instilled into a wound, the symptoms will always be propor- 
tionately severe. The moment the inoculation has taken place, excessive pain is expe- 
rienced in the part, rapidly followed by swelling, which soon diffuses itself extensively over 
the surrounding surface, and is attended with a livid, mottled appearance, dependent upon 
extravasation of blood into the subcutaneous connective tissue. If the wound, for instance, 
occupies a finger, the tumefaction speedily extends up the limb, as far as the shoulder, 
and, perhaps, over a large portion of the corresponding side of the trunk, a feeling of 
numbness, weight, and coldness attending the other symptoms. 
Within a few minutes after the first manifestation of the local affection, marked evi- 
dence appears of the absorption of the poison into the system. The patient looks exces- 
sively pale, sees objects indistinctly, is sick at the stomach, perhaps ejecting its contents, 
and has frequent swooning fits, with clammy sweats, and coldness of the body. By and 
by, as the system becomes more fully impressed with the deleterious effects, insatiable 
thirst arises ; a sense of constriction is experienced in the chest; the breathing is oppressed; 
the pulse is feeble and vacillating; great anxiety and restlessness exist; the tendons 
twitch; the mind wanders, or is furiously delirious ; and death soon closes the scene. In 
the worst cases of the affection, a universal yellowness of the skin is observed, and the 
parts are not only frightfully swollen, but, if the patient survive some hours, large vesicles 
appear upon the surface, containing bloody serum, and indicating the approach of mortifi- 
cation. When death does not take place for a considerable number of days, large abscesses 
form in the connective tissue under the skin and among the muscles, and the system 
gradually sinks under the resulting irritation. 
The appearances presented in the bodies of those who die from the effects of this poison 
are pretty uniform. In the birds, rabbits, guinea-pigs, and dogs experimented upon by 
Dr. Mitchell, extravasation of blood and softening of the tissues in the neighborhood of 
the bite were almost invariably observed ; the brain and spinal cord were more or less 
injected; the heart was distended and flabby; the lungs were sometimes engorged; and 
the intestines were occasionally ecchymosed. In several instances the kidneys were chap. x. 
WOUNDS BY VENOMOUS SERPENTS. 
acutely congested and filled with blood. The ureters and bladder contained sanguineous 
urine. The blood in the heart and vessels was dissolved, and of a dark color. 
The genus trigonocephalus includes several species, of which the water moccasin, or 
cotton-mouth, and the copperhead, are the most important. They have no rattles, but 
the upper jaw is armed with poisonous fangs, and their bite is very deadly. The cotton- 
mouth snake is met with extensively in the Southern States, its northern limit being the 
Pedee River in North Carolina. Professor Holbrook states that it is the terror of the 
negroes about the rice plantations, being more dreaded by them than the rattlesnake, 
which attacks only when irritated, whereas the water moccasin makes war on everything 
that comes within its reach. 
Of the genus elaps, the only species known in this country is the elaps fulvius, whose 
body, twenty inches in length, is of a beautiful red color, surrounded with black rings, 
margined with yellow. Its upper jaw is armed on each side with a permanently erect 
poisonous fang. It is found chiefly in the Southern States, in sweet potato fields, and is 
so gentle in its habits as to be regarded as almost harmless. 
The most noxious serpent in the East Indies is the cobra di capello, the spectacled or 
hooded snake, of which there are a number of varieties, all distinguished for their veno- 
mous properties. The effects of its bite are very similar to those of the rattlesnake, only 
that they are generally somewhat more tardy, and accompanied by less swelling. The 
poison is of a semitransparent, yellowish appearance, not unlike olive oil. It has been 
known to kill a large dog in less than twenty minutes; and in the case of the keeper at 
the Zoological Gardens in London, who was bitten by a cobra on the root of the nose, 
death occurred in ninety-five minutes. The internal viscera were found, on dissection, 
to be intensely congested, and the blood, which was dark, alkaline, and fluid, emitted a 
peculiarly acid and sickening smell. In an instance observed by Sir George Ballingall, 
a girl, a native of India, expired in a quarter of an hour after she had been bitten by a 
serpent of this kind, notwithstanding the excision of the injured part, and the exhibition 
of large quantities of ammonia. Experiments performed by Sir Joseph Fayer, formerly 
of Calcutta, show that the poison of the cobra may exert its virulent effects by absorption 
through contact with the mucous and serous membranes. The poison of the pliursa—the 
echis carinati of naturalists and the most common of all the East India serpents—is com- 
paratively slow in its action, and only about 20 per cent, of the cases prove fatal. 
In Europe, the viper is the most venomous serpent known. It is rare in England, but 
sufficiently common in France, Spain, and Italy, as well as in several of the more northern 
States of the Old World. The poison, which has a yellowish, oily appearance, may be 
swallowed almost with impunity, provided there is no abrasion upon the mouth. It is 
most active in hot weather, killing small birds and animals almost instantly. Applied to 
the human subject, it causes acute pain and diffused swelling, followed by a puffy, 
cedematous state of the subcutaneous connective tissue, and a livid and vesicated condition 
of the skin. The general symptoms, which seldom manifest themselves under three- 
quarters of an hour to an hour, bear so close a resemblance to those produced by the 
wound of the rattlesnake as to render it unnecessary to describe them. 
A great deal has been written concerning the treatment of wounds inflicted by veno- 
mous serpents, and yet there is not a solitary reliable remedy. The fact that so many 
articles have been recommended as specifics clearly shows that these lesions are often so 
slight as not to require any treatment at all, the unpleasant effects generally passing off 
spontaneously in a few hours, either because the poison has not been introduced in suffi- 
cient quantity, or because it has been too inoxious to produce any serious harm. The first 
thing to be done, so far as the part is concerned, is to constrict the limb as tightly as 
possible, a short distance above the wound, which is then to be instantly excised and 
cupped, the glass being retained as long as the blood is disposed to flow, when the surface 
should be well washed with dilute tincture of iodine, the same remedy being thoroughly 
applied to the skin over the whole extent of the swelling. Subsequently, warm water- 
dressing, medicated with laudanum and acetate of lead, will form the most suitable 
application. Thorough constriction of the limb with Esmarch’s bandage, or, in the 
absence of this, with a tightly drawn roller, might be of service in retarding the entrance 
of the poison into the system, and affording time for the operation of medicines administered 
internally. 
The practice of sucking the wound is of great antiquity, and there have been men, from 
time to time, in different parts of the world, who have made it their special occupation. 
The Psylli, of Africa, and the Marsi, of Italy, acquired great celebrity for their skill in 
this business, and the custom still prevails among many of the Indian tribes of this 392 
WOUNDS AND CONTUSIONS. 
chap, x. 
continent. The operation, however, cannot be performed with safety if there is any 
abrasion upon the lips or in the mouth, and should, therefore, always give way to the 
cupping glass. 
Pain must be relieved, and the strength supported by morphia and alcohol, the latter 
being given, in any of its more common forms, to the utmost possible extent compatible 
with the patient’s power of endurance. Whiskey is the great remedy, although it is not 
a specific, among the mountaineers of this country for this class of wounds, and there can 
be no question that it is entitled to great consideration. The treatment should be rapidly 
pushed to gentle inebriation, as men bitten when dead drunk have been known to die, 
although such an occurrence is seldom to be looked for when there is such marked depres- 
sion of the general system as so often attends this lesion. Ammonia may occasionally 
be advantageously combined with the alcohol on account of its diffusible stimulating 
properties. When there is excessive prostration, along with great gastric irritability, 
enemata of brandy and laudanum should be employed. Olive oil has been highly recom- 
mended as an antidote against snake-bite ; but experience has shown that it possesses no 
such virtues. In the East Indies, the Tanjore pill formerly enjoyed great celebrity in 
the treatment of wounds inoculated with the poison of the cobra di capello and other 
noxious serpents, its efficacy being supposed to depend upon the arsenic which enters into 
its composition. Fowler’s solution has also been much lauded for its supposed neutralizing 
qualities, especially of the poison of the fer-de-lance, a venomous serpent in the Island of 
St. Lucia: it is administered every three hours in doses of two drachms along with a 
small quantity of laudanum, until active vomiting and purging are induced. But none of 
these remedies are reliable, and my opinion is that no time should be wasted upon their 
exhibition. 
In the first edition of this work attention was directed to the use of Bibron’s antidote, 
as it has been called—a mixture of bromine, iodide of potassium, and bichloride of mercury 
—as a means of neutralizing the effects of the poison of the rattlesnake; but it has been 
ascertained by Dr. Mitchell that it possesses no such properties ; nor are arsenic and 
ammonia, or, indeed, any other articles of the materia medica, so far as we know, 
endowed with such virtues. In regard to topical remedies, he found, experimentally, that 
iodine, injected subcutaneously, as originally suggested by Brainard, of Chicago, exerted 
a great influence over the local effects of the venom, but none in preserving life or 
defending the system at large. Some simple astringents also possess this power, and are 
equally as useful as iodine. Carbolic acid, injected into the envenomed tissues, sometimes 
delays the fatal result, and usually lessens the local hemorrhage. Among the internal 
stimulants, he assigns, in common with all American practitioners, the highest rank to 
alcohol, looking upon it, not as a chemical antidote, or neutralizer of the venom, but as a 
great supporter of the vital forces. When the patient is too weak or too sick to sivallow, 
it may be administered in the form of an enema; and in that event, the inhalation of hot 
alcohol, or even of ether, will be of service as a means of reexciting the flagging energies 
of the system. In a severe case of rattlesnake poisoning, recently under the care of Dr. 
Moorman and Dr. Fuqua, large quantities of iodide of potassium conjoined with alcoholic 
stimulation seem to have been attended with marked benefit, the patient making a good 
recovery, although the limb was enormously swollen, and the system greatly exhausted. 
When the immediate effects of the poison have passed off, quinine and a nutritious diet 
will be necessary, along with spirituous stimulants, to aid restoration. Dr. Mitchell has 
ascertained, by direct experiment, that carbolic acid and the sulphites of sodium and lime 
possess no antidotal power. 
Finally, it may be observed, in regard to the so-called antidotes for snake-bite, that the 
remedies which have, from time to time, been invested with this virtue, doubtless owed 
their temporary reputation to the fact that the cases in which they were used were cases 
of a comparatively slight character, which would probably have recovered as well, or 
nearly as well, without as with their use. The history of surgery certainly warrants this 
conclusion. 
3. WOUNDS INFLICTED BY KABID AMIMALS. 
There is a peculiar disease in man and animals known by the name of hydrophobia, its 
characteristic symptoms, at least in the human subject, being a dread of water, as the term 
by which it is generally designated literally signifies. It is due to the influence of a 
particular poison, generated by certain animals, and capable of propagating the disease 
by inoculation. Of the nature of this poison all that is known is that it is contained in 
the saliva, and that, after having remained latent for some time in the wounded part, it CHAP. X. 
WOUNDS INFLICTED BY RABID ANIMALS. 
393 
is absorbed and carried into the system, where it produces the peculiar effects by which 
the malady is distinguished. 
That the virus of hydrophobia resides in the saliva, and not in the secretion of the 
mucous follicles of the mouth and fauces, has been fully established by experiments upon 
the inferior animals. Thus, Zine inoculated a dog, cat, hare, and cock, with the saliva 
of a rabid dog, and readily induced the disease. Similar results followed the investiga- 
tions of Depuy, Youatt, and other veterinary surgeons. The former of these writers rubbed 
a sponge wet with the saliva of a mad dog upon the sore of a sheep, which subsequently 
perished from hydrophobia; and the latter communicated the affection from one brute 
to another by means simply of a silk thread, impregnated with this fluid and used as a 
seton. If further proof of this fact were needed, it could be found in the experiments of 
Raymond, who repeatedly induced the disease in healthy rabbits by inoculating them 
with the salivary glands of rabid ones. Magendie and Breschet developed hydropho- 
bia in dogs by inserting frothy fluid taken from the mouths of human beings affected with 
rabies. Dr. Gaultier, of Lyons, finds that the saliva of a rabid dog is perfectly harmless 
if injected into a vein, and that its contact with the nerves is indispensably necessary to 
produce the disease. 
It is supposed by many pathologists, as Bouley, Fleming, Lindsay, and Bruecken- 
mueller, that certain animals, as the dog, wolf, fox, jackall, and badger, if not also the 
cat, tiger, and lion, have the faculty of generating the virus of hydrophobia spontaneously ; 
while others, as Magendie, Dupuytren, Breschet, Bollinger, and Virchow, positively 
assert that rabies can only originate from inoculation with the peculiar virus of this disease. 
The latter doctrine is certainly the more plausible of the two, as it is much more in ac- 
cordance with our knowledge of the habits of other poisons. I cannot, indeed, see how 
the affection could be induced in any other manner. It is extremely probable that all the 
higher classes of animals are capable of contracting hydrophobia by inoculation. Breschet 
repeatedly induced it in dogs by inserting the saliva of rabid horses and asses; and cases 
have been reported of human beings having suffered from the bite of rabid horses and 
pigs. It is uncertain whether hydrophobia can be communicated from one person to 
another. In the case of Wheeler, a dresser at Guy’s Hospital, London, who was bitten 
by a rabid patient, no ill effects followed, and I know of no well-authenticated instance of 
the disease having been produced in this wise. Rabbits and similar animals, as well as 
fowls, soon die from inoculation with this poison, without exhibiting any of the ordinary 
symptoms of hydrophobia. 
The inoculation in hydrophobia is usually effected by the teeth, which, however, need 
not necessarily penetrate the true skin, as the disease may readily be communicated by 
the slightest scratch or abrasion. An instance has been reported in which death was pro- 
duced by the licking of a wart upon the face, by a poodle supposed to be laboring under 
rabies. It has been conjectured that the disease may be communicated merely by the 
contact of the saliva of a hydrophobic animal with sound skin and mucous membrane. It 
is also believed to be possible that a mother may transmit the affection to her infant 
through her own milk. Cases now and then occur which lead to the suspicion that the 
disease may be induced by dogs and other animals not actually mad, but simply enraged, 
or in which the disease is simply in its incubative state. Finally, experiments have been 
performed which prove that the morbid saliva may be administered internally with entire 
impunity. 
It is notorious that many of the persons bitten by rabid animals do not contract hydro- 
phobia, the saliva containing the specific virus being no doubt wiped off as the teeth 
penetrate the clothes. Hunter and Hamilton supposed that out of twenty or thirty per- 
sons bitten only one would take the disease, an estimate altogether too low. The wounds 
inflicted by rabid wolves are much more dangerous than those of rabid dogs, the differ- 
ences being due to the fact either that the virus of the former animals is more virulent 
than that of the latter, or else that wolves generally attack the exposed parts of the body, 
as the face, neck, and hands, whereas dogs more generally infix their teeth into those 
that are covered. Of 254 persons bitten by rabid wolves, 164, according to Renault, died 
of hydrophobia. For a similar reason the bite of a cat is always peculiarly dangerous. 
The period of latency of this disease varies from a few weeks to several months. In 
89 cases, analyzed by Dr. Blatchford and Dr. Spoor, of Troy, the average period was about 
seventy days, the minimum in 23 cases was thirty days and under, and the maximum in 
6 cases was upwards of two hundred days. According to Bollinger sixty per cent, of all 
cases occur between eighteen and sixty-four days. In the only three cases of hydropho- 
bia that I have ever seen, the disease appeared, in two, at the end of four weeks, and in 394 
WOUNDS AND CONTUSIONS. 
chap, x. 
the other nine months from the date of the inoculation. In an instance under the care of 
Dr. Demme, of this city, the patient, a man, aged twenty-six, had been bitten eighteen 
months previously. Dr. J. W. Lodge has reported to me the particulars of a case of 
hydrophobia in a child three years old, in which the period of latency was precisely seven 
weeks. According to John Hunter, the extremes range from thirty days to eighteen 
months. Wenderburg has related an example in which the poison remained quiescent for 
four years; Breva, one of five years; and Bardsley, one of twelve years; each, apparently, 
well authenticated, and yet wholly unreliable. An undoubted case of hydrophobia, in 
which the poison remained in a latent condition for nearly three years and a half, occurred 
in this city last winter, in a young man, twenty-two years of age. Death took place in 
less than three days from the commencement of the attack. The time of incubation is 
generally considerably shorter in animals than in man, and in very young persons than 
in adults. 
Although a considerable period always elapses between the inoculation and the appear- 
ance of hydrophobic symptoms, it is extremely probable that the virus is speedily absorbed 
into the system, although some time is necessary to develop its zymotic properties. What 
countenances this view is that nearly all the other known poisons, when brought in con- 
tact with the living tissues, are promptly absorbed, so as to make, sooner or later, their 
peculiar impression upon the constitution. The poison of syphilis is absorbed very speedily, 
and the probability is that the same is true with respect to the virus of smallpox, measles, 
scarlatina, and other zymotic affection. A certain period, however, is necessary, in every 
case, to enable the poison to explode upon the general system, or, in other words, to in- 
crease its virulence and extend its influence. With regard to the virus of rabies, it is a 
well-known fact that the disease is often developed within the usual period, after the most 
prompt and thorough excision of the bitten parts. 
When the virus lies in a dormant state for an unusually long period, it is no doubt 
locked up, as it were, in the cicatrical tissues of the wound in such a manner as to be 
unable to extricate itself until, by some organic changes, of the precise nature of which 
Ave are ignorant, they are so softened and disintegrated as to bring it under the control of 
the absorbent vessels, through the agency of which it finally gains admission into the system. 
Many persons are bitten by rabid animals and yet never contract the disease, the virus 
having either been exhausted before the rencontre takes place, or, what is more probable, 
having been wiped off by the clothes in the act of inflicting the wound. In this way 
more than half of those bitten occasionally escape with impunity; on the other hand, it 
sometimes happens that nearly every one is effectually inoculated. It is not impossible 
that idiosyncrasy may exert an important influence in the production of the disease. It is 
well known that this is true of other zymotic poisons, and it is, therefore, reasonable to 
suppose that it may also hold good of this. Of fifty dogs inoculated by Dr. Herwitch, 
of Berlin, with saliva taken from a rabid animal of the same species, not one in five Avas 
affected. 
Hydrophobia is not peculiar to any age. It has been observed in infants at the breast, 
in children, and at every period of adult life. It occurs in all countries, in all climates, 
and at all seasons of the year. France, Italy, Austria, Russia, and Germany, however, 
have furnished a greater number of cases than any other parts of the world. It is also 
frequently met with in England; and, as a general rule, it is more common in northern 
than in southern regions. Throughout the West Indies it is comparatively rare, although 
the number of dogs there is unusually great as compared with the number of inhabitants. 
Hydrophobia is more common in Canada and New England than in the Southern States 
of the Union. Of 2520 cases observed on the continent of Europe, in Great Britain, and 
in the United States, and referred to by Dr. Charles P. Russell, in Johnson’s UnUersal 
Cyclopaedia, 1704 occurred in the spring, 621 in the summer, 608 in the autumn, and 
587 in the Avinter, thus showing that the influence of season is comparatively slight. 
The symptoms of rabies necessarily divide themselves into local and constitutional; or 
those furnished by the Avounded part, and those afforded by the system, after the absorp- 
tion of the specific virus. 
The Avound inflicted by a rabid animal generally heals as kindly as any similar wound 
made by a sound animal; the scar, perhaps, remaining a little red and tender, as it usually 
does after an ordinary bite, but exhibiting no other peculiarity, and the system being 
perfectly free from disease. By and by, however, Avlien the period of incubation is 
about to draw to a close, the part begins to itch, burn, or smart, and soon becomes sore 
and irritable, hot, numb, or rigid, pain darting through it in different directions, and 
sometimes extending to a considerable distance beyond the site of injury, as from the CHAP. X . 
WOUNDS INFLICTED BY RABID ANIMALS. 
hand up to the shoulder, or from the foot to the knee or groin. Sometimes the wound 
reopens, the cicatrice gives way, or red lines are traceable in the direction of the lym- 
phatics. Almost simultaneously with the local affection, evidence of general indisposition 
appears. The patient feels unwell; his head aches ; his sleep is disturbed by unpleasant 
dreams; he feels melancholy and depressed ; and he has occasional attacks of chilliness, 
with a highly impressible state of the system. The poison is now fairly at work, and in 
a few hours—generally from twelve to twenty-four—explodes with frightful violence. 
The period of latency is passed; the disease has reached its second stage; the dread of 
water and the difficulty of deglutition have declared themselves; in a word, hydrophobia 
is fully established. The patient, on attempting to drink, is suddenly seized with spasm 
in the throat, and finds that he is unable to swallow a particle of fiuid ; he tries and tries, 
but every effort is only succeeded by a renewal of suffering, and presently he dashes away 
the cup as if it were charged with some deadly poison, unwilling again to bring it to his 
lips. Tortured with thirst and a sense of dryness of the mouth, he will endure his dis- 
comfort rather than subject himself to the dreaded spasm. Should he succeed in forcing 
down a little water, he will be instantly seized with suffocative cough, convulsive tremors, 
and lividity of the face, compelling him to jump up in bed, and to pant for breath. The 
painful sensations are usually referred to the throat, and are often accompanied by a feel- 
ing of constriction in the chest, difficulty of respiration, a disposition to sigh, and a fre- 
quent desire to clear the mouth and fauces, which soon become clogged with an inordi- 
nate secretion of thick, viscid saliva and mucus, which greatly aggravate the patient’s 
suffering. At this stage of the disease, and, generally, indeed, before it has reached this 
point, there is superadded to the previous distress a remarkable susceptibility to atmo- 
spheric impressions, the slightest contact of cold air being a source of profound torture, 
producing a sense of suffocation and even violent convulsions. The agony thus occasioned 
is sometimes much greater than that caused by the attempt to swallow fluids. The least 
opening of a door, the slightest motion of a fan, or even the smallest whiff of air directed 
from the attendant’s mouth upon the body, instantly brings on a paroxysm of this kind. 
Light and noise, too, are always offensive; and hence the patient usually insists upon his 
room being kept dark, quiet, and closed. The mind, at this stage, is peevish and fretful, 
and nothing that can be done pleases the sufferer, who, in consequence, often quarrels 
with his best friends. At times his imagination is completely perverted; he fancies 
that he hears noises and sees objects that have no real existence; he gets out of bed, 
walks about the room, screams, or gesticulates, very much like one affected with delirium 
tremens. 
In the last stage, which is characterized by an aggravation of all the previous symp- 
toms, the countenance has a haggard and distressed appearance, horror and anxiety 
being depicted on every feature. The pupils are dilated, and the eyes have a wild, 
glaring expression ; the tongue is dry and parched ; the voice is hoarse and shrill, almost 
like that of a dog; the respiration is short and panting; more or less delirium is present, 
often amounting to complete mania; the strength is much impaired ; and the pulse, small 
and feeble, beats from one hundred and thirty to one hundred and sixty in the minute. 
Thus the disease progresses, paroxysm after paroxysm recurring until the frame is worn 
out by exhaustion, death usually taking place suddenly in a fit of suffocation. Occasion- 
ally a slight calm is experienced a few hours before the fatal event; the spasms almost 
completely subside, the power of swallowing returns, the mind becomes clear, and the 
patient, perhaps, sinks into a tranquil sleep. The duration of the attack varies, on an 
average, from thirty-six hours to three days. 
In a case of hydrophobia which I attended in 1842, the patient, a young man, twenty- 
one years of age, was attacked precisely four wreeks after having been bitten in the left 
hand by a rabid dog. When I first saw him the disease was already in its second stage, 
well-marked symptoms having appeared the previous day. The difficulty of swallowing 
and the morbid sensibility of the skin were present in a high degree. Every effort at 
drinking, nay, the very mention of fluid of any kind, and the attempt to raise the glass 
to the lips, caused violent convulsions ; the countenance was flushed and tumid ; the eye 
red and suffused ; the mouth parched; the throat clogged with viscid mucus; the pulse 
frequent and rather strong ; the respiration hurried ; the thirst and restlessness intense ; 
the mind exceedingly peevish and irritable; and the sensibility of the skin so exalted 
that the slightest approach to a current of air, inappreciable by any one else, produced 
the most horrible torture. The inability to bear light and noise was also very great. The 
hand felt numb and painful, although the wound had not reopened. These symptoms 
gradually progressed, increasing steadily in severity, until towards the end of the third 396 
WOUNDS AND CONTUSIONS. 
chap, x. 
day from the attack, when the young man expired in a state of complete exhaustion. 
The pulse, during the latter stage of the malady, was exceedingly irregular, and upwards 
of one hundred and fifty in the minute ; the breathing was short and panting; and the 
mind was excessively agitated and distressed, but clear and intelligent, except when a 
convulsion was about to occur. The voice was not materially affected. 
It is impossible to mistake hydrophobia for any other disease. The dread of water, 
the difficulty of deglutition, and the suffering occasioned by the contact of cold air, 
are always sufficiently diagnostic of the affection, even when no history of it can be 
obtained. 
The dissection of persons dead of this disease has thrown no light upon its seat or its 
pathology. In the case of a young man of twenty-four, who died in 1840, nine months 
after he had been bitten on the hand, and whose body I assisted in examining, no lesion 
whatever could be detected by the closest scrutiny. The mouth, fauces, pharynx, and 
oesophagus, the larynx, trachea, and bronchial tubes, where disease might naturally be 
supposed to exist, under such circumstances, were perfectly free from morbid appear- 
ances. The brain and spinal cord, lungs, stomach, bowels, and other viscera, were 
equally sound. Occasionally, especially in protracted instances, the membranes of the 
brain have been found congested, and the ventricles partially filled with serum. The 
stomach, oesophagus, and pharynx have also been found inflamed ; and several cases are 
mentioned where pus was discovered in some of the larger joints. Very little reliance, 
however, it seems to me, should be placed upon such reports, especially when we consider 
the loose manner in which most of them are drawn up, and the fact that comparatively 
few men are competent to make accurate dissections. Microscopic inspection in the 
hands of Meynert, Benedict, Hammond, Schultze, Wassilieff, Gower, and others, has 
thrown no reliable light upon the subject. 
The prognosis of hydrophobia is always bad, the disease invariably ending fatally. 
There is no case of recovery, of a reliable character, upon record. I know that a num- 
ber of instances have been published in which the patient is said to have got well, but 
there is not a single one, so far as my information extends, that can withstand the test of 
scientific scrutiny. 
The period at which death occurs is generally very short. The average in 72 cases, 
analyzed by Blatchford and Spoor, was three days. Of 120 cases, collected by I)r. J. L. 
Smith, of New York, 65 perished in from one to two days. In some instances the dis- 
ease proves fatal during the first twenty-four hours, while in others this event does not 
happen until the tenth day, although when postponed so late it must necessarily create 
very great doubt as to its true nature. 
In the treatment of this variety of poisoned wounds, reliance must be placed solely upon 
preventive measures ; for, as just stated, when the disease is once developed, there is no 
possible chance of doing anything more than mitigating the suffering, and even that only 
in a slight degree. If, as I have supposed, it be true that the poison is speedily absorbed 
after being brought into contact with the living tissues, the importance of promptly dis- 
lodging it cannot be too forcibly impressed upon the attention of the practitioner. As 
soon, therefore, as such a case is presented to his notice, the injured part should be thor- 
oughly excised, along with a portion of the sound tissues. The flow of blood is then to 
be encouraged with a cupping glass, i-etained for some time, when the raw surface is well 
cleansed, and immediately cauterized with nitrate of silver. If the teeth of the rabid ani- 
mal have penetrated between two bones, as, for example, when the bite has been inflicted 
upon the hand, excision must be performed with increased care, otherwise a portion of 
the virus will be liable to be left behind. In such a case it might become a nice ques- 
tion to determine whether the operation should not be made to include a portion of the 
bones also ; for almost any local sacrifice is justifiable to secure immunity from so horrible 
a disease. It would seem from the observations of Mr. Youatt and Mr. Blane, two emi- 
nent veterinary surgeons, that there is no remedy which so certainly neutralizes this 
poison as nitrate of silver. The former of these writers, whose opinion is entitled to the 
greatest respect on account of his large experience in the treatment of canine madness, 
states that he employed this article in upwards of 400 persons, as well as repeatedly upon 
himself, with complete success, and such was his confidence in its virtues that he regarded 
it in the light of a specific. His plan was to cleanse the parts well with soap and water, 
and then to cauterize them most thoroughly, previously enlarging the wound, if necessary. 
If I were myself so unfortunate as to receive such an injury, I should certainly feel more 
confidence in my escape, if the wounded structures had been excised and cupped prior to 
the application of the caustic. CHAP. X. 
WOUNDS INFLICTED BY RABID ANIMALS. 
397 
Excision should also be practised even when the injured part has been neglected, or 
imperfectly removed in the first instance, it being well known that the individual may 
escape the constitutional effects of the disease after the wound has begun to fester, or after 
it has partially reopened. But even if there were no hope of preventing the develop- 
ment of the disease by this procedure, it should, nevertheless, be adopted if for no other 
reason than the soothing effect it would exert upon the mind of the poor sufferer. Every- 
thing tending to allay his fears and contribute to his comfort is justifiable under such try- 
ing circumstances. If the symptoms of hydrophobia, however, have already been de- 
veloped, neither such an operation, nor even the amputation of the limb above the site of 
injury, can be of any service. 
When the poison has reached the system, and has evinced its explosive effects, no treat- 
ment, however judiciously and perseveringly conducted, is of any avail as a curative 
agent. The experience of two thousand five hundred years fully attests the truth of this state- 
ment. The whole materia medica has been exhausted in search of a remedy for this dis- 
ease, and there is hardly any article, vegetable or mineral, that has not been used, either 
singly or combinedly, and yet no instance has ever occurred in which any permanent 
benefit ensued. 
To relieve the frightful suffering from the disease, chloroform and ether, either alone, 
or variously combined ; morphia, in large quantities in the form of hypodermic injections, 
frequently repeated; the application of steam conveyed to the patient’s body as he lies in 
bed ; and the exclusion of cold air, noise, and light from the apartment, constitute the 
most reliable means. General bleeding, the hot bath, and tartar emetic, so much vaunted 
by some, will only expedite the fatal issue, without affording any decided mitigation of 
the suffering. Opium is of no use, even if given in enormous quantity, as the stomach 
cannot dissolve it. An ice bag stretched along the spine may do good by allaying ner- 
vous excitability. The food should be given in the most concentrated form, or what is pre- 
ferable, administered by the rectum. I)r. Physick, with a view of relieving the dyspnoea, 
and preventing suffocation, advised laryngotomy, but I am not aware that it has ever 
been practised, or, if practised, that it has ever done any good. It certainly could not 
cure the disease, and it admits of doubt whether it would even moderate the spasm. 
More benefit will, I am sure, accrue from the hypodermic use of morphia, and from the 
exhibition of the bromides and of chloral, in allaying the terrible distress, mental and 
corporeal, than from all other means combined, unless an exception be made in favor of 
nitrite of amyl, to which attention was called in connection with this affection, in 1877, 
by Dr. William S. Foster, of this city. Administered in doses of fifteen to twenty-five 
drops in the form of inhalation, it promptly calms the system, and enables the poor suf- 
ferer to swallow fluids with the greatest facility, a property which, so far as is now known, 
no other remedy possesses in such condition of the system. 
Hydrophobia in the Dog—In concluding the subject of hydrophobia, a few remarks 
may be made respecting the character of this disease as it occurs in the dog, as it is im- 
portant for the practitioner to be able to judge of the probability of his having been mad 
in the event of his having bitten a human being. 
How the disease originates in the dog is not ascertained. It has been supposed that 
unsatisfied salacity, the use of filthy and unwholesome food, too close confinement, and 
extremes of heat and cold, constitute so many causes of the malady; but it is obvious 
that, although this may be true, our knowledge at present amounts to nothing but con- 
jecture, which further and more carefully conducted observation alone can either verify 
or disprove. The average period of incubation is about forty days, the minimum being 
a fortnight, and the maximum three months and a half. The higher classes of dogs 
suffer less frequently from hydrophobia than the mongrel breeds, and it is also affirmed 
that bitches are less liable to the disease than males; a statement which requires further 
proof before it can be accepted as true. 
The early symptoms of rabies in the dog are thus graphically described by Mr. Youatt: 
“ In the greater number of cases,” he remarks, “ there are sullenness, fidgetiness, and 
continual shifting of posture. When I have had opportunity, I have generally found 
these circumstances in succession. For several successive hours perhaps he retreats to 
his basket or his bed. He shows no disposition to bite, and he answers the call upon him 
laggardly. He is curled up, and his face is buried between his paws and his breast. At 
length he begins to be fidgety. He searches out new resting-places ; but he very soon 
changes them for others. He takes again to his own bed ; but he is continually shifting 
his posture. He begins to gaze strangely about him as he lies on his bed. His counte- 398 
WOUNDS AND CONTUSIONS. 
chap, x. 
nance is clouded and suspicious. He comes to one and another of the family, and he 
fixes on them a steadfast gaze, as if he would read their very thoughts. ‘ I feel strangely 
ill,’ he seems to say : ‘ have you anything to do with it ? or you? or you?’ Has not a dog 
mind enough for this ? If we have observed a x’abid dog at the commencement of the 
disease, we have seen this to the very life.” Delirium is an early and characteristic 
symptom; the dog sees imaginary objects, and often springs at them with a furious dart; 
he is restless and excessively irritable, gazing wildly around, and snapping at everything 
within his reach. The saliva is secreted profusely, and collecting at the corners of the 
mouth, the animal makes frequent attempts to detach it with his paws; his appetite is 
strangely perverted, and he will sometimes greedily devour horsedung, or even his own 
excrements; the voice is changed in its character, being generally hoarse, and more or 
less shrill; the eyes are singularly bright; and the thirst is intense and insatiable, the 
dog drinking frequently, and having no fear whatever of water, as is the case with the 
human subject. 
The disease is now in full force, and tending rapidly to a fatal issue. The muscular 
powers being greatly exhausted, the animal finds it difficult to sustain himself upon his 
limbs ; he reels and staggers about like a man in a drunken fit; his tail is depressed, and 
the tongue protruded ; the eyes have lost their brightness, and are of a dull, glassy appear- 
ance ; the respiration is hurried and panting; finally, worn out by his suffering, the poor 
creature dies, either from convulsions, or from sheer exhaustion, the duration of the attack 
varying from three to five days. The power of communicating the infection exists, ac- 
cording to Youatt, in all the confirmed stages of the disease, and continues even for twenty- 
four hours after the death of the animal. 
4. GLANDERS, FARCY, OR EQUJNIA. 
The horse, ass, and mule are capable of spontaneously generating a disease, which, al- 
though it affects the whole system, expends itself with peculiar force and virulence upon 
the mucous membrane of the nose, causing violent inflammation and a copious discharge 
of thick, fetid matter. It is accompanied by a pustular eruption of the skin ; and the 
name by which it is generally known is glanders, from the fact that it is always associated 
with disease of the maxillary and of the lymphatic glands of the ear and neck. There 
is a form of the affection which is characterized by the development of small tumors be- 
neath the skin in different parts of the body, varying from the size of a pea up to that of 
a hazel-nut, of a spherical shape, very hard, almost immovable, and generally exquisitely 
painful to the touch. When very numerous, they give the surface a remarkably tubercu- 
lated appearance. To this disease the term farcy is commonly applied; and an attempt 
has been made by several writers to establish for it a distinctive character. Others, on 
the contrary, assert that it is identical with glanders, differing from it only in its location, 
or in the character of the structures in which it appears. This view of the case derives 
confirmation from the fact that the two affections often coexist, which could hardly happen 
if they did not possess a strong natural affinity for each other. 
It is not likely that this disease, as was once supposed, arises spontaneously; on the 
contrary, there is every reason to believe that it is invariably the result of the action of a 
peculiar virus generated during the existence of glanders. Absorption is generally ef- 
fected with wonderful rapidity. Renault, surgeon to the Veterinary School at Alfort, 
inserted the poison into horses, and, although the wounded part was excised and thoroughly 
cauterized within one hour afterwards, they all died from the disease. AVhatever its true 
nature may be, it is certain that the strongest and most healthy animals speedily contract 
it when exposed to its influence, hard usage, inadequate feeding, and confinement in damp 
and ill-ventilated stables, especially if underground, powerfully predisposing to its occur- 
rence. It was at one time thought questionable whether the disease could be propagated 
by atmospheric agency ; but multiplied observation long ago fully settled that point. It 
would seem, indeed, that the air of an infected stable, after all the wood work, pavement, 
and plastering have been completely replaced, and every possible precaution used in regard 
to cleanliness, is capable of reproducing the disease in all its former severity. 
The fact that glanders may occur in the human subject was first enunciated by Mr. 
Muscroft, in the Edinburgh Medical and Surgical Journal, in 1821. The case was that 
of a man who had accidentally inoculated his hand in cutting up a horse that had died of 
this disease; violent symptoms soon showed themselves, and he expired in great agony at 
the end of a week. Since that time a number of similar examples have been recorded 
by other observers, thus indisputably establishing the transmissibility of glanders from CHAP. X. 
GLANDERS, FARCY, OR EQUINIA. 
399 
animals to the human subject. As yet no facts had occurred proving that the affection 
might be communicated from one human being to another, or from man to beast. In 
1840, however, a case of this kind was admitted into St. Bartholomew’s Hospital, London, 
which conclusively settled the question. The patient, a knacker, had died of glanders, and 
the nurse who attended him took the disease and also perished from it. 
These facts regarding the transmissibility of glanders from animal to man, from man to 
man, and finally from man to beast, are of great pathological interest, and serve to incul- 
cate the great necessity of caution on the part of the professional attendants and nurses in 
their intercourse with persons laboring under this horrible disease; since the smallest 
particle of the specific virus coming in contact with an abraded surface, or even the mere 
inhalation of the infected air of the patient’s apartment, may give rise to the malady. 
In the equine tribes of animals, glanders may be propagated by inoculation with the 
pus and mucus of the pituitary membrane, the fluids being inserted under the skin with a 
lancet, or rubbed upon the greasy heel of the horse. It may also be produced by apply- 
ing these secretions to the mucous lining of the nose ; and a curious case has been reported 
of its having been caused by introducing balls of farcied matter into the stomach. The 
poison of glanders seems to enter the system very rapidly ; sometimes, indeed, almost 
instantaneously. Bouley and others of the Veterinary School at Alfort inoculated horses 
with the pus of this disease; and, although the inoculated structures were cut out one 
minute after its insertion, glanders speedily followed. An experiment performed by Mr. 
Coleman, of London, shows that the blood of an infected animal transfused into the 
carotid artery of a sound one, will rapidly engender the malady in its most virulent form. 
The period of latency of this disease is generally very short, rarely exceeding two or 
three days. It is probably a little longer in the human subject than in animals, but the 
difference, if any, is very slight. It has already been seen that the first case that ever 
occurred, so far as is ascertained, in the human subject, terminated fatally at the end of a 
week from the time of the inoculation. The first local evidence of the disease is generally 
some swelling and tenderness of the maxillary glands, and inflammation of the mucous 
membrane of the nose ; sometimes the one, at other times the other, taking precedence. 
The symptoms of glanders naturally divide themselves into constitutional and local. 
Shortly after the inoculation, the patient begins to feel unwell; his head, back and limbs 
ache ; chilly sensations, alternating with flushes of heat, creep over his body ; sleep and 
appetite are impaired ; the strength sensibly diminishes ; the joints are stiff and sore ; the 
spirits are depressed; the stomach is irritable ; and the bowels are costive. After the 
lapse of twenty-four to forty-eight hours, a severe and protracted rigor generally occurs, 
followed by violent fever, profuse perspiration, and a marked elevation of temperature, the 
thermometer often rising to 102°, 103°, or even 104° Fahr. ; an evidence that the stage of 
incubation is passed, and that the poison has gained full admission into the system. The 
symptoms now rapidly assume a typhoid character. The pulse becomes quick, frequent, 
and tremulous ; the tongue is dry and brownish ; sordes accumulate upon the gums and 
teeth ; the voice is weak and often husky; the respiration is short, panting, and accom- 
panied by a sense of constriction across the chest; the surface is bathed with fetid, clammy 
perspiration ; the thirst and jactitation are excessive ; the urine is scanty and high-colored; 
the alvine evacuations are slimy and extremely offensive; the mind wanders; and the 
pains are atrocious. 
Coincident with these phenomena there are marks of serious disease of the mucous 
membrane of the nose, which is highly inflamed, and the seat of a copious, viscid, and 
irritating discharge. Excessive pain and soreness exist in the forehead, over the frontal 
sinuses, evidently from an extension of the inflammation to the lining membrane of those 
cavities ; and for the same reason there is generally great uneasiness in the throat and 
larynx. The nose and cheeks soon become hot, swollen, purple, excoriated, and exqui- 
sitely painful; the discharge from the nostrils assumes a bloody, purulent character, and 
is both copious and disgustingly offensive; the eyelids are infiltrated and nearly closed ; 
and the features are hideously disfigured. About the tenth or twelfth day hard pustules 
make their appearance on various parts of the body, especially on the trunk, face, genital 
organs, and inside of the limbs, resembling those of smallpox, and attended with profuse, 
fetid sweats. Occasionally they are accompanied by black bullae, which, breaking, dis- 
charge a thin, sanious fluid, and bring into view gangrenous spots, varying from the size 
of a three-cent piece to that of a quarter of a dollar. In some cases, again, numerous 
tubercles appear in different situations, interspersed among the pustules, or pustules and 
vesicles; they are generally small, of a roundish shape, hard, and exceedingly painful; as 
the disease proceeds, they give way on the surface, and exude a thin, ichorous fluid. The 400 
WOUNDS AND CONTUSIONS. 
chap. x. 
lymphatic glands of the groin, axilla, and other regions frequently participate in the dis- 
ease, becoming enlarged, tender, and painful; the lungs are also apt to suffer, and, indeed, 
it is not uncommon to see serious involvement of various viscera. 
As the disease progresses, the prostration rapidly increases; the fever displays a more 
malignant character; deep coma supervenes; and the body exhales a horribly offensive 
odor, almost characteristic of the disease, and strongly denotive of the dissolved state of 
the blood and the putrescent nature of the secretions. 
The period at which death occurs varies from eight or ten days to four or five weeks. 
In a majority of the reported cases, the disease terminated fatally before the eighteenth 
day ; some of the patients died as early as the end of the first week, while a few lived 
until after the fiftieth day. 
When glanders pursues this rapid course it is said to be acute, and chronic when it is 
more tardy. In the former case, the local symptoms usually precede the general, frequently 
setting in within a few hours after the absorption of the virus. The inoculated part* 
becomes red and tender, and the epidermis is soon elevated into a vesicle, or pustule, from 
which the inflammation rapidly extends along the lymphatic vessels as high generally as 
the glands of the groin or axilla. The swelling is excessive ; the limb is stiff and numb; 
and the connective tissue, infiltrated with sero-albuminous exudation, before long becomes 
the seat of numerous abscesses. In the more severe cases, black spots appear upon the 
surface, indicative of the existence of gangrene. Sometimes the local disease begins in 
the lymphatic glands of the groin or axilla, from which it spreads over the corresponding 
side of the trunk, and even over the whole limb. 
In contemplating the progress of this disease, it is impossible not to be struck with the 
resemblance which it bears to that of a dissection wound. It evidently belongs to the 
hemotoxic class of affections, consisting essentially in a disorganized condition of the 
blood and solids, paralyzing and crippling the heart and brain, and thus bringing about 
that typhoid condition of the system which forms so prominent a feature of the complaint. 
Dissection always discloses the existence of serious lesions in the nose and internal 
organs. The pituitary membrane, of a deep purple or livid hue, is coated with tough, 
viscid secretions, studded with tubercles, ulcerated at some points, and gangrenous at 
others; the nose is occasionally nearly eaten away; and large cavities generally exist upon 
the cheeks. The frontal sinuses, larynx, and bronchial tubes are livid and excessively 
congested; and the lungs often contain abscesses, occupied by ill-elaborated matter, looking 
more like aplastic lymph than genuine pus. The heart is commonly softened. The 
mucous coat of the stomach and bowels is diminished in consistence, discolored, and some- 
times studded with minute tubercles, similar to those observed in the nose. The pustules 
which exist beneath the skin and in the connective tissue among the muscles, bear a great 
resemblance, in the nature of their contents, to metastatic or multiple abscesses; they 
contain no true pus, at least not in their earlier stages, but a dense, solid, fibrinous matter, 
strikingly like that so generally found in pyemia and other forms of blood-poisoning. 
The diagnosis of glanders is, in general, sufficiently easy. An inexperienced practi- 
tioner, deceived by the aching pains and soreness of the joints and limbs, might possibly 
mistake it in its earlier stages for rheumatism; but the occurrence of secondary symptoms 
would soon dispel the illusion. From the effects of a dissection wound it may readily be 
distinguished by the peculiar discharges from the nose, and by the character of the cuta- 
neous eruption. The history of the case, too, will always furnish important diagnostic 
data. The fact that the patient has nursed or examined a glandered horse or person, will 
generally of itself afford strong presumptive proof of the true character of the attack. In 
the latter stages of the disease, the nasal discharges, the existence of pustules, abscesses, 
and gangrenous spots, and the horribly fetid exhalations from the body, are signs which 
it is impossible to mistake. 
The character of the prognosis may be gathered, in great measure, from what precedes. 
The acute form of the disease is nearly always fatal. Of fifteen cases, collected by Rayer, 
only one recovered. The danger in chronic glanders, on the other hand, is much less. 
Thus, of ten cases, mentioned by the same writer, seven recovered and three died. 
The treatment of this affection is preventive and curative. The former consists in the 
adoption of proper measures for destroying the poison as speedily as possible after the in- 
oculation. With this view, the affected or abraded surface should be freely washed by 
holding it for a considerable length of time under a concentrated stream of water, and 
then thoroughly cauterized with acid nitrate of mercury, or some other active escharotic, 
or, what is better, effectually excised. If the operation is impracticable, and the wound 
is of a punctured nature, it should at once be enlarged, and then brought fully under the chap. x. 
DISSECTION" WOUNDS. 
401 
influence of some caustic, otherwise a portion of the poison lurking deep in the wound 
may escape its contact, and thus be absorbed into the system. If a person is known to 
have died of glanders, the safest plan for the practitioner is to avoid a post-mortem ex- 
amination, especially if there are any abrasions, however slight, upon his hands and fingers. 
The curative treatment, if it deserve such a name, has hitherto been entirely unavail- 
ing. Bleeding, both local and general, purgatives, tonics, and stimulants have proved 
alike useless. Obviously our chief reliance must be upon the employment of supporting 
measures, especially quinine, carbonate of ammonium, tincture of chloride of iron, and 
brandy, given in large and frequently repeated doses, in combination with liberal quanti- 
ties of morphia, with a view both of allaying pain and controlling gastric irritability. 
Infiltrated fluids and abscesses should be promptly evacuated, and the affected parts 
wrapped up in flannel wrung out of saturnine and anodyne lotions. The nose should be 
frequently injected with tepid water impregnated with creasote, carbolic acid, or tannate 
of iron ; liquid chlorinated sodium freely sprinkled upon the body and bedclothes; the 
apartment constantly ventilated ; and the utmost attention paid to cleanliness. To these 
means should be added, in chronic cases, change of air, or residence near the sea-coast. 
5. WOUNDS INOCULATED WITH A PECULIAR SEPTIC POISON GENERATED IN DEAD 
ANIMAL BODIES. 
a. Dissection Wounds. 
Wounds contracted in the examination of dead human bodies are named dissection 
wounds, and are deserving of special attention on account of the severe effects which they 
are capable of producing. These injuries generally occur in the form of punctures, abra- 
sions, or slight incisions, and would generally be altogether unimportant if it were not 
for the fact that they are often inoculated with a peculiar poison, septic in its character, 
and, therefore, liable, if absorbed, to contaminate both the part and system. The instru- 
ments with which they are usually inflicted are the scalpel, tenaculum, and needle, espe- 
cially the latter, as it is very apt to prick the fingers in sewing up dead bodies. Not 
unfrequently, the inoculation is effected through the medium of a preexisting abrasion, or 
scratch, of the presence of which the person may, at the time, be perfectly unconscious. 
It is not necessary, however, for the entrance of the virus that there should be an open 
wound or a denuded surface, experience having shown that it may find its way into the 
system through a hair follicle or even through unbroken skin, as when the hand is im- 
mersed for an unusual length of time in poisonous fluid, as, for example, during the dis- 
section of a person dead of puerperal peritonitis. 
Of the nature of the poison which produces these severe effects nothing whatever is 
known. It is supposed that it is generated a short time before death, during the act of 
dying, or soon after dissolution, and that its development is due to a vitiated state of the 
blood hitherto unexplained. The idea is certainly plausible, supported as it is by the 
circumstances that the poison is generally most virulent when it is communicated by per- 
sons dead of puerperal fever, erysipelas, carbuncle, phlebitis, pyemia, septicemia, carci- 
noma of the liver, and kindred atfections. Punctures received in the examination of the 
bodies of persons who have died from strangulated hernia are peculiarly dangerous. 
Once formed, the poison, like the virus of chancre, becomes independent of its source. 
A proof of this fact was afforded me, some years ago, in the person of a young cutler, 
who, in sharpening a case of dissecting instruments for me, which had not been used for 
nearly five months, slightly pricked one of his fingers. The hand and arm soon became 
exceedingly painful, as well as a good deal swollen, a characteristically red line extending 
up as high as the axilla, the glands of which were also speedily involved in the disease. 
Nearly a month elapsed before he recovered from the immediate effects of the injury. 
A prick of the finger received in cleaning bones has sometimes been followed by severe 
suffering and even loss of life. It is generally supposed that a fresh body is more liable 
to convey the poison than one that has been kept for some time. This, however, is not 
always true ; for in a subject which had been on hand for nearly a month, and which I 
dissected, in 1827, along with Dr. .Temple, of Virginia, that gentleman came very near 
losing his life from a little puncture inflicted upon his thumb at the end of that period. 
It is worthy of remark that the body was that of an old woman, who had perished from 
the effects of tertiary syphilis, as was apparent from the extensive disease of the skull 
and other portions of the skeleton. 
Violent effects sometimes follow the dressing of wounds, from the contact of foul and 402 
WOUNDS AND CONTUSIONS. 
chap. x. 
irritating discharges, and a number instances are upon record of surgeons having lost their 
lives from this cause. Similar results occasionally occur during the removal of malig- 
nant growths from inoculation with the secretions of the affected structures. The 
health of Professor Dudley, of Lexington, suffered seriously for several years from the 
inoculation of his hand with the matter of an encephaloid sarcoma during the amputation 
of the patient’s arm. Dr. Physick met with a case of death from the effects of a slight 
scratch with an oyster-shell. Bad effects not unfrequently follow punctured wounds 
caused by the fin of a fish, especially in persons of intemperate habits and of dilapidated 
constitution, although they are probably not of a poisoned character. 
An accoucheur, a friend of mine, suffered very severely from the inoculation of two of 
his fingers with the juices of a decomposed child. In opening and extracting the head, 
he slightly scratched himself with the broken bones ; in ten hours after the accident he 
was seized with a violent and protracted rigor, followed by vomiting and high fever ; a 
red line soon extended up each arm as high as the axilla, and nearly a week elapsed be- 
fore he regained his health sufficiently to be able to attend to business. 
The period of latency of this poison is usually very brief, or, more properly speaking, 
only a short time elapses before the occurrence of well-marked symptoms ; for it is ex- 
tremely probable that it begins its peculiar operation upon the inoculated structures almost 
immediately after its introduction, although its explosive effects may not manifest them- 
selves nearly so soon. Generally they do not come on before the end of the second day, 
or the commencement of the third. In one case—the most remarkable, in this respect, 
on record—very severe symptoms ensued within the first twelve hours, and the patient 
died in forty hours from the receipt of the wound. In the case of Dr. Temple, above 
alluded to, violent indisposition set in within less than thirty-five hours from the time of 
the inoculation. The accident happened late on a Saturday night, and on the following 
Monday morning he was taken so ill that he was obliged immediately to retire to his 
room, which he did not leave again for nearly two months. In the case of Kissam, a 
medical student, recorded by the late Dr. Godman, grave symptoms supervened in less 
than fifteen hours, although death did not occur until the fifth day. On the other hand, 
the patient occasionally remains free from suffering for a comparatively long period, as in 
the instance of Mr. Newby, an English surgeon, who, having received a puncture in 
opening the body of a child dead of enteritis, experienced no serious inconvenience until 
the commencement of the fourth day. 
Some persons seem to be peculiarly liable to suffer from this poison. Thus, I, myself, 
seldom, in my younger days, while much engaged in post-mortem examinations, opened a 
dead body without the operation being followed by a boil upon my hand, thumb, or finger. 
Occasionally the consequences were more serious, the disease extending up the arm, along 
the course of the absorbents, as high as the axilla. Disordered health, hard study, gene- 
ral debility, mental anxiety, and other causes, no doubt, powerfully predispose to the de- 
velopment of the disease. A student who has for weeks inhaled the foul atmosphere of 
the dissecting room, taken little exercise, and sat up late at night, eating, perhaps, withal, 
very heartily, will be much more likely to contract the disease, and to suffer severely, if 
he be wounded, than one who has taken better care of himself. 
Symptoms—The usual point of departure of this disease is the inoculated part, from 
which it rapidly spreads in every direction. A smarting, stinging, or burning sensation 
is generally the first circumstance which attracts attention. Upon looking at the part, 
it is found to be covered with a little, whitish vesicle, perhaps hardly the size of an 
ordinary pin’s head, filled with serum, and resting upon a hard, reddish base, extremely 
sensitive on pressure. When this vesicle breaks, as it usually does within the first 
twenty-four hours, a small ulcer is exposed, having a foul base, and discharging a thin, 
sanious fluid. The pain by this time is generally very distressing, burning, and pulsatile, 
depriving the patient of appetite and sleep ; the sore enlarges; the swelling augments; 
and the part feels exceedingly hot, tense, heavy, and numb. Generally a red line is seen 
extending from the seat of the inoculation along the arm to the axilla, marking the course 
of one or more of the absorbent vessels. As the poisonous influence spreads, the whole 
limb becomes enormously enlarged, pitting on pressure, and exhibiting a dusky, erysipe- 
latous appearance. With this increase of swelling there is a proportionate increase of 
pain, which now amounts to torture; the limb feels heavy, like a mass of lead, and is 
completely powerless. In bad cases the inflammation extends to the top of the shoulder, 
the axilla, and even to the corresponding side of the trunk. 
Such is the ordinary course of the disease; but cases occur where the order of the 
symptoms is reversed, the poison exploding in the axilla, and thence extending up the chap. x. 
DISSECTION WOUNDS. 
403 
neck and down the side, the arm being, perhaps, almost free from inflammation, and there 
being no appearance, or only a very slight appearance, of disease at the seat of the in- 
oculation. The swelling, which sometimes reaches as low as the crest of the ilium, is, at 
first, of a doughy character, and of a pale pink hue ; but it soon becomes hard, and assumes 
the peculiar erysipelatous blush already described as belonging to the more common 
variety. The pain is generally exquisite from the beginning, and is sometimes of itself 
sufficient to crush the system, before sufficient time has elapsed for the formation of the 
distinctive pustule. Such cases, which are always fraught with danger, occasionally 
terminate fatally in a few days. 
It is not every case of inoculated dissection wound that gives rise to general symptoms; 
on the contrary, in the great majority of instances the affection is entirely local, being 
confined to the immediate neighborhood of the original injury, diffused over the hand 
and wrist, or, it may be, limited to a few absorbent vessels, as indicated by the red lines 
extending up the limb. Under such circumstances the patient may feel a little unw'ell, 
have some headache, and want of appetite, or suffer from chilliness and aching of the 
limbs, but there is no serious disturbance of the general health. This will, however, be 
sure to occur if the virus has gained full admission into the system, the symptoms showing 
themselves, on an average, in from twelve to twenty-four hours. The patient, at first, 
has merely a feeling of depression, or faintness, with a sense of chilliness, pain in the 
head, and slight derangement of the digestive organs. This prodroma is speedily suc- 
ceeded by violent rigors, alternating with flushes of heat, by nausea and vomiting, 
excessive restlessness, intense thirst, an increase of cephalalgia, a haggard, woebegone 
state of the countenance, and indescribable despondency. The tongue is coated, the 
respiration hurried, the skin dry and hot, the pulse sharp and frequent, but feeble. The 
bowels are either constipated, or, as more frequently happens, hai-assed with diarrhoea. 
The disease, in its worst forms, soon reaches its crisis, the system rapidly falling 
into a typhoid state. During this downward course the symptoms above described be- 
come more and more marked ; the tongue is dry and brown; the pulse quick and tremu- 
lous ; the countenance sallow and withered ; the skin yellow and covered with clammy 
sweat; and the suffering indescribably severe. Delirium always sets in at an early period, 
and is a prominent symptom throughout. Death occurs in a few days to a few weeks, 
according as there is overwhelming exhaustion, or depression from gangrene and metas- 
tatic abscesses. 
The appearances discovered on dissection are variable. When the case has run its 
course very rapidly, the internal organs may, apparently, be entirely free from disease, 
or there may be evidence of slight effusion into the chest, with an engorged condition of 
the lungs, the affected structures themselves being somewhat infiltrated with serum and 
lymph. Under opposite circumstances, there will generally be marks of inflammation 
of the arachnoid membrane, pleura, lungs, and peritoneum, with, perhaps, deposits of 
pus in the larger joints, among the muscles, and in the subcutaneous connective tissue. 
The parts more immediately involved in the morbid action will be found to be enormously 
distended with the ordinary products of inflammation, highly softened at some points 
and greatly indurated at others, with, here and there, an abscess, and, perhaps, a 
gangrenous spot. 
The prognosis of this affection may be deduced, in some degree, from the preceding 
remarks. When the disease is strictly local, much suffering may be the consequence, 
but ultimate recovery will be certain, the part immediately affected becoming, perhaps, 
withered and completely useless, as often happens when the lesion is seated in a finger. 
In the very worst cases death may occur in less than forty-eight hours, apparently from 
the empoisoned condition of the nervous system, with little or no evidence whatever of 
local disease. In another class of cases, also very bad, the patient may live five or six 
days, and then perish from the violence of the resulting inflammation ; or he may linger 
for weeks and months, abscess after abscess forming in the limb, on the side, or in other 
regions of the body, and finally die from constitutional irritation ; or, lastly, he may, after 
having been for a long time on the very brink of the grave, struggle through the disease, 
and in the end make a good recovery, or he may remain permanently weak, and crippled 
in some internal organ. 
Some persons are a long while in recovering from apparently very trifling accidents 
of this kind, depending either upon some idiosyncrasy, or upon some derangement 
of the general health. I myself formerly suffered a great deal in this way. On one 
occasion my thumb, accidentally pricked in examining the body of a woman dead of 
phthisis, remained sore for fifteen months; and a former colleague of mine, Professor 404 
WOUNDS AND CONTUSIONS. 
chap. x. 
Rogers, of Louisville, had an affection of this kind upon one of his fingers which 
troubled him for upwards of three years. When the disease is thus protracted, the 
probability is that disorder of the digestive organs is essentially concerned in nursing 
its latent embers. 
Treatment The treatment is preventive and curative. As soon as a wound of this 
kind has been received, the part should be most thoroughly washed with warm water and 
Castile soap, and then subjected to a stream of cold water, followed by suction performed 
with the mouth. If the wound be very small, or valvular, the best plan will be to dilate 
it, as a preliminary step, in order to facilitate the extraction of the poison. Whatever 
method be adopted, the operation is completed by effectual cauterization with acid nitrate 
of mercury, inserted into the wound by means of a small, pointed stick of wood. In 
the absence of this article, which I prefer to everything else for the purpose, use may be 
made of nitrate of silver, butter of antimony, hydrochloric, nitric, or sulphuric acid, 
or a saturated solution of equal parts of alum and nitre. Persons who habitually suffer 
from dissection wounds should always employ some precautionary measures in ex- 
amining dead bodies, such as anointing the hands well with pomatum, lard, tallow, 
or simple cerate, and even wearing thin leather gloves, any fluids that may be present 
being previously removed by an assistant. Fortunately, since the introduction of chloride 
of zinc injections, now in common use in our schools, inoculation in any form from 
dissection wounds is much less frequent than formerly. In the Jefferson Medical College, 
no case of a serious character has occurred since this article was first employed by Pro- 
fessor Wallace. The pupils of the other institutions of this city have, 1 believe, been 
equally exempt. 
If the case has been neglected, or if, despite the above precautions, a vesicle forms at 
the site of the wound, a free incision should at once be made, when, bleeding having 
been encouraged by immersion in warm water, the part should be thoroughly cauterized 
with nitrate of silver, or brushed over with dilute tincture of iodine, an ectrotic effect 
being still hoped for, although not likely to be attained. Warm water-dressing with 
laudanum is then applied, and a brisk cathartic administered, the patient being kept 
strictly at rest upon light diet and carefully watched. If the disease extend, means must 
be employed to limit its action, and to sustain the system. In view of the inevitable 
typhoid tendency, all exhausting remedies must be scrupulously withheld, especially the 
lancet and active purgation. If nausea and vomiting are present, a mustard and salt 
emetic, or an emetic of ipecacuanha, is administered, and the bowels and secretions are 
regulated by mercurial laxatives, aided, if there be high fever, by tepid sponging of the 
surface, and the use of the neutral mixture. To relieve the excessive pain and restless- 
ness, morphia must be given in large and sustained doses, united, if the skin be hot and 
dry, with aconite or veratrum viride. The distressing headache so often attendant upon 
the disease, must be treated with cold applications, the hot foot-bath, and the exclusion 
of light and noise ; but anodynes generally afford more ease than anything else. If 
inflammation of the arachnoid be threatened, a few leeches may be applied to the temple, 
or a blister to the nape of the neck. To meet the typhoid symptoms milk punch, quinine, 
iron, and ammonia are indispensably necessary. In the more terrible forms of the 
disease, commencing with violent pain in the axilla, side, and shoulder, these means 
should be used at once, in large quantity, especially the brandy, with the hope of 
neutralizing the poison, and thus arresting its zymotic tendency. Although we know 
nothing of the nature of this poison, it is not at all improbable, judging from the good 
effects which attend the employment of alcohol in the treatment of snake-bite, that 
brandy and other spirituous liquors might be of great service in dissection wounds. The 
suggestion, at any rate, seems to me to be worthy of attention. Their beneficial effects 
might possibly be increased by the free use of carbonate of ammonium ; certainly by that 
of anodynes. 
As it respects the parts more immediately concerned in the disease, the best application, 
after the first ten or twelve hours, is warm water-dressing, medicated with laudanum and 
Goulard’s extract, acetate of lead, or chloride of ammonium, preceded and accompanied by 
dilute tincture of iodine. Lint wet with oil of turpentine and laudanum sometimes affords 
great comfort. Blisters and nitrate of silver are objectionable, their vesicating effects 
interfering with other remedies. Leeches are occasionally productive of great relief, but 
they are not to be used, except in very robust subjects, and in the earlier stages of the 
affection. When there is much oedema, the pressure of the bandage will be useful. 
Tension is relieved, and matter evacuated, by free and timely incisions. 
Covering the parts thickly with strong mercurial ointment, along the whole track of CHAP. X. 
MALIGNANT PUSTULE. 
405 
the inflamed lymphatic vessels, is sometimes useful in arresting the spread of the morbid 
action, and promoting the absorption of effused fluids. Professor Wallace speaks in high 
terms of this mode of treatment, which is especially worthy of trial in the earlier stages 
of the disease. 
The secondary effects of this class of injuries yield most readily to change of air, atten- 
tion to the secretions, and the use of tonics, iodide of potassium, and cod-liver oil. In 
obstinate cases, a mild course of mercury may be necessary. 'I he most eligible topical 
remedies are evaporating spirituous lotions, or solutions of acetate of lead, Goulard’s 
extract, or chloride of ammonium. Sometimes a deep and free incision will afford more 
prompt relief than anything else. 
Finally, it mqst not be forgotten that students and physicians who spend much of their 
time in the dissecting-room, in the dead-house, or in making post-mortem examinations 
in private families, are not fit to attend women in their confinement, or to dress 
wounds, compound fractures and dislocations, or to perform surgical operations, however 
simple, without previously subjecting themselves to thorough ablutions with disinfecting 
fluids and even, in many cases, changing their clothing. The finger nails, in particular, 
should be thoroughly cleansed, otherwise inoculable matter may readily be conveyed to 
healthy persons. 
b. Malignant Pustule. 
This is a disease, primarily, of the cutaneous and connective tissues, commencing in the 
form of a little vesicle, and rapidly terminating in gangrene, its cause being a septic virus 
generated by horned cattle laboring under murrain. The French surgeons usually describe 
it under the name of charbon, and in many parts of Europe it is vulgarly known by the 
term Persian fire, or malignant pimple, the former having reference to the horrible pain 
which attends it, the latter to its destructive tendency. 
The disease is met with in various sections of the Union, although it appears to be less 
common here than in Europe. Cases of it have occasionally been noticed in this city 
and its vicinity, and I have myself seen it in Kentucky, where, as well as in Ohio, Illinois, 
Tennessee, Mississippi, and Louisiana, murrain sometimes prevails as an epidemic. In 
the latter State it caused great havoc in the summer of 1851, among the stock of the 
parishes of St. Mary and Vermillion, carrying off an immense number of cattle, as well 
as a considerable number of horses and mules, among the latter of which it first broke 
out. Hogs and dogs that ate of the carcasses took the distemper, and soon died of it. 
Several cases occurred in which the disease was communicated to the human subject by 
the green carrion-fly. During my residence at Louisville, four cases of the malady, all 
contracted in flaying and eviscerating cows dead of murrain, came under my observation. 
In Europe, malignant pustule has hitherto been chiefly observed on the continent, 
particularly in France, Holland, Switzerland, Germany, and Russia. It is also very 
common in Siberia and South America. The inhabitants of Great Britain appear to be 
nearly exempt from it. In France it is most common in Lorraine, Franche-compte, 
Burgundy, Province, Lyonnais, and some of the other southern regions. It is rare at 
Paris, but frequent at Marseilles, showing that locality is favorable to its production. 
The disease is most common upon the hands and face, because these parts, being habitu- 
ally exposed, are most liable to inoculation. Persons who work among hides, both green 
and dry, tanners, butchers, shepherds, blacksmiths, and veterinary surgeons, are most 
liable to its attacks. It is often contracted by the common people in flaying and evisce- 
rating animals dead of murrain. It has also occurred from introducing the hand into the 
rectum and vagina of cows laboring under putrid fever. The virus has occasionally been 
conveyed by insects from diseased brutes to man. I have already alluded to the fact that 
it may be communicated by the green carrion-fly. It would seem that certain parts of 
an animal, as the hair and wool, retain the poisonous matter for a long time, and even 
after they have been most thoroughly washed and cleansed. Dr. Bourgeois refers to an 
instance in which the disease was apparently produced by picking the horsehair taken out 
of an old sofa; and of eight cases reported, in 1868, by Dr. G. E. Stone, of Massachusetts, 
all, except one, occurred in workmen, women, or children engaged in the manufacture of 
curled hair. A very common way in which it is contracted is in handling dry hides. 
Even tanned leather is said to be capable of communicating the affection. It has been 
conjectured that it might be contracted by eating the flesh of brutes dead of murrain, 
but there are no facts that justify such a conclusion. Whether it can be conveyed from 
one human being to another, or from man to the inferior animals, is also undetermined. 
What the nature of the poison is which produces this disease, or when, where, or how 406 
WOUNDS AND CONTUSIONS. 
chap. x. 
it is developed, is a question which we have no means of solving. It is evidently of a 
zymotic character, like the virus of smallpox and chancre, and is generated by most of 
the domestic animals, especially cattle dead of murrain, its occurrence being less frequent 
in the horse, mule, ass, and sheep. It is also probable that it may be generated by birds, 
as the hen and turkey. In a case, of which I have collected the particulars, the disease 
was contracted by three persons in picking and eviscerating several buzzards with a view 
of extracting their oil. Both the hands and forearms of each individual were inoculated. 
Violent local and constitutional symptoms showed themselves by the end of the second 
day after the operation, the parts being excessively swollen and painful, and covered with 
numerous vesicles, which, upon bursting, exposed ill-looking ulcers, discharging a thin, 
sanious fluid, and remaining open for many weeks. The inflammation reached up to the 
axilla, the glands of which were enormously enlarged, some of them finally suppurating. 
Recovery took place only after a long time, and after great suffering, reducing the patients 
to the utmost degree of exhaustion. It is difficult to say whether, in these instances, the 
poison was actually generated by these birds, or merely conveyed by them through their 
feathers inoculated by carrion. 
Dr. Davaine, in 1863, advanced the idea, based upon personal observation, that this 
disease is communicated exclusively through the agency of bacteria, which are found in 
the blood and lymph of the vesicles of diseased animals, and some recent investigations 
would seem to corroborate this view*. The bacteria consist of very minute, slender fila- 
ments, cylindrical, straight, stiff”, detached, devoid of motion, and capable of successive 
and indefinite transmission from the pustule of charbon by inoculation so long as the blood 
and solids retain their vitality. 
Symptoms—The period of latency of the disease is very brief, generally, perhaps, not 
exceeding a few hours. The first distinguishable evidence of the operation of the poison 
is a small reddish point, not larger than a pin’s head, and the seat of a burning, itching 
sensation, attended with a desire to scratch. Gradually spreading in size, it is speedily 
followed by a little vesicle, filled with a thin, turbid serum, which, in its turn, is soon 
replaced by a pustule of a yellowish, brownish, or reddish color, according as it contains 
pure pus, or pus mixed with blood. Around the pustule is a distinct areola, not unlike 
that of smallpox ; the part is exquisitely painful, hard, circumscribed, and easily lifted from 
the adjacent structures. Continuing to extend, it becomes gradually more and more promi- 
nent, until it acquires a base equal to the diameter of a twenty-five cent piece, a half- 
dollar, or even a dollar, and is surrounded by a zone of oedema. Meanwhile the pustule 
bursts, revealing a foul, gangrenous ulcer, discharging a sanious, fetid, irritating fluid, 
sometimes quite abundant. Long before the disease has reached this crisis, the affected 
limb is enormously swollen, stiff”, numb, heavy, and exquisitely painful, the inflammation 
often reaching as far as the shoulder, and seriously involving the axillary glands. The 
number of vesicles is variable ; in one of my cases there was only a single one ; in another 
there were two, one on the hand and the other on the forearm ; in the third there were 
five ; and in a fourth the whole arm and hand were literally covered with them, their 
number amounting to several hundred. When numerous, they are always proportion- 
ately small, not exceeding the diameter of a currant or a split pea. 
When the disease is seated in the face, the swelling is generally so great as to give rise 
to the most hideous distortion, and to render it almost impossible to distinguish one fea- 
ture from another. The eyelids are closed and distended like bladders, the lips are 
several times their natural thickness and hardly movable, the cheeks are enormously 
puffed out, and the natural line of demarcation between the jaw and neck is completely 
obliterated. The face, in fact, looks more like a dark, shapless mass than a human coun- 
tenance. When seated here, the malady is apt to extend to the throat, causing great 
swelling of the palate and tonsils, attended with intense difficulty of deglutition and res- 
piration, sometimes followed by suffocation. 
The constitutional symptoms are those, in the first instance, of general malaise, or 
uneasiness, with a feeling of depression and foreboding of evil. Presently high fever sets 
in, preceded and accompanied by rigors ; after which, in a very short time, the patient sinks 
into a low, typhoid condition, commonly attended with muttering delirium, loss of sleep, 
and excessive restlessness. Death often follows in three or four days from the first mani- 
festation of the disease ; but sometimes it does not take place under a week, and in rare 
cases not before the end of a fortnight. The patient’s habits and state of health at the 
time of the inoculation, the quantity of matter absorbed into the system, and the nature 
of the treatment, all, doubtless, exercise an important influence upon the issue of the CHAP. XI. 
RAILWAY INJURIES. 
407 
case. As a general rule, however, it may be stated that few recoveries occur under any 
circumstances. 
Dissection has hitherto thrown no light upon the nature of this disease. The internal 
organs, especially the lungs, are generally considerably engorged ; and in a few instances 
metastatic abscesses have been found. The affected limb is usually distended with 
serum and lymph, the latter of which often exists in large quantity, giving the parts 
their characteristic hardness, and exhibiting occasionally, here and there, a greenish, 
gelatinous appearance. In one case I discovered several depots of blood. If the patient 
survive sufficiently long, abscesses may form in the subcutaneous connective tissue, and 
probably even in some of the viscera, especially the lungs and liver. The inflammation 
seldom extends deeply among the muscles, its progress being, apparently, limited by the 
aponeuroses. The axillary glands are sometimes much enlarged, softened, discolored, 
and infiltrated with various kinds of fluids. In the immediate neighborhood of the vesi- 
cles the parts are of extreme density, cutting with a grating noise very much like fibro- 
cartilage. Doubtless the veins and absorbents are implicated in the disease, but in what 
manner, or degree, has not been ascertained. There is usually, after death, a tendency 
to rapid decomposition. 
Treatment.—The treatment is prophylactic and curative. As soon as it is ascertained 
that an individual has been inoculated, the part should be cut out, after which it should 
be well washed with warm water, to encourage vascular disgorgement, and then still fur- 
ther drained by the cupping glass, these means being followed by thorough cauterization 
with dilute acid nitrate of mercury or solid nitrate of silver. Or, instead of this, the part 
is destroyed with the Vienna paste, or the hot iron. When the pustule is fully formed it 
should be excised or destroyed; the zone of induration should be incised and thoroughly 
cauterized ; and the zone of oedema, as recommended by Verneuil, should be injected with 
ten drops of a one-half per cent, solution of iodine. When early and effectual riddance 
has been neglected, or found impracticable, the treatment must be conducted upon gen- 
eral principles, by mild, soothing, and supporting measures. All sanguineous depletion, 
both by the lancet and leeches, active purgation, and other debilitating means, are 
avoided, as calculated, inevitably, to hasten the fatal crisis. The secretions, always 
seriously deranged in this disease, are rectified by small doses of calomel, the excessive 
pain is allayed by morphia, and the system is sustained by the liberal use of brandy, qui- 
nine, and other stimulants. The limb, placed in an easy, elevated position, is wrapped 
up in light flannel cloths, wrung out of a tepid solution of lead and opium, tension and 
throbbing being relieved by early and free incisions. Sometimes great comfort is expe- 
rienced from the employment of an emollient cataplasm, covered with laudanum and 
olive oil. Fetor is allayed by the chlorides, which may also sometimes be advantageously 
given internally. During convalescence, the cure must be promoted by nutritious food, 
and change of air. The most efficient disinfectants of poisoned commercial hair, hides, 
and other articles are sulphuric acid and a moist temperature at from 140° to 150° Fahr. 
CHAPTER XI 
RAILWAY INJURIES. 
Railway injuries present so many points of interest, and differ, withal, so much from 
other lesions, as to demand special notice in a work of this kind. Indeed, the differences 
between such injuries and ordinary wounds are quite as striking as the differences be- 
tween the latter and gunshot wounds, or the gunshot wounds of the present day as com- 
pared with those of former times, prior to the invention of the conical ball. Moreover, 
lesions of this kind are worthy of particular study, not less so on account of the frequency 
of their occurrence than the frightful mortality that attends them. In this country alone, 
where, in 1882, there are nearly 100,000 miles of railway, the loss of life, in one form or 
another, from these accidents, is absolutely appalling, the number of persons destroyed 
by them amounting annually to several thousand, while the number of those permanently 
maimed is vastly greater. 
The lesions in railway accidents may be caused by the passage of the wheel of the 
carriage, by the pressure of the buffer, or by fragments of broken timber entering the 408 
RAILWAY INJURIES. 
chap, xr. 
body, cutting, lacerating, and contusing the tissues, perforating the joints, and laying 
open the viscera. The most frightful shocks and concussions are generally caused by 
railway collisions, in which the passengers are thrown forcibly from their seats against 
such objects as may happen at the moment to be near them, the violence of the injury 
being generally in proportion to the speed of the train. Frightful accidents, attended 
with excessive injury of the soft parts and the bones, as well as extreme shock, placing 
limb and life in jeopardy, are of frequent occurrence from the passage of the wheels of 
street cars. 
Railway injuries may, like injuries from other causes, be limited exclusively to the soft 
parts, or, as is most generally the case, they may involve both these structures and the 
bones, the latter, indeed, often suffering in a far greater degree than the former. In 
extent they may be slight, on the one hand, or, on the other, so severe as to prove fatal, 
either instantaneously, without any attempt at reaction, or secondarily, as the result of 
inflammation and its consequences. In their character they may simply exhibit the 
features of a contusion, or they may occur in the form of a wound, either open or subcu- 
taneous, most generally the former, contusion and laceration preponderating. Beside 
these peculiarities, railway injuries are further distinguished from the more ordinary 
lesions by excessive shock and concussion of the nervous system, by the small amount of 
hemorrhage, by the impossibility of procuring union by the first intention, by the frequent 
necessity of amputation, and by the great liability to erysipelas, pyemia, and osteomyelitis ; 
all concurring to impart to these accidents distinctive features. 
These lesions may be grouped, according to their effects, under different heads: 1st. 
Cases that are instantaneously fatal, or that soon become fatal, either from shock and 
concussion, or from the combined influence of shock and hemorrhage; 2dly. Cases in 
which reaction occurs, followed by recovery, or by death from exhaustion, inflammation, 
erysipelas, or pyemia ; 3dly. Cases of incomplete recovery, some parts remaining perma- 
nently incapacitated ; 4thly. Cases in which remote effects, as epilepsy, hysteria, paralysis 
loss of memory, morbid sensibility, or insanity, manifest themselves, perhaps not until a 
number of months or even several years after the infliction of the primary injury. 
1st. In the worst forms of railway injury, death may be due solely to the violent con- 
cussion, not of the nervous system merely, but of the entire body, every organ and tissue 
feeling its baneful influence. In such a condition there may perhaps not be any outward 
evidence of injury, not even, it may be, a scratch upon the skin, although generally the 
injury sustained both by the soft parts and the bones is very great. In some of the more 
severe cases, the local injury is associated with extensive rupture of the capillary vessels. 
Thus, in one recorded by Mr. Hill, numerous vascular points, the size of a pin’s head, 
and, here and there, minute clots, existed in the muscles of the head, chest, and abdo- 
men, as well as in the brain, heart, lungs, liver, spleen, and kidneys. The blood, under 
such circumstances, is of a semifluid, black appearance, very much as in death from 
lightning. In fact, the whole train of morbid phenomena is such as clearly shows that 
death was occasioned by the sudden, total abstraction of nerve fluid. Such accidents find 
their counterpart in injuries caused by falls from a great height, as a tree or a scaffold, 
producing death instantaneously by concussion of the whole body. 
Excessive shock is often conjoined with more or less serious hemorrhage. The largest 
bleeding usually occurs in injuries of the extremities, attended with laceration of the prin- 
cipal vessels, as the femoral, popliteal, or tibial arteries and veins; but, now and then, as 
in railway lesions of the chest or abdomen, large quantities of blood may be poured out 
iuto the splanchnic cavities, thus greatly complicating the case, and rendering it more 
snrely fatal. 
Intense shock, rapidly terminating in death, may result from injury of a single organ, 
as the brain, heart, or lung, the rest having in great degree escaped. Such accidents find 
their counterpart in death from a blow or kick on the stomach. Or, the viscera may be 
free from injury, and the fatal shock be due solely to the extensive lesion sustained by the 
external parts, as those, for instance, of the lower extremity, the skin, muscles, vessels, 
and nerves being mashed and pulpified, the large joints torn open, and the bones crushed 
and ground to powder. 
2dly. Shock, although very violent, is often followed by reaction, even when there is 
very grave injury, in the same manner as in concussion of the brain from falls and blows 
on the head. In the generality of cases, the reaction is slow, twelve, twenty-four, or 
even forty-eight hours elapsing before it is fully established, the system frequently falter- 
ing in the interval even under the sustained employment of the most powerful stimulants. 
Or, the reaction, after various efforts, at length fails, and fatal collapse ensues. Some CHAP. XI. 
RAILWAY INJURIES. 
409 
times the system rallies sufficiently to admit of the removal of the injured structures by 
the knife, the patient, if there has been much shock or loss of blood, either dying under 
the operation or soon after ; or, if he survive the immediate effects, standing a fair chance 
of perishing from fever, erysipelas, or pyemia. Experience has proved that amputations 
performed for severe railway injuries afford a very high rate of mortality, far greater, 
indeed, than after almost any other class of lesions, those made by the round ball not 
excepted. The stump, in such cases, is not unfrequently assailed by erysipelas, osteomye- 
litis, or even gangrene, the disease either causing death or necessitating further operative 
interference. 
If an attempt be made to preserve the injured structures, the surgeon will run great 
risk of losing his patient by the violence of the resulting fever, erysipelas, gangrene, 
septicemia, pyemia, or profuse suppuration, death generally supervening within the first 
five, eight, or ten days. Railway wounds never unite by the first intention ; and in most 
cases, even when the contusion and laceration are comparatively slight, some degree of 
sloughing is almost inevitable. 
The symptoms of shock in railway accidents do not differ from those of shock produced 
by ordinary causes. When the accident has been uncommonly severe, as when a man is 
knocked down by a train in rapid motion, the patient is frightfully collapsed, the pulse 
and breathing are hardly perceptible, the countenance is of a deadly pallor, the pupils are 
widely dilated, and the surface of the body is covered with cold sweat. These symptoms 
often exist when there is no evidence whatever of local injury. 
3dly. Incomplete recovery after railroad accidents is of very frequent occurrence, and 
may manifest itself in a great variety of ways, depending upon the nature of the injury 
and the character of the organs or structures involved. Thus, special sensation is often 
impaired in accidents involving the base of the brain, as shown in the loss of the sense of 
smell, taste, sight, or hearing. Paralysis of an arm or of a leg, or even of one side of the 
body, may be caused by a severe wrench or twist of the spine, eventuating in direct pres- 
sure by displaced bone, or indirect pressure by effusion of blood. Atrophy of a part of a 
limb, or even of an entire limb, is by no means uncommon; sometimes a joint is perma- 
nently disabled ; and contraction of the muscles and tendons may be mentioned as another 
effect that properly falls under this head. The speech is occasionally considerably impaired, 
being weak and indistinct; and various anomalous symptoms are often present, as confusion 
of ideas, a sense of cold or of unnatural heat about the head, inability to attend to busi- 
ness, a pinched expression of the face, and a withered condition of the whole body. Occa- 
sionally, especially after injuries of certain nerves, there is a feeling of numbness, of 
formication, or of pricking, as if pins and needles were moved about in the parts. These 
and similar effects may be the sequences of the slightest as well as of the most violent 
injuries. 
4thly. Remote effects, coming on at a variable period after the primary, not unfre- 
quently follow upon railway accidents. These effects manifest themselves in various 
degrees as well as in various forms ; sometimes in one manner, and sometimes in another, 
from the slightest departure from the normal condition of an organ to the complete per- 
version of its functions. The exciting cause is more commonly a slight than a severe 
one, the patient, after having suffered from shock, having, perhaps, made a rapid recovery, 
or so nearly regained his mental and physical vigor as to be able in a short time to resume 
his accustomed occupation as if nothing had happened to him. By and by, however, 
generally after the lapse of several months, without any assignable cause, his general 
health gives way, or he gradually loses his control over some particular organ. The 
approaches denotive of these occurrences are usually very stealthy and insidious, and 
hence, long before the patient is made fully sensible of their import, the most serious 
pathological changes may take place at the seat of the original lesion ; changes which, if 
correctly interpreted at the time, might have easily been prevented, but which, now that 
they have acquired the ascendency, may lead to fatal, or, if not to fatal, to permanently 
ill consequences. Most of these remote effects are referable to injuries of the nervous 
system, more especially to those of the spinal cord and of the base of the brain, manifest- 
ing themselves in various forms of functional derangement and in impairment of the 
circulation and nutrition either of the entire body or of some particular part. 
Among the more common and distressing of these remote effects are various uneasy 
sensations in the head, as a feeling of numbness, dizziness, weight, and tension, as if a 
hoop were firmly stretched around it. Occasionally there are shooting pains, or pains 
seated at some particular spot, more or less tender on pressure ; a throbbing feeling is not 
uncommon; various kinds of noises are complained of; the mind is peevish and irritable; 410 
RAILWAY INJURIES. 
CHAP. XI. 
the ideas are confused ; the sleep is disturbed by harassing dreams ; volitional power, 
mental and physical, is greatly at fault; the patient is often very emotional, frequently 
bursting into tears, and he is unable to apply himself to business, the slightest effort of the 
kind being attended with an aggravation of suffering. The organs of the special senses 
are frequently affected, as is evinced by the impairment of the function of smell, hearing, 
taste, and sight. The speech is rarely much, if at all, involved. Marked strabismus 
occasionally exists. The countenance has a contracted appearance, and an uneasy expres- 
sion, the person often looking much older than he actually is, or than he did before he was 
hurt. The pulse is generally small, and somewhat above the numerical standard; the 
breathing is short and abnormally frequent; the digestive organs are deranged, the appe- 
tite being irregular, and the taste more or less vitiated ; the bowels are constipated, and, 
as assimilation is impaired, the patient loses weight and strength. The kidneys and the 
bladder usually act naturally, but the sexual functions are often very deeply implicated, 
and in some cases the individual is completely impotent. Paralysis often exists, more 
generally in the inferior than in the upper extremities, sometimes on one side and at 
other times on both ; in various degrees, from slight failure of motor power to total loss, 
occasionally associated with defective sensation, and usually coexistent with loss of tem- 
perature and clammy perspiration. In many cases the loss of power is confined to special 
muscles and tendons, which, in consequence, soon become permanently shortened and con- 
tracted, leaving the patient in a weak, tottering condition, and extremely liable to fall. 
More or less wasting of the affected limb generally occurs, amounting occasionally, in the 
more advanced stages of the complaint, to the most degraded atrophy. Among the more 
uncommon of the remote occurrences after railway accidents may be mentioned mental 
imbecility, epilepsy, and insanity, coming on, perhaps, at the end of several years, long 
after the patient had apparently completely recovered from the immediate effects of the 
injury. 
It is generally very difficult, if not impossible, to refer these effects to their true sources; 
it is reasonable, however, to suppose that in the great majority of cases they are essen- 
tially due to changes effected in the cineritious substance of the cerebro-spinal axis by 
inflammatory irritation. Occasionally the immediate cause undoubtedly is an effusion of 
plasma, or of this material and of serum, of serum alone, or of blood, either in a fluid or 
solid state, poured out at the time of the accident, remaining unabsorbed, and by its 
pressure interfering with the transmission of the nerve current. 
The prognosis in these secondary affections must necessarily depend upon the circum- 
stances of each individual case. If, after they have remained stationary for some time, 
or if, after various fluctuations and changes, there is a gradual but decided improvement 
in the symptoms and the general condition of the patient, strong hopes may be entertained 
of ultimate restoration ; the pi-ogress to health must, however, necessarily be slow, and it 
will be well, in order to guard against disappointment, to look for occasional interruptions. 
Now and then a case occurs in which the improvement is steady and persistent. The 
prognosis may be considered as unfavorable when there is a progressive increase of the 
local distress along with a gradual failure of the general health, the more especially when 
the downward tendency is due to great involvement of the cerebro-spinal axis, as indi- 
cated by loss of muscular power and perverted sensation. As it respects the continuance 
of life, the patient may last for many years, and eventually die of some intercurrent disease. 
In the treatment of railway injuries four distinct indications are presented : to relieve 
shock, to arrest hemorrhage, to prevent undue inflammation, and to guard against the 
occurrence of secondary effects. 
In the treatment of shock the same general rules are to be observed as in shock from 
any other cause ; the usual management being by recumbency, cold water, sinapisms, the 
smelling-bottle, stimulating injections, and, if the patient can swallow, by the exhibition 
of brandy and ammonia. Overaction is prevented by morphia and the neutral mixture 
in conjunction with veratrum viride and other suitable measures. 
Hemorrhage is controlled by ligature, torsion, acupressure, and styptics. Any wound 
that may exist is dressed and treated in the usual manner. If the injury occupy an ex- 
tremity, and is so excessive as to demand amputation, the operation should be performed 
as soon as reaction has been sufficiently established to enable the patient to bear the shock 
and loss of blood, the limb being always removed some distance beyond the apparent seat 
of the lesion, lest some of the bruised and lacerated tissues being left, gangrene may seize 
upon the stump. If the system has only partially rallied, anaesthetics should be dispensed 
with, the knife then often acting as a salutary stimulus, favoring reaction and increasing 
the chances of recovery. CHAP. XII. 
PROSTRATION, COLLAPSE, OR SHOCK. 
411 
Inflammation must be limited by the usual means, opium being freely given to control 
the heart’s action, to tranquillize the system, and to promote sleep ; the secretions are 
corrected with blue mass; and the heat of the skin is allayed by mild diaphoretics, and 
by sponging the surface frequently with tepid water containing a little alcohol and vine- 
gar. Quinine and tincture of iron are freely administered, if there has been much loss of 
blood; cooling drinks are used ; the temperature of the room is properly regulated ; and 
milk punch, beef essence, and the different kinds of broths are relied upon to sustain the 
system. 
Convalescence is carefully watched, any untoward occurrence being promptly met by 
appropriate measures. Local irritation is combated by leeches and blisters, aided by rest 
and elevation of the affected part. Bodily and mental excitement must be avoided, the 
bowels and secretions duly attended to, and the diet properly regulated. Involvement of 
the lungs and other internal organs must be guarded against by more than ordinary vigi- 
lance. If secondary effects ensue, a mild course of mercury will be indicated, the remedy 
in many cases being advantageously given in union with iodide of potassium. Slight 
ptyalism, steadily maintained for several consecutive weeks, is sometimes required. In 
these chronic affections great benefit is often derived from the use of the cold shower-bath, 
change of air, mild tonics, and the judicious application of electricity. 
CHAPTER XII. 
EFFECTS OF INJURIES UPON THE NERVOUS SYSTEM. 
Under this head may he considered the more immediate effects of injuries, as nervous 
depression, or shock, and, as it has not inaptly been termed, traumatic delirium. These 
effects may succeed to almost any lesion, however trivial or complicated, their production 
being greatly influenced by the temperament, habits, age, and idiosyncrasy of the indi- 
vidual ; and they deserve the most careful study, inasmuch as they are frequently followed 
by the worst consequences. The subject of tetanus might properly be included under the 
present division, but as this disease occasionally arises without any external injury, the 
discussion of it will be postponed until I come to speak of the affections of the nerves. 
SECT. 1 PROSTRATION, COLLAPSE, OR SHOCK. 
Shock is a depression of the vital powders, induced suddenly by external injury, and 
essentially dependent upon reflex paralysis of the entire circulatory system, but especially 
of the heart and abdominal vessels. It bears, in effect, the same relation to the nervous 
system as syncope to the vascular; in the one case the result is caused by inhibition of 
the vasomotor centres, in the other by a diminution of blood ; in both, the consequence 
is more or less prostration, with perturbation of mind and body, extremely variable both 
as to intensity and duration. When the nervous shock is severe, it may instantaneously 
terminate in death, as so often happens in falls and blows upon the head ; more generally, 
however, after having continued for an indefinite period, it passes into reaction, the pow- 
ers of life gradually coming up, as the different organs and the general system regain their 
nervous fluid. The most severe and fatal cases of shock are generally those that super- 
vene upon direct injury to the great nervous centres, as the brain and spinal cord ; no 
less disastrous effects occasionally succeed blows upon the epigastric region, in consequence 
of the violence thus inflicted upon the solar plexus of nerves. In some of these and simi- 
lar instances life is destroyed with the same rapidity as by lightning, the nervous fluid 
being instantaneously annihilated without the individual being rendered conscious of his 
doom. Such cases have their counterpart in those frightful hemorrhages in which, a 
large artery, as, for example, the aorta, being divided, the patient perishes in a few seconds 
from loss of blood. The blood is a vital fluid, the integrity of which is indispensably 
necessary to the well-being of the system and the maintenance of healthy action. But 
it is certainly not the only fluid entitled to this distinction ; the nervous fluid is both more 
subtle and more important as a life preserver. When blood flows away in a mighty and 
overwhelming torrent, the person dies, and life is then said to be destroyed, as it certainly 412 
EFFECTS OF INJURIES UPON THE NERVOUS SYSTEM, chap. xii. 
is, by the excessive sanguineous drainage. But in shock, the same effect may happen, 
and yet the body be literally surcharged with blood, not a single drop, perhaps, having 
been spilled in the accident causing the fatal result. Thus, of the two fluids, the nervous 
is, in every respect, the more important, because the more essential to life; and its dis- 
turbance is, therefore, a more frequent cause of death. 
Shock may be produced by a great variety of causes, some of a bodily, others of a 
mental, character; some external, others internal. It may be purely nervous, or partly 
nervous and partly hemorrhagic, that is, dependent upon the conjoined loss of the ner- 
vous and sanguineous fluids. The nature and extent of shock are greatly influenced by 
the state of the general health at the time of the accident, the amount of the injury, the 
importance of the part more directly assailed, and, also, in an especial manner, by the 
idiosyncrasy of the individual. There are some persons, soldiers, for example, of the 
most undoubted courage, men who would not hesitate to face the mouth of the cannon, 
who fall into a state of the most profound prostration from the most trifling accident; who 
turn pale and tremble like a leaf; whose minds are perfectly bewildered, and who are, as 
it were, completely stunned, from injuries so insignificant as not to effect, in the slightest 
degree, ordinary persons. Such an occurrence can only be explained by a reference to 
idiosyncrasy; and it has its counterpart in those persons who, although extremely ple- 
thoric, faint from the slightest loss of blood, or even from the mere sight of that fluid. 
There are other persons, on the contrary, whom hardly any accident, however severe, 
can shock ; they are insensible to pain; their nervous system is obtuse ; nothing affects 
them, either bodily or mentally; a severe blow may stun them, but the impression is 
transient; in a few minutes they are completely restored to consciousness and power. 
Here, again, is an example of idiosyncrasy, a peculiarity of organization; in the former 
case, the individual is all nerve, all sensibility ; in the latter, all blood, all muscle. But 
it is not only the nervous and irritable that suffer from shock ; the fat and corpulent are 
prone to be affected by it from the slightest causes, and hence such persons seldom make 
good subjects for the knife; they bear the loss of blood badly, and are extremely liable 
to perish from erysipelas and pyemia, in consequence, as it appears to me, rather of loss 
of nervous fluid than from any toxic state of the blood, or blood-poisoning, properly so 
called. There are some individuals whom the slightest operation will kill; touch them, 
and they are sure to die; they are destitute of life power, and incapable of resisting the 
slightest shock. The fainting produced by the pricking of a needle and the introduction 
of a bougie affords a familiar illustration of shock from trivial causes. 
Among the external causes of shock deserving of particular notice, on account of their 
crushing effects, are injuries of the skull and spine, such, for example, as are produced 
by a fall or blow; gunshot, railway, steamboat, and factory wounds; dislocations and 
fractures ; violent sprains, burns, and scalds ; and some of the more severe operations, as 
the extirpation of enormous tumors, and the amputation of the larger limbs, even when 
not attended with any considerable hemorrhage. The extraction of a tooth, in a very 
nervous person, has been known to occasion fatal shock. 
Severe shock is frequently produced by internal causes. One of the most familiar ex- 
amples of this kind is afforded in perforation of the bowel, consequent upon typhoid 
fever, and followed by extravasation of fecal matter. The moment this takes place, the 
shock is immense; if the patient had been struck severely on the head, it could not be 
more so ; in some cases it is so overwhelming as to destroy life in a few hours. The pain 
which attends the passage of a gall-stone, or of a renal concretion, is often followed by sim- 
ilar results; extravasation of urine may be mentioned as another illustration. Many a 
woman has perished from shock induced by severe labor; and the excessive prostration 
consequent upon apopleptic. seizures is familiar to every practitioner. 
The occurrence of shock is more or less influenced by the state of the system. What- 
ever undermines the vital powers renders the system less capable of resisting an effect of 
this kind, and should be duly considered in weighing the prognosis after a severe injury, 
or the probable consequences of a severe or protracted operation. Shock is never borne 
well by persons laboring under organic disease of the heart, liver, or kidneys, and for 
this reason they are, as a rule, unfit subjects for the knife. Children and old persons 
suffer, other things being equal, more disastrously from shock than persons in the prime 
and vigor of life. General debility, intemperance, anemia, and debauchery of any kind 
exercise an unfavorable influence, and often sadly interfere with reaction. The location 
of an injury often exercises a remarkable influence upon the degree and duration of shock. 
Compound fractures and dislocations and gunshot lesions of the splanchnic cavity and 
of their contents are often followed by severe and long-continued, if not overwhelming CHAP. XII. 
PROSTRATION, COLLAPSE, OR SHOCK. 
413 
shock ; but of all depressing effects of this kind, and the one most surely fatal is that con- 
sequent upon extensive scalds and bruises, in which the collapse is widespread and com- 
plete, often unattended even by the faintest possible show at reaction. 
Mental shock is often extremely severe, and is occasionally followed by the worst con- 
sequences, especially when it occurs during the progress of a severe illness, or after a 
severe surgical operation. Fright is perhaps the very worst of the causes of mental shock. 
The effect of terror, in suddenly exhausting nervous power, is well illustrated by the his- 
tory of those persons, who, sentenced to be bled to death, actually died on hearing water 
trickling into the basin, which they supposed to be blood issuing from their veins, after 
the arm had been slightly pricked, although no vessel had been opened. It is related of 
Desault that he one day lost a patient, about to be lithotomized, from sheer fright. The 
man, who was very cowardly, fainted and died under the impression that the operation 
was progressing, when this distinguished surgeon was, in fact, only tracing with his nail 
the line of the intended lesion on the perineum. A sick, bedridden person, in danger of 
being burnt to death, has been known to perish from shock brought on by excessive men- 
tal trepidation. The receipt of disagreeable news, the sudden loss of property, and, in 
short, violent mental emotion of almost any kind, may give rise to similar effects. 
Mental and corporeal shock are often combined; and it is then not uncommon to see 
the former preponderate, in a very marked degree, over the latter. The soldier on the 
field of battle may suffer from bodily shock induced by a severe wound; he may feel that 
he is badly hurt, but still he is sanguine of recovery, and cheerfully and manfully bears up 
under his affliction. The surgeon examines his wound, and, perceiving its grave charac- 
ter, informs him that it will probably cost him his life. Instantly the case assumes a dif- 
ferent aspect; the system is overwhelmed with perturbation and excitement; the vital 
powers are depressed to the utmost; and death takes place, perhaps, several days sooner 
than it would otherwise have done. In railway accidents, caused by the collision of the 
cars, this combination of mental and physical shock frequently exists in an astonishing 
degree, sometimes affecting large numbers of persons simultaneously. Here the shock is 
the result evidently not of mere concussion of the cerebro-spinal axis, but of the whole 
body and mind as well. 
The symptoms of shock, although extremely variable, are generally such as attend 
syncope from loss of blood, or concussion of the brain, which is itself only a form of ner- 
vous depression, or expenditure of the vital forces. If the accident has been slight, the 
effect will be that of a moderate stun, that is, the patient will experience some degree of 
mental confusion, look pale, and feel weak and tremulous; objects will appear dark to 
him, and he will probably reel, if not fall. Presently, however, especially if he lies 
down, reaction will take place, and in a short time he will recover both his mental and 
physical powers, so as to be able to converse, act, and walk in the same manner as before 
he was hurt. When the injury has been severe, the effect upon the nervous system will, 
of course, be proportionately greater. The patient, unable to support himself, falls to 
the ground, often, as he does so, inflicting serious violence upon his person. Consciousness, 
special sensation, and volition are, perhaps, completely abolished; the countenance is 
deadly pale ; the respiration is slow and feeble; the pulse is small, fluttering, and, at 
times, altogether imperceptible; the extremities become rapidly cold; and the surface is 
soon bathed with an abundant, clammy sweat. Gasping and sighing, with convulsive 
tremors, are often present, generally but too clearly denoting the serious character of the 
lesion. Not unfrequently there are involuntary discharges from the bowels, with nausea 
and even vomiting. 
The duration of these symptoms is subject to no little diversity ; at times they pass off 
in a few minutes, or, at furthest, in a few hours ; at other times they last for several days, 
and even then, perhaps, they do not disappear entirely, one or more persisting for a con- 
siderably longer period. When the shock is very severe, death may occur instantaneously, 
or the case may linger for some time in a state of doubt and uncertainty, with, now and 
then, an attempt at reaction, and at last prove fatal. Instances occasionally occur in which, 
after tolerably complete reaction has been established, the system sinks again into a par- 
tial state of collapse, the vital forces evidently having not sufficient stamina to maintain 
the functions of the brain and heart. Such cases are very liable to end fatally, generally 
within the first twenty-four hours after their occurrence. 
Reaction, after shock, is denoted by a gradual, or more or less rapid, resumption of the 
functions of the different organs, which awake, so to speak, from their slumber, and spring 
back again into life and happiness. One of the first evidences of this change is a return 
of the color of the face, with an increase of the heart’s action, as indicated by the state 414 
EFFECTS OF INJURIES UPON THE NERVOUS SYSTEM. 
CHAP. XII. 
of the pulse, which is not only stronger and fuller, but more steady and regular ; the 
respiration is more free and open ; the surface becomes warmer and dryer ; the sphincters 
again obey the will; and the mind regains its self-possession and power of action. Often 
the first symptom of reaction, after severe shock, is vomiting, followed by complete clear- 
ance of the contents of the stomach, itself generally a favorable sign, as it is often denotive 
of a return of muscular power. 
There is a form of shock which has been, not inaptly, called insidious, as the symptoms 
are generally of a masked character, and are, therefore, well calculated to deceive both 
the patient and practitioner. The person, although severely injured, congratulates him- 
self upon having made an excellent escape, and imagines that he is not only in no danger, 
but that he will soon be about again ; in fact, to look at him, one would hardly suppose, 
at first sight, that there was anything serious the matter; the countenance appears well, 
the breathing is good, the pulse is but little affected, except that it is too soft and frequent, 
and the mind, calm and collected, possesses its wonted vigor, the patient asking and an- 
swering questions very much as in health. But a more careful examination soon serves 
to show that deep mischief is lurking in the system; that the machinery of life has been 
rudely unhinged, and that the whole system is profoundly shocked; in a word, that the 
nervous fluid has been exhausted, and that there is not enough power in the constitution 
to reproduce and maintain it. The skin of such a person assumes an icterode, or sallow, 
cadaverous appearance, feeling at the same time doughy and inelastic ; the extremities are 
deadly cold; the pulse makes a desperate effort at reaction, but is, at best, weak and 
tremulous; there is little or no pain ; and the patient is altogether too composed and tran- 
quil for one who has sustained such an amount of violence. The system does not seem 
to be conscious of what has occurred ; its sensibilities are blunted, and it is incapable of 
suffering. Nature, to use the language of Hunter, does not feel the injury. 
The countenance, in this form of shock, has often a peculiarly, melancholy expression, 
as if foreshadowing the fatal event; a sad smile plays upon the lips, and illumines the 
lower part of the face, while the upper part wears a gloomy aspect, in striking contrast 
with the other. The forehead, as the patient looks at his attendants, especially if he has 
just been roused from sleep, is strongly knit and wrinkled, giving it a scowling and sinis- 
ter air. As the case progresses, the brain gradually sinks into a comatose condition, the 
signs of prostration become more pronounced, and death finally occurs from mere exhaus- 
tion, life seldom lasting longer than three or four days. 
The treatment of shock must be conducted with two objects in view, to promote reac- 
tion, and to moderate supervening inflammation, for to prevent it altogether is by no 
means always possible. 
A patient affected with shock should immediately be placed recumbently, all constric- 
tion should be removed from his person, free access of cold air should be provided, cold 
water should be dashed upon the face, smelling-bottles should be passed to and fro under 
the nose, and sinapisms should be applied to the extremities and to the precordial region. 
If the case is unusually severe, with a decidedly downward tendency, atropiaor tincture of 
digitalis should be injected under the skin, stimulating injections should be thrown into 
the rectum, and turpentine rubbed along the spine. If deglutition is practicable, brandy 
and water should be given, but in trying to convey these or any other fluids into the stom- 
ach, great care must be taken, otherwise they may descend into the windpipe, and so cause 
strangulation. The most prudent plan, in sucli a condition, is to introduce the drink with 
a spoon, the mouth being previously forced open, and a powerful effort made to excite the 
patient’s attention by hollowing loudly into his ears. If he cannot swallow, no attempt 
should be made at compulsion, but, for the reasons just mentioned, the effort should at once 
be discontinued. Stimulants, especially alcoholic, should never be given in large quanti- 
ties at a time. Teaspoonful doses, administered every five, ten, or fifteen minutes, are, 
as a rule, much more efficacious and reliable than larger quantities, the only effect of 
which, at least in many cases, is to add still further to the depression of the system, and, 
consequently, to render reaction more difficult, if not impracticable. The hypodermic in- 
jection of a fourth of a grain of morphia occasionally greatly promotes respiration. 
In the milder cases of shock, the most simple treatment often suffices to bring about 
reaction, as the recumbent posture, a drink of cold water, and the use of the fan and smell- 
ing-bottle. The blood and nervous fluid soon resume their wonted channels, and the 
vital forces rapidly regain their supremacy. 
In the mental form of shock, a soothing word, or an assurance of the absence of danger, 
often goes further in promptly effecting restoration than the most powerful stimulants, 
steadily and regularly administered. Persons suffering from this variety of prostration CHAP. XII. 
TRAUMATIC DELIRIUM. 
415 
are frequently much more frightened than hurt, and promptly regain their animation and 
self-possession on being told that their injuries are altogether of a simple, trivial charac- 
ter, devoid of all danger, both present and future. 
Occasionally reaction is sadly interfered with by an overloaded and oppressed stomach, 
as when the accident occurs soon after a hearty meal. In such cases, the patient often 
lies in a state of deadly pallor, with more or less retching, for hours, before he can shake 
off the oppressive burden. The indication obviously is to assist nature in her efforts at 
emesis, by the administration of a dose of alum, ipecacuanha, or sulphate or zinc, or, 
what, perhaps, is better, under such circumstances, equal parts of common salt and mus- 
tard, or mustard alone. Serious lesion of the brain is hardly to be considered as a con- 
traindication to such a course, when it is recollected that the digestive powers are com- 
pletely suspended, and with what difficulty reaction takes place when the stomach is 
oppressed by a heavy meal. 
The silly and reprehensible practice of bleeding persons laboring under the exhaustion 
of shock, once so common, has happily become obsolete. No surgeon should do anything 
without a reason, and it is, therefore, difficult to perceive what could ever have induced a 
procedure so contrary both to physiology and common sense. In the opinion of the vul- 
gar, there are no cases in which it is not proper, immediately after such an accident, to 
draw blood from the arm ; but assuredly no practitioner would yield his judgment to such 
an erroneous view, and perform an operation that might speedily prove destructive to his 
patient. Fortunately, whenever such an attempt is made by the ignorant and thoughtless 
charlatan, the blood generally refuses to flow, and consequently no harm is done. 
The second indication is to moderate the resulting inflammation. To do this, much 
maybe accomplised, in the way of prevention, by letting on the reaction gradually; 
avoiding, on the one hand, the undue use of stimulants, and, on the other, cautiously 
interposing antiphlogistics as occasion may arise for their exhibition. Proper allowance 
is made for the apparent violence of the symptoms, the excitement without power ; the 
struggle may be furious, but will in all likelihood be brief, for, if the previous depression 
has been at all severe, the flame will ere long cease of its own accord, or readily yield to 
the influence of very simple means, such, for instance, as sponging the surface frequently 
with cool or tepid water, and administering a little morphia and antimony, aided by i-igid 
abstinence, and perfect tranquillity of mind and body. Bleeding should be practised only 
in young and plethoric subjects, with a tendency to serious inflammation of some import- 
ant internal organ, and where, consequently, the fire is real, not feigned. The opposite 
course often exerts a most pernicious influence upon the patient’s recovery ; impairing his 
vital powers, and preventing the system from keeping up a due supply of healthy nervous 
fluid, so conducive to the restoration both of the part and system. As the secretions are 
commonly materially deranged in all cases of severe shock, early and effectual means 
should be adopted for their correction and improvement; a gentle mercurial purge will 
often admirably fulfil the indication, and render any further use of this class of remedies 
unnecessary. The diet for the first few days should consist mainly of animal broths, con- 
joined, if necessary, with milk punch, or wine whey, and cautiously followed by food of 
a solid and more substantial character. Starvation, in cases of severe shock, is not to 
be thought of. Such a course cannot be too pointedly or too forcibly condemned, as it is 
contrary alike to sound sense and the dictates of an enlightened experience. 
Anodynes are always borne well after severe shock, and should be administered early 
and freely, to allay vascular action and tranquillize the nervous system. The most suita- 
ble article is morphia, or the ammoniated tincture of opium, either alone or conjoined 
with valerian, the latter remedy being especially serviceable in nervous, hysterical per- 
sons, or what is far better, bromide of potassium. If the vital powers sensibly flag after 
the occurrence of reaction, recourse must be had, in addition to anodynes, to quinine, 
carbonate of ammonium, and brandy, liberally and diligently administered. Determination 
to internal organs is met by leeches, blisters, and other counterirritants. 
SECT. II TRAUMATIC DELIRIUM. 
One of the most unpleasant effects with which the surgeon has to contend in the treat- 
ment of wounds and other injuries, as well as after surgical operations, is the occurrence 
of delirium, at a period too, perhaps, when everything is apparently progressing in the 
most favorable and gratifying manner. All of a sudden, the nature of the case under- 
goes a remarkable change for the worse ; the horizon, just a moment before perfectly calm 
and serene, like a summer’s sky, is almost instantly overcast by a dark, lowering cloud; 416 
EFFECTS OF INJURIES UPON THE NERVOUS SYSTEM, chap. xxi. 
the system is thrown into nervous tremors, and the mind, agitated with disagreeable fore- 
bodings, is absorbed in some peculiar fancy, in which the patient imagines himself pursued 
by his enemies, or annoyed by persons peeping at him through the keyhole of his door, 
making grimaces at him through the window, or concerting measures for his destruction. 
Great diversity obtains in respect to the manner in which the disease is ushered in. In 
some cases the symptoms are apparently of a hysterical character, the patient laughing 
and talking in a loud, boisterous, and incoherent manner; or perhaps indulging in un- 
meaning jokes about the nature of his disease, the manner in which lie was hurt, or the 
conduct which he exhibited during the operation he has undergone. In another class of 
cases, by no means uncommon, he is completely absorbed in his business; he harnesses 
his horses, hitches them to the carriage, and swears at them because they do not move 
to please him. In some cases, again, he is seized with a species of religious frenzy; he 
prays and sings, and utters pious exclamations. Occasionally, he labors under some 
demoniacal delusion ; he fancies that the devil has possession of him, and that he is about 
to be carried to the infernal regions. Finally, there are instances in which the patient is 
sadly annoyed by the idea that he is pursued by snakes, dogs, or rats, or that some horri- 
ble reptile is trying to creep into his throat. In short, there is no end to these delusions, 
which are often as ludicrous to the observer as they are distressing to the patient, to whom 
they are always a source of severe suffering, not less so than if they were real. 
The cause of these symptoms is not always apparent. In the great majority of cases, 
they are produced, either directly or indirectly, by the inordinate use of alcoholic spirits, 
suddenly interrupted by the occurrence of a severe injury, attended, it may be, by dreadful 
shock or copious hemorrhage, thus greatly increasing the susceptibility of the nervous 
system to external and internal impressions. It is not necessary for their development 
that the individual should have been an habitual drunkard; they often show themselves 
nearly as readily if he has merely been a free drinker without having carried the use of 
liquor to the extent of intoxication. On the other hand, they occasionally occur in per- 
sons of the most temperate habits, who have, perhaps, never used alcohol in any form, 
or for any purpose whatever. Dupuytren, who first called attention to this variety of the 
disease, has given it the name of nervous delirium, and in the paper which he published 
on the subject he has reported a number of cases in which it supervened upon various 
kinds of injuries and operations, some of them of a very trivial character, or such as usu- 
ally produce no unpleasant results of any description, the patient rapidly recovering from 
their effects. It cannot be doubted that, in these cases, the affection is generally of a 
purely nervous nature, arising from the effects of the commotion inflicted upon a delicate 
and highly susceptible constitution. Under such circumstances, it is often mixed up with 
the effects of shock, rendering it difficult, if not impossible, to distinguish them accurately 
from each other. All practical surgeons have frequent opportunities of witnessing sucli 
cases. So far as my observation extends, I am not aware that any class of injuries is 
entirely exempt from the disease; sometimes the most trivial scratch or contusion is fol- 
lowed by it. Corpulent persons, who generally bear injuries and operations very badly, 
are particularly liable to this form of delirium. Burns and scalds, railway lesions, lacerated 
wounds, and compound fractures may be enumerated as among the more powerful causes 
of the affection. It has been thought that children are less liable to suffer from nervous 
delirium than adults and elderly subjects, but this is certainly not true; on the contrary, 
such is the susceptibility of the system at this tender age to physical and mental impres- 
sions that the slightest accident is often sufficient to develop it. If women are less fre- 
quently affected than men, it is simply because they are less exposed to the various exciting 
causes of the disease. There is certainly every other reason why they should suffer quite 
as much as men, if indeed not more. 
Nervous delirium generally comes on within the first twenty-four or forty-eight hours 
after the application of the exciting cause: it may last for a variable period, but rarely 
longer than five or six days, and may terminate either in health or in death, according 
to the gravity of the injury that has produced it. Its leading symptoms are a confused, 
wandering, or flighty state of the mind, with excessive vigilance; incoherency of speech 
and manner; absence of fever; an open, moist state of the skin; and little or no excite- 
ment of the pulse. The eyes have generally a wild expression, and the patient is easily 
disturbed by noise and light; as well as by the presence of his attendants. The appetite 
is usually impaired, the bowels are costive, the urine is scanty and rather high-colored, 
and the feet are disposed to be cold. If the patient be spoken to, he is generally readily 
roused, but soon lapses into his former condition. 
Nervous delirium properly so called, is easily distinguished from delirium tremens by the CHAP. XII. 
TRAUMATIC DELIRIUM. 
417 
absence of tremors, which form such a striking feature in the latter disease as to be char- 
acteristic. In delirium tremens the limbs are always in a tremulous condition ; the symp- 
tom comes on early in the attack, and generally lasts until the effects of the disease are 
nearly worn off. When the delirium is fully developed, the hands and fingers are inces- 
santly in motion, the patient carrying them to his mouth, face, and head, as if he were 
desirous of swallowing something, or removing some imaginary object from his person. 
The countenance is usually flushed, the eyes are deeply injected, the pulse is small, fre- 
quent, and quick, and the mind is roused with difficulty. Added to these circumstances 
is the history of the case, which generally affords valuable, if not conclusive, information 
respecting the patient’s habits prior to his attack. 
Delirium tremens, the result of alcoholic stimulation, is an extremely common occur- 
rence after all severe operations and injuries, and is one of the most serious causes of their 
mortality. Hence operations should never, if possible, be performed upon this class of 
persons so long as they can be put off, or without due preparation of the system ; special 
care should also be taken to avoid shock and loss of blood, as these are two of the most 
predisposing causes of the disease. 
It is well known that persons addicted to the immoderate use of opium and tobacco are 
liable to suffer from a peculiar form of nervous delirium after severe injuries and operations, 
characterized by excessive wakefulness, and a sense of indescribable wretchedness, with 
a bewildered and confused state of the mind, from which it is sometimes extremely diffi- 
cult to rouse them, so as to induce them to take their necessary food and medicine. It 
is not improbable that the excessive use of coffee and tea may, in persons of a very ner- 
vous, excitable temperament, produce similar effects. 
As was previously intimated, traumatic delirium usually sets in at an early period after 
the application of the external injury that provokes it; sometimes, however, the patient, 
perhaps contrary to expectation, goes on exceedingly well for some considerable time, 
happily surmounting the primary effects but suffering severely from the secondary, the con- 
sequence commonly of profuse, unhealthy, and exhausting suppuration. Again, instances 
occur in which he may have several attacks of this nervous suffering, with a variable 
interval of several days to several weeks, during which the mind may be perfectly clear 
and tranquil, the patient bearing up manfully under his disorders, sanguinely and fully 
anticipating none other than the most favorable termination. 
Trautmatic delirium, however induced, or in whatever manner it may present itself, is 
often extremely difficult of management. In its worst forms, the mind is frequently so 
completely disordered as to render confinement of the patients with the strait-waistcoat 
an indispensable element of the treatment. This is the more necessary when, as some- 
times happens, the patient is disposed to tear off the dressings from his wounds, to commit 
suicide, or to hurt his attendants and nurses. There is a remarkable circumstance which 
has been noticed by all practitioners in this class of persons; I allude to their utter indif- 
ference to pain. So great is this, in many instances, that they will not only uncover their 
wounds, but absolutely take pleasure in handling and picking them. Dupuytren refers to 
the case of an old man who, having been operated upon for strangulated hernia, tore away 
the dressings from his groin, and composedly squeezed his bowels, his friends all the 
while thinking he was getting on most admirably, such was his calm and quiet demeanor 
as he lay in bed. 
One of the most important indications, then, is to set a careful watch over the patient, 
in order that he may not do any harm either to himself or others ; in wounds and fractures 
the most perfect quietude is generally necessary, and the greatest pains should, therefore, 
be taken to secure it to the fullest extent, for whatever has a tendency to disturb and fret 
the parts will be sure to act as a cause of additional excitement. Moral force alone will 
be of no avail; the patient can neither reason correctly himself, nor comprehend the 
arguments of those about him. Hence, if medicine does not promptly effect the object, 
the only resource is the strait jacket, applied of course with proper care, so that, while, 
on the one hand, it shall not be so loose as to frustrate the intention of its use, it shall not, 
on the other, be so tight as to occasion injurious constriction ; a circumstance which, 
although a matter of paramount importance, is not always, as I well know from experi- 
ence, so scrupulously attended to as it should be by nurses and practitioners. 
The next indication is to tranquillize the nervous system, and induce sleep, or, in other 
words, to get rid of the reduntant excitement. To fulfil this indication, anodynes must 
be administered in such doses as shall most promptly and effectually bring about the 
desired result. The patient must sleep before he can obtain relief; the early interposi- 
tion, therefore, or suitable treatment is a matter of primary moment, attacking and routing 418 
EFFECTS OF INJURIES UPON THE NERVOUS SYSTEM. 
ciiap. xii. 
tlie disease, as it were, in its very incipiency, ere yet it has taken firm hold of the system. 
The most trustworthy and unexceptionable remedies are bromide of potassium and hydrate 
of chloral, in the proportion of twenty to thirty grains of the former to ten, fifteen, or 
twenty of the latter, repeated every two or three hours, until tranquil and refreshing sleep 
ensues. Of all the remedies that I have ever employed in the treatment of this class of 
cases, none have proved so speedily and permanently successful as these; and the great 
advantage which they possess over opium is that they do not cause nausea, constipation, 
headache, or, in short, any of the unpleasant effects which so often follow the exhibition 
of the latter article. There are, however, cases in which opium, either in the form of 
morphia or of the acetated tincture, in moderate and sustained doses, may be given with 
great advantage, especially if it be combined with tartar emetic. The latter remedy is 
particularly valuable when there is much vascular excitement, on account of its tendency 
to relax the system and promote perspiration. In the milder cases, the disease often 
promptly yields under the influence of a small quantity of laudanum, as from fifteen to 
twenty-five drops, in half an ounce of camphor-water and a drachm of compound tincture 
of cardamom, repeated every two or three hours. Dupuytren was in the habit of employ- 
ing laudanum as an injection in this disease, giving from ten to twenty drops with a small 
quantity of water, and frequently repeating the dose, until he succeeded in accomplishing 
his purpose. The medicine thus administered often exerts, he declares, a much more 
prompt and happy effect than when taken by the mouth; and the result of my own expe- 
rience amply corroborates the truth of the statement. As a preliminary measure, the 
rectum should be well cleared with an ordinary enema. 
When opium and its preparations cannot be borne, an excellent substitute will occa- 
sionally be found in hyoscyamus, lupulin, aconite, belladonna, or Indian hemp; aided by 
the cool shower-bath, followed by dry frictions, or, what will generally answer quite as 
well, and be more convenient, sponging of the surface freely and repeatedly with tepid, 
cool, or cold water. When the delirium is furious, leeches should be applied to the 
temples, or a large blister to the nape of the neck, and cold to the scalp, previously 
divested of hair. As a temporary expedient, and as an auxiliary for allaying the violence 
of the spasms, the judicious inhalation of chloroform may be of service. General bleed- 
ing will not be proper in any case, whether of nervous delirium or delirium tremens, un- 
less there is excessive plethora, with marked determination to the brain. In nervous, 
hysterical females, the free use of assafoetida and of valerianate of ammonia often pro- 
duces a very happy effect. 
When the patient has been an habitual drunkard, or when the delirium can be distinctly 
traced to the effects of the sudden withdrawal of alcoholic stimulation, the dictates of 
common sense, not less than the results of sound experience, indicate the propriety of a 
resumption of the accustomed drink, or a resort to an appropriate substitute. Much 
judgment will, of course, be necessary under such circumstances, lest the remedy be car- 
ried too far, causing thereby additional excitement and vigilance instead of composure 
and refreshing sleep. Nutritious food taken in small quantities, and frequently repeated, 
is generally very beneficial, the best articles being milk, beef essence, animal soup, and 
raw eggs beaten up with milk. When a mild stimulant is required there is hardly any- 
thing so reliable as a mixture of essence of brandy and catchup, or an infusion of capsicum. 
In most cases a good supply of nourishment is indispensably necessary to a cure. The 
bowels must not be neglected. A large dose of calomel, when there is much disorder of 
the secretions, given at the commencement of the disease, often excercises a powerful 
influence in quieting the nervous system and controlling morbid action. Vomiting, not 
unfrequently a prominent symptom, is most effectually relieved with the neutral mixture, 
champagne, and pounded ice. Sometimes a mustard emetic acts like a charm. CHAP. XIII. 
EXAMINATION OF THE PATIENT. 
419 
CHAPTER XIII. 
GENERAL DIAGNOSIS. 
Diagnosis is the art of distinguishing and identifying diseases and accidents, or, in 
other words, of determining their seat, nature, and effects. Its study is of paramount 
importance to every practitioner, and he should, therefore, omit no opportunity of improv- 
ing his knowledge of it. Its value, practically considered, has been felicitously expressed 
by Louis, the illustrious secretary of the French Academy of Surgery. “ The science of 
diagnosis,” says he, “ holds the highest rank among the different branches of the healing 
art, as it is at once the most useful and the most difficult. The discernment of the peculiar 
character of each kind of disease and of its different species constitutes the source of all 
curative indications. Without a clear and exact diagnosis, theory must always be at 
fault, and practice frequently uncertain.” It is by his knowledge of diagnosis that the 
practitioner acquires a command over disease which he who is destitute of it can never 
attain. It should, therefore, form the great object of his inquiry in every case of disease 
and accident; for to be able to locate and define their seat and character is almost to be 
able to cure them. To be incapable of doing this, is literally to grope in the dark ; or to 
toss to and fro, like a mariner without a helm, upon an ocean of uncertainty. To disen- 
tangle truth from error; to give to disease “ a local habitation and a name ;” to distinguish 
one injury from another; and to base upon the knowledge thus derived a rational and 
scientific course of treatment, calculated to restore the sufferer to comfort and health, are 
among the highest attributes of the practitioner, and require an amount of talent, tact, 
and experience such as few men possess. “ Know what ails the patient and he is already 
half cured,” is a Chinese aphorism affirmable in almost every instance. 
The very first thing that a surgeon should do when he is called to a case of disease is 
to set up an inquiry into its true nature; to ascertain where it is situated, or what struc- 
tures it involves ; how it has been brought about; what progress it has made ; and what 
are its essential characteristics, or in what particulars it differs from other lesions. In 
order to do this with any tolerable degree of success, it is necessary, in many cases, 
literally to interrogate every important organ and tissue of the body, with a view of 
ascertaining which of them are more directly implicated in the disorder, which are free 
from suffering, and which are affected only sympathetically. Such a step is generally 
indispensable when the lesion is of spontaneous origin, or when it arises without any 
appreciable cause. When the converse is the case, a less elaborate examination will 
usually suffice to supply the requisite light. Not unfrequently the nature of the complaint 
is perceived at a glance. 
SECT. I EXAMINATION OF THE PATIENT. 
To examine a patient well, so as to elicit all the light that may be necessary to a 
thorough comprehension of the nature of his malady, requires generally great tact and an 
extensive knowledge of morbid and healthy anatomy, physiology, pathology, and animal 
chemistry, not to say anything of microscopy, now so much employed as a means of 
diagnosis. Any one may make a superficial investigation, and in the more ordinary cases 
such a mode of procedure may perhaps be all that is required; but under opposite circum- 
stances, where everything is shrouded in obscurity, nothing short of the most patient and 
elaborate exploration will usually answer the purpose. Knowledge and tact alone, how- 
ever, will not insure success; they may go very far, it is true, in enabling the practitioner 
to solve the mysteries of a case, but unless they are aided by a nice faculty of observation, 
and by a just sense of discrimination, he will never be able to analyze and group the 
facts presented to him in such a manner as to render them fully available when he comes 
to apply his therapeutic agents. Unfortunately, however, the power of observation is a 
rare gift, which few possess, and still fewer use to advantage. Surgeons, like physicians, 
have eyes, but they do not always see, and ears, but they do not always hear. Another 420 
GENERAL DIAGNOSIS. 
CHAP. XIII. 
fault, of which, unfortunately, too many, even among the most sagacious and best informed, 
are frequently guilty, is the hasty manner in which examinations are made; and, hence, 
it is no wonder that so many disgraceful and fatal blunders are daily committed by men 
who, if they would only allow themselves proper time, might see disease as clearly as if 
they were looking at it in a mirror. Hasty examinations commonly lead to hasty deduc- 
tions, as hasty deductions do to hasty generalization and slovenly practice. All practi- 
tioners do not, of course, require the same amount of time to arrive at a correct judgment 
respecting the diagnosis of their cases ; some literally jump at conclusions ; others reach 
them only by a slow and tedious process of investigation and induction. Of the two, the 
latter are generally the safer practitioners. 
The object of an examination is often seriously interfered with, if not entirely frusti'ated, 
by the want of cooperation of the patient, in consequence of his timidity, his want of 
intelligence, or the perverseness of his disposition. Much adroitness is, therefore, often 
required to bring out the desired result; fully as much as the lawyer is obliged to expend 
in the examination of a witness who is incapable of appreciating the responsibility of his 
position, or of making a proper use of his knowledge. To gain the confidence of a 
patient is one of the first duties of a practitioner, as this is often necessary not only to a 
full development of the history of his case, but to its successful management. A gentle 
word, an agreeable tone, a winning manner, are well calculated to effect this result, and 
are, practically considered, attributes of the highest value. “To question fitly,” says 
Rousseau, “ is the art of a master.”- The examination should always be conducted with 
the greatest delicacy; no unnecessary exposure should be made; and great care should be 
taken to guard against fatigue, especially when the patient is exhausted by disease, shock, 
or loss of blood. 
Age, occupation, climate, and habits of life, being so many circumstances calculated to 
modify morbid action, should be among the first objects of inquiry at the bedside of the 
sick. There are many diseases which occur only at particular periods of life. Thus, 
scrofula is most common in children, scirrhus in elderly persons, chronic enlargement of 
the prostate in advanced age. The influence of occupation in the production of disease 
is well shown in hemorrhoids, varix, and ulcers of the legs, and, to go no further, in 
necrosis of the lower jaw in persons engaged in the manufacture of lueifer matches. Gout, 
rheumatism, pneumonia, and pleurisy are most common in northern latitudes, while 
dysentery, hepatitis, and fever are most frequent in southern. Individuals of dissipated 
habits are particularly prone to erysipelas, boils, and carbuncles, and are often attacked 
with delirium tremens wdien they become the subjects of severe injuries, as lacerated 
wounds, fractures, and dislocations. 
Particular inquiry should be made into the previous history of the case; wdiether there 
is any hereditary predisposition to disease; whether the suffering organ was ever similarly 
affected ; how the present attack came on, howr long it has been in progress, and what 
have been its chief symptoms. ‘ A careful examination of this kind cannot fail to elicit 
important and valuable information, which, if properly applied, may go far in saving the 
patient’s life, or in cutting short his disease. 
A knowledge of the causes of diseases often throws valuable light upon their diagnosis. 
Thus, the knowledge that a youth affected with urethritis recently had connection with a 
lewd female, at once leads to a proper comprehension of the nature of the case; and in 
the same manner important aid may be obtained in deciding between a specific and a 
non-specific ulcer on the head of the penis. The diagnosis of a malignant pustule upon 
the hand is generally determined at a glance by a surgeon of experience; but one of an 
opposite character will hardly arrive at such a result without being told that the patient 
a few days previously was engaged in flaying a diseased ox, or in handling green hides. 
During the existence of endemic and epidemic diseases, all persons brought within their 
influence are liable to their attacks, and the similarity of their symptoms is consequently 
sufficient to stamp their character. The knowledge that pyemia frequently follows upon 
severe injuries and capital operations is of the greatest value to the practitioner, as it 
enables him at once to interpret correctly the symptoms which attend that peculiar affec- 
tion, the nature of which was so long a mystery. 
In accidents, a knowledge of the manner of their occurrence is often a matter of great 
moment in a diagnostic point of view. Thus, if a man, in the act of falling from a con- 
siderable height, has alighted upon the vertex, and is immediately rendered insensible, 
and particularly if he remains in that condition for a long time, the inference is strong 
that the base of the skull is fractured, and that he will perish from the effects of the 
lesion, although there may be no apparent injury upon the portion of the head which re- CHAP. XIII. 
EXAMINATION OF THE DIFFERENT ORGANS. 
ceived the blow. In railway accidents the leg may be severely hurt, and yet not suffi- 
ciently so to account for the extraordinary depression of the system ; inquiry discloses the 
fact that the body was violently compressed between the car and a post, and a more 
thorough exploration leads to the discovery of a rupture of the spleen, liver, bowel, or 
bladder; a circumstance which at once establishes the diagnosis, and prevents the patient 
from being subjected to useless amputation. 
When the patient is unconscious, whether from disease or accident, valuable information 
respecting the nature of the affection may often be obtained from his nurses and friends; 
or, in the latter case, from the by-standers, who thus become important witnesses of 
what transpired at the moment in regard to the manner in which the injury was inflicted, 
the previous state of the intellect, and the condition of the person immediately consequent 
upon the receipt of the lesion. 
In the more obscure cases of diseases and accidents, the diagnosis can be arrived at 
only after the most patient, thorough, and systematic examination, a random exploration 
being worse than useless. Every organ must be questioned, and even then it will often 
be extremely difficult to determine what the lesion really is. In my own examinations I 
usually begin with the alimentary canal, from which I pass, successively, to the abdominal 
and pelvic viscera, the lungs and their envelops, the heart, brain, and spinal cord, and, 
finally, the external surface, carefully noting everything of importance as I proceed. In 
this manner, it is difficult for any serious disease to escape detection, if the practitioner is 
at all endowed with the faculty of correct observation. 
EXAMINATION OF TIIE DIFFERENT ORGANS. 
Digestive Organs—Very useful diagnostic information is generally afforded by the 
state of the tongue in surgical affections. In traumatic fever, abscesses, rheumatism, and 
gout, the organ is unnaturally dry, and covered with a thick, white fur, at the same time 
that its tip and edges are abnormally red. A narrow, pointed, or accumulated appearance 
of the tongue is also frequently observed under these circumstances, especially in young 
subjects. In profuse hemorrhages, the tongue is generally very pallid, soft, flabby, and 
indented at the edges. A dry, brownish, and tremulous state of the organ, with diffi- 
culty of protrusion, is generally denotive of the existence of a typhoid condition of the 
system, and, in connection with other symptoms of exhaustion, is to be regarded as an 
unfavorable occurrence. It is the kind of tongue which commonly attends gangrene, 
malignant erysipelas, and the latter stages of traumatic fever. 
The appearances of the tongue sometimes afford useful hints respecting the state of the 
digestive apparatus, and even of the general system. Thus, aphthae upon this organ, or 
small ulcers scattered over its surface, are usually denotive of chronic gastric disorder, or 
derangement of the stomach and liver, by correcting which the disease promptly vanishes. 
In constitutional syphilis, the existence of mucous tubercles upon the tongue affords at 
once a satisfactory solution of the nature of the complaint. The presence of an excavated 
ulcer upon this organ, or upon the tonsils, with a copper-colored border and a foul bottom, 
is generally equally diagnostic of a contaminated state of the system. 
A thick and tumid upper lip is generally denotive of a scrofulous taint of the system, 
or of a vitiated state of the alimentary canal, depending upon the presence of worms, and 
disorder of the hepatic and follicular secretions. A cracked, chapped, or fissured state 
of the lower lip is often an accompaniment of general plethora, overfeeding, and gastro- 
enteric derangement. A pale prolabium is indicative of a deficiency of the coloring mat- 
ter of the blood, and of the necessity of tonics. 
Useful information is sometimes derived from an examination of the gums. A red, 
spongy, and tumid state of these structures is usually denotive of a scorbutic diathesis, espe- 
cially if it be conjoined with frequent bleeding and hemorrhagic spots in different parts 
of the body. An eroded appearance is indicative of an accumulation of tartar or of caries 
of the teeth, while the presence of sordes is expressive of a typhoid condition of the system. 
Pain in the throat and difficulty of deglutition are evidences of tonsillitis, and of dis- 
ease or mechanical obstruction of the oesophagus. A careful inspection of the fauces and 
the introduction of the probang usually readily determine the precise locality of the affec- 
tion, as well as its nature. In the former case, the tongue is carefully depressed with the 
handle of a spoon, or a tongue-holder, the mouth being widely opened as the patient sits 
upon a chair in a strong light; in the latter, the surgeon, standing behind the patient, 
whose head rests against his chest, carries the instrument gently and cautiously along the 
tube until it comes in contact with the obstruction, which is not passed all at once, or 422 
GENERAL DIAGNOSIS. 
CHAP. XIII. 
forcibly, lest undue violence should be inflicted, perhaps eventuating in rupture, inflam- 
mation, or ulceration of the oesophagus. 
No examination in any case of disease, if at all serious, whether surgical or medical, 
can he considered as complete without a thorough exploration of the condition of the 
stomach and bowels. When it is recollected that disorder of the secretions of these 
organs, the presence of irritating ingesta, or the accumulation of fecal matter, is frequently 
a source of disease in other parts of the body, as well as in these organs themselves, the 
importance of an attentive examination of them cannot be too much insisted upon. The 
insertion of the finger into the rectum, and the use of the speculum, often lead to the 
most useful knowledge of the condition of the anus and lower bowel. An examination of 
the alvine evacuations not unfrequently reveals important information in regard to the 
state of the liver, as the presence, absence, or quality of the bile, and the action of the 
mucous follicles of the alimentary tube, and should never be omitted in any case of serious 
disease or accident. 
Intellect The intelligence is often remarkably altered in disease and accident. Deli- 
rium and incoherency are common effects of all lesions attended with high arterial excite- 
ment. Their character, degree, and duration vary much in different cases, and are 
greatly influenced by surrounding and intrinsic circumstances, as the nature of our treat- 
ment, the intensity of the morbid action, the importance of the affected organ, and 
probably also by the idiosyncrasy of the individual. In general, as they are of a purely 
sympathetic character, they rapidly disappear with the excitement that induced them ; 
coming and going, perhaps, several times in the twenty-four hours, especially during the 
vesperal and nocturnal exacerbations which are so liable to distinguish most febrile attacks, 
whether traumatic or idiopathic. 
In organic disease of the brain and its envelops, on the contrary, a different order of 
things usually occurs. Here the delirium, once fairly begun, continues uninterruptedly, 
although it may be characterized by intervals of remission ; and, as the morbid action 
progresses, it generally lapses into stupor, and this, ere long, into deep coma, which is but 
too often the immediate forerunner of dissolution. In compression of the brain, whether 
from extravasated blood, excessive congestion of the cerebral vessels, effusion of serum, 
or depression of the cranial bones, the intelligence is commonly completely abolished ; 
the patient is deprived of all sensation and volition, and cannot be l-oused by the most 
powerful stimulants. He is, in fact, a mere automaton, dead to all surrounding impres- 
sions. If, from any cause, inflammation of the brain or of its membranes arise, the face 
soon becomes flushed, the eye suffused, the pupil contracted and impatient of light, the 
skin hot and dry, and the pulse quick, hard, and frequent. Delirium soon sets in ; the 
mind becomes incoherent, and, although questions may still with some effort be answered 
rationally, yet the patient speedily lapses into his former condition, knitting his brows, 
tossing from side to side, withdrawing his hand from the attendant, muttering constantly, 
and falling gradually into a more unconscious state. Rigors generally occur early in the 
disease, and are always denotive of great danger. If effusion of serum, lymph, or pus 
take place to any considerable extent, convulsions and deep coma are sure to follow, soon 
terminating in death. 
Countenance The state of the countenance is always a subject of inquiry with the 
intelligent practitioner. The mirror of the soul, it reflects, to a greater or less extent, alike 
the sensations of pleasure and of pain, of joy and of sorrow, and is thus capable of sup- 
plying important diagnostic indications in a great variety of diseases and accidents. To 
vail attention to all the details which necessarily connect themselves with the study of the 
physiognomy under these circumstances, would be out of place in such a work as this, and 
I shall, therefore, content myself’ by referring to a few of the more frequent and con- 
spicuous. 
Excessive pallor of the countenance, especially of the prolabia, is generally denotive of 
great loss of blood, or of extreme shock of the nervous system. In the latter case it is 
often associated with a peculiar withered and shrunken expression of the features, remind- 
ing one sensibly of the decay of a leaf in autumn. In apoplectic affections of the brain, 
the face is turgid, flushed, and paralyzed on one side, thus causing serious distortion, the 
angle of the mouth being drawn to the opposite side, while the eyelid on the affected side 
has a drooping appearance, descending hardly half-way over the ball. In general inflam- 
matory fever, whether the result of accident or of internal causes, the countenance is red 
and tumid, the eye is suffused, and the ala of the nose is rapidly dilated and contracted 
by the hurried inspiration. When the breathing is much embarrassed, as when there is 
deep congestion of the lungs, or mechanical obstruction to the entrance of the air, as CHAP. XIII. 
EXAMINATION OF THE DIFFERENT ORGANS. 
423 
when a foreign body exists in the larynx or trachea, the face is livid and often remarkably 
puffy, particularly when the affection is of long standing, and accompanied by oedema of 
the subcutaneous connective tissue. All painful affections of these organs are characterized 
by an anxious expression of the features, attended by an unusual dilatation of the nostrils 
during each act of inspiration, and by a peculiar heaving movement of the chest. “ In 
inflammation of the abdominal viscera,” observes Dr. Marshall Hall, “attended with severe 
pain, the muscles of the face are in a state of continued contraction ; the features are unnat- 
urally acute, the forehead is wrinkled, and the brows knit. The nostrils are acute and 
drawn up; the wrinkles, which pass from them obliquely downwards, are deeply marked; 
the upper lip is drawn upwards, and the under one frequently downwards, so as to expose 
the teeth. The state of the features is aggravated on any increase of the pain from change 
of position or external pressure. When the abdominal pain arises from spasm, the muscles 
of the face are exceedingly contracted and distorted during the paroxysms of pain ; but 
in the intervals of the paroxysms the countenance assumes a calm and placid aspect.” 
The diagnostic value of the Hippocratic countenance has long been recognized by prac- 
titioners. Its presence is always denotive of extreme danger, and is commonly associated 
with other symptoms of an untoward import, as twitching of the tendons, high delirium, 
a dry tongue, sordes on the teeth and gums, and excessive prostration. It consists in a 
peculiarly sharp, retracted, and withered appearance of the features, and generally attends 
the closing scenes of all typhoid states of the system, whatever may be their cause or 
character. 
Respiratory Organs—The state of the voice often furnishes useful information respect- 
ing the nature of the lesions of the larynx and trachea. Its peculiarity in croup is well 
known, being either sharp and shrill, like the crowing of a young cock, or low, hoarse, 
and almost extinct, especially if the disease has made considerable progress. In oedema 
of the glottis, without being always hoarse, it is generally reduced to a mere whisper; 
and in thickening of the vocal cords and ulceration of the mucous membrane of the larynx, 
partial loss of voice, and ultimately complete aphonia, generally attend. 
The respiration should always be attentively examined. In all acute diseases, attended 
with unusual vascular excitement, it is increased in frequency, short, and laborious. In 
pneumonia and pleurisy it is generally diaphragmatic, the intercostal muscles being almost 
completely quiescent, with hardly any perceptible elevation and depression of the ribs. 
The patient, alarmed and anxious, breathes with great difficulty, dilating his nostrils at 
every inspiration, and raising the shoulders and upper part of the chest, so as to draw iii 
as much air as possible at each effort. In inflammation of the abdominal viscera, on the 
contrary, the diaphragm is nearly stationary, while the intercostal muscles are in full play, 
the act of inspiration being short and panting, lest the descent of the diaphragm should 
produce an aggravation of suffering by rudely compressing the affected organs. In affec- 
tions attended with cerebral congestion, effusion of blood, or depression of the skull, the 
breathing is slow, labored, and irregular; often stertorous, and accompanied by a peculiar 
whiff. In spasmodic diseases of the respiratory organs, the inspiration is quick and im- 
perfect, as if the patient was unable to dilate the chest, and is usually accompanied with 
a characteristic wheezing sound, often audible at a considerable distance, during expira- 
tion, which is, at the same time, labored, and protracted. Short, difficult, and anxious 
breathing, aggravated by muscular exertion, as in ascending a hill, or rapid talking, is 
generally denotive of hydrothorax, of solidification of the lungs, or of organic disease of 
the heart and great vessels. 
Heart and Pulse—The diagnostic signs manifested by the heart and arteries deserve 
careful consideration. In examining the pulse, the exponent of the great central organ 
of the circulation, particular attention should be paid to its frequency, volume, and force, 
as these constitute the leading features by which the practitioner judges of the state of the 
system ; or, in other words, of the character and effects of the morbid action. To do this 
properly requires not a little knowledge and experience, for nothing varies more than the 
condition of the pulse in health and disease. Hence it is not surprising that it should 
have been pronounced by one of the ancient physicians to be the most fallacious of 
symptoms. 
In traumatic fever the pulse, as a general rule, is quick, frequent, and hard, and similar 
qualities usually characterize it in idiopathic affections. The increase in the number of 
its beats ranges from ten to thirty and even forty in the minute ; they are performed with 
a peculiar sharpness and rapidity, and the blood is sent into the arteries with such momen- 
tum as to cause their coats to rebound under the finger, offering thus a decided resistance 
to its pressure. When this is the case, the pulse is said to be hard. Hardness, quickness, 424 
GENERAL DIAGNOSIS. 
CHAP. XIII. 
and frequency are often associated with fulness, especially in very plethoric subjects, 
laboring under intense inflammatory excitement; but such a coincidence is by no means 
always necessarily present; on the contrary, instances occur where the pulse is so exceed- 
ingly small and thready as to require some care to detect it. This is generally the char- 
acter of the pulse in peritonitis, from whatever cause arising, and, therefore, it affords 
valuable diagnostic information. In certain affections of the brain, as in compression, 
whether a result of apoplexy or external injury, the pulse is slow, full, and laboring, as if 
the heart were oppressed by a heavy load which it is found difficult to carry or to shake 
off. The pulse after hemorrhage is strikingly peculiar, although it is not easy to define its 
character; it may be described as being very sharp, quick, and thrilling, as if the blood 
were sent into the artery with a kind of jerk, imparting thus a vibratory sensation to the 
finger. Once felt, it is impossible ever to forget it. An intermittent pulse is generally 
denotive of organic disease of the brain, or of the heart, lungs, or great vessels; some- 
times, however, it appears to be the result altogether of functional disease, as dyspepsia, 
or gastro-intestinal irritation. 
In examining the pulse with a view to its diagnostic value, it is to be remembered that 
it may be naturally slow or frequent, hard or soft, full or small, strong or feeble, depend- 
ing upon idiosyncrasy, or the effects of previous or existing disease. 
The time and mode of examining the pulse require some attention. Asa general rule, 
the surgeon should not put his hand upon the wrist immediately after he has sat down by 
the side of the bed, as such a course would be likely to cause alarm, and thus lead to 
erroneous inferences. Nor should he use a watch for the purpose of counting it, especially 
if the patient is very sick and nervous, as this also might excite injurious apprehension. 
In fact, it is impossible to conduct the examination too carefully ; for, unless this be done, 
the intention of the practitioner will often be completely thwarted, simply in consequence 
of his awkwardness. At least two fingers should be placed upon the radial artery, and 
the application should be continued sufficiently long to enable him to determine fully the 
character of its beats, particularly their frequency, volume, and power of resistance. 
Kidneys The renal secretion should claim particular attention in every severe case 
of accident and disease. A very superficial inspection will generally at once detect re- 
markable deviations from the normal standard, both as it respects the color, quantity and 
consistence of this fluid, as well as any tendency it may manifest to the formation of 
deposits after having stood for some time in the receiver. But if a more thorough inves- 
tigation be deemed necessary, as when organic disease of the kidney is suspected, or with 
a view to the detection of the existence of any particular calculous diathesis, a more 
minute and elaborate examination, conducted with the microscope and chemical tests, 
will be required; and it need hardly be added that such a procedure generally calls for an 
amount of knowledge, skill, and experience such as few professional men possess. As 
this subject will receive special consideration in the chapter on the urine and its deposits, 
no further allusion to it need here be made. 
Finally the practitioner must not neglect to examine the state of the skin, noting par- 
ticularly the character of its temperature, the presence or absence of moisture, the degree 
of its contractility, and any change of color it may have experienced ; the condition of the 
limbs, as to the existence or non-existence of paralysis or injury ; and, lastly, the state 
of the genital organs, if, upon inquiry, there is reason to suppose that they are either the 
seat of the morbid action, or that they deeply sympathize in the disorder of other parts of 
the body. 
SECT. II MENSURATION. 
An examination of the dimensions of a part occasionally affords valuable aid in deter- 
mining the diagnosis of its lesions. Such a mode of investigation is particularly service- 
able in fractures and dislocations, in coxalgia, and in affections of the chest, especially in 
pleuritic effusions, so common after accidents and disease. 
The best contrivance for ascertaining the amount of shortening in an injured or diseased 
limb is the graduated tape, used by seamstresses and tailors, and inclosed in a metallic 
case, so as to admit of its being carried in the pocket. It is a yard in length, by half an 
inch in width, and being composed of oil-cloth it is perfectly inextensible, thus rendering 
it admirably adapted to the object. In order to attain perfect accuracy of result, it is 
necessary that the sound and affected members should be placed as nearly as possible 
parallel with each other ; for if there is the slightest variation in their inclination it must 
proportionately impair the value of the examination, if not completely destroy it. Thus, 
for example, in trying to ascertain the amount of overlapping of the fragments of a broken CHAP. XIII. 
ATTITUDE OF THE PATIENT. 
425 
femur, the two thighs should be placed not only parallel with each other, but great care 
should be taken that they, as well as the buttocks, rest evenly upon the bed, table, or floor 
on which the patient lies. Finally, in order to perform the operation in the most unex- 
ceptionable manner, the additional precaution should be taken of maintaining the head, 
chest, pelvis, and extremities all in a straight line until the measurement is completed. 
After the limbs and body have been adjusted as here described, two flxed points are 
selected, between which the tape is stretched. Thus, to take the thigh again as an illus- 
tration, the two proper points are the anterior superior spinous process of the ilium and 
the inner border of the patella. The distance between these two prominences having 
been ascertained upon the affected member, the tape is next stretched between the same 
points on the sound limb, the difference in the length between the two being the sum of 
the shortening of the injured bone. When no fixed points can be obtained, a mark may 
be made upon the skin, either with ink, iodine, or nitrate of silver. In trying to ascertain 
the precise amount of shortening in fractures of the extremities, especially the lower, we 
must not overlook the important fact, that there is in many cases, naturally, a marked dif- 
ference in the length of the limbs, the disparity varying from a few lines to half an inch 
or even an inch. 
The graduated tape may also be employed for measuring the diameter of a limb, as in 
disease of an important joint, or a suspected morbid growth. Or, instead of this, recourse 
may be had to the graduated compass of Mayor, which, however, notwithstanding its 
ingenious mechanism, really possesses no positive advantages over the tape. This instru- 
ment consists of four pieces, the central one, which is a flat rod, being marked by a scale 
of inches and lines. 
Mensuration of the chest is often practised in pleuritic effusions, although such a means 
of diagnosis is seldom necessary in the hands of an intelligent and skilful surgeon, auscul- 
tation, percussion, and inspection being quite sufficient for the purpose in almost every 
instance that may come under his observation. When more than ordinary care is desired, 
the graduated tape, extending from the middle of the sternum to the centre of the spine, 
will readily supply the requisite information. 
The plumb-line is occasionally used for determining the existence of curvature of the 
spine; such an expedient, however, can only be necessary in the earlier stages of the 
malady, before marked deformity has set in. When the disease is fully established, such 
a mode of investigation would savor alike of affectation and stupidity. 
A ready method of determining the angle of on object, as, for example, that of a broken 
bone, has been suggested by Malgaigne. It consists in applying a sheet of paper, by its 
edge, to the limb so as to represent its vertical axis. At the point where the axis changes 
its direction, the paper is so folded as to follow it exactly; the result will be that the 
salient angle thus found will necessarily give the entering one caused by the fragments ot 
the deformed bone. In order to determine the degree of this angle, a sheet of paper is 
folded in four, which “ makes a right angle, or 90° ; folding again, one of the sides affords 
an angle of 45° ; adding this angle of 45° to the unchanged right angle, gives an angle 
of 135°, and so on. Applying now this extemporaneous quadrant to the already ascer- 
tained angle of the fracture, we obtain without trouble, or loss of time, as accurate an 
estimate as possible.” 
SECT. III.—ATTITUDE OF THE PATIENT. 
The attitude of the patient and the position of the affected part are variously and often 
remarkably changed in disease and accidents, and afford, in many cases, valuable diag- 
nostic indications, not attainable in any other way. The study of the variations in the 
configuration of the body is of much greater moment, as a means of distinguishing differ- 
ent lesions, than is generally imagined, and has received less attention than its impor- 
tance merits. In some affections, the diagnosis absolutely hinges mainly, if not entirely, 
upon the attitude assumed by the patient in consequence of the morbid action. We need 
only instance the peculiar distortion of the body in tetanus, caused by the continued and 
violent contraction of the muscles, drawing the trunk, in one case, powerfully forwards, 
in another backwards, and in a third to one side. No one that has ever witnessed this 
change of configuration can possibly mistake it in a similar attack ; for there is no other 
lesion capable of producing it. In caries of the vertebrae, usually known as Pott2s disease, 
and in lateral curvature of the spine, the result of irregular muscular action, the distortion 
of the body is characteristic. In coxalgia, the flattening of the hip, the elevation of the 426 
GENERAL DIAGNOSIS. 
CHAP. XIII. 
pelvis of the affected side, the retraction of the heel, and the effacement of the femoro- 
gluteal crease are among the most valuable diagnostic signs of the malady. 
In disease and injuries of the chest, the position of the patient is often highly character- 
istic. In inflammation of the lungs and pleura, attended with slight effusion, he generally 
lies on the affected side, or else upon his back, not on the sound side, as the weight and 
pressure of the diseased organ would seriously impede respiration and excite violent 
coughing. In hydrothorax, with large accumulations on both sides, the patient is obliged 
to raise his head and shoulders very much, or even to sit up in bed, in order to obtain the 
requisite supply of air. When he lies down, the effused fluid is diffused over a larger 
portion of lung, an occurrence which is instantly followed by increased difficulty of breath- 
ing, and by the necessity of a change of posture to prevent impending suffocation. “ When 
out of bed, he is often observed to sit with the arms placed along the side, and the hands 
fixed and pressing forcibly on the chair or sofa on which he rests ; in other cases he leans 
a little backwards, still supported by the arms and hands, which are pressed behind his 
back.” 
The attitude assumed by the patient in inflammation of the abdominal and pelvic vis- 
cera is generally very striking and characteristic. Unable to shift his position, he lies 
constantly upon his back, with his head and shoulders considerably elevated, the knees 
raised, and the thighs partially flexed, the object being to relax the abdominal muscles in 
the greatest possible degree, so as to take off their weight and pressure from the inflamed 
surface. In spasmodic affections, on the contrary, the position of’ the patient is altogether 
different; instead of observing dorsal decubitus, he lies at one time on this side and then 
on the other, now on the back, and next on the belly ; and instead of avoiding pressure, 
he actually courts it, not feeling comfortable without it. Hence, he often doubles himself 
up, and twists and contorts his body in almost every possible manner, in order to obtain 
relief. 
In stone of the bladder impeding the flow of urine, the attitude of the patient is fre- 
quently very singular. Sometimes lie is compelled to assume a stooping posture; at other 
times lie crosses or separates his legs, inclines his body to one side, lies down, rests on his 
elbows and knees, or lies on his back, and throws up his buttocks. In traumatic and 
other affections, attended with typhomania, retention of urine may be suspected if the 
patient lies on his back, with the limbs retracted. In acute inflammation of the kidney, 
the body is generally inclined a little forwards and towards the affected side, so as to relax 
the lumbar muscles, and take off any pressure they might otherwise exert upon the diseased 
organ. 
The nature of an accident is not unfrequently revealed by the attitude of the part and 
body ; sometimes by the one, sometimes by the other, and occasionally by both. Thus, 
the manner in which the patient inclines his head and supports his arm in fracture of the 
clavicle is so peculiar as to be absolutely, in great degree, pathognomonic of the nature of 
the lesion. Dislocations of the shoulder, hip, and other joints are denoted by striking, if 
not characteristic, changes in the attitude of the body and limb. The existence of a 
fracture is often revealed by a peculiar change in the conformation of the affected member, 
consisting either in a marked shortening, or in a peculiar alteration in the axis of the 
part. The disease called wryneck derives its name from the peculiar twist of the neck 
by which it is distinguished. 
SECT. IV EXTERNAL CHARACTERS. 
Important diagnostic data are sometimes furnished by the color, form, consistence 
mobility, pulsation, temperature, crepitation, sensibility, or odor of a part, and by the 
spots, scars, or ulcers upon its surface. A mere glance at these different topics will serve 
to show their value as means of distinguishing morbid action, whether it be considered 
simply in reference to its nature, or its nature and degree. 
Thus, as stated under the head of inflammation, the color of the diseased part may be 
scarlet, as in inflammation of the mucous membrane of the fauces ; lilac, as in sclerotitis ; 
grayish or brick-colored, as in iritis. When the redness occurs in the form of a streak, 
extending up the arm or leg, it is denotive of phlebitis, or of angeioleueitis. Diffused 
discoloration characterizes erysipelas ; circumscribed discoloration, boils and carbuncles. 
A scarlet hue implies great vascular activity, such as exists in acute inflammation ; a 
purple hue, on the contrary, denotes partial stasis of the blood, which, if not soon arrested, 
may lead to gangrene. 
Change in the form of a part may be caused by swelling, as in inflammation attended CHAP. XIII. 
EXTERNAL CHARACTERS. 
427 
•with effusion, or it may depend upon the presence of a new growth, or it may be the result 
simply of hypertrophy. In fractures it is caused by displacement of the ends of the frag- 
ments ; in dislocations, by the presence of the head of the bone in its new situation. In 
hernia, very striking changes generally attend the figure of the affected parts, especially 
when the protrusion is old and unusually bulky. 
Extraordinary consistence of a part is indicative either of excessive induration from 
inflammatory deposits, particularly semiorganized lymph, or of the presence of a solid 
tumor, or a displaced bone. When the part is unusually soft, the alteration of consistence 
may depend upon the presence of pus, fluid blood, serum, or serum and lymph, and often 
requires the closest scrutiny for the successful detection of its precise character. Under 
such circumstances the history of the case frequently affords important diagnostic data, 
especially the age of the accumulation, and the presence or absence of inflammatory symp- 
toms. If the part fluctuates distinctly, and is, withal, red, tender, or painful, the proba- 
bility is that the alteration of consistence is due to the existence of pus; if, on the other 
hand, it is perfectly free from discoloration and uneasiness, although the undulation under 
pressure may be most perfect, the conclusion must be that the disease is either a chronic 
abscess, or else some serous or hematoid cyst. 
The mobility of a part may be diminished or increased, thus throwing important light 
upon the nature of the case. As a general rule, it may be stated that it is lessened in 
dislocations, and augmented in fractures. The value of this symptom is well shown in 
diseases of the articulations, as well as in inflammation of other parts of the body, which, 
if at all seriously involved, have their mobility always proportionately diminished. In 
malignant tumors, loss of mobility of the morbid growth generally forms a prominent 
phenomenon in the advanced stage of the disease, in consequence of the firm adhesions 
that take place between it and the surrounding structures. A similar effect may be pro- 
duced by the manner in which such tumors are bound down by the aponeuroses and 
muscles. In affections of the eye an alteration of the mobility of the iris often affords 
most important diagnostic information. 
Abnormal pulsation in a part leads to the suspicion of the existence of aneurism, a 
suspicion almost converted into certainty, if, in addition to this phenomenon, there is a 
peculiar thrill, with a vibratory sensation, and a decided diminution of the volume of the 
part upon the application of pressure on the cardiac side of the artery supplying it with 
blood. The mere fact of the existence of abnormal pulsation should put the surgeon upon 
his guard, in order that, by redoubling his efforts at a thorough exploration, he may not 
commit any errors of diagnosis ; laying open, perhaps, an aneurism, when he supposes 
that he is only dealing with an abscess or a hygroma. 
The surgeon occasionally meets with what is denominated crepitation, a rough, grating, 
or friction sound, of great value as a diagnostic in fractures, emphysema, and inflammation 
of the sheaths of the tendons. In many cases it may be both felt and heard. In fractures 
it is produced by rubbing together the ends of the broken bone, and is generally so dis- 
tinct as to be completely characteristic of the nature of the lesion. In order to elicit it, 
a good deal of management is often necessary; but in general it will be sufficient, after 
the ends of the broken bone have been fairly placed in contact, to grasp one piece firmly, 
and to hold it so while the other is rotated on its axis; or both fragments may be moved 
simultaneously in opposite directions. 
The crepitation of emphysema is a kind of crackling sound, similar to what is produced 
by the rumbling of dry parchment, or by rubbing together numerous little dry, friable 
balls filled with air. The part, moreover, feels soft and puffy, and the contained air may 
be easily pressed from one spot to another. 
Bony tumors of the antrum of Highmore and of the lower jaw, attended with great 
expansion and attenuation of their walls, occasionally emit, when pressed between the 
fingers, a peculiar crackling noise, similar to that of dry parchment. The sound thus 
elicited, however, is altogether different from crepitation, properly so termed, and its 
chief value consists in showing the alteration which the osseous tissue is capable of under- 
going when it is subjected to long-continued, eccentric pressure. 
The crepitation attendant upon inflammation of the sheaths of the tendons is altogether 
different from the two preceding varieties, resembling the sound caused by rubbing dry 
starch between the fingers. When the disease is chronic, it may sometimes be both heard 
and felt. It evidently depends upon the presence of plastic matter, and is most common 
about the wrist and ankle. This sound is often closely imitated in affections of the 
mucous burses, especially when they are considerably distended with fluid, intermixed 
with flakes of lymph and fibrinous concretions. 428 
GENERAL DIAGNOSIS. 
CHAP. XIII. 
A faint crepitating sound is sometimes produced by breaking up the clots of a 
sanguineous cyst, and rubbing the fragments between the fingers. The noise, if any occur, 
is always most distinct at the base of the tumor, where most of the solid matter is neces- 
sarily collected. 
An alteration of temperature in parts affected with disease is sufficiently common, and 
occasionally affords valuable diagnostic intimations. With what interest does not the 
surgeon watch the rise of heat in a limb after the ligation of its principal artery ! A casual 
examination is generally sufficient for its detection ; when more than ordinary nicety is 
required, recourse may be had to the thermometer. The intensity of the morbid action 
may sometimes be pretty accurately measured merely by observing the increase of its 
temperature. A sudden diminution of temperature, in a part previously in a high state of 
inflammation, may generally be regarded as an omen of unfavorable import, as it is deno- 
tive of the approach of gangrene. 
An increase of the sensibility of a part is a frequent, if not an almost constant occur- 
rence in disease, especially when acute. In ophthalmia, the slightest ray of light is a 
source of distress to the patient; in otitis, the ear is intolerant of sound ; and in gastritis 
the stomach is oppressed by the smallest quantity of fluid, however bland, or however 
cautiously used. Parts, such as bones and ligaments, that are perfectly devoid of feeling 
in health, often become exquisitely sensitive in inflammation; and thus it is that the 
practitioner is not unfrequently enabled to detect the existence of morbid action in struc- 
tures hidden from view, much better than he can in any other manner. The proper way 
of ascertaining the existence and amount of morbid sensibility is to make gentle and 
methodical compression, or to percuss the affected part, so as to communicate to it the 
vibrations of the whole hand, or, what is preferable, of one of the fingers. 
When pain exists, a careful distinction should be drawn between that which arises from 
inflammation and that produced by spasm and neuralgia. In inflammation, the pain is 
steady and persistent, increased by motion and pressure, commencing with the morbid 
action, keeping regular pace with it, and gradually disappearing as the morbid action 
declines. In spasmodic affections, or colic, on the contrary, the pain is paroxysmal, or 
marked by distinct intermissions; abrupt, both in its invasion and departure; relieved by 
pressure, and change of posture, and generally attended with flatulence of the stomach 
and bowels. In neuralgia, the pain occurs in transient and violent paroxysms, darts 
along the course of the affected nerves with the rapidity of lightning, and is usually 
accompanied by more or less tenderness of the part, without any distinct tumefaction, 
discoloration, or augmentation of temperature. 
Finally, there are certain affections which may sometimes be readily diagnosticated by 
a careful examination of the cutaneous surface, and that of the mucous outlets. Thus, 
if there are copper-colored eruptions upon the skin, excavated ulcers on the fauces, or 
tubercles upon the tongue, cheek, or lip, no one could fail to conclude that the system 
is laboring under a syphilitic taint. Partial or complete destruction of the uvula, tonsils, 
or arches of the palate, would inevitably lead to a similar inference, especially if, added 
to this, there is evidence of actual disease. Scars upon the cutaneous surface, scattered 
irregularly about, large, deep, white, and permanent, are generally denotive of the former 
existence of rupia. 
The character of the ulcer will occasionally lead to the detection of its cause, or to the 
state of the system which has induced it. A girl, aged fourteen, was brought to the 
Clinic at the Jefferson Medical College, on account of a large chronic ulcer, of nearly one 
year’s duration, seated in front of the leg, directly over the tibia ; it was excessively 
painful, and had resisted a great variety of local and constitutional remedies. Having 
placed her under the influence of chloroform, I scraped away a thick mass of semi- 
organized substance which formed the bottom of the ulcer together with the carious and 
softened portion of the bone; and when she returned, a week afterwards, I was struck 
with the remarkable improvement that had taken place both in the part and system. 
Shortly after her visit, however, not less than five or six small unhealthy-looking ulcers, 
with thick, everted edges, and a foul, ugly surface, broke out around the old one, which 
by this time had also changed for the worse. Convinced that the disease was of a 
syphilitic nature, the patient was placed, without any further inquiry into the history of 
the case, upon the use of iodide of potassium and bichloride of mercury, under the influ- 
ence of which, and of a nourishing diet, she rapidly regained her health and strength, 
with good sound cicatrices. 
Absence of contractility in the muscles, whether dependent upon organic changes of 
their fibres, or upon loss of nerve power, is often very readily determined by electricity, CHAP. XIII. 
which thus becomes a most valuable means of diagnosis. In paralysis of the extremities, 
for example, if contraction be promptly provoked on the application of the electric current, 
it is evident that the integrity of the nervous connection of the limb with the spinal cord 
must be perfect, and also that the portion of the cord through which this connection is 
established is in a sound state, and conversely. The cause of the paralysis must be 
seated either higher up in the cord, in the brain, or in the muscular tissue, altered by 
disease, as the fatty or fibroid degeneration. In case of injury, as a bruise or wound, a 
similar test will determine the seat of the affection. 
SECT. Y THERMOMETRY. 
Thermometry, as a means of diagnosis, is extensively practised in all cases of fever, 
whether traumatic, idiopathic, or specific ; its object, as the name implies, being to ascer- 
tain the amount of heat developed in the system during the progress of disease, and 
thereby determine the degree of the morbid action present in any given instance. The 
knowledge derivable from such an examination is not less valuable than the information 
obtainable from an examination of the pulse and of the respiration. 
The normal average temperature of the body in the axilla, in the milder regions of the 
world, is about Fahr., from which it seldom deviates in health more than 1.8° to 
3.6°. Besides, any such departures are always very transient, 
whereas those occasioned by disease invariably continue so 
long as the morbid action exists. The temperature is height- 
ened by exercise, reduced by sustained mental labor, and 
influenced by food, stimulants, age, temperament, habit, 
occupation, climate, the condition of the atmosphere, and 
other causes. It is liable to fluctuate during the twenty-four 
hours, and is usually at its maximum in the morning. The 
pulse and temperature in health usually rise synchronously, 
and every degree above 98° corresponds with an increase of 
ten beats of the pulse in the minute. Any persistent rise of 
the mercury above 99.5°, or depression below 97.3° Fahr., is 
an indication of disease. 
Unnatural heat cannot exist without fever, any more than 
fever can exist without abnormal heat. They are dependent 
the one upon the other. A patient may have a severe rigor, 
shiver, or feel icy cold, and yet the inner parts be inordi- 
nately warm, so that he may literally, as far as his sensations 
are concerned, burn and freeze at the same moment. 
In pyemia the temperature is often very high, ranging 
from 106° to 108°. There is, however, nothing very definite 
in this respect; for observation has shown that, while in some 
cases and under certain circumstances, it is normal or nearly 
so, in others it presents remarkable variations, a sudden rise 
being often followed by a sudden decrease, and conversely. 
A temperature of 101° to 103° shows a mild disease, and 
one of 10o° a grave one. In fever it ranges from 100° to 
106°. In low forms of this malady the hands and feet may feel 
cool,and yet the thermometer in the axilla may rise to 104°. 
In acute rheumatism a temperature above 104° is always an 
alarming symptom; and a similar remark is applicable to pneu- 
monia. A rise of heat from 106° to 108°, 109°, or 110°, is 
generally an indication of 'rapidly approaching dissolution. 
The highest rise of the thermometer before death has been 
noticed in tetanus and scarlatina. A persistence even of an 
inconsiderable degree of abnormal heat is an evidence of 
incomplete recovery; and a recurrence of a high temperature 
duringconvalescence isacertain sign of an approaching relapse. 
Decrease of temperature is of great assistance in determining the prognosis of grave in- 
juries and operations, a fall of one degree below the normal standard indicating depression, a 
fall of two degrees being an evidence of collapse, and a fall of from three to five degrees indi- 
cating algid collapse. 
The thermometer usually employed for measuring the temperature in disease is the 
THERMOMETRY. 
429 
Fig. 119. 
Fig. 120. 
Thermometer. 
Surface 
Thermometer. 430 
GENERAL DIAGNOSIS. 
CHAP. XIII. 
one depicted in fig. 119. It is a very delicate, sensitive instrument, with a range of scale 
from 90° to 115°, and a subdivision of each degree into fifths. It may be furnished with 
a curved bulb for the sake of greater convenience in its application to the axilla, the 
situation generally selected for the purpose, as calculated to insure greater accuracy. 
The patient must have been in bed, well covered about the chest and shoulders, for at 
least one hour before the experiment is made. The instrument, previously a little 
warmed, is retained in the axilla, from which the perspiration has been wiped away, for 
ten minutes, at the end of which the rise or fall of the mercury must be carefully noted 
and recorded. The observations should be taken regularly every day twice, as nearly as 
possible at the same hour, either by the attendant himself, or by a trustworthy assistant, 
throughout the entire period of the sickness, the best time being between seven and nine 
o’clock in the morning, and between five and seven o’clock in the evening. The 
frequency of the pulse and of the respiration should be noted at the same time. In 
chronic cases, attended with occasional exacerbation, and also in acute attacks after the 
temperature has regained the normal standard, one daily observation made in the after- 
noon will be sufficient. 
Important information in regard to deeply seated abscesses and rapidly growing tumors, 
particularly the small-celled sarcomas, may be derived from the use of the surface 
thermometer depicted in fig. 120. The temperature should first be taken over the 
seat of the disease, and then be compared with the temperature of the corresponding 
point of the opposite side of the body, the increase denoting the activity of the morbid 
action. 
SECT. VI INSTRUMENTAL EXPLORATIONS. 
There are certain affections the character of which can only be ascertained by a careful 
examination with the aid of instruments, full access to them in any other manner being 
impracticable. The instruments mainly required for this purpose are the probe, bougie, 
sound, speculum, stethoscope, and exploring needle, each of which will, therefore, demand 
some notice. 
Probe—The probe, fig. 121, is chiefly employed for the purpose of exploring fistulous 
tracks and sinuses, the course of balls, and the presence of foreign bodies. It may, 
therefore, be considered as a highly valuable instrument, one which is daily and hourly 
Fig. 121. 
brought into requisition by the surgeon in extensive practice. It is generally made so as 
to be flexible, being composed of silver or other suitable metal; and varies in length, 
diameter, and shape according to circumstances. The ordinary pocket probe is about five 
inches in length, and of the diameter of a crow-quill, one extremity being blunt, the 
other somewhat pointed, or furnished with an eye. For exploring the lachrymal passages 
a much more delicate instrument is required; the uterine probe, on the contrary, is very 
large; a long and rather stout instrument is generally employed for ascertaining the exist- 
ence of a foreign body in the air-passages after the trachea has been opened, for tracing 
the course of a ball, and for exploring certain varieties of fistules and sinuses. 
For detecting the presence of deep-seated balls, a probe, tipped with porcelain, has been 
advantageously used, as in the celebrated case of Garibaldi; and Mr. L’Estrange, of 
Dublin, many years ago invented what may be called a reverberating probe, an instrument 
provided with a little drum, consisting of a small circle of light wood, mounted on a stem 
which, secured to an ordinary probe, or sound, conveys to the ear, as well as to the finger, 
a more perfect idea of the nature of the material touched, whether muscle, bone, cloth, 
calculus, or metal, than any other contrivance. 
Dr. L. A. Sayre, in 1871, devised what is now known as the vertebrated probe, fig. 122, 
consisting of a series of hollow silver disks, connected by a linked longitudinal chain, 
terminating in a square rod. The contrivance is particularly serviceable in the exploration 
of sinuous ulcers, in diseased joints, in flexions of the uterus, and in gunshot wounds, the 
small end of the instrument being, in the latter case, tipped with porcelain. 
The index finger, if sufficiently long, and not too thick, is the best probe of all, as the 
information furnished by it is generally much more reliable than that supplied by a 
metallic instrument. It is particularly available in the examination of the vagina, uterus, 431 
CHAP. XIII. 
and rectum, whether the object be to detect the presence of disease, mal- 
position, or the existence of an extraneous body. 
The rectal touch, performed with the index finger, is constantly practised 
by the surgeon in sounding patients for stone in the bladder, with a view 
not only of ascertaining the presence of the foreign substance, but also of 
determining its size and situation. Enlargement of the prostate gland, 
and the existence of calculi in its substance, can seldom be satisfactorily 
diagnosticated in any other manner. Displacements of the uterus, pelvic 
tumors, and malformations of the internal genital organs, are often promptly 
detected by the rectal touch ; and there is no practitioner that does not 
employ the finger in suspected disease of the anus and lower bowel. The 
rectal touch can readily discriminate between a hemorrhoidal tumor and a 
carcinomatous growth, a polyp, a prolapse of the mucous membrane, or a 
foreign body. The extent of the spasmodic contraction of the anus, which 
attends fissure of that outlet, is generally readily ascertained by the inser- 
tion of the finger. 
The vaginal touch affords important information in relation to the dis- 
eases of the vagina and the uterus. It is in this manner that the practi- 
tioner ascertains the existence of the various kinds of tumors that are liable 
to form in these organs, whether'benign or malignant, and also the different 
displacements to which they are subject. A practised finger will readily 
detect a carcinomatous ulcer of the uterus, a rent in the vagina, and a 
calculus in the bladder. 
Whatever may be the instrument employed, it should be well oiled and 
warmed, to facilitate its introduction, and passed along in as gentle and 
easy a manner as possible. If the structures are inflamed and tender, it 
may be necessary, as a preliminary step, to lessen the sensibility by sooth- 
ing measures, otherwise the procedure may be productive not only of 
severe pain, but of an aggravation of the disease. No general rules can be 
laid down respecting the position of the part or of the body during the examination, 
although it must be sufficiently obvious that this is a matter of paramount importance to 
.a satisfactory result. In exploring fistulous tracks it.is occasionally necessary to enlarge 
their orifice somewhat, in order to afford a more ready passage to the instrument or finger. 
Bougie.—For ascertaining the condition of the mucous outlets of the body, as the 
urethra, oesophagus, and rectum, a bougie, which is but another name for a probe, is gene- 
rally employed, the principle upon which the examination is conducted being the same as 
in exploring a part with a probe, properly so called ; that is, the instrument, which is 
either straight or curved, and composed of gum elastic or metal, is well oiled and warmed, 
and then carefully introduced as far as the seat of the obstruction, the distance between 
which and the external orifice is now determined by looking at the graduated scale upon 
the surface of the bougie, or by making a scratch upon it with the nail. The examina- 
tion is completed by insinuating the instrument gently into the stricture, so as to measure 
its extent and the degree of its resistance. The information thus elicited is generally of 
the greatest diagnostic and practical value. 
Sound The instrument employed for exploring the bladder is called a sound, although 
it is in reality nothing but a probe, blunt-pointed at the distal extremity, and a good deal 
curved, so as to adapt it to the course and shape of the urethra. It is composed of steel, 
being perfectly smooth and of a round shape. Its object and mode of use will claim 
special attention in connection with the diagnosis of vesical diseases, which could not be 
established satisfactorily in any other way. , 
Speculum Of the value of the speculum as a means of diagnosis in affections of the 
vagina, uterus, anus, larynx, nose, and ear, it is unecessary to say anything of a formal 
character, as it is fully appreciated by every intelligent practitioner. For the exploration 
of these passages, instruments of various forms and sizes are used, which will be particu- 
larly noticed under their respective heads. The uterine speculum, of which fig. 123 
affords an illustration, was invented several thousand years ago, but had been entirely lost 
sight of until it was brought before the attention of the profession early in the present century 
by Iiecamier, of Paris, who thus conferred an inestimable boon upon the female sex by 
opening a new path to the treatment of her diseases. To impart perfection to such 
examinations a good light, either natural or artificial, is indispensably necessary. 
Exploring Needle The value of the exploring needle cannot be too highly appreciated 
by the practical surgeon, as he is obliged to use it in the examination of a great variety 
INSTRUMENTAL EXPLORATIONS. 
Fig. 122. 
Sayre’s Verte- 
brated Probe. 432 
GENERAL DIAGNOSIS. 
CHAP. XIII. 
of external affections, the diagnosis of which does not admit of accurate determination 
in any other manner. On the other hand, however, there is reason to believe that there is 
no instrument, certainly none of its size, that is more frequently misapplied by the unin- 
formed practitioner, or one which may do a greater amount of harm when used without 
Fig. 123. 
proper judgment and discrimination. Like everything else that is good, it is liable to 
abuse ; a circumstance which cannot be too strongly impressed upon the mind ot‘ the young 
surgeon. I am sure I have seen immense injury, and even loss of life, produced by its 
careless and reckless use. 
Numerous exploring needles are in the hands of the profession ; some of which, dis- 
playing great delicacy and ingenuity, seem to combine all the advantages that such contri- 
vances are capable of affording, while others are extremely clumsy, and, consequently, 
very imperfectly adapted for the purpose they are designed to fulfil. The great fault with 
most of them is that they are too large, thus inflicting an amount of injury upon the 
affected parts, which, especially in malignant diseases, is often followed by the most dis- 
astrous effects, causing, perhaps, not merely severe pain and hemorrhage, but such a 
change in the vital relations of the morbid growth as to lead to its rapid development, if 
not to the speedy destruction of the patient. I recollect seeing, some years ago, a tumor 
upon the hip of a lad, aged sixteen, which, after having been subjected to various exami- 
nations by highly respectable surgeons, was at length pierced with a large exploring 
needle. The swelling, which had been supposed to be nothing but a chronic abscess, and 
which for some time had been almost stationary, now rapidly increased in volume, ulcer- 
ated, and fungated, and in less than a fortnight destroyed life. Dissection showed that 
the morbid growth was a round-celled sarcoma, the activity of which had been greatly 
augmented by the changes induced in its vital relations by the injury inflicted by the 
instrument. A large volume might be filled with a rehearsal of the mischief that has 
been committed by the exploring needle in the hands of ignorant and careless practitioners. 
Exploring needles consist either of a solid cylinder or of a species of trocar and canula, 
sharp-pointed, line, and perfectly smooth, so as to facilitate their introduction and easy 
management. They are made of various lengths and diameters, according to the depth, 
volume, and nature of the part to be examined. The annexed cut, fig. 124, represents 
an exploring needle, with a lateral groove. The best instrument of the kind, according 
to my experience—one which answers every purpose in superficial affections, and which 
Speculum. 
Fig. 124. 
Exploring Needle. 
may always be used with the most perfect safety—is the ordinary cataract needle, spear- 
shaped, and sufficiently stout to prevent it from breaking. This is inserted into the most 
prominent portion of the tumor or morbid accumulation, with a kind of rotatory motion, 
the object being to condense, as it were, the edges of the opening to promote the escape 
of the contents of the swelling, which readily occurs, if they are of a fluid consistence, a 
drop of the liquid often adhering to the instrument, or resting upon the orifice of the little 
puncture. When the contents are of a semisolid nature, or the tumor is very deep- 
seated, the needle should be larger; or, what is preferable, it should be replaced by a very CHAP. XIII. 
INSTRUMENTAL EXPLORATIONS. 
433 
small trocar, long enough to reach and penetrate the affected structures. Whatever in- 
strument be used, it must not, on any account, be permitted to come in contact with any 
important vessels or nerves. When the swelling is of unusual bulk, it may be explored 
at several points of its extent at the same sitting. The little puncture made in the ope- 
ration should immediately be closed with adhesive plaster or collodion. When the object 
is to exclude the entrance of air, the instrument may be carried some distance between 
the integument and the swelling, so as to make the opening somewhat valve-like. 
A needle, perforated in its entire length, is occasionally used on the ground of its sup- 
posed superior efficacy in exploring deeply seated disease, its great value consisting in the 
facility of discriminating between different kinds of fluids, or in reaching deeply-seated 
fluids without the admixture of the superficial. 
Kuhn, Duchenne, Noeggerath, Hewson, Dresher, and others, have invented exploring 
instruments for the purpose of extracting a minute portion of a tumor, morbid deposit, 
or muscular tissue, with a view to a microscopical examination of its structure prior to an 
operation,' the tube employed for this object being furnished with a peculiar contrivance 
attached to a sliding rod in its interior. Such a procedure, it appears to me, is more in- 
genious than useful, as its disturbing influence upon the morbid mass can hardly fail at 
least occasionally, to impart new life and energy to the affected tissues. It possesses, 
however, an actual value in trichinosis and certain forms of paralysis and muscular atrophy, 
inasmuch as it enables us to ascertain the precise condition of the muscular tissue, and 
determine whether any benefit will be likely to accrue from the employment of electricity 
and other curative agents. The most suitable instruments for such examinations are those 
of Duchenne and Noeggerath, depicted in figs. 125 and 126. 
Fig. 125. 
Fig. 126. 
Syringe—The use of the syringe occasionally affords valuable aid in the determination 
of the nature of a case. In suspected fistule of the bladder, rectum, and some of the 
other mucous outlets, the diagnosis may often be established, in the most unequivocal 
manner, in a few seconds, by the injection of a stream of water. Sometimes the fluid 
may be advantageously colored with indigo. A fistule of the neck, dependent upon or- 
ganic stricture of cesophagus, may generally be promptly detected by making the patient 
swallow a liquid of this kind. 
The ophthalmoscope, laryngoscope, rhinoscope, otoscope, and endoscope are of great 
service in the detection and treatment of diseases, difficult, if not impossible, to be reached 
in any other way. They all essentially consist of two mirrors for concentrating the 
light upon the object designed to be examined, and, as now constructed, are exceedingly 
simple, and, for the most part, easy of application. 
The ophthalmoscope, devised by Helmholtz, who published an account of it in 1851, 
has been greatly improved by Loring, and is now a very perfect instrument, well adapted 
to fulfil the intentions of its ingenious inventor. 
The laryngoscope owes its origin mainly to the genius of Czermak, of Vienna, by 
whom it was at once brought to a high state of perfection. It is designed, as the name 
implies, to assist in the explorations of the windpipe, and the only objection to it is the 
difficulty of its application, few practitioners being possessed of the requisite degree of 
tact to use it to advantage. The most valuable monographs upon the subject that have 
yet appeared, are those of Czermak, Turck, Semeleder, Stoerk, Voltolini, Mackenzie, 
Cohen, Gibb, and Moura-Bourouillon. 
The invention of the rhinoscope was a necessary consequence of the application of the 434 
GENERAL DIAGNOSIS. 
CHAP. XIII. 
laryngoscope in the hands of its distinguished inventor. In exploring the windpipe, it 
Avas easy to see the upper part of the pharynx, the orifices of the Eustachian tubes and 
the posterior nares, and thus arose what may very properly be called the science of rhi- 
noscopy. 
To Mr. Toynbee, of London, belongs the merit of introducing an instrument called 
the otoscope, which is of great aid in the examination of the ear, with a view of deter- 
mining its precise condition in cases of supposed disease. It is of very simple construc- 
tion, as well as of easy application. 
The endoscope is employed chiefly for exploring the urethra and the bladder, although 
it may also be advantageously applied to other canals, as the rectum, vagina, uterus, nose, 
larynx, pharynx, and ear. It is a contrivance of recent invention, brought to a remark- 
able degree of perfection by the ingenuity of Desormeaux, Cruise, and other observers. 
The endoscope of the Dublin surgeon is, in principle, identical with that used in 1824 by 
Dr. Fisher, of Boston. It consists simply of a tube or speculum, which is inserted into 
the cavity to be examined ; of a mirror of polished silver, perforated at the centre, and 
placed at an angle of about 45° ; and of a plano-convex lens, of suitable focal length, 
for concentrating the light. 
The use of the stethoscope, as a means of surgical diagnosis, is comparatively limited, 
and it might be altogether dispensed with by those who have a well-practised ear, and 
are not averse to the employment of immediate auscultation, or the direct application of 
the ear to the affected parts. Lisfranc thought the stethoscope might be advantageously 
resorted to for the purpose of detecting crepitus in deep-seated fractures ; or, what is the 
same thing, in fractures covered by a large amount of muscular and other tissues, as, for 
example, those of the neck of the thigh-bone in very fleshy subjects. Few occasions, 
however, arise in which such a mode of exploration can be of any real service, and I am 
not aware that any of our more experienced practitioners ever employ the instrument 
with this object. 
Laennec, in the early part of the century, proposed auscultation as a means of detect- 
ing the presence of calculi in the bladder. He thought that it would be particularly 
serviceable in ascertaining the existence of very small concretions, which, wiien struck 
with the sound, emit only a very indistinct noise; and he suggested that, under these 
circumstances, the stethoscope should be applied to the pubic or sacral region while the 
instrument is freely moved about in the organ. The recommendation, liowrever, has not 
met with any particular favor, and there are, I suppose, few surgeons who would feel in- 
clined to cut a patient for stone on such slender evidence of its presence. 
The chief value of auscultation, then, is restricted to the examination of diseases of 
the heart, pericardium, lung, and pleura; and to the investigation of certain lesions of 
the abdomen, uterus, and ovaries, simulating pregnancy, with a view to the detection of 
the foetal circulation. Dry tapping, as it has emphatically been called, would probably 
be of much less frequent occurrence, if the stethoscope were oftener employed in sup- 
posed dropsy in young, unmarried females. 
SECT. VII. EXAMINATION OF THE DISCHARGES. 
The discharges, normal and abnormal, from different parts of the body, often furnish 
the surgeon important diagnostic information. Thus, an habitual flow of tears over the 
cheek is usually denotive of disease of the lachrymal passages, and necessarily suggests 
the propriety of a careful examination of them with a view to the detection of obstruction. 
For a similar reason the surgeon is prompted to inspect the ear in otorrhcea, and the nose 
when it is the seat of muco-purulent profluvium. The very nature of the discharge in- 
forms him of the existence of inflammation, but how that inflammation is produced, 
whether by the presence of a foreign body, a piece of dead bone, or a polyp, is a question 
which can only be decided by the most careful scrutiny; requiring, perhaps, the employ- 
ment of the syringe to wash away the secretion, and repeated inspection before the pre- 
cise nature of the case can be satisfactorily made out. One of the most important 
symptoms of inflammation of the maxillary sinus is a flow of pus into the throat; but no 
surgeon can be certain that it proceeds from that cavity unless he has previously ascer- 
tained that there is no disease of the mucous membrane of the nose. 
The character of the sputa has long been an object of study with practitioners, on ac- 
count of the useful information which they afford in regard to the existence of particular 
diseases. Such information is hardly of less value to the surgeon than to the physician, 
as it apprises him of the presence of lesions which forbid surgical interference, or places CHAP. XIII. 
EXAMINATION OF THE DISCHARGES. 
435 
him in possession of useful data respecting the occurrence of pulmonary complications, so 
common after accidents and capital operations. The reddish streaks in the expectora- 
tion excite suspicion of the existence of pneumonia; the rust-colored sputa confirm that 
suspicion, and at once invest the case with its proper importance. The fetid, putrilagi- 
nous matter coughed up in gangrene of the lungs is characteristic of that disease, from 
whatever cause proceeding. In phthisis, after the occurrence of caverns, the expecto- 
rated matter is ejected in distinct, rounded masses, with irregular and indented edges; it 
sinks in water, and is of a yellowish color, with various shades of ash and even green, 
and streaked with opaque specks. A discharge of blood by vomiting is denotive of he- 
moptysis when the fluid is of a scarlet color, and of hematemesis when it is perfectly 
black. In affections of the throat, attended with thick, mucous or muco-purulent secre- 
tion, the sputa are sometimes streaked with blood. The saliva in mercurial stomatitis has 
a characteristic odor, and the same is true of the discharge which accompanies gangrae- 
noris. 
A thick, yellowish discharge, more or less abundant, from the vagina, is indicative of 
inflammation of that canal, of the uterus, or of both, and the addition, of blood may 
usually be regarded as an evidence of concomitant ulceration. In a chaste woman such a 
profluvium is generally to be considered as the result of accidental causes; in the courte- 
san, on the contrary, it at once awakens suspicion of the existence of gonorrhoea or 
chancroid. In carcinoma of the womb, the disease is attended, in its earlier stages, by 
hemorrhage, and afterwards, when ulceration has set in, by a foul, purulent, or sero-san- 
guinolent discharge, more or less copious, and so excessively fetid as to indicate unmis- 
takably the character of the lesion. 
In the male, a discharge of matter from the urethra generally furnishes useful informa- 
tion respecting the character of the disease under which the individual is laboring. When 
the discharge is thick, yellowish, and abundant, it is denotive of gonorrhoea, or chancre, 
though in the latter case it is seldom very profuse ; when thin and lactescent, or like the 
white of an egg, it indicates the existence of gleet, or prostatorrhoea. A large and sud- 
den discharge, especially wdien no profluvium precedes or follows it, is to be taken as an 
evidence of spermatorrhoea. 
The presence of spermatozoa in hydrocele sometimes throws important light upon the 
source of the water. It has been ascertained that whenever the fluid contains cells 
of this kind, the disease is generally of an encysted nature ; for, although they also occur 
in ordinary hydrocele, yet the circumstance is so uncommon that it must be regarded as 
altogether of an exceptional character. 
Of the signs afforded by the renal and urinary secretions, as evidences of disease, 
either of a local or general character, proper mention will be made in the chapter on the 
affections of the urinary organs. Here I shall only add that a careful examination of 
these secretions is often a matter of the greatest importance to the surgeon, especially 
when he is obliged to decide respecting the propriety of a severe operation, the result of 
which might be seriously compromised by the existence of organic lesion either of the 
kidneys or of some other important viscera. Hardly any man, however reckless, would 
attempt such an undertaking if the urine were loaded with albumen and renal casts. 
The existence of disease of the anus and rectum, and even the true nature of such dis- 
ease, may often be satisfactorily inferred by the discharges furnished by these parts. A 
flow of pure blood, especially during defecation, is generally denotive of internal hemor- 
rhoids ; so also if there are frequent evacuations of thick, bloody mucus, either while the 
person is at the water-closet, or in the intervals of his visits. A narrow, compressed, or 
flattened state of the feces is indicative of mechanical obstruction, occasioned either by 
stricture of the rectum, enlargement of the prostate gland, or contraction of the anus. 
In ulcerated carcinoma of the lower bowel, the discharges are generally very profuse, of a 
muco-purulent nature, mixed with blood and mucus, and excessively fetid; in fact, char- 
acteristic of the nature of that horrible malady. 
The matter of certain abscesses serves to point out their nature and situation, or their 
accidental communication with neighboring parts. Thus, in the mammary glaitd, the 
fluid may contain milk; in the liver, bile; in the kidney, as when an opening takes 
place externally, urine. Abscesses of the wrall of the abdomen have been known to 
contain biliary calculi ; of the joints, fragments of cartilage and bone. In acute ab- 
scesses, the contents are thick and yellowish ; in chronic, or strumous, thin and slightly 
greenish, with an intermixture of small opaque, whitish flakes, resembling grains of 
boiled rice. 
The discharge accompanying ulcers generally affords valuable hints respecting the 436 
MINOR SURGERY. 
CHAP. XIV. 
nature of their action. Healthy granulating ulcers or wounds always yield a thick, 
yellowish pus, possessing all the properties of laudable pus, as described under the head 
of suppuration ; when, on the contrary, their action is unhealthy, the discharge is thin 
and bloody, ichorous, sanguinolent, and more or loss irritating. In carcinomatous ulcers, 
the discharge is generally profuse, foul, devoid of pus globules, and excessively fetid. 
In ulcers of the bones, it is ichorous and irritating ; never healthy, so long as there is any 
diseased osseous tissue. 
The odor emitted by a part in a state of disease sometimes supplies important data for 
the diagnosis of a case. Most readers are familiar with the remarkable anecdote related 
of J. L. Petit. Travelling through Germany, this celebrated surgeon, while stopping at 
an inn to change horses, was struck with the odor of gangrene, which he distinguished 
from several others, hardly less offensive. Not understanding the language of the coun- 
try, he made his wishes known to a female, who showed him into an adjoining room, 
where he found a man apparently moribund from a mortified intestinal hernia. Happy 
in being able to render him some assistance, he carefully dressed the parts, and meeting, 
before he set out upon his journey, with a French physician, he instructed him in the 
future management of the case. Upon his return, five months afterwards, he had the 
gratification to learn that the man had completely recovered his health without a sterco- 
raceous fistule. 
The odor attendant upon ozmna is characteristic ; no one that has ever perceived it can 
mistake it. The contents of an abscess at the verge of the anus always emit a fecal smell; 
a peculiar fetor accompanies the formation of a urinary fistule, and no one can be deceived 
by the odor of the breath in salivation. In hospital gangrene the stench is so remarkable 
that, once noticed, it can never be forgotten, although it is so unlike everything else of 
the kind as to render it impossible to define or describe it. The odor which accompanies 
gangrene of the mouth of children is unmistakable. The diagnosis of ulcerated carcinoma 
of the uterus may often be established by the sense of smell alone. Large wounds in a 
state of profuse suppuration not unfrequently exhale a peculiar nauseous or sickening 
odor, in some degree characteristic of the attendant action. The pus of a scrofulous 
lymphatic gland, for a long time pent up, is sometimes horribly fetid. A smell, similar 
to that of a macerating tub, often attends abscesses depending upon caries of the spine. 
In all these cases, as well as in many others that might be adduced in illustration of the 
subject, it is probable that the peculiarity of the odor is due partly to the admixture of 
the natural secretions of the affected structures. 
CHAPTER XIV. 
MINOR SURGERY. 
Minor Surgery comprises an account of some of the more common instruments used in 
surgery, of the mode of making incisions, or of performing the elementary operations, the 
establishment of issues, the introduction of the seton, the application of the actual cautery, 
bleeding, and the art of bandaging and of dressing. As some of these topics have already 
been incidentally discussed, especially in the chapter on inflammation, I shall here confine 
myself to the consideration of those that have not yet been touched upon in previous parts 
of the work. 
SECT. I INSTRUMENTS. 
Instruments are as necessary to the surgeon in the execution of his operations as they 
are to fche mechanic in the performance of his daily labor. But as the best workman 
employs the fewest tools, so the best operator employs the fewest instruments; and to the 
man of science and taste nothing is more disagreeable than an ostentatious display of such 
material. A few articles, well selected, and kept in proper order, ready to do their work 
at the shortest notice, are all that any surgeon really requires for the successful perform- 
ance of nearly every operation that he may be called upon to undertake. The simplicity 
of his armamentarium often affords a better idea of his skill and science than the most daring 
feat upon the operating table. CHAP. XIV. 
INSTRUMENTS. 
437 
The elementary and really important instruments are very few in number ; they are the 
scalpel, needle, saw, forceps, probe, and director, which are the parents of nearly all the 
numerous and diversified surgical contrivances found in the shops of the modern cutler. 
With a little modification the scalpel is converted into the bistoury, the lancet, and the 
amputating knife, and may thus be made to answer all the purposes required of a cutting 
instrument. The same needle with which a suture is made, may, with a little difference 
of size and shape, be readily used for couching and lacerating a cataract, or inserting a 
seton. The saw may be modified without limit, and the same is true of the forceps, 
whether intended for dissection, dressing, or the division of bone. The probe, which, 
from its great usefulness, may almost be regarded as another finger, varies in size and 
shape, from the little delicate, almost thread-like instrument devised by Anel for examin- 
ing the lachrymal canal, to the sound employed by the lithotomist for exploring the con- 
dition of the bladder. The grooved director, which serves to guide the knife in the division 
of the soft parts, as in operations for hernia, impermeable stricture, and stone in the 
bladder, is, in fact, nothing but a modification of the ordinary probe. 
The knives generally in use among surgeons for the more ordinary daily operations are 
the scalpel and bistoury, of various sizes and shapes, so as to adapt them to the exigencies 
of each particular case. All such instruments should have a tolerably large handle, and I 
decidedly prefer one that is somewhat rough, as being less likely to slip from the fingers 
when wet with blood. The blade should be rather long and slender, gradually tapering 
to a point, which should be quite sharp, or, at any rate, not at all rounded. In some 
operations, a double-edged, spear-shaped knife is very serviceable, as in the extirpation of 
Fig. 127. 
Fig. 128. 
Fig. 129. 
Fig. 130. 
Fig. 131. 
Fig. 132. 
tumors, and the extraction of cataract. Finally, it is sometimes advantageous to have a 
knife the handle of which terminates in a semisharp steel edge. Such an addition is 
occasionally of great use in the excision of morbid growths. The above figures afford 
a good idea of the more common of scalpels. 
Fig. 133. 
The bistoury differs from an ordinary scalpel chiefly in being longer and more slender; 
it may be straight or curved, with a sharp or blunt extremity. It is often made so as to MINOR SURGERY. 
CHAP. XIV. 
open and shut like a penknife, as in fig. 133 ; but the best instrument of the kind is one 
with a fixed handle. The term bistoury lias been supposed to be derived from Pistorium, 
the name of a town where it was at one time extensively manufactured. Particular forms 
of this instrument, invented for particular operations, will be alluded to in different parts 
of the work. 
The adjoining sketches afford good illustrations of the ordinary forms of the bistoury : 
fig. 134 represents the sharp-pointed instrument, and fig. 135 the probe-pointed. 
Fig. 135. 
There is hardly any operation in which it is not necessary to use forceps. The instru- 
ment usually employed is the common dissecting-forceps, represented in fig. 13(1. In 
some cases, as when the object is to pinch up a delicate structure, as the conjunctiva, or 
Fig. 136. 
a very thin layer of fascia, a pair of forceps provided with a small tooth, as represented 
in fig. 137, will be found not only very convenient, but almost indispensable. 
Fig. 137. 
Scissors are essentially nothing but two knives united by a screw, and furnished each 
with a ring-handle; if thin, and properly sharpened, they divide the tissues with little or 
no contusion, and may be employed for a great variety of purposes. They are particu- 
larly valuable in many of the more delicate operations upon the eye. They may be 
straight or curved on the edge or on the flat, pointed or blunt at the extremity, or one 
blade may be sharp and the other blunt. The rings should always be large for the ready 
accommodation of the thumb and finger. Figs. 138 and 139 exhibit the two principal 
forms of surgical scissors. 
Fig. 138. 
For holding the flaps out of the way in performing certain operations, especially such 
as involve the removal of morbid growths, among the more deep-seated structures, or the 
exposure of arteries, instruments, called retractors, are often of gi*eat service, and should CHAP. XIV. 
INSTRUMENTS. 
439 
find a place in every well-arranged operating case. The best instruments of this kind 
are made of flexible metal, mounted upon handles. 
Fig. 139. 
For holding and pulling out morbid growths, such as deep-seated tumors of the neck 
or thigh, and for drawing down the cervix of the uterus in operating for vesico-vaginal 
fistule, as well as for other purposes, a Museux’s forceps, shown in fig. 140, or a common 
Fig. 140. 
volsella, is of great use. The teeth being plunged into the morbid mass, the instrument 
is either held by the surgeon himself, or the requisite traction is exerted by an assistant. 
Fig. 141 represents another contrivance, which may be used for a similar purpose, its 
prongs being firmly screwed into the substance of the morbid growth. 
Fig. 141. 
The forceps shown in fig. 142 are very serviceable in the extirpation of large tumors of 
the uterus, in grasping, holding, and pulling down the morbid growth. Their mode of 
action is apparent at a glance. 
Fig. 142. 
The grooved director, fig. 143, is indispensable for laying open sinuses and fistules, in 
exposing arteries, and in dividing the coverings of hernias and of deep-seated tumors. It 
is generally blunt at the extremity, but in some cases it must be somewhat sharp, so as 
to effect more easy penetration of the tissues. The double director, fig. 144, is very 
serviceable in operating for strangulated hernia and in the extirpation of tumors with un- 
usually firm and extensive adhesions. 
Fig. 143. 
The trocar, represented in fig. 145, and so called from the circumstance of having a 
three-edged extremity, consists of a cylindrical rod, passed through a silver canula. It 440 
MINOR SURGERY. 
CHAP. XIV. 
is employed for drawing off various kinds of fluids, as serum and pus. Its use, at the 
present day, is chiefly confined to the removal of water from the chest, abdomen, and 
vaginal tunic of the testicle. There is a contrivance of this kind with a flat, spear-shaped 
extremity, but it is not much employed, its canula being more liable to obstruction than 
that of the round trocar. Special instruments are employed for particular operations. 
Fig. 144. 
'GEMRIG O] 
Fig. 145. 
The pneumatic aspirator is simply a delicate trocar attached by means of a short gum 
tube to a bottle, which is exhausted of air by means of a syringe, the invention of which, 
apparently, belongs to Palletan, although it has been claimed by other surgeons, as 
Dieulafoy, Potain, and Protheroe Smith. The instrument represented in fig. 146, may 
be advantageously employed for removing fluids from the thoracic cavity in empyema, 
for emptying abscesses and distended joints, and for evacuating the urine in retention 
from enlargement of the prostate gland, organic stricture of the urethra, and other causes. 
It is also used for withdrawing gas and the fluid contents of the intestine in strangulated 
Fig. 146. 
Fig.-148. 
Potain’s Aspirator. 
Tig. 147. 
Suture needle in fixed 
handle, useful in tying 
erectile and other tumors. 
hernia, and for diagnosticating hydatids, abscesses, and serous cysts of the liver and other 
abdominal viscera. The trocars are of different sizes, for ready adaptation to various 
contingencies, and range in number from three to half a dozen. Many modifications of 
the original instrument are in use. CHAP. XIV. 
INSTRUMENTS. 
441 
Surgical needles are straight, curved, round, or flat, and of various sizes, as in fig. 147. 
In some instances, as when it is necessary to take a deep stitch, sew up a fissure of the 
palate, penetrate an unusually hard structure, or encircle a deep-seated artery, it is con- 
venient to secure the instrument to a handle, as in fig. 148. In sewing up large wounds 
a needle at least two and a half inches in length, perfectly straight, like a sewing needle, 
slender, and very sharp, will be found to be the most convenient. 
For operations upon the bones, the surgical engine, devised by Dr. Bonwill, of this 
city, is destined to come into common use in hospital practice. It consists, essentially, as 
is represented in fig. 149, of a frame, a driving wheel, provided with a crank, and a flexi- 
Fig. 149. 
Bonwill’s Surgical Engine. 
ble arm, to the extremity of which a hand piece is fitted for the reception of the drills, 
burrs, and saws, the power being transmitted by a cord passing from the wheel to the 
hand piece. The great speed that can be imparted to the instruments, through which 
they are made to revolve at the rate of fifteen thousand revolutions in the minute, enables 
the surgeon to perform operations with great rapidity, and with comparatively little pain. 
The circular saw is especially useful in dividing the lower jaw, in removing the ends of 
the bones in ununited fracture, in facilitating the withdrawal of sequesters, and in incising 442 
MINOR SURGERY. 
CHAP. XIV. 
bones affected with osteomyelitis. I have found the burrs very serviceable for shaving 
off the alveolar process in the neuralgia of edentulous jaws, for removing tumors of the 
maxillae, for making the necessary openings in excision of the second and third branches 
of the fifth pair of nerves, for effecting riddance of redundant callus, for the relief of cer- 
tain deformities of the nose, for the removal of carious bone, and for the extirpation of 
the coccyx. The drills are employed for making openings for the insertion of ivory pegs 
or wii-e in cases of false joint. The reciprocating saw is useful for subcutaneous division 
of the long bones for the correction of various deformities. It is provided with an attach- 
ment for fixing the bone previous to the section of its ends in pseudarthrosis, when, from 
the comparatively inaccessible position of the false joint, it is difficult to bring the frag- 
ments through the wound, as when the upper portion of the femur is affected. 
The syringe forms an important element in the armamentarium of the surgeon. Great 
improvement has taken place of late years in the manufacture of this class of instruments, 
both as it respects their excellence and their variety. For washing out the vagina and 
rectum the most eligible syringe is Davidson’s, fig. 150, and the same contrivance may 
be advantageously used for throwing fluids, whether simple, medicated, or intended as 
food, into the lower bowel. The hard rubber syringe, capable of holding from half a pint 
to a quart, is also well adapted to the object, and there are cases in which it is to be pre- 
ferred, as when an enema requires to be thrown high up into the bowels. Syringes for the 
urethra, eye and ear will receive separate 
notice in the chapters on diseases of those 
organs. For cleansing wounds and ulcers 
nothing answers so well as a tin tank, pro- 
vided with a gumelastic tube from a yard to a 
yard and a half in length, and fitted with a 
delicate nozzle capable of being insinuated into 
any recess, however small. When the object 
is to wash out the vagina, or any deep cavity, 
Fig. 150. 
Fig. 151. 
Davidson’s Syringe. 
Vaginal Syringe Nozzle with Reverse Current. 
covered with blood or adherent secretions, a large nozzle with numerous large apertures 
may generally be used with advantage. A syringe nozzle, fig. 151, with a reversed 
current, is another serviceable contrivance in such a condition. 
SECT. II INCISIONS. 
It is not my intention to enter into any minute details respecting the manner of holding 
the knife, in operating upon the living subject, as this is a kind of information which 
should be acquired in the dissecting-room, in connection writh the study of surgical 
anatomy. A few rules, concisely and plainly stated, will be quite sufficient for the pur- 
pose, and will enable any man of sense to execute, with facility, neatness, and celerity, 
any operation he may be called upon to undertake. Anything like a flourish for the 
sake of display or the hope of attracting the applause of the vulgar, is as repugnant to 
good taste as it is out of place upon such an occasion. 
There are four principal positions in which the knife may be held for operative pur- 
poses, and with these every surgeon should make himself familiar. The annexed sketches 
will serve to convey a better idea of their character than any description, however elabo- 
rate. They are generally distinguished by the prefix of first, second, third, and fourth. 
In the first position, fig. 152, the knife is held like a writing-pen, between the thumb CHAP. XIV. 
INCISIONS. 
443 
and the first two fingers, which grasp the instrument gently yet firmly at the junction of 
the handle with the blade, the edge being inclined downwards or upwards, according to 
Fig. 152. 
Fig. 153. 
the intentions of the surgeon. This position is 
a very common one, as it is employed in a 
great variety of operations, as lithotomy, the 
extirpation of tumors, herniotomy, and the ex- 
traction of cataracts. 
In the second position, fig. 153, the handle 
of the instrument lies in the palm, the thumb 
and middle finger holding it at its anterior 
extremity, while the index finger is slightly 
extended along the back of the blade, the ring 
and little fingers assisting in supporting and steadying the handle. The edge of the blade 
is inclined downwards or upwards, according to circumstances. 
In the third position, fig. 154, the knife is held like the bow of a violin; that is, the 
instrument, turned away from the palm, is lightly balanced in the hand, the four fingers 
being applied against one side, and the thumb against the other. In the dissection, the 
blade is usually held somewhat sidewise, and the operation is performed chiefly by alter- 
nately flexing and extending the wrist. 
In the fourth position, fig. 155, the knife is held like an ordinary carving-knife, the 
handle, which inclines towards the ulnar margin of the wrist, being firmly grasped by, and 
almost completely concealed in, the hand, the tips of the last three fingers nearly touching 
the hypothenar eminence. This position is chiefly used in the amputation of the larger 
limbs, and, occasionally, in the extirpation of huge superficial tumors, when the surgeon 
wishes to produce a rapid and brilliant effect. 
The incisions employed in operative surgery may be conveniently reduced to three 
principal ones, the straight, curvilinear, and angular, which are the parents of all the rest. 
In executing these incisions certain rules should be observed, of which the most import- 
ant are the following:— 
Fig. 154. 
Fig. 155. 
1. The knife, whether a bistoury or scalpel, should be in as complete a condition as 
possible, being perfectly sharp and clean, and as light as may be consistent with the 
necessary strength ; its size should also be carefully adapted to the occasion. 
2. Before commencing the incisions, care should be taken to stretch, extend, or tighten 
the skin, which is done either by the surgeon alone, or partly by him and partly by his 
assistants. Attention to this rule is of great importance in numerous operations, as it 
not only expedites the movements of the knife and imparts precision to the incisions, but, 
what is often a matter of the greatest consequence, enables us to save integument, as, for 
instance, in case of amputations and in the removal of benign tumors. 
3. The incisions, of whatever shape, should be sufficiently large to answer the purpose, 
for which they are designed, being made so, if possible, before the dissection is begun, as 
this generally greatly facilitates the removal of the parts, or their separation from each 
other. The principal exception to this rule is where the operation involves the division 444 
MINOR SURGERY. 
CHAP. XIV. 
of' large vessels, which, if they were all wounded at once, might be productive of serious 
hemorrhage. 
4. The superficial incisions should be of equal depth throughout, the knife being entered 
perpendicularly at one extremity, and brought out similarly at the other, the object being 
the avoidance of what is called a tail, or a partial division of the integument at each end, 
as would inevitably happen if the point of the instrument were introduced obliquely. A 
gentle but steady sawing motion of the knife should be employed rather than firm pressure. 
5. In dividing the common integument, the knife should always, if possible, be carried 
parallel to the axis of the parts to be exposed or removed, in order that there may be no 
interference with any important vessels or nerves, which usually run in that direction. 
Another great point to be gained, in observing this precaution, is that the flaps are pre- 
vented from bagging, and so serving as receptacles for the lodgment of blood and inflam- 
matory deposits. 
6. The incisions should be made as rapidly as possible, seeing that the division of the 
common integument is generally the most painful part of an operation. Moreover, while 
they should be sufficiently extensive for the object in view, care should be taken not to 
make them larger than is necessary. 
7. All cutaneous incisions should be made with special reference to the prevention of 
unseemly scars. To do this successfully is not always either easy or even practicable. 
As a general rule, the object is best attained by carrying the knife in the direction of the 
muscular fibres of the part, or in the line of its wrinkles. Thus, in operating on the 
forehead, the surgeon will best attain his wishes if he makes his incision horizontal, not 
oblique, much less perpendicular. In operating upon the lower jaw, or in extirpating 
tumors from this region, the incision should be so directed as to run along the base of the 
bone, which will thus offer the best chance of concealing the resulting cicatrice. 
8. The operator, in the exercise of his functions, must be careful not to wound himself, 
his assistant, or his patient; an occurrence as awkward as it is unseemly, and one that 
will seldom happen, if everything be properly arranged beforehand. 
The straight incision may be made either from without inwards, or from within out- 
wards. The former method is usually adopted in the ordinary operations, as in the 
extirpation of tumors, in opening abscesses, and in the ligation of arteries. Where great 
caution, however, is required, as in operating for strangulated hernia, or in the removal 
of morbid growths in front of the neck, the incision must be made from within outwards. 
For this purpose a fold of integument is pinched up and held by the surgeon and his 
assistant, while its base is transfixed by the knife, and divided by making the instrument 
cut its way out. The dissection is afterwards conducted upon a grooved director. 
Occasionally, as in operating about the neck, especially when the object is the removal 
of a large tumor at the angle of the jaw, the incision may advantageously be made in a 
curvilinear direction, either like an Italian f, or in the form of a semiellipsis, 
as in fig. 156. The chief reason for this procedure is that, while it affords 
the operator more room, it leaves a more seemly cicatrice. 
The elliptical incision consists of two curvilinear cuts, meeting at 
their extremities, as in fig. 157. It is chiefly employed in the extirpa- 
tion of tumors, where the object is to remove along with the diseased mass a por- 
tion of redundant or unhealthy integument. The incisions are made rapidly, in the 
usual manner, one after the other, the skin being properly stretched, and care taken not 
to cut away more than is absolutely necessary, since it will otherwise 
be difficult, if not impossible, to bring the edges of the wound together, 
after the operation is over, so as to obtain a good and rapid union. Not 
a little judgment is frequently required to determine, in a given case, 
how much integument may conveniently be preserved or removed ; the 
surgeon, remembering how contractile the skin is, will generally be cautious how he 
sacrifices it. Even if the flap is unseemly immediately after the operation, a few days 
will generally suffice to reduce it to a proper shape and size. 
Two semielliptical, crescentic, or semilunar incisions, as in fig. 158, may sometimes be 
advantageously made, also with the object of removing a portion of integu- 
ment, as for instance, in extirpating a diseased mammary gland. 
The incisions may be directed vertically, obliquely, or horizontally, as 
may seem most suitable. The angular incision may be used for various 
purposes, as in the extirpation of tumors, herniotomy, excision of joints, 
the exposure of diseased bone, and in the transplantation of flaps for the restoration of 
lost or mutilated parts. It may be made in different ways, but commonly so as to repre- 
Fig. 156. 
Fig. 157. 
Fig. 158. CHAP. XIV. 
AVULSION, ENUCLEATION, ETC. 
445 
sent the shape of some letter, as in the subjoined figures, according to the exigencies of 
the particular case. 
Fig. 159. 
Fig. 160. 
Fig. 161. 
Fig. 162. 
Fig. 163. 
Fig. 164. 
In dissecting up the flaps, made by these different incisions, the instrument should, as 
a general rule, be kept in close contact with the parts to be removed; the knife should be 
swept along as rapidly as may be consistent with safety; and good use may commonly be 
made of the fingers, which will in most cases be found altogether preferable to the forceps. 
Special regard should always be had to the prevention of hemorrhage. If well-trained, 
intelligent assistants be at hand, there will generally be no necessity for tying every little 
artery as soon as it is divided ; the instant it springs, a finger is clapped upon it, and thus 
the operation proceeds to its completion, when, satisfactory clearance being effected, the 
ligation is at once promptly entered upon, and continued until every bleeding vessel is 
properly secured. 
When the dissection involves the exposure of an important structure, as a large artery, 
a strangulated hernia, or a cystic tumor, which it is desirable not to pierce, the tissues 
must be divided layer by layer upon a grooved director gently and cautiously insinuated 
beneath them ; or they may be pinched up with a pair of forceps, although this is both 
less elegant and less safe than the other method. In performing this‘part of the opera- 
tion, the successive divisions must be effected in the line of the external incisions, the 
best knife for the purpose being a narrow, probe-pointed bistoury. 
SECT. Ill AVULSION, ENUCLEATION, LIGATION, AND CRUSHING. 
1. Avulsion—Instead of cutting away morbid growths with the knife or bistoury, 
removal is sometimes effected by avulsion, or by twisting and tearing. It is in this way 
that the surgeon usually deals with polypoid tumors of the nose and uterus, the agent that is 
employed for the purpose being a suitable pair of forceps, with which the tumor is seized 
and broken off, by rotating the instrument gently yet firmly upon its axis. All active, 
sudden, or forcible pulling is avoided,‘as tending to inflict serious mischief upon the parts 
around by lacerating and injuring them to an undue extent; or, as in the case of the nose, 
perhaps dragging away the turbinated bone, or, as in that of the uterus, inverting that 
organ, or pulling it down beyond the vulva. Moreover, copious hemorrhage, intense pain, 
and severe shock are liable to follow such rude measures. 
Avulsion is sometimes advantageotfsly practised in the extirpation of tumors developed 
in and among the tissues, especially when they are deeply situated, or when they lie in 
the immediate vicinity of large vessels, which it would be hazardous to approach with the 
edge or extremity of the knife. Under such circumstances, the finger may occasionally 
advantageously take the place of tlie cutting instrument, the connecting structures being 
forcibly lacerated, and the mass twisted and lifted out of its bed. This mode of procedure 
is often resorted to in the removal of tumors from the neck and parotid region dipping 
deeply down behind the base and angle of the jaw, in close proximity with the pharynx 
and the large cervical vessels and nerves, where a false movement with the scalpel might 
instantly be fatal. It is astonishing what little bleeding frequently follows operations 
thus performed, and how well the parts generally heal after such manipulations. One 
reason why there is usually so little hemorrhage is that the vessels are torn, instead of 
being evenly divided, as they are in the ordinary procedure. 
2. Enucleation Enucleation, another species of avulsion, is often advantageously 
employed in the extirpation of fatty, fibrous, and sarcomatous tumors. The integument, 
having been thoroughly divided over the morbid growth, along with its capsule, if there 
be any, the diseased structures are rapidly peeled out either with the finger, or with the 
handle of the scalpel. In certain cystic tumors the bag with its contents may often be 
peeled off bodily, or its cavity being laid freely open, and its contents evacuated, the walls 
of the cyst may be pulled away with the forceps. 
8. Ligation—There are certain operations in which the removal of the diseased parts 
is effected chiefly through the agency of the ligature, which may be constructed of silk, 
flax, or gum elastic. Of this mode of procedure familiar examples are afforded in the 446 
MINOR SURGERY. 
CHAP. XIV. 
removal of hemorrhoidal tumors, polypoid growths of the nose, vagina, uterus, and anus, 
and nsevoid formations about the face, forehead, and other regions of the body. The 
ligature may be applied either directly to the part by the fingers, or by means of a needle, 
and should be drawn with sufficient firmness to strangulate the included structures, as the 
object is to cut off the supply of blood, and cause an eschar. Occasionally the ligature is 
used subcutaneously, as in case of naevoid growths, often involving very interesting and 
complicated operations. Instead of the ligature, a silver wire is sometimes used, either 
by itself, or by means of a double canula, as in fig. 165. 
Fig. 165. 
Double Canula. 
4. Crushing Parts, again, may occasionally be removed by a process of crushing, as 
proposed by Chassaignac, of Paris, the instrument which he has devised for that purpose 
being called the ecraseur; the inventor hoping thus to meet certain contingencies in 
operative surgery which he, in common with others, had frequently encountered in prac- 
tice, and which he supposed could not be overcome in any other manner. His chief 
object was to supply a substitute for the ligature in the removal of certain tumors, as 
hemorrhoids, and polyps of the vagina and uterus. The idea seems to have been to con- 
trive an instrument that should combine the security of the ligature with the rapidity of 
the knife, thus preventing hemorrhage and pain, and promptly ridding the part of abnor- 
mal structures. The ecraseur, as might be supposed, was originally rude and clumsy, 
but, by the ingenuity of surgeons and cutlers, has been rendered very graceful and con- 
venient, if not absolutely perfect. 
The annexed sketch, fig. 166, affords an excellent representation of the shape and 
construction of the instrument, as manufactured by Gemrig, Kolbe, and others of this 
city. It will be perceived that it essentially consists of two pieces, a sheath, barrel, or 
tube, either flattened or cylindrical, and of an articulated chain, attached to a steel rod, 
lying within the sheath, and moved by a handle. The chain is constructed upon the same 
principle as the ordinary chain saw, but the links are stronger and perfectly obtuse, ex- 
cept when it is desired to combine division with crushing, when their edges are somewhat 
bevelled. The instrument is made of different sizes and shapes, so as to adapt it the 
more readily to the various cases presented in practice. The chain, unless constructed 
with great care, is very liable to break, especially if used for the removal of dense, indu- 
rated structures, the division of which requires a good deal of force. 
One great trouble in regard to the ecraseur is the difficulty of managing the flexible 
chain, especially in the removal of fibrous and other growths of the vagina and uterus. 
To remedy this defect, Dr. J. Marion Sims has added a pair of dilating forceps with 
spring blades, by which this portion of the instrument is rendered so stiff that it may be 
introduced into almost any cavity with the same facility as a probe. 
Fig. 166. 
£craseur. 
The smaller variety of Ecraseur, in which, as represented in fig. 167, the articulated 
chain is replaced by one or more strands of iron wire, will be found convenient for the 
removal of polypoid and superficial vascular growths, as well as for laying open fistulous 
tracks. CHAP. XIV. 
SKIN-GRAFTING. 
447 
The ecraseur is less frequently employed now than formerly, and the class of cases to 
which it is more particularly adapted is much better understood. Its use, at present, is 
very much restricted to the removal of various kinds of tumors, especially hemorrhoidal, 
naevoid, and ovarian, and of the tongue, penis, prepuce, and neck of the uterus. The 
Fig. 167. 
Wire Ecraseur. 
advantages that may be fully claimed for it are, first, the rapidity of the operation, which 
is greater than that with the ligature, although less than with the knife, the instrument 
acting more powerfully upon the tissues embraced in its loop ; secondly, the prevention 
of shock, the chain doing its work gradually and almost imperceptibly, so as hardly to 
afford the system an opportunity of taking cognizance of what is going on ; thirdly, the 
protection of the part against hemorrhage, the vessels being placed in a condition similar 
to those in a lacerated and contused wound ; and, lastly, the making of a smaller and less 
exposed wound than either the ligature or knife, followed by less inflammation and more 
rapid cicatrization. 
The principal rules to be observed in the application of the ecraseur are the following. 
In the first place, if the tumor has a broad base, it should, if possible, be pedunculated, 
by drawing it away from its points of attachment, and casting a ligature around it, its 
base having previously been transfixed by one or two stout needles. When the coverings 
of the morbid growth are unusually hard, or insensibly lost in the surrounding parts, a 
gutter may be formed in them with the knife, preliminary to the application of the chain. 
Secondly, the division of the tissues is to be effected slowly and gradually, not rapidly or by 
fits and starts, and for this purpose the handle of the ecraseur should be tunrned only 
about once every ten, twenty, twenty-five, or thirty seconds. The time occupied in the 
entire operation must of course vary according to circumstances, from five minutes, as the 
average minimum, to twenty minutes, as the average maximum. The great objection to 
a rapid operation is the danger of hemorrhage. Thirdly and lastly, the patient, during 
the whole procedure, should be under the influence of an anaesthetic, otherwise the pain 
will be extreme, especially in the earlier stages. 
The subsequent treatment is very simple. If pain arises when the patient wakes from 
the effects of the anaesthetic, a full anodyne is given, the part is kept at rest in an elevated 
position, under the influence of water-dressing, and any constitutional symptoms that may 
show themselves are met as they occur, precisely as after any other operation. The 
wound generally heals in a very short time, with very little appearance of inflammation. 
I am not aware that the application of the ecraseur has ever been followed, in cases at all 
adapted to its use, by pyemia, or any grave constitutional effects, and this is certainly one 
of the strongest arguments that can be urged in favor of its employment. 
SECT. IV SKIN-GRAFTING. 
Cicatrization of ulcers and wounds may often be 
greatly accelerated by the transplantation of skin, 
or skin-grafting, a practice the introduction of which 
has been generally, but unjustly, ascribed to Dr. J. L. 
Reverdin, who did not call attention to it until 1869, 
fifteen years after Professor Frank H. Hamilton 
had published an account of his first operation in 
a paper entitled “ Old Ulcers Treated by Skin- 
grafting,” published in the New York Journal of 
Medicine for 1854. His patient had a large wound, 
caused by the fall of a heavy stone fifteen months 
previously, and attended with so much loss of skin, 
as to render Nature unable to effect a cure. To 
cover this gap, Hamilton transplanted a portion of 
integument from the opposite limb, not sufficient, 
however, to take in the whole surface. In three 
Fig. 168 
Cutting Grafts. 448 
MINOR SURGERY. 
CHAP. XIV. 
months the cicatrization was complete, the new piece of skin having grown from its peri- 
phery in every direction, and in the end acquired nearly twice its original size. By this 
operation, which foreshadowed the whole principle involved in skin-grafting, the New York 
surgeon hoped to establish, as he expressed it, “a new centre of life on an oasis, from whose 
outer verge a true and healthy vegetation shall advance in every direction over the exhausted 
soil.” To the French surgeon, however, is unquestionably due the credit of introducing 
and generalizing skin-gralting, or the insertion of minute grafts at various points of the 
exposed surface, now so generally practised. Availing himself of a knowledge of the 
physiological law that cicatrization always begins at the periphery of an open surface, he 
happily conceived the idea of implanting small pieces of skin upon the granulations of 
wounds and ulcers, in order to afford these bodies, as it were, so many points of departure for 
the formation of new integument by virtue of the proliferation of their own cells. A very 
simple plan, both bloodless and painless, which I believe originated with Professor Hodgen, 
of St. Louis, and which is represented in fig. 108, consists in raising portions of the skin, of 
the size of millet seeds, with a needle and detaching them with a small knife. The grafts, 
which include only the epidermis with its mucous layer, and which should be taken from 
the inner surface of the upper arm of the patient himself to avoid the risks of syphilitic 
inoculation, are then placed flat upon the raw surface, at a distance of about three-quarters 
of an inch from one another, and confined with a layer of patent lint, spread with simple 
cerate, and supported with adhesive strips and a roller, 
smoothly and lightly applied. If the granulations are 
uncommonly large and firm, the grafts are inserted 
into slight incisions, to afford them a more secure hold. 
The dressings are allowed to remain for four or five 
days, when the buds will generally be found to be 
firmly attached, as in fig. 1G9. If the buds are very 
small, they may be so completely imbedded and hidden 
in the granulations as to be quite invisible for a short 
time. Soon, however, a bluish-white, opaque speck 
appears—a little island, as it were, upon the raw sur- 
face—indicative of their presence, and of the gradual 
development of new cicatricial tissue. The new skin 
thus formed makes a firmer and sounder scar than 
one formed in the ordinary manner, and therefore is much less liable to fall a prey to 
inflammation and its consequences. One of the prerequisites to the success of this pro- 
cess is the existence of healthy granulations, and it is well, wdien the ulcer is very large, 
not to insert too many grafts at one time, but to trust to consecutive transplantations 
as more likely to answer the object, which is to impart new life and vigor to the whole 
surface. 
Experiments performed by Guyon and others show that skin-grafting is nearly as 
successful when practised with epidermic scales as when it is done with bits of skin. 
Professor Hodgen has obtained excellent results simply by dusting the granulating 
surface with scrapings of this kind, which, it would seem, are capable of imbibing 
nourishment, and of generating germinal cells for the development of new epithelium. 
It has generally been supposed that the success of skin-grafting is essentially due to the 
presence of epithelium ; but that this is not true has been clearly proved by the experi- 
ments of Professor Howard, of New York, who has obtained precisely similar results 
from grafts of bits of muscle, inserted into granulating wounds. 
SECT. Y SPONGE-GKAFTING. 
It has long been known that fibrinous lymph or a clot of blood becomes organized by 
extension into it of the bloodvessels of the surrounding tissues, those substances playing 
merely a passive part in situations in which they are replaced by cicatricial tissue. 
Recognizing these facts, Ur. D. J. Hamilton, of Edinburgh, in 1880, conceived the idea 
of resorting to very fine porous sponge as a framework for the construction of new 
material for filling up the deficiencies of ulcers and large surgical wounds; and his ex- 
periments demonstrate that a firm cicatrice, which is less contractile than an ordinary 
cicatrice, may be obtained in this way. The only practical objection that can be urged 
against this method is that the healing process does not appear to be expedited, since in 
one of his cases five months were required to reduce an ulcer from a diameter of five 
inches to that of an inch and a half. In performing the operation the wound should be 
Fig. 169. 
Skin-grafting. CHAP. XIV. 
ABSTRACTION OF BLOOD. 
449 
accurately filled with one or more pieces of sponge prepared by dissolving out the animal 
matter by dilute nitro-hydroehloric acid, subsequently washing in liquor potassae, and 
then steeping in a one-to-twenty carbolic solution. A piece of protective is placed over 
the surface and covered with lint soaked in a one-to-twenty solution of carbolic acid in 
glycerine, and on this a pad of boracic lint, oakum, or antiseptic gauze is confined by a 
bandage. At the expiration of about five days, the interstices of the sponge will be 
found to be filling with granulation tissue and bloodvessels, and cicatrization will com- 
mence as soon as the new tissue has attained the level of the surrounding skin, at which 
time the sponge will have entirely disappeared. Throughout the treatment the wound 
and the discharge must be maintained in an aseptic condition, irrigation with the carbolic 
solution being resorted to if at any time there is a putrefactive odor. A healthy granulat- 
ing surface is not an essential requisite for success. 
SECT. VI ABSTRACTION OF BLOOD. 
The abstraction of blood may be effected by scarification, puncture, incision, leeching, 
and cupping. The fluid is sometimes taken from a vein or an artery; the operation, in 
the former case, constituting what is termed venesection, in the latter, arteriotomy. 
1. Scarification—Scarification is performed with the lancet, scalpel, or bistoury, 
passed lightly and rapidly over the inflamed surface, so as to divide the engorged vessels, 
and thus afford them an opportunity of freeing themselves of their contents. It is 
employed chiefly in conjunctivitis, tonsillitis, erysipelas, and irritable ulcers, and may be 
repeated once a day, or once every other day, according to the exigencies of the case, the 
bleeding being promoted by the liberal use of warm water. In irritable ulcers of the 
extremities as well as in other parts of the body, scarification is an exceedingly useful 
practice, which I have long pursued with great advantage. The proper mode of proceed- 
ing is to immerse the limb, previously constricted just below the knee, in a vessel of warm 
water, and then to make from four to eight vertical incisions over the sore, extending 
merely through the. superficial portion of the true skin. In this manner I have repeatedly 
bled patients to syncope, making thus a most salutary impression both upon the part and 
system. In granular conjunctivitis, the eyelids, especially the upper, may often be scarified 
with the happiest effect; and in ophthalmia, attended with chemosis, deep incisions are 
generally practised to relieve engorgement and prevent strangulation of the vessels of 
the cornea. In tonsillitis, scarification nearly always greatly mitigates the symptoms; 
while in erysipelas, especially in the phlegmonous variety of that disease, it forms a most 
important element of the local treatment, nothing else being so well adapted to remove 
tension and prevent gangrene. 
2. Puncturing Puncturing is performed very much with the same intention as scarifi- 
cation. It is particularly valuable in erysipelas, active oedema, boils, carbuncles, hemor- 
rhoids, and affections of the tonsils, uvula, lymphatic glands, scrotum, prepuce, uterus, 
labia, and nymph®, its beneficial effects depending upon the amount of drainage following 
the operation. The best instrument for performing the operation is a very narrow, sharp- 
pointed bistoury, thrust rapidly into the inflamed surface, to a depth varying from a line 
to half an inch, according to the degree of swelling of the affected parts, care being taken 
to avoid injuring important vessels and nerves. In the more severe forms of phlegmonous 
erysipelas, as many as fifty, seventy-five, or even a hundred punctures may sometimes be 
made with advantage. 
3. Leeching Leeching is applicable to a great variety of affections, and is, perhaps, 
more frequently employed than any other mode of topical bleeding. The operation, 
however, is not without pain, and, unless properly performed, may even be followed by 
danger. Thus, in epidemic erysipelas, I have known it to give rise to an attack of this 
disease, which speedily destroyed the patient. Sometimes, again, leech-bites degenerate 
into bad sores, and produce much constitutional irritation. Ill effects are most likely to 
arise when the leeches are sickly, or when they are applied to persons of a nervous, irri- 
table temperament. Hence, great caution should always be exercised in their selection, 
as well as in the manner of using them. 
The best leeches are the Swiss, German, French, and Spanish, which generally take 
hold with great avidity, and draw each from half an ounce to six drachms of blood, 
including the flow after the animal drops off. The American leeches, although much 
larger than the European, bite reluctantly, and suck sluggishly, on which account they 
are rarely used. Moreover, the wound made by the foreign leech emits four times as 
much blood as that made by the native ; a fact not to be lost sight of in ordering this kind 450 
MINOR SURGERY. 
CHAP. XIV. 
of bleeding. Whatever species be employed, the rule is to divest the part of hair and 
dirt, otherwise the animal, which is very fastidious in its tastes and habits, will either not 
take hold at all, or oidy after much coaxing. If, notwithstanding these precautions, it is 
not inclined to bite, a little blood should be smeared upon the surface, drawn from the 
part with a delicate needle, or from the operator’s own finger, previously constricted with 
a tight cord, or the surface may be wet with sugared water or sweetened milk. Immer- 
sion of the animal for a few minutes in beer or ale will sometimes induce it to take hold 
when hardly anything else will. When the number of leeches to be applied is consider- 
able, they should be confined in a tumbler, inverted upon the part, to prevent them from 
crawling about; they must not be crowded too closely together, and they must, as a rule, be 
allowed to remain on until they drop off of their own accord, as they will be sure to do 
as soon as they have “taken their fill.” Their forcible separation is not only productive 
of pain, but sometimes leaves a portion of the jaw in the little triangular wound made by 
its bite, which soon becomes inflamed and irritable in consequence. The bleeding is 
encouraged by sponging the surface well with warm water, and then covering it with a 
thickly-folded flannel cloth, wrung out of hot water, and frequently renewed, for a period 
varying from thirty minutes to two hours, or even longer, according to the desired effect. 
The blood having ceased to How, the part is sprinkled with powdered starch, and covered 
with a dry cloth. If there is any disposition to bleed more, or longer, than is deemed 
proper, the bites are covered with a piece of dry tinder, which, especially if conjoined 
with a little pressure, generally soon puts a stop to the effusion. 
The number of leeches to be applied at any one time varies from one to several dozens, 
according to the intensity ot the morbid action, and the age and strength of the patient. 
In the adult, from fifteen to twenty is a good average number ; in children under five years 
of age, from three to six. In infants the bite of a single foreign leech is sometimes 
followed by fatal depression. The extraordinary delicacy of the skin, and, consequently, 
the great depth of the bite, are reasons why leeching should be practised with more than 
common caution at this tender age. 
There are certain localities where leeches are inadmissible. Thus, in the first place, 
the face, neck, and other parts habitually exposed are, if possible, avoided, because the 
bites of these animals are liable to be followed by disfiguring scars, particularly objection- 
able in the female. Secondly, they must not be applied to the eyelids, scrotum, prepuce, 
labia, and nymphse, structures abounding in loose connective tissue, and therefore readily 
admitting of great infiltration of blood, as well as extensive discoloration. Thirdly, they 
must not be placed along the course of a superficial artery, large vein, or nervous trunk ; 
lest they should occasion serious hemorrhage and severe pain. Fourthly, care is taken 
to avoid the focus of an inflamed surface, as they might seriously aggravate the morbid 
action, if not induce gangrene. Fifthly, it is a rule not to apply these animals in the 
vicinity of specific ulcers, as chancroids and open buboes, for fear of inoculating their bites, 
and thus propagating the specific disease. Finally, leeches should never be used upon per- 
sons affected with the hemorrhagic diathesis. 
A discharge of blood by leeches for a number of successive hours is sometimes very 
desirable, as soon as one set drops off another supplying its place. In violent ophthalmia, 
croup, peritonitis, erysipelas, and bubo, there is no mode of depletion so beneficial, or so 
likely to put a prompt and permanent stop to the disease, as this. 
In leeching the uterus, vagina, ano-rectal outlet, the nose, and inside of the cheek, the 
animals must be confined in a glass or wire speculum, the opening in the instrument being 
held upon the part from which the blood is desired to be taken. 
Serious, and, indeed, frightful hemorrhage sometimes follows a leech-bite. The occur- 
rence is especially to be dreaded in children, in whom it occasionally produces fatal 
exhaustion, as I have myself witnessed in two instances. The best remedies are dried 
tinder, bound firmly upon the part, compresses wet with a saturated solution of alum or a 
solution of subsulphate of iron, the application of a thick layer of collodion, and cauteri- 
zation with solid nitrate of silver, cut to a delicate point, and inserted into the little 
wound, previously well cleansed and dried. Pressing the glazed surface of a visiting 
card firmly upon the orifice sometimes answers the purpose. If these means prove 
abortive, the edges of the wound should be transfixed with a cambric needle, and approxi- 
mated by ligature; a procedure which seldom, if ever, fails. 
When the natural leech is not at hand, a tolerable substitute may be found in the 
artificial leech of Baron Ileurteloup, consisting of a small cylindrical drill, and of a glass 
exhausting-tube with an air-tight piston, worked with a screw. The incision may be 
carried to any depth, and, if the instrument be properly managed, several ounces of blood CHAP. XIV. 
ABSTRACTION OF BLOOD. 
451 
may thus be drawn in a very short time. I he great points to be observed are to make a 
free opening, and to accommodate the screw-movement to the rate of bleeding, otherwise 
there will be a vacuum above the column of blood, thereby interfering with its flow. 
4. Cupping—Cupping is by no means so eligible a mode of bleeding as leeching, 
being more painful, less elegant, and not so generally applicable. It is, nevertheless, 
when properly executed, a valuable operation, particularly in the early and declining 
stages of inflammation. An incipient pleurisy, pneumonia, or articular inflammation is 
often promptly relieved by the application of half a dozen cups ; but it is chiefly in the 
latter stages of acute disease, after the morbid action has been weakened by other reme- 
dies, and in chronic affections, that cupping asserts its true rank as an antiphlogistic 
agent. It is seldom, if ever, permissible in gastritis, peritonitis, and enteritis, on account 
of the great pain produced by the application of the scarificator. The operation, to be 
really serviceable, should be performed as near to the seat of the disease as practicable, 
care being taken not to open any large vessel, to prick any nervous trunk, or to wound 
any tendons. The surface selected for the applica- 
tion of the cups must be free from bony prominences, 
and, without being very soft, must have a good 
stratum of subcutaneous connective tissue, other- 
wise it will be impossible for the cups to maintain 
their hold, and extract a sufficient amount of blood. 
If the part is thickly covered with hair, it must 
previously be shaved. 
The scarificator, fig. 170, usually employed for 
cutting the skin, is provided with eight, twelve, or 
sixteen little blades, moved by a common spring, 
and so arranged as to make a corresponding num- 
ber of incisions, none of them being deep enough to 
wpiextend entirely through the cutaneous tissue, lest 
the fatty matter, projecting into them, should fill up the little orifices, and 
thereby impede the flow ot' blood. The cup is capable of holding from one 
to two ounces; it is bell-shaped, and is composed of glass, having a large 
mouth, with a stopcock at the other end, to adapt it to a syringe for exhaust- 
ing the air, as in fig. 171. When such an apparatus is not at hand, the 
ordinary cupping-glass may be used, or any still more simple contrivance, 
the air being rarified by inverting the vessel over the flame of a lamp, or by 
means of a little pellet of cotton, wet with alcohol, and set on fire in the 
glass. In a few moments the skin rises and forms a red, conical swelling, which is now 
scarified, the cup being immediately replaced, and allowed to remain until the coagulum 
in its interior arrests the flow of blood, when it is carefully removed, to be again replaced 
as soon as the incisions have been freed from obstruction. If the bleeding cease before 
the requisite supply has been obtained, the surface is cut crosswise, 
and the operation proceeded with as previously. As much blood 
having been drawn as may be considered proper, the glasses are re- 
moved, and the parts covered with a soft cloth moistened with oil. 
The number of cups varies from one to a dozen, according to the de- 
sired effect. 
The most elegant and convenient contrivance, by far, is one made 
of the body of the ordinary glass cup, surmounted by a cone of vulcan- 
ized India-rubber, as seen in fig. 172. In order to apply it, all that is 
necessary is to indent the top with the finger, the removal of which 
permits the part instantly to regain its former position, thus exhausting 
the air within, as it does with great force and efficiency. 
Although cupping is generally a perfectly safe operation, instances 
have occurred in which it was followed by annoying, if not fatal, hem- 
orrhage. Such a result is most likely to happen when a superficial 
artery, as, for instance, the temporal, has been penetrated, when the 
blood has lost its coagulability, as when there is some idiosyncrasy, or 
when the system has been exhausted by protracted disease, as typhoid 
fever, a severe wound or a compound fracture. The treatment must be conducted upon 
the same principles as in bleeding from leech-bites. 
5. Venesection Venesection is commonly regarded as so trivial, simple, and easy an 
operation, that it has rarely received the consideration and attention to which its in- 
Fig. 170. 
Fig. 171. 
Scarificator. 
Cupping ap- 
paratus. 
Fig. 172. 
Cupping-glass with 
Vulcanized India-rub- 
ber top. 452 
MINOR SURGERY. 
CHAP. XIV. 
trinsic importance really entitles it. Everybody, no matter whether he has any knowl- 
edge of the anatomy of the parts involved in the operation, or the slightest skill in the 
use of instruments, is supposed to be capable of performing it, and it is, therefore, often 
done in the most bungling manner, entailing much suffering, if not loss of limb and life, 
upon the patient, and great discredit, if not ruin, upon the practitioner. During the 
reign of the lancet accidents from its use were sufficiently common, and, for a time, I had 
quite my share of them, although, fortunately, not as the result of my own bad luck. 
Thus, in two cases I saw the patients perish from phlebitis; in five, I was obliged to tie 
the brachial artery at the bend of the arm ; in several, great and protracted suffering en- 
sued from the puncture of a nerve ; and in three instances the arm was endangered by 
erysipelatous inflammation, followed by immense abscesses, and great impairment of the 
functions of the elbow, wrist, and finger joints. The character of the operator is some- 
times seriously injured by these mishaps. It is related of Marechal, who flourished in 
the reign of Louis XIV., and who was styled, by one of the poets of his day, the prince 
of surgeons, that he suffered greatly in his reputation for several years, on account of a 
fatal accident which followed the bleeding of a foreign nobleman. 
A vein may be opened with a spring lancet, a thumb lancet, or a bistoury, according 
to the whim, fancy, or habit of the operator. I have myself been so long accustomed to the 
use of the first of these instruments, that I seldom employ any other. Experience has taught 
me that the operation, when done with the spring lancet, generally answers every pur- 
pose, as it respects the size and shape of the orifice, the safety of the parts, and the facility 
of manipulation, while it is incomparably less painful than when it is performed with the 
thumb lancet or bistoury. These are, I think, important desiderata, which no unpreju- 
diced practitioner can overlook. No one who has himself been bled with these different 
instruments can hesitate about his future choice. I know that the thumb lancet is gen- 
erally considered as a more scientific instrument than the spring lancet; it is certainly 
more simple, and, perhaps, also more easily kept in order; but these advantages do not, 
in my judgment, outweigh the disadvantages. Both these instruments are so well known 
that any description of them here would be superfluous. If a bistoury be used, one of 
very small size should be selected, somewhat like that employed in opening abscesses, 
described at page 437. It should be quite narrow in the blade, slightly spear-shaped at 
the extremity, and not more than half an inch long in the cutting part. Such an instru- 
ment, confined in a light handle, is more elegant than the ordinary thumb lancet, as well 
as more easily managed, and is decidedly more surgical and scientific; a circumstance so 
much insisted upon by some practitioners. 
Whatever instrument be employed, it should be perfectly sharp, clean, and always well 
washed and wiped both before and after the operation, for it is only by observing these 
precautions that it can be kept in proper order, and that the surgeon can hope to avoid 
undue irritation and other mischief in the wounded structures. The use of a foul lancet 
has often been a cause of death. 
Bleeding at the Bend of the Arm—In bleeding at the bend of the arm, the best plan 
is to select the largest and most superficial vein, having previously ascertained that the 
brachial artery is not in danger of' being wounded, as it might be when it lies just behind 
the vessel, or close along its side. When the artery separates high up, one of its branches 
generally passes immediately under the skin, and might thus be easily opened by an 
incautious operator. As to the superficial nerves, it is seldom possible altogether to avoid 
them, whatever vein may be selected ; nor is this a matter of much moment, provided 
they are completely divided, and not merely pricked. The veins of the bend of the arm, 
with the accompanying nerves, are well seen in fig. 173. 
In order to distend the vein, a fillet, a yard long by an inch in width, is tied firmly 
round the arm, about two inches and a half above the bend, the ends being secured with 
a slip knot. It must not be draAvn so tightly as to interrupt the circulation in the brachial 
artery. The patient, extending his arm at a right angle with the trunk, in a state mid- 
way between pronation and supination, grasps a common cane, a yardstick, or any other 
suitable object, holding the limb in an easy, gentle position. The surgeon, standing be- 
hind the limb, then pierces the vein, making the opening obliquely, and of sufficient size 
to furnish a free stream. The adjoining sketch affords a better idea of the manner of 
holding the lancet than the most elaborate description could. The surgeon uses what- 
ever hand may be most convenient: the vein is thoroughly steadied with the finger pre- 
viously to making the incision, and care is taken that the orifices of the skin and the 
vessel do not afterwards lose their parallelism, lest the flow of> blood should thereby be 
seriously embarrassed, or the fluid escape extensively into the subcutaneous connective tis- CHAP. XIV. 
ABSTRACTION OF BLOOD. 
sue. Should the latter accident occur, the fillet must be immediately removed, and the 
requisite abstraction effected from another vein. Sometimes the blood flow’s sluggishly, 
although the opening may be quite capacious and unobstructed. When this is the case, 
the patient should alternately flex and extend his fingers, so as to cause energetic con- 
traction of the muscles of the forearm, w’hich often powerfully promotes the bleeding; or, 
instead of this, or along with it, the operator rubs the limb from below upwards, although 
Fig. 173. 
Fig. 174. 
such a procedure is seldom attended with much advantage. Some- 
times the flow of blood is interrupted by the protrusion of a pel- 
let of fat into the oritice of the vein, the timidity of the patient, or 
the occurrence of partial syncope. 
When the spring lancet is used, the instrument is held between 
the thumb and first two fingers, the heel being raised a little from 
the surface, while the fleam is gently pressed upon the distended 
vein. The opening is effected in the same oblique manner as in 
bleeding with the thumb lancet. 
The blood should always be received into a large basin held by 
an assistant, and special pains should be taken not to soil the pa- 
tient’s body- or bedclothes. When the object is to make a strong 
and permanent impression, the blood is taken from a large orifice, 
the patient being in the semierect posture. If he is very plethoric, and the object is to 
abstract a very large quantity of blood without occasioning syncope, the recumbent posture 
is selected. When the requisite amount of fluid has been discharged, the fillet is untied, 
and the arm is wiped with a towel wet at one end, the edges of the orifice being carefully 
approximated and covered with a small, thick compress, supported by a narrow roller 
passed round the elbow in the form of the figure 8. The arm is maintained at rest in a sling 
forty-eight hours, as premature motion might be productive of suppuration and erysipelas. 
When blood cannot be obtained from the arm, it may, in case of urgency, be drawn 
from a vein on the back of the hand, from the cephalic vein as it runs along the groove 
between the deltoid and pectoral muscles, or from the external jugular vein. Bleeding in 
the veins of the leg and foot is now seldom practised, although it was at one time very 
common, especially among the lower classes of people. 
The accidents that are liable to attend and follow this operation are, infiltration of blood 
into the subcutaneous connective tissue, inflammation of the edges of the wound and of 
the surrounding parts, phlebitis, angeioleucitis, puncture of the nerves, and wound of the 
brachial artery. 
a. An extravasation of blood beneath the skin is one of the most common effects of this 
operation, and may be caused by various circumstances, as the smallness of the incision, 
the want of parallelism between the outer and inner openings, the great laxity of the con- 
nective tissue, transfixion of the vein, and the accidental occlusion of the wound by the 
interposition of adipose substance. The extravasation may be diffused or circumscribed, 
forming in the one case an ecchymosis, in the other a thrombus. In the former variety, 
the blood sometimes extends along the anterior part of the limb, nearly as high up, on 
the one hand, as the axilla, and, on the other, as far down as the inferior third of the 
forearm ; imparting to the skin, at first, a dark, purplish hue, and afterwards, as the fluid 
is absorbed, a mottled, greenish, yellowish, or sallow appearance. A thrombus is a col- 
lection of blood immediately around the wound, from the volume of a marble to that of a 
pullet’s egg, irregularly rounded at the base, and usually somewhat pointed at the top. 
Both these accidents are most liable to occur in thin, emaciated subjects, in bleeding at 
the basilic vein, and they should always be promptly remedied by attention to the exciting 
cause ; or, when this is impracticable, the bandage should immediately be removed, and 454 
MINOR SURGERY. 
CHAP. XIV. 
the requisite quantity of blood taken from another vessel. The latter procedure is par- 
ticularly indicated when the infiltration is dependent upon transfixion of the vein, the 
presence of a pellet of fat, or unusual laxity of the connective tissue. Defective parallelism 
may sometimes be corrected by changing the position of the limb ; and a small orifice 
may be enlarged by the reintroduction of the instrument. Under no circumstances, 
whatever may be the nature of the difficulty, should the operator attempt to promote the 
flow of blood by the use of the probe, inasmuch as this would inevitably be followed by 
mischief. 
When the extravasation is slight, it will usually disappear spontaneously in a very few 
days ; when considerable, recourse must be had to refrigerant and sorbefacient applica- 
tions, particularly a strong solution of thehydrochlorate of ammonia, alcohol, and water, 
and, in the latter stages, camphorated lotions, soap liniment, and similar articles. If 
matter form, or if the parts become angry and inflamed, leeches, blisters, and cataplasms 
may be necessary, with incisions to evacuate the effused blood and other fluids. 
/3. The edges of the wound, made in this operation, are sometimes seized with inflam- 
mation and suppuration ; or, instead of this, a small abscess, conical, circumscribed, and 
very painful, forms immediately around it. Occasionally, especially in feeble, sickly, and 
intemperate persons, the morbid action assumes an erysipelatous type. The most common 
causes of these mishaps are a dull, rusty, or foul lancet, imperfect apposition of the lips 
of the wound, improper tightness of the dressings, premature use of the parts, and, above 
all, the contact of the fingers, after the removal of the fillet, for the purpose of preventing 
the further escape of blood. The latter circumstance has not received sufficient attention. 
The fingers of the operator, without his being aware of the fact, are often covered with 
perspiration and other matter, which, when brought in contact with the edges of the inci- 
sion, are almost certain to irritate and inflame them. The only safe plan is never to touch 
the wound for any purpose, but, after the fillet is removed, to approximate its lips with 
a clean compi-ess, made of old muslin, and confined by an appropriate bandage. If, despite 
proper precautions, inflammation and suppuration arise, the usual antiphlogistic means 
must at once be employed. 
y. Phlebitis, to a slight extent, is probably of much more frequent occurrence after this 
operation than is generally imagined, while the severer forms of the disease, those, which, 
properly speaking, constitute pyemia, are comparatively rare. It may be induced by 
various circumstances, of which the employment of a foul lancet is, perhaps, the most 
common. In one instance I knew it to be caused by probing the wound, under the sup- 
position that it contained a piece of the fleam of a spring lancet, broken off in the opera- 
tion, performed by a young and inexperienced practitioner. The patient, a man, thirty-six 
years of age, was laboring under bilious fever, from which, but for this unfortunate event, 
he would probably have recovered; phlebitis, however, set in, and in less than a week he 
died. In another fatal instance, the vein was opened with a thumb lancet, and the disas- 
trous effects arose without any evident cause, the patient, a stout negress, being at the 
time affected with inflammation of the wrist-joint. 
The symptoms of this form of phlebitis do not require special notice, inasmuch as they 
do not differ from those of phlebitis in general. The attack is commonly ushered in by 
pain, stiffness, and swelling of the affected part, and by rigors, alternating with flushes of 
heat, and followed by copious perspiration. The inflamed vein is gradually converted into 
a hard, rigid cord, the morbid action steadily pursuing its course towards the heart, its 
progress being indicated by a reddish blush of the skin. In some instances, metastatic 
abscesses form in different parts of the body, particularly in the subcutaneous connective 
tissue around the larger joints, if not also in the joints themselves. The symptoms soon 
assume a typhoid character, the mind wanders, great soreness is felt in the muscles and 
articulations, the patient complains of excessive prostration, and death generally follows 
in from six to eight days from the commencement of the invasion. 
The treatment consists in the application of leeches, blisters, and iodine along the 
course of the vein, and the exhibition of calomel and opium, with the twofold object of 
bringing the system promptly under the influence of mercury, and allaying pain and pro- 
moting sleep. Abstraction of blood, except by leeches, is always prejudicial. Purgatives 
and antimony must always be avoided. If abscesses form, they must be promptly and 
thoroughly opened. Diffusible stimulants, tonics, milk punch, and beef essence, with an 
abundance of fresh air, are the proper remedies, in the event of great and rapid exhaus- 
tion. Should recovery take place, sorbefacients will be required to promote the removal 
of effused fluids in and around the diseased vein, which, however, despite our treatment, 
usually remains impervious. CHAP. XIV. 
ABSTRACTION OF BLOOD. 
455 
5. Angeioleucitis is usually produced by the same causes as phlebitis, which it also 
resembles in its nature, progress, and symptoms. The morbid action, still more than in 
the latter disease, has a tendency-to extend up the limb, the course of the affected lym- 
phatics being indicated by reddish lines, very narrow, and exquisitively tender on pres- 
sure. The disease, which generally occurs in a mild form, requires the same treatment 
as phlebitis, with which it is occasionally associated. 
e. Puncture of a nerve, whether it be a trunk of considerable size, or a mere thread- 
like filament, may prove to be a very serious accident. The nature of the injury is al- 
ways indicated by a peculiar, stinging, burning, or pricking pain, and a sense of numb- 
ness, creeping, or formication in the distal portion of the limb. When very severe, the 
local distress may be attended with a certain degree of shock and a tendency to syncope, 
which, however, generally soon pass off. Very unpleasant secondary symptoms some- 
times succeed this accident, at a period varying from several weeks to several months. One 
of the most common and distressing of these is neuralgia, often occurring in regular 
paroxysms, as neuralgia from ordinary causes in other situations. The disease is then 
liable to be exceedingly severe and obstinate, often resisting, for months, and even years, 
the best directed efforts at relief. In the cases which have fallen under my observation, 
it has usually been accompanied, especially in its earlier stages, with considerable swelling, 
numbness, and stiffness in the distal portion of the limb, together with exquisite tender- 
ness on pressure along the course of the affected nerve. I have never known tetanus to 
follow this accident, but such an occurrence is not impossible, particularly in a person of 
a nervous,irritable temperament, laboring, at the time of the injury, under disorder of 
the digestive organs. 
The milder effects of this injury usually pass off in a very short time without any re- 
medial measures, simply by attention to rest and elevation of the limb. When the case 
is obstinate, recourse is had to anodyne and astringent fomentations, the application of 
iodine and even blisters, purgatives, light diet, and other antiphlogistic means. The ban- 
dage is often of great service, especially when there is considerable swelling. When 
the pain is of a neuralgic character, quinine, strychnia, and arsenious acid will be indi- 
cated, and, if given persistently, and in suitable quantities, will be of immense benefit. 
When the suffering is extremely violent and intractable, the best remedy is division of the 
affected nerve, as near as possible to the seat of the injury, by the subcutaneous method ; 
or, when this is impracticable, by exposing the nerve first, and then severing it. Occa- 
sionally it becomes necessary to remove a small portion of the affected nerve, especially 
if, as now and then happens, it is expanded into a little nodule, or is exquisitely tender 
and sensitive on pressure. 
f. A wound of the brachial artery, always a very serious accident, maybe very slight, 
amounting to a mere puncture, or it may be several lines, half an inch, or even an inch 
in extent, as in a case under my observation some years ago. The direction of the wound 
may be oblique, longitudinal, or transverse, according to the manner in which the instru- 
ment is held at the time of the operation. Occasionally the artery, instead of being 
pierced or stabbed, as it ordinarily is, is tranfixed; a circumstance which always seriously 
complicates the case. 
The immediate effect of this accident, which is always denoted by the impetuous salta- 
tory nature of the stream, and by its scarlet complexion, is to send the blood into the 
connective tissue, forming a soft, dark-colored, circumscribed tumor, or a diffused swelling, 
which may involve the greater portion of the anterior surface of the limb from the 
middle of the forearm to within a short distance of the axilla. Such an occurrence is 
always formidable in its character, alarming to the patient, embarrassing to the surgeon, 
and liable to be followed by the worst consequences. 
The treatment of this accident is by systematic compression, when the opening is small, 
and by ligation of each extremity of the artery, when it is large. 
Bleeding at the Jugular Vein The opening of this vessel, fig. 175, may become ne- 
cessary in cases of great urgency, as in sudden and severe apoplectic seizures, and in 
violent inflammation of the brain, eye, and ear. In general, however, it maybe dispensed 
with even here, the requisite quantity of blood being more easily obtainable at the bend of 
the arm. The patient’s head being firmly supported upon a pillow, and inclined a little 
upwards and towards the opposite side, the vein is made to raise by pressure with the fin- 
ger or thumb, applied immediately above the clavicle. The lancet is then introduced 
about midway between this point and the jaw, and carried obliquely upwards and outwards, 
so as to divide the fibres of the platysma myoid muscle crosswise instead of vertically, as 
this affords the edges of the wound a much better chance of retracting. A pasteboard 456 
MINOR SURGERY. 
trough or glass tube maybe used to guide the blood into the receiver. The pressure below 
the orifice should not be removed until the operation is completed, lest air should pass 
into the vein, and thus destroy life. The requi- 
site quantity of blood having been drawn, the 
wound is covered with a few strips of adhesive 
plaster, aided, if need be, by a compress and 
bandage carried round the neck and shoulders. 
Bleeding at this vein in the child is peculiarly 
embarrassing. The best mode of performing it 
is to place the patient’s head between the sur- 
geon’s knees, the body and limbs being firmly 
held by the nurse, otherwise the blood will not 
oidy flow very imperfectly, but spirt over every 
one present. The vein, compressed against the 
first rib, should be opened quite freely. A com- 
press and a few adhesive strips, lightly applied, 
constitute the proper dressing. 
Bleeding at this vessel in the child is not 
practised sufficiently often. It is particularly 
applicable to violent affections of the brain, 
larynx, and lungs, and might, in most cases, 
advantageously take the place of venesection 
at the bend of the arm, the veins of which are generally opened with great difficulty, 
especially in very fat subjects. 
Bleeding at the Ranine Vein—Bleeding at this vessel was formerly quite fashionable, 
and is no doubt entirely too much neglected at the present day. It is said to have been 
performed by the elder Mestivier, during a practice of twenty years, nearly fifteen hun- 
dred times, and generally with very gratifying results. It is alluded to by many of the 
older writers, but was in great measure forgotten until attention was recalled to it by 
Cruveilhier. The operation has been found particularly serviceable in acute affections of 
the tongue and salivary glands, the tonsils, palate, fauces, larynx, and lymphatic glands 
about the jaws and throat. The two veins may be opened in immediate succession, or, 
if the case present no special urgency, one alone may be punctured; and, as they lie im- 
mediately beneath the transparent mucous membrane, at the side of the frenum, the ope- 
ration may always be performed without any risk to the ranine arteries. The incision 
may be transverse, and extend completely across the vessel, as suggested by Aran, or it 
may be made in the direction of its length, which, perhaps, is generally preferable, as the 
blood will then issue in a larger stream and for a longer time. In this way several ounces 
of fluid may usually be readily obtained. The bleeding may, if necessary, be encouraged 
by rinsing the mouth frequently with warm water. If the discharge is more copious 
than is desirable, a lump of ice laid under the tongue will generally promptly arrest it. 
The patient, during the operation, should sit upon a chair or the edge of the bed, and 
the tongue should be gently pressed against the incisors of the upper jaw. In children, 
it will generally be necessary to draw the tip of the organ 
out of the mouth with a dry cloth. 
I have thus briefly described this operation in the belief 
that it may often be advantageously practised in the class of 
cases above alluded to. It certainly deserves to be revived. 
6. Arteriotomy This operation is occasionally necessary 
in urgent affections of the brain and eye, and is usually per- 
formed upon the anterior branch of the temporal artery, a 
vessel which possesses the twofold advantage of being very 
superficial, and at the same time resting upon a resisting 
bone. Feeling for the artery, in front of the temple, the 
surgeon employs firm pressure upon it with the finger, so as 
to steady it properly, while he makes the requisite incision 
with a small bistoury, carried obliquely across the vessel, 
care being taken to cut the parts in such a manner as to ad- 
mit of a full and rapid stream. A sufficient amount of blood 
having flowed, the artery is completely divided, in order 
that its extremities may retract, and thus prevent the forma- 
tion of an aneurism, an effect of which I have seen several examples. A small, thick 
CHAP. XIV. 
Fig. 175. 
Bleeding at the Jugular Vein. 
Fig. 176. 
Bleeding at the Temporal Artery. CHAP. XIV. 
TRANSFUSION OF BLOOD. 
457 
compress is then placed upon the wound and firmly secured by a bandage, carried round 
the head in the manner represented in fig. 176. 
SECT. YII TRANSFUSION OF BLOOD. 
Transfusion of blood from the veins of one person into those of another is imperatively 
demanded when a patient is rapidly sinking from hemorrhage, whether the result of dis- 
ease, accident, or operation. It has hitherto been more particularly employed in profuse 
and exhausting flooding, and there are numerous cases upon record where it was thus instru- 
mental in preserving life. In such an event it is the last resource of the obstetrician, 
and no one should hesitate to perform it, even although the woman should literally be in 
the act of dying, or when, to borrow the language of an eminent writer, “ the vital spirit 
is fluttering with tremulous delay upon the lip.” Instead of blood, saline fluid is some- 
times transfused, as in attacks of Asiatic cholera, attended with excessive prostration, 
consequent upon the rice-watery discharges from the bowels effectually draining the 
vessels of their serous contents. The intravenous injection of milk, to which attention 
has been especially directed by T. Gaillard Thomas, is liable to be followed by fat embol- 
ism, and should, therefore, only be resorted to when blood cannot be obtained from a 
healthy person. 
The operation in question requires great care and skill for its successful execution. The 
chief danger to be guarded against is the entrance of air into the vein, the smallest quan- 
tity of which might prove destructive. As ordinarily performed, it is necessary to have 
at hand, besides a lancet, a tumbler and a glass syringe, the latter being in complete work- 
ing order. The person from whom the blood is taken must be in good health, and free 
from all constitutional taint. The arm being tied up, and the vein opened, the blood is 
allowed to fall into the tumbler as it stands in a basin of water, at a temperature of about 
100°, lest the fluid should coagulate, and thus become unfit for use. As soon as about 
two ounces have been drawn, it is sucked up into the syringe, the nozzle of which is then 
inserted into the patient’s vein, the median basilic, for example, previously exposed by an 
incision at least an inch in length, and raised upon a probe. In this manner one portion 
after another is cautiously thrown in until from twelve to sixteen ounces have been trans- 
fused, a quantity which it will seldom be judicious to exceed. Should the pulse flag 
during the operation, or convulsive tremors arise, the proceeding must immediately be 
suspended, as it is an evidence that injury instead of benefit is accruing. 
A great number of contrivances have been devised for imparting to this operation a 
more scientific character than when it is performed with the ordinary syringe. The 
method, however, here described will generally be found to answer every purpose, com- 
bining, as it does, simplicity with convenience and safety. 
When greater nicety is aimed at, the apparatus represented in fig. 177, and constructed, 
at my suggestion, by Mr. Gemrig, may be used. It consists of a small cupping-glass and 
Fig. 177. 
Author’s Transfusing Apparatus. 
syringe, with a gum-elastic tube, about eighteen inches long, having a stopcock at its 
distal extremity, which is surmounted with a nozzle cut off obliquely, like the barrel of a 
pen. The patient’s vein having been exposed by an incision and freely opened, the noz- 
zle is inserted into it, and securely held by an assistant. A vein is then punctured in a 
healthy person’s arm, but the blood is restrained from flowing by the pressure of the finger 
applied some distance below, until the cup has been placed over the orifice and exhausted 458 
MINOR SURGERY. 
CHAP. XIV. 
of air by means of the syringe. As soon as this has been done, the stopcock is turned, so 
as to permit the fluid to pass readily from one vessel into the other. 
Professor Ilueter, of Greifswald, is an advocate of arterial transfusion, as he is con- 
vinced that in this method the blood is conveyed to the heart more slowly and equably 
than in venous transfusion, in which the sudden disturbance of the circulation has occa- 
sionally been the cause of death. Another advantage possessed by arterial transfusion is 
that if a small quantity of air gains admission into the current of blood, it does no harm, 
but is absorbed, at the same time that the dangers of phlebitis are thus avoided. 
The radial artery above the wrist, or the posterior tibial under the malleolus, should be 
isolated to the extent of about an inch, and be surrounded by four ligatures, one of which 
is intended as a reserve ligature in case of accident to the others. The thread nearest the 
heart is first tied, and the syringe having been filled with blood, the peripheral ligature 
is somewhat tightened, to cut off the collateral supply of blood. At this moment the 
artery is divided through about half of its caliber with the scissors, and into the gaping 
wound the point of the syringe is inserted and secured by the third ligature. The second 
thread being then loosened, the piston of the syringe is put into action, and when the 
injection is completed, the thread is permanently tied as an ordinary ligature. The artery 
itself is divided close to the central and peripheral threads, and the portion attached to 
the canula of the syringe removed with it. 
The transfusion of defibrinated blood into the peritoneal cavity for the relief of various 
affections has within the last few years been practised by a number of physicians, atten- 
tion having originally been called to it by Ponfick. The operation, which should be 
performed under antiseptic precautions, is easy of execution, and generally devoid of 
danger. The only instruments required are an ordinary trocar connected with an elastic 
tube provided with a glass funnel, through which the defibrinated blood is thrown through 
the linea alba into the abdomen. Anemia, whether caused by loss of blood or protracted 
disease, as pulmonary phthisis, carcinoma, syphilis, or typhoid fever, is the disease mainly 
demanding, and likely to be benefited by, this mode of transfusion. 
SECT. VIII HYPODERMIC INJECTIONS. 
To Dr. Alexander Wood, of Edinburgh, the profession is mainly indebted for having 
utilized, if not actually originated, the hypodermic method of treatment, now so widely 
and so successfully employed in this and other countries. Its great certainty renders it a 
most valuable resource in many cases and forms of disease that could hardly be reached 
in any other way, while the effect of the remedies thus employed is far more rapid and 
powerful than when the same articles are administered by the mouth or the rectum. 
The medicines that are most commonly used in this way are anodynes; but they need 
not necessarily be of this character, as various other agents may be equally successfully 
injected. Arsenic, strychnia, quinine, atropia, duboisia, aconite, belladonna, and kindred 
articles are daily thrown under the skin, and the list of remedies thus introduced into the 
system will no doubt be eventually very much extended. Subcutaneous injections of 
quinine have been very successfully employed in numerous cases of intermittent fever, a 
solution of five grains thus administered being fully as efficacious as five or six times that 
quantity given in the usual manner, at the same time that relapses are much less frequent. 
Arsenic has been similarly employed. In the nocturnal incontinence of urine of children 
few remedies are so efficacious as subcutaneous injections of belladonna. Morphia intro- 
duced under the skin generally dispels the most agonizing pain of every description within 
a few minutes. Excessive gastric irritability is usually promptly allayed by this method 
of medication; and I know of no remedy that so speedily and effectually relieves the 
intolerable anguish caused by the twitching of the muscles in fractures, dislocations, ampu- 
tations, resections, gunshot wounds, and inflammation of the joints, especially coxalgia. 
Spasm of the eye after the operation for cataract and artificial pupil generally yields in a 
peculiarly happy manner to morphia employed in this way. Of late the hypodermic injec- 
tion of bichloride of mercury has met with a good deal of favor as a remedy in the treat- 
ment of constitutional syphilis. 
In using any medicine hypodermically, it is of the utmost importance to remember 
that the quantity required is much less than when the same article is given by the 
stomach or the rectum. Thus, even when a patient is in great agony, a quarter of a 
grain of morphia may usually be considered as a full dose, whereas double that quantity 
might be required if administered in the ordinary manner, and so with all other agents CHAP. XIV. 
VACCINATION. 
459 
whatever. Repetition may be safely effected several times in the twenty-four hours, or, 
in urgent cases, as when there is intense pain, in rapid succession. 
The operation is performed with a portable syringe, tig. 178, capable of holding about 
one drachm of fluid, and furnished with a slender, delicate nozzle, bevelled off obliquely 
to a very sharp point. Some practitioners prefer a graduated instrument, 
but such a contrivance possesses no advantage whatever over the ordinary 
one. The best hypodermic syringe now in use, one least liable to get out 
of order, is that devised by Dr. Dowler, of Brooklyn, and described in 
the New York Medical Record for 1879. In performing the operation, a 
fold of skin, pinched up with the thumb and forefinger, is pierced at the 
base with the sharp point of the nozzle, which is then pushed on into the 
connective substance beneath, followed by the medicated fluid. The moment 
the instrument is withdrawn a finger is placed upon the puncture, while 
with another finger the fluid is pressed about until the elevation produced 
by it has been completely effaced, as the object is to promote its speedy 
absorption by bringing it into contact with as large an amount of tissue as 
possible. The medicine, whatever it may be, is mixed with nearly a 
drachm of cool water, and great care is taken that there is no air intro- 
duced along with it. It is not at all important that the place selected for 
the operation should be near the seat of the pain or of the disease for 
which it is performed ; the most convenient points are the back of the arm 
and the corresponding part of the forearm, where there are no large veins, 
which must always be avoided, lest the medicine, passing directly into the 
circulation, should endanger life by the rapidity and violence of its action. 
For the same reason, if a very potent remedy be used, the injection should 
be performed very slowly, so that, if unpleasant symptoms arise, the operation 
may at once be stopped, or the fluid be even sucked out. 
Hypodermic injections are not always, so far as the tissues where they are made are 
concerned, wholly harmless, especially when they contain irritating substances. A num- 
ber of cases of tetanus, induced by hypodermic injections of quinine, dissolved in water 
with the aid of a little aromatic sulphuric acid, for the cure of intermittent fever, have 
been reported ; and instances in which the puncture made in the operation was followed 
by erysipelas, abscesses, painful ulcers, and other distressing local effects have been wit- 
nessed by different observers. Hard nodules sometimes form, giving the surface a rough 
tuberculated appearance; and cases have been reported in which the puncture gave rise 
to fatal pyemia. 
SECT. IX. VACCINATION. 
The surgery of vaccination is very simple. It may be performed either with lymph- 
removed between the sixth and ninth day, or, what answers nearly equally well, with the 
dried scab rubbed upon a plate of glass, with tepid water, until it is of a 
thin consistence, and of a very pale milky hue. The matter is taken 
up with the point of a sharp, narrow lancet, represented in fig. 179, a 
tenotomy knife, or a common needle, and inserted into the skin on the 
outer surface of the arm, just below the deltoid muscle, or on the outer 
and upper part of the leg at a suitable distance from the knee, at two 
spots, each about the diameter of a three-cent piece, and sufficiently far 
apart to prevent them from running together during the height of the 
resulting inflammation. The impregnation may be effected by a number 
of little punctures, by three or four superficial incisions, or, simply, by a 
slight abrasion of the epidermis. Whatever method be adopted, no 
blood should be drawn, as it might wash away the vaccine matter. 
When the operation is performed with lymph taken up on bits of ivory, a procedure 
which some practitioners prefer to any other, the points should be held for a few seconds 
in the steam of hot water, and then rubbed upon the raw surface. 
The wound, on the third day after a successful operation, is found to be slightly in- 
flamed and elevated ; and on the fifth day a characteristic vesicle appears, of a beautiful 
pearl-colored aspect, circular or oval in shape, and occupied by a drop of thin, limpid 
fluid. On the eighth day the vesicle is in its greatest perfection ; it is now somewhat of 
a yellowish hue, distinctly cellulated in structure, very prominent, slightly umbilicated at 
the centre, and surrounded by a circular areola, the skin around being inflamed, tense, 
Fig. 178. 
Hypodermic 
Syringe. 
Fig. 179. 
Vaccine Lancet. 460 
MINOR SURGERY. 
chap. xiv. 
and painful. Occasionally considerable swelling of the glands of the axilla exists. The 
constitution is nowr thoroughly implicated, and, as a consequence, the patient is feverish 
and restless. On the eleventh day the areola begins to lade, and the vesicle, which 
usually spontaneously bursts, gradually dries up into a hard, brownish, circular scab, 
which, dropping off from the eighteenth to the twenty-first day, leaves behind it a small, 
rounded, pitted, and indelible cicatrice, attesting the success of the operation. 
Vaccination may be performed as early as the sixth week after birth, and at all periods 
of life subsequently. If the child is sickly, the general health should previously be 
amended, particularly if there be any eruptive disease. Some persons evince the most 
remarkable insusceptibility to the influence of the vaccine virus. I have seen a number 
of cases in which the operation was performed upwards of twenty times before it finally 
succeeded. Healthy children afford the best lymph, and the matter of primary is more 
enei’getic than that of secondary vaccination. 
Lymph taken from the cow is now commonly preferred ; it is usually collected upon the 
end of a quill or a piece of ivory, and is softened with cold water immediately before 
it is inserted or rubbed upon the surface. Six or eight superficial incisions merely 
carried through the epidermis in a vertical direction are generally quite sufficient. 
Bleeding must be prevented. The lymph must be kept in a dry place. 
The bad effects of the operation are, 1st, too much local action, the inflammation 
sometimes assuming an erysipelatous character; 2dly, severe inflammation of the axil- 
lary glands; 3dly, ulceration, or even gangrene, at the seat of the vesicle, leaving a sore 
which is occasionally very tedious in healing; 4thly, a lichenous or roseolar eruption, 
attended with distressing itching, and often considerable swelling; and othly, an ap- 
pearance of vesicles upon the general surface, resembling those of varicella, or even those 
of genuine cowpox. The regular development of vaccinia is sometimes retarded by the 
preoccupation of the system by other affections, as measles and scarlatina. 
It is impossible to exercise too much care in the selection of vaccine virus. To a want 
of this precaution may be ascribed most of the bad effects that follow the operation. A 
number of well-authenticated cases have ’been recorded during the last twenty years in 
which it gave rise to syphilis in its very worst forms. 
The effects of vaccination are sometimes completely lost, in the proportion, probably, 
of about forty persons in one thousand. It is for this reason that the operation should 
be occasionally repeated. 
SECT. X COUNTERIRRITATION. 
Counterirritation may, as stated elsewhere, be established in various ways, as by 
rubefacients, vesicants, and dry cupping; but when the object is to make a deep and 
protracted impression, the means usually selected are the permanent blister, the seton, 
and the issue. Sometimes the inoxa and acupuncturation are employed. 
1. Rubefacients A rubefacient effect, or temporary irritation of the skin, may readily 
be produced by a great variety of articles, as mustard, ammoniated liniments or unguents, 
spirits of turpentine, chloroform, hot water, and the hot iron. The latter, in the form 
of the objective cautery, as the French term it, consists in passing a piece of iron, heated 
perfectly white, rapidly over the surface at a distance of three to five inches. The 
skin becomes almost instantly red, and if the application be continued for a few minutes, 
vesication follows. 
Mustard is generally applied in the form of mustard-paper, kept for ready use by the 
apothecary, and cut into suitable strips as it is needed. A mustard plaster may be made 
of mustard flour, mixed with water at a temperature of 90° to 100°. If the water is 
too hot, it will coagulate the albumen; if too cold it will prevent the disengagement of 
the oil upon which the irritating properties of the mustard depend. As more or less of 
the mustard is liable to adhere to the skin, the best plan always is to interpose a layer of 
gauze, or very thin muslin, wrung out of warm water. The time during which the ap- 
plication should be continued must vary, on an average, from ten to twenty minutes, 
according to the effect desired. Great care must be exercised in the use of sinapisms in 
children and in persons generally of very delicate skin, as well as in patients worn out 
by disease and intemperance, otherwise serious mischief may ensue. The smarting, 
burning pain which so often follows their application is commonly promptly relieved by 
lead-water, olive oil, or iced water. 
A very useful and speedy rubefacient action may be produced by means of Dr. Corri- CHAP. XIV. 
COUNTERIRRITATION. 
461 
gan’s button cautery, fig. 180, heated in the flame of a spirit lamp until the forefinger, 
resting upon the shank of the instrument near the disk, begins to feel uncomfortably hot, 
the period usually required not exceeding a quarter of a minute. As soon as it is ready, 
it is applied as quickly as possible, the skin being tipped successively, at intervals of half an 
inch, over the whole of the affected part, which soon assumes a bright red appearance, and 
becomes the seat of a glowing sensation. The disk of the instrument is half an inch in 
diameter by three lines in thickness, with a flat surface, and a thick, iron- 
wire shank, two inches in length, and inserted in a small wooden handle. 
Very efficient counterirritation may be produced by the actual cau- 
tery, heated to a white heat, and drawn lightly, but rapidly over the sur- 
face near the seat of the morbid action, at several points, for a distance of 
two to three, four, or even six inches. The application is immediately 
followed by reddish-brown welts, surrounded by a zone of scarlet, indica- 
tive of hyperemia. The pain is generally very insignificant, and there is 
seldom any vesication. The epidermis in a few days drops off in dry scales, 
leaving a slightly brownish stain, which soon disappears. The remedy is 
particularly valuable in neuralgia, gout, and rheumatism, and in superficial 
inflammations of the joints and other parts of the body. The cautery 
should be tipped with platinum, as it will thus preserve its smoothness, a 
desideratum of great importance. 
2. Dry Cupping Dry cupping is occasionally employed, especially in 
chronic affections, in which it is often of great value. The air being ex- 
hausted, as in the more common operation, the cup is allowed to remain on 
the part for a period varying from thirty to forty-five minutes. At the end 
of this time it will generally be found that there is not only a marked afflux 
of blood, but likewise more or less vesication of the skin, objects which the 
practitioner should always endeavor to attain whenever he advises such an 
operation; for, unless it be performed efficiently, no benefit whatever will 
be likely to result from it. 
Dry cupping is particularly serviceable in chronic disease of the brain and spinal cord, 
the thoracic and abdominal viscera, and the larger joints. The number of cups employed, 
and the repetition of the operation, must be regulated by the exigencies of the case. 
An instance has been communicated to me in which this operation was followed by 
gangrene. The patient, a soldier, was affected with typhoid fever. Four dry cups were 
applied over the lower part of the spine, where they were retained for ten minutes. The 
surface soon began to assume a livid aspect, and the integument included in two of the 
cups sloughed out to the depth of a quarter of an inch, the others suffering in a less degree. 
3. Permanent Blisters A permanent blister is made by letting the fly remain on the 
skin an unusual length of time, and then divesting the part of epidermis. It is capable 
of furnishing a free discharge of pus, which may often be maintained for a long time, 
either by the occasional reapplication of the fly, or by means of some irritating ointment, 
as the savin or mezereon ; or, what I prefer, an ointment composed of an ounce of cosmoline 
and three to eight drops of nitric acid. Whatever article be used, the surface should be 
constantly protected with an emollient poultice or warm water-dressing, otherwise the 
sore will become excessively irritable, and cease to furnish the desired discharge. When- 
ever the secretion begins to slacken, a little of any of the unguents here mentioned may 
be applied to the sore to renew the morbid action. 1 have occasionally used the dilute 
fly ointment for this purpose, but having several times produced strangury with it, I have 
latterly abandoned it. 
4. Seton—A seton is a subcutaneous wound, holding a foreign body. It may be made 
with a bistom-y, and a piece of 
gum-elastic tape, or in the absence 
of this, a narrow strip of muslin, 
conveyed beneath the skin by 
mean of an eyed probe or the seton 
needle, represented in fig. 181. 
The integument being pinched up, 
the instrument is pushed through the 
connective tissue, care being taken 
not to interfere with any muscular 
fibres, tendon, nerve, or vessel. 
The ends of the seton are tied long, 
Fig. 180. 
Corrigan’s But- 
ton Cautery. 
Fig. 181. 462 
MINOR SURGERY. 
CHAP. xiv. 
and held out of the way by a strip of adhesive plaster. The mode of introducing a seton 
with knife and probe is shown in fig. 182. 
An emollient cataplasm is the most suitable dressing, both immediately after the opera- 
tion and subsequently, during the sojourn of the foreign body. At the end of the second 
day the tape is drawn gently across the wound, a fresh portion taking its place, and this 
process is afterwards repeated as often as cleanliness and other circumstances may render 
Fig. 182. 
it necessary. If the discharge becomes deficient, recourse is had to some stimulating oint- 
ment ; if offensive, to the chlorides. When the tape becomes soiled, a new one takes its 
place. Sometimes'fungous granulations spring up at the orifices of the subcutaneous wound, 
causing much pain and inconvenience. The best remedy is excision, followed by nitrate of 
silver. The insertion of a seton is usually attended with little bleeding; but I recollect the 
case of an elderly gentleman, a patient of a late eminent practitioner, who nearly lost his 
life from this cause, the operation having been performed upon the nape of the neck. The 
blood seemed to have proceeded from a small artery among the cervical muscles, the 
instrument having penetrated too deeply. Great care should be exercised in the intro- 
duction of setons in front of the neck, as the operation has been followed, in several 
instances, by the admission of air into the veins and the speedy death of the patient. 
A seton is, on the whole, a filthy, painful, and imperfect form of counterirritation, 
which it might, perhaps, be well to exclude altogether from practice, as its place may 
always be easily supplied by the issue. 
The seton is sometimes employed as a means of obliterating cavities, as in hydrocele 
and the so-called housemaid’s knee. Great care is necessary when it is thus used that it 
does not provoke too much inflammation. The filiform seton, as it is termed, generally 
consists of a single thread. 
5. Issue—An issue is an artificial ulcer, intended to furnish a discharge of pus. It is 
adapted to the same class of cases as the seton, but is more cleanly, less painful, and more 
convenient. Moreover, such a sore affords a good surface for the local application of 
morphia and other remedies, which may often be advantageously used, in this manner, for 
relieving pain, as well as for other purposes. 
Issues may be made in various ways, as with the knife, the Vienna paste, the galvanic 
and actual cauteries. The first of these methods is not sufficiently efficient to justify its 
general employment; it is better adapted to the scalp than to any other region of the 
body, and may be advantageously used in diseases of the pericranium and of the brain 
and its meninges. An incision being made through the skin and connective tissue, from 
half an inch to an inch in length, its cavity is filled with some foreign body, as a pea, grain 
of corn, small pebble, piece of orris root, or, what is best of all, a solid glass bead, which 
soon produces a pyogenic action that may afterwards be increased, if necessary, by the 
use of some stimulating ointment. The substance is confined with a strip of adhesive 
plaster and a bandage, and is occasionally replaced by a fresh one, cleanliness being main- 
tained in the usual way. 
An excellent issue may be made with the Vienna paste, composed of equal parts of quick- 
lime and hydrate of potassium, thoroughly triturated together, and preserved in a closely- 
corked vial until required for use. The requisite quantity is then put upon the bottom of 
a saucer, and converted into a thick paste with alcohol. A layer, about two lines in 
thickness and of the desired diameter, is put on the skin, and allowed to remain for eight, 
ten, or fifteen minutes, according as it is desired to make a slight or deep impression. 
The surface, which will be found to be of a pale drab color, is washed with vinegar and 
water, to neutralize the alkali, and covered with an emollient cataplasm, to promote the 
detachment of the slough, which usually happens in from five to eight days. Some pain CHAP. XIV. 
COUNTERIRRITATION. 
463 
attends the operation, but this is soon over, and bears no comparison with the horrible 
distress produced by the application of' hydrate of potassium alone ; besides, the Vienna paste 
does not diffuse itself over the adjacent parts, and thus unnecessarily destroy the skin. 
The extent of the issue is regulated by the extent of the layer ; one of the diameter of a 
twenty-five cent piece affording, when the sloughing is completed, a sore two or three 
times that size. The best permanent dressing is a poultice; the best promoter of dis- 
charge, some stimulating ointment, or the occasional use, for a few hours, of a small blister. 
What is called the “ London paste” is composed of equal parts of caustic sodium and 
unslaked lime, converted into a powder, and kept in a well-corked vial until required for 
use, when it is mixed with water instead of alcohol. Its advantage over the Vienna paste 
is that it is far less painful and much more manageable. 
The most eligible issue of all, however, is that made with the actual cautery; it affords 
not only an abundant and protracted discharge, far beyond what follows the more ordinary 
issue, but, what is often a matter of no little consequence, it makes an impression both 
upon the part and system, which no other mode of counterirritation is capable of pro- 
ducing. On these accounts, this kind of issue should have a decided preference over 
every other in all protracted and obstinate cases of disease where the employment of 
revulsives is indicated, as in caries of the hip-joint, Pott’s disease of the spine, and similar 
affections, in which its powers, as a topical remedy, are unequalled. 
To perform the operation properly, the iron, heated to a white heat in a small charcoal 
furnace, should be pressed with some degree of firmness upon the spot selected for the 
issue until the skin is converted into a black eschar, the patient being fully under the 
influence of an anaesthetic. Care must be taken not to penetrate beyond the subcutaneous 
connective tissue. A cloth, wrung out of cold water, is immediately laid upon the part, 
and frequently renewed, for a few hours, when it is replaced by a poultice or warm water- 
dressing. The slough usually drops off in from five to eight days, leaving a sore, which, 
while it is easily kept clean, furnishes a free discharge, and may be kept open, with but 
little care, for an almost indefinite period. A cautery the size of a half-eagle will make 
an issue, after the separation of the eschar, of the diameter of a silver dollar. The instru- 
ment should be fully half an inch thick, otherwise it will not retain its heat sufficiently long. 
6. Moxa The moxa is a soft, combustible substance held upon the skin, and suffered 
to burn down slowly, so as to produce a temporary irritant effect. It may be prepared 
from various articles, as agaric, hemp, cotton, rotten wood, the pith of the 
common sunflower, and the down of the artemisia chinensis; but the one 
which I usually prefer is soft patent lint, soaked in a strong solution of 
nitrate of potassium. When thoroughly dried, this is rolled up into toler- 
ably firm, cylindrical cones, an inch and a half long by one inch in diameter. 
In applying them, they should be ignited at the top, and held upon the part 
intended to be cauterized with a pair of dressing forceps, a long hair-pin, 
or a porte-moxa, fig. 183; the surrounding surface is protected with a piece 
of wet linen perforated at the centre. When it is desired to hasten the 
combustion, a blowpipe may be employed, but in general this is unneces- 
sary. Whatever substance is used, the heat can be so graduated as to pro- 
duce any amount of irritation, from the slightest rubefaction to a superficial 
eschar. When the latter effect is desired, the moxa should remain on until 
it is wholly consumed; otherwise it may be removed as soon as the pain 
becomes somewhat severe; or, instead of placing the burning material in 
contact with the skin, it may be held at a little distance from it. The 
eschar is of a yellowish, gray, or dark color, and usually drops off in six 
or eight days. The pain produced by the operation may be promptly relieved 
by the application of ammonia, cold water, or pounded ice. 
The moxa seems to act on the same principle as the objective cauterization, and the 
ammoniated counterirritants, already spoken of, and is a valuable agent in many chronic 
cases, when it is intended to produce a sudden impression upon the nerves of the affected 
part; it should always be applied as near as possible to the seat of the malady, and the 
effect should be sustained for weeks, or even months, by the repeated application of the 
agent.' The diseases in which it seems to be most efficacious are amaurosis, neuralgia, 
nervous deafness, partial paralysis, coxalgia, and spinal irritation. 
7. Acupuncturation Counterirritation may be effected also by acupuncturation. 
This consists in the insertion of very slender, well-polished, sharp-pointed, steel needles, 
figs. 184, 185, 186, from two to four inches in length, furnished with a metallic head, or 
Fig. 183- 
Porte-Moxa. MINOR SURGERY. 
CHAP. XIV. 
Figs. 184, 185, 186. 
a head of sealing-wax. To prevent them from breaking, they should 
be rather soft and flexible. They are introduced into the affected 
part, previously stretched, by a gentle rotary motion, aided by slight 
pressure, and are suffered to remain from one to six hours, accord- 
ing to the effect they produce, or the object they are intended to 
fulfil. In some instances a period of ten minutes is sufficient; in 
others, they may be kept one or two days. They may be carried to 
a depth of several inches, but care must be taken not to transfix any 
important viscera, vessels, or nerves, though this has often been 
done without ceremony, and without any injurious results. The 
number of needles to be used varies from one to a dozen, according 
to the extent of the affected part and the sensibility of the patient. 
The operation rarely causes much pain, and is scarcely ever followed 
by any unpleasant symptoms. In most cases a slight blush, which 
subsides in a few hours, is observed around each puncture. In 
withdrawing the needles, which is sometimes effected with difficulty, 
owing to their having become oxidized, a movement of rotation should 
be given to them, at the same time that pressure is made upon the 
adjacent surface with the thumb and forefinger. 
Acupuncturation has been employed in a great variety of affec- 
tions, as neuralgia, rheumatism, gout, sciatica, paralysis, cephalalgia, 
and epilepsy; recently it has been recommended in the treatment of aneurism, hydrocele, 
varicocele, and anasarca. Its advantages have been much overrated, and the practice, 
borrowed from the Chinese and Japanese, has fallen into disrepute. 
SECT. XI SURGICAL APPLICATIONS OF ELECTRICITY. 
Electricity is employed locally, as a surgical measure, under two forms, faradism, or 
the induced current, and galvanism, or the continuous current, and they are termed, 
according to their application, faradization and galvanization. The former finds its widest 
and most legitimate range of employment in the treatment of paralysis of movement, of 
muscular atrophy, and rheumatic contractions; while the calorific properties of galvanism 
are utilized principally for the removal and discussion of tumors, either as an actual cautery 
or as a catalytic agent. 
Faradization, as an antiparalytic measure, acts by restoring the impaired or lost func- 
tions of the affected muscle, by throwing it into alternate contractions and expansions, 
through which a more abundant supply of arterial blood is transmitted to it, promoting its 
local circulation, and, consequently, augmenting its nutrition. 
For the proper practice of local electrization, the choice of a good apparatus is of the 
first importance. Without entering into a description of electro-magnetic machines, or 
the properties which such instruments should possess, which would be out of place here, 
suffice it to say the requirements of the surgeon are fully met in the portable bisulphate of 
mercury battery of Gaiffe, of Paris, the induction apparatus of Stdhrer, of Dresden, or, 
in their absence, the instrument of Kidder, of New York. The larger zinco-carbon 
apparatus of Stohrer, now thoroughly appreciated in this country, is preferable. It is 
constituted of two cells, which may be arranged as two pairs, or as a single pair of elements, 
and has a much greater range of power, and more thorough means of graduating the 
currents, than the smaller instrument. It does not require constant attention, and is 
always ready to act, since, by a simple contrivance, the elements can at once be immersed 
or removed from the exciting liquid, through which they retain their activity for a long time. 
The electrodes, or reophores, vary in form, but they are commonly metallic cups or 
plates, fixed to insulating handles, the former of which contain a moist sponge, while the 
latter are covered with wet, soft leather. The handles are provided with clamps for the 
attachment of the conducting wires, through which they communicate with the poles of 
the battery. The diameter of the electrodes varies. When a large muscle is to be acted 
upon, it should range from one to three inches, while for the smaller ones, as the inter- 
osseous, and for indirect muscular faradization, the diameter need not exceed one-third of 
an inch, and they may even be conical in shape. 
In cases of paralysis the muscles may be electrified in two different ways, either indi- 
rectly through the nerves which supply them, or directly by acting upon their proper 
tissue. The former method, known as extramuscular excitation, produces contraction of 
several muscles, or of all parts of a single muscle ; while the latter, termed intramuscular 
Acupuncture Needles. 465 
CHAP. XIV. 
SURGICAL APPLICATIONS OF ELECTRICITY. 
excitation, provokes contraction of only one muscle, or parts of one muscle, and requires 
a current of greater power. In either method, both the skin and electrodes should be 
kept thoroughly moistened with warm water, or salt water, not only that the current may 
traverse the skin and concentrate its power on the deeper tissues, but also to prevent the 
disagreeable sensations of heat and pricking which are sure to occur when the electrodes 
are dry. If it be desired to act directly upon a muscle, the reophores should be applied 
over their fleshy bellies, and never over the tendons, and be moved near together over all 
portions of the muscle corresponding to the surface. If the substance of the muscle be 
thick, the current must be more intense than when a thin muscle is operated upon, as a 
weak current only produces contraction of the superficial layers. The tension of the cur- 
rent should also be proportioned to the thickness of the tissues to be traversed, as is exem- 
plified in fat persons, in whom a moderate current does not reach the muscle at all. 
Nothing can be more simple than direct faradization of muscles; but the same remark 
does not apply to the extramuscular method, in which the current is directed to the points 
of entrance of the motor nerves, and which requires an exact knowledge of the entrance 
and exit of nerves, a knowledge, it need scarcely be added, that can only be attained by 
repeated dissections. The points of selection for the production of isolated contractions 
of muscles, however, have been mapped out by Professor Ziemssen, in his work entitled, 
Die Electrieitat in der Medicin, which may be consulted with advantage by those who 
desire specific information on indirect muscular faradization. 
Localized faradization is a remedy of great value in the treatment of traumatic para- 
lysis ; and it has also been employed, by means of peculiar forms of electrodes, for atony 
and paralysis of the rectum, bladder, pharynx, oesophagus, and larynx, but without any 
striking results, excepting in cases of aphonia from loss of power in the vocal cords. 
In treating paralysis by electricity, the fact should not be lost sight of that reliance is 
not to be placed upon faradization alone, since muscles which refuse to respond to induced 
currents, sometimes evince a i-emarkable degree of excitability by continuous galvanic cur- 
rents. In such cases local galvanization is superior as a therapeutic agent to local faradi- 
zation ; but with return of mobility the excitability by the continuous current is commonly 
gradually lost, and that by induced currents gradually returns. Under these circumstances 
faradic currents must be employed. 
Galvanization is chiefly applicable to the discussion and removal of certain tumors, dis- 
eases of the bloodvessels, chronic glandular swellings, firm inflammatory exudations in 
and around joints, serous effusions, the formation of issues, and the treatment of rebellious 
sinuses, fistules, and ulcers. 
Fig. 187. 
Bunsen’s Battery with the Cauteries attached. 
Of the many kinds of batteries used for the generation of the galvanic current, none is 
more excellent, less trying to the patience of the practitioner, and, in the end, more 
economical, than the portable battery, with lifting apparatus, of Stohrer, consisting of 466 
MINOR SURGERY. 
CHAP. XIV. 
twenty-four, or more, pairs of elements. Bunsen’s battery, fig. 187, with six cells, which 
contain essentially the same elements as those in Stohrer’s battery, will furnish the 
desired amount of heat for galvanic cauterization; but the elements are generally found to 
be too few for the electrolytic treatment of the firmer morbid growths. In the absence of 
these batteries, that invented by Daniell, with which every medical student is perfectly 
familiar, is the best, on account of its reliability, cleanliness, and cheapness. Fifteen cells, 
arranged in a case, will furnish a sufficient quantity of electricity for all surgical purposes. 
It should be taken apart every six or eight weeks in order that the zinc may be cleansed, 
and the solution of sulphate of copper renewed. 
Galvanic cauterization is commonly practised with the electrode of Professor Middel- 
dorpf, an instrument which contains twTo gilt copper wires that communicate at the handle 
Fig. 188. 
Fig. 189. 
Fig. 190. 
with the poles of the battery, while its anterior extremity 
terminates in a platinum wire, wrapped spirally around 
grooved, hollow porcelain shells, which are rendered incan- 
descent as soon as the circuit is established. The instrument 
and the variously shaped cauteries are exhibited, in minia- 
ture, in the preceding figure, while two are represented of the 
full .size in figs. 188 and 189. They are designed for the 
establishment of issues, the destructive removal of superficial 
tumors, as the naevoid and epithelial, and the treatment of 
epithelioma, ulceration, and other affections of the mouth and neck of the uterus ; and are 
placed in contact with the parts while cold, when the circuit is established, and continued 
until the desired effect is produced. The galvanic cautery of Mr. Marshall, of London, 
fig. 190, will be found to be a useful instrument for the management of rebellious sinuses 
and fistules. 
The galvanic cautery, in the form of a loop of platinum wire, is a powerful, rapid, and 
generally bloodless agent for the removal of superficial tumors, polyps, portions of the 
tongue, the neck of the uterus, and malignant growths in situations in which the use of 
the knife would be difficult, and attended with severe and troublesome hemorrhage. It 
las been employed very successfully for the removal of growths of the larynx by Dr. 
Yoltolini, and other practitioners; but Bruns, Mackenzie, and others are averse to its use, 
not only on account of the many inconveniences it causes to the patient and the trouble 
t gives to the surgeon, but also, and more especially, for the reasons that it is very difficult 
to limit the action of the incandescent loop to a small surface, and that, on that account, 
it is liable to produce acute oedema of the glottis. 
The electrolytic treatment of tumors is more universally applicable, although it is far 
more tedious than the preceding method. The only instruments required are fine gold, 
or gilt steel, needles, and a sponge electrode. In performing the operation, the needle is 
passed into the interior of the growth, and attached to the negative pole of the battery, 
while the sponge electrode, previously wet with salt water, and connected with the posi- 
tive pole, is placed outside on the skin. When the tumor is small, one needle will suffice; 
but when it has acquired considerable volume, the serres-fines conductor of Dr. Althaus 
will prove serviceable, as it permits the introduction of several needles in any direction 
that may appear most suitable. They should be insulated to within a short distance of 
their points with vulcanite, so that they may not affect the skin, thereby producing 
unnecessary suffering and subsequent inflammation. 
Although the transmission of the current is not painful, yet, to prevent any unpleasant 
shock, the precaution should be taken of commencing with low power, and gradually 
increasing it to the full quantity that it is designed to employ. The duration of the appli- 
cation will vary according to the nature of the case, two or three minutes being sufficient 
for small tumors, while larger growths require from fifteen minutes to half an hour. The 
sittings may be repeated every second or third day. The number of cells, or the quantity 
of electricity employed, must be proportionate to the consistence of the tumor; solid 
Marshall’s Galvanic Seton. 
Galvanic Cauteries. CHAP. XIV. 
ANTISEPTICS. 
467 
goitres and scirrhus, for example, demanding from thirty to forty cells, while other growths 
will yield to a battery of fifteen pairs of elements. 
The best results from electrolysis have been obtained in vascular, sebaceous, and 
goitrous tumors, particularly the cystic variety; in chronic glandular tumors; in hydatid 
tumors of the liver; in hydrocele, and in stricture of the urethra. In the treatment of 
aneurism it has almost been abandoned ; but it has proved successful in several cases of the 
cirsoid form* of the disease that have been subjected to it. Nsevoid, venous, and small 
sebaceous tumors rarely resist the influence of the galvanic current, while the testimony 
of Dr. Althaus and Dr. Mackenzie is strongly in favor of it in the management of goitre, 
the former observer believing “ that all cases of bronchocele, however large, may be cured 
by electrolysis, if the treatment be persevered in for a sufficient time.” Dr. Fagge and 
Dr. Durham, some years ago, recorded eight cases of hydatid tumors of the liver, in seven 
of which, one remaining doubtful, a cure was promptly effected. Dr. Ruschenberger, of 
our Navy, Scoutetten, and PtStrequin have cured obstinate hydroceles by introducing both 
electrodes into the sac; while other surgeons have successfully employed electrolysis in 
similar instances with the cathode only in the sac. The observations of Mallez. and 
Tripier, Brenner, and others demonstrate that good results may occasionally be anticipated 
from it in the treatment of stricture of the urethra. Thus, of forty-four cases, only two 
proved fatal, and in only two febrile symptoms were set up. Electrolysis has also been 
employed in carcinomatous tumors, but a more extended experience is necessary to decide 
its applicability in these affections. 
As a mode of counterirritation, needles are sometimes introduced into the tissues for 
the purpose of transmitting to the affected part a current of electricity or galvanism. The 
operation, denominated, in the one case, electro-puncturation, and, in the other, galvano- 
puncturation, is performed in the same manner and with the same instruments as in the 
ordinary process, except that the latter have a small ring at the top for receiving the 
conducting wires of the poles of the battery. Only two needles are used at first, but the 
number is gradually increased as the patient becomes able to endure the action of the 
current. When it is intended to produce a shock, a Leyden jar may be employed, but 
for maintaining a steady effect a small horizontal galvanic pile is the most appropriate 
apparatus. This mode of counterirritation is almost entirely restricted to the treatment 
of chronic affections attended with deep-seated and inveterate pains, as gout, rheumatism, 
neuralgia, and sciatica. 
SECT. XII ANTISEPTICS. 
The employment of antiseptic agents has for its object the prevention and arrest of 
putrefaction in jvounds, whether accidental or surgical, by devitalizing or rendering 
inactive the germs which induce it. According to the panspermic theory of Pasteur, the 
atmosphere is loaded with invisible living germs, which, coming in contact with the 
putrescible material—effused blood and plastic matter—of open wounds, induce decompo- 
sition and consequent irritation, which, in its turn, gives rise to suppuration and consti- 
tutional disorder. Hence the aim of the antiseptic method of treatment is to destroy the 
septic energy of the atmospheric germs, through which putrefaction and the morbid pro- 
cesses which result from it are prevented. 
Although the researches of Pasteur, Virchow, Rindfleisch, Hueter, Vogt, Sanderson, 
Klebs, Cohn, Cheyne, Lister, and other observers have established the existence of myriads 
of low forms of organisms in our breathing atmosphere, the demonstration of living, 
disease-producing germs is wanting. Hence, physicians, myself included, have been some- 
what chary in accepting the germ theory of the decomposition of animal matter. There 
is not the slightest difficulty, on the other hand, in comprehending that the atmosphere of 
ill-ventilated and long-occupied hospitals contains a noxious, invisible, permeable dust, 
holding in suspension epithelial and pus cells and other particles of organic matter, which 
is capable, by direct contact with wounded surfaces or open sores, of inducing putrefaction, 
suppuration, and their evil consequences, and also of giving rise to the phenomenon of 
blood-poisoning through its absorption by the lungs. During our late war I had repeated 
opportunities of observing the toxic effects of the tainted atmosphere of our city military 
hospitals, and the rapid improvement in the condition of the wounded upon their removal 
to the purer atmosphere of tent hospitals in the vicinity of the city. My experience, 
moreover, in private practice, has convinced me that abscesses may be opened, that 
wounds, as those made in the removal of tumors, may close, and that compound fractures 
may unite, as readily without as under the use of antiseptic agents, and I have, therefore, 468 
MINOR SURGERY. 
CHAP. XIV. 
of' late, employed them, not to prevent, but merely to arrest the processes of putrefac- 
tion, and to destroy its products. In hospital practice, however, prevention should be 
aimed at. 
Among the antiseptic agents are generally, but improperly, included certain articles 
which should be classed as deodorants, as chlorine, bromine, iodine, and permanganate of 
potassium, all of which oxidize the gaseous products of decomposition, destroying their odor, 
but exerting no effect upon the specific virus or septic germs. Solutions of the metallic 
salts, as the chlorides of zinc and aluminium, the sulphates of zinc and copper, and nitrate 
of lead in the form of Ledoyen’s disinfecting fluid, perchloride of iron, bichloride of 
mercury, through oxidation of the morbific agent, and their chemical action on the tissues, 
must be ranked among the septicides as well as deodorizers. 
A solution of chloride of zinc, of the strength of forty grains to the ounce, was 
highly recommended by Mr. De Morgan, as a permanent antiseptic, its action penetrating 
the tissues deeply, and forming with their albuminoid constituents a dense coagulum 
incapable of putrefaction. The wound, exposed tissues, or cavity of an abscess, should be 
soaked with the solution by irrigation and sponging, and the application need not be 
repeated, as its effect is permanent. Perchloride of iron, in aqueous solution, is one of 
the best articles of this class, as it forms a resisting, adherent coagulum, which is readily 
absorbable as cicatrization advances. 
Chloralum, or chloride of aluminium, is a very powerful septicide and deodorizer, non- 
poisonous, astringent, styptic, devoid of odor and causticity, and is particularly serviceable 
in wounds, hemorrhages, and foul discharges, absorbing noxious gases and destroying 
parasites and germs. The agent in general use which it most closely resembles is chloride 
of zinc. 
Of the antiseptics, properly so called, by far the most efficacious are carbolic acid, 
sulphurous acid, the sulpho-carbolates of zinc and copper, eucalyptus, thymol, and iodo- 
form. 
Carbolic acid is a powerful disinfectant and antiseptic, effectually destroying the germs 
which induce putrefaction, and arresting the process when it has set in. It is not a 
deodorizer, but unhappily substitutes one bad odor for another, and in this respect it is in- 
ferior to the other septicides. On account of its destructive action on all minute forms of 
organisms, which cannot exist in its presence, it has been employed with alleged remark- 
able success, by Professor Lister and others, for preventing the access of putrefactive 
fermentation in compound fractures and dislocations, lacerated wounds, amputations, 
excisions, and different kinds of abscesses, especially chronic. It should be remarked, 
however, that the solutions usually employed are entirely too weak to act as germicides, 
and that if the strength be increased the agent proves to be not only a direct irritant, 
but is also liable to excite alarming effects of narcotico-irritant poisoning, which generally 
terminate fatally. For these reasons carbolic acid is now employed less frequently than 
it was a few years ago, the agents with which it is being replaced being thymol and 
eucalyptus. 
Sulphurous acid is one of the most valuable and powerful of the septicides, and pos- 
sesses the advantage over most of the other agents of this class of being, at the same time, 
a deodorizer. The fluid acid of full strength may be applied to ■wounds and ulcers either 
by sponging or in the form of spray. It is superior to carbolic acid when added to 
moist, putrefying matter, as it not only destroys organic germs, but also the odor of the 
mephitic gases of decomposition, a property not possessed by the latter agent. 
Sulpho-carbolates of zinc and copper have been employed in the treatment of wounds 
by Professor John Wood and others, in the proportion of three to five grains to the ounce 
of water. The solution may be applied by irrigation, or by patent lint covered with some 
impermeable material, as gutta-percha cloth. As direct antiseptics they are inferior to 
carbolic acid, sulphurous acid, and the metallic salts; but, as Mr. Sansom observes, their 
value lies in the protraction of their action, the carbolic acid being slowly liberated by 
the disintegrating action of the fluids on the salts. 
Eucalyptus and thymol, like all aromatics, are excellent remedies for substituting a 
pleasant lor an offensive odor, and lor restraining putrefactive fermentation. They do 
not, moreover, irritate the tissues, nor do they produce toxic effects upon the system. As 
an antiseptic dressing, eucalyptus may be employed in the form of the oil or alcoholic 
tincture, while the best solution of thymol consists of one part of that substance to ten of 
alcohol, twenty of glycerine, and one thousand parts of water. 
Iodoform is at present attracting no little attention as an antiseptic, especially in the 
hands of German surgeons. It may be sprinkled upon the wound, or the latter may be CHAP. XIV. 
ESCHAROTICS . 
469 
enveloped in gauze impregnated with it. The pungent odor of the remedy may he cor- 
rected by the use of the Tonka bean, or by the addition of two parts of balsam of Peru, 
or of one-tenth of its weight of thymol, which do not appear to impair the efficiency of 
its action. Great care should be exercised in its employment in infants and in exten- 
sive wounds, since it has occasionally proved fatal, under these circumstances. 
SECT. XIII ESCHAROTICS. 
There is a class of operations which consists in destroying the affected tissues with 
caustics, consisting of the hot iron and of various escharotic substances. These proced- 
ures, however, once so much in vogue among surgeons, have become almost obsolete, 
although they are perhaps still too much practised in certain quarters, especially in France. 
At the present day they are restricted, in great measure, to affections of the neck and 
orifice of the uterus, superficial morbid growths, hemorrhoidal tumors, varicose veins of 
the extremities, specific ulcers, as chancroids, and malignant pustules, and bites of snakes 
and rabid animals. 
When the hot iron is used for any of the purposes in question, it should be heated to a 
white heat, and retained in contact with the diseased parts sufficiently long to effect their 
destruction, their surface being pre- 
viously thoroughly dried. In per- 
forming the operation, the surrounding 
structures should be carefully pro- 
tected from injury, and in order to 
obtain the desired result it is frequently 
necessary to have two, three, or even 
four cauteries in readiness, so that, as 
one becomes cold, another may take its 
place. The eschar generally drops off 
at a period varying from six to eight 
days. The best apparatus for heating 
the iron is a little furnace charged with 
charcoal, the combustion being pro- 
moted with a pair of bellows. The 
annexed sketch, fig. 191, conveys a good idea of the principal forms of iron in use at the 
present day. The conical-shaped instrument is well adapted for cauterizing narrow and 
deep-seated cavities, and the cylindrical one may also be used for this and similar purposes. 
The hatchet-shaped iron is well adapted for making a linear eschar, and the large round 
one for establishing a deep, permanent issue. 
Many of the inconveniences attendant upon the use of the ordinary hot iron may be 
done away with by the employment of the thermo-cautery of Paquelin, represented in fig. 
192. The platinum tip, a, which is the essential part of the contrivance, is first heated 
in the flame of an alcohol lamp, 5, and then rendered incandescent by compressing the 
bulb, c, through which a steady stream of painter’s benzine of 0.715 sp. gr. contained in 
the bottle, d, is carried to a. Unless great care be exercised the apparatus is liable to 
get out of order; hence it should be thoroughly cleaned every time it is used. 
Hydrate of potassium, ethylate of sodium, the Vienna paste, chloride of zinc, bichloride of 
mercury, arsenic, ammonia, and certain acids, as the nitric, hydrochloric, and sulphuric, 
are powerful caustics, producing their peculiar effects more or less promptly, according to 
the length of time during which they are retained, and the strength in which they are 
used. As their application is generally attended with severe pain, it is proper that the 
patient be previously put under the full influence of an anaesthetic. Moreover, as some 
of the articles here specified have a tendency to diffuse themselves over the surrounding 
healthy surface, care should be taken to prevent this by placing a wall of simple cerate or 
collodion around the part to be cauterized. 
Hydrate of potassium is a powerful escharotic, but as it is extremely painful and very 
tardy in its action, it is now seldom employed. The Vienna paste, composed, as already 
stated, of equal parts of quicklime arid hydrate of potassium, although also productive of 
severe suffering, does its work much more rapidly—generally in from ten to fifteen 
minutes—and is, therefore, usually preferred. Hydrate of potassium is often used most 
conveniently in the form of small sticks. 
The ethylate of sodium which is converted into caustic soda when brought in contact 
with moist tissues, is a gradual but potent agent, which I have found to be very useful in 
Fig. 191. 
Different forms of Cauteries. 470 
MINOR SURGERY. 
CHAP. XIV. 
cicatrizing epithelioma, rodent ulcer, and other malignant affections in which the use of 
the knife is contraindicated. If the pain produced by its application should be severe, it 
may be checked by dropping chloroform upon the part, which converts the agent into 
an inert ether and chloride salt. 
Fig. 192. 
Thermo-cantery of Paqnelin. 
Chloride of zinc is usually mixed with farina, forming thus what is called the phage- 
denic paste of Canquoin, of which there are three strengths, known as number one, two, 
and three; the first consisting of one drachm of the salt to double that quantity of farina, 
the proportions of the second being as one to three, and of the third as one to four, the 
latter being of course much the weaker. The preparations act with great efficiency, but 
are productive of excessive pain. 
Bichloride of mercury, in the proportion of three parts to one of powdered opium, with 
the addition of a sufficient quantity of sulphuric acid to convert it into a paste of the con- 
sistence of tar, makes a powerful escharotic; but, owing to the excessive pain which it 
causes, and the risk of its inducing salivation, it is now rarely used. A similar objection 
is applicable to the caustic mixture, formed of equal parts of white arsenic and sulphur, 
formerly so much in vogue. A decided escharotic effect may speedily be produced by 
the use of equal parts of ammonia and lard. 
A very destructive escharotic, admirably adapted for the removal of epithelial growths, 
may be prepared with fifteen grains of white arsenic, seventy-five of cinnabar, and thirty- 
five of burnt sponge, made into a thick paste with a few drops of water. This constitutes 
what is called Manec’s paste, and is applied in the form of a thin layer to the surface of 
the affected part, previously well cleansed in order to promote its effects. The great 
objection to this remedy is the excessive pain it produces and its liability to cause vomit- 
ing, depending, doubtless, upon the absorption of some of the arsenic. Generally, also, 
its application is followed by deep discoloration and severe swelling. For these various 
reasons it should be employed with great caution, or be replaced by Esmarch’s powder, 
which is composed of one part each of arsenious acid and muriate of morphia, eight parts 
of calomel, and forty-eight parts of powdered gum arabic. 
The carbo-sulphuric paste, as it is termed, is prepared by mixing powdered charcoal 
and sulphuric acid in sufficient quantities to form a semisolid mass. It is a powerful 
escharotic, formerly much employed by Ricord in the treatment of chancroid. Applied in 
the form of a thin layer, it rapidly destroys the tissues, and soon dries into a thick, 
adherent crust, which usually drops off in from six to eight days, leaving a clean sore. 
The only objection to this caustic is that it causes excessive pain. 
The stronger acids, as the nitric, hydrochloric, and sulphuric, produce an instantaneous 
escharotic effect when applied to a denuded surface; hence they are often used for cau- CHAP. XIV. 
MASSAGE. 
471 
terizing inoculated wounds and destroying the edges of ulcers. Of all the acid prepara- 
tions, however, the best and most reliable is the acid nitrate of mercury. The formula 
which I employ is that usually known in this country as Bennet’s. It is prepared by 
dissolving, with the aid of heat, 100 parts of mercury in 200 parts of nitric acid, and 
evaporating the solution to 225 parts. The application produces a white eschar, which 
is detached, piecemeal, from the third to the tenth day. Chromic acid also deserves 
favorable mention ; its application, which causes but little pain, is particularly valuable in 
cases of warty excrescences and of recent chancroids. When merely a superficial caustic 
effect is desired, carbolic acid will be found highly serviceable: it is particularly beneficial 
in unhealthy, suppurating wounds, in gangrenous ulcers, and in open carcinomas attended 
with foul discharges, the odor of which it promptly and effectually arrests. It may be 
used pure, or variously diluted with glycerine, according to the intention of the application. 
Whatever article be employed, the utmost care must be taken to prevent its diffusion 
over the surrounding healthy tissues, otherwise the effects may be most unfortunate. 
Cauterization with caustic arrows is a method of destroying the tissues in carcinomatous 
and other growths originally employed, in 1858, by Maisonneuve, of Paris. It is 
particularly applicable to carcinoma of the breast and uterus, but is also practised, espe- 
cially by its inventor, in epithelioma of the lip, tongue, tonsils, palate, anus, and rectum. 
The arrows are flattened, wedge-shaped pencils, of variable sizes, cut from a thin cake of 
dough, composed of three parts of wheat flour with one of chloride of zinc, as much water 
being added as may be necessary to give the mass proper consistence. When the arrows 
are dried, they may be kept a long time without losing any of their properties. To facili- 
tate their insertion, a small preliminary incision in the skin is required. The number 
employed varies, of course, with the amount of substance to be destroyed. As the attend- 
ant pain is very great, the patient 
should always have the benefit 
of a full anaesthetic. The ne- 
crosed tissues gradually become 
hard, black, and insensible, and 
drop off at a period varying 
from six to twelve days, leaving 
a raw surface which, under the 
influence of mild emollient 
dressings, is soon covered with 
healthy granulations. The 
advantages claimed for this 
method of cauterization are that 
it is entirely free from hemor- 
rhage, that it may be employed 
in situations inaccessible by the 
knife, and that it is rarely fol- 
lowed by erysipelas, pyemia, or 
violent fever. These advan- 
tages, however, have been greatly overrated. Copious bleeding sometimes accompanies, 
or succeeds, the application; nor are the other ill effects as uncommon as the French 
surgeon asserts. The annexed cuts, figs. 193 and 194, afford a good idea of the shape of 
the arrows and the manner in which they are inserted. 
Perchloride of iron is a very mild, but in many cases a very efficient caustic, and at 
the same time a powerful hemostatic, producing rapid contraction of the vessels, and 
checking hemorrhage at once with very little pain. It is particularly adapted to carcino- 
matous sores and old ulcers attended with exuberant and flabby granulations. It may be 
applied either in substance or in saturated solution. A few drops may occasionally be 
advantageously injected into the tissues at the periphery of a fungating and bleeding tumor. 
SEiDT. XIV. MASSAGE. 
Massage, in its original sense, implies kneading; but, as at present used, it has a much 
wider signification, comprising all kinds of passive manipulation, as friction, shampooing, 
percussion, and rolling of the soft parts. As a therapeutic agent, it has been in vogue, in 
some form or other, from time immemorial, although it has only been, of late years, chiefly 
through the influence of the labors and writings of some of the Danish physicians, that it 
has attracted much attention. Its principal claim to notice is in connection with the 
Fig. 193. 
Fig. 194. 
Fig. 193.—Maisonneuve’s Plan of Circular Cauterization by Wedge- 
Shaped Pieces of Caustic. 
Fig. 194.—Maisonneuve’s Plan of Parallel Cauterization by Lancet- 
Shaped Pieces of Caustic. 472 
MINOR SURGERY. 
chap, xi v. 
treatment of subacute and chronic affections of the joints, in which in the hands of the 
skilful operator, it is frequently productive of very marked benefit. It may also be 
advantageously used in subacute and chronic cellulitis, attended with deposits of serum 
and lymph, especially the latter, and consequent induration of the soft parts. Massage 
has also been found serviceable under similar circumstances in affections of the lym- 
phatic glands. 
The beneficial effects of massage are, doubtless, due to the influence which it exerts 
upon the lymphatic vessels, and possibly, also, upon the veins, stimulating them to aug- 
mented action, and thus inducing them to remove inflammatory deposits. These vessels 
during the progress of disease are often so thoroughly choked up by plasma and other 
material as to deprive them completely of then- power as absorbing agents. They 
are, indeed, not only compressed by, but frequently even filled with, these substances. 
The object in the employment of massage is to increase the activity of the lymphatic 
vessels, so that, by the ridding of them of these deposits, they may be enabled to resume 
their normal condition, and at the same time assist in restoring the structures around 
them to their natural size, shape, and pliancy. What the husbandman does for his grain 
when choked by weeds, massage does through the agency of the absorbent vessels for the 
affected structures. 
Massage, in whatever form employed, may be used dry, or with the aid of various 
lotions, embrocations, liniments, or unguents, according to the fancy or caprice of the 
operator, or the special indications of the case. Dry massage is particularly applicable 
in chronic affections, whereas the other form is generally best adapted to the subacute. 
There are of course many exceptions; and, to render the remedy effectual in every case, 
it must be frequently varied. 
The treatment by massage is wholly inapplicable during the height of inflammatory 
action, or during the existence of suppuration. The parts covered with hair should be 
well shaved before the operation is begun, otherwise irritation will be likely to be set up 
in the piliferous bulbs, so as to interfere more or less seriously with the result. The 
period during which the manipulations should be continued must vary, according to cir- 
cumstances, from a few minutes to half an hour or more. 
In regard to friction, there are two principal directions in which it may be employed, 
the transverse and vertical, the former being more especially adapted to the removal of 
deep-seated, and the latter to superficial, affections and deposits. To render the rubbing, 
in whatever direction made, effective, both hands previously oiled are generally required. 
Kneading, rolling, and percussing the structures are often important auxiliary measures, 
powerfully aiding in the removal of plastic material. In the treatment of stiff joints, 
passive motion should always be performed immediately after the massage, and the parts, 
if need be, should be covered in the intervals of the operation with compresses wet with 
cold water, or some astringent and sorbefacient lotion. The absorption of effused fluids 
is often powerfully promoted by combining massage with irritating embrocations, lini- 
ments, or unguents. 
Muscle-beating is a peculiar form of massage introduced by Klemm, of Riga. It is 
performed with an instrument called the muscle-beater, consisting of three elastic tubes, 
each about the size of a finger, and fastened together near the handle to which they are 
attached. The length of the tubes varies according to the object it is desired to secure. 
The skin should be protected with a thin cloth covering, and the force used in the beating 
proportioned to the impressibility of the patient. The application which should be inter- 
rupted by short pauses, should not be too long continued, lest undue irritation be excited. 
Muscle-beating may be advantageously practised in various chronic affections, attended 
with stiffness or partial ankylosis, sprains, rheumatism, dislocations, fractures, spinal 
weakness, and locomotor ataxia. With a little instruction in the use of the instrument, 
the patient can perform the manipulations as well as the professional attendant. An 
elastic hammer having a surface one inch and a half in diameter would answer quite as 
well as lvlemm’s elastic tubes; and, in their absence, effective muscle-beating could 
readily be performed with the thick part of the palm of the hand. 
SECT. XV DRESSING. 
The art of dressing, humble though it be, must not be despised by the surgeon; since, 
in many situations, both in private and hospital practice, it must necessarily form a part 
of his daily routine duties. There is, indeed, great reason to believe that this matter is CHAP. XIV. 
DRESSING. 
473 
too much neglected by practitioners, and that it is too frequently delegated to ignorant, 
careless, and unscrupulous nurses, and to the so-called dressers, who are often not a whit 
more enlightened, or more con- 
scientious. 
The most important appliances 
used in dressing are forceps, scis- 
sors, and syringes, sponges, lint, 
pledgets, tents, adhesive plaster, 
bandages, cataplasms, and un- 
guents. 
The dressing forceps, fig. 195, 
differs from the ordinary dissecting forceps in having ring handles, and cross blades, 
terminating each in a rounded, spoon-shaped extremity, supplied internally with serrated 
edges, to adapt it the better for seizing and holding such substances as may require re- 
moval. They are light and slender, and from four and a half to five inches in length. 
When not at hand, the ordinary dissecting forceps may advantageously be used as a 
substitute. 
The best scissors, for dissecting purposes, are the ordinary straight, pocket-case instru- 
ment, which may be used either for cutting adhesive strips and bandages, or, if necessary, 
for paring the edges of ulcers, or for removing redundant granulations. Scissors curved 
on the edge or fiat are sometimes very convenient. 
The sponges used in dressing should be very soft and clean, and the same articles should 
never be employed upon different persons, especially if affected with open ulcers, as the 
discharges might thus be made the vehicle of propagating disease, as, for instance, in 
chancroid, gonorrhoea, erysipelas, malignant pustule, pyemia, and hospital gangrene. In 
all such cases they should be destroyed as soon as the dressing is completed, or thoroughly 
washed in water, and then soaked in a solution of chlorinated sodium or carbolic acid. 
No sore should ever be wiped ; instead of this, the water should be pressed upon it from 
a sponge held some distance from its surface, which will usually effectually wash away 
any secretions that may be in contact with it. Adherent lymph, charpie, or unguent may 
be picked away with the forceps. The surface around, however, may be gently sponged, 
if soiled; otherwise it may be wiped with a soft, dry cloth. The water, which may be 
tepid, cool, or cold, according to circumstances, is received into a suitable basin, placed 
beneath the affected parts. The old dressings are put into a separate vessel, and promptly 
removed from the patient’s apartment. Fetor is allayed by the free use of deodorizers, 
sprinkled both upon the body and bedclothes, as well as about the room. 
Lint is a soft, fleecy substance, consisting either of prepared cotton or scraped linen, 
or, what is preferable, the ravellings of linen, as those of an old napkin, sheet, or pillow- 
case, each thread being picked out separately. The article generally employed in this 
country is patent lint, which is kept in rolls in the shops, and makes an excellent dressing, 
although not equal to linen ravellings, or the charpie of the French surgeons : one surface 
is glazed, the other smooth. The objection to it is that it is not sufficiently poi’ous to 
admit of the free escape of the secretions of the parts to which it is applied, and, conse- 
quently, also, that it keeps them too warm. 
A very excellent, cheap, and convenient article for dressing wounds and ulcers may be 
prepared by folding a piece of old muslin, until it forms a body from a quarter of an inch 
to half an inch in thickness, and then punching numerous holes into it, giving it thus a 
sieve-like appearance. It is very light and airy, and, while it absorbs moisture, it also 
admits of ready drainage. It forms a good substitute for patent lint, and is much used, 
both in private and hospital practice, in cases where the other is not applicable. It is 
known as perforated muslin. 
Oakum, consisting of picked ship rope, was extensively used during the late war as a 
dressing in gunshot and other wounds, attention having been specially directed to it in 
connection with this subject by Professor Lewis A. Sayre. It combines cheapness with 
softness, is easily adapted to the affected surface, and, being impregnated with tar, is an 
excellent antiseptic and deodorizer. As an absorbent, however, it is far inferior to patent 
lint, charpie, and tow. 
Instead of oakum, tenax is now much employed as a dressing for wounds. It is an 
absorbent and antiseptic substance, which possesses the tarry odor of oakum, but is much 
softer and lighter, and readily imbibes and retains the secretions of the affected surface, 
at the same time that it effectually prevents any unpleasant emanations. Its cheapness 
is an additional reason for its employment. 
Fig. 195. 
Dressing Forceps. 474 
MINOR SURGERY. 
CHAP. XIV. 
Tow lias long been employed as an absorbent of persistent discharges in wounds and 
ulcers, and, if properly picked and carded, is equal to any substance that can be applied 
for the purpose. The ordinary article contains so much hard, sharp matter as to be 
unfit for use. 
Cotton-wool, saturated with water, tepid, warm, or cold, may often be advantageously 
employed for cleansing wounds, as it is less irritating, when applied directly to the raw 
surface, than sponge. It may also be conveniently used as a medium of medicated 
dressings. 
Spongiopiline is a valuable dressing. It is a soft, light, porous fabric, made of sponge 
and muslin, in sheets from half an inch to an inch in thickness, covered with a glazing 
of India-rubber, to fit it the better for retaining water and preventing evaporation. It is 
more particularly adapted as a dressing to inflamed surfaces unattended with breach con- 
tinuity. 
Paper, prepared in various ways, forms a very good cheap substitute for patent lint as 
a surgical dressing. Professor Agnew, some years ago, recommended the use of a very 
thick, soft paper, made of old rags, deodorized with chloride of lime. One surface is 
velvety, and the other dense and leathery. 
Sometimes the lint is arranged in the form of a compress, pledget, ball, roll, tampon, 
tent, or pellet, thus adapting it the more conveniently to particular purposes. Thus, a 
compress consisting of a strip of folded muslin, lint, or linen, maybe employed for press- 
ing together the sides of a deep abscess, or a number of pieces may be piled upon each 
other, so as to form a graduated compress, which is often advantageously used for com- 
pressing a bleeding vessel, as the brachial artery where it runs along the inner edge of the 
flexor muscle. The pledget is a strip of patent lint, usually spread with cerate, for pro- 
tecting the surface of a granulating ulcer. Balls, rolls, and tampons are simply masses 
of soft substance, as charpie, lint, or cotton, arranged so as to adapt them to particular 
cavities, as the uterus, the nose, or a deep wound, either with a view of arresting hemor- 
rhage, or for absorbing pus and other fluids. The tent consists of a piece of linen, mus- 
lin, or patent lint, twisted on its axis, slender, and usually several inches in length, its 
object being the prevention of the reunion of the sides of the incisions made in evacuating 
abscesses, and in laying open sinuses, as in the operation for anal fistule. Tents are 
sometimes prepared with wax, generally of a conical shape, and employed as dilators. 
Finally, the pellet is a ball, roll, or mass of soft tissue, inclosed in a strip of soft cloth, 
firmly tied; it may be used for the same purposes as the tampon, of which, in fact, it is 
merely a variety. When intended for the nose, uterus, or 
rectum, a stout thread or piece of twine may be tied to it 
in order to facilitate its removal. Dr. Addinell Hewson 
employs ordinary paper, similar to that used for printing 
purposes. When the object is to confine heat and moisture, 
as in the application of a poultice or warm water-dressing, 
the best article is oiled silk, or when this cannot be ob- 
tained, oiled paper or impervious lint. 
The drainage-tube, as a means of favoring the dis- 
charge of matter from abscesses and sinuses, especially 
when large, devious, or deep seated, is not, as has been 
generally supposed, a recent invention, but of ancient date, 
extending back to the time of Ambrose Pare, by whom it 
is repeatedly mentioned in his great work on surgery in 
connection with gunshot wounds and injuries of the chest. 
He speaks of it as preferable, in many cases, to tents, in free- 
ing wounds and ulcers of irritating matter, and promoting 
the formation of healthy granulations. He used lead and 
various other materials in its composition, with apertures 
near its extremities. The surgeons of Philip II., king 
of Spain, employed drainage-tubes in the treatment of that 
monarch’s case to drain a large abscess with which he was 
afflicted. To Chassaignac, however, is unquestionably due 
the credit of calling the attention of the profession to the 
subject in modern times, and of pointing out, in clear and distinct terms, the class of cases 
in which the drainage-tube can be used to the best advantage. 
Drainage-tubes are composed of various materials, as soft rubber, fig. 196, decalcified 
bone, lead, or silver; they are cylindx-ical in shape, of variable length and diameter, and 
Fig. 196. 
Drainage-tube and Forked Probe. CHAP. XXV. 
DRESSING. 
475 
perforated with numerous apertures, to admit of the free ingress of matter in every di- 
rection, at the sides as well as at the extremities. Whatever the substance may be, it 
should be smooth, light, and non-irritant, and the openings must be sufficiently large to 
prevent them from becoming clogged. No sulphur should enter its constitution, as this 
would impart an offensive odor to the secretions.' 
The late Dr. H. Lenox Hodge invented what he called a drainage-probe, which he 
considered preferable to the ordinary drainage-tube. It is made of flexible silver, and 
terminates at each end in an olive-shaped bulb. 
Poultices form an important element in a great variety of dressings, but as this subject has 
already been fully described, I shall here only add, that when they are selected for this 
purpose, they should be used with special reference to the comfort of the parts, care being 
taken that they do not oppress by their weight, or irritate by their long retention and the 
stimulating character of their ingredients. The mode of employing water-dressings has 
also been so fully considered in another part of the work as to render any further remarks 
regarding them here unnecessary. 
Unguents, ointments, or salves of various kinds are employed as dressings in ulcers 
and other open surfaces; much has been said and written upon the subject, especially of 
late years, and attempts have been made to discard these substances altogether from prac- 
tice. Still, notwithstanding all this, unguents hold a prominent place in the affection of 
many practitioners, as well as in that of the common people, and it would be difficult, I 
am sure, always to dispense with their use. Prejudice, I imagine, has had much to do in 
proscribing this class of remedies. No one will pretend to assert that rancid ointments 
do not act as irritants; this, however, is not the fault of the article, but simply of its 
misuse. Prepared and employed for the occasion, experience shows that the application 
of unguents is often attended with the most salutary effects, admirably protecting granu- 
lating surfaces, and rapidly promoting cicatrization. As a general rule, I have found 
that all the officinal medicated ointments are much too strong, requiring to be diluted 
from one-half to seven-eighths. Petroleum has, in great degree, taken the place of most 
of the older simple ointments, inasmuch as it is less liable to become rancid and offensive. 
Cosmoline or vaseline is one of the most approved preparations of this kind, and another, 
recently introduced, is fossiline,a hydrocarbon jelly of superior consistence and smoothness. 
Glycerine, either alone or variously combined, forms an excellent dressing in granu- 
lating wounds and ulcers, in different eruptive diseases of the skin, in ulceration of the 
uterus, and in certain forms of deafness, especially when dependent upon dryness of the 
drum of the ear, or the presence of indurated wax. Although its utility has been greatly 
exaggerated in these and other affections, it is unquestionably a valuable addition to the 
domain of modern surgery. It is best applied upon soft cotton or coarse lint, previously 
well pressed out of tepid water. Its effect, thus employed, is to exclude the air, to keep 
the sore moist and clean, and to favor capillary drainage by osmosis, thereby depleting 
the tissues, provoking a copious discharge of serum, lessening suppuration, and promoting 
cicatrization. Glycerine has great affinity for water, and a bit of cotton saturated with 
it will retain its humidity for days, even if continually exposed to the air. It has the 
additional advantage of being perfectly bland, non-adherent, and easily removable by 
ablution. 
Glycerine may often be advantageously combined with other articles, as tannic acid, 
opium, soda, and the mineral acids, according to the indications of the case. 
Dr. Ilewson has extensively employed dry earth as a dressing in burns and scalds, 
ulcers, wounds, both recent and suppurating, and in compound dislocations and fractures, 
with the effect, not only of excluding the air and preventing the offensive odor so com- 
mon in such cases, but also of allaying pain and hastening the healing process. Dr. 
Darby, of Boston, has been equally successful in the management of these affections with 
the use of carbolized dry earth and carbolized bran. 
The earth, as used by Dr. Hewson in his dressing, is always taken at a depth of from 
two to three feet below the surface, and is kept in large dry lumps until needed, when it 
is pulverized, sifted, and applied, either dry, as in an open surface, or converted into a 
thick paste with water when employed as a sorbefacient, as in the case of sprains, con- 
tusions, or tumors, a layer half an inch thick, confined in muslin, and covered with a 
suitable bandge, generally sufficing. Or, instead of this, the paste may be spread all 
over the affected parts, or applied on strips. The dressing is renewed as soon as it be- 
comes offensive or ceases to produce the desired effect. In most cases it is necessary to 
effect the change on a sound surface by the end of the third day, and, on an open one, as 
often as every twenty-four hours. 476 
MINOR SURGERY. 
CHAP. XIV. 
Compressed sponge as a remedial agent, in the form of conical tents, as represented in 
fig. 197, or of flattened plates, is particularly useful in the treatment of sinuses and fistules, 
strictures of the rectum, contraction of the canal of the neck of the uterus, 
chronic enlargement of the lymphatic glands, venereal buboes, and chronic 
swelling and induration of the testicle and mammary gland. It may also be 
advantageously employed for dilating the female urethra, and the wound 
made in the operation for the relief of atresia of the vagina and anus. The 
late Dr. J. P. Bachelder, who published an elaborate article on this mode of 
treatment in the New York Journal of Medicine for May, 1859, asserts 
that he had repeatedly employed it with great benefit in the suppression and 
arrest of various morbid growths, both benign and malignant, and similar 
testimony is borne by other observers. 
The sponge, which should be soft, elastic, and well cleaned but not 
bleached, may be compressed with any heavy weight, or, what is better, a spe- 
cial apparatus, and, when perfectly dry, cut into strips of appropriate size 
and shape. When the object is to compress a swollen and indurated organ, 
as the breast or testicle, the piece should be sufficiently large to embrace the 
whole of the affected structures, to which it should be secured with a suita- 
ble bandage, the dressing being kept constantly wet with cold water, to pro- 
mote the expansion of the sponge. Change or substitution is affected when- 
ever pain, discharge, or fetor renders it necessary. 
When sponge is intended to be used for sinuses or mucous outlets, it should 
be formed into tents by cutting it into conical pieces, slightly tapering at the 
end, from one to two inches and a half in length, traversed by a wire in the 
long axis, saturated with thick mucilage of gum arabic, and tightly wrapped 
around with small twine, beginning at the narrow extremity, and gradually 
terminating at the larger. When perfectly dry, the wire and cord are re- 
moved, and the surface smoothed with fine sand-paper. Daily substitution 
is effected, as the sponge soon becomes filthy, fetid, and worthless, not only 
exciting irritation and discharge, but endangering the system by pyemia. 
These effects may, it is true, be in some degree, counteracted by the addition of a little 
carbolized glycerine, but the objection to this is that it sometimes interferes with the ex- 
pansion of the sponge. 
The period during which the application should be continued must vary with the 
nature of the case. Great dilatation of a sinus or natural canal, as the urethra or vagina, 
may usually be effected in a very short time, and an enlarged breast or testicle may often 
be astonishingly reduced in a few days. 
The stem of the sea tangle—the laminaria digitata of botanists—is another article 
that may be advantageously used for dilating purposes. The only objection to it is the 
presence in it of a certain amount of iodine, sodium, and potassium, which causes it to 
be more or less irritating to the parts with which it is brought in contact. Previous 
thorough maceration in simple water, however, 
will readily deprive it of this quality. Its ex- 
traordinary expansion under the influence of the 
warmth and moisture of the living tissues admi- 
rably fits it as an agent for rapid dilatation. Its 
surface, which is naturally rough, should be well 
smoothed before it is introduced. Dr. Green- 
halgh uses a tubular sea-tangle tent, fig. 198, as 
it expands more rapidly than the solid one. 
Tupelo tents, to which attention has been called 
by Dr. Leopold Landall, are prepared of the root and stem of the nyssa aquatica, and 
form excellent dilators in contracted conditions of the vagina, uterus, and other mucous 
canals. Their superiority over sea tangle and sponge-tents consists in their more rapid 
and uniform expansion. 
Whatever the dressings may be, they should be carefully confined by means of a band- 
age, evenly and lightly applied, so as to afford the requisite support, and no more. In 
most situations, this may readily be done with the common roller; but in certain regions, 
as the groin, perineum, anus, and head, particular contrivances may be necessary, as the 
spica, the T bandage, and the four-tailed bandage. For retaining dressings upon the 
scrotum and mammary gland the suspensory bandage will be found most convenient. 
Adhesive strips also answer a good purpose. 
Fig. 197. 
Sponge-Tent 
Holder. 
Fig. 198. 
Greenhalgli’s Sea-tangle Tent. CHAP. XIV. 
BANDAGING. 
For confining the heat and moisture of poultices and warm water-dressings oiled silk 
is usually employed, although oiled or waxed paper answers quite as well, and, as it is 
much cheaper than oiled silk, it is entitled to 
preference for general use. To maintain clean- 
liness, frequent substitution should be effected. 
A very cheap and convenient dressing made 
of thick porous paper, rendered water-tight on 
one surface with a film of India-rubber, was 
introduced at the Pennsylvania Hospital, a few 
years ago by Professor Agnew, and has been 
found very serviceable as an application in 
wounds and other affections, as it not only 
readily absorbs their secretions, but prevents 
the evaporation of water and other fluids. 
The adjoining cut, fig. 199, represents the 
“ward carriage,” as it is called, devised by 
Dr. Thomas G. Morton, of this city, and used 
with such signal benefit since 1806 at the 
Pennsylvania Hospital. Its arrangements 
could not possibly be more perfect, more com- 
pact, or better adapted to the objects for which 
it was constructed. The carriage is made of 
oak, with gutta-percha tires, and is so light as 
to be easily pushed noiselessly across the floor 
from bed to bed. It is provided with a heating 
apparatus, a long gutta-percha tube for cleans- 
ing wounds and ulcers, and with compartments for the accommodation of jars, bottles, 
sponges, and, in short, all the means and appliances necessary for dressing purposes in a 
large hospital. 
SECT. XVI BANDAGING. 
Bandages are substances employed for retaining dressings in cases of wounds, ulcers, 
abscesses, fractures, dislocations, and other affections, as well as with a view to their 
direct curative effects, which, as will be shown by and by, are probably much greater 
than they are generally supposed to be. They vary much in shape and size, and also in 
regard to the materials of which they are composed, and the object which they are de- 
signed to fulfil. A vast number of bandages have been described in certain modern 
works, especially those on minor surgery, much ingenuity, and, according to my belief, 
much time having been wasted, in trying to adapt them to every part and region of the 
body, and to every circumstance, however insignificant, to which such contrivances can 
possibly be applied. By running into these extremes, the art of bandaging has been 
greatly complicated, and much injury inflicted upon a department of surgery, which, if 
properly administered, is capable of conferring immense benefit in almost every form of 
accident and disease affecting the external parts of the body. The ancient surgeons 
racked their brains to invent names for designating bandages, and the claims of not a few 
© © © ~ 
of them to distinction were based almost exclusively upon such absurd and puerile pur- 
suits. If a man was so fortunate as to devise an apparatus for expelling peccant humors, 
for retaining a cataplasm upon the scalp, or for supporting a diseased breast, the height 
of his ambition was generally amply gratified. It is to be feared that these employments 
have had too many imitators in modern times. 
The more simple a bandage is, the more likely will it be, if judiciously used, to answer 
the purpose for which it is intended, all complicated contrivances of this kind being ob- 
jectionable on account of the difficulty of applying them, the ease with which they be- 
come deranged, and the trouble and vexation of changing them, the attempts to do so 
being frequently attended with serious inconvenience and pain to the patient, and perhaps 
great detriment to the parts affected. In general, the single-headed roller is all that can 
be required in almost any case ; occasionally the strip-bandage, commonly known as the 
bandage of Scultetus, represented in fig. 200, may advantageously be employed, especially 
in compound fractures and dislocations. The many-tailed bandage ought, on the con- 
trary, to be discarded from practice, as inconvenient and useless. It consists, as the 
name indicates, of a number of transverse slins. of the same width but uneuual length. 
Fig. 199. 
Morton’s Ward Carriage. 478 
MINOR SURGERY. 
CHAP. XIV. 
stitched to a longitudinal portion, and was formerly much employed in fractures of 
the leg. 
Bandages are composed of various materials ; commonly of muslin, bleached or un- 
bleached, of calico, or of linen, the only objection to the latter being its expense. Occa- 
sionally they are made of flannel, especially when 
it is desirable to protect the parts from cold, as in 
oedema of the extremities, and in the swelling at- 
tendant upon a gouty or rheumatic state of a joint, 
in persons of an unhealthy, broken constitution, 
who are commonly so extremely susceptible of at- 
mospheric vicissitudes. In general, muslin will be 
found to answer every purpose, being both cheap 
and easily procured ; it should be soft, firm, smooth, 
strong, and not too yielding, divested of selvage 
and seam, and washed before it is applied. Calico 
is not a good material for bandages, as it is usually 
too light and flimsy. The gum-elastic bandage is 
of great service in the treatment of old ulcers, in 
eczema of the lower extremities, in chronic affec- 
tions of the joints, in elephantiasis, in chronic 
oedema, and in varicose conditions of the veins, 
and deserves more attention than it has hitherto 
received. Dr. Henry A. Martin, of Boston, is en- 
titled to much praise for the pains he has taken to 
introduce this invaluable agent to the notice of the 
profession. The use of Esmarch’s bandage in pre- 
venting hemorrhage in amputations and in the 
cure of aneurism is too well known to need com- 
ment. 
The length and width of a bandage are of.course 
subject to much diversity, depending upon the shape 
. and size of the part to which it is intended to be 
applied. Hence, while in one case it need hardly be half an inch in width, and not more 
than a foot in length, in another it may require a width of two, three, or even six inches, 
as in injuries of the chest, and a length of many yards. Muslin is usually torn into strips 
of the requisite size, whereas linen, being much stronger, is best shaped with the scissors. 
The ravellings being picked away, each piece is rolled into a firm cylinder, and put away 
for use, so that it may be ready for any emergency that may arise. The winding may be 
effected either by hand, the cloth being held upon the front of the thigh, or by appropriate 
machinery, such as is to be found in the office of every practitioner, and of which illustra- 
tions may be seen in most of the works on minor surgery. However effected, it should 
be done with great care, since no one can possibly apply a bandage well that has been 
wound in a loose and slovenly manner. 
When intended to be used upon an extremity, the rule is always to begin at the distal 
portion of the limb, and to proceed from thence upwards some distance beyond the seat 
of the disease or injury. The end of the bandage being slightly unfolded, is held firmly 
upon the part with one hand, while the cylinder is carried round the limb with the 
other, and thus the application is continued by circular and reversed turns, as they are 
named, until the object has been completed, the fingers being pressed upon each reverse 
to flatten and equalize it, as in fig. 201. If the bandage were put on spirally, it could 
not maintain itself upon the limb for any length of time; and, what is worse, the com- 
pression would be so unequal as to cause severe suffering and perhaps even mortifica- 
tion. The application, then, must be made circularly, and care taken that each turn of 
the roller be reversed, so that the inner surface shall be the outer, and the upper edge 
the lower, the pressure being uniform throughout, or not greater at one point than at 
another, as in fig. 202. 
The evil effects of unequal compression by the bandage are well illustrated in fig. 203, 
copied from John Bell; it also shows how important it is always to begin the application 
of the bandage at the distal extremity of a limb, and not above the wrist or ankle, as 
happened in the case so graphically described by the celebrated Scotch surgeon. In all 
cases of severe injury or disease, with a tendency to swelling and to the extension of the 
Fig. 200. 
Bandage of Scultetus. CHAP. XIV. 
BANDAGING. 
morbid action, due allowance must be made for the inflammatory effusions that will neces- 
sarily occur. Hence, too much care cannot be taken both in applying the bandage and 
in watching its effects For want of this precaution many a limb has been 
destroyed, and the reputation of many a practitioner irretrievably ruined. 
Fig. 201. 
Fig. 202, 
Mode of Applying the Roller by Circular and 
Reversed Turns. 
Appearance of the Bandage after it has been 
Applied. 
Some surgeons employ the double-headed roller; but I have never had occasion to use 
it, and am satisfied that there are few cases, if any, in which it may not be advantageously 
replaced by the single-headed. The double-headed bandage is considered as being par- 
ticularly serviceable in the treatment of wounds penetrating deep among the muscles, 
where it is of paramount importance to effect accurate apposition of the deep as well as of 
the superficial sides of the solution of continuity; but even here no indication is presented 
that cannot be readily fulfilled with the compress and single-headed roller. In my own 
practice I have certainly never been at a loss in this respect. 
The bandage of Scultetus, represented in fig. 200, consists of a number of strips, gen- 
erally from ten to twenty, or of pieces of an ordinary roller, of equal or unequal length 
and breadth, according to the intentions of the surgeon. They are arranged in such a 
manner as that, when applied, each succeeding one shall overlap from one-third to one- 
half of the preceding one, the compression being made in the same gentle, uniform man- 
ner as in the employment of the ordinary roller. This form of bandage is peculiarly useful 
in the treatment of compound fractures and dislocations, in connection with which it will 
frequently be mentioned. 
Bandages are sometimes applied wet; but in doing this much vigilance must be exer- 
cised, lest, shrinking too much as they dry, they produce a greater degree of compression 
than is compatible with the comfort and safety of the parts. What is called the starched 
bandage, an excellent modern device, will receive particular attention in connection with 
the treatment of fractures of the extremities, to which it is more especially adapted. 
When it becomes dry, it forms a stiff, firm, immovable case, well adapted to maintain the 
ends of a broken bone in contact with each other. Amidon, gum-shellac., plaster of 
Paris, and kindred articles may be used for the same purpose, the bandage being wet with 
them, and immediately applied to the affected limb. 480 
MINOR SURGERY. 
CHAP. XIV. 
The bandage, viewed as a therapeutic agent, has been too much neglected by modern 
practitioners. No one who has properly used it, or who is capable of properly applying it, 
can, for a moment, doubt its great utility; my experience 
with it for the last fifty-live years amply attests this 
fact; still, it is necessary that we should temper our en- 
thusiasm, and that we should not allow ourselves to be 
betrayed into a species of hobbyism, calculated to mis- 
lead the judgment, and to bring surgery into discredit. 
Employed indiscriminately, it cannot fail, in many cases, 
to cause serious mischief, and to be followed by chagrin 
and disappointment. When the hand of a master is not 
present to direct and guide our practice, the result may 
frequently be most disastrous both to the patient and the 
surgeon. The evil effects of bandages, in their aggregate 
capacity, are hardly less serious than those of mercury, 
the lancet, and other potent remedies ; or, if they are, it 
is only because they are less frequently employed. Nu- 
merous instances have come to my knowledge, where 
limbs, and even life, were the forfeit of their injudicious 
use. 
It is not difficult to perceive how the bandage acts in 
producing its salutary effects. In fractures and disloca- 
tions, as w-ell as in large wounds, it powerfully controls 
muscular contraction, and at the same time prevents 
tumefaction, by giving tone and support to the capillary 
and other vessels. Its influence as a sorbefacient is 
evinced in the rapid abatement of the swelling which so 
often follows compression by the bandage in erysipelas, 
oedema, and various kinds of injuries; or, more strik- 
ingly still, in orchitis, when, after the subsidence of the 
more active disease, the testicle is strapped with adhesive 
plaster, which is but another form of bandage. Here in 
a short time, ordinarily in less than twenty-four hours, 
the swelling usually so far disappears as to allow the 
organ to slip out of its artificial case; or, at all events, 
to such an extent as to require renewal of the dressing. 
The general effect of the bandage would thus seem to be 
somewhat similar to that of mercury, controlling capil- 
lary action, and promoting the absorption of effused 
fluids; but it has the additional advantage, and no tri- 
fling one it is, that it supports the muscles and prevents 
spasm, as is so remarkably evinced in fractures and in 
the stump after amputation. 
Of the extent to which bandaging may be carried, a 
good idea may be formed from the frequent allusion that 
will be made to it in different parts of this work ; it will suffice here to observe that it is 
applicable, as a general rule, to the treatment of all classes of wounds, from the most sim- 
ple to the most severe, to fractures and dislocations, ulcers, abscesses, erysipelas, whitlow, 
orchitis, chronic inflammation of the superficial veins, and to nearly all affections of the 
limbs in which there is an effusion of serum, or serum and plasma. 
A bandage, once applied to an open wound, especially if there be much discharge, 
should never be used a second time. However carefully washed, it is very difficult, if not 
impossible, to remove all the matter, and hence it may readily become a source of infec- 
tion, causing erysipelas, pyemia, hospital gangrene, and other bad effects. The danger 
will be particularly great in a recent wound, in a person laboring under severe shock or 
loss of blood. Even the act of washing a dirty, filthy bandage is not always devoid of danger. 
Fig. 203. 
Gangrene from Strangulation of an In- 
jured Limb by Injudicious Bandaging. CHAP. XV. 
QUALIFICATIONS OF A SURGEON. 
481 
CHAPTER XV. 
OPERATIVE SURGERY. 
Operative Surgery has too often been regarded as an opprobrium of the healing art. 
This opinion, as foolish as it is unfounded, is not peculiar to the public, who, in matters 
of this kind, are generally but poor judges, but has frequently been advanced even by 
medical men. That this department of surgery is often abused cannot be doubted ; but 
does it thence follow that it is a disgrace to the profession and an injury to the commu- 
nity? Such a view would be absurd, because it would be utterly irreconcilable with the 
dictates of common sense and the results of daily experience. So long as the human 
body is liable to accidents, and so long as nature is incapable of arresting, by her own 
efforts, the various morbid processes which she herself institutes, so long will practitioners 
be compelled to invoke the aid, and, I may add, the blessings, of operative surgery. Is 
it a disgrace to amputate a leg for a mortification of the foot, to extirpate a testicle that 
has been destroyed by cystic disease, to divide the stricture in strangulation of the bowel, 
to remove a stone from the bladder, to extract a cataract, or to trephine the skull in a 
punctured fracture ? Surely, no one will doubt that in these, and a hundred other in- 
stances, our object can only be attained by an operation. Medicine, under such circum- 
stances, however judiciously administered, is not only utterly futile, but is always ready 
to avail itself of the aid of surgery. Its empire is temporarily suspended, and it only 
resumes its legitimate functions after the use of the knife. It is true beyond doubt, and 
it is fortunate that it is so, that, in the hands of judicious and enlightened practitioners, a 
resort to instruments is much less frequent now than it was even ten years ago; many 
limbs which would formerly have been subjected to amputation are now easily saved, and 
many diseases which were once regarded as utterly hopeless now readily yield under the 
influence of our therapeutic efforts. 
Operative surgery, as practised at the present day, is entitled to the highest respect and 
admiration of the profession, and the most profound gratitude of mankind. It has attained, 
if not its finality, certainly a wonderful degree of perfection ; it has emerged out of chaos 
into order, and out of darkness into light; it has laid aside its farrago of instruments, and 
its fondness for blood and torture; in a word, it has assumed the fair and stately propor- 
tions of an exact science; and little remains to be done, in order to place it upon a firm 
and immutable basis, beyond its efforts to determine the best plans by which it seeks to 
accomplish its various purposes. Within the last twenty-five years it has literally invaded 
every organ and region of the body, and achieved feats of a character evincive of the highest 
daring, of the most varied knowledge, and of the most marvellous dexterity. Once 
regarded as a disgrace, it can be regarded so now only when it is practised for base and 
selfish ends ; not when it interposes its humane and beneficent resources for the purpose 
of removing disease, prolonging life, and averting death. 
Qualifications of a Surgeon The performance of operations presupposes the posses- 
sions of certain qualities on the part of the surgeon. It is not every man that can become 
an operator, even presuming that he has the requisite knowledge of anatomy and of the 
use of' instruments. Courage, which is so indispensable, is possessed by comparatively few ; 
the sight of blood, and the idea of inflicting pain, were so disagreeable to Haller, that, 
although he taught surgery with great success for seventeen years, he never, it seems, dur- 
ing all that time, performed a solitary operation upon the living subject. Courage, like 
poetry, has often been said to be a gift of nature, and nothing is, perhaps, more true ; but it 
is equally certain that a timid man may, by attention to his education, and by constant prac- 
tice, become, in the end, a good operator. Habit does a vast deal for us in such cases, for it 
literally becomes a second nature. I know a surgeon who in his youth nearly fainted at the 
sight of blood as it flowed from a vein of the arm into the basin, which it devolved upon him to 
hold during the operation of venesection, and yet who, by a course of self-training and a com- 
plete knowledge of anatomy, has made himself a thorough master of the knife. Celsus, 
long ago, happily defined the qualities which constitute a good operator. He should pos- 482 
OPERATIVE SURGERY. 
chap. xv. 
ses, says the illustrious Roman, a firm and steady hand, a keen eye, and the most unflinch- 
ing courage, which can disregard alike the sight of blood and the cries of the patient. 
But the above are not the only qualities, important though they be, which an operator 
should possess. If he is not honest in his purposes, or scrupulously determined, in every 
case, to act only with an eye single to the benefit of his patient, and the glory of his 
profession, he is not worthy of the name which he bears, or fit for the discharge of 
the solemn duties which he assumes. In a word, such an operator is not to be trusted, 
for he will be certain, whenever opportunity offers, to employ the knife rather for 
the temporary eclat which may follow its use, than for the good of the individual whom 
he unnecessarily tortures. He will not hesitate to amputate a limb, although the patient 
should die the moment he is removed from the table, or to tie the carotid artery for a 
malignant disease of the eye, although he knows full well that such a procedure never has, 
in any instance, been of the slightest benefit. Such men, of whom there are, even yet, 
unfortunately, too many in our profession, deserve the name of knivesmen and knaves 
rather than of surgeons and honest men. No operation should ever be undertaken with- 
out due deliberation, and without a careful consideration of the various consequences 
involved in the result. Everything that is done should be done with reference exclusively 
to the patient; self should not have the slighest weight in the matter. The question, in 
every case, should be, is an operation necessary to save life, or to place the individual in 
a condition calculated to promote and insure his recovery ? If this can be answered 
affirmatively, the operation should by all means be proceeded with; but if it be ascer- 
tained, clearly and satisfactorily, that it presents no such prospect, both humanity and 
common sense dictate the propriety of declining it. It is a sad and humiliating spectacle 
to see a surgeon cut off a limb, or remove a carcinomatous tumor, merely for the sake of 
having it said that he performed an operation. The conscientious and enlightened surgeon, 
unlike the heartless soldier, carefully respects life; he regards life as a great boon, and 
uses every possible endeavor to preserve and to prolong it. “ I have been reared,” said 
Napoleon, “ on battle-fields, and such a man as I am makes no account of a million of 
men’s lives.” 
No surgeon can be a skilful operator unless he has a thorough knowledge of anatomy. 
His acquaintance with the healthy structures and their relations with each other should 
be so clear and distinct that he should be able to see them as it were in a mirror, or with 
his eyes shut. He should carefully study their color and consistence, that, seeing and 
feeling them, he may readily distinguish them from each other, and not be obliged to ask 
his assistants whether this is an artery, that a nerve, or this a tendon, a muscle, or a liga- 
ment. Nor should he limit himself merely to the study of healthy and relative anatomy. 
He should also have an intimate and comprehensive knowledge of morbid anatomy, or of 
the changes which are impressed upon the organs and tissues by disease and accident, and 
also of the various growths, formations, and deposits. The information thus derived will 
be of the greatest aid in facilitating the different steps of the operation, and in enabling 
the surgeon to determine what to remove and what to spare. 
No man can become an accomplished operator unless lie practices constantly on the dead 
subject. Dexterity, grace, and elegance are to be acquired only by long and patient 
exercise. In all operations involving unusual anatomical complexity, a good plan is to 
make a thorough dissection of the parts immediately beforehand, Langenbeck, Lisfranc, 
Cooper, and Mott always adopted this method, and I have often profited by it in my own 
practice. 
Preparation of the Patient—No operation, unless it be of the most trivial nature, 
should ever be attempted without due preparation of the patient’s system. The only ex- 
ception to this rule is in case of emergency, where, in order to save life, we are obliged 
to act on the instant, without any precaution of this kind, and sometimes even without 
the necessary assistance. The character and amount of the preliminary treatment must, 
of course, vary in different cases and under different circumstances, and do not, there- 
fore, admit of precise specification. It may be stated, in general terms, that, even if the 
patient be unusually plethoric, it will rarely be necessary to bleed him at the arm. In ope- 
rations about the head, eye, and throat, this may be a wise precaution, but in most other 
situations this is uncalled for. In all instances it is well to take into the account the probable 
loss of blood that may take place during the operation. If this is likely to be consider- 
able, all preliminary abstraction must be carefully refrained from, even in healthy, robust 
subjects ; for there can be no doubt whatever that a copious, or even a considerable, loss 
of blood before, during, or immediately after an operation, has a marked tendency, in 
many cases, to retard recovery, and to dispose to the occurrence of erysipelas, pyemia, CHAP. XV. 
PREPARATION OF THE PATIENT. 
483 
tetanus, and other ill effects. Indeed, so thoroughly am I convinced of the truth of this 
remark that I feel as if it could not be urged too forcibly upon the mind of the practi- 
tioner. It was formerly thought that a certain amount of hemorrhage, under such cir- 
cumstances, would not only do no harm, but that it would positively be beneficial, by 
rendering the system less liable to inflammation. Modern experience, however, has 
shown that such an opinion is utterly untenable. 
In regard to the use of laxatives and purgatives, much judgment is required. While 
in many cases this class of remedies may be entirely dispensed with during the prelimi- 
nary treatment, in others their exhibition is imperatively demanded. Their employment 
is especially indicated when the bowels are in an overloaded condition, or when there is 
some derangement of the secretion of the salivary glands, the liver, and mucous follicles 
of the alimentary canal, as denoted by the fetid state of the breath, the dryness of the 
mouth, the want of appetite, nausea, vomiting, or headache, or other other symptoms of 
malaise. The best articles for this purpose are blue mass and eolocynth, or calomel and 
rhubarb, either alone, or in union with a small quantity of ipecacuanha or tartar emetic. 
The latter substances are especially valuable when there is much disorder of the secre- 
tions, with headache and loss of qppetite. Occasionally nothing answers better than, or 
hardly as well as, a dose of castor oil, Epsom salt, or citrate of magnesium. Independently 
of their direct cathartic effect, purgatives are often extremely useful in clearing out the 
bowels, when, as, for example, in lithotomy and in anal fistule, it is desirable to prevent 
any action upon them for several days after the operation. 
A proper regulation of the diet is generally of paramount importance. The extent to 
which this should be carried must, of course, depend upon the circumstances of each 
particular case; but, as a rule, should not, on the one hand, be too rigid or protracted, 
and, on the other, not too abundant. Much of the success of an operation is often di- 
rectly traceable to the attention that is bestowed upon this subject. In general it will be 
advisable to enjoin entire abstinence from meat and the coarser kinds of vegetables, coffee 
and strong tea, hot biscuit, pastry, condiments, and, in short, all articles of an indigesti- 
ble and heating nature. The quantity of food taken in the twenty-four hours should also 
be less than ordinary, for nearly, if not quite, as much harm may result from an undue 
amount of mild and unstimulant food as from the moderate use of the more solid and 
substantial articles. 
Instead of dieting and purging the patient, it may be necessary to feed and stimulate 
him before it is safe to use the knife. He may be exhausted, deficient in nerve-power, or 
pale and anemic, requiring a rich, concentrated animal, or mixed diet, milk, brandy, ale, 
or porter, and, perhaps, quinine and iron, especially the tincture of the chloride. Such a 
course is particularly indicated when there is a tendency to epidemic disease, lest the pa- 
tient, from shock and loss of blood, should fall a ready prey to its effects. The employ- 
ment of quinine is generally of immense benefit in all severe injuries, whether accident- 
ally or designedly inflicted, in preventing erysipelas, phlebitis, angeioleucitis, septicemia, 
pyemia, and kindred affections, and in promoting recovery. This treatment is especially 
called for in persons living in, or coming from, malarial regions of country. 
Finally, attention should be paid to the state of the body and mind. For some days, 
or even, perhaps, an entire week, the most perfect quietude should be observed, especially 
if the operation is at all likely to be of a serious character. If, for example, the object 
is to extract a foreign substance from the knee-joint, or to perform an operation for the 
radical cure of varicose enlargement of the veins of the leg, it is hardly possible to use 
too much caution in this respect. In such cases the patient should not only refrain from 
exercise, but remain recumbent much longer than usual, with the limb in an elevated, 
relaxed position. In ordinary cases a few days’ confinement to the house will be quite 
sufficient. 
Tranquillity of mind is a matter of great moment. All business cares should be laid 
aside, and no outward troubles of any kind be permitted to obtrude themselves during 
this probationary period. No unpleasant forebodings concerning the result of the opera- 
tion should be indulged in; or, if this be inevitable, the surgeon should exert himself to 
the utmost to assuage and mitigate them by proper explanations. In a word, it is his 
duty, in all cases, to encourage the timid and console the desponding by every means in 
his power. Many of our patients are from abroad, away from home and friends, and, 
therefore, peculiarly in need of sympathy. 
Nothing depresses the powers of life more injuriously, or interferes more effectually with 
the reparative process than fear. It lowers the heart’s action, disorders the secretions, 
and not unfrequently leads to the worst results. We now and then meet with a patient 484 
OPERATIVE SURGERY. 
chap. xv. 
’who labors under an undefined apprehension that the operation to which he is about to 
submit will prove fatal. Every argument that the surgeon can employ fails to convince 
him ; the impression is firmly fixed in his mind, and, if he does not die, his convales- 
cence is sure to be tedious, and, for a long time, unsatisfactory. I never approach such 
a case without serious misgivings as to its final issue, and I question whether it would 
not be well, in sucli a condition, to refrain from the use of the knife altogether, at least 
for a time. 
The influence of fear in depressing the vital powers is well illustrated in a case that oc- 
curred, in 18G6, in the practice of Cazenave, of Bordeaux, in a man sixty years of age, 
who was about to undergo the bilateral operation of lithotomy. The surgeon was on the 
point of introducing the staff, when the patient, who had exhibited entire calmness and 
serenity during the preparations, was observed to become pale and faint, and in the course 
of ten minutes, in spite of all that was done, he expired. When this nervous syncope 
seized him, the instrument had not yet even touched him. A case of a similar nature 
occurred to Desault. An old man, suspected to be laboring under stone in the bladder, 
was about to be sounded by Civiale, but died of terror almost before the instrument had 
touched the meatus. Perrin refers to the case of a soldier, twenty-five years of age, 
affected w ith phimosis, who, reluctantly consenting to an operation, no sooner saw the sur- 
geon’s knife than he fell into a syncope and instantly expired. 
The sudden supervention of grief, after a severe operation, often gravely complicates 
the case, by weakening, if not completely destroying, the efforts at restoration. The loss 
of a relative may, in such an event, unexpectedly cost a patient his life. The shock oc- 
casioned by the mental despondency violently depresses the system ; the wound at once 
assumes an unhealthy aspect; the adhesive action is arrested; and gangrene, pyemia, 
or erysipelas finishes the wrork. 
Anger operates in a similar manner. It disturbs the various functions of the body, 
especially those of the liver, and frequently destroys the process of repair, devitalizing 
the plasma that is effused between the opposed surfaces, and causing an amount of inflam- 
mation altogether incompatible with adhesive action. 
Nostalgia is a powerful depressant; and in case of an operation, may, if not speedily 
relieved, exert a fatal effect. I am sure that I lost from this cause, in 1878, a child 
eleven years old, from whom I had removed sixteen days previously a small sequester 
from the lower part of the femur. The operation, performed under the influence of ether, 
was almost bloodless, and everything went on well during the first week, except that the 
child was terribly homesick, when gradually arachnitis showed itself, causing death at 
the end of nine days. 
I have never put off an operation on account of the particular season of the year. 
When it is recollected that the gravest accidents, requiring amputation, occur every hour 
of the day, and every day of the year, such a precaution would seem to be entirely at 
variance with common sense, if not wholly useless. Nevertheless, I should certainly not 
advise the undertaking of any serious operation in extremely hot weather, if it were pos- 
sible to postpone it without detriment to the patient. The same objection, however, does 
not lie against very cold weather, inasmuch as a good fire and a properly regulated tem- 
perature of the apartment may generally be obtained, without much trouble, even in 
midwinter and in the most rigorous climate. 
No operation, even of the most trivial nature, unless imperatively demanded, should be 
performed during the prevalence of an epidemic. This remark is particularly applicable 
to erysipelas, which, under such circumstances, is almost sure to ingraft itself upon the 
wound, much to the detriment both of the part and system. During an epidemic of this 
kind in Kentucky in 1845, ’46, and ’47, the slightest abrasion of the skin, a leech-bite, 
or the application of a blister, was often followed by an obstinate, and sometimes even a 
fatal, attack of the disease ; and the consequence was that I was compelled, for many 
months, to decline the use of the knife nearly altogether. 
Age is, as a general rule, no barrier to an operation. Even infants at the breast have 
occasionally undergone the operation of lithotomy, and in certain congenital affections, 
as occlusion of the anus and urethra, the knife is obliged to be used almost immediately 
after birth. I am, however, as will be stated in its proper place, no advocate for very 
early interference in harelip; and I am clearly of opinion that it is best, as a general 
rule, to put off all severe operations in infants as long as possible, for it cannot be denied 
that they bear the shock and loss of blood, consequent upon such undertakings, much 
worse than persons of riper years and more developed constitutions. Very old people CHAP. XV. 
PREPARATION OF THE PATIENT. 
485 
often bear operations remarkably well, and recover from their effects with surprising facility. 
Pregnancy should always be considered as a bar to the use of the knife, except in those 
cases in which it is imperatively demanded to save life, Even the extraction of a tooth 
is occasionally followed by abortion or miscarriage, from the perturbating influence which 
it exerts upon the system. 
The habits of the patient should not be disregarded in considering the question as to 
the propriety or impropriety of operative interference, for there can be no doubt that 
they frequently materially influence the result. Intemperance of every description, 
especially if long continued, always modifies the constitution, and renders it less able, 
as a general rule, to bear the shock and subsequent effects of the operation than in 
ordinary cases. In habitual drunkards mania a potu, erysipelas, and unhealthy suppura- 
tion are of frequent occurrence after the use of the knife. Huge feeders, or persons 
who are fond of the pleasures of the table, and who take little exercise in the open air, 
are scarcely less exempt from these affections. Inordinate sexual indulgence, the 
habitual loss of blood, and debility from previous suffering, often place the life of the 
patient in danger after a severe operation. Fat persons, and individuals of a doughy, 
inelastic constitution, do not bear the knife so well as the fleshy and more robust. 
The same is true, only in a still greater degree, of strumous people. Nervous, 
hysterical females are bad subjects for severe operations. Hospital patients, especially 
in the larger cities, do not, as a general rule, possess the same tolerance of the knife as 
private patients. 
Should females be subjected to operations during the menstrual period, or immediately 
before its occurrence ? Of the impropriety of such a course there can, as a general rule, 
be no doubt, and yet there may be exceptions even here. Certainly no sensible surgeon 
would extract a cataract at such a time, or remove a diseased mamma; or, in short, per- 
form any serious operation, if it could possibly be postponed. But, on the other hand, 
daily observation teaches that women who are badly hurt during the menstrual period 
often make most excellent recoveries. I should, therefore, deem it perfectly proper to 
perform at least any of the minor operations at this time, and, in fact, almost any other 
where delay might prove prejudicial. 
There are certain diseases, even some of which are not of a malignant character, in 
which surgical interference is wholly inadmissible, either for the time being, or altogether. 
I allude to those cases in which the malady demanding operation is complicated with 
other affections. Thus, in anal fistule, associated with tubercular phthisis, the knife 
should certainly not be used, unless the case is of an unusually distressing nature. The 
disease, in such a case, may be regarded as nature’s issue, the drying up of which would 
almost be sure to be followed by an aggravation of the pulmonary symptoms. In stone of 
the bladder no one operates when there is serious organic disease of the kidneys, or even 
of the bladder itself. Amputation of a limb is never performed, except in cases of acci- 
dent, when there is an aneurism of the heart; nor is the femoral artery ever tied for 
popliteal aneurism when a similar affection exists in the arch of the aorta. Persons 
laboring under diabetes do not bear operations well; their vital powers are always greatly 
depressed by the disease, and they are very liable to sink rapidly under injury, especially 
if attended with shock, or shock and loss of blood. 
Persons affected with jaundice are bad subjects for operation. The blood, under such 
circumstances, is unusually dark, oozes freely from the cut surface, and is indisposed to 
coagulate. Besides, the adhesive process rarely advances kindly when the system is in 
this condition ; the stomach and bowels are not easily regulated; and the slightest shock 
or hemorrhage may be followed by pyemia. 
Indiscriminate operations cannot be too severely condemned, as they are injurious alike 
to the patient, the reputation of the surgeon, and the true interests of science. Like a 
prudent general, the surgeon should know when to retreat as well as when to advance. 
It is difficult to conceive of anything more laudable than a bold undertaking in a case 
which must prove fatal without speedy relief. At the same time, it would certainly 
indicate a degree of weakness, it not of absolute wickedness, to attempt an operation when 
there is not the slightest prospect of benefit. 
There is a class of operations to which the French writers have applied the term com- 
plaisance, that is, operations of expediency, not of necessity. An individual, for example, 
has an infirmity, as a distorted foot, or a contracted finger, which is a source of annoyance 
rather than of suffering or even positive inconvenience; his pride is piqued, and as a con- 
sequence his mind is so incessantly disturbed by it as, perhaps, to be wholly disqualified 486 
OPERATIVE SURGERY. 
CHAP. xv. 
for business and social enjoyment. Such persons often importune the surgeon’s aid, and 
it, therefore, becomes a nice question how he should govern himself. Shall he advise an 
operation, and run the risk of destroying his patient, or shall he refrain, and persuade 
him to bear his cross, for such it actually is? There can, I think, in general, be very 
little difficulty in arriving at a proper conclusion in such a state of things. For myself, 
I can see no difference between the physical suffering that is induced by a diseased bone 
and the mental distress that results from a deformed foot; so far as their effect upon the 
comfort and happiness of the individual is concerned they are precisely on the same level, 
and hence, if it be right and proper to amputate in the one case, why should it not be in 
the other? If a young man has a varicocele, even of moderate size, and it completely 
destroys his happiness and usefulness, not by its physical but by its mental effects, is it 
not our solemn duty to attempt relief by an operation, although the attempt should jeopard 
his life? I must confess, I should not hesitate as to the line of conduct to be pursued 
under the circumstances; at the same time, however, I should not omit to warn my 
patient of the risk he would be likely to run, and if, after a thorough explanation of the 
whole matter, he should still persist in his desire to be operated on, I should use every 
possible precaution, by a course of diet, rest, and other means, to put his system in the 
best possible condition for sustaining the shock of the approaching ordeal. Operations 
involving the same principle, although not the same risk, are of daily occurrence, and few 
surgeons hesitate to perform them: I allude more especially to the division of tendons in 
club-foot and strabismus, the extraction of the crystalline lens in cataract of one eye, 
when the other eye is sound, and other analogous affections. 
Are double synchronous operations, or operations performed in immediate succession, 
justifiable? There can be no hesitation in answering this question affirmatively when the 
case is a comparatively simple one, as, for instance, when a man has several sebaceous 
tumors upon the scalp, or two or three small fatty tumors upon his back and shoulder. 
Here there could certainly be no impropriety, provided the system is in a sound condition, 
in extirpating all the morbid growths at one sitting. A similar course would be very 
proper if a hydrocele coexisted with a phimosis, a club-foot with a strabismus, a hemor- 
rhoid with a polyp of the rectum. Even synchronous amputations are not unfrequently 
performed, and, occasionally, with the most happy results. A thigh has sometimes been 
cut off, and a skull trephined, at one sitting. Nevertheless, it is a good rule, one, indeed, 
which should seldom, if ever, be violated, not to perform two severe operations simulta- 
neously or in rapid succession, if it be possible to avoid it, inasmuch as the shock and loss 
of blood thus entailed might be followed by fatal collapse or destructive inflammation. 
The rule is particularly applicable to chronic cases; in injuries, on the contrary, as gunshot 
wounds, railway accidents, and compound fractures, the surgeon may have no choice, as 
delay may then be altogether out of the question. 
Assistants—There are few operations which a surgeon can perform alone; in general, 
he is obliged to have assistants, and the number of these must necessarily vary in different 
cases and under different circumstances. Sometimes only one is required; at other 
times two, three, four, or even half a dozen will hardly suffice. The more simple an 
operation the less aid will commonly be necessary. In lithotomy an assistant holds the 
staff, two others support each a leg, one administers chloroform, another takes charge of 
the patient’s hands, and a sixth presents the surgeon his instruments. In extracting a 
cataract, the operator usually requires only one assistant, to support the head and upper 
eyelid. Operations on children, especially when we are not permitted to employ anaes- 
thetics, are often peculiarly embarrassing, and demand an unusual amount of aid for their 
successful execution. 
The beauty, elegance, and rapidity, nay even the success of an operation, are often 
marred by the awkwardness of the assistants. To act well their part, they should be 
thoroughly acquainted with the different steps of the operation which is about to be per- 
formed, as well as with the nature and relations of the structures involved in it, so as to 
be able to anticipate every thought and wish of the principal. It is not necessary that 
they should be compelled, like so many Thespians, to rehearse the part which they are 
expected to play in the approaching task ; but they should be thoroughly instructed in 
their business, and perfectly understand their duty, which should always be carefully 
explained and assigned beforehand. Nothing can be more awkward for a surgeon than 
to stop in the midst of an operation to ask for a knife, sponge, or ligature ; once begun, 
everything should proceed with the utmost regularity, and without the slightest interrup- 
tion from any cause. Good, well-trained assistants are, unfortunately, not always to be 
obtained; I he older members of the profession are too much occupied to afiord their CHAP. XV. 
DUTY OF THE SURGEON. 
487 
services, and the younger are too often ignorant of the duties required of them. These 
obstacles to success are usually much less in hospital than in private practice. 
Duty of the Surgeon When the surgeon has perfect control of his time, as he almost 
always may have, except in cases of emergency, he generally selects a particular hour for 
performing the operation. The best period of the day, at least in this country, is from 11 
to 3 o’clock, as he will then have the advantage of a good light, and also be in better 
trim for the discharge of his duty. An operation, especially an important one, should 
never, as a matter of choice, be performed late in the afternoon, or in cloudy weather; 
for, should hemorrhage arise, it might be very difficult to arrest it, on account of the want 
of good light, so indispensable on such occasions. 
Artificial light may sometimes be used to great advantage in certain operations; and 
occasionally the aid of reflected light, as when it is thrown from the mirror of an ophthal- 
moscope, is of great service, especially in deep wounds, as those made in lithotomy, the 
ligation of the innominate and subclavian arteries, and the extirpation of tumors of 
the neck. 
At the hour specified for the operation everything should be in its place; the assistants 
should attend with military punctuality; the table should be properly prepared ; the 
anaesthetics, ammonia, and brandy, instruments, ligatures, sponges, water, and towels, 
should all be at the precise spot where they are required ; in short, nothing should be 
wanting, but everything be at hand, and arranged in the most perfect order. I have 
heard of a surgeon, engaged in an amputation, making his flaps, and asking for his saw, 
which had been left in an adjoining room ! A lithotomist performed the lateral section, and 
was about to introduce the forceps to extract the stone, when, lo and behold, the instru- 
ment had not been put on the tray! Such blunders might create a smile, if they did not 
sometimes involve serious consequences. It need hardly be added that all these prepara- 
tions should be made in an adjoining room, away from the patient; it is enough for him 
to know that he is about to suffer, without seeing the instruments of his torture deliberately 
spread out, one after another, before his eyes. “ The best general,” said one of the greatest 
who ever lived, “ is he who makes the fewest mistakes. Victory does not necessarily 
crown the best devised plan, but the want of one is almost certain to entail defeat.” 
Of the precise time, as to the day and hour, of the operation, the patient should usually 
be kept in ignorance, as the information, if made, could hardly fail to exert a perturbating, 
and, consequently, a prejudicial, influence upon the mind, and, through it, upon the 
general system. It is only in the milder cases that this intelligence should be communi- 
cated. There is, however, much difference in this respect in different individuals; for, 
while some would shrink from the disclosure, and be, perhaps, seriously affected by it, 
others will not only be indifferent to, but absolutely court it. 
Position of the Patient and Surgeon—The position of the patient, the surgeon, and 
the assistants must vary, of course, in different cases, and can be discussed here only in 
a general manner. When chloroform is to be given, absolute recumbency is required, to 
guard not only against delay, but also against the occurrence of serious mishaps. But, 
apart from this consideration, the horizontal posture should always be preferred whenever 
the operation is likely to be protracted, or attended with much shock and loss of blood. 
In other cases, again, as in lithotomy, the operation cannot be performed in any other 
posture than in the recumbent. In amputating the thigh and leg, as well, indeed, as the 
arm and forearm, the patient always lies down, not only on account of apprehended 
weakness, but because it is always easier, when he is thus placed, to hold the limb and 
control hemorrhage. In lacerating a cataract, the patient generally sits in a chair, with 
his head supported upon the breast of an assistant; in operating on harelip, the child 
usually sits upon an assistant’s lap, the head being firmly held by another assistant, stand- 
ing behind or by the side of the first. In lithotomy, the patient lies on his back, with 
the breech projecting over the edge of the table: two assistants support the legs, another 
holds the staff’, a fourth takes charge of the sponges, and a fifth administers chloroform, 
while the surgeon sits on a low stool in front of the perineum, or, as I usually prefer, 
rests on one of his knees. Now that anaesthetics are so much in vogue, it is seldom that 
we are obliged to tie our patients, or to roll them up in sheets or aprons, as was the custom 
prior to the discovery of these agents. 
The more important operations are generally most conveniently performed upon a firm, 
narrow breakfast table, well covered with blankets or comforts. Several pillows and 
folded sheets, and, if the ease is likely to be a bloody one, a piece of soft oil-cloth, should 
be at hand, with a tray filled with sand or sawdust, to receive the discharges. Sometimes 
a lounge or sofa may conveniently be used; and, in many instances, the edge of the bed 488 
OPERATIVE SURGERY. 
chap. xv. 
answers very well. The patient should have as few clothes on as possible, for two reasons: 
first, that his dress may not be unnecessarily soiled, and, secondly, because it will afford 
him more freedom in breathing. 
The surgeon and his aids should be careful, during the operation, that they do not, on 
the one hand, inoculate themselves with the discharges of the patient, and, on the other, 
that they do not communicate disease to him through their own persons, as might readily 
happen if they have recently been engaged in the dissection of patients dead of erysipelas, 
phlebitis, pyemia, or diffuse inflammation, especially of the peritoneum and of the pelvic 
veins of lying-in females. That there is frequently, if not generally, a virulent poison 
present in these affections, the influence of which may readily be disseminated by means 
of the hands and clothes, is fully established, and, therefore, every possible care should 
be taken to guard against all such contingencies. Accoucheurs often communicate disease 
and death in this manner from one parturient woman to another, and there are few practi- 
tioners extensively engaged in operative surgery, whether in private or public, who have 
not had similar experience among their own patients. A number of cases have been 
recorded in which surgeons in amputating limbs and excising tumors have contracted 
fatal diseases by the inoculation of their hands. In performing any delicate operation the 
hands should always be well washed and the finger nails thoroughly cleaned as a pi’elimi- 
nary measure, in order that, no dirt or perspiration may be deposited upon the wound, and 
thus become a source of irritation, interfering with the reparative process. 
Operation.—Everything being thus prepared—the assistants being at their posts, the 
instruments arranged upon a tray in the order in which they are likely to be required, the 
parts divested of hair and dressings, and the patient fully under the influence of an 
anaesthetic—the operation is proceeded with, slowly, deliberately, and in the most orderly, 
quiet, and dignified manner. All display, as such, is studiously avoided ; ever remember- 
ing, in the language of Desault, that the simplicity of an operation is the measure of its 
perfection. No talking or whispering should be permitted on the part of the assistants, 
and, as to laughter, nothing could be in worse taste, or more deserving of rebuke. Every 
important operation should be looked upon as a solemn undertaking, which may be followed 
in an instant by the death of a human being, whose life, on such an occasion, is often 
literally suspended by a thread, which the most trivial accident may serve to snap asunder. 
The time occupied in performing an operation is a matter of some moment, but not so 
much, perhaps, as is commonly supposed. When a patient is unconscious, whether from 
cerebral oppression, or from the use of an amesthetic agent, it is of very little consequence, 
other things being equal, whether the operation lasts five minutes or ten minutes, provided 
it is well executed, which it certainly cannot always be when we aim at great speed. Le 
Cat, it is said, lithotomized half a dozen patients in nearly twice as many minutes, and 
the result was that he lost nearly every one. Prior to the application of amesthetics to 
the relief of suffering, rapidity was most commendable, inasmuch as it served to prevent 
shock and pain, although I am well convinced that it was often secured at the expense of 
much subsequent mischief, if not immediate detriment. The maxim of the schools has 
always been cito, tuto et jucunde; but, as it respects the first of these injunctions, it may 
be added, in the language of Cato, sat cito si sat bene. 
Accidents during Operation The next topics to be considered are the accidents which 
are liable to take place during the operation, and the best methods of avoiding or meet- 
ing them. These are, first, hemorrhage, and, secondly, shock. 
The amount of blood lost during an operation may be very small when measured by 
ounces, but very large in relation to its effects upon the system. Much will depend, in 
every case, upon the state of the. constitution, and the temperament, habits, and health 
of the patient. A hemorrhage which may affect one individual very slightly, if, indeed, 
at all, may affect another most seriously and even fatally. A good deal, again, will depend 
upon mere idiosyncrasy, and upon the presence or absence of epidemic disease, which, as 
has already been intimated, generally impresses itself, to a greater or less extent, upon 
every individual in the community in which such disease prevails. Anything like a copious 
loss of blood is, as before stated, a great evil, and should, therefore, always if possible, be 
prevented. I cannot agree with those who think that the loss of twelve, sixteen, or 
twenty ounces will be likely to be beneficial, even when there is unusual vigor of constitu- 
tion. If there be any undue vascular repletion, it can always be relieved, if the neces- 
sity arises, after the operation is over. In all cases, therefore, I deem it to be our duty 
to guard against hemorrhage as much as possible. 
In amputations, the removal of necrosed or carious bone, the excision of bones and CHAP. XV. 
OPE RATION. 
489 
joints, the extirpation of morbid growths, and all other surgical procedures upon the 
extremities, the field of operation may be rendered perfectly bloodless by the use of 
Esmarch’s apparatus, which, as represented in figs. 204, 205, consists of an elastic band- 
age and an elastic flat band, the latter being preferable to the rubber tubing originally 
Fig. 204. 
Fig. 205. 
employed for constricting the limb above the last turn of the bandage. The bandage is 
applied by spiral turns, commencing at the toes or fingers, and when a sufficiency of 
the extremity has been covered, the band is wound rather firmly several times round the 
limb, and secured by the hook and chain. When the bandage is removed, the necessary 
incisions can be made without the loss of blood. Before the use of the compressing band, 
the constriction excited by the rubber cord was not infrequently followed by sloughing of 
the edges of the wound, but I have not met with examples of a similar nature since I have 
resorted to the former contrivance. If the band be too firmly applied it paralyzes the 
vasomotor nerves of the part, so that, after its removal, and the ligation of the principal 
arteries, there is free and prolonged bleeding from the smaller branches, thus leading to 
the necessity of employing a much larger number of ligatures than when the operation is 
performed according to the old method. Even when the constriction is merely sufficient 
to arrest the circulation in the limb, there is always pretty free capillary oozing, for the 
control of which Esmarch relies upon elevating the limb before the band is removed, 
as well as for half an hour after the wound has been dressed; Riedinger, to produce 
a similar effect, applies the faradic current to the wound. I myself have never 
had occasion to resort to these annoying and troublesome measures, as I have always 
found that the parenchymatous hemorrhage is readily controlled by retaining a cloth or 
sponge wrung out of water at a temperature of 110° to 115° Fahr. in the wound, and 
afterwards loosening the band very slowly. In operations for necrosis the bleeding is 
readily arrested by stuffing the wound with oiled lint before the band is removed. An 
ordinary bandage and tourniquet, such as I have used for the last forty years, in all my 
larger amputations, will, if properly applied, empty the vessels sufficiently for all practical 
purposes, and effectually protect the parts from this reaction, always so trying to the sur- 
geon, if not fraught with danger to the patient. This method of preventing hemorrhage is 
contraindicated when a limb is the seat of gangrene or of collections of septic fluids, 
which might be pressed into the veins and lymphatic vessels and thus carried into the mass 
of circulating blood. 
When the apparatus of Esmarch is not used, it is not necessary, or even proper, to tie 
every vessel as fast as it is divided. A well-trained assistant will generally obviate this 
necessity by compressing the bleeding orifice the moment the knife lias swept beyond it, 
and by the proper exercise of this dexterity a large tumor may often be removed before a 
single ligature is applied. If the bleeding, however, be not controllable by this means, 
measures must be adopted to arrest it without delay by ligating the principal vessels from 
which it proceeds. 
It is seldom, at the present day, that a patient sustains anything like serious shock 
from an operation, even if it be comparatively severe and protracted. The use of anesthe- 
tics, if it do not always effectually prevent, generally restricts it within the limits of tol- 
erance, and thus saves the surgeon a vast amount of trouble and anxiety. It is not, 
however, to be forgotten that the very means which are employed to prevent pain and 
shock may themselves induce severe, if not fatal, prostration. Hence, as will be seen by 
and by, too much caution cannot be used in their administration, the effects of the remedy 
being most carefully watched throughout, so that any symptom denotive of danger may 
instantly be recognized and counteracted. By keeping the patient perfectly recumbent 
Esmarch’s Apparatus. 490 
OPERATIVE SURGERY. 
chap. xv. 
and providing for tlie free admission of air into the lungs, all mischief may, in general, be 
happily avoided. The syncope, caused by the loss of blood, is met by a depressed position 
of the head, by means of the fan, by dashing cold water upon the face and chest, by hold- 
ing smelling-bottles near the nose, and, in severe and alarming cases, by sinapisms to the 
extremities, spine, and precordial region, aided, if necessary, by the use of stimulating 
injections, as brandy, turpentine, ammonia, or mustard. 
Dressings and After-Treatment The operation being over, the next thing to be done 
is to adjust the dressings ; these should always be as light as possible, and applied in such 
a manner as to insure the greatest chance for union by the first intention. The question 
has been much agitated, of late years, whether the dressings should be applied at once, 
the moment the knife has accomplished its object, or whether the parts should be per- 
mitted to remain free for several hours, to afford them an opportunity of contracting and 
becoming glazed with plastic matter. Much might be said in favor of both methods. The 
proper rule of practice, I think, is to steer a middle course, adopting neither plan exclu- 
sively. In large wounds, as those, for example, left in amputations of the thigh, leg, or 
arm, and in the extirpation of large tumors, the best plan always is to keep the parts open 
for three, four, or five hours, or until all oozing has ceased, and the raw surface has become 
incrusted with plastic matter, a light, porous towel, properly folded and frequently wrung 
out of cold water, being kept constantly applied to promote these occurrences. If, under 
such circumstances, approximation be effected immediately after the operation, the surgeon 
will often be compelled, a short time afterwards, even when he has taken the greatest pos- 
sible care to secure the vessels, to remove his dressings, in order to arrest the flow of blood ; 
a procedure which is generally not less painful and alarming to the patient than disagree- 
able and vexatious to the attendant. If, on the other hand, the wound is small, the best 
plan, I conceive, is to bring the edges together at once, as this saves both time and 
anxiety. 
The dressings being applied, the patient is carried into his bed, previously prepared for 
his accommodation, and placed in such a position as will best promote his comfort and the 
reunion of the divided parts. Feathers and heavy quilts are to be carefully avoided ; and, 
in general, it will be well, especially if there is a probability of there being much dis- 
charge, whether of blood, secretion, or excretion, to protect the bedding with a piece of 
thin, soft oil-cloth, spread beneath a folded, movable sheet. The affected parts are placed 
in an elevated and relaxed position, and maintained, throughout, in a cool, comfortable 
state. The diet must be light and unirritant, the drink cooling and palatable, and the 
temperature of the apartment from 65° to 72° Fahr. All unnecessary conversation 
should be avoided; and no persons, except the nui-se and the immediate friends of the 
patient, should be permitted to enter the room during the first twenty-four hours after the 
operation, or, in cases of great danger and severity, not until a much longer time. 
When an operation is performed in private, in the patient’s own room, or in the apart- 
ment which he is afterwards to occupy, all extraneous material, as the table, sheets, towels, 
basins, and cloths, should be removed as speedily as possible after the work is over, and 
everything set in pi'oper order, so that the patient, when he wakes from the effects of 
the anaesthetic, may find nothing, as he casts his eyes around him, to shock his feelings or 
offend his taste. It is impossible to bestow too much attention upon the aesthetics of the 
sick-room. 
When the operation is at all severe, my invariable rule is to administer a full anodyne, 
generally a fourth or a third of a grain of morphia hypodermically immediately after it is 
over, or even sometimes an hour or two before it is commenced. The object is not only 
to allay pain, which is always a great desideratum, but to induce sleep and tranquillity of 
the system; in other words, to put the part, body and mind, all in a state of absolute 
repose for at least the first twenty-four hours after the use of the knife. By a full dose of 
morphia, I mean not less than one-third of a grain ; a smaller quantity than this would 
only serve to fret and worry the patient instead of composing him. In cases of unusual 
severity, I do not hesitate to give half or even two-thirds of a grain, never forgetting 
that excessive suffering always establishes a certain amount of tolerance to the use of 
anodynes. 
Too much attention cannot be bestowed upon the patient’s diet. If the operation has 
been at all severe, or attended with unusual shock and loss of blood, he must be fed, not 
starved, in order to enable the system to reinstate itself as promptly as possible into its 
former condition, by the manufacture of blood and nervous fluid, both, perhaps, frightfully 
expended during the previous contest, and now in danger of being still further exhausted 
by the traumatic fever and the tumultuous action of the heart. The vessels must be CHAP. XV. 
DRESSINGS AND AFTER-TREATMENT. 
491 
replenished ; the brain and spinal cord supported. The most suitable articles for this 
purpose are milk and stale bread, with the free use of brandy, followed, in a day or two, 
by animal broths, beef essence, rich soups, and the lighter kinds of meats. Subacid 
fruits will also generally prove both grateful and nourishing. The drink should consist 
of iced water, either pure or acidulated, as may be most agreeable to the patient. A cup 
of tea or coffee is often exceedingly soothing and refreshing soon after a severe operation. 
Starvation after violent shock and loss of blood is frequently followed by the worst conse- 
quences, from the tendency in the system to run into erysipelas, pyemia, and hectic fever, 
independently of its incompatibility with the adhesive process. 
The effects of diet upon mortality after injuries and operations are well illustrated by 
what occurred among the wounded soldiers that were received in the different hospitals of 
Paris in 1814. The table, drawn up by Malgaigne, included French, Prussians, Aus- 
trians, and Russians, the latter of whom had a liberal allowance of bread, vegetables, 
meat, wine, and even brandy, while the others were subjected to a strict dietetic regimen. 
The mortality among the French soldiers was 1 in 7, of the Prussian 1 in 9, of the Aus- 
trian 1 in 12, and of the Russian 1 in 27; an astonishing difference if we assume, as we 
are authorized, that it was due solely to a difference of treatment, and not to any pecu- 
liarity in the nature of the wounds, the surgical treatment, or the air of the hospitals in 
which the soldiers were accommodated. 
But patients must not be fed indiscriminately after operations; when the individual is 
young and robust, perfectly temperate in his habits, and, above all, when he has not suf- 
fered severely from shock or loss of blood, his diet should be restricted and of the blandest 
character for a number of days, or, in fact, until the wound left by the knife is in great 
measure healed. Improper indulgence, under such circumstances, cannot fail to light up 
a tire which hardly anything afterwards may be able to extinguish. 
If the patient has sustained severe shock or loss of blood, he should not only be well fed 
from the very beginning, but promptly subjected to the use of tincture of chloride of iron, 
in doses varying from twenty to thirty drops every three or four hours, as a preventive of 
erysipelas and pyemia, so liable to occur under such circumstances. Quinine may often 
be advantageously conjoined with the chalybeate, especially if the patient has been 
affected with malarial disease. Anodynes should also be freely exhibited. 
Attention to the temperature of the patient’s apartment is often a matter of great 
moment; in general, it will be best to regulate it by the thermometer, especially in opera- 
tions on the respiratory organs, and after the extirpation of ovarian tumors. Everything 
like a direct draught must be carefully avoided; and in wet weather it will be well, espe- 
cially if the moisture of the air be combined with cold, to employ artificial heat, while 
the doors and windows are sufficiently opened to secure proper ventilation. 
The dressings should not be disturbed too soon, or oftener than is absolutely necessary 
to the comfort of the part and system. As a general rule, they require to be changed 
more frequently in warm than in cold weather, and in copious than in slight discharge. 
The proper practice is never to meddle with them so long as they answer the purpose for 
which they are applied. The sutures and adhesive strips should be removed with the 
utmost care; the substitute dressings should be prepared and ready for use before the old 
are taken off; the sponge should be employed with the greatest gentleness; in a word, all 
rude manipulation should be most studiously avoided. No bandage, however thoroughly 
washed, should be used twice, as it is liable, from the retention of matter, to become the 
carrier of infection, especially in large suppurating wounds and in compound fractures and 
dislocations. For the want of this precaution many a patient has perished from pyemia 
and erysipelas. 
Some of the above precepts may seem trivial; but I am sure that they are of the 
greatest importance, and that the want of their observance is often followed by the worst 
consequences. It is a much easier matter to talk a patient to death, or to retard his 
recovery, after he has undergone a severe operation, or sustained a violent injury, than 
most people imagine. If symptomatic fever arise, or if the parts exhibit evidence of 
overaction, prompt recourse must be had to the usual antiphlogistic remedies, employed in 
a decided yet cautious manner, lest they produce harm instead of good. 
The after-treatment should always, if possible, be suplerintended by the surgeon himself; 
his duty is not over with the operation; it ceases only with the cure or the death of his 
patient. “ The practice,” remarks an eminent authority, “ of performing a serious opera- 
tion, and leaving the after-treatment to others, has, in my knowledge, repeatedly proved 
disastrous. The medical treatment, a duty not less responsible than the operative, belongs 492 
OPERATIVE SURGERY. 
chap. xv. 
to tlie surgeon; and, indeed, to be employed merely as a handicraftsman, conveys an 
imputation at which the dignity of' a scientific mind revolts.” 
An operation, if well performed, does not, in ordinary eases, require repetition. It is 
only, as a general rule, where it has been executed in a slovenly and imperfect manner 
that such a step will be likely to be necessary. Such an error is the more to be deprecated 
because the repetition of the operation may seriously, if not fatally, compromise the 
patient’s life, after he has successfully surmounted the hazards of the first. If a tumor 
has been well excised, a limb properly amputated, an artery carefully ligated, there will 
seldom be any necessity for going over the same ground a second time. If, now and then, 
the reverse is the case, it only serves as an exception to an important rule. Repetition 
of an operation is most frequently required in malignant diseases, after lithotomy, and in 
amputations for the relief of gunshot, railway, and other severe accidents, where the 
injury often extends much farther up the limb than the eye can discover, and where, 
consequently, the most enlightened and skilful surgeon may be at fault. 
Pei’sons often submit with alacrity to the repetition of an operation when it promises to 
prolong life, or to afford even temporary relief from suffering; and recovery, under such 
circumstances, is sometimes very surprising. In a case of recurrent sarcoma of the 
mammary gland, described in a previous chapter, not less than twenty-three separate 
operations were performed before a cure was finally brought about. In a case of spindle- 
celled sarcoma of the neck, I excised the morbid growth five times, at varying intervals, 
with the effect of prolonging life for upwards of five years. Examples of lithotomy have 
occurred in which the patient was cut successfully four, five, six, and even seven times, 
as in the celebrated case of Grangeret. 
Sources of Danger after Operations The great sources of danger, after a severe ope- 
ration, are, first, excessive depression of the system from shock and loss of blood ; sec- 
ondly, traumatic fever; thirdly, undue inflammation of the parts; fourthly, secondary 
hemorrhage ; fifthly, erysipelas ; sixthly, pyemia ; seventhly, tetanus ; and, lastly, consti- 
tutional irritation. 
a. The prostration, consequent upon an operation, is usually denoted by great pallor of 
the countenance, feebleness of the pulse and respiration, coldness of the extremities, 
yawning and sighing, partial blindness, dizziness, noises in the ears, restlessness, thirst, 
nausea, and even vomiting. To meet these symptoms, all that is generally necessary is 
to place the patient recumbent, to use heat, friction, and sinapisms, to allow free access of 
air, and to administer stimulants, as brandy, or brandy and ammonia, by the mouth, if 
the power of deglutition still remains, or, if not, by the rectum, in the form of enemata. 
A full anodyne will usually form a most valuable adjunct to these remedies, and should 
seldom, if ever, be omitted. Great care, however, must be observed in the management 
of these cases, lest violent reaction follow the depression, and hurry the patient on to a 
fatal termination. It is only in instances of extreme prostration that stimulants should 
be given boldly and freely, and without any regard to consequences in respect to the parts 
involved in the operation. 
18. Great distress is often experienced after operations, especially if unusually severe or 
protracted, from nausea and vomiting, attended with more or less prostration, and not un- 
f’requently very difficult of management. The exciting causes of this derangement are 
not always obvious, but in most of the cases that have been under my charge, the trouble 
was due to the effects of the anresthetic, taken in excess, either from want of care in its 
administration, or want of proper cooperation of the patient. Ether, in particular, is 
liable to produce such effects, often extending over a period of many hours, or even sev- 
eral days. Occasionally the gastric disturbance depends upon the anodynes given to pre- 
vent or relieve pain, and promote sleep after the operation; and, in some cases again, it 
is evidently due to disorder of the secretions brought about by shock and loss of blood. 
A malarial state of the system, constipation of the bowels, a redundancy of acid or of bile 
in the stomach, organic disease of the liver or kidneys, and excessive thirst, may be re- 
garded as so many predisposing causes. When the vomiting is very severe or protracted, 
it may lead to very serious, if not fatal, exhaustion. The treatment must be regulated by 
the nature of the exciting cause. In my own practice, I have generally found the best 
remedy to be a hypodermic injection of morphia, with the internal use of ice, and ice ap- 
plied to the region of the stomach. Chloral and bromide of potassium are also valuable 
articles ; and the use of bicarbonate of sodium in peppermint water is especially indicated 
when the distress depends upon the presence of acid in the stomach. When the patient is 
harassed with flatulence, iced champagne often affords prompt relief. Occasionally a mus- 
tard emetic answers an excellent purpose, especially in bilious vomiting. Passing a cloth CHAP. XV. 
TRAUMATIC FEVER. 
493 
with a few drops of nitrite of amvl upon it rapidly before the nose, sometimes acts like a 
charm. In some cases, again, an irritating enema does more good in quieting the stomach 
than anything else. Now and then the most satisfactory remedy is a large dose of calomel. 
The best food is milk with lime-water and hot broths, taken in small quantity and frequently 
repeated. 
y. More or less fever must almost necessarily follow every severe operation, offering 
thus an additional source of suffering and danger to the patient, and of anxiety to the 
surgeon. To this disease the term traumatic is usually applied; the older writers called 
it bed or wound fever, and the late Sir James Y. Simpson gave a very excellent account 
of it under the name of surgical fever. 
Fever generally sets in within the first six or eight hours after the operation, and is 
characterized by a flushed appearance of the face, a frequent, quick, and irritable state of 
the pulse, elevation of temperature, dryness of the skin, restlessness, and thirst, which is 
often excessive, especially after profuse losses of blood. In some cases there is extreme 
jactitation, with nausea, if not actual vomiting, and a tendency to delirium, or a confused 
and bewildered condition of the intellect. The breathing is generally somewhat hurried, 
and slight mucous rales are often present. The appetite is impaired or entirely wanting, 
the bowels are constipated, and the urine is scanty, high-colored, and often offensive, 
being surcharged with saline matters and occasionally even slightly albuminous. Now and 
then the disease is ushered in by distinct rigors. After the fever has continued for some 
time, a tendency to remit appears; the heat, thirst, and restlessness diminish, the pulse 
and temperature descend, the gastric distress vanishes, and the skin becomes covered with 
a gentle moisture, which often increases to profuse perspiration. 
The duration of traumatic fever varies from a few hours to a number of days. In the 
milder cases it is generally very evanescent, while in the more severe it is often very pro- 
tracted, and is then usually attended with regular vesperal, if not also matinal, exacerba- 
tions. Not unfrequently the disease disappears entirely for a few days, and then recurs, 
with more or less violence, the attack being provoked either by some dietetic or other 
indiscretion on the part of the patient, or by some change of the system, as the arrest of 
an important secretion, or the commencement of blood-poisoning. 
The causes of surgical fever are sufficiently obvious. Every operation of the slightest 
severity, acts as a disturbing agent, depressing the vital powers, and deranging, as a 
direct and inevitable consequence, all the secretions. Familiar illustrations of these oc- 
currences are daily met with even in very slight operations, as the lancing of boils, the 
extraction of teeth, and the abstraction of blood. The least shock, however induced, is 
sure to be followed by more or less general disorder, and it is hardly necessary to state 
that the amount of this disorder is always materially augmented when, in addition to the 
nervous lesion, there has been more or less copious hemorrhage. Nothing so rapidly or 
so powerfully irritates and frets the vascular and nervous systems as these two circum- 
stances. The heart evinces its suffering first, by the feebleness and irregularity, and, 
after the occurrence of reaction, by the frequency and rapidity of its contractions. The 
nausea and vomiting, the excessive prostration, the yawning, and confusion of intellect, 
not to mention other symptoms, are unmistakable signs of the shock, or loss of power, 
sustained by the great nervous centres. The use of anaesthetics, doubtless, often con- 
tributes to the production of traumatic fever, by the disturbance which it occasions in the 
general system. 
Now, if we take all these circumstances into view, and the fact that thousands of 
patients are subjected to operations without due preparation of the system, or, indeed, 
any preparation at all, as in cases of primary amputations, trephining, and the ligation 
of the larger arteries for the arrest of hemorrhage in gunshot and other wounds, it is 
certainly not necessary to invoke the agency of blood-poisoning, as is of late so frequently 
done, to account for the occurrence of traumatic fever. These causes are all sufficient to 
create the most violent disturbance ; or, in other words, to set the whole system in a 
perfect state of ferment, subverting all its functions, and thus occasioning an amount of 
reaction capable of destroying life in a few hours, or, at all events, in a few days. While 
this perturbation is progressing, other and still more serious consequences may ensue, as 
erysipelas, pyemia, and effusions into the splanchnic cavities, the result of disordered se- 
cretion, and of the retention of hurtful matter, eventuating in a diseased state of the 
blood, and in a px-edisposition to local inflammation in parts more or less remote from the 
seat of the original injui-y. The constitutional derangement will, of course, be materi- 
ally increased if, in addition to these disturbing agencies, there is an absorption or ingi-ess 
of foul secretions into the system, constituting septicemia, or blood-poisoning. 
The danger in ti’aumatic fever is often very gi’eat, and it is, therefore, impossible to 494 
OPERATIVE SURGERY. 
chap. xv. 
watch the patient too attentively. The risk will be particularly imminent if the disease 
is very violent, or the system was much prostrated prior to the operation. The danger 
will then be twofold ; first, from constitutional irritation and fatigue of the heart, leading 
to paralysis of its fibres; and, secondly, from internal congestion and local inflammation. 
The proper remedies are cooling drinks, taken in moderation, or ice, if there be nausea, 
or gastric oppression ; sponging the surface with cool or tepid water ; mild laxatives ; and 
the neutral mixture, or camphor water, with a minute quantity of antimony and morphia, 
to promote diaphoresis. If the symptoms are disposed to continue, more active measures 
may be required, especially purgatives, assisted, perhaps, by a few grains of calomel, 
particularly when there is marked disorder of the secretions. The lancet can seldom, if 
ever, be needed in any case. Leeching, cupping, and blistering may be necessary when 
there is congestion, or impending inflammation, of important internal organs. Local 
remedies must, of course, not be neglected. If the fever is obstinate, quinine will be 
indicated, combined, if there be profuse perspiration with a tendency to hectic, with iron 
and elixir of vitriol. The greatest possible attention is paid to cleanliness and ventilation. 
This febrile commotion of the system is sometimes very deceptive, exhibiting an ap- 
pearance of great violence, when in reality it is most slight, promptly yielding to the 
most simple remedies, or subsiding of its own accord. It resembles a sudden and violent 
storm, quite alarming, but altogether transient and harmless. 
5. The resulting inflammation will rarely exceed the adhesive limits, if proper care 
has been taken to prepare the patient for the operation, and the parts have not been too 
roughly handled during its performance. But prevention is not always possible, and 
hence the wound should be diligently watched, lest it be assailed, and even overwhelmed 
before the patient and his attendants are aware of the fact; for it should be remembered 
that the morbid action is not always characterized, under such circumstances, by the 
usual symptoms ; there may even be an entire absence of pain and tension, perhaps even 
of discharge. Great vigilance, therefore, is often necessary to detect the earliest inroads 
of the disease, and to counteract its progress. Of course, all officious interference is 
avoided, and nature is carefully protected in the maintenance of her rights and privileges. 
The moment overaction is perceived, the dressings are either removed, or, at all events, 
slackened, suitable means being substituted. Of these the most important consist of 
leeches, water-dressings, and cataplasms, either simple or medicated, according to the 
exigencies of the case. If matter form, free vent is afforded, either by a change of posi- 
tion of the parts, or by puncture and incision. Constitutional treatment, of course, 
receives due attention. 
a. Secondary hemorrhage may come on within a few hours after the adjustment of the 
parts, or it may be postponed to a later period, even to a few days or weeks. It may be 
arterial or venous, slight or profuse, transient or persistent, as in the primary form of the 
accident. The most common causes are, imperfect ligation of the vessels, defective dress- 
ing, sloughing, and premature detachment of the ligatures. Whatever they may be, they 
should be carefully sought out, and at once counteracted by appropriate measures. The 
occurrence is always to be deprecated, because it has a tendency, not only to alarm the 
patient and his friends, but to impede and even to prevent the adhesive process, requiring, 
as it not unfrequently does, the reopening of the wound for its successful management. 
Fortunately, however, it is, in general, easily avoided, especially if proper attention be 
paid to the dressings and after-treatment. 
f. Erysipelas is most apt to occur in persons of intemperate habits, or of a broken con- 
stitution, and usually makes its appearance within the first three days after the operation, 
generally at the site of the wound, or in the parts immediately around. Its presence is 
always denotive of disorder of the digestive apparatus, and hence one of the first things 
to be done is to administer medicines designed to clear out the bowels and to restore the 
secretions of the liver, the mucous follicles, and the salivary glands. For this purpose 
the best articles are calomel and compound extract of colocynth, or blue mass and rhubarb, 
followed, if necessary, by saline and antimonial preparations, with anodynes to allay pain 
and procure sleep. When evidence of debility exists, free use must be made of quinine, 
either alone, or, preferably, of quinine and tincture of chloride of iron, the latter espe- 
cially being given in large and frequently repeated doses. The local treatment must con- 
sist, mainly, of dilute tincture of iodine, and solutions of acetate of lead, with punctures 
and incisions to relieve tension and afford vent to effused fluids. 
r\. Pyemia may set in almost at any time after an operation, but the most common 
period is from the third to the eighth day. It is usually ushered in by bold and well- 
marked symptoms, such as violent rigors alternating with flushes of heat, severe cepha- CHAP. XV. 
CONSTITUTIONAL IRRITATION. 
495 
lalgia, aching pains in different parts of the body, excessive restlessness, great thirst, a 
quick and frequent pulse, and inordinate dryness of the cutaneous surface. Delirium and 
extreme prostration soon ensue, and thus the case progresses from bad to worse, until, fre- 
quently in less than a week from the commencement of the attack, the patient expires in 
a state of utter exhaustion. Little is to be done for a system thus assailed. In nine cases 
out of ten the disease proves fatal. The proper remedies, at the start, especially if the 
patient is robust and plethoric, are moderate depletion, especially by leeches, the exhibi- 
tion of the milder purgatives, as calomel and rhubarb, and mercury with a view' to a 
rapid but gentle constitutional impression. When excessive prostration is threatened, 
brandy, w ine, quinine, iron, and nourishing broths are indicated, and must be admin- 
istered with a generous hand. Locally, besides leeching, iodine, blisters, and medicated 
fomentations will be advantageous: if matter form, early and free incisions are made. 
9. Tetanus is fortunately a rare occurrence after operations in this country. It is most 
common in tropical regions. In Europe and North America it is met with chiefly in dis- 
sipated persons of a broken, dilapidated constitution. It would seem that in India the 
operation of lithotomy is occasionally followed by this disease, an effect which, so far as I 
know', is very seldom, if ever, witnessed in this country. Excessive loss of blood, severe 
shock, and exposure to currents of air, undoubtedly predispose to the occurrence, wdiich 
usually shows itself within the first five or six days after the operation. The principal 
remedies, as indicated in the chapter on tetanus, are, anodynes, in full and sustained 
doses, atropia, chloral, quinine, iron, brandy, ammonia, and chloroform, with emollient 
applications to the wounded parts. 
i. Life may be assailed by constitutional irritation and profuse discharge, and that, too, 
long after all apparent danger is over. The patient gradually becomes hectic ; his appe- 
tite and sleep fail; the bow'els are irregular, at one time constipated and at another 
relaxed ; and the parts, exhibiting an unhealthy aspect, refuse to heal. Such a state of 
things, wdiich, in general, but too surely foreshadow's an unfavorable result, is to be com- 
bated upon the same principles as hectic produced by ordinary causes. 
x. Death sometimes takes place suddenly and unexpectedly after operations without any 
ascertainable cause, and where, at the time, everything seemed to be in a promising con- 
dition as to ultimate recovery. A more sad and distressing occurrence can hardly be 
imagined, and yet it is one which cannot always be avoided, no matter what precautions 
may be observed. Mere loss of blood, or shock, is not always sufficient to account for this 
unfortunate event, although in many instances it doubtless materially contributes to its 
production ; for death not unfrequently happens where no such effects were witnessed. 
Nor can it be due to the introduction of air into the veins, as, for example, when opera- 
tions are performed about the neck, inasmuch as, in this case, the patient either perishes 
instantaneously, or, at any rate, exhibits unmistakable evidence of the accident. Besides, 
this occurrence is not peculiar to operations upon the cervical region ; it has been wit- 
nessed in operations upon all parts of the body, even in some of the more insignificant 
amputations and in the removal of small tumors. When there has been much loss of 
blood, or severe shock, the event is probably due, at least for the most part, to syncope, 
or actual paralysis of the heart, preventing this organ from transmitting a sufficiency of 
blood to the brain for the due performance of its functions; and such an effect is most 
likely to take place when the patient, through neglect, w'ilfulness, or mismanagement, sits 
up in bed, or stands on the floor, thus suddenly depressing the heart’s action. In this 
way life is sometimes instantaneously destroyed in lying-in females, especially in those 
w'ho have suffered seriously from hemorrhage; and similar results are occasionally wit- 
nessed after surgical operations and accidents. In another class of cases, death is prob- 
ably caused by embolism, that is, by the formation of heart-clots, and of fibrinous concretions 
in the vessels, impeding the passage of blood, and so arresting, suddenly and unexpect- 
edly, the functions of an important organ. It is well known that copious hemorrhage, or 
severe shock, invariably renders the blood more coagulable, and hence such a state of the 
system must be regarded as powerfully predisposing to the occurrence of embolism. It 
is not improbable that rupture of the heart from fatty degeneration is an occasional cause 
of sudden death after severe operations, especially when the use of the knife has been 
attended with inordinate nervous and muscular excitement. 
It is sufficient for all practical purposes to know that such an event may occur after 
operations, without any formal attempt at its solution, which the present state of the 
science hardly enables us to do. Whatever the cause may be, no efforts should be spared 
to prevent it. For this purpose, the utmost care should be taken, after all serious opera- 
tions, not to prop the patient up in bed, or to let him get upon his feet ; nay, further, he 
should not, if he is very weak or exhausted, be permitted to move about in bed, or, in 496 
OPERATIVE SURGERY. 
chap. xv. 
short, to do anything tending to induce syncope, or promote the occurrence of embolism. 
The diet should be of a suitable kind, and such medicine should be given as shall have a 
tendency to impart tone and strength to the system. Free use, in particular, should be 
made of brandy and milk. If syncope occur, the head must immediately be placed low, 
and recourse be had to sinapisms and stimulating injections, to reassure the heart, 
although this will probably be in vain, especially if the cause of the failure of its action 
is the presence of a clot, either in its own cavities or in some vessel. As it is impossible 
to foretell, in any given case, when a patient may be exempt from sudden death, after 
severe shock, or great loss of blood, the precautions here enjoined should be rigidly 
observed until there is reason to believe that all danger from this cause is passed. 
x. Various intercurrent diseases may arise after an operation, and seriously compro- 
mise the patient’s safety. The poison of an eruptive fever, as, for example, scarlatina may 
lie in the system in a state of latency before the operation, and after its performance break 
out in full force, perhaps within the first few days, the shock, hemorrhage, and disordered 
function contributing to its development, whereas, if no such disturbance had taken place 
its effects might never have manifested themselves. Malarial affections, supervening upon 
the use of the knife, often give rise to serious complications, greatly retarding recovery, 
if not inducing fatal results. A violent attack of dysentery, diarrhoea, gout, rheumatism, 
pleurisy or pneumonia, is always to be greatly dreaded after any serious surgical operation. 
[a. The mortality of surgical operations is subject to numerous contingencies, some of 
which have an intimate relation with the patient himself, some with the nature of the 
injury, or accident necessitating the interference, and some with the surgeon, either 
directly or indirectly. It may be assumed, as a general rule, that all the capital opera- 
tions, as they are termed, are attended with a certain degree of risk to life, while not a 
few of the minor or more insignificant ones have, from causes which it is not always easy 
to determine, a fatal issue. A man who undergoes a grave operation is like a soldier who 
engages in a fierce and bloody battle, with this difference, however, so far as danger is 
concerned, that, while the one is sure to be severely wounded, the other may escape with- 
out the slightest injury. The soldier who serves as a forlorn hope will stand a fair chance 
of being killed; and so will a patient who submits to the knife on account of some terrible 
accident or desperate disease. But such cases constitute the exception, not the rule ; 
ordinarily, if the system is properly prepared, and the operation well performed, the sur- 
geon looks with great confidence fora good recovery. If he could always select his cases, 
the general result would be very different. He would then not employ the knife against 
his judgment, as a dernier resort, with the certainty that there was hardly one chance out 
of a hundred for a favorable issue ; he would let all the bad, desperate, or unpromising 
cases alone, to get well or perish, as a kind Providence might direct. But so long as a 
surgeon has any feelings of humanity he cannot do this; he must take the good, bad, and 
indifferent cases as they present themselves, and do the best he can with them. It is only 
when he is guilty of neglect, or of serious mismanagement, that he should be considered 
culpable. He does not expect to save all; he knows that many must necessarily perish, 
not so much as an effect of the operation as of the injury or disease for which the opera- 
tion is performed, and, in attempting to estimate the probable result of his interference, 
he does not forget to take into the account the risk which his patient is obliged to incur 
from hemorrhage, erysipelas, pyemia, tetanus, and other intercurrent but often unavoid- 
able affections. He is assured that there is no case, however apparently desperate, that 
may not recover, or one, however apparently insignificant, that may not perish. 
The following tables will serve to show what has hitherto been the mortality after some 
of the so-called capital operations :— 
Operations. 
Cases. 
Recoveries. 
Deaths. 
Per cent. 
Lithotomy . . . 
11,584 
10,246 
1,338 
11.11 
Ligation of arteries . . 
1,710 
988 
722 
42.23 
Herniotomy 
622 
326 
296 
47.57 
Amputation of the thigh . 
2,011 
1,150 
861 
42.80 
But these results, so humiliating to surgery, refer chiefly to hospital practice, and can, 
therefore, hardly be considered as affording a fair average of the experience of the profes- 
sion in general. The great majority of the most desperate cases, both of injury and 
disease, in all large towns and cities, find their way into public institutions, where they 
rapidly sink under the joint influence of vitiated air, erysipelas, pyemia, and want of 
proper attendance. It is a notorious fact that many more patients recover after bad in- 
juries and severe operations in the country than in the city ; and, to go no further, it may 
confidently be asserted that an experienced operator will lose fewer cases than one who is 
just commencing his career. CHAP. XVI. 
PLASTIC SURGERY. 
497 
CHAPTER XVI. 
PLASTIC SURGERY. 
Plastic Surgery is that branch of the subject which treats of the restoration of lost 
parts by the transplantation of healthy integument from some neighboring region. Origi- 
nally restricted to the repair of the nose, it has, during the present century, busied itself, 
in different ways, with the emendation of various other organs, and has thus greatly en- 
riched the domain of general surgery; having, in fact, created a new department of 
operative medicine, as fertile in its resources as it has already been brilliant in its results. 
The perfection which plastic surgery has attained within the last twenty-five years is 
truly wonderful, and affords a striking evidence of the ingenuity, talent, and enterprise of 
the medical profession in different parts of the world. It has literally been a field of con- 
quests, upon which have been achieved some of the proudest triumphs of the human mind 
in modern times. Among the many names that are honorably associated with this de- 
partment of surgery, on account of their persevering efforts to advance its interests, those 
of Carpue, Dieffenbach, Blandin, Zeis, Jobert, Serre, Liston, and Yon Ammon of Europe, 
and Pancoast, J. M. Warren, Mutter, Buck, Post, Hamilton, Prince, and several others 
of this country, hold deservedly a high rank. Some of these surgeons have composed 
able treatises on plastic surgery, and have thus indelibly identified themselves with its 
history. 
Various names have been devised to designate this branch of surgery. Thus, Blandin 
denominates it autoplasty, while Velpeau prefers the word anaplasty, such literally signi- 
fying reconstruction. By others the term plastic, from the Greek verb to mould, model, 
or adjust, is used, and this is, perhaps, less objectionable than any other; at all events, it 
possesses the advantage of being easily understood. 
It is exceedingly probable that one branch of plastic surgery has been practised in 
India from time immemorial. In that country the barbarous custom has existed for ages 
of punishing certain classes of criminals by cutting off' their noses, and there can be no 
doubt that sympathy for these poor wretches gradually induced persons to turn their atten- 
tion to the means of affording them relief. Hence arose rhinoplasty, or the operation of 
making new noses, pursued chiefly by a low order of native priests, whose ignorance of 
the healing art was too profound to justify the idea that their efforts were often crowned 
with success. According to Galen, the ancient Egyptians were well acquainted with 
rhinoplasty, but self-interest and pride prevented them from communicating a knowledge 
of it to other nations. Whether the operation was ever performed in Greece and Rome his- 
tory does not inform us, although it can hardly be supposed that, if it had been, it would have 
been silent upon the subject. In Europe attention was first prominently drawn to the 
restoration of lost parts by Gaspar Taliacozzio, Professor of Anatomy and Surgery in the 
University of Bologna. In a work on the subject, remarkable for its erudition, and the 
simplicity of its diction, published at Venice, in 1597, he has described with great min- 
uteness the art of repairing mutilated noses, lips, and ears, illustrated by numerous 
engravings. It bears the title of “ De Curtorum Chirurgia per insitionem,” and is 
curious as furnishing a record of the observation and experience of a truly great surgeon 
soon after the revival of learning. His practice must have been very great as a rhino- 
plastic surgeon, for it is distinctly stated that patients visited him from all parts of 
Europe. The pupils of Taliacozzio, settling in different parts of the continent, took great 
pains to disseminate a knowledge of the operation among the profession, although it does 
not seem to have been often applied in practice, doubtless from fear of failure. The 
operation, moreover, was doomed to encounter many obstacles from ridicule, which always 
exerts a powerful influence upon the weak and prejudiced in every country, and not un- 
frequently has the effect of throwing a new and useful invention completely into the shade. 
The method of Taliacozzio consists in borrowing the required material from the arm; 
the operation is very tedious and complex, and has been almost entirely superseded by 
the Indian method, in which the flap is taken from the forehead. These two processes 
vol. i 32 498 
PLASTIC SURGERY. 
CHAP. XVI. 
will be described in their proper place. Meanwhile, it may be observed that the Oriental 
operation was first successfully performed in Europe in 1814, by Carpue, of London, who, 
in 1816, published an account of this and of another case, equally fortunate. To Dieffen- 
bach, however, more than to any one else, is due the merit of having first generalized the 
operation, by pointing out the sphere of its application. 
The nomenclature of these plastic operations has assumed quite an imposing character, 
from the numerous structures to which they are applicable. It is formed by adding the 
word “ plasty” to the anatomical name of the part concerned, as rhinoplasty, genioplasty, 
and urethroplasty. Before I proceed to speak of these operations separately, it will be 
necessary to offer some remarks of a general nature respecting the causes which necessi- 
tate them, the preparation of the system, the proper mode of conducting them, and the 
character of the after-treatment. 
The causes necessitating these operations are various kinds of accidents and diseases. 
Thus, in India, as already stated, rhinoplasty is generally required on account of wilful 
mutilation of the nose as a punishment for crime; in Germany, on the contrary, it is often 
called for on account of injury sustained by the small sword in duelling. The vicious 
cicatrices left by burns and scalds frequently lead to the necessity of their performance; 
in fact, a large field for plastic surgery has been opened in this class of lesions, in which 
good service w7as rendered by the late Dr. Mutter, since attention was first directed to it. 
Of the various diseases which may create a necessity for this kind of interference, carci- 
noma, struma, and syphilis occupy the first rank, these affections not unfrequently destroy- 
ing the greater portion of the nose and lip, and thus causing the most disgusting deformity. 
Genioplasty is generally required on account of ulceration of the cheek from the effects of 
mercury; and urethroplasty, in consequence of urinary fistule, the result generally of 
stricture and abscess. 
Whatever may be the causes leading to the necessity of these operations, none should 
ever he undertaken without thorough preparation of the system, extending through a 
number of days, if not several weeks. Upon this subject it is impossible to insist too 
strongly. I have seen enough of these cases to satisfy me that too little attention is paid 
to preliminary treatment, and that most of the failures which attend the procedure are 
due to the neglect of this precaution, for which there is the less excuse, seeing that there 
is never any need of immediate interference. There is no necessity, unless the patient 
is very plethoric, for the use of the lancet; light diet, rest, and an occasional purgative 
will generally suffice to bring down the system to a proper point of tolerance for the 
approaching ordeal. If the patient is from abroad, he must not be molested until he has 
recovered from his fatigue, and become accustomed, in some degree, to his apartment 
and to those who are to attend to his wants. His room should he spacious, cheerful, and 
w7ell ventilated. If the weather be cold, the temperature should be regulated by the 
thermometer, uniformity in this respect being of paramount importance to the success of 
the enterprise. No operation of this kind should be undertaken in the heat of summer, 
or during the existence of any bodily ailment. 
It is hardly necessary to state that no plastic operation should ever be attempted so 
long as the disease necessitating it is not completely eradicated from the part and system. 
It w'ould be the height of folly, for example, to undertake the restoration of a nose lost 
in consequence of syphilis if there wrere any traces of this affection, in any portion 
of the body, however remote, or however distinctly connected with the disfigured organ; 
for there could be no possible guarantee here that the disease might not attack the 
new7 nose or the adjoining parts of the old, and so frustrate the design of the surgeon. 
Besides, even supposing that such an untoward occurrence did not take place, still, it 
would he improper to operate, because the subjects of this disease are not only very prone 
to erysipelas, hut wounds in them generally unite with more difficulty than in healthy 
persons. The same remarks apply to struma, although I have great doubts whether this 
disease, by itself, ever destroyed any nose, ear, or lip. The mischief that is so often 
ascribed to it is nearly always done by syphilis, or by a combination of these affections 
from the transmission of the two poisons from the parent to the offspring. It is different 
with carcinoma. Here the plastic operation may, generally, be performed immediately 
after the excision of the offending disease. 
The manner of executing the operation relates to the position of the patient, the sur- 
geon, and the assistants; the administration of the anaesthetic; the mode of selecting, mak- 
ing, and fastening the flaps; and several other circumstances which it is not necessary to 
specify. 
If the operation be very simple, and likely to be soon over, the patient may sit up; CHAP. XVI. 
PLASTIC SURGERY. 
499 
otherwise he should lie down, his head and shoulders being properly supported by pillows. 
The surgeon and the assistants should dispose themselves in such a manner as may seem 
most useful for the prompt and successful execution of the operation. An anaesthetic is 
proper in almost every case, since the operation is frequently not only very tedious, but 
it is always desirable that the patient should be as passive as possible while it is in 
progress. 
There are, as has already been stated, two points from which the integument may be 
transplanted for filling up the chasm in the mutilated organ; either from the immediate 
vicinity of the part or from a distance. Thus, in making a new nose, or mending an old 
one, the flap may be taken from the forehead, according to the Indian method ; or, if the 
gap be very small, even from the cheek, at a still shorter distance from the nose. Or the 
surgeon, adopting the plan of Taliacozzio, now known as the Italian operation, may bor- 
row the necessary material from the arm, although this method, owing to its tedious and 
complicated character, has become almost obsolete. In some cases the flap is obtained 
by a kind of migratory process, being successively transferred from one region to another 
until it reaches its final destination. Roux in this manner attempted to close an opening 
in the cheek, by inserting a piece of the lower lip into the upper, and, after a time, 
when the parts had contracted thorough adhesions and become accustomed to each other, 
transferring it to the place which it was intended to occupy permanently. Such a pro- 
cedure would seem, at first sight, to be puerile, but upon reflection it will readily be seen 
that cases might arise where it would not only be justifiable but very proper. 
However obtained, it is important that the integument should, if possible, be perfectly 
sound; free, not only from disease, but from scars. The necessity of attention to this 
rule is too obvious to require comment. A cicatrice, having only a low vitality, is ex- 
tremely apt to slough when transplanted. A sickly graft cannot take root on a sound 
bough, nor will a diseased bough permit the growth of a sound graft. To unite and 
maintain their future relations both must be healthy. Another point of consequence is 
that the flap should be as destitute as possible of hair; for, although it might be divested 
of this after it has grown fast in its new position, it is always best not to incur any risk 
of unseemliness from this source. 
The size of the flap must, as a general rule, be at least one-third larger than the opening 
which it is intended to cover, to allow for the necessary shrinkage. If the integument 
be very thick, the contraction will be less than under opposite circumstances, but even 
here it is well for the surgeon to be on his.guard, lest, when the cure is completed, the 
result should disappoint him. The shrinkage is always gradual, and generally continues 
for many months after the operation, the part gaining in thickness and density what it 
loses in circumference. 
The shape of the flap must accurately correspond with that of the gap which it is 
destined to close. Hence the best plan is always to define its outline before the 
operation by means of a pattern, placed upon the surface whence the integument is to 
be taken, and marked off with ink, nitrate of silver, or, what is better than either, tincture 
of iodine. 
The composition of the flap is a matter of paramount importance. It should consist 
merely of skin and connective tissue, with a small quantity of adipose substance, muscular 
fibre, nerves and veins being carefully excluded. The presence of a thin layer of fat is 
always conducive to the preservation of the flap, as it tends to protect the subcutaneous 
vessels, and facilitate adhesion. A large pedicle must always be left, otherwise the part 
may die from inadequate supply of blood and nervous fluid. No large artery should be 
embraced in it, as this would convey more blood into it than would be required for its 
nutrition, or than the veins could return. 
These preliminaries being disposed of, the surgeon with a sharp scalpel pares the edges 
of the part to be repaired, vivifying them with great accuracy, and removing all redundant 
and callous matter ; or he may first dissect up the flap, and do the paring afterwards, as 
fancy or convenience may dictate. In executing this step of the operation, great care 
must be taken not to press or pinch, either with the finger or forceps, any portion 
of the flap or old skin, but to leave everything in as natural condition as possible, 
since nothing will so readily promote reunion. The edges may be bevelled off or 
cut straight, according to circumstances, as will be more particularly described hereafter. 
The dissection is frequently attended with smart hemorrhage, but the rule is never 
to apply any ligature to the flap, lest it should interfere with the adhesive process, 
although any vessel of the wound that may spirt should at once be secured, and the 
wound itself promptly closed by suture. More or less gaping will of course remain, but 500 
PLASTIC SURGERY. 
CHAP. XVI. 
it is astonishing how small a cicatrice is usually left even in the most extensive lesions of 
this description. 
All bleeding having ceased, the flap is gently sponged, and accurately stitched to the 
edges of the chasm which it is designed to close. The most eligible sutui-e will be found 
to be the interrupted, with an interval of two to three lines between the threads, the ends 
being tied with a slip-knot over a narrow roll of adhesive plaster. The advantage of this 
procedure is that the suture may be loosened at any time if it be found to be too tight. 
Much harm is often done by placing the stitches too closely, the effect being to cut off the 
circulation. The twisted suture is objectionable for the reason, first, that the needles are, 
in many places, difficult of introduction, and secondly, that they are liable to cause too 
great a degree of tension. The grooved suture, so happily used in plastic surgery by 
the late Professor Pancoast, will be described in connection with rhinoplasty, to which 
it is more particularly applicable. 
The dressing is completed by covering the edges of the newly related parts with lint, 
spread with simple cerate, or wet with olive oil, in order to prevent them from becoming 
dry and shrivelled, an effect very liable to happen when this precaution is not duly 
attended to. The surface of the flap may be protected with dry lint, or, what is generally 
preferable, be exposed to the air. If it is very large, it will be necessary to confine it 
lightly in its place with adhesive plaster and a bandage, but anything like firm pressure 
must be carefully avoided. The wound from which the flap has been borrowed is dressed 
with cold water, and a similar application may be made to the amended organ if appear- 
ances indicate that there is a likelihood of overaction. The operation being completed, 
the part is kept at rest in a relaxed and elevated position ; a light, cooling diet is enjoined; 
and the air of the apartment is carefully regulated by the thermometer, an equable tem- 
perature being of the greatest consequence to the welfare both of the part and system. 
A full anodyne is given the moment the patient is put to bed; but, if things go on well, the 
bowels must not be disturbed under forty-eight hours, when they may be opened by a 
cooling laxative. 
The sutures may be removed, on an average, from the fifth to the seventh day ; but 
so long as they are doing well they should not be disturbed, and there are few cases 
in which it is proper to take all away at once. Great attention to cleanliness must be 
observed, and the best mode of effecting this is to irrigate the parts occasionally with the 
syringe. 
If undue swelling and discoloration arise, the patient must be promptly bled and purged, 
and such local means employed as are best calculated to meet the emergency of the case. 
Leeches may be applied to the neighborhood of the flap, but not to the flap itself, for fear 
of exciting erysipelas. Occasionally a considerable flow of blood may be obtained by 
slightly lifting the flap at one or more points, the bleeding being encouraged with a sponge 
and warm water. 
The great danger after an operation of this kind is erysipelas, which may be so con- 
siderable as to destroy not only the flap but also the patient. Such an occurrence should 
be promptly met by the topical use of the dilute tincture of iodine, and by appropriate 
internal remedies, especially quinine and iron, aided, if there is any tendency to a typhoid 
state of the system, by stimulating drinks and a generous diet. Now and then a patient 
is lost by pyemia, but such an event is fortunately very uncommon. Gangrene of the 
flap, either from inadequate nutrition, overaction, or undue constriction, occasionally 
occurs, and mars the success of the operation. 
For a time the flap remains pale and cold, but these effects soon pass off, and ai'e 
succeeded by a bluish appearance and an increase of temperature. The circulation is 
evidently temporarily embarrassed, the arteries conveying blood faster to the part than the 
veins can remove it. Hence a certain degree of stagnation ensues, followed by a bluish, 
threatening condition of the part, which, however, soon disappears spontaneously. Natural 
sensation does not return for a long time; it begins first along the edges of the flap, and 
thence gradually extends over the rest of its surface. For the first few months the 
transplanted skin may appear unnaturally large and unseemly; gradually, however, it 
becomes smaller, and eventually it may shrink so much as to answer but imperfectly the 
objects of the operation. 
One of the latest improvements in plastic surgery is skin-grafting, an operation 
introduced, as stated in a previous chapter, in 1869, by Keverdin, and consisting in 
the transplantation of a bit of skin, hardly the size of a mustard seed, among the 
torpid granulations of an old ulcer or any raw surface indisposed to heal. Union 
soon occurs, and in a short time the little bud becomes the centre of a new growth, CHAP. XVII. 
SUBCUTANEOUS SURGERY. 
501 
standing, island-like, in the middle of the granulations, and serving as a point of departure 
for the formation of new skin. What is remarkable is the well-attested fact that epithelial 
scales, scraped from the cutis, and applied to the granulations of an ulcer, speedily contract 
adhesions, and answer nearly, if indeed not quite, as well for the purpose designed as the 
more perfect skin. 
CHAPTER XVII. 
SUBCUTANEOUS SURGERY. 
Subcutaneous Surgery is one of the creations of modern times, due chiefly to the 
genius and intrepidity of one man, Dr. Louis Stroymeyer, of Hanover, who was the first 
to practice, upon a rational and philosophical plan, a subcutaneous operation, the under- 
taking consisting in the division of the tendo Achillis for the cure of clubfoot. The 
operation was performed in February, 1831, and eventuated in the complete restoration 
of the use of the limb. Prior to that period several attempts had been made, by different 
surgeons, as Lorenz, Thilenius, Michaelis, Sartorius, and Delpech, to relieve this com- 
plaint, but they had all signally failed, simply because they had not been based upon 
correct scientific principles. 
Since the discovery of Stromeyer, the domain of subcutaneous surgery has been 
greatly enlarged, by the application of its principles to other parts of the body, for 
the relief of which it has already performed the most valuable services. Dieffenbach, in 
1839, gave it a new impulse by devising the operation for strabismus, which, although 
not practised by him subcutaneously, did much to inspire new confidence in the procedure, 
and to awaken a new interest in its application. Soon afterwards, however, the section 
of the muscles of the eye was performed without external wound, by Guerin, but the 
operation, if not obsolete, has never met with much favor by the profession. The French 
surgeon has extended the subcutaneous practice to the treatment of lateral curvature of 
the spine, by the division of the muscles of the back; and, at a more recent period still, 
it has been applied to the relief of numerous other affections, which would hardly admit 
of cure in any other manner. Among the more important procedures that have grown 
out of this branch of surgery are the removal of cartilaginous bodies from the joints, the 
radical cure of hernia, the reduction of chronic dislocations, the evacuation of abscesses, 
the cure of ankylosis, and the obliteration of serous cavities. Too short a time has 
elapsed since the discovery of subcutaneous surgery to enable us to form a just estimate 
of its limits, or the extent to which it may with propriety be carried into practice; but it 
is not difficult to perceive that in a field affording such unbounded opportunities for the 
exhibition of display and selfishness, much abuse must creep in, which time alone will be 
able to rectify. 
The practice of subcutaneous surgery is founded upon the great law that all wounds 
and injuries occurring without an opening in the integument unite with very little, or, 
according to some, with no inflammation, and with no suppuration, differing thus essen- 
tially from similar lesions accompanied with a solution of continuity of the skin, which 
are always followed by considerable inflammation, and also very frequently, if not gener- 
ally, by a discharge of pus. This law, which is now universally recognized by surgeons, 
was clearly enunciated by John Hunter, in his writings, near the close of the last century, 
but did not attract the serious attention of his countrymen until within a very recent 
period ; not, indeed, until the facts of the subcutaneous section had been placed upon a 
firm and immutable basis by the practitioners of the continent of Europe. The idea of 
the illustrious Englishman lay in his writings, like a pebble upon the sea-shore, often 
seen but never observed, until accident directed attention to it years after the establish- 
ment, by others, of the great principles which he had so clearly enunciated. One reason, 
perhaps the chief one, of this was that he himself had never performed a subcutaneous 
operation : if he had, there is certainly no evidence of the fact in any of his writings. 
The only passage in his works which has any relevancy to the present subject is the Fol- 
lowing :—“ The injuries done to sound parts, I shall divide into two sorts, according to 
the effects of the accident. The first kind consists of those in which the injured parts do 
not communicate externally, as concussions of the whole body or of particular parts, strains, 502 
SUBCUTANEOUS SURGERY. 
CHAP. XVII. 
bruises, and simple fractures, either of bone or tendon, which form a large division. The 
second consists of those which have an external communication, comprehending wounds 
of all kinds, and compound fractures. Bruises which have destroyed the life of the part 
may be considered as a third division, partaking, at the beginning, of the nature of the 
first, but finally terminating like the second. The injuries of the first division, in which 
the parts do not communicate externally, seldom inflame, while those of the second com- 
monly both inflame and suppurate.” It is evident, from the tenor of this passage, that 
Hunter had carefully studied the influence of the air upon the healing of wounds, but it 
is not very clear, from aught that appears in it, that he had any conception whatever of 
the nature of subcutaneous surgery, properly so called. 
Several of what are now dignified as subcutaneous operations have been performed for 
a long time. The mode of evacuating chronic abscesses by a valvular incision, first prac- 
tised by John Abernethy, early in the present century, legitimately belongs to this division 
of surgery, its object, as clearly enunciated by the originator, being the exclusion of the 
air, on the ground that the contact of this fluid with the pus in the interior of the sac is 
the cause of the excessive local and constitutional disturbances which so often follow the 
old mode of opening these collections. Of the value of this procedure there can be no 
doubt, although the class of cases which it is intended to relieve is, from their very nature, 
unfortunately too often fatal. The operation of dividing the stricture in strangulated 
hernia, external to the sac, originated with J. L. Petit a century and a half ago, but has 
only of late years received the attention it merits. Some of the English practitioners, 
commencing with Ashton Key, have recently bestowed much attention upon the subject, 
and have adduced a body of testimony in its favor highly flattering to this mode of treat- 
ment. The object of the operation, the advantages and disadvantages of which will be 
considered in their appropriate place, is, by relieving the bowel subcutaneously, to guard 
against the occurrence of the severe inflammation which so frequently attends the ordinary 
procedure, even in the hands of the best practitioners. The injection of hydrocele with 
irritating fluids, as suggested by Sir James Earle, early in the present century, is another 
instance of a subcutaneous operation, which has long been familiar to the profession, and 
been practised by every enlightened surgeon in Europe and America. Some recent 
writers have gone so far as to class the use of the seton in the treatment of ununited frac- 
ture among the expedients of subcutaneous surgery : such an application is certainly 
carrying this department altogether beyond its legitimate limits, and is, therefore, calcu- 
lated to do the subject much harm by giving to it a wrong direction. The wound made 
by a seton is, to all intents and purposes, an open wound, followed not only by high in- 
flammation, but by profuse suppuration ; occurrences which it is the peculiar province of 
subcutaneous surgery to guard against. A better example of a subcutaneous operation, 
performed for the relief of ununited fractures, is the division by means of a long, slender 
knife, of the soft tissues which form around the ends of the broken bone, the raw surfaces 
being afterwards approximated and maintained by appropriate apparatus. 
On the whole, regarding subcutaneous surgery in its legitimate application, it appears 
to me that the cases to which it is adapted are susceptible of being arranged under the fol- 
lowing heads: 1. Cases involving the division of tendons, muscles, bones, and aponeuroses for 
the relief of various distortions, as clubfoot, clubhand, spinal curvature, knockknee, and stra- 
bismus ; the reduction of dislocations, especially those of the foot; and the cure of ankylosis 
of the joints, depending upon contraction of the soft parts. 2. Operations for the radical 
cure of hernia, whether by puncture or injection; and division of the stricture in stran- 
gulated hernia external to the sac. 3. The evacuation of chronic abscesses and of puru- 
lent, serous, and sanguineous collections of the chest and other cavities, by a valve-like 
opening of the skin. 4. The withdrawl of cartilaginous concretions from the joints, as 
originally suggested by Goyrand and Syme. 5. Operations for obliterating serous cavi- 
ties, when, in consequence of inflammation, they become occupied by serous fluid ; as the 
vaginal tunic of the testicle, certain synovial burses, especially those about the hand and 
wrist, and various adventitious cysts, particularly those which are so liable to form in the 
neck in connection with the thyroid gland. 6. The comminution, by the knife, of dis- 
eased lymphatic glands, the incision of inflamed periosteum, and the division of morbid 
adhesions, as those existing in chronic luxations, in depressions of the nose, and similar 
affections. 7. Forced extension of ankylosed joints, rendered so by the formation of 
fibro-ligamentous bands. 8. The subcutaneous obliteration of vascular tumors, by liga- 
ture or injection. 9. The operation for the radical cure of varicocele. 10. The relief of 
deformities of the hip-joint by the division of the thigh bone, as originally practised by 
Barton, and more recently by Sayre, Adams, Volkmann, and other surgeons. CHAP. XVII. 
SUBCUTANEOUS SURGERY. 
503 
The mode of operating for subcutaneous purposes must vary of course according to the 
particular indication which it is designed to fulfil. Whatever, however, the object may 
be, the rule is to make as small an external wound as possible, consisting, in fact, rather 
of a puncture than an incision, for it is ever to be borne in mind that one of the cardinal 
aims of every procedure of the kind is the exclusion of the.air. The knife with which the 
operation is performed must, therefore, always be very narrow, sharp-pointed, and rather 
short, a length of edge from half an inch to an inch being a good average. The annexed 
sketch, fig. 206, represents the knife which I 
have long been in the habit of using in all my 
subcutaneous operations. Such an instrument 
is generally much more manageable than a 
longer one, while one of greater width would 
make too large an opening. If the object be 
to evacuate an abscess, a medium-sized trocar 
may be used, the skin having previously been divided with a bistoury. The instrument 
is then passed for a variable distance—usually from an inch to an inch and a half— 
through the subcutaneous connective tissue, when its point is plunged into the pyogenic 
pouch, its entrance being denoted by the want of resistance and the escape, perhaps, of a 
few drops of thin pus. In extracting cartilaginous concretions from the joints, a delicate 
knife is carried along under the integument through the capsular ligament and synovial 
membrane, which are then divided to a sufficient extent to admit of the displacement of 
the morbid growth, previously fixed by the thumb and fingers, into the connective tissue 
external to the articulation, from which, after the wound is healed, it is removed by a 
second operation. The operation for the radical cux-e of hernia, requiring instruments of 
particular construction and use, will be described in its proper place, and so in regard to 
several other procedures which cannot be here noticed. 
All operations of this kind should be performed with great gentleness and care; for 
whenever this is done, there will be no risk either of’ severe inflammation, or of the 
division of any important vessels, nerves, or other structures not concerned in the 
particular affection for the relief of which the procedure is undertaken. I do not agree 
with those who maintain that tendons and other textures may be cut without the operation 
being followed by inflammation ; on the contrary, I am convinced that a certain degree 
of incited action is present in every instance, and, if this view be correct, it proves how 
important it is that it should be kept within proper limits. This subject, however, will 
again be adverted to in speaking of tenotomy. In general, the little puncture made in 
the operation unites in a few hours, while the gap which intervenes between the retracted 
ends of the divided structure is gradually filled up by plastic matter, which is eventually 
converted into analogous tissue. 
Most subcutaneous operations are nearly bloodless, a circumstance which constitutes 
one of their leading peculiarities. While open wounds always bleed, to a greater or 
less extent, those made beneath the skin by a narrow, sharp-pointed knife, used with 
proper care, are almost free from hemorrhage. In dividing the tendo Achillis for 
clubfoot, frequently not more than a few drops of blood are lost. As to shock, or 
serious depression of the nervous system, consequent upon such an operation, such 
an occurrence is never witnessed. The procedure, however, is not always free from 
pain, especially during the efforts which are sometimes required to straighten the 
affected part after the division of the faulty structures; and hence it is often useful to 
administer an anaesthetic, the more so, because this not only prevents suffering, but, 
by rendering the patient passive, gives the surgeon more complete control over his own 
movements. 
Active preparatory treatment is rarely required in these operations. I have frequently 
performed the most extensive tenotomy at the College Clinic, as well as, in private 
practice, upon children whom I had seen for the first time only an hour before, and yet 
in no instance, so far as I have been able to learn, have any bad effects followed. The 
operations, however, for the radical cure of hernia, for breaking up adhesions in ankylosis, 
for the removal of cartilaginous bodies from the joints, and for the relief of some other 
affections, always demand more or less attention of this kind. 
The after-treatment, for the first few days, is generally very simple. As soon as the 
operation is over, the little wound is covered with adhesive strips, to exclude the air, 
and the part, surrounded by a bandage, is maintained in a perfectly easy, quiet position. 
If active inflammation arise, which, however, is seldom the case, the usual antiphlogisties 
Fig. 206. 
Tenotome. 504 
AMPUTATIONS IN GENERAL. 
CHAP. XVIII. 
must be employed. After nearly all such operations suppuration must be prevented at all 
hazard. 
When the operation is practised for the relief of some deformity, as clubfoot or spinal 
curvature, the cutting constitutes only a trivial part of the procedure. The great care 
and trouble of the case come afterwards, in the fitting and wearing of the necessary 
apparatus. It is usually reconfmended that no apparatus should be used until after the 
lapse of several days, or until the primary effects of the operation have passed off. I 
have, however, in many cases, so far deviated from this rule as to confine the affected 
limb at once, and usually without any disadvantage. Indeed, I am strongly inclined to 
believe that this ought to be the rule, and delay the exception. As this subject, however, 
will be considered in connection with the various operations to which it relates, any 
further remarks upon it here would be out of place. 
CHAPTER, XVIII. 
AMPUTATIONS IN GENERAL. 
SECT. I. INTRODUCTORY CONSIDERATIONS. 
Tiie word amputation was formerly, and is occasionally even yet, employed to 
signify the removal of various kinds of tumors; thus, many of the older writers speak 
of amputation of the breast, amputation of the jaw, and amputation of the scrotum. 
At the present day, however, the term excision is generally used as more appropriate 
in connection with these procedures, while that of amputation is applied exclusively 
to operations for the removal of the limbs, whether in their continuity or at their 
articulations. 
I cannot agree with those who have denounced amputations as a disgrace to surgery; 
it is only when they are performed unnecessarily that they ought to be stigmatized by the 
profession and the public as an evil. Every pursuit is liable to abuse, to sins of omission 
and commission, and it would be strange if limbs were not occasionally cut off that might, 
under judicious management, have been saved. To denounce amputations, and to declare 
that they afford evidence only of the impotency and imperfection of our art, is to take a 
very narrow and erroneous view of the subject. It is not intended, so far as our own 
feeble powers of reflection enable us to comprehend the matter, that man should be able 
to cure every disease to which “flesh is heir.” There are many maladies, as well as 
accidents, which are of necessity mortal; lesions which no human agency can repair or 
remedy. Who can save a limb that has been mangled and cut to pieces by the passage 
of a railway car, by the explosion of a steamboat boiler, by the fierce contact of a cannon 
ball, or by a fall from the top of a house down upon a heap of stones ? Where is the 
surgeon that can prevent mortification from a burn that has charred the flesh, from a cold 
that has completely frozen the toes and feet, or from a malignant pustule that has 
inoculated all the tissues of an extremity? Is surgery to be held responsible because it 
cannot cure sarcoma of the bones, scrofula of the joints, and aneurism of the thigh 
and leg? So far from imputing blame to it, in these and similar cases, we should be 
grateful for the assistance which it is capable of affording us as a means of relieving 
suffering and prolonging life. It is under such circumstances, in particular, that we can 
best appreciate its great and inestimable value. If it were not for the merciful interposi- 
tion here of the knife, such cases would inevitably be doomed to a rapid and miserable 
death. Mortification wrould speedily do its work, the sarcomatous tumor would steadily 
spread and finally ulcerate, forming a frightful, disgusting, and painful mass of disease, 
and the scrofulous joint would soon wear out the system by hectic irritation. It is a 
sad thing to lose a limb, but it is also a sad thing to die ; and what rational being, if 
he could have his choice, would not rather part with an extremity than with his life ? 
No humane, enlightened, and conscientious surgeon will ever resort to amputation without 
being satisfied of its entire and perfect necessity; if he is young and inexperienced, he 
will be sure to avail himself of the best counsel within his reach, while, if he is thrown 
upon his own resources, he will not fail to give the case all the consideration and reflection 
that his own knowledge, wisdom, and judgment may enable him to bring to his aid for CHAP. XVIII. 
CIRCUMSTANCES DEMANDING AMPUTATION. 
505 
the relief of the poor sufferer whom he is obliged to mutilate in order that he may rescue 
his life from the dangers which threaten him. I know of no operation which I approach 
with so much reluctance as the amputation of a limb, or one which gives me more real 
pain. To cut off’ an arm at the shoulder on account of an incipient sarcomatous 
affection of the head of the humerus, when the elbow, forearm, hand, and fingers are all 
perfectly natural and glowing with health, unconscious, so to speak, of the fate which 
awaits them, is enough to sicken the stoutest heart, and to discourage the boldest operator. 
If there is a more disagreeable task than this, I am ignorant of it; and yet I w'ould 
not shrink from its performance even when there is but a faint prospect of prolonging 
life, if only for a few months. But the case is different, widely different, when the 
surgeon is called upon to amputate a limb crushed and lacerated by machinery; here 
there is no choice, no question concerning a cure by mere therapeutic measures ; the 
knife is the only remedy, and the sooner it does its work the greater, as a general rule, 
will be the patient’s chance of recovery. The body, it is true, is mutilated, perhaps sadly 
disfigured, but life is safe, and surgery, science, and humanity have achieved a real 
triumph. So long as there are accidents and diseases incurable by medical treatment, so 
long will there be a necessity for amputation, and happy is he who shall know when and 
how to perform it to the best advantage for his patient and the greatest credit to the art 
and science of surgery. 
SECT. II CIRCUMSTANCES DEMANDING AMPUTATION. 
The circumstances for which amputation may be required are not only numerous, but 
extremely diversified in their character, and, therefore, deserving of the most careful con- 
sideration. They may be comprised under the following heads :—1. External injury, as 
wounds, fractures, and dislocations. 2. Mortification, however induced. 3. Morbid 
growths. 4. Aneurisms. 5. Diseases of the bones and joints. 6. Intractable ulcers. 
7. Malformations and deformities. 8. Tetanus. The topics here enumerated comprise 
almost every kind of morbid action that can arise in the animal economy, and it will be 
perceived that they afford a wide and complicated field for the exercise of the talents and 
judgment of the surgeon. Space will not permit me to enter as fully into their details 
as might, perhaps, be desired; but I shall endeavor to advert briefly to the more impor- 
tant facts included under each head, having already called attention to some of them in 
the chapters on gangrene and wounds. 
1. Injuries. There are no lesions for which amputations are so frequently required as 
for wounds, fractures and dislocations. Although they differ widely from each other in 
regard to the nature of the structures involved, these injuries may all be very properly 
classed under the same head, the more especially as they often coexist, thus rendering it 
difficult to determine which of them is the most serious. 
Of wounds, properly so called, the only ones which require to be considered in connec- 
tion with the present subject are the lacerated, contused, gunshot, and railway. Wounds 
inflicted by rabid animals occasionally, it is true, demand amputation, particularly when 
they extend deeply among the bones, as in the hands and feet; but even here complete 
riddance may generally be easily effected by a careful excision of the bitten parts, and the 
cauterization of the raw surface after the cessation of hemorrhage. I should certainly 
hesitate to cut off" an arm or a leg in such an event; with the knife and saw I should ex- 
pect to accomplish all that was necessary, in any case, for the safety of the patient. 
Lacerated wounds, as well as contused and gunshot wounds, of a most frightful, and, at 
first sight, apparently of the most desperate character, are sometimes recovered from in an 
extraordinarily short time, and with hardly any untoward symptoms. On the other hand, 
experience shows that the most insignificant injuries of this kind occasionally prove fatal 
in a manner and under circumstances which render it extremely difficult to account for the 
result. It would be fortunate, both for our p>atients and for the interests of science, if we 
could always form, if not a positive, at least an approximate, estimate of the danger in- 
volved in each particular case of these wounds, for then it would be comparatively easy to 
adopt a suitable plan of treatment; but, as it is, much must be left, in every instance, to 
the experience and judgment of the practitioner. In general, however, it maybe observed 
that all such wounds are fraught with danger, both to limb and life, when they are 
attended with extensive laceration of the soft parts, when the muscles have been horribly 
bruised and pulpified, important nerves cut across, the principal arteries, or arteries and 
veins, torn open, large joints penetrated, and the bones broken in pieces. Under such 
circumstances there is not even a “forlorn hope,” no matter what may have been the 506 
AMPUTATIONS IN GENERAL. 
CHAP. XVIII. 
previous health and habits of the sufferer; the knife is required, and the sooner it is em- 
ployed the better. Such cases are absolutely desperate, and no one who has any know- 
ledge of consequences can hesitate as to the course to be pursued. Upon this point there 
is no discrepancy of opinion whatever among surgeons. But the injury may be of a less 
severe character, involving, it may be, merely a considerable contusion of the soft struc- 
tures with a compound fracture ; or several muscles may be badly lacerated and the 
principal artery of a limb cut across; or a large nerve, the main trunk, perhaps, be divi- 
ded, or the interior of a large joint exposed. The case now assumes a more trying aspect; 
the responsibility falls upon the surgeon with tenfold force; for the question naturally and 
at once arises, What shall be done ? Shall such a limb be immediately amputated, or 
shall an attempt be made to preserve it ? This is a question which will probably be asked 
by the patient himself, or by his friends for him, and which it is often extremely embar- 
rassing and difficult to answer; in fact, it can only be answered upon general principles 
in one sense, and upon special principles in another. Looking at such injuries in a gen- 
eral manner, we might be inclined to give a favorable prognosis, because it is undoubtedly 
true that recovery from such lesions is by no means uncommon ; but when we come to 
examine into the particulars of the case, we might not regard it in so auspicious a light. 
Thus, for example, the patient’s antecedents may all have been bad, perhaps of the worst 
possible description ; intemperance and dissipation of various kinds may have undermined 
his constitution, and thus rendered it unable to bear up under an injury which he would 
formerly have supported without difficulty ; or, instead of this, there may be serious 
structural disease of some vital organ, as the heart, stomach, or lungs, disqualifying him 
for enduring the accidental and now heavy burden. All these circumstances must have 
their weight with the practitioner when he sits in judgment respecting the propriety or 
impropriety of an amputation. Conservative surgery may and does do much, but it can- 
not do everything ; it has its limits, beyond which it cannot safely go, and there are many 
points which require to be considered in order that it may do itself justice. A very severe 
injury, occurring in a stout youth, of healthy constitution and temperate habits, is often 
promptly recovered from, while less than one-third of its amount, in a sickly, anemic, or 
dissipated person, will frequently destroy life in a few' days; or, at all events, so far 
endanger it as to cause great anxiety for the result. 
Gunshot, railway, and steamboat accidents, and injuries occasioned by the caving in of 
stone quarries, are extremely liable, if an attempt be made to save the limb, to be followed 
by the worst results; and, vvliat is particularly embarrassing, in these cases, is the diffi- 
culty which the practitioner often has to encounter in ascertaining the precise amount of 
the lesion. The limb, perhaps, is entirely free from contusion and wound ; or, if there be 
any injury of this kind, it may be so slight as to be regarded as of no consequence. The 
mischief is deep-seated, and, upon careful examination, it will, probably, be found to in- 
volve nearly every important structure, muscle, tendon, aponuerosis, vessel, nerve, bone, 
and joint. Such cases obviously require the closest scrutiny with a view to the speedy 
detection of their true nature and their proper mode of management. Generally the limb 
is so hopelessly injured as to require removal. 
Compound fractures and dislocations, and gunshot wounds of the joints, often require 
amputation, and yet it is remarkable how the parts and system sometimes bear up under 
such injuries, especially in young and healthy subjects. Under the improved methods of 
management of modern surgery recoveries occasionally occur, which, in former times, 
when their treatment was less perfectly understood than it is now, would have astonished 
the practitioner. In this country the treatment of compound fractures and dislocations 
by occlusion, thereby converting these lesions into simple accidents, and of the former by 
extending and counterextending bands of adhesive plaster, has greatly contributed to 
this result. The danger of these injuries is much greater, other things being equal, when 
they occur in the inferior extremity than when they are situated in the arm and forearm, 
and in all cases the risk is much increased when they are accompanied by an open state 
of an important articulation, as that of the hip, knee, or ankle. Compound fractures in 
the continuity of a limb, unless complicated with serious lesion of the soft structures, do 
not generally require amputation ; if judiciously managed, they will usually get well with- 
out much trouble. Gunshot wounds, occurring in civil practice, are commonly less dan- 
gerous than injuries of this kind happening on the field of battle or on shipboard. I have 
seen enough of the former of these accidents to satisfy me that the patient will often 
recover with a very good limb, even when there has been extensive loss of substance and 
great comminution of the bones. In military practice, on the contrary, there will often 
be much difficulty in preserving the parts, simply because it is frequently impossible to CHAP. XVIII. 
CIRCUMSTANCES DEMANDING AMPUTATION. 
507 
treat the case properly on account of the want of suitable accommodations and a salubri- 
ous atmosphere. It is for these reasons that amputation is so often resorted to, during 
and after engagements, in cases which, if they took place under ordinary circumstances, 
could be successfully managed by milder means. 
When amputation is determined upon, in these and similar accidents, the next question 
is, when should it be performed? Should it be done immediately, or should the surgeon 
wait until the system has recovered from the shock of the injury? To use the knife 
while the patient is in an exhausted, pallid, and, perhaps, almost pulseless condition, 
would only serve the more certainly and effectually to seal his fate ; the additional shock 
to the constitution from the loss of blood and nervous fluid could hardly fail to prove most 
disastrous. Hence the rule is to postpone a resort to the knife until there is satisfactory 
evidence of reaction ; until, in a word, warmth and color return to the surface, the pulse 
beats vigorously at the wrist, and the sufferer regains, in some degree, his consciousness 
and courage. Now the use of an anaesthetic is well borne, and the limb is removed with 
comparative impunity. On the other hand, care is taken not to wait until the part and 
system are assailed by inflammation, which, under such circumstances, often extends witli 
frightful rapidity, placing the case, perhaps, literally beyond the resources of surgery in 
the course of a few hours. There is, therefore, a time when interference must be avoided, 
not less than when it must be courted. The limits of these two periods are not always 
well defined, and must, therefore, be left, in each individual case, to the judgment of the 
attendant. 
An amputation, performed immediately after the occurrence of reaction, is usually 
designated by the prefix “primary,” while the term “secondary” is used to denote the 
operation when it is executed after the limb has passed through the different stages of 
inflammation, an attempt having been made, perhaps well grounded, so far as the 
interpretation of the symptoms is concerned, to save the parts. Such a contingency must 
necessarily happen rather frequently, especially in civil practice; indeed, it is often 
altogether unavoidable on account of the obstacles interposed by the patient and his friends, 
independently of the wavering and indecision of the professional attendant. But, although 
often unavoidable, such an occurrence is always much to be regretted; for if the chances 
of saving limb and life were bad in the first instance, they are now generally much worse ; 
the system has been impaired by fever and perhaps hectic irritation, the secretions are 
seriously deranged, the patient has little appetite and sleep, the blood is thin and watery, 
and the whole body is much emaciated. Life may possibly still be preserved, but the 
probability is that the operation will be attended with much risk, and that ultimate 
recovery is far oft'. Moreover, a much larger amount of limb may now have to be sacrificed; 
originally a foot might have sufficed, whereas now, in consequence of the ravages of the 
inflammation, the whole leg may require removal. There is, then, obviously, an advan- 
tage in a primary over a secondary amputation, provided it is performed at the proper 
time, that is, after the establishment of reaction and before the occurrence of inflammation ; 
and this circumstance is often eageidy embraced by the military surgeon, whose will is 
always law with his patients. 
In addition to these divisions, some writers speak of what they term an “intermediary” 
amputation, performed immediately, or soon, after the supervention of inflammation, and, 
consequently, before the establishment of suppuration. This distinction was first made by 
Bucher, in the last century, in a memoir addressed to the French Academy, and was 
subsequently adopted by Guthrie, Alcock, and other military surgeons, in the early part 
of the present. Such an amputation is unquestionably the very worst that can be selected, 
inasmuch as it is performed at a period when the part and system, assailed by inflamma- 
tion and fever, are ill able to bear up under its effects. Hence the mortality must 
necessarily be much greater than after either of the other procedures; and yet it is easy 
to perceive that cases might arise, both in private, hospital, and military practice, where 
it would be perfectly unavoidable. Accidents, as gunshot, railway, and other injuries, of 
the very worst character, must often occur under circumstances in which the patient is 
either neglected, or where it is impossible to remove the mutilated parts before the 
occurrence of inflammation and symptomatic disturbance. The moment the surgeon sees 
the case it is obvious at a glance that amputation is necessary ; there is no other chance 
for the patient’s life ; nor is any time to be lost. Mortification is either impending or has 
already taken place, and in a few hours the case may be wholly beyond the reach of the 
knife. Here there is no choice. Operative interference is compulsory and imperative. 
In estimating the mortality of primary and secondary amputations it is very important to 
exclude the intermediary, otherwise the calculations must lead to error. 508 
AMPUTATIONS IN GENERAL. 
CHAP. XVIIT. 
2. Mortification.—Mortification, in whatever manner induced, necessarily imperils 
limb and life, and, therefore, often becomes a subject for amputation. Hence the question 
arises, under what circumstances is a resort to the operation advisable and proper? This 
question can only be answered satisfactorily by a consideration of the nature of the morti- 
fication. In the chapter on mortification will be found an account of the several varieties 
of this affection, the causes under the influence of which they take place, their symptoms, 
and the means required for their relief. By a reference to that portion of the work, it 
will be seen that, as it respects the operation under notice, the great rule, recognized by 
nearly all practitioners at the present day, in acute gangrene, is, to wait for the formation 
of a line of demarcation between the dead and living parts, on the ground that it is not 
generally safe to interfere sooner, lest the disease should reappear upon the stump, and 
thus destroy the patient, or necessitate a repetition of the amputation. Of the propriety 
of this rule there can be no question, for there is no surgeon of experience who has not 
witnessed its beneficial effects in his own practice, as well as in that of his friends, and 
yet it is equally true that it may occasionally be violated with great advantage. But I 
would apply to these cases the term “exceptional,” comprising under this head those 
attacks of mortification wdiich are so liable to supervene upon inflammation from external 
injury, as wounds, fractures, and dislocations, which often spread with immense rapidity, 
hopelessly overwhelming, if they are not promptly arrested, both the part and system in 
a few hours. It will not do for the surgeon, in such an emergency, to fold his arms and 
become an idle spectator; he must have his eyes and wits about him, or his patient will 
be irretrievably lost; whatever is done must be done quickly. The wished-for line of 
demarcation will be looked for in vain ; the gangrene will rapidly extend to the trunk, 
and death must soon close the scene. But in spontaneous mortification, or in mortification 
from erysipelas, carbuncle, and analogous affections, the judicious surgeon waits for the 
arrest of the morbid action, his chief care being to bring about this event as speedily as 
possible by appropriate local and constitutional measures. His rule of action is the same 
in hospital gangrene; in both cases means are employed for supporting the system, or, 
what is equivalent to the same thing, for improving the condition of the fluids and solids, 
and the knife is used only when the line of circumvallation is fully established, not a 
minute before. 
In senile, chronic, or dry gangrene, the result usually of calcification of the arteries and 
of their occlusion by fibrinous concretions, thus depriving the tissues of their due supply 
of blood, the rule has heretofore been to wait for the cessation of the mortification, expe- 
rience having shown that, when this precaution is neglected, the disease will be certain to 
reappear in the stump. It is in view of this relapsing tendency in mortification that some 
surgeons, of great eminence and experience, have given it as their judgment that the case 
should always be left entirely to nature’s efforts ; in other words, that we should wait for 
spontaneous amputation, shaping the stump after the sloughs have been nearly completely 
detached, when, it is alleged, the part and system will be better prepared to withstand the 
shock of the knife. The propriety of such advice is sufficiently obvious when it is con- 
sidered that this disease occurs nearly always in very old and infirm subjects, and that it 
is essentially dependent upon obstruction of the arteries leading to the affected structures. 
Such individuals, as I know from personal observation, are usually very feeble, and, 
consequently, ill able to resist the effects of shock or loss of blood. They often rapidly 
sink after the operation, even when there has been a distinct line of demarcation ; or, if 
they survive its immediate effects, the disease speedily reappears upon the stump, and 
soon destroys life secondarily. When we reflect how common these events are, would it 
not be wdse, in these cases, to amputate early at a great distance from the disease, before 
the vital powers have been seriously assailed by the morbid action ; to remove, for 
instance, the limb at the knee, for senile or chronic gangrene of the toes and feet? 
The only objection to such a procedure, it seems to me, would be where the occlusion of 
the main artery of the limb reaches above this point. When no such disease exists, and 
the general health has not materially suffered, I should not hesitate to resort to the 
expedient, under the conviction that, however severe, it was perfectly justifiable in a class 
of cases so unpromising as this confessedly is. 
3. Morbid Growths Amputation is sometimes required on account of morbid growths 
or tumors, both benign and malignant. The removal of the forearm is perfectly proper 
for the cure of sarcoma of the hand, and of the arm at the shoulder for a similar affec- 
tion of the humerus. A similar rule is applicable to the inferior extremity. Half-way 
measures here, as elsewhere, are worse than useless. To amputate in the continuity of CHAP. XVIII. 
CIRCUMSTANCES DEMANDING AMPUTATION. 
509 
the thigh when the lower part of the limb is affected with a malignant growth would be a 
blunder and a crime. No operation is of course admissible if there be marked constitu- 
tional involvement, enlargement of the neighboring lymphatic glands, or decided tendency 
to ulceration ; the propitious period has gone by, and interference would only hasten the 
fatal event. It is not so, however, so long as the health remains good, and there is no 
evidence of general or local contamination ; under such circumstances there is a strong 
probability that removal of the limb, although it may not prevent a recurrence of the 
disease, may yet considerably prolong the patient’s life. 
A tumor, wholly divested of malignancy, may, in consequence of acting obstructingly, 
cause so much functional and other disturbance as to demand removal of the limb upon 
which it is situated. The procedure will be particularly called for when the morbid 
growth is intimately connected with a bone, or deeply and inseparably involved in the 
soft parts, or prolonged into an important joint, compelling free exposure of its surfaces 
during the operation. A valuable rule in tumors is to excise the benign, and to get rid of 
the malignant by amputation. 
4. Aneurism—A neglected aneurism, seated in an extremity, and unamenable to 
ordinary treatment, occasionally calls for the removal of a limb; in former times such 
operations were sufficiently frequent when the disease occupied the popliteal region, 
though at present they are seldom, if ever, required, except when mortification sets in 
after ligation of the femoral artery, or from the injurious compression exerted by the tumor 
upon the leg. 
5. Affections of Bones and Joints Various affections of the bones and joints, as 
caries, necrosis, morbid growths, tuberculosis, and ankylosis, may impose the necessity of 
amputation ; and there is, according to my experience, no class of diseases in which the 
operation has been more frequently abused or misapplied. There can be no question that 
many a limb, merely temporarily crippled by remediable disease, has been ruthlessly sacri- 
ficed to ignorance and a desire for eclat: carious joints, now that excision has been 
revived, can seldom demand so harsh a procedure, and as to necrosis, pure and uncompli- 
cated, it is difficult to conceive of a case justifying the use of the knife. It is only, or 
mainly, in white swelling, or scrofulous disease of the knee, ankle, and elbow, attended 
with hectic irritation, excessive pain, and exhausting diarrhoea, that the removal of a 
limb can be proper, and even then it should not be thought of if it be possible to exsect 
the affected structures without imperilling life by shock and loss of blood. In whatever 
manner the offending parts are disposed of, it is surprising to witness the great improve- 
ment which usually follows the operation ; the profuse sweats and alvine discharges rapidly 
disappear, the appetite improves, the sleep becomes refreshing, and the patient soon 
regains his flesh and strength. Unfortunately, the operation is generally put off to an 
unreasonable period, so that, when it is at length performed, the sufferer too frequently 
sinks under its effects. 
Of malignant growths of the bones almost the only primary one demanding amputation 
of the limbs is sarcoma. When epithelioma of the skin extends to the osseous system, 
as sometimes happens, the same treatment must be applied to it as to sarcoma; that is, 
early and thorough removal by the sacrifice of the suffering extremity. Temporary 
relief only, as a rule, is aimed at; sooner or later the disease recurs, either at the 
cicatrice, or in some neighboring organ, and carries off the patient. 
Fibrous, cartilaginous, and osseous growths involving the bones sometimes constitute a 
legitimate ground for amputation. An exostosis, of enormous size, and grotesque form, 
may render an extremity not only perfectly useless, but a source of the greatest inconve- 
nience and even suffering. Pulsating tumors of the osseous tissue, met with chiefly in 
the head of the tibia, nearly always demand the same remedy. 
Finally, amputation may be required on account of ankylosis of a joint, interfering 
with the comfort and usefulness of an extremity. Thus, in ankylosis of the knee, the 
leg may stand off at a right angle with the thigh, so as to interfere materially with the 
occupation of the individual, and induce a wish for an artificial limb, which, if well con- 
structed, is generally worn with great satisfaction. Stiff and crooked fingers and toes are 
often the subjects of amputation. 
6. Ulcers—Amputation is sometimes performed on account of old and inveterate ulcers 
of the extremities; the operation, however, is less frequently resorted to now than for- 
merly, and might, with proper management, be almost entirely dispensed with. Unless 
the sore is of a carcinomatous character, or caused by burns, scalds, or frost-bites, or com- 
plicated with serious lesion of the bones, excessive enlargement of the veins, or great 510 
AMPUTATIONS IN GENERAL. 
CHAP. XVIII. 
hypertrophy of the integument, there are few cases, it seems to me, that will not gradually 
yield to judicious treatment. Of the numerous ulcers of the extremities that have fallen 
under my observation, embracing, of course, many of the wmrst description, I have a dis- 
tinct recollection only of three that required this harsh measure. Whether other prac- 
titioners have been equally fortunate I am not able to state ; but, judging from the reports 
of cases in our periodicals, it is highly probable that the operation is still not unfrequently 
performed on this account. 
7. Malformations—There are certain malformations and deformities for the relief of 
which amputation may be demanded. An irremediable clubfoot, especially if compli- 
cated with a painful bunion, an intractable ulcer, or excessive atrophy of the leg, would 
form a proper subject for such an operation ; for there are few men who would not rather 
run the risk attending its performance than to be incessantly fretted and worried by such a 
disagreeable and useless companion. Supernumerary thumbs and fingers are disposed of 
in a similar manner; the operation is usually done within a few months after birth, and 
I have never known it to be followed by any bad consequences. Amputation is occa- 
sionally necessary on account of deformity caused by burns and scalds, or badly treated 
fractures and luxations. 
8. Tetanus—The propriety of amputating in tetanus has been so long doubted by 
many of the highest authorities in surgery that the question hardly merits serious consid- 
eration in a work of this kind. I have certainly not seen anything in my own practice 
tending to contradict an opinion now almost universally entertained by the profession in 
this and other countries. If such a measure is ever justifiable, it must be at the very 
commencement of the disease, before the supervention of the characteristic symptoms. I 
have seen a very considerable number of instances of acute traumatic tetanus, and, with a 
few solitary exceptions, they have all proved fatal. One of the cases was that of a stout, 
well-fed countryman, fifty years of age, the fore and middle fingers of w'hose right hand 
had been badly crushed by the passage of the wheel of a wagon ; symptoms of tetanus 
came on upwards of a month after the accident, and, although the disease had existed for 
five days when I amputated at the metacarpo-phalangeal articulation, yet complete re- 
covery followed, not, however, without a slight continuance of the spasms for a short time 
after. In another case the little finger of the left hand had been crushed a fortnight pre- 
viously, and I amputated it the morning after my first visit. Although the symptoms 
had all day been very severe, a gradual improvement soon became apparent, and the 
patient, a young man, twenty-four years of age, made an excellent recovery. The prin- 
cipal remedies were saturnine and anodyne lotions, quinine, morphia, and milk punch in 
liberal quantities. I presume a practitioner would hesitate to cut off a large limb after 
the development of tetanus under any circumstances ; for, whatever notions may be 
entertained respecting the pathology of this affection, there can be no doubt that, once 
fully established, it must be looked upon as a constitutional disorder in the widest sense 
of that term. 
SECT. Ill METHODS OF AMPUTATION. 
Two principal methods are in vogue for performing amputation of the limbs, whether 
in their continuity or at the joints. These are the circular and the flap, both of which, 
but especially the former, are of ancient date, and therefore well grounded in the esteem 
of the profession. To these was added, early in the present century, the oval operation, 
which, although excellent in its way, has hitherto received but little attention ; certainly 
less than it deserves. In 1855, an operation, termed the rectangular, was also proposed. 
At present, flaps constructed entirely of integument are much in vogue. It is not my 
object to enter into the history of these different methods, for to do so would carry me 
back into the regions of doubt and speculation ; but it will be expected that I should 
offer some remarks concerning their respective advantages and disadvantages, and this I 
shall endeavor to do in as concise and impartial a manner as may be consistent with the 
great interest and importance of the subject. 
1. Circular Method The circular operation, the most ancient of all, was originally 
performed in the most simple manner, the integument, muscles, and bones being all di- 
vided upon the same level. The consequence of this procedure was that the bones, inad- 
equately covered by the soft parts, or, rather, not covered at all, invariably perished to 
the distance of several inches, thus sadly protracting the cure, besides subjecting the 
patient to much suffering and not a little risk in the interval. As surgeons became more CHAP. XVIII. 
METHODS OF AMPUTATION. 
511 
enlightened, they endeavored to provide against this contingency by forcibly pulling 
back the muscles, by means of a peculiar contrivance called a retractor, before using the 
saw, which was then applied close to the surface of the tissues. At a later period still, 
and as a decided improvement upon the preceding methods, arose the plan of double in- 
cision, devised by Cheselden, better known for his success as a lithotomist than for his 
exploits as a general operator. It consisted, as, indeed, the name sufficiently indicates, 
of two stages, in the first of which the integument was cut and drawn back, while in the 
second the muscles were divided higher up, the object being to afford more thorough pro- 
tection to the bone. The operation of the English surgeon has undergone various modi- 
fications, some of which, having only served to render it more complex, have been justly 
discarded from practice. To this category belong the division of the muscles by two 
circular incisions, one higher up than the other, and the plan of scooping out the parts 
as the knife was being swept obliquely around them by cutting from below upwards and 
from without inwards towards the bone, which thus formed the apex of the hollow cone. 
The circular operation, as now generally practised, consists, first, in dividing the com- 
mon integument, dissecting it from the parts beneath, to a variable extent, and then draw- 
ing it back, or even turning it up like the cuff of a coat; secondly, in cutting through 
the muscles on a level with the retracted skin, and, after de- 
taching them for some distance from the bone, holding them 
also forcibly back ; and, thirdly, in sawing off the bone as 
high up as possible without doing violence to the soft struc- 
tures. In executing these several stages of the proceeding, a 
long amputating knife, poised lightly between the thumb and 
fingers, is carried rapidly around the limb, the point being in- 
serted into its anterior surface, external to the middle line, and 
thence drawn towards the operator in such a manner that the 
heel of the instrument shall finish the incision. The wound 
thus made extends simply down to the aponeurosis, and care 
should be taken that it occupies the same level throughout, un- 
less there be special reasons for carrying it higher or lower at 
one point than another, rendered necessary, it may be, by the 
presence of a vicious cicatrice, ulceration, gangrene, or some 
morbid growth. The flap is then rapidly dissected up, either 
with the same instrument or with a large scalpel, and held out 
of the way, its length being regulated by the thickness of the 
limb, about two inches and a half being a good average. The 
amputating knife being now resumed, and held as before, is 
applied closely to the edge of the retracted integument, and 
then drawn around the member so as to divide all the muscles 
down to the bone, as represented in fig. 207. This part of the 
operation is usually the work of a few seconds. The next step is to separate the muscles 
carefully from their connection with the bone, to the distance of at least an inch and a 
half, if not more, when, being pressed forcibly back by means of a retractor, the bone is sawed 
off’close to their surface. The adjoining cuts, figs. 208 and 209, afford a good illustration 
of the appearances of the limb, both below and above the stump, after this operation. 
In sawing the bone, whether in this or in the flap operation, it is an object of primary 
importance to inflict as little injury as possible upon the periosteum; for the less the in- 
tegrity of this membrane is disturbed the less likelihood there will be of necrosis, myelitis, 
and other bad consequences. When the periosteum is very thick, as in the thigh-bone, 
a circular track may be made in it for the saw, to lessen the risk of laceration. The 
value of the practice of saving a sufficiency of periosteum to cover in the extremity of 
the bone, followed of late years by certain operators, is not as yet fully determined. The 
object is to protect the medullary canal against the entrance of pus and other fluids, 
thereby preventing the occurrence of osteomyelitis, pyemia, and other mischief. Much 
might certainly be said in favor of the procedure, which, however, is not, by any means, 
always easy of execution. In every instance the utmost care should be taken to injure 
this membrane as little as possible with the saw. 
The manner of dividing the bone is a matter of some moment. In most of the ampu- 
tations that I have witnessed the instrument was applied against the front of the bone, 
instead of being held perpendicularly so as to divide the bone from side to side, as it gen- 
erally should be to avoid fracture, which is so liable to happen if proper care be not taken 
to support the limb in this stage of the procedure. Particular rules are usually laid down 
Fig. 207. 
Circular Amputation shown in 
the Leg, the Integument being 
turned back, and the Muscles 
divided down to the Bones. 512 
AMPUTATIONS IN GENERAL. 
CHAP. XVIII. 
by authors for working the saw. Thus, it is generally stated that the heel alone of the 
instrument should be used until a sufficient track is made for it; but I consider all such 
directions as unnecessary, if not frivolous. If the saw is properly set, it is of little conse- 
quence, according to my experience, what part is applied first or last, or whether it is moved 
Fig. 208. 
Fig. 209. 
Fig. 208.—Appearance of the Limb below the seat of Fig. 209.—Appearance of the Stump in the 
the Amputation, in the Circular Operation. Circular Amputation. 
rapidly or slowly, although, as a matter of choice, I should prefer to finish the operation 
as quickly as possible. When there are two bones of equal size to be cut, as in amputa- 
tions of the forearm, they should be divided simultaneously; but if one is thicker than 
the other, as in the leg, the weaker must always be severed first, lest, if it remain until 
the other is sawed through, it should be broken or splintered, and so impose the necessity 
of employing the nippers to smooth its extremity. 
When a limb is removed at a joint, the best plan, as a general rule, is to dispense with 
the use of the saw and the pliers altogether, experience having shown that the preserva- 
tion of the articular cartilages greatly favors the adhesive process, and thereby expedites 
the cure. Sawing off the ends of the bones exposes the parts to suppuration, erysipelas, 
caries, necrosis, and even to the danger of pyemia. 
2. Flap Method Although the flap operation was described, and no doubt practised, 
by some of the earlier surgeons, it does not seem to have received any particular 
attention until towards the close of the seventeenth century, when Lowdham, of Oxford, 
England, published a short tract upon it, setting forth its advantages over the circular 
method. After this period it was occasionally performed in different parts of Europe, 
especially in France and England, but it never fully acquired the confidence of the pro- 
fession until the time of Mr. Liston, whose teachings and writings brought it into general 
notice. 
There are several methods of forming the flaps, the choice of which must be regulated 
by the particular circumstances of each individual case. Thus, the operation may be 
performed by transfixion of the limb, and cutting from within outwards; by commencing 
at the surface, and carrying the knife inwards towards the bone ; or, lastly, by making 
one of the flaps after the former fashion, and the other after the latter. In amputations of 
the thigh and arm, it is customary to make both flaps by transfixion, as the operation is 
thus greatly simplified and rendered more expeditious; but in the forearm, hand, fingers, 
leg, foot, and toes, they are formed either by cutting inwards, or one by cutting inwards 
and the other by cutting outwards. The number of flaps varies ; in general there are two, 
but occasionally there is only one, and, on the other hand, there may be as many as three; 
accident, or the situation and structure of the limb, rendering one of these modes prefer- 
able to another. Thus, in one instance, I amputated the thigh at its middle by a solitary 
flap, and succeeded in effecting an excellent cure. The military surgeon is often com- 
pelled to form his flaps as best he can, owing to the manner in which the soft parts are 
injured, and in civil practice the same difficulty sometimes occurs in consequence of the 
effects of disease or accident. Whatever may be the nature of the case, the rule is never CHAP. XVIII. 
METHODS OF AMPUTATION. 
513 
to include any unsound tissues or any portion of bone that is fractured or divested of peri- 
osteum. In amputating the thigh and arm at their middle, the flaps are generally cut of 
the same length; but in most other situations one is usually made considerably longer 
than the other, depending upon the greater amount of muscular substance. Their rela- 
tive length must be regulated by the thickness of the limb, and the quantity, laxity, and 
contractility of the soft parts. It is better, in every case, to have too much substance than 
too little, but the judicious surgeon will always endeavor so to cut his flaps as to have just 
enough, and no more, to form a well-shaped and useful stump, redundancy being always 
unseemly, if not actually in the way of comfort and convenience. As a general rule, 
their length should equal about three-fourths of the diameter of the limb, being invariably 
greater than in a similar operation upon the dead subject, to allow for contraction and 
shrinkage. The form of the body of the flaps is commonly somewhat convex, while the 
extremity is more or less oblique, care being taken that they do not terminate in thin, 
narrow ends, and that there is always an abundance of integument after they are adjusted 
over the bone. When the muscular tissue is unusually abundant, as often happens in 
amputating through the calf of the leg, I have found it advisable to retrench it with the 
knife, in order to give the stump a more seemly shape, as well as to place it in a better 
condition for bearing the pressure of an artificial limb. 
In performing the operation the same general rules are to be observed as in the circular 
method; hemorrhage is restrained by the same means, and the skin is drawn back by the 
hands of an assistant, who also retracts the flaps as one after the other is formed, and thus 
holds them out of the way of the knife and saw. Any important vessels that may be 
bleeding are instantly compressed by the fingers until they can be tied. Before applying 
the saw, the knife is passed closely around the bone so as to divide every muscular fibre, 
and also, if possible, the periosteum. The most suitable instrument for removing the 
larger limbs is a long amputating knife; for the smaller ones, an ordinary scalpel, bis- 
toury, or catlin will answer best. Separation of the member having been effected, and 
the vessels carefully secured, the next thing is to cut off the principal nervous trunks a 
little above the level of the surface of the stump, and, as the operation is one of excessive 
pain, it should always be performed before the patient has fully recovered from the 
Fig. 210. 
Fig. 211. 
Fig. 210.—The Flap Operation illustrated in the Thigh. 
The Sloping Wounds, whence the Flaps have been taken, 
shown in the Amputated Part. 
Fig. 211.—The Corresponding Stump ; intended to Exhibit 
the Comparatively Small Extent of Wound that Remains. 
influence of the anaesthetic. I need not dwell upon the importance of thus dealing with 
the nerves involved in the flaps ; the necessity of the procedure must be obvious upon the 
slightest reflection. When it is considered that they always become more or less enlarged 
and bulbous after all operations of this kind, it is easy to perceive what would be the con- 
sequence if they were brought in contact, as some of them almost inevitably would be, 
with the extremity of the bone, before it has had time to become rounded off. I regard 
no amputation by the flap method as being finished unless provision has been made against 
such a contingency. The adjoining cuts, figs. 210 and 211, represent the appearance of 
the stump and of the limb after its removal. 514 
AMPUTATIONS IN GENERAL. 
CHAP. XVIII. 
3. Oval Method.—In the oval method, as it is termed by Scoutetten, by whom it has 
been generalized, or the oblique process, as it has been called by others, the wound has 
somewhat of the shape of an ovoid, the small extremity of which corresponds to the bone 
or joint which is the seat of the amputation. The operation holds a kind of intermediate 
position between the other two, resembling the circular process in the mode of incising 
the soft parts, and the flap in the form of the wound. It is principally adapted to ampu- 
tations of the joints, particularly the smaller, as, for example, the metacarpo-phalangeal, 
but it has also been applied to the joints of the hip and shoulder, especially by Guthrie, 
Larrey, and Scoutetten, who have devised plans which severally bear their names. 
In the oval operation the flaps are formed by cutting from without inwards, or one is 
formed in this way and the other by cutting in the opposite direction, or from within out- 
wards. It is commenced by making two incisions in the shape of the letter Y reversed, 
the angle of union falling a little above the place where it is intended to saw the bone or 
effect disarticulation. These incisions are, of course, extended as far as the periosteum, 
when the knife, drawn closely around behind the bone, is carried downwards on a level 
with the termination of the two cuts already made, thus connecting them by one thrust, 
as the instrument sweeps through the intervening tissues. By adopting this plan of pro- 
cedure the surgeon will have it in his power to leave the principal vessels and nerves until 
the operation is nearly completed, a circumstance which thus affords him a much better 
control over the hemorrhage. 
The oval operation usually makes an excellent stump, there being always an abundance 
of material for covering the bone : it is generally a little more tedious than the flap ampu- 
tation, but this should not be urged as an objection to it, as in all other respects the result 
is most satisfactory. 
4. Rectangular Method—Mr. T. Pridgin Teale, of Leeds, in 1855 modified the double 
flap operation by substituting a long and a short rectangular flap. The long flap should 
be made from the portion of the limb which does not contain important bloodvessels and 
nerves, these being included in the short one. Before proceeding to the operation, the 
lines of the incision should be traced with ink, in order to insure the proper dimensions 
of the large flap, which should be equal, in length and breadth, to one-half the circum- 
ference of the limb at the point amputated. Thus, for example, if the circumference of 
the limb be nine inches, the length and breadth of the flap should each be four inches and 
a half. The short flap, which should be made last, must be one-fourth the length of the 
long one. The lines of the incisions and the length of the flaps will be more easily under- 
stood from the annexed cut, fig. 212, representing an amputation of the thigh. The parts 
Fig. 212. 
Fig. 213. 
Teale’s Amputation shown in the Thigh, the Lines 
indicating the Size and .Form of the Flaps. 
Teale’s Operation, the Flaps being Drawn 
Together. 
having been dissected off, in close contact with the periosteum, the long flap will be found 
to be perfectly square, and to contain a sufficient amount of movable soft parts to form a 
complete cushion for the end of the bone, which must be sawed off perfectly straight, and 
must be free from spicules, in order to prevent ulceration of the soft structures. The 
arteries having been tied, and the larger nerves retrenched, as in the ordinary flap opera- 
tion, the long flap is brought down over the end of the bone, and attached to the short one 
by several points of the interrupted suture. The short flap is also attached to the long 
flap laterally, as is also the reflected portion of the long flap to its unreflected portion. 
The dressing is completed by the application of a few narrow adhesive strips. The 
appearances of the parts, when brought together, are shown in fig. 213. CHAP. XVIII. 
METHODS OF AMPUTATION. 
515 
The rectangular operation makes an excellent stump, furnishing an abundant covering 
for the bone; but, although this is true, it possesses no advantages whatever in ordinary 
cases over the common flap amputation, and will, therefore, not be likely to meet with 
general adoption. If it has any superiority whatever, it is in amputation of the thigh, 
where, by admitting of a greater saving of bone, it diminishes the risk to life. Unless 
great care be taken in forming the flaps, and in superintending the after-treatment, there 
will be danger of non-union, if not also of sloughing, from inadequate nervous and vas- 
cular supply. 
Mr. Teale, in 1861, published the results of 103 cases of rectangular flap amputations, 
of which 84 were cured, and 19 died, or in the ratio of 1 in 5.4. Of the whole number 
35 were of the thigh, and of these 11 died; 37 were of the leg, with a mortality of 4; 
14 of the arm, with 4 deaths; and 17 of the forearm, without any deaths. On comparing 
these results with those of other amputations, it will be seen that the mortality is very 
slightly in favor of the rectangular method. It should be added that all the operations 
were performed at the Leeds Gefieral Infirmary by Mr. Teale and his colleagues, Mr. 
Smith and Mr. Hey. 
Mr. James H. Wharton, of Dublin, in 1868, proposed a modification of Mr. Teale’s 
operation, by which the posterior flap is dispensed with, and the bone sawed off on a level 
with what in the original method would form the lower border of the short flap, the object 
being to save as much bone as possible. The modification thus proposed has found warm 
advocates in several Irish sux-geons, as Stokes, Mapother, Macnamara, Mayne, and Kelly, 
all of whom have performed it with the most gratifying results. The chief objection 
alleged against it is the retraction of the soft parts at the back part of the limb, an oc- 
currence which, so far from being an evil, can always be readily counteracted by proper 
attention during the after-ti'eatment. 
5. Cutaneous Method Flaps composed exclusively of tegumentary structure are now 
much in vogue, both in this country and in Europe, even in the larger amputations, as in 
those of the thigh, leg, and arm. The advantages claimed for them ai’e, first, that, as no 
muscles enter into their composition, there is less danger of sepxiration of the edges of the 
wound, and, therefore, a better chance of union by the first intention ; secondly, deep- 
seated suppuration, so common in the ordinary pi-ocesses, is less frequent; thirdly, the 
operation is not so often followed by caries, necrosis, neuralgia, and other serious acci- 
dents ; and, lastly, as the skin, after the completion of cicatrization, is movable over the 
exti-emity of the bone, the stump is better adapted to bear the pressure of an artificial 
limb. The chief objections to the method are, first, the liability of the flaps to slough, 
especially in cases of injury, attended with more or less contusion ; and, secondly, the 
danger that the stump may eventually become conical in consequence of the retraction 
of the muscles. 
The flaps in this operation may be of equal or unequal length and width, according to 
circumstances. In some instances one is made quite large, and the other pi-oportionally 
small, the former being drawn, like a curtain, over the extremity of the bone, as the long 
flap in the rectangular operation of Teale. In case of accident, three or even four flaps 
may sometimes be advantageously made; and occasionally, again, the surgeon is obliged 
to content himself with one, as when the skin is disfigured by a vicious cicatrice, when a 
chasm has been made in it by an ulcer, or when it has been encroached upon by a morbid 
growth. However fashioned, they should always embrace as large an amount of connec- 
tive and adipose tissues as possible, otherwise, their nervous and vascuhir supplies being 
thus greatly diminished, there will be danger of sloughing. The length of the flaps must 
vary, of course, with the diameter of the limb at the seat of the amputation. In an am- 
putation of the thigh in an adult of ordinary stature, it should not, on an average, be less 
than from three and a half to four and a half inches. The golden rule here, as in all 
similar opei’ations, is to provide an abundant covering for the bone, a result which may be 
materially aided by dividing the muscles a little below its level. The stump, after the 
flaps have been approximated, should be carefully bandaged from above downwai-ds, as a 
means of preventing retraction. In the after-dressings the flaps should be disturbed as 
little as possible, as it is all-important that they should speedily unite to the extremity of 
the bone, in the hope of thereby lessening the risk of the occurrence of osteomyelitis, 
erysipelas, abscesses, and other serious consequences. 516 
AMPUTATIONS IN GENERAL. 
CHAP. XVIII. 
SECT. IV OPERATION AND AFTER-TREATMENT. 
The position of the patient and the surgeon, the number and duties of the assistants, 
and the character of the instruments, must necessarily vary in different cases and under 
different circumstances, and can, therefore, be pointed out here only in a general manner. 
The patient should always, if practicable, be recumbent, as he will thus be much less 
liable to become faint, and at the same time bear the effects of the anaesthetic much better 
than when he sits up. He may, however, put himself in the latter position without any 
inconvenience during the amputation of a finger or toe, or even of the arm or leg, if lie 
is courageous, and willing to dispense with chloroform, or to take ether in its stead. The 
limb, well shaved, is generally held horizontally, away from the table, one assistant re- 
tracting the integument, and another supporting the portion to be removed. To prevent 
the loss of blood, always a great desideratum in an operation of this kind, the limb in all 
large amputations, should be firmly constricted, eithgr with an ordinary roller, or a gum- 
elastic bandage, as originally suggested by Esmarch, extending from the distal extremity 
upwards, wrhen the limb should be encircled by a Petit’s tourniquet or an elastic band, 
so as to cause complete stoppage of the circulation. I have satisfied myself that the ordi- 
nary muslin roller, if properly applied, answers quite as well in preventing hemorrhage 
in these operations as the elastic bandage; while it is far less liable to cause serious con- 
striction of the cutaneous capillaries and nerves, and hence less liable to be followed by 
gangrene of the skin at and around the stump, an effect which is sure to supervene occa- 
sionally upon the use of the elastic compressor. An amesthetic having been administered, 
the operation is proceeded with in as rapid, orderly, and careful a manner as possible. 
When the amputation is performed high up near the trunk, the tourniquet or elastic band 
may sometimes be advantageously replaced by the hands of an assistant, who trusts either 
to his thumbs alone, or else makes the requisite pressure by means of the handle of a stout 
key, wrapped around with a piece of muslin. In separating a large limb, not less than five 
assistants are generally necessary ; one for administering the anaesthetic, a second to see to 
the bleeding, a third to hold up the flaps, one to support the distal portion of the member, 
and a fifth to hand the instrumentsand sponges, and aid in securing the arteries. A smaller 
number will, of course, suffice for the removal of a finger or other insignificant part. 
The different methods of amputation are described in the preceding section. The one 
which I prefer is that by flap, although a most excellent stump may also be made by the 
circular operation. The rectangular method is wTell worthy of attention, as the arrange- 
ment of the long flap not only thoroughly protects the bone, but, what is of great conse- 
quence, admits of ready drainage. The oval operation is admirably adapted to ampu- 
tations at the joints and to resections of the bones. 
My reasons for preferring the flap to the circular operation are, first, because it is more 
simple and easy of execution ; secondly, because it generally affords a much better cover- 
ing for the bone ; and, lastly, because the patient experiences much greater comfort in 
wearing an artificial substitute. 
During the sitting of the commission appointed by Surgeon-General Hammond, to 
report on the subject of artificial limbs, convened at New York, in 1862, upwards of a 
dozen manufacturers, then present, unanimously assured me that stumps made by the 
circular operation are, as a general rule, in every respect, inferior to such as are made by 
the flap method ; that it is much more difficult to fit them with an artificial substitute; 
and that they are a great deal more liable to become chafed, irritated, and ulcerated. 
The results of my own observations strongly corroborate this statement. I wras at much 
pains, by visiting some of our military establishments during our late war, to inform 
myself personally of the comparative merits of the two operations, and, from all that I 
witnessed, I am satisfied that the preponderance is vastly in favor of the flap method. 
Dr. R. J. Levis, in charge of the government hospital in this city for the cure of bad 
stumps, during our late war, bears similar testimony. 
The principal instruments required for the operation are, for the larger limbs, a tourniquet, 
or Esmarch’s apparatus, described on page 489, an amputating knife, a catlin, saw', and 
pliers, which are properly arranged upon a tray in the order in which they may be needed. 
For removing the fingers, hand, toes, or toot, an ordinary scalpel will commonly suffice. 
The tourniquet in general use is that of Petit, the construction and arrangement of which 
may be readily learned from the annexed sketch, fig. 214, a circumstance which, besides the 
fact that it is found in every cutler’s shop, renders any formal description of it unnecessary. 
The tourniquet of Petit has been modified by Mr. Tiemann, of New York, in such a 
manner as to concentrate a much greater amount of pressure upon the artery, at the same CHAP. XVIII. 
OPERATION AND AFTER-TREATMENT. 
517 
time that it does not embarrass the venous circulation. The pad is placed either horizon- 
tally or crosswise upon the vessel, and the strap, carried round the limb, is passed through 
Fig. 214. 
Fig. 215. 
the two side apertures in the metallic plate, after 
which the ends are drawn very tight, and fas- 
tened on the protruding hooks. The arrange- 
ment of the different pieces of the instrument is 
seen in fig. 215. 
Fig. 216 represents an arterial compressor 
devised by me in 1856, as a convenient sub- 
stitute for the ordinary tourniquet, over which, 
I conceive, it possesses several decided advan- 
tages ; first, in the facility of its application; 
secondly, in the amount of pressure which it is 
capable of exerting; thirdly, in its ready adap- 
tation to limbs of different dimensions ; fourthly, 
in the circumstance that it makes pressure only at two points, that is, over the artery, and 
at the spot immediately opposite to the artery ; and, lastly, the facility with which it may 
be slackened or removed at any stage of the operation. With a little modification, the 
instrument may readily be adapted to the femoral artery as it emerges from beneath 
Poupart’s ligament, or even to the external iliac just above this ligament, in amputation 
at the hip-joint, and also to the axillary artery, in disarticulation o. the shoulder-joint. 
Tiemann’s Improved Tourniquet. 
Petit’s Tourniquet. 
Fig. 216. 
Artery Compressor. 
The instrument, as will be seen by reference to the cut, is composed of two blades, 
differing in the degree of their curvatures, united by a screw, and regulated by a ratchet. 
Each short blade is provided with a pad, controlled by a screw, and designed to rest upon 
the artery which it is intended to compress. By this arrangement two tourniquets are 
formed: a large one for the thigh, and a small one for the arm, or the thigh of a small 
subject. 
The ordinary amputating knife, fig. 217, is from nine to twelve inches in length, by 
about five lines in width, with a moderately thick back, spear-pointed, and furnished with 
a stout, rough, ebony handle, to prevent it from dropping out of the hand if it should 
become smeared with blood. The principal edge should extend the whole length of the 
blade, and be in the best possible condition for executing its important office, well temp- 
ered, and perfectly sharp. The edge upon the back should not be longer than an inch 
and a half. With such an instrument, properly managed, nearly all the amputations of 518 
AMPUTATIONS IN GENERAL. 
CHAP. XVIII. 
the body may be performed with great neatness and celerity. The catlin, shown in fig. 
218, is a double-edged knife, used principally in removing the forearm and leg, and for 
Fig. 2i7. 
Amputating Knife. 
dividing the interosseous muscles and ligaments: I cannot see, however, that it possesses 
any special advantage, even in these cases, over the larger knife just described. 
Fig. 218, 
Catlin, or Double-edged Knife. 
Every amputating case contains a large saw, resembling the common dove-tail saw of 
the cabinet-maker. The adjoining*sketch, fig. 219, represents the form of the instrument, 
which 1 am myself in the habit of using. The blade, which is very firm, is ten inches 
and a half in length at the cutting edge, by two inches and one-eighth in breadth, exclu- 
Fig. 219. 
sive of the back, which is very thick and convex, in order to afford the proper degree of 
strength which such an implement should always possess. The handle is rough, and 
sufficiently large to receive two fingers, while the thumb and forefinger are applied to its 
surfaces, parallel with the upper border, to keep it steady while engaged in the discharge 
of its duty. The teeth are rather large but sharp, and set crosswise on the edge, that the 
instrument may not hang or hitch as it works its way through the bone. The manner of 
using the saw has already been described. What is known as Butcher’s saw, represented 
in the chapter on excision, is now generally put up in our amputating cases, and is by 
many surgeons preferred to the saw there described. It is certainly a very excellent 
instrument. 
A small saw, such as is represented in fig. 220, will be of great service in amputations 
of the hand and foot. 
Amputating Saw. 
Fig. 220. 
Cutting pliers, fig. 221, of various sizes and forms, must be at hand; they should be 
short hut rather slender in the blades, and very long and strong in the handle. Although 
I never use these instruments when it is possible to employ the saw, on account of their 
tendency to bruise the osseous tissue, yet they are of great convenience for removing sharp 
spicules, and cutting off certain pieces of the skeleton, as the phalanges of the toes and 
fingers, the ribs, and the jaws. 
The limb being removed, and the nerves, if necessary, retrenched, every bleeding artery 
is promptly secured, commencing with the main trunk and then tying up successively each 
smaller branch until the flow of blood is effectually arrested. 
It is seldom that more than from four to six arteries require to be tied, especially when 
the operation is performed on account of recent injury. When, on the contrary, a limb 
Small Amputating Saw. CHAP. XVIII. 
OPERATION AND AFTER-TREATMENT. 
519 
is removed on account of a morbid growth, as, for example, a sarcomatous tumor, ele- 
phantiasis, or chronic inflammation, the smaller arteries are often immensely enlarged, 
and may, therefore, each demand separate attention. A similar arrangement generally 
exists when the main artery of a limb has been obliterated, whether designedly or acci- 
Fig. 221. 
Bone Nippers. 
dentally, for then all the anastomotic branches carry an unusual amount of blood to atone 
for the loss sustained by the interruption of the principal channel. Hence we occasion- 
ally hear of cases in which as many as twenty, thirty, and even forty ligatures were ap- 
plied before the hemorrhage could be completely arrested. Such a necessity is always to 
be regretted on account of its liability to be followed by serious inflammation and suppu- 
ration from the irritation of so much foreign material. 
Hemorrhage of a troublesome kind often arises when the flaps in an amputation are 
taken from parts recently in a state of inflammation, as the arteries are then firmly embedded 
in the tissues by partially organized plasma, and so rendered incapable of retracting and of 
being drawn forth with the forceps or tenaculum. When this is the case the vessels must 
be separated with the knife, or controlled by acupressure. * 
Not a little trouble is often experienced in checking the flow of blood from the veins, 
especially in amputations of the thigh and leg, performed on account of chronic disease, as 
old ulcers, long-continued inflammation, and various morbid growths. When this is the 
case, the bleeding vessels, which are sometimes quite varicose, may either be tied in the 
same manner as an artery, compressed by means of a long needle, as in ordinary acupres- 
sure, or occluded with a very small pair of forceps, as suggested by Mr. G. II. Porter, of 
Dublin, the instrument being removed at the end of forty-eight hours. Great prejudice 
exists against ligating veins, but experience has shown that the fears that are entertained 
upon this subject ai’e, if not entirely ill-founded, greatly exaggerated. The largest veins, 
as the internal jugular and femoral, have repeatedly been tied with impunity. I have 
myself never hesitated to adopt this treatment when occasion seemed to demand it; and 
in no instance, so far as I remember, have any evil consequences ensued. The testimony 
of other surgeons is equally conclusive upon the subject. 
That the fears of exciting dangerous inflammation of the veins by the application of a 
ligature are utterly groundless, has been conclusively demonstrated by Dr. S. W. Gross, 
in an elaborate communication in the American Journal of the Medical Sciences for January 
and April, 1867. Of forty cases of ligation of the internal jugular vein, analyzed by him, 
death was fairly ascribable to the ligature in only four, all due to secondary hemorrhage, 
coming on about the time of the separation of the thread. In not a single instance was 
diffused phlebitis excited. Since the publication of his paper, Dr. Gross has analyzed 
twenty cases of ligation of the external jugular vein, and fifteen of the axillary vein, which 
add additional testimony to the safety and efficiency of the ligature, inasmuch as all did well. 
The troublesome bleeding which occasionally proceeds from the nutrient artery of the 
bone is usually easily arrested by plugging the orifice temporarily with a piece of soft 
wood, or a little tampon of lint attached to a thread. The oozing from the end of the bone 
sometimes requires the application of a lint compress, but, in general, it speedily stops of 
its own accord, or under the influence of the contact of cold air, or hot water. The 
sponge occasionally used in this form of hemorrhage is objectionable, as it is liable to con- 
tract firm adhesions, rendering its separation difficult, and endangering the occurrence of 
osteomyelitis and the rapid healing of the stump. 
After- Treatment As it respects the permanent dressings after amputation, they should 
be of the lightest and most simple character. In the larger operations they should not, 
as a rule, be applied under four or five hours, or until the wound is well glazed with lymph, 
and all danger of hemorrhage past. It is difficult to conceive of anything more awkward 
for the surgeon, or more disagreeable to the patient, than the necessity of undoing the 
dressings, some hours after the removal of a limb, for the purpose of searching for bleed- 
ing vessels. Such a procedure is sure to cause alarm and suffering; and, although it is 520 
AMPUTATIONS IN GENERAL. 
CHAP, xvi 11. 
always, in ordinary cases, desirable to complete the dressings as early as possible, yet after 
a large amputation, involving vast and numerous muscles liable to conceal arteries of con- 
siderable size, I regard it as a matter of great consequence not to hazard the necessity of 
their removal. During the period that intervenes between the operation and the perma- 
nent dressings, the limb should be placed in an easy, elevated position, and the flaps should 
either be loosely approximated with a few adhesive strips, or, what is better, left apart, 
and covered with light compresses wet with cold water, and frequently irrigated; not changed, 
unless soaked with blood, as this would only lead to exposui’e and irritation of the parts. 
The rules here laid down are chiefly applicable to amputations in civil practice. In 
operations of this kind performed on the battle-field no such delay is, of course, admissible. 
All bleeding and danger of bleeding having ceased, the flaps are carefully stitched in 
place, the ligatures are brought out at the nearest points, and the intervals between the 
sutures are covered with long and rather narrow strips of plaster, to admit of proper drain- 
age. This should be still further favored, when the breach is very large and deep, by the 
insertion of a slender tent in the lower angle of the wound, and by strict attention to the 
position of the stump. To a want of these precautions are unquestionably to be ascribed 
some of the bad effects of these operations, as septicemia, profuse suppuration, and the 
death of the extremity of the bone. The wound being firmly closed at all points 
the matter, of which there is nearly always more or less after all large amputations, 
accumulates in the depths of the stump, around the bone, and among the muscles, 
thus causing necrosis of the former, and affording the veins and lymphatics of the latter 
an opportunity of conveying the fluid into the system, and thereby inducing blood-poi- 
soning. All this risk may be effectually prevented by adopting the plan here suggested 
of keeping a long, slender, and well-oiled tent in the lower part of the wound for the first 
thirty-six or forty-eight, hours ; at the end of this time it may be carefully removed, and 
any pus that may be present gently pressed out. A gum-elastic tube may now, if neces- 
sary, take the place of the tent, with a view to more ready and steady drainage, or, if the 
suppurative crisis is passed, the foreign body may be dispensed with, and the case managed 
in the ordinary way. 
When numerous ligatures are required to arrest the bleeding, as in some of the larger 
amputations, performed on account of chronic disease or morbid growths, the best plan is 
to bring out their extremities at the nearest points of the flaps, instead of at the edges of 
the wound, by means of a large, long, slender needle. Such a procedure will not only 
abridge suffering, but greatly promote the chances of primary union. Chromicized catgut 
ligatures, to which I have recently resorted in all my amputations, are preferable to the 
ordinary ligature, and will, doubtless, come into general use. 
The adhesive strips must, if possible, extend four or five inches beyond the upper ex- 
tremity of each flap, especially in the larger amputations, so as to prevent the retraction 
of the integument, and also for the purpose of quieting the muscles and bringing them 
well forward over the bone. I have been in the habit for many years of beginning the 
application of the roller at the part of the limb nearest to the trunk, carrying it firmly 
and equably downward to the very verge of the stump, which is then enveloped by a few 
crucial turns of the bandage, to give it greater support. No other dressing is necessary. 
The limb is placed in an easy and slightly elevated position, upon a pillow or splint 
covered with oil-cloth, and kept constantly wet with cold water, applied by means of a 
light, porous towel, renewed whenever it becomes in the slightest degree bloody or offen- 
sive. If suppuration be threatened, or the cold is disagreeable and ehilling in its effects, 
the most eligible substitute will be an emollient cataplasm or warm water-dressing medi- 
cated with lead-water and laudanum. The stump is of course carefully protected from 
the contact of the bedclothes. As soon as the operation is over, a full anodyne is ordered, 
for the twofold purpose of relieving pain and preventing spasm, the dose being afterwards 
repeated from time to time as circumstances may seem to demand. The diet should be 
light, but rather nourishing than otherwise; and, with the exception of a mild aperient 
on the second day, no medicine whatever should be given unless it is absolutely necessary 
on account of the violence of the traumatic fever, or the danger of exhaustion from shock 
and hemorrhage. When the system is much depressed at the time of the operation, the 
patient should at once be put upon the use of quinine and iron along with a generous diet, 
aided, perhaps, by milk punch. From what I have seen of such cases, I am satisfied that 
the worst possible plan that can be pursued is starvation, as this not only weakens the 
system still further, but tends powerfully to the production of pyemia, erysipelas, and 
typhoid fever. 
The dressings may require removal within twenty-four, thirty-six, or forty-eight hours CHAP. XVIII. 
OPERATION AND AFTER-TREATMENT. 
521 
after the operation, or not under three or four days, according to the condition of the 
parts. When the adhesive action is progressing favorably, the less interference there is 
the better, any discharge that may collect on the surface of the stump being soaked up 
with a soft sponge. If considerable swelling and pain take place, or profuse suppuration 
set in, the change cannot be effected too soon or too frequently, the limb being well sup- 
ported while this is being done by an assistant, at the same time that all pressure and 
unnecessary manipulation are avoided. Any tendency to bagging is to be counteracted 
by the judicious application of adhesive strips and the bandage, aided by declivity of the 
stump, so as to favor drainage, now of vital importance both to the part and system. Per- 
manganate of potassium or chlorinate of sodium is freely used as a stimulant and a deodor- 
izer. The sutures should not be cut out too soon ; as long as they are affording support 
they should be permitted to remain. 
The antiseptic and cotton-wool dressings, to which reference is made on page 346, are 
much employed in this class of cases ; but as I do not believe that they possess any 
advantages over the simple treatment which I have just described, I never resort to them. 
A mode of treatment, known as pneumatic aspiration, intended to exclude the air from 
the stump, has been extensively practised in some of the Parisian hospitals, especially in 
the wards of the Hotel-Dieu, by Maisonneuve, its inventor. It simply consists in sur- 
rounding the stump with a closely-fitting hood of vulcanized India-rubber, to the centre 
of the free extremity of which is attached a tube, of similar material, from two to three 
feet in length, the opposite end of which is fitted, by means of a metallic canula, in a 
rubber plug secured in a gallon glass jar. “A second metallic tube pierces the India- 
rubber plug, and is connected with a vulcanized tube, of convenient length, attached to a 
brass exhausting pump. A few strokes from the piston morning and evening suffice to 
drawr the discharges from the stump into the jar, where, in the absence of air, they accu- 
mulate without danger of decomposition ; while the healing of the wound is facilitated by 
the accurate and immovable adaptation of its surfaces, and the exclusion of air.” It is 
proper to add that the edges of the wound are held together simply with adhesive plaster, 
unaided by sutures. 
Of the efficacy of' this mode of treatment facts are still wanting to enable us to form an 
accurate opinion. Mr. Gamgee, of Birmingham, who has called the special attention of 
English surgeons to it, speaks of it in very flattering terms, and in the hands of its in- 
ventor it seems to have already achieved great success. 
The treatment of amputation by the “ open method,” as it is termed, orginated by 
Burow, of Germany, and introduced into this country nearly simultaneously by Dr. J. E. 
Link, of Indiana, and Dr. James R. Wood, of New York, deserves more consideration 
than has hitherto been accorded to it. My conviction is that, as a rule, it is preferable 
to every other plan that has ever been devised; more rational, more safe, and more free 
from the risk of complications and bad consequences. Dr. Link, in 1875, reported 190 
cases of amputations treated in this manner, 150 in military, and 40 in civil, practice, 
with results eminently gratifying; and Dr. Wood, who introduced the method many 
years ago, at Bellevue Hospital, has achieved with it the most remarkable success. In 
nearly one hundred operations of this kind performed upon the upper and low'er extremi- 
ties, including the wrrist, elbow, shoulder, ankle, and knee-joints, there was not one death 
which, as he informs me, could justly be ascribed to blood-poisoning, or to the exposure 
of the stump to the air, although, as a rule, his patients were in an indifferent physical 
condition, and often in bad hygienic surroundings. He lays great stress upon the manner 
in which the amputation is performed ; his flaps, which are either lateral or antero-poste- 
rior, are entirely cutaneous, every particle of muscular substance being excluded, and every- 
thing is done with reference to thorough drainage. The “ open method” has found warm 
advocates in Professor Humphry, of Cambridge, and in Mr. Teale, of Leads ; and it may 
safely be predicted that the day is not distant when it will be generally adopted. 
In this mode of dressing, the flaps are left completely open, sutures, adhesive strips, and 
bandages being dispensed with during the first week. The wound is washed immediately 
after the operation with a moderately strong solution of carbolic acid, and then filled with 
balsam of Peru, the drainage, as practised by Dr. Wood, being completed by interposing 
between the flaps a pledget of oakum soaked in the balsam. The stump is left in this con- 
dition during the first twenty-four hours, unless it become hot or painful from overaction, 
when it must be removed at once. After this period the wound is washed twice daily 
with weak carbolized water by means of a douche or syringe, and treated with balsam 
and oakum as in the first instance. When the suppuration has nearly ceased, as it usually 
does by the end of the sixth or eighth day, the flaps are moulded into shape, and gradually 522 
AMPUTATIONS IN GENERAL. 
CHAP. XVIII. 
approximated with adhesive plaster. As this mode of treatment is attended with an un- 
usual shrinkage, the Haps must be made proportionally large. The “open method,” while 
admitting of free drainage, leaves an excellent stump, and is not liable to be followed, as the 
ordinary close dressing, by erysipelas, abscesses, pyemia, septicemia, or suppurative fever. 
The ligatures should be removed as fast as they are detached, with as little injury as 
possible to the vessels and other structures. Their unnecessary retention is a great evil. 
That around the main artery will generally come away last, and special care should be 
taken not to make any undue traction upon it, as its premature separation might be fol- 
lowed by serious, if not fatal, bleeding. 
Secondary hemorrhage occurring after amputation must be treated upon general prin- 
ciples ; by the ligature, if this be practicable, at the stump ; by styptics, as the subsulphate 
of iron ; or by the compress, applied either directly to the orifice of the bleeding vessel, 
the wound having previously been thoroughly dried, or indirectly over the course of the 
affected vessel. The latter expedient is often successful after amputation even of the 
larger limbs. When everything else fails, the only resource is ligation of the main artery 
of the extremity some distance from the seat of the operation. 
After the wound has healed, the stump should be protected for some time with a piece 
of soft flannel, to prevent the ill effects that might otherwise arise from atmospheric vicis- 
situdes ; and all pressure upon its surface should be carefully avoided until the parts have 
regained their natural sensibility. 
Synchronous Amputations In cases of accident, as well as in certain diseases, but 
especially in the former, it occasionally become necessary to amputate two limbs simulta- 
neously, or in immediate succession, the circumstances which call for the removal of the 
one demanding the separation of the other. This constitutes what is termed the synchro- 
nous double operation. It is founded upon the assumption that recovery is more rapid 
when two limbs are cut off simultaneously than at two separate and distinct periods; that 
the loss of blood will be comparatively little more from two amputations thus performed 
than from one alone ; that there will be in the aggregate, much less pain, shock, and 
inconvenience ; and, lastly, that the patient will thus escape the harassing anxiety of mind 
growing out of the knowledge that he will be obliged to submit to another operation. 
Synchronous double amputation has occasionally been performed in various parts of this 
country and Europe ; but, so far as my information extends, it was first adopted, as a rule 
of practice, by the surgeons of the IIotel-Dieu, at Quebec, the first case having occurred, 
many years ago, in the hands of Dr. Morris, of that city. Within the last twenty-five 
years the operation has also been performed by Dr. Carnochan, Dr. S. W. Gross, Robert 
H. Seiler, Paul F. Eve, Amerman, and a number of other surgeons. In 1847, Dr. John 
G. Koehler, of Schuylkill Haven, Pennsylvania, removed simultaneously, on account of a 
railway injury, both legs and one arm from a lad, thirteen years of age, recovery taking 
place without the supervention of any serious symptoms. The limbs were frightfully 
crushed, and the operation was performed within a short time after the accident. The 
arm being cut off first, the pulse immediately sank, but under the influence of stimulants 
it rose sufficiently in five minutes to justify amputation of both legs below the knee. So 
excessive had been the shock of the system that the boy hardly experienced any pain 
during the operation. Professor Stone, of New Orleans, had a similar case, equally 
successful, in a man, thirty-three years of age, the subject of a railway accident. Dr. 
Alfred Muller, of the army, in 1866, amputated both arms on one day, and both legs on 
the next, on account of frostbites, the patient making an excellent recovery. Mr. Begg, 
of Dundee, Scotland, in 1869, amputated all the extremities in a young woman on account 
of embolic gangrene, and she not only recovered but has since been able to walk with the 
aid of crutches, and to earn a livelihood by knitting and various other kinds of work. 
She feeds and dresses herself, and writes an excellent hand. This case, apart from its 
pathological value, as indicating how life may be saved by judicious interference in 
embolic gangrene, is of special interest as showing how lost parts may be supplied by 
ingenious mechanical contrivances, so as to be of great use to an individual who would 
otherwise be wholly helpless. Professor Ashhurst, in 1879, removed successfully, on 
account of railway injury, the left leg at its middle and the right lower extremity at the 
hip-joint, from a boy thirteen years of age. 
The synchronous double operation may be performed by two surgeons, or by one alone, 
the latter being perhaps the preferable method. In either event, it is a matter of para- 
mount importance to protect the patient from the loss of blood, the slightest effusion of 
which might prove prejudicial to his safety. Dr. Carnochan cuts off both limbs before CHAP. XVIII. 
RE AMPUTATIONS. 
523 
he ties any vessels, and this is undoubtedly the preferable plan if we can be certain of hav- 
ing perfect control over the hemorrhage, as when proper assistants are at hand, and the 
removal is effected rapidly by the flap operation. Synchronous amputation of the lower 
extremities may be performed with very little loss of blood, with the aid of the abdominal 
tourniquet. 
The prognosis of synchronous double amputations is, of course, for obvious reasons, 
more unfavorable in the lower extremities than in the upper. Experience shows that the 
operation, when performed for gunshot injuries through both legs, knees, and thighs, is 
nearly always fatal. Both feet, hands, arms, and forearms, on the contrary, may generally 
be removed with comparative impunity. 
Reamputations Such operations may become necessary on account of the bad shape 
of the stump, as when it is too square or too conical, great retraction of the skin and 
muscles leading to protrusion of the bone, extensive caries of necrosis, ulceration of the 
soft parts, and hypertrophy of the nerves, attended with neuralgia and exquisite morbid 
sensibility. The suffering that may be caused by some of these affections may not only 
greatly interfere with progression and the use of an artificial limb, but seriously impair 
the general health and render life perfectly miserable. I have seen cases where the 
extremity of the stump was so irritable as to be intolerant of the slightest touch, the 
patient screaming and wincing as if he had been electrified. 
A second amputation should be performed upon the same principles as a first one. If 
the general health is much deranged, the knife should be withheld until it has been recti- 
fied, otherwise serious, if not fatal, consequences may ensue. Instead of amputation, 
resectipn may sometimes be advantageously performed, the offending parts being removed 
either with the scalpel, or the scalpel and pliers. Hemorrhage is carefully guarded against, 
as the slightest loss of blood may prove highly prejudicial. 
The question has of late years been much agitated, whether, when the bone of a stump 
is extensively diseased, it would not be better to exarticulate the limb than to reamputate 
in its continuity? Valette and Roux, two eminent French surgeons, of large experience 
as military practitioners, have expressed themselves warmly in favor of the former pro- 
cedure, on the ground that there is always great danger, when a bone has been affected 
with osteomyelitis, of a persistence of the morbid action, despite every possible precaution 
that may be used in the removal of the limb in its continuity. The cases under the care 
of Valette were, it would seem, principally of an acute character, while in those of Roux 
the disease had attained its chronic stage. The practice advocated by these surgeons 
cannot, in my judgment, be too strongly condemned, as it is alike harsh and hazardous. 
In acute myelitis, the proper course, as a general rule, is, to wait until, under appropriate 
local and constitutional measures, the disease is effectually arrested, when the mere 
extraction of the sequester will commonly suffice to effect a cure. If this do not answer 
the purpose, the bone may be safely excised, or the limb may be reamputated in its 
continuity, an operation especially indicated when, superadded to the disease of the bone, 
there is serious lesion of the soft parts, or a very defective condition of the stump from 
loss of substance. If it be said that the patient cannot, from the drain and irritation 
consequent upon such an affection, successfully struggle through the period necessary for 
the arrest of the morbid action, it may be replied that such an occurrence, although possi- 
ble, is not probable, and that it must, therefore, be viewed as an exceptional circumstance. 
As it respects the chronic form of osteomyelitis, I am satisfied, from personal experi- 
ence, that exarticulation, so ably advocated by Roux, can only be required in exceptional 
cases. Ordinarily, it will be quite sufficient to remove the sequester, to excise the bone, 
especially if it be carious and disintegrated, or to reamputate in the continuity of the 
limb. With this statement the results of the observations of our army surgeons fully 
coincide. Dr. Richard J. Levis, during his connection with the large government 
hospital of this city for the treatment of diseased stumps, was not obliged to exarticulate 
in a single instance. He always accomplished his object by the adoption of some one of 
the operations here specified. 
I am aware, as is every surgeon of experience, that, in chronic osteomyelitis, the part 
and system become inured to suffering, and, consequently, more tolerant of interference; 
but this, surely, is no valid reason for substituting so hazardous an operation as exarticu- 
lation for one so simple as the extraction of a sequester, the excision of a carious bone, or 
even the amputation of a stump in the continuity of a limb. 
It is not often that a limb is obliged to be reamputated more than once on account of a 
bad stump. The existence of neuralgia requires such interference, perhaps, more 524 
AMPUTATIONS IN GENERAL. 
CHAP. XVIII. 
frequently tlmn any other affection. At all events, it is in this class of cases that the 
operation has most commonly been performed. Instances have been reported in which 
one part of an extremity after an other has been sacrificed for the relief of this disease, 
and yet no ulterior benefit accrued even after amputation at the shoulder or hip-joint. 
Spontaneous Amputations Under this head may be briefly described those amputa- 
tions which occasionally occur during utero-gestation, in consequence of the constriction 
of a limb by a cord or band of plastic matter. Such accidents, which are, surgically 
considered, of comparatively little interest, are usually designated by the term “ sponta- 
neous,” and are liable to take place in the upper as well as in the lower extremities, in 
the larger as well as in the smaller limbs. The division is sometimes complete, at other 
times partial. 
The cause of this occurrence was for a long time a mystery. The prevalent opinion, 
tip to a comparatively recent period, was that it was due to gangrene developed during 
foetal life by some agent, the precise nature of which no one could explain. Unfortunately, 
however, for this view of the case, no evidence was ever discovered, either in the ampu- 
tated limb or in the stump, of the existence of such a condition, and, consequently, the 
notion was at length abandoned. It remained for Professor Montgomery to solve the 
enigma. In a paper published in the Dublin Journal of Medical Science for May, 1832, 
he distinctly asserted that the agency by which the lesion is produced is a cord or band of 
false membrane, thrown accidentally around a limb, acting on the principle of a string, 
drawn more and more tightly by its own contraction, until, if the pressure be continued, 
complete severance of the tissues, hard as well as soft, is effected. That this explanation 
is correct is, I think, unquestionable. The fact that lymph is liable to be poured out by 
the surface of the child, by the placenta, and by the umbilical cord, during pregnancy, is 
well established, and every pathological anatomist knows how prone such matter is, when 
it has become organized, to contract and shrink. This tendency to contract and shrink 
steadily increases with the age of this substance, and, hence, it is easy to conceive how a 
cord or band of membrane might, if drawn firmly around an arm or leg, eventually lead 
to its separation. Zagorsky has published a drawing of a case which affords an excellent 
illustration of partial and complete amputation of the leg by a process of this kind. The 
foot of the severed limb is suspended, as it were, from the centre of the fibrous cord. The 
foetus, which had attained the fifth month, was greatly deformed in the head and hands, 
especially the left. In a remarkable instance described in the London Medical Times and 
Gazette for 1853, intrauterine amputation took place in all the limbs. The child was 
born alive, and was in all other respects well formed. 
The stump after such an occurrence is not always well shaped, and may, therefore, if 
the child survive its birth, require retrenchment or improvement. In general, however, it 
is perfectly cicatrized, and sufficiently seemly. Now and then inconvenience is experienced 
by the protrusion of a piece of bone, the removal of which is followed by a speedy cure. 
SECT. Y AFFECTIONS OF THE STUMP. 
These affections are either of a primary or consecutive character, and both may be 
purely of a local, or of a local and constitutional origin. The primary consist of hemor- 
rhage, spasm of the muscles, excessive pain, undue inflammation, osteomyelitis, and 
inordinate retraction of the soft parts, thereby permitting exposure of the bone. Among 
the secondary effects may be mentioned necrosis and exfoliation of the bone, degeneration 
of the nerves and neuralgic pain, aneurismal enlargement of the vessels, and contraction 
of the tendons in the neighborhood of the stump, by which the latter is drawn out of its 
proper position, and so made a source of inconvenience and discomfort. 
1. PRIMARY AFFECTIONS. 
a. Hemorrhage may come on soon after the dressing of the stump, or not until some 
time has elapsed ; perhaps not for several days. It is usually occasioned by the want of 
a sufficient number of ligatures, in consequence of the retraction of some of the smaller 
arteries, thereby escaping the surgeon’s attention while he is looking out for the principal 
and more accessible branches; or it may be that the vessel has been cut obliquely, and 
that it has not been tied high enough up ; or that the arterial tunics are so much diseased 
as to give way under the pressure of the cord before the formation of an adequate internal 
clot, as when the bleeding supervenes several days after the operation ; or, finally, that 
the vessels are embedded in inflamed tissues, and, consequently, incapable of retraction. CHAP. XVIII. 
AFFECTIONS OF THE STUMP. 
525 
However induced, or whatever may be the circumstances which give rise to the hemor- 
rhage, the proper remedy consists in exposing the open artery, and securing it with a 
ligature, either by separating the flaps, or, if adhesion is already far advanced, by 
dilating the canal along which the blood flows over a grooved director. The main artery 
of the limb is not tied unless it be found impossible, on account of disease, or some other 
cause, to effect ligation at the stump. 
Sometimes the hemorrhage is purely venous, the blood flowing away lazily in a dark 
purple stream, without any jet, and then it will generally be found to depend upon the 
want of accurate coaptation of the flaps, or some defective application in the bandage, 
making either too little or too much pressure ; in the former case keeping the vessels open 
and gaping, in the latter interfering with the passage of their contents. Occasionally 
the blood oozes out at different points, as water oozes out of a sponge, and this may take 
place either from the soft parts, or from the Haversian canals of the bones, or from the 
medullary membrane and the marrow. Arrest of the bleeding is usually effected simply 
by compression of the stump, the compress and roller being made to bear steadily against 
the otfending vessels, aided by elevation and cold applications; when this fails, the 
ligature may be required. When the blood proceeds from the Haversian canals, it will 
generally be necessary to undo the flaps, and apply a compress directly to the surface of 
the bone, the wound being kept open until the flow is arrested. Caustic applications must 
not be used, as they might cause necrosis. 
/3. Spasm of the muscles, which is frequently a source of deep distress, and which 
presents itself in the form of jerks or twitchings, usually sets in within a few hours after 
the operation, and is generally most severe in persons of a nervous, irritable tempera- 
ment. No patient, however, is ever entirely exempt from it after amputation, and 
it is always sure to be materially aggravated on the occurrence of inflammation. In 
regard to treatment, much is to be done in the way of prophylaxis ; by the judicious 
use of the roller to give equable support to the muscles of the stump, by elevation 
of the part to favor venous return, and also by the early exhibition of a full anodyne. 
The use of morphia, or of morphia and antimony, along with warm fomentations, 
will be required if the spasm is at all severe, as when no such precautionary measures 
have been adopted. In most cases prompt relief may be afforded by the subcutaneous 
injection of morphia. 
y. The degree and continuance of the pain which follows an amputation will be 
influenced very materially by the character of the case, the size of the limb, the pre- 
sence or absence of complications, and, above all, by the temperament of the patient. 
Coming on usually as the system emerges from the influence of the anaesthetic, it is some- 
times remarkably slight, while at other times it is so severe as to require large quantities 
of anodyne medicines for its relief. When the pain is associated with spasmodic 
twitching of the stump, as it generally is during the first twenty-four hours, it must 
be promptly met with anodynes, or anodynes and antimony. In order to render these 
two phenomena as light as possible, I have long been in the habit of administering a full 
opiate about two hours before the operation, and have never been disappointed in my 
expectations. 
5. The inflammation consequent upon an operation of this kind may be either of 
the ordinary character, or it may be erysipelatous, the determining circumstances not 
being always appreciable. In general, however, the danger of erysipelatous action will 
be considerable when there has been severe shock or excessive loss of blood, conjoined 
with previous bad health or habits of intemperance. It usually makes its appearance 
within the first forty-eight hours, and is characterized by the ordinary phenomena, 
such as a red, dusky state of the skin, more or less throbbing, a sense of tension, and 
burning, smarting pain, with marked disorder of the general system. Whatever may 
be the degree or character of the inflammation, it is always hostile to the adhesive pro- 
cess ; some parts may, it is true, unite in this way, but suppuration will be almost sure 
to follow, so as to lead to the necessity of healing the greater portion of the wound by 
granulation. In persons of a very dilapidated constitution the inflammation may pass 
into gangrene. I have found this termination most commonly in patients of a scrofulous 
habit of body and in those whose system has been contaminated by syphilis. 
When the suppuration takes place, as it will be very apt to do when there is much 
inflammation, the matter is often widely diffused, burrowing extensively along the inter- 
muscular spaces to a great distance up the stump. This is particularly liable to happen in 
amputations in the lower part of the forearm and leg, the hand, and tarsus, owing to the 
numerous synovial sheaths in those situations readily permitting the entrance of the pus. 526 
AMPUTATIONS IN GENERAL. 
CHAP. XV II i. 
Gangrene is often quite common after amputations in crowded military hospitals and 
barracks, and on board transports, from the vitiated condition of the atmosphere, and the 
generation of noxious emanations, which, rapidly depressing the vital powers, induce a 
low form of fever, and cause every wound, sore, or ulcer, however insignificant, to assume 
an unhealthy, sloughing appearance. 
The treatment of this disease must be conducted upon general antiphlogistic principles. 
Special attention must be paid to the state of the system, and with this view it will gener- 
ally be necessary to employ a mildly stimulating course, consisting of quinine and milk 
punch, with blue mass and ipecacuanha to evacuate the bowels and correct the secretions. 
Morphia is given in liberal doses to allay pain and procure sleep. The most suitable local 
remedies are dilute tincture of iodine, and fomentations or cataplasms medicated with 
solutions of acetate of lead and opium. Leeches generally prove prejudicial. Sometimes 
the disease is promptly arrested by the application of a large blister. Inordinate tension 
and confined fluids are relieved by puncture and incision. Abscesses are opened and 
sinuses traced out in the usual manner, infiltration of pus being always zealously guarded 
against. Counteropenings are made wherever they are likely to be useful, as affording 
a more ready exit to the pus. If mortification is threatened, the parts are freely touched 
with nitrate of silver, sulphate of copper, or dilute acid nitrate of mercury, and enveloped 
in a fermenting poultice. The chlorides are used for allaying fetor, and the syringe for 
washing away secretions from beneath the flaps. 
£. Bad effects occasionally follow amputation as a result of osteomyelitis. In the 
Crimean war this affection was of such frequent occurrence after gunshot injuries that the 
question was at one time seriously debated by a number of surgeons whether it would not 
be best to abandon amputation altogether in the continuity of the larger bones, and resort 
to disarticulation as a substitute. The disease is also sufficiently common in hospital and 
private practice, especially in railway and other severe accidents, attended with violent 
concussion of the osseous tissue. The probability is that it is occasionally caused by 
injury inflicted in sawing the bone. However induced, it generally sets in within a short 
period after the operation, so that by the time the dressings are removed, as they usually 
are on the third, fourth, or fifth day, it is found to have already made considerable 
progress, the marrow being of a brownish, blackish, or greenish appearance, of a soft, 
putrilaginous consistence, excessively fetid, and partially detached from the bone, which 
is itself either dead, or in a dying state, and more or less denuded of periosteum. 
The disease is generally attended with considerable pain, although in some of the cases 
that I have seen there was almost an entire absence of local suffering. It is not unfre- 
quently coincident with pyemia and erysipelas. Hence the prognosis is often exceedingly 
unfavorable. 
The treatment of osteomyelitis must be antiphlogistic, modified by the peculiarity of 
the constitutional symptoms. Great attention must be paid to cleanliness ; the dressings 
must be frequently changed, and free use made of weak solutions of chloralum, perman- 
ganate of potassium, or thymol. The judicious application of nitrate of silver to the 
affected structures might possibly assist in circumscribing and ultimately arresting the 
morbid action. If the bone die, no attempt should be made to remove it until the part 
and system have sufficiently recovered from the effects of the disease to bear the shock 
of the operation. 
£. Finally, amputation is occasionally followed by inordinate retraction of the muscles, 
so as to uncover the bone, and, perhaps, lead to the necessity of its removal. The acci- 
Fig. 222. 
Thigh Stump, with Splint for Extension. 
dent is most liable to happen after amputation of the thigh, in consequence of the action 
of the numerous, large, and strong muscles in that situation, and cannot always be pre- CHAP. XVIII. 
vented even wlien more than ordinary care is taken in forming the stump. The occur- 
rence is always to be deprecated, inasmuch as it not only interferes with the union of the 
flaps, but is very apt to cause the death of the bone. The remedy consists in bandaging 
the limb firmly from above downwards, preceded by the application of long adhesive 
strips, and in placing the parts in the best condition for relaxing the affected muscles. 
Professor Warren, formerly of Baltimore, has suggested, in cases of this kind, the employ- 
ment of extension by means of adhesive strips, weight and pulley, as seen in fig. 222, 
from Bryant, upon the same principle as in the treatment of fractures, and has published 
the results of some cases illustrative of the beneficial effects of his method. When these 
means are unavailing, we may, provided the bone remains sound, divide some of the 
muscles of the stump subcutaneously, and then draw them forward, either with or without 
incision of the integument, as the case may seem to demand. If the bone, however, is 
diseased, the best plan will be to saw it off' higher up ; but such an operation is often more 
hazardous than the original one, and should, therefore, always, if possible, be avoided. 
2. SECONDARY AFFECTIONS. 
The most common, as well as the most serious, secondary effects of amputation are, as was 
previously stated, hemorrhage, necrosis, caries, neuralgia, synovial burses, varicose enlarge- 
ment of the arteries, and permanent shortening of the tendons in the vicinity of the stump. 
a. Secondary hemorrhage is by no means uncommon after amputations, especially in 
persons exhausted by intemperance, loss of blood, and other debilitating iniluences, and 
usually depends either upon the premature detachment of the ligature from ulceration of 
the arteries, or upon the supervention of gangrene, by which the structures of the stump 
are softened and disorganized before the vessels are sufficiently occluded by clots and 
plastic matter. The bleeding may be sudden and copious, or gradual and slight, though 
ultimately, if not checked, not the less surely injurious, or even fatal. It seldom occurs 
before the tenth or twelfth day, and frequently not until after the third week. The blood 
may ooze out at many points, or, if not, in a full stream, either arterial or venous; more 
commonly the former. In the more ordinary cases, the flow may occasionally be promptly 
arrested by systematic compression, applied directly over the course of the affected artery, 
immediately above the bleeding oriiice ; or, instead of this, the vessel may be included 
along with some of the surrounding tissues in a ligature. Now and then the object may 
be attained by means of an acupressure needle. When all these attempts fail, the only 
resource is to cut down upon the main trunk of the artery, some distance above the stump, 
and to secure it with a ligature, as in the operation for aneurism. 
A troublesome form of hemorrhage sometimes accompanies necrosis of the stump, the 
blood oozing away at each dressing from the gap between the dead and 
living structures, much to the detriment of the patient and the annoy- 
ance of the surgeon. It evidently depends upon the inability of the 
vessels in the indurated and diseased parts immediately around the dead 
bone to retract and occlude their orifices, and generally promptly ceases 
upon the removal of the sequester, the exciting cause of the hemorrhage. 
j3. Disease of the bone, eventuating in necrosis, may be induced in 
various ways : in general, it is caused by injury inflicted upon it during 
the operation, consisting either in the laceration and separation of the 
periosteum, in the excessive jarring of its substance, or in the violence 
inflicted upon its nutrient artery, thereby cutting off its wonted supply 
of blood. Uncovering of the bone, in consequence of too great a brevity 
of flap, and the accumulation around its extremity of pus, are also very 
apt to produce it. Sometimes it perishes from the intensity of the in- 
flammatory action. The loss of vitality is indicated by the peculiar 
whitish, greenish, or pale yellowish aspect of the bone, the absence of 
bloody points upon its surface, and a characteristic hollow noise when 
struck with the handle of the knife. The marrow and its envelop gene- 
rally retain their vitality for a short time after the osseous tissue has 
died, an event most likely to happen when the bone perishes only in a 
part of its circumference. Necrosis, as a result of amputation, is more 
liable to occur in the thigh-bone than in any other piece of the skeleton, 
depending probably upon some peculiarity of its organization. The tibia is also occa- 
sionally affected, and a similar occurrence is sometimes met with in the humerus. The 
dead bone may come off in the form, first, of an exfoliation, consisting merely of a part 
AFFECTIONS OF THE STUMP. 
Fig. 223. 
Necrosis of the Bone 
after Amputation. 528 
AMPUTATIONS IN GENERAL. 
CUAP. XVIII. 
of its outer compact substance; or, secondly, as an osseous ring, with long, narrow, sharp 
spicules; or, finally, as a complete cylinder or tube, as when it involves several inches of 
the entire circumference of the bone. The more common appearances of the necrosed bone 
are exhibited in fig. 223. 
The management of these cases must be left very much to the operation of time, espe- 
cially when the bone has perished high up, and when, in order to reach it, extensive 
dissection would be required. If, on the other hand, the necrosis is very limited, an 
attempt may be made to get rid of it with the saw, cutting forceps, trephine, or burr of 
the surgical engine. Too much caution, however, cannot be used in "such an operation, 
trifling as it appears to be. I have seen death produced by it in two cases, and similar 
instances have been witnessed by others. It would seem, when a bone is thus affected, 
as if the system were more than usually intolerant of instrumental interference and loss 
of blood; the parts are generally excessively irritable, and the constitution rarely fails to 
sympathize with them in the most lively manner. Besides, the operation is necessarily 
attended with some degree of hemorrhage, and I am not certain that a patient may not 
be destroyed in this way alone, especially if he is very feeble and irritable at the time. 
Instances occur in which the sequester is firmly, and even obstinately, imprisoned by 
the remains of the living bone; or, more properly speaking, by the new matter that is 
thrown out upon its surface, thus occasioning great difficulty in regard to its removal. 
In a case kindly communicated to me by Professor Markoe, of New York, the sequester, 
consisting of an inner shell of the femur, was retained for many months by a spur of new 
osseous substance extending through an opening in its sides, in such a manner as to nail 
the dead and living parts together, but at the same time allowing the former to be moved 
freely backwards and forwards upon the latter. It was not until after several attempts 
had been made at extraction, attended with much pain and constitutional suffering, that 
riddance was finally effected by means of the chisel and forceps. 
y. Caries of the bone, as a consequence of amputation, is by no means uncommon. I 
have also seen cases where it was obviously due to injury inflicted previously to the opera- 
tion, as when a bone has been severely jarred by a blow, fall, or a partially spent bullet. 
In this condition it is not unusual to find the caries conjoined with necrosis, one part of 
the bone being in a state of ulceration, while another is completely deprived of vitality. 
When the disease is of long continuance, the areolar and compact tissues have an inflamed, 
discolored appearance, and their consistence is so much diminished that they may be cut 
with the knife or crushed with the finger; the periosteum is opaque, thickened, and 
easily pealed off; and the medullary canal is either completely hollowed out, or occupied 
by a softened, reddish, pulpy substance, without any trace of marrow and endosteum. 
No stump can, of course, be healthy under such a state of disease. The bone keeps 
up constant irritation ; abscess after abscess forms; and the soft parts, incessantly in- 
flamed and swollen, are tender, painful, and intolerant of pressure. The proper remedy 
is excision of the affected bone, or reamputation, according to the extent of the disease. 
S. A stump is sometimes rendered exceedingly painful and uncomfortable by the 
development of an exostosis upon the extremity of the bone. The new growth generally 
presents itself in the form of a stalactite, or of an elongated, spur-like projection, narrow7, 
cylindrical, straight, or crooked, from an inch to an inch and a half in length, and of 
variable thickness. The proper remedy is excision. 
?. Another disagreeable, frequently, indeed, a most distressing effect of this operation, 
is neuralgia, coming on at a variable period after its performance, and often continuing, 
despite the most judicious and persevering efforts at relief, to molest the patient during 
the remainder of his life. Supervening generally without any assignable cause, it is most 
common in nervous, irritable persons, subject to the disease in other parts of the body. 
Women are more prone to it than men, and in them the attack frequently coincides with 
the eruption of the menses. Sometimes the disease is periodical, especially in residents 
in malarial regions, the paroxysms coming and going very much as in intermittent fever. 
Most commonly, however, the pain is irregular, one portion of the day being as liable to 
it as another. It is generally of a darting, shooting nature, or dull, heavy, and aching, 
and is invariably aggravated by damp states of the atmosphere, fatigue, and disorder of 
the digestive apparatus. 
In the more violent forms of this affection the immediate cause of the suffering is a 
bulbous enlargement of the nerves ramifying through the stump, as in fig. 224. This 
degeneration takes place, to a greater or less extent, after nearly every amputation, and 
is, therefore, to be considered as a disease only when it exists in excess. Under such 
circumstances the tumor, which sometimes attains the size of a hickory-nut, or even of a CHAP. XVIII. 
SECONDARY AFFECTIONS. 
529 
pullet’s egg, is of a firm, dense consistence, and is composed of a strong fibrous stroma, 
inlaid with hypertropied and curiously interlaced nervous trunks and filaments. It is, in 
fact, a true neuroma. The accompanying pain is exquisite, and the part is so sensitive 
as to be intolerant of the slightest touch ; the general health is much affected, and the 
patient is remarkably susceptible of atmospheric vicissitudes, every change in the weather 
from warm to cold and dry to wet being followed by 
an increase of suffering. The malady is of a much 
more serious character than the other, and requires 
proportionately stronger measures. In general, nothing 
short of removal will avail; by excision, if the tumor 
be single and easily accessible, by amputation, if it be 
multiple and deep-seated. The subcutaneous division 
of the affected nerves seldom affords even temporary 
relief, and stretching of the principal nerves of the 
stump is generally equally futile. 
For the milder varieties of neuralgia the ordinary 
remedies sometimes suffice, as in neuralgia in other 
parts of the body, especially quinine ; or, if the patient 
is anemic, quinine and iron, combined, in either case, 
with strychnia and arsenious acid, belladonna, stra- 
monium, or aconite; the effects of the articles being 
studiously watched, lest an overdose be given, and life 
placed in jeopardy. Sometimes marked benefit accrues 
from the exhibition of colchicum and morphia, admin- 
istered in full doses at bedtime, as one drachm of 
the wine to half a grain of the salt. These medicines are particularly valuable in sub- 
jects with a rheumatic state of the system. Locally, iodine, blisters, issues, and other 
counterirritants are used, along with anodyne embrocations. Hypodermic injections of 
atropia and morphia are occasionally serviceable. The stump is well protected from cold, 
friction, and pressure. 
£. A remarkable trembling—perhaps it might be called a spasm of chorea—of the stump 
is occasionally met with. 1 have seen only two cases of this occurrence, both the result 
of gunshot injury. The affection, in each instance, supervened several months after the 
amputation, and closely resembled what is called shaking palsy. The muscles were in 
constant motion except during sleep, when they were perfectly quiescent; and the stumps 
were exceedingly susceptible to cold. The general health was good. No mode of treat- 
ment that could be devised exercised the slightest influence upon the disease. In one of 
the cases, the whole of the cicatrice had been cut away without any visible benefit. 
rj. A burse sometimes forms upon the stump, generally immediately over the end of the 
bone, in consequence of the long-continued pressure of an ill-constructed and ill-adapted 
artificial leg. The tumor, in time, becomes exquisitely tender and painful, compelling 
the patient to seek relief. The seat and character of the disease are usually pointed out 
by the discoloration and swelling of the part, which often fluctuates on pressure. The his- 
tory of the case, aided by the exploring needle, will readily serve to distinguish it from 
abscess, the only lesion with which it is likely to be confounded. The proper remedy is 
excision in the severer grades of the affection, and in the milder a more careful adaptation 
of the artificial to the natural limb. 
9. Of fibroid degeneration of the tissues of the stump a number of cases have com • 
under my observation since the late war, principally in soldiers who had undergone the 
circular operation with inadequate covering of the bone. In some instances, however, I 
have also noticed it where there was no such deficiency, from the long-continued pressure 
of an artificial limb, provoking and keeping up inflammatory irritation. The skin, in 
these cases, is unusually red, indurated, puckered, tender, exquisitely sensitive, and, here 
and there, perhaps, even ulcerated. The parts in front of the bones, immediately beneath 
the skin, are of a dense fibroid consistence, creaking under the knife, of a whitish or 
grayish color, and composed of a striated matter, interspersed with cells containing nuclei 
and nucleoli. The only available remedy is excision, conjoined, if there be a deficiency 
of covering, with removal of a portion of bone. Occasionally reamputation is required. 
i. Fatty degeneration of the muscles is always present in old stumps, existing, in 
greater or less degree, either by itself, or, as is more generally the case, in union with the 
fibroid transformation. The oily matter gives the altered muscles a peculiar yellowish 
Fig. 224. 
Neuromas of a Stump, after Amputation 
of the Arm A large mass at a ; opposite 6> 
the tumors are more defined. 530 
AMPUTATIONS IN GENERAL. 
CHAP. XVIII. 
appearance, and causes by its pressure more or less atrophy of the fibres, without mate- 
rially diminishing the size of the stump. 
x. Fracture of the bone in the stump of an amputated limb is a very uncommon occur- 
rence, and presents nothing peculiar either as it respects its symptoms, its union, or mode 
of treatment. 
x. Varicose enlargement of the arteries of the stump is extremely rare, only a few 
instances of it being upon record. Unless the disease is unusually extensive, which, how- 
ever, it is not likely to be, nothing need be done for its relief, as it does not generally act 
even as an inconvenience. 
In a case of this kind, under my care in 1870, in a colored man, twenty-four years of 
age, the enlargement began nearly six years previously in consequence of amputation of 
the lower third of the thigh performed on account of a gunshot injury of the knee. The 
stump was exceedingly conical, and a source of so much suffering as to render it almost 
impossible to wear an artificial limb beyond a few hours at a time. The femoral and 
saphenous veins were excessively enlarged and varicose, especially towards the lower part 
of the stump, where they formed a mass fully the size of an ordinary fist, throbbing and 
pulsating violently, and emitting the peculiar whirring sound so characteristic of aneur- 
ismal varix. As the pulsation could readily be controlled by pressure upon the femoral 
artery, I cut down upon that vessel at Porter’s space, a few lines below Poupart’s liga- 
ment, and applied a temporary ligature, hoping to effect occlusion : owing, however, to 
the diseased condition of the artery, and probably also of the blood, ulceration took place 
at the site of the ligature, followed, on the sixth day, by copious and exhausting hemor- 
rhage, terminating fatally three days afterwards. 
Mr. Cadge, of Norwich, has given the particulars of a remarkable case of aneurismal 
varix found in a stump, after amputation of the ankle-joint. The tumor, situated just 
above the internal malleolus, immediately beneath the skin, was elastic, pulsatile, two 
inches in length, and the seat of a 
peculiar thrill, so characteristic of 
this class of affections. Compression 
of the posterior tibial artery readily 
arrested its pulsation. The annexed 
sketch, fig. 225, from Erichsen, 
affords a good illustration of this ex- 
tremely rare occurrence. 
A case of aneurism of the brachial 
artery formed after amputation of the 
lower portion of the arm, from in- 
jury inflicted by the knife during the operation, has been reported by G. W. Smith, of 
Plainfield, Pennsylvania. The tumor, upwards of six lines in diameter, was situated 
about two inches and a half above the point of ligation of the artery, and consisted ex- 
clusively of the internal and middle tunics, the outer one encircling it in the form of a 
well-defined ring. As the stump was not sound in other respects, reamputation was per- 
formed. In an instance related by Warner in his “ Cases of Surgery,” an aneurism 
formed three times on this vessel after amputation of the arm. For the cure of two of 
the tumors the artery was tied immediately above the seat of the disease ; but for the 
last, he applied his ligature high up near the axilla, on the principle of the Hunterian 
operation, and there w'as no further trouble. In a case reported by Delacour an aneurism 
formed on the anterior tibial artery after amputation for a compound fracture of the leg ; 
repeated hemorrhages occurred, and life was saved only by ligation of the femoral artery. 
In all the cases an unsound condition of the coats of the affected vessel was unquestion- 
ably the cause of the aneurism. 
jit. Permanent shortening of the tendons in the immediate vicinity of the stump is 
sometimes a source of great discomfort, as well as of serious interference with the useful- 
ness of the limb. The accident is most liable to happen in the tendons of the hamstring 
muscles after amputation of the leg, and in the tendo Aehillis after removal of the foot 
by Chopart’s method. Much may be done, in both cases, in the way of prevention, by 
attention to position during the after-treatment: it is, in fact, the neglect of this precau- 
tion that usually occasions the difficulty. When the occurrence is unavoidable, or is 
already fully established when first brought under the notice of the surgeon, rectification 
is attempted, generally with a fair prospect of success, by the subcutaneous section of the 
shortened tendons, and the subsequent use of an extending apparatus, constructed on the 
Fig. 225. 
Aneurismal Varix in a Stump. CHAP. XVIII. 
CONSTITUTIONAL EFFECTS OF AMPUTATIONS. 
531 
principle of the double inclined plane, with such modifications as may be required to 
adapt it to each particular case. 
v. The surface of an old stump occasionally suffers from eczema, coming on, perhaps, 
long after the amputation. The occurrence, which is most common in an imperfectly 
healed stump, is characterized by the formation of little blebs and chaps, cracks or fissures, 
the seat of a thin, pale, watery discharge, and of more or less itching. The most suitable 
remedies are cleanliness, conjoined with an occasional laxative, and the application of 
zinc ointment, dilute tincture of iodine, and solutions of acetate of lead. Occasionally 
nothing allays the itching so promptly and effectually as the use of cosmoline with the 
addition to the ounce of ten grains each of camphor and chloral. In obstinate cases 
gentle ptyalism may be required. 
|. Ulceration of the stump from insufficiency of skin, violent inflammation of a diseased 
cicatrice, and other causes, is one of the most distressing of the secondary effects of am- 
putations, keeping the parts tender and painful, and interfering with the use of an artificial 
limb. In the milder cases relief is afforded by the application of nitrate of silver, lotions 
of acid nitrate of mercury, and various kinds of unguents, along with leeches and scarifi- 
cations. Occasionally great benefit is experienced from thorough vesication with can- 
tharidal collodion. In obstinate cases I have sometimes been obliged to excise the ulcer, 
especially when it depended upon the presence of a badly healed cicatrice. When the 
bone is in a diseased, softened, or carious condition, the affected part must be removed at 
the same time, otherwise the operation will be of no avail. 
Filling up the gap left by the removal of the ulcer with sound skin taken from the 
neighboring parts is sometimes advisable, although the operation is one necessarily attended 
with occasional failure. Indeed, such a result will almost be inevitable unless the bones 
are perfectly healthy, and the transplanted flap is very thick and large, properly secured 
in its new place, and well protected during the after-treatment. Skin-grafting, properly 
so-called, may occasionally prove serviceable under such circumstances. 
Resection of the stump may be required when the bone is uncovered, or imperfectly 
protected by soft structures. The operation is easily executed, care being taken to keep 
the knife as closely as possible in contact with the bone during the necessary dissection, 
so as not to interfere with any important vessels and nerves. A similar proceeding may 
be required in case of caries, necrosis, or exostosis. 
Reamputation will be necessary when the stump is so conical as to unfit it for the use 
of an artificial limb; when the soft parts are seriously diseased; when the bones are 
extensively thickened, necrosed, or carious; and, finally, as already stated, when the 
stump is the seat of incurable neuralgia. It is barely possible that an aneurism of the 
stump might also necessitate such a resort. The operation is performed upon the same 
general principles, as the primary one, either in the continuity of the stump or at the 
nearest joint, as circumstances may demand. The result, of course, is not always favor- 
able, especially when reamputation is performed near the trunk for the relief of a stump 
of the lower extremity. 
o. Malignant disease of the stump, in its primary form, is uncommon, but sufficiently 
frequent as a secondary occurrence. Primary carcinoma usually appears in the form of 
epithelioma, as the result of protracted irritation from the pressure of the artificial sub- 
stitute, and pursues the same course as in other parts of the body. Secondary carcinoma 
may take place either upon the cicatrice of the stump or in the skin and connective tissue, 
the period of its occurrence varying, on an average, from six weeks to three months from 
the time of the amputation. The treatment, in favorable cases, is by excision or ampu- 
tation ; under opposite circumstances, by palliation. 
SECT. VI CONSTITUTIONAL EFFECTS OF AMPUTATIONS. 
The most common constitutional occurrences after amputations, especially of the larger 
limbs, are excessive prostration, traumatic fever, pyemia, congestion of the lungs, tetanus, 
retention of urine, and, as a secondary consequence, hectic irritation. 
«. The shock, consequent upon amputation, is frequently extremely severe, and may 
be due, either partly or exclusively, to mere depression of the nervous system, caused by 
the extent, violence, and duration of the operation, to loss of blood, or to the effects of 
anaesthetic agents, or to all these circumstances combined. More or less nervous depres- 
sion will almost necessarily occur during such an operation, however slight, but it gener- 
ally passes off without any particular treatment, simply under the influence of repose, 
exposure to the air, and a drink of cold water. In the more severe forms of the affection, 532 
AMPUTATIONS IN GENERAL. 
CHAP. XVIII. 
however, it may endanger life by its long continuance or excess, and then demands prompt 
attention. The most appropriate remedies are, lowering of the head, so as to facilitate 
the flow of blood to the brain ; the administration of brandy and ammonia, and tincture 
of digitalis, by the mouth, if the patient can swallow, or by the rectum, or under the 
skin, if the power of deglutition is lost; a full dose of morphia and atropia; and sina- 
pisms to the spine, extremities, and precordial region. 
j3. Traumatic fever generally sets in within from six to twelve hours after the operation, 
and will be violent or otherwise according to circumstances, of which the most important 
are, the extent of the previous shock and loss of blood, and the temperament, habits, and 
state of health of the patient. It is characterized by heat and dryness of the skin, flushed 
countenance, suffusion of the eyes, headache, restlessness, excessive thirst, rapid respira- 
tion, and a frequent, hard, and irritable state of the pulse, attended, when there has been 
much hemorrhage, by a peculiar jarring impulse. These symptoms, in the milder cases, 
will often speedily subside spontaneously, but under opposite circumstances they will require 
attention, and, if the surgeon is not fully on his guard, he will be very apt to do a great 
deal more than is either necessary or proper. The fact is, this is not unfrequently the 
critical point in such cases; if we do too much, the patient is irretrievably gone, the con- 
sequence being death either from exhaustion, pyemia, erysipelas, or a low state of fever, 
which nothing can cure. Hence the greatest caution is to be observed; the symptoms 
must be watched, and the utmost care must be taken that they do not deceive us by their 
violence, which is often feigned rather than real, and, therefore, extremely apt to entrap 
the unwary and inexperienced. In general, it will suffice to administer a mild aperient, 
as a little Rochelle salt, a Seidlitz powder, or citrate of magnesium, to sponge the surface 
frequently witli tepid water, and to give cooling, acidulated drinks, which are always very 
grateful in such cases. If the fever threatens to be obstinate, a little antimony is pre- 
scribed, either alone or in union with morphia, to promote perspiration, allay the heart’s 
action, and induce sleep. The lancet is scrupulously withheld, unless the symptoms are 
of extraordinary urgency, and the patient is very plethoric, without having been weak- 
ened by shock or loss of blood. Then a vein in the arm may be opened, and the effect 
of the stream carefully watched, the bleeding being arrested as soon as the pulse evinces 
signs of flagging. 
Very often after amputations of the larger limbs, especially those performed for com- 
pound fractures and dislocations, gunshot wounds, and railway accidents, a low form of 
fever ensues, the system reacting badly, the countenance looking pale and haggard, the 
skin being icterode, cold, and doughy, and the pulse shattered, with great depression of 
spirits, and an utter indifference on the part of the patient as to his fate. It is difficult 
to say what the real condition of the system under such circumstances is, but the prob- 
ability is that the disorder is mainly due to the loss of blood and nervous fluid consequent 
upon the excessive shock to the system at the time of the accident, heightened, perhaps, 
by the effects of the operation. However this may be, the system being depressed and 
withered, the issue is usually most disastrous, very few persons recovering, no matter 
what course may be adopted for their relief. The chief reliance must obviously be upon 
stimulants, as brandy, quinine, ammonia, and nutritious food, with opium to allay pain 
and procure sleep. 
y. Amputations, especially those of the thigh, are often followed by retention of urine, 
caused apparently, not by any actual paralysis of the bladder, but by a want of proper 
volition, the organ retaining its power, without the patient being able to call it into action. 
It usually supervenes within the first twenty-four hours after the operation, and seldom 
lasts less than two or three days, when it gradually passes off. From what I have seen of 
this affection, in this class of cases, I am not disposed to ascribe to it, as some have done, 
an inflammatory origin : that such a condition occasionally exists, is certain, but, in general, 
I am sure it does not. Knowing how frequent intention of urine is after this and other 
capital operations, the attendant should diligently watch for it, and promptly use the 
catheter, in the event of its occurrence. 
8. A not unfrequent event after amputation is •pyemia. Experience shows that it is 
most to be dreaded in cases preceded by extensive shock to the system ; hence it is very 
common after gunshot, railway, and steamboat accidents, attended with extensive lacera- 
tion of the soft parts, and after compound fractures and dislocations. Professor Ashhurst 
finds that of 3110 cases of amputation collected from the records of several hospitals, pyemia 
occasioned death in 30.1 per cent, of all the fatal cases, and in 9 per cent, of the entire 
number. The attack generally comes on within the first six or seven days, being ushered 
in by violent rigors alternating with flushes of heat, and followed by a bad state of the CHAP. XVIII. 
ARTIFICIAL LIMBS. 
533 
stump, with aching pains in the limbs and joints, excessive thirst, restlessness, and a ten- 
dency to delirium even early in the disease. When the joints are involved, there is 
commonly an erysipelatous blush upon the overlying skin, with great tenderness on pres- 
sure and exquisite pain on motion. The case generally proves fatal in less than a week 
from its commencement, and examination after death usually reveals the existence of 
small and ill-defined abscesses in some of the internal organs, particularly in the lungs, 
liver, and spleen. 
The treatment is by stimulants and tonics, such as brandy and milk, quinine, and 
opium, given in large quantity to support the rapidly sinking powers of nature. Mercury, 
in the form of calomel, is sometimes useful, and may be administered in doses of three 
grains every four, six, or eight hours, with a view to rapid but gentle ptyalism. The 
bowels are moved by enemas, all active purgation being inadmissible. Locally, the ordi- 
nary remedies are employed, generally only such as are of a soothing character. 
f. Congestion of the lungs, if not actual inflammation of these organs, is another effect 
of this operation, occurring either alone, or conjointly with pyemia, erysipelas, or an 
adynamic state of the system. It generally comes on in a slow and insidious manner, 
and is, therefore, liable to make serious, if not fatal, inroads before its true nature is sus- 
pected, none of the characteristic signs of pneumonia being present. The only way in 
which it is usually detected is by auscultation and percussion, or by the changes percepti- 
ble in the respiratory movements and sounds of the chest. These changes are generally 
most conspicuous in the lower and posterior portions of the lungs, where the greatest 
amount of blood, in debilitated states of the system, is, in obedience to the laws of grav- 
ity, most liable to accumulate, and, consequently, to produce the greatest degree of mis- 
chief. In most of the cases of pulmonary congestion that I have met with after amputa- 
tion of the larger limbs, there was either an entire absence of pain and cough, or these 
symptoms were so trivial as, in themselves, to attract hardly any attention. The patient 
is able to lie upon his back or on either side, and it is not often that the respiration is 
materially hurried or embarrassed. 
Dry cupping, rubefacients, and blisters are the most reliable local remedies, the system 
being supported with stimulants and tonics, aided by morphia and minute doses of tartrate 
of antimony and potassium. The prognosis is generally unfavorable, especially if the 
disease has made considerable progress and the patient is much exhausted. 
f. The occurrence of tetanus after amputation is uncommon, especially in the more 
temperate regions of this and other countries. Mr. Curling, in his work on this disease, 
gives a table of 128 cases of traumatic tetanus, three of which only were caused by am- 
putation. The affection is much more frequent in military than in civil practice, and is 
most liable to be produced in persons of a nervous, irritable temperament, in consequence 
of exposure to direct currents of cold air. A few years ago I lost a man on the third 
day after an amputation of the thigh, solely from this cause; he had been moved, during 
my absence from the hospital, to an open door, so as to allow the air to blow upon him in 
a full stream. I have known other cases that were induced in similar manner ; and I 
refer to the fact in order to attract special attention to it. The treatment of this disease 
being discussed elsewhere, it is unnecessary to refer to it here. 
rj. Hectic irritation is observed only, or chiefly, as a secondary effect of amputation, 
being caused either by profuse suppuration, or by a poisoned state of the blood and solids, 
from shock, hemorrhage, or the absorption of pus. The symptoms are characteristic, and 
the treatment consists of such means as are calculated to sustain the flagging powers of 
the system, especially quinine and iron, with aromatic sulphuric acid, atropia, milk punch, 
and nutritious food. 
SECT. VII ARTIFICIAL LIMBS. 
The stump, after the cicatrization of the wound, gradually undergoes, as might be ex- 
pected, important changes in its several structures, so as to adapt it the better for the 
various hardships which it is destined to experience in the daily routine of a business life, 
and especially for the support of an artificial limb. The muscles, deprived of the power 
of motion, soon become pale and wasted, and are eventually transformed into hard, 
dense, fibrous bands, entirely destitute of their primitive properties. The bloodvessels 
are obliterated as high up as their first large collateral branches, and converted into 
solid, rigid cords ; the extremities of the nerves are expanded into bulbous masses, of 
an elongated, cylindrical shape, exhibiting more of a nervous than of a fibrous structure; 
and the ends of the bones are rounded off, and covered in by a thin shell of osseous 534 
AMPUTATIONS IN GENERAL. 
CHAP. XVIII. 
matter, which thus effectually closes the medullary canal, as seen in fig. 226. The 
subcutaneous fat gradually disappears, and the skin, unless habitually subjected to 
pressure, is rendered abnormally thin and sensitive. These changes are, of course, the 
work of time, and hence they are always more conspicuous in proportion to the age of 
the stump. In the forearm and leg, the ends of the two bones 
are always united, when the cure is perfected by a kind of 
osseous bridge. 
The period at which the stump may be in a condition for 
the reception and support of an artificial limb must necessa- 
rily vary according to circumstances; if the operation has 
been well done, and the cicatrization has gone on favorably, 
the substitute may be used as early as the sixth or eighth 
week, although in general it will be better to wait some time 
longer, inasmuch as too early a recourse to it will be likely 
to render the parts sore and sensitive, if not the seat of ulce- 
ration and severe pain. So much, indeed, is the patient’s 
comfort influenced by attention to this point, that it is hardly 
possible to be too cautious respecting it. The stump should 
be tightly bandaged for several weeks previous to the ap- 
plication of the artificial limb, to promote the absorption of 
redundant material, and thus impart to it somewhat of a con- 
ical shape. Washing it well several times a day with a strong 
solution of tannic acid and alum will have the effect of 
hardening the integument, so as to moderate its sensibility 
and prevent excoriation. 
Great improvement has been effected in modern times in the construction and adaptation 
of artificial limbs, and there is reason to believe that the inconvenience and suffering oc- 
casioned by their use are more frequently attributable to the misconduct of the surgeon 
than to the want of skill on the part of the manufacturer of the substitute. It has only 
been within a comparatively recent period that operators have hit upon the correct prin- 
ciples of making good and serviceable stumps. Allanson, upwards of three-quarters of a 
century ago, understood the subject much better than it has been understood since, if we 
except the last twenty-five or thirty years. He strongly insisted upon a long and wrell-shaped 
stump, and exerted himself with great ability, but in vain, to induce the profession gen- 
erally to follow his example. The happy changes lately introduced into this department 
of operative surgery are, I believe, mainly due to the manufacturers of artificial limbs, 
who, with an ingenuity and perseverance worthy of so good a cause, 
have reduced the whole process to one of principles founded upon 
the study of anatomy and mechanical philosophy. It would 
be difficult to conceive of any apparatus more beautiful it its con- 
struction, or more admirably adapted to the end proposed, than 
the artificial substitutes manufactured in this country. Combining 
lightness with strength, and neatness with symmetry, they are 
worn with great comfort and satisfaction, and are apparently as 
perfect as any piece of mechanism of the kind can well be made. 
The joints, constructed on the principle of the ball and socket 
articulation, are situated at the proper points, and their surfaces 
move upon each other with great accuracy and facility, through 
the intervention of cords, wires, springs, and levers, the whole 
arrangement being a close imitation of the natural muscles and ten- 
dons, if not in shape, at least in position and function. The socket 
is made with special care, neatly fitting the stump in every portion 
of its extent, and is well padded to prevent friction and excoria- 
tion, the pressure being diffused over the entire circumference of 
the stump, while the extremity of the latter is perfectly free in 
the interior of the former. The annexed cut, fig. 227, affords a 
good illustration of this apparatus. 
To enable the patient to wear his artificial limb with comfort 
and convenience, it is necessary that he should have a good, long stump, well covered, 
perfectly even, and of proper shape, being neither too square and fleshy on the one hand, 
nor too thin and conical on the other. A short, thick, ill-formed stump is a great evil, 
from which the patient can promise himself no good; on the contrary, it can hardly tail 
Fig. 226. 
Appearance of the Bony Stump 
after Amputation. 
Fig. 227. CHAP. XVIII. 
ARTIFICIAL LIMBS. 
535 
to be a constant source of annoyance and pain, becoming sore and excoriated under the 
slightest exercise. The duty of the surgeon, therefore, is one of great responsibility, and 
cannot be discharged without properly weighing, in every instance, the probable conse- 
quences of the operation. When he has his choice, his invariable aim should be to make a 
long stump, so as to afford an abundant leverage and support for the artificial contri- 
vance. In the leg and thigh its length should not, if possible, be less than nine or ten 
inches ; hence the place of election, for the former, should be only about from three inches 
to three inches and a half above the ankle, and for the latter about the same distance 
above the knee. It is not always, however, by any means, in the power of the sur- 
geon to select the point where he might otherwise cut off the limb, and he must then be 
contented in leaving as much substance as he can. If the leg is amputated very high up, 
the Aveight of the body may be supported upon the knee, especially if the patient’s social 
position is such as to prevent him from wearing an expensive substitute, and this will be 
the more necessary because it is often very difficult, if not impossible, to preserve the 
straightness and flexibility of the joint in the event of a very short stump, on account of 
its incessant tendency to retraction and ankylosis. It is for this reason that some sur- 
geons have advised amputation of the thigh just above the knee, when accident or disease 
interferes with the formation of a suitable stump below ; but, if we consider the difference 
in the danger of the two operations, we should hesitate before we give our sanction to 
such counsel, not forgetting that the risk increases Avith every inch the nearer the knife 
approaches the trunk. In amputation of the thigh, the principal pressure of the artificial 
limb upon the stump is concentrated near the body, but care is taken not to apply any 
direct pressure to the perineum, lest it should produce excoriation. 
After amputation at the hip-joint an artificial limb can only be worn with the aid of a 
gutta-percha stump, about ten inches in length, firmly secured around the pelvis by a 
broad, well-lined girdle. With such a contrivance very little difficulty is experienced in 
walking. 
In amputations in children, the development of the limb is always partially arrested, so 
that, by the time the individual attains his full stature, it will be several inches shorter, 
as well as thinner, than its felloAv of the opposite side. Now, surgeons in applying this 
knowledge to amputations of the inferior extremity, have advised that it should never be 
cut off beloAV the knee, but at the loAver third of the thigh, on the 
ground that, if this precaution be neglected, one knee will ultimately 
be elevated a considerable distance above the other, thereby impart- 
ing to the gait a peculiar grotesque appearance. Experience, how- 
ever, has shoAvn that amputation of the leg, even if the stump is only 
a few inches in length, instead of being an objection, is a decided 
advantage, the limb thus affording a much longer leverage than 
when it is cut off through the thigh, for the adaptation of the arti- 
Fig. 228. 
Fig. 229 
ficial substitute, the knee-joint of which can always be made to correspond, in situa- 
tion, with that of the sound limb. Moreover, by adopting this procedure, the weight of 
the body, provided the stump is not too long, is supported upon the knee; another most 
important desideratum under such circumstances. 
Dr. Bly, of Rochester, has devised an artificial limb, which, in addition to the ordinary 
qualities of such a contrivance, admits of lateral motion at the ankle, in imitation of the 536 
AMPUTATIONS IN GENERAL. 
CHAP. XVIII. 
natural joint, and is, in all respects, constructed upon strictly anatomical principles. The 
artificial leg of Dr. Byrd, of Baltimore, has the advantage of affording perfect ventilation 
to the inclosed stump, thus keeping it constantly at an even temperature through the pro- 
cess of insensible evaporation from the surface. 
The annexed drawing, fig. 228, conveys a good idea of the artificial limb usually worn 
by the laboring classes after the loss of a leg or thigh. It may be made very light, and, 
if the stump be of proper length, affords an admirable substitute, the person being able to 
walk nearly with the same facility as in the natural state. 
Various attempts have been made to construct artificial hands and arms, and there are 
now a great many of these contrivances in the shops, which, in point of neatness and 
adaptability, leave hardly anything to be desired upon the subject. Fig. 229 affords an 
illustration of such a limb. 
SECT. VIII MORTALITY AFTER AMPUTATIONS. 
The mortality from amputations is so much influenced by extraneous and intrinsic cir- 
cumstances, and requires such a vast amount of statistical material for comparison and 
contrast, that it is extremely difficult, if not impossible, in the existing state of the science, 
to arrive at any satisfactory conclusions respecting it. It has long been known that the 
danger of the operation is always greater in proportion to its proximity to the trunk and 
the size of the limb. Hence, amputation of the leg is less hazardous than amputation of 
the thigh, and of the thigh in its continuity than of the thigh at the hip-joint. The mor- 
tality of the operation is also greater, as a general rule, in hospital than in private practice, 
in military than in civil practice, and in private practice in cities than in the country. 
Amputations on account of railway accidents are extremely dangerous, and are liable to be 
followed by the worst consequences, even in subjects perfectly healthy at the time of the 
accident, owing to the excessive tendency to mortification and pyemia. 
The circumstances which mainly influence the mortality after amputation may con- 
veniently be arranged into four classes, the first of which refers to the age, previous health, 
and social position of the patient; the second, to the causes necessitating the operation ; 
the third, to the nature, seat, and extent of the operation ; and the last, to the afte r 
treatment. 
1. It will readily be granted that the condition of the patient at the time of the acci- 
dent rendering amputation necessary must exert an important influence upon his fate. If 
he is old, broken in constitution, or in a state of poverty, so as to preclude the possibility 
of receiving proper attention after the operation has been performed, the chances are that 
l e will die, either from shock, erysipelas, pyemia, or congestion of the lungs. The pre- 
vious state of his health exerts no little influence upon the recovery; not, perhaps, how- 
ever, to the extent that is generally imagined. A person who is in bad health at the time 
he is severely injured cannot be expected to bear the shock of an amputation with the 
same impunity as one whose health is good. The system, exhausted by previous suffering, 
is ill qualified in such a case to react favorably after the nervous depression consequent 
upon the operation. 
Age also exerts considerable influence over recovery. Children generally bear ampu- 
tation better than adults and elderly persons, being less subject to attacks of erysipelas 
and pyemia, and making a more rapid recovery. The parts, too, unite more frequently 
by the first intention. At the Hopital des Enfants in Paris, Guersant, who annually per- 
forms from fifteen to twenty operations of this kind, including all the larger limbs, and 
also occasionally the hip and shoulder-joints, loses not more than one out of about nine 
cases, although nearly all are of a scrofulous character. He ascribes his extraordinary 
success mainly to two circumstances; first, a thorough preparation of the system, and, 
secondly, the use of an abundance of good, wholesome, and nutritious food immediately 
after the operation, on the well-known principle that children do not tolerate abstinence 
nearly so well as adults. 
Notwithstanding the success of Guersant at the above institution, it is a well-known 
fact, a fact amply attested by the experience of surgeons in all parts of the world, 
that scrofulous children are usually bad subjects for amputation as it respects their ulti- 
mate fate. Many of them do well for some time after the operation, especially if they are 
properly fed and cared for; the wound often heals with surprising rapidity, and, for a 
time, everything looks uncommonly promising. By and by, however, perhaps at a com- 
paratively early period, the wound breaks out afresh, the neighboring bones or joints 
become involved, the general health gives way, and the patient finally perishes of pulmo- CHAP. XVIII. 
MORTALITY AFTER AMPUTATIONS. 
537 
nary phthisis, meningitis, albuminuria, dropsy, general oedema, fatty degeneration of the 
liver, or some other disorder denotive of a vitiated and depraved state of the constitution. 
Advanced age is eminently unfavorable to a good result, experience having shown that 
amputations in old persons, especially amputations of the lower extremities, almost inva- 
riably terminate disastrously. 
The social position, or the habits and occupation of the patient, must materially influ- 
ence the result of an amputation. The poor man cannot command the same care and 
attention as the rich; he often suffers for want of proper food and nursing, and even 
medicine, at a time, perhaps, when he is most in need of them, and there is no doubt 
that many patients perish from this cause alone that might otherwise be saved. Intem- 
perance in eating and drinking, and unwholesome occupations, must necessarily produce 
a prejudicial effect upon the result. 
2. The influence of the causes necessitating amputation has long been a subject of 
remark on the part of practitioners, both in private and public. Thus, it is an established 
fact that a person who undergoes amputation of one of the larger limbs on account of a 
severe injury, as a compound fracture, or a lacerated and contused wound, is much more 
likely to perish from its effects than one who loses a limb on account of chronic disease. 
The system, in the former case, deeply depressed by the shock of the accident, often 
reacts very slowly and imperfectly, and is, therefore, ill prepared for the approaching 
ordeal of another violent commotion, the effect of which is felt by every organ and tissue 
of the body. In disease, on the contrary, the constitution, although perhaps extensively 
implicated, has become inured to suffering, and, unless too much prostrated, will gen- 
erally be immensely benefited by the removal of the offending parts. The chief excep- 
tion to this rule is in malignant affections, in which, in consequence of the vitiated state 
of the solids and fluids, amputation is often followed, and that very rapidly, by the wrorst 
results. 
3. In considering the probable result of a case of amputation, we must not forget to 
take into view the nature, seat, and extent of the operation. Experience has proved 
that, in civil practice, primary amputation is, other things being equal, a decidedly more 
dangerous procedure than secondary. The very fact that such an operation is required 
shows that the accident for which it is performed must have been a severe one, involving, 
perhaps, the most dreadful lesion of the bones, muscles, joints, and bloodvessels, with 
frightful depression of the nervous system. Now, it is surely impossible that a patient 
thus circumstanced should be in a favorable condition to submit to another violent shock, 
such as must necessarily attend the removal of the affected limb, within a short time after 
reaction has been established. The statistics, both of private and hospital practice, in 
America and Europe, are decisive upon this subject, proving, beyond the possibility of 
doubt, a greater mortality after primary than secondary amputations. Thus, of 456 pri- 
mary amputations of the thigh, leg, and arm, performed in four American hospitals, 157, 
or 34.21 per cent., terminated fatally, while in 174 secondary ones the number of deaths 
was 73, or in the ratio of 41.95 per cent. 
In military practice, on the contrary, the results of amputations are reversed, the pri- 
mary being incomparably more favorable than the secondary. This has been the result of 
the experience of surgeons in all ages and in all countries since the invention of gun- 
pow'der. Larrey and Guthrie saved three-fourths of their cases after primary operations, 
and the returns of the British surgeons in the Crimea are of a similar character, although 
the rate of mortality here was considerably higher, owing to the fact that most of the 
wounds were inflicted with the conical ball; whereas in the campaigns of Bonaparte, and 
in the Peninsular war, they were made with the round ball, the effects of which are, as a 
general rule, much less destructive than those of the former. The observations of Euro- 
pean surgeons in regard to the superiority of primary over secondary amputations were 
abundantly verified during our late war, on both sides of the line. 
The differences between the results of primary and secondary amputations in civil and 
military practice are no doubt due to the circumstances under which they are performed 
and the causes which lead to their necessity. In the first place, there is generally less 
shock in injuries received on the field of battle than in those received in civil life. Sec- 
ondly, the soldier usually submits to the removal of his limb with greater sang-froid than 
the civilian, and often glories in his loss, believing that the world will regard it as an 
evidence of his prowess and patriotism ; whereas the latter finds in his misfortune nothing 
but regret and private calamity. Thirdly, the operation is commonly more promptly 
performed in military than in civil practice, delay, in the latter case, being frequently 
occasioned by the doubts of the surgeon and the interference of the patient and of his 538 
AMPUTATIONS IN GENERAL. 
CHAP. XVIII. 
friends ; and, lastly, a soldier lias not much chance of recovery from an amputation, when, 
an attempt being made to save his limb, he is subjected to rough and tedious transporta- 
tion, and is afterwards obliged, when the operation has been performed, to breathe the 
contaminated atmosphere of a crowded hospital, tenanted by persons borne down by 
similar accidents. Under such circumstances, the mortality from erysipelas, pyemia, and 
typhoid fever will, other things being equal, be much greater than in private practice. 
Faure, from these and other causes, lost 270 out of 300 secondary amputations consequent 
upon injuries received in battle. 
The size and situation of the wound exert an important influence upon the recovery. 
Here again the statistics furnished by various authorities are most eloquent and decisive. 
They have conclusively established the fact, now regarded as a great general law, that 
the larger the wound is, and the nearer it is to the trunk, the greater is the danger to 
life. Thus, Malgaigne, in his statistics of amputations of all kinds in the hospitals of 
Paris, found that the mortality after the removal of the great toe was in the ratio of one 
to six, whereas that of one of the smaller toes was only as one to twenty-six. In ampu- 
tations of the loot the proportion of deaths was about twenty-five per cent., of the leg 
fifty-six per cent., and of the thigh sixty-two per cent. These results have been abund- 
antly verified by the statistics of other institutions, as well as by those of military and 
private experience, and they are full of interest as establishing a law, which should never, 
if possible, be violated. 
The causes which induce this difference in the larger and smaller amputations are chiefly 
shock, hemorrhage, pulmonary congestion, septicemia, pyemia, erysipelas, profuse suppura- 
tion, and gangrene of the stump. Tetanus, too, is more frequent after the former than the 
latter, although the mortality from this affection is not great under any circumstances, 
especially in the more temperate regions of this and other countries. It is certainly not 
difficult to understand the reason why the removal of a large limb should be attended with 
so much more risk than that of a small one. In the former case, the patient has to contend 
not only with the shock of the accident necessitating amputation, which is often of itself 
almost sufficient to destroy him, but as soon as reaction is established he is subjected to 
another source of depression, perhaps almost equally great, from the operation, frequently 
involving copious hemorrhage, and liable to be followed by profuse suppuration and high 
febrile excitement, all tending to depress and exhaust the vital powers. In the latter, on 
the contrary, there is little or no shock, either from the accident or the operation ; the 
loss of blood is inconsiderable; and the inflammatory effects, local and constitutional, are 
comparatively trivial. In short, there is no disorganization of the blood as there is in the 
former, and hence no predisposition to pyemia, or purulent infection, and pulmonary con- 
gestion, which are a source of so much mortality after the large amputations performed 
for severe injuries. 
The result of an amputation may be materially affected by the situation at which the 
bone is divided. Experience has shown that, in the femur, tibia, and humerus, more par- 
ticularly, the danger is much greater when the bone is sawed through its shaft than when 
it is cut off at its articular extremity, owing to the injury inflicted upon the endosteum, 
and the consequent liability of this membrane to diffuse suppuration, phlebitis, and ery- 
sipelas, followed, not unfrequently, by pyemia in its worst form. 
4. Finally, it needs no labored argument to prove that the mortality from amputation 
must be materially affected by the nature of the after-treatment. That many persons 
perish after such an operation from sheer neglect, bad nursing, or bad surgical manage- 
ment, is a fact too well known to require comment. This is true both of private and of 
hospital practice, but the remark applies with increased force when it is made with refer- 
ence to military practice, which, however well the surgical staff of an army may be 
organized, must often, from the very necessity of the circumstances in which the opera- 
tions are performed, and the difficulty of conducting the after-treatment in a proper and 
satisfactory manner, be followed by the most disastrous results, many lives being lost 
that might, under more auspicious circumstances as to locality, comfort, and convenience, 
be saved. The state of the atmosphere, as it respects purity and temperature, the preva- 
lence of epidemic diseases, mental depression, want of proper diet, severe depletion, and 
inattention to the dressings, all exert a more or less powerful influence upon the issue of 
such an operation. The crowded wards of hospitals in large cities, incessantly pervaded 
by foul air, are notoriously prejudicial to recovery after amputations ; gangrene, exhaust- 
ing suppuration, erysipelas, and pyemia are the common lot of such patients, and the 
consequence is that many of them perish. Hence it is that private practice, especially 
that of the country, always shows a much more favorable result than that of large public CHAP. XVIII. 
MORTALITY AFTER AMPUTATIONS. 
539 
institutions, or that of large towns and cities. During epidemic diseases, the percentage 
of deaths from amputations always exhibits a great increase ; for it is then that patients 
are particularly prone to erysipelas, pyemia, and congestive pneumonia. Starvation and 
depletion are a serious source of mortality after this operation, establishing, as they do, a 
tendency to purulent infection and to a typhoid state of the system, from which often no 
stimulants, however powerful and well directed, can afterwards rouse it. I regard such 
treatment after amputation of a large limb, as, indeed, after every other capital operation, 
as a great evil, and one which, in my judgment, demands thorough reform on the part of 
our civil and military practitioners. Finally, I may mention, as another source of mor- 
tality, want of attention to the dressings, which, if allowed to remain on too long, not 
only taint the surrounding atmosphere, but favor the absorption of pus, much to the detri- 
ment both of the part and system. 
Statistics I subjoin the following summary of the statistics of amputations performed 
at the Pennsylvania, New York City, Massachusetts General, and Boston City Hospitals, 
because it seems to place the whole subject of the mortality after these operations in a 
clear and satisfactory light. The table was constructed by Dr. James R. Chadwick, of 
Boston, and embraces the results of 1370 cases, of which 384, or 28 per cent., proved 
fatal. 
Primary Traumatic. 
Secondary Traumatic. 
Pathological. 
Recovered. 
Died. 
Total. 
Ratio of 
mortality. 
Recovered. 
Died. 
Total. 
Ratio of 
mortality. 
Recovered. 
Died. 
Total. 
Ratio of 
mortality. 
Shoulder-joint 
21 
20 
41 
48.78 
3 
3 
6 
50 
11 
4 
15 
26.66 
Arm 
106 
16 
122 
13.11 
17 
12 
29 
41.37 
38 
6 
44 
13.63 
Forearm . 
117 
14 
131 
10.68 
21 
7 
28 
25 
38 
8 
46 
17.39 
Hip-joint 
5 
5 
100 
2 
0 
2 
0 
Thigh 
58 
62 
120 
51.66 
24 
24 
48 
50 
183 
53 
236 
22.03 
Knee-joint 
2 
3 
5 
60.00 
7 
4 
11 
36.36 
Leg 
135 
79 
214 
36.91 
60 
37 
97 
38.14 
143 
27 
170 
15.88 
439 
199 
638 
31.03 
125 
83 
208 
39.90 
422 
102 
524 
19.46 
The most extended statistical tables of amputations, both primary and secondary, that 
have yet been furnished, are those of Mr. James R. Lane, of London. They embrace an 
aggregate of 5722 cases, derived from various sources, civil and military, private and 
hospital, European and American, and may, therefore, be regarded as exhibiting a very 
fair view of the mortality after these operations in different parts of the world. 
Forearm 
Arm. . . 
Shoulder . 
Leg . . . 
Knee • . 
Thigh . . 
Table 1 Amputations for Disease and Injury. 
co 
05 
CN 
Ox 
t-J t-* 
CO H 1—1 05 CO 
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Number of 
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Total Number. 
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Mortality 
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1471 
co ; it* co to 
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Primary. 
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Mortality 
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Number of 
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OX . C7X co to 
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Mortality 
per cent. 540 
AMPUTATIONS IN GENERAL. 
CHAP. XVIII. 
H tr* co > 
►“-* ® S3- *- o 
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Mortality 
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M 
so 
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HfcOWH HMH 
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Number of 
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per cent. 
In the American Journal of the Medical Sciences for October, 1867, Dr. S. W. Gross 
published the statistics of 13,514 amputations for gunshot injuries, and since that date he 
lias materially added to the number, as will be seen from the subjoined table, comprising 
an aggregate of 20,933 cases, derived principally from the late military hospitals of the 
United States, the Austrio-Prussian campaign of 1866, and the wars in the Crimea, 
Schleswig-Holstein, and Italy. 
Amputations for Gunshot Injuries. 
Amputations of the Superior Extremity. 
Total. 
Recovered. 
Died. 
Percentage of 
deaths. 
Wrist-joint 
176 
125 
51 
28.97 
Forearm 
2462 
1954 
508 
20.62 
Elbow-joint 
93 
65 
28 
30.10 
Arm 
7292 
5258 
2034 
27.89 
Shoulder-joint 
1392 
883 
509 
36.56 
11,415 
8285 
3130 
27.42 
Amputations of the Inferior Extremity. 
Ankle-joint 
148 
112 
36 
24.32 
Leg 
4011 
2645 
1366 
34.05 
Knee-joint 
246 
74 
172 
69.1 
Thigh 
4876 
1349 
3527 
72.53 
Hip-joint 
237 
30 
207 
87.38 
9518 
4210 
5308 
55.76 
20,933 
12,495 
8438 
40.30 
The comparative death-rate of limb-amputations in metropolitan and provincial hos- 
pitals, in large and small hospitals, and in hospitals and private country practice in Great 
Britain, was placed in a very striking point of view in 1870 by the researches of the late 
Sir James Y. Simpson. The results obtained by him may be arranged in tabular form. 
Hospital. 
Beds. 
Amputations. 
Recoveries. 
Deaths—Ratio. 
Metropolitan 
300 to 500 
2089 
1134 
855 or 1 in 2.4 
Provincial . . . 
200 to 300 
803 
575 
228 or 1 in 3.5 
i ( 
100 to 200 
1370 
1069 
301 or 1 in 4.4 
U 
26 to 100 
761 
627 
134 or 1 in 5.6 
U 
25 or under 
143 
123 
20 or 1 in 7.1 
Private practice 
2098 
1872 
226 or 1 in 9.2 
6264 
5400 
1764 or 1 in 3.5 CHAP. XIX. 
EXCISION OF BONES AND JOINTS. 
541 
The results of the tables of Mr. Lane show, it will be perceived, in their aggregate 
relations, a mortality of 36.92 per cent., or one death in every 2.7 persons subjected to 
operation. Of the 1370 cases in the four American hospitals, 384 died, giving a mortal- 
ity of 28 per cent., or one in every 3.5. Of the 6264 amputations analyzed by Sir James 
Y. Simpson, 1764, or 28 per cent., proved fatal, thereby affording a ratio of one in 3.5 ; 
while the mortality after amputation for gunshot injuries was 40 per cent., or one in every 
2.48 cases. 
CHAPTER XIX. 
EXCISION OF BONES AND JOINTS. 
The term excision serves to denote the removal of’a bone, whether in its continuity or 
at its extremity, whether it be limited to a portion of its extent or embrace its totality. 
When only the head of a bone is concerned in the operation, the word decapitation is 
occasionally used, and, as meaning the same thing, some authors have adopted the name 
of exsection, while others, especially the French and German surgeons, employ that of 
resection. Plxeision differs from amputation in this, that, while in the latter the bone is 
removed along with the soft parts which surround it, in the former the bone alone is cut 
away, the integument, muscles, and other tissues being retained, in order that they may 
contribute to the future usefulness of the limb; or, in other and more comprehensive lan- 
guage, while in the one case all the structures are destroyed, in the other as many of them 
as possible are preserved. Hence this department of surgery lias very appropriately been 
denominated conservative surgery, and it is most gratifying to know that it constitutes one 
of the leading characteristics of the healing art of the present day. It is not to be 
expected that excision of the bones and joints will ever entirely supersede the necessity of 
amputation, for so long as the various tissues of the body are subject to disease and acci- 
dent, so long will they require removal by the knife in order to prevent the extension of 
their effects ; but that the frequency of the operation will eventually be greatly diminished, 
the experience of the last twenty years abundantly attests. Conservative surgery is still 
in its infancy, and it is needless to conceal the fact that it will take a long time to deter- 
mine its legitimate limits. 
Although incidental mention of excision of the bones occurs in the writings of some ot 
the earlier surgeons, yet it is probable that, if such an operation was ever performed by 
them, it was in great measure, if not entirely, limited to the removal of the protruding 
ends of fractured bones. However this may be, it is certain that there is no well-authen- 
ticated case of excision of the heads of any of the bones until 17G2, when Mr. Filkin, of 
Northwich, removed those of the knee-joint. Soon after this a similar service was per- 
formed for the superior extremity of the humerus by Vigaroux, David, and White. In 
1781, Mr. Park, of Liverpool, repeated Filkin’s operation, and, from the gratifying suc- 
cess attending it, he was led to propose its extension to all the principal articulations, 
much to the surprise of most of his contemporaries, who looked upon the measure as harsh 
and reckless. The consequence was that the proceedure met with much opposition, and 
it might even have been entirely lost sight of if it had not been for the boldness and skill 
of Moreau, the elder, of Bar-sur-Ornain, who, towards the close of the last century, 
exsected, in rapid succession, the articular extremities of the shoulder, knee, and elbow\ 
The success of the French surgeon was followed up by that of his son and successor, who 
obtained great celebrity for his operations upon the joints, attracting patients from all 
parts of France, and who, at various intervals, embodied the results of his observation and 
experience in separate monographs addressed to the Academy of Surgery at Paris and 
other learned societies. In the early part of the present century excision of the joints 
received a powerful and salutary impulse from the French army surgeons, particularly 
Larrey, Percy, Willaume, and Bottin, who repeatedly performed extirpation of the articular 
extremities of the bones, especially those of the shoulder, on account of gunshot injury. The 
operation, indeed, was performed, at one time, upon a large scale, and many limbs,as well as 
lives, were doubtless saved by it. Notwithstanding this, however, the procedure was 
generally regarded with suspicion in Great Britain, where, although it originated there, it 
made no actual progress until about fifty years ago, when, chiefly through the example of 542 
EXCISION OF BONES AND JOINTS. 
CHAP. XIX. 
Liston, Syme, and Ferguson, it began to attract universal attention among medical men. 
During the last third of a century the operation lias been performed in numerous in- 
stances, by surgeons of the highest eminence, upon all the principal articulations, and the 
results have been such as to show that this department of the healing art now rests upon a 
solid and immutable basis. In this country excision of the joints was, until recently, greatly 
neglected, both in hospital and private practice: this, however, is no longer the case, for, 
since the civil war, the intelligence, zeal, and skill of our surgeons have nowhere been 
displayed to greater advantage in this branch of the healing art. All innovations require 
time for their adoption, and what De Condillac said of another subject is equally true of 
this. “ II est rare que l’on arrive tout-a-coup ft l’evidence: dans toutes les sciences et 
dans tous les arts, on a commence par une espece de talonement.” 
Excision of the bones in their continuity has been practised, for various purposes, for a 
long time, and modern surgery is indebted to it for many of its most brilliant exploits. It 
is in this department, more particularly, that American operators have displayed their 
greatest skill. Commencing with excision of the inferior jaw by Dr. Deadrick, of Ten- 
nessee, in 1810, we may with just pride point to the operations of Mott upon the clavicle, 
of Mussey, McClellan, and Gilbert upon the scapula, of Butt and Carnochan upon the 
ulna, and of the latter upon the radius, not to mention numerous minor cases, which, 
although less known, have reflected the highest credit upon the scientific character of the 
profession, and conferred the greatest benefit upon a class of sufferers who would other- 
wise have been doomed to loss of limb and life. 
The principal circumstances necessitating excision are, disease of the bones and joints, 
as caries and necrosis, gunshot, railway, and other injuries, and various kinds of deform- 
ity. The existence of malignant disease in or around an articulation contraindicates its 
performance. Excision has often been advantageously practised in ununited fractures, 
and it is also occasionally resorted to for the relief of deformity dependent upon ankylosis. 
The most common cause for which excision is employed is caries of the bones, more 
especially of their articular extremities, and the operation, if properly executed, is gen- 
erally followed by the most gratifying results, not only as it respects the life of the patient, 
but the usefulness of the limb. The operation is particularly adapted to chronic cases, in 
which the morbid action is in great degree arrested, and the system has become inured to 
suffering. Under opposite circumstances, it is liable to lead to disastrous effects, and 
should, therefore, if possible, be avoided. 
In compound fractures and dislocations excision has been practised almost from time 
immemorial, and frequently with the most satisfactory results. In the latter of these acci- 
dents in particular, whether involving the large or small articulations, experience has 
shown that it is generally more safe, both as it respects limb and life, to resect the ends of 
the protruded bones than to restore them in the usual manner. In the ordinary reduction, 
the synovial membranes and cartilages are usually rapidly destroyed ; profuse suppuration 
takes place, and the patient gradually sinks under hectic irritation ; or if, after having 
struggled through the general danger, he at length escapes with his life, he is very liable 
to lose his limb, or, at all events, to have a permanently stiff, deformed, and useless joint. 
Statistics of excisions for gunshot injuries will be given in a future chapter. Here I 
shall only observe that extended experience has demonstrated that the only large joints 
to which the procedure is at all applicable are the wrist, elbow, shoulder, and ankle. 
Performed upon the hip and knee, it is either promptly fatal, or so unsatisfactory as to 
require subsequent amputation. 
Instruments Various instruments are required for the ready and successful perfor- 
mance of this operation, and it is always desirable to have rather too many than too few, 
so that every emergency may be promptly met as it arises. The incisions through the 
skin and muscles are made with ordinary scalpels, but for detaching the bones from the 
soft parts and dividing the ligaments, stout, probe-pointed knives, with broad steel handles, 
convex and semisharp at the end, will be necessary. Excision of the bone is effected 
with a band-saw, a pair of pliers, or the gouge and chisel, according to the structure, size, 
and situation of the affected piece. The saw, which may be a common amputating one, 
should be from six to ten inches in length by three to twelve lines in width, its teeth 
being sharp and widely set, and its handle long and thick. A saw introduced by Mr. 
Butcher, of Dublin, and bearing his name, will be found very useful, especially when 
there is but little space, or when it is necessary to divide the bone obliquely. It has, as 
will be perceived by a reference to the engraving, fig. 230, a very narrow blade, the angle 
of which can be changed at pleasure. In addition to these instruments, it will be well 
to have upon the tray a Hey’s saw, fig. 231, and also a very narrow concave saw, fig. CHAP. XIX. 
EXCISION OF BONES AND JOINTS. 
543 
232, with a blunt end, in the event of its being necessary to divide the bone from behind 
forwards. As to the chain saw, fig. 233, even in its most approved forms, it may well 
Fig. 230. 
Butcher’s Saw. 
be dispensed with, as its use is generally only productive of delay, vexation, and dis- 
appointment. Bone forceps or pliers, figs. 234-35-36, usually known as Liston’s, 
Fig. 231. 
Key’s Saw. 
Fig. 232. 
Curved Saw for Small Bones. 
although long ago described and delineated by Scultetus, should be at hand, of various 
shapes and sizes, as they may frequently be employed with great advantage in places 
Fig. 234. 
Fig. 235. 
Chain Saw. 
Bone Forceps. 
where it is impossible to introduce and work the saw. The surgeon should also be pro- 
vided with several gouges and chisels, a strong mallet, trephines, scrapers, and a large 544 
EXCISION OF BONES AND JOINTS. 
CHAP. XIX. 
elevator, together with a thick leather strap or leaden spatula for protecting the soft parts, 
during the division of the bone, suitable instruments for holding the flaps apart, and a 
syringe for washing out the wound or clearing away sawdust and the debris of diseased 
bone and cartilage. 
The different steps of the operation will be greatly facilitated by the use of the elastic 
bandage, which, if skilfully applied, will render the proceeding completely bloodless. 
The ordinary tourniquet is not only unnecessary but absolutely hurtful by damming up the 
blood in the recent seat of the diseased structures. If proper care be taken, there 
will be no danger of laying open any of the larger arteries, none certainly that may not 
be readily secured by ligature. 
Position of the Patient The position of the patient, the surgeon, and the assistants, 
as well as the number of the latter, varies in different cases and under different circum- 
stances, and does not admit of any precise rules. Generally speaking, the recumbent 
posture will be the most suitable, especially if an anaesthetic is given and the operation is 
at all likely to prove tedidus. In cases of any magnitude, as in exsection of the knee- 
joint, the number of assistants should not be less than five or six ; one administering the 
anaesthetic, two holding the limb, one handing instruments and tying arteries, and another 
having charge of the sponges. 
As it respects the operation itself, it may conveniently be considered as consisting of 
three stages, the division of the soft parts, the excision of the bone, and the dressing of 
the wound. 
Incisions.—In planning the incisions, care must, of course, be taken not to interfere 
with any structures, the division of which might compromise in any way the result of the 
operation. The sheaths of the tendons are to be especially avoided. To lay them open 
■would be to invite inflammation and plastic deposit, which could not fail to impair their 
usefulness. The nervous trunks are turned aside, out of harm’s way, and the larger 
vessels, both arterial and venous, are studiously protected from injury. 
The number and direction of the incisions will necessarily vary in different cases. In 
most cases, even in such large joints as the hip and shoulder, a single longitudinal cut, 
either straight or more or less curvilinear, will be quite sufficient for the purpose. 
Langenbeck, who has acquired great distinction in this field of surgery, seldom employs 
any other incision than the simple longitudinal, and his success, as is well known, has 
been very extraordinary. Operations in which the parts are exposed by flaps of a 
semilunar, square, or horseshoe form, are seldom practised at the present day, it having 
been found that the wound is much longer in healing, and that the danger from 
erysipelas, pyemia, and other bad consequences is greatly increased. Incisions made 
after the manner of some of those depicted in the chapter on minor surgery will afford 
the surgeon an opportunity of adapting his operations to any case that will be likely to 
come under his observation. 
The elliptical incision may be adopted, when it is necessary to remove diseased integu- 
ments, but, in any event, the great rule is to sacrifice as little soft substance as possible. 
Even when the flap is very large and unseemly, it must not be retrenched, experience 
having proved that it will always contract down to the proper dimensions during the pro- 
gress of the cure. In separating the bone from its muscular and ligamentous connections, 
the knife must be kept as close as possible to its surface ; any deviation from this rule 
will be likely to be followed by the division of structures which should not be meddled 
with, especially important bloodvessels. 
Removal of the Bone Insulation of the bone having been effected, it is next to be 
pushed through the wound, and excised, the parts around being carefully protected from 
injury by a piece of leather or a metallic spatula placed underneath. Whenever it is 
feasible, I prefer sawing off the bone to cutting it away with the pliers, as the surface 
thus made is more smooth, as well as less bruised, and, consequently, more liable to heal 
well. In operating upon the smaller bones, as those of the carpus and tarsus,“we are 
generally obliged to make free use of the gouge and chisel. In whatever manner the ex- 
cision may be accomplished, the invariable rule is to cut through the healthy structure; 
and this is applicable even when the bone is merely denuded of its periosteum, observa- 
tion having shown that, when the osseous tissue is divested of its natural covering, it is 
either already dead, or must soon die. In excision of the long bones, the condition of the 
medullary canal and its contents should always be carefully scrutinized, with a view of 
ascertaining whether the part should be still further retrenched or not. Imperfect ex- 
cision is worse than useless, as no thorough cure can take place after it without another 
operation. Finally, when two bones require to be removed, as, for example, in excision CHAP. XIX. 
EXCISION OF BONES AND JOINTS. 
545 
of the tibia and fibula, they should be sawed off upon the same level, otherwise the limb 
will be apt to be forced to one side, and so be rendered comparatively worthless. 
In excision of the joints, none of the capsular ligament should be left, experience hav- 
ing shown that the danger from infiammation is materially increased when this precaution 
is neglected. 
With the regard to the periosteum, the rule of practice is to preserve every particle not 
involved in disease. Of the value of this precept there can be no question, seeing what 
an important part this membrane plays in the formation, nourishment, and reproduction 
of the osseous tissue. In the chapter on diseases of the bones an instrument is represented 
which I have long employed for effecting the separation of the periosteum, and which is 
admirably adapted to such an object. It is a good plan always to raise the attachments 
of the muscles and tendons along with the periosteum, as its vitality is thus less likely to 
be interfered with. After the operation is over, the membrane should be thoroughly un- 
folded, and carefully spread over the surface of the wound. 
In cases of long standing, requiring excision, the periosteum is generally very consider- 
ably thickened, and, therefore, comparatively easily detached, the inverse being true in 
excision performed in accidents and in cases of recent disease, in which the greatest care 
and patience are usually required to enable one to accomplish the object. 
Dressing.—Bleeding having been arrested, the wound is washed out with cool water 
thrown in with a large syringe, in order to get rid of the sawdust, which, if allowed to 
remain, would act as foreign substance, liable to provoke suppuration and erysipelas, if 
not worse consequences. Any sinuses that may exist are also pared or laid open. The 
edges of the wound are then approximated by the interrupted suture and adhesive plaster, 
aided, if necessary, by a compress and bandage. The most dependent portion of the 
wound, however, should always be kept patent by means of a small tent or tube, to favor 
drainage. If this precaution be neglected, the result will be that the secretions, which 
are always more or less profuse after such an operation, will accumulate in the wound, 
thus not only impeding the cure, but often inducing necrosis of the bones, and affording 
an opportunity for the easy entrance of pus into the system. 
Before the patient is returned to bed, the limb should be placed in the position in which 
it is to rest during the after-treatment, and kept perfectly quiet by means of appropriate 
apparatus. In excision of the inferior extremity osseous union is usually desired, as the 
limb would hardly be useful without it, and, hence, it will not be proper, as a rule, to 
make passive motion. In the upper extremity, however, this rule is not applicable ; here 
motion is both sought for and attained at all hazard, an ankylosed wrist, elbow, or 
shoulder being of little value. 
The great sources of danger, after excision of bones and joints, are excessive suppura- 
tion, pyemia, septicemia, hemorrhage, and erysipelas. These accidents are to be carefully 
guarded against by the ordinary means, and treated upon general principles in the event 
of their occurrence. If the convalescence is unusually protracted, and especially if the 
wound is slow in healing, if sinuses form, or if there is much discharge of an unhealthy 
character, there will be reason to suspect that the bones have again become diseased, and 
that further interference will be required before a cure can finally be effected. 
The twitching of the muscles after these operations, so often interfering with the repara- 
tive process, and causing the patient intolerable anguish, is generally very promptly relieved 
by hypodermic injections of morphia, or by morphia and valerian administered by the mouth. 
Statistics The statistics of excision of the bones and joints have been placed in a very 
prominent and satisfactory point of view by the researches of Dr. Richard M. Hodges, of 
Boston, and by Dr. Oscar Heyfelder, of St. Petersburg, in two excellent and exhaustive 
monographs, published in 1861. The subjoined tables, compiled by the latter of these 
writers, comprise the aggregate results of 2241 cases, of which 1280 relate to the bones, 
and 961 to the joints. 
Excision of Bones. 
Cases. 
Recoveries. 
Deaths. 
Failures. 
Percentage 
deaths. 
Extremities 
605 
471 
60 
74 
9.91 
Face 
559 
379 
174 
6 
31.12 
Trunk 
116 
82 
32 
2 
27.58 
1280 
932 
266 
82 
36.04 546 
EXCISION OF BONES AND JOINTS. 
CHAP. XIX. 
Excision of Joints. 
Cases. 
Recoveries. 
Deaths. 
Failures. 
Percentage 
deaths. 
Wrist 
49 
35 
9 
5 
18.36 
Elbow 
286 
205 
32 
49 
11.18 
Shoulder 
196 
131 
30 
8 
15.30 
Ankle 
174 
149 
16 
9 
9.19 
Knee 
213 
129 
64 
20 
30.04 
Hip 
70 
35 
35 
50 
| 961 
684 
186 
91 
36.78 
From these tables it will be seen that in excision of the joints the smallest mortality is 
afforded by the ankle, and the largest by the hip. In regard to excision of the bones, the 
greatest percentage of fatal cases is furnished by the face. The mortality after all ampu- 
tations, according to Mr. James II. Lane, calculated from a total of nearly 6000 cases, is 
as high as 36.92 per cent., or one in every 2.7 of the patients submitted to the operation. 
Dr. S. W. Gross has collated the most extensive statistics of excision of the shafts of 
the bones for gunshot injuries, of which I have any knowledge. The subjoined table, 
compiled by him, comprises 1657 cases. 
Excision 
of Bones. 
Cases. 
Recoveries. 
Deaths. 
Percentage 
deaths. 
Radius 
359 
311 
48 
13.37 
Ulna 
312 
262 
50 
16.02 
Radius and ulna 
64 
56 
8 
12.50 
Humerus 
700 
496 
204 
29.14 
Fibula 
81 
65 
16 
19.75 
Tibia 
72 
57 
15 
20.83 
Tibia and fibula 
19 
15 
4 
21.05 
Femur 
50 
6 
44 
88 
1657 
1268 
389 
23.47 
In a recent exhaustive work on excision of the joints for gunshot injuries, Professor 
Gurlt, of Berlin, lias analyzed 3667 cases, the results of which, as are shown in the follow- 
ing table, were determined in 3596. 
Excision 
of Joints. 
Cases. 
Recoveries. 
Deaths. 
Percentage 
deaths. 
Wrist 
132 
112 
20 
15.15 
Elbow 
1403 
1054 
349 
24.87 
Shoulder 
1634 
1067 
567 
34.70 
Ankle 
145 
94 
51 
35.17 
Knee 
144 
33 
111 
77.08 
Hip 
138 
16 
122 
88.40 
3596 
2376 
1220 
33.92 
It will thus be perceived that in excision of the long bones the smallest mortality is 
afforded by the radius and ulna, and the largest by the femur. In regard to excision of 
the joints, the smallest percentage of deaths is afforded by the wrist, and the largest by 
the hip. The aggregate mortality of the above cases is 30.63 per cent., while of the 
20,933 amputations for gunshot injuries, according to Dr. Gross, 8438, or 40.30 per 
cent., proved fatal. CHAP. XX. 
ANAESTHETICS. 
547 
CHAPTER XX. 
ANAESTHETICS. 
The prevention of pain in surgical operations has been an object of anxious solicitude 
with practitioners from time immemorial, and we accordingly find that suggestions, more 
or less plausible, have been made at different periods with a view of meeting this im- 
portant end. One of the most remarkable of these suggestions, inasmuch as it was a 
clear foreshadowing of the anaesthetics of the present day, occurs in the surgical writings 
of Theodoric, in the latter part of the thirteenth century. The means recommended by 
him consisted in thoroughly impregnating a sponge with a strong aqueous extract of vari- 
ous anodyne articles, especially opium, hemlock, hyoscyamus, lettuce, and mandragora, 
and then after having been immersed for an hour in warm water, holding it to the nose 
until the patient fell asleep, when the operation was proceeded with. In order to rouse 
him when the operation was over, another sponge, dipped in vinegar, took the place of 
the “ spongia somnifera,” as the former was denominated ; and, if this expedient failed, 
the juice of the root of fenugreek was freely injected into the nostrils. In India, the 
extract of the hemp plant, cannabis Indica, indigenous to that country, has been employed 
for the same purpose for ages past. Near the close of the last century, great hopes were 
entertained that a successful agent had at length been found in the inhalation of nitrous 
oxide gas, either alone, or variously combined with other vapors ; but after numerous 
experiments, in which Sir Humphry Davy and other eminent philosophers took an active 
part, the project was at length abandoned as chimerical. Some time prior to this period, 
Mr. Moore, of London, had suggested the possibility of diminishing pain in surgical opera- 
tions, especially in amputations, by compression of the principal nerves, by means of an 
instrument, somewhat similar to a tourniquet, but so constructed as to constrict the limb 
only at two points, one of the pads being regulated by a screw. The experiment was 
tried at St. George’s Hospital, by John Hunter, upon a man whose leg was cut off below 
the knee on account of a large, irritable ulcer of the foot, and the suffering is said to have 
been exceedingly slight. Very few, however, seemed inclined to repeat it, and the con- 
sequence was that it was soon given up; a result which might have been anticipated 
by the originator of the plan, as the instrument used for the compression was not only 
uncertain in its operation but productive of great uneasiness during its application. 
In 1819, Mr. James Wardrop, of London, proposed to diminished the sensibility of the 
patient in surgical operations by means of copious venesection, and in a paper which he 
published on the subject in the tenth volume of the Medico-Chirurgical Transactions he 
cites several cases illustrative of its beneficial influence. He thought the practice particu- 
larly adapted to persons of a nervous, irritable temperament, and he recommended that 
it should be carried to the extent of syncope, so as completely to annul all sensation 
during the dissection. In one of his cases, he bled the patient, a young, robust woman, 
to fifty ounces before he began the operation, which consisted in the extirpation of a 
small tumor from the orbital plate of the frontal bone, during which she remained per- 
fectly unconscious, expressing great surprise when she found it was over. As might have 
been expected, however, she remained very weak for several days after the operation, 
although she made a rapid recovery. I am not aware that this recommendation met with 
any particular favor. 
The administration of the different preparations of opium for the purpose of lessening 
the pain in surgical operations is an old practice, highly lauded by some, and as greatly 
condemned by others. I was myself in the habit of employing it for many years in almost 
every case that fell into my hands previously to the discovery of anesthetics : I generally 
preferred morphia to laudanum or opium in substance, and always gave it in full doses, 
either alone, or, when the patient was strong and plethoric, combined with a moderate 
quantity of tartrate of antimony and potassium, with a view of inducing a greater degree of 
relaxation and insensibility. I became very fond of the practice, and never, so far as I 
could determine, experienced any bad effects from it; on the contrary, I know that it 548 
ANAESTHETICS. 
CHAP. xx. 
was commonly productive of great benefit, not only blunting sensibility but preventing 
shock, and, consequently, severe reaction. 
Notwithstanding these various attempts to prevent suffering in surgical operations, no 
anaesthetic agent, using the term in its legitimate sense, was discovered until 1844, when 
Dr. Horace Wells, a dentist of Hartford, Connecticut, wishing to have a tooth extracted, 
rendered himself completely insensible by inhaling nitrous oxide gas ; and he soon after- 
wards administered the same remedy to several of his patients with effects equally grati- 
fying. Shortly after this, Dr. Wells repeated his experiment before the medical faculty 
and students of Harvard University at Boston, but, owing to mismanagement either in the 
apparatus or the gas itself, the attempt signally failed, and the only reward which he 
received for his pains was ridicule, which, in his case, was the more cruel, because he*was 
a man of uncommon sensibility. Two years later, Dr. Morton, also a dentist, and a pupil 
of Wells, resorted to the inhalation of sulphuric ether, first in his own person, and after- 
wards in some of his patients, until he became convinced that it might be taken not only 
with impunity, but with the most perfect certainty of preventing pain in any operation, 
however severe or protracted. Fortified with this knowledge, he applied at the Massa- 
chusetts General Hospital, at Boston, for permission to repeat his experiments upon a 
man who was about to undergo an operation for the removal of a tumor of the neck by 
Dr. John C. Warren. The result was everything that could have been desired. The 
next day, Morton etherized a patient for Dr. Hayward; and the news of the remedy 
rapidly spreading, its use soon became general, both in the United States and in Europe. 
In the latter country the subject attracted perhaps even greater attention than at home, 
and soon led to the discovery of chloroform by Sir James Y. Simpson, of Edinburgh, in 
1847. Various other articles possess anaesthetic properties, as chloride of hydrocarbon, 
nitrate of ethyl, aldehyd, benzin, the Dutch liquid—a compound of chlorine and olefiant 
gas—kerosoline, bisulphuret of carbon, amylen, protoxide of nitrogen, and bichloride of 
methylene, but, with the exception of the last three, it is questionable whether any of 
them are sufficiently innocuous to justify their exhibition. 
Practically it is of no importance to know who the discoverer of anaesthetics was; but, 
if we carefully inquire into the history of the matter, we cannot fail to award to Dr. 
Wells the credit of having made the first successful application of this class of agents for 
the prevention of pain during a surgical operation. Nearly fifty years previously, Sir 
Humphry Davy had, it is true, employed nitrous oxide gas for the relief of a severe 
headache, brought on by the intoxication caused by the rapid drinking of a bottle of wine 
for experimental purposes, and afterwards as a means of preventing the pain in cutting the 
gum over a wisdom tooth ; but, as every one knows, no further use of the remedy was made 
until it was resumed by Dr. Wells, and applied with express reference to the production of 
anesthetic effects. He was beyond doubt the first to establish the possibility of preventing 
pain in surgical operations ; and had his experiments at Boston not eventuated in chagrin 
and disappointment, he would unquestionably have pushed his researches much further, 
and perhaps speedily hit upon the very articles which were afterwards found by Dr. Mor- 
ton and Professor Simpson to possess such valuable properties. To both the latter gen- 
tlemen the world owes an immense debt of gratitude for having brought to light the 
wonderful anaesthetic effects of ether and chloroform. 
In an article in the Virginia Medical Monthly for May, 1877, J. Marion Sims has fur- 
nished evidence going to show that sulphuric ether was first intentionally employed as an 
anaesthetic in surgical operations in 1842, by Dr. C. W. Long, of Athens, Georgia. The 
only circumstance invalidating this claim is the persistent silence of Dr. Long and his 
friends during the long and heated controversies growing out of the labors of Wells, 
Morton, and Jackson. Hence, although he may have been, and probably was, the first to 
use this fluid as a means of preventing pain, he failed to interest the profession in it, and 
has thus lost all just claim to the honor of one of the greatest discoveries ever achieved 
by human genius. 
It is not a little singular that the two countries in which the anmsthetic virtues of ether 
and chloroform were discovered should each, respectively, have preferred for many years 
its own remedy; America ether, and Great Britain chloroform. There are, however, in 
Great Britain, many surgeons who now employ ether, and in this country many practi- 
tioners who prefer the latter article, both in surgical and obstetrical practice, and I have 
myself constantly used it ever since its introduction among us in 1848, believing it to pos- 
sess decided advantages over ether, although its administration unquestionably requires 
the greater care and attention. Among the more important of these advantages are, first, 
the more rapid manifestation of the anaesthetic action of the remedy, the system becoming CHAP. XX. 
ANESTHETICS. 
549 
affected much sooner, as a general rule, than it does by ether; secondly, a smaller amount 
of laryngeal and bronchial irritation ; thirdly, the more easy maintenance of the anaesthetic 
influence, after the system has once been fairly affected; and, lastly, the less liability to 
cause vomiting and other unpleasant consequences. The very odor of ether is to many 
persons excessively offensive, and there are very few in whom the inhalation does not pro- 
duce more or less cough and vomiting. On the other hand, it certainly requires less 
caution in its administration, and thus far it has furnished but few deaths, whereas the 
mortality from chloroform is already above three hundred. Dr. Maddin, of Nashville, 
who has carefully investigated the subject, finds that most of the fatal cases of antesthesia 
have occurred in minor surgery, or in operations of a comparatively trifling nature, and 
in which, consequently, the remedy might probably have been entirely dispensed with. 
For a number of these cases the dentist is accountable, nearly all the earlier and not a 
few also of the later having happened during the extraction of teeth, from the want of 
precaution in not sufficiently depressing the head during the operation. 
It is remarkable that many of the fatal cases have occurred in private practice, or in 
small institutions, a circumstance which would seem to show that there had been some 
fault in the mode of administration of the remedy. At Guy’s Hospital, London, chloro- 
form had been employed in upwards of 12,000 cases before there was any serious acci- 
dent ; in the war in the Crimea, according to the testimony of Flourens, it was adminis- 
tered more than 25,000 times without a single death ; and during the late war in this 
country there were, according to Dr. George A. Otis, only 8 cases out of upwards of 
120,000 in which a fatal result could fairly be attributed to its use. Dr. J. S. Wellford, 
of Richmond, ascertained that, in the Confederate army, during the same period, chloro- 
form was used in 22,000 cases without any accidents, and only one death in 15,000 
cases is recorded by Professor Hunter McGuire. 
From statistics collected from fourteen hospitals in London and Liverpool, in 1867, it 
appears that chloroform was administered in 83,059 cases, of which 24, or 1 in 3461, 
proved fatal. In the eye department of Guy’s Hospital this article was employed, up to 
1870, in 3221 cases without a single death, although 45 of the patients became blue in 
the face and suddenly stertorous, with irregular pulse and breathing. 
Professor Andrews, of Chicago, in 1870, collected from different American and Euro- 
pean hospitals the statistics of 117,078 cases in which chloroform was administered, with 
43 deaths, affording thus a ratio of mortality of 1 to 2723. Of 92,815 cases, obtained in 
a similar way, of etherization, only four perished, or 1 to 23,204. A mixture of chloro- 
form and ether was employed in 11,176 cases, of which only 2 died, the mortality being 
as 1 to 5588. Of the results of the administration of bichloride of methylene, all we know 
is that, up to 1872, in 7000 cases there had been only a few deaths. 
In the hands of certain surgeons, the use of chloroform, as an anaesthetic agent, has 
been attended with astonishing success. I have now administered it in all kinds of opera- 
tions in several thousand cases without a single death, and in only three cases did 1 feel 
any serious alarm for the safety of the patient. Syme gave it in about 5000 cases with- 
out any serious occurrence, and Simpson, it is said, met with only one death in all his 
immense experience. Professor Nussbaum, of Munich, in 15,000 cases, never lost a pa- 
tient; and Billroth had no deaths in 12,500 cases. The results of the experience of other 
practitioners are equally gratifying. It is to be regretted than an agent capable of confer- 
ring such vast benefit should be so little employed in this country, because a fatal in- 
stance, produced, for the most part, by maladministration, is occasionally reported, as if 
death in surgical operations never arose from any other cause. 
I ascribe my ov/n success in the use of chloroform to the extraordinary care with which 
it has been administered in my practice, to the proper selection of my cases, and to the 
pains which have always been taken to procure a pure article, preference having generally 
been given to Squibb’s preparation. An assistant who is accustomed to superintend the 
inhalation of chloroform is far safer than an inexperienced one, and neither in hospital 
nor private practice should any other ever be permitted to meddle with it. 
It has been asserted by the opponents of chloroform that the rate of mortality in the 
great operations of surgery has been essentially increased since the introduction of that 
article into practice, and Mr. Arnott, of London, has taken pains to collect elaborate 
statistics with a view of establishing the fact upon an irrefragable basis. On the other 
hand, the statistics of Sir J. Y. Simpson, the discoverer of the anaesthetic properties of chlo- 
roform, go to show that the number of deaths is not only not increased, but absolutely 
diminished. Perhaps the truth lies between these two statements. Dr. Macleod, in his 
Notes on the Surgery of the War in the Crimea, published in 1858, declares it as his 550 
ANAESTHETICS. 
CHAP. xx. 
conscientious belief that the use of chloroform in the British army saved many lives, and 
that numerous operations were performed by its assistance which could not otherwise have 
been attempted. It is not improbable that, if there has really been an increase in the 
mortality after operations since the introduction of anaesthetics, it has been owing, not to 
the pernicious effects of the remedy, but to the fact that surgeons have been emboldened 
to undertake operations in cases which were formerly regarded as unfit for the employment of 
the knife, and, above all, to the circumstance that of late years there has been a fearful 
increase of railway and other terrible accidents, many of which are necessarily fatal, no 
matter to what treatment they may be subjected. 
Dr. Henry W. Davis, of Illinois, in a paper in the Chicago Medical Examiner for 18G2, 
declares that chloroform, judiciously administered, so far from being a depressant, in se- 
vere shocks from gunshot injury, is a powerful stimulant, rapidly raising the pulse, and 
soon followed by healthy reaction. He states that he could cite numerous instances, 
presenting every degree of severity, but all attended with extreme prostration, in which 
the exhibition of this agent produced the most happy effects, and he adds that no amount 
of exhaustion, however intense, would induce him to withhold it, provided the lesion is 
recent. The experience of Dr. Davis has been confirmed by other observers, and I have 
myself seen a number of cases illustrative of the truth of his statements. 
Anesthetics not only prevent pain and mental suffering, but by placing the patient in 
a passive condition give the surgeon a control over him which he could not possibly ob- 
tain in any other manner. Deprived of sensibility and consciousness, the former is vir- 
tually dead to all external impressions, and permits the surgeon to conduct his dissections 
and other manual processes with as much ease and deliberation as if he were operating 
upon the cadaver. The advantages thus gained are absolutely incalculable, and he who 
would fully appreciate them must be able to put himself in the twofold situation of patient 
and surgeon, and then, in imagination, contrast their condition with that of the patient 
and surgeon of former times, before the discovery of anesthetics, when the one was 
writhing in pain and agony during a tedious dissection, and the other had his progress 
incessantly interrupted by the cries and struggles of the sufferer. 
The exhibition of anaesthetics is important not merely as a preventive of pain, but also 
as a means which enables us to investigate our cases more thoroughly prior to an opera- 
tion. Exploration of the bladder, formerly a source of so much suffering, is now per- 
formed without the slightest uneasiness, and the same is true of stricture of the urethra, 
diseased bones, affections of the anus and rectum, and various other lesions. The use of 
anaesthetics affords immense advantages in the examination of dislocations and fractures, 
permitting us to handle the parts more satisfactorily, and, therefore, to form a more correct 
diagnosis. 
There are some operations in which the use of anaesthetics is usually regarded as 
inadmissible; thus, in harelip, the excision of the tongue, and removal of the jaw, the 
patient, as a general rule, should be under the influence of these remedies only at the 
beginning of the procedure ; after the dissection has been fairly commenced, he should 
be sufficiently conscious to enable him to cooperate with the surgeon, otherwise the blood, 
passing down into the windpipe, might cause severe cough and other inconvenience, 
seriously embarrassing him. The same remark applies to excision of the tonsils, although 
I have frequently removed these glands while the patient was so far under the influence 
of chloroform as to render him incapable of offering any resistance. Extirpation of the 
jaw I have repeatedly performed under similar circumstances, passing through the different 
stages of the operation while the person was in a state of perfect unconsciousness. Even 
the more delicate operations upon the eye, as the establishment of an artificial pupil, and 
the extraction of cataract, may be safely performed with the aid of anaesthetics, although, 
as it respects the latter, it should not be forgotten that the vomiting which occasionally 
attends their use might destroy the organ. 
It has been asserted that one advantage of the use of anaesthetics is that it diminishes 
the liability to hemorrhage during an operation, but I have never been able to satisfy 
myself that this is true; nor have I any reason to believe, as has been so frequently 
alleged, that there is greater danger of secondary hemorrhage after the employment of 
these agents, due to loss of tone in the smaller vessels and to a decrease of coagulability 
of the blood. Both opinions are without proof. 
Chloroform.—Chloroform, a terchloride of formyl, is a clear, colorless liquid, very 
volatile, of an agreeable, aromatic odor, of a pungent, saccharine taste, very dense, of 
the specific gravity of 1.500 at 60° Fahr., almost insoluble in water, non-inflammable, 
and perfectly neutral, neither reddening nor bleaching litmus paper. It is a compound CHAP. XX. 
CHLOROFORM. 
551 
of three atoms of carbon, one of hydrogen, and three of chlorine. Various impurities are 
liable to be mixed up with it, especially the chlorinated pyrogenous oils, ether, and alcohol. 
The presence of oils is readily detected by pure, strong sulphuric acid, to which they 
impart a change of color, varying from yellowish to reddish-brown, according to the 
quantity of the extraneous substances. A still more simple test consists in pouring the 
suspected fluid upon the hand, where, rapidly evaporating, it deposits its oily impurities, 
which are easily recognizable by their offensive smell. Dropped upon white paper, pure 
chloroform speedily disappears without leaving any stain. The existence of alcohol is 
detected by dropping a small quantity of chloroform into distilled water; if pure, it will 
retain its transparency at the bottom of the glass, if not, each globule will acquire a 
milky appearance. The presence of ether may be detected by the inflammable character 
of the fluid. It is practically important to know that chloroform deteriorates by ex- 
posure to heat and to a strong light. The most reliable article is prepared with methy- 
lated spirit. 
There are five principal circumstances which should be closely attended to during the 
exhibition of chloroform, and, if this be done, it will be difficult, unless the article is bad, 
or the patient has some idiosyncrasy, to produce any unpleasant effects with it. These 
are recumbency, an empty state of the stomach, a free play of the diaphragm, an abund- 
ance of atmospheric air, and a gradual administration. 
1st. During etherization the patient may sit up with impunity, but this is not the case 
during the inhalation of chloroform, owing, apparently, to the greater relaxation of the 
muscles, and, consequently, to the increased difficulty in maintaining the circulation of 
the brain through the influence of the heart’s action. Lying upon the side, when this is 
practicable, is perhaps the safest posture of all, as the breathing will then be less likely 
to suffer by the falling back of the tongue. The head should never be much raised, nor 
the neck bent. 
2d. An empty state of the stomach is desirable for two reasons ; first, because if chlo- 
roform be given soon after a heavy meal it will almost certainly induce vomiting ; and, 
secondly, because a crowded condition of the organ interferes materially with the move- 
ments of the diaphragm. Food must not be taken for at least four hours before the 
exhibition ; but, on the other hand, the interval should not be too protracted, lest serious 
exhaustion result from the want of necessary stimulus. 
3d. Care must be taken, before the inhalation is commenced, that the patient’s clothes 
are sufficiently loose to prevent constriction of the chest and abdomen. Any compression 
from this source would necessarily impede the action of the diaphragm, and might thus 
become a cause of mischief. 
4th. The importance of having an abundance of atmospheric air during the inhalation 
of an article so potent as chloroform is self-evident; in etherization this is of comparatively 
little consequence, but in the exhibition of chloroform for surgical and obstetrical purposes 
it is absolutely indispensable to the safety of the patient. 
5th. The inhalation must be effected gradually, not hurriedly, time being allowed the 
system to accommodate itself to the influence of the remedy, thus avoiding the shock 
which might otherwise be inflicted upon the heart and brain. From three to eight minutes 
should usually be spent in producing the full effects of the anaesthetic. 
6th. When the patient is very feeble, or pale and timid, it will be advisable to give 
him immediately before the operation, from half an ounce to an ounce of brandy; and 
the dose may afterwards be repeated, if the effect is obliged to be maintained for an 
unusual length of time, sufficient consciousness being permitted for the performance of 
deglutition. 
7th. It is a good plan, as a rule, to administer about an hour before the operation is begun 
a hypodermic injection of morphia to quiet the nervous system, and shorten or avert the 
stage of excitement, sustain the action of the heart, and prevent laryngeal and bronchial 
irritation. This has been my practice for many years at the College Hospital as well as 
with my private patients, and I have found no reason to regret it. Indeed I am satisfied 
that it not only adds greatly to the safety of the patient, but that it also renders anaesthe- 
sia possible with a less quantity of chloroform than is required under ordinary circum- 
stances. Bonwill’s method of rapid respiration also exercises an obtunding effect on the 
air passages, and may often be beneficially employed when the use of an anodyne is not 
deemed advisable or proper. 
The best mode of administering chloroform is to pour the fluid upon a napkin or hand- 
kerchief, previously folded into a cone or cup-shaped hollow, and held securely in the 
hand. Or, instead of this, a small hollow sponge may be used. As to the various 552 
ANESTHETICS. 
CHAP. xx. 
inhalers that have been devised for the purpose, most of them are objectionable on 
account of their inconvenience and the difficulty of obtaining a sufficiency of atmospheric 
air. One of the best of these contrivances is that devised by Professor Chisholm, of 
Baltimore, used extensively in the Southern States during the late war. It consists of 
a metallic instrument, fitted for insertion into tlie nostrils, the mouth being left entirely 
free for breathing. In this way, amesthesia is rapidly induced without any waste of fluid 
from evaporation even in the open air. The apparatus of Dr. Skinner, of Liverpool, a 
very simple and efficient one, consists of a wire frame in the shape of a shallow ladle 
covered with flannel, the concavity being held over the nose and mouth while the chloro- 
form is dropped upon the convex surface. The apparatus of Mr. Clover, so extensively 
employed in London, is too troublesome and expensive for general use. 
The patient having taken his place upon the table, and emptied his lungs by a deep 
and protracted expiration, the napkin, impregnated with a drachm of chloroform, is held 
over the mouth and nose, at a distance of about two inches, being gradually brought 
nearer and nearer until it is within one-fourth of that distance, beyond which it should 
not be carried, the chest being at the same time regularly and powerfully distended. The 
pungent effect of the liquid upon the skin should be prevented by anointing the face with 
some protective unguent, otherwise vesication may arise. All unnecessary conversation 
is avoided, lest the attention of the patient should thereby be unduly distracted. The assist- 
ant having charge of the administration gives it his earnest and undivided care, wetting 
the napkin from time to time with the fluid, and seeing that the patient obtains an abundance 
of air, his vigilance increasing as the effects of the medicine become more and more 
apparent. As soon as the sensibility is completely abolished, the operation is commenced, 
a return to consciousness being prevented by holding the napkin, sprinkled with a small 
quantity of the vapor, occasionally before the nose, and thus the impression is maintained, 
steadily and cautiously, not only until the knife has fully accomplished its object, but 
until the principal arteries have been secured, and, in some cases, even until the dressings 
have been applied. 
As soon as the inhalation has been fairly entered upon, an attendant should sedulously 
watch the pulse, respiration, and countenance. If any sudden change be noticed in 
their condition, the administration must instantly be discontinued, or, if persisted in, 
conjoined with a more liberal supply of atmospheric air. It is not necessary that a 
finger should be constantly kept upon the pulse ; for the color of the face and the nature 
of the breathing will always sufficiently indicate the effects which the anassthetic is 
exerting upon the system, and thus afford abundant opportunity for preventing any un- 
pleasant occurrence. 
When chloroform acts as a decided depressant, as in excessive anemia, organic disease 
of the heart, or inordinate exhaustion from profuse discharge, the anresthetic effect should 
be maintained with ether, experience having shown that, if it be not, in such an event, 
a positive antidote to the evil consequences of chloroform, it restores the force of the 
circulation, and may be administered without the slightest risk to life. 
The quantity of chloroform required during an operation, and the time during which its 
effects may be safely maintained, must, of course, vary according to the exigencies of each 
particular case. In general, from half an ounce to an ounce may be regarded as a fair 
average, but very frequently it takes three, four, or even five times that amount, depend- 
ing upon the severity and duration of the operation, and the susceptibility of the 
individual. In some instances almost an incredibly small portion answers the purpose. 
Children usually require comparatively little ; and it is well known that women are 
generally more susceptible to its influence than men. Persons exhausted by hemorrhage 
are very easily affected by it, owing to the rapidity of its absorption, and hence it should 
always be administered to them with unusual care. In obstetric practice, the effects of 
chloroform may be maintained, with impunity, for many hours together, and the same 
remark is true of severe and tedious surgical operations. Thus, in an attempt to reduce 
a chronic dislocation of the shoulder-joint, I kept the patient steadily under the influence 
of the remedy for two hours, during which not less than twelve ounces were consumed. 
Age is no bar to the use of anaesthetics. I have given chloroform repeatedly to very 
young children, and, in several instances, with excellent effect, even to infants under two 
months. In fact, the more tender the age is, the more easy is the induction of insensi- 
bility. Old persons also bear the inhalation well. On one occasion I gave it with the 
most gratifying effects to a lady of ninety-two, supposed to be laboring under a fracture 
of the neck of the thigh-bone. Certain diseases are very properly regarded as contra- 
indicating the employment of chloroform, particularly organic lesions of the heart, lungs, CHAP. XX. 
EFFECTS OF CHLOROFORM. 
553 
and brain, anemia, and the habitual use of intoxicating drinks. It should never be 
administered in cases of accidents attended with severe shock or loss of blood until after 
thorough reaction has taken place. In administering chloroform to infants and very 
young children, only a few drops should be poured upon the napkin at a time, and care 
should be taken to hold the cloth at a considerable distance from the mouth and nose, so 
that the fluid may enter the lungs well diluted with atmospheric air. 
Effects—The effects of chloroform upon the system may, for practical purposes, be 
divided into two stages, that of excitement, and that of insensibility. The first begins 
soon after the commencement of the inhalation, and is characterized by various cries and 
struggles, as if the patient, feeling alarmed, were anxious to escape from the table. The 
face becomes flushed, the eye has a wild and staring expression, the pulse is preternatu- 
rally frequent, and the mind is incoherent; as the effects increase, the brain falls into a 
species of exhilaration closely akin to that of intoxication. It is now that the individual 
usually exhibits his peculiarities of temperament and habit. Thus, if he is of a boisterous 
disposition, he will be apt to be noisy, to swear, or to fight, and to make the most violent 
efforts to disengage himself from the assistants. One man will laugh and joke ; another 
will weep, or moan and sigh ; the sportsman will fancy himself occupied in the pleasures 
of the chase ; the wily craftsman, in driving a good bargain ; the lawyer, in addressing a 
jury ; the preacher, in exhorting his congregation ; and the physician, in prescribing for 
his patient. The mind is in a dreamy, perverted condition, and whatever is most 
predominant at the time in thought and feeling is sure to exhibit itself in expression. 
This excitement varies much both in degree and duration; in many cases it is very 
slight and transient, while in some it is even entirely wanting, the patient being perfectly 
tranquil throughout. When considerable, it is very liable to be reproduced, to a greater 
or less extent, as the effects of the remedy wear off, so that the individual will, perhaps, 
be quite as boisterous after the inhalation is over as he was soon after its commencement. 
In very nervous, excitable persons the intoxication may last for several hours, although 
this is uncommon. 
In the second stage, which succeeds imperceptibly to the first, the individual gradually 
lapses into a state of entire unconsciousness; the muscles, thoroughly relaxed, are no 
longer under the control of the will, the limbs retaining any position in which they may 
be placed; the eyelids are closed and the balls turned up, the pupils being contracted, 
and insensible to light; the respiration is calm and easy ; and the pulse is soft and 
undisturbed, or, if at all changed, it is rather below than above the normal frequency. 
Feeling and intellection are suspended, and everything indicates that the patient is in a 
quiet and pleasant sleep, wholly unconscious of surrounding objects, and, therefore, com- 
pletely insensible to pain. If this state be carried a little further, coma will arise ; the 
patient will snore as if he were apopletic, the pulse and respiration will diminish in force 
and frequency, and the pupil will become notably dilated. As yet, all is safe, but a few 
more whiffs, and an important link in the chain of life may give way, and the patient be 
sent into eternity. In the administration of chloroform we should always strive to prevent 
coma. The most unexceptionable form of anesthetization unquestionably is that in which 
there is a perfect suspension of sensibility without the complete abolition of consciousness; 
but it need hardly be added that it is, practically, extremely difficult to produce such a 
nice result in any case. In general, the patient, on recovering from the effects of the 
remedy, has no distinct recollection of anything that passed while he was under its 
influence. 
The effects of chloroform seldom completely disappear under several hours. After the 
more characteristic symptoms have subsided, the mind will still be somewhat bewildered, 
the muscles relaxed, and the feelings perverted. In some cases, especially in children, 
the patient, after having passed through a most severe operation, will fall into a tranquil 
sleep, and, perhaps, not wake fully for an hour or two. In other cases, again, the effects 
go off very rapidly, and the individual will be roused not only to a state of consciousness, 
but to severe pain. When the vapor is very freely employed, there will frequently be 
some degree of' nausea or even vomiting, either during the operation, or at its close, upon 
the return of consciousness. Emesis is most common in children and in persons of a 
nervous, irritable temperament, but may generally be entirely prevented by the adminis- 
tration of a little brandy or whiskey immediately before the inhalation of the anaesthetic 
is commenced. Headache, although infrequent, is occasionally met with, and may last 
for a number of hours. It is most liable to occur when impure chloroform is used. 
I have never witnessed any permanently ill effects from the exhibition of chloroform, 
such as partial paralysis, loss of sensation, or perversion of taste and smell; and a similar 554 
AN J3STHKTICS. 
chap. xx. 
declaration lias been recorded by the late Dr. Snow, of London, in bis work on Anais- 
thetics, published in 1858. 
Although chloroform is one of the greatest boons which a kind and beneficent 
Providence has bestowed upon man for the prevention and alleviation of pain, yet, like 
every other remedy, it is capable, when abused, or injudiciously administered, of produc- 
ing the most deadly effects. These effects are those of a narcotic poison ; and as they 
may follow, in persons of unusual susceptibility, the inhalation of the smallest quantity of 
the liquid, it is of the utmost importance that they should never, for a moment, be lost 
sight of in the use of the article. An overdose may destroy life almost instantaneously, 
or death may occur at a variable period after the exhibition ; sometimes even after partial 
reaction has taken place. The phenomena indicative of danger are, stertorous respiration, 
a small, feeble pulse, lividity of the features, dilatation of the pupils, relaxation of the 
sphincters, and rapid diminution of the temperature of the body. 
Death by chloroform may occur in at least four different ways, by coma, by asphyxia, 
by syncope, and by gastric irritability, as it effects the brain, the lungs, the heart, or the 
stomach. Dr. J. C. Reeve, of Ohio, who, in 1807, was at great pains to investigate the 
causes of death from the inhalation of this fluid by the examination of a large number of 
recorded cases, is of opinion that the fatal event is not unfrequently produced by mere 
shock, in the same manner as in a blow upon the stomach, or as when a draught of cold 
water is taken in an overheated state of the body. 
Death by coma generally occurs suddenly, apparently from the absorption of the 
chloroform, and its direct sedative effect upon the brain ; or, as is more probable, upon the 
brain and spinal cord. The occurrence is always preceded by stertorous breathing, by 
lividity of the surface, and by convulsive movements of the muscles, the action of the 
heart ceasing with the respiration, or even before the respiration is completely extin- 
guished. Elderly persons, worn out by intemperance, protracted disease, and the 
depressing passions, are most subject to this mode of death. 
In death by asphyxia the breathing stops suddenly, the heart continuing to beat for a 
short time after all motion of the chest has ceased. The occurrence is denoted by the 
gasping character of the respiration, the lividity of the features, the distension of the 
jugular veins, the flickering nature of the pulse, and the dilated and insensible condition 
of the pupils. Death takes place, not directly from the effects of the chloroform, but 
indirectly from deprivation of oxygen, the anaesthetic not having been admixed with a 
sufficient quantity of air during its inhalation. 
In death by syncope from an overdose of chloroform the fatal event is due to paralysis 
of the heart, or the sudden abstraction of nervous fluid, the patient dying very much as 
in shock, induced, perhaps, only by a very few inhalations. The heart ceases to beat 
before the breathing, the countenance is of a ghastly, livid hue, the pulse is weak and 
flickering, and life is usually destroyed very suddenly. Persons with a soft, flabby heart, 
accompanied with fatty degeneration of its muscular structure, and dilatation of the left 
ventricle, are most liable to suffer in this way. 
Death from gastric irritability does not occur suddenly but gradually, not perhaps under 
several days, the primary impression being apparently made upon the pneumogastric 
nerves, and the secondary upon the brain, heart, and lungs. The event is uncommon. 
In a typical case, a very remarkable one of its kind, observed by the late Dr. Thomas 
Wood, of Cincinnati, the very first inhalation produced retching, followed by vomiting before 
the patient became insensible ; the anmsthesia was maintained for half an hour, and, on 
the return of consciousness, the gastric trouble reappeared, and continued until the close 
of life on the sixth day. The retching and vomiting, in this case, were evidently, in the 
first instance, entirely independent of any cerebral disturbance, although, in its progress, 
both the brain, the lungs, and the heart became seriouly implicated, as is shown by the 
fact that at the end of twenty-four hours there was delirium, with tremulous movements 
of the muscles, dilatation of the pupils, and lividity of the general surface, symptoms 
which steadily persisted up to the time of death. When a person, after having been 
comatose or asphyxiated, partially recovers, he may linger for several hours, or even a 
much longer period, in a state of partial unconsciousness, and finally die under all the 
symptoms of profound congestion of the brain and lungs, with a tendency to serous effu- 
sion and deposits of lymph ; or he may gradually regain his health, without, perhaps, any 
bad ulterior effects. 
The repeated inhalation of chloroform does not seem to establish a tolerance of the 
remedy, or to serve as a security against a fatal occurrence. A very considerable per- 
centage of the recorded deaths by this agent took place during the inhalation for the CHAP. XX. 
EFFECTS OF CHLOROFORM. 
555 
second, third, or fourth time. To produce a fatal effect, it is not necessary that the quan- 
tity of chloroform should be large or that the inhalation should be at all protracted. 
Frequently a few hurried whiffs are sufficient. Of 102 cases of death from chloroform, 
tabulated by Sansom, in which the stage of anaesthesia was noted, 50 perished before the 
full effects of the remedy were produced. 
When death ensues from these trivial causes, the probability is that the event is gene- 
rally dependent upon extraneous circumstances, as the idiosyncrasy of the individual, the 
amount of shock or loss of blood, exhaustion from disease, an overloaded state of the 
stomach, the semierect posture, mental emotion, and other untoward conditions of the 
system, not always appreciable before the inhalation is begun. The baneful influence of 
fear in debilitating the system is well known ; and it is not to be forgotten that a person, 
although pretty completely influenced by chloroform, may suffer violently from shock 
induced by a severe and protracted operation. 
Treatment The treatment for the relief of the poisoning consequent upon an overdose 
of chloroform must be prompt and efficient; for everything depends upon the surgeon’s 
presence of mind and the rapidity and energy with which he applies his remedies. The 
first thing to be done is to desist from the further administration of the remedy ; the second, 
to place the head below the general level of the body, and to draw the tongue out of the 
mouth with a towel or tenaculum, so as to lift it away from the glottis ; the third, to cause 
a full access of cold air, by throwing open the doors and windows of the apartment, and 
making free use of the fan ; the fourth, to dash cold water upon the body, or still better, 
to pour it from a height of several feet; the fifth, to institute artificial respiration, by 
introducing a tube into the windpipe and percussing the body, or blowing air into the 
mouth ; the sixth, to stimulate the surface, especially over the spine and heart, with 
hot mustard water, lotions of veratria, or dilute spirit of hartshorn ; the seventh, to 
administer an injection of turpentine; and the last, to apply galvanic electricity, passed 
through needles inserted into different parts of the body, more especially over the heart, 
diaphragm, and spine. A lump of ice inserted into the rectum often produces an excellent 
effect. “ Flipping” the surface with the end of a towel wrung out of cold water is a 
powerful excitant. As soon as the patient is able to swallow, free use is made of brandy 
and ammonia. These means should be employed with great diligence and regularity until 
it is perfectly evident that life is irrecoverably extinct. 
Striking the patient with the fiat hand, sharply and rapidly, upon all parts of the body 
—the face, trunk, arms, and legs—is worthy of trial. The clothes, as a preliminary step, 
should be removed as speedily as possible, and the efforts should be uninterruptedly con- 
tinued until there is a return of breathing and pulsation. Accoucheurs often resort to 
this process of reviving stillborn children ; it is a powerful stimulus making its primary 
impression upon the sensitive nerves of the skin, and through them, by reflex action, 
upon the spinal cord, the heart, and the capillaries. Striking the surface gently and 
rapidly with small switches, or the end of a fringed towel wrung out of ice water, is often 
of great service ; and there is, according to my experience, no more powerful excitant 
than a strong solution of veratria rubbed freely and roughly upon the back and chest. 
Mouth to mouth insufflation is also a very valuable method of resuscitation in chloroform 
poisoning. To render it effective, the larynx should be pressed against the spine, to pre- 
vent the air from passing into the oesophagus, and the insufflation should not be performed 
too rapidly or too forcibly, lest the lungs be injured. 
The late Professor Nelaton, of Paris, under a conviction that death from the use of 
chloroform is due to syncope or anemia of the brain, strongly recommended inversion of 
the body, thus rendering the head the most dependent portion, and at the same time keep- 
ing up steady artificial respiration. Numerous cases successfully treated by this method 
have been recorded by different observers, and there is no longer any doubt respecting its 
efficacy. 
The inhalation of the vapor of ten to fifteen drops of nitrite of amyl has frequently 
proved successful in restoring the heart’s action, and the agent should always be in readi- 
ness whenever chloroform is exhibited. 
For the minor effects of chloroform very little is necessary, beyond a discontinuance 
of the inhalation, sprinkling the face and chest with cold water, allowing a free access of 
cold air, and passing a smelling bottle rapidly to and fro under the nose. If any lividity 
exist, indicative of impending asphyxia, the tongue must immediately be pulled out and 
steadily held till the breathing is fully reestablished. 
If vomiting occur, the patient must instantly be turned upon his side—not on his 
abdomen, lest the action of the diaphragm be impeded—with the head inclining down- 556 
ANESTHETICS. 
chap. xx. 
wards, otherwise the contents of the stomach, as they are lazily ejected from the oesophagus 
and fauces, might easily descend into the larynx, and thus induce suffocation. When the 
gastric distress is obstinate or protracted, the best remedies are brandy and a hypodermic 
injection of morphia. 
In women, the unconsciousness, consequent upon the inhalation of chloroform, some- 
times continues so long as to cause serious alarm for the safety of the patient. Such 
apprehension, however, is generally groundless, experience having shown that, when this 
state lasts beyond half an hour, it is due to hysteria, and not to the effects of the anes- 
thetic. Sometimes convulsions are induced, but they always promptly subside under the 
continuance of the inhalation. 
Anesthetics should never be administered to women except in the presence of witnesses. 
The cases of the two dentists, the one of this city and the other of Montreal, which some 
years ago created so much excitement both in and out of the profession, show that no 
man’s character, however pure or exalted, may altogether escape censure, if, indeed, ruin. 
The remarkable instance which, a few years ago, occurred at the Philadelphia Hospital, 
of a woman who, while under the influence of aaesthesia, Avent through all the movements 
of the sexual congress, and analogous examples reported in the medical journals, clearly 
prove how strongly the imagination of the patient may be impressed in this way, while 
thus affected, and how vividly the idea may remain after the ordinary effects have 
passed off. 
Ether The administration of sulphuric ether may be effected with a large, broad 
sponge covered with soft leather, with a towel inclosed in a thick paper cone, or, what is 
far better, and much more economical, with the inhaler 
of Dr. Oscar Allis, of Philadelphia, or of Dr. Lente, 
of New York, the latter of which is represented in fig. 
237. The apparatus essentially consists of a bottle, a 
gum-elastic tube fitted with a stopcock, and a light, 
helmet-shaped framework, covered with two layers of 
flannel. Upon inverting the bottle and holding it 
above the mouth-piece, the either diffuses itself very 
rapidly, the quantity used at the commencement of the 
operation being about two drachms, succeeded by three 
more as soon as the patient begins to respire fully, the 
effect being thus maintained until complete anaesthesia 
is induced. When the inhaler is removed from the 
face, as when stertorous breathing ensues, it must be 
placed on its base, to prevent the escape of vapor. The 
quantity of ether consumed does not, ordinarily, ex- 
ceed two or three ounces, and from four to five minutes usually suffice to effect the de- 
sired object. 
When the inhalation is effected with a sponge or towel, not less than half an ounce of 
ether should be used in the first instance, and the administration should be steadily con- 
tinued until the full object is attained, which often occupies from five to ten minutes. 
No particular attention need be paid to the admission of atmospheric air, as this 
fluid possesses none of the poisonous properties of chloroform. The quantity of ethei 
consumed in this mode of administration is seldom, in ordinary cases, less than from four 
to eight ounces, while in the more protracted, twice or even thrice that amount may be 
necessary. 
The first effect of the inhalation of ether is usually a short, hacking cough, but this 
soon subsides, and the system gradually lapses into a calm, quiet condition, attended with 
muscular relaxation, closure of the eyelids, and mental obliviousness, followed, in many 
cases, especially if the head lie low, and the tongue be permitted to fall back, by stertor- 
ous respiration. Sickness and vomiting are common occurrences ; and occasionally there 
are spasmodic or tetanic movements, the body being thrown forcibly and convulsively 
backwards, as in opisthotonos. After the patient recovers his consciousness he often com- 
plains of severe headache, sometimes lasting upwards of twenty-four hours. Moreover 
the breath usually retains for a long time, occasionally, indeed, for several days, the 
disagreeable odor of the anaesthetic. 
In administering chloroform, the patient must always be recumbent; in etherization 
on the contrary, he may sit up, or recline, as may be most convenient to the operator, no 
injury resulting even from the protracted maintenance of the erect posture. The inhala 
tion, too, may be carried on more rapidly, and, as already stated, without any specia 
Fig. 237. 
Lente’s Inhaler. CHAP. XX. 
ETHER. 
557 
reference to the admixture of atmospheric air, a sufficiency always entering through the 
inhaler. Any bad effects that may arise from etherization should be treated upon the 
same general principles as those produced by an overdose of chloroform. The cold douche, 
in particular, will be of much service in recalling the patient to consciousness. The head 
should be depressed and the tongue drawn out if there be stertorous breathing, and the 
patient rolled upon his side and the ether withheld, if there be spasmodic, tetanic, or con- 
vulsive movements of the body. All the different varieties of ether possess anaesthetic 
properties; but the one universally preferred is the sulphuric, thoroughly washed, and 
divested of impurities. It is the article which Dr. Morton originally introduced to the 
notice of the profession under the name of letheon, or pain-destroyer, and which is now 
so much employed in surgical and midwifery practice in this country. 
Some practitioners prefer a mixture of ether and chloroform to either of these articles 
alone, considering it to be equally efficacious, and at the same time more safe. I have 
myself frequently employed them in this way, and regard the combination as unobjection- 
able in every respect. The ordinary proportion is three parts of sulphuric ether to one of 
chloroform ; but the quantity of either agent may be increased or diminished, according 
to the exgencies of the case, or the whim, fancy, or caprice of the surgeon. A mixture 
of equal parts of chloroform and alcohol was recommended by Dr. Snow, and is generally 
regarded as a very safe and efficient anaesthetic. In administering it to vex-y young children, 
it may be diluted with rectified spirit, although, if proper care be taken, this is not at all 
essential, either to safety or convenience. Dr. Washington L. Atlee used one part by 
measure of chloi’oform and two of pure sulphuric ether in 300 ovarian operations without 
a solitary loss. The “ Vienna Mixture,” as it is tex-med, is made up of six parts of ether 
and two of chloroform ; and has been administered in 8000 cases without one fatal result. 
The committee appointed by the Medico-Chirurgical Society of London, in 1864, to 
examine into the merits of different anaesthetics, arrived at the conclusion that the safest 
way to administer chloroform is to combine two parts of this article with one of pure 
alcohol and three of concentrated ether. The superiority of this mixture is due, the com- 
mittee allege, to the stimulating influence of the alcohol, and to its modifying effect upon 
the rate of evaporation of the two other constituents. The perfect safety of the mixture 
when properly administered, is fully attested by the expedience of many of the best prac- 
titioners both at home and abroad. 
In administering ether for sui-gical purposes in which the hot iron or galvanic cautery 
is employed, as, for instance, in operations about the face, mouth, or jaws, great caution 
must be exercised, otherwise the fluid, which is a highly inflammable one, may burn the 
patient or ignite his clothing. The flame of a lamp held in close proximity to the vapor 
is especially dangerous. 
How the inhalation of ether proves fatal has not been decided. When death occurs 
promptly, as during, or very soon after, the administration, the probability is that it is 
caused by asphyxia, whereas when it occurs at a later period, as after the lapse of hours 
or days, there is reason to believe that it is due to the effects of congestion of the bi'ain 
and lungs, either alone, or in conjunction with gastric irritability, which often exists in a 
most distressing degree. The number of deaths occasioned by the administration of ether 
is by no means inconsiderable. Hence the greatest caution should be used when employed 
as an anaesthetic. Old, sickly subjects, especially such as labor under fatty degeneration 
of the heart, seem to be most liable to suffer from its depressing effects. Lividity of the 
countenance or stertei-ous breathing imperatively demand the prompt suppression of its 
administration and the employment of i-estoi-atives. 
Ethyl Bromide or Hybrornic Ether, a compound of bromine, alcohol, and ether, is an 
anaesthetic that was at one time largely used by the late Mr. Nunneley, of Leeds, and 
subsequently strongly recommended by Dr. Richardson, of London. An atmosphere 
containing from eight to ten per cent, of the vapor causes, when inhaled, rapid reduction 
of the common sensibility, the pulse and bi-eathing remaining tranquil, and the expression 
of the countenance good. Owing to the rapid transition from the first to the third stage 
of narcotism, there is little, if any, muscular excitement. No apnoea occurs, and the 
i-ecovery is usually veiy prompt. An attempt was made a few yeai’s ago, in this city, by 
Dr. Laurence Turnbull and Dr. Richard J. Levis, to recall the attention of the pro- 
fession to the use of this substance as an anaesthetic agent; but, owing to several deaths, 
occurring in pretty quick succession from its exhibition, it has again fallen into disrepute 
as a safe and reliable article, and it is not at all likely that it will ever again be aroused 
from its slumbers. 558 
ANESTHETICS. 
chap. xx. 
Bichloride of Methylene.—Bichloride of methylene, or chloromethyl, as it may be 
more properly called, was introduced into practice, as a general anmsthetic agent, in 
1867, by Di\ B. W. Richardson, who administered it for the first time to the human 
subject in October in that year, in a case of ovariotomy performed by Mr. T. Spencer 
"Wells. It possesses many of the properties of chloroform, but differs from it in having a 
sweeter odor, in being more pleasant to inhale, and in containing one atom more of hydro- 
gen and one atom less of chlorine. It resembles ether in being inflammable in air. As 
an anaesthetic it causes less excitement than chloroform, is not so liable to produce vom- 
iting, is more persistent in its action, and does not provoke rigidity of the muscles of the 
jaw, or lividity of the countenance. The sleep is usually very gentle, and with proper 
care may be maintained without injury for any reasonable time. Complete narcotism 
may be induced with from one and a half to three drachms in adults, and in children with 
less than one-third of that quantity. Like chloroform, it may be administered at all 
periods of life and in all kinds of operations, in the most severe and protracted as well as 
in the most simple and expeditious. 
The mode of administering chloromethyl and the precautions with regard to the patient, 
as recumbency, emptiness of stomach, and absence of constriction, are the same as in 
the induction of anaesthesia with chloroform. The fluid may either be poured upon a 
thickly-folded napkin or it may be placed in an inhaler carefully fitted to the nose, from 
half a drachm to a drachm being used in the first instance, and a smaller quantity at each 
repetition until the desired effect is induced, when the anaesthetic influence may readily be 
maintained with a few drops applied from time to time as long as may be necessary. Air 
must, of course, be admitted, but not too freely, more especially at first, otherwise it will 
retard the induction of narcotism. A slight choking condition is often experienced at the 
beginning of the administration, but this usually passes off rapidly; if not, the inhalation 
must be momentarily suspended. Any ill effects that may arise must be treated upon 
the same general principles as in poisoning from chloroform. The agent is more danger- 
ous than chloroform, and it has caused death in a number of instances. 
Protoxide of Nitrogen—This substance, better known as nitrous oxide gas, or laugh- 
ing gas, was originally employed as an anesthetic agent by Dr. Beddoes and Sir 
Humphry Davy, and afterwards by Dr. Horace Wells, of Connecticut, who was the first 
to administer it successfully for surgical purposes. It is a sweetish, colorless gas, destitute 
of odor, and is composed of equal parts of nitrogen and oxygen. When perfectly pure, 
and unmixed with atmospheric air, it is a supporter of vitality and of combustion, and, there- 
fore, entirely safe as an anaesthetic. Its effects are very similar to those of carbonic acid 
gas, and hence its administration cannot be continued beyond a few minutes without the 
risk of asphyxia. For this reason it cannot be safely employed in protracted operations. 
Anaesthesia generally follows in from thirty to sixty seconds, snoring with unconscious- 
ness being usually the first evidence of its induction. The pulse is slightly accelerated, 
the muscles are relaxed, the lips are livid, the eyes are rolled up, the conjunctiva is 
insensible, and, if the inhalation be at all protracted, the respiration will be considerably 
embarrassed and the blood of a dark color, owing to the absence of oxygen. Unless the 
stomach is loaded with ingesta, there is seldom any vomiting. In the female a good deal 
of hysterical excitement occasionally occurs. No secondary effects, such as sick headache, 
mental depression, nausea, or emesis, are liable to arise from its use. 
The administration of this gas is effected by means of a gum-elastic inhaler, to which 
is attached a long tube of similar material, furnished with a mouth-piece, a cylinder of 
wood, fastened to a string, being previously interposed between the jaws. Recumbency 
need not be observed, as in the case of chloroform, but it is well to free the body from all 
constriction. Alarming symptoms are pi'omptly relieved by a supply of fresh air. From 
six to eight gallons of the fresh gas is the quantity usually required to produce complete 
anaesthesia. It is proper to add that its effects are weakened by keeping. 
Protoxide of nitrogen is more particularly applicable to the minor operations of surgery, 
as the extraction of teeth, the evacuation of abscesses, the removal of small tumors, and 
the ligation of hemorrhoids ; but it may also be employed in some of the larger operations, 
as excision of the mammary gland, lithotomy, the perineal section, and the more ordinary 
amputations. Its great disadvantage is the rapidity with which it loses its anaesthetic 
effects. It should be given with great caution, if at all, in organic disease of the heart, 
in pulmonary phthisis, and in congestion of the brain. 
Dr. John D. Thomas, of this city, informs me that, up to January, 1882, this gas had 
been administered by him and his brother, the late Dr. Franklin R. Thomas, since 1865, 
to 101,500 persons for the extraction of teeth, without one fatal accident. Included in CHAP. XX. 
RAPID BREATHING. 
559 
these cases are two amputations, one of the leg and one of the foot, and operations for 
sounding for stone in the bladder, anal fistule, clubfoot, and stricture of the urethra. The 
ages of the patients varied from three to ninety-two. Although some of them labored 
under organic maladies of the heart and lungs, asthmatic complaints, and various other 
complications, none experienced any ill effects. Nervous, hysterical women occasionally 
suffer from temporary depression, which, however, generally readily yields under the use 
of a glass of sherry or a little brandy and water. Persons in the advanced stages of 
disease of any important organ, anemic persons, and persons who are liable to frequent 
attacks of epilepsy, cannot with safety use the gas in this form. The number of deaths 
from the exhibition of this gas in the hands of different operators probably does not exceed 
a dozen. 
Of all the anassthetics now before the profession ether is unquestionably the safest, and 
is the one now universally employed in the hospitals of this country. In private practice, 
too, it enjoys a decided preference, although there are still many surgeons who use 
chloroform, believing that, if carefully administered, it is equally free from danger. For 
many years, I never employed any other article, and even now my confidence in its safety 
remains unshaken. For some time past, however, I have, in great measure, restricted 
myself, both in public and private practice, to the use of ether, except in the case of 
children, in whom I generally prefer chloroform on account of the rapidity of its action 
and the absence of unpleasant secondary effects. No article that has yet been tried as a 
means of averting pain is perfectly safe. Anresthesia is, in almost any event, partial 
death ; and hence no matter what substance may be used for inducing it, the occasional 
destruction of life must be inevitable. 
The danger of the use of chloroform as an anesthetic may, as a rule, be materially 
lessened by the administration of a dose of morphia, laudanum, or black drop, within an 
hour to an hour and a half of the operation. This practice has long been in force in all 
my more severe clinical cases, and I have the greatest confidence in its efficacy, not only 
in sustaining the heart’s action, which the different preparations of opium are so well 
known to do, but in preventing the cough, excitement, and muscular rigidity so often 
witnessed, especially in nervous persons. What is true of chloroform in this respect is 
still more true of ether, which rarely fails to cause more or less severe and annoying 
laryngeal and tracheo-bronchial irritation, not unfrequently followed by partial asphyxia 
due to spasm of the laryngeal muscles. When a full anodyne is given in this way— 
not, as some have recommended, just before the administration of the ether or chloroform 
is commenced—I am satisfied from long experience that the agent acts not only more 
kindly but also much more speedily; that its use may be prolonged with much less 
danger; and that its after-effects are more promptly recovered from, with less tendency 
to the nausea and distress in the head so liable to follow, when this practice is neglected, 
the administration of ether. 
At my Clinic at the Jefferson Medical College Hospital where, until recently, I employed 
chloroform in all my operations, no mishap from its use has ever occurred. Dr. Joseph 
Hearn, who has been my anaesthetizer for the last eleven years, has given it in many 
hundred cases, at all periods of life and under almost every variety of disease and acci- 
dent without any serious occurrence. The fluid, whether chloroform or ether, is always 
administered gradually, during recumbency, on the empty stomach, with all sources of 
constriction removed; the respiration and circulation are carefully watched; and a wet 
towel is always at hand to slap the face the moment any signs of asphyxia appear. In 
regard to chloroform, my conviction is that there is less risk in the agent itself, provided 
it is perfectly pure, than there is in the mode of administering it. 
It is worthy of remembrance, in regard to the use of anaesthetics, that, as rapid respi- 
ration obtunds the morbid sensibility of the respiratory passages, it may often be advan- 
tageously employed to prevent the unpleasant primary irritant effects of ether and chloroform 
inhalation, especially of the former. 
For many of the minor operations of surgery, as the opening of boils and abscesses, 
the ligation of hemorrhoids, and the exploration of the bladder, complete anaesthesia is 
unnecessary. In such and similar cases, the knife and whatever else may be required, 
may very properly be employed the moment partial unconsciousness is obtained. Very 
frequently, indeed, a few whiffs of chloroform are quite sufficient for the purpose, especi- 
ally in children. I have pursued this method for many years both in private and hospital 
practice, and its importance has been ably discussed in a paper published upon the subject 
in 1877 by Dr. John A. Packard, of this city. 
Rapid breathing, as a means of preventing pain, was introduced to the notice of the 560 
ANAESTHETICS. 
chap. xx. 
profession a few years ago by Dr. William G. A. Bonwill, an eminent dentist of this city, 
and is worthy of more attention than has hitherto been accorded to it. It is, of course, 
adapted only to minor operations, such as the opening of abscesses, the division of strictures 
of the urethra, the extraction of teeth, and the explorations of the bladder, vagina, and 
rectum for the detection and diagnosis of diseases. To produce anything like marked 
insensibility the number of inspirations should not be less' than forty, forty-five, or 
fifty in the minute, steadily continued for three to five times that period. The best 
posture is the recumbent, but the sitting posture is not objectionable, provided there are 
no contraindications. The first effect is generally a feeling of fatigue, with a sense of 
tingling and of expansion or fullness in different parts of the body. Consciousness is 
preserved but not always in its full extent; the heart’s action is increased in frequency 
and somewhat weakened ; and, when the breathing is carried to an extreme degree, the 
countenance becomes cyanosed and the patient is seized with dizziness, confusion of ideas, 
lassitude, and incapability of resistance. These phenomena speedily subside on discon- 
tinuing the breathing. In operations it has been noticed that the blood which follows the 
knife is, when the system is fully impressed, of a venous color. The condition induced 
by rapid respirations strongly resembles that induced by the inhalation of nitrous oxide 
gas, and seems, to depend essentially, as Dr. Addinell Ilewson, who has paid much atten- 
tion to the subject, imagines, upon a diminished oxidation and decarbonization of the blood. 
This mode of inducing anaesthesia should be practised with a certain degree of care in 
elderly persons worn out by long-continued suffering, and in persons laboring under organic 
disease of the heart with a tendency to apoplexy. 
Local Ancesthesia—Various plans have been tried for the purpose of inducing local 
anaesthesia, but the results have not been such as to hold out much encouragement for 
their practical application. When we consider the absorbent powers of the skin, it might 
reasonably be supposed that the endermie use of the more potent anodynes, as opium and 
its different preparations, aconite, belladonna, hyoscyamus, and kindred articles, might 
be employed beneficially in this wise, but experience has proved that any effect of this 
kind that they may possess is exceedingly transient and altogether incapable of serving 
as a preventive of pain during the application of the knife. The employment of ice, or 
of the frigorific mixture recommended by Mr. James Arnott, of London, is hardly enti- 
tled to more confidence; my experience with it is, it is true, very limited, but I have 
seen enough of it to satisfy me that its value has been greatly overrated, and that it can 
never, except, perhaps, in the most trivial cases of injury and disease, be carried to a 
sufficient extent to prevent pain in surgical operations. In a case in which I tried it 
during the removal of the mammary gland in an old lady, although the skin and subcuta- 
neous connective tissue were completely congealed, the ice in the latter producing a crack- 
ling noise, yet the suffering was most intense, especially during the dissection of the deeper 
structures, where the effects of the freezing mixture had evidently not penetrated. No 
one can deny that, in this instance, the remedy had not been carried to a sufficient ex- 
tent, and yet it certainly exercised but a very feeble influence as an anaesthetic. Besides, 
the application is not without risk, as the part, if not carefully watched, may be frost- 
bitten, and thus experience unpleasant secondary effects. 
Mr. Arnott’s freezing mixture consists of two parts of ice and one of common salt, the 
former being previously reduced to a fine powder in a canvas bag, pounded with a flat- 
iron. The latter should also be pulverized. The two articles are then thoroughly and 
quickly mixed, either with a knife, or by stirring them together in a gutta-percha or 
other non-conducting vessel. The mixture is inclosed in thin gauze netting, and as soon 
as the action of the salt upon the ice is rendered apparent by the dripping of the brine, it 
is placed upon the part to be benumbed, which is held in a horizontal position during the 
application. The netting should occasionally be raised to watch and equalize the effect of 
the remedy. About a quarter of a pound of ice and half that quantity of salt suffice for 
an ordinary application. 
The first effect of the remedy is to chill the part, but this rapidly disappears, and is 
succeeded by pallor of the surface and a sense of numbness. Very soon the skin is found 
to be notably shrunken, and to assume a deadly, tallow-like appearance, at the same time 
that it is rendered somewhat stiff and perfectly insensible. If the application be con- 
tinued longer, the subcutaneous connective and fatty tissues become partially congealed, as 
is proved by the fact that they feel hard and crackle slightly under the finger. When the 
application is properly made, that is, gradually and cautiously, the netting being occa- 
sionally raised for the purpose of inspection, it is perfectly harmless and almost unattended 
with' suffering. It is only when it is continued too long that it is likely to be productive CHAP. XX. 
LOCAL ANAESTHESIA. 
561 
of mischief. Ordinarily from fifteen minutes to half an hour will he required to secure 
the desired anesthetic effect. 
Rhigoline, introduced as an anesthetic, in 1866, by Professor Henry J. Bigelow, pro- 
duces its specific effects by evaporation, freezing the skin firmly in from five to ten 
seconds. Gently applied, the impression is evanescent; protractedly, it is followed by 
discoloration of the surface and desquamation of the cuticle. Rhigoline is particularly 
serviceable in opening abscesses and felons, in the removal of small tumors, in amputa- 
tions of the fingers and toes, in phimosis, hemorrhoids, anal fistule, and other minor ope- 
rations. The only objection to it is its inflammable character, which prevents it from 
being conveniently carried about in hot weather. 
The method of inducing local anaesthesia with the ether spray, devised by Dr. B. W. 
Richardson, consists in directing upon the part to be operated upon a series of jets ot 
pure rectified ether by means of a small hand-bellows connected with a double tube 
Fig. 238. 
Kicliardson’s Spray Apparatus. 
inserted into a graduated bottle through a perforated cork, as represented in fig. 238. 
An intense degree of cold may thus be produced, rendering the skin insensible in less 
than a minute, and the narcotism may, if necessary, be readily extended, after the 
part has been incised, to any depth that may he desired. With the aid of a spray ca- 
theter, the fluid may he thrown into the nose, rectum, bladder, or uterus. In operating 
on the extremities, anaesthesia will be more promptly induced if the current of blood be 
stopped by compression of the main artery of the limb. Pure rectified ether thus em- 
ployed is entirely free from irritating qualities, and possesses the additional advantage of 
not causing any painful reaction. It is applicable to the same class of cases as rhigoline. PART SECOND. 
SPECIAL SURGERY; 
OR, 
DISEASES AND INJURIES 
OF 
PARTICULAR ORGANS, TEXTURES, AND REGIONS. PART SECOND. 
SPECIAL SURGERY; OR, DISEASES AND INJURIES OF PARTICULAR 
ORGANS, TEXTURES, AND REGIONS. 
CHAPTER I. 
DISEASES AND INJURIES OF THE SKIN AND CONNECTIVE TISSUE. 
SECT. I. ERYSIPELAS. 
Erysipelas is not only a frequent but a most formidable disease. Produced by various 
causes, both local and constitutional, it may exist as a primary affection, or occur as a com- 
plication of other lesions, modifying their character, interfering with their evolution, and 
even, at times, entirely supplanting them. Although most common in the skin and con- 
nective tissue, it is liable to attack various other structures, particularly the mucous and 
serous. By dermatologists it is usually ranked among the exanthematous diseases, on 
account of the discoloration which forms so striking a feature in its symptomatology. 
The term by which it is generally designated is a Greek one, signifying a tendency to 
spread. 
The most common division of erysipelas is into the simple, phlegmonous, and oedema- 
tons. The terms idiopathic and traumatic are also used, according as the disease is depen- 
dent upon some constitutional vice, or upon external injury. Attempts have been made 
to draw a distinction between erysipelas and what has been so graphically described by 
Dr. Duncan, of Edinburgh, under the name of “ Diffuse Inflammation of the Cellular 
Texture,” now more generally known as “ cellulitis.” No one, however, w'ho has care- 
fully studied the subject, can fail to perceive that the two affections are in reality identical, 
the only difference between them being that in the one case the morbid action begins in 
the skin, and in the other in the connective tissue, both structures being always more or 
less seriously involved during the progress of the disease. The causes, march, symptoms, 
morbid changes, termination, and mode of treatment are precisely alike in the two cases. 
Hence I agree perfectly with the late Mr. Thomas Nunneley, of Leeds, who has so criti- 
cally and ably examined the subject in his excellent Treatise on Erysipelas, published in 
1841, that such a distinction is as unnecessary as it is unscientific. 
Erysipelas occurs at all periods of life, and in both sexes; but of the two forms of the 
disease, the idiopathic is most common in women, while the traumatic is most frequently 
met with in men, simply because the latter are more liable than the former to all kinds of 
injury and exposure. What influence, if any, temperament exerts upon its production, 
has not been determined. Nervous, irritable, and intemperate persons are particularly 
subject to it. The greatest number of cases, at least in this country, occur in the latter 
part of autumn and early in the spring. Locality, doubtless, exerts an important influence 
in its causation. Thus, it is well known that it is particularly liable to occur in the nar- 
row, crowded, and filthy streets of large cities, in the confined and ill-ventilated wards of 
hospitals, and in marshy, malarial districts. The effect of occupation in producing ery- 
sipelas has not been ascertained ; but there is no question that cooks, blacksmiths, foundry- 
men, and persons habitually exposed to dry heat, are particularly obnoxious to its attacks. 
No region of the body is exempt from its affection, though some are more liable to it 
than others. The idiopathic form is most frequent in the face, scalp, neck, and trunk, 
while the traumatic appears to be most common in the extremities, particularly the 
inferior. The eyelids, nose, and forehead are especially prone to be assailed. Old, de- 566 
DISEASES OF THE SKIN AND CONNECTIVE TISSUE. 
CHAP. i. 
crepit subjects, and persons worn out by intemperance and disease, often suffer from 
erysipelas of the scrotum, vulva, feet, and legs. Injuries of the scalp, tendons, and apo- 
neuroses frequently give rise to the disease, and are liable, in consequence, to be followed 
in many cases, by the worst results. 
Erysipelas occasionally assumes an epidemic type. Hippocrates had already observed 
this fact. During the middle ages a gangrenous erysipelas repeatedly ravaged France, 
where, from its excessive violence, the disease was called the plague of fire. Erysipelas 
has frequently prevailed as an endemic in camps, barracks, hospitals, and prisons. In 
modern times it has been observed in both of these forms in various localities. Dr. Greg- 
ory expresses the belief that there is not a single hospital in London which has not occa- 
sionally been visited by the endemic variety of the disease. At St. George’s Hospital, 
in that city, he repeatedly saw erysipelas so prevalent that all important surgical operations 
were obliged to be postponed for fear of the supervention of the malady. The inmates of 
the old IIotel-Dieu of Paris were frequently assailed in this way, and the mortality thence 
arising is said to have been very great. Calmiel states that there are periods when erysipelas 
prevails so extensively in the lunatic asylums of the French metropolis that the physicians 
of those institutions are compelled to suspend all treatment by counterirritants, as blisters, 
setons, issues, and moxas, on account of its great liability to be followed by an outbreak 
of this affection. Velpeau describes an epidemic erysipelas which prevailed at La Pitie 
in 1831. In 1844, ’5, and ’6, the disease was so common in the Louisville Hospital, and 
also throughout the city of Louisville, where I then resided, that I was obliged, on numer- 
ous occasions, to postpone the performance of all operations in which delay wras admissible, 
for fear of giving rise to it. Such was the tendency, at that period, to its occurrence, that 
the most trivial incision, puncture, or scratch was almost sure to be followed by an attack. 
For a long time we were obliged, in consequence of this proclivity, to refrain from the use of 
blisters, leeches, venesection, setons, and issues. Chancroids, buboes, and common ulcers 
were often invaded in a similar manner. But the epidemic was not confined to that city; 
it prevailed more or less extensively in different sections of the Union, and carried off an 
immense number of all classes of people. In many localities there was a marked con- 
nection between the affection and puerperal peritonitis, the latter of which proved very 
fatal. 
The epidemic here referred to first showed itself, in 1842, in Canada, whence it rapidly 
spread to Vermont and New Hampshire. The disease usually began in the throat and 
fauces, or simultaneously in these parts and upon the cranio-facial region, in the form of a 
deep red, glossy, oedematous swelling, which gradually extended until it involved the 
whole of the neighboring structures, the countenance being generally distorted in the most 
hideous manner, so that the patient could hardly be recognized even by his most intimate 
acquaintances. The tongue, uvula, and tonsils were enormously swollen, deglutition and 
breathing were extremely difficult, and death was often produced by suffocation. Delirium 
and excessive prostration were early and prominent symptoms, and many of the cases 
perished within the first five days. The disease remained generally confined to the parts 
originally affected. If the patient survived any length of time, profuse suppuration, and 
sometimes even extensive sloughing, occurred ; abscesses formed in various regions of the 
body; and, after much suffering, the patient either recovered, or died from exhaustion. 
In some of the persons whom I attended there was extensive ulceration of the tonsils and 
arches of the palate, and, in several, complete destruction of the gland of one side. In 
one case, almost the whole of the occipital bone was stripped of pericranium. Dissection 
disclosed deep engorgement of the lungs, accompanied, in many cases, by inflammation 
of the bronchial tubes, and even of the pulmonary parenchyma, and by effusion of serum, 
or of serum and pus, in the pleura and arachnoid sac. The abdominal and pelvic viscera 
were generally sound, except in lying-in females, who usually exhibited high evidence of 
peritonitis, metritis, and phlebitis. In one instance, which occurred quite early in the 
epidemic, the immediate cause of death was a large metastatic abscess in the left lung, 
the erysipelas being seated in the corresponding leg. 
The disease thus briefly described was generally known in the West under the name of 
“ black tongue,” “ swelled bead,” or “ erysipelatous fever.” It seldom attacked any one 
under fifteen years, but from that period up it was indiscriminate in its selection of sub- 
jects. Females seemed to suffer quite as frequently as men. The poor and the intem- 
perate were its most common victims. 
If a dissection be made of a limb in an erysipelatous state, it will be found to exhibit 
various appearances, according to the amount of the diseased action. In the milder 
grades, there will merely be some degree of induration of the skin, unusual distension of CHAP. I. 
ERYSIPELAS. 
567 
the vessels, and slight effusion of serum, or of serum and lymph, in the subjacent connec- 
tive tissue. In the phlegmonous variety, there is generally extensive infiltration of the 
ordinary inflammatory products; the lymph has a spoiled and unnatural appearance, 
looking like lard or a mixture of flour and water; abscesses exist in various situations; 
the connective tissue is converted into grayish or ash-colored sloughs ; and the muscles 
are extensively separated from each other. In a case which I attended in 1846, during 
the prevalence of epidemic erysipelas, the abscess reached from the hip to the ankle, 
extensively detaching the muscles from each other and from the bones, which might have 
been lifted almost bodily from the diseased mass, so completely were they severed from 
their connections. Pure blood is sometimes extravasated in considerable quantity; and 
the matter, which varies much in its color and consistence, is often excessively offensive. 
Metastatic abscesses are occasionally found in the internal viscera, and effusions in the 
serous cavities. Endocarditis with granular degeneration is not unfrequently observed, 
and in the more severe and protracted cases, the heart is more or less flabby. Organic 
disease of the kidneys is often met with, manifesting itself in the lighter forms of nephri- 
tis. Evidences of inflammation of the brain and its membranes are occasionally present 
when the erysipelas occupies the scalp. 
The question as to the contagiousness of this disease is not fully settled. Much may 
be said both against and in favor of such a view. My own opinion, founded upon con- 
siderable experience, is that the affection, at times, possesses such a character. It is very 
well known that it is inoculable. Thus, a sponge impregnated with the matter of an 
erysipelatous sore will very readily communicate the disease to an ulcer or an abraded 
surface in a sound person, and the same thing is true of poultices, ointments, and other 
dressings. Facts showing that the nurses and friends of individuals affected with erysipe- 
las often contract the disease are of frequent occurrence. In this way whole families are 
sometimes cut down. A gentleman, in 1852, lost his only son by this disease. A cousin 
and a female acquaintance who attended him soon became ill with it, and both died ; it 
then spread to other members of the family, and produced most serious ravages before it 
was finally arrested. In 1846, when erysipelas reigned as an epidemic in Kentucky, a 
man was received into the Louisville Hospital with an ulcerated bubo, and about the 
same time his mistress was also admitted with the prevailing distemper. In consequence 
of an inability to obtain a female nurse, the man was permitted to attend upon her in 
that capacity. He soon cohabited with her; in a few days he became excessively ill, the 
sore in the groin assumed an erysipelatous aspect, and in less than a week from the time 
of his admission he died from the effects of the malady. In the wards of hospitals 
erysipelas often spreads from one person to another; and in private practice it is occa- 
sionally carried by the physician from one house to another. It is in this manner that 
the parturient female not unfrequently becomes the victim of the accoucheur. 
Causes The causes of erysipelas are too numerous and diversified to admit of any 
very definite specification. As a rule, it may be assumed that whatever has a tendency 
to disorder the digestive, hepatic, or, in short, any other important function, is capable 
of producing the disease. So true is this that there is seldom, if ever, a case of the 
complaint in which such derangement does not play a more or less conspicuous part. The 
fact is important, as leading to valuable therapeutic considerations. Certain articles of 
diet either predispose to or induce the malady. Thus, there are some persons who cannot 
eat shell-fish or some particular kinds of fruit, as strawberries, nuts, and similar sub- 
stances, without suffering from an attack. The retention of vitiated secretions and un- 
digested food in the alimentary canal often leads to similar results. Derangement of the 
uterine functions, suppression of the cutaneous perspiration, great mental excitement, 
the habitual use of ardent spirit, loss of sleep, hard study, inordinate sexual indulgence, 
and, in short, whatever has a tendency to weaken the corporeal faculties, may be enu- 
merated as so many causes of the disease. A vitiated state of the atmosphere, such as is 
witnessed in hospitals and other charities, often powerfully predisposes to its attacks, as 
well as to its continuance. Some of the worst cases of this disease that I have ever seen 
came on during the progress of albuminuria. Indeed, there is reason to believe that 
organic disease of the kidney is a not unfrequent cause of erysipelas, especially after vio- 
lent injuries, severe shock, or great loss of blood. 
Erysipelas frequently supervenes upon wounds, both accidental and artificial, interfer- 
ing with the healing process, and, at times, seriously compromising both the part and the 
system. The period at which this occurs varies from twenty-four hours to several days, 
according to the nature and extent of the lesion, the presence or absence of complications, 
the habits of the patient, the condition of the system, and the state of the atmosphere. 568 
DISEASES OF THE SKIN AND CONNECTIVE TISSUE. 
CHAP. 1. 
Lacerated, punctured, gunshot, railway, and poisoned wounds are much more liable to be 
assailed in this manner than incised wounds, although the latter are by no means exempt 
from it, especially if they involve the scalp, hands, or feet, or if they affect old, intempe- 
rate, or debilitated individuals. In a case reported to me by Dr. J. P. Miller, of Ken- 
tucky, a severe attack of erysipelas of the eye supervened upon the bite of the common 
house-fly; and in 18'/ 7, in this city, a woman from a similar occurrence lost her life, the 
wound having been inflicted upon the lip. I have seen destructive erysipelas of a finger 
produced by a wound inflicted by the fin of a fish, the prick of a needle, and the teeth of 
man and other animals. Indeed, a punctured wound from any cause is peculiarly prone 
to take on this kind of action, often followed by the most violent symptoms and the most 
serious consequences. 
When the disease is epidemic, it often shows itself within a very short time after the 
receipt of an injury, however slight or insignificant. Under such circumstances, indeed, 
I have, as already stated, known it to follow upon the most trivial wodnd, scratch, or 
puncture, as a leech-bite, venesection, vaccination, or the application of a blister. Frac- 
tures, dislocations, sprains, contusions, and various other injuries not unfrequently give rise 
to it. Ulcers, whether common or specific, are often invaded by it, especially when the 
patients are of a broken constitution. Lying-in females are, in certain conditions of the 
atmosphere, particularly prone to suffer from erysipelas of the uterus and pelvic veins. 
Finally, erysipelas frequently engrafts itself upon other diseases. During the winter 
of 1857, when the malady was endemic in this city, a number of instances occurred where 
it supervened upon measles, scarlatina, and typhoid fever. During the epidemic of erysi- 
pelas in Louisville, in 1844, ’5, ’6, every case of disease that was admitted into the public 
hospital of that city received its peculiar impress, and wore for a time its peculiar livery. 
When the affection was raging at its fullest height in the institution, many of the patients 
who were convalescing from other maladies were suddenly seized with diarrhoea, pneumo- 
nia, and bronchitis, over which the usual remedies exercised no control, and which gene- 
rally proved fatal in a few days after the attack. 
When erysipelas supervenes upon wounds, its approach is usually denoted by an arrest 
of the adhesive process, by a tensive, burning sensation in the affected part, by a discharge 
of thin, sanious matter, or an entire suspension of secretion, and by an oedematous 
appearance of the surrounding structures. Finally, the characteristic blush occurs, and, 
gradually diffusing itself, often spreads over a considerable extent of surface. 
When erysipelas seizes upon ulcers, as it may at any time, whether they are benign or 
malignant, simple or specific, the local symptoms closely resemble those which charac- 
terize the complaint when it follows upon wounds and contusions. The granulations, if 
any exist, assume a pale, glossy, unhealthy aspect, the pus is replaced by a thin, ichorous 
fluid, the part is rendered uncommonly painful, and the edges of the sore, along with the 
adjacent surface, exhibit a reddish, oedematous appearance. In chancroids and dissection 
wounds the presence of erysipelas is indicated by reddish, tender lines, formed by the 
superficial lymphatic vessels, generally extending as high up as the neighboring glands, 
which, in turn, become swollen and exquisitely painful. The morbid action may, in both 
cases, be simple or phlegmonous, and is almost always dependent upon derangement of 
the digestive organs, or the suppression of some habitual discharge. 
Erysipelas, consequent upon wounds, contusions, fractures, and dislocations, generally 
manifests itself within the first forty-eight hours after the receipt of the injury, and often 
spreads very rapidly over a large extent of surface, as the greater portion of a limb, one 
side of the trunk, or the whole scalp and face. The accident is particularly liable to 
supervene upon the more severe forms of these lesions, and is always to be viewed with 
distrust, as it not unfrequently compromises the patient’s recovery. Erysipelas of the 
scalp, caused by wounds and fractures of the skull, generally appears from the second to 
the third day, and often proves dangerous by its extension to the brain and its envelops, 
through the intervascular communications between the pericranium and the dura mater. 
Such cases always demand the greatest vigilance on the part of the practitioner. 
Varieties—In simple erysipelas, described sometimes as the erythematous form, the 
disease is confined exclusively to the skin. It manifests itself in a bright, vivid, almost 
scarlet discoloration of the surface, a pungent, smarting, or burning pain, and a sense 
of stiffness, with, perhaps, here and there a little vesicle, not larger than the head of a 
pin, and filled with a serous fluid. The swelling is very slight, and, unless the extent of 
disease is considerable, there is no particular constitutional disturbance. The attack is 
usually of short duration, and the subsidence of the local disease is always followed by a 
furfuraceous desquamation of the epidermis. CHAP. I. 
ERYSIPELAS. 
569 
Phleymonous erysipelas is a much more serious lesion than the simple, all the symp- 
toms existing in a higher degree, and the disease often terminating in extensive suppura- 
tion, abscess, and even gangrene. The discoloration varies from scarlet to deep purple ; 
there is extensive swelling ; vesication soon arises ; and the pain is of a violent, burning, 
tensive, and throbbing character, the part feeling heavy, stiff, numb, and as if it were on 
fire. The inflammation extends deeply among the different tissues, affecting the skin, 
connective tissue, muscle, and, in short, everything that comes in its way. As it pro- 
gresses, suppuration takes place, leading to the formation of extensive abscesses, and the 
destruction of large portions of the connective and adipose tissues. If the morbid action is 
very intense, mortification will be apt to arise, its approach being indicated by the 
development of large blebs, filled with bloody, yellowish, or muddy serum, and by a 
dark, livid, brownish, or ash-colored appearance of the skin. The constitution sym- 
pathizes early and deeply, the symptoms being at first of a sthenic character, but soon 
becoming typhoid. 
The cedematous variety depends entirely upon accidental causes, its name being derived 
from the circumstance of the parts being infiltrated with sei-osity, and, consequently, 
pitting under pressure. It is most common in the eyelids, scrotum, prepuce, vulva, and 
inferior extremities, in persons who are debilitated by previous disease, or who naturally 
possess a feeble constitution. The swelling is often considerable, but the discoloration 
and pain are comparatively trivial. The diseased surface has a glossy, distended appear- 
ance, and retains the mark of the finger for some time after it has been withdrawn. The 
inflammation is attended by constitutional disorder, generally of a typhoid character, and 
is apt to terminate in mortification rather than in abscess, although the latter is often 
present in the more severe cases. 
Erratic erysipelas is characterized, as the name imports, by a disposition to extehd 
from one point to another; it is most commonly met with on the face and forehead, from 
which it frequently spreads, on the one hand, to the hairy scalp, and, on the other, to the 
neck and ears. In a case of this form of erysipelas, under my charge, the attack, com- 
mencing on the left nates, finally extended over the whole trunk. The disease is gener- 
ally superficial, and is characterized by an erythematous appearance of the surface, with 
pungent pain, but little swelling. 
Although erysipelas, as previously stated, is generally a disease of the skin, or of 
the skin and subcutaneous connective tissue, it not unfrequently occurs in other struc- 
tures, more particularly in the mucous and serous, the joints, the veins, and the 
absorbent vessels, either as an idiopathic or traumatic affection. Of the mucous mem- 
branes the parts most liable to suffer are the tonsils, the palate, the uvula, the pharynx, 
and the larynx, the disease existing sometimes independently, but more commonly in 
conjunction with erysipelas of the skin. The affected structures are of a crimson or 
bright scarlet color, cedematous, incrusted with patches of lymph, exquisitely painful, 
and attended with great functional disturbance, and high constitutional excitement, 
rapidly passing into a low, typhoid condition. The breath is excessively fetid, and 
of a peculiarly contagious character, the attendants not unfrequently becoming in- 
oculated by it. 
Erysipelas of the larynx is met with chiefly in the upper portion of the tube, at and 
immediately below the rima of the glottis, constituting what, since the time of Bayle, has 
been known as oedema of the windpipe, the parts here being supplied with a considerable 
quantity of loose connective tissue, whereas lower down the mucous membrane is so firmly 
adherent as to render distension by inflammatory deposits impossible. The disease, which 
will receive special attention in the chapter on affections of the air-passages, is particularly 
dangerous on account of the mechanical impediment which it causes in respiration, as 
well as the great depression of the vital powers which, usually even at an early stage, 
attends it. The attack is frequently secondary, or a consequence of an extension of 
erysipelas from the fauces. 
Erysipelas of the serous membranes is most common in the arachnoid and the peri- 
toneum ; in the former as a result of injuries of the scalp and cranial bones, and in the 
latter of the effects of strangulated hernia and contusions of the pelvis and abdomen. 
Lying-in females not unfrequently suffer from a bad form of erysipelas, the disease some- 
times prevailing as an endemic, especially in the crowded wards of hospitals. Attacks 
of this kind generally begin in the veins of the uterus or in those of the broad ligaments, 
from which the disease extends to the subserous connective tissue and thence to the perito- 
neum, the symptoms which follow it being strongly denotive of pyemia, attended with a 
low, typhoid condition of the system, soon terminating in death. The secretions that are 570 
DISEASES OF THE SKIN AND CONNECTIVE TISSUE. 
CHAP. i. 
poured out in this form of erysipelas are commonly aplastic, very copious, highly inocul- 
able, and liable to cause dangerous, if not fatal, dissection wounds in making post-mortem 
examinations. 
Erysipelas of the joints is usually associated with the disease as it occurs in other 
parts of the body, the most common exciting causes being punctured and gunshot 
wounds, contusions, and suppression of the cutaneous perspiration. In pyemia the larger 
joints often suffer more or less severely from this cause, the lining membrane being in- 
crusted with aplastic lymph, and their interior distended with sero-purulent fluid, generally 
of a highly acrid character. 
The veins and lymphatic vessels are often attacked with erysipelas, sometimes primarily, 
but most frequently secondarily. The most common exciting causes are injuries, as 
wounds and contusions, surgical operations, as the ligation of varicose veins of the ex- 
tremities, and violence sustained by the veins of the uterus during parturition. Punctured 
wounds, more especially of the foot and hand, are very liable to give rise to erysipelas of 
the absorbent vessels. 
Erysipelas sometimes occurs in new-born infants, most commonly in lying-in hospitals, 
the parts most liable to suffer being the genital organs and the abdomen about the 
region of the umbilicus. It generally comes on within a few days after birth, and often 
spreads with frightful rapidity, involving a great extent of surface within a few hours 
from its first manifestation. Occasionally an instance of congenital erysipelas has been 
noticed. Want qf cleanliness and a vitiated state of the atmosphere are the most 
common exciting causes of the disease. Inflammation of the umbilical vein is pro- 
bably occasionally concerned in its production. In the worst forms of infantile 
erysipelas the affected parts are of a dark red, purple, or livid color, greatly dis- 
tended, and of extraordinary firmness. A swollen, oedematous condition is sufficiently 
common when the disease is seated in regions of the body largely supplied with loose 
connective tissue. 
Constitutional Symptoms Whatever form it may assume, erysipelas is usually preceded 
by symptoms denotive of general indisposition, such as a feeling of malaise, or discomfort, 
creeping, chilly sensations, lassitude, pain in the head and limbs, impaired appetite, and 
an indisposition to exertion. After continuing in this state for a period varying from 
twenty-four to thirty-six hours, the disease declares itself in a more open manner. The 
patient is now suddenly seized with shivering, or violent rigors, followed by, or alternat- 
ing with, excessive heat, and accompanied by severe cephalalgia, nausea, intense thirst, 
restlessness, and a great sense of muscular prostration. The tongue is dry and coated, 
the skin hot, the pulse strong and frequent, the urine high-colored and scanty, and, if 
the temperature rise to or above 103°, almost invariably albuminous. Systolic murmurs 
are not uncommon, especially in delapidated or anemic subjects. As the disease pro- 
gresses, the system becomes more and more exhausted, the mind wanders, and the case 
soon assumes a typhoid character. Or, typhoid symptoms may be present almost from 
the very commencement, especially if the patient is old, decrepit, or depressed by previ- 
ous suffering. In the milder forms of erysipelas, there is often very little, if any, consti- 
tutional disturbance. 
If blood be drawn during the progress of the disease, it will generally be found to 
exhibit a sizy appearance. Sometimes it is deeply buffed, and even cupped. What 
internal or intrinsic changes the mass of blood undergoes in this affection has not been 
satisfactorily determined. Enough, however, is known to show that in the more 
severe forms of the affection there is generally a marked increase of fibrin and white 
corpuscles. 
Diagnosis—Erysipelas is generally so well marked as to render it impossible to 
confound it with any other disease. The only form which is liable to cause error of 
diagnosis is the simple, which may be mistaken for erythema, which it certainly very 
much resembles. The signs of discrimination are, the peculiar character of the pain, 
which is sharp, pungent, and smarting in erysipelas, and almost absent in erythema; the 
deeper redness in the former than in the latter, and the tendency also to the evolution of 
vesicles, which does not exist in erythema. 
Pathology—The pathology of erysipelas is still involved in obscurity. How it is 
induced, what is its seat, or where it originates, are points concerning which we are wholly 
ignorant. All that is known is that it has a peculiar predilection for the dermoid and 
connective tissues, the cellular elements of which, along with the emigrant leucocytes, 
undergo rapid and enormous proliferation, and that it is usually, if not invariably, asso- 
ciated with disorder of the general system, affecting, probably, both solids and fluids. So CHAP. I. 
ERYSIPELAS — TREATMENT. 
571 
thoroughly am I convinced of the latter fact that I do not believe it would be possible for 
erysipelas ever to appear in a perfectly sound individual. If this be true, then derange- 
ment of the general health, especially as displayed in a vitiated condition of the digestive 
organs, must be regarded as a most important element in the pathology of this affection, 
and one which must exert a marked influence upon our curative agents. The opportuni- 
ties constantly afforded the surgeon, in cases of accidents and operations, of testing this 
point, peculiarly qualify him for pronouncing upon the question. These remarks do not, 
of course, apply to epidemic erysipelas, to which every one is more or less liable, but to 
the ordinary form, the development of which, as is well known, is always so much influenced 
by intrinsic and extraneous circumstances, as the health and habits of the patient, his resi- 
dence, the nature of his diet, and the state of his mind. When a person is intemperate, 
breathes a foul air, eats bad food, or has a troubled mind, the most trivial injury, as the 
merest prick of the finger, is often followed by a fatal attack of the disease, whereas 
another, although severely hurt but enjoying better health, may, perhaps, escape entirely, 
or suffer only in a slight degree. The surgeon, aware of this circumstance, constantly 
acts upon it in practice, making it a rule never to perform any serious operation until he 
has put his patient in a proper condition for it by the rectification of his secretions and 
the improvement of his general health. 
Erysipelas has frequently been regarded as consisting essentially in a bad form of capil- 
lary phlebitis, it being alleged that the smaller veins are generally found to be involved in 
the disease, as is shown by the inflamed condition of their coats, and by the existence in 
their interior of various kinds of substances, as lymph, pus, and coagulated blood. Such 
changes undoubtedly occur, to a greater or less extent, in all severe cases of the malady; 
but they occur, not as a cause, but as a consequence, of the morbid action. Other patho- 
logists, again, consider erysipelas as being essentially an affection of the lymphatics, or of 
these vessels and of the veins. Finally, there is another class who look upon it as being 
altogether, from first to last, a blood disease, or, in other words, a species of toxemia. 
All these views, however, are merely so many conjectures, their truth or falsity not being 
fully established. 
Prognosis—The prognosis of erysipelas is greatly influenced by the character, extent, 
and seat of the morbid action, by the age and habits of the patient, and by the absence 
or presence of complications. Phlegmonous erysipelas is generally more dangerous than 
the simple or cedematous, as it is more liable to end in extensive suppuration, gangrene, 
and metastatic abscesses. A simple erysipelas, however, if of great extent, is hardly less 
dangerous to life than a phlegmonous one, the shock to the nervous system being nearly 
as severe as in a superficial but extensive burn, which often kills on this account. The 
disease is particularly to be dreaded when it attacks the scalp, from its liability to 
extend to the brain. For a similar reason erysipelas of the orbit is often a dangerous 
affection. Infants, young children, old persons, and the habitually intemperate bear up 
badly under it. Erysipelas occurring during the progress of other affections, as measles, 
scarlatina, and typhoid fever, is generally fraught with danger. An epidemic erysipelas 
is always more destructive than a sporadic one, as it is sure, under such circumstances, 
to impress itself with peculiar force upon the constitution. Traumatic erysipelas often 
proves fatal in a surprisingly short time, as in the case of a young butcher, who died under 
my care in less than three days from a violent attack of this disease of the hand and arm, 
brought on by a punctured wound inflicted by a hook used for hanging up meat. 
Erysipelas occasionally manifests a remarkably relapsing tendency, the disease, after 
having disappeared from the part originally affected, fastening itself soon after upon some 
other part. In this way it may linger in the system for weeks or even months, each 
successive attack being, perhaps, more severe than the preceding one. Such outbreaks 
are generally characterized by a high degree of temperature. 
Treatment—As erysipelas is developed by such a variety of circumstances, it neces- 
sarily demands a corresponding variety of treatment. Experience long ago showed that 
remedies which afford relief in one case are productive of no benefit in another, and, 
hence, it is all-important, in every instance, that the curative measures should, if possible, 
be based upon a correct appreciation of the nature of the exciting causes. 
The most important constitutional remedies are bloodletting, emetics, purgatives, dia- 
phoretics, mercurials, anodynes, and stimulants. 
General bloodletting is rarely necessary; in fact, in most cases, it proves mischievous, 
by augmenting the debility of the system, already, perhaps, greatly depressed by the 
violence of the morbid action. The circumstances which, in mv judgment, render a 
resort to the lancet proper in this complaint are, first, a strong, full, and frequent pulse ; 572 
DISEASES OF THE SKIN AND CONNECTIVE TISSUE. 
CHAP. i. 
secondly, a robust and vigorous state of the system ; thirdly, excessive pain and tension 
of the parts; and, lastly, the involvement, threatened or actual, of important internal 
organs, as the brain, lungs, and throat. The amount of blood to be abstracted must 
depend upon the effects which the operation exerts upon the system. One moderately 
copious bleeding, performed early in the disease, will usually be sufficient, and will answer 
a much better purpose than two or three small ones. Venesection, should, as a rule, be 
avoided in epidemic erysipelas, and in old, sickly, and intemperate persons. In the epi- 
demic erysipelas which prevailed so extensively thirty-five years ago in various sections 
of the United States, the abstraction of blood was generally borne very badly, and many 
lives were lost by its injudicious employment. In the Louisville Hospital not a single 
patient recovered that was bled for this disease. In erysipelas supervening upon capital 
operations and severe accidents, as compound fractures and dislocations, wounds, and 
contusions, proper allowance must be made for the effects of shock, the loss of blood, and 
the resulting suppurative discharges. Children affected with erysipelas rarely, if ever, 
require bleeding in any form. 
Great contrariety of opinion has prevailed among writers respecting the employment 
of emetics in this disorder, some having pointedly condemned them, while others have 
expressed themselves most warmly in their favor. In the hands of Desault and his dis- 
ciples the greatest benefit seems to have attended their exhibition. The probability is 
that here, as elsewhere, in similar cases, the truth lies between the two extremes; for it 
can hardly be supposed that a class of remedies of such acknowledged potency in many 
cutaneous affections should be altogether useless in erysipelas. The cases in which, 
according to my observation, emetics are mainly indicated are those in which there is 
marked biliary derangement, along with nausea, loathing of food, headache, pain in the 
back and limbs, great restlessness, and dryness of the surface. These symptoms, so dis- 
tressing to the poor sufferer, are often promptly relieved by full emesis, excited by ipeca- 
cuanha and tartar emetic, ipecacuanha alone, or salt and mustard, and encouraged by the 
free use of tepid drinks. In protracted cases, and in the erratic form of the malady, 
attended with derangement of the digestive organs, gentle emetics often operate like a 
charm in breaking up the chain of morbid action. 
Great stress has always been very justly placed upon the use of purgatives in the 
treatment of erysipelas; and when it is remembered that this disease is often directly 
dependent upon an overloaded state of the bowels, the presence of irritating ingesta, and 
the suppression of the secretions of the digestive organs, it is not difficult to discover the 
reason for the practice. Indeed, it would be hard to find a case in which it would be 
altogether safe to dispense with them. They are more especially valuable in the earlier 
stages of the complaint and in strong, robust subjects. In the weak and delicate they 
must be used with the greatest possible care, lest they induce premature exhaustion. The 
articles which are mainly relied upon are calomel, rhubarb, and compound extract of 
colocynth, variously combined, and given in sufficient quantity to produce two or three 
free and consistent motions. Sometimes the addition of a little tartar emetic or ipecacu- 
anha proves beneficial, especially when there is an arid state of the skin and mouth ; 
while occasionally they may be advantageously replaced by others, as castor oil and spirit 
of turpentine, castor oil alone, senna, or Rochelle salt. When nausea and headache exist, 
along with a highly coated tongue, the best cathartic generally is calomel and ipecacuanha, 
in the proportion of about ten grains of the former to two of the latter, followed, if neces- 
sary, in six or eight hours, by a stimulating enema, or some mild laxative. When the 
bowels have been thoroughly evacuated, none but the most gentle aperients should be 
employed, as blue mass and rhubarb, Seidlitz powder, or colocynth and hyoscyamus. 
Diaphoretics are of the first importance in the treatment of this affection, as there are 
few cases in which the cutaneous function is not more or less interrupted, perverted, or 
suspended. After proper depletion, gentle evacuation of the bowels, and the restoration 
of the secretions of the digestive organs, the adminstration of medicines calculated to act 
upon the skin often proves highly serviceable. Among the best of this group of articles 
are Dover’s powder and the salts of antimony and morphia, aided by tepid sponging, or, 
when the patient’s strength admits of it, the warm bath. In children and debilitated 
persons, the neutral mixture and wine of ipecacuanha may be advantageously resorted to. 
Aconite, in doses of three drops of the tincture, every two, three, or four hours, generally 
answers an excellent purpose, especially when there is a hot and arid condition of the 
surface, with inordinate excitement of the heart. The same is true of veratrum viride. 
Anodynes are required to allay pain and induce sleep. When the disease occupies an 
unusual extent of surface, the system is very much in the condition of that of a person CHAP. I. 
ERYSIPELAS—TREATMENT. 
573 
laboring under a severe burn or scald, and requires, at a very early stage of the complaint, 
the employment of soothing measures. The remedy, commonly one of the salts of mor- 
phia, is administered either by itself, or in union with other articles, especially diapho- 
retics, in quantities proportioned to the exgencies of the case. As a general rule, the 
object is best attained by a full dose, repeated twice in the twenty-four hours. To an adult, 
laboring under great pain and restlessness, provided there is no cephalic trouble, not less 
than half a grain of morphia should be given at a time. Tlius administered, the effects 
of the remedy are much more decided and beneficial than when it is exhibited in smaller 
quantities. Delirium, or cerebral disorder, does not necessarily contraindicate the use of 
anodynes; on the contrary, persons so affected are often greatly benefited by their judici- 
ous exhibition. To no class of patients is this remark more applicable than to habitual 
inebriates, and individuals worn out by previous disease, loss of blood, protracted drain- 
age of the system, or constitutional irritation. Such persons absolutely require at an 
early period, and in every stage of the malady, the use of anodynes in large doses, in 
order to prevent exhaustion, and afford time and opportunity for the more efficient action 
of other remedies. Belladonna, in the form of the extract, is very serviceable in cases of 
idiopathic erysipelas, and especially the facial variety. When there is much febrile 
excitement the remedy should be combined with depressants, but when there is much 
depression it should be administered with quinine. 
Mercurials are sometimes useful. They are particularly valuable in the erratic form 
of erysipelas, and when there is a tendency in the disease to linger in the system, after 
its principal force has been expended. In such cases they occasionally act like a charm, 
even when they are not carried to the extent of slight ptyalism, which, however, is often 
necessary, before the disorder finally relinquishes its grasp. During the epidemic erysipe- 
las which prevailed in Louisville and its vicinity in 1844, ’5 and ’6, I treated a number 
of cases upon this plan with the most happy results. Mercury should be most scrupu- 
lously avoided in erysipelas attended with a low, typhoid state of the system in old, worn- 
out subjects, and in persons exhausted by intemperance and dissipation. The best form 
of exhibition, when the remedy is indicated, is calomel with a small quantity of opium 
and ipecacuanha, or Dover’s powder, to restrain its action on the bowels and allay ner- 
vous irritation. In urgent cases two grains of the mineral may be given to an adult every 
four, six, or eight hours, combined with half a grain of the anodyne. When a less rapid 
impression is desired, blue mass, iodide of mercury, or the gray powder may be used. In 
whatever form or manner the remedy be given, its effects should never be carried beyond 
the limits of the slightest possible ptyalism. 
The late Professor John K. Mitchell derived, as he informed me, more benefit in this 
disease, from the use of iodide of potassium than from any other remedy. His plan was, 
after gentle alvine evacuation, to begin at once with the article, giving it, largely diluted 
with water, every two or three hours, in doses of five to ten grains, until the attack was 
arrested, as it usually was in a few days. In the few trials which I have made of this 
remedy, I have witnessed no material benefit, and in several cases I was obliged to sus- 
pend its use at an early period, on account of its nauseating effects. 
Stimulants and tonics are imperatively required when there is a tendency to prostra- 
tion, as indicated by the hard, dry, and brownish tongue, the sordes on the teeth, the 
small, feeble, and frequent pulse, the twitching of the muscles, the coolness of the surface, 
and the copious sweats, with more or less delirium. The most reliable articles for this 
purpose are quinine and iron, in the form of the tincture of the chloride, a scruple of the 
former being dissolved in an ounce of the latter, and the mixture given in doses of fifteen 
to thirty drops every two, three, or four hours. When this combination disagrees with 
the stomach, the articles may be employed separately. In the malarial form of the dis- 
ease, a not infrequent complication in various sections of the United States, quinine, in 
large doses, is an indispensable remedy and cannot be administered too soon. It also 
is particularly reliable when there is a relapsing tendency in the disease, and may then 
generally be advantageously combined with iron and mercury. The treatment should be 
aided by the liberal use of brandy, milk punch, wine, ale, or porter, and a generous diet. 
Throughout the whole treatment, the greatest attention should be paid to the ventila- 
tion and temperature of the patient’s apartment; the body and bedclothes should be daily 
changed, and the cutaneous surface should be frequently sponged with tepid salt water, 
or some slightly alkaline solution. As disinfectants, free use is made of the chlorides, 
Labarraque’s solution, or permanganate of potassium. As soon as his strength admits of it, 
the patient should take gentle exercise in the open air, and change his sleeping apartment. 
Although topical remedies in the treatment of this affection are to be regarded simply 574 
diseases of the skin and connective tissue 
chap, i. 
as auxiliary agents, there are few cases in which, if properly employed, they are not of 
signal service. The list is a very large and varied one, embracing applications of the 
most opposite character, as warm and cold, dry and moist, astringent and relaxing, stimu- 
lating, vesicant, and anodyne. 
Leeching is indicated when the patient is young and plethoric, or the disease is in its 
gravescent stage, and making rapid strides. The fact that the operation is occasionally 
followed by erysipelas does not, in my judgment, prove that it may not at times be bene- 
ficial. It is only in rare cases, and in peculiar conditions of the system, as when the 
patient is of a very irritable habit, or when the leeches are sickly, that such a result is at 
all likely to occur. Against such a contingency the judicious practitioner will, of course, 
always guard. The use of the remedy is particularly indicated in erysipelas of the throat 
and larynx, the scalp, eyelids, vulva, toes, and fingers. The number of leeches must 
vary according to circumstances, as the intensity of the morbid action and the vigor of 
the patient, the flow of blood being always encouraged by warm fomentations until the 
desired quantity is obtained. 
One of the most valuable topical remedies is tincture of iodine, diluted with an equal 
quantity of alcohol, and laid on by means of a large camel-hair pencil, the end of a stiff 
feather, or a soft cloth mop, until the surface is of a yellowish, brownish, or mahogany 
color. The application, which should embrace a small portion of the sound skin, should 
be repeated at least twice, if not thrice, in the twenty-four hours. In the milder grades 
of erysipelas a single application occasionally suffices for a cure, while in the more aggra- 
vated a long continuance of the remedy may be required. Iodine, employed in the early 
stage of the disease, generally promptly relieves pain and tension, rapidly promotes the 
removal of effused fluids, and greatly assists in checking morbid action. Used very freely, 
it occasionally vesicates, and is thus instrumental in unloading the cutaneous capillaries. 
Doubtless, it also acts advantageously upon the blood and its vessels, indisposing them to 
further effusion. 
Nitrate of silver, employed either in substance, or in strong solution, as from thirty to 
sixty grains to the ounce of water, is another very valuable agent in the treatment of 
this disease. It is applied either directly to the affected surface, or a belt is drawn around 
it upon the healthy skin, to prevent its further spread. I commonly prefer the former 
method, using the solid nitrate instead of the solution, so highly recommended by Mr. 
Higginbottom. In order to apply this substance properly, the surface should previously 
be divested of all greasy and perspirable matter, otherwise it will not unite with the epi- 
dermis, and so prove, in great measure, inert. The part should then be gently moistened 
with soft water, when the caustic is passed firmly and efficiently over it until the whole 
has been thoroughly touched. Thus employed, it speedily blackens the epidermis and 
coagulates its albuminous matter, thereby forming an excellent defence to the delicate 
tissues beneath. When used more freely it generally vesicates, elevating the cuticle into 
tolerably large blisters. Mr. Higginbottom applies a strong solution of the nitrate of 
silver, consisting of three drachms of the salt to the ounce of water, writh the addition of 
a small quantity of nitric acid. I have no experience with the remedy in this form. The 
probability is that nitrate of silver produces its beneficial effects very much in the same 
manner as tincture of iodine, changing the tone of the capillary vessels and promoting the 
absorption of the effused fluids, besides serving as a direct defence to the cutaneous sur- 
face by its union with the albuminous matter of the superficial layer of the skin. 
The late Dr. Gilbert, of this city, often used pure creasote as a remedy in erysipelas. 
He applied it lightly once a day to the affected surface with a camel-hair pencil, and 
found it more effectual in arresting the disease than any other article. Creasote destroys 
the cuticle, converting it into a whitish substance, which thus defends the inflamed sur- 
face from the contact of the air. 
Solutions of acetate of lead and opium, Goulard’s extract, chloride of ammonium, 
alcohol, chloride of sodium, carbonate of potassium, sulphate of copper, and quinine, often 
prove highly beneficial. They are employed of varying strength, and are generally most 
grateful when used tepid, upon flannel cloths, frequently renewed. In warm weather, 
and in strong, plethoric subjects, they may be applied cold, but when this is done their 
effects should be sedulously watched, lest they repel the disease, or throw it upon some 
internal organ. 
Warm w’ater alone, at a temperature of 96° to 100°, is often exceedingly efficacious, 
especially in erysipelas of the scalp, and in the more ordinary traumatic forms of the 
disease. It is applied by means of wadding or patent lint, covered with oiled silk, and 
frequently renewed. CHAP. I. 
ERYSIPELAS — TREATMENT. 
575 
The late Dr. Pitcher, of Detroit, strongly recommended, as an external application, 
bichloride of mercury, in the proportion of twenty grains of the salt to the ounce of 
alcohol. During the prevalence of the epidemic, already so frequently alluded to, I 
had occasion to try this treatment in a number of instances, but I did not find it to possess 
any advantages whatever over iodine and nitrate of silver. In nearly all the cases, 
upwards of twenty, the application was promptly followed by vesication and excessive 
pain, and, in a few, by pretty profuse ptyalism ; effects which greatly aggravated the local 
and constitutional suffering, and rendered a speedy discontinuance of the remedy neces- 
sary. Since then I have tried the remedy in a weaker solution, but without any encourag- 
ing results. 
Velpeau had great confidence in the use of sulphate of iron as a local remedy in 
erysipelas. The praises, however, which he lavished upon it have not been realized 
by practitioners generally; and I have myself been entirely disappointed with it. It 
may be employed in solution, in the proportion of half an ounce to two-thirds of a 
quart of water ; or as an ointment, prepared by mixing one drachm of the impalpable 
powder with an ounce of lard. The former is applied by means of compresses, 
frequently moistened; while the latter is rubbed on freely several times in the twenty- 
four hours. 
Dr. Holston has derived marked benefit from the local use of chloroform, brushed over 
the affected surface for a few minutes with a large camel-hair pencil, the parts being 
immediately afterwards covered with wadding, and the application repeated, if necessary, 
at intervals of three to four hours. Prompt relief, it is asserted, usually follows, the 
disease, even if extensive, often yielding in a very short time. 
Bromine has been highly extolled as a local remedy in this disease, more especially 
by our army surgeons, by whom it was extensively employed during the late war. 
It is applied directly to the inflamed surface in solution, from twenty to forty drops 
being mixed with the ounce of water, according to the severity of the morbid action. 
A small quantity of bromide of potassium may sometimes be advantageously combined 
with it. 
In the milder varieties of erysipelas I have occasionally witnessed excellent results 
from a liniment of equal parts of laudanum, ammonia, and olive oil, applied upon a 
soft, thin compress. When the skin is very delicate, the proportion of ammonia may 
be diminished. The common soap liniment, with the addition of a small quantity of 
tincture of iodine, and confined with a roller, is also a valuable remedy in simple 
erysipelas. 
Of the various greasy substances that have been recommended in the treatment of this 
affection, one of the most celebrated is mercurial ointment, first advised in this complaint 
by Dean and Little, of Pennsylvania. A thick layer of this is spread upon cloth, and 
secured to the part by means of a bandage, or, what is preferable, rubbed gently but 
efficiently upon the diseased surface. The article has been highly lauded by Rayer and 
others, but my own experience has not supplied me with any facts in its favor; indeed, 
it is doubtful whether it possesses any advantage whatever over common lard, suet, or 
simple cerate. In infantile erysipelas, I have sometimes derived excellent effects from 
the application of the ointment of oxide of zinc. Professor Gibson speaks favorably of 
the use of British oil; and Dr. Coates, of this city, has successfully employed tar oint- 
ment. The cranberry poultice has long been a popular remedy in this country, its virtues, 
as supposed by Dr. Munroe Bond, of New Hampshire, probably depending upon the 
presence of malic acid. 
Dusting the affected surface with starch, flour, arrowroot, prepared chalk, carbonate of 
zinc, pearl powder, and similar substances, is sometimes useful in the more simple 
varieties of erysipelas, but entirely unavailing when the disease is deepseated, or of a 
phlegmonous character. In the former, they occasionally prove beneficial by relieving the 
disagreeable itching, smarting, or burning sensation of the skin. In superficial erysipelas, 
I have sometimes obtained advantage from painting the inflamed surface with collodion, 
the application appearing to impart a healthful stimulus to the cutaneous capillaries, to 
incite the absorbents, and to contract the skin and subjacent connective tissue. 
The treatment of erysipelas by blisters, is peculiarly valuable in the phlegmonous form 
of the disease, and in erysipelas supervening upon wounds, ulcers, chancroids, buboes, and 
abrasions. The proper plan is to apply the vesicant directly to the inflamed surface, 
and to retain it until it has raised the epidermis most thoroughly. The serum is then 
evacuated with a needle, and the part dressed with a light starch, elm, or linseed poultice. DISEASES OF THE SKIN AND CONNECTIVE TISSUE. 
chap. i. 
In children, and in old or sickly persons, the blister must be removed at an early period, 
otherwise serious mischief may ensue. 
The subcutaneous injection of a three per cent, solution of carbolic acid, first suggested 
by Professor Ilueter, on account of the assumed dependence of the disease on the develop- 
ment of parasitic fungi in the tissues, has been abandoned. 
When the disease is accompanied by suppuration, great tension, or impending gan- 
grene, nothing short of free incisions or punctures will answer, all other topical remedies 
being then of a subordinate character, as the object is to afford vent to effused fluids, as 
serum, lymph, pus, and blood, to relieve capillary strangulation and remove pain and 
tension. The practice is indicated the moment there is the slightest perceptible fluctua- 
tion, and, in violent cases, even as soon as there is considerably throbbing. By thus 
anticipating the suppurative process, the patient escapes much suffering, as well as loss of 
texture ; for, if the matter is retained in the parts, its inevitable tendency is to burrow 
among the surrounding structures, and to contaminate the system. 
To afford relief, the incisions need not be three, four, or five inches in length, as 
formerly recommended by Mr. Lawrence and other British surgeons. Such a course is 
highly cruel and reprehensible ; for, independently of the pain which attends the opera- 
tion, it is liable to be followed by copious hemorrhage, which, occurring at a time when 
the patient is perhaps ill able to bear it, must often cause serious, if not fatal mischief. 
A few cuts from half an inch to an inch and a half in length, and deep enough to liberate 
the pent-up fluids, ought to be sufficient in any case, unless it has been greatly mismanaged, 
or neglected. In such an event, the incisions may be multiple, being made at suitable 
distances from each other, and in such a manner as not to interfere with any important 
structures, as large vessels, nerves, or joints. If hemorrhage be unavoidable, it is to be 
arrested by the usual means, as compression, styptics, or igation. The best application 
after the bleeding has ceased is an emollient poultice, or the warm water-dressing, medi- 
cated with acetate of lead and opium. The loss of a small quantity of blood is often of 
essential benefit in relieving the disease. 
Punctures are more particularly useful in the oedematous forms of the disease, to evacu- 
ate the serous fluid upon which the distension, which is often a source of so much mischief, 
mainly depends. When suppuration or gangrene is threatening, punctures must give way 
to incisions. The number of punctures, and the depth to which they are carried, must 
vary according to circumstances. The best instrument for making them is a very narrow, 
sharp-pointed bistoury, introduced perpendicularly to the surface, with the necessary care 
to avoid important structures. 
In the milder forms of erysipelas of the extremities, valuable aid may often be derived 
from the application of the bandage. It is particularly efficacious in the early stages of 
the disease, as it tends, if judiciously employed, to support the affected structures, and to 
prevent vesication and suppuration. The application should be made as equably as 
possible, and with a certain degree of firmness, its effects being carefully watched, and 
aided by simple or medicated lotions. 
Finally, in the epidemic form of this disease, much may be accomplished by way of 
prophylaxis. Among the more important elements in this kind of treatment are isolation 
of the sick, thorough ventilation, personal cleanliness, and an abundance of good, wholesome 
food. These precautions are particularly necessary in hospitals, prisons, asylums, camps, 
barracks, and ships. When persons are crowded together, in narrow and confined situa- 
tions, the air is speedily contaminated, and the disease is sure to spread with fearful 
rapidity and violence, especially if the body is affected with wounds, contusions, ulcers, 
or compound fractures. The best internal prophylactic is the tincture of chloride of iron, 
given in doses of twenty to thirty drops every four or six hours, either alone or in union 
with quinine, the latter remedy being particularly valuable when the disease is of a malarial 
character. Arsenic will then also be of great service. 
SECT. II FURUNCLE OR BOIL. 
A furuncle, vulgarly called a boil, is a peculiar inflammation of the skin and connective 
tissue. Liable to occur upon any portion of the body, excepting, perhaps, the palm 
of the hand and the sole of the foot, it is most common upon the face, nape of the neck, 
buttocks, and fingers, often forming in considerable numbers, either simultaneously or 
successively, although generally there is only one. Both sexes, and all periods of life, 
are subject to it; the young, however, suffer more frequently than the old or middle-aged. 
Some persons are habitually affected with boils, being seldom entirely free from them at CHAP. I. 
FURUNCLE OR BOIL. 
577 
siny time for years. Now and then they disappear for a while, and then suddenly break 
out again. Boils are a very common sequel of eruptive affections, as smallpox, measles, 
scarlatina, and typhoid fever, and, under these circumstances, they occasionally display a 
marked epidemic tendency. In the latter event, they are very liable to occur in associa- 
tion with carbuncle and whitlow. Children during dentition, and during chronic attacks 
of cholera, sometimes suffer excessively from this disease. I have often, in these com- 
plaints, seen the whole surface literally covered with boils, the patient experiencing great 
pain and prostration. 
The causes of furuncle are generally inappreciable. Occasionally their formation may 
be traced to external violence, as a contusion, or the concussion sustained by the skin 
and connective tissue in riding on horseback. In the majority of cases, if not in all, it 
is obviously connected with a disordered state of the digestive organs, or with some de- 
rangement of the secretions. Thus, persons who labor habitually under disease of the 
liver, and females who are troubled with irregularity or suppression of the menses, are 
very prone to suffer from its attacks. Diabetes and albuminuria predispose to its occur- 
rence. Large, painful, and obstinate boils not unfrequently follow the application of 
blisters, especially in young, broken-down children and elderly subjects. Cold water, 
used endermically for any considerable length of time, as a therapeutic agent, is liable to 
give rise to similar effects. On the fingers a painful form of boil occasionally has its ori- 
gin in a hair follicle. 
A boil consists essentially in a circumscribed inflammation of the sebaceous and sweat 
glands and hair follicles, eventuating in suppuration and sloughing. It usually begins as 
a small, hard, red pimple, which, as it proceeds, gradually assumes a conical figure, the 
apex being formed by the skin, and the base by the connective tissue, its volume vary- 
ing from that of a currant to that of a pigeon’s egg. The pain which accompanies it is, 
at first, of a burning, smarting character, but afterwards, especially when matter is about 
to be formed, it becomes throbbing and exceedingly severe. A sense of tension is also 
commonly present. The skin is of a dusky, reddish aspect, and exquisitively sensitive to 
the slightest touch. As the tumor increases, a little vesicle forms at its apex, containing 
a drop of serum, and indicating the point where the boil will discharge itself. When the 
furuncle is large, or multiple, there is usually more or less constitutional disturbance, as 
manifested by the want of appetite, a bad taste in the mouth, headache, chilliness, and a 
feeling of great uneasiness. Finally, a boil in the lower extremity, or upon the buttock, 
often gives rise to sympathetic enlargement of the glands of the groin, and in the upper 
extremity of the glands of the axilla. The period required for the disease to reach its 
height varies from three to eight days. 
If a section be made of a boil, with a view to the examination of its structure, it 
will be observed to consist of a mass of dead tissue, ordinarily called a core, immersed 
in thick, yellowish pus, the parts around being very hard, matted together with lymph, 
and preternaturally vascular. The skin is also indurated, and abnormally tense, red, 
and injected. Occasionally the contents of the swelling are almost wholly made up 
of blood, or of a mixture of blood, pus, and slough. This form of boil, to which the 
term hematoid may be applied, is most common in elderly persons of a broken constitu- 
tion, and is usually attended with much local and general distress. 
It is seldom, under any circumstances, that a furuncle can be made to abort, or to ter- 
minate in resolution, its invariable tendency being to suppurate and slough. In its very 
incipiency, I have occasionally succeeded in arresting its course by a brisk purge, and the 
application of iodine, but if it has already made some progress, such an attempt will prove 
altogether futile. The best plan generally is at once to poultice the part, and to make an 
early and free incision to let out its contents. The relief experienced from the operation 
is always prompt and decided. The burning, throbbing pain, so constantly present, is 
always greatly mitigated by the use of a strong solution of carbolic acid in glycerine, ap- 
plied upon a compress. If the sore is slow in healing, either from the retention of dead 
connective tissue, or a want, of healthy action from other causes, its surface should be well 
touched with nitrate of silver, the same article, iodine, or a small blister being applied to 
the surrounding surface. In most, cases the patient will be benefited by purgative medi- 
cine and light diet. 
When there is a decided furuncular diathesis, as when a great number of boils exist 
simultaneously, or form in rapid succession, benefit may be expected from an occasional 
emetic, and from mercurial purgatives, with the internal use of iodide of potassium and 
Donovan’s solution. Sometimes Fowler’s solution answers a good purpose, or, what I 
prefer, arsenic in substance, from the tenth to the fifteenth of a grain three times a day. 578 
DISEASES OF THE SKIN AND CONNECTIVE TISSUE. 
CHAP. i. 
In very obstinate cases slight ptyalism may be required before the disease finally yields. 
When boils are developed as a consequence of exhausting diseases, tonics, mineral acids, 
a nutritious diet, and country air are indicated. Alkalies are useful when there is 
acidity of the stomach and bowels. Daily bathing with salt water, or water impregnated 
with bicarbonate of potassium, will occasionally be serviceable, especially when there is 
unusual torpor of the skin. 
SECT. Ill ANTHRAX OR CARBUNCLE. 
The most accurate definition that can be given of a carbuncle is that it is a boil on a 
large scale, with the addition of gangrene, it being, like that affection, a peculiar inflam- 
mation of the cutaneous and connective tissues, not circumscribed, however, as in that dis- 
order, but disposed to spread. Its most common seat is the posterior part of the trunk 
and the nape of the neck, particularly near its junction with the occiput. The gluteal 
and safcral regions are also liable to the disease, but it is very seldom that it occurs in the 
extremities. A bad form of carbuncle occasionally forms upon the chin and lower lip. 
Elderly persons are most prone to carbuncle, and it is generally believed that such as 
are fat and indolent, or addicted to the pleasures of the table, are more frequently at- 
tacked than the lean and active. In my own practice, however, this has not been the 
case. On the contrary, the greatest number of instances has occurred in thin subjects, 
after the age of fifty, whose constitution has been broken down by long-continued intem- 
perance, impoverished diet, deficient clothing, and mental anxiety. In London carbun- 
cle is said to be remarkably common among the lower orders, in consequence of the enor- 
mous quantities of ale and porter which they habitually consume. The disease is more 
frequent in winter than in summer, and in men than in women : occasionally it displays 
an epidemic tendency. Carbuncle is one of the symptoms of plague. The extent of the 
inflammation varies from that of a dollar up to that of a large saucer, its average being 
about that of the palm of a small adult hand. 
Of the exciting causes of carbuncle nothing satisfactory is known. Most commonly 
the outbreak of the disease is ascribed to the effects of cold, to disorder of the stomach, 
overeating, constipation of the bowels, loss of sleep, excessive venery, and other debili- 
tating influences; but how far, or in what degree, these circumstances tend to favor its 
development it is impossible to say. I have myself long regarded the malady as essen- 
tially of a constitutional nature, resembling, in this respect, erysipelas and some other 
affections; and a careful study of the history of the disease certainly warrants such an 
interference. A long course of debauch, or indulgence in the pleasures of the table, 
attended with a vitiated state of the secretions, is, as is well known, highly conductive to 
the development of carbuncle in its worst forms. When a person has been for years in 
this condition, eating and drinking luxuriously, and taking hardly any exercise, the 
slightest exposure to cold, suddenly checking the cutaneous perspiration, would, it may 
easily be imagined, tend to produce the disease in a part habitually congested and en- 
feebled in its action. There is then not merely a bad state of the solids, but the blood 
also comes in for a share in the proceeding, surcharged, as it must be, with irritating ma- 
terials which the solids have long been unable to throw off as recrementitious substance. 
Wdiether, however, this conjecture is correct or not, the fact is indisputable that carbun- 
cle is rarely, if ever, of traumatic origin, or found in persons of a vigorous and healthy 
circulation. Cases occur in which the disease is evidently connected with, if not directly 
dependent upon, a diabetic condition of the system. , 
One of the first symptoms of carbuncle is generally an itching, burning, or smarting, 
with a sense of numbness, in a particular part of the skin, which, on examination, is 
found to be of a dusky, reddish color, slightly tumid, and somewhat tender on pressure. 
As the disease progresses, the local distress sensibly increases; the pain soon becomes 
throbbing and exceedingly violent, the part feeling as if it were in contact with melted 
lead ; the surface assumes a livid hue ; the swelling spreads both in circumference and 
in depth ; and the slightest touch of the finger is intolerable. Along with these pheno- 
mena, the patient usually experiences a sense of weight and tension, which greatly adds to 
his suffering. The part is hard, and circumscribed, feeling like the rind of bacon, and 
occupying a space from the size of a dollar to that of the palm of the hand. Presently 
vesicles begin to form at the focus of the inflammation, containing a dirty, turbid, yel- 
lowish, or sanguinolent fluid, and generally not exceeding the diameter of a pea, although 
occasionally they are quite large. Upon bursting, these vesicles expose a corresponding 
number of openings in the true skin, giving the surface a cribriform appearance, and lead- CHAP. 1. 
ANTHRAX OR CARBUNCLE. 
579 
ing down into the connective tissue, which is already in a state of mortification. The 
ulcers, for so they may be called, have an irregular, ragged appearance, and are the seat 
of a foul, irritating discharge, which is often very abundant and exhausting. 
Upon dividing the affected structures, the skin is found to be remarkably dense and 
firm, cutting very much like the rind of bacon. The connective tissue beneath is con- 
verted into a slough', having the appearance of a mass of wet tow, bathed with ill-looking 
matter, and intermixed with flakes of lymph, or matter like putty, thick pus, or curds. 
When the disease is of unusual extent, there may be considerable involvement of the 
aponeuroses and muscles, but, in general, these structures are excluded from the morbid 
action, the skin and subjacent connective tissue alone suffering. At the periphery of the 
Fig. 239. 
Fig. 240. 
Incipient Carbuncle. 
Ulcerated Carbuncle. 
disease the parts are always uncommonly dense, the boundary between it and the healthy 
structures being established by a deposit of plastic matter, less organizable, however, than 
in furuncle, the morbid anatomy of which that of a carbuncle so closely resembles. The 
annexed sketches, figs. 239 and 240, represent this disease in its earlier and more 
advanced stages. 
Important light has recently been thrown upon the peculiar character of some of the mor- 
bid processes of carbuncle by the beautiful researches of Dr. J. Collins Warren. In a paper 
published a few years ago in the Boston Medical and Surgical Journal, he described and 
delineated what he has called the adipose columns, and has ingeniously pointed out the part 
they play during the progress of the disease. The columns are particularly well-marked 
beneath the thick skin on the back and shoulders, where carbuncle is so often met with. 
The skin here, as well as in some other situations, is perforated, or nearly so, by vertical 
adipose columns which pass from the fatty structure beneath to the base of each downy 
hair follicle. Near the base of each column is given off a band of fibrous tissue from the 
lower borders of the cutis, which extends obliquely downward, and is inserted into the 
fascia below. These interlacing bands of tissue form a dense recticulum, or network, in 
which, in this disease, the inflammation takes its rise. As the inflammation is of that 
variety which rapidly leads to the development of pus, no protective barrier is formed as 
in abscess, and the result is that purulent infiltration takes place. The dense integument, 
held firmly down by the tendon-like bands of tissue referred to, yields with difficulty before 
the accumulating pressure, while the soft structures of the adipose columns offer but 
slight resistance to the pus globules, which, consequently, find their way rapidly into 
them, and thence directly upwards to the surface, destroying the hair follicles as they 
proceed, and forming at the surface a pustule of considerable size. The pus also spreads 
liberally from the columns into the cutis, working its way through the lymphatic meshes 
to the papillae which become enormously distended, and thus give rise to the numberless 
minute pustules which stud the surface of the carbuncle. 
This mode of the formation of pustules is very different from that usually recognized, 
the ordinary pustules of the skin being described as being situated in the rete mucosum. 580 
DISEASES OF THE SKIN AND CONNECTIVE TISSUE. 
chap, i. 
In those portions of the skin in which this process of purulent infiltration is rendered 
excessive, the circulation is arrested and gangrene follows. The honey-combed crater 
which is thus exposed is formed by the interlacing of bands of tissue, which, tendon-like, 
have retained their form, if not their vitality. 
In purulent infiltrations of the subcutaneous tissue of other portions of the body, the 
structures are less resisting ; the skin is not bound down so firmly, the connective sub- 
stance is of a delicate nature, and the pus spreads with great facility in a lateral direction. 
The skin being much thinner the adipose columns are either very short or entirely absent, 
and the pus finds its way to the surface, if at all, through the ordinary lymph spaces to 
one of the papillae, which it distends in the manner already described. 
The constitution always, even at an early period of the disease, strongly sympathizes, 
with the part affected. Hence, fever is generally present soon after its commencement, 
and sometimes, indeed, almost before there is any marked evidence of the local affection, 
the first symptom being often a severe rigor, followed by high vascular excitement. 
However this may be, the case soon assumes an asthenic type, indicative of the depraved 
condition of the solids and fluids so intimately concerned in the production of the disease. 
The tongue speedily becomes dry, hard, and brown, sordes collects upon the gums and 
teeth, the appetite fails, gastric derangement exists, the bowels are constipated, the urine 
is scanty and high-colored, the skin is hot and arid, the mind is disposed to wander, and 
the pulse is frequent, soft, and without force. Vomiting is often present to a consider- 
able extent, and the alvine evacuations are generally excessively fetid. 
The diagnosis of anthrax is sufficiently easy. Its large size, the severity of the atten- 
dant pain, and the great constitutional disturbance, will always readily distinguish it from 
furuncle at its commencement, and afterwards the discrimination will be still further 
aided by the vesicated and cribriform condition of the skin, so characteristic of carbuncle. 
The only affection which it at all resembles is a bedsore, but the history of the case, and 
the situation of the swelling, will always serve as unerring means of distinction. Malig- 
nant pustule begins as a little, circumscribed pimple, not as a diffused swelling, as in 
anthrax, and soon forms a large vesicle, raised above the surrounding level, and resting 
upon a hard, solid base, which rarely acquires much extent, at least not until the affec- 
tion has made considerable progress. 
The 'prognosis is variable. In general, a carbuncle may be regarded as dangerous 
when it is multiple, when it is very large, or when it occurs in old, fat subjects, addicted 
to indolence and over-feeding. The site of the disease also exerts a marked influence 
upon the issue of the case. Thus, a carbuncle situated on the posterior part of the head 
and neck will, other things being equal, be more likely to produce death than when it occu- 
pies the back, nates, or extremity, inasmuch as it is very liable to involve the brain and 
arachnoid membrane, causing effusion of serum and lymph. Young and compai'atively 
healthy persons will often recover, although generally not without great suffering, whatever 
may be the site of the malady. In a case of an immense carbuncle of the nape of the 
neck, recently under my charge in a stout, fat man, sixty-two years of age, death was 
occasioned at the end of a fortnight by the supervention of pneumonia and erysipelas. 
Treatment The treatment of carbuncle must be conducted with special reference to 
the improvement of the secretions and the support of the system. Few patients will be found 
to bear bleeding, active purgation, or depletion in any form. It is only when there is 
extraordinary plethora, combined with great vigor of constitution, that these means should 
be carried into effect. In all other cases, their inevitable tendency is to do harm, by 
bringing on premature exhaustion. Efficient purging, however, may be regarded as an 
indispensable remedy in almost every instance, the object being not only to get rid of 
irritating fecal matter, but to produce a change in the secretions. For this purpose the 
medicine should be given early in the disease, and a mercurial cathartic should always be 
preferred to any other. When marked gastric derangement exists, as indicated by nausea, 
headache, and pain in the limbs, no time should be lost in administering an efficient 
emetic, or an emeto-cathartic, as ten grains of calomel and from ten to twenty of ipecacu- 
anha, followed by large draughts of chamomile tea, or infusion of valerian. Clearance 
having been effected, and function improved or restored, stimulants and tonics will come 
into play, exhibited warily, especially if cerebral trouble is threatened, yet efficiently if 
evidence of exhaustion is present, the most suitable articles being quinine, tincture of 
chloride of iron, and brandy, with nourishing broths. Anodynes will generally be re- 
quired, in large doses, to allay pain and procure sleep. After the first few days a mild 
laxative, as blue mass or castor oil, is occasionally given. Determination to the brain 
must be promptly met by a large blister applied as near as possible to the occiput. CHAP. I. 
GANGRENE AND BEDSORES. 
581 
The best topical application, at the commencement of the disease, is the warm water- 
dressing, strongly medicated with acetate of lead and opium. Pencilling the surface well 
with tincture of iodine, and then covering it with a mixture of equal parts of olive oil, 
laudanum, and spirit of turpentine, sometimes produce a very soothing effect. In many 
cases there is nothing so promptly beneficial as a blister, large enough to include a con- 
siderable portion of the healthy skin, and retained until there is thorough vesication: it 
drains the vessels of serum, allays pain, and makes a salutary impression upon the 
general system. Leeches are commonly inadmissible, as they occasion severe pain and 
undue depletion. In the earlier stages of carbuncle, especially in those cases in which 
the morbid action is spread over a very large surface, speedy and effectual relief may 
often be afforded by the subcutaneous division of the indurated tissues with a delicate 
tenotome, introduced at four opposite points, and carried about, under the guidance of 
the index-finger of the left hand, in such a manner as to traverse the entire swelling. The 
skin itself is left intact, except at the entrance of the knife. The operation is generally 
followed by a good deal of bleeding. The pain and tension rapidly subside, the danger 
of extensive sloughing is effectually obviated, and the vital powers soon begin to rally 
under the improved condition of the parts. Compression, by means of adhesive strips, 
applied concentrically from the margin to within a short distance of the centre of the car- 
buncle, is sometimes highly beneficial, the treatment greatly and rapidly assuaging pain 
and tension, and materially abridging the cure. 
When the disease has passed into gangrene, as evinced by the cribriform and boggy 
condition of the affected tissues, the great remedy is free incision, the knife being carried, 
at different points, through the skin down to the healthy structures beneath. The opera- 
tion at once relieves the horrible pain and tension of the parts, affords nature an oppor- 
tunity of casting off the sloughs, and puts an effectual barrier to the further extension of 
the morbid action. Caustics in such a condition are far inferior to the knife, but if the 
latter is contraindicated, pure carbolic acid, which is the least painful of the escharotics, may 
be inserted into the openings or injected into the mass with a view of checking the spread 
of the inflammation and hastening the separation of the sloughs. If the dead tissues are 
slow in coming away, their extrusion may be expedited with the scissors, the surface of 
the ulcer being well touched immediately afterwards with dilute acid nitrate of mercury, 
or solid nitrate of silver, to promote the formation of healthy granulations. The accumu- 
lation of matter must be prevented and cleanliness insured by the frequent use of the 
syringe, charged with weak solutions of chlorinated sodium, carbolic acid, permanganate 
of potassium, or common salt. As soon as the sore assumes a healthy aspect the parts 
should be dressed with some mild unguent, as the opiate cerate, elemi ointment, or oint- 
ment of the balsam of Peru. 
After recovery, the tendency to a recurrence of carbuncle, which is sometimes very 
strong, should be counteracted by a change of air, attention to diet, a proper regulation 
of the secretions, and the avoidance of exposure to cold, fatigue, and loss of' sleep, conjoined 
with an alterative course of iodide of potassium, the dose of which should not exceed two 
grains and a half thrice in the twenty-four hours. If there has been much disorder of the 
secretions, a very minute quantity of bichloride of mercury may be advantageously con- 
joined with the potassium. When there is marked derangement of the digestive functions, 
attended with acidity and flatulence, chlorate of potassium may be given, three times a day, 
in doses of five to ten grains, until there is manifest improvement in the tone of the 
stomach and of the general health. A change of air is’ often indispensable to complete 
convalescence. 
SECT. IV GANGRENE AND BEDSORES. 
The skin is liable to gangrene, both idiopathic and traumatic, simple and specific, acute 
and chronic; but as these several varieties have already received a sufficient share of 
attention, nothing need be said respecting them here. There is one species, however, 
which may be briefly described in this place, inasmuch as no special mention has been 
made of it elsewhere. I allude to what is called white gangrene of the skin, an affection 
the true character of which is still involved in obscurity, nothing that has yet transpired 
having thrown any light either upon its pathology or treatment. 
White gangrene usually comes on without any appreciable cause or premonitory symp- 
toms, in patches of irregular shape, from one to three inches in diameter. The sloughs 
are of a dead, milky color, and of hard, dryish consistence, yielding little, if any, moist- 
ure on pressure. Any portion of the body may be the seat of this affection ; but the 
arms, back, and chest are the regions most frequently implicated. The disease is ob- 582 
DISEASES OF THE SKIN AND CONNECTIVE TISSUE. 
chap, i. 
served chiefly in old persons of a broken, anemic constitution. The treatment is con- 
ducted with special reference to the improvement of the health by tonics, brandy, and 
nutritious diet. 
Bedsores There is another variety of gangrene of the integument which, from the 
frequency of its occurrence, and the severity of the attendant suffering, merits special 
attention here. Its immediate cause is steady and protracted pressure, impeding, and 
generally arresting, the circulation ; hence it is exceedingly liable to arise on the sacro- 
lumbar region, the iliac projections, on the nates, and over the great trochanter, in 
consequence of long-continued confinement to one particular posture, as in typhoid fever, 
in severe fractures and wounds, and after surgical operations. It is also very common 
after violent injury of the spine. I have at this moment under my charge a tall young 
man, affected for the last six months with paraplegia, who has a large and excessively 
painful ulcer upon the left buttock, simply from the pressure sustained in sitting on a 
chair. Occasionally a sore of this kind forms with extraordinary rapidity, leading to the 
belief that it is due rather to the irritation of the spinal cord or the nerves thence arising 
than to any direct compression. 
The disease is always necessarily preceded by inflammation, but in consequence of the 
absence of the usual symptoms, the want of proper care in examining these parts and 
keeping them clean, or the impossibility which the patient experiences in communicating 
a knowledge of his sufferings, as when he is exhausted by typhoid fever, or other causes, 
it does not always attract attention until great mischief has been done, eventuating in 
extensive sloughing, and the establishment of painful, irritable ulcers, which it is often 
extremely difficult to heal. In some instances the first intimation the patient has of the 
approaching mortification is a sense of prickling in the affected parts, as if he were lying 
upon some rough substance, as sawdust or coarse salt. At other times he feels severe 
pain, of a stinging or biting character, within a few days after he has been exposed to 
pressure, and which is often so constant and distressing as to deprive him both of appetite 
and sleep. Upon examining the parts to which the suffering is referred, the surgeon finds 
that they are red, or marked by an erythematous patch, slightly swollen, with a dense 
base, congested, and excessively tender on pressure. Ulceration, if it has not already 
taken place, will be sure to begin in a short time, unless suitable measures are adopted 
for the patient’s relief, and will be speedily followed by mortification, or mortification may 
take place without being preceded by ulceration. 
The extent to which the gangrene may proceed is variable; occasionally it occupies 
an immense surface, perhaps as large as the crown of a hat, and reaching down to the 
very bones; at other times it is more limited both in diameter and depth, laying bare 
merely the muscles, or being even, in great degree, confined to the skin. In rare cases 
the ravages involve the osseous tissue, and even the coverings of the spinal cord. 
Bedsores, unless of very trivial extent, are among the most formidable complications 
that are liable to arise during the progress of fevers and other diseases, as well as after 
accidents and operations. As they seldom occur until the vital powers have been ma- 
terially depressed, the excessive pain and drainage occasioned by them are often so severe 
as to destroy the patient, or, at all events, greatly retard his convalescence. 
The treatment of bedsores, or gangrene from pressure, is prophylactic and curative. 
When there is any probability from the nature of the case that the confinement is likely 
to be tedious and attended with constant decubitis, or a helpless state of the patient, 
means should promptly be adopted for hardening those parts of the surface which long 
experience has taught us as being most liable to suffer under such circumstances. For 
this purpose they should be brushed once or twice a day with tincture of iodine, at first 
diluted, and then pure, or washed repeatedly with a saturated solution of alum and tannic 
acid. The greatest possible attention should be paid to cleanliness, and to the arrange- 
ment of the sheets and clothes, that they may not be rolled up under the body, and thus 
become a source of suffering and disease. As to the use of plasters, I have very little 
patience with them, for, unless they adhere well, they are extremely liable to become 
rumpled, much to the detriment of the part and system. Change of posture should re- 
ceive early attention, although this is not always practicable, from the inability of the 
patient to maintain himself in any other situation than on the back. When it can be 
afforded, an air bed should be used, as this is preferable to everything else. 
The moment any decided suffering is experienced, or the parts become red and inflamed, 
a ring-shaped air cushion should be provided for the purpose of equalizing the pressure, 
or, in the absence of this, an ordinary cushion, with a suitable central hole, the edges 
being broad and well padded with wool or horsehair. Such a contrivance, however, is a 
very imperfect substitute for an air or water cushion. CHAP. I. 
BURNS AND SCALDS. 
583 
When gangrene is threatened, the best application is tincture of iodine, aided, if there 
be much pain and tension, by one or two moderately free incisions, and followed by a 
yeast or port-wine poultice, sprinkled with laudanum, morphia, or powdered opium. 
Cleanliness is promoted by the liberal use of the chlorides and by the early removal of 
the sloughs. When granulations begin to spring up, the best dressing will be opiate 
cerate, a mixture of equal parts of castor oil and balsam of copaiba, or mild mercurial, 
elemi, balsam of Peru, or blue ointment. 
In the more rapid varieties of bedsores, dependent upon spinal irritation from external 
injury, with paralysis, Dr. Brown-Sequard strongly recommends the application of cold 
and heat, in the form of pounded ice and hop poultices, frequently alternated, with a view 
of effecting a salutary change in the circulation of the part. When the sore is indisposed 
to heal, on account of its inability to form healthy granulations, the most reliable stimulant 
is the galvanic current, applied in the manner pointed out in the chapter on ulcers. 
The constitutional treatment of bedsores must be conducted according to the general 
rules followed in typhoid states of the system, from whatever cause proceeding. Nutri- 
tious food, wine, brandy, milk punch, quinine, iron, and anodynes, are the means chiefly 
to be relied upon for upholding the flagging powers of nature. This treatment can hardly 
be commenced too soon whenever there is any tendency to the formation of bedsores, for 
the very fact that such a disposition exists is a sufficient reason for redoubling our efforts 
to support the patient’s system. 
SECT. Y BURNS AND SCALDS. 
There are few accidents which are of more common occurrence than burns and scalds, 
or which entail a greater amount of suffering and deformity. The progress of civiliza- 
tion, and the improvements in the arts and sciences, have greatly multiplied their 
frequency and severity, and call for corresponding attention on the part of the surgeon. 
From what I have seen of these lesions, I am satisfied that few practitioners understand 
their character, or treat them with the success of which they are capable. One reason, 
perhaps, of this is that every one has a remedy for them, and that hardly any two agree 
as to the kind of treatment best adapted to their relief. 
Burns and scalds differ from each other simply in this, that the one is the result of dry 
heat and the other of moist. They both present themselves in various degrees from the 
slightest erythematous blush of the skin to the total destruction of all the structures of a 
limb. Their extent is also extremely variable, both as it regards their depth and their 
superficial area. Thus, while in one case they may involve only a little patch of skin hardly 
the size of a half-dime, in another they may occupy an immense extent of surface ; or, 
instead of being diffused over a large space, the injury may be concentrated upon a small 
spot, but penetrate to a considerable depth. These differences are of great practical im- 
portance, on account of the influence they exert upon the issue of the case. The division 
of Dupuytren of burns and scalds, so generally adopted at the present day, seems to me 
to be most complex and unscientific, and, therefore, well calculated to embarrass the pro- 
gress of the inquirer. No one can doubt that the more simple the arrangement of a sub- 
ject is, the more easily, in general, it is understood. In accordance with this idea, I shall 
describe burns and scalds as consisting of two classes, the simple and complicated, com- 
prehending under the former term those lesions which, however extensive, give rise 
merely to inflammation, and under the latter those which cause the death of the parts, 
either on the instant, or within a short time after their infliction. 
Burns are most common in winter, among the poorer classes, who are very liable to 
have their clothes set on fire from the manner in which they crowd around the hearth and 
grate to keep themselves warm. Women, on account of their peculiar occupations, are 
more subject to them than men, and children than grown persons. Blacksmiths, plum- 
bers, glassblowers, and foundrymen are particularly exposed in this way. The introduc- 
tion of gas, camphene, and petroleum has been a fruitful source of these casualties. Scalds, 
on the other hand, are most common in kitchens, breweries, factories, especially soap and 
candle, and, in short, in all places where steam is employed, whether for domestic or 
public purposes. On our western waters, where steamboat explosions are of such 
frequent occurrence, many persons are annually destroyed by the effects of hot water. 
Those parts of the body which are habitually exposed, as the hands and face, are most 
liable to suffer both from burns and scalds, particularly the latter, steam often penetrating 
the clothes in every direction. Dry and moist flame, hot water, and steam often enter the 
mouth and throat, producing violent, if not fatal effects. A heated iron has been known to 
be thrust up the rectum for the purpose of homicide, as in the famous case of Edward II. 584 
DISEASES OF THE SKIN AND CONNECTIVE TISSUE. 
CHAP. i. 
Persons with a delicate skin not unfrequently suffer severely from long-continued expo- 
sure to the rays of the sun during the heat of summer, as is witnessed among soldiers, 
carpenters, bricklayers, masons, and farm hands. The affected surface exhibits a red, 
erythematous appearance, with or without vesication, and the pain is of a burning, itching, 
or smarting character. As the inflammation recedes, the epidermis drops off in small 
furfuraceous scales, leaving the surface beneath red and tender. 
It is well known that different agents possess different degrees of capacity for caloric, 
and that, consequently, they are capable of producing different effects when brought in 
contact with the living tissues. Thus, experience has shown that boiling metal will cause 
a more severe impression than boiling oil, and boiling oil than boiling water. The in- 
tensity of the injury, however, is not always in proportion to the relative capacity of the 
substance for heat; for it is well ascertained that copper will, other things being equal, 
occasion a more violent effect than iron, although the latter possesses a greater capacity 
for caloric. This fact can be explained only on the assumption that some articles are not 
only better conductors of heat than others, but that they adhere more firmly to the surface, 
thus favoring its protracted extrication. Alcohol and ether, from their great volatility, 
usually produce superficial burns; oils, from their more adhesive properties, deep ones. 
In the milder forms of these accidents there is merely an erythematous appearance of 
the skin, such as may readily be produced by exposing the back of the hand for a few 
moments to a stove, or by applying hot water to it. The discoloration is usually very 
transient, but at times it is more permanent, lasting for a number of hours, and being, 
perhaps, soon followed by slight vesication. The pain, of a smarting, pungent character, 
is comparatively trifling, and soon goes off. The constitution remains unaffected. 
The application of heat, whether dry or moist, unless sufficient instantly to destroy the 
vitality of the part, or so slight as to make only the most superficial and transient impres- 
sion, is always speedily followed by an evolution of vesicles, containing a thin, watery 
fluid, identical with the serum of the blood, from which it is derived. When the vesicles 
are more slow in forming, as when they are the product of the resulting inflammation 
rather than of the immediate effect of the caloric, their, contents are, in general, partly 
fluid and partly solid, the latter consisting either of lymph or of fibro-albuminous matter. 
Their volume varies from a pin-head up to that of a fist, their number being usually in 
an inverse ratio to their dimensions. Cases are occasionally met with where the epidermis 
nearly of a w hole limb, or of the greater portion of the trunk, is elevated into one enormous 
blister, establishing a most frightful drainage upon the system. 
The surface around the vesicles is of a scarlet color, more or less tumefied, and exqui- 
sitely tender on pressure, and on exposure to the atmosphere. The pain is of a burning, 
scalding character, and so severe as to cause the most violent agony. The part rapidly 
swells, feeling stiff'and tense, and the pain assumes a throbbing character. Well-marked 
constitutional symptoms are always present, especially if the lesion is at all extensive; 
and the patient may be delirious, excessively restless, and intensely thirsty. 
These injuries are said to be complicated when they are attended with the destruction 
of the vitality of the part, or some other serious lesion, as a wound, fracture, or disloca- 
tion. The devitalization may be limited to the skin and subjacent connective tissue, or it 
may extend much deeper, involving muscle, aponeurosis, vessel, nerve, and bone all in one 
common eschar. Such accidents are never produced in any other wTay than by burns, as 
when a person falls into the fire, or gets his limb in a stove, grate, or furnace. Dreadful 
scalds, however, sometimes occur from the protracted application of boiling fluids, as 
happens, nowr and then, in breweries and soap factories. Under such circumstances, the 
loss of vitality, although not as extensive as we sometimes find it from the operation of 
dry caloric, is yet sufficient to be productive of the most terrible ravages. The epidermis 
comes off in large sheets, no vesicles exist, or only around the border of the injured sur- 
face, and the skin is of a dirty grayish, cineritious, or yellowdsh color, sodden, insensible, 
and marked, here and there, by a purplish line, indicating the course of a subcuta- 
neous vein. 
Besides the pain which invariable attends all burns and scalds, however slight, there is 
ordinarily more or less constitutional disturbance, coming on at a variable period after 
the accident; sometimes immediately, at other times not for several hours, days, or weeks. 
When the injury is at all extensive, all the symptoms of a severe shock will be present. 
The patient will feel exceedingly cold, or, perhaps, have violent rigors; the pulse will be 
small, frequent, and feeble; the respiration will be oppressed; and there will be extreme 
restlessness, along with great thirst and sickness at the stomach. He is, in fact, in great 
torture, pale, prostrated, agonized. When the shock is excessive, sensibility may be com- CHAP. I. 
BURNS AND SCALDS. 
585 
pletely abolished. Reaction taking place, he will have violent fever, a flushed counte- 
nance, and a quick, irritable pulse, with a tendency to delirium ; pain, of a pungent, 
burning character, forming all the while the prominent suffering. If the excitement run 
high, there will be danger of overaction in the part, and of inflammation of some of the 
internal viscera, the arachnoid membrane, and the mucous lining of the bowel. Numerous 
cases have been published within the last twenty-five years going to show that ulceration 
of the duodenum is one of the most frequent secondary lesions of scalds and burns; and, in 
the more chronic forms of these accidents, the same disease is sometimes widely diffused 
over the colon, thus accounting for the profuse and obstinate diarrhoea then so often present. 
Albuminuria is a frequent, if indeed not a very common, occurrence in burns and scalds. 
A large number of the cases admitted into the Pennsylvania Hospital show, according to 
Dr. Morton, evidences of this occurrence. The urine is generally of high specific gravity, 
and the quantity of albumen, although variable, is often so considerable as to be declara- 
tive of at least more or less congestion of the kidneys. The change makes its appearance, 
in violent burns and scalds, soon after reaction takes place, and usually increases in a 
marked degree with the rise of temperature. No special clinical significance, certainly 
no very serious one, attaches to the presence of albumen, as ordinarily found, in these 
lesions. Similar changes, as is well known, not unfrequently occur in the urine after 
various other injuries, and after many surgical operations. 
Among the more common local consequences of burns and scalds are, the formation of 
vicious scars, the adhesion of contiguous surfaces to each other, the retraction of the 
affected parts, ankylosis of the joints, and various transformations of the cicati’icial struc- 
tures, especially the keloid. The scars, which are often of frightful extent, and horribly 
disfiguring, possess an extraordinary contractile power, which does not cease for a long 
time, which it is almost impossible to counteract, and which frequently draws out of place 
every tissue that is brought under its influence, bone not excepted. Owing to this cir- 
cumstance, the chin is occasionally drawn down against the sternum, as seen in fig. 241, 
Fig. 241. 
Fig. 242. 
Vicious Cicatrices of the Face and Neck. 
Contraction of Elbow from Cicatrice of Burn. 
and the lower maxilla singularly changed in shape. The lingers may be retracted like 
claws, or literally buried in the palm, the hand thrown back at right angle with the wrist, 
or the forearm drawn up against the arm, as in fig. 242, from a clinical case, which is 
itself, perhaps, firmly pinioned to the side. Similar effects occur in the inferior extremity. 
Thus, the foot is sometimes tied to the forepart of the leg, or the leg to the posterior sur- 
face of the thigh. In neglected burns of the hand, the fingers are often united to each 
other, so as to give them a webbed appearance. 
Burns and scalds are among the most dangerous of accidents. If at all extensive they 
often terminate fatally from mere shock of the system, without, perhaps, even the slightest 
attempt at reaction; or, reaction occurring, life may be assailed by inflammation of some 586 
DISEASES OF THE SKIN- AND CONNECTIVE TISSUE. 
internal organ ; or death may take place at a more remote period, from the secondary 
effects of the lesion. A superficial injury of this kind is generally dangerous in propor- 
tion to its extent. Thus, a scald involving an entire limb, or the greater portion of the 
trunk, although merely affecting the external layer of the true skin, is always a most 
serious accident, liable to be followed by the worst results. On the other hand, the danger 
is hardly less when the lesion is very deep, even if it be not more than a few inches in 
diameter. When depth and great extent of surface coexsist, the chances are that death 
will occur without reaction, or soon after the system has rallied from constitutional irrita- 
tion. Of 125 cases, collected by Erichsen and Holmes, 35 succumbed within the first 
forty-eight hours. After reaction has taken place, the great danger is from inflammation 
of the brain, lungs, and intestines, many of the worst cases perishing during the first 
fortnight. Inflammation of the duodenum, leading, as was originally pointed out by 
Mr. Curling, to ulceration of its mucous membrane, is an occasional occurrence, coming 
on, on an average, about the tenth day, the resulting sore, which is generally solitary, and 
situated just below the pylorus, being of a circular shape, sharp-edged, indolent, and 
unaccompanied by any characteristic phenomena. Burns and scalds of the chest and 
abdomen are the most common exciting causes. Death may be produced by hemorrhage, 
or by peritonitis from perforation of the bowel. 
Such injuries are, other things being equal, more dangerous in infants and children 
than in adults, on account of the greater susceptibility of the nervous system. Old 
persons, too, are very intolerant of them, and are liable to suffer severely, both primarily 
and secondarily. Pregnant females occasionally abort from their effects; and in the 
intemperate they often give rise to delirium tremens and other distressing symptoms. 
A burn of the neck and scalp is liable to cause arachnitis ; of the chest, inflammation of 
the lung and pleura; of the abdomen, peritonitis and enteritis. Finally, a patient, after 
having manfully struggled against ebb and tide, as it were, for weeks and months, may 
finally perish from the effects of profuse discharge, pyemia, erysipelas, or hectic irritation. 
Treatment—The indications in the treatment of these lesions are, first, to produce 
reaction and calm the system ; secondly, to limit the resulting inflammation ; thirdly, to 
promote the sloughing process, when death has taken place, and to favor the develop- 
ment of granulations; fourthly, to moderate contraction, and prevent ankylosis; and, lastly, 
to sustain the strength during the wasting effects consequent upon the protracted suffering 
which so often occurs when the patient has escaped from the primary effects of these injuries. 
To raise the system from the depression or collapse into which it so frequently sinks, 
even in comparatively slight burns and scalds, immediate recourse should be had to a full 
anodyne, along with hot toddy, ammonia, sinapisms to the extremities, and the warm 
foot-bath, the immersion being cautiously continued from thirty minutes to an hour, 
according to the exigencies of the case. The quantity of morphia, or whatever form of 
opium may be used, should be at least double what it is in ordinary accidents, the system 
being always, under these circumstances, uncommonly tolerant of the medicine. A large 
dose will not only be conducive to speedy reaction, but will greatly assist in allaying pain 
and calming the system. If the shock has been unusually severe, it may be necessary, 
in addition to these means, to use stimulating injections and to rub the spine with some 
irritating lotion. In the child and the old man, care is taken not to urge on the reaction 
too rapidly, or to give opium without a certain degree of caution, lest the subsequent 
excitment should overtax the enfeebled brain and heart, thereby leading to visceral effu- 
sion. As the circulation comes up, the stronger stimulants are gradually withdrawn, the 
more simple alone being now trusted to for relief. 
The severe pain consequent upon burns and scalds, is generally promptly relieved, as 
originally suggested by Dr. F. S. Waters, of Massachusetts, by the use of bicarbonate 
of sodium, applied in the former case, in the form of a paste made with water, and in the 
latter, in that of a powder freely sprinkled upon the raw surface. 
The second indication is to moderate the resulting inflammation. With this view, 
various remedies may be employed; but what these remedies ought to be is a point 
respecting which there is still much contrariety of opinion. In the milder forms of 
burns and scalds the surgeon can hardly go amiss if he uses almost any of the more 
common popular articles. He will find that at one time the part and system are 
most comforted by cold applications, at another by warm ; that the one is borne best 
to-day, the other to-morrow ; that one patient is benefited by an ointment, another by a 
lotion; that in one case he may employ moist applications with most advantage, in 
another, dry ; in short, that the utmost diversity obtains in regard to the tolerance of this 
remedy or that. 
CHAP. i. CHAP. I. 
BURNS AND SCALDS. 
587 
Cold applications are chiefly adapted to very young, robust subjects, during the heat of 
summer, but even then they should not be employed without the greatest care, on account 
of their liability to cause internal congestion and effusion. They should be used only so 
long as they are grateful and soothing to the system, and be discontinued the moment 
they are found to be disagreeable. They may consist simply of cold water, spirit and 
water, or weak solutions of acetate of lead ; and the same articles may be applied warm, 
care being taken, when the one class follows the other, that the transition is gradual and 
gentle, not sudden and violent. If the lesion is very slight, the surface may be covered 
with poultices of scraped potato, apple, turnip, starch, arrowroot, or slippery elm ; carded 
cotton; saturnine unguents; or cloths wet with liniment made of lime-water and linseed 
oil. The latter constitutes the famous application so much used at the Carron Iron 
Works in Scotland; it is, however, exceedingly filthy and disgusting, and should, there- 
fore, be discarded from genteel practice. Carded cotton, an American remedy, has always 
stood high in the estimation of the public, and there are few articles which are more 
constantly or more advantageously employed in the treatment of superficial burns and 
scalds. Tincture of iodine diluted with two parts of alcohol, I have often found of great 
benefit in the milder varieties of these affections. It is only applicable, however, when 
the skin is unbroken. The burning, scalding, or smarting sensation, attendant upon this 
class of injuries, is often promptly relieved by pencilling the affected surface with a weak 
solution of nitrate of silver, and covering it immediately after with a thick layer of cotton. 
In my own practice, I have found nothing so beneficial in the treatment of burns and 
scalds as carbonate of lead, in the form of wdiite paint, a substance to which, in 1845, I 
called attention in a short article in Dr. Bell’s Bulletin of Medical Science. Numerous 
observations made since that time by myself and others have only served to confirm the 
views which I then expressed. The remedy is more particularly applicable to the milder 
forms of these injuries, but I have also employed it with great advantage in the more 
severe. If vesicles exist, they must, as a preliminary measure, be evacuated with a fine 
needle, and the surface well dried, otherwise the lead will not adhere. The lead, mixed 
with linseed oil to the consistence of thick cream, is then freely applied with a soft brush, 
the dressing being completed by covering the painted surface with a layer of carded cotton, 
or old muslin, supported by a moderately firm roller. In the milder cases one such appli- 
cation, retained for several days, generally suffices; whereas in the more severe occasional 
renewal will be required, depending upon the amount and character of the discharge. 
I have never witnessed any bad effects from white lead paint, applied as here directed, 
although I have used it very freely in numerous cases. In one instance, that of a negro 
girl, sixteen years of age, who had a most severe and extensive burn of the neck, chesty 
and abdomen, I continued the remedy for upwards of five weeks, consuming more than a 
quart of the lead, without observing the slightest injury. In short, my experience induces 
me to believe that the treatment is perfectly safe in all cases, whatever may be the extent 
or depth of the lesion, or the age of the patient. When a counterpoison, however, is 
deemed necessary, it will readily be found in the occasional exhibition of a dose of sul- 
phate of magnesium, which, while it keeps the bowels in a soluble state, combines with the 
lead, forming an inert sulphate. 
White lead paint probably produces its good effects in two ways: first, by forming a 
varnish to the affected surface, and, secondly, by directly obtunding its nervous sensibility. 
In many cases it literally acts like a charm, the patient in a few moments becoming per- 
fectly calm, and passing, as it were, from torment to Elysium. 
Professor T. G. Richardson, of New Orleans, has obtained excellent effects, in the 
treatment of burns and scalds, from the use of subnitrate of bismuth and glycerine con- 
verted into a thick paint, and freely spread upon the affected surface with a suitable brush, 
the parts being afterwards covered with carded cotton retained by a roller. In the milder 
forms of the accident a single application is often sufficient for a cure. 
Dr. Addinell Hewson has employed with marked advantage in many cases of burns and 
scalds, of various grades, what he calls the earth treatment. It consists in covering the 
raw surface with finely sifted earth, either in the form of dry powder, or of a thick aqueous 
paste spread upon strips of old, coarse muslin, confined with a roller, and removed as soon 
as it becomes offensive or saturated with the discharges. In superficial burns and scalds 
one dressing often suffices for a cure, the parts healing underneath in a few days, the hard- 
ened mass coming off in a solid crust. In the more severe cases the application requires 
occasional renewal, sometimes as often as once every twenty-four hours. Of the efficacy 
of this plan of treatment I have had sufficient proof to satisfy me of the propriety of its 
employment. Its beneficial effects seem to be due to two circumstances, the exclusion of 588 
DISEASES OF THE SKIN AND CONNECTIVE TISSUE. 
CHAP. i. 
the air from the raw surface, and the specific action of some of the ingredients of the 
earth, more especially the alumina. One great advantage of this mode of treatment is 
that the inodular tissue after the completion of the cicatrization is a great deal softer and 
much more pliant than after the use of any other remedies with which 1 am acquainted. 
In Boston, a plan of treating burns and scalds is used with much advantage, consisting 
of the application of a thick coating of mucilage of gum arabic, which is immediately after 
well dusted with the dry powder, the whole forming a complete defence to the raw surface 
beneath. Mr. Meadows, of London, recommends, for a similar purpose, a mixture of col- 
lodion and castor oil, in the proportion of two parts of the former to one of the latter. 
The preparation, which may be kept ready for use for any length of time in an air-tight 
bottle, is applied by means of a camel-hair brush, and is speedily converted into a firm, 
adherent covering, the thickness of which may afterwards be increased if deemed proper. 
In the mere simple forms of scalds and burns, the application of glycerine is occasionally 
very beneficial; and Dr. John II. Packard, of this city, has derived excellent effects from 
the use of fresh lard, both in the mild and the more severe varieties of these accidents. 
Dupuytren’s favorite remedy was an aqueous solution of Goulard’s extract, retained upon 
pledgets of old linen ; and, with the exception of white lead paint, there is probably no 
more soothing application. 
When a stimulant effect is required, as when the parts are in a condition verging upon 
gangrene, the most eligible dressing, perhaps, is Kentish’s ointment, composed of one 
ounce of basilicon ointment and one drachm of spirit of turpentine, and spread upon 
strips of old muslin, bound on lightly with a roller; or, instead of this, the surface may 
be carefully pencilled with a weak solution of nitrate of silver, nitric acid, or acid nitrate 
of mercury, and then covered with a yeast, port wine, or tannic acid poultice. Thick soft 
soap also answers a good purpose, often promptly allaying the smarting consequent upon 
burns and scalds. When a mere protective is required, finely-powdered charcoal answers 
an excellent purpose, the surface being thickly sprinkled with it, and renewal effected as 
soon as the crust becomes saturated with the secretions. 
Along with these means, proper attention is paid to the state of the constitution, the 
bowels are maintained in a soluble condition, diaphoretics are given to restore the func- 
tions of the skin, and the diet is carefully adapted to the particular emergencies of the 
case. The internal organs, especially the brain and lungs, are sedulously watched, any 
approach of danger from inflammation being promptly counteracted by suitable measures. 
If, despite the utmost care and attention, the injury terminates in mortification, or if 
the parts were devitalized in the first instance, an effort should be made to check its fur- 
ther progress, and to promote the separation of the sloughs, the most eligible remedies 
being such as are in use for ordinary gangrene. Fetor is corrected with the chlorides. If 
the sloughs are very firm, they may be detached with the knife, the greatest caution being 
employed, lest pain and hemorrhage be induced. 
As soon as the sloughs have dropped off, the indication is to promote the development 
of granulations ; a circumstance which often requires much judgment and practical skill. 
One of the best remedies for this purpose is the warm water-dressing, with the addition 
of two drops of nitric acid to the ounce of fluid. Sometimes the calamine cerate is very 
soothing, and seems to do good when almost everything else fails. If the granulations 
manifest a tendency to exuberance, as they are very apt to do, they must be repressed 
with the scissors, nitrate of silver, and systematic compression, tonics being given to sup- 
port the system. Cases occur in which these bodies are rendered exquisitely sensitive, 
the slightest touch being followed by the most lively pain. This condition is generally 
attended with an irritable state of the constitution, for the relief of which something more 
than mere topical medication is required. A judicious course of anodynes and tonics, 
with the occasional application of nitrate of silver, and the constant use of an elm-bark 
poultice, constitute the proper treatment. Occasionally, no local remedy is so soothing as 
white lead paint. Whatever means may be employed, it will be found that they will 
require to be frequently varied, as one loses its effects another taking its place. 
In burns from the effects of solar heat, prompt relief is generally afforded by applica- 
tions of cold water, either simple or medicated with acetate of lead. In the more severe 
cases the affected surface should be thickly covered with white lead paint. 
To obviate deformity constitutes the fourth indication in the treatment of these injuries. 
The points to be attended to are threefold: first, to prevent adhesion between contiguous 
surfaces; secondly, to counteract the tendency to vicious contraction ; and, thirdly, to 
guard against ankylosis. 
The tendency which the contiguous surfaces have to unite with each other during the CHAP. I . 
BURNS AND SCALDS. 
589 
progress of these accidents has already been alluded to. This tendency is not confined to 
the fingers and toes, but is also exhibited in other parts of the body, as between the arm 
and trunk, the labia, the thigh and scrotum, the ear and scalp. Wherever it appears, it 
must be carefully counteracted by the use of the bandage and the interposition of lint, 
aided, if need be, by splints. It does no credit to a surgeon to send forth his patient, 
after the completion of cicatrization, with webbed hands and feet, or with his arms pinioned 
to the side of the chest, although such occurrences are not always entirely avoidable. 
The disposition to contraction in burns and scalds attended with loss of substance is 
always great, and is often productive of the most frightful deformity. To counteract this 
disposition, recourse should be had, early in the treatment, to carved splints and wire 
cases, judiciously applied, and steadily used, not only until the parts are well, but for a long 
time afterwards; experience having shown that the tendency to contraction continues for 
months, if not for years, after the completion of the cicatrization. 
If, from neglect, mismanagement, or unavoidable circumstances, the contraction has 
seriously impaired the usefulness of the part, or greatly marred good looks, relief should 
be attempted by the division of the offending cicatrice, or, perhaps, by its excision, the 
raw edges being afterwards united by suture, or adapted to a flap of the adjacent integu- 
ment. This operation, constituting what is termed dermoplasty, and in connection with 
which the names of Mutter, Pancoast, and Teale deserve especial commendation, should 
not, however, be undertaken without due preparation of the system; for it is easy to 
perceive that, when the cicatrice is very large, two most extensive wounds would have to 
be made, thus inflicting a violent shock upon the constitution, extremely liable to be fol- 
lowed by erysipelas and a low form of fever, under which the patient might readily sink. 
The operation should be performed while the patient is under the influence of an anaes- 
thetic, with the precaution of dissecting out every particle of the inodular tissue. To 
accomplish this, the surgeon is sometimes obliged to pass deeply among important vessels 
and nerves, which must, of course, not be interfered with. In conducting such an ope- 
ration about the neck, care must be taken to prevent the entrance of air into the veins. 
The bleeding which attends the excision of the cicatrice is generally trifling, and is easily 
arrested by torsion : when the ligature is unavoidable, it should be composed of raw silk 
or carbolized catgut, and be left in the wound. 
The skin for filling up the gap left by the removal of the inodular tissue should always 
be taken from the immediate vicinity of the part. Thus, in the neck, it is usually ob- 
tained from the shoulder or top of the chest, and, when the wound is very large, two flaps 
are generally made, one on each side, the object being to guard against sloughing from 
inadequate nutrition. Due allowance must always be made for shrinkage. Hence the 
flap should invariably be at least from one-fourth to one-third larger than the wound, have 
a good, broad pedicle, and be well stitched in its new position, although care must be 
taken not to place the sutures too near each other, for fear of embarrassing the circula- 
tion. The central portions of the flap must be loosely confined with adhesive strips, and 
the edges covered with charpie, soaked in oil. The wound made by the transplantation 
of the integument is immediately closed in the usual manner. The parts are kept per- 
fectly at rest, being immovably fixed by suitable apparatus, and the case is afterwards 
managed according to the general principles of plastic surgery. 
Although the results of this operation have been much lauded, my confidence in its 
ultimate efficacy has been a good deal shaken, experience having shown that, in very many 
cases, more or less of the deformity for which it was performed will be sure, at no distant 
day, to recur, the more especially if any portion, however small, of the inodular tissue is 
left. For this reason few of such procedures can be classed among the triumphs of sur- 
gery. It is only when the cicatrice is very soft and superficial that they hold out any 
prospect of a permanent cure. When the contraction involves the muscles, tendons, 
fibrous membranes, and bones, forcing them out of their natural shape and position, the 
art of surgery can be of no avail. 
The late Mr. Skey, of London, with a view of obtaining extension of the vicious 
cicatrice, was in the habit of making numerous minute incisions, extending both through 
the skin and the subjacent tissues, basing his practice upon the assumption that the 
contraction of a wound is slight in proportion as the time consumed in the healing process 
is short. It does not appear, however, that this practice has had any imitators, and I 
should certainly have no faith in its efficacy or permanent utility. 
Skin-grafting will no doubt be found to be of essential service in pi’omoting the cica- 
trization of burns and scalds, and should be practised as soon as the granulations have as- 
sumed a sufficiently healthy appearance to justify the belief that the transplanted skin 590 
DISEASES OF THE SKIN AND CONNECTIVE TISSUE. 
CHAP. I. 
will be able to take root and grow. Whether this expedient, however, will prevent the 
extraordinary tendency to contraction so often witnessed after these lesions, is very ques- 
tionable. Of several cases which have come to my knowledge, among others one men- 
tioned to me by Dr. J. M. Barton, no permanent, benefit resulted. 
The joints often become involved during the progress of burns and scalds, either from 
direct inflammation, or in consequence of the contraction of neighboring muscles, ten- 
dons, and aponeuroses. The parts are carefully watched, being moved from time to time, 
and constantly retained in splints, until all tendency to ankylosis has ceased. 
Finally, the secondary constitutional irritation and drainage, so common, and so haz- 
ardous in the more severe forms of these accidents, must be met by stimulants, tonics, and 
anodynes, along with nutritious food, and exercise in the open air. Any diarrhoea that 
may be present must be checked with opium and astringents, of which acetate of lead 
and sulphate of zinc deserve particular mention, the former being given in doses of two 
grains, and the latter in half that quantity, with half a grain of opium, three times in the 
twenty-four hours. Night-sweats are controlled with atropia, quinine, and elixir of vitriol. 
Secondary amputation may be necessary, when, an attempt having been made to save 
the part, death is likely to occur from the excessive discharge and hectic irritation ; or 
when the part is found not only to be useless, but to be greatly in the way of the patient’s 
comfort and convenience. 
SECT. YI FROST-BITE AND CHILBLAIN. 
Man possesses in a remarkable degree the faculty of resisting the influence of physical 
agents. His constitution is able to bear almost any amount of heat and cold, provided 
the transition from the one to the other is not too great or sudden, and that he himself is 
at the time in the full enjoyment of his bodily powers. The experiments of Fordyce, 
Blagden, and others, show what an amount of artificial heat may be endured without 
entailing any serious effects, and the experience of travellers, as Banks, Solander, Kane, 
and Hayes, is equally decisive in regard to his capacity of withstanding the effects of low 
degrees of temperature. It is only, or chiefly, when the alternation from heat to cold is 
very rapid, or when the application of cold is made in a very concentrated form, upon a 
part of the body the circulation of which is naturally very languid, that severe conse- 
quences are apt to ensue. Baron Larrey, who enjoyed extraordinary opportunities of 
studying the effects of cold, during Bonaparte’s celebrated retreat from Russia, was forcibly 
struck with the little suffering which the soldiers experienced when exposed even for 
several successive days to the influence of a very low, dry, uniform temperature. Thus, 
after the battle of Eylau, although the mercury had fallen fifteen degrees below zero of 
Reaumur’s thermometer, none of the French troops complained of frost-bite, notwith- 
standing many of them had remained in the snow, in an almost inactive state, for upwards 
of twenty-four hours. Presently, however, a fall of sleet coming on, during which the 
temperature rose suddenly from eighteen to twenty degrees, immense numbers of those 
who had been exposed began to suffer from the effects of cold, consisting principally in 
sharp, pricking pains in the remote parts of the body, especially in the feet, and in a dis- 
agreeable sense of numbness and weight. Severe swelling soon followed ; the skin assumed 
a dusky, reddish appearance ; the joints became stiff and insensible ; feeling and warmth 
rapidly diminished; and black spots formed at the roots of the toes and on the back of 
the foot, announcing the occurrence of gangrene, the extremity looking dry and shrivelled, 
as in chronic mortification. It was observed that those who had warmed themselves at 
fires suffered more severely than those who had been more discreet in this respect. 
Frost-bite was very prevalent among the English troops during their first winter in the 
Crimea, and the French suffered in still larger numbers, as well as more severely. The 
habit which the men had of sleeping in their wet boots, at one time almost universal, 
contributed greatly to its production, wet and cold combined diminishing the circulation 
and the vitality of the feet and toes. On the 21st of January, 1855, when, according to 
Dr. Macleod, the thermometer stood at 5°, not less than 2500 cases of frost-bite were 
admitted into the French ambulances, and of these 800 died, death in many having no 
doubt been expedited by the effects of erysipelas, pyemia, and hospital gangrene. 
The first effect of dry, cold air is a sense of numbness and weight, with a peculiar 
prickling or tingling, and an afflux of blood to the surface, giving it a lively reddish 
appearance. If the impression be maintained for any length of time, the parts become 
stiff and perfectly insensible; and the blood, retreating from the surface, leaves it of a 
pale, whitish aspect, contrasting strikingly with the previous discoloration. When the 
cold is intense, and suddenly applied, so as speedily to overwhelm the parts, the skin CHAP. I. 
FROST-BITE AND CHILBLAIN. 
591 
occasionally is raised into blebs or vesicles and exhibits a mottled appearance, depending 
upon the presence of coagulated blood in the subcutaneous veins. 
The effects of moist cold are very similar to those of dry cold. Upon immersing the 
hand, for instance, in iced water, there is generally an immediate rush of blood to the 
surface, and a decided augumentation of its color, soon succeeded by an unpleasant ting- 
ling sensation and a marked degree of numbness. By and by, however, the surface 
becomes white, the skin is elevated into blebs or blisters, exquisite pain arises, and the 
whole limb notably shrinks. There is thus, in fact, no essential difference in regard to 
the effects of these two varieties of cold ; and the observer cannot fail to perceive how 
closely the first impressions of both resemble those produced by the application of artificial 
heat, especially in its dry form. 
All parts of the body are liable to suffer from the effects of cold: excepting, however, 
those rare cases, where the impression has been maintained for an unusual length of time, 
the toes, feet, heels, fingers, hands, nose, and ears, together with the lips and cheeks, will 
be found to be more frequently affected than any other structures. Accidents of this 
description are most common among the poorer classes, those wretched beings whose 
system is broken down by starvation, intemperance, and every kind of exposure and 
hardship, tending to depress the vital powers, and to predispose to the development of 
disease. Sailors and the boatmen on our lakes and rivers are particularly liable to frost-bite. 
The primary effects of cold upon the general system are those of an agreeable stimu- 
lant : the circulation is increased in force and frequency, a slight glow pervades the surface, 
and the individual is universally exhilarated. By and by, this agreeable feeling is changed 
into one of pain and torpor; the brain is oppressed as if under the influence of a powerful 
narcotic; the whole body is cold and benumbed ; and the person, overwhelmed by drow- 
siness, is obliged to make the most powerful efforts to keep awake. If, in an unlucky 
moment, he should yield to his inclinations, away from friends and assistants, he sleeps 
to wake no more ; the blood rapidly settles in the internal organs; the nervous fluid ceases 
to be generated ; the respiration becomes heavy and stertorous, and death takes place very 
much as in ordinary apoplexy. Should the individual, after long and severe exposure, be 
suddenly brought into a hot room, or placed near a fire, he will run the risk of speedily 
perishing from asphyxia, brought on by the repulsion of the blood to the brain and lungs ; 
or, should he survive a short time, the frost-bitten parts will be seized with gangrene, 
the spread of which, as observed by Larrey, is often so rapid and striking as to be per- 
ceptible by the eye. 
Such are some of the more important local and constitutional effects of cold, when applied 
in its more severe and protracted forms. As just seen, it may prove destructive both to 
the part and system ; or, reaction taking place, the patient may recover, although he will 
be likely afterwards to suffer more or less in various parts of the body, especially the 
feet, ears, nose, and fingers, from the secondary effects of his accidents, which are often 
as distressing to him as they are perplexing to the practitioner. 
Treatment The treatment of frost-bite requires no little judgment and adroitness to 
conduct it to a successful issue. The great indication is to recall the affected parts 
gradually to their natural condition by restoring circulation and sensibility, in the most 
gentle and cautious manner, not suddenly, or by severe measures. The first thing to be 
done is to immerse them in iced water, or to rub them with snow, the friction being made 
as carefully and lightly as possible, lest overaction be produced, as they are necessarily 
greatly weakened. If no ice or snow is at hand, the coldest well-water that can be pro- 
cured must be used ; and if the immersion is inconvenient, wet clothes are applied, with the 
precaution of maintaining the supply of cold and moisture by constant irrigation. Mode- 
rate reaction is aimed at and fostered. All warm applications, whether dry or moist, are 
scrupulously refrained from ; the patient must not appproach the fire, immerse his limbs 
in hot water, or even be in a warm room, otherwise mortification or other disastrous con- 
sequences will be certain to follow. 
As soon as the natural temperature has been in some degree restored, slightly stimula- 
ting lotions will be found serviceable, such as weak solutions of camphor, soap liniment, 
or tincture of arnica with the addition of a few drops of ammonia to each ounce of fluid. 
The parts are placed at rest, in an easy and rather elevated position, and lightly covered 
with a blanket; or, what is better, exposed to the warm air of the apartment, there being 
now no longer any necessity for keeping the patient in a cool room, as there was in the 
earlier stages of the treatment. Some mild cordial may now also be given in small 
quantity, along with a little warm gruel or broth. If the local reaction threaten to be 
severe, it must be checked by astringent and cooling lotions, attention to position, a 592 
DISEASES OF THE SKIN AND CONNECTIVE TISSUE. 
CHAP. i. 
properly regulated diet, and the exhibition of a purgative. For incipient mortification, 
consequent upon cold, the best remedy is dilute tincture of iodine. 
Dr. Hayes, the companion of Dr. Kane in his last Arctic voyage, gives an account of 
a mode of treatment of frost-bite pursued by the Esquimaux, which deserves brief mention, 
although it does not differ essentially from that just laid down. A native, says the writer, 
who had his leg frozen above the knee, to such an extent that it was stiff, colorless, and 
apparently lifeless, was placed in a snow-house at a temperature of 20° degrees below 
zero. The parts were now bathed with ice-cold water for about two hours, and then 
enveloped in furs for about twice that period. At the end of this time frictions were 
commenced, first with the feathery side of a bird’s skin, and then with snow, alternately 
wrapping the limb in furs, and continuing the rubbing for nearly twenty-four hours. The 
limb was now carefully covered, and the temperature of the room elevated by lamps above 
zero. On the third day the man was removed to his own house, and in seventy hours he 
was able to walk about, with only a slight frost-bite on one of his toes. 
When a person has been overpowered by cold, or is nearly frozen to death, the attempts 
at restoration must be conducted upon the same general principles as when he is suffering 
merely from the local effects of cold; that is, he should be put in a cool room, and be 
gently but efficiently rubbed with flannel, wet with brandy, spirit of camphor, or ammo- 
niated liniments, gradually followed by dry frictions and warm covering. If he can 
swallow, brandy should be given by the mouth, or this or some similar article should be 
thrown into the rectum ; stimulants should be cautiously applied to the nose, especially 
snuff, and sinapisms to the precordial region, the stomach, and spine. As the circulation 
and respiration improve, the temperature of the apartment may be gently elevated, and 
warm broths, or wine whey, or, what is better, warm toddy, administered. The efforts 
at resuscitation should not be discontinued too soon, since they have occasionally been 
crowned with success long after all reasonable expectation of recovery had ceased. The 
practice formerly recommended of immersing the whole body in cold water, in this condi- 
tion, cannot be too much deprecated, as it could not fail to prove exceedingly injurious. 
Pernio or chilblain The secondary effects of cold are usually described under the 
name of pernio or chilblain, and there are several varieties of form in which they may 
present themselves, as the erythematous, ulcerated, and gangrenous. These effects may 
supervene upon slight exposure, and hence they are occasionally met with among the 
better classes of citizens, the parts most liable to suffer being the toes, heel, instep, ears, 
nose, and fingers. They are usually preceded by a slight vesication, and by burning, 
tingling sensations, as if the surface had been held near the fire. These effects may soon 
subside, or they may prove a source of annoyance for many months ; in general, however, 
they are of a transient nature, but the parts, instead of getting completely well, remain 
weak and congested, and are liable to new attacks of suffering from the slightest causes. 
Any sudden change in the weather is extremely apt to bring on a paroxysm; the affected 
structures become red, or of a dusky, purplish hue, swollen, painful, and cedematous; the 
epidermis is often raised into little blisters, distended with yellowish, turbid, or sangui- 
nolent fluid; and there are few cases in which itching, sometimes almost insupportable, is 
not a prominent symptom, the patient feeling as if he could tear the parts to pieces. 
Ulcers not unfrequently form as an effect of frost-bite. Generally preceded by slight 
vesication, they are superficial, irritable, and indisposed to heal, the discharge being of a 
thin, ichorous character ; the parts around are red, inflamed, and congested, and the erosive 
action often spreads over a considerable surface. In some cases it extends very much in 
depth, and may thus ultimately invade a neighboring joint, bone, tendon, or muscle. 
Gangrene is more frequently a primary than a secondary effect of frost-bite ; the affected 
part is of a dark brownish, purplish, or blackish color, cold, insensible, and exquisitely 
fetid; in some cases the slough is dry and shrivelled, like a rotten pear, in others it is 
moist and expanded. In persons of weak constitution, and in the more remote parts of 
the body, wdiere the circulation is naturally very feeble and languid, it often spreads to a 
considerable extent ; but, in general, its tendency is to limit itself to a small space. When 
considerable, it may invade all the component tissues of a limb, the bones and joints as 
well as the soft parts. 
Pernio may, as already stated, last for many years, alternately disappearing and recur- 
ring under the slightest local and constitutional changes. Atmospheric vicissitudes gene- 
rally exercise a marked influence upon these attacks, the patient being often a complete 
barometer; a combination of cold and moisture is particularly prejudicial. During the 
dry weather of summer the disease not unfrequently disappears spontaneously, but is sure 
to return on the approach of winter. In this manner life may be rendered perfectly CHAP. I. 
HYPERTROPHIES OF THE SKIN-. 
593 
miserable, especially when the chilblain is seated in the feet, the patient being hardly 
ever able to walk with any degree of comfort or satisfaction. 
In the treatment of pernio, remedies of a slightly stimulating character are most 
entitled to confidence. The milder forms of the disease are often speedily relieved by 
immersion of the part in cold water, followed by the use of a strong solution of acetate 
of lead and opium, or, what is preferable, dilute tincture of iodine, which, on the whole, 
I have found to be more beneficial than any other article. Sometimes prompt ameliora- 
tion is afforded by the application of carded cotton, soap liniment, spirit of camphor, or 
some other stimulating embrocation. 
Any blisters that may form should immediately be opened, and the affected surface 
freely touched with solid nitrate of silver, or painted with very dilute tincture of iodine. 
Not unfrequently excellent effects follow the use of weak citrine ointment, or of benzoated 
zinc ointment. In obstinate cases great advantage often arises from thorough vesication 
with cantharidal collodion. 
The gangrenous form of pernio is treated upon general principles. Fetor is allayed by 
deodorizers, and sloughs are removed as they become detached. Amputation is refrained 
from until there is a well-marked line of demarcation, and even then the surgeon should 
hesitate if the system is not in a healthy condition. Baudens asserts that most operations 
of this kind, performed in the Crimea, on account of frost-bite, were unsuccessful, owing 
to the shattered and wasted state of the sick, the great majority of whom had been affected 
with diarrhma. 
In all cases proper attention must be paid to the general health, the diet being duly 
regulated, the bowels gently evacuated, and the secretions improved. From neglect of 
these precautions great temporary suffering is often induced. 
SECT. VII HYPERTROPHIES OF THE SKIN. 
Under hypertrophies of the skin are included two diseases, of which one, dermatolysis, 
consists of enormous development of the integument as a whole, and the other, elephan- 
tiasis, is composed of excessive enlargement of the individual elements of the skin and 
subcutaneous connective tissue. 
1. Dermatolysis Dermatolysis, oc pachydermatocele, occurs chiefly, if not exclu- 
sively, as a congenital affection. It is characterized by a soft, pendulous condition of 
the skin, which hangs off in loose folds from the surface to which it is naturally attached, 
as if it had been stuck on without any special object. In all other respects, the integu- 
ment is apparently perfectly normal, there being not the slightest alteration of color, 
consistence, or structure, at least so far as we are enabled to judge from inspection. The 
most common sites of hypertrophy of the skin are the nates, scrotum, prepuce, and vulva. 
The most remarkable example that I have met with occurred, as a congenital vice, on 
the back of the neck of a female child, upwards of a year old, the integument forming a 
large pendulous mass, of a doughy, inelastic feel, extending from ear to ear, and causing 
unseemly deformity. The child was, in other respects, well formed. 
When the hypertrophied integument forms an unsightly mass, or when it proves incon- 
venient by its bulk, it should be included in an elliptical incision, care being taken not 
to cut avray so much of the skin as to interfere with reunion. If the tumor is very large, 
and the patient of tender age, the employment of the knife should be postponed until the 
constitutional stamina are sufficiently developed to enable the child to bear the shock 
attendant upon so severe an operation. Special pains should be taken to guard against 
hemorrhage, which might otherwise be profuse. 
2. Elephantiasis Arabian elephantiasis, Egyptian sarcocele, tropical bucnemia, 
spargosis, or the glandular disease of Barbadoes, as it is variously denominated, although 
uncommon in this country, deserves passing notice, not less on account of the hideous 
deformity which it induces than its obstinate and intractable character. The favorite 
seat of this singular disease is the leg, which often acquires an enormous volume and a 
most grotesque appearance, causing a striking resemblance to the leg of the elephant, 
whence its name. It is not, however, confined to this part of the body; on the contrary, 
it is liable to occur in various organs, particularly the scrotum, prepuce, and pudendum, 
which, in consequence, sometimes acquire an enormous bulk. A tumor of this kind, 
presented to me by Dr. Bozeman, and removed by him from the genital organs of a negro, 
weighed forty pounds; and Clot-Bey extii-pated one, occupying a similar situation, which 
weighed one hundred and ten pounds. The adjoining cut, fig. 243, taken from a clinical 
case, affords a good illustration of elephantiasis of the foot and leg. The enormous bulk 594 
DISEASES OF THE SKIN AND CONNECTIVE TISSUE 
CHAP. I. 
which the lower extremity may attain in this 
disease is well shown in a case reported by 
Dr. Isaac Smith, of Massachusetts, in which the 
weight of the limb after amputation exceeded 
one hundred pounds. Dr. Carnochan has re- 
corded a remarkable example of elephantiasis 
of the head, face, ears, and neck in a woman 
of forty-four years of age. 
The disease is met with in both sexes, but 
much oftener in males than in females; it oc- 
curs in various races of men, and frequently 
begins at an early age, although it is most 
common in young adults. In this country and 
in Europe the affection is very rare, but in 
certain parts of Asia, Africa, Syria, Arabia, 
Egypt, and the West Indies it is extremely 
prevalent, and sometimes even endemic. It 
occasionally occurs in several members of the 
same family; and cases have been recorded in 
which it was hereditary. In the swampy districts of Bengal, where elephantiasis is 
exceedingly common, especially in the genital organs, its origin is sometimes apparently 
due to malarial influences. 
Of the intimate nature of elephantiasis nothing satisfactory is known. The disease is 
evidently of an inflammatory character, but how this is brought about we are entirely 
ignorant. It has been supposed to be owing to an obstruction of the principal veins of the 
affected parts, impeding the return of blood, and thus creating congestion and irritation, 
followed by plastic exudation in the interstices of the cutaneous and connective tissues. 
From the fact that attacks of erysipelas are not uncommon in the earlier stages of the disease, 
or, rather, that this affection not unfrequently precedes the outbreak of elephantiasis, it has 
been imagined that it is essentially dependent upon the disturbance which it occasions in the 
nutritive and secretory functions of the parts. Others, again, have been led to conclude 
that the malady essentially consists in an inflammation of the lymphatic vessels, attended 
with plastic deposits within and around these vessels, and in the lymphatic glands, whereby 
their caliber is choked up, and, as a necessary consequence, their contents are prevented 
from discharging themselves into the thoracic duct. This view is, on the whole, extremely 
plausible, for it really comprises all the cardinal elements of a consistent theory, which 
the others do not. That there is, in this disease, serious mechanical obstruction of some 
kind or other, is unquestionable, and I know of none that would be more likely to produce 
such a result than compression of the lymphatic vessels. If then, it is allowable, in the 
existing state of the science, to frame a doctrine in respect to the origin of an affection so 
obscure as elephantiasis is acknowledged to be, we may conclude that it is an inflammation 
of the absorbents, attended with obstruction of their caliber, and deposits of lymphoid 
cells, which, becoming gradually organized, are ultimately converted into an analogous 
fibrous tissue, thereby completely changing the character of the primitive structures, 
especially the cutaneous and connective. 
Dissection shows that the epidermis in this disease is very much thickened, rugose, and 
so firmly adherent as to come off with difficulty. The cutis is of a whitish color, striated 
in its texture, and very hard and dense, cutting almost like the rind of bacon. In many 
cases it is from a quarter of an inch to half an inch in thickness. The papillae are enor- 
mously hypertrophied, and of an elongated shape, forming large bodies which stand off 
prominently from the substance of the true skin. The connective tissue is completely 
changed in its character; its areolae are obliterated, and their place is supplied by a 
dense, inelastic, fibroid substance, exhibiting none of the properties of the original, 
interspersed with and occupied by irregular lacunae filled with lymph or stuffed with 
desquamated endothelium. In elephantiasis of the leg, the muscles, compressed by the 
new matter, and deprived of activity, are found to be wasted, pale, and in a state of fatty 
degeneration. The bloodvessels are generally very much enlarged and thickened, and 
hence, when an attempt is made to extirpate the morbid mass, as when it occupies the 
genital organs, tremendous hemorrhage is to be expected. In some cases, however, the 
larger veins are obliterated, especially in elephantiasis of the lower extremity. The 
principal nerves have a white, flattened appearance, and are sometimes apparently aug- 
mented in size, forming true neuromas. Under the microscope the newly formed tissue— 
Fig. 243. 
Elephantiasis of tlie Foot and Leg. CHAP. I. 
ELEPHANTIASIS. 
595 
that upon which the increased volume of the affected parts essentially depends—is found 
to be uniformly composed of free nuclei, cells, and fibres, in every stage of development, 
precisely similar to those of a fibroid tumor, properly so called. The development of lym- 
phoid cells, forming thick sheaths around the vessels, is in some instances very striking. 
The symptoms are variable. Often, if, indeed, not generally, the disease comes on 
suddenly and unexpected, without any apparent local or constitutional cause. At times, 
however, its development is directly traceable to local injury, as a blow, sprain, or contusion ; 
and in quite a number of cases it has seemingly followed upon the protracted immersion 
of the parts in cold water, the occupation of the individual compelling him to pursue 
such a habit. The symptoms are at first of an inflammatory type ; the affected surface, 
red and painful, pits on pressure, and imparts a nodulated, cord-like sensation to the fin- 
ger; the subcutaneous connective tissue is hard and infiltrated ; and the movements of the 
diseased structures soon become stiff, awkward, and embarrassed. Sometimes red lines 
or streaks extend along the course of the lymphatic vessels, as high up as the nearest 
glands, which are themselves more or less tender and swollen. Considerable febrile 
commotion is generally present, but this soon subsides, and the disease gradually lapses 
into a chronic state, which often ceases only with the patient’s life. In the more con- 
firmed cases, fatty degeneration of the other organs occasionally exists. 
The diagnosis of elephantiasis is unmistakable, as there is no other affection which 
bears any resemblance to it. Once seen, it can never be forgotten. The part is not only 
enlarged; but enormously increased in weight and consistence; it feels heavy and cumber- 
some, and is as hard, dense, unyielding, and rough as the leg of the animal from the 
resemblance to which it has derived its name. The surface of the skin, usually much 
darker than natural, is fissured, grooved, nodulated, or tuberculated, and completely 
deprived of its normal sensibility. Sores occasionally form upon it, and, gi'adually 
spreading in diameter and depth, add greatly to the local distress. Sometimes small, 
hard, shining scabs exist, not unlike those of ichthyosis. The chronic march of the dis- 
ease, the remarkable deformity of the affected parts, and the peculiar condition of the skin, 
will always prevent it from being confounded with anasarca, the only lesion which bears 
any resemblance to it. 
The disease, once fully established, may remain stationary for years, or even during 
the remainder of life, or it may go on gradually increasing until the affected parts have 
acquired a volume and a weight many times beyond the natural state. Even under these 
circumstances, however, the suffering is chiefly of a mechanical character, the general 
health often continuing good to the last. It is only, in fact, when intractable ulcers 
form, with an abundant discharge of pus, that the constitution is likely to give way under 
the local drain and irritation. The prognosis is of course most unfavorable in those 
countries where the disease is endemic ; in Europe and the United States, where it 
occurs only as a sporadic affection, very few die of it. 
There is a form of elephantiasis to which the term naevoid is strictly applicable, as it 
consists essentially in an enlargement of the affected parts, caused by the presence of a 
great quantity of dense connective tissue, inlaid with venous structures of a cavernous cha- 
racter, with numerous meshes, not unlike the cavernous structure of the penis, of variable 
size and shape, some being very fine and delicate, and others equal to the volume of a 
small marble. The disease is always congenital, and, like ordinary elephantiasis, is gene- 
rally attended with excessive deformity, its most common site being the lower extremity. 
The skin is thickened, rugose, very dense, and more or less tuberculated. The tumor can 
be diminished by pressure, but immediately returns to its former bulk when the pressure 
is removed. The principal veins and arteries of the part are generally somewhat enlarged. 
The treatment of elephantiasis is, at best, very unsatisfactory, however early it may be 
commenced, or however perseveringly and judiciously it may be conducted. Regarding 
the disease as essentially consisting in inflammation of the lymphatic vessels, or of these 
vessels and the veins, the most rational plan of treatment that suggests itself is the anti- 
phlogistic, of which leeching, blistering, and the application of tincture of iodine are 
among the more important and reliable means. The object, in the first instance, should 
be to reduce local action, in order to prevent subversion of structure. Hence the sooner 
these remedies are applied, the more likely they will be to effect resolution. As a sorbe- 
facient, no article holds out such strong hopes of relief as tincture of iodine, used either 
pure or variously diluted to suit the exigencies of each particular case. It not only pro- 
motes the removal of effused fluids, but produces a powerful revulsive and antiphlogistic 
action, and should be employed, steadily and persistently, for many months together. The 
effects of the treatment will be greatly augmented if the parts be occasionally scarified, to 596 
DISEASES OF THE SKIN AND CONNECTIVE TISSUE. 
chap. x. 
relieve engorgement, kept at rest in an elevated position, and well bandaged, strapped, or 
mechanically compressed. Inunction with very dilute ointment of biniodide of mercury 
also sometimes proves highly beneficial; and, in the earlier stages of the complaint, 
lotions of acetate of lead, chloride of ammonium, and of rectified spirit, are worthy of 
trial, especially when there is much pain, with a tendency to rapid effusion and organi- 
zation. Wh atever the local remedies may be, they should invariably he aided by the use 
of the bandage, renewed twice in the twenty-four hours. I have witnessed good, 
although not permanent, effects from the earth dressing of Dr. Addinell Hewson. 
Constitutional treatment is not to be disregarded. The action of local remedies will 
be greatly promoted by a restricted diet, by the occasional use of a brisk cathartic, and 
by the steady influence of saline and antimonial medicines, with a few grains of calomel 
every night at bedtime, until slight ptyalism is induced. Even general bleeding might 
be advantageously employed at the beginning of the treatment, in persons of a robust 
and plethoric state of the system. 
When the malady has attained an extraordinary degree of development, or has gone on 
tor many years progressively increasing, or has remained stationary for a long time, no 
treatment at present known, not even ligation of the principal arteries of the affected tis- 
sues, will be likely effectually to eradicate the disease, or, more properly speaking, enable 
the parts to resume their primitive condition. All topical and general means are, under 
such circumstances, absolutely unavailing; and the utmost that can reasonably be ex 
pected from cutting off the supply of blood to the part is a diminution of its size, not 
complete restoration of its normal condition. Professor Carnochan deserves great credit 
for the laudable effort he made, in several cases of elephantiasis of the leg, to arrest the 
morbid growth, and ultimately cause its absorption, by ligation of the femoral artery ; 
but, although his patients, three in number, were, from all accounts, much benefited, it is 
questionable whether, in any, a complete cure has been effected. In 1857, I was present 
at the Philadelphia Hospital, when Dr. Campbell, then surgeon-in-chief, performed an 
operation of this kind upon a negro, about fifty years of age, who had long been afflicted 
with this complaint in one of his legs ; but the result was not at all encouraging. I saw the 
man occasionally afterwards for many months, and during my last visit to him, more than 
a year after the operation, the limb had not undergone any material change, either in vol- 
ume or consistence. Indeed, such a procedure could hardly be expected to eventuate 
favorably, when we take into consideration the excessive transformation of the parts and 
the astonishing enlargement of the branches of the femoral artery. The operation might, 
if performed early in the disease, and, if conjoined with the use of sorbefacients and the 
rubber bandage, be worthy of further trial, but its indiscriminate employment is certainly 
not to be commended. Several cases have been reported by Defour, Vanzetti, and others, 
in which a cure of this disease is said to have been effected by diminishing the supply of 
blood in the affected structures by compression of the femoral artery. 
Since Dr. Carnochan performed his first operation for the cure of this affection, in 1851, 
a number of other cases have occurred. Dr. George Fischer, of Hanover, in 1869, pub- 
lished a table of 21 cases, including one of elephantiasis of the neck, face, and ears, of 
which only 4 were positively known to have terminated successfully. Among the failures 
were 3 relapses, 2 deaths, and 1 amputation, on account of gangrene of the limb. Dr. 
Bauer had an instance in which the ligation of the femoral artery was followed by marked 
relief at the time it was reported, several months after the operation. How far these 
cases were benefited by the associated treatment, as compression and sorbefacient lotions 
and unguents, is a point which does not seem to have been well considered. In Dr 
Garnochan’s patient, a Avoman forty-four years of age, affected with elephantiasis of the 
head, face, ears, and neck, only a partial cure was effected by the ligation of both primi- 
tive carotid arteries after an interval of six months. In three cases of elephantiasis of 
the leg treated by ligation of the femoral artery, by Sir J. Fayrer, then of Calcutta, one 
died of pyemia, and in the other two no permanent benefit accrued from the operation. 
Dr. McGraw, of Detroit, was unsuccessful in a similar case. 
In a man, in whom he had five years previously ligated the femoral artery, Dr. T. G. 
Morton, of this city, in 1878, excised an inch and a quarter of the sciatic nerve. Six 
weeks subsequently the leg had diminished in size rather more than one-half, and the skin 
had resumed its natural appearance. As the patient died of pulmonary phthisis at the 
expiration of five months, it is impossible to determine whether the operation would 
have resulted in permanent relief; the limb at the time of death had regained its functions, 
and the continuity of the nerve was found to be reestablished. 
When the diseased mass is very large, greatly incommoding by its weight and bulk, chap. r. 
MORBID GROWTHS. 
597 
and entirely unamenable to treatment, the only resource is removal with the knife. If it 
occupy a limb, amputation will be both safe and easy; but if it involve the scrotum, 
penis, or pudendum, excision may not only be very difficult, but exceedingly perilous, 
life being endangered, in the first instance, by shock and hemorrhage, and afterwards by 
erysipelas, pyemia, and exhausting suppuration. Undue loss of blood may, under such 
circumstances, occasionally be prevented by elevating and firmly compressing the tumor 
prior to the operation. In a case of Arabian elephantiasis in charge of Professor Briggs, 
of Nashville, in 1875, the limb, removed at the hip-joint, weighed eighty-eight pounds. 
The treatment of the naevoid form of the disease must be conducted upon the same 
general principles as that of ordinary elephantiasis. The result is usually unsatisfactory. 
SECT. VIII. MORBID GROAVTIIS. 
The skin is liable to a great variety of morbid growths, some of a benign, others of a 
malignant nature. The ordinary sebaceous tumor and the molluscous tumor have their 
seat in the sebaceous follicles. Lupus is composed of granulation tissue. The hard and 
soft fibromas, and keloid are derived from the connective tissue of the cutis, and sarcoma 
represents embryonic connective tissue. Of the neoplasms, which are derived from the 
higher tissues, myoma and neuroma are very uncommon, and angioma is discussed in the 
chapter on affections of the capillaries. The epithelial formations include warts, moles, 
corns, horns, and epithelioma. Primary scirrhus and encephaloid carcinoma are, so far 
as I am aware, never met with in the skin. 
1. SEBACEOUS TUMORS. 
The sebaceous tumor, essentially consisting of an enlargement of a sebaceous gland 
with the retention of its secretion, has been described under various names, founded either 
upon the character of its walls, the fancied nature of its contents, or the kind of structure 
in which it originates, as encysted, atheromatous, meliceric, steatomatous, and follicular. 
Wen was the familiar appellation by which it was known by the older surgeons. 
The manner in which such a tumor is formed is easily explained. The first link in the 
morbid chain is the obstruction of a sebaceous gland or cutaneous follicle, either in con- 
sequence of adhesive inflammation, or of the inspissated 
condition of its own secretion, thereby offering a me- 
chanical impediment to its escape. The matter, thus 
forcibly retained, gradually increases in quantity, and 
as it does so it necessarily presses everywhere upon the 
walls of the gland, which, in time, expands into a 
strong sac, varying in size from a pea up to a small 
orange. A good illustration of this class of morbid 
growths, as it occurs upon the scalp, is afforded in fig. 
244, from a preparation in my private collection. 
The contents of the sebaceous tumor are extremely 
variable, both in color and consistence: in general, 
however, they are thick and whitish, looking and feel- 
ing very much like a mass of lard or tallow; occasion- 
ally they present the appearance and consistence of 
honey ; and cases are met with in which they bear a 
very close resemblance to putty, or a thick mixture of 
flour and water. Sometimes the contents of a tumor 
of this kind are thin, watery, or oleaginous, and ex- 
ceedingly offensive. 
The sebaceous tumor is sometimes filled, either par- 
tially or completely, with calculous matter, consisting 
of phosphate and carbonate of lime, cemented together 
by a minute quantity of animal substance. A case has 
been recorded in which the integument of the buttocks was completely studded with small 
collections of this description, evidently seated in the skin follicles. Similar formations 
have been observed on the forehead, scalp, nose, shoulders, trunk, and scrotum. 
The cyst of the sebaceous tumor is greatly influenced by age, being generally very thin, 
soft, and delicate in recent cases, and nearly always very thick, tough, and fibrous in old 
ones; occasionally, indeed, fibrocartilaginous, fibroplastic, or even calcified. Externally 
Fig. 244. 
Sebaceous Tumors of the Scalp, one of 
them being laid open to show its Cyst and 
Contents. 598 
DISEASES OF THE SKIN AND CONNECTIVE TISSUE. 
CHAP. I. 
the cyst is rough, and more or less intimately adherent to the surrounding parts, while 
internally it is smooth and glistening, not unlike the inner surface of the dura mater. 
Small sacs are sometimes observed in its interior, and I have occasionally seen indistinct 
partitions thrown across it, so as to give it a kind of multilocular appearance. 
The sebaceous tumor is free from pain, has few vessels, and is generally very tardy in 
its development, except when the cyst remains for a long time uncommonly thin, when 
it may be quite rapid. 1 have never known it to manifest any malignant tendency, 
although occasionally it inflames, suppurates, and even ulcerates, and becomes the seat 
of a very fetid discharge. Under these circumstances granulation tissue may spring up 
from the inner surface of the cyst, and give rise to an irregular fungous mass which simulates 
malignant disease, as in fig. 245, from Bryant. It originally occupies the substance of the 
skin, but, as it increases in size, the cyst gradually pushes its way through, so that the 
connection between them is ultimately completely lost. Meanwhile, the skin itself is 
remarkably attenuated, and often, in great measure, deprived of hair, especially on the 
scalp, where, particularly in cases of long standing, the surface is frequently very hard. 
Here, too, the steady, persistent pressure of such a tumor occasionally indents the skull. 
The degree of mobility of the morbid growth is extremely variable, depending upon 
its age and volume, but, above all, upon the amount and laxity of the connective tissue 
in the structure in which it is developed. Its shape is almost globular, except when 
it is subjected to considerable pressure, when it is always more or less compressed or 
flattened. Its most common sites are the face, forehead, 
and scalp. It is also met with on the neck, eyelid, 
shoulder, back, buttock, and scrotum. I have seen 
two cases of it on the prepuce of small boys who had 
been circumcised according to the rites of the Jewish 
Church. It very rarely occurs on the extremities. 
The number of sebaceous tumors, although usually 
small, is extremely variable. Sometimes there is only 
one, while at other times there may be as many as 
five or six on the same person. In one instance, in 
a man forty years of age, I counted upwards of two 
hundred, mostly upon the head, face and neck, where 
they nearly all made their appearance when he was 
quite young, soon after bathing in cold water. They 
were of the meliceric kind, the contents of many being visible at the enlarged and partially 
obstructed follicle, where they had concreted into a yellowish, dirty, wax-like substance. 
They were of a globular or ovoidal shape, and varied in volume from a pea up to that of 
a hen’s egg. Several cases have come under my observation in which two and even three 
tumors were inclosed in one cyst. 
Childhood and adolescence are the periods of life most liable to these formations. I 
have met with a number of cases in which they existed either before birth, or came on 
soon after. They occasionally occur in several members of the same family; and now 
and then they display an evident hereditary tendency, as in a case under my observation, 
in which the disease existed upon the scalp of a young woman of twenty-seven, and also 
upon that of her father, a paternal aunt, and her paternal grandmother. The tumors 
were, respectively, from four to seven in number, and varied in volume from a marble to 
that of a walnut. Four other instances of a similar character have come under my notice. 
The diagnosis of the sebaceous tumor is sufficiently easy. Its chronic march, indolent 
character, soft, doughy consistence, mobility, and peculiar situation, together with the 
absence of enlargement of the subcutaneous veins, and the normal appearance of the skin, 
always serve to distinguish it from other morbid growths. 
The only remedy for this variety of tumor is thorough excision, not a particle of the 
cyst-wall being left, otherwise there will inevitably be repullulation. When the tumor 
is situated upon the scalp, a single longitudinal incision may be made across it, the flaps 
being dissected off from each side, and the morbid mass lifted out bodily, without exposing 
its contents. In fact, simple enucleation is sometimes sufficient. In most other regions, 
however, the best plan is to lay the tumor open from within outwards, turn out its con- 
tents, and then tear away the cyst. If the integument be diseased, the altered structures 
should be included in an elliptical incision. When a tumor of this kind has been long 
subjected to pressure, a tedious dissection is sometimes required to effect its removal. 
However performed, the operation should never be undertaken without due preparation 
of the system, as I have repeatedly known it to be followed by erysipelas. On one occa- 
sion, I removed a small sebaceous tumor from the back part of the head of a young gentle- 
Fig. 245. 
Fungating Sebaceous Tumor. LUPUS. 
599 
CHAP. I . 
man, the case going on well for the first few days ; then erysipelas set in, and in a short 
time this was followed by an immense carbuncle, which came very near proving fatal. 
The bleeding after such an operation is usually trilling. 
2. MOLLUSCOUS TUMORS. 
The molluscous tumor, or molluscum sebaceum of the dermatologist, is so called from 
its fancied resemblance to the knot so often seen upon the bark of the maple tree. When 
fully developed, it is about the size of a currant, with a central depression, caused by the 
peculiar arrangement of its contents. Usually of a round, oval, elongated, pedunculated, 
or wallet-shape, it is of a soft, spongy consistence, of a red, reddish-brown, or dusky 
yellowish color, and is most commonly met with in adults and elderly subjects, although 
children are by no means exempt from it. Occurring upon various parts of the body, as 
the face, neck, back, shoulders, nates, and extremities, it often exists in such immense 
numbers as to constitute a veritable molluscous diathesis. From the fact that it some- 
times affects several members of the same family, it has been supposed by some to be 
occasionally contagious, or communicable from one person to another by actual contact ; 
an idea which derives countenance from its rapid and consentaneous development in 
some of these cases. Of its predisposing and its exciting causes nothing is known. The 
immediate influence under which it is developed is inflammation of the sebaceous glands, 
leading to a rapid secretion of their peculiar fluid, which, accumulating in their interior, 
presses their walls asunder, and gives them a lobulated appearance, as is rendered evident 
on a section of them. Dr. Beale is of opinion that the growth essentially consists in an 
alteration of the hair follicles and hypertrophy of the dermoid tissues. 
The contents of the molluscous tumor are made up mainly of epidermic scales, in union 
with ovoid, oblong, or cuboid cells, heaped together like a pile of eggs, and occupied 
either by granular matter, oil globules, or a peculiar homogeneous, undetermined substance. 
Left to themselves, molluscous growths are very liable to pass into ulceration, generally 
beginning at their summits, and gradually progressing until their contents are completely 
discharged, when the parts usually readily heal. Occasionally they are invaded by gan- 
grene, which may extend so deeply into the subjacent tissues, as to lead, in the event of 
recovery, to disfiguring scars. Finally, cases occur in which the tumors are atrophied, 
or transformed into little pendulous wart-like excrescences. 
The treatment is best conducted with topical stimulants, of which the most efficacious 
are tincture of iodine, acid nitrate of mercury, sulphate of copper, chloride of zinc, and 
chromic acid, all more or less diluted, the object being to produce a sorbefacient rather 
than an escharotic impression. It will generally be found that brushing the surface of 
the tumor freely once a day with tincture of iodine will not only promptly arrest its 
development, but rapidly promote its removal. Laying open the morbid growth, and 
touching the raw surface slightly with solid nitrate of silver, is sometimes very beneficial. 
The most expeditious method of all, however, more especially if it has a narrow pedicle, 
is to cut it away with the knife, or to strangulate it with the ligature. 
Constitutional treatment is not to be neglected. Occasionally the molluscous tumor 
disappears, in great degree, if not entirely, simply under the influence of a change of air, 
a judiciously regulated diet, and attention to the bowels and secretions. When the 
general health is much disordered, it should be amended by suitable remedies. Cleanli- 
ness is of great importance. When there is a scorbutic state of the blood, iron and 
quinine, with subacid drinks and vegetables, are indicated. Arsenic has sometimes been 
serviceable in the earlier stages of the disease. 
3. LUPUS. 
Lupus belongs to the class of granulation tumors, and arises from an independent 
growth of small cells around the vessels of the cutis. In its earlier stages, the epithelial 
cells of the sebaceous and sudorific glands proliferate as the result of the irritation to 
which they are subjected by the accumulation of clusters of germinal cells in their im- 
mediate vicinity. Hence Rindfleisch declares that the affection is an adenoma of the 
sweat and sebaceous glands. As it progresses, however, and the infiltration of the cutis 
increases, those structures disappear. 
Under the term lupus are comprehended two varieties of disease. In the first, which 
is known as non-exedent lupus, the granulation tissue extends throughout the entire 
integument, and, undergoing the fibroid transformation, converts the skin into cicatricial 
tissue. In the second form, or exedent lupus, the small-celled infiltration breaks down, 600 
DISEASES OF THE SKIN AND CONNECTIVE TISSUE. 
CHAP. I. 
and the skin and adjacent tissues are destroyed by rapid ulceration. The two affections 
are, therefore, identical; the oidy difference being that the non-exedent variety is milder 
than the other, more tardy in its progress, and not characterized by loss of tissue. The 
term lupus, signifying wolf, is suggestive of the destructive tendency of the exedent variety. 
1. The non-exedent, or erythematous, lupus begins as a circumscribed, roundish, swollen, 
red, or violaceous patch, which is covered by fine grayish or yellowish scales of exfoliating 
epidermis. The patch slowly spreads over a large extent of surface, and as it increases, 
the older portions contract, and induce deformity of the features and stiffness in their 
movements, when it occupies the face, which is its ordinary seat. The altered skin may 
remain red, and look like a thin cicatrice ; or the centre of the diseased area may become 
polished, of a livid-white color, and dense and hard, feeling like the rind of bacon, and 
be surrounded by bluish-red nodules or tubercles, of a soft consistence, and covered with 
epidermic desquamation. These nodules indicate the further extension of the disease. 
Erythematous lupus generally comes on without any assignable cause, and soon exhibits 
its peculiar features. It is commonly supposed that a scrofulous state of the constitution 
predisposes to its occurrence, and this is probably true, although in a much less degree 
than has been imagined. My experience certainly does not warrant the conclusion that 
the origin of the disease has generally any such relation ; in most of the cases that have 
come under my observation, the patients seemed to be peculiarly free from strumous 
taint, both as it respected the actual state of their own system, and everything like here- 
ditary transmission. Persons of a delicate, ruddy complexion, with light hair, blue eyes, 
and an unusually active capillary circulation, are most prone to the disease. How far a 
syphilitic taint of the constitution may act as a predisposing cause of lupus has not been 
ascertained; unfortunately, it is seldom in the power of the practitioner to obtain a 
sufficiently accurate account of his cases to enable him to trace, in a satisfactory manner, 
their various relations. 
Although this variety of lupus may occur in any part of the body, it manifests a peculiar 
predilection for the nose, cheeks, and eyelids, especially the latter. It seldom appears 
before puberty; and is most common in females after the age of forty. The general 
health usually remains good; but the altered skin is occasionally the seat of itching or 
burning pain. 
In the treatment of this variety of lupus, none but the mildest and most soothing 
applications should be employed. The one from which I have derived most benefit is the 
dilute tincture of iodine, which, while it changes the action of the secernent vessels, 
promotes the removal of the granulation tissue, and serves as a protective against atmos- 
pheric and other injurious impressions. Brushing over the part once every three or four 
days with a mixture of collodion and glycerine often answers a good purpose ; and benefit 
has also been derived from the application of sapo viridis, tar and mercurial ointment, 
naphthol, and a mixture of twenty grains of crysophanic acid to the ounce of cosmoline. 
If under these measures the patch enlarges and its area is limited, it may be scarified, 
excised, scraped away, or destroyed with the thermo-cautery. 
Along with these topical remedies, special attention must be paid to the state of the 
general health, which is often not a little disordered. The diet should be light, simple, 
unirritant, and chiefly, if not exclusively, of a vegetable character, the drinks consisting 
of water, milk, or weak tea ; the bowels and secretions should be regulated with blue mass 
and ipecacuanha, or blue mass and coloeynth ; and, if signs of debility exist, tonics should 
be resorted to, in combination with alterants, of which the best are quinine and iodide of 
iron, with a minute quantity of bichloride of mercury and arsenious acid. Of late, very 
favorable mention has been made of the use of the chloride of arsenic in the treatment 
of this affection, in doses varying from eight to fifteen drops thrice a day, and a number 
of cases illustrative of its beneficial effects have been reported. Of its efficacy, however, 
I can say nothing from personal experience. When the vital forces are much impaired, 
cod-liver oil and milk punch must be pressed into the service. 
2. The exedent lupus, often described as the serpiginous ulcer of the face, generally 
begins either as small, hard, white, shining tubercles, or as a fissure, crack, or excoriation, 
with indurated edges, and a thin, brownish incrustation. In either case, it soon exhibits 
its characteristic tendency to spread, not in depth, but circumferentially, for it rarely, at 
least in its earlier stages, penetrates beyond the substance of the true skin, or even far 
into that. In fact, it is essentially a superficial ulcer, passing generally from one point 
to another, but seldom involving the deeper structures, except, perhaps, when it appears 
on the ala of the nose, where it occasionally evinces a highly erosive disposition. When 
it effects the eyelids, it may, in time, extend to the fibres of the orbicular muscle, and CHAP. I. 
FIBROUS TUMORS. 
601 
even to the tarsal cartilage, but, in general, it remains limited for years to the skin, or 
skin and connective tissue. The parts around the ulcer are hard, puckered, tender, and 
usually somewhat reddish, although very often they retain their normal color. The ulcer 
is the seat of occasional, darting, stinging, or shooting pain, and of more or less itching, 
generally much more disagreeable than the pain itself. When the crust, which is usually 
very thin, and of a brownish or blackish color, drops off, it is speedily succeeded by 
another of a similar kind. When the surface is thus exposed, it is occasionally found to 
be covered by very red, sensitive granulations, smeared over with thick, yellowish, viscid 
pus, and disposed to bleed on the slightest touch. The edges of the ulcer are usually 
steep, jagged, and slightly everted. As the sore spreads in one direction, it often heals 
in another, leaving a yellowish, hard, and shrivelled scar, strikingly contrasting with the 
surrounding parts. 
The exedent variety of lupus is most common before puberty, a feature which, when 
considered in connection with its liability to coexist in several regions of the body, and 
the. absence of hard, everted edges, serves to distinguish it from epithelioma. The pro- 
bability is that writers often confound this affection with the effects of a syphilitic taint 
of the system, exhibiting itself in the form of one or more superficial, foul, obstinate ulcers, 
which, when the diagnosis is properly understood, always promptly disappear under the 
use of iodide of potassium and bichloride of mercury. 
In the treatment of exedent lupus the same general remedies are indicated as in the 
erythematous variety. Of local measures the caustic agents are always required to arrest 
the progress of the disease and to set up a healthy action. Of late years I have been in 
in the habit of scraping away the diseased tissues, and immediately applying to the raw 
surface either the ethylate of sodium or Esmarch’s powder, which is composed of one part 
each of arsenious acid and muriate of morphia, eight parts of calomel, and forty-eight 
parts of powdered gum arabic. When the eschar drops off, cicatrization is promoted by 
a slippery-elm poultice or water dressing. 
4. FIBROUS TUMORS. 
1. Hard fibromas—Circumscribed fibromas, composed of compact fibrillar connective 
tissue, are occasionally met with in the cutis, especially in young adults ; they usually come 
on without any assignable cause, are always very tardy in their development, and are free 
from malignancy. The most common site of circumscribed hard fibromas of the skin are 
the neck, chest, and shoulder, but they may occur at all points of the body, even upon the 
fingers and toes. Varying in size in different cases, thqy seldom exceed, when attention 
is first called to them, the volume of a hazlenut or an almond; they are of a firm con- 
sistence, dense, and inelastic, creaking under the knife, and exhibiting, when divided, a 
homogeneous appearance not unlike that of an unripe pear or turnip, with but little evidence 
of vascularity. Their surface is generally smooth, or slightly fissured, pervaded by small 
straggling vessels, and somewhat lighter than that of the skin in the substance of which 
they are developed. Movable at first, they manifest a disposition, as they increase in bulk, 
to extend into the subcutaneous connective tissue, to contract adhesions, and to become 
affected with sharp, darting pains, seldom, however, so severe as to cause much annoyance. 
In time, a process of disintegration may be set up in them, eventuating finally in ulceration, 
especially if the part is habitually fretted or compressed. The general health never suffers. 
In the treatment of these tumors nothing is to be expected from sorbefacient remedies. 
So long as they remain inactive, or are so situated as to occasion no inconvenience, they 
may be let alone; when the reverse is the case, they should be extirpated. 
2. Keloid The keloid tumor, so called from its fancied resemblance to a crab, is also 
a peculiar hard fibroma of the cutis, first accurately described by Alibert, in his treatise 
on cutaneous diseases, in 1810. It is characterized by the existence of hard, semielastic, 
prominent ridges, of a cylindrical or rounded form, more or less discolored, and the seat 
of an unpleasant itching sensation. Processes, roots, or branches usually extend from 
it into the neighboring parts, the whole looking very much like the cicatrice of a burn. 
The disease is generally described as being extremely infrequent; but, judging from my 
own experience, this is not the fact. I have notes of at least thirty cases, and many 
more have come under my observation of which I have neglected to keep a record. It 
occurs in all grades of society, in both sexes, in nearly all parts of the body, and at almost 
all periods of life. I have seen it at three years and a half, and repeatedly after the age 
of sixty. A number of my patients were negroes ; but whether they are more subject to 
the disease than whites I am unable to affirm, although this is highly probable. 602 
DISEASES OF THE SKIN AND CONNECTIVE TISSUE. 
CHAP. I. 
The exciting causes of keloid are not always the same. It sometimes arises spontane- 
ously, and is then very liable to show itself in various parts of the body, as if the individual 
was laboring under a veritable keloid diathesis, as in two remarkable examples under my 
observation. In general, keloid succeeds to some local injury, sometimes of a severe, but 
more commonly of a trivial, character, as a scratch, puncture, or abrasion. In four of my 
cases it supervened, respectively, upon the operation of cupping, the application of a 
blister, the contact of nitric acid, and the cicatrices left by smallpox. In another instance 
it broke out upon a vaccine scar. In a young lady of seventeen, it was produced by the 
application of hydrate of potassium, employed for destroying an enlarged lymphatic gland 
of the neck. In several cases it followed upon the extirpation of tumors. Thus, in an elderly 
lady from whom I removed the right mammary gland, two well-marked keloid growths 
came on, soon after the operation, at the site of two small incisions made to ease one of 
the flaps with a view to more accurate approximation ; and the occurrence of the disease 
after the ablation of keloid tumors, both at the line of union of the edges of the wound 
and at the parts transfixed by the pins used for the twisted suture, is familiar to every 
surgeon. The most common causes, however, of keloid, so far as my experience extends, 
are burns and scalds, and I have also seen a considerable number of cases in which the 
disease was directly traceable to the irritation produced by wearing a bad form of ear 
ring. Young negresses are particularly prone to suffer from this source. 
The period which intervenes between the occurrence of the exciting cause and the 
actual development of the disease is altogether uncertain; in many cases it is very short, 
not exceeding a few weeks, or, at furthest, a few months ; on the other hand, however, the 
time is occasionally much longer. In several of my cases the tumors had acquired a large 
bulk in the space of a single year. Once fairly commenced, the disease generally proceeds 
with marked rapidity, especially when it is traumatic; the same is also true, although not 
so generally, when it arises spontaneously. Thus, in an instance recently under my 
observation, an immense number of these excrescences appeared spontaneously upon dif- 
ferent parts of the body within a few months after the first manifestation of the morbid 
action. 
The peculiar external characters of keloid will readily be understood from the annexed 
drawing, fig. 246, taken from a patient of mine, a colored man upwards of fifty years of 
age, whose body was literally cov- 
ered with growths of this kind. They 
were particularly numerous on the 
neck and trunk, both in front and be- 
hind, and also on the shoulders and 
arms, while the forearms, hands, and 
lower extremities were entirely free 
from them. In size they ranged from 
a small Lima bean up to that of a 
sausage from six to eight inches in 
length. They were of all shapes; 
some round orcylindrical, some elon- 
gated and flattened, some angular, 
some crucial, some crablike or full of 
processes, roots, or prongs; in short, 
nature seemed to have exhausted 
her ingenuity in devising figures for 
their representation. The surface 
of nearly all was rough, wrinkled, or 
puckered. Most of them projected 
from a line and a half to an inch and 
a quarter above the surrounding 
level; some were isolated, others ran 
into each other, thereby adding still 
further to their grotesque appear- 
ance. Their consistence varied; 
most of them were remarkably hard 
and firm, feeling very much like a 
mass of fibro-cartilage, with a slight 
degree of the elasticity inherent in that tissue. In regard to their color, while some 
resembled the natural skin, the great majority were several shades lighter. The inter- 
Fig. 246. 
Keloid Tumors. 603 
CHAP. I. 
veiling integument was sound up to the very borders of the keloid tumors, which were 
all distinctly circumscribed, and, with the exception of a very few, slightly movable. 
The disease had begun early in life, but had for years been almost stationary. The man 
was otherwise well conditioned, his general health having all along been excellent; the 
only annoyance which he experienced was an itching or stinging sensation in some of the 
tumors, which, although at times very severe, especially when he labored under constipa- 
tion, dyspepsia, or accidental overheating of the body, did not materially interfere with 
his sleep and other enjoyment. 
In another case of spontaneous, universal keloid disease, in a young gentleman, eighteen 
years of age, a native of Cuba, the general health had always been excellent until twelve 
months previously, and there was no hereditary taint of any description. The tumors 
were, for the most part, of a rounded or oval shape, not very hard to the touch, movable, 
vascular, of a dusky reddish hue, free from pain, and quite tolerant of manipulation. In 
a few situations they formed distinct ridges, from a line to an inch in width, projecting 
prominently beyond the level of the surrounding surface. The hands and feet were cov- 
ered with them, particularly the joints of the fingers and toes; they were also found on 
the legs, knees, buttocks, right arm, and elbow. The general health was somewhat im- 
paired, the youth looked dyspeptic, and he labored under partial paralysis of the left superior 
extremity. 
In white persons the keloid tumor is generally a few shades redder than the adjoining 
skin ; occasionally, indeed, it has a very fiery appearance, and is pervaded by numerous, 
delicate, superficial vessels, in a state of habitual congestion. 
A distinction has been made between keloid tumors by separating them into two varie- 
ties, the true and the spurious. The former, it is alleged, arise spontaneously, whereas 
the latter are always caused by some local injury. Such a division, however, is altogether 
arbitrary, inasmuch as the structure in both of the so-called forms of the disease is per- 
fectly identical. 
Keloid rarely, if ever, degenerates into malignancy. Of all the cases that have come 
under my notice, not one exhibited such a tendency. When excised, however, it nearly 
always speedily returns, rising, like a phoenix, with increased activity, from its ashes; so 
that the second state is generally much worse than the first. In some cases the tumors 
remain completely stationary for a long time, while, in others, they gradually advance until 
they have acquired a considerable bulk, when they usually become passive, and so con- 
tinue for many years. Occasionally, in consequence apparently of prolonged pressure or 
local irritation, they take on ulcerative action. 
In regard to their structure, keloid formations belong to the class of fibrous growths, 
described in the chapter on tumors, although an example is now and then met with in 
which the minute structure is 
very similar to that of spindle- 
celled sarcoma. According to 
Dr. J. C. Warren, of Boston, 
whose investigations have been 
confirmed by Dr. Neumann, of 
Vienna, they are developed from 
the walls of the small arteries of 
the cutis, and, in consonance 
with the arrangement of these 
vessels, the fibres of the tumor 
are all more or less parallel to 
its long axis. The tendency 
which they manifest to recur- 
rence after extirpation is doubt- 
less due to the formation of 
spindle cells in the external 
coat of the arteries, a change 
which extends for some distance 
beyond the limits of the morbid 
mass. The tumor, on section, 
presents to the naked eye a 
whitish, homogeneous aspect, 
or, if the mass is old, very much 
the appearance of an unripe turnip. It creaks slightly under the knife, and is of a dense, 
firm consistence, with very little elasticity. Hardly any vessels are perceptible in its in- 
FIBROUS TUMORS. 
Fig. 247. 
Microscopical Characters of Keloid. 604 
DISEASES OF THE SKIN AND CONNECTIVE TISSUE. 
CHAP. I. 
terior, but the surface of the growth is usually, as already stated, quite vascular, the 
vessels passing over it in distinct lines, more or iess tortuous and varicose in their arrange- 
ment. The minute structure of keloid is well seen in fig. 247, drawn from one of my spe- 
cimens by Professor Da Costa. 
The treatment of keloid is altogether unsatisfactory. So far as I know, there is no 
remedy which exercises the slightest influence in arresting its progress or promoting its 
removal. Sorbefacients and alterants of every description, in every form of combination, 
and in every variety of dose, have been employed, and yet I am not aware of a solitary 
instance in which their exhibition, however protracted, has been followed by a cure. 
The different preparations of iodine, arsenic, chloride of barium, chloride of ammo- 
nium, and kindred articles, so serviceable in some other morbid growths, have all 
signally failed in effecting any beneficial change in this. The excessive itching, burning, 
or stinging, which is a source of such annoyance when the tumors are large or numerous, 
is best relieved, according to my experience, by a proper regulation of the diet, an 
occasional active purgative, the exhibition of the antimonial and saline preparations 
with Fowler’s solution of arsenic, and the frequent use of the tepid bath, either simple, 
or medicated with carbonate of sodium or potassium, salt, or bran. Anointing the tumors 
occasionally with oil, glycerine, or mild pomatum will also prove serviceable. Benzoated 
zinc ointment, or an ointment composed of camphor and chloral, often affords great 
relief. Everything like pressure or local irritation must be carefully guarded against. If 
ulceration arise, only the most soothing remedies should be employed. 
As to excision, my experience is decidedly opposed to it. In the many cases in which 
I have tried it, signal failure has been the result, the disease always recurring at the site 
Fig. 248. 
Fig. 249. 
Molluscous Fibroma. 
of the cicatrice in a short time, in some cases, 
indeed, as I know from ample personal experi- 
ence, within the first four or five weeks. It is 
only when the tumors act obstructingly, as when 
they impede the opening of a natural outlet, or 
become a source of great disfigurement, that in- 
terference should be considered as warrantable. 
Possibly in some cases relief might be afforded 
by a plastic operation, but of this I am not able 
to say anything from personal experience. 
In a case of an immense keloid tumor, en- 
circling the neck, and causing serious inconveni- 
ence by its pressure, in a negro, twenty-eight 
years of age, an inmate of the Philadelphia 
Hospital, the late Dr. F. F. Maury succeeded, after 
three separate operations, in effecting complete 
riddance with the ecraseur, the entire mass weigh- 
ing nine pounds. A number of similar growths 
existed in other parts of the body. The man re- 
coved without a single accident. 
3. Soft fibromas—Under the term mollus- 
cous fibroma., Virchow has described a form of 
cutaneous fibrous tumor, in which the growth, 
composed of a soft, very succulent, loose connective 
tissue, as in tig. 248, from that author, appears 
Molluscous Fibroma. SARCOMATOUS TUMORS. 
605 
CHAP. i. 
to be derived from the fibrous structure of the papillse. Varying in size from a millet 
seed to that of an adult head, the smaller ones are made up of round and spindle-celled 
tissue, while the larger tumors are composed of soft, poorly organized, fibrous tissue. 
The former are seated principally in the superficial layer of the cutis, from which they 
may readily be enucleated. Soft, almost to the point of fluctuation, they are generally 
multiple, covering the entire body, although their favorite seats are the face and trunk, 
giving rise in the former situation to the affection described by the older authors as 
leontiasis. Occasionally congenital, they are free from pain, not contagious, little dis- 
ulcerate, and tardy in their development. 
In its multiple form, molluscous fibroma induces general nutritive disturbances, which 
lead, in the course of time, to death from inanition. Its analogy to nodular elephantiasis 
of the genital organs is very great, the only difference being that the progress of the 
former is unattended with fever and local inflammation. The accompanying sketch, fig. 
249, from a photograph of a Chinaman, kindly sent to me by Dr. J. G. Kerr, of Canton, 
affords an excellent illustration of this affection. 
The treatment of these tumors does not differ from that prescribed for the ordinary 
fibrous growth. When they produce unsightly deformity, or occasion much inconvenience, 
they may be excised. 
5. SARCOMATOUS TUMORS. 
These tumors are uncommon in the skin. Occurring most frequently after the fortieth 
year, they are usually of the spindle-celled variety, and begin as a smooth, firm, elastic, 
reddish, or violaceous nodule, although they are occasionally ingrafted upon a mole, wart, 
or cicatrice, grow rapidly, and may attain a considerable bulk, at length ulcerating and 
becoming the seat of a more or less abundant and fetid discharge. No involvement of the 
lymphatic glands takes place, and the general health does not suffer unless the growth 
assumes malignancy. Recurrence is common after extirpation. 
A case of round-celled sarcoma lately under my care, in a lady seventy-two years of age, 
very well illustrates the clinical nature of this affection. The tumor, about the size of a 
common orange, occupied the inside of the middle of the forearm, where it was first noticed 
about five months before, as a small, hard, movable lump. It rapidly enlarged, and in a 
short time assumed an angry and inflamed appearance, the skin giving way at several 
points, followed by a thin, sanious, offensive discharge, which eventually became very 
abundant and irritating to the surrounding surface, which, to an extent of several inches, 
was habitually red, tender, and deeply congested. There was occasionally a little shooting 
Fig. 250. 
Fig. 251. 
Verrucous Sarcoma. 
Nodule of Melanotic Sarcoma in the True Skin. 
pain in the tumor, but the health was excellent, and the axillary lymphatic glands were 
perfectly sound. A section of the tumor after removal was found by Dr. Keen to be 
composed chiefly of small round and oval cells, with multiple nuclei, and with a moderate 
amount of friable, filamentary intercellular substance. The wound, which was only skin 
deep, healed very kindly, and up to the present time, some months after the operation, 
there is no evidence of recurrence. Verrucous sarcoma, which presents itself as an 
aggregation of enlarged papillae, incrusted with an epithelial covering, as in fig. 250, from 
Liicke, is usually composed of small round cells. 
Pigmented or melanotic sarcoma of the skin, fig. 251, nearly always coexists with melanosis 
in other parts of the body. In a case that was under my observation, some years ago, in 
a man, aged fifty-eight, it involved nearly all the principal organs, and, of course, finally 
proved fatal. In another instance, which I saw in the practice of the late Dr. George 
McClellan, an immense number of melanotic tumors existed in the skin and connective 606 
DISEASES OF THE SKIN AND CONNECTIVE TISSUE. 
CHAP, i. 
tissue of the abdomen, varying from the volume of a small pea up to that of a mass the 
size of a large almond ; they were of a firm, fibro-cartilaginous consistence, slightly 
movable, exquisitely painful, and of a bluish-black color. The remedy in this case was 
excision, a few of the larger tumors being removed at a time ; the operation was repeated 
every ten or twelve days, for several months, when, as but little progress had been made 
towards a cure, the patient became discouraged, and declined further interference. He 
finally died, completely exhausted by the disease. 
When melanotic sarcoma is confined to the integument, and occurs as a circumscribed 
tumor, the proper remedy is early and free excision ; but under opposite circumstances, 
or when it coexists in other parts, or is extensively diffused through the cutaneous and 
connective tissues, all interference of this kind should be avoided, as likely to accelerate 
the fatal crisis. 
6. MYOMATOUS AND NEUROMATOUS TUMORS. 
1. Myoma of the skin, composed of smooth muscular fibres, has occasionally been ob- 
served, as single or multiple growths, in the scrotum, nipple and its areola, trunk, extrem- 
ities, penis, and labia. It is usually pedunculated ; is smooth, hard, and of a rosaceous 
tint; varies in size from a pea to an orange, being generally of the volume of an almond ; 
and grows slowly, and, as a rule, painlessly. The proper remedy is excision. 
2. Neuroma The only cases of neuroma of which I have any knowledge are those 
of Dr. Duhring and Dr. Kosinski. The tumors were multiple and composed of amye- 
linic nerve fibres. In the case of Duhring, numerous small, rounded, and excessively 
painful tubercles were situated upon the shoulder and arm; and excision of an inch of the 
brachial plexus of nerves, by Dr. Maury, was temporarily followed by diminution of suf- 
fering and decrease in the size of the tumors. In the case of Kosinski, the buttock and thigh 
were affected in a similar manner. Removal of an inch of the small sciatic nerve re- 
sulted, at the expiration of four months, in the almost complete disappearance of the 
nodules and the relief of pain. 
7. PAPILLARY TUMORS. 
The morbid growths comprised under this appellation include two varieties, the hard and 
the soft, the first consisting of warts, corns, and horns, and the second of moles and con- 
dylomas, or the excrescences situated about the anus, on the head of the penis and on 
the vulva, in connection with which organs they will be described. 
1. Warts Warts, or verrucous growths, are those peculiar excrescences, or promi- 
nences, so often seen upon the hands and face of young persons, although the old are by 
no means exempt from them. They are outgrowths of the papilla; of 
the skin, which are collected into a circular group, as seen in the ad- 
joining sketch, fig. 251, from Follin, and covered with indurated epi- 
dermis. The intervals between the individual papillae are occupied by 
a large number of transitional cells of the mucous layer of the epider- 
mis. The vessels of the papillae are enlarged and extend close up to 
their extremities. They sometimes occur in such numbers as to con- 
stitute a genuine verrucous diathesis. When this is the case, they are 
not only developed with remarkable rapidity, but are apt to attain an 
extraordinary size. A very painful and disagreeable wart occasionally forms under the 
nail, either in front or at the side. It occurs both on the fingers and toes, although much 
more frequently on the former than the latter. Of the exciting causes of warts nothing 
is known : they are often met with in several members of the same family, and instances 
are observed in which they betray a hereditary tendency. 
A wart is a hard, insensible excrescence, generally of a conical shape, more or less 
movable, and attached by a broad base, although sometimes the reverse is the case, the 
union being effected by a very narrow pedicle ; its surface is rough, fissured, or tubercu- 
lated, and usually a few shades darker than the adjacent skin ; its size seldom exceeds 
that of a common pea. When cut, it is painful, and bleeds somewhat. The fluid which 
follows a section of a body of this kind has been supposed, but erroneously, to be conta- 
gious, or inoculable. A wart of the face, arm, or shoulder sometimes becomes the seat 
of carcinoma, or sarcoma, especially when it is constantly rubbed or irritated. 
The treatment of warts is very simple. In young persons, in fact, they often disappear 
spontaneously. The best local remedy is chromic acid, with equal parts of water, applied 
with a glass brush. It instantly turns the skin black, and forms an eschar, which drops 
Fig. 252. 
Common Wart. CHAP, i. 
PAPILLAEY TUMORS. 
607 
off in six or eight clays, leaving a healthy, granulating sore, which soon heals. Tincture 
of iodine, acetic acid, dilute nitric acid, and sulphate of copper, also answer an excellent 
purpose. When the excrescence is attached by a very delicate pedicle, riddance is easily 
effected with the ligature or scissors. The verrucous diathesis is best counteracted by the 
exhibition of arsenic, or Donovan’s solution. Excision is necessary when a wart displays 
a tendency to malignancy. 
2. Corns—Corns, or clavi, consist in a circumscribed indurated overgrowth of the 
horny layer of the epidermis, the central portion of which is directed inwards towards the 
papilla}. They are caused by irritation of the superficial portion of the dermis and hyper- 
trophy of the papilke; affect different parts of the toes and feet; and are generally pro- 
duced by wearing tight shoes and boots, whereby these organs are habitually compressed 
and even forced out of their natural position. A short, tight stocking occasionally pro- 
duces a similar result. Corns are very variable in regard to their size, form, and consist- 
ence. They are usually distinguished into hard and soft. 
Hard corns are dry, scaly, insensible callosities, occurring mostly on the dorsal sur- 
face of the toes, opposite the middle joints. All these structures are occasionally affected, 
but the great and little toes suffer much more frequently than any of the rest. These 
bodies are met with also in the sole of the foot, in the hollow or arch, and on the under 
part of the heel. Occasionally a very hard corn is found under the nail of the big toe, 
or between the nail and the fleshy part of the toe. 
A hard corn, when fully developed, is lamellated, firmer at the centre than at the peri- 
phery, and furnished with a kind of central nucleus, core, or blunt cone, of a whitish, 
horny appearance, not unlike the eye of a fowl. A small, but distinct burse, containing 
a minute quantity of serous fluid, and sometimes a drop of blood, is almost always inter- 
posed between it and the dermis, the papilke of which are depressed, diminished in num- 
ber, or entirely destroyed. These apppearances are well shown 
in the adjoining sketch, fig. 253, from Follin. The hard corn 
consists of many layers with their convexities turned downwards ; 
it is commonly of a circular shape, is either fixed or movable, 
and varies in size from the head of a pin to that of a dime. In 
many cases it has a kind of radiated root. 
The hard corn, from a continuance of the pressure by which 
it is produced, becomes gradually a source of pain and tender- 
ness, which are much increased by exercise, and are often accom- 
panied by heat and swelling of the whole foot. In time the burse 
under the horny cuticle inflames, and pours out an unusual quan- 
tity of fluid, which distends the sac, and thus greatly aggravates 
the suffering. When matter forms, the pain becomes excruciat- 
ing, the slightest touch is intolerable, and the patient is unable to use the limb. In such 
cases the lymphatic vessels are sometimes inflamed as high up as the groin. 
Soft corns are always situated between the toes, usually opposite a joint or at their 
angle of union, and derive their characteristic features from being in a constant state of 
moisture, from the perspiration which collects between these parts; they are usually su- 
perficial, and are produced by wearing narrow-soled shoes, by which the toes are habitu- 
ally squeezed together, bent at their articulations, or forced over or under each other. For 
this reason ladies are more subject to this variety of corn than men or the poorer classes 
of females. The soft corn is of a circular or oval figure, of a whitish, yellowish, or gray- 
ish color, with a radiated or horny-looking nucleus, and is seldom larger than a split-pea 
or half a dime. Occasionally it is broad, oblong, flat, and of a dark color, from the pre- 
sence of extravasated blood. In some instances, especially in old people and in cases 
of long standing, the corn is very hard at the centre, has a small synovial burse, and con- 
sists of several distinct layers. From being constantly compressed, it is very painful, and 
remarkably prone to inflammation, suppuration, and even ulceration. 
The treatment of corns consists in scraping away the thickened cuticle, and lightly 
touching them with nitrate of silver, or tincture of iodine, repeated occasionally until the 
cure is completed. This may be greatly expedited by washing the feet night and morning 
with cold wrater and soap, and afterwards rubbing them well with a soft, dry towel. The 
shoe, which should have a low, broad heel, should be accurately adapted to the shape of 
the limb, and all undue pressure carefully avoided, even from the seam of the stocking. 
When the toes are much deformed, or incurvated, they are to be kept apart by pledgets 
of lint, a piece of soft sponge, or strips of adhesive plaster passed from one to the other. 
When this cannot be done from their fixed position, amputation may become necessary. In 
Fig. 253. 
Structure of a Corn. 608 
DISEASES OF THE SKIN AND CONNECTIVE TISSUE. 
CHAP. i. 
some instances it is useful to make the patient wear a stocking constructed on the princi- 
ple of a glove, each of these stockings having a separate stall. A shoe made of buckskin 
or cloth sometimes affords great relief. 
When corns are very tender, they should be frequently scraped with a blunt knife, and 
kept constantly covered with a piece of soap plaster, or a bit of linen spread with simple 
cerate to prevent them from becoming hard and dry. In some instances the pressure may 
be warded off by letting the corn project through a hole in the plaster, which ought then 
to be very thick, or consist of several layers. When the corn is seated in the sole of the 
foot, and this treatment is employed, it must be first covered with a piece of adhesive 
plaster, otherwise the weight of the body will cause the skin to project into the opening, 
and thus produce severe pain in walking. Occasionally it is necessary to cut a hole in the 
boot or shoe, or to wear a felt sole with a hole in it, to protect the corn from pressure and 
friction. All these means, however, are merely palliative, and, when they fail, nothing 
short of complete eradication will answer. The operation, which is seldom painful, is 
performed with a small narrow-pointed scalpel and pair of forceps, care being taken not 
to injure the sensitive skin beneath, and to soften the corn by previous immersion in 
warm water. When an abscess forms, it should be opened as speedily as possible, after 
which the offending part may be removed, or this may be postponed to another day. 
Sometimes the matter escapes by ulceration, leaving a fistulous sore with thick, irregular 
edges, and constantly bathed with a thin, ichorous fluid. In such a case nitrate of silver 
constitutes the best remedy. 
When corns are inflamed, they cannot be treated with too much care, since, if neglected, 
they may give rise to serious mischief. The foot should be kept perfectly at rest, and it 
may even be necessary to resort to leeches 
and medicated fomentations. The knife 
should be used most cautiously. Several 
instances have fallen under my observa- 
tion in which the cutting of an inflamed 
corn was followed by violent erysipelas and 
mortification ; and numerous cases are re- 
corded in which these diseases, thus occa- 
sioned, have caused death. 
3. Horns The horny tumor, or kera- 
toma, is met with principally in those 
regions of the body which abound in papillm 
and sebaceous follicles, as the face and 
forehead. Of seventy-one eases collected 
by Villeneuve, not less than thirty-one 
occurred in these situations. They have 
been found on the lips, the ear, the penis, 
and the scrotum. I have in a number of 
instances seen well-marked horn-like ex- 
crescences on the free extremity of the 
stump after amputation. Several such 
growths are sometimes observed in the 
same person. Although they are most 
common in elderly subjects, I have met 
with two cases in children under ten years 
of age. They seem to occur with nearly 
t equal frequency in both sexes. 
The size, shape, color, and consistence 
of the horny tumor are subject to much 
diversity, depending on its age, and other 
circumstances. A length of three to six 
inches by half an inch to an inch in 
diameter, as in fig. 254, is by no means 
uncommon. In the British Museum there 
is a growth of this description, eleven 
inches in length by two and a half in 
circumference; and examples of a still 
more remarkable nature have been reported by authors. In that curious book, An Essay 
for the Recording of Illustrious Providences, by Increase Mather, are briefly mentioned 
Fig. 254. 
Horny Excrescence growing from the Scalp. CHAP. I. 
PAPILLARY TUMORS. 
609 
the particulars of the case of a “ man that has an horn growing out of one corner of his 
mouth, just like that of a sheep; from which he has cut seventeen inches, and is forced 
to keep it tied by a string to his ear, to prevent its growing up to his eye.” 
The shape of these excrescences is usually conical, being larger at their adherent than 
at their free extremity, which is always somewhat tapering, and their direction is either 
spiral, twisted, or bent, very much like the horn of a sheep. In a case recorded in the 
New York Medical Repository for 1820, an enormous growth of this kind, measuring 
fourteen inches in circumference at its shaft, consisted of three distinct branches. The 
surface is generally marked by rough, circular rings, indicative of the successive steps of 
their development. Now and then it is imbricated, knobbed, or covered with small 
pearl-colored scales. In color the excrescences vary from a dingy yellow to a dark grayish, 
brown, bronze, or black, according to their age, and the amount of 
their exposure. They are more or less flexible, and of a firm, fibro- 
cartilaginous consistence. Their internal arrangement, as seen on a 
section, is longitudinally lamellated, as in fig. 255. 
When burned, these formations exhale a characteristic animal odor. 
They are chiefly composed of albumen, in union with a small quantity 
of mucus, phosphate of lime, and chloride of sodium, with a trace of 
lactate of soda. On the addition of acetic acid, numerous epidermic 
scales become apparent, with all the characteristic properties of such 
structures. Under the microscope, the minute texture of these growths 
exhibits epithelial cells, which, accordingto Sir Erasmus Wilson, are of 
a flattened shape, closely condensed, and, here and there, fibrous in 
their arrangement. They are somewhat larger than those of the 
epidermis, and possess nuclei, for the most part of an oval shape, their 
long diameter measuring the short of an inch. The average 
size of the flattened cells is about five times greater than that of the 
nuclei. 
II liman horns are generally connected with hypertrophied papilke, in which they pro- 
bably take their rise. Their development is frequently directly traceable to the effects of 
chronic inflammation, or external injury, as a burn, wound, or contusion. When first 
observed, they are quite soft, semitransparent, and invested by a distinct cyst, which, 
extending over their base, is gradually and insensibly lost upon their trunk. Very soon, 
however, they become hard, and, assuming a darker iiue, thus acquire the veritable pro- 
perties of the horny tissue as it exists in the inferior animals. Their growth is always 
very tardy. 
Although these excrescences sometimes drop off spontaneously, a cure rarely, if ever, 
follows such an occurrence ; for, as the matrix remains, it soon becomes the starting-point 
of a new growth, which, pursuing the same course as its predecessor, may eventually 
acquire a similar, or even a greater, bulk. The proper remedy is extirpation, the whole 
of the epigenic cyst being included in two elliptical incisions, the edges of which are 
afterwards carefully approximated by suture and adhesive strips. When the operation 
is thoroughly executed, there is no chance of a recurrence of the morbid product. 
4. Moles—Moles, or fleshy warts, are congenital spots, occurring upon various por- 
tions of the external surface of the body, usually of a dark, grayish, blackish, tawny, or 
brownish color, and closely covered with short, thick, almost bristly hairs. They pro- 
ject somewhat above the surrounding level, are. usually a little harder than the natural 
skin, and are of various forms, of which the round and oval are the most frequent. Some 
persons are remarkably liable to the formation of moles, and it is then not uncommon to 
see them scattered over different parts of the body. The face, shoulder, neck, and arms 
are their most frequent seats. In size they range from a three-cent piece to that of a 
dinner plate. 
These spots are due to pigmentation of the soft mucous layer of the epidermis and of 
the dermis, with hypertrophy of the latter and its papillae, and hyperplasia of the hair 
follicles. 
Long-continued local irritation, as that caused by friction, pressure, or want, of cleanli- 
ness, may occasion ulceration in these bodies, but generally they remain perfectly station- 
ary and innocuous. Not long ago, I excised from the back part of the arm of a gentleman 
of upwards of eighty a mole which had been a source of annoyance to him for thirty years. 
It had latterly become ulcerated, had often bled, and was the of a very fetid discharge. 
It was included in an elliptical incision, the parts healing kindly, and there being no return 
Fig. 255. 
A Section of a Horn, 
showing its Lamellated 
Structure. 610 
DISEASES OF THE SKIN AND CONNECTIVE TISSUE. 
CHAP. I. 
of the disease. Moles, like healthy structure, may take on malignant action, the most 
common of which is the epithelial. 
Moles only become the subjects of surgical interference when they cause serious disfig- 
urement, or when they pass into ulceration. It has been proposed to get rid of them by 
mild caustic applications, as Vienna paste, chromic acid, or chloride of zinc ; but as such 
a procedure might be followed by keloid, the best plan always is to use the knife, the 
morbid structures being included in an elliptical incision, the edges of which are afterwards 
healed, if possible, by the first intention. 
8. EPITHELIOMA. 
Epithelioma of the skin differs from epithelial carcinoma of the mucous surfaces or of 
the junction of the latter with the integument in being, as a rule, superficial or more 
disposed to extend along the surface than to infiltrate the deeper tissues. The affection 
may be divided into two varieties, which differ widely in their clinical features and in the 
amount of destruction of the structures involved in the morbid action. They are known 
as cicatrizing epithelioma and rodent ulcer or cancer. 
1. The cicatrizing epithelioma,, a term which is synomynous with fressende fleclite of the 
German authors and with the lepoid of Dr. Warren, the latter name having been applied 
to it from its resemblance to the bark of a tree, is most generally observed upon the face, 
nose, and forehead of elderly persons, usually males, of a delicate, florid complexion, with 
an habitual tendency to congestion of the capillary vessels, light eyes, and light brown, or 
reddish hair. Although occasionally single, I have more commonly found it to be multiple. 
In some instances, indeed, quite a number of spots are observed, scattered about in differ- 
ent directions, with intermediate healthy skin. It generally makes its appearance in the 
form of a small, circumscribed speck, not larger, perhaps, than a mustard seed, and of a dirty, 
grayish color, which becomes covered with a very rough, brownish crust or scale. This, 
falling off, is soon succeeded by another, of the same complexion, form, and consistence. 
Thus the disease is often kept up for many successive years. At last, however, super- 
ficial ulceration sets in, and the dermis is converted into a red, glossy, retracting cicatricial 
tissue, covered with a thin layer of epithelium. The progress of the disease is attended 
with hardly any pain ; but the patient is generally very much annoyed by itching, leading 
to an irresistible desire to scratch, which always aggravates it. 
The precise derivation of cicatrizing epithelioma is undetermined, although it is highly 
probable that the morbid action is confined to the superficial stratum of the mucous layer 
of the epidermis. 
The best remedy for this disease is non-interference. The rough, bark-like scale may 
occasionally be softened with a little dilute citrine ointment, or covered with a mixture of 
two parts of collodion and one of castor oil, to serve as a defence from the air. All irri- 
tating applications must be refrained from. If the disease is inclined to spread, the tissues 
may be destroyed with the Vienna paste, or removed with the knife, although it will gen- 
erally be best to avoid all operative interference, as it is likely to aggravate the case by 
an early recurrence of the formation. 
2. Rodent idcer, Jacob’s ulcer, cancroid, noli me tangere, flat or superficial epithelial 
carcinoma, is the phase of epithelioma, which in all probability is derived principally from 
the external root-sheath of the hair follicles or the involuted continuation of the mucous layer 
of the epidermis. The cells are smaller than those found in ordinary epithelioma ; they 
do not evince signs of activity and proliferation ; and they grow into the connective tissue 
of the cutis in the form of solid, anastomosing plugs or cylinders. When the new struc- 
ture is fully developed, concentric globules of corneous epithelium are occasionally found 
in the plugs, as is well represented in fig. 256, from Dr. J. Collins Warren. 
Iiodent ulcer generally begins in the form of a hard nodule, pimple, or warty excres- 
cence, which, after perhaps an existence of several years, ulcerates superficially and becomes 
covered with a crust. As the infiltration of the tissues progressively advances, the scab 
drops off, and leaves an ulcer which has a depressed or excavated appearance, with hard, 
raised, and rolling edges, and a mammillated bottom, composed of small, indurated granu- 
lations. There is little secretion, and at the advancing borders of the sore the orifices 
of the sebaceous glands, plugged by sebum, are very distinct. The progress of the 
disease is generally very slow; or the malady, after having evinced a most destructive 
tendency, may suddenly stop, with all the appearances of a complete cessation of hostilities. 
A case has been reported to me where the morbid action, after having destroyed the greater 
portion of one cheek, with the corresponding antrum, has remained in a state of abeyance CHAP. I. 
INSECTS IN THE SKIN AND CONNECTIVE TISSUE. 
611 
for the last ten years, although it had been steadily pursuing its course for upwards of 
fifteen. Its march is occasionally remarkably rapid, great mischief being done in a few 
Fig. 256. 
Vertical Section of Bodent Ulcer—a, Stroma—5, Epithelial globes. 
months, being attended with the most frightful ravages and the most disgusting de- 
formity. Thus, it may consume the whole of the nose, one cheek, the chin, the orbit, and 
forehead, and even extend to the dura mater and the 
brain, as in fig. 257, taken from a patient of Mr. Ericli- 
sen. 
The affection progresses by destroying its own margins 
and by invading the continuous and the contiguous tis- 
sues ; and as it advances there is often a tendency on 
the part of the older portion of the ulcer to cicatrize. 
During its course it appears to obliterate the bloodves- 
sels and the lymphatics, so that the lymphatic glands and 
the viscera are never the seats of secondary tumors. 
Rodent ulcer is a disease of advanced age. It evinces 
a remarkable predilection for the upper part of the face 
and head, its favorite situations being the cheek, the side 
of the nose, the eyelids, and the temple. The pain is 
generally slight; but now and then it is severe, being of 
a sharp, biting, darting or shooting character, and liable 
to temporary exacerbations from exposure, and atmos- 
pheric vicissitudes. The general health, at first entirely 
sound, becomes seriously affected during the progress of 
the disease; the appetite and sleep are impaired; the 
strength declines; marasmus gradually ensues; and the patient, worn out by suffering, 
finally dies completely exhausted. 
The great object in the treatment of rodent ulcer is to arrest the. morbid action, either 
with the knife, or with some suitable escharotic, as the acid nitrate of mercury, chloride 
of zinc, Vienna paste, or Esmarch’s powder. Excision, as a rule, deserves the preference. 
The operation should be performed as early as possible. Sometimes the actual cautery 
may be employed with advantage, its action being, seemingly, of a more repressive char- 
acter than that of the knife. When an extremity is involved and the bone is invaded, 
amputation should be resorted to. The constitutional remedies are limited to anodynes 
and supporting measures, since internal agents are not of the slightest service in arresting 
the progress of the affection. 
SECT. IX INSECTS IN THE SKIN AND CONNECTIVE TISSUE. 
The skin and connective tissue are liable to be infested by certain insects, which, al- 
though not poisonous, may induce serious suffering, especially in persons of a nervous, 
irritable temperament. I refer more particularly to the chigoe and the Guinea worm. 
The chigoe, which is very common both in this country, South America, and the West 
Indies, is a little insect, scarcely half the size of the smallest pin-head, which penetrates 
Fig. 257. 
Bodent Ulcer ; Perforation of Skull and 
Exposure of Dura Mater. 612 
DISEASES OF THE SKIN AND CONNECTIVE TISSUE. 
CHAP. i. 
the skin of the hands and feet, as well as of other exposed parts of the body, for the pur- 
pose of sustenance and hatching. It is a species of flea, with a rostrum as long as the 
body, of a pale-brownish, semitransparent appearance, with legs of a light lead color, 
which often deposits its eggs in immense numbers. The first effect is an itching sensation, 
which is soon followed by heat, redness, and swelling, and, ultimately, by an ugly, irri- 
table, spreading ulcer. If the part, when it has attained this stage, be carefully exam- 
ined, it will be found to contain a cyst, about the size of a pea, and of a bluish color, in 
which the ova live and multiply with astonishing rapidity. When a number of chigoes 
penetrate the skin together, the suffering produced by them may be so great as to cause 
violent constitutional disturbance, and even death. 
The treatment consists in picking out the insect and its eggs with a fine needle, care 
being taken not to rupture the cyst, otherwise the young brood may produce further mis- 
chief. Clearance having been effected, the part is well washed with salt water, tobacco 
juice, or spirit of turpentine, and thoroughly painted with dilute tincture of iodine. The 
female slaves in the West Indies are said to extract these insects with great dexterity. 
The Guinea worm, or little dragon, technically called filaria medinensis, also buries itself 
in the body. It is chiefly met with in tropical countries, particularly in Egypt, Arabia, 
Persia, Abyssinia, and Guinea, the inhabitants of which are often sorely afflicted by it. 
Of a white color, and of a filiform shape, it has an orbicular mouth, and a slightly pointed 
tail, its usual length being from five to twenty inches, and its thickness that of a small 
violin string. Its ordinary abode is the subcutaneous connective tissue of the feet and legs, 
although it is also found in other parts of the body, as the scalp, face, neck, scrotum, hands, 
and arms. It is commonly coiled up circularly, and is inclosed by a distinct cyst, which 
thus separates it from the surrounding parts. The animal enters the skin when quite 
young, and gradually increases in size, exciting intolerable itching, inflammation, swell- 
ing, and suppuration, often attended with fever, and sometimes followed by gangrene. 
The precise situation of the worm is generally indicated by a kind of boil, or a hard, 
ridge-like elevation. When ulceration sets in, the head of the creature usually protrudes 
at the opening, thus confirming the diagnosis of the case. 
In the treatment of this affection, the proper plan is to cut down at once upon the part 
and extract the intruder. It is worse than useless to waste time in the application of 
leeches, liniments, and embrocations, which, so long as the cause of irritation lies buried 
under the skin, can produce none but the most transient effect. If the tumor is already 
open, and the head of the animal is protruding, extrusion may be promoted by gentle 
traction. 
SECT. X. AFFECTIONS OF THE HAIRS. 
The principal affections of the hairs, surgically considered, are hypertrophy and atrophy. 
Hypertrophy presents itself in several varieties of forms, as well as of situation, as in 
excessive length of the hair on the scalp, beard, or pubes, in extraordinary numbers, or in 
places which are naturally destitute of it. A redundant development of hair now and 
then occurs on the forehead, face, or neck. A male child, four months old, was brought 
to the College Clinic, in I860, the greater portion of whose forehead, on the left side, 
was thickly covered with long hair, of the same color precisely as that of the scalp. The 
corresponding eyebrow was very heavy, and the countenance exhibited altogether a very 
singular appearance. In the female, hypertrophy of the hair occasionally exists in the 
form of a strong beard, nearly, if not quite, equal to that of the male. The affection is 
most common in barren women, of masculine figure and erotic temperament. An acci- 
dental development of hair is not unusual. Moles, certain ntevi, and congenitally hyper- 
trophied skin, are often covered with hair. 
A redundant growth of hair becomes an object of treatment only when it occupies a 
part of the body that is naturally exposed to observation, as the forehead, face, or neck. 
The principal remedies are excision and evulsion. The former is more particularly appli- 
cable when the affected surface is of very limited extent, as in the case of a congenital 
mole, or an inconsiderable hypertrophy of the integument. Evulsion is effected with the 
tweezers, one hair after another being pulled out by the root. The operation, however, 
is not only painful, but seldom successful, inasmuch as the formative organ still remains, 
and there is, consequently, a constant reproduction of the hair. The same is true of the 
use of depilatories, formerly so much in vogue in the treatment of this affection. Most 
of these preparations are powerful caustics, their active ingredients consisting of quicklime 
and arsenic, in the form of orpiment, and hence, if great care be not observed in their CHAP. II. 
MUSCLES. 
613 
management, their destructive influence may extend much more widely than is desirable. 
Besides, if employed superficially, the hair bulbs will necessarily remain intact, and thus 
in a short time the new growth will be likely to be as vigorous as the original. 
In the case of the child above alluded to, where the redundant hair occupied a large 
portion of the forehead, I dissected away the entire mass by carrying my knife through 
the substance of the skin, sufficiently deep to include the hair bulbs, and had the satis- 
faction to effect a complete cure. Very little bleeding attended the operation, and no un- 
pleasant effects followed. The resulting scar was very trifling. 
Atrophy of the hair and depilitation are natural consequences of advancing age, and of 
certain diseases, as typhoid fever, scarlatina, porrigo, psoriasis, and secondary syphilis. 
The falling of the hair is often temporary, and then probably depends upon some transient 
affection of the piliferous follicles. Baldness of the scalp generally begins at the crown 
of the head, whence it slowly extends in different directions, the hair bulbs gradually 
wasting and disappearing. I have seen five cases of secondary syphilis in which, in the 
course of a few months, every hair of the body dropped off, and was never reproduced. 
The baldness is sometimes congenital, as in the case of a child, four years of age, a patient 
of mine, whose entire body was destitute of hair. 
The treatment of depilitation must be conducted with special reference to the nature 
of the exciting cause ; for so long as this continues in operation little progress can 
be made towards a permanent cure. The general health, if at fault, must be amended, 
and the suffering surface excited with stimulating lotions, as solutions of zinc, copper, 
tannic acid, iodine, and nitrate of silver. The use of iodide of potassium in union 
with bichloride of mercury is indicated when there is a syphilitic taint of the system. 
In gradually gravescent baldness of the head, great benefit often accrues from cutting 
the short, stunted, and broken hair once a month close to the scalp. The operation 
imparts a new impulse to the piliferous follicles, and is frequently followed by great and 
permanent improvement. 
CHAPTER II. 
DISEASES AND INJURIES OF THE MUSCLES, TENDONS, BURSES, AND APONEUROSES. 
SECT. I MUSCLES. 
The muscles are liable to wounds and lacerations, inflammation, atrophy, hypertrophy, 
and different kinds of transformations, especially the fatty, which occasionally exists in 
a very high degree, and over a considerable extent of the body. They are also subject 
to some of the morbid growths, and to the development of hydatids and serous cysts. 
1. Wounds—When a muscle is divided by a sharp instrument, or accidentally 
ruptured, its fibres immediately retract so as to drag the edges of the wound more or 
less widely asunder. The extent to which this separation may be carried varies, in 
general, according to the length and thickness of the muscle, from a few lines to as 
many inches. In transverse fractures of the patella, the action of the straight muscle 
of the thigh often draws the superior fragment from three and a half to four inches 
away from the inferior; and it is reasonable to conclude that fully as extensive a gap 
would be produced between the ends of this muscle if it were cut in two, or torn 
asunder. In rupture of the straight muscle of the abdomen, the edges of the subcutane- 
ous wound have repeatedly been found to be separated from an inch and a half to two 
inches. In the operation for the cure of strabismus, the retraction of the posterior ex- 
tremity of the divided muscle is seldom less than from four to six lines, and often even 
considerably more. 
The above facts are highly interesting in a practical point of view, inasmuch as they 
point out the propriety of adopting prompt and energetic measures for effecting and 
maintaining apposition of the ends of the divided muscle ; for observation has shown that 
the more accurate this is the more speedy and perfect will be the cure. If the edges are 
brought fully and intimately together, the union will necessarily require but a small 
quantity of plastic matter for its early and complete consolidation. If, on the other hand, 614 
DISEASES OF MUSCLES AND THEIR APPENDAGES. 
CHAP. II. 
the gap amounts to several inches, either no union will occur, or it will be effected 
through the intervention of a large quantity of fibrous tissue, possessing none of the 
properties of muscular fibre. Hence the affected structures must always remain propor- 
tionately weak and disabled. But this is not the only inconvenience that follows such 
an accident; in wounds of the abdominal muscles, for example, the gap is sure to give 
rise to hernia, and it is easy to see that a deficiency of this kind elsewhere would hardly 
be productive of less serious effects. The only rational remedy under such circumstances, 
is the thorough union of the divided ends of the muscles by sutures, metallic ones being 
the best. 
2. Laceration Rupture of the muscles is often produced by very trifling causes, the 
most common of which are leaping, or jumping across ditches or over fences, lifting heavy 
weights, or falls from a considerable height, in which the person makes a powerful effort 
to ward off injury. Cases are upon record of women having lacerated the abdominal 
muscles during parturition. Injuries of this kind are most likely to happen, other things 
being equal, when a muscle has undergone the fatty degeneration, which, by rendering 
its fibres soft and lacerable, acts as a powerful predisposing cause of rupture. Long-con- 
tinued inactivity of a muscle, followed by sudden and violent contraction, may be mentioned 
as another predisposing cause of the accident. 
The muscles which are most liable to rupture are the straight muscles of the abdomen, 
the psoas, deltoid, the two-headed flexor of the arm, the straight femoral, and the 
gastrocnemius. 
The place where the rupture usually occurs is near the junction of the fleshy fibres with 
their tendons ; but occasionally a muscle may give way at its middle, or, in fact, at almost 
any portion of its extent. In twenty-one cases of this affection analyzed by Sedillot, the 
rupture, in thirteen, took place at the insertion of the fleshy fibres into their tendons, while 
in the remainder it was seated in the body of the muscle itself. The laceration is some- 
times limited to a few fibres ; at other times it involves the entire thickness of a muscle, 
or of a muscle and its aponeurotic envelop. Finally, cases occur in which a number of 
muscles are ruptured. 
The symptoms are not always well marked, especially when the affected muscle is deep- 
seated. In general, it may be assumed that such an accident has occurred, if, at the 
moment of some violent bodily exertion, as in leaping a ditch or fence, the individual 
hears a distinct noise or snap, like the crack of a whip, feels severe pain in some 
particular spot, and either falls, or has but an imperfect use of himself. Upon examining 
the suffering part, a vacuity will probably be noticed at one point, and an unusual 
prominence at another, followed by more or less discoloration and tenderness under 
manipulation. Occasionally the accident is attended with considerable hemorrhage, from 
the rupture of some of the smaller vessels. The pain is often very sharp, and rarely 
entirely disappears until after the primary effects of the lesion have measurably passed off. 
Temporary lameness and inability to move about for some time are, generally, the only 
serious consequences to be apprehended from this accident, provided it is properly managed 
immediately after its occurrence. In most cases, a considerable period must necessarily 
elapse before the reunion of the torn structures will be sufficiently firm to justify their 
accustomed use. Occasionally violent symptoms supervene; and an instance has been 
reported to me of a young man who lost his life from rupture of the psoas muscle, death 
having been preceded by severe inflammation and infiltration of pus. 
The treatment of this lesion cannot be the same in all cases, or under all circumstances. 
Whenever it is practicable, from the superficial situation of the affected muscle, its ends, 
whether cut or ruptured, should be freely exposed, and then carefully approximated by a 
sufficient number of stitches to hold them in contact until firm union has been established. 
For this purpose the threads should be carried nearly through the entire thickness of the 
muscle, the object being thorough apposition both of the superficial and deep portions of 
the wound. In case the muscle has been ruptured, the edges of the wound may be so 
ragged as to require some retrenching before placing them in contact, precisely as in a 
lacerated wound of the integument. If the precaution of stitching the parts be neglected, 
the results above adverted to will be inevitable, and it is, therefore, impossible to insist 
too strongly upon the importance of attention to this rule, which is so much neglected by 
surgeons. 
The parts, being properly approximated, are next placed in an easy, elevated, and 
relaxed position, splints and bandages being employed for this purpose, if necessary, and 
they are then treated upon general antiphlogistic principles. If the ruptured muscle is 
deep-seated, our chief reliance must be upon rest and relaxation, conjoined with soothing CHAP. II. 
MUSCLES. 
615 
and astringent applications, along with suitable internal remedies, to moderate the result- 
ing inflammation. In laceration of the muscles of the extremities, important advantage 
may always be obtained from the use of two rollers, applied in opposite directions, as 
the ends of the wound may thus not only be more effectually approximated, but the con- 
traction of the fleshy fibres more easily controlled, than in any other manner. 
3. Inflammation—Inflammation of the muscles, or myositis, occurs in two varieties of 
form, the acute and chronic; both, however, are uncommon, and are chiefly observed as 
consequences of external injury, as blows, wounds, or contusions, such as are met with in 
fractures and dislocations; or as effects of gout and rheumatism. The sheaths of the mus- 
cles very frequently, if not generally, participate in the morbid action. When the inflam- 
mation is at all severe, considerable effusion of serum and lymph may take place, but it is 
seldom that the disease runs into suppuration, much less mortification. The latter termi- 
nation is chiefly met with in erysipelas and carbuncle, in old, worn-out subjects, and in 
persons of different habits and conditions after violent external injury. It is easily recog- 
nized by the dark, greenish color of the fleshy fibres, by their softness and lacerability, and 
by their excessively fetid odor. The parts are detached in ragged shreds, and bathed in a 
thin, sanious dirty, and offensive fluid. 
Acute inflammation of the muscles is characterized by excessive pain, of a sharp, dart- 
ing character, or by dull, heavy, aching sensations, accompanied with a feeling of soreness, 
and aggravated by the slightest motion and pressure. In some cases, as when the disease 
supervenes upon fractures or the amputation of a limb, it is attended by a remarkable 
twitching or jerking, occasionally amounting to actual spasm, which only yields to large 
doses of anodynes, and hot, soothing applications. 
Chronic myositis is not uncommon; like the acute variety, to which it generally suc- 
ceeds, it is more frequently met with, surgically considered, as a secondary than as a 
primary affection. When long continued, it is very prone to give rise to fatty degenera- 
tion, softening, ulceration, and other changes, which it is often impossible to cure. 
4. Fatty Transformation Fatty degeneration of the muscles is often, if not generally, 
a result of chronic inflammation, especially when conjoined for any considerable period 
with steady, persistent inactivity, or want of exercise. Whether inflammation, however, 
is always necessary to its production is still a mooted question, although it is highly prob- 
able that it is. When thus affected, the fleshy fibres assume a pale yellowish, whitish, or 
slightly reddish color, at the same time that they are unctuous to the touch, and so much 
softened as to yield under the most trivial force. On pressure, a clear, oily fluid exudes, 
which greases the finger, is highly inflammable, and is composed of elain, adipocire, and 
ordinary fat, in variable proportions. These substances are not deposited, as some have 
conjectured, between the fleshy fibres, but form actually a portion of their constituent 
principles, their proper tissue being found, when examined microscopically, to be filled 
with granules, partly interposed between their striae, and partly replacing them. 
The fatty transformation is most common, as well as most marked, in the muscles of the 
loins, hip, thigh, and leg of old persons affected with paralysis. It is likewise occasion- 
ally observed in the heart, and now and then in the muscles around unreduced luxations, 
large exostoses, and old, deep-seated ulcers. When the change is profound and extensive, 
it sometimes involves the corresponding tendons and aponeuroses, which, in consequence, 
lose their polished, satin-like lustre. The disease does not admit of cure. 
5. Ulceration—Ulceration of the muscles is an uncommon occurrence. It is chiefly 
noticed in phagedenic sores of the leg, extending successively through the integument, con- 
nective tissue, aponeuroses, and, finally, the muscles, which, however, generally resist its 
encroachments in a very remarkable degree. In some of these cases the fleshy fibres are 
in a complete state of fatty degeneration, of a whitish color, and so soft as to admit of 
being scraped away with the greatest facility. When the ulceration is slight, the restora- 
tive process usually proceeds kindly, and the breach is soon filled with healthy granula- 
tions. No special treatment is required in this disease, apart from the remedies ordinarily 
employed under such circumstances. 
6. Contraction.—Another effect of inflammation of the muscles, or of the muscles and 
their fibrous envelops, is contraction of their fleshy fibres, leading to marked disorder of 
their functions, along, perhaps, with severe pain, and even great deformity, as is so often 
seen in wryneck, consequent upon inflammation of the sterno-cleido-mastoid and splenius 
muscles, and in the muscles of the thigh from the effects of hip-joint disease. In many 
of these cases the disease is obviously of a gouty or rheumatic character, and it then often 
occurs at a very early age, the immediate exciting cause being usually exposure to cold, 
or cold and wet. 616 
DISEASES OF MUSCLES AND THEIR APPENDAGES. 
CHAP. II. 
In the treatment of myositis attended with contraction of the affected muscles, the first 
object should be to ascertain, if possible, the nature of the exciting cause, as to whether it 
is the result of rheumatism, gout, scrofula, or syphilis, or of external injury, as a sprain, 
twist, blow, wound, or contusion ; for upon the knowledge thus derived must necessarily 
depend the character of our remedies, and the chance or otherwise of a cure. I have 
usually received marked benefit in these cases from the use of the wine of colchicum in 
combination with a full dose of morphia at bedtime ; aided by active purgatives and dia- 
phoretics, especially the warm bath, a well-regulated diet, and the frequent application of 
Granville’s lotion in union with laudanum and soap liniment, thoroughly rubbed upon the 
affected parts. The muscular rigidity attendant upon a syphilitic state of the system is 
best treated with iodide of potassium, either alone, or conjoined with mercury. 
In the more subacute or chronic cases of muscular contraction, great benefit may be 
expected from the use of the hot and cold douches, employed twice a day, and followed 
first by dry friction, then by the application of stimulating liniments, and finally by 
thorough shampooing. Frequent motion is also generally of great service, to break up 
adhesions, and to promote the absorption of effused fluids, upon which the affection so often 
mainly depends, as is observed in the shortened and rigid state of the limbs after severe 
fractures and dislocations. 
7. Atrophy.—Atrophy of the muscles, of varying degrees, is occasionally observed ; it 
may occur in any of the voluntary muscles, but is most common in those of the shoulder 
and hip, the deltoid suffering perhaps more frequently than any other. It may depend 
upon different causes, but generally it is produced by inflammation, palsy, or defective 
circulation ; indeed, whatever has a tendency to impair the function of innervation, retard 
or diminish the supply of blood, or induce permanent inactivity in a muscle, may be con- 
sidered as a cause of the affection. Hence it is found that the lesion is usually associated 
with paralysis, whether proceeding indirectly from disease of the cerebro-spinal axis, or 
directly from injury of the nerves distributed to the suffering structures. The muscles 
around luxated joints, especially those of the hip and shoulder, are frequently atrophied, 
either simply from want of use, or, what is more probable, the conjoint influence of inflam- 
mation and inactivity. In coxalgia, similar effects generally occur, the wasting usually 
involving all the muscles of the lower extremity. The fact that gout and rheumatism are 
frequently productive of atrophy of the muscles is familiar to every practitioner. 
The extent to which the wasting of the muscles may proceed is variable. When it 
exists in a high degree, they may be reduced to mere membranous bands, pale, flaccid, 
and almost devoid of irritability; in some rare instances their fleshy fibres are completely 
absorbed, a dense fibrous substance being all that is left in their place; or, instead of 
this, they are found to be softened and transformed into fatty matter. 
In the treatment of atrophy of the muscles, the first object should be to ascertain, if 
possible, the nature of the exciting cause, by removing which the lesion sometimes rapidly 
disappears of its own accord, or, at all events, under very simple management. Atrophy 
dependent upon imperfect supply of blood is often irremediable, and the same is frequently 
the case when it is caused by gout or rheumatism, or when it is conjoined with the fatty 
degeneration. The treatment of atrophy dependent upon loss of innervation, constituting 
what is called wasting palsy, will receive special attention in the chapter on the diseases 
and injuries of the nerves, where its consideration properly belongs. 
Whatever the cause of atrophy of the muscles may be, much may be done, after that 
lias been removed, towards effecting restoration, by the steady and persistent use of the 
hot and cold douches, stimulating embrocations, dry frictions, and regular, systematic ex- 
ercise of the affected structures, educating them, so to speak, and thus gradually qualify- 
ing them, for the resumption of their appropriate functions. 
8. Tumors—Various morbid growths occur primarily in and among the muscles, the 
principal of which are the hydatid, cystic, fibrous, muscular, and erectile. 
a. It is uncommon to meet with hydatids in the muscles, and I have myself seen only 
one case. The patient, a laboring man, twenty-five years of age, had accidentally dis- 
covered a swelling in the substance of the right deltoid muscle six months previously, 
when it was hardly as large as a hazelnut. At the time of my examination, it was of the 
volume of an almond with its shell, of a rounded, elongated shape, a little movable, and 
of a firm, fibrous consistence, with a slight degree of elasticity. Within the last few 
weeks the tumor had become somewhat painful, especially after exercise, and the pressure 
made in examining it was productive of considerable uneasiness. The skin over it was 
perfectly healthy. 
The diagnosis of the tumor could not, of course, be determined before hand; what it cnAP. ii. 
TENDONS. 
617 
resembles most, especially in point of consistence, was an enlarged lymphatic gland, but 
the rarity of such a disease in this situation invalidated this conclusion, and left me in 
complete doubt as to the true nature of the case. It was too deep-seated for a sebaceous 
tumor, and it possessed none of the external characters of a fatty, fibrous, or sarcoma- 
tous one. 
During the excision the knife penetrated the tumor, letting out a small quantity of thin 
pus; a circumstance which seemed, at the moment, to confirm the idea that the affection, 
after all, was simply a diseased lymphatic gland. On continuing the dissection, however, 
I soon found that there was a distinct cyst, which, being collapsed, was sepa- 
rated with some difficulty from the fibres of the deltoid muscle, in which it was 
imbedded. The operation being completed, a small body, fig. 258, was picked 
up, which, on inspection, proved to he a globular hydatid, not more than six 
lines in diameter, and furnished with a distinct sucker. The cyst was very 
soft and thin, smooth internally, and externally filamentous. 
f3. Tumors of a cystic character are occasionally met with in and among the 
muscles. In a case of this kind, which I saw with Professor Da Costa, the growth, 
occupying the upper and outer portion of the thigh, was nearly of the volume of an adult 
head. The patient, a female, fifty-eight years of age, in a fall down a flight of stairs, 
struck the limb severely, causing deep ecchymosis and great difficulty in walking. At 
the end of two months a swelling formed, which, gradually increasing, in less than a 
year, acquired the size above mentioned, being at the same time the seat of severe dart- 
ing pain, with considerable discoloration of the integument. The tumor fluctuated indis- 
tinctly, and a puncture with the exploring needle gave vent merely to a few drops of oily 
fluid. When removed by Dr. Brinton, it was found to be composed of a very thick, 
dense, fibrous cyst, filled with a sero-oleaginous liquid. The patient gradually recovered 
from the effects of the operation, but was troubled for a long time afterwards with pain in 
the limb and difficulty in walking. 
The voluntary muscles are sometimes occupied by cysts containing blood, owing to the 
laceration of their fibres and vessels, the latter of which thus part with their contents. 
The effused fluid, coagulating, is gradually organized and eventually encapsulated, the 
covering being occasionally very thick, dense, and strong. In rare cases the blood is 
poured out spontaneously, or under the influence of very slight injury, as a blow or con- 
tusion. If the blood be partially devitalized at the moment of the accident, it will he 
likely to retain its fluidity, and to become ultimately, in great degree, if not entirely, de- 
colorized, so as to resemble an accumulation of serum, and act as a foreign body. 
y. Tumors of a fibrous and myomatous structure have been found in different volun- 
tary muscles, especially in those of the chest, shoulder, arm, and thigh ; they are gene- 
rally of small size, slow in growth, and of firm consistence, with a tendency, now and 
then, to recurrence after excision. 
5. Osseous tumors are uncommon in the voluntary muscles. Mr. W. F. Teevan, in a 
monograph on morbid growths in this situation, has been able to find only three cases of 
the kind. 
i. Tumors of an erectile character have been seen in the sterno-mastoid, deltoid, semi- 
membranous, external oblique, long supinator, and semitendinous muscles. At the Col- 
lege Clinic, in 1870, I removed from the deltoid muscle of a girl, fifteen years of age, a 
cavernous tumor, which presented all the external features of a cyst. 
SECT. II TENDONS. 
The tendons, like the muscles, are liable to wounds and lacerations, but, unlike them, 
they very rarely, if' ever, suffer from morbid growths. Inflammation of these structures 
is also very infrequent. 
1. Wounds.—Tendons, when divided subcutaneously, readily unite through the inter- 
vention of plastic matter, without the occurrence of any considerable degree of inflam- 
mation. Indeed, the idea is very common at the present day that such wounds are al- 
ways repaired without inflammation, it being alleged that this process, instead of being 
necessary for this purpose, is a positive detriment. Such a doctrine, however, is unten- 
able. If its advocates mean that the inflammation is very slight, or not characterized by 
the ordinary phenomena, I perfectly agree with them; but if they wish to be understood 
as affirming that inflammation is entirely absent throughout, it is certainly not true. 
When a tendon, such, for example, as that of the heel, is cut across subcutaneously, 
the first thing that is noticed is the retraction of the divided ends, so as to leave a distinct 
Fig. 258. 
Hydatid. 618 
DISEASES OF MUSCLES AND THEIR APPENDAGES. 
CHAP. II. 
gap between them, often ranging from an inch and a half to two inches, according to the 
size of the cord and its previous tension, or the degree of force employed in stretching the 
parts with which it is connected. Inflammation, generally of a very slight form, next 
takes place, and, soon after this is established, plastic matter is poured out, filling up the 
space between the two extremities of the tendon, and at the same time connecting them 
together. As the abnormal action subsides, fusiform cells form in the interior of the 
effused matter, and, the process of organization thus begun steadily advancing, the new 
substance is gradually converted into fibrous tissue, and this, in turn, at length into 
tendinous, which, however, although well adapted to fulfil the purpose for which it is in- 
tended, is, like all new tissues, a very imperfect type of the original. The reproductive 
process generally progresses very rapidly, so much so that the person soon acquires an ex- 
cellent use of the affected parts. It is upon a knowledge of this property in tendon, when 
subcutaneously divided, to speedy reunion, that is founded the operation of tenotomy, 
one of the great improvements in modern surgery. 
When a tendon is divided in an open wound, there is rarely, if ever, any spontaneous 
reunion, for the reason, first, that the ends retract too far to admit of thorough adjustment, 
and, secondly, that the wound nearly always suppurates; an occurrence highly inimical 
to adhesive action. All the earlier operations of tenotomy that were performed according 
to this principle failed, in consequence of the violence of the resulting inflammation. 
The treatment of a divided tendon, then, with an open wound, is very different from 
that where the wound is subcutaneous. In the latter, the application of a bit of adhesive 
plaster to the puncture, to exclude the air, and a little attention to rest and position, make 
up the sum total of the surgeon’s duty. In the former, on the contrary, the cut ends 
must be carefully approximated by the silver wire suture, the remainder of the wound 
being firmly closed ; or the limb with which the tendon is connected must be placed in the 
most thoroughly relaxed position possible, in order to approximate its extremities, and 
thus afford them an opportunity of reuniting, an occurrence, however, which will certainly 
seldom take place under any circumstances, however propitious. The experiments of 
Dr. Levert, of Mobile, performed many years ago, prove that union between the divided 
ends of a tendon will be much more likely to proceed kindly and satisfactorily when the 
parts are held in contact by a metallic suture than by an ordinary one. Surgeons do not 
seem to have taken sufficient advantage of the results of these researches, and it is fortu- 
nate that the introduction of the wire suture by Dr. Sims has tended to recall attention to 
them. 
Cases occasionally arise in which a tendon remains ununited, with a large intervening 
gap, long, perhaps, after the external wound has healed. In such an event it has been 
proposed to puncture the retracted extremities in different directions with a delicate teno- 
tome, on the same principle that we sometimes perforate the ends of an ununited fracture. 
The procedure, however, seldom, if ever, succeeds, even in the most favorable circum- 
stances. A much better plan is to expose the parts by a free incision, and, having pared 
the retracted extremities of the tendon, to unite them with silver wire, care being taken 
to keep the resulting inflammation within the limits of moderate fibrinous exudation. 
Since I first recommended this method, many years ago, successful cases of it have been 
reported, among others, by Dr. Warren Webster, of Illinois, Delore, of Lyons, and Dr. 
Simmons, of Sacramento. 
2. Rupture—Tendons are sometimes torn away from their sheaths along with the 
fleshy fibres into which they are inserted, hanging, perhaps, merely by one extremity : 
when this is the case, it would be useless to replace them, even if this were practicable, 
as there would be no likelihood whatever of reunion ; on the contrary, severe inflammation 
and sloughing would be inevitable. 
When a tendon is ruptured subcutaneously, a loud snap, like the crack of a whip, is 
generally heard at the moment of the accident, especially if the cord is a large one ; the 
part is instantly deprived of its functions, and a well-marked gap, interval, or hollow is 
perceptible at the site of the injury. More or less inflammation follows, and a long time 
usually elapses before the patient regains the use of the affected limb. The tendon which 
is most liable to suffer in this way is that of the heel, its rupture being generally caused 
by violent muscular exertion, either for some special effect, as in the case of persons on 
the stage, or for the purpose of saving the body from a fall, as when the individual makes 
a false step. John Hunter ruptured his tendo Acliillis in dancing. 
The treatment of a subcutaneously ruptured tendon must be conducted by rest and 
complete relaxation of the affected structures, so as to enable us to bring the divided ends 
as closely together as possible. To effect this to the best advantage, special apparatus is CHAP. II. 
TEXDOXS. 
619 
generally required, as well as the greatest attention and vigilance on the part of the prac- 
titioner. The time necessary for obtaining satisfactory union varies, on an average, from 
six to eight weeks. 
3. Dislocations The tendons are sometimes dislocated, or thrown out of the canals in 
which they are naturally situated, in consequence of the laceration of the connecting 
ligaments, or retaining bands. The accident, which is most, apt to befall the tendon of 
the two-headed flexor of the arm, as it runs along the bicipital groove of the humerus, is 
generally attended with severe pain at the site of injury, inability to move the affected 
limb, and more or less discoloration of the integument. Considerable swelling often fol- 
lows, and, if the accident is overlooked, permanent lameness may result. Replacement 
should be effected as speedily as possible, a procedure which is usually very easy, pro- 
vided the true nature of the case is recognized soon after its occurrence. 
4. Hypertrophy Finally, the tendons are occasionally the subjects of hypertrophy, 
exhibiting an irregular, knotty appearance, which is not only unseemly, but sadly pro- 
ductive of discomfort. The affection is most common in gouty, rheumatic, and syphilitic 
persons, and is usually very readily detected both by touch and sight. The proper reme- 
dies are removal of the exciting cause, the exhibition of iodide of potassium, either alone 
or in union with mercury, and sorbefacient applications with massage. 
5. Thecitis—Inflammation of the sheaths of the tendons, technically called thecitis, 
may originate as an independent affection, or, as not unfrequently happens, it may begin 
consentaneously with inflammation of the parts which it surrounds and lubricates. In 
either event, the disease is often of a much more serious character than is generally 
imagined, nothing short, perhaps, of permanent lameness and deformity being the result. 
Various causes may give rise to thecitis; thus it is occasionally induced by gout, rheuma- 
tism, syphilis, and exposure to cold. On the other hand, it often supervenes upon exter- 
nal injury, as a sprain, blow, puncture, or contusion. In the hand and fingers it is 
frequently met with as a consequence of sprains of the wrist-joint, or fracture of the lower 
extremity of the radius and ulna. In regard to its character, it may be acute or chronic; 
more generally, perhaps, the latter than the former. Once fairly established, it is com- 
monly removed with much difficulty, and is liable, as just stated, to be followed by the 
most disastrous effects. 
The most common sites of thecitis are the sheaths of the tendons of the fingers, the 
wrist, elbow, feet, ankles, and knees; the disease may occur by itself, or in union with 
inflammation of burses and the lining membrane of the neighboring joints. In thecitis of 
tlie hands and fingers it is seldom that the disease exists except in this association, espe- 
cially when it has been caused by a sprain, dislocation, or fracture of the radio-carpal 
articulation. In this condition, as I have had frequent occasion to notice, the inflamma- 
tion is extremely liable to extend to the sheaths of all the tendons, as well as the joints 
of the fingers, rendering them stiff, tumid, and exquisitely painful. If the case is 
neglected or improperly treated, the whole hand becomes rigid ; and the fingers, wasted 
and attenuated, present more the appearance of the claws of some of the inferior animals 
than the natural structures. The pain accompanying this form of thecitis often reaches 
as high up as the axilla, and I have known it to be so distressing at night as to deprive 
the patient completely of sleep for days together. 
Thecitis, although apparently a trivial disease, assumes a most important character when 
it invades a number of thecae simultaneously, or successively, and the gravity of the case 
is greatly augmented if there is at the same time considerable involvement of the neigh- 
boring joints, as when the attack takes place in the hands and fingers. Hence no time 
should be lost, and no pains spared, to get rid of the inflammation before it has produced 
any serious structural changes, particularly firm and extensive adhesions of the thecae to 
their tendons. Leeches and tincture of iodine, either alone or in union with saturnine and 
anodyne fomentations, are the chief topical remedies upon which reliance is to be placed, 
while the patient is freely purged and restricted in his diet. Venesection and antimony 
will be necessary if the case prove obstinate. When the disease is associated with a gouty 
or rheumatic state of the system, wine of colchicum will be of service. In thecitis 
dependent upon a syphilitic taint, recourse must be had to iodide of potassium. 
If the parts have become stiff in consequence of firm adhesions, the hot and cold 
douches, followed in immediate succession, along with frictions with sorbefacient liniments, 
embrocations, or unguents, steady, systematic passive motion twice a day, and the appli- 
cation of the bandage to support the affected structures, will gradually, although in general 
not under several months, effect restoration. In obstinate cases a mild mercurial course 
may become necessary, on the same principle that such a plan is occasionally adopted in 620 
DISEASES OF MUSCLES AND THEIR APPENDAGES. 
CHAP. II. 
inflammation of other tissues attended with plastic effusions and morbid adhesions. When 
the disease is located in the hand, I have generally found it expedient to bandage each 
finger separately, and to support the parts upon a carved splint. In short, in many of 
these cases nothing but the most zealous and determined perseverance will enable us to 
effect a cure. 
6. Painful Crepitation—There is a singular affection of the tendons originally described 
by some of the French surgeons, as Boyer, Velpeau, Michou, and others, under the phrase 
of* “ painful crepitation.” It is most generally met with in the tendons of the muscles of the 
forearm and hand, particularly the radial extensors at the outer and back part of the 
wrist, but is also liable to occur in those of the leg and toes. Now and then it is observed 
in the long head of the biceps. The disease evidently consists in inflammation of the 
sheaths of the affected tendons, followed by a deposit of plastic matter, roughening the 
contiguous surfaces, and thus occasioning the peculiar pain and crepitating sensation by 
which it is distinguished. The most common exciting causes are sprains, gout, rheumatism, 
and overexertion of the muscles. The affection is often attended by a certain degree of 
swelling of the limb at the seat of the morbid action, but there is rarely any decided dis- 
coloration of the surface, or, if there is, it readily disappears under pressure. More or 
less impainnent of function is present. The characteristic symptom is a crepitation, which 
closely resembles the noise produced by rubbing coarse starch between the fingers, or the 
sound occasioned by treading on dry snow in very cold weather. In the forearm it may 
always be readily elicited by alternately pronating and supinating the limb. Great care 
is often necessary not to confound this species of crepitation with that of fracture. Its 
roughness and the mode of producing it will generally be sufficiently diagnostic of its nature. 
The affection often disappears spontaneously, or under very simple measures, of which 
the most important are rest, sorbefacient lotions and liniments, and the hot and cold 
douches. 
7. Ganglion—A ganglion, as seen in fig. 259, from a clinical case, is a small circumscribed 
cyst, situated along the course of a tendon, to which it is intimately united. Composed 
of a single layer, which rarely exceeds the thickness of the dura mater, it is filled with a thin, 
yellowish fluid, more or less ropy in its character, and bearing a very strong resemblance, 
in its general features, to olive oil, the white of an egg, or a solution of gum arabic. In 
Fig. 259. 
Ganglion of the Extensor Tendons of the Hand. 
cases of long standing, the contents of the sac are sometimes nearly entirely solid, consist- 
ing of a thick, ropy substance, of a dark color, not unlike currant jelly ; of masses, appa- 
rently, of semiorganized lymph ; or of small bodies similar, in shape and size, to cucumber 
seeds. In a ganglion of the hand upon which I operated some years ago, I observed the 
singular-looking bodies sketched in fig. 260. They appeared to be in different stages of 
development, and were evidently merely so many enlarged fringe-like processes of the 
synovial membrane, which had undergone fibroid transformation, and become detached 
in consequence of the continual friction of the tendon to which the sac wras connected. 
The volume of the cyst varies from a pea to that of a hickory nut; it is of a globular 
or ovoidal shape, somewhat elastic, perfectly movable, free from pain, and unaccompanied 
by any discoloration of the skin. A sense of stiffness and of uneasiness, felt chiefly along 
the course of the tendon on which it is situated, sometimes attends its formation, and 
induces the patient to apply for advice. I have never known a ganglion to suppurate. 
The tumor is most common in women, and is met with chiefly along the extensor 
tendons on the back of the hand, wrist, and lower extremity of the forearm. I have CHAP. II, 
SYNOVIAL BURSES. 
621 
seen several cases in which such a swelling was situated over the radial artery, the pulsa- 
tions of which were so thoroughly imparted to it as to induce the belief, at first, that it was an 
aneurism of that vessel. A cyst of this kind in the palm of 
the hand is a rare occurrence. On one occasion I operated 
upon a young woman who had two ganglionic cysts, eacli 
of the size of a small bird’s egg, upon the dorsal surface 
of the foot. The sole of the foot sometimes suffers in 
a similar manner. The affection now and then appears at 
an early age. I have met with it in a child only eight 
years old. The great majority of cases, however, occur 
in young adults. 
How this cyst is formed is still a mooted question. The 
probability, however, is that it is merely a sacculated ex- 
pansion of the sheath of the tendons, and not, as some 
pathologists suppose it to be, a new formation. From the 
fact that it is most common in hard-working people, it, 
doubtless, owes its origin to inflammation, although it is 
seldom directly chargeable to external violence. 
The most simple and trustworthy method of treatment consists in rupturing the ganglion, 
and scattering its contents into the surrounding connective tissue, where they are speedily 
absorbed. The operation may usually be performed with the two thumbs, but, if the cyst is 
old and very firm, it will be necessary to strike it with a book, as was done by the older 
surgeons, or to pierce it previously with a bistoury or tenotome. Evacuation having been 
effected, a compress inclosing a piece of coin or sheet lead is applied to the part, to 
promote the adhesion and obliteration of its cavity, the limb being maintained at rest 
until the resulting inflammation has subsided. When the ganglion is quite young, relief 
may occasionally be afforded by the application of iodine and systematic compression ; 
ordinarily, however, such means are quite futile. Iodine is sometimes advantageously 
employed as an injection, in the same manner as in hydrocele. When the ordinary means 
fail, my practice is to cut up the sac as minutely as possible with a delicate bistoury, 
inserted subcutaneously, steady compression being afterwards maintained until obliterative 
inflammation has taken place. Both excision and direct incision must be avoided, as they 
are liable to cause erysipelas and to endanger the functions of the part. 
What is called by authors the diffused or compound ganglion is merely a sacculated 
condition of one or more of the sheaths of the flexor tendons of the hand and wrist, and 
of the dorsum, sole, or inner side of the foot. The pouch thus formed is sometimes several 
inches in length, especially in the palm of the hand, by an inch or more in width, soft, 
fluctuating, irregular in shape, and, at first, free from pain, but liable, when inflamed, to 
more or less suffering and consequent lameness of the limb. In the older cases the sac 
often contains little bodies like melon seeds, and, under such circumstances, pressure always 
elicits a distinct crepitating sensation, characteristic of the nature of the affection. In 
the earlier stages of the disease the fluid is generally clear and thin, but as the morbid 
action advances, it becomes dark, turbid, bloody, and more or less thick, owing to the 
change of structure in the synovial sheath, which is often much thickened and studded 
with reddish and imperfectly organized granulations. The affection usually comes on 
without any assignable cause, and is much more frequent in women than in men, in whom 
it often occurs at an early age. 
Rest, blistering, and iodinization afford temporary relief in this form of ganglion, but 
beyond this they do no good. The radical cure is based upon the use of the seton, con- 
sisting of two or three strands of well-oiled threads, introduced with a curved needle 
or eyed probe, and retained until a sufficient amount of inflammation has been excited to 
produce obliteration of the pouch. The limb meanwhile must be kept at rest, and every 
precaution taken to restrict the inflammation within proper limits. Excision is fraught 
with great danger. 
. SECT. Ill SYNOVIAL BURSES. 
The synovial burses, bursae mucosae, or mucous pouches, exist in considerable numbers 
in various regions of the body, especially about the joints of the extremities, being small, 
semiti'ansparent sacs, occupied by a thin, unctuous fluid. They are for the most part 
interposed between bone and tendon, tendon and tendon, bone and skin, or tendon and 
skin, their object being to facilitate motion and ward off pressure. Hence, they are 
Fig. 260. 
Fibroid Bodies of Ganglion. 622 
DISEASES OF MUSCLES AND THEIR APPENDAGES. 
CHAP. II. 
always most conspicuous in those situations which are habitually subjected to friction ; 
and for the same reason they are occasionally developed to meet special contingencies 
arising from accidental causes, as the pressure of the shoe, crutch, or artificial limb. In 
club-foot synovial pouches are constantly formed upon those parts of the foot which, being 
partially displaced, are compelled to sustain the weight of the body. Altogether there are 
about one hundred and fifty of these sacs in the natural state. 
The largest and most important synovial pouches, surgically considered, are situated on 
the acromion process of the scapula, the space between the hyoid bone and thyroid carti- 
lage, the condyles of the humerus and the olecranon process, the styloid projections of the 
ulna and radius, the tuberosity of the ischium, the great trochanter, the anterior superior 
spine of the ilium, the front of the patella, the condyles of the femur, the tuberosity of the 
tibia, the ankle, the calcaneum, and the heads of the first and fifth metatarsal bones. 
The principal affections of the burses are inflammation, suppuration, induration and 
thickening, dropsical accumulations, the development of fibro-cartilaginous concretions in 
their interior, and contusions. If is not improbable that they may occasionally be the 
seat of some of the malignant formations; but as I have never met with any examples, 
it may be assumed that they are very uncommon. 
Inflammation of these sacs may occur either in an acute or a chronic form, the latter 
being, however, by far the more frequent. The usual cause is inordinate and long-con- 
tinued friction conjoined with pressure. The disease may also be produced by blows, 
contusions, wounds, and punctures, and, in persons predisposed to gout, rheumatism, 
scrofula, and syphilis, by exposure to cold, or the sudden repulsion of the cutaneous per- 
spiration. The housemaid’s knee, and the collier’s elbow, are examples of inflamed and 
enlarged burses developed under the influence of concentrated and protracted pressure ; 
another instance not less striking, is afforded by the bunion which so frequently forms 
over the inner surface of the metatarso-phalangeal articulation of the big toe. Constitu- 
tional syphilis, especially in its later forms, is an occasional cause of bursitis, having its 
origin either in the sac itself, or by extension from the neighboring tissues. 
1. Acute inflammation of the burses is-genex-ally productive of very severe suffering; 
the pain is tensive, throbbing, persistent, and greatly aggravated by motion, pressure, and 
dependency ; the swelling, which is often considerable, is usually due partly to exterior 
deposits, partly to an accumulation of synovial fluid, the quantity of which is commonly 
very much increased; the skin, of a dusky, reddish color, is deeply congested; and the 
functions of the affected structures are greatly impaired, if not completely arrested. 
Not unfrequently the swelling, is of an cedematous or erysipelatous character, pitting 
readily under pressure, and being the seat of a dull, heavy, prickling sensation. In the 
more severe forms of acute bursitis, there is usually considerable constitutional involve- 
ment, the patient being feverish, thirsty, restless, and troubled with headache, loss of 
appetite, and other disagreeable symptoms. 
Upon cutting into the affected sac, its inner surface is found to be deeply congested, 
and roughened with lymph, while its cavity is filled with a bloody, serous, or sero-oleaginous 
fluid, often in considerable quantity, especially if the disease has been of some standing. 
Bursitis occasionally passes into suppuration, the symptoms, when this is about to 
occur, suddenly assuming a more severe form, precisely as when matter is about to be 
deposited in any other part of the body. The pus, usually of a thin, oleaginous character, 
and intermixed with flakes of lymph, may find its way to the surface by ulcerative action, 
or it may discharge itself into a neighboring joint, although such an event is extremely 
rare, and is not likely to occur unless the joint has freely participitated in the inflammation. 
The treatment of this disease must be actively antiphlogistic; the part and system are 
kept perfectly at rest; leeches are applied to the affected surface, followed by anodyne 
and saturnine fomentations; the bowels, diet, and secretions are duly attended to; and 
the pain, which is generally severe, is controlled by morphia, or morphia, antimony, and 
aconite. If matter form, as denoted by an increase of pain and other symptoms, a free 
and early incision is made, the edges of the opening being kept asunder by a small tent 
to prevent reaccumulation. The milder forms of bursitis are generally easily combated 
by rest, cooling laxatives, and the application of tincture of iodine, or, what is frequently 
preferable, a blister, large enough to extend over the affected surface, and retained suffi- 
ciently long to produce thorough vesication. 
2. Chronic inflammation of the burses occasionally gives rise to remarkable structural 
changes, the most common of which is an indurated and hypertrophied condition, the 
result either of long-continued interstitial deposits, or of the formation of adventitious 
membranes. However this may be, the walls of the affected sac are sometimes found to CHAP. I I. 
SYNOVIAL BURSES. 
623 
be upwards of a quarter of an inch in thickness, and of a dense, fibrous consistence, 
without the slightest trace of its primitive characters. In this condition, the cavity of 
the pouch is generally very small, filled with altered synovial fluid, and roughened upon 
its surface, so as to exhibit an appearance not unlike that of a honeycomb. Now and 
then shreds of lymph are stretched across its interior, dividing it into different compart- 
ments. In cases of very long standing, partial ossification of the cyst has been noticed, 
but such an occurrence is very uncommon. 
These chronic enlargements of the burses are often very obstinate and troublesome, 
resisting not unfrequently the best directed efforts of the surgeon for their removal. The 
remedies upon which most reliance is to be placed are sorbefacient applications, as iodine 
and chloride of ammonium, blisters, mercurial inunctions, and systematic compression. 
When these means fail, and the tumor is productive of pain and other inconvenience, our 
only resource i&thorough excision, care being taken, especially if a large joint is close by, 
not to cut too widely away from the morbid mass, lest the synovial membrane of the 
articulation be inadvertently pierced, or so much injured as to excite violent inflammation. 
3. Another result of chronic inflammation of these bodies is an accumulation of their 
natural secretions, giving rise to what is called dropsy, or hygroma, of which one of the 
best examples is afforded in the so-termed housemaid’s knee. The fluid, varying in 
quantity from a few drachms to six or eight ounces, according to the size and situation of 
the affected burse, and the duration of the disease, is generally of a pale straw color, of 
a slightly unctuous consistence, and of a notably saline taste ; now and then it is reddish 
or brownish, and remarkably thick and viscid. It is readily coagulable by heat and acids, 
showing that it is essentially composed of albumen. The presence of the fluid is easily 
detected by the elastic and fluctuating character of the swelling, and very frequently a 
distinct friction sound and sensation can be perceived upon handling the tumor: if neces- 
sary, an exploring needle is used. The integument is free from discoloration, there is no 
enlargement of the subcutaneous veins, and the principal inconvenience experienced by 
the patient is of a mechanical nature. Now and then there is a good deal of pain, but 
more generally simply a sense of soreness and stiffness. 
The size and shape of the tumor formed by these dropsical collections are subject to 
great diversity; in general, it does not exceed the volume of an orange, or a goose’s egg, 
but cases occur in which it reaches the bulk of a foetal head, although this is very uncommon. 
Its shape is generally irregularly rounded or ovoidal, with a compressed, flattened appear- 
ance. 
Dropsy of the synovial pouches may often be relieved, in its earlier stages, by the diligent 
application of iodine, astringent and sorbefacient lotions, and, above all, by blisters, con- 
joined, with rest, attention to the bowels, 
and the use of the bandage. In cases of 
long standing, however, such treatment 
is seldom of any permanent advantage, 
nothing short of a complete and radical 
change in the action of the secernent 
vessels answering the purpose. With 
this view, the water being drawn off 
with a trocar, the same remedies may 
be adopted as in the treatment of hydro- 
cele, that is, injections of stimulating 
fluids, as tincture of iodine, nitrate of 
silver, or iodide of iron; or, what I 
deem better, because more certain, the 
introduction of a small seton, retained 
for a period varying from three to six 
days, according to the amount of the 
resulting inflammation. In either case, 
the part is carefully kept at rest, and 
every precaution used to prevent undue 
morbid action. When the tumor has 
become solidified and nearly of its origi- 
nal size, it is an evidence that the seton should be withdrawn. From three to six weeks 
will usually elapse before a complete cure is effected. 
The operation by incision is sometimes practised in these dropsical accumulations ; but 
Fig. 261. 
Fibroid Bodies of a Synovial Burse 624 
DISEASES OF MUSCLES AND THEIR APPENDAGES. 
ciiap. ir. 
as it is not only severe, but liable to be followed by violent inflammation, sometimes 
seriously implicating a neighboring joint, it should be abandoned. 
4. Intermixed with the fluid above described, or occurring independently of it, there 
are occasionally loose concretions, of a dense, fibrous, fibro-cartilaginous, or cartilaginous 
consistence, of a light yellowish, grayish, or whitish color, and of a flat oval form, not 
unlike small melon seeds. Their number is sometimes very remarkable, upwards of fifty 
having been extracted from a single pouch. The adjoining sketch, fig. 2G1, affords a 
good idea of the appearances of these bodies, as they are exposed on dissection, and also 
of the changes which the burse has undergone in consequence of their presence. When 
existing in considerable numbers, a careful examination will rarely fail to detect their 
true character. The symptoms which they occasion are such as usually attend chronic 
bursitis. More or less of a friction feel is generally present, and cases occur in which the 
little bodies may readily be pushed about from one place to another. 
How are these bodies formed? Two theories have been advanced upon the subject. 
According to one, they consist essentially of plastic matter, originally poured out in soft, 
amorphous granules or flakes, which, increasing in size and density, are gradually 
moulded into a determined shape by the pressure of the surrounding parts, as well as by 
the friction which they exert upon each other as they are pushed about from place to 
place in their confined situation. The other explanation is that they are originally con- 
nected to the inner surface of the sac, from which they receive temporary support and 
nourishment; but, finally becoming detached, by the constant friction to which they are 
subjected, they present themselves as loose bodies, of varying shape and consistence. 
The latter theory is favored by the results of dissection, which not unfrequently shows 
some of these bodies as still firmly adherent to the inner surface of the affected pouch, 
and by the analogy which exists between them and the concretions met with in some of 
the movable joints, which are, apparently, always formed in this manner. 
The only way to get rid of these bodies is to effect their extrusion by free incision, a 
drainage tube being afterwards placed in the bottom of the sac, to promote its obliteration. 
Bodies, closely resembling small hydatids, are occasionally found in these pouches. J. 
Cloquet met with an instance in which there were upwards of one hundred and forty, 
varying in size from one to three lines in diameter, nearly transparent, and of a lenticular 
shape. They were situated in the large burse between the great trochanter and the tendon 
of the gluteal muscle. 
5. Contusions of the burses are produced by violent blows and falls, and are followed 
either by acute inflammation or by a collection of blood in their interior, which generally 
undergoes changes similar to those witnessed in an apoplectic effusion, terminating in a 
fibrinous mass of varying firmness and density. When the contusion has been very severe, 
the extravasated blood remains fluid, and is converted into a dark, grumous mass, of the 
consistence of syrup. 
The tumor formed by the extravasated blood is easily recognized by its sudden develop- 
ment in the situation of a normal burse after external violence, by its well-defined, cir- 
cumscribed form, and by ecchymosis of the surrounding parts. It is always soft and 
fluctuating at the beginning, and sometimes it retains this feature throughout, although it 
generally soon becomes comparatively firm and hard, from the coagulation of its contents. 
If the sac be not too much distended, the clots may be felt through its walls, and a very 
distinct crepitation may be elicited by crushing them between the fingers. 
Accumulations of blood in the burses disappear spontaneously, or under very simple 
measures, as rest, refrigerant, astringent, and sorbefacient lotions, and systematic compres- 
sion. If inflammation and suppuration set in, the sac must be laid open. When the case 
proves obstinate, subcutaneous evacuation, followed by compression, will be necessary. 
SECT. IV. APONEUROSES. 
The aponeuroses, considered by themselves, offer very little of interest in a surgical 
point of view, since their diseases are not only infrequent, but very imperfectly under- 
stood. From the intimate relations which they sustain, on the one hand, to the muscles, 
and, on the other, to the connective tissue, it is obvious that there can be but few diseases 
or injuries, of a serious character, of these structures, without more or less mutual involve- 
ment. At the same time, it is evident that the aponeuroses, from their peculiar arrange- 
ment, must necessarily, in many cases, play a very important part in preventing the 
extension of morbid action to the muscles which they serve to inclose, just as the peri- 
osteum impedes the propagation of disease to bone, and, conversely, from bone to the CHAP. III. 
DISEASES AND INJURIES OF THE NERVES. 
625 
surrounding textures. This barrier, of course, is often broken in both cases, and then the 
ravages of the morbid action will be likely to be both rapid and extensive, as we see exem- 
plified in the worst forms of erysipelas, carbuncle, and other affections, in which every 
variety of structure is rudely and indiscriminately assailed by inflammation, not unf're- 
quently terminating, in a few days, in the destruction of an entire limb. 
Acute aponeurositis is an uncommon occurrence, and is chiefly observed as a consequence 
of external injury, or as an effect of erysipelas, carbuncle, and whitlow. Gout and rheu- 
matism are generally believed to be seated exclusively in the fibrous envelops of the 
muscles; but the probability is that the tendinous, ligamentous, and bursal structures are 
nearly always implicated along with them, the two diseases sometimes beginning in the 
former, and sometimes in the latter, but usually ultimately attacking all. 
A bad form of inflammation of the aponeuroses is occasionally produced by punctured 
wounds, especially when occurring in the palm of the hand and the sole of the foot, in 
persons of broken constitution and dissipated habits, or nervous temperament. The dis- 
ease soon assumes an erysipelatous disposition, and leads to excessive suffering, both local 
and constitutional: occasionally it is followed by tetanus. Inflammation of these structures 
manifests but little disposition to pass into suppuration, ulceration, or gangrene. 
Chronic inflammation of the aponeuroses is much more common than the acute, and 
leads to various alterations of structure, as thickening, atrophy, induration, and contrac- 
tion, often followed by serious, if not irremediable, deformity. Sometimes they are affected 
with slight ossification, the new substance presenting itself in the form of bony spicules ; 
and cases are met with in which, from long-continued pressure, they are remarkably attenu- 
ated, and pierced with numerous apertures, giving them a sieve-like appearance. 
The treatment of aponeurositis is conducted upon ordinary antiphlogistic principles. 
Anodynes must be exhibited in full and repeated doses to relieve pain and nervous symp- 
toms ; if plethora exist, or the local action is very severe, blood must be taken from the 
arm and by leeches from the affected parts; the bowels must be freely moved; and recourse 
must be had to saline and antimonial medicines. Free incisions are made if much tension 
is present, or the formation of matter is threatened ; followed by medicated fomentations 
and emollient poultices. 
Aponeurositis dependent upon a gouty, rheumatic, or syphilitic state of the system, 
must be managed according to the general principles of treatment laid down for the relief 
of these affections; by colchicum, iodide of potassium, and mercury, in combination with 
other suitable means. 
Sarcomatous and fibrous tumors, especially the spindle-celled variety of the former, are 
frequently met with in connection with the aponeuroses. The fact of this occurrence need 
only be mentioned, as they obey the same laws here as in other parts of the body. 
CHAPTER III. 
DISEASES AND INJURIES OF THE NERVES. 
SECT. I WOUNDS AND CONTUSIONS. 
Nekves that are divided readily unite, and, after the lapse of several months, their 
structure and functions are restored. In order, however, that the connecting medium 
shall be useful, the interval between the two extremities must be very short, otherwise 
each end may become expanded into a bulbous mass, having all the characteristics of a 
neuromatous tumor, similar to that which occasionally forms in a stump after amputation, 
and liable, like it, to become the seat of neuralgia. It is worthy of notice that a nerve, 
slowly divided with a ligature, will generally unite more rapidly and completely than one 
divided with a sharp knife ; in the former case there is commonly very little retraction 
of the ends, whereas in the latter they sometimes separate to a considerable distance, thus 
requiring a larger quantity of new material to fill up the gap. 
When a nerve is cut completely across, the parts to which it is distributed are neces- 
sarily deprived of their functions, an occurrence which, consequently, serves as a diagnos- 626 
DISEASES AND INJURIES OF THE NERVES. 
chap. in. 
tic sign of the accident. Thus, if the nerve be one of motion, the parts will be paralyzed, 
while, if it be one of sensation, they will be divested of sensibility. If the division be 
only partial, the loss of function will, of course, be partial also. In general, the structures 
beyond the seat of injury feel numb and heavy, with a sense of tingling, prickling, sting- 
ing, or burning. When the section is complete, there is always a remarkable diminution 
of temperature in the parts supplied by the affected nerve, seldom amounting to less than 
six, eight, or ten degrees. The structures remain for a long time sore, tender, painful, 
and prone to inflammation, and eventually they become greatly atrophied. The capillary 
circulation is seriously disturbed ; the vessels are habitually congested, and the skin is of 
a pale, livid hue, and easily impressed by atmospheric changes. In cases of long stand- 
ing, the papilla? of the skin waste and shrink, and there is a material decrease of tactile 
sensibility. 
The recent observations and experiments of Letievant, Arloing, Tripier, and others 
have show n that, “ despite the division of a nerve, there always remains, in the parts it 
supplies, a certain amount of sensation, if it be a sensory nerve ; of motion, if it be a 
motory nerve; or of both, if it be a mixed nerve.” These functions, which are at first 
very imperfectly performed, gradually increase in power with the lapse of time, and are 
evidentally due to the agency of anastomotic nervous filaments, the restoration being the 
same in principle as the restoration of the circulation after the ligation of an artery. The 
paralysis which supervenes upon the division of a nerve of motion is ultimately followed, 
in every case, by more or less muscular atrophy. Sensation is relatively more marked 
than motion, but, like the latter, it never attains the normal standard, except when the 
ends of the divided nerve are completely reunited, and is liable to be influenced by 
accidental conditions, especially by inflammation and oedematous swelling. 
Wounds of t he nerves are treated upon the same general principles as wounds of other 
structures. When there is no serious loss of substance, the divided ends should be as 
closely approximated as possible by attention to position, and by suture of the neuri- 
lemma, introduced with a very fine needle. A suture will be particularly serviceable 
when a large trunk has been severed, or when there is inordinate tendency to separation 
in the ends of the cord. The operation is very simple, and, if carefully performed, 
almost free from pain. The best substance is the earbolized catgut ligature, the ends 
being cut off close. 
A similar procedure may be adopted when a large nerve has been severed, but has 
failed to unite. An incision being made down to the nerve, the two ends are carefully 
retrenched, and then tacked together by several points of suture, apposition being favored 
by stretching of the nerve and by attention to the position of the parts in which it is 
contained. 
Suturing of divided nerves was advocated in the first edition of this w'ork, issued in 
1859, and since then numerous cases have been reported in which the operation was 
attended with the most gratifying success. The operation, in fact, is now one of the 
established procedures in surgery. Experience has shown that no harm results when 
the suture is pushed through the entire thickness of the nerve, neurilemma and all. 
Nerves, when punctured, pricked, or partially divided, usually occasion severe pain, 
of a neuralgic character, extending up and down the affected parts, and attended with 
muscular weakness, perverted sensation, convulsive movements, and derangement of the 
general health. Such effects not unfrequently follow venesection at the bend of the arm, 
from injury sustained by one of the subcutaneous nerves. The proper remedy is complete 
division of the affected filament, either subcutaneously, or, when this is impracticable, by 
free incision. The operation, however, is not always permanently successful, owing to 
the deep impression which the lesion has made upon the general system. Besides, the 
divided extremities of the nerve are very apt to take on diseased action, either by being 
incorporated in the original cicatrice, or by being expanded into a species of neuroma. 
When this is the case, the proper procedure will be free excision instead of subcutaneous 
section, the ends, if not too widely separated, being afterwards united by suture. 
Severe effects often follow contusion of the nerves, the parts to which they are dis- 
tributed becoming numb, cold, withered, more or less painful, and, ultimately, almost 
entirely useless. Effects of this kind sometimes succeed to accidents, apparently, of the 
most trifling character. The nerves, so far as an opinion can be formed without the 
light of dissection, soon become inflamed, and are often irretrievably ruined, being 
effectually and permanently disqualified for the performance of their functions. It is 
hardly probable that these effects are due, as has been conjectured, to mere concussion 
of the nerve-substance; for, if this were so, they would be much more transient, as CHAP. III. 
TUMORS. 
627 
well as less severe. What corroborates the idea that inflammation is deeply concerned 
in the production of the secondary suffering is the fact that the parts, although seriously 
crippled at the start, do not evince much derangement until the disease is established in 
all its intensity. 
Concussion of the nerves has been very ably described by Professor Willard Parker, 
who considers the accident as similar to concussion of the brain, the nerves receiving a 
shock eventuating in a sudden suspension of their functions. In a paper upon the subject, 
in the New York Journal of Medicine for September, 1856, he has related six cases 
illustrative of the nature of the injury. When the paralysis, which is generally temporary, 
subsides, the affected nerves are in danger of being assailed by inflammation, which, if 
it cannot be prevented, must be treated in the usual antiphlogistic manner. A long time 
frequently elapses before recovery takes place, the nerves remaining weak, irritable, and 
incapable of performing their proper functions. The limb supplied by the affected cords 
is soon exhausted by exercise, and is the seat of a dull, aching, tired sensation, which is 
always aggravated by exertion, especially if carried beyond a given limit; in time, it be- 
comes cold, atrophied, and, in great degree, useless. The general health also suffers, 
although the disease never proves fatal. 
The treatment, in the first instance, is by rest, absolute and unconditional; and, after 
the nerves have recovered from the immediate effects of the injury, by passive exercise, 
by slapping with a fringed towel wrung out of iced water, followed by massage and dry 
friction, and by attention to the general health, which, in the more severe forms of the 
accident, is always materially, if not seriously, impaired. 
Severe pain is often produced by compression of the nerves, without, so far as can be 
determined, any particular disease of the nerves themselves. In aneurism, for example, 
of the larger arteries, the patient often experiences extreme suffering from this cause. 
The pain, in this case, is either sharp and darting, as in certain forms of neuralgia, or of 
a burning, tearing, boring, or gnawing character, especially if there is at the same time 
erosion of the osseous and cartilaginous tissues. 
When the nerves of the distal portion of an extremity are injured, the fingers and 
toes are peculiarly prone to suffer, becoming, at first, inflamed, swollen, glossy, oede- 
matous, and excessively painful, and afterwards, as more remote effects, atrophied and 
deformed, with various eruptions, ulcers, disease of the nails, and desquamation of the 
cuticle. Such affections are always difficult to manage, and often resist every attempt at 
a perfect cure. 
Finally, the nerves are occasionally the seat of foreign bodies, introduced during the 
infliction of wounds, which they thus serve to complicate. Various kinds of substances 
may thus be carried in, as portions of clothing, pieces of wood, glass, porcelain, or iron, 
and fragments of bone. Denmark has related a case in which part of a bullet was im- 
bedded in the radial nerve ; and Dupuytren met with one in which the end of a lash was 
buried in the ulnar nerve. 
The immediate effects of such accidents are violent pain, spasmodic contraction of the 
muscles, loss of appetite and sleep, and great disorder of the health. Tetanus and neu- 
ralgia are also sufficiently common. The slightest motion and pressure always aggravate 
the local suffering. 
The only remedy is removal of the foreign body, the presence of which is generally 
indicated by the seat of the pain. Sometimes the substance may be distinctly felt with the 
finger. When the suffering persists, it may be necessary to excise a portion of the affected 
nerve. 
SECT. II TUMOKS. 
Various kinds of tumors, as the myxomatous, fibrous, sarcomatous, fatty, and cystic, 
have been found in the nerves, but their occurrence is very uncommon, and their dis- 
crimination is not only difficult, but frequently impracticable. Such growths, which 
seldom attain much bulk, probably always begin in the interfibrillar connective tissue, 
from which, as their development proceeds, they gradually extend to, and ultimately 
more or less seriously involve, the proper substance of these cords. The neuromatous 
tumors, described in a previous chapter, consist mainly of myelenic and amyelenic 
fibres. Cysts, occupied by a gelatiniform, serous, hematoid, calcareous, or osseous sub- 
stance, have been met with in different nerves, especially in the larger trunks of the 
extremities. 
Mr. C. H. Moore, of London, in 1866, described a very curious case, perfectly unique 628 
DISEASES AND INJURIES OF THE NERVES. 
CHAP. III. 
in character, of arterio-venous tumor of the popliteal nerve, in a woman, thirty-one years 
of age, who had been struck in the middle of the ham with an iron pump-handle. It 
presented itself in the form of a vast cyst, shaped like a double cone, occupied by serum, 
black clots, and loose fibrin, interspersed with small clusters of white corpuscles, and 
consisted essentially of an expanded and hypertrophied condition of the component 
elements of the nerve, the fibres of which were disparted in such a manner as to resemble, 
in their mode of arrangement, the fleshy columns of the heart. The inner surface of 
the cyst had a smooth, shining appearance, and was marked by two orifices, one represent- 
ing a large vein, and the other a small artery, which had thus poured their contents into 
the interior of the sac. When Mr. Moore first saw the case, nearly two years after the 
accident, the tumor completely filled the ham, and projected backwards in two prominent 
lesser swellings, which seemed to be partly fluid and partly solid, and which might have 
been mistaken for a large burse, so liable to form in this situation. The tumor was ex- 
quisitely tender on pressure, as well as the seat of severe pain, and violent pain, with a 
sense of tingling, was also felt in the leg and foot. An exploratory incision revealed the 
true nature of the disease, but as the cyst could not be dissected out, and as it would have 
been improper, on account of the woman’s health, to allow it to suppurate, amputation 
was at once performed, and life thus preserved. 
Bertrand met with a cystic tumor in the upper part of the median nerve, of the size of 
a hen’s egg, in a man eighty years of age. It had never occasioned any pain, and was 
filled with sanguinolent fluid, intermixed with clots of blood. 
The treatment of these tumors, whether benign or malignant, resolves itself into three 
distinct procedures :—1st, the removal of the morbid structure by a careful and patient dis- 
section, with as little disturbance as possible of the proper nerve substance; 2dly, the exci- 
sion of the affected portion of the nerve ; and, 3dly, amputation of the limb. The first of 
these procedures would, for obvious reasons, be inapplicable to malignant growths, and the 
second could not be performed with safety when the tumor, benign or malignant, involves 
one of the principal nervous trunks of an extremity, as the operation might be followed 
not only by serious paralysis, but by extensive, if not fatal, mortification. Amputation 
should never be performed, unless it has been clearly ascertained, by a most careful in- 
spection of the morbid mass, that it is the only available expedient. In a case recorded by 
Moutard-Martin excision of a malignant tumor of the median nerve was followed by the 
development in the brain of a similar growth, which caused the death of the patient. 
SECT. Ill TETANUS. 
The term tetanus is a generic one, employed to denote a peculiar affection of the nerves, 
characterized by violent contraction of the voluntary muscles, with irregular intervals of 
partial, .although seldom of complete, relaxation. Different names have been devised to 
designate the disease, according to the nature of the predominant local symptoms occa- 
sioned by the affected muscles. Thus, when the muscles of the lower jaw are spasmodi- 
cally contracted, so as to prevent the patient from opening his mouth, the word trismus 
is employed ; or, to use a common expression, the person is said to have locked jaw. 
When the body is bent forcibly forwards by the action of the abdominal muscles, the 
affection is denominated emprosthotonos, and opisthotonos when it is drawn backwards 
by the dorsal muscles. The term pleurothotonos is used when the body is drawn to one 
side, which, however, is a very rare occurrence. A distinction of much greater impor- 
tance is that of tetanus into traumatic and idiopathic, acute and chronic. The disease 
occasionally comes on within a few days after birth, and is then designated as infantile 
tetanus, the trismus nascentium of authors. 
In this country, especially in its more temperate latitudes, the surgeon has to deal chiefly 
with traumatic tetanus* the idiopathic variety being extremely infrequent. Cases of it, 
however, occasionally occur in the more tropical States of the Union, especially in South 
Carolina, Georgia, Mississippi, Florida, Louisiana, and Texas ; while in the West and 
East Indies it is sufficiently common. The tetanus of new-born infants is met with 
chiefly in the southern and southwestern States of North America, in consequence, 
apparently, of injury sustained in the ligation of the umbilical cord. Infantile tetanus 
seems to have at one time been very common in certain portions of Europe. Thus, it is 
asserted by Dr. Joseph Clark, that in the year 1782, of 17,550 children born in the 
Lying-in Hospital of Dublin, 2944 perished from this cause alone within the first fortnight 
after birth. 
Traumatic tetanus, to which the ensuing remarks are more particularly intended to CHAP. III. 
TETANUS. 
629 
apply, is not peculiar to any age or to any particular pursuit; but is met with at all periods 
of life and in all classes of society. The young, however, suffer more frequently than the 
aged, and it is particularly liable to occur in persons of a nervous, irritable temperament. 
Ill health, especially disorder of the digestive apparatus, grief, anxiety of mind, and whal- 
ed r has a tendency to depress the energies of the system, powerfully predispose to its 
development. Women are quite as liable to the disease as men, but the greatest number 
of cases occur among the latter because they are much more exposed to its exciting causes. 
Blacks and mullattoes suffer more frequently from tetanus than whites. In some portions 
of the West Indies the disease is almost exclusively confined to the colored population. 
Traumatic tetanus occasionally assumes an epidemic tendency. In 1858, numerous 
cases of the disease appeared in rapid succession in several of the London hospitals, the 
attack having often followed upon the most trivial injuries and operations, as the ligation 
of a hemorrhoidal tumor or the amputation of a finger. In one of these institutions not 
less than nine deaths occurred from tetanus within two months. 
Causes—The causes of traumatic tetanus are, as the term implies, various kinds of 
external injury, as punctured, lacerated, contused, and gunshot wounds, burns, scalds, 
abrasions, compound fractures and dislocations, and surgical operations, as amputations 
and the excision of tumors. A number of cases have been recorded in which tetanus was 
produced by salivation. Some of the most trivial accidents are, at times, sufficient to 
occasion the disease. Thus, cases have been observed in which it followed the application 
of the scarificator in cupping, the introduction of a seton, and the extraction of a tooth. 
In three cases of tetanus under the care of Dr. Richard J. Levis, at the Philadelphia 
Hospital, the disease, in one, was occasioned by a slight scald of the back of the hand and 
wrist; in the second, by frost-bite of the feet, and, in the third, by several Vienna paste 
issues made for the cure of varicose veins of the leg. Dr. John Lodge has mentioned to 
me the case of a youth, fourteen years of age, who died from locked jaw, caused by a 
slight scratch on the ball of the thumb, received three weeks previously. Baron Larrey 
has recorded an instance in which it was caused by the lodgment of a fish bone in the 
fauces. Examples of tetanus, consequent upon the ligation of the iliac, femoral, and 
carotid arteries, have been recorded by Brodie, Dazille, and Dudley. I have met with 
it as an effect of the injection of a hydrocele; now and then it follows upon parturition. 
The fact is, in persons of a nervous, irritable temperament, any injury, however trifling, 
may readily induce the affection, especially in hot and damp states of the atmosphere, or 
during sudden transitions from heat to cold. Exposure to cold draughts, by which the 
body is suddenly chilled, is, under such circumstances, extremely liable to provoke an attack. 
In our larger cities numerous cases of tetanus have of late years been caused by injuries 
inflicted with the “toy pistol” during our 4th of July celebrations, at the time when the 
thermometer was high up in the nineties. Of the many persons, chiefly boys, that were 
wounded in Philadelphia, on that day, in 1880, thirty-three, as I am informed by Dr. J. 
Sabastian Miller, perished from this disease, most of them within the first ten days. The 
lesions were in almost every instance inflicted upon the fingers, and the majority of them 
were apparently of a very insignificant character. The average duration of the cases was 
about ten days. In Baltimore, in July, 1881, upwards of twenty fatal cases of tetanus 
occurred from this cause. 
The influence of injuries upon the production of tetanus is apparently much less than is 
generally supposed. Thus, of 3668 cases of operations, large and small, wounds of all kinds, 
injuries and contusions, burns and scalds, and compound fractures, treated at Guy’s Hospital 
during a period of seven years, only 23, according to Mr. Poland, suffered from this disease. 
The effect of cold air, when permitted to play directly upon the body, is well illustrated 
by what occurred after the battle of Ticonderoga, in 1758. The wounded were exposed 
the whole night after the action, in open boats upon Lake George, and the consequence 
was that nine of them died of locked jaw. During our war with Great Britain, most of 
those wounded by fire-arms on board the frigate Amazon, before Charleston, were attacked 
with tetanus on the fourteenth day, from a sudden change of very wet and cold weather 
following a long drought. Wounded soldiers lying on damp or wet ground, are particu- 
larly prone to attacks of this disease. Thus, after the battle of Bautzen, where the men 
were left all night on the field, exposed to severe cold, more than 100 were seized with 
tetanus; and similar effects were witnessed after the engagement at Dresden, from the 
suffering induced by the sudden transition from a hot to a cold, chilly atmosphere. 
The injury inducing the disease may be situated upon any part of the body. It was 
at one time supposed that lesions of the head and face were singularly exempt from tetanus, 
but more enlarged experience has demonstrated that, although it does not occur with the 630 
DISEASES AND INJURIES OF THE NERVES. 
chap. 11r. 
same relative frequency as when the cause is seated in other regions, yet its invasion atter 
such accidents is by no means uncommon. Injury of the inferior extremity is more prone 
to be followed by tetanus than a similar affection of the superior extremity ; and every- 
body knows how remarkably liable the disease is to supervene upon wounds involving the 
tendons and aponeuroses of the hands and feet, especially of the latter. Lesions of fhe 
nerves themselves are peculiarly dangerous in this respect, more particularly when they 
are of a punctured character, or when they are limited to a partial division of their fibres 
and neurilemma, by a blunt instrument, as a piece of glass or a rusty knife. Fatal cases 
of tetanus from the ligation of nerves have been reported by Larrey and other surgeons. 
The extent of the injury does not, so far as can be judged, exert any material influence 
upon the production of the disease, as it has been known to follow, on the one hand, the 
most insignificant scratch, and, on the other, the most frightful wound. I believe, in fact, 
that it may be assumed, as a general principle, that the danger of the occurrence of 
tetanus is, other things being equal, almost in direct ratio to the diminutive size of a 
wound. This is certainly true of a majority of the cases that have fallen under my per- 
sonal observation, an apparently trivial injury, mostly a little puncture, having served as 
the exciting cause. 
Symptoms—The period which intervenes between the occurrence of the injury and 
the development of the disease is liable to considerable variety. Generally it ranges 
from four to ten days. In some instances well-marked symptoms supervene within 
several hours after the receipt of the injury; and, on the other hand, the attack may not 
occur under eight or ten weeks. In rare instances the disease does not appear until after 
the wound that provoked it is completely closed, owing, doubtless, to some lurking irrita- 
tion in the nerves of the affected parts, or to the retention of some foreign substance. 
Although tetanus may come on suddenly, with hardly any premonition, yet, in general, 
the attack is preceded by various anomalous nervous sensations which but too clearly 
foreshadow' its approach. The most important and reliable of these precursories are, a 
feeling of malaise or universal uneasiness, aching in the muscles, stiffness about the lowrnr 
jaw7, pain in moving the head, and difficulty in protruding the tongue. The wound, if 
any exist, commonly puts on an unhealthy appearance, discharging a thin, sanious fluid, 
and manifesting no further disposition to heal. After these symptoms, w'hich are often 
attributed by the patient to the effects of cold, have continued for a variable, but usually 
a very short, period, others, more bold and decisive in their character, set in, leaving no 
longer any doubt respecting their true nature. The jaw now becomes firmly locked ; the 
faculty of mastication is completely abolished; attempts at deglutition excite spasm in 
the throat, with a sense of impending suffocation ; and there is an indescribable distress in 
the precordial region, extending from the ensiform cartilage backwards towards the spine, 
Fig. 262. 
Opisthotonos. 
as if the chest were tightly encircled by a cord. The muscles of the back and abdomen 
are rigidly contracted, and, in no long time, those of the extremities become similarly 
affected. When their action is very violent, the spinal muscles may shorten themselves 
so much as to draw the trunk into a distinct arch, the body resting only upon the occiput 
and heels, the affection thus constituting the variety of tetanus called opisthotonos, illus- CHAP. 111. 
TETANUS. 
trated in fig. 262, from Bell. The opposite state of this, emprosthotonos, is extremely 
uncommon ; for, although the abdominal muscles are usually very firmly contracted, 
being often as hard as a board, yet it is seldom that they are able to counteract the exten- 
sor muscles of the back to such a degree as to bend the head and chest forwards. The 
disease having reached this stage, may be said to be completely and characteristically 
established. Frequent spasms now occur, convulsing and agitating the whole frame, and 
greatly increasing the general suffering. The teeth are firmly clenched; the eyes are 
fixed in their sockets, and have a wild, unnatural expression; the nostrils are expanded; 
the corners of the mouth are retracted ; the countenance has an old, haggard, and withered 
look; the respiration is laborious and hurried; and the smallest quantity of fluid is unable 
to descend the fauces and oesophagus. So great, in fact, generally, is the impediment to 
deglutition, that the very sight of water is a source of suffering. The pain is usually 
severe, particularly about the jaw, throat, chest, and spine; while the general sensibility 
of the surface is so excessive that the slightest breath of air is often sufficient to bring on 
violent spasms. 
Fever is seldom present in traumatic tetanus, even when it has reached its height, 
although the thirst is generally very considerable; the pulse, which rarely exceeds eighty, 
eighty-five, or ninety in the minute, is soft and regular, except, perhaps, during the vio- 
lence of the muscular spasms, when it may be considerably agitated, small, and feeble; the 
tongue, at first moist, becomes gradually dry and brownish ; the stomach is extremely torpid; 
the bowels are generally obstinately constipated; the urine is scanty and high-colored ; and 
the skin is hot and bathed with a copious perspiration, which is occasionally very clammy 
and offensive, especially towards- the latter stages of the disease. The mind is usually 
unimpaired. 
Although such is the most common course of the disease, yet more or less irregularity 
occasionally arises, giving the symptoms somewhat of an anomalous character. Thus, 
there may be little or no pain ; the throat may be free from uneasiness ; the respiration 
may be gasping, or performed with a sort of catch; the eyelids may be half closed and the 
ball fixed; the orbicular muscle of the mouth may be firmly contracted over the teeth; 
and the extremities may remain completely relaxed and powerless. Epilepsy, hysteria, 
and delirium are sometimes noticed. The skin is, occasionally, remarkably hot, the tem- 
perature in the axilla, in some cases, having been found to range as high as 100°, 110° 
and even 112° Fahr. A complete remission of the symptoms is one of the anomalies 
• of the disease, extending sometimes over a period of several weeks, as in an instance 
reported by Dupuytren. Duval refers to several cases in which the disease assumed the 
form of an irregular ague; and Mr, Morgan, of London, saw two patients in whom the 
spasm, instead of affecting the muscles of the jaw, primarily attacked the muscles of the 
part injured. I recently attended, with Professor Wallace and Dr. George T. Barker, a 
young lady of seventeen, who, in consequence of severe irritation of the upper jaw, arising 
from disease of one of the canine teeth, was seized with tetanic symptoms, attended with 
locked jaw, pain in the epigastrium, back of the neck, face, and lumbar region, and the 
most violent opisthotonos. The paroxysms during the first twenty-four hours recurred 
with great frequency, often, indeed, every five or ten minutes, but afterwards, under the 
influence of hypodermic injections of morphia, aided by the use of chloral and quinine, 
they became less frequent, although they did not completely disappear under several weeks. 
The peculiar feature in this case was the entire absence of locked jaw during the intervals 
of the paroxysms, the attack having evidently been one of hysteria associated with tetanus. 
Diagnosis The diagnosis of tetanus rarely, if ever, presents any difficulties. In 
general, the history of tbe case alone is quite sufficient to determine its true character. 
The only disease with which it can be confounded is hydrophobia, but the symptoms of 
the two affections are so very different that none but the most heedless practitioner could 
possibly commit such an error. The period of latency in hydrophobia is, on an average, 
not less than a month, while tetanus is usually developed in from five to fourteen days 
from the infliction of the injury which provokes it. Besides, in rabies there is an absence 
of locked jaw and of opisthotonos, which constitute such striking features in tetanus. 
One of the most valuable diagnostic symptoms of tetanus is the terrible distress in the 
precordium ; it is usually described as of a painful, dragging nature, and is no doubt 
dependent upon spasmodic contraction of the diaphragm. Coming on early in the disease, 
it generally continues to its close, and is nearly always attended with opisthotonos, the 
head and shoulders being drawn, as it were, instinctively backward, to relieve pain and 
to favor the introduction of air into the lungs. In tetanus, the muscular contraction is 
steady and persistent, although liable to frequent and sudden exacerbations; in hydrophobia 632 
DISEASES AND INJURIES OF THE NERVES. 
CHAP. III. 
it is clonic, occurring paroxysmally, and having distinct intermissions. In tetanus, 
swallowing is difficult, chiefly by reason of the impossibility of separating the jaws; in 
rabies, it is dependent upon spasm of the throat and oesophagus ; in the former, the mind 
is calm and unaffected ; in the latter, it is often powerfully excited, and, at times, even 
furious. , 
Tetanus, especially in its chronic form, has sometimes been mistaken for rheumatism, 
from which, however, it is always readily distinguishable by the history of the case and the 
absence of spasm in the muscles of the jaw. 
Poisoning by strychnia closely simulates tetanus. There is, however, no locked jaw ; 
the patient is able to open his mouth and swallow; the agitation, trembling, and convul- 
sions are more violent; the symptoms come on suddenly, and rapidly disappear when the 
dose is small, or death soon occurs when the quantity is large. 
Prognosis The prognosis in traumatic tetanus is extremely unfavorable. In the great 
majority of cases death occurs from the third to the fifth day; and if an instance of recov- 
ery is occasionally met with, it only goes to confirm the general law of the mortality of 
this affection. In an experience of fifty years, I have seen but three cases where the 
patient escaped with his life, and then only after a protracted and painful struggle. When 
the disease has once fairly commenced, the tetanic spasms generally continue to recur, 
with more or less severity, until they prove fatal. There are no reliable signs which can 
serve to guide us in regard to the prognosis in this affection. The previous state of the 
general health, the age of the patient, and the character of the pulse, afford no clue as to 
the probable issue of the case. The young and the robust fare no better, in this respect, 
than the old and infirm. Both alike perish from its attacks. The danger is undoubtedly 
always, other things being equal, in proportion to the violence and duration of the parox- 
ysms, and it has been found that any tendency to chronicity is generally so much in favor 
of ultimate recovery; although patients sometimes live for several weeks, and then die 
from the effects of the malady. 
Of 415 cases of this disease tabulated by the late Dr. R. O. Cowling, of Louisville, 
Kentucky, 233 recovered, and 182 died, the mortality being greatest in children under 
ten years of age, and least between ten and twenty years. Professor D. W. Yandell, from 
a careful analysis of these cases, finds that persons are most likely to recover from acute 
tetanus when the attack occurs subsequent to the ninth day after the injury, and that, when 
the symptoms have lasted fourteen days, restoration is the rule, and death the exception, 
apparently independently of the treatment. Of 363 cases of traumatic tetanus that occur- 
red during our late war, 336 terminated fatally. Of 27 reported cures, the disease was of 
a chronic character in 23. 
The manner in which death occurs is not well understood. In some instances it is, 
apparently, caused by suffocation, from spasm of the muscles of the larynx ; occasionally 
it results from mere exhaustion, life being worn out by the intensity of the suffering; and 
in a third class of cases it may probably be induced by spasm of the heart, interrupting the 
passage of the blood to the lungs and brain. 
Pathology It might reasonably be supposed that a disease which is characterized by 
so much violence during life, would leave some traces of its existence after death ; but, to 
show how erroneous such a conclusion is, it is only necessary to refer to the fact that all 
the dissections that have hitherto been made of persons dead of this affection have utterly 
failed to throw any satisfactory light upon its pathology and morbid anatomy. Many 
statements have been reported with reference to these dissections that are entirely without 
foundation; in fact, in not a few of the cases, natural or accidental appearances have been 
confounded with morbid, and lesions have been described which existed only in the imagi- 
nation of the examiners. From the circumstance that tetanus is essentially a nervous 
affection, the brain and spinal cord, as well as the nerves emanating from them, and even 
the great sympathetic, with its plexuses and ganglia, have all been most thoroughly scru- 
tinized in numerous instances, and that, too, by some of the ablest men in the profession, 
and yet, notwithstanding all this, we are no wiser now in regard to the actual lesions of 
this disease than surgeons were centuries ago. The whole subject is, in truth, still a mys- 
tery. I have myself made several dissections of this kind, and have witnessed others, 
amounting, perhaps, altogether to eight or ten, without having, in a single one, observed 
any morbid appearances that could justly be ascribed to the effects of the disease. It has 
been noticed in several instances that the nerves leading from the wound which caused 
the attack were in a state of inflammation, their substance and neurilemma being congested 
and discolored. 
Of the true pathology of tetanus, then, nothing whatever of a satisfactory nature is TETANUS. 
633 
CHAP. III. 
known ; that it is essentially an affection of the nervous system, or of the nerves of par- 
ticular muscles, must be admitted from the symptoms which characterize it; but in what 
the peculiar change consists, and to what extent it is carried, are points in the history of 
the lesion of which we are completely ignorant. 
Treatment.—The treatment of this obstinate, and, unfortunately, too generally fatal, 
disease, is altogether of an empirical character. That this should be so is not surprising, 
when it is remembered how completely ignorant we are of its pathology, and the fact that 
there is hardly an article of the materia medica, of any reputed efficacy, that has not been 
employed, either singly, or in various forms and modes of combination, for its relief. 
Although patients occasionally get well of this disease, under circumstances, apparently, 
the most desperate, yet, when the practitioner comes to analyze his treatment, in the true 
spirit of philosophy, he is generally compelled to confess his ignorance as to the share 
which his remedies may have exerted upon the fortunate event, and to acknowledge that 
accident, rather than his own skill, performed the cure. However this may be, it is cer- 
tain that the disease sometimes either wears itself out, or yields to the most insignificant 
measures, while at other times it resists the best directed efforts of the ablest and most 
experienced practitioner. The chances, indeed, of effecting any good, when the malady 
is fairly established, are very slender in any case, however mild. Hence, whatever is 
done should be done promptly, and with a view to a prophylactic rather than to a curative 
result. 
One of the first and most important indications in traumatic tetanus is the removal, if 
possible, of the exciting cause, which is, of itself, occasionally sufficient to effect a cure. 
Thus, if any foreign body remain in the wound, or in contact with the living tissues, the 
surgeon cannot too speedily extract it, especially if there is already some evidence of 
approaching disease. Sometimes a vicious cicatrice may keep up the tetanic irritation. 
Many years ago, I attended, in consultation with Dr. Buck, a young girl of fourteen, who 
had locked jaw from having been accidentally hurt, nearly a month pi-eviously, in the 
right cheek, by a small splinter of wood. Although the substance was immediately ex- 
tracted, yet the parts continued to be tender, being, at times, even quite painful, and in 
less than a week tetanus set in. When I saw the case, free use had already been made, 
without any material benefit, of anodynes and antispasmodics, along with an occasional 
purgative, and the cheek had been leeched and repeatedly painted with iodine. The girl 
was pale and feeble, and had lost her appetite. Upon examining the original site of the 
injury, I found a small, circumscribed spot, exquisitely tender under pressure, and of 
almost fibro-cartilaginous hardness. This being carefully dissected out, no more paroxysms 
occurred ; and in a few days, with the aid of iron and quinine, wine, and a generous diet, 
complete recovery ensued. 
Amputation of the wounded part has occasionally been performed; and, judging from 
the statistics that have been published upon the subject, there is reason to believe that the 
operation has now and then proved successful. Nevertheless, few surgeons would, prob- 
ably, be found to be so venturous as to remove a leg or an arm on the approach of such a 
disease, and none certainly would be foolish enough to attempt the expedient after it is 
fully established. In the one case, the possibility is that the affection might yield to other 
and milder means; and, in the other, as the disease is no longer one of a local character, 
but diffused, as it were, through the system, it is difficult to see how amputation, however 
early performed, could be of any benefit in arresting the morbid action, unless it be upon 
the principle of substituting a fresh and clean wound for one of an inflamed and irritable 
character. An interesting case, bearing directly upon this point, fell under my observa- 
tion, in a patient of Dr. Mattingly, of Kentucky. The man, who was fifty years of age, 
was a stout, healthy farmer, of a nervo-sanguineous temperament, who, about five weeks 
previously, had the fore and middle fingers of the right hand, between the second and third 
joints, severely mashed by the passage of the wheel of a wagon, the phalanges being com- 
pletely comminuted, and supported merely by a few shreds of integument. A physician, 
shortly after the accident, removed the injured parts with the scissors, and, binding up 
the ill-formed stumps, sent the man home, a distance of thirty-five miles. Excessive pain 
soon ensued, followed, at the expiration of the time above specified, by well-marked symp- 
toms of tetanus. Five days after this, while the patient was under the influence of chloro- 
form, I removed the mutilated fingers at the metacarpo-plialangeal joints, the whole hand 
being at the time much swollen and exquisitely tender, the tongue coated, the pulse hard 
and accelerated, and the system irritable from the want of sleep. The tetanic spasms 
continued for several days after the operation, but they became gradually lighter, shorter, 
and less frequent, and in a few weeks all symptoms of the disease had entirely disappeared. DISEASES AND INJURIES OF THE NERVES. 
CHAP. III. 
How far the recovery in this case was due to the amputation of the affected fingers, 
it would be difficult to determine; but it is reasonable to suppose that the operation was 
serviceable by ridding the system of a mass of irritation and disease, which, if it had 
been permitted to continue, might have proved highly detrimental, if not destructive, to 
the patient. 
In regard to the treatment of the wound itself, it cannot be doubted that prompt atten- 
tion to it is of great moment. The remedies should generally be of the most soothing 
character, consisting of warm water-dressing, or emollient cataplasms, with a liberal ad- 
mixture of laudanum, powdered opium, or, what is better than either, sulphate of mor- 
phia. If the parts are girded by inflammatory engorgement, or various kinds of deposits, 
as will be likely to be the case when the wound is of a punctured character, free inci- 
sions must be made, the knife being carried thoroughly through the tissues in every direc- 
tion. A similar method should be adopted when there is reason for suspecting the 
lodgment of foreign matter. The practice, at one time so common, and, perhaps, not 
yet sufficiently exploded, of pouring irritating fluids into the wound, or of applying es- 
eharotics, cannot be too severely censured, as it must inevitably increase the suffering, 
and aggravate the disease. 
I have no experience with excision of the nerves connected with the injured structures; 
an operation said to have sometimes been successfully performed by foreign surgeons. 
Such a step could only be justified in the case of the smaller nerves, and then, I presume, 
all the good that would be likely to accrue from it might readily be accomplished by the 
free division of the affected parts. Excision of the larger nerves might be followed by 
permanent paralysis. Stretching the nerves has occasionally succeeded in traumatic 
tetanus, and is worthy of further trial. 
The patient must be carefully protected from the contact of cold air. Exposure of the 
body to a direct current is often, of itself, sufficient to bring on an attack of tetanus in a 
susceptible, nervous person ; and, after the attack is fairly established, such an occurrence 
never fails to aggravate the spasms, rendering them both more frequent and violent. The 
atmosphere of the room should, moreover, be perfectly warm and dry, experience having 
shown that cold and moisture combined are extremely prejudicial in all affections of this 
description. 
The most important internal remedies, undoubtedly, are anodynes and antispasmodics, 
of which opium, chloroform, Calabar bean, tartar emetic, aconite, camphor, assafoetida, 
and Indian hemp occupy the highest rank. They should be administered in large doses, 
with a view to an immediate and decided impression upon the general system, and should 
be given either by themselves or in various states and degrees of combination. 
The most eligible preparations of opium are the acetated tincture and the salts of mor- 
phia, particularly the sulphate. Opium in substance is objectionable, on account of its 
insolubility, the stomach, under such circumstances, being extremely torpid, and unable 
to act upon it. For the same reason, a much larger quantity of laudanum and morphia 
is required to produce their specific effect than in ordinary diseases. If the patient be 
young and robust, or when the spasms are violent and obstinate, the anodyne should be 
combined with tartar emetic, in doses sufficiently large to relax the system. The latter 
remedy is sometimes employed by itself, and cases have come under my observation where 
it seemed to have effected a complete cure. I am satisfied, however, that its efficacy will 
always be materially enhanced by its judicious combination with morphia. The most 
prompt and efficacious method of administering morphia is by hypodermic injection, 
from a third to half a grain being thus introduced, either alone, or in union with the 
fiftieth of a grain of atropia, two or three times in the twenty-four hours, according to the 
violence of the suffering. 
Aconite is a medicine of great efficacy as a depressant, and may be given as an adju- 
vant to morphia, or morphia and tartar emetic, in cases of tetanus attended with a robust 
and plethoric state cf the system. It lowers the action of the heart, promotes perspira- 
tion, and relieves spasm. Yeratrum viride acts in a similar manner. 
Camphor and assafoetida, administered in large doses, occasionally aid in controlling 
the spasms in this disease, but they should never be trusted in alone. Their influence, as 
antispasmodics, is far inferior to that of morphia and tartar emetic. 
Indian hemp, soon after its first introduction into practice, received a large share of 
attention in the treatment of this disease, especially from the East India practitioners, 
some of whom were at one time disposed to regard it as a specific. Subsequent experi- 
ence, however, has greatly disappointed these expectations, and in this country very little, CHAP. III. 
TETANUS. 
635 
if any, confidence is placed in the remedy. I certainly have never derived any appreci- 
able benefit from it in the few cases of tetanus in which I have employed it, although the 
trials in each were very fair. The preparation usually given is the extract, in doses vary- 
ing from one to two grains, repeated every two hours, or even more frequently, the object 
being the production and maintenance of narcotism. 
The Calabar bean has been repeatedly employed in the treatment of tetanus, and cases have 
been reported in which its use was apparently followed by a complete cure. Its virtues, 
however, have undoubtedly been greatly overrated, and in two cases in which I made 
trial of it no appreciable benefit whatever resulted. The best form of the medicine is the 
extract, given in doses of one grain every two, three, or four hours, according to the vio- 
lence of the symptoms. 
Professor Christopher Johnston, of Baltimore, has reported several cases of traumatic 
tetanus, treated successfully with hypodermic injections of conia. His formula consisted 
of two drops of conia with one of sulphuric acid in one drachm of water, of which fifteen 
drops were introduced every two hours, day and night. In two other cases, one caused 
by gangrene from frost-bite, and the other by syphilitic ulcers of the leg, although the 
attacks were fatal, the remedy exerted a powerful influence in controlling spasm and 
muscular rigidity. Successful results have also been ascribed to the exhibition of gelse- 
mium, tobacco, nitrite of amyl, and bromide of potassium. 
Chloroform, administered internally, or inhaled in the form of vapor, has been much 
employed in this disease, and cases said to have been successfully treated by it have been 
reported by different observers, but how far they were really relieved by it is not deter- 
mined. It is, however, certain that it generally signally fails to cure, and that it is of 
use chiefly in assuaging pain and spasm. 
Much comfort is often experienced from the use of the vapor bath in the treatment of 
tetanus; the steam should be conveyed, by means of a tube, from the spout of a tea- 
kettle, or other suitable apparatus, under the bedclothes, and may be advantageously 
medicated with laudanum, or laudanum and chloroform. The remedy possesses no cura- 
tive agency. 
In my own hands nothing has afforded so much relief in mitigating suffering and pre- 
venting pain and spasm as quinine, combined with morphia, and given in doses of three 
to five grains every three or four hours. Other practitioners have found it equally valu- 
able in this respect. Chloral, administered more or less freely, often acts beneficially in 
promoting sleep and preventing spasm. Even a cure is occasionally, at least apparently, 
effected by this agent; I say apparently, because in most of the recorded cases it is diffi- 
cult, if not impossible, to eliminate the effects of chloral from those of other remedies. 
Dr. John B. Roberts, in 1877, published a table of nineteen cases of traumatic tetanus, 
treated with hydrate of chloral, in the Pennsylvania Hospital, of which sixteen perished, 
and three recovered. The remedy deserves further trial in this disease. 
Bloodletting and mercury, the latter carried to the effect of salivation, were at one 
time much vaunted on account of their supposed efficacy in the treatment of tetanus. They 
have, however, of late years, been entirely abandoned. The patient is certainly reduced 
sufficiently soon without venesection ; and as to mercury, its use has occasionally, as 
stated elsewhere, been followed by the very disease which it was intended to cure, the saliva 
streaming at the time from the mouth in enormous quantities. 
When much exhaustion exists, the use of brandy, wine, and a generous diet is indicated, 
along with quinine and other corroborants. Rectal alimentation must be employed when 
the patient is unable to swallow. The profuse and exhausting sweats so often attendant 
upon the disease are best controlled by atropia or atropia and aromatic sulphuric acid, 
and by frequent sponging of the surface with a strong solution of alum. 
Whatever treatment may be adopted, proper attention should be paid to the bowels, 
which are generally excessively torpid, and, consequently, difficult to be moved. When 
the patient is in a condition to swallow, he may take ten grains of calomel, with double 
that quantity of jalap, every six hours, until there are free alvine evacuations. If the 
medicines are tardy in their action, the operation may be promoted by the addition of a 
drop of croton oil, or by means of a stimulating injection, as spirit of turpentine and 
castor oil. Occasionally, croton oil may advantageously be rubbed upon the abdomen. 
Severe purging must be carefully avoided, as, from its irritating and prostrating effects, it 
cannot fail to aggravate the complaint. 
The treatment of tetanus by counterirritation is, in great degree, obsolete. It was for- 
merly thought, when the disease was supposed to be essentially connected with inflamma- 
tion of the cerebro-spinal axis, that extensive and rapid vesication of the spine would 636 
DISEASES AND INJURIES OF THE NERVES. 
CHAP. III. 
afford valuable aid in combating the morbid action, and putting a stop to the spasms; and 
examples illustrative of the beneficial effects of this mode of treatment have been pub- 
lished by different observers. The remedy usually selected is either the common blister, 
hydrate of potassium, or the actual cautery. The late Dr. Hartshorne, of this city, was in 
the habit of employing a solution of hydrate of potassium, in the proportion of one drachm 
and a half to two fluidounces of distilled water. It produces a powerful rubefacient effect, 
and may be applied by means of a cloth mop to a narrow line of skin, from the occiput to 
the sacrum. If the hot iron be used, it should be applied transcurrently. I have, however, 
great doubts in regard to the propriety of any measures of this kind, believing that they 
frequently aggravate the symptoms instead of relieving them. 
When the disease is chronic, and there is a wound which is still open, but indisposed 
to heal, the best plan is to divide the parts freely with the knife, so as to relieve them of 
engorgement, and invite a more salutary action. It is under such circumstances that the 
actual cautery occasionally answers a good purpose. In a case in the practice of Dr. W. 
D. Stewart, of Indiana, the particulars of which he has kindly communicated to me, an 
immediate stop was put to the paroxysms by this procedure, after various other means 
had been fruitlessly tried for nearly a fortnight. No spasms took place after the applica- 
tion, and the patient, a lad nine years of age, made a prompt and perfect recovery. The 
wound which had provoked the attack was a large lacerated one, occupying the right side 
of the scalp, and extending down to the bones. 
Anodyne and stimulating liniments, strong veratria ointment, and ice-bags applied along 
the spine, have sometimes acted beneficially, both in moderating the spasms and in eradi- 
cating the disease. Chloroform has also been used a good deal in this manner, and cases 
of its successful employment have been reported; among others, a very interesting one, 
by Dr. Hinkle, of Pennsylvania, of a woman who suffered from tetanus from the bite of 
an eel. The treatment was conjoined with purgatives and antispasmodics, as cannabis 
Indica, valerian, and compound sulphuric ether. 
Finally, if the patient be so fortunate as to survive the disease, the greatest care must 
be observed during his convalescence, lest relapse occur and destroy him, when he is 
apparently on the verge of returning health. The clothing should be warm, the diet 
light but nutritious, the bowels and secretions duly regulated, and exposure to atmospheric 
vicissitudes sedulously avoided. 
After all that has been done by modern science for the cure of traumatic tetanus, the 
humiliating fact stares us in the face that, of the many remedies that have been paraded 
before the profession, there is not one that is worthy of special confidence. An analysis 
of the cases tabulated by Dr. Cowling clearly shows, as Professor Yandell very justly 
remarks, that the results of treatment by different remedies are so nearly alike that no 
one agent can properly be considered as possessing any decided superiority over any other. 
All, in fact, are equally of apocryphal virtue. 
SECT. IV NEURALGIA. 
Neuralgia is an affection of the nerves attended with severe, agonizing pain, often 
paroxysmal in its character, liable to occur in all parts of the body, and generally de- 
pendent upon some local irritation, or upon the joint agency of a local and constitutional 
cause. As it would be out of place in a work of this kind to treat of neuralgia in general, 
I shall limit my remarks here chiefly to the disease as it manifests itself in certain nerves, 
particularly those about the face, where the lesion not unfrequently becomes the subject 
of surgical interference. 
The causes of neuralgia are various and of the most opposite character. They are pre- 
disposing and exciting. Persons of a nervous, irritable, or hysterical temperament are 
more prone to the disease than any other class of individuals. The gouty and rheumatic 
also frequently suffer from it. Depressing influences, whether mental or corporeal, are 
among its most common predisposing causes. Dyspepsia and anemia, by lowering the 
powers of the system, remarkably favor its development. 
The disease occurs in both sexes, at all ages, and at all seasons ; it is most common, 
however, from the twentieth to the fiftieth year, and in winter and spring, in cold 
northern regions, and in districts abounding in malarial exhalations. Cold and damp 
states of the atmosphere are especially favorable to its production. Like gout and 
rheumatism, the disease occasionally manifests a hereditary predisposition, and in a 
number of instances I have met with it in several members of the same family. No 
parts of the body are exempt from its attacks. It is particularly frequent in the head, CHAP. III. 
NEURALGIA. 
637 
face, and jaws. The hysterical temperament disposes to neuralgia of the spine, joints, 
and bones. 
The exciting causes of neuralgia are of a local and general nature. Among the former, 
exposure of a nerve to the air, or its compression by some tumor, as an exostosis, or soft 
growth, is the most common. The most atrocious attacks of this disease are generally 
witnessed in the branches of the trifacial nerve, in consequence of caries of the teeth, 
laying open their cavity, and thus allowing the air and other irritating substances to come 
in contact with the denuded nerve within. Similar effects are often produced by the 
pressure of a dental exostosis, or by the mere thickening of the periosteum covering the 
fang of a tooth. Occurrences of a like nature often excite neuralgia in the bones. Some- 
times the disease is awakened by the contusion of a nerve, occasioned by a blow, fall, or 
kick ; by the irritation of an old, indurated cicatrice; or by the excitement induced by 
the presence of a foreign body, as a splinter of wood. In the face, neuralgia may be 
caused by the lodgment of a piece of dead bone in the nose or antrum. A calculus may 
produce the disease in the bladder, worms in the bowels, and the larvae of insects in the 
frontal sinus. Neuralgia of the pelvic viscera is often induced by the pressure of a dis- 
placed uterus upon the surrounding structures. 
Exposure to cold while the body is overheated and covered wTith perspiration is a 
very common exciting cause of neuralgia. When the predisposition to the disease is 
very strong, the slightest draught of cold air will often almost instantaneously bring on 
an attack. Exposure to heat is less injurious, although it is also capable of exciting the 
disease, especially when the heat is concentrated for any length of time upon one partic- 
ular locality. 
Attacks of neuralgia are sometimes induced by gastro-intestinal irritation, dependent 
upon a redundancy of acid, indigestible food, worms, impacted feces, or an overloaded 
state of the bowels. The disease is not uncommon in dysmenorrhoea, in ulceration of the 
neck of the uterus, in spinal irritation, and in organic lesions of the brain. 
A syphilitic taint of the system occasionally gives rise to it. Lancereaux has recorded 
three cases of sciatica which, having long resisted all treatment, yielded as if by enchant- 
ment to the use of mercury and iodide of potassium. Gonorrhoea may act in a similar 
manner, the attack being characterized by the suddenness of its invasion, the rapidity 
with which it attains its maximum of intensity, and the shortness of its duration. 
Occasionally the cause is seated in the nerve itself, as when it is inflamed, partially 
ulcerated, or denuded of its natural coverings. After amputation, the stump often be- 
comes affected with neuralgia in consequence of the extremities of some of the nerves 
being expanded into neuromatous tumors ; and similar effects sometimes supervene upon 
the division of the nerves in cases of wounds, especially lacerated ones. 
Finally, the occurrence of neuralgia, as a consequence of malaria, is familiar to every 
one. In the southern and southwestern States of the Union, where neuralgia of every 
form and grade is extremely prevalent, the disease, in the great majority of cases, recog- 
nizes no other cause. The attacks, under such circumstances, are generally of a distinctly 
intermittent type, very similar to those of intermittent fever, recurring once every day 
or every second day, and, after having continued with great severity for several hours, 
gradually going off, to reappear about the same period on the next day ; each paroxysm 
being, perhaps, ushered in by chilly sensations, and terminating in more or less profuse 
perspiration. 
Symptoms—The nature of the pain in neuralgia is not always the same. In one case, 
it is dull, heavy, and aching ; in another, acute and extremely violent ; in a third, it re- 
sembles the pain produced by thrusting needles into the tissues; in a fourth, it is pungent, 
smarting, or burning; in a fifth, it is sharp and darting, like an electric shock, running 
through the parts with the rapidity of lightning. 
The pain, whatever its character may be, is generally attended with more or less sore- 
ness and tenderness of the affected parts, which sometimes pit on pressure, although they 
are seldom discolored. Finally, the pain may be concentrated, or diffused ; that is, 
it may be strictly localized, or limited to one particular spot, and that, perhaps, a very 
small one ; or it may be extended over the greater portion of a nerve, or even over its 
entire length. 
It is important to bear in mind that the pain often breaks out at a point very remote 
from the one upon which the impression provoking the attack is made. Thus, supra- 
orbital neuralgia is often produced by disorder of the stomach, or of the stomach and 
bowels; a carious tooth has been known to give rise to neuralgia of the hip ; and spinal 
irritation not unfrequently occasions neuralgia of the leg, heel, and foot. A very singular 638 
DISEASES AND INJURIES OF THE NERVES. 
CHAP. III. 
case lias been reported where a severe attack of neuralgia of the left forearm could always 
be instantly excited by touching the meatus of the right ear. 
Neuralgia is sometimes associated with rheumatism, and it is to this form of the disease 
that the term rheumatico-neuralgic is usually applied by nosologists. The combination 
is most generally met with in persons of an arthritic predisposition, commonly affects the 
muscles, especially the intercostal and spinal, and is often exceedingly intractable, render- 
ing the patient miserable for life, and at length wearing him out by the constancy of his 
pains. 
Neuralgia often exists simultaneously in different parts of the body, and when it is 
once fairly established it is easily excited by the most trivial circumstances. Its progress 
is variable. In many cases it readily yields to treatment, or disappears even spontane- 
ously ; on the other hand, it is sometimes a most intractable disease, worrying and fretting 
the patient, undermining his general health, and disqualifying him for business and enjoy- 
ment. In its worst forms the suffering is almost constant; whereas, in the milder, there 
are not unfrequently long intervals of complete, or nearly complete, exemptions from pain. 
When the affection is contracted early in life, and proves rebellious, it is seldom entirely 
got rid of, whatever means may be adopted tor its relief. 
Pathology—The pathology of neuralgia is not understood. It has generally been 
supposed to consist in a mere exaltation of the sensibility of the nervous tissue, but if 
this were true it would, probably, not be so intractable a disease as it often is. The 
explanation may, perhaps, hold good in those cases in which the disorder is very transient, 
or of malarial origin. In general, however, there is some degree of inflammation, either 
in the nerve-pulp or in the neurilemma, or in both, as is proved by the fact that the parts 
supplied by the affected nerves are commonly more or less tender, oedematous, and even 
somewhat discolored; phenomena clearly indicative of an engorged and incited state of 
the capillary vessels with a tendency to effusion. In other cases, again, it may consist in 
a mere perversion of the nervous fluid, as when a nerve is compressed by interstitial 
deposits, or by causes acting upon its periphery, thereby interrupting the current across 
the seat of the obstruction. 
Neuralgia seldom proves fatal. Its course is irregular. It may last for months, years, 
a lifetime, the patient finally dying of some other disease. The most dangerous form is 
visceral neuralgia, which sometimes causes death by the constancy and violence of the 
attendant pains. 
Treatment—.The treatment of neuralgia must be deduced, in great degree, from the 
nature of the exciting cause, which should, therefore, always receive prompt attention, 
removing it where this is practicable, or modifying it where it is not, so as to render it 
as harmless and inoperative as possible. In neuralgia of the face, for example, it will 
often be found that the cause of the trouble is a carious tooth, upon extracting which the 
pain instantly vanishes. Neuralgia dependent upon the presence of an old, callous cica- 
trice, can only be successfully relieved by the excision of the offending tissues. Vermi- 
fuge medicines are indicated when it is caused by worms ; antacids, when it is excited 
by vitiated secretions of the stomach ; purgatives, when it is occasioned by an overloaded 
state of the bowels. Thus, it will be perceived that no single remedy, or class of remedies, 
is adapted to all cases; a fact which strongly suggests, in every instance, the importance 
of a most thorough and critical examination of the state of the part and system, with a 
view to the institution of a rational therapeutics. 
It must not be expected, however, that the disease will always disappear upon the 
removal of the exciting cause. Generally, indeed, it will, and that very promptly and 
effectually ; but there are cases where it is inclined to linger, with little or no mitigation, 
for an indefinite period, the affected parts being seemingly unable to recover their natural 
functions, either because they have become habituated to the morbid action, or because 
they have experienced some organic change which no medication can reach. 
The treatment of neuralgia is general and local, except when the cause is obviously of 
a purely local character, when general means may usually be dispensed with. Purgatives, 
a proper regulation of the diet, and antineuralgic remedies, as they are named, constitute 
the more important constitutional measures; while embrocations, leeches, vesicants, the 
hypodermic use of morphia, and section of the affected nerves, comprise the more efficient 
and reliable topical agents. 
There are few cases of neuralgia which are not benefited by the use of purgatives; 
sometimes, indeed, the disease promptly disappears under a few brisk cathartics. Their 
exhibition is particularly indicated when there is a coated staite of the tongue, disorder of 
the stomach, a vitiated condition of the secretions, headache, pain and aching in the limbs, CHAP. III. 
NEURALGIA. 
or an overloaded condition of tlie bowels. The best articles are blue mass, colocynth, and 
jalap, or the compound calomel pill, repeated every other night until there is a decided 
improvement in the general health. Emetics may often be advantageously exhibited, 
especially when there is evidence of biliary and gastric derangement. The pain is gene- 
rally mitigated by their action, and sometimes completely removed, the moment they 
begin to manifest their specific effect. 
The diet must be plain and simple, easy of digestion, and adapted, in regard to its 
nutritive qualities, to the exigencies of each particular case. The plethoric will be bene- 
fited by abstinence ; the pale and anemic, by good living. When the general health is 
much impaired, tonics, as quinine and iron, a generous diet, wine, brandy, porter, and 
ale, with exercise in the open air, will be of service. Sometimes a sea voyage, or a 
residence near the sea shore, is salutary. 
There are several articles of the materia medica which may be considered as exerting, 
in some degree, a specific influence over neuralgic affections, and which have hence 
received the name of antineuralgic remedies. To this class belong quinine, arsenic, 
strychnia, aconite, and morphia, along with some other anodynes, and the different pre- 
parations of iron. 
Quinine, the great antiperiodic in intermittent fever, is entitled to the highest rank in 
the treatment of neuralgia, particularly in that variety in which the paroxysms observe a 
regular diurnal relapse, with an interval of entire freedom from suffering. It may be 
administered by itself or in union with an opiate, and a few efficient doses are almost 
sure to break up the attack promptly and effectually. In my own practice, I seldom give less 
than ten grains at a dose, repeated every six or eight hours, until the affection is either 
vanquished, or the specific effects of the medicine are rendered apparent by the aural and 
cephalic distress. Some practitioners prefer smaller doses, but experience has shown me 
that they are less trustworthy, and that, at all events, a much longer time elapses before 
they put a stop to the disease. Quinine is sometimes very beneficial when the affection 
is not of malarial origin, but, in general, its effects are much less apparent. 
In chronic neuralgia, or in acute but obstinate attacks, arsenious acid is generally found 
to be one of the best remedies, given in doses varying from the eighth to the fifteenth of 
a grain, three times a day, in union with an anodyne, or anodyne and tonic. There are 
few cases of the disease, however obstinate, that will not be materially benefited by the 
use of this article, if administered with proper judgment and perseverance. The acid is 
far preferable, in every respect, as an antiperiodic, to Fowler’s solution, as it is much less 
liable to cause nausea and anasarca. 
With the value of strychnia, as an antineuralgic, every practitioner is familiar. I have 
used it, as such, for many years, and its effects have rarely entirely disappointed my 
expectations. The dose recommended in the books is much too large. I rarely give 
more than the sixteenth or twentieth of a grain, thrice in the twenty-four hours. Extract 
of mix vomica is also employed for the same purpose, but is seldom productive of any 
decided benefit. 
In trigeminal neuralgia the most reliable remedies are croton chloral, gelsemium, and 
Duquesnel’s crystallized aconitia. The first of these articles may be exhibited in one 
grain doses every hour. The gelsemium is administered in the form of tincture in doses 
of twenty drops every half hour until three doses have been taken. Aconitia is contra- 
indicated in disease of the heart. In ordinary cases the one hundred and fortieth of a 
grain, dissolved in alcohol, glycerine, and water, is repeated every eight hours. 
In some cases relief is more readily obtained from the exhibition of chloride of am- 
monium than from any other remedy. It is particularly serviceable in neuralgia of the 
face and head, especially in that form of the disease known under the name of hemicrania ; 
but it may also be very advantageously employed in neuralgia of the viscera, spine, chest, 
and extremities. The dose should generally be large, as from twenty to thirty grains, 
repeated three or four times in the twenty-four hours. 
The use of morphia is absolutely indispensable in the treatment of neuralgic complaints, 
not so much as a curative agent, as for the purpose of controlling the excessive pain and 
inducing sleep. There are cases, however, which are radically cured by the persevering 
exhibition of this remedy, but then it is generally necessary to give it in large and sus- 
tained doses. Protracted narcotism has occasionally vanquished the disease after all 
other means have failed to afford even temporary relief. Several examples of this kind 
have fallen under my own immediate observation, and others have been mentioned to me 
by professional friends. For ordinary purposes the quantity need not exceed a fourth 640 
DISEASES AND INJURIES OF THE NERVES. 
C1IAP. III. 
or third of a grain, and, in chronic or subacute cases, I rarely give more than the tenth, 
twelfth, or fifteenth of a grain, repeated thrice a day. 
For many years past I have been in the habit of employing, with very happy effects, 
in a great variety of cases of neuralgia, a combination of some or all of the above articles, 
giving them in pill form three or four times in the twenty-four hours. The subjoined 
will serve as a type of such a formula.1 It need hardly be added that the effects of the 
prescription should be carefully watched, as several of the articles are of a potent and 
even a poisonous character. If the system be anemic, two grains of the sulphate of iron 
or of the valerianate of that salt may be incorporated with each pill. Carbonate of iron I 
never use, as it has always disappointed my expectations, even when administered in 
large doses and for a long time, and my experience, in this respect, is, I believe, fully 
corroborated by the results of the observations of other practitioners. When the attack 
depends upon the presence of a redundancy of vitiated gastric acid, the solution of vale- 
rianate of ammonium will be found a highly efficient remedy, administered in the dose of 
a drachm every two or three hours until relief is afforded. Iodide of potassium has been 
much lauded as an antineuralgic; but, although I have used it in many cases, I cannot 
recall to my mind a solitary one wherein it seemed to be really of any material service. 
If it ever does any good in this disease, it is when it partakes of a syphilitic nature. 
When the attack is of a rheumatico-neuralgic type, colchicum will generally act more 
kindly and promptly than any other article. My invariable plan, however, is to give it 
in union with a full dose of morphia, as half a grain of the salt with one drachm of the 
wine of colchicum, every night at bedtime, which will be found to be a much better 
practice than administering these substances in smaller and more frequently repeated 
quantities. 
The topical remedies which particularly claim attention on account of their real or 
imputed virtues are counterirritants, leeches, morphia, electricity, and the steam of hot 
water, either simple or medicated. 
The only counterirritants that, in my judgment, are at all admissible, in the treatment 
of this disease, are blisters, ammonia, and iodine. Setons and issues are out of the ques- 
tion, except in deep-seated, obstinate visceral neuralgia, when the latter occasionally 
prove beneficial, especially if made with the hot iron, directly over the seat of the pain, 
so as to afford a free and protracted discharge. The moxa, formerly so much used, has 
of late years fallen into disrepute. Blisters are particularly valuable in inflammatory 
neuralgia; they should be retained until the epidermis is well raised, and they are the 
more desirable because the raw surface thus made may be advantageously employed for 
the topical application of morphia. Temporary relief, but nothing more, occasionally 
follows the use of ammonia in the form of liniment, or of Granville’s lotion, frictions with 
ointment of veratria, and painting the parts with tincture of iodine. Leeching is some- 
times useful, by relieving congestion, and thus removing one cause of compression of the 
nerve-pulp, the operation being performed as nearly as possible to the seat of the disease. 
Professor Hammond speaks highly of the primary galvanic current, furnished by fifteen 
or twenty Smee’s cells. The positive pole should be placed over the seat of pain, and the 
application should be continued for half an hour every day for several weeks. 
Hot applications are generally beneficial in putting a prompt stop to the severity of the 
pain, especially if they are medicated with laudanum, or some other anodyne preparation. 
They may be used in the form of cloths wrung out of hot water, and covered with oiled 
silk, to prevent evaporation ; or, in that of steam conveyed directly to the part by means 
of a tube connected with a tea-kettle placed over a spirit lamp near the bed. 
Of all the local remedies for neuralgia, the most reliable, so far as my experience 
goes, at all events so far as transient relief is concerned, is the hypodermic injection of 
morphia, as nearly as possible to the seat of the pain. A good average quantity of the salt 
is from one-third to half a grain, dissolved in one drachm of tepid water, and introduced 
with a good syringe. In very urgent cases the quantity may be increased, and its value 
greatly enhanced by the addition of the fiftieth of a grain of sulphate of atrophia. 
Another remedy of great value, strongly recommended by Professor C. G. Comegys, 
of Cincinnati, is the hypodermic injection of twenty to thirty drops of sulphuric ether, 
1 li Quinise sulph. 5j ; 
Morpliiae sulph. gr. jss ; 
Strychniae sulph. gr. ij ; 
Acid, arseniosi gr. ij ; 
Ext. aconiti gr. xv. 
Mix, and make xxx pills ; one to be given three or four times a day. CHAP. III. 
WASTING PALSY 
641 
thrown into the affected tissues twice a day. The remedy has been found especially 
beneficial in sciatica. 
Veratria ointment, prepared with from forty to sixty grains of the alkaloid to the ounce 
of simple cerate, is also an excellent remedy, from which I have frequently derived the 
very happiest effects. A small quantity—a portion about the size of a cherry—is applied 
two, three, or four times a day to the seat of the disease, with the bare fingers, the fric- 
tion being continued until it produces a strong tingling, smarting, or burning sensation, 
when the surface is covered with wadding or soft flannel. In the milder forms of the 
disease veratria occasionally acts as a curative agent, although, in general, it is simply a 
palliative. 
Mere division of a nerve for the cure of neuralgia is a perfectly useless procedure. 
Excision, on the contrary, is often followed by the happiest results, especially when per- 
formed for neuralgia of the face, caused by disease of the second and third branches of 
the fifth pair. Quite a number of very bold and novel operations have been performed 
within the last thirty years upon these nerves, especially the superior maxillary, by 
American surgeons, Professor Carnoehan having led the way. The methods by which 
the object is accomplished will be fully described in their proper place. Sections of the 
larger nerves, as, for example, the sciatic, median, ulnar, and musculo-spiral, have some- 
times been removed, and, indeed, even the brachial plexus itself, as in the examples 
recorded by Sands and Seguin, Maury, and others, although rarely with any permanent 
benefit. Occasionally, however, there is an exception to this rule, as in a case of neuralgia, 
consequent upon a gunshot wound of the median nerve, treated by Dr. J. L. Stewart, of 
Erie. The injury had been inflicted ten years previously, and the pain, which had been 
of the most atrocious character, requiring immense doses of morphia for its relief, was 
speedily and permanently cured by the excision of three inches of the affected nerve, 
without any unpleasant consequences in the parts naturally supplied by it. 
Nerve-stretching, for the relief of neuralgia, has lately been attracting much attention, 
and from the success, partial or complete, which has attended it, is worthy of more extended 
trial. The operation consists, first, in exposing the affected nerve by a free incision ; 
secondly, in hooking it up, if large, with the index finger, or, if small, with an aneurism 
needle ; thirdly, in stretching it more or less thoroughly ; and, lastly, in replacing it in 
its natural locality, the wound being closed and treated in the usual manner. In a nerve 
like the sciatic, the patient’s limb, after the stretching is effected, is lifted from the table 
by the nerve. The success of the operation is complete when the neuralgia is of trau- 
matic origin. 
SECT. V PARALYTIC AFFECTIONS. 
1. WASTING PALSY. 
A peculiar affection of the muscles, consisting essentially in atrophy and fatty degene- 
ration of their fibres, has been described under the name of progressive muscular atrophy, 
or wasting palsy, from the fact that wasting and loss of power of these structures are its 
most prominent features. The disease, first accurately delineated by Cruveilhier, has 
been studied with great care by several European observers, especially Aran, Duchenne, 
Waclismuth, Eisenmann, Meryon, Jackson, and Roberts. 
Wasting palsy presents itself under two varieties of form, the partial and general; the 
first, as the name implies, being limited to particular muscles, or sets of muscles ; whereas 
the other involves nearly all the voluntary muscles, those of mastication and those of the 
eyeball, including the elevator of the upper lid, being the only ones exempt from its 
ravages. The involuntary muscles, however, remain altogether intact, even in the worst 
cases and in the most advanced stages of the disease. Hence, the reason why the general 
health is usually so perfect amidst this wreck of the active agents of locomotion. 
Of the causes of atrophy and palsy of the muscles nothing is positively known. If their 
development has occasionally been clearly traced to the effects of cold, to rheumatism, or 
to excessive and long-continued fatigue, such as attends various mechanical pursuits, it is 
equally certain that, in the great majority of instances, no plausible reason can be 
assigned for their occurrence. Now and then the lesion appears to have a syphilitic or 
strumous origin. 
The time of life at which the disease occurs is variable ; it has been noticed in young 
children, and, on the other hand, occasionally in old subjects; but the most obnoxious 
period would seem to be between twenty-five and thirty-five. Thus, in eighty-eight cases, 642 
DISEASES AND INJURIES OF THE NERVES. 
CHAP. III. 
analyzed by Dr. Roberts, in 1858, tlie average period was thirty years and six months. 
General atrophy is not limited to any particular age, hut attacks indiscriminately children, 
adults, and old persons; whereas the partial form rarely shows itself before puberty and 
after fifty. Both sexes are liable to it, hut males suffer much oftener than females. The 
lesion has occasionally been observed in several members of the same family, and also in 
the offspring of persons who had themselves been its victims, thus exhibiting a kind of 
hereditary tendency. 
The muscles that are most liable to suffer in this affection are those of the extremities, 
especially the upper. The wasting generally begins at one particular part of a limb, from 
which it gradually extends to another; hut, now and then, cases are met with in which 
it attacks simultaneously several points. 
It has been noticed that there is usually a tendency in certain muscles to suffer together, 
as if they were united by a very close fellow-feeling; thus, it has been found that when- 
ever wasting palsy occurs in the muscles of the hand, it is extremely liable to affect those 
of the forearm also; a similar disposition has been remarked in reference to the muscles 
of the shoulder and those of the arm. Moreover, experience has shown that when one 
limb is invaded, its fellow is very apt to share the same fate. 
The most important symptoms of this disease are wasting of the muscles and loss of 
contractile power, generally coming on in a slow, gradual, and stealthy manner. In the 
great majority of cases, indeed, the person is unconscious of the mischief that is taking 
place, until attention is accidentally directed to the subject by a failure of the power of 
one of his limbs, especially the hand and foot. “ The tailor discovers,” says Dr. Roberts, 
“ that he cannot hold his needle ; the shoemaker wonders he cannot thrust his awl; the 
mason finds his hammer, formerly a plaything in his hand, now too heavy for his utmost 
strength ; the gentleman feels an awkwardness in handling his pen, in pulling out his 
pocket handkerchief, or in putting on his hat. One man discovered his ailment in thrusting 
on a horse’s collar; another, a sportsman, in bringing the fowling-piece to his shoulder.” 
The wasting, at first very slight, progressively increases until the affected muscles are 
rendered perfectly soft and flaccid, and their substance is so much wrasted that they are 
hardly one-fifth of the natural bulk ; they are, in fact, completely withered, as if they had 
been starved, and deprived of all nervous influence. The loss of power is generally in 
proportion to the wasted condition of the muscles, proceeding gradually from bad to 
worse, until the parts are entirely disabled and useless, no effort of the will being capable 
of exciting the slightest action. 
Besides the above more prominent symptoms, there are others of a minor and subsidiary 
character. These are fibrillary tremors, cramps and twitches, pain, and a remarkable 
susceptibility to cold. 
Fibrillary tremors, or convulsive twitchings, are very common, especially in the earlier 
stages of the complaint; they are dependent upon the irregular contraction of individual 
muscular fibres, and are, consequently, always absent when the disease has reached its 
full development. They generally occur without the consciousness of the patient, and 
may usually be readily excited by exposure of the affected parts to a current of cold air or 
water. Cramps are also very frequent; they come on at various intervals, and often con- 
stitute a source of actual suffering, especially when they are accompanied with pain, which 
is present in about one-fourth of the cases. The pain may be slight and wandering, 
severe and fixed, or sharp and neuralgic, shooting about in diffex-ent directions with the 
rapidity of lightning. In some instances it occurs in different parts of the muscular 
system, more or less remote from the seat of the disease, and is then apparently of a rheu- 
matic character. Wasting palsy causes a remarkable sensibility to cold, especially to a 
cold, humid atmosphere, so that the patient requires an uncommon amount of clothing to 
keep himself warm and comfortable. Finally, the galvanic excitability of the muscles 
regularly diminishes with their decay, although it is not wholly annihilated until they 
have completely lost their primitive structure. 
It is remarkable that, amidst all this wear and ruin of the muscular system, the general 
health should uniformly remain unimpaired, even in the -worst forms of the disease. The 
appetite and sleep are excellent; digestion is well performed ; the bowels move with their 
accustomed regularity; and the functions of the kidneys are perfectly normal. The 
intellect is clear to the last, and the senses retain their wonted vigor. The only trouble 
which the patient occasionally experiences is difficulty of respiration, from involvement 
of the diaphragm. 
The progress of the disease is generally slow, the muscles steadily decaying, until they 
are at length completely changed in their character; for months and even years they CHAP. Ill, 
INFANTILE PALSY. 
643 
retain some contractile power, and are even susceptible of restoration. General atrophy 
is always a gradual affection ; it seemingly begins in the partial form of the lesion, and is 
probably merely an aggravated state of it. When the disease has reached this crisis, the 
patient may be unable to use any of the muscles, excepting, as already mentioned, those 
of mastication and those of the eye. 
The appearances revealed on dissection are characteristic. The muscles, as might be 
expected, are wasted in various degrees; some slightly, others very much, and others, 
again, so completely as to be hardly recognizable, consisting merely of fibrous vestiges, 
with no distinct trace of the normal structure. The color of those that still remain is 
much faded, being pale red, rose, buff, or yellowish, according to the extent of the atrophy; 
and in all, or nearly all, there are well-marked evidences of granular and fatty degenera- 
tion, the former generally preceding the latter, although they occasionally exist indepen- 
dently of each other. Sometimes these changes are confined to one particular part of the 
muscle, as one-half or two-thirds of its belly, while the other portion retains its natural 
hue and consistence. Under the microscope, the striped primitive fibres are observed to 
have vanished, their place being supplied by granular matter and oil globules, and their 
investing tunic broken down and disintegrated. 
The nervous system has been closely scrutinized during the past few years in many of 
the reported cases of wasting palsy, and it appears to be well established that the affection 
depends upon chronic inflammation of the gray substance of the anterior tract of the spinal 
cord, with secondary atrophy of the anterior roots of the nerves derived from the seat of 
the lesion. 
The prognosis is generally unfavorable; the partial form is occasionally recovered from, 
the complete never. In the latter case death, which does not occur under several years, 
is usually preceded by great difficulty of respiration, in a paroxysm of which the patient 
suddenly expires. In partial atrophy, the disabled muscles, after having struggled on 
for many months, perhaps neither sensibly advancing nor receding, gradually awake from 
their torpor, and ultimately regain some contractile power, although never their full vigor. 
In the treatment of wasting palsy, any disorder of the general health should promptly be 
corrected. If the lesion can be clearly traced to a syphilitic or strumous taint of the 
system, as is occasionally the case, the proper treatment will be iodide of potassium with 
bichloride of mercury ; or, when a tonic effect is required, potassium with iodide of iron. 
Gentle purgatives will be useful when there is constipation with derangement of the 
secretions. The diet must be plain, simple, and unirritant. 
The best local remedy, in the early stage of the disease, is a blister sufficiently large to 
cover the whole of the affected muscles, and retained long enough to produce thorough 
vesication. If decided improvement do not follow in a week or ten days, the application 
should be repeated. The hot douche, immediately followed by the cold, will also be found 
serviceable, but to prove efficacious it should be aided by frictions with some stimulating 
embrocation, as spirit of camphor, or alcohol and ammonia. Veratria ointment is a pow- 
erful excitant, and has frequently proved highly efficacious in my hands. The cold douche 
alone is objectionable, on account of its depressing tendencies. Massage will be found 
useful, and should be practised several times a day. Galvanism has been greatly extolled 
by Duchenne, Meyer, Gros, and others, and there can be no doubt that it has occasionally 
rendered good service. The constant primary current should be passed rapidly over the 
disabled muscles, taking care to return to each several times during the same sitting ; it 
should be strong in proportion to the obtuseness of the parts, but be gradually diminished 
as the sensibility augments, otherwise overstimulation may occur, and thus do harm 
instead of good. The application may be repeated, at first, every twenty-four hours, and 
afterwards twice a day. 
The treatment, whatever it may be, should be combined with gentle exercise of the 
affected parts, to recall them, as it were, to a sense of their duty. They should, in fact, 
be reeducated by a system of careful training, steadily and perseveringly continued for 
many months, if not for several years. Conducted in this way, great confidence may 
be entertained of ultimate benefit. 
2. INFANTILE PALSY. 
There is a variety of paralysis which, occurring in young children, generally during the 
first dentition, is, in point of obstinacy and incurableness, if possible, still more deplor- 
able than the one above described. It may be called infantile palsy. Its attacks are 
usually sudden and unaccountable. The child goes to bed in the evening, perhaps to all DISEASES AND INJURIES OF THE NERVES. 
CHAP. III. 
appearances perfectly well; during the night, however, he becomes feverish and restless, 
and in the morning, on attempting to walk, he is unable to stand or use his legs. The 
limbs soon lose their round, plump appearance, the muscles are rendered soft and flaccid, 
the feet trail the floor, and the surface feels cold and numb, although sensibility is seldom 
entirely destroyed in any case, however extensive. 
The seizure is much more common in the lower extremities than in the upper; very 
often it is confined to one thigh and one leg, or to one thigh or one leg alone ; but occa- 
sionally both limbs, or even all four, are involved, the child being perfectly helpless, and 
in the most pitiable condition. The paralysis is generally complete, but cases occur in 
which the little sufferer is still able to use certain muscles, although not with anything at 
all like their natural freedom and strength. When the upper exti’emity is attacked, the 
deltoid muscle is very liable to be affected, becoming remarkably soft and wasted, so that 
the patient finds it impossible to elevate the arm or lift the smallest weight. 
The cause of this variety of palsy is not always very evident. In general, however, it 
depends upon inflammation of the anterior horns of gray matter of the spinal cord, fol- 
lowed by atrophy and disappearance of the nerve cells. As the result of these central 
changes, the muscles usually undergo fatty degeneration, and the development of the bones 
is arrested. 
The general health is seldom impaired in infantile palsy; the mind acts with its accus- 
tomed vigor, and all the bodily functions are well executed. As the child advances in 
years, all the limbs, excepting the disabled ones, increase in size and strength, but the 
latter remain stationary, or dwindle away still further, and thus form a striking contrast 
with the sound. In cases of long standing, there is often fatty degeneration of the mus- 
cles, although occasionally the paralysis continues for years without any change of this 
kind. 
The prognosis is variable, although generally unfavorable, especially if the disease is 
neglected or improperly managed in the first instance. Little, if any, benefit will be likely 
to accrue from any mode of tx-eatment, however judiciously or perseveringly conducted, 
after the lapse of six, eight, or ten months. The difficulty of effecting restoi’ation is much 
increased when there is fatty degeneration of the muscles; a circumstance which may 
readily be ascertained by exti-acting, by means of a small trocar, devised by Duchenne, 
and delineated at page 433, a minute portion of the suspected structure, and subjecting it 
to a mici’oscopical examination. The absence of elective contractility is also an unfavor- 
able sign. If the induced current is powei’less, the cure will be difficult, while it will be 
impossible if the muscles do not respond to the galvanic cui-rent. 
The treatment of infantile palsy must mainly be dii’ected, in the first instance, to the 
spinal cord, upon the disorder of which the disease essentially depends. For this pux-pose, 
leeching, cupping, rubefacients, and blistering, with absolute rest in the recumbent pos- 
ture, should promptly be employed, soon followed, if the case is likely to be obstinate, by 
a free issue with the actual cautexy, applied as nearly as possible to the seat of the lesion. 
The discharge must not be too abundant, or protracted, otherwise it may occasion undue 
debility. Fi’ictions with vei’atria ointment along the whole length of the spine and of the 
sciatic nerve, repeated twice in the twenty-four hours, have been of great service in my 
hands. An early resort to mercury is very important. The best form is calomel, in doses 
of the fourth of a grain, night and morning, continued, with an occasional brief intermis- 
sion, for sevei'al successive months. The fluid extiact of ergot is also indicated in the 
early stage of the disease, or before ati-ophy of the muscles has set in. In some instances, 
especially in the more chi’onic forms of the disease, I have derived signal benefit from a 
combination of iodide of potassium and bichloride of mercui-y. As recovei'y advances, 
strychnia may be of use, but I have never seen any good from its exhibition in the earlier 
stages of the complaint. When the child is feeble and anemic, iron and quinine, milk 
punch, and fresh air must be conjoined with other means to invigorate the system. The 
bowels and seci-etions must receive proper attention. 
The affected extremities must frequently be rubbed, shampooed, switched, and placed 
upon a course of careful training, as advised under the head of wasting palsy. Immer- 
sion of the limbs in water as hot as it can be borne, for twenty to thirty minutes, twice 
in the twenty-four houx-s, will be found to exert a highly beneficial influence in restoring 
tempei’atui-e. The early and long-continued application of electricity is often followed 
by great improvement, if not positive relief, and sliould never be neglected. The alternate 
use of faradization and galvanization will probably insux-e the best results. 
The contraction of the tendons, consequent upon this variety of palsy, must be x-ectified 
by appropi’iate apparatus, aided, in obstinate cases, by tenotomy. CHAP. III. 
PARTIAL PALSY. 
645 
3. PSEUDO-HYPERTROPHIC MUSCULAR PARALYSIS. 
A distinct form of paralysis, first observed and accurately described by Duchenne, in 
1858, and consisting essentially in hypertrophy and sclerosis of the interfibrillar muscular 
connective tissue, is occasionally met with in infancy and early childhood, and is known 
as the pseudo-hypertrophic or myo-sclerosic paralysis, or progressive muscular sclerosis. 
The disease generally begins before the tenth year, mostly in boys, without any assign- 
able cause, but now and then after convulsions. As soon as the child begins to walk, 
weakness of the lower limbs, with inability to stand or move without stumbling, is noticed, 
and is soon followed by a peculiar, stiff, waddling gait, the limbs being separated from each 
other, and the body rolling from side to side. The spine is curved forwards in the dorso- 
lumbar region, the belly being prominent and the shoulders thrown backwards, thereby 
producing the characteristic attitude of the affection, which is due to debility of the exten- 
sor muscles of the trunk, and disappears during recumbency. In the course of a few 
weeks or months the muscles of the calves become enormously hypertrophied, and, while 
those of the thighs, buttocks, and loins are soon involved, the muscles of the upper extrem- 
ities are less commonly affected. With the advance of these changes, the paralysis is more 
strongly marked, the gait is more uncertain and tottering, and the child becomes finally 
utterly helpless. The circulation of the affected limbs is lessened, the skin being cold and 
mottled, but its sensibility is not impaired, and reflex and electro-muscular contractility 
are also decidedly diminished. Double equinus, or equino-varus, is not of infrequent 
occurrence. 
The progress of muscular sclerosis is generally slow, the disease rarely terminating 
before five or six years from its commencement. As the paralysis advances, emaciation 
and impairment of the intellectual powers set in, and death results either from pulmo- 
nary complications induced by weakness of the respiratory muscles, or from some inter- 
current disease. 
Of the intimate nature of this variety of palsy nothing very definite is known, but it is 
probable that the anterior tract of gray matter of the cord is the seat of the morbid 
changes. The muscular fibres themselves are atrophied and non-striated, but otherwise 
unchanged; while the interstitial connective tissue is greatly hypertrophied, and, in the 
later stages of the affection, replaced by fat cells. 
The treatment of this affection does not differ from that of ordinary infantile palsy, 
but all measures generally prove unavailing. Duchenne obtained one cure in thirteen 
cases by the induced current and shampooing, but the gastrocnemial muscles were only 
slightly enlarged, and Benedikt noticed marked improvement in three cases from the con- 
stant current to the lower cervical sympathetic ganglion and the lumbar region. 
4. PARTIAL PALSY. 
Besides the above forms of palsy there are some others, to which the term partial, tran- 
sient, or anomalous may be applied, such, for instance, as loss of motion of one side of 
the face, one eyelid, one side of the tongue, or of the hand, forearm, arm, or shoulder, or 
even of the entire superior extremity. The subjoined facts will serve as illustrations of 
its character. 
Pressure upon the nerves is liable to be followed by interruption of their functions, at 
one time temporary, at another permanent. A case recently came under my observation 
in which a man, thirty-five years of age, suffered from partial palsy of the forearm and 
hand from having rested for two hours with his head upon the limb as he lay asleep 
upon the floor. 
In another case, under my notice several years ago, temporary paralysis of the left 
upper extremity was produced by the arm, thrown across the top of a chair, being com- 
pressed by the head while the man was asleep. Pressure of the head of a crutch upon 
the axillary plexus of nerves occasionally leads to weakness, numbness, and pricking pain 
in the arm, hand, and fingers. Recently a youth of fifteen was under my charge on ac- 
count of paralysis of the arm, consequent upon a fall on the shoulder from a railway car, 
two months previously. The limb was instantly deprived of motion and sensation, and 
so continued up to the time of his visit. The head of the humerus had been thrown 
slightly forwards against the coracoid process, but it exerted no perceptible pressure upon 
the brachial plexus of nerves. 646 
DISEASES OF THE LYMPHATIC VESSELS. 
CHAP. IV. 
Paralysis of one side of the face from injury of the portio dura is not infrequent; more 
generally the affection is caused by suppression of the cutaneous perspiration, from expo- 
sure to cold and wret; and an instance is occasionally met with in which it is produced 
by disease of the petrous portion of the temporal bone. The subjoined case affords a 
good illustration of a very common form of facial palsy. A blacksmith, eighteen years 
of age, of temperate habits, came under my care on account of paralysis of the left side of 
the face. The attack had occurred suddenly three days previously, without any apparent 
cause, soon after eating a moderately hearty dinner. He had been subject to frequent 
and severe paroxysms of headache, preceded by dizziness and vertigo. On the morning, 
however, on which he was seized with palsy he had felt uncommonly well. His appetite 
and sleep had always been good, and his bowels regular. The palsy was characterized by 
loss of motion in the muscles of the left side of the face, and by inability to close the left 
eyelids, accompanied with a want of sensibility of the skin. The tongue, when pro- 
truded, inclined to the right side, and was deprived of feeling and taste, a lump of sugar, 
held in the mouth, making no impression on the affected side of the organ. The general 
health was excellent. 
In the treatment of these paralytic affections, special attention must be directed to the 
improvement of the general health, which is often seriously impaired, by the use of laxa- 
tives, alteratives, and a properly regulated diet. In obstinate cases, a mild mercurial 
course is sometimes serviceable, especially when the lesion is dependent upon organic dis- 
ease of the hrain, or of the cerebro-spinal axis. The principal local remedies are leeches, 
blisters, stimulating embrocations, veratria ointment, and the hot and cold douches, fol- 
lowed by dry friction. Occasionally electricity proves beneficial. 
CHAPTER IV. 
DISEASES OF THE LYMPHATIC VESSELS AND GLANDS. 
The pathologist can certainly not boast of his knowledge of the diseases of the lym- 
phatic vessels; he knows, it is true, that they are liable to inflammation, but of the man- 
ner in wdiich it is produced, and of the effects to which it gives rise, he is, in great 
measure, ignorant. That these vessels play an important part in various affections is ex- 
tremely probable; but such are their excessive tenuity and the great delicacy of their 
structure that no one has yet been able to point out the character and amount of their par- 
ticipation. It has been supposed that at least one form of cutaneous disease, namely, 
erysipelas, essentially consists in inflammation of the absorbents, and it must be confessed 
that the opinion, although insusceptible of demonstration, is highly plausible. Much light 
has, however, been thrown upon the injuries and diseases of the absorbent system, by the 
waitings of Dr. S. C. Busey, of Washington, which may be profitably consulted by the 
reader. 
SECT. I. LYMPHATIC VESSELS. 
Inflammation of these vessels, technically called angeioleucitis or lymphangitis, is 
most advantageously studied in connection wdth external injuries, particularly punctured 
and poisoned wounds, of which it is by no means an infrequent consequence. Doubtless, 
the disease is sometimes idiopathic, or dependent upon internal causes, such as give rise 
to erysipelas and other bad forms of inflammation in the cutaneous and other tissues. In 
the case of a gentleman recently under my observation, the disease, which involved both 
upper extremities, was evidently due to disorder of the digestive apparatus, occasioned by 
malaria. Three similar attacks had been experienced before, each coming on during the 
latter part of August, and promptly yielding to quinine. Numerous superficial vessels 
were involved in each of the attacks. When arising as a consequence of an abrasion, or 
the prick of a needle, as in sewing up a dead body, the affected vessels can be easily CHAP. IV. 
LYMPHATIC VESSELS. 
647 
traced, as they pass beneath the skin, as small, reddish cords, tense, nodulated, and painful 
to the touch, accompanying the principal veins, and extending as far as the nearest glands, 
in which they appear to terminate. The number of these reddish lines is variable ; some- 
times there are only two or three, while at other times there are as many as six, ten, or a 
dozen, forming a kind of band, from half an inch to an inch in width. Whenever the 
number is considerable, there is always a good deal of concomitant swelling; and the 
parts, feeling stiff, sore, and tender, readily pit on pressure, owing to the effusion of sero- 
plastic matter. In the more severe attacks of angeioleucitis, as those consequent upon 
inoculation with putrid or poisonous matter, the tumefaction soon becomes general, spread- 
ing rapidly over the whole limb, and the discoloration, losing its striated appearance, so 
characteristic of the disease in its earlier stages, also assumes a diffused disposition. Ar- 
rived at this point, it is usually impossible to distinguish this affection from ordinary ery- 
sipelas, so closely do the two lesions resemble each other. 
Occasionally the inflammation seems to take its rise in the deeper layers of vessels, and 
then the discoloration is generally preceded by considerable induration of the subcutaneous 
connective tissue, giving the part a kind of brawny sensation; by and by, however, red 
streaks appear in the skin, and then the disease follows very much the same course as 
when it begins in the superficial vessels. 
However originating, the affection nearly always involves the neighboring lymphatic 
glands, causing them to enlarge, and to become tender, red, and painful. In some of the 
worst forms of angeioleucitis, the glands manifest signs of being diseased before the ab- 
sorbents themselves are apparently implicated. Such an occurrence, although uncom- 
mon, is occasionally met with in inflammation of these vessels consequent upon dissection 
wounds. 
Angeioleucitis no doubt sometimes passes into suppuration, and, perhaps, even into 
gangrene; but of these occurrences, as pure, uncomplicated affections, our knowledge is 
too imperfect to justify any positive opinion. 
The symptoms ushering in an attack of angeioleucitis are usually such as are denotive 
of constitutional depression, following pretty closely upon the injury sustained by the 
affected vessels. The patient, after having felt indisposed for some hours, seldom more 
than from twelve to twenty-four, is seized with chilly sensations, accompanied with flushes 
of heat, a disposition to yawn, headache, pain in different parts of the body, and a dry 
and contracted state of the skin. Sometimes the attack is announced by violent rigors, 
rapidly succeeded by high fever and delirium. If the local affection is at all severe, the 
symptoms soon assume a typhoid character, the pulse becoming weak and frequent, the 
surface hot and dry, and the tongue covered with a brownish fur. The local distress, 
meanwhile, increasing, abscesses form in different portions of the limb, the matter being 
of a foul, unhealthy character, and disposed to spread extensively among the surround- 
ing-structures, in the same manner as in erysipelas and other bad forms of inflamma- 
tion. 
Angeioleucitis may be confounded with other diseases, particularly erysipelas and 
phlebitis, and the distinction is by no means always so easy as might at first sight appear. 
In fact, it can only be made out satisfactorily in the earlier stages of the complaint, the 
principal source of diagnosis being the red, striated appearance of the affected surface, 
reaching from the seat of the injury up to the nearest lymphatic glands. In phlebitis, 
the discoloration is also linear, but the cords are much larger, firmer, more knotty, and 
more deeply seated; they are also less numerous, and there is not nearly so much involve- 
ment of the lymphatic glands. In erysipelas, the inflammation usually begins as a cir- 
cumscribed affection, with diffuse, uniform redness, not striated, as in angeioleucitis, or in 
phlebitis. 
In the treatment of this disease, the same general principles are to be observed as in 
erysipelas and phlebitis, to which it bears so close a resemblance. The exciting cause 
being removed, such local and general means are to be employed as may seem to be best 
adapted to the exigencies of each particular case. Bearing in mind that, if the disease is 
at all severe, the symptoms will be likely soon to assume a typhoid character, the surgeon 
will take care not to deplete much, especially with the lancet and purgatives, lest he be 
instrumental in inducing fatal exhaustion, of which the danger may be already sufficiently 
great in consequence of the progress of the morbid action. Leeches may be applied 
along the course of the affected vessels, but not directly over them, if the disease is in its 
earlier stages, and the patient is robust and in the prime of life. They should be employed 
in considerable numbers, and be succeeded by warm fomentation, the whole limb being 648 
DISEASES OF THE LYMPHATIC VESSELS. 
CHAP. IV. 
enveloped in flannel cloths wrung out of a strong solution of acetate of lead and opium, 
and kept constantly wet. Hie application ot iodine is sometimes advantageous ; and good 
effects occasionally arise from thorough vesication, the blister being stretched along the 
course of the affected vessels. If matter form, or great tension and throbbing exist, 
suitable incisions must be made. 
fhe constitutional treatment must be regulated by the character of the general symp- 
toms. 1 urgatives, to clear out the bowels and correct the secretions; iron, or iron and 
quinine, to improve the tone of the system and the state of the blood; and anodynes, to 
allay pain and induce sleep, with a properly regulated diet, will constitute the most reliable 
and efficient means. It marked debility arise, brandy, wine, or porter, with nutritious 
broths, will be required. When the disease proves obstinate, or becomes chronic, a mild 
mercurial course may be beneficial. 
Varicose enlargement of the lymphatic vessels, or lymphangiectasis, has occasionally 
been noticed, chiefly among the inhabitants of warm countries. It is most common in 
the vessels of the scrotum and lower extremity, in union with elephantiasis. The enlarge- 
ment is sometimes so great and so well defined as to give rise to distinct swellings, which 
have been described by Virchow and other pathologists, under the name of lymphangioma. 
In a case mentioned by Carswell, in a young man, twenty-six years of age, a tumor nearly 
as huge as an orange existed in each groin, for which he had worn a double truss from his 
boyhood, under the supposition that he had hernia. On dissection, however, each tumor 
was found to consist of enormously dilated absorbent vessels connected with the inguinal 
glands. V hen cut into, instead of presenting a solid, compact structure, it had the 
appearance of a coarse sponge, most of the vessels being from one to three lines in dia- 
meter. The same phenomenon was witnessed, only in a more striking degree, in the 
lymphatics of the pelvic and lumbar regions. The spongy and elastic character of such a 
swelling ought to prevent any serious error of diagnosis. Hardly any treatment would be 
necessary in such a case. Excision might prove dangerous, and should not be practised 
without due deliberation. Bean has reported three cases in which he effected a cure by 
establishing adhesive inflammation by means of the seton. 
In wounds of these vessels there is occasionally a veritable lymphorrhcea,, or a discharge 
of thin, pale, whitish fluid, standing like drops of sweat upon the affected surface. The 
exudation has been known to continue for a considerable length of time, and to interfere 
perplexingly with the healing process. Vidal and Lebert have each described a case in 
which small, transparent vesicles, filled with lactescent fluid, formed upon the thigh and 
scrotum. In the case detailed by the latter, the vesicles, after having attained a certain 
bulk, broke, and discharged their contents, which, on analysis, were found to contain sugar 
of milk and minute clots. The patient, aged twenty-one years, was affected with hyper- 
trophy of the scrotum. 
In the case of a boy, nineteen years of age, affected with elephantiasis of the lower 
extremity, Dr. J. C. Morris, of the Episcopal Hospital of this city, observed, two weeks 
after his admission, several vesicles on the thigh, which soon gave exit to lymph, which 
flowed at the rate of nearly a pint in twelve hours. This continued for five days, when it 
ceased, apparently in consequence of an attack of erysipelas. In a case of Desjardins 
eleven pounds escaped in the course of forty-eight, hours. At the clinic of the University 
of 1 adua, in the summer of 18G8, Professor Y anzetti was kind enough to show me a man 
who had suffered in this way for five years in the left side of an hypertrophied scrotum, 
large quantities of fluid being discharged every few days. 
A wound with such a discharge may, if it heal slowly, at length degenerate into a 
troublesome jistule, difficult to cure, and the seat of a constant exudation of milky fluid, 
mixed with pus. A similiar accident occasionally follows upon an abscess situated in 
the course of a large lymphatic trunk. The remedies most likely to afford relief in such 
cases are systematic compression and the application of the solid nitrate of silver. If 
these fail, recourse should be had to the knife, Vienna paste, or the actual cautery. 
A congenital lymph fistule is sometimes met with, especially in front of the neck. It 
has generally a very small, almost imperceptible, orifice, and is the seat of a transparent, 
limpid discharge, possessing all the properties of ordinary lymph. The discharge usually 
occurs in drops, and may, with occasional intermissions, continue for years. The treat- 
ment is similar to that of the accidental lymph fistule. CHAP. IV. 
LYMPHATIC GLANDS. 
649 
SECT. II LYMPHATIC GLANDS. 
The lymphatic glands are liable to inflammation, chronic enlargement or hypertrophy, 
lymphoma, sarcoma, tubercle, and earthy degeneration. 
Inflammation of these bodies, technically called adenitis, may show itself either as an 
acute or a chronic affection, and is of such remarkable frequency as to demand special 
consideration. In whatever form it occurs, it is most common in young children of a 
strumous predisposition, and is generally brought on by attacks of cold, or by some local 
irritation implicating the afferent lymphatic vessels. The disease, moreover, may be com- 
mon or specific, of the latter of which illustrations are afforded in syphilitic bubo, in the 
bubo of plague, and in the swelling of the lymphatic glands of the axilla consequent upon 
dissection wounds and malignant pustule. 
1. Acute adenitis is most common in the glands of the neck, jaw, and supraclavicular 
region ; it is also occasionally met with in those of the groin and axilla. The disease may 
be limited to one of these bodies, or, as is more generally the case, affect a considerable 
number of them ; beginning as a hard, painful knot, exquisitely tender to the touch, and 
rapidly augmenting in bulk, until, in some instances, it attains the volume of an almond 
or a pullet’s egg. The increase in the size of the tumor is sometimes exceedingly rapid, 
as is often seen in adenitis of the neck from exposure to cold, where a body of this kind, 
scarcely perceptible in the natural state, may, in the course of a few hours, acquire the 
size of a filbert, or a small marble. As the disease advances, the swelling extends to the 
adjacent connective tissue, the skin becomes red and inflamed, and the parts pit on pres- 
sure. The discoloration is not unfrequently of an erysipelatous character. When the 
inflammation is fully developed, the local distress is usually very severe, and the consti- 
tution actively sympathizes with the suffering textures, the patient being feverish, deprived 
of appetite and sleep, and affected with constipation. 
Dissection shows the affected glands to be of a deep reddish or brownish color, infiltrated 
with sero-plastic fluid, softened, lacerable, or easily crushed with the finger ; the connec- 
tive tissue around is also abnormally vascular and infiltrated, and, in many cases, it seems 
to be the principal seat of the morbid action. 
Adenitis may end in delitescence or resolution, pass into suppuration or assume a 
chronic character. The occurrence of gangrene is very uncommon. 
The disease sometimes vanishes in a few hours, either spontaneously, or under mild 
treatment. Enlarged and inflamed glands of the neck, and at the angle of the jaw, often 
rapidly disappear under frictions with ammoniated liniment, conjoined with the use of 
hot drinks and immersion of the feet in hot water. When the inflammation is more 
severe, an active purgative will be necessary, followed by a gentle diaphoretic, as one- 
fourth of a grain of morphia with one-half that quantity of tartar emetic. The diet must 
be light, and the part and system must be kept perfectly at rest. If the morbid action 
threaten to prove troublesome, or to pass into suppuration, leeches and medicated fomen- 
tations must be employed. In many cases, dilute tincture of iodine will be very bene- 
ficial in cutting short the disease. 
When adenitis passes into suppuration, matter generally begins to form from the fifth 
to the tenth day, the event being usually most rapidly excited in young, weakly, or 
scrofulous children, with an impoverished state of the blood. The pus is not always 
situated in the enlarged glands ; in many cases, in fact, it is limited, in great degree, if 
not entirely, to the neighboring connective tissue. It is of a light 
yellowish color verging on greenish, thick, and often very copious; 
occasionally it is mixed with blood, and with the debris of the affected 
glands. Finally, the matter may occur as an infiltration, or as a dis- 
tinct abscess. The microscopical characters of pus from a lymphatic 
gland are seen in fig. 263. 
The occurrence of suppuration is announced by increased heat, pain, 
redness, and swelling, along with a sense of throbbing, and by high 
constitutional disturbance, attended by chilly feelings, or even rigors, 
followed by fever and perspiration. 
The treatment is strictly antiphlogistic. If the phenomena are 
clearly denotive of the existence of pus, an early incision is made, free and dependent, to 
favor thorough evacuation and prevention of reaccumulation. The operation is followed 
by warm water-dressing or an emollient cataplasm. The use of a tent or drainage tube 
will occasionally be required to maintain patency of the puncture. 
In regions of the body which are habitually exposed, as, for instance, the neck, and 
Fig. 263. 
Scrofulous Pus from a 
Lymphatic G laud. .2.5.0 650 
DISEASES OF THE LYMPHATIC GLANDS. 
CHAP. IV. 
where, consequently, it is of great importance to avoid unseemly scars, the best plan 
generally is to evacuate the pus by a series of small punctures, succeeded immediately by 
gentle pressure, the operation being repeated every two or three days until the matter 
ceases to form. Some surgeons, with the same end in view, use the aspirator, but I am 
not aware that the method possesses any advantage over the ordinary operation. 
2. Chronic adenitis is a very common occurence, generally as a consequence of the 
acute form of the disease, but sometimes it is, apparently, a primitive affection. However 
this may be, its effect is gradually to subvert the natural 
structures through increased thickness of the reticulum 
and diminution in the number of the lymph cells, as in 
fig. 264, from Green. In the earlier stages of the disease, 
the gland is of a reddish, brownish, mottled hue, con- 
siderably increased in size, and of a firm, fleshy consist- 
ence ; by and by, however, it assumes a grayish or whit- 
ish aspect, becoming almost homogeneous, and cutting 
very much like an unripe apple or pear ; in some cases it 
is very soft and lacerable. When the transformation is 
very great, the hardness of the gland may be equal to 
that of scirrhus, with which it is then liable to be con- 
founded. A distinct capsule, composed of dense connec- 
tive tissue, generally surrounds the enlarged body, which 
is capable, in this condition, of attaining the volume of a small orange. When a number 
of such glands are agglomerated together, a large tumor is formed, of a hard, firm con- 
sistence, more or less adherent to the neighboring parts, and of an irregularly lobulated 
appearance, as in fig. 265, copied from one of my preparations. 
Chronically enlarged or hypertrophied lymphatic glands are most commonly met with 
in the neck, or about the lower jaw. In the internal cavities they are most frequently 
seen in the mesentery and pelvis, and at the root of the lungs. The effect which these 
bodies exert upon the structures among which they are situated is principally of a 
mechanical character, compressing them, and so interfering more or less with the exercise 
of their functions. Thus, in the neck they may cause injurious compression on the 
trachea, vessels, and nerves; in the pelvis they may interfere with parturition by pre- 
venting the descent of the child’s head ; while in the lungs they may occasion suffocation 
by obstructing the entrance of air into the bronchial tubes. 
Various causes may give rise to this affection ; some of a local, others of a purely 
constitutional nature. In the neck, it is often occasioned by cold, or by disease of the 
jaw, teeth, gum, or tonsil; in the groin, by 
ulceration of the penis; in the axilla, by 
disorder of the mammary gland; in the 
mesentery, by irritation of the small bowel. 
The most efficient general cause is a strum- 
ous state of the system ; but there is reason 
to believe that the lesion may be produced 
by anything that has a tendency to derange 
the general health, or to impoverish the fluids 
and solids. 
Chronic enlargement of the lymphatic 
glands often continues for years, now ad- 
vancing, then stationary, and now, perhaps, 
receding; in general, however, the disease 
is obstinate, especially when the structure 
of these bodies has undergone serious organic 
changes, in which case it is often extremely difficult, if not impossible, to reclaim them 
by any mode of medication, however perseveringly or judiciously employed. 
The treatment of chronic adenitis is both constitutional and local. In the first place, 
the exciting cause is looked for, and, if possible, removed ; the carious tooth is extracted, 
the ulcer on the penis healed. The general health is improved by attention to the 
bowels and secretions, and by strict hygienic observances. When plethora exists, de- 
traction of blood, and antimonial and saline preparations, will be of service ; under 
opposite circumstances, the proper remedies will be a nutritious diet, and alterant tonics, 
consisting of iodide of iron and quinine, bichloride of mercury, iodide of potassium, 
and cod-liver oil. When there is no contraindication, minute doses of mercury in 
Fig. 264. 
Chronic Inflammation of a Lymphatic 
Gland, 
Fig. 265. 
Hypertrophied Lymphatic Glands. CHAP. IV. 
SARCOMATOUS TUMOURS. 
651 
Huxham’s tincture of bark will often be highly efficacious, but care should be taken 
not to carry it to decided ptyalism. Tartar emetic also, given in small doses, as the 
tenth or twelfth of a grain, three times a day, is frequently very beneficial. In most 
cases a regular system of purgation should be maintained. The German practitioners are 
fond in this disease of the use of chloride of ammonium, administered in doses of five 
to ten grains three times in the twenty-four hours. The article is a powerful sorbe- 
facient, and is, therefore, worthy of trial, especially in cases which do not yield to the 
more ordinary measures. Quinine has often yielded excellent results in my hands. 
Among the more important topical remedies are leeches, and sorbefacient liniments, 
unguents, and embrocations, conjoined with systematic and steady compression. These 
means must be employed with great caution and judgment, otherwise they will be sure to 
be productive of harm instead of benefit. All sorbefacient applications should, in the 
first instance, be of a mild character, their strength being gradually increased as the parts 
become more tolerant of their impression, and their peculiar effects are rendered more 
and more apparent. Of these one of the best is composed of one part of iodoform to 
two parts of balsam of Peru, and five of cosmoline. When the enlarged glands are 
favorably situated, compression will often be found to be a most valuable remedy, 
applied with the pad of a truss, as in hypertrophy of the inguinal glands, or with a 
compress and bandage when it affects the glands of the neck. In obstinate cases, a 
blister occasionally exerts a salutary influence, relieving the enlarged structures of en- 
gorgement, and stimulating the absorbent vessels so as to induce them to remove morbid 
deposits. The electric current has sometimes been advantageously used. Subcutaneous 
division of the enlarged glands, or comminution with the bistoury, has occasionally been 
practised, but the effects, at least in my hands, have not been such as to render a repe- 
tition of the operation at all desirable. 
Finally, when the disease is intractable, the only resource is removal of the morbid 
mass, provided it be favorably situated for such a procedure. Such a step, however, 
should not be lightly taken, as it must often involve serious consequences, on account of 
the great depth of the tumor, and its connection with important structures. In the 
cervical region, for example, the excision of a mass of enlarged and indurated lymphatic 
glands not unfrequently proves a most difficult, embarrassing, bloody, and hazardous 
operation. Removal will be much facilitated if the knife be kept close to the hypertro- 
phied glands. Sometimes the enlarged and disintegrated structures may be pressed out 
bodily through a small opening in the skin. When the diseased mass compresses the 
trachea or great vessels of the neck, and does not admit of removal, relief must be sought 
by the subcutaneous section of some of the constricting muscles, especially the sterno- 
cleido-mastoid. 
3. The lymphatic glands are occasionally the seat of hyperplastic formations, termed 
lymphomas, or lymphadenomas, which, in their minute structure, consist essentially of a 
very delicate, reticulated stroma, inclosing lymph corpuscles in greatly increased numbers. 
The general features of this growth have been so fully described at page 218 that the 
merest reference here must suffice. 
4. Sarcomatous tumors of the lymphatic glands are characterized by proliferation of 
the cells of the trabeculae, with atrophy and final disappearance of the lymph follicles. 
Lymphosarcoma differs from ordinary lymphoma in the following particulars, the clinical 
features of the two affections being so distinct that a mistake in the diagnosis is scarcely 
possible. Commencing usually as a single tumor, it is not circumscribed by a capsule, but 
is diffused through the surrounding tissues, sparing neither the muscles, the bloodvessels, 
the sheaths of nerves, nor the adjacent lymphatic glands. Its growth is progressive and 
very rapid, enormous dimensions being attained in a short time, and, as it advances, it 
contracts adhesions with the skin, which becomes discolored and, finally, ulcerated. If 
extirpated, it is almost certain to return, and secondary deposits occur early in the lungs, 
liver, spleen, and skin. The dissemination may often be traced to embolism, the mass 
adhering to and perforating the walls of the large venous trunks, and permitting the 
detachment of small fragments, which are carried to distant organs by the blood. 
In 1871, I removed a growth of this description, of the size of a large fist, from the 
neck of a gentleman, twenty-eight years of age. It was first noticed two years previ- 
ously, and, after having attained the volume of a small orange, it remained stationary 
until six months before the operation, when, suddenly and without assignable cause, it 
took on renewed action. It was lobulated and elastic; the skin was discolored and 
closely adherent, and, on account of its deep and important connections, the dissection 
wTas tedious. Death occurred, apparently from cellulitis, on the tenth day. On micro- 652 
DISEASES ANI) INJURIES OF THE ARTERIES. 
CIIAP. v. 
Iscopical examination, the neoplasm was found to be composed of closely-packed, small, 
round cells, with large nuclei and bright nucleoli, the intercellular substance being sparse 
and homogeneous. 
5. Tubercular disease of these bodies, as stated in the chapter on scrofula, is met with 
chiefly in young subjects, before and soon after the age of puberty ; most generally in 
children. Now and then it occurs in elderly persons, but this is very uncommon. Sur- 
gically considered, it is most frequent in the glands of the neck and jaw, and may be 
limited to one of these bodies, or, as is most generally the 
case, affect a large number, either simultaneously or succes- 
sively. It often coexists with tubercular disease of the lungs, 
joints, and other parts. The proper remedy, when the disease 
is not too far advanced, is excision with a view to prevent 
infection of other organs. 
6. The lymphatic glands occasionally undergo earthy de- 
generation, as in fig. 266, being converted into a soft, whitish 
substance, not unlike chalk. Such an occurrence is most 
common in the bronchial and mesenteric glands, but is also sometimes seen in those of 
the neck. Not long ago I met with a case in which not less than five of the cervical 
glands had become completely calcified, being of stone-like solidity, of a light brownish 
color, rounded, and from the size of a pea to that of a hazelnut. The patient was a 
middle-aged, strumous woman, and the glands, forming a chain along the inner edge of 
the sterno-cleido-mastoid muscle, on the right side, had been affected from early youth. 
Their character was obvious on the slightest touch. Excision was easily effected. Such 
tumors need not be interfered with, unless they are a source of annoyance by their situation. 
Fig. 266. 
Cretaceous Degeneration of the 
Lymphatic Glands. 
CHAPTER y. 
DISEASES AND INJURIES OF THE ARTERIES. 
SECT. I WOUNDS AND HEMORRHAGE. 
There can be no more terrible and appalling sight to a patient and his friends than 
hemorrhage from a divided artery, especially when the blood is gushing out in a full and 
angry torrent, threatening every moment to put an end to existence. There is something 
indescribably sickening and distressing in such a scene, from which every sensitive mind 
shrinks with dismay and bewilderment. The horror of the scene is increased a hundred- 
fold when we are unable to afford the requisite relief. But the sight of blood is not dis- 
agreeable only to the common observer; there are few surgeons, however heroic or well 
disciplined, who do not, at times, participate in this feeling. If it were not for the fright- 
ful hemorrhage which so frequently attends them, operations would be divested of nearly 
all their terror, and few men would shrink from their performance. Fortunately or 
unfortunately, however—for it is not easy to determine which—this is not the case; the 
slightest incision is often followed by profuse bleeding, and in the extirpation of tumors, 
in the removal of limbs, and in various other procedures, the patient has reason, in many 
cases, to congratulate himself if he do not perish from the loss of blood. Some of the 
more serious accidents, as incised, gunshot, and punctured wounds, often prove instantly 
fatal from hemorrhage; or, if syncope should, luckily, ensue, and thus temporarily arrest 
the bleeding, death may occur subsequently, but not less certainly, from the same cause. 
It is for these reasons that hemorrhage has always been a source of so much anxiety to 
the surgeon, and that its study has engaged so large a share of his attention from the 
earliest stages of medical science down to the present time. It is, indeed, impossible for 
him to be too well acquainted with the subject, or too thoroughly prepared to meet its 
various, trying and painful emergencies. The reflection, which must often arise under 
such circumstances, that possibly all was not done that might have been done if greater 
skill had been exercised, is well calculated to overwhelm tlie sensitive and conscientious 
surgeon, and to induce a degree of distress which no one, who had not himself experienced 
it, can possibly appreciate. I do not envy the feelings of that man who, through ignorance, chap. v. 
WOUNDS AND HEMORRHAGE 
653 
inattention, or indecision, allows his patient to perish from loss of blood when he ought to 
save him. 
The characteristics of arterial hemorrhage are, first, the scarlet color of the blood, and, 
secondly, the peculiar manner in which it issues from the injured vessel; it spirts out in 
jets, synchronously with the contraction of the left ventricle, and not in a steady, con- 
tinuous stream, as when it comes from a vein. This, however, is true only of the larger 
arteries; for, when the smaller branches are severed, their contents escape very much 
like those of a vein, only more forcibly, the fluid even then often projecting to a distance 
of several feet. When one of the principal trunks is divided, the blood is frequently sent 
with great violence to the ceiling, or far across the room, to the horror and dismay 
of every one present. It is worthy of note that arterial blood in a person partially 
asphyxiated, or fully under the influence of an anaesthetic, is of a dark color, like that of 
venous blood. The effects of hemorrhage vary very much, and are not by any means 
always in proportion to the extent of the injury. When proceeding from a large artery, 
or a considerable number of small ones, it may prove almost instantly fatal, or, at all 
events, in a few minutes. In general, however, the case does not progress so rapidly. 
The patient, after the bleeding has continued for some time, is seized with syncope, and 
now, the heart’s action being greatly depressed, an opportunity is afforded for the forma- 
tion of a clot both within and around the artery, followed by an arrest of hemorrhage. 
By degrees reaction takes place, color returns to the cheek, the extremities become warm, 
and the pulse reappears at the wrist. With these phenomena recurs the danger of bleed- 
ing. As the heart’s action augments, the blood is again vigorously propelled through the 
body, and, presently, the temporary clot being washed away, the wound is reopened nearly, 
if not quite, to its original extent. Again fainting occurs, a new plug is formed, and for 
a time life is once more free from immediate risk ; but this truce, like the first, is of short 
duration ; the same scene is reenacted a second and a third time, until at last, by the 
repeated drain, the heart and the brain are no longer capable of supporting each other in 
the fearful struggle, and the patient sinks completely exhausted. 
A person dying from repeated losses of blood, consequent upon the division of a large 
vessel, presents a fearful picture. Ilis countenance is ghastly pale ; his pupils are widely 
dilated ; he pants and sighs for breath ; his ideas are vague and confused ; he is sick at 
the stomach, and vomits; the extremities are icy cold ; and the whole surface is covered 
with a profuse, clammy perspiration. The thirst is usually intense and unquenchable, 
the largest quantity of water failing to satisfy the urgent wants of the system ; excessive 
restlessness and jactitation succeed; the patient calls loudly for cold air; paroxysm after 
paroxysm of swooning recurs; the pulse has, perhaps, already been long absent from the 
wrist; the eyes assume a glazed and fixed expression ; the respiration grows more and 
more feeble ; and death often steals on so imperceptibly as to render it difficult to deter- 
mine the precise moment of its occurrence. During all this time, whether it embraces 
only a few minutes or hours, or whether it extends through several days, there is generally 
an entire absence of pain, the loss of blood operating as an anaesthetic. 
The reaction which follows upon copious loss of blood is generally attended with high 
excitement, known as “ hemorrhagic fever.” The symptoms which characterize it are 
peculiar. The blood, the natural stimulus of the heart, is utterly inadequate for the wants 
of the system, and hence, to send a certain supply to the more imporiant viscera, espe- 
cially the brain and lungs, as well as to its own substance, the organ is obliged to make 
extraordinary efforts, as is shown by the tumultuous nature of its action. The pulse is 
unusually soft and frequent, and accompanied with a peculiar jerking, vibratory sensation, 
distinguished as the hemorrhagic pulse, the skin is hot and dry, the countenance is slightly 
flushed, the eyes are suffused, the thirst and restlessness are intense, distressing noises 
are complained of, the head aches, and the temples throb and feel as if they were con- 
stricted by a cord. Nausea and vomiting are often present; the sleep is imperfect, and 
the mind not unfrequently wanders. If prompt relief be not afforded, the patient may 
perish from effusion of serum into the arachnoid sac and into the pleuritic cavities. The 
most suitable remedies are perfect rest of mind and body, cold applications to the head, 
frequent sponging of the body with tepid water, and full doses of morphia in union with 
the neutral mixture. Beef essence, chicken broth, and milk punch constitute the most 
appropriate diet. As soon as the condition of the stomach will admit of it, iron and ergot, 
or ergot and acetate of lead, should be freely given to increase the plasticity of the blood. 
If, during the progress of the case, the brain and lungs are threatened, the main reliance 
must be upon blisters and dry cupping, with, perhaps, in the former case, a few leeches 
to each temple. Light and noise must, of course, be excluded from the apartment. 654 
DISEASES AND INJURIES OF THE ARTERIES. 
chap. v. 
When the hemorrhage has been excessive, as indicated by the pallor of the countenance, 
the feebleness of the pulse, and the gasping character of the breathing, transfusion of 
blood, as a dernier resort, should be employed. 
The operation, if not performed too late, is very 
encouraging, the statistics of Landois affording 
not less than 65 recoveries out of 99 cases, more 
than one-tliird of the fatal cases being moribund 
at the time. 
Wounds If we inquire into the nature of 
wounds of the arteries, it will be found that they 
do not differ, as it respects the weapons with 
which they are indicted, from wounds in other 
tissues. Thus, they may be incised, punctured, 
lacerated, contused, or gunshot, and it would fre- 
quently be difficult to determine which class is the 
worst, or the most certainly and speedily fatal. 
In regard to their size they present every possible 
gradation, from the slightest incision to the com- 
plete division of the vessel; the wound being either 
oblique or transverse in the latter case, but of 
various shapes when the lesion is partial. Occa- 
sionally the wound consists of a mere vertical fissure. The different appearances here 
alluded to are all well displayed in fig. 267. The extent and character of the wound 
necessarily exert great influence upon the amount and duration of the hemorrhage, and, 
therefore, demand careful study. 
When an artery has been completely 'cut across, there is an instantaneous and impetu- 
ous flow of blood, followed immediately by the retraction and contraction of each end of 
Fig. 267. 
Plan of Wounded Arteries, a. A mere Longi- 
tudinal Slit, extending to an oval space, b. A 
Similar Wound, in an Oblique Direction, gaping 
more. c. A less Wound transverse, with the pro- 
portional gaping great, d. A Transverse Wound 
of the same size at a and b, causing a very wide 
hiatus. 
Fig. 268 
Fig. 269. 
Contraction of a Divided Artery, a. The Orifice of a Dead Artery. 6. The 
Orifice of a Living Vessel immediately after Section. 
the vessel, as exhibited in fig. 268. The effect of this 
double action is to diminish the amount and force of the 
stream, but not to arrest it; instead of this, it usually con- 
tinues until a coagulum has formed upon the orifice of the 
artery, as well as in the parts immediately around, particu- 
larly in the loose connective tissue constituting its sheath. 
In this manner a mechanical obstacle is opposed to the 
effusion of blood, but this would soon be washed away if it 
were not aided and fortified by the speedy development of 
a coagulum within the vessel, extending usually as high up 
as the first large collateral branch. These clots, of which 
the first bears the name of external, and the other that of 
internal, fig. 269, are the means which nature employs to 
put a stop to the hemorrhage; not, however, until, as a gen- 
eral rule, it has proceeded to the extent of syncope, a cir- 
cumstance always eminently favorable to the coagulation of 
the blood, and, consequently, also to the formation of the 
clots now described. But these clots, at this stage of the 
process, are necessarily very soft, as well as very imper- 
fectly adherent; hence, in order to guard against their de- 
tachment, or, what is tantamount to this, against a recurrence 
of the hemorrhage, it is indispensable that these parts— 
clots, vessel, and surrounding structures—should become effectually and permanently sol- 
dered together. This accordingly soon happens ; for within a few hours after the occur- 
rence of the injury inflammation is enkindled, both in the divided artery and in its sheath, 
and this is followed by the proliferation of the endothelial cells of the internal coat and 
of the fixed cells of the sheath, and their extension into the clots, and the appearance of 
Plan of Natural Hemostatics, in a 
Cut Artery. At a, the Cut End of the 
Arterial Tube; Conical by Contraction. 
At b, the Arterial Sheath Vacated by 
the Retracted Artery, and Occupied by 
Coagulated Blood. At c, the Coagu- 
lum Projecting from the Orifice of the 
Sheath. CHAP. V. 
WOUNDS AND HEMORRHAGE. 
655 
colorless blood corpuscles, which are partly resident in the clots, and partly intruders from 
without. This new cellular tissue fixes the clots, and is subsequently transformed into 
connective tissue ; and vessels finally show themselves, some of them being of new' forma- 
tion, while others, and perhaps the greater number, are derived from the divided artery 
and its sheath, as well as from the surrounding structures. 
The two clots now described are, it will be seen, inseparably blended at the orifice of 
the divided vessel, and their form and arrangement may not inaptly be compared to a glass 
stopper, closely fitted into the neck of a decanter. The outer clot is 
rough and irregular, whereas the internal is perfectly smooth and cylin- 
drical, except its cardiac extremity, which is nearly always conical. 
The longer the internal coagulum is the less danger will there generally 
be of its premature detachment. 
The changes above mentioned as occurring in the two clots are gen- 
erally the work of time; the gluing process is usually effected rapidly, 
since its function is to protect the patient against hemorrhage: but the 
removal of the serum and coloring matter of the blood, and the conver- 
sion of this fluid into solid matter, take place more slowly, and are often 
not completed under several months. Finally, if the parts be examined 
at a still later period, it will be found that both clots have entirely dis- 
appeared, and that the injured vessel, as high up as the first large col- 
lateral branch, has been transformed into a dense, strong, fibrous cord, 
fig. 270, similar to that observed in the umbilical arteries of the infant. 
Such, then, is the process which nature employs for arresting the 
flow' of blood from a divided artery. Taking advantage of the exhausted 
condition of the system consequent upon the shock and loss of blood, 
she instinctively forms the two clots, having, first of all, drawn away 
the vessel from the main wound, as w'ell as caused it to diminish its 
caliber, and then she goes deliberately to work to fasten these clots at 
points precisely where they are most needed for the purpose. The ves- 
sel being thus hermetically sealed, she afterwards busies herself still further in getting rid 
of these plugs, as they now are no longer required, and, finally, completes the labor by 
converting the obsolete extremity of the artery into an analogous tissue. These changes, 
so profoundly curious and interesting, bear, it will be perceived, a very close resemblance 
to those which take place in the callus of a broken bone. 
After the ligation of an artery, the supply of blood in the parts beyond the seat of the 
obstruction is maintained by what is called the collateral circulation, the vessel above 
communicating freely with that below, as in fig. 271, by its anastomosing branches. 
Fig. 270. 
Change in the Shape 
and Structure of an 
Artery after Ligation. 
Fig. 271. 
Diagram of Collateral Circulation. 
When an artery is divided only partially, whether transversely, obliquely, or longitudi- 
nally, an external clot forms, but this is generally so imperfect as to render it incapable 
of opposing an effectual barrier to the flow of blood. The edges of the wound, however 
small, have a constant disposition to gape; and hence, although plastic matter may, per- 
haps, be deposited in great abundance, yet it is impossible for the parts to contract per- 
manent and satisfactory adhesions to each other. As soon as-the circulation regains any 
of its natural vigor, the blood as it sweeps along washes off the clot, and appears upon 
the exterior of the wound; and thus the hemorrhage usually continues, paroxysm after 
paroxysm recurring in more or less rapid succession, until it proves fatal. 656 
DISEASES AND INJURIES OF THE ARTERIES. 
chap. v. 
Although such is the course usually pursued when an artery is only partially divided, 
experience has shown that a spontaneous cure does occasionally take place. Such an 
event, which, however, at best is extremely uncommon, is most likely to occur when the 
opening is longitudinal; when the wound in the overlying structures is a mere fissure or 
canal, offering an imperfect outlet to the contents of the vessel; when the system remains 
for a long time in a prostrate condition ; and when, finally, there is a very rapid and 
abundant deposit of plasma in the various tissues involved in the lesion, serving to glue 
them speedily and firmly together. That an incised wound, however, of considerable 
size, is sometimes healed in this manner, is proved by what occasionally happens when 
the brachial artery is injured at the bend of the arm in venesection. 
Punctured wounds of the arteries are dangerous or otherwise, according to their size 
and the size of the affected vessel. If a pin be thrust into a large artery of an animal, 
and immediately withdrawn, a drop of blood exudes, but there is no further bleeding, the 
aperture being promptly closed by the natural elasticity of the coats of the vessel. 
Whether a similar effect follows such an occurrence in the human subject is not positively 
determined. Mr. Guthrie mentions a case in which fatal hemorrhage v/as produced by 
wounds of the carotid artery inflicted by pins ; and he refers to two instances in which a 
similar result was witnessed from a puncture of the femoral artery made with a tenacu- 
lum. On the other hand, it is a well-known fact that acupuncture needles have repeatedly 
been inserted into the largest arteries with perfect impunity. It is very probable that an 
instrument of small size will produce different effects, so far as hemorrhage is concerned, 
in a denuded artery and in an artery that retains its natural relations, the blood, owing 
to the difference in the atmospheric pressure, being more readily forced out in the former 
than in the latter. However this may be, it is a matter of paramount importance, in 
performing operations upon the arteries, to avoid even the most delicate puncture, since 
such an accident might be followed by ulceration, and serious, if not fatal, hemorrhage. 
Wounds inflicted by small shot partake of the nature of punctured wounds. In two 
cases of this kind under my charge, one involving the subclavian and the other the 
femoral artery, the openings made by the shot were found to be perfectly closed in less 
than three weeks after the accident. In gunshot wounds the hemorrhage is usually copi- 
ous, if not speedily fatal, whether the artery, especially if it be one of large size, be par- 
tially or completely divided. When the coats are badly contused, or bruised and lace- 
rated, as when they are grazed by the missile, secondary hemorrhage may be expected 
from ulceration or gangrene. 
When the outer and middle coats of an artery are dissected off to a slight extent in an 
animal, no bleeding takes place, because the current of blood is not sufficiently strong to 
rupture the inner tunic ; but such an occurrence in the human subject is fraught with 
great danger, as it is almost inevitably followed by fatal hemorrhage. A case recorded 
by Mr. Guthrie strikingly illustrates this fact. A man cut his throat with a razor, the 
instrument inflicting a transverse wound upon the carotid artery, but did not penetrate 
beyond the middle coat. The vessel gave way at the point of injury on the eighth day, 
and the patient died of hemorrhage. When an artery is nicked with a knife or forceps, 
as occasionally happens in the extirpation of a tumor with unusually firm and extensive 
adhesions, safety demands that the vessel should immediately be secured with the liga- 
ture. When the internal and middle tunics are divided, as in case of accident, the exter- 
nal, if severely injured, will be very liable to be assailed by ulceration ; whereas, if it 
retain its integrity, the probability is that it will be gradually expanded into an aneuris- 
mal pouch, the more especially if it has undergone the atheromatous or calcareous degen- 
eration. 
Contused and lacerated wounds of the arteries generally bleed much less freely than in- 
cised and punctured. Occasionally, indeed, there is no hemorrhage whatever, even when 
the largest arteries are involved in the injury, and their denuded extremities are hanging 
loosely on the exposed tissues. In some instances the hemorrhage is momentarily profuse, 
and then ceases permanently ; in other cases it continues, and proves speedily fatal. The 
reason why there is generally so little blood lost in injuries of this description is, as is 
fully explained in the chapter on wounds, that the ragged and paralyzed coats of the artery 
readily intercept the blood, and that the blood itself, in lesions involving the separation of 
an entire limb or the rupture of the larger vessels and nerves, always coagulates much 
more promptly and firmly than in ordinary incised wounds, the shock sustained by the 
system being highly conducive to the occurrence. Sometimes an effectual barrier is op- 
posed to the effusion of blood in a ruptured artery by the sheath being drawn forward 
over its mouth, in the form of a hood. CHAP. V. 
WOUNDS AND HEMORRHAGE. 
657 
When an artery is severely contused in its continuity, the resulting inflammation may 
be so great as to cause complete occlusion of the vessel at the seat of the injury, the blood 
coagulating as it sweeps over the affected surface, and the clot becoming firmly adherent 
through an abundant effusion of lymph. Or, instead of this, ulceration or gangrene may 
occur, and the patient may die of hemorrhage, as not unfrequently happens after gunshot 
injuries, the bleeding usually coming on within the first eight or ten days after the inflic- 
tion of the wound. 
But, although nature may, and, indeed, sometimes does, arrest tlie hemorrhage from a 
divided artery, yet no sensible surgeon would intrust her with such an office, when it is 
in his power to get at the seat of the wound ; for it is hardly possible to conceive of a 
case involving one of the larger trunks where her efforts would be likely to be successful, 
or where, if ultimately triumphant, the patient would not be brought repeatedly at death’s 
door before she could attain her end. It is only in wounds of the internal arteries, as 
those of the chest and abdomen, and in the aorta and its larger branches, that we must 
refrain from direct interference, and limit ourselves to the use of general means calculated 
to keep down vascular action, especially the liberal use of anodynes and sedatives, as 
opium, aconite, and acetate of lead, the application of ice over the seat of the injury, 
exposure of the patient to cold air, and perfect quietude of mind and body. All active 
exertion must for a long time be avoided, in order that, if a cure should take place, the 
wound may not be suddenly reopened by the giving way of its edges, in consequence of 
the imperfect organization of the clots and of the plasma. 
Treatment The means employed by art for suppressing hemorrhage are quite nume- 
rous, as well as greatly diversified in their nature, and will, therefore, require to be con- 
sidered somewhat in detail. The most important of these means are : first, ligation; 
secondly, acupressure, thirdly, compression ; fourthly, torsion ; fifthly, forced flexion; 
and, sixthly, styptics. Besides these, there are several others of a subordinate character, 
meriting merely a passing notice. 
1. Ligation Ligatures are composed of various materials, as silk, linen, and soft 
leather. Of these, the first is the most unexceptionable, and almost the only one now em- 
ployed. It should be round, smooth, well twisted, colorless, and so strong as not to break 
without considerable effort. For the smaller arteries, as the radial, tibial, and temporal, 
common sewing silk is well adapted; but for the larger trunks, as the femoral, iliac, and 
carotid, stay silk, a much stouter article, is required. Some practitioners prefer what is 
called dentist’s silk, no matter what may be the size of the vessel, on the ground that it is 
much stronger in proportion to its thickness than any similar substance, and, therefore, 
less liable to excite undue irritation. This thread, which is employed in making fishing 
lines, is rendered very hard and stiff by means of gum, which, however, is easily re- 
moved by boiling it for a few minutes in a slightly alkaline solution. Treated in this 
manner, a piece long enough to tie the iliac artery will hardly weigh the twenty-fifth of a 
grain. Hemp or linen thread makes an excellent ligature ; and, in case of emergency, a 
sensible surgeon will not hesitate to take anything that may be in his way. Whatever 
substance be employed, it is very important that it should be thoroughly waxed, 
otherwise it will be difficult, if not impracticable, to draw and tie it with a requisite 
degree of firmness, to say nothing of the greater tendency of the knot to slip. From 
eight to ten inches is a good average length for a ligature. 
Animal ligatures were first introduced to the notice of the profession by Dr. Physick, 
early in the present century, and they have ever since been occasionally employed by dif- 
ferent practitioners, chiefly American. The late Dr. Jameson, of Baltimore, used them 
nearly altogether for many years, under the belief, founded upon numerous experiments 
and clinical observations, that they were decidedly superior to all others, their presence 
never causing any of the irritation which so often follows the application of the ordinary 
substances. The article to which he gave the preference was soft buckskin leather, cut into 
thin, narrow strings, not tied too firmly, lest they should break, and be thus prematurely 
detached. Ligatures made of the fibrous elastic coat of the aorta of large animals have 
been introduced by Mr. Barlow. Dr. Ishiguro, of the Japanese army, strongly recom- 
mends the use of ligatures prepared from the tendon of the whale ; they are sufficiently 
strong to bear heavy pressure, do not cause irritation, and, although they are readily ab- 
sorbed, they retain their hold long enough to prevent secondary hemorrhage. Mr. Croft, 
in 1881, tied the external iliac artery with a ligature made of the tendon of the kangaroo, 
and found great reason to be satisfied with the result. Other practitioners recommend 
catgut, or ligatures manufactured from the small intestine of the sheep, and others, again, 
the fibres ot' the sinew of the deer, the latter having been found to be particularly useful 658 
DISEASES AND INJURIES OF THE ARTERIES. 
CHAP. v. 
by Professor Eve ; while the former, rendered antiseptic by immersion in a weak solution 
of carbolic acid, has been highly lauded by Mr. Lister. The advantage of the animal 
ligature is that, besides approaching more nearly to the living tissues than any other ma- 
terial, the ends may be cut off close to the knot; its disadvantage, as formerly prepared, 
is that it soon becomes softened and disintegrated, from the imbibition of fluids, 
thereby rendering it liable to separate before it has accomplished the object for which it 
was applied. This objection, however, is overcome by steeping the catgut for two weeks 
in chromicized glycerine, a process by which it is greatly strengthened, drying it, and 
afterwards storing it in a one-to-five solution of carbolic acid and glycerine. Dr. Macewen, 
of Glasgow, has found that the best mixture for rendering the substance capable of re- 
sisting the action of the tissues for a fortnight is made by adding one part of a one-to-five 
watery solution of chromic acid to five of glycerine. For arteries of large size, the 
violin string, “ E, No. 70,” answers an excellent purpose. Prepared in the above man- 
ner, I believe that the catgut ligature is less liable than the ordinary ligature to be fol- 
lowed by suppuration, ulceration, and secondary hemorrhage ; and I have, therefore, no 
hesitation in giving it my entire approval. It is now fully ascertained that the carbolized 
catgut ligature is generally entirely absorbed within a few weeks after its application, and 
that its action on the coats of the artery is similar to that of hemp or silk, with the im- 
portant exception that the outer tunic is not ulcerated. Dr. G. F. Arnaud recently tied 
the carotid or femoral artery fourteen times in dogs, which were afterwards killed at pe- 
riods varying from four to sixteen days. In nine cases the ligature had entirely disap- 
peared ; in two it was partially absorbed ; and in three it was little altered. In twelve 
of the cases the inner and middle tunics were divided, or the middle alone. The clot, 
when not absorbed, was very small, and the obliteration of the vessel was complete and 
firm. Pure raw silk is at present being employed as a substitute for catgut, but with 
what success remains to be determined. 
Of late years the attention of surgeons in this country has been repeatedly directed to 
the use of metallic ligatures for tying arteries. The innocuous character of lead, gold, 
silver, and platinum wire, thus employed, was fully established by Dr. Henry S. Levert, 
of Mobile, in a series of experiments which he performed in 1828, and an account of 
which was published in the fourth volume of the American Journal of the Medical Sciences. 
The results proved not only that the inflammation consequent upon the operation was 
generally comparatively slight, but that in nearly every instance the metallic thread 
became speedily encysted, and might, if it had not been purposely removed, have remained 
for an indefinite period as a harmless tenant in the parts. Dr. Stone, of New Orleans, 
in 1859, tied the common iliac artery with a silver wire, and I soon afterwards secured 
the femoral in a similar manner. Since then I have adopted the procedure in a number 
of cases, and on two occasions I have left a metallic ligature permanently around the 
spermatic cord after extirpation of the testicle. In 1866, Dr. C. H. Mastin successfully 
tied the external iliac artery with silver wire, and in the same year I performed a similar 
operation upon the same vessel with equally good results. A number of other examples, 
of later date, might be cited, but this is unnecessary, as the safety and value of the opera- 
tion are fully established. 
Fig. 272. 
Toothed Artery-forceps. 
The wounded artery may be very conveniently drawn out with a pair of toothed forceps, 
fig. 272, with a tenaculum, fig. 273, or, what generally answers the purpose exceedingly 
well, an ordinary pair of pocket forceps. 
If the vessel is small, it should be 
seized in its longitudinal axis, but in 
the horizontal if it is large, since it is 
more easy in this way to occlude its 
orifice, and prevent the flow of blood. 
It is for this reason, also, that the for- 
ceps are generally to be preferred to 
the tenaculum ; the latter instrument, 
however, possesses an advantage over the former when the artery is cut off very closely, 
or when it is desired to include some of the surrounding tissues. Care must be taken not 
to transfix the coats of the vessels, and then tie the ligature below the point of perfora- 
Fig. 273. 
Tenaculum. 659 
CHAP. V. 
WOUNDS AND HEMORRHAGE. 
tion, as this might lead tr> secondary hemorrhage. When no good assistant is at hand, 
the artery-forceps, delineated in fig. 274, an instrument with broad, serrated extremities, 
and a movable slide or catch, to close the blades, will be found convenient. 
Fig. 274. 
Dr. Prince, of Illinois, has devised a contrivance for seizing arteries, called the tena- 
culum-forceps, represented in fig. 275. As the names implies, it combines the advantages 
Sliding-forceps. 
Fig. 275. 
Prince’s Tenaculum-forceps. 
of the two instruments, and may be applied with great efficiency to all arteries of medium 
size, as the blades are sufficiently wide to effect complete occlusion of their caliber. 
The vessel being pulled gently out, as in fig. 276, is carefully isolated from its connec- 
tions, either with another pair of forceps, the finger, or the knife, or all three together, as 
may be most expedient. The propriety of excluding from the ligature the smallest 
nervous filament, as well as the most insignificant vein, and every particle of muscular 
tissue, is too obvious to require any comment. Such a proceeding is absolutely necessary, 
not only to prevent pain and suppuration, but to promote the separation of the ligature. 
It is only when the vessel is very small that any of the tissues in which it is embedded 
should be included in the ligature. The ligature is applied to a sound portion of the 
artery, immediately above the instrument, and tied into a single knot, when it is drawn 
so firmly as to divide the inner and middle tunics, as in fig. 277, if the artery is large, or 
Fig. 276. 
Fig. 277. 
Mode of Drawing Out and Isolating an Artery. 
Effects of Ligation upon the 
Inner Coats of the Artery. 
even of medium caliber; while, in the smaller branches, mere contact of the opposite sur- 
faces is aimed at. In executing this part of the operation, the extremities of the ligature 
should be wound around the fore and middle fingers of each hand, while the thumb is 
extended upon them nearly as far over as the vessel, in order that the force may be 
exerted as gently and equably as possible. Nothing is more unseemly, or more truly 
reprehensible, in a surgeon or his assistant, than to pull a ligature by fits and jerks, 660 
DISEASES AND INJURIES OF THE ARTERIES. 
CHAP. V. 
or so violently as to break it, or, perhaps, lacerate and tear off the artery itself. With 
a little care and gentleness, a comparatively weak ligature may be thrown around a vessel 
so as to answer the intention most fully. I dwell upon this point with some degree of 
emphasis, because it has happened to me to witness a very unusual number of these 
Herculean feats with the ligature, the men often pulling as if they had hold of a rope and 
piece of wood, instead of a delicate thread and artery. Fig. 278 shows the indented 
appearance of the artery after ligation. < 
The tying is completed with a double knot, when one end is cut off close, and the 
other brought out at the nearest angle of the wound. The knot which is thus made is 
the reef-knot, fig. 279, in which the ends of the thread lie across the artery, as in the lips 
of the wound in the ordinary interrupted suture. The surgeon’s knot, fig. 280, is no 
longer used for the purpose, as, from the manner of making it, it is very irregular, and, 
consequently, ill adapted to the object. In tying very small vessels, sometimes only one 
knot is employed. 
The practice of cutting off both ends of the ligature, and of closing the wound over the 
injured vessel, first suggested, towards the latter part of the last century, by Mr. Haire, 
of England, and subsequently so warmly lauded by Mr. Lawrence and Mr. Hennen, is 
Fig. 278. 
Fig. 279. 
Fig. 280. 
Reef-knot. 
Surgeon’s Knot. 
now universally abandoned, and very justly so, on the ground that the 
noose, after having performed its duty, creates irritation among the 
parts with which it lies in contact, leading thus to the development of 
abscesses, which continue to discharge so long as the foreign substance 
remains. When the ordinary animal ligature is used, this objection does 
not obtain, as the noose is soon removed by absorption, and a similar 
remark is applicable to the carbolized catgut ligature, which, when 
properly prepared, retains its hold sufficiently long to effect obliteration 
of the vessel without exciting undue irritation. 
When the artery is diseased, or abnormally brittle, from the fibrous, 
cartilaginous, earthy, or fatty degeneration of its tunics, it may become 
necessary to employ a flat ligature, consisting of two or more silk 
threads, carefully waxed, and arranged side by side, or of a piece of 
soft, narrow' braid, draw'n so gently around the vessel as merely to approximate its serous 
surfaces. In using the round ligature, the division of the inner and middle tunics is 
aimed at, as this is most favorable to adhesion; but in this case the object is to pre- 
serve their integrity, so as to promote the retention of the cord until a permanent clot is 
formed. If this precaution be neglected, the cox’d may fall off permaturely, and thus 
occasion secondary hemorrhage. Instances occur in which the fragility of the arteries is 
so gi'eat as to render them incapable of beai'ing even this degree of pressure ; and then 
the only resource is to include the vessel along with a poi’tion of muscular or aponeurotic 
substance in a flat ligature. Such a procedure is much more rational than the pi’actice, 
formerly recommended, of tying the vessel over a l’oll of adhesive plaster, an operation 
which could hardly fail to be followed by mischief. 
In regard to the propriety of drawing the ligature so fii*mly as to divide the inner and 
middle tunics, no doubt is any longer entertained by enlightened practitioners. In the 
time of Scarpa much disputation prevailed respecting this point in the ligation of arteries, 
it having been alleged by this distinguished surgeon, on the strength of numerous experi- 
ments, that a cure could be effected quite as rapidly, and, in the end, more safely, simply 
by placing the serous surfaces gently in contact with each other. It was supposed that 
the part, treated in this wray, would unite by dii*ect adhesion, and that, consequently, 
w’hen the ligature finally became detached, there would be much less risk of hemorrhage 
than vdien the vessel is lacerated and contused by the ruder method of pi’ocedure above 
described. . Plausible as this theory may, at first sight, appeal*, it is found to be wholly 
unreliable in practice, for the very reason which induced Scarpa and his followers to 
Exterior of an 
Artery after liga- 
tion. CHAP. V. 
WOUNDS AND'HEMORRHAGE . 
661 
advocate its adoption, the ligature being not only a much longer time in separating, but 
the two ends of the artery being much less effectually occluded. When it is recollected 
that a certain degree of inflammation is necessary, after this operation, in order to afford 
the requisite amount of plasma, for gluing the inner clot to the surface of the vessel, it 
is reasonable to suppose that it would be much more easily induced by a partial division 
of the inner and middle tunics than by the mere approximation of the opposite sides of 
the tube ; and this is precisely what the general experience of the profession has at length 
established in relation to the subject. 
When a considerable portion of neighboring tissue is obliged to be included along 
with the artery, the best instrument for performing the operation is a sharp tenaculum, 
with an eye near its point, as seen in fig. 281 ; a curved needle armed with a double liga- 
ture ; or Physick’s artery forceps, fig. 282. 
Fig. 281. 
Fig. 282. 
Tenaculum-needle, armed witli a Ligature. 
Physiek’s Artery Forceps. 
An artery is sometimes rendered incapable of bearing a ligature in consequence of the 
softening of its tunics by inflammation. Such an event, which is often exceedingly per- 
plexing, is most liable to happen in cases of secondary hemorrhage after wounds and 
amputations. The remedy is to isolate the vessel a short distance beyond its diseased 
limits, and to ligate it there in the usual manner; or, this being impracticable, to tie the 
diseased part along with more or less of the surrounding tissues; or, this also tailing, to 
cut down upon and secure the main trunk of the artery. 
In tying an artery in its continuity, whether as a means of arresting hemorrhage or of 
curing disease, the ligature is passed around the vessel by means of an aneurism-needle, 
fig. 283, a kind of blunt tenaculum, 
with an eye at the free extremity. 
The point of the instrument is gently 
carried around the vessel, without 
including any of the accompanying 
structures, steady counterpressure 
being made with the end of the fore- 
finger, especially as it penetrates the 
connective tissue. 
The precise situation of an artery 
is determined by its pulsation, and by 
its anatomical relations. Sometimes 
its course may be accurately defined 
by stretching a line from one point to 
another. At the commencement of the 
operation, the limb should be forcibly 
extended, as the muscles and tendons 
will then be rendered most prominent; 
but, as the dissection proceeds, the ob- 
ject will be greatly promoted by flexing 
the limb in order to relax the soft parts. 
That the artery may not be wounded, 
its sheath should be carefully pinched 
up with the forceps, nicked slightly 
with the scalpel, as in fig. 284, from 
Erichsen, and then slit open to the 
distance of a few lines upon a grooved 
director. Isolation is best effected with 
the point of this instrument, either 
alone, or aided with the forceps and 
Fig. 283. 
Aneurism-needle armed with a Ligature. 
Fig. 284. 
Exposure and Opening of the Sheath. 662 
DISEASES AND INJURIES OF THE ARTERIES. 
chap. v. 
finger nail. The proper sheath must be disturbed as little as possible, as it is intimately 
connected with the nutrient vessels, the injury of which might occasion softening, ulcer- 
ation, or gangrene of the artery. The muscles are separated with the handle of the scalpel, 
without any material interference with the integrity of their fibres; and great care is taken, 
before commencing the incisions, to ascertain the situation of the superficial veins, by com- 
pressing the parts above the seat of the proposed operation, as it is very important that 
they should not be wounded. 
The practice of applying two ligatures, and dividing the artery between them, is now 
very properly abandoned. Ihe operation, which dates as far back as the time of Aetius, 
was revived by Mr. Abernethy, through whose influence it became for a while quite 
popular. It was soon found, however, that it was liable to be followed by secondary 
hemorrhage, owing chiefly to the injury inflicted during its execution, and it has, there- 
fore, deservedly fallen into desuetude. 
It was also in the operation of Aetius that some of -the surgeons of the last century 
employed what was termed the reserve ligature, intended as a ready resource in sudden 
emergencies. The cord was placed loosely around the artery, to be tied instantly in the 
event of hemorrhage, from the premature detachment of the original ligature. Experience, 
however, soon showed that the procedure, instead of answering the design for which it 
had been intended, had a direct tendency to bring about the mischief, from its liability to 
produce ulceration of the denuded and tortured vessel. Its evils, indeed, are so palpable 
that there is no probability that it will ever be revived by any intelligent surgeon. 
When an artery as, for instance, the femoral, is cut completely across in the continuity 
of a limb, two ligatures are necessary, one for the cardiac, and the other for the distal, 
extremity of the vessel. The reason of this is that, however securely the cardiac end 
may be tied, there will inevitably be more or less hemorrhage from the lower end, unless 
this be tied also, in consequence of the activity of the recurrent circulation. Every one 
who has ever had occasion to ligate the brachial artery at the bend of the arm, on account 
of injury inflicted upon the vessel in bleeding, must have seen that the hemorrhage was 
only partially controlled by tying its upper extremity. The blood, under such circum- 
stances, wells up from the lower part of the artery as water bubbles up from the bottom 
of a spring; it does not issue in jets, or in a saltatory manner, as when it proceeds from 
the upper orifice, but lazily, and of a dark color, the bleeding resembling that of a vein 
rather than of an artery; and thus the hemorrhage goes on, with little or no intermission, 
until it is arrested by ligature, or until it proves fatal. The flow may, it is true, be 
temporarily stopped, during an attack of syncope; but even then seldom perfectly, for 
the reason, apparently, that the vessel here does not possess the same power of contrac- 
tion and retraction that it does above, and is, therefore, not capable of forming any 
efficient clot, either external or internal. 
The changes which occur in an artery after the application of a ligature are essentially 
similar to those which occur when the bleeding is arrested spontaneously. The first thing 
that happens, after such an operation, is the coagulation of the blood within the artery as 
high up, generally, as the first considerable collateral branch, thus forming what is named 
the internal clot. The external clot is, of course, wanting, a circumstance which consti- 
tutes the main difference in the two cases. The injured tunics, becoming inflamed, the 
cellular elements, particularly those of the intima or internal coat, multiply, and they, 
along with wandering lymph cells, give rise to a plastic formation, which grows between 
the clot and the ligature, and firmly and permanently fixes the former in its situation. 
In the course of a few days granulations spring from the plastic formation, extend into 
the clot, and cause it to disintegrate and finally to disappear. At about the sixth day the 
plastic formation begins to show signs of organization, and is soon permeated by a rich 
capillary network. Between the fifteenth and twentieth day, an anastomosis is established 
between the former vessels and those of the wall of the artery, the communication being 
established at the point at which the internal and middle coats have been divided by the 
ligature. Finally, after an indefinite period, the plastic formation being transformed into 
cicatricial tissue, disappears, and the corresponding portion of the artery is converte*d 
into a dense, fibrous cord. 
The changes experienced by the arteries, the clot, and the plastic formation in their 
interior, after the application of the ligature, are admirably illustrated in the adjoining 
sketches from Dr. E. O. Shakespeare, to whose researches we are mainly indebted for a 
knowledge of the part played by the endothelial elements of the internal coat of the vessels 
in the process of repair. Fig. 285 represents a transverse section of the femoral artery 
of a dog forty-eight hours after deligation. At a and c the external and adventitious 
coats show proliferation of their cellular elements; at m the same change has occurred in CHAP. V. 
WOUNDS AND HEMORRHAGE. 
663 
the middle tunic ; at e the folds of the elastic layer of the inner coat are still very distinct; 
and at p the plastic material, formed principally by proliferating endothelial cells, is 
very conspicuous. Fig. 286 exhibits the artery eight days after the operation. At p granu- 
lations are seen springing from the plastic formation. They consist of spindle cells, the 
direction of the long axis of which is in the main parallel to the axis of the granulations. 
Fig. 287, from O. Weber, represents the 
artery fifty days after deligation : numerous 
vessels are seen coming from the external 
coat, Z, to communicate with the newly- 
formed vessels of the plastic clot, Th. 
It is impossible to state, except in a general 
manner, how long an internal clot must be 
in order to effect thorough closure of an artery, 
so as to prevent hemorrhage on the separa- 
tion of the ligature. There is unquestionably 
less danger of hemorrhage when the dis- 
tance between the ligature and the first large 
collateral branch is considerable than when 
the reverse is the case ; and yet instances not 
unfrequently arise in which no bleeding takes 
place, although there is hardly any internal 
clot at all. Such an occurrence can only 
be explained upon the assumption that the 
plasma poured out during the progress of 
the inflammation provoked by the pressure of the ligature serves under such circum- 
stances the purpose of a clot, which, hermetically sealing the mouth of the vessel, opposes 
an effectual barrier to the effusion of blood on the detachment of the ligature. Secondary 
hemorrhage will be most likely to occur when there is extensive separation of the sheath 
of an artery, in our attempts at isolation, thereby cutting off the supply of blood and 
nerve fluid from its tunics, and, as a necessary consequence, causing gangrene and pre- 
mature detachment of the slough. In such an occurrence, which is sometimes unavoid- 
able, the best plan is to adopt the practice of Professor Toland, of San Francisco, of 
employing two ligatures applied in such a manner as to exclude the denuded portion of 
the vessel entirely. The operation is based upon the fact that the integrity of the sheath 
of an artery is just as necessary to the preservation of its vitality as the periosteum is to 
that of a bone. 
The period at which a ligature is detached varies with many circumstances, of which 
the principal are, the size of the cord and the manner in which it is tied, the state of the 
Fig. 285. 
Effects of Ligation, at the end of Forty-eight Hours. 
Fig. 286. 
Fig. 287. 
artery, and the amount of the resulting inflammation. 
A small ligature will, other things being equal, be 
separated sooner than a large one, and a firm sooner 
than a loose one ; a sound artery will be longer in 
throwing it off than a diseased one, simply because 
it has more power of resistance. A ligature upon 
the brachial artery will generally be detached in about 
ten days; upon the femoral, in from twelve to four- 
teen ; upon the external iliac, in sixteen ; upon the 
common iliac, in about twenty-one. To this rule there are, of course, many exceptions. 
I recollect an instance in which, after an amputation of the leg, the ligature was still 
Effects of Ligation, at the end of Eight Days. 
Effects of Ligation, at the end of Fifty Days. 664 
DISEASES AND INJURIES OF THE ARTERIES. 
CHAP. V. 
firmly adherent to the anterior tibial artery at the end of the fourth month. Dr. Lopez, 
of Mobile, communicated to me the particulars of a case in which the separation was not 
effected before the end of the eleventh month ; and Professor Eve met with one in which 
it did not take place until after the thirteenth month. Such occurrences usually depend 
either upon the faulty manner in which the operation is performed, or upon the presence 
of an extraordinary quantity of organized plasma, interfeiing mechanically with the 
detachment of the thread. 
When a ligature is indisposed to come away, its separation may generally be promoted 
by making, once every twenty-four hours, gentle traction upon it; great care and judg- 
ment, however, must be exercised in performing the operation, otherwise the patient may 
not only be subjected to severe pain, but to the risk of secondary hemorrhage. 
The detachment of the ligature is effected by ulcerative absorption, and, if the mass be 
carefully inspected, it will be found to embrace a dead portion of the artery in the form 
of a slough. 
When the cord is drawn very tightly, the corresponding part of the artery is strangu- 
lated, if not at once, at any rate, within a few hours ; but, in general, the process takes 
place more tardily, and thus affords the two ends of the vessel time to prepare and fortify 
themselves for the approaching crisis. If we study the whole subject minutely, it will be 
found to embrace the following facts :—first, the strangulation and death of the vessel 
at the site of the ligature ; secondly, the adhesion of the clot to the inner surface of 
the vessel, speedily followed by its replacement by organized tissue; thirdly, ulceration 
and the consequent separation of a part of the artery, thus producing a gap in its con- 
tinuity ; and, lastly, the disappearance of the new tissue and the transformation of each 
extremity of the tube into a dense, fibrous cord. In addition to these changes, there is 
occasionally slight suppuration, the matter usually presenting itself in the form of a little 
abscess. When an artery is tied at its extremity, as in an amputation or the extirpation 
of a tumor, tlie part of the vessel beyond the seat of the ligature mortifies, and is eventually 
detached as a slough. 
Percutaneous—more properly called subcutaneous—ligation of the arteries in their con- 
tinuity for the arrest of hemorrhage may occasionally be advantageously practised. It is 
particularly applicable to hemorrhage of the palm of the hand and sole of the foot, at- 
tended with inordinate swelling of the parts, rendering it difficult, if not impossible, to 
expose the bleeding vessel, and to tie it in a satisfactory manner. The operation consists, 
as the term implies, in carrying a stout needle, more or less curved, and armed with a 
strong thread, through the skin around the artery at a distance of one-tliird of an inch 
to an inch and a half from its track, so as to include a considerable portion of soft 
structure, and then bringing the needle out through the skin near the opening of 
entrance, and tying the ends of the thread over a roll of adhesive plaster. The vessel 
is thus firmly embraced in the loop of the ligature, which may generally be withdrawn 
by the end of the third day, or even before, as by that time complete occlusion will have 
taken place. 
Subcutaneous ligation, mentioned by Ledran, in 1720, was originally practised by Pro- 
fessor Middledorpf, of Breslau, who has adduced a number of cases illustrative of its 
value. In this country the subject was first brought prominently before the profession by 
Dr. H. Z. Gill. The operation, which is performed with a slightly curved and some- 
what flexible needle, armed with a thread or silver wire, is obviously not adapted to the 
larger arteries, as the ligature would necessarily include the corresponding vein, the 
obliteration of which might be followed by most disastrous consequences, independently 
of the compression of the large nerves, which are often in such close relation with the 
bloodvessels. 
The discovery of the use of the ligature is due to Ambrose Pare, in the sixteenth 
century, prior to whose time surgeons were in the habit of stanching hemorrhage with 
the actual cautery, hot pitch, and all kinds of styptics, of the most cruel and barbarous 
nature. “ For the good of mankind,” says this great man, “ and the improvement and 
honor of surgery, I was inspired by God with this good thought.” Pare himself fully 
appreciated the utility of his invention, but his contemporaries spared no pains to under- 
value it, and to revile and persecute its author, subjecting him to the humiliation of 
searching the writings of the ancient fathers of medicine for traces of the use of the 
ligature as a justification of his practice. Gourmelen, the jealous and malignant Pre- 
sident of the College of Physicians of Paris, made himself particularly conspicuous on 
the occasion, and thus earned an infamous reputation ; for the only act by which he is 
now remembered is his bitter and unrelenting persecution of Pare, rendered immortal by 
his great achievements. CHAP. V. 
WOUNDS AND HEMORRHAGE. 
665 
2. Acupressure—Acupressure, as a means of arresting hemorrhage, was devised by 
Sir James Y. Simpson, who published his first account of it in 1860 ; and, although it 
has attracted great attention since, more especially in Europe, and its results have, in the 
main, been of a very flattering character, time alone can determine its ultimate fate. That 
it is destined entirely to supersede the use of the ligature, so easy of application, so efficient 
in its action, and so universally approved, even its warmest advocates will hardly claim. 
In this country acupressure has made little progress; and, with the exception of Hewson, 
L. Weber, and Hutchison, all of whom have written able papers upon the subject, few, 
if any, prominent surgeons employ it. I have myself seldom used it, having always been 
satisfied with the harmless character of the ligature and its efficiency as a safe and ready 
hemostatic agent. 
The advantages claimed for this operation over that of the ligature are, first, that it is 
more easy, simple, and expeditious of execution; secondly, that the acupressure needle 
does not, like the ligature, provoke irritation, much less suppuration, ulceration, or mor- 
tification at the seat of the constriction ; thirdly, that the instrument may generally be 
removed, even in an artery of large size, as, for example, the femoral, at the end of the 
second or third day; fourthly, that the wound, other things being equal, is more liable 
to unite by the first intention ; fifthly, that there is much less risk of erysipelas, pyemia, 
phlebitis, abscesses, traumatic fever, and secondary hemorrhage; and, lastly, that it may 
be safely employed in diseased arteries, too soft, brittle, or friable to bear the pressure 
of a ligature. It may also be used with great advantage when the blood oozes from 
numerous points, as in certain operations upon the vulva and other regions where liga- 
tion is impracticable. In regard to the occurrence of secondary hemorrhage the results 
of acupressure are highly flattering. Pirrie and Keith had, up to 1869, treated nearly 
one thousand vessels by this method, with less than five cases of bleeding after the with- 
drawal of the needle. 
Acupressure may be practised according to different methods, of which, however, only 
four need to be here described, as they have virtually superseded all the rest. Of these 
some originated with Simpson himself; the others mainly witli Knowles, Keith, and Pirrie, 
of Aberdeen, the latter of whom has greatly simplified the operation, and devised conve- 
nient names for the designation of its principal methods. 
A formal description of acupressure pins and needles is unnecessary, as they may 
readily be obtained at any of our cutlers. They must, of course, vary in size and shape, 
according to the object in view, and be sufficiently strong to prevent bending, perfectly 
smooth, sharp-pointed, and coated with silver, nickel, or gold, although this is not absolutely 
essential. When such instruments are not at hand, convenient substitutes will be found 
in long shawl pins. Flexible steel wire is required only in one of the present methods of 
acupressure. 
No special isolation of the artery is required, as when the ligature is used, and any 
bleeding veins may, if necessary, be very properly included along with that vessel without 
detriment. Occlusion is effected by fibrinous plugs, as in ordinary ligation, but, owing to 
the preservation of the vitality of the coats of the vessels, they are much more rapidly 
organized, and, consequently, less liable to lose their hold after the removal of the pin. 
In the original operation of Simpson, the pin, previously oiled, is passed from without 
inwards through the skin, and thence on through the muscles and other structures down 
to, and underneath, the artery, in such manner as to obliterate completely its caliber 
by bringing together its opposite surfaces. The instrument is then pushed through 
the tissues on the other side from within outwards, so that, when the transmission is 
effected, the extremities shall rest upon the skin, while the middle firmly embraces the 
Fig. 288. 
Fig. 289. 
Position of the Artery and Pin in 
Acupressure. 
Acupressure, showing the manner in which the Ends 
of the Pin project across the Skin. 
artery. If the constriction is not sufficient to arrest the flow of blood, a ligature may 
be thrown tightly around the pin, as in the operation for harelip ; but this will seldom 
be necessary, especially if the precaution be taken of inserting the compressor close to 666 
DISEASES AND INJURIES OF THE ARTERIES. 
chap. v. 
the vessel, at a rather acute angle. The point of compression for the larger arteries 
should be at least six lines from the open orifice, and about half that distance for those 
of smaller size. The pin should be left entirely free during the application of the dress- 
ings, and in withdrawing it the parts must be well supported in order to avoid the risk of 
hemorrhage. 
The annexed sketches show, at a glance, this method of acupressure. Fig. 288 displays 
the manner in which the instrument embraces and constricts the artery, while fig. 289 
exhibits the extremities of the pin as they project through the skin. A good idea of it 
may also be formed by the manner in which the stalk of a flower is fastened to the lapel 
of a coat by transfixing the cloth with a pin. 
In circumclusion, as it is called by Pirrie, the pin or needle, armed with a twisted wire, 
is passed completely under the vessel, which is then pressed firmly against it by means of 
a loop of wire hooked over its point, while the ends are 
fixed by a single twist around the pin, as in fig. 290. 
In a torsoclusion, formerly described as the Aberdeen 
method, the pin is inserted into the tissues close to and 
parallel with the bleeding artery, and its point caused 
to emerge at a distance of several lines, as in fig. 291. 
The second step consists in giving a quarter rotation to 
the pin, so as to place its point above and at a right an- 
gle to the vessel ; in pressing it well down, and in push- 
ing this for some distance into the tissues beyond, so as 
to fix it there and maintain the twist, when the parts 
will present the appearance shown in fig. 292. 
Retroclusion, so named because the pin is passed immediately behind the artery, con- 
sists of two steps. In the first the pin is entered a little to one side of the artery, caused 
Fig. 290. 
Circumclusion. 
Fig. 291. 
Fig. 292. 
Second step of Torscoclusion. 
to emerge, and passed in front and a little beyond the 
track of the artery, as in fig. 293. In the second step 
the head of the pin describes the fourth of a semicircle ; 
its point is then sent behind the vessel, and pushed on un- 
til it is fixed in the tissues beyond, as in fig. 294. 
Of all these methods of acupressure, torsoclusion de- 
serves the preference, especially for large arteries ; while 
retroclusion is very convenient for securing vessels of small size. 
I he period during which the pins should be retained must necessarily vary in different 
cases and under different circumstances. For a large artery, such as the femoral, a good 
First step of Torsoclusion. 
Fig. 293. 
Fig. 294. 
fr onTtwJnfv°fn f10Tl to sixty hours; for a small one, as the ulnar or radial, 
r°m enty-four to thirty-six. A longer time should be allowed when the patient is 
First step of Retroclusion. 
Second step of Ketroclusion. CHAP. V. 
WOUNDS AND HEMORRHAGE. 
667 
restless or affected with cough, vomiting, or high constitutional excitement, or when the 
local action is unusually great and rapid, threatening to run into suppuration, ulceration, 
or gangrene. Withdrawal of the pins is effected by a gentle twist of the thumb and fore- 
finger, everything like rudeness being avoided, lest it should provoke hemorrhage and 
interfere with the adhesions of the parts. 
Substitutes for the Ligature and Acupressure—As temporary substitutes for the liga- 
ture and acupressure numerous instruments have been contrived, all of which possess 
nearly the same mode of action. Professor N. R. Smith, of Baltimore, proposed noosing 
the extremity of the artery with a loop of fine annealed iron wire passed through a small, 
double silver tube and fastened to its free extremity, which has a slit on each side for the 
sake of greater security. The tube is brought out at the wound, and may be safely de- 
tached even from a vessel as large as the femoral artery on the second day after the ope- 
ration. The wire, in the act of removal, is carefully unrolled, and forcibly drawn with 
pliers through the canula in such a manner as to sever the artery as with a small ecraseur. 
The late Mr. Nunneley, of Leeds, employed a pair of forceps, delineated at p. 255, fig. 
72, for arresting hemorrhage. He retained the instrument, hanging out of the wound, 
from thirty-six to forty-eight hours, and found the method so efficacious that he rarely 
employed any other. Mr. B. W. Richardson, of Dublin, uses a tubular compressor, and 
I myself long ago recommended for stopping bleeding in deep-seated arteries a pair of 
light forceps with a movable handle. 
The wire loop, as a temporary expedient for arresting hemorrhage, is a modern device, 
first practised, a few years ago, almost simultaneously by Dr. A. M. Pollock, of Pittsburg, 
and Mr. Dix, of England. It consists in encircling the artery with a thread of silver or 
annealed iron wire, the ends of which, brought out at the surface one-fourth of an inch 
apart, are twisted together or tied upon the skin, over a short cylinder of wood, gutta 
percha, or adhesive plaster. The procedure is applicable to vessels in their continu- 
ity as well as to cut vessels, and, although the artery should always be separated from its 
accompanying veins, no harm is likely to result if they are embraced in the same loop. 
The period during which the loop should be retained varies, on an average, from two to 
five days. If taken off too soon, secondary hemorrhage might occur; and, on the other 
hand, if kept on too long, dangerous ulceration. The easiest and safest way of effecting 
the removal of the loop is to roll one end, after it is cut, around a pair of forceps in the 
direction of its concavity. When an artery is thus secured in its continuity, the ces- 
sation of pulsation immediately above the loop will generally serve to show that the time 
has arrived when it may with propriety be taken off, or, at all events, when the pressure 
may be safely slackened, to be again tightened if there be a recurrence of pulsation. 
In an article on the wire loop, in the New York Medical Journal for July, 1869, Dr. 
Pollock gave an account of twenty-six amputations in which he employed this method 
of treatment, the number of arteries thus secured being forty-seven, including seventeen 
femoral. In no instance did any accident arise that was justly attributable to the pro- 
cedure. In one case only was there secondary hemorrhage. The average period at which 
the wire was removed was about five days and a half. 
While the wire loop does not, apparently, possess any advantages over acupressure, ex- 
cept that in certain situations it is more easily applied, it is unquestionably preferable to the 
ordinary ligature, inasmuch as it causes less irritation, is retained only for a comparatively 
fehort time, and is more frequently followed, in open wounds, by union by the first inten- 
tion. The most serious objection to it is the difficulty which sometimes attends its removal. 
Dr. S. F. Speir, of Brooklyn, has described in the New York Medical Record for 
April, 1871, a very ingenious and useful contrivance, by which arteries may be perfectly 
Fig. 295. 
Artery Constrictor. 
occluded, without any foreign material being left in the wound to interfere with its union. 
The instrument, delineated in fig. 295, and termed the artery constrictor, consists of a 
flat metal tube, from three to six inches in length, with a sliding steel rod, one end of 668 
DISEASES AND INJURIES OF THE ARTERIES. 
chap. v. 
which terminates in a hook-shaped tongue, with which the vessel is constricted, while the 
other end has a screw arrangement, through which the tongue can be made to protrude 
from or retract within the sheath. The divided artery having been brought out of the 
wound by a tenaculum or pair of forceps, the tongue of the constrictor is placed around, 
and drawn tightly upon it. As soon as the screw meets with a considerable degree of 
resistance, the instrument is detached. When the operation is properly performed, it 
will be found that the artery is completely occluded by the manner in which the internal 
and middle tunics are ruptured and invaginated, at the same time that the outer one is 
drawn more or less firmly over them. The advantages of this mode of treatment are 
said to be its efficiency, safety, and facility of application ; and I am informed by Dr. 
Speir that it has been successfully employed in amputation at the hip, of the thigh, and 
of the leg, and applied to the carotid and femoral arteries for the cure of aneurism. 
3. Compression.—Although ligation and acupressure are the most certain means of 
arresting hemorrhage, cases occur to which they are either not at all adapted, or where, 
from the great depth and narrowness of the wound, they are impracticable. It is then 
that compression becomes available; an agent often hardly less valuable than either of 
the other methods. It is particularly serviceable when the injured vessel lies upon a 
bone, as in injury of the brachial and temporal arteries; in wounds penetrating deep 
cavities, as the thoracic and abdominal; and, lastly, when the blood issues from a con- 
siderable number of small vessels instead of escaping from one large one. 
The compression may be temporary or permanent, according to the exigencies of the 
case. Temporary compression is made with the hand, finger, tourniquet, or compress and 
bandage, until the injured artery can be ligated, or secured in some other effectual way. 
In permanent compression, the application is con- 
tinued until the vessel is completely obliterated, 
whether the time be short or long. 
Temporary compression is necessary chiefly in cases 
of sudden emergency, as, for example, when an indi- 
vidual is stabbed in the femoral artery, and the sur- 
geon cannot obtain any assistance in tying the vessel. 
In such an event, an attempt is made to arrest the 
hemorrhage with a tourniquet, fig. 296, or with a 
graduated compress and bandage; the former being 
placed directly over the course of the artery from 
which the bleeding proceeds, or, if this be impracti- 
cable, over the main trunk of the limb, and the latter 
directly over the wound as well as for some distance 
above, along the track of the vessel. In either case, 
it is to be borne in mind that the compression, even 
if maintained only for a few hours, may become a 
source not only of excessive pain, but also of morti- 
fication. The greatest possible vigilance should, 
therefore, be exercised in its employment. 
The original idea of the tourniquet is generally 
ascribed to Morel, a French military surgeon, who 
employed it in the treatment of various kinds of’ 
wounds at the siege of Besan<jon, in 1674. Hans 
von Gerstorff, however, had previously devised an 
instrument for arresting hemorrhage, and out of these 
crude attempts arose the beautiful and very perfect contrivance now known as the tourni- 
quet of Petit, delineated in fig. 296. 
M hen the ordinary tourniquet is not at hand, very efficient compression may be made 
by tying a piece of bandage, a cravat, or a handkerchief loosely around the limb, and 
then twisting it firmly over a thick compress by means of a stick, fig. 297, a cane, or the 
hilt of a sword, fig. 298, inserted underneath it. This contrivance, usually called the 
field tourniquet, because it was originally employed on the field of battle, may advantage- 
0UfL,y. applied when a surgeon is obliged to amputate an extremity without having a 
sufficient number of intelligent assistants, although it labors under the inconvenience of 
not always concentrating the pressure upon the spot where it is most needed. For this 
reason the common tourniquet is decidedly preferable. 
Foi attesting hemorrhage in gunshot and other wounds on the field of battle, the most 
c ective tourniquet is that of Mr. Lambert, of Peekskill, consisting of two concavo- 
Fig. 296. 
Tourniquet applied to the Femoral Artery. CHAP. V. 
WOUNDS AND HEMORRHAGE. 
669 
convex pads of tin plate, connected by a non-elastic ribbon, nearly two feet in length by 
an inch and a half in width. When the instrument is applied, one of the pads rests upon 
the main artery of the limb, and the other upon a point directly opposite, without the 
slightest intermediate constriction, and, consequently, without any embarrassment what- 
ever of the venous circulation. 
Fig. 297. 
Fig. 298. 
Field Tourniquet; Handkerchief and Stick. 
Field Tourniquet; Handkerchief and Sword. 
Compression with the hand, thumb, or finger may often be advantageously employed 
for the arrest of accidental hemorrhage, until a ligature can be applied ; and it is also 
occasionally resorted to for the purpose of controlling the circulation in the main artery 
Fig. 299 
Fig. 300. 
of a limb during amputation. In the upper extremity it is generally applied to the 
brachiaT artery, as it courses along the inner border of the flexor muscle; and the 
Digital Compression of the Brachial Artery. 
Digital Compression of the Femoral Artery. 670 
DISEASES AND INJURIES OF THE ARTERIES. 
chap. v. 
lower, to the femoral artery where this vessel lies upon the pubic bone beneath Poupaits 
ligament. The annexed drawings, figs. 299 and 300, are illustrative of the subject. 
°The arteries which most readily admit of indirect temporary compression are, first, the 
common carotid, with some of the branches ot the external carotid, as the facial, coronary, 
temporal, and occipital ; secondly, the subclavian, axillary, brachial, radial, and ulnar ; 
and, lastly, the iliac, femoral, and popliteal. The circulation of the abdominal aorta may 
be arrested in a similar manner, especially in lean subjects, as has been shown in a multi- 
tude of cases of hemorrhage of the uterus, wounds of the groin and thigh, and in amputa- 
tion at the hip-joint, in the latter of which, as experience has proved, this mode of 
compression is of the greatest consequence as a means of preventing loss ot blood. 
1st. The most eligible point for compressing the common carotid is the omo-hyoid 
angle, between the sterno-cleido-mastoid muscle and thyroid cartilage. The vessel here 
is situated more superficially than lower down, and may, especially if it be pushed a little 
over towards the middle line, be readily forced against the bodies of the cervical vertebras. 
If the finger or instrument, whatever this may be, be applied perpendicularly, or carried 
too far outward, there will be danger of arresting the circulation in the jugular vein, and 
thus causing serious cerebral disturbance, to say nothing of the injurious effects that might 
result from the compression of the phrenic, sympathetic, and pneumogastric nerves. In 
any event the operation is always painful, and can seldom be borne for any length of time. 
When it is obliged to be protracted, the best plan is to use alternate pressure with two 
fingers, applied to different portions of the vessel. 
The pulsation of the facial artery may be effectually controlled by pressure made with 
the finger against the outer surface of the lower jaw, a little in front of the masseter 
muscle. The vessel is so superficial that it may always be readily found. 
The coronary artery is compressed by seizing the lip with the the thumb and forefinger, 
or with a Nunneley’s forceps, on each side of the wound, fissure, or disease, otherwise 
the hemorrhage will only be partially controlled, as is evinced in the operation for harelip 
and in the excision of carcinomatous growths. 
The temporal artery is compressed in front of the ear, about two lines from the tragus, 
and a little above the zygomatic process. The vessel, at this point, is very superficial, 
and is, therefore, easily flattened against the bone, from which it is separated only by a 
thin layer of fibro-muscular substance. The supraorbital artery is controlled by the 
application of the finger immediately above the supraorbital notch, at the distance of 
about an inch from the root of the nose; and the occipital, in the space midway, or 
nearly midway, between the mastoid process and the attachment of the complexus muscle. 
2dly. Compression of the subclavian artery is often required on account of wounds and 
operations in and upon the axilla, the lower part of the neck, and the upper part of the 
chest. The necessary pressure, which, however, can seldom be borne long, owing to the 
presence of the axillary plexus of nerves, may be made with the instrument delineated 
at p. 517, the thumb, or the handle of a stout, well-covered key, applied to the supraclavi- 
cular fossa, near the outer border of the sterno-mastoid muscle, the shoulder being forcibly 
depressed. The artery at this point lies upon the first rib, and can be easily controlled, 
provided the pressure be directed downwards and somewhat inwards, in the line of the bone. 
The axillary artery is most effectually compressed against the head of the humerus, 
while the arm is extended at nearly a right angle with the trunk. The vessel, when the 
limb is in this position, is put considerably upon the stretch, and is thus easily maintained 
in contact with the bone. 
Compression of the brachial artery may be effected in almost any portion of the extent 
of this vessel, as it courses along the biceps and coraco-brachial muscles, but cannot be 
maintained for any length of time on account of the pain experienced in the accompany- 
ing nerves. It is most conveniently made by grasping the limb with the thumb and 
fingers, the latter being applied in such a manner as to press the artery perpendicularly 
against the humerus. The circulation is always easily controlled by the tourniquet. 
Hemorrhage of the brachial artery from venesection has been temporarily arrested by 
flexing the forearm forcibly upon the arm. A similar procedure will stop the pulse at 
the wrist. 
The proper place for arresting the circulation in the radial and ulnar arteries is the 
inferior third of the forearm, where these vessels are not only quite superficial, but where 
they may easily be flattened against the bones. 'Temporary compression may conveni- 
ently be made with the fingers ; permanent, with two small compresses, confined in such 
a manner as not to embarrass the return of the venous blood. The arteries of the fingers CHAP. V. 
WOUNDS AND HEMORRHAGE. 
671 
may be controlled by pressure applied at tlie junction of the anterior with the external 
surface. 
3dly. The aorta in lean subjects, or even in a person of ordinary embonpoint, with 
empty bowels, may easily be compressed at the umbilicus against the lumbar vertebras, 
either with the fingers, or, what is better, a Pancoast’s tourniquet. The force should be 
applied a little to the left of the middle line, so as to avoid the vena cava, and the 
abdominal muscles should be well relaxed by the elevation of the hips and shoulders. 
This mode of compression is often highly serviceable in arresting uterine hemorrhage, 
and is now almost universally employed as a means of controlling the circulation in 
amputation at the hip-joint. Bleeding from a wound of the external iliac artery may 
also thus be commanded. In using the tourniquet, care must be taken not to bruise any 
of the abdominal viscera. In ordinary cases, in thin subjects with empty bowels, com- 
pression of the aorta is usually easily effected with the thumbs, or thumbs and fingers. 
The circulation of the common iliac artery may be controlled by relaxing the parieties 
of the abdomen and making pressure against the brim of the superior strait of the pelvis. 
To command the external iliac, the force must be applied against the inner border of the 
psoas muscle. In neither of these situations, however, can compression be employed with 
much certainty of success ; but the circulation can be effectually stopped by compressing 
the common iliac artery through the rectum with the hand, as suggested by Dr. Frank 
Woodbury, of this city, or with a lever of wood, as practised by Mr. Davy, of London. 
In the lower extremity, compression of the femoral artery, at its exit from the pelvis, 
is almost exclusively relied upon for commanding the circulation in amputations, resec- 
tions, and accidental hemorrhage. Louis was the first to substitute this method for the 
tourniquet in ablation of the thigh, and the practice is now very common among the best 
surgeons in this and other countries. One decided advantage which it possesses over the 
tourniquet is that it is less painful, more certain, and attended with much less venous 
hemorrhage. The compression is generally made with the two thumbs placed the one 
upon the other, just beneath Poupart’s ligament, and midway between the pubic symphysis 
and the anterior superior spinous process of the ilium. In order that the pressure may 
be perpendicular, and, therefore, the more effective, it should be made, as Malgaigne has 
very properly remarked, rather obliquely upon the artery, upwards and backwards, form- 
ing with the horizon an angle of 45°. When the assistant is unwilling to trust himself 
with his thumbs or fingers, a large key, with an appropriate pad attached to the handle, 
may be used as a substitute. 
The femoral artery in the middle third of the limb may be effectually compressed against 
the thigh-bone, either with the fingers grasping the limb, tourniquet, or the compressor 
described at p. 517. 
The tourniquet is sometimes applied to the popliteal artery, opposite the knee, a tolerably 
thick roller, pad, or compress being placed beneath the instrument in order to render the 
pressure more effective. Compression with the fingers is difficult and inoperative, on 
account of the great depth of the vessel. 
The tibial arteries can be compressed only in the lower portion of their extent, as they are 
there comparatively superficial, while higher up they are deeply buried among the muscles. 
The anterior vessel is commanded as it passes along the side and front of the bone, between 
the tendon of the common extensor of the foot and the proper extensor of the great toe. 
A tourniquet applied here, over a hollow splint, stretched along the inner and back part 
of the limb, as suggested by the late Dr. Alexander II. Stevens, in 1818, will readily 
control the circulation. The posterior tibial artery is compressed between the heel and 
the ankle, its pulsation serving as a guide to its situation. The dorsal artery of the foot 
is easily controlled, as it runs down across the instep, being covered merely by aponeurosis, 
connective tissue, and skin. 
The veins, from their superficial situation and the greater softness of their tunics, are 
much moi’e easily compressed than the arteries. The deep-seated ones, however, often 
require a good deal of force, and even then their circulation is sometimes controlled with 
difficulty. 
The proper place for compressing the external jugular vein is about one inch above the 
clavicle, at the centre of this bone, in the inferior triangle of the neck, where it empties 
into the subclavian. The vessel runs perpendicularly across the sterno-mastoid muscle, in 
the direction of a line drawn from the angle of the jaw to the middle of the clavicle. 
The subclavian, axillary, and brachial veins accompany the arteries of those names, 
and cannot be compressed independently of them, except in the case of their division. 672 
DISEASES AND INJURIES OF THE ARTERIES. 
CHAP. V. 
The cephalic and basilic veins with their branches are easily commanded at the bend of 
the arm. . . . 
The saphenous and femoral veins are most effectually compressed in the upper portion 
of Scarpa’s triangle, from an inch and a half to two inches below Poupart’s ligament. 
The former vessel is superficial, and the latter lies in close contact with the inner border 
of the femoral artery. > 
In permanent compression the force is applied in one of two ways, either directly or 
indirectly. The former method is particularly adapted to the suppression of hemorrhage 
from deep wounds, as in the lateral operation of lithotomy; in wounds of the rectum, 
whether accidental or wilful; in bleeding of the nose and uterus ; in the removal of tumors 
from the maxillary sinus; in the extraction of teeth; in the extirpation of the eye; and, 
finally, in wounds of the middle artery of the dura mater, as well as in a number of injuries 
in other regions of the body. 
The great objection to this mode of compression is its liability to be deranged and to 
produce severe pain and inflammation, the latter of which is often sufficient to cause pro- 
fuse suppuration. It should, therefore, never be employed with a view of arresting hemor- 
rhage from a large artery, or even from a small deep-seated one, if it be practicable to 
apply a ligature, as this is, of course, always the most certain and efficient means ; but this 
objection°does not obtain when the blood proceeds from a bleeding cavity, or when it oozes 
from the bottom of a recent wound. In such a case, indeed, compression must be used at 
all hazard, for there is frequently no other way by which the flow can be arrested. 
The compression may be made with a graduated pad and roller, or by means of sponge, 
cotton, wool, patent lint, or any other porous substance. Whatever article be employed, 
the bleeding surface must previously be freed from coagula, in order that the compress 
may be placed directly in contact with the 
orifices of the vessel, as exhibited in fig. 301. 
When the blood proceeds from a large artery, 
the circulation must be controlled, during this 
part of the proceedure, with the finger or 
tourniquet applied some distance above the 
wound. The compress is then thrust gently 
but firmly into the breach, the smallest piece 
being placed directly upon the mouth of the 
vessel, the next above this, and so on until a 
sufficient number have been applied, when 
the operation is completed by bandaging tli£ 
limb from its distal extremity upwards, care being taken that the pressure be made in as 
equable and uniform a manner as possible. The part is then put at rest, in an elevated 
position, and action moderated by the use of cold water, anodynes, and other suitable 
means. The dressings are frequently examined, but not disturbed under four or five days, 
unless they become displaced, or offensive from the discharges. 
When hemorrhage proceeds from a wound, as, for example, from that made in lithotomy, 
the part must be plugged with a sponge, or a piece of patent lint, the hollow of which is 
filled up with similar material, or raw cotton, an instrument having previously been intro- 
duced through the foreign substance to conduct off the urine. A like plan is pursued in 
bleeding of the rectum. In hemorrhage of the uterus, the vagina is plugged ; in epistaxis, 
the nostrils. 
In injuries of the bones, a plug of soft wood, as a piece of pine, is sometimes used. In 
compound fracture of the skull, attended with lesion of the middle meningeal artery, run- 
ning in an osseous canal, such an expedient is often the only one which can be successfully 
opposed to the hemorrhage. Bleeding of the nutrient artery of the long bones is occa- 
sionally stopped in a similar manner. 
In some cases the tissues of the part whence the hemorrhage proceeds are employed as 
the compressing agents. In the operation for harelip, for example, the simple approxima- 
tion of the edges ot the fissure by the twisted suture effectually arrests the flow of blood 
from the coronary arteries. 
1 he compression is said to be indirect or lateral, when it is applied to the track of the 
injured vessel instead of to its orifice. It is generally a more eligible way of arresting 
hemorrhage, as it is free from the objections that have been urged against direct compres- 
sion, with which, however, it is occasionally combined. The best mode of effecting it is 
to place a long and rather narrow compress over the course of the artery, extending from 
the neighborhood of the wound some distai ce above, and to confine it by means of a roller, 
Fig. 301. 
Plan of a graduated Compress, a. The Artery wounded. 
6, b. The graduated Compress, arranged so that the apex 
of the cone is in immediate contact with the bleeding 
Orifice, while its Mass occupies the general Wound, and 
projects somewhat above the Integumental level. CHAP. V. 
WOUNDS AND HEMORRHAGE. 
673 
commencing at the distal portion of the limb, and carried upwards in such a manner as to 
afford equable support at every point. In other respects, the treatment is conducted as in 
direct compression. This mode of management is often employed, with the happiest 
effects, in wounds of the brachial artery, at the bend of the arm, caused by venesection. 
Digital compression has been successfully employed in hemorrhage of wounded arteries, 
and is worthy of further trial. It is conducted by a relay of assistants in the same man- 
ner as in the treatment of aneurism, described in the next chapter. The procedure is 
particularly applicable to hemorrhage of the brachial artery. 
4. Torsion Torsion of the arteries is an old procedure, mentioned by Celsus, and 
reintroduced to the notice of the profession by Thierry, Amussat, Velpeau, and others; 
at one time pointedly condemned, at another immeasurably lauded, and even now opinion 
is by no means settled in regard to its safety as a general hemostatic agent, although the 
experience of Syme, Humphry, 
Bryant, Hewson, Tillaux, and 
others goes to show that it may 
be confidently applied to all arte- 
ries of the extremities, healthy 
and diseased, and also to such 
arteries of the trunk as do not ex- 
ceed the volume of the femoral. 
The operation, which answers ad- 
mirably in the inferior animals, 
as a substitute for the ligature, 
is executed with two pairs of 
forceps, as seen in fig. 302; a 
small one for drawing out the artery by grasping it horizontally, and a long, stout one pro- 
vided with a slide and serrated blades, for twisting it in its longitudinal axis; from six to 
eight turns being required, according to the size of the vessel, to lacerate and bruise its 
tunics so as to intercept and coagulate its contents. The vessel, properly isolated, must be 
held firmly, and twisted sharply until all resistance is overcome. When the artery is in- 
flamed, softened, ulcerated, or rendered fragile from fatty degeneration, the operation must 
be performed more cautiously, with less force, and fewer rotations. The end of the vessel 
must not be twisted off; and the current of blood should always be allowed to enter the tube 
before the forceps are removed, in order to test the completeness of the occlusion, as the safety 
of the procedure must necessarily depend upon the manner in which this has been effected. 
When torsion is properly executed, the inner and middle coats of the artery are not 
only lacerated, but the resulting shreds are more or less incurvated, or bent across the 
caliber of the vessel in such a manner as to form almost complete valves, which, while 
they oppose the flow of blood, entangle the fibrin of that fluid, and thus accelerate its 
coagulation. The outer tunic, on the contrary, is simply twisted, not broken up, an 
arrangement which adds greatly to the safety of the patient. 
The advantages of torsion are that it favors the repair of wounds, and lessens the dan- 
ger of suppuration ; its disadvantages, that it is sometimes troublesome, and that it does 
not always arrest bleeding. The risk of secondary hemorrhage is inconsiderable, if the 
operation be done with due caution. 
The annexed cut, fig. 303, represents the torsion-forceps of Dr. Addinell Ilewson, con- 
sisting of two sets of blades, one broad and flat, for seizing and drawing out the artexy ; 
the other, a nutch smaller instrument, duck-bill shaped or curved at the point, and designed 
for dividing the coats of the vessel. The torsion is effected by rotating the foi'ceps upon 
their axis, from two to three turns being sufficient to insui’e the occlusion of the largest 
vessel by lacerating the two inner coats and bruising the outer one, these effects being 
highly favorable to the coagulation of the blood and to the stoppage of hemorrhage. In 
an artery of the size of the femoral it is proper to let the forceps hang for a few minutes 
after the torsion is completed ; or, instead of this, another turn may be made, in order tc 
fix the twist more securely. 
Torsion, as effected with the common forceps, is represented in fig. 304, from hollin. 
the twist being so firm as to prevent the possibility of undoing itself. _ ■ 
5. Forced Flexion This mode of treatment, introduced mainly through the 
of Dr. Heath, of Newcastle-on-Tyne, although previously practised by others, as Mai- 
gaigne and Richet, is applicable exclusively to the arteries of the extremities, and com- 
mends itself by its great simplicity, the principle of treatment consisting in moderating 
and restraining the flow of blood by overflexion of the joints. In wounds of the arterie: 
Fig. 302. 
Torsion-forceps. 674 
DISEASES AND INJURIES OF THE ARTERIES 
chap. v. 
of the forearm and palmar arches, the former should be bent on 
the arm, the hand being pronated, and either flexed or extended 
at the wrist. For the arrest of hemorrhage of the lower extrem- 
ity, a roll of lint, or other soft material, having been placed in 
the ham, the leg should be flexed on the thigh and the thigh on 
the abdomen, and confined by means of adhesive strips or a roller. 
6. Styptics Styptics are remedies which arrest hemorrhage 
by their direct influence upon the blood, and the arteries furnish- 
ing it. They comprise a long and varied catalogue of articles, 
some of which produce merely an astringent effect; others act ap- 
parently mechanically; and others, again, are escharotic, destroy- 
ing both the vessels and the connecting tissues. 
The most powerful, and, at the same time, the least objection- 
able styptic at present known is Monsel’s salt or subsulphate of 
iron. It is applied either in substance, or, what is preferable, in 
strong solution upon cotton or patent lint, and possesses the 
property of instantaneously coagulating the blood, converting it 
into a very dense, insoluble clot, which continues to increase and 
to harden for several hours afterwards. What adds greatly to 
the value of this remedy is its entire freedom from causticity and 
its remarkable antiseptic property. It is particularly adapted to 
hemorrhage of the nose, mouth, throat, and uterus, as well as of 
other parts of the body where it is impos- 
sible to ligate the bleeding vessels, on ac- 
count of the great depth at which they are 
situated. One part of the officinal solution 
diluted with from four to six times that 
quantity of water is an efficient hemostatic 
for ordinary purposes. The wound, well 
wiped as a preliminary measure, is covered 
with a thick compress wet with the fluid, 
and confined by a suitable bandage. Lint, 
thoroughly saturated with a solution of the 
salt, and then dried and rolled up makes 
au excellent extemporaneous styptic. 
A mong the minor and less reliable styptics 
are alum, sulphate of copper, creasote, and 
matico. Of these, the first is by far the 
most valuable. It may be applied in satu- 
rated solution, or in powder, upon patent 
lint, directly to the bleeding surface, pre- 
viously freed of clots, and generally pro- 
duces a powerful astringent effect, causing 
speedy coagulation of the blood, and marked 
contraction of the vessels, without necessarily provoking suppuration. Sulphate of copper 
may be used in a similar manner, or in the form of a stick, held firmly for some minutes 
upon the oozing capillaries. Creasote and matico possess none of the hemostatic qualities 
formerly ascribed to them, and are now never applied with such a view. 
Pagliari’s styptic consists of a strong watery solution of benzoin and alum, which causes 
instantaneous coagulation of the blood. The clot, however, is less firm than that produced 
by subsulphate of iron, and I have myself very little confidence in its efficiency as a 
hemostatic, except in hemorrhage from very small vessels, in which it sometimes answers 
exceedingly well. A good styptic, often used with great advantage by the late Professor 
Pancoast, especially in the milder forms of hemorrhage, is composed of one drachm of 
\ enetian soap and twice that quantity of carbonate of potassium dissolved in three ounces 
ot alcohol. Hemorrhage of some of the internal cavities, especially of the uterus, con- 
sequent upon the presence of fibrous tumors, is often promptly arrested by the injection of 
a solution of one drachm of iodine and twice that quantity of iodide of potassium in two 
ounces of alcohol and four ounces of water. Alcohol alone is not a bad styptic in an 
oozing wound; it seems to do good by coagulating the albuminoid principles of the blood. 
Cold is a powerful styptic, and may be used in various ways. A current of cold air 
Fig. 303. 
G EM RIG 
CEMRIG 
Fig. 304. 
Hewson’s Torsion-forceps, 
Mode of applying Torsion. CHAP. V. 
WOUNDS AND HEMORRHAGE. 
675 
will often promptly and effectually arrest capillary hemorrhage, or even hemorrhage caused 
by the division of a small artery, as is exemplified in operations upon the tonsils and 
anus, or ano-rectal region, as well as upon other parts of the body. To prove beneficial, 
the air must have free access to the part, and hence it may often be usefully directed by 
means of the fan, which has the additional advantage of rendering it more cool. 
Cold water, refrigerating lotions, pounded ice in bladders, or lumps of ice rolled up in 
cloths, applied to the bleeding surface or in its immediate vicinity, occasionally promptly 
arrest hemorrhage. These applications are particularly valuable in deep-seated hemor- 
rhage, or in hemorrhage of the internal organs and cavities; they must, however, be used 
with a certain degree of caution, as their protracted continuance may be followed by 
injurious reaction, and even by mortification of the part. When the wound is situated 
externally, but too deeply to render the injured vessels accessible to the ligature, the 
bleeding may often be speedily and effectually checked by a full stream of iced water, 
directed upon the part, and maintained steadily for some time, from a large syringe. 
Hot water has lately been found very efficacious in arresting the oozing from wounds, 
as after amputations, excisions, and the extirpation of tumors. Its beneficial effects are 
doubtless due to its coagulating effect upon the albumen of the blood, and to its producing 
contraction of the vessels. It should be applied as hot as can be borne by means of a soft 
sponge. 
The actual cautery can hardly be considered as a genuine styptic, although it is usually 
classed under this head. Its effect is not to constringe the vessels, but to destroy them, 
by producing an eschar, by which their mouths are, for the time, hermetically sealed. 
Upon the separation of the slough, however, there is frequently a recurrence of the 
hemorrhage, especially if the wounded vessels are at all large, owing to the imperfect 
coagulation of their contents. The cases to which the cautery is mainly applicable 
are those in which the hemorrhage proceeds from a deep and narrow osseous cavity, 
and in wounds of the tonsils, uterus, and rectum. The instrument, which may be of a 
conical form, should be heated to a black or slightly red heat, and used in such a manner 
as not to injure the structures around the seat of the affected vessels. When the artery 
is very diminutive, the object may sometimes be attained with a hot knitting-needle, a 
wire, or a probe. 
General Means Whatever mode of procedure be adopted for arresting the bleeding, 
it is an object of primary importance to place the affected part perfectly at rest, in an 
easy and elevated position ; the slightest motion might be injurious, especially when no 
ligature has been used, and should, therefore, be sedulously guarded against. Repose of 
the body is equally necessary with that of the part, and it is hardly needful to add that 
mental tranquillity is also of the greatest moment. Cardiac action, too, must be main- 
tained in the most perfect quietude, as any perturbating agency of this kind cannot fail 
to favor a return of the hemorrhage and exhaust the system. With this view, a full 
anodyne should be administered early in the disease, the dose being repeated from time 
to time so as to sustain the soothing influence of the remedy. Too much stress cannot 
be laid upon the use of opiates in the management of arterial hemorrhage, and it is sur- 
prising that the remedy is not more generally employed than it seems to be. To allow 
the heart to go riot, or to move and toss about tumultuously, as it is so liable to do after 
serious loss of blood, while every local precaution is taken for the suppression of the bleed- 
ing, is assuredly a strange inconsistency, and one altogether irreconcilable with experi- 
ence and common sense. When the bleeding proceeds from a great number of small 
vessels, a restraining influence may be expected from the administration of ergot in full 
and repeated doses. 
When high constitutional excitement exists, the effect of the anodyne should be aided 
by the judicious use of aconite or veratrum viride. When the skin is very hot and dry, 
a full dose of Dover’s powder often answers an excellent purpose in calming the heart s 
action. 
The diet should be perfectly bland, and sufficient in quantity to supply the wants of 
the body. To give less, might cause irritability of the system ; to give more, over- 
stimulation. The drink must be cold and acidulated, and not taken so freely as to 
oppress the stomach, as it will be sure to do if the quantity is not carefully 
as the thirst is always urgent after the loss even of a comparatively small amount of 
blood. Lumps of ice, or pounded ice, held in the mouth, and gradually swallowed, 
often prove most grateful and beneficial. The air of the apartment must be kept 
perfectly cool ; in short, every effort must be made to maintain the tranquillity of the 
circulation. 676 
DISEASES AND INJURIES OF THE ARTERIES. 
CHAP. V. 
Secondary Hemorrhage.—Secondary hemorrhage occurs at variable periods; some- 
times in a few hours, at other times not under several days or weeks. It is not neces- 
sarily preceded by primary hemorrhage, but may come on where the loss of blood in the 
first instance was, perhaps, altogether insignificant, and where everything, so far as this 
event is concerned, gave promise of a most favorable issue. The bleeding often supervenes 
without any assignable cause, generally suddenly and unexpectedly; hence it often makes 
great progress before an opportunity is afforded to arrest it. When proceeding from a 
large vessel, it may prove fatal in a few minutes, in the same manner as when the bleed- 
ing is primary. The scarlet hue of the blood always denotes its source. 
The causes of secondary hemorrhage are various, but the most important are the 
following:—1st. The faulty application of the ligature; 2d. A diseased state of the 
arteries ; 3d. Morbid changes in the clot; 4th. Improper traction upon the ligature ; 
5th. Tight dressing, or too great dependency of the part; 6th. Want of retraction in 
the vessels; 7th. Organic lesion of the liver, heart, and other viscera; 8th, scurvy; and, 
9th, a hemorrhagic diathesis. 
1. When a ligature is properly applied, it simply divides the inner and middle tunics, 
leaving the outer intact ; this too, however may be cut, not completely, but partially, 
and, therefore, the more insidiously, in consequence of the force used in tying the liga- 
ture ; or, the deligation may not have been sufficiently firm, the opposite surfaces being 
only slightly approximated, and the resulting adhesion, therefore, inadequate to effect 
hermetic closure of the artery on detachment of the cord ; or, lastly, the fault may have 
existed in the ligature itself, on account of the rottenness of its substance, or the im- 
perfect tightening of the knot. Whatever the cause may be, the proper remedy is more 
efficient ligation. 
2. The hemorrhage may arise from disease of the artery, either from undue inflamma- 
tion, or degeneration of its coats, rendering them incapable of supporting the ligature 
until the clot has contracted sufficiently firm adhesions. The mode of procedure is ob- 
vious ; a more healthy portion of the vessel must be sought for, and the ligation effected 
with more caution ; or, this failing, the hemorrhage may be arrested by tying the main 
trunk of the limb, some distance from the seat of the injury. If both these expedients 
prove unavailing, or if their employment be deemed inadvisable, an attempt should be 
made to arrest the bleeding by means of styptics, either alone, or in union with a grad- 
uated compress and roller. Experience has shown that this method is often far prefer- 
able to the ligature, which, under such circumstances, seldom main- 
tains its hold upon the vessel until a sufficient amount of repair has 
been set up to prevent a recurrence of the hemorrhage. 
3. Morbid changes in the clot, commencing in a process of softening 
and disintegration, occasionally occur after ligation, leading to its 
premature detachment, perhaps several weeks after the operation. 
Such changes, which are well illustrated in fig. 305, are most frequent 
in cases of pyemia and diffused erysipelas, consequent upon some 
injuries and amputations, eventuating in a tendency to suppurative 
inflammation. The only remedy is the ligation of a healthy portion 
of the artery; or, when this is impracticable, the employment of acu- 
pressure or the application of styptics and the graduated compress. 
4. Surgeons sometimes bring on hemorrhage by improper traction 
of the ligature, with a view of promoting its separation, forgetting 
that they may thus tear the artery, or break up important adhesions. 
Such a procedure cannot, as stated elsewhere, be too severely cen- 
sured. Religation is obviously the remedy in such a case. 
5. Tight dressing, causing unequal constriction of the part, or im- 
proper dependency, favoring undue afflux of blood, may induce this 
form of hemorrhage. The result will be most likely to occur when 
a number of small arteries have been divided, without any attempt 
having been made to secure them with a ligature. Bleeding having 
ceased, the dressings are applied, but too firmly, or the part is placed 
too low, and presently blood begins to appear, issuing, perhaps, with 
great freedom. rI he treatment consists in the removal and readjust- 
ment of the dressing, with strict attention to posture. 
f 6. Secondary hemorrhage occasionally comes on after operations 
.or ? ie ie anal, perineal, and other fistules, chronic abscesses, and old ulcers, from an 
inability of the vessels to retract in consequence of the indurated condition of the divided 
Fig. 305. 
Partial Absorption of 
the Clot in the Femoral 
Artery, a Fortnight after 
Amputation. CHAP. V. 
SUBCUTANEOUS HEMORRHAGE. 
677 
parts. Exposure of the surface to cold air, the application of ice, direct compression, or 
styptics constitute the best means of relief. In some cases the actual cautery may be 
required. 
7. Organic disease of some of the principal viscera, especially of the liver, heart, and 
spleen, often favors secondary hemorrhage after injuries and operations. Indeed, sponta- 
neous hemorrhage is by no means uncommon under such circumstances, and it is, there- 
fore, not surprising that it should occasionally occur after accidents and the employment 
of the knife. 
8. Scurvy is a powerful predisposing cause of secondary hemorrhage. The blood in 
this condition of the system is, in great degree, deprived of its coagulability, and hence 
the clot that forms above the seat of the wound is easily disintegrated and washed away. 
The coats of the vessel are also softened and diseased, and, therefore, ill able to bear for 
any length of time the pressure of the ligature, which is generally detached at a period 
varying from the fifth to the eighth day, before the clot has had time to become firmly 
adherent to the sides of the affected artery. The most effectual means of counteracting 
this condition of the system are fresh air, tonics, stimulants, anodynes, vegetable acids, 
and other antiscorbutic remedies. 
9. The bleeding may be due to a hemorrhagic diathesis, an affection which, as will be 
stated elsewhere, may occur at any period of life, and which it is often extremely difficult 
to control by any mode of treatment, however judiciously conducted. 
Finally, this form of hemorrhage is sometimes brought on by injuries inflicted in the 
transportation of the patient, as in time of war and after severe operations, lacerated 
wounds, and compound fractures. The clot, if not firmly adherent, is easily detached 
from the jolting of the affected artery and the cardiac excitement consequent upon the 
disturbance of the part and system. Excessive mental perturbation is capable of produc- 
ing similar effects, especially when a vessel, previously partially occluded by a clot, has 
not been properly ligated. 
SECT. II SUBCUTANEOUS HEMORRHAGE. 
There is a form of arterial hemorrhage to which, from its situation, the term subcuta- 
neous is very properly applicable. It takes place when, from any cause, an artery has 
been laid freely open, and its contents, instead of escaping externally, are extensively 
extravasated among the surrounding structures. In ordinary hemorrhage, the blood 
issues directly from the injured vessel, because the outer wound is sufficiently capacious 
to admit of its free and unrestrained passage, and the consequence, generally, is that it 
continues until the patient faints, and the bleeding orifice is closed by coagula. In the 
variety of hemorrhage, however, under consideration, the opening in the integument is 
so small as to prevent the blood from appearing externally, and it, therefore, accumulates 
beneath the skin, in the subcutaneous connective tissue when the artery lies superficially, 
or in the subcutaneous and intermuscular connective tissue when it is deep-seated. The 
accident which usually causes this hemorrhage is a puncture, such as that inflicted in 
venesection at the bend of the arm, where, in civil practice, it is most commonly met 
with. It may, however, in consequence of a stab, the thrust of a bayonet, a gunshot 
wound, or the laceration occasioned by the sharp end of a broken bone, occur in any part 
of the body. 
The smaller as well as the larger arteries are sometimes ruptured by the passage of the 
wheel of a carriage, by falls, blows, kicks, and other external injury. The subclavian 
and axillary arteries have occasionally been lacerated in the attempts to reduce an ancient 
dislocation of the shoulder-joint. Spontaneous rupture not unfrequently occurs, especially 
in the arteries of old subjects, in consequence of the degeneration of their tunics, by which 
they are rendered so brittle as to be incapable of resisting the pressure of the current of 
the blood. In general, however, the rupture thus induced is partial, or limited to the 
internal and middle membranes. 
The hemorrhage may be very slight, or exceedingly profuse, its extent being regulated 
chiefly by the size of the affected vessel, and the quantity and laxity of the connective 
tissue. In the superior extremity, the extravasated fluid often reaches nearly as high 
up, on the one hand, as the axilla, and, on the other, as low down as the inferior third of 
the forearm, extensively separating the muscles from each other by breaking up their 
attachments, and forming a large, ill-shaped, and confused swelling, attended, especially 
when inflammation sets in, with violent pain, numbness, and oedema of the whole limb, 
and discoloration of the integument. More or less pulsation is generally present, espe- 678 
DISEASES AND INJURIES OF THE ARTERIES. 
CHAP. V. 
cially in the earlier stages of the case, and, upon applying the ear over the site of the 
wound, a well-marked bruit may frequently be recognized, attended, occasionally, with a 
peculiar thrill, or a whirring noise, and a vibratory sensation. It is tor these reasons that 
this affection has usually been described as a variety of aneurism; and, as the blood is 
always widely extravasated, the prefix “diffuse” is commonly added to that term, as 
particularly expressive of its more important attributes. Strictly speaking, however, 
there is no aneurism here; there is simply a subcutaneous accumulation of blood, the 
consequence of external injury, without any dilatation of the vessel, or degeneration of 
its tunics ; and, although there frequently is, as just stated, more or less concomitant 
pulsation in the part, yet this does not any more entitle it to be regarded as an aneurism 
than it would be if the effused fluid were so much pus or serum. 
The blood that is extravasated in this accident usually promptly coagulates, and exerting 
injurious compression upon the parts with which it is in contact, soon excites severe 
inflammation, which, especially in persons of an irritable constitution, is liable to assume 
an erysipelatous character, and to terminate in suppuration, ulceration, and even gan- 
grene. The pain is often intense, depriving the patient of appetite and sleep, and making 
rapid inroads upon the system. I have witnessed cases in which, from the excessive distress 
thus produced, hectic fever soon came on, and life was placed in imminent peril. 
The treatment of this lesion is precisely similar to that which is necessary when there 
is an open wound ; that is, the artery must be secured promptly and at all hazard, and 
the coagulated blood thoroughly evacuated. The operation is often one of great em- 
barrassment, owing to the confused and displaced condition of the parts, and the difficulty 
experienced in finding the injured vessel, which is not unfrequently lost in the midst of 
the coagulated blood. A large incision is generally required, and two ligatures must be 
applied, one above and the other below the wound in the vessel, precisely as in ordinary 
cases, the object being the prevention of hemorrhage by the recurrent circulation. As 
a preliminary step, the injured artery is compressed by the finger or tourniquet, or, if 
seated in an extremity, controlled by the elastic bandage, and, after the operation is 
over, the limb is wrapped up in warm water-dressing, medicated with laudanum and 
acetate of lead, or laudanum and alcohol, to favor the reduction of inflammation. 
SECT. Ill COLLATERAL CIRCULATION. 
Among the more interesting phenomena that occur after the deligation of the larger 
arteries, not the least curious and important is the manner in which the circulation is 
carried on and maintained in the structures beyond the seat of the ligature. A long time 
elapsed after the discovery of the ligature before surgeons could be induced to believe 
that such an operation could be performed in the continuity of a limb without endanger- 
ing the parts below by gangrene, in consequence of the sudden abstraction of their 
accustomed supply of blood. Chance gradually led to the correction of this apprehen- 
sion, which, however, is not without some foundation, as is proved by the fact that the 
procedure is occasionally followed, even at the present day, in the hands of the most 
scientific surgeons, by loss of limb and life. Cases had been observed, from time to time, 
of the obliteration of the largest arterial trunks by fibrinous concretions, and yet it was 
perfectly certain that the structures in the distal portions of the extremity had retained 
their normal growth, no difference being discoverable between them and those of the 
opposite side. Such a result, it was obvious, could only have been brought about by an 
enlargement of the collateral vessels, thus enabling them to keep up the normal supply 
of blood, after the obstruction of the main artery. A number of instances had been 
noticed of complete closure of the aorta, both in its thoracic and abdominal divisions, 
without any apparent detriment of any kind, either proximate or remote. These facts, 
the fruits of the cultivation of morbid anatomy, were eminently suggestive, and we 
accordingly find that they gradually paved the way for some of the most daring 
feats in surgery. The original trials with the ligature upon the principal arteries 
in the continuity of the limbs were highly gratifying, as tending to show that, although 
the distal structures were temporarily deprived of their accustomed supply of blood, this 
occurrence did not sufficiently interfere with their vitality to cause gangrene, the circula- 
tion being speedily reestablished through the collateral routes. The process employed 
by nature in effecting this object has been demonstrated, in repeated instances, by dissec- 
tion of the parts at variable periods after they had been subjected to operation. 
The moment a large artery, as, for example, the femoral, is tied, the blood is obliged 
to seek new channels for its transmission to the distal portion of the limb. For this pur- CHAP. V. 
COLLATERAL CIRCULATION. 
679 
pose it passes on in all directions, entering every vessel, both large and small, into which 
it can find access. This, however, does not occur all at once, but gradually; for as the 
arteries which are to carry on this collateral circulation, as this arrangement is termed, 
are comparatively small, some time is necessary to prepare them for the reception and 
accommodation ot the increased flow of blood. In fact, they are compelled to submit to a 
species of preliminary dilatation, their tonicity being such as rather to resent its encroach- 
ment than to yield to its effects. This is the case both with the branches that are de- 
tached from the sides of the vessel above the seat of the ligature, and with the capillaries 
ol the various tissues entering into the composition of the limb, which, immediately after 
such an event, always play an important part in maintaining the distal circulation. 
Hence, for some time after the operation, the quantity of blood below the point of obstruc- 
tion is necessarily considerably less than in the normal state, as is demonstrated by the 
cold and pallid state of the integument, the defective sensibility, and the loss of muscular 
power, which is occasionally so great as to deprive the patient of motion in the affected 
member. The diminution of temperature is liable to a good deal of variation, but, in 
general, it amounts to several degrees, and the surgeon is, therefore, often obliged to 
employ artificial heat. Gradually, however, as the circulation increases in vigor, the 
temperature returns to the natural standard, and in many cases even exceeds it, owing to 
the enlargement and inordinate activity of the cutaneous capillaries, although such an 
occurrence is usually of short duration. 
An instance occasionally occurs in which there is either no change of temperature at 
all from this cause, or where it is so very slight as to be hardly perceptible. Such a phe- 
nomenon is most apt to happen in old aneurisms, where, owing to the obstruction in the 
artery connected with the tumor, the anastomosing vessels have had time to become 
enlarged prior to the application of the ligature, so that the operation exerts little, if any, 
influence upon the circulation in the distal portion of the limb, as it necessarily must in 
X’ecent cases of that disease, and also in wounds of the arteries, in which no such oppor- 
tunity is afforded tor an increase in the size of the collateral channels. 
Coincident with this effort on the part of the affected structures to establish the collat- 
eral circulation, there is generally a feeling of uneasiness, if not of actual pain, of a burn- 
ing or tingling character, obviously occasioned by the compression which the enlarged and 
distended vessels exert upon the neighboring nerves. Usually, however, this effect is of 
short duration, as the nerves soon accommodate themselves to their new relations. After 
some time, the parts gradually recover their natural functions, all disagreeable sensations 
vanish, the muscles increase in vigor, and the process of nutrition proceeds apparently as 
well as it did prior to the deligation of the vessel. 
Although such is the ordinary course of events after the main artery of a limb has been 
tied, important exceptions are occasionally met with. Thus, it now and then happens 
that the circulation remains extremely languid for an unusual length of time, perhaps for 
a number of days, if not several weeks, the anastomosing branches being seemingly inca- 
pable of enlarging to a sufficient extent to convey an adequate supply of blood to the 
affected structures ; the extremity is, consequently, cold, heavy, numb, and of a reddish or 
purplish hue, from passive congestion of the capillaries, and is moved with pain and diffi- 
culty. A struggle is evidently going on between nature and disease, in which the latter 
but too often comes off* victoriously ; the limb either falling into gangrene without the 
occurrence of reaction ; or, reaction taking place, it is overpowered by the resulting 
inflammation. Finally, cases occur, although, fortunately, very unfrequently, in which 
the parts remain permanently weak and crippled ; the muscles are soft and flaccid, the 
adipose tissue is absorbed, and the surface is habitually cold and congested, the circulation 
having never attained the normal standard after the operation. 
It is worthy of notice that gangrene, from defective circulation, is much less liable to 
occur after the ligation of an artery, in the continuity of a limb, in wounds than in aneu- 
rism. This fact, at all events, is clearly deducible from the statistical tables of Dr. Nor- 
ris, from which it appears that in seventeen cases in which the femoral artery was secured 
on account of recent injuries and different tumors, gangrene did not occur in a single one, 
whereas this result w'as witnessed in thirty-one cases out of two hundred and four in which 
the operation was performed for the cure of aneurism. May not the cause ol this dis- 
parity be the compression which the tumor in this disease exerts upon the neighboring 
structures, thereby obstructing the circulation in the distal portion of the limb, and at the 
same time seriously embarrassing the functions of the nerves? I presume that this result 
is very materially influenced by the nature of the wound, necessitating the deligation ol 
the artery. If, for example, the parts are extensively divided ti’ansversely, or very 680 
DISEASES AND INJURIES OF THE ARTERIES. 
CHAP. V. 
obliquely, so as to destroy the continuity of a large number of its more important branches 
in the immediate vicinity of the wound, gangrene will be much more likely to occur than 
under opposite circumstances, in which, the neighboring vessels being but little injured, 
the blood will easily find its way into the distal structures, thus affording them the requi- 
site supply not only for the preservation of their vitality, but also for the maintenance oi 
their nutrition. 
Although the capillaries are greatly instrumental in carrying on the circulation in the 
distal portion of the limb, immediately after the deligation of its main artery, their agency 
is really merely of a temporary character, ceasing with the establishment 
of the collateral circulation, properly so called, as developed by the 
larger arterial branches in the vicinity of the ligature. These arterial 
branches are occasionally given off by the affected artery itself, but 
most commonly they arise from some neighboring trunks. Thus, when 
the superficial femoral is tied high up, the collateral circulation is estab- 
lished through the agency mainly of the profunda, the branches ol 
which inosculate with the articular, offsets of the popliteal. In ligation 
of the brachial, the blood is transmitted to the forearm and hand by 
the communications naturally existing between the anastomotic and 
profunda arteries, branches of the affected vessel, and the recurrent 
branches of the radial and ulnar, in which the brachial terminates. In 
ligation, on the contrary, of the common carotid, the circulation of the 
corresponding side of the head and neck is kept up mainly by the com- 
munications between the occipital and deep cervical arteries. 
It has been noticed, as an interesting physiological fact, that the 
anastomotic arteries, before they unite with each other, separate into 
several branches, often as many as three or four, so as to form a kind 
of circle, as if nature were particularly anxious to guard against any 
risk that might otherwise occur to the collateral circulation from 
accident or disease. It has also been noticed, especially by Porta 
and Stilling, that, when the fibrous structure which connects the two 
ends of the artery after the detachment of the ligature is unusually 
short and thick, a narrow, tortuous canal is occasionally developed in 
its interior, admitting of the passage of blood to the distal portion of 
the vessel. 
However established, the collateral vessels gradually augment in size, 
until, at length, their united capacity is fully equal to that of the oblit- 
erated trunk, as in fig. 306, whatever may have been its size. There 
are, of course, as already stated, exceptions, but they are, probably, 
much less frequent than is generally imagined. A very interesting 
case, beautifully illustrative of the present topic, occui-red in the prac- 
tice of the late Dr. Francis West, of this city, in a stout, athletic man, 
aged thirty-two, who died suddenly from rupture of an aneurism of the 
thoracic aorta. On dissection, this vessel was found to be entirely ob- 
literated, just beyond the remains of the arterial duct, its coats having 
a constricted appearance, as if they had been embraced by a tightly- 
drawn ligature. Everywhere else, excepting at the place of aneurism, 
the aorta was perfectly natural. All the branches of the subclavian 
arteries wrere much increased in size; and the internal mammary and 
epigastric, which served to keep up the connection of the circulation above and below 
the seat of the stricture, Avere fully as large as the external iliac, the foi’mer having 
coursed along the Avails of the chest in a very tortuous manner. As no tumor Avas dis- 
covered at the seat of the oblitei-ation, it could not be determined whether the disease 
had been the result of accident or of a congenital vice. Be this as it may, the case affords 
an admii’able example of the manner in which the collateral circulation is carried on after 
the interruption of the column of blood in such an immense vessel as the aorta. 
The collateral circulation is not developed with equal facility at all periods of life, or 
under all circumstances; it is most readily established in young subjects, in Avhom the 
arteries, besides being very acthTe, enjoy a high degree of elasticity and pliancy, Avell 
adapted for such an enterprise. In old persons, on the contrary, the functional actiA’ity 
of these vessels is often much impaii-ed, many of the small branches are obliterated, and 
their coats are extremely liable to earthy deposits, com7erting them into firm, rigid tubes, 
ill qualified for the discharge of their duties. In many cases, loss of blood, ill-health, or 
Fig. 306. 
Collateral Circula- 
tion shown in the 
Thigh. Ata, the Fem- 
oral Artery has been 
Obliterated by Liga- 
ture. CHAP. V. 
HEMORRHAGIC DIATHESIS. 
681 
defective vital power, seriously interferes with the development of the collateral cir- 
culation. 
Finally, the collateral circulation may be too active. Such an event is not likely to 
happen when the main artery of a limb is tied on account of hemorrhage from a wound, 
but its occurrence is by no means uncommon in aneurism, and is then apt to be followed 
by a return of the circulation and pulsation in the tumor, in consequence of the activity 
of the anastomosing branches, which thus continue to feed the sac, and perhaps effectu- 
ally oppose the cure. 
SECT. IV HEMORRHAGIC DIATHESIS. 
Haemophilia, or the hemorrhagic diathesis, is that peculiar state of the system in 
which, generally from some slight traumatic cause, there is a strong tendency to inordinate 
bleeding. Persons laboring under this constitutional infirmity are often placed in immi- 
nent jeopardy by the most insignificant scratch, puncture, or incision, which, under ordi- 
nary circumstances, would hardly emit more than a few drops of blood. Occasionally the 
cause of the bleeding is the accidental rupture of some of the smaller vessels of the 
mucous membrane of the nose, lungs, rectum, or urinary bladder. The extraction of a 
tooth is sometimes followed by this form of hemorrhage. I recollect one case in which 
death was thus produced; and another where the bleeding, having persisted for nearly 
four days, gave rise to severe exhaustion and great apprehension respecting the safety of 
the patient. Many years ago I lost a child, six months old, affected with cholera morbus, 
from hemorrhage consequent upon lancing of the gums over the upper central incisors, 
which were nearly ready to protrude. His health previously to this attack had always 
been excellent. The bleeding commenced in less than twenty-four hours after the opera- 
tion, and continued, despite all that could be done for his relief, until the end of the fifth 
day, when he died completely exhausted. A short time before he expired, hemorrhagic 
spots appeared on different parts of the body, and blood began to be discharged from the 
bowels. In a case of strabismus, in a young gentleman who possessed this peculiarity, 
the division of the internal straight muscle was followed by an oozing of blood, which 
continued, despite all I could do, nearly constantly, for the greater part of a fortnight, 
when, the wound being almost healed, it ceased. In a case reported to the Academy of 
Surgery of Philadelphia, in 1881, by Dr. John H. Packard, an infant, a fortnight old, 
died of hemorrhage from a slight scratch of the lip. 
The blood in this variety of hemorrhage oozes from the injured part, as water from a 
sponge ; it does not spirt in jets, as when it issues from an artery, or in a continuous 
stream, as when it flows from a vein. Its color is neither scarlet nor black, but interme- 
diate between the two; it generally partially coagulates when it is received into a vessel, 
but rarely while it is in contact with the living surface. 
This affection has occasionally been noticed in several members of the same family. In 
a remarkable case, reported by the late Dr. John A. Swett, of New York, it existed in all 
the children, eighteen in number. All, except one, had died from this cause, and he 
was suffering under profuse hemorrhage of the nose and rectum. Twelve sisters died 
before the age of twelve from bleeding of the uterus; and two of the brothers had fallen 
victims of traumatic hemorrhage. 
Mr. Wardrop has reported a curious case in which this peculiarity was hereditary. The 
patient was a boy, in whom the hemorrhagic tendency displayed itself when he was 
scarcely two months old. On several occasions he nearly lost his life from the most in- 
significant wounds. His brother, twenty-two years old, was frequently afflicted in a sim- 
ilar manner. Of his five uncles, not one was free from this predisposition, three having 
died from the division of the frenum of the tongue, and one from the extraction of a 
tooth ; while the other, although he suffered from the same disease, finally died from some 
other cause. His two aunts exhibited no signs of this diathesis; but all the male branches 
of their families, excepting one, were thus affected. 
A still more remarkable case has been described by Dr. Hughes, of Kentucky. The 
predisposition here was associated with the rheumatic diathesis, and was satisfactorily 
traced as far back as five generations. It was confined exclusively to the male branches 
of the different families; but the females, nevertheless, invariably transmitted it to their 
offspring. Many of the individuals died in infancy and childhood, death resulting, in 
some, from the cut of the lancet; in some, from accidental wounds ; in some, from inter- 
nal hemorrhage ; and, in two, simply from the application of blisters, the vesicles being 
filled with blood instead of water. 682 
DISEASES AND INJURIES OF THE ARTERIES. 
CHAP. V. 
Of the remote causes of the hemorrhagic diathesis nothing is known. Whatever they 
may be, it is evident that they are deeply engrafted in the constitution, as is proved by 
the fact, first, that the affection generally shows itself at a very early age ; secondly, that 
it often occurs in several members of the same family; and, thirdly, that it is sometimes 
hereditary. The immediate causes seem to be two, want of coagulability in the fibrin of 
the blood, and an imperfectly organized state of the capillary vessels, the actual seat of 
the hemorrhage. 
If one were inclined to speculate in regard to the cause of this defective coagulating 
property of the blood, it would be easy to find it in an insufficient supply of nervous 
power, upon the presence of which, as is well known, the vitality of this fluid essentially 
depends. Whatever has the effect of weakening this influence, proportionately interferes 
with the concretion of the blood, both as it circulates through the body and after its re- 
moval by venesection. The fact that the blood remains fluid in sudden death from light- 
ning has long been familiar to practitioners. Similar phenomena occur when a person is 
killed by a blow on the stomach, by prussic acid, the poison of the rattlesnake, excessive 
bodily fatigue, or violent agitation of the mind. Certain diseases, as Asiatic cholera, 
plague, and malignant fevers, produce analogous effects. It has been satisfactorily ascer- 
tained that, when the pneumogastric nerves are tied in animals, the blood loses its pro- 
perty of coagulating, the coloring matter at the same time separating from the fibrin, and 
assuming an unusually black color. 
But as, in all these cases, the loss of nervous power is sudden, it is easy to perceive 
how it should influence the coagulation of the blood. In persons laboring under the 
hemorrhagic diathesis, on the contrary, the blood is generally habitually indisposed to 
coagulate, so that they are more or less liable to bleeding whenever any injury, however 
slight, is experienced. The analogy, then, between these different states of the system 
is exceedingly remote, and can, indeed, hardly be said to be established. Its force, more- 
over, is weakened by the fact that the subjects of the hemorrhagic diathesis generally 
enjoy as good health, and as much vigor of constitution, as those who are free from it. 
The other appreciable element in the pathology of the hemorrhagic diathesis is a want of 
contractility in the capillary vessels, dependent, in all probability, upon some defective 
organization and an absence of native tone in the muscular tunic. 
The prognosis of this form of hemorrhage is generally not very favorable, particularly 
when it is of a hereditary nature, in which event it is extremely liable to prove fatal. In 
the case related by Swett, seventeen out of eighteen members of a family thus affected 
had perished, and the survivor himself had repeatedly suffered from severe bleeding in 
different parts of the body. In the case of Hughes, in which the diathesis prevailed in 
not less than five generations, nearly every individual died from hemorrhage; many of 
them in infancy and childhood. 
In the treatment of the hemorrhagic diathesis, the two leading indications are to pro- 
mote the coagulability of the blood, and to increase the contractility of the capillary 
vessels. 
The first of these objects is best fulfilled by the judicious use of acetate of lead and 
opium, the former of which seems to exert a direct influence upon the coagulability of the 
blood, while the latter affords important aid in controlling the action of the heart, gene- 
rally rendered turbulent by the bleeding and by the patient’s mental anxiety. The dose 
of the salt should vary from half a grain to a grain and a half, every two, three, or four 
hours, according to the tolerance of the stomach and the amount of hemorrhage, and 
should contain at least one grain of opium, or its equivalent of acetate of morphia. If 
heat and dryness of skin exist, a small quantity of antimony or ipecacuanha may be 
added to each dose, to promote perspiration. Severe depression, however, must be vigi- 
lantly guarded against. Cardiac action is controlled by tincture of aconite or veratrum 
viride, its effects upon the system being carefully watched. 
lo increase the contractility of the capillary vessels, ergot must be freely employed, in 
union with tonics, as tannate of iron and quinine, and a nutritious diet. Dilute sulphuric 
acid, in doses ol eight or ten drops, repeated four or five times a day, is often highly 
beneficial. I he diet should be light and non-stimulant, consisting largely of milk and 
beef essence, along with more or less alcohol. Tranquillity of mind and body is of para- 
mount importance. 
Laxatives usually prove highly serviceable, both as evacuants, as counterirritants, 
and as restorers of the secretions, which are nearly always much disordered in this variety 
of hemorrhage. Estimating these remedies at their real value, I am satisfied that they 
are entitled to the highest rank in the treatment of this affection ; they must not, however, CHAP. V. 
ACUTE INFLAMMATION. 
683 
be carried too far, otherwise they may induce irritability of the heart, and thus do harm 
instead of good. If the patient is plethoric, sulphate of magnesium may be taken, as it is 
pai ticulaily appropriate, under such circumstances, on account of its chemical action upon 
the blood ; or, what will generally be better, especially when there is marked derange- 
ment ot the secretions, a few grains of calomel and compound extract of colocynth. 
hen the bleeding is attended with fever, or with heat and dryness of the surface, 
diaphoretics, as antimony and morphia, or the neutral mixture, aided by tepid ablutions, 
are indicated. Coldness of the extremities must be relieved by hot mustard baths and 
bottles of hot water. 
It need hardly be added that the sooner these constitutional measures are carried into 
effect, the more likely will they be to prove efficient in arresting the hemorrhage ; the 
longer the bleeding has lasted, or the greater the amount of blood lost, the more difficult 
will it be to arrest the disease and prevent its downward tendency. Moreover, a proper 
plan of treatment having been selected, it should be diligently persisted in, otherwise it 
will not be able to exert any beneficial influence, inasmuch as some time must necessarily 
elapse, in such an affection, before the system can be favorably impressed by any meas- 
ures, however judicious or energetic. 
lopical treatment is generally very essential. When the hemorrhage proceeds from a 
wound, the affected structures should, if possible, be included in a firm ligature. For this 
purpose, the twisted suture may be used; or, if this be impracticable, systematic com- 
pression may be made by means of a graduated compress, wet with Monsel’s solution, and 
confined with a roller, the surface of the wound having previously been dried, so as to 
allow the lint to come directly in contact with the bleeding orifices of the divided vessels. 
Occasionally, the application of pounded ice will restrain the bleeding more effectually than 
anything else. Rubbing the wound freely with nitrate of silver or sulphate of copper is 
sometimes useful. The actual cautery, the Vienna paste, and the different acids, have 
all been recommended when the hemorrhage resists the more ordinary measures; but 
the objection to them is that, wdien the eschar drops off, and frequently even before, the 
bleeding is apt to recur with increased violence. When the blood proceeds from the nose, 
uterus, or rectum, the most efficient adjuvant is the tampon. Attention to the position of 
the part is indispensably necessary. 
SECT, y DISEASES OF THE ARTERIES. 
The arteries are liable to inflammation, acute and" chronic, suppuration, softening, 
ulceration, and various kinds of transformations ; occlusion is also met with, and is worthy 
of special consideration, as a cause of gangrene and other mischief. 
1. ACUTE INFLAMMATION. 
Acute arteritis is generally induced by external injury, or by an extension of disease 
from adjoining structures. Nevertheless, it occasionally exists as an idiopathic affection, 
or comes on without any assignable cause, chiefly in persons of a gouty or rheumatic pre- 
disposition, from the age of thirty to fifty. Restricted, in the majority of instances, to 
one or more of the larger trunks, it not unfrequently involves the smaller branches, and 
sometimes even the capillaries. Occasionally, the malady appears to pervade nearly the 
whole arterial system. 
When arising spontaneously, the disease usually begins in the internal membrane and 
subserous connective tissue, from which it gradually spreads to the other tunics ; the reverse 
being the case when it is induced by external violence. The anatomical characters 
of acute arteritis are redness, opacity, rugosity, and softening of the lining membrane, 
with an engorged, lacerable, and thickened state of the outer and middle coats. When 
the inflammation is severe, the parietes of the affected artery are generally remarkably 
pulpy, and so much diminished in consistence as to be easily torn or divided by the liga- 
ture. The nutrient vessels are loaded with blood, and often exhibit a veritable varicose 
aspect, their ultimate twigs ending apparently in the subserous connective tissue. With 
regard to the redness of the internal membrane, it is liable to considerable diversity ; 
generally speaking, it occurs in small patches, which are diffused over a greater or less 
extent of surface, and which vary in diameter between that of a split pea and a five-cent 
piece. In intensity, it ranges from a light pink to a deep scarlet, through numerous in- 
termediate shades of lilac and purple. In some instances the redness is uniform. With 
this change of color are always associated important alterations of texture. The inner 684 
DISEASES AND INJURIES OF THE ARTERIES. 
CHAP. V. 
membrane, losing its smoothness and polish, assumes a rough, fleecy aspect, and, owing 
to the softened state of the subserous connective tissue, is easily detached from its 
natural connections. Globules of lymph, either 
alone or blended with pus, occasionally adhere 
to its inner surface ; and, in the large arteries, 
it is not uncommon, as seen in figs. 307 and 
308, to meet with well-developed pseudo-mem- 
branes, similar, in all respects, to those of the 
serous textures. The other tunics are also 
much affected, being moist, tumid, friable, and 
transformed into a reddish, homogeneous mass, 
almost devoid of cohesive power. Their elas- 
ticity, naturally so great, is partially lost, and 
in many instances they are freely infiltrated 
with serosity, sanguinolent fluid, or even pure 
pus. A common occurrence is the formation 
of fibrinous concretions, closing up the caliber 
of the affected vessels. 
Suppuration of the arteries is probably more 
frequent than is commonly imagined. The 
matter being generally formed upon the inner 
surface of the vessels, is soon swept away by 
the circulating current, which is, doubtless, the 
reason why it is not oftener noticed after death. 
Sometimes, however, it is entangled in the sub- 
stance of the false membranes, infiltrated into 
the arterial tissues, or collected into small ab- 
scesses between the inner and middle tunics. 
Arteritis is much less liable to terminate in sup- 
puration than phlebitis, in which respect the one 
resembles inflammation of the serous mem- 
branes, the other of the mucous. 
The arteries are almost insusceptible of gan- 
grene. Their conservative powers are certainly 
very great, as is evinced by the fact that they 
often escape destruction in the midst of parts 
that are perfectly devitalized. In such cases, 
their outer surface is incrusted, at an early 
period of the disease, with a thin layer of fibrin ; and, long before the sloughs begin to 
separate, the blood coagulates in their interior, thus opposing an effectual barrier to the 
occurrence of hemorrhage. 
Softening of the arteries is a common occurrence, especially in the smaller branches. 
It is often witnessed in organic diseases of the principal viscera, and is a frequent attend- 
ant upon acute inflammation, carcinomatous affections, and the application of the ligature. 
The lesion is characterized, as the name indicates, by a diminution of the cohesive power of 
the vessels, the coats of which are rendered friable, spongy, and inelastic. It is generally 
accompanied with slight tumefaction, engorgement of the capillary vessels, and effusion 
of serosity, or sanguinolent fluid, into the interstitial connective tissue. 
The symptoms of acute arteritis are generally so obscure as to render it extremely dif- 
ficult to distinguish it, especially when it occurs in the more deep-seated vessels. In the 
majority of cases, the attack strongly resembles one of rheumatism. The most reliable 
phenomena, in a diagnostic point of view, are excessive pain and tenderness along the 
course of the affected arteries, increased by pressure, cough, and change of posture, and 
accompanied by violent and tumultuous throbbing, which is sometimes felt over the greater 
portion of the body, and may often be easily perceived at a considerable distance. The 
action of the heart is much increased in force and frequency, the pulse is hard, wiry, and 
thrilling, and the system is disturbed by irritative fever, which rapidly assumes an asthenic 
type. When the disease is at all extensive, the patient soon succumbs under its influence, 
the immediate cause of death being either exhaustion from the violence of the inflammation, 
or from the formation of the fibrinous concretions in the larger arteries, thereby arresting 
the circulation in some of the more important organs. 
There are no symptoms denotive of suppuration, ulceration, or softening of the arteries, 
Fig. 307. 
Fig. 308. 
Plastic Deposits of tlie 
Aorta. 
Plastic Plugs occluding 
the Axillary Artery. CHAP. V. 
CHRONIC AFFECTIONS. 
685 
apart from those of acute or chronic inflammation. The formation of matter would prob- 
ably be ushered in by rigors, followed by copious sweats, hectic irritation, and excessive 
prostration, but the occurrence would hardly be of so marked a nature as to serve any 
diagnostic purpose. 
Acute arteritis is best treated by the lancet, purgatives, and antimonials, if the patient 
is young and plethoric, or by a conservative course, if he is weak, decrepit, or exhausted 
by previous suffering, intemperance, or dissipation. Aconite, veratrum, or colchicum will 
usually form valuable additions to the other means, especially if they be combined with 
morphia, which is so necessary to allay pain and quiet the heart’s action. If the disease 
is connected with the rheumatic diathesis, calomel must be given, in full and frequently 
repeated doses, with a view to early but gentle ptyalism. Colchicum will then also prove 
useful. The most suitable topical remedies, when the affected arteries are superficial, are 
leeches, iodine, and saturnine lotions, in union with laudanum. 
2. CHRONIC AFFECTIONS. 
The most common chronic affections of the arteries are the fibrous, calcareous, and 
atheromatous transformations, which, although of frequent occurrence, are chiefly interest- 
ing in relation to the influence which they exert upon the production of 
spontaneous aneurism. It is for this reason, therefore, that they should 
be carefully studied. These transformations, notwithstanding that they 
widely differ in their physical and chemical properties, possess several 
characters in common, of which the most important are, first, that they are 
met with almost exclusively in elderly subjects ; secondly, that they render 
the coats of the vessels brittle, and, consequently, prone to rupture ; thirdly, 
that they nearly always occur in association; and, lastly, that they usually 
begin in the connective tissue, between the inner and middle tunics, which, 
liow'ever, in time, generally participate in the morbid action. 
The fibrous transformation is characterized by the appearance of small, 
hard, firm patches beneath the serous layer of the arteries, usually isolated, 
but sometimes grouped, of no definite shape, thin, and of a whitish, gray- 
ish, or pale yellowish aspect. When the patches are numerous or unusually 
large, they convert the affected arteries into firm, inelastic tubes. The 
basis matter of this transformation is fibrin, which gradually undergoes the 
fibroid change. 
The calcareous degeneration—the calcification of modern wrriters—is a 
disease of advanced life, although it has occasionally been noticed in early 
childhood, and is most common in the aorta and its larger branches, as the 
iliac, femoral, popliteal, and innominate. The brachial artery is seldom 
affected. The transformation is comparatively rare in the female; a fact 
which satisfactorily accounts for the difference in the relative frequency of 
spontaneous aneurism in the two sexes. An instance occasionally occurs 
in which there is a strong calcareous diathesis, nearly all the arteries in the 
body being converted into rigid cylinders. The abnormal matter is de- 
posited in an amorphous form, and is destitute of bone corpuscles ; consist- 
ing essentially of phosphate and carbonate of lime, in combination with a 
small quantity of albumen, which apparently serves as its matrix. 
The calcareous matter exists in various forms ; sometimes in small 
grains and nodules, now in scales, plates, and patches, and now in com- 
plete rings, which, encircling the vessel, convert it into a firm, rigid, in- 
flexible tube, completely destitute of its natural attributes, as seen in fig. 
309, from a specimen in my cabinet. The inevitable effect of these changes, 
which are always most conspicuous in the inner coat, is to render the artery 
abnormally brittle, and, therefore, ill able to withstand the pressure of its 
contents. 
The starting-point of this deposit is the subserous connective tissue, 
whence it gradually extends to the inner and middle tunics, both of which 
are sometimes completely transformed by it. It is rare that the outer coat 
suffers from it; such a change, however, is not impossible, and I have seen 
specimens in which the deposit was apparently entirely restricted to it. 
The exciting cause of the calcareous degeneration is chronic inflammation, 
as is evinced by the fact that it is invariably accompanied by more or less 
thickening and induration of the arterial tunics, independently of those produced by the 
Fig. 309. 
Calcareous De- 
posits. 686 
DISEASES AND INJURIES OF THE ARTERIES. 
chap. v. 
deposit itself. From investigations made a few years ago by Gubler it is highly probable 
that a strong predisposition to this disorder is established by the constant use of vegetables 
containing a large percentage of mineral substances, particularly the earthy salts. 
The atheromatous or fatty degeneration, fig. 310, is very rare among our native inhab- 
itants, but sufficiently common in our immigrants, especially the Irish and English. In 
Europe, it is said to be more prevalent in 
Great Britain than in any other country; a 
fact which accounts for the remarkable fre- 
quency of aneurism in that part of the world. 
The change always begins in the subserous 
connective substance, generally in minute, 
isolated points, not larger than the head of a 
pin, of a pale yellowish, whitish, or brownish 
color, somewhat greasy to the touch, and of 
a semiconcrete, friable consistence. In time, 
many of these points, or dots, coalesce, and 
so form irregular-shaped patches, which, push- 
ing the lining membrane before them, may 
involve the whole circumference of the tube, 
and extend several lines or even inches up 
and down in the direction of its length. 
Having remained stationary for an indefinite 
period, the deposit manifests a disposition to 
softening and disintegration, and is ultimately 
converted into a curdy, friable, or, more properly speaking, a pap-like substance, possess- 
ing, apparently, all the properties of scrofulous pus. At this stage of the disease, the 
lining membrane is often elevated into small pustules, or little abscesses, which, bursting, 
discharge their contents into the blood, thus leaving a corresponding number of ragged 
and irregular ulcers, cracks, or fissures, the base of which is formed by the middle tunic. 
The fatty deposit is most common in the aorta, particularly in its thoracic portion, near 
the origin of the great cervical trunks. Its occurrence is almost peculiar to the aged. 
What the causes are, under the influence of which it is developed, has not been ascer- 
tained. That it is occasionally connected with imperfect alimentation, and the inordinate 
use of ardent spirits, is unquestionable, but that these circumstances are essential to its 
production is not at all probable, as the disease is frequently witnessed in the stoutest and 
most temperate subjects, a fact which is entirely at variance with such a conclusion. 
Under the microscope the atheromatous matter is observed to consist of albuminous 
and earthy particles, of crystalline plates of cholesterine, of an imperfect fibrous texture, 
and of oil globules. The amount of fatty substance is 
frequently so great that it imparts a greasy stain to paper 
when dried on it by heat. The minute appearances of 
this deposit are well shown in fig. 311. 
The amyloid, or, more properly speaking, albuminoid, 
degeneration of the coats of the arteries is uncommon 
in the inhabitants of this country, and little is known 
respecting the influence which it exerts upon the produc- 
tion of aneurism and the repair of injuries. It always 
begins in the middle tunic, the cells of which are gradu- 
ally transformed into compact, pellucid, hyaline particles, 
the effect of which is to change the affected vessel into 
a hard, rigid, silvery-looking cord, more or less trans- 
lucent, and of a clear, glassy appearance, with a lustre 
not unlike that of rough ice. The deposit upon which the degeneration depends is essen- 
tially composed of albumen. 
Ulceration, as a consequence of arteritis, whether acute or chronic, is seldom witnessed. 
Manifesting a peculiar predilection for the larger trunks, it commonly commences in the 
serous membrane, from which it gradually extends to the middle and outer tunics until 
it leads to complete perforation. Such a termination, however, is extremely rare. The 
ulcers, which are very irregular in their form, vary much in size, number, and general 
character. At times they are very small, scarcely exceeding the diameter of a mustard 
seed; but they may be as large as a split pea, a five-cent piece, or even a guinea, accord- 
ing to the caliber of the affected tube. Their margins are usually ragged, irregular, and 
Fig. 310. 
Atheromatous Deposits. 
Fig. 311. 
Fatty Granules, -with Crystals of Cho- 
lesterine, from Atheromatous Deposits in 
the Aorta. chap. v. 
VARICOSE ENLARGEMENT. 
687 
considerably elevated, but seldom injected ; their bottom, which is rorndi and uneven is 
commonly formed by the middle tunic, the fibres of which frequently present a shreddy 
lacerated appearance. In many instances, the erosions look like so many fissures, cracks, 
or chaps, with sharp, prominent, and irregular borders. This form of the disease is 
ordinarily dependent upon the presence of calcareous matter. The number of ulcers is 
seldom considerable, although in a few rare cases the inner surface of the larger trunks 
has been found completely checkered with them. When confined to the internal tunic, 
they sometimes admit of cicatrization. 
In legard to the different affections now described, there are no remedies which, so far 
as is at present known, are capable of exerting any influence over their development and 
cure. hat treatment might accomplish, if their diagnosis could be satisfactorily estab- 
lished, is an interesting problem for future inquiry to solve. 
3. DISSECTING ANEURISM. 
There is an affection of the arteries, occurring exclusively in old persons, more particu- 
larly in women, to which the term dissecting aneurism, fig. 312, has been applied: it is 
not, however, in reality, an aneurism at all, but 
merely a separation of the lamellae of the middle 
tunic, as has been satisfactorily established by the 
investigations of Dr. Pennock, and by an exami- 
nation by myself of nearly all the reported cases 
of the disease. A more appropriate name would 
be intraparietal separation. The lesion, which 
presents nothing of practical interest, inasmuch as 
it is always fatal, is entirely limited to the aorta 
and the larger trunks more immediately connected 
with it, and is always dependent upon organic 
disease of the coats of the arteries, rendering 
them lacerable, and, consequently, incapable of 
resisting the impulse of the blood. The manner 
in which the affection takes place is easily under- 
stood. In the natural state the different coats are 
so intimately connected together that it is almost 
impossible, even' by the nicest dissection, to de- 
tach them from each other; but when they are 
altered by disease, or by some of the degenera- 
tions to which they are so liable, the connective 
tissue is rendered soft and friable, and their sepa- 
ration may then be very easily effected. In this 
condition, moreover, the tunics themselves are 
frequently very much changed, so that they are 
scarcely able to resist the slightest impulse. Now, 
if under these circumstances the lining membrane 
gives way, whether from ulceration, erosion, or 
rupture, the blood insinuates itself into the acci- 
dental opening, which is thus gradually enlarged, 
at the same time that the fluid is forced on be- 
tween the layers of the weakened middle tunic, 
dissecting them from each other as with a knife, and forming thus either a blind pouch or 
a distinct canal, open at both extremities, or at some intermediate point. 
The separation rarely embraces more than one-fourth, one-half, or two-thirds of the 
circumference of the tube, while in length it may vary from six, eight, or ten lines to as 
many inches. Occasionally it reaches nearly from one extremity of the aorta to the 
other, being, perhaps, prolonged at the same time into the carotid, subclavian, and iliac 
arteries. 
4. VARICOSE ENLARGEMENT. 
The arteries are liable to a dilated and nodulated condition, similar to that of the veins, 
and hence very frequently termed varicose enlargement. The affection has also been 
described under the name of cirsoid aneurism, or arterial varix. Its general features are 
well illustrated in fig. 313. The lesion, which is exceedingly rare, is met with chiefly in 
Fig. 312. 
The so-called Dissecting Aneurism, a, Semi- 
lunar Valves; External Vessel laid open in 
its entire Extent, so as to Expose the Aorta at c ; 
d, Valvular Opening in the Coats of the Aorta, 
showing the Communication of this Vessel with 
the Artificial Channel, b ; the Probe e passed 
through the Abnormal Opening; / exhibits the 
Foramina between the Aorta and the Outer Canal. 688 
DISEASES AND INJURIES OF THE ARTERIES. 
chap. v. 
the superficial arteries, particularly in those about the hand, forearm, leg, and foot; and 
consists in a remarkably tortuous, elongated, and convoluted state of these vessels, evi- 
dently dependent upon the effects of inflammatory action, as is shown by the fact that 
their coats are always abnormally thickened, either uniformly, or alternately thickened 
Fig. 313. 
Varicose Enlargement of the Arteries of the Hand. 
and attenuated. In elderly subjects it is generally associated with the fibro-cartilaginous, 
earthy, or fatty degeneration. The dilatation and varicosity sometimes atfect an entire 
artery, but more commonly they are limited to particular portions of it; they may be 
restricted to one vessel, or occur simultaneously in several. When the diseased artery is 
superficial, the character of the lesion is rendered sufficiently clear by the tortuous and 
nodulated course of the vessel beneath the surface ; but there are no pathognomonic signs 
when it is deep-seated. 
This affection rarely requires any treatment; for, even when the enlargement is con- 
siderable, it is rather an inconvenience than an actual disease. In ordinary cases, the 
vessels may be supported by the constant use of a well-applied bandage, or of an apparatus 
constructed upon the principle of the laced stocking. During the forming stage, much 
may be done in the way of repressing development by astringent and soothing lotions, 
along with rest and elevation of the parts, and the occasional abstraction of blood, pro- 
vided the patient is plethoric, in order to moderate the momentum of the circulation. 
When the disease proves troublesome, by causing pain and functional disorder, the only 
effectual remedy is ligation of the offending vessels, at the cardiac side of the enlargement. 
5. OCCLUSION. 
Accidental occlusion of the arteries was long ago noticed by pathologists, but its great 
practical importance was not fully appreciated until within a comparatively recent period. 
One form of gangrene, the senile, so graphically described by Pott, has long been known 
as one of its principal effects. 
The causes of accidental occlusion are various. The most important are, 1st, acute 
inflammation ; 2dly, the atheromatous and calcareous degeneration of the coats of the 
vessels; 3dly, embolism, or the formation of clots; 4thly, fibrinous concretions; 5thly, 
morbid vegetations ; Gthly, pressure of the ends of fractured bones ; 7thly, exuberant 
callus ; and, lastly, different kinds of tumors, soft, hard, and aneurismal. 
The effects of acute arteritis and the atheromatous and calcareous degenerations of the 
coats of the arteries upon the circulation have already been considered under the respec- 
tive heads of those maladies. Such changes, which are most common in the aorta 
and its larger branches, and in the arteries of the inferior extremities, are very liable to 
be followed by the formation of clots and fibrinous concretions, by which the caliber of 
the vessels is obstructed and the nutrition of the parts supplied by them materially 
impaired, if not completely interrupted. Embolism, properly so called, acts precisely in 
a similar manner. Clots are liable to form in all arteries, large as well as small, often 
suddenly and unexpectedly, and followed by the worst results, both local and general. 
Inflammation of the lining membrane of the arteries, attended with a deposit of plasma, 
is generally the exciting cause of embolism, the blood as it sweeps over the affected 
surface becoming adherent to it, and thus acting as a nucleus around which the fluids 
concrete. Embolism has been noticed in all the principal organs of the body, as well as 
in all the main arteries of the extremities, especially the lower. Fibrinous concretions CHAP. V. 
ANEURISM. 
689 
are sometimes detached from the interior of an aneurism, and, being transmitted into 
the distal portion of the diseased artery, effectually arrest its circulation. The valves 
of the heart in gouty and rheumatic affections are liable to be studded with morbid 
vegetations, which, being accidentally detached, occasion obstruction in the arteries, 
often followed by gangrene and other grave effects. These vegetations may, like the 
clots in embolism, be transported by the sanguineous current to remote parts of the body, 
and thus cause occlusion and disease in vessels up to that period in a perfectly sound 
condition. 
An artery compressed by the px-ojecting end of a broken bone is sometimes occluded in 
its distal extremity as completely as if it had been embraced by a ligature. Similar 
effects may be produced by the pressure of exuberant callus, of an exostosis, and of 
fibrous and other morbid growths. Under such circumstances, however, the obstruction 
usually occurs slowly, not rapidly or suddenly, as when it is caused by the projecting 
extremity of a fractured bone. The pressure of an aneurism may lead to occlusion 
of the distal arteries, as is occasionally witnessed in popliteal aneurism, the effect of 
which is to block up the arteries of the leg and to bi’ing about gangrene in the unnourished 
structures. 
Embolism, however induced, is not peculiar to any period of life, although it is un- 
questionably most common in the aged. This, however, is true mainly of the chronic 
form of the affection ; for the acute, if so it may be termed, or that which arises suddenly, 
is not unfrequently met with in very young subjects, and even in children and infants, 
although such an occurrence is very infrequent. 
The most common effect of accidental occlusion of the arteries is gangrene in the 
structures below the seat of the obstruction. Such an occui-rence is almost a necessary 
and inevitable consequence of sudden obstnxction ; in chronic cases, on the contrary, 
the circulation may be maintained by the collateral vessels, and the clots be even 
ultimately absorbed, although such a termination is very uncommon. Instantaneous 
death may be produced when a clot suddenly finds its way into the heart, the mouth 
of the aorta, the lung, or the brain. Organs supplied by a single artery, as the retina 
and testicle, lose their function and fall into a state of atrophy when their circulation is 
thus cut off. 
The symptoms denotive of arterial occlusion are generally so obscure as to render the 
diagnosis exceedingly difficult, if not impossible, in the earlier stages of the occurrence. 
Obstruction of the trunks of the extremities is usually attended by a sense of numbness 
and tingling along the course of the principal vessels, rapidly followed by tenderness and 
pain, both of which are often extremely violent. The skin, at first pale, soon becomes 
purple, and then mottled ; temperature, motion, and sensation are diminished, and the 
impoverished structures are finally seized with gangrene. Sometimes the pain is of a 
wandering character, very much as in gout or rheumatism ; and cases occur, although 
rarely, in which it is perceived at distant parts of the body. More or less fever generally 
attends, and the system, in most cases, speedily sinks into a typhoid condition. Children 
and young subjects commonly bear up better under arterial occlusion than elderly persons, 
few of whom i*ecover. Acute occlusion is more dangerous to life than chronic, and is 
generally more rapidly fatal. 
The treatment of arterial occlusion is unsatisfactory. In general, little can be done 
beyond attention to the posture of the limb, and the preservation of its temperature by 
means of cotton and flannel, the relief of pain by anodynes, and the maintenance of the 
strength by suitable food and drink. Moist applications are usually hurtful. When 
gangrene arises, the object should be to promote the separation of the sloughs, and to 
prevent fetor by the liberal use of deodorizers, fresh air, and rigid attention to cleanliness. 
Amputation is seldom proper, especially in chronic cases, even when a distinct line of 
demarcation exists, experience having shown that, unless the patient possesses uncommon 
constitutional vigor, the operation generally proves fatal. Now and then there is, of 
course, an exception, but death is unquestionably the rule. In the acute form of the 
affection amputation sometimes succeeds in saving life, provided there is a well-formed 
line between the dead and living structui-es, with a good state of the system, and perfect 
exemption fi'orn internal complications. 
SECT. VI ANEURISM. 
An aneurism may be defined to be a pulsating tumor, occupied by blood, and communi- 
cating with an artery deprived, either partly or completely, of its integrity. 690 
DISEASES AND INJURIES OF THE ARTERIES. 
chap. r. 
The subject of aneurism has been encumbered by too many divisions and subdivisions, 
and the consequence is that several lesions have been included under it which do not, 
properly speaking, appertain to it. The effect of this overrefinement has been to em- 
barrass the study of this disease, and to invest it with difficulties which are altogether 
foreign to it. The distinction of aneurism into true and false is one of great importance, 
and should, therefore, be retained. The same may be said in regard to spontaneous and 
traumatic aneurism. The term dissecting aneurism, introduced by Laennec, and adopted 
by most modern authors, should be discarded, inasmuch as the affection which it serves 
to designate has nothing whatever in common with aneurism ; it is, in fact, as already 
stated, merely a separation of the coats of the arteries, without any tumor or symptoms 
denotive of that lesion. Then again, as to the term varicose, which I have myself, along 
with others, employed, in my writings, to designate a peculiar form of arterial lesion, it 
is obviously improper when we come to make a practical application of it. A varicose 
artery is, in reality, no more an aneurism than a varicose vein ; both affections consist 
essentially in a dilated and tortuous state of these two classes of vessels, and not, as an 
aneurism, in a pulsating tumor, caused by the destruction, partial or complete, of the 
tunics of an artery. An anastomotic aneurism is a pulsating tumor formed by hypertrophy 
of the arterial and venous capillaries of a part ; critically speaking, therefore, the term 
aneurism is not applicable to it, and yet, as it has been fully engrafted upon our surgical 
nomenclature, it is difficult to dispense with it, or to substitute one of a more expressive 
and appropriate character. 
The term true is applied to that species of aneurism in which one or more of the arterial 
tunics, without being necessarily perfect, form a part of the tumor. In a false aneurism, 
on the contrary, all the coats have given way, and the sac is composed of condensed con- 
nective tissue. It was formerly supposed, chiefly through the influence of the writings 
of Scarpa, that there was no such disease as a true aneurism, but that in every instance, 
whatever might be the size, form, or site of the tumor, there was a complete absence of 
the arterial tunics. This opinion, however, has become obsolete, experience having 
shown that there are cases, although they are confessedly rare, in which the aneurism 
clearly consists of at least one, if not more, of the coats of the artery from which it springs. 
Each of these great divisions comprises several varieties, founded principally upon the 
form and volume of the tumor. Thus, an aneurism is 
said to be sacculated when it consists of a distinct 
pouch, as so often happens in aneurism of the aorta 
and its principal branches ; the term cylindroid is used 
when the swelling affects the artery uniformly in its 
entire circumference, Avhile the tapering tumor is 
known by the appellation of fusiform. The words 
circumscribed and diffused refer mainly to the dimen- 
sions of the aneurism. 
The annexed sketches afford a good idea of the 
arrangement of the tunics of the arteries in the princi- 
pal varieties of spontaneous aneurism. In fig. 314 
the tumor is formed by the expansion of all the coats 
of the vessel, an extremely rare event; in fig. 315 
the middle tunic has given way, the inner and outer 
being preserved; in fig. 316 the aneurism is formed 
by the external tunic alone; in fig. 317 the two outer 
membranes have been ruptured, the inner projecting 
t irough the crevice thus left in the form of a hernia. This variety is very uncommon, 
but cases of it have been reported by different authors, especially by Haller, Laennec, 
Dupuytren, and Dubois. It can occur only when the inner coat of the artery has been 
thickened and fortified by interstitial and surfacial deposits. 
Filially, aneurisms are divided into internal and external, the former expression being 
use chiefly in reference to the aorta and to the arteries of the viscera, the latter in rela- 
tion to t le vessels of the head, neck, and extremities. The words spontaneous and 
traumatic sufficiently explain themselves. 
1. LOCALITY, PREVALENCE, AGE, SEX, AND CAUSES. 
Spontaneous aneurism does not occur with equal frequency in all parts of the body; on 
le contrary, there are a number of arteries which are almost entirely exempt from it, or 
Fig. 314. 
Fig. 315. 
Fig. 316. 
Fig. 317. CHAP. V. 
ANEURISM. 
691 
which, at all events, so seldom suffer as to be scarcely entitled to notice. The vessel 
which is most frequently involved is the aorta ; first in its ascending portion, then in the 
thoracic, and lastly in the abdominal. Next in point of liability to the disease are the 
popliteal artery, the femoral, common carotid, subclavian, innominate, axillary, and 
external iliac. The arteries of the leg and foot, hand, forearm and arm, face, upper part 
of the neck, and of the viscera, together with the common and internal iliac, rarely suffer 
in this wise. Traumatic aneurism may occur in any of the arteries, but is most common 
in those that are most exposed to external injury. 
Of the causes which induce spontaneous aneurism more frequently in one artery than in 
another, nothing definite is ascertained. Several circumstances, however, may be assigned 
as affording at least a plausible explanation of the circumstance. 
1. It is well known that certain arteries are peculiarly prone to the calcareous and 
atheromatous degenerations, while others are almost entirely exempt from them, whatever 
may be the condition of the rest of the arterial system, or the age of the patient. Now, 
dissection has shown that those vessels which are most frequently diseased in this way are 
also those which are most frequently affected with aneurism, and conversely. Spontaneous 
aneurism of the arm and forearm is among the rarest occurrences, and everybody knows 
how free their vessels are from the degenerations in question. In the aorta and popliteal 
artery, on the other hand, they are extremely common, and it is here, as already seen, 
that spontaneous aneurism is most frequent. 
2. In the next place, some influence is no doubt due, in the production of this difference, 
to the force with which the blood impinges against the walls of the vessels. Thus, in the 
aorta, w’hich is more prone to aneurism than any other artery, the ascending portion, 
particularly its anterior and right side, suffers more frequently than any other part, and it 
is here that the blood exerts its greatest force, as it is pumped up from the left ventricle. 
The popliteal artery, wdiicli comes next in the order of involvement, is subjected, in a 
degree beyond that of any other vessel in the extremities, to a similiar influence during 
the flexed condition of the limb. 
3. It is not improbable that some influence is also due to the weakness which the 
arteries experience at the origin of their larger branches. The fibres of the middle tunic 
suffer a species of separation here, in consequence of which they are less capable of with- 
standing the shock of the blood as it is directed against them. However this may be, 
experience teaches that aneurism is peculiarly liable to occur at these points. 
4. Another circumstance which may be supposed to favor the production of aneurism 
is the motion to which the arteries are subjected, especially during sudden and violent 
efforts. Such an influence must be particularly felt by the ascending portion of the aorta 
during bodily and mental excitement, and by the popliteal artery in the various muscular 
exertions of the lower extremity. 
How far any one of these causes alone is capable of producing aneurism is altogether a 
matter of conjecture. Without degeneration of the arterial tunics, they would probably 
exert but little influence, while under opposite circumstances it must be very great. 
Indeed, it is very questionable whether aneurism would be the one-twentieth part as com- 
mon as it is, if the arteries were exempt from the earthy and atheromatous deposits; nay, 
we may go further, and assert, positively, that if these deposits could be prevented, spon- 
taneous aneurism would almost cease to exist. 
The occurrence of aneurism would seem to be influenced by climate or locality. The 
infrequency of the lesion in the inhabitants of the southwestern States of North America 
is proverbial. In an extensive practice in Ohio and Kentucky of twenty-three years, I 
rarely met with an example of spontaneous aneurism ; and my experience, in this respect, 
is fully borne out by that of the late Dr. Dudley, of Lexington, whose practice embraced 
a wide field, afterwards so successfully cultivated by Professor James B. Bush. The 
testimony of other western and southwestern surgeons is precisely of the same import. 
To what this extraordinary immunity is due, we have no means of determining. The 
population of those regions of the United States is a mixed and laborious one, made up 
from all parts of the civilized wrnrld, and pursuing all kinds of occupations, from the most 
delicate and refined to the most rude and vigorous, and yet a case of spontaneous aneurism, 
in any class of its citizens, is absolutely an anomaly. The disease, if I mistake not, is 
equally uncommon in our northern and middle States. 
In regard to the prevalence of aneurism in our larger towns and cities, our information 
is very imperfect. Professor Gibson, formerly of the University of Pennsylvania, asserts 
that the disease is very uncommon in Philadelphia, and this I know to be the fact from 
the results of my own observations. In New York, on the contrary, it would seem, 692 
DISEASES AND INJURIES OF THE ARTERIES. 
chap. v. 
according to the statement ot I)r. to be quite frequent; a ciicumstance which is, 
perhaps,°not surprising, when we consider the heterogeneous character of the people of 
that city, and, above all, the extent of its commerce, and the numerous accidents incident 
to its pursuits. What is remarkable, however, is, that all the cases met with by this dis- 
tinguished surgeon, during a period of nearly forty years, occurred among native-born 
citizens of the United States. In opposition to this fact, however, I have the authority 
of Dr. John Watson and others, of New York—as communicated to me by Dr. Lente— 
for stating that the great majority of cases of aneurism in that city, especially in hospital 
practice, are met with among those of foreign birth. Its negroes would also seem to be 
particularly liable to the disease. 
Aneurism is uncommon in the East and West Indies, in the British Provinces of North 
America, and on the continent of Europe, especially in France, Italy, and Germany. 
In Great Britian, on the contrary, it is sufficiently frequent ; more so, perhaps, than in 
any other part of the globe. According to the report of the registrar-general, it appears 
that the number of deaths from aneurism, in England and Wales alone, during a period of 
five years—namely, from 1838 to 1842—was 593; being an annual average of one in 
about 131,000 of the inhabitants. The various hospitals of London receive every year a 
large number of cases of this disease. The people of Ireland are said to suffer more fre- 
quently from aneurism than any other race. In Egypt aneurism is almost unknown. 
The causes of aneurism are predisposing and exciting. Of the former, the most con- 
stant, and, therefore, the most important, is a diseased condition of the arterial tissues, 
usually in the form of the earthy or atheromatous degeneration. These degenerations, 
by rendering the coats of these vessels preternaturally brittle and lacerable, induce them 
to yield more readily under the impulse of the blood and the various extraneous cir- 
cumstances which have a tendency to stretch and twist them. I have already expressed 
the belief that, but for these alterations, spontaneous aneurism would be almost unknown. 
All laborious pursuits, involving sudden and violent muscular exertion, powerfully 
predispose to its occurrence. Hence, it is more common among sailors, and those 
who are much accustomed to athletic exercises, than among any other classes of indi- 
viduals. Soldiers suffer much less frequently than was formerly supposed. Men 
engaged in agricultural pursuits, although their labor is often severe, are, in great measure, 
free from the disease, owing to the fact that their arteries are singularly exempt from the 
calcareous and atheromatous degenerations. Popliteal and femoral aneurism used to be 
sufficiently common in Great Britain among post-boys, but their frequency, according to 
Dr. P. H. Watson, has much diminished since the introduction of railroads has replaced 
this class of persons. Protracted courses of mercury, a syphilitic taint of the system, 
and the constant and inordinate use of ardent spirits, are supposed to predispose to the 
formation of aneurism ; but how far, or in what degree, remains to be demonstrated. 
Embolism is an occasional cause of aneurism, especially of the popliteal artery, pro- 
ducing first obstruction of the caliber of the vessel, and then softening and expansion of 
its coats. Traumatic aneurism, as the name implies, is the result of external injury, as 
various kinds ot wounds, incised, lacerated, punctured, and gunshot. Roux has reported 
a case in which an aneurism of the axillary artery was produced by the pressure of an 
exostosis; and Dr. Thomas, of Closmadeuc, met with a similar occurrence in the popli- 
teal artery. Dr. Castle, of New York, saw a case in which the disease was developed in 
the palatine artery by the pressure of the plate of a set of artificial teeth. 
The formation of aneurism is remarkably influenced by age. Prior to the thirtieth year 
the disease is extremely rare, and up to the period of puberty it is almost unknown, even 
in the aorta, which is so much more frequently affected than the other vessels. The 
greatest number ot cases, by far, occur between the thirty-fifth and fiftieth years; a good 
many cases are also met with during the next decennial period and a half, but after that 
time the malady is very rare ; probably not that the predisposition to it ceases, but because, 
as it seems to me, in the first place, the number of subjects is comparatively small; and, 
secondly, because persons at this age are much less exposed to violent muscular and men- 
tal excitement than during the meridian of life. That this supposition is true is rendered 
highly probable by the fact that the earthy and atheromatous deposits generally exist in 
greatest abundance in advanced life. The absence of these deposits in young subjects 
readily explains the rarity of aneurism in children and adolescents. 
Although spontaneous aneurism in early life is very uncommon, examples have been 
noticed by different observers, all, apparently, referable to the effects of embolism. Mr. 
Syme, in 1844, operated upon a boy for a popliteal aneurism that had made its appearance 
at the age of seven years ; and he alludes to two other instances in which the disease occurred CHAP. V. 
ANEURISM. 
693 
in children. Sir Astley Cooper met with it in the anterior tibial artery at the age of 
eleven years; Mr. Hutchinson, in the arch of the aorta at four; Mr. Armitage, in the 
abdominal aorta at seven and a half; and Dr. Ogle, in the ulnar artery at seventeen. 
Dr. \\ . S. Church, of London, has published a table of thirteen cases of intracranial 
aneurism occurring in subjects under twenty years of age. 
I he immediate cause ot aneurism is rupture of the coats of the arteries, in consequence 
of severe muscular exertion unduly stretching these vessels ; or, as in the case of the 
aorta and its larger offsets, an inordinate impulse of the blood, during the sudden and 
violent contraction of the left ventricle of the heart. The vessels, weakened by chronic 
inflammation and the degeneration of their tissues, and deprived of their elasticity, readily 
yield to the forces thus applied, commonly at a particular point, which is afterwards con- 
verted into a distinct pulsating tumor, generally composed, in great measure, if not exclu- 
sively, of the external tunic of the artery, along with more or less of the circumjacent 
connective tissue. Sometimes the exciting cause of the disease is ulceration, but such an 
occurrence is comparatively rare, especially as an affection independent of the earthy and 
atheromatous deposits. The process, as stated in a previous section, should not be con- 
founded with the cracks or fissures which so often follow upon these deposits, inasmuch as 
the latter are usually the result, not of a vital action, as in true ulceration, but of a mere 
mechanical one, gradually effected under the impulse of the blood, as it rushes over the 
inner coat of the diseased vessel. 
Aneurism occasionally exists simultaneously in several arteries. Thus, it is by no 
means uncommon for a patient to have one tumor of this kind in the aorta, and another 
in the carotid, subclavian, popliteal, femoral, or external iliac artery. I have seen several 
instances of the coexistence of popliteal aneurism on both sides in the same individual. 
When the disease affects a considerable number of arteries, it constitutes what is termed 
the aneurismal diathesis; a circumstance which, as a rule, imperatively contraindicates 
surgical interference, however favorably the external tumor may be situated for operation. 
Weak, sickly persons, of depraved constitution, and intemperate habits, are the most 
common subjects of this diathesis. Several remarkable examples of this predisposition 
to the formation of aneurism are upon record. Pelletan gives one in which the number 
of tumors was upwards of sixty, and in another, related by J. Cloquet, there were more 
than two hundred, the patient being a man fifty years of age. The aneurisms, in this 
instance, affected nearly all the arteries in the body, but they were most numerous in those 
of the extremities, the axillary, brachial, radial, ulnar, femoral, popliteal, tibial, and 
peroneal being all closely studded with them. 
Sometimes two aneurisms form in close proximity with each other; and, the fact not 
being recognized beforehand, may, in the event of an operation, cause so much embarrass- 
ment in the attempt to pass the ligature as to necessitate its abandonment. 
Men suffer from aneurism more frequently than women, but in what precise proportion 
is not determined. The question has hitherto engaged but little attention, and it is obvious 
that it can only be decided by the analysis of a much larger number of cases than have 
yet been adduced for the purpose. It has been alleged that the relative frequency of 
carotid aneurism in the two sexes is nearly equal, and the occurrence has been attempted 
to be accounted for on the supposition that the arteries of the neck of the female are 
nearly as much exposed to all kinds of violence and muscular exertion as those of the male. 
Little confidence, however, can be placed in such opinions ; for, before we can recei ve them 
as true, we must be satisfied that the disease is as common in women as in men, which I am 
very certain it is not. The statistics of Mr. Crisp show that of 551 cases of aneurism of 
all kinds, more than seven-eighths occurred in men. 
Having long been impressed with the belief, founded upon numerous dissections, that 
the difference in the relative frequency of aneurism in the two sexes was due, not to any 
difference in their occupation, but to the difference in the relative frequency of the earthy 
and fatty degenerations of the arteries, I was induced to institute a special inquiry into 
the subject, and am gratified to be able to say that my views are fully confirmed by the 
statements of Professor Agnew, Dr. C. E. Isaacs, T. G. Richardson, and J. B. S. 
Jackson. The testimony of these teachers, all well known as able and experienced prac- 
tical anatomists, tends to show, indisputably, that females are much less subject to chronic 
disease of the arteries of every description than males. Neither their information, how- 
ever, nor my own, is such as to enable me to determine the relative proportion of these 
degenerations in the two sexes, in a given number of cases; but that it corresponds very 
closely with the difference in the number of cases of aneurism is, I think, fully established. 
If what is here said be true, it follows that the opinion which ascribes the greater fre- 694 
DISEASES AND INJURIES OF THE ARTERIES. 
chap. v. 
quency of spontaneous aneurism in males than in females to their more laborious occupa- 
tion, their more intemperate habits, and their greater exposure to all kinds of disease, is 
entirely untenable, and, therefore, unworthy of confidence. Women, it is true, are not 
sailors, carpenters, blacksmiths, or hod-carriers, but in many parts of the world they are 
tillers of the soil, and engaged in almqst every variety of pursuit calculated to rupture 
the arterial tunics if they were in a serious state of disease, such as we so often meet with 
in the other sex. 
2. VARIETIES OF ANEURISM. 
True aneurism presents itself under two varieties of form, differing from each other 
materially in their appearance and mode of formation, although their essential symptoms 
and effects are usually perfectly similar, if not identical. These two varieties are the 
tubular and the sacciform, terms which are sufficiently expressive of their general confor- 
mation. Each consists of one or more of the arterial 
tunics, and forms a tumor, which, in time, is capable 
of exerting the most injurious effects upon the neigh- 
boring structures, and of causing the death of the pa- 
tient. The diffused aneurism, properly so called, is 
always the result of a diseased condition of the cir- 
cumscribed, especially of the sacculated. 
The sacciform variety, fig. 318, is by far the more 
common of the two. It essentially consists, as the 
name denotes, in the formation of a pouch, bag, or 
sac, connected with the side of the affected artery. In 
the tubular variety the tumor is formed at the expense 
of the entire circumference of the vessel; in this, on 
the contrary, it occupies only a limited portion of it. 
The arteries most liable to sacciform aneurism are the 
aorta, particularly its thoracic division, the popliteal, 
femoral, innominate, carotid, and subclavian. The 
number of tumors is subject to considerable diversity ; 
cases have been reported in which there were so many 
as to constitute a genuine aneurismal diathesis, nearly 
all the principal arteries in the body being more or less implicated. In general, how- 
ever, there is only one, although others may be developed during its progress. Thus, it 
occasionally happens in popliteal aneurism that an aneurism forms in the aorta, the carotid, 
or in the popliteal artery of the opposite side. 
The sacciform aneurism is capable of assuming a great variety of forms ; the most 
common is the globular or ovoidal; in rare cases it is conical, elongated, or irregularly 
flattened, like a shot-pouch. Much diversity also obtains in regard to its dimensions ; 
thus, while in some instances it is hardly of the volume of a hazelnut, in others it is as 
large as a fist, or the head of the patient; in general, however, it does not exceed a hen’s 
egg, or a medium-sized orange. The largest aneurisms of this kind are usually found in 
the aorta, and in the popliteal, iliac, and innominate arteries. The attachment of the 
tumor to the artery is commonly effected by a narrow 
footstalk; but cases occur in which it takes place by 
a broad and extended base, and it is then not unusual 
for the artery to suffer serious compression during 
the progress of the disease. 
The orifice of communication, fig. 319, between 
the sac and the artery varies in different prepara- 
tions. When the tumor arises by a narrow foot- 
stalk, the opening is usually proportionately small, 
with smooth and well-defined margins. When, on 
the other hand, it is attached by a broad base, the 
aperture is always much larger, and its edges are 
also more irregular, sometimes, indeed, quite shreddy 
and ragged, as if they had been torn. The situa- 
tion of the orifice is commonly towards the centre 
of the sac but it may be at one side, or even at one of its extremities. The form of the 
opening is extremely variable, and admits of no specific description. In the early stage 
Fig. 318. 
Sacculated Aneurism, 
Fig. 319. 
Aneurism of tlie Aorta: the greater part of 
the Sac being filled with clots, and the Aper- 
ture of Communication being small. CHAP. V. 
VARIETIES OF ANEURISM. 
695 
oi the disease, and in nearly all cases where the tumor is small, the orifice is of a rounded 
or circular configuration, while in cases of an opposite character it is generally more or less 
irregular. _ The internal and middle tunics may terminate abruptly at the margins of the 
opening of communication, or they may extend into the cavity of the sac, and thus serve 
to give it a partial lining. 
1 he sac generally consists simply of the external tunic, the inner and middle having 
given way either prior to, or during, the development of the disease. The first thing, in 
fact, that commonly happens, in all such cases, is the destruction, by ulceration or some 
other disorder, first, of the internal, and, soon after, of the middle layer of the artery, 
leaving thus a kind of crevice, which gradually enlarges under the influence of the im- 
pelling column of blood, and thus permits the corresponding portion of the vessel, now, 
of course, greatly weakened, to be converted into a pouch. This pouch, usually called 
the aneurismal sac, is then originally composed exclusively of the external coat of the 
affected vessel, the other strata terminating abruptly at the margin of the opening of 
communication, neither of them being prolonged into its interior. But this pouch would 
be very weak, and, consequently, ill adapted to withstand the shock of the blood as it rushes 
into its interior, if it were not strengthened by adventitious aid, derived from interstitial 
deposits in the surrounding connective tissue. We accordingly find that nature, ever on the 
alert to save the part and system, is prompt in supplying the required relief by setting up 
inflammation and pouring out plastic matter, both in the substance of the sac and in the 
neighboring structures, thereby thoroughly gluing them together, at the same time that 
they are greatly increased in thickness and density, and thus enabled more effectually to 
resist the effects of the ever-beating, dashing, and tumultuous sanguineous current within. 
Such aid, then, is wise and needful, and, fortunately, always comes in play at an early 
stage of the disease, the laceration of the inner and middle tunics of the artery, and 
the pressure of the blood against the tumor, being sufficient causes of inflammation. 
When the periosteum contributes to the formation of the sac, as it occasionally does in 
aneurism of the thoracic aorta, the walls of the tumor may be partly earthy, or even 
partly osseous. 
Although the sac is generally composed of the outer tunic alone, cases, nevertheless, 
occasionally occur where it consists, in the first instance, exclusively of the inner coat, 
the other two having given way. That such an arrangement is exceedingly infrequent, 
is proved by the fact that many surgeons of large experience have warmly contested the 
possibility of its existence. Haller and his contemporaries, however, met with undoubted 
cases of it, and, in more recent times, it has been witnessed by Breschet, Dupuytren, and 
other observers, who have given particular descriptions of it. One ground for assuming 
that this form of aneurism cannot occur, is that it has never followed the numerous at- 
tempts that have been made to produce it in the inferior animals, by exposing the carotid 
artery and dissecting off its outer and middle tunics. In every experiment of this kind, 
the denuded membrane maintained its integrity, and the breach was speedily repaired by 
a free deposit of plastic matter. There is, however, no analogy between a sound and a 
diseased artery, and this fact should be borne in mind in the discussion of the subject. 
When the outer and middle tunics are destroyed by ulceration, as they always must be 
in such a case, not rapidly, but slowly, it is not difficult to suppose that the inner mem- 
brane may, at the injured and weakened part of the vessel, be made to bulge across the 
opening, in the form of a thin, translucent cyst. Interstitial deposits would soon aid in 
strengthening the cyst, although ere long, and before it has acquired any considerable 
bulk, it would be obliged to yield to the resistless impulse of the blood within. Haller 
has described this variety of aneurism under the term hernia of the inner coat of the 
arteries. 
Cases in which the sac consists of the outer and inner coats of the artery, the 
middle having been destroyed, although also exceedingly infrequent, are more common 
than those in which it consists of the internal tunic alone. Such an arrangement is 
occasionally observed in aneurism of the carotid, femoral, and popliteal arteries ; but, 
in time, the lining membrane is sure to give way, leaving thus the cyst composed of the 
outer coat and of the surrounding tissues, as in the ordinary form of sacculated aneurism. 
The sac varies in thickness in different cases and under different circumstances, from 
the fourth of a line to the fourth of an inch. It is often remarkably tough, and, in cases 
of long standing, it is generally composed of several distinct strata, of a grayish, whitish, 
or drab-colored aspect, consisting of fibres which intersect each other in every con- 
ceivable direction. The outer surface of the tumor is rough and shreddy; the internal, 696 
DISEASES AND INJURIES OF THE ARTERIES. 
chap. v. 
on the contrary, is smooth and polished, only, however, as a general rule, in its earlier 
stages, for in time it also becomes rough, and is finally incrusted with fibrinous matter. 
Notwithstanding the thickness of the aneurismal sac, and the 
efforts which nature makes to strengthen it, it gradually di- 
lates, as in fig. 320, under the impulse of the inflowing 
column of blood, and at length, after the lapse, perhaps, of 
several months, manifests a disposition to yield at one or 
more points, very much as an abscess, the activity of the 
absorbent vessels exceeding that of the capillary. 
The sacciform aneurism always contains, even at an 
early period of its formation, fibrinous concretions, the 
presence of which constitutes one of its most interesting 
and important features, as they are evidently designed not 
only to strengthen the tumor, but to aid in its obliteration, 
and, consequently, in the production of a permanent cure, 
although such an event is extremely rare. In their arrange- 
ment, these clots are always concentric, not unlike the layers 
of an onion, one being piled upon, and closely connected to, 
another. Their color and density vary according to the period 
of their formation, the older being usually of a pale, yellowish 
appearance, and of a firm, fibrous consistence, while those 
that are of a comparat ively recent date exhibit very much the 
aspect and consistence of a common heart clot. Their thick- 
ness ranges from the fourth of a line to that of a sheet of paper, 
their number being often immense, thousands existing in a tumor, perhaps, not larger than 
an ordinary fist. That these concretions are organized, at least in many cases, is evinced 
by their intimate adhesion, not only to each other, but also to the inner surface of the 
sac, by their extraordinary density, and by their yellowish hue, which contrasts most 
strikingly with that of recently deposited fibrin and coagulated blood. These circum- 
stances show that these lamellse undergo most important changes after they have been 
deposited ; that absorbent vessels are busily engaged in carrying away the serum and 
coloring matter of the blood, and in solidifying the fibrin after it has been extricated 
from the general mass ; while the successive development of concretions clearly denotes 
that the process is as much a vital as a mechanical one. No arteries and veins have, I 
believe, yet been demonstrated in them ; but that such vessels are always present—often, 
indeed, in great numbers—in cases of long standing, does not admit of any reasonable 
doubt. We may, therefore, look upon these clots as exceedingly interesting structures, 
capable, after a certain period, of maintaining a kind of independent existence. Their 
primary object evidently is to strengthen the aneurismal sac, and, under favorable cir- 
cumstances, to fill it up, so as to effect a radical cure. What adds to the force of this 
conclusion is the fact that, when a cure of this description has been effected, the tumor 
is gradually brought under the influence of the absorbent vessels, by which it ultimately 
entirely disappears, with the exception, perhaps, of a little nodule not larger than a pea, 
and just sufficient to indicate the former site of the disease. It is proper to state that 
the recently-formed strata of an aneurismal sac are, in general, very imperfectly, if at all, 
organized; they are certainly not vascularized and furnished with absorbents. 
How are these aneurismal concretions formed? Upon this subject there still exists 
some contrariety ot sentiment. Most pathologists, however, suppose, and very correctly, 
as I think, that they are deposited from the blood as it sweeps over the inner surface 
of the sac, during which more or less of its fibrin is disengaged, while the other 
elements of the fluid are sent forward to mingle with the current in the affected artery. 
This opinion derives plausibility from the fact that the development of these strata 
always proceeds most rapidly when there is a comparatively small orifice of communica- 
tion, with a languid state of the systemic and of the aneurismal circulation. It has 
been conjectured that the clots had their origin in an effusion of plastic matter, such as 
occurs in injuries and ordinary inflammation ; but for such a view I can myself perceive 
no just ground, as it is impossible to discover the slightest similarity between the two 
processes. The act of formation, as stated in the preceding paragraph, is both a mechan- 
ical and a vital one; mechanical, as far as the mere separation of the fibrin from the blood 
is concerned ; vital, as it respects the decolorization, condensation, and intimate adhesion 
of the concretions. 
The tubular aneurism is extremely rare; it is observed principally in the aorta and 
Fig. 320. 
Sacciform Aneurism of the Aorta 
ready to give way. CHAP. V. 
VARIETIES OF ANEURISM. 
697 
its larger branches, especially the innominate, carotid, and iliac, and consists in a uniform 
dilatation of the vessel, usually composed of all its tunics in varying degrees of altera- 
tion. In its shape, the tumor is commonly somewhat spindle-like, and hence it is often 
described under the name of fusiform aneurism ; the term cylindroid has also been applied 
to it, as its conformation occasionally par- 
takes strongly of that character. The word 
tubular, however, is more expressive of its 
appearance, and I therefore adopt it in pre- 
ference to any other. The annexed drawing, 
fig 321, from a specimen in my collection, 
affords a good idea of this variety of the 
disease. 
The size of the tubular aneurism varies 
from slight increase of the normal diameter 
of the vessel to a tumor capable of receiving 
a large fist. When it occupies the arch of' 
the aorta, it often projects up into the neck 
so as to form a prominent swelling above 
the sternum, admitting of satisfactory ex- 
amination, both by touch and auscultation. 
The distance between the roots of the carotid 
arteries is greatly increased, and the aneurism 
generally encroaches sensibly upon the heart. 
In nearly every instance its length consider- 
ably exceeds its diameter. The dilatation of 
which it consists seldom terminates abruptly, 
but is lost by insensible degrees in the vessel 
above and below, thus giving the tumor the 
appearance of two cones united at their 
bases. In the smaller arteries, as, for example, the innominate, the aneurism sometimes 
involves the whole length of the vessel. 
The structure of the tubular aneurism is usually made up of all the tunics of the 
affected artery, in a notable state of alteration, of which hypertrophy constitutes the 
most striking feature. In two remarkable specimens in my collection, the different 
tunics are immensely thickened, and increased in strength and density, the effect, 
evidently, of long-continued interstitial deposits ; they both occupied the arch of the 
aorta, extending as far as the root of that vessel, and were taken from male subjects 
upwards of fifty years of age. The lining membrane has lost its white and glossy 
appearance, and has been replaced by a thick, opaque, and rugose structure, having none 
of the properties of the original texture. The middle coat is at least ten times 
as thick as natural, very strong, elastic, and deprived of its yellowish hue; the outer 
one is also greatly changed in its appearance, being remarkably strong, thick, and firm. 
No evidence whatever exists in any of the tunics of the earthy, atheromatous or fatty 
degeneration. 
From a careful examination of this form of aneurism, it appears to me to consist essen- 
tially in a dilatation of the caliber of the artery, with hypertrophy of its different tunics. 
The first step, probably, in its formation is chronic inflammation, causing weakness of the 
walls of the vessel, and uniform enlargement of its diameter. By and by, however, as 
the dilatation increases, the coats become strengthened in every direction by interstitial 
deposits, and it is thus that a tumor is at length formed, capable of offering great resist- 
ance to the impulse of the blood. It is owing to this superaddition of matter that the 
tubular aneurism so seldom gives way by rupture; a circumstance in which, as well as 
in several others, it differs remarkably from the sacciform variety of the disease. 
It is not to be supposed, from what precedes, that this form of aneurism always con- 
sists of the different tunics of the affected artery ; this is unquestionably true in most 
cases, but we now and then meet with an instance in which the lining membrane, and 
perhaps, also, the middle layer, are partially deficient, thus causing irregularity in the 
dilatation, unless, as occasionally happens, the defect is atoned for by plastic deposits. 
Indeed, the retention of all the tunics would seem to be an essential condition to the 
formation of the true tubular aneurism ; if the inner and middle lamellaa be destroyed, 
even to a small extent, the blood will dilate the vessel unequally, and inevitably give rise 
Fig. 321. 
Tubular Aneurism of the Aorta. DISEASES AND INJURIES OF THE ARTERIES. 
CHAP. V. 
to a sacculated tumor. It is in this way that may be explained the occasional coexistence 
of the two forms of the malady. 
The tubular aneurism is remarkable, besides some of the characters already pointed 
out, for the absence of fibrinous concretions, which are so common in the sacciform ; and 
the circumstance may be employed as an additional evidence of the correctness of the 
view, so long and so generally entertained, that the formation of these substances takes 
place directly from the circulating fluid, and not, as some have conjectured, as an effect 
of the deposition of plastic matter, consequent upon inflammation. If the development 
arose in the latter way, it ought to be of frequent, if not of constant occurrence, inasmuch 
as the inner coat of the affected artery is seldom entirely free from inflammation, and 
would thus afford a large surface for the effusion of fibrin ; but every one who has ever 
examined a specimen of tubular aneurism knows how extremely rare it is to find its walls 
incrusted with anything. In the annexed sketch, fig. 
822, from Hodgson, a tubular aneurism is seen to be 
occupied by concretions, with a central canal, which 
preserves the continuity of the vessel, and thus main- 
tained the circulation. The stratification appears to 
have been very perfect. 
A diffused aneurism, as it is termed, is, strictly 
speaking, an outgrowth of the circumscribed variety, 
especially of the sacciform, which, during the progress 
of its development, is liable to give way by the partial 
destruction of its sac, followed by an escape of blood. 
The immediate cause of such an occurrence is ulcera- 
tion, gangrene, or rupture, the effect of muscular exer- 
tion, violent cardiac impulse, or severe compression. 
It is thus that an aneurism, originally quite small, and 
distinctly circumscribed, may eventually become dif- 
fused and of enormous dimensions, the blood being 
more or less extensively infiltrated into the surrounding 
tissues, separating them from each other, and thus 
adding greatly to the patient’s suffering, as well as 
to his peril. This secondary occurrence usually takes 
place late in the advanced stage of the disease, from 
gradual weakening of the sac by the pressure of its 
contents, or by the pressure of the parts around, leading 
either to rupture or ulceration. Only a small quantity 
of blood may escape in the first instance, and, if it 
should coagulate very firmly, the clot so formed may, 
for a time, serve as an effectual barrier against further 
loss. Most generally, however, the effusion is great 
and rapid, and local suffering proportionately imminent. 
The newly extravasated blood is sometimes intermixed 
with fibrinous concretions, especially such as are of 
more recent formation and have not yet become firmly 
adherent to each other and to the sides of the sac. 
However this may be, it usually speedily coagulates, 
gradually increases in consistence, and ultimately, perhaps, even undergoes a certain 
degree ol organization, more particularly if the patient survives the accident for any con- 
siderable length of time. Meanwhile, the structures among which the blood has been 
extravasated become more or less indurated, inflamed, and infiltrated with serum, while 
the abnormal pouch itself is incrusted with plastic matter; an arrangement evidently 
designed to protect the sac, and to prevent it from breaking at once through its confines. 
Eventually, however, if life be not worn out by pain and irritation, the tumor is sure to 
give way by ulceration, gangrene, or rupture, followed more or less speedily by death. 
3. SYMPTOMS OF ANEURISM. 
The symptoms of aneurism exhibit, as might be supposed, much diversity, the principal 
circumstances which influence them being the nature, seat, and age of the tumor. Hence, 
in order to comprehend the subject thoroughly, it must be studied with special reference 
to these points. 
Fig. 322. 
Aneurism by Dilatation. The Abnormal 
Space is almost entirely tilled up by Fi- 
brin ; the Arterial Canal remaining clear. 
Spontaneous Cure exists in an advanced 
stage. CHAP. V. 
SYMPTOMS OF ANEURISM. 
699 
In spontaneous aneurism, usually dependent upon rupture of the coats of an artery, the 
patient is often apprised of the commencement of the disease by the occurrence of a sharp 
pain, not unlike that produced by an electrical shock ; he feels as if he had received a 
smart blow, and, perhaps, turns to see who inflicted it. Occasionally, also, he is con- 
scious of something having suddenly given way—he may even have heard a slight noise 
and on examining the part, a small, pulsating tumor is found. Upon being interro- 
gated as to the cause of the accident, he will usually state that it took place while he was 
engaged in some severe bodily exertion, as leaping, running, lifting, or coughing. But 
the origin of the disease is not generally thus marked ; in the majority of cases, in fact, 
the patient has no distinct perception of its occurrence, and he is only apprised of its 
existence by degrees ; not, perhaps, until it has already made serious progress. Such an 
event will be particularly apt to happen when the lesion consists essentially in a dilated 
condition ot the arterial tunics, unattended with rupture, as it is then often extremely 
stealthy in its mode ot invasion. In traumatic aneurism, on the contrary, the character- 
istic symptoms ordinarily show themselves immediately after the receipt of the injury of 
the vessel upon which the disease is situated. 
The aneurismal tumor is usually quite small at its commencement, not exceeding, per- 
haps, the volume of a filbert, a small hickory-nut, or an almond ; by degrees, however, it 
augments in size, and may ultimately acquire a bulk equal to that of a man’s fist, or even 
of an adult’s head. In its form it may be globular, elongated, ovoidal, conical, fusiform, 
or cylindrical; or so irregular as to defy description. However this may be, it is a living, 
beating tumor, rising and expanding synchronously with the contraction of the left ven- 
tricle of the heart. Its pulsations are often perceptible at the distance of a number of feet, 
especially in strong, plethoric subjects, and are always increased in force and frequency 
by whatever has a tendency to excite the general circulation. It imparts a distinct im- 
pulse to the hand, rising and falling as the blood enters and passes out; it is soft and 
elastic, and in its earlier stages permits itself to be emptied by steady and uniform pres- 
sure. Upon applying the ear to the tumor, a peculiar noise is perceived, differing very 
much in its character and intensity. In general, it is a kind of sawing, rasping, hissing, 
or bellows sound, so loud as to be heard with great distinctness at a distance of several 
inches ; occasionally it is of a peculiar whizzing, whirring, or purring nature, and cases 
occur, although they are rare, in which it strongly resembles the buzzing of a fly in a bottle. 
The immediate cause of the sound is the manner in which the blood rushes into the 
tumor; its pitch is always greatest, other things being equal, when there is a compara- 
tively small opening of communication, and when the sac, containing but little solid 
matter, is seated superficially. 
The phenomena now described are generally susceptible of great modification by pres- 
sure applied to the artery above and below the tumor. In the former case, the size of the 
swelling is notably diminished, and all motion and noise disappear; in the latter, it is 
sensibly augmented, the tumor heaves and rises under the resistance, and the blood, rush- 
ing violently against the inner surface of the sac, at each systole of the heart, produces 
great tumult, with a corresponding increase in the intensity of the different sounds. Con- 
siderable changes in the aneurismal sounds are sometimes occasioned by the rugose con- 
dition of the margins of the orifice of' communication, and by partially detached clots, or 
projecting filaments, within the sac, intercepting the column of blood, and causing various 
murmurs and vibrations, together with a tremulous shaking of the tumour, isochronous 
with its pulsations. 
The pain attendant upon aneurism is constant, but subject to variation in its intensity; 
slight early in the disease, and while the swelling is still small; more severe and harass- 
ing as it progresses and encroaches upon the surrounding parts. Diversified in its char- 
acter, it is generally dull, aching, and throbbing, as if matter were about to form ; in 
some cases it is sharp and darting, in others dull, heavy, or gnawing. Occasionally it is 
of a neuralgic nature, coming in fits and starts, or, as sometimes happens, in regular 
paroxysms, once or twice in the twenty-four hours. The immediate causes of the pain 
are, inflammation of the sac, and the pressure of the sac upon the neighboring structures; 
hence, as a general rule, it is always most violent in large and old aneurisms, and in those 
parts of the body which are most abundantly supplied with nerves, or where there is 
naturally a great deal of dense, firm, unyielding structure, interfering with the develop- 
ment of the tumor. 
For the same reason that the pressure of the tumor causes pain, the distal parts usually 
suffer from numbness, and a sense of aching and weariness. Their temperature is dimin- 
ished, and they are weak and crippled. Great swelling, of an oedematous character, is 700 
DISEASES AND INJURIES OF THE ARTERIES. 
chap. v. 
often present, the result, evidently, of the compression of the veins and lymphatics im- 
peding the return of their contents. As the tumor enlarges, the distal portion of the 
artery contracts, and conveys less of its wonted supply to the part below it. Gradually, 
however, this is compensated for by the collateral vessels, which, naturally existing, 
augment in size, and, in time, amply atone for the diminished stream in the main trunk. 
If it were not for this arrangement, the parts would soon shrivel and wither, or, worse, 
fall a prey to gangrene. Fortunately, such an event can only happen when the aneurism 
is of extraordinary bulk, or of very rapid development, thereby compressing also the col- 
lateral vessels and the principal nerves. 
Aneurism of the thoracic aorta, and of the innominate and carotid arteries, is nearly 
always attended with distressing dyspnoea, severe pain, and palpitation of the heart, which 
is itself often seriously implicated in the disease, being especially liable to suffer from 
hypertrophy, softening, and fatty degeneration, along with chronic endocarditis and dis- 
order of the tricuspid and semilunar valves. As the tumor enlarges, the respiratory 
difficulty rapidly increases, rendering walking painful, and the maintenance of the recum- 
bent posture ultimately impossible. Compression of the trachea may induce asphyxia; of 
the oesophagus, inanition. In the abdomen and pelvis, aneurism of the larger arteries, 
besides causing violent pain, may occasion serious functional disturbance, by interfering 
with the return of the blood in the vena cava, and thus leading to ascites and anasarca. 
4. DIAGNOSIS OF ANEURISM. 
Although the symptoms of aneurism are, in general, so well marked as to render it dif- 
ficult to mistake their import, yet, as the disease may be simulated by other affections, and 
as doubts may thus arise in the mind of the inquirer concerning its true nature, it is neces- 
sary, in every case, however well characterized it may apparently be, before he comes to 
a final decision, to institute a faithful examination into its history, progress, and existing 
condition. It has been for the want of proper care in the investigation of this disease that 
some of the most serious and disgraceful blunders that disfigure the records of surgery 
have been committed; and, although such errors are now less frequent than they were 
formerly, owing to the more general use of the exploring needle, and a better acquaint- 
ance with pathological anatomy, yet it cannot be denied that what has occurred once may 
happen again, and that with tenfold effect, as it respects the character of the surgeon, who, 
to his skill as an operator, is always supposed to unite that of an enlightened diagnos- 
tician. The affections with which aneurism is most liable to be confounded are, chronic 
abscesses and different kinds of tumors, especially the glandular and encephaloid sarcoma. 
Attention to the following circumstances cannot fail, if carefully considered, to protect the 
practitioner from error. 
I. Aneurism is always, from the first, seated in the direction of one of the larger arteries, 
whose course may often be distinctly traced by the finger; it is soft and elastic, pulsates 
more or less violently, is free from pain, and is unattended with discoloration of the integu- 
ment. Abscess, on the contrary, begins as a hard swelling, and becomes soft only after 
it has passed through its different stages ; if chronic, matter will form very slowly, and, 
although it may surround the artery, and thus receive its impulse, yet the peculiar fluctua- 
tion of the swelling, and the changes that may be induced in it by pressure and posture, 
will always suffice to prevent error. In acute abscess, there is severe pain, pus is poured 
out rapidly, and there is marked discoloration of the surface, with more or less constitu- 
tional disturbance. Glandular lymphatic swellings are most common in the neck, axilla, 
and groin in children and young persons of a strumous diathesis ; they generally advance 
pretty rapidly, and, after having attained a certain bulk, either remain stationary, or alter- 
nately advance and recede ; they are usually multiple, and not unfrequently occur simul- 
taneously on both sides of the body. External aneurism, on the contrary, is most common 
in the popliteal, femoral, innominate, and carotid arteries in middle-aged and elderly sub- 
jects, and, progressing slowly but steadily, never recedes, and rarely exists in more than 
one situation at the same time. Sarcomatous growths occur at all periods of life and in 
nearly all regions of the body; soon acquire a large bulk ; are of varying degrees of con- 
sistence, some parts being solid, some soft, and some semisolid; are attended with great 
enlargement of the subcutaneous veins; and soon give rise to a pale and sallow state of 
the features. Aneurism, as just stated, advances tardily, is of uniform consistence, espe- 
cially in its earlier stages, is not accompanied by any enlargement of the subcutaneous 
veins, and, although the general health may seriously suffer, there is an entire absence of 
carcinomatous impress. CHAP. V. 
DIAGNOSIS OF ANEURISM. 
701 
2. Aneurism pulsates the moment it is developed; no matter how small it may be, it 
throbs and heaves isochronously with the heart, and possesses all the characteristic traits 
that distinguish it in its later stages, although they are, perhaps, less strongly marked. 
Abscesses and solid tumors, on the contrary, are seldom affected by the beating of the 
underlying vessel until they have acquired some bulk, and even then the impulse is often 
very faint, occurring rather as an undulatory movement than as a distinct shock. 
3. In aneurism the tumor is generally firmly fixed, any attempt to grasp and lift it up 
proving abortive; possibly, it may be pushed gently to one side or the other, but this is 
all. Moreover, whatever changes may be effected in its relations, none can be effected in 
its pulsations ; it throbs and heaves as before. With solid growths this is not so ; unless 
very large, they can readily be isolated from the vessel, and be thus deprived of all impulse, 
however strong. 
4. The pulsation in aneurism is generally uniform, being perceived equally at every 
point of the circumference of the tumor, which rises and falls synchronously with the 
systole and diastole of the heart; in abscesses and solid growths, on the other hand, it is 
very irregular, and is usually limited to some particular spot. In aneurism the swelling 
bounds and recedes under the hand; it feels as if it were alive and panting; in solid 
tumors the morbid mass rises at each impulse, but there are no expansion and contraction. 
5. When an aneurism is firmly and uniformly compressed, it sensibly diminishes in bulk, 
which, however, recovers itself the moment the hand is removed ; in solid growths and 
abscesses, px*essure produces no such effect. 
6. In aneurism, the size of the swelling is diminished by pressure upon the cardiac side 
of the tumor, and increased by pressure upon the distal side. In morbid structures not 
arterial, no change of bulk follows this procedure. 
7. The sounds of aneurism are different from those of solid tumors. Both may yield a 
sawing, bellows, or rasping noise, but in the latter this is never conjoined with the pecu- 
liar thrill, or whirring noise, which constitutes so prominent a symptom in the former. 
8. Aneurism of the larger arteries ordinarily affords two alternate shocks, one of which 
corresponds with the diastole of the heart, the other with its systole. These phenomena 
are never present in solid tumors and abscesses, and are therefore pathognomonic. 
When, as is sometimes, though very rarely, the case, an aneurism opens into an abscess, 
the ordinary phenomena, as pulsation, bruit, and thrill, are suddenly superadded to those 
of the latter disease, with great increase in the volume of the tumor, and more or less 
marked expansion of its walls. Such an occurrence is most common in the neck, axilla, 
groin, and ham, in consequence of chronic suppuration, and demands special vigilance 
for its successful discrimination. 
An aneurism has occasionally been mistaken for rheumatism, and, conversely, rheu- 
matism for aneurism. I have known the pain and swelling caused by an aneurism of the 
popliteal artery to be treated for rheumatism of the knee-joint ; and a number of instances 
have fallen under my observation in which the pulsation and expansion that are so liable 
to accompany neuralgia of the abdominal aorta and of the innominate and carotid arteries 
were supposed to have been occasioned by aneurism of those vessels. Finally, aneurism 
may be simulated by anemia, especially when it occurs in conjunction with neuralgia, or 
neuralgia and rheumatism, in a person of broken-down constitution. Errors of diagnosis, 
under such circumstances, are generally easily avoided by a thorough examination of the 
part affected, and by a careful consideration of the history of the case. 
Such are the distinguishing characters of aneurism and of the more important diseases 
with which it is liable to be confounded. It must be obvious, from what has been said 
respecting them, that mistakes can only be avoided by the most rigid and thorough exami- 
nation, made not once, but repeatedly, in every case of tumor situated along the course 
of an artery and influenced by its pulsation. When, after such a painstaking process, no 
satisfactory decision can be arrived at, the only resource is the insertion of a delicate 
exploring needle, which, while it can do no possible harm, if it be properly employed, 
will at once determine the diagnosis. 
Serious, and sometimes even fatal, accidents occur during the examination of an aneu- 
rismal tumor, either from a detachment of some of its clots, causing embolism, or from a 
rupture of the sac, followed by destructive hemorrhage. In a case of aneurism of the 
common carotid artery, the size of a hen’s egg, reported by Esmarch, firm pressure upon 
the tumor suddenly produced symptoms of apoplexy, of which the patient died in three 
days; and in a similar case, recorded by Mr. T. P. Teale, of Leeds, hemiplegia was 
suddenly induced, ending in death in a few weeks. In both of these instances the trouble 702 
DISEASES AND INJURIES OF THE ARTERIES. 
CHAP. V. 
was no doubt occasioned by obstruction of some of the cerebral arteries, by small clots 
finding their way into the brain. Dr. Bontecou, of Troy, several years ago, tied the 
external iliac artery in a case of inguinal aneurism, ruptured by the manipulations of a 
professional rubber, employed to relieve pain. The rude handling of an aneurism some- 
times gives rise to violent inflammation of its sac, followed by gangrene and death. Facts 
like these should teach the surgeon the importance of great caution in his attempts at 
arriving at a correct diagnosis in tumors situated in or involving arteries, especially those 
of the neck, ham, and the abdomen. 
5. EFFECTS AND TERMINATION. 
The effects which an aneurism exerts upon the surrounding parts vary according to 
circumstances, of which the most important are, the situation of the affected vessel, and 
the size of the tumor. An aneurism of the arch of the aorta produces, other things being 
equal, more serious disturbance, both organic and functional, than one of the abdominal 
portion of that vessel, and an aneurism of the carotid artery than one of the popliteal. 
It is obvious also that a small tumor will, as a general rule, cause less serious effects than 
a large one. 
The effects which such a disease produces upon the parts with which it is in contact 
are purely of a mechanical character, eventuating in their displacement, compression, or 
ulceration, or in all these occurrences combined. An aneurism of the thoracic portion of 
the aorta must necessarily encroach more or less upon the contents of the chest, pushing 
the heart and lungs out of their natural position, and thereby interfering essentially with 
the performance of their proper functions. In aneurism of the carotid artery there will 
be displacement of the trachea, oesophagus, and the great vessels of the neck, along with 
compression of these parts, and also of the pneumogastric and sympathetic nerves. In 
popliteal aneurism the portion of the limb below the site of the tumor generally suffers 
from obstructed circulation, as is evinced by the occurrence of anasarca and decrease of 
temperature, with a feeling of numbness, the result of interruption of the nervous current. 
When the embarrassment to the flow of blood is very great, or long continued, mortifi- 
cation of the distal portion of the limb is liable to ensue. 
When the tumor is situated externally, it may produce serious changes in the muscles, 
which, in many cases, are not only widely separated from each other, but remarkably pale, 
flattened, and attenuated, exhibiting more the appearance of thin ribbons than of thick, 
solid, fleshy bodies. The nerves, too, are often very much spread out, the vessels are 
thrust aside, and the aponeuroses are stretched out like tense sheets. When pressing 
upon an important joint, the tumor is sure to impede its motion, and may even cause 
permanent ankylosis, as occasionally happens in aneurism of the popliteal artery. 
The effect produced by aneurism upon the osseous tissue is sometimes very remarkable. 
It is generally most conspicuous in the dorsal portion of the spine. When the disease 
involves the thoracic aorta, the tumor, crowded into 
a comparatively small space, is liable, especially 
when it is of large bulk, to encroach seriously upon 
the bony walls of the chest, pressing upon and erod- 
ing the bodies of the vertebras behind, as seen in fig. 
323, the sternum in front, the ribs at the side, and 
the clavicle above. There is no osteological cabinet, 
of any extent, that does not contain specimens of 
this kind. I have seen cases where as many as four 
of the bodies of the dorsal vertebrae were completely 
absorbed as far as the spinal canal, which, forming 
the posterior boundary of the tumor, was thus freely 
exposed to its pulsations. The sternum suffers 
mostly at its lateral and upper aspect, but occasion- 
ally, as in an instance now under my care, it is per- 
forated at the centre, the movements of the aneurism 
being distinctly visible at that part. The ribs and 
. < their cartilages do not generally participate to any 
considerable extent in the erosion, and the clavicles are rarely affected, unless the tumor 
is of great bulk, and projects unusually high up into the neck. 
It is not surprising, after what has been said respecting the effects which aneurism is 
Fig. 323. 
Erosion of the Vertebra from Aneurism. CHAP. V. 
SPONTANEOUS CURE OF ANEURISM. 
703 
capable of exerting upon the osseous tissue, that the tumor should occasionally cause 
serious lesion in the soft structures, apart from their mere compression. In its earlier 
stages, before the swelling has attained any considerable bulk, the inroads are slight, and, 
consequently, well borne, the parts manifesting no disposition to resent its encroachments; 
by and by, however, as-it progresses, its pressure bears heavily upon the adjacent textures, 
which, taking on inflammatory action, become matted together by interstitial deposits, 
which, for a time, thus materially strengthen the aneurismal sac. But such a state of 
things is not destined to last long; gradually the morbid action increases, the superin- 
cumbent tissues are more and more expanded, and, at length, ulceration setting in, the 
integument yields over the more prominent portion of the sac, followed by destructive 
hemorrhage. 
6. SPONTANEOUS CURE. 
Unfavorable as the prognosis of aneurism generally is, it is gratifying to know that a 
cure is occasionally effected spontaneously, without the intervention of art in any way. 
That such an event is rare, forming merely an exception to the great law, is unfortunately 
too true; yet it sometimes occurs under circumstances, apparently, the most desperate, 
bidding defiance alike to medical and surgical skill. There are, indeed, few practitioners 
of enlarged experience who have not met with cases of this disease in which, contrary to 
all calculations of the doctrine of chance, the patient made an excellent recovery, after 
having literally hovered, for days and weeks, over the very verge of the grave; where, 
in short, everything portended speedy destruction, and yet every vestige of the aneurism 
ultimately disappeared, the person living for years afterwards in the enjoyment of good 
health, and in the exercise of his former occupation. IIow the cure is effected in these 
cases our information does not enable us to explain, as an opportunity is seldom afforded 
of making a dissection of the body after the event has taken place, in consequence of the 
individual being usually lost sight of. A knowledge, however, of the possibility of such 
a cure is highly encouraging, and holds out the hope that it may be of more frequent 
occurrence than has hitherto been imagined. 
The most remarkable case of the spontaneous cure of this disease that I have ever seen, 
was that of a gentleman sixty-two years of age, whom I attended in January, 1862, along 
with Dr. E. L. Carter. The tumor, which had come on about twelve months previously 
without any assignable cause, presented all the characteristic features of an aneurism of 
the left subclavian artery. It occupied the whole of the triangular space above the clavicle, 
between the trapezius and sterno-cleido-mastoid muscles, where it formed a large promi- 
nence, heaving and pulsating synchronously with the contraction of the left ventricle of 
the heart, and imparting a peculiar blowing or sawing sound to the ear. The patient 
experienced excessive pain in the tumor, as well as in the shoulder and arm; there was 
great numbness of the whole extremity, and he was obliged to be constantly propped up 
in bed, as well as to use anodynes freely to enable him to sleep. The prognosis, in fact, 
could not have been more unpromising. Early in May, however, he was able to take 
gentle exercise in the open air ; his health now gradually improved, and the tumor began 
to diminish in size, the process of absorption steadily progressing until December, 1863, 
when every trace of it had disappeared. The left arm and hand remained cold and 
atrophied, but in all other respects the recovery was perfect. The treatment consisted 
principally of the internal use of iron and quinine, along with a properly regulated nutri- 
tious diet. 
Although we are not always able to account for the manner in which the patient re- 
covers in this disease, observation has demonstrated that it generally occurs in one of five 
ways, all leading, essentially, to the same result, namely, the formation of clots, by 
which not only the aneurismal sac is closed up, but also the artery immediately above 
and below it. When the cure is gradual, the clots are usually arranged concentrically, 
and exhibit every mark of organization ; but the reverse is the case when it is effected 
suddenly, for then they are nothing but soft, red blood-masses, similar to what are so 
often observable after death in the heart and large vessels. 
1. The most common way in which the cure takes place is by the gradual filling up 
of the sac by the formation of clots, thereby ultimately converting it into a firm, solid 
tumor. The most beautiful and perfect specimen of this kind, sketched in fig. 324, that 
I have ever seen, was presented to me by an old pupil, Dr. Shumard, who had removed 
it from the body of a young steer. What renders it still more interesting is the circum- 
stance that it was connected with the hepatic artery, which had given way at one side 
from the rupture, apparently, of its inner and middle tunics. The tumor, which is of a 704 
DISEASES AND INJURIES OF THE ARTERIES. 
CHAP. V. 
rounded shape, and nearly three inches in diameter, is occupied by hundreds of lamellae, 
many of them not thicker than a sheet of paper, of a pale grayish color, closely adherent 
J to each other, concentrically arranged, 
of a dense, firm texture, and, beyond 
question, thoroughly organized, even 
those most recently deposited. At the 
centre of the tumor, a large irregular 
cavity exists, which still admitted some 
blood, as is proved by the fact that the 
hepatic artery is completely pervious. 
Such a mode of repair is greatly facilitated 
by the small size of the opening of com- 
munication between the artery and the 
aneurismal sac. 
2. Another mode of spontaneous cure 
is the occurrence of inflammation, fol- 
lowed by the coagulation of the contents 
of the sac, and the ultimate obliteration 
of its cavity as well as of the artery in 
its immediate vicinity. The disease may 
begin in the tumor itself, or be propagated to it from the circumjacent structures; if it is 
mild and slow, the cure may be easy and safe, but if very active, it may terminate in 
suppuration, and thus endanger life by hemorrhage, the matter being evacuated along 
with the clots before the artery is hermetically sealed by an internal coagulum. 
3. The repair occasionally occurs through gangrene, either beginning in the tumor 
itself, or extending to it from the parts immediately around it. The blood coagulates in 
the sac as in an artery in ordinary gangrene, and when the sloughs separate the clots are 
discharged, the gap being afterwards closed by the granulating process. Such a mode of 
restoration must necessarily be infrequent, inasmuch as the morbid action by which it is 
effected generally terminates fatally. 
4. The contents of an aneurism are sometimes solidified by the compression of the artery 
leading to it, caused either by the tumor itself or by some morbid growth in its immediate 
vicinity. Such a result may follow with nearly equal certainty, whether the pressure is 
apjdied to the cardiac or to the distal portion of the vessel. 
5. Finally, there is a very rare mode of spontaneous obliteration, consisting in the 
detachment of a small clot and of its introduction into the distal portion of the artery, 
thereby more or less completely blocking it up. The blood, thus checked in its onward 
flow soon coagulates, just as in artificial compression. It was upon a knowledge of this 
species of spontaneous cure that the late Sir William Fergusson, many years ago, 
attempted to found a new mode of treatment of aneurism by breaking up the contents of 
the tumor by manipulation, and urging on some of the fragments into the distal commu- 
nicating vessel. 
When, by any of the above modes, a radical cure is effected, the tumor is gradually 
brought under the influence of the absorbent vessels, and is ultimately completely oblite- 
rated ; or, at all events, so far reduced as to leave only a small nodule, indicative of the 
former site of the disease. The period required for the perfection of these changes varies 
from three or four weeks to as many'months, according to the size of the aneurism and 
the state of the part and system. 
Although an aneurism may occasionally get well spontaneously, or under internal treat- 
ment, such an event is entirely exceptional. The great law of the disease is death. The 
period at, and the mode in, which this takes place are extremely variable, and can, there- 
fore, be pointed out only in a general manner. In aneurism of the aorta, especially in 
the arch of this vessel, the disease often terminates in less than three months from its 
commencement; in the innominate its course is generally also rather rapid, and a similar 
remark applies to aneurism of the primitive iliac; in aneurism, on the contrary, of the 
carotid, subclavian, axillary, external iliac, femoral, and popliteal arteries, the fatal event 
is often postponed several months longer. To these statements they are, of course, many 
exceptions; thus, on the one hand, we occasionally meet with an aneurism that kills in a 
few weeks, the tumor expanding rapidly, and, perhaps, bursting quite suddenly during a 
violent muscular effort; and, on the other, the disease may continue, with very little 
variation, as to size, for a number of years. 
There are three distinct modes in which aneurism may cause death : 1. By the injuri- 
Fig. 324. 
An Aneurismal Tumor obliterated by the Deposition and 
Organization of Fibrin. chap. v. 
SPONTANEOUS CURE. 
705 
ous compression which the tumor exerts upon the neighboring organs. 2. By the sudden 
mpture of the sac, and the occurrence of hemorrhage. 3. By the development of inflam- 
mation, suppuration, or mortification. 
1. Aneurismal tumors of the neck and chest often cause death by compression of the 
trachea and bronchial tubes, although perhaps not so frequently as has generally been sup- 
posed, owing to the wonderful power which these tubes possess of flattening themselves so as 
to make room for the entrance of air into the lungs. Indeed, I am inclined to think that 
death from direct suffocation, from this cause, is an uncommon event. Great difficulty is 
often produced by the pressure of the sac upon the pneumogastric and phrenic nerves, and it 
is extremely probable that life is sometimes destroyed in this way, the more especially when 
the pressure is conjoined with serious lesion of the air-passages. Finally, death occasion- 
ally proceeds from compression of the heart and lungs, interfering with the circulation 
and respiration; or from compression of the oesophagus, causing inanition. In the ab- 
dominal and pelvic cavities, and also in the extremities, the danger from compression is 
not nearly so great, as the structures here are less important to life, as well as more dis- 
posed to yield under the encroachment of the tumor. 
2. After an aneurismal tumor has attained a certain bulk, it is extremely apt to give 
way, as in fig. 325, either suddenly or gradually, under the impulse of the blood, or 
under severe muscular exertion. Such an occurrence will be 
the more likely to happen when the tumor has been of rapid 
growth, and especially if its interior has not been fortified by 
the formation of hard, organized clots, so as to increase the 
thickness and strength of its tunics. It is in this manner that 
most of the internal aneurisms, which do not cause destruction 
by mere compression, ultimately terminate, the immediate cause 
of death being hemorrhage into some internal and contiguous 
organ. Thus, in the chest the tumor usually opens into the 
trachea, bronchial tubes, pleura, pericardium, mediastinum, or 
oesophagus. Sometimes a communication is established between 
the sac and the heart, between it and the pulmonary artery, or 
lastly, between it and the vena cava. An aortic aneurism has 
also been known to burst into the spinal canal, some of the bodies 
of the vertebra? having previously been destroyed by absorption. 
In the abdomen, the tumor may break into the peritoneal 
cavity, or into one of the hollow viscera, as the stomach, intes- 
tine, or urinary bladder. In the neck, axilla, groin, and ex- 
tremities, an aneurism, if permitted to pursue its course, gen- 
erally finds its way to the surface, very much after the manner 
of an abscess. 
The hemorrhage succeeding to the rupture of an aneurism 
may be slight, as when the aperture is small or devious, or 
copious and destructive, as when the opening is large or straight. 
Most commonly, life is worn out by the frequent recurrence of 
the bleeding; thus, twenty ounces of blood may be lost to day, 
in a week twenty or thirty ounces more, and so on until the 
patient dies completely exhausted, his condition being, in the mean time, perhaps sadly 
aggravated by serous effusions into some important cavity. Occasionally the aneurism 
gives way by a large rent, and the patient expires instantly from hemorrhage. On 
the other hand, the sac may give way, and yet there may be no hemorrhage, the 
patient finally perishing from some other cause. Thus, in the case of Mr. Liston, the 
opening which had formed between the aneurism and the trachea was clogged up with 
a mass of coagulum, which effectually prevented the escape of blood, death finally re- 
sulting from the irritation produced by the pressure of the tumor upon the inferior laryn- 
geal nerve. 
3. More or less inflammation attends all aneurisms; whatever may be their volume, 
situation, age, or character, they play the part of intruders, encroaching upon, compress- 
ing, and irritating the surrounding structures, and thus giving rise to various deposits, 
especially of serum and plasma. It is by means of the latter that, as was previously 
stated, the sac increases in thickness and density, «o as to qualify it the better to bear 
with impunity the impulse of the inflowing current of blood ; without such an occurrence 
few tumors of this kind would be able to maintain themselves for any length of time, 
but would soon yield to the resistless pressure from within ; in a word, speedy rupture of 
Fig. 325. 
Aneurism of the descending’ 
Aorta, burst, the Patient dying 
suddenly in consequence. 706 
DISEASES AND INJURIES OF THE ARTERIES. 
CHAP. V. 
the sac, and fatal hemorrhage, would, in most cases, be inevitable. Hut, although inflam- 
mation is set up for wise and beneficial purposes, the process, unfoi tunately, is not always 
kept within the strict limits required to fortify the sac and protect it against early rup- 
ture ; on the contrary, many circumstances concur to provoke its increase, and to cause it 
to pass into ulceration, suppuration, or even mortification. Among these circumstances 
some are of a constitutional, others of a purely local, character; thus, mere plethora and 
the use of stimulating food and drink may powerfully augment the inflammation, and 
bring about these untoward results. In general, however, it will be found that the 
mechanical compression of the tumor, in consequence of the resistance offered to its 
extension, has more to do with its production than anything else. Sometimes a clot 
is accidentally detached, and thus becomes a cause of mischief. In external aneurism, 
the manipulation employed in examining the tumor is occasionally productive of severe 
inflammation, and similar effects often follow' the injudicious use of the affected limb. 
Suppuration of the tumor is an infrequent event. A case occurred in 1857, at the 
Pennsylvania Hospital, in the service of Dr. Pepper, in which an abscess had formed in 
connection with an aneurism of the innominate artery, and destroyed the patient, a man 
aged thirty-eight, by bursting into the trachea. A report, with a drawing of the case, 
has been published by Dr. Humphreys, in the Transactions of the Pathological Society of 
Philadelphia. Ulceration and mortification are more common, and are particularly liable 
to take place when the tumor is of large size. 
Finally, aneurism may prove fatal by exciting inflammation in an important internal 
organ, as the lung, heart, or pleura. In popliteal aneurism, the pressure of the tumor 
upon the nerves and arteries below sometimes causes death from mortification of the leg 
and foot. 
TREATMENT. 
In the time of Celsus, as well as for a long period subsequently, the treatment of ex- 
ternal aneurism was conducted in the most cruel and unscientific manner. The only 
operation which appears to have been know n was that of laying open the tumor by a bold 
incision, and, after turning out its contents, applying the hot iron to the extremities of 
the affected artery, so as to seal up their mouths. The effect of such a procedure may 
easily be imagined; upon the separation of the eschar, hemorrhage was sure to take 
place, and in this way nearly every patient perished, either at the first onset of the 
bleeding, or by its frequent repetition. This miserable practice continued in vogue until 
the time of Antyllus, in the third century, who adopted a more scientific, although hardly 
a less hazardous, procedure. It consisted in freely opening the tumor, clearing out its 
contents, and tying the artery above and below, the ends of the vessel having previously 
been searched for with a probe. The sac wras then stuffed with charpie, to promote sup- 
puration and occlusion, the object being to heal the wound from the bottom. Occasionally 
the more adventurous surgeon took the more speedy route of extirpating the tumor, 
adopting a plan similar to that which is sometimes pursued at the present day in treating 
aneurism at the bend of the arm consequent upon venesection and other injuries. The 
result, too, of this operation was often most disastrous ; many of the patients died 
of the effects of inflammation, some of secondary hemorrhage, and not a few of the 
shock of the amputation performed, as a dernier resort, to save them from impending 
destruction. To prevent these sad occurrences, and afford the sufferer a better chance of 
recovery, the removal of the limb was often only expedient thought of for his relief. 
The operation of Antyllus has been repeatedly performed for traumatic aneurism at 
the bend of the arm. Morel, of Paris, performed it in a case of carotid aneurism in the 
seventeenth century; Keyslere, in 1744, performed it in a case of popliteal aneurism, 
and Sabatier, not long aftenvards, in a case of femoral aneurism. Mr. Syme, of Edin- 
burgh, employed it successfully in aneurism of the common carotid, axillary, and internal 
iliac arteries, his first case having occurred in 1857. Several other surgeons have been 
equally daring. 
a. DELIGATION OF THE ARTERY AT THE CARDIAC SIDE OF THE TUMOR. 
It is very surprising that some of the procedures above described should have con- 
tinued in vogue until near the close of the last century. The fact attests, more fully 
than any other circumstance with which we are acquainted, the low state of surgery up 
to that period. . Tim merit of performing the first operation for the cure of aneurism 
upon strictly scientific principles is due to John Hunter. From having witnessed so CHAP. V. 
ANEURISM — TREATMENT. 
707 
many failures from the ordinary methods, he was led to the conclusion that the cause 
consisted in the fact that the artery is always diseased for some distance above the aneu- 
rism, and that it was, therefore, incapable of becoming sufficiently occluded prior to the 
detachment of the ligature to prevent hemorrhage. Acting under this conviction, amply 
confirmed by dissection and observation, he determined, upon the first favorable oppor- 
tunity, to apply the ligature to a sound portion of the vessel. While thus revolving the 
matter in his mind, a man, laboring under popliteal aneurism, was admitted into St. 
George’s Hospital, of which he was then one of the surgeons. The patient was a coach- 
man, forty-five years of age; and the tumor, first perceived three years previously, was 
not only quite large, but attended with great swelling of the foot and leg. The operation 
was executed in December, 1785, the femoral artery being exposed a little below its 
middle, and surrounded by four ligatures drawn so gently as simply to bring the sides of 
the vessel together. “The reason for having four ligatures was,” as is stated by Sir 
Everard Home, by whom the case was reported, “ to compress such a length of artery as 
might make up for the want of tightness, it being wished to avoid great pressure on the 
vessel at any one part. The ends of the ligature were carried directly out of the wound, 
the sides of which were now brought together and supported by sticking-plaster and a 
linen roller, that they might unite by the first intention.” 
It is unnecessary to enter into any details respecting the after-treatment of the case. It 
will be sufficient for my purpose to state that on the second day after the operation the 
tumor had lost more than one-third of its original bulk; that the ligatures, some of which 
came away on the fifteenth day, excited severe inflammation in the artery, as well as in 
the surrounding parts; and that the man left the hospital on the 8th of July following, in 
good health, and with no appearance of any tumor in the ham. He subsequently resumed 
his former occupation as coachman, and died from an attack of remittent fever, fifteen 
months after the operation. The limb being dissected, the femoral artery was found to be 
impervious as high up as the profunda, while below the site of the ligatures, as far down 
as the tumor, it was open, and contained blood, except just where it entered the aneurism, 
where it was obliterated. The sac was a little larger than a hen’s egg, but more oblong 
and flattened, and contained a solid coagulum adherent to its internal surface. 
I have been induced to give a brief outline of this case for two reasons. In the first 
place, it deserves to be commemorated because it embodies the application of a new prin- 
ciple to the cure of a disease which, until then, was almost uniformly fatal; and, secondly, 
because it will enable us to establish, in a more satisfactory manner than we could other- 
wise do, the claims of Mr. Hunter to the credit of having originated the operation, which 
has been so sturdily denied him by the French surgeons, who have, almost with general 
consent, ascribed it to their countryman, Dominic Anel. 
The case of Anel, which occurred at Rome in 1710, was that of a priest, who, from a 
prick of the brachial artery received in venesection, had an aneurism at the bend of the 
arm ; the tumor was large, and apparently on the point of bursting. Having controlled 
the circulation in the limb by means of the tourniquet, he cut cautiously down upon the 
artery, and, after separating it from the accompanying nerve, raised it upon a hook, and 
tied it as near to the tumor as possible. All pulsation instantly ceased, the ligature came 
away on the eighteenth day, and at the end of a month the friar was able to use his arm 
as well as ever. 
It will thus be perceived that the operations of the English and French surgeons dif- 
fered from each other in evei'y particular; and it is only surprising that there ever should 
have existed any contrariety of opinion respecting them. I he procedure of Anel was 
executed for the cure of a traumatic aneurism; the artery was perfectly healthy, and it 
was tied as closely to the tumor as possible. He never supposed that he was about to 
establish a new principle in surgery ; he nowhere alludes to any such intention ; his only 
object seems to have been to afford his patient, who was suffering great agony, and who 
might bleed to death at any moment from the sudden bursting of his tumor, piompt relief. 
Hunter, on the contrary, had studied the subject with extraordinary care and attention ; 
he had made numerous dissections, and even performed some experiments upon the infer ioi 
animals, as the dog and horse, with a view of ascertaining the condition of the aiteiy in 
aneurism, and its ability to bear the ligature; and he had clearly perceived that, as the 
cause of failure of the old operation was that the ligation was always made too near to the 
tumor, the only safety would be to tie a sound portion of the vessel, even although this 
should be at a very considerable distance from the aneurism. Ilis object was not to cut 
off the supply of blood at once, but simply to weaken its passage through the tumor, 
thereby giving its contents an opportunity of undergoing gradual coagulation, and at 708 
DISEASES AND INJURIES OF THE ARTERIES. 
chap. v. 
the same time preventing the distal parts of the limb from perishing from the sudden 
stoppage of the circulation. The result of the case above detailed proved the correctness 
of his Reasoning, and established, upon a firm and immutable basis, what is now uni- 
versally recognized in Great Britain and in this country as the Hunterian operation for 
aneurism. 
The operation of Hunter has been performed upon almost every artery of the body 
liable to suffer from aneurism. Even the aorta itself has repeatedly been tied ; and, 
although all the cases have proved fatal, yet the result has been such as to show, most con- 
clusively, that the event has been due much more to the injury inflicted upon the surround- 
ing structures than to the violence done to the circulation by cutting off so great a quan- 
tity of blood from its accustomed channels. Remarkable simplicity now characterizes the 
operation ; a healthy portion of artery is selected, great care is taken, in exposing the ves- 
sel, to disturb its sheath as little as possible, and only one ligature is used, but that is 
drawn so tightly as to divide the inner and middle tunics, when, a double knot being 
made, one extremity is cut off, and the other is brought out at the nearest point of the 
wound, which is then treated in the ordinary manner. In separating the artery from its 
accompanying vein or veins, the greatest possible care must be taken not to inflict any 
injury upon these vessels, as this would not only embarrass the operator, but might lead 
to severe phlebitis, and even mortification, especially in aneurism of the lower extremity. 
The procedure may generally be materially expedited and its safety insured by the cau- 
tious use of the grooved director, aided by dissecting forceps and the finger-nail. 
Cessation of pulsation usually occurs at once upon tightening the ligature, although not 
necessarily so; sometimes, indeed, several days elapse before it is fully established, but 
even then it is commonly very much diminished in force, thus paving the way for the 
gradual formation of clots upon which the cure ultimately depends. The persistence of 
the circulation, after the main artery of a limb has been ligated, arises from the anasto- 
mosing branches continuing to pour their contents into that portion of the vessel which 
lies between the cord and the sac, as well as into the sac itself, and, perhaps, also into the 
distal portion of the artery. When these branches are inordinately large, or numerous, 
they may keep up such a supply of blood as to compromise effectually the success of the 
operation. 
More or less pain usually attends the tightening of the ligature round the artery, if the 
patient is not under the inlluence of an anaesthetic. It is occasionally very severe; and 
cases occur, as when a nervous filament is included in the cord, in which there is a sense 
of tingling and of numbness. 
The operation is generally followed by a slight diminution of temperature in the limb, 
but this rarely lasts beyond a few hours, when it is succeeded by a marked increase of 
heat, owing to the augmented activity of the cutaneous circulation, in consequence of the 
blood being forced principally through the superficial capillaries. Subsequently, howTever, 
as the anastomotic branches enlarge, and the circulation becomes equalized, the tempera- 
ture sinks again, and now, perhaps, somewhat below the normal standard, the parts really 
feeling, for the first time, the loss of blood occasioned by the ligation of the artery. In 
not a few cases the limb retains its temperature after the operation with hardly any varia- 
tion, as if nothing at all had happened. 
Instead of using the ordinary silk ligature, Dr. Stone, of New Orleans, in 1859, in a 
case of aneurism, tied the common iliac artery w'ith a silver wire, simply approximating 
the sides of the vessel, and leaving the wire in the w'ound, convinced of its entire lmrm- 
lessness. I he patient died on the twenty-sixth day, but, as no autopsy was made, the 
disposition of the ligature was not ascertained. At the Clinic of the Jefferson Medical 
College, in 1861, I secured, in a similar manner, the femoral artery in a case of popliteal 
aneurism; the patient rapidly recovered without any untoward symptom, and the wire 
still remains in the thigh, nearly the entire wound having healed by the first intention. 
Since that period I have operated, equally successfully, with the metallic ligature upon 
four other cases, the last of which concerned the external iliac. Dr. Bozeman, of New 
Tork, in 1867, tied the common carotid with the silver wTire, and other vessels have been 
thus secured by other surgeons. 
Experiments made upon the lowrer animals, on the ligation of arteries with silver wire, 
by Dr. B. F. Howard, of New Tork, fully substantiate the results obtained from its em- 
ployment in the human subject. He has shown that when the wire is drawn tightly, it 
causes not only death of the portion of the artery embraced by it, as after ligation with a 
silk thread, but that the loop is cast off, and is either discharged at the surface, or becomes chap. v. 
ANEURISM —TREATMENT. 
709 
encysted at some distance from the point of application. He, therefore, concludes that 
silver wire is not an innocuous material if the internal and middle coats of the artery are 
severed, but that, when applied so loosely as merely to obstruct the flow of blood through 
the vessel, it remains permanently at the point where it is placed, thereby greatly dimin- 
ishing the risks of secondary hemorrhage. 
In ligating an artery in its continuity for the cure of aneurism, the greatest possible 
care must be taken not to wound the accompanying veins, as such an accident inevitably 
endangers the issue ot the case by provoking a bad form of phlebitis, from the effects of 
which tew persons recover. The ligature, passed through the vessel, embraces a portion 
alonS Wlth the artery, and, consequently, acts precisely as a seton, causing 
diffusive inflammation not only in the vein itself, but also in the surrounding structures! 
lhe risk will be particularly great when an artery is tied close to the aneurism, as, during 
the progress of this disease, the inflammation of the sac not unfrequently extends along 
the connective tissue which connects the two vessels, thus rendering them specially intol! 
erant of interference. When such an accident happens, the ligature must at once be 
withdrawn, and repassed with more care, either at the same point or a short distance 
above or below, lhe bleeding is not always easily arrested by compression. 
However executed, the operation should never, if possible, be undertaken without some 
preliminary treatment. For a week or so previously, perfect rest both of the part and 
system should be enjoined, the diet should be carefully regulated, and proper attention 
should be bestowed upon the bowels and secretions. If there be any doubt in regard to 
the establishment of the collateral circulation, this desirable object should be promoted 
by compressing, for a few hours daily, the main artery of the limb. Mr. Charles H. 
*1 odd, of Dublin, in a paper on aneurism published in 1822, strongly insisted upon this 
mode of treatment, and expressed his conviction that, when neglected, the operation must 
often be followed by mortification and other bad consequences from the want of a due 
supply of blood in the distal portion of the limb after the application of the ligature. 
Compression, under such circumstances, would have the additional effect of favoring the 
solidification of the contents of the sac. 
Mr. Syme suggested that, in aneurism of the carotid, axillary, gluteal, and iliac arte- 
ries, in which the Hunterian operation is not admissible, the sac should be freely 
opened, and, after evacuating its contents, the artery should be sought for, and tied above 
and below. In several instances in which he adopted this procedure, his efforts were 
crowned with complete success. The last case to which he applied it was one of aneurism 
of the external iliac, in which, after ripping open the sac to the extent of six inches, 
and turning out six pounds of blood and fibrin, he secured not only this vessel but also 
the common and internal iliac arteries, and had the satisfaction of saving his patient. 
\ ery little suppuration took place. Such operations are replete with interest, as showing 
the skill and daring of the surgeon, and the astonishing powers of endurance of the sys- 
tem, but are hardly to be held up as examples for general imitation. 
Two grave objections may be urged against the adoption of this procedure. In the 
first place, the artery in the immediate vicinity of the aneurism is often so much diseased 
as to render it incapable of sustaining the slightest pressure of the ligature; and, secondly, 
it is frequently no easy matter to expose the vessel, owing to the manner in which it is 
overlapped by the expanded sac. Moreover, the sac, especially when of large size, is 
often fed by a number of arteries, the bleeding of which it would be extremely difficult 
to control by any mode of management that can be devised. The plan, however, should 
not, on these accounts, be entirely rejected, for it is easy to perceive that circumstances 
might arise where it would afford the only chance of safety. Many years ago, I operated 
upon a case of aneurism of subclavian artery, where, nearly one month after the ligation 
of the vessel, the sac burst into the chest and occasioned fatal pleurisy. If such an 
event could have been foreseen, the opening of the sac, and the evacuation of its contents, 
might have saved the patient’s life. 
In tying deep-seated arteries, especially those at the root of the neck, great advantage 
may often be derived from throwing reflected light, with the mirror of an ophthalmo- 
scope, into the recesses of the wound. No operation of this kind should be performed on 
a cloudy day; and, after the division of the integument and muscles, the knife should be 
used as little as possible. 
After-treatment The treatment after the Hunterian operation must be conducted with 
great judgment and attention. The patient being carried to bed, the limb is placed in an 
easy and relaxed position, but not elevated, lest arterial influx be interfered with ; and 710 
DISEASES AND INJURIES OF THE ARTERIES. 
CHAP. V. 
it will be well, especially if there be a diminution of temperature, to envelop it in cotton 
or flannel, aided, if necessary, with bottles of hot water, until it regains its natural 
warmth. Cold applications must be carefully avoided, even if the skin is hot and 
swollen, as they tend to lower the vital powers, and so predispose to mortification. A 
full anodyne should be administered immediately after the operation, to relieve pain and 
tranquillize the action of the heart; light diet, with cooling drinks, should be enjoined ; 
and the temperature of the apartment should not be permitted to exceed 65° of Fahren- 
heit. The bowels must not be opened for several days, and then only by the mildest 
laxatives, drastic purgatives being particularly objectionable on account of their tendency 
to cause excitement and throbbing of the arteries; occurrences which would inevitably 
be injurious after such an operation. All bodily and mental exertion should be studiously 
guarded against for several days after the separation of the ligature, lest, the feeble adhe- 
sions giving way, secondary hemorrhage ensue. 
Causes of Failure The causes of failure after the Hunterian operation are, first, 
violent inflammation, followed by mortification ; secondly, death of the limb from defi- 
ciency of blood ; thirdly, secondary hemorrhage, either from premature detachment of 
the ligature, or rupture of the sac ; and, fourthly, maintenance of the circulation by means 
of a redundant anastomosis. 
Ligation of an artery is not often followed by severe inflammation at the seat of the 
dperation ; the parts, indeed, frequently, if not generally, unite by the first intention, or, 
if there is any suppuration, it is chiefly at the seat of the ligature. It is only, or mainly, 
in persons of bad constitution that the resulting action is apt to run riot, or to assume an 
erysipelatous character, threatening limb and life. 
Mortification of the limb below the seat of the operation, from inflammation and de- 
fective circulation, is met with almost exclusively in the inferior extremities after ligation 
of the femoral artery for aneurism of the popliteal. Of 156 cases of this operation, 
analyzed by Dr. Norris, 28, or about per cent., were followed by this accident. Of 
these cases, 11 died and 7 recovered, 6 of the latter having escaped with the loss of the 
affected limb. The probability is that gangrene may arise from a mere want of blood in 
the parts, but most generally it is dependent upon inflammation of the artery leading to 
the formation of fibrinous clots, and the consequent closure of the caliber of the vessel 
and also of some of the collateral channels. The mortification usually begins within the 
first forty-eight hours in the distal portion of the limb, from which it gradually spreads 
until the patient dies, as he usually does in from five to ten days after the first appearance 
of the disease. 
The best means of averting this untoward occurrence is to place the limb in a proper 
position and to guard against overaction in the parts. If gangrene manifest itself, not- 
withstanding our endeavors to prevent it, amputation must at once be performed, the limb 
being, it possible, removed above the seat of the aneurism. 
Secondary hemorrhage after this operation is most liable to occur about the time of the 
separation of the ligature, but it may come on before or it may not take place until much 
later. In general, it supervenes from the seventh to the eighteenth day. A diseased 
state of the artery, excessive inflammation, or the malapplication of the ligature, may be 
considered as so many exciting causes of the accident. 
The frequency of secondary hemorrhage after the Hunterian operation has been differ- 
ently estimated by different writers. Lisfranc collected 180 cases, of which 32 were 
followed by this occurrence. In 530 cases analyzed by Porta, secondary hemorrhage took 
place in 73, of which more than one-half perished, either directly or indirectly from loss 
of blood. If we descend to particular operations, it will be found that of 38 cases of 
ligation of the carotid there were 7 cases of secondary hemorrhage, with 2 cures and 5 
deaths; the external iliac affords 8 cases out of 97, of which 5 died and 3 were cured. 
Of 187 operations upon the femoral artery, 19 were followed by hemorrhage, and of these 
9 died and 9 were cured, the other recovering after amputation, rendered necessary on 
account of the persistence of the bleeding. 
I he principal remedies for secondary hemorrhage, after such an operation, are gentle 
but systematic pressure at the site of the bleeding, and also over the main trunk of the 
vessel, assisted by the internal use of acetate of lead and opium in union with ergot and 
aconite. Occasionally it will be necessary to tie the artery higher up; or even to ampu- 
tate, especially if, when the surgeon is called to the case, the loss of blood has already 
been great, and the parts are much obscured from swelling and infiltration. 
Rupture of the aneurismal sac is uncommon after the operation. It is observed chiefly 
in cases of long standing, where interference has been delayed on account of the neglect chap. v. 
ANEURISM — TREATMENT. 
711 
of the surgeon or the obstinacy of the patient. The rupture may be caused either by the 
gradual absorption and attenuation of the sac, aided, perhaps, by the pressure of some 
bony prominence, or it may be due solely to the effects of inflammation. In the latter 
case, which is by far the more frequent of the two, the accident generally occurs at a 
comparatively early period after the operation, and is always preceded by well-marked 
local and constitutional symptoms, indicative of the impending mischief. 
This accident hardly admits of satisfactory treatment. When the aneurism is favor- 
ably situated, the best plan is to lay it freely open, and to secure the main artery leading 
to it above and below the tumor. When this is impracticable, the chief reliance must be 
upon well-adjusted pressure, assisted by cold applications, Monsel’s solution, and other 
means tending to moderate the force of the circulation. 
A return of pulsation in the aneurismal sac, an occasional occurrence, is commonly due 
to a redundant collateral circulation, or an anomalous arrangement of the main artery 
leading to the tumor, as, for example, the high division of the femoral. In some cases it 
continues after the application of the ligature ; in general, however, it comes on at a 
variable period, and now and then an instance arises in which it reappears several times 
during the progress of the after-treatment. The pulsation usually ceases spontaneously, 
followed by the gradual shrinking of the sac. When it continues obstinate, and the tumor 
either retains its former bulk or progressively enlarges, the remedy most likely to be 
successful is steady compression both of the aneurism and of the main artery of the limb. 
In popliteal aneurism, forced flexion of the leg might be tried. 
None of these accidents, save the last, and that is a very improbable one, will be likely 
to happen if the part and system have been thoroughly prepared for the operation, if the 
disease has not made too much progress, and, finally, if proper care and judgment be 
employed in managing the case after the application of the ligature. Deligation of the 
carotid arteries for the cure of aneurism is liable to be followed by inflammation of the 
brain and lungs, with softening of the former of these organs and hepatization of the 
latter. Much of the mortality from the operation is attributable to these diseases. Cases 
have occurred in which this operation was followed by erysipelas, phlebitis, pyemia, 
tetanus, and apoplexy, but such results are extremely rare, and scarcely deserve to be 
taken into account in connection with it. 
The subjoined table shows that the mortality after the Hunterian operation is truly 
frightful; a circumstance which should induce every one to regard it with suspicion and 
distrust. 
Arteries. 
Cases. 
Deaths. 
Per cent. 
Innominate. 
13 
92.85 
Subclavian 
. 124 
59 
47.58 
Carotid . 
. 106 
37 
34.90 
Abdominal aorta 
8 
8 
100. 
Common iliac . 
. 32 
25 
78.1 
Internal iliac . 
. 7 
3 
42.8 
External iliac . 
. 126 
35 
27.77 
Femoral . 
. 278 
105 
37.76 
Total 
# 
. 695 
285 
41. 
It is almost needless to state that such an operation should never be performed when the 
case is attended with great disorder of the general health, serious disease of an important 
internal organ, as the heart or lungs, or the coexistence of aneurism in any of the larger 
vessels, more especially if’ the concomitant lesion has already made unusual progress. 
Particular inquiry should always be made into the condition of the kidneys ; for tlieie is 
hardly any affection which exercises so prejudicial an influence upon recovery as albu- 
minuria. Pregnancy is no bar to the procedure ; and several instances have been reported 
in which the patients made an excellent recovery, and lived for a considerable period, 
after the deligation of a large artery for the cure of an aneurism complicated with aneuiism 
of the arch of the aorta. 
b. DELIGATION OF THE ARTERY AT THE DISTAL SIDE OF THE TUMOR. 
It is well known that aneurism occasionally occurs so near the trunk as to render it 
impracticable to perform the Hunterian operation, or that the artery, although accessible 
at the cardiac side of the tumor, is too much diseased to support a ligature. Brasdor, 
of Paris, nearly a century ago, suggested the idea that gradual and efficient coagula- 
tion of the blood in the aneurism might be produced by placing the cord upon the artery 712 
DISEASES AND INJURIES OF THE ARTERIES. 
chap. v. 
at its distal aspect. He had no opportunity, however, of solving the problem upon 
the human subject. The merit of this was reserved for Deschamps, although the case 
upon which he tried it could hardly have been worse for such an undertaking. The 
patient, besides being old, was worn out by suffering, and the tumor, which occupied the 
upper part of the thigh, extending to within a short distance of Poupart’s ligament, was 
nearly seventeen inches in circumference. I he operation was tedious and difficult, on 
account of the depth of the artery and the absence of pulsation, but the vessel was at 
length discovered and effectually secured. Contrary, however, to expectation, the aneu- 
rism, which had not made any marked progress for some time previously, now rapidly 
increased in volume, and on the fourth day, when it appeared to be on the point of burst- 
ing, it was resolved to perform the ordinary operation, notwithstanding the reasons which 
had just before been urged against its adoption. Two ligatures were applied, but the 
operation was attended with copious hemorrhage, and the man died at the end of eight hours. 
The operation of Brasdor was next performed by Sir Astley Cooper, in a case of aneu- 
rism of the external iliac artery, extending so high up into the abdomen as to render it 
impossible to place a ligature between it and the heart. The femoral artery was, there- 
fore, tied a short distance below Poupart’s ligament, between the epigastric and profunda. 
The patient did well for some days, when the tumor, which had been gradually diminish- 
ing in volume, burst, causing death by hemorrhage. 
What the results of these two efforts might have been, if the cases had been of a more 
favorable character, is a matter which must, of course, be left to conjecture. It is certain, 
however, that no attempt was made to repeat the operation until 1825, when, almost 
forgotten by the profession, it was performed by Mr. James Wardrop, of London, in a 
case of aneurism of the carotid artery. The success was complete. The ligation was 
followed by an immediate diminution of the tumor, which gradually progressed until, at 
the end of the fifth week, the neck had nearly regained its natural form ; the ligature had 
dropped off, and the general health was entirely reestablished. The patient, a woman, 
seventy-five years old, continued to be perfectly well three years after the operation. 
Having been equally successful in several other cases, Mr. Wardrop was induced to 
extend the principle of Brasdor’s operation to aneurism of the innominate artery. It 
occurred to him that, by tying one of the 
branches of this artery, the force of the cir- 
culation might be so far diminished in the 
tumor below as to cause the solidification of 
its contents. The patient upon whom he per- 
formed this operation was a woman, forty-five 
years of age, who had a pulsating swelling, of 
the size of a turkey’s egg, in the inferior part 
of the neck, its base being concealed by the 
sternum, and evidently connected with the 
innominate artery. For the cure of this dis- 
ease the right subclavian was tied in July, 
1827, with the effect of a gradual amelioration 
of the distressing symptoms, and the ultimate 
disappearance of the tumor, its site being 
occupied merely by an unnatural hardness, 
the result, probably, of the remains of the 
aneurism. This was the condition of the 
patient fourteen months afterwards, at which 
time the carotid artery still pulsated, although 
not so vigorously as the left, and the woman 
was in better health than she had been for a 
long time. 
The procedure now described constitutes 
what is called W ardrop’s operation, although it is in reality, as was before intimated, 
merely an extension of that of Brasdor; and is only applicable to aneurism of the in- 
nominate artery. It has been performed within the last thirty years in a considerable 
number of cases, generally by tying the common carotid; but the results have, for the 
most part, been unfavarable, owing, as has been alleged, and as is probably the fact, 
to the occuirence of violent inflammation both in the aneurismal sac and in the vessels 
in immediate communication with it, terminating fatally in a few days, or, at most, in a 
few weeks. J 
Fig. 326. 
Fig. 327. 
Fig. 328. 
Hunter’s. 
Brasdor’s. 
Wardrop’s. CHAP. V. 
ANEURISM TREATMENT. 
713 
Looking at the statistics of deligation of the artery at the distal side of the sac, how- 
ever performed, we find that of 84 cases, death speedily occurred in 42. The majority 
of the patients who recovered were greatly benefited, and in not a few life was prolono-ed 
tor several years. ° 
I he annexed cuts afford an illustration of the various methods of ligating arteries for 
the cure of aneurism, above described. A glance will serve to show how inefficient such 
an operation must be when performed according to the plan suggested by Mr. Wardrop. 
C. INSTRUMENTAL COMPRESSION. 
The treatment of aneurism by compression dates back to a very early period of the 
profession, and, although the principles upon which it was formerly conducted were far 
from being scientific, numerous cases have been published illustrative of its efficacy. 
It is not my design to inquire into the history of the operation, or to seek out its 
inventor for the purpose ot awarding him praise for his ingenuity and enterprise ; it is 
sufficient to state that the compression was originally applied directly to the tumor, 
or to the tumor and the limb upon which it was situated, either by means of an apparatus 
specially constructed for the object, or by a compress and roller, extended from the 
distal portion of the extremity upwards, beyond the seat of the disease. The practice 
was most frequently employed for the relief of traumatic aneurism, particularly that 
form of it consequent upon injury of the brachial artery, at the bend of the arm ; 
and, although it proved occasionally successful, in not a few cases, it was followed by 
violent inflammation ot the sac and limb, eventuating in ulceration, abscess, or gangrene. 
The compression may be direct or indirect; that is, it may be applied either to the 
swelling itself, or to the artery upon which the swelling is situated. Aneurisms of various 
arteries, as the carotid, subclavian, brachial, iliac, femoral, and popliteal, were success- 
fully cured by the former method by Fabricius, Tulpius, Acrel, Petit, Plainer, Guattani, 
Ciniselli, Brunker, and many others ; and, although the treatment is now obsolete, 
there is no doubt that it might still occasionally be advantageously employed, especially 
in tumors of small size. The compressing agents were generally pieces of sponge, 
agaric, or linen, confined by adhesive strips and a roller. Sometimes the pressure 
was rendered more firm by the interposition of a solid substance, as sheet lead, papier- 
mache, or sole leather. Dionis refers to a case in which a man cured himself of a false 
aneurism at the bend of the arm by keeping up gentle pressure upon the tumor for a year 
with a cushion. 
In the latter part of the last century, Yernet, a French military surgeon, conceived 
the idea of curing aneurism by applying compression upon the artery immediately beyond 
the tumor, upon the same principle as that upon which Brasdor soon after suggested the 
use of the ligature. He thought that the operation was particularly adapted to aneurism 
situated so near to the trunk as to forbid a resort to the ligature, or compression upon the 
cardiac side of the swelling. It would appear, however, that he practised it only in one 
instance—upon a man affected with inguinal aneurism—and that so great was the dis- 
turbance which it created in the pulsation of the sac, that he was obliged, in a very 
short time, to abandon it. From the want of success attending the case, ill adapted 
as it was to test the principles of a new process, no one, it seems, felt afterwards disposed 
to make further trial of it, and it was accordingly forgotten, or remembered only as an 
ingenious sugestion. 
The late Dr. J. M. O’Ferral, of Dublin, was a warm advocate of compression of the 
artery both above and below the tumor, or at its cardiac and distal aspects, and the signal 
success which attended the operation in three cases thus treated by him affords a strong 
argument in favor of its general adoption. As the coagulation of the blood in this method 
of treatment is the great desideratum, it is reasonable to conclude that it will be more 
rapidly effected when the compression is applied at two points than one, the blood within 
the tumor being thus brought more thoroughly and promptly into a state of repose so 
favorable to the accomplishment of the object. 
Compression of the artery above the tumor, or between it and the heart, was first 
distinctly insisted upon as a remedy for the cure of this disease by the late Mr. Freer, 
of Birmingham, in his observations on aneurism, published early in the present century. 
In the work here referred to, he gave special directions for applying the compression, 
enjoining that it should be made by enveloping the whole limb with a bandage, and 
placing upon the vessel, in the most superficial portion of its extent, a small pad, 
which was then to be screwed down by means of a tourniquet. To render its action more 714 
DISEASES AND INJURIES OF THE ARTERIES. 
c II a p. v. 
effective, a plate was secured to the opposite side of the limb, which, while it defended 
the integument and muscles from injurious constriction, concentrated the force upon 
the particular point of the artery where it seemed to be most needed. Notwithstanding 
this precaution, the application of the tourniquet was soon followed by pain and 
oedema of the extremity, generally so violent as speedily to necessitate its removal. 
Short, however, as the compression was, it occasionally laid the foundation ot a cure, 
which was afterwards perfected by the steady but cautious use of the ordinary compress 
and bandage. 
Acting upon the suggestions of Freer, Dupuytren and others applied themselves to 
this mode of curing aneurism, devising useful and ingenious instruments as substitutes 
for the more clumsy contrivance above described. The French surgeon, in particular, 
invented a most admirable compressor, at once simple and efficient, which still bears his 
which he employed successfully in several cases of aneurism of the inferior 
extremity. The cures, however, that were effected in this way were few compared with 
the great number of failures, and the consequence was that the treatment never met with 
much favor. What added to the dissatisfaction of practitioners was that, in quite a 
considerable number of cases, it Avas followed by results highly prejudicial to the limb, if 
not both to limb and life. 
Thus stood the treatment of aneurism by compression, when, in 1843, it was destined 
to experience a complete revolution in the hands of several eminent surgeons of Dublin, 
particularly Hutton and Bellingham, the latter of whom, in a short tract upon the subject, 
was the first to point out, upon correct and scientific principles, the manner in which it acts 
in curing the disease. Prior to this period, one replete with interest to the progress of 
surgery and humanity, compression was a very painful and hap-hazard proceeding, con- 
ducted without any discrimination and judgment, and, consequently, without any certainty 
as to its results. The idea AATas that, in order to succeed, it was necessary that it should 
be applied firmly and steadily, so as to arrest the circulation, and cause adhesion of the 
sides of the artery, very much as in the operation of ligation. Hence the poor patient 
Avas generally subjected to immense torture, often compelling the speedy discontinuance 
of the treatment, which, however, notwithstanding this, Avas occasionally followed by the 
worst consequences, as manifested in the violent sAvelling of the affected limb, and per- 
haps its ultimate loss by gangrene. The procedure was altogether a blind one, and, 
therefore, just as likely to prove prejudicial as useful. It was employed by one practitioner 
simply because it had occasionally been employed successfully by another, and not because 
any one had, as yet, been so fortunate to lay doAvn any broad and definite rules of action. 
It was for this reason that it was so long in acquiring the confidence of surgeons ; that it 
Avas totally abandoned at one time, and resumed, with doubts and misgivings, at another. 
Its principles Avere not yet fully developed, or placed upon a just and comprehensive 
basis. This labor was performed by Dr. Bellingham and his able associates, avIio thus 
created a new era in the treatment of aneurism, hardly less brilliant than that of the 
ligature. What the ultimate fate of this treatment will be, time alone can determine ; 
that it is destined to supersede entirely, as some have predicted, the use of the ligature, 
is extremely questionable, and yet, considering the remarkable success which has 
attended it, such an occurrence seems not improbable. 
Compression, as noAV conducted, is not only safe, but comparatively free from pain ; 
and, although it is often tedious, yet few cases wfill ultimately resist its influence. It is 
more especially applicable to the cure of popliteal aneurism, in which its greatest triumphs 
have hitherto been achieved, but it has also been successfully employed in aneurism of the 
femoral artery, both in its upper and lower extent, and in aneurism of the brachial artery, 
particularly at the bend of the arm. It is applied upon a sound portion of the vessel, at 
the cardiac site of the tumor, and generally at a considerable distance from it; gently and 
intermittently, not firmly and persistently as in the old method ; just sufficiently to retard 
and weaken the circulation in the sac, not to arrest it, and so as to faAror the gradual 
formation of clots; alloAving time for the development of the collateral vessels, and the 
maintenance of the nourishment of the distal portion of the member. Occlusion of the 
artery at the site of compression is not wished for; on the contrary, it is desirable that 
the vessel should remain pervious, and retain as many of its normal properties as possible. 
As the stratification of the sac proceeds, as layer after layer of fibrin is deposited and 
becomes firmly cemented to that which preceded it, the hollow pouch is gradually filled 
up, and usually, along with it, also the upper orifice of the artery. To this rule, how- 
ever, there are occasional exceptions, the blood continuing to Aoav from the artery in a CHAP. V. 
ANEU R IS M —T R EATMENT 
715 
direct stream across the sac in a sort of ditch, groove, or 
narrow channel. 
tor the purpose of making the compression, various in- 
struments have been devised, one of the most simple and 
efficient of which is represented in fig. 329 ; it is a modi- 
fication ol that of Charriere, and was successfully employed 
hy one of my former assistants, Dr. Thomas P. Gibbons, 
in a case of aneurism of the popliteal artery. It consists 
of a l°ng? wide, concave, steel plate, supporting three semi- 
circles of the same metal, arranged in two segments, which 
slide upon each other, and are connected each at their free extremity with a screw and 
pad. The whole construction of the instrument is such as to enable the surgeon to regu- 
late the pressure with the greatest nicety ; making it more or less firmly, and at one or 
more points, or alternately at different points, as circumstances may seem to require. The 
annexed drawings, figs. 330, 331, and 332, are added for the purpose of enabling the 
Fig. 329. 
Gibbons’s modification of Charrifere’s 
Compressor. 
Fig. 330. 
Fig. 331 
Carte’s Compressor for the cure of Femoral and Popliteal Aneurism 
Hoey’s Clamp. 
reader to avail himself of the use of other compressors, if the one here described should 
prove inadequate. A compressor, almost identical with Hoey’s clamp, will be found de- 
scribed in the sixth volume of Mr. Benjamin Bell’s Sur- 
gery, published in 1788. It was invented by Mr. James 
Moore, of London, and was originally designed as a com- 
pressor of the principal nerves of the extremities, as a 
means of preventing pain in amputations. 
It will generally be well, if the patient is at all intelli- 
gent and trustworthy, to instruct him in the use of the 
instrument, so that he may regulate the compression ac- 
cording to its effects ; lessening it if it is productive of 
pain, and conversely. 
One important principle in the treatment is to com- 
press the artery against the bone, as a point of support; 
if the pressure is widely diffused, it will only serve to 
embarrass the venous circulation, and to retard the cure. 
The preliminary treatment should be the same as in the 
Hunterian operation ; and during the progress of the 
cure the limb should be kept constantly bandaged from 
its distal extremity upwards, to support the capillary 
vessels, and thus prevent oedema. Strict quietude, both 
of mind and body, should be observed ; the diet should be mild but sufficiently nutritious ; 
and free use should be made of aconite, opium, and acetate ot lead, as suggested under 
Fig. 332. 
Carte’s Circular Compressor. 716 
DISEASES AND INJURIES OF THE ARTERIES. 
chap. v. 
the head of the treatment of internal aneurism. If the case is very protracted, and the 
health is likely to suffer from the consequent confinement, gentle exercise may be per- 
mitted in the open air, the instrument being worn several hours in the morning and 
evening. If any considerable swelling arise in the limb, all treatment must be tempor- 
arily suspended, and measures adopted for the relief of the morbid action. "lo continue 
the compression under such circumstances would be to jeopard the safety both of the part 
and patient. 
The period at which a cure may reasonably be looked for in this treatment is subject to 
much diversity; in some instances compression for a few hours has sufficed to produce 
this event; in others, and these embrace the great majority of cases, a number of days 
are required; occasionally several weeks elapse ; and examples have been reported where 
the stratification and obliteration of the sac were not completed under two months. 
As a general rule, it may be assumed that, other things being equal, the cure will be more 
rapid in proportion to the small volume of the tumor, the tolerance of the part to com- 
pression, and the absence of complications. 
Within the last few years the old method of treatment of aneurism by forced or steady, 
persistent compression has, w'ith some modification, been revived, and is likely, in great 
degree, if not entirely, to supersede the gradual method, upon which, until recently, so 
much stress was laid. The credit of recalling attention to this plan of treatment is mainly 
due to Dr. William Murray, of Newcastle on-Tyne, who, aware of the great pain attend- 
ing it, accompanied its employment with the administration of chloroform, thus paving 
the way to a new application of this invaluable anaesthetic agent. His case was one of 
aneurism of the abdominal aorta in a man twenty-six years of age. The tourniquet was 
applied to the vessel above the tumor on two distinct occasions, at an interval of three 
days; on the first for two hours, without any material impression, and on the second for 
five hours, followed by the complete arrest of pulsation, and a rapid cure. The man 
survived the operation, performed in 1864, six years, when, dying from the effects of 
another aneurism of the aorta, an opportunity was afforded of verifying the correctness 
of the previous diagnosis, so that no doubt could be entertained about the success of the 
treatment. 
Since the publication of Dr. Murray’s case, a number of other examples, with equally 
gratifying results, have been reported by other observers. Thus, Dr. E. D. Mapother, of 
Dublin, in a case of ilio-femoral aneurism, succeeded in effecting consolidation of the 
tumor in four hours and a half, by compressing the common iliac artery. In another 
case—one. of popliteal aneurism—the time occupied in arresting the pulsation was ninety- 
seven hours, although pressure was applied both at the proximal and distal sides of the 
tumor, the limb having previously been elevated and bandaged to interrupt the return of 
venous blood, and direct pressure made upon the sac with an elastic roller. Dr. Heath, 
of Sunderland, cured an aneurism of the external iliac artery by compressing the abdom- 
inal aorta for seven hours; Mr. Lawson was successful in a case of inguinal aneurism by 
pressure continued for four hours; and in another case consolidation was effected in 
twenty minutes. In a case reported by Mr. Russell, a cure took place in a few hours. 
In all these instances the use of chloroform was conjoined with the compression. That 
the exhibition of this anaesthetic, however, is not at all essential to success, although gen- 
erally of inestimable service in preventing suffering, and thus rendering the patient com- 
paratively comfortable during the treatment, is proved, first, by the case of Mr. Tait, in 
which he effected a cure of an inguinal aneurism by compression of the aorta partly with 
and partly without the aid of chloroform ; and, secondly, by one by Mr. Bannon, in which 
a popliteal aneurism was consolidated in six hours under the stupefying influence of a 
large opiate. In the case of a negro, twenty-seven years of age, recently under my care 
in the Jefferson Medical College Hospital, I succeeded in effecting consolidation of the 
contents of a femoral aneurism in four hours by compressing the common femoral artery 
with two bags of small shot, each of which weighed five pounds, which were kept steadily 
in place by a meniscus-shaped mass of lead weighing ten pounds. 
The practice pursued in these cases, it seems to me, is worthy of general adoption, as it 
usually requires only a very short time to effect a cure, and is unattended with suffering. 
rIhe success of the treatment, as originally planned and carried out by Dr. Murray, hinges 
entirely upon the complete arrest of the movement of the blood in the aneurismal sac, and 
its firm coagulation without the deposition of laminated fibrin, as generally happens in 
gradual compression. They prove, as the English surgeon justly affirms, that chloroform 
does not in the slightest degree interfere with the coagulation of the blood, and that, with 
the aid of this anaesthetic, the treatment is applicable to arteries in the most delicate and CHAP. V. 
ANEURISM — TREATMENT. 
717 
sensitive situations in the body, without any danger from its protracted exhibition. Dr. 
Murray assumes, as a principle, that in all cases ot aneurism ot the larger arteries spring- 
ing from the aorta the best plan is to compress this vessel itself, experience having 
demonstrated its entire safety. 
The results of the treatment of aneurism by instrumental compression are, on the whole, 
highly flattering, contrasting most favorably with those of the Hunterian deligation. 
Thus, of 124 eases of compression for popliteal aneurism collected by Mr. Holmes from 
the records of British hospitals for a period of ten years, 66 were successful, and 58 failed. 
None died, and there are, indeed, not more than five or six cases of death from the effects 
ot the operation. On the other hand, of 77 cases of aneurism of the popliteal artery, 
treated according to the Hunterian principle, 11 died, or 1 in 7. 
Besides its indisputable safety, compression, whether forced or gradual, has the advan- 
tage, if it fail, that it does not preclude the propriety of a resort to the ligature. 
d. DIGITAL COMPRESSION. 
Digital compression for the cure of external aneurism, originally proposed as a distinct 
measure, in 1846, by Professor Vanzetti, of the University of Padua, was first success- 
fully employed, a year later, by Professor Knight, of New Haven, in a case of popliteal 
aneurism, in which he cured his patient in forty hours, the compression having been 
maintained by a relay of assistants. During the past twenty years, this mode of treat- 
ment has attracted much attention, both in this country and abroad, and has been fully 
discussed in statistical papers, particularly by Broca, Verneuil, Petiteau, S. W. Gross, 
Abbadie, Gaultron de la Bate, Barlemont, and Fischer. 
In a series of communications in the Vierteljahrschrift fiir Praktische Heilkunde for 
1869, Dr. George Fischer has given a statistical report of 188 cases treated by this method. 
As this paper contains a more full account of the subject than any other which has fallen 
under my notice, I shall freely avail myself of its contents. 
It has been shown that digital compression has been successful where mechanical com- 
pression was unbearable, or had failed, whether alone or conjoined with other means, 
interrupted or continued, complete or incomplete ; it has even, in several cases,been applied 
by the patients themselves, and in these instances either a cure was effected, or the tumor 
was so modified that subsequent ligation or mechanical compression of the artery always 
resulted in recovery. 
The pain produced by the pressure of the finger is not greater than that caused by the 
pad of. an instrument; should the point of contact become tender and inflamed, chalk, 
starch, or flour may be sprinkled upon the surface, or a thin, Avet cloth may be interposed 
between the finger and the skin. However this may be, suffering, both local and general, 
may easily be allayed by the free exhibition of anodynes, or by keeping the patient pretty 
freely under the influence of chloroform. 
Of the 188 cases analyzed by Dr. Fischer, 124 were spontaneous and 64 traumatic 
aneurisms; 13 were diffuse and 16 w'ere varicose. The tumors seated in 3 cases 
upon the iliac; common femoral, in 7 ; femoral, in 8; popliteal, in 90; tibio-peroneal 
trunk, in 1 ; anterior tibial, posterior tibial, and external plantar, each, in 1 ; subclavian, 
in 1; axillary, in 4; brachial, in 32; radial, in 7; ulnar, in 1; superficial palmar arch, 
in 5; carotid, in 4; temporal, in 2; ophthalmic, in 6; supraorbital, in 1; and inferior 
coronary,in 1. 
Of the entire number, 121 were cures and 67 failures, including 4 deaths: 104 cures 
were effected by digital compression alone, and 17 by compression aided by other plans of 
treatment: 33 cases which had resisted instrumental compression, and which ought not to 
have been treated by this process, are to be deducted from the 67 instances of failure, so 
that there remain 138 cases, Avith 104 cures by digital compression alone, thus affording 
75.3 per cent, of success. In these cases, other methods of treatment, chiefly instrumental 
compression, had previously failed. Digital compression, preceded by instrumental com- 
pression, was unsuccessful in 19 instances. 
One death was due to digital compression employed as the sole method of treatment. 
The case was that of a man, seventy-one years of age, affected Avith popliteal aneurism, 
which became solid at the end of twenty-four hours. Dimited gangrene set in, under 
which he succumbed in tAvo months. In three instances death ensued from the combined 
employment of the finger and apparatus. 
The period required for the cure of aneurism by this method is much shorter than by 
any other known plan of treatment, except forced instrumental compression. When 718 
DISEASES AND INJURIES OF THE ARTERIES. 
CHAP. V. 
employed alone from the very commencement, it frequently does not exceed nine or ten 
hours. Compared with ordinary instrumental compression, the length of time is most 
striking. According to Dr. Fischer, a cure, on an average, is effected in three days, 
whereas the mean duration of treatment by the latter method is fourteen days. The 
greatest objection to digital compression is the difficulty of procuring a sufficient number 
of competent assistants. 
Dr. Boughter, of the Army, has reported in the Philadelphia Medical Times for Octo- 
ber, 1871, the case of a soldier, twenty-four years of age, affected with a double aneurism 
of the femoral artery, in which the lower tumor, seated in Scarpa’s triangle, was cured in 
five hours and a half by digital compression. No effect was produced upon the upper 
tumor, which extended slightly under Poupart’s ligament, on the one hand, and, on the 
other, to within an inch and a half of the upper end of the lower sac. The pressure was 
made over the artery, or, rather, over the mouth of the proximal tumor, against the brim 
of the pelvis, and was resumed for six hours, at the expiration of four days, with the view 
of obliterating the latter. Slight diminution in size alone resulted. 
In all cases of this operation in which the consolidation of the tumor occurs rapidly, as, 
for instance, within a few hours after the commencement of the treatment, it is obvious 
that it must be brought about simply by the coagulation of the blood, without any effort 
at fibrinous stratification, as always happens when the cure is gradual. 
e. DIltECT COMPRESSION OP THE DENUDED ARTERY. 
Direct compression of the denuded artery as a means of cure in aneurism has been 
practised at different by different surgeons with a degree of success, in the main, 
highly flattering and worthy of repetition. Among the earliest operations of this kind 
are those of Birch, Dubois, Cline, Foster, Deschamps, Percy, Assalini, and Monteggia, 
near the close of the last and the commencement of the present century. As the original 
proceedings were more or less rude, it is not surprising that they were occasionally fol- 
lowed by violent inflammation, secondary hemorrhage, and even death. They consisted in 
exposing the artery at a sound portion of its extent, and surrounding it with a ligature 
tied over a cylinder of linen, wood, cork, or agaric, retained until the sides of the vessel 
were supposed to be firmly adherent to each other. Mr. Birch, of London, in 178G, in a 
case of femoral aneurism, inclosed the artery in two cords, only the lower one of which 
was tied, the upper one remaining loose, to be tied in the event of accident or secondary 
hemorrhage. The operation was followed by severe inflammation at the wound, and the 
aneurism burst on the twelfth day, death occurring soon after. Cline, in a case of a simi- 
lar kind, employed two broad tapes, one lying behind the other, the outer embracing a 
piece of cork. Deschamps invented what he termed a serre-artere—a kind of double 
canula—with which the artery was looped in a manner very similar to that of snaring a 
nasal polyp with the canula of Levret. A temporary ligature, ligature d’attente of the 
French surgeons, was placed underneath the artery, above this instrument, to be used in 
the event of hemorrhage from ulceration of the vessel. Percy employed a pair of forceps 
with two flat surfaces; while Dubois preferred what is called a presse-artere. Scarpa 
surrounded the artery with two stout, flat ligatures, the ends of which were tied over a 
small linen cylinder, six lines in length by three in diameter, the wound being afterwards 
filled with charpie. Professor Assalini, in the early part of the present century, in a 
case of popliteal aneurism, successfully employed an instrument very similar to that of 
Percy, consisting of two short silver blades, united by a rivet, the degree of pressure being 
regulated by a screw passed through the handle of the instrument. Assalini, as Hodgson 
informs us, subsequently treated two other cases in a similar manner, the clamp in each 
being removed at the end of twenty-four hours, without any return of pulsation. 
Mr. Crampton, of Dublin, in 1814, in a case of popliteal aneurism, exposed the femoral 
artery, at the usual site, by an incision three inches in length, and arrested the pulsation 
with a narrow tape arranged in such a manner as to admit of being tightened or relaxed 
at pleasure without interfering with the wound. At the end of two hours and a quarter, 
when the cord was gently slackened but not entirely loosened, all pulsation in the aneurism 
had ceased. In twenty-four hours the compression was taken off; but, as a measure of 
precaution, the ligature was retained a day longer. The tumor by the fifth day had 
decreased one-half in size, and was not only free from pulsation, but almost incompressible. 
On the eighteenth day the wound was completely cicatrized. Dease, soon after, in a 
similar case, removed the ligature at the end of twenty-four hours. Travers, of London, chap. v. 
ANEURISM — TREATMENT. 
719 
in 1817, tied the brachial artery in a case of traumatic aneurism at the bend of the arm, 
the ligature being taken away at the expiration of fifty hours. A single noose was 
employed. Ihe pulsation in the tumor at once ceased, and a complete cure followed 
without any accident. 
The primary object which these surgeons had in view' in performing the operations here 
described was to bring about the consolidation of the contents of the aneurism by retard- 
ing and diminishing the flow of blood, precisely in the same manner as in the Hunterian 
method. In addition to this, some, at the head of wrhom was Scarpa, aimed at the same 
time to effect occlusion of the compressed artery by the division of its lining membrane, 
in the hope of being thus able to favor the effusion of plasma and the adhesion of the 
contiguous surfaces. 
In the modern method the object is to remove the ligature, clamp, or forceps from the 
artery the moment it is ascertained that there is complete consolidation of the contents of 
the aneurism. To effect this to the best advantage and in the safest manner, the artery 
is exposed at the Hunterian site of the tumor to an extent only of a few lines, and inclosed 
in a single ligature of iron wire, without the addition of the underlying cylinder employed 
in former times. The best contrivance for the purpose is a fiat, metallic button, about one 
inch and a half in diameter, with two central apertures for the reception of the extremities 
of the ligature. The wound being closed in the usual manner, the ligature can be tight- 
ened or slackened according to circumstances. The pressure may generally be safely 
removed by the end of the first day. 
The value of this operation, as now performed, is still undetermined. I am myself 
favorably impressed with it. In a case of femoral aneurism, under my charge in 18G9, 
in a man fifty years old, recovery ensued w'ithout a single untoward occurrence, the 
ligature having been removed at the end of the second day. The operation saves time, 
does not cause much disturbance at the seat of ligation, and is not likely, with proper 
care, to be followed by secondary hemorrhage, the great danger after such a proceeding. 
The chief objection to the employment of the wire is the difficulty of detaching it. If a 
cylinder, as, for example, a piece of gum-elastic catheter or adhesive plaster, be used, it 
should be placed in direct contact with the skin, the w'ound having previously been 
thoroughly closed, otherwise the pressure might provoke severe inflammation, if not ulcera- 
tion and secondary hemorrhage. 
Acupressure of the denuded artery may be substituted for the ligature, wire-loop, or 
forceps; but it does not appear, from the few trials that have been made of it to possess 
any special advantages. Mr. Henry Lee refers to a case of small traumatic aneurism of 
the ham cured by this method. Dr. Cheever, of Boston, has applied it successfully to 
the femoral artery in popliteal aneurism, but in a second case death resulted from mortifi- 
cation ; and Professor Porter, of Dublin, acupressed unsuccessfully the axillary artery in 
a case of subclavian aneurism. 
f. FORCED COMPRESSION AVITH THE ELASTIC BANDAGE. 
In aneurisms of the extremities forced compression of the arteries leading to and from 
the seat of the disease has not infrequently succeeded. The treatment is a recent device, 
first practised, in 1875, by Surgeon Walter Reid, of the English Navy. The compressor 
employed is Esmarch’s bandage. This is applied quite firmly, at first, to the distal side 
of the tumor, commencing at the extremity of the limb, and reaching as high up as the 
swelling; it is then carried loosely o\rer the latter so as not to compress it; and, when it 
has reached its proximal side, it is again applied firmly for a short distance, Avhen the rubber 
tubing or band is wound round the limb with sufficient tightness to arrest the circulation in 
the sac, and the bandage is removed. The compression is maintained for a period varying 
from three-quarters of an hour to three hours and a half, or until there is reason to believe 
that the contents of the aneurism are completely solidified. As the pain, attendant upon 
the operation, is often very severe, the patient should, for at least a portion of the time, 
be kept under the influence of anaesthesia; and, lest the clotted blood should be washed 
away after the removal of the tubing, the compression should be continued for some hours 
longer with an ordinary instrument or by means of the finger. The great efficiency of 
this operation is due mainly, if not entirely, to the arrest of the circulation through the 
collateral channels as well as through the main artery, thereby securing absolute stagna- 
tion of the contents of the sac. 
Dr. S. W. Gross has collected seventy cases of aneurism thus managed, ihe seat 720 
DISEASES AND INJURIES OF THE ARTERIES. 
chap. v. 
of the disease was the popliteal artery in fifty-three instances, the femoral artery in ten 
examples, the anterior tibial in two cases, and the posterior tibial, the internal circumflex, 
the external iliac, the brachial, and the axillary artery, each, in one case. Of the entire 
number thirty-nine were cured, twenty-seven failed, and four died. In the four cases in 
which death followed the treatment, the sac and tributary artery were occupied by recent 
clots. In the successful cases pulsation was perceived in the tumor on the removal of the 
tubing, but remained permanently absent after the continuance of several hours of digital 
or instrumental compression. The chief danger after this operation is from gangrene of 
the limb from the size or extension of the clot. The four deaths were due to gangrene in 
two, to collapse and impending gangrene in one, and to collapse with rupture of an aneu- 
rism just above the pad of the tourniquet in one. 
g. FORCED FLEXION. 
Fleury, a French military surgeon, it would seem, originally suggested the idea that 
forced flexion might be beneficially employed in the treatment of aneurism of the extremi- 
ties ; a suggestion which was first successfully practised in 1852, by Thierry, of Paris, in 
a case of traumatic aneurism at the bend of the arm. In 1857, Maunoir, of Geneva, 
availed himself of this treatment for the cure of a large aneurism of the ham ; and shortly 
afterwards the treatment was successfully employed by Mr. Ernest Hart, of London, 
through whose writings it became known in Great Britain and in this country. It is 
chiefly applicable to aneurism of the ham and of the bend of the arm, although it has 
also been successfully employed, by Dr. Gurdon Buck and Dr. Eldridge, in aneurism of 
the groin, and it might, possibly, be practised in aneurism of the axilla. The principle 
of the treatment consists in moderating and retarding the flow of blood in the tumor, as 
for instance, in the lower extremity, by bending the leg forcibly upon the thigh, so as to 
approximate the heel to the buttock, and confining it there by means of a strap, the limb 
being previously enveloped in a bandage. The patient need not be rigidly confined to 
bed, but may occasionally sit up, and even exercise on crutches. Pain and stiffness of 
the limb may be diminished with inunction of oil and chloroform. Care is taken to move 
the knee occasionally, lest ankylosis should occur. The cure is commonly very tedious, 
from three to six weeks being required for the complete arrest of the pulsation, and in a 
number of the cases in which this treatment has been pursued it has signally failed ; in 
several, the patient was unwilling to bear the restraint which it imposed, and in one at 
least it was followed by rupture of the sac into the joint, necessitating the ligation of 
the femoral artery. In a case of popliteal aneurism, the volume of a small fist, in a man 
nearly forty years of age, a patient at the College Clinic, I effected a cure by forced 
flexion in less than twenty-four hours. 
It is obvious that this mode of treatment, which commends itself chiefly by its great 
simplicity, is more likely to succeed in small and recent aneurisms than in large and old, 
in which it must of necessity be occasionally attended with failure. Indeed, it can hardly 
be considered as applicable to the latter class of cases, as it might induce rupture of the 
sac, or even be productive of gangrene of the leg. 
Of 106 cases of popliteal aneurism, treated by forced flexion, the statistics of Dr. 
Fischer and Liegeois, afford 45 cures and 54 failures, the successful issues in 29 of the 
former cases having been obtained with the aid of other methods. 7 cases died from rupture 
of the sac. 
h. GALVANO-PUNCTURE. 
It would seem that this operation for the radical cure of aneurism was first suggested, in 
1832, by Mr. Benjamin Phillips; so far, however, as my information extends, it was not 
practised by him upon the human subject, and the idea had been almost lost, when, 
about thirty years ago, it was revived, principally through the agency of Petrequin, of 
Lyons. The operation is founded upon a knowledge of the fact that the galvanic current 
has the effect, if properly directed, of coagulating the blood as it circulates through the 
different parts of the body. It is executed by means of two long, slender steel needles, 
introduced into the aneurismal sac at right angles, and in such a manner as to touch each 
other, their heads being then connected with a battery of large electro motor force. The 
action of the battery is maintained uninterruptedly for a period varying from ten to 
twenty-five minutes, according to the tolerance of the part, and is usually required to be 
several times repeated. When the tumor is large, the number of needles is increased, 
and the direction of the current frequently changed, so as to afford a better chance for CHAP. V. 
ANEURISM — TREATMENT. 
721 
the formation of clots. As the operation is generally very painful, it is proper that the 
patient should be placed under the influence of anaesthesia during its performance. 
Moreover, as there is danger of seriously charring the integument, and thus endangering 
the sac by mortification, the needles should be carefully coated, in a part of their extent, 
with gum-lac. The success ot the procedure is enhanced by compression of the artery 
above and below the tumor, thereby preventing the clots from being washed away, before 
an opportunity has been afforded them of becoming consolidated and united with each 
other and with the walls of the aneurism. The after-treatment consists in the application 
of ice to the part, in perfect quietude, and in the administration of a full anodyne, to 
tranquillize the action of the heart and arteries. 
Experience has not fully determined the value of this mode of treatment. That it is 
liable to occasional failure is sufficiently evident from the unsuccessful cases that have from 
time to time been published in England and on the continent.of Europe. On the other 
hand, a considerable number of cases have been reported in which its employment was 
followed by a perfect cure. Of 50 cases, collected by Ciniselli, in 1856, in which the 
operation had been practised, 23 were successful, 20 failed, and 7 died. Examples of cure, 
by this method, of aneurism of the aorta, the brachial, subclavian, popliteal, and external 
iliac arteries, have been reported by different observers since that period, and, doubtless, 
others have occurred of which I have no knowledge. 
Galvano-puncture is not only painful, but far from being devoid of danger. In some 
of the reported cases it produced severe inflammation and even suppuration of the sac, 
followed by great swelling of the limb, together with excessive constitutional disturbance, 
threatening the destruction both of the part and system. The operation is, therefore, a 
hazardous one, and on this account should never be attempted without due consideration of its 
consequences, especially when the aneurism is large, and situated at, or near to, the trunk. 
Coupling this circumstance with the want of success of the operation, and the severe pain 
attending its execution, not to say anything of the danger of producing sloughing in the 
skin and sac by the action of the galvanic fluid as it is being transmitted from the battery 
to the tumor, it is questionable whether it is w'orthy of repetition, notwithstanding the 
high estimate placed upon it by Petrequin, Burci, and some other surgeons. The force 
of this conclusion derives additional support from the facts collected by Boinet, that in 
seven of the successful cases, above referred to, compression and ice were employed 
simultaneously, thus creating a just doubt whether these agents had not as much to do 
with the cure as galvano-puncture, if, indeed, not more. 
i. INJECTIONS. 
Attempts have been made in modern times to effect the radical cure of aneurism by the 
injection of certain fluids with a view of favoring the concretion of the blood, the consoli- 
dation of the sac, and the obliteration of the affected artery at the seat of the disease. 
The practice was originally suggested, early in the present century, by Professor Monteggia, 
of Milan, who proposed the use of solutions of acetate of lead, tannic acid, and other astrin- 
gents, as, in his opinion, well adapted to the purpose, although he never, it would seem, 
performed the operation. His idea was that, by throwing these substances into the sac, 
so as to bring them fully into contact with the blood within, it might be possible to pro- 
voke the rapid formation of coagula, and thus effectually arrest the circulation. He sup- 
posed, moreover, that the remedy might occasionally be advantageously combined with 
Brasdor’s operation and with compression of the artery upon the cardiac side of the tumor, 
applied by means of a tourniquet or some other suitable instrument, very much as it is 
Fig. 333. 
Pravaz’s Syringe. 
performed at the present day. The suggestion of the Italian surgeon, however, received 
little, if any, attention until within a comparatively recent period, when it became the 
subject of numerous experiments upon the inferior animals, as the sheep, dog, and horse, 
principally by the French practitioners, who, after having tried various articles have at 722 
DISEASES AND INJURIES OF THE ARTERIES. 
chap. v. 
length been induced to give a decided preference to a concentrated solution of perchloride 
of iron in water. The fluid is introduced into the sac by means of a small glass syringe, 
invented by Dr. Pravaz, of Lyons, and represented in fig. 333. The piston is moved 
slowly by means of a screw, not more than five or six drops of fluid being thrown into the 
sac, that quantity having been found to be amply sufficient for the purpose. As it takes 
at least half a minute before the blood can be made to coagulate, during which the heart 
performs not less than thirty-five pulsations, it is necessary to keep the contents of the 
tumor perfectly quiet, while the injection is progressing, by compression of the artery 
immediately above and below the aneurism. 
The operation is generally productive of severe pain, and as it is liable to be followed 
by considerable inflammation, it often becomes necessary to make use of antiphlogistic 
measures, both locally and constitutionally. Its repetition must be governed by circum- 
stances ; if everything passes off well, and the sac is promptly solidified, no further inter- 
ference will, of course, be demanded ; but, if the reverse be the case, a similar quantity 
of the solution is thrown in at the end of the third or fourth day, in the same cautious 
manner as before. The slightest inflammation of the tumor contraindicates the repetition 
of the injection. 
Since 1853, when Pravaz first published the results of his experiments on animals, a 
number of cases have been reported in which injections of perchloride of iron have been 
employed in aneurism of different parts of the body, as well as in aneurism of different 
kinds, as spontaneous, traumatic, and varicose. The arteries upon which the disease 
occurred were the supraorbital, carotid, brachial, ulnar, femoral, popliteal, and tibial. 
More recently the treatment by injection has been extended to aneurism of the innominate 
artery by Barrier and Eliot, of the subclavian by Petrequin, and of the aorta by Syme 
and Hutchinson, but in no instance with success. 
Although a few cures have been effected by this treatment, such is the great risk of 
inflammation, suppuration, and even gangrene, both of the sac and of the surrounding 
structures, that it is extremely questionable whether any prudent surgeon should repeat 
it. Of eleven cases, reported by Malgaigne in 1854, it is announced that four had proved 
fatal, that every one had had bad symptoms, and that only two had been successful. This 
statement alone, if true, as no doubt it is, is sufficient to condemn the operation as unsafe, 
and to render its adoption improper in the face of the more unexceptionable methods of liga- 
tion and compression. The great desideratum is to discover an article, which, while it shall 
promptly coagulate the blood, will not cause any severe irritation in the sac and parts around 
it. It has been supposed that the acetate of the peroxide of iron might have this effect, 
but, although at least one successful cure by its use has been reported, it has not been 
tried sufficiently often to enable us to pass any definite judgment upon its true merits. I 
should myself have more confidence in the efficacy and safety of subsulphate of iron than 
in any other preparation of this metal. It is perfectly destitute of caustic properties, and 
is the most prompt and efficient coagulator of the blood at present known. 
At a meeting of the Philadelphia Academy of Surgery, in 1882, Dr. W. W. Keen 
reported the particulars of a case of aneurism of the palm of the hand, in which an injec- 
tion of ten drops of diluted Monsel’s solution caused rapid mortification necessitating 
amputation of the lower part of the forearm. 
Subcutaneous Injection of Ergotine The subcutaneous injection of ergotine, in view 
of its influence in provoking contractions of organic muscular fibres, has been employed 
in a few instances of aneurism, and the results have been so far favorable as to warrant its 
further trial. Professor Von Langenbeck, with whom the practice originated, has reported 
the case of a man, forty-two years of age, who had been affected with an aneurism of the 
radial artery, of the size of a hazelnut, for twenty years. The injection of about three 
grains of ergotine between the skin and the tumor, was followed, in twenty-four hours, by 
its complete subsidence. It reappeared momentarily, in consequence of a slight effort 
made by the patient, but had entirely vanished at the end of eight days. In a second 
case, one of subclavian aneurism, of the size of a fist, in a man, aged forty-five years, about 
thirty grains were injected in the course of six weeks, at intervals of three days, and in 
quantities varying from half a grain to three grains. The tumor was somewhat shrunken, 
the pulsations were sensibly weakened, and the pain and paralysis of the arm and hand 
were diminished to a remarkable extent. CHAP. V. 
ANEU RISM TREATMENT. 
723 
The idea of curing aneurism by acupuncture seems to have first suggested itself to the 
fertile mind of Velpeau, who ascertained by experiments upon dogs that, if needles be 
thrust into an artery, the blood manifests a tendency to form clots around them, which, in 
a short time become so firmly adherent as to cause more or less obstruction in the circula- 
tion. He thought that this plan might be applied to the treatment of aneurism, but this 
was not done until 1831, when it was successfully employed in a case of carotid aneurism 
by Mr. Benjamin Phillips, of London. In 1879, Mr. Christopher Heath inserted three 
pairs of fine sewing needles into a traumatic subclavian aneurism, for which he had ampu- 
tated at the shoulder-joint two months previously. The needles were withdrawn on the 
fifth day, and the tumor became solid. After death from bronchitis, the aneurism was found 
to be nearly filled with dense fibrin. In a case of ilio-femoral aneurism recorded by Dr. 
Macewen, acupuncture conjoined with proximate compression proved successful. In view 
of the limited experience with the procedure, it is difficult to form an estimate of its 
value ; and this is particularly true of the cases of Heath and Macewen, in which the 
other measures employed probably contributed greatly to the success. 
Under this head may be briefly mentioned caloric puncture, a process originally em- 
ployed in 1825, by Sir Everard Home, under the supposition that the application of heat 
would favor the coagulation of the blood. His case was one of aneurism of the external 
iliac artery, for which he had twenty-eight days previously tied the superior portion of 
the femoral. He inserted a solitary needle into the tumor, and then heated its head with 
the flame of a spirit lamp. The pulsation became somewhat weaker under the applica- 
tion, but the tumor was not lessened by it. A second application was made six days 
after, with a large needle, retained for thirty-five minutes. The pulsation greatly diminished 
in force, and the contents of the tumor seemed to be solidified. Three days later, how- 
ever, the pulsation recurred with its accustomed freedom, a circumstance which suggested 
a third trial. At the end of twrenty minutes all pulsation had ceased and did not reappear 
afterwards. 
Mr. Moore, of London, in 1864, in a case of large aneurism of the arch of the aorta, 
projecting across the ribs, and almost ready to burst, attempted to induce coagulation by 
means of the introduction of a large quantity of fine iron wire, altogether twenty-six 
yards in length. It was inserted through a delicate canula, and deposited in every 
direction in the sac. Rapid coagulation was the consequence. Violent inflammation, 
however, soon ensued, pulsation recurred in the tumor, and the man died exhausted on 
the fifth day after the operation. 
The procedure suggested by Mr. Moore has been imitated by Domville, Murray, Levis, 
Bryant, Stimson, Maury, Montenovesi, and Bacelli, the materials used having been iron 
wire, catgut, horsehair, or watch springs. It has proved to be utterly useless, and is 
tedious and difficult of execution. 
1c. MANIPULATION. 
The treatment of aneurism by manipulation was first formally proposed, in 1852, by 
Sir William Fergusson. It consists in the forcible squeezing of the tumor, with the 
intention of breaking up its fibrinous contents, in order that some of the fragments thus 
detached may be carried by the circulation into the distal extremity of the artery, thereby 
closing its orifice, and so effecting a radical cure. The first case in which the treatment was 
tried was one of aneurism of the right subclavian artery, seated partly within and partly 
on the outside of the scalene muscles, the tumor being about the size of a hen’s egg. The 
sac being emptied of fluid blood, its sides were forcibly rubbed against each other, with 
the immediate effect of an arrest of pulsation in all the vessels in the limb below. The 
pulsation, however, returned in about seven hours, and the manipulation was accordingly 
repeated the next day with a similar result, but it wras not until the end of a week that 
any permanent impression appears to have been made upon the circulation. The tumor 
now gradually diminished in size, and everything gave promise of an ultimate cure, when 
suddenly, seven months afterwards, the patient was seized with violent fever attended 
with excruciating pain in the part, and died after a few days’ illness. Although the axil- 
lary artery was found, on dissection, to have been blocked up, the tumor, instead of being 
obliterated, not only remained hollow, but had extended downwards over the axillary 
plexus of nerves, the pressure upon which had probably caused the excessive pain which 
immediately preceded dissolution. In another instance, also treated by Fergusson, the 
j. ACUPUNCTURE, AND INSERTION OF FOREIGN MATERIALS. 724 
DISEASES AND INJURIES OF THE ARTERIES. 
CHAP. V. 
result was more fortunate, but the cure was not finally effected until towards the end of 
the second year. Dr. Little, in 1856, obliterated by this means an aneurism of the right 
subclavian artery. 
In a case of popliteal aneurism, reported in 1859 by Mr. Teale, of Leeds, this plan of 
treatment was successfully conjoined with digital compression. After the lattei had been 
carried on for some time, with, apparently, very little effect, a portion of clot was detached, 
leading at once to the consolidation of the tumor. The late Professor Blackman, in a case 
of large femoral aneurism, was equally fortunate. In 1872, Herbert Page, of England, 
treated a case of popliteal aneurism successfully by this means. 
Although no opportunity has presented itself to me of trying this plan of treatment, it 
is, I think”, extremely questionable whether it ought to be repeated. The great objections 
to it are, first, the uncertainty of the operation, even when the distal end of the artery 
has been blocked up; secondly, the tardiness of its progress; and, thirdly, the danger 
that some of the detached clots may find their way into the brain, as in aneurism of the 
neck, thus causing fatal apoplexy, as has already happened in several cases in which the 
method has been tried. If employed at all, therefore, it should be restricted to aneurism 
of the subclavian, axillary, femoral, and popliteal arteries, in the early stage of the dis- 
ease, before the tumor has acquired any considerable bulk ; and the treatment will be so 
much the more likely to be successful if the circulation in the tumor be kept in check for 
some hours by pressure upon the cardiac side of the artery. 
1. OPERATION OF OPENING THE SAC. 
For the reintroduction of this operation, known as the operation of Antyllus, one of 
the most delicate, difficult, and hazardous that can be undertaken, the profession, as stated 
in a previous page, is indebted to the late Professor Syme, who did so much to advance 
practical surgery. It consists, as the name implies, in laying open the sac, turning out its 
contents, and ligating the diseased vessel above and below the tumor. The procedure 
is mainly applicable to aneurism of the arteries of the extremities, particularly the femo- 
ral and popliteal, to the former of which it has been successfully applied by Mr. Gay, 
Mr. Birkett, and Mr. Cooper Forster, and to the latter by Mr. Henry Smith ; but it has 
also been performed for aneurism of the common carotid, axillary, and external iliac, as 
in the remarkable case of Mr. Syme, in which, for an enormous tumor of the last vessel, 
he tied the common, internal, and external iliac arteries, after having turned out six 
pounds of coagulated blood and fibrinous concretions. The patient recovered from the 
operation, but died in three months from another disease. In 1875, Dr. Frothingham,of 
Ann Arbor, in a case of traumatic aneurism of the common carotid artery, turned out the 
clots, and tied the artery at both ends, the operation being followed by a perfect cure. 
One great danger of this operation is from hemorrhage, which may be so rapid, exces- 
sive, and overwhelming as to render it impossible to control it before it proves fatal. 
Another source of danger is from the resulting inflammation, w hich must necessarily be 
very great when the tumor is large and of long standing, and liable to be followed by 
profuse suppuration, if not idceration and gangrene. As yet, the number of cases of this 
operation is too limited to justify us in pronouncing a final verdict in regard to its value. 
Indeed, even the particular class of cases to which it is applicable has not been deter- 
mined. 
The first point in such an operation is to guard against hemorrhage by means of the 
tourniquet or the elastic bandage, or, if this be impracticable, by digital compression. In 
Mr. Syme’s celebrated case, the circulation in the aorta was controlled by an instrument 
passed around the abdomen, and the patient, consequently, lost hardly any blood. In 
laying open the sac, the proper plan undoubtedly is to make, at first, as suggested by the 
Scotch surgeon, a very small incision, an incision barely sufficient to admit the fingers, 
and then to enlarge it gradually until the whole hand can be insinuated, which thus 
answers as a plug to the wound while the fingers are pressed firmly against the orifices of 
the diseased artery so as to restrain the escape of their contents. As soon as the flow of 
blood is fully arrested, the aneurism is freed of its clots and concretions, and the artery 
tied above and below', or at its cardiac and distal extremities, the latter precaution being 
essential to the prevention of hemorrhage by the recurrent circulation. The application 
of the ligature will be greatly facilitated if, as was originally practised by Antyllus, and 
lately by Mr. Birkett, of Guy’s Hospital, a probe, bougie, or director be introduced into 
the vessel, to serve as a guide to the knife, which cannot be used with too much caution, CHAP. V. 
ANEURISM — TREATMENT. 
725 
inasmuch as the artery is often overlapped, to a considerable extent, by the aneurism, and 
cannot be properly exposed without a most delicate and tedious dissection. Any undue 
oozing from the inner surface of the sac may readily be arrested by the use of Monsel’s 
salt. 
The after-treatment must be conducted with special reference to the avoidance of sec- 
ondary hemorrhage, high inflammation, erysipelas, and pyemia. The suppuration must 
necessarily be often very profuse, and it is, therefore, impossible to be too zealous in the 
use of detergent and deodorizing lotions, fresh air, and a properly regulated diet. 
m. valsalva’s treatment of internal aneurism. 
Internal aneurisms, inaccessible to the ligature and compression, occasionally recover 
under a regular and systematic course of treatment designed to promote the coagulation 
of the blood in the interior of the tumor, by increasing the plastic properties of this fluid, 
and quieting the action of the heart and arteries. This treatment, which was originally 
suggested by Valsalva, and which still bears his name, consists in the strict observance of 
the recumbent posture, perfect mental quietude, the occasional abstraction of blood from 
the arm, and the use, simply, of a sufficiency of food and drink to prevent starvation. 
When, writes Morgagni, Valsalva had taken away as much blood as was deemed neces- 
sary, he diminished the diet “ more and more every day, until only half a pound of pud- 
ding was taken in the morning, and in the evening half that quantity, and nothing else 
except water, the weight of which was also regulated, and which he medicated with what 
is called quince-jelly, or the lapis osteocolla, ground down into a very fine powder. After 
the patient had been sufficiently reduced by this method, so that he could scarcely raise 
his bead from the bed, to which, by Valsalva’s direction, he was confined, the quantity of 
aliment was day by day increased, until the strength that was necessary to enable him to 
get up hud returned.” 
Whether Valsalva effected any cures by this method of treatment is not known ; if he 
did, they must have been very few, as the plan is, with one or two exceptions, founded 
upon entirely erroneous principles, frequent venesection, and a very reduced diet, almost 
carried to starvation, being anything but conducive to the fibrinization of the blood in the 
aneurism, by which alone the alteration of the sac can be essayed. Indeed, experience 
has shown that the only true course to be pursued is the physiological one, in which the 
abstraction of blood is scrupulously abstained from, at the same time that a sufficient 
amount of food is allowed to prevent that irritability of the system which is always sure 
to arise when the body is for any length of time imperfectly nourished. The quantity of 
solid food should not be less, on an average, in the twenty-four hours, than from nine to 
twelve ounces, consisting of equal parts of hashed meat and bread, potato, or rice, at din- 
ner, with a suitable quantity of stale bread, toast, or cracker at breakfast and supper; tea, 
coffee, and all other drinks, excepting water, lemonade, and milk, as well as all kinds of 
condiments, being strictly avoided. The patient should be kept perfectly at rest, in the 
recumbent posture, with the mind in as tranquil a state as possible, while the system 
should be steadily maintained under the use of tincture of aconite, or of veratrum viride, 
conjoined with acetate of lead and opium ; or, what would be better, as more likely to pro- 
mote fibrinization of the blood, ergot and subsulphate of iron. The pulse should be brought 
down, if practicable, to forty-five or fifty beats in the minute, and the chances of success 
would be all the greater if a prolonged state of somnolency could be maintained, the 
patient sleeping the greater part of the twenty-four hours. Protracted constipation of the 
bowels should be aimed at; if purgatives become indispensable, they must be of the mild- 
est character, as all irritating and griping articles are sure to do harm by exciting the 
action of the heart and arteries. 
The length of time during which this treatment should be continued must vary accord- 
ing to the circumstances of each individual case, and no attempt should, therefore, be 
made to reduce it to any general principles. It certainly might, with judicious manage- 
ment, be kept up, without detriment, for a number of consecutive weeks, if, indeed, not 
several months. As the patient emerges from it, he should return, very gradually and 
cautiously, to his accustomed diet, except that, fora long time afterwards, it should be free 
from all stimulants ; nor should he, for a similar reason, take any, except the most gentle, 
exercise. In short, everything should be done to second nature in her efforts to effect the 
cure thus auspiciously begun, and which, other things being equal, will always be so much 
the more likely to take place if the aneurism is small and of recent standing. 726 
DISEASES AND INJURIES OF THE ARTERIES. 
CHAP. V. 
My opportunities for treating abdominal and intrathoracic aneurisms according to the 
plan here sketched have not been sufficiently extended to enable me to form anything like 
a correct estimate of its value. In the cases in which I have employed it, although the 
patients seemed to be materially benefited, so far as pain was concerned, and the pulse 
was brought down below fifty, the progress of the disease was apparently not at all re- 
tarded. It is proper, however, to add that all the cases were far advanced when they fell 
into my hands. Professor Tufnell, of Dublin, in 1874, reported a number of instances 
treated upon this principle, in which permanent cures were happily effected. In a case 
reported by Mr. Head, in 1877, an aneurism of the innominate artery, apparently in a 
very unfavorable condition, was successfully relieved by this method. Pelletan, Surgeon 
to the Hotel-Dieu, of Paris, in the early part of the present century, obtained remarkable 
results from the Valsalvian method ; he conjoined with it the application of ice, or of cold 
and astringent lotions, and a number of his cases were either partially or completely cured 
by it. Roux also had a successful case of aneurism of the thoracic aorta. 
To sum up the modern medical treatment of internal aneurisms, the essential points 
consist of perfect tranquillity of mind and body, absolute confinement in the recumbent 
posture, a restricted diet, consisting principally of solids, a retarded circulation, and a 
healthy state of the blood. 
When the cause of the disease is a syphilitic taint of the system, the most reliable inter- 
nal remedy undoubtedly is iodide of potassium, either alone or in union with mercury, in 
doses, at first, of eight or ten grains thrice a day, gradually increased to fifteen or even 
twenty grains, according to the tolerance of the stomach. Excellent cures are occasion- 
ally effected by this remedy in cases even apparently more or less desperate. 
n. GENERAL MEDICAL AND SURGICAL TREATMENT. 
Persons affected with aneurism often experience, as stated elsewhere, great pain and 
other suffering, both from the inflamed condition of the tumor and from the pressure which 
it exerts upon the surrounding parts. In aneurism of the thoracic portion of the aorta 
and of the arteries at the root of the neck, the pain and dyspntca are sometimes excessive, 
demanding prompt and vigorous measures for their relief. If the patient is plethoric, and 
the pulsation in the tumor uncommonly active, the loss of six, eight, or even twelve ounces 
of blood will be useful, but care must be taken not to carry the venesection too far, other- 
wise injurious reaction may take place, and thus aggravate tlie suffering. When the tumor 
is accessible, or situated externally, whether partly or entirely, the blood is often most 
advantageously abstracted directly from the part by means of leeches, which, even when 
employed only in small numbers, generally afford immense relief, both as it respects the 
pain and the difficulty of breathing. Topical depletion is always extremely serviceable,in 
inflamed aneurism, and it is here also that fomentations and refrigerating lotions, simple 
or medicated, come into play, frequently exerting their happiest influence. The choice of 
these remedies must be governed in these, as in other cases, by the tolerance of the part 
and system. Attention to position and rest must be enjoined, and strictly carried out. 
'fhe bowels are not neglected, but great care is taken to avoid active purgation, experience 
having shown that this always produces undue excitement of the vascular and nervous sys- 
tems. Anodynes are always well borne in these cases, and are often indispensably necessary 
to relieve pain and promote sleep; they should be administered in full doses, either alone 
or in union with diaphoretics and expectorants, according to the condition of the skin and 
of the respiratory organs. Any complications that may arise during the progress of the 
disease, whether self-existent or dependent upon the irritation produced by the pressure of 
the tumor, must be treated upon broad general principles. 
When an aneurism becomes diffused, by parting with its fluid contents, in consequence 
of the partial destruction of its sac, whether by ulceration, gangrene, or rupture, the case 
at once assumes an additional importance, inasmuch as the occurrence greatly increases 
the patient’s danger. In internal aneurism little is to be done in the way of treatment, 
under such circumstances, beyond attention to the circulation, the moderation of the force 
and frequency of which may, perhaps, assist in prolonging life, and, occasionally, there is 
reason to believe, even in effecting a radical cure by promoting the formation of coagula. 
When the disease is seated in an extremity, as the thigh or leg, and the tumor is of com- 
paratively small size, without any tendency to gangrene in t! • distal portion of the limb, 
the proper plan unquestionably is, either to tie the main artery, or to arrest the circula- 
tion in the tumor by rapid and forcible compression while the patient is under the 
influence of anaesthesia. In this way, further extravasation will be prevented, and the FALSE ANEURISM. 
727 
CHAP. V. 
case will be likely to progress favorably. If, on the contrary, the tumor is of immense 
size, the limb hugely swollen, and the pulsation completely arrested ; or if, in addition to 
all this mischief, there is marked gangrene, the only safety is immediate amputation at a 
suitable distance above the aneurism. 
FALSE ANEURISM. 
A false aneurism is a pulsating tumor formed external to the affected artery, and, con- 
sequently, without any aid whatever from its tunics. A number of affections, of a very 
opposite character, have been described under this appellation, and much confusion has 
been the result. To remedy this evil, I shall limit myself, in the account which I am 
about to give of the disease, to two varieties of false aneurism, the arterial and arterio- 
venous, the tumor in each being strictly circumscribed, and connected, in the former, 
with an artery, and, in the latter, both with an artery and a vein. What is called a dif- 
fused aneurism is, in fact, as stated elsewhere, no aneurism at all, but simply an accumu- 
lation of blood in the subcutaneous and intermuscular connective tissue, which, although it 
may be somewhat condensed around it, does not, in reality, in the true meaning of the 
word, constitute a proper aneurismal sac. 
The most common cause of the spurious arterial aneurism is external injury, as a stab 
or puncture, such, for example, as was formerly so often inflicted in venesection at the 
bend of the arm, permitting the blood to escape in small quantity into the surrounding 
connective tissue, which is soon condensed into a firm, circumscribed, pulsating cyst, 
often not exceeding the volume of a pullet’s egg, and of a rounded or ovoidal figure. 
Similar effects occasionally follow the laceration of an artery, as that of the ham, from 
the sudden and forcible extension of the leg, from the intrusion of the sharp end of a 
broken bone, or from ulcerative action. 
Sometimes the aneurismal formation is secondary; that is, consequent upon the partial 
cicatrization of the wound, the interposed or overlying plasma being unable to withstand 
the impulse of the blood, and so yielding before it. However induced, all the tunics of 
the artery are at once perforated, and the blood is sent abroad into the circumjacent con- 
nective tissue, in the manner and with the effect just stated. 
The sac in this variety of aneurism, formed originally out of the neighboring connective 
tissue, is speedily strengthened by the effusion of plastic matter, so that, in time, it often 
acquires considerable thickness, with an extraordinary degree of density. A number of 
cases have been under my observation in which the cyst, even at an early stage of the 
disease, was of a very firm, compact, fibroid consistence, and of a white, glistening 
appearance, its substance being convertible, by dissection, into several distinct strata. 
The tumor, particularly in cases of long standing, generally contains well-organized con- 
cretions, arranged in the same concentric manner as in the true sacculated aneurism, and 
presenting a similar hue and consistence. The course, symptoms, and termination of this 
disease do not require any special notice, as they do not differ, in any respect, from the 
ordinary form of the affection. 
The treatment may be conducted by compression, or, this failing, by ligature. T! e 
compression is applied, as in true aneurism, upon the cardiac aspeet of the tumor, four, 
six, or eight inches from it, with the instruments already described, retardation of the 
circulation and gradual obliteration of the sac being steadily kept in view. If an opera- 
tion becomes necessary, a free incision is carried across the tumor, and a ligature applied 
immediately above and below, as in an ordinary wounded artery. The tumor may then 
be dissected out, or, as some prefer, although I think improperly, it may be left to the. 
influence of the absorbents. As a preliminary step, a tourniquet is cast around the limb, 
to control the circulation in the affected vessel. Although one ligature is occasionally 
sufficient to effect a cure in this disease, it is always best to ligate the vessel both above 
and below the swelling, lest trouble should arise on account of the recurrent circulation, 
and thus lead to the necessity of doing at a subsequent period what ought to have been 
done in the first instance. The memorable case of Ariel affords an excellent illustration of 
the fact that an aneurism of this kind, especially when seated at the bend of the arm, 
may occasionally be cured by one ligature applied just above the tumor. 
1. The arterio-venous aneurism, originally described under the name of variocose 
aneurism, is a tumor situated, as the term implies, between a contiguous artery and vein, 
so as to admit of a ready interchange of the two kinds of blood. The most common site 
of it is the bend of the arm, as seen in figs. 334 and 333, where it is generally caused 
by a puncture in bleeding, in which the overlying vein, usually the median basilic, is 728 
DISEASES AND INJURIES OF THE ARTERIES. 
CUAP. V. 
completely transfixed along with the superficial wall of the brachial aitery. A similar 
accident may, of course, happen in any other part of the body, from a stab or wound of a 
contiguous artery and vein, as between the femoral, or the aorta and vena cava; and, what 
is remarkable, the disease occasionally does not show itself until long after the infliction 
Fig. 334. 
of the injury. Thus, Roux relates a case in which an arterio-venous aneurism formed at 
the bend of the arm four years after venesection; and Rokitansky observed a similar 
tumor in the axillary artery and vein thirty 
years after they had been struck by a shot. 
Sometimes, again, the aneurism forms in 
consequence of ulceration, beginning in one 
vessel and gradually extending to the other, 
and so eventually establishing a communica- 
tion between them through the intervention 
of a sac. Dissection has proved that such a 
connection may take place in deeply-seated 
as well as in superficial veins. In a case de- 
scribed by Schottin the aneurism existed be- 
tween the radial artery and the cephalic vein; 
and in one seen by Charnal it had formed 
between a deep vein and the brachial artery. 
A remarkable case of arterio-venous tumor, altogether unique in character, in which 
the cyst was formed by the expansion of the component structures of a nerve, has been 
reported by Mr. C. II. Moore, of London. 
In whatever manner the aneurism is formed, the cyst is usually of small size, seldom 
exceeding, and not often equalling, that of a pullet’s egg. It is composed partly of con- 
densed connective tissue and partly of plastic matter, the latter always greatly predomi- 
nating, as is shown by its extraordinary thickness as well as density, which closely 
resembles that of the fibrous tissue. The aneurism, although seldom very painful, always 
interferes more or less with the functions of the affected limb. As the opening of com- 
munication is always very small, the blood rushes into it with a peculiar noise, not 
unlike that produced by the buzzing of a fly in a paper box, or the purring of a cat. 
Sometimes the sound is of a whirring character, similar to the prolonged articulation of 
the letter Ii. It is perceived both by the ear and linger, and is so extraordinary that it 
may be regarded as pathognomonic. The sac rarely contains any well-formed fibrinous 
concretions, and, hence, it is generally found to be perfectly smooth, white, and glisten- 
ing, like the interior of an artery. Manifesting little disposition to increase, it may 
remain stationary for years, and seldom, if ever, undergoes spontaneous cure, or termi- 
nates in rupture, ulceration, or grangrene. 
When the tumor is very small, not exceeding the volume of a filbert, or a pigeon’s egg, 
and does not occasion any suffering, interference is neither desirable nor proper ; it is 
merely an inconvenience, and had better be let alone. The reverse, however, is usually 
the case, and then the same treatment will be required as in spurious aneurism connected 
with an artery only; that is, the vessel is tied immediately above and below the tumor, 
which is either left to undergo absorption, or, what is often preferable, it is carefully dis- 
sected out; an operation which, if performed with the aid of the elastic bandage, is gene- 
rally bloodless. 
Digital compression of the artery above the sac and of the opening leading from the 
sac to the vein should be employed before resorting to harsher ...easures. Of fourteen ex- 
amples, in at least six of which the above method was employed, eleven were cured. In a 
case of varicose aneurism of the brachial artery Vanzetti succeeded in effecting a cure in 
six hours. 
Varicose Aneurism ; External Appearance. 
Fig. 335. 
Varicose Aneurism ; Internal View. a. The Artery. 
b. The Vein. c. The Intermediate Cyst. 729 
CHAP. V. 
When the disease Occurs in connection with the aorta and vena cava, operative inter- 
ference will, of course, be out of the question ; nor can anything be hoped for from medical 
treatment. The case, in fact, is irremediable, and will be sure eventually to cause death, 
either by the gradual giving way of the sac, or by exciting violent irritation, pain, and 
constitutional disorder. 
2. Aneurismal varix, fig. 336, consists in a direct communication between a contiguous 
vein and artery, without the intervention of a sac ; it differs, therefore, essentially from a 
varicose aneurism, in which, as has just been seen, there is always a distinct cyst, formed 
FALSE ANEURISM. 
Fig. 336. 
Aueurismal Varix. 
out of the surrounding tissues, along with more or less plasma. The affection is altogether 
so unlike aneurism, whether true or spurious, that it is surprising it should ever have been 
included in the same category. 
The cause of aneurismal varix—a disease first described by Dr. William Hunter, in 
1756—is usually some external injury, such as a puncture, transfixing a vein and piercing 
the contiguous wall of an underlying artery. Hence the lesion is most common at the 
bend of the arm, between the median basilic vein and brachial artery, in consequence ot 
venesection. It may, however, occur between other veins and arteries lying in juxta- 
position with each other, either through accident, or from the effects of ulceration com- 
mencing in the coats of one vessel and gradually perforating those of the other. In fact, 
it has been noticed in all the larger vessels, as the carotid and jugular, the subclavian, 
and axillary, the aorta and vena cava, the iliac, femoral, popliteal, and tibial. Several 
cases have fallen under my observation in which the disease followed upon amputation of 
the thigh. The orifice of communication is usually small, and of a circular shape, 
with well-defined margins, although there is, in this respect, no particular uniformity. The 
adhesion between the two vessels is generally very firm, as well as of considerable extent, 
and it is well that it should be so, otherwise there would be constant danger .of the 
connection giving way. Owing to the incessant interchange and commingling of the two 
kinds of blood, the vessels gradually undergo important changes, the most interesting of 
which are that the vein assumes the pro(>erties of an artery, and the artery those of a 
vein. The vein, from the impetuous manner in which the arterial blood is sent into it at 
each stroke of the heart, becomes greatly enlarged both above and below the abnormal 
opening, at the same time that it acquires an extraordinary degree of density, and pulsates 
with unusual force. In the arm, in which I have met with a number of instances of this 
disease, I have found the dilatation of the vein to extend, on the one hand, nearly as 
high up as the axilla, and on the other, as low down as the middle of the forearm. The 
artery, which now receives black blood, but not in any large quantity, is eventually trans- 
formed into a soft, thin, flexuous tube, which, possessing the properties of a vein rather 
than those of an artery, pulsates but feebly under the finger. 
The formation of this disease is generally attended with some degree of pain and swell- 
ing, along with interstitial effusions, causing the integument to pit slightly on pressure. 
The parts below the seat of the lesion are imperfectly nourished, and hence they usually 
feel somewhat cold and numb until the circulation is fully reestablished through the agency 
of the collateral branches. As the blood passes from one vessel into the other, it pro- 
duces a peculiar jarring sensation and a singular whirring noise, not unlike the purring of 
a cat, which often extends to a great distance along the dilated vein, now performing 
vicariously the functions of an artery, and which may be regarded as the pathognomonic 
signs of the disease. Occasionally a distinct tumor of considerable bulk is formed, con- 
sisting mainly of enlarged and tortuous veins. 
In most of the cases of this lesion that have fallen under my observation, the incon- 
venience has been so trifling that I have not considered it proper to resort to operative 
interference. In one instance the patient had an aneurismal varix on the right arm from 
venesection performed upwards of fifteen years previously, and, although he was a black- 780 DISEASES AND INJURIES OF THE ARTERIES. ciiap. v. 
smith and a hard-working man, it did not in the least interfere with his occupation. Cases 
of aneurismal varix in different parts of the body, in which the disease remained station- 
ary for fourteen, twenty, thirty, and even thirty-five years, are mentioned by Hunter, 
Pott, Bell, Guattani, Scarpa, Breschet, Dupuytren, and other writers. 
Several instances have been recorded in which a spontaneous cure is said to have taken 
place, but such an event must necessarily be very uncommon. The inconvenience caused 
by the pain and throbbing, which are often very distressing, may generally be greatly miti- 
gated by the steady and persistent use of an elastic bandage or stocking, as in the treat- 
ment of varicose veins of the extremities. When the parts are hot and inflamed saturnine 
lotions will be of benefit, especially if combined with rest and elevation of the parts. 
Cases in which a cure was effected by steady systematic compression have been recorded 
by Guattani, Monteggia, Oldknow, Samuel Cooper, and others. 
The surgical treatment of this variety of aneurism has, within the last few years, ac- 
quired new interest from the fact that in nearly every instance in which the so-called 
Hunterian operation has been employed, the result has been fatal, the immediate cause of 
death being gangrene, or secondary hemorrhage, or a union of both. The cases of Physick, 
Atkinson, Mott, Charles Bell, Dupuytren, Harris, Baroni, Fleischer, Morrison, and others, 
sufficiently attest the danger of surgical interference in this form of aneurism, especially 
when the disease is chronic, and accompanied by great enlargement of the vessels, extend- 
ing far beyond the original seat of the affection. Even, however, in recent cases, ligation 
of the principal artery is by no means devoid of risk, since the effect is to deprive the parts 
in the distal portion of the limb of an amount of blood which they can ill spare. Another 
source of danger in all cases of aneurismal varix is the diseased and attenuated condition 
of the arteries, causing their coats to yield readily under the slightest pressure of the 
ligature. Finally, I may mention, as another source of risk after the Hunterian operation, 
the difficulty which the blood experiences in forming a firm clot, owing to the fact mainly, 
if not exclusively, that blood is still freely sent into the artery by the associate vein after 
the application of the ligature. 
The danger of secondary hemorrhage after such an operation is well illustrated in a 
case of aneurismal varix, in the stump of the thigh of a man, twenty-eight years of age, 
for whose relief in 1870 I ligated the femoral artery a short distance below Poupart’s 
ligament. The thigh had been amputated six years previously by the circular method, 
three inches above the knee. The stump was eleven inches in length, very conical, greatly 
atrophied, and the seat of constant throbbing pain, rendering the use of an artificial limb 
impracticable. The femoral artery and vein were greatly enlarged as high up as the brim 
of the pelvis, while the vein, just above the end of the stump, was expanded into a convo- 
luted pulsating tumor, nearly the size of an ordinary fist. Pressure upon the artery below 
the groin completely arrested the pulsation in the tumor and also the aneurismal thrill. 
A vertical incision two incites in length, commencing twelve lines below Poupart’s ligament, 
exposed the artery, which was then cautiously isolated, and encircled with a silk ligature 
loosely tied over a cylinder of adhesive plaster resting upon the skin exterior to the wound, 
which was united by four sutures. The object of this procedure was to remove the liga- 
ture as soon as a firm clot should form, but no clot of any kind was developed, and the man 
died, completely exhausted, of repeated at tacks of hemorrhage, nine days and a half after 
the operation, the first bleeding having occurred at the end of the sixth day. 
In view of all these circumstances,—the changed condition of the bloodvessels, the 
imperfect circulation in the distal portion of the limb, the difficulty of obtaining a firm clot 
after the ligation of the main artery, and the fact that patients thus affected occasionally 
live for many years in comparative comfort, with the additional knowledge that a spon- 
taneous cure now and then occurs, and that the disease if left to itself, rarely causes death— 
1 am satisfied that the Hunterian operation for the relief of aneurismal varix should be 
abandoned as an unjustifiable measure. In desperate cases involving the distal portion of 
a limb, and attended with intolerable suffering, amputation is, of course, the only resource. 
SECT. VII.—ANEURISM OF PARTICULAR ARTERIES. 
ANEURISM OF THE THORACIC AORTA. 
I he merest glance at the situation of this vessel is sufficient to impress us with the 
great importance ot its relations, and to show that any deviation from its normal con- 
dition, however slight, may be productive of the most fatal consequences. 
The disease may exist, 1st, as a fusiform expansion ; 2dly, as a dilatation of the coats ot ANEURISM OF THE THORACIC AORTA. 
731 
CHAP. V. 
the vessel, affecting the greater portion, if not the whole, of its circumference ; or, 3dly, 
as a true, false, or mixed aneurism, properly so called, of variable size and shape, gene- 
rally connected with the anterior or lateral aspect of the artery, the posterior being seldom 
implicated. The ascending portion and arch of the aorta, especially the latter, are by far 
the most frequent seats of the disease, owing to their vicinity to the heart, which thus 
imparts to them its impulsive and expansive movements, and to their greater proneness to 
fatty and other degenerations, rendering their tunics weak and brittle, and, consequently, 
liable to laceration. Of 703 cases, collected by Dr. Sibson, of London, 87 occurred in the 
arch of the aorta within the pericardium, and 193 on the outside of this bag. The ascend- 
ing and transverse portions were affected in 140 cases; the transverse alone in 120 cases; 
and, conjointly with the descending aorta, in 20 cases ; the descending portion of the arch 
in 72 cases; and the vessel below the arch in 71 cases. The aneurism is generally of the 
true species, commencing as a sac-like enlargement, which, as it increases, usually in- 
clines to the right side of the chest, and is capable of acquiring a volume equal to that of 
a double list. It is soon occupied with organized clots, which occasionally, though very 
rarely, accumulate to such an extent as to lay the foundation of a spontaneous cure. The 
opening of communication between the tumor and the artery varies in size from that of a 
dime to that of a twenty-five cent piece. 
The disease is more common in men than in women, and not unfrequently arises at a 
comparatively early age, as from twenty-five to thirty, in consequence, apparently, of 
severe straining and other bodily exertion. Mr. Hutchinson has reported a case of aneu- 
rism of the arch of the aorta in a girl four years old, probably due to ulceration caused by 
the pressure of an abscess. Sailors and mechanics are peculiarly liable to the disease. 
The remarkable frequency of aneurism of this vessel is shown by the tables of Mr. Crisp, 
embracing 915 cases, of which 382 affected the thoracic aorta. 
The duration of thoracic aneurism varies from a few months to upwards of three years, 
the average being from nine to twelve months. The tumor usually bursts into the left 
pleura, pericardium, trachea, bronchial tubes, oesophagus, or 
posterior mediastinum; sometimes into the heart, lungs, or 
spinal canal; and sometimes, again, but also very rarely, 
externally. Dr. Darrach, of Illinois, has shown by an 
analysis of twenty-three cases that aneurism of the descend- 
ing aorta terminates pretty uniformly by rupture, while that 
of the arch generally ends by exhaustion and irritation, 
or some concomitant disease of the heart, brain, lung, or 
kidney. Occasionally the tumor gives way when it is not 
larger than a pullet’s egg. Fig. 337 represents an aneurism 
of the arch of the aorta which had burst into the trachea. 
The symptoms of aneurism in this situation are chiefly of 
a mechanical character, arising from the pressure of the 
tumor upon the surrounding structures. They consist 
mainly of pain, cough, dyspnoea, dysphagia, enlargement at 
the sterno-clavicular region, and of various kinds of sounds, 
synchronous with the action of the heart. 
Pain, from the constancy of its occurrence, is a symp- 
tom of great value. It comes on early in the disease, is 
more severe in sacculated than in fusiform aneurism, and is evidently dependent, at first, 
or so long as the tumor is comparatively small, upon the pressure which the aneurism 
exerts upon the spinal and sympathetic nerves, and afterwards upon this cause and upon 
the erosion and perforation of the tissues, especially the sternum, ribs, and vertebrae. It 
varies much in degree, character, and situation. In the earlier stages of the disease it is 
most conspicuous on the left side; it is sharp, lancinating, and intermittent, not unlike the 
pain of neuralgia, darting about in different directions ; at one time into the neck and face, 
at another through the chest and spine, now along the shoulder and arm, and now through 
the diaphragm and even the loins. As the tumor enlarges, and, by its pressure, erodes 
the neighboring structures, the pain becomes more steady, fixed, and severe; it gradually 
shifts to the right side, and is generally of a burning, gnawing, or boring character. 
Cough is also a common symptom ; it generally begins early in the disease, and is liable 
to severe exacerbations, often productive of intense suffering. It is of a crowing, stridulous, 
or ringing character, and obviously depends upon the irritation caused by the pressure of 
the tumor upon the air-passages. Sometimes it is short, spasmodic, and laryngeal. 
The dyspnoea is always more or less distressing, especially when the disease has made 
Fig. 337. 
Aneurism of the Arch of tho Aorta 
opening into the Trachea. 732 
DISEASES AND INJURIES OF THE ARTERIES. 
chap. v. 
considerable progress, and is invariably aggravated by severe bodily exertion, as in walk- 
ing up a hill, or ascending a flight of stairs. It is occasionally extremely violent, although 
the tumor may not exceed the size of a walnut, owing to the pressure which it exerts upon 
the trachea, or the trachea and bronchial tubes. During the latter stages of the complaint, 
the breathing is always so difficult as to prevent the patient from lying down, perhaps for 
days before lie expires. 
Dysphagia is seldom present until after the disease has made considerable progress, 
although it is sure, in the end, to become a prominent symptom ; so that, ultimately, the 
sufferer finds it very difficult to swallow anything either in the form of food or drink. 
Derangement of the functions of the stomach is frequently present, manifesting itself 
in a sense of fulness and oppression ; flatulence, acidity, and eructations, evidently 
dependent upon the pressure of the sac upon the pneumogastric and sympathetic nerves. 
Now and then there is obstruction of the thoracic duct from the direct pressure of the 
tumor, interfering with nutrition, and aiding in the production of the peculiar cachexia 
so common in the latter stages of this disease. 
It is not often that there is any external tumor, except when the aneurism points in 
front of the chest, as it frequently does in its latter stages, after it has partially destroyed 
the sternum and the ribs, or the ribs and intercostal cartilages. In the great majority of 
cases it shows itself on the right side of the chest from three to four inches below the 
collar-bone, as a pulsating swelling, lifting up the integument synchronously with the 
contraction of the heart, furnishing a distinct bellows, sawing, or purring sound, and 
being exquisitely tender on pressure. Occasionally the sac projects into the neck above 
the fourchette of the sternum, inclining towards the right sterno-clavicular articulation. 
When this is the case, it must necessarily overlap the innominate, common carotid, and 
subclavian arteries on the right side, and may even so effectually compress them as to 
cause their obliteration, although such an event is very unusual. 
A distinct aneurismal sound, or purring tremor, is usually perceptible at an early stage 
of the disease, although it is extremely difficult, if not impossible, always to refer it to its 
proper source. It is synchronous with the beat of the heart, and gradually becomes more 
and more faint as the disease advances, in consequence of the progressive filling up of the 
sac by coagula. 
Among the less constant symptoms are, palpitation of the heart, wheezing, panting, or 
asthmatic respiration, tracheal and bronchial rales, sense of constriction of the chest, 
oedema and lividity of the face, permanent contraction, or, more rarely, dilatation of one 
of the pupils, feebleness and irregularity of the pulse at the wrist, from the pressure of the 
tumor upon the innominate or subclavian artery, and anasarca of the extremities, espe- 
cially the inferior. Alteration of the voice is by no means uncommon, and occasionally 
amounts to complete aphonia. In the more advanced stages of the disease there is also 
frequently an enlarged and varicose state of the subcutaneous veins over the upper part 
of the chest, generally towards the right side. 
The diagnosis of intrathoracic aneurism is often extremely difficult; for, although the 
disease manifests itself by numerous symptoms, there is not a single one that can be con- 
sidered as absolutely reliable. It is not surprising, therefore, that it should frequently 
terminate fatally, without any suspicion as to its true nature. Such an error will be most 
likely to happen when the tumor is small, or when it bursts into some neighboring canal 
before it has sensibly encroached upon the walls of the chest. As it increases in volume, 
its character becomes daily more and more apparent, and all doubt must, of course, vanish 
when the tumor points externally, although even then a careless practitioner might regard 
it as an abscess, and under this supposition, be perhaps even induced to open it, as I have 
known in two cases, notwithstanding the heaving and pulsating nature of the swelling, 
and the existence of all the other signs of aneurism. When the aneurism arises from the 
summit of the aorta, the tumor projects into the root of the neck, and may, in fact, ascend 
so high up as to simulate aneurism of the innominate or carotid artery. From this, how- 
ever, it may generally be readily distinguished by the history of the case, by the impos- 
sibility of tracing with the finger the lower boundary of the tumor, by the dulness on 
percussion of the upper part of the chest, and by the presence of a larger amount of dyspnoea 
than usually attends cervical aneurism, particularly in its ea-*»er stages. 
I he auscultatory signs rarely afford any conclusive evidence of intrathoracic aneurism. 
1'ew surgeons are able to discriminate between the sounds of the heart and those of such 
a tumor, and the difficulty must necessarily be much increased when, as not unfrequently 
happens, aneurism and cardiac disease coexist. When the heart is sound, and the aneu- 
rism has attained a considerable bulk, the diagnosis will be less ambiguous ; but even CHAP. V. 
ANEURISM OF THE THORACIC AORTA. 
733 
then it will require a very practised ear to detect the varying shades of difference. The 
sound of a thoracic aneurism is more like the purring of a cat than the clear murmur 
attending the first sound of the heart, and its distinctive features are still further defined 
by the presence of a peculiar tremor or vibratory movement. In the sacculated variety 
of the affection, it is often impossible to distinguish any abnormal sound whatever; at 
first, because of the small size of the swelling, and subsequently, because the tumor is 
filled witli coagula, impeding if not preventing, the transmission of sound. In fusiform 
aneurism, and also in simple but extensive dilatation, the sound characteristic of the dis- 
ease is generally easily recognized throughout its entire progress. 
Gastric disturbance is generally a prominent symptom of intrathoracie aneurism, and 
occurring in association with dysphagia, is a sign of great value. Dr. Walter F. Atlee 
recently called attention to long-continued obstinate eructation as a symptom of much 
significance. He attended a gentleman for eighteen months on account of what appeared 
to be simply a rebellious attack of dyspepsia, accompanied with the most distressing flatu- 
lence and eructation. Death occurred suddenly and unexpectedly from the rupture of a 
circumscribed aneurism of the thoracic aorta not larger than a walnut. 
Dulness on percussion, in a marked degree, can exist only in the event of the tumor 
being of considerable bulk ; a small aneurism may be present, and even prove fatal, with- 
out any change of resonance. When there is dulness, it is always most conspicuous at 
the upper and middle parts of the chest. 
Sometimes valuable diagnostic information may be derived from the displacement of 
the heart by the tumor, its pulsations being perceived in an abnormal position, where 
there is no evidence of pleuritic effusion or disease of the lungs to account for the change. 
The precise situation of an intrathoracie aneurism is frequently, if not generally, indi- 
cated by the character of the functional disturbance. Thus, when the suffering is chiefly 
laryngeal, the inference is that the innominate artery, or the posterior and inferior portion 
of the arch of the aorta, is involved. Excessive pectoral constriction is caused when the 
tumor compresses the cardiac plexus, as when it springs from the ascending portion of 
the arch. Dysphagia denotes pressure either upon the oesophagus or upon the pneumo- 
gastrie nerve, and a corresponding situation of the aneurism. When the disease produces 
bronchial asthma and orthopncea, the probability is that the tumor involves the commence- 
ment of the descending portion of the arch. Permanent contraction of the pupil is caused 
by compression of the sympathetic nerve, as when the aneurism, arising from the superior 
and posterior part of the arch of the aorta or its primitive branches, projects backwards 
into the chest and neck. 
Dr. W. T. Gardiner, of Edinburgh, who has carefully studied the nature of these func- 
tional disorders, states that “all aneurisms coming within the range of physical diagnosis, 
and not attended by any of the above symptoms, must necessarily arise either from the 
descending aorta, below the range of the pulmonary plexus, or from the upper part of the 
arch, projecting upwards and forwards; as it is in these situations alone that a thoracic 
aneurism can attain sufficient bulk to be discoverable, without involving important internal 
structures, and leading to very marked functional disturbance.” 
Among the affections with which aneurism of the thoracic aorta is most liable to be con- 
founded are malignant tumors of the chest, especially sarcomas and lymphomas, abscess 
of the neck and of the anterior mediastinum, disease of the heart, as hypertrophy and 
valvular derangement, and aneurism of the innominate, carotid, and subclavian arteries. 
The best security against error will be an attentive consideration of the history of the 
case, and a thorough study of its progress, time often throwing more light upon the 
character of the malady than the most elaborate auscultatory explorations. 
I)r. Drummond, of New Castle, England, has drawn attention to a sign, which, if 
verified by future observation, may prove to be of great value in determining the diagnosis 
of thoracic aneurism. It is based upon the fact that when the patient takes a deep inspi- 
ration, and then closes the mouth and expires slowly through the nose, short, puffing 
sounds are heard, synchronous with the systole of the heart, on auscultation of the 
trachea. The phenomenon is supposed to be due to the sudden systolic expansion of the 
sac compressing the lungs and forcing out the air. 
The treatment of intrathoracie aneurism rpsolves itself into the adoption of measures 
to relieve the patient’s sufferings rather than to cure his disease, of which there is, in any 
event, hardly even a remote possibility. If plethora exist, an occasional bleeding cannot 
fail to ameliorate, at least for a time, the pain and difficulty of breathing. The circula- 
tion should be controlled by perfect quietude of mind and body aided by the cautious use 734 
DISEASES ANI) INJURIES OF THE ARTERIES. 
CHAP. V. 
of aconite or veratrum virule; the diet must be light and concentrated, the bowels main- 
tained in an open state, and suffering allayed by anodynes. 
When, in spite of medical treatment, the progress of the tumor is not arrested, the 
common carotid artery, or that vessel and the subclavian artery, may be ligated. 1 hat a 
reasonable hope of prolonging, and even of saving, the life of the patient, may be antici- 
pated from these procedures, is satisfactorily demonstrated by a number of cases, which are 
placed before the reader in the following tables compiled by Dr. S. W. Gross. 
In 11 cases the carotid has been tied for aneurism of the aorta alone, with a result of 8 
recoveries and 3 deaths. The symptoms were ameliorated in every instance ; life was 
prolonged in four cases, respectively, for four, four, four, and five months; one patient 
was still living at the expiration of half a year in good health, with the tumor diminished 
in volume and much firmer than before the operation ; and the patient of Mr. Holmes 
was alive, and supporting herself as a nursery maid, nearly five years after the ligation. 
There was still considerable pulsation and thrill, and a harsh bruit in the diminished 
tumor. In the case of Heath the relief was marked ; but the man died at the expiration 
of four years and seven months from rupture of the sac externally. In seven examples 
the left carotid was tied, and the right in four. The former were all successful, while 
three of the latter died. 
Cases of Aneurism of the Aorta treated by Ligation of Carotid Artery. 
No. 
Opprator. 
Date. 
Sex. 
Ago. 
Result. 
Remarks. 
i 
Montgomery 
1829 
M. 
40 
Recovered 
Died in 4 months from extension of inflammation 
to tumor. 
2 
Rigen 
1829 
... 
Recovered 
Died in 4 months from asphyxia. 
3 
Tillanus 
M. 
Recovered 
Died suddenly in 5 months. 
4 
O’Shaugnessy 
1842 
M. 
42 
Died 
Died 10th day from rupture of sac. Galvano- 
puncture also employed. 
5 
Knowles 
1807 
M. 
42 
Died 
Died on 35th day from apoplexy. 
(5 
Heatli 
1872 
Recovered 
Died in 4 years and 7 months from rupture of sac. 
7 
Holmes 
1875 
F. 
21 
Recovered 
In good health at end of 4 years and 10 months. 
8 
Annandale 
1875 
M. 
62 
Recovered 
Alive at end of 6 months. Tumor smaller and 
firmer. 
9 
Bryant 
1877 
M. 
56 
Died 
Died on 10th day from pyemia. 
10 
Bar well 
1877 
M. 
56 
Recovered 
Died in 4 months from disease of kidneys and 
liver. 
11 
Asliliurst 
1878 
M. 
Recovered 
Died on 45th day from suffocation. 
In 0 cases the carotid lias been tied for aneurism involving both the aorta and the 
innominate artery, with a result of 5 deaths and 1 recovery. The right carotid was 
ligated 4 times, with 4 deaths, and the left carotid was ligated in 2 cases with 1 death. 
The symptoms as a rule, were improved, and the sac of the aneurism was occupied by 
limited clots. 
Cases of Aneurism of the Aorta and Innominate Artery treated by Ligation of Carotid 
A rteru. 
No. 
Operator. 
Date. 
Sex. 
Age. 
Result. 
Remarks. 
1 
Key 
1830 
F. 
61 
Died 
Died in a few hours from cerebral anaemia. 
2 
Campbell 
1S45 
M. 
48 
Died 
Died on 19th day from suffocation. 
3 
Pirogoff 
1804 
M. 
Recovered 
In two months and a half tumor smaller and 
pulsation weaker. 
4 
Pirogoff 
1864 
F. 
Died 
Died in 3 weeks from softening of brain. 
5 
Hutchinson 
1866 
M. 
48 
Died 
Died in 41 days from suffocation. 
6 
Hewson 
1867 
M. 
51 
Died 
Died on 10th day from suffocation. 
I he carotid and subclavian arteries have been tied for aneurism of the aorta alone in 9 
cases, i ot which recovered from the operation, and 2 died. Two patients were still 
living with marked relief at the expiration, respectively, of ten weeks and eight months; 
and life was prolonged in three (or thirteen months, fifteen months, and four years and 
seventeen days. In one-half of the cases the tumor was supposed to be innominatal; but 
its true nature was disclosed after death. In the case ot Ilobart, the first portion of the 
subclavian artery was tied ; in the remainder the ligature was applied to its third division. ANEURISM OF THE THORACIC AORTA. 
735 
CHAP. V. 
In the case of Spier, the carotid artery was occluded by constriction with the instrument 
depicted at page 667, and the subclavian was tied forty-eight hours subsequently. In all 
of the other examples both vessels were ligated simultaneously. Dr. A. B. Mott, of New 
York, in 1876, ligated the subclavian of a man, forty years of age, in whom the carotid 
had been tied one year previously for supposed aneurism of the innominate. On death 
from phthisis at the expiration of three years, the ascending and transverse portions of the 
arch of the aorta were merely dilated, and did not contain laminated clots. 
Cases of Aneurism of the Aorta treated by Ligation of the Carotid and Subclavian 
Arteries. 
No. 
Operator. 
Date. 
Sex 
Age. 
Result. 
Remarks. 
1 
Hobart 
1839 
F. 
25 
Died 
Death on 16th day from hemorrhage from caro- 
tid. First portion of subclavian tied. 
2 
Heath 
1865 
F. 
30 
Recovered 
Death in 4 years from rupture of sac externallv. 
3 
Maunder 
1867 
M. 
37 
Died 
Death on 5th day from extension of clot to heart. 
4 
Sands 
1868 
F. 
43 
Recovered 
Death in 13 months from asphyxia. 
5 
Spier 
1874 
M. 
31 
Recovered 
Death on the 34th day from rupture of sac ex- 
ternally. 
6 
Maury 
1874 
M. 
45 
Recovered 
Death in 2 months from rupture of sac externallv. 
7 
Bar well 
1879 
M. 
36 
Recovered 
Death in 15 months from dissipation and ex- 
haustion. 
Lediard 
1880 
M. 
42 
Recovered 
Alive at expiration of 8 months. 
9 
Wyeth 
1880 
F. 
42 
Recovered 
Alive at expiration of 10 weeks. 
The carotid and subclavian arteries have been tied for aneurism involving both the 
aorta and innominate artery in 6 cases, with a result of 4 recoveries and 2 deaths from 
the operation. The deligation was simultaneous in all except the case of Bickersteth, in 
which there was an interval of forty-eight days. In one instance life was prolonged for 
three months, and in another for nineteen months. In 1868 Hodges, of Boston, tied 
both vessels lor a supposed true aneurism of the aorta and innominate ; but, on death on 
the eleventh day from exhaustion, the latter vessels were found to be merely dilated. In 
the majority of the cases, the sac was almost entirely filled with laminated clots. 
Cases of Aneurism of the Aorta and Innominate treated hy Ligation of the Carotid and 
Subclavian Arteries. 
No. 
Operator. 
r>ate. 
Sex. 
Age. 
Keeult. 
Remarks. 
1 
Bickersteth 
1864 
M. 
35 
Recovered 
Death in 3 months from progress of the disease. 
Vessels tied at interval of 48 days. 
2 
Barwell 
1877 
F. 
37 
Recovered 
Death in 19 months from bronchitis; sac filled 
with fine clot. 
3 
Barwell 
1877 
M. 
45 
Recovered 
Death in 3 months and 10 days from broncho- 
pneumonia. Sac nearly filled with laminated 
clot. 
4 
Barwell 
1877 
M. 
48 
Died 
Death in 30 hours from asphyxia. 
5 
RansohofT 
187!) 
M. 
48 
Died 
Death on 7th day from asphyxia. 
6 
Palmer 
1880 
F. 
50 
Recovered 
Death on 125th day from hemorrhage. 
Of the 32 cases contained in the tables, 20 recovered, and 12 died. The best results 
were obtained from ligation of one or both vessels for aneurism of the aorta alone. The 
mortality after tying the carotid artery was 27.27 per cent., while it was only 22.22 per 
cent, after deligation of the carotid and subclavian arteries; but the former operation was 
the more favorable in regard to the extension of life. In the majority of all the cases the 
tumor was diminished in size, and the distressing symptoms were relieved, while life 
was prolonged in nearly one-half for several months. In two cases, the fatal result was 
retarded for four years, and one patient was still living at the expiration of nearly five 
years. 
These facts are of sufficient importance, in my opinion, to warrant the surgeon, after 
the failure of general measures, in following the suggestions of Mr. Heath, to ligate the 
left carotid for aneurisms involving the left side of the aorta, and to practise simultaneous 
deligation of the right carotid and subclavian arteries for aneurisms involving the right 
side of the aortic arch, or of the aorta and the innominate artery. 736 
In a case of tubular aneurism of the innominate and arch of the aorta, Blackman tied 
the subclavian artery; but death occurred on the eighth day, from hemorihage caused by 
the patient jumping out of bed. . . 
The electrolytic treatment of aortic aneurism, first practised hy ( lniselli, is particularly 
adapted to cases in which the tumor is situated within the chest, and communicates with 
the aorta by a narrow opening. The insulated 
needles, two or three in number, should be at- 
tached to the positive pole of a battery of large 
electro-motor force, and the action ‘ should be 
maintained for a period varying from five to thirty 
minutes, and be repeated as occasion may require. 
The results of galvano-puncture have thus far been 
rather encouraging, since of 27 cases collected by 
Dr. John Duncan, of Edinburgh, 5 were cured, 10 
were relieved, 9 were unrelieved, and 3 died. 
The insertion of iron wire, horsehair, and other 
foreign materials, with the view of inducing co- 
agulation of the contents of the sac, holds out no 
prospect whatever for permanent relief, and has 
been attended with an almost invariably fatal 
result. 
Laryngotomy has been advised when suffocation 
is threatened by spasm of the glottis from irrita- 
tion of the recurrent laryngeal nerve, as a means 
of palliating suffering and prolonging life; but, 
owing to the difficulty of the diagnosis, it is not 
probable that many eases will be subjected to such 
an ordeal. When the constriction depends upon 
pressure of the aneurism upon the windpipe, such an operation w ould, of course, be useless. 
The annexed sketch, fig. 338, from Jones and Sieveking, represents an aneurism of the 
arch of the aorta, the cavity of which is nearly filled with laminated clots. Nature had 
evidently made an effort, almost a successful one, at spontaneous cure. 
ANEURISM OF THE INNOMINATE ARTERY. 
The relative frequency of aneurism of the innominate artery does not admit of any 
definite statement, owing to the great discrepancy in our statistics. Thus, in 179 cases 
of spontaneous aneurism, excluding those of the aorta, analyzed by Lisfranc, the innomi- 
nate is mentioned only four times, while the carotid is mentioned seventeen times, and 
the subclavian sixteen. In Mr. Crisp’s table of 551 cases, embracing 234 of aneurism of 
the aorta, the innominate was affected in 20, the carotid in 25, and the subclavian in 23. 
The disease, as in the other arteries, is much more common in men than in women, and 
in the laboring than in the higher classes of persons. The greatest number of cases occur 
between the thirty-fifth and fifty-fifth years. It may exist by itself, or be associated with 
aneurism of the arch of the aorta, the carotid, or subclavian. The extent of involvement 
varies from the slightest increase of the normal size to an enormous tumor, either tubular, 
fusiform, or sacculated in its character. Whether every portion of the vessel is equally 
liable to be affected is uncertain, but observation shows that the disease is sometimes 
situated so low down as to become identified with the arch of the aorta, while at other 
times it is so high up as to extend into the carotid and subclavian. Occasionally it is 
limited to the middle of the vessel, each extremity retaining its healthy appearance. 
Symptoms—Aneurism of the innominate artery usually begins as a small projection at 
the right sterno-clavicular articulation, between the trachea and the inner edge of the 
sterno-mastoid muscle, immediately above the inner third of the clavicle. In some cases 
the patient is conscious of the moment when the accident takes place, from a feeling as 
if something had given way while he was shaken by a violent paroxysm of coughing or 
engaged in lifting a heavy weight. The tumor is at first generally very diminutive, 
probably not exceeding the size of a little almond, of a rounded or ovoidal shape, dis- 
tinctly circumscribed, and slightly movable on pressing the finger firmly down into the 
hollow at the top of the sternum. It is not long, however, before it increases in volume; 
commonly, in fact, it grows rapidly, soon attaining a large bulk, extending upwards into 
the neck, and laterally towards each side, but especially towards the right, where there is 
DISEASES AND INJURIES OF THE ARTERIES. 
CHAP. v. 
Fig. 338. 
Aneurism of the Arch of the Aorta nearly 
filled with laminated Clots. CHAP. V, 
ANEURISM OF THE INNOMINATE ARTERY. 
least resistance. As it progresses, it gradually pushes forwards the sterno-mastoid muscle, 
and even the sterno-clavicular articulation, forming thus a large prominence, beating and 
throbbing violently beneath the skin. Now and then, upon escaping from the chest, the 
tumor ascends high up into the neck, per- 
haps nearly on a level with the larynx, and 
it is then not uncommon for it to present a 
constricted, hourglass-like appearance, as if 
a cord had been drawn tightly across its 
middle. 
Effects on Neighboring Structures The 
effects which the tumor exerts upon the 
neighboring parts, fig. 339, are chiefly of a 
mechanical character, and must be con- 
sidered with reference, first, to the vessels 
of the superior extremity, neck, and head ; 
secondly, the trachea and oesophagus; 
thirdly, the aorta, heart, and vena cava ; 
fourthly, the nerves of the neck and chest; 
and, lastly, the sternum, clavicle, and ribs. 
The pressure of the tumor upon the 
subclavian has the effect of weakening 
the force of the circulation at the wrist, 
and in some cases even of entirely sup- 
pressing it. Occasionally the pulse is extremely irregular, beating not only more feebly 
than that in the opposite limb, but ceasing to act synchronously with it, the blood hitching 
and halting, as it were, on its way to the hand. Any tumor may, of course, produce 
such an effect, and there is, therefore, nothing characteristic in it. In aneurism of the 
aorta, the signs of enfeebled circulation are, as a general rule, most strongly marked on 
the left side, as the tumor, from its proximity to the left subclavian, exerts a more direct 
and controlling influence upon that vessel than it does upon the right subclavian. The 
pulsation of the carotid and its branches is sometimes diminished both in innominatal and 
aortic aneurism, but more frequently in the former than in the latter. It is, however, a 
rare occurrence in either case, and, therefore, of no diagnostic value. # 
Compression of the veins at the root of the neck, as the innominate, jugular, and sub- 
clavian, but especially the first, by impeding the return of blood to the heart, occasionally 
causes oedema of the right side of the head, face, and eyelids, and of the corresponding 
limb, extending as low down as the hand and fingers. The occurrence, however, is 
uncommon, and it is probable that it may be due, in part, to obstruction of the right 
lymphatic duct, as it lies just behind the tumor. 
As the aneurism enlarges, it necessarily encroaches more and more upon the trachea, 
pushing it over towards the left side, and also somewhat backwards. When the displace- 
ment is considerable, the patient breathes with difficulty, and is occasionally unable to lie 
down, owing to the mechanical obstruction to the introduction of the air. Should the 
tumor be situated unusually low, or be of extraordinary size, it may compress and flatten 
the right bronchial tube. Dyspntea from both of these causes, however, is less frequent 
in aneurism of the innominate artery than in aneurism of the arch of the aorta, as, in the 
latter disease, the tumor enlarges most in a backward direction, its progress forwards being 
interfered with by the sternum and clavicle. Displacement of the oesophagus is some- 
times present in both affections, but not so often as has generally been supposed. When 
existing in a high degree, it may seriously embarrass the function of deglutition, especi- 
ally the passage of solids. 
When the aneurism occupies the inferior portion of the artery, and especially when it 
extends downwards into the chest, it follows, as a necessary consequence, that it must 
press upon the aorta, heart, and vena cava, pushing them out of their natural position, 
and perhaps seriously diminishing their capacity. The particular effect which such com- 
pression must exert cannot always be diagnosticated, but it is reasonable to conclude that it 
will manifest itself in disordered circulation, especially in tumultuous and confused cardiac 
action, enfeebled pulse, and more or less dyspnoea. An aortic aneurism will, of course, 
be more likely to produce such phenomena than an innominatal. 
Pressure of the tumor upon the nerves of the neck and chest induces not only pain 
and cough, but gives rise, in many cases, to severe dyspmea and dysphagia, the two latter 
symptoms being not always, by any means, exclusively dependent upon the displacement 
Fig. 339. 
Aneurism of the Innominate Artery, proving fatal by 
bursting into the Trachea. 738 
DISEASES AND INJURIES OF THE ARTERIES. 
chap. v. 
and flattening of the trachea and oesophagus. On the contrary, they sometimes exist in 
a very marked and even in an aggravated degree when there is apparently very little, if 
any, compression of these tubes. We must, therefore, look for some other explanation 
of these phenomena, and the most plausible one that suggests itself is that they are due 
to the compression of the pneumogastric, phrenic, laryngeal, and sympathetic nerves, which 
are thus disqualified for transmitting, in a regular and harmonious manner, their peculiar 
influence to the organs to which they are distributed, and in which they naturally play so 
important a part. 
The dyspnoea, although not a constant symptom, is often enough present to render it 
one of great importance. It varies in degree from the slightest change in the natural 
respiration to the most frightful embarrassment, in which the patient is almost suffocated, 
and unable to maintain the recumbent posture. It is, of course, most severe and distress- 
ing when the tumor has acquired an unusual bulk, compressing the pneumogastric and 
other nerves, and so interrupting their healthy action. It may be constant, or paroxysmal, 
coming on at irregular intervals, lasting for some time, and then gradually receding, 
although, perhaps, at no time wholly absent. 
The dysphagia is also variable in degree, being at one time very slight, and at another 
so severe as almost to prevent the patient from swallowing any kind of food, whether 
solid or fluid. In the more aggravated cases the diflieulty is constant, and the patient 
finally dies from starvation. It is a remarkable fact that in almost every instance of 
dysphagia this symptom is preceded by dyspnoea. 
The pain which accompanies the disease is most severe in the right side, in the situation 
of the tumor, from which it radiates in various directions, particularly along the right 
side of the neck and head, and the corresponding side of the chest, shoulder, and arm. 
Occasionally, although rarely, it is also keenly felt on the opposite side. It is generally of 
a dull, aching, or gnawing character, and is often so excessive as to require the use of 
large doses of anodynes for its temporary relief. 
Cough is occasionally present, probably in one case out of every three or four, but it is 
less common than in aortic aneurism, and is a symptom of no special value. It is evi- 
dently produced by the pressure of the tumor upon the laryngeal nerves, and varies much 
in frequency and severity in different cases and under different circumstances. From the 
same cause there is sometimes an altered state of the voice. 
When thj tumor is very large, and extends outwards and downwards, so as to compress 
the cervical and brachial plexus of nerves, it may induce partial paralysis, as well as, in 
some cases, partial loss of sensation, in the upper extremity. Such an occurrence, how- 
ever, is extremely rare, as the sac seldom attains so much magnitude. 
Permanent contraction of the pupil on the affected side is occasionally noticed ; it often 
comes on early in the disease, and is evidently due to the pressure which the tumor exerts 
upon the sympathetic nerve. 
There is sometimes marked alteration in the respiratory sounds ; more frequently, 
however, in aortic than in innominatal aneurism. The breathing, when affected, is dis- 
posed to be stridulous, or wheezing, and this is sometimes the case even when the patient 
is in the erect posture. The respiratory murmur is seldom affected in innominatal aneu- 
rism, obviously because the tumor encroaches but little, if any, upon the lungs ; it is only 
when it extends deep down into the thorax that it is likely to produce such an effect, and 
then, but not otherwise, there will, also, of necessity, be dulness on percussion of the 
chest, over the site of the disease. Both these phenomena are more frequent in aortic 
aneurism, because the tumor in that disease always encroaches more upon the lungs than 
in the former case. 
finally, the pressure of the tumor occasionally induces serious disease in the neighbor- 
ing bones, as the sternum, clavicle, and first rib, the contiguous portions of which are 
liable, in the first instance, to be displaced, then to become carious, and ultimately to be 
wholly absorbed. In some cases there is complete dislocation of the sterno-clavicular joint. 
Diagnosis—After what has just been said, it will easily be understood that the diagnosis 
of aneurism of the innominate artery must often be extremely difficult, its situation at 
the root of the neck rendering it liable to be confounded with aneurism of the arch of the 
aorta, the carotid, and subclavian. Then, again, certain tumors—fatty, fibrous, glandular, 
and cystic—sometimes form here, and receiving an impulse from the innominate, or 
even from the aorta itself, may thus simulate the affection in question. I have occasion- 
ally encountered great difficulty in determining the diagnosis of disease in the inferior 
cervical region in consequence of abnormal pulsation either of this vessel or of the aorta, 
apparently dependent upon an anemic condition of the system, or neuralgia of the arteries, CHAP. V. 
ANEURISM OF THE INNOMINATE ARTERY. 
739 
and so violent as to communicate a severe shock at every contraction of the left ventricle 
of the heart to the innominate and its two branches, the carotid and subclavian. The 
embarrassment, in these cases, is materially increased if, superadded to the pulsation, 
there is an unusual quantity of fat, or some solid growth, and the sharp thrill so common 
in the arteries of anemic subjects. 
This difficulty was strikingly felt in a case, which occurred a few years ago in the prac- 
tice of Dr. Sands, of New York, in a middle-aged woman, a patient in the Bellevue 
Hospital, who had a soft, pulsating tumor at the root of the neck. It was situated behind 
the right sterno-clavicular articulation,and extended upward two inches above the clavicle, 
being partly covered by the sterno-mastoid muscle. The patient was carefully examined 
by a number of the most eminent surgeons and physicians, who all concurred in the diag- 
nosis of innominatal aneurism, except one, wrho thought that the aorta, as well as the 
innominate, was dilated, his opinion being founded on the presence of a circumscribed 
spot in the right suprascapular space, which was dull on percussion, and which trans- 
mitted, very distinctly, the aneurismal murmur. On the 16th of July, 1868, Dr. Sands, 
to whom I am indebted for an account of the case, performed the distal operation, by 
tying simultaneously the'carotid and subclavian arteries. The ligature of the carotid 
was applied immediately above the omohyoid muscle; that of the subclavian was exter- 
nal to the scalene. The patient recovered from the operation, and the tumor diminished 
in size, the dyspnoea and other pressure symptoms being at the same time relieved, so that 
hopes were entertained of a permanent cure. Gradually, however, the swelling again 
increased, and the patient sank from dyspnoea, thirteen months after the operation. At 
the dissection, a sacculated aneurism was oliscovered, about the size of a large pear, 
arising by a narrow orifice from the aorta, directly in front of the origin of the innominate 
artery. The latter vessel was healthy, and was behind the aneurismal sac, nearly four 
inches from the external surface. 
On the whole, the most reliable diagnostic signs of aneurism of the innominate are, 
first, the situation of the tumor at the right sterno-clavicular joint, immediately above 
the inner third of the clavicle, where it forms a distinct, well-marked prominence ; 
secondly, stoppage of aneurismal beat, thrill, and bellows sound by pressure upon the 
carotid and subclavian ; and, thirdly, unnatural weakness of the pulse at the right wrist, 
with pain and cedema on the corresponding side of the neck, shoulder, and arm. In 
aortic aneurism, the tumor seldom projects sensibly above the sternum ; certainly not 
before it has attained considerable bulk, and then it is situated rather in the middle line 
than on the right side; the arterial pidse, if affected at all, is weakest on the left side, 
and there also the oedema and pain are most conspicuous ; the dyspnoea, dysphagia, cough, 
stridulous respiration, and change of voice are more frequent than in the innominatal dis- 
ease ; and compression of the carotid and subclavian produces no diminution in the 
sounds of the tumor. 
The prognosis of brachio-cephalic aneurism is extremely unfavorable. The disease, it 
is true, may last for a considerable time, but this is very unusual; in general, it progresses 
very rapidly, and soon reaches a fatal crisis, the tumor either opening externally, into the 
trachea, or into the chest, or else, as is commonly the case, wearing out the patient by 
constitutional irritation, asphyxia, or inanition. No instance of spontaneous cure has ever 
been known to occur in this disease. 
Treatment.—The treatment of aneurism of the innominate has hitherto been most 
unsatisfactory. Owing to the short and stunted character of this vessel, and the close 
proximity of the aneurism to the arch of the aorta, deligation on the Hunterian principle 
is, of course, altogether impracticable, and hence the only resource is either to treat the 
disease upon the plan of Valsalva, or to tie the carotid and subclavian at the distal side 
of the sac, according to the method originally suggested by Brasdor. The treatment of 
the Italian surgeon holds out but little encouragement, the disease generally going on from 
bad to worse until it reaches its fatal crisis, despite the most abstemious course of dieting, 
rest in the recumbent posture, the use of the lancet, and the exhibition of digitalis, opium, 
and acetate of lead, to promote the formation of clots. With the exception of Mr. 
Luke’s case, there is hardly an instance upon record in which it was followed by any 
ultimate benefit. Squeezing the tumor, if practicable, would certainly not be justifiable, 
as the detached clots might, and probably would, fall into the aorta, and thus cause seri- 
ous, if not fatal, results on the spot, from mechanical obstruction to the circulation. The 
operation of Brasdor has been performed in a number of cases, which will be placed before 
the reader in tabular form. 740 
DISEASES AND INJURIES OF THE ARTERIES. 
chap. v. 
In 3 cases the carotid and subclavian have been tied successively, as recommended by 
Mr. Fearn, of Derby, England, with 3 deaths. 
Cases of Aneurism of the Innominate treated by Consecutive Ligation of the Carotid and 
Subclavian Arteries. 
No. 
Operator. 
Sex. 
Arc. 
Carotid 
ligature. 
Subclaviau 
ligature. 
Remarks. 
1 
Fearn 
F. 
28 
August 30, 
1830 
August 2, 
1838 
Died from pleurisy nearly four months after se- 
cond operation. The aneurismal sac was found 
filled with dense, organized coagula, except a 
channel the size of the artery for the passage 
of blood. 
2 
Wickham 
M. 
5.r> 
Sept. 25, 
1839 
Dec. 3, 
1839 
The aneurism increased, and burst with mortal 
hemorrhage 63 days after the second operation. 
3 
Malgaigne 
M. 
March, 
1845 
October 17, 
1845 
Four days after the operation the tumor increased 
rapidly in size, the tumefaction became diffused, 
and the patient died on the 7th Nor. At the 
autopsy, the sac could not be dissected ; it was 
confounded with the muscles ; in other words, 
the aneurism was diffused. 
In 14 cases the carotid and subclavian have been tied simultaneously, with a result of 
7 recoveries and 7 deaths from the operation. Two patients were still living with 
alleviation of the symptoms and decided diminution in the size of the tumor, at the expi- 
ration respectively, of three and a half and ten months; and life was extended in one 
for twenty-two months, and in another for three years and four months, when, on death 
from phthisis, the sac in both cases was found to be almost filled with firm, laminated clot. 
Cases of Aneurism of the Innominate treated by simultaneous Ligation of the Carotid 
and Subclavian Arteries. 
No. 
Operator. 
Date. 
Sex. 
Age. 
Result. 
Remarks. 
1 
Rossi 
1843 
• •• 
Died 
Death on 6th dav from cerebral anemia. 
2 
Lane 
1871 
F. 
40 
Recovered 
Death in 3 months from rupture of sac. 
3 
Holmes 
1871 
M. 
50 
Recovered 
Death on 55th day from rupture of sac. 
4 
McCarthy 
1872 
M. 
... 
Died 
Death on 15th day from hemorrhage from sub- 
clavian. 
5 
Ensor 
1874 
M. 
50 
Died 
Death on 65th day from hemorrhage from sac 
through carotid wound. 
6 
Eliot 
1876 
M. 
41 
Died 
Death on 26th day from repeated hemorrhage 
from ruptured sac. 
7 
Weir 
1876 
M. 
45 
Died 
Death on 15th day. Aneurism had burst into 
trachea. 
8 
King 
1876 
M. 
37 
Recovered 
Death on the llltli dav from rupture of sac. 
9 
Little 
1877 
M. 
46 
Recovered 
Death from phthisis in 3 years and 4 months. 
10 
Stimson 
1879 
M. 
34 
Recovered 
Patient died of phthisis at expiration of twenty- 
two months. 
11 
Barwell 
1879 
F. 
27 
Recovered 
Patient .alive at expiration of ten months. 
12 
Durham 
Died 
Death on 6th day from shock. 
13 
Pollock 
1881 
M. 
37 
Died 
Death on 10th day from dyspnoea. 
14 
Browne 
1881 
M. 
32 
Recovered 
Pulsation diminished, and bruit and pain had 
disappeared at expiration of three mouths and 
a half. 
In 4 cases the subclavian stone has been tied, with a result of 3 recoveries and 1 death 
from the procedure. In the successful cases there was marked improvement in the symp- 
toms, and life was prolonged in one instance for three years. 
Cases of Aneurism of the Innominate treated by Ligation of the Subclavian Artery. 
No. 
Operator. 
Date. 
Sex. 
Ape. 
Result. 
Remarks. 
1 
Wardrop 
1827 
F. 
45 
Recovered 
Death in 2 years from dropsy. 
2 
Laugier 
1834 
M. 
57 
Died 
Death in 1 month from asphyxia. 
3 
Broca 
18(52 
M. 
50 
Recovered 
Death in 6 months from gangrene of lung. 
4 
Bryant 
1871 
M. 
33 
Recovered 
Death in 3 years from dyspnoea. CHAP. V. 
ANEURISM OF THE INNOMINATE ARTERY. 
741 
The common carotid artery alone lias been tied in 20 cases, of which 5 recovered and 
15 died. 
Cases of Aneurism of the Innominate treated by Liyation of the Carotid Artery. 
No. 
Operator. 
Date. 
Sex. 
Age. 
Result. 
Remarks. 
1 
Mott 
1820 
M. 
60 
Died 
Death on 20th day from hemorrhage. 
2 
Evans 
1828 
M. 
30 
Recovered 
Patient alive at expiration of 34 years. 
3 
Mott 
1829 
M. 
55 
Recovered 
Death in 7 months from asphyxia. 
4 
Neumeister 
1830 
M. 
51 
Died 
Death on 5th day from cerebral complications. 
5 
Morrison 
1832 
M. 
42 
Recovered 
Sudden death in 20 months. 
6 
Scott 
1834 
Recovered 
Death some time after from rupture of sac. 
7 
Dohlhoff 
1837 
F. 
... 
Died 
Death on 6th day from cerebral complications. 
8 
Fergusson 
1841 
M. 
56 
Died 
Death on 7th day from pneumonia. 
9 
Porta 
1842 
Died 
Death in 40 hours from erysipelas. 
10 
Hutton 
1842 
M. 
47 
Died 
Hemorrhage on 22d day. Rupture of sac into 
trachea on 76th day. 
11 
Vilardebo 
1843 
M. 
70 
Died 
Death on 21st day from hemorrhage. 
12 
Wright 
1855 
M. 
70 
Died 
Death on 88th day from abscess of brain. 
13 
Ordile 
1859 
Died 
14 
Broad bent 
1860 
M. 
50 
Died 
Death on 115tli day from hemorrhage. 
15 
Butcher 
1867 
M. 
42 
Died 
Death in 88 hours from dyspnoea. 
16 
Newton 
M. 
• •• 
Died 
Death on 12th day from effusion into the chest. 
17 
PirogolF 
M. 
Recovered 
Patient alive at expiration of two months and a 
half. 
18 
N ussbaum 
Died 
Death from rupture of sac. 
19 
Nussbaurn 
... 
Died 
Death from rupture of sac. 
20 
Bryant 
1880 
M. 
40 
Died 
Death on 19th day from dyspnoea. 
A careful examination of the above cases affords the following conclusions concerning 
the deligation of the primitive carotid for the cure of innominatal aneurism:— 
1. It reduces the volume of the tumor. Thus, in the case of Mr. Evans, of Derby, in 
1828, although the aneurism was as large as a walnut, it entirely disappeared in a little 
upwards of a month. In Dr. Mott’s second case, in 1829, it was of the size of a pigeon’s 
egg, and disappeared in twenty-six days. 
2. The operation leads to fibrinization of the contents of the sac. These changes, 
which are due, not to arteritis, but to remora of the blood, were well displayed in the 
cases reported by Mr. Morrison, of Buenos Ayres, in 1832, Sir William Fergusson, in 
1841, and Dr. Wright, of Montreal, in 1855. In the first, the innominate artery was 
larger than natural; and in all, the tumor was nearly filled with firm clots. 
3. The operation is attended with certain risks; but the deaths were due not, appa- 
rently, to any agency of the aneurism, but to the danger which naturally succeeds to the 
ligation of the common carotid, for whatever purpose. Thus, in the instances of Mott, 
Vilardebo, and Broadbent, death resulted from secondary hemorrhage. In the ease of 
Fergusson, the patient died of pneumonia; and in the case of Porta the fatal result was 
due to erysipelas. In the instances of Ilutton, Scott, and Nussbaum, the cause of death 
was rupture of the sac, also a very common effect of the operation for carotid aneurism, 
whether the ligature be placed above or below the tumor. In two instances, those of 
Neumeister, and Dohlhoff, the patients died of the effects of ligation of the artery upon 
the brain; and in that of Wright, death was due to abscess of the brain. 
4. The operation has not been productive of a long after-life, chiefly, perhaps, because 
the cases demanding it were nearly all inherently hoj>eless, from being associated with 
organic disease of the aorta, or of this vessel and of the heart. Distinct evidence of this 
fact existed in at least seven of the cases; in the rest no accurate examination was made. 
The influence of such complications is shown by the results which followed Brasdor’s 
operation in aneurism of the root of the carotid unmixed with any other lesion. Of eight 
cases of this kind, six completely recovered, and two died. 
5. The operation lengthens life if perilled by rupture of the sac, or pressure on the 
windpipe. In fact here is its great triumph. In the case of Professor Wright, although 
the man was in imminent danger before the operation, yet he survived it eighty-eight 
days. The mean duration of life after deligation of the carotid, under ordinary circum- 
stances, is about four months and a half. 
6. The operation has occasionally failed to effect any local improvement. This result 742 
DISEASES AND INJURIES OF THE ARTERIES. 
CHAP. V. 
followed in several of the cases, in consequence of a want of fibriuization of the contents 
of the sac. 
The facts above stated, deduced mainly from the paper of Professor Wright, in the 
Montreal Journal of Medicine, clearly point, as that gentleman justly remarks, to a divi- 
sion of cases in regard to the applicability of the operation. 1. 1 he most suitable cases 
are those of uncomplicated innominatal aneurism, being akin to the pure carotid form, 
the sac, which is confined to the part of the vessel near the bifurcation, springing from 
the left segment of the artery, and not coexisting with degeneration of its tunics or car- 
diac disease. 2. Those imperatively requiring it are such as entail imminent danger 
from external rupture of the tumor or from other causes. 3. The most favorable cases 
are aneurisms proceeding from the left segment of the artery, because then the introduc- 
tion of blood into the sac is most effectively impeded, as it is derived from the current 
destined for the vessel which is tied, whereas, when the aneurism is dextro-lateral, the 
same benefit cannot be afforded, as the supply is furnished by the subclavian. Next to 
this situation, the most preferable, anatomically, would be the origin of the tumor from 
the anterior circumference of the vessel. 4. The less advantageous cases are those in 
which the external tumor extends towards the middle of the clavicle, for this occurrence 
denotes such an engagement of the subclavian as must effectually counteract any benefit 
derivable from ligature of the carotid. When the swelling is equal on each side of the 
innominate, or symmetrical, then the only hope of a certain stasis of blood would be 
afforded by tying both branches. 5. The cases contraindicating the operation are those 
having complications with aortic aneurism, or serious disease of the heart, unless excepted 
by extreme urgency. 
ANEURISM OF THE COMMON CAROTID ARTERY. 
Spontaneous aneurism of this vessel is less frequent than is generally supposed, owing, 
doubtless, to the fact that it is so seldom the seat of the fatty and calcareous degenera- 
tions. Of 551 eases of aneurism of different parts of the body, embracing 234 of the 
aorta, the carotid is stated by Mr. Crisp to have been affected in 25, or in the ratio 
of 1 to 22. Of 179 cases analyzed by Lisfranc, 17 refer to the carotid, 16 to the sub- 
clavian, 14 to the axillary, 26 to the femoral, and 59 to the popliteal. The disease in 47 
involved the aorta. 
The affection is much more frequent in men than in women, in the proportion of about 
three to one. Thus, in the statistics of 712 cases out of 789, compiled by Dr. Wyeth, 
in which the sex is stated, 538 were males, and 174 were females. 
Age exerts a marked influence upon the production of the disease. The period of life 
from the twentieth to the fortieth year furnishes the greatest number of cases. It is 
occasionally witnessed at a very early age. Wyeth’s tables comprise 16 cases under 
twelve months, and 22 cases under ten years. Although the fact is not stated, it is 
evident that most of these cases must have been of traumatic origin or of an anastomotic 
nature. The disease occurs with nearly equal frequency on both sides, and, in fact, some- 
times exists simultaneously in both arteries. No occupation is exempt from it. 
The site of carotid aneurism is variable. Sometimes the tumor is situated very low 
down in the neck, close to the origin of the vessel; on the other hand, it may be high 
up, near its bifurcation. In the great majority of cases, however, it will be found to 
be between these two points, or near the middle of the artery ; usually rather above 
than below. 
Symptoms—The tumor, when first observed, is generally quite small, perhaps not ex- 
ceeding the size of a filbert, and of an irregularly globular, rounded, or ovoidal shape. 
The patient, upon being questioned as to the history of the case, usually expresses his 
ignorance as to the time of its occurrence, though occasionally he is rendered conscious of 
it by a peculiar stabbing sensation in the neck, or a feeling as if something had suddenly 
snapped asunder. Commonly the surgeon is not consulted until the tumor has made 
considerable progress, and acquired the volume of a hen’s egg, or of a small orange, the 
patient, perhaps, having all along supposed that the swelling was merely an enlargement 
of some of the cervical glands. A careful inspection, however, promptly reveals its 
true character, its pulsation, thrill, and bellows sound affording unmistakable evidence 
of its close and intimate arterial connection. Pressure upon the cardiac side of the 
aneurism, by stopping its circulation, arrests these symptoms, and causes a sensible 
diminution of the size and consistence of the tumor, while pressure upon its distal side 
produces an opposite result. As long as it is small, the tumor may readily be moved ANEURISM OF THE COMMON CAROTID ARTERY. 
743 
CHAP. V. 
about, and even raised out of its bed, especially if it be grasped with the thumb and 
forefinger during the relaxed condition of the sterno-mastoid muscle ; as it augments in 
volume it becomes more fixed in its position, and is eventually rendered almost, if not 
entirely, stationary. 
The symptoms of carotid aneurism are mainly of a mechanical character, being such 
as arise from the pressure of the tumor upon the neighboring parts ; hence, their gravity 
is generally in proportion to the volume of the morbid growth. In the earlier stages 
of the disease, there is either no functional disturbance whatever, or it is so insignificant 
as not to attract any special attention ; by and by, however, as it progresses, the tumor 
necessarily encroaches more and more upon the delicate and important structures of 
the neck, thus occasioning congestion of the brain by retarding the return of the blood 
in the jugular vein, numbness, pain, and cough, by compressing the cervical, pneumo- 
gastric, and phrenic nerves, and difficulty of respiration, and, perhaps, even of degluti- 
tion, by bearing against the trachea and (Esophagus. The surface of the swelling, at 
first perfectly natural, becomes gradually indurated and inflamed, the subcutaneous 
veins are unusually conspicuous, and the neck is stiff, distorted, and almost immovable. 
The greatest enlargement of the tumor is generally in the direction of the middle plane, 
as the resistance is much less there than externally, under the edge of the sterno-cleido- 
mastoid muscle. 
Diagnosis.—Notwithstanding that the symptoms of carotid aneurism are usually well 
marked, cases, nevertheless, occur in which they are so obscure as to render it extremely 
difficult to determine the diagnosis, even after the most careful and patient investigation. 
The affections of the neck which are most liable to be confounded with carotid aneurism, 
and to render the discrimination doubtful, are diseased lymphatic glands, abscesses, 
cystic tumors, goitre, dilatation of the internal jugular vein, and aneurism of the in- 
nominate artery and arch of the aorta. 
Enlargement of the lymphatic glands of the neck is most common in young subjects, 
before the age of twenty, whereas aneurism of the carotid is rarely met with until after 
thirty; moreover, it is almost peculiar to scrofulous persons, while aneurism occurs in all 
classes of individuals, the strumous and the non-strumous. In aneurism the tumor is 
generally well defined; its surface is smooth and uniform, and the swelling heaves and 
throbs, as if it were alive. In glandular enlargement, there is generally a chain of dis- 
eased glands, either scattered about in different |«irts of the neck, or stretched along the 
inner border of the sterno-cleido-mastoid muscle; the tumors feel hard, and may, with a 
little care, be easily separated, not ordy from each other, but from the carotid artery, so 
as to get entirely beyond the reach of its pulsation. 
An aneurism of the carotid artery has sometimes been mistaken for an abscess ; the 
tumor has been punctured, and the patient has speedily perished of hemorrhage. Such 
an error, of course, implies great carelessness, and could hardly happen at the present 
day, when our means of diagnosis are so much more perfect than they were formerly. 
The discrimination must be determined on general principles. If there is an abscess, the 
history of the case, conjoined with the unnatural heat and redness of the part, the rapid 
progress of the swelling, the febrile disturbance, and the absence of the characteristic 
pulsation, thrill, and bellows sound, will be sufficient to distinguish it from aneurism of 
the carotid artery. 
Cystic tumors, usually containing a serous or sero-sanguinolent fluid, are liable to 
form at the front and sides of the neck, most generally in connection with the thyroid 
gland, but sometimes independently of it, in the connective tissue beneath the muscles. 
They may usually be readily distinguished by their slow growth and fluctuating feel, the 
absence of pain and pulsation, and, when they are attached to the thyroid gland, by their 
obeying the movements of the larynx in the act of deglutition. If, after a careful ex- 
amination of their history, any doubt exists as to their real nature, the only resource will 
be the cautious introduction of the exploring needle. 
Goitre is liable to be mistaken for carotid aneurism only when it spreads laterally over 
the neck, so as to overlap the carotid, and receive its pulsation. It is certainly not 
|M>ssible to commit any error of diagnosis in the more ordinary and simple forms of the 
disease. Confusion is most apt to arise when aneurism and goitre coexist, or when, as 
occasionally happens, the latter disease is developed uncommonly rapidly, and is attended 
with considerable local distress. Ordinarily, goitre forms in early life, at a period 
when aneurism is extremely infrequent ; it is generally tardy in its progress, several 
years elapsing before it attains any material bulk, and it is subject to occasional 
interruptions, and even total suspension, whereas aneurism generally advances rapidly DISEASES AND INJURIES OF THE ARTERIES. 
chap. v. 
and steadily, the symptoms proceeding from bad to worse, until it attains its crisis. 
Another important criterion is the fact that goitre is almost peculiar to females, whereas 
carotid aneurism occurs by far most frequently in men. But the most satisfactory 
diagnostic signs are, first, that in goitre, the tumor obeys the movements of the larynx, 
whereas in aneurism it remains stationary, however strong the efforts at deglutition ; 
secondly, that in the former the tumor may be drawn away from the vessel, raised up or 
pushed to one side, while in the latter the vessel follows it, forming, as it does, a part of 
it; and, lastly, that in goitre the general health rarely suffers, even when the tumor is of 
large bulk, whereas in aneurism it is always more or less impaired, especially when it has 
reached such a stage as to be likely to occasion embarrassment in regard to the discrimi- 
nation between the two affections. 
A dilated condition of the internal jugular vein may simulate aneurism of the carotid 
artery. The deception will be the more likely to happen if the vein receive a pulsatory 
movement from the heart or from the carotid, as when the artery is overlapped by the 
vein. The venous tumor may generally be distinguished by its softness and compressi- 
bility, by its situation, which is commonly just above the sternum, and rather behind 
than in front, of the sterno-cleido-mastoid muscle, and by the circumstance that its motion 
is more of an undulatory, wave-like, or tremulous character, than shock-like and vibratory, 
as in aneurism. Superadded to this is the fact that the venous swelling may readily be 
effaced by pressure applied to its distal extremity, whereas, in aneurism, the pressure, 
to produce any appreciable effect of this kind at all, must be applied to the cardiac 
extremity of the tumor, and then it will result only in a diminution, not in complete 
obliteration. 
Finally, a carotid aneurism may be confounded with aneurism of the innominate 
artery, or of the arch of the aorta, especially if it be situated low down in the neck. 
When this is the case, the difficulty may be very great, if not insurmountable. The 
most reliable diagnostic sign with which I am acquainted, and one that will rarely fail, 
in such an emergency, is afforded by our ability to insinuate the point of the forefinger 
between the top of the sternum and the lower extremity of the aneurism, while the head 
is being bent powerfully forwards, so as to relax as fully as possible the sterno-inastoid 
muscles. If this can be done, the probability is that the tumor is connected with the 
carotid ; otherwise it may be inferred that it is formed by the innominate artery, or by 
the arch of the aorta. 
Several examples have been recorded in which aneurism of the vertebral artery was 
mistaken for aneurism of the common carotid, the latter vessel having actually been tied 
for the relief of the disease. All the cases, about four in number, proved fatal. 
Progress—The progress of carotid aneurism, although usually rapid, is not so always. 
The annals of surgery contain several cases where the disease remained almost stationary 
for a considerable number of years ; in one as many as fourteen. A spontaneous cure 
sometimes occurs, but such an event must necessarily be extremely rare. The tumor, 
it allowed to go on unchecked, eventually, generally at a period varying from three to 
twelve months, destroys life either by excessive constitutional irritation, hemorrhage, 
gangrene, pneumonia, or asphyxia. When seized by ulceration, it may burst either 
externally, or it may open into the pleura, the anterior mediastinum, the trachea, or one 
of the bronchial tubes. Esmarch and Teale have each related a case of fatal embolic 
apoplexy from the detachment of fibrinous clots in an aneurism of the common carotid 
artery, from pressure exerted upon the tumor with a view of ascertaining its real char- 
acter. 
Treatment—1 he treatment of carotid aneurism is generally conducted according to 
the Hunterian principle of ligating the supplying vessel at the cardiac side of the tumor; 
and, fortunately, as the disease is ordinarily situated rather high up, this may commonly 
be done without any very great difficulty, especially in the earlier stages of the affection, 
before the swelling has attained much bulk. When the tumor is of great size, or located 
at the inferior part of the neck, we may be compelled to adopt the method of Brasdor, 
and tie the carotid on the distal side of the aneurism, trusting that the blood in the 
tumor, no longer finding an outlet, will gradually coagulate, and so effect its obliteration. 
I he fact is, this artery, owing to the total absence of collateral branches, is peculiarly 
adapted to this operation, and it is well that it should be so, seeing that, if it were other- 
wise, we should be obliged to resign many of the more severe cases of carotid aneurism 
to their fate, without any attempt whatever at surgical interference. It is obvious, from 
the relations of the vessels and nerves of the neck to the tumor, that, compression, now so 
much employed in the treatment of aneurism of the lower extremity, can seldom be CHAP. V. 
ANEURISM OF THE COMMON CAROTID ARTERY. 
745 
brought into play here, the parts being intolerant of the requisite manipulation, to say 
nothing of the obstruction which it would occasion to the return of the blood in the 
internal jugular vein, which, being dammed up in the brain and the sinuses of the dura 
mater, might speedily induce apoplexy, or other serious cerebral symptoms, endangering 
the patient’s life. When the tumor is of extraordinary bulk, rendering ligation of the 
carotid impracticable at any point, our only hope, faint though it be, is the success of 
general measures, particularly Valsalva’s method; for experience has conclusively proved 
that no benefit is to be expected from the ligation of the innominate artery, as originally 
proposed and practised by I)r. Mott. The deligation of the terminal branches of the 
carotid might be tied with a better prospect of success, but this also would be likely to 
fail, owing to the numerous offsets of the external carotid, which, unless included in sepa- 
rate ligatures, would continue to transmit the blood from the tumor with sufficient force 
and activity to maintain its circulations unimpaired, and so inevitably frustrate the inten- 
tions of the operation. 
When the tumor is unusually voluminous, or even of moderate size, but situated very 
low down, overlapping and compressing the trachea, the symptoms may be so urgent as 
to demand the operation of laryngotomy, to save the patient from impending asphyxia. 
Such an event must, however, be very uncommon. 
A very interesting case of carotid aneurism has been related by Dr. Robertson, of 
Edinburgh, in which he performed an operation after the tumor had burst into the oesoph- 
agus. The swelling was situated so low down that he was compelled to ligate the vessel 
only half an inch above its origin from the innominate artery. Notwithstanding these 
unfavorable circumstances, the patient made an excellent recovery, the ligature coming 
away on the seventeenth day. 
The operation of tying the carotid is ordinarily easy enough, but when the aneurism 
is large, or the neck very short and fat, it is one of the most difficult and trying under- 
takings in surgery. The principal accidents likely to attend it are the inclusion of the 
jugular vein and pneumogastric nerve in the ligature, and the wounding of some of the 
smaller vessels of the neck, which it is sometimes more difficult to find and secure than 
the carotid itself. 
The old procedure of laying open the sac, turning out its contents, and tying both ends 
of the vessel, was practised by Mr. Syme, in a case of traumatic aneurism of the lower part of 
the left carotid, the result of a stab two months previously. A small incision being made 
into the tumor, the finger was passed in so as to plug the puncture, and then the point 
was carried about till it hit the precise spot where pressure controlled the pulsation. 
The sac was now freely opened, the clots sponged out, and a ligature applied to each end 
of the vessel. In this part of the operation great annoyance was experienced on account 
of the difficulty of finding the orifices of the artery, and it was not until after the division 
of the sterno-cleido-mastoid that the object could be attained, such was the confused con- 
dition of the inner surface of the sac. The patient, notwithstanding his apparently des- 
perate condition, made an excellent recovery. This bold operation was successfully 
imitated, in 1875, by Dr. Frothingham, of Ann Arbor, in a similar ease, in which he 
emptied the sac, and tied the artery at both ends. Such an operation, it is evident, can 
be performed only by a surgeon of consummate ability, with thorough anatomical know- 
ledge, and the most perfect self-possession. In the hands of a less competent man it 
might instantly be fatal. 
Mortality and other effects Of the mortality of the operation for carotid aneurism, a 
tolerably accurate estimate may be formed from the data now before the profession. Of 
21 cases mentioned by Mr. Crisp, 10 were successful, and 11 fatal. In 5, the artery 
was ligated at the distal side of the tumor, and of these, 3 recovered, the other 2 being 
only somewhat benefited. Of the 11 fatal cases, 5 were lost by hemorrhage, 2 by inflam- 
mation of the sac and artery, and 1 by spasm of the glottis, the cause of death in the 
remaining 3 being doubtful. The table of I)r. Norris contains an analysis of .38 cases, in 
which the carotid was tied for aneurism, including 4, however, in which the disease was 
found, alter the operation, not to have been connected with the artery. Of these cases, 
22 recovered, and 16 died. The cause of death is mentioned in only 12 of the cases; in 
5 it was hemorrhage, in two inflammation of the sac, in 2 apoplexy and congestion of the 
brain, in 1 cerebritis, in 1 spasm of the glottis, and in 1 exhaustion. 
In 6 of the 38 cases, the aneurism suppurated, and either burst or was laid open ; of 
these, 4 died and 2 recovered. In one instance the opening in the sac occurred four 
months, and in another nearly eight months, after the operation. In one fatal case, the 
tumor burst into the pharynx fifteen days after the deligation of the artery, and iji DISEASES ANI) INJURIES OF THE ARTERIES. 
chap. v. 
another case, which, however, recovered, it had discharged some of its contents into the 
mouth prior to the operation. 
Return of pulsation in the tumor, after the operation, was noted in 9 of the 38 cases; 
in one the pulsation never ceased entirely for two months, and in another it continued 
for upwards of four months. 
The detachment of the ligature occurred, in 13 cases, before the twentieth day; in 7, 
between the twentieth and thirtieth, and in 1 on the thirty-third day. The time in the 
remaining cases was not observed. 
In seven of the cases, analyzed by Dr. Norris, there was a mistake in the diagnosis, 
as was proved on the dissection, for all the patients died. In four, the disease consisted 
of different kinds of tumors; in two, of aneurisms supposed to be abscesses; and in one 
of an aneurism of the vertebral artery. The examples of mistaken diagnosis include the 
celebrated case of Mr. Liston, of a lad, nine years of age, who had a tumor on the right 
side of the neck, of two months’ standing, which, although seated over the carotid, was 
entirely free from pulsation, except along the track of that vessel. Under the conviction 
that it was merely an abscess, a bistoury was introduced, the removal of which was fol- 
lowed by a gush of arterial blood to the amount of four ounces. The bleeding being 
arrested by closing the wound with the twisted suture, the common carotid was tied on 
the following day, October 21st, close to its origin from the innominate artery. On the 
3d of November, the arterial hemorrhage suddenly recurred, but was suppressed by plug- 
ging the wound with lint; it, however, again broke forth, and proved fatal on the 5th, 
that is, fifteen days after the operation. Although the ligature had retained its hold upon 
the artery, the proximal end of the vessel was found to be quite patulous, no attempt 
having been made at the formation of a coagulum. The probability is that, as Mr. 
Liston has suggested, the tumor, in this remarkable case, was originally a scrofulous 
abscess, a part of the wall of which was formed by the carotid ; the latter, becoming 
ulcerated, finally gave way, and thus sent its contents into the cyst inclosing the matter. 
Of lb cases of ligature of the common carotid artery on the cardiac side of the tumor 
for aneurism of the common carotid alone, analyzed by Wyeth, 9 recovered and 7 died. 
Distal ligature of the vessel for aneurism of the root of the common carotid has been 
practised 8 times, with a result of G recoveries and 2 deaths. The case of Demme is 
excluded, as the arch of the aorta was also involved. The operation was first resorted to 
by Wardrop, in 1820, and this patient was alive three years afterwards. 
Injury to the internal jugular vein has been a cause of death in several cases of ligation 
of the carotid. In one in which Barovero included this vessel with the artery, the patient 
died on the sixty-ninth day of gastric fever. Mr. Crisp met with an instance where a 
surgeon tied the internal jugular vein instead of the carotid ; the patient was a child, and 
the error was not discovered until after death. Fatal results have occurred several times 
from injury done to the pneumogastric nerve in ligating this artery. 
Various serious cerebral and pulmonic symptoms occasionally follow the ligation of the 
carotid artery, and are among the principal sources of the mortality from this operation. 
The effects which the operation produces upon the brain have been elucidated both by 
experiments upon the inferior animals and by observations upon the human subject, and 
manifest themselves in various ways and at different intervals. Their full importance, 
however, was not determined until after the publication of the researches of Mr. Che- 
vers, of London, in 1845, to whom the profession is greatly indebted for the valuable 
light which he has thrown upon a subject which, up to that period, had been entirely 
overlooked. In the 789 cases analyzed by Dr. Wyeth, in which the common carotid was 
tied either lor aneurism, wounds, or other causes, more or less severe cerebral disturbance 
occurred in 52. Some of these cases recovered completely, some got well of the opera- 
tion, but remained afterwards in a crippled condition, and some, perhaps the majority, 
died, at a period varying from a few hours to several months. 
I here is no uniformity either in the character or in the manifestation of the cerebral 
symptoms. Sometimes they come on immediately, or, at all events, within a few hours, 
after the deligation of the vessel; while at other times, and perhaps most generally, they 
do not appear until the end of several days, weeks, or months. Their access is usually 
sudden, but occasionally so gradual and imperceptible as to keep the patient in ignorance 
of it until it is discovered accidentally. The most frequent symptoms are convulsions 
and paralysis. I he former may be general, but much oftener they are partial, affecting, 
for example, one arm, a leg, or one side of the face ; in some cases there are merely spas- 
modic twitches, or irregular, involuntary movements. The paralysis occasionally exists 
on the side of the affected artery, but in most cases it occurs on the opposite side, and CHAP. V. 
ANEURISM OF THE COMMON CAROTID ARTERY. 
747 
then it may pervade one-half of the body, as in hemiplegia, although generally it is more 
limited, being confined, perhaps, to the face, tongue, throat, fauces, eyelid, hand, arm, 
leg, or thigh. Sometimes there is dimness of vision, with or without dilatation of the 
pupil; a feeling of drowsiness, somnolency, stupor, or coma; dizziness, vertigo, or head- 
ache ; noise in the ears or partial deafness; delirium, either alone or conjoined with 
paralysis or convulsions ; difficulty of deglutition ; dyspnoea ; a sense of coldness, or cold- 
ness and numbness. Various other symptoms, mostly of an anomalous, nervous character, 
are often present. Occasionally these effects rapidly disappear, but, in general, they are 
more or less persistent, and in some cases they remain up to the moment of the patient’s 
death. In some instances, inflammation of the brain, or of the brain and its envelopes, 
supervenes, either soon after the deligation of the vessel, or at a more or less remote period. 
How are these phenomena produced? Are they caused merely by an inadequate sup- 
ply of blood to the brain, or are they due solely to a loss of equilibrium in the cerebral 
circulation ? To answer these questions satisfactorily is of course impossible. It would 
seem probable, from the free anastomosis which exists between the branches of the inter- 
nal carotid arteries, on the one hand, and between these arteries and the vertebral, on the 
other, that they could not be occasioned by a mere want of blood, inasmuch as these ves- 
sels are capable of furnishing the organ with an abundant supply of that material for the 
purpose of carrying on its healthy functions. Nevertheless, it is not likely that unplea- 
sant effects may and do follow the sudden withdrawal of a certain quantity of blood from 
the brain, resembling those produced by copious bleeding at the arm, or by a smart con- 
cussion of the brain. In some instances, it is reasonable to conclude that they are the 
result of the inclusion of an important nerve; while in another class of cases, as when 
several weeks or months elapse before their supervention, they would seem to be the 
direct consequence of inflammation. Under the latter circumstances, dissection reveals 
softening of the cerebral substance and effusion of serum, or of serum and lymph, in the 
ventricles and upon the surface of the brain. 
The most constant pulmonary effects occasioned by the ligation of the carotid artery 
are cough, bronchitis, and inflammation of the pulmonary tissue. Cough is not only a 
very frequent occurrence, but often one of great severity, rendering it sometimes ex- 
tremely difficult to check it. It generally comes on soon after the operation, in fits of a 
violent spasmodic character, in which the patient is in the deepest distress, looking and 
acting as if he were about to be suffocated. Its duration is variable; sometimes lasting 
only a few hours, while at other times it continues, as a prominent symptom, for days 
together. When very severe, it may occasion hemorrhage in the wound, by reopening 
some of the vessels. Violent hiccough sometimes follows the operation, and may last for 
an almost indefinite period. 
It is not easy to determine how this cough is induced. From the fact that it often fol- 
lows immediately upon the operation, it is not unlikely that it may arise from the inclu- 
sion in the ligature of some nervous filament, which thus sets up irritation in the mucous 
membrane of the air-passages, especially of the larynx and trachea, causing an effect not 
dissimilar from that awakened by the sudden intromission of a drop of water into the 
windpipe. That the effect must be somewhat of this character would seem probable, when 
we reflect upon the spasmodic and uncontrollable nature of the cough which generally 
characterizes the attack. At other times, the cough may be purely sympathetic ; or, what 
is more likely, may be caused by the compression of the filaments of the sympathetic 
nerve, which are so abundantly distributed through the coats of the arteries, especially 
those about the neck and chest. May not the pressure of the ligature upon the pneumo- 
gastric nerve occasion this distress? 
The effects which the ligation of the carotid exerts upon the bronchia and lungs set in 
at various periods after the operation, and are denoted by the usual rational and physical 
signs. On dissection, the mucous membrane of the former is found to be of a reddish 
color, either uniformly or in patches, greatly engorged with blood, and covered with pus, 
or pus and lymph. The lungs are abnormally vascular, loaded with black blood, more or 
less hepatized, or solidified at one point and softened at another. IJlood and pus are 
sometimes contained in the anterior mediastinum ; the pleura has been known to be the 
seat of extensive effusions ; now and then there are traces of inflammation of the larynx 
and trachea; and occasionally, although rarely, the examination reveals the existence of 
pericarditis and endocarditis. When the inflammation of the respiratory organs is at all 
considerable, the blood drawn during life generally evinces a buffed, if not also a cupped, 
appearance. 
Such being the effects which are liable to follow, probably in one case out of every four 
or five, in the brain and lungs, in consequence of the deligation of the carotid, it is obvi- 748 
DISEASES AND INJURIES OF THE ARTERIES. 
CIIAP. v. 
ous that they should be carefully looked for, in order that proper measures may be adopted 
for their prompt and efficient removal the moment they arise. Much may be done, in 
most instances, by way of prevention, by a judicious preparatory course, consisting of 
venesection, purgatives, light diet, and repose ot mind and body, which cannot fail to 
contribute materially to the protection both of the brain and lungs. The operation hav- 
ing been performed, these organs are most sedulously watched, the least indication that 
presents itself being met by appropriate means, and, in this way, the case safely conducted 
to a favorable issue. If the patient be pale and faint, alcoholic stimulants, cautiously 
and judiciously administered, will be of service; cough and convulsive symptoms are 
treated with anodynes and antispasmodics, particularly morphia; and inflammation is con- 
trolled by the lancet, leeches, blisters, purgatives, aconite, and antimonials. 
The treatment of aneurism of the carotid artery by digital compression has not been 
tried upon a sufficiently extended scale, or under sufficiently varying circumstances, to 
enable us to form anything like a correct estimate of its value, or of the particular class 
of cases to which it is applicable ; but the successful examples that have been reported 
by Kerr, Rouge, Gioppi, Vanzetti, Sheppard, Humphry, Gay, and Sir R. Dagin, are quite 
encouraging, and point to the propriety of further efforts in this direction. In the cases 
recorded by De Castro and Delore the procedure failed. The compression must, of 
course, be intermittent, and the best plan is to make it laterally, the thumb being placed 
against the anterior border of the sterno-mastoid muscle, and the next three fingers under 
its posterior edge, an expedient which allows the artery to be seized and controlled with- 
out injury to the pneumogastric nerve. In Rouge’s case, in which this practice was 
successfully pursued, the compression was continued for seventeen days, on an average of 
seven to eight hours each. 
The heart’s action should be controlled during the treatment by venesection, opium, 
and veratrum viride. The exhibition of acetate of lead and ergot might be of service in 
promoting the formation of coagula. As little pressure as possible should be made upon 
the internal jugular vein, otherwise the functions of the brain might be seriously disturbed. 
The chief objection, I conceive, to digital compression in this situation, is the danger of 
embolism. The sudden impaction of a clot in the internal carotid artery or in one of its 
principal branches might cause instantaneous death. 
Anenrismal Varix.—This affection is uncommon. It is generally caused by external 
injury, as a puncture made by a knife, dirk, shot, or piece of glass, establishing a com- 
munication between the carotid artery and jugular vein, so as to admit of a ready inter- 
change of their respective contents. Instances have been published in which the affection 
was occasioned by ulceration. The symptoms present nothing peculiar. In the few 
cases of this variety of aneurism that have been recorded by different observers, as Larrey, 
Marx, Williamson, and Rigaud, life did not seem to have been at all abridged by the 
disease. Operative interference would, in fact, in any event, be unjustifiable, as it would 
be fraught with great danger. Of varicose aneurism, properly so called, of these vessels, 
no instance has, 1 believe, ever been reported. 
ANEURISM OF THE EXTERNAL CAROTID AND ITS BRANCHES. 
Spontaneous aneurism of the external carotid is perhaps still more uncommon than of 
the internal carotid ; its history, consequently is involved in obscurity. The situation of 
the tumor just below the angle of the jaw, its throb- 
bing, pulsatile character, and its gradually increasing 
volume, would serve to distinguish it from ordinary 
growths in this portion of the cervical region. In 
an aneurism of this artery, digital compression would 
be worthy of trial; should this fail, the proper remedy 
would, of course, be ligation of the common carotid. 
False aneurism of the external carotid is rarely 
met with, the only cases of which I have any knowl- 
edge being those of consecutive arterial aneurism 
reported by Professor Lisco, and Dr. S. W. Gross, 
and two examples of arterio-venous aneurism de- 
scribed by Rufz, of Martinique, and Gabe, of Masa- 
rellos. In the first case the old operation of opening 
the sac was successfully performed, but such a pro- 
cedure is too hazardous to be imitated. The patient 
ot Dr. Gross was a negress, twenty-five years of age, 
Fig. 340. 
Traumatic Aneurism of External Carotid. CHAP. V. 
ANEURISM OF THE INTERNAL CAROTID ARTERY. 
749 
who was wounded by a pistol ball, which entered the neck opposite the upper border of 
the thyroid cartilage. Six months subsequently a small pulsating tumor was perceived 
just above the bifurcation of the common carotid, which rapidly increased until it meas- 
ured eight inches transversely by five inches from above downwards, and formed an exten- 
sive swelling, the external features of which are depicted in the adjoining sketch, fig. 340. 
The common carotid was ligated in July, 1868, and in two months the tumor had 
diminished at least two-thirds. At the expiration of one year not a trace of it remained. 
In the case of Gabe, the tumor, of the size of a nut, was seated near the lobule of the 
ear, and was caused by a sabre wound. It was treated unsuccessfully by Chelius, first by 
compression and afterwards by ligation of the common carotid, but was finally cured by 
Stroymeyer by the old operation. 
The temporal artery has never, so far as I know, been the subject of spontaneous 
aneurism, but an aneurism of this vessel is occasionally met with as a result of external 
injury. In 1868, I)r. Macnainara, of Dublin, showed me a tumor of this kind, in a man 
thirty years of age, on the anterior branch of the temporal artery, caused by the scarifi- 
cator in cupping; and cases of aneurism of this trunk or of its offsets have also been 
observed by Petrequin, Deces, Malgaigne, Frestel, and Pavesi. 
The tumor, rarely exceeding the volume of a pigeon’s egg, is usually of a spherical 
shape, and situated just in front of the ear, where it can nearly always be readily distin- 
guished by its history, by its firm consistence, by its pulsation, and by its peculiar whiffing 
sound. The only two diseases with which it might be confounded are cystic tumors of 
the parotid region and aneurism of the middle meningeal artery, attended with absorption 
of the walls of the cranium, the swelling thus presenting itself directly beneath the com- 
mon integument. 
For the cure of this disease two procedures may be employed ; the one consists in ex- 
posing and tying the temporal artery at the cardiac side of the tumor, as in the ordinary 
Hunterian operation, and the other in laying open the sac, and, after having turned out 
its contents, securing the vessel above and below. The former method, when practicable, 
should always be preferred, as it is not only more simple, but less liable to be followed by 
a disfiguring cicatrice. 
Gamma saw an aneurism in the facial artery, near the commissure of the lips ; Iloef- 
nagels, in the inferior coronary ; Boyer and Klaving, in the posterior auricular; Giehrl 
and Agnew, in the occipital; Pancoast, in the stylo-mastoid ; Rufz and Heyfelder, in the 
inferior dental; and Castle, Herapath, Tierlinck, and I myself, in the palatine. In nearly 
all of these cases the tumor was of small size, and owed its origin to external injury. In 
the case recorded by Castle the aneurism was caused by the pressure of the plate of 
artificial teeth. 
The middle meningeal artery has, in a few instances, been the seat of aneurism, the 
result, apparently, of external injury. The nature of the disease can be recognized only 
when the tumor, causing absorption of the walls of the cranium, appears externally under 
the temporal muscle. A case has been related in which an aneurism of this vessel, making 
its way into this situation, was mistaken for a common cystic tumor of the scalp. As 
there was no pulsation, the surgeon cut boldly into the swelling, and found, to his dismay, 
that it was filled with blood. After repeated but fruitless efforts to arrest the hemorrhage, 
the patient expired. The dissection showed that the disease had been an aneurism of the 
middle artery of the dura mater. Had the real nature of the case been suspected in time, 
the proper remedy would have been ligation of the external carotid. 
Some of the branches of the external carotid artery have occasionally, though rarely, 
been the seat of arterio-venous aneurism. In a case recorded by Laugier, the abnormal 
opening existed between the posterior auricular artery and its satellite vein. A similar 
example has been reported by Broca; and Moore met with one in which a communication 
was established between the temporal artery and the accompanying vein. 
ANEURISM OK THE INTERNAL CAROTID AND ITS BRANCHES. 
Aneurism of the internal carotid has been observed only in a few instances, its deep 
situation at the side of the neck and its exemption from ossifie and fatty degeneration 
serving to protect it from this disease. The diagnosis must be obscure. The tendency 
of the tumor is to extend inwards towards the pharynx, as there is much less resistance 
here than in any other direction, the only opposing obstacles being the constrictor muscle, 
some lax connective tissue, and the mucous membrane. The consequence is that more or 750 
DISEASES AND INJURIES OF THE ARTERIES. 
chap. v. 
less prominence exists in the throat, attended with pain and pulsation, and closely simu- 
lating an abscess of the tonsil. The treatment is the same as in ordinary carotid aneurism. 
A remarkable case of aneurism of this vessel has been recorded by Mr. Syme. The 
patient, a woman aged sixty, had had a tumor for about five months in the throat, in the 
usual situation of abscess of the tonsil. It had attained about the size of a large walnut, 
exhibited a diffused appearance when viewed through the mouth, and pulsated in a strong 
and characteristic manner in every portion of its extent. The ligation of the common 
carotid artery diminished, but did not completely arrest, the throbbing. The woman died 
in thirty hours after the operation, without any assignable cause. Had a less careful sur- 
geon had the management of this case, he might probably have punctured the tumor 
under the supposition of its being an abscess, and thus instantly hurled his patient out of 
existence, much to his own discredit and that of the profession. 
Aneurism of the ophthalmic artery is rare, both as a traumatic and as a spontaneous 
affection. The former, caused by various kinds of external injury, is liable to be followed 
by excessive enlargement of the structures of the orbit with protrusion of the eye. A 
number of cases of spontaneous aneurism of this artery are upon record, in only a few of 
which, however, the nature of the disease has been verified by dissection. Aneurism by 
anastomosis is also sometimes met with. The progress of aneurism of the ophthalmic 
artery is usually slow, and the symptoms nre always characteristic. The proper remedy 
is ligation of the common carotid artery as early in the disease as possible, before there is 
any serious structural change in the parts. In anastomotic aneurism, a cure has occa- 
sionally been effected with injections with perchloride of iron ; and lately several cases 
have been successfully treated by digital compression of the carotid. For further infor- 
mation on pulsating tumors of the orbit, the reader is referred to the affections of the 
orbit in the second volume of this work. 
Of aneurism of the supraorbital artery only a few cases have been recorded. It is 
always produced by a wound or rupture of the vessel, and is readily recognized by its 
history, by the rounded or ovoidal shape of the tumor, and by the concomitant thrill and 
pulsation. The proper remedy is incision of the sac, with ligation of the artery. In an 
instance observed by Raoult Deslongechamps, a cure was promptly effected by an injection 
of perchloride of iron. 
In the Transactions of the Academy of Medicine of Leipsic, mention is made of a case 
of aneurism of the frontal artery, and three other examples have been recorded, respec- 
tively, by Velpeau, Brodie, and Godiehon. In the one observed by the latter, the tumor 
was of a pedunculated form, and larger than an ordinary thumb. 
De Haen is said to have met with an aneurism in the dorsal artery of the nose ; but it 
is questionable whether the lesion was anything more than an inordinate dilatation of that 
vessel. 
Anterio-venous aneurism of the extracranial portion of the internal carotid artery is 
extremely rare. Instructive cases of it have been reported by Berard, Despamnches, 
Joret, and Giraldes, all caused by external injury. One instance has been observed in 
which it was occasioned by a wound inflicted in opening an abscess. In two of the cases 
here referred to, the carotid artery, as was shown by the dissection, communicated with 
the internal jugular vein, and a well-marked aneurismal pouch existed between the two 
vessels. The injury was produced in two cases by a ball, in one by a particle of lead, 
and in the fourth by a shoemaker’s knife. In the case of Giraldes the projectile was 
found in the aneurismal sac. The symptoms and treatment are the same as in arterio- 
venous aneurism of the common carotid. 
INTRACRANIAL ANEURISM. 
Intracranial aneurism possesses little interest in a surgical point of view. Of 85 cases, 
analyzed, in 1869, by Dr. James II. Hutchinson, of this city, nine occurred under twenty 
years of age, twelve between twenty and thirty, thirteen between thirty and forty, four- 
teen between forty and fifty, nineteen between fifty and sixty, eight between sixty and 
seventy, nine between seventy and eighty, and one between eighty and ninety. Of the 
85 cases, 48 were males and 82 were females, the sex in five not being given. The basilar 
artery was the seat of the aneurism in 25 cases, the middle cerebral in 26, the internal 
carotid in 10, and in the remaining cases the smaller vessels. From an examination of 
142 cases, Professor Bartholow, in 1872, found that the basilar was affected in 40, the 
middle cerebral in 41, and the internal carotid in 23. The disease may be the result of 
external injury, as a blow or fall on the head, or of syphilis, but more generally it arises ANEURISM OF THE SUBCLAVIAN ARTERY. 
751 
CHAP. V. 
without any assignable cause. The aneurism, which is not always distinctly sacculated, 
is usually confined to one artery, and ranges in volume from that of a pea up to that of a 
pullet’s egg. The vessels of the brain seldom exhibit any evidence of disease ; but as 
the aneurism advances, the cerebral substance is displaced and disorganized, one of the 
most frequent lesions being softening. The cranial bones rarely suffer. 
The most reliable symptoms are apoplexy and hemiplegia, buzzing noises in the ears, 
deafness, dizziness, vertigo, epileptiform convulsions, and pain in the head, either circum- 
scribed or diffused, intermittent or continued, increased by motion, and accompanied by 
peculiar morbid sensations. These symptoms may come on suddenly, without any pre- 
monition, or, as is more frequently the case, arise gradually and almost imperceptibly. 
The diagnosis is always very obscure. In a few instances, the nature of the disease has 
been detected by a loud, rough, or whizzing noise on one side of the head, heard by the 
patient, and distinguished by auscultation. 
Death may be produced, first, by the sudden rupture of the sac, and the escape of its 
contents into the surrounding parts; secondly, by long-continued irritation ; and, lastly, 
by disorganization of the cerebral substance. Of these different terminations, the first 
is by far the most frequent, it having occurred in 49 of the cases collected by Dr. 
Hutchinson. 
Very little can be effected by treatment. When the diagnosis can be satisfactorily 
determined, the carotid artery should be tied on the affected side, as was done successfully 
in a case of this disease by Mr. Coe, of Bristol, England, and in one by Mr. Berkeley 
Hill, of London. 
ANEURISM OF THE VERTEBRAL ARTERY. 
Aneurism of this artery, both spontaneous and traumatic, is extremely uncommon, a 
circumstance no doubt due to the deep situation of this vessel and to its freedom from 
ossification. In two very interesting cases of this disease, described by Ramaglia, of 
Naples, and South, of London, the diagnosis was so obscure that the true nature of the 
disease was not detected until after death. In both the common carotid was tied, with- 
out, of course, any benefit. In the former, which was an example of traumatic aneurism, 
situated behind the left ear, the operator, finding that the deligation did not arrest the 
pulsation, removed the ligature and treated the case upon general principles, death occur- 
ring soon after. In the other instance, in which the carotid artery could be distinctly 
traced over the tumor, this vessel was also tied under the supposition that it was the seat 
of the swelling. The tumor, however, rapidly increased, and in a fortnight after caused 
death by bursting into the trachea. Dissection showed that it was an aneurism of the 
vertebral artery, situated between the transverse processes of the fourth and fifth cervical 
vertebrae. 
Moebus, a German surgeon, has reported a case of aneurism of the vertebral artery, 
the result of a wound of the neck, in which a cure was effected by compression and the 
use of ice. 
ANEURISM OF THE INTERCOSTAL ARTERIES. 
Aneurism of these arteries is exceedingly uncommon ; and the few cases of it upon 
record are interesting rather as showing the errors of diagnosis committed by surgeons, 
than as facts illustrative of the history of the nature, progress, and termination of the dis- 
ease. Dr. Schuster, of Lippe-Detmold, met with a case of caries of the fourth rib in 
which the corresponding intercostal artery was perforated, the blood which had escaped 
from the vessel being contained in a distinct sac. A case of aneurism of the intercostal 
artery, consequent upon a fracture of the rib, has been recorded by Dr. Uhde, of Bruns- 
wick. Dr. Martini, of Liibeck, opened an aneurism of the sixth intercostal artery, under 
the impression that it was a sebaceous tumor. It had apparently been caused by a contu- 
sion of the chest, and was associated with caries of the corresponding rib. The patient 
died. There are doubtless other cases of this affection upon record, but these are the 
only ones I can find. For the references I am indebted to Gunther. 
ANEURISM OF THE SUBCLAVIAN AND ITS BRANCHES. 
Statistics prove that aneurism of the subclavian is nearly as frequent ns that of the 
carotid. In Lisfranc’s table the popliteal comes first, then the femoral, next the carotid, 
and then the subclavian, the latter having suffered in 1G cases out of 179. In the table 752 
DISEASES AND INJURIES OF THE ARTERIES. 
CHAP. V. 
of Mr. Crisp, comprising 295 cases of external aneurism, the subclavian was concerned 
in 23, and the carotid in 25. The disease is more frequent in the right artery than in the 
left, in men than in women, and in the laboring than in the higher classes. The period 
of life during which most of the cases occur is between the thirtieth and fiftieth years. 
The disease may arise spontaneously, as the result of degeneration of the arterial tissues, 
but most frequently it is caused by external injury. 
Mr. Alfred Poland, of London, who some years ago collected all the reported cases of 
subclavian aneurism, upwards of 120 in number, finds that 85 affected the right artery 
and 28 the left, only 2 cases involving both sides. Of the cases in which the sex was 
observed, 100 occurred in men and 11 in women. Of 79 male cases, in which the age is 
recorded, 24 occurred under forty years, 28 from forty to forty-nine, 17 from fifty to fifty- 
nine, and 10 over sixty years. The whole extent of the artery, from its origin to the 
axilla, was involved only in thirteen cases. The size of the aneurism ranged between a 
pigeon’s egg and a child’s head: 13 of the cases were traumatic, and 72 were idiopathic, 
the artery in 33 affording distinct proof of the existence of atheroma. 
Although the disease may affect any portion of the artery, it is most frequent beyond 
the scalene muscles, a short distance before it becomes merged in the axillary. The form 
of the aneurism is generally globular or ovoidal, but cases are observed in which it has a 
singularly compressed appearance; and, on the other hand, it may be remarkably tabu- 
lated, especially when it is very capacious, and extends deeply among the surrounding 
structures, which thus indent its surface. Its volume is seldom very large, unless it 
becomes diffuse, when it may attain an enormous magnitude, reaching nearly up to the 
angle of the jaw, pushing out the clavicle, overlapping the trachea, displacing the scapula, 
pressing backwards against the ribs and spine, and dipping into the cavity of the chest so 
as to force down the lung and impede respiration. 
As the aneurism enlarges, it necessarily encroaches upon and compresses the neighbor- 
ing parts, causing more or less pain, oedema, difficulty of respiration, dilatation of the 
veins of the neck, chest, and upper extremity, and a feeling of numbness and sometimes 
even partial paralysis. Loss of motor pow'er in the corresponding arm and hand, diminu- 
tion of temperature, contraction of the pupil, and increased action in the carotid artery, 
are occasional symptoms. The pulse at the wrist is often sensibly diminished, and some- 
times totally absent. Originally small, deep-seated, circumscribed, indolent, and movable, 
the tumor generally steadily augments in volume, approaching, as it does so, nearer and 
nearer to the surface, loses its defined shape, becomes the seat of incessant pain, and at 
length contracts firm adhesions to the surrounding structures, identifying itself, as it were, 
with them. Examined with the ear and hand,-it readily imparts to them the peculiar 
beat, thrill, and bellows sound so characteristic of aneurism in other regions. 
Diagnosis.—The diagnosis of subclavian aneurism is sometimes extremely difficult, and 
several cases have been reported in which the vessel was ligated where no disease of the 
kind existed. The affections with which it is most liable to be confounded are aneurism 
of the innominate artery or arch of the aorta, abscesses, and various kinds of tumors, solid 
and cystic, benign and malignant. As these lesions are of frequent occurrence in this 
region, it is impossible for the surgeon to be too cautious in his examination of cases 
involving questions of diagnosis. 
The history of the tumor and its situation at the side of the neck, just above the clavicle, 
generally afford important data in regard to the diagnosis. If the patient is under thirty 
years of age, it may almost certainly be assumed that the disease is not spontaneous aneu- 
rism, as there are probably not three well-authenticated instances on record in which the 
subclavian w'as thus affected at this early period. Aneurism of the innominate is situated 
lowrer down, and approaches nearer to the middle line, than aneurism of its subclavian 
division; and in aneurism of the aorta, the tumor, although it may extend into the neck, 
rarely projects as far above the clavicle as in the lesion in question ; certainly not in its 
earlier stages, when alone a correct diagnosis can be of any avail in an operative point of 
view. If the case is seen soon after its commencement, before the tumor has attained any 
considerable bulk, a very good idea may often be formed as to the precise portion of tlie 
artery that is affected by it. rims, for example, if the aneurism occupies the space imme- 
diately exterior to the sterno-cleido-mastoid muscle, and manifests a tendency to extend 
upwards into the neck, and downwards in the direction of the axilla, it may be assumed 
that it is seated upon the outer portion of the vessel beyond the scalene muscles. On the 
other hand, it may be concluded that it is connected with the inner portion of tlie artery 
if the tumor is placed under cover of the sterno-mastoid muscle, and is gradually making its 
way over towards the middle line, thus leaving the inferior triangle of the neck clear. It CHAP. V. 
ANEURISM OF THE SUBCLAVIAN ARTERY. 
753 
may be added that in subclavian aneurism the tumor is less liable to encroach upon the 
windpipe and oesophagus than in innominatal and aortic aneurism, and hence there is 
generally much less cough, dyspnoea, and dysphagia in this than in the other affections. It 
is only, in fact, when the tumor is of great bulk, or when it happens, from the peculiarity 
of its position, to exert much pressure upon the pneumogastric, phrenic, and laryngeal 
nerves, that any serious symptoms of this kind will be likely to arise. 
Progress—Subclavian aneurism is always a serious disease, a spontaneous cure, although 
possible, as several cases upon record testify, being an extremely rare occurrence. In 
general, the disease progresses until it attains a certain point of development, when it ter- 
minates fatally, either by ulceration and hemorrhage, or by the induction of constitutional 
irritation. The sac may open externally, a not uncommon event, especially when it is 
invaded by gangrene ; or it may burst into the pleura, lungs, trachea, or oesophagus; in 
either case, death takes place, either instantly or within a short time after the tumor has 
begun to give way. There are several cases on record in which the aneurism pointed in 
the axilla and on the shoulder, having completely eroded some of the upper ribs and the 
body of the scapula, the latter being scooped out so as to form a kind of bed for the 
accommodation of the sac. 
Of 35 cases tabulated by Poland, in which no mechanical or surgical interference was 
adopted, 11 recovered, 23 died, and 1 was relieved. In 22 of these cases, 4 underwent a 
spontaneous cure, without any treatment whatever, while of the remaining 13, in which 
tlie patient was either bled or some internal remedy administered, 7 were cured, 5 died, 
and 1 was benefited. 
Treatment—The treatment of subclavian aneurism has hitherto been exceedingly un- 
satisfactory, and there is no probability, judging from the deep situation and intricate 
relations of the tumor, that much benefit will ever accrue from any mode of management 
that may be devised for its relief. Acupuncturation and electricity, from which so much 
benefit had at one time been anticipated, have likewise disappointed expectation. Some 
time ago a case was reported in which a cure was alleged to have been effected by galvano- 
puncture, but the example is a solitary one, and the procedure is of too problematical a 
character to merit serious attention. The measures which have hitherto proved to be the 
most promising are the plan of Valsalva, direct compression of the sac, and manipulation. 
In the event of the failure of these methods of treatment, of what resource can the sur- 
geon avail himself in this Unfortunate class of cases? Ligation of the affected artery is 
not only difficult, under any circumstances, from the position of the tumor and the intri- 
cacy of its anatomical relations, but is frequently absolutely impracticable on account of 
the diseased state of the artery, rendering it unable to support the ligature. Shall he 
adopt the operation of Dr. Mott, and secure the innominate, of which the subclavian, on 
the right side, is one of the main divisions? Here, again, obstacles meet him in every 
direction, for even if he should be so fortunate as to get his ligature around the vessel, 
which, however, is by no means always the case, he will find, by consulting the history of 
the operation, that every instance, with one exception, in which it has been performed has 
had a fatal termination. Nothing, therefore, is to be gained from this procedure. In short, 
the Hunterian principle of operation is hardly applicable to any case of subclavian aneurism. 
On the right side, we are not only obliged to encounter, as just stated, great difficulties in 
reaching the innominate artery, but in throwing a ligature around the vessel we effectually 
cut off a large and important supply of blood from the brain, thus greatly enhancing the 
dangers of the case. 
The innominate artery has been tied for the cure of aneurism of the subclavian in 14 
cases, and in 2 for hemorrhage. The results are subjoined in tabular form. 
Ligation of the. Innominate Art erg. 
No. 
Operator. 
Date. 
Age 
Sex 
Disease. 
Rosalt. 
Remarks. 
1 
Mott 
1818 
57 
M. 
Subclavian 
Died on 
Artery tied half an inch below its bifurca- 
aneurism 
26th day 
tion ; ligature separated on the 14tli day ; 
hemorrhage on the 9th, and again on the 
23d day ; death on 26th day. Ulceration 
of the artery, and want of occlusion. 
2 
Graefe 
1822 
... 
M. 
Subclavian 
Died on 
Ligature came off on the 14th day ; death 
aneurism 
67th day 
from hemorrhage. 
3 
Norman 
1824 
M. 
Died 
Death from pericarditis in sixty hours. 
4 
Arendt 
1824 
36 
M. 
Subclavian 
Died on 
Cause of death inflammation of the aneurifT- 
aneurism 
8th day 
mal sac and of the pleura and lung. 754 
DISEASES AND INJURIES OF THE ARTERIES. 
CHAP. V. 
No. 
Operator. 
Date. 
Arc 
Sex 
Disease. 
Result. 
Kcinarks. 
5 
Hall 
1830 
45 
M. 
Subclavian 
aneurism 
Died on 
5th day 
Artery morbidly adherent, dilated, soft, and 
friable ; torn in the attempt to separate it, 
at two points, between which the ligature 
was applied ; copious hemorrhage during 
operation; plugging of the wound ; par- 
ticipation of the aorta and carotid in the 
disease. 
6 
Bland 
1832 
31 
M. 
Subclavian 
aneurism 
Died on 
18th day 
Ligature placed around the artery near its 
bifurcation ; hemorrhage on the 17th day, 
proving fatal on the 18tli ; the innominate 
and carotid closed by solid clots ; the sub- 
clavian still open. 
7 
Lizars 
1837 
30 
M. 
Subclavian 
aneurism 
Died on 
21st day 
Ligature separated on the 17th day ; pleuri- 
tis ; death caused by repeated hemor- 
rhages; twenty ounces of coagulated blood 
at the root of the neck ; arteries imperfectly 
closed. 
8 
llutin 
1842 
26 
M. 
Hemorrhage 
after liga- 
ture of sub- 
clavian 
Died in 
12 hours 
Tied for secondary hemorrhage, after sub- 
clavian had been secured for wound of the 
axillary. 
9 
Gore 
1856 
52 
M. 
Subclavian 
and axillary 
aneurism 
Died on 
17th day 
Death from hemorrhage; aneurism con- 
tracted and filled with coaguluin. Artery 
cut through by ligature. Pus in subcla- 
vian vein and anterior mediastinum. 
10 
Cooper 
1859 
M. 
Subclavian 
and carotid 
aneurism 
Died on 
9th day 
Upper end of sternum and clavicle removed 
to facilitate operation ; dyspnoea and re- 
tention of urine; pus in right kidney; 
death probably from uraemia and pyaunia. 
11 
Cooper 
1860 
31 
M. 
Subclavian 
aneurism 
Died on 
41st day 
Ligature, applied an inch from the aorta, 
detached on the 18th day; patient did 
well for three weeks, when hemorrhage 
occurred, and finally caused death. Upper 
end of sternum and clavicle removed. 
12 
Pirogoff 
1864 
46 
M. 
Subclavian 
aneurism 
Died in 
24 hours 
Cause of death oedematous suppuration of 
sheath of artery, extending to the medi- 
astinum and pericardium. 
13 
A. W. Smyth 
1864 
M. 
Subclavian 
aneurism 
Recovery 
Ligature applied to innominate a quarter of 
an inch below point of division, and at the 
same time to carotid one inch above origin. 
Hemorrhage on 15tli day, controlled by 
plugging wound with small shot and liga- 
ture pulled away. Hemorrhage recurred 
on 33d and 51st days, and vertebral artery 
tied on 54tli day. Patient died at end of 
ten years of the original aneurism, which 
again formed by the reverse collateral cir- 
culation. 
14 
Lynch 
1867 
23 
M. 
Hemorrhage 
from gun- 
shot wound 
of internal 
carotid and 
vertebral 
arteries 
Death 
Common carotid ligated one month previ- 
ously. Death from hemorrhage on 12th 
day, when the ligature was found lying 
loose in wound. Partially organized clots 
in cardiac end of artery. Close to point of 
ligation an anomalous branch was given 
off, which, by keeping up the circulation 
on the cardiac side of ligature, permitted 
the clot to be loosened on its separation. 
15 
A. B. Mott 
1868 
M. 
Subclavian 
aneurism 
Died on 
23d day 
of 
hemor- 
rhage in 
thorax. 
Carotid was tied at same time ; sac burst into 
pleural cavity. 
16 
Bickers tetli 
1868 
40 
M. 
Subclavian 
aneurism 
Death on 
6th day 
from 
hemor- 
rhage 
Artery was first secured by lead wire, which 
was replaced on second day by two liga- 
tures, one above and the other below the 
wire. Clot firm in innominate on cardiac 
side ; subclavian occluded; carotid open, 
and hence seat of fatal hemorrhage. CHAP. V. 
ANEURISM OF THE SUBCLAVIAN ARTERY. 
755 
All the cases in the above table, except six, proved fatal from hemorrhage of the 
wound, caused by the want of occlusion either of the ligated artery, or of the carotid and 
subclavian. It will be observed that Graefe’s patient survived upwards of two months. 
I purposely exclude from the table the cases which are usually referred to as having 
occurred in the practice of Dupuytren and Bujalski, not considering them as sufficiently 
well authenticated to entitle them to a place in it. I also reject from it several reported 
cases in which the operation of ligating the innominate artery was commenced but not 
completed. 
Dr. Peixotto, of Portugal, in 1851, surrounded the innominate artery with a ligature, 
on account of secondary hemorrhage from the common carotid, which had been ligated 
three weeks previously. The ligature, however, which was a precautionary one, was not 
tightened, but applied merely so as to flatten the vessel. The patient mado a good re- 
covery. Such an operation can hardly be regarded as a true case of deligation of the 
innominate artery. The cure was doubtless effected by the ligation of the other vessel. 
Mr. Key, of London, in a case of aneurism of the subclavian, found it impracticable to 
apply a ligature to the innominate, in consequence of the volume of the tumor, and the 
diseased condition of the latter vessel. The patient was seized soon after the operation 
with symptoms of pulmonary distress and exhaustion, and died on the twenty-third day. 
The operation of ligating the innominate artery is one of no inconsiderable difficulty 
even in the dead subject, but in the living the perplexity is greatly increased by the 
proximity of the aneurism, by the presence of glandular swellings, and, above all, by 
the manner in which the parts at the root of the neck are matted together by plastic 
deposits, rendering it thus exceedingly troublesome to separate them. These embarrass- 
ments were experienced in a striking degree by Dr. Hall, of Baltimore; he had great 
difficulty in isolating the vessel, and, in attempting to do so, tore it at two points, ligating 
it afterwards between them. Hemorrhage occurred at the time, but was checked by 
plugging the wound. Another obstacle to successful deligation is disease of the vessel, 
consisting either in a morbid dilatation, or in a softened and lacerable condition of its 
coats. Unforeseen difficulties were present in more than one-fourth of the cases in which 
ligation of the artery has been attempted, compelling the operators to desist, notwith- 
standing their great dexterity and profound knowledge of the anatomy of the neck. 
Mr. Porter, of Dublin, in 1831, attempted to tie this artery on account of aneurism, 
but was obliged to desist on account of its diseased condition. The tumor, nevertheless, 
gradually disappeared, and the patient, a man forty-seven years of age, finally recovered. 
Dr. Hoffman, of New York, in a case of subclavian aneurism in a man sixty-three 
years of age, cut down upon the innominate artery with the design of applying a ligature 
to it, should he be unable to ligate the subclavian; but, as the vessel was found to be 
much enlarged, it was deemed inexpedient to proceed any further. The operation was 
performed in October, 1839, anti death occurred in January, 1840. 
The proposal to ligate the innominate artery originated with Allan Burns, from a con- 
viction that the circulation in the head and upper extremity could be maintained without 
the agency of this vessel, and that it could be easily enough exposed by tracing it down- 
wards towards the aorta, by a careful and patient dissection, the head being at the time 
bent well back. It remained, however, for Dr. Mott, in 1818, to put the suggestion to 
the test of experiment upon the living subject; and, although the operation had an un- 
favorable issue, the man dying, as has already been stated, on the twenty-sixth day, we 
cannot but admire the genius which could plan, and the intrepid skill which could exe- 
cute, so daring and brilliant a feat. The case was one of subclavian aneurism above the 
clavicle, and the design had been to apply the thread to the latter vessel, but, after ex- 
posing it on the tracheal side of the scalene muscle, it was found that its tunics were too 
much diseased to bear the pressure of the ligature, and he accordingly tied the innominate 
in its stead. 
It will thus be seen that the only successful case of ligation of this vessel, is that of Dr. 
Smyth, who tied both the innominate and the carotid at the same time, and the vertebral 
fifty-four days after, an expedient which alone saved the patient’s life. Alexander B. 
Mott also tied the innominate and carotid simultaneously, but the man died on the twenty- 
third day, from the rupture of the aneurism into the pleural cavity. All the cases re- 
corded in the table were males, most of them under forty years of age. In fourteen out 
of the sixteen the operation was performed for the relief of subclavian aneurism. In the 
cases of Lizars and Valentine Mott, an anomalous branch, probably the middle thyroid, 
arose from the innominate near the ligature and probably interfered with the success of 
the operation. Dr. John A. Wyeth, in referring to this vessel, states that he met with it 
five times in thirty-four consecutive dissections. DISEASES AND INJURIES OF THE ARTERIES. 
CHAP. V. 
LIGATION OF THE SUBCLAVIAN ARTERY ON ITS TRACHEAL ASPECT, 
This vessel is sometimes ligated in the first portion of its course for aneurism between 
or beyond the scalene muscles. The subjoined table, comprising eleven cases, will sene 
to place the subject in its true light. 
No. 
Operator. 
Sex. 
Atfe. 
Result. 
Remarks. 
1 
Colles 
M. 
33 
Death 
In this case there was only a space of three lines between 
the sac and the bifurcation of the innominate. The patient 
died of hemorrhage on the fourth day. 
2 
Mott 
F. 
21 
Death 
The patient died on the eighteenth day, of hemorrhage. 
3 
Hayden 
F. 
ft 7 
Death 
Death on the twelfth day, from hemorrhage. 
4 
O’Reilly 
M. 
39 
Death 
The patient died on the thirteenth day, of hemorrhage. 
5 
Partridge 
M. 
38 
Death 
Fatal on the fourth day, from pericarditis and pleurisy. 
6 
Liston 
M. 
32 
Death 
The patient died on the thirty-sixth day, of hemorrhage. 
7 
Auvert 
Death 
Fatal hemorrhage on the twenty-second day. 
8 
Auvert 
Death 
Fatal hemorrhage on the eleventh day. 
9 
J. K. Rodgers 
M. 
42 
Death 
Fatal hemorrhage on the fifteenth day. 
10 
Arendt 
M. 
Death 
Death from exhaustion on fifth day ; no hemorrhage. 
11 
Bayer 
M. 
21 
Death 
Fatal hemorrhage in twenty-four hours. 
The result in all the above cases, except two, was death by hemorrhage, notwithstand- 
ing the undoubted ability and skill ot* the operators, comprising some of the most illus- 
trious names in surgery. Should this fact not be sufficient to deter practitioners from repeat- 
ing the operation, or should they continue in their efforts to save life until some one, more 
fortunate than the rest, shall succeed in finding an exceptional case? The case of Dr. 
J. Kearney Rodgers, of New York, in which the artery was secured on the left side on 
account of an aneurism, is of the deepest interest in this respect, as showing that, although 
the patient finally perished from hemorrhage, yet the ligated vessel was completely closed 
by an adherent coagulum. The cases of Cuvellier and Parker, and one of Liston are 
excluded from the table, since they were examples of simultaneous ligation of the carotid 
and subclavian arteries ; as are also those of Ayres and Bullen in which the subclavian 
was tied for shot wounds, and the ease of Kuhl in which the carotid and subclavian 
arteries were ligated for a vascular tumor of the frontal region. 
Until the operation of Dr. Rodgers, it was universally regarded as impracticable to 
ligate the left subclavian artery on the inside of the scalene muscles, such being the 
intimate relation of the vessel in this situation to the sac of the pleura, the carotid artery, 
internal jugular vein, pneumogastric nerve, and thoracic duct. It had been thought 
that, from the severe injury which would necessarily be inflicted upon the surrounding 
structures during the operation, violent and fatal inflammation must be the speedy and 
inevitable consequence. At all events, no one had yet been found ingenious enough to 
devise, and bold enough to execute, such an enterprise. Although it is not likely that 
the operation will soon be repeated, the case in question deserves notice here as a matter 
of surgical history, if nothing more. 
The patient was a man, aged forty-two, who, in lifting a heavy weight, upwards of a 
month previously, was suddenly seized with an aneurism of the left subclavian artery. 
At the time of his admission into the New York Hospital, the tumor could be seen above 
the clavicle, about the size of a small hen’s egg, extending outwards towards the shoulder, 
and inwards towards the sterno-cleido-mastoid muscle, by the outer border of which it 
was considerably overlapped. The operation was performed on the 14th of October, 
1845. Two incisions were made; one, three inches and a half in length, along the inner 
border of the sterno-mastoid muscle, terminating at the sternum, and dividing the in- 
tegument and platysma-myoid muscle ; the other, two inches and a half in length, ex- 
tending horizontally over the inner extremity of the clavicle, the two meeting at a right 
angle near the trachea. Several small veins having been ligated, and the flap thus formed 
dissected up, the sternal portion with half of the clavicular of the mastoid muscle was 
divided upon a grooved director, a procedure which fully brought into view the sterno- 
hyoid and omohyoid muscles and the deep-seated jugular vein, all covered by the cervical 
fascia. A part of the aneurismal sac was also in sight, overlapping a considerable 
portion of the anterior surface of the scalene muscle, upon which the operator could 
distinctly feel the phrenic nerve. By digging with the handle of the knife and fingers, 
the deep cervical fascia was now divided close to the inner edge of the scalene muscle, ANEURISM OF THE SUBCLAVIAN ARTERY. 
757 
CHAP. V. 
when, after a little search, the subclavian artery was easily discovered as it passed over 
the first rib, pressure upon this portion readily arresting the pulsation of the tumor. The 
next step of the operation consisted in passing the ligature around the vessel without 
injury to the pleura and thoracic duct, but this proved to be one of extreme difficulty, 
owing to the great narrowness and depth of the wound, the latter nearly equalling the 
length of the forefinger. This, however, was at length successfully accomplished by 
means of an aneurismal needle with a movable point, carried from below upwards. The 
moment the ligature was tied all pulsation in the tumor ceased, and the patient, if not 
entirely comfortable, made no complaint of any kind. 
The wound became somewhat erysipelatous after the operation, but, on the whole, the 
patient got on well until the 2Gth of October, when, on changing his position in bed, 
hemorrhage supervened, and, continuing to recur at various intervals, destroyed him on 
the fifteenth day. On dissection, the wound was found to be tilled with clotted blood, 
beneath which the artery had been completely divided by the ligature, which lay loose 
close by. The stump of the subclavian, between the aorta and the point of ligation, Was 
about an inch and a quarter in length, and thoroughly impervious to air and liquids, its 
caliber being occupied by a solid and firmly adherent coagulum. The distal extremity of 
the subclavian contained a soft, imperfect clot, while the vertebral artery, which was 
given off immediately at the site of the ligature, was almost patulous, and had evidently 
been the seat of the hemorrhage which caused the patient’s death. The aneurismal sac, 
the size of a small orange, was completely blocked up with coagula. The thoracic duct 
was uninjured, but the pleura at the bottom of the wound was found to be extensively 
lacerated, and through the opening thus formed a large quantity of blood had passed into 
the left cavity of the chest. 
In reflecting upon this interesting case, Dr. Rodgers regretted that he laid not secured 
the vertebral artery and also the thyroid axis, believing that this would have effectually 
prevented the fatal hemorrhage. Professor Willard Parker, acting upon this suggestion, 
in September, 1863, tied the left subclavian artery on the inside of the scalene muscles, 
along with the common carotid and vertebral, on account of subclavian aneurism. The 
case progressed well until the tenth day, when there was a slight hemorrhage. The 
ligature separated from the vertebral on the twelfth day, from the carotid on the four- 
teenth, and from the subclavian on the twenty-fourth. Death occurred at the end of the 
sixth week, from hemorrhage of the distal side of the subclavian. 
In examining the tables of Dr. Wyeth, I find that ligation of the second or third 
portion of the subclavian artery has been practised for the cure of aneurism of that vessel 
38 times, with 18 recoveries and 20 deaths. Of the cures, seventeen were examples of 
subclavio-axillary vessel, while one was an example of pure subclavian aneurism. In 
two instances partial division of the scalene muscle was required to give more room for 
the operation. The average period at which the ligature separated, according to Mr. 
Poland, who has recorded twenty-one cases, was 32 days, the minimum 15, and the max- 
imum 96. The latter was the remarkable case of Dr. J. M. Warren, in which the sub- 
clavian artery was successfully tied on the outside of the scalene muscles for an aneurism 
of this vessel situated above the clavicle. 
All of the 20 fatal cases were subclavio-axillary aneurisms except one, and in one 
partial division of the scalene muscle was necessary. Nine deaths were due to hemor- 
rhage, two to coma, four to exhaustion, and three to lung complications, the cause being 
unknown in two. 
Aneurism of the subclavian has also been treated by the distal ligature, but with the 
most unpromising results. Thus, ligature of the carotid proved fatal on the fourth day 
in the hands of Mr. Butcher, while ligation of the axillary, performed by Dupuytren, 
Schuh, and Canton, was equally unsuccessful. In a case of aneurism of the first part of 
the subclavian, Petrequin also tied the axillary artery. The tumor continuing to pulsate, 
the sac was punctured, and eight or nine drops of a solution of perchloride of iron were 
thrown in, the brachio-cephalic trunk being compressed during the injection and for ten 
minutes afterwards. The next day all pulsation had ceased in the tumor, but the patient 
died of hemorrhage at the place of ligature twelve days alter its application. In 1874 
Dr. Toland, of San Francisco, ligated the third portion of the subclavian artery with 
two threads for an aneurism as large as the fist. The ligatures came away on the 
twentieth day, and neither pulsation nor bruit could be detected in the tumor at the end 
of six weeks. 
In 1838, Mr. Liston secured the common carotid and the first portion of the subclavian, 
in a tailor, thirty-one years of age, in whom galvano-puneture had been unsuccessfully 758 
DISEASES AND INJURIES OF THE ARTERIES. 
employed. Death resulted from hemorrhage on the thirteenth day. In a case of traumatic 
subclavian aneurism, from a bayonet-thrust at the battle of Magenta, in a dragoon, aged 
twenty-one years, Cuvellier performed a similar operation, followed by hemorrhage on the 
tenth day. 
It thus appears that the treatment of subclavian aneurism by the ligature is most un- 
satisfactory. Of 72 cases, 52, or 72.22 per cent., proved fatal, the only successful issues 
having been obtained in one case out of fourteen of ligation of the innominate, in two 
cases out of five of ligation of the second portion of the subclavian, in sixteen cases out 
of thirty-three of ligation of the third portion of the subclavian, and in one case out of 
six of distal ligation. Under these circumstances it is questionable whether ligature of 
the innominate, or of the first portion of the subclavian should be repeated. As pointed 
out by Wyeth ligation of the second portion of the left subclavian is as safe as that of the 
third division, so that it may be tied when the necessity exists. 
Mr. George H. Porter, of Dublin, in 1867, treated unsuccessfully a case of aneurism 
of the right subclavian artery by acupressure of the axillary artery, followed, at the end 
of about five weeks, by direct pressure of the innominate artery, death occurring ten days 
after the latter operation, from secondary hemorrhage caused by slight gangrene of the 
vessel at the site of the compression. 
Benefit may occasionally arise in subclavian aneurism from manipulation of the tumor, 
as practised by Fergusson ; some of the clots detached in the operation may accidentally 
find their way into the distal extremity of the vessel, and thus occlude its caliber along 
with the interior of the aneurismal sac. In a disease so desperate as this, in which every 
expedient hitherto devised has been tried in vain, any suggestion that holds out the least 
possible chance of relief is worthy of trial. Of seven cases that were subjected to this 
mode of treatment, three died, one was unsuccessful, and three recovered, the latter having 
been reported by Fergusson, Little, and Pemberton. 
Compression, whether digital or mechanical, proximal or distal, of the artery leading 
to or from the sac, has been attempted in several instances, but, from the difficulty of 
applying and maintaining pressure, it has, with three exceptions, been uniformly attended 
with failure. Mr. Poland has narrated a case of subclavian aneurism, of the size of a 
filbert, occurring in a man, forty-four years of age, cured by digital compression of the 
artery on the cardiac side of the tumor, the thumb having been placed over the vessel at 
the outer border of the scalene muscle. It was kept up for ninety-six hours, with a few 
minutes’ intermission, when the tumor was much harder and smaller, although it still 
pulsated slightly. At the expiration of a week the pulsation had ceased, and the tumor 
subsequently entirely disappeared. The course of the artery was high above the clavicle, 
having, probably, been lifted up by a cervical rib, which thus afforded a good point for 
counterpressure. Digital compression, combined with the subcutaneous injection of 
ergotine, proved successful in the hands of Dutoit; but Mr. Willett lost his patient from 
rupture of the sac, which had at the same time been subjected to direct compression. Dr. 
Warren Stone applied compression with the finger on the distal side of the sac for thirty- 
nine hours; but the pulsation did not cease entirely until the expiration of nine months. 
In several cases the measure had to be abandoned in consequence of the severe suffering 
to which it gave rise. 
Moderate direct compression of the sac has been successfully employed in four instances, 
collected by Mr. Poland, and is worthy of more extended trial. In two cases in the 
hands of Dr. J. M. Warren, too far advanced for ligation, a cure was effected by direct 
compression, aided by the application of bags of ice. The tumor, in one of the cases, 
suppurated and partially discharged its contents. In a fifth case death ensued. 
Galvano-puncture has effected one cure in five cases, but this mode of treatment is too 
dangerous to deserve imitation. 
Injection of the sac with coagulating fluids has been practised at least three times. In 
the case of Dr. Mott, immediate death ensued. The case of Petrequin, above referred 
to, was a failure, while the third case terminated fatally from hemorrhage. 
I he introduction of horsehair, to which Dr. Levis resorted in 1873, was followed by 
death on the thirty-fourth day. 
Finally, amputation of the arm at the shoulder-joint, with distal ligation of the axillary 
artery on the face of the stump, may be resorted to, as originally suggested by Fergusson, 
and successfully practised by Spence, in 1864. The patient, an engineer, thirty-three 
years of age, left the hospital on the forty-fourth day in excellent health, but four years 
subsequently death ensued from supposed internal aneurism. In three other cases, in the 
hands, respectively, of Mr. Ileath, Mr. Ilolden, and Mr. Smith, the measure failed ; but 
chap. v. CHAP. V. 
ANEURISM OF THE AXILLARY ARTERY. 
759 
in the case of Mr. Rose, in which the common carotid artery was also ligated, the 
tumor, at the end of three weeks, was reduced one-third, and the patient was free from 
suffering. 
Arterio-venous aneurism of the subclavian artery is extremely uncommon. Sanson 
met with an example, the result of a bullet wound, and Baron Larrey has recorded two 
cases, produced, respectively, by a sabre-thrust and gunshot injury. In none of these 
cases did the tumor give rise to serious inconvenience. In an instance of this kind under 
my own observation during the last six years, the only annoyance experienced is from the 
noise of the tumor. 
ANEURISM OF THE TRANSVERSE CERVICAL ARTERY. 
A case of aneurism of this artery, the only one of which I have any knowledge, was 
reported, in 1869, by Mr. Pick, in the Transactions of the Pathological Society of London. 
The tumor, situated on the left side of the neck, just above the clavicular origin of the 
sterno-mastoid muscle, was of the size of a walnut, soft and fluctuating, with forcible 
pulsation, and a peculiar upheaving of the entire mass as if the sac lay merely over an 
artery instead of forming a component part of it. There was scarcely any audible bruit. 
The tumor took its rise close to the origin of the transverse cervical artery, which in this 
instance came off directly from the subclavian, and not, as is usually the case, from the 
thyroid axis. It rested upon the subclavian vessels, was partially covered by the clavicular 
attachment of the sterno-mastoid muscle, and was completely filled with a firm, semitrans- 
parent clot, intimately adherent to the walls of the sac, but without any laminated arrange- 
ment. All the coats of the artery seemed to have been involved in the aneurism, the 
communication between them having been established by a small orifice. The patient 
was a soldier, forty-five years of age, recently discharged from the army, and the tumor 
had been noticed for the first time only three weeks before death, which was caused by 
phthisis. Direct pressure with a pad and bandage was kept up for some time, after which 
iodine was daily applied with marked advantage, although the pulsation and the upheaving 
appearance continued to the last. The diagnosis was obscure. 
ANEURISM OF THE SUBSOAI'ULAR ARTERY. 
Of spontaneous aneurism of this vessel I do not find a solitary instance upon record; a 
circumstance easily accounted for, by the deep situation of this vessel, its small size, and 
the infrequency of the degeneration of its tunics. Of the traumatic form of the lesion a 
case was reported in 1874, by Dr. Monmonier, of Baltimore, in a man twenty-one years 
of age, who, sometime previously, had fallen down a flight of stairs, the arm being thrown 
suddenly upwards and violently extended so as to rupture the vessel. The tumor, which 
was of considerable size, occupied the left axilla, was of a firm, fibroid consistence, and 
destitute of pulsation. Fearing that the hemorrhage might prove troublesome, Dr. Mon- 
monier tied the subclavian artery in the third part of its course, and then laid open the 
tumor and turned out the clots. Recovery occurred without any accident. 
ANEURISM OF THE AXILLARY ARTERY. 
Aneurism of the axillary artery is less frequent than that of the subclavian. In 364 
preparations of aneurism in the London museums, examined by Mr. Crisp, including 249 
of the aorta, the axillary artery was affected only in 8. In 551 cases analyzed by him 
from different sources, including 234 cases of aneurism of the aorta, 18 only were of the 
axillary artery. 
The disease is most frequent in men, between the ages of thirty-five and fifty. It is 
very often of traumatic origin. In an instance recorded by Roux it was caused by the 
pressure of an exostosis. The volume of the tumor ranges from an egg to that of a 
child’s head, the average being that of a fist. Arterio-venous aneurism of the axillary 
vessels is very uncommon. 
Symptoms.—The symptoms of axillary aneurism are generally so well marked as to 
render it impossible to mistake their character. When the disease arises spontaneously, 
or without any assignable cause, it may exist for several months without attracting any 
particular notice, and the same thing occasionally occurs when it results from external 
violence, as a blow or strain. Generally, however, the tumor rapidly augments/in bulk, 760 
DISEASES AND INJURIES OF THE ARTERIES. 
and produces such a train of phenomena as to lead at once to its detection. Ot these, 
one of the earliest, and at the same time most unpleasant, is the sense of fatigue or uneasi- 
ness in the affected part arising from the pressure on the axillary plexus ol nerves. 1 his 
symptom is usually succeeded in a few weeks, sometimes, indeed, in a few days, by a 
feeling of pain, which is always in direct ratio to the size of the aneurism, being com- 
paratively slight when it is small, and more or less intense when large. Nor is the pain 
confined to the site of the disease ; in most cases it radiates from it, as from a common 
centre, in different directions, outwards into the shoulder, downwards along the arm, and 
upwards into the neck. Pressure, severe coughing, the recumbent posture, and the weight 
of the limb, greatly increase it. Numbness of the shoulder, chest, and arm, is another 
symptom which generally manifests itself at an early period of the disease, and is never 
absent when the tumor has acquired considerable magnitude. It is always very distressing 
to the patient, is greatly aggravated by pressure on the swelling, and commonly extends 
to the ends of the fingers. Indeed, it is here that the sensation in question is often most 
keenly felt. 
The pulsation of the tumor, at first faint and scarcely perceptible, becomes very dis- 
tinct during the progress of the disease, so that it cannot only be felt by the fingers, but 
seen at a considerable distance; sometimes, indeed, ten or twelve feet from the patient. 
On applying the ear or the stethoscope to the tumor, the blood is found to rush into it 
with more or less violence, producing a peculiar thrill, or whizzing noise, synchronous 
with the contraction of the left ventricle of the heart. In the early stage of the disease, 
the swelling is soft and elastic, and may readily be emptied by pressure; by degrees, 
however, it becomes firm, tense, and, in great measure, if not entirely, incompressible. 
In some cases, especially in those attended with great enlargement, there is considerable 
diminution of the temperature of the affected limb, with indistinctness, if not entire 
absence, of the pulse at the wrist, more or less cough, dyspmea, and shortness of breath- 
ing. Occasionally the pulse is fully as strong as in the other arm, but irregular or inter- 
mittent, losing several strokes in a minute. 
In addition to these symptoms, there is always, when the swelling is large, so much 
displacement of the clavicle as to render it difficult, if not impossible, to distinguish the 
pulsation of the subclavian artery, the vessel being deeply buried behind and below the 
bone. In some instances the collar-bone has been found to be considerably imbedded in 
the tumor, or partially removed by absorption. Another symptom, which, from its fre- 
quency, especially in the latter stages of the disease, requires mention here, is the swelling 
of the affected limb. This varies in degree in different cases, often extends from the 
shoulder to the ends of the fingers, and is usually of an ccdematous character, pitting 
under pressure, and becoming aggravated by the dependent position of the part. When 
thus affected, the muscles lose their contractile power, and the motions of the extremity 
are proportionately impaired, or entirely annihilated. Sometimes, again, owing to the 
great magnitude of the tumor, the patient is unable to approximate the limb to the side 
of the chest. Finally, there is another phenomenon, which, as it is almost invariably 
present in the latter stages of axillary aneurism, I am disposed to regard as pathogno- 
monic. I allude to the peculiar attitude of the patient, arising from the constant inclina- 
tion of the head towards the affected side, and the manner in which he supports the 
corresponding arm ; the object of both being evidently to prevent the tension which 
would otherwise be caused in the tumor. Under these circumstances, too, the countenance 
wears an anxious and distressed appearance, and, as the system always deeply sympa- 
thizes with the local affection, there is more or less derangement of the general health. 
When the tumor is unusually bulky, it will necessarily greatly encroach upon the 
clavicle, forcing it upwards into the neck, and at the same time exerting severe pressure 
upon the subclavian artery, perhaps so much as to render it difficult, if not impossible, 
to distinguish the pulse at the wrist. 
Diagnosis—Notwithstanding that the symptoms of this disease are usually well marked, 
sometimes tumors of this description have been opened, under the belief that they were 
abscesses. For such an error no apology can be offered. Still, cases occasionally present 
themselves, although very rarely, in which it is extremely difficult, at first sight, to distin- 
guish between this and other swellings in the armpit or subclavicular region. Enlarged 
lymphatic glands, adipose tumors, or sarcomatous growths, for example, if they chance to 
lie along the course of the axillary artery, might have its pulsation imparted to them, and 
thus create some doubt in regard to their real character. Under such circumstances, the 
facility with which the mass can be elevated or removed from the vessel, the absence of 
the peculiar whizzing sound, previously alluded to, as being generally present in aneu- 
CHAP. V. ANEURISM OF THE AXILLARY ARTERY. 
761 
CHAP. V. 
risinal disease, the slight pain and numbness in the part and in the corresponding limb, 
the continuance of the swelling on the application of pressure to the subclavian artery, 
and, above all, the history of the case, will generally be sufficient to establish the diagnosis. 
In this disease the tumor may be situated either immediately below the clavicle, or in 
the axilla, properly so called. In the former case, it may not only elevate the clavicle, 
but extend up into the neck, beneath the bone, as far as the outer border of the scalene 
muscles. In the latter, it has been known to reach some distance down the arm, so as 
to compress the brachial artery and nerves, and prevent the approximation of the limb to 
the side. 
Prognosis—Axillary aneurism occasionally undergoes spontaneous cure, as in the 
instances reported by S. Cooperand Breschet. Such an occurrence, however, is extremely 
uncommon. Most generally, the disease, if left to itself, terminates fatally, either by 
rupture of the sac and exhausting hemorrhage, or by gangrene of the limb. Sometimes, 
although rarely, the tumor destroys life by inducing caries of the ribs and perforation of 
the pleura, followed by an escape of its contents into the cavity of the chest. In a case 
narrated by Mr. Guthrie, it was ascertained, on dissection, that the aneurism had forced 
its way into the right side of the chest by the destruction of a portion of the first five ribs, 
and had contracted adhesions to the upper lobe of the lung, into which it had gradually 
opened and discharged its contents, the man having spat blood more or less profusely for 
several weeks prior to his death. In a similar case mentioned by Dr. Neret, of Nancy, 
an aneurism, about the size of a large chestnut, communicated with a cavity of the volume 
of the head of a new-born infant in the upper part of the left lung. The man had been 
admitted into the hospital on account of hemoptysis. 
Treatment—Intermittent digital compression of the subclavian artery, as it passes over 
the first rib, should always be resorted to for this disease before recourse is had to the ligature, 
as it holds out considerable prospect of permanent relief. Thus, of 9 cases in which it was 
practised, 6 were cured. In one the compression was applied under chloroform, once 
for three hours and a quarter, and on another occasion for eight hours. In a second case 
it was maintained for six hours a day for six days. In two other successful examples, on 
the other hand, it was applied at intervals, respectively, for three months and six months. 
In the event of the failure of the measure, the only remedy is ligation of the subclavian 
artery, and the sooner this is done, the more likely will it be to succeed. The operation, 
however, should not be declined, even although gangrene of the sac has already commenced, 
provided there is nothing else to forbid it. 
Mr. Syme laid open, with complete success, a spontaneous aneurism in this region, turn- 
ing out its contents, and tying the axillary artery above and below the points of communi- 
cation with the sac. As a means of safety, the subclavian was compressed by the finger of 
an assistant against the first rib, through an incision in the neck which divided the skin 
and fascia. By this procedure the circulation was so effectually controlled that there was 
hardly any hemorrhage. Few operators, unless possessed of the most consummate skill, 
would be willing to imitate the example of the Edinburgh surgeon, or not prefer the liga- 
tion of the subclavian artery on the outside of the scalene muscle. 
In a case of axillary aneurism, the size of a child’s head, the result of a gunshot injury 
received six years previously, under the care of I)r. C. C. F. Gay, of Buffalo, the tumor, 
previously pierced by a large trocar at the softest part, burst under the pressure of the 
fingers during the examination, followed by profuse hemorrhage. This was, however, 
speedily controlled by thrusting the hand through the rent, behind the clots, and seizing 
the axillary vessels. The subclavian artery was then compressed, and next tied at the 
junction of its second and third portions. On the ninth day secondary hemorrhage super- 
vened, but was promptly arrested by plugging the wound with lint wet with Monsel’s salt. 
The ligature came away on the seventeenth day after the operation, and in six weeks the 
patient was well, with the exception of slight paralysis of the arm. 
Mortality—Of 27 cases of axillary aneurism, which I analyzed in 1841 in the Western 
Journal of Medicine and Surgery, including one of my own, for which the subclavian 
artery had been tied, 17 recovered and 10 died, death occurring from the third to the 
thirtieth day, either from hemorrhage, gangrene of the arm, ulceration of the artery, 
pericarditis, pleurisy, or pneumonia. In one case it was caused by effusion into the brain, 
and in another, my own, by rupture of the aneurismal sac into the thoracic cavity. In 
the tables of Dr. Norris, showing the mortality in (59 cases in which the subclavian artery 
was tied for aneurism, including 9 of wounds of the axillary artery and 2 of tumors not 
aneurismal, although supposed to be so at the time, 36 recovered, and 33 died. 
According to Professor Parker, the subclavian artery has been ligated 81 times, with DISEASES AND INJURIES OF THE ARTERIES. 
chap. v. 
29, or 85.80 per cent, of deaths, for idiopathic and traumatic axillary aneurisms. Of 57 
idiopathic cases, 21 died, while of 24 traumatic cases, 8 proved fatal. Le Fort has 
collected 97 cases of ligature of the third portion of the subclavian for wounds, or for 
diffused and circumscribed aneurisms of the axillary artery. Excluding the wounds, 
there were 80 deligations for aneurism, with 29 deaths, or a mortality of 36.25 per cent., 
which corresponds very closely with the results obtained by Parker. Of the 80 cases, 9 
were examples of diffused aneurism, with 5 deaths, and 71 examples of circumscribed 
aneurism, of which 24 died. Wyeth’s tables embrace 75 cases in which the subclavian 
was tied in its third course on account of axillary aneurism with 47 recoveries, or a death- 
rate of 37 per cent., in which secondary hemorrhage played a conspicuous part. To these 
cases may be added a successful one recently reported by Harrison, of Liverpool. 
In three of the cases mentioned in my paper, the subclavian was secured on the tracheal 
side of the tumor, and all proved fatal. In one of the cases, that of Mr. Colles, the liga- 
ture was not tightened till the fourth day after the operation, owing to the supervention 
of excessive dyspnoea and cardiac oppression. 
In my own case, a traumatic one, the tumor burst at the end of the twenty-sixth day 
after the operation, discharging its contents into the right thoracic cavity, and thus causing 
fatal pleuritis. The patient, a man thirty-six years of age, was suddenly seized with intense 
pain in the chest, which was particularly severe at the base of the right lung, from which 
it extended over towards the sternum, on the one hand, and up towards the axilla, on the 
other. The respiration was hurried, laborious, and fifty-six in the minute ; and the pulse, 
which was quick and tense, rose rapidly to one hundred and forty. Two days after the 
accident, the patient experienced a sensation near the upper part of the chest, as if a fluid 
were passing from the pleural cavity into that of the aneurismal sac, and, on carefully 
auscultating the spot, a splashing sound could be distinctly heard at every inspiration, the 
noise resembling that produced by shaking water in a closed vessel. The respiration in 
the right lung was now bronchial, and there was extensive dulness on percussion of that 
side of the chest. It is proper to add that the tumor prior to the operation was about the 
volume of a large fist, and that the ligature, which had been placed on the artery on the 
external side of the scalene muscle, came away on the fourteenth day. The dissection 
revealed the following facts, the arteries having previously been injected. 
The wound made in the operation was completely cicatrized, and the pectoral muscles, 
although somewhat attenuated, retained their natural appearance. The subclavian artery 
terminated abruptly at the outer margin of the scalene muscle, where the ligature had been 
applied, its caliber being closed by a mass of solid fibrin, about one-third of an inch in 
length, which adhered firmly to the lining membrane, and thus afforded an effectual 
barrier to the passage of the blood. Between this and the thyroid axis the vessel was occu- 
pied by a dark coagulum of blood, which, as it wTas unadherent, was probably formed only 
a short time before death. Beyond the seat of the ligature the artery had a rough, ragged 
appearance, and was sufliciently pervious to admit of the ready passage of a small probe 
into the aneurismal sac. Superiorly the tumor was overlapped by the brachial plexus of 
nerves, while in front, at its lower part, was the subclavian vein, which, besides being 
thrown out of its natural course, was considerably diminished in size. No pus was any- 
where discoverable, the parts immediately involved in the operation being intimately 
consolidated by plastic matter. The aneurismal tumor, placed immediately below the 
clavicle, was of a conical form, and about the volume of a moderate-sized orange, being two 
inches and a quarter in diameter at its base. Its walls varied in thickness at different 
points from half a line to the eighth of an inch, and its interior communicated by 
means of an oval aperture, one inch and three-quarters in length by an inch and a half in 
width, with the pleural cavity; it was situated between the first and second ribs, nearly 
equidistant between the sternum and spine, and was obviously the result of ulceration, 
induced by the pressure of the tumor. Both ribs were denuded of their periosteum 
immediately around the opening, and the serous membrane had a shreddy, ragged aspect. 
The aneurismal sac contained a few reddish clots arranged in a laminated manner, and 
closely adherent to its inner surface, especially at the part corresponding with the apex 
of the tumor. 
I he right thoracic cavity contained nearly three quarts of bloody-looking serum, inter- 
mixed writh flakes of lymph and laminated clots, the latter of which were of a reddish- 
brown color, and had evidently been originally lodged in the aneurismal sac. The pleura 
exhibited everywhere marks of high inflammation, while the right lung was greatly reduced 
in volume, from the compression of the eflused fluid. The left lung was considerably 
engorged, and at one or two points almost hepatized. The heart and pericardium were CHAP. V. 
ANEURISM OF THE AXILLARY ARTERY. 
763 
sound. The abdominal viscera presented nothing unusual. None of the arteries were 
diseased. 
There can be no doubt, from the manner in which this case terminated, that the ulcer- 
ation which gave rise to the opening above referred to, and which finally led to the escape 
of a portion of the contents of the aneurismal sac, commenced prior to the deligation of 
the artery, having been produced by the violent pulsatory action of the tumor. Could such 
an accident have been foreseen, I should not have hesitaed to empty the sac to relieve the 
parts of pressure, objectionable as such a procedure certainly would be in ordinary cases. 
An instance of a character similar to the above occurred in 1823, in the practice of Mr. 
Bullen, of England, and is related in the twentieth volume of the London Medical Re- 
pository. The patient was a man, thirty-six years of age, and the aneurism, which was 
of nearly five months’ standing, also occupied the right side. Eighteen days after the 
operation, the tumor began to increase in size and to become painful. Very soon evi- 
dences of suppuration appeared, and at the end of a week, from six to eight ounces of 
bloody pus were ejected during a violent paroxysm of coughing, the sac immediately 
diminishing one-half in volume. A puncture being made into the swelling, five ounces 
of a similar fluid were discharged, to the great relief of the patient. It was now apparent 
that there was a cavity between the first and second ribs, near their sternal extremities, 
through which the matter had found its way into the lung, and which now readily admit- 
ted air from the latter organ, whenever the man coughed, at which time a little also 
escaped at the artificial opening. By degrees, the discharge of matter ceased, the cough 
grew less and less, and at the end of three months the recovery was perfect. 
Dr. Thomas G. Morton, of this city, in 1866, met with a case of spontaneous aneurism 
of the axillary artery, in a man fifty-one years of age, in which he successfully tied the 
subclavian artery on the left side, between the scalene muscles, the ligature coming away 
on the eighteenth day. Subsequently, however, the tumor sloughed, followed, on the 
forty-third day, by violent and frequently recurring hemorrhage, and eventually by gan- 
grene of the limb, necessitating amputation at the shoulder-joint. Notwithstanding these 
untoward occurrences, the patient made an excellent recovery. 
Mr. Erichsen, struck with the extraordinary mortality after ligation of the subclavian 
artery, in the third part of its course, for spontaneous aneurism in the axilla, determined, 
if possible, to ascertain the cause of death. For this purpose he analyzed 48 cases of the 
operation, of which 23 recovered, and 25 were fatal. Of the latter, 10 perished from 
inflammation within the chest, 6 of suppuration of the sac, 3 of hemorrhage, 1 of gangrene 
of the hand and arm, 1 of suppurative phlebitis, and 1 of general gangrene, the cause of 
death in 3 not being mentioned. 
The ten cases in the first category died of pneumonia, or of this disease and of inflam- 
mation of the pleura and pericardium, produced, as Mr. Erichsen suggests, either by an 
extension of the inflammation of the deep connective tissue of the neck to the contents of 
the chest, by the inward pressure of the aneurismal sac, or, lastly, by the injury inflicted 
during the operation upon the phrenic nerve. 
Suppuration of the sac was the immediate cause of death in six cases, and it occurred 
also in two of the cases that died of inflammation of the chest. Besides these fatal cases 
there were six of recovery, making thus an aggregate of 14 cases, or a ratio of nearly one 
in three. The period at which the suppuration set in varied, on an average, from eight 
days to four weeks. 
II emorrhage proved fatal in three of the cases, and appeared to be a frequent cause of 
death after suppuration of the sac. It may proceed from the distal orifice of the artery 
opening into the sac, or from one of the large branches in its immediate vicinity, as the 
subscapular or posterior circumflex. 
Gangrene of the hand and arm was the cause of death in one instance only, although 
the disease occurred also in two others. In Blizard’s case, in which there was sloughing 
of the sac and pericarditis, the gangrene was confined to two fingers ; while in Brodie’s 
case it occurred both in the upper and lower extremities, thus showing that it depended, 
not upon a want of power in the collateral circulation, as in the other examples, but upon 
some peculiar state of the constitution. 
Ligation of the axillary artery below the clavicle has been practised in 21 cases, with 
8 deaths, or a mortality of 38 per cent. Not only is the ratio of deaths slightly greater 
than that of ligation of the third portion of the subclavian, but the operation is not so safe 
as the latter procedure, especially in cases of spontaneous aneurism, as the artery is liable 
to be diseased, thereby enhancing the risks of hemorrhage upon the separation of the thread. 
Arterio-venous aneurism of the axillary artery has been observed in two cases by Lar- DISEASES AND INJURIES OF THE ARTERIES. 
CHAP. V. 
ray, as the result of sabre-thrust, and by Dupuytren, Wattman, Legoucst, and others, in 
consequence of gunshot injury. The case of Wattman occurred in 1843, in a man, sixty- 
two years of age, in whom the subclavian artery was ligated in the third portion of its 
course. A fatal termination ensued in the third week, from hemorrhage. In the other 
instances, surgical interference was not deemed either necessary or advisable. 
ANEURISM OF THE RUACIIIAL ARTERY AND ITS BRANCHES. 
Spontaneous aneurism of the brachial artery and of its terminal branches, the radial and 
ulnar, is extremely uncommon, for the reason, adverted to in a previous section, that ossi- 
fication and fatty degeneration of the coats of these vessels are of such great rarity com- 
pared with the same lesions of the femoral and its principal divisions. Of fourteen cases 
of spontaneous aneurism of the brachial artery, including one of his own, analyzed by Dr. 
L. E. Holt, of New York, in the American Journal of the Medical Sciences, for April, 
1882, the tumor was seated at the bend of the elbow in six, in the lower third of the vessel 
in two, the middle third in two, at the junction of the middle with the upper third in one, 
and in the upper third in three. Of the thirteen which underwent treatment two recov- 
ered and one failed after instrumental compression; one was cured by combined mechanical 
pressure and flexion ; one recovered after digital compression ; and the remainder were 
cured by ligation of the brachial in four, the axillary in three, and tying the artery above 
and below the tumor in one. Ligature of the axillary was followed by secondary hemor- 
rhage in two instances, and by suppuration and excision of the sac in the third case. 
Spontaneous aneurism of the ulnar and radial arteries is spoken of by several writers, but 
in so vague a manner as to render it difficult to determine whether the disease depended 
upon degeneration of the coats of the vessels, or merely upon laceration by external injury. 
All these arteries are subject to traumatic aneurism ; the brachial, however, is much 
more frequently involved than the radial and ulnar, and one of the most common causes 
of the occurrence is venesection at the bend of the arm, the puncture of the lancet estab- 
lishing a communication between the vein and the artery, thus giving rise to what is called 
an arterio-venous aneurism. Or, instead of this, the instrument may almost completely 
sever the artery, and so induce a diffused aneurism, not opening into the vein, but sending 
its contents, up and down, over a large portion of the inner and fore part of the limb. 
Some of these latter cases are occasionally very formidable, requiring great judgment and 
skill for their successful management. A good illustration of the traumatic form of aneu- 
rism of the brachial artery is afforded in fig. 341. 
An arterio-venous aneurism at the bend of the arm may sometimes be cured by sys- 
tematic compression of the brachial artery, at a distance of five or six inches from the seat 
of the disease; but, in general, the most expeditious plan is to lay 
open the sac, turn out its contents, and tie the artery above am 
below, the inferior ligature being necessary to prevent hemorrhage 
from the recurrent branches. 
In extensive extravasation of blood, constituting what is usually, 
but improperly, called a diffused aneurism, the brachial artery musi 
be exposed at the site of injury, and ligated at its cardiac and dista 
extremities. Compression is commonly useless. 
Aneurisms of the ulnar and radial arteries must be managed upoi 
the same general principles as those of the brachial artery. Com 
pression can rarely be rendered available, except at the wrist, ant 
even here it will usually be found to be unsatisfactory, on accoun 
of the difficulty of maintaining it in a firm and steady manner. Hence 
the proper way is always to ligate the affected vessel at once, no 
waiting until the parts have become obscured by the extravasatet 
blood. As both arteries are very deep-seated in the upper and middle 
portions of their extent, rendering it very difficult to expose them 
it has been proposed, when they are wounded in these situations, tc 
ligate the brachial; but the objection to this procedure is that, while 
the cardiac extremity of the affected vessel will thus be closed, the 
distal one will remain patent, and thus admit of a continuance of the 
hemorrhage by the recurrent circulation. 
A case of aneurism of the lower part of the radial artery, causec 
by a rupture of this vessel in an effort which the patient made tc 
raise himself in bed upon his hands, has been recorded by Sir Astle; 
Fig. 341. 
Traumatic Aneurism of 
the Brachial Artery. ANEURISM OF THE ABDOMINAL AORTA. 
765 
CHAP. V. 
Cooper. Tt was promptly cured by the application of two ligatures. In a case in the prac- 
tice of Langenbeck, a cure was effected in twenty-tour hours by a single subcutaneous in- 
jection of ergotin. 
The symptoms of aneurism of the radial artery at the wrist are sometimes singularly 
simulated by the existence of a synovial cyst or ganglion, immediately under the vessel, 
within the sphere of its pulsation. Not less than five or six cases of this kind have 
occurred in my practice, most of them in young females in the higher walks of life. The 
tumor varies in size from a marrowfat pea to that of a hazelnut, and is remarkably dense 
and firm, with a slight degree of elasticity. The artery, stretched across it like a tense 
cord, beats with great vigor, and imparts to the finger of the surgeon the sensation pre- 
cisely of an aneurism. The deception will be much increased if, in addition to this sensa- 
tion, there is considerable pain in the part, with a feeling of stiffness in the joint. The 
diagnosis is determined by placing the hand in a state of forced flexion, which, by removing 
the tension from the tumor, either arrests the pulsation in the vessel, or changes its rela- 
tion in such a manner as to lead at once to the detection of the true nature of the 
affection. 
Mr. Pilcher met with an instance of aneurism under the ball of the right thumb in a 
goldsmith, from the repeated, although slight, blows inflicted with his hammer in the exer- 
cise of his trade. The disease speedily disappeared after ligation of the radial and ulnar 
arteries at the wrist. In a case in the practice of Mr. Syme, in a man who had, at the 
root of the thumb, a tumor about the size of a flattened gooseberry, all pulsation had 
ceased at the end of tw’enty-four hours under the pressure of a small spring truss applied 
to the vessel at the wrist. Guattani describes a case of aneurism of the muscular emi- 
nence of the thumb in a man, forty-five years old, which he cured by direct compression 
after it had been freely opened by a longitudinal incision. The tumor was of the size of 
a common apple, circumscribed, tense, indolent, and unattended with pulsation. 
ANEURISM OF THE ABDOMINAL AORTA. 
Aneurism of the ventral aorta is much more frequent in men than in women, and is met 
with chiefly between the ages of thirty and fifty. In an instance recorded by Mr. Armi- 
tage the disease occurred at the age of seven years and a half, the tumor being situated 
at the bifurcation of the vessel, and death being caused by the rupture of the sac. The 
disease, which is much less common than aneurism of the thoracic aorta, generally begins 
near the cocliac axis, in the form of a sac-like expansion, connected with the antero-lateral 
aspect of the vessel, and communicating with it by a rounded opening, from the size of a 
quill to that of a finger. The volume of the tumor is variable ; in some cases it may not 
exceed an orange, while in others it may equal an adult’s head. Its contents, at first fluid, 
soon become solidified, and arrange themselves in the form of concentric lamellae, the 
number and firmness of which are often very remarkable. The sac usually inclines a little 
to one side, generally to the left, as there is less resistance in that direction than in the 
other; and, as it increases, it seriously encroaches upon the abdominal viscera, and even 
upon the diaphragm, especially when it is of large bulk or situated high up. The imme- 
diate cause of the disease is commonly the fatty, fibrous, or calcareous degeneration of 
the artery. 
The symptoms of aneurism of the ventral aorta resemble, in general terms, those of 
aneurism of the thoracic. The pulsation, however, is usually more distinct, while the 
functional distress is less, owing to the more yielding character of the abdominal viscera, 
and the fact that they are not so important to life. The tumor, which is immovably 
fixed, is dull on percussion, especially in the flaccid condition of the bowels, and gradually 
increases in size and solidity with its age. The pain, at first slight, often becomes very 
severe, and usually darts about in different directions. It is generally most violent in the 
course of the solar, coeliac, and hypogastric plexuses, and occasionally assumes a decidedly 
neuralgic character. When the vertebra; are eroded, the pain is of a boring nature, more 
fixed, and attended with a greater amount of sympathetic disturbance. Dyspeptic symp- 
toms are frequently present; and respiratory embarrassment invariably exists whenever 
the aneurism seriously encroaches upon the diaphragm. 
The diagnosis of ventral aneurism is sometimes very difficult. The most reliable con- 
siderations are derived from the history of the case, the sudden nature of the attack, the 
existence of a pulsating and gradually enlarging tumor, with a distinct bellows sound 
heard over the inferior dorsal, or the upper lumbar, vertebrae, and the great pain, which is 
experienced in the situation of the disease, both in front and in the back, in the latter of DISEASES AND INJURIES OF THE ARTERIES. 
which it is never absent. The affections with which the malady is most liable to he con- 
founded are, abnormal pulsations ot the ventral aorta, whether arising from anemia, neu- 
ralgia, or inflammation of its coats; hydatids of the liver; enlargement of the pancreas; 
carcinomatous and other tumors of the omentum, stomach, colon, mesentery, or ovary; 
intestinal concretions; indurated feces; and abscesses ot the walls of the abdomen. In 
older to render the examination perfectly satisfactory, the bowels should be well emptied 
as a preliminary step, when the patient should be 
placed in the horizontal position, with the abdomen 
raised somewhat higher than the chest. In this way 
the tumor will not only become more conspicuous, 
but the blood will rush into it with greater force, 
and thus produce more active pulsation and bellows 
sound. A case has been recorded by T. Spencer 
Wells in which a large aneurism of the lower part 
of the aorta was tapped through the vagina, on the 
supposition that it was a pelvic abscess. 
Although a case of spontaneous cure of an aneu- 
rism of the abdominal aorta is occasionally met 
with, the prognosis is extremely unfavorable. The 
disease almost invariably proves fatal, death occur- 
ring either from sheer exhaustion, or from rupture 
of the sac behind the peritoneum, or into the peri- 
toneum, the intestine, bladder, chest, kidney, or 
inferior vena cava. The period at which this event 
takes place varies from a few months to several 
years. In the case from which the annexed cut, 
fig. 342, from Jones and Sieveking, was taken, the 
aneurism produced fatal compression of the spinal 
cord. 
It may be stated as an interesting fact, not with- 
out practical significance, that in every case of spontaneous cure of aneurism of the aorta 
that has ever been reported the patient was in a wasted and exhausted condition, equiva- 
lent to that produced by the treatment of Valsalva. 
The treatment in most cases is mainly palliative, our chief dependence being placed 
upon rest, a properly regulated diet, and anodynes, in union with aconite, ergot, and ace- 
tate of lead. If the patient is plethoric, blood may occasionally be taken from the arm, 
to moderate the force of the circulation and to subdue pain. 
When the aneurism is situated some distance below the diaphragm, and is not very 
large, experience recently furnished shows that the case may yield to rapid and persistent 
compression under chloroform, a method successfully practised by Murray, of Newcastle- 
on-Tyne, in 18G4, upon a man twenty-six years of age. A tourniquet was applied above 
the tumor, and pressure kept up for two hours, but without any perceptible change. 
Three days afterwards the pressure was renewed, with the result, at the end of five hours, 
of the perfect consolidation of the swelling, followed by so rapid a cure that the patient 
was soon able to resume his occupation {is a laborer. lie survived the operation six 
years, when he died from the effects of another aneurism of the aorta situated too high 
up for compression. The dissection showed that the circulation within the abdomen, after 
the cure of the tumor, had been carried on between the middle colic of the superior mesenteric 
and the left colic of the inferior mesenteric arteries, including the sigmoid and hemor- 
rhoidal branches, between the upper and ilio-lumbar, and between the inferior lumbar 
and circumflex iliac arteries. The arteries concerned in maintaining the collateral circu- 
lation on the outside of the abdomen were the internal mammary and deep epigastric, 
the hepatic and a branch of the epigastric, and the intercostal and the two epigastric, 
with the superficial and circumflex iliac. The superior mesenteric artery was as large as 
the aorta. 
The operation of Murray has also been successfully practised by Moxon and Durham, 
Greenhow, and Philipson. It has, however, failed in the hands of Mr. Pollock, and 
proved fatal in the cases of Sir James Paget, and Durham, the causes of death having 
been peritonitis and abscess in the mesentery, and bruising of the pancreas. In two cases 
the pad of the tourniquet was applied on the distal side of the aneurism. In that of 
Skerritt, the patient died from rupture of the sac, and the case of Marshall was a failure. 
In the case of Bryant, which was also one of distal compression, the aneurism after death 
CHAP. V. 
Fig. 342. 
Aneurism of the Aorta, inducing Caries of the 
Vertebrae, and fatal Compression of the Spinal 
Cord. ANEURISM OF THE COMMON ILIAC ARTERY. 
767 
CHAP. V. 
proved to have been connected with the caeliac axis. It thus appears, that, of 9 cases of 
proximal or distal compression for aneurism of the abdominal aorta, 4 were cured, 2 
failed, and 3 died ; results which are so brilliant and creditable as to render the procedure 
one of the established usages of surgery in a class of cases formerly regarded as utterly 
hopeless. Ligation of the aorta for the cure of its own aneurisms must always necessarily 
be fatal. 
Sir William Fergusson, in a case of aneurism of the abdominal aorta, tied the femoral 
artery, but, with the exception of a diminution of pulsation for a single day, no effect was 
produced on the disease. 
Electrolysis has occasionally been tried in the treatment of aneurism of the abdominal 
aorta; but, beyond an apparently trifling amelioration, with no ulterior benefit. Indeed, 
it is questionable whether, as a rule, the remedy does not do more harm than good. 
The aorta may be the seat of varicose aneurism, caused by a communication with the 
vena cava by ulceration or external injury. The occurrence is uncommon. The tumor 
is of variable size and shape, compressible, especially in its earlier stages, and readily 
detectable by the finger. The pulsation is generally less distinct than in ordinary aneu- 
rism, and there is occasionally a loud whizzing noise heard both by the patient and the 
attendants. In a case of varicose aneurism of the aorta and left common iliac vein, under 
the care of Mr. Simon, compression of the former vessel terminated fatally from gangrene 
of the intestine. 
ANEURISM OF THE BRANCHES OF THE ABDOMINAL AORTA. 
Aneurism of these vessels has been observed in a few rare instances, the order of its 
occurrence being the superior mesenteric, the splenic, the hepatic, the coeliac axis, and 
the renal. The subject is of interest chiefly in a diagnostic point of view. In a case 
of aneurism of the left gastro-epiploic artery, recorded by Dr. Alle, death was caused 
by the rupture of the sac, from inordinate exertion in dancing. The patient was a 
young woman, in the fifth month of her pregnancy, and the abdomen was filled with blood, 
partly fluid, partly coagulated. 
In aneurism of all these vessels, except the hepatic, the renal, and the cceliac axis, the 
tumor is always movable, changing with the patient’s position, circumscribed, more or 
less globular, and accompanied by pulsation as it is pushed from side to side. In an inte- 
resting case of aneurism of the hepatic artery, recorded by I)r. Stokes, the sac was bound 
down by the capsule of Glisson, and lay in close contact with the biliary ducts, which 
were remarkably dilated throughout the liver, forming tortuous projections on its peri- 
toneal surface. 
Besides the pulsation which is always present in aneurism of these arteries, the pressure 
of the tumor upon the liver and gall-bladder not unfrequently causes jaundice, while its 
pressure upon the pancreas occasions imperfect duodenal digestion, as indicated by the 
pain, flatulence, acid eructations, and vomiting some time after taking food. In a num- 
ber of the recorded cases troublesome hematemesis existed. 
In two cases of aneurism of the trunk of the superior mesenteric artery observed by J. 
Arthur Wilson, of London, the most prominent symptom in one was jaundice, in the 
other vomiting of blood. Both patients complained of severe and constant pain in the 
middle of the back, between the shoulders. 
The great uncertainty in the diagnosis of aneurism of these vessels teaches the necessity 
of the most careful examination in all cases of doubt, not only with the eye and finger, 
but the ear. The detection of various sounds, as the bellows, sawing, or purring, in con- 
nection with the existence of a movable tumor, could not fail to throw important light 
upon the nature of the complaint, and thus protect the patient from the employment of 
harsh and useless remedies. 
ANEURISM OF THE COMMON ILIAC ARTERY. 
The history of aneurism of this vessel remains to be developed. Nothing short, in 
fact, of a careful analysis of the various recorded cases of it can place it in its true light. 
That the disease is extremely uncommon in its occurrence is a circumstance which has 
long been familiar to surgeons. The table of Mr. Crisp supplies only two cases of 
aneurism of this artery in 551 cases of the lesion, as it shows itself in different portions 
of the arterial system. Both occurred in males. In one, the tumor was seated on the 
right side; the patient was a sailor, exposed to hard labor in whale-fishing; the aorta 
was tied by Dr. Murray, of the Cape of Good Hope, but the man died twenty-three DISEASES AND INJURIES OF THE ARTERIES. 
CHAP. V. 
hours after the operation. In the other case, the aneurism, also seated on the right side, 
was of a fusiform shape, and communicated with the common iliac vein. No operation 
was performed. 
Varicose aneurism of the common iliac artery is very uncommon. Only a few well- 
authenticated cases of it are upon record. Of these, one of the most interesting is that 
observed by Mr. Adams, of Dublin, which seems to have been of spontaneous origin. 
The patient, who expired one day within a few hours after having taken a walk, had 
labored for several years under a tumor at the lower part of the abdomen, accompanied 
with severe pain and throbbing. The dissection revealed a fusiform dilatation of the 
primitive iliac, with an opening, at one side, of the diameter ot a goose-quill, with which 
it communicated with the corresponding vein. 
In a case observed by Leflaive, in a man, twenty-two years of age, the aneurism was 
caused by the thrust of a knife into the abdomen, a little below the umbilicus, towards 
the right side. The accident was followed by excessive swelling of the lower extrem- 
ities, especially the left, by great enlargement of the veins, and, finally, by the formation 
of numerous troublesome ulcers, from the effects of which the man eventually perished. 
A tumor, extending nearly as high up as the bifurcation of the aorta, existed between 
the primitive iliac artery and vein; its walls were ossified, and its cavity was partially 
filled with fibrinous concretions. The artery bore evidence of former injury. 
ANEURISM OF THE EXTERNAL ILIAC. 
Aneurism of the external iliac is a rare affection. In the table of Mr. Crisp, the most 
elaborate hitherto furnished, it occurs only f) times in 551 cases, while the femoral is 
mentioned 66 times, and the popliteal 137 times. In 364 specimens of aneurism, con- 
tained in the London museums, the same writer found the external iliac affected in 7 
cases, the femoral in 12, and the popliteal in 50. The nine cases analyzed by Mr. Crisp 
all occurred in males: two between twenty and thirty, four between thirty and forty, one 
at forty, and one at fifty-six, the age of the other not being given. The disease is most 
common in hard working persons. One of the worst cases of it that I have ever seen 
occurred in a priest. 
The tumor in this disease may be seated in any part of the artery, but, in general, it 
will be found rather low down, and, as it progresses, it manifests a tendency to pass 
underneath Poupart’s ligament into the upper part of the thigh. It usually rapidly aug- 
ments in size, and is capable of attaining a large bulk, encroaching upon the iliac fossa and 
the pelvic cavity, lifting up the peritoneum, and pressing forward the structures in the 
inguino-femoral region, so as to give rise to great deformity in this situation. The pulsa- 
tion, thrill, and bellows sound are usually very distinct. If the patient is very thin, 
compression of the abdominal aorta will arrest the movements of the tumor, and diminish 
its volume, thus serving to distinguish it from other affections. The diagnosis is, never- 
theless, not always so easy as might at first appear. Several cases have been reported 
where the common iliac artery was ligated on account of morbid growths, supposed to be 
aneurismal, which afterwards proved to be of a malignant character. On the other 
hand, a tumor really aneurismal has occasionally been confounded with one altogether of 
a different character. Such a mistake is most likely to happen when the aneurism is par- 
tially solidified by coagulation of its contents, thereby preventing the perception of pulsa- 
tion. It is only necessary to allude to the possibility of such an occurrence in order to 
put the practitioner upon his guard in his investigations. 
When an aneurism of the external iliac artery has attained a considerable bulk, the 
patient walks with extreme difficulty, and is unable to fb*x the thigh upon the pelvis. The 
whole limb is enlarged and oedematous from obstruction to the return of the venous blood, 
while the pressure of the tumor upon the femoral nerve keeps up constant pain, with a 
sense of numbness and stiffness in the parts below, generally extending as far down as 
the foot and toes. 
Aneurism of the external iliac artery, left to itself, proves fatal in one of three wavs, 
by rupture and hemorrhage, gangrene of the sac or limb, or constitutional irritation. 
Occasionally a spontaneous cure occurs. 
Varicose aneurism of the external iliac artery, an exceedingly uncommon affection, 
may be caused, as the same disease elsewhere, by ulceration or external injury, as a stab, 
puncture, or gunshot wound. The symptoms present nothing peculiar. The most impor- 
tant, perhaps, is the extraordinary purring, whizzing, or whirring sound which the blood 
makes as it rushes from the diseased vessels into the intervening sac. The tumor is 
capable of acquiring a large bulk, and it is impossible always to distinguish it satisfactorily CHAP. V. 
TREATMENT OF ILIAC ANEURISMS. 
769 
from an ordinary aneurism. If compression fails, as it will be likely to do, the only 
resource is ligation of the common iliac, as in the interesting case of Professor Ilargave, 
of Dublin. Although the patient, a soldier, forty-three years old, died on the seventy- 
third day, the operation, so far as the artery was concerned, was perfectly successful, the 
ligature having come away nearly a month and a half previously without a drop of blood. 
The immediate cause of the disastrous result was an enormous abscess of the pelvis, 
attended with hemorrhage. 
ANEURISM OF TIIE INTERNAL ILIAC AND ITS BRANCHES. 
Aneurism of the internal iliac, gluteal, and sciatic arteries is very uncommon, and its 
history has not been studied with sufficient care to enable us to present anything like a 
satisfactory account of it. Owing to the deep situation of the former of these vessels, the 
diagnosis of aneurism occupying its course would necessarily be attended with consider- 
able difficulty, and should not be declared without a good deal of reserve and circumspec- 
tion. Perhaps the best way of arriving at a satisfactory conclusion, is by the rectal 
exploration, as originally suggested by Professor Henry B. Sands, of New York. Indeed, 
in no case of suspected pelvic aneurism, should this mode of examination be neglected 
or overlooked. Aneurism of the sciatic and gluteal arteries is more frequently traumatic 
than spontaneous. In fat, muscular subjects the disease is generally difficult of recogni- 
tion, and hence it is not surprising that solid growths have sometimes been mistaken tor 
it. Mr. Guthrie and I)r. Morton each tied the internal iliac artery for a tumor which 
had been taken to be aneurismal, but which, after death, was found to be of a sarcoma- 
tous character, the deception having been caused by the circumstance of the tumor having 
received a distinct impulse from the artery. I have not met with aneurism of the pudic 
artery, and am not aware that the disease has ever been observed in this country. Mr. 
Erichsen states that the only instance of the kind with which he is acquainted is exhib- 
ited in a preparation in the Museum of the College of Surgeons at London. 
Dr. George Fischer, of Hanover, has collected thirty-five cases of traumatic and spon- 
taneous aneurisms of the gluteal and sciatic arteries, of which three-fourths affected the 
former vessel. They may be distinguished from each other by their seat, those of the 
gluteal artery being generally situated at the upper border of the great sciatic notch, 
while aneurisms of the sciatic artery are situated nearer to the tuberosity of the ischium, 
from which they extend towards the thigh or reach into the pelvis. Laying open the sac 
and ligaturing both ends of the divided vessel have been employed in six instances of 
traumatic gluteal aneurism, with four recoveries, one failure, and one death from hemor- 
rhage. In the spontaneous and traumatic aneurisms, ligation of the internal iliac has 
been performed in thirteen cases, with six recoveries and six deaths, the result in one 
being uncertain, and ligature of the common iliac in three instances, all of which died. 
Galvano-puncture was tried in one case, but without benefit, while the injection of per- 
chloride of iron was followed by four recoveries and two deaths. 
Aneurism of the gluteal and sciatic arteries may be treated by ligating the internal 
iliac, by rectal compression, or exposing the sac by a free incision, turning out its con- 
tents, and tying the vessel above and below. Such a procedure would, unquestionably, 
be very bloody, but far less hazardous in the end than the deligation of the internal iliac. 
The gluteal artery has been tied at least twice in this country for the cure of aneurism ; 
once by Dr. Davidge, of Baltimore, and once by Dr. George McClellan. The tumors 
being of great bulk, the incisions were obliged to be unusually large, and the loss of blood 
was very profuse. Notwithstanding this, however, both patients made an excellent 
recovery. Professor Campbell, of Montreal, has successfully ligated the gluteal artery 
for a traumatic aneurism of that vessel. Sappey, of Paris, and Dr. Dugas, of Georgia, 
have tied the sciatic artery for aneurism. The case of the former was not cured, 
although the patient recovered ; while the case of the latter terminated fatally four days 
after ligation of the common iliac artery for secondary hemorrhage. 
TREATMENT OF ILIAC ANEURISMS. 
In the treatment of aneurism of the common and external iliac arteries, compression 
should always be resorted to before operative interference is instituted. If it be possible, 
the pad of Pancoast’s tourniquet should be applied to the common iliac trunk, but as this 
is more difficult of execution than compressing the abdominal aorta, the latter vessel is 
to be preferred. Of 11 cases treated by this measure, 8 were cured, and 3 were failures. 
In the cases of Heath and Murray, consolidation of the contents of the sac was effected. 770 
DISEASES AND INJURIES OF THE ARTERIES. chap. v. 
respectively, in twenty and forty-live minutes. The patient of Professor Agnewr was 
cured by maintaining the compression under ether for two hours on one day, and for half 
an hour, without an anaesthetic, on the following day. 
No. 
Operator. 
Date 
Sex. 
Age. 
Reeult. 
Remarks. 
1 
Cooper 
1817 
M. 
38 
Died in 
40 hours 
The operation was performed for aneurism of the left 
iliac artery. The tumor was of enormous size, and 
extended four inches above and four inches below 
l’oupart’s ligament; the thread was applied three- 
quarters of an inch above the bifurcation of the 
aorta. The sac contained an immense quantity of 
clotted blood. 
2 
J ames 
1829 
M. 
44 
Died in 
3£ hours 
There was an external iliac aneurism, for which the 
femoral was ligated. Increasing in size, 33 days 
afterwards the aorta was tied. The ligature was 
applied eleven lines above the bifurcation of the 
vessel, and five below the mesenteric artery. 
3 
Murray 
1834 
M. 
33 
Died in 
23 hours 
There was an extensive aneurism of the right exter- 
nal iliac, the tumor reaching as high as the umbili- 
cus, and more than half-way across the lower part 
of the abdomen. Mortification of the limb was 
rapidly approaching when the operation was per- 
formed. The aorta was tied about four lines above 
its bifurcation. 
4 
Monteiro 
1842 
M. 
31 
Died in 
10 days 
A large tumor occupied the lower part of the alaio- 
men and upper part of the thigh. It was a spurious 
aneurism of the femoral artery, caused by the burst- 
ing of that vessel. The patient died, at the expira- 
tion of ten days, of secondary hemorrhage, from a 
small opening in the vessel corresponding with the 
knot of the ligature, which had been applied four 
lines above the point of bifurcation. 
5 
South 
1856 
M. 
28 
Died in 
43 hours 
The aneurism occupied the external and common 
iliac, and was of immense size. The ligature was 
applied a little above the bifurcation of the aorta. 
6 
McGuire 
1868 
M. 
30 
Died in 
11 hours 
The operation was undertaken with the view of tying 
the common iliac, but after it was begun it was 
found that the aneurism involved the external iliac 
on one side, both common iliacs, and the lower ex- 
tremity of the aorta. The sac hurt during the opera- 
tion, without much hemorrhage, and a ligature was 
hastily cast around the aorta at the origin of the 
inferior mesenteric artery, the cord, as was found 
after death, including the left ureter. 
7 
P.H. Watson 
1869 
M. 
Died in 
65 hours 
Secondary hemorrhage after ligature of the common 
iliac nine weeks before ; cut through the mesentery, 
and at the same time secured the external and in- 
ternal iliac branches of the same side, to prevent 
recurrent bleeding ; did well for two days ; no fur- 
ther hemorrhage ; limbs regained their temperature 
after operation, but it sank 6° in the affected leg 
prior to death. 
8 
W. Stokes 
1869 
M. 
50 
Died in 
12 hours 
Aneurism involved the right common iliac, the ex- 
ternal iliac, and femoral arteries. Pulsation re- 
turned in the sound femoral artery in nine hours. 
Cases of Iliac Aneurism, treated by Ligation of the Abdominal Aorta. 
Digital compression lias been tried in several cases of ilio-femoral aneurism, but only 
in one successfully—a patient of Dr. Nichols, of New Orleans—after an effort of thirty 
hours. In a similar instance, in charge of Dr. R. J. Levis, a eure was effected with 
the aid of ether in less than six hours by mechanical compression applied to the external 
iliac. In a former edition of this work I expressed the opinion that an aneurism of the 
external iliac might generally he promptly obliterated, especially in its earlier stages, by 
compression of that vessel as it passes over the brim of the pelvis; and Dr. T. R. Varick, 
of Jeisey City, acting upon the suggestion, in June, 1880, employed it successfully in a 
cast' of inguinal aneurism in a man forty-eight years of age. The pressure was applied 
with a Ricord’s bubo compressor over the ramus of the pubes, and was kept up for forty- 
eight hours, a small slough following the operation. This mode of treatment is certainly CHAP. V. 
TREATMENT OF ILIAC ANEURISMS. 
entitled to a fair trial. Digital compression would, T think, be preferable to any other, 
on account of the greater facility of its application, and the avoidance of all risk. 
If compression fail, the only recourse is deligation of the artery leading to the tumor, 
the external iliac, when the aneurism is situated low down so as to leave a sufficiency of 
the vessel in a suitable condition for the reception of the ligature; or, when the reverse is 
the case, the common iliac; or, when the latter is implicated, the abdominal aorta. The 
result of ligation of the external iliac is encouraging, since of 1G9 cases in which it has 
been tied for all causes, only 61, or 36.09 per cent. died. Ligation of the common iliac, 
on the other hand, is one of the most formidable operations in surgery, 49 or 77.77 per 
cent, ot the 63 cases in which it has been practised for various affections, having perished. 
The table, p. 770, indicates the results of eight cases in which the abdominal aorta has 
been tied for iliac aneurisms, the case of Mr. Stokes being included, although Porter’s 
wire compressor was employed instead of an ordinary ligature. 
It will be perceived from the table that the eight cases in which the abdominal 
aorta has been tied terminated fatally; a result which might assuredly have been foreseen 
by the distinguished surgeons who performed the operation. Questionable as the pro- 
priety of such an operation is, I should, I confess, be strongly tempted to perform it if my 
patient were placed in circumstances precluding all hope of relief from any other source. 
That this was the feeling which prompted Sir Astley Cooper, in 1817, to undertake it, 
and which has since induced others to imitate his example, is more than probable, and 
our only regret is that their efforts were not crowned with success. What the effect might 
have been if the cases had been of a more favorable nature prior to surgical interference 
is, of course, merely a matter of conjecture, but it is perfectly evident, from their history, 
that they were all in as desperate a condition as they could well have been at the time. 
The tumor, in every instance, was of enormous volume, almost, in fact, ready to burst: 
in Mr. Murray’s patient there was, besides, incipient gangrene of the lower extremity. 
In the case of Mr. James, an error of diagnosis had been committed, which led, impro- 
perly, as was afterwards proved, to ligation of the femoral artery, thereby causing the 
patient not only much suffering but the loss of much valuable time, upwards of four weeks 
having elapsed between the two operations. 
In performing the operation, the peritoneum was divided in three of the cases, and left 
intact in five; in one instance, it was opened to the extent of nearly four inches. Such a 
procedure would probably of itself have been a cause of death, had the patient survived 
the immediate effects of the deligation of the vessel. 
The case of I)r. Monteiro, the most successful of all, is replete with interest, as it es- 
tablishes the fact that the circulation may go on in the lower extremities, after the flow of 
blood in the abdominal aorta has been completely arrested by the ligature. The patient 
survived the deligation ten days, when he died of secondary hemorrhage, caused by a 
small aperture in the side of the vessel corresponding with the knot in the thread. The 
dissection showed that the peritoneum, which had not been cut in the operation, was 
perfectly free from inflammation. The aorta had been ligated four lines above its bifur- 
cation, and an inch below the inferior mesenteric artery. The aneurism, which was a 
false one, had originated in a rupture of the superior extremity of the femoral artery, 
from which the blood had made its way upwards, underneath Poupart’s ligament, through 
the intermuscular connective tissue, into the iliac fossa, and thence on behind the perito- 
neum along the posterior part of the abdomen, as high up as the diaphragm and liver. 
The common and external iliac arteries were involved in the tumor, and were in an 
inflamed and friable condition. The external wound had nearly healed. 
It is worthy of remark that the pulsation in the tumor ceased immediately on tying the 
ligature, but returned slightly on the third day, and became more marked on the fourth. 
Hemorrhage supervened the day before death. The operation was followed by coldness 
of the lower extremities, but in four hours afterwards this had passed off, and the tem- 
perature rose a little above the natural point. No paralysis of the limbs was at any time 
present. 
In addition to the foregoing eight cases, the aorta has been tied twice by Czerny, on 
account of hemorrhage. In the first case the femoral and common iliac arteries had been 
previously ligated for bleeding from a gunshot wound of the thigh, and the patient died 
in twenty-six hours. In the second case the operation was resorted to for the arrest of 
hemorrhage from a torn renal artery in removing a kidney for malignant disease, and the 
patient survived ten hours. 
In a remarkable case of traumatic aneurism of the external iliac, in a seaman, thirty- 
one years of age, Mr. Syme, in 1862, laid open the sac, to the extent of six inches, turned DISEASES AND INJURIES OF THE ARTERIES. 
CHAP. V. 
out a mass of blood and fibrinous clots, to the amount of six pounds, and tied the common, 
internal, and external iliac arteries where they communicated with the tumor. 1 he 
circulation in the aorta was controlled by a compressor fastened around the abdomen. 
The edges of the wound were united by silver sutures, covered with dry lint, and gently 
supported by a bandage. Although the ligatures dropped off on the nineteenth day, the 
patient remained in a very precarious state until the end nearly of the third month, when 
so decided an improvement took place as to remove all doubt as to his ulterior recovery. 
A short time after this, however, he contracted a severe cold, from the effects of which 
he soon died. The enormous tumor, prior to this bold and brilliant operation, extended, 
on the one hand, from below Poupart’s ligament considerably above the umbilicus, and, 
on the other, from nearly two inches beyond the middle of the abdomen, towards the 
right side, completely across the left iliac region, so as to overlap the crest of the iliac 
bone. Another remarkable circumstance in the case was the small amount of suppuration 
that followed the opening of the sac. 
ANEURISM OF THE FEMORAL ARTERY. 
Aneurism of the femoral artery is very common, although less so than that of the 
popliteal. In Mr. Crisp’s cases, 551 in number, G6 relate to the femoral artery, of which 
G1 occurred in males, thus showing that the disease is very rare in women. The period 
of life at which it is most frequently met with is from thirty to fifty. As in the other 
arteries, aneurism of the femoral is most common in the laboring classes, particularly in 
those persons who are subject to severe muscular exertion of the lower extremities, caus- 
ing a sudden strain upon the vessel. Instances have been observed in which each femoral 
artery was simultaneously affected with aneurism, and it occasionally happens that the 
same vessel has two such tumors connected with it. 
The femoral artery is not equally subject to aneurism in all parts of its extent. The 
superior third suffers more frequently than the rest of the vessel, and spontaneous aneu- 
rism occurs here much oftener than in any other external artery, except the popliteal. 
Sailors are said to be particularly liable to the disease in this situation, owing, as Mr. 
Crisj) supposes, to the violent flexion and extension of the thigh which they are obliged 
to make in mounting the rigging and performing other labor on shipboard. I have never 
seen an instance of spontaneous aneurism in the lower third of the thigh, and general 
experience concurs in declaring that such an occurrence is extremely uncommon. In 
some of the published cases, the disease is described as having been femoro-popliteal, a 
term evidently intended to convey the idea that the lesion involved both the terminal por- 
tion of the femoral and the superior portion of the popliteal. 
Diagnosis—The diagnosis of femoral aneurism, although generally easy, is sometimes 
involved in so much obscurity as to cause not a little perplexity. This is more especially 
the case when the tumor is seated along the middle or lower third of the thigh, where the 
artery is tightly bound down by the muscles and aponeuroses. Abscesses and various 
morbid growths, solid, semisolid, or fluid, and malignant and non-malignant, are the affec- 
tions with which it is most liable to be confounded ; and it behooves the surgeon, in every 
case of doubt, to institute the most careful and thorough examination before he expresses 
an opinion in regard to its character, or permits himself to engage in any operative pro- 
cedures for its relief. The best diagnostic, unquestionably, is the effect which compression 
of the femoral artery exerts upon the tumor, when it is situated some distance below 
Poupart’s ligament, or of the ilio-femoral, when it occupies the superior part of the thigh. 
If the tumor is aneurismal, the compression will not only arrest its pulsation, thrill, and 
bellows sound, but, while it is being kept up, it will enable the surgeon to squeeze out its 
contents, and thus greatly diminish its volume, circumstances which cannot possibly occur 
when the swelling is of a non-aneurismal character, whatever may be its structure or con- 
sistence. The exploring needle is only to be used in cases not admitting of discrimination 
by this method, and then it should be so fine as not to cau.se hemorrhage or excite inflam- 
mation. It is worthy of note, in a diagnostic point of view, that the tumor in aneurism 
of this vessel almost invariably springs from its anterior surface. 
1 he femoral artery, in the upper portion of its extent, is sometimes protruded forward 
by a synovial burse, situated behind the psoas muscle, just below Poupart’s ligament, 
especially when the pouch is inflamed and much distended, in which case it will probably 
receive an impulse from the vessel, so as to cause the swelling to simulate aneurism. The 
proper way to determine the diagnosis is to flex the thigh upon the pelvis, a procedure ANEURISM OF THE FEMORAL ARTERY. 
773 
CHAP. V. 
which, by taking off the tension of the muscles, puts a stop to the pulsation of the tumor, 
and thus reveals the true nature of the disease. 
A number of lymphatic glands lie in the upper part of the thigh, immediately upon 
and around the femoral artery. Enlargement of these glands has been mistaken for 
aneurism, and, conversely, aneurism for enlargement of the glands ; but the history of 
the case and a careful examination of the parts will generally promptly clear up the 
diagnosis. 
Psoas abscess occasionally points below Poupart’s ligament, and might be mistaken, by 
a careless observer, for aneurism of this vessel, or of the external iliac. The best diag- 
nostic signs are the want of pulsation, the soft and fluctuating character of the swelling, 
the absence of discoloration of the skin, and our ability to efface the swelling almost 
entirely when the patient lies on his back with the thigh and pelvis a good deal elevated. 
Moreover, if there be any pus, a drop will be sure to follow the withdrawal of the exploring 
needle. 
Progress.—The course of the aneurism is variable. When it is situated high up, it is 
liable, in its progress, to extend upwards, and to project at length beneath Poupart’s liga- 
ment into the pelvic cavity. When, on the other hand, it involves the inferior portion of 
the artery, it may pass down into the ham, and so simulate popliteal aneurism. The 
swelling usually increases rather rapidly, and, in time, often spreads over a large space, 
diffusing itself, in fact, widely, in consequence of the 
giving way of the two inner tunics of the artery. 
When this is the case, the limb below the seat of the 
tumor becomes greatly enlarged and oedematous, from 
obstruction to the return of the venous blood, and the 
patient constantly complains of stiffness, pain, and 
numbness in it, extending generally as low down as the 
feet and toes. In the more advanced stages of the dis- 
ease, progression becomes difficult and finally impracti- 
cable, the whole limb feeling like a dead, heavy mass. 
A spontaneous cure occasionally occurs, as in a case 
from which the adjoining cut, fig. 343, was taken ; but 
most commonly the disease goes on from bad to worse, 
until life is destroyed by gangrene, excessive suppura- 
tion, hemorrhage, or constitutional irritation. 
Treatment.—The treatment of aneurism of the super- 
ficial femoral artery may, I think, generally be success- 
fully conducted by compression, especially now that 
our means of applying and regulating it are so much 
better understood than formerly. The compression 
may be made either with the finger or by means of one 
of the numerous mechanical contrivances before the 
profession. In the case of a negress, aged thirty-two, 
who was under the joint care of I)r. S. W. Gross and 
myself, in 1859, on account of a large aneurism of the 
upper third of the femoral artery, the assistants suc- 
ceeded in effecting complete solidification of the con- 
tents of the sac in forty-six hours, by digital compression alone. The tumor progressed 
most favorably, and in less than three weeks after the operation the woman was able to 
walk about the house. In this case, referred to in a previous section, there was not more 
than an inch of space between the aneurismal sac and Poupart’s ligament, in consequence 
of which the compression was obliged to be applied to the iliac artery as it passed over the 
brim of the pelvis. Several instances of an equally gratifying termination have followed 
this treatment in the hands of other surgeons. In a case of aneurism of the femoral 
artery, the size of a small orange, six inches below Poupart’s ligament, in a man seventy- 
eight years old, under the charge of Mr. F. It. P. Drake, of England, in 1873, a rapid 
cure followed digital compression maintained for ninety minutes. 
In a case of aneurism of the upper portion of the femoral artery, in a man thirty-eight 
years of age, under the charge of Dr. Buckminster Brown, of Boston, in 18(53, a cure was 
effected by direct compression of the tumor by means of a pad, accurately fitted to the 
swelling, and secured around the pelvis by a belt, the degree of pressure being regulated 
most of the time by two cannon balls, one of twelve and the other of twenty-four pounds, 
each applied on every alternate day. The patient was confined to his back for ten months, 
Fig. 343. 
Spontaneous Cnre of an Aneurism of the 
Femoral Artery by the Sac being filled with 
Coagulum ; the Vessel remaining pervious. DISEASES AND INJURIES OF THE ARTERIES. 
CHAP. V. 
and retained under surveillance upwards of six months longer. The tumor extended as 
high up as the brim of the pelvis, and was three inches and a half in diameter. Full 
particulars of the case are given in the Boston Medical and Surgical Journal for March, 
1866. 
Several instances of aneurism of the femoral artery cured by flexion of the thigh upon 
the pelvis have lately been reported, one, among others, by I)r. Buck, of New York, and 
the treatment is well worthy of further trial, especially in cases of recent standing and of 
small size. 
When compression and flexion are inapplicable, the only resource, of course, is deliga- 
tion of the artery which supplies the tumor with blood. The operation is easily done at 
Scarpa’s triangle when the aneurism occupies the middle or lower third of the femoral 
artery, or even when it extends up to the inferior portion of this space, provided the coals 
of the vessel are sufficiently sound to bear the pressure of the ligature. When this is not 
the case, or when the tumor is situated high up, near l*ou part’s ligament, or projects 
beneath it partly into the pelvic cavity, the remedy usually adopted is ligation of the 
external iliac, an operation which, although not devoid of risk, has now been performed 
so often and so successfully as to be justly ranked among the established resources of 
surgery. 
Ligation of the external iliac is generally regarded as a much safer operation than 
ligation of the common femoral. Of 12 cases referred to by Mr. Erichsen, in which the 
latter vessel was secured, under such circumstances, secondary hemorrhage occurred in 9, 
of which 3 proved fatal. The causes of this disaster are usually supposed to be the great 
shortness of the common femoral artery, and the numerous branches that are detached 
from it and the external iliac, rendering it thus very difficult for a solid coagulum to form 
above the ligature. 
These statistics are in striking contrast with those of the Dublin surgeons, who, in 8 
cases of this operation, have not had a solitary death. The first operation was performed, 
in 1849, at the Meath Hospital, by the late Professor William II. Porter, and the next 
by his son, Mr. George II. Porter, in 1860. The vessel, in this situation, is cpiite super- 
ficial, and is easily exposed by a short horizontal incision, half an inch below Poupart’s 
ligament. The femoral vein lies at its inner side, and is, of course, carefully avoided. 
During the past five years the old operation of opening the sac, and taking up both ends 
of the vessel, lias been successfully performed by Mr. Birkett and Mr. Cooper Forster on 
account of rupture of the sac, and by Mr. John Gay in a case in which the sac was 
perfect. In the first two instances the circulation was controlled by the abdominal 
tourniquet. 
A number of cases of femoral aneurism have been recorded in which a cure was effected 
simply by refrigerant applications to the tumor, aided by steady compression with the 
bandage, strict recumbency, and an abstemious regimen. This treatment has occasionally 
succeeded both in the spontaneous and traumatic form of the disease. 
A singular case of aneurism of a large anomalous artery of the thigh has been recorded 
by Mr. C. II. Fagge in Guy’s Hospital Reports for 1861. The vessel arose from the 
internal iliac artery, ran down the back of the thigh, and terminated in the popliteal, as 
the main artery of the lower extremity. 
Mortality—In Mr. Crisp’s 66 cases, above referred to, the external iliac alone was tied 
in 44, and in two others both this artery and the femoral; 36 of the patients recovering 
and 10 dying. Of the latter, three perished from hemorrhage, four from gangrene of the 
sac or limb, one from tetanus, one from exhaustion, and one without any apparent cause. 
In 12 of the cases the femoral artery alone was tied, with a result of 9 cures to 3 deaths. 
Amputation was successfully employed in five cases; in two the tumor was obliterated by 
compression, and in one the disease spontaneously disappeared. 
In the table of Dr. Norris, comprising 118 cases of ligation of the external iliac artery, 
of which, however, 97 only relate to aneurism, 85 recovered, and 33 died, three of the 
former having undergone amputation of the limb in consequence of gangrene. In 4 of the 
97 cases of aneurism the disease existed simultaneously both in the thigh and in the ham, 
and in 3 of these the operation succeeded in curing both tumors. A return of pulsation 
in the sac took place in 9 cases, and hemorrhage in 14, of which 7 proved fatal, and 7 
recovered. In 10 cases the tumor suppurated after the operation, although they all ulti- 
mately did well. Gangrene of the limb occurred in 16 cases out of the 118, of which 12 
died. In two instances the peritoneum was wounded, but both patients recovered. To 
these cases may be added ol, of which 35 were analyzed by Dr. Cutter, of Newark, and 
16 are tabulated in Circular No. 6. Of the entire number, or 169, 61, or 36.09 percent., CHAP. V. 
ANEURISM OF THE POPLITEAL ARTERY. 
775 
died. In 126 cases, the vessel was tied for aneurism, with a result of 35 deaths, ora 
mortality of 27.77 per cent. 
Varicose aneurism of the femoral artery and vein is occasionally observed. The 
accident is commonly produced by external injury, as a gunshot, knife, or sabre wound, 
but it may be also caused by ulceration ; and Baroni has related a case in which it fol- 
lowed upon a contusion of the thigh. The treatment should, as a general rule, be entirely 
of a hygienic character, experience having proved that operative interference is usually 
followed by fatal results. In some of the recorded cases of this affection the patients 
lived for many years, in one as many as twenty, in comparative comfort. 
In a case of this description, in a lad, fifteen years of age, in consequence of a stab 
with a knife, Professor Spence, of Edinburgh, succeeded in curing the affection by ligating 
the superficial femoral artery above and below the aneurism, without opening the sac. 
In a similar operation, in the hands of Malgaigne, the patient died from the combined 
effects of hemorrhage and profuse suppuration. 
A very interesting case of aneurismal varix of these vessels was kindly brought to 
my Clinic at the Jefferson Medical College, in 1864, by Dr. W. B. Atkinson. The man 
had been wounded a year previously by a musket ball, lie experienced no incon- 
venience whatever from the disease. 
ANEURISM OF TIIE DEEP FEMORAL ARTERY. 
Aneurism of this vessel is extremely uncommon, and I am not aware that it has 
ever been observed in this country. Mr. Erichsen refers to five cases, which, he says, 
are the only ones of which he could find any record ; and Mr. Bryant has met with 
another case. This remarkable exemption from disease is the more surprising, when 
it is remembered how very liable the deep femoral artery is to calcification and athe- 
romatous degeneration, the ordinary predisposing causes of spontaneous aneurism. Trau- 
matic aneurism, the result of gunshot injury and fracture of the thigh-bone, is more 
frequent. 
The symptoms of aneurism in the deep femoral artery present nothing peculiar. The 
pulsation is easily arrested by compression of the external iliac at the groin, and the 
superficial femoral is without ditliculty drawn away from the tumor, so as to show its 
independent character. Care must be taken not to mistake the disease for a malignant 
growth. The sac seldom attains any great bulk. The treatment usually suggested is 
ligation of the external iliac ; but were I to meet with such a case, I should certainly tie 
the common femoral, immediately below Poupart’s ligament, as a far safer procedure, 
with a temporary ligature, removed at the end of forty-eight hours. 
In a case of this disease, treated by Mr. Erichsen, in 1870, all pulsation in the 
aneurism, one of large size, was arrested in twenty-four hours by means, first, of 
Carte’s compressor, and afterwards by the finger, applied to the common femoral artery. 
The patient, for a considerable portion of the time, was under the heavy influence of 
a large dose of chloral. 
ANEURISM OF THE POPLITEAL ARTERY. 
The extraordinary frequency of aneurism of the popliteal artery has long been familiar 
to pathologists and surgeons. With the exception of the thoracic portion of the aorta, 
there is no artery in the body which is so often the subject of this disease. The table 
of Mr. Crisp, already so frequently referred to, comprises an analysis of 551 cases 
of spontaneous aneurism, of which 137 occurred in the vessel under consideration, the 
thoracic aorta suffering 175 times. Three circumstances seem to serve to establish 
this extraordinary liability to aneurism on the part of this artery ; one is its extreme 
proneness to ossitic and fatty degeneration, another, the curve which it forms behind the 
knee, and the third, the sudden and forcible extension to which it is so constantly 
exposed in the various movements of the lower extremity. Broca ascribes the great 
frequency of the disease to the pressure to which the popliteal artery is subjected in the 
ring-like opening in the soleus muscle. 
Age and Sex Popliteal aneurism occasionally occurs at a comparatively early age, a 
number of cases having been observed in which it took place before the twenty-filth 
year. Mr. Syme has related one in a child of seven years. The great majority of 
instances, howrever, are met with between thirty and fifty. Both sides seem to suffer 
nearly in an equal degree, and both are occasionally affected simultaneously, or sue- 776 
DISEASES AND INJURIES OF THE ARTERIES. 
CHAP. V. 
cessively, as I have myself witnessed in several individuals. The disease is almost 
peculiar to men. In Mr. Crisp’s cases, 137 in number, 133 occurred in males, and 
only 4 in females. No occupation is exempt from aneurism of the popliteal artery, 
but the stastistics which have been published upon the subject conclusively show that 
the laboring classes, especially soldiers, sailors, bargemen, and porters, who are in the 
constant habit of making long-continued and violent exertions of the muscles of the lower 
extremities, are more liable to it than any other. The idea, first broached by Morgagni, 
that postillions and coachmen are particularly prone to popliteal aneurism, has been proved 
to be erroneous. 
Diagnosis.—Aneurism of the popliteal artery is probably produced in most cases by a 
sudden and violent sprain or twist of this vessel while its coats are in a state of calcareous 
degeneration, and, consequently, deprived of their elasticity, by which they are prevented 
from following the various movements of the leg with their accustomed freedom, a sudden 
rupture being thus induced, of which the patient is himself often made conscious, either 
by his feeling, or by a kind of snapping noise. The tumor, being at first quite small, 
generally escapes attention until it has acquired a considerable bulk, as, from the great 
depth at which the artery is situated, and the unyielding nature of the parts in the ham, 
it takes some time for it to reach the level of the surrounding surface, or to exhibit to 
the eye the characters of a distinct swelling. A careful examination, however, will always 
enable us, even at an early period, to arrive at a satisfactory conclusion respecting the 
nature of the case, except, perhaps, in very fat subjects. The tumor will be found to 
throb synchronously with the artery in the groin, and, by grasping it firmly between the 
thumb and finger, it may readily be pushed about in the hollow between the tendons of 
the flexor muscles, feeling like an elastic, circumscribed knob, which is easily diminished 
by pressure, but immediately regains its former size when the pressure is removed. As 
the disease progresses, the sac increases in volume, and encroaches more and more upon 
the popliteal space, pushing aside the soft parts, compressing the popliteal vein and nerve, 
and interfering seriously with the movements of the limb. The leg is habitually bent at 
an obtuse angle with the thigh, and all efforts to straighten it prove abortive; it is the 
seat of constant aching pains, with a sense of numbness or tingling; its temperature is 
notably diminished, and its subcutaneous connective tissue, owing to the obstruction to the 
return of the venous blood, is loaded with serum, or serum and lymph, giving the surface 
a glossy, shining appearance, and causing it to pit under pressure. The ear and the hand 
readily detect the characteristic thrill and bellows sound. 
Aneurism of the popliteal region is liable to be confounded with various kinds of tumors, 
and we read of cases in which the sac was laid open under the impression that the disease 
was not arterial. The lesions for which it is most apt to be mistaken are abscesses, solid 
and fatty growths, and synovial burses. 
Abscess of the ham is of very uncommon occurrence, and is generally easily dis- 
tinguished by its inflammatory character, and by the history of the case, and by the ab- 
sence of pulsation, by the presence of fluctuation, especially when the matter is con- 
siderably in quantity, and by our inability to produce any change in the volume of the 
swelling by compression of the femoral artery high up in the thigh. When any doubt 
exists, a small exploring needle, carefully inserted into the tumor, will readily determine 
the diagnosis. 
Solid growths, of various kinds, benign and malignant, are liable to form in the pop- 
liteal region, and might be mistaken for aneurism, especially by a careless and inexperienced 
surgeon. The fact that such tumors are usually stealthy in their origin, tardy in their 
development, firm in their consistence, and free from pulsation, will always readily dis- 
tinguish them from aneurism of the popliteal artery. 
A synovial burse is occasionally developed in this space, but the occurrence is rare, 
and it would be difficult to imagine how such a growth as this should ever be confounded 
with an aneurism in this region. In the Louisville Medical Review, a case of this affec- 
tion is reported by Dr. S. W. Gross, in which the largest tumor of this description that 
I have ever seen, occurring in a man twenty-nine years of age, was readily diagnosticated 
by the exploring needle, although its history—especially the absence of pain and pulsa- 
tion, its non-interference with the patient’s occupation, and the preservation of the natural 
appearance of the leg below the knee—had been sufficiently denotive of its true nature 
without any expedient of this kind. 
Progress.—Aneurism of the popliteal artery may remain circumscribed for a considera- 
ble length of time; in general, however, it soon becomes diffused, and by its pressure 
upon the surrounding structures causes not only great pain and swelling in the leg below ANEURISM OF THE POPLITEAL ARTERY. 
777 
CHAP. V. 
the knee, but a tendency to mortification by cutting off the nervous and vascular supplies. 
Such a termination, in tact, is almost inevitable it' the case be permitted to proceed un- 
checked. Gangrene may occur at a very early stage of the disease, while the tumor is yet 
quite small, by its direct pressure upon the lower part of the popliteal artery, or upon its 
immediate offsets. Generally speaking, however, it is one of the more remote effects of 
the disease, as the gradual or sudden destruction of the more attenuated portion of the 
sac, and the escape of its contents into the neighboring tissues, rendered thus additionally 
tense by the unyielding aponeurosis. In this manner, an aneurism originally circum- 
scribed, and, perhaps, quite small, may, in a few hours, become widely diffused and of 
enormous bulk, obscuring the pulsation both in the tumor and in the distal portion of the 
limb, if, indeed, not completely arresting the circulation. Similar effects often follow 
upon what is improperly called a diffused traumatic aneurism, in which the blood escapes 
more or less rapidly from the wounded vessel, and inundates the surrounding structures, 
frequently to a great and most injurious extent, arresting the circulation, and occasioning 
gangrene of, perhaps, a large portion of the limb below the seat of the compression. The 
foot and leg are cold, heavy, insensible, cedematous, of a speckled, glossy, or tallowy hue, 
and exquisitely painful. The patient, weak and feverish, soon becomes delirious, and, if 
relief be not promptly afforded, dies from exhaustion. Occasionally a popliteal aneurism 
discharges its contents into the knee-joint, where they speedily set up violent inflamma- 
tion, necessitating amputation. 
Sometimes a spontaneous cure occurs, probably by the pressure of the tumor upon the 
artery, or the detachment of a clot, thereby arresting the circulation in the sac. The late 
Professor Pancoast had a case of popliteal aneurism upon which he had intended to operate 
the next day ; but when the time arrived all pulsation in the tumor had ceased, and the man 
gradually recovered without any further trouble. 
Treatment—The treatment of popliteal aneurism was, until recently, usually conducted 
by deligation of the femoral artery in the superior third of the thigh, according to the 
method of John Hunter, first practised in 1785. Since 1840 numerous cases have been 
treated by other means, more especially compression in its several forms, and so gratifying 
have been the results, in most instances, that the old operation is likely, before long, to 
become, in great measure, obsolete. Of 403 cases, analyzed by Professor Agnew, 250 
were cured. Blackman effected a cure by digital compression in two hours; Ilolt, in 
sixteen hours; and Bryant, in one case, in four hours and a half, and in another, in 
twenty-four hours. Examples, equally remarkable, have occurred in the practice of other 
surgeons. On the other hand, in a case of my own, digital compression was incessantly 
maintained for four days and a half without any benefit whatever, a cure being afterwards 
readily effected by ligation of the femoral artery. I)r. James R. Wood, in 1850, published 
an account of two cases of popliteal aneurism successfully treated by the joint agency of 
mechanical and digital compression. I)r. Cheever, of Boston, effected a cure by acupres- 
sure of the femoral artery ; and in a case reported by Herbert Page, of England, a similar 
result followed the manipulation of the sac. Mr. Henry Lee, in a case of traumatic 
aneurism of the ham, was also successful with acupressure. 
Digital compression for the cure of popliteal aneurism is generally applied to the com- 
mon femoral artery immediately below Poupart’s ligament, and mechanical compression 
to the superficial femoral, in Scarpa’s triangle. The pressure, however, may, from time 
to time, be shifted from one point to another, according to the tolerance of the patient, 
who should be freely narcotized during the whole course of the treatment. 
Forced flexion, described at p. 720, is particularly applicable to aneurism of the ham, 
and always deserves a fair trial, if the tumor is not so large as to encroach seriously upon 
the structures of the joint or to threaten to discharge itself into its interior. In a case 
which I treated, in 1801, at the College Clinic, in a man thirty-five years of age, all 
pulsation in the aneurism ceased in less than twenty-four hours. The disease had come 
on three months previously, from a severe strain. The tumor was of an elongated, oval 
shape, large, circumscribed, and characterized by the ordinary phenomena. A number 
of examples of popliteal aneurism successfully treated by this method have occurred within 
the last ten years. 
When compression and forced flexion fail, or when the case is not a suitable one for 
such procedures, the only resource is ligation of the superficial femoral artery in the lower 
part of Scarpa’s triangle, where the vessel, although closely invested by the femoral vein, 
is always easily exposed, the sartorius muscle serving as a guide to the knife. The 
greatest possible care must be taken in separating the two vessels, as their adhesions are 
most intimate, and the ligature must be passed from within outwards. As a rule, it is 778 
DISEASES AND INJURIES OF THE ARTERIES. 
not advisable to perform the operation until the tumor has acquired si considerable bulk, 
or until there is reason to believe thsit the collateral circulation is sufficiently active to 
enable it to carry on the circulation in the distal portion of the limb after the ligation of 
the main trunk. The limb, placed in an easy, relaxed position, is enveloped in flannel, 
and, if need be, surrounded with bottles of warm water, until it lists regained its normal 
temperature, which is often materially depressed after the operation. The feet should be 
carefully protected from pressure, lest gangrene arise, and everything should be done, by 
the avoidance of motion and officious interference, to promote the healing of the wound. 
The patient must not be allowed to sit up in bed, or to move the limb for some time after 
the detachment of the ligature, otherwise, the adhesions giving away prematurely, secondary 
hemorrhage might supervene. The ligature is usually detached from the tenth to the 
thirteenth day. 
When ligation, digital and mechanical compression, and forced flexion fail to afford 
relief, or when, after the employment of these measures, gangrene sets in, the oidy re- 
source is amputation of the thigh, performed as speedily as possible, after the supervention 
of the disease. A similar procedure will be required when the aneurism has burst, and 
sent its contents widely through the connective tissue beneath the skin and among the mus- 
cles. Obstinate secondary hemorrhage may also necessitate amputation, although, in such 
an event, acupressure may occasionally be successfully employed. Partial gangrene, 
occurring in small spots on the tumor, the leg, or the foot, does not always demand the 
removal of the limb, especially if the patient is otherwise in good condition. 
In two remarkable cases of incipient gangrene due to the interruption of the collateral 
circulation by pressure of the tumor, the limb was saved, in one by Lawrence, and in the 
other by Benza, by cutting down upon the sac, laying it freely open, and turning out its 
contents, a ligature being applied to each extremity of the diseased artery. Such a pro- 
cedure necessarily involves great risk, both immediate and remote; the former depending 
upon hemorrhage, which must always be more or less copious ; and the latter upon inflam- 
matory irritation and its consequences, as extensive suppuration, ulceration, and sloughing 
of the exposed structures. 
Mortality.—The mortality from the operation for popliteal aneurism by the Hunterian 
method would seem to be variable. In the table of Dr. Norris, comprising a list of 153 
cases of aneurism, for which the femoral artery was tied, 112 were cured, and 41 died. 
The table of Mr. Crisp furnishes 110 cases, operated upon according to the Hunterian 
method, of which 91 recovered completely, 7 required amputation after the use of the 
ligature, and 12 died. Of the 11 cases of double popliteal aneurism comprised in it, all 
were cured ; 10 by ligature, and one by compression. The greatest cause of the mortality 
after the ligation of the femoral artery is gangrene of the leg. 
Of 278 cases collected by Professor Agnew, 173 were perfectly cured. The remarkable 
freedom from danger in this operation in the hands of certain surgeons is admirably ex- 
emplified in the practice of Mr. Syme, who, up to June, I860, had ligated the femoral 
artery for the cure of popliteal aneurism in 35 cases, without any bad results, except in a 
single one, which had previously been subjected to compression, and in which the sac 
suppurated without any fault of the ligature. 
Amputation performed as a means of saving life, in crises of incurable popliteal aneu- 
rism, shows a very fair amount of success. There are, however, no statistics by which a 
comparative estimate may be formed between the results of this operation and the ligature 
of the femoral artery practised for the cure of this affection. 
The ham is occasionally the seat of aneurismal rarix. One of the most extraordinary 
cases of the kind on record is that related by Dr. Dorsey, in his “ Elements of Surgery.” 
The patient had been wounded in the upper part of the leg twelve years before, by a load 
of buckshot. The limb was very painful, all the veins were enormously enlarged from 
the toes to the groin, and incorrigible ulcers existed upon the foot and ankle. The thrill 
so peculiar to this species of aneurism could be distinctly perceived. The femoral artery 
was tied at the middle of the thigh ; but the operation was followed by mortification of 
the leg, and during the separation of the slough, one of the enlarged veins suddenly gave 
way, causing copious hemorrhage, which, although it was for a time controlled by ligating 
the vessel, again broke out, and finally proved fatal. The femoral artery was in a dilated 
and unnatural condition as high as the groin, and a bougie was readily passed from the 
popliteal into the posterior tibial artery, and thence into a venous pouch at the inner 
part of the leg, below the knee. 
Varicose aneurism of the ham is uncommon. Cases of it have been recorded by 
Larrey, Hodgson, Porter, and other observers, generally as a result of injury, as a punc- 
cuap. v. CHAP. V. 
ANEURISM OF ARTERIES OF LEG AND FOOT. 
779 
ture or gunshot wound, but now and then as a spontaneous occurrence. The tumor may 
acquire a large bulk, and be accompanied by excessive dilatation of the popliteal vein. 
The treatment should be altogether hygienic, except when the disease is productive of great 
pain and inconvenience, when the sac should belaid open, and the artery tied above and below. 
Traumatic aneurism, properly so called, may occur in this region from a sabre wound, 
a musket ball, or the sharp end of a piece of bone, as in fracture of the femur or tibia. 
The blood is generally widely diffused, and the diagnosis is often greatly obscured by the 
attendant swelling. If the symptoms are urgent, the artery should be exposed and ligated 
at each extremity ; otherwise the case should be treated upon general principles, in the 
hope of gradual ulterior accommodation of the tumor, if not a spontaneous cure. 
ANEURISM OF THE ARTERIES OF THE LEG AND FOOT. 
Spontaneous aneurism of the arteries of the leg is very uncommon. In a paper, read 
before the American Surgical Association, in September, 1881, Professor R. A. Kinloch, of 
Charleston, analyzed 20 cases of spontaneous aneurism of the posterior tibial artery, of 
which 18 occurred in males, the sex being uncertain in 2. In two the supposed cause 
was stamping with the foot, and in one, each, pulling on a boot, a fall, standing long in 
one position, and overexertion, the cause being undetermined in 14. The age of the sub- 
jects ranged from nineteen to sixty-six years. The femoral artery was ligated in 12 cases, 
in three of which compression had previously failed, with a result of 5 cures and 7 deaths. 
Compression alone was employed in 5 cases,of which 3 were cured and 2 were failures. One 
of the cures was obtained by Esmarch’s bandage. Amputation was resorted to in 5 instances, 
in only one of which was it the primary plan of treatment, with a result of 3 recoveries and 
2 deaths; and in one case the sac was successfully laid open, and two ligatures applied. 
The traumatic form of the disease is the most frequent, and there are few lesions in 
surgery more difficult to manage, especially when the affection involves the posterior 
tibial artery, owing to the great depth at which this vessel is situated, and the confused 
condition of the parts arising from the extravasated blood. The proper remedy, of course, 
is free exposure of the affected vessel, removal of the coagula, and ligation of both ends. 
To accomplish this to the best advantage, often involves great coolness on the part of the 
operator, and an unusual amount of anatomical knowledge and dexterity. During the 
operation, the iliac artery should be compressed at the brim of the pelvis, or a tourniquet 
be applied around the up|>er part of the thigh. Without such precaution, the hemorrhage 
might be frightfully profuse. 
In 1873, a man thirty-five years of age, was admitted into the Jefferson Medical College 
Hospital, under the joint care of Professor Wallace and myself, on account of an aneurism of 
the posterior tibial artery, the size of a large fist, which had made 
its appearance eight months previously, in consequence of a wound 
inflicted by the sharp bony spine of the sting-ray, or trygon pasti- 
naca. After much difficulty, owing to the confused condition of the 
surrounding structures, I succeeded in tying the artery above and 
below the tumor, which was thoroughly freed of its contents, but not 
removed. The man did well for the first forty-eight hours, when 
erysipelas and pyemia ensued, from the effects of which he died 
seven days afterwards. 
The annexed cut, fig. 344, affords a good illustration of an aneu- 
rism of the posterior tibial artery undergoing spontaneous cure, the 
sac being filled with concentric coagula. The tibial nerve is spread 
over the back part of the pouch. 
A case of spontaneous aneurism of the dorsal artery of the foot 
was reported by Mr. Adams, of the London Hospital, in 1877, in a 
man, twenty-nine years of age. The tumor, the size of a walnut, 
was situated over the outer side of the astragalo-scaphoid articula- 
tion, and had come on without any assignable cause, about one month 
previously to the admission of the patient. The ligation of the ante- 
rior tibial artery in the upper portion of its extent, performed for the 
site of the disease, was followed by violent inflammation of the foot, 
necessitating amputation of the leg. The dissection of the parts 
showed that the aneurism had penetrated the astragalo-scaphoid joint. 
In a case under my care in 1874, in an old colored man, the aneu- 
rism, situated in front of the ankle-joint, had come on spontaneously 
Fig. 344. 
Aneurism of the poste- 
rior Tibial Artery, with 
the Nerve spread over 
the back part of the 
Pouch, which is entirely 
obliterated by concentric 
Coagula. DISEASES AND INJURIES OF THE ARTERIES. 
780 
chap. v. 
seven years previously, and was about the size of a pullet’s eg" ; the artery was tied above 
and below the tumor, and then dissected out, but the operation was followed by erysipelas, 
which ended fatally a few days afterwards. , 
The traumatic form of the disease has occasionally occurred, chiefly as a result of vene- 
section, at one time so much in vogue among the common people, especially on the conti- 
nent of Europe. Examples of the accident have been recorded by Guattani, Itoux, 
Vidal, and other writers. From the firm support which the artery receives as it passes 
over the tarsal bones in front of the foot, the probability is that such a tumor might 
easily be obliterated by compression, either digital or mechanical, applied immediately 
below the ankle-joint. If the effort should fail, the tumor should be dissected out, and 
the artery tied above and below. 
SECT. VIII OPERATIONS ON THE ARTERIES. 
LIGATION OF THE INNOMINATE OR BRAC11IO-CEPIIALIC. 
Although the innominate may be easily exposed on the dead subject, as was shown by 
Dr. George McClellan as early as 1820, by a linear incision carried vertically down in 
front of the trachea, without dividing any of the cervical muscles, yet I believe that such 
a plan would be ill suited to the purpose when there is a large tumor pressing upon and 
displacing the parts which environ this vessel. The operator must have ample room, and 
it will not, I presume, materially affect the issue of the case whether a little more or a 
little less tissue is cut. The plan suggested by Dr. Mott, in his celebrated ease, is, on 
the whole, it seems to me, the one best adapted for obtaining ready access to this artery, 
and is that which I should myself follow if I were called upon to secure the innominate 
for the cure of aneurism. The incision resembles, in outline, the shape of the letter 
the horizontal limb corresponding with the upper border of the clavicle and sternum, and 
the vertical with the inner margin of the sterno-cleido-mastoid muscle, each being about 
three inches in length. The lower incision extends as far inwards as the centre of the 
trachea. The triangular flap thus mapped off, embracing the skin and platysma-myoid, 
being dissected up, the sterno-cleido-mastoid, sterno-hyoid, and sterno-thyroid muscles 
are respectively separated upon a director from their inferior connections and turned out 
of the way. A layer of the deep cervical fascia is now cautiously pinched up and divided, 
when, by a little scratching with the finger-nail, the handle of the scalpel, or the end of 
a probe, the carotid will be brought into view a few lines above the top of the sternum, 
accompanied by the jugular vein and pneumogastric nerve. Taking this vessel as his 
guide, the surgeon can easily trace the course of the innominate downwards towards the 
heart, and isolate it from its associate vein. The ligature, when the case admits of it, 
should be applied about the middle of the vessel, the needle being carried around it from 
left to right and from behind forwards. When the aorta is situated unusually low, it may 
be necessary, in order to obtain more easy access to the innominate, to excise, as a pre- 
liminary step, the external extremity of the clavicle with a small segment of the sternum, 
as was done by Cooper, of San Francisco, in both his cases. 
In performing this operation, it should be remembered that this artery is only about 
sixteen lines in length ; that it rests upon the trachea, which it crosses somewhat obliquely 
at the base of the neck ; that the middle thyroid veins, and sometimes the middle thy- 
roid artery, run along its inner side ; and that on the right side, and on a plane ante- 
rior to it, is the innominate vein, the two vessels being intimately united together by 
connective tissue, and in close relation behind with the pneumogastric and phrenic 
nerves, the latter lying external to the former. The top of the pleura is a little inferior 
and external to the artery, and might, unless great caution is used, be easily wounded. 
The middle thyroid artery is sometimes given off by the innominate on its tracheal as- 
pect, and should be looked for in isolating the vessel, as its division might be followed 
by annoying hemorrhage. 
LIGATION OF THE COMMON CAROTID. 
To Mr. Abernethy is usually, but erroneously, ascribed the merit of having first tied 
the common carotid. I rom some remarks of Ilebenstreit, it appears pretty certain that 
the operation had been performed some time previously by a surgeon during the extirpa- 
tion of a tumor of the neck, in which he accidentally divided this vessel, and immediately 
surrounded it with a ligature, the patient soon recovering. The English surgeon did not CHAP. V. 
LIGATION OF THE COMMON CAROTID. 
781 
ligate the artery until 1798; the case was one of wound of the internal corotid, and the 
man died in thirty hours. The first operation that was performed upon it for carotid 
aneurism was by Sir Astley Cooper, in 1805, and was unsuccessful, the case terminating 
fatally on the nineteenth day. Three years subsequently, he ligated the vessel again, and 
now with a happy result. 
There are two points at which the common carotid may be tied, the place of election 
being regulated by the circumstances of the particular case. These are the upper and 
inferior cervical regions, and it will be well, in every instance, before the operation is 
begun, to call to mind the more important anatomical relations of the parts, otherwise 
serious blunders may arise, such, for example, as tying the omo-hyoid muscle or jugular 
vein instead of the artery, or including along with the artery the vessel just named, or 
some important nerve, as the pneumogastric, sympathetic, or laryngeal. As the artery 
proceeds upwards, it is overlapped by the sterno-mastoid, sterno-hyoid, and sterno-thy- 
roid muscles, and crossed by the omo-hyoid towards its superior extremity. Running 
down in front of its sheath is the descending brand) of the ninth pair of nerves, a little, 
thread-like filament, easily recognized by its whitish appearance, while within the sheath 
are, on the external side of the artery, the internal jugular vein, and behind and between 
them the pneumogastric nerve, the sympathetic and recurrent being posterior to the 
sheath. These relations are very intimate, and, therefore, the utmost caution is necessary 
in isolating the parts previously to the application of the ligature. The embarrassment 
is often immensely increased by the manner in which the artery is overlapped by the jug- 
ular vein, which occasionally, although less frequently than is generally supposed, swells 
out enormously during every effort at expiration, so as to obscure the vessel and render 
its ligation extremely difficult. The best way of remedying this is to request an assistant 
to compress the vein both at the upper and lower angle of the wound, the blood having 
previously been pressed out of it. 
The common carotid, on the right side, is sometimes absent, its place being supplied by 
two trunks, which, arising separately from the arch of the aorta, ascend along the neck, 
assuming the office of the external and internal carotid. When this arrangement exists, 
which, however, is extremely rare, the order of origin of the branches of the aorta is as 
follows: the right subclavian, right external carotid, right internal carotid, left common 
carotid, and left subclavian. It should also be borne in mind that the common carotid 
may, on the other hand, bifurcate very low down, not perhaps reaching as high up as the 
inferior border of the thyroid cartilage, and, on the other hand, it may not separate into 
its terminal divisions until it gets to the angle of the jaw. Morgagni met with an instance 
in which the artery, only an inch and a half in length, divided at the root of the neck. 
Lastly, it may be crossed in front by the inferior thyroid artery, lie upon the vertebral 
artery as this vessel passes along the spine, and include in its sheath the descending branch 
of the ninth pair of nerves. 
In ligating the carotid, the patient should be recumbent, with the head inclined to the 
opposite side, and well supported by pillows, the shoulders being at the same time some- 
what raised, in order to place the neck in a proper horizontal position. In the lower part 
of the neck the artery may be exposed by making an incision, from two and a half to 
three inches in length, along the inner border of the sterno-cleido-mastoid muscle, com- 
mencing just above the clavicle. The skin and platysma-myoid muscle being divided, a 
portion of the cervical fascia is pinched up with the forceps, and opened transversely to 
an extent large enough to admit a grooved director, upon which the membrane is then slit 
up and down nearly to the length of the outer incision. Two retractors are now inserted 
into the wound, one being used to draw the sterno-cleido-mastoid muscle outward, and the 
other to draw the sterno-thyroid inwards toward the trachea. The sheath of the artery 
being thus exposed, a little piece of it is now raised with the forceps, and divided hori- 
zontally, when, the director being introduced, it is slit open so as to denude the artery to 
a small extent, and enable the operator to isolate it from the jugular vein and the pneu- 
mogastric nerve, the ligature being passed from without inwards. Generally a small sub- 
cutaneous vein will be found passing along the line of incision, communicating above with 
the facial vein, and below with the thyroid plexus. This must, of course, be carefully 
avoided. 
The artery being more easy of access in the superior part of the neck than the inferior, 
this point should always be selected, when this is in our power, for ligating it. To expose 
the vessel in this situation, an incision should be carried along the inner margin ot the 
sterno-cleido-mastoid muscle, commencing a little below the cricoid cartilage, and reach- 
ing nearly as high up as the angle of the jaw. Embracing the integument, platysma- 782 
DISEASES AND INJURIES OF THE ARTERIES. 
CHAP. V. 
myoid muscle, and cervical fascia, it will thus conduct the operator at once down to the 
sheath of the vessel, which is then to be opened in the same cautious manner as in the 
previous case ; and the artery being gently separated from the accompanying structures, is 
ligated by passing the needle around it from without inwards, so as effectually to exclude 
the jugular vein.° The omo-hyoid muscle, which crosses this part of the carotid, must be 
held aside with a hook. 
The annexed cut, fig. 345, from Bryant, represents the common carotid as being exposed 
by H long incision, with a view of showing where it is crossed by the omo-hyoid muscle. 
Fig. 34.r). 
Ligation of tlie Common Carotid and Facial Arteries. 
When access to the common carotid, in the inferior part of the neck, is rendered diffi- 
cult on account of the low situation of the tumor, the best plan is to divide the sterno- 
hyoid and sterno-thyroid muscles, either alone, or jointly with the inner portion of the 
sterno mastoid, so as to enlarge the space between the aneurism and the sternum. By 
observing this precaution, Mr. Porter, of Dublin, was enabled, in one case, to ligate the 
vessel successfully within the eighth of an inch of the innominate ; and examples of a 
similar character have occurred in the practice of other surgeons. 
The carotid is sometimes tied at a very early age, as in a case in which I assisted the 
late Dr. George McClellan, where he successfully secured this vessel in a child five months 
old, on account of an immense naevus of the upper part of the face. The descending 
branch of the ninth pair of nerves was divided, as it interfered with the passage of the 
ligature, without any apparent harm. Dr. Valentine Mott, in a similar affection, tied the 
common carotid in a child only three months old, the whole of the operation being equally 
gratifying. 
Ligation of the common carotid is required on account of wounds of the 
neck involving the external carotid or some of its branches. The first successful case of 
the kind occurred in 180.3, in the hands of Mr. Fleming, an English naval surgeon. The 
operation is often embarrassing in consequence of the confused condition of the parts from 
the extravasation of blood, and is, besides, not always successful, owing to the establish- 
ment. of a return current through the internal carotid into the external carotid. Hence 
secondary hemorrhage, sometimes of a very profuse character, is liable to ensue, necessi- 
tating further proceeding, at a time, perhaps, when the wound is in a high state of inflam- 
mation. In order to avoid all this, Dr. Gordon Buck has proposed the simultaneous 
ligation of the common and internal carotid arteries, and, in the New York Medical LIGATION OF THE COMMON CAROTID. 
783 
CHAP. V. 
Times for November, 1855, he has given the particulars of a case in which the operation 
was followed by the most gratifying results. 
Ulcers of the fauces have sometimes necessitated the ligation of the primitive carotid, 
as in the cases reported by Luke, Mayo, and Syme, in all of which the operation was 
successful. The patient of the latter, however, came very near perishing from secondary 
hemorrhage. 
The common carotid artery has been repeatedly secured for wounds, ulcers, epilepsy, 
and erectile and other tumors, as well as for restraining hemorrhage in operations and 
injuries upon and about the head, ear, jaws, face, neck, mouth, and pharynx. The statis- 
tics of these operations present points of much interest, and they have been placed in a 
very clear light by the tables of Dr. Norris. In 30 cases in which the artery was tied on 
account of wounds, 15 recovered, and 15 died; in 16 cases in which it was ligated pre- 
viously to, or at the time of the extirpation of, tumors of the jaw, face, or neck, 8 died ; 
in 6 in which it was tied for the cure of epilepsy, all recovered from the effects of the 
deligation, although in 2 both vessels were secured ; and in 42 cases in which it was tied 
for the cure of erectile tumors and various growths of the diploe, orbit, neck, jaw, and 
maxillary sinus, 20 were cured, 13 died, and 9 recovered from the effects of the operation 
without being materially benefited. In upwards of 20 of the 94 cases, more or less severe 
cerebral symptoms followed the operation. 
Of 600 cases of ligature of the common carotid artery, analyzed by Dr. C. Pilz, of 
Breslau, in 1868, 319 were cured, 259 died, and of the remainder the result is not stated. 
Of 537 cases in which the sex is given, 403 were males and 134 were females. In 578 
cases, in which the result is recorded, the ligature was applied in 222 for hemorrhage, in 
86 for aneurism, in 136 for tumors, in 63 before and during the removal of tumors, in 34 
for nervous affections, and in 37 for Brasdor’s operation. In 27 cases both arteries were 
tied, the right in 251, and the left in 194. In the majority of instances, the ligature was 
detached after the thirtieth day. Nervous affections followed the operations in 160 cases, 
and hemiplegia in 8 per cent. 
These figures are not materially affected by those of Dr. Wyeth published in 1879. 
Thus, for instance, of 462 cases of wounds of all kinds for which the common carotid was 
tied 262 proved fatal. Of these cases 111 were gunshot wounds contracted in military 
service with a mortality of 81, while of 16 cases in civil life, only 4 died, thus presenting 
a difference in favor of the latter of 48 per cent., due mainly to the milder form of the 
injury, and to the less amount of shock. The table of Dr. Wyeth includes 52 cases of 
ligation for non-malignant tumors of the orbit, of which 28 were cured, 6 died, 5 were 
improved, and 6 were not benefited. Of 71 operations performed for the relief of aneu- 
rism by anastomosis, not affecting the orbit, 51 recovered, with 20 cures, and 20 died. 
Of 166 cases in which the artery was tied for sacculated aneurism 76 died, and of the 90 
recoveries only 66 were cured. Of the 166 cases the artery was tied on the cardiac side of 
the tumor in 106, of which 37 perished, and 90 recovered with 60 cures. Of 60 cases in 
which the ligature was applied at the distal side of the aneurism 39 died, and 21 recovered, 
but only 6 were permanently relieved. 
Wyeth’s tables comprise 789 cases of ligation of this artery for all causes, of which 323, 
or 41 per cent., perished. Of the 466 cases reported as having recovered, only 255 were 
cured, 49 were improved, 14 temporarily benefited, and 53 unimproved. The principal 
factors of death in the fatal cases were, hemorrhage, exhaustion, and cerebral disturbance, 
or interference with the functions of the brain, from the want of blood, and other causes. 
Paralysis followed the ligation of the artery in 52 of the 789 cases. Of the 323 fatal 
cases 7J? per cent, occurred within the first 24 hours after the operation ; 23 per cent, 
within three days; 45 per cent, within one week ; 64 per cent, within a fortnight; and 75 
per cent, within twenty-one days. The same artery was tied twice in 8 instances with six 
fatal results, and in one thrice followed by death. The right artery was ligated in 361 
cases, and the left in 290 of the 651 in which the seat of the operation is stated. The 
ligature was detached on an average, from the tenth to the twenty-fourth day. Among 
the great dangers after the operation are softening of the brain and inflammation of the 
air-passages. A very distressing symptom occasionally witnessed is violent hiccough, due, 
apparently, to compression of the pneumogastric nerve by the ligature. 
In wounds of the neck, involving the great vessels, the common carotid should never, 
as has been justly remarked by Dr. Wyeth, be tied for injury of the external carotid, or 
of its branches, when there is space enough between the seat of the lesion and the bifur- 
cation of the common carotid to admit of the application of a ligature to the external 
carotid. He bases this conclusion upon the fact that the death-rate in 789 cases tabulated DISEASES AND INJURIES OF THE ARTERIES. 
CHAP. V. 
by him of ligation of the common carotid is 41 per cent., while that of the external carotid 
in 91 cases is only per cent. He also lays great stress upon an analysis of 121 dis- 
sections made by him with a view of determining the relations of these arteries and of 
their branches to each other. He condemns, in pointed language, the teaching which 
advises the ligation of the common trunk instead of the external carotid when there is 
sufficient space between them to place the ligature; he declares that the practice, hitherto 
almost universal, is as wrong in principle as it is dangerous in its results, and should there- 
fore be abandoned. 
The following table affords a summary view of nearly all the examples in which both 
these vessels have been tied, either simultaneously or after a variable interval. 
Ligation of both Carotids. 
No. 
Operator. 
Date 
Age 
Sex 
Disease!*. 
Interval. 
Kenult. 
Remark*. 
1 
Dupuytren 
and Robert 
1819 
... 
... 
Anastomotic 
aneurism 
of scalp. 
36 
years 
Died 
Brain symptoms. 
2 
Macgill 
1823 
F. 
Fungous 
tumor of 
both orbits. 
1 
month 
Recovered 
Improved. Vision destroyed before 
operation. 
3 
Ullman 
1823 
20 
Erectile 
tumor of 
orbit. 
12 
months 
Died 
Death on 3d day from hemorrhage. 
4 
Mussey 
1827 
20 
M. 
Anastomotic 
aneurism 
of scalp. 
13 
days 
Recovered 
Failed. Pulsation returned in tumor, 
which was excised after second ope- 
ration. 
5 
Mussey 
1827 
19 
... 
Anastomotic 
aneurism 
of scalp. 
28 
days 
Recovered 
6 
Moller 
1831 
4* 
Erectile 
tumor. 
4* 
months 
Recovered 
7 
Preston 
1831 
24 
M. 
Epilepsy. 
39 
days 
Recovered 
Failed. Convulsions the day after 
each operation. 
8 
Preston 
1831 
51 
M. 
Epilepsy. 
84 
days 
Recovered 
Failed. Fits had existed for six 
years, latterly palsy on one side. 
9 
V. Mott 
1832 
M. 
Epilepsy. 
6 
months 
Recovered 
10 
V. Mott 
1833 
M. 
Disease of 
parotid. 
15 
min. 
Died 
Death in forty-eight hours. 
11 
Kuhl 
1834 
53 
M. 
Aneurism 
of occiput. 
72 
days 
Recovered 
12 
Hamilton 
1838 
18 
M. 
Epilepsy. 
6 
months 
Recovered 
Last operation followed by destruc- 
tive inflammation of the left eye. 
13 
Velpeau 
1839 
29 
Aneurism of 
both orbits. 
3 
months 
Recovered 
14 
V. Mott and 
Eve 
1839 
19 
M. 
Hemorrhage 
from nasal 
polyp. 
13 
months 
Recovered 
15 
Pirogoff 
1843 
20 
Hemorrhage 
from aneur- 
ism of scalp. 
1 
year 
Recovered 
Hemorrhage and vomiting after each 
operation. 
10 
J. Ellis 
1844 
21 
M. 
Shot wound 
of tongue. 
H 
days 
Recovered 
17 
Reynolds & 
Van Buren 
1844 
11 
Aneurismby 
anastomosis. 
6 
years 
Recovered 
18 
J. M. Warren 
1845 
23 
M. 
Erectile tu- 
mor of face. 
33 
days 
Recovered 
Failed. Subsequent excision of dis- 
eased structure followed bv cure. 
19 
Robert 
1840 
19 
F. 
Aneurism of 
forehead 
8 
months 
Recovered 
Headache; temporary disturbance 
of vision. 
20 
Blackman 
1848 
15 
M. 
Disease of 
antrum. 
21 
days 
Recovered 
Temporary loss of vision of left eye. 
21 
V. Mott 
1851 
M. 
Malignant 
disease of 
nose. 
5 
months 
Recovered 
22 
W. Parker 
1854 
45 
M. 
Malignant 
disease of 
nose and 
orbit. 
32 
days 
Recovered 
Died at end of five months from re- 
turn of the disease. CHAP. V. 
LIGATION OF THE EXTERNAL CAROTID. 
No. 
Operator. 
ttatej Age 
1 
Sex 
Diseases. 
iutervyil. 
Result. 
Remarks. 
23 
V. Mott 
1854 
M. 
Malignant 
disease of 
orbit. 
3 
months 
Died 
Death on fourth day. 
24 
J. R. Wood 
1856 
53 
... 
Eneephaloid 
of antrum. 
5 
months 
Died 
Death on sixteenth day. 
25 
Buck 
1857 
22 
M. 
Aneurism 
of orbit. 
26 
months 
Recovered 
2(5 
O.C.E.VVeber 
1857 
20 
M. 
Epilepsy. 
17 
days 
Recovered 
Improved. Disease had existed for 
five years. 
27 
Oarnocliau 
1658 
44 
F. 
Elephantia- 
sis of neck, 
ear, and face 
7 
months 
Recovered 
Growth, which had existed for four- 
teen years, diminished. 
28 
V. Mott 
1858 
21 
M. 
Malignant 
disease of 
antrum. 
8 
months 
Recovered 
2.9 
U. S. Army ? 
IS62 
... 
M. 
Shot wound 
of neck. 
Same 
day 
Died 
Death same day. 
33 
Murdoch 
1863 
... 
M. 
Shot wound 
of neck. 
3 
days 
Died 
Death on fifth day after second opera- 
tion from recurrence of hemorrhage 
31 
Longmore 
1863 
... 
Shot wound 
6 
days 
Died 
Death in thirty-eight hours. 
32 
Billroth 
1864 
27 
Hemorrhage 
from ulcer- 
ated inter- 
nal carotid 
artery. 
14 
days 
Died 
Secondary hemorrhage on sixteenth 
day. Death two days after second 
operation from exhastion. 
33 
Lewis 
1864 
M. 
Shot wound 
of face. 
4 
days 
Died 
Death on ninth day. 
34 
Parker 
1864 
38 
M. 
Malignant 
disease of 
antrum. 
28 
days 
Recovered 
Disease not arrested. 
35 
H. E. Poote 
1867 
20 
M. 
Orbital 
aneurism. 
30 
days 
Recovered 
Complete cure of aneurism, and 
marked improvement of vision. 
3t; 
Buenger 
34 
Aneurisraby 
anastomosis 
and wound. 
5 
years 
Recovered 
Left tied for aneurism, and the right 
for suicidal wound five years after- 
wards. 
Of the above cases, 36 in number, 26 recovered from the effects of the oj>eration, and 
10 died. In the instance of Dr. Mott, in which both vessels were tied almost simultaneously, 
coma soon supervened, and the man died in forty-eight hours. In the case of I)r. Ellis, 
of Michigan, the second deligation was performed after an interval of four days and a half, 
on account of secondary hemorrhage consequent upon a gunshot wound, and no unpleasant 
symptoms followed, the patient making an excellent recovery. In Dr. Mussey’s case 
twelve days intervened between the two operations, neither of which was succeeded by 
any accident. To Dr. Maegill, of Maryland, belongs the credit of being the first to tie 
both carotid arteries on the same subject within a short interval. 
Most of the cases marked as recoveries were only temporarily relieved; very few' were 
cured. Most of the cases in which the operations were performed for gunshot injuries 
perished from secondary hemorrhage. Of 22 operations performed by American surgeons 
17 recovered, and 5 died. 
LIGATION OF THE EXTERNAL CAROTID AND ITS BRANCHES. 
The external carotid, extending from the superior border of the thyroid cartilage to the 
neck of the lower jaw, is situated, just above its origin, in the triangular space formed by 
the omo-hyoid muscle below, the digastric above, and the sterno-mastoid externally, 
immediately beneath the integument and platysma-myoid; but it soon sinks deeper in, 
passing up under cover of the stylo-hyoid and digastric muscles, and is finally buried in 
the substance of the parotid gland. It is accompanied by two veins, and is crossed near 
its commencement by the hypoglossal nerve, and also, in various parts of its course, by 
branches of the external jugular and other veins. The glosso-pharyngeal nerve is inter- 
posed between this artery and the internal carotid, while the superior laryngeal nerve lies 
under both. 
Ligation of the external carotid artery is seldom required except in wounds of the neck 786 
DISEASES AND INJURIES OF THE ARTERIES. 
and in vascular growths, as nevoid tumors and aneurism by anastomosis, of the face and 
scalp. The operation has occasionally been performed as a preliminary step to the re- 
moval of the lower jaw and of the parotid gland, but such a measure can certainly rarely 
be necessary in the hands of a skilful surgeon; and, as for tying this vessel for the cure of 
carcinoma of the neck, tongue, palate, or pharynx, as has been done by Mutzer, Maison- 
neuve, and others, I hold that such a procedure, in the face of our present experience, is 
utterly unjustifiable. The vessel is often opened in attempts at suicide, although less 
frequently than is generally imagined; for persons intent upon self-destruction usually 
bend the neck so far back as to place the artery beyond the reach of the knife. Some of 
its branches are, however, commonly injured under such circumstances, especially the 
superior thyroid and lingual, and the hemorrhage thus produced may be promptly fatal. 
A ligature may readily be placed around the external carotid between these two arteries, 
in the first part of its course, that is, from four to six lines above its origin, and imme- 
diately below the digastric muscle, by carrying an incision, about two inches and a half 
in length, parallel to and about six lines in front of the inner edge of the sterno-mastoid 
muscle, commencing opposite the middle of the thyroid cartilage, and terminating a short 
distance below the angle of the jaw. The trunk of the common carotid will guide the 
finger to its external division; and it will always be well, before the ligature is tied, to 
feel for the pulsation of the temporal artery. The incision should be made with great 
care, lest violence be done to some of the numerous offsets of the vessels. The artery, as 
it lies beneath the digastric and stylo-hyoid, is exposed with difficulty; the incision must 
be proportionately large, and the muscles just mentioned must be well depressed with the 
retractor. 
Some of the branches of this artery occasionally arise so closely to its origin as to render 
it improbable that if a ligature were applied at the usual point of election, a sufficiently large 
and firm clot would form to occlude its caliber securely on the detachment of the ligature. 
For such a case the safest plan would be to tie at the same time the nearest offset. 
Dr. Wyeth, in his statistics, finds that the external carotid artery was tied alone in 67 
cases with 3 deaths, and simultaneously with the common carotid in 10 cases, all of which 
chap. v. 
Fig. 346. 
ended fatally. Of the 04 recoveries, in which the external carotid alone was concerned, 
only 31 are reported as having been cured. Of the 67 cases, the sex is given only in 47, of 
which 34 were males, and 13 females. 1 he ligature, in most of the cases, came away before 
the seventeenth day, in one as early as the fifth day, and in one as late as the twenty-second 
Ligation of the Subclavian and Lingual Arteries. CHAP. V. 
LIGATION OF THE EXTERNAL CAROTID ARTERY. 
787 
day. The artery was tied on both sides in the same patient in six eases, all eventuating 
in recovery. The causes necessitating the operations were various, as wounds, hemor- 
rhages, tumors, malignant and benign, and vascular growths of the head, ear, face and 
nose, facial neuralgia, and injury of the external carotid and facial arteries. 
The principal branches of this artery, requiring surgical consideration, are the superior 
thyroid, lingual, facial, occipital, and temporal. 
The superior thyroid artery is much exposed to injury in attempts at suicide, and may 
then be easily traced simply by following the wound. If it becomes necessary to ligate it 
on account of hypertrophy of the thyroid gland, with a view to diminish the supply of 
blood, it may be laid bare by making an incision across the upper part of the neck, ob- 
liquely downwards and outwards from the side of the hyoid bone to the edge of the sterno- 
mastoid muscle. Or, instead of this, the object may be attained by making an incision, 
two inches in length, along the inner border of the sterno-mastoid muscle, as in the 
operation for tying the external carotid. The skin, platysma-myoid, and cervical aponeu- 
rosis having been carefully divided, the superior thyroid will be found deep in the omo- 
hyoid space, between the sheath of the carotid and the thyroid gland. 
The lingual artery may be exposed in the same manner as the thyroid, near which it 
takes its origin; its situation, however, is very deep, and its relations are so complicated 
that it generally requires a great deal of skill and perseverance to reach it. Unless the 
patient is fully under the influence of an anaesthetic, the difficulty of the operation will be 
much increased by the incessant spasmodic action of the larynx, which, forcing the hyoid 
bone up and down, renders it very troublesome to fix the points of incision. 
If the operation, fig. 346, from Bryant, should be deemed necessary, it may be performed 
as follows, according to the plan laid down by Mr. Skey in his valuable work on Operative 
Surgery: “The head of the patient being placed horizontally, and the neck lengthened by 
raising the chin, an incision of about twelve lines in length should be made immediately 
behind the cornu of this bone, the outline of which should be distinctly ascertained before 
proceeding to the operation; the incision should be directed downwards and forwards. The 
skin and platysma being divided, the fascia is exposed, which should also be divided to 
the length of the external wound. The facial vein, often of considerable size, will be 
brought into view at the upper part of the wound, in its course downwards to the internal 
jugular, and should be drawn outwards. The remaining parts should be torn, rather 
than cut asunder, passing transversely inwards, nearly parallel to the upper edge of the 
cornu of the os-hyoides, when the artery will be exposed. In passing the needle behind 
it, care must be taken to avoid the superior laryngeal nerve, which descends nearly at 
right angles behind the artery.” 
Demarquay has tied both lingual arteries on three occasions, to produce atrophy of 
carcinomatous affections of the tongue, with the result of prolonging life in each case ; 
and a similar operation for gunshot wound of the tongue was successfully performed dur- 
ing the War of the Rebellion. 
The facial artery, so frequently .concerned in operations about the neck, face, and lips, 
may easily be compressed with the finger as it passes over the jaw. If divided, it should 
immediately be secured. When its ligation becomes necessary, in case there is no wound, 
its pulsation will point out the proper situation for the incision. When it is desired to 
secure it just above its origin, the incision should be made as in the operation upon the 
lingual, its approach being facilitated by drawing the digastric muscle strongly upwards. 
The vessel is most easily exposed and tied where it lies over the jaw, as in fig. 345. 
The occipital artery sometimes requires ligation on account of wounds, but its depth 
in the lower part of its extent is such as to protect it generally from injury involving the 
cervical region. On the back of the head, however, it is not unfrequently laid open, and 
usually bleeds very freely. It may be exposed just above its origin by carrying an inci- 
sion along the inner border of the sterno-mastoid muscle, in the angle formed by it and 
the digastric, the latter of which must be well drawn down. It is in intimate relation 
here with the hypoglossal nerve, which hooks around it as it passes forward toward its 
destination. The artery, after emerging from the splenius muscle, on the back of the 
head, fig. 347, is superficial, its course beneath the scalp being denoted by its pulsation. 
A fatal case, in which, on account of a wound in this vessel, and of the jugular vein, and 
the confused condition of the parts, a ligature was applied to the common carotid artery 
by Dr. G. W. Norris, is reported in the American Journal of the Medical Sciences for 
April, 1856. 
The temporal artery is occasionally wounded, and may be secured immediately above 
the zygoma, by a short vertical incision, fig. 348, embracing the temporal aponeurosis, 788 
DISEASES AND INJURIES OF THE ARTERIES. 
cnAP. v. 
immediately beneath which it is situated. Lower down, tin; depth at which it lies is too 
great to justify an attempt at ligation. Should it be divided in this poition of its extent, 
the best plan is to tie the external carotid. 
Fig. 347. 
Fig. 348. 
The anterior branch of this vessel is the one always selected in arteriotomy, when it 
is wished to practice depletion on account of affections of the brain, or the brain and 
its membranes. After a sufficient amount of blood has escaped, the artery is cut across, 
and a graduated compress applied. If this precaution be neglected, a false aneurism 
will form. 
The internal maxillary artery is sometimes wounded by a thrust with a sharp knife or 
dirk. The immediate result, of course, is a copious hemorrhage, for the arrest of which 
the only remedy is ligation of the external carotid: compression, it is true, now and then 
succeeds, but the only reliable means is the ligature. When the vessel is wounded in 
the extirpation of the jaw, it may commonly be seized and tied; wdien this is impractica- 
ble, the bleeding may generally be stopped with the hot iron, or with the tampon, wet 
with a saturated solution of subsulphate of iron. 
LIGATION OF THE INTERNAL CAROTID ARTERY. 
Ligation of this vessel is rendered necessary for the arrest of hemorrhage, and for the 
cure of traumatic aneurism, the result of injury inflicted upon its own tunics. Varying in 
length in different individuals, the artery extends directly upwards from the upper border 
of the thyroid cartilage to the carotid foramen of the temporal bone, and is in intimate 
relation with numerous and most important structures. Lying deeply in the neck upon 
the anterior rectus muscle, it is concealed below by theisterno-mastoid muscle, and above 
by the parotid gland, the internal jugular vein being situated at its posterior aspect, and 
somewhat superficial to it, the pharynx and tonsil at its inner side, and the pneumogas- 
tric and sympathetic nerves deeply behind. The main trunk of the external carotid is 
on the outside, and a little in front of it. Superiorly, the artery is crossed by the digas- 
tric and stylo-hyoid muscles, the occipital artery, and the glosso-pharyngeal nerve, and, 
near the base of the skull, by the styloid process, and the stylo-pharyngeal muscle. 
Considering the intricate relations of this vessel, the narrow space in which it is 
embedded, and the fact that in cases of injury the parts must necessarily be greatly con- 
fused by extravasated blood and inflammatory deposits, some idea may be formed of the 
great difficulty which the surgeon must experience in any attempt to cast a ligature 
around it. In order to expose the artery, the anterior border of the sterno-mastoid mus- 
cle must be taken as a guide to the knife, and an incision made from three to five inches 
in length, an abundance of room being indispensably necessary to success. Two liga- 
tures are required—one above and the other below the seat of injury—when the vessel is 
secured on account of hemorrhage, or for the cure of traumatic aneurism. This fact, long 
ago pointed out by Guthrie, was strikingly illustrated in the case of Professor Briggs, of 
Nashville, in which the artery was tied in 1871, for aneurism, and in that of Professor II. 
B. Sands, of New Vcrk, in which it was ligated in 1872, on account of secondary hemor- 
rhage, consequent upon the extirpation of the lower jaw. In both of these examples, as 
well as in every other, so far as I have been able to ascertain, in which the common caro- 
tid artery was secured for the suppression of hemorrhage of the internal carotid, the 
Ligation of the Occipital Artery 
Ligation of the Temporal Artery. CBAP. V. 
LIGATION OF THE SUBCLAVIAN ARTERY. 
patients perished from loss of blood. When the artery is ligated on account of hemor- 
rhage from the ear, the tonsil, or epithelioma of the throat, as in the cases reported, 
respectively, by Billroth, A. Smith, and Von Langenbeck, only one ligature will be 
required. 
The case of Professor Briggs was one of traumatic aneurism in a man twenty-three 
years of age, the result of a stab received six weeks before. The tumor, which was as 
large as an ordinary fist, and occupied the left parotid region, was laid very freely open, 
the clots turned out, and the artery tied above and below the wound, the common carotid 
having been previously secured without any effect upon the hemorrhage. In Professor 
Sands’s case, the internal carotid artery gave way ten days after disarticulation of the left 
half of the lower jaw, performed on account of malignant disease in a man fifty-three 
years of age. Two ligatures were applied, one on the proximal and the other on the 
distal side of the ulcer in the vessel, and immediately after a ligature, previously placed 
around the common carotid artery, was tightened. AH bleeding now ceased. The two 
ligatures around the internal carotid separated on the ninth day, and that on the common 
carotid on the fourteenth day, followed by complete recovery. 
The ligation of this vessel may be greatly facilitated, especially as has been suggested 
by Guthrie, when it has been wounded through the mouth, by severing the lower jaw at 
the second molar tooth. By drawing the posterior fragment outward, increased space 
will be obtained which will be of material assistance in the efforts necessary to pass and 
tie the ligature. In performing any operation upon this vessel, the surgeon must be in 
full possession of a knowledge of the anatomy of this part of the neck, otherwise his 
efforts will be sure to eventuate in disappointment, if not in discomfiture and disgrace. 
The statistics of this operation are very unsatisfactory. Wyeth has found only 19 
cases, and in only two of these was the internal carotid alone tied. In 6 cases, the com- 
mon carotid was tied at the same time, with 3 cures and 3 deaths; in 3 the external, all 
being successful; and in 6 cases the common, external and internal, 3 recovering and 3 
dying. In one instance, the internal carotid and internal jugular vein were tied, the 
result being favorable, and in another case, equally successful, the three carotids and 
internal jugular vein were ligated. The operation in 14 cases was performed for hem- 
orrhage, of which 5 died ; in one, for aneurism, followed by recovery, and in a fatal 
one for an erectile tumor. The 2 cases in which the internal carotid alone was ligated 
recovered. 
LIGATION OF THE SUBCLAVIAN AND ITS BRANCHES. 
The point which is usually .selected for tying the subclavian artery is just external to 
the scalene muscle, in what is considered as the third course of the vessel, excellent illus- 
trations of which are afforded by fig. 34fi, from Bryant, 
and fig. 349, from Erichsen. One single incision will 
generally be found to be sufficient for the free exposure 
of the artery, and this may be strictly horizontal or more 
or less curvilinear, according to the fancy of the operator. 
It is only when the tumor is so bulky as to cause great 
malposition of the shoulder, forcing the collar-bone high 
up into the neck, that two incisions can really be required, 
the one extending along the upper border of the clavicle, 
and the other vertically upwards, parallel with the outer 
edge of the sterno-cleido-mastoid mnscle. 
The patient, in this operation, rests in the horizontal 
position upon a narrow table, with his head and chest 
moderately elevated, and the face slightly inclined towards 
the sound side. An assistant taking hold of the hand 
keeps the affected limb close to the trunk, at the same 
time that he pulls down the shoulder as much as possible, 
in order to draw the clavicle away from the subclavian artery as it passes from the scalene 
muscle towards the first rib. The surgeon, standing by the side of the patient, above the 
shoulder, stretches the integument of the neck upon the upper part of the chest with the 
fingers of the left hand, while with the other he makes an incision, about two inches and 
a half in length, directly along the middle of the clavicle, commencing at the sternal 
origin of the mastoid muscle and terminating near the anterior margin of the trapezius. 
In this manner he divides the skin, superficial fascia, and platysma-myoid. Letting go 
his hold with his left hand, the parts will be found instantly to resume their natural 
Fig. 349. 
Diagram of Right Subclavian Artery- 
in Third Part of its Coarse, crossed by 
transverse cervical artery and vein. o. 
Subclavian artery. n. External jugular 
receiving the transverse cervical veins. 
n. Brachial plexus of nerves, m. Omo- 
hyoid muscle. DISEASES AND INJURIES OF THE ARTERIES. 
790 
CHAP. V. 
situation, leaving thus the incision on a level with the superior border of the clavicle. 
The next step of the operation consists in detaching from this bone the deep cervical 
aponeurosis, which may readily be accomplished by a few gentle strokes of the handle 
of the scalpel instead of the point of the instrument, which would greatly endanger the 
surrounding vessels and nerves. The external jugular vein will be found close to the 
outer edge of the mastoid muscle, and should be held out of the way with a blunt hook. 
The suprascapular artery will also generally appear, at this stage of the procedure, just 
above and behind the clavicle, or partially covered by it, and should be treated in a similar 
manner; or, if divided, it should immediately be tied. The omo-hyoid lies at the outside 
of the incision, bound down by a process of the cervical aponeurosis, which should next 
be torn through‘with the knife. Taking the anterior scalene muscle for his guide, the 
operator feels tor the tubercle of the first rib, a little to the outside of which the artery 
will be found pulsating, more or less distinctly, and where it may generally be easily 
secured by passing the needle from before backwards and from below upwards. Pre- 
viously to tightening the ligature, it should be ascertained that it controls the circulation 
in the aneurismal sac, and, above all, that it does not include any of the cords of the 
axillary plexus of nerves, a circumstance which has happened in several of the cases in 
which this operation has been performed. When the clavicular origin of the sterno- 
mastoid muscle is unusually broad, as it not unfrequently is, it should be divided upon the 
grooved director, as this will greatly facilitate the approach to the vessel, particularly 
when the design is to apply the ligature behind the scalene muscle. 
In this manner, the subclavian may generally be easily reached without much loss of 
blood or waste of time. In some instances, however, the operation is rendered extremely 
difficult, tedious, and embarrassing, owing either to the magnitude of the tumor and the 
consequent elevation of the clavicle, the diseased state of the artery, the unusual course 
of the vessels of the neck, or even when these follow their natural direction, the swollen 
and distended condition of the subclavian vein, the irregularity of the omo-hyoid muscle, 
the enlarged condition of the cervical lymphatic glands, the great condensation of the 
parts from the effusion of plastic matter, or, finally, the upward extension of the pleura. 
1. The elevation of the clavicle is generally in direct proportion to the size of the 
tumor. Sometimes, however, even when the swelling is comparatively diminutive, this 
bone is situated much higher up than usual, owing to the peculiar conformation of the 
individual. In either case, the dilliculty of finding the vessel will be much increased. 
In one instance, in which the elevation was produced by the enormous development of the 
disease, Sir Astley Cooper was forced to abandon the operation altogether. When such 
a contingency arises, which, on the whole, must be extremely rare, instead of giving up 
the case in despair, as was done by the English surgeon, the best plan, it seems to me, 
would be to divide the anterior scalene muscle, so as to enable us to apply the ligature 
somewhat nearer to the heart, or even on the tracheal side of that muscle. 
2. The operation is occasionally rendered more or less intricate and embarrassing by 
the diseased state of the artery. In this case, although the vessel may be easily enough 
approached, it is impossible to apply the ligature at the usual situation. To divide the 
scalene muscle, or to cut down along its margin, for the purpose of securing the vessel at 
one or other of these points, is here our only resource. The brachial plexus of nerves 
may also be so much in the way of the operator as to render this course necessary, as 
happened on one occasion to Dupuytren. 
3. The cervical vessels, both arterial and venous, are almost constantly in the way of 
the operator, even when they pursue their usual route. This is particularly true of the 
external jugular vein and of the suprascapular artery. The former of these vessels, 
commencing at the angle ot the jaw, passes vertically down the neck under cover of 
the platysma-myoid. In the early stage of its course, it rests upon the sterno-mastoid ; 
afterwards it gets to the outer border of this muscle, and, finally, at the inferior part of 
the neck, sinks behind it, to terminate in the subclavian vein near its junction with the 
internal jugular. Just before it disembogues, which it sometimes does by several distinct 
trunks, it receives two pretty large branches, the suprascapular and transverse cervical, 
which traverse the neck in a horizontal direction trom without inwards, parallel with the 
arteries of that name. I hese arteries, as well as their accompanying veins, lie deeply at 
the root ot the neck, especially the suprascapular, which is frequently concealed for some 
distance by the clavicle, on a line with which it runs to reach the root of the coracoid 
process ; it is generally a branch of the thyroid axis, and rests at first upon the anterior 
scalene muscle, crossing as it passes outwards the subclavian artery. The course of the 
transverse cervical artery is nearly similar, but it is usually situated somewhat higher up; CHAP. V. 
LIGATION OF THE SUBCLAVIAN ARTERY. 
791 
it is also considerably smaller, and is not unfrequently derived immediately from the sub- 
clavian. 
Now, in attempting to reach the subclavian, it is almost impossible to avoid wounding 
some of the vessels above mentioned. The external jugular vein is particularly in danger, 
and can scarcely escape without the utmost coolness and dexterity on the part of the 
operator. As soon as it is recognized, it should be separated from the surrounding struc- 
tures by a few gentle strokes with the handle of the scalpel, and drawn to the outer side 
of the wound. This plan is undoubtedly always the best and safest when it can be 
adopted ; sometimes, however, it happens that the vessel is so much in our way as not 
only greatly to embarrass our progress, but absolutely put a stop to it. In this case it 
must be tied with two fine ligatures, and then divided. Such a procedure not only pre- 
vents hemorrhage, but also the introduction of air into the lower portion of the vessel, an 
occurrence which cannot be too carefully guarded against. The suprascapular artery, if 
in the way, should be drawn aside, or, if it be wounded, immediately secured. Any 
bleeding vessels, indeed, no matter whether arterial or venous, provided they pour out a 
sufficient amount of blood to interfere with the operation, should at once be tied. 
4. The inordinate swelling of the subclavian vein is another source of embarrassment 
occasionally experienced in operations of this kind. This vessel is usually situated some- 
what below and superficially to the artery, being separated from it by the anterior scalene 
muscle, upon which it lies. Commencing at the inferior margin of the first rib, where it 
is continuous with the axillary, it passes horizontally inwards until it joins the internal 
jugular vein, within a few lines of the sterno-clavieular articulation. In this course, in 
which it is almost entirely concealed by the clavicle, it receives the small branches which 
accompany the different offsets of the artery as well as the external jugular, which last 
enters it, as before stated, nearly opposite the centre of the bone, but sometimes more 
internally. After the division of the cervical aponeurosis in the lower part of the neck, 
the operator will occasionally observe this vessel alternately to swell and subside, owing 
not so much, as some have supposed, to the natural flow of the current within it as to the 
reflux caused by the action of the right auricle of the heart, aided by the hurried and 
agitated state of the respiratory movements. The difficulty thus occasioned is not only 
annoying, but sometimes so embarrassing as to render it almost impossible even to see the 
artery, much less to separate and tie it. To remedy this, it has been suggested that the 
operation should be suspended for a moment, and the patient placed in the semierect 
posture, to allow him to make several full and easy inspirations, after which, it is said, 
the tension of the vein will be diminished, and the regurgitation of the blood cease. The 
surest and most expeditious plan, however, is to hold the vessel out of the way by means 
of a broad, blunt hook, or copper spatula, carried down behind the clavicle. In this 
manner the vein may be effectually compressed to the extent of half an inch, or more, if 
necessary, and the artery fairly brought into view. 
5. The omo-hyoid muscle, instead of forming a triangular space, as it usually does, with 
the scalene muscle and the clavicle, may run parallel with, and just above, that bone, or 
even entirely below it. In either case, should it be productive of inconvenience to the 
operator, he should pass a director under and divide it. Such a procedure, however, 
can seldom be called for, as, by laying open its sheath, the muscle may generally be drawn 
out of our reach. 
6. The lymphatic glands, at the inferior part of the neck, may be so much enlarged as 
to interfere seriously with the different stages of the operation. When this is found to 
be the case, instead of trying to save these bodies, they should be carefully dissected out, 
as we shall thus not only expedite our arrival at the artery, but, what is a matter of no 
little importance, greatly facilitate the healing of the parts after the vessel is tied. 
7. Considerable embarrassment may arise from the condensed and indurated state of 
the parts, caused by an effusion of plastic matter. This may always be looked for when 
the disease is of long standing, or when the tumor is so large as to excite severe inflam- 
mation in the deep-seated structures immediately above the clavicle, thereby obscuring 
the nerves and vessels. 
Finally, the position of the pleura above the clavicle often presents a very serious 
impediment to the ligation of the subclavian. The extent of this projection varies, on 
an average, from an inch and nearly a half to two inches, and sometimes even exceeds 
the latter measurement. What adds to the embarrassment, especially when the aneurism 
is very large, is the fact that the artery in the third part of its course runs for some dis- 
tance in close contact with the pleura, which, in the effort at detaching the vessel, thus 
incurs great risk of being penetrated, as has, indeed, happened in a considerable number 792 
DISEASES AND INJURIES OF THE ARTERIES. 
of cases. The late Dr. Isaacs, of New York, ascertained that the top of the pleura, or 
that portion which projects above the clavicle, is not always dome-aha| ed, but that it 
occasionally forms cul-de-sacs, extending upwards, and sometimes even laterally into the 
very recesses at the root of the neck. 
If, from any of the above causes, it is sometimes difficult to denude the artery, to convey 
a ligature around it will often be found to be much more so. Indeed, this generally con- 
stitutes the most annoying and embarrassing step of the operation. To facilitate this 
procedure, various mechanical contrivances have been resorted to, some of them so com- 
plicated in their character as to be well calculated to enhance instead of diminishing 
the difficulty. Under ordinary circumstances every indication may be fulfilled with the 
common aneurism-needle, or even with a common eyed-probe. Whatever mechanical con- 
trivance be employed, the ligature, as a general rule, should be passed from before backwards 
and from below upwards, as it will be found much easier in this way to prevent injury to 
the subclavian vein, while there will be no danger whatever of including any of the cords 
of the brachial plexus of nerves. Owing to the great depth of the wound, not a little 
difficulty is sometimes experienced in tightening the knot. In -this case the ingenious 
instrument invented by Dr. Hosack, of New York, will be found very useful. By holding 
the first knot firm, it enables the surgeon to tie a second or third with the utmost facility. 
Notwithstanding the assistance to be derived from the different instruments that have 
been invented for that purpose, such has been the difficulty, in some instances, of convey- 
ing the ligature around the artery as to lead not only to great delay, but almost 
to an abandonment of the operation. It has been suggested under these circumstances, 
to saw through the clavicle, a proposal to which I can see no objection, provided the 
shoulder is so much elevated as to offer an almost insurmountable barrier to the passage of 
the ligature. By this practice, although a compound fracture of the clavicle would be 
superadded, yet this would be of the most simple kind, while the operation, instead of 
occupying from one to two hours,as has repeatedly happened heretofore, could be completed 
in a comparatively short time ; the vessel could be much more effectually secured, the 
risk of wounding the subclavian vein and other important structures would be greatly 
diminished, and the patient would have a much better chance for recovery. 
The great embarrassment that is occasionally experienced in tying the subclavian artery 
for axillary aneurism, is well illustrated in a case that occurred in the hands of Dupuytren, 
in which that celebrated surgeon spent an hour and forty-eight minutes in performing the 
operation, a part of the time, however, being wasted in consequence of the suffering of 
the patient. The man died of hemorrhage at the end of four days, when it was found 
that the ligature included one of the large brachial nerves and only half of the artery, 
which had been perforated with the aneurismal needle. Ramsden tied one of the brachial 
nerves instead of the artery; White included three nerves in his ligature, and Desault 
the greater portion of the brachial plexus. The pleura has been repeatedly wounded, 
and in several cases the aneurismal sac has been penetrated. The subclavian and jugular 
veins are liable to be injured in attempts to secure this artery. 
The subclavian, instead of pursuing its usual course, occasionally passes in front of the 
anterior scalene muscle, its situation being thus rendered comparatively superficial. Of 
this anomaly, I have witnessed not less than five examples in dried preparations. Occa- 
sionally, again, the artery, on the right side, is situated considerably higher up than usual, 
arising, not from the innominate, but from a short, stunted trunk in common with the right 
carotid; while in other cases, it takes its origin from the arch of the aorta, and passes 
behind the oesophagus, lying deeply in the neck, so as to render it difficult to find it, as in 
the celebrated case of Mr. Liston. 
The arteries which are more particularly concerned in maintaining the collateral cir- 
culation after the ligation of this vessel are the suprascapular, transverse cervical, internal 
mammary, long thoracic, circumflex, and subscapular, the first three being branches of the 
subclavian, the other three of the axillary. The thoracic artery frequently arises from 
the aneurismal sac, and is, therefore, liable to be obliterated for some distance in the pro- 
gress of the disease. 
The subclavian artery has been tied several times in the second course of its extent, but 
the procedure is very difficult, as well as replete with danger, owing to the proximity of 
numerous important structures, especially the phrenic nerve, jugular vein, pleura, and 
thyroid axis. The external incisions are similar to those employed for exposing the 
artery in the other parts of its extent; as soon as the anterior scalene muscle is fully 
brought into view, a grooved director is carried behind it, and its lower attachment care- 
fully severed from the first rib, the phrenic nerve having previously been placed beyond 
CHAP. V. LIGATION OF THE SUBCLAVIAN ARTERY. 
CHAP. V. 
the reach of the knife. The top of the pleura, lying close by, must not be wounded in 
passing the needle. It will thus be perceived that tlie operation is one of excessive deli- 
cacy, requiring consummate anatomical knowledge and skill for its successful execution. 
The greatest objection, however, to its performance is that the subclavian is obliged to be 
tied so close to the superior intercostal and deep cervical branches ; a circumstance which 
must necessarily materially interfere with, if not wholly prevent, the formation of a firm 
and adherent clot. 
The manner of exposing and ligating this artery in the first part of its course need not 
be pointed out, since, from the fact that all the cases in which the operation has been per- 
formed have ended fatally, it is questionable whether it should ever be repeated. 
Among the most elaborate statistics of ligation of the subclavian artery are those con- 
tributed to the eighteenth volume of the Transactions of the American Medical Associa- 
tion by Professor Willard Parker, of New York. They comprise 196 cases, of which 
88 were cured, and 107 died, the result in one not being stated. Of 153 cases in which 
the sex is given, 138 were males and 15 females. The right artery was tied in 82, and 
the left in 52 cases, in which the side is noticed. The average date of separation of the 
ligature was the 21st day. In the first portion of its course, it was ligated 13 times, 
without a single recovery ; in the second portion of its course 9 times, with 4 deaths, 
and in the third portion of its course 174 times, with 89 deaths. In their point of 
order, the most frequent causes of death were hemorrhage, exhaustion, pyemia, pleurisy, 
and rupture of the sac. The artery was ligated 57 times, with 21 deaths, for spon- 
taneous axillary aneurism ; 24 times, with 8 deaths, for traumatic axillary aneurism ; 24 
times, with 15 deaths, for spontaneous subclavian aneurism ; 5 times, with 3 deaths, for 
traumatic subclavian aneurism ; and 8 times, with fi deaths, for aneurism of the inno- 
minate artery. In the remaining cases the subclavian artery was ligated for other causes 
than aneurism. 
In the collection of Dr. Koch are comprised 185 cases of ligation of the subclavian 
in the third portion of its course, for all causes. Of these, 100 died, 82 recovered, and 
in 3 the result is not stated. Ligature between the scalene muscles was practised in 12 
cases, of which 7 recovered ; in 9 of the operations, for aneurism, and in 3 for other 
causes. 
Dr. Wyeth’s tables, published in 1877, embrace an analysis of 283 cases of ligature 
of the subclavian artery, all, excepting 32, relating to the third surgical division of its 
course. The sex is given in 202 cases, of which 240 occurred in males, and only 22 in 
females. The right side was affected in 132 cases, and the left in 90 of the 222 cases in 
which these particulars are stated. The greatest number of tin; cases occurred from the 
twentieth to the fortieth year. Of the 283 cases affecting the three surgical divisions of 
the artery, 162, or 57 per cent., proved fatal. Hemorrhage after the operation was 
noticed in 93 cases, in 47 of which it proved fatal. In the majority of cases, in which 
the fact is stated, the ligature came away between the eleventh and twenty-first days ; in 
one as early as the seventh day, and in one as late as the ninety-sixth day. Of 19 cases 
in which the subclavian was tied in its first course not one recovered. Of these cases 13 
were for ligature of the subclavian alone, and 6 of this artery and the carotid on the 
right side. In 8 of the fatal cases the cause of death was hemorrhage. From these 
facts it is evident that, as stated by me in former editions of this work, ligation of this 
portion of the artery for aneurism on the distal side of the ligature is not a safe or 
proper operation. Ligation of the subclavian in the second part of its surgical course, 
behind the scalene muscle, presents 13 cases, of which 4 completely recovered, and 9, 
or 69 per cent., perished. Of the former cases, in one—that of Morton—gangrene seized 
on the extremity, and death was averted by amputation at the shoulder-joint. Of liga- 
tion of the artery in its third division, that is, from the outer border of the anterior 
scalene muscle to the lower border of the first rib, the tables give 251 cases, of which 
134, or 53 per cent., were lost. Of the 117 recoveries, the great majority were complete. 
Tn gunshot and other wounds of the subclavian artery, considered as a whole, the only 
safe procedure is ligation of the injured vessel at both ends. Experience has proved that, 
if the artery be tied in its continuity, death from hemorrhage is inevitable. 
In a case reported in 1868, by Mr. Turner, of Brighton, that gentleman tied success- 
fully both subclavian arteries, at an interval of two years, for axillary aneurism. 
The subclavian is occasionally tied for wounds of the axillary artery. Mr. Guthrie 
refers to 22 cases in which it was secured for this purpose, 11 times above the clavicle, 
and 11 times below. Of the former cases, 9 recovered, and two died ; death in one being 
caused by the bursting of an internal aneurism, and in the other by gangrene after 794 
DISEASES AND INJURIES OF THE ARTERIES. 
chap. v. 
amputation at the shoulder-joint. Of the 11 eases in which the artery was tied below 
the clavicle, 6 recovered, and 5 perished, three from gangrene of the limb, one from 
exhaustion, and one from hemorrhage. During our late war this vessel was secured 
above the clavicle, for a similar object, 17 times, with 2 recoveries; 13 times after 
amputation at the shoulder-joint, of which 9 perished ; and twice, with one cure, for 
secondary bleeding after excision of the humerus. Of 66 cases of ligation of the third 
portion of the subclavian for hemorrhage from gunshot and other wounds, analyzed by 
Dr. Wyeth, 19 recovered, and 47 died. 
LIGATION OF THE VERTEBRAL. 
The vertebral artery is usually the first largest branch of the subclavian, and always 
bleeds profusely when divided, as it occasionally is in wounds of the neck. Taking 
the opening as the guide, the vessel should be traced to the seat of injury, and a liga- 
ture applied to each extremity. The dissection necessary for its exposure should be 
conducted with the greatest caution, on account of the important and complex relations 
which the vertebral sustains to the surrounding parts. The best guide to the seat 
of the vessel is the transverse process of the sixth cervical vertebra, situated about two 
inches above the clavicle, and usually known as the carotid tubercle. The artery will be 
found just below this prominence, deep in the wound, and at the inner side of the anterior 
scalene muscle. 
A case has been reported by Maisonneuve in which he tied successfully the vertebral 
artery, together with the inferior thyroid, below the sixth cervical vertebra, on account 
of a gunshot wound, lie carried his incision along the anterior edge of the sterno- 
cleido-mastoid muscle, and exposed the sheath of the common carotid artery, which 
was then carefully held aside while he denuded and secured the injured vessels. Nuntianti 
Ippolito has related two cases in which the vertebral artery was successfully tied at its 
origin. Dr. Smyth, of New Orleans, successfully tied this vessel for secondary hem- 
orrhage after ligation of the innominate and carotid ; and Professor Parker secured it 
simultaneously with the carotid and subclavian for subclavian aneurism, but the patient 
died of hemorrhage. Dr. Alexander, of Liverpool, has recently recorded six success- 
ful examples of ligation of the left vertebral artery for epilepsy, in one of which the 
common carotid was simultaneously tied, and in another the internal carotid was con- 
secutively ligated. 
When the vertebral artery is laid open in such a manner as to render its ligation 
impracticable, the hemorrhage may sometimes be promptly and effectually arrested by 
means of a graduated compress, as in an interesting case treated by Professor Warren 
Stone, of New Orleans. 
LIGATION OF THE INTERNAL MAMMARY. 
No instance has been reported, so far as I am aware, of spontaneous aneurism of this 
artery, but of the traumatic form of the lesion an example has been related by Demon- 
tegre as having occurred in a man seventy-six years of age, from the thrust of a sabre. 
The tumor was two inches in length. 
The internal mammary artery is sometimes cut across in gunshot injuries, and it is not 
unlikely that it might be opened in a bad fracture of the sternum and of the ribs. How- 
ever this may be, the proper way to secure it, in the event of hemorrhage, is to follow 
the track ot the wound, enlarging it freely, if necessary. The artery with its two veins 
will be found, in the early part of its course, about three lines from the edge of the 
sternum, in front ot the triangular muscle, which separates it from the pleura. It may 
readily be reached in the three upper intercostal spaces by a vertical incision, two inches 
and a half in length, carried in the direction just indicated, successively through the 
superficial fascia, skin, pectoral, and intercostal muscles ; the deep structures must be 
divided with great care upon a grooved director, and the artery cautiously separated from 
its satellite veins. The pleura must not be interfered with. Below these points the 
operation will be very difficult, if not impracticable, on account of the great narrowness 
of the intercostiil spaces. In case of emergency, the only feasible plan would be to cut 
away one of the costal cartilages. LIGATION OF THE AXILLARY ARTERY. 
795 
CHAP. V. 
LIGATION OF THE INFERIOR THYROID. 
The inferior thyroid has been repeatedly tied for hemorrhage and for the cure of goitre. 
In wounds of the neck, involving this vessel, the ligation is, in general, easily effected 
simply by enlarging the existing opening in the direction of the part whence the blood 
issues; but when there is no such guide, the operation is usually one of considerable diffi- 
culty, requiring nice anatomical knowledge and careful dissection. 
The inferior thyroid artery, in the first part of its course, ascends a little, and then 
inclines inwards, passing behind the great vessels and nerves of the neck. The easiest 
way of exposing it, when there is no wound, is to make an incision along the inner border 
of the sterno-eleido-mastoid muscle, as in the operation for tying the primitive carotid, the 
sheath of which should be drawn carefully outwards. The artery will be found to cross 
over towards the thyroid gland, opposite, in most cases, to the fifth cervical vertebra, and 
may readily be encircled with a common aneurism-needle. Care must be taken not to 
injure the sympathetic, recurrent, and hypoglossal nerves. On the left side the artery 
lies in close contact with the oesophagus and thoracic duct. 
LIGATION OF THE AXILLARY. 
Deligation of the axillary artery was first performed by Mr. Richard Chamberlaine, of 
Jamaica, in 1815. The operation is required chiefly on account of penetrating wounds 
of the chest, secondary hemorrhage after amputation at the shoulder-joint, or the acci- 
dental laceration of the vessel during the reduction of ancient dislocations. Of the latter 
occurrence, a number of cases have been reported by surgical writers. There are two 
regions where the artery may be secured, either just below the clavicle, or in the hollow 
of the axilla. In the intermediate point it is so deeply situated, and is in such intricate 
relations as to render its approach very difficult. 
As the artery in the first of these regions is very deep-seated, it has been advised, 
instead of tying it, to ligate the subclavian in the third stage of its course. Cases, how- 
ever, occur, in which it is desirable to secure it soon after its origin, and this may gen- 
erally be done without any difficulty, provided the surgeon is sufficiently cool and collected, 
and has a thorough knowledge of the anatomy of the parts. The patient being placed in 
a half-sitting posture, with the arm slightly abducted, an incision is carried along the 
inferior border of the clavicle, through the skin and platysma-myoid, commencing one 
inch from the sternum, and extending to within a short distance of the deltoid muscle, 
care being taken to avoid the cephalic vein, as it lies in the groove between the latter and 
the great pectoral. The next step consists in dividing the fibres of the great pectoral to 
the full extent of the external wound. The 
small pectoral is now seen at the lower por- 
tion of the wound, and should be relaxed by 
bringing the arm close to the trunk. A re- 
tractor being inserted, and the divided struc- 
tures well depressed, the artery will be found 
at a short distance below the clavicle in- 
vested by a dense fascia, which must be care- 
fully scraped through before the vessel can 
be fairly exposed to view. The accompany- 
ing vein, which often swells suddenly cut 
during expiration, lies below and in front of 
it, while the brachial plexus is behind, ex- 
cept one of its branches, which is above and 
in contact with it. The anterior thoracic 
artery, one of the offsets of the axillary, is also on its anterior surface. The needle is 
passed from within outwards, in order to exclude the vein. As difficulty is sometimes 
experienced in distinguishing the artery from the cords of the axillary plexus of nerves, 
it will be well, before tightening the thread, to ascertain what effect its application has 
upon the pulse at the wrist, or upon the aneurismal sac. The costo-coracoid ligament 
sometimes requires division in this operation. The anatomical relations of the artery are 
well shown in fig. 350, from Erichsen. 
Instead of cutting through the substance of the great pectoral muscle, the artery may 
easily be exposed by carrying the incision along the groove between its two bellies, com- 
mencing about one inch external to the sterno-clavicular joint, and extending outwards 
Fig. 350. 
DiagramofLeftAxHlarybelowclavi.de a. Axillary 
artery giving off thoracico-acromial. v. Axillary vein 
receiving the cephalic, n. Brachial plexus of nerves. 
The great pectoral muscle is cut across. 796 
DISEASES AND INJURIES OF THE ARTERIES. 
CHAP. V. 
and downwards, for at least three inches and a half, in the direction of the insertion of the 
muscle. If, upon separating the two bellies, it be found that there is not sufficient room, 
the upper one should be divided perpendicularly as far as the collar-bone. The artery has 
sometimes been tied in the first part of its course, as in the cases of Desault and Roux, by 
simply separating the pectoral and deltoid muscles, without any division of their substance. 
To expose the artery in its inferior section, fig. 351, from Bryant, the arm should be 
abducted and supinated, and an incision, nearly three inches in length, made through the 
Fig. 351. 
Ligation of the Axillary Artery. 
axilla, close to the border of the broad dorsal muscle. The connective and aponeurotic 
structures being next divided, the median nerve and axillary vein will be brought into 
view, the two roots of the former embracing the artery on each side, and the latter run- 
ning along its anterior surface. Cautiously separating these with the finger, or the forceps 
and director, and turning them in opposite directions, the artery is exposed, and tied by 
passing the ligature from within outwards. 
It is barely possible that the axillary artery might require ligation in its second course, 
as it lies under cover of the small pectoral muscle. If so, the muscle should be divided 
about three-quarters of an inch from its attachment to the coracoid process. The great 
objection to the operation is, not the depth of the artery in this situation, but the difficulty 
of separating it from the axillary plexus of nerves, and tin; close proximity of the ligature 
to the origin of the thoracic vessels, thus embarrassing the formation of a firm clot. 
Of If) cases of ligation of the axillary artery for gunshot wounds during the War of the 
Rebellion only 3 were successful. 
LIGATION OF THE BRACHIAL. 
The brachial artery, in consequence of wounds and various kinds of traumatic aneurisms, 
requires to be ligated more frequently than any other artery in the body. Extending from 
the lower border of the axilla, on a level with the tendon of the teres muscle, to nearly 
one inch below the bend of the elbow, it is overlapped above by the coraco-brachial muscle 
and in the middle by the two-headed flexor, while inferiorly it is completely covered by a 
reflexion of the brachial aponeurosis. Its whole course, however, is comparatively super- 
ficial, so that it is easy to feel its pulsations in the greater portion of its extent. In 
attempting to secure the artery high up, near its origin, an incision, two inches and a half 
in length, should be made along tlie inner margin of the coraco-brachial muscle, the limb 
being extended and supinated with the forearm in a state of partial flexion. The artery, 
accompanied by its two veins, lies here between the median and ulnar nerves, the former 
being on its outer side, and the latter on the inner. If the artery is sought for at the 
middle of the arm, the best guide to its seat will be the ulnar edge of the two-headed 
flexor muscle. The median nerve, in this part of the course of the artery, is usually on 
the inside and in front of the vessel, as in fig. 352, from Bryant. At the bend of the arm, 
the brachial is readily exposed by dividing the brachial aponeurosis in a line with the 
ulnar border of the tendon of the two-headed flexor muscle, as in fig. 353, also from 
Bryant. In none of these operations is it necessary to divide any muscular fibres. CHAP. V. 
LIGATION OF RADIAL, ULNAR, AND PALMAR ARTERIES. 
797 
In operating upon the brachial artery, it should be borne in mind that this vessel is 
subject to certain varieties, which may serve both to perplex the surgeon, and mar the 
result of the undertaking. The most frequent of these anomalies is the high division of 
Fig. 352. 
Ligation of Brachial Artery. 
the artery into the radial and ulnar, which, on reaching the elbow, either pursue their 
usual course, or, as is more generally the case, the former proceeds superficially down the 
forearm, while the latter becomes deep-seated ; or their course may be reversed, the radial 
following its ordinary route, while the ulnar descends immediately under the skin. Sev- 
Fig. 353. 
Ligation of Brachial Artery. 
eral instances have been met with in which the brachial divided high up into two branches, 
which subsequently united into a single trunk, which afterwards bifurcated regularly into 
the radial and ulnar. 
During the War of the Rebellion the brachial artery was ligated for hemorrhage con- 
sequent upon gunshot injuries 7f> times, with a result of 5o recoveries and 21 deaths. In 
9 cases consecutive amputation was practised, and only 3 recovered. 
LIGATION OF THE RADIAL, ULNAR, AND PALMAR ARTERIES. 
The radial artery, whose course along the forearm is indicated by a line drawn from 
the middle of the bend of the elbow to the forepart of the styloid process of the radius, 
may be tied near its origin, at its middle, and at its inferior extremity. When the design 
is to ligate it above, or in the first of these situations, it may be approached by an incision, 
about three inches in length, parallel to the inner border of the long supinator muscle, 
between which and the rotmd pronator the vessel will be found, accompanied by its two 
veins, the radial branch of the musculo-spiral nerve lying at its outer side, and some dis- 
tance from it. Care is taken not to wound the basilic vein. In the middle third of the 
forearm, the artery lies between the long supinator and flexor muscle of the carpus, the 
radial nerve descending close along its radial border, as in fig. 3.34, from Bryant. In the 
inferior portion of its extent, the artery is comparatively superficial; its pulsation is very 
distinct in the greater part of its length, and thereby serves as a ready guide to its course. 
The artery, as it lies upon the back of the carpus, underneath the tendons of the extensors 798 
DISEASES AND INJURIES OF THE ARTERIES. 
chap. v. 
of the metacarpal bone and first phalanx of the thumb, is easily reached by an oblique, 
transverse, or longitudinal incision. It is accompanied by two veins. 
The ulnar artery is sometimes divided in the upper part of its extent by a knife or ball, 
and may then generally be easily found by taking the wound as our guide, enlarging it, 
if necessary, and tying the vessel at each extremity. When a false aneurism exists in 
this situation, it is usually recommended to ligate the brachial, but I am satisfied that it 
Fig. 3134. 
Ligation of Radial Artery. 
would be more safe, in every instance, to tie the ulnar soon after its origin, by cutting 
boldly through the thick muscular mass at the upper third of the forearm, as we could 
thus effectually guard against hemorrhage from the recurrent circulation. In the middle 
of the limb the artery lies along the radial border of the ulnar fh*xor of the carpus, which 
should, therefore, he taken as a guide to the knife, and he carefully separated from the 
common flexor of the fingers. The ulnar nerve here lies on the inner side of the vessel. 
Near the wrist the artery is generally found with facility, its situation being indicated by 
its pulsation. 
During the War of the Rebellion the ulnar artery was ligated 10 times, with 3 deaths, 
and the radial artery 20 times, with 4 deaths. 
Ligation of the palmar arteries is rendered necessary incase of external injury, and can 
only be successfully effected by enlarging the wound freely upon a grooved director. This 
should always he done as early as possible, before the supervention of swelling, which 
greatly increases the difficulty. When the parts are much obscured, acupressure will 
sometimes arrest the bleeding more readily than the ligature. 
The superficial palmar artery, forming what is called the palmar arch, is the continua- 
tion of the ulnar artery, and lies, at its commencement, on the annular ligament of the 
wrist, and then on the tendons of the superficial flexor of the fingers, in close relation 
with the divisions of the median and ulnar nerves. It is covered near the inner border 
of the hand by the short palmar muscle, and afterwards by the palmar aponeurosis and the 
integument. At the thumb it inosculates with a small branch of the radial artery. The 
deep palmar artery arises from the ulnar artery at the origin of the palmar arch, a little 
beyond the pisiform bone, and, passing forward under cover of the short flexor of the little 
finger, unites with the palmar termination of the radial artery, thereby completing, as 
stated by Quain and Sharpey, the deep palmar arch. 
LIGATION OF THE ARDOMINAL AORTA. 
Ligation of the abdominal aorta may be required on account of a wound, either of itself 
or of the common iliac, and in that event the best plan would probably be to enlarge the 
external opening to an extent sufficient to encircle the vessel with the thread. In ligating 
the vessel for aneurism, the patient should lie on his right side, and care should be taken 
to avoid injury to the peritoneum, which can easily be done by adopting the procedure of 
Dr. Murray, since followed by Monteiro and South, of making a curvilinear incision with 
the convexity towards the vertebrae, from an inch above the anterior superior spinous 
process of the ilium to the cartilage of the tenth rib, as in fig. 355, from Bryant. It 
should be fully six inches in length, and should extend, in the first instance, merely 
through the common integument. 1 he various underlying structures should then be sev- 
erally divided until the peritoneum is brought into view, which is cautiously peeled off 
from the iliac and psoas muscles with the hand a short distance beyond the contemplated 
point of ligation. I he separation of the aorta from its accompanying vein on the right LIGATION OF THE COMMON ILIAC ARTERY. 
799 
CHAP. V. 
side, and the filaments of the sympathetic nerve in front, constitutes one of the greatest 
difficulties of the operation, and is generally best effected with a long director, slightly 
Fig. 355. 
Ligation of the Aorta. 
sharp at the extremity, and the nail of the index finger. The ligature should be passed 
around the artery from left to right, and from behind forwards, about one inch above its 
bifurcation into the common iliacs. 
LIGATION OF THE COMMON ILIAC. 
The common iliac artery was first ligated by Dr. William Gibson, of this city, in 1812, 
in a case of gunshot wound. Ilis patient died in thirteen days, of peritonitis and second- 
ary hemorrhage. In 1827 it was tied, for the first time, for aneurism, by Dr. Mott. The 
disease occupied the external iliac artery; the ligature came away on the nineteenth day; 
and in less than two months the man was entirely well. 
This artery has been secured 65 times, with a result of 14 recoveries and 50 deaths, 
the issue in 1 being unknown ; 36 of the operations were for aneurism, of which 10 were 
successful, and 25 died,'the result being undetermined in 1 ; 16 were practised for hemor- 
rhage, with 15 deaths; 4 were for malignant pulsating tumors, of which 3 died; 2 were 
for arterio-venous aneurism of the external iliac artery and vein, and both were fatal; 1 
was for anastomotic aneurism, and the patient, a 
child six weeks old, recovered ; and in 6 the nature 
of the disease is unknown, but 5 died. The mor- 
tality of the procedure, based upon 64 cases in which 
the result is known, is, therefore, 78.15 per cent. 
Three fatal cases occurred in the army during our 
late war. 
Ligation of the common iliac, fig. 356, is far from 
being an easy operation, especially in case of aneu- 
rism, attended w ith a large tumor and morbid adhe- 
sions of the peritoneum. The patient lying on his 
back, with the thighs somewhat relaxed, a slightly 
curvilinear incision is made along the lower part of 
the abdomen, about half an inch above Poupart’s 
ligament, commencing at the external ring and 
passing upwards and outwards a short distance be- 
yond the anterior superior spinous process of the 
ilium, its length varying from five to seven inches, 
according to the exigencies of the particular case. 
The operator should, in every instance, give himself 
an abundance of room. The first cut extends merely 
through the skin and superficial fascia. The other 
Fig. 356. 
Ligation of the Common Iliac. 800 
DISEASES AND INJURIES OF THE ARTERIES. 
chap. v. 
structures, beginning with the aponeurosis of the external oblique muscle, are then sever- 
ally divided upon the director down to the peritoneum, more and more caution being 
observed in proportion as we approach the deeper parts. The serous membrane is now 
gently and slowly detached, by means of’ the finger, from the aneurism and other textures, 
as high up as the necessities of the case may demand. The artery being thus denuded, 
is next isolated from the accompanying vein, and the thread deposited by passing the 
needle from within outwards, above the middle of the vessel. The different steps of the 
operation will be greatly facilitated if the patient has previously taken an active cathartic, 
to unload the bowels. Care must be employed not to wound the spermatic cord. 
From numerous trials upon the dead subject, I)r. Stephen Smith advises, as the easiest 
and safest method of approaching the vessel, that an incision be made extending from near 
the anterior extremity of the eleventh rib to within a few lines of the internal ring, with 
a sharp curve inward of one inch. It will thus pass about an inch and a half within the 
anterior superior spinous process of the ilium, and be about seven inches in length. The 
curve at the lower extremity of the wound will allow the most perfect freedom in the 
elevation of the peritoneum, and the complete exposure of the artery. 
In a case reported by Professor Sands, of New York, in 1881, the incisions were made 
directly down to the artery, through the peritoneum in the linea alba. The operation, 
wdiich was performed with the carbolized catgut ligature under antiseptic precautions, was 
followed by gangrene of the foot and leg, requiring subsequent amputation of the thigh. 
Notwithstanding these untoward occurrences, the intemperate habits of the patient and 
a syphilitic taint of the system, complete recovery took place. 
The primitive iliac arteries extend from the cartilage between the fourth and fifth 
vertebne to the sacro-iliac symphyses, diverging from each other as they descend at a 
somewhat acute angle, their point of commencement being nearly one inch and a half 
below the umbilicus. Each rests on the spine and psoas muscle, and is crossed anteriorly, 
at its bifurcation, by the ureter. On the right side, the accompanying vein lies, above, 
behind and external to it, while, lower down, a portion of the vein appears on the inner 
side; on the left side, the vein passes along the inner side of the artery, both vessels being 
placed under cover of the sigmoid flexure of the colon. The course of the artery is indi- 
cated by a line extending from the umbilicus to Poupart’s ligament, a little nearer to the 
pubes than to the ilium. 
The length of the common iliac artery is generally about two inches, from which it 
varies from less than twelve lines as the minimum to three inches and a half as the 
maximum, depending, as has been shown by Mr. Luther Ilolden, either uj>on a high 
division of the aorta, or a low division of the common iliac, or both. It is often short in 
tall men, and conversely. Both vessels are usually of the same length. 
LIGATION OF THE INTERNAL ILIAC. 
The ligation of the internal iliac has now been practised twenty-six times, the operators 
having been Altmiiller, Arendt, Atkinson, Bigelow, Cianflone, Coluzzi, Galozzi, Iliggin- 
son, Kasinski, Kimball, Landi, McKee, McLean, Morton, V. Mott, A. B. Mott, Oeverent, 
Porta, Stevens, Syme, Thomas, Thompson, Torracchi, Tripler, and White, the remaining 
case having occurred in Bellevue Hospital. It was first performed by Dr. Stevens, of St. 
Croix, in 1812, upon a negress, for what was supposed to be an aneurism of the gluteal 
artery, but which was found, on dissection, three years afterwards, to have arisen from 
the sciatic. The tumor had originated spontaneously, and was, at the time of the opera- 
tion, ot the volume of a child’s head. Of the 26 cases, 8 terminated successfully, and 18 
fatally, a result which need not create surprise when wre take into consideration the great 
depth at which this vessel is situated, the injury that must necessarily be inflicted upon 
the surrounding parts in exposing it, and the exceedingly unfavorable character of most 
ot the cases themselves prior to the operation. The artery, moreover, is very short and 
disproportionately large, being generally less than two inches in length ; it is, besides, 
in intimate relation with various important structures, thus rendering it extremely difficult 
of access. Thus, it lies on the internal iliac vein, which, however, on the right side, 
projects from underneath it over its outer edge ; it is crossed above by the ureter, and is 
overhung by the bladder, while that on the left side lies immediately behind the rectum. 
Close by are the sacro-lumbar and obturator nerves, the latter, along with the external 
iliac vein, running in the angle which separates the internal from the external iliac artery. 
I he manner ot exposing the artery is the same as in ligating the common iliac. Dr. CHAP. V. 
LIGATION OF THE GLUTEAL ARTERY. 
801 
White, of Hudson, who tied this vessel successfully in 1827, for gluteal aneurism, made 
a semicircular incision on the side of the abdomen, with its convexity to the ilium, seven 
inches in length, commencing two inches to the left of the umbilicus, and terminating 
close to the external ring. It is not necessary, however, I conceive, to carry the incision 
so far inwards, as the object may be just as well attained by the other procedure, and with 
less risk of bad consequences. The peritoneum is carefully raised with the tingers, and 
it is worthy of notice that the membrane, as it is being peeled off', invariably carries with 
it the ureter, thus placing this duct completely beyond the reach of the ligature. The 
fascia investing the artery is scraped away with the nail or handle of the scalpel, and, 
taking the precaution of avoiding the external iliac vein, as it lies in the angle between 
the internal and external iliac arteries, the surgeon deposits the ligature by passing the 
needle from within outwards. 
When the internal iliac artery is very short, or the pelvis unusually small, so as to 
render the ligation of the vessel very difficult, it would be more prudent to secure the 
common trunk ; the procedure would be attended with less violence to the parts, and with 
less risk of peritonitis and secondary hemorrhage. 
The most common cause of death after this operation is secondary hemorrhage, of which 
one of the patients perished within the first twelve hours. In Mott’s case, a successful 
one, the peritoneum was opened. One of the difficulties of this operation, is the separa- 
tion of the iliac artery from its accompanying vein. The circulation, after the application 
of the ligature, is carried on mainly by the lumbar and sacro-lateral branches. 
LIGATION OF THE GLUTEAL. 
The gluteal artery has been repeatedly ligated on account of hemorrhage and traumatic 
aneurism, as, for example, in the famous case of Mr. John Bell, where, to use his own 
hyperbolical language, the incision was upwards of a foot and a half in length. In ex- 
posing the vessel for the relief of hemorrhage, the surgeon is necessarily obliged to take 
the external wound as his guide, enlarging it, if possible, in the direction of the muscular 
fibres, and giving himself an abundance of room, especially if the artery is divided just as 
it emerges from the saero-sciatic notch. It must be remembered that the vessel is accom- 
panied by a vein and nerve, which must be carefully excluded from the ligature. If the 
artery is cut off close, it may be necessary to pass the thread with a curved needle, and 
to include in the*noose some of the surrounding tissues, as it will probably be impractica- 
ble to raise it with the tenaculum. 
In case,of traumatic aneurism of this artery, most writers recommend the ligation of 
the internal iliac; but, when we remember the difficulties and dangers of this operation, 
and the probable occurrence of peritoneal inflammation and of secondary hemorrhage, it 
seems to me that it would be better, in every respect, to cut down upon and tie the gluteal 
itself. The operation, will, of course, be bloody and formidable, but skill, boldness, and 
promptness may accomplish much, even in a ca>e like this, especially when everything is 
well ordered beforehand, and the assistants are properly instructed in their respective duties. 
The incision, made in the direction of a line extending from the posterior superior spinous 
process of the ilium to a point midway between the tuberosity of the ischium and the 
great trochanter, must be at least eight inches in length, and should be carried at one 
stroke down into the aneurismal sac, the contents of which should then be turned out, and 
the artery instantly secured, as it lies towards the upper part of the wound. 
When ligation is impracticable, on account of the great shortness of the artery, the 
hemorrhage may sometimes be effectually arrested by means of a graduated compress, 
thrust into the bottom of the wound, previously cleared of clots, and firmly bound down 
by a roller carried around the thigh and pelvis. 
In a case of traumatic aneurism of the gluteal artery, in a boy, fourteen years of age, 
Professor Campbell, of Montreal, in 1862, secured this vessel at the upper and anterior 
portion of the sciatic notch, without opening the tumor. Some difficulty was experienced 
in passing the ligature, but as soon as this was tied all pulsation in the sac ceased, and a 
rapid recovery was the consequence. 
In 1834, Mr. Richard Carmichael, of Dublin, reported a case of wound of the gluteal 
artery in a youth, seventeen years of age, in which he made an incision, five inches in 
length, into the sac of the aneurism, turned out from one to two pounds of coagulated 
blood, and ligated the vessel, the patient making a rapid recovery. In a similar case, 
Mr. Syrne, after having evacuated the contents of the tumor, passed a double thread under 
the artery, and tied it on both sides of the wound, the bleeding of which was effectually 802 
DISEASES AND INJURIES OF THE ARTERIES. 
controlled by the pressure of the finger. The operation was completely successful. In 
1877, Mr. Edward L. Hussey, of Oxford, tied the large descending branch of the gluteal 
artery on account of an aneurism, the result of a punctured wound. The sac was laid 
open by a large incision. Death occurred on the sixteenth day from secondary hemor- 
rhage. Of live cases of ligation of the gluteal artery for hemorrhage during the War of 
the Rebellion, two recovered, and three died. 
LIGATION OF THE SCIATIC. 
The sciatic artery is also liable to be injured, either by sharp-pointed bodies penetrating 
the gluteal region, or by falls upon the buttock in which the vessel is laid open by a 
splinter of bone around which it passes as it proceeds forwards. It is situated under the 
great gluteal muscle, at first posterior and then internal to the great sciatic nerve, and 
winds around the spinous process of the ischium, near its root, behind the muscles which 
are inserted into the intertrochanteric line of the femur. It may be exposed by making 
a similar incision, as in the preceding case, but about an inch and a quarter lower down. 
When the operator is in doubt as to which artery is implicated, whether the sciatic or 
gluteal, the incision should be made as nearly as possible in the intermediate space. 
The sciatic artery has been tied, in at least one instance, for an aneurism seated upon 
its own trunk, Dr. Dugas, of Georgia, being the operator. Owing, however, to secondary 
hemorrhage, caused, apparently, by the patient’s own imprudence, the common iliac had 
to be secured at the end of a week, when the man was almost moribund from the loss of 
blood. Death occurred four days afterwards. Both of the cases in which this vessel was 
tied, during our late war, died. 
LIGATION OF THE EXTERNAL ILIAC. 
Ligation of the external iliac artery was first practised by Mr. Abernethy, in 1796, in 
a case of aneurism of the femoral artery, which he had previously tied at the distal side 
of the tumor; but severe hemorrhage coming on some time after, he found it necessary 
to apply a ligature above the swelling. The operation, however, failed ; and it was not 
until 1806, after two other attempts, 
that his efforts were finally crowned 
with success. In this country it was 
first performed by Dr. Dorsey, of this 
city, in 1811, in a case of inguinal 
aneurism. 
There are several methods in vogue 
for exposing this artery and encircling 
it with a ligature, each of which has 
its advantages and disadvantages, al- 
though the results have perhaps not 
essentially varied in any. That of 
Abernethy, slightly modified, shown in 
fig. 357, from Erichsen, is, perhaps, 
the most unexceptionable. It consists in 
making a curvilinear incision, with the 
convexity downwards, along the in- 
ferior portion of the abdomen, com- 
mencing about an inch and a half 
above Poupart’s ligament, just outside 
of the external ring, and terminating 
on a level with the anterior superior 
spine of the ilium, about two inches on 
the inner side of this process. Its length should be from three inches and a half to four 
inches, according to the size of the tumor and the stature of the patient. The first cut, 
extending through the skin and superficial fascia, will probably sever a few little arteries 
that should be tied before proceeding any further. The aponeurosis of the external 
oblique muscle is now in sight, and should be divided upon the director. Then comes 
the internal oblique muscle, next the transverse muscle, and, finally, the transverse fascia, 
i< adily recognized by its opaque, whitish appearance. A small hole having been scratched 
into this membrane with the nail or scalpel, it is slit open to the full extent of the outer 
CHAP. V. 
Fig. 357. 
Ligation of the External Iliac by Abernethy’s Operation, 
modified. CHAP. V. 
LIGATION OF THE EXTERNAL ILIAC ARTERY. 
803 
wound. The next step, and one of the most delicate of all, consists in gently and cau- 
tiously detaching the peritoneum from its connections in the iliac fossa ; an operation which 
is often attended with considerable difficulty on account of the morbid adhesions. The 
iliac artery will now be felt pulsating at the bottom of the wound, having the anterior 
femoral nerve at its outer side and on a somewhat deeper plane, and the iliac vein at first 
behind, but afterwards, near Poupart’s ligament, internal to it. The sheath of the artery 
is now carefully penetrated, when the instrument bearing the ligature is gradually insinu- 
ated around the vessel from its inner side, this procedure being found best to avoid injury 
to the vein. The course of the artery is indicated by a line extending from the umbilicus 
to a point midway between the pubic symphysis and the anterior superior spinous process 
of the ilium. 
Arendt has placed upon record a case in which he successfully tied both the external 
iliacs in the same patient after an interval of only eight days. In a similar case in the 
hands of Mr. Tait, of London, the interval was upwards of eleven months; and in another, 
in the practice of Dr. Watson, of Glasgow, the interval was nearly nine months. Mr. 
Newbiggin, in a remarkable instance, by tying the external iliac artery, cured both an 
inguinal and a popliteal aneurism at the same time. 
There are several circumstances worthy of attention in connection with the ligation of 
the external iliac. In the first place, the ligature should, if possible, be placed around 
the vessel about its middle, which will be nearly two inches above Poupart’s ligament, the 
artery being usually from three inches and a half to four inches in length. If the liga- 
ture is applied low down, near to the origin of the epigastric artery, there may not be suffi- 
cient room for the formation of a eoagulum, and the patient may perish of secondary 
hemorrhage, as happened in a case recorded by Beclard. 
Secondly, if the transverse fascia be not properly divided there will be danger in peel- 
ing off the peritoneum of detaching the iliac fascia along with it, and so dragging the 
artery out of its normal position to such an extent as to cause, perhaps, serious embarrass- 
ment in finding it. 
Thirdly, care must be taken not to wound the peritoneum. I have witnessed several 
instances in which it was separated with immense difficulty, on account of the great firm- 
ness with which it adhered to the aneurismal sac, from the effects of plastic deposits. In 
a case of Dr. Wright Post, of New York, the membrane was so much thickened and 
altered by disease that he found it impossible to detach it, and was consequently obliged 
to make an opening into it in order to admit the ligature. Both in this case and in one 
in the practice of Mr. Tait, the patient recovered. 
Fourthly, no little difficulty is occasionally experienced in separating the artery from 
its accompanying vein, owing to their naturally firm union, which is often greatly increased 
by disease. The object is most easily attained with a grooved director slightly sharpened 
at the extremity. In passing the ligature, care must be taken not to include the genital 
branch of the femoral nerve. 
Fifthly, should the external iliac be found to be too much diseased, or the tumor so 
large as to overlap the greater portion of the artery, as it may when the sac extends up- 
wards beneath Poupart’s ligament, it will be easy to ligate the common trunk simply by 
enlarging the wound, especially at its upper angle. 
Sixthly, the manipulations will be greatly facilitated if the patient’s bladder and bowels 
are well evacuated a short time previously to the operation. 
Seventhly, the ligation of this artery is sometimes rendered very difficult on account 
of the presence of an inguinal hernia, as in a case in the practice of Mr. Morgan, of Lon- 
don. Should such a contingency arise, unusual caution must be exercised, otherwise the 
bowel may be opened. 
Lastly, the wound made in the operation should in this, as in the ligation of the other 
pelvic arteries, be sewed up carefully from the bottom, by carrying the needle close down 
to the peritoneum ; in other words, the muscular and integumental lips should be tacked 
together separately, the object being the production of firm union, so that there may be no 
risk of hernia when the patient begins to set up and walk about. 
The tables of Dr. Norris and Dr. Cutter show that this vessel has been tied for all 
causes 153 times, with 47 deaths, 17 having perished of gangrene, 3 of sloughing of the 
sac, 9 of hemorrhage, 5 of peritonitis, 3 of exhaustion, 2 of tetanus, and the remainder 
of various other affections. During our late war our army surgeons had 16 deligations 
of this artery, with only 2 recoveries. 
This artery is sometimes tied on account of external injury. The operation, however, 
is seldom successful, owing to the violence inflicted upon the peritoneum. In a case of 804 
DISEASES AND INJURIES OF THE ARTERIES. 
wound from an accidental stab, in a lad seventeen years of age, the bleeding was tempo- 
rarily arrested by compresses, until Velpeau placed a ligature around the vessel. The 
patient made a speedy recovery. 
After the ligation of the external iliac, the collateral circulation is maintained chiefly 
by the anastomosing branches of the gluteal, sciatic, obturator, and pudic arteries with 
the circumflex and deep branches of the femoral. 
LIGATION OF THE EPIGASTRIC. 
The epigastric artery is occasionally wounded, either accidentally or in operating for 
hernia, tapping the abdomen, or ligating the iliae. The vessel, although small, may give 
rise to fatal hemorrhage, the more readily as the bleeding is generally insidious and deep- 
seated, and it should, therefore, be secured without delay. To do this, an incision, about 
two inches in length, is made just above, and parallel to, Poupart’s ligament, in a line 
corresponding with its centre, cautiously dividing the parts until the artery is reached, as it 
lies between the transverse fascia and peritoneum. It is accompanied by two veins, which 
must be carefully excluded from the ligature. The artery arises on the inner side of the 
external iliac, about three lines above Poupart’s ligament, and ascends inwards just within 
the inner border of the internal ring, where the deferent duct hooks around it on its way 
to the inguinal canal. Should the vessel be cut off close to the external iliac, it might 
become necessary to cast the thread round this artery instead of the epigastric. 
LIGATION OF THE CIRCUMFLEX ILIAC. 
The circumflex iliac artery, given off by the external iliac, usually a little lower than 
the epigastric, is sometimes wounded, and may, from its large size, cause embarrassing, if 
not fatal, hemorrhage. It may be secured, in the first part of its course, in the same 
manner, very nearly, as the epigastric, the incision being made close to, and parallel with, 
Poupart’s ligament, its centre being opposite the internal ring. Further out, it may be 
exposed by dividing the tendon of the external oblique muscle within half an inch of the 
margin of the ilium, where it is firmly bound down by the transverse fascia. 
LIGATION OF THE COMMON FEMORAL. 
The common femoral artery begins on a level with Poupart’s ligament, and terminates 
from an inch and a half to two inches below in the superficial and deep femoral, the former 
being its direct continuation. The vessel, in all this course, is perfectly superficial, being 
covered merely by the skin, fascia, and aponeurosis; it is involved, however, in a num- 
ber of lymphatic glands, which, when enlarged, may receive the pulsation of the artery, 
and so simulate aneurism. The femoral vein lies on the inside of the vessel, in the same 
sheath, and great care is required in separating it previously to passing the ligature. The 
femoral nerve lies external to the artery, and is, therefore, not endangered in the opera- 
tion. Exposure of the artery is easily effected here by a vertical incision two and a half 
to three inches in length. The aneurismal needle should be conveyed from within out- 
wards. The saphenous vein, which lies in close proximity to the artery, must not be 
wounded. 
The late Professor W. II. Porter, of Dublin, who secured this vessel three times, made 
an oblique incision instead of a vertical one, six lines below and parallel with Poupart’s 
ligament, its length being about one inch and three-quarters. Although the operation, 
when thus performed, is sufficiently easy, I should give a decided preference to the verti- 
cal incision, as it admits of more ready access to the artery, as well as of its more easy 
separation from the accompanying vein, especially in the event of any considerable en- 
largement of the lymphatic glands. 
Great objection has been urged against the ligation of this vessel, in any portion of its 
course, on account of the liability of the operation to be followed by secondary hemor- 
rhage, it being alleged that no permanent clot can form above the site of the ligature, in 
consequence of the close proximity of the epigastric and circumflex iliac arteries. One 
writer, Mr. Erichsen, indeed, declares that the operation should be banished from surgery. 
Others, on the contrary, assert that there are cases in which it may be very proper, an 
opinion with which my own views entirely coincide. When secondary hemorrhage arises, 
it w’ill generally be found that it is due rather to a diseased condition of the coats of the 
vessel than to the vicinity of large collateral branches. Mr. Porter tied the common 
chap. v. CHAP. V. 
LIGATION OF THE COMMON FEMORAL ARTERY. 
805 
carotid artery within a quarter of an inch of the innominate, and the patient recovered. 
Mr. Key successfully ligatured the subclavian artery close to the deep cervical; Dr. 
Bellingham, of Dublin, with an equally fortunate result, tied the external iliac near its 
root, on account of an aneurism of this vessel ; and in his case of deligation of the com- 
mon femoral, Mr. Oliver Pemberton cast the thread just above the origin of the profunda, 
the artery, notwithstanding this, being firmly plugged above and below. Ilis patient, 
moreover, was generally diseased, and sixty years of age. Other cases, of a similar 
character, might be adduced, but these are quite sufficient, to prove that the immediate 
vicinity of a large collateral vessel is no hindrance to the formation of a solid, substantial 
clot after the application of a ligature, provided the artery is free from disease, as chronic 
inflammation, and calcareous, fatty, or amyloid degeneration. I have myself in one in- 
stance succeeded in obtaining a firm clot in less than forty-eight hours after the applica- 
tion of a ligature to the femoral artery according to the method originally practised by 
Mr. Porter, the pressure being taken off completely by the end of that period. In a case 
in which I exposed the vessel by a vertical incision, fatal hemorrhage set in at the end of 
the ninth day, owing to a diseased condition of the artery, no protective coagulum having 
formed. 
The number of cases in which this artery has been ligated for aneurism is, so far as I 
have been able to ascertain, eight, with a mortality of only two, or 25 per cent., a result that 
ought to satisfy the most exacting statistician. The case of Mr. Collis, usually quoted as 
one of deligation of the common femoral, is excluded from the accompanying table, since 
it was not an example of the operation at all, the ligature having been placed just below 
the profunda, which was given off high up, and the patient dying of secondary hemor- 
rhage. Excluding the case of Mr. Gelston and my last case, in both of which the artery 
was extensively diseased, it will be perceived that the operation was uniformly successful 
when the artery was sound. It is true, in two instances, secondary hemorrhage super- 
vened, but it was easily commanded by pressure, while the bleeding in the fatal cases was 
so alarming as to require deligation of the external iliac in one and acupressure of that 
vessel in the other. The common femoral trunk has been ligatured several times on 
account of external injury or for hemorrhage after amputation of the thigh, but the results 
have not been gratifying. 
Date. 
Operator. 
Disease. 
Result. 
Remarks. 
1848 
VV. H. Porter 
Popliteal aneurism 
Recovery 
1840 
W. B. Porter 
Femoral aneurism 
Recovery 
I860 
G. II. Porter 
Femoro-popliteal 
aneurism 
Recovery 
Hemorrhage on 25th day, or five days after 
separation of ligature, commanded by slight 
pressure. 
1860 
J. Smyly 
Popliteal aneurism 
Recovery 
Slight hemorrhage on 11th day, or four days 
before separation of ligature, easily controlled 
by pressure. 
1868 
T. G. Gelston 
Femoro-popliteal 
aneurism 
Died 
Hemorrhage on 15th day, controlled by liga- 
tion of external iliac. Successive hemor- 
rhages from old wound; death from pyemia 
and gangrene of foot and leg. Femoral artery 
extensively diseased at site of ligature. 
1868 S. D. Gross 
Femoral aneurism 
Recovery 
Pressure of ligature taken off in 48 hours. 
1870 
S. D. Gross 
Aneurismal varix 
of femoral vessels 
of stump 
Died 
Hemorrhage on 6th day, from detachment of 
ligature, controlled by acupressure of exter- 
nal iliac and distal end of femoral. Patient 
never rallied. The femoral artery was much 
dilated and thinned. 
1870 
0. Pemberton 
Femoral aneurism 
Recovery 
Ligature separated on 40th day. Death from 
inanition ten days subsequently. 
In all the recorded cases in which this artery has been secured for aneurism, except in 
a single one by myself, the operator did not act from choice, but from necessity, the 
superficial femoral being inaccessible on account of the situation of the tumor. In the 
exceptional instance here referred to, the artery was included in a silver wire, loosened in 
less than forty-eight hours after its application, all pulsation in the aneurism having ceased 
before the expiration of that period. 806 
DISEASES AND INJURIES OF THE ARTERIES. 
CHAP. V. 
Ligation of this artery is often necessary on account of wounds involving its continuity, 
and, until a comparatively recent period, it was almost exclusively practised for the cure 
of popliteal aneurism. If the artery is severed by a cut, or pierced by a sharp-pointed 
body, it is evident that it should be secured at the site of injury, the wound being, if 
necessary, enlarged, and a ligature applied to each extremity of the vessel. 
In aneurism, the artery may be tied at two points of its extent, the superior and middle, 
the former being, however, by far the more eligible, as the vessel here is comparatively 
superficial, and, therefore, easy of access. Its course along the thigh is indicated by a 
line extending from a quarter of an inch within the centre of Poupart’s ligament to the 
inner margin of the patella. In the upper third of the limb, it lies immediately beneath 
the skin and aponeurosis, its pulsation being easily felt as it runs along the inner margin 
of the sartorius muscle. This space is from four to five inches in length, and is of a 
triangular shape, its base being formed by Poupart’s ligament above, and its apex by the 
convergence of the sartorius and adductor muscles below. The femoral vein descends 
along the inner border of the artery, and is inclosed in the same sheath; the connection 
between them is very firm and intimate, and it, therefore, requires great caution to effect 
their separation. The femoral nerve lies on the outside of the artery. It is worthy of 
remark that the moment a ligature is tightened around this artery in any portion of its 
course, the patient, unless fully anaesthetized, experiences great pain, not unfrequently 
accompanied by a sense of numbness and tingling in the limb. This effect is probably 
due to the inclusion of a minute nervous filament, and generally promptly disappears of 
its own accord. 
LIGATION OF TIIE SUPERFICIAL FEMORAL. 
Fig. 358. 
Ligation of External Iliac and Superficial Femoral Arteries. 
To expose the artery in this part of its course, an incision should be made along the 
inner border of the sartorius muscle, beginning about two inches and a half below Pou- 
paits ligament, and extending obliquely downwards to the inferior extremity of the LIGATION OF THE SUPERFICIAL FEMORAL ARTERY. 
807 
CHAP. V. 
triangle through the skin and superficial fascia. A portion of the aponeurosis is now 
pinched up with the forceps, and a horizontal opening made into it barely large enough 
to admit the point of a grooved director, upon which the sheath of the vessel is carefully 
divided for about nine lines. The artery is separated from the vein in the usual manner, 
but with extreme caution, and the ligature passed from within outwards, close to the 
former vessel. Injury to the vein would be a serious calamity, as the patient might perish 
from phlebitis, or gangrene of the limb. The occurrence is usually denoted by a gush of 
black blood upon drawing out the thread. Pressure will readily arrest the flow, and the 
vessel must on no account be tied, as such a procedure would inevitably give rise to a bad 
form of suppuration, the ligature acting very much as a seton, exciting and keeping up 
morbid action. A little nerve occasionally runs down in front of the artery, and must be 
drawn out of the way. 
The femoral artery, in its middle course, as seen in fig. 3o8, from Bryant, is deep- 
seated, lying under cover of the sartorius muscle, which must, consequently, be turned to 
one side in the act of exposing it. The corresponding vein will be found external to the 
artery. In some instances it is double, and then the artery runs between the two vessels, 
closely hugged by them; or one of the veins lies in front of the artery and the other in 
the usual position. In operating upon the superior portion of this space, just below the 
triangle above described, the incision should be made along the inner edge of the sartorius, 
which is then everted so as to afford free access to the vessel as it lies beneath the apon- 
eurosis. If, on the other hand, the lower site be selected, the cut should be made on the 
outside of the muscle; but no one will be likely to do this if he can avoid it, as the ope- 
ration will be both tedious and difficult, and possesses no advantage whatever over the 
more common procedure. 
The femoral artery is subject to certain anomalies which should not be forgotten when 
we undertake its ligation, as they might seriously affect the result. The most important 
of these anomalies are the following:—First, the high division of the artery, the vessel 
separating a short distance below Poupart’s ligament into two branches, which go to form 
the posterior tibial and peroneal. Secondly, the artery may be double, the supernumerary 
one giving off’ the branches usually furnished by the profunda. Thirdly, it may consist 
of two equal trunks which afterwards unite to form the popliteal. Sir Charles Bell found 
this curious anomaly in a negro upon whom he operated for popliteal aneurism, the two 
vessels coalescing as they entered the ham. In this case the blood in the sac had in a 
great measure coagulated, notwithstanding that the circulation through it had been main- 
tained by the non-ligated artery. A similar instance occurred to Sir Astley Cooper. An 
abscess formed in the sac, after the detachment of the ligature, and the patient died of 
hemorrhage. The dissection showed that a large branch had been given off by the 
femoral artery above the point of ligation, and had again united with that vessel just 
before it terminated in the popliteal, thereby feeding the tumor, and preventing its oblite- 
ration. Mr. Fleming, of Dublin, in 1866, met with a case of double femoral artery, in 
which he was obliged to secure each vessel separately before any decided impression could 
be made upon the pulsation of the tumor, an aneurism of the popliteal artery. Matters 
progressed favorably for some time, when, suddenly, an abscess formed in the sac, neces- 
sitating amputation of the limb. Several examples of entire absence of the superficial 
femoral artery have been recorded, one, among others, by Manec, its place having been 
supplied by the sciatic, which passed down along the back of the limb to become the 
popliteal. The femoral vein is occasionally, although rarely, double. 
One of the most serious accidents incident to ligation of the femoral artery, for the cure 
of aneurism, is the puncture of the femoral vein, especially liable to occur, if the greatest 
caution be not exercised, in the upper portion of the thigh, in consequence of the abnormal 
adhesions which occasionally form between the two vessels from inflammatory deposits 
caused by an extension of irritation from the tumor. The injury may be inflicted with 
the knife in the efforts to separate the two vessels, or with the aneurism needle in the act 
of passing the ligature. However this may be, the artery must at* once be exposed either 
higher up or lower down, and the wound in the vein treated by compression, so as to 
convert it into one of a simple character. If, as when the vein is transfixed with the 
needle, the ligature be left in the vessel, it will inevitably act as a seton, lighting up 
diffuse phlebitis, speedily followed by the death of the patient. All such accidents are 
sure to end fatally ; indeed, even the mere wounding of the femoral vein is always a very 
serious occurrence. It remains still an open question whether, when the vessel is merely 
pricked, it would not be perfectly safe to include the edges of the opening in a delicate 808 
DISEASES AND INJURIES OF THE ARTERIES. 
chap. v. 
ligature, as lias repeatedly been successfully done in perforation of other veins, provided 
the operation do not interrupt the current ot blood in tbe injured vessel. 
Another accident of a very embarrassing nature, and one which has occurred to me on 
two occasions, sometimes arises in ligating the femoral artery. 1 allude to a welling up 
of blood in the wound either before or after the ligature has been passed, evidently due 
to the division of a small anomalous branch, given off by the femoral, and unavoidably 
opened in separating the vessel from the surrounding structures. The bleeding is very 
embarrassing, the blood filling the wound as fast as it is sponged out; and in the two cases 
adverted to I was obliged to tie the main artery above and below the anomalous branch, 
inasmuch as it could not be included in a ligature. 
The tables of Dr. Norris show that this artery has been tied for all causes 201 times, 
with 50 deaths, the mortality being about one in four. 
Compi-ession of the femoral artery is often necessary on account of hemorrhage, either 
of this vessel itself, or of some of its branches. Jt is also frequently employed for the 
purpose of controlling the circulation of the limb in amputations of the thigh and leg; 
and latterly it has been much resorted to for the cure of popliteal aneurism, having, in 
many cases, superseded the use of the ligature. When the object is to arrest the flow of 
blood, or stanch hemorrhage, the most suitable point for its application is the margin of 
the pubic bone, which is separated from the artery only by the pectineal muscle, and 
upon which, consequently, the pressure may be made with great efficiency. The best 
instrument for the purpose is the thumb of a stout assistant, or the handle of a large key, 
resting upon a small, thick pad. The more concentrated the pressure is, the more effica- 
cious it will be in stopping the bleeding, and in preventing injury to the accompanying vein 
and nerves, circumstances that must not be overlooked in such a procedure. If the force 
be applied with the thumb, it may often be maintained, for several successive days by a 
relay of assistants, without detriment to the parts. 
The other situations at which the artery may be compressed are the upper part of the 
thigh, just below Poupart’s ligament, and those portions of the limb where the vessel 
may be pressed against the shaft of the femur, by directing the instrument outwards and 
backwards. When the compression is designed to be permanent, as in the treatment of 
popliteal aneurism, it should be frequently varied, making it now at this point, and then 
at that, as it may be painful or otherwise ; and it is, moreover, of great importance, under 
these circumstances, that the instrument with which it is applied should not completely 
encircle the extremity, lest it impede the return of the blood in the veins, and thus occa- 
sion swelling and other mischief. 
The principal agent in carrying on the collateral circulation after ligature of the femoral 
artery is the profunda, the branches of which soon become greatly enlarged, and by their 
anastomoses with the articular offsets of the popliteal artery, send the requisite supply of 
blood to the distal portion of the limb. 
LIGATION OP THE DEEP FEMORAL. 
The deep femoral artery has been known to be the seat of spontaneous aneurism, but 
the occurrence is extremely rare, and very difficult of diagnosis. The profound situation 
of the tumor, underneath the muscles at the anterior and inner part of the thigh, will 
usually serve to throw some light upon its character; but the only reliable sign is the 
continuance of pulsation, thrill, and bellows sound, and somewhat of an augmented 
intensity in the swelling when firm pressure is made upon the superficial femoral, about 
two inches below Poupart’s ligament, so as to direct the blood with increased force into 
the deep vessel. The proper remedy, in such a case, as well as in traumatic aneurism, 
would be ligation either of the affected artery, or of the common femoral, an inch below 
its origin, where it may be felt beating immediately beneath the skin and aponeurosis. The 
application ot the ligature to this vessel is sometimes required on account of hemorrhage. 
The deep femoral is usually given off by the common femoral, from an inch and a half 
to two inches below Poupart’s ligament; sometimes, however, it is detached considerably 
higher up, and occasionally it is furnished by the external iliac or by the femoral, imme- 
diately after the commencement of this vessel. The artery, soon after its origin, passes 
inwards, behind the superficial trunk, and gradually places itself under cover of the long 
adductor muscle, between which and the great adductor it afterwards descends towards 
the femur, near which it pierces the latter muscle, and finally disappears on the posterior 
part ot the thigh. lien this vessel is injured, the wound will, of course, serve as the 
readiest guide to it; and two ligatures will always be necessary to put an effectual stop CUAP. V. 
LIGATION OF THE ANTERIOR TIBIAL ARTERY. 
809 
to the hemorrhage. In case of aneurism, the artery may easily be exposed, near its 
origin, by an incision similar to that made in ligating the common femoral, or the super- 
ficial femoral, in the superior portion of its extent, beginning an inch below Poupart’s 
ligament, and descending obliquely in the direction of the inner border of the sartorius 
muscle. The deep trunk may then be readily traced to the requisite extent, and should 
be encircled a few lines below the origin of its two circumflex branches. 
LIGATION OF TIIE POPLITEAL. 
The popliteal artery, situated deeply in the cavity of the ham, in close relation with 
numerous important structures, is very difficult of access, especially in fat subjects. 
Fortunately it is seldom necessary to attempt its deligation, as 
wounds and traumatic aneurism here are of extremely infre- 
quent occurrence. The artery is in intimate connection by its 
outer and posterior surface with the popliteal vein, from which 
it is not always easily detached. Sometimes the vein is double, 
and then the artery lies between the two trunks, closely and 
firmly embraced by them. The popliteal nerve is separated 
from the vessels by a thick layer of fat; superiorly it lies ex- 
terior to the artery, but as it descends towards the leg it gradu- 
ally winds around it to place itself along its internal border. 
There are two points at which the popliteal artery may be 
exposed for the application of the ligature; these are its 
superior third and its inferior third. The middle portion of 
the vessel is never interfered with, on account of its great 
depth, its near proximity to the knee-joint, the unyielding 
character of its lateral boundaries, and its intimate connection 
with the accompanying vein and nerve. 
The artery may be ligated in the upper third of its extent, 
where it is more accessible than anywhere else, by carrying a 
vertical incision along the outer border of the semimembranous 
muscle, for about three inches, extending down as far as the 
popliteal nerve. The muscle is then drawn inwards and the 
nerve outwards, when, by tlie cautious use of the forceps and 
handle of the knife, the vein and artery will be easily found, 
and must be gently and carefully separated from each otiier, 
the needle being passed from without inwards. 
Exposure of the artery, in the lower third of its extent, may 
be effected by a vertical incision between the heads of the gastrocnemial muscle. Care 
is taken not to injure the posterior saphenous vein and nerve, which lie close by, but to 
draw them, along with the popliteal nerve, away from the knife. The artery will be 
found to be deeply imbedded in the ham, partially concealed by the popliteal vein, but 
projecting somewhat to its outer side. 
In his attempts to expose the popliteal artery, the surgeon must be careful not to make 
too free use of the knife, for fear of wounding the articular branches which are given off 
at a right angle, and which might, if injured, cause embarrassing hemorrhage. 
This artery sometimes requires to be ligated on account of the subcutaneous rupture of 
its coats, as in a case reported by Mr. Poland. Xo difficulty was experienced in effecting 
the object, although much blood had been effused. The patient did well until the third 
day, when gangrene came on, followed by amputation and death. The ends of the artery, 
separated by an interval of an inch and a half in length, were each included in a ligature. 
In two other cases in which a double ligature was applied to this vessel, the result was 
also unfavorable. 
LIGATION OF THE ANTERIOR TIBIAL. 
The anterior tibial artery may require to be tied on account of hemorrhage or traumatic 
aneurism, and the best plan always is to take the external wound as a guide to the seat of 
the injury. The vessel, whose course is indicated by a line drawn from the head of the 
fibula to the base of the great toe, may be secured at three different points. 
The artery, in the superior third of its extent, lies underneath and between the anterior 
tibial and common extensor muscles, and may be exposed by a vertical incision, four 
inches in length, carried down in the direction of the line just mentioned. The skin and 
Fig. 359. 
Ligation of the Popliteal at 
its upper and lower parts, a. 
The Popliteal Vein. b. The 
Popliteal Artery, c. The Pos- 
terior Saphenous Vein The 
Popliteal Nerve, on the outside 
of the Artery, has been omitted 
in the Diagram. 810 
superficial fascia being divided, the aponeurosis is split open upon a director to the full 
extent of the outer wound ; the two muscles are then separated from each other along 
their raphe, and the artery, which lies in close contact with the interosseous ligament, is 
surrounded with the ligature in such a manner as not to injure the.accompanying veins. 
The anterior tibial nerve is exterior to the vessels. 
In the middle third of the leg, the relations of the vessel are essentially the same as in 
the upper, except that the long extensor of the toe is interposed between the anterior tibial 
and common extensor. The artery is still deep-seated, and a 
long incision is required for its full exposure. A branch of the 
peroneal nerve sometimes attaches itself to the artery here, and 
must be drawn away before passing the ligature. 
In the inferior third of the limb, the artery lies on the tibia, 
between the tendons of the common extensor of the foot and 
the proper extensor of the great toe, the latter overlapping it 
on the inside. The vessel here is, therefore, comparatively 
easy of access. 
The dorsal artery of the foot, the continuation of the an- 
terior tibial, is easily tied in any portion of its extent, as it 
runs down across the instep, its course being indicated by a line 
extending from the centre of the ankle-joint to the posterior 
extremity of the first interosseous space. It lies under cover 
of the integument and aponeurosis, and may readily be exposed 
by carrying the knife along the outer border of the tendon of 
the long extensor muscle of the great toe. The incision need 
not exceed one inch. The vessel is accompanied by a nerve 
and two veins. 
LIGATION OF THE POSTERIOR TIBIAL. 
The posterior tibial artery occasionally requires ligation on 
account of wounds and aneurisms of its own caliber, and, if the 
operation is performed high up, the task is one of the most 
arduous and perplexing that a surgeon can be called upon to 
execute. It has fallen to my lot to tie it in this situation in 
three instances, and the dilficulties in two were very great, 
having been increased tenfold by the confused condition of the 
parts, in consequence of the large quantity of extravasated 
blood. In one of the cases the artery had been laid open by a 
pistol ball, and in the other by a dirk-knife: the hemorrhage 
was profuse, and could only be effectually controlled by the 
ligature. The third case was one of aneurism in the lower 
part of the vessel. 
The situation of this artery is very deep ; its course, at first 
obliquely inwards, and then vertical, is indicated by a line ex- 
tending from the centre of the ham to the fossa between the 
heel-bone and the inner ankle. It is covered in the superior 
two-thirds of its extent by the gastrocnemial, soleal, and plantar muscles, but during the 
remaining portion it lies immediately below the integument, except at its commencement, 
where it is slightly overlapped by the tendo Achillis. It is accompanied and embraced 
by two veins, one being on each side of it. The attendant nerve lies internal to it in the 
upper part of the leg, but as it descends it. crosses the artery superficially, and places itself 
along its outer margin. The posterior tibial artery is sometimes double, and cases occur 
in which it is unusually small, or even absent, its place being supplied by a large peroneal 
artery. 
The artery may be exposed and tied in the upper and middle portions of its extent in 
one of two ways. The first consists in detaching the gastrocnemial muscle for about four 
inches along the inner border of the tibia, and cutting across the inner head of the soleal, 
by reflecting which we come directly down to the posterior layer of the aponeurosis of the 
leg, the free division of which brings the vessel at once fully into view. Care must be 
taken to avoid the internal saphenous vein, which runs close along the line of incision. 
The limb, during the operation, should rest upon its outer side, the leg being flexed at the 
knee, and the foot extended. 
DISEASES ANI) INJURIES OF THE ARTERIES. 
CHAP. V. 
Fig. 360. 
Ligation of the Anterior Tibial 
at various parts. The Wounds 
are supposed to bo held asunder. 
The Ligature is under the Vessel. LIGATION OF THE POSTERIOR TIBIAL ARTERY. 
811 
CHAP. V. 
In the other method, originally suggested by Mr. Guthrie, the artery is laid bare by a 
long, vertical cut, extending through the centre of the muscles of the calf. Its advan- 
tages are, first, that the artery, being more directly ap- 
proached, is more effectually under our control, and, 
secondly, that there is less danger of bagging, if blood 
and pus are poured out. The length of the incision need 
not exceed that in the other operation, and the hemor- 
rhage is generally insignificant. 
Of these two methods, I give a decided preference to 
that of Mr. Guthrie, who has justly stigmatized the other 
“as difficult, tedious, bloody, and dangerous.” That it 
is so is fully confirmed by my own observation, in a case of 
circumscribed, traumatic aneurism of the lower portion of 
the tibial artery, in a man, between thirty-five and forty 
years of age, a patient at the College Clinic. Although 
I made a very long incision, and was ably assisted in the 
operation by Professor Wallace and others, such was the 
difficulty experienced in separating the artery from the 
concomitant veins, that, despite the utmost caution, one 
of the latter was wounded, followed by such an annoying 
hemorrhage that I was finally compelled to include the 
artery and the wounded vessel in the same ligature. The 
case went on well for a few days, when pyemia ensued, 
rapidly terminating in death. 
In a case of pistol-shot wound of the posterior tibial 
artery, in a man, thirty-six years of age, I experienced 
no difficulty in finding and securing the vessel by what 
maybe called the “direct method,” so forcibly advocated 
by Mr. Guthrie. The incision required to expose the 
artery is, it is true, a long and deep one; but it has the 
advantage, and a very great one unquestionably it is, of 
affording more room, and of admitting of more thorough 
drainage. 
The posterior tibial sometimes requires ligation in the 
lower portion of its extent, between the heel and ankle. 
Taking the pulsation for his guide, the surgeon makes an 
incision, about two inches in length, directly along its track, which is nearly midway 
between the two points here indicated. The direction of the incision should be somewhat 
curvilinear, with the concavity towards the inner malleolus. The artery here lies beneath 
three aponeurotic layers, which must be successively divided upon the director, when the 
needle is passed under the vessel from behind forwards, care being taken not to include 
the accompanying veins and nerve. 
In consequence of the superficial situation of this artery in the lower portion of its 
extent, a convenient point is afforded between the inner malleolus and the tendo Achillis 
for the application of pressure in the treatment of hemorrhage of the sole of the foot. The 
effect may be greatly increased if the circulation is also arrested in the anterior tibial, as 
may readily be done by placing a compress over it, just above the joint. A bandage is 
then extended from the toes upwards as far as the ankle, around which it is to be passed 
in the form of the figure 8, until the bleeding is completely arrested. Sometimes a 
metallic arch may advantageously be stretched across the front of the joint, one end 
resting upon each cpmpress, the object being to ward off injurious pressure. 
Wounds of the arteries of the foot are often followed by troublesome hemorrhage, which 
may, eventually, lead to great, if not fatal, exhaustion. The cause of this is twofold, the 
deep situation of the plantar arteries, and their extensive and intricate anastomoses with 
each other. The general arrangement bears a very strong resemblance to that of the 
palmar arteries. It might be supposed, at first sight, that, when these vessels are wounded, 
the bleeding could readily be arrested by regular, steady, and systematic compression. 
This, however, is not the ca.se. Why, then, not ligate them at once, without waiting 
until the patient is blanched and worn out by the loss of blood, in the vain hope that the 
operation may at length put a stop to it? That this is the proper course is unquestion- 
able ; hence the sooner it is carried into effect the better. The only objection to it is the 
large wound that is obliged to be made in order to expose the bleeding vessel; but this 
Fig*361. 
Ligation of the Posterior Tibial, at va- 
rious parts. The Wounds are held asun- 
der, and the Ligature is under the Vessel. 812 
DISEASES AND INJURIES OF THE ARTERIES. 
CHAP. v. 
must be done at all hazard, and a ligature applied to each extremity, lest the hemorrhage 
should continue through the recurrent circulation. 
It has been proposed in these cases to cut down upon and tie the principal arteries of 
the leg, and we read of instances in which even the great trunk of the thigh was ligated 
for such a purpose. Such a procedure cannot be too strongly condemned, as being con- 
trary both to common sense, anatomical knowledge, and sound experience. The experi- 
ment of tying both the tibial arteries has been tried again and again under such circum- 
stances, and the almost invariable effect has been complete failure ; as might, indeed, have 
been anticipated from a careful study of the disposition of the vessels of the foot. 
Notwithstanding the somewhat pointed manner in which I have here spoken against 
compression in hemorrhage of the plantar arteries, it is but proper to add that I have seen 
this very method occasionally put a most prompt and effectual stop to the flow of blood. 
I recollect distinctly the case of a little girl, which came under my observation many years 
ago, where I succeeded, by a single dressing, in arresting an exhausting and daily recur- 
ring hemorrhage of upwards of a month’s duration. A graduated compress placed over 
the oritice of the bleeding vessel, and confined by a roller extending from the toes upwards, 
aided by elevation of the leg and cold applications, constituted, as it always should when 
such a procedure is adopted, the means employed on the occasion. 
Sometimes we may advantageously resort to the expedient of compressing the anterior 
and posterior tibial arteries by means of two corks, placed directly over these vessels, 
opposite the malleoli, and bound down (irmly by a suitable bandage, passed around the 
foot and leg in the form of a figure 8. The corks should each be wrapped up in a bit of 
patent lint, and should be at least three-quarters of an inch in length, and of proportionate 
thickness and breadth, otherwise it will be difficult to make them retain their proper posi- 
tion. When the compression is obliged to be made with great firmness, it may be well, 
in order to defend the soft parts, to extend a piece of sheet lead across the limb under the 
bandage. 
When the parts are so much inflamed and swollen as to render it difficult, if not impos- 
sible, to expose the affected vessel, tlie hemorrhage may sometimes be promptly arrested 
by acupressure, or by percutaneous ligation. 
Venous hemorrhage, of an obstinate character, sometimes occurs in the foot, either as 
the result of accident, of amputation, or of the excision of a morbid growth, as a fibrous, 
fatty, or malignant tumor. The immediate cause of the trouble is generally a varicose 
and enlarged condition of the veins, the blood welling up from the bottom of the wound 
from numerous points. A tampon of cotton wet with a strong solution of subsulphate of 
iron, thrust firmly in contact with the bleeding vessels, covered with dry lint, usually 
arrests the flow in an instant; when this fails, the edges of the wound should be trans- 
fixed with a pin, and then drawn tightly together with a thread, as in the operation for 
harelip. In a case of Chopart’s amputation of the foot, followed by profuse venous hemor- 
rhage, in which all the more ordinary remedies had been fruitlessly tried, Dr. Beck, of 
Freiburg, promptly succeeded by ligating the posterior tibial artery three inches above 
the internal ankle. The veins were very numerous and extremely enlarged. 
LIGATION OF TIIF. PERONEAL. 
The peroneal artery, after running a short distance, passes obliquely downwards and 
outwards to reach the fibula, along which it descends until it arrives near the outer mal- 
leolus, where it divides into its two terminal branches. It may be secured, in the upper 
portion ot its extent, by making an incision, long and vertical, towards the fibular side of 
the leg, through the bellies ot the gastrocnemial and soleal muscles; and interiorly, as it 
lies between the outer malleolus and the tendo Achillis, by a cut at least two inches and 
a halt in length, directed upwards and outwards towards the fibula. The vessel here rests 
upon the interosseous ligament, close to the inside ot the bone, under cover of the long 
flexor ot the great toe, which must be detached as far as it may be necessary from the 
bone, and drawn downwards. CHAP. VI. 
WOUNDS AND HEMORRHAGE. 
813 
CHAPTER VI. 
INJURIES AND DISEASES OF THE VEINS. 
The affections of‘ the veins requiring to be noticed under this head are, wounds, hemor- 
rhage, inflammation, varicosity, the formation of phlebolites, and the introduction of air. 
SECT. I WOUNDS AND HEMORRHAGE. 
Of wounds of the veins not much need here be said, as they rarely exhibit any diffi- 
culty in regard to their treatment, or much danger in respect to their termination. Like 
wounds of the arteries, they may be produced by various weapons, and are, therefore, dis- 
tinguished by different names, as incised, punctured, lacerated, contused, and gunshot. 
They are always followed by more or less hemorrhage, according to the size of their 
caliber, the blood issuing from them in a continuous stream, of a dark, purple color. When 
the division is complete, there is hardly any retraction, or annular constriction, and hence 
the bleeding often progresses until it proves fatal, especially if the vessel is large and 
superficial, as in wounds of the jugular and femoral, fainting not materially favoring the 
formation of a clot. Partial wounds, of whatever direction, will also bleed copiously, if 
they are at all extensive, and no mechanical obstacle is offered to the flow of blood. If 
the incision is small, exhibiting the character of a puncture rather than of a cut, the bleed- 
ing, after having continued for some time, will gradually cease, in consequence of the 
formation of a minute, but gradually increasing, clot upon the edges of the wound. These 
phenomena may often be witnessed in ordinary venesection at the bend of the arm, the 
clot adverted to constituting one of the impediments to the flow of the blood, and occa- 
sionally compelling the operator to open another vein. In gunshot wounds, severing a 
large vein, the hemorrhage frequently proves as suddenly fatal, or nearly so, as in corre- 
sponding lesions of an artery ; or, life being preserved by the narrow state of the wound, 
or the valve-like disposition of its walls, the blood may be extensively, and, perhaps, most 
prejudicially, infiltrated into the intermuscular and subcutaneous connective tissue. 
The best examples of lacerated wounds of the veins are met with in those frightful 
accidents in which a limb is torn either partially or completely from the body. In such 
condition the hemorrhage is generally extremely small, perhaps hardly amounting to a 
few ounces ; a circumstance due partly to paralysis of the vessels, and partly to the 
shreddy state of their tunics, together with the shock experienced by the system, the 
whole tending to the rapid coagulation of the blood, and the prevention of its further 
escape. This disposition is shared alike by the veins and arteries. 
Spontaneous rupture of a vein sometimes occurs, as for example, of the external saphen- 
ous, from excessive distension of its weakened and attenuated coats, so frequent in varicose 
enlargement of this vessel. A similar accident may befall an internal vein. Contused 
and lacerated wounds of these vessels may be caused in various ways, one of the most 
common of which is the passage of a heavy vehicle over the body, or body and limbs. 
A case of rupture of the ascending cava, thus occasioned, has been reported by Piper. 
The vein was torn longitudinally near the auricle by the passage of the wheel of a gun- 
carriage over the chest. 
Copious venous hemorrhage occasionally after excision of different kinds of 
morbid growths, especially when they are seated upon the back or the side of the chest, 
parts in which the veins are either destitute of valves, or very imperfectly supplied with 
these important structures. I lately removed a sarcomatous tumor, the size of a double 
fist, from the inferior region of the scapula, in a man, thirty-eight years of age, in 
which I had an excellent illustration of this occurrence. Thirty hours after the opera- 
tion, copious hemorrhage set in, the loss of blood amounting to at least a quart and 
a pint. Upon removing the stitches, and sponging away the clots, the most careful 
search failed to detect any bleeding vessel, or even the slightest oozing anywhere, 
thus conclusively showing, the more especially as there was no further trouble after- 814 
INJURIES AND DISEASES OF THE VEINS. 
CHAP. VI. 
wards, that the blood must have proceeded from valveless veins. Similar occur- 
rences are occasionally witnessed in the stump, after amputation of the larger limbs, 
the blood issuing directly from the open mouths of the larger veins, in consequence 
of the deprivation of their valves from the manner in which the vessels are divided in 
the operation. 
The chief danger from wounds of the veins arises from loss of blood, and inflammation 
of their tunics. The latter occurrence is occasionally observed as a consequence of the 
operation of bleeding at the arm with a foul or blunt lancet. Ordinarily, however, there 
is little risk of this kind, the parts readily uniting by adhesive action, since there is no 
impediment to this process from the sanguineous current, as there is, under similar cir- 
cumstances, in an artery; all is calm and quiet within, and the most extensive wounds 
are often repaired in an almost incredibly short time. 
The treatment of a wounded vein is generally very simple, merely by compress and 
bandage, and attention to position. If seated superficially, the mere contact of the edges 
of the breach generally promptly arrests the hemorrhage, without any direct application 
to the vein itself. In the operation of bleeding, the only dressing commonly employed, 
after the necessary quantity of blood has been evacuated, is a small pledget of muslin, 
placed immediately over the part, and confined by means of a roller. The slight inflam- 
mation that follows furnishes the requisite amount of plasma, and in less than twenty-four 
hours the union is generally so firm as to render it difficult to break it. When the divided 
vessel is deep-seated, as in wounds of the neck, axilla, groin, and thigh, and the bleeding 
cannot be arrested by compression, the only resource is the ligature, or, this failing, 
acupressure, applied in the same manner as in a bleeding artery. 
A great dread of the ligature, as a hemostatic agent, in venous hemorrhage, until 
lately existed among surgeons. Convinced that this apprehension had been much 
exaggerated, Dr. S. W. Gross has examined the subject statistically, in an elaborate 
paper published in the American Journal of the Medical Sciences for January and April, 
1867. Most of the cases tabulated by him refer to the internal jugular vein, wounded 
either accidentally, or in the removal of morbid growths. Of 43 wises, in which this 
vessel was tied, only 4 terminated fatally from the effects of the operation, the cause in 
all being secondary hemorrhage. In only one instance was there any evidence of pyemia; 
in none of diffused phlebitis. The average period at which the ligature separated was 13 
days, the minimum 4, and the maximum 23. In the femoral vein, the detachment 
occurred, on an average, on the 11th day, in the axillary on the 9th, and in the external 
jugular on the 7th. 
It will thus be seen that the danger of ligating veins is in great degree, if not entirely, 
unfounded. I have myself repeatedly tied the larger vessels of this kind, both in ampu- 
tations and in the removal of tumors, with entire impunity, and the operation has often 
been practised, with equally happy results, by other surgeons. One important circumstance, 
upon which it is impossible to place too much stress, has been developed in the paper 
above alluded to, that the ligature should always be applied in such a manner as to effect 
complete occlusion of the vein. If any portion of its cavity be left open, there will be 
great danger of secondary hemorrhage, if not also of the entrance of air, pyemia, and 
diffused inflammation, owing to the insufficiency of the clots, and of the adhesions of the 
sides of the vessel. 
The practice of applying a lateral ligature, as it is termed, when a vein is merely 
nicked, pierced, or partially divided, should be discarded, as the operation is almost 
invariably followed, on the detachment of the thread, by fatal hemorrhage, as will be 
perceived by a reference to the tabulated cases of Dr. S. W. Gross. In wounds of the 
internal jugular vein, fatal reflux bleeding will be likely to arise unless the vessel is tied 
at both ends. 
Styptics are not suitable for the arrest of hemorrhage from a vein, unless the mouth of 
the vessel is previously occluded by a compress. Even the most innocuous article of this 
class, the subsulphate of iron, is dangerous, from the fact that it gives rise to the formation 
of large and numerous clots which afterwards become a source of irritation, liable to be 
followed by pyemia and diffusive erysipelas. 
lying main artery of a limb for the arrest of venous hemorrhage has been 
practised successfully, in one instance, by Professor Langenbeck. The occasion for 
the operation was the removal of a large fibrous tumor of the thigh, in which the fem- 
oral vein was accidentally divided at Poupart’s ligament. The bleeding was excessive, 
but ceased instantly upon ligating the already exposed femoral artery. The patient 
did well. A similar result, as is proved by cases quoted by Dr. Crisp, follows in CHAP. VI. 
DISEASES OF THE VEINS. 
815 
wounds of a vein made accidentally during the operation for popliteal aneurism. 
Langenbeck recommends ligation of the main artery of a limb whenever it is found 
that compression is of no avail in hemorrhage from large venous trunks. lie thinks 
the simultaneous ligation of the principal vein improper, from its tendency to cause 
thrombus. Such practice should, in my opinion, be avoided ; first, because to cut off the 
supply of blood suddenly from an extremity is attended with great risk of mortification; 
and, secondly, because I have never seen an instance in which venous hemorrhage could 
not be readily arrested by the compress or ligature. Acupressure has not been sufficiently 
tried as a means of checking venous hemorrhage. I have employed it in numerous cases 
with satisfactory results. 
Rest is of great moment after wounds of the veins ; it should be absolute, for the 
slightest motion may break up the adhesions, and endanger the part by inflammation. 
Exclusion of the air is also very desirable, and may be secured by compress and bandage 
alone, or by these means, aided by collodion. 
SECT. II.—DISEASES OF THE VEINS. 
Inflammation of the veins, technically called phlebitis, is occasionally an idiopathic 
affection ; most commonly, however, it arises from injury inflicted either directly upon 
these vessels, or indirectly through other structures. It frequently follows upon severe 
accidents and surgical operations, and, when this is the case, it is apt to give rise to 
pyemia, or multiple abscess, a disease which, as stated elsewhere, nearly always proves 
fatal. Phlebitis is a much more common affection than arteritis, and differs from this 
lesion still further in its liability to terminate in suppuration, which arteritis seldom does, 
the ordinary product of the latter being plastic matter, not pus. Another peculiarity 
of phlebitis is its tendency to extend along the vessels towards the heart, thus greatly 
increasing its dangers. Recent researches, however, render it probable that this tendency 
is much less frequent than was formerly imagined. The affection is sometimes confined 
to one vein ; but, in general, it involves a considerable number, either simultaneously or 
successively. In the former case it is said to be circumscribed; in the latter, diffused. 
Finally, it may be acute or chronic. 
I. Acute Phlebitis.—The symptoms of acute phlebitis are not always well marked. 
When the affected vessels are superficial, their course is generally indicated by the exis- 
tence of a corresponding number of red lines, which, on applying the 
finger, feel like hard, rigid cords, exquisitely sensitive to the touch, 
anil reaching from the seat of the injury up the limb as far as the 
eye can follow them. The discoloration, which varies from a faint, 
rosy tint to deep red, or even purple, according to the intensity of the 
morbid action, gradually diffuses itself over the surrounding surface, 
and eventually exhibits all the characters which distinguish that of 
erysipelas. Considerable swelling usually attends, not unfrequently 
pitting on pressure. The pain is of a sharp, smarting, or burning 
nature, and is generally so severe as to deprive the patient effectually 
of appetite and sleep. 
The constitution always deeply sympathizes in phlebitis, even when 
of comparatively limited extent. The disease is often, if not generally, 
ushered in by chilly sensations, if not actual rigors, alternating with 
flushes of heat; the pulse is frequent, quick, and irritable; the skin hot 
and dry; the stomach nauseated and otherwise disordered; the bowels 
costive; the urine scanty and high colored. If the patient was in ill 
health immediately prior to the attack, the symptoms will usually be of 
an adynamic character from the beginning; or, if not, they will soon 
become so. Excessive prostration, delirium, an icterode state of the 
countenance, gastric irritability, and great restlessness, are commonly 
prominent symptoms in every severe case of phlebitis. 
The anatomical characters of acute phlebitis are swelling, opacity, 
and pulpiness of the internal membrane of the veins, with uniform 
redness, varying from light pink to deep florid. The middle and 
outer coats soon become profoundly injected, and their proper sub- 
stance, although at first preternaturally soft and humid, is at length 
rendered so dense and firm that the vein feels like a hard, contracted 
cord. The cavity of the inflamed vessel is filled with clotted blood, as seen in fig. 362, 
Fig. 362. 
Phlebitis; a Section 
of the Femoral Vein, 
occupied principally 
by Fibrinous Clots. 816 
INJURIES AND DISEASES OF THE VEINS. 
CHAP. VI. 
sometimes blended with pus or lymph, and in many cases it is lined by a false membrane, 
susceptible, under certain circumstances, of organization. Instances occur in which the 
pus is infiltrated into the substance of the vein, or collected into small abscesses beneath 
the serous lining. The pus of phlebitis is generally an imperfectly elaborated fluid, con- 
taining a large quantity of plastic matter, and comparatively few characteristic globules. 
Acute phlebitis occasionally, but very rarely, passes into ulceration. The morbid action 
may either begin in the coats of the vessels, or it may be propogated to them during the 
progress of disease in the neighboring structures. Thus, in scarlatina, after the more 
immediate effects of the malady have disappeared, abscesses are liable to form in the 
neck and fauces, which have been known to communicate with the internal jugular vein, 
ending in copious, if not fatal, hemorrhage. The subjects of such occurrences are, 
for the most part, young children of a weak, cachectic constitution, and the danger is 
generally in proportion to their exhausted condition at the time of the accident. 
Acute phlebitis is always a dangerous, and often a fatal, disease, few persons recover- 
ing when the morbid action is well established or extensively diffused. This remark is 
true both of the traumatic and idiopathic forms of the disease; also of external and 
internal phlebitis, or of inflammation of the superficial and deep-seated veins. The pus 
formed in the affected vessels, commingling with the blood, soon poisons the system, and 
thus renders the heart, brain, and spinal column unfit for the performance of their functions. 
The treatment of phlebitis cannot be conducted with too much caution. When the 
disease is situated superficially, an attempt should be made, by leeches, blisters, iodine, 
and nitrate of silver, to circumscribe the morbid action, and thus prevent the formation 
of pus. Such a result, however, is not to be expected when the disease involves the 
internal or deeper veins, where the inflammation often makes great, if not irreparable, 
progress before the surgeon is aware of its true character, and where, consequently, treat- 
ment of every kind is of little or no avail. All lowering measures are generally inadmis- 
sible, even when the patient is comparatively young and plethoric ; debility, great and 
marked, is sure to arise, and to call imperatively for the use of tonics and stimulants. 
Purgatives are exhibited to clear out the bowels and correct the secretions; and mercury 
is given in frequent and liberal doses with a view to early and decisive constitutional 
impression, the best form being calomel, or calomel and blue mass. The addition of mor- 
phia will be required for the threefold purpose of preventing undue purgation, allaying 
pain, and inducing sleep. The best stimulants are milk punch, quinine, and iron, espe- 
cially the tincture of the chloride. 
If abscesses form their contents must be evacuated by early and free incisions; the 
internal organs must be diligently watched, and any complications that may arise must 
be met by appropriate measures. The hemorrhage that follows ulceration must be 
arrested by compression and styptics. 
2. Chronic Affections—The characters of chronic inflammation of the veins differ 
considerably from those of the acute form. The coats of the vessels are usually so much 
thickened, hypertrophied, and indurated, as to preserve, when cut across, their cylin- 
drical figure, like an artery. The redness is of a brownish tint, interspersed with nume- 
rous shades of gray, violet, or purple; and the inner membrane, rough and shrivelled, 
may easily be raised in large, opaque shreds. In some instances, the vein is dilated, or 
contracted, obstructed with clotted blood, lined by lymph, or filled with pus. 
The disease sometimes passes into ulceration, but the occurrence is much less frequent 
than in the arteries. Commencing most commonly at one or more points of the inner 
membrane, it gradually extends to the other tunics, which it sometimes completely erodes. 
The immediate effect of this accident is an effusion of blood, which may be so great as to 
produce fatal results. The ulcers, which affect various forms, are occasionally quite 
numerous, and spread over a large extent of surface. 
The veins are sometimes laid open during the progress of malignant disease, the ulcer- 
ation extending from the exterior towards the interior. The hemorrhage caused in this 
way, especially when it proceeds from the larger veins, as the jugular or femoral, may be 
so great as to occasion death in a few minutes. 
Chronic phlebitis is observed chiefly in the veins of the inferior extremity, and in those 
of the spermatic cord and of the ano-rectal region, as a complication of hemorrhoids. 
I he principal symptoms are pains, of a sharp, pricking, or dull aching character, tender- 
ness on pressure, and a sense of fulness or distension at the seat of the disease. The 
treatment is gently antiphlogistic, removal of the exciting cause constituting an object of 
primary importance. 
1 here are certain states of the system in which the veins attain a very great size, and, CHAP. VI 
V A RIX 
817 
consequently, carry an inordinate amount of blood. This hypertrophy, for so it may be 
termed, is very conspicuous in chronic affections of the joints, and in various kinds of 
tumors, both vascular and malignant. It is always conjoined with hypertrophy of the 
arteries, and forms one of the most serious obstacles to the cure of certain diseases. 
Obliteration of the veins is by no means uncommon, and is nearly always the result of 
inflammation. Sometimes it is caused by the pressure of a tumor forcing the sides of the 
vessel closely in contact, and so converting it into a dense, fibrous cord. The largest 
veins are sometimes thus obliterated. Such a condition is extremely liable to be followed 
by dropsical effusions and other ill effects inimical to health and life. 
Loose concretions, phlebolites, or vein-stones, varying in size from a currant to a pea, 
are occasionally found in the interior of these tubes. Commonly of a yellowish, brown- 
ish, or bluish color, they are of a hard, brittle consistence, and of an oblong, oval, or 
spherical form, with a smooth, even surface. When divided, they are found to be made 
up of several thin but distinct lamella;, disposed concentrically around a small delicate 
nucleus, frequently consisting of fibrin. The number of these concretions is extremely 
variable ; occasionally as many as ten, twenty, or even thirty, are observed. They are 
generally met with in the smaller veins; more frequently, perhaps, in the spermatic, 
uterine, vaginal, vesical, hemorrhoidal, and splenic, than in any other. In the saphenous 
and its branches they often exist in connection with varicose enlargement. Their com- 
position is principally phosphate and carbonate of lime, with a small amount of animal 
matter, probably albumen, and a trace of oxide of iron. 
SECT. Ill VAKIX. 
A varicose and dilated state of the veins is by no means uncommon, especially in the 
lower classes of working people, and in mechanics whose avocation compels them to 
maintain habitually the erect posture. The veins which are most liable to suffer, in this 
respect, are those of the inferior extremity and of the spermatic cord, but those of the 
abdomen, scrotum, vulva, trunk, and face are also occasionally implicated, while those of 
the superior extremity are almost exempt from the disease. Nevertheless, an example 
of great enlargement occasionally occurs in them, as in a case recently under my obser- 
vation in a man sixty-one years of age, in which the affection was complicated with varix 
of the corresponding shoulder and side of the chest. Of the deep-seated veins, those 
most frequently affected are the jugular, azygos, subclavian, and hemorrhoidal. I have 
met with a number of cases where there was apparently a varicose diathesis, almost all 
the principal veins in the body being abnormally tortuous and dilated. 
Age exerts a remarkable predisposition to this disease. Thus, varicose enlargement of 
the spermatic veins is most common in young men soon after the period of puberty ; while, 
in the inferior extremity, the greater number of cases occur after the thirtieth year. In 
the hemorrhoidal veins, the malady is most frequent in elderly subjects. 
The veins, in this disease, are preternaturally large, tortuous, knotty, and convoluted, 
or as if they were folded upon themselves, being augmented both in diameter and length, 
and observing a singularly serpentine course, as they proceed to their place of destination. 
Their coats are hard, dense, and elastic, rolling under the finger like fine cords, with, here 
and there, a portion that retains its normal characters, or that is uncommonly thin and 
expanded, as if it were ready to give way under the slightest exertion. In cases of long 
standing, they frequently offer a good deal of resistance to the knife, perhaps even emitting 
a sort of grating noise. On being laid open, they are found to be rough and irregularly 
sacculated, strong bands being sometimes stretched across their interior, which divide 
the tube into small cells, occupied by coagulated blood, phlebolites, or fibrinous concre- 
tions, in a state of organization. In the advanced stages of the disease many of the valves 
are broken down, if not completely destroyed, while in recent cases they are simply thick- 
ened, indurated, displaced, or ruptured. These changes, which are generally m< st con- 
spicuous in the internal saphenous vein and its branches, are obviously brought about by 
chronic inflammation, or by repeated attacks of the acute form of that disease, and often 
lead to great and irreparable mischief. Occasionally, the affected vessels are converted 
into dense, rigid, and impervious cords, altogether disqualified forthe discharge of their 
functions. In confirmed cases of varix of the lower extremity, the superficial, inter- 
muscular, and deep-seated veins most commonly suffer together. Very frequently, 
indeed, the disease begins in the latter vessels, and gradually, through the intermuscular 
branches, extends to the former. 818 
INJURIES AND DISEASES OF THE VEINS. 
CHAP. VI. 
The state of the vessels here described is well depicted in fig. 363, taken from a patient 
of mine, a stout, robust, laboring man, upwards of fifty years of age. The enlargement, 
which wras much greater than any of the kind I had ever seen, was principally situated 
on the inner surface of the limb, and was associated with similar disease of the veins of 
the scrotum, penis, and abdomen. 
The disease may be caused in various ways. In the inferior extremities of pregnant 
females, it is generally induced by the pressure of the distended uterus, creating a mechanical 
impediment to the return of the blood in the iliac 
veins, and, indirectly, in the saphenous. Wearing 
tight garters, drawers, or stockings, may also occa- 
sion the disease, and a similar effect is brought 
about by the habitual maintenance of the erect 
posture. Hence the disease is very common in 
persons who are compelled to stand much. Yarix 
of the hemorrhoidal veins generally depends upon 
habitual distension of the rectum and frequent 
straining in defecation. The causes of varicocele 
are still imperfectly understood, although there is 
reason to believe that the disease is most commonly 
developed under the influence of onanism, and 
other mechanical obstruction tending to weaken the 
spermatic veins. 
A natural predisposition to varicose enlargement 
occasionally exists in certain individuals; the veins 
seem to be unusually large and feeble, and become 
tortuous and dilated under the most trifling obstacles 
to the onward movement of their contents. When 
this is the case, the disease often occurs simultane- 
ously in different parts of the body, superficial as 
well as deep. 
The effects of varicose veins vary according to 
the situation of the malady. In the legs, the 
pressure of the enlarged and distended vessels is 
always productive of a good deal of pain, of a 
pricking or stinging nature, of tumefaction of the skin and connective tissue, and of more 
or less tenderness along the track of the affected veins. In the more aggravated cases, 
ulceration of the integument is apt to take place, commencing usually at one particular 
spot on the inner surface of the limb, and gradually progressing until a large sore is 
established, called, from this circumstance, the varicose ulcer, which always heals with 
difficulty, and which occasionally extends into the enlarged veins, causing copious, if 
not fatal, hemorrhage. In the spermatic veins, the disease may give rise to atrophy of 
the testicle, and to distressing neuralgic pains; while in the hemorrhoidal it leads to the 
formation of piles, and other disagreeable effects. 
Although the development of varix is generally slow, cases occasionally occur in which 
the reverse is the case. During the latter months of utero-gestation, the veins of the feet, 
legs, and thighs often attain an enormous bulk in a few weeks, and I have seen repeated 
instances of a similar kind in the spermatic and hemorrhoidal veins. In the inferior 
extremity, the disease, after having gone on for some time, often remains stationary for 
an indefinite period, neither perceptibly advancing nor receding. In some instances it 
undergoes a sort of spontaneous cure, inflammation being set up in the affected veins, 
followed by the formation of fibrinous concretions, by which their caliber is ultimately 
rendered so completely impervious as to compel the blood to seek other channels. Instead 
of this favorable result, the inflammation occasionally leads to erysipelas, abscess, pyemia, 
and even death. Varicocele never proves fatal, nor does varix of the hemorrhoidal veins, 
although both are, at times, a source of severe suffering. 
Treatment.—The treatment of varix resolves itself into palliative and radical. The 
former consists, as the term implies, in the removal of the exciting cause of the disease, 
and the adoption of such remedies as tend to relieve the part and system of suffering 
without positively curing the malady. In varicocele, onanism must be interdicted ; in 
varix of the hemorrhoidal veins, straining and constipation must be counteracted ; and 
in varicose enlargement of the veins of the lower extremity, all sources of constriction 
must be removed, together with whatever else may have a tendency to weaken, irritate, 
Fig. 363. 
Varix of the Leg. CHAP. VI 
VARIX. 
819 
and inflame the diseased structures, and thereby occasion further enlargement. Giving 
artificial support to the affected veins often has a good effect. Hence the use of the sus- 
pensory bag in varicocele, and of the laced-stocking in varix of the saphenous vein. In 
every form of the lesion, great benefit accrues from attention to the general health, and 
from the occasional administration of an active purgative, which, by clearing out the 
bowels, thus affords a freer passage to the blood in the diseased veins towards the heart. 
If the patient is very plethoric, blood may sometimes advantageously be abstracted. In 
varix of the legs commonly nothing affords more prompt and satisfactory relief than a 
good bleeding at the arm ; and the same remedy must be called into requisition, along 
with astringent and anodyne lotions and perfect rest of the parts, when the veins are 
unusually tender and painful from accidental access of inflammation. 
For the radical cure of this disease numerous operations have been devised, a few only 
of the more important of which need to be noticed here, as the rest have either fallen 
into merited neglect, or are too dangerous to justify their repetition. Besides, the claims 
of these different operations will more naturally come to be considered in speaking of the 
several varieties of varix, as varicocele and hemorrhoids. There are really only two 
operations which, according to my experience, should ever be practised for the permanent 
relief of this disease, namely, the ligature and the caustic issue ; and if we apply these 
remedies to individual forms of the lesion, it will be found that the former is exclusively 
adapted to varicocele and hemorrhoids, and the latter to varix of the feet, legs, and thighs. 
Both procedures are extremely simple, but, although this is true, they should never be 
employed without a thorough preparation of the part and system ; and I deem this the 
more necessary, because, in the great majority of cases upon which we are obliged to 
operate, the disease is rather an inconvenience than a serious evil, threatening loss of limb 
and life. I will not pretend to assert that there are no cases of varix when an operation 
is not absolutely necessary ; to do this would be absurd ; what I mean is simply that no 
man, however skilful or experienced, should endanger his patient’s life by rushing head- 
long into measures which, if injudiciously used, may lead to the worst results. The pre- 
liminary treatment should be mild, but of longer duration than in ordinary diseases ; the 
object is to remove all irritation that may exist in the affected veins, to soothe and calm 
them, in order that they may be the better prepared to withstand the rude assault about to be 
made upon them. To accomplish this object, the patient must be subjected to light diet, 
gentle purgation, and almost absolute rest in the recumbent or semierect posture, for at 
least a week. This will be the more important if he be plethoric, intemperate, or very 
excitable. When it is remembered how intolerant the veins are of injury and of surgical 
interference, such precautions cannot be considered as idle. 
The operation with the ligature is either direct, as in piles, or subcutaneous, as in vari- 
cocele, and in either case it is as safe as it is effectual. The principle on which it ope- 
rates is that of strangulation, by which the enlarged vessels are converted into a slough, 
which is subsequently detached by ulcerative action. For this purpose it is necessary to 
draw the cord with great firmness, so as to produce this result in the shortest possible 
period, as well as with the least suffering. When the ligation is direct, as in hemorrhoids, 
it is always necessary to encircle the base of the tumor, or to tie it as near as practicable 
to its point of attachment to the bowel. When the base is unusually large, it is sometimes 
transfixed with a needle armed with a double ligature, one of which is then drawn around 
each half of the morbid growth, the object being its more effectual strangulation. The 
subcutaneous operation is particularly applicable to varicocele, although it is sometimes 
also practised upon the leg and thigh in varix. It is performed by means of a stout spear- 
pointed needle and a strong ligature, introduced in such a manner as to avoid the sper- 
matic cord, the instrument making only two punctures, one in front of the scrotum and 
the other behind, by retracing its steps after it has effected transfixion. The ends of the 
cord are then firmly tied in the usual manner, the pressure being increased from day to 
day until the ligature is completely detached, or but feebly adherent. 
In operating upon the veins of the inferior extremities, my experience is that the safest 
plan is the establishment of a series of issues, made with the Vienna paste, the proper 
mode of applying which will claim special attention in the section on varix in the second 
volume. 
The after-treatment is not to be disregarded in these operations. The great danger is 
a bad form of erysipelas, connected, doubtless, with phlebitis, its tendency being to diffuse 
itself extensively over the system, and to give rise to pyemia and typhoid symptoms. I 
have not myself, however, witnessed any such effects in any of my cases, and I am inclined 
to ascribe my good fortune more to the pains I have always taken in preparing my patients 820 
INJURIES AND DISEASES OF THE VEINS. 
than to any particular skill in performing the operation or in conducting the after-treat- 
ment. If everything goes on well, little else will be necessary than strict attention to the 
diet, and quietude of the part and system, with an occasional laxative ; if erysipelas super- 
vene, the use of opium, quinine, and iron will be indicated, along with milk punch, and 
the application of iodine, astringents, and emollient cataplasms. 
Excellent cures of enlarged veins have been effected by injections of the solution of 
subsulphate of iron, consisting of one part of the officinal preparation to twenty or thirty 
parts of water. Used stronger than this, the remedy is liable to excite undue inflammation. 
SKCT. IV INTRODUCTION OF AIR. 
A fatal, although, fortunately, not a common occurrence, incident to certain operations, 
is the accidental introduction of air into the veins. It is most frequent in operations about 
the neck, face, and axilla, and was first noticed, as a distinct event, in 181H, by lleau- 
chesne, in exseeting a tumor from the cervical region of a young man, in which it was 
necessary to disarticulate and raise the clavicle. At the moment of effecting this, the 
patient became faint, and, exclaiming that he was dying, expired in less than half an hour 
afterwards. The examination of the body revealed the existence of an aperture in the 
internal jugular vein, at its junction with the subclavian, through which the air, causing 
the fatal result, had, doubtless, entered the circulation. Shortly after this, a similar acci- 
dent happened to Dr. Mott and Dr. Stevens, as well as to several European surgeons, so 
that, in due time, the attention of the profession became fully aroused to the nature and 
importance of the subject. 
The disastrous effects of the introduction of air into the venous circulation were known, 
long ago, to Wepfer, Vander-Heyden, and other physiologists; but they were lost sight 
of, in great measure, until attention was recalled to the subject by the experiments of 
Bichat, Nysten, and Magendie, wdio showed that a very small quantity of this fluid, sud- 
denly injected into the jugular vein of dogs and other animals, was sufficient, in most 
cases, to cause death almost instantaneously. On the other hand, it has been found that 
a large quantity, as, for example, several cubic inches, will not destroy life, if it be intro- 
duced slowly, the air, in this case, combining with the blood in such a manner as to pre- 
vent it from producing any serious mechanical inconvenience. Upon dissection, air is 
readily discovered in the cavities of the heart, as well as in other parts of the circulatory 
apparatus, thus accounting satisfactorily for the fatal event. 
The symptoms which characterize the entrance of air into the venous system are essen- 
tially those of cerebral apoplexy. The patient is generally seized, suddenly and unex- 
pectedly, in the midst of the operation, with a sense of faintness, or a horrible feeling of 
terror, oppression, and exhaustion, inducing him to believe, and, perhaps, to exclaim, that 
he is dying. The countenance, in a moment, assumes a dark, livid hue, the body is agi- 
tated with convulsive movements, the breathing is slow, difficult, and stertorous, the 
muscles are completely relaxed, the pulse is feeble and almost imperceptible, the pupils 
are dilated, and the individual is wholly unconscious. In short, he dies in a state of pro- 
found coma, like a person in a fit of apoplexy. On applying the ear to the cardiac region, 
the action of the heart is found to be excessively oppressed, the organ struggling power- 
fully to overcome the mechanical obstruction caused by the admixture of the gaseous and 
sanguineous fluids, which, swept slowly and heavily along over the fleshy and tendinous 
columns, occasions a loud, churning noise, synchronous with the contraction of the left 
ventricle, and at the same time a peculiar thrill, or vibratory sensation, perceptible by the 
hand as it rests upon the chest. 
Such are the effects usually observed when air has been introduced suddenly, even in 
small quantity, into the venous circulation ; and there is a strong probability that they 
will steadily increase in severity until they prove fatal, despite the most judicious and 
energetic measures that may be employed to counteract them. The period at which death 
occurs varies from a few' minutes to several hours; occasionally life is destroyed almost 
with the rapidity of lightning, and in most cases in from twenty to forty-five or fifty 
minutes. I he fatal event, if not instantaneous, is always preceded by a rapid reduction 
of the temperature, and by a diffusion of the lividity over the whole body, the surface 
being of a leaden hue, as in death from asphyxia. Cases have been noticed in which, after 
the symptoms had continued for some time in a very bad form, the purplish appearance 
of the cheeks was suddenly replaced by a reddish tinge, affording evidence, although gen- 
erally of a deceptive character, of speedy reanimation and ultimate recovery. 
I he immediate cause of death, in this accident, has been variously explained; indeed, 
CHAP. VI. CHAP. VI. 
INTRODUCTION OF AIR. 
821 
it is remarkable what little coincidence of opinion there is upon the subject among writers. 
From the fact that air has occasionally been found in the right cavities of the heart, after 
surgical operations in man, and in animals after experiments, it has been assumed that it 
was the inability of this organ to contract upon its contents, and thus send a sufficient 
quantity of blood to the lungs and brain for the due performance of their functions. Others 
have maintained that the primary trouble is in the pulmonary tissues. Thus, Mr. Erichsen 
supposes that it depends upon the manner in which the air and blood are beaten up 
together in the right cavities of the heart into a spumous fluid, which is unable to pass 
through the lungs, thus depriving the brain and spinal cord of their due supply of blood, 
and inducing fatal syncope, usually attended with convulsions. In opposition to this view, 
it may be stated that, if air be injected in considerable quantity into the carotid artery ot 
an animal, all the phenomena of apoplexy, such as stertorous breathing, loss of sensibility, 
and spasmodic rigidity of the muscles, will instantly be produced, and soon occasion death 
from obstruction of the cerebral circulation. Whatever of truth these different explana- 
tions may embody, it is evident that the secondary effect of the presence of the gaseous 
fluid, that which really causes the fatal termination, is the want of a sufficient quantity of 
oxygenated blood in the great tripod of life, the heart, lungs, and brain. 
If the patient survive, the transition to health is seldom instantaneous ; on the contrary, 
several hours generally elapse before he recovers his consciousness and strength. In a 
case mentioned by I)r. Warren, the man, after having lain in a state of insensibility for 
two hours and a half, awoke as if from a profound sleep, still breathing, however, apoplee- 
tically. The night was passed without any accident, and on the following morning he was 
as well as usual, except that he had a headache, and some soreness in the chest. Some- 
times the patient recovers from the immediate consequences of the accident, but dies after- 
wards from pneumonia, produced, probably, by the irritating effects which the fluid exerts 
upon the pulmonary capillaries, and through them upon the air-vesicles. Such an occur- 
rence, however, is uncommon. 
The local phenomena accompanying the introduction of air into the veins are of great 
interest, particularly in their diagnostic relations. In general, there is some noise, or 
sound, so loud and distinct as to be plainly perceived by the operator and his assistants, 
and which, occurring in combination with the sudden distress of the patient, is of the 
utmost value as a means of discrimination. In some cases, the sound is of a hissing 
nature, like that arising from air rushing into a narrow and exhausted receiver; in some, 
it is bubbling, clucking, or lapping; in some, gurgling, sucking, or licking. The imme- 
diate causes of these variations are, the size, shape, and situation of the opening in the 
injured vein, the quantity of blood in the wound, and the volume of the vessel and the 
relation which it bears to the surrounding parts. Whatever may be the nature of the 
sound, or the degree of its intensity, it cannot, when once heard, be forgotten, and is 
always clearly characteristic of the accident. In addition to this phenomenon, there is 
occasionally, but by no means constantly, an appearance of bubbles of air about the wound 
in the vein, especially if it be somewhat deep-seated. 
The veins through which air is usually spontaneously admitted in surgical operations 
are those about the neck, particularly the external and internal jugular and their imme- 
diate branches. It may also enter by the veins of the face, the axilla, and the chest. 
Thus, in one of Dr. Mott’s cases, it passed in through the facial vein during the extirpa- 
tion of an enlarged parotid gland. Dr. Warren met with an instance in which it was 
introduced by the subscapular vein ; Clemot saw it enter by the veins of the chest; and 
Delpech had a case in which it gained admission by the axillary vein. In operations on 
the trachea, and in the removal of tumors from the anterior part of the neck, the veins 
lying in this region might easily be wounded so as to let in air. 
A case in which the introduction of a seton in the forepart of the neck was followed 
by the entrance of air into the veins has been recorded by Dr. Willis, of England. The 
patient, who had labored under chronic laryngitis, died in seven hours after the ope- 
ration. The large cervical vessels were found, on the dissection, to be uninjured, but the 
right auricle and pulmonary artery were distended with frothy blood, and the lungs were 
emphysematous. 
The reason why the veins in the localities here enumerated alone are subject to this 
accident is that they are under the influence of a suction action during inspiration, owing 
to a tendency to the formation of a vacuum within the chest during the expansion of the 
lungs. This action is naturally limited to the veins at the root of the neck, and it is here, 
therefore, that air is most liable to be introduced spontaneously; it may, however, as has 
already been stated, pass in through the veins of the face, axilla, and thorax, but in order 822 
INJURIES AND DISEASES OF TIIE VEINS. 
CHAP. VI. 
to do this it is necessary that these vessels should he in the condition of rigid tubes, or in 
a state of canalization ; for if they are merely collapsed, flattened conduits, it is evident 
that the air will not be able to enter them, however freely they may be punctured. There 
are various circumstances which may induce this accidental canalization of a vein, of 
which the principal are the adhesion of its walls to the parts through which it passes, and 
the manner in which it is held during the operation, rendering it open-mouthed and gap- 
ing when divided. Sometimes the introduction takes place in a perfectly healthy vessel 
at a considerable distance from the root of the neck, in consequence of the tension into 
which it is thrown by the position of the head and arms, as happened in one of Warren’s 
cases, where the air was admitted by the subscapular vein. The probability of this occur- 
rence is much increased when operations are performed upon the neck, face, and axilla, 
for the removal of large tumors, especially such as are of a glandular nature, including 
veins of considerable size. In injury of the jugular veins the accident will be most likely 
to happen if the wound is made just above the clavicle, where the suction action is natu- 
rally strongest. Air thrown into the veins in remote parts of the body will destroy life 
as promptly and effectually as when it enters in the localities above alluded to, and the 
only reason why the accident so seldom occurs in them is that the vessels are not under 
the immediate influence of the respiratory organs, as they are about the neck and chest. 
Legallois witnessed three cases of instant death in female animals from the introduction 
of air into the inferior vena cava and heart by the uterine veins, and the same occurrence 
has been met with in the human subject. 
Treatment The treatment of this accident is preventive and curative. For the former, 
different plans have been suggested, most of which may occasionally be adopted with 
advantage. In the first place, the operator should remember where, and under what cir- 
cumstances, such an occurrence is most likely to happen; for, being thus put upon his 
guard, he will be more cautious in the movements of his knife, and thereby, in all prob- 
ability, altogether avoid the much dreaded mischief. Secondly, when he is about to begin 
his incisions, an intelligent assistant should compress at the root of the neck any veins 
that may be within reach, and, consequently, in danger of being injured in the early stage 
of the procedure. As a preliminary step in operations in this region I occasionally pass a 
pin underneath the jugular vein, and twist the thread around it, as in the common hare- 
lip suture. In conducting the deep dissection, he should make careful use of the handle 
of the scalpel, as well as of his fingers, to detach the morbid structures, or to separate the 
sound, as the case may be, and if it be found that any veins are included within them, so 
as to require to be severed, they should at once be secured w ith the ligature at the cardiac 
side of the tumor. Sometimes a temporary ligature may be proper, to be removed, or 
tied, after the completion of the operation, according to the exigencies of the case. It 
has been recommended that, when we are compelled to divide any of the vessels about 
the neck, the patient should be desired previously to make a full inspiration ; such a pro- 
cedure, however, would hardly be safe unless the vessel should become instantly collapsed, 
and remain so afterwards. Thirdly, in operating in the different regions under considera- 
tion, care must be taken to avoid those positions of the head and arm which are calcu- 
lated to produce tension and canalization of the veins. Fourthly, it having been found that 
the entrance of air into the veins can be prevented in the inferior animals by compressing 
the chest and abdomen, Mr. Erichsen strongly insists upon the propriety of swathing the 
body as tightly as the comfort of the patient will admit, with the view of compelling respira- 
tion solely by the diaphragm. Such a plan I should think of questionable utility, espe- 
cially if the patient requires the use of an anaesthetic during the operation. Lastly, should 
the accident happen, notwithstanding every possible precaution, as indicated by the occur- 
rence of the peculiar hissing, clucking, lapping, or gurgling noise, previously mentioned, 
or by the appearance of bubbles about the wound in the vein, compression must instantly 
be applied, and all further proceeding suspended until the trouble is effectually remedied. 
To recover a patient from the effects of this accident, various methods of treatment 
have been proposed, some of which are, to say the least, anything but philosophical. 
Thus the idea of sucking out the air from the injured vein, a plan proposed by a French 
surgeon, by the introduction of a suitable instrument, such as a silver canula or catheter, 
amounts to little less than positive absurdity; for, independently of the difficulty and 
tediousness of such an operation, it would be far more likely to be followed by an addi- 
tional entrance of air than the abstraction of that which has already been admitted. But, 
even granting, for the sake of argument, that a tube could readily be passed into the vein 
without the risk of letting in more air, it would not be practicable to remove the fluid 
from the lungs, which it must necessarily reach within a few seconds after the occurrence 823 
CHAP. VII. 
ARTERIAL TUMORS. 
of the accident. Once admitted, no skill can dislodge it, either by this or any other 
means. When the patient is plethoric, and has lost but little blood during the operation, 
it has been recommended to open the temporal artery, on the ground that it might have 
the effect of removing cerebral and pulmonary congestion, and thus favoring the restora- 
tion of the circulation. The utter futility of such a procedure must be apparent, when it 
is recollected that this congestion depends, not solely upon an imperfectly aerated blood, 
but also upon the presence of a spumous fluid, which the capillaries are incapable of pro- 
pelling onward. The same remarks are applicable to the section of the right jugular vein, 
which, it has been alleged, might prove beneficial by unloading the corresponding cavities 
of the heart. 
The fact is, all that can be done, in any case of this kind, is to make an effort to sup- 
port the system. With this view, the treatment should be conducted very much upon the 
same principles as in syncope from the loss of blood, or in asphyxia from drowning. The 
patient is laid at once recumbent, with the head and shoulders even lower than the rest 
of the body, and, if the circulation is stjll going on, firm pressure is immediately applied 
to the axillary and femoral arteries, or the limbs are enveloped in elastic bandages, for 
the purpose of allowing as free an access of blood to the heart and brain as possible. 
Sinapisms of the most powerful kind are applied to the extremities, the spine, and the 
precordial region, or, what is far better, the body and extremities are thoroughly and per- 
sistently flagellated with the end of a fringed towel wet with hot water. As soon as reaction 
has been established, the body is wrapped up in warm blankets, at the same time that cold 
air is freely admitted to the nose and mouth. Brandy and ammonia are freely given, if 
the patient can swallow ; otherwise these fluids must be promptly injected into the rectum. 
Finally, as a dernier resort, artificial respiration should be established, by means of a tube 
introduced through the glottis, or through an opening in the larynx, and steadily and 
faithfully maintained until some time alter all signs of breathing and circulation have 
disappeared. 
CHAPTE R V I I. 
AFFECTIONS OF THE CAPILLARIES. 
The capillaries are liable to enlargement, consisting of a species of hypertrophy of their 
tunics, with more or less dilatation of their caliber. The disease may be limited to the 
arterial capillaries, or to the venous capillaries, or it may involve both classes of vessels, 
constituting thus a kind of compound affection. However this may be, the consequence of 
the enlargement is the formation of a distinct tumor, which may eventually acquire a 
large bulk, and seriously compromise the safety of the patient, especially when it is of an 
arterial character. The disease is generally, if not invariably, congenital, and it is, 
therefore, not uncommon to find that it has made considerable progress before birth. It 
is to this group of lesions that the term naevus is usually applied. Vulgarly they are 
known as mother’s marks, or blood marks. The term ntevoid, or naivous-like, is also 
frequently employed. 
SECT. I ARTERIAL TUMORS. 
The only arterial tumor, properly so called, that can be recognized, in a practical sense, 
is that which was originally so ably and graphically described by John Bell, of Edinburgh, 
under the name of aneurism by anastomosis. His account of the disease is by far the 
most clear and elaborate that has yet appeared, and it is remarkable that hardly anything 
of importance has been added to it by subsequent observers, either as it respects its ana- 
tomy, etiology, or mode of treatment. The only error which the Scotch surgeon committed 
was the assertion that the lesion was peculiar to adults, and that it was a perfect aneurism. 
The most common sites of the arterial tumor are the scalp, lip, nose, orbit, eyelid, cheek, 
and chin ; it may, however, occur in any part of the body, and I have repeatedly met with 
it upon the shoulder, trunk, fingers, and foot. Some years ago, I removed a considerable 
tumor of this kind from the big toe of a young man of twenty-two. I have also seen 
examples of the disease in the vulva of young girls. The texture in which it is usually 
situated is the connective, especially the subcutaneous and submucous*, I do not recol- 
lect ever to have seen it anywhere else, although its occasional occurrence has been 824 
AFFECTIONS OF THE CAPILLARIES. 
CUAP. VII. 
noticed in the liver, spleen, and kidney. In the bones of the skull it occupies the 
dipice. 
'Fhe tumor is essentially composed of a network of arteries and capillaries, closely 
connected together by fibrous tissue, as exhibited in fig. 364. It is, in fact, originally 
nothing but a species of hypertrophy of the capillary vessels, 
commencing in a little speck, perhaps, not larger than the head of 
a pin, and going on gradually enlarging until, at length, it ac- 
quires an enormous volume. The arteries, which are free from 
the earthy and fatty degeneration, have a singularly convoluted 
arrangement, and, in cases of long standing, or of extraordi- 
nary bulk, some of them are often as large as a small goose- 
quill ; their walls are disproportionately thin and diaphanous, 
and from being pressed out laterally into short, blind pouches, 
it is very common for them to have a sacculated appearance. 
This increase in the caliber of the arteries is not limited to the 
tumor, but always extends some distance beyond its proper bound- 
aries, as can readily be ascertained by a careful examination with 
the finger; in fact, it is sometimes easily detected with the naked eye. The general dis- 
position of the veins is similar to that of the arteries; they are, however, usually less 
capacious, relatively considered, and hence the blood returns with less facility than in 
parts naturally constituted. 
The tissue by which the vessels are connected together is, in the first instance, nothing 
but ordinary connective substance, naturally existing in the part where the tumor is devel- 
oped ; it is perfectly soft, spongy, and extensible. In time, however, it necessarily under- 
goes important changes, brought about by the pressure exerted upon it by the impetuosity 
of the inflowing blood, and by its temporary sojourn in the midst of the morbid mass. 
Hence it is that, while in some situations it exists most sparingly, so much so, indeed, as 
to be hardly demonstrable, in others it is preternaturally abundant, and truly fibrous. 
Such are the grosser elements of this form of tumor. Examined more minutely, it is 
found to consist of a kind of areolar structure, the cells of which, varying in size from 
that of the smallest pin’s head to that of a pea, freely communicate witli each other, not 
unlike those of a sponge, by means of lateral pores. These cells, which exhibit every 
diversity of shape, are formed apparently by the ampullar expansions of the coats of the 
arteries, and bear, in their general character, a considerable resemblance to those of the 
erectile organs, as the penis and clitoris. In old tumors of this description, some of 
the sacs occasionally become closed, thus assuming, as it were, an independent existence. 
The cause of this occurrence is probably inflammation, leading either to direct adhesion of 
the contiguous surfaces of the arteries, or to the formation of coagula. The contents of these 
cysts are either sero-sanguinolent or sanguineous. In the latter case they are generally solid. 
Finally, the arterial tumor has no distinct, separate envelop ; the only covering which 
it has is derived from the superincumbent structure, as the skin or mucous membrane, 
which, in time, becomes atrophied by the incessant beating of the blood beneath, and 
ultimately gives way by ulcerative action. In general, the surface of the tumor is of a 
reddish scarlet hue, with here and there a purple spot, and so transparent as to allow many 
of the enlarged vessels to be seen through it. Occasionally a few granules of adipose mat- 
ter overlie the tumor, or are dispersed through its substance. 
It will thus be perceived that this tumor is in reality not a true aneurism, preceded and 
accompanied by the fibrous, earthy, or atheromatous degeneration, but simply an abnor- 
mal dilatation of the capillary arteries, involving, in time, the larger arteries in their im- 
mediate vicinity, and attended by a corresponding but less developed state of the capillary 
and adjacent veins. It consists, in fact, clearly and distinctly, in a hypertrophied condi- 
tion of these vessels; or, in other words, as was previously remarked, in a gradual evolu- 
tion and growth of arteries and veins from tubules that are imperceptible by the naked 
eye to vessels of extraordinary size. There is no addition of new vessels, at least not 
originally, but the whole tumor is formed out of those which naturally exist in the part, 
enlarged in every direction, in length as well as in diameter, under the pressure of the 
steadily increasing afflux of blood. The coats of the vessel are not, it is true, as thick 
and firm as those of the arteries and veins, properly so called, usually are, but the aggre- 
gate capacity is so much greater than what the part naturally possesses that it must be 
regarded as essentially a product of supernutrition. 
The origin of the arterial tumor is often ascribed to the effects of external violence, as 
a blow or fall, and that it may occasionally be so excited is highly probable; in general, 
however, it arises without any assignable cause, as a naevus, or mother’s mark. Indeed, 
Fig. 3G4. 
Anastomotic Aneurism. ARTERIAL TUMORS. 
825 
CHAP. VII. 
I am inclined to think that the affection is nearly always congenital, even in those cases 
in which it is said to have arisen in the adult. This may be accounted for on the assump- 
tion that the naevus was originally so exceedingly minute as to have entirely escaped 
attention, until it began to assume an active character. However this may be, the start- 
ing-point of the disease is usually a little reddish speck, not larger than the head of a 
small pin, perfectly free from pain, and seated just beneath the skin, or partly in the skin 
and partly in the subcutaneous connective tissue. Its growth is generally very gradual, 
so that a number of months, and perhaps even several years, may elapse before it attains 
the volume of a pigeon’s egg. Occasionally, however, it increases with great rapidity, 
and soon acquires a frightful bulk, as in a case under my care, not long ago, in a female 
child, thirteen months old. At birth a reddish spot, as large as a dime, was observed at 
the centre of the left cheek. At the end of five weeks it had nearly doubled its dimen- 
sions. A charlatan now applied some caustic substance, eventuating in a large slough. 
The sore, which was the seat of occasional hemorrhage, healed in a little more than two 
months, leaving an unseemly scar upwards of two inches in diameter, with red, spongy 
edges. A year after the use of the escharotic, when I first sawr the child, the tumor was 
of immense volume, horribly disfiguring the features,and occupying the whole of the left side 
of the face, extending forwards to the nose and mouth, upwards to the eyelid and temple, 
backwards behind the ear, and downwards into the neck, its antero-posterior diameter 
being eight inches and a half, and the vertical six. The tumor, of a bluish color, and of 
a soft, spongy consistence, sensibly increased whenever the child cried, laughed, sneezed, 
or coughed. At its lower and back part it had a peculiar aneurismal thrill and bruit, 
synchronous with the action of the heart. During the last few months the inside of the 
cheek had become much enlarged, and now presented a knotty feel and a bluish appear- 
ance. The upper jaw, along its alveolar process, was of unusual size, evidently from the 
same cause, and was beginning to encroach seriously upon the mouth. The swelling was 
free from pain, and there was no disorder of the health. 
In general, however, the tumor proceeds more slowly, and we not unfrequently meet 
with cases in which, after having made some progress, it remains for a while stationary. 
When it begins as a naevus, or mother’s mark, it is not unusual for it to continue as a 
little reddish spot for several years, when, its activity being aroused, how or why we 
know not, it grows with unwonted vigor, and soon attains a large bulk. The tumor has 
generally an irregular outline, and rarely projects more than a third or half an inch beyond 
the level of the surrounding parts. It is soft and compressible, the finger sinking into it 
as it would into a wet sponge, but the moment the pressure is removed it regains its 
former volume, the blood rushing into it with a peculiar whizzing or blowing noise. Its 
color varies in different cases; when it occurs in the skin, or skin and connective tissue, 
it is generally of a reddish hue, inclined to scarlet, especially in its earlier stages; but in 
all cases, and especially when it lies beneath the mucous membrane, it is more commonly 
of a bluish or purplish color. It beats and throbs synchronously with the contraction of 
the left ventricle of the heart, and imparts a peculiar aneurismal thrill to the finger. Its 
movements are often perceptible at a considerable distance, and are always sensibly aug- 
mented under the influence of mental emotion. When of considerable volume, the tumor 
may produce severe pain and other inconvenience by its pressure, but, as a rule, there is 
little local suffering or constitutional disorder. 
Such a tumor sometimes ulcerates and sloughs, causing more or less hemorrhage, and 
ultimately, perhaps, death, as in the case of one of my patients, a female child, ten mont hs 
old, who had a large congenital arterial naevus upon the right shoulder and arm, of a dark 
purple color, and of a soft spongy consistence, throbbing and beating violently. Although 
the general health was good, ulcers, after some time, began to form on different parts of 
the tumor, which now became very painful and inflamed, and, in a few weeks, gangren- 
ous. The hemorrhage which succeeds the ulceration in this affection, profuse as it some- 
times is, seldom proves fatal; for, after it has continued for a while, the blood coagulates 
upon the eroded surface, and thus prevents further effusion. In the female, the hemor- 
rhage is occasionally vicarious of the menstrual flux ; the tumor becomes full and tense 
at the return of each period, and, giving way at the top, allows the blood to drain off, 
without serious injury to the parts or system. It has been asserted that such a growth 
may degenerate, changing its primitive character, and assuming one of a worse kind, as 
the sarcomatous. Without altogether denying the possibility of such an occurrence, I 
never seen anything to justify the conclusion. 
Treatment—The treatment of this form of tumor may be conducted by excision, 
escharotics, strangulation, starvation, injections, and, lastly, by amputation, as w hen the 
disease occupies one of the extremities. Besides these methods, there are several others 826 
of a more doubtful and less trustworthy character, which will be briefly noticed in their 
proper place. 
o. Excision is chiefly adapted to small arterial tumors, before they have acquired much 
functional activity, or given rise to any enlargement of the neighboring arteries. The 
operation is then perfectly safe, easy of execution, and likely to be entirely successful, 
liut if the case be neglected until the morbid growth has attained a large bulk, beating 
and throbbing violently at every pulsation of the heart, as if it were ready to burst, the 
attempt, besides proving one of immense difficulty, may be attended with so copious a 
hemorrhage as to cause speedy exhaustion ; we have then a formidable enemy to deal with, 
and we may consider ourselves fortunate if the patient do not perish from the loss of blood, 
gushing forth, as it will, in torrents, at every stroke of the knife. In such a case the 
prudent surgeon weighs well, before he begins his perilous operation, the chances of suc- 
cess; he measures every inch of ground, and equips himself thoroughly, at every point, 
for the trials and perplexities of his portentous undertaking. 
When excision is determined upon, the rule of practice is, as John Bell long ago so 
correctly observed, not to cut into the tumor, but around it, and yet not so widely around 
it as to include an unnecessary quantity 
of sound tissue. The operation is per- 
formed rapidly, the finger of a good 
assistant quickly following the knife in 
order to compress any important artery 
that may be divided, until the whole mass 
is completely extirpated; and it will be 
wise, if practicable, always to arrest the 
circulation in the main artery leading to 
the tumor before we begin the incisions. 
Removal being thus effected, the ligature 
may often be entirely dispensed with, all 
bleeding ceasing the moment the opera- 
tion is over; or as soon as the edges of 
the wound are thoroughly approximated 
by the twisted suture, a mode of dressing 
peculiarly adapted to this form of disease, 
on account of the hemostatic influence 
exerted by its compression. 
The cutaneous method of removing 
na;void and other vascular tumors, sug- 
gested by Mr. T. P. Teale, of Leeds, has 
been successfully practised in a number 
of instances. It consists in dissecting off 
the skin, as a preliminary step, and then 
replacing it, experience having proved 
that, when the case is thus managed, the 
enlarged vessels gradually shrink, and 
eventually all trace of disease disappears. 
J. Small arterial tumors may often be 
readily destroyed by escharotics, of which 
the Vienna paste, used as in making an 
ordinary issue, is preferable to any other. The paste is retained for fifteen minutes, 
being spread out sufficiently to cover the whole of the affected surface; the application 
is followed up by an emollient poultice, and when the slough is detached the sore is 
treated upon general principles. When the tumor is very large, and so situated as not 
to involve any important structures, interference with which might prove prejudicial, it 
may be attacked, either simultaneously or successively, at several points of its extent, for 
the purpose of converting the whole mass into an eschar. For obvious reasons the caustic 
should not be used upon those parts of the body which are habitually exposed, as the 
face and neck. 
y. Strangulation may be effected by transfixing the base of the tumor with one or more 
pins, and then drawing a ligature firmly around them, so as to cut off at once, and effectu- 
ally, its sanguineous supply. Or, instead of this, a stout, double thread may be conveyed 
beneath and around it by means of a spear-pointed needle, provided with an eye, one 
cord being tied upon one side of the swelling, and the other upon the opposite side. If the 
AFFECTIONS OF THE CAPILLARIES. 
CHAP. VII. 
Fig. 365. 
Erectile Tumor. The Integument, uninvolved, has been 
reflected by Flaps: Transfixion is being completed, pre- 
vious to Deligation. The larger Ligature, in the act of 
being pulled through. It tills the aperture of puncture, 
preventing Bleeding; and, besides, bears a stronger strain 
on tying. CHAP. VII. 
ARTERIAL TUMORS. 
827 
integument be sound, the ligation is preceded by its careful division and reflection, as in 
fig. 365, in order that, when the morbid growth has been removed, it may be replaced, 
and thus serve to protect the parts from an unseemly cicatrice. 
When the tumor is so flat and elongated as not to admit of inclusion by the quadruple 
ligature, recourse may be had to the ingenious expedient of Eriehsen, which combines the 
great advantage of thorough strangulation with a small ultimate cicatrice, it being un- 
necessary to embrace an undue quantity of integument for the eradication of the disease. 
The operation is performed in the following manner. “A long triangular needle is 
threaded on the middle of a whip-cord, about three yards in length; one-half of this is 
stained black with ink, the other half is left uncolored. The needle is inserted through a 
fold of the sound skin, about a quarter of an inch from one end of the tumor, and trans- 
versely to the axis of the same. It is then carried through, until a double tail, at least 
six inches in length, is left hanging from the point at which it entered; it is next carried 
across the base of the tumor, entering and passing out beyond its lateral limits, so as to 
leave, as shown in fig. 366, a series of double loops about nine inches in length on each 
side. Every one of these loops should be made about three-quarters of an inch apart, 
including that space of the tumor, and the last loop should be brought out through a fold 
of healthy integument beyond the tumor. In this way we have a series of double loops, 
one white, and the other black, on each side, as in fig. 367. All the white loops should 
now be cut on one side, and the black loops on the other, leaving hanging ends of thread 
of corresponding colors.” 
Fig. 366. 
Fig. 3G7. 
Erichsen’g Mode of Ligating Vascular Tumors 
“The tumor may now be stragulated by drawing down and knotting firmly each pair 
of white threads on one side, and each pair of black ones on the other. In this way the 
tumor is divided into segments, each of which is strangulated by a noose and a knot: by 
black nooses and white knots on one side, by white nooses and black knots on the other, 
as in fig. 367.” 
8. Starvation may be attempted in one of two ways; either by tying the arteries which 
immediately feed the tumor, or else by occluding the main vessels which lead to the parts 
where the tumor is located. Of these two methods, preference should always, if possible, 
be given to the former, on account of its having a more direct and controlling influence 
upon the arrest of the morbid growth ; when the swelling is very large, the two plans 
may sometimes be advantageously combined. Ligation of the arteries in the immediate 
vicinity of the tumor should be performed at .several points at once, otherwise but little 
impression will be likely to follow; and care is taken, in performing the operation, not to 
interfere with the proper substance of the tumor, lest embarrassing hemorrhage ensue. 
Deligation of the main artery leading to the parts upon which the morbid growth is 
situated has hitherto been practised chiefly upon the common carotid, in aneurism by 
anastomosis of the orbit, face, and scalp. The success has been variable, but, in the main, 
not very flattering, and yet I conceive that the procedure may be very proper when no 
other treatment is available. The misfortune, perhaps, is, that it is always employed as a 
dernier resort, and it is, therefore, not surprising that it should have so often failed. Dr. 
Mott, in one instance, tied the common carotid artery on account of a large arterial 
tumor, involving both orbits, the nose, and part of the forehead, in a child only three 
months old; the mass gradually diminished in size, and became so much consolidated as 828 
AFFECTIONS OF THE CAPILLARIES. 
to lead to the belief that it might afterwards be extirpated, if such a measure should be 
deemed expedient. The final result of the case has not been reported. In 1828, I as- 
sisted I)r. George McClellan in ligating the right common carotid for the cure of an 
aneurism of the corresponding side of the face and orbit, in a child five months old. The 
operation seemed to arrest the growth of the tumor for a fortnight, but at the end of that 
time its activity was again aroused, and it went on progressively increasing until it caused 
death by hemorrhage and constitutional irritation. Dr. Mussey, Dr. J. Mason Warren, 
and others, both of this country and of Europe, have tied both carotids for the cure of this 
disease. The first of these surgeons applied the second ligature, after an interval of 
twelve days, without the occurrence of any untoward symptoms. In the case of Dr. 
Warren, a little upwards of a month elapsed between the first and second operations ; no 
unpleasant effects supervened, and the patient, a man aged twenty-three years, made a 
rapid recovery, although the arterial tumor was of enormous size, involving the mouth, 
face, and neck. Professor Kuhl, of Leipsic, tied the left carotid in a man of fifty-three, 
and, in seventy-two days afterwards, the right carotid, on account of an extensive arterial 
disease of the scalp. The patient recovered, but not without considerable cerebral dis- 
turbance and repeated hemorrhages from the tumor. Of 13 cases of consecutive ligation 
of both carotids, 2 died. Of these Ullman, Velpeau, Buck, and Foote, performed the 
operation on account of anastomotic aneurism of the orbit; while it was resorted to for 
similar disease of the scalp or face in one case by Dupuytren and Robert, by Mussey, in 
two instances, and in one each, respectively, by Pirogoff, Reynolds and Van Buren, 
Warren, Robert, Buenger, and Kuhl. In tying two such large arteries for the cure of 
this affection, it is important to allow a sufficient period to intervene between the two 
operations for the dilatation of the collateral vessels which supply the brain, so as to 
enable this organ to obtain the requisite supply of blood for the proper execution of its 
functions. Several cases, it is true, have been published, in which the ligation was 
performed after a very brief interval, without any serious detriment to the cerebral 
circulation, but this fact does not invalidate the necessity of this precaution in the class 
of maladies in question. 
Dr. Wyeth has adduced some valuable statistics upon this subject. Of 71 cases in 
which the ligature was applied to the common carotid artery, 20 were cured, 20 died, 9 
were improved, 16 were unsuccessful, and in 6 the result was not given. In all of these 
cases the operation was performed for vascular growths not implicating the orbit. Of 52 
cases in which the artery was ligated for pulsating tumors of the orbit, 28 were cured, 6 
died, 5 were improved, 6 were failures, and in 7 tlie result was not known. 
*. Of the various injections that have been used for the relief of this tumor, the principal 
are nitric acid, creasote, iodine, and perchloride of iron, introduced in small quantity, 
either pure or diluted, with a delicate syringe, similar to that spoken of under the head of 
aneurism. These fluids are all more or less irritating, while several of them are capable 
of exciting high inflammation; hence it is hardly necessary to add that they should be 
employed with the greatest possible care and gentleness. At least one case is upon record, 
where a drop of nitric acid, thrown into a small arterial growth of a child, caused death 
by convulsions. In a case under the care of the younger Teale, of Leeds, instant death 
followed the injection of the perchloride of iron. 
The most unobjectionable injection, for the cure of this disease, is a strong solution of 
subsulphate of iron, a few drops of which may be deposited in different parts of the tumor, 
by means of a delicate syringe, the nozzle of which, introduced subcutaneously, is moved 
about in such a manner as to break up the coats of some of the capillary vessels. Coagu- 
lation occurs almost instantaneously, and in the course of five or ten days the whole 
growth drops off' in the form of a slough, leaving a sore which gradually heals by granu- 
lation. By means of this salt any case of arterial or venous tumor, unless very bulky, 
may generally be promptly and effectually cured. 
£. Finally, among the subordinate and less certain remedies may be mentioned the use 
of heated needles, vaccination, compression, the use of collodion, and the seton. 
The introduction of heated needles into the midst of the morbid growth was strongly 
recommended, many years ago, by several surgeons, who followed up the suggestion by 
the publication of a number of cases illustrative of its efficacy. On the strength of these 
reports, I was induced to make trial of the remedy in a number of instances which fell 
into my hands shortly afterwards, but such was my disappointment that I soon abandoned 
it altogether as worthless. 
A few cases of cure of the arterial tumor by vaccination have been reported, the 
patients having been persons whose systems had not been previously protected by this 
CHAP. VII. VENOUS TUMORS. 
829 
CHAP. VII. 
operation. In order to prove successful, it is necessary that the virus should be inserted 
at different points of the affected surface, so that the resulting inflammation may be felt 
by the whole growth. The operation is sometimes followed by violent inflammation and 
high constitutional disturbance, threatening convulsions, and other serious accidents. 
Compression is sometimes employed, generally by means of the pad of a truss, or of a 
piece of ivory, coin, or sheet lead, confined by adhesive strips, a compress, and a roller. 
To prove efficient, it must be made in a steady, uniform manner, the cases to which it is 
chiefly adapted being those in which the tumor is diminutive, and situated upon a hard, 
bony surface. The procedure is exceedingly unsatisfactory. 
The seton is, perhaps, on the whole, more reliable than any other of these subordinate 
remedies; introduced underneath the tumor, and left there until suppuration is fully 
established. If the growth is small, a single thread may suffice, otherwise three or four 
may be necessary, or, perhaps, even a larger number. A small needle, inserted into a 
handle, is used, the cord being dragged through so as to fill the puncture made by the 
instrument, thereby preventing hemorrhage. I have treated three cases of small arterial 
tumors on the scalp successfully by this method. 
The steady, persistent application of collodion has occasionally been successfully 
employed in arresting the growth of such a tumor, and in finally obliterating it. The 
treatment, which, however, is always tedious, and seldom reliable, is adapted only to 
the more simple forms of the disease, and to be at all effective the tumor must be situated 
upon a firm, bony base. 
7], When the tumor is irremediable by the various measures now described, and is so 
situated as to admit of it, amputation may become necessary. Much as such a step 
is to be regretted, no one should hesitate to take it when the disease occupies a finger, 
hand, arm, foot, leg, or thigh. 
SECT. II VENOUS TUMORS. 
Under this head may be described a morbid growth composed chiefly of dilated and 
varicose veins, held together by connective tissue ; situated, for the most part, upon 
the scalp, cheek, lip, and chin, but also liable to occur in other regions, as the trunk and 
extremities. The submucous connective substance of the mouth, tongue, and vulva may, 
likewise, be mentioned as occasional seats of the disease, and there is one form of 
hemorrhoidal tumor which evidently closely assimilates itself to it in structure. Varying 
in size and prominence, it may, originally, not be larger than a small pimple, which, 
gradually spreading in different directions, may ultimately acquire an extraordinary 
bulk, forming a considerable projection, and occupying a diameter many inches in 
extent. Its color is usually purple or claret, either continuously, or intermixed with 
various shades of red; occasionally it is dark-mottled, especially when the enlarged 
veins lie nearer the surface at one point than at another, thus rendering their con- 
tents distinctly visible through the attenuated integument. In its consistence it is 
soft and spongy, diminishing sensibly under pressure, but speedily regaining its former 
bulk when the pressure is removed. It is free from pulsation, bruit, and expansion, 
and is comparatively little influenced by mental emotion. Sometimes the growth is 
tardy, at other times rapid ; it is usually congenital, but may occur at any period of 
life ; sometimes, and most generally, without any assignable cause, and at other times 
as a consequance of external injury. At first there is commonly no cutaneous involve- 
ment, the tumor being strictly limited to the connective tissue ; by and by, however, 
the skin becomes uniformly attenuated, or thickened at one spot, and atrophied at 
another, and thoroughly incorporated with the morbid structures. As the disease ad- 
vances, but generally not until the tumor has attained considerable bulk, ulceration may 
take place, followed by occasional hemorrhage, chiefly of a venous character, and easily 
checked by pressure. 
The venous tumor is usually solitary ; sometimes, however, it exists in considerable 
numbers, either in close proximity or scattered over different parts of the body. I have 
frequently met with them in the same person on the scalp, face, and ears. In a remark- 
able instance reported by Mr. Hutchinson, of London, the child had upwards of one 
hundred, all of them very distinct and superficial. What is vulgarly called a mother’s 
mark, nyevus or n ye void, is by far the most common form of venous tumor. 
The angiomatous growth essentially consists of a network of dilated capillaries, which 
are, as a rule, simply an exaggeration of those which are peculiar to the part where 
the morbid growth is situated. They are connected together by loose connective 830 
DISEASES AND INJURIES OF THE BONES. 
CHAP. VIII. 
tissue, are more or less tortuous in their disposition, and have exceedingly thin, 
delicate walls, so that, when a body of this kind is excised, they immediately collapse, 
the structure, which previously formed a large mass, shrinking away into a little, spongy 
remnant. In the specimens which I have had an opportunity of examining, no ab- 
normal vascular cells or fibrous hands were distinguishable ; and, as the operations per- 
formed for their removal were almost bloodless, it is evident that the arteries which 
entered into their composition must have been few in number and exceedingly small. In 
very old and large growths of this kind, some of the individual veins are occasionally of 
enormous size, as well as remarkably tortuous, and contain fibrinous and earthy concre- 
tions, lodged in separate compartments. Such occurrences are most frequent on the trunk 
and buttocks. 
There is a form of naevoid tumor, known as naevoid elephantiasis, consisting of a hy- 
pertrophied condition of the skin and subcutaneous connective substance, occupied by a 
dense, reticulate, spongy, venous tissue of a cavernous structure, interspersed with enlarged, 
varicose veins, of a truly erectile character. The skin is greatly thickened, especially at 
certain points of the diseased surface, rugose, fissured, or tuberculated, very hard and 
firm, grating under the knife, studded with long, coarse hairs, and generally a few shades 
darker than natural. The connective tissue is much increased in quantity, of a whitish 
or grayish hue, and of a dense, fibrous consistence. The affection, which is either con- 
genital or arises soon after birth, is most common in the feet and legs ; but in a number 
of instances I have met with it on the face, the scalp, and the trunk, more especially the 
side of the chest. 
The venous tumor is most easily dealt with by excision, and, unless the growth is 
of inordinate volume, such a procedure will be almost bloodless. If any considerable 
artery be embraced in the general mass, it must, of course, be secured, either during 
the dissection, or immediately after it has been completed. The same rule of cutting 
around the tumor, and not into it, should be observed here as in the removal of arterial 
growths. 
When the knife is objectionable, a venous tumor, if small, may readily be destroyed by 
the subcutaneous injection of a few drops of a strong solution of subsulphate of iron. The 
procedure, with proper care, is perfectly safe, and productive of little suffering. I have 
performed the operation in several cases with very gratifying results. The diseased tissues 
usually slough off' in from five to eight days. Electrolysis is particularly applicable to 
such growths, which may also be readily destroyed by strangulation, either with the ecra- 
seur, the ligature alone, or the ligature and needle, in the form of the twisted suture; if 
very large, however, they must not be meddled with in this way, lest, violent inflamma- 
tion arising, the operation may prove fatal. In naevoid elephantiasis but little is to be 
done beyond the steady use of the bandage and the application of dilute tincture of iodine. 
If the disease be seated in the lower extremity, the employment of a laced stocking will 
be of service in supporting the affected structures. 
Venous growths, especially when they occur as naevoids, occasionally take on malignant 
action, after having, perhaps, been, for many years, in great degree, if not entirely, 
stationary. The most common changes, under such circumstances, are the epithelial and 
sarcomatous. An interesting example of melanotic degeneration of a congenital naevus, 
in a lady, forty years of age, has been reported by Dr. Stiles. 
CHAPTER VIII. 
DISEASES AND INJURIES OF THE BONES AND THEIR APPENDAGES. 
The bones, being organized upon the same principles as the soft structures, are liable 
to similar diseases, both of a benign and malignant nature. The presence of earthy mat- 
ter, however, to which they are indebted for their solidity and strength, so as to render 
them fit organs for locomotion and protection, exerts a modifying influence upon their dis- 
eases, not only as it respects their frequency, hut also their progress, the character of their 
products, and the mode of their termination. This influence is particularly noticeable, on 
the one hand, in the difficulty with which inflamed osseous tissue suppurates, and, on the 
other, in the facility with which it becomes softened and deprived of its vitality, even, 831 
CHAP. VIII. 
WOUNDS AND CONTUSIONS OF BONES. 
apparently, under very slight action. Inflamed soft texture generally suppurates with 
remarkable readiness, and often becomes the seat of large abscesses; in pure osteitis, on 
the contrary, pus is rarely seen in any form, much less in that of abscesses, such an occur- 
rence being usually impossible, first, on account, probably, of some peculiarity in the 
habits of the secernent vessels, and, secondly, because of the absence of free connective 
substance, which, in the soft tissues, always serves as a bed for the reception and accom- 
modation of the purulent fluid. Bones inflame with difficulty, but when the morbid pro- 
cess is once fairly lighted up, it is sure to produce the most serious structural disorder, 
often followed by the worst consequences, as softening, protracted ulceration, hypertrophy, 
fragility, and even necrosis. In tertiary syphilis, gout, rheumatism, and scurvy, the 
bones frequently suffer immensely, receiving and harboring disease with great facility. 
They are a common seat of various kinds of tumors, some of which, as the exostoses, are 
very similar to, if not identical with, their own structure, while others are essentially 
different in most particulars. The carcinomatous formations have not been observed pri- 
marily in the skeleton, but the frequency of sarcoma has been a subject of remax-k by every 
systematic modern writer. Tubercle, which plays so important a part in caries of the 
carpal and tarsal bones, in Pott’s disease of the spine, and in certain affections of the 
larger joints of the extremities, is very common. 
SECT. I WOUNDS AND CONTUSIONS OF THE BONES, PERIOSTEUM, AND ENDOSTEUM. 
1. Wounds of Bones—Wounds of bones are liable, if at all severe, to give rise to very 
serious consequences, both local and constitutional. In respect to their nature they admit 
of the same general division as wounds of the soft parts, into incised, contused, lacerated, 
punctured, and gunshot. In degree they may be slight or severe; and, from their situa- 
tion, they must necessarily, in all cases, be more or less complicated with injuries of other 
structures. The articular extremities cannot suffer without more or less involvement of 
the corresponding joint; and in the long bones the wound often peneti’ates the medullary 
canal, thus greatly increasing the danger to limb and life. 
Among the best examples of incised wounds of the bones are the injuries inflicted in 
surgical operations, as in cases of excision of the jaws and joints, in chopping wood, and 
in encounters with the sword and sabre. Wounds made with the saw, as in the amputa- 
tion of a limb, are necessarily attended with a certain degree of contusion, and are on this 
account more liable to be followed by severe inflammation. Punctured wounds of bone 
are generally caused by bullets, nails, dirks, sabres, arrows, and similar weapons, and are 
most frequently met with in the skull, hands, and feet. Lacerated wounds are best exem- 
plified in fractures, especially the comminuted varieties, in which the osseous tissue is not 
only forcibly dissevered, but torn into numerous fragments, spicules, or splinters. Pene- 
trating wounds are those in which the lesion extends, either partially or completely, 
through the substance of a bone, as, for instance, in gunshot injuries of the cranium and 
pelvis. Great mischief is sometimes inflicted upon the osseous tissue by mere contusion 
or concussion, as when a bone is struck by a glancing ball, a kick, or a fall. 
1st. Incised Wounds Incised wounds, properly so called, of the osseous tissue, are 
uncommon. The most remarkable example of the kind that I have ever witnessed occur- 
red in a man, thirty-nine years of age, from a cut with a butchei*-knife, which completely 
severed the ulna at its junction with the olecranon process. The wound extended from 
behind forward, dividing the osseous tissue as smoothly as if it had been a pei*fectly soft 
substance, laying open the joint freely at its posterior surface, and for a time bleeding 
quite profusely. The treatment was conducted upon general principles, and in less than 
eight weeks the union was complete. The elbow, however, remained permanently 
ankylosed. 
Incised wounds from accident occur, perhaps, more frequently in the bones of the hand 
and fingers than in any other pieces of the skeleton. Laborers in chopping wood often 
meet with such injuries, and it is not surprising, when we consider the vascularity of the 
parts, that they should sometimes be attended with veiy serious hemorrhage. 
In sword and sabre wounds, portions of bone, occasionally of considerable size, are 
liable to be sliced off, sometimes completely, at other times partially. In the latter case, 
the fragment retains its attachment either by osseous tissue alone, or, as is more genei’ally 
the case, by osseous tissue and soft structure. 
Wounds made with the sword partake of the character of incised and contused wounds: 
the osseous tissue is more or less bruised by the motion of the vulnerating body, and 
necessarily unites more slowly than in an ordinary simple cut. 832 
DISEASES AND INJURIES OF THE BONES. 
The treatment is by apposition and rest of the parts, maintained uninterruptedly until 
there is complete union, as there generally will be in from three to live weeks, according 
to the extent of the wound, the condition of the system, and the absence of complications. 
In incised wounds in which a portion of bone is sliced off, but still retains some of its 
attachments through the soft parts, the flap should immediately be replaced, and confined 
by sutures, plaster, and bandage. When, on the contrary, the separation is complete, 
reunion could hardly be expected, although the attempt might not be unworthy of trial. 
When a small bone, as a digital phalanx, is entirely cut through, the ends may very pro- 
perly be connected with silver wire, the more especially when there is more than ordinary 
difficulty experienced in keeping the parts in place. 
2ndly. Contused Wounds.—In this variety of injury, the osseous tissue is, as the name 
implies, not only denuded,but more or less bruised, compressed, or condensed by the forcible 
approximation of its component elements. The lesion is strictly analogous to a contused 
wound of the soft structures. The most common causes of such an occurrence are blows, 
falls, kicks, and gunshot violence, especially that variety of it in which the force of the bullet 
is in great measure spent before it reaches the bone. A bone may be severely bruised 
without any wound either of its own substance or even of the skin. Such an injury falls 
properly under the denomination of a contusion. A simple fracture, as it is called, affords 
a good illustration of the amount of injury which a bone may sustain without any serious 
participation of the soft structures. 
A bruise of the osseous tissue, however slight, is always attended with rupture of the 
vessels of the part, and, consequently, with more or less effusion of blood, occupying its 
cells, and thus compressing its substance. When the infiltration is considerable, it must 
necessarily act as a foreign agent, exciting inflammation, which, if not kept within proper 
limits, may eventuate in suppuration and even gangrene. Another serious effect of such 
a lesion, especially if it is at all severe, is the immediate destruction of the vitality of the 
affected tissue, from the arrest of its circulation and innervation. The component ele- 
ments are fatally compressed, being placed in a condition similar to that of a soft structure 
in a bruised and pulpified state. In both instances death occurs without inflammation. 
In general, however, this action is set up, and finally terminates either in resolution, sup- 
puration, or gangrene. If the injury is severe, its effects will not be likely to be limited 
to the bone, but extend also to the periosteum, to the medullary membrane, and even to 
the muscles and other textures. Osteitis, periostitis, and endosteitis, indeed, are by no 
means uncommon after such accidents; large pieces of bone sometimes perish in this way, 
and the patient, after passing through intense suffering, both local and constitutional, may 
consider himself happy if he escapes with limb and life. The morbid action is excessive; 
the soft parts are enormously swollen from inflammatory deposits; the pain is agonizing; 
the skin exhibits an erysipelatous blush ; and there is high general excitement, with a 
tendency to delirium and rapid prostration: Matter forms in large quantities both within 
the medullary canal, in the osseous tissue beneath the periosteum, and among the muscles, 
and, if not speedily evacuated, is apt to diffuse itself more or less extensively through 
the surrounding structures. Such cases are often followed by death from constitutional 
irritation and hectic fever. The worst attacks may end fatally in a few days. The dan- 
ger is always imminent when the contusion involves the articular extremity of a large 
joint, as the knee, hip, or ankle. 
Among the more remote secondary effects of contusion of the osseous tissue is intersti- 
tial absorption, leading to atrophy and change of form of the affected structures, as is 
exemplied in interstitial absorption of the head and neck of the thigh-bone after severe 
contusion, or contusion and concussion of the great trochanter from falls and other 
injuries upon the thigh and hip. 
Even a very slight contusion, if a bone, as the tibia, ulna, clavicle or cranium, is only 
thinly covered, is sometimes followed by severe local and constitutional symptoms; the 
inflammation is prone to assume an erysipelatous character, and to give rise to subperios- 
teal abscesses, attended with great pain and swelling. In elderly subjects, contusion of 
the osseous tissue often gives rise to atrophy and various ossifie deposits. 
The diagnosis of contusion of the osseous tissue is often very diflieult. Indeed, in 
many cases it is purely a matter of conjecture, based upon the condition of the parts, as 
the discolored and bruised appearance of the skin, the existence of ecehymosis, and the 
peculiar character of the secondary symptoms. When the bone is laid bare by the acci- 
dent, the true nature of the case is often perceptible at a glance. 
The prognosis should always be guarded; for, as previously stated, even an apparently 
insignificant injury of this kind is sometimes followed by loss of limb, if not also by loss 
CHAP. VIII. WOUNDS AND CONTUSIONS OF BONES. 
833 
CHAP. VIII . 
of life. When the lesion is very severe, the worst results may be anticipated, either 
proximately or remotely, the most common sources of danger being shock, erysipelas, 
pyemia, and hectic irritation. 
In the treatment of this variety of injury, the ordinary means must be adopted for 
counteracting inflammation and its consequences. Leeches and saturnine lotions will be 
needed in the earlier stages, and afterwards free incisions to relieve pain and tension, and 
afford vent to the pent-up deposits. Dead bone is removed as soon as it is sufficiently 
detached. If symptoms indicative of the existence of abscess of the affected bone arise, 
recoui'se is had to the trephine. Amputation will be likely to be demanded when one of 
the principal joints has been laid open, or when, along with severe contusion, there is a 
comminuted fracture, serious lesion of the soft parts, or a wound of the main artery, veins, 
or nerves of the limb. 
3rdly. Lacerated, Punctured, and Gunshot Wounds.—The best example of a lacerated 
wound of a bone is an ordinary fracture, in which the osseous fibres are forcibly torn 
asunder. The injury is essentially similar to a lacerated wound of the soft structures. 
Such a lesion may be perfectly simple as it respects the osseous tissue, or this tissue 
may be torn into fragments, of variable shape and size, constituting what is known as a 
comminuted fracture. The soft structures may be little implicated, or they may be more 
or less extensively bruised and lacerated, and in this way a case, in itself comparatively 
unimportant, may assume a most serious character, placing limb and life in jeopardy. 
Punctured wounds are generally caused by bullets, and will be serious or otherwise, 
according to the shape and size of the projectile, the force with which it is impelled, and 
the importance, as a protective organ or an agent of locomotion, of the part struck. 
Punctured wounds of the skull, for example, however inflicted, are always fraught with 
danger, inasmuch as the inner table is almost invariably more or less depressed, and thus 
brought injuriously in contact with the brain and its envelops, leading to suppuration and 
other mischief. Punctured wounds of the long bones, especially such as are caused by 
gunshot violence, are generally attended with comminution of the osseous structure, and 
are to be regarded as among the most serious of accidents, liable to be followed by loss of 
limb and life. Even the milder forms of such lesions are often productive of the worst 
consequences, the primary effects being osteitis, periostitis, or medullitis, and the secon- 
dary suppuration, abscess, or necrosis. 
The vulnerating body in a punctured wound either lodges in the bone, or it perforates 
the bone and then either makes its escape or buries itself in the soft structures. The 
edges of the opening of entrance in a gunshot wound are generally somewhat depressed, 
whereas the edges of the orifice of exit are always more or less ragged and irregular. In 
fact, there is the closest resemblance, in these respects, between a gunshot wound of a 
bone and a similar lesion of the common integument. 
In regard to the treatment of these several classes of wounds, nothing need be said 
here, as it is discussed at sufficient length in the chapters on gunshot injuries, fractures, 
and other lesions. 
2. Wounds of the Periosteum Simple incised wounds of this membrane are of little 
moment; for, if properly managed, they either unite by the first intention or they are 
speedily repaired by the granulating process. Suppuration and gangrene seldom occur, 
except in persons of dilapidated health, or when the lesion is associated with more or less 
contusion, or contusion and laceration. Ordinary punctured wounds also generally read- 
ily heal; gunshot wounds, on the contrary, are often followed by violent inflammation, 
extensive infiltration of pus, and even devitalization, not only of the membrane itself, but 
also of the corresponding portion of the bone and of the endosteum. A severe contusion, 
such, for example, as that caused by the glancing of a musket-ball, or by a blow, fall, or 
kick, is always a grave accident, especially if the periosteum is partially detached; for 
then suppuration of the membrane, if not also necrosis, will be almost sure to ensue from 
the disruption of the circulation and innervation of the part. Even a slight contusion of 
this membrane, if thinly covered, as in the tibia and ulna, may cause severe erysipelas 
and other troublesome inflammatory symptoms. 
It is generally believed that when a bone is deprived of periosteum it must necessarily 
perish; but this is so only when the loss is very considerable. Ordinarily the part retains 
its vitality, granulations gradually spring up, and ultimately the breach is repaired by the 
formation of an analogous tissue, not so perfect, indeed, as the original, yet sufficiently to 
answer the purpose of a substitute covering. When the denudation is extensive, death 
is inevitable; for then the osseous tissue is deprived both of blood and nerve fluid, and, 
consequently, dies from the want of nourishment. The effect thus produced closely 834 
DISEASES AND INJURIES OF THE BONES. 
CHAP. VIII . 
resembles senile gangrene, the result of obstruction of the vessels by fibrinous concretions. 
In some cases the death of the affected bone is direct, that is, it takes place without the 
intervention of inflammation; in general, however, a slight action of this kind is set up, 
but soon terminates in gangrene, the osseous tissue being incapable of furnishing pus and 
of undergoing the various changes which ordinarily precede the occurrence of necrosis. 
The most common cause of denudation of bone is external violence. In compound 
fractures attended with protrusion of the ends of the fragments, the periosteum is often 
extensively stripped off, and the consequence is that the part, unless speedily replaced, 
soon perishes. Great mischief is frequently inflicted upon this membrane by the saw in 
amputation. The femur, in particular, is remarkably prone to suffer from inflammation 
from this cause, as is proved by the immense exfoliations which sometimes occur after 
this operation. A bone is occasionally completely stripped of its fibrous covering by an 
accumulation of pus between the two opposed surfaces, in consequence of periostitis and 
osteitis. 
Owing to the important role which this membrane plays in the nourishment and pre- 
servation of the osseous tissue, the utmost care should be taken to keep it intact in surgi- 
cal operations, and to place it in the most favorable position for speedy reunion in cases 
of injury. Not a particle, unless it is absolutely dead, should be cut away. If any por- 
tion lias been accidentally torn off, the denuded bone should be promptly covered with the 
natural tissues in its immediate vicinity, or, in the event of their loss, with an emollient 
poultice, to protect the exposed surface from the contact of the air, and thus afford it a 
chance to develop granulations. If matter form beneath the-periosteum, it cannot be too 
speedily evacuated, on account of the danger to the corresponding bone. In the milder 
forms of contusions leeches and saturnine lotions are the most reliable means. 
3. Wounds of the Endosteum—Wounds of the endosteum, medulla, or marrow, can 
occur only in connection with similar lesions of the periosteum and osseous tissue, its 
peculiar situation precluding it from being injured by itself. The most common causes of 
such wounds are fractures, blows, falls, and kicks, and operations performed for the relief 
of disease either of the soft parts or of the bones, as amputations and resections. Among 
the more severe forms of wounds of the endosteum are compound, comminuted fractures 
from gunshot injury, laying open the medullary canal, lacerating and bruising the lining 
membrane, and shattering the osseous tissue into numerous fragments. Very serious 
injury is sometimes inflicted upon this membrane by the concussion of a bone produced 
by being struck by a partially spent ball, the effect being analogous to that inflicted upon 
the brain and its membrane when a person receives a blow upon the skull. The bone 
itself may in reality be very little hurt, and yet the shock transmitted across the osseous 
fibres be sufficient to light up violent morbid action. 
The effects, immediate and remote, of wounds of the medulla, must necessarily vary 
with many circumstances, as the character and extent of the lesion, the presence or 
absence of complications, and the state of the system at the time the injury was received. 
Owing to the vascularity of the membrane, there is often a good deal of blood effused, 
the pressure of which may afterwards provoke more or less inflammation. Sometimes 
this is the case when the amount of fluid is extremely small, as when it presents itself 
simply as an ecchymosis. When the medullary canal is extensively exposed, the hemor- 
rhage may be quite profuse, especially if the endosteum is extensively lacerated and 
detached. The resulting inflammation may, on the one hand, be very slight; or, on the 
other, so violent as to pass rapidly into suppuration and even gangrene, not only of the 
membrane itself, but also of the corresponding portion of the bone and of its fibrous 
envelop. Such cases are generally attended with severe constitutional disturbance, as 
well as much local suffering; the soft parts are the seat of erysipelas; and the system, 
especially if not in a sound condition at the time of the infliction of the injury, is very 
prone to be invaded by pyemia. The marrow, if exposed to the contact of the air, will 
be found to be, at first, of a pale violet hue from vascular congestion, and afterwards of 
a grayish, brownish, or ashy color, softened, diffluent, excessively fetid, and bathed with 
pus or sero-oleaginous fluid. The bone around is dead, the periosteum is detached, and 
the muscles and other tissues in the neighborhood of the disease are in a high state of 
inflammation. 
The treatment must be conducted upon the same principles as in wounds of the bones 
and periosteum. The parts must, if possible, be placed in their natural relations, and 
every effort made to limit the morbid action. The hemorrhage may generally be checked 
by compression with a soft pledget of lint, sponge, or agaric, retained by the finger, until 
the flow ceases. All irritating applications must be avoided, as likely to excite undue PE RIOSTITIS. 
835 
CHAP. VIII. 
inflammation. A free outlet should be formed for matter, and dead bone should be 
removed as soon as it is sufficiently detached. 
SECT. II PERIOSTITIS. 
The occurrence of periostitis is by no means infrequent, its causes being those of osteitis, 
with which, especially in its acute form, it is usually associated. Among the most common 
of these causes are various kinds of external injury, as fractures and dislocations, blows, 
contusions, gunshot wounds, and the application of escharotic substances; and the effects 
of gout, rheumatism, and syphilis, operating upon a disordered and dilapidated state of 
the system. There is one form of whitlow which is essentially a periostitis, attacking 
usually one of the fingers, and liable, if neglected or improperly treated, to terminate in 
extensive suppuration and necrosis of the distal phalanx. Inflammation of the periosteum, 
of a very severe and destructive nature, is occasionally produced by deep-seated abscesses, 
extending to, and irritating that membrane, as sometimes happens, for example, in phleg- 
monous erysipelas, where the matter burrows extensively among the surrounding tissues. 
Two forms of the disease are met with, the acute and chronic, the latter being the more 
common. 
Acute Periostitis—In the acute form of inflammation, the fibrous membrane is com- 
monly of a reddish, pink, or lilac hue, its vessels are loaded with blood, and its substance 
is sensibly softened, as well as slightly thickened from interstitial deposits. Its attach- 
ment to the bones is also considerably diminished, so that it may readily be peeled off, 
and the connective tissue immediately over its outer surface is generally infiltrated with 
sero-albuminous matter. These changes, which are present, in greater or less degree, in 
all cases of periostitis, are often very conspicuous upon the fragments of a broken bone, 
and in incised wounds of the muscles, involving the membrane in question. 
The disease not unfrequently passes into suppuration, the occurrence being particularly 
liable to happen in the periosteum of the bones of the inferior extremity, as the femur 
and tibia, and in the phalanges of the thumb and fingers ; in the former as a consequence 
of cold acting upon a strumous constitution, or of the effects of mercury, or of mercury 
and syphilis, and in the latter as a result of whitlow. 
Abscesses of the periosteum are of two kinds, the circumscribed and the diffused. Of 
the former familiar examples are seen in the jaws, in what is called a gum-boil, and in 
the ends of the fingers in whitlow. A syphilitic node affords another illustration of such 
an occurrence, so frequently witnessed in the tibia, clavicle, cranium, and other superficial 
pieces of the skeleton. The matter in this variety of abscess is ordinarily very thick, of 
a pale yellowish or yellow-greenish color, deep-seated, and of rapid formation. The 
periosteum at the focus of the morbid action is spongy, swollen, congested, and infiltrated 
with sero-sanguinolent fluid, and the corresponding portion of the bone is in a carious or 
necrosed condition. 
The diffused abscess of the periosteum is a most formidable disease, generally proceed- 
ing with extraordinary rapidity, and often committing the most frightful ravages in a few 
days. It usually occurs in young subjects under fifteen years of age, of a scrofulous or 
syphilitic taint of the system. Its most common sites are the femur and tibia, which are 
not unfrequently almost completely stripped of their fibrous covering. The matter, which 
often forms in enormous quantities, is thin, bloody, fetid, and intermixed with flakes of 
lymph, clots of blood, and the debris of disintegrated tissue. The nearest joints in 
these violent cases usually participate in the disease; the synovial membrane becomes 
inflamed ; and, if great care be not taken, ankylosis ultimately ensues. The bone and 
endosteum are always seriously involved in the mischief. 
A violent form of periostitis not unfrequently supervenes upon injury of the skull, 
especially in punctured and contused wounds, and is very prone to terminate in extensive 
suppuration, the pus lifting up the pericranium from the bone, which looks white, grayish, 
or drab-colored, and often perishes from the effects of the disease. In lying-in women 
violent periostitis sometimes occurs as a secondary affection in the iliac bone, near the 
hip-joint; the suffering is excessive, and the affection is very liable to be mistaken for 
coxalgia, the more so, as it sometimes passes into suppuration. Inflammation of the peri- 
osteum over the great trochanter is also apt to be confounded with coxalgia, and is often 
followed by abscess, caries, and even necrosis of the upper portion of the femur. 
Mortification, as a termination of this disease, is uncommon. The occurrence is charac- 
terized by a dirty, ash-colored appearance of the affected membrane, which is, at the same 
time, very much softened in its texture, and saturated with a foul, offensive fluid, emitting 836 
DISEASES AND INJURIES OF THE BONES. 
CHAP. VIII. 
an unmistakably gangrenous odor. Such an event is necessarily associated with necrosis 
of the corresponding bone, and frequently, also, with mortification of the endosteum, all 
perishing together in consequence of the destruction of their vascular connections. The 
best examples of this mode of termination occur in the periosteum of the alveolar processes 
of the jaws, from the abuse of mercury, and in that of the tibia, from the effects of 
syphilis. The sloughs, which are always tough and shreddy, are usually thrown off with 
considerable difficulty, owing to the tardy and imperfect action of the circumjacent 
structures. 
The symptoms of periostitis are similar to those which usually attend inflammation of 
the deep-seated structures generally, the pain being of a violent and pulsatile character, 
and the swelling of the soft parts diffused and (edematous, with excessive heat of surface, 
and more or less constitutional disturbance. The occurrence of suppuration is announced 
by rigors, with a marked increase of local suffering; and as the pus accumulates, the 
superincumbent integument assumes a shining, glossy, erysipelatous aspect, pitting under 
pressure, and imparting a distinct sense of fluctuation. Both in suppuration and mortifi- 
cation the pain is intense, and the patient generally labors under high fever and often also 
under delirium. If relief be not speedily afforded, hectic irritation sets in, and death may 
occur from sheer exhaustion. The danger from pyemia is always great in such cases. 
In periostitis consequent upon a syphilitic taint of the system, the suffering is always 
worst at night, the pain being of a severe, aching, or gnawing character, and invariably 
aggravated when the patient becomes warm in bed. Small, circumscribed swellings, or 
nodes, frequently exist, and are exquisitely tender on pressure and motion, the skin over 
them being red, inflamed, and oedematous. The contents of these swellings are generally 
of a thick, gummy character, possessing none of the properties of genuine pus. 
In gouty and rheumatic periostitis the pain is deep-seated, wandering, or migratory, 
and generally very severe ; the soft parts over the seat of the disease are discolored, glossy, 
and puffy ; slight effusions of sero-plastic matter often exist beneath the affected membrane, 
forming small, rough, and irregular swellings, which are easily detected by the finger ; 
the system is disordered by fever; the perspiration is acid and copious; and the urine is 
scanty and high-colored, depositing a large quantity of lateritious substance upon the 
bottom of the receiver. The most reliable symptoms, in a diagnostic point of view, are, 
the shifting character of the disease, the involvement of the joints, and the history of 
the case. 
In the treatment of acute periostitis, a primary object is to seek for, and, if possible, to 
remove, the cause of the disease. The traumatic form is to be managed upon ordinary 
principles. Idiopathic periostitis is often a self-limited affection, tending to terminate in 
suppuration, despite the best directed efforts of the surgeon. Examples of this constantly 
occur in whitlow and in some varieties of necrosis, in which periostitis commonly plays 
an important part, the morbid action being apparently dependent rather upon some iir- 
scrutable constitutional trouble than any special local cause. General treatment can 
seldom be altogether dispensed with, while in many cases it constitutes our most valuable 
resource, no progress of a favorable character being made without it. In the more severe 
forms, bloodletting, active purgatives, and saline and antimonial preparations, will proba- 
bly be required, along with anodynes, to allay the excessive pain which is so often pre- 
sent. The most important topical remedies are leeches, iodine, blisters, and saturnine 
lotions with laudanum. If great tension exist, with a tendency to suppuration, deep 
incisions are made without waiting for fluctuation, which is often extremely difficult of detec- 
tion, unless the affected structure is very superficial, as, for example, in periostitis of the 
tibia. The necessity of this operation cannot be too strenuously insisted upon, as it is 
the only way in which we can afford prompt relief to the suffering, and obviate extensive 
and irremediable mischief, as must inevitably happen when the matter is permitted to 
burrow. After evacuation has been effected, the sides of the abscess should be brought 
together with a compress and bandage, otherwise copious hemorrhage may arise in con- 
sequence of the crippled and enfeebled condition of the vessels, and finally destroy the 
patient. When mortification takes place, the same treatment must be adopted as under 
ordinary circumstances. 
In all the more violent forms of diffused abscess, antiphlogistics, if eligible at all, must 
soon give way to stimulants and tonics. The system, exhausted by the intensity of the 
suffering, must be supported with milk-punch, quinine, iron, and opium, in full and sus- 
tained doses. Great attention must be paid to cleanliness, the air of the apartment must 
frequently be renewed, and the cavity of the abscess must be injected several times a day CHAP. VIII. 
NEURALGIA. 
837 
with weak solutions of carbolic acid, chloride of zinc, permanganate of potassium, or 
chlorinated sodium. During convalescence, cod-liver oil often proves serviceable. 
In syphilitic periostitis the best remedy is some one of the iodides, in doses of five to 
ten grains three times a day, either alone or in union w’ith bichloride of mercury. If 
nodes form, they will generally disappear under the influence of tincture of iodine, blisters, 
or mercurial inunctions, interference with the knife being seldom demanded. 
Periostitis caused by rheumatism and gout requires the use of colchicum, Dover’s pow- 
der, or Dover’s powder and quinine, with systematic purgation, and occasionally, perhaps, 
slight ptyalism, with leeches, fomentations, and alkaline and anodyne liniments. 
Chronic Periostitis The periosteum, in chronic inflammation, is thickened and indu- 
rated from the effusion of plastic matter. The hypertrophy—for so it may be termed— 
often involves a considerable extent of surface, forming a diffused, incompressible swelling, 
fibrous, cartilaginous, or even osseous in its character. Sometimes, on the other hand, 
the enlargement is very small and circumscribed, not exceeding, perhaps, the end of the 
little finger or half a dime. It may be caused by some specific constitutional poison, 
especially the syphilitic, or by external violence, as a blow, fall, or kick, as is often the 
ease when it exists on the skull. However induced, its development is attended with a 
constant, deep-seated, gnawing pain, which is usually most severe at night w’hen the body 
becomes warm in bed, and which occasionally assumes a veritable neurrdgic character. 
After continuing for an indefinite period, the disease often remains stationary, gradually 
disappears, or excites suppuration in the overlying tissues. 
These chronic affections of the periosteum are generally peculiarly obstinate and in- 
tractable, requiring specific remedies, frequently varied and long continued, for their cure. 
Iodide of potassium and mercury, Donovan’s solution, and the different preparations of 
arsenic, with blisters, iodine, leeches, the vapor bath, and mercurial fumigations, are the 
means most likely to prove beneficial. In obstinate cases, resisting the ordinary remedies, 
free incisions, extending through the substance of the thickened and indurated membrane 
down to the bone, will afford more relief than anything else, especially if the wound be 
made to suppurate abundantly. 
Bony tumors, growths, or deposits of this membrane, are to be treated upon the same 
principles as exostoses, properly so termed. When small, not painful, or not inconve- 
niently situated, they will probably require no attention. Occasionally they disappear 
spontaneously, or under the influence of very simple remedies. Such formations are 
nearly always caused by the effects of the gouty, rheumatic, or syphilitic poison, and are, 
therefore, generally greatly benefited by iodide of potassium and a mild course of mercury. 
Finally, the periosteum is sometimes the seat of the morbid growths, as the sarcomatous 
and fibrous, affections which will be discussed in the section on tumors of the bones. 
NEURALGIA. 
Neuralgia of the periosteum, as a simple, uncomplicated affection, is infrequent. The 
most common exciting causes are, external injury, as a bruise or contusion, miasm, sudden 
suppression of the cutaneous perspiration, and a syphilitic taint of the system. Any por- 
tion of the skeleton may suffer from it, but the parts most frequently assailed are the 
cranium, clavicle, ulna, ribs, and tibia, bones which are comparatively superficial, and 
which, apparently for this reason, are particularly prone to exposure and accident. I 
have repeatedly met with severe neuralgia in the pelvic bones, and a peculiarly obstinate 
form of the disea.se, known as coccydynia, is occasionally witnessed in the coccyx. The 
affection is generally associated with neuralgia of the osseous tissue, and is not confined to 
either sex or to any particular period of life. What influence, if any, temperament may 
exert upon its production is undetermined. 
The characteristic symptom is violent pain, generally limited to some particular bone 
or portion of bone, occupying a space not larger, perhaps, than two or three inches in 
extent; either sharp and darting, or, as more frequently happens, dull, heavy, and aching, 
increased by pressure, motion, and dependency, commonly worst at night and in damp 
states of the atmosphere, especially when the cause is syphilitic. The pain usually remits 
several times in the twenty-four hours, and cases occur, as when it is of miasmatic origin, 
in which it is distinctly periodical, the attack occurring with the same regularity as a 
paroxysm of intermittent fever. However this may be, the parts are always exquisitely 
sensitive on pressure, with a feeling of weight and numbness; and pain, of a severe char- 
acter, is not unfrequently experienced along the course of some particular nerve. There 
is no discoloration of the surface, or hardly ever any decided tumefaction. The general 838 
DISEASES AND INJURIES OF THE BONES. 
health, at first perfectly normal, is gradually impaired, and, in the more severe cases, 
ultimately completely ruined. 
Of the precise nature of this complaint nothing is known. It is probably, in the first 
instance, merely an affection of the nerves ; but, as the disease progresses, other structures 
become involved, until, eventually, inflammatory deposits are superadded, as is shown by 
the thickened, spongy, and congested condition of the periosteum and the roughened 
appearance of the corresponding portion of the bone. 
The diagnosis of this disease is not always very clear. The great trouble generally is 
to determine whether the morbid action is seated in the periosteum or in the bone which 
it covers. Practically, the distinction is of little moment, as the treatment is the same 
in the two complaints. The disorder, which often coexists with neuralgia in other parts 
of the body, is usually exceedingly obstinate and difficult to cure. 
The treatment must be regulated with special reference to the nature of the exciting 
cause of the complaint. The most reliable internal remedies are quinine, iron, strychnia, 
arsenic, and aconite, either hlone or variously combined, with an occasional laxative to 
regulate the bowels and secretions. The iodides will be required when the disease depends 
upon a syphilitic taint of the system. The best local applications are leeches, blisters, 
veratria ointment, iodine, lotions of chloroform and aconite, and hypodermic injections of 
morphia and atropia. In obstinate cases, attended with thickening of the periosteum, 
or organic disease of this membrane and the bone, nothing short of deep and extensive 
incision will be likely to do any good. 
SECT. Ill ENDOSTEITIS, MEDULLITIS, OK OSTEOMYELITIS. 
Under this name may be described a disease of the endosteum or medullary membrane, 
possessing all the characters of true inflammation, either acute or chronic, invariably 
coexisting with osteitis, and presenting itself in two distinct varieties of form, the idio- 
pathic and the traumatic. The former, like osteitis, is most common in children and 
young subjects before the age of puberty, and the tibia and femur are the bones that 
most frequently suffer. How this variety of the disease originates is not always easy of 
determination. In the great majority of the cases that have come under my observation, 
the immediate exciting cause seems to have been cold, or sudden suppression of the 
cutaneous perspiration, operating upon a weak, delicate constitution. Occasionally the 
affection depends upon some peculiar taint of the system, as the syphilitic, strumous, or 
scorbutic, provoking inflammation consentaneously in the endosteum, osseous tissue, and 
periosteum. 
The most common traumatic causes are fractures, gunshot wounds, the lodgment of 
foreign bodies in the substance of the bones, violent blows, contusions, concussion of the 
spongy tissue, and laceration of the endosteum by the saw in amputation of the limbs, of 
which the lesion is by no means an uncommon consequence, as is shown by the suppura- 
tion and necrosis which so often follow this operation. There can be little doubt that the 
disease is frequently produced by mere concussion of the limbs, transmitting its injurious 
effects along the canals of the long bones, thereby, perhaps, partially detaching portions 
of the lining membrane, and inducing serious disruption of the circulation. 
The morbid anatomy of the disease is best studied in one of the long bones, as the 
femur or tibia, after amputation. If several days have elapsed since the operation, the 
membrane will be found to be of a pale pink hue, more or less injected, and apparently a 
little thickened; the marrow is abnormally soft ; and the cells of the spongy structure of 
the canal are pervaded by a sero-sanguineous fluid. At a later period, when the inflam- 
mation is more fully established, the discoloration of the endosteum is of a more decided 
character, being of a deeper red with a shade of brown or purple, the fatty matter is 
broken up into a semiliquid substance, and, in addition to the bloody sanies just alluded 
to, traces of pus may be seen, forming numerous little points, of a yellowish aspect, which, 
gradually coalescing, at length assume the character of small abscesses. When the disease 
is uncommonly violent or protracted, portions of the endosteum are converted into veri- 
table eschars, of a brownish color, and of a characteristically fetid color; the periosteum 
opposite the seat of the morbid action is detached, and the intervening part of the bone, 
thus deprived of its vessels, speedily perishes. 
In the chronic form of the disease, which sometimes lasts for years, the osseous struc- 
ture is rendered abnormally hard, dense, and heavy, the medullary canal is in great 
measure, if not entirely, obliterated, and the endosteum, at the seat of the morbid action, 
is completely destroyed. Small cavities filled with a soft, oily material, or fatty, gelati- 
CHAP. VIII. ENDOSTEITIS, MEDULLITIS, OR OSTEOMYELITIS. 
839 
CHAP. VIII. 
nous substance, and surrounded by softened, vascular, reticulated tissue, are not unfre- 
quently found ; and cases are occasionally met with in which there are small abscesses 
and dead pieces of bone. When the disease is of long standing, the affected bone is 
always more or less changed in its form, rough on the surface, and remarkably thickened, 
compact, and heavy; in fact, greatly hypertrophied by the addition of new matter. 
The symptoms of endosteitis are so vague and unreliable as to render it very difficult, 
if not impossible, to distinguish them from those which attend inflammation of the bones 
and their fibrous envelop. Indeed, it is only when the disease occurs as the result of 
injury, as after amputation, that anything even like a plausible conjecture can be formed 
as to its real nature. Under such circumstances, upon taking off’ the first dressings, the 
wound opposite the end of the bone will probably be found to be gaping and filled with 
pus, the bone itself being either entirely denuded, or only slightly covered with lymph 
below, while the medullary membrane is of a reddish or brownish color, and more or less 
vascular. If six or eight days have elapsed since the operation, the exposed medullary 
surface will be likely to be studded with pale, flabby, unhealthy granulations, somewhat 
sensitive to the touch, if not decidedly painful, and discharging an abundance of thin, 
sero-sanguinolent fluid. Around this red and inflamed circle, the compact layer exhibits 
an unusually white, glistening appearance, without any trace of reparative action ; in 
fact, the bone is devitalized, or, if not actually dead, soon will be. Superadded to these 
phenomena, there is occasionally an escape of marrow, with or without fragments of the 
medullary membrane ; a sure sign of the inflamed and disorganized state of the parts. 
Endosteitis is always attended with considerable swelling and puffiness of the soft 
structures immediately over the affected parts, but there is not necessarily any discolora- 
tion of the surface, or any unusual pain. Considerable irritative fever is commonly 
present; the skin has a peculiar sallow hue ; and there are apt to be rigors, alternating 
with flushes of heat, and followed by copious sweats, generally of a disagreeable acid 
nature. When the disease is idiopathic, there may be tumefaction and pain, deep-seated 
and throbbing, at the site of inflammation, but neither of them of so distinctive a character 
as to be of any service in a diagnostic point of view. 
However induced, or in whatever form occurring, the disease generally manifests a 
disposition to affect the contiguous joints, being apparently propagated from the cancel- 
lous structure to the synovial membrane. The form in which the articular affection 
usually appears is that of a moderate degree of inflammation, attended with more or less 
effusion of synovial fluid, or of this fluid and of plastic matter, and a certain degree of 
pain and functional disturbance, so constantly present in disease of the joints. When the 
malady is uncommonly severe, the articular structures generally suffer in a proportionate 
degree; for then not only the synovial membrane, but also the end of the bone and its 
cartilaginous covering participate in the morbid action ; abscesses are liable to form both 
within and around the affected joint; the soft structures are enormously swollen ; the skin 
has a glossy, erysipelatous appearance; and there is excessive constitutional disturbance, 
rapidly followed by hectic fever. If the case is not properly treated, the pus may burrow 
extensively among the surrounding parts, giving rise to numerous sinuses, which it will 
be difficult, if not impossible, to heal. The joints that are most liable to suffer in this 
way are those of the knee and ankle, especially the former. 
In the idiopathic form of endosteitis of young subjects the epiphyseal fibro-cartilage not 
unfrequently suffers, becoming inflamed, and, in the more severe cases, the seat of puru- 
lent depots. Now and then the connection is entirely destroyed, the head and shaft of 
the bone being detached from each other as completely as in diastasis. 
The danger in endosteitis is generally very great, as it is liable, if the disease is at all 
severe or wide-spread, to cause extensive necrosis, and to place limb and life in peril by 
the induction of inflammation in the principal veins of the corresponding extremity and 
the formation of abscesses in the different viscera, especially the lungs and liver. Occa- 
sionally, it would seem to be capable of assuming a kind of endemic tendency. Thus, in 
1814, nearly all the patients at the Uotel-Dieu, in Paris, who died after amputation, and 
the number was very considerable, were observed to have suppuration in the medullary 
membrane of the long bones. 
The treatment of endosteitis must be conducted upon general antiphlogistic principles, 
local and constitutional, in the hope of limiting morbid action and preventing the occur- 
rence of suppuration and gangrene. If the medullary canal is exposed, some mildly stimu- 
lating injection, such as a very weak solution of nitrate of silver, tannic acid, or acetate 
of zinc, may be useful, the part being protected from the atmosphere by lint wet with a 
similar fluid, or an emollient cataplasm. When the membrane is affected in its con- 840 
DISEASES AND INJURIES OF TIIE BONES. 
tinuity, and there is much swelling of the soft structures, free incisions may be necessary 
in order to relieve tension and promote the escape of the effused fluids. If there is reason 
to apprehend the existence of medullary abscess, as when there is deep-seated, aching, 
gnawing, or boring pain, with oedema of the subcutaneous connective tissue, the matter 
must be exposed with a small trephine, as the only chance of averting still more serious 
consequences. 
In the strictly chronic form of the disease, our chief reliance is upon iodide of iron and 
iodide of potassium, with minute doses of bichloride of mercury, tonics, cod-liver oil, 
change of air, and counterirritation. In the more hopeless cases it may be necessary to 
trephine the affected bone, or even to resort to amputation. 
SECT. IV. EPIPHYSITIS. 
Under this appellation may be briefly described an affection which, commencing in the 
osseous tissue, the periosteum, or the medullary membrane, gradually extends to, and 
eventually expends itself chiefly upon, the soft pulpy, vascular fibro-cartilage between the 
epiphysis and the shaft of a bone. This substance, which performs a most important role 
in the growth of bone, does not entirely disappear until the completion of the ossific pro- 
cess, about the close of the twenty-fourth year. Its main object seems to be twofold: 
first, to serve as a bond of connection, and, secondly, to assist in maintaining the circula- 
tion in the two pieces of bone between which it is situated. 
Epiphysitis is essentially a disease of early life, the great majority of cases occurring 
before the tenth year. Although occasionally arising spontaneously, it is ordinarily 
caused either by suppression of the cutaneous perspiration or by external injury, as a 
sprain, blow, or contusion. Children of a strumous, scorbutic, or sypliilitic taint of the 
system, ill-fed, pale and anemic, are its most common subjects. Sometimes it would 
seem to have a rheumatic origin. The attack may be primary, beginning in the epiphy- 
sary structure, but this is unusual. In the great majority of cases it is, as already stated, 
propagated from the neighboring tissues. However this maybe, the affection is generally 
of an acute character, and runs its course with extraordinary rapidity and violence. 
The pieces of the skeleton which are most liable to suffer are the femur, tibia, humerus, 
ulna, and radius, the relative frequency being in the order here stated. Of 13 cases 
observed by Dr. Klose, 7 affected the femur at the knee, and 4 the tibia, of which 3 
involved the superior epiphysis. From the fact that so many cases of this disease were 
observed by one surgeon, it may be inferred that it is very frequent in Germany; in this 
country, on the contrary, it is very uncommon, or, if not uncommon, it has not hitherto 
been accurately discriminated. 
The approach of the disease is generally announced by febrile disturbance, if not by a 
severe rigor, and by violent pain, often apparently of a rheumatic nature, in the situation 
of an epiphysis, in the immediate vicinity of a joint. The affected part, hot and tender, 
pits on pressure, but, except in rare cases, there is, as yet, no decided redness of the skin. 
The contiguous joint, which always participates in the morbid action even at an early 
period of the attack, is stiff, semiflexed, and exquisitely sensitive upon the slightest motion. 
In the more severe cases, there are cord-like indurations below the affected surface, 
evidently caused by inflamed veins and lymphatic vessels; and, if an exploring needle 
be introduced, it will be found that the bone is roughened and separated from the peri- 
osteum by a thin, turbid fluid. If the disease be not checked, it will gradually run into 
suppuration ; the matter is deep-seated, and, unless promply evacuated, will diffuse itself 
extensively among the surrounding structures, separating them from each other, and 
thus occasioning irreparable mischief. Finally, the connecting medium is completely 
destroyed, and the ends of the two pieces of bone may be seen and felt beneath the 
skin as in a common fracture. The local and constitutional symptoms are proportionately 
severe. The pain and swelling are excessive, the surface is covered by an erysipelatous 
blush, the limb is perfectly useless, and the system is exhausted by hectic irritation and 
profuse sweats. 
The diagnosis of epiphysitis is generally very difficult. The affections with which it is 
most liable to be confounded are periostitis, osteitis, and endosteitis, from which it is 
often impossible to separate it, especially in its earlier stages. When the epiphysary fibro- 
cartilage has been completely destroyed, the preternatural mobility, crepitation, and dis- 
placement of the extremities of the bone will sufficiently indicate the nature ot the com- 
plaint. An error of diagnosis is the less to be regretted, because the treatment of these 
different maladies is essentially similar. 
CHAP. VIII. CHAP. VIII. 
OSTEITIS. 
841 
If the patient dies in the second stage of the disease, the ends of the bones will be 
found to be soft and spongy, and soaked in thin, ichorous matter, the line of demarcation 
between them being indicated by a deep groove. The muscles are of a dark brownish 
color, isolated, and marked by little blackish dots of blood and pus. The veins, large as 
well as small, are obliterated, and occupied by hard coagula. The contiguous joint con- 
tains serum and plasma, but only in very small quantity; for, as yet, its structures are 
not seriously injured. When the morbid action has reached its maximum, the contents 
of the abscess are intermingled with clotted blood ; the connecting bond at the epiphysis 
is completely annihilated ; the shaft of the bone for a considerable distance is necrotic, 
denuded of periosteum, bathed in pus, and of a dark, black, or grayish color; the 
medullary canal everywhere exhibits traces of high inflammation, with unhealthy-looking 
exudation and a tendency to suppuration ; and the neighboring joint, filled with pus, is 
extensively disorganized, the cartilaginous incrustations being broken down and the liga- 
ments partially destroyed. 
The prognosis of the disease may be gathered from its clinical history. If the milder 
cases occasionally get well, the more severe must, of necessity, be nearly always fatal; 
or, if not fatal, followed by loss of limb. The great danger is from erysipelas, pyemia, 
exhaustion, and hectic irritation. Recovery seldom occurs without partial ankylosis of 
the contiguous joint, and a slight arrest of development of the affected limb, below the 
epiphysis, the latter of which, as it possesses an independent vitality, continues its 
accustomed growth. 
The treatment must be conducted upon the same principles as in periostitis, osteitis, 
and endosteitis ; by rest and elevation of the part, anodyne and lead lotions, tincture of 
iodine, leeches, and, above all, early and free incisions, the knife being carried down to 
the surface of the bone. The system is supported with opium, iron, quinine, and milk 
punch. In the worst cases amputation alone holds out any hope of saving life. 
SECT. V OSTEITIS. 
Osteitis is a very common occurrence, especially in early life, owing, doubtless, to the 
great vascularity of the osseous tissue at that period rendering it more susceptible of dis- 
ease than in old age, when many of the, vessels shrink and disappear. It may be primitive 
or consecutive, acute or chronic; and in either event it may be limited to a particular 
portion of a bone, or prevade its entire length and breadth, although this is unusual. The 
spongy tissue suffers more frequently than the compact; and, while in the former, 
the disease often passes into ulceration, in the latter it more frequently causes necrosis, 
or mortification, the two structures being evidently endowed with different powers of 
resisting the effects of inflammation. The pieces most liable to be affected are those 
which are naturally the least covered by soft substance, as the tibia, fibula, ulna, clavicle, 
and frontal bone. The disease is generally slow in its progress, and a considerable period 
may, therefore, elapse before there is any very appreciable alteration of tissue. Cases, 
however, occur, in which it proceeds with immense and overwhelming rapidity, suppura- 
tion, ulceration, and even mortification appearing in less than forty-eight hours from the 
commencement of the attack. 
If a bone affected with inflammation be carefully examined, it will be found to exhibit 
several important structural changes of great interest. At first it is simply enlarged, 
although less so than is usually imagined, because much of what appears to be an increase 
of volume is due rather to swelling of the periosteum than to any actual expansion of 
the osseous tissue itself. Gradually the affected bone loses its density, becoming softened, 
and infiltrated with sanguinolent fluid, of a sero-plastic nature, and assuming a bright 
reddish hue, the capillaries being very numerous, turgid, and distinct. As the disease 
advances, the osseous fibres separate from each other, and the widened intervals are 
immediately filled with embryonic tissue, often intermingled with little clots of pure 
blood. These alterations are always attended by an absorption of earthy matter, which 
has the effect of fendering the bone both soft and spongy, at the same time that it 
causes an actual diminution of its weight. The lamellm of the compact substance are 
resolved, as it were, into their primitive distinctness, the Haversian canals are greatly 
enlarged, and the cells of the areolar texture are remarkably rarefied. When the disease 
has reached its maximum, the osseous tissue is frequently so soft as to be easily bent and 
cut. When the inflammation is superficial, affecting the outer layers of a bone, it always 
promptly extends to the periosteum, which, in consequence, becomes red, swollen, and 
infiltrated with serous and plastic matter. If, on the other hand, the inner structure is 842 
DISEASES A X D INJURIES OF THE BONES. 
CHAP. VIII. 
involved, the endosteum is sure to suffer, assuming a discolored, bloodshot appearance, 
while the adipose matter is either rapidly absorbed, or converted into a soft, diffluent mass, 
of a light reddish hue, and of a peculiarly fetid character. When the inflammation of the 
bone is at all extensive, both periosteum and endosteum participate in the morbid action, 
and it is in these cases, more especially, that, the circulation being cut off' by fibrinous 
exudation, necrosis is liable to arise. 
Osteitis may terminate in resolution, the morbid phenomena gradually disappearing, and 
the affected structures regaining their primitive texture ; or the disease may cease, and 
the bone become indurated and enlarged by interstitial osseous deposits; or, lastly, the 
inflammation may pass into suppuration, ulceration, softening, or mortification, the results 
resembling those of inflammation of the soft parts. It is seldom that a bone, after having 
Fig. 368. 
Hypertrophy of the Tibia from Inflammation. 
been inflamed for any length of time, will not, upon recovery, remain somewhat hyper- 
trophied, or larger and harder than it was before the attack, as illustrated in fig. 3G8. It 
is, in fact, nature’s mode of cure, the process which she employs for repairing the mis- 
chief committed by the disease. 
The causes of osteitis are either traumatic or constitutional, the former consisting of 
injuries inflicted in surgical operations, fractures, contusions, and wounds, especially gun- 
shot and punctured, and the latter of a syphilitic, strumous, scorbutic, rheumatic, or gouty 
taint of the system, together with the operation of cold. The disease may begin directly 
in the osseous tissue, or this may be involved secondarily, from extension of disease 
from the surrounding parts. Thus, in dislocations, particularly compound, and also in 
simple dislocations of the larger hinge-joints, as the elbow and knee, the inflammation 
consequent upon the accident is nearly always communicated to the contiguous extremities 
of the bones, rendering them soft and brittle, and liable to give way under the slightest 
influences. In like manner the periosteum often becomes the propagator of the morbid 
action ; for, although, in general, this membrane serves to ward off disease, forming a 
kind of wall between the soft structures and the bones, yet this barrier is not unfrequently 
overleaped, and inflammation kindled up in the very centre of these pieces. A great 
similarity is thus found to exist between the bones, periosteum, and endosteum, on the 
one hand, and the lungs, pleura, and bronchial mucous membrane, on the other, expe- 
rience having proved that disease cannot be present in any considerable degree, or for any 
length of time, in any one of these component elements without being propagated to the 
rest, which subsequently have often to bear the chief brunt of the incited action. 
Although acute osteitis is seldom dangerous, it may, nevertheless, occasionally prove 
fatal, especially if it be extensive, or complicated with other maladies, by the induction 
of erysipelas, pyemia, or constitutional irritation. Such an event will be most likely to 
happen in young scrofulous subjects, or in persons worn out by syphilis. The disease 
often terminates in serious and irremediable structural disorder of the affected part, as 
softening, caries, and necrosis, requiring important operations, themselves frequently a 
source of much risk. Recovery, under any circumstances, is generally extremely tedious. 
The symptoms of osteitis bear a great resemblance to those of periostitis and endosteitis, 
and, therefore, the most adroit diagnostician often finds it difficult to discriminate correctly 
between them. Practically, an error of this kind is of no special moment, as the treat- 
ment is essentially similar in the three affections, but as a matter of science it is very 
desirable in every instance to ascertain, if possible, in what structure the disease is located, 
or, if all are implicated, in what degree. There is really, however, no one symptom, or 
group of phenomena, upon which the least reliance can be placed in this respect. It may 
be said that the pain in osteitis is more intense, agonizing, and deep-seated than in inflam- 
mation of the periosteum and endosteum, and yet this is so only as a general rule; in 
many cases the difference is too slight to be appreciable. The same is true in regard to 
the swelling of the soft parts, and the constitutional disorders, which are often very great OSTEITIS. 
843 
CHAP. VIII. 
in all these affections, but, as they do not possess any distinctive features, are of no value 
in a diagnostic point of view. 
Acute osteitis is generally attended by the same symptoms as acute inflammation of the 
soft structures. The pain is excruciating, the part feeling as if it were torn, or bored, or 
as if insects were feeding upon it ; it is deep-seated, more or less circumscribed, and 
increased by motion, pressure, and damp states of the atmosphere ; it is also usually more 
violent at night when the patient becomes warm in bed, especially when it recognizes a 
constitutional origin. The swelling is extensive, firm, and almost inelastic, pitting, per- 
haps, after a time, under the application of the finger; the skin has a glossy, shining 
appearance; and there is intense heat of the surface, conjoined, in most cases, with an 
erysipelatous blush. The constitution sympathizing powerfully with the local disorder, 
there is high fever, with excessive thirst, a full, bounding pulse, great dryness of skin, and 
elevated temperature, with all the minor phenomena of general incited action. If the 
disease is not promptly restrained, the soft parts suppurate, the event being announced 
by rigors and delirium, followed by copious sweats. 
The symptoms of chronic osteitis are usually well marked. The bone is the seat of 
more or less pain, circumscribed, increased by motion and pressure, and aggravated at 
night, often depriving the patient of sleep and appetite. Enlargement of the affected 
part, with swelling and induration of the overlying tissues, is commonly a prominent 
phenomenon. Eventually suppuration occurs, followed by the formation of sinuses, diffi- 
cult to heal, and the seat of a constant discharge of thin, ichorous, sanious, or unhealthy 
matter, occasionally mixed with osseous [(articles. The constitution frequently sympathizes 
with the local disorder, as indicated by the pallor of the countenance, the gradual emacia- 
tion, and other evidences of failing power. 
Palpation and digital percussion have long been employed in the diagnosis of diseases 
of the osseous tissues, especially in the more superficial bones, as those of the head, back, 
pelvis, and leg. Although Roux called attention to the subject, we are mainly indebted 
for our present light to the researches of Professor Liicke, of Strasburg, published in 
1877, and comprising a series of valuable and laborious observations upon healthy and 
diseased bones. Instead of employing the finger, Liicke uses a hammer, consisting of 
metal tipped with an acorn-shaped point of caoutchouc, and furnished with a whalebone 
handle, so thin as to vibrate readily under the slightest touch. The percussion should be 
slight or considerable according to the depth of the bone, or the amount of substance by 
which it is covered, and successively applied to homologous [tarts, in order to test their 
comparative sensibility, otherwise the exploration will be, in great degree, if not wholly, 
worthless. In examining the limbs, they should be held up and firmly supported by an 
assistant, to prevent the sounds from being masked by the bedclothes or other material. 
In inflammation of the osseous tissue, the periosteum, or endosteum, a few smart taps with 
the hammer are sure to elicit marked tenderness, if not actual pain, and such an explora- 
tion is especially valuable in the incipient stages of the affection before the occurrence of 
serious structural changes. The amount of pain elicited by the percussion will afford a 
tolerably correct idea as to whether the disease is superficial or deep-seated. Thus, if, on 
gentle percussion, the patient complain of severe aching pain, and the pain is intensified 
under a more decided blow, the inference is that the affection is superficial; whereas the 
reverse is the case if pain be experienced only under forcible percussion. 
The character of the sound elicited by percussion presents important variations in health 
and disease. Liicke has shown that the shaft of a long bone yields a duller resonance under 
the hammer than its extremity, and also that the sound emitted by a bone is entirely inde- 
pendent of its connection with a neighboring joint, or the surrounding structures. As 
might naturally be supposed, all inflammatory deposits render the affected bone more or 
less dull on percussion ; and similar effects are produced in chronic osteitis attended with 
enlargement and condensation of the osseous tissue, as in hypertrophy, hyperostosis, or 
osteosclerosis. The callus of a broken bone emits a duller sound than the bone in its 
immediate vicinity. In osteoporosis, in which, as the name implies, the osseous tissue is 
more or less expanded, a remarkably hollow sound is often produced by percussion. 
Obviously such explorations are only applicable in chronic diseases of the bones, and in 
the earlier stages of the acute form. When acute inflammation is fully established, 
whether limited to the osseous tissue, or involving also the periosteum and endosteum, 
the morbid action affects the surrounding structures to such an extent as to render them 
intolerable of such rude manipulation. 
Treatment.—The most importment elements in the treatment of osteitis are bleeding, 
tartar emetic, purgatives, calomel, and opium, with perfect rest both of the part and body. 844 
DISEASES AND INJURIES OF THE BONES. 
CHAP. VIII. 
The prompt abstraction of blood by the lancet, or by leeches from the affected structures, 
generally proves of marked benefit in abridging suffering and limiting morbid action. 
Calomel is given as soon as the patient has been properly depleted, and is steadily con- 
tinued until gentle ptyalism is induced. There is no remedy which exerts so powerful 
and controlling an influence over inflammation of bone as this; and, although it should 
not be used causelessly, or without due precaution, there are few cases to which it is not 
applicable. To prevent it from running off by the bowels, and, at the same time, to miti- 
gate the excessive general and local distress, it should be administered in combination 
with large doses of opium, repeated as frequently as the exigencies of the case may seem 
to require. 
The best local remedies, apart from leeches, are warm anodyne fomentations, light 
cataplasms, medicated with acetate of lead and laudanum, dilute tincture of iodine, and 
cantharidal collodion, the hitter being applied in such a manner as to cover in the whole of 
the affected surface, and allowed to remain on until thorough vesication has been produced. 
If matter form, or even if there be merely great tension, the knife must be used, the in- 
cisions being long and deep, extending down to the very surface of the bone. Without such 
an expedient, relief is impossible. If the pus be allowed to accumulate, it will be sure to 
burrow, insinuating itself freely among the muscles, and, perhaps, even between the peri- 
osteum and bone, thereby detaching these parts from each other, and inducing exten- 
sive necrosis. What is done, in such a condition, for the soft structures, should, on the 
same principle, be done for the osseous. No surgeon hesitates when there is confined pus, 
along with great pain, tension, and swelling, to use the knife, making long and deep inci- 
sions to give vent to the effused fluid. Why should not a similar practice be adopted in 
suppurative osteitis? Here the matter is literally imprisoned, and can only be reached 
with the trephine. With a small instrument the bone is perforated at one or more points, 
followed by instantaneous relief, and the prevention of further inflammation, caries, and 
necrosis. This mode of treatment, in every respeet so rational and effective, was origin- 
ally brought before the notice of the profession in this country, in the latter part of the 
last century, by the late Professor Nathan Smith, of New Haven, and is one of the most 
valuable of the many practical suggestions made by that distinguished surgeon. An 
excellent paper, accompanied by the details of four cases illustrative of the beneficial 
effects of the operation, wras published by his son, Dr. T. Morven Smith, in the American 
Journal of the Medical Sciences for 1838. In every one of these cases matter flowred freely 
from the bone, although only a few days had elapsed from the commencement of the 
attack. 
In chronic osteitis the chief dependence is upon alterants, purgatives, and counter- 
irritation, of which the best form is an issue made with the hot iron as near as possible 
to the seat of the disease. A free discharge should be established and steadily main- 
tained until the morbid action is effectually broken up. The most reliable internal 
remedy is iodide of potassium in union with mercury, carried, in obstinate cases, to 
gentle and somewhat persistent ptyalism. Such a course is particularly indicated in 
syphilitic osteitis, but is hardly less beneficial in the rheumatic, gouty, and strumous 
varieties of the malady. 
Sir James Paget has described, under the term osteitis deformans, a remarkable variety 
of inflammation of the bones, characterized by enlargement and softening, with absorption 
of the old structure, and its replacement by fibrillar inflammatory tissue. The atfection, 
which has also been observed by Wilks and Bryant, is usually symmetrical, and affects 
especially the skull and the long bones of the lower extremity, which become curved and mis- 
shapen under the superimposed w'eight of the body. It begins in middle age, advances 
slowly, does not appear to shorten life, and is attended with dull, aching pains. Three 
of the five recorded cases terminated in connection with carcinoma. The disease is pro- 
gressive and irremediable. 
SECT. VI.—SUPPURATION AND ABSCESS. 
Suppuration of the external surface of bone is a very common occurrence, and may 
arise from various causes, as fracture and other external injury, or a syphilitic taint of the 
system. As the morbid action, however, which precedes and accompanies the suppura- 
tion, is usually associated with inflammation of the periosteum, it is difficult, in most 
cases, to determine which structure is really the source of the purulent matter. When 
the osteitis is of long standing, or characterized by inordinate severity, the pus is occa- 
sionally diffused through the proper substance of the bone, but such an occurrence can 
only happen in the event of the osseous tissue having undergone previous softening, the SUPPURATION AND ABSCESS. 
845 
CHAP. VIII. 
removal of the earthy matter being followed by the formation of cells or cavities for the 
lodgment of the. fluid. If a vertical section be made of a long bone, as the tibia, in an 
advanced state of inflammation, it will be found that the pus, presenting itself in small 
globules, will be scattered both through the Haversian canals and the cells of the areolar 
substance, no disposition being manifested in the little depots to arrange themselves into 
abscesses. The intermediate structure is of a reddish color, filled with fibrinous exuda- 
tion, and so soft as to be easily divided with the knife. This punctiform variety of 
suppuration is seldom so conspicuous as in inflammation of bone complicated with endo- 
steitis. 
Abscess of bone, distinct, circumscribed, and well defined, such as is seen in phlegmo- 
nous suppuration of the soft parts, is a very uncommon affection, almost invariably a 
remote result of a syphilitic taint. The 
formation generally takes place slowly, 
an unusual degree of chronicity being one 
of its natural concomitants. The most 
frequent seat of the disease is the head 
of the tibia, as seen in fig. 3G9, or the 
head and lower extremity of that bone, 
the expanded and rarefied tissue of 
which is peculiarly well adapted to such 
an occurrence. The abscess ranges in 
size from that of a pea to that of a 
pigeon’s egg; is generally solitary; is 
lined by a thin, although distinct, mem- 
brane; and is occupied by a dark-colored, 
ill-elaborated pus, more or less fetid, and 
intermingled with aplastic matter or 
curdy flakes similar to those observed in 
strumous pus. The surrounding tissues 
are softened, congested, and infiltrated 
with sero-sanguinolent fluid. The man- 
ner in which the abscess terminates is 
variable; when seated near the extremi- 
ty of a bone, it sometimes discharges its 
contents into the contiguous joint; at 
other times, and more generally, it 
maintains its position, becoming, as it were, encysted by a deposit of new bone around it, 
as delineated -in fig. 370. Finally, in a third class of cases, the matter continues to ac- 
cumulate, apparently, for a long time, and, pressing upon the osseous tissue in every 
direction, gradually expands the bone into a large shell, capable of holding several ounces, 
and so thin and soft as to be bent and cut like cartilage. 
The symptoms denotive of the formation of pus are usually such as characterize this 
event in the other tissues, only that the local suffering is generally much more intense, 
especially if the matter has no free vent. The existence of abscess in the interior of a 
bone is indicated by a dull, gnawing, heavy pain, circumscribed, deep-seated, remittent, 
and more like a violent toothache than anything else to which it can be compared. In 
many cases it is of a throbbing, boring, tearing, or lancinating nature. It is always 
worse at night than in the day, and is usually so intense and exhausting as to make 
serious inroads upon the general health, the patient soon becoming wan, sallow, and 
hectic. Occasionally the pain completely intermits, the parts being wholly free from 
suffering for many hours, and even days together; more generally, however, it is con- 
tinued with partial remissions. The soft structures, at the seat of the abscess, are always 
exquisitely tender, especially at one particular spot directly over the matter, more or less 
tumefied, glazed, and oedematous, often pitting on pressure. The formation of matter is 
generally announced by rigors, alternating with flushes of heat; and similar attacks are 
very common during the progress of the disease, particularly in the early part of the 
night, the body being usually drenched towards morning with acid, offensive perspiration. 
Although the symptoms of abscess are generally well marked, yet, as they may be 
simulated by other diseases, they cannot be said to be characteristic. The principal 
affections with which they are liable to be confounded are necrosis and deposits of new 
bony matter, compressing and irritating the parts so as to keep up intense pain and 
tenderness, similar to what is produced by collections of pus in the soft structures. 
Fig. 369. 
Fig. 370. 
Abscess in the Head of the Tibia. 
Large Chronic Abscess, 
with a thickened, expand- 
ed Wall. 846 
Fortunately, accuracy of diagnosis is of little consequence in these cases, as the treat- 
ment is essentially the same, whether the symptoms arise from abscess, the lodgment of 
dead bone, or interstitial osseous deposits. The discrimination between abscess and 
neuralgia, which often closely imitate each other, is of more importance, on account of 
the difference of treatment, but, so far as 1 know, there are no diagnostic signs by which 
the distinction can be effected. 
The treatment of abscess of the osseous tissue is by efficient evacuation. In no 
other manner can the pent-up fluid be reached. The operation is not always so 
easy as might at first be imagined, owing to the excessive 
firmness of the affected bone, in consequence of interstitial 
deposits, which often give it the closeness and density of 
ivory. The best instrument is the burr of the surgical engine 
or a common trephine, fig. 371, from three to four lines in 
diameter, with sharp, well-set teeth, and fluted on the surface, 
so as to make a wide track. The surgeon, taking the site of 
pain and swelling, or the “ tender spot,” as his guide to the 
seat of the abscess, exposes the bone by a free incision, either 
single, T-like, curvilinear, or crucial, as may be deemed 
necessary, and then, turning aside a small portion of peri- 
osteum, applies the instrument. Its arrival at the abscess 
is generally denoted by a sudden cessation of resistance, and 
by the escape of a few drops of pus mingled with blood. If 
no matter is found after sinking the instrument to a consider- 
able depth, it is applied at some other point, in the vicinity of 
the former, in the hope of a more successful result, for it is 
often quite impossible, in these cases, to hit the precise spot 
where the fluid is located in a first or even second attempt; 
on the other hand, however, care must be taken not to make 1 
too many perforations, lest the bone be thereby unduly weakened or suffer other injury. 
Moreover, it is not to be inferred by any means that although no pus has been detected, 
the operation will, therefore, be a failure; perhaps the instrument may have come in 
contact with a small sequester, lying loose in the connective tissue of the articular extremity 
of the bone, and by removing this rapid recovery make take place; or, instead of this, 
the pain and other symptoms may have been occasioned by the pressure of interstitial 
deposits, and the excision of a disk of bone may afford relief on the principle of taking off 
tension, as a free incision does in deep-seated, purulent collections in the soft structures, j 
The abscess having been opened, the cavity is washed out with a syringe, as much to 
get rid of the sawdust as to clear away pus and stimulate the pyogenic sac. A narrow 
tent is then inserted into the bottom of the opening, and the wound gently supported with 
adhesive strips, the after-treatment being conducted upon strictly antiphlogistic princi- 
ples. The relief from the operation is often immediate, and there is no class of cases in 
which the efforts of the surgeon are generally rewarded with more unalloyed satisfaction. 
The patient, tortured for months with pain and sleepless nights, is suddenly translated 
from torment into Elysium. 
Trephining bone for the cure, of circumscribed abscess was originally performed by 
Petit, in the earlier part of the last century; but to Sir Benjamin Brodie, who performed 
his first operation in 1828, is usually ascribed the credit of generalizing it. In this 
country the first case of the kind is said to have occurred in the practice of Dr. Walker, 
of Virginia, in 1757. 
SECT. VII EROSION. 
This condition of bone is altogether different from caries, although it is often confounded 
with it; nor does it, in any respect, resemble necrosis. It is simply a wasting of osseous 
tissue, induced by the force of steady and long-continued pressure. Practically, it is of 
little interest, except in so far that, as experience has abundantly proved, when the excit- 
ing cause of the erosion has been removed, the affected part, unless too greatly injured, is 
susceptible of repair to such an extent as to enable it to perform its aceustomed function as 
a portion of the skeleton. 
Three processes seem to be necessary to the production of this lesion, softening, absorp- 
tion, and pressure; the latter acting as the exciting cause. Whether the softening is of 
an inflammatory character, or the result merely of the disintegration of the bone-corpus- 
cles and the deposit of sero-oleagineous fluid, is still a disputed point, and one, indeed, 
DISEASES AND INJURIES OF THE BONES. 
CHAP. VII i. 
Fig. 371. 
Trephine. CHAP. VIII. 
CARIES OR ULCERATION. 
847 
which, in the existing state of the science, cannot be determined. However this maybe, a 
certain amount of softening is an indispensable preliminary to the morbid change, as, 
without it, the absorbents would be unable to perform their part of the work. The most 
common exciting cause is aneurism ; but erosion of bone may also be produced by the 
pressure of an ordinary tumor, or even by an accumulation of pus, as is exemplified in 
chronic abscess of the spine, chest, head, and pelvis. When an aneurism is brought into 
contact with a bone, the surface of the sac contracts firm adhesions to it ; then the com- 
pact layer of the bone, becoming softened by the pressure and pulsation of the tumor, gradu- 
ally disappears, and thus the morbid action progresses until, at least in the worst cases, 
the piece is completely perforated, as is so often witnessed in the sternum, ribs, clavicle, and 
bodies of the dorsal vertebrae in aneurism of the thoracic aorta. In most of such cases 
the sac in immediate contact with the affected bone gives way, and thus allows its contents 
to bathe the osseous tissue. 
The eroded bone has a rough, granular surface, with various depressions and elevations, 
owing to the irregularity of the absorption, and, in the dried state, looks very much as if 
it had been gnawed by the teeth of an animal. In case the pressure is relieved, as in an 
aneurism cured by the ligation of its feeding artery, the bone gradually assumes a hard, 
dense, ivory-like consistence, the surface ultimately becomes completely smooth and 
polished, and the areolar texture is, in great degree, if not wholly, annihilated. As to 
treatment, the only thing to be done is to remove the exciting cause, and, as this is sel- 
dom practicable, the surgeon is literally powrerless. 
SECT. VIII CARIES OR ULCERATION. 
Caries is a disease of the osseous tissue, strictly analogous to ulceration of the soft parts. 
It is essentially of an inflammatory type, and is characterized by an increase of vascu- 
larity, softening, and disintegration, the earthy matter being separated from the animal, 
and eliminated along with the discharges, which are often quite profuse, especially when 
the malady has made considerable progress. Caries differs from ordinary osteitis chiefly 
in this, that it is attended with actual loss of substance, the affected tissue being gradually 
broken down, excavated, or destroyed, whereas in the latter it retains its various elements, 
although in an altered condition, the principal changes consisting in congestion, softening, 
and the formation of granulation tissue. There are other points of difference, as the seat 
of the two diseases, the age at which they respectively occur, and the nature of the con- 
comitant secretions, as will be rendered evident by a careful study of the subject. 
Caries is most liable to occur in parts of the skeleton distinguished by the abundance 
of their areolar tissue, as the vertebrae, the skull, the sternum, the innominate bones, the 
bones of the carpus and the tarsus, and the articular ends of the long bones, especially of the 
femur, tibia, and humerus. The compact tissue is more frequently the seat of necrosis 
than of caries; indeed, the affection cannot occur here unless this tissue has previously 
undergone a certain degree of softening, so as to prepare it, as it were, for the disintegrat- 
ing process which characterizes it. 
Young persons are most subject to caries, particularly children under ten years of age ; 
it is seldom that it is met with even so late as middle life, and then chiefly as a result of 
some specific taint of the system, more especially the syphilitic. I am not aware that 
sex exerts any material influence upon its production. What are called strumous children 
are especially obnoxious to it, and this circumstance, of which daily observation furnishes 
abundant evidence, long ago created a doubt in my mind whether caries is not really, in 
a great majority of cases, of a syphilitic nature. The more I examine the subject, the 
more I am satisfied of the truth of this opinion. Most of the children that come under 
my observation with this disease, as it occurs in the spine, the hand, foot, and ends of the 
long bones, present all the characteristic features of the inherited form of that affection ; 
and I am quite sure that this experience, instead of being peculiar to myself, must be 
common to all intelligent practitioners. 
The exciting causes of caries'are of two kinds, local and constitutional, of which the 
latter are by far the more common and influential. As appertaining to the first, are 
various injuries, as blows, kicks, tails, fractures, contusions, and concussions, disturbing 
the circulation and innervation of the osseous tissue, or depriving it of its fibrous cover- 
ing, and thus modifying its nutritive action. In the bones of the foot, especially those of 
the tarsus, the disease is sometimes induced by the penetration of a foreign body, as a 
nail, or splinter of wood. The sawing of the bones in amputation and resection, and 
their accidental division by sharp instruments, are occasionally followed by caries, both 
extensive and protracted. 848 
DISEASES AND INJURIES OF THE BONES. 
CHAP. VIII. 
Among the internal causes of caries may be cited whatever has a tendency to induce 
general debility, or to impoverish the fluids and solids, and, consequently, to exhaust the 
constitution. Hence we may place at the head of the list severe and protracted courses 
of mercury, the operation of the syphilitic poison, scurvy, scrofula, profuse losses of blood, 
and severe attacks of dysentery, diarrhoea, typhoid fever, and eruptive diseases, as scar- 
latina, measles, and smallpox. All these circumstances are capable of producing ulcera- 
tion both in the skeleton and the soft parts, as is proved by the numerous sores which so 
Fig. 373. 
Fig. 372. 
Caries of the Head of the Humerus 
often arise in different regions of 
the body, as the sequela? of these 
affections, and which it is usually 
found so difficult to cure. 
A carious bone exhibits marked 
differences in its appearances, ac- 
cording to the duration of the dis- 
ease and the nature of the affected 
piece. In the earlier stages the 
osseous tissue is merely inflamed, as is evinced by its vascular and softened condition ; 
its spongy texture is rarefied, and occupied by a serous, oily fluid, intermixed with a good 
deal of the coloring matter of the blood, thus giving it a reddish aspect. It may be cut with 
the knife, or even indented with the finger, especially if the bone is a carpal or tarsal one, 
and, upon macerating it, the water soon becomes covered with a layer of fatty matter. 
Exposed to the air, it dries with difficulty, and assumes a pale yellowish hue, verging 
slightly upon greenish. When the disease has reached its more confirmed stages, the 
bone is found to be excavated, or riddled with cavities, of variable size and shape, as in 
fig. 372, sometimes lined by a kind of pyogenic membrane, and filled with thin, sanious, 
and offensive matter, without any of the characteristic properties of laudable pus. These 
cavities are due to the absorption of the osseous lamellae by the granulation tissue, which 
has formed at the expense of the cells of the medullary spaces and the Haversian canals, 
and the emigrant white corpuscles, and they correspond to Howship’s lacuna?, seen in 
minute sections, as is represented in fig. 373, from Rindfleisch. Occasionally small frag- 
ments of bone, which have been deprived of their vascular supply, lie loose in these cavi- 
ties, unable to escape on account of their disproportionate dimensions. The osseous 
tissue is now extremely soft and brittle, breaking down readily under the finger ; it is still 
more porous than before, and is of a grayish, brownish, or blackish color. It is apparently 
destitute of vessels, and yields a considerable quantity of 
oil on maceration. In a chemical point of view, the 
only notable difference between carious and healthy 
bone is the greater amount of cartilage and fat in the 
former than in the latter, the quantity of cartilage often 
forming as much as thirty-seven per cent., while the 
amount of fat is upwards of three. This quantity of fat, 
although much greater than normal, is not sufficient to 
justify the opinion expressed by some that this disease 
essentially consists in adipose degeneration of the osse- 
ous tissue. 
The substance immediately around the softened and 
disintegrated structure is always more or less inflamed, 
red, and vascular; the periosteum is thickened, spongy, 
Caries, with Howship’s Lacuna;. 
Fig. 374. 
Caries of the Astragalus, with Soften- 
ing and incipient Separation of the Carti- 
lage. CHAP. VIII. 
CARIES OR ULCERATION. 
849 
and injected; and the endosteum exhibits all the phenomena of active participation in 
the disease. The compact lamella has often a worm-eaten appearance, and it is not un- 
common to find it partially incrusted with bony matter. The adjacent soft parts are infil- 
trated with sero-plastic matter, indurated, closely matted together, and otherwise altered. 
In articular caries there is always more or less involvement of the cartilages, which are 
gradually softened and disintegrated, large pieces often coming away with the discharges, 
as in fig. 374. 
The symptoms of caries are usually obscure, especially in its earlier stages, as there is 
no line of demarcation between it and osteitis. It is only when the affection has termi- 
nated in suppuration, ulceration of the soft parts, as in fig. 375, or the formation of 
sinuses, that its true character can be fully made out. Prior to this the nature of the 
disorder may be suspected, but cannot be certainly determined. All the symptoms, in the 
first instance, are those simply of osteitis. There is a dull, heavy, aching pain, which 
Fig. 375. 
Caries of the Tibia, with an Ulcer in the Skin. 
appears to be deeply seated in the substance of the bone, and which gradually increases in 
extent and severity with the progress of the morbid action; the part is exquisitely tender 
to the touch; the skin has a glazed, reddish aspect; and there is marked tumefaction, 
particularly at the focus of the inflammation. The local phenomena gradually augment 
in intensity, the pain assumes a throbbing disposition, the swelling becomes more pointed, 
and presently the loose, flabby integument gives way by ulcerative action, thus allowing 
the contents of the abscess, for such in fact the case is, to drain off. The bone thus laid bare 
has a foul, eroded appearance, at the same time that it is rough and so soft as to be easily 
penetrated with the probe. 
The sinuses leading to the seat of the disease are either straight or tortuous, and vary 
in length from a few lines to several inches, according to the depth of the affected bone, 
and, above all, the place of opening of the abscess. In general they are multiple, and 
have separate orifices, so as to give the cutaneous surface a sieve-like appearance. In 
chronic cases the sinuses are lined by a species of false membrane, and their situation is 
indicated by a mass of reddish granulations, somewhat mammillated in shape, in the cen- 
tre of winch the aperture of communication is generally easily detected with the point 
of the probe. This nipple-shaped body, which is often entirely insensible, and almost 
always bathed with pus, projects considerably above the surrounding level, and is of great 
diagnostic value, as it is invariably denotive of the existence of carious or necrosed bone. 
The sinuses do not commonly all form at once; perhaps there may be only one or two at 
the beginning, the rest being superadded during the progress of the disease, or, perhaps, 
as one closes another appears. However this may be, the parts around are always more 
or less indurated, inflamed, and tender on pressure. 
The discharge is commonly of a thin, ichorous, sanious, or bloody character, loaded 
with earthy matter, more or less fetid, and so irritating as to erode the parts with which 
it comes in contact. It usually tarnishes silver, a circumstance which shows that it con- 
tains sulphuretted hydrogen, and is often so profuse as to cause serious exhaustion. The 
earthy matter, which is easily detected by its gritty character, by rubbing the fluid be- 
tween the thumb and finger, frequently amounts to two per cent, of the entire discharge. 
Sometimes the pus is of a laudable nature, but when this is the case it may generally be 
assumed that it is furnished by the adjacent soft parts rather than by the bone itself. It 
is not uncommon for it to contain flakes of lymph, the debris of connective and aponeurotic 
substance, and even considerable fragments of bone and cartilage, the latter being most 
apt to show themselves when the sinus penetrates a neighboring joint. 
There is a form of caries, which, as there is an entire absence of suppuration, may be 
called dry caries ; it is most commonly met with in syphilitic disease of the cranium, and 850 
DISEASES AND INJURIES OF THE BONES. 
CHAP. VIII . 
I have also witnessed it in ulceration of the articular extremities of the long bones, espe- 
cially of the head of the humerus, and of the femur. Associated with this condition of 
the osseous tissue, there is usually marked rarefaction of the cancellated structure with 
inflammatory thickening of the surrounding soft parts. 
The constitutional disturbance is not always proportionate, so far as can be judged, to 
the amount of the local disorganization. The general health is often but little affected, 
especially in the early stages of the disease ; by degrees, however, it begins to give way, 
and ultimately suffers severely. The patient loses flesh and strength, the countenance is 
wan and pallid, and the sleep and appetite are destroyed. If the disease is at all extensive, 
or if, even when it occupies but a small compass, it opens into a large joint, as, for 
example, the knee, hectic irritation soon sets in, and, making rapid inroads upon the 
system, speedily reduces the vital powers. The pain is often excruciating, particularly 
at night and in damp states of the atmosphere, and is one of the principal sources of 
exhaustion. 
The diagnosis of caries can, in general, be determined only by a careful consideration 
of the history of each individual ease. Until ulceration of the soft parts occurs, the 
nature of the disease must almost necessarily remain an enigma. The only affection with 
which it is liable to be confounded is necrosis, but from this it may usually be easily 
distinguished, before the skin has given way, by the comparatively small amount of the 
attendant pain, as well as by the lesser degree of constitutional disturbance, and by the 
fact that caries is usually met with in the short bones, while necrosis mostly occurs in the 
shafts of the long. When sinuses have formed, the eye, finger, and probe are usually 
able to determine the diagnosis, by the appearance and feel of the affected structure. In 
both cases the bone is roughened, but usually much more so in necrosis than in caries; 
in the former it always retains its original consistence, whereas in caries it is so much 
softened as to be readily penetrated by the probe. Nothing of a definite character can 
be learned from the nature of the discharge, since it is nearly identical in the two maladies. 
Occasionally valuable information may be obtained from a consideration of the exciting 
cause. Thus, osteitis from syphilis terminates more frequently in necrosis than in caries, 
the reverse being the case in inflammation dependent upon a scorbutic or strumous taint 
of the system. To this statement, however, numerous exceptions occur, and the diagnosis 
must, therefore, at least in most cases, be a matter of time and of repeated critical ex- 
aminations. 
The prognosis of caries is generally unfavorable, a spontaneous cure, although not 
impossible, being an extremely uncommon occurrence. When the disease is of limited 
extent, a cure may often be promptly effected by operative measures directed against the 
affected parts, but under opposite circumstances nothing short of resection or amputation 
holds out the slightest prospect of relief. In many cases the affection continues for years, 
apparently neither advancing nor materially receding, the general health in the mean time 
experiencing but little change; on the other hand, however, its progress is sometimes 
very rapid, and the constitutional disturbance proportionately great, hectic irritation, loss 
of strength, and emaciation setting in early, and steadily proceeding until the patient 
dies completely exhausted. Caries is less likely to terminate favorably when it assails 
the vertebra; and the articular ends of the long bones than when it appears in any other 
portions of the skeleton, except, perhaps, the carpal and tarsal bones, in which it is often 
so extremely obstinate as to require the removal of the limb in order to save life. The 
prognosis is, of course, more unfavorable in sickly and debilitated persons than in such as 
are healthy and robust at the time of the attack. 
Treatment The treatment of caries should always, if possible, be conducted with 
strict reference to the nature of its exciting causes. When the disease has been induced 
by a syphilitic, strumous, or scorbutic taint of the system, remedies adapted to these 
respective contingencies will, of course, promptly suggest themselves, as most likely to 
fulfil the particular indication of the case ; but where no such affection is visible, and 
where, in fact, nothing whatever of an appreciable character exists, the surgeon must 
disregard all rules, and limit himself to the application of general principles. The diet 
should be very plain and simple, but at the same time nutritious, so as to build up the 
system, and create a better state of the blood, which is generally so much at fault in 
caries of nearly all portions of the skeleton. Chalybeate tonics, quinine, nux vomica, 
and cod-liver oil are the most valuable internal remedies; aided, as occasion may seem to 
demand, by blue mass and alkalies, to modify and improve the secretions. Active purg- 
ing is avoided, as it would inevitably prove prejudicial by its debilitating effects. Exercise 
in the open air is often of great service, but, to render it efficient, the diseased bone must 851 
CHAP. VIII. 
CARIES OR ULCERATION. 
not be moved or irritated during its performance. Salt-bathing, followed by dry friction, 
will be beneficial in imparting tone and vigor to the cutaneous capillaries; and in many 
cases the general health is much improved by a residence at the seaside. 
Irritation of the soft parts is allayed by attention to rest and position, and by the appli- 
cation of leeches, fomentations, and poultices, or warm water-dressings medicated with 
laudanum and acetate of lead. When there is much induration from deposits, the skin 
should be freely painted twice a day with dilute tincture of iodine, followed, if the case 
prove obstinate, by a large blister, experience having shown that, in superficial caries, 
this is more effectual in arresting inflammation than any other remedy. Even in deep- 
seated caries it frequently answers an excellent purpose, promptly allaying the excessive 
pain, and promoting the absorption of effused fluids. As soon as evident fluctuation 
exists, or even before, if there be inordinate tension and throbbing, a free incision should 
be made, extending, if possible, into the very depths of the hone, so as to admit of the 
most thorough drainage. To allow the matter to remain pent up always proves excessively 
injurious, from its tendency to burrow among the surrounding structures, detaching them 
from each other, and leading, in the end, to the formation of numerous sinuses. Besides, 
the early evacuation of the matter greatly abridges the suffering, constitutional as well as 
local, and thus prepares the system better for the future struggle. When the matter is 
lodged in the interior of a bone, as, for instance, the extremity of the femur or tibia, 
evacuation should be effected with the trephine. 
The means now described are all merely of a palliative nature; they relieve pain, 
swelling, and constitutional disturbance, but cannot cure the disease, however slight. To 
fulfil this indication, other remedies are necessary; some for modifying the affected tissues, 
so as to afford them an opportunity of regaining their normal characters, and others for 
effecting riddance of the diseased bone either in part or in whole. 
Under the first head may be mentioned various detergent and acidulated preparations, 
as solutions of the chlorides, creasote, nitrate of silver, and acetic, nitric, and hydrochloric 
acid, their strength varying with the age and constitution of the patient, and the state of 
the parts, the contact being effected by means of a large glass syringe, repeated twice in 
the twenty-four hours. The chlorides are particularly serviceable in these cases, on 
account of their cleansing and deodorizing effects, while the acids act more directly upon 
the osseous tissue, stimulating the capillary and absorbent vessels, and thereby promoting 
a more healthy tone, at the same time that they produce disinWgration of the earthy 
matter of the diseased bone. These remedies, and all others of a kindred nature, are 
certainly not without some benefit in the milder and more accessible cases of caries, but 
they all have the disadvantage of being difficult of application, as well as uncertain in 
their results, and can rarely be relied upon for a cure. I have, therefore, of late years, 
entirely abandoned their use with this intention, and now employ them only with a view 
to their detergent and deodorizing effects, preferring, of course, the chlorides to any of 
the other articles for this purpose. 
The actual cautery, formerly so much vaunted in the treatment of certain forms of 
caries, especially in that of the carpal and tarsal bones, is obnoxious to the same objections 
as the remedies just mentioned. In applying it, it is necessary not only to divest the 
affected bone thoroughly of its soft parts, but to employ the greatest circumspection, 
otherwise a much larger amount of tissue may be destroyed than is desirable. Moreover, 
the eschar is always a long time in coming away, and the iron has generally to be used 
again and again before a cure is finally effected. 
In the treatment of caries of the deeply-seated bones, Dr. Fitzpatrick enlarges the 
sinuses with the Vienna paste, and after having pierced the exposed bone with a strong 
knife, inserts the caustic into its interior. I have had no experience with this practice; 
but regard it as even more objectionable than the application of the actual cautery. 
Under the second head are included the operations necessary for scraping or cutting 
away the diseased structure, excising the affected bone, either in part or in whole, and 
amputating the affected limb, wdien the case is unmanageable by other means. 
All operative interference, having for its object the removal of the carious matter, is, 
as a rule, carefully abstained from until the disease has become strictly chronic, or, in 
some degree, ceased to spread. If this injunction be disregarded, injury and not benefit 
will be certain to follow, the irritation excited by them giving new impetus to the morbid 
action. The precise time for interference cannot, of course, be specified, but it is evident 
that no attempt should be made to scrape or cut the bone so long as the superimposed 
parts are very tender, tumid, and inflamed. The proper treatment, in this condition, 852 
DISEASES AND INJURIES OF TIIE BONES. 
consists in the use of leeches, medicated fomentations, and other antiphlogistic measures 
designed to soothe the irritated structures, and prevent the spread of the disease. 
When the caries is of small extent, it may generally be removed by means of a burr- 
head drill, similar to that used by the dentist for scraping away caries from decayed teeth 
previously to plugging. With such an instrument, of which the adjoining sketch, fig. 37G, 
affords a good idea, the whole of the diseased substance may be cut away in a few minutes, 
CHAP. VIII. 
Fig. 376. 
Fig. 377. 
Fig. 378. 
Fig. 379. 
Fig. 380. 
Instruments for removing Carious Bone. 
with little pain to the patient, and no detriment whatever to the neighboring parts, which 
should always be turned aside immediately prior to the operation. Every bone-case 
should have from three to six drills, of varying size and shape, so as to meet every con- 
tingency that may arise in practice. Several trephines, pliers, gouges, chisels, and 
scrapers should also be at hand. In operating upon the tarsal and carpal bones, a short, 
stout scalpel, with a rather sharp convex extremity, and a large handle, will generally be 
found to be very desirable. Such an instrument is peculiarly advantageous in paring the 
surface of deep-seated cavities. When the ligaments and cartilages are involved, dissection 
can hardly be completed in a satisfactory manner without a pair of blunt-pointed scissors, 
with long, thick, narrow blades. The raspatory is useful in smoothing carious cavities 
after the removal of the disorganized substance. During the operation the diseased cavity 
is kept free from blood by means of the elastic bandage and of sponge mops. 
When all the diseased structure has been removed, the affected cavity should be 
thoroughly washed out with a syringe. Unless this be done, more or less of the bony 
matter will be left, thus keeping up irritation and discharge, and interfering with the re- 
parative process. 
Considerable hemorrhage often attends these operations, the blood either proceeding 
from small arteries, or oozing from numerous points. In the former case the ligature will 
usually be required, more particularly as the vessels are unable to retract on account of 
the indurated condition of the surrounding parts, while in the latter the temporary appli- 
cation of the sponge wrung out of hot water will commonly speedily arrest the flow. If 
this do not answer the purpose, the bleeding cavity must be stuffed with lint soaked in a 
strong solution of subsulphate of iron, the plug being retained until it is loosened by the 
suppurative process. 
Doubt is often experienced, in these operations, as to the amount of substance to be 
removed, the precise line of demarcation between the sound and diseased structures 853 
CHAP. VIII. 
not being always easy of determination. A good diagnostic, under such circum- 
stances, is to wash the fragments in water, when, if they are carious, they will ex- 
hibit a whitish, grayish, greenish, or blackish appearance; whereas, if they are healthy, 
they will be found to be vascular and red, and to retain their normal consistence, 
presenting none of the fragile and porous characters which distinguish them in the 
former case. 
Bleeding having been arrested, the edges of the wound are loosely approximated by 
suture ; and the limb, placed in a favorable position for drainage, is inclosed in a bandage, 
the affected parts being covered with lead water 
dressing. Occasionally a tent is needed to conduct 
off the matter, and prevent premature closure; and 
for some time the bony cavity should be injected 
twice or thrice daily with tepid water and castile 
soap, or some gently detergent lotion. The great 
sources of danger after the operation are erysipelas 
and pyemia. 
The healing process, after such an operation, is 
attended by the development of granulations, which, 
under the microscope, display very much the same 
appearances as those of the soft parts. The vessels, 
as shown in fig. 381, from a drawing made for me 
by Dr. Packard, have a remarkably looped and 
varicose arrangement. The specimen was taken 
from an ulcerated patella, which was covered by an 
immense number of beautiful scarlet granulations, 
hardly the size of the smallest pin’s head, closely grouped, and exceedingly tolerant of 
rude manipulation. The section was magnified sixty diameters. 
Excision of an entire bone is sometimes necessary for the relief of this disease. 
Such a procedure is most frequently required on account of caries of the carpal and 
tarsal bones, upon which it is frequently performed with great advantage, a useful limb 
being generally left even after the removal of several of these pieces. In the long 
bones, the operation is usually limited to the articular end, or to this and to a portion 
of the shaft. Respecting the manner of executing this operation, and the estimate to 
be placed upon it, in a curative point of view, special mention is made in the chapter 
on excision. 
When the disease is so extensive as to be uncontrollable by the means now de- 
scribed, and the attendant discharges are so copious as to give rise to profuse night- 
sweats, marasmus, and colliquative diarrhoea, amputation of the limb, comprising the 
carious bone, affords the only chance of safety, and should be performed without delay. 
It is surprising bow the system usually rallies after such an operation. The patient, 
in the course of a few days, generally looks like a new being ; his sweats and diarrhoea 
soon leave him, and he rapidly improves in health and spirits, making often an excellent 
recovery. 
SECT. IX NECROSIS OR MORTIFICATION. 
The word necrosis denotes the death of a bone, and is strictly synonymous with morti- 
fication, gangrene, or sphacelus, used to designate the death of a soft structure. The 
immediate cause of the occurrence is inflammation, eventuating in an arrest of the circu- 
lation and innervation of the osseous tissue. 
Necrosis is most common in the superficial bones, or in those which lie immediately 
beneath the integument, as the tibia, ulna, lower jaw, clavicle, femur, and the phalanges 
of the fingers. The long bones suffer more frequently than the short, and the short than 
the flat, the reverse being the case in caries, for the reason that, in the former, the com- 
pact tissue is most commonly affected, and in the latter, the spongy. 
Children under fifteen years of age, of a strumous diathesis, or a syphilitic taint, are 
the most common subjects of this disease. Of the influence of sex, climate, and 
occupation, upon its production, nothing satisfactory is known. It has generally been 
supposed, and not without reason, that it is most common in cold, damp, and variable 
regions, on the assumption that the inhabitants of these countries are particularly 
subject to suppression of the cutaneous perspiration, which, in individuals predisposed 
to disease, may, it is alleged, readily cause death of the more superficial bones. Persons 
engaged in the manufacture of lucifer matches are liable to necrosis of the jaw, from 
NECROSIS OR MORTIFICATION. 
Fig. 381. 
Structure of a Granulation in a Bone. 854 
DISEASES AND INJURIES OF THE BONES. 
CHAP. VIII . 
the contact of the fumes of phosphorus with the interior of decayed teeth ; and it is 
not improbable that there are other pursuits which may conduce to destructive inflam- 
mation of the osseous tissue, although of their precise nature and mode of action we are 
not informed. 
Causes.—The idiopathic form of necrosis will he found, as a rule, to be most common 
in young subjects whose constitution lias been hereditarily damaged, or who exhibit well- 
marked evidence of the scrofulous diathesis, as evinced by the delicacy of the skin, the 
languid circulation, the tumid belly, and the deficient temperature of the extremities. 
This has certainly been the case in the great majority of instances that have come under 
my own observation, and I believe that my experience, in this respect, in the main, agrees 
with that of other writers. It is in persons of this description, more particularly, that 
W’e so frequently meet with the worst species of necrosis of the tibia, femur, and humerus, 
telling so fearfully upon the constitution, and so often requiring amputation in order to 
save the patient’s life. The most common exciting cause of the disease, in this class of 
subjects, is exposure to cold, as w’hen a boy, overheated by play, sits down in a current 
of air, and thus suddenly repels his perspiration ; or wdien, under similar circumstances, 
he strips himself and plunges into cold water. Not aware, perhaps, for several days that 
he has sustained any injury he is suddenly seized, not unfrequently while asleep, with 
violent pain in one of his limbs, attended with severe rigors alternating with flushes ot 
heat, and, upon examining the affected part, he observes that it is exquisitely tender on 
pressure, more or less swollen, and covered with an erysipelatous blush. The local and 
constitutional symptoms progressing, matter soon forms deeply beneath the muscles, the 
swelling becomes more and more circumscribed, and, ulceration taking place, the contents 
of the abscess gradually find their way to the surface, leaving the bone dead below. Such 
is the manner in which necrosis is generally produced in weakly, scrofulous subjects, and 
it is hardly necessary to add that all the attendant phenomena are indicative of a rapidly 
destructive osteitis, osteomyelitis, or osteitis and periostitis. 
Tertiary syphilis is another cause of necrosis, and the history of this disease shows 
that the osteitis growing out of it is more liable to occasion death of the bone when 
the patient has been subjected to free courses of mercury for its cure, than when the 
affection has been treated on general antiphlogistic principles. The two poisons coming 
together, and mingling their baneful influence, induce a form of inflammation which 
is extremely prone, especially in persons of a worn-out, debilitated constitution, to 
terminate in gangrene of the bones, particularly those of the nose, palate, upper jaw, 
leg, and arm. 
Protracted courses of mercury, especially in young subjects of a strumous diathesis, or 
exhausted by diarrhoea, cholera, or eruptive diseases, often cause necrosis of a frightful 
character, generally of the maxillary bones, but sometimes, also, of other pieces of the 
skeleton. What is termed dry salivation is frequently more destructive to the gums, teeth, 
and jaw'-bones than salivation accompanied by profuse discharge. The debility provoked 
by the injudicious use of drastic purgatives and tartar emetic has occasionally eventuated 
in necrosis of some of the bones of the head, trunk, and extremities. Scurvy has been 
known to produce similar effects, although more commonly it causes caries. In short, 
there is reason to believe that idiopathic necrosis may be induced by whatever has a ten- 
dency to bring about an impoverished condition of the blood and solids. 
Among the local causes of necrosis the most common are wounds, contusions, fractures, 
amputations, and chemical irritants. In the tibia and femur, the probability is that mere 
concussion, as happens when a person falls from a considerable height and alights upon his 
foot or knee, is often sufficient to produce a destructive form of osteitis. Gunshot injuries 
are a frequent source of the occurrence, whether the bone is merely grazed by the passage 
of the projectile, or whether the ball lodges in its substance and acts as a foreign body. 
Partially detached splinters frequently perish under such circumstances. Mere denudation 
of a bone, however occasioned, is often followed by its death, especially when the loss of 
periosteum is very considerable, or if, even when it is comparatively trivial, it is accom- 
panied by the laceration of the nutrient artery, or extensive destructive of the soft parts 
generally. In this condition, the necrosis is usually limited to the outer compact struc- 
ture, the part ultimately coming away in the form of an exfoliation. Such an event, 
however, is by no means inevitable. The periosteum may be stripped off to a considerable 
extent, and yet, if the bone is in other respects healthy, or enjoys a tolerably active cir- 
culation, granulations will spring up, and thus gradually repair the breach. It is only 
wrhen the vascular connection between the two structures has been materially impaired, 
or totally destroyed, that necrosis will be likely to ensue, the bone becoming white and NECROSIS OR MORTIFICATION. 
855 
CHAP. VIII. 
dry, and ultimately dark and even black. These appearances are well illustrated in what 
so often happens in compound fractures, attended with protrusion of the end of the hone 
divested of its fibrous covering, and in the phalanges of the fingers in whitlow. 
Death of hone is occasionally produced without the intervention of inflammation, from 
mere shock, contusion, or compression of the component elements of the osseous tissue, 
and the sudden arrest of the circulation from obstruction of its vessels, however induced. 
Embolism probably plays an important part in the causation of such cases, just as it some- 
times does in mortification of the soft parts, and, occasionally, again the trouble may be 
due to the rupture of the nutrient artery. 
Necrosis may be partial or complete, simple or complicated, superficial or deep ; that is, 
it may be limited to a portion of a bone, or it may pervade its entire thickness. It is 
seldom that an entire bone perishes. Such an occurrence is sometimes observed in the 
carpus and tarsus, in consequence of external injury, but it is extremely uncommon in the 
long bones; in these the shaft alone generally suffers, the articular ends retaining their 
vitality. Necrosis of the whole lower jaw has been repeatedly noticed as a result of the 
action of phosphorus, and some interesting cases in which the entire bone was successfully 
removed on account of this disease have been related by Dr. Carnochan, Dr. J. R. Wood, 
and others. Finally, necrosis may be limited to the outer surface of a bone, involving 
merely its superficial lamelke, the dead portion being ultimately detached in the form of a 
thin scale or plate ; or it may invade its entire thickness, and it then not unfrequently 
begins in the very depths of the cancellated tissue, generally from injury or disease of 
the medullary membrane. 
The occurrence of necrosis, the elimination of the dead bone, usually called the seques- 
ter, and the formation of new bone as a substitute for the old, or that which has died, 
involve some very curious pathological and physiological processes, deserving of attentive 
consideration. The symptoms which immediately precede, and those which accompany 
the death of the bone, are generally such as are denotive of violent inflammation, deep- 
seated, attended with excruciating pain, and rapidly tending to the suppurative crisis, the 
mischief being often done in a few days, or even in a few hours. Action, general as well 
as local, is excessive, and both the part and system occasionally fall a prey to its devas- 
tating influence, especially when there is involvement of a large neighboring joint, as now 
and then occurs when the necrosis attacks the inferior extremity of the femur, and extends 
into the knee. Progress, however, is not always so swift and overwhelming; often it is 
quite the reverse, the parts and system suffering but little, and the malady pursuing appa- 
rently a chronic course. 
A very common way in which the occurrence of gangrene of a long bone is announced 
is this. The patient, usually a lad from six to ten years of age, after having been over- 
heated or exposed to severe cold, retires at night apparently perfectly well, but towards 
morning he is aroused by pain in the thigh or leg, deep-seated, circumscribed, of a sharp, 
aching character, and so excessively severe as to deprive him of further sleep and rest. 
The soft parts over the seat of the disease soon become exquisitely tender to the touch, 
swollen, and discolored, the surface having a glazed, dusky, reddish, or purplish tint, and 
pitting under pressure from the infiltration of the subcutaneous connective tissue. These 
local phenomena are always attended by severe constitutional disturbance. There is high, 
raging fever, with a tendency to delirium, and excessive restlessness ; the pulse is full, hard, 
and frequent; the skin is hot and dry ; the thirst is incessant; and the urine, thick and 
scanty, is surcharged with lithic acid. By and by, violent rigors set in, succeeded by 
flushes of heat, the pain assumes a tensive, throbbing character, the swelling becomes more 
diffused, extending often to a great distance up and down the limb, as well as widely cir- 
cumferentially, the discoloration acquires an erysipelatous blush, and a careful examination 
soon detects, what, indeed, the existing symptoms sufficiently declare, the presence of pus, 
deep-seated, lying partly between the affected bone and the periosteum, and partly on the 
outside of the membrane, in the connective tissue of the muscles and aponeuroses, which 
it often extensively dissects and separates from each other, forming large pouches from 
which it is frequently difficult to dislodge it. Sometimes the abscess opens into a neigh- 
boring joint, and thus becomes a source of additional mischief, exciting inflammation in 
the synovial membrane, perhaps ultimately followed by destructive softening of the car- 
tilage, and caries or necrosis of the end of the bone. 
The quantity of matter at this stage of the disease varies from a few ounces to upwards 
of a pint, and is mostly derived, not from the affected bone, or bone and periosteum, but 
from the soft parts in their immediate vicinity, which always freely participate in the 
morbid action. In spontaneous necrosis, it is usually of a strumous character, of a yel- 856 
lowish color, verging upon greenish, more or less fetid, especially if long retained, and of a 
thick, cream-like consistence, interspersed with curdy substance, and, not unfrequently, also 
with shreds of dead connective tissue. Occasionally the matter is thin, ichorous, or sanious, 
but such an occurrence is unusual until after the bursting and the evacuation of the abscess. 
When the matter has been discharged, whether spontaneously or artificially, there is 
always a marked improvement in the symptoms, both local and constitutional, and an 
opportunity is now afforded for a thorough examination of the parts. The best instrument 
for this purpose is the finger, or, when the opening is very small or devious, the probe. 
With either of these it is generally easy to determine the extent of the destruction of the 
periosteum, and the amount of injury sustained by the bone, the surface of which will 
generally be found to be more or less rough, and of a whitish, grayish, or ashy hue, with- 
out any appearance whatever of vascularity. 
Such is a succinct account of the circumstances which precede, accompany, and follow 
the ordinary occurrence of necrosis. The first stage of the disease is over; the matter 
consequent upon the inflammation has been discharged ; and the inflammation itself has 
measurably subsided, although the soft parts are still swollen, indurated, tender, painful, 
and disabled. Nature, never idle, now begins the double work of elimination and repair, 
both usually very tardy, often imperfect, and sometimes altogether unsatisfactory, the 
powers both of the part and system being inadequate to accomplish the object. In gan- 
grene of the soft structures, the separation of the eschar is generally an easy matter com- 
pared with that of a bone, provided the patient’s strength holds out ; the 
process, once fairly commenced, proceeds rapidly and energetically, the 
surgeon each day seeing decisive evidence of the fact; soon the line of 
demarcation between the dead and living parts is perceived ; then granu- 
lations spring up in the intervening chasm ; and, finally, the reparative 
efforts still advancing, the breach is gradually closed over with new skin, 
a circumstance clearly denotive of the completion of the cure. But it is 
altogether different in necrosis ; here the detachment of the slough is a 
matter of time, requiring many weeks, if not several months, for its satis- 
factory conclusion, and even then generally demanding the interference of 
art before it can finally be effected. The cause of the difference is suffi- 
ciently obvious. In the one case there is an active circulation and an 
energetic system of absorbents, the former furnishing an abundance of 
plastic material for the repair of the lost tissues, and the latter exerting 
themselves to cast off the dead substance ; in the other, on the contrary, 
everything is the reverse, and the parts labor under the additional dis- 
advantage of being loaded with earthy matter, which is obliged to be soft- 
ened and disintegrated before it can be removed by the vessels whose duty 
it is to get rid of it. 
The necrosed substance may, as already stated, embrace merely a por- 
tion of the periphery of a bone, as, for example, its outer layer; or it 
may include its entire thickness, and also the greater part of its length. 
In the former case it constitutes, when detached, what is called an exfolia- 
tion, in the latter a sequester, a distinction of considerable importance, not 
so much on account of the extent of the dead substance, as of the manner 
in which the breach of continuity is repaired, or a new bone formed. 
An exfoliation is commonly merely a thin scale, plate, or lamella of the 
outer, peripheral portion of a long bone, of variable color, and consistence. 
In general it is either whitish, grayish, or of a light brownish hue, rough, 
more or less porous, very brittle, and in great measure deprived of animal 
matter. 
A sequester, properly so called, varies much in size and shape, consisting, at one time, 
of a part only of the circumference or length of a bone, and, at another, of its entire 
shaft, with perhaps a portion of its articular ends. The adjoining sketch, fig. 382, from 
a preparation in my collection, represents a very common form ; it was a part of the body 
of the tibia, in which all the spongy structure is completely destroyed, while the compact 
is remarkably hard and firm. A dead bone, as a rule, is rough, pitted, or excavated, 
seldom perfectly smooth, spiculated at the extremities, of a grayish, brownish, or blackish 
color, and emitting when struck with a probe or piece of metal, a peculiar hollow sound, 
by which it is usually readily distinguished from healthy bone. In the cylindrical pieces, 
as in the femur and tibia, it is generally dense and dry; in the short and fiat, porous, 
moist, brittle, and easily crumbled. The analyses of Von Bibra show that there is a very 
DISEASES AND INJURIES OF THE BONES. 
CHAP. VIII. 
Fig. 382. 
Sequester of the 
Tibia. 857 
CHAP. VIII. 
great reduction of organic matter in necrosis, with a corresponding increase of earthy, the 
latter forming as much as eighty per cent, of the entire mass. The same experimenter has 
ascertained that the difference is considerably less in the acute variety of the lesion than 
in the chronic. 
Bone recently dead, or bone in a dying condition, before the establishment of the elimi- 
nating process, is generally of a dirty grayish, greenish, or brownish color, more or less 
moist, and excessively fetid, the odor resembling the stench of a macerating tub. In rare 
cases it is of a purple, lilac, or blackish hue, especially when the devitalization has been pre- 
ceded by deep congestion, or congestion and ecchymosis, of the osseous structure. When 
a bone perishes very suddenly, the affected part is comparatively dry, and free from smell. 
Necrosis of the articular extremity of a bone does not differ essentially from that of its 
shaft. It may be superficial, as when it affects the articular surface alone; deep-seated, 
as when it occurs in the cancellated structure; or universal, as when it invades the entire 
thickness of the extremity. However this may be, it is always accompanied by inflam- 
mation of the synovial membrane, or of this membrane and of the articular cartilage, and 
is very liable to be followed by permanent ankylosis. The joint is swollen and indurated, 
excessively painful, pierced by sinuses, and the seat of more or less profuse discharge of 
unhealthy matter. The affected bone itself is generally remarkably soft, saturated w'ith 
sanious fluid, and of brownish, grayish, or slightly greenish color. The disease is most fre- 
quent in young, scrofulous children, and after gunshot, railway, and other severe injuries. 
When necrosis occurs in the spongy structure of an articular extremity, the sequester 
may be so firmly incarcerated in the interior of the bone as to render it difficult of access. 
Sometimes the entire extremity perishes, as is exemplified in the head of the thigh-bone 
in coxalgia, in the condyles of the femur after gunshot and other injury, and in strumous 
or syphilitic disease of the head of the humerus. In a case of necrosis of the latter bone, 
in a lad ten years of age, recently under my care at the College Hospital, the head of the 
bone had entirely disappeared; and a similar fate is occasionally experienced by the cor- 
responding portion of the femur. 
In what is known as dry necrosis, a rare affection, there is an entire absence of suppura- 
tion, the bone being free from moisture, and of a brownish or dark grayish color. The dis- 
ease, originally described by Stanley, in 1849, has since been noticed by Baker, Sir James 
Paget, and other observers, chiefly in the long bones, and is, in every respect, analogous to 
senile gangrene of the soft structures, the osseous tissue 
gradually dying in consequence of disordered circulation 
interfering with a due supply of blood, and followed by 
chronic inflammation. The sequester, in such cases, 
is usually slow in separating, and so firmly imprisoned 
by the new bone as to render it extremely difficult to 
remove it. In some cases a portion of endosteum re- 
tains its integrity, and thus two involucres are formed, 
one by this membrane, and the other by the perios- 
teum ; but such anoccurrence is uncommon. 
Mode of Repair While the adjacent living bone is 
engaged in detaching the dead bone, with a view to its 
ultimate expulsion, the latter acts as a foreign body, 
and sets up mild inflammatory changes in the perios- 
teum, the soft layer of which proliferates, becomes em- 
bryonic, and furnishes the material for the formation of 
the substitute or new bone, the process by which this 
is accomplished being similar to that which presides 
over the creation of the original structure, the period 
required for the completion of the development vary- 
ing, according to the age and vigor of the patient, 
and the character and amount of the local disease, from 
a few weeks to several months. The new bone is at 
first a mere shell encasing the old, and thus serving to 
separate it from the surrounding parts, which ill brook 
its presence. In time, however, it increases in thick- 
ness, being often from three to six lines in depth, and 
occasionally it is fully as large as the original piece. 
Its surface is usually somewhat rough, and it is not 
uncommon to observe upon it considerable eminences 
NECROSIS OR MORTIFICATION. 
Fig. 383. 
Fig. 384. 
Necrosed Tibia, the 
dead Bone lying loose 
within the New. 
Cloac« in a ne- 
crosed Tibia. 858 
DISEASES AND INJURIES OF THE BONES. 
CHAP. VIII. 
and depressions, owing evidently to the irregularity of the developmental process. The 
new substance, too, has comparatively little areolar tissue, and, therefore, especially if 
some time has elapsed since its formation, it is always cut with great difficulty, the resist- 
ance offered by it being much greater than that of the preexisting structure. In cases of 
long standing, indeed, it often acquires the solidity and density of ivory, so that it requires 
great patience and perseverance to penetrate it with the saw and pliers. The vessels, in 
this event, are always very small and sparse, and the Haversian canals are traced with 
difficulty. In the long pieces, after the death and removal of the shaft, there is never a 
complete reproduction of the medullary canal and its lining membrane, or of the endosteum. 
In fact, the new bone, although it possesses all the essential attributes of the osseous tissue, 
is, nevertheless, a very imperfect type of the original, and, therefore, much less capable of 
resisting the effects of disease and accident. The appearances of the new bone, encasing 
the old or dead, are admirably depicted, in fig. 383, taken from a specimen in the collection 
of the late Professor Pancoast. 
In viewing the new bone as it surrounds the old, its surface is found to be pierced by 
several apertures, to which, from their fancied resemblance to the rectal pouch of a bird, 
the term cloaca, fig. 384, is usually applied. These openings, which play an important 
part in the expulsion of the dead bone, owe their existence to a deficiency of periosteum, 
or of secreting structure, as is proved by the fact that, when the formation of new osseous 
tissue goes on uniformly around every portion of the periphery, the old bone will be com- 
pletely imprisoned, thus not only obscuring the diagnosis, but rendering the removal of 
the sequester a matter of great difficulty and perplexity. The size of these cloacae varies, 
in different cases, from that of a three-cent piece to that of a quarter of a dollar, their 
shape being generally rounded, or somewhat oval. Not unfrequently, however, they occur 
in the form of long, irregular fissures, or slits. Their number is indefinite ; sometimes 
there is but one, while at other times there may be as many as half a dozen, the latter 
number being by no means uncommon in necrosis of the shaft of the tibia. However this 
may be, they always communicate with the surface of the limb in which the affected bone 
is situated, the passages between them constituting so many channels for the discharge of 
matter and the ultimate elimination of the sequester, although, owing to the inadequate 
dimensions of the cloacae, this is seldom effected without the intervention of art. It is 
an interesting fact, of no little practical value, that these openings are always situated in 
that portion of the new bone which is least covered by soft parts. After the removal of 
the sequester they generally disappear under the development of new osseous matter. 
There has been much dispute among pathologists as to the agents by which the new 
bone is produced. Without entering into any details, I may state, as the result of |>er- 
sonal observation, that the perfection of the new bone will generally be in proportion to 
the integrity and activity of the periosteum. I have always found that, when this mem- 
brane lias suffered much during the inflammation which precedes and accompanies the 
necrosis, the reproductive process, or new osseous epigenesis, is tedious and difficult, and 
often extremely inadequate, the new bone being comparatively small and stunted, and, 
therefore, ill adapted to answer the purpose of a substitute bone. The part which the 
periosteum plays in the development of the new bone is well shown in the formation of 
cloacie, which, as already stated, is clearly dependent upon the partial destruction of that 
membrane. If the periosteum everywhere retained its integrity, the new bone would be 
without a solitary opening, and, consequently, the sequester, or slough, would be an 
encysted body, imprisoned, as it were, in a closed canal. When this membrane has 
perished along with the bone, as occasionally happens in the shaft of the tibia or femur, the 
new bone will be formed by the surrounding structures, whatever these may be, but it 
will be so short, thin, and imperfect as hardly to deserve the name of substitute, to which, 
in general, it is so well entitled. 
When the eschar presents itself as an exfoliation, or as a thin, superficial scale, the 
breach is repaired through the medium of granulations, which, being derived from the old 
bone, are extremely vascular and sensitive, and soon assume the ossific process, throwing 
out an abundance of proper material for the accomplishment of the object. A similar 
process is set up when the central portion of a bone perishes; for here, the endosteum 
being also destroyed, it can have no agency in the reproductive act. When this mem- 
brane retains its vitality, it must necessarily exert an important influence as an osteogenic 
agent. 
The idea has been broached, and warmly defended, that when the shaft of a bone is 
necrosed, so as to leave merely its articular ends, the new bone is formed exclusively by 
these ends, the osseous matter extending gradually towards the middle of the chasm, and 859 
CHAP. VIII. 
NECROSIS OR MORTIFICATION. 
ultimately coalescing there. Such a theory, however, is wholly untenable, as it is con- 
trary to what occurs in the growth of the original bone, which always takes place by 
several distinct points, one of which is invariably central. However well the surviving 
extremities might perform their duty, yet, as there is no central nucleus, serving as a 
point of departure for the ossific matter, it is easy to conceive that the bone would always 
necessarily be so deficient at that particular spot as to disqualify it materially for the per- 
formance of any useful functions. 
Although the osteogenic properties of the periosteum, have long been familiar to the 
surgeon, through the labors of Troja, Koehler, Weidmann, and other observers, new 
light has been thrown upon the subject by the admirable and exhaustive experiments of 
Dr. Ollier, of Lyons, since confirmed by other observers. He found that, in rabbits, por- 
tions of this membrane, completely detached from the bone, might be pushed into the 
soft structures, and still preserve their power of generating osseous matter. In some 
cases, indeed, this faculty was not lost when the periosteum was transplanted to remote 
parts of the body, or from one animal to another. The results of these researches, how- 
ever, although pathologically interesting, possess little, if any, practical value, inasmuch 
as they cannot be rendered available in the human subject. 
Symptoms—The symptoms attendant upon necrosis, in its earlier stages, have already 
been pointed out; those which accompany the separation of the old bone and the forma- 
tion of the new', are, in general, sulficiently characteristic. The most important of these 
are, little ulcers, surrounded by large, unhealthy granulations, arranged in a papilla-like 
manner; sinuses leading from these ulcers down to the dead bone; and a discharge, more 
or less constant and copious, of thin, fetid, sanious matter, or of thick, white, inodorous 
pus; accompanied, in all cases, by a certain amount of hardness and swelling, pain and 
tenderness on pressure, wasting of the soft parts above and below the seat of the disease, 
and marked impairment of the functions of the neighboring joints. The general health 
always suffers; the patient is wan and emaciated; and, if the irritation is at all extensive, 
there will usually be hectic fever. In some cases the end of the sequester protrudes at 
one of the cloaca;, thus at once declaring the true nature of the complaint; but, more 
commonly, the dead bone is completely imprisoned by the new, and can only be reached 
by the probe or finger, carried along the sinuses leading from the surface to the cloaca;. 
In order to ascertain whether the separation has been effected, or whether the dead bone 
still maintains its relations, in some degree, with the living, the surgeon may often ad- 
vantageously use two probes, introducing one at each extremity of the eschar, and moving 
them alternately in different directions, as may frequently be easily done when the 
detachment is complete. In general, also, useful information, in this respect, may be 
obtained from a consideration of the history of the case, as the size of the affected bone, 
the age of the patient, and the commencement of the attack. Thus, other things being 
equal, it will usually be found that a small bone will be more readily separated than a 
large one, and the bone of a young subject than that of an old one, while in every instance 
the process may be supposed to be more advanced in proportion to the period that has 
elapsed since the death of the bone. 
A sequester or loose piece of bone occasionally causes serious mischief by its pressure 
upon neighboring structures, especially the nerves and bloodvessels, giving rise, perhaps, 
on the one hand, to severe neuralgia, and on the other, to more or less copious hemor- 
rhage. The latter accident is most likely to occur from erosion and perforation of the 
popliteal artery in necrosis of the lower extremity of the femur; but it has also been met 
with in the anterior tibial artery, and even in the artery of the tongue, in connection 
with necrosis of the lower jaw. 
Prognosis The prognosis of this disorder is variable. In general, it may be con- 
sidered to be favorable when it is owing to external or local causes; when it is confined 
to the outer portion of a bone, the necrosis occurring in the form of an exfoliation; when 
it is simple and of moderate extent; and when the patient is young, robust, and of good 
constitution. On the other hand, the cure is difficult, and the issue doubtful, when the 
disease is acute, extensive, or complicated with other affections; when it attacks pieces 
which are of high importance on account of their function or situation, as those of the 
skull; when it occupies the interior of a bone, and involves several parts of it; when it 
arises from an internal or constitutional cause, as struma or syphilis; when it extends 
into the adjacent joints, especially when they are of large size; and, lastly, when the 
patient is enfeebled by age, long suffering, or previous disease. The most common causes 
of death are erysipelas, pyemia, and profuse discharge. 
The time required for the separation of the eschar and the development of the sub- DISEASES AND INJURIES THE BONES. 
CHAP. VIII. 
stitute bone will depend, as already stated, in great measure, upon the situation and 
extent of the disease, the age, health, and the condition of the patient, and various other 
circumstances not admitting of definite statement. That the whole of a necrosed hone 
may be regenerated is a fact so well established as not to admit of any doubt. The new 
bone, however, as intimated elsewhere, is always, at best, only an imperfect copy, although, 
as regards its functions, it usually answers the purpose well enough, both as it respects its 
length and thickness, especially the former, which is usually equal to tlie old, or the 
original piece. When the substitute bone, during its development, is subjected to strong 
muscular contraction or made to bear too heavy a weight, it is very apt to become 
crooked, and hence all such mishaps should be carefully guarded against. 
Treatment Although the treatment of necrosis must of necessity depend very much 
upon circumstances, there are three indications which deserve special attention; tlie first 
is to limit and moderate the inflammation which is the immediate cause of the mischief, 
the second, to watch nature during the separation of the old bone and the formation of the 
new, and the third, to promote the removal of the sequester, slough, or eschar. 
The first of these objects is to be attained by the proper employment of antiphlogistic 
remedies; by the lancet, if the patient is plethoric, laxatives, antimonial and saline medi- 
cines, light diet, repose, and the free use of opiates to allay pain and induce sleep. The 
affected parts, placed in an easy, elevated position, are leeched and fomented, or, what is 
particularly serviceable, painted with a strong solution of iodine at least three times in the 
twenty-four hours, the surface being protected in the intervals with an emollient, anodyne 
cataplasm, or medicated water-dressing. In some instances, great benefit is derived from 
the application of a blister large enough to encircle nearly the whole of the affected limb, 
and kept on sufficiently long to produce vesication. By these means, the surgeon not 
only limits the inflammation, but promotes the absorption of effused fluids, and hastens 
the suppurative crisis, which is always inevitable, to a greater or less degree, in every case 
of this kind. As soon as fluctuation is perceived, or even before, if there be inordinate 
pain and tension, or deep-seated matter, a large incision is made at one or more points, 
in the direction of the long axis of the bone, in the hope of saving osseous as well as soft 
tissue, especially the periosteum, the integrity of which is so essential to the development 
and formation of the substitute bone. In making the opening, due attention is, of course, 
given to drainage, and to the prevention of its premature closure. 
The second indication is to watch the part and system during the sloughing process and 
the stage of repair, to enable them to bear up under the trying ordeal. The case requires 
active vigilance rather than active treatment ; care, on the one hand, that the disease do 
not spread, and, on the other, that the debility consequent upon the drainage and irrita- 
tion do not obtain the mastery, and so bring on fatal exhaustion. A certain amount of 
inflammation must necessarily attend both operations, and, therefore, action must not be 
too much repressed, lest nature be thwarted in her efforts. A nutritious diet will gene- 
rally be required, and the patient will often be immensely benefited by animal food and 
milk-punch, ale, porter, or wine, and the use of quinine, iron, and aromatic sulphuric acid, 
especially if there be hectic fever and night sweats. Gentle exercise should, if the strength 
will permit, be taken daily in the open air upon crutches; or, if this be impracticable, 
he should be pulled about in a hand-car, or swung in a hammock. Attention is, of course, 
paid to the bowels and secretions. Pain is allayed with anodynes. The principal local 
remedies are leeches, provided there is any disposition to overaction, the daily applica- 
tion of iodine, and the use of the bandage to support not merely the affected parts, but 
also the distal portion of the limb, which, when this precaution is neglected, has usually a 
tendency to become oedematous. Fetor is allayed, and discharge moderated, with chlori- 
nated sodium or permanganate of potassium, int roduced with the syringe and sprinkled upon 
the dressings. Much has been said about the employment of solvents, thrown in through 
the principal sinuses upon the dead bone, in the hope of promoting its gradual disinte- 
gration and elimination. Special stress used to be laid upon various acid solutions, par- 
ticularly the nitric, hydrochloric, and pyroligneous; but experience has proved that they 
are always productive of harm, from their irritating effects upon the new bone and the 
soft parts, whilst, unless they are intolerably strong, they can exert no destructive influ- 
ence upon the sequester itself. If such lotions be employed at all, they should, therefore, 
be employed in the mildest possible form, simply with a view to their detergent and 
alterant effects, which are often very salutary, expediting the sloughing and restorative 
processes. In general, however, all the good that can be expected to result from such 
remedies may be accomplished by injections of tepid water, impregnated with castile soap, 
a little potassa, or common salt, followed, if there be much fetor, by a weak solution of CHAP. VIII. 
NECROSIS OR MORTIFICATION. 
some deodorizer. If new abscesses form, they must, as already mentioned, meet with 
prompt attention. 
During this stage, a stage of comparative inactivity, inquiry is made into special dia- 
theses, or states of the system. The patient, if strumous, may be in need of special reme- 
dies ; or his system may be impregnated with the syphilitic poison, and a course of mer- 
cury, or of iodide of potassium, may be required. It must be obvious that no satisfactory 
progress can be made towards a cure so long as the system is borne down by a vitiated 
state of the solids and fluids. 
The third indication is to get rid of the sequester, for so long as this remains it must 
necessarily keep up inflammation and discharge, the latter of which is generally not only 
highly offensive, but often so copious as to establish a serious drain upon the system. It 
was commonly supposed, until recently, that the dead bone, during its sojourn among the 
living tissues, was acted upon by the absorbent vessels, so as materially to diminish its 
size and weight, the idea having, apparently, derived support from the altered and pitted 
condition of the surface of the affected piece. This notion, however, was completely 
dispelled by the experiments of Mr. Gulliver, who ascertained, as might, indeed, 
have been anticipated, that such an occurrence is altogether impossible. Portions of 
necrosed bone, carefully weighed before and after exposure, were confined on suppurating 
surfaces, in the medullary canal, and in the subcutaneous connective tissue, for months, 
and in one instance for upwards of a year, without undergoing the slightest alteration 
whatever. 
Inasmuch, then, as the dead bone acts as an extraneous body, and is no wise amenable 
to the agency of the absorbents, the indication plainly is to remove it by operation. Such 
a step is the more imperative because of the manner in which it is imprisoned, the sub- 
stitute bone forming a firm, solid case around it, and thus effectually preventing its ex- 
trusion. The only circumstance which should make the surgeon at all hesitate is the 
doubt that may arise in his mind respecting the probability of the dead bone being com- 
pletely detached, and the new one sufficiently advanced to enable it, after the removal of 
the sequester, to maintain its position without bending under the weight of the limb, in 
turning in bed, walking, or sitting. If he is satisfied of this, as he usually may be after 
a careful examination, the operation should at once be proceeded with. The instruments 
that will be required are several scalpels, a trephine, a Iley’s saw, an elevator, pliers, 
chisels, gouges, and stout forceps, with a good syringe for washing away osseous debris. 
The adjoining cuts represent some of the more important of these instruments. Bonwill’s 
surgical engine often affords valuable aid in operations on the bones. The different steps 
of the procedure will be greatly facilitated by the use of the elastic bandage, which, while 
it effectually prevents bleeding, enables the surgeon to do his work more rapidly and 
more thorougldy. 
The incisions should be made in the direction of the long axis of the bone, out of the 
way of the great vessels and nerves. The best plan is usually to select one of the prin- 
cipal cloacae, or, when two or three are close together, especially if they are on the same 
plane, to connect them, thereby affording more room to work in. When the soft struc- 
tures are much diseased, they may be included in an elliptical incision, as, in this event, 
it may be best to get rid of them. When it is deemed advisable to connect two or more 
cloacae, the object may easily be attained by a Iley’s saw, the circular saw of the surgical 
engine, or, if the new bone is not very thick and firm, by the pliers. The trephine is 
chiefly of use when the openings in the substitute bone are very small, or when this bone 
possesses unusual density and thickness, rendering its division extremely difficult by 
the more ordinary instruments. Access having thus been obtained, the sequester is to 
be seized by one of its extremities, with a pair of forceps having long, thin blades, serrated 
on their inner surface, and from a third of an inch to half an inch in width, the handles 
being well curved, so as to facilitate prehension and maintenance. In executing this 
step of the operation great care must be taken not to press the extremity of the sequester 
into the soft parts, on account of the danger of wounding important vessels and nerves. 
Such a precaution is especially important in removing dead bone from the lower end of 
the femur, on account of the proximity of the popliteal artery. 
When the sequester is unusually long, it may be necessary to bisect it, and extract 
each piece separately ; an operation which is always easily performed with the pliers or 
chisel. 
The dead bone having been removed, the next step is to scrape away the semiorgan- 
ized granulations from the inner surface of the new bone, and to wash out the canal with 
the syringe and cold water, in order to free it completely of any debris that may have 862 
DISEASES AND INJURIES OF THE BONES. 
CHAP. VIII. 
been left behind. Unless this be done, a long time may elapse before the canal takes on 
healthy action, as the old granulations are too feeble to furnish reparative material. 
Fig. 385. 
Fig. 386. 
Fig. 387. 
Fig. 388. 
Fig. 389. 
Instruments for removing Dead Bone, 
The hemorrhage after the removal of the elastic bandage is usually very free, the blood 
oozing out at every point, in consequence of the great vascularity of the parts, both 
osseous and soft, and occasionally requires plugging of 
the cavern with lint steeped in some styptic lotion, as a 
weak solution of subsulphate of iron, alum, or alum and 
tannic acid. It is seldom that any arteries require to be 
tied. 
The edges of the wound are drawn lightly together 
with adhesive strips; the limb, placed in an easy posi- 
tion, is bandaged from the distal end upwards; and the 
parts more immediately affected are kept constantly wet 
with cold water medicated with laudanum and acetate of 
lead. The dressings are removed in forty-eight hours, 
when the wound is well syringed, and covered with an 
emollient poultice, to favor the granulating process. The 
only general means usually required are light diet and a 
little attention to the bowels, with a full anodyne after 
the patient is put to bed. If the newr bone is not suffi- 
ciently strong to prevent the limb from bending or break- 
ing, it must be supported by appropriate splints, or, what 
is better, a case made of sole-leather, gutta-percha, or 
trunk-maker’s board. Extension and counter-extension 
may be necessary when there danger of shortening, as in 
necrosis of the thigh or leg. Ankylosis of the neighbor- 
ing joints should be prevented or counteracted by passive 
motion. 
The cicatrization will be greatly facilitated, after such 
an operation, if the edges of the cloacae and sinuses be 
thoroughly pared before the parts are dressed, as they will thus be placed in a much better 
condition for the rapid development of healthy granulations. In general, the edges of 
such openings will be found to be livid, undermined, and partially devitalized, and, 
therefore, incapable of throwing out healthy material. 
Soon after the sequester has been removed, whether by nature or art, the new7 osseous 
Fig. 390. 
Fig. 391 
Hammer. 
Gouge. CHAP. VIII . 
NECROSIS OR MORTIFICATION. 
863 
shell begins to contract, and by degrees assumes the shape of the old bone, which it is 
designed to replace. While this change is going on externally, osseous matter is deposited 
upon the inner surface of the shell, as well as upon the articular ends of the surviving 
portions, thereby gradually filling up the cavity, the period required for this being gene- 
rally in proportion to the size of the eschar. The medullary canal, in case there has 
been one, is, as already stated, seldom reestablished. 
It is not often that the surgeon is not able to effect a good cure in necrosis ; in general, 
even with little deformity and loss of function. Cases do, however, occur, where, from 
neglect or injudicious treatment, the neighboring structures are so extensively and ruin- 
ously involved as to render it difficult, if not impossible, to save the affected limb. Such 
an event will be particularly liable to happen when a large joint is implicated, as, for 
instance, that of the knee in necrosis of the thigh, or of the ankle in necrosis of the tibia. 
Under such circumstances, hardly anything short of amputation will be likely to answer; 
and a similar procedure may become necessary when the patient’s constitution is so much 
shattered by previous or concomitant disease as to preclude the possibility of its holding 
out during the time that may be required for the separation of the dead bone. In other 
cases, again, amputation may be demanded on account of hemorrhage from some large sinus, 
presenting itself either as a general oozing, or as a flow from an artery of considerable size, 
opened by ulcerative action at a period when the loss of a few more ounces of blood might 
prove fatal. Another reason for such interference is excessive deformity of the limb, ren- 
dering it not only very unseemly, but utterly unserviceable. It is impossible, however, 
to exercise too much caution in attempting to decide so grave a question. In weighing 
the several points involved in its consideration, we must not lose sight of the fact that 
cases, apparently of the most forlorn character, where life literally hangs, as it were, by a 
thread, will sometimes promptly recover upon the removal of the dead bone. 
Resection of bone deprived of vitality may occasionally be advantageously practised 
instead of its removal in the form of a sequester. Such a procedure is especially indicated 
in young subjects exhausted by previous suffering, where delay would be likely to be 
followed by great damage to the constitution, if not destruction to life. Another advan- 
tage is that the periosteum may often be much better preserved than when the disease is 
left for several months to itself, as it must generally be when the bone is detached sponta- 
neously. This whole subject has been placed in a very favorable light by Ollier, who, in 
in his great work, etitled Traite Experimentale et Clinique de la Regeneration des Os, 
published in 1867, has adduced a number of cases illustrative of the beneficial effects of 
this mode of treatment, derived chiefly from the practice of Larghi, Creus-y-Manzo, Jambon, 
Lentenneur, and T. Holmes, in all of which large portions of bone were removed, with 
the effect of useful limbs. Other instances, equally gratifying, have since been furnished, 
among others, one by Dr. Cheever and one by Dr. Buckingham, of Boston. The bone 
which yields the best results under this mode of treatment is the tibia, although it is 
applicable to every piece of the skeleton. Excision of the shaft of the tibia, however, is 
always followed, as was first pointed out by Ollier, by dislocation of the fibula at the 
superior tibio-fibular articulation, in consequence of the contraction of the muscles of the 
leg, whereby the head of this bone is gradually pushed beyond its natural level. This 
change was strikingly manifest in the case reported by Dr. Cheever. To counteract this 
tendency, proper mechanical appliances should be employed to insure perfect quietude of 
the limb until the parts are healed. 
It occasionally happens that nature fails to repair the loss after the removal of the dead 
bone. In a case of this description, occurring in a child four years of age, in which two- 
thirds of the humerus were wanting, Dr. MacEwen, of Glasgow, transplanted small 
fragments of wedges of bone, obtained from the curved'tibim of other patients, into the soft 
tissues, in the position of the deficiency, with the result of filling the gap with a new shaft, 
the limb being only half an inch shorter than its fellow. This ingenious practice has been 
imitated by Mr. Macnamara, of London, who inserted several grafts taken from an ampu- 
tated metatarsus into a groove prepared in the leg of a child, from whom he had removed, 
some months previously, the greater part of the shaft of the tibia, but with what result I 
am not aware. That this operation is perfectly feasible is shown by some recent experi- 
ments of Bruns, in which the power of the cells of the medulla of the Haversian canals to 
form new bone is conclusively demonstrated. DISEASES AND INJURIES OF THE BONES. 
CHAP. VIII. 
SECT. X SOFTENING. 
The essential characteristic of osteomalacia, mollities ossium, or softening of the bones, 
is a diminution of the firmness and solidity of the osseous tissue, depending upon the 
gradual removal of its earthy constituents, and the 
increase in its medullary elements. The disease 
is often confounded with rachitis, but differs from it 
in the circumstances, first, of its being a disorder of 
adult life, and, secondly, in being always attended 
with severe pain ; whereas rickets is peculiar to in- 
fancy, and free from local suffering. 
Softening of the osseous tissue varies in degree and 
extent, occurring at one time as a very slight affec- 
tion, with hardly an appreciable change of structure, 
and at another as a most serious lesion, in which it 
is difficult to distinguish any trace of the normal sub- 
stance. In regard to its extent, it may be general 
or partial; in the one case pervading the entire 
skeleton, while in the other it is limited to particular 
bones, or even a portion of bone. Of general osteoma- 
lacia, the case of Madame Supiot, so minutely de- 
scribed by Morand, the younger, in the Memoirs of 
the Academy of Sciences of Paris, for 1710, affords a characteristic, as well as a most 
extraordinary, example, as shown in fig. 392. In this woman, who died at the age of 
thirty-seven, the bones were so completely softened that they could be bent like wax, and 
put in almost any position, although she herself had lost all control over them, her head 
and left arm being the only parts she could move. Most generally the disorder is con- 
fined to particular bones, as the ribs, sternum, vertebraj, and the pelvic pieces, the latter 
being especially liable to suffer in child-bearing women. 
The osseous tissue in this disease gradually loses its firmness and solidity, becoming 
decalcified and ultimately so soft and pliant that it may be easily bent, if not cut. It is 
of a pale reddish color, often inclining to yellow', is specifically 
lighter than the healthy structure, and is infiltrated with a tur- 
bid, viscid serum, removable by pressure. Occasionally the 
osseous fibres are widely separated from each other, so as to 
leave large cells, which are filled with a bloody-looking, adipose 
substance, as seen in fig. 393. When this is the case, the bone 
is sometimes remarkably pliant, bending like semiconcrete wax. 
Boiling completely dissolves it; and exposure to the air, by 
abstracting its moisture, sensibly diminishes its weight. Such 
are the principal changes observable in the osseous tissue. The 
periosteum over the affected part is abnormally thick, rough, 
and but feebly adherent; it is of a grayish hue, deeply injected, 
and, like the bone, infiltrated with sanguinolent matter. Upon 
being macerated, however, it is found to retain its fibrous struc- 
ture. The marrow is converted into a reddish, greasy sanies, 
and the medullary membrane is wasted away to a few' soft, 
connective shreds. The cartilages sometimes participate in the 
softening, while the muscles are pale, atrophied, and infiltrated 
with a rdHdish fluid. 
In the advanced stages of the disease, the bone is deprived 
of its laminated structure, the osseous corpuscles are greatly 
changed in their shape, as well as diminished in number, and 
the Haversian canals are enormously swollen and distended. 
The red, grumous substance, so abundantly diffused through its 
interior, has been shown by Dalrymple to consist of granular 
matter, nucleated cells, and caudate corpuscles. 
The softening generally involves the whole thickness of the 
bone ; but cases occur in which the outer table remains un- 
changed, consisting of a thin, brittle shell. The disorder ob- 
viously consists either in an inordinate absorption of the phosphate of lime upon which 
the solidity of the osseous structure naturally depends, or in a deficient deposition of this 
Fig. 392. 
Madame Supiot, in a Posture quite practica- 
ble in the advanced Stage of the Disease. 
Fig. 393. 
Section of a softened Femur; 
the Medullary and Cancellous 
Structures are occupied by a 
Transparent jelly-like Fat, of 
various Colors. CHAT. VIII. 
SOFTENING. 
865 
matter into its meshes. Dr. Leeson, who has carefully investigated this subject, has 
found a specimen of softened bone to be composed of 18.75 of animal matter, 29.17 of 
phosphate and carbonate of lime, and 52.08 of water. As a general rule, it may be stated 
that there is always a notable increase of fatty matter, a diminution of phosphate and 
carbonate of lime, and an increase of animal substance. 
Respecting the causes of osteomalacia our information is entirely at fault. It is generally 
supposed, and not without reason, that a gouty, rheumatic, syphilitic, or scorbutic state 
of the system predisposes to the occurrence. However this may be, it is evident that the 
disease is essentially connected with, if not directly dependent upon, a vitiated and de- 
praved condition both of the solids and fluids; but whether the disorder of the one pre- 
cedes that of the other, or whether they have a simultaneous origin, and afterwards keep 
steady and regular pace with each other, are questions which our knowledge is inadequate 
to solve. Whatever the real causes may be, it is a well ascertained fact that inflammation 
plays a most important part in the production of the changes which characterize it. If 
it were not so, how could we account for the excessive vascularity of the affected tissues, 
the sanguinolent nature of the infiltrated fluids, the thickened, spongy, and congested con- 
dition of the periosteum, and, finally, the atrocious and constant pains which form so 
notable a feature in the history of osteomalacia ? All these circumstances unerringly point 
to inflammation as the great agent in the production of these changes; changes which, 
when existing in the soft structures, are invariably referred to this cause, and to none 
other. The morbid action, whatever it may be, is always of a chronic character, and is 
attended with important lesions of nutrition, leading to the removal of the earthy matter 
of the bones, and the excretion of it from the system, or its deposition among parts where 
it does not naturally occur. Or, what is more probable, there is both absorption of the 
original solid structure and a want of secretion of new, thus causing a complete disin- 
tegration, or decomposition, of the osseous tissue. All these circumstances are sufficiently 
obvious and tangible; but if we attempt to go beyond them, we involve ourselves at once 
in difficulties from which it is impossible to extricate ourselves. 
Osteomalacia is rarely seen before the age of puberty, its favorite period of attack being 
between the thirtieth land fiftieth years. Another singular feature in its history is that it 
is much more frequent in women than in men, in the proportion, it has been said, of ten 
to three. Of 145 cases collected by Litzman, only 13 were males. It is most common 
in females who have borne several children ; and it often begins either during pregnancy, 
or within a short time after parturition. Of the above cases, 91 were of this description. 
Examples have been reported in which it was hereditary, having been distinctly traced 
through three generations, but in none of the offspring did it show itself until after 
puberty. The bones of insane persons are frequently in a softened condition, approach- 
ing that of osteomalacia. At the Carmethen Asylum, as stated by Dr. Hernder, of twenty 
bodies examined after death, the ribs in nine were found to be abnormally soft and fragile. 
The symptoms of this disease vary in its different stages. Its invasion and progress are 
generally very insidious. The earliest, and for a long time the most prominent, occur- 
rence is pain in the limbs, spine, and pelvis, of a wandering, shifting character, which the 
patient usually supposes to be of a rheumatic nature, and which is often so severe as to 
cause immense distress, especially at night, and in damp, chilly states of the atmosphere. 
By and by, dyspnoea sets in, with palpitation of the heart, and a sense of constriction 
across the chest, and the patient is seized with an overwhelming feeling of prostration, 
which utterly unfits him for business, and usually compels him to keep his bed. If he 
attempts to walk, his limbs bend under him, and if the effort is often repeated, they soon 
become badly curved; should his toe catch in the folds of the carpet, or should he be so 
unfortunate as to trip, or fall, or give his body a sudden twist, he will probably hear some 
of his bones crack, and yield under the superincumbent weight. Emaciation gradually 
takes place, the appetite is deranged, the skin is bathed with clammy perspiration, the 
tongue is foul, the bowels are irregular, being either costive or too loose, and the urine, 
surcharged with earthy phosphates, is very thick, heavy, of a whitish aspect, and fre- 
quently also albuminous. In the latter stages of the malady, the saliva, tears, and sweat 
often contain similar ingredients. Great distortion frequently occurs; and the bones, 
bent in every direction, are effectually disqualified for the performance of their functions. 
The chest projects like that of a pigeon, the spine is bent laterally, as well as backwards, 
the pelvis is twisted, or rotated upon its axis, and the whole stature of the individual is 
sensibly diminished, the head being thrust down between the shoulders, which are un- 
naturally arched and prominent. Amidst all this disturbance, however, the intellect is 
unclouded, menstruation is perfect, and even conception is still possible. The period at 866 
which death occurs varies from a few months to several years, its approaches being 
usually very gradual, and the consequence of sheer exhaustion. 
The diagnosis of osteomalacia cannot always be very clearly defined. The disease for 
which it is most liable to be mistaken is rachitis, but from this it may generally be dis- 
tinguished by the following circumstances:—Osteomalacia rarely occurs before the age of 
twenty-five or thirty, while rachitis is altogether peculiar to infancy and childhood, the 
disease in the former attacking the bones after the completion of ossification, whereas in 
the latter it assails them before they are fully developed. In softening, the patient is 
harassed with excessive pain and an overwhelming sense of exhaustion; in rickets, on the 
contrary, there is a total absence of pain, and the little patient generally retains a good 
share of strength. In osteomalacia there is more deformity than in rachitis; the disease 
is also of a more fatal character, few persons getting well, whereas in rachitis recovery is 
the rule, death the exception. Softening is much more common in women than in men, 
especially in such as have had several children ; rachitis, on the contrary, is nearly equally 
frequent in both sexes. In softening the urine always contains a large quantity of earthy 
matter, whereas in rickets this excretion is unusually laterititious. Finally, the two affec- 
tions are signalized by marked differences in their anatomical characters. In osteoma- 
lacia the osseous structure is completely disintegrated and decomposed ; in rachitis, on the 
other hand, it is merely modified, and, therefore, susceptible of restoration. 
The prognosis of osteomalacia is generally so unfavorable that Solly, Dalrymple, 
and some other authors are inclined to regard it as of a truly malignant character. 
Although this opinion requires confirmation, it serves to show how exceedingly unman- 
ageable the disease has hitherto proved to be in the hands even of the best practitioners. 
The period at which death occurs is very variable, some patients dying in a few months, 
others not under several years. 
The great point in the treatment of osteomalacia is to improve the general health by a 
well-regulated diet and by the employment of tonics, as iron and quinine, the shower-bath, 
and change of air. Mercury has occasionally been administered, and carried to the 
extent of ptyalism, but, instead of proving beneficial, it has usually been productive of 
injury by still further exhausting the powers of life. Phosphate of lime, as having a ten- 
dency to supply the deficiency of osseous matter, has also been tried, but apparently with 
no better effect. If we adopt the idea that the disease is of an inflammatory nature, 
antiphlogistics ought to be advantageous, but thus far their employment has yielded no 
good results, but rather the reverse. When the 
disease is fully established, confinement in bed upon 
a soft, elastic mattress will be necessary; and every 
precaution should be taken to avoid the occurrence 
of curvature and fracture of the affected bones. 
Pain must be relieved by the liberal use of ano- 
dynes. 
SECT. XI RACHITIS. 
Rachitis, or rickets, is a disease of the osseous tis- 
sue, consisting in a deficiency both of its earthy and 
organic elements, as is shown by the diminished 
quantity of phosphate and carbonate of lime, and 
the absence of gelatin, which form such important 
constituents of normal bone. The consequence is 
that the different classes of bone, the long, short, 
and flat, become so excessively softened as, in time, 
to yield under the slightest pressure, bending and 
twisting in various directions, and thus occasioning 
serious and generally irremediable deformity, as ob- 
served in the drawing, fig. 394, taken from a patient 
at the Philadelphia Hospital. 
Rickets, essentially a disease of early infancy, is 
most frequently witnessed from the eighteenth to 
the twentieth month, although many cases occur 
before the end of the first year. Now and then an 
instance is observed as late as the twelfth year; but 
this is extremely uncommon, and altogether con- 
trary to the usual course of the affection. Occasionally it is congenital. The influence 
DISEASES AND INJURIES OF THE BONES. 
CHAP. VIII. 
Fig. 394. 
Rickets. CHAP. VIII. 
RACHITIS.- 
867 
of age in the production of this affection is well shown by the combined statistics of Bruen- 
nische, Von Rittershain, and Ritsche, which indicate that of 903 cases, 358 occurred 
during the first year, 342 during the second, 134 during the third year, 31 during the 
fourth, 17 during the fifth year, and 21 from the sixth to the ninth. Instances have been 
noticed in which it seemed to be hereditary, or in which it attacked several members ot 
the same family. 
From the accurate and masterly account of this disease by Glisson, published upwards 
of two centuries ago, it appears that it first took its rise about the year 1620, in the 
western parts of England, from which it gradually spread over the rest of Europe. In 
this country it has always been extremely uncommon, even among the lower classes, 
whose children are its most frequent subjects. An exception, however, to this statement 
occurs in regard to the children of some of our eleemosynary institutions. Thus, accord- 
ing to Dr. Parry, in the Philadelphia Hospital, 25 per cent, of all the children between 
two months and four years of age are rickety; and in some of the foreign institutions, as 
in those of London, Prague, and other cities, the proportion is still greater. These dif- 
ferences are doubtless due to the differences of constitution, and modes of living, children 
that are crowded together, ill-fed, and confined in small, ill-ventilated apartments, being 
most liable to suffer from the disease. 
Of the causes of rickets nothing is known. From the circumstance of its appearing 
occasionally in several members of the same family, it has by many been supposed to be 
of a hereditary character, nearly all of the older, and not a few of the modern, authori 
ties concurring in this view of its origin. IIow far a strumous, or scorbutic state of the 
system is influential in its production is undetermined; nor is anything positive known of 
the effects of a vitiated atmosphere upon its development, as living in damp, crowded, 
and ill-ventilated underground apartments, so prejudicial to the general health. That 
these and other causes may engender it when there is a predisposition to its occurrence is 
highly probable, but then the question arises, What creates the predisposition ? There 
must necessarily be some defect in the constitution, otherwise the disease could not take 
place. Mere disorder of the digestive and assimilative functions could not produce it, 
for thousands of children are thus affected, and yet do not suffer from rickets. A syphi- 
litic taint of the system is a powerful factor in its production, as is shown by the fact 
that the majority of children born with congenital syphilis become ricketty despite the 
best nursing; and Parrot, one of the latest writers on the subject, teaches that the disease 
can be traced to no other cause. Whatever the exciting cause may be, there is no ques- 
tion that the immediate one is a deficiency of phosphate and carbonate of lime, upon 
which the solidity of the osseous tissue essentially depends. IIow far the want of cartil- 
age, which is such an important element of healthy bone, may disqualify the osseous 
tissue in rachitis for the reception of earthy matter, is a problem which remains to be 
solved. 
The pathological alterations of the osseous tissue consequent upon this disease may be 
conveniently arranged under three heads, each possessing marked peculiarities. In the 
first, the bones are saturated with a reddish, watery fluid, a considerably quantity of 
which is also interposed between their outer surface and the periosteum, on the one hand, 
and between the medullary membrane and their internal walls, on the other. At a more 
advanced period, this fluid is replaced by a sort of gelatiniform substance, which becomes 
gradually organized, and ultimately adheres with great firmness to the parts with which 
it lies in contact. The periosteum is thickened and injected, the nutrient vessels are 
remarkably enlarged, and the medullary membrane is very spongy and vascular. The 
lamellae of the long bones, naturally so hard and compact, are a good deal softened, while 
the areolar structure is greatly rarefied, many of the cells being more than double the 
natural size. Similar alterations are observed in the short and fiat bones. 
In the second stage, a peculiar spongoid substance is formed between the periosteum 
and the outer surface of the bones, varying from two to three lines, or upwards, in thick- 
ness. When the quantity of this “ transition tissue” is unusually great, it may exert 
such a degree of pressure upon the lamellae of the compact tissue as to push them inwards 
towards the medullary canal, in such a manner as to reduce it very materially in size, if 
it do not entirely obliterate it. Simultaneously with these changes the bones are rendered 
so soft that they may easily be bent, cut, and even indented with the finger. 
In the third stage, that of resolution, the recently formed substance in the long bones, 
as well as in some of the flat and short, assumes a compact character, and is gradually 
identified with the preexisting tissues, which at the same time regain their primitive 
solidity. Owing to the presence of this new matter, the bones are much larger than in 868 
DISEASES AND INJURIES OF THE BONES. 
CHAP. VIII. 
their natural state, and their firmness, especially in the adult, resembles that of ivory. 
Hence the term eburnation is sometimes applied to this condition. 
When rachitis proves fatal, the body is usually found in a state of excessive emaciation ; 
the muscles are thin, pale, and flabby ; the ligaments are relaxed ; the adipose matter is 
almost entirely consumed ; the cerebral substance is unnaturally soft ; the liver and spleen 
are enlarged and flaccid ; the intestines are attenuated and distended with gas, and there 
is not unfrequently marked tumefaction of the muciparous follicles; the mesenteric glands 
are increased in volume and consistence ; the heart is softened, and smaller than common; 
the lungs, which are often congested, are more or less tuberculized in about one-sixth of 
the cases ; and the bronchial glands are hypertrophied, loaded with serosity, and of a deep 
purplish hue. Occasionally there is partial ossitication of the arteries, muscles, and other 
structures, as if they had become the recipients of the earthy matter which naturally 
appertains to the bones. 
The symptoms of rickets possess nothing of a definite character in the earlier stages 
of the disease. Its approaches are generally stealthy, and at times almost imperceptible. 
The child, gradually losing its health and spirits, becomes dull and listless, and labors 
under derangement of the digestive organs, especially flatulence and colicky pains. When 
craniotabes exists, the child is very fretful, its sleep is disturbed, and it is liable to suffer 
from spasm of the glottis. After a while, marked emaciation sets in ; the muscles are 
soft and flabby; the abdomen is tympanitic; the skin is dry and sallow ; the face looks 
pale and doughy; the urine is scanty, turbid, and laterititious; and the alvine evacuations 
are thin, watery, and fetid, there being nearly always considerable diarrhoea. Bronchial 
catarrh is of frequent occurrence. Dentition advances slowly, and the teeth, of a black, 
fuliginous aspect, often begin to decay almost as soon as they pierce the gums. The fon- 
tanelles and sutures are unnaturally open, the occipital and posterior half of the parietal 
bones, especially, being thinned, and the seat of depressions or of open spaces from 
absorption of their plates, the pericranium and dura mater being in contact with each other; 
and the whole process of ossification is peculiarly slow and imperfect, sometimes, indeed, 
almost stationary, if not actually retrogressive. As the disease proceeds, the bones grow 
more and more soft, and, being unable to sustain the weight of the body or to resist the 
action of the muscles, are at length strangely and frightfully distorted. The head, 
although abnormally small, is disproportionately large to the size of the face, and is sunk 
down between the shoulders; the clavicles are bent and extremely salient; the spine is 
curved in various directions, especially laterally, and diminished in length ; the pelvic 
bones are curved inwards, so as to lessen very materially the corresponding cavity ; the 
ribs, thickened at their point of union with the costal cartilages, are flattened, and the 
chest, in consequence, is sensibly increased in its antero-posterior diameter, giving it a 
narrow, pigeon-shaped appearance. The bones of the extremities are shortened, bent, 
and twisted upon their axes, while their articular ends, or epiphyses, are softened, rarefied, 
and greatly expanded, thus appearing much larger and more prominent than naturally. 
If the child has begun to walk, he becomes daily more feeble on his legs : he waddles, 
trips, falls, and soon returns to his nurse’s arms. 
In rachitis there is an actual arrest of development of the bones, which, although it 
pervades the entire skeleton, is always most conspicuous in the lower extremities, the 
femur, tibia, and fibula being often fully one-third shorter than in the natural state, and 
also diminished in diameter, except at the epiphyses, which, as already seen, are always 
unusually large and prominent, especially if the child has been much on his feet. Under 
such circumstances, the head and neck of the femur are sometimes forced by the weight 
of the body into a horizontal position below the level of the great trochanter; the indi- 
vidual is bow-legged, and the joints of the knee and ankle suffer great distortion from the 
weakened and relaxed condition of their ligaments. The flat bones, during the repara- 
tive process, become solidified and hypertrophied in their areolar texture, while the long 
ones are increased in thickness and strength along the concavity of their curvatures, that 
they may be the better able to support the superincumbent pressure, and resist the effects 
of muscular action. 
The only disease of the bones with which rachitis is at all liable to be confounded is 
osteomalacia, or softening. The signs of distinction, however, are commonly very evi- 
dent. In the first place, rachitis is an affection of infancy and early childhood, whereas 
mollescence never occurs until after middle age. Secondly, in rickets the softened and 
flexible state of the skeleton is only temporary; after a time, a process of repair is set 
up, and gradually continuing, the affected tissues become at length more firm and compact 
than they are in the natural state; in osteomalacia, on the contrary, the disease, once be- CHAP. VIII. 
RACHITIS. 
869 
gun, generally progresses until the patient is worn out by his suffering, no attempt being 
usually made at restoration. Thirdly, in rachitis there is no material alteration in the 
urine, whereas in mollescence this fluid is always loaded with a large quantity of earthy 
salts, the kidneys taking on a vicarious action, and so carrying off the material destined 
for the supply of the bones. Fourthly, in rickets there is an actual arrest of develop- 
ment, in consequence of which the bones remain disproportionately short, thin, and 
dwarfish ; in softening, on the contrary, the affected pieces retain their normal shape, 
although they are so changed in their consistence that they may readily be cut and bent 
in almost any direction. Lastly, in rachitis one of the earliest symptoms, as originally 
pointed out by Elsiisser, and fully confirmed by Vogel, is the existence, on the posterior 
surface of the skull, of little depressions, pits, or hollows, varying in size from a linseed 
to that of a bean, easily detectable by the tips of the fingers, and having a soft, elastic 
feel, not unlike cartridge paper. In osteomalacia no such occurrence is found. 
The prognosis of rachitis is generally unfavorable, few persons recovering without per- 
manent deformity. In regard to the danger to life, it is commonly in proportion to the 
number of bones affected, the rapid progress of the complaint, and the age of the subject. 
Very young children are more liable to die of it than those who are more advanced in 
years, and those who are born of scrofulous or syphilitic parents than those who come 
into the world under more happy auspices. The duration of the disease is extremely 
variable ; very tardy at one time, very rapid at another. In general, even under the 
most favorable circumstances, several years elapse before complete recovery occurs. The 
progress of the cure is often fatally arrested by some intercurrent malady, as measles, 
scarlatina, smallpox, or cholera. The longer recovery is postponed, the greater will be 
the danger of serious deformity. The duration of life is not necessarily shortened in 
persons who get well of rickets, as cases have occurred in which they attained the age of 
sixty, seventy, or even seventy-five. 
Treatment.— In the treatment of rachitis active measures are out of the question. The 
chief reliance must be upon a properly regulated regimen and the use of tonics, with a 
view of invigorating the general system, and of improving the condition of the blood, 
which is always materially altered in its properties. Whatever, therefore, has a tendency 
to strengtlien the patient, and to enrich the circulating mass, must prove indirectly bene- 
ficial in removing the disease, and should claim serious consideration in every case. 
The diet should be mild and nutritious, comprising an adequate amount of nourishment 
in the smallest possible space, so as not to oppress the stomach and create flatulence and 
acidity. The best article is, of course, the mother’s milk, or, when this is insufficient or 
unwholesome, fresh cow’s milk, or, better still, the milk of the ass, which is now so much 
used in some of the larger cities of continental Europe, and which approaches nearer, in 
its composition, to human milk than that of any other animal. If the teeth are properly 
developed, a small amount of animal food will be useful, especially fat bacon, well boiled, 
and not too salt, with good stale bread, and a little mashed potato. The body should be 
washed at least twice a day with salt water, followed by dry friction, or rubbed with a 
moderately stiff salt towel; and, if the system is not too much reduced, cool or cold bath- 
ing will be found highly invigorating. Frequent exposure of the little patient to the 
fresh air, and exercise suited to his age and strength, are to be rigidly enforced. The 
secretions are improved by alteratives, especially blue mass and mercury with chalk, while 
the bowels are kept soluble with rhubarb, magnesia, or oil. Acidity is allayed by the 
alkalies, as lime water, soda, or potassa. 
Tonic medicines, particularly quinine and iron, given in small doses, and long con- 
tinued, with an occasional intermission for a few days, are always imperatively indicated, 
and there are few cases which are not promptly benefited by their exhibition, especially 
in the early stages of the disease, although they are nearly equally useful throughout its 
entire progress. The mineral acids, and the tincture of the chloride of iron, are particu- 
larly advisable when the disease is associated with a scorbutic condition of the system. 
Alterative doses of mercury occasionally exercise a salutary influence, especially when 
the patient labors under the strumous diathesis, the best form being the bichloride, in 
combination with a small quantity of iodide of potassium, given in syrup of orange peel. 
The pain, which is often considerable, is controlled with opiates, either alone or con- 
joined with diaphoretics. 
Lately, the phosphates, formerly so much employed in the treatment of rachitis, on the 
ground that they would tend to supply the deficiency of earthy matter, have again come 
into vogue, but it remains to be seen whether they really possess any advantage over the 870 
DISEASES AND INJURIES OF TJIE BONES. 
CHAP. VIII. 
more ordinary tonic remedies, already referred to, or whether, indeed, they are not inferior 
to them. Their best form of exhibition is the syrup. 
Of all the so-called antirachitic remedies, however, the most valuable, so far as any 
individual article is concerned, is cod-liver oil, given several times a day, in doses suited 
to the age and other circumstances of the patient. Possessing highly nutritive and alte- 
rative properties, it is admirably adapted to support the system, to enrich the blood, and 
to improve the secernent powers, which are so much at fault in rachitis. It may be ad- 
ministered either alone or in union with some of the more important tonics above 
mentioned. 
The mattress upon which the child lies should be perfectly free from hollows or depres- 
sions, it being a matter of the first moment that the head, trunk, and limbs should rest 
upon the same plane. As soon as softening occurs, support must be afforded to the 
weakened structures by appropriate mechanical appliances. The erect posture and pro- 
gression must be interdicted until the bones are sufficiently strong and firm to bear the 
weight of the body. 
The angular deformity left after recovery from this disease is not only very unseemly, 
but often a serious impediment to progression, and, therefore, demands surgical interfer- 
ence. When the bones are still soft, the object may generally be attained by forcible ex- 
tension, performed in a direction opposite to the projection, with the precaution of pre- 
venting separation of the epiphyseal connections. When the reverse is the case, subcu- 
taneous osteotomy must be performed, the division, as stated in the second volume, being 
effected by means of a saw, trephine, chisel, or dentist’s drill, and rectification produced 
by suitable apparatus, or the use of the plaster bandage. 
SECT. XII FRAGILITY. 
Fragility of the osseous tissue is one of those affections which are to be regarded rather 
as an effect of disease than as a disease itself. It consists, as the name implies, in a 
peculiar brittleness of the bones, in which, especially in its more advanced stages, their 
substance is so completely changed in its character as to give way under the most trivial 
circumstances. All the bones are liable to this morbid brittleness, and cases occur, al- 
though rarely, where it literally pervades the whole skeleton. In 1857, the body of a 
female, suposed to be upwards of seventy years old, was brought into the dissecting rooms 
of the Jefferson Medical College, with upwards of eighty fractures, received a few days 
before in a fall from a third story window upon the pavement below. Nearly all the ribs, 
several of the vertebrae, and a number of the long bones, were broken, and signs of for- 
mer fractures existed in the humerus, thigh, scapula, and other pieces. Devergie exam- 
ined the body of a woman who died under symptoms of fragility, in whose skeleton there 
were not less than eighty-three fractures. The late Professor William Gibson met with 
a young man, whom I also saw many years ago, the bones of whose extremities were 
repeatedly broken by the most trivial accidents. The clavicles had suffered still more 
frequently, having been fractured altogether eight times. This universal fragility of the 
osseous tissue occasionally occurs at a very early period; sometimes, indeed, even in the 
foetus in the womb. Chaussier met with a remarkable example of this kind, where the 
long bones had experienced not less than one hundred and thirteen fractures, some being 
perfectly consolidated, thus showing that they had taken place some time previously, 
while the rest were either recent or had partially united. The child survived its birth 
oidy twenty-four hours. General fragility, however, is a comparatively rare affection ; 
usually the disease is limited to particular bones ; or, still more commonly, to particular 
portions of a bone; and those which are most prone to suffer are the head and neck of 
the femur, the ribs, sternum, radius, ulna, clavicle, and the superior extremity of the 
humerus. 
When the affection exists in its highest degree, the slightest accident is frequently suf- 
ficient to produce fracture, as a severe tit of coughing, kneeling upon a hard floor, or 
turning round in bed. Sometimes, indeed, the fragility is so great that the individual 
cannot be touched rudely without the occurrence of the injury. Of this description was 
the memorable case of the woman, recorded by Saviard, who could not be moved about 
in bed without breaking some of her bones. After a confinement of six months she died, 
when it was found that she had had fractures in all the long bones of the extremities, as 
well as of the clavicles, ribs, vertebr.e, and pelvis, many of the pieces being so brittle that 
they could not be handled without crumbling into fragments, similar to old, dry bark. 
Fragility of the bones usually comes on without any assignable causes, and the general FRAGILITY. 
871 
CHAP. VIII. 
health not unfrequently remains good until long after it has made its appearance. In 
most cases, if not in all, it is merely symptomatic of some other disease, particularly of 
rheumatism, gout, syphilis, scrofula, and scurvy, attended with an altered and impover- 
ished state of the blood, and impairment of the assimilative powers. The bones them- 
selves are very much in the condition in which they are in osteomalacia, that is, they are 
more or less softened by the removal of their earthy matter, and often so completely 
saturated with fat as to render them unfit for preparations. On the other hand, however, 
they are sometimes remarkably dry and brittle. These facts show that their intimate 
structure undergoes some important anatomical change, the immediate result, apparently, 
of inflammation. What tends to support this view of the nature of the affection is the 
circumstance that, long before the bones manifest any disposition to break, the patient is 
harassed with severe pains, deep-seated, fixed, and referred to particular portions of the 
skeleton, and that, upon dissection, the diseased parts are generally found to be extremely 
vascular, their areolar tissue being profoundly injected and infiltrated with bloody matter, 
while the periosteum is very thick, spongy, and highly congested. 
Fragility of the bones is one of the usual concomitants of old age. As life advances, 
their vascularity sensibly diminishes, many of the vessels shrinking, and becoming finally 
entirely obliterated. It is owing to this circumstance that old persons, especially females 
after the fifty-fifth year, are so much more liable to fracture than to dislocation, the part 
most prone to yield being the neck of the femur within the capsular ligament, whose 
areolar tissue is often astonishingly rarefied, while the compact is hardly as thick as 
ordinary letter paper. A fatty and brittle state of the bones is not uncommonly an effect 
of general paralysis. 0 
This disease is sometimes observed in several members of the same family. In an 
instance related by Dr. Pauli, of Landau, it was distinctly traceable through three genera- 
tions on the father’s side. All the grandchildren, five in number, had each had several 
fractures, one as many as five, in the bones of the extremities, mostly as the result of 
inconsiderable injury. They were all remarkably healthy, without any evidence in any 
of them of a scrofulous taint of the system. 
An instance of a similar kind was recently communicated to me by Dr. II. L. Battle, 
of Wadley, Georgia. Of a family of eleven children five, all boys, have inherited this 
peculiarity, evidently through the mother’s side, although she has never suffered from 
fractures. She is affected, however, with curvature of the spine, and her father and 
several of her brothers and sisters have fragility of their bones. All the unsound children 
resemble their mother in complexion and in the color of their eyes. The oldest, now 
twenty-four years of age, has had sixty-four fractures; the next, two years younger, 
thirty-four; the third, aged thirteen, thirty; the fourth, eleven years, ten ; and the fifth, 
two years old, two. All the fractures occurred in the femur, generally from very slight 
causes. The other children, all girls, strikingly resemble their father, and enjoy excellent 
health. Under proper treatment the fractures always unite very promptly, and, what is 
singular, none of these persons have, at any time, experienced any severe pain, so common 
under such circumstances. 
There are, unfortunately, no reliable symptoms of this affection. On this account it is 
usually overlooked until it has reached its highest degree of development, when it is 
always incurable. In general, the person is laboring under severe pain, which, as it is 
usually regarded as of a gouty, rheumatic, or syphilitic character, is rarely, if ever, 
referred to its proper source, until after the occurrence of curvature, or fracture, from 
causes so slight as to awaken, for the first time, a suspicion of the real nature of the 
disease. As the disorder progresses, the appetite and strength become impaired, the 
suffering increases in violence, and the urine is surcharged with earthy constituents, 
especially phosphate and carbonate of lime. This alteration in the urine is observable at 
an early period, and in general fragility goes on gradually augmenting down to the time 
of death, which happens at from six to eighteen months, the patient meanwhile being 
perfectly bedridden. 
There are then only two circumstances that can be at all relied upon as diagnostic of 
this complaint; one is the severe and intractable character of the pain, deep-seated, and 
usually referred to the bones; the other, the altered condition of the urine, as declared by 
the presence of an inordinate quantity of earthy matter, especially the phospliatic. When 
these phenomena coexist, there will be strong reason to conclude that there is serious 
lesion going on in the skeleton, and this suspicion will be converted into certainty when, 
superadded to them, there occurs, without any considerable external violence, curvature, 
fracture, or displacement of some of the bones. 872 
DISEASES AND INJURIES OF THE BONES. 
CHAP. VIII. 
Fragility, like softening, is generally an incurable affection. The only exception, per- 
haps, to this rule is when it occurs as an effect of the syphilitic or rheumatic poison, but 
even then it seldom admits of complete relief unless it presents itself in a very circum- 
scribed form. The fragility of old age is always irremediable. 
No rational treatment lias yet been laid down for this disease, nor will it be possible to 
do so until we shall have more enlightened views of its etiology, pathology, and diagnosis. 
Jn all cases strict inquiry should be instituted into its origin, when such remedies should 
be administered as the result may seem to indicate. A. tonic and supporting course, con- 
sisting of the different preparations of iron and quinine, and of the syrup of the phosphates, 
along with cod-liver oil, and vegetable acids, especially the citric, and a well-regulated, 
nutritious diet, will afford the best chance of relief in the scorbutic diathesis. Iodide of 
potassium and bichloride of mercury should be given in the syphilitic variety of the dis- 
order; while in the gouty and rheumatic forms, colchicum may, probably, prove beneficial. 
In Dr. Battle’s cases, above referred to, marked benefit has accrued from a change of vege- 
table to animal food. To relieve the excessive pain which is so prominent a symptom in' 
the latter stages of the affection, especially when it involves a large portion of the skeleton, 
anodynes must be given in full and sustained doses. Curvatures and fractures must be 
treated upon general principles. In most cases union occurs very promptly ; sometimes, 
however, it is very tedious, and now and then the parts refuse to heal, despite the best 
directed efforts of the surgeon. 
SECT. XIII ATROPHY. 
Atrophy of the osseous tissue is characterized by the partial absorption of its elementary 
constituents, as is evinced by its lightness and porosity. It may occur in any portion of 
the skeleton, but the long bones are oftener affected than the short or fiat. Like hyper- 
trophy, it may be partial or general; that is, it may involve an entire piece, or be limited 
to a particular part of it. Atrophy, moreover, may be concentric or eccentric. In the 
former variety the bone is diminished in its diameter; in.the latter it retains its original 
size, but is reduced in weight, and rarefied in structure. The principal causes are, pro- 
tracted pressure, chronic inflammation, deficient nervous influence, and insufficient supply 
of arterial blood. 
o. The influence of steadily exerted pressure, in producing atrophy of the osseous 
tissue, is well exemplified in the cranial bones in tumors of the dura mater; in the sternum 
and dorsal vertebne in aneurism of the aorta ; and in the ribs in carcinoma of the mammary 
gland. In all these instances the compact substance is reduced to a thin, translucent 
plate, while the spongy texture is either wholly destroyed, or worn down to a few slender 
shreds. The immediate cause of the wasting process here is absorption, acting simultan- 
eously and equally upon the animal and earthy constituents. 
/3. Atrophy from chronic inflammation is probably infrequent. One of the best speci- 
mens of it that I have ever seen occurred in a colored woman, who died of pulmonary 
phthisis at the age of forty. The body was much emaciated, and all the long bones were 
remarkably reduced in weight, although they had experienced no 
change in their external configuration. The compact substance was 
wasted to a mere shell, scarcely thicker than common wrapping paper, 
while the cells of the spongy texture wrere increased many times beyond 
the natural size. The medullary canal was much enlarged, and filled 
with a greasy reddish substance, not unlike fresh adipocire. These 
appearances are well shown in fig. 395, and afford a beautiful illus- 
tration of the eccentric form of atrophy. 
Atrophy is sometimes the result of local injury, as a blow, wound, 
or contusion. The wasting in this case may be limited to the site of 
the original mischief, or it may extend to the entire bone, which, how- 
ever, is uncommon. In what manner such an injury operates, whether 
through the agency of inflammatory irritation or otherwise, in giving 
rise to atrophy, is unknown. 
A bad form of atrophy, often followed by permanent lameness, 
occasionally occurs in the neck of the femur, as well as in other por- 
tions of the skeleton, from what is called interstitial absorption of the 
osseous tissue. It is generally caused by external injury, but may 
also arise from attacks of cold, gout, rheumatism, and syphilis. The 
Fig. 395. 
Atrophy of Bone. 873 
CHAP. VIII. 
HYPERTROPHY. 
osseous structure wastes under its influence, and is frequently followed by important 
alterations in the conformation and direction of the affected bone. 
y. Deficient nervous influence is a frequent cause of atrophy both of the osseous tissue 
and of the soft parts. In paralysis of the lower extremities there is usually notable wast- 
ing, not only of the muscles, but also of the long bones, which are greatly reduced in 
weight, rarefied in their texture, and diminished in size. Atrophy of the osseous tissue 
is occasionally dependent upon general paralysis, especially if long continued. 
8- The effect of a diminished supply of blood in inducing atrophy of bone is sometimes 
very conspicuous in old fractures. In such injuries there is often considerable wasting of 
Fig. 396. 
Fig. 397. 
Atrophy of connective Structure 
of the Thigh-bone. 
Advanced stage of senile Atrophy 
of the Thigh-bone. 
the osseous tissue, simply from obliteration of the nutrient artery by the pressure of the 
callus. The atrophy is always eccentric, and is usually limited to one-third, one-half, or 
two-thirds of the affected bone, according to the seat of the original injury; or, more 
properly speaking, the quantity of the new matter, and the extent of the vascular 
obliteration. 
t. Finally, there is what is termed senile atrophy. In old age, the bones are rendered 
light, porous, and brittle; the compact substance is reduced to a mere parchment-like 
shell, while the areolar texture is remarkably rarefied or expanded ; the muscular promi- 
nences are diminished in size ; the animal matter is partially absorbed ; and many of the 
vessels are obliterated. These changes are nowhere more conspicuous than in the neck of 
the femur, which, in consequence, often breaks from the most trifling causes, and which, 
after this occurrence, is seldom, if ever, repaired by osseous matter. Fig. 396 is a section 
of a well-marked specimen of this kind ; the internal structure is very much rarefied ; and 
the head of the bone, flattened and expanded, is approximated to the shaft, from the 
partial absorption of its neck. Fig. 397 exhibits the affection in a still more advanced 
stage with porcellanous deposits. Wasting of the alveolar process in edentulous subjects 
is a beautiful illustration of senile atrophy of bone unaccompanied by disease. 
Atrophy of the osseous tissue does not admit of cure. All that the surgeon can do is 
to amend the general health, when that is at fault, and to remove any local causes of 
disease when they are found to exist. 
SECT. XIV HYPERTROPHY. 
Hypertrophy of the osseous tissue may be partial or general, as the abnormal growth 
affects either a portion or the whole of a bone. The latter, however, is very uncommon, 
except in some of the broad pieces of the skeleton, particularly those of the skull, which, 874 
DISEASES AND INJURIES OF THE BONES. 
CHAP. vm. 
now and then, present an extraordinary degree of development, being, perhaps, three or 
four times the natural thickness, and so hard as to render it very difficult to saw them. 
The diploe is totally obliterated by dense, earthy matter. Similar appearances are some- 
times witnessed in the cylindrical bones of the extremities. In an old femur in my pri- 
vate collection, the medullary canal is scarcely large enough to admit a common-sized 
quill; the whole shaft consists almost entirely of compact substance, in many places more 
Fig. 398. 
General Hypertrophy, showing the Internal Condition of the Bone. 
than six lines in thickness. The bones of the male are always larger and more distinctly 
developed than those* of the female, and the bones of persons who take much exercise than 
those who are indolent or inactive. By labor, their weight and dimensions increase; their 
spongy structure diminishes, whilst the compact becomes harder and more dense, and 
acquires an almost rock-like solidity ; the muscular prominences are rendered more con- 
spicuous ; in short, everything indicates that they are in a state of general hypertrophy. 
The osseous tissue usually contains its due proportion of animal matter, and on this account 
does not readily yield under external injury. 
Hypertrophy may affect a bone both in length and in thickness. The former occur- 
rence, however, is only possible during tbe developmental period of bone, for as soon as 
the osseous tissue has attained its full growth it ceases. 
An increase in the thickness of a bone, on the contrary, 
may arise at any time from any cause capable of pro- 
ducing irritation and hyperemia. 
Sometimes the hyperostosis affects tbe entire skeleton, 
as in a case reported by Dr. J. Ewing Mears, in which 
the disease wqs associated with osteoporosis. The pa- 
tient, a boy fourteen years of age, had died from ex- 
haustion, after having long suffered, as was supposed, 
from strumous inflammation. The change of structure 
was most conspicuous in the bones of the extremities, 
those of the trunk and skull being but slightly affected. 
The adjoining cut, fig. 398, from a specimen in my 
cabinet, is an excellent representation of general hy- 
pertrophy of the femur of a man affected with tertiary 
syphilis. The section of the bone exhibits its in- 
terior structure, which is very much condensed through- 
out, except at the superior extremity, where there are 
still some remains of the areolar tissue ; the medullary 
canal is entirely obliterated, and the weight of the bone 
is nearly twice as great as in health. The exterior 
of the bone is very rough ; and the periosteum was 
greatly thickened and indurated from chronic inflam- 
mation. 
The annexed sketch, fig. 399, is a specimen of hy- 
pertrophy of the bones of the leg and foot, both in 
thickness and length. It is from a drawing of a pre- 
paration in the collection of the late Professor Buchanan, 
of Nashville. All the bones are much enlarged, in- 
creased in weight, and ankylosed at the ankle, tarsal, and metatarsal joints. The inter- 
osseous ligament was completely ossified. The foot and leg had been the seat of exten- 
sive ulceration, followed by exfoliation from the hypertrophied bones. 
General hypertrophy of the bones is usually incurable. It is only, or chiefly, when it 
depends upon a syphilitic taint of the system that it admits of relief; but as this subject 
Fig. 399. 
Hypertrophy Involving both the Thickness 
and Length of the Bone. CHAP. VIII. 
OSTEOPHYTES — TUMORS. 
875 
lias already been fully discussed elsewhere, it is not necessary to revert to it here. Elon- 
gation is always irremediable. 
SECT. XV OSTEOPHYTES. 
An osteophyte is an osseous growth, differing from an exostosis in not forming a well- 
defined tumor, growing, as it does, upon rather than from bone. It occurs chiefly in 
middle-aged and elderly subjects, upon the more vascular 
portion of bone, as its articular extremities, its rough lines, 
and its sutural cartilages, and is more frequent in the femur, 
fibula, and vertebra? than in any other pieces of the skeleton. 
The ordinary osteophyte presents itself in a great variety 
of forms; sometimes as a pointed stalactite, or sharp, thorn- 
like spicule, sometimes as a warty excrescence, sometimes 
as a lamella several lines in length and thickness, and some- 
times, again,as a body bearing a close resemblance to a coral. 
In the vertebrae, an osteophyte occasionally extends like a 
bridge from one piece to another, tying them firmly together ; 
and a similar arrangement now and then occurs between the 
articular extremities of some of the long bones, as between 
the femur and tibia. The annexed cut, fig. 400, affords a 
good illustration of this disease as it sometimes occurs in the 
lower extremity of the femur. The whole surface of the 
bone is roughened by the new growths. 
The exciting causes of these osseous formations are not 
always appreciable. In general, they are developed under 
the influence of a gouty, rheumatic, syphilitic, or scorbutic 
state of the system ; occasionally they are directly traceable 
to the effects of external injury, and cases occur in which 
they succeed to caries or necrosis. Immense numbers of osteophytes are sometimes seen 
in osseous tumors, especially the fibrous and sarcomatous. The immediate cause of 
the disease is inflammation, attended with a deposit of lymph, which is gradually converted 
into osseous tissue, similar to the callus of a broken bone. 
There are no symptoms by which this disease can be recognized during life, unless the 
osteophytes are of great size or unusually prominent, when they may occasionally be dis- 
tinguished by a careful digital examination. Its progress is generally very tardy, and there 
is seldom any danger so long as these bodies do not exert any severe pressure upon im • 
portant structures. 
In the treatment of osteophytes, the first object should be to ascertain, if possible, the 
nature of the exciting cause, tor upon a knowledge of this the whole management of the 
case will necessarily hinge. A gouty, rheumatic, or syphilitic state of the system should 
be met in the usual manner. The inflammatory character of the affection must not be 
overlooked. Mercury is indicated in the earlier stages of the disorder. The most 
suitable local remedies are tincture of iodine, iodide of lead ointment, leeches, and blisters. 
SECT. XVI.—TUMORS. 
The bones are liable to sarcoma, osteoma, chondroma, osteoid-chondroma, fibroma, 
myxoma, angioma, and hydatid cysts. Primary carcinoma is not observed in the skeleton, 
although it is quite common as a secondary formation. Cysts, with the exception of those 
which occur in the maxilla; in connection with the glandular follicles of the mucous 
membrane of the antrum, or with impacted and misplaced teeth, or with the periosteum 
of the fangs, are probably always due to mucoid softening and cystoid degeneration of 
myeloid, cartilaginous, and myxomatous neoplasms. The only vascular tumor of the 
osseous system is aneurism by anastomosis or arterial erectile growth, true aneurism of 
the arteries of the bones being unknown, the pulsating tumors hitherto classed under that 
term being merely highly vascular sarcomas. 
Neoplasms originate either from the surface or from the interior of the bones. The 
superficial, peripheral, or periosteal growths, which are rather the more common, develop 
from thesoft, osteogenic layerof the periosteum, theouter fibrous layer of the membrane con- 
stantly regenerating itself to form a limiting capsule for the tumor, as is shown in fig. 
401, from S. W. Gross, which represents a peripheral round-celled sarcoma of the hu- 
merus. The bone itself, between which and its investing membrane the mass is seated, 
Fig. 400. 
Osteophytes of the Inferior Extrem- 
ity of the Femur. 876 
DISEASES AND INJURIES OF THE BONES. 
C1UP. VIII. 
may be entirely normal, sclerosed, more or less absorbed and eroded, or fractured, or it 
may be the seat of new deposits in the medulla from the extension of the disease along 
the Haversian canals. The periosteal growths are moreover distinguished by their oval 
or fusiform outline, or by their pyriform shape, with the base towards the articulation, 
when they surround the articular extremities of the bones. 
The central, endosteal, or myelogenic tumors start in the medulla and in the osteoblastic 
layer of cells which line the interior of the medullary canal, and they are also surrounded 
by a capsule which may be entirely bony, as in fig. 402, also from 8. W. Gross, represent- 
Fig. 401. 
Fig. 402. 
Periosteal Round-celled Sarcoma 
of the Humerus. 
Central Giant-celled Sarcoma of the Head of the Tibia. 
ing a giant-celled sarcoma of the head of the tibia, but which is usually partly osseous and 
partly membranous. The bone, in which the neoplasm originates, finally disappears, and 
as the latter approaches the surface, it induces chronic ossifying periostitis, through which 
new layers of bone are constantly being produced to encapsule the growth in an osseous 
case. With the increase of the tissue of the tumor, the same changes occur in the newly 
formed shell as occurred in the original bone ; but as it disappears, new osseous layers 
are simultaneously formed by the osteoblastic surface of the periosteum, and the deposit 
of new bone goes on step by step with the absorption of the older layers. In this way a 
more or less perfect bony capsule is formed around the central tumors, the minute pro- 
cesses concerned in its production being well shown in fig. 403, from Rindfleiseh. The 
central tumors are generally spherical in shape, and, like the periosteal growths, their 
surface is generally smooth and even. 
The majority of the neoplasms of the bones merely push aside and stretch the adjacent 
tissues; but sarcoma may become diffused and infect the surrounding textures. Fibroma, 
chondroma, and sarcoma are very liable to calcification and ossification ; and sarcoma is 
frequently highly vascular and the seat of large effusions of blood. When a pulsating 
tumor is found in connection with a bone, it may be accepted to be a central sarcoma 
composed either of giant or of round cells. 
Of the various degenerations of these growths, particularly the central myeloid and 
cartilaginous, the most common, as well as the most interesting, is the cystoid, through 
which cysts or cystoid spaces, both unilocular and multiloeular, with fluid, semifluid, fatty, 
bloody, sanguinolent, or serous contents, are scattered throughout the mass, and sometimes 877 
CHAP. VIII. 
TUMORS. 
to so great an extent as to have replaced almost entirely the original structure, thereby 
giving rise to the term cystic tumor of the older writers. Sections of growths which have 
undergone this retrograde change convey the impression that the specimen is one of true 
cystic disease of the bones. The cavities are not, however, true cysts, but irregular spaces, 
Fig. 403. 
Formation of Bony Capsule In Central Tumors. 
the walls of which are composed of fibrillated tissue studded with granular fat and drops 
of oil, or of the fibrous or osseous bands which intersected the original growth. Their 
origin is due either to liquefaction, or mucoid softening, of the cellular elements which 
have undergone fatty metamorphosis, or to extravasations of blood in the softened fatty 
areas from rupture of the enlarged and degenerated vessels. The contents, in the former 
event, are turbid, opaque, buff-colored, straw-colored, or clear, and, in the latter mode of 
formation, they consist of blood, coagula, or sanguinolent fluid. The consistence of the 
contents is variable; sometimes thin, sometimes glutinous, sometimes semisolid, and, 
finally, again, solid. The amount of fluid is occasionally so great as to give rise to enormous 
tumors, as in the examples of cystoid chondroma, recorded by Nelaton and Crampton, in 
which the thigh measured, respectively, six feet, and six feet and a quarter, in circum- 
ference. 
Cystoid degeneration of neoplasms of the bones is of sufficient importance to give rise 
to a class of growths, which, as they differ materially from the solid tumors, are entitled 
to some consideration at this place in regard to their progress, prognosis, and symptoms. 
Such a division is incorrect from the standpoint of pathological histology, but it is conve- 
nient from a clinical point of view, and cannot well be ignored. 
Cystic tumors of the bones are most common in young adults and middle-aged subjects; 
they are seldom met with before puberty, or after fifty ; and they generally arise without 
any assignable cause, although sometimes their origin is directly traceable to the effects 
of external injury, as a blow, fall, or contusion. The progress of this disease is always 
slow. In the lower jaw serous cystic growths of six, twelve, and even fifteen years’ standing 
often occur, without any serious disturbance of the general health, or any particular local 
disorder, save what results from the pressure of the tumor upon the surrounding structures. 
Neither the cysts, their contents, nor the parts adjacent manifest, as a rule, any tendency 
to malignancy ; but when the tumor is large, it generally exhibits a marked tendency to 
destroy the bone in which it is located. 
The symptoms of cystic disease of the osseous tissue are originally very vague. The 
first thing that usually attracts attention is a dull, aching pain in some particular bone, as, 
for example, the jaw, which is often mistaken for toothache, or rheumatism ; this gradually 
increases in severity and frequency, and is at length found to be dependent upon the pres- 
ence of a hard tumor, or the expansion of a portion of the bone, more or less tender on 
pressure and motion, but unattended by any discoloration or intumescence of the overlying 878 
DISEASES AND INJURIES OF THE BONES. 
CHAP. VIII. 
textures. The progress of the disease is always tardy, and it often happens that, after 
having attained considerable development, it remains, to all outward appearance, for some 
time perfectly stationary. Then, taking a new start, it again increases, and thus it con- 
tinues, now advancing and now ceasing, until it has, perhaps, acquired the volume of a 
large orange, or even of a fist. Still, the general health continues good, there is no 
emaciation, and the countenance is perfectly free frorn that distressed, anxious, and sallow 
state which characterizes it in malignant disease. Even the pain is generally compara- 
tively trivial, and if it were not for the mechanical obstruction occasioned by the encroach- 
ment of the tumor upon the adjacent parts, the patient would hardly be conscious of being 
unwell. If the parts be now carefully examined, they will be found to be of unequal 
consistence, the firmer being incompressible, while the softer ones readily yield under the 
finger, emitting a peculiar crackling noise not unlike that of dry parchment. When the 
investing capsule is entirely membranous, the consistence is soft and apparently fluctuating. 
In the absence of signs of malignancy, pulsation, lividity, and varicose enlargement of 
the overlying vessels, these circumstances afford the best evidence of the true nature of 
the disease ; but if there is any doubt respecting it, this may generally be promptly dis- 
pelled by a resort to the exploring needle, the want of resistance and the escape of serous 
or sero-sanguinolent fluid determining the diagnosis. The tardy growth of the tumor and 
the absence of constitutional disorder are, indeed, commonly of themselves sufficient to 
mark the character of the malady. Between cystic and hydatid affections of the bones 
no signs of distinction exist, nor is this a matter of importance, as the treatment is essen- 
tially similar. 
1. SARCOMA. 
By far the most important of the tumors of the osseous system, as it constitutes nearly 
one-half of the neoplasms of the maxilhe, and affects the long bones almost as frequently 
as all the other morbid growths combined, is sarcoma, which up to comparatively a recent 
period was described under a great number of different and confusing names. In an elabo- 
rate paper on sarcoma of the long bones, published by I)r. S. W. Gross in the American 
Journal of the Medical Sciences for July and October, 1879, the entire subject has been 
so exhaustively investigated that its contents have been freely utilized in the following 
description. The consideration of the disease, as it involves other pieces of the skeleton, 
will be found in the second volume of this work in its appropriate places. 
Sarcomas of the long bones evince a great predilection for their articular extremities, in 
the spongy substance of which the majority are developed. Whether of central or periphe- 
ral origin, their favorite seats are the femur, tibia, humerus, fibula, ulna, and radius. In ac- 
cordance with their point of departure and histological construction, they may be classified, 
in the order of their frequency, as central giant-celled, periosteal osteoid, central spindle- 
celled, periosteal round-celled, central round-celled, and periosteal spindle-celled, the first 
two varieties constituting nearly 70 per cent, of the entire number. Males are more liable 
to their occurrence by 17 per cent, than females. The age at which they first appear 
averages twenty-seven years, G8 per cent, occurring before the thirtieth year, and 32 per 
cent, after that period, the disease being comparatively uncommon after the age of forty. 
The period of life at which they manifest themselves appears to be influenced by their 
seat and structure, the average being twenty-two years for the periosteal osteoid, twenty- 
three for the periosteal round-celled, twenty-four for the periosteal spindle-celled, twenty- 
eight for the central round-celled, a fraction above twenty-eight for the giant-celled, and 
thirty-six for the central spindle-celled. In about one-half of all cases they may be traced 
to injuries, such as blows, falls, sprains, fractures, and kicks. 
With the exception of carcinoma of the soft parts, sarcoma of the bones is the most 
malignant of all neoplasms ; but the lymphatic glands are, as a rule, free from contamina- 
tion, thereby showing that systemic infection takes place through the blood and not 
through the lymph channels. Metastatic tumors were discovered, especially in the lungs, 
lymphatic glands, and other parts of the osseous system, in 46 per cent, of the 165 cases 
analyzed by Dr. Gross, and they were histologically identical with the primary growth. 
In the order of their malignity, the sarcomas may be classed as periosteal spindle- 
celled, periosteal round-celled, periosteal osteoid, central round-celled, central spindle- 
celled, and central giant-celled, the periosteal tumors being more malignant than the central 
by 43.5 per cent. 
Sarcoma not only evinces a decided tendency to infect the surrounding tissues, but in 
one example out of every seven and one-third it projects masses into the adjacent joint, as CHAP. VIII. 
SARCOMA. 
879 
is represented in fig. 404, from a preparation in my collection, and may even extend along 
the intraarticular ligaments into the apposed bone. In the majority of these cases, however, 
the cartilage of incrustation remains intact, and affords 
a delicate investment for the growth. Invasion of the 
joints is met with in 18 per cent, of the central and 
in 7 per cent, of the periosteal tumors; and the possi- 
bility of its occurrence should not be lost sight of in 
selecting the point at which an amputation should be 
performed for the relief of the disease. 
In the absence of minute examination, a pretty 
accurate idea of the structural nature of these tumors 
may be formed from their gross appearances. Thus as 
dark-red or maroon color suggests a giant-celled sar- 
coma; a firm, glistening, grayish-white tissue is char- 
acteristic of fibrous or large spindle-celled growths; 
and a tint and consistence similar to that of the foetal 
brain indicate a round-celled or small spindle-celled 
tumor, to which the term medullary or encephaloid is 
applicable, and the assumption will be greatly strength- 
ened if the tissue resembles a recent coagulum, or is 
interspersed with cavities filled with blood. An ad- 
mixture of osseous or calcareous masses with soft tissue 
warrants the diagnosis of an osteoid sarcoma, the 
nature of the softer portions determining the variety 
of sarcoma to which the specimen belongs. 
The differential diagnosis of these varieties of sar- 
coma may usually be determined by attention to their 
affinities and contrasts, which are set forth in the 
following tables:— 
Fig. 404. 
Periosteal Spindle-celled Sarcoma, invading 
the Knee-joint. 
Clinical Features of Central Sarcomas, 
Giant-celled. 
Spindle-celled. 
Round-celled. 
Frequency of occurrence 
. 71.42 per cent. 
16.32 percent. 
12.24 percent 
Appear before the 30th year 
. 66.66 
4 4 
37.5 
44 
58.33 
44 
Seated in the shaft of the long bones 
. b.71 
44 
27.27 
44 
33.33 
44 
Ushered in by pain 
50 
44 
60 
44 
75 
44 
“ “ swelling 
10 
44 
30 
44 
25 
44 
“ “ “ and pain . 
31 
it 
10 
44 
0 
44 
Pain throughout the disease 
40 
ii 
100 
44 
91 
44 
Skin variously altered . 
33 
i l 
40 
44 
41 
44 
Subcutaneous veins enlarged 
27 
ii 
50 
44 
41 
44 
Infection of adjacent tissues 
12 
i i 
18 
44 
66 
44 
Lymphatic glands tumified or involved 
16 
i i 
0 
44 
25 
Metastatic deposits 
. 22.72 
a 
23.07 
44 
33.33 
44 
Local recurrence .... 
8 
t i 
20 
44 
25 
44 
Pulsation ..... 
20 
(4 
12.5 
44 
33.33 
44 
Joints invaded .... 
14 
44 
25 
4 4 
25 
44 
Fracture, spontaneous, or from slight 
causes 4 
44 
44 
4 i 
50 
44 
Clinical Features of Periosteal Sarcomas. 
Relative frequency ..... 
Ronnd-celled. 
1:1.40 percent. 
Spindle-celled. 
13.43 per cent. 
Osteoid. 
67.16 per cent. 
Occur before 30th year .... 
63.63 
if 
66.66 
if 
91.66 
( 4 
Seated around shaft of the long bones . 
09 
If 
55. 
ii 
39 
a 
Ushered in by pain 
55 
if 
85.71 
n 
62 
i i 
“ “ swelling .... 
44 
if 
14 29 
a 
33 
u 
“ “ “ and pain . 
0 
if 
0 
a 
4 
t i 
Pain throughout the disease 
60 
it 
100 
a 
98 
a 
Skin variously altered ..... 
50 
(f 
22.22 
it 
20 
i 4 
Subcutaneous veins enlarged 
41 
ii 
33.33 
n 
31 
if 
Infection of adjacent tissues 
60 
i f 
44 
i t 
40 
ii 
Lymphatic glands tumified or involved 
38.46 
ii 
11 
11 
21 
t i 
Metastatic deposits 
66.66 
n 
100 
f i 
65.62 
ii 
Local recurrence ...... 
50 
li 
60 
u 
41 
ii 
Pulsation 
0 
(4 
0 
u 
3 
ii 
Joints invaded ...... 
15.38 
41 
0 
(( 
6 
if 
Fracture, spontaneous, or from slight causes 
7 
it 
11 
(4 
3 
ti 880 
DISEASES AND INJURIES OF THE BONES. 
It will thus be observed that giant-celled tumors, which arc the least malignant, occur at 
an earlier age, and are marked by sympathetic lymphatic involvement, nearly two-thirds as 
frequently as the round-celled, which are the most pernicious of the central tumors. It 
is also notable that the lymphatic glands are never enlarged in the central spindle-celled 
sarcomas, and as this statement is almost true of the same variety developed from the 
periosteum, it forms an important point in the diagnosis. It will, moreover, be seen that 
a central tumor occupying the shaft of a bone is far more likely to be round-celled or 
spindle-celled than giant-celled. Spontaneous fracture and invasion of the joints is far 
more common in the central than in the periosteal tumors, and are quite characteristic of 
medullary growths. Enlargement of the subcutaneous veins and alterations of the in- 
tegument are also more frequent in the central than in the peripheral sarcomas, although 
the latter occur at an earlier age. Of the various symptoms, one of the most interesting 
is pulsation, which is observed in one case out of every eight, and which has led certain 
writers to describe these tumors as aneurisms. It is not, met with in any other neoplasm 
of the bones, and is, therefore, when present, of great diagnostic value. With one ex- 
ception it has oidy occurred in the central tumors, and is more common in the round- 
celled than in the other varieties. A curious fact in regard to pulsation, and it is one 
that is useful in the discrimination between the sarcomas, is that the chances are three to 
one that a pulsating sarcoma of the shaft of a long bone is composed of round-cells, and 
that in no instance is it a myeloid sarcoma: whereas, if the pulsating growth occupies the 
epiphysis, the chances are ten to one that it belongs to the giant-celled variety. 
The only one of the neoplasms of the tubular bones that is liable to occasion errors in 
diagnosis is chondroma. When compared with central sarcoma, central chondroma is of 
infrequent occurrence; it is less painful, of slower growth, of firmer consistence, and has 
a bosselated outline, which is rarely seen in sarcoma unless the capsule is perforated. It 
is more common in males; never occurs so early or so late in life as sarcoma; does not 
pulsate, invade the joints, fungate, or give rise to metastatic deposits. Central 
chondroma, however, in consequence of the cystoid degeneration to which it is so liable, 
attains a larger volume than sarcoma, and is accompanied in the majority of cases 
by enlargement of the subcutaneous veins. Periosteal chondroma is relatively more 
common than periosteal sarcoma. It is far less painful, of slower growth, of denser con- 
sistence, and of a nodular outline. It is usually met with in females; does not occur so 
early in life, and is observed at a more advanced age than sarcoma. The subcutaneous 
veins are not so liable to enlargement; the integuments evince little disposition to 
inflame or ulcerate; the tumor does not pulsate, fungate, or invade the joints, or con- 
taminate the glands; and it occasions secondary deposits only one-twentieth as often. In 
one-third of all cases other portions of the skeleton are simultaneously affected; while 
multiple growths are only witnessed in sarcoma as the result of infection. 
Sarcoma is liable to be confounded with other affections, of which strumous articular 
osteitis is the most common. White swelling of the knee, for example, usually occurs in 
scrofulous subjects before the age of fifteen. The pain, which is experienced from the 
very outset, finally becomes very severe; the skin is tense and glossy; the superficial 
veins are abnormally prominent; the temperature is elevated; the joint is stiff, resents 
efforts at motion, and is, moreover, distorted and flexed; puncture gives vent to turbid 
synovial or purulent fluid; and the swelling does not pulsate, nor does it impart a parch* 
ment like crepitation on manipulation. In sarcoma, the movements of the joint are pre- 
served, there is no suffering on motion, and the limb is not fixed in a vicious position. 
In this affection there is no tendency to the formation of pus; the tumor not infrequently 
pulsates and affords crepitation on palpation; and spontaneous fracture is not uncommon. 
White swelling yields to rest, extension, and gentle and equable compression ; but sarcoma 
continues to grow under the employment of these measures, and compression occasions 
not a little local suffering. The latter affection is not met with at so early an age as 
white swelling, and it occurs in persons of excellent general health. 
The principal features of the sarcomas as a class having thus been considered, the gen- 
eral pathology and diagnosis of the individual tumors demand attention. 
1. Giant-celled Sarcoma Myeloid or giant-celled sarcoma, which invariably occurs as 
a central growth, and of which a beautiful illustration is afforded by fig. 402, consti- 
tutes 42 per cent, of all the sarcomas of the long bones, and has a predilection for the 
epiphyses of the tibia, femur, and fibula, the shafts being involved in only one example 
out of every fourteen. It is most common between twenty-one and forty years; increases 
more slowly than the other sarcomas; is free from pain and tenderness; the skin almost 
always preserves its mobility and natural tint ; the subcutaneous veins are rarely 
CHAP. VIII. CHAP. VIII. 
SARCOMA. 
881 
enlarged ; the surrounding tissues are not implicated by extension of the disease; the lym- 
phatic glands are never involved except in 16 per cent, of all cases, and then only as the 
result of irritation ; the joints are invaded in 16 per cent, of all examples ; the spherical 
tumor pulsates in one example out of every five ; and the affected bone is rarely broken. 
The prognosis is comparatively favorable, metastatic tumors developing in only about 23 
per cent, of all examples, and local recurrence after amputation or resection being wit- 
nessed in one case out of every twelve and a half. In connection with the general dis- 
semination of the disease it is interesting to note that the tumor had undergone calcareous 
or osseous degeneration, through which it resembled the periosteal osteoid growths, in four- 
fifths of the cases; while of the cases in which these changes were not present, only one 
out of fifteen was characterized by .secondary growths. 
2. Central Spindle-celled Sarcoma Central spindle-celled sarcoma,which includes many 
examples of the encephaloid tumors of the older writers, is next to the preceding variety the 
most common of the myelogenic growths. Rather more than one-fourth of all cases origi- 
nate in the medulla of the shaft of the long bones, and they appear less frequently in early 
adult life than myeloid tumors. Its growth is slow,and attended with suffering; the skin 
is discolored or adherent in 40 per cent., and the veins are enlarged in one-half of all cases. 
Spontaneous fracture, or fracture from trifling causes, of the affected bone is observed in 
44 per cent, of all examples, and is a sign of great diagnostic value. Pulsation and other 
signs of aneurism are met with in one case out of every eight. The lymphatic glands are 
never involved; but metastatic tumors form in 23 per cent, of all cases; and local recur- 
rence is observed in one example out of every five, the malignity being, therefore, slightly 
greater than that of myeloid sarcoma. 
3. Central Round-celled Sarcoma.—Myelogenic round-celled sarcoma, which includes 
the alveolar variety of the disease, and which always constitutes medullary tumors, is the 
least common of the central growths, but forms in the shafts of the tubular bones in 
the proportion of 33.33 per cent. It occurs, on an average, earlier in life than spindle- 
celled sarcoma, but at about the same period as giant-celled. Its development is very 
rapid and is marked by suffering, changes in the skin, enlargement of the veins, infection 
of the adjacent tissues, invasion of the joints, and fracture of the bone in which it origi- 
nates. Pulsation is observed in one-third of all examples, and hence a pulsatile growth 
of the shaft of a long bone may very properly be referred to this variety. The lymphatic 
glands are enlarged in one-fourth of all cases ; metastatic deposits occur in one-third; and 
repullulation after removal in one-fourth ; thus showing that round-celled tumors are the 
most malignant of the endosteal sarcomas. 
4. Periosteal Spindle-celled Sarcoma Peripheral spindle-celled sarcoma surrounds 
the epiphyses more frequently than the shafts of the long bones, and is a disease of early 
adult life. Its growth is relatively slow, and invariably accompanied with suffering; the 
skin is variously altered in 22 per cent., and the subcutaneous veins are prominent in 33 
per cent, of all cases ; the lymphatic glands are enlarged, and spontaneous fracture occurs 
in 11 per cent.; it does not pulsate, nor does it invade the joints ; but the adjacent tissues 
are infected in nearly one-half of all cases. It is the most malignant of all the sarcomas, 
recurring in six-tenths of all cases after amputation, and invariably giving rise to metas- 
tatic deposits. 
5. Periosteal Round-celled Sarcoma Periosseous round-celled tumors are developed 
around the shaft nearly twice as often as around the articular extremities of the bones. 
Like the preceding variety it is most common before the thirtieth year. Its increase is 
very rapid, and usually painful; the skin is adherent, discolored, or ulcerated in 51 per 
cent, of all instances; the veins are enlarged in 41 percent.; the lymphatic glands are 
tumefied in 38 per cent.; spontaneous fracture occurs in 7 per cent.; and the temperature 
is elevated in 33 per cent, of all cases. The tumor never pulsates ; but it invades the 
surrounding soft tissues in 50 per cent., and the joints in 15 per cent, of all examples. 
Local recurrence after operation is observed in one-half of all cases, and metastatic tumors 
are developed in two-thirds of all examples. 
6. Periosteal Osteoid Sarcoma.—From the remarkable tendency evinced by the peri- 
pheral sarcomas, especially the spindle-celled variety, to qndergo calcareous infiltration, 
or osseous transformation, a variety has arisen which is imperfectly understood, as it is 
generally described as osteoid cancer. In the most characteristic specimens of the disease 
the osseous or cretified material radiates from the surface of the atfected bone to the cir- 
cumference of the growth, in the form of long, delicate, fragile spicules, tufts, or plates, 
which are closely aggregated at their bases, and pursue a parallel course perpendicular to 
the surface of the bone, or diverge towards the circumference, as in fig. 405, from a sketch 882 
DISEASES AND INJURIES OF THE BONES. 
CHAP. VIII. 
sent me by the late Professor Buchanan, of Nashville. These tumors constitute 27 per 
cent, of all the sarcomas of the long bones, and 67 per cent, of the periosteal growths ; 
and they develop, as a rule, around the epiphyses of the femur and the tibia. The average 
age of their appearance is twenty-two years. During their rapid growth the suffering 
becomes intense; the skin is altered in one instance out of every five; the veins are 
enlarged in less than one-third of all cases ; the adjacent tissues are infected in 40 per 
Fig. 405. 
Osteoid Sarcoma of the Head of the Tibia. 
cent, of all examples, but the joints are rarely invaded ; and pulsation and spontaneous 
fracture are rarely observed. The lymphatic "lands are swollen in 21 per cent, of all 
cases, and in one-half of these they are converted into bony tissue ; secondary growths 
are met with in 65 per cent, of all cases; and the disease recurs locally after amputation 
in two-fifths of all examples. Hence, they are, next to the periosteal spindle-celled and 
round-celled, the most malignant of the sarcomas. 
Treatment If left to itself, sarcoma inevitably proves fatal, whereas timely operations 
not only prolong life, but not infrequently eventuate in permanent recovery in all the 
varieties except the periosteal spindle-celled. In regard to the choice of the procedure, 
as to whether this should be amputation or excision, the decision must be given in favor 
of the former, the removal being effected as high up, or as near to the trunk as possible, 
for the reason that the joints are liable to be invaded by the disease, and that nodules of 
sarcomatous tissue may exist in the medullary canal at some distance above the original 
growth. In giant-celled tumors Dr. S.W. Gross has framed, in what I entirely concur with 
him, the following general rules for guidance in selecting the point at which amputation 
should be performed. For tumors of the lower epiphyses of the tibia and fibula, just 
below the knee ; when the upper articular extremities of these bones are involved, through 
the lower part of the thigh; at the junction of the upper and middle thirds of the thigh 
for disease of the condyles ; at the hip-joint for that of other portions of the femur ; below 
the elbow for tumors of the lower epiphyses of the radius and ulna; through the lower 
third of the arm when the upper epiphysis of the ulna is affected ; at the junction of the 
upper and middle thirds of the arm, for disease of the condyles of the humerus; and at 
the shoulder-joint when the head of the humerus is involved. When the growth is very 
bulky the incision may have to be made higher up. Thus, a sarcoma, as large as the 
head, commencing in the lower extremity of the radius, had best be removed by disarticu- 
lation at the elbow. In all of the other varieties of sarcoma, the rule should be to ampu- 
tate as far as possible from the seat of the disease as may be consistent with the safety of 
the patient. Of nine cases of excision of the affected bone for giant-celled sarcoma, death 
ensued in four, either as the result of the operation or of recurrence of the disease, and 
moderately useful limbs were obtained in two. In deciding upon the propriety of an 
operation, enlargement of the lymphatic glands should not be regarded as a bar to inter- 
ference, since their tumefaction was due to irritative hyperplasia in more than two-thirds 
of the cases in which their condition was determined. 
2. OSTEOMA OR EXOSTOSIS. 
An exostosis, of which fig. 406 affords a good idea, is an osseous outgrowth, the word, 
which is a Greek compound, signifying a bone growing from a bone. It is, in fact, a local CHAP. VIII. 
OSTEOMA OR EXOSTOSIS. 
883 
hypertrophy, a circumscribed tumor, possessing essentially the same structure as the bone 
from which it springs, and with the substance of which it is usually intimately identified. 
The disease occurs chiefly in young and middle-aged subjects, being very infrequent 
before puberty, and after the fiftieth year. It is more common in males than in females, 
and is generally confined to particular bones, as those of the cranium and extremities, 
especially the femur, and the phalanx of the great toe. The superior maxillary sinus is 
Fig. 406. 
Exostosis of the Thigh-bone. 
occasionally the seat of exostoses, as in a specimen in my collection, in which the inner 
surface of the left antrum is literally studded with these growths, none of which exceed 
a small grain of wheat, which they also much resemble in shape. A bony tumor in this 
locality sometimes acquires an enormous bulk, and, w hen both cavities are affected simul- 
taneously, may occasion great deformity. 
In the Hat bones, as those of the head and pelvis, the outgrowth may occur upon either 
surface ; in general, however, it evinces a preference for the external one, probably because 
it has a more perfect periosteum. When the tumor is attached to the inner surface, con- 
stituting what is known as an enostosis, its tendency is to encroach more or less seriously 
upon the contents of the cavity which the bone assists in forming. Enostosis is most 
common in the cranium of syphilitic subjects. 
A tendency to exostosis is sometimes observed in several members of the same family, 
as in the case of a lady who wras under my charge on account of a tumor of this kind on 
the shaft of the left radius, and whose sister and brother each had a similar enlargement., 
the former on the occipital bone, the latter on the clavicle. Boyer has recorded the par- 
ticulars of a case in which the disease was hereditary, the patient’s father, brothers, sisters, 
nephews, and children having all suffered in a similar manner. 
The number of these outgrowths varies from one to a great many. Cases occur in which 
there is a kind of exostosic diathesis. Thus, in the Mutter collection there is the skele- 
ton of a female in which nearly all the bones are thus affected. 
Exostoses sometimes observe a symmetrical arrangement, tumors of the same size and 
shape occurring at the same points of the corresponding pieces of the two sides. Such a 
disposition is occasionally witnessed on the frontal bone and the lower jaw, but is most 
common on the humerus and femur, especially at their inferior extremities. 
The volume of these growths is subject to no little diversity, some being very small, 
while others are extremely large—equal, perhaps, to the size of an adult head. The most 
bulky usually occur upon the bones of the extremities, particularly the lower part of the 
femur, although they are also occasionally seen upon the cranial, facial, and pelvic bones, 
where their presence may be a source of the most hideous deformity. 
Their shape is also very variable ; sometimes they have a distinct, well-defined outline, 
being of a globular, ovoidal, or hemispherical figure ; occasionally they jut out like long, 
slender spines or stalactites; in another series of cases, they have a knobby, nodulated, 
tubercular, or mammillated appearance ; and, lastly, instances occur in which they assume 
the form of plates or lamellae. These varieties of shape are doubtless entirely due to acci- 
dental circumstances; but they nevertheless deserve attention, on account of their practical 
relations. In regard to their surface, this may be either perfectly smooth, scabrous, or 
spiculated ; most generally the latter. 
The adjoining sketch, fig. 407, represents a remarkable form of exostosis, from a draw- 
ing of a specimen kindly presented to me by Dr. Lewis, of Alexandria. It grew upon 
the right femur of a lady, fifty-one years old, having commenced when she was only 
nine years of age. The tumor, before removal, was about the volume of a cocoanut, oval, 
smooth, and very hard. The integument over its summit had latterly become inflamed and 
ulcerated, followed by a discharge of sanious matter, and the protrusion of a portion of 
bone. The general health becoming somewhat impaired, amputation was performed 884 
DISEASES ANI) INJURIES OF THE BONES 
CHAP. VIII. 
at the lower third of the thigh, the woman making an 
excellent recovery. This case is additionally interest- 
ing from the circumstance that several of the rela- 
tives of the patient had been affected with similar 
tumors. 
As to their origin, there is no doubt that, in the great 
majority of instances, exostoses arise without any assign- 
able cause. On the other hand, they may often be 
traced directly to the effects of injury, as a blow or kick. 
In the distal phalanx of the great toe, a not uncommon 
seat of the disease, it is not unlikely that the pressure 
of the boot is able to produce it. Exostosis in the 
stump after amputation of the thigh and leg is probably 
due to the jarring which the femur and tibia experience 
during the operation of sawing, aggravated, perhaps, by 
a partial laceration of the periosteum. Numerous ex- 
ostoses are sometimes developed under the influence 
of a syphilitic, gouty, or rheumatic state of the system. 
The immediate cause of exostosis is formative inflam- 
mation, the process of development being precisely simi- 
lar to that which governs the formation of normal bone. 
The concomitant inflammation is not always seated exclusively in the bone, but partly in 
the bone and partly in the periosteum; and cases occur in which there is reason to believe 
that the latter is mainly involved in the production of the tumor. 
In regard to its structure, an exostosis differs in no wise from that of healthy bone. 
It is essentially composed of two parts, a compact and an areolar, the former inclosing the 
latter as a dense, firm layer, varying in thickness from the sixth of a line to a quarter 
of an inch, according to the volume of the tumor. The compact substance sometimes 
constitutes the greater bulk of the morbid mass, and there are cases, especially when it 
involves the cranium, where it is of the consistence of ivory, being so close and hard as 
to render it extremely difficult to saw it. Such a structure is represented in fig. 408, from 
a specimen in my collection. The areolar texture is sometimes directly continuous with 
that of the bone from which the exostosis grows ; at other times, however, it is independent 
of it, as in fig. 409, being either in immediate contact with the 
compact structure, or separated from it by a stratum of carti- 
lage, or fibrous tissue. Its cells are of variable size and form, 
and are generally loaded with fatty matter, very much as in a 
short bone of the skeleton, or in the articular extremity of a 
Ions one. 
The identity of the structure of exostosis with that of natural 
Fig. 407. 
Exostosis of the Femur. 
Fig. 408. 
Fig. 409. 
Spongy Exostosis of the Femnr, with a broad Base and pointed 
Processes. 
Ivory-like Exostosis, showing 
its internal Structure. 
bone is proved, moreover, by chemical analysis. Even when the new substance is of 
unusual firmness, as in the eburnized variety of exostosis, the difference is much less than 
might, at first sight, be imagined. The following comparative analysis of healthy bone 
and of an ivory exostosis, by Berzelius, places the subject in a clear light. The princi- 
pal difference, it will be observed, consists in the presence, in the latter, of an unusual 
quantity of phosphate of lime, and in a marked diminution of carbonate of lime and salts. CHAP. VIII, 
OSTEOMA OR EXOSTOSIS. 
885 
Animal matter ...... 
Phosphate of lime and magnesium 
Carbonate of lime and salts 
Loss ....... 
Healthy Bone. 
54.20 
12.50 
00.00 
Eburnized Exostosis. 
28.57 
68.88 
2.00 
00.55 
100.00 
100.00 
An enostosis is precisely of the same structure as an exostosis. The distinction, in fact, 
has reference merely to the situation of the tumor, the one, as the name implies, being 
developed upon the inner, and the other upon the outer, surface of the bone. 
When an exostosis is seated in a part of the body which is habitually the subject of 
considerable motion, as, for example, the inferior portion of the femur, it is usually sur- 
rounded by a distinct capsule, a sort of synovial burse, designed evidently to ward otf 
friction and facilitate gliding. The inner surface of the capsule, which is of variable 
thickness, is perfectly smooth, unadherent, and lubricated by a sero-oleaginous fluid, so as 
to qualify it the better for the performance of its functions. Where no motion is required, 
the growth lies in immediate contact with the natural structures, the union between them 
being commonly so intimate as to demand a careful use of the knife to effect their separa- 
tion. Occasionally, indeed, the soft parts are partially imprisoned in the osseous tumor, 
thereby rendering the dissection peculiarly tedious and difficult. 
The progress of this disease is generally tardy; it is only now and then that a case 
pursues a different course, or where the symptoms partake of an acute character. A 
syphilitic exostosis occasionally attains a considerable bulk in a short time, and a similar 
occurrence has been observed, although less frequently, in the rheumatic form of the com- 
plaint. Under such circumstances, the formation of the tumor is generally attended with 
severe pain, liable to nocturnal exacerbations, tenderness and swelling of the part, and 
more or less constitutional disturbance. Ordinarily, however, there is nothing of the 
kind ; the disease comes on slowly and almost imperceptibly, the first thing that arrests 
attention being a small tumor, which is altogether insensible, and exceedingly tardy in its 
progress, years elapsing before it acquires the size, perhaps, of a pullet’s egg. If it be 
superficial, so as to admit of examination, it will be found to be hard and immovable from 
the first, and so it generally continues ever afterwards, whatever may be its bulk. Mean- 
while, although it may itself be entirely indolent, it may be productive of pain in the sur- 
rounding structures, by the compression which it exerts upon the nerves, and in this way 
the suffering is sometimes rendered exceedingly severe, being often of a neuralgic char- 
acter, darting about in different directions, and extending far beyond the seat of the bony 
growth. When the tumor is situated among parts that are much exposed to motion, it 
frets and irritates them, and thus greatly aggravates the local distress. As the morbid 
mass enlarges, it must necessarily act obstructingly, interfering with the functions of the 
affected structures, and ultimately, perhaps, entirely abolishing them. Thus an exostosis 
of the orbit may continue to increase until it pushes the eye completely out of its socket, 
not only filling the whole cavity, but encroaching more or less extensively upon the cheek 
and cranium. In a similar manner an osseous tumor may project into the pelvis, and im- 
pede the delivery of the child. Boyer refers to a case in which a growth of this kind, 
attached to the pubic bone, pressed against the neck of the bladder, and caused retention 
of urine, for the relief of which it was impossible to introduce the catheter. An exostosis 
of a rib may compress the lungs ; of a vertebra, the spinal cord ; of the cranium, the 
brain. Another effect is that it stretches, flattens, and displaces the muscles, tendons, 
nerves, and vessels, thereby partially disqualifying them for the exercise of their functions. 
Sir Astley Cooper has recorded an instance of gangrene of the arm from compression of 
the axillary artery by an exostosis of the lower cervical vertebrae. 
Sometimes the coverings of the tumor are invaded by ulceration and even gangrene, 
thereby more or less freely exposing its surface, which occasionally, in turn, takes on the 
same kind of action. At other times the morbid mass perishes, apparently from a want 
of nourishment, and is detached very much in the same manner as a slough of the soft 
parts. Exostoses of immense volume occasionally experience such a fate. The occur- 
rence is most likely to happen when the tumor has a narrow, cartilaginous base. 
The diagnosis of exostosis cannot always be easily determined unless the tumor is 
situated superficially, when its great firmness and immobility generally serve to point out 
its true character. When the tumor occupies some internal cavity its nature may be 
suspected, but no surgeon, however skilled in diagnosis, can positively say to what class 886 
DISEASES AND INJURIES OF THE BONES. 
CHAP. VIII. 
of growths it belongs. On the other hand, an exostosis may sometimes seriously interfere 
with the diagnosis of other affections. Thus, a tumor of this kind, occupying the pelvic 
cavity, may impinge against the bladder, or even project into it, in such a manner as that 
the sound, coming in contact with its surface, shall impart a noise and sensation similar 
to those communicated by the presence of a calculus. 
An exostosis, lying immediately beneath an artery, may simulate an aneurism, as in a 
case mentioned by Stanley. A patient was admitted into the Middlesex Hospital with a 
tumor presenting all the symptoms of aneurism of the subclavian artery. The pulsation 
in front of the swelling was very strong, and extended over a large space; but none could 
be detected at the sides. The axillary artery beat feebly, and no motion whatever ex- 
isted in the vessels of the arm. A careful examination discovered an exostosis of the first 
rib, pushing the subclavian artery forwards, and flattening it. 
The prognosis varies. So long as the tumor is small and indolent, it may commonly 
be considered as of little moment; but when it increases rapidly, or is so situated as to 
interfere with the functions of a joint, or to encroach upon an important organ, it becomes 
a matter of serious import; the more so, because it is then not always possible to get rid 
of it by an operation, and there is generally nothing else that can reach it. When an 
exostosis projects into a joint, an operation is a hazardous undertaking, liable to be fol- 
lowed by the worst results; and when it occupies an internal cavity it is generally utterly 
inaccessible. An exostosis of the inner surface of the cranium usually proves dangerous 
by determining epilepsy, paralysis, and other bad symptoms; in the pelvis it may, as 
already stated, interfere with parturition, and in almost any part of the body it may in- 
duce neuralgia. 
Treatment The treatment of exostosis must be guided, in great degree, at least in its 
earlier stages, by the nature of the exciting cause. When the affection has been occa- 
sioned by a deranged state of the system, or by the rheumatic, gouty, or syphilitic poison, 
colchicum, aconite, and iodide of potassium, either alone, or in union with bichloride of 
mercury, will be indicated, and can hardly fail, if judiciously administered, to prove 
highly beneficial. Under the influence of these remedies growth is often promptly arrested, 
and the tumor eventually entirely dispersed. The use of mercury is particularly service- 
able in these cases, but to produce its full effects it is generally necessary to carry it to 
the extent of gentle ptyalism, maintained for some time, especially in obstinate cases. 
When the complaint gives rise to much pain, opium, conjoined with diaphoretics, will be 
required. 
Topical applications are particularly useful when the tumor is of rapid growth, ex- 
quisitely sensitive, and the result of external injury, or of a syphilitic taint of the system. 
In the earlier stages of the disease, the remedies most to be relied upon are leeches, 
blisters, saturnine and tincture of iodine employed in the ordinary way. If 
blisters, which are the most valuable of all topical means, are used, the skin over the 
tumor should be raised very thoroughly, a free discharge being afterwards maintained by 
some stimulating unguent, with a view to a permanent pyogenic effect. In the syphilitic 
form of exostosis, mercurial fumigations sometimes answer a good purpose, succeeding 
when all other remedies fail. 
When the tumor has attained considerable bulk, and, above all, when it is of long 
standing, and of great firmness, or productive of excessive suffering, the only chance of 
relief is ablation ; or, if this be impracticable on account of the nature and extent of the 
exostosis, amputation of the affected limb. The incisions through the integument are 
made as in ordinary growths, the most eligible shape being the crucial, elliptical, curvi- 
linear, or T-like. Free exposure is effected, without interfering with any important 
structures, the division of which might afterwards impair the usefulness of the parts. If 
the skin is diseased, or much attenuated, the affected portion is, of course, removed. The 
exostosis is then attacked with the knife and a metacarpal saw, the former alone, if stout, 
being commonly sufficient to effect ablation when the tumor has a cartilaginous base, or 
an unusually soft structure. In general, however, the saw will be necessary, and there 
are many cases where the gouge, chisel, and trephine may advantageously be employed. 
If the tumor has a very large base, and is insensibly blended with the substance of the 
bone from which it grows, it should be divided into several sections, by perforating it at 
different points, and then detaching them separately, or piecemeal. Various kinds of 
saws have been invented for removing exostoses, but they are all more or less complicated 
and unwieldy, and may well be replaced by the more simple instruments in common use. 
The surgical engine has lately been called to the surgeon’s aid in the removal of exostoses, 
and promises to supersede most, if not all, other instruments hitherto used in these ope- CHAP. VIII. 
CHONDROMA. 
887 
rations. In whatever manner the ablation is effected, the bony portion of the wound 
should be rendered as smooth as possible by means of the raspatory, otherwise it will 
seriously interfere with cicatrization. As it is, there will, in any event, be more or less 
suppuration, retarding the progress of the cure, and the patient may congratulate himself 
if he escapes erysipelas and other bad consequences. The hemorrhage attending the 
operation is usually very slight. The edges of the wound should be lightly approximated, 
and the parts kept constantly wet with saturnine and anodyne lotions, either cold, cool, 
or tepid, according to the exigencies of the case. 
3. CHONDROMA. 
The cartilaginous tumor may be developed in the cancellated structure or upon the outer 
surface of the bones, beneath the periosteum, the latter mode of origin being the more com- 
mon. Its figure is globular ; its surface rough, or nodulated ; its consistence firm, dense, and 
elastic ; its color white, or grayish. The morbid mass may attain a large bulk. When it 
originates in the central part of the bone its capsule persists longer than in other central 
osseous tumors ; but it finally becomes attenuated and gives way at one or more points, 
and thus allows the morbid growth to protrude beneath the surrounding soft tissues. 
This tumor ordinarily affects only one bone, is not, as a rule, malignant, and is pro- 
ductive of little inconvenience, except from its size and weight. It is peculiar to early 
life, is often directly chargeable to external violence, manifests, when of long standing, a 
tendency to undergo certain degenerations, especially the calcareous, mucous, and cystic, 
is generally slow in its progress, and occasionally appears simultaneously in several 
parts of the skeleton. Every portion of the osseous system is liable to it; but the pieces 
most frequently affected are the metacarpal bones, the phalanges of the fingers, the humerus, 
and the lower jaw. In old cases the growth sometimes undergoes 
partial ossification, as in the specimen represented in fig. 411. Fig. 
412 exhibits a cartilaginous tumor of the ribs, from a drawing of 
a preparation in my collection. 
Although the periosteal and central chondromas of the lontr 
bones possess many features in common, they exhibit certain con- 
trasts, which have been carefully studied by Dr. 8. W. Gross, and 
which may prove useful in distinguishing them from each other, 
and from the sarcomatous growths. Thus, the periosteal tumors 
appear between the tenth and sixty-first years, or, on an average, 
at the age of twenty-six ; nearly two-thirds of all cases are met 
with in females; pain is present throughout in 47 percent.; the 
subcutaneous veins are dilated in 21 per cent.; the skin is vari- 
ously altered in one example in every ten ; spontaneous fracture, 
or fracture from slight causes, is met with in 5 per cent. ; meta- 
static deposits occur in 3.17 percent.; and the lymphatic glands 
are never enlarged. The central tumors, on the other hand, appear 
between the seventeenth and fifty-ninth years, the average being 
the thirty-third year; four-fifths of all cases are met with in males; pain is experienced 
throughout in 30 per cent. ; the superficial veins are enlarged in GO per cent.; the skin 
is variously altered in one example in every five; fracture is met with in 20 per cent.; 
metastatic tumors are unknown ; and the lymphatic glands are enlarged in one instance 
in every ten. 
A tumor of this kind occasionally attains an enormous bulk, as in a chondroma of the 
scapula and humerus in a young man of twenty-six, whom I saw at the College Clinic, the 
weight of the mass being upwards of thirty pounds. 
There is a form of this tumor to which, from the superaddition of sarcomatous tissue, 
the term sarco-chondrornct is applied, a striking example of which came under my ob- 
servation, in 1871, in a strong, robust man, thirty years of age, in connection with the 
tenth rib, which it involved from its angle almost to its costal attachments. Extending 
from near the spinal column obliquely downwards and forwards to within an inch of the 
crest of the ilium in front, it was seven years in attaining its growth, one-half being 
added during the last twelve months. It was of a flattened, ovoidal shape, with the nar- 
row end below, perfectly painless, very firm, and unadherent to the skin. Excision was 
effected without any material loss of blood, but during the dissection a portion of pleura, 
very much thickened, and about the size of the palm of the hand, was unavoidably ex- 
Fig. 410. 
Cartilaginous Tumors of 
the Hand. 888 
DISEASES AND INJURIES OF THE BONES. 
chap, v 111. 
posed, although not penetrated, separation being accomplished by enucleation. Death 
occurred on the twelfth day from pleuro-pneumonia. 
The tumor, after removal, was found to weigh two pounds and a half, its greatest lon- 
gitudinal circumference being twenty inches, and the transverse twelve. It was distinctly 
lobulated, and was, apparently, composed of two portions; an upper, cartilaginous, finely 
tuberculated, bright, grayish-white, corresponding with the affected rib ; and a lower, of 
Fig. 411. 
Fig. 412. 
Chondromatons Tumor undergoing Ossification. 
Chondromatons Tumor of the Ribs. a. External Appear- 
ance. b. Internal Structure. 
a dense, shining, fibrous appearance, succulent, of a pale straw color, consisting of carti- 
lage cells, most of which were filled with drops of oil, and of an intercellular substance, 
made up, in great degree, of fasciculated spindle-celled tissue. The more rapidly developed 
portions of the morbid mass were interspersed with large spindle-cells, mottled with 
vascular and greenish gelatinous points, and inlaid with cysts of varying sizes, some of 
which were filled with mucous fluid, while others were undergoing disintegration. There 
were also, in different situations, islets of hyaline cartilage, calcareous deposits, and deli- 
cate masses of bone, with well-marked lacunal cells but no Haversian canals, the whole 
growth affording a remarkable illustration of the various degenerations which such a 
tumor occasionally experiences during the progress of its development. 
The only remedy for these tumors is free excision or amputation, as when they occupy 
an extremity. All local and general means, even in their earlier stages, are unavailing. 
4. OSTEOID CHONDROMA. 
The term osteoid chondroma has been applied by Virchow to those peripheral neoplasms 
which originate in the ossifying cell-layer existing between the periosteum and the surface 
of growing bones, and is called by him membranous or osteoid cartilage, since it forms 
the starting point of ossific processes, as indicated by the normal growth of bone and the 
development of callus, osteophytes, and other pathological formations, and, for that reason, 
is the equivalent of cartilage. Holding an intermediate position between osteoma and 
chondroma, osteoid chondroma is made up of cells, which differ from those of cartilage 
in being small, fusiform, or round-oval with short prolongations, and devoid of capsules. 
They lie free in a very dense, striated, but non-fibrillated, sclerosed, or cartilaginous 
intercellular substance, which is greatly in excess of the cellular elements, although the 
latter may predominate, and increase in size, in which event the tumor becomes sarcoma- 
tous. On section the mass is seen to be extensively pervaded by bone, at one point fragile 
and porous, at another dense and hard, which forms a delicate skeleton or framework, 
attached to the surface of the bone. In some specimens the ossific process has advanced 
so far as only to require the deposition of the salts of lime in the remaining softer portions CHAP. VIII. 
FIBROMA — MYXOMA. 
889 
of the growth to convert it into an osteoma. It is rich in bloodvessels which penetrate 
its very substance, in which respect it differs from chondroma. 
Osteoid chondroma is seated most frequently on the articular extremities of the shafts 
of the long bones, and on the lower jaw. Some pathologists, indeed, are disposed to 
include it among the ossifying periosteal sarcomas, from which they are unable to distin- 
guish it, either by its minute, gross, or clinical features. 
Osteoid chondroma does not possess a single element by which it may be diagnosticated 
from periosteal sarcoma. It is most frequent in young persons; is of a firm consistence, 
and of an ovoidal or pyriform shape, with a smooth or only slightly uneven surface ; grows 
rapidly, and attains a large volume. Closely connected with the bone, it receives an 
investment from the periosteum, which, however, may finally give way, and permit the 
mass to infiltrate the surrounding tissues. The huge dimensions which it may acquire 
are well illustrated by a case under the charge of Sir Astley Cooper, in a girl, thirteen 
years of age, in whom the tumor, of twelve months’ growth, and ocecupying the 
inferior maxilla, measured sixteen inches in circumference. The tongue was pushed not 
only to one side but backwards into the pharynx, while the epiglottis was recurvated upon 
the superior aperture of the larynx, death finally ensuing from the combined effects of 
starvation and respiratory embarrassment. The prognosis is bad, as the tumor is not only 
liable to recur after removal, but to give rise to metastatic deposits. The only remedy is 
amputation as far as possible from the seat of the disease, when an extremity is involved, 
or excision when the lower jaw is affected. 
5. FIBROMA. 
Fibrous tumors of bones, whether originating in the periosteum or in the endosteum, 
resemble similar formations in other tissues. As hyperplastic outgrowths of the perios- 
teum, they are met with most frequently in connection with the base of the skull, as 
polyps, in the antrum of Highmore, and upon the alveolar borders of the upper and 
lower jaws, where they give rise to one form of epulis. In any of these situations they 
may attain an enormous size, and commit frightful ravages by their encroachment upon 
the surrounding structures. 
The central or endosteal variety of fibroma is confined almost exclusively to the lower 
jaw, although it has also been observed in the extremities of the long bones and in the 
phalanges of the fingers. In the former situation the plates of the maxilla are expanded 
so as to form a round, or oval, and more or less distinctly lobulated tumor, the interior of 
which is now and then intersected by osseous spicules. 
The treatment of these affections must vary according to their site, complete removal 
being indispensable under all circumstances, by detachment with suitable instruments or 
by excision of the entire thickness of the bone, as when they occupy the jaw. 
6. MYXOMA. 
Pure myxoma of the osseous tissue is very uncommon, the majority of the recorded 
instances of this affection being due to mucous degeneration of chondromas. A case in 
which a myxomatous tumor grew from the body of the 
sphenoid bone, outside of the dura mater, fig. 413, came 
under my notice in a patient who died at the age of thirty- 
nine years from epilepsy, produced by a fall twelve months 
previously. On examination, Dr. Colescott and myself 
found a lobulated tumor, of irregular form, and about the 
size of a pullet’s egg, which had flattened the Varolian 
bridge, and had evidently induced the disease in question. 
It is generally developed from the medullary membrane of 
the lower jaw, disparting the compact tissue, which it ex- 
pands into a thin, bony investment, as in other central 
osseous growths. Its progress is slow, but, as it increases, 
the bony capsule is finally perforated. It is a strictly local 
affection, evincing no disposition to return after removal, 
or to contaminate the neighboring lymphatic glands. 
Fig. 413. 
Myxomatous Tumor. 890 
DISEASES AND INJURIES OF THE BONES. 
CHAP. VIII. 
7. ANGIOMA. 
The only form of vascular tumor met with in the hones is aneurism by anastomosis, to 
which attention was first clearly drawn by Mr. Stanley. The disease, which exhibits the 
same general characters as an arte- 
rial erectile tumor of the soft parts, 
and which is represented in fig. 414, 
has been chiefly noticed in the broad 
bones, especially those of the cra- 
nium of young children. The causes 
of this lesion are obscure. Any ex- 
ternal injury, by disturbing the vas- 
cular action of the bone, might pro- 
duce it. 
The enlargement, even in its 
early stages, is tense, painful, and 
attended with distension ofthesuper- 
licial veins, swelling of the surround- 
ing structures, and slight discolora- 
tion of the skin. In a short time a 
deep-seated pulsation or throbbing 
synchronous with that of the left 
ventricle, and similar to what is 
witnessed in some erectile tumors, may be perceived in the affected part. In the advanced 
stage of the malady the beating is accompanied by a sort of undulating movement, and is 
easily interrupted by compressing the carotid artery. 
When anastomotic aneurism involves the scapula, the lower jaw, or the clavicle, and it 
is of limited extent, it may be removed. When it is situated in the cranial bones, it 
gradually destroys the osseous tissue, and ultimately involves the brain and its envelops, 
rendering interference out of the question. Several cases have been reported in which 
the carotid arteries were tied for this disease, but in none with any permanent benefit. 
8. IIYDATID TUMORS. 
The bones are occasionally the seat of hydatids, but the occurrence is very uncommon. 
The first account of these bodies in these situations was given by two Dutch pathologists, 
Van Vy and Van der Haar, whose observations have since been confirmed by other 
observers, as lveate, Cruveilhier, and Lucas. 
Although it is extremely probable that all the different classes of bones are liable to 
these formations, they have hitherto been observed almost exclusively in the long and flat 
bones, particularly in the tibia, for which they appear to have a decided preference. They 
have been found seven times in the tibia, five times in the humerus, five times in the 
bones of the pelvis, four times in the bones of the skull, three times in the vertebrae, 
twice in the femur, and once in the phalanx of the finger. What was formerly known 
under the vague name of spina ventosa was an osseous tumor which probably occasionally 
contained bodies of this kind. 
These bodies always take their rise from germs contained in the blood developed in the 
spongy texture of the bones, as this alone affords them an opportunity of growing and 
expanding, the compact tissue being too dense and firm to admit of their increase. The 
only exception to this occurs when they form in the frontal sinus, but even here there is 
no new law in operation, since the cavity in question is, in fact, only a large cell, well 
adapted as a residence for such bodies. Of the exciting or predisposing causes of these 
bodies nothing whatever is known; for if, as has occasionally happened, they have formed 
in a particular portion of the skeleton after the occurrence of a blow, contusion, or other 
injury, it does not prove that their development was the consequence of such mischief. 
Hydatids occur with nearly equal frequency in both sexes ; and all the patients in whom 
they have hitherto been found were adults, excepting four, of whom two were children 
three and seven years of age. Borchard has recorded a case in which they existed in 
several situations in the same individual. 
Examination has proved that these bodies are veritable acephalocysts, similar to those 
which occasionally infest the liver, ovaries, lungs, and other internal viscera. Of a 
spherical or rounded shape, they are sometimes irregularly flattened or compressed, 
Fig. 414. 
Anastomotic Aneurism of Bone. CHAP. VIII. 
HYDATID TUMORS. 
891 
especially the older ones, and they vary in size from a pea to that of a marble, their 
dimensions being evidently influenced by their age, and the extent of the cavity in which 
they are developed. Their number, which is seldom large, is usually in an inverse ratio 
to their volume. They are inclosed in a sort of parent cyst, soft in structure, thin, and 
of a whitish appearance, and they float about in the midst of a serous fluid,- of a saline 
taste, and partially coagulable by heat and acids; circumstances clearly betraying its 
albuminous character. 
The cavity in which these bodies are situated is, evidently, in the first instance, simply 
a cell of the areolar tissue, in which the germ of the parasite is deposited, and in which 
it is destined afterwards to attain its full development. As its growth proceeds, it presses 
upon the osseous matter, pushing its fibres farther and farther part, at the same time 
causing a partial removal of it by the action of the absorbents, until what remains is at 
length converted into a mere bony sheet, hardly as thick as a piece of parchment, elastic, 
and crackling under the finger. The shell is lined, as already stated, by a thin, closely 
adherent membrane, which evidently plays an important part in the development and 
protection of the new being. Cases occur in which it consists of several compartments, 
although in general it is unilocular. The bone immediately adjacent to the disease is 
usually thickened and roughened by irregular deposits. 
The symptoms attending the formation of these bodies are extremely obscure, and 
cannot, for a long time, be separated from those which accompany other diseases in and 
about the skeleton. Their growth is always very tardy, and a number of months generally 
elapse before there is any pain or discoloration of the surface. The patient is merely 
aware that there is some tumor, steadily augmenting in bulk, and slowly encroaching upon 
the surrounding parts ; hard and firm at first, afterwards more soft, and ultimately becom- 
ing distinctly elastic, and emitting a peculiar crackling sound on pressure very similar to 
that of dry parchment. When deep-seated, it causes a gradual wasting of the super- 
imposed tissues, the muscles and tendons being spread out in the form of thin ribbons, 
while portions of the fibrous membranes are actually absorbed. Meanwhile the tumor 
mechanically impedes the functions of the surrounding parts, pain and tenderness set in, 
and the skin evinces signs of irritation. At this stage of the complaint the affected bone 
sometimes gives way under the most trivial accident, refusing afterwards to unite, or under- 
going consolidation only after a long while. Occasionally the most prominent portion of 
the tumor ulcerates, and discharges a part of its contents. The health remains good for 
years, but in the end it is always much impaired by the local distress. 
The most important diagnostic signs of this affection are, the tardy progress of the 
tumor, the absence of pain and swelling, the change from a hard, incompressible substance 
to one of comparative softness and even elasticity, and the complete absence of all appear- 
ance, both local and constitutional, of malignancy. After all, however, these symptoms 
are merely of a negative character; for at last the only reliable source of information is 
the exploring needle, although this also, unfortunately, is not available until the morbid 
growth has acquired great bulk, and is almost on the verge of bursting. Even the elastic 
feel and crackling noise which, in the latter stages of the complaint, form such prominent 
features, are of no diagnostic avail, as they are common to several other varieties of bony 
tumors, especially the cystic, properly so called. 
Hydatid disease of the osseous tissue is always a grave occurrence, not so much on 
account of the damage to the general health as of the injury it inflicts upon the affected 
bone, weakening its structure and thus impairing its usefulness, generally to an irreme- 
diable extent. In some of the recorded cases the acephalocysts burst into the knee-joint, 
causing destructive inflammation, while in others the animals perished, and gave rise to 
high constitutional disturbance, attended with excessive pain and hectic fever. 
The treatment of this disease is by extirpation, performed early, before there is any 
serious structural lesion of the bone. The tumor being freely exposed by an incision, 
either crucial or elliptical, and attacked with the saw, pliers, trephine, or chisel and mallet, 
as may seem most advisable. Its contents being turned out, the lining membrane of the 
osseous shell is carefully peeled off, or, if this be impracticable, painted with a strong 
solution of iodine, to destroy its secreting surface, lest there be a speedy reproduction, if 
not of hydatids, at all events of serous fluid. The cavity is then filled with oiled lint, 
and the flaps, being approximated, are lightly held in place with a few strips of adhesive 
plaster. The cavity gradually shrinks, and a cure is ultimately effected by the granulat- 
ing process. 
When the case is a very aggravated one, involving the entire circumference of the 892 
DISEASES AND INJURIES OF THE BONES. 
CHAP. VIII. 
affected bone, or when the hydatids open into a joint, the only resource is resection or 
amputation, the former being applicable only when the disease is of limited extent, while 
amputation is absolutely necessary when it has induced so much disturbance, local and 
constitutional, as to threaten life. 
SECT. XVII TUBERCLE. 
Tubercles of the osseous tissue are much more common than is generally imagined. 
The bones usually affected are the vertebra;, the short bones of the hand and foot, and 
the articulating extremities of the long bones. The particular seat of tubercles is the 
spongy texture, from the marrow of which they arise, although occasionally they are formed 
upon the outer surface of the bones, beneath the periosteum. 
There are two varieties of form in which this matter is deposited. In one, perhaps the 
more common, the tubercles are encysted, the inclosing membrane, which varies in thick- 
ness from the fifth of a line to half a line, being composed of plastic matter, very soft at 
first, but gradually becoming harder and harder, until finally, in some cases, it acquires 
the character of fibro-cartilage. It is of a dull, grayish color, is made up of delicate, 
inelastic fibres, and is frequently furnished with small vessels, passing into it from the 
surrounding structures. The number of tubercles is generally small; their size ranges 
from a pea to that of a cherry ; and they are of a yellowish, opaque appearance. When 
they become softened, as they commonly do in a few months, the pus either works its way 
out, or it escapes, by a kind of fistulous route, into a neighboring joint, establishing thereby 
an analogy with pulmonary tubercles opening into the bronchial tubes. Sometimes a spon- 
taneous cure takes place, the tubercle granules being absorbed, and the cavity occupied by 
the cyst being obliterated by osseous matter. 
In the second variety, the tubercular matter is deposited directly into the cells of the 
osseous tissue, forming grayish, semitransparent, opaline patches, from the one-sixth of an 
inch to an inch in diameter. This infiltration, ex- 
hibited in fig. 415, is noticed chiefly in the bodies of 
the vertebrae and in the bones of the tarsus. The 
bony tissue immediately around is sometimes deeply 
injected, and the trabecula; are eroded. In this, as 
in the preceding variety, the tubercular deposit, after 
having existed for some time, gradually softens, and 
the cells in which it was contained are filled with 
earthy matter. This, however, is not always the 
case ; for now and then the ulcerative process con- 
tinues until the bone is totally destroyed. 
The progress of tubercular disease of the bones is 
always chronic, although not equally so in both forms, 
the infiltrated proceeding more tardily than the en- 
cysted, and causing generally also a greater amount 
of havoc in the osseous tissue. There is nothing 
definite, however, in regard either to the commence- 
ment of the softening process, or to the ultimate 
elimination of the resulting matter from the affected 
structures. Much will doubtless depend, in every 
case, upon the condition of the system, the age of the 
patient, and the presence or absence of complications. 
As a general rule, from six to twelve months will 
elapse from the moment of the deposition of the tubercular substance to the completion 
of the softening process. The pus left by the disintegration of the deposit is similar 
to that which occurs in the lungs in the advanced stage of phthisis, being of a pale 
yellowish color, bordering slightly upon greenish, and of a thin, fluid consistence, with 
small whitish flakes not unlike soft-boiled grains of rice. After an opening has been 
effected into the abscess, the discharge generally becomes very watery and bloody, as well 
as irritating, and comes away in large quantities, a number of sinuses often existing in the 
diseased parts, as if they were necessary to carry off the superabundant secretions. In 
many cases, broken-down osseous tissue is intermingled with the pus, passing otf either 
as little granules or as minute fragments, which not unfrequently choke up the abnormal 
track, and thus excite new irritation. 
Fig. 415. 
Bone infiltrated with Tubercle. 893 
CHAP. Till. 
The adjoining cut, fig. 416, from a specimen in my cabinet, exhibits the effects which 
a tubercular abscess may exert upon the osseous tissue, in causing a well-marked ex- 
cavation, similar to what occurs in the 
lungs. 
The abscess that arises from the 
disintegration of tubercular matter is 
the form which is usually met with in 
bone, the phlegmonous, as stated else- 
where, being of extremely rare occur- 
rence. The symptoms attending it 
are generally obscure, but its existence 
may be suspected when, along with 
the ordinary signs of osteitis, the 
affected part is the seat of circum- 
scribed, deep-seated, gnawing pain, 
with excessive tenderness at one particular spot, and a glossy, shining, cedematous 
condition of the integument. The breaking of the abscess is always preceded by 
considerable swelling of the soft structures, and by more or less disturbance of the 
system, the constitution frequently sympathizing severely with the local trouble. In 
addition to these circumstances, the history of the case, as the age of the patient, the 
site of the morbid action, and the absence of coexistence of strumous disease in other 
structures, will generally furnish useful light, and thus materially aid in the establishment 
of a correct diagnosis. 
The treatment of tuberculosis of bone does not materially differ from that of tuber- 
culosis generally. As the loeal deposit is usually merely a reflection of the state of the 
system, the great object should be to employ such remedies as are necessary to modify 
this condition of the constitution and to provide for the supply of a better and richer blood. 
The principal means included under this head are, a well-regulated and adequately nutri- 
tious diet, cod-liver oil, and the various chalybeate preparations, either alone, or in union 
with quinine, mild purgatives, and gentle exercise in the open air. 
The local remedies are of the ordinary antiphlogistic character, consisting of leeches, 
blisters, and tincture of iodine, with early and free incisions of the soft structures to 
relieve pain and tension. If the existence of an abscess is suspected, the trephine must 
promptly be employed, the operation and after-treatment being conducted in the same 
manner as in acute abscess of bone. 
SECT. XVIII.—NEURALGIA. 
Neuralgia of the osseous tissue is infrequent. I have seen vast numbers of cases of 
neuralgia of the soft structures in almost every part of the body, but comparatively few of 
neuralgia of the bones. In nearly every instance that has fallen under my observation 
the disease was associated with some organic lesion of the affected texture, such as abscess, 
caries, exostosis, or interstitial deposits into the Haversian canals and cancellated tissue, 
thereby compressing the vessels and the nerves distributed through their tunics. A lady, 
aged fifty, had long been afflicted with neuralgia of the cranium, caused by the falling of 
a window-sash upon the upper and posterior angle of the left parietal bone. The pain, 
without observing any regularity in its accession, gradually increased in severity, and 
became at length so intense as to require from one to two drachms of morphia a week, 
besides enormous quantities of sulphuric ether, even for temporary relief. The seat of 
pain was a small spot, not larger than the end of a finger, and exquisitely tender to the 
touch. A disk of bone, embracing the affected portion, being removed with the trephine, 
an exostosis, not more than the eighth of an inch in thickness, was discovered upon its 
inner surface, which thus at once explained the nature of the case. Complete recovery 
followed the operation. 
A married woman, aged twenty-eight, had suffered, at times, most acute and distressing 
pain from a small bony tumor at the anterior and outer part of the lower extremity of the 
left radius. The tumor had come on about twelve years previously, and had all along 
been exquisitely sensitive on pressure even on the slightest touch. It projected but 
little beyond the natural level, and was unaccompanied by any visible change in the soft 
parts. The pain had been liable to periodical exacerbations, and was often so severe as 
to deprive the woman of appetite and sleep. The general health had always been good; 
the complexion denoted a robust state of the system, and the menstrual function was 
NEURALGIA. 
Fig. 416. 
Tubercular Excavation of the Cuneiform Bone. 894 
DISEASES AND INJURIES OF THE BONES. 
usually performed with great regularity. Upon removing the tumor, I found that its 
substance was almost as hard and dense as ivory. The pain at once disappeared, and has 
never returned. 
I have met with a number of cases similar to the last, which may be regarded as, in 
some degree, typical of this affection as it usually appears in the bones. Most of them 
occurred in young females, between the ages of fifteen and thirty, without, seemingly, 
any direct connection with the catamenial function, or any marked hysterical predispo- 
sition. In all these cases, the pain was liable to periodical exacerbations, not, how- 
ever, by any means, always coincident with menstruation, and the parts were exquisitely 
sensitive under motion and pressure. The pieces that are most commonly affected 
are the radius, ulna, tibia, fibula, and clavicle, along with the skull and the innominate 
bones. The coccyx also not unfrequently suffers, especially in married women who have 
borne children. 
Neuralgia of hone may arise spontaneously, or be a result of direct injury, as a blow, 
wound, or contusion, causing inflammation in the affected part. It may also be produced 
by a syphilitic taint of the system, as is witnessed in the tertiary form of this disease, in 
which the pains are not unfrequently of a darting, shooting, lancinating nature, or else 
dull, heavy, and aching, as in neuralgia of the soft structures. In abscess of bone tlie 
suffering is frequently of the same character; hence the difficulty so often experienced in 
discriminating between the two affections. The disease is frequently associated with 
neuralgia in other parts of the body. 
What the precise nature of the change is which the osseous tissue undergoes in this 
affection has not been determined. The probability is that it is sometimes altogether 
functional, while at other times it depends upon interstitial deposits, either as a simple 
hypertrophy or as a small exostosis, compressing the vessels and nerves at the seat of the 
disease, and thus causing the excessive pain which so often attends it. 
The treatment of neuralgia of bone is too often conducted upon empirical principles ; 
a circumstance, doubtless, due to the fact that it is generally difficult, if not impossible, 
to ascertain the true nature of the disease. In recent cases, especially in such as are 
directly chargeable to the effects of external injury, a free incision down to the seat of 
the disease, dividing the periosteum and even the superficial layer of the bone, will 
occasionally effect a prompt cure, especially if the wound be kept open for some time 
with stimulating dressings to promote discharge. Now and then a small issue, made 
with the actual cautery, answers an excellent purpose. When the cause is of a syphilitic 
nature, iodide of potassium and mercury are the best means of relief. Quinine, arsenic, 
and strychnia are indicated when the disease is of miasmatic origin. In obstinate cases, 
the only reliable plan is removal of the affected bone with the trephine or other 
suitable instrument, as the object is to get rid of the compressing agent, whether this 
is merely simple hypertrophy of the part, or an exostosis, properly so termed. The 
late I)r. Nott, of New York, twice excised the greater portion of the coccyx for the cure 
of this disease, and a similar operation has been performed by others, although not always 
with a satisfactory result. 
SECT. XIX FRACTURES. 
1. GENERAL CONSIDERATIONS. 
There is no class of injuries which a practitioner approaches with more doubt and mis- 
giving than fractures, or one which demands a greater amount of ready knowledge, 
self-reliance, and consummate skill. Constant in their occurrence, and often extremely 
difficult of diagnosis and management, they frequently involve consequences hardly less 
serious and disastrous to the surgeon than to the patient himself. If I were called upon 
to testify what branch of surgery I regarded as the most trying and difficult to practise 
successfully and creditably, 1 should unhesitatingly assert that it was that which relates to 
the present subject, and I am quite sure that every enlightened practitioner would concur 
with me in the justice of this opinion. I certainly know none which requires a more 
thorough knowledge of topographical nnatomy, a nicer sense of discrimination, a calmer 
judgment, a more enlarged experience, or a greater share of vigilance and attention ; in 
a word, none which demands a higher combination of surgical tact and power. As for 
myself, I never treat a case of fracture, however simple, without a feeling of the deepest 
anxiety in regard to its ultimate issue ; without a sense of discomfort, so long as I am 
conscious that, despite the most assiduous attention and the best directed efforts, the patient 
CHAP. VIII. CHAP. VIII. 
GENERAL CONSIDERATIONS. 
895 
is likely to be lame and deformed for life. A crooked limb, whether rendered so by inju- 
dicious treatment or not, is an unpleasant sight to a sensitive surgeon, inasmuch as it 
continually reminds him of his had luck or want of success. I do not wish by these 
remarks to he understood to say that it is always in his power to cure these accidents 
without deformity or impairment of function. 8uch a view would be contrary to expe- 
rience and common sense. There are many cases of fracture which do not admit of any 
other result, however attentively or skilfully they may be treated ; and there are not a few 
which turn out badly, disgracefully badly, simply because of the want of proper coopera- 
tion of the patient. In such cases no surgeon is responsible. 
A fracture is a solution of continuity of the osseous tissue, or, in other words, a division 
of the bony fibres, occasioned by external violence or muscular contraction. The lesion 
presents itself in various forms, of which the principal are the simple, compound, com- 
minuted, impacted, and complicated. To these may he added the incomplete fracture, in 
which a bone, instead of being entirely broken, is divided only in a portion of its 
diameter. 
A fracture is said to be simple when there is no wound of the soft parts directly over 
the ends of the fragments, so as to expose them to view, or permit them to he felt. It is, 
in fact, a subcutaneous wound of a hone, and nothing more. The case is a simple one, so 
far as the bone is concerned, even if there be a wound in the immediate vicinity of the 
fracture, provided it has no direct communication with it. A fracture is compound when 
there is an opening in the skin and muscles extending down to the bone, the ends of which 
often protrude through the wound, girted, perhaps, by its edges. When a bone is broken 
into a number of pieces, the term comminuted is applied to it. The word impacted is 
employed to signify that the extremity of one fragment is forced into that of the other. 
Finally, fracture is complicated when it is associated with a dislocation, a wound, hemor- 
rhage, laceration, or other mischief. It will greatly facilitate the study of the subject if all 
these terms, excepting the first and last, be discarded. Hence, after some general observa- 
tions, I shall treat first of simple fractures, and afterwards of fractures complicated with 
other lesions. 
All the bones of the body are liable to be broken, although not by any means with equal 
frequency. Those which are most prone to suffer in this manner are the long bones of the 
extremities, particularly those of the leg and forearm. The clavicle is also often fractured. 
The scapula, the two jaw-bones, the sternum, ribs, innominate bones, vertebrae, sacrum, 
and coccyx, together with the bones of the hand and foot, are rarely broken, owing either 
to their protected situation, to their mobility, or to the manner in which they are united 
to each other and to the surrounding parts. It may be stated also, as a general law, that 
the long bones are more liable to give way at or near their middle than at their extremi- 
ties; a circumstance of some importance in a diagnostic and practical point of view’. 
The relative frequency of fractures of the bones of the superior and inferior extremities 
varies in different institutions and in different localities, according to the nature of the 
occupations of those who are the subjects of them. The following table, composed of the 
statistics of four different hospitals, shows the preponderance to be very slightly in favor 
of the lower limbs :— 
Cases. 
Upper 
extremity. 
Lower 
extremity. 
Pennsylvania Hospital 
7670 
3760 
3910 
Hotel-Dieu, Paris .... 
1S56 
850 
1006 
Middlesex Hospital, London 
1280 
764 
516 
Naval Hospital, Calcutta 
1346 
665 
681 
12,152 
6039 
6113 
Respecting their direction, fractures may be oblique, transverse, or longitudinal. Of 
these varieties, the first is by far the most common, although it is impossible, from the want 
of statistics, to estimate its relative frequency. My experience is that transverse fractures, 
except in young children, are extremely rare, and even in them they are by no means 
frequent. In the extensive osseous collection of Dr. Miitter, now in the College of Phy- 
sicians, there is not a solitary specimen of the kind ; and my own is equally barren. 
These remarks apply, of course, only to fractures of the long bones, and especially to 
fractures of their shafts ; for in the short and flat bones such an occurrence is not without a 
certain degree of frequency. There is reason to believe that many of the so-called cases 
of transverse fractures of the shafts of the long bones are in reality oblique fractures, 
approaching more or less closely to the horizontal line, and yet not strictly falling within 
it. There are few practitioners, I imagine, who will not coincide with me in this view, DISEASES AND INJURIES OF THE BONES. 
and who, like myself, have not had frequent occasion, upon further and more thorough 
exploration, to correct their diagnosis in cases of this description. If the question were 
one solely of a. speculative nature, it would be of little consequence ; but when its practi- 
cal bearing is considered, it is impossible to lay too much stress upon it. As it will, 
however, be again adverted to in speaking of the treatment of fractures, nothing further 
need be said respecting it here. The annexed cut, fig. 417, conveys a good idea of an 
oblique fracture. 
CHAP. VIII. 
Fig. 417. 
Oblique Fracture of the Forearm. 
Longitudinal fractures are extremely rare, and are nearly always produced by gunshot 
violence. They are chiefly met with in the humerus, femur, and tibia. The fracture 
occasionally extends nearly through the entire length of the shaft of a bone ; but generally 
it is not more than a few inches long. Now and then a fissure of this kind, after having 
passed a certain distance, runs oft’ in an angular direction towards the 
surface of the bone, where it terminates, as in fig. 418. A longitudinal 
fracture sometimes occurs at the inferior extremity of the humerus, and 
also, but more rarely, at the lower end of the femur, separating one of 
the condyles of these bones, or even both of these protuberances, espe- 
cially if there be at the same time a horizontal or oblique fracture a short 
distance above the corresponding joint. A longitudinal fracture is occa- 
sionally met with in the patella. Bone fissures, which are often, if, 
indeed, not generally extremely difficult of diagnosis, are occasionally 
compound, and are then usually of a very serious character, evidently 
from exposure of the medullary canal, as they are very liable to be fol- 
lowed by erysipelas, pyemia, osteomyelitis, and death. 
The extremities of the fragments of a broken bone exhibit much 
diversity in regard to their form and size ; in general, one is much larger 
than the other, as well as more sharp, rough, and irregular, as in fig. 
419. In the majority of cases, they have a ragged, serrated, or denticu- 
lated appearance, the projecting pieces of one end corresponding with 
the depressions in that of the other. This arrangement, which is pro- 
duced by the irregular division of the osseous fibres, bears no little anal- 
ogy to that which occurs in the edges of a lacerated wound. The truth 
is, to carry out the analogy still further, an oblique fracture is nothing 
but a lacerated wound of the osseous tissue, which presents the same 
difficulty in regard to its perfect coaptation and speedy reunion as a similar lesion in the 
skin and muscles. The irregularities upon the extremities of the fragments are often 
sadly in our way, offering a great obstacle to the successful reduction and subsequent 
maintenance of tlie parts. Sometimes, indeed, the projecting pieces are so long and sharp 
Fig. 418. 
Longitudinal and 
Oblique Fracture. 
Fig. 419. 
Appearances of the Ends of the Fragments. 
as to pierce the integument, or require to be sawed off before the bone can be properly 
set. Such an occurrence is not uncommon in fractures of (he tibia, and it is also wit- 
nessed, although less frequently, in the femur, radius, and clavicle. 
Sometimes the fracture is impacted, the end of one fragment being forcibly driven into 
the other, so as to be, as it were, interlocked. Such an occurrence, of which fig. 420 CHAP. VIII. 
GENERAL CONSIDERATIONS. 
897 
affords an excellent illustration, can only arise, as a general rule, in those bones which 
contain an extraordinary amount of areolar substance, as the head of the humerus, the 
neck of the thigh-bone, and the lower extremity of the radius. 
As a bone may give way at any part of its extent, at its middle, or at either end, it 
follows that the two fragments are rarely of the same length; instead of this, there is often 
a most marked disparity, as is exemplified in fractures of the 
extremities of the long bones, as the femur, in which, espe- 
cially in fractures of its neck within the capsular ligament, the 
superior fragment is sometimes hardly an inch and a half in 
length, while the other is perhaps upwards of a foot and a 
quarter. Fracture of the olecranon affords a similar illustration. 
Such an occurrence is not without its influence in regard to the 
treatment and final issue of the lesion; for the nearer, as a 
general rule, the length of the fragments corresponds, the easier, 
other things being equal, will it be to maintain their apposition, 
and to secure prompt and perfect union. 
A fracture may be single or multiple; that is, a bone may 
break at one or more places, sometimes as many as three, four, 
or even five; in other words, it may literally be crushed and 
comminuted. Such lesions are generally the result of inordinate 
violence, and are, therefore, very liable to be followed by serious 
consequences; often, indeed, by loss of limb and life. 
In fractures of the leg and forearm, affecting both bones, it is extremely rare to find 
the injury situated on the same level; on the contrary, there is generally a considerable 
distance between the two fractures, amounting, according to my observation of numerous 
cases, ordinarily to from one to two, three, and even four inches. The interval is usually 
considerably greater in the leg than in the forearm, probably because of the greater in- 
equality in the size of its two bones. What the cause of this occurrence is it is not easy 
to determine; but it may be supposed that it is due mainly, if not entirely, to the manner 
in which these pieces are respectively articulated to the wrist and ankle joints, in conse- 
quence of which the violence occasioning the lesion is transmitted more forcibly along 
one bone than the other, thereby compelling the former to yield before the latter. Thus, 
as the tibia is more intimately connected with the foot than the fibula, it follows, if this 
explanation be correct, that it ought to break lower down than the fibula, and this, I 
believe, is what usually happens, although there are many exceptions. 
Fractures occur at all periods of life. During delivery, the bones of the arm and leg 
are occasionally broken in rude attempts at extraction. An infant, four weeks old, was 
brought to me on account of a fracture of the shaft of the right femur, caused two days 
previously by a child rolling over it in bed. The thigh was much swollen, and at least 
an inch and a half shorter than the sound one; all the extension and counterextension 
that I could make with my hands failed to restore it to its normal length. Fractures 
occasionally occur in the fetus in the womb. Chaussier met with a remarkable example 
of this description, in which each of the long bones had suffered more or less from these 
lesions, some of which were recent, others beginning to unite, while others were con- 
solidated. The infant survived its birth only twenty-four hours. Analogous cases have 
been reported by other observers. In very young children the bones, owing to their 
softness and flexibility, instead of breaking, are very apt to bend, or give way at their 
epiphyses; in elderly subjects, on the contrary, they are very light and brittle, from the 
rarefaction and fatty degeneration of their substance, and are, therefore, extremely liable 
to yield under the slightest violence. Thus, a fracture of the neck of the femur within 
the capsular ligament is often produced by a mere twist of the thigh in bed, by entangling 
the big toe in a fold of the carpet, or by stepping off the curbstone. 
Statistics have been collected which show that fractures of the upper extremity before 
the end of the fifth year occur with nearly equal frequency in both sexes; between this 
period and the fiftieth year they are most common in the male, and after the fiftieth 
year in women, owing to the remarkable frequency of fractures of the lower extremity of 
the radius and of the neck of the femur. Children are particularly liable to fractures 
of the clavicle, and to separation of the condyles of the humerus. 
Causes The causes of fractures are divisible into predisposing and exciting; the first 
having reference to the part and system, or to local and constitutional circumstances, the 
second to external violence and muscular action. 
The conformation, situation, and office of certain bones are so many predisposing causes 
Fig. 420. 
Impacted Fracture of the Neck 
of the Femur. 898 
DISEASES AND INJURIES OF THE BONES. 
CIIAP. VIII. 
of fracture. Thus, as was before stated, the long bones, which are the great levers of 
locomotion, and which, in consequence, are constantly under the intluence of large and 
numerous muscles, are much more subject to this accident than the short or flat bones, 
which are more passive in their character, as well as more closely articulated together, so 
that any force that may be communicated to them is more easily broken. The body of 
the scapula is seldom broken, because it is not only thickly covered by muscles, but, 
having no fixed point below, it is incapable of being injured by any shock transmitted by 
the hand, elbow, or shoulder. The acromion process, however, owing to its exposed 
situation, is not unfrequently fractured; while the coracoid process, protected by the del- 
toid, clavicle, and head of the humerus, rarely suffers from this cause. The radius, being 
articulated with the hand, is more liable to break than the ulna; the fibula, owing to its 
slender form and brittle texture, is oftener broken than the thick and heavy tibia; and 
every surgeon knows how very prone the collar-bone is to fracture, its exposed situation, 
the peculiarity of its conformation, and its connection with the sternum and scapula, 
rendering it particularly obnoxious to this occurrence. 
Of the influence of age, in promoting the occurrence of fracture, mention was made in 
a previous paragraph. As life advances the bones not only become more brittle, but the 
muscles, the active agents of locomotion, lose their elasticity and suppleness, thus render- 
ing persons more liable to falls, and, consequently, more prone to the accident in question. 
Various diseases or states of the general system are usually regarded as predisposing 
causes of fracture. Of these, the most common are syphilis, carcinoma, sarcoma, scurvy, 
rickets, and osteomalacia. 
A syphilitic state of the system, involving the skeleton, may so affect some of the bones 
as to render them abnormally fragile, and predispose them to this occurrence, as in the 
case of a man, thirty-one years of age, whom I attended for a fracture of the body of the 
right humerus, caused a short time previously, by throwing a small chip at a dog. lie 
was perfectly well at the time, with the exception of some nocturnal pains in the arm and 
forearm. He had had primary syphilis seven years previously, and had been treated 
with mercury. The bone united in five weeks. 
Carcinoma, as stated in a previous page, may so alter the osseous tissue as to render it 
preternaturally brittle, and cause it to yield under the slightest accident. Such an occur- 
rence, indeed, is probably not so uncommon as is generally supposed. I have myself, 
however, seen only one instance of it. The patient was a lady, seventy-three years old, 
from whom I had removed, nine months previously, the left mammary gland, on account 
of scirrhus, under which she had labored for nearly three years. The wound healed 
kindly, but, some time after, the disease reappeared at the cicatrice, and gradually carried 
her off, not, however, before she had become extremely emaciated and bedridden. Dur- 
ing the last month of her life, she complained of almost constant pain in the right thigh, 
deep-seated, and particularly severe at night; and three days before she expired, in an 
attempt to turn in bed, the femur gave way immediately above its middle. The limb was 
free from swelling and discoloration. No carcinomatous matter could be detected in the 
affected bone, which was quite soft, humid, and brittle, for some distance above and below 
the seat of fracture. 
Sarcoma, especially when it takes its rise in the medullary structure of a bone, is often 
followed by fracture, the affected bone frequently giving way under its own weight, or 
under the most trivial accident. 
Of the influence which scurvy exerts upon the osseous tissue, in predisposing it to 
fracture, the modern practitioner has little opportunity of judging, as the disease at the 
present day seldom appears in that violent form which characterized it in former times. 
As described by the older writers, it was often attended with the most horrible ravages, 
in which the skeleton not unfrequently participated, the synovial membranes, cartilages, 
and ligaments being ulcerated, and the epiphyses separated from the bones. 
There are certain states of the skeleton, including rickets, in which the bones are so 
very brittle as to break under the most trivial injury. Cases are recorded in which from 
these and other causes, nearly every one of the long bones was broken, not only once, but 
a number of times. What is remarkable in these cases is that recovery is usually quite 
as rapid as in ordinary fractures. My collection contains a part of the skeleton of an 
old woman, who, in falling from a third-story window upon the pavement below, re- 
ceived not less than eighty-three fractures, involving the ribs, vertebra?, the scapula, the 
bones of the pelvis, and most of the bones of the extremities. 
In osteomalacia fractures are sufficiently common in all parts of the skeleton, especially 
in the long bones of the extremities. In this disease the osseous tissue parts with its GENERAL CONSIDERATIONS. 
899 
CHAP. VIII. 
earthy salts, and is rendered so soft and brittle as to give way under the slightest injury ; 
often, indeed, under mere muscular contraction. 
Charcot has reported a case of locomotor ataxia in a woman who suffered from nume- 
rous fractures of the femur and of both bones of the forearm. It is highly probable that 
diminished nerve power not unfrequently acts as a predisposing cause of such lesions. 
Gout and rheumatism are sometimes enumerated as predisposing causes of fracture, and 
the following case, which I saw with Dr. Metcalf, would seem to countenance the possi- 
bility of such an occurrence. The patient, a common laborer, aged thirty-two, had 
always enjoyed good health until two years and a half before, when he was attacked writh 
articular rheumatism, affecting the principal joints, first of the superior, and then of the 
inferior extremities, where it had continued for the last twelve months. The only cause 
which could be assigned for his suffering was exposure to cold and fatigue in a pork-house, 
where he had worked for fourteen successive winters. In December, 1855, he broke his 
thigh-bone, at the junction of the lower with the middle third, while pulling off his boot 
with his hands, the foot being at the time bent at a right angle with the leg. No pain or 
swelling followed the accident. The most remarkable feature in the case, when Dr. 
Metcalf first saw it, was the imperfect aeration of the blood, as indicated by the livid 
state of the face; the bowels were torpid, the tongue was coated, and there was consider- 
able emaciation, but no disease of the heart and lungs. No chalky deposit existed in the 
joints and there was, so far as could be ascertained, no syphilitic taint. At the end of a 
month and a half, the parts being united, the dressings were removed, and the man was 
permitted to walk about on crutches. A week after this, he struck the affected thigh 
slightly against the rail of the bed, fracturing the bone at its upper third. Union took 
place within about the same time as before, the quantity of callus in each instance being 
uncommonly large. 
The osseous tissue is sometimes remarkably brittle without any obvious cause. A 
gentleman, a patient of mine, fifty-four years of age, broke the right femur near its middle 
in the act of drawing off his boot, the leg being at the moment placed over the other. 
He heard a loud noise, and the limb became immediately useless. lie had labored for a 
number of years under diarrhoea, but was in other respects well. At Guy’s Hospital, 
London, a similar case occurred in a healthy man, of temperate habits, while engaged in 
raising his leg across the other to look at the sole of his foot. 
'Fhe exciting causes of fracture are two, external violence and muscular contraction. 
The former, which is by far the more common, may act upon a bone either directly, or 
indirectly, through some other bone. In the first case, the force is applied to the bone 
itself, as in fracture of the jaw from the kick of a horse, or in fracture of the leg from the 
passage of the wheel of a carriage. Most fractures are of this description, and they are, 
therefore, generally complicated with more or less injury of the soft structures. In the 
other case, the force, instead of being applied immediately to the bone, is transmitted to 
it through another bone, or perhaps a chain of bones. It is in this way that the radius is 
so frequently broken just above the wrist by falls upon the hand, the force being concen- 
trated upon its extremity, in consequence of the manner in which it is articulated with 
the carpus, while the ulna, which is but slightly connected with it, generally escapes. 
Fracture of the clavicle affords an instance of a bone being broken by indirect mechanical 
violence operating at two opposite, points. Thus, in falls upon the shoulder, the sternal 
end being impelled by the weight of the body, and the acromial end by the object against 
which it strikes, the bone, acted upon by the two forces, gives way at its weakest part, 
which is usually about its middle. When a bone is very brittle, the slightest external 
violence may be sufficient to break it. In old people, the neck of the femur is frequently 
fractured by the merest twist of the limb in bed, or by stepping carelessly out of bed upon 
the floor. 
A lady, eighty years of age, a patient of mine, while apparently in excellent health, 
broke her thigh bone in a fall in walking across her room. Fractures occasionally occur 
during parturition from violence inflicted upon the child by the accoucheur, or from the 
pressure exerted upon it by the contraction of the uterus. 
It is not often that a bone is broken by muscular action, and yet such an accident is 
not, perhaps, as uncommon as is generally imagined. I have myself met with several 
examples of it. In three, the subjects were remarkable for their health and muscular 
development, and the fracture in each was produced while they were engaged in feats of 
strength, in which the elbows were planted firmly upon a counter, and the hands inter- 
locked with each other. While the muscles of the arm and forearm were in a state of the 
utmost tension, the humerus snapped off suddenly, with a loud noise; in two cases at its 900 
DISEASES AND INJURIES OF THE BONES. 
CIIAP. VIII. 
middle, and in the other at its inferior extremity. In another ease, the fracture, also 
seated in the humerus, was caused by throwing a small chip at a dog. In this instance, 
alluded to in a previous paragraph, the bone had suffered for a considerable time under 
nocturnal pains, and had, no doubt, been rendered brittle by the effects of the syphilitic 
virus. The patient, who was thirty-one years of age, was otherwise in good health, but 
the muscles of his arm were rather soft and flabby. Dr. Ilewson Bache has related to 
me the particulars of the case of a lady, ninety-seven years old, who broke her humerus 
in the act of throwing the arm about. She died seven weeks after the accident, without 
any union of the fracture. 
Mere muscular contraction is sometimes sufficient to break the femur, as in the case of 
an eminent physician of Buffalo, who fractured this bone in the act of throwing a tenpin 
ball. A similar accident occurred in this city, in a gentleman, aged fifty-two, apparently 
in the most perfect health at the time. The femur gave way a short distance below the 
great trochanter, at a moment when the limb was strongly rotated upon its axis. Dr. 
Lente has recorded the case of a boy, twelve years of age, who broke both his thigh- 
hones during a severe epileptic convulsion. The patella and olecranon are frequently 
fractured by the action, respectively, of the extensor muscles of the thigh and arm. 
From some of the above cases it is evident that a diseased state of the bone is not at all 
necessary to the production of this accident by muscular contraction, although such a 
change is perhaps generally present at the time of the fracture, and, therefore, deserves to 
be considered as a predisposing cause of it. 
2. SIMPLE FRACTURES. 
The symptoms of simple fracture may be considered, first, in relation to the broken bone 
itself; secondly, in relation to the soft parts; and thirdly, in relation to the constitution. 
So far as the affected bone is concerned, there are only three symptoms which are at 
all reliable as evidences of the existence of fracture, namely, crepitation, deformity, and 
preternatural mobility. 
Crepitation is the peculiar noise that is caused by rubbing the two ends of the broken 
bone against each other, and is always, when well marked, characteristic of the nature of 
the injury. In general, it can be both heard and felt. In order to produce it, it is neces- 
sary that the ends of the fragments should be at least partially in contact, and hence, to 
effect this object, the surgeon is often obliged, as a preliminary step, to extend and counter- 
extend the affected limb. For this reason it is always absent in impacted fractures, while 
in fractures of the leg and forearm, involving only one of the bones, it is usually very 
faint and indistinct from the difficulty of moving the broken pieces upon each other. 
Much swelling, great depth of tissue, or the interposition of blood, muscle, or other 
matter may also obscure the crepitation. 
Deformity, although not invariably present, is generally one of the most prominent 
symptoms of fracture. It occurs in different forms, as in shortening, or in angular dis- 
placement, usually at the time of the accident, the cause which produces the fracture being 
also the cause of the distortion. Occasionally, however, it does not come on until several 
hours, or, perhaps, even several days after ; as, for example, in a partially impacted fracture 
of the neck of the thigh-bone, in which the patient may be able to walk some distance, 
and yet the limb retain its normal shape. The degree and character of the deformity are 
greatly influenced by the nature and situation of the fracture. Thus, the more oblique 
the fracture is, the greater, as a general rule, will be the displacement of the ends of the 
fragments, and, consequently, also, the distortion of the limb. Sometimes, as in fracture 
of the patella, the olecranon, and calcaneum, the deformity manifests itself by a vacuity 
or hollow at the natural situation of the bone, and by an unusual protuberance upon the 
lower part of the thigh, arm, or leg, caused by the separation of the upper fragment by 
the action of the extensor muscles. Finally, the deformity may be much increased by 
extravasation of blood, or by effusion of serum and lymph consequent upon the resulting 
inflammation. 
Preternatural mobility is, next to crepitation, the most important and reliable symptom 
of fracture. There are few instances in which it is wholly absent, while in the great 
majority it exists in a well-marked, if not in a high, degree. It usually appears imme- 
diately after the occurrence of the accident, and continues, to a greater or less extent, 
until the completion of the consolidation of the fracture. In the impacted fracture it may 
be entirely wanting, or remain absent until the ends of the fragments are unlocked. In 
fracture of the leg and forearm, involving only one bone, the degree of mobility is some- SIMPLE FRACTURES. 
901 
CHAP. VIII. 
times very slight, the sound bone impeding, or altogether preventing, the motion of the 
affected one. 
In every fracture produced by external violence, whether applied directly or indirectly 
to the part, there must, of necessity, be a certain degree of contusion of the soft structures 
at the seat of the injury. It may be limited to the skin and subjacent connective tissue, 
or it may extend deeper, and involve the muscles, aponeuroses, vessels, nerves, periosteum, 
and even the bone itself. In consequence of this occurrence, there is not unfrequently a 
considerable effusion of blood beneath the skin, and in the connective tissue of the muscles, 
causing distension and sometimes discoloration. For the same reason, there is generally 
a good deal of pain, often of a sharp, spasmodic character, which is aggravated by the 
slightest motion of the parts, and by every attempt at exploration. It has its seat rather 
in the soft structures than in the affected bone, although the latter generally participates 
in it, and by the sharpness of its extremities frequently increases its severity. A short 
time after the accident, swelling usually sets in, and often proceeds to a considerable 
height, its degree being greatly influenced by the amount of injury sustained by the soft 
parts, by the motion to which the fractured bone is subjected, and by the state of the system 
at the time of the accident. As a general rule, it may be affirmed that the pain and 
swelling are less in fractures produced by muscular contraction than in fractures caused 
by mechanical violence, whether directly or indirectly applied. 
Inability of motion in the affected bone, and in the portion of the limb articulated with 
it, is generally a prominent symptom. Cases, however, occur in which it is either very 
slight or entirely absent. In an impacted fracture of the thigh-bone, for instance, a patient 
will sometimes walk a considerable distance without the slightest assistance even from a 
cane, and in fracture of the clavicle I have repeatedly seen him carry his hand to his head, 
and even circumduct the arm. 
Another symptom, consequent upon fracture, is spasm of the muscles at the seat of the 
injury; it is most common in nervous, irritable persons, and generally comes on within a 
short time after the accident. When severe, as it frequently is, it constitutes a source of 
great suffering. It is aggravated by motion and inflammation, and may continue, with 
more or less interruption, for several hours, if not days. 
Finally, the patient often experiences a sense of numbness in the affected part, reaching 
frequently to the distal extremity of the limb. This may be caused either by the injury 
sustained by a nervous trunk at the time of the accident, or by the compression of the 
soft parts by extravasated blood or by the ends of the broken bone. Sometimes it does 
not arise until inflammation has supervened, and then it is generally owing to the presence 
of an unusual quantity of serum and lymph. 
The amount of constitutional disturbance in fracture varies, in different cases, from the 
slightest exaltation of the normal action to the most intense excitement, depending mainly 
upon the nature of the fracture, the degree of injury sustained by the soft parts, and the 
state of the system at the time of the accident. In very many cases there is an entire 
absence of traumatic fever, while in others it is present in a very high degree, the pulse 
being strong and frequent, the countenance flushed, the skin hot and dry, the thirst intense, 
the appetite and sleep much impaired, if not totally suspended, and the temperature above 
100° Fahr. In the more violent forms of fracture, the patient often experiences severe 
shock, from which he may not fully recover for many days, or which may even terminate 
in death. Whenever there is much constitutional disturbance, the affected limb will be apt 
to be in a high state of inflammation, the parts be hot, swollen, painful, and, at times, 
even covered with small vesicles, such as a heedless observer might easily mistake for the 
phlyctenulae which so often announce the occurrence of gangrene. Pyemia is uncommon 
in simple fractures. 
Displacement of the Ends of the Fragments Displacement of the fragments shows 
itself, as already stated, in two principal directions, the longitudinal and horizontal. Of 
these, the former is by far the more common, as it is present, to a greater or less extent, 
in nearly all cases of oblique fracture, in whatever portion of a bone occurring. It is pro- 
duced by the overlapping of the extremities of the fragments, the lower being drawn 
above the upper, or the one riding over the other, as it is sometimes expressed. The 
extent of this form of displacement varies from the slightest possible change in the length 
of the affected bone to two, three, and even four inches, which may be regarded as its 
maximum. It is generally most conspicuous in fracture of the femur and humerus, while 
in fracture of the forearm and leg, affecting only one bone, it is either very slight or totally 
wanting. Finally, the displacement may be lateral, or posterior, according to the nature 
of the exciting cause. 902 
DISEASES AND INJURIES OF THE BONES. 
CHAP. VIII. 
In the horizontal displacement, the lower fragment may form an angle, more or less 
acute, with the superior, thereby giving the bone an arched appearance ; or, the two pieces 
remaining in contact with each other, the inferior one may perform a rotary movement, 
while the other continues perfectly stationary. In some cases, as in fracture of the lower 
end of the radius, there is often considerable lateral displacement, and similar phenomena 
are apt to occur in fracture of the tibia and fibula at or near the ankle-joint. 
The causes of displacement are muscular action, mechanical violence, and the weight 
of the limb connected with the broken bone. Of these the first is the most common, 
and it need hardly be added that a knowledge of the fact is of the greatest practical 
importance in regard to the proper management of the injury. In some instances the 
displacement is entirely produced by the vulnerating body. Thus, in fracture of the nose, 
the blow which inflicts the injury also displaces the fragments. The wheel of a carriage 
passing over the leg may not only break its two bones, but likewise cause great deformity 
by forcing asunder their extremities. Finally, the displacement may be occasioned by 
the weight of the limb connected with the injured bone, as in fracture of the clavicle, in 
which the outer fragment is drawn downwards and inwards by the weight of the shoulder 
and arm. 
Diagnosis The most valuable symptoms of fracture, diagnostically considered, are, 
crepitation, deformity, and preternatural mobility. The coexistence of these symptoms 
is unmistakably denotive of the nature of the accident, but, unfortunately, they are not 
always associated ; one or even two may be absent, and, therefore, a case that ought to be 
treated in the most prompt and decisive manner, may, for the want of a correct appreci- 
ation of its character, be either entirely neglected, or, at all events, grossly mismanaged. 
Besides, the symptoms here enumerated may be simulated by other accidents, especially 
dislocation, and certain affections of the joints. 
The crepitation of fracture is sometimes imitated by the grating produced by an effu- 
sion of plastic matter into a joint, the sheath of a tendon, or a synovial burse ; and the 
difficulty may be still further increased, if, under such circumstances, the suspected frac- 
ture is situated near a large articulation. In general, however, it will be sufficiently easy 
to distinguish between them by a consideration of their respective characters. In frac- 
ture, the crepitation can be both felt and heard; it is dry, coarse, or rough, resembling 
the sensation and noise produced by rubbing two unequal surfaces against each other. The 
,crepitation from plastic matter, on the contrary, is of a finer quality, or more faintly 
marked, and may be likened to the feel and noise caused by gently rubbing over each 
other two pieces of sole leather; in a word, it lacks the roughness and distinctness of the 
other. Moreover, it must be remembered that it is never present until after the occur- 
rence of inflammation, whereas the other always exists the very moment after the 
accident. Crepitation, it is true, might be produced as a consequence of previous disease, 
and the possibility of such an occurrence should not be lost sight of in our examinations. 
Finally, when the case is obscure, the crepitation may sometimes be detected by the aid 
of the stethoscope, especially when the bone is thickly covered by muscles, as in fracture 
of the neck of the femur within the capsular ligament, or in fracture of the ribs in cor- 
pulent subjects. This mode of examination was originally suggested by Lisfranc, but as 
the expectations held out by him have not been realized, few practitioners of the present 
day resort to it. 
The deformity in fracture manifests itself either in shortening, in lateral displacement, 
or, as not unfrequently happens, in the two united. Elongation is never present, in which 
respect fracture differs from certain forms of dislocation, in which lengthening is a promi- 
nent symptom. The degree of shortening varies from a few lines to several inches, and 
is, therefore, an event of much diagnostic value. It may exist from the commencement 
of the accident, or it may not show itself until some time after its occurrence, being ma- 
terially influenced by the action of the muscles, and the nature of the treatment. What- 
ever the degree of the deformity may be from these causes, it may always be effectually 
removed by extension and counterextension, either alone or aided by pressure ; but as 
soon as these forces cease to operate, it is usually immediately reproduced, which is not the 
case in dislocation. Here, the reduction having been effected, the parts generally retain 
their relations until some new cause produces a new displacement. 
Too much stress cannot be placed upon preternatural mobility as a sign of fracture. 
Next to crepitation, it is unquestionably the most important diagnostic symptom. There 
may be unnatural latitude of motion in a dislocation, but this can only happen when the 
accident is attended with extensive laceration of the ligaments of the joint; in ordinary 
cases there is either an absence of motion, the displaced bone being firmly fixed in its SIMPLE FRACTURES. 
903 
CHAP. VIII. 
new position, or the motion is so slight as to bear only a faint resemblance to that observ- 
able in fracture. 
The “ physiognomy,” or general expression of the affected parts, as in fig. 421, often 
affords valuable diagnostic aid. The deformity, for example, of the hand and wrist, in 
fracture of the lower extremity of the ra- 
dius, the eversion of the toes in intracap- 
sular fracture of the femur, and the short- 
ened and retracted appearance of the arm 
in fracture of the humerus, are generally 
unmistakable evidences of the nature of 
the accident. The manner in which the 
patient inclines his head and supports the 
elbow and forearm in fracture of the clavi- 
cle, is too significant to be overlooked by 
any one who has ever witnessed it. The 
peculiar aspect and attitude of a broken 
thigh, conjoined with the utter helplessness of its muscles, or the absence of all voluntary 
power, are signs which seldom admit of misinterpretation. 
In fracture without displacement there is sometimes a persistent soreness or tenderness 
on pressure with the finger at the site of the injury, which, with proper care in the 
examination, may lead to useful diagnostic information. I have seen this repeatedly in 
fracture of the clavicle in children, and also in fracture of the bones of the forearm in fat, 
elderly subjects, and, therefore, look upon it as a most valuable symptom where the 
ordinary means of recognition fail. 
The pain, swelling, and loss of function, present in suspected fracture, are of no practical 
value, as similar phenomena are produced by other injuries, as contusions, wounds, sprains, 
and dislocations. Their occurrence being wholly accidental, must, therefore, not influence 
the surgeon in his attempt to form a correct estimate of the true nature of the case, or the 
relative value of the symptoms of this and analogous affections. 
In fractures of the inferior extremities accurate measurement must not be neglected, 
similar to those indicated in a former chapter. A very safe and excellent plan is that sug- 
gested by the late Professor R. O. Cowling, of Louisville, Kentucky. The patient lying upon 
a hard, level surface, and the parallelism of the iliac spines and the proper extension of the 
limbs being looked to, a tape is carried from the umbilicus around a corresponding part of 
the sole of each foot, and back again to the point of departure. The reference, however, 
between the two measurements thus obtained represents twice the amount of difference 
which exists in the length of the limbs, a circumstance that must be borne in mind in 
determining the actual amount of shortening. Ingenious contrivances for ascertaining the 
relative lengths of the lower extremities have been devised by Dr. II. Z. Gill, of Illinois, 
Dr. John Bartlet, of Chicago, Dr. Morton, and several other surgeons. 
Mode and Time of Examination—Although the symptoms which have now been 
described will generally be sufficient, along with a careful consideration of the history of 
the case, to enable the surgeon to determine the diagnosis of this lesion, especially if he 
takes the trouble of comparing them with the symptoms of other accidents, it will, never- 
theless, be proper, in concluding these remarks, to say a few words respecting the manner 
of conducting the examination of the affected parts, as the ultimate issue of the case will 
greatly hinge upon this circumstance. 
Few practitioners know how to examine a broken limb. They take hold of it as if 
they were afraid of causing suffering, and it is, therefore, not surprising that the result is 
often most disastrous. I am far from wishing to be understood as being an advocate of 
rough surgery—on the contrary, no one deprecates it more than I do—and yet there are 
times and circumstances when the best interests of the patient demand that he should be 
most thoroughly examined, no matter what amount of pain he may be compelled to 
undergo. But there is no longer any need of such infliction now that suffering can be 
prevented by anaesthesia. The patient being rendered insensible, perquisition is per- 
formed at the surgeon’s leisure, slowly and deliberately, and with an eye to the ultimate 
result, not forgetting self. The sooner such manipulation is instituted the better, for there 
will then be less likelihood of inflammatory swelling and other obstacles calculated to em- 
barrass our progress or to obscure the diagnosis. Fractures of the shafts of the bones 
will rarely offer any difficulty, inasmuch as their symptoms are generally so well marked 
that the most casual inspection will be sufficient for their detection. But it is different 
when the lesion involves their extremities. Here the most laborious and painstaking 
Fig. 421. 
Fracture of the lower End of the Kadius. 904 
DISEASES AND INJURIES OF THE BONES. 
chap. viii. 
examination sometimes hardly enables the practitioner to form an accurate judgment 
respecting the real nature of the injury. Under such circumstances, therefore, he must not 
content himself with one or two trifling explorations; he must handle the parts again 
and again, until he has thoroughly established the diagnosis. 
For the reason already assigned, the parts should always he examined as early as pos- 
sible after the infliction of the injury, but no exception should, in my judgment, be made 
even when some time has elapsed, and a good deal of swelling has supervened; for it is 
impossible that a broken bone, or the parts by which it is covered, should do well so long 
as its extremities are displaced, and thus permitted to fret, irritate, and, perhaps, prick 
the muscles and other structures in contact with it. The sooner, indeed, the parts are 
restored to their natural relations, the more likely will they be to do well, and to escape 
the ill effects of inflammation. There are instances, however, where, as may be supposed, 
immediate interference might prove highly prejudicial, using the term immediate here 
with reference to the surgeon’s first visit. The patient may have been neglected, or his 
attendant may have mistaken the nature of the case, and in this manner several days may 
have passed uselessly away. The limb is now found to be very much swollen, extremely 
painful, and intolerant of the slightest manipulation, nay, perhaps, in an erysipelatous 
condition. To make an elaborate examination under such circumstances would be very 
injudicious, as it could not fail to aggravate the morbid action, and, perhaps, urge on 
gangrene. The hand is withheld ; the limb is placed in an easy position, and anti- 
phlogistics, both local and constitutional, are freely plied ; when action has sufficiently 
abated, but not until then, the proper examination is effected, and the diagnosis, if possi- 
ble, established. 
The mode of conducting the examination varies. In the upper extremity the surgeon 
will usually be able to get on without any assistance, but in fracture of the thigh and leg 
it is often necessary to make extension and counterextension while the parts are sub- 
jected to methodical manipulation. When there is marked displacement, the merest touch 
of the hand will generally suffice to detect the nature of the lesion ; whereas, under op- 
posite circumstances, the nicest digital exploration may be required. In general, it will 
be necessary to make pressure and counterpressure at the seat of the injury, and to 
rotate the portion of the limb below the fracture upon its axis. In this manner, espe 
cially if proper extension has been effected, the ends of the fragments, brought into close 
contact, may be made to yield the friction-sound, previously described, and at the same 
time display the full extent of their mobility. Another procedure is to grasp the two 
extremities of the suspected bone, and then, while the superior one is firmly held with the 
thumb and finger, to roll the inferior upon its axis. If both parts move together, the 
probability is that there is no fracture; whereas, if the lower move, and the upper 
remain stationary, there can be no doubt of the fact. 
Mode of Repair A fracture is repaired precisely upon the same principle as a wound 
of the soft parts, the only difference being the superaddition of carbonate and phosphate 
of lime, or the earthy constituents of bone. In order, however, to understand the matter 
thoroughly, it is necessary to study it with reference to the situation and disposition of 
the ends of the fragments of the broken bone, as the rapidity and perfection of the cure 
are greatly influenced by the manner in which they are arranged and held together during 
the treatment. The more perfect the apposition is, the more complete, generally, other 
tilings being equal, will be the reunion. For practical purposes, the whole subject of 
repair may be considered as consisting of four stages. 
The first stage, which, on an average, in the adult, extends from the first to the sixth 
or eighth day, is one altogether of preparation, in which nature clears away the rubbish, 
and places the ends of the fragments in a suitable condition for the process of repair, 
properly so called. The blood which was extravasated at the moment of the accident, at 
and around the seat of the fracture, is, in great degree, if not entirely, absorbed ; the 
inflammatory products, especially the intermuscular, are also disposed of; the swelling sub- 
sides, the pain disappears, and there is no longer any tendency to spasmodic action, the 
muscles having become calm and quiet under their new relations. Any traumatic fever 
that may have been present will also be found to have vanished. Thus the part and 
system have happily passed through the preliminary stage of the reparative process. 
If the parts be examined at the beginning of the second stage, it will be seen that the 
ends of the broken bone, as well its the periosteum, and the other soft parts in their imme- 
diate vicinity, are abnormally red and injected, and covered with a layer of embryonic 
cells, resembling very much, in color and consistence, pale currant jelly, or a thick solu- 
tion of isinglass. It is usually most abundant upon the surface of the bone, and is often CHAP. VIII. 
SIMPLE FRACTURES. 
905 
sufficient to lift up the periosteum ; a considerable quantity is also generally seen between 
the periosteum and the muscles, and even among the muscles themselves, all these struc- 
tures being more or less actively engaged in the process of repair. A similar tissue, but 
usually less abundant, is formed by the medulla of the central canal, the lining mem- 
brane of which is also in a state of inflammation, as is evinced by its discolored and 
injected condition. In the latter part of this stage, which lasts from the eighth to the 
sixteenth, eighteenth, or twentieth day, the granulation tissue, which differs in none of 
its properties from that which serves to unite a recent wound, becomes gradually more 
and more firm, until at length it assumes the consistence of a semisolid substance. 
The third stage is characterized by still further changes in the consistence of the newly- 
formed tissue, and by its gradual conversion, first into fibro-cartilage, then into carti- 
lage, and finally into bone ; or, more correctly speaking, cells are developed in the new 
substance, into which the osseous granules are deposited, the wdiole process bearing the 
closest possible resemblance to that which takes place in the formation of the original 
bone. It should, however, be stated that while the embryonic tissue which surrounds the 
surface of the broken bone is first transformed into cartilage, the mass of cells which result 
from the proliferation of the medulla, and which form the central plug, are converted into 
bone without the intervention of cartilaginous tissue. The period at which the osseous 
matter begins to be developed in the adult varies from the eighteenth to the twenty-fifth 
day, its appearance and progress being influenced by numerous local and constitutional 
causes, to be described under another head. 
The ossific process proceeding in the way now' described, two layers of bony matter are 
formed, one lying upon the outer surface of the ends of the fragments, the other within the 
medullary canal, each extending some distance beyond the seat of fracture, as is seen in 
fig. 422. To these two strata is confided the office of temporarily supporting the fragments, 
or of holding them together until their ends are permanently united by osseous substance ; 
a circumstance which does not, as a rule, take place until several months later. To this 
Fig. 422. 
Fractured Tibia, with new Bone beneath the Periosteum, and within the Medullary Canal. 
new formation the older pathologists applied the term callus, in consideration of its hard- 
ness, which, when the process of repair is completed, is fully equal to that of the original 
bone, which it also closely resembles in its structure. From its office, the outer and inner 
callus, or that which invests the broken bone and lies in its medullary canal, is now uni- 
versally known as the temporary or provisional callus, while that which is placed between 
the two ends of the bone, and thus serves to cement them together, is designated as the 
definitive or permanent callus. The temporary callus is, figuratively speaking, nature’s 
splint, or the means which she employs to support the fractured bone until the continuity 
of the fragments is reestablished by the deposit and organization of osseous matter between 
their extremities. 
Callus, after having gone through its various stages of development and growth, is 
always much harder than normal bone, or the bone which it serves to unite. Its density, 
which often approaches that of ivory, is essentially due to a disproportionate increase of 
earthy matter. In natural bone the quantity of animal substance varies, on an average, 
from fifty-five to fifty-eight per cent., whereas in the callus of a broken bone it hardly 
reaches forty-five. The quantity of carbonate of lime is more than twice as great as in 
the natural state, and there is also a considerable increase in the amount of phosphate of 
lime. The composition, density, and strength of callus vary, of course, in different 
pieces of the skeleton, and in different conditions of the system, as it respects the age 
and health of the patient. 
As the first stage in the reparative process is one of preparation, so the last is one of 
completion ; reunion having been effected, nature now busies herself in removing whatever 
is redundant or superfluous, thereby fitting both bone and muscle for the resumption of their 
respective functions. The provisional callus, having ceased to perforin its office as a 
splint, is gradually brought under the influence of the absorbents, the more superficial 
portions being taken away first, and afterwards the more deep, until the broken bone 
regains not only its original form and volume, but also its pristine smoothness, all evi- DISEASES AND INJURIES OF THE BONES. 
CHAP. VIII. 
dence of fracture disappearing, excepting, perhaps, a little seam or ridge corresponding 
with the line of junction of the two fragments. While these changes tire going forward 
upon the exterior of the bone, nature is busy at work in its interior, disposing of the pro- 
visional callug in that situation, and thus restoring the medullary cavity to its normal 
condition. This can occur, however, only when there has been perfect apposition of the 
ends of the fragments; for, when the reverse is the case, the new bone remains perma- 
nently in the canal, as is shown in fig. 423, from a specimen in my collection. Any 
Fig. 423. 
United Fracture, showing the Condition of the Medullary Canal. 
fibrous, cartilaginous, or osseous matter that may have been formed between the perios- 
teum and muscles, or among the muscles themselves, is likewise removed as a substance 
foreign to the part, and, therefore, useless, if not positively prejudicial. 
It will thus be seen that the fate of the provisional callus is precisely similar to that of 
the plasma which is effused between the edges of a wound, both gradually disappearing, as 
soon as their service can be dispensed with, or as soon as the parts have acquired sufficient 
firmness to enable them to maintain their connection. The period required for effecting 
these changes in a broken bone varies from a few weeks to several months, according to 
the circumstances of the case, more especially the age and health of the patient, and the 
nature of the treatment. 
Such is a brief account of the several changes which attend the repair of bone in the 
more simple forms of fracture, when the ends of the fragments are thoroughly maintained 
in their natural relations. Under such circumstances there is but little need of provisional 
callus ; the ends of the fragments soon inflame, and unite almost by the first intention. 
But it is seldom that a patient is so fortunate ; on the contrary, the fracture being gene- 
rally oblique, is subject to more or less displacement, thus compelling nature to provide a 
temporary splint by the formation of provisional callus. I do not believe, however, as 
has recently been so much insisted upon, that there ever is an entire absence of this 
kind of callus, however intimately the ends of the bones may be in apposition with each 
other. To prove the truth of this remark, it is only necessary to examine the numerous 
specimens of fracture of the skull and other portions of the skeleton in our museums; 
they will conclusively demonstrate that even the most simple fracture, unaccompanied by 
the slightest displacement, is seldom repaired without the development of a certain 
quantity of osseous matter upon its surface. At the same time it must be admitted that 
the provisional callus, in such cases, is very small, and that it bears no proportion to the 
enormous amount of substance that is so often formed when the ends of the bone are 
separated from each other. Under the latter circumstances, nature labors under great 
disadvantage, and is, therefore, obliged to make extraordinary efforts to effect reunion, 
which she can do only by the development of a large provisional callus. From these 
facts, then, we may deduce the general law that the quantity of new bone is always, other 
things being equal, in proportion to the contact of the ends of the fragments, being small 
when this is very accurate, and more or less large when it is imperfect. 
When the ends of the bones are not closely approximated, their edges are gradually 
Fig. 424. 
Appearance of the Ends of the Fragments in an old Ununited Fracture. 
rounded off by the absorbents, the opening in the medullary canal is closed by a shell of 
new matter, as in fig. 424, and a large provisional callus is formed for the more secure CHAP. VIII . 
SIMPLE FRACTURES. 
907 
protection of the fracture. The whole process is one of time and 
labor, not of speed and ease, as in the former case. When the 
ends are completely separated, but opposite, or nearly opposite, to 
each other, they are generally united by a bridge of new bone, ex- 
tending from one to the other, and ultimately affording sufficient 
strength for the support of the weight of the body upon the affected 
limb, as in fig. 425, from a specimen in my cabinet, representing 
the humerus of a turkey. Or, instead of this, especially in elderly 
subjects, the junction is effected by fibrous, fibro-ligamentous, or 
cartilaginous matter. Finally, osseous union is not impossible when 
the extremities of the fragments overlap each other to an extent 
even of several inches, provided they are in contact; for in this 
case inflammation is established in the contiguous surfaces, followed, 
after a long time, by a large permanent callus. We see many 
curious specimens illustrative of this fact, although, in general, the 
union is ligamentous. 
There are certain pieces of the skeleton in which in fracture pro- 
visional callus seldom, if ever, forms. Of this description are the ole- 
cranon, acromion, patella, and neck of the femur. Instead of uniting 
by osseous matter, as the other bones do, the cure is generally effected 
through the medium of fibrous, ligamentous, or cartilaginous sub- 
stance, and the consequence is that the part commonly remains weak 
ever afterwards. Various causes conspire to produce this result, as 
the difficulty of maintaining the contact of the broken surfaces, and 
the inordinate secretion of synovial fluid, which, mingling with the 
effused plasma, thus impairs its vitality, and renders it unfit to 
become the nidus of bony deposit; but the most efficient one of all 
is the want of nourishment of the smaller fragment produced by 
the laceration of its nutrient vessels. Thus, in intracapsular fracture of the femur, the 
only connection between the upper fragment and the pelvis is by the round ligament, the 
arteries of which are altogether unequal to its proper support. 
Treatment The leading indications in the treatment of fracture are to procure reunion 
and to prevent deformity. Before the manner of fulfilling these indications is discussed, 
it is proper to lay down certain rules for the transportation of the patient, and the mode 
of preparing his bed. 
Fractures are often received by persons at a considerable distance from their homes, 
either on the road, in the field, or at some secluded building. This renders it necessary 
to carry them to their own houses or to some hospital, in order that they may undergo 
the proper treatment. In fractures of the superior extremity, clavicle, scapula, or ribs, 
the requisite dressings may be applied at once ; or, if this is not convenient, the patient 
may either walk or ride, the suffering limb being supported in a sling; or, in the case of 
a broken rib, the body may be swathed with a long towel. It is only, as a general rule, 
in fractures of the inferior extremity, spine, or pelvis, that the patient will require to be 
carried, and the best way of effecting this, if the distance is not too great, is to place him 
upon a narrow door, a long shutter, or two pieces of board, supported by two cross-pieces, 
the ends of which are intrusted to four assistants, a pillow and comfort having previously 
been put under the patient’s head and body. Or, instead of this, the transportation may 
be conducted upon an easy furniture-car, provided with a good mattress, and drawn slowly 
along in order to avoid jolting. Whatever mode be adopted, the limb should be tempo- 
rarily splinted, and placed in as comfortable a position as possible, an intelligent person 
sitting by the patient’s side, and rendering such aid as may be required on the way. In 
carrying him to his chamber, four assistants will generally be necessary, two to support 
the body, which they do by crossing their arms behind the trunk and interlocking their 
hands, and two for the lower extremities, the surgeon himself taking charge of the 
broken one. 
It may be assumed as an axiom in surgery that no man with a broken thigh or leg can 
be treated successfully without the advantages of a suitable bed. Prompt attention should, 
therefore, always be given to this matter, in order that no injurious delay may arise. 
When we reflect upon the fact that in fractures of the lower limbs the patient is often 
compelled to remain in the recumbent posture for weeks together, and how difficult it is, 
in most cases, to maintain the requisite extension and counterextension, the force of this 
injunction cannot fail to be perceived in its true light. The essentials of a good fracture- 
bed are, first, firm, stout slats, instead of a cord or sacking bottom ; secondly, a well- 
Fig. 425. 
Fracture of the Arm-bone 
of a Turkey. 908 
DISEASES AND INJURIES OF THE BONES. 
CHAP. VIII. 
constructed mattress of liair, moss, or cotton ; and, thirdly, a hole in the mattress, opposite 
the buttocks, for the easy relief of the bowels, the opening being closed by a door of 
similar manufacture, and furnished with hinges and other appliances. If long confine- 
ment in one posture is necessary, or if the patient has been worn out by previous disease, 
an air-mattress may be required, in order to prevent bed-sores. If a sheet be used, the 
edges should be carefully pinned to the sides of the mattress, otherwise it will soon become 
rumpled, and a source of more or less annoyance, if not of great suffering. 
It has been a much mooted question whether, as a general principle, a fracture should 
be set as soon as possible after its occurrence, or whether time should be allowed for the 
subsidence of the resulting inflammation. It appears singular that upon a subject so clear 
as this there should be any difference of opinion. It certainly requires no great knowledge 
of the nature of accidents to discover why such cases should receive the earliest possible 
attention ; so long as the ends of the fragments are permitted to remain apart, their tendency 
inevitably must be to excite spasm and inflammation, thereby increasing the suffering of 
the patient and retarding his cure. Of this fact there can be no doubt, and, therefore, 
my plan is to treat every case of the kind as early as possible with the bandage and 
splint; applied, of course, not firmly, but gently and cautiously, simply with a view of 
giving support to the parts, and thus preventing further mischief from the sharp and pro- 
jecting ends of the broken bone. It is difficult to imagine an instance to which such 
treatment would not be adapted. It might as well be expected that a man’s limb would 
do well if it had a thorn imbedded in its muscles, as that it would be comfortable with 
two pieces of bone sticking in them. It is absurdity to think it could be otherwise. 
When, in consequence of excessive inflammation, a fracture cannot be set at once, the 
limb should be maintained perfectly at rest, in the easiest possible position, and the parts 
kept constantly wet with lotions of lead and laudanum until the case admits of the appli- 
cation of the permanent dressing. This practice is nowhere more necessary than in frac- 
tures affecting the joints, which are always followed by more or less copious effusion of 
synovial fluid. To get rid of such fluid as soon as possible is a cardinal rule of treat- 
ment; and certainly no sensible surgeon would use any tight dressing so long as there is 
any considerable swelling of the soft structures. 
Apparatus.—Before an attempt be made to set the fracture, it is necessary to provide 
the requisite apparatus for effecting its maintenance. The means which are employed for 
this purpose are splints, cushions, bandages, and adhesive strips. 
Splints are made of various materials, as wood, trunk-board, leather, felt, gutta percha, 
tin, wire, and iron, according to the nature of the fracture, or the fancy, whim, or caprice 
of the practitioner. In fracture of the thigh and leg, especially in that form which requires 
permanent extension and counterextension, the best article is wood. In fracture of the 
superior extremity, particularly of the humerus and of the bones of the forearm, splints 
made of trunk-board generally fulfil every indication, as by a little manipulation, after 
immersion in hot water, they may easily be moulded to the form of the limb. A piece of 
thick pasteboard affords a good support to a broken jaw or finger. Unoiled sole leather, 
gutta percha, and felt, the latter being rendered stiff by gum shellac, make excellent 
splints, which are often used with much satisfaction in fractures both of the upper and 
lower extremities. Previously to applying them, they must be softened in hot water, 
the sharp angles and edges having been pared off with a knife. The tin ease I have 
employed a great deal, especially in fracture of the humerus at the elbow, and of the tibia 
at the ankle, ever since I entered the profession. Iron splints, in the form of the double 
inclined plane, are sometimes used ; and very good splints may be made of light wire 
and of perforated zinc. For fractures ot the bones of the hand and fingers, carved 
splints are very serviceable. 
An excellent splint may be made by filling the meshes of a piece of linen, muslin, or 
canton flannel with a thick solution of plaster of Paris in water, and then doubling the 
cloth upon itself as many times as may be requisite to obtain the proper strength, when 
it is immediately secured to the limb with a roller. The advantages of this apparatus 
are that it dries in a few minutes, forming thus almost instantaneously a firm, stiff’ shell 
for the broken limb, perfectly adapted to its inequalities, exceedingly light, indisposed 
to absorb discharges, and admitting of easy application and removal. The plaster splint 
was first employed in this country by Professor James L. Little, by whom it was intro- 
duced into the New York Hospital as early as 1801. It is rapidly coming into general use. 
Felt splints, adapted to the different regions of the body, and put up in portable cases, 
have of late years been a good deal employed ; they are very light and flexible, are not 
affected by cold or warm water-dressings, and are easily moulded to every inequality of 
the surface of the parts to which they are applied. SIMPLE FRACTURES. 
909 
CHAP. VIII. 
Fracture cushions are generally made in the form of small hags, stuffed with bran, fine 
chaff, cotton, wool, hair, moss, or any other soft material. They are designed to fill up 
the inequalities between the splints and the limb, and must necessarily vary in shape, 
length, breadth, and thickness, according to the exigencies of each particular case. Instead 
of cushions, simple pads or compresses are often used, especially in fractures of the supe- 
rior extremities. For enveloping short splints, calico, muslin, or old flannel is employed ; 
or, what I always prefer, glazed wadding. The same article or batting answers admirably 
for filling up the inequalities between the short splints and the affected limb. Bags filled 
with sand are sometimes very convenient and useful, especially in fractures of the leg and 
thigh. Stretched along the sides of the limb, they keep up steady, equable pressure, well 
calculated to prevent displacement of the fragments. 
The fracture bandage is made of coarse linen or muslin, of sufficient strength to an- 
swer the purpose for which it is intended. Nothing is worse, or more likely to cause 
annoyance, than a thin, flimsy bandage. If the material is new, it must be washed be- 
fore it is used, to rid it of its glazing, and the selvage is torn off'to prevent it from excit- 
ing irritation, or producing welts in the skin. The bandage most commonly used is the 
ordinary single-headed roller, of a length and breadth suitable to the affected limb or 
part of the body to which it is to be applied. In fractures of the leg and thigh, espe- 
cially complicated ones, the bandage of Scultetus may often be advantageously employed, 
as it can be easily undone and reapplied without any disturbance to the limb. It consists 
of numerous strips of the ordinary roller, of equal or unequal length, according to the 
size and shape of the affected parts, applied in such a manner that one overlaps another 
nearly one-half. 
Too much caution cannot be observed in the use of the bandage in the treatment of 
fractures. It is an agent for good or for evil; for good, if applied properly ; for evil, if 
applied improperly. Its object is twofold ; first, to afford uniform compression of the 
limb, thereby preventing swelling and spasm ; and, secondly, to retain the necessary 
apparatus. The application is always begun at the distal portion of the limb, and continued 
upwards some distance beyond the seat of the injury, care being taken not to interrupt 
the circulation, or, to inflict other mischief. If it be too slack to support the parts in a 
proper and uniform manner, it will be useless ; if too tense, it will give rise to severe in- 
flammation, swelling, and even gangrene. For the want of this precaution, many limbs 
are lost, and a still greater number rendered permanently useless. 
The application of the roller to the surface of the skin in the treatment of fractures, 
has at the present day many opponents, on the ground that, when thus employed, it is 
liable, by its pressure, to embarrass the circulation, and predispose to the occurrence of 
gangrene. It is alleged that it is particularly objectionable when applied high up to the 
forearm when the limb is greatly flexed, or placed nearly at a right angle with the arm ; 
or when, under similar circumstances, it is applied to the foot and leg. Any thing is 
liable to abuse, and it is certain that a roller, if improperly applied, may do a great deal 
of harm ; a circumstance against which a judicious surgeon always carefully guards. If 
he has not sufficient confidence in his ability to use the roller, or the circumstances for its 
employment are inauspicious, the only rational plan is to dispense with its application as 
a covering for the skin. 
Adhesive plaster, cut into suitable strips, is now universally employed in this country, 
as a means of making extension, in the treatment of fractures of the lower extremity, 
and nothing, certainly, could generally answer a better purpose. To this plan of treat- 
ment I called special attention, in my Treatise on the Diseases of the Bones and Joints, 
published in 1830, having a short time previously witnessed its good effects in the prac- 
tice of the late I)r. Joseph K. Swift, of Easton, in a case of very oblique fracture of both 
bones of the leg, complicated with so much injury of the soft parts as to interfere effec- 
tually with the use of the garter and other extending bands. The man had suffered a 
great deal of pain, until his patience was almost exhausted, when trial was made with 
adhesive strips, carried along the sides of the limb towards the knee, their free extremi- 
ties being tied below the foot, to the transverse block connecting the two splints. Great 
comfort was at once experienced, and the case progressed favorably from that time forward. 
Soon after, I had occasion to use adhesive strips in a case of my own, with results equally 
gratifying: I subsequently extended the practice with great advantage to the treatment 
of fractures of the clavicle, ribs, olecranon, and patella, as well as of the thigh and leg. 
Valuable papers have been published on this mode of management by Ellerslie Wallace, 
David Gilbert, John Neill, Josiah Crosby, and others. In a short article in the Phila- 
delphia Medical Examiner for 1852, I also called attention to the subject, giving very 910 
DISEASES AND INJURIES OF THE BONES. 
CHAP, VIII. 
briefly the results of my experience up to that period. The importance of this agent, for 
the purposes here referred to, will be fully pointed out under the head of special fractures. 
Coaptation and Dressing—Everything having thus been provided, and the requisite 
number of assistants obtained, the surgeon proceeds to restore the broken pieces to their 
original situation ; or, to use a common expression, to set the fracture. This may be done 
either by simple manipulation, or by pressure and counterpressure, or by this means 
aided by extension and counterextension. The former will usually suffice in fracture of 
the upper extremity, the jaw, and nose, while the latter will generally be required in 
fracture of the thigh and leg; in either case, the affected limb should be held as quietly 
as possible, not only during the adjustment of the fragments, but also during the applica- 
tion of the dressings. It need hardly be observed that these manipulations should be 
conducted in the most gentle manner, with an eye both to present comfort and future con- 
sequences. There is no department of surgery where the humane practitioner may ex- 
hibit his skill and sympathy to greater advantage than in this, or where his conduct will 
be more closely watched and commented upon than upon such an occasion. 
There are several causes which may seriously interfere with, and sometimes even 
entirely prevent, the reduction of a fracture. Of these one is muscular contraction, in- 
duced by the irritated condition of their fibres, which, however, is generally easily over- 
come with the aid of an anaesthetic. Occasionally the obstacle is some foreign substance, 
as a piece of bone or a portion of muscle, accidentally interposed between the ends of the 
broken bone. Now and then the difficulty depends upon the presence of coagulated blood. 
The most common cause, however, of all is the shape of the extremities of the fragments. 
If these be denticulated, very sharp, notched, or uncommonly oblique, accurate adjust- 
ment and maintenance will be extremely difficult. In extensive comminution, as in cer- 
tain multiple fractures, the obstacle to reduction is often very great, if not positively 
insurmountable, owing to the manner in which the fragments are wedged into each other 
and into the surrounding structures. 
Extension and counterextension are always necessary in oblique fractures of the ex- 
tremities, attended with displacement. By the term extension is understood the force 
which is required to draw the upper end of the lower fragment to a level with the lower 
end of the upper fragment, in order to place them in their natural relations; by counter- 
extension, on the contrary, is implied the resistance which is employed to prevent the 
limb, or even the body, from being dragged along by the extending power. The exten- 
sion is generally made upon that part of the limb which is articulated with the lower 
piece, and the counterextension upon that which is articulated with the upper. Thus, 
for example, in fracture of the shafts of the bones of the forearm, the extending power 
acts upon the hand, and the counterextending power upon the arm, while in fracture of 
the body of the humerus the two forces are respectively exerted upon the forearm and the 
chest; and so in regard to fracture of the inferior extremity. When but little muscular 
resistance is anticipated, as in a child or feeble person, the extension and counterexten- 
sion may be applied directly to the two fragments, but at as great a distance from the seat 
of the injury as practicable. On the whole, however, the former method is decidedly pre- 
ferable, as it is much less likely to irritate and worry the muscles. 
In reducing a fracture, the parts must be put in the most favorable position for relaxing 
the muscles, and the extending forces applied in as slow and gradual a manner as possible. 
If the limb is suddenly pulled, or stretched by fits and starts, the muscles concerned in 
effecting and maintaining the displacement will inevitably be thrown into violent spas- 
modic contraction, thus not only causing pain, but, perhaps, severe injury to the soft 
structures, if not actually frustrating our intention. The degree of force used in making 
extension must vary according to the amount and character of the displacement, and the 
number and power of the muscles engaged in producing it; in all cases it should be suffi- 
cient to remove the shortening of the limb, or, what is the same thing, to restore it to its 
normal length, and to surmount every obstacle that opposes the reduction. The extension 
is always begun in the direction of the lower fragment, and is afterwards continued in that 
of the injured bone, until the object is fully attained. The ends of the fragments being 
now pressed into their natural situation, the fractured limb is immovably fixed by splints, 
every hollow between them and the skin being filled with cotton, to ward off pressure. 
Any spasmodic action of the muscles that may interfere with the reduction of a fractured 
bone is generally very readily counteracted by a few deep whiffs of chloroform ; or, even 
without the aid of this agent, simply by the compression of the main artery of the limb, 
thereby lessening the flow of blood to the parts. 
In fractures of the superior extremity, the hand and forearm are suspended in a sling, 911 
CHAP. VIII. 
SIMPLE FRACTURES. 
and the patient may walk about and attend to business ; but when the thigh or leg is 
involved, he must remain in bed until the ends of the broken pieces are completely con- 
solidated, or until he has so far recovered that he can use the immovable dressing and 
exercise in the open air upon crutches. During his confinement, the limb is placed in 
the most favorable manner for relaxing and resting the muscles which pass over the 
fracture; for this purpose it should be put in the extended position, and be well secured 
with apparatus designed to maintain permanent extension and counterextension. In some 
cases the limb is placed in the semiflexed position, over a double inclined plane, but this 
w ill seldom be necessary or proper, except, perhaps, in fracture of the upper part of the 
body of the thigh-bone, attended with great and obstinate displacement of the superior 
fragment, in consequence of the joint action of the psoas and iliac muscles. In transverse 
fracture of the patella, the thigh and leg are sometimes placed over a single inclined plane, 
the foot being considerably elevated above the level of the trunk. 
The treatment of fractures of the lower extremities is now very generally conducted in 
this country by extension with adhesive strips, weight and pulley, inasmuch as it is not 
only very simple but very effective. The limb is supported by appropriate splints, long 
and short, by the immovable bandage, or by sand-bags, as necessity or convenience may 
dictate. A short, narrow piece of wood is placed between the adhesive strips below the 
sole of the foot for the attachment of the cord connected with the pulley. The weight, 
composed of shot, iron, or other material, varies, on an average, from five to fifteen pounds, 
according to the age of the patient, the obliquity of the fracture, and the amount of mus- 
cular resistance. The necessary counterextension may readily be made by raising the 
foot of the bedstead. In paralysis of the limb but little weight will be required, and in 
no event should it be so great as to cause uneasiness or suffering. 
When adhesive strips and the immovable apparatus are used, it will save the patient 
much suffering and the surgeon great trouble if the limb be well shaved previously to their 
application. Indeed, it is hardly possible to pay too much attention to every little detail 
tending to promote comfort and speedy recovery. 
A fracture occurring in an ankylosed limb requires no special treatment beyond the 
adaptation of peculiar splints, to meet the exigencies of the particular case. A similar 
remark applies to fracture of the bones of the stump of an amputated limb, and to frac- 
ture of a limb which is the seat of an old, unreduced, or irreducible dislocation. 
After-treatment The fracture having been reduced and dressed, the patient is carefully 
watched, in order that he may be safely conducted through his long and arduous confine- 
ment. His diet for the first few days should be light and cooling, and the bow’els should 
not be disturbed for the better part of a week, unless it is absolutely necessary, in which 
event some mild aperient, as a dose of castor oil, Rochelle salt, or citrate of magnesium, may 
be administered. If fever supervene, antimonial and saline preparations are to be freely 
used, aided, if the symptoms are urgent, and the patient is plethoric, by venesection, and 
aconite or veratrum viride, although general bleeding will rarely be called for. Action 
having subsided, the patient gradually resumes his accustomed diet, being still careful, 
however, to err rather on the side of abstinence than on that of excess. Pain is relieved 
by anodynes ; the bladder, if necessary, by the catheter. 
During all this time the fractured limb is carefully watched, the patient being visited 
for a while at least once a day, or, if the case is at all troublesome, even twice a day, 
until all danger of mischief is over. If considerable pain and swelling exist, it will be 
well to remove the dressings at the expiration of the first twenty-four hours, otherwise 
they may be retained for a longer time. While I am an advocate for the careful super- 
vision of the dressings, I am opposed to frequent change, as it tends to injure the ends of 
the broken bone, and to impede the reparative process. If the first dressings have been 
applied lightly, as they always should be, and the parts are well seen to afterwards, it is 
hardly possible for the patient to do badly. The great danger, in nearly all cases, so far 
as the safety of the limb is concerned, is during the first week ; that passed, there is seldom 
any risk. 
In most fractures of the long bones there is more or less spasm, jerking, or twitching of 
the limb, coming on within the first ten or twelve hours after the accident, much to the 
discomfort both of the part and system. This is owing partly to the pressure and irrita- 
tion produced by the ends of the fragments, partly to the inflammation of the muscles, 
and is, in general, easily remedied by the rectification of the displacement, aided by warm 
applications and a full anodyne, either alone or in union with camphor and tartar emetic. 
Relief often follows in a peculiarly happy manner the hypodermic introduction of morphia. 
The worst forms of this complaint are met with in nervous, irritable persons, in whom it occasionally persists with great obstinacy, despite our remedies, for a number of days, 
much to the annoyance of all concerned. 
In fractures of the thigh and leg, especially the latter, the limb must be carefully pro- 
tected from the pressure of the bedclothes, by means of a con- 
trivance, such as that exhibited in tig. 42G. It consists of two 
pieces of wood connected by several semicircles of hoop, or 
wire, attached by a longitudinal piece. 
In fracture of the superior extremity, the patient is often 
able to walk about immediately after the accident, taking out- 
door exercise, and, perhaps, even attending to business. But 
it is very different when he has a broken leg or thigh. Here, 
as a general rule, he is obliged to remain recumbent, often for a 
most unreasonable time, until, it may be, he is bedridden, and 
worn out with suffering. This is wrong. Such a case demands an immediate change of 
treatment. The starched bandage is substituted for the previous dressings, and the patient 
is sent out into the open air upon crutches. Prompt amendment follows ; the general 
health rapidly improves, and the process of repair, having received a new impulse, steadily 
advances to completion. 
As fractures are constantly liable to be followed by weakness and stiffness of the limb, 
the rule is to move the joint nearest the injury as soon as the union is sufficiently ad- 
vanced to preclude the possibility of displacing the fragments or interrupting the consoli- 
dating process. This constitutes what is called passive motion, a most important element 
in the management of this class of lesions. It should not be commenced, as a general 
rule, before the end of the third week, after which it should be repeated once a day, or every 
other day, according to circumstances; it should be very gentle at first, and be gradually 
increased until the limb has completely regained its normal functions. During its per- 
formance the parts are properly supported by assistants, and the dressings are reapplied the 
moment it is over. The restoration of lost function will be greatly promoted by frequent 
ablutions with warm water and soap, followed by systematic massage and frictions with 
some sorbefacient lotion, as spirit of camphor, soap liniment, or weak solutions of iodine. 
As soon as the callus has acquired sufficient firmness to sustain the ends of the broken 
bone, the splints and bandages are either discontinued, or applied more loosely, the object 
now being merely to keep the parts at rest until the union is perfectly consolidated. In 
fractures of the inferior extremity, some days should usually elapse before the patient is 
allowed to rise, and no weight should be thrown upon the affected limb under a fortnight 
or three weeks; the new bone is still weak, no definitive callus has yet formed, and the 
individual, awkward from long disuse of his joints, is liable to fall from the slightest acci- 
dent. These precautions are so extremely important that they should always receive the 
most scrupulous attention. 
Immovable Dressing—The treatment of fractures by the immovable dressing is now 
almost universally employed in this and other countries, either alone or in union with 
other means. The plan is applicable to fractures not only of the extremities but also to 
those of the trunk, especially of the clavicle, scapula, ribs, and pelvis, and, if properly 
carried out, is a time-saving expedient, at the same time that it adds greatly to the 
patient’s comfort and the ultimate success of the treatment. To Seutin, of Brussels, Vel- 
peau, of Paris, and I)r. Van Buren, of New York, the profession is mainly indebted 
for the introduction of this valuable method of treatment. It is not, of course, applic- 
able to all cases; but if proper care and judgment be exercised in their selection, there 
are few in which, in some stage or other of their progress, it may not be advantageously 
employed. There are many excellent surgeons, prominently among them Yandell 
and Cowling, of Kentucky, Erichsen and Croft, of England, and Von Langenbeck, o 
Germany, who are in the habit of applying this dressing, as a rule, immediately after the 
occurrence of the fracture, whether simple or complicated, and such a treatment has cer- 
tainly its advantages, especially in hospital practice. But is it equally safe in private 
practice? In public institutions, where the surgeon is an autocrat in his wards, where 
lie has complete control over his patients, and where the resident physicians and nurses 
exercise a constant surveillance, there can be no objection to such a procedure; tor, i 
anything untoward arises, immediate relief is at hand. But it is widely different in pri- 
vate practice, especially when the patient and the professional attendant are at a consid- 
erable distance from each other ; if, in such cases, the dressing is too tight, or improperly 
applied, great suffering, violent inflammation, or even gangrene may occur, before it can 
be removed and the evil remedied. For these reasons, I am myself averse to the early 
DISEASES AND INJURIES OF THE BONES. 
CHAP. VIII. 
Fig. 426. 
Wire Rack for Fracture of the 
Leg. CHAP. VIII. 
SIMPLE FRACTURES. 
913 
use of the immovable apparatus, convinced that, as a rule, the safest plan is to wait until 
the resulting inflammation and swelling, of which, even in the more simple cases, there 
must generally be more or less, has completely subsided. From five to ten days, according 
to the amount of injury, should, on an average, in my opinion, be allowed to pass before 
a fractured extremity is put up in such a dressing; employed earlier, it may induce undue 
compression, and thus compel removal. I would, then, have an eye to time and circum- 
stances ; avoiding premature interference, on the one hand, and too long delay, on the other. 
The immovable dressing may be prepared with various substances, all of them pos- 
sessing more or less, although not equal, merit. Cowper, an old English surgeon, employed 
compresses and bandages, saturated with a mixture of the albumen of eggs and wheat 
flour, which was replaced by Lawrence by powdered chalk. Seutin was the first to 
recommend starch; Velpeau used dextrine; Smee prefers gum arabic and whiting; 
gum shellac and glue have their advocates ; the plaster of Paris dressing has been justly 
lauded, and of late much has been said in commendation of paraffin, silicate of sodium, and 
silicate of potassium. All these various articles possess the advantage of cheapness, and 
of being easily prepared, applied, and removed, as well as being always easily procurable. 
Of all these substances, the most valuable and reliable are plaster of Paris, silicate of 
sodium or potassium, and paraffin. The starch bandage has become obsolete; and dex- 
trine is seldom, if ever, employed by the surgeons of this country. 
Plaster of Paris was originally recommended as a scientific dressing in the treatment 
of fractures by Professor Kluge, of Berlin, in 1829, although it had been previously 
used for a similar purpose by Hendrikes, of Groningen. The bandage is prepared by 
rubbing the dry plaster, of the finest quality, and frerhly calcined, thoroughly into the 
meshes of a thick, coarse muslin or crinoline roller, which, if not required for immediate 
use, is loosely wound, and kept in a dry place until needed, when it is soaked for a few 
minutes in cold water. The limb, carefully enveloped in flannel, wadding, or old linen, 
is surrounded with the bandage in the usual manner, from three to four layers generally 
sufficing for the purpose. If, when the application is completed, the dressing is not firm 
enough, a mixture of plaster and cold water, of cream-like consistence, may be rubbed on 
with the fingers until the surface presents a smoothly polished appearance. Care, how- 
ever, must be taken not to apply it too freely, otherwise it will make the dressing too 
brittle for comfort and usefulness. No splints need be employed, as any additional sup- 
port that may be required may readily be supplied by folded cloths, saturated with the 
plaster, and stretched along the limb. It should be remembered that a solution of salt in 
warm water promotes the setting of the plaster, while the addition of a small quantity of 
glue or stale beer retards it. The great advantages of this dressing are, the rapidity with 
which it dries and adapts itself to the 
parts, and the fact that it forms an un- 
usually firm, hard casing, which per- 
mits the limb to be handled and 
moved with great ease during any 
transportation that may be necessary 
to place the patient in more suitable 
quarters. A layer of varnish, applied 
the day after the dressing, will pre- 
vent the plaster from chipping. 
It is very important that the plas- 
ter, in preparing the bandage, should 
be rubbed as thoroughly and equably 
as possible into its meshes. This can 
seldom be done with the hand. To 
meet this contingency, Dr. Marcy, of 
Boston, has devised an apparatus, rep- 
resented in fig. 427, which distributes 
the powder uniformly upon both sides 
of the cloth by drawing it from below 
upwards through the dry plaster. 
The Bavarian dressing for frac- 
tures, so extensively used during the 
Franco-German war, is an easy and 
effectual mode of applying plaster 
of Paris. When employed for frac- 
Fig. 427. 
Marcy’s Plaster Bandage Roller, a, the part of the apparatus 
secured to the table c; b, the slide, which, when pushed down, 
holds the plaster on both sides of the bandage d, which is rolled 
np at e. 914 
DISEASES AND INJURIES OF THE BONES. 
ttires of the leg, two pieces of flannel, long enough to extend from the ham nearly 
to the toes, are stitched together behind, so that the seam shall correspond to the 
middle line as far as the heel, beyond which both layers are divided in the same line for 
adaptation to the foot. The sides of the layer next the skin are firmly sewed together in 
front of the limb and along the sole and instep, when the plaster is thickly spread over 
the entire casing, and covered by the outer layer of flannel, the flaps of which are then 
secured with stitches in front. When the plaster is set, the stitches are cut, the super- 
fluous edges of the splint are trimmed off, 
and the apparatus is secured by a band- 
age or by tapes passed through eyelets. 
The seam behind serves as a hinge, 
through which the dressing may be re- 
moved and readjusted with the utmost 
facility. In fig. 428, from Bryant, the 
limb is seen to be supported by a band- 
age carried through the superfluous 
edges of the flannel, for greater conve- 
nience of application. 
The silicate of sodium or potassium in 
,, . saturated solution, applied with a stout 
brush, constitutes what is called the glass dressing, as it forms, when well rubbed into the 
meshes of a wet roller, a firm, immovable apparatus, in no wise inferior to that of plaster of 
Paris. Indeed, in certain situations, as in fractures of the clavicle, scapula, and ribs, it 
deserves a decided preference. The glass dressing dries very rapidly, does not irritate the 
skin, is easily procured, and is, withal, very cheap. The under dressing is the same as in 
the plaster dressing. From three to five layers of bandage are, on an average, necessary to 
impart the requisite amount of stiffness ; and occasionally the surgeon is compelled to 
interpose a binder’s board, or some other thin substance, to afford additional support. 
An excellent fracture dressing may be made of paraffin. After being thoroughly 
melted, this substance is partially cooled, to render it more viscid, when it is rubbed 
freely into the meshes of the bandage with a coarse paint-brush, forming thus a very 
neat, light dressing, perfectly impermeable to water, pus, and other fluids, and, therefore, 
admirably adapted to the treatment of compound fractures, and also to simple fractures in 
young children, in whom the ordinary contrivances soon become soiled with the natural 
excretions. 
The glue dressing, also a very excellent one, is prepared by rubbing into the bandage 
warm glue, diluted immediately before it is used with a fifth part of its bulk of alcohol or 
a small quantity of oxide of zinc, to promote desiccation. The mixture, applied in the 
usual manner, soon begins to harden, although it does not become perfectly dry under 
several hours. From two to four layers of bandage, with one of wadding next to the 
limb, usually suffice. If additional strength be required, fresh strips of linen may be 
glued on without changing the original dressing, which generally retains its place until 
the fracture is consolidated. 
The apparatus of Smee, known as the moulding tablet, forms a very good dressing, 
nowise inferior to the stiff bandage, and but little, if any, more expensive. It consists of 
two layers of coarse, old sheeting, cemented together by means of a thick paste made by 
rubbing very finely powdered whiting with mucilage of gum arabic. The sheeting soon 
dries, without shrinking, into a hard, firm substance, which, with the aid of a sponge and 
hot water, may afterwards be accurately moulded to the fractured limb, and worn with 
great comfort and efficiency. 
Tripolith was suggested, in 1880, by Von Langenbeck, as a substitute for plaster of 
Paris in the treatment of fractures, on the ground of its making a lighter dressing, and 
one that would dry more rapidly, from three to five minutes generally sufficing to render 
it perfectly solid. It has been asserted that it does not readily absorb moisture, and that 
it undergoes no change from contact with water; a statement which, however, is not 
strictly correct. Dr. Samuel N. Nelson, of Boston, who has made some trials with it, 
considers it utterly untrustworthy. The dressing is prepared and used in the same man- 
ner as the plaster dressing. Tripolith consists mainly of calcium and silicium with a 
small quantity of protoxide of iron. 
The egg paste, as it is termed, makes, if properly used, a very firm dressing, admirably 
adapted to cases requiring the immovable apparatus. It is prepared by mixing the white 
of eggs with a sufficient quantity of flour, until it assumes the consistence of a thick solu- 
C II A P. VIII. 
Fig. 428. 
Bavarian Splint, a, first layer of fiannel applied to the 
limb ; 6, second layer about to be applied. CHAP. VIII. 
SIMPLE FRACTURES. 
915 
tion of gum arabic, when it is rubbed into the meshes of the roller previously wrung out 
of water. When dry, the bandage forms a firm, hard case. 
Whatever immovable dressing be used, it is indispensably necessary to keep up exten- 
sion and counterextension by assistants, or other suitable means, until the apparatus is 
sufficiently solidified to prevent displacement of the fragments. In some cases, as when 
there is inordinate tendency to displacement, the extension and counterextension may be 
obliged to be continued for a considerable length of time, if, indeed, not permanently, or 
until the process of reunion is completed. 
When the dressing, of whatever material it is composed, is perfectly dry, it forms an 
immovable case for the limb, making equable and uniform pressure throughout, and 
maintaining the fragments of the broken 
bone accurately in apposition. If the parts 
feel entirely comfortable, the patient may 
now sit up in bed or on a chair, or he may 
even walk about on crutches, the leg being 
properly supported in a sling. Generally, 
however, it will be found that there is for 
a day or two a sense of soreness, with, 
perhaps, some degree of throbbing, invit- 
ing recumbency rather than the erect post- 
ure. If the apparatus causes marked discomfort, by bearing unequally upon any portion 
of the limb, or if throbbing and swelling arise, it must immediately be removed. For 
this purpose it should be slit up with Seutin’s scissors, represented in fig. 429, or with 
a shoemaker’s knife, or a Hey’s saw, the tract to be cut in the dressing being pre- 
viously softened with hot w’ater applied with a sponge. The limb being properly supported 
by an assistant, the hardened shell is gently peeled off' from its surface, which is then 
carefully sponged with alcohol and laudanum, or spirit of camphor, when the apparatus 
Fig. 429. 
Seutin’s Scissors. 
Fig. 430. 
Fig. 431. 
Fracture of the Thigh, done up in Immovable Dressing. 
Dressing in Compound Fracture of the Leg. 
is immediately reapplied with the aid of a roller; or, instead of this, eyelet holes may be 
inserted, at suitable distances, in the border of the dressing, and retention effected with 
pieces of narrow tape. Thus, by simply opening the dressing from time to time, an 
opportunity is afforded of inspecting the limb, and ascertaining its precise condition, not 
only at the seat of fracture, but everywhere else. When the patient is able to move about 916 
DISEASES AND INJURIES OF THE BONES. 
on crutches, the limb should be carefully supported in a sling, arranged in the manner re- 
presented in fig. 430. 
When the fracture is seated high up in a limb, the apparatus should extend a short 
distance above it, as it is a matter of great moment to keep the joint in as passive a 
condition as possible. In compound fracture, attended with discharge, a hole should be 
cut in the apparatus opposite the wound, so as to admit of the necessary drainage, as 
shown in fig. 431. 
Great care should be taken that the edges of the splints do not produce any injurious 
compression ; to obviate this, it is usually recommended that they should be torn instead 
of being cut, it being alleged that, when thus treated, they will be much less likely to 
create mischief. My experience, however, is that this is not the fact, and I, therefore, 
invariably bevel the inner edges with a stout knife, thereby effectually preventing all risk 
of this kind. 
It is impossible, also, to bestow too much attention upon the bandage ; the care or negli- 
gence with which this is applied will make all the difference in the result, both as it 
respects the patient’s comfort and the character of the cure. 
Shortening of the Limbs after Fractures I think I am not wrong when I assert that 
more or less shortening of the limb in fractures of the lower extremity is almost universal, 
no matter how carefully, or in what manner, the treatment may be conducted. This re- 
mark, however, applies solely to oblique fractures, and has no relevancy whatever to 
transverse fractures which, as a rule, if not in every case, if properly managed, ought to get 
well without any deformity whatever of this kind. The amount of shortening will vary, 
of course, with the particular circumstances of each case, as the degree of obliquity of the 
fracture, the nature of the treatment, and, above all, the cooperation of the patient, on 
an average from the eighth of an inch to half an inch. In many cases it will necessarily 
exceed half an inch, and it may even reach twice that extent without in the slightest 
degree impairing the usefulness of the affected limb, unless it should naturally be con- 
siderably shorter than the sound one. In exceptional cases there may be an entire 
absence of shortening ; and it should be borne in mind that in hospital practice, where 
the patient is always more fully under the control of the surgeon, and where the means 
and appliances for treatment are better adapted to the object, there is less excuse for the 
occurrence of shortening and deformity than in private practice, where the reverse is so 
often the case. The treatment of fractures of the humerus, however carefully conducted, 
is very liable to be followed by more or less shortening; in fractures of the shafts of the 
bones of the forearm shortening is uncommon. 
Shortening in fractures of the bones of the lower extremity is often due to the pre- 
mature removal of the extending apparatus and to the too early use of the limb. The 
weight of the body being thus thrown upon the broken bone, before the callus is suffi- 
ciently hardened, forces the ends of the fragments apart, and thereby occasions not only 
shortening but more or less lateral deformity ; in fact, the connecting material may, in 
this way, even be completely destroyed. 
The subject of the symmetry in the length of the extremities, upper as well as lower, is 
one that intimately connects itself with the present inquiry, and is of great interest not only 
in its practical bearings but also in a medico-legal point of view, as cases attended with 
marked shortening of the limb after the cure of fractures are not unfrequently carried into 
court for the recovery of damages, on the ground of alleged malpractice. Fortunately, 
thanks to the labors of a number of recent zealous investigators, this matter is now fully 
settled, and while I cannot agree with some of them, as for example, Dr. William Hunt, of 
this city, who has greatly interested himself in the study of this subject, and thrown valuable 
light upon it, that asymmetry of the limbs exists as a rule, I am prepared to affirm that 
it is present in very many, if not indeed, in a majority, of cases. The attempts to solve this 
question were begun at the Pennsylvania Hospital, in 1875, at the instance of Dr. Thomas 
G. Morton, by Dr. William C. Cox, one of the resident physicians, wrho found, in 54 
cases, the right lower limb the longer in 23, and the left in 25, 0 presenting no difference. 
In the 48 cases the variations ranged from £ to £ of an inch. It is proper to observe that 
these observations w’ere made with a tape extended from the anterior superior spinous 
process of the ilium to the internal malleolus, wdiile the subject lay flat upon his back, 
upon a hard surface. Similar results w'ere obtained two years later by Dr. J. S. Wright, 
of Brooklyn. Finally, in 1879, as if to remove all doubt upon the subject, Dr. Morton, 
in an examination of 513 boys from eight to eighteen years of age, found inequality 
in the lower limbs in 272, while in 241 there was no appreciable difference. In 91 the 
difference was £ of an inch ; in 100, ; in 41, § ; in 22, in 12, $ ; in 2, in 2, l£ ; 
CHAP. vm. CHAP. VIII. 
COMPLICATED FRACTURES. 
917 
and in 1, 1§. Of the 272 cases of inequality the right limb was the longer in 198, and 
the left in 74. 
These measurements tally well with similar ones made on the skeleton. Thus, in eight 
examinations made by Dr. John B. Roberts, of this city, the difference in the length of 
the lower extremities ranged from one-eight to three-eighths of an inch ; the tape being 
extended from the top of the femur to the internal malleolus. Dr. J. G. Garson, in 1879, 
examined the thigh-bone and tibia of 70 skeletons of various ages and races in the 
museum of the Royal College of Surgeons of London, in only twenty per cent, of which 
the extremities were of equal length. The left leg was the longer in 38 cases, and the 
right in 2.5. The left femur in 40 cases, and the right in 20. It is worthy of note that 
in advanced life, and especially in persons who have suffered severely from chronic 
arthritic disease of the hip-joint, there is often, as all anatomists and surgeons know, 
great diminution in the length of the thigh-bone, from interstitial absorption of its head 
and neck, attended with great alteration in their form and direction. In this manner, 
shortening, often amounting to upwards of an inch, may readily be induced, as I know 
from the inspection of numerous specimens, and as I have long taught in my lectures. 
Various contrivances for accurately determining any irregularities that may exist in the 
length of the lower extremities in health and after injuries have been devised by different 
surgeons, among others by Dr. T. G. Morton, and Dr. B. E. Gibbs, the former of whose 
paper on the subject, accompanied by a graphic illustration, may be found in the American 
Journal of the Medical Sciences for January, 1877. 
3. COMPLICATED FKACTURES. 
The only class of fractures, besides the simple, which deserves to be considered under 
a distinct head, is the complicated, as it is easy to comprise under this denomination every 
form of accident that can possibly arise either at the moment of the injury, or during 
the progress of the treatment. The most important topics requiring attention are wounds, 
hemorrhage, dislocation, comminution of bone, excessive laceration of the soft parts, 
erysipelas, pyemia, and, lastly, tetanus. 
Complicated fractures may be oblique, transverse, or longitudinal, the frequency of their 
occurrence being in the order here enumerated. They are always caused by mechanical 
violence, as gunshot, falls from a great height, severe blows, or the passage of the wheel 
of a carriage, wagon, or railway car. Complicated fractures from the latter cause are very 
common, and are a frequent source of loss of limb and life. 
The symptoms of this variety of fracture are, like those of simple fracture, sometimes 
extremely obscure, requiring great care and skill on the part of the surgeon to determine 
their character. In general, however, they are sufficiently well marked to enable him to 
distinguish them from such as attend other accidents, especially if the parts can be 
thoroughly examined before the supervention of much swelling. There are usually 
greater pain and shock than in an ordinary fracture, the resulting inflammation is more 
severe, and there is greater risk of violent secondary effects, as erysipelas, gangrene, 
copious suppuration, necrosis, caries, prostration, hectic irritation, and tetanus. In 
fact, complicated fractures are among the most serious occurrences that are met with in 
practice, being alike perplexing to the surgeon and dangerous to the patient; demanding 
the nicest judgment and skill for their successful management, and entailing, not unfre- 
quently, the greatest possible suffering, horrible deformity, and loss of limb, if not also 
of life. It may be stated, as a general rule, that complicated fractures of the lower 
extremity are more dangerous and difficult of management, as well as more liable to be 
followed by distortion and permanent lameness, than those of the superior. 
The process of repair in complicated fracture proceeds on the same principle as in the 
simple form of the lesion, only that it is usually more tedious, and that it is attended 
witli a larger quantity of callus. When there is a wound in the soft parts, the union is 
generally effected through the medium of granulations, which, arising from the medulla 
of the Haversian canals and the central canal, are directly converted into osseous tissue, 
and thus form the connecting link between them. 
The treatment of this form of fracture varies according to the circumstances of the case, 
or the nature and severity of the complication. When the case is associated with a 
wound in the soft parts, constituting what is called a compound fracture, as in fig. 432, 
and the limb is deemed capable of preservation, the first and most important consideration 
is the reduction of the fracture. This may generally be done by putting the limb in the 
most favorable position for relaxing its muscles, and by well-directed and gentle efforts at 918 
DISEASES AND INJURIES OF THE BONES. 
CUAP. VIII. 
extension and counterextension, along with proper manipulation, especially if the fracture 
is transverse, and the opening large; but if it is oblique, and there is a projection of one 
or both ends of the fragments, they occasionally fail, and compel us to resort to other 
measures. Under such circumstances, the soft parts which gird or bind the bone, 
and prevent it from yielding, should be carefully divided, when a renewed attempt at 
Fig. 432. 
Fracture of the Leg complicated with Wound and Comminution of the Bone. 
reduction will probably be successful. Should every reasonable effort of the kind, how- 
ever, prove fruitless, then, instead of leaving the bone in its exposed situation, where it 
would be sure to die, the proper plan would be to cut away a portion of it, especially if it 
terminate in a very long and narrow point, care being taken to retain as much as possible 
of the periosteum. 
Whatever may be the character of the wound, its edges should be carefully approxi- 
mated by suture and plaster, aided by collodion to exclude the air ; or, instead of this, 
the wound may be covered with a light compress wet with carbolized oil, and supported 
by a bandage. In this way, a compound fracture may occasionally be speedily converted 
into a simple one, union sometimes occurring in a few days. To facilitate cleanliness 
and the application of the dressings a bracketed splint must be used, one of the best of 
which is that of Dr. Packard, described in a future page. 
Mr. Lister, in compound fractures, always injects the wound very thoroughly, as 
a preliminary measure, with a solution of carbolic acid, in the proportion of one part 
to twenty of water, the object being the prevention of suppuration by destroying the germs 
which, he alleges, constantly float about in the air, and which, if permitted to enter the 
wound, invariably interfere more or less with the reparative process. After the wound 
has been well cleaned and all fluid removed, the edges are adjusted in the usual manner, 
the surface is covered with a piece of protective antiseptic gauze, and the part is sur- 
rounded with lac plaster. The subsequent management is conducted upon general princi- 
ples, the dressing being renewed as often as may be necessary, on account of the discharges, 
under a spray of a weak solution of carbolic acid continually playing upon the part, to 
prevent the ingress of air and of germs. 
Whether carbolic acid, apart from the other means, recommended by Mr. Lister, is 
really of any benefit in the treatment of these injuries is still a mooted question. The 
rapidity with which wounds placed in the condition of subcutaneous wounds by the ex- 
clusion of the air heal, has long been familiar to surgeons. In India oil is extensively 
used for this purpose ; and I have myself for many years employed this substance as a 
favorite dressing in all wounds made with the knife, as well as in fresh accidental ones. Sir 
Astley Cooper was in the habit of treating all compound fractures and dislocations with 
pledgets wet with the patient’s blood, and confined by means of the bandage. Mr. 
Bennion, a Shropshire surgeon, enjoyed, as we are told by Mr. Adams, of London, great 
reputation for his successful treatment of compound fractures, accidents of frequent occur- 
rence in his district, based upon similar principles. Ilis method was, first, to effect 
thorough reduction of the ends of the fragments, even, if necessary, at the risk of great 
force; secondly, to clear away all effused blood ; thirdly, to approximate carefully the 
edges of the wound ; fourthly to cover the parts with a large pledget of lint, saturated 
with compound tincture of benzoin ; fifthly, to bandage the entire limb, and support it 
with a well-fitting splint; sixthly, to pqt the patient at once under the influence of opium, 
maintained for a considerable length of time; and, lastly, to retain the dressings so long CHAP. VIII. 
COMPLICATED FRACTURES. 
919 
as they did not cause any serious disturbance, evidently on the principle that meddlesome 
surgery is bad surgery. 
A modification of the Lister treatment was introduced a few years ago into the New 
York Hospital by Professor Markoe, and has given most flattering results, only one 
death having occurred in nearly two hundred cases. The method consists in passing a 
large drainage-tube through a counter opening at the seat of the injury, in putting up the 
limb in plaster dressing provided with suitable fenestra, and in injecting a stream of 
carbolized water through the drainage-tube, at first every two hours and afterwards regu- 
larly three times a day until a cure is effected. No change of dressing is required ; the 
thermometer rarely rises above 102° Fahr.; and the danger of erysipelas and pyemia is 
vastly lessened. 
The opium treatment in these accidents cannot be too strongly commended. Much ot 
the mischief caused by them is doubtless due to the neglect of its employment. Given in 
liberal doses, opium not only allays pain but prevents spasm and tranquillizes the system, 
all important elements of treatment in such cases. The wound should be most thoroughly 
closed by suture, proper provision being made for drainage, especially if the parts be much 
bruised or lacerated ; and covered with lint wet with blood, benzoin, collodion, or Richard- 
son’s styptic colloid, supported by an oiled compress and a roller, extending from the 
distal portion of the limb. 
The hemorrhage in complicated fracture may be open or concealed, according as there 
is a wound or no wound ; arterial or venous ; insignificant or copious. In the first case, the 
bleeding will manifest itself in the usual manner, and is to be arrested by ligature, acupres- 
sure, or compression ; in the second, it will be indicated, if it is at all considerable, by 
unusual swelling, attended with a sense of fluctuation or unusual softness, and by more or 
less discoloration of the integument. If the principal artery of a limb has been severed, 
there will be an absence of pulsation in the parts below, with coldness of the surface. 
When no doubt remains concerning the diagnosis in such a case, the main trunk of the 
vessel is exposed some distance above the seat of fracture, and ligated; or, if this be 
deemed improper, an incision is made through the bloody tumor, and, its contents being 
turned out, the divided artery is sought and secured above and below the seat of injury. 
This, in fact, is usually the preferable procedure, especially as there must frequently be 
considerable uncertainty whether the effusion is arterial or venous ; a circumstance which, 
perhaps, thus leads to the performance of a most serious operation in a case where one of 
a most simple character might suffice. 
The formation of a distinct aneurismal tumor is very uncommon in injuries of this kind. 
The occurrence is denoted by pulsation, by thrill, and by a sawing, rasping, or purring 
noise, by circumscribed enlargement, and by the other usual concomitants. If the disease 
do not disappear spontaneously, as occasionally it does, an attempt must be made to effect 
a cure by compression, either digital or mechanical; or, if this fail, by ligation of the 
affected artery. 
When a fracture is attended with a dislocation, the case necessarily assumes a very 
serious character, as it may give rise, especially if the joint involved is a large one, or the 
bone greatly shattered, to the question of primary amputation. In such an event the most 
experienced surgeon will often find it difficult to come to a prompt and correct decision. 
The principal circumstances which should induce him to make an attempt to save the 
limb are, the integrity of the patient’s health at the time of the injury, together with a 
knowledge of his previous habits, and the simplicity of the dislocation, or the almost total 
absence of complication, as it respects the affected joint. If, on the other hand, the dis- 
location is compound, and the bone is badly broken, at the same time, perhaps, that it 
protrudes at the articulation ; if all these injuries exist; or if, along with them, serious 
mischief has been inflicted upon the soft parts, as a violent contusion of the skin and 
muscles, or the laceration of important vessels or nerves, no doubt should be entertained 
respecting the propriety of the operation, and the sooner it is performed after the occur- 
rence of reaction the better it will be for all parties concerned. I believe that a compound 
fracture, extending into a large joint, as the knee or ankle, and attended with extensive 
rupture of the ligaments, muscles, and other structures, should always, as a general rule, 
be treated in this way. It is true, a case, apparently of the most desperate character 
occasionally recovers, but such a consideration should not have too much weight, or 
induce us to neglect a measure which is sanctioned not less by reason than by experience. 
When the case is such as not to demand amputation, the dislocation should be reduced 
before an attempt is made to adjust the fracture. For this purpose the limb at the seat of 
the injury should be rendered as firm and immovable as possible by splints and bandages, 920 
DISEASES AND INJURIES OF THE BONES. 
and the efforts persisted in until the object is attained. To wait until the broken bone 
has become sufficiently consolidated to enable it to bear the requisite manipulation would 
be sheer folly ; one of two things would almost inevitably happen in such a case, either a 
reproduction of the fracture, or an utter failure to replace the luxated bone. 
The most common causes of comminuted fracture are, gunshot violence, railway acci- 
dents, falls from a great height, and the passage of the wheel of a carriage. If the bone 
is splintered and any of the pieces are completely detached, or so loose as to render their 
reunion improbable, they must be carefully removed, the edges of the wound being after- 
wards gently approximated, and kept in position by sutures and adhesive strips, covered 
with collodion. The limb, surrounded by the bandage of Scultetus, and supported by appro- 
priate apparatus, is placed in an easy position, and care is taken to moderate inflammation 
by the usual antiphlogistic means. If the wound suppurate, the best application will be 
an emollient poultice or the warm water-dressing, with as little disturbance as possible to 
the injured bone. 
The so-called simple fracture, that is, a fracture without wound, is sometimes attended 
with a shattered and comminuted condition of the bones, imperilling limb and life, and 
imperatively demanding amputation. When there are only three or four fragments, and 
they admit of accuiate adjustment, such an operation is of course not to be thought of, 
ordinary measures generally sufficing for a good cure. 
A simple fracture becomes occasionally a complicated fracture from the manner in which 
the ends of the fragments pierce the muscles, thereby, although the fracture may be 
strictly subcutaneous, rendering it impossible to restore them to their proper relations. In 
such a case the only thing to be done, after failure of the ordinary means, is to cut through 
the skin and liberate the fragments with the bistoury, a procedure not likely to alter 
materially the risk of the case. 
A fracture complicated with impaction of the ends of the fragments is occasionally a 
source of great annoyance to the surgeon. The most common sites of such a fracture are 
the head of the humerus, the lower extremity of the radius, and the neck of the femur. 
In most cases it will be good practice not to disturb the parts, but let them unite in their 
new position, as their separation is liable to be followed by want of union and other bad 
consequences. 
When the fracture is complicated with violent contusion of the soft structures, the 
retentive apparatus should be applied rather slackly, and the parts kept constantly wet 
with cold water, or, what is better, a strong solution of acetate of lead and opium. If the 
inflammation run high, and the patient is strong and vigorous, bleeding, purgatives, and 
antirnonial preparations may become necessary. The limb is carefully watched, in order 
that prompt advantage may be taken of any changes that may arise. 
In gunshot fractures of the bones of the lower extremities attended with great displace- 
ment, Dr. Benjamin Howard, of New York, has on several occasions cut down upon the 
bone, and connected the ends of the fragments with silver wire. IIow far such a pro- 
cedure may be judicious or proper, future experience alone can determine. When the 
tendency to displacement is very great, or cannot be controlled by the ordinary measures, 
I should think well of it; but few such cases will be likely to occur under the present 
improved system of treatment. 
In consequence of injury sustained by the skin, either at the time of the accident, or 
from the pressure of the bandage, the cuticle is sometimes raised into little resides, tilled 
with a thin, limpid, reddish, or yellow fluid. Such an occurrence always awakens anxiety 
both in the patient and practitioner, especially if he is young and inexperienced, as it is 
apt to be associated with the idea of gangrene. From this, however, it may always be 
easily distinguished by the absence of lividity, severe pain, and other symptoms of excessive 
action. The proper treatment consists in puncturing the vesicles with a fine needle, and 
dusting the surface with powdered zinc, unless the part is hot and inflamed, when water- 
dressing, simple or medicated, should be used. 
If the principal artery, vein, or nerve of a limb has been destroyed, at the same time 
that there is extensive laceration of the soft parts around, the case will probably require 
amputation, especially if there has been severe shock or extensive hemorrhage, with pre- 
vious derangement of the general health. Such a case is, at all events, a bad one, liable 
to be followed by loss of limb, if not also of life. If, on the other hand, the principal 
artery retains its integrity in the midst of the torn and broken structures, and the patient 
is young and vigorous, although he may have bled severely, we should by all means make 
an attempt to save the limb, having previously explained to the patient and his friends 
the risk which such an undertaking involves. Some of the most gratifying results that 
CHAP. VIII. COMPLICATED FRACTURES. 
921 
CHAP. VIII. 
reward the care and skill of the practitioner are cases of fracture complicated with exten- 
sive laceration of the soft structures and comminution of the bones. I have several times 
succeeded in effecting excellent cures when, the main artery being intact, the limb hung 
merely by a comparatively small quantity of skin and muscle, and when I was compelled 
to remove a number of pieces of bone, or even saw off' the ends of the fragments. 
A fracture complicated with ankylosis of a neighboring joint, or occurring in the bone3 
of a stump, must be managed upon the same principles as an ordinary fracture, the 
apparatus being modified to meet the peculiar contingencies of the case. A fracture occur- 
ring in a paralyzed limb generally unites in the ordinary time, provided care be taken not 
to make undue compression during the after-treatment, lest it interfere with the nutrition 
of the bone and the formation of callus. 
Accidents after Complicated Fractures.—The most common and important accidents 
after complicated fracture are spasm, erysipelas, oedema, abscess, gangrene, tetanus, 
pyemia, delirium, and congestion of the brain and lungs. 
Spasm of the rmiscles is sufficiently common after all fractures of the limbs, but is 
especially liable to occur after fractures complicated with severe luxation of the soft 
structures and injury to the nerves from the contact of the sharp ends of the fragments. 
It is generally most severe and troublesome during the first two or three days, and always 
requires the liberal use of anodynes for its relief. The best local remedy is hot water 
medicated with acetate of lead and laudanum. 
Erysipelas is very common after complicated fractures, and usually comes on within 
the first forty-eight hours after the receipt of the injury, manifesting itself in discoloration 
of the skin, more or less tumefaction and burning pain. The disease is most liable 
to appear in persons of intemperate habits, and in such as are dyspeptic, or enfeebled 
by previous suffering, and generally adds very much to the danger of the case, perhaps 
already sufficiently grave. Its extent and continuance will depend upon various circum- 
stances, which will readily suggest themselves to the mind of the reader. The treatment 
is conducted upon general principles, the main reliance being upon the correction of the 
secretions, and the support of the system by fresh air, quinine, iron, milk punch, nutritious 
food, and anodynes, with the topical application of dilute tincture of iodine. Scarifications 
and incisions are not omitted in the event of great tension, or tension and suppuration. 
The occurrence of cedema is sufficiently frequent in complicated fractures of old, dilapi- 
dated subjects, and is best remedied by the bandage, aided by spirituous lotions, tonics, 
and a nutritious diet. Punctures will seldom be necessary, and should always be employed 
with the greatest caution, as they are liable to be followed by bad sores ami even 
gangrene. 
Abscesses, diffuse, painful, and troublesome, may form at the seat of the fracture, or in 
its immediate vicinity. In either case, the matter should be speedily evacuated and 
thorough drainage established : otherwise it may not only cause extensive havoc among 
the soft parts, but caries and necrosis of the ends of the broken bone, with risk of pyemia 
and phlebitis. 
Gangrene may be produced by injudicious bandaging obstructing the circulation, ex- 
cessive inflammation, or injury of the main artery, vein, or nerve of the affected limb. 
The occurrence is most common in unhealthy subjects and in young persons after railway 
and other severe accidents, and often makes fatal progress before its presence is suspected 
by the patient or his attendant. Great pain in the part, of a smarting, pungent, or burn- 
ing character, accompanied by discoloration and tumefaction in the distal portion of the 
limb, should always excite alarm and lead to a thorough examination. Tight bandaging, 
in particular, should be avoided in complicated fractures, especially in the early stages of 
the treatment. 
Gangrene in complicated fractures is sometimes produced by excessive compression of 
the soft parts by extravasated blood, poured out in such quantity as to arrest the circula- 
tion in the principal vessels of the limb. Such an occurrence will be still more likely to 
take place when an important artery, vein, or nerve has been seriously wounded. The 
treatment must be by free incision and evacuation of the clotted blood, along with liga- 
tion of any wounded vessels above and below the seat of the injury. Amputation may 
be required if mortification has taken place. 
Mere embolism may possibly give rise to gangrene below the seat of fracture, the blood 
coagulating in the principal vessels from the effects of inflammation independently of any 
pressure by the ends of the fragments. Such an event would be most liable to occur in a 
comminuted fracture, attended with great contusion and laceration of the soft structures, 
partially devitalizing the blood. 922 
DISEASES AND INJURIES OF THE BONES. 
CHAP. VIII. 
Secondary hemorrhage is an occasional occurrence in accidents of this kind, caused 
either by injury of an artery at the time of the fracture, or by the pressure of a fragment 
of displaced bone, producing ulceration in the coats of the vessel. In a case observed by 
Pelletan, the pressure exerted by a displaced piece of bone upon the anterior tibial artery 
caused profuse hemorrhage upwards of two months after the receipt of the injury, neces- 
sitating amputation. The management of such an occurrence must be conducted upon 
ordinary principles. 
Necrosis of the ends of the fragments is not uncommon in compound fractures, espe- 
cially if they have been stripped of periosteum, or long exposed to the air. The 
occurrence is denoted by the whitish and denuded appearance of the hone, the unhealthy 
condition of the granulations in the soft parts around, and the thin, watery nature of the dis- 
charges. In effecting retrenchment of the dead bone, whether with the hand or pliers, 
the same care must be taken to guard against hemorrhage, shock, and contusion of the 
osseous tissue. I have known a very slight loss of blood to be promptly followed by exces- 
sive exhaustion, placing the patient’s life in jeopardy. 
Severe spasm frequently attends this class of injuries, but as this subject has already 
been discussed in connection with simple fractures, nothing further need here be said 
respecting it. 
Complicated fractures, especially if attended with loss of substance, are occasionally, 
followed by the formation of a false joint, despite the best directed efforts of the surgeon. 
When the loss of bony matter is considerable hardly anything else is to be expected. 
Chorea of a limb, whether existing previously to, or supervening after, the occurrence 
of the fracture, constitutes a very grave complication, seriously interfering with the suc- 
cess of the treatment. Chalybeate tonics, bromide of potassium, and anodynes, along 
with a properly regulated diet, afford the best chance of relief. In a case of fracture of 
the humerus, complicated with chorea, in charge of Dr. William Hunt, of this city, the 
patient died on the tenth day from the effects of the uncontrollable spasms of the limb. 
Pyemia, as an effect of complicated fractures, is uncommon, at least in private practice* 
except when the accident has been caused by railway injury, the bursting of a gun, the 
passage of the wheel of a wagon, or some similar violence. It is distinguished by its 
usual insidious character, and generally sets in from the fifth to the tenth day, its approaches 
being announced by violent rigors, alternating with flushes of heat, great depression of the 
system, delirium, and excessive restlessness. The structures which are most apt to suffer 
are the lungs, liver, spleen, joints, and connective tissue. The treatment is supportant 
and alterant; by quinine, iron, brandy, and nourishing broths, for the former; by the 
sulphites of sodium and potassium, in moderately large and properly sustained doses, for the 
latter. In general, such cases fare badly, death occurring within a week from the com- 
mencement of the attack, despite our best directed efforts. 
Tetanus, in complicated fractures, is most liable to supervene in nervous, irritable sub- 
jects, during hot weather, although it may take place at any season of the year, as well 
as in every description of individuals. It is an extremely formidable symptom, which 
should be promptly met by the removal of the affected parts, and by large quantities of 
anodyne and antispasmodic remedies. If occasionally a case is cured without amputation, 
it forms the exception, not the rule. In such an event, there is no time for delay; what- 
ever is done must be done quickly and effectively, at the very inception of the disease, 
before there is any decided evidence of stiffness in the muscles of the jaw. 
Traumatic delirium is sufficiently frequent after these accidents, especially in old intem- 
perate persons, and should be treated upon the principles laid down in a previous chapter, 
the most important remedies being bromide of potassium, chloral, aconite, and opium. 
Congestion of the lungs and other internal organs, as a consequence of these injuries, 
is most liable to occur in elderly persons, as a result of a determination of blood either 
from actual irritation or a sluggish condition of the vessels during protracted confinement. 
As such attacks are very liable to prove disastrous, everything should be done to prevent 
them, by getting the patient as speedily as possible out upon crutches into the open air. 
Fatty embolism of the lungs and other viscera, caused by oil globules introduced into their 
substance by the veins at the seat of the fracture taking up some of the crushed marrow, and 
carrying it to these organs, where it causes fatal obstruction, is an occasional occurrence 
after such a lesion. The possibility of such an occurrence was first enunciated in 1862 by 
Zenker and Wagner, but it remained for Busch and Czerny to establish the fact by actual 
dissection. In the case reported by Czerny, the patient, a stout, healthy man, thirty-two 
years old, had a simple fracture of the thigh-bone, which was followed soon after the acci- 
dent by symptoms of pulmonary obstruction, terminating in death in less than forty hours. CHAP. VIII. 
COMPLICATED FRACTURES. 
923 
The post-mortem examination revealed the existence of great numbers of oil globules in 
the capillaries and smaller arteries of the lungs, brain, liver, and kidneys. Observations 
made by Bergmann, Hamilton, Busch, and others show that, while this form of 
embolism is most common after fractures, it may also take place in caries, in osteomyelitis, 
in bony tumors, in fatty degeneration of the liver and arteries, and in certain abscesses 
developed in regions abounding in adipose tissue. 
Fractures of the joints are frequently complicated with sprains, laceration of the liga- 
ments, detachment of portions of bone and cartilage, and extravasation of blood. The 
intlammation consequent upon such injuries often runs very high, large quantities of syno- 
vial fiuid are liable to be effused, and the swelling in the surrounding structures is fre- 
quently very extensive. A severe sprain always adds greatly to the suffering, increasing 
the pain, and delaying recovery. In many cases the nutrition of the limb is seriously 
impaired, the muscles become atrophied, the skin is cold and discolored, motion is im- 
peded, and the general health is more or less deranged. Extensive laceration of the 
ligaments is frequently followed by permanent ankylosis, or by such an amount of dis- 
organization of the proper structures of the joints as to lead to the necessity of resection 
or amputation. When the articular extremity of a bone is severely shattered, a small 
fragment is sometimes completely detached, and, falling into the joint, sets up violent, if 
not destructive, inflammation. A piece of cartilage, however minute, may occasion simi- 
lar effects. Abscesses, either circumscribed or diffused, are liable to form as a consequence 
of such injuries, sometimes at a period quite remote from their occurrence. More or less 
extensive extravasation of blood generally takes place in fractures of the joints, both into 
their interior and into the surrounding connective tissue, not only obscuring the diagnosis, 
but seriously impeding the cure. Permanent ankylosis occasionally follows upon a com- 
plicated fracture, even when situated at a considerable distance from a joint, simply from 
an extension of the resulting intlammation. 
The nerves, like the bloodvessels, often suffer severely in fractures, sometimes at the 
moment of the injury, from contusion, laceration, or compression by sharp or displaced 
pieces of bone, or more or less remotely from the manner in which they are constricted 
by the plasma that is effused around their trunks at the seat of the original mischief. 
Exuberant callus may occasion similar effects, as I have witnessed in several cases. What- 
ever the cause may be, the suffering generally manifests itself in pain, more or less severe, 
and often of a neuralgic character, a sense of numbness, coldness or tingling, gradual 
wasting of the muscles, great susceptibility to atmospheric impressions, dryness and 
roughness of the skin, superficial ulcerations, the formation of little vesicles, desquama- 
tion of the cuticle, partial paralysis, and a tendency to ankylosis of the joints near the 
seat of injury. Some of these affections are remediable, yielding gradually to sorbefacient 
lotions, the hot and cold douches, and veratria ointment; others, on the contrary, obsti- 
nately persist despite the best directed efforts of the surgeon. Now and then relief, 
prompt and permanent, follows excision of a portion of the affected nerve. 
The muscles and tendons passing along the seat of fracture often sustain serious injury, 
in the first instance from the displaced extremities of the fragments, fretting and irritating 
their fibres; and, at a later period, from their involvement in the callus, which, when this 
substance is unusually abundant, surrounds and compresses them in such a manner as to 
interfere permanently with the exercise of their functions. 
As a remote effect of a fracture, even of the most simple kind, there is occasionally a 
development of sarcoma at the seat of injury, coming on within a variable period after its 
occurrence, and characterized by rapid formation and great bulk. In a case recently 
under my observation, an immense tumor of this kind existed in the forearm, in a boy, 
eight years old, who, twelve months previously, met with a fracture of the ulna. Latterly 
the lymphatic glands of the corresponding axilla had become involved, and the general 
health showed marked evidence of impairment. A section of the tumor exhibited, under 
the miscroscope, a typical round-celled structure. 
Amputation.—The circumstances which are likely to call for primary amputation have 
already been casually alluded to, and it may now be added that the operation should 
always be performed, as a general rule, whenever, along with a shattered or comminuted 
condition of the fractured bone, there is extensive laceration of the soft parts, with almost 
total disorganization of their substance. It is true, as was before intimated, that appa- 
rently desperate cases are sometimes cured, and that limbs, so mashed and wounded as to 
render amputation the only probable chance of success, are now and then saved. But it 
is equally true that such instances are extremely rare, and if we take into account the 
protracted sufferings of the patient, and the likelihood that he will ultimately perish, the 924 
reasons for performing immediate amputation are, to use the language of Percivall 
Pott, “vindicable upon every principle of humanity or chirurgic knowledge.” 
It is not uncommon to meet with cases in which the fracture is multiple, or in which 
the bone is broken at several points, but the upper fracture is perfectly simple, and 
perhaps situated in a portion of the limb which it is desirable to preserve. Ilence it 
becomes an important question how the surgeon should act in such an event. To my 
mind, the subject is a very plain one. If it is really important to save the broken bone 
beyond the part that must necessarily come off, in order to make a longer and better 
stump, there can certainly be no objection to such a course, provided, however, that the 
proximal fracture is perfectly simple in itself, and that there is no serious lesion of the 
soft structures, endangering limb and life by gangrene or other bad consequences. I have 
more than once adopted this plan, without ever having had any cause to regret it. No 
sensible surgeon would, of course, allow a bone to remain, if, in addition to extensive com- 
minution, there is serious injury of the muscles, integument, or other important textures; 
to do so would only be to trifle with the safety of the case. Severe fractures, the result 
of gunshot injury, nearly always demand primary amputation, especially when they occur 
on the battle-field. 
Secondary amputation may be required when, after an attempt to save a limb, and the 
employment of suitable antiphlogistic remedies, the parts become gangrenous; or when 
the consolidation of the fracture is prevented by profuse suppuration, and the patient is 
gradually worn out by diarrhoea and colliquative sweats. In the first case, the operation 
is performed as soon as the mortification is arrested, and there is a distinct line of demar- 
cation between the dead and living parts; in the second, as soon as it is perceived that 
the suppuration cannot be arrested, and that the patient has still sullicient strength to bear 
the pain and shock which must necessarily attend its performance. 
4. INCOMPLETE FRACTURES OR BENDING OF THE BONES. 
The bones are liable not only to break, but also to bend, as seen in figs. 433 and 434. 
Such an accident can only happen in young subjects, principally infants and children, 
in whom the osseous tissue, containing a preponderance of animal matter, is compara- 
tively soft, flexible, and elastic. Bend- 
ing of the bones of the skull, especially 
the frontal and parietal, is occasionally 
witnessed at an early age, sis an effect of 
external violence, as that, for instance, 
produced when a child falls, head fore- 
most, down a flight of stairs, or out of a 
second-story window upon the pavement 
below. Under such circumstances, the 
cranial bones, at the part struck, are de- 
pressed beyond their natural level, and 
yet there is not, so far as can be ascer- 
tained, any fracture, strictly so called; 
they are merely bent or indented, and, 
if no untoward occurrence take place, 
they will, generally, in the course of a 
few days, resume their proper position 
by their own resiliency, aided, doubtless, by the locomotive action of the brain, propelling 
them outwards away from its surface. In an adult, an accident, capable of producing 
such a result, would almost inevitably lead to fracture of the skull, probably of a very 
grave character, for the reason that the cranial bones, after a certain time, are always 
loaded with a quantity of earthy matter, in the form of carbonate and phosphate of lime, 
the presence of which renders them more or less brittle, and thus predisposes them to 
fracture. This tendency to fracture increases in proportion as we advance in years, and 
is, consequently, most distinctly marked in old age and decrepitude, in which the osseous 
tissue, almost destitute of animal substance, generally yields under the slightest force, the 
accident frequently eventuating in incurable injury. 
Bending of the bones was incidentally observed by a considerable number of practitioners 
in the last century, and, indeed, even prior to that period ; but the first systematic account 
of it was published in 1810, by Professor Jurine, of Geneva. In 1821, it was described 
DISEASES AND INJURIES OF THE BONES. 
CHAP. VIII. 
Fig. 433. 
Fig. 434. 
Incomplete Fracture of the Bones of the Forearm. CHAP. VIII. 
INCOMPLETE FRACTURES. 
925 
by Dr. John Rhea Barton, and since then it has been carefully investigated by Professor 
Hamilton and other surgical pathologists. 
I have myself met with this accident in ten cases, in children whose ages varied from 
three to eleven years, three being girls, and the other seven boys. Although it is most 
common in the ulna, radius, and clavicle, it also sometimes occurs in other pieces of the 
skeleton, as the humerus, femur, tibia, fibula, and ribs. External violence alone is capa- 
ble of producing this lesion. I am not acquainted with any cases in which it was occa- 
sioned by muscular action. In fact, considering that bending of the bones is exclusively 
confined to children, it is hardly possible that the accident could arise from such a cause ; 
certainly not, unless there existed extraordinary muscular development with remarkable 
flexibility of the osseous tissue, a condition hardly compatible with a healthy state of the sys- 
tem. In the bones of the forearm, which suffer more frequently than any other, the injury 
usually originates from force applied indirectly, as, for example, when a child, in the act 
of falling, instinctively throws out the arm to protect the body, and so receives the shock 
upon the hand, the concussion concentrating and exploding upon the radius, or the radius 
and ulna. In one of my cases, the bend wras produced by the body of the child being 
suddenly propelled against the forearm at a moment when the elbow was planted upon the 
floor, and the wrist was lying upon a stool. Flexion of the clavicle is the result either 
of direct violence, or of force applied to the top of the shoulder, especially if the body is 
at the same time propelled in the opposite direction, as in the case of a fall. 
The seat of this lesion is variable ; in the long bones, as those, for instance, of the fore- 
arm, it usually occurs a short distance below their middle, but it may also take place higher 
up, or farther down. The radius and ulna may both suffer synchronously, but very fre- 
quently one alone is affected ; or, if both are implicated, they do not suffer in an equal 
degree. 
Judging from the cases of this accident that have fallen under my observation, I am 
induced to believe that it generally takes place without any particular predisposition, either 
local or constitutional. In every instance of the kind, the subject of the injury was in 
good health at the time of its occurrence. An exception, however, must be made in regard 
to the bones of rachitic children, in which incomplete fractures are always preceded by 
softening. 
What is the precise nature of this lesion ? Is it really, as the name implies, a mere 
bending of the bones, or is it a flexion combined with partial fracture? These questions 
are easily answered. In very young subjects, as in children not more than a few years of 
age, and in the milder forms of the lesion, the osseous fibres are merely extended or 
stretched, so as to permit themselves to be drawn out of their natural course ; in cases of an 
opposite character, on the other hand, there is no doubt, that while some of the fibres are 
bent, others are both bent and broken. These conclusions are beautifully borne out by 
the experiments of Dr. Hamilton upon the bones of young chickens, which, from the fourth 
to the sixth week, and, consequently, before the completion of the ossifie process, could 
readily be bent without fracture to an angle varying from twenty-five to thirty-five degrees ; 
whereas the bones of older chickens, thus treated, always partially broke, their fibres being 
incapable of withstanding the force used in flexing them. 
These partial fractures, sometimes called interperiosteal, from the fact 
that the periosteum remains intact, bear a close resemblance, in the 
mode of their production, and the nature of the resulting injury, to the 
appearances presented by a green hickory stick, forcibly bent over the 
knee, but not to such an extent as to occasion any external sign of 
fracture, although it will be found, upon making a section of the wood, 
that many of its fibres have actually been broken, while others, and, 
perhaps, the greater number, have merely been bent. These appearances 
are well shown in fig. 435, from Fergusson. 
The symptoms attendant upon this accident are pain and deformity 
at the seat of the injury, loss of power in the limb, and absence of crepi- 
tation. The pain varies in degree, being sometimes slight, at other times 
severe; swelling soon supervenes, and the part feels numb and heavy. 
A marked curvature, generally very gentle, but occasionally quite abrupt, 
always exists at the affected part, and can seldom be completely effaced 
without the application of very considerable force ; indeed, often not 
without breaking the bone entirely across, especially if it was partially 
fractured previously. In the latter case, there is usually at the convexity 
of the curvature a slight depression, capable of receiving the point of the 
Fig. 435. 
Case mentioned by 
Fcr^nsson. DISEASES AND INJURIES OF THE BONES. 
CHAP. VIII. 
finger, its boundaries being formed by rough, sharp, bony fibres. Further than this there 
is no displacement, and under no circumstances is there any crepitation. The use of the 
limb is always greatly impaired, but not completely destroyed, as it commonly is in 
ordinary fracture. Finally, I may mention, as another highly important and diagnostic 
sign, the great difficulty which is so frequently experienced in restoring the parts to their 
proper position. 
The treatment must he conducted upon the same general principles as in ordinary frac- 
tures. When the hones are merely bent, slight pressure and extension usually sutfiee to 
accomplish restoration, the affected parts being compelled, as it were, to retrace their 
former steps. If flexion he conjoined with partial solution of continuity, the reduction 
will necessarily he more difficult, and may, in fact, altogether fail, owing to the manner in 
which the osseous fibres are interlocked with each other, and the inability which is expe- 
rienced in disengaging them, so as to induce them to slip hack into their proper position. 
However this may he, the attempts to remove the curvature by extension and pressure 
should neither he too violent nor too long continued, lest they prove injurious. The object 
should be to restore as much as possible by gentle means ; what cannot he effected in this 
manner may well he left to the operation of time, the absorption of the broken and resist- 
ing osseous fibres, and the action of the muscles, which seldom fails to reinstate the parts, 
although from six to eight weeks may elapse before the final completion of the cure. I 
have generally found the use of leather splints, well padded, and accurately shaped to the 
limb, of great service in bringing the bones into their proper relations. Pressure with the 
elastic bandage, as suggested by Dr. II. A. Martin, of Boston, will also be found to be 
very useful. When the accident is followed by grave inflammation, the usual antiphlo- 
gistic remedies, especially leeching and cooling lotions, will be required. 
There is a variety of partial fracture, known by the term Jissure, which is peculiar to 
the bones of elderly subjects, no well-marked instance of it having ever been met with in 
infants and children. Such an occurrence, which is generally much more interesting in a 
pathological than in a practical point of viewr, is by no means uncommon in the skull, es- 
pecially along its base, where it is always associated with severe, and frequently fatal, 
injury of the brain and its envelops. The fissures in many of these cases are most exten- 
sive, involving the sphenoid, occipital, temporal, frontal, and, perhaps, even the ethmoid 
and parietal bones. In the other pieces of the skeleton the occurrence is more rare; but 
examples are occasionally seen both in the long, short, and flat bones, as the result of 
external violence, generally directly applied. The accident is, now and then, produced 
by gunshot injury. The lesion, however induced, consists essentially in a forcible sepa- 
ration of the osseous fibres, and exhibits itself in a great variety of forms, the crack 
sometimes extending through the entire thickness of a bone, at other times merely through 
its outer table, and at other times, again, involving both the compact and areolar tissues, 
but not passing completely through them. The length of the 
fissure varies from a few lines to a number of inches, perhaps as 
many as six or eight, although this is exceedingly uncommon. 
The width of the crevice is generally very slight, perhaps barely 
sufficient to admit the blade of a penknife. In rare cases, as 
when it involves the extremity of a bone, it may gape somewhat, 
so as to give the part the appearance as if it consisted of two 
fragments, firmly adherent at one end. Finally, the fissure may 
be straight, curved, or angular. 
Of the rarity of this lesion, as an uncomplicated occurrence, 
an idea may be formed when it is stated that there are probably 
not more than three or four well-marked specimens of it in all 
the osteological cabinets of this city. As a conjoint affection, it 
is occasionally met with in compound fractures, especially when 
caused by railway accidents. There are no signs by which the 
nature of the injury can be distinguished during life ; a circum- 
stance which is the less to be regretted, because the treatment 
does not differ from that of ordinary wounds, fractures, and con- 
tusions, with which it is so generally associated. 
Bryant has described a rare case of deformity, fig. 436, conse- 
quent upon a green-stick fracture of the leg, in which the bones were allowed to remain 
in the position into which they were thrown by the accident. The tibia and fibula meas- 
ured six inches across the centre, owing to the deposit of a large quantity of osseous matter 
in the concavity of the arch. 
Fig. 436. 
Hyperostosis after Green- 
stick Fracture. CHAP. VIII. 
UNUNITED FRACTURES. 
927 
5. EPIPHYSEAL FRACTURES. 
The extremities of the bones of young subjects are united to their shafts or bodies 
by means of cartilaginous matter, which, in some of the pieces, and in some indi- 
viduals, does not assume the osseous form until after the twenty-first year, and occa- 
sionally, indeed, not until even a later period. Up to this time, con- 
sequently, these junctions are liable to be severed, so as to allow the 
contiguous extremities to separate from each other, and it is this occur- 
rence which constitutes what is technically called diastasis, as seen in fig. 
437 ; an affection first accurately described nearly at the same time by 
lioux and Gueritin. 
It is probable that this accident may occur in all parts of the skeleton 
united in this manner, although there are, doubtless, some in which it is 
more common than in others. Its occasional existence has been recog- 
nized, by dissection, in the humerus, radius, femur, and tibia, and there 
are few systematic treatises that do not allude to it as being now and 
then met with in some of the other bones. The most common cause of 
diastasis is a wrench of the part, violent traction, or a severe fall. I 
am not aware that it has ever been produced by muscular action ; and, 
on the other hand, it is rarely the result of direct violence, as, for in- 
stance, the kick of a horse, or the passage of the wheel of a carriage, 
such an accident more generally eventuating in fracture of the bones 
than in a separation of their epiphyses. The lesion may happen at any 
period of life, prior to the completion of ossification, but is most common 
from the fifth to the fifteenth year. Its occurrence in middle-aged and 
elderly subjects is, for the reasons already mentioned, impossible. Girls 
are more prone to it than boys, owing, probably, to the fact that they 
are more frequently exposed to its exciting causes. The affection, like 
fracture, may be simple, compound, or complicated. Cases are noticed 
in which the diastasis is blended with fracture of the shaft of the bone, 
and it is by no means uncommon to find that small processes of bone 
are dragged away with the epiphyses. 
The symptoms of this lesion do not differ essentially from those of fracture, properly so 
called. Its existence may generally be suspected when an accident affecting a bone occurs 
in a young subject, in the neighborhood of a joint; when the ends of the fragments are 
transverse, or nearly so; when the articular piece retains its position, while the other 
moves about; and, lastly, when the crepitation produced by rubbing the ends of the frag- 
ments against each other is of an unusually dull, rough, grating character. Moreover, it 
will commonly be found that the parts, when once reduced, are less liable to be dragged 
asunder by the action of the muscles than in an ordinary fracture. 
The prognosis is generally favorable, union commonly taking place very promptly, espe- 
cially in very young subjects. The accident, if neglected, or unskilfully treated, is liable 
to be followed by severe inflammation, abscesses, erysipelas, and more or less deformity. 
The treatment is the same as in ordinary fractures. 
6. UNUNITED FRACTURES. 
Fractures occasionally refuse to unite, either in consequence of causes inherent in the 
part or system, or on account of mismanagement growing out of the surgeon’s want of 
attention and skill, or else out of the patient’s own misconduct. It is practically important 
that a distinction should be drawn between a fracture that unites tardily and one that does 
not unite at all, or only through the medium of fibrous, ligamentous, or fibro-cartilaginous 
tissue. Slow consolidation is by no means uncommon ; the parts may be loth to take on 
the requisite degree of ossific action, and the result may be that a fracture that is ordinar- 
ily repaired in four or five weeks, may, perhaps, be still imperfectly united at the end of 
twice that period. The process of restoration is only held in abeyance, neither advancing 
nor receding; by and by it begins again, and then often proceeds with its wonted rapidity. 
Such cases are frequently very trying to the surgeon’s patience, although they generally 
turn out well in the end, provided sufficient care has been taken to preserve the parts in 
their proper relations. In the ununited fracture, on the other hand, the process of con- 
solidation is either completely thwarted, or, after having made some progress, is at length 
permanently arrested. Under these circumstances, the ends of the fragments are gradu- 
Fig. 437. 
Diastasis of the Fe- 
mur: reunited. 928 
DISEASES AND INJURIES OF TIIE BONES. 
ally rounded off by absorption, and remain either entirely loose and unconnected, or they 
become adherent through the medium of fibrous, ligamentous, or fibro-cartilaginous 
matter. Sometimes, although rarely, an adventitious 
joint is formed, as in fig. 438, provided with a more 
or less distinct synovial membrane, thus permitting 
the ends of the bone to move upon each other with 
great facility. 
The bones most liable to non-union after fracture 
are those of the arm and thigh. Of 150 cases col- 
lated by I)r. George W. Norris, 48 related to the hu- 
merus, 48 to the femur, 1 9 to the forearm, 33 to the 
leg, and 2 to the lower jaw. Bad injuries of this 
kind of the clavicle, rendered so by severe contusion 
and great displacement of the ends of the fragments, 
are often followed by imperfect consolidation. The 
occurrence of non-union, however, of fractures gen- 
erally is probably much less frequent than is usually 
supposed. Of nearly 4000 cases treated in the Mid- 
dlesex Hospital, London, there were, as stated by 
Lonsdale, only five or six of non-union. Of 946 
cases of recent fractures admitted into the Pennsyl- 
vania Hospital, from 1830 to 40, not an instance of 
the kind occurred; and of 367 cases, treated in the 
Massachusetts General Hospital, there was, according 
to Dr. Moreland, only one in which a false joint had 
formed. Within the last few years not less than five 
cases of this kind have come under my observation, three of them in the Jefferson 
College Hospital. 
Want of reunion in a fracture may depend upon a great variety of causes, some of them 
inherent in the parts themselves, others connected with the system. Thus, it may be 
occasioned by the interposition of a clot of blood or of a piece of muscle, tendon, or bone. 
An instance is recorded where the consolidation of a fracture was prevented by the pres- 
ence of a musket ball ; and Dupuytren observed a fracture of the humerus, in a man, 
twenty-three years of age, in which a similar effect was produced by the lodgment of a 
large number of hydatids. Fragility, softening, and other affections of the bones, are 
usually enumerated as circumstances interfering with the reparative process, but it is not 
improbable that their influence has been greatly exaggerated ; at all events, it is certain 
that in many cases of this kind the fracture unites as readily as when the bones are per- 
fectly healthy. Too much motion, the long-continued use of cold water, especially in 
persons of a nervous, irritable temperament, and tight bandaging, may also bring about 
this result. Many years ago, I saw a case in which, from the latter cause, the consolida- 
tion of a fracture of the thigh-bone was delayed for nearly twelve months. The limb 
had become excessively atrophied from the protracted and injudicious employment of the 
roller, and it was not until after the bandage had been entirely laid aside, and the man 
permitted to exercise upon crutches in the open air, that nature fairly began the process 
of repair. 
Old age is no barrier to reunion, if the patient is in good health at the time of the acci- 
dent, and the fracture, unattended by complications, is properly treated. I have met with 
several cases of fracture of the humerus, in persons after the eightieth year, followed by 
complete consolidation in the usual time ; and Dr. W. W. Dale has reported one in a 
lady of one hundred, in which the union was equally prompt and satisfactory. A fracture 
of the upper third of the thigh, in a woman, ninety-three years old, treated by Dr. J. K. 
Holloway, of Ohio, was completely consolidated in seven weeks. 
The most common of all the local causes of tardy reunion, in injuries of this kind, 
are motion and imperfect apposition of the ends of the fragments. Either of these cir- 
cumstances will inevitably interfere with, if not effectually prevent, the consolidating pro- 
cess, however favorable to a cure the condition of the system itself may be. Hence, as 
stated elsewhere, the absolute necessity, in every fracture, of carefully guarding against 
those occurrences until the process of repair is so far advanced as to enable the fragments, 
so to speak, to take care of themselves. 
Fractures situated at or near the entrance of the nutrient arteries unite less rapidly 
than such as are situated further off', as they interfere more or less with the circulation 
CHAP. VIII. 
Fig. 438. 
ITnunited Fracture of the Bones of the Leg. CHAP. VIII. 
UNUNITED FRACTURES. 
929 
and nourishment of the osseous tissue. It is easy to suppose that the laceration of these 
vessels, as occasionally happens both in simple and compound fractures, might be a cause 
of non-consolidation, especially when conjoined with other unpropitious circumstances. 
Statistics show that, when the supply of blood is cut off, to any considerable extent, so as 
to impose upon the periosteum the exclusive duty of nourishing the fragments, either one 
or both pieces will become atrophied, their walls being visibly thinned and their areolar 
structure rarefied. 
Inadequate supply of nervous fluid may be a cause of non-union. A case reported by 
Mr. Travers beautifully illustrates this point. A patient had a fracture in the arm and 
another in the leg, complicated with an injury of the spine which palsied the lower half 
of the body. The broken humerus readily united, but the tibia and fibula refused to heal. 
Want of union is sometimes dependent upon the absorption of the ends of the frag- 
ments, or even of the greater portion of the fragments themselves, as in a very singular 
case which came under my observation in a man, fifty-three years old. At the age of 
eighteen, lie received two simple fractures of the right humerus, at an interval of three 
months, one being situated about the middle of the bone, the other an inch and a half 
higher up. The first was repaired in the usual time, but the second refused to unite, the 
ends of the fragments becoming rounded off, as in the formation of an artificial joint; the 
process gradually proceeding, the whole bone was finally absorbed, nothing remaining ex- 
cept the condyles and a little of the head. The period occupied in the absorption was 
about six years, the general health being all the while unimpaired. The muscles of the 
arm are well developed, and are capable, when thrown into powerful action, of diminish- 
ing the interval between the shoulder and elbow' to an extent of several inches. Al- 
though the man is unable to perform any of the 
usual movements of the limb, he can readily 
raise a weight of upwards of one hundred 
pounds, and can apply his hand to various pur- 
poses. The accompanying cut, fig. 439, repre- 
sents the appearance of the arm during the con- 
traction of its muscles. 
The principal constitutional causes which 
interfere with the reparative process are, de- 
bility, whether from loss of blood, want of 
nutritive action, or exhausting disease, as long- 
continued fever, a gouty, rheumatic, scorbutic, 
rachitic, or syphilitic state of the system, and 
loss of nervous influence, however induced. Pregnancy has sometimes been accused of 
preventing union, on the ground that the nourishment required by the foetus establishes 
too great a drain upon the blood ; but in the few cases of this kind that have fallen under 
my observation, I have not witnessed any such effect, and I am strongly inclined to be- 
lieve that this influence has been greatly exaggerated, if, indeed, it is not wholly chimerical. 
The same remarks are applicable to suckling. Another cause, probably much more effi- 
cient, as well as much more common, is the protracted and inordinate use of ardent spirits, 
exhausting the nutritive energies of the system, and rendering the blood and its vessels 
unfit for the performance of the important duties assigned to them in the reparative process. 
Treatment—Whatever the cause of the non-union may be, every effort should be made 
to discover it, with a view to its early and efficient rectification. Nutritious food and 
drink, as porter, ale, w'ine, or brandy, aided, if necessary, by tonics, more especially iron 
and quinine, will be required if the patient be very weak or anemic. A gouty or rheu- 
matic state of the constitution is best remedied by purgatives, alkalies, and colchicum. 
Syphilitic symptoms must be met with the iodides, in union with mercury, the latter of 
which should sometimes be carried to the extent of slight ptyalism. Debility from 
drunkenness must be counteracted by the judicious employment of the patient’s accus- 
tomed stimulants. 
Sometimes a change of air is very serviceable, especially such as attends upon a sea- 
voyage. An army surgeon, stationed in the West Indies, had under his care six cases of 
fracture which remained ununited for a long time, but were all promptly cured on being 
sent to Europe. 
The local treatment must be regulated by circumstances. The precise cause of the 
tardy or imperfect union must, if possible, be clearly ascertained, and promptly remedied 
by appropriate measures. If any motion exists perfect quietude must be insured ; any 
defect of contact must be redressed by a more accurate adjustment of the ends of the frag- 
Fig. 439. 
Absorption of the Humerus. 930 
DISEASES AND INJURIES OF THE BONES. 
merits ; cold applications, if injurious, must be discontinued ; and any extraneous inter- 
vening substance must be removed, either through the agency of the absorbent vessels, by 
pressure and other means, or, as in the case of a piece of dead bone, with the knife and 
forceps. The cause of the defective union having been thus remedied, the case will be 
likely, of its own accord, to proceed to a favorable termination, the ordinary principles of 
treatment being, of course, observed. 
A large number of local remedies have been employed for the cure of united fractures. 
Among these the most important are friction, compression, vesication, acupuneturation, 
cauterization, subcutaneous division or perforation, the use of setons and ivory pegs, and 
excision of the ends of the fragments. 
1. Cutaneous friction, either dry or moist, by means of the bare hand, or with a piece 
of rough cloth is sometimes serviceable, especially in the more simple cases; if moist, 
various liniments, lotions, or unguents may be employed, often with decided benefit, 
inasmuch as they tend to excite capillary action in and around the ends of the fragments, 
thus promoting the formation of callus. 
2. Compression is occasionally worthy of trial. It may be made with splints of 
leather, felt, or binder’s board, and the bandage; or by an apparatus expressly con- 
structed for the purpose, and so arranged as to concentrate the pressure at the seat of the 
fracture. It must be steady and persistent as well as uniform and gentle. 
3. lllisters and iodine now and then act beneficially. Their application is particularly 
indicated when the want of union is dependent upon undue vascular excitement, and is, 
of course, entirely restricted to cases of recent standing. 
4. Friction of the ends of the fragments against each other was recommended by 
Celsus, and has often been successfully practised by modern surgeons. It should be per- 
formed very gently, and be repeated every four, six, or eight days, according to its effects. 
5. Percussion of the ends of the fragments, originally recommended by II. O. Thomas, 
of Liverpool, has been successfully employed in some cases of ununited fractures, more 
especially in cases of recent standing. The skin at the seat of the fracture being pro- 
tected with felt or sole leather, and the patient placed under the influence of an anaesthetic, 
the ends of the broken bone are smartly struck five or six minutes with an iron hammer. 
The operation is followed by a good deal of swelling, which, however, promptly disappears 
under local treatment. 
6. Acupuneturation with a long, slender needle may be tried ; or a small incision may 
be made over the seat of the injury, and a heated wire thrust between the ends of the 
fragments. The galvanic cautery might, perhaps, occasionally be employed with advan- 
tage, especially when a more powerful excitant is needed. 
7. Cauterization of the integument over the seat of the fracture with some caustic 
alkali, was recommended and successfully employed, in 1803, by Dr. llartshorne, of this 
city. Sometimes the ends of the bones may advantageously be exposed, and rubbed 
over with nitrate of silver, although such a proceeding is not always devoid of danger. 
8. Subcutaneous division of the ligamentous bands between the two ends of the frag- 
ments has been successfully practised. The operation is per- 
formed with an ordinary tenotome, used in such a manner as to 
cut the parts as thoroughly as possible, especially over the ex- 
tremities of the broken pieces. 
In very recent cases, such a procedure is occasionally fol- 
lowed by a good cure. In using a tenotome for such a purpose 
care must be taken not to wound any important vessels or nerves. 
9. The injection of five to ten drops of glazial acetic acid 
between the ends of the fragments, in cases of recent standing, 
has been successfully employed by Fitzgerald. The fluid acts, as 
is supposed, by softening the interposed fibrous tissue, and thus 
placing it more readily under the influence of the absorbent 
vessels. The smarting pain which follows the operation always 
speedily subsides of its own accord. 
10. The introduction of ivory pegs was originally proposed by 
Dieflenbach. They are from an inch and a half to two inches in 
length, conical in shape, and inserted into the ends of the frag- 
ments, previously pierced with a gimlet, such sis that sketched in 
fig 440. They must be forcibly driven into the openings, and 
retained until the consolidating process is well advanced. Excellent and rapid cures 
have repeatedly followed this plan in my hands. 
11. The seton, introduced into practice in 1802, by Dr. Physick, is ordinarily, in 
CHAP. VIII. 
Fig. 440. CHAP. VIII. 
UNUNITED FRACTURES. 
931 
obstinate cases, a very reliable, but not always a safe method, as it is liable to give rise 
to erysipelas and other bad consequences. It should be passed by means of a long, thin, 
flat needle, sharp and lancet-shaped at the point, between the ends of the fragments; 
or, if this be impracticable, as close to the site of the fracture as possible, for experience 
has shown that the operation, thus performed, is nearly as successful as the usual pro- 
cedure. The foreign body, a piece of elastic tape, silk ribbon, or French braid, is 
generally retained until it has excited slight suppurative action. The patient is carefully 
watched, the seton being at once withdrawn, if the pain and swelling become at all severe. 
Immediately after the introduction, the fragments are properly adjusted, and steps taken, 
if necessary, to maintain extension and counterextension. In the first case in which 
this treatment was employed, the seton was retained many weeks, and the patient recovered 
the perfect use of his limb. The practice of withdrawing the seton at the end of a few 
days, as is occasionally advised, is objectionable, for the reason that it will hardly have 
sufficient time to excite the requisite degree of inflammatory action. 
12. Perforation of the ends of the bone by means of a special instrument, fig. 441, an 
operation proposed, in 1853, by Professor Brainard, is sometimes serviceable. It consists 
in piercing subcutaneously the extremity of each fragment at several points, and cutting 
Fig. 441. 
Brainard’a Perforator. 
up the intervening tissue, with a view of exciting ossific action. The instrument should 
have an immovable handle. A preliminary puncture is made with the bistoury, and any 
hemorrhage that may arise is controlled by compression. The operation is repeated every 
eight, ten, or twelve days until consolidation has occurred, the limb being in the mean 
Fig. 442. 
Fig. 443. 
Gaillard’a Fracture-pin. 
time kept quietly at rest in splints, and the treatment being in other 
respects conducted upon general principles. From what I have seen 
of the effects of this treatment, I am satisfied that it is adapted 
chiefly to cases of delayed union, and that it is altogether inadequate 
in those of long standing. 
13. Connecting the ends of the fragments together subcutaneously 
by means of an iron screw, as originally practised by the late Professor 
Pancoast, in 1857, often succeeds where the more ordinary plans prove 
abortive. Indeed, I know of no method of treatment that is so effec- 
tive and at the same time so perfectly free from danger as this in 
old ununited fractures and in recent false joints. It is particularly 
suited to ununited fractures of the femur and humerus, but is not so well 
adapted to those of the leg and forearm, in which it occasionally 
fails. The instrument, fig. 442, with which the operation is per- 
formed, is shaped somewhat like a gimlet, and is provided with 
a movable handle. A puncture being made down to the seat of the 
fracture with a long, narrow bistoury, the screw is carried through the 
end of one fragment into that of the other, and retained until there is 
complete consolidation, from six to eight weeks being usually required to accomplish the 
object. When the treatment is over, the instrument may be removed; or, if it do not 
cause any inconvenience, it may be permanently left, the more especially when it is 
completely buried beneath the skin. Its presence is rarely, in any case, productive of 
Iron Screw for con- 
necting the Ends of 
Unnnited Fracture. 932 
DISEASES AND INJURIES OF THE BONES. 
CHAP. VIII. 
serious inconvenience. Now and then slight erysipelas arises after the operation, but this 
generally soon disappears of its own accord. In the seven or eight cases in which I have 
employed this treatment the success in all was complete. In three of these cases the 
screw was retained upwards of four months. Such a procedure will not be likely to 
succeed well when an artificial joint exists. 
Dr. E. S. Gaillard has invented a fracture-pin, fig. 443, provided with a silver sheath 
and brass nut, which is tightened after the instrument is firmly buried in the ends of the 
fragments. The contrivance does not, apparently, possess any advantages over the screw 
above described. 
14. The method of scraping the end$ of the bone, through an open wound, introduced 
at an early period of the profession, and occasionally practised in modern times, is an 
inefficient procedure, and should, therefore, be abolished, the more especially as it is not 
always by any means free from danger. 
15. Finally, as a dernier resort, excision of the ends of the fragments, as originally 
performed in 1700, by Mr. White, of England, may be practised ; but it should be borne 
in mind that the operation is not only difficult of execution, but that it is by no means 
devoid of danger, more especially when it is performed upon the thigh, where it has 
occasionally proved fatal. A very free incision is made through the soft parts down to 
the ends of the broken bone, which are then carefully liberated, brought out at the 
wound and retrenched, either with a stout knife, a saw, a pair of pliers, or the surgical 
engine. Sometimes the mere removal of the cartilaginous incrustation is sufficient, an 
object which may be easily accomplished with a scraper. 
To maintain the freshened ends in accurate and steady apposition, it was proposed by 
Iloreau, in 1805, to connect them together by means of wire, retained until the com- 
pletion of the cure. The procedure has been frequently employed in this country, in 
consequence, apparently, of the high authority of the late Dr. J. Kearney llodgers, of 
New York, who was the first to perform it on this side of the Atlantic. It consists, first, 
in cutting off* the rounded ends of the fragments; secondly, in drilling a hole through 
each ; and, lastly, in tying them firmly together with a silver wire composed of five or 
six ordinary suture threads, so as to keep them closely and evenly in contact during the 
consolidating process. It is generally imagined that this procedure is necessarily followed 
by violent inflammation, jeoparding both limb and life ; but this is an error. If the 
operation be carefully performed, and the after treatment properly conducted, I believe 
that it will commonly be found to be entirely free from danger, while the utmost confi- 
dence may be placed in its efficacy. In nearly every instance in which I have employed 
it, very little pain, inflammation, or fever occurred, and the result in all, except one, was 
most satisfactory. The operation is, of course, less dangerous in the upper than in the 
lower extremity, where, especially if the bone be thickly covered with muscles, it is often 
attended with great difficulty. When the false joint is situated very high upon the femur 
such an undertaking is altogether out of the question. 
In the first case in which I tried this plan, the fracture occupied the inferior fourth of 
the shaft of the humerus, and various remedies, among others Dr. Brainard’s, had been 
faithfully but fruitlessly employed. The patient, a man, twenty years of age, being 
thoroughly anaesthetized, a longitudinal incision, about three inches in length, was carried 
along the posterior aspect of the arm, through the triceps muscle, over the site of the 
fracture. The lower fragment was found to overlap the upper about one inch and a half. 
The ends of the bone were surrounded by a strong fibrous membrane, which was firmly 
adherent to the neighboring parts, and formed a sort of shut sac, in which the bone was 
imbedded. About an inch of the lower portion of the upper fragment, and half an inch 
of the upper portion of the lower fragment, were removed with a delicate saw; but on 
account of their firm adhesions, and especially the shortness of the inferior piece, some 
difficulty was experienced in bringing them fully into view. The fragments were conical, 
rounded, smooth, and invested by a thick, fibrous periosteum: no synovial membrane or 
fluid existed. The next step of the operation consisted in drilling a hole into each ex- 
tremity of the bone with a common gimlet, when a piece of wire was introduced to main- 
tain them in apposition. The ends of the wire were twisted together, and allowed to 
protrude from the wound, the edges of which were approximated by three sutures and 
adhesive strips. Two splints and a roller being applied, the arm was firmly supported in 
a sling. There was very little hemorrhage, and no vessels required ligation. As the 
patient suffered great pain, a grain of morphia was given immediately after the operation. 
Very little local or constitutional disturbance followed, and nearly the whole wound healed 
by the first intention. At the end of the eighth week, the union had advanced so far that 
there was any perceptible motion. In a fortnight after, the wire was removed, CHAP. VIII. 
UNUNITED FRACTURES. 
933 
and the patient went home perfectly restored, the arm being about an inch and a half 
shorter than the sound one. Under the influence of frequent passive motion, the elbow- 
joint was gradually regaining its functions. 
In another case, that of a man, thirty-two years of age, I treated with equal success, by 
an operation of this kind, an ununited fracture of the humerus of twenty-seven months’ 
standing. The ends of the fragments were connected by two silver wires, which were 
permanently retained. The case is reported at length in the North American Medico- 
Chirurgical Review for July, 1861. 
In performing excision, it is very important that the periosteum should not be stripped 
off the ends of the bone. In a case in which this accident happened to me through the 
carelessness of an assistant, violent erysipelas with some necrosis was the consequence, 
endangering the safety of both limb and life. 
Professor Henry J. Bigelow, in 1867, published the results of eleven cases of ununited 
fractures, successfully treated, with one exception, by connecting the excised extremities 
of the bones with silver wire, great care being taken to preserve the periosteum; a pre- 
caution to which he very justly attributed much of the happy effects of the operation. 
The results of some of the above operations have been placed in a striking and inter- 
esting light by the statistics of Professor Agnew. Thus, of fifty-three cases in which 
manual friction was used, twenty-five were cured. Of eighty cases treated by mechanical 
appliances, fifty-seven were cured, and two died. Of seventy-three cases in which the 
seton was used, twenty-seven were cured, and two died. Of forty-nine cases of immobili- 
zation, twenty-seven were cured, and one died. Of one hundred and seventy-eight cases 
of resection, with its modifications, one hundred and four were cured, and eleven died. 
Of one hundred and eleven cases of drilling, with its modifications, sixty were cured, and 
one died. It is worthy of remark that the treatment by the seton is more successful in 
fractures of the femur and humerus than in those of any other bones. The danger of the 
more severe operations, especially the seton and resection, follows the same laws as in 
amputations, increasing with the size of the limb and its proximity to the trunk. Of the 
seventeen deaths, eight occurred after resection and drilling 
of the ends of the bone in ununited fractures of the femur; and 
the operation should, therefore, always be performed with the 
utmost care. 
Whatever plan of treatment be adopted, it is impossible to 
be too attentive during the after-management of the case, 
especially in securing repose and accuracy of apposition to 
the ends of the fragments. As soon as the immediate effects 
of the operation have passed off', the limb should be incased 
in the immovable bandage, with an opening opposite the 
wound for facilitating drainage, and the patient should be 
permitted to exercise in the open air upon crutches, if the 
fracture be seated in the lower extremity, the general health 
should be properly cared for, and every means employed to 
assist nature in her efforts in effecting a cure. In incurable 
cases of ununited fracture, or in a false joint consequent upon 
fracture, the patient will derive great comfort from wearing 
the admirable contrivance devised for this purpose by Dr. 
Henry II. Smith, of this city. The apparatus, delineated in 
fig. 444, is constructed upon the same principles sis the ordinary 
club-foot apparatus, consisting of a shoe, and of a leg and a 
thigh-piece, connected by hinges, and fastened round the limb 
by straps and buckles. 
If any of the more severe operations are performed, the 
treatment, for the first few days, must be strictly antiphlogis- 
tic, the patient being most carefully watched, lest the inflam- 
mation, running too high, produce fatal consequences. If 
abscesses form, they should be promptly opened, and the 
utmost attention should, throughout, be bestowed upon cleanli- 
ness. The great danger to be apprehended after such opera- 
tions is from erysipelas, pyemia, and phlebitis. 
When all the known remedies, after a thorough trial, fail, 
and the limb is utterly useless, the only resource is amputa- 
tion. Few cases, however, demanding such a terrible alter- 
native, will be likely to arise in the present state of the science. 
Fig. 444. 
Smith’s Apparatus for Unnnited 
Fracture, modified by Kolbo. 934 
DISEASES AND INJURIES OF THE BONES. 
CHAP. VIII. 
7. VICIOUS UNION OF FRACTURES. 
From inattention of the surgeon, or a want of cooperation of the patient, the ends of a 
broken bone sometimes unite in a very unseemly and injurious manner, entirely at vari- 
ance with the beauty and usefulness 
of the affected limb, as represented 
in fig. 445. The deformity thus 
arising may be produced by the 
overlapping of the extremities of the 
fragments, attended, of course, with 
corresponding shortening; or, it may 
be owing to the imperfect contact of 
the two ends, thus occasioning a cer- 
tain amount of angular displacement, 
without any abbreviation of the 
length of the bone. In whatever 
way the deformity may be induced, 
it is obvious that it should be rectified 
at the earliest possible moment; for 
the longer a case is permitted to 
remain on hand, the more difficult it 
will be to afford relief. There are 
several procedures by which this object maybe attained: 1st. Compression and exten- 
sion; 2dly, forcible flexion, or rupture of the callus; 3dly, subcutaneous division of the 
connecting medium; and, lastly, resection of the ends of the fragments. These methods 
are not, of course, all equally adapted to every case. 
1st. The safest as well as the most simple procedure, but one which is applicable only 
in the more early stages of vicious union, consists in applying pressure opposite to the 
seat of the deformity, in the direction of its convexity. This may be efficiently done by 
means of appropriate splints and bandages, or with special apparatus provided with pads 
and screws, and appliances for making extension and counterextension, particularly if 
there is marked shortening. It is not necessary to give any description of these con- 
trivances, as they may be readily fabricated by any ingenious mechanic, or even by the 
surgeon himself. No preliminary treatment will be required. It is absurd to suppose 
that the callus may be softened by cataplasms and fomentations. The compression and 
extension should be made, at first, in as gentle a manner as possible, and be gradually 
increased and steadily maintained up to the point of easy tolerance, being occasionally 
intermitted if productive of pain, or likely to induce excoriation. 
2dly. If the preceding method fail, or is inapplicable, forcible flexion and extension, 
or rupture of the callus, may be attempted, compelling the displaced fragments to retrace 
their steps. This plan is also chiefly applicable to recent cases, but has occasionally been 
employed at the end of six, eight, ten, or even twelve weeks. I have myself successfully 
employed it at the expiration of the second month, and repeatedly within the first three 
weeks. It would be difficult to state when it should be refrained from ; much will neces- 
sarily depend upon circumstances, for in one case the union may be firm in a month, 
while in another, perhaps, equally simple, if not more so, twice or thrice that period may 
elapse before it is consolidated. Perhaps as good a guide as any would be the existence 
of slight mobility between the ends of the fragments; if the union is very strong, the 
attempt to break it might be attended with fracture of the bone above or below the 
seat of the callus, thus seriously complicating the case. Besides, the operation, except 
in the more simple forms of the affection, should not be undertaken without some prepara- 
tion of the system, as it is occasionally followed by violent inflammation, erysipelas, ab- 
scess, and even death. 
The operation is easily performed, before the union is consolidated, simply by bending 
the limb over the knee, or by placing it upon a table, and applying pressure upon the 
distal extremities of the fragments. When the case is of long standing, and the union 
firm, the callus can only be broken by the employment of force applied by some special 
apparatus, designed either to act directly upon the callus, or by means of a weight 
appended to the distal extremity of the bone, the fractured part projecting slightly over 
the edge of the table, while the portion of the limb containing the upper fragment is 
carefully held down by assistants. One of the best of the various contrivances devised 
for this purpose is that of Butcher, fig. 446, the force of which can be made to bear 
Fig. 445. 
Viciously united Fracture of the Leg. CHAP. VIII. 
DISEASES OF THE CALLUS. 
directly upon the displaced angle of the broken bone. It has been ascertained by ex- 
periments, performed by Jacquemin, Bosch, CEsterlen, and others, that the callus of a 
thigh-bone, broken fifty days previously, requires a weight of fifty to sixty pounds to sever 
the fragments at the seat of the callus. 
3dly. When the union is complete, and the preceding methods have either failed or are 
inapplicable, partial division of the bone should be practised, the object being to weaken 
it in such a manner as to admit of its more 
ready fracture, or gradual bending by syste- 
matic compression, as the new osseous matter 
becomes softened from the effects of the in- 
fiammation consequent upon the operation. 
The perforation is effected subcutaneously by 
means of a suitable drill, or, what is better, a very 
narrow chisel. If it be intended to break the 
bone, this should be done at once, and the limb 
immediately placed in a suitable apparatus. 
If, on the other hand, the rectification is to be 
effected by bending, no formal measures, for 
this purpose, should be adopted for the first 
eight or ten days, or until the osseous tissues 
have undergone a certain amount of softening. 
4thly. Other means failing, the only resource 
is excision of the bone at the seat of the fracture, 
along with a portion of the callus. The pro- 
cedure, which took its rise in the early part of 
the sixteenth century, consists in exposing the 
extremities of the broken bone, and removing, 
with the saw or pliers, a sufficient piece to 
admit of the accurate coaptation of the raw 
surfaces. The case is afterwards treated as one 
of ordinary compound fracture. 
Finally, when relief is impracticable by any 
of the means now described, and the limb is 
sadly in the way of comfort and usefulness, the individual being, perhaps, obliged to 
labor for his daily subsistence, the only alternative is either to abandon him to his fate or 
to resort to amputation. 
In 1851 I met with an instance of compound fracture of the tibia, in a young man 
of nineteen, in whom about two inches of that bone, near its middle, had been shot away, 
two years previously, by a rifle ball. The fibula had remained intact, but with the aid 
of a stiff leather splint, forming a case which reached from just below the knee to within 
a short distance of the ankle, progression was performed with tolerable ease, although not 
without the use of a crutch. If the deficiency of bone had been somewhat less, I should 
have been tempted to cut away a portion of the fibula, and, after refreshing the ends of 
the tibia, to approximate the bones by means of splints, or silver wire, fully anticipating 
a good cure. Since this suggestion was thrown out, many years ago, this treatment has 
been carried into effect by the Professors Pancoast, who have reported several successful 
cases. Instead, however, of exsecting a portion of the fibula, they simply broke that 
bone opposite the fracture in the tibia. 
8. DISEASES OF THE CALLUS. 
Callus, like all new tissues, is liable to different diseases, both during its development 
and after its completion, more or less hostile to its welfare and perpetuity. Some of these 
affections have a local origin, some depend upon the state of the constitution, and others, 
again, seem to partake of the nature of both of these. Deficiency of callus, although not, 
properly speaking, a disease, may, nevertheless, become a source of great difficulty on 
account of its inability to subserve the purpose of a supporting medium. The causes 
which may induce this condition, and the means of remedying it, when it exists, have 
already been pointed out. 
An exuberant callus is by no means uncommon ; it occasionally arises without any 
obvious cause, but more generally it is dependent upon the separation of the ends of the 
broken bone, as if nature were determined to effect union, despite the neglect of the sur- 
Fig. 446. 
Batcher’s Clamp for Kefracturing badly set 
Bones. DISEASES AND INJURIES OF THE BONES. 
CHAP. VIII, 
geon. The annexed cut, fig. 447, from a drawing of a specimen in the collection of the 
late Professor Cobb, of the University of Louisville, affords a graphic illustration of an 
excess of this substance, obviously produced in this way. The fracture, an oblique one, 
situated just above the middle of the right femur, had evidently occurred several years 
Fig. 447. 
Exuberant Callus after Fracture of the Thigh. 
before death. The callus, which was exceedingly porous as wrell as very brittle, was 
eleven inches in circumference at the widest part, by six inches in length. From its 
superior extremity projected two processes, which overlapped the upper fragment, and must 
have materially impeded the action of the muscles of the limb. 
An exuberant callus is occasionally produced by the presence of pieces of dead hone, 
which it thus imprisons as foreign bodies are sometimes inclosed by a cyst, or by a wall 
of plastic matter. The sheath thus formed, however, is always imperfect, openings exist- 
ing in different parts of its extent for the purposes, apparently, of drainage. Neglected 
or badly-treated comminuted fractures, caused by gunshot, railway, and other severe 
injury, are not unfrequently followed by an extraordinary redundancy of callus ; and as 
the effect of this substance is to incarcerate the fragments of the broken bone, profuse 
discharge, generally of an unhealthy, fetid, and sanious character, may be thus kept up 
for almost an indefinite period. The proper remedy, obviously, is the extraction of the 
dead fragments, a procedure occasionally of a very embarrassing character, especially 
when the callus is situated in a bone thickly covered by muscles, or in close proximity 
with important vessels and nerves. In a case under my charge many years ago, I re- 
moved not less than twenty-four pieces of this kind, some of considerable size, having 
previously made a long incision over the tumor in front of the thigh. With the aid of 
chisels, gouges, and pliers, riddance was achieved with but little loss of blood, and with 
no pain, as the patient was thoroughly under the influence of chloroform. Although the 
number of dead pieces was unusually great, such was the size and firmness of the callus 
that, notwithstanding it was obliged to be divided in almost every direction, no separation 
of the ends of the broken bone ensued, and the patient, after having recovered from the 
immediate effects of the operation, was able to walk about as before. The fracture had 
been caused nine months previously by an escapette ball. When exuberant callus exists 
in its more simple forms unaccompanied by dead bone, its removal may occasionally be 
effected by the persevering inunction with compound iodine ointment and other sorbefa- 
cient remedies. 
An extraordinary degree of brittleness, arising from an excess of earthy matter, occa- 
sionally exists in the callus of a broken bone. Sucli an event may occur at a compara- 
tively early period, as a result of causes the true nature of which is not always easy of 
detection. I believe, however, that fragility of the callus is more frequently met with in 
persons of a gouty, rheumatic, or syphilitic state of the system, than in any other class of 
individuals. However induced, the slightest injury, as a mere twist of the bone, or even 
muscular exertion, is generally capable of fracturing it, and, consequently, of reseparating 
the ends of the fragments. 
Callus is subject to softening, disintegration, and absorption, if not, also, to fatty degene- 
ration. The causes under the influence of which these changes are affected are not always, 
or, perhaps, even generally, distinguishable. In some cases they are plainly owing to 
undue compression, as from tight bandaging; in others, they are induced by premature 
exercise, or the weight of the body causing undue pressure upon the callus. Occasionally, 
the absorption is distinctly traceable to the inordinate use of mercury, carried to profuse 
salivation ; or it may depend upon a syphilitic taint of the system, especially when this 
affection has reached its third stage, in which the bones and periosteum are so constantly, 
and often .so seriously, involved. But the most common cause, perhaps, of all, is an 
impoverished and diseased state of the blood, from a want of proper food and fresh vegeta- CHAP. VIII. 
FRACTURES OF THE NASAL BONES. 
937 
bles and subacid fruits. The influence of ill-health arising from this cause upon the con- 
dition of the callus was strikingly exemplified in Lord Anson’s voyage to the Pacific 
Ocean, in which many of the crew suffered severely from scurvy. It was noticed that 
those who had formerly had fractures were attacked with absorption of the callus, speedily 
terminating in separation of the ends of the broken bone. Cicatrices, whether the result 
of the healing of wounds or of ulcers, experienced a similar fate, the parts breaking out 
into open sores, remarkably pale, languid, flabby, and difficult to cure. Similar effects are 
occasionally observed to follow the attacks of typhoid fever and anemic states of the 
system, however engendered. 
The treatment of softened and disintegrated callus must depend upon the nature of the 
exciting cause, due inquiry into which should, therefore, always be made as a preliminary 
step. Tight bandages and splints are removed ; premature exercise is avoided ; iodide of 
potassium and mercury are administered if the cause is obviously of a syphilitic nature ; 
scurvy is relieved by a change of diet, especially by the use of subacid fruits and vegeta- 
bles ; and anemia is met with tonics and stimulants, as iron and quinine, with milk punch 
and nutritious food. 
Finally, callus is sometimes the seat of severe pain, generally of a dull, aching char- 
acter, but occasionally very sharp, and recurring at every change of the weather, so that 
the part literally subserves the purpose of a barometer. Persons of a gouty, or rheumatic 
predisposition, and those affected with tertiary syphilis, are particularly prone to suffer in 
this way. Now and then the pain appears to be of a neuralgic nature. The most accu- 
rately united fracture may be followed by such an occurrence, but it is by far most com- 
mon in those in which there is a redundant or very irregular callus. The cause of the 
pain has been variously explained. The probability is that it is generally due to the 
pressure exerted by the exuberant substance upon the nerves in its immediate vicinity. 
This idea appears the more plausible when it is recollected that filaments of nerves of con- 
siderable size are sometimes imprisoned in the callus of a broken bone. 
Among the more important remedies for the relief of this pain, are various sorbefacient 
and anodyne lotions, as acetate of lead and laudanum, tincture of iodine, chloroform 
liniment, and veratria ointment. Sometimes a blister answers a good purpose. When 
the pain is dependent upon a syphilitic taint of the system, the iodides must be employed, 
either alone or in union with mercury. Colchicum will be useful when there is a gouty 
or rheumatic state of the system. Excision of the callus might be required when it is 
obvious that the suffering is due to the presence of a compressed and imprisoned nerve. 
SECT. XX FRACTURES OF PARTICULAR BONES. 
1. HEAD AND TRUNK. 
FRACTURES OF THE NASAL BONES. 
Falls and blows are the causes of this fracture, which may be either simple or compli- 
cated ; oblique, transverse or longitudinal; limited to one bone or extended over both. 
It is usually attended with severe injury of the soft parts, and sometimes with fracture 
of the ascending process of the superior maxillary bone. Occasionally, again, there is a 
separation of the nasal cartilages, or fracture of the ungual bone, the ethmoid bone, the 
vomer, or the turbinated bone. The symptoms are generally well marked, except when 
there is considerable swelling of the integument, when the nature of the lesion may easily 
be overlooked, perhaps much to the detriment of the patient. If an examination be made 
soon after the occurrence of the accident, the nose will be found to be out of shape, from 
displacement of the fragments, one of which may be depressed towards the nostril, while 
the other may form an unusual prominence beneath the skin. Crepitation is also com- 
monly distinguishable, especially when the fracture is multiple, or the bone is broken into 
several pieces. In all cases, the point of the finger should be passed over the surface of 
the nose, with a view of ascertaining whether there is any irregularity or mobility, as 
there will almost certainly be when there is a fracture. If, after this, there be still some 
doubt, it will be well to introduce a large probe, metallic bougie, or grooved director into 
the nostril, for the purpose of making counterpressure, while pressure is applied in the 
opposite direction with the end of the finger. When the bone is denuded by a wound, 
the diagnosis will seldom be difficult. 
More or less bleeding generally attends this accident; occasionally, indeed, it is very 
profuse, and in some instances it is said to have proved fatal. Another symptom, some- 938 
DISEASES AND INJURIES OF THE BONES. 
CHAP. VIII. 
times present, is emphysema at the root of the nose, extending along the eyebrows. It 
usually comes on within a short time after the accident, and is owing to an escape of air 
from the nostril across a rentof themucous membrane into thesuhcutaneousconnectivetissue. 
It is in itself of no moment, as it usually disappears spontaneously in a few days. An 
escape of tears is also an occasional occurrence. Sometimes violent cephalic symptoms 
attend these fractures, depending upon the intimate connection between the nasal and 
frontal bones, which permits the jarring effects of the blow or fall to be communicated to 
the brain and its envelops. 
Fracture of the nasal bones is not always free from danger, although the patient gene- 
rally recovers without any untoward symptoms. Danger to life is to be apprehended only 
when there is serious cerebral involvement, as when the lesion is associated with fracture 
of the cribriform plate of the ethmoid bone, separation of the dura mater at the anterior 
part of the base of the skull, copious effusion of blood, or severe concussion of the brain. 
Under such circumstances, the patient may die from shock, compression, or inflammation. 
The prognosis should, therefore, be guarded, especially as the degree of danger cannot 
always be estimated by the amount of visible injury. If the fracture is multiple, or the 
bones are crushed in, more or less deformity may be expected after the cure. 
The reduction is generally easy. The patient being seated upon a chair, with his head 
reclining against the breast of an assistant, any depression that may exist is to be reme- 
died by means of a female catheter or grooved director, inserted into the nostril, and 
made to bear against the displaced fragment until it resumes its proper level. Sometimes 
a good deal of pressure and counterpressure will be necessary, while at other times hardly 
any manipulation will be required, the mere passage of the finger over the seat of the 
fracture being sufficient to adjust the fragments. When the nasal septum, or perpendi- 
cular plate of the ethmoid bone, is thrown out of place, restoration may be effected by 
means of the finger, or some suitable instrument, introduced into the nostril. 
When the fragments have a tendency to cave in, or to fall asunder, the best means of 
counteracting it is a stout adhesive strip, carried across the bridge of the nose from one 
cheek to the other; the plaster promptly adheres to the skin, and, assuming the shape of 
the nose, effectually prevents further displacement. Or, instead of this, the depressed 
fragments may be supported, as suggested by Dr. Lewis 1). Mason, by means of a sharp, 
three-cornered, nickel-plated needle passed through the line of fracture, and retained with 
a lightly applied rubber band stretched across the bridge of the nose, and secured to the 
ends of the instrument. The older surgeons were in the habit in such cases of stuffing the 
nostrils with dossils of lint, smeared with ointment, and frequently changed for the sake 
of cleanliness. Subsequently, metallic tubes were recommended, and in modern times 
tubes of gum elastic have been used. All such contrivances are now very properly dis- 
carded ; or, if they are ever employed, it is only in cases where it is impossible, from the 
manner in which the bones have been crushed, to remedy the displacement in any other 
way. During the whole of the after-treatment the patient should refrain from blowing 
his nose. 
The symptoms which usually follow this accident, such as inflammation of the pitui- 
tary membrane, fetid discharge, and swelling of the nose and face, are combated by general 
and local bleeding, purgatives, and other antiphlogistics. The brain is carefully watched, 
and any untoward occurrence promptly met. Hemorrhage is restrained by cold applications, 
and elevation of the head and arms; if obstinate by plugging the nostrils, or by injections of 
a strong solution of subsulphate of iron. In neglected cases of this injury a not uncommon 
occurrence is deformity caused by the irregular projection of some of the fragments. In 
an instance of this kind, recently under my charge, the nose was restored to its natural 
form by rasping away the offending and superfluous matter with the aid of a dentist’s 
engine. 
FRACTURES OF THE NASAL CARTILAGES. 
The nasal cartilages are sometimes broken, or broken and partially detached from the 
nasal and maxillary bones, the most common cause of the accident being a violent blow 
or fall, inflicting, perhaps, at the same time serious injury upon the soft parts. The 
nature of the case can seldom be mistaken. When the cartilages are displaced inwards, 
the nose will necessarily be more or less flattened and depressed, and the effects will 
assume increased importance, if the lesion be conjoined with fracture of the nasal bones 
and the cartilaginous septum. The treatment must be conducted upon general principles. 
The great aim should be to preserve the contour of the nose; hence, after having 
restored the parts to their proper relations, it may be necessary to plug the nostrils with CHAP. VIII. 
FRACTURES OF THE MALAR BONE. 
939 
lint, well oiled, a metallic tube or piece of quill having previously been inserted to facili- 
tate respiration. Leeches may be required to moderate inflammation. 
In the case of a man, forty years of age, brought to the Clinic of the Jefferson Medical 
College, by Dr. McWhinney, the septum, broken into several pieces four months pre- 
viously, encroached so much upon the left nostril as to cause almost complete obstruction 
to respiration on that side. In order to afford relief, I was compelled to cut away the 
whole of the offending part with a probe-pointed bistoury. The nose seemed to have 
been very little deformed by the accident. 
Dr. Bolton, of Richmond, in a case of old displacement of the nasal septum, effected 
restoration by an ingenious process, consisting of a stellate incision made in such a man- 
ner as to form eight triangles with their apices converging to a common point. lie then 
seized the triangles separately with a pair of forceps, and broke them at their base with- 
out .detaching them. The comminuted part was next forced into its natural position and 
supported by appropriate dressings in the nostrils until union occurred. 
FRACTURES OF THE UPPER JAW. 
A fracture of the upper jaw implies the application of direct mechanical injury, in 
a concentrated and severe form. No ordinary force could produce such a result. In a 
few instances it has been caused by contre-coup, the head and lower jaw being wedged in 
between two hard, resisting bodies. Portions of the alveolar process, of variable shape, 
and even of large size, are sometimes broken off in the extraction of a tooth. There is 
nothing definite at all in regard to the situation of the fracture, since it may affect any 
portion of the bone, its body, ascending process, horizontal plate, or alveolar process. It 
is always accompanied by severe injury of the soft and hard parts, and is usually of easy 
recognition, simple inspection, or touch, commonly sufficing for the purpose. The acci- 
dent is apt to be followed by violent inflammation, requiring prompt measures for its relief. 
In the reduction, pressure and counterpressure are chiefly relied upon, the parts being 
moulded gently into their natural position by the fingers, either alone, or aided, as in 
fracture of the horizontal plate of the bone, by the grooved director inserted in the nos- 
tril. If the alveolar process has suffered, it may become necessary, in order to secure its 
proper maintenance, to tie together several of the contiguous teeth with thin silver wire. 
W hatever may be the nature of the case, the rule is, if possible, to save all, and take 
away nothing. 
In 1865, I attended, along with the late Dr. Smiley, a man forty-seven years of age, 
who had broken the left upper jaw in falling head foremost from the third-story window 
of his house upon the cellar-door belowr, a distance of about thirty-five feet. He was 
much stunned by the blow, and it was not until after he had freely vomited, seven hours 
after the accident, that entire consciousness was restored. The face and forehead were 
greatly bruised and discolored, the nasal bones were comminuted, the left eye was rup- 
tured, a considerable quantity of blood escaped from the nose and mouth, and the jaw 
was broken in such a manner that it could easily be moved about in different directions 
with the fingers. The line of fracture extended from behind forwards between the cuspid 
and small grinder, but none of the teeth were knocked out or even loosened. Notwith- 
standing the severity of the injury, the man rapidly recovered, with hardly any perceptible 
deformity, except what was caused by the state of the eye. For the first few weeks there 
was great difficulty in swallowing, and several months elapsed before solid food could be 
masticated. The treatment was very simple. Until the eighth day the principal reme- 
dies were anodynes, laxatives, and saturnine lotions. When the inflammation and swel- 
ling had measurably subsided, the head was carefully bandaged in such a manner as to 
keep the lower jaw in constant contact with the upper until the parts were thoroughly 
reunited. 
FRACTURES OF THE MALAR BONE. 
Fracture of the malar bone, as an uncomplicated lesion, is very uncommon. Like fracture 
of the upper jaw, it is always produced by direct violence, is invariably attended with 
severe contusion, if not with other injury of the soft parts, is, in general, readily recog- 
nized, is liable to be followed by high inflammation, and is easy or difficult of manage- 
ment according to the presence or absence of displacement. When the broken part is 
sunk down beyond its natural level, an attempt may be made to raise it, especially if 
there is already a wound denuding the bone, and admitting of the insertion of a suitable 
lever; if not, an incision is made, provided it seems probable that there will be unsightly 940 
deformity after the cure, if the fragment be left in its abnormal situation. Such a pro- 
cedure is much better than leaving the bone unreduced. 
In fractures of the zygomatic arch of the malar and temporal bones, the fragments, as 
a rule, are forced backwards, and hence the deformity is sometimes very considerable, 
calling for reposition with an elevator. In a case recorded by Duverney, and in another 
mentioned by Packard, the displacement took place in a forward direction. 
FRACTURES OF THE LOWER JAW. 
The lower jaw bone may be broken in any portion of its extent, not excepting even the 
symphysis. Fracture here, however, is unusual, and is met with chiefly in young sub- 
jects, before the complete union of the two opposite halves of the bone. The most com- 
mon site of fracture is the body of the maxilla, towards its anterior extremities, as in fig. 
448, and next in point of frequency, at least accor- 
ding to my observation, its ascending ramus. The 
condyle, neck, and coronoid process are seldom 
broken. The fracture may be transverse, oblique, 
or longitudinal; single or multiple; simple or com- 
plicated. When the bone yields at two points, 
there will necessarily be three fragments, and cases 
occur in which the number is still greater, the bone 
being literally crushed. Thus, Houzelot has pub- 
lished the particulars of one in which the bone was 
broken, in a fall from a height, at both condyles, 
through both coronoid processes, and at( the sym- 
physis. Sometimes the lesion is limited to the 
alveolar process, or to this process and the body of 
the jaw. In either event, there will be involvement of the gums and teeth, with, per- 
haps, extensive separation, if not complete evulsion, of the latter. Occasionally, a longi- 
tudinal fracture of the body of the bone is intersected at each extremity by a transverse 
or an oblique one. The accident, which rarely occurs before the age of manhood, is 
much more frequent in males than in females. When the ends of the fragments are 
unusually long and sharp, they may, if the parts are not well supported, pierce the mucous 
membrane, thus converting a subcutaneous into an open fracture. 
Direct violence, as a fall, blow, or kick, is the most common cause of fracture of the 
inferior jaw. In four instances, under my charge, it was produced by a blow with the 
fist upon the chin or side of the bone, one of the cases being a healthy lad, between fif- 
teen and sixteen years of age; the others, persons between twenty-five and thirty-two. 
A very common cause of this fracture is the kick of a horse. Dentists often break off 
portions of the alveolar process in the effort to extract teeth. Sometimes frightful injury 
is produced in this way. Muscular action is capable of breaking the lower jaw. A man, 
upwards of seventy years of age, an out-patient at the College Clinic, presented himself 
to the late Professor Pancoast in January, 1857, on account of a fracture of the neck of this 
bone, caused the night before in a violent paroxysm of coughing. The symptoms were 
unmistakable. The explosion of powder in firing oft' a pistol within the mouth has also 
been known to give rise to the accident. Finally, the lower jaw is sometimes broken on 
one side from a blow upon the opposite, or by counterstroke, as in a case related by Dr. 
Coekburn, in which the bone yielded at its neck. 
The symptoms of fracture of the body of the lower jaw are generally so well defined as 
to render it easy of diagnosis. Crepitation may almost always be detected by moving the 
fragments; and upon looking into the mouth the teeth will usually be found to have lost 
their natural relations. There is also commonly a perceptible inequality at the inferior 
border of the bone, which may readily be increased by motion, and which is of itself suffi- 
cient to point out the character of the injury. When the jaw gives way on both sides, 
the central piece is drawn downwards by the muscles of the throat, the front teeth are 
out of their normal position, and the mouth is open and distorted. 
In fracture of the ramus there will be a grating noise at the site of the injury, and exces- 
sive pain near the ear. From the fact that the masseter muscle is attached to, and covers 
in, both fragments, there is seldom, if ever, any considerable displacement. 
A fracture of the neck of the bone is easily detected, except in very fat subjects, by 
the crepitation produced on moving the jaw, by the preternatural mobility in front of 
DISEASES AND INJURIES OF THE BONES. 
CHAP. VIII. 
Fig. 448. 
Fracture of the Jaw. FRACTURES OF THE LOWER JAW. 
941 
CHAP. VIII. 
the ear, and by the manner in which the body of the bone is dragged forward by the action 
of the external pterygoid muscle. Similar symptoms characterize fracture of the condyle. 
In addition to the symptoms now described as indicative of fracture of different por- 
tions of the inferior maxilla, there will be more or less impediment in speaking and swal- 
lowing, difficulty in opening and closing the mouth, and inability to masticate. The 
patient experiences severe pain at the seat of fracture, aggravated by motion and manipu- 
lation ; the soft parts are usually considerably contused, if not also lacerated; and there 
is often smart hemorrhage, either from rupture of the mucous membrane or of the infe- 
rior dental artery. 
Simple fractures usually unite in from four to five weeks, without ultimate deformity 
or functional impediment. Those of the neck of the bone require a longer time, and 
more care in their management, than those of the body and ramus. Complicated frac- 
tures of the jaw are often followed by severe suffering, caused either by inflammation, 
abscess, caries, or necrosis. Great emaciation sometimes arises from the inability of the 
patient to take sufficient nourishment during the long confinement of the parts. 
During the reduction of these fractures, the patient should be seated upon a chair, with 
his head firmly supported upon the breast of an assistant. The surgeon, passing his 
fingers along the base of the jaw, supposing that it is the body that is broken, moulds the 
parts into proper shape, and then, closing the mouth, sees that the lower teeth rest fairly 
against the upper. When the fragments overlap each other, they must be drawn in oppo- 
site directions, when the slightest pressure will generally suffice to effect their restoration. 
If any of the teeth are loosened, or partially forced from their sockets, and they are per- 
fectly sound, they should by all means be retained, being secured, if need be, to the 
adjacent ones, by a silver wire. Formerly it was the custom to treat all such teeth as 
extraneous bodies, under the erroneous belief that they were incapable of readhesion. 
The fracture being reduced, as may always be known by the evenness of the dental 
arch and of the inferior margin of the jaw, a piece of pasteboard, or, what is preferable, 
of felt, fig. 449, immersed in hot water, is accurately moulded to the base and sides of the 
jaw, and, after being well lined with wadding, confined by a roller carried round the top of 
the head in the form of the figure 8, one portion of the bandage lying in front, the other 
behind the ears. The lower jaw being thus pressed firmly against the upper, the bandage 
is next conducted across the chin and the occiput above the ears, so as to give the frag- 
ments due support in front. This mode of dressing is very simple and efficient, and gen- 
erally answers the purpose exceedingly well. When any unusual tendency to anterior 
displacement exists, it may readily be counteracted by a stout adhesive strip, extending 
from the chin along the lower part of the face to the side of the occiput. The annexed 
cuts, figs. 450 and 451, represent the bandages of Gibson and Barton, formerly so much 
Fig. 449. 
Fig. 450. 
Fig. 451. 
Felt Mould. 
Gibson’s Jaw Bandage. 
Barton’s Jaw Bandage. 
employed in this country in the treatment of fractures of this bone. Instead of the felt 
or pasteboard splint, a mould of sheet lead may sometimes be advantageously used, as it 
readily adapts itself to the parts, and affords steady, uniform support. Recently I had 
under my charge a case of fracture of this bone, unattended with displacement, where a 
rapid and perfect cure was effected without any dressing whatever. 
Professor Hamilton, in the treatment of fractures of this bone, employs an apparatus 
consisting of three straps, one of which, composed of firm leather, extends round the jaw 942 
DISEASES AND INJURIES OF THE BONES. 
and head in the direction of the coronal suture, while the other two, made of strong linen 
webbing, pass horizontally round the head, above the ear, the anterior being buckled to 
the forepart, and the posterior to the baekpart, of the 
vertical one. The great advantage of this contrivance, 
represented in tig. 452, is the strong support it gives 
to the ends of the fragments, thus effectually prevent- 
ing displacement. 
Instead of confining the splints or moulds used in 
the treatment of fractures of the lower jaw with the 
ordinary roller, a great point is gained by using the 
CHAP. VIII. 
Fig. 452. 
Fig. 453. 
Hamilton’s Apparatus. 
Thomas’s mode of adjusting Fractures of the lower Jaw 
with wire and key. 
immovable bandage, the hair previously been cut very close, and the head covered with a 
layer of wadding or thin flannel. Such a bandage, properly applied, keeps the parts effectu- 
ally in position until complete union is obtained. 
In fracture of the neck and condyle of the jaw, maintenance is always peculiarly diffi- 
cult, on account of the action of the external pterygoid muscle. The most effective means 
of counteracting this tendency is to confine a thick, graduated compress behind the angle 
of the bone, the case being treated, in other respects, as if it were one of fracture of the 
body of the jaw. 
In comminuted fracture, it is sometimes exceedingly difficult, if not impossible, despite 
the best directed efforts, to keep the fragments on a level with each other, such being 
their constant tendency to displacement. To rectify this tendency, the contiguous teeth 
should be connected together with delicate silver wire ; or, what is better, because more 
efficient, some of the teeth may be secured to a thin silver plate, interposed between them 
and the cheeks. Mr. Tomes, of London, has suggested the use of a silver cap for the 
teeth, and Mr. Hugh O. Thomas, of Liverpool, connects the fragments together with silver 
wire, secured with a key, as in fig. 453. Mr. Hammond’s ingenious contrivance also 
answers an excellent purpose. It consists of a frame of iron wire, fig. 454, which is 
slipped over the teeth, and fastened by passing around each a thin iron thread, as a 
Fig. 454. 
Fig. 455. 
Hammond’s Wire Splint for Fracture of the Jaw, 
Hammond’s Wire Splint applied. 
binder, to keep the frame firmly in its place, as shown in fig. 455. The operation is 
completed by cutting off the ends of each thread, and turning them in between each two 
contiguous teeth, so as not to interfere with the movements of the lips and cheeks. Occa- 
sionally it is necessary to take a plaster cast of the jaw as a preliminary step. 
The interdental splint, devised nearly at the same time by Dr. Gunning, of New York, CHAP. VIII. 
FRACTURES OF THE LOWER JAW. 
943 
and by Dr. Bean, of Georgia, is adapted to fractures both of the upper and lower jaw, 
particularly to comminuted and compound fractures, attended with inordinate and constant 
tendency to displacement of the fragments. The only objections to its employment are, 
that it is somewhat expensive, and that it cannot always be readily obtained. The splint, 
as seen in fig. 456, consists essentially of a plate of vulcanized India-rubber, accurately 
moulded by means of a wax or plaster impression to the dental arches, and kept in posi- 
tion by a chin compress of the same material, fastened by an occipito-frontal bandage. In 
this way the most complete adjustment can be maintained without inconvenience to the 
patient, and, if the apparatus be properly constructed, without the slightest deformity, 
except in the event of great loss of bone. A good idea of the external parts of the appa- 
ratus is afforded by the annexed sketch, fig. 457. 
Fig. 456 
Fig. 457. 
Bean’s Interdental Splint. 
Interdental Splint, applied. 
In edentulous subjects, a mould of hard rubber, constructed after the manner of the 
plate for artificial teeth, should be interposed between the two jaws. In no other way, in 
fact, can the ends of the fragments be maintained in apposition. Wedges of cork, recom- 
mended by some surgeons, are highly objectionable, as, from their porous character, they 
readily imbibe the secretions of the mouth, and thus become a source ol fetor, it not of 
disease. 
Wounds, contusions, and hemorrhage, complicating these fractures, are managed upon 
general principles ; inflammation is combated by the usual measures; loosened teeth and 
necrosed bone are promptly removed ; and the parts are kept steadily at rest, renewal ot 
displacement being guarded against by the most sedulous attention both of the patient and 
the surgeon. The food should consist of slops, as grated cracker and milk, broths, gruel, 
beef essence, and similar articles, introduced into the mouth with a small spoon. The 
custom which formerly prevailed of conveying nourishment into the stomach by means of 
a tube passed through the nose, has become obsolete, as well as the still more reprehen- 
sible practice of extracting one of the front teeth, to afford room for feeding the patient. 
After the case has advanced for several weeks, a semisolid, farinaceous diet may be allowed. 
In compound and comminuted fractures of the lower jaw, especially in those caused by 
gunshot injury, the secretions of the mouth and of the salivary glands are always exces- 
sively foul and abundant, and are liable, it swallowed, to give rise to a low, typhoid con- 
dition of the system; in fact, to a bad form of septicemia, followed gradually, if not soon 
relieved, by death. In order to prevent such an occurrence, the greatest attention should 
be paid to cleanliness, the mouth being frequently washed with lotions of chlorinated 
sodium, alcohol, or permanganate of potassium, abscesses promptly opened, dead bone 
removed, and the strength supported with quinine, iron, opium, and alcoholic stimulants. 
An instance of ununited fracture of this bone is sometimes met with, and now and then 
a false joint is found to exist, requiring, in the former case, the employment of ordinary 
measures, and in the latter, denudation of the ends of the fragments, aided, perhaps, by 
the silver wire suture or the insertion of a metallic pin. 944 
DISEASES AND INJURIES OF THE BONES. 
CHAP. VIII. 
FRACTURES OF THE IIYOII) BONE. 
The hyoid bone, from its great mobility, and from the protection which it receives from 
the lower jaw, is seldom the seat of fracture. The accident is usually occasioned by falls 
or blows, or by the pressure of the thumb and fingers in attempts at strangulation. An 
instance is mentioned where it was produced by muscular action, the patient having fallen 
violently backwards upon his head. Persons who commit suicide by hanging occasionally 
break this bone with the rope. The fracture is generally seated in the large horns, some- 
times in both, at other times only in one. It is liable to be complicated with injury of 
the larynx, lower jaw, and other parts, the skin being usually bruised and discolored. 
The patient is unable to swallow, to articulate distinctly, and to move his tongue, except 
in the most limited degree, and then not without great suffering, and, perhaps, a sense of 
suffocation. Crepitation is generally sufficiently evident, especially during deglutition 
and when the index finger is placed in the throat in contact with the smaller fragment, 
the corresponding finger resting upon the neck. The pain is very acute, and is aggra- 
vated by the slightest motion. Sometimes the patient is conscious of a peculiar crushing 
sound at the moment of the accident. Occasionally there is laceration of the mucous 
membrane of the fauces, followed by copious hemorrhage, as in a case reported by Pro- 
fessor Wood, of Cincinnati. 
Fracture of the hyoid bone, although not in itself necessarily dangerous to life, often 
becomes so in consequence of its complications, death having occurred in 12 cases out of 
23 referred to by Fischer, of Hanover. Even in the most simple cases it is generally 
exceedingly troublesome, on account of the great mobility of the fragments, and the 
severity of the supervening inflammation and swelling. Occasionally abscesses form, the 
detached piece becomes necrosed, and the neck is pierced with fistulous orifices, which are 
slow in healing. The accident has hitherto been noticed chiefly in aged subjects, probably 
on account of the great brittleness of the bone at that period of life. 
In the treatment of this fracture, the head must be inclined forward, and maintained 
in a state of the utmost quietude, by an appropriate bandage secured around the chest. 
If there is much displacement, readjustment should be attempted by means of the finger 
in the throat while counterpressure is made externally. Perfect silence should be 
enjoined. Pain and swelling are subdued by leeches applied to the neck, followed by 
saturnine and anodyne fomentations ; the bowels are freely evacuated by stimulating injec- 
tions, and fever is combated by the usual means. For the first few days, the amount of 
food and drink should be barely sufficient to sustain life. If the patient cannot swallow, 
the stomach tube must be used, or nourishment must be administered by the rectum. 
After the swelling of the neck has measurably subsided, an attempt should be made to 
keep the fragments in place by compresses and adhesive strips. If necrosis occur, the 
dead bone should be promptly extracted. In ordinary cases, the fracture will unite in 
from six to eight weeks. 
FRACTURES OF THE CLAVICLE. 
The clavicle, owing to the delicacy of its structure, its exposed situation at the top of 
the chest, and its connection with the shoulder and arm, is extremely liable to break. Of 
2358 cases of fractures of different pieces of the skeleton, referred to by Malgaigne, 228 
occurred in this bone, and of this number nearly three-fourths were observed in the male, 
thus exhibiting a remarkable disparity in regard to the relative frequency of the lesion in 
the two sexes. The accident is not peculiar to any particular period of life ; I have wit- 
nessed it in a child under six months of age; and Dr. W. Keller, formerly of this city, 
showed me a case in which it had taken place in the foetus from the fall of the mother 
upon the wheel of a carriage, at the eighteenth week of gestation. The child, at the time 
of my examination, was several months old, and the seat of the fracture, which was near 
the middle of the right clavicle, was indicated by a well-marked forward angular projec- 
tion of the ends of the fragments, which, however, were firmly united before birth. A 
similar case was shown to me, in 1861, by Dr. William B. Atkinson, the fracture having 
been produced by a blow upon the abdomen of the mother at the end of the seventh 
month of pregnancy. Gurlt has collected the particulars of seven cases of intrauterine 
fracture of this bone caused by external violence. 
Fractures of this bone may be simple, compound, or comminuted; unilateral or bilate- 
ral ; transverse or oblique ; partial or complete. A strictly transverse fracture of the 
clavicle is among the rarest of accidents, and I have myself never met with an instance FRACTURES OF THE CLAVICLE. 
945 
CHAP. VIII. 
of it, either in the living subject, or in any of the specimens contained in our museums. 
The bone nearly always gives way obliquely, the ends of the fragments being generally 
rather long and sharp, and often distinctly serrated. When very sharp, they may pierce 
the skin, or, at any rate, press against it with so much force as to cause much uneasiness, 
and not a little difficulty in maintaining apposition. It is very uncommon for the bone to 
break at several points; such an accident, in fact, can only happen from the application 
of direct injury. Simultaneous fracture of both clavicles is exceedingly rare. I have 
two clavicles in my possession, from the same subject, which were broken in the same 
situation, but whether by the same accident, I am unable to say. Only six instances of 
the double injury are referred to by Malgaigne. To these may now be added three others, 
recorded, respectively, by Foucher, Rhoads, and Burr. Of io8 cases of fractures of the 
clavicle treated in the New York Hospital, 4 were double. The incomplete fracture of 
this bone is an accident of early childhood, and is of much more frequent occurrence 
than is generally supposed. 
The seat of the fracture is usually at or near the middle of the bone, as it is here that it 
is thinnest and weakest. Of twelve preparations now before me, it is about this point in 
eight; in three it is towards the acromial ex- 
tremity, and in one towards the sternal. 
Fracture of either end is very uncommon, 
and I have never met with an instance, either 
during life or after death. 
Great displacement, as shown in fig. 458, 
generally attends fractures of the clavicle ; 
now and then, however, the broken ends main- 
tain their natural relations, as I have myself 
noticed in five instances. Such an event can 
only occur when the fracture is incomplete, 
or when the periosteum is only partially divided and there has been no dragging of the 
shoulder. Generally the outer fragment is drawn downwards, forwards, and inwards, by 
the weight of the limb and by the action of the deltoid, pectoral, and subclavian muscles; 
the inner, on the contrary, is usually somewhat raised by the sterno-cleido-mastoid, but 
not so much as its extraordinary prominence would 
seem to indicate, its tendency to displacement in that 
direction being pretty effectually counteracted by the 
great pectoral muscle and the costo-clavicular liga- 
ment. These appearances are well seen in fig. 459. 
Cases in which the acromial fragment overlaps the 
sternal, although infrequent, have been witnessed by 
numerous observers, as Desault, Malgaigne, Gueretin, 
Syme, Hamilton, and Stephen Smith. In fracture of 
the extremities of the clavicle, the loss of apposition 
is usually very slight, owing to the manner in which 
the bone is attached to the scapula and the sternum. 
In comminuted fracture, the displacement may be so 
great as to render reposition impracticable, the mid- 
dle fragment being occasionally tilted up perpendicu- 
larly. When the bone gives way external to the 
coraco-acromial ligaments, the outer fragment is 
sometimes turned round at a right angle with the inner. 
The accident is generally caused by indirect violence, as a fall upon the hand, elbow, 
or shoulder, especially the latter, in which the sternal extremity of the bone is impelled 
by the weight of the body, at the same time that the acromial end is thrust forcibly in the 
opposite direction by the object struck against. Not unfrequently, however, it occurs 
from direct injury, as a blow or fall. I have seen two cases in which it was occasioned 
by the recoil of a shot-gun ; and a similar example was reported to me by the late I)r. 
Ilerschel Foote, of West Philadelphia. Children often break the clavicle by tumbling 
out of bed, or by rolling down a flight of stairs. In several instances, as in one recently 
reported by Dr. W. E. Whitehead, of the Navy, the accident was caused by the inordi- 
nate action of the pectoral and deltoid muscles. Gurlt has collected the particulars of twenty 
cases of fracture of the clavicle produced by muscular contraction. In a case observed 
by Dr. Willard Parker, it was produced in an effort to strike a dog with a whip, the bone 
Fig. 458. 
Fracture of the Clavicle. 
Fig. 459. 
Complete Oblique Fracture near the Middle 
of the Clavicle. DISEASES AND INJURIES OF THE BONES. 
CHAP. VIII. 
being slightly diseased at the time. When both clavicles are broken, one generally gives 
way by indirect, and the other, immediately after, by direct force. 
The symptoms are generally well marked. The shoulder has a singularly depressed 
appearance, being drawn downwards, forwards, and inwards by the weight of the limb 
and the action of the muscles, especially the deltoid and small pectoral; the head and 
trunk are inclined towards the injured side ; there is impossibility of rotating the arm, or of 
carrying the hand to the face ; and the patient commonly supports the elbow in order to 
take off the weight of the limb from the broken bone. The seat of the fracture is gene- 
rally readily discovered by the eye, the deformity being nearly always extremely con- 
spicuous; and the finger, as it traces the outline of the bone, cannot fail to detect any 
existing irregularity. Crepitation is elicited by taking hold of the elbow and pushing the 
arm upwards, outwards, and backwards, in a direction opposite to that of the displace- 
ment. The same procedure will serve to efface the deformity, which, however, is in- 
stantly reproduced upon the removal of the restraint. When the fracture is imperfect, 
serrated, or unattended with displacement, there is usually an absence of crepitation, and 
the diagnosis can be established only, as a general rule, by a careful digital examination, 
aided by the alternate elevation and depression of the shoulder. In such a case the plan 
suggested by Roberts is worthy of trial. The patient is desired to raise himself upon 
his two wrists, and, while he does this, the fingers applied to the clavicle readily detect 
crepitation. 
Although the patient is generally unable, in fracture of the clavicle, to carry his hand 
to the head, I have met with some very striking exceptions to this rule, both in children 
and adults. In a man, forty years of age, whom I saw with Dr. O’Reilly, this move- 
ment could be executed with quite as much facility as with the other limb. He could 
even swing the limb about without any pain or inconvenience. The fracture, caused by 
a fall upon the edge of a doorstep, was situated towards the acromial extremity of the 
bone, and was attended with marked displacement. In children, this anomaly is much 
more frequent than in grown persons. 
Fractures of the clavicle are, according to my experience, seldom cured without more 
or less deformity, whatever pains may be taken to prevent it. In some of my cases I have 
found it impossible, despite the greatest care and patience, to effect accurate restoration ; 
but even when the parts are placed in the closest relations with each other, the slightest 
movement of the head, neck, trunk, or arm is often sufficient to separate them. This 
difficulty will, I think, be most likely to occur when the fracture is situated at or towards 
the acromial extremity of the bone, in which the outer fragment is frequently, if not 
generally, thrown backwards in such a manner as to render it almost impossible to bring 
it to its natural position. From the cases that I have seen of this fracture, as treated by 
other surgeons, and from the numerous specimens of it to be found in our museums, it is 
certain that a cure without deformity is very uncommon. It is gratifying, however, to 
know that the deformity, even if considerable, does not generally at all impair the useful- 
ness of the limb. Union will, of course, be materially retarded, but in time nature will 
succeed in rounding off the ends of the fragments, and in connecting them firmly together, 
either by an osseous clasp or by a kind of bridge. When union fails to occur, the power 
of the arm is always weakened. In some cases a false joint is formed, and the ends of 
the fragments move more or less freely upon each other. Consolidation ordinarily takes 
place, in the adult, in about five weeks ; in children, in eighteen to twenty days. 
Among the more serious effects of fracture of this bone are, violent inflammation of 
the soft parts, followed by erysipelas, suppuration, and great swelling; extensive extrav- 
asation of blood, with consequent discoloration of the skin ; and paralysis of the arm 
from concussion, contusion, or compression of the axillary plexus of nerves. These oc- 
currences, especially the latter, are most frequent in compound, comminuted fractures of 
the clavicle, attended with inordinate displacement of the fragments. A few examples 
of gangrene of the superior extremity from compression of the subclavian vein have been 
recorded, and the subclavian artery has occasionally been lacerated. Annoying abscesses 
sometimes form, and in all compound injuries of this bone, erysipelas is a common occur- 
rence. Gunshot fractures of this bone are often very serious accidents, from the injury 
inflicted upon the soft parts around both by the bullet and the osseous splinters, which 
are sometimes scattered about in every direction. Partial paralysis of the superior ex- 
tremity, with atrophy and permanent contraction of some of the muscles of the arm, fore- 
arm, and hand, may be mentioned as an occasional result of these lesions, as in a case 
recently under my observation in a lad, fifteen years of age, who had the right collar-bone 
badly broken four months and a half previously by the recoil of a shot-gun. CHAP. VIII. 
The reduction is generally easily effected by grasping the elbow and carrying the arm 
upwards, outwards, and backwards. If anything further be required, the lingers may be 
passed along the broken bone, to mould the ends of the fragments into proper shape. To 
maintain the parts in this position, the elbow should be permanently secured to the an- 
terior and lateral aspect of the chest, the forearm lying across the front in such a manner 
as to make the hand grasp the sound shoulder, where it should remain during the whole 
of the after-treatment. Of the numerous contrivances that 
have been devised as retentive means in fractures of this 
bone, I give the most decided preference to that depicted 
in fig. 460, known as Velpeau’s dressing, consisting of a 
wedge-shaped pad and an ordinary muslin roller, carried 
around the limb, shoulder, and chest, so as to secure the 
parts firmly in the position above indicated. The pad 
should rest in the axilla, with the large end uppermost, 
and should be well secured to the opposite shoulder by 
broad tapes. As a preliminary step, the trunk should be 
incased in a layer of wadding to protect the skin. The 
different turns of the bandage should be thoroughly wet 
with a saturated solution of silicate of potassium, applied 
with a suitable brush, and thus kept permanently in place, 
the whole forming an immovable dressing, which, unless 
the weather is very hot, or the skin unusually perspirable, 
may be worn comfortably without being changed, until the 
fracture is completely consolidated. If any of the turns 
of the bandage become loose, they may easily be glued 
together with the silicate, thus obviating the necessity of 
renewing the entire dressing. 
The adhesive plaster dressing which I introduced to the 
notice of the profession in 1852, and which I at one time 
employed a great deal in the treatment of fractures of the 
collar-bone, is, when properly applied, not only very 
efficient, but neat and comfortable, easily renewed, and particularly adapted to children. 
The strips, which should be from two to three inches in width, may be so arranged as to 
make a certain degree of pressure, through the medium of a compress, directly upon the 
seat of the fracture; or, if this be deemed unnecessary, the seat of the fracture may be 
kept under constant surveillance by letting it remain uncovered. The dressing need not 
be renewed oftener than once or twice, if, indeed, at all, during the entire treatment. If 
the skin be covered with hair, the surface should previously be well shaved, to facilitate 
the removal of the plaster. Any tendency in the shoulder to sink forwards and inwards 
should be counteracted by means of an axillary pad. 
The apparatus of Dr. Fox, for the treatment of fractures of the clavicle, has become 
classical with the profession of this country, having been in general use for upwards of 
thirty-five years. At the Pennsylvania Hospital, where it was originally introduced, 
hardly anything else was, until recently, employed for this purpose. It is composed, as 
seen in fig. 461, of an axillary pad, of a sling for the forearm and elbow, and a well-stuffed 
muslin ring to encircle the sound shoulder, and receive the tapes attached to the ends of 
the sling. An additional support for the hand is suspended from the neck. The appa- 
ratus of Dr. Fox has been highly lauded, on the ground that it perfectly fulfils all the 
indications of treatment. I have not, however, found it at all equal to either of the con- 
trivances above described. Its great defect consists in its allowing too much freedom of 
motion of the arm, thereby endangering displacement of the ends of the fragments; and a 
similar remark is applicable to the various modifications of this apparatus by Levis, Ham- 
ilton, Bartlett, and other surgeons. The great desideratum is to keep the arm, forearm, 
and hand immovably fixed, otherwise accurate maintenance of the fractured extremities 
will be impossible. Hence, in the employment of these contrivances the arm should 
always be well bandaged to the trunk. An axillary pad I use only when there is a strong 
tendency in the shoulder to sink downwards and inwards. In all other cases it may very 
properly be dispensed with, the more especially as its employment, if not carefully 
watched, may produce undue compression of the axillary vessels and nerves, terminating, 
as it has occasionally done, in inflammation, ulceration, gangrene, or partial paralysis of 
the corresponding limb. An instance has been reported in which, from this cause, the 
brachial artery was obliterated. 
FRACTURES OF THE CLAVICLE. 
947 
Fig. 460. 
Velpeau’s Clariclo Bandage. 948 
DISEASES AND INJURIES OF THE BONES. 
CHAP. VIII. 
The stellate or figure-of-8 bandage was at one time a great favorite with French sur- 
geons in the treatment of this injury, and there is no doubt that many excellent cures 
Fig. 4G1. 
Fig. 462. 
Fox's Apparatus for Fracture of the Clavicle. 
Figure-of-S Bandage. 
were effected with it. It consists, as shown in fig. 4G2, of a wedge-shaped pad and a 
long roller, carried alternately around each shoulder, after which the arm and forearm are 
secured to the side and front of the chest in the 
usual manner. The bandage of Desault, once 
so much employed in this country, has become 
obsolete. Boyer’s apparatus for fracture of the 
clavicle is represented in fig. 4G3, and is a very 
neat and efficient contrivance. 
Dr. Moore, of Rochester, prefers to all other 
contrivances in the treatment of these fractures 
what he terms the “ elbow figure-of-8 bandage,” 
consisting of a piece of cotton clotb, two yards 
long, and, when folded like a cravat, eight 
inches in breadth at the middle. The object of 
this arrangement is to form a sling for the elbow 
and to carry the arm backward in close contact 
with the side of the chest, so as to maintain the 
clavicular portion of the great pectoral muscle 
in a state of tension. The centre of the band- 
age resting on the elbow, the posterior tail is 
carried by a spiral movement across the front of 
the shoulder of the affected side, and intrusted 
to an assistant; the other end is then carried 
across the forearm, raised at an acute angle 
with the arm, behind the back, over the opposite 
shoulder, and around the axilla, where the ex- 
tremities are firmly stitched or pinned together. 
The forearm is suspended by a broad strip of 
muslin to the top of the main bandage, the hand being left free. The adjoining cuts, figs. 
464 and 465, afford a good view of the arrangement of Moore’s dressing. 
Dr. Dugas, of Georgia, in fractures of this bone, simply employs a triangular piece of 
thick, unbleached muslin, to each angle of which is attached a bandage from three to four 
yards in length by three inches in width. The apparatus, which is described at length in 
the Southern Medical and Surgical Journal for 1852, is applied in such a manner as to 
form a sling for the elbow and forearm, at the same time that the arm is firmly secured to 
the side. No pad is used. 
In children the most simple management frequently suffices, in the treatment of this 
Fig. 463. 
Boyer’s Apparatus. FRACTURES OF THE CLAVICLE. 
949 
CHAP. VIII. 
lesion, especially when the fracture is incomplete, the ends of the fragments remaining 
partially in apposition. In such a case all that is really necessary is to suspend the fore- 
arm and elbow in a sling, and to confine the arm to the chest with a few broad strips of 
adhesive plaster. In the treatment ot fractures of the collar-bone in women special care 
must be taken in the application of the bandages not to injure the breasts. 
Fig. 464. 
Fig. 465. 
Moore’s Apparatus for Fracture of the Clavicle. Front 
view. 
Moore’s Apparatus. Back view. 
Great stress is very properly laid by surgeons in the treatment of fractures ot the collar- 
bone since attention was first prominently directed to the subject by Dr. Edward Harts- 
horne, of this city, upon the employment of the supine posture, the special efficacy of the 
plan depending largely upon the pressure made uj>on the lower angle of the scapula. In 
order to render the treatment as efficient as possible, the patient’s back should rest upon a 
broad, firm, unyielding mattress, the head should be raised and slightly inclined forwards 
to relax the sterno-cleido-mastoid muscles, and the forearm and elbow should be supported 
in a sling across the chest, the palm of the hand grasping the shoulder. To assist in 
pressing the shoulder backward it has been suggested to keep it covered for the first few 
weeks with a bag of shot weighing six or eight pounds. The great objection to this mode 
of management is that it necessitates a long and tedious confinement in bed, which few 
persons are willing to undergo. Women ought to be more willing than men to submit to 
it, inasmuch as the avoidance of deformity in them is of much greater importance. 
Von Langenbeek, in view of the great difficulty of keeping the ends of the frag- 
ments in contact in fractures of this bone, has of late employed the wire suture, and he 
warmly recommends the general adoption of this measure. Such a procedure, however, 
is not only difficult, but few cases can arise in which it can be necessary or proper. 
When both clavicles are simultaneously fractured, the treatment should be conducted 
upon the same general principles as when one alone of these bones is broken. Two small 
axillary pads will generally be required to keep the shoulders properly in place, and the 
elbows should be raised with more than ordinary care. Confinement of the patient in bed 
for several weeks will materially conduce to his comfort and rapid recovery. The treat- 
ment will be greatly facilitated under such circumstances, by the use of the figure-of-8 
bandage, or Boyer’s apparatus in keeping the fragments in place. 
In comminuted fracture of the clavicle attended with compression of the subclavian vein 
threatening gangrene of the superior extremity, the only rational procedure is speedy re- 
moval of the offending fragment, provided reposition by the ordinary means is unavailing. 
A compound fracture, in such a case, would be far preferable to the risk of loss of limb 
and life. Laceration of the subclavian artery, consequent upon comminuted fracture of 
this bone, must be treated with the ligature, the vessel being tied at both ends. 950 
An ununited fracture of this bone is an unfortunate occurrence, especially when it is 
caused by great loss of substance, as it is then irremediable. In ordinary cases a seton, 
cautiously inserted, will answer the purpose ; or the ends of the fragments might be con- 
nected together with a steel screw, or silver wire. 
FRACTURES OF THE SCAPULA. 
Fractures of the scapula are extremely uncommon. Of 1902 cases of fractures of 
different pieces of the skeleton, treated at the Middlesex Hospital, London, only 18, ac- 
cording to Lonsdale, occurred in the shoulder-blade. At the IIotel-Dieu, at Paris, the 
scapula, in 2358 cases, was broken only in 4. On the contrary, a remarkable disproportion 
of such cases sometimes occurs in the hands of particular surgeons. Thus, Dr. Dugas 
has met with four cases of this accident, and Dr. Bullock with not less than six, although 
neither has witnessed an unusual number of other fractures. The injury may show itself 
in various forms and directions, and may occupy either of the two processes of the scapula, 
its neck, its body, or its inferior angle. 
a. The acromion process, fig. 4GG, from its exposed situation, is more frequently broken 
than any other part of the bone, the accident being usually caused by a blow upon the 
top of the shoulder, or by violence applied directly to the pro- 
cess itself. It may also be produced by force transmitted along 
the humerhs by a fall upon the elbow or the palm of the hand. 
In a case treated by Mr. Phillips, of London, the accident was 
the result of muscular contraction. There is reason to believe 
that what is sometimes regarded as a fracture of this process is 
merely a separation of its epiphysis, which frequently fails to 
coalesce with the rest of the bone until late in life, as I have 
seen in a number of examples. The osseous consolidation is 
occasionally postponed until after the age of forty. The frac- 
ture is generally somewhat oblique, and its signs are so peculiar 
as to be characteristic. The natural rotundity of the shoulder 
is destroyed; the outer fragment is drawn down by the weight 
of the arm, which hangs motionless by the side of the body ; 
the head of the humerus can be felt in the axilla; there is a 
depression at the situation of the fracture ; the distance between 
the shoulder and the t >p of the sternum is diminished ; and 
crepitation may be detected on lifting the arm in contact with 
the displaced fragment. In addition to these symptoms there 
is acute pain at the seat of the injury ; the limb cannot be raised by its own efforts ; and 
the patient inclines his head towards the affected side, and supports the forearm as in 
fracture of the clavicle. 
The only accident with which fracture of the acromion process is liable to be confounded 
is dislocation of the humerus, from which, however, it may generally be easily distinguished 
by the sunken appearance of the shoulder, the mobility of the outer fragment, the existence 
of crepitation, and the ready effacement of deformity by the elevation of the arm, fol- 
lowed by its instantaneous recurrence when the surgeon relinquishes his hold. In dis- 
location, the acromion process stands out in bold relief, crepitation is absent, and the head 
of the humerus is firmly fixed in its abnormal position. 
The union is usually ligamentous instead of osseous, owing to the difficulty experienced 
in preserving the contact of the fragments. This occurrence will be more likely to happen 
when the tip of the acromion is broken off than when the fracture is seated near its root. 
In the treatment of this accident the leading indications are to secure the arm and fore- 
arm firmly to the antero-lateral part of the chest, and to raise the humerus against the 
top of the shoulder-joint, so that its head may serve as a splint for the broken process. 
For this purpose, the same bandage is used as for fracture of the clavicle, but the axillary 
pad is dispensed with, lest the broken piece should be pushed too far outwards. 
0. In fracture of the neck of the scapula, fig. 4G7, the coracoid process and glenoid 
cavity are detached from the rest of the bone in an oblique direction. The accident is 
one of such great rarity that many surgeons have doubted the possibility of its occurrence. 
It can be produced only by great direct violence, although one case—that of Mr. May, 
of England—is known in which it was caused by muscular contraction in a young lady, in 
the act of throwing her necklace over her shoulder, the bone having doubtless been 
exceedingly brittle from some organic defect. 
DISEASES AND INJURIES OF THE BONES. 
OHAP. VIII. 
Fig. 466. 
Fracture of the Acromion 
Process. CHAP. VIII. 
FRACTURES OF THE SCAPULA. 
951 
The symptoms are always well marked. The acromion is unusually prominent, 
the head of the humerus is felt in the axilla, the shoulder has a flattened appear- 
ance, the limb is lengthened, the coracoid process is 
thrown down below the clavicle, between the deltoid 
and pectoral muscles, severe pain and numbness are 
experienced in the axilla, and distinct crepitation is 
perceived on rotating the arm upon the scapula. The 
accident bears, at first sight, considerable resemblance 
to a dislocation of the humerus into the axilla, from 
which, however, it may always be readily distinguished 
by the facility with which the parts may be restored to 
their natural situation, by the immediate return of the 
symptoms when the limb is left to itself, and by the 
existence of crepitation. From fracture of the neck 
of the humerus it may be known by the circumstance 
that, in the latter, the shoulder retains its rotundity, 
and that the limb, instead of being lengthened, is short- 
ened ; the acromion also is much less prominent. 
In two cases of this accident, observed by Dr. Dugas, 
the fracture, produced by a blow upon the shoulder from 
a falling tree, was instantly followed by paralysis of the 
limb and cessation of pulsation in all its arterial trunks ; 
a consequence, evidently, of injury done to the axillary nerves and vessels. Treatment 
having been neglected, no union took place, and the arms never recovered their functions. 
This fracture is retained with difficulty, and is liable to be followed by stiffness of the 
shoulder-joint, atrophy and paralysis of the muscles of the arm, and other disagreeable 
effects. It is managed in the same manner as fracture of the clavicle, with an axillary 
pad, the elbow being kept well raised, and the scapula thoroughly steadied until there is 
complete reunion. If the parts are much contused, leeches, fomentations, and other anti- 
phlogistics may be required. Passive motion should be instituted at the end of four weeks, 
and afterwards renewed every few days. Consolidation may be expected in two months. 
It is not improbable that the edges of the glenoid cavity may occasionally be broken 
off, either by direct force, or by the sudden and violent propulsion of the head of the 
humerus. It is remarkable, however, that the existence of such a lesion has never been 
demonstrated by dissection. Is it not likely that some of the bad forms of luxation of the 
shoulder-joint, in which the reduction is maintained with great difficulty, and which are 
so liable to terminate in permanent ankylosis and ruin of the articulation, are cases of this 
description ? The subject is worthy of greater attention than it has hitherto received. 
Fig. 467. 
Fracture of the Neck of the Scapula. 
Fig. 468. 
Fig. 469. 
In the annexed cut, fig. 4f*8, from Fergusson, the fracture extends 
through the glenoid cavity. 
y. The coracoid proctss is sometimes broken by a severe fall 
or blow, generally a short distance from its tip, the fracture being 
usually accompanied by great contusion of the soft parts, and 
fracture of the acromion, clavicle, or humerus. The accident, 
which is of very rare occurrence, is characterized by inability 
to raise and adduct the arm, by preternatural mobility, by depression of the detached 
fragment by the conjoined action of the small pectoral, two-headed flexor, and coraco- 
Fracture of the Coracoid Process. 
Fracture of the Glenoid 
Cavity. 952 
DISEASES AND INJURIES OF THE BONES. 
CHAP. VIII . 
brachial muscles, and by the detection of crepitation on moving the arm upon the 
shoulder, the finger being placed between the deltoid and great pectoral muscles. The 
adjoining sketch, tig. 409, from a preparation in Professor Neill’s collection, afibrds an 
illustration of a well-marked specimen of fracture of the coracoid process. 
The treatment consists in confining the arm and forearm to the anterior part of the chest 
by means of a bandage and sling, similar to those used in fracture of the clavicle, care 
being taken to keep the elbow well raised, so as to fix the top of the scapula, and support 
the broken part. By this proceeding, the pectoral and flexor muscles of the arm are 
relaxed, and prevented from acting injuriously upon the tip of the coracoid process. 
Violent inflammation, occasionally terminating in profuse suppuration, and even in 
death, is liable to follow this accident, from injury inflicted upon the pectoral muscles and 
the axillary vessels, nerves, and glands. The matter, being 
deep-seated, experiences great difficulty in reaching the sur- 
face, and is, therefore, disposed to burrow extensively among 
the surrounding structures. The proper remedy is an early 
and free incision at the most dependent portion of the ab- 
scess. 
6. The body of this bone, fig. 470, rarely suffers from 
fracture, and then only from great direct violence, causing 
at the same time serious injury in the soft parts. In one 
case, recorded by a foreign writer, the accident is said to 
have been produced by muscular action. The fracture ex- 
hibits no regularity in regard to shape, is often multiple, and 
is rarely attended with displacement. 
Fracture of the body of this bone occasionally extends 
through its spine, so as to divide it into two nearly equal 
vertical parts, as in a case which I attended with Dr. Rohrer. 
The patient was a strong laboring man, thirty-seven years 
of age, who, in a fall from a scaffold, struck his right shoulder 
violently against the corner of a plank, fracturing the scap- 
ula through the spine and body near its centre. Five days 
had elapsed before I saw him. The parts were then much 
swollen and ecchymosed, the top of the shoulder was depressed and forced forwards, and 
there was a marked irregularity between the ends of the fragments, the outer being drawn 
downwards and forwards, so as to form with the posterior a kind of triangle, thus 
, with distinct crepitation upon the slightest motion. The man, who expe- 
rienced great pain at the time of the accident, was unable to put his hand to his head, but 
could easily touch the opposite shoulder. 
To steady the shoulder-blade, which is the leading indication in the treatment of this 
accident, two large, narrow, and moderately thick compresses should be placed along its 
axillary and vertebral borders, and confined by a broad roller carried round the upper 
part of the trunk ; or, instead of this, they may be secured by means of large adhesive 
strips. The arm and forearm are fastened to the anterior part of the chest, as in fracture 
of the clavicle. In the case above described, apposition was easily maintained by a 
modification of Desault’s apparatus. 
e. Fracture of the inferior angle of this bone is marked by preternatural mobility, by 
displacement of the smaller fragment by the action of the great serrated muscle, and by 
acute pain at the seat of the injury. The diagnosis may readily be established by fixing 
the top of the scapula and moving the lower angle; if they follow each other, it will be 
an evidence that there is no fracture, and conversely. The treatment is the same as in 
fracture of the body of the bone. 
FRACTURES OF THE RIBS. 
The central ribs, from their exposed and fixed position, are much more liable to be 
broken than the upper and lower; the former being safely protected by the collar-bone, 
the scapula, and numerous thick and strong muscles, while the latter, from their great 
shortness and mobility, can readily glide out of the way of any injury that might other- 
wise affect their integrity. However this may be, they usually yield at their more promi- 
nent points, in an oblique direction, a transverse fracture being here, as elsewhere, an 
unusual occurrence. A denticulated or serrated appearance of the ends of the fragments 
is occasionally met with, and now and then, although rarely, they are impacted, or driven 
Fig. 470. 
The ordinary Situations of Fracturo 
of the Body of the Scapula. CHAP. VIII. 
FRACTURES OF THE RIBS. 
953 
into each other. The accident is most frequent in elderly subjects, children and young 
persons seldom suffering. The causes are twofold, external violence and inordinate mus- 
cular action. The first produces its effect either in a direct or indirect manner; most 
commonly in the former, as when the ribs are struck by a fall or a blow, or when the body 
is traversed by the wheel of a carriage. In the second case, the ribs, being impelled by 
forces operating upon their extremities, break at or near their middle, as when, for exam- 
ple, the back of the chest is pressed against a wall by a railway car. When these pieces 
are acted upon directly, their curvature is diminished, but increased when the violence is 
applied indirectly. I recently attended a lady, seventy-four years old, who had the 
eleventh rib of the left side fractured by her granddaughter, a stout girl of fourteen, by 
throwing her arms around the body, in a friendly embrace, on going to bed. In 1837 a 
number of persons met with severe injuries of this kind, by being severely squeezed in a 
crowd in the Champs de Mars, at Paris. A rib has occasionally been broken by mere 
muscular contraction in the act of coughing, sneezing, or slipping, as in a case reported by 
Dr. Groninger; but such an occurrence is unusual, and generally implies an abnormal 
condition of the osseous tissue. 
Fractures of the ribs are said to be common among insane persons, but whether they 
occur spontaneously or as the result of accidental causes is not determined. In many of 
the reported cases they did not seem to have been productive of pain or to have been 
accompanied by the usual phenomena, not even by any evidence of contusion or discolora- 
tion of the skin. 
The number of ribs broken at any one time is variable. The largest number I have 
ever met with was eight; sometimes, however, it is still greater. In a specimen in my 
collection, from the body of a woman, upwards of seventy years of age, who threw herself 
out of a second-story window, there are not less than fifty-nine fractures, twenty-seven on 
the right side and thirty-two on the left. 
The fracture may occur simultaneously upon both sides, as in the case just mentioned ; 
and it may be either simple, or complicated with other injury, as rupture of the inter- 
costal artery, wound of the soft parts, and laceration of the pleura and lung. 
A fracture of the more superficial ribs is often easily detected simply by placing the 
hand upon the part where the violence is supposed to have been inflicted, and requesting 
the patient to cough. The bones being thus obliged to undergo a sudden motion, the 
lesion, if any exist, will almost be sure to manifest itself by the occurrence of crepitation 
and preternatural mobility. If, however, the fracture is placed under cover of a large 
quantity of muscular and fatty matter, as in certain situations in robust and corpulent sub- 
jects, it may be very difficult, if not impossible, to discover it. In such an event, the 
examination should be repeated again and again, until the diagnosis is satisfactorily 
determined. The difficulty will be increased if only one rib is broken, or if the broken 
bone retains its normal position ; on the other hand, the diagnosis may be established at 
a glance if the injury is extensive, and attended with marked displacement, as when it 
has been inflicted by a fall, or by the kick of a horse. Finally, the patient, as he takes a 
deep inspiration, is occasionally sensible of a peculiar cracking noise at the site of the 
fracture. 
The pain attending the fracture of a. rib is generally very acute, and is always most 
severe at the seat of the injury; it is aggravated by the respiratory movements, and is 
commonly so excessive as to compel the patient to breathe entirely with the diaphragm. 
Every attempt at a full inspiration, coughing, or sneezing, is followed by exquisite suffer- 
ing. In very violent cases, the pain resembles that of pleurisy, and is accompanied with 
intense thoracic oppression. If the lung has been wounded by a spicule of bone, or the 
projecting end of the broken rib, there will probably be spitting of blood, if not hemoptysis, 
and, perhaps, also emphysema. In the latter event, the air may fill the cavity of the 
chest, causing a hollow, drum-like sound on percussion, and total extinction of the respira- 
tory murmur, attended with great increase of dyspnoea. Sometimes, as in injury of the 
costal and pulmonary pleurae, the air escapes into the subcutaneous connective tissue forming 
a diffused tumor, soft and crackling, and at once indicative of the nature of the case. 
More or less copious hemorrhage will be present when there is laceration of an intercostal 
artery, the blood occasionally passing into the chest, but more generally escaping externally. 
The ribs being firmly connected to the costal cartilages in front, and to the vertebra 
behind, it is impossible for them to undergo any shortening when they are fractured, or 
for the ends of the fragments to overlap each other, at least to any extent, as in fracture 
of the long bones. Derangement, however, may take place in almost any other direction, 
although the angular displacement is by far the most common, and this may be either DISEASES AND INJURIES OF THE BONES. 
outwards, as in fig. 471, or inwards, as in fig. 472, according to the manner in which the 
injury was inflicted, the hitter being usually produced by direct violence, the former by 
indirect. It is seldom, however, that more than one end of the bone is displaced in this 
direction at the same time. The Mutter cabinet contains several specimens in which one 
of the fragments projects above the level of the others. 
CHAP. VIII. 
Fig. 471. 
Angular Displacement Outwards. 
Fractures of the ribs are not always devoid of danger, even when they are perfectly 
simple, or apparently free from complications. Their number may be so great as to 
occasion severe shock, or such an amount of local and constitutional disturbance as to 
cause alarming illness and even death. The danger is generally greater, other things 
Fig. 472. 
Angular Displacement Inwards. 
being equal, in fracture of the upper ribs than in fracture of the middle and lower, because 
a greater degree of violence is generally required to produce it. A fracture complicated 
with injury of the lung and pleura must be looked upon as a serious occurrence, as it is 
sure to be followed by more or less inflammation, if not by hemorrhage and pneumothorax. 
An escape of air beneath the skin is a matter of no consequence, except as indicating 
serious lesion within the chest. Hemorrhage from a wound of an intercostal artery is 
usually rather troublesome than dangerous. ’ 
A case, under my observation in 1854, strikingly illustrates the danger of fracture 
involving a number of these bones without any very serious complication. A tall, slender 
woman, fifty-four years of age fell, while the railway cars were in the act of running off 
the track, against the top of one of the seats, breaking eight of the ribs on the left side. 
The second, third, fourth, and fifth bones were fractured in front, about two inches and a 
half from their cartilages, while the eighth, ninth, tenth, and eleventh had given way 
behind, within a short distance of the spine. There was no displacement of any of the 
fragments, excepting the posterior one of the tenth rib, which projected slightly inwards 
towards the chest, and pierced the pleura. Excessive pain, dyspnoea, crepitation, and 
preternatural mobility marked the accident. The cough was violent, and recumbency 
impossible. The ordinary treatment was pursued, but without any material benefit, and 
the woman died exhausted at the end of the fourth day. The left side of the chest con- CHAP. VIII. 
FRACTURES OF THE COSTAL CARTILAGES. 
955 
tained about three ounces of coagulated blood, evidently furnished by the wounded pleura, 
but there was no sign of inflammation, except at the seat of the upper fracture, where the 
serous membrane was a little roughened by lymph and slightly ecchymosed. The lung 
was free from disease. All the other organs were sound. 
Fracture of the ribs, without complication or displacement, is easily managed with the 
plaster or glass dressing, the surface being protected with a layer of wadding, or an 
ordinary flannel shirt. The bandage should be from two and a half to three inches in 
width, and drawn so tightly as to compel the patient to breathe chiefly with the diaphragm. 
A thin, flat compress, as a small, old towel, properly folded, to give greater support to the 
broken bone, may sometimes be advantageously used. In children I know of no better 
dressing for a fractured rib than one made of adhesive strips. 
Similar dressings will answer in outward displacement of the fragments, only that a 
somewhat thicker compress may be necessary; if, on the contrary, the bone is driven 
inwards towards the chest, it is obvious that counterpressure applied to the extremities 
of the broken rib can be of no avail. When there is a wound, it might be easy enough 
to insinuate a small lever, to raise the bone, if not to its proper level, at least out of harm’s 
way. My conviction, however, is that there should be no such interference, even when 
the depression is considerable, and the case most urgent, unless a fair trial has been made 
of other means, as the bandage and ordinary antiphlogistics, especially the lancet, leeches, 
and the free use of anodynes. If relief do not follow, and it is perfectly clear that the 
suffering depends upon the vicious projection of the ends of the fragments, no surgeon 
would hesitate to expose the parts, and use his best endeavors to rectify the displacement. 
Cases requiring such heroic measures must, however, be exceedingly rare, and hardly 
deserve formal mention in a work of this kind. 
Wounds, contusions, and hemorrhage, consequent upon these accidents, must be treated 
upon general principles. When the blood proceeds from an intercostal artery, it may be 
necessary to enlarge the opening in the 
chest, or even to excise a portion of an 
adjacent rib, as in a case during our 
late war in the hands of Dr. Cuyler, of 
the army. If air collect within the 
chest in sufficient quantity to cause ex- 
cessive respiratory embarrassment, it 
should be evacuated with the aspirator 
ora delicate trocar, introduced through 
a valvelike opening in the skin. Pain 
and cough are relieved in the usual 
manner. If the local distress is urgent, 
leeches may be used, followed by the 
application of a large opiate plaster. 
The patient observes the semierect posture, and remains within doors until he is able to 
exercise with impunity. If the bandage becomes insupportable, it must not be laid aside, 
but simply slackened. 
Cases occasionally occur in which the rational symptoms of fracture of the ribs exist, 
but the characteristic signs are absent. The rule of practice, under such circumstances, 
is to treat the patient precisely as if the bones were actually broken. 
The annexed drawing, fig. 473, from a specimen in my collection, affords an illus- 
tration of the manner in which the ribs, after fracture, are sometimes bound together by 
bony matter. 
FRACTURES OF TIIE COSTAL CARTILAGES. 
Fracture of the costal cartilages is so uncommon that a long time elapsed before sur- 
geons were willing to believe in the possibility of such an occurrence. That it does take 
place, however, is a fact fully established by modern observation ; and, what is remark- 
able, experience has shown that it is not always necessary for these bodies to be ossified 
before they can be broken, although this is usually the case. The accident, which is 
observed chiefly in elderly persons, is invariably produced by external violence, either 
directly or indirectly applied. The fracture is usually single, and the pieces which are 
most liable to suffer are the fifth, sixth, and seventh, owing probably to their great length 
and to their exposed situation. The direction of the fracture is commonly somewhat 
oblique, and the ends of the fragments often overlap each other, the posterior passing in 
Fig. 473. 
Fractured Ribs united by Osseous Matter. DISEASES ANI) INJURIES OF THE BONES. 
CHAP. VIII. 
front or behind the anterior, which, from its connection with the sternum, serves as the 
fixed point. 
The symptoms are similar to those of fractured ribs. The accident, whether simple 
or complicated, is, in general, comparatively free from danger. The broken ends 
are united by a clasp or ferule of bone, in which the cartilaginous tissue remains 
measurably unchanged. The reduction and maintenance of the fracture are often 
very difficult, but by a careful observance of the rules laid down under the head of 
fracture of the ribs, a cure may usually be effected in six or eight weeks. Malgaigne 
advises the use of a broad truss for keeping the fragments together, the pad making 
direct but gentle pressure upon their extremities. In obstinate cases they might be 
united with silver wire. 
FRACTURES OF THE STERNUM. 
This bone may give way in almost any portion of its extent, but more commonly near 
its middle, the direction of the fracture being generally somewhat oblique. Instances of 
longitudinal fracture of the sternum have been observed by Meyer, Malgaigne, and others, 
as the result of severe injury. Diastasis of this bone is exceedingly infrequent; and, so 
far as I know, there are only a very few well authenticated examples of fracture of the 
ensifonn cartilage upon record. In one of these the patient, a man, twenty-eight years 
of age, met with the accident in a fall in which he struck the lower extremity of the 
sternum against the top of a candlestick, bending the cartilage at a right angle with this 
bone towards the spine, and causing by its pressure upon the stomach frequent and violent 
attacks of vomiting for a long time afterwards. 
Blows, kicks, and falls are the ordinary causes of fracture of the sternum. Examples 
in which it was occasioned by violent muscular contraction during labor, have been 
recorded by different observers. In 1858 I attended, along with Dr. Rolirer, a case, in a 
large, heavy, muscular man, forty-seven years of age, who had received a transverse 
fracture of the upper part of this bone, from inordinate contraction of the sterno-cleido- 
mastoid muscles, in jumping, in a state of intoxication, off a shed eleven feet high. The 
heels, striking the ground obliquely, threw the body violently backwards, the head and 
neck coming in contact with the edge of a board. The fracture was, doubtless, occasioned 
by the effort which the man made to regain his equilibrium. 
The ends of the fragments either preserve their natural relations, or, if displacement 
occur, it will be in the direction of the thoracic cavity, when the broken bones may 
lacerate some of the contained viscera, cause effusion of blood into the anterior medias- 
tinum, and, perhaps, induce emphysema by wounding the lungs. 
When the fracture is attended with displacement, it may usually be detected at a 
glance, or by merely passing the finger over the line of injury. Grating, sometimes 
audible at a considerable distance, and increased at every respiratory effort, is generally 
present. The pain is excruciating; recumbency is, for a time at least, impracticable ; 
and there is great dyspnoea, along with cough, spitting of blood, and other evidence of 
internal injury. 
In the case above referred to, there was, even several days after the accident, a marked 
depression at the site of the fracture, with considerable irregularity of the ends of the 
fragments, which was much increased when the patient sat up in bed. During recum- 
bency, when he coughed hard, the hand, placed over the seat of the injury, could 
distinctly feel the fragments ride over each other, the upper evidently moving more 
freely than the lower. It seemed as if their edges had been bevelled off obliquely, 
that of the lower piece from above downwards and from before backwards, that of the 
upper in the opposite direction. Two or three times, as the man coughed, a distinct 
grating noise was heard. Percussion upon the spine, immediately opposite the fracture, 
had also the effect of displacing the ends of the fragments, and a similar result followed 
when firm pressure was made upon the anterior surface of the fragments. When the case 
was first seen, the upper piece was thrust backwards towards the thoracic cavity, fully one 
inch behind the level of the other ; but it was easily restored to its natural situation by 
bending the chest backwards over a thick pillow. The pain at the seat of fracture was 
comparatively slight; but very distressing in the back of the neck and head. There was 
neither cough nor emphysema, and the fever that followed was slight. 
The prognosis varies. When the thoracic organs have sustained much violence, the 
patient may die from shock, hemorrhage, or emphysema; or, surviving the immediate 
elfects of the accident, he may perish from the consequences of inflammation of the CHAP. VIII . 
FRACTURES OF THE VERTEBRAS. 
957 
lungs, abscess of the mediastinum, or disease of the hone itself. In the Mutter Museum 
there is a skeleton in which a fracture of the sternum, near its middle, had undergone 
perfect repair, although not without marked deformity from the want of accurate apposi- 
tion. Evidence of fracture exists in several other hones, and there must also have been 
a remarkable predisposition to the development of exostoses, the number of which is very 
considerable. 
The treatment is, in great measure, restricted to the application of compresses and an 
immovable bandage, to afford support to the chest and quietude to the intercostal 
muscles. In the event of serious internal complication, local and general bleeding, active 
purgatives, antimonials, and anodynes may be required, along, perhaps, with medicated 
fomentations. If the fracture be simple, no attempt should be made to rectify the 
depression of the offending fragment, unless it is causing compression of the heart 
or lung. In such a case, and also when there are loose pieces of bone projecting into 
the chest, restoration should promptly be effected at all hazard. To accomplish this, the 
patient may lie across a table, over a double inclined plane, in order to extend the spine, 
and afford the muscles attached to the extremities of the sternum an opportunity of draw- 
ing the ends of the broken bone asunder. "While this is being done, pressure should be 
made upon the parts in a direction opposite to that of the displacement, at the same time 
that the lungs are, if possible, thoroughly distended with air. Or, this failing, the bone, 
the body being still in this position, may, perhaps, be raised with a small, delicate elevator, 
used subcutaneously, supposing that a wound does not already exist. If this also prove 
unsuccessful, the urgency of the case will fully justify the application of the trephine, or 
the removal of a sufficiency of bone with a Iley’s saw. A similar procedure may be 
necessary when an abscess forms in the anterior mediastinum, or when a portion of the 
sternum is ulcerated or necrosed, although in the former event it may not always be pos- 
sible to reach the fluid. 
In fracture of the ensiform cartilage with outward protrusion of the fragment, the chief 
reliance must be upon systematic and long-continued compression with a well-adjusted 
pad, confined with a suitable bandage. When the point of the bone is driven backwards 
towards the spine, forming a right angle with the lower extremity of the sternum, and 
causing more or less suffering by its pressure upon the stomach, as nausea and vomiting, 
the only resource is excision, an operation requiring some care and skill for its successful 
execution, but in every respect proper. 
FRACTURES OF THE VERTEBRA. 
The vertebra? are so compactly constructed, so strongly articulated, and so thickly cov- 
ered by muscles, as to render their fracture a matter of great difficulty. The most common 
causes are violent blows or falls, giving rise at the same time to severe injury of the soft 
parts. Occasionally the lesion is produced by contre-coup, as when a person falls from a 
great height and alights upon his feet, the force being transmitted along the extremities 
and the pelvis to the spinal column, where, concentrating upon a particular bone, it 
breaks its substance or severs its ligamentous connections. Any part of such a bone may 
give way, its body, plates, and processes being all liable to yield under the influence of the 
causes here mentioned. The symptoms and effects of this lesion must be considered with 
reference to the different divisions of the vertebral column, as the cervical, dorsal, and 
lumbar, each possessing certain peculiarities growing out of its relations with the spinal 
cord and the nerves which are detached from it. 
In fracture of the cervical vertebrce, the symptoms vary according to the situation of the 
affected bone. Thus, if the lesion is above the fourth piece, or the principal origin of the 
phrenic nerve, and the spinal cord is at all compressed, the diaphragm will be paralyzed, 
the respiration will be more or less embarrassed, and death will follow, either immediately, 
or within a short time after the accident. If, on the other hand, the fracture is seated 
below this point, there will be paralysis, to a greater or less extent, of all the extremities, 
embarrassment of breathing, relaxation of the anal sphincters, incontinence of urine, and 
tympanitic distension of the abdomen. When the fracture is oblique, one arm is some- 
times more disabled than the other. Recovery may ensue if the injury of the soft parts 
is not very severe, but in most cases death occurs in from three to five days. 
Fracture of the odontoid process is very uncommon, and generally proves promptly fatal 
from injury to the spinal cord. Now and then, however, a remarkable exception is found. 
Thus, in a case related by Dr. Willard Parker, the patient survived the accident five 
months, when he suddenly expired from displacement of the process, during some inad- 958 
vertent movement of the head, a result favored by the destruction of the occipito-axoid 
ligament. The dissection showed that the odontoid process had been completely broken 
off, and that its lower extremity had been turned backwards towards the spinal cord, as 
exhibited in fig. 474. The patient, a man, forty years of age, 
had been thrown violently from his carriage, alighting, about fif- 
teen feet off, upon his head and face. After recovering from the 
immediate effects of the accident, lie was able to resume his busi- 
ness as a milkman, which he followed, diligently and uninter- 
ruptedly, every day for four months. lie complained, however, 
constantly of pain in the occipito-cervical region, and was always 
obliged to support his head, which he was incapable of rotating. 
The only visible deformity was a protuberance of the neck, just 
below the base of the occiput, to the left of the median line, with 
a corresponding indentation. 
Hyrtl has reported a case of fracture of the odontoid process 
which occurred very unexpectedly in a woman while sitting up 
in bed to take her meal. Death was instantaneous. The bone 
was found to be diseased. In a case related by Professor Flint, 
the bone, inflamed and softened, gave way in consequence of a 
blow inflicted upon the neck a few months before. 
In fracture of the dorsal vertebra, the upper extremities are 
free from paralysis, unless the injury is seated very high up, when 
they may participate in this affection with the subdiaphragmatic portions of the body. 
The bowels, in either case, will be torpid and distended with gas, and the bladder unable 
to expel its contents. Life is seldom prolonged beyond a fortnight, although in some rare 
cases it lasts for several months. In this event, the bowels and bladder may partially 
regain their original tone, but the urine soon becomes loaded with phosphates, and the 
lining membrane of the bladder suffers from subacute inflammation, adding thus greatly to 
the patient’s discomfort. 
When the lumbar vertebra are broken, the lower extremities are generally deprived 
both of volition and sensibility, the feces pass off involuntarily, and the bladder is unable 
to relieve itself. Life usually lasts longer than in fracture of the dorsal vertebrae, the 
paralysis not extending so high up, and, consequently, not involving so many important 
organs. In the majority of cases, the patient dies in five or six weeks; but he may sur- 
vive a much longer time, the bladder suffering as in fracture of the other divisions of the 
spine. 
Priapism is an occasional symptom of these accidents; it is evidently dependent upon 
lesion of the spinal cord, and is most liable to occur when the injury is situated high 
up in the neck. It is generally associated with paralysis, and is nearly always an early 
phenomenon, manifesting itself within the first forty-eight hours, and often continuing, 
more or less obstinately, up to the moment of dissolution. It is sometimes present even 
when there is complete deprivation of sensibility and consciousness. 
The sexual powers are sometimes remarkably preserved after these injuries, as in an 
interesting case recorded by the late Professor Childs, of New York. The man, who 
lived for fifty-three years in a perfectly paraplegic condition, consequent upon a fracture 
of the twelfth dorsal vertebra, was married at the age of thirty-six, and became the father 
of six children. The spinal cord was completely atrophied below the seat of the injury. 
The capacity for coition was unimpaired, but there never was any venereal orgasm. Sen- 
sation existed only in front of the abdomen, of the scrotum, and of the thighs. The 
urine was expelled, after the first four weeks, by a painful effort of the will, aided by a 
loop of rope tightly twisted with a stick over the hypogastric region. 
The symptoms here enumerated may follow fracture of any portion of a vertebra, except, 
perhaps, that of the spinous process, when the suffering is generally comparatively slight, 
unless the lesion is complicated with serious mischief of the spinal cord. 
The concussion of the spinal marrow, which so frequently attends these accidents, espe- 
cially when induced by severe falls, or blows, may be so violent as to cause death almost 
instantaneously. When the case is less urgent, the patient may live, but will be likely to 
suffer, temporarily, from loss of power, partial or complete, of the sphincter muscles of the 
bladder and anus, and, permanently, from paralysis of the lower extremities, if not also 
of the upper. 
Fracture of the spinous processes of the vertebrae occasionally occurs independently of 
the bodies of these pieces, as seen in fig. 475, the usual exciting cause being a blow, fall, 
DISEASES AND INJURIES OF THE BONES. 
chap, v r 11. 
Fig. 474. 
Fracture of the Odontoid 
Process of the Axis: a, Broken 
Surface ; b, Odontoid Process. CHAP. VIII. 
FRACTURES OF THE VERTEBRAE. 
959 
or kick. Preternatural mobility and lateral displacement, with more or less contusion and 
discoloration of the soft parts, are the most reliable phenomena. 
Fracture of the arches of these bones, of which the accompanying cut, fig. 47G, affords 
a good illustration, is often comminuted, and attended with depression of the fragments, 
some of which may be driven into the substance of the spinal cord, crushing and pulpify- 
ing it. It is generally produced by violence directly applied, and is frequently quite as 
dangerous as a fracture of the bodies of the vertebrae. 
Fig. 475. 
Fig. 476. 
The transverse processes of the vertebrie cun only be broken by excessive force, as the 
passage of a ball, or a severe blow, or a fall from a considerable height. Hence the result 
of such accidents is commonly very unfavorable. 
The diagnosis of fracture of the spine is usually a matter of inference rather than of 
positive conviction. Its most important elements are the mode of production of the 
injury, and the paralysis of the extremities, but it should be recollected that this symp- 
tom may depend entirely upon lesion of the spinal cord, unconnected with fracture of the 
vertebrae; and cases have been observed by Cooper, Dupuytren. South, and others, in 
which the effects of violent strains of the spinal ligaments and muscles closely simulated 
fracture of these bones. Owing to the small size of these bones, and the manner in which 
they are covered in by the muscles of the back, it is generally impossible to detect either 
crepitation, deformity, or preternatural mobility. All these phenomena may, however, 
be present in fracture of the spinous processes. 
after an injury of this kind, usually reveals more or less displacement of the 
broken bone, which is sometimes quite comminuted, laceration of the connecting liga- 
ments, and injury of the spinal cord, with more or less extra- 
vasation of blood in the spinal canal and the surrounding parts. 
The cord is compressed, bruised, pulpitted, perhaps nearly com- 
pletely severed, pieces of bone sometimes being imbedded in its 
substance, as shown in fig. 477. 
The prognosis of these accidents may be inferred from what 
has been said respecting their symptoms and effects. If the 
patient escape immediate destruction, he will almost certainly 
succumb under his suffering at no very remote period; or, if life 
be spared, be doomed to carry on a miserable; bedridden ex- 
istence, palsied and otherwise crippled in the exercise of some of 
his more important functions. A remarkable case of fracture of 
the fifth dorsal vertebra, with displacement of the bodies of the 
third and fourth of these bones, in which, notwithstanding the 
complete division of the spinal cord, life was prolonged for two 
months, has been recorded by Dr. Parkman, of Boston. 
In the treatment of fractured vertebrae, very little is to be done 
in the way of restoring displaced fragments, all such attempts 
being not only uncertain, but, even if successful, likely to aggra- 
vate the danger by the additional mischief that is inflicted upon the spinal coni. The 
same remark is applicable to the operation of cutting down upon the injured part, and 
Fracture of the Spinous Process. 
Fracture of the Vertebral Arches. 
Fig. 477. 
Fracture of the Vertebr®. 960 
DISEASES AND INJURIES OF THE BONES. 
removing the offending portion of bone with the trephine or saw, as originally suggested 
by Paul of yEgineta, and first practised, in 1814, by Mr. Henry Cline, of London. Of 
38 cases, tabulated by Dr. John Ashhurst, in which this procedure has been employed, 
including those of Barton, Rogers, Potter, Blackman, Hutchinson, and Stephen Smith, 
29 died, 3 were relieved, 2 were not benefited, and the result is unknown in 4. In the 
cases reported as relieved, the improvement was ordy partial, a circumstance that might 
have been expected when it is recollected how seriously the spinal cord is generally in- 
jured by the depressed fragments. The operation, although difficult, on account of the 
great depth at which the broken bone is situated, may be executed with but little loss of 
blood ; and I must confess that, notwithstanding the want of success which has hitherto 
attended it, I should feel strongly tempted to resort to it, if the symptoms were such as to 
render it certain that the lesion was accompanied by depression. 
Whether an operation is performed or not, it is clearly the duty of the surgeon to 
adopt prompt measures for the prevention of inflammation. With this view, blood is freely 
taken from the arm, and also by leeches from the seat of the injury; the bowels are 
relieved by purgatives or stimulating enemas, and pain is alleviated by full doses of 
anodynes, combined, if there be much fever, with depressants. The bladder is carefully 
watched, and the urine, if retained, is drawn off regularly twice or thrice a day, instead 
of allowing the catheter to remain permanently in the bladder. The patient is kept on 
his back, upon an air- or water-bed, his head resting upon a low pillow, and his position 
being as seldom changed as possible. Great care is taken not to turn him upon his face, 
as he might be almost instantly asphyxiated while in this situation, from the imperfect 
descent of the diaphragm, caused by the pressure of the abdominal viscera, on account of 
the paralyzed condition of the abdominal muscles, and tbeir consequent inability to offer 
any resistance to the weight of the body. After the lapse of a few weeks, the back and 
limbs should be frequently rubbed with stimulating liniments, and a large issue estab- 
lished in the vicinity of the injury with the actual cautery. Along with these means, 
trial may be made of small doses of strychnia, in union with iron, quinine, and mercury, 
especially if there is evidence of the existence of spinal meningitis, or of extravasated 
blood. All treatment of this kind will, of course, be useless when the spinal cord has 
been crushed. 
When the lesion is confined to the spinous processes, the fragments must be moulded 
into shape, and retained by two long, thick compresses, stretched along the side of the 
spine, and secured with a circular bandage, fastened by a scapulary. If the broken 
pieces, however, are much shattered, so as to preclude the possibility of reunion, they 
should be removed. 
FRACTURES OF THE PELVIC BONES. 
a. The innominate bone may give way in various parts of its extent, but the one which 
is most apt to suffer is the upper crest, owing probably to its exposed situation. 
The acetabulum is sometimes broken by a severe blow upon the hip, or by a counter- 
stroke, as when a person falls upon his 
knee or foot, thereby driving the head of 
the femur into the pelvis. The most 
common form of the accident is that in 
which the lip or border of this cavity is 
chipped off, either as a single piece of 
variable size and shape, or where it is 
broken into several fragments. In the 
adjoining cut, fig. 478, from a prepara- 
tion in the possession of Professor Neill, 
the fracture runs in a semicircular direc- 
tion through the acetabulum. Occasion- 
ally the floor of the acetabulum is driven 
by tbe head of the thigh-bone into the 
pelvic cavity, so as to inflict, more or less 
injury upon its contents. In young sub- 
jects, the innominate bone has been found separated at the acetabulum into its three 
primitive pieces. In a case of this kind, dissected by Moore, the head of the femur had 
completely penetrated the pelvic cavity, the limb, placed in a state of slight flexion and 
adduction, being shortened two inches. 
CHAP. VIII. 
Fig. 478. 
Fracture of the Acetabulum. CHAP. VIII. 
FRACTURES OF THE PELVIC BONES. 
961 
Whatever may be the site, form, or extent of these fractures, they can happen only 
through the agency of direct mechanical violence, which, at the same time, generally 
seriously compromises the soft structures, both outside and inside the pelvis. The most 
frightful accidents of this kind that have fallen under my observation have been the result 
of railway injury, caused by the body being jammed in between a car and a wall, literally 
crushing the bone, and fatally implicating the bladder and other organs. 
The symptoms will necessarily vary according to the seat and extent of the fracture. 
When the bone has given way at the cotyloid cavity, the nature of the case may usually 
be recognized by the circumstance that the head of the femur is drawn upwards, and the 
great trochanter somewhat forwards, so that the limb is diminished in length, and the 
foot inverted. When the head of the thigh-bone is impacted in its new position, the 
limb may be firmly fixed, as in dislocation, but, in general, it will be found to be more or 
less movable, and to afford distinct crepitation when an attempt is made to rotate it. 
Fracture of the brim of the acetabulum is generally associated with dislocation of the 
femur, and hence, although the reduction of both injuries may be sufficiently easy, yet 
the displacement is sure to recur the moment the efforts required to effect this object 
cease. 
The diagnosis of these accidents is very uncertain, and, in many cases, their true 
nature is only discovered on dissection. The most reliable signs are, shortening from six 
lines to an inch and a half, inversion of the foot, unnatural elevation of the great tro- 
chanter, excessive pain on pressure over the joint, crepitation, generally more decided 
than in fracture of the neck of the femur, and prompt effaeement of the deformity under 
extension and counterextension, followed by an immediate return of it when these efforts 
are discontinued. 
The prognosis of fracture of the acetabulum is variable. In many cases, the injury 
inflicted upon the bones and soft parts is so great as to cause death either from shock or 
from inflammation. When the patient recovers, he is usually maimed for life, as the case 
is either misunderstood, or, if understood, unsuccessfully treated, often as a necessary 
consequence of the peculiar character of the injury, and, therefore, without any just 
blame as it respects the skill of the professional attendant. In the female, a fracture of 
the floor of the acetabulum, accompanied with great displacement, might seriously inter- 
fere with parturition, and in both sexes the pressure of the bone upon the pelvic nerves 
might become a cause of severe and protracted neuralgia. 
In regard to the treatment of these injuries it is difficult to lay down any definite plan. 
When the floor of the cavity is broken, reposition is, of course, impracticable, and the 
less, therefore, the case is interfered with the better. When the fracture involves the 
rim of the bone, and coexists with displacement of the femur, an attempt should be made 
to maintain the parts in their proper relations by keeping the limb in a straight line with 
a long side splint and a weight appended to the foot, while the joint is carefully supported 
with a broad compress confined by a suitable band passed around the pelvis. 
In fracture of the pubic and ischiatic bones, the corresponding limb is either some- 
what shortened, or it retains its natural length; the fragments are pushed either directly 
downwards, forwards towards the femur, or back- 
wards towards the acetabulum; the patient is unable 
to sit, stand, or walk; and on placing one hand upon 
the ilium, and the other upon the pubes, crepitation 
may usually be perceived. A well-characterized frac- 
ture of the pubic and ischiatic bones is delineated in 
fig. 479, from a preparation in the collection of Pro- 
fessor Neill. A very interesting case, of a similar 
nature, attended with fatal injury of the bladder, 
occurred a few years ago under the observation of Dr. 
John W. Lodge, and is fully described in the Ameri- 
can Journal of the Medical Sciences for October, 
1865. A case of fracture of the body of the pubic bone by muscular contraction, in a 
very stout, hard-working woman, forty-three years of age, in the act of lifting a heavy 
stone, has been reported by Letenneur, of Nantes. 
The pubic bones are sometimes severed at their symphysis. Of four cases collected by 
Malgaigne, the accident, in three, was occasioned by muscular contraction during the for- 
cible abduction of the thighs, and of these two perished. The same author has analyzed 
seventeen cases in which the separation occurred during parturition, with a loss of ten. 
Maret met with an instance of fracture of the pel vis in which he was obliged to excise nearly 
Fig.'473. 
Fracture of the Pubic and Ischiatic Bones. DISEASES AND INJURIES OF THE BONES. 
chap, v i r i. 
the whole of the body of the pubic hone by an incision through tlie labium. The frag- 
ment had been pushed forward and inward, and interfered with the introduction of the 
catheter, rendered necessary on account of retention of urine. The patient, a girl eigh- 
teen years of age, not only made si good recovery, but afterwards gave birth to two 
children in easy and natural labors. 
Fracture of these bones is generally produced by severe injury, and is, therefore, nearly 
always complicated with serious lesion of the soft parts. Cappelletti met with an instance 
in which their branches were broken by violent muscular contraction, as the patient, a 
man, fifty-four yesirs old, was jumping out of his carriage, while the horses were running 
away. A ease of fracture of the anterior superior spinous process of the ilium by muscu- 
lar contraction has been reported by Dr. Joy and Dr. McWhinnie, of Canada. 
Fracture of the crest of the ilium is characterized by more or less displacement, pre- 
ternatural mobility, and crepitation; the pain is severe, and progression impracticable. 
The nature of the accident is sometimes rendered apparent by the existing deformity and 
by slight manipulation. 
Besides the above symptoms, denotive of fracture of different parts of the innomihate 
bone, there are always more or less contusion of the external soft parts, and not unfre- 
quently, also, serious injury of the pelvic viscera, followed by loss of motion of the inferior 
extremities, retention of urine, and other distressing affections. The prognosis should, 
therefore, be very guarded, as such accidents are generally fraught with danger, death 
often occuiTing in a few days from inflammation or extravasation of urine, or, at a later 
period, from abscess, phlebitis, and other mischief. Of 65 cases of fracture of the pelvic 
bones, analyzed by Dr. J. W. Lyon, 41 recovered, and 24 died, one-half of the latter 
having labored under rupture of the bladder. 
Owing to their peculiar character, it is usually found very difficult to x*educe these frac- 
tures, or to prevent relapse after this has been done. To effect restoration, our main 
reliance must be upon pressure, while the maintenance is best accomplished by well- 
arranged compresses, secured by a belt or an immovable bandage. Even when no displace- 
ment exists, great comfort will be experienced from such support. In any event, the 
utmost quietude must be enjoined; the patient must lie upon his back, his shoulders being 
elevated, and the thighs flexed, to l’elax the muscles about the pelvis; inflammatory action 
is promptly dealt with, and the bowels are moved as seldom as possible. The bladder is 
cai'efully watched, retention of urine being relieved with the catheter. An air-bed some- 
times affords great comfort in such a condition. 
(3. The sacrum may be broken by falls, blows, gunshot violence, and similar injury, 
usually in a transverse or oblique direction: a comminuted condition is sometimes 
observed, and Richerand met with a case in which the fracture was vertical. The lesion 
is generally discoverable, especially when attended with displacement, by mei*e manual 
examination, as the patient lies upon his abdomen. It is accompanied with severe pain 
at the affected part, and great difficulty in walking, associated, when there is involvement 
of the sacral nerves, with paralysis of the lower extx-emities, retention of urine, and 
involuntary discharge of the feces. The danger attending this accident is always con- 
siderable, on account of the mischief done to the soft parts; hence, even if the patient 
survive the immediate shock of the injury, he may perish afterwards from the effects of 
inflammation of the pelvic viscera. 
When the fragments are pushed inwards, reposition may be attempted by the insertion 
into the rectum of a stout bougie, a lithotomy scoop, or a vesical sound, care being taken 
not to do any injury to the mucous membrane; or, if the displacement is very slight, the 
bone may be left in its new situation, as it can then not do any harm. Backward dis- 
placement may easily be remedied by pressure with the finger, relapse being prevented by 
a compress and a T bandage. Recovei'y is promoted by rigid recumbency, antiphlogis- 
tics, and the use of a water bed. 
A remarkable case of compound fracture of the sacrum, caused by a railway accident, 
attended by discharge of urine through the wound, and ultimately followed by recovery, 
has been reported by Dr. II. D. Burling!)am, of Illinois, in the American Journal of the 
Medical Sciences for April, 1868. The bladder was supposed to have been torn at its 
neck. The ui'ine, after the first few days, was allowed to flow off constantly through 
the catheter. 
y. The coccyx is sometimes broken by a fall, by a kick upon the buttock, or by the 
passage of the child’s head in labor. The accident is most common in elderly subjects, 
in whom the joints of this bone have been destroyed by a deposit of osseous matter. The 
characteristic signs are, preternatural mobility, acute pain, and crepitation on inti-oducing FRACTURES OF SHAFTS OF RADIUS AND ULNA. 
963 
CHAP. VIII. 
the finger into the bowel. Paralysis of the bladder and rectum is a frequent, if not gene- 
ral, phenomenon. During labor, the occurrence of the injury is sometimes rendered 
evident by a sense of yielding and a peculiar noise perceived by the attendant as he is 
engaged in supporting the perineum. If displacement exist, it is remedied by pressure 
upon the surface and counterpressure with the finger in the rectum. It is very impor- 
tant, especially in the female, that the coccyx should be preserved in a continuous line 
with the sacrum, otherwise serious deformity of the pelvis may ensue, interfering with 
defecation and parturition. After the reduction has been effected, the parts should be 
supported with a compress, confined by adhesive strips; perfect quietude and lateral re- 
cumbency should be observed; and the bowels, without being acted upon at all frequently, 
should be maintained in a strictly soluble condition. Paraplegia and violent neuralgia 
occasionally follow this accident, owing to injury sustained by the nervous plexus of 
the pelvis. 
2. SUPERIOR EXTREMITY. 
FRACTURES OF THE BONES OF THE HAND AND FINGERS. 
The symptoms of fracture of the bones of the thumb and fingers are so obvious as to 
render any formal account of them unnecessary. The treatment is by a pasteboard, leather, 
felt, plaster, or rubber splint, accurately moulded to the shape of the member and the 
palm of the hand, to which it must be well secured by appropriate rollers. 
The metacarpal bones are sometimes broken by machinery, and I have met with a 
number of instances in which the fourth and fifth of these pieces had given way under 
a blow of the fist, the part struck being, in one of the cases, the face, and another the 
forehead. Such accidents are characterized by marked displacement upon the back of 
the hand, from the projection of the anterior fragment, with distinct crepitation and 
swelling of the soft parts, but hardly any pain. In young subjects these bones occasion- 
ally give way at their epiphyses. The treatment consists in the use of a well-padded tin 
case for the palm of the hand, extending from just above the wrist to the ends of the 
fingers, and of a short, narrow splint for its dorsal surface, firm pressure being made with 
it over the seat of fracture. Union generally occurs in a month, with little if any 
deformity. 
Occasionally the fifth bone alone is broken, as I have witnessed in at least half a dozen 
cases. The prominent symptom in all was a marked posterior projection. Great circum- 
spection is necessary in the treatment of this fracture, otherwise deformity will be sure 
to follow. 
The carpal bones are never broken, except by direct violence, which always seriously 
implicates the soft parts, not unfrequently necessitating the removal of a portion, if not of 
the entire, hand. The nature of the accident is usually apparent from the attendant 
deformity, the excessive pain, loss of function, and crepitation on manipulation. Reposi- 
tion of the fragments having been effected by pressure and counterpressnre, retention is 
secured by means of two splints, ether of binder’s board or wood, long enough to extend 
from the middle of the forearm to the ends of the fingers, the hollow of the hand being 
well padded, and the limb supported in a sling. 
There are no fractures in any region of the body where the surgeon will find a finer field 
for the exercise of his skill in saving mutilated structures than in those of the hand, thumb, 
and fingers. It is here, emphatically, that conservative surgery may often display its 
highest excellence. Bad as many of the cases are, there are very few in which, if a proper 
attempt be made, the parts may not be treated on general principles with a fair prospect of 
success. Occasionally a joint may be lost, and still a thumb or finger be of great use to 
the patient. It is only in the most desperate cases that primary amputation should be 
resorted to; in all others an attempt should be made to save the parts. 
FRACTURES OF THE SHAFTS OF THE RADIUS AND ULNA. 
The radius and ulna may be broken conjointly by direct violence, or, as more frequently 
happens, by a counterstroke, as when a person falls upon the hand, and the force is con- 
centrated by transmission upon the forearm. The fracture, although it may occur at any 
point, is most common in the inferior half of these bones, and rarely takes place at the 
same level, whatever may be its cause. In general, too, it is oblique, and not transverse, 
as is usually supposed. The nature of the accident is commonly sufficiently apparent from the angularity of the fragments, as seen in fig. 480, and their preternatural mobility, 
to say nothing of the facility of eliciting crepitation on rotating the hand. The patient 
experiences an inability to supinate and pronate the limb, the forearm is in a state of 
semiflexion, and acute pain is felt at the seat of the injury. 
The chief danger in this fracture, as it usually exhibits itself, is from the tendency of 
the ends of the fragments to sink inwards into the interosseous space, and to become 
united by a common callus, thereby materially impeding the usefulness of the limb, by 
destroying the functions of supination and pronation. With ordinary care, however, such 
an accident is not likely to happen, and, in most cases, the consolidation is completed in 
from thirty to thirty-five days, without any deformity or ultimate inconvenience. The 
vicious union here mentioned is well show in fig. 481, from a preparation in my collection. 
The fracture having been adjusted in the ordinary manner, the forearm is bent at a 
right angle with the elbow, and enveloped by a roller extending from the fingers upwards. 
Two thick binder’s board splints are next applied along 
the anterior and posterior surfaces of the broken bones, 
and secured with the remainder of the bandage. They 
should be a little wider than the limb, and long enough 
to reach just from below the elbow to the extremities 
of the fingers, both being well covered with wadding, 
and accurately moulded to the parts. The hand and 
forearm are then suspended in a broad sling, with the 
thumb looking directly upwards. 
1 have myself for many years entirely dispensed with 
the compresses upon which so much stress has generally 
been laid for counteracting the tendency of the ends 
of the fragments to approach each other at the inter- 
osseous space. I am satisfied that all the pressure that 
can be required, at least in ordinary cases, may be 
effected by the two splints which are usually employed 
in the treatment of fracture in this situation. The 
bandage, too, has received a great deal of unjust blame 
in these cases, it being alleged that, if applied directly 
to the surface, it will force the bones together, and 
thus lead to vicious union. It would unquestionably 
be easy enough to produce such an effect, but this 
would be an abuse, and not a proper use, of the band- 
age, its appropriate office being to afford equable sup- 
port to the muscles of the broken limb, and to prevent 
swelling and spasmodic action. Whenever it causes 
such an amount of compression as to force the frag- 
ments towards each other, it cannot fail to excite pain 
and inflammation, if not worse consequences. It is 
the manner, then, in which the application is made, 
and not the application itself, that is objectionable in 
the treatment of this fracture. As to the splints, they 
should be carefully moulded to the shape of the limb, a narrow interval being left between 
them at its radial and ulnar borders. When binder’s board splints cannot be obtained, 
light pieces of wood may be used. 
When the fracture is multiple, consisting, for example, of three fragments, the interme- 
diate one, having lost its support, may have a tendency to sink in towards the inter- 
osseous space. To counteract this disposition, a thick, narrow pad may be placed along 
the border of the loose piece, in an opening in the anterior splint, so as to enable the 
surgeon to make the pressure more firm and direct. But even here such an expedient 
will rarely be necessary, if the parts have been moulded into their proper position prior 
to the application of the apparatus. 
FRACTURES OF THE ULNA. 
Fractures of the ulna may with great propriety be divided into those which take 
place in its body, its inferior extremity and its two principal processes, the olecranon and 
coronoid. 
1. Shaft.—The body of the bone is most commonly broken in the lower half of its 
DISEASES AND INJURIES OF THE BONES. 
CHAP. VIII. 
Fig. 480. 
Fig. 481. 
Malapproximation 
of the ends of the 
Fragments in Frac- 
ture of the Ulna and 
Radius. 
Fracture of the 
Shaft of the Ka- 
dius, with vicious 
Union. CHAP. VIII. 
FRACTURES OF THE ULNA. 
extent, in an oblique direction, as exhibited in fig. 482, from causes acting directly upon 
the forearm. The accident may, however, be produced by a counterstroke ; and at least 
one instance is known where it was occasioned by muscular action in wringing clothes, the 
patient being a stout, healthy girl of eighteen. The fracture is evinced 
by a marked depression at the inner border of the forearm, by the mobility 
of the fragments, and by the crepitation on rotating the hand. The lower 
fragment alone is generally displaced, being drawn over towards the inter- 
osseous space by the inferior pronator muscle, while the other, from its 
firm connection with the humerus, remains stationary. An exception to 
this rule is seen in the adjoining figure. 
Great care is necessary in the treatment of this fracture, lest the upper 
end of the lower fragment retains the vicious position into which it is 
forced at the time of the accident, and so is ultimately soldered to the 
inner margin of the radius. To prevent this occurrence, the hand should 
be permanently inclined towards the thumb, by two splints, the extremities 
of which are rendered somewhat sloping from behind forwards, in a direc- 
tion opposite to that of the splints sometimes employed in the management of 
fracture of the corresponding end of the radius. Such an expedient will 
be much more efficient than the long, thick, narrow compress, generally 
recommended for that purpose. 
The head of the ulna is sometimes broken off, either separately, or along 
with the head of the radius. The circumstance is easily detected by the 
mobility of the part, by the disabled condition of the wrist-joint, by the 
severity of the pain, and by the concomitant distortion. The treatment 
is conducted with two splints, aided, if necessary, by two compresses ap- 
plied directly over the seat of the fracture. 
2. Olecranon Process.—Fracture of the olecranon, fig. 483, is caused 
either by direct violence, or by the inordinate action of the three-headed 
extensor muscle, attached to its up[>er extremity. Of 35 cases collected 
by Malgaigne, 27 were the result of falls, 3 of blows, and 5 of muscular contraction. 
Situated at various points of its extent, the fracture may be transverse or oblique, single 
or multiple, simple or complicated. 
Fig. 482. 
Fracture of the 
Shaftof theUlna. 
Fig. 483. 
» 
The symptoms are semiflexion of the limb, impossibility of extending the forearm, a 
hollow at the back of the elbow, as seen in tig. 484, and a movable prominence at the postero- 
inferior surface of the arm, along with more or 
less pain and swelling. The interval between 
the two fragments varies from one and a half to 
two inches, and may be augmented or dimin- 
ished at will by moving the forearm. The 
radius may be rotated upon the ulna, and crepi- 
tation may be elicited by the approximation of 
the extremities of the broken bone. When the 
tip of the olecranon is severed, there is no sepa- 
ration of the fragments ; and the same thing may 
happen when the fracture, whether oblique or 
transverse, is situated above the ligamentous ex- 
pansion of the extensor muscle. 
The union of this fracture is generally fibro- 
ligamentous, as in fig. 485, from a specimen 
in my collection. The causes of this occurrence are, want of proper nourishment of the 
upper fragment, difficulty of maintaining apposition, and inordinate deposit of synovial 
fluid, all, but especially the first, interfering with the healing process. I have, in a few 
instances, seen osseous union ; but this is extremely rare, and is not at all likely to happen 
if there be any considerable separation of the fragments, or if the fracture extend through 
the lower part of the process. The period required for the repair of the injury varies 
Fracture of the Olecranon Process, 
Fig. 484. 
Fracture of the Olecranon I’roceas. 966 
DISEASES AND INJURIES OF THE BONES. 
from six to eight weeks ; but many months elapse before the patient regains a good use 
of his limb. When the lesion is of a complicated nature, violent inflammation of the 
elbow-joint may arise, ending in permanent ankylosis, or in caries and necrosis of the 
bones. 
CU AP. VIII. 
Fig. 485. 
Fracture of the Olecranon Process United by Fibrous Tissue. 
The treatment consists in maintaining the limb in an extended position, by means of a 
wooden splint, long enough to reach from a level with the wrist-joint to within four 
inches of the shoulder, as represented in fig. 48G, from Hamilton. A roller having been 
Fig. 486. 
Hamilton’s Apparatus for Fracture of the Olecranon Process. 
applied from the fingers upward, the small fragment is drawn into its proper place, where 
it is confined by a few long adhesive strips and a compress, the whole being firmly secured 
by carrying the roller around the joint somewhat in the form of the figure 8 ; or, instead 
of this, the arm is bandaged from the shoulder downwards, so as to obtain a more perfect 
control over the extensor muscle, the great agent in effecting displacement. Passive 
motion is instituted at the end of four weeks, and frequently renewed, to prevent anky- 
losis. When the fracture is associated with severe injury of the soft parts, leeches, 
fomentations, and other antiphlogistic measures must be employed. 
Some practitioners give a decided preference to the flexed position in the treatment 
of this fracture, and there is no doubt that such a position vastly enhances the comfort 
of the patient, as it enables him to take out-door exercise and attend to business. The 
cure, however, is less perfect and at the same time more protracted, owing to the greater 
difficulty of keeping the ends of the fragments in accurate apposition. Dr. E. A. Clark, 
of St. Louis, has devised a special apparatus for the purpose, consisting of a band of 
ordinary sole-leather buckled around the lower part of the arm, and attached by means 
of two leather straps at the anterior and posterior surfaces of the forearm to a stout buck- 
skin glove. The forearm is well bandaged and supported at an angle of forty-five degrees. 
A similar contrivance, in which the counterextension is made from the side of the chest 
by means of adhesive strips, and the apparatus elongated by a ratchet connected with two 
steel bars, has been invented by Dr. Henry A. Martin, of Boston. 
3. Coronoid Process—A considerable number of cases of fracture of the coronoid 
process of the ulna, fig. 487, have been reported, both in systematic treatises and in 
Fig. 487. 
Fracture of tho Coronoid Process. 
medical periodicals, but it is very questionable whether even a minority of them should 
he considered as true examples of that lesion. I have myself never met with the accident; 
Professor Hamilton, who has investigated the subject with great care, is very decidedly 967 
CHAP. VIII. 
of opinion that most of the published cases are unworthy of acceptance, either because 
they were badly observed or imperfectly reported, and because the existence of very few 
of them have been verified by dissection. Recently the whole subject has been reexamined 
by Dr. R. M. Hodges, of Boston, who has cited a number of examples clearly establish- 
ing the occasional occurrence of this fracture. In the case of a boy, nine years of age, 
treated by I)r. A. A. Scott, of Missouri, to whom I am indebted for the particulars, the 
coronoid process formed a distinct prominence upon the anterior and inferior surface of 
the humerus, a short distance above the joint, movable from side to side, the olecranon 
being at the same time displaced slightly backwards, and the forearm somewhat flexed. 
The accident was caused by a fall upon the hand while the arm was forcibly extended. 
It has generally been supposed that the accident may be caused by inordinate contrac- 
tion of the anterior brachial muscle ; but as this muscle is not attached to the coronoid 
process, it is impossible for it to produce such an effect. The most reasonable conclusion, 
therefore, is that fracture of this prominence is always the result either of direct injury, 
as a fall, a blow, or the passage of the wheel of a carriage, or of force applied to the 
hand, pushing the ulna and radius violently upwards against the lower extremity of the 
humerus while the forearm is in a state of extreme extension and the body is impelled in 
the opposite direction. The accident is usually complicated with fracture, or fracture and 
dislocation of the elbow-joint. 
In whatever manner the fracture is produced, the diagnosis is always attended with 
unusual difficulty. The ulna, having lost its support in front, will necessarily be drawn 
backwards and upwards by the action of the three-headed extensor muscle, so that the 
injury will present all the features of a dislocation of the bone in this direction, the prom- 
inence of the olecranon being characteristic. The patient is unable to flex the limb, and 
the detached portion of bone may be felt immediately above the elbow, where it may 
readily be grasped and moved about, especially soon after the accident, before any swell- 
ing has set in. By bending the forearm at a right angle with the arm, and drawing down 
the fragment of bone, crepitation might possibly be elicited, but this must, in any event, 
be very faint and indistinct. The accidents with which the injury is most liable to be 
confounded are fracture of the humerus and dislocation of the ulna and radius backwards. 
The union must always necessarily be fibro-ligamentous, as is sufficiently evident when 
we reflect upon the small size of the detached fragment, the difficulty of. keeping it in 
place, its imperfect nourishment, and its connection 
with the joint; circumstances which are so many 
impediments to the formation of osseous matter. 
In young subjects, and under proper management, 
a cure may generally be looked for in four or five 
weeks. 
The treatment is conducted with a view to the 
thorough relaxation of the flexor muscles of the 
limb. For this purpose, the forearm, after having 
been properly bandaged from the fingers up as far 
as the elbow, and the arm from the shoulder down- 
wards, in the opposite direction, is placed at a right 
angle, as in fig. 488, in a tin case or suitable splints, 
and supported by a sling, care being taken to pre- 
vent the radius and ulna from slipping backwards, 
away from the condyles of the humerus. The ful- 
filment of this indication will generally be materi- 
ally aided by the use of adhesive strips, carried around the joint in the same manner ns 
in fracture of the olecranon. Whatever apparatus be employed, it should be long enough 
to insure complete immobility of the hand, the fingers being left free. Passive motion 
should be instituted at the end of four weeks, and |>erseveringly renewed from time to 
time, lest ankylosis ensue. 
An epiphyseal fracture of the extremities of the ulna is an occasional occurrence ; for 
the heads of this bone are not united to the shaft by osseous matter until after the eighteenth 
year, and often not so soon. The exciting cause is external violence; the symptoms are 
such as characterize ordinary fracture, except that there is distinct crepitation, and 
the treatment, in the upper fracture, is similar to that of fracture of the olecranon, while 
in the lower two straight splints are required. 
FRACTURES OF THE ULNA. 
Fig. 488 
Apparatus forFracture of the Coronoid Process. DISEASES AND INJURIES OF THE BONES. 
C1IAP. VIII. 
FRACTURES OF THE RADIUS. 
1. Shaft Fracture of the body of the radius may take place independently of that 
of the ulna, as shown in fig. 481), and is the more frequent accident of the two : its most 
common seat is the inferior half of 
the bone ; its ordinary cause, a fall 
upon the palm of the hand. Dr. 
Packard has reported a case of frac- 
ture of the upper portion of the ra- 
dius from violent muscular exertion 
in driving a pair of horses. 
The symptoms are usually well 
marked, there being more or less de- 
formity, preternatural mobility, in- 
ability to perform the motions of pronation and supination, and crepitation upon rotating 
the hand. The ends of the fragments have a singular tendency to approach the interos- 
seous space, and hence, if the case be not judiciously managed, there is apt to be perma- 
nent distortion, with partial loss of function of the limb. One of the evil consequences 
of this tendency is the want of osseous union, or the formation of a false joint within two 
and a half or three inches of the wrist. A number of well-marked examples of this kind 
have fallen under my observation, and I know of no fracture wdiere an unskilful surgeon 
may show his ignorance to greater disadvantage. 
The limb, being bandaged in the usual manner, is steadied by two splints extending as 
far forwards as the extremities of the fingers, the hand being inclined inwards towards 
the ulna, and maintained in a state midway between pronation and supination. For this 
purpose, the ends of the splints should be shaped somewhat like the handle of a pistol, as 
this arrangement will afford an opportunity of bearing upon the radius in such a manner 
as to force the lower fragment outwards in contact with the superior, thereby counteract- 
ing the tendency above alluded to. If this point be strictly attended to, the cure can 
hardly fail to be perfect. Ordinarily, consolidation may be looked for in four weeks. 
2. Superior Extremity—This bone is occasionally broken at its superior extremity, the 
fracture detaching its rounded head, or extending through its neck. It is very rarely that 
the bone gives way at the bicipital tubercle. A comminuted fracture is not uncommon, 
and the injury is then often, if indeed not generally, complicated with fracture of the 
humerus and serious lesion of the elbow-joint. The accident could hardly be produced 
in any other way than by direct violence. Owing to the manner in which the parts are 
enveloped by the muscles, the diagnosis is usually very difficult. 
The ordinary symptoms are, deformity just below the elbow-joint, caused by the flatten- 
ing of the muscular prominence in that situation ; the projection of the upper end of the 
lower fragment in front of the limb, being drawn thither by the two-headed flexor mus- 
cle ; impossibility of executing the functions of rotation ; and the rapid supervention of 
severe swelling. To render the diagnosis certain, the best plan is to grasp the head of the 
radius with the thumb and index finger of one hand, and to rotate the forearm with the 
other. If there be a fracture, its existence will be rendered evident by the head of the 
bone refusing to obey the motions of the inferior fragment. By adopting this manoeuvre, 
it will hardly be possible to mistake the nature of the case, unless there is so much swelling 
as to prevent the bone from being felt, in which event the examination must be repeated 
as soon as the tumefaction has measurably subsided. 
In the treatment of fracture in this situation, the limb is placed at a right angle with 
the arm, in a state midway between pronation and supination, and the same splints are 
employed as in fracture of both bones of the forearm, care being taken to extend them 
as high up as possible, in order that they may afford adequate support to the upper frag- 
ment. When there is great disposition in the pronator muscle to draw the lower fragment 
over towards the interosseous space it should be counteracted by a compress. 
The annexed drawing, fig, 490, from a preparation in my collection, exhibits a rare 
form of fracture, in which a portion of the head of the radius has been chipped off, and 
permanently united to the contiguous border of the coronoid process of the ulna. The 
specimen was obtained in the dissecting-room, and, therefore, nothing is known of its 
history. 
Inferior Extremity The frequency of fracture of the lower extremity of the radius, 
its liability to be confounded with dislocation of the wrist-joint, and the imperfect recovery 
Fig. 489. 
Fracture of the Shaft of the Radius. CHAP. VIII. 
FRACTURES OF THE RADIUS. 
969 
of the functions of the hand which so often follows it, sufficiently attest the importance of 
the subject, and afford a satisfactory reason for the extraordinary attention that has 
been accorded to it by modern surgeons. Its literature is 
voluminous. Among those who have particularly interested 
themselves in its elucidation may be mentioned Colles, Du- 
puytren, Goyrand, Diday, Barton, Voillemier, Robert Smith, 
Busch, Lecomte, Callender, Gordon, Levis, Moore, Wight, 
Pilcher, Cruce, and Packard. In 1838 Dr. John Rhea Barton 
described a fracture of the radius involving the wrist-joint, 
but the existence of which was never, until recently, verified 
by dissection. The particulars of one such case have been 
reported by Dr. Butler, of Brooklyn, and of another by 
Lenoir, of Paris. In 1814 Mr. Colies, of Dublin, gave an 
account of a fracture which he had repeatedly witnessed at 
the distance of about one inch and a half above the articu- 
lation, and within the last ten years the whole question has 
been examined anew by some of the French, German, Eng- 
lish, and American surgeons, especially the latter, who have 
contributed valuable suggestions in regard to its mechanism, 
diagnosis, and treatment. 
Two circumstances powerfully contribute to the produc- 
tion of this fracture, namely, the large amount of spongy substance in the inferior ex- 
tremity of this bone, and the peculiarity of its connection with the wrist-joint. The 
relative quantity of this matter in its lower and middle portions, and also the difference in 
their compact structure, are very striking. These appearances, which are sufficiently 
conspicuous even in young subjects, are remarkably prominent in elderly persons, in whom 
the spongy substance of this part of the bone is generally exceedingly rarefied and in- 
filtrated with oily matter, while the compact is often merely a thin crust, hardly as thick 
as an egg-shell, and scarcely less brittle. The singular mechanism of the wrist-joint 
cannot fail to arrest the attention of the surgeon. From the intimate manner in which 
the radius is articulated with the scaphoid and semilunar bones, any shock received upon 
the palm of the hand is readily communicated to it, causing it, if the force is at all severe, 
to give way under its influence; whereas the ulna, which has no such close relation, 
generally escapes injury. 
Fracture of the lower extremity of the radius is most common in elderly subjects, for 
the reason already stated that this bone is remarkably brittle in advanced life. Young 
and middle aged persons seldom suffer from it. In children diastasis generally takes the 
place of fracture. The occurrence is comparatively rare in men. 
Respecting the site, direction, and extent of fracture, the greatest possible diversity 
exists. While in some cases it is within three or four lines of the joint, in others, and 
these constitute the great majority, it ranges from a half to three-quarters of an inch or 
even an inch. In what is known as Colies’s fracture, the distance is generally estimated 
at an inch and a half. Occasionally the fracture extends into the joint; and in very rare 
instances a portion of the articular surface, representing its 
posterior border, is chipped off, with or without the styloid 
process. A multiple fracture is by no means uncommon 
both above and within the joint. In the annexed drawing, 
fig. 491, from a preparation in the New York Hospital, 
there are four fragments, and in several cases 1 have met 
with five and even six. Occasionally, in fact, the end of 
the bone is literally ground into pieces. Fig. 492, from a 
specimen in the Pennsylvania Hospital, kindly lent me by 
Dr. Longstreth, represents a common form of fracture, both 
in site and direction, of this portion of the radius. 
The direction of the fracture is,doubtless, as asserted 
by Voillemier, Malgaigne, Nelaton, Robert Smith, Levis, 
and others, for the most part transverse or nearly so, the 
line of fracture extending either directly from before back- 
wards, across the bone, or from before backwards, and from 
below upwards, so as to render the posterior surface of the 
lower fragment considerably higher behind than in front. 
Cases, however, unquestionably occur, and that not uu- 
Fig. 490. 
Fracture of the Head of the Kadius. 
Fig. 491. 
Multiple Fracture of the lowor Ex. 
treinitv of the Radius. 970 
DISEASES AND INJURIES OF THE BONES. 
chap, v 111. 
frequently, in which the fracture is more or less, if not very decidedly, oblique. Goyrand, 
who, in 1832, published an admirable memoir on injuries of this kind, broadly asserts that 
this is uniformly the case, and he has adduced an analysis of 47 cases in illustration of his 
position. Whatever the direction may be, the edges of the fragments are nearly always 
Fig. 492. 
Simple Fracture of the Inferior Extremity of the Radius. 
more or less irregular, roughened, notched, serrated, or denticulated. An impacted frac- 
ture is occasionally seen, the most common form being that in which the end of the superior 
fragment is driven into the cancellated structure of the inferior. When the force causing 
the impaction is very great the inferior fragment may literally be crushed by the superior. 
A double penetration is occasionally observed. When the interlocking is very firm much 
difficulty may be experienced in effecting separation and in restoring the parts to their 
natural relations. 
Not a little diversity of sentiment has been expressed by observers respecting impaction 
in this fracture. While some actually deny the possibility of its occurrence, others 
equally entitled to credit do not hesitate to declare that it is very frequent. Voillemier 
asserts that impaction is always present, the upper extremity being forcibly impelled into 
the lower, and he has adduced proof going to show that the impaction is occasionally 
double, the upper fragment being driven into the lower, and the latter into the former. 
Nelaton, basing his opinion upon a series of experiments performed upon the dead subject, 
shares this view. I have myself no doubt of the occasional existence of impaction; the 
very mechanism, in fact, of the fracture, or the manner in which it occurs, is sufficient to 
prove this. That it is frequent or constant is not true. 
Luxation of the ulna is not uncommon in this fracture. Moore, indeed, thinks that it 
is present in one half of the cases ; but this is probably too high an estimate. Fracture 
of the styloid process of this bone nearly always exists in the more severe forms of the 
accident, especially when the force is received upon the palm and on the inner margin of 
the hand. Fracture of the lower extremity of the ulna is then not uncommon. Displace- 
ment, if not actual rupture, of the flexor muscles of the carpus is an occasional occurrence. 
The carpal ligaments and the interarticular cartilage also not unfrequently sustain serious 
injury, the latter being sometimes wrenched from its bed. Finally, the instances are 
not uncommon in which the radius is broken on both sides, especially in falls from a 
considerable height in which both arms are outstretched to break the force of the blow. 
The accident nearly always results from a fall upon the open hand, in which the patient, 
stretching out the limb, receives the shock upon the palm, whence it is transmitted to the 
inferior extremity of the radius. When the force is expended upon the palm and the ulnar 
margin of the hand, there will be likely to be, as a serious complication, a luxation of the 
ulna, either alone or in union with fracture of the styloid process of that bone. Fracture 
of the styloid process of the radius will be a probable occurrence, if much of the weight 
of the body be thrown upon the palm and thenar eminence, or the palm and the thumb. 
Occasionally, the fracture is caused by a fall upon the back of the hand, or by direct 
violence, as the passage of the wheel of a carriage. 
Fracture in this situation may be complicated, first, with fracture of the styloid process 
of the ulna, or of the head and shaft of that bone; secondly, with dislocation of the wrist- 
joint; and, thirdly, with serious injury of the soft parts. In the case of a young man 
whom I attended along with Dr. Chenowith, the lower extremity of the radius was split 
in two by a transverse and an oblique fissure, the larger fragment being completely de- CHAP. VIII. 
FRACTURES OF THE RADIUS. 
971 
tached, and thrown forwards and inwards over the ulna, whence, as it was impossible to 
replace it, I removed it by incision. A good recovery took place, with hardly any im- 
pairment of the functions of the wrist-joint. In my private collection is a specimen of 
transverse fracture of the radius, extending into the joint, and detaching the head of the 
bone by several small, vertical fissures. In this case I had an opportunity of dissecting 
the parts after the removal of the forearm, above its middle, by another surgeon, several 
weeks after the accident. The hand and wrist were much swollen, and infiltrated with 
pus, which was also freely diffused through the sheaths of the flexor tendons, while the 
connective tissue along the inner part of the palm contained a good deal of blood. The 
joint was filled with matter, and the scaphoid and semilunar bones, as well as the ulna, 
which was dislocated backwards, were almost completely divested of cartilage. 
Among the most conspicuous symptoms of this fracture is the singular deformity of the 
hand, giving the limb the appearance of a dislocation of the wrist-joint, as exhibited in 
fig. 493, or an appearance not 
unlike the back of a silver fork. 
This is owing either to the impac- 
tion of the upper fragment into the 
lower, or to the fact that the lower 
fragment, along with the carpus, 
is drawn upwards and backwards, 
from an inch to an inch and a 
half above the joint, by the force 
of the injury, or by the continual 
agency of this force, and of the 
action of the extensor muscles of 
the thumb, while the upper fragment forms a slight projection on the palmar aspect of the 
forearm. Immediately above the posterior prominence is a well-marked depression which 
gradually slopes off towards the ulna, and is generally sufficiently large to receive the little 
finger. These appearances are always very striking when the limb is held in a situation 
midway between pronation and supination, and are easily effaced by extension and 
counterextension, although they are promptly reproduced when these forces are relaxed. 
The lower extremity of the forearm has a rounded form, from the increase of its antero- 
posterior diameter; the fingers are usually flexed, and the patient is unable to supinate 
the hand, which is, moreover, completely powerless; the pain is excessive, and consider- 
able swelling soon arises, especially along the palmar aspect of the limb. Crepitation, 
except in case of impaction, may commonly be readily detected by rotating the hand upon 
the lower part of the forearm while the thumb and forefinger of the surgeon are applied 
just above the wrist-joint. Some surgeons assert that crepitation is never present; this is 
an error. 
Instead of being thrown backwards, the inferior fragment is sometimes forced in the 
opposite direction, forming a projection in front of the forearm, beneath the flexor tendons. 
Another tumor, more conspicuous, and consisting of the lower extremity of the superior 
fragment of the radius, occupies the dorsal surface; it extends across the entire breadth 
of the limb, and is bounded above by a well-marked furrow, more distinct internally than 
externally. The accident, which is exceedingly rare, closely simulates dislocation of the 
carpus forwards, but may readily be distinguished from it by the presence of crepitation, 
and the facility with which the symptoms may be temporarily effaced under slight ma- 
nipulation. 
Fracture of the inferior extremity of the radius is, perhaps, most frequently liable to 
be mistaken than fracture of any other bone. The accident with which it is most liable 
to be confounded is dislocation of the wrist-joint, but from this it can always be easily 
distinguished by a careful examination and by the fact that a luxation here is one of 
the rarest of occurrences, while fracture, especially in women and in advanced life, is 
one of the most common. The singular deformity of the hand is absolutely charac- 
teristic, for there is no other accident which precisely resembles it. Crepitation, too, is 
always easily elicited by grasping the patient’s hand and steadying the forearm near its 
middle, while the radius at the wrist is rotated upon its axis. The deformity is always 
easily effaced by extension and counterextension, but is immediately followed by recur- 
rence when these forces are relaxed. 
The adjoining sketch, fig. 494, represents a fracture of the inferior extremity of the 
radius, complicated with luxation of the ulna. The signs of both injuries are characteristic. 
The drawing was taken from a private patient. 
Fig. 493. 
Fracture of the lower Extremity of the Radius. 972 
DISEASES AND INJURIES OF THE BONES. 
CHAP. VIII. 
The prognosis of this fracture is greatly influenced by the nature of the case and the 
manner in which it is managed. In any event, however, it must, even in its more simple 
forms, be regarded as a serious accident, often followed, despite 
the best directed efforts of the surgeon, by permanent deformity 
and impairment of the functions of the wrist-joint. Although com- 
plete consolidation ordinarily occurs in from four to five weeks, 
several months—commonly from three to six—elapse before the 
patient regains a good use of his hand and fingers, owing to 
the remarkable tendency, in all such injuries, in the resulting 
inflammation to extend to the synovial membrane of the digital 
articulations, and of the sheaths of the tendons. If the fracture 
is compound, comminuted, or involves the wrist joint, the danger 
of permanent impairment of function will be especially imminent. 
These facts should always be carefully explained to the patient at 
an early stage of the treatment, otherwise the surgeon may be 
unjustly censured for what cannot possibly be avoided. Of 92 
cases of fracture of the inferior third of the radius, referred to by 
Professor Hamilton, only 2G are positively known to have left 
no perceptible deformity or stiffness about the wrist-joint. The 
adjoining cut, fig. 495, from a specimen in my collection, exhibits 
a very common species of deformity in badly treated fractures of 
this portion of the radius. The injury was accompanied by fracture 
of the styloid process of the ulna. The whole hand is drawn over 
towards the radial border of the wrist. 
Among the various contrivances that are before the profession 
for the treatment of these fractures, that of Dr. Levis is, perhaps, 
Fig. 494. 
Fracture of the lower End 
of the Kadius. 
Fig. 495. 
An Old Fracture of tlio Inferior Extremity of the Radius attended with Separation of the Styloid Process of the Ulna. 
the very best and most reliable. That of Dr. Gordon, of Belfast, is also a very superior 
article, as it admirably fulfils all the indications presented in such lesions. The splints 
invented by Dr. E. H. Coover, of Harrisburg, Dr. Henry C. Hewit, of New York, and Dr. 
Carr, of Boston, also merit favorable mention. Dr. Moore’s dressing is very simple and 
effective ; and excellent cures, as I know from personal experience, may be obtained from 
the use of the apparatus of Dr. Thomas Bond, so long in vogue among Philadelphia sur- 
geons. The pistol-shaped splint, said to have been devised by Nelaton, possesses few 
of the requisites necessary for the successful management of fractures of the inferior 
extremity of this bone, although Erichsen declares that he has always had excellent 
results from it. The splint of Dr. Levis, fig. 496, is made of copper, coated with tin to 
prevent oxidation ; it is very thin and flexible, to adapt it to the peculiarities of the size 
and form of the forearm, ends in a curve in front to receive the palm of the hand, and 
has a series of little elevations along its edges to keep the bandage used in confining it 
from slipping. A layer of wadding or flannel serves as a lining;*no dorsal splint is required, 
but in most cases a pad should be placed over the back of the wrist to guard against dis- 
placement of the lower fragment. The thumb and fingers are left free, while the anterior 
extremity of the splint, following accurately the radial curvature, fixes the thenar and 
hypothenar eminences of the hand in their moulded beds. Fig. 497, shows the manner 
in which the splint grasps the limb before the application of the roller. 973 
CHAP. VIII. 
FRACTURES OF THE RADIUS. 
The apparatus of Dr. Bond consists, as shown in figs. 498 and 499, of two splints, one 
of medium-seized binder’s board, and the other of thin, light wood, furnished with a block 
Fig. 496. 
Levis’s Splint. 
Fig. 497. 
Levis'g Splint Applied 
and edges of thin sole-leather, 
about an inch in height, the whole 
presenting somewhat the appear- 
ance of a shallow trough. They 
are long enough to reach from a 
short distance below the elbow to 
within an inch of the knuckles of 
the metacarpal bones, the block of 
the latter resting in the hollow of 
the palm, and both being well 
padded with wadding. They are 
fastened in the usual manner. 
When there is any marked ten- 
dency to displacement, a narrow, 
square compress, not more than a 
third of an inch in thickness, may 
be laid over the projecting frag- 
ment, to give greater concentra- 
tion and effect to the pressure of 
the apparatus opposite the seat of 
fracture. Sometimes it is found 
necessary to use a compress on each side of the wrist; but such is the accuracy with 
which the palmar splint fits the parts that this portion of the dressing may generally 
be dispensed with. There is no use, in any case, of an interosseous compress, as there 
is never any tendency in the fragments to inward displacement. The advantage of the 
apparatus of Dr. Bond is, as in those of Levis and Gordon, that, while it maintains 
the thumb perfectly at rest, and, consequently, prevents its extensor muscles from dis- 
turbing the fragments, the fingers may be freely moved in front of the block ; a circum- 
stance of no trifling importance in an accident so liable to be followed by inflammation 
and adhesions of the sheaths of the tendons, and ankylosis of the thumb and fingers. 
Fie. 498 
Bond’s Splint, for the Back of the Forearm. 
Fig. 499. 
Bond’s Splint, for the Front of the Forenrm and Hand. 974 
DISEASES AND INJURIES OF THE BONES. 
CHAP. VIII. 
In Gordon’s mode of dressing these fractures, the forearm is placed in the prone posi- 
tion, and is supported by a splint, which, to use the inventor’s own language, “consists 
of tlie body, the ulnar, and bevelled portions, with a curved back splint, fig. 500. The 
lower end of the ulnar portion is curved forwards and hollowed to receive the inner 
border of the flexed hand, with a slit for the carpal strap. The bevelled portion is secured 
to the body of the splint nearly half an 
inch internal to its margin ; it is cut off 
obliquely from without inwards and from 
below upwards ; it is applied to the pal- 
mar surface of the upper fragment, which 
it is its office to fix. The lower end of the 
back splint is much curved forwards. This 
curve, with a thick pad, is necessary to 
enable it to press the base of the metacarpus, 
the carpus, and the lower end of the lower 
fragment well forwards for the restoration 
of the natural aspect of the carpal surface 
and the concavity of the radius.” The dress- 
ing is confined with three wide straps, not 
with a roller, and the forearm is well sup- 
ported by a sling; when the fracture is 
only a short distance above the joint, the 
lower strap is passed over the back of the 
splint and over the carpus when it is higher 
up, as in Colles’s fracture. Fig. 501, shows 
the application of the apparatus and the 
position of the limb. 
The dressing of Dr. Moore, fig. 502, consists of a compress from one-half to three- 
quarters of an inch in diameter and two inches in length, which, after the reduction of 
the fracture, is placed under the ulna, abutting against the pisiform bone and slowly dis- 
placing the thumb, and while the parts are held in position, is confined with a strip of 
Fig. 500. 
Gordon’s Splint for Colles’s Fractnro. 
Fig. 501. 
Gordon's Splint Applied. 
Fig. 502. 
Moore’s Method of Treatment. 1. A Cylindrical Compress ; 2. Bandage of Adhesive Plaster ; 3. Line of Cut in Plaster 
six hours after the reduction. 
adhesive plaster, of similar width, and drawn forcibly around the wrist, its distal edge 
being brought around on a line with the end of the radius. The operation is completed 
by suspending the arm in a sling, three inches wide, and so arranged as to bear exclu- 
sively on the dressing. The hand is brought down and allowed to hang naturally, its 
weight and that of the forearm being used to press the ulna upwards into its proper 
place. Motion of the wrist-joint is counteracted, if necessary, by a light splint stretched 
along the dorsal surface of the limb. The dressing, which is applied very tightly in the 
first instance, is relaxed at the end of six hours by thrusting one blade of a pair of scissors 
underneath it on the back of the wrist, dividing it completely. Dr. Moore’s treatment 
is simplicity itself, and its efficiency has been attested by several eminent American prac- 
titioners, among others by Dr. Prince, of Illinois. 
Good results may be secured in the treatment of these fractures with two straight 
splints, extending from near the elbow as far forward as the knuckles of the lingers, the 975 
CHAP. VIII. 
anterior one being well padded in the part corresponding with the palm of the hand. 
Compresses should be applied over the seat of the fracture both in front and behind, 
and the thumb should be made to look directly upward, while the fingers are left unin- 
cumbered. In applying the bandage the hand should be slightly inclined toward the 
ulna. Dr. Barton always obtained excellent cures by the use of two straight splints 
reaching forward to the ends of the fingers. His plan was to make passive motion at a 
very early period after the accident. 
Whatever splint or apparatus may be used, the cardinal point is to effect thorough 
reduction of the fracture, by extension and counterextension on the hand and forearm, 
while the hand is inclined towards its ulnar margin, and pressure is made at the seat of 
the fracture, so as to force or draw the ends of the fragments into their proper positions. 
To accomplish this, great difficulty will often be experienced, especially when the fracture 
is impacted, comminuted, or associated with luxation of the lower end of the ulna; under 
such circumstances, indeed, very considerable force is often required to restore the sym- 
metry of the limb. The tendency to displacement, which, however, is seldom great, and 
often entirely absent, generally ceases of its own accord in five or six days, the muscles 
becoming, so to speak, reconciled to their new relations. Meanwhile any disposition of 
the kind must be counteracted by strict attention to the dressings. In children reduction 
is generally easily effected and maintained. The splints need not be retained, in the adult, 
longer than five weeks, or four weeks in young subjects. Stiffness of the fingers will not 
be likely to occur if the movements of their joints be properly attended to during the 
earlier stages of the treatment. 
The treatment of fracture of the inferior extremity of the radius, suggested by Dr. 
John Swinburne, is very simple and effective. It consists in confining the forearm upon 
a single splint, stretched along its posterior aspect from the elbow to the metacarpo- 
phalangeal joints, and composed of a thin piece of wood of the width of the limb, and 
provided with two compresses, one of which fills up the concavity of the carpus, while 
the other supplies the deficiency in the straight line of the arm above. The splint is 
secured with adhesive strips, the application of which is commenced at the elbow, and 
continued, at intervals of several inches, down the limb to the hand, which, the displaced 
parts having previously been adjusted, is then firmly fastened, in such a manner as to 
allow perfect freedom to the thumb and fingers. Additional support may be given, 
if necessary, with an ordinary roller. The annexed cuts, figs. 503, 504, and 505, 
afford a good idea of the apparatus and of the appearance of the limb after its appli- 
cation. 
The above dressings answer equally well, whatever may be the character of the dis- 
placement, whether backwards or forwards. Passive motion is instituted at the end of 
three weeks, proper support being given 
to the fracture while this is being made. 
The operation is afterwards repeated 
every other day, until the end of the 
fifth week, when the apparatus may 
generally be discontinued, the bandage 
alone being used. If the joints of the 
fingers are stiffened, they should receive 
special attention at each dressing. I 
have met with cases in which bandag- 
ing, douching, and pressure were obliged 
to be continued daily for many months 
before the affected joints regained their 
full motion. 
Finally, the radius, in young subjects, 
occasionally gives way at the lower 
epiphysis. The accident is uncommon, 
but a number of cases, showing the 
possibility of its occurrence, are scat- 
tered through the records of surgery, 
and several have come under my per- 
sonal observation. Voillemier, in experimenting upon the dead body, produced separation 
at the epiphysis with great facility, simply by forcible flexion or extension of the wrist, 
not only in young subjects, but, in one instance, in a stout, robust man of twenty-four. 
FRACTURES OF THE RADIUS. 
Fig. 503. 
Fig. 504. 
Fijr. 505. 
Swtnburne’s Apparatus for Fracture of the Radius. DISEASES AND INJURIES OF THE BONES. 
CHAP. VIII. 
The injur}’’, however induced, is managed upon the same general principles as an ordinary 
fracture of the radius, from which it is not always easy to distinguish it. 
FRACTURES OF THE HUMERUS. 
Fractures of the humerus are of frequent occurrence, and are of great practical import- 
ance, from the difficulty which so often attends their diagnosis and treatment. They may 
take place in the shaft of the bone, at its surgical neck, at its head within the capsular 
ligament, and at its condyles. 
1. Shaft.—The simplest fractures of the humerus are those which occur in its shaft, as 
they are most easily detected and treated, and least liable to be followed by deformity and 
loss of function. Caused occasionally by direct violence, they more frequently result from 
falls upon the palm of the hand, in attempts to save the body from more serious injury. 
In several instances that have come under my observation, and which are alluded to in 
another part of this section, the accident was produced by muscular contraction ; in one 
case, while the patient was in the act of throwing a chip. The fracture is usually oblique, 
a transverse one, properly so termed, being exceedingly uncommon. A complicated frac- 
ture of the shaft of the humerus is occasionally met with, as a consequence of the explo- 
sion of firearms, the contact of machinery, or the passage of the wheel of a carriage. 
The symptoms of fracture of the humerus in this situation are usually characteristic, 
the deformity, preternatural mobility, and crepitation being well marked. In general, 
there is some shortening, the amount varying according to the obliquity of the fracture 
and the size of the limb ; in ordinary cases it is very slight, the weight of the arm being 
sufficient to counteract the action of the muscles, at least to a considerable extent. The 
direction of the displacement is regulated by the line of fracture; if this be below the 
insertion of the deltoid, the inferior fragment will be drawn inwards, but outwards if it 
be above that point. However this may be, any deformity that is present is easily effaced 
by extension and counterextension. The limb is completely powerless, and is always 
supported by the patient at the wrist. 
The treatment of this fracture is very simple, the only apparatus necessary being two 
splints, and a roller applied from the fingers up. The splints may consist of two stout 
pieces of unoiled sole-leather, felt, or binder’s board soaked in hot water, and accurately 
moulded to the shape of the limb ; one extending from the axilla to within an inch of the 
internal condyle, and the other from the shoulder-joint to the corresponding point of the 
outer condyle, the two, when applied, nearly meeting each other. The forearm and hand 
are well supported in a sling; and, tor the sake of greater security, the arm may be 
fastened by a few turns of a bandage to the side of the trunk. Special care is taken not 
to raise the elbow, as a certain degree of weight is necessary to prevent overlapping of the 
fragments. 
This apparatus may be advantageously replaced at the end of a week, or as soon as the 
swelling consequent upon the fracture has measurably subsided, by the immovable dress- 
ing. If the tendency to overlapping of the fragments is uncommonly great, a weight, 
as a few pounds of shot, may be temporarily suspended from the elbow, which, under 
all circumstances, must be left free. If the dressing be properly applied there is no reason 
for supporting the forearm with splints, as is urged by Boyer and some other surgeons, in 
order, as is alleged, to place the brachial muscles in a quiescent condition, and thereby 
counteract any tendency to displacement. Such a precaution, however, is wise, and 
cannot be too strenuously insisted upon, when the fracture affects the lower portion of the 
shaft of the bone, an accident in which there is always unusual danger of overlapping, if 
the parts be not thoroughly supported and carefully guarded. It is in this portion of the 
bone in which, if the treatment be not most cautiously conducted, want of union is so 
liable to occur. 
In simple fractures of the shaft of the humerus union may usually be expected by the 
end of the fifth week. Injuries of this kind are generally readily repaired even in very 
old persons. Cases are recorded in which consolidation occurred within the ordinary 
limits at seventy-five, eighty-nine, and even one hundred years, as in an instance observed 
by Dr. W. W. Dale, of Pennsylvania. 
Fractures of the shaft of the humerus are occasionally followed by “ wrist drop,” de- 
pendent upon imprisonment and compression of the musculo-spiral nerve by the callus at 
the seat of the injury. Two cases of this occurrence have fallen under my observation ; 
one in a patient of my own, and the other in an out-door patient at the College Hospital. 
The only remedy is the removal of the offending callus. CHAP. VIII. 
FRACTURES OF THE HUMERUS. 
977 
2. Inferior Extremity.—Fracture of the condyles may be caused by a fall upon the 
point of the elbow, by a blow, or by the passage of the wheel of a carriage. I have 
repeatedly known it to be produced by a fall upon the palm of 
the hand, the limb being at the time in an extended position. 
The accident may be simple, or, as not unfrequently happens, 
complicated with serious mischief to the joint and soft parts. 
Both condyles may be broken, as in tig. 506, or one only may be 
affected. Jn the former case, a longitudinal fracture usually ex- 
tends some distance along the centre of the bone, and then ter- 
minates, probably an inch and a half to two inches above the 
joint, in an oblique or transverse fissure in the lower portion of 
the shaft of the humerus, thus producing three fragments. Not 
unfrequently, however, there is a separation merely of one of 
these prominences, the fracture being then usually directed ob- 
liquely downwards into the joint. In a third series of cases, the 
small projection, the internal epicondyle as it is termed, is broken 
off, either obliquely or perpendicularly, without any involvement 
whatever of the articulation. 
Fracture of the condyles, especially when it affects only one 
of these prominences, is almost invariably an accident of early life, the great majority of 
cases occurring before the fifteenth year. Occasionally an instance is met with in old age, 
in consequence of the inordinate brittleness of the osseous tissue. 
The symptoms of fracture of this portion of the humerus vary according to circum- 
stances, as might be expected from a consideration of the structures of the elbow'-joint. 
When both condyles are severed just above the articulation, the radius and ulna project 
backwards, a hollow exists at the bend of the arm, the forearm is slightly flexed, and the 
distance between the elbow and wrist is sensibly diminished. When the fracture involves 
both the condyles and the inferior extremity of the shaft of the bone, there will be, in 
addition to these phenomena, an increase in the width of the bend of the arm, and an 
appearance of greater flattening. The accident, whether accompanied by this occurrence 
or not, is liable to be mistaken for dislocation of the radius and ulna backwards ; but the 
diagnosis may generally be readily de- 
termined by the fact that the symp- 
toms which mark the former lesion 
promptly disappear on extending the 
limb, and that crepitation may be pro- 
duced when the forearm is rolled upon 
the humerus. 
When the inner condyle alone is 
detached, as in fig. 507, the ulna pro- 
jects backwards, but resumes its natural position on extending the limb ; the condyle 
forms a tumor at the back part of the elbow ; crepitation is perceived on bending the fore- 
arm ; and, if the forearm be extended, the humerus will advance in front of the ulna as 
the latter recedes. 
Fracture of the external condyle, fig. 508, is characterized by the existence of a tumor 
at the outer and back part of the elbow, 
by crepitation on rotating the radius, 
by the supine position of the hand, by 
the inability to move the joint, and by 
the constant semiflexion of the forearm. 
Whatever may be the nature or ex- 
tent of these fractures in the vicinity of 
the elbow-joint, there is always severe 
pain, with complete inability to move 
the limb. Considerable swelling soon follows, and effusion rapidly takes place within the 
articulation, obscuring the characteristic features of the injury, and rendering the diag- 
nosis proportionately difficult. When such a condition exists, leeches, fomentations, and 
other antiphlogistic measures may be necessary before the parts will be sufficiently tolerant 
of the requisite manipulation. 
The inferior extremity of the humerus occasionally gives way just above the condyles, 
generally in a more or less oblique direction, as seen in fig. 509. Such an occurrence 
may, unless great care be taken, be readily confounded with dislocation of the ulna and 
Fig. 506. 
Fracture of the Condyles of 
the Humerus. 
Fig. 507. 
Fracture of the Internal Condyle. 
Fig. 508. 
Fracture of the External Condyle. 978 
DISEASES AND INJURIES OF THE BONES 
CUAP. VIII. 
radius backwards, which its symptoms, at 
first sight, closely resemble. The signs of 
distinction are the mobility of the limb 
and the facility with which the parts can be 
restored to their natural position, followed 
by the immediate return of deformity upon 
discontinuing the extension. The acci- 
dent, which should be treated on the same 
principles as fracture of the shaft of the 
humerus, is extremely liable to be suc- 
ceeded by stiffness of the joint. 
In children, prior to the completion of 
the ossific process, there is sometimes a 
separation of the epiphysis of the inferior 
extremity of the humerus, induced by falls upon the hand or elbow. The symptoms resem- 
ble those of fracture in this situation in the adult, there being an unnatural projection 
at the back of the joint, caused by the retraction of the lower fragment along with the 
bones of the forearm, and the ready production of crepitation on extending the limb. 
The accident is treated as if it were a fracture. 
Fractures of the inferior extremity of the humerus, involving the elbow-joint, are pecu- 
liarly liable to be followed by severe inflammation of the synovial membrane, extensive 
effusion, ankylosis, and deformity. Even in the more simple forms of these injuries, 
where the treatment is most skilfully conducted, there is generally great risk of an 
unfavorable result, and in any event a long time must elapse before there will be a good 
use of the articulation. A prudent surgeon should, therefore, at once inform his patient of 
the nature and probable consequences of the case. From five to six weeks is the average 
period necessary for the reunion, which, unless the apposition is most perfect, will occa- 
sionally be fibro-cartilaginous instead of osseous. 
Fig. 509. 
Fracture of the Lower End of the Humerus. 
Fig. 510. 
Badly-treated Fracture of the External Condyle of the Humerus. 
The nature of the deformity, in badly-treated fracture of the condyles of the humerus, 
may exhibit itself in a variety of ways, depending upon the peculiar mode of management. 
Sometimes a posterior projection remains, caused by the backward displacement of the 
lower end of the bone; not unfrequently the limb has a strangely twisted appearance, 
either in the direction of pronation or supination ; occasionally it is permanently flexed 
or extended ; and sometimes, again, it is greatly increased in breadth. A very common 
form of badly-treated fracture of the external condyle is exhibited in tig. 510, from a 
clinical case. 
Most practitioners are agreed upon the propriety of treating these fractures with the 
forearm in the rectangular position. There are but few that pursue the opposite plan, 
and the alignments that have been adduced in its favor have by no means convinced me 
that it is at all equal to the ordinary method. To maintain the limb in the flexed position, 
I have long been in the habit of employing a light, well-shaped tin case, extending from 
the axilla to the metacarpo-phalangeal articulations. This, being properly lined with 
wadding, affords an admirable support to the limb, and effectually prevents displacement 
of the fragments, whatever may be their size or number. The skin over the inner con- 
dyle must be well protected from pressure, otherwise it may become seriously inflamed, if 
not ulcerated. To obviate this occurrence, a small gap should be made in the apparatus 
for its special accommodation. A case made of India-rubber, felt, thin wire, sole-leather, 
or plaster of Paris answers quite as well as one of tin, and is even, in some respects, CHAP. VIII. 
FRACTURES OF THE HUMERUS. 
979 
superior to it, inasmuch as it admits of more accurate adaptation to the irregularities of the 
limb. The forearm is supported in a sling, in a state midway between supination and 
pronation. 
The rectangular splint, originally recommended in the treatment of these fractures by 
Physick, is still capable, when judiciously used, of rendering good service in this class of 
cases. The best contrivance of the kind, however, is that of Professor Agnevv, in which 
the two pieces are united by hinges, thus permitting the angle of flexion to be regulated 
at pleasure. There is some diversity of opinion as to whether the splint should be applied 
to the outside or inside of the limb. My own experience is that the advantages are de- 
cidedly in favor of the latter, provided an opening be left at the elbow for the accommoda- 
tion of the epieomlyle, which should always be carefully protected from harm, whatever 
apparatus be employed. Excellent cures may be effected, especially in young children, 
by applying the splint in front of the limb, so as to concentrate the pressure at the seat 
of tl*; fracture. 
I)r. Oscar II. Allis, of the Presbyterian Hospital of this city, recently called atten- 
tion to the importance of treating fractures of the lower extremity of the humerus in the 
extended position. Having enjoyed uncommon facilities for the study of injuries of this 
kind, he is convinced that much better cures can be effected in this than in any other 
way. The inflammation consequent upon the accident having been reduced, suitable 
means, as a splint of felt, binder’s board, or unoiled sole leather is moulded to the ante- 
rior surface of the arm and forearm, and confined by means of the egg-paste dressing, the 
bend of the elbow having been previously well covered in with cotton or some other soft 
material. Three layers of bandage are generally amply sufficient. The extended position is 
maintained until complete consolidation has taken place, usually from three to four weeks 
and a half, according to the age of the patient, when a more convenient position is assumed, 
and the limb carried in a sling, passive motion being now for the first time attempted. 
Dr. Allis assures me that his success with this treatment, extending over many years, 
has been most gratifying, and he has adduced a number of cases, going to show that the 
deformity of the limb, illustrated in fig. 510, is a very common occurrence when fractures 
of the condyles of the humerus are treated with the forearm in the flexed position, but may 
be readily prevented in the extended. 
Fracture of the tubercle of the internal condyle—the so-called epicondyle of the French 
anatomists—is by no means a rare occurrence, especially in very young children, and is 
generally caused by direct injury, as a fall or blow upon the 
elbow. Prior to the completion of the ossific process, it is 
sometimes occasioned by sudden and violent muscular con- 
traction. The direction of the fracture is usually more or 
less oblique. Not unfrequently the lesion is complicated 
with dislocation of the radius and ulna upwards, or with 
fracture of the inner condyle. When it exists as an inde- 
pendent affection, it does not, of course, extend into the 
joint, although it is liable, even then, unless properly treated, to be followed by ankylosis. 
The diagnosis is readily established by the great mobility of the fragment, represented 
by the epicondyle, by the easy production of crepitation, and by the other ordinary signs 
of fracture. The fragment either retains its natural position, or, as is more generally the 
case, it is pulled down a short distance over the forearm, occasionally almost in a straight 
line, but more commonly to one side, by the action of the flexor muscles. The move- 
ments of the joint are more or less impaired, and, when the accident has been caused by 
external violence, there is often a considerable amount of ecchymosis. 
Although the small fragment may generally be readily restored to its normal position, 
great difficulty is experienced in keeping it there until it has regained its former attach- 
ments. For this reason it is always well to give a guarded prognosis, as few cases recover 
without a certain degree of deformity or even ankylosis. 
The treatment is by the rectangular case, with an opening opposite the inner condyle 
to ward off pressure, the limb being carefully bandaged from the fingers up, and the epi- 
condyle confined by adhesive strips and compresses. Passive motion must be commenced 
at the end of a month, and afterwards repeated daily until all danger of ankylosis is over. 
Now and then the cure is best effected with the limb treated in the straight position. 
No example, of a reliable character, of fracture of the external epicondyle has ever 
been recorded. Indeed, the very possibility of such an occurrence is generally denied, 
surgeons in the most extensive practice having never met with any cases of it. 
There are no fractures which require more constant vigilance after their adjustment 
Fig. 511. 
Fracture of the Epicondyle. 980 
DISEASES ANI) INJURIES OF THE BONES. 
CHAP. VIII. 
than those about the elbow-joint. The dressings should, therefore, during the first week, 
be frequently examined, in order that they may be promptly changed in the event of their 
being either too tight or too slack, and special pains must be taken that the bandage, in 
the first instance, be applied rather loosely, due allowance being always made for the 
resulting swelling. As a general rule, the best plan is to reduce the inflammation conse- 
quent upon the injury, as a preliminary step, by placing the limb in the extended posi- 
tion upon aqdllow, and keeping the parts constantly wet with a strong solution of lead 
and opium. The first five or six days may generally be well spent in this manner. Pas- 
sive motion should not be instituted until complete union is obtained, after which it should 
be repeated, at first every other day, and then daily, until all danger of ankylosis is over. 
At this stage, too, it is highly important that the limb should be released from the con- 
strained position which it occupied during the treatment, being gradually extended if it 
was flexed, and flexed if it was extended. 
Fractures of the elbow are often of a complicated character, as in fig. 512, especially 
when caused by railway injury, or falls from a great height, penetrating the joint, exten- 
sively lacerating the soft parts, and, 
perhaps, comminuting the bones. 
Such accidents are always fraught 
with danger, both to limb and life, 
and usually promptly require ampu- 
tation. Even supposing that the 
limb could occasionally be saved un- 
der such circumstances, the patient’s 
recovery will be extremely tardy, 
and when, at length, he does get 
well, it will be found, as a rule, that 
the joint will be worse than useless, 
only serving as a hindrance. Re- 
section is sometimes admissible in 
these injuries; but, as a principle, 
amputation is altogether preferable, 
especially when they are accompanied by extensive laceration of the soft parts. 
In the treatment of these fractures about the elbow great comfort is derived from placing 
the limb upon a pillow arranged along the patient’s side; or, what often answers a better 
purpose, a Stromeyer’s cushion, a triangular, wedge-shaped appliance, about fifteen inches 
in length by six inches in width, and four inches in thickness at its inferior extremity. 
It is secured to the limb and to the neck by suitable 
straps, and to the body, if necessary, by several turns 
of a roller. Fig. 513, from Bryant, affords a good 
idea of this very excellent apparatus. 
3. Superior Extremity.—The superior extremity 
of the humerus includes the hemispherical head of 
this bone and its two necks, the anatomical and surgi- 
cal ; the former being the narrow, constricted portion 
between the head and its tuberosities, and the latter 
all that portion which intervenes between these 
prominences and the insertion of the broad dorsal 
muscle, its length varying from an inch and a half to 
two inches, according to the stature of the individual. 
o. Fracture of the Head—Fracture of the head of the humerus is so extremely un- 
common that its possibility was for a long time a matter of controversy among surgeons. 
The cases, however, that have been reported by Bichat, Astley Cooper, Dorsey, Gibson, 
li. W. Smith, Malgaigne, and others, have effectually dispelled all doubt upon the subject. 
I saw, myself, during my pupilage, in a patient of Dr. George McClellan, an instance of 
the kind, which had been mistaken by the attendants for a fracture of the acromion pro- 
cess, and the true nature of which was not detected until several years after the occur- 
rence of the accident, when the man, who was upwards of forty years of age, died of dis- 
ease of the liver. The fracture, as was shown on dissection, had extended obliquely from 
above downwards through the head of the bone ; and, although it had become perfectly 
consolidated, there were several rough prominences which, while they unmistakably indi- 
cated the seat of the injury, greatly impeded the movements of the shoulder-joint. The 
accident had been caused by a fall from a carriage. 
Fig. 512. 
Complicated Fracture of the Elbow. 
Fig. 513. 
Stromeyer’s Cushion, with Straps applied. CHAP. VIII. 
FRACTURES OF T1IE HUMERUS. 
981 
In a specimen in my private collection, obtained from the body of an insane woman, 
upwards of seventy years of age, whose skeleton had been broken in numerous places, in 
a fall from a second-story window, the bead of the humerus is completely detached from 
the anatomical neck, the articulating surface, which retained its smooth and polished 
aspect, being tilted over the great tuberosity against the posterior surface of the bone, to 
which it is firmly and inseparably united by osseous matter, the fracture having evidently 
occurred a long time before death. 
Directly opposite to the prominence 
thus formed, on the inner surface of 
the humerus, is another large projec- 
tion, fully an inch in length, having 
the character of a stalactitic exostosis. 
The bicipital groove is completely 
effaced. The whole bone is extremely 
light, its weight being hardly two 
ounces and a half. The annexed cut, 
fig. 514, conveys a good idea of the distinguishing features of this remarkable, if not uni- 
que, specimen. 
When the head of the humerus is completely detached from the tubercles along the 
anatomical neck, it must necessarily act as a foreign body, speedily perishing from the 
want of nourishment. In some cases, however, it is enabled to preserve its vitality, 
although imperfectly, by retaining its con- 
nection with the rest of the bone through 
the intervention of a few bands of fibrous 
tissue. 
j3. Fracture of the Anatomical Neck 
In old persons, the head of the bone, fig. 
515, is sometimes not oidy broken off, but 
thrown down into the axilla, where it forms 
a distinct tumor that may easily be felt by 
the hand, but which does not obey the move- 
ments of the arm. Such an occurrence, 
which occasionally happens in the act of 
reducing a shoulder dislocation, always seri- 
ously complicates the case. The accident 
is generally caused by a fall on the elbow, 
or by violence applied directly to the shoul- 
der, and is very liable to be mistaken for 
other injuries. 
The intracapsular fracture of the hume- 
rus is occasionally impacted, the upper 
fragment being propelled into the inferior 
or conversely. The occurrence, which is 
extremely uncommon, is met with exclu- 
sively in old subjects, laboring under atro- 
phy and great fragility of the osseous tissue. The head of the bone can be felt in 
the glenoid cavity, there is a slight hollow below the acromion process, the axis of the 
arm is directed inwards towards the coracoid process, and the elbow is somewhat sepa- 
rated from the trunk. Crepitation is either very faint or entirely wanting. The length 
of the humerus is diminished, but generally in so slight a degree as to render it unavail- 
ing in a diagnostic point of view. 
Fig. 516, from a specimen in my collection, represents an ancient fracture of the ana- 
tomical neck of the humerus, in which the head of the bone, united by a thick layer of 
osseous matter, is turned upside down, the centre of the articular surface corresponding 
with the outer border of the shaft. Several stalactites, one of large size, bad been devel- 
oped immediately below the head. The joint was of course completely annihilated. Such 
a case would have formed a proper subject for excision. 
y. Fracture of the Surgical Neck Fracture of this portion of the humerus is uncom- 
mon, but may take place from the same causes as fracture of the shaft of the bone, as a 
fall upon the hand or elbow, direct violence, or, although rarely, from muscular action. 
The injury is always attended with marked displacement, forming an important feature in 
its history. The superior fragment, yielding to the influence of the spinate muscles of 
the scapula, is generally drawn outwards and slightly backwards, while the inferior one is 
Fig. 514. 
Fracture with Detachment of the Head of the Humerus. 
Fig. 515. 
Fig. 516. 
Fracture of the Anatomi- 
cal Neck of the Humerus 
Fractnre of the Anatomi- 
cal Neck of tho Humerua, 
in which the Head of the 
Bone is turned upside down. 982 
DISEASES AND INJURIES OF THE BONES. 
CHAP. VIII . 
directed inwards towards the side of the trunk by the pectoral, broad dorsal, and large 
teres muscles, attached to the inner border of the bicipital groove. At the same time that 
this portion of the humerus is dragged 
inwards, it is usually somewhat raised 
by the joint agency of the muscles that 
pass from the scapula to the forearm ; 
the extent of the displacement, how- 
ever, is commonly trivial, inasmuch as 
the weight of the limb is almost suffi- 
cient to counteract its occurrence. 
Fig. 518, from a specimen in my 
cabinet, affords a good illustration of a badly-treated fracture of the surgical neck of the 
humerus, followed by exuberant callus, as must always be the case when the ends of the 
fragments are not kept properly in place. 
The diagnosis of these different fractures is not always so easy as might, at first, be sup- 
posed. Their character is often greatly obscured by the swelling, and the consequent 
difficulty of making a thorough examination. In general, there is 
marked deformity at the shoulder-joint, the deltoid muscle is flattened, 
the arm is twisted upon its axis, and, if the injury is situated on the 
outside of the capsular ligament, there is usually slight shortening of 
the humerus, with distinct projection of the upper end of the lower 
fragment. If extension and counterextension be made, so as to draw 
the parts in place, crepitation may be elicited, followed by a recurrence 
of all the previous symptoms the moment the surgeon relinquishes his 
hold. In cases of doubt, the best plan is to grasp the head of the 
humerus firmly with the thumb and fingers of one hand, while with 
the other we seize the elbow and move the arm on its axis. If fracture 
be present, it will almost be sure to be detected by the crepitation pro- 
duced by this manoeuvre, whereas, if there be a dislocation, no noise 
will be perceived, and there will also be little or no mobility. When 
the head of the bone is fractured, and thrown off’ the glenoid cavity, 
the symptoms will be of a compound character, the crepitation and 
abnormal mobility coexisting with flattening of the deltoid muscle, ex- 
traordinary saliency of the acromion process, and a remarkable ful- 
ness in the axilla, caused by the presence of the displaced bone, at the 
same time that the upper extremity of the inferior fragment projects 
prominently upwards and inwards. 
Treatment—Fractures of the superior extremity of the humerus 
must all be treated upon the same general principles as fractures of the 
shaft of the bone. The limb being bandaged from the fingers up, 
two splints, broad and hollow, made of unoiled sole-leather, bind- 
er’s board, gutta-percha, or gum sheeting, are applied, one on the outside and the other 
on the inside of the limb, the former being long enough to extend from the external con- 
dyle to the top of the shoulder, which it should cover well, as in fig. 519, 
as it is designed to give firm support to the broken parts. The inner 
splint should be thickly padded at its superior extremity, otherwise it may 
chafe the skin or exert undue pressure upon the axillary vessels and 
nerves. No cushion will be required for the axilla. The arm is carefully 
secured to the side of the chest, and the forearm is supported in a sling, 
but the elbow is left free, in order that its weight may counteract the ten- 
dency to overlapping of the fragments. Passive motion is instituted at 
the end of the fourth week, and firm union may reasonably be expected in 
a fortnight more. A long time, however, will elapse before the joint will 
completely regain its functions, if, indeed, it ever do. Permanent lame- 
ness will be inevitable, if the fracture be intracapsular and comminuted, 
owing to the difficulty of readjusting the fragments. 
When fracture of the superior extremity of the humerus is complicated 
with dislocation, the proper plan, of course, is to restore the displaced 
bone to its natural position before any attempt is made to adjust the ends 
of the fragments. The operation, however, will necessarily be one ot 
extreme difficulty, on account of the shortness of the superior piece, which 
thus deprives the surgeon of the advantage of a suitable lever. Ills whole 
reliance must, therefore, be upon well-directed pressure and counter- 
Fig. 517. 
Fracture of the Surgical Neck of the Humerus. 
Fig. 518. 
Badly United Frac- 
ture of the Surgical 
Neck of the Humerus 
with Exuberant Cal- 
lus. 
Fig. 519. 
Welch’s Shoulder 
Splint. CHAP. VIII. 
FRACTURES OF THE HUMERUS. 
983 
pressure, while the patient is fully under the influence of an anaesthetic, complete mus- 
cular relaxation being essential to success. When the operation fails, it has been recom- 
mended to let the dislocated head of the bone remain in its unnatural situation, and to 
bring the upper extremity of the lower fragment in contact with the glenoid cavity, 
in the hope that, in time, as the bone becomes rounded off', it will contribute to the res- 
toration of the motion of the limb. Such an idea, however, it seems to me, must be 
perfectly delusive; for it is impossible, under such circumstances, for nature to make a 
good or useful joint. Instead, therefore, of pursuing such a practice, I should not hesi- 
tate, if a case of the kind were to present itself to me, to cut down upon the dislocated 
bone, and push it back into its natural position; or, if this be impracticable or deemed 
inexpedient, and the head of the bone be found to compress the axillary plexus of nerves, 
to perform excision. 
Fractures of the surgical neck of the humerus are occasionally impacted, the upper 
extremity of the inferior fragment being forcibly driven into the cancellated structure of the 
superior, or conversely. Such an occurrence is most common in old subjects, after the age of 
fifty-five, in consequence of interstitial absorption of the osseous tissue, and may be produced 
either by a blow upon the shoulder, or, what is more common, by a fall upon the elbow. 
The extent of the impaction varies from a few lines to half an inch or more. As the 
bone retains its continuity, the symptoms of the accident are usually very obscure, there 
being neither mobility nor crepitation, unless the fragments are unlocked by being pulled 
forcibly asunder. Nevertheless, there is generally some deformity perceptible upon firmly 
grasping the humerus, and an alteration in the axis of the limb, which often looks as if it 
were twisted together with severe pain, and usually also more or less contusion of the 
soft parts. If the impaction is extensive, there will, in addition, be some degree of short- 
ening of the arm, or a slight diminution in the distance between the shoulder and «lbow. 
These circumstances, conjoined with the fact that the patient has received a severe injury, 
that there is loss of motion in the joint, and that all the symptoms of dislocation are absent, 
afford sufficient evidence of the probable nature of the case. 
The impacted fracture requires no special treatment on its own account. To pull 
the fragments forcibly asunder would only produce mischief and trouble. Instead of 
such interference, the surgeon contents himself with supporting the limb, and combating 
inflammation by leeching, fomentations, and other means. In due time passive motion is 
instituted, lest ankylosis of the shoulder-joint should arise. 
5. Great Tuberosity Fracture of this portion of the humerus, although uncommon, 
is probably not as infrequent as is generally supposed, the obscurity of its symptoms ren- 
dering it extremely liable to be mistaken for other lesions in and around the scapulo-hume- 
ral articulation. The accident may occur at almost any period of life, except, perhaps, 
in early childhood, and is usually caused by a fall or blow upon the forepart of the shoulder, 
the force being concentrated upon the upper extremity of the humerus so as to separate 
the large tubercle from the hemispherical head and shaft of the bone. Pitha, Theden, 
and others, have met with cases in which the detachment was caused by the violent con- 
traction of the two spinate and small teres muscles. 
The existence of the fracture is denoted by considerable flattening of the deltoid muscle, 
by a remarkable increase in the width of the upper portion of the arm, which is nearly 
double what it is in the natural state, and by the presence of two osseous prominences, 
one of which, consisting of the detached tuberosity, is situated at the superior and outer 
part of the joint, and the other, formed by the head of the humerus, at the upper and 
inner part. The acromion is abnormally salient, and the arm is separated from the side, 
but may be approximated to it without difficulty, and readily rotated in every direction 
by the surgeon. 
The diagnostic signs most worthy of reliance, are the great increase in the breadth of 
the articulation, the refusal of the thumb to sink into the glenoid cavity, as it always does 
in dislocation of the shoulder, the preservation of the length of the limb, and the produc- 
tion of crepitation upon rotating the humerus by seizing it just above the elbow while the 
surgeon encircles the head of the humerus with both hands. Another important evidence 
is that the deformity is readily effaced by manipulation, but instantly reappears when it 
ceases. » 
Repair, generally of an osseous character, is effected in from four to six weeks, accord- 
ing to the age of the patient, the immobility of the fragments, and the amount of the 
resulting inflammation, which is always very considerable from the contusion of the soft 
parts. The motions of the joint, in consequence, remain imperfect for many months; and 
in not a few cases, even when the greatest vigilance is exercised, they are never com- 984 
DISEASES ANI) INJURIES OF THE BONES. 
CHAP. VIII. 
pletely regained, owing to a redundancy of callus and the formation of osseous excres- 
cences around the articular surfaces. 
In the treatment of this fracture, one of the leading indications is to neutralize the 
action of the muscles which are attached to the tubercles of the humerus, the larger one 
receiving the insertion of the two spinate and the small teres, and the lesser the subscapu- 
lar, which necessarily tend to draw the fragments away from each other, the subscapular 
being materially aided in this way by the action of the broad dorsal, the great pectoral, 
and the short head of the flexor of the arm. To accomplish this object, the limb should 
be put up in two felt, leather, or binder’s board splints, the inner of which is nicely padded 
above to prevent undue pressure upon the axillary vessels and nerves, while the outer is 
bent well over the top of the shoulder. No cushion will be necessary, especially if the 
arm and forearm are properly secured to the chest. The elbow is supported in a sling, but 
not so firmly as to push the head of the bone too high up towards the acromion process. 
For the first five or six days after the accident, leeches and fomentations may be required. 
Passive motion should be instituted at the end of four or five weeks. 
Fractures of the humerus, especially of the superior part of the bone, are often attended 
with a remarkable disposition to overlapping of the ends of the fragments from the action 
of the muscles of the arm and chest, particularly the great pectoral, and great teres, which 
generally draw the upper fragment inwards and backwards more or less away from the 
lower broad dorsal. In most cases, however, the tendency rapidly disappears spontane- 
ously. as the irritation of the muscles subsides, so as to permit the fragments to fall into 
their natural position. The ordinary dressings are generally quite sufficient to keep the 
parts in apposition, provided the elbow is permitted to hang free and the forearm is well 
supported, the weight of the arm thus counteracting any tendency to displacement. I 
have, indeed, never witnessed an instance in which there was any trouble of this kind. 
If such a contingency, however, should arise, it could readily be remedied by attaching 
a weight to the lower extremity of the arm by means of adhesive strips, as suggested by 
Dr. E. A. Clark. The extension apparatus of I)r. Henry A. Martin, consisting of a 
splint, stretched along the posterior surface of the limb, and regulated by a ratchet 
operating on two steel bars, might also be worthy of trial. 
Epiphyseal Fractures of the Head of the Humerus The epiphyseal fracture of the 
head of this bone is always caused by direct violence, as a blow or fall upon the shoulder, 
and is peculiar to early life, rarely occurring after the fifteenth year. It has been well 
described by Sir Astley Cooper, Mr. Robert Smith, Dr. Hamilton, and, above all, by Dr. 
Moore, of Rochester. 
The symptoms, which are generally characteristic, are preternatural mobility of the 
limb, faint crepitation, even when the ends of the fragments are rudely rubbed together, 
the retention of the head of the humerus in its normal position, a marked projection below 
the coracoid process, formed by the upper extremity of the shaft of the bone, and a de- 
pression at the distance of about half an inch below the acromion process. The shoulder- 
ioint, viewed in profile, is slightly flattened and increased in breadth. The motions of 
the arm are more or less impeded. 
The diagnosis hinges mainly on the tender age of the patient, the indistinctness of the 
crepitation, which is much less than in fracture, the preternatural mobility, and the lodg- 
ment of the head of the humerus in its normal situation. The upper extremity of the 
shaft of the bone projects in front of the joint, and, instead of being sharp and angular, 
as in fractures, is convex, and comparatively smooth. When the parts are displaced, 
there is shortening of the arm, the elbow hangs off from the side, and the hand cannot, 
without difficulty, grasp the sound shoulder; all these phenomena being reversed when 
the fragments remain in apposition. The shortening seldom exceeds half an inch. Any 
deformity that may exist is readily effaced by extension and pressure, but recurs the 
moment these efforts are relaxed. The accident is liable to be confounded with disloca- 
tion of the shoulder-joint and fracture of the head of the humerus and of the scapula. 
The reduction is effected by extension, aided by manipulation, and is maintained by 
an apparatus similar to that used in fracture of the superior extremity of the humerus. 
A thick compress should be placed over the inner side of the joint to prevent displace- 
ment of the upper extremity of the shaft of the humerus. In neglected cases,.the limb 
eventually, in great degree, regains its normal usefulness, the lower fragment being gradu- 
ally rounded off, and the capsular ligament elongated. FRACTURES OF THE FOOT. 
985 
CHAP. VIII. 
3. INFERIOR EXTREMITY. 
FRACTURES OF THE FOOT. 
Fractures of the bones of the foot do not require any special notice, as their manage- 
ment is conducted upon the same principles as that of fractures of the hand. From the 
fact that they are generally complicated, the treatment must be largely antiphlogistic, and 
the surgeon will have cause to congratulate himself if he is not occasionally obliged to 
amputate the foot, or exsect some of its bones. Any loose and displaced fragments, 
if they cannot be moulded into shape, should always be promptly removed, even when 
there is no external wound ; for such pieces would not only act as foreign bodies, but 
might, in the event of vicious reunion, seriously interfere with the wearing of a boot. 
Simple fractures of the toes and metatarsal bones are best managed with the immovable 
dressing, with the addition of thin binder’s-board splints to afford proper support at the 
seat of injury. 
The calcaneum, or heel-bone, notwithstanding its exposed situation, the importance.of 
its functions, and the manner in which it lies beneath the tibia and fibula, is seldom the 
subject of fracture. Direct violence is the most common cause of the accident, which is 
often attended with severe lesion of the neighboring structures, both soft and hard. Fall- 
ing from a great height, in which the person alights upon his heel or foot, is the manner 
in which it commonly happens. The bone being thus forcibly acted upon, on the one 
hand by the weight of the body, and on the other by the resistance offered by the surface 
struck, yields at its weakest point, breaking, perhaps, into several pieces. More rarely 
the accident is produced by the inordinate contraction of the muscles of the calf, as in 
dancing and leaping; but in this case it is only the posterior extremity of the bone that 
suffers, its tip being the part generally torn off. The amount of displacement varies 
according to circumstances, being necessarily very slight when the fracture extends across 
the body of the bone, whereas it is always very considerable when it involves its back 
part, on account of the action of the gastrocnemial muscles, which, exerting their influ- 
ence through the tendo Achillis, sometimes draw up the posterior fragment from an inch 
and a half to two or even three inches. An impacted fracture of the calcaneum has been 
met with, but is extremely uncommon. 
The symptoms of this fracture are always sufficiently characteristic when the posterior 
portion of the bone is broken off, the hollow at the heel, the protuberance at the lower 
and back part of the leg, and the impossibility of flexing the foot, being unmistakable 
evidences of the nature of the accident. Upon bringing down the upper fragment in 
contact with the inferior, crepitation may be obtained, although it will be very faint if 
ordy the tip of the bone has been detached. The diagnosis will be more difficult when 
the fracture extends across the body of the calcaneum ; for then there will be no displace- 
ment, the lateral and interosseous ligaments keeping the posterior fragment in position. 
In general, however, it may be determined by the history of the case, and by making 
pressure upon the calcaneum in different directions, thus eliciting crepitation if fracture 
actually exist. 
A fracture of the calcaneum from the laceration of its fibres is usually slow in healing, 
on account of the difficulty of keeping the fragments in contact, the muscles of the calf 
constantly tending to separate the upper from the lower. For this reason the union is 
generally ligamentous, and a long time is necessarily required for the complete restoration 
of the functions of the foot. When the fracture is caused by direct violence, the repair 
is effected in the ordinary manner. 
When the accident is accompanied by much contusion of the soft parts, antiphlogistics 
should be freely used before the permanent dressings are applied. The nature of these 
dressings must depend upon the presence or absence of displacement. In the former 
case, the chief obstacle to the cure is the contraction of the gastrocnemial muscles, which 
must, therefore, be effectually controlled until the consolidation is sufficiently advanced to 
enable the upper fragment to maintain its position independently of extrinsic aid. The 
least objectionable contrivance for this purpose is a short splint, of perforated zinc, well 
padded, and adapted to the shape of the limb, the anterior part of which it should cover 
from the middle of the leg nearly as far as the toes. When zinc cannot be obtained, 
wood, felt, sole-leather, or binder’s board may be used. The object of this splint is to 
maintain the leg and foot in a permanently flexed position, to relax the muscles of the 
calf. To maintain the upper fragment in place, the leg and foot may be bandaged in 
opposite directions, adhesive strips and a compress having previously been applied around 986 
the heel and sole. This position should be observed for at least six weeks, or until the 
connecting medium is firmly established. When the tendency to displacement is very 
great, the division of the tendo Achillis may become necessary. The apparatus of Petit, 
formerly so popular in the treatment of this form of fracture, is worse than useless, as the 
tendency of the cord and slipper is to separate the upper fragment and to irritate the soft 
parts about the heel. 
In the other variety of fracture, as there is no displacement, all that is necessary is to 
subdue inflammatory action, and to keep the foot and leg in a quiet and relaxed position 
with a tin case, or two light side splints, the limb lying upon its outer surface over a 
pillow, with a proper support for the foot. 
Fracture of the astragalus is very uncommon, especially the simple variety; the acci- 
dent is generally complicated with fracture of the tibia and fibula, severe injury of the 
soft parts, and dislocation of the fragments. The latter lesion existed in eight cases out 
of ten of fracture of the astragalus collected by Dr. Monahan. 
In consequence of the severe injury inflicted in this accident upon the foot and leg, 
primary amputation will frequently be required. If this be neglected, the patient may 
perish from erysipelas, mortification, pyemia, or hectic irritation. When the fracture is 
complicated with dislocation, without serious lesion of the ankle-joint and the soft parts, 
an attempt should be made, by extension, counterextension, and pressure, aided, if neces- 
sary, by the subcutaneous division of the resisting structures, to restore the fragments to 
their proper position ; if this fail, excision must be performed. 
FRACTURES OF THE TIBIA. 
The tibia, like other long bones, is liable to give way at various points of its extent, but 
more frequently below its middle than anywhere else. A fracture of its condyles is un- 
usual, and its occurrence is always denotive of great direct violence. Occasionally the 
bone is broken near its upper extremity, from an inch to an inch and a half below the 
knee. The internal malleolus is sometimes detached by a twist of the ankle, by a fall 
upon the sole of the foot, or by direct injury. 
The ordinary cause of fracture of this bone is external violence, as a blow or fall. A 
fracture of the tibia from a fall upon the foot is by no means uncom- 
mon. The bone sometimes gives way under muscular action, especially 
in very old subjects, in whom the osseous tissue is often unusually 
rarefied and brittle. Complicated and comminuted fractures of the 
tibia are more frequent than in any other piece of the skeleton. 
An instance of intrauterine fracture of the tibia, in the sixth month 
of pregnancy, caused by violent pressure upon the abdomen, has been 
reported by Dr. Proudfoot, of New York. Madame Lachapelle saw a 
case of separation of the upper epiphysis of this bone, from traction of the 
child’s footduring parturition ; and Dr. Voss met with an example of dias- 
tasis of the inferior epiphysis from a fall in a lad fourteen years of age. 
Most fractures of the shaft of the tibia are oblique, very few, if any, 
transverse ; nevertheless, as the fibula retains its integrity, there is 
seldom any considerable displacement, the sound bone acting as a 
splint to the broken one. It is not often, however, that the frag- 
ments completely retain their apposition ; in general, there is some 
degree of separation, which may always be easily detected, even when 
there is a good deal of tumefaction, by passing the finger along the 
tibia, and tracing its outline. If there be a fracture, it will manifest 
itself by an abnormal depression at some particular point, or by an un- 
natural projection, sufficiently obvious to establish at once the nature 
ot the case. The amount of this projection is occasionally very great, 
especially when the upper fragment is very long, sharp, and oblique, 
in which event it is generally extremely prominent, and with difficulty 
prevented from piercing the skin. The annexed drawing, fig. 520, 
from a preparation in my collection, conveys a good idea of this form 
of the injury. For the reason just mentioned, there will usually be 
very little, if any, crepitation. The fracture, if perfectly free from 
complication, unites in from four and a half to five weeks. 
A peculiar form of fracture of the tibia, originally described, in 1855, by Gosselin, 
under the name of the V-shaped, cuneiform, or spiroidal fracture, although infrequent, 
DISEASES AND INJURIES OF THE BONES. 
CHAP. VIII. 
Fig. 520. 
Oblique Fracture of 
the Tibia. CHAP. VIII. 
FRACTURES OF THE FOOT. 
987 
is worthy of special notice on account of the gravity of its prognosis. In this country 
attention was first directed to it by Dr. R. M. Hodges, of Boston. It is often, if not 
generally, associated with fracture of the fibula, and usually occurs at about the junction 
of the middle with the lower third of the tibia, the line of fracture representing the form 
of the letter V, with the base looking upwards, while the apex terminates in a fissure 
which extends obliquely or spirally down around the shaft of the hone, into or near to 
the ankle-joint. The mechanism of the injury is not well understood, and there are no 
signs by which it can be distinguished from an ordinary fracture in this situation. The 
prognosis is always grave, the lesion, especially if compound, as it generally is, being 
very liable to give rise to erysipelas, pyemia, and osteomyelitis from exposure of the 
medullary canal. Fatty emboli, in a putrid state, have been repeatedly found in the 
lungs of persons dead from the effects of the injury. The only safety of the patient, as 
experience has clearly shown, in compound Y-shaped fractures of the tibia, is in prompt 
amputation of the limb. 
Fracture of the internal malleolus is met with in various forms. In some cases, the 
process is broken off at, or close to, its connection with the lower end of the tibia; in 
others, near its articular extremity; but the most common site of the lesion is about the 
centre of the process. Its direction is nearly always oblique; rarely, if ever, strictly 
transverse or perpendicular. Occasionally the process is comminuted or broken at several 
points. Finally, cases not unfrequently occur in which the fracture coexists with fracture 
of the lower extremity of the fibula. The diagnosis is easily established by the position 
of the foot, which is always turned upwards and inwards, as if it were partially dislocated, 
and by the facility with which the detached piece of bone may be moved about with the 
thumb and finger; a procedure which also readily elicits crepitation. 
The most simple contrivance for the treatment of fracture of the tibia is a tin case, 
fig. 521, accurately shaped to the limb, provided with a foot-piece, 
and reaching a few inches above the knee. A bandage is applied 
in the usual manner, and any tendency to displacement is easily 
counteracted by means of a compress and a short splint, arranged 
so as to bear gently and equably upon the ends of the fragments. 
I have never found it necessary to employ any other apparatus 
than this, no matter where the tibia was broken. When the 
fracture involves the malleolus the foot-piece will effectually pre- 
vent displacement. In fracture of the superior extremity of the 
tibia, extending into the condyles, the plan usually adopted is to 
place the leg and thigh in the straight position, so as to compel 
the condyles of the femur to support the broken bone, extension 
and counterextension being made with two long splints. Such 
a contrivance, however, will be entirely unnecessary if the tin case 
be employed, especially if it be sufficiently long to embrace the 
inferior third of the thigh, as it will thereby completely counteract 
any tendency in the muscles of the limb to draw the upper 
fragment backwards into the popiliteal space. An efficient appa- 
ratus for these fractures will also be found in Dr. Welch’s splints, fig. 522; and in the 
wire splints of Dr. Bauer, fig. 523, the latter being particularly valuable on account ot 
their light, airy, and pliable character. 
Fig. 521. 
Tin Case. 
Fig. 522. 
Welch’s Splints. 
Mr. Jolm Croft is a warm advocate of the treatment of fractures of the leg, whether of 
one or of both bones, by the use of two plaster of Paris splints, carefully adapted to the 988 
DISEASES AND INJURIES OF THE BONES. 
CHAP. VIII. 
sides of the limb, and applied as soon as possible after the infliction of the injury. He 
does not hesitate to adopt this method even w'hen there is considerable inflammation of 
the soft parts, as evinced by discoloration or discoloration and the development of vesicles, 
provided the circulation is unimpaired. Mr. Croft’s position of surgeon to St. Thomas’s 
Fig. 523. 
Bauer’s Wire Splits. 
Hospital, one of the largest institutions of the kind in the world, justifies him in taking 
high ground in relation to this mode of management, especially when he can back up his 
experience by an appeal to 587 cases thus treated without any ill results. Professor Lit- 
tle, of New York, is also an advocate of this method of treatment in a modified form. 
The sharp point of bone which occasionally remains after fracture of the shaft of the 
tibia, in consequence of the inordinate projection of one of the ends of the fragments, 
generally, in time, disappears through the agency of the absorbent vessels, the parts 
becoming softened, roundecLoff, and entirely harmless. When the projection is very con- 
siderable, causing pain and ulceration of the skin, and resisting the usual remedies, the 
best plan is to remove the offending structures with the surgical engine, or the pliers and 
chisel, as I have done with excellent effect in several instances. 
FRACTURES OF THE FIBULA. 
Fracture of the fibula is, relatively considered, a sufficiently common occurrence, its 
frequency being due apparently to the slender form of this bone, to its superficial situation, 
and, above all, to the important part which it plays in the formation of the ankle-joint. 
The accident may take place at any portion of the bone, but is by far most common in 
the inferior fifth of its extent, owing to its intimate connection with the astragalus, which, 
constituting the pivot of the foot, readily receives and transmits the various shocks to 
which the latter is so continually exposed. Of fractures of the shaft and head of the fibula 
no particular description is necessary, since they are always easy of detection, and the 
treatment does not differ materially from that of similar injuries of the tibia. Put it is 
different with fractures of the inferior fifth of the bone, where, as just stated, the lesion is 
most common, and where, from being usually associated with other mischief, it is extremely 
liable to be followed by deformity and permanent lameness. For these reasons, fractures 
in this situation require to be studied with more than ordinary care. 
Fractures of the fibula are much more common on the right side than on the left. In 
207 cases collected by Dupuytren, more than two-thirds involved the right leg. The 
statistics of Malgaigne show that it is most frequently met with between the ages of twenty- 
five and fifty, and that men are more than four times as liable to it as women. Of 104 
cases examined by this author, not one occurred before the fifteenth year. 
The causes of fractures of this portion of the fibula can only be properly appreciated by 
a careful examination of their mechanism. The tibio-tarsal articulation, being a hinge- 
joint, admits only of flexion and extension, its lateral movements being restrained by the 
two malleoli, and the ligaments by which the bones of the leg are connected with those of 
the foot. Hence, the latter cannot be turned outwards or inwards to any considerable 
extent without producing a fracture of the former, the site of injury being determined by 
the particular inclination of the limb. Thus, when the foot is forcibly abducted, its inner 
edge resting on the ground, the upper surface of the calcaneum will be pressed violently CHAP. VIII. 
FRACTURES OF THE FIBULA. 
989 
against the external malleolus, in a direction parallel to the fibula, which will, consequently, 
yield at its weakest point, which is about an inch and a half above the joint, at the part 
sometimes called the neck of the bone. In most cases there is a rupture of the deltoid 
ligament, if not also a fracture of the internal malleolus. When the foot is forcibly 
abducted, the astragalus becomes the immediate cause of fracture, for this bone, turning 
upon its antero-posterior axis, escapes from the arched cavity formed by the tibia and 
fibula, and, pressing against the outer malleolus, breaks the fibula nearly at the same 
level as in the preceding case, the direction of the fissure being usually somewhat oblique. 
The external lateral ligament is either torn or violently stretched. 
The most ordinary cause of this fracture is a fall upon the foot, in which this portion of 
the limb is forcibly inclined laterally, at the moment the weight of the body impels the 
bones of the leg forcibly against those of the foot, rendered stationary by the resistance 
ottered by the ground. The fibula may also be broken across by violence applied directly 
to the part, as a blow, or the passage of the wheel of a carriage. Of 207 cases of this 
accident, recorded by Dupuytren, 120 were the result of forcible adduction, and 60 of 
forcible abduction, the rest being caused by direct violence. 
However the fracture may be induced, the superior extremity of the inferior fragment 
is always thrust inwards against the tibia, while the inferior extremity of the superior 
fragment either remains fixed, or inclines in the same direction. The latter usually hap- 
pens when the injury is direct, the former when it is indirect. 
The inferior extremity of the fibula is sometimes broken almost vertically; such an 
occurrence, however, must be extremely uncommon, and I have seen only two instances 
of it, both of them being in the Mutter collection. In one, represented 
in fig. 524, the bone looks as if it had been split, the fissure extending 
upwards, almost in a straight line, fully an inch and a half; the 
posterior, longer, and larger fragment being pushed considerably back- 
wards, so as to form with the other an intermediate triangular space. 
In the other bone the fracture is also vertical, but the separation is 
much less. 
The symptoms of fracture of the lower extremity of the fibula vary 
according to the circumstances of the case. When this bone alone is 
severed, the chief signs will be slight eversion of the foot, a depression at 
the site of injury, and some change, usually not very conspicuous, in the 
contour of the ankle-joint. When the internal malleolus is broken off, 
or when the tibia has given way a short distance above the articulation, 
these characters will exist in a more marked degree, and point out un- 
erringly the nature of the lesion. The foot will be so much abducted 
as to present the appearance of being dislocated outwardly; the width 
between the two malleoli will be much increased; the hollow at the line of*fracture will 
be quite deep; and the external margin of the foot will be considerably elevated, while 
the internal will be proportionately depressed. Upon taking hold of the foot, it will be 
found that it is unusually movable, and that it can easily be restored to its natural rela- 
tions, but that the moment the grasp ceases it will return to its former position. In per- 
forming these manipulations, crepitation is very easily perceived ; and, upon tracing the 
outline of the lower portion of the bone, the finger usually sinks in at the seat of fracture, 
owing to the fact, previously mentioned, that the upper enj of the lower fragment always 
falls over towards the tibia. A good deal of ecchymosis is often present, and a consider- 
able amount of swelling quickly follows, obscuring the characteristic features of the injury, 
and embarrassing the diagnosis. The only accident with which fracture of the inferior 
extremity of the fibula is liable to be confounded is a sprain of the ankle-joint, from which, 
however, it may always readily be distinguished by the great distortion which attends it, 
and by the presence of crepitation. 
A simple fracture of the fibula in the inferior fifth of its extent will, if properly treated, 
usually unite in a month, without any deformity of the limb, although even then a con- 
siderable time will elapse before the ankle-joint will perfectly regain its functions. When 
the injury is complicated with rupture of the ligaments, fracture of the corresponding por- 
tion of the tibia, or other serious lesion, the repair will be much slower, and there will be 
danger, unless the case be managed with the most consummate skill, of permanent de- 
formity and lameness, the former manifesting itself in an everted condition of the foot and 
in increased width of the ankle-joint. 
The material point in the treatment of fracture of the fibula in this situation is to main- 
tain the foot in a position the reverse of that which it assumes in consequence of the 
Fig. 524. 
Fracture of the 
Fibula. • 990 
injury. To accomplish this object, which is designed to draw away the upper extremity 
of" the lower fragment from the tibia, and to restore it to its proper relations, the limb, 
after having been enveloped in the ordinary bandage, with the precaution of not com- 
pressing it opposite the site of fracture, is placed in a tin case, the foot being directed 
permanently inwards. The requisite inclination may easily be imparted by means of a 
piece of roller, or a few adhesive strips, carried around the instep and heel, and attached 
to the inside of the leg. Or, instead of this, the fracture may be treated with Dupuy- 
tren’s apparatus, fig. 525, con- 
sisting of a light wooden splint 
and a wedge-shaped cushion, the 
former reaching from the upper 
third of the leg to about three 
inches below the sole of the foot*, 
and the latter from the same 
point to a level with the ankle. 
The limb being bandaged in the 
same cautious manner as in the 
former case, the apparatus is stretched along its inner surface with the tapering end of 
the pad upwards, and secured, first above, and then below, the roller being passed around 
the foot and ankle in such a manner as to turn the internal margin of the foot upwards 
and inwards. The limb may afterwards be kept in the extended position ; or, what is 
preferable, placed, half bent, upon its outer surface, over a large pillow. The parts are 
diligently watched, the dressing being changed as occasion may require, and passive 
motion instituted at the end of the third week, and diligently repeated for many months. 
The ankle-joint always remains weak long after the fracture has become consolidated, 
from an extension of the inflammation consequent upon the injury. 
FRACTURES OF BOTH THE TIBIA AND FIBULA. 
Fractures of both bones of the leg are sufficiently common, particularly in young and 
middle-aged subjects, and are deserving of special attention, on account of the difficulty 
of their management, and their liability to be followed by deformity and lameness. 
Much diversity obtains in regard to the seat of these fractures, as well as their direc- 
tion, and the nature and extent of their displacement. In twenty-two specimens, con- 
tained in the Mutter collection and my own, I find that in ten the tibia and fibula were 
broken at their inferior extremity, the line of separation in none of them extending be- 
yond three inches above the joint. In four the tibia gave way at its lower third, and the 
fibula at from two to three inches and a half from its head, or junction with the upper end 
of the tibia. .In six of the cases the tibia was broken from two to three inches above its 
inferior articulating surface; in two of these the fibula had yielded at its middle, and in 
the remaining four at different points of its extent. In only two cases had both bones 
been broken at the same level; in one of these the fracture occurred at the middle of 
these pieces, and in the other a little below that place. 
In the twenty-two cases here referred to, the tibia had been broken only twdce above 
its middle; whereas the fibula had given way above this situation in six cases. In six- 
teen of the cases the seat of fracture of the tibia was either at the ankle-joint, or below 
the middle of the bone, generally in its inferior fourth or third. In ten cases of fracture 
of the fibula the seat of the injury was either at the joint, or within the first three inches 
from its articulating extremity. 
From the above examinations it follows, first, that the tibia and fibula rarely break on 
the same level; secondly, that both bones are most liable to yield either at the ankle- 
joint, or within the first three inches above that point; and, thirdly, that the fibula is 
more frequently fractured at its superior extremity than the tibia. 
An examination of these specimens has supplied me with some other interesting 
facts. Thus, I have found that the fracture in nearly all was more or less oblique, the 
line of separation in fifteen specimens of broken tibia extending from above downwards, 
and from without inwards. As a natural consequence of this occurrence, the superior 
extremity of the inferior fragment projected outwards towards the fibula, which it 
touched in several of the preparations, on account of a want of proper adjustment during 
the treatment; the lower extremity of the upper fragment, on the contrary, projected 
inwards, and had, apparently, generally been much the sharper of the two. The fibula, 
in most of the specimens, afforded evidence of having been broken across more abruptly 
DISEASES AND INJURIES OF THE BONES. 
CHAP. VIII. 
Fig. 525. 
Dupuytren’s Apparatus. CHAP. VIII. 
FRACTURES OF BOTH THE TIBIA AND FIBULA. 
991 
than the tibia, but still with a considerable degree of almost every instance 
that I inspected. 
In recent fracture of the tibia, complicated with fracture of the fibula, the inferior 
extremity of the upper fragment is generally remarkably sharp, and, consequently, often 
projects through the skin at the time of the injury, the feame cause that produces the 
lesion forcing it across the soft parts. Or, if it is not pushed out at the moment of the 
accident, it frequently escapes afterwards, through ulceration, induced by the pressure 
which it exerts upon the overlying structures. The obliquity of fractures of the tibia is 
often very extraordinary, and there are few instances in which it does not become a 
source of great suffering to the patient, and of annoyance to the surgeon, on account ot 
the trouble that is experienced in keeping the parts in their proper relations. This is 
more especially the case when the fracture, situated at the lower fourth of the tibia, is 
directed from above downwards and forwards, in consequence of the constant tendency of 
the muscles of the calf to draw the inferior fragment backwards and upwards. When the 
direction of the fracture is reversed, the extremity of the inferior fragment projects forwards, 
riding over the lower end of the upper fragment. In either event, the fracture is often 
rendered compound by the pressure of the sharp extremity of the bone against the soft parts. 
A rare form of fracture of these two bones is represented in fig. 526, from a specimen 
in my collection. The tibia was broken off immediately above its articulating surface with- 
Fig. 526. 
Fracture of the Tibia and Fibnla at the Ankle-joint. 
out affecting the internal malleolus, while the fibula had given away about an inch and a 
quarter above the joint. The foot was characteristically everted. In fig. 527, also from 
a specimen in my possession, the fracture was comminuted, and extended into the ankle- 
joint, the articular surface of the tibia having been broken into several pieces, one of 
which embraced the internal malleolus. The fibula had given way about two inches 
above its inferior extremity. 
The most common causes of this accident are falls, as in slipping upon the ice, or when 
the foot is suddenly caught in a hollow, or between two hard, resisting objects, so as to 
throw the whole weight of the body upon the leg. In a case, recently under my obser- 
vation, both bones gave way just above the ankle by the foot being caught in the fold of 
the carpet. It may also be caused by a fall from a considerable 
height, in jumping out of a carriage under full speed, and by direct 
violence, as the kick of a horse, the caving in of a sand-bank, or 
the fall of a heavy stone. An instance of fracture of both bones of 
the leg by muscular action, in a man forty-two years old, has been 
recorded by Hevlhard D’Arcy. 
The symptoms of the injury, however induced, are generally well 
marked, if not positively unmistakable. In nearly every case the 
limb is shortened from one and a half to three inches, and there is 
also, generally, great deformity in its diameter, both depending upon 
the overlapping of the fragments, which, as already stated, is fre- 
quently very extraordinary. Besides, upon making extension and 
counterextension, it is generally easy to elicit crepitation. When 
the fracture is very oblique, the lower end of the superior fragment 
may usually be felt immediately beneath the integument, forming a 
sharp, prominent projection either in front of the limb, or at its 
inner aspect. Sometimes the soft structures are much bruised and 
ecchymosed. Another remarkable symptom, one, indeed, which is 
seldom absent, is a spasmodic twitching of the limb, coming on soon 
after the accident, and frequently lasting for several days or even 
weeks, much to the annoyance and distress of the patient. 
Fig. 527. 
Fracture of both Bones 
of the Leg at the Ankle- 
joint. 992 
DISEASES AND INJURIES OF THE BONES. 
When the fracture is situated just above the ankle, the foot is usually a good deal 
everted, causing an appearance of dislocation outwards, as exhibited in fig. 528, and con- 
stituting what is usually known as Pott’s fracture. In this 
form of the injury the fibula is broken at a distance of one 
and a half to two and a half inches above the joint at the 
same time that the astragalus is dislocated from the tibia, in 
consequence of the rupture of the internal lateral ligament, 
either alone or in conjunction with fracture of the inner 
malleolus. The foot is everted, not by the action of the 
long peroneal muscle, but by the vulnerating force, which 
renders that muscle powerless. 
The prognosis of fracture of both bones of the leg may 
be gathered, in part, from what precedes. In the more 
simple forms of the injury, attended with but little obliquity, 
a good cure may generally be effected in from four to five 
weeks. If, however, the obliquity is uncommonly great, it 
will be extremely difficult, if not impossible, to effect con- 
solidation in a manner altogether unexceptionable, no matter 
with what skill and attention the treatment may be con- 
ducted. More or less deformity will almost be inevitable, 
either in the length or in the diameter of the limb, owing 
to the remarkable tendency of the ends of the fragments to 
overlap each other, which it is often impossible to counteract successfully by any means 
that can be adopted for the purpose. 
Fractures of the tibia and fibula, like those of the bones of the forearm, are occasion- 
ally connected by a bridge of callus, or of new osseous matter, which does not, however, 
as in the latter, so far as can be determined, impair their usefulness. I have several 
times met with this occurrence when the lesion was confined to one of these bones; and 
I have noticed that it is not necessary to its production that there should be any approxi- 
mation of the ends of the opposite fragments, as it may occur when they are perfectly 
straight, although any considerable displacement no doubt acts as a predisposing cause. 
Treatment—The treatment of fracture of both bones of the leg, attended with short- 
ening of the limb,'must be by extension and counterextension, steadily and persistently 
maintained throughout, otherwise, as just stated, deformity will almost be inevitable. If, 
on the other hand, the fracture is transverse, or nearly so, such a procedure may of course 
be dispensed with, the object being attained by confining the leg in a tin case, or fracture- 
box, care being taken to keep the great toe constantly on a line with the inner border 
of the patella, the surest evidence that there is no rotation of the ends of the fragments 
upon each other. Any tendency to forward, backward, or lateral displacement is gene- 
rally easily counteracted by means of compresses and short splints, aided, if necessary, 
by the elastic bandage. The limb may then be placed in an easy position upon a slightly 
inclined plane, made of a bolster 
or pillow, or it may be suspend- 
ed by a cord and pulley to the 
tester of the bed, as may be found 
most agreeable or convenient. 
Counterextension may be made 
when the fracture is oblique by 
means of a box provided with a 
foot-board, and twolateralsplints, 
one extending to the perineum, 
and the other to the axilla*, as I 
have generally myself preferred ; or, with the contrivance of Dr. Neill, consisting of a 
box, reaching as high as the middle of the thigh, counterextension being made with 
adhesive strips, passed through holes at the upper part of the apparatus, and tied on the 
outside, as exhibited in tig. 529. 
The use of the gaiter, tig. 530, in the treatment of fractures of the leg and thigh, at- 
tended with shortening and deformity, cannot be too pointedly condemned, as it is almost 
impossible, in any case, however carefully watched, to prevent chafing, and other incon- 
venience. A similar remark is applicable, only more forcibly, to the handkerchief, fig. 
531, at one time so much employed for tins purpose. Both appliances should be pro- 
scribed, especially as an admirable substitute may always be found in adhesive strips, 
CHAP. VIII. 
Fig. 528. 
Fracture of the lower End of the 
Tibia and Fibula. 
Fig. 529. 
Dr. Neill's Apparatus for Fracture of the Leg. CHAP. VIII. 
FRACTURES OF BOTH THE TIBIA AND FIBULA. 
993 
secured to the sides of the limb, as in fig. 532, and at the bottom of the foot to a piece 
of board about four inches in length and three in width. From this board extends 
Fig. 530. 
Fig. 531. 
Application of the Gaiter. 
Application of the Handkerchief. 
a cord which plays over the pulley in the stand, fig. 533, or over the apparatus, fig. 534, 
devised by Dr. Levis, and attached to the foot of the bed. The requisite weight may be 
obtained by a bag of shot, piefce of iron, or the elegant contrivance of Levis, fig. 535. 
Fig. 532. 
Application of Adhesive Strips for making Extension. 
Fig. 533. 
Fig. 534. 
Fig. 535. 
Stand and Pully for making Extension in Fractures 
of the Lower Extremity. 
Levis’s Stand and Pulley. 
Perforated one-pound weights 
for Extension. 
The annexed cut, fig. 536, represents the method of treating oblique fractures of the 
leg, recommended by I)r. Swinburne. A narrow, delicate splint and foot-piece are fast- 
ened by means of adhesive plaster, while counterextension is made from the knee by 
strips of the same material looped about the limb below the joint. A strong cord is then 
passed through this loop, and thence on through a hole in the side splint, opposite the 
lower part of the thigh, in order to afford the requisite degree of tension. If, after the 
apparatus has been applied, the limb is not sufficiently steady, adhesive strips must be used 
as represented in the engraving. 
Suspension of the leg may sometimes be advantageously practised, both as it respects 994 
DISEASES ANI) INJURIES OF THE BONES. 
CHAP. VIII. 
the comfort of the patient and the welfare of the fracture. This may be done either 
according to the method recommended, many years ago, by Professor N. R. Smith, or by 
Fig. 536. 
Swinburne’s Apparatus. 
the very simple contrivance of Mr. Salter, of England, depicted in fig. 537, representing 
the limb surrounded by the apparatus and slung to the tester of the bed. The case in 
Fig. 537. 
Salter’s Apparatus for Suspending the Leg. 
which the leg rests is made of light metal; and the whole contrivance is so arranged as 
to admit of lateral motion, as well as of sliding up and down, simply by the rolling of the 
pulley-wheels upon the horizontal bar. The attachment of a foot-piece would greatly 
improve the apparatus, as* the limb could then be more effectually steadied. 
The apparatus of Dr. N. R. Smith may be used for fractures of any of the long bones of 
the lower extremity, whether simple, compound, or complicated, it consists, as is seen in 
fig. 588) of two pieces, united by a 
hinge, after the fashion of a double 
inclined plane, one corresponding 
with the thigh, and the other with 
the leg, the latter supporting a shoe, 
which is attached by a thumb-screw, 
and is so arranged as to be rotated 
outwards or inwards, thereby ele- 
vating or depressing the toe, as may 
be deemed most desirable. The two 
pieces are supplied with side-boards, 
joined by the bows of iron beneath; 
and they are so constructed, both at 
the knee and at the foot, that they 
may be elongated or shortened at 
pleasure. Moreover, a short crutch, 
movable and well padded, is secured 
to the inner and upper extremity of the thigh portion, in order to prevent injurious pres- 
sure upon the perineum. Another piece, also well padded, movable, and composed of iron, 
is appended to the superior and outer part of the apparatus, and is fastened around the 
Fig. 538. 
N. R. Smith’s Suspending Apparatus. CHAP. VIII. 
COMPLICATED FRACTURES OF THE LEG. 
995 
trunk by a strong band. The thigh and leg rest on slings attached to the side pieces, the 
latter being confined in the apparatus by its own weight, aided by a bandage, while the 
former is supported in front by a well-padded, flexible splint. The whole contrivance is 
suspended to the ceiling, or to the tester of the bed, by a single cord, attached below the 
knee, near the centre of gravity of the limb and apparatus. The cord ascends with a 
slight obliquity from the trunk, so as to effect the requisite extension, by making gentle 
traction on the limb, which is completely grasped by the apparatus, and consequently 
firmly held by it. In this manner, the member is compelled to obey all the accidental 
and necessary movements of the body, thus obviating all strain and tension at the seat of 
fracture. 
In Pott’s fracture, the plan of treatment which I have usually found most efficacious is 
to place the limb in the extended position in a tin or wire case provided with a vertical 
foot-piece. To counteract the tendency to displacement, a short splint should be stretched 
along the inner surface of the limb, and secured by means of adhesive strips or several 
turns of a roller. Mr. Pott thought that deformity was due to the action of the muscles 
of the leg, and hence his invariable practice was to lay the limb upon its outer side, 
with the knee moderately bent. My opinion is that this is not the fact, but that the 
weight of the foot is the direct, if not the only, cause of the displacement, especially 
after the first few days, and that the difficulty is most easily counteracted by keeping the 
foot well supported during the after-treatment. Any tendency that may exist in the mus- 
cles to produce displacement usually subsides within a few days after the accident. 
COMPLICATED FRACTURES OF THE LEG. 
Fractures of the leg are not unfrequently complicated, whether involving both bones or 
only one, as in fig. 539. In the latter case, the tibia, much more frequently than the 
fibula, is the piece that is most liable to suffer. Such accidents are produced in various 
ways; sometimes by violence applied to the foot, as when a man jumps out of a second- 
story window, or falls from a scaffolding; but more generally by direct force, as the pas- 
sage of the wheel of a carriage, a blow from a stone, or the kick of a horse. When pro- 
Fig. 539. 
Complicated Fracture of the Leg. 
duced by these and similar causes, the lesion is usually situated in the inferior portion of 
the leg, towards the ankle-joint, which is not unfrequently penetrated. Fractures of the 
leg, occasioned by railway violence, are always of a comminuted character, the bones 
being extensively crushed, and the soft parts severely lacerated and contused, if not actu- 
ally pulpitied. Hemorrhage, both venous and arterial, often sadly complicates such inju- 
ries, and, along with the shock, sometimes proves speedily fatal, the system, perhaps, 
never fairly reacting after the accident. Now and then, the nutrient artery of the tibia 
bleeds profusely. Complicated fractures of the leg, of a very bad character, are also fre- 
quently produced by machinery in rapid motion, and by gunshot violence. Sometimes, 
again, especially when tilery is unusual brittleness of the osseous tissue, the bones are 
frightfully broken by causes so trivial as to surprise one how they could have induced such 
a result. 
In whatever manner complicated fractures of the leg may happen, the ends of the frag- 
ments, particularly those of the tibia, are extremely liable to protrude at the wound; the 
latter often in such a manner as to render it very difficult to effect replacement, owing to DISEASES AND INJURIES OF THE BONES. 
their being tightly girt by the edge of the opening in the integument, and also to the 
great length which so frequently distinguishes them. The symptoms of such accidents 
are always sufficiently characteristic, since there is usually not only great deformity, but 
likewise, as just stated, exposure of the ends of the broken pieces. Nevertheless, although 
no difficulty can attend the diagnosis, under such circumstances, so far as the existence 
of fracture is concerned, the surgeon should always institute a most careful and search- 
ing examination, with a view of ascertaining the true condition of the soft structures, the 
welfare of which is often much more deeply interested than that of the bones themselves. 
The first object, in every case of the kind, should be to determine what should be done ; 
whether an attempt should be made to save the limb or whether it should be sacrificed. As 
a general rule, it may be stated that when—if I may use an antithetical and apparently 
contradictory expression—the complicated fracture is simple, that is, without any serious 
lesion of the soft parts, an effort should always be made to preserve the limb, especially if 
the patient is young and robust, and the bone not comminuted, although perhaps broken 
at several different points. It is true, such cases sometimes terminate unfavorably, both 
as it respects limb and life; and it should also be borne in mind that the injury sustained 
both by the soft and osseous tissues may be much greater and more serious than the eye 
and hand can possibly trace. The dangers, too, from tetanus, pyemia, erysipelas, second- 
ary hemorrhage, and profuse and exhausting suppuration, are not to be overlooked by the 
surgeon in his laudable endeavors to save a patient from mutilation ; nor is he to forget 
that such lesions, especially when seated near the ankle-joint, are extremely liable to be 
followed by ankylosis. 
When the bones are severely comminuted, the soft parts terribly lacerated, or the ankle- 
joint extensively opened—in short, when the limb has been frightfully bruised, torn, and 
crushed—no one would hesitate to use the knife the. moment sufficient reaction has taken 
place to enable the system to withstand the additional shock. The case even then is fre- 
quently a bad one, the patient often rapidly sinking from exhaustion, or soon alter from 
the effects of erysipelas or pyemia. 
When an attempt is made to preserve the limb, the indications obviously are to arrest 
hemorrhage, to coaptate the ends of the broken bone, to place the limb in an easy, com- 
fortable, retentive apparatus, and to moderate the resulting inflammation. These inten- 
tions are best fulfilled in conformity with the principles laid down under the head of gen- 
eral observations on fractures. When the ends of the fragments protrude, replacement 
may usually be readily effected by extension and counterextension, except when they are 
tightly girt by the edges of the wound, when they must be liberated either with a blunt 
hook, or by enlarging the opening with a bistoury. When the ends are unusually long 
and sharp, and disposed to protrude despite these 
efforts, the best plan is to retrench them with the saw 
or pliers, care being taken, however, not to cut off 
more than is absolutely necessary. Malgaigne in 
such cases advises the insertion of an iron screw, at- 
tached to a strap encircling the limb, into the pro- 
jecting fragment, in order to place it in proper 
position, but of the propriety of such a procedure I 
entertain great doubt, as it must often be followed 
by erysipelas and other evil effects. The edges of 
the wound are accurately approximated by suture 
and collodion, every effort being made to exclude the 
air. Hemorrhage is checked in the usual manner. When the blood proceeds from the 
nutrient artery, and is profuse or troublesome, it may be necessary to plug the canal in 
which the vessel runs temporarily, with a soft piece of wood. Ample provision must be 
made for drainage, either by counteropening or the use of suitable tubes. Weak carbolic 
acid lotions and injections must be freely and frequently used, especially during the first 
five or six days. In short, everything must be done to maintain cleanliness and to prevent 
the retention of pus and blood. 
The best fracture apparatus is the wooden box, fig. 540, so much used in this city, 
both in private and hospital practice, consisting of four pieces, one corresponding with the 
back of the leg, and two with its sides, the fourth being intended for the foot. The 
latter, projecting nearly perpendicularly, is provided with two mortise holes, for the recep- 
tion of the extending bands. The two lateral pieces are secured each by two binges to 
the back board, so as to admit of being opened or shut at pleasure during the application 
and removal of the dressings. The limb, enveloped in the bandage of Scultetus, is care- 
CHAP. VIII. 
Fig. 540. 
Fracture-box. COMPLICATED FRACTURES OF THE LEG. 
997 
CHAP. VIII. 
fully laid into the box, which is then closed, and filled with coarse bran until the whole leg 
and the spaces on each side of it are completely covered in. The advantage of the bran, 
thus used, is that it affords not only easy, equable, and comfortable 
support to the broken bones, but readily absorbs the discharges, 
and prevents the deposit of the ova of the fly, so common during 
the hot months of this and other countries. Substitution is 
effected whenever the bran becomes soiled and caked. This 
mode of treating compound fractures of the leg, originally 
suggested by the late Dr. John Rhea Barton, is unquestionably 
one of the most valuable improvements that have been intro- 
duced into the management of this class of injuries, whether it 
be viewed with reference to the comfort of the patient, the safety 
of the limb, or the convenience of the surgeon. 
The necessary extension and counterextension are easily 
effected by adhesive strips. For the first week or ten days, 
leeches and cold water-dressing will generally be required. If 
suppuration arise, the most soothing application will be an emol- 
lient poultice. 
The fracture-box need seldom be employed longer than eight 
or ten days, unless the case is an unusually bad one. By the end 
of this time it may generally be advantageously replaced by a 
McIntyre’s screw splint, Fig. 541, well padded and extended, 
suspended in a Salter apparatus, or supported with the plaster 
bandage, a suitable opening being left opposite the seat of the 
fracture for drainage and ready dressing. In due time, the 
patient should be put on crutches, and sent into the open air. 
Complicated fractures of the leg are necessarily troublesome 
and tedious occurrences, requiring the utmost care and atten- 
tion to prevent deformity and permanent lameness, and even 
then this is by no means always possible. Erysipelas, in its worst forms, often speedily 
follows, generally within the first forty-eight hours ; copious suppuration arises, the mat- 
ter, unless evacuated by timely incisions, perhaps burrowing extensively among the sur- 
rounding structures; and the system becomes rapidly undermined by hectic irritation, 
loss of sleep, and impaired nutrition. Great swelling, the 
result of a deposition of serum and lymph, frequently exists; 
the limb, tender and heavy, readily pits on pressure ; and the 
joints are stiff, painful, and in danger of permanent ankylosis. 
The heel, unless carefully watched and protected, is sure to 
suffer; first, from inflammation, and afterwards, at no dis- 
tant period, from ulceration, or even gangrene. Most of these 
local troubles may generally be prevented by the judicious use 
of the bandage, applied gently and equably, yet somewhat 
firmly, to support the capillary vessels, control muscular ac- 
tion, and promote the absorption of effused fluids. Passive 
motion should be instituted by the end of the third week, 
and daily repeated for many months. 
There are no fractures in the whole body so liable to be 
attended with tardy union as those of the leg, or which are so 
frequently followed by deformity. The chief cause of these 
mishaps is the great difficulty which the surgeon encounters 
in effecting maintenance of the ends of the fragments, in con- 
sequence of their remarkable obliquity and splintered cha- 
racter, especially of the upper one of the tibia, which is often 
very thin and several inches long. 
Ununited fractures of the leg are not uncommon, and may 
involve both bones, or be limited to one of them. In either 
event, the treatment is generally tedious and perplexing. In 
most of the cases under my observation, my main reliance has 
been upon the use of the perforator and the ivory peg, which 
have generally rendered me good service. Setons, the steel 
pin, and excision are inapplicable. When the patient’s health is much dilapidated, and 
exercise in the open air is imperatively demanded, great benefit will accrue from wear- 
Fig. 541. 
Compound Fracture of the 
Leg, Dressed. 
Fig. 542. 
Gillingham’s apparatus for Un- 
united Fracture of the Leg. 998 
DISEASES AND INJURIES OF THE BONES. 
ing the apparatus, fig. 542, devised by Mr. Gillingham, of England, and which is thus 
described by Mr. Holmes: “ It consists of, first, a collar, which is moulded to the leg just 
below the knee, and on each side of which is a stud ; secondly, of a boot with a socket at 
the heel; and, thirdly, of two steels, with ankle-joints bifid at the top to catch the studs 
on the collar, and capable of elongation or shortening, as seen in the engraving. Thus 
the weight of the body is taken off the leg-bones, and transmitted down the two side- 
steels.” The apparatus can be equally adapted to ununited fractures of the femur. 
FKACTUKKS OF THE PATELLA. 
Fracture of the patella, figs. 543 and 544, although comparatively uncommon, derives 
great practical importance, from its proximity to the knee-joint, and the imperfect manner 
in which it is usually repaired. It may 
extend through the bone in any direction, 
tr ansversely, obliquely, or vertically, the 
frequency of the occurrence being in the 
order here stated. When the fracture is 
comminuted, the fissures often exhibit the 
most irregular arangement. Compound 
fracture of the patella is an uncommon, but 
dangerous complication. 
The causes of the accident, are two, ex- 
ternal violence, and muscular action. The 
transverse fracture is nearly always pro- 
duced by the latter, or by the joint agency of the two, while the oblique and vertical are 
invariably the result of direct injury, as a fall, blow, or kick. In the latter case, conse- 
quently, there is frequently severe contusion of the soft parts, and sometimes the knee- 
joint is even laid open. The transverse fracture is produced by falls in which the leg is 
\strongly flexed upon the thigh, while the body is thrown 
suddenly and forcibly backwards, thereby putting the ex- 
tensor muscles powerfully upon the stretch, the line of 
fracture usually taking place just above the middle of the 
bone. Jumping out of a carriage and falling backwards 
upon the ground, is a very common way in which the 
accident is occasioned. Circus riders and ballet dancers 
sometimes break this bone in the act of leaping in the ex- 
ercise of their profession. 
Desault met with a case in which a man broke both 
of these bones simultaneously by a violent effort of the 
muscles to disengage the limbs from the constrained po- 
sition in which they were placed during the operation of 
lithotomy. 
Muscular fractures of this bone are very uncommon be- 
fore the age of twenty-five. The greatest number occur 
between this period and the fifty-fifth year. 
Transverse fracture of the patella is sometimes caused 
by direct violence, as when the bone is struck in a fall or 
blow, and forcibly impelled against the condyles of the femur. On the other hand, cases 
occur, although rarely, in which the bone is broken from within outwards, as in fracture 
ot the articular extremity of the femur, in which one of the fragments is violently thrust 
against the posterior surface of the patella, perhaps shivering it into a number of pieces. 
The symptoms of fracture of the patella are generally well marked. In the transverse 
form of tlie lesion, the nature of the accident is at once detectable by the change in the 
contour of the knee, by the inability to extend the limb, and by the displacement of the 
upper fragment, as seen in fig. 545. In many cases the person is conscious, at the moment 
of the injury, of something having given way, and, perhaps, he may even have heard the 
peculiar characteristic snap. If he attempts to get up and walk, he will be almost sure to 
fall, from his inability to extend the leg and support the weight of the body upon it. The 
displacement is usually considerable, the superior fragment being drawn upwards upon the 
forepart of the thigh by the extensor muscles. The height to which it may be carried 
varies according to the extent of the destruction of the ligamentous connection of the ten- 
don of these muscles. When the separation is complete, it may amount to two and a half, 
CHAP. VIII. 
Fig. 543. 
Fig. 544. 
Transverse Fracture of 
the Patella. 
Oblique Fracture of the 
Patella. 
Fig. 545. 
Fracture of the Patella. FRACTURES OF THE PATELLA. 
999 
CHAP. VIII. 
three, and even four inches, while, under opposite circumstances, it may not exceed six, 
eight, or ten lines, or be even entirely absent, the structures in front of the joint holding 
the fragments more or less firmly together. The distance between the two fragments is 
always, as a rule, considerably increased by bending the leg. The front of the knee has a 
flattened appearance, and upon passing the finger over it its point will be found to sink down 
abruptly, as it were, into the joint. The lower fragment is stationary, but the upper is 
easily moved, and may, by thorough extension of the limb, be brought down into its nor- 
mal situation, so as to enable one to detect crepitation. If some time have elapsed since 
the occurrence of the accident, considerable swelling may be present, due to an effusion 
of synovial fluid, or this fluid and to extraarticular deposits, and more or less obscuring 
the diagnosis ; occasionally a considerable quantity of blood is poured into the joint, espe- 
cially when the fracture has been caused by external violence. The synovial burses over 
the patella and over the head of the tibia occasionally become greatly inflamed, and thus 
seriously complicate the case. 
In respect to its mode of union, the transverse fracture of the patella holds the same 
relation as a similar injury of the olecranon. In both cases the nutrition of the fragments 
is seriously impaired by the laceration of their vessels ; in both there is an inordinate quan- 
tity of synovial fluid, and in both great difficulty is experienced in maintaining coaptation. 
Hence, as a rule, the union is by fibrous, ligamentous, or fibro-ligamentous tissue, not by 
osseous. In all the examples of this fracture that I have been able to examine, both in 
the living subject and in museums, I have not met with any in which the consolidation 
was completely osseous. A few such cases, however, have been recorded by surgeons, 
and one well-marked specimen of the kind, found in the dissecting-room of the College, 
is contained in my private collection. In the inferior animals osseous union is not uncom- 
mon, if care be taken to keep the ends of the bone accurately in contact. When the inter- 
val between the broken pieces is very considerable, as, for instance, when it amounts to 
two inches, the union is established by the aponeurotic tissue which naturally covers the 
patella, and which, in this event, extends from one fragment to the other, the plastic 
matter which is poured out in consequence of the injury not being capable of being 
converted into ligamentous matter. Whatever may be the nature of the connecting 
medium, it is important that it should be as close and perfect as possible ; for the joint will 
always be weak and unprotected precisely in proportion to its length and thinness. 
Fig. 546. 
Fig. 547, 
Arteiial Supply of the Patella. 
Old Fracture of the Patella, showing 
the Separation of the Fragments. 
It is highly probable that the very means that are generally employed to keep the ends 
of the fragments in contact often serve to interfere with their reunion by cutting off the 
supply of blood. Mr. Manning has shown by the dissection of a number of specimens that 1000 
DISEASES AND INJURIES OF THE BONES. 
CHAP. VIII. 
the vascular arch of the upper fragment is situated at the precise spot where the greatest 
amount of pressure is usually made by the retentive apparatus ; and that the lower fragment 
inevitably experiences a similar fate when, as not unfrequently happens, the internal, supe- 
rior, and inferior articular arteries arise from a common trunk. Fig. 54G illustrates Mr. 
Manning’s ideas. 
The annexed cut, fig. f)47, represents a specimen of fracture of the patella in the cabinet 
of the late Professor Pancoast. The bone was broken into three pieces, the superior of 
which was drawn up in front of the thigh, far away from the joint, and nearly four inches 
from the inferior, which consisted of a mere little chip, hardly two inches in width, cor- 
responding with the lower edge of the bone. No union followed. 
The fragments after this accident occasionally experience important changes in form 
and bulk. Now and then they undergo remarkable atrophy, but more commonly they 
increase in size and strength, so as to afford a broader surface for the fibro-ligamentous 
tissue which serves to hold them together. 
The treatment of transverse fracture of this bone is attended with serious difficulty, on 
account, first, of the pressure from the accumulation of synovial fluid, and, secondly, of 
the difficulty experienced in controlling the action of the extensor muscles, the constant 
tendency of which, especially during the first six or eight days, is to draw the superior 
fragment upwards, away from the lower. To counteract this tendency, therefore, consti- 
tutes the chief indication of the treatment. This can be effected only by maintaining the 
leg steadily and faithfully in a complete state of extension, the thigh being at the same 
time flexed upon the pelvis, and the body kept in the semierect posture. In this manner, 
the extensor muscles are thoroughly and effectually relaxed. The most efficient contri- 
vance for insuring this position of the limb is a strong, well-padded tin or wire ease, long 
enough to reach from the middle of the thigh to the corresponding point of the leg, a roller 
having previously been applied from the toes upwards, and another from the groin down- 
wards. The superior fragment, having been brought into place, is next confined by nume- 
rous adhesive strips, carried around the bone above and below the joint, and connected 
afterwards by vertical and transverse pieces. The dressing is completed by the application 
of a long, thick, and rather narrow compress, extended around the upper border of the 
patella, and confined by the two rollers passed around the joint in the form of the figure 
8. Managed in this way, it is hardly possible for the fracture to suffer the slightest dis- 
placement, or to conceive of anything better adapted to fulfil the end in view. The tin or 
wire case maintains the limb in the extended position, the adhesive strips and compress 
retain the upper fragment in contact with the lower, and the rollers, applied in opposite 
directions, aid powerfully in controlling muscular action. Leeches, ice, and lotions of 
acetate of lead may be required when the parts are much contused or otherwise in- 
jured, and no good can result from any attempt to approximate the fragments so long as 
the joint is distended with synovial gland. Hence the best plan, during the first six or 
eight days, is to limit the treatment to the employment of rest and other antiphlogistic 
means, all corrective appliances being dispensed with until the immediate effects of the 
injury have passed off. When the quantity of effused fluid is unusually great the aspirator 
should be used, and the same plan may be adopted when the joint is filled, as is occasion- 
ally the case, with uncoagulated blood. 
Fig. 548. 
Hamilton’s Apparatus. 
When a suitable case cannot be procured, the object may be attained by the use of a 
wooden splint, well padded, and stretched along the posterior part of the thigh and leg. 
The adjoining drawing, fig. 548, represents the mode of dressing transverse fractures of 
the patella, pursued by Professor Hamilton, and also, at one time, with slight modifica- CHAP. VIII. 
FRACTURES OF THE PATELLA. 
1001 
tions, at the Pennsylvania Hospital. The plan is an excellent one, and seldom fails to 
effect a good cure ; often with hardly any interspace between the ends of the fragments. 
Mr. Krichsen, as a rule, prefers the immovable dressing, with which he has generally 
effected excellent cures. lie applies a pad above the upper fragment and secures it with 
a figure-of-8 bandage, as a preliminary step. Manning’s apparatus', fig. 549, which has 
met with much favor in England, “consists,” observes Krichsen, “of a wooden back- 
Fig. 549. 
Manning’s Splint for Fractured Patella. 
piece, a little wider than the knee-joint, and long enough to reach from the sole of the foot 
to the gluteal fold, and provided at the lower end with a foot-piece, A. At the junction 
of the middle and lower thirds is a transverse oblique slit, b, one and a half inches long. 
Strips of strong plaster, two inches broad and long enough to encircle the thigh and over- 
lap by some inches, are attached to a calico band, c. The free end of this band is carried 
through the slit, and the straps of plaster are open on the upper part of the splint. A 
piece of wood, e, is attached to the lower part of the splint, and another piece of corre- 
sponding size is attached to a loop at the end of the calico band, so that, when drawn 
down and the splint is adjusted, these three pieces may be five or six inches apart.” 
The limb having been previously bandaged from the toes up as far as the lower edge of 
the patella, and the splint well padded without obstructing the slit, an assistant draws 
down the upper fragment by grasping the extensor muscles, while the surgeon carries the 
plasters-firmly around the thigh from above downwards, beginning immediately below the 
gluteal fold, and terminating about three inches from the upper border of the patella. 
The calico band being kept carefully in the middle line is then fastened to the splint by a 
few turns of a roller. “ Lastly,” says Krichsen, “as many elastic rings—those known 
as ‘ office bands’ answer the purpose very well—as will serve to approximate the frag- 
ments without causing too much pain to the patient, are passed over the projecting ends 
of the pieces of wood, as at f, fig. 550, on each side of the splint, so as to exercise suffi- 
cient traction on the muscles pulling on the upper fragment.” 
Fig. 550. 
Manning’s Splint applied. 
Numerous contrivances are before the profession for the treatment of these injuries, 
nearly all constructed upon the same principles. Among the more ingenious are those of 
Lonsdale, Burge, Lausdale, and Boisnot. The iron ring, employed by Alhucasis, I)e 
Vigo, Bassuel, Purmann, Ileister, and others in the treatment of transverse fractures of 
the patella, was reintroduced into practice, in 1866, by I)r. W. A. Gibson, of Missouri, 
and in the case reported by him bony union is said to have taken place in thirty days, fol- 
lowed by the perfect use of the knee-joint. The ring, being well padded, is secured first 
to the knee by adhesive strips, and then by a roller to a light splint, two feet in length, 1002 
stretched along the posterior surface of the thigh and leg. Perhaps the very best of these 
contrivances is that of Wolfermann, consisting of a simple, padded steel spring, encircling 
the knee from behind, and ending in front in two cresecentic arms, so arranged as to 
embrace very closely the periphery of the patella, and kept in place by two leather straps. 
The apparatus, properly applied, effectually prevents flexion of the joint, and induces 
accurate apposition of the fragments. A splint should be stretched along the posterior 
surface of the limb in every case in which such a contrivance is used. Excellent results 
have followed this mode of treatment in the hands of Eve, Blackman, Kocher, and 
others. 
The hooks of Malgaigne, delineated in fig. 551, were employed by that eminent surgeon 
in a considerable number of cases, with bony union in some, and no bad results in any; 
and they are now used a good deal both in this country and in Europe. 
The shape and construction of the instrument are perceived at a glance. 
Two of the hooks are inserted into the tendon of the extensor muscle, 
at the upper edge of the patella, and two into the lower, when they are 
drawn together, and kept in place by the screw. The hooks cannot 
penetrate the bone, much less the joint; and the only objection to them 
is that they may produce erysipelas. The great advantage is that they 
prevent the ends of the fragments from tilting up in front, thus hold- 
ing them more closely and firmly together, and thereby more effectually 
insuring osseous union. From six to eight weeks is the period during 
which they should he retained. 
This treatment in this form of fracture has of late years been very 
fashionable at the Pennsylvania Hospital in the hands of Drs. Levis 
and Morton, who prefer it to every other method- Professor Agnew, 
on the contrary, denounces it as “ diabolical.” My own opinion is that 
it is perfectly safe when skilfully employed and carefully watched. The 
instrument used by Levis is composed of two separate hooks, fig. 552, an 
arrangement which has the advantage, as is claimed, of holding the 
fragments more evenly and firmly together than can be done with the 
original contrivance. Morton has still further modified the instrument 
by imparting to it, as seen in fig. 553, the form of a double triangle. 
That this treatment has been occasionally followed by ulceration of the 
joint and even the death of the patient is unquestionable, and hence it cannot be employed 
with too much caution. As a rule, however, I believe it to be perfectly safe. 
Dr. John Rhea Barton, upwards of half a century ago, in one instance, connected the 
fragments together with silver wire, but lost his patient. The operation was not repeated 
until 1861, when it was successfully performed by the late Professor E. S. Cooper, of San 
Francisco, and, three years later, by Logan, of Sacramento. Dr. Hector Cameron, of 
Glasgow, in 1877, successfully wired the fragments under antiseptic precautions, and similar 
operations have now been performed in 17 additional cases, Lister having had three, and 
Rose and Schede each two, while single cases have been recorded by Van der Meulen, 
Smith, Metzler, Socin, Langenbuch, Trendelenburg, Uhde, Bell, Holmes, and Schneider. 
All of the 18 cases recovered with useful limbs, except three in which the joint suppurated 
and became ankylosed. The operation unfortunately has not been performed sufficiently 
often to justify us in offering any positive opinion respecting its safety. Lister declares that 
it should never be employed except by practitioners who are thoroughly conversant with 
antiseptic surgery. I certainly should doubt the propriety of resorting to it under any 
other circumstances, and even then it must always be a dangerous procedure. 
Volkmann connects the fragments by passing a silver wire or a strong silk ligature sub- 
cutaneously through the tendon of the extensor muscles and the ligament of the patella, 
and he has reported a number of cases in which he succeeded in obtaining, by this pro- 
cedure, excellent osseous union. It is evidently too soon to praise of condemn this opera- 
tion ; but its dangers are certainly less than those attendant upon the operation which opens 
the knee-joint. 
The injection of fresh marrow cells between the fragments, as practised by Ollier, 
Goujon, Wyeth, and others, has failed to secure the desired object, and scarcely deserves 
repetition. 
Instead of raising the heel in the treatment of transverse fractures of the patella, some 
surgeons place the limb in the horizontal position upon a well-padded posterior splint, 
provided with a footboard, and extending nearly as high up as the tuberosity of the ischium, 
the patient observing the semierect posture as he lies in bed. The extensor muscles, it 
DISEASES ANI) INJURIES OF THE BONES. 
CHAP. VIII. 
Fig. 551. 
Malgaigne’s Hooka. 1003 
CHAP. VIII. 
FRACTURES OF THE PATELLA. 
is alleged, if not paralyzed by the accident, soon become so completely relaxed as not to 
exert any strain whatever upon the fragments. After the immediate effects of the injury 
have subsided the parts are approximated with adhesive strips, and supported with com- 
presses and the immovable bandage. Excellent cures may no doubt he obtained by this 
method, but I give the elevated position a decided preference. Dupuytren declares that 
be treated some cases of transverse fractures of the patella successfully without the employ- 
ment of any apparatus whatever, simply by keeping the limb perfectly at rest in the 
extended position. 
Fig. 552. 
Fig. 553. 
Levis’s Hooks applied. 
Morton’s Hooks applied. 
Oblique and vertical fractures of the patella generally readily unite by osseous matter, 
as there is but slight tendency to displacement of the fragments, owing to the fact that they 
are little, if at all, influenced by the action of the extensor muscles of the thigh. The prog- 
nosis is, therefore, other things being equal, always favorable, although, from the involve- 
ment of the knee-joint, a considerable period usually elapses before the patient regains the 
perfect use of the limb. 
The signs of these oblique and vertical fractures are sometimes very obscure, especially 
when there is much swelling of the soft parts. In general, however, the nature of the 
case may be determined by the impaired motion of the knee-joint, by the fixed character 
of the pain, and by pressure applied to the patella in opposite directions, when, if such 
lesions exist, crepitation will be sure to be elicited. 
The limb, having been enveloped in a bandage, should be kept at rest in an elevated 
and extended position until there is complete subsidence of inflammation, when the water- 
glass dressing should be applied, the patient being permitted to move about upon crutches. 
If the fracture be vertical, or nearly so, it will be necessary to support the fragments by 
means of two compresses, stretched along the lateral borders of the bone, and confined by 
adhesive strips and a roller. When the fissure is very oblique, the displacement may be 
such as to demand a course of treatment similar to that necessary in transverse fracture. 
The stiffness of the knee-joint, which always remains after fractures of the patella, and 
which is often very great, no matter what mode of treatment is adopted, requires special 
attention, not for days or weeks, but generally for months, otherwise irremediable lame- 
ness will almost be sure to follow. Passive motion should not, as a rule, in transverse 
fractures, be instituted before the close of the seventh or eighth week, or until there is 
reason to believe that the process of reunion is sufficiently advanced to withstand the 
efforts. The adhesions must be broken up gradually and in the gentlest possible manner, 
and should be repeated, at first, every second day, and afterwards daily, until all danger 
of ankylosis is over. Friction with stimulating liniments, massage, and the hot and cold 
douches will do much in stimulating the absorbent vessels, and restoring the parts to their 
primitive suppleness. 
A patella that has once been broken transversely is exceedingly liable to a recurrence 
of the accident from comparatively slight muscular contraction. The patient should, 
therefore, always be put upon his guard in this respect. The fracture may occur at the 1004 
DISEASES AND INJURIES OF THE BONES. 
CHAP. VIII. 
same point, but generally it takes place a little higher up. Finally, when, one patella has 
been broken, the other is apt to suffer in a similar manner, owing to the imperfect use of 
the affected limb, and the consequent liability of the patient to fall. Cases of this kind 
have occurred in my own practice, and others are referred to by Bromfield, Meuscliner, 
Camper, Sir Astley Cooper, Malgaigne, and other high authorities. 
In all fractures of this bone it is a good rule, after the first ten or twelve weeks, to 
protect the knee for a long time with a suitable gum-elastic cap, to rub the parts well at 
least once a day with some stimulating liniment, and to observe the greatest possible care 
in the use of the limb. The extensor muscles, especially the straight, always remain very 
weak after transverse fractures of the patella, and in many cases they experience a 
remarkable degree of atrophy, which generally lasts through the remainder of life. 
Compound fractures of the patella, with penetration of the synovial membrane, are 
among the most dangerous of accidents, life, when an attempt is made to retain the limb, 
being liable to be assailed by profuse suppuration of the knee-joint, erysipelas, pyemia, 
pleuro-pneumonia, tetanus, and hectic irritation. For these reasons primary amputation 
is generally demanded. When the bone is comminuted, but the joint is not laid open, all 
loose fragments should at once be removed, and the case managed upon ordinary principles. 
In a case of this kind recently under my care, in a youth twenty years of age, owing to 
previous mismanagement, violent inflammation took place attended with the formation of 
large abscesses, and followed by necrosis, necessitating the removal of nearly the entire 
patella. The patient was laid up for upwards of a year, but finally made a good recov- 
ery with partial ankylosis of the knee. The great points in the treatment of such injuries 
are, first, to maintain the limb in an elevated position uj>on a posterior splint, and to keep 
the knee constantly covered with a bladder partially filled with pounded ice. If the 
symptoms are very urgent, and the patient is young and plethoric, blood should be taken 
freely from the arm and by leeches from the affected parts. The danger to limb and life 
in such accidents is generally in proportion to the amount of injury sustained by the knee- 
joint. Incised wounds usually do much better than lacerated and contused. Antiseptic 
measures should be rigidly enforced. IIow far they should be trusted in bad cases is an 
open question. 
Secondary amputation may become necessary, when, an attempt having been made to 
save the limb, life is threatened with exhaustion by profuse suppuration and hectic irrita- 
tion. Mr. Poland, who has made a special study of compound fractures of the patella, 
involving the knee-joint, finds, by an appeal to statistics, that such an operation, whether 
primary or secondary, is much less frequently called for than has generally been imagined. 
Of 08 cases treated without this extreme measure, only 12, or 17.65 per cent., died, 
while of 14 cases treated by amputation and excision, 8 perished, thus exhibiting a very 
great difference in favor of non-interference. In all the fatal cases, as well as in a majority 
of those that recovered, suppuration of the joint had occurred. Ankylosis, partial or 
complete, must, of course, in such an event, be a frequent sequence. 
FRACTURES OF THE FEMUR. 
Fractures of the femur deserve the most attentive study; for not only are they of fre- 
quent occurrence, but they present themselves under every possible variety of form, and 
there are no injuries of the kind which, to use the language of Pott, “ so often lame the 
patient and disgrace the surgeon.” Any portion of the bone may give way, and hence it 
is customary, in treating of the subject, to speak of fractures of the shaft of the femur, of 
its condyles, and of its superior extremity, or of its neck, and of its trochanters. 
1. FRACTURES OF THE SHAFT. 
The shaft of the femur may be broken in any portion of its extent, but there are three 
points which are particularly obnoxious to fracture. These are the upper fourth of the 
bone, the middle, and the inferior fourth, the relative frequency of the accident being in 
the order here stated, although it is generally asserted that the bone yields more frequently 
at or near its middle than anywhere else. This idea, however, accords neither with the 
results of my observations upon the living subject, nor with my examinations of specimens 
of fractured bones in different collections. The relative difference, however, is, no doubt, 
very slight. Fractures of the shaft of this bone are nearly always, in adtyits and elderly 
subjects, oblique, and, therefore, liable to be attended with great displacement, the long 
and sharp ends of the fragments often indicting serious injury upon the soft parts. In FRACTURES OF THE FEMUR. 
1005 
CHAP. VIII . 
children, on the contrary, they are more frequently transverse ; or, at all events, the 
obliquity is usually much less, and, as the muscles are less vigorous, the tendency to over- 
lapping is not nearly so marked. 
An impacted fracture of the shaft of the femur is sometimes met with, although the 
occurrence is very uncommon. At a meeting of the Surgical Club, of Philadelphia, in 
1878, Professor Agnew exhibited the femur of a gentleman, thirty-five years of age, which 
had given way about its middle in the act of pulling on his boots, and in which the upper 
extremity of the lower fragment was partly driven into the upper a distance of upwards 
of two inches. Death occurred at the end of a fortnight from the effects of erysipelatous in- 
flammation, notwithstanding which there was already a considerable amount of fibrous union. 
Fractures of the Upper Fourth of the Shaft The most common site of fracture of 
this portion of the bone is from two and a half to three and a half inches below the small 
trochanter ; the line of fracture is almost always oblique, extending from behind forwards, 
and from above downwards, being frequently from an inch and a half to two inches in 
length. A transverse fracture here is an exceedingly rare occurrence. It is also very 
uncommon to see the bone give way just below the small trochanter, and it is worthy of 
note that, when it does break at this point, it is generally complicated in its character, or 
associated with intracapsular fracture, properly so termed. 
The symptoms of fracture seated in this portion of the femur are generally so obvious 
as to indicate at once the nature of the injury, the characteristic signs consisting of great 
shortening and angular deformity. The shortening varies from two to four inches, and 
usually exists in full force immediately after the receipt of the injury. The superior por- 
tion of the limb is remarkably distorted, being convex on its external surface, with a cor- 
responding concavity internally, occasioned by the overlapping of the ends of the broken 
bone, the upper nearly always lying in front of the lower, being drawn in this direction by 
the action of the psoas and iliac muscles, and both being usually drawn somewhat out- 
wards. In ten specimens of fracture of the upper fourth of the shaft of the femur, 
that I have carefully examined, I find that in all, except one, the upper fragment is 
in front of the lower, the reverse being the case in the other. In these ten specimens 
the superior piece is drawn forwards and outwards in six ; in two it is tilted upwards and 
inwards; and in two it is raised up and in a straight line with the lower, or without any 
lateral deviation whatever. The distance of the fracture from the small trochanter ranges 
from two inches and two-thirds to three inches and a quarter. 
In the six specimens in which the superior fragment is directed forwards and outwards, 
the lower fragment is also inclined outwards in four, the junction between them being 
such as to give the bone more or less of an arched appearance, the convexity being exter- 
nal and the concavity internal. In the two specimens in which the upper end is directed for- 
wards and inwards, the lower end, in one, is inclined inwards also, and in the other it is 
straight, or in a line with the superior fragment. In seven of the eight specimens in 
which the displacement is lateral, the inferior fragment is more or less strongly everted, 
and, consequently, the knee and foot, during life, must have been in the same position. 
The fractures, so far as can be determined, were all oblique, the line of disjunction, in 
nine, extending from behind forwards, and from above downwards, one only being in the 
opposite direction, and in this the lower fragment lies in front of the upper, overlapping 
it four inches. The distance at which the ends of the bones are separated anteriorly 
varies from half an inch to an inch and three-quarters. The angle which the superior 
fragment forms with the inferior does not, in any of the ten specimens, exceed 45°, while 
in most it falls considerably short of this. 
I have been thus particular in giving the results of these examinations, on account of 
their practical bearing upon fractures of the superior extremity of the shaft of this bone. 
Sir Astley Cooper, and those who have adopted his views, have evidently formed very 
erroneous ideas, not only as regards the extent and direction of the displacement of the 
upper fragment, but also of its causes. Thus, it has been asserted that the upper end 
often overlaps the other almost at a right angle, which is not the case in any of the speci- 
mens that I have examined ; on the other hand, it has been alleged that the two pieces 
are usually inclined outwards, which the specimens alluded to also disprove, there being 
no lateral deviation whatever in two, while in two others the projection was inward, leav- 
ing thus only six cases of outward displacement. The displacement forwards of the upper 
end is due to the joint action of the psoas and iliac muscles, assisted, perhaps, by the 
pectineal and the short head of the adductor, while it is dragged outwards mainly by the 
agency of the external rotators. The lower fragment, on the contrary, is drawn up by 
the action of the flexor muscles of the thigh, and outwards by the tensor, vastus, and glu- DISEASES AND INJURIES OF THE BONES. 
teal muscles. That the direction of the fracture materially influences the direction of the 
displacement is shown by the fact that, in the only specimen out of the ten examined by 
ine in which the line of fracture extended from before backwards, and from below up- 
wards, the lower fragment overlapped the upper, and that to a great extent. 
Although the specitnes here described are, I conceive, of great pathological and prac- 
tical value, it must not be forgotten that any inferences deducible from their examina- 
tion are impaired, in some degree, by the fact that the displacement which character- 
izes them may have been influenced more or less by the nature of the treatment. Thus, 
in consequence of the use of splints, the ends of the fragments, originally inclined inwards 
or outwards, may have been pushed and held in the opposite direction, thereby completely 
reversing the primitive order of the deformity, {is caused by the direction of the fracture, 
the weight of the limb, and the action of the muscles. 
The annexed drawings, figs. 554, 555, and 556, two of which are from my own prepa- 
rations, w ill serve to illustrate the nature of the displacement so often met with in fractures 
of the superior portion of the shaft of the femur. 
Fractures at the Middle of the Shaft A fracture at the centre of the shaft of the 
femur is, according to my observation, an uncommon occurrence; most generally the bone 
gives way some distance above or below this point. The line of fracture is, for the most 
part, very oblique, extending from behind forwards and from above downwards, and the 
consequence is that the superior fragment nearly always overlaps the inferior, the upper 
extremity of which is drawn backwards, and usually, also, somewhat outwards, by the 
action of the flexor muscles, causing thus an amount of shortening from two and a half 
to three and even four inches, with more or less angularity at the site of injury, and 
marked eversion of the limb. The lower end of the superior fragment, on the contrary, 
forms a prominent projection on the forepart of the thigh, easily perceived by sight and 
touch. The symptoms are characteristic. 
CHAP. VIII. 
Fig. 554. 
Fig. 555. 
Fig. 556. 
Fracture of the Shaft of the Femur. 
A perfectly transverse fracture of the shaft, of the femur is, as stated above, so ex- 
tremely uncommon that, although the phenomena might be such as to lead to the 
suspicion of its existence, the idea that it really is an injury of that kind should not be 
carried out in practice, lest, the requisite extension and counterextension being omitted, 
permanent shortening should follow. When there is no marked tendency to displacement, CHAP. VIII. 
FRACTURES OF THE FEMUR. 
1007 
it will generally be found that the fracture, instead of being transverse, is slightly impacted, 
or that its extremities, being denticulated, are interlocked with each other, and thus held 
in place. Comminuted fracture of this portion of the shaft is not uncommon, especially 
in old subjects, laboring under fragility of the osseous tissue. 
The accident may be the result of direct violence, as a kick from a horse or the passage 
of the wheel of a carriage; or it may be occasioned indirectly by a fall upon the foot or 
knee. In the former case it is often of a compound or complicated character. Several 
examples have come under my observation in which a fracture in this situation occurred 
in the act of pulling off' the boot, the limb at the moment lying across its fellow. 
Fractures of the Inferior Fourth of the Shaft Fracture of the inferior portion of the 
shaft of this bone derives a special interest from the fact that, when occurring very low 
down, the inferior end of the upper fragment may, particularly if very long and sharp, 
penetrate the joint, and thus seriously complicate a case otherwise easy of management. 
The fracture, moreover, is liable to be compound, the upper piece piercing the muscles 
and integument just above the knee. As in fracture of the other divisions of the shaft, 
already described, so in this the line of the solution of continuity generally ranges from 
behind forwards and from above downwards, a transverse fracture, properly so termed, 
being extremely uncommon. The degree of obliquity, although very variable, is generally 
so considerable as to cause great shortening of the limb and angularity of the part; which, 
together with the everted state of the knee and foot, are characteristic signs of the nature 
of the accident. The inferior fragment is always drawn backwards and upwards, its 
superior extremity forming a distinct prominence in the popliteal region, which may easily 
be effaced by restoring the pieces to their proper position. When the fracture occupies 
the lower extremity of the shaft, nearly on a level with the joint, the upper fragment may 
descend so far down as to push the patella away from the trochlea of the femur, over upon 
the tibia, so as to create an appearance simulative of partial luxation of this little bone. 
If several hours have elapsed since the receipt of the Injury, the diagnosis will sometimes 
be obscured by tumefaction of the joint; but, in general, whatever may be the condition 
of the parts, any existing doubt may be cleared up by a thorough examination of the 
Fig. 557. 
Fracture of the Femur at Us Inferior Fourth. 
limb. The relative positions of the fragments in this fracture are well depicted in fig. 
557, from a specimen in my cabinet. 
Much swelling in and around the knee often, if not generally, attends fractures in this 
situation, the former being due to an effusion of synovial fluid from an extension of the 
irritation to the synovial membrane, and the latter to the extravasation of blood, which is 
frequently poured out very freely by the lacerated tissues at the seat of the injury, whence 
it gravitates to the capusule of the joint, hut does not penetrate it. An intracapsular 
swelling is always readily distinguishable from an extracapsular by the fact that, in the 
former, the patella may be movable from side to side, and rebounds when tapped; whereas, 
in the latter, it remains firmly fixed. 
The causes of fracture in this situation are commonly of a direct nature, a greater 
amount of force seeming to be necessary to produce it than when it occurs higher up. It 
may, however, be induced in an indirect manner, as when a person, falling from a con- 
siderable height, alights upon his foot or knee, the violence of the shock being concentrated 
upon the inferior portion of the femur. 1008 
DISEASES AND INJURIES OF THE BONES. 
Treatment The treatment of fractures of the shaft of the thigh-bone may be conducted 
according to several plans, of which that by extension and counterextension, the limb 
being in the straight position, is, as a rule, the most eligible, fulfilling, as it does, more 
effectually than any other, the different indications presented by this class of injuries. 
Before any steps, however, are taken to adjust the broken pieces, a suitable bed must be 
procured for the comfortable accommodation of the patient, as well as for the secure man- 
agement of the case. This subject having been fully discussed in a previous part of the 
work, it will be sufficient, for my present purpose, merely to allude to it here, with the 
hope of enforcing more fully its importance. I am so thoroughly convinced of the utter 
impossibility of treating fractures of the femur successfully without a good bed, that I 
should consider any surgeon justifiable in declining to undertake tlie management of any 
case unless his efforts are properly seconded in this respect. There must be no compro- 
mise upon the subject; for, if the cure turn out badly, no allowance will be made by the 
patient and his friends for any deficiencies, shortcoming, or want of cooperation on their 
part. The whole blame falls upon the professional attendant, it being very properly 
assumed that la; ought to know better than any one else what the emergency demands, 
and lie should, therefore, spare no pains to meet it. Every fracture-bed should have slats, 
a good, firm but elastic mattress, and arrangements for the evacuation of the bowels, so 
that the patient may not be compelled to rise when he wishes to relieve himself. These 
essentials are all admirably combined in the ingenious and well-known contrivances of 
Dr. B. II. Coates, I)r. Addinell Hewson, Dr. E. Cutter, and others. 
When both thighs are broken, or even when only one is affected, Jenk’s fracture-bed, 
represented in fig. 558, will be found extremely convenient, both for evacuating the bowels 
and for making up the bed. It is thus described by Dr. Gibson:— 
CHAP. VIII. 
Fig. 558. 
Jenk’8 Fracture-bed. 
“It. is composed of two upright posts about six feet high,supported each by a pedestal; 
of two horizontal bars, at the top, somewhat longer than a common bedstead; of a windlass 
of the same length placed six inches below the upper bar; of a cog-wheel and handle; of 
linen belts, from six to twelve inches wide; of straps secured at one end of the windlass, 
and at the other having hooks attached to corresponding eyes in the linen belts; of a head- 
piece made of netting; of a piece of sheet-iron twelve inches long, and hollowed out to lit 
and surround the thigh ; of a bed-pan, box and cushion to support it, and of some other 
minor parts.” 
For the purpose of securing quietude of the limb, and accuracy of apposition of the 
ends of the fragments, numerous contrivances have been devised, all possessing, appa- 
rently, more or less merit, and yet not one of them being so perfect as to be wholly 
unexceptionable. A bare description and delineation of all the fracture apparatus now 
before the profession would form a stately volume. The surgical cabinets of some of our CHAP. VIII. 
FRACTURES OF THE FEMUR. 
1009 
medical schools contain cart-loads of such material, most of it as effete as the contents of 
a curiosity shop. Much of this apparatus has been patented, and extensively distributed 
by the inventors. The character of most of it is familiar to me, and I do not hesitate to 
declare that a large proportion of it is most villanous. The great and fundamental prin- 
ciples which every contrivance of the kind must necessarily possess are enjoyed by all, 
although in different degrees of perfection, and it cannot be doubted that the constant 
multiplication of such machinery, and the implicit confidence reposed in it by the younger 
members of the profession, are a prolific source of the many disastrous results which so 
frequently attend the treatment of fractures of the thigh. I have long been satisfied 
that the more simple the apparatus is, the more easily it is managed, and the more likely 
to prove efficient. With a proper knowledge of what is needed, and a little ingenuity on 
the part of the surgeon, the requisite means for the successful management of almost 
every case of fracture of the femur, however bad, may generally be provided either upon 
the spur of the occasion, or within a reasonable time after the occurrence of the injury. 
The plaster splint now coming into general use is one of the best of the many modern 
contrivances. 
The apparatus at one time so extensively employed in this country was that of Desault, 
as modified and improved by Phjsick, consisting of one long splint, fig. 559, extending from 
below the sole of the foot to the axilla, and of a short one extending from 
the same point to the perineum. They are connected below by a transverse 
bar, for receiving the extending bands, and along the leg and thigh by strips 
of bandage. The counterextension is effected by a suitable thigh belt, the 
ends of which are passed through the mortise holes near the upper end of 
the splint. The apparatus is, however, an awkward one, constantly subject 
to derangement, and the results obtained by its aid are by no means so 
gratifying as they should be. It has always been found extremely unsatis- 
factory in my practice, and I have, therefore, for many years, never employed 
it in a single case, having given the preference to the fracture-box, repre- 
sented in fig. 560. This box, which I used, for the first time, upwards of 
Fig. 559. 
Fig. 560. 
Fracture-box with Side Splints. 
forty years ago, extends from the tuberosity of the ischium to a level with the 
sole of the foot, which rests against the vertical piece, provided with two 
slit-like holes for the passage of the extending bands. The posterior surface 
of the box is hollowed out for the more easy accommodation of the thigh and 
leg, while the side pieces, fastened by hinges to the horizontal one, project 
so as to come to a level with the surface of the limb in front. To the out- 
side of the box is secured a movable splint, about two inches in width, crutch- 
shaped and well padded above, and long enough to reach into tlie axilla, 
while another similarly arranged and constructed, is attached to the inside, 
being intended to press against the perineum. The whole apparatus is made 
as light as possible, and any intervals that may exist between it and the 
limb, after it has been properly adjusted, may be filled with cotton, tow, 
or, wdmt is preferable, especially in compound fractures, wheat bran, the 
latter answering an admirable purpose, under such circumstances, not only 
affording an agreeable protection to the broken bone, but absorbing the dis- 
charges and preventing the development of maggots, which are so liable to 
form in such cases in hot weather. In changing the dressings, all that is 
necessary is to let down the sides of the box, the extension being, in the 
mean time, kept up, if necessary, by an assistant having hold of the foot. A broad leather 
splint, or one of binder’s board, extending from the groin to the knee, should cover the 
thigh in front; it should be accurately moulded to the parts, and be firmly secured in 
its place with pieces of tape encircling the box. 
Physick’s 
long Splint. 1010 
DISEASES AND INJURIES OF TIIE BONES. 
Instead of the fracture-box now described, use may be made of two splints, one of 
binder’s board and the other of wood, the former, which is intended for the inside of the 
thigh, reaching from the groin to the knee, while the other, placed along the outside of 
the limb, extends as high up, on the one hand, as the crest of the ilium, and, on the other, 
as low down as four inches below the level of the sole of the foot. These splints being 
well padded, are secured with an ordinary roller, the adhesive strips being attached to the 
inferior extremity of the long one, in order to keep up the requisite degree of extension. 
Adhesive plaster is now universally employed in this country, both for maintaining 
extension and counterextension in fractures of the thigh, and is unquestionably a great 
improvement upon the means heretofore in use, as it tends not only to preserve the ends 
of the fragments in better and closer union, but, what is of great moment to the patient, 
prevents the pain, chafing, and ulceration which so frequently attended the old methods. 
The treatment is equally serviceable in simple and in compound oblique fractures of the 
lower extremity. 
In a remarkable case of compound fracture of both thigh-bones, in a boy eleven years 
of age,' under the care of the late I)r. Gilbert, an excellent cure was effected by the appa- 
ratus represented in fig. 561, aided by adhesive plaster. 
A long splint was stretched along the outside of each 
limb, from a few inches below the sole of the foot to with- 
in a short distance of the axilla; the extending strips, 
tied under the sole of the foot, and secured to a horizontal 
block, were controlled by a tourniquet; while the counter- 
extending strips were carried along the pelvis, botli in 
front and behind, and firmly fastened by transverse bands 
I assed around the hip-bones, the back, and abdomen. The 
dressing was removed on the forty-fifth day. 
CUAP. VIII. 
Fig. 561. 
Fig. 562. 
Hodge’s Method of Counterextension in Fracture of the Femur. 
A valuable addition to the long splint, affording in- 
creased means for making counterextension, was suggested 
by the late Dr. Id. Lenox Ilodge. It consists, as will 
be seen by reference to fig. 562, of a bar of wrought iron, 
secured to the outer and upper part of the splint by bolts 
with movable nuts, and bent to the right or left, in accord- 
ance with the slide to which it is applied. The splint 
should be sutfieiently wide above to permit the rod, which 
terminates in a horizontal hook, about six inches in length, 
to pass clear of the patient’s arm and shoulder. A long 
strip of adhesive plaster, at least two inches and a half in breadth, is extended along the 
front of the body from the pelvis to the top of the shoulder, and thence down the back to 
the buttock, leaving, as it crosses the shoulder, a short loop, in which is placed a small 
block of wood, fastened by means of a tape to the hook of the bar. To prevent the long 
strip from becoming detached, the body is completely encircled, at different heights, by 
three horizontal bands. 
The advantages of this contrivance are that the extension and counterextension are 
made in a straight line, that the dressings maintain their place much longer than the 
ordinary ones, and, lastly, as the patient cannot sit up in bed, there is less danger of dis- 
Gilbert’s Fracture Apparatus. CHAP. VIII. 
FRACTURES OF THE FEMUR. 
placement of the ends of the broken bone. To impart efficiency to the apparatus a foot- 
board should be added. 
The anterior splint, as it is called, invented by the late Professor N. 11. Smith, often 
yields excellent results in the treatment of fractures of the thigh, especially in the more 
complicated ones. It consists, as seen in fig. 563, of a single piece, made of wire, of the 
Fig. 563. 
size of a No. 10 bougie, and bent at each extremity, the whole representing the form of a 
long parallelogram, three inches wide above, and two inches and three-quarters below. It 
must be long enough to reach from a point a little above the anterior spinous process of the 
ilium to an inch beyond the toes, when the thigh, leg, and foot are extended, three feet 
eight inches being a good average length for adults. The side-pieces are firmly connected 
by cross-pieces at a distance of about eight inches from each other. Thus constructed, the 
wire frame is easily bent to suit the case in hand. The angle at the tibio-tarsal joint, six 
inches from the extremity, is about 120°, to secure an easy posture for the foot; that at 
the knee and the one at the hip are each about 160°, the latter being seven inches from 
the upper extremity. 
The splint, properly padded or tightly wrapped with a muslin bandage, and secured to 
the limb by a roller extended from the toes upward, is suspended by means of a pulley, 
cord, and hooks to the ceiling, as represented in fig. 564, a compress being placed upon 
N. R. Smith’s Anterior Splint. 
Fig. 564. 
the instep and another upon the groin, to ward off pressure. The proper position of the 
hooks is a matter of great consequence. In general, the upper one should be attached 
nearly over the seat of the fracture, and the lower a little above the middle of the leg, 
the object being the thorough equalization of the pressure of the splint. The roller, con- 
fining the apparatus, should be well stitched to prevent it from slipping, or, what is better, 
wet, with a solution of silicate of sodium, and great care should be taken that it do not 
make undue constriction. This apparatus, which is exceedingly light and comfortable, is 
equally well adapted to fractures of the thigh and leg, in every portion of their extent. 
The late Professor IIodgen,of St. Louis, used with great success a wire suspension splint, 
the bars of which are traversed by cotton sacking for the more easy and equable sup- 
port of the limb. The apparatus, depicted in fig. 565, is particularly adapted to the treat- 
ment of compound fractures of the lower extremity. 
The mode of treating fractures of the thigh, originally suggested by Dr. Gurdon Buck, 
is now generally pursued in this country in most cases in which confinement in bed is 
necessary, and every surgeon of experience can bear testimony to its great excellence. 
N. R. Smith’s Apparatus applied to the Limb. 1012 
DISEASES AND INJURIES OF THE BONES. 
The long splints are entirely dispensed with, the extension being made by the action of a 
weight and pulley, and counterextension by the usual perineal strap lengthened out and 
fastened to the head of the bedstead. A strip of adhesive plaster, from two and a half 
to three inches in width, is stretched along each side of the limb, to a short distance above 
CHAP. VIII. 
Fig. 5(>5. 
Hodgen’s Suspension Apparatus. 
the knee, and confined with a roller extended from the toes up, the middle of it forming 
a loop below the sole of the foot. A thin block of wood, the width of the plaster, and 
long enough to prevent pressure over the ankle, is inserted into the loop, and thus serves 
to receive the extending cord, which is fastened to 
an elastic rubber band passing around the block, 
and playing either over the footboard of the bed- 
stead, or, if there is no footboard, over a tempo- 
rary frame, perforated at a height of about five 
inches above the level of the mattress, or, what is 
better, an adjustable clamp, holding in position 
the rod which supports the pulley, as seen in fig. 
566. The thigh, at the seat of fracture, is sur- 
rounded with short splints, the heel is supported 
upon a thin, wedged-shaped hair cushion, and a 
bag, filled with sand, is placed along the outside of 
the leg and foot to prevent rotation. The amount 
of weight employed must be determined by the 
age of the patient and the other circumstances 
of the case. A child under eight years of age will seldom require more than five or six 
pounds, while an adult may require from fifteen to twenty, the substance being shot, iron, 
or sand. The most suitable perineal band is a piece of India-rubber tubing of one inch 
caliber, two feet in length, with a ring at each end, stuffed with bran or cotton lampwick, 
and covered with canton flannel, wrapped spirally round it, and renewed whenever it 
becomes soiled. The apparatus of Dr. Buck is represented in fig. 567. 
The treatment of fractures of the thigh, introduced by Dr. Swinburne, recommends 
itself by its simplicity and efficiency. It consists, as will be seen by a reference to the 
annexed sketch, fig. 568, exclusively of extension and counterextension, without splints, 
the perineal and crural bands being secured to the bedstead, as in Dr. Buck’s apparatus, 
and composed of similar materials. Free use is made of adhesive strips at the leg and 
foot, and also, if necessary, at the thigh. With such an arrangement the affected limb 
may be inspected or measured as often as may be desired, all danger of embarrassing the 
circulation is done away with, perfect cleanliness may be preserved, and any topical appli- 
cations that may be required may be made and removed with the utmost facility. The 
advantages of this method are particularly conspicuous in complicated fractures of the 
thigh. Fractures of the femur and tibia treated in this manner leave very little, if any, 
shortening, except in the intracapsular form of the accident. 
Fig. 566. 
Levis’s Extending Apparatus with Pulley and 
Weights. FRACTURES OF THE FEMUR. 
1013 
CHAP. VIII. 
In addition to the contrivances here described and delineated for the treatment of frac- 
tures of the lower extremity, numerous others have been devised, some of which are suffi- 
Fig. 567. 
Buck’s Fracture Apparatus. 
ciently meritorious as to be worthy of special notice. Among these, two of the most 
valuable are those of l)r. Richard J. Levis and Dr. Thomas G. Morton. The subjoined 
drawings are so graphic as to render any description needless. Fig. 566 illustrates the 
apparatus of Levis. The pulley is secured by its shaft to the end of the bed, and receives 
Fig. 568. 
Swinburne’s Method of treating Fractures of the Thigh. 
the cord which is attached to the patient’s limb. The weight consists of a number of 
perforated pieces, and is secured to the extending cord by means of a hook. Morton’s 
apparatus, fig. 509, so extensively used at the Pennsylvania Hospital, is also very simple, 
Fig. 569. 
Morton’s Extending apparatus for Fracture of the Femur. 
and, like that of Levis, fulfils every indication for which such a contrivance can he em- 
ployed. 
Finally, counterextension may advantageously be made by elevating the foot of tie 1014 
DISEASES AND INJURIES OF THE BONES. 
bedstead, so as to allow the patient’s body to sink into the upper part of the bed, and thus, 
by its weight, draw the superior fragment away from the inferior. This mode of treat- 
ment, in which a perineal strap is rendered unnecessary, was extensively practised during 
our late war, and its efficiency is undeniable, as every experienced surgeon can testify from 
personal observation. 
Whatever apparatus be employed, whether those now described, or others of a similar 
character, there are several circumstances which should claim the special attention of the 
practitioner, particularly in the treatment of fractures of the shaft of the femur. The 
kind of bed to be used is described under the head of general treatment. 
1. The ends of the broken bone must be steadily maintained on a line with each other, 
any tendency to angularity, lateral distortion, or tilting up of the fragments being 
promptly counteracted by pressure opposite the point of projection. This disposition 
manifests itself, more or less, in nearly all fractures of the femur, and should never for a 
moment be lost sight of, otherwise it may not be discovered until it is too late to remedy 
it. It is particularly strong when the lesion is situated from two and a half to three 
inches below the small trochanter, in consequence of the action, on the one hand, of the 
iliac and psoas muscles, and, on the other, of the external rotators; the former, as before 
stated, tilting the lower end of the superior fragment forwards, and the latter outwards. 
For want of attention to this circumstance, wretched deformity of the limb is a frequent 
result of this injury. 
2. No shortening must be permitted, and, therefore, constant vigilance must be exer- 
cised in regard to the tightening of the extending and counterextending bands. If any 
doubt exists, a comparative estimate must be made from time to time of the length of the 
two limbs, by stretching a piece of tape from the centre of the umbilicus to the centre of 
the inner border of each patella, or from the anterior superior spinous process of the 
ilium to the internal malleolus, the body and limbs lying perfectly straight. 
3. A slightly everted position of the limb being the most natural when the body is 
dorsally recumbent, the surgeon should aim to maintain it in that way during the 
period necessary for the reunion of the ends of the broken bone. 
4. The heel must be seen to ; if neglected, it will be sure to inflame and ulcerate, if not 
slough. Too much care, therefore, cannot be taken to ward off pressure by filling up the 
hollow on each side of the tendo Achillis with cotton, or by employing, if necessary, a 
small air-bag, or a bladder partially filled with water. The foot should always be well, 
supported. 
5. Extension must be maintained with two broad strips of adhesive plaster, stretched 
along the sides of the leg, previously shaved, to three inches above the knee, secured by 
cross-pieces, and fastened to the foot-board of the splints or fracture-box. Or, instead of 
this, two long, broad strips of muslin are secured to the limb by means of a roller, the 
upper extremity of each being turned, loop-like, down upon itself, over the bandage, and 
then properly fastened. The gaiter and handkerchief should be discarded from practice, 
for reasons previously mentioned. 
6. The perineal band must receive due attention, otherwise it will be sure to gall and 
fret the parts, and thus greatly distress the patient. Besides, if not properly managed, it 
will be extremely liable to displace the upper fragment, by dragging it outwards, away 
from the inferior. 
7. In compound fractures, one of the splints may be bracketed, as originally recom- 
mended, in 1813, by I)r. Ilayes, of Indiana. The opening thus left permits ready access 
to the wound, and, consequently, great convenience for the application of the necessary 
dressing. The annexed cut, fig. 570, 
affords an illustration of an excellent 
apparatus of this kind, devised by 
Dr. John II. Packard, of this city. 
8. Great objection has been urged 
by certain writers against the employ- 
ment of the bandage in the treatment 
of fractures of the thigh, on the ground 
that it is not only inconvenient, but 
absolutely useless. My experience 
does not corroborate this statement. 
On the contrary, I have always de- 
rived the most marked advantage from the bandage, both in controlling spasm, in counter- 
acting the tendency to shortening, so common in nearly all cases of this kind, and in 
CHAP. VIII. 
Fig. 570. 
Packard’s Fracture Apparatus. CHAP. VIII. 
FRACTURES OF THE FEMUR. 
1015 
promoting the absorption of inflammatory deposits. To answer the purpose, however, it 
must be applied with great care; otherwise harm, not benefit, will result. 
In simple fractures of the thigh, the ordinary roller is sufficient; but in compound, 
preference is given to the bandage of Scultetus, inasmuch as, being composed of separate 
strips, it admits of more easy removal and reapplication. 
The water-glass, starch, gum, or plaster bandage, may often be employed with great 
advantage, giving adequate support to the broken limb, and enabling the patient to take 
exercise in the open air, or about the house, upon crutches, a matter frequently of great 
importance. My experience, however, is averse to its use in the early stage of the treat- 
ment; applied too soon after the accident, before there is complete or nearly complete 
subsidence of inflammation and swelling, it may do incalculable harm, not only mate- 
rially aggravating the local trouble, but endangering the safety of the limb by the induc- 
tion of gangrene. For these reasons I seldom employ it before the end of a fortnight. 
In hospital practice, where the patient is under the constant surveillance of the profes- 
sional attendant, the permanent dressing may generally be employed much sooner. 
9. The bedclothes must be kept off the fractured limb, as their weight would not 
only be oppressive, but tend to derange the ends of the fragments. A good and ready 
mode of accomplishing this is to cut a stout barrel-hoop through at the middle, and to 
place the two halves, tied firmly together, crosswise, over the injured extremity. Or, 
instead of this contrivance, the surgeon may use, what is much better, the frame depicted 
at page 912. 
10. It is very important, in the treatment of fractures of the lower extremity requiring 
extension and counterextension, that the patient’s head and shoulders should not be 
raised high ; a small pillow is generally quite sufficient, and, in some cases, even this may 
very properly be dispensed with. 
11. Mr. Pott conceived the idea that the best mode of treating fractures of the femur 
was to place the affected limb upon its outside, the body inclining in the same direction, 
and the knee being in a semiflexed state. The leg and foot, supported upon smooth pil- 
lows, were elevated somewhat above the level of the thigh, which was enveloped by a 
many-tailed bandage, and covered in by two broad, carved wooden splints. This plan, 
which Mr. Pott recommended with all the enthusiasm of a man of genius, was based 
upon the erroneous notion that it would completely relax the different sets of muscles 
connected with the broken bone, thus preventing them from acting injuriously upon its 
fragments ; forgetting that, in proportion as he took off the tension from one class, he 
necessarily increased that of another. It has been found to be altogther impossible to 
carry out this plan successfully in practice, experience having shown that the patient is 
utterly unable to remain so long in one position without suffering greatly from bed-sores, 
and that the apparatus, with all the care that can be taken to keep it in its place, is wholly 
inadequate to answer the purpose of an accurate adjuster. 
12. Another mode of treating fractures of the body of the femur, very different from 
any hitherto described, was formerly much in vogue both in England and in this country, 
chiefly in consequence of the influence of the late Sir Charles Bell, by whom it was ex- 
tensively employed for a long time at the Middlesex Hospital, London. It consists in 
placing the limb upon two grooved cushions, resting upon two pieces of board, united by 
hinges in the form of a double inclined plane, as seen in fig. 571, and long enough to 
Fig. 571. 
Double Inclined Plane of Sir Charles Bell. 
extend from the tuberosity of the ischium to the back part of the heel. A roller having 
previously been applied from the toes to the groin, two light but firm binder’s board 
splints, carefully softened in hot water, are secured to the outer and inner parts of the 
thigh, meeting nearly in front and reaching from the groin to the knee. The extremity is now laid over the inelined plane, in an easy, comfortable position, the angle of flexion 
having special reference to this point; the foot is attached to the foot-board, and the limb 
and plane being tied firmly together by tapes, or, what is better, by a bandage, the dress- 
ing is completed. 
The method of treatment by the double inclined plane ought not to be too lightly con- 
demned, for it cannot be denied that very excellent cures are occasionally effected with 
it. Much less frequently employed now than formerly, it is more particularly applicable 
to the treatment of fractures of the condyles of the femur and of the upper extremity of 
this bone, attended with a constant disposition to displacement of the lower end of the 
superior fragment. In transverse fractures immediately above the knee-joint, and in 
separation of the inferior epiphysis of the femur, the gastrocnemial muscles drag the lower 
fragment backwards into the popliteal space; an effect which can only be counteracted 
by the flexed position of the limb, the leg, in the more troublesome cases, being bent 
almost at a right angle with the thigh. 
The double inclined plane may also 
be advantageously employed in com- 
pound fractures, attended with severe 
contusion and laceration of the integ- 
ument, where confinement in the ex- 
tended position would be productive 
of violent pain and great discomfort. 
The extension is made mainly by the 
weight of the leg and foot, while the 
counterextension is made by the 
pressure of the apparatus against the 
tuberosity of the ischium. The annexed drawing, fig. o72, represents McIntyre’s splint, 
a double inclined plane, modified by Liston. Fig. o73 exhibits it as it is applied to the 
limb. 
DISEASES AND INJURIES OF THE BONES. 
CHAP. VIII. 
Fig. 572. 
McIntyre’s Splint, simplified and improved by Liston. 
Fig. 573. 
McIntyre’s Splint applied to the Limb. 
Finally, when both thighs are broken, the case may be treated with a double inclined 
plane, or a fracture-bed, the hinges being arranged in such a manner as to permit the 
trunk to be raised or lowered at pleasure, without causing any motion of the hips. The 
limbs should be well protected with side and front splints, and immovably tied together. 
13. The period required for the consolidation of fractures of the shaft of the femur 
must necessarily be greatly influenced by circumstances, as the age and health of the 
patient, and the care with which the ends of the fragments are kept together. In chil- 
dren from five to fifteen years, complete union may usually be looked for in from twenty- 
four to twenty-eight days. In eighteen eases analyzed by Dr. A. L. Peirson, of Massa- 
chusetts, the cure, in persons of thirty years of age and under, occupied 35.88 days ; 
while in seventeen, where the age was upwards of thirty, the average period was 36.G4 
days ; thus showing only a very trifling difference in the two series. On no account 
should any weight he thrown on the affected limb under ten or twelve weeks. From a 
want of this precaution great shortening often results, especially in those cases in which 
the new osseous matter is slow in acquiring its proper density and firmness. 
It has been asserted by many highly respectable practitioners that it is always ex- 
tremely difficult, if not impossible, to effect a cure in fractures of the shaft of the thigh- 
bone without some degree of shortening, and my conviction is that this conclusion is 
only too well founded. There can be no question at all that in many cases a certain 
degree of shortening is absolutely and positively unavoidable, not on account of any defect 
in the treatment, but from the very nature of the fracture itself. How is it possible it FRACTURES OF THE FEMUR. 
1017 
CHAP. VIII. 
should be otherwise, when the ends of the fragments are driven the one into the other? 
The best skill and the most devoted attention would utterly fail, under such circumstances, 
to make a good limb. So, also, when a fracture is compound or comminuted, more or 
less deformity and shortening will almost be inevitable. In the New York Hospital, 
where fractures of the shaft of the thigh-bone are very common, and where this accident 
is probably treated with as much adroitness and care as anywhere in the world, from a 
third to half an inch of shortening is generally looked for, as a natural consequence, by 
the surgeons of that Institution, and it is questionable whether the statistics of similar 
establishments, if ascertainable, would exhibit a more favorable result. 
In 149 cases of fractures of the thigh, reported by Dr. Buck, as having been treated 
according to the method which bears his name, the average shortening in patients under 
fifteen years of age was | of an inch, and § in those over fifteen years. In some of the 
cases there was no shortening whatever. 
Professor Hamilton finds, as the result of his investigations, that the average shortening 
in simple fractures of the upper third of the femur is about four-fifths of an inch, and of 
the remainder of the bone, stated in round terms, three-quarters of an inch. He adds 
that, in oblique fractures of the shaft of the femur, in which the muscles retain their con- 
tractile power, no apparatus that has yet been devised can entirely prevent shortening; 
and the same, he remarks, is true of transverse, oblique, and denticulated fractures, in 
which the ends of the fragments have become completely deranged, owing to the impossi- 
bility of placing them in such relations as that they will rest upon and support each other 
during the time necessary for reunion. He further states that in children, and in persons 
under eighteen years of age, the cure is frequently so perfect as to render it impossible to 
discover any material shortening by measurement of the limb. 
2. FRACTURES OF THE INFERIOR EXTREMITY. 
Fracture of the condyles of the femur is, in comparison with fracture of the condyles 
of the humerus, an extremely infrequent occurrence. Indeed, it is very uncommon, not 
only relatively, but absolutely, speaking. Sir Astley Cooper mentions only two instances 
of the kind in his work on Dislocations and Fractures; the Dupuytren Museum at Paris, 
so rich in osteological preparations, contains but five specimens of the lesion; and in the 
Miitter collection, not a single bone, illustrative of the occurrence, is to be seen. The 
cabinet of Professor William Gibson, now in the Government collection at Washington 
City, has, however, several beautiful specimens of fracture of the condyles; and among 
my own preparations is a very rare one, in which these eminences are broken off vertically, 
leaving the trochlea attached to the low'er end of the shaft, which exhibits a remarkably 
comminuted appearance, consisting of not less than five distinct fragments. 
The fracture may be limited to one of the condyles, which, however, is extremely rare, 
or it may implicate both, the fissure in the latter case extending between the two promi- 
nences, and terminating above in an oblique fracture of the shaft, 
so as to give rise to three distinct fragments. From the amount 
of force required to produce this fracture, it is generally attended 
with a great deal of injury to the soft parts, and, for the same 
reason it is not unfrequently of a compound and comminuted 
character, the ends of the fragments protruding either externally 
or projecting into the cavity of the knee-joint. A partial fracture 
of one of the condyles occasionally occurs. In rare cases, the 
fracture presents the character of impaction, the lower end of 
the shaft being forcibly impelled into the cancellous structure of 
the condyles, which are completely severed in their entire length. 
Fig. 574 conveys an excellent idea of a fracture of the external 
condyle from a drawing of Sir Astley Cooper. 
Whatever form the fracture may assume, it is nearly always 
the result of direct violence ; generally of a fall upon the knee, 
the passage of the wheel of a carriage, or the kick of a horse. 
In one of three cases that have been under my observation, 
it was occasioned by a fall from a high scaffold, the individual, 
a man upwards of fifty years of age, alighting upon his feet, but 
striking, before he could recover himself, his knee against a large 
stone. The subjects of these fractures are usually old persons, in 
whom the condyles of the femur have become atrophied and brittle 
from the effects of interstitial absorption and fatty degeneration. 
Fig. f>74. 
Fracture of the External 
Condyle. 1018 
DISEASES AND INJURIES OF THE BONES. 
The symptoms of fracture of the condyles'are not always well characterized, owing to 
the fact that the fragments are generally held in place by the ligaments of the knee, thus 
preventing marked deformity, and rendering the production of crepitation difficult. The 
joint appears to be wider and flatter in front than usual, and, if the patella be pressed 
backwards, the condyles may be considerably separated, so as to increase the transverse 
diameter of the limb. The joint is much swollen and bruised, the member is completely 
powerless, and, when the fracture affects both prominences, there is nearly always marked 
shortening, often amounting to from one*to two inches, the lower fragment being drawn up 
behind the superior by the action of the hamstring muscles. When only one condyle is 
broken, the deformity, other things being equal, will be less than when both suffer, and 
there will also, of course, be less shortening. Blood, often in considerable quantity, is 
generally poured into the joint in injuries of this kind, and more or less synovitis is an 
inevitable consequence. 
In the specimen of vertical fracture of the condyles in my cabinet, previously alluded 
to, the short fragment is drawn upwards against the posterior surface of the shaft of the 
femur, to a distance of at least two inches, its upper surface looking towards the trochlea, 
with which it forms an obtuse angle, thus greatly increasing the antero-posterior diameter 
of the joint. The various appearances of this rare specimen are well represented in 
fig. 575. 
CHAP, v 11 r. 
Fig. 575. 
Comminuted Fracture of the Lower Extremity of the Femur. 
Fracture of both condyles occasionally simulates partial luxation of the head of the 
tibia backwards; and, when this is the case, the only way to determine the diagnosis is 
to take hold of the condyles, and to press them in opposite directions, which cannot he 
done when there is no fracture. The same proceeding can hardly fail to elicit crepitation, 
although this may he rather slight, especially if the fragments are held firmly together by 
the ligaments. 
The prognosis of this fracture is especially grave, on account both of the injury done to 
the soft parts, and of its connection with the joint, which may he involved in an alarming 
degree. The fracture may, as already stated, be compound or comminuted, and, in such 
an event, the danger will, of course, he greatly increased, perhaps to such an extent as to 
require amputation, or, when this is not deemed advisable, in such a manner as to jeopard 
life by mortification, pyemia, erysipelas, or congestive pneumonia. 
The treatment, in the first instance, must usually he strictly antiphlogistic, leeches and 
evaporating lotions being necessary, on account of the injury done to the soft parts. The 
limb, enveloped in a bandage, is laid in an easy position, being extended, if the fracture 
be transverse, or nearly so, and placed over a double inclined plane, if it be very oblique, 
with a strong tendency to displacement of the broken ends. Spasm, so common after 
such accidents, is allayed by anodynes, and an effort is made to prevent erysipelas and other 
bad consequences. When the tendency to displacement is uncontrollable by ordinary 
means, the best plan is to divide the tendo Achillis in order to counteract the action of 
the gastrocnemius muscle. Passive motion is instituted at the expiration of five or six 
weeks, but, despite the attention of the surgeon, a good, unexceptionable cure will be ex- 
tremely difficult, if not impossible, especially when both condyles are implicated. 
Complicated fracture* of the condyles are generally the result of direct violence, as the 
passage of the wheel of a carriage, a fall from a great height, or gunshot injury, and are 
among the most dangerous of accidents, bringing life in jeopardy by tetanus, erysipelas, 
pyemia, profuse suppuration, and hectic irritation. The danger is proportionately increased 
when the lesion is attended with an extensive wound of the knee-joint, or a comminuted 1019 
CHAP. VIII. 
condition of the bone. An attempt may be made to preserve the limb when the patient 
is young and in good health at the time of the fracture, when the weather is not too hot 
and exhausting, and when the injury in the soft parts is comparatively slight; under 
opposite circumstances the best plan, as a rule, will be to amputate immediately after the 
occurrence of reaction. To hesitate, in such a case, would only be to trifle with the 
patient’s life, which could hardly fail to be the forfeit of the surgeon’s timidity. 
Examples of diastasis of the inferior epiphysis of the femur are occasionally met 
with. In a case observed by Coural, the accident happened in the act of falling forward 
at a moment when the leg was buried up to the knee in a hole. 
The shaft of the femur was driven behind the condyles into 
the popliteal space, and there was such an amount of injury 
as to necessitate amputation of the limb. The patient was a 
boy, eleven years of age. Little, Voss, and Buck have re- 
ported similar instances. I have met with this accident not 
less than four times in attempts at breaking up the adhesions 
in ankylosed knees, and have never found any difficulty in 
effecting good and prompt cures by putting up the limb at 
once in appropriate apparatus. In most of the cases hitherto 
reported the accident was the result of such severe violence 
as to necessitate amputation. The injury has generally been 
of the nature of compound fracture, attended with extensive 
laceration of the soft parts. In one case the anterior tibial 
artery was torn open, and in another, related by Dr. Willis S. 
Davison, of Pennsylvania, the popliteal vessels were ruptured : 
in a few instances the knee-joint wras exposed. In all such 
cases the prognosis must needs be unfavorable. When the 
injury is uncommonly severe, or the condyles are commin- 
uted, great deformity may result, or shortening of the limb 
may take place from an arrest of development of the femur. 
The epiphyseal fracture is well illustrated in fig. 57G, from 
Holmes. Such occurrences are, for obvious reasons, peculiar 
to young subjects before the twentieth year. Madame Lach- 
apelle saw a case of diastasis of the inferior epiphysis of the thigh-bone from traction on 
the child’s foot during parturition. The lesion was conjoined with a separation of the 
upper epiphysis of the tibia. 
3. FRACTURES OF THE SUPERIOR EXTREMITY OF TIIE FEMUR. 
The superior extremity of the femur comprises the head and neck of that bone, 
together with the two trochanters, so that in an individual of ordinary stature it is from 
three inches and a quarter to three inches and a half in length, there being, however, no 
distinct boundary line between it and the shaft. The head composes nearly two-thirds 
of a sphere, and rests upon the neck, which is inclined obliquely upwards and inwards, so 
as to form an obtuse angle with it; they are surrounded by the capsular ligament, the 
strongest membrane of the kind in the body, and consist of a large amount of spongy 
tissue, inclosed by a thin lamella of compact substance. Both these structures undergo 
important changes with advancing age, the former becoming greatly rarefied, light, and 
porous, while the latter is so attenuated as to be, in some places, hardly as thick as 
common letter paper. These changes, the necessary effect of which is to render the 
bony texture frail and brittle, are particularly conspicuous after the fiftieth year, and 
readily explain the frequency of fracture of the neck of the femur at and after this 
period of life. There is another circumstance, also, which, doubtless, materially con- 
tributes to this accident, namely, the alteration which this portion of the femur under- 
goes in its direction in old persons, causing it, in many cases, to stand off almost at 
a right angle with the shaft of the bone, or even to sink slightly below this level. 
This alteration in the obliquity of the bone is, generally, more common, as well as 
more marked, in women than in men, and hence it is that the former are always more 
liable to this fracture than the latter. These various appearances are well illustrated in 
the adjoining sketches, fig. 577 representing the ordinary normal shape of the head and 
neck, together with its spongy and compact structures, while fig. 578, from a preparation 
in my collection, affords a good idea of the changes which these parts experience in con- 
sequence of the effects of age. 
FRACTURES OF THE FEMUR. 
Fig. 576. 
Separation of the lower Epiphy- 
sis of tho Femur combined 
with Fracture. 1020 
DISEASES ANI) INJURIES OF THE BONES. 
CHAP. VIII. 
The ligaments of the hip-joint always sustain very grave injury in fracture of the 
superior extremity of the femur. When the lesion occurs within the articulation, the 
capsule is always torn across, the rent being frequently so large as to permit the escape 
of the upper extremity of the lower fragment, either at the moment of the accident, or 
Fig. 577. 
Fig. 578. 
Natural Appearances of the Head and Neck of the Femur. 
Alterations of the Head and Neck of the Femur from 
the Effects of Old Age. 
soon after, thus accounting for the great shortening which is so often witnessed. The 
upper fragment, representing the head and a portion of the neck of the bone, on the con- 
trary, remains attached to the round ligament, which thus supports and nourishes it, its 
supply of blood and nervous fluid being cut off in every other direction. This circum- 
stance alone is sufficient to account for the fact that such a fracture cannot unite by osse- 
ous matter; but there are two other causes which powerfully contribute to such a result, 
the imperfect development of periosteum, and the large quantity of synovial fluid which 
is always poured out in the intracapsular fracture, the former disqualifying the fragments 
for the formation of callus, and the latter opposing their union. 
Fractures of the neck of the femur are divisible into two classes, those which occur 
within the capsular ligament, and those which take place exterior to it ; the former 
being now usually termed intracapsular, the latter extracapsular. The distinction is 
one of great pathological as well as practical importance, and is, therefore, worthy of 
profound consideration. 
INTRACAPSULAR FRACTURES. 
Fracture of the neck of the femur within the capsular ligament may occur at any 
portion of this part of the bone, as exhibited in the accompanying figs. 579, 580, and 
581 ; but, in general, it is met with at a short distance below the head, or between the 
head and centre of the neck, where the compact structure is unusually weak, and where, 
consequently, the slightest force frequently produces the accident. Sometimes the line of 
fracture is on a level with the globular head, which, therefore, alone constitutes the upper 
fragment; and, on the other hand, cases are observed where the bone yields just above 
the attachment of the capsular ligament. Finally, the fracture is sometimes, although 
very rarely, partly within and partly without the ligament, forming an interesting variety, 
especially in reference to the question of the process of consolidation. 
The direction of the fracture is usually more or less oblique; a strictly transverse 
fracture is a very uncommon occurrence ; in rare cases, the bone is comminuted, as in a 
specimen in my private collection ; and, now and then, the fracture is impacted, the upper 
extremity of the lower fragment being thrust into the cancellous structure of the superior. 
The head of the bone occasionally suffers along with the neck. The ends of the fragments 
are generally very sharp pointed, or spiculated. 1021 
CHAP. VIII. 
INTRACAPSULAR FRACTURES OF THE FEMUR. 
An incomplete variety of intracapsular fracture is sometimes, although seldom, met 
with, a portion of the compact structure retaining its integrity, while the remainder 
yields under the force of the exciting cause of the accident. Again, instances occur in 
which, the fracture being complete, the ends of the fragments are temporarily retained 
Fig. 579. 
Fig. 580. 
Illustrations of Intracapsular Fractures. 
in apposition by the periosteum, thickened, perhaps, by inflammatory or aital changes. 
A well marked example of an incomplete intracapsular fracture has been reported by Dr. 
J. 11. S. Jackson, of Boston, as having happened in a man forty-two years of age, in con- 
sequence of a fall through two stories of a building upon a hard floor, breaking his spine 
and femur at several points. The fracture of the neck, commencing at its junction with 
the head, reached, as seen in fig. 582, nearly in a perpendicular direction, to within 
about a quarter of an inch of the inferior and internal wall of the bone, the fissure being 
so extensive that, if the man had been able to walk, the unbroken part could probably not 
have supported the weight of his body. 
Fig. 581. 
Fig. 582. 
The cause of intracapsular fracture is generally some trivial accident; most commonly 
a fall upon the great trochanter, or a blow upon the hip when the thigh is fixed and 
separated from its fellow, thus increasing the strain upon the upper portion of the bone. 
I have known the injury to be produced by the great toe catching in the fold of the 
carpet, while the person, an old lady of seventy-six, was walking across the floor. In 
London, according to Sir Astley Cooper, it most frequently occurs trom the foot suddenly 
Intracapsular Fracture of the Femur. 
Vertical Fracture of the Neck of the Femur. 1022 
DISEASES AND INJURIES OF THE BONES. 
CIJAP. VIII. 
slipping off the edge of the side-walk over the curbstone, upon the horse pavement, the 
weight of the body being thus thrown forcibly upon the neck of the bone in a perpendic- 
ular direction, when it is unprepared for such an event. The fracture may also happen 
in turning awkwardly in bed, or in stepping carelessly out of bed upon the floor, the indi- 
vidual in either case powerfully twisting the thigh-bone. The fact that so serious a lesion 
may arise from so trivial a cause, while it is of great value in a diagnostic point of view, 
affords the clearest possible proof that a bone, liable to be so affected, cannot be very 
sound, but that, on the contrary, its structure must have undergone serious changes to 
render it capable of an accident which, in other pieces of the skeleton, requires an extraor- 
dinary degree of force. That this is true, as a principle, has already been shown, the 
immediate cause being a fatty, atrophied, and rarefied state of the compact and spongy 
tissues of the neck of the bone, the animal matter being absorbed, and the earthy alone 
left, the result of the whole being a weakened condition of the affected parts, and, conse- 
quently, a predisposition to fracture. Although the lesion is usually occasioned by slight 
accidents, instances are observed in which the reverse is the case, and it is then ordinarily 
also of a complicated character. 
The age at which this variety of fracture occurs is, diagnostically considered, a matter 
of great importance. A fracture in other bones, or parts of a bone, may take place at any 
period of life, even in infancy and early childhood. Thus, I have seen the shaft of the 
femur itself broken in an infant of four weeks. Hut it is very different with the neck of 
this bone within the capsular ligament, experience having shown that it is subject to 
fracture only, as a rule, after the age of fifty, when, as already stated, its spongy and com- 
pact tissues suffer from atrophy and fatty degeneration, thus rendering it more or less 
brittle, and incapable of withstanding injury. The youngest subject in whom I have 
witnessed this fracture was a lady thirty-four years of age, the injury having been caused 
by a fall upon the hip; Mr. Stanley observed an instance at nineteen; Dr. William Hunt 
one at twenty-five; Bryant at twelve; and Dr. II. Wardner, of Illinois, one at fourteen. 
All such cases are, however, exceptional. The oldest subject in whom I have met with 
this fracture was a lady of ninety-four. The accident happened in a fall from her chair 
upon the floor, her general health being much impaired at the time. In Hunt’s case the 
patient died from the effects of other injuries, and the dissection revealed the existence of 
a transverse fracture in the cervix immediately above the attachment of the capsular 
ligament. The accident took place in a railway train. 
Sex also exerts a considerable influence upon the production of intracapsular fracture. 
Of its precise relative frequency in males and females, no reliable statistics, at least none 
upon a large scale, have been placed before the profession, although a sufficient amount of 
information has been obtained to justify the assertion that it is more common in the latter 
than in the former. In the tables of Mr. R. W. Smith, in his Treatise on Fractures, the 
sex is given in 28 cases, of which 17 were women and 11 were men. The cause of this 
difference appears to be twofold, the more horizontal position of the neck of the femur and 
the greater amount of atrophy and fatty degeneration of this portion of the bone in old fe- 
males than in old males. 
The intracapsular fracture may be complicated with fracture of the neck on the outside 
of the capsular ligament, the lines of disjunction running into each other. Such an occur- 
rence, indeed, is not infrequent. Again, an intracapsular fracture may be associated with 
a fracture of the great trochanter; but this is extremely rare. In twenty-three specimens 
of this lesion in the Dupuytren Museum, at Paris, there is not a solitary example of such 
a coincidence. 
The symptoms of intracapsular fracture are deserving of particular attention. They are: 
1. Shortening of the thigh. 2. Eversion of the foot. 3. Preternatural mobility. 4. 
Crepitation. 5. Change of situation in the great trochanter. G. Pain at the site of 
injury. 7. Peculiarity of the patient’s body in the erect posture. 
The shortening of the thigh, or of the limb through the thigh, is one of the most strik- 
ing phenomena of this variety of fracture, and is the more valuable because of its almost 
universal occurrence. It is usually the first circumstance that attracts the attention of the 
surgeon, whether the patient is lying on his back or standing up. As might be expected, 
it varies in different cases and in different conditions of the same patient, its extent being 
greatly influenced by the state of the capsular ligament, being generally less in proportion 
to the integrity of this membrane, and conversely. It is always less immediately after 
the occurrence of the injury than it is after the lapse of several days, and also in impacted 
fracture than in the ordinary form of the accident. The amount of instantaneous shorten- INTRACAPSULAR FRACTURES OF THE FEMUR. 
1023 
CHAP. VIII. 
ing ranges from half an inch to an incli ; it may, however, be considerably less than this, 
not, perhaps, exceeding three lines; and, on the other hand, it may reach an inch and a 
quarter, and even an inch and a half, especially if there be extensive laceration of the 
capsular ligament. During the progress of the case, the shortening not unfrequently 
amounts to upwards of two inches, and in rare instances it has been known to exceed 
even three. 
The diminution in the length of the limb, although generally immediate, is not always 
so, depending, perhaps, not so much, as has usually been supposed, upon the integrity of 
the capsular ligament, as upon the want of separation of the ends of the fragments, due 
to their peculiar denticulated condition, the incompleteness of the fracture, or the thick- 
ened and untorn condition of tlie periosteum, all tending to favor temporary contact of 
their surfaces. It is hardly reasonable to imagine that, if the integrity of the capsular 
ligament were the only cause of it, this ligament would become so stretched or torn within 
so short a time after the accident as to admit of the amount of shortening above men- 
tioned. We must, therefore, seek for some other cause, and I know of none that is so 
plausible as the one here suggested. Under such circumstances, the shortening generally 
takes place suddenly ; perhaps after the patient has made considerable exertion with his 
limb, several days, it may be, after the accident, from the instantaneous unlocking of the 
ends of the fragments. When the fracture is impacted, the shortening will, of course, be 
immediate, and will also be likely to be permanent, unless the broken pieces be pulled 
forcibly asunder by the surgeon in the examination of the limb, or by the patient in his 
efforts at walking, sitting, or turning in bed. 
Erersion of the foot, or rather, of the whole limb, is another striking symptom, seldom 
absent in any case. When the patient stands up, it is such as to cause the heel of the 
affected side to point towards the hollow between the ankle and tendo Achillis of the 
sound limb; while, when lie is recumbent, the foot inclines outwards almost horizontally, 
dropping involuntarily upon its external surface, nearly or quite in contact with the floor 
or bed. The eversion, although generally an immediate effect of the accident, does not 
always reach its maximum until some time after, depending upon the manner in which 
the ends of the fragments are held together. 
The cause of the eversion is generally supposed to be the action of the external rotator 
muscles, which, as they are connected with the superior extremity of the bone, readily 
roll the thigh outwards when, from any circumstance, it has lost its support above, the 
irritation consequent upon the fracture being an additional incentive to contraction. My 
own opinion, however, is that, although the external rotator muscles may not be wholly in- 
operative in the production of this occurrence, it is generally due, in a very great degree, 
if, indeed, not wholly, to the weight of the limb, the natural tendency of which is to 
eversion whenever it is free from restraint as the patient lies on his back. In the im- 
pacted fracture, this symptom may be entirely absent, or. in other words, the limb, 
instead of being turned out, may be inverted; and a similar occurrence is occasionally, 
although rarely, noticed in an intracapsular fracture, due, apparently, to the action of the 
adductor muscles of the thigh, aided, perhaps, by a rent in the inner portion of the cap- 
sular ligament; or, if we adopt the explanation of the late Mr. II. W. Smith, of Dublin, 
to the manner in which, in such an event, the lower fragment is drawn up in front of the 
upper. Examples of this occurrence have been recorded by Guthrie, Langstaff, Stanley, 
Cruveilhier, Hamilton, Hudson, Bigelow, and others. A few cases have also been met 
with in which the foot pointed directly forwards, the limb being neither everted nor 
inverted. Finally, it is possible, as Mr. Erichsen has stated, that cases may arise in 
which the inversion of the limb in an ordinary fracture may be due to paralysis of the 
muscles on its outer side. 
Preternatural mobility, common to all fractures, is particularly observable in the intra- 
capsular variety, and, therefore, serves as an important diagnostic sign of the accident. 
There are cases, however, in which it is absent; in some entirely, as in the impacted 
fracture, and in others only in the early stage of the injury, as when the ends of the bone 
are held partially together by the interlocking of their fibres, by the incompleteness of the 
solution of continuity, or by some other cause. Its existence, as well as its degree, is 
always readily ascertained by taking hold of the limb and rotating it upon its axis, or 
flexing it upon the pelvis, extending it behind the line of the sound limb, or carrying it 
inwards or outwards; movements which cannot be executed when there is a dislocation 
of the head of the femur. Extension and counterextension will have the effect of restor- 
ing the limb promptly to its proper length, but as soon as the forces are discontinued the 
original shortening is reproduced. 1024 
DISEASES AND INJURIES OF THE BONES. 
Crepitation, the most valuable sijxn of all in fractures generally, is rarely wanting in 
this. Indeed, it can only be absent in the impacted form of the lesion, or in those rare 
eases where the ends of the fragments remain still partially in apposition with each other. 
It is usually discoverable immediately after the accident, and may, of course, be elicited 
as long as the fracture continues ununited. In order to determine its existence, it is 
necessary to bring the ends of the broken bone fully into contact by extension and counter- 
extension, when, upon rotating the limb, it will at once declare itself, although in many 
eases it is very faint. 
Change of position in the great trochanter is always a symptom of much importance in 
intracapsular fracture. This bony prominence is not only drawn upwards towards the 
ilium, but it is brought in close contact with the border of the acetabulum, and is, there- 
fore, much less easily felt and seen than in the normal state, in which it is always so con- 
spicuous. Moreover, when the thigh is rotated upon its axis by taking hold of the foot, 
the great trochanter will be found to turn, as it were, upon a pivot, or to move in a seg- 
ment of a lesser circle than natural. From the circumstance of the limb being generally 
strongly everted, the portion of the broken neck attached to the trochanter is directed 
inwards and upwards, and is thus placed in closer proximity with the anterior superior 
spinous process of the ilium than the trochanter itself. 
Another sign upon which much stress is laid is the condition of the fascia lata. In the 
natural state this fascia is in a state of tension ; but in fracture of the neck of the thigh- 
bone it is, as was first pointed out by Dr. Allis, invariably more or less relaxed between 
the great trochanter and the crest of the ilium. 
To determine the existence and the amount of shortening in fractures of the neck of 
the thigh-bone, Mr. Bryant’s test-line, as it is termed, will be found to be of great value. 
“ For purposes of demonstration,” says the 
English surgeon, “ I have described it as 
the base of the ilio-femoral triangle, c b, 
fig. 583, the two sides of the triangle being 
made up of two lines drawn from the an- 
terior superior spinous process of the ilium, 
one of them, a c, being vertical, and tra- 
versing the outside of the hip to the hori- 
zontal plane of the body ; and the second, 
a by impinging on the tip of the trochan- 
ter major and corresponding in the normal 
condition of the hip-joint to the anterior 
half of Nelaton’s test-line for dislocation 
of the head of the femur backwards. 
“ The ‘ test line’ c b for fracture or shortening of the neck, joins the two at right angles 
to the vertical line, and extends from it to the trochanter. 
“Any shortening of this line, on comparing it with the same taken on the uninjured 
side, indicates with precision a shortening of the neck of the thigh-bone; and, when the 
shortening has followed at once upon an injury, fracture of the neck of the thigh-bone, 
impacted or otherwise, is certain. Compared with this line, all other measurements are 
uncertain. By its use, manipulations of the injured limb are often rendered unnecessary. 
For practical purposes, the vertical line a c and the test line c b are alone required. To 
compare the two sides of the body, it is necessary to see that the pelvis is straight.” 
Pain at the site of injury, being common to all fractures, is of special value only in 
connection with the other symptoms already described. It derives its chief importance 
from the fact that it is located at the upper and inner part of the thigh, in the direction 
of the. small trochanter, and that it is always greatly increased whenever an attempt is 
made to rotate the limb, to bend it upon the pelvis, or to carry it inwards over the sound 
one. When the patient is perfectly quiet, with the limb in a relaxed position, the suffer- 
ing is usually very trivial, except when the bone, in addition to the fracture, has been 
severely concussed or contused, when the pain will frequently be excessive. It is gene- 
rally worse, too, at night than in the day, and in wet weather than in dry. 
There is a peculiarity in the patient’s attitude as he stands up, which cannot fail to 
strike the most careless observer. The body, in this position, is inclined forwards in such 
a manner as to throw its weight upon the sound limb, which is firmly planted upon the 
floor, while the other hangs off in a constrained, unseemly, and awkward manner; the 
foot and knee are strongly everted; the leg is supported upon the ball of the toes, while 
the heel, resting in the interval between the ankle and tendo Achillis, is elevated from 
CHAP. VIII. 
Fig. 583. 
The ilio-femoral rectangle a c b. c b test line for fracture 
or shortening of the neck of the thigh-bone. CHAP. VIII. 
INTRACAPSULAR FRACTURES OF THE FEMUR. 
1025 
two to three inches from the surface; the natural prominence of the hip is destroyed ; 
and the least attempt to walk or to raise the limb not only proves abortive, but is pro- 
ductive of exquisite pain. 
Finally, there is seldom much swelling in this variety of fracture ; it is only when the 
hip has been struck a severe blow that the superficial parts are likely to be the seat of any 
considerable effusion, ecchymosis, discoloration, or contusion, and even then the symptoms 
are usually very evanescent. 
The pathological changes in intracapsular fracture vary very much, according to the 
period of the examination, as well as the character of the original injury. In recent 
cases there is usually some sanguineous effusion, although the quantity of blood is gene- 
rally very small, unless, as occasionally happens, there is extensive rupture of the capsular 
ligament, when it may be considerable. Most commonly the ligament preserves its integ- 
rity, but if the accident has been unusually severe it may be torn at one or more points, 
so as to admit of the partial escape of the inferior fragment, the soft covering of which 
is often partially detached, hanging off in loose, irregular shreds. If several days have 
elapsed since the receipt of the injury, the synovial membrane will be observed to be un- 
naturally vascular, and slightly coated with plastic matter, a small quantity of which is 
also sometimes found upon the ends of the fragments. There is likewise, at this stage, a 
marked increase of synovial fluid, and the structures around the joint frequently exhibit 
a contused appearance, with more or less infiltration of blood and serum. 
If the dissection be made after the lapse of some months, the capsular ligament will be 
found to be much thickened by interstitial deposits, as well as by the addition of plastic 
matter to its synovial lining; the head and neck of the bone are also incrusted with 
lymph ; and the ends of the fragments are softened, unnaturally vascular, and rounded 
off, or partially connected by fibro-ligamentous bands. The interarticular ligament retains 
its normal structure, except in rare cases, in which it is inflamed and changed into fibrous 
tissue. 
In old cases, or such as have lasted for some years, there are not only great thickening 
and induration of the capsular ligament, but extraordinary alterations in the broken bone, 
the neck of which is often completely annihilated, the shaft terminating abruptly on a line 
with the two trochanters. At other times the neck is converted into a short, conical 
knob, partially incrusted with cartilage, or scooped out, as it were, into a cup-like depres- 
sion. The trochanters themselves are occasionally a good deal changed in their appear- 
ance, especially the great, which is liable to be diminished in size and altered in configura- 
tion. The head of the bone generally retains its position in the acetabulum, but that 
portion of the neck which remained attached to it at the time of the accident is usually 
Fig. 584. 
Fig. 585. 
Senile Atrophy of the Neck of the Femur 
Atrophy which might be raUtaken for United Fracture 
totally absorbed ; and cases occur, although rarely, where the entire fragment is either 
destroyed or represented by the merest possible remnant held in place by the round liga- 
ment. When the head is left, its lower surface is occasionally hollowed out into a kind of 1026 
DISEASES AND INJURIES OF THE BONES. 
CHAP. VIII. 
socket for the reception of the rounded conical end of the lower fragment; or the reverse 
obtains, the head being rounded of!', and the lower fragment scooped out. In either event, 
the two extremities, continually moving upon each other, in time acquire a smooth, pol- 
ished, eburnized character, the better qualifying them for the performance of their various 
functions. 
The changes now described are sometimes closely imitated by those produced in the 
head and neck of the femur by a fall or blow on the hip, leading to interstitial absorption 
of the osseous tissue, and to shortening of the limb, with destruction of the articular car- 
tilage and eburnization of the resulting stump, very much as in arthritic rheumatism. 
There is reason to believe that cases of this kind are not unfrequently mistaken, botli 
during life and after death, for fractures of the neck of this bone. The appearances here 
alluded to are well illustrated in figs. 584 and 585. 
The mode of repair of intracapsular fractures is peculiar. Ordinary fractures generally 
unite by osseous matter, but in this variety of injury the connecting medium is of a fibro- 
ligamentous nature, as in similar lesions of the olecranon process, the patella, and the 
skull, llut it is not always that the surgeon is to look even for such a union, imperfect 
as it is; in many cases the ends of the broken bone utterly refuse to unite, being gradually 
rounded off, and, perhaps, slightly incrusted with cartilage, or, as not unfrequently hap- 
pens, especially in very aged and decrepit subjects, becoming, in time, completely 
absorbed, the lower fragment disappearing as far down as the two trochanters, and the 
upper as high up as the brim of the acetabulum. In rare cases, indeed, even the entire 
head is removed, along with the greater portion both of the round and capsular ligaments. 
A very excellent idea of the fibro-ligamentous union of 
this variety of fracture is afforded in tig. 580, from Sir 
Astley Cooper. It was taken nine months after the 
accident, from a patient between thirty and forty years 
of age. 
The causes of this want of union are of easy recog- 
nition. In the first place, the parts have to encounter 
the prejudicial influence which results from the difficulty 
of maintaining accurate apposition of the broken ends of 
the bone; a circumstance which is so essential to the 
successful repair of fractures in other pieces of the 
skeleton, but which it is almost impossible to effect here, 
in consequence of the want of proper leverage in the 
upper fragment. All the apparatus that has yet been 
devised for the purpose has utterly failed to accomplish 
the object ; whatever may be done, more or less motion 
is inevitable. Secondly, the accident is always followed 
by a considerable degree of synovitis, and, as a neces- 
sary result, by an increased quantity of synovial fluid, 
which, bathing the ends of the bone, acts inimically to 
the consolidating process. Thirdly, the most important 
reason, however, of all, is the want of power in the parts to furnish the requisite amount 
of plastic matter from the injury sustained by their vessels and nerves at the time of the 
accident. The superior and smaller fragment, represented by the globular head of the 
bone, or the head and a little remnant of the neck, is solely dependent for its vascular and 
nervous supplies upon the round ligament, and every one who knows how small this 
ligament is, and how insignificant its vessels are in the natural state, must be aware how 
utterly inadequate it must be for the nourishment of the bone to which it is attached. 
It need not, then, be wondered at that there never is any osseous matter effused by this 
fragment. Nor does the inferior fragment fare much, if any, better in this respect. 
Destitute, in great measure, of periosteum, with many of its vessels in a hopelessly lace- 
rated condition, its powers are too feeble to afford any substantial aid in the process of 
repair. Hence the result must necessarily always be as above stated; that is, there will 
either be no union at all, or, if an attempt is made at establishing a connection between 
the two fragments, that attempt will go no further than the formation of a fibro-ligamen- 
tous substance. 
When no effort whatever at repair occurs, the ends of the fragments speedily undergo 
the fatty degeneration, and fall an easy prey to the action of the absorbent vessels, event- 
uating in their partial destruction or complete annihilation. 
It would, perhaps, be going too far to deny altogether the possibility of bony union in 
Fig. 586. 
Fracture of the Neck of the Thigh-bone, 
United by Fibrous Tissue. INTRACAPSULAR FRACTURES OF THE FEMUR. 
1027 
CHAP. VIII. 
intracapsular fracture of the thigh-bone, and yet I have certainly never seen what I could 
regard as an unequivocal example of the kind. I have examined most of the specimens 
in this country, purporting to be cases of osseous consolidation, and in no instance have 
the appearances been such as, in my opinion, to justify such a conclusion. The history of 
these cases has generally either been so exceedingly defective, or the necroscopic char- 
acters have so closely resembled those witnessed in the changes which the head and neck 
of the femur undergo in consequence of old age or disease, as to destroy all confidence in 
their authenticity as genuine examples of intracapsular fracture. I need not insist here 
upon the great difficulty which the practitioner frequently encounters in establishing a 
correct diagnosis in injuries about the hip; what skill and care are generally required to 
discriminate accurately between a mere sprain and a fracture, or a fracture and a dislo- 
cation ; or how frequently even slight lesions of the ilio-femoral articulation, and of the 
head and neck of the femur, are followed by changes in the structure and conformation of 
these portions of bone which so closely simulate those produced by fracture as to deceive 
the most enlightened and cautious observer. 
The question, then, in regard to the repair of intracapsular fracture, resolves itself into 
four groups of facts, which may be thus stated:—1. Under favorable circumstances, both 
as it respects the patient and the treatment, there may be fibro-ligamentous union, 
answering the purpose of a sufficiently strong bond to admit of tolerable progression after 
recovery from the more immediate effects of the accident. 2. Under adverse circum- 
stances, that is, when the patient is old, decrepit, or worn out by disease, and cannot, in 
consequence, submit to proper treatment, or when, although the system is sufficiently 
vigorous, the case has been injudiciously managed, no consolidation whatever will take 
place, and not only so, but the neck of the bone, or both the neck and head, will be ab- 
sorbed, the limb remaining, of course, permanently shortened and deformed. 3. Osseous 
union, although, perhaps, not wholly impossible, is yet so exceedingly infrequent that it 
cannot reasonably be looked for in any case, however propitious the circumstances attend- 
ing it, both as it respects the patient and the skill and attention of his attendant. The 
event, other things being equal, will be most likely to happen in the impacted form of the 
injury, and in the ordinary fracture in comparatively young and robust persons. 4. 
When the fracture is of a mixed character, that is, partly within and partly without the 
capsular ligament, the mode of repair will be similar to that of ordinary fracture, although 
the process will require more time and care lor its successful completion. 
The prognosis in this variety of fracture is embraced in the above remarks respecting 
its repair, and need not, therefore, engage further attention here. In regard to life, the 
danger is generally inconsiderable, as the lesion is usually the result of very trivial acci- 
dents, involving no serious injury to the soft parts, or any comminution of the bone. I 
have, however, seen several instances in old, dilapidated subjects, followed by death from 
shock, or shock and its effects. In the case of an old lady ninety-four years of age, 
recently under my observation, death was produced by gradual exhaustion from excessive 
pain and want of appetite. In regard to the limb, as the consolidation of the fracture is 
always more or less imperfect, its usefulness will necessarily be impaired in a degree pro- 
portionate to the defective character of the connecting medium. For a long time the 
patient will be obliged to employ a crutch, but eventually he will be able to walk with the 
aid of a stick and a high-heeled shoe, the parts strengthening by exercise, notwithstanding 
there is a strong tendency to atrophy of the muscles. The hip-joint generally remains 
permanently weak, and it is seldom that the patient does not experience more or less pain 
in it, often of a neuralgic, gouty, or rheumatic character. 
Treatment—Fractures of the neck of the femur within the capsular ligament are not, 
I think, generally so well managed as they should be, owing chiefly, if not wholly, to the 
influence of the writings of Sir Astley Cooper, who taught that, inasmuch as there never 
is any osseous union in this variety of injury, it is not, therefore, proper to torture the 
patient with a protracted confinement in the recumbent posture, and the application of an 
extending apparatus. He considered such a proceeding the more necessary because a 
great majority of the subjects of this fracture are old and decrepit persons, many of whom 
bear confinement very badly, soon becoming affected with foul bed-sores, and eventually 
perishing from hectic irritation or congestive pneumonia. In accordance with this view, 
he was in the habit of placing the limb upon a long pillow', in an easy position, for about 
a fortnight, or until the pain and inflammation, consequent upon the accident, had in great 
measure subsided. The patient was then allowed to leave his bed, and sit in a high chair, 
or exercise upon crutches, care being taken to bear, at first, very gently upon the foot, for 
fear of disturbing and fretting the ends of the fragments. Subsequently, as the limb 1028 
DISEASES AND INJURIES OF THE BONES. 
CHAP. VIII. 
improved in strength, a high-heeled shoe was ordered, and a stiek was substituted for the 
crutches. 
If this treatment were the exception, and not the rule, every practitioner of sense and 
experience would concur in its propriety ; but the English surgeon, in his desire to gene- 
ralize it, has carried it much further than the interests of our patients justify. It is 
unquestionably true that many of the subjects of intracapsular fracture do not bear con- 
finement well; they suffer from the slightest restraint, and soon become bedridden. Such 
cases are extremely difficult to manage, and are not likely to be benefited by the use of 
splints, or any other mechanical contrivances calculated to compress the limb and hold it 
in an uneasy and constrained position. To this class the treatment of Sir Astley Cooper 
is peculiarly applicable; indeed, no other can be employed. All that can be done is to 
make the patient comfortable, and let the limb get on as best it may. lint there is another 
class of subjects, who, although perhaps a good deal advanced in years, are, nevertheless, 
quite stout and robust, enjoying excellent health at the time of the injury, whose constitu- 
tion has never been impaired by intemperance or excess of any kind, and who can bear 
the long confinement incident to such an accident with the most perfect impunity. The 
persons composing this class are, for the most part, residents of the country, and not the 
poor, broken-down inhabitants of the crowded city, without any bodily vigor, or any re- 
cuperative power. Hence, no exclusive plan of treatment should be adopted ; but the 
management should be varied according to the exigencies of each particular case. Such 
a course is the more necessary because it is utterly impossible always to determine posi- 
tively, by the most careful examination, whether the injury is one purely of intracapsular 
or extracapsular fracture, or whether it partakes, as, indeed, it not unfrequently does, of 
the character of both, the two being conjoined. 
Acting upon the above principles, 1 have, for many years, treated most of the cases of 
intracapsular fracture that have come under my notice as any other fracture of the femur, 
by permanent extension and counterextension, not with the hope, as already stated, of 
obtaining bony consolidation, but with the view simply of keeping the ends of the frag- 
ments more accurately in contact, and thus affording them an opportunity of becoming 
united by fibro-ligamentous tissue. It is obvious that such a result can only reasonably 
be anticipated when this condition is fully complied with. When the broken pieces are 
permitted to overlap each other constantly, hardly any union will be possible, certainly 
none of a useful kind ; and there is, moreover, in such a condition, always great risk that 
at least the neck, if not also the greater portion of the head, of the bone, will be absorbed, 
and the patient, in consequence, never regain the functions of his limb. If the treatment 
fail, the surgeon has the consolation to know that he has discharged his duty, by having 
kept the parts in the only position in which it is ever possible for them to unite in any 
way. The thigh maybe maintained in the extended position, and among the apparatuses 
Fig. 587. 
Daniel’s Fracture-Bed. 
which best fulfil this indication is that depicted at page 1009, extension and counterexten- 
sion being made by the usual means. A splint of unoiled sole leather, well padded, and 
furnished with straps at the upper extremity, and carefully secured to the inner side of EXTRACAPSULAR FRACTURES OF THE FEMUR. 
1029 
CHAP. VIII. 
the limb will be required to give due support to the ends of the fragments, or to prevent 
inward displacement. The splint should reach from the knee high up into the groin, inclose 
fully one-half of the thigh, be well fastened with a water-glass roller, and be attached by 
means of its two straps to a cord playing over a pulley with a weight of six, eight, or ten 
pounds, according to the age of the patient and the tendency to displacement. The object 
of this arrangement is to keep up a certain degree of lateral or oblique extension in order 
to effect and maintain more accurate apposition of the ends of the fragments than is possi- 
ble by mere longitudinal extension. Good cures may also be obtained by placing the limb 
over a double inclined plane; or, what is better, when it can be procured, the patient may 
be put upon a Daniel’s fracture-bed, represented in fig. 587. The latter contrivance, 
which, unfortunately, however, is too expensive for general private use, is particularly 
adapted to cases of old persons likely to require protracted confinement. The bed is so 
arranged that, while the patient can sit up, or vary his position, efficient extension and 
counterextension may be maintaned with adhesive strips. An elaborate description of 
the apparatus may be found in the tenth 
volume of the Transactions of the Ameri- 
can Medical Association. 
When a Daniel’s fracture-bed cannot 
be obtained, a most excellent, as well as 
a comparatively cheap, substitute may be 
found in what is known as the Charles- 
ton reclining chair, fig. 588, modified and 
improved by Professor William H. Pan- 
coast, the most important additions being 
a bed-pan and a movable footboard. The 
chair, made very strong and wide, is 
well stuffed, and arranged in the form of 
a double inclined plane, the patient, by 
means of pillows and other appliances, 
being thus rendered far more comfort- 
able than he can be in any ordinary bed, 
the more especially as he can at any time 
shift his posture without any detriment 
to the affected parts. Professor Pancoast 
finds that this contrivance is peculiarly 
adapted to the treatment of fractures of 
the upper extremity of the thigh-bone in elderly subjects, having emjdoyed it success- 
fully in a number of cases, with very little shortening of the limb in any. Apposition of 
the ends of the fragments is effected by means of compresses and short splints, confined 
by adhesive plaster and bandage, or the immovable dressing. 
Whatever plan of treatment be adopted, its effects should be most carefully watched, 
so that it may not prove irksome, much less injurious. Particular care should be taken 
to see that the great trochanter preserves its natural prominence. Any flattening of the 
hip may be regarded as as an evidence that there is inward displacement of the ends of 
the fragments, and danger of a want of ultimate reunion. The length of time during 
which the patient should be confined must vary, on an average, from ten weeks to three 
months and a half. During all this trying period he should be on a full allowance of meat 
and porter; at all events, upon a generous diet, in order to sustain the system and pro- 
mote repair. Purgative medicines and all other depressing means should be used as 
sparingly as possible. Anodynes, if necessary, must be freely given in the evening to 
allay pain and procure sleep. 
When the patient is able to move about he will derive great comfort from the use of a 
Willard’s double hinge-joint apparatus, delineated in the section on tuberculosis of the 
hip-joint; one part corresponding with the thigh and the other with the hip and lower part 
of the trunk. 
EXTRACAPSULAR FRACTURES. 
The extracapsular fracture is situated at the base of the neck of the femur, extending 
from above downwards and from behind forwards in the direction of the intertrochanteric 
line. It is not always, however, as the name declares, strictly exterior to the capsular 
ligament; on the contrary, it occasionally passes above the attachment of that structure, 
Fig. 588. 
Reclining Chair. 1030 
DISEASES AND INJURIES OF THE BONES. 
CHAP. VIII. 
so as to partake of the character both of an inner and of an outer fracture of the neck, 
constituting what may be called a mixed fracture. Moreover, the injury is always asso- 
ciated with fracture of the trochanters, sometimes with one, at other times with both, thus 
leaving in the former case three fragments, and four in the latter. Again, the fracture is 
often comminuted independently of its connection with the trochanters; and in many 
instances it is attended with more or less penetration of the superior piece into the infe- 
rior. Observation, however, induces me to believe that, generally speaking, the penetra- 
Fig. 589. 
Fig. 590. 
Extracapsular Fracture of the Femur. 
Commiuuted Fracture of the Upper Extremity of the Femur. 
lion is very trivial, hardly ever exceeding three lines, and often not reaching even so high 
as that. Figs. 589 and 590 afford a good idea of the situation and direction of the extra- 
capsular fracture. 
In regard to the frequency of the occurrence of impaction in this lesion opinion varies. 
Robert \V. Smith, of Dublin, asserts that all extracapsular fractures are, in the tirst 
instance, also impacted fractures ; a statement which should be received with a considera- 
ble degree of allowance, for examples are certainly occasionally seen in which the reverse 
is the case. 
The extracapsular fracture is not so common as the intracapsular; the difference, how- 
ever, is trivial. Men sire somewhat more subject to it than women, and, while it may 
take place at smy period of life, experience teaches that by far the greater number of cases 
occur after the sixtieth year. It may be stated, as a rule, that a much greater amount of 
violence is required to produce this fracture than the intracapsular, but the rule admits of 
many exceptions. The most common exciting cause is a fall or blow upon the hip, in 
the direction of the great trochanter; it may also follow a fall upon the foot or knee, and 
the passage of the wheel of a carriage sicross the pelvis or upper part of the limb. Finally, 
cases occur where it happens from the body being crushed by a heavy load descending 
upon the back, the lower extremities being in a fixed state at the moment of the accident. 
In not a few instances, however, the fracture is occasioned by very slight causes, while in 
most there is reason to believe that the bone at the site of the lesion is in a remarkably 
brittle condition, predisposing it to the disruption of its fibres. In some of the prepara- 
tions that I have examined in different osteological collections, the compact structure, 
although not very materially diminished in thickness, was almost of a vitreous consistence, 
while the spongy was extremely rarefied and expanded, thus occasioning great weakness 
of the part. The cervical portion of the bone, under such circumstances, frequently 
retains a remarkably healthy appearance. When the osseous tissue is so very fragile at 
this point, it is not improbable that it may occasionally give way under mere muscular 
contraction, as has happened in at least one well-authenticated case, the patient, a woman, 
eighty-three years of age, having met with the aceident in an effort to preserve her equi- 
librium in the act of falling. 
The symptoms of this variety of fracture bear a strong resemblance to those of the EXTRACAPSULAR FRACTURES OF THE FEMUR. 
1031 
CHAP. VIII. 
intracapsular, some existing in a less, others in a greater, degree, but none, considered 
separately, possessing any diagnostic value. In describing these symptoms it will be most 
satisfactory if they be presented in the same order as in the preceding case. 
The shortening, which is a constant occurrence, varies from half an inch to an inch, as 
its minimum, to an inch and a half, as its maximum. In exceptional cases it may, how- 
ever, amount to two inches and upwards. It is usually most distinct when there is a 
badly comminuted state of the bone, or when the great trochanter, forming a part of the 
upper fragment, is drawn uncommonly far outwards, so as to permit the lower fragment to 
ride considerably over the upper. Moreover, it possesses the peculiarity of being gene- 
rally as great immediately after the fracture as at any subsequent period. 
The hip, as the result of these changes in the position of the great trochanter, is more 
or less flattened ; and the femoral aponeurosis, as has been shown by Dr. Oscar Allis, 
will be found to be relaxed on the affected side when the patient stands up. 
The knee and foot are generally everted, the limb lying as if it were perfectly power- 
less, the muscles having apparently lost all influence over it. This symptom is even more 
striking than in the intracapsular fracture. Eversion, however, is not so constant an 
occurrence as in the latter accident; in a considerable proportion of cases the limb is 
strongly rotated inwards, and in both varieties, but especially in the former, the displace- 
ment is occasionally so obstinate as to require an unusual degree of force to rectify it, 
depending, doubtless, upon the interlocking of the fragments. 
The extracapsular fracture is characterized by complete mobility of its fragments, ex- 
cept when they are impacted, an occurrence which, as just stated, is more common here 
than in fracture within the capsule. The loss of function is also complete, the patient being 
unable to lift the limb by the effort of his muscles, or to execute any of its natural movements. 
The crepitation is generally very distinct, being often loud and cracking, and is readily 
perceived by the hand and ear, applied to the hip when the limb is rotated upon its axis. 
It is usually more marked than in intracapsular fracture, and does not, as in the latter, 
require extension and counterextension for its production. When the fracture is badly 
comminuted, the fragments may often be readily detected with the fingers, and be made 
to move upon each other so as to emit a grating sound not unlike that caused by rubbing 
together several pieces of broken china. 
The position of the great trochanter may be the same as in the intracapsular fracture, 
obeying the movements of the limb, and turning, as it were, upon a pivot, describing the 
segment of a lesser circle, as it does in the natural state. In many cases, however, it is 
completely detached, and then, of course, it either remains stationary on rotating the foot, 
or it follows the inferior fragment as a separate body. In general, it will be found to be 
somewhat farther off from the spine of the ilium than in the intracapsular fracture, de- 
pending upon the smaller amount of retraction of the limb. 
The pain is always unusually severe, and is greatly increased by every attempt at mo- 
tion and manipulation; it is more superficial than in intracapsular fracture, and is concen- 
trated, as it were, upon the two trochanters. 
The swelling is also uncommonly extensive, and there is nearly always considerable 
discoloration of the surface, owing to the contused and ecchymosed condition of the skin and 
subcutaneous connective tissue, the latter of which is often extensively infiltrated with blood. 
The attitude of the patient possesses nothing peculiar; it partakes of the same general 
character as in intracapsular fracture, and, in fact, so closely simulates it as to be with 
difficulty distinguished from it. 
Finally, along with the symptoms now described, there is generally, in extracapsular 
fracture, evidence of severe shock immediately after the occurrence of the accident, and 
the resulting reaction is not unfrequently followed by high fever, lasting often for a num- 
ber of days, and requiring great attention on the part of the professional attendant. In 
intracapsular fracture the patient may feel very faint, but he soon recovers, and has after- 
wards seldom much constitutional disturbance. 
Repair of the extracapsular fracture is effected precisely in the same manner as in 
fracture of any other piece of the skeleton provided with periosteum. It differs, there- 
fore, wholly, in this respect, from that of the intracapsular form of the lesion. Here osseous 
union is the rule, the want of it the exception, the reverse being the case in intracapsular 
fracture. The period at which the consolidation is completed will, of course, depend, as 
a general rule, upon the age and health of the patient, the presence or absence of compli- 
cations, and, above all, upon the care which is observed in keeping the ends of the frag- 
ments in accurate apposition. 
Although the extracapsular fracture invariably unites by osseous matter, the prognosis 1032 
DISEASES AND INJURIES OF THE BONES. 
CHAP. VIII. 
is very far from being always favorable either as it respects the possibility of avoiding 
deformity and lameness, or our ability to save the patient. When the fracture is commi- 
nuted, or the bone is broken into a number of pieces, including the two trochanters, a good 
result is hardly to be anticipated even under the most judicious management. Under 
such circumstances, the neck of the bone, having lost its support, is pushed downwards 
and inwards below its natural level, and a certain degree of shortening with deformity of 
the upper part of the thigh will be inevitable. The same result must necessarily follow 
when the fracture is impacted. These facts should be well studied and appreciated, and 
should always be promptly communicated to the patient, lest, when the cure is completed, 
he should blame his attendant for making him a bad limb when it was impossible to make 
a good one. 
From the great violence that is so frequently inflicted upon the parts, both soft and 
hard, the extracapsular fracture often proves hazardous both to limb and life. Occasion- 
ally, although rarely, the patient dies from shock : in some instances he suffers greatly from 
the effects of excessive reaction. Most generally, however, when there is danger, life is 
put in jeopardy by the supervention of erysipelas or pyemia, the former commonly setting 
in within the first forty-eight hours from the occurrence of the fracture, and the latter 
towards the end of the first week or the beginning of the second. Some idea of the 
danger of extracapsular fracture may be formed when it is stated that, of eighteen cases 
treated in the Richmond Hospital at Dublin, nine proved fatal, the period of death rang- 
ing from the fifth to the fifteenth day. In some cases the patient sinks from the exhaustion 
consequent upon extensive suppuration or the formation of large sloughs over the sacrum 
and buttocks from protracted confinement in one position. 
The treatment of extracapsular fracture differs in no wise from that which is necessary 
in fracture of the shaft of the bone. The limb, placed in the straight position, is kept 
perfectly sit rest by means of splints, stretched silong its outer and issuer surfaces, and con- 
nected below in such a manner ns to admit of the requisite extension and counterexten- 
sion until a cure is effected. The foot should incline slightly outwards to favor relaxation 
of the external rotator tnuscles, and special care should be taken to prevent overlapping 
of the fragments, or angular deformity, by the use of a gutta-percha splint, accurately 
moulded to the outer and anterior part of the thigh, and well secured by the bandage. The 
dressing should be continued for at least six weeks. 
IMPACTED FRACTURES OF THE NECK OF THE FEMUR. 
Frsicture of the neck of the femur occasionally presents itself as an impacted lesion, 
the lower extremity of the upper fragment being forcibly impelled into the cancellated 
structure of the upper end of the lower fragment, the 
great trochanter being usually carried along with the 
descending portion. The accident, which is sufficiently 
rare, and of which fig. 591, from a specimen in the 
Mutter collection, affords a beautiful illustration, is 
nearly always associated with the extracapsular frac- 
ture, and occurs under two varieties of form, the com- 
plete and the incomplete, of which the latter is by far the 
Fig. 591. 
Fig. 592. 
Impacted Fracture of the Neck of the 
Femur. 
Impacted Fracture through the Trochanter, the Upper 
Fragment being Wedged into the Lower. CHAP. VIII. 
FRACTURES OF NECK OF FEMUR. 
more frequent. 01«1 persons only are subject to it, and it is most common in those in 
whom the neck of the femur is of inordinate volume from the expansion of its spongy 
structure. The line of fracture is generally at the base of the neck, or at the junction of 
the neck with the shaft, the penetration occurring in the direction of the anterior surface 
of the hone, with which the neck is more immediately continuous, being separated from it 
behind by a well-marked depression, and by the large ridge connecting the two trochanters. 
The fracture usually happens from the body being crushed by the falling of a heavy sub- 
stance upon the trunk, while the chest is inclined forwards, and the knee rests upon a 
solid surface, the hip at the same time receiving a severe blow, as when a person is buried 
by the caving in of a coal-bank ; or, it may be produced by a fall from a height upon the 
knee, in which the weight of the body is violently impelled in the opposite direction, 
the two forces continuing to act after the bony tissues have given way. The direction of 
the fracture is generally oblique, extending from above downwards from the great to 
the small trochanter, both of which are not unfrequently included in the injury, as in 
fig. 592. 
The distance at which the upper fragment is buried in the lower varies from a few lines 
to half an inch, three-quarters of an inch, or even an inch, depending upon the degree of 
the impelling force and the amount of expansion of the cancellated structure at the base of 
the cervix. The compact substance of both fragments is often extensively comminuted, 
and the fragments themselves are usually interlocked in such a manner as to give the 
thigh-bone the appearance of being twisted upon its axis, the limb after the accident 
being generally everted, as in fracture without impaction, although in a less marked 
degree. 
In this form of impacted fracture, Professor Bigelow is of opinion that, in the large majority 
of cases, the thin, friable posterior wall of the neck of the bone alone is driven into the 
trochanter, while the thick anterior wall remains free, its dense and more resisting struc- 
ture refusing to yield except as a kind of hinge upon which the shaft rotates at the moment 
of the accident. To this circumstance may be ascribed the eversion of the foot, while 
the shortening is generally due to the obliquity of its hinge, which follows the anterior 
intertrochanteric line. 
There is a variety of impacted fracture of the neck of the femur in which the lower 
fragment is impelled into the reticulated structure of the upper. The occurrence is 
uncommon, and the amount of shortening is a good deal less than in the more ordinary 
form of injury. 
The symptoms of impacted fracture of the neck of the femur are generally very charac- 
teristic, although a good deal of care is tiecessary, in every case, in order to make a cor- 
rect diagnosis. The most valuable and reliable phenomena are, the shortening of the 
thigh, the eversion of the foot, the ability of the patient to walk or to bear the weight of 
the body upon the thigh, after the accident, and the resistance which the fragments offer 
to extension and counterextension when an attempt is made to restore the limb to its 
natural position. The pain is usually very intense, generally much more so than in ordi- 
nary cervical fracture, and there is not unfrequently extensive eechymosis over the great 
trochanter, causing unwonted swelling and discoloration. Crepitation can only be elicited 
by unlocking the ends of the fragments. 
The degree of shortening varies, as already stated, from a few lines to an inch or more, 
the average ranging from a quarter of an inch to half an inch, which it rarely exceeds. 
The eversion of the foot, although well marked, generally exists in a slighter degree than 
in fracture of the neck of the bone without penetration, whether the injury is seated on 
the outside or within the capsular ligament. The occurrence is the more valuable as a 
diagnostic from the fact that it is rarely, if ever, entirely absent. As the continuity of 
the femur is preserved, the patient is generally able to walk after the accident, although 
not without much suffering, or, at all events, he can bear the weight of his body upon the 
affected member. For the same reason, the limb is easily rotated upon its axis, bent 
upon the pelvis, extended, abducted, or adducted ; and when an attempt is made to restore 
it to its normal length, the effort, unless very powerful, ordinarily fails, the ends of the 
fragments retaining their interlocked position, despite the extension and counterextension. 
Finally, there is generally, in addition to the symptoms now described, more or less 
deformity, although this cannot always be easily detected on account of the excessive 
swelling, and, when present, is not, of course, characteristic. 
What, then, are the most important phenomena in a diagnostic point of view ? Beyond 
all doubt, the shortening of the thigh, the immobility of the limb, the existence of deformity 
at the hip, in the situation of the great trochanter, and the absence of crepitation. When 1034 
DISEASES AND INJURIES OF THE BONES. 
these signs are present, it may be assumed that there is no dislocation of the ilio-femoral 
joint, nor any ordinary fracture of the neck of the femur, but fracture of this portion of 
the bone with impaction of the uppper fragment. 
The prognosis of this variety of fracture is much more favorable, so far as it respects 
reunion, than that of ordinary fracture of the cervix ; for, inasmuch as the fragments are 
firmly wedged together, it usually requires but little callus to effect their consolidation. 
Besides, very little retentive apparatus is usually necessary, the two fragments serving as 
their own splints. On the other hand, however, there must always remain a certain 
degree of deformity, consisting of slight shortening of the limb, and of an incurvated 
state of the thigh just below the hip. Some permanent lameness may, therefore, reason- 
ably be looked for after the accident, even under the most favorable circumstances. I 
have seen several specimens of impacted fracture of the neck of the femur where great 
and irremediable ankylosis was produced by osseous matter being extended, in the form 
of bridges, from the seat of injury to the innominate bone, immediately around the aceta- 
bulum, connecting the two together in a solid mass. 
These protective means are displayed in a remarkable manner in a specimen, above 
depicted, of impacted fracture of the neck of the left femur, in the Mutter collection. 
The head and neck of the bone, being nearly two inches and three-quarters in length, 
occupy a horizontal position in regard to the shaft, the neck being driven into the cancel- 
lated structure of the latter some distance below the trochanters. The superior third, or 
more, of the shaft is bent strongly forwards and outwards, and is surrounded by a casing 
of new osseous matter, more than half an inch in thickness at the concavity of the curve, 
or weakest portion of the femur, and at a point, consequently, where, after such an acci- 
dent, the greatest amount of support is required. A large ledge of bone, two inches long, 
and very broad, thick, and firm, projects from the anterior and inner aspect of the superior 
extremity over towards the hip-joint, being connected by a strong, round ligament, upwards 
of two inches in length, with the anterior inferior spinous process of the ilium, which juts 
out as a remarkably long, slender prominence, more than twice the normal size. An idea 
of the amount of shortening of the femur may be formed, when it is stated that the summit 
of the great trochanter projected fully one inch above the upper border of the acetabulum. 
Nothing is known of the history of the case ; but, judging from the completeness of the 
reparation, the accident must have occurred many years before death. Some degree of 
motion, certainly very slight, must have existed both in the acetabulum and at the junc- 
tion of the two fragments, the upper end of the lower of which was converted into a 
socket into which the lower end of the upper was received, a kind of adventitious mem- 
brane having been interposed between the contiguous surfaces. 
In the treatment of this fracture, one important point is not to pull the ends of the 
broken bone asunder in the examination of the case. Hence, whenever impaction is 
suspected, the rule is to refrain from all rotation and extension. As soon as the nature 
of the accident is detected, the limb is placed in an easy position in bed, a pillow lying 
under the ham, and gentle but steady pressure is made, by means of a compress and 
bandage, in the direction of the great trochanter, with a view of rectifying any deformity 
that may exist in that situation. Generally, no splint will be required, but sand bags may 
be useful; and in ordinary cases the patient will be able to move about on crutches in 
three or four weeks. 
General Diagnosis—Fractures of the neck of the thigh-bone are liable to be mistaken 
for other lesions, and it is, therefore, a matter of great importance to have accurate con- 
ceptions of their real nature, errors of diagnosis here being always particularly prejudicial 
both to the patient and to the practitioner. The affections with which they are most apt 
to be confounded are sprains and dislocations of the hip-joint; and, in many cases, great 
difficulty is also experienced in deciding whether the injury is one of fracture within the 
capsular ligament, or of fracture exterior to it. 
The symptoms of fracture of the neck of the femur, especially the intracapsular, are 
sometimes closely simulated by sprains and contusions of the hip, causing involuntary 
obliquity of the pelvis, with apparent shortening of the limb, and eversion of the knee 
and foot, along with excessive pain and difficulty of motion. The resemblance is occa- 
sionally so perplexing as to create doubt in the mind of the most skilful diagnostician, and, 
among the less informed, has often led to the most serious errors of practice, by the employ- 
ment of harsh means when the most mild and soothing alone were necessary. The signs 
of distinction are the following:—1. In fracture the shortening is real, and can be effaced 
only by extension and counterextension ; in sprains and contusions, on the contrary, it is 
not real, but feigned, as may be proved by placing the limbs parallel with each other, and 
CHAP. VIII. 1035 
CHAP. VIII . 
FRACTURES OF NECK OF FEMUR. 
bringing the two iliac crests on the same level. 2. In fracture the eversion of the foot is 
complete, the extremity presenting an appearance characteristic of total loss of power; in 
ordinary injuries of the hip and upper part of the thigh the eversion is comparatively 
slight, and the patient can generally rectify it by his own efforts, although they may be 
productive of severe distress. 3. In fracture there is usually complete abolition of mus- 
cular action ; so that the thigh can neither be flexed, extended, nor rotated, however 
determined the attempt. It is only in the impacted fracture that the individual has still 
some control over the limb, and then the best guide for avoiding mistake is the existence 
of actual shortening. In sprains and contusions motion is diminished, perhaps very greatly, 
but not abolished. 
A very unpleasant consequence of sprains and contusions of the hip-joint is shortening 
of the thigh from interstitial absorption of the neck of the femur. Hence the patient, on 
recovering from the immediate effects of the injury, finding that the limb is permanently 
disabled, might accuse his attendant of ignorance. In order to guard against such a 
charge, it is well for the surgeon to inform the patient, at an early period of the treatment, 
of the possibility of such a contingency. 
It might be supposed, at first sight, that it would be very difficult, even for an inex- 
perienced practitioner, to mistake a fracture of the neck of the thigh-bone for a dislocation 
of its head upon the dorsal surface of the ilium, yet numerous cases are upon record 
testifying not only to the possibility of such an accident, but to its actual occurrence in 
the hands of the most distinguished surgeons. The only way to avoid error is to remember 
clearly the most prominent signs of each lesion. The subjoined tabular arrangement will 
serve to place the subject in its proper light, at the same time that it renders a comparison 
of these symptoms an easy task :— 
Intracapsular Fracture. 
1. Occurs nearly always in old persons. 
2. Is most common in women. 
3. Usually the result of slight causes. 
4. The foot is strongly everted. 
5. There is great shortening, readily efface- j 
able by extension and counterextension, but re- 
curring the moment the force is discontinued. 
6. Marked crepitation exists. 
7. There is preternatural mobility, the ends 
of the fragments being movable upon each other. j 
Iliac Dislocation. 
1. Is most common in adult and middle life. 
2. Occurs with equal frequency in both sexes. 
3. Always produced by severe force. 
4. The foot is inverted. 
5. The shortening is also great, and can be 
effaced only by restoring the bone to its natural 
position, when it will not return. 
6. There is no crepitation. 
7. The bone is in a fixed and constrained posi- 
tion. 
But the greatest difficulty in the diagnosis of these affections of the thigh and hip arises 
from the embarrassment which the surgeon experiences in determining whether the case 
is one of intracapsular fracture, or fracture exterior to the capsular ligament. As the 
subject is one of great practical consequence, it deserves to be studied with unusual care, 
and I shall, therefore, arrange the principal points in tabular form:— 
Intracapsular Fracture. 
1. The result commonly of slight injury, often 
indirect. 
2. The shortening, slight at first, generally 
not exceeding a third or half an inch, gradually j ; 
increases to two inches and upwards. , 
3. The crepitation is indistinct, and can only 
be fully elicited by extension and counter-1 i 
extension. I i 
4. Function is much impaired, but often, at 
first, not wholly abolished. 
5. The great trochanter, on rotating the limb, \ 
moves, as it were, upon a pivot. 
6. The pain is unreliable, both as it respects 
site and intensity, being generally most severe at 
the upper and inner part of the thigh, in the 
direction of the small trochanter. 
7. There is generally little or no contusion, j 
swelling, or discoloration. 
Nothing of any diagnostic value can be 
which these two fractures occur, since, as was 
Extracapsular Fracture. 
1. Usually caused by direct and severe injury. 
2. The shortening is as great immediately 
after the accident as it is at any time afterwards, 
and its extent also is usually less than in the 
intracapsular fracture. 
3. Crepitation is uncommonly distinct, being 
often loud and ringing, and is readily perceived 
on laying the hand on the trochanter and rota- 
ting the limb. 
4. The loss of power is complete, the limb 
lying in a helpless, paralyzed condition. 
5. The great trochanter is often partially sepa- 
rated from the shaft of the bone, and then but 
imperfectly obeys the movements of the limb. 
6. The pain is usually very severe, especially 
on manipulation or motion, and seated more in 
the direction of the great trochanter. 
7. Usually severe contusion, with considerable 
swelling, ecchymosis, and discoloration. 
deduced from a consideration of the age at 
s previously stated, botli are met with almost 1036 
DISEASES AND INJURIES OF THE BONES. 
exclusively sifter the fiftieth year, there being only a few well-authenticated cases on 
record of its occurrence prior to that period. The same is true in relation to sex, expe- 
rience having shown that this exercises much less influence upon the production of these 
two varieties of fracture than was formerly imagined. I am inclined, from a careful study 
of the subject, to place more reliance, in this respect, upon the existence of severe exter- 
nal injury, as contusion, swelling, and ecehymosis, and upon the presence of shortening, 
than upon any other phenomena. In the intracapsular fracture, the external signs of 
injury are, certainly, as a general rule, exceedingly slight, while the reverse is usually the 
case in the extracapsular, the parts being nearly always much bruised and discolored. 
In regard to shortening, it possesses, I think, great value as a diagnostic of the two 
lesions; for it tnay be assumed, on the one hand, that when it is very slight imme- 
diately after the receipt of the injury, and gradually increases afterwards, it depends upon 
intracapsular fracture; and, on the other, that when it is very considerable immediately 
after the accident, it is caused by extracapsular fracture. Rodet, who studied the subject 
with much attention, arrived at the conclusion that every fracture of the neek of the 
femur, produced by a fall or blow upon the great trochanter, was of an extracapsular 
nature; whereas every one occasioned by a fall upon the feet, or by muscular action, must 
be seated within the ligament. This conclusion, however, is altogether unfounded; in 
adopting it, we should be compelled to assume that all intracapsular fractures are the 
result of falls upon the feet, when all experience teaches that they are almost invariably 
produced by force applied directly to the hip. 
The most important diagnostic characters of the impacted fracture of the neck of the 
femur, whether within or without the capsule, are, as has already been stated, shortening 
of the limb, the absence of crepitation, and the comparative or complete immobility of the 
fragments. The shortening is always immediate, and remains permanent in its original 
degree, unless the ends of the bone are rudely drawn asunder; hence it is a sign of an 
unequivocal character; the absence of crepitation is also very significant, and the trivial 
mobility, or complete absence of motion, is another circumstance of importance. The 
great danger in such a case is that the fracture may be mistaken for a dislocation; but 
from this it may usually be readily distinguished by a careful study of its history, and a 
thorough examination and comparison of the symptoms characteristic of the two lesions. 
FRACTURES OF THE GREAT TROCHANTER. 
Fracture of this bony apophysis may take place as an independent lesion, or as a con- 
comitant of fracture of the neck of the femur, outside of the capsular ligament, sis men- 
tioned previously, sind as exhibited in fig. 593, from a speci- 
men in my collection. As an independent fracture, it is 
very infrequent in comparison with the other variety. It 
may occur at any period of life, but is chiefly observed in 
elderly subjects, as a consequence of direct violence, as a fall, 
blow, or kick, breaking off the trochanter in an oblique 
direction from above downwards. The fracture is sometimes 
comminuted, the trochanter being broken into several 
pieces, of irregular size and shape, the fragments grating 
under the fingers like so many pieces of china. It may also 
be compound, although, in general, it is unaccompanied by 
any wound of the soft parts. 
The symptoms of this fracture are generally well marked, 
the most important consisting of eversion of the limb, with 
separation of the fragments, inability to sit down, and diffi- 
culty of obtaining crepitation. The eversion is unusually 
distinct, and is probably due, at least in great degree, to the 
loss of power in the external rotator muscles; the limb lies 
in a helpless condition, and no effort that the patient can 
make can change its position. The broken trochanter is 
commonly widely separated from the shaft of the bone, and 
hence the difficulty which is generally experienced in elicit- 
ing crepitation, this being only practicable by placing the 
parts in apposition with each other. The displacement is either upwards towards the 
ilium, or downwards towards the tuberosity of the ischium, the former being the more 
frequent. If the patient attempt to sit down he is completely foiled, and immediately 
CHAP, v 11 i. 
Fig. 593. 
Fracture of the Great Trochanter. CHAP. VIII. 
FRACTURES OF THE GREAT TROCHANTER. 
1037 
experiences great increase of pain, compelling him to desist. Most authors speak of 
shortening of the limb as a symptom of this fracture, but, if shortening really exist, it can 
only be in a very slight degree. More or less contusion and ecchymosis of the soft parts 
are usually present. 
The diagnostic signs are the eversion of the limb, the loss of prominence at the natural 
site of the trochanter, the fixed position of the small fragment on moving the shaft of the 
femur, and crepitation on approximation of the broken ends. 
The union is by osseous matter, and, unless the bone is comminuted, a cure may 
reasonably be expected without any deformity of the hip or impairment of the functions 
of the limb. Considerable difficulty, however, is generally experienced in maintaining 
apposition of the fragments, and hence such an injury always requires more than ordinary 
vigilance on the part of the attendant. 
The treatment consists in maintaining the limb in a perfect state of quietude by means 
of two long splints, the foot being supported in a perpendicular direction, with a slight 
tendency to eversion, which is the most natural position for a person when he lies on his 
back, and, therefore, the most eligible for relaxing the external rotator muscles when 
there is a fracture of the trochanter. The broken trochanter, being drawn into its natural 
situation, is confined there by a soft leather belt, long enough to extend around the pelvis, 
and furnished with a hollow pad, from three to four inches in diameter, for the purpose 
of embracing more effectually the prominence of the hip. Hardly any extension will be 
necessary. If the soft parts are much contused, leeches and fomentations should be 
applied before putting on the permanent dressings. After the patient has been confined 
tor a month, he may be permitted to exercise on crutches. The annexed cut, fig. 594, 
represents an excellent mode of treating fractures of the great trochanter recommended 
by Sir Astley Cooper. 
Fig. 594. 
Sir Astley Cooper’s Method of Treating Fractures of the Great Trochanter. 
The great trochanter is occasionally detached from the neck and shaft of the femur, by 
the forcible laceration of the fibro-cartilage by which it is connected to these parts during 
early life, constituting what is known as the epiphyseal fracture, 
fig. 59;"), from Bryant. The union between these two parts is seldom 
completed before the twentieth year. The accident, which is very 
uncommon, is usually produced by a severe fall upon the hip, and 
is always extremely difficult of diagnosis, owing to the fact that 
there is seldom much, if any, appreciable displacement. In most 
of the recorded cases there was much diversity in the symptoms; 
in some the patient was able to walk immediately after the acci- 
dent, while in others he had lost all control over the muscles of his 
limb; in some the foot was everted, while in others it preserved 
its natural position, or was even inverted; in all there was severe 
pain, with considerable swelling, either alone or conjoined with 
ecchymosis, at the site of injury, and, during their progress, more 
or less constitutional disturbance. 
The best manner of determining the diagnosis, in this accident, is to make the patient 
lie on his back arid incline the pelvis over the injured side, while the affected limb is 
thoroughly abducted, or carried away from the sound one. The gluteo-femoral muscles 
being thus completely relaxed, the trochanter, if detached, may easily be pushed into its 
natural position, and crepitation elicited by rubbing it against the neckandshaft of thefemur. 
The occurrence of this accident is not without danger, several cases having been re- 
corded in which it proved fatal from extensive suppuration and constitutional disturbance. 
Fig. 595. 
Epiphyseal Fracture of the 
Great Trochanter. 1038 
DISEASES A XI) INJURIES OF THE BONES. 
CHAP. VIII. 
When recovery takes place, the limb remains long weak and painful. The union, under 
such circumstances, is fibro-cartilaginous, or partly cartilaginous and partly osseous. The 
treatment must be conducted upon the same principles as in ordinary fracture of the tro- 
chanter. A very instructive case of this accident, in a lad sixteen years old, caused by 
a sprain, and eventuating in death from periostitis and pyemia, wsis reported in 1875, by 
Professor Roddick, of Montreal. 
FRACTURES OF THE THIGH IN CHILDREN. 
Fractures of the femur sometimes occur in very young children, and are always 
peculiarly troublesome. The bone generally gives way at its shaft, as the result of ex- 
ternal violence, and the symptoms are characteristic. Diastasis of the femur is extremely 
uncommon. It is most frequently met with in the lower extremity of the bone; separation 
of the head is an occasional occurrence, and epiphyseal fracture of the great trochanter is 
also a possible accident at a very early age. In a case of diastasis of the head of the 
femur in a stout, lat, healthy girl, twelve years of age, the accident was produced by a fall 
on the hip, from a low hand wagon. The case was at first treated as one of dislocation. 
After the lapse of four months, during part of which the limb was kept in a state of rigid 
extension, there was shortening of scarcely half an inch, and the thigh could be moved in 
every direction. Unfortunately there are no symptoms by which diastasis of the head 
of this bone can be distinguished from ordinary fracture of the neck. 
Fractures of the thigh-bone are much more frequent in children than is generally 
supposed. Coulon states that in one year 140 cases were admitted into the St. Eugenia 
Hospital at Paris. Of these, 20 affected the femur. This bone is occasionally broken 
during delivery. The youngest case that I have ever met with was an infant four weeks 
old, in whom the accident was caused by a child rolling over its thigh as it lay in bed. 
The obliquity in fractures of the thigh in children is generally considerably less than 
in adults, and cases are met with in which they are nearly transverse. Ilence the 
tendency to overlap is usually comparatively slight, although in some cases it amounts 
to several inches. A species of green-stick fracture is occasionally witnessed, similar to 
that of the bones of the forearm. 
In infants at the breast the treatment of this class of injuries is always attended with 
peculiar embarrassment and annoyance, owing, first, to the remarkable tendency to dis- 
placement of the fragments, and, secondly, to the constant liability of the dressings to 
be soiled by the discharges. To meet the first of these contingencies, the limb, after 
the subsidence of the inflammation and swelling, should be enveloped in a plaster of 
Paris bandage, and incased in two very light splints, either of wood, gutta-percha, or 
binder’s board, the outer one reaching from a short distance below the level of the foot 
to the crest of the ilium or even to the chest. Layers of wadding should be applied to 
ward off pressure, when the splints should be secured with adhesive plaster, and covered 
with a roller. A little additional support is generally necessary in front of the thigh. 
Soiling of the dressings is best obviated by a thick coating of gum-shellac, paraffin, or 
coaclunaker’s varnish, frequently renewed. The object of the long splint is to keep up a 
certain degree of extension, and to prevent the child from Hexing the pelvis upon the 
thigh. It is very important that the limb should be frequently examined, otherwise it 
may become shortened and crooked. The consolidation will be completed in from fifteen 
to twenty days. 
In children from five to ten years old 1 have usually found the most convenient and 
suitable apparatus to be a case made of stout, unoiled sole leather, long enough to extend 
from the groin to an inch and a half below the heel, and sufficiently wide to come well 
around the limb, especially the thigh. It is supplied with a foot-piece of the same 
material, and is well padded at its upper extremity, to prevent undue pressure upon the 
perineum. The outside portion of the trough is continued for some distance over the 
hip, to which it is secured by a spica, or common roller, carried around the thighs 
and pelvis. A splint, also of leather, binder’s board, gutta-percha, thin wood, or plaster 
of Paris, is stretched along the forepart of the limb from the groin to the patella, 
wadding being suitably interposed to ward off pressure ; the apparatus is held in place 
by means of an ordinary bandage, adhesive strips having previously been secured to the 
leg and attached to the foot-piece. The dressing is completed by placing the limb, with 
its apparatus, in an easy position upon a hair or cotton bolster, gradually tapering up- 
wards, its thickness below not exceeding four inches. By this simple contrivance I 
have always found it easy to obtain the requisite extension and counterextension, the CHAP. IX. 
WOUNDS. 
1039 
perineum affording a point d’appui which effectually prevents the ascent of the apparatus, 
while the foot-piece serves to keep the foot in place, at the same time that it receives the 
extending bands. 
When the patient is very restive, it may be necessary to emply long splints, connected 
below by a cross-piece crutched-shaped above, and provided with a foot-board, stretched 
along each side of the body, to which, as well as to each limb, they are attached by appro- 
priate belts or straps, so as to render the lower extremities perfectly immovable. The 
belt that passes around the pelvis must have an opening in it for the easy evacuation of 
the bowels. The plaster dressing, if properly applied, may be very serviceable in the 
treatment of fractures of children, notwithstanding what has been said to the con- 
trary. A splint made of this material, and closely fitted to the limb, forms an excellent 
support in fractures of the femur, when there is little or no tendency to displacement. 
Even when this tendency exists in a marked degree, the necessary extension can generally 
be readily made with the aid of such an apparatus, provided it be prolonged a few inches 
below the level of the sole of the foot, the adhesive strips being attached to the sides of 
the splint. 
In diastasis of the head of the bone, osseous union should, I think, always be looked 
for, if the case be judiciously managed. One important element in the treatment 
of such an injury obviously is compression, by suitable apparatus, of the hip, the. more 
effectually to prevent displacement. The extension should be steadily maintained for 
at least six weeks, and the trunk kept as quietly as possible. Passive motion should not 
be instituted under two months. 
CHAPTER IX. 
DISEASES AND INJURIES OF THE JOINTS. 
SECT. I WOUNDS. 
The joints are liable to be laid open in various ways—by cuts, stabs, punctures, balls, 
machinery, and other means—and hence such lesions are said to be incised, punctured, 
gunshot, contused, or lacerated, according to the nature of the vulnerating body. In 
extent they may be small or large ; in character, simple or complicated ; in effect, trivial 
or severe. 
The symptoms are generally sufficiently distinct. When any of the large joints are 
opened, whether by a cut, laceration, or bullet, the nature of the accident is ordinarily 
denoted by an immediate escape of synovial fluid, rapidly followed by great pain, tension, 
and swelling of the part, with severe constitutional disturbance. When the wound is 
very large, especially if it is of a gunshot nature, there will generally be, along with these 
symptoms, violent shock, the patient being deadly pale, faint, sick at the stomach, and 
slow in reaction. In from twelve to twenty-four hours after the accident, fever commonly 
sets in, often preceded by rigors, and soon succeeded by delirium, great gastric distress, 
intense thirst, and excessive restlessness, with a strong, full, bounding pulse. The 
local phenomena assume a more aggravated character. The heat, pain, redness, and 
swelling increase in intensity; the surface of the limb, at the seat of the injury, often 
assumes an erysipelatous aspect, sometimes as early as the first twenty-four hours after 
the accident, and the discharge of synovial fluid steadily augments in quantity, as well as 
in consistence, exhibiting a thick, ropy, turbid appearance ; or, if the wound is closed, 
and the fluid is retained, the joint becomes distended in every direction, but particularly 
in its more dilatable [tarts, the skin pits on pressure, and distinct fluctuation is perceived. 
The secretion now takes on a puriform character ; the patient has frequent rigors, alter- 
nating with flushes of heat, and followed by copious sweats ; the joint is exceedingly tense ; 
the synovial membrane is universally involved ; perforative ulcers form at different points; 
matter, often of a highly fetid nature, is freely discharged ; the bones are rendered cari- 
ous ; and the ligaments, softened and thickened, yield at various points of their extent. 
In many cases matter forms exterior to the joint, and is extensively diffused among the 
muscles and through the subcutaneous connective tissue. 
But it is not always that the affection progresses in this rapid and untoward manner. 1040 
DISEASES AND INJURIES OF THE JOINTS. 
In many instances, depending mainly upon the nature and extent of the lesion, and the 
character of the treatment, the inflammation, after having persisted for a few days, 
gradually disappears, and the patient recovers with hardly an unpleasant symptom, the 
joint, it is true, remaining temporarily stiff, but ultimately completely regaining its 
functions. 
All lesions of this kind, however, should be regarded with suspicion ; for, if they are 
not dangerous in the first instance, they are exceedingly liable to become so during their 
progress, and this is true of the most trivial wound as well as the most extensive. Some- 
times a fortunate recovery occurs in cases, apparently, of the most desperate character. 
Thus, 1 attended a lad, fourteen years of age, who, while bathing, struck his knee against 
the sharp point of a rock, causing a severe penetrating wound, which healed without any 
serious local or constitutional symptoms, ulthough it was at first in all respects most 
unpromising. In another instance, the knee-joint was opened by a pistol ball, entering 
by the side of the patella, and permanently lodging in one of the condyles of the femur, 
with no other effect than that of a moderate synovitis, and slight lameness. 
Simple incised wounds are generally less to be dreaded than lacerated and gunshot, 
although undoubtedly many cases occur where the symptoms are extremely severe, and 
where the risk to limb and life is very great. It may also be assumed that wounds of a 
small joint are less dangerous than similar injuries of a large joint, incised than lacerated, 
small than large, and simple than complicated; the lesions, in these respects, being 
governed by the same laws as wounds in other parts of the body. There are several cir- 
cumstances, however, which render wounds of the joints, especially the more important 
ones, as those of the knee, ankle, and elbow, peculiarly perilous, and which are the more 
to be dreaded because they are of frequent occurrence. These are erysipelas, pyemia, 
and tetanus. 
Erysipelas, as a consequence of articular wounds, usually sets in within the first thirty- 
six hours, beginning at the site of injury, and spreading thence gradually over the neigh- 
boring surface. Its precise type will depend materially upon the state of the system at the 
time of the accident; its symptoms exhibit nothing peculiar, but its progress is often very 
rapid, and its presence is always denotive of a bad state of the constitution, which it is 
frequently difficult to counteract by remedies. 
Pyemia and septicemia are frequent results of wounds of the larger joints, especially 
when of a lacerated, contused, or gunshot nature. Abscesses of the internal organs, as a 
consequence of pyemia, were occasionally noticed by some of the older surgeons. The 
viscera which are most liable to suffer are the lungs, liver, spleen, and kidneys, the dis- 
ease usually appearing within the first five or six days, and speedily undermining the con- 
stitution. Large accumulations of pus occasionally take place in various parts of the 
connective tissue and in the splanchnic cavities, particularly the thoracic. As a concom- 
itant of this occurrence, important changes take place in the local symptoms. The pain 
becomes extremely intense, the swelling rapidly increases, and the wound discharges an 
abundant fluid, of a thin, sanious, and highly fetid character, denotive of the bad nature of 
the inflammation. The general phenomena are typhoid, the patient is delirious, and death 
soon closes the scene. 
Tetanus is an occasional occurrence after injuries of this kind, but not so frequent a 
one, perhaps, as is generally supposed. It usually comes on within the first week after 
the accident, and often terminates fatally in three or four days, few persons recovering 
from its effects. The occurrence is much more common in military than in civil practice. 
The hemorrhage attendant upon wounds of the joints, although generally trivial, is 
occasionally very profuse, not always so much from lesion of the articular vessels them- 
selves as from injury sustained by those in the immediate vicinity. When from any 
cause the blood accumulates in the articulation, it will be very apt to act as an extraneous 
substance, undergoing decomposition, and thus greatly aggravating the case. 
Although injuries of this kind are generally attended with an escape of synovial fluid, 
there are cases, as when the wound is very long and narrow or valvular in its shape, in 
which there is no such appearance. Moreover, it must not be forgotten that in fat sub- 
jects wounds over a joint may furnish a fluid which closely resembles the synovial, but 
differs from it in being destitute of the oleaginous feel, which distinguishes the latter 
when rubbed between the fingers. 
Treatment.—The treatment of these wounds is sufficiently simple, inasmuch as it in- 
volves no principles different from those which guide the surgeon in the management of 
similar lesions in other regions of the body. It consists, mainly, in removing extraneous 
CHAP. IX. WOUNDS. 
1041 
CHAP. IX. 
matter, approximating the edges of the incision, excluding the admission of air, forbidding 
all motion of the joint, and employing antiphlogistics to their fullest extent. 
In a simple incised wound, a few strips of adhesive plaster generally suffice to effect 
approximation, and the risk of admitting air will be greatly diminished, if the part be 
covered with a compress wet with blood, and bound down by a roller, extending from the 
distal portion of the limb. Collodion, applied upon strips of patent lint, often makes an 
excellent dressing. If the.wound is large, a few sutures may be necessary, carried, of 
course, merely through the common integument. When the wound is very ragged, the 
edges should be carefully pared, to place them in a better condition for immediate reunion. 
No air must be allowed to enter the joint, lest it cause decomposition of the inflammatory 
products. 
When the wound is large, the synovial membrane may be covered with extraneous 
matter, as dirt, sand, or other substance, which may not only prove difficult of removal, 
but will be sure to enhance the danger of erysipelas, pyemia, and tetanus. Clearance 
must be thorough, and the finger and forceps will be the best instruments for effecting it. 
Any clotted blood that may exist must be similarly dealt with. If the foreign matter is 
deeply imbedded in the joint, and the wound is disproportionately small, rendering a 
search for it difficult and uncertain, the safest plan will be to let it alone. Balls ought 
certainly always to be treated in this manner. If, on the contrary, the projectile lie 
loose in the articulation, it should unquestionably be extracted at once, and so with every 
other movable or floating body, provided it is readily accessible, or that it can be taken 
away without the risk of inflicting serious additional injury. All officious interference, by 
finger, probe, or other instruments, must be scrupulously avoided, as the synovial mem- 
brane is exceedingly intolerant and resentful of manipulation, however gently conducted. 
Needles imbedded in a joint should be extracted without delay, and at all hazard, 
otherwise the most serious effects, as violent inflammation, suppuration, and ankylosis, 
will be sure to arise. The proper plan is to make a sufficiently large incision to obtain 
ready access to the foreign body without the risk of bruising and irritating the soft struc- 
tures, the wound being immediately made air-tight by suture and collodion, and the 
limb placed upon a suitable splint, with the muscles in an easy, relaxed position. Mor- 
phia and quinine should be freely administered, and the joint enveloped in pounded ice, 
to prevent undue reaction. 
When there is no prospect of union by the first intention, or when the condition of the 
wounded joint is such as to render suppuration inevitable, the proper plan is to draw the 
edges of the gap lightly together with adhesive strips, and to employ at once medicated 
applications, as lotions of acetate of lead and opium, or emollient cataplasms. 
The joint is maintained in an easy, elevated, and relaxed position, Jill motion being 
guarded against by the use of splints and other suitable means. If the inflammation run 
high, and the patient is young and plethoric, blood is drawn from the arm, or, at all 
events, by leeches from the affected parts, the bowels are thoroughly moved, and the 
heart’s action is controlled by depressants. Morphia, in large quantity, will be required 
to relieve pain and spasm ; and there is hardly a case, certainly no severe one, where it 
will not be proper to combine calomel with the anodyne, with a view to its speedy effects 
upon the system. The acknowledged efficacy of mercury in all inflammations of the 
serous textures clearly points to its administration as a matter of paramount importance 
here. It not only exerts a most happy influence upon the capillary vessels of the diseased 
membrane, modifying and changing their action, but it is a powerful sorbefacient, caus- 
ing the removal of effused fluids. Its effects, however, must be carefully watched, lest 
they exceed our intention, which is only to cause tenderness of the gums, not positive 
ptyalism. Along with these general measures, local remedies must be used, of which the 
most trustworthy are evaporating lotions, the early and energetic use of ice, and inter- 
mittent, digital compression of the main artery of the limb. 
During the progress of the treatment, matter may form within the joint, and become 
pent up for the want of an adequate outlet. Under such circumstances, relief must be 
afforded by a valve-like aperture, the puncture being immediately closed by collodion, 
and afterwards reopened as occasion may demand. When the quantity of pus is very great, 
pressing upon the joint in every direction, a free, direct incision should be made to admit 
of full drainage. It has always appeared to me that surgeons are too timid in these 
cases, and that they do not sufficiently cooperate with nature in her efforts at relief. It 
is not necessary here to describe the pernicious consequences which purulent accumula- 
tions, especially if long retained, must inevitably exert upon the component elements of 
the articulation. They can be nothing short of utter ruin of the synovial membrane, ear- 1042 
DISEASES AND INJURIES OF THE JOINTS. 
tilnge, and bone. Early evacuation must also be effected, if matter form immediately 
around the joint, beneath the skin, and among the muscles. 
When the discharge is profuse and offensive, injections of infusion of linseed, slightly 
medicated with the chlorides, will be of service; they should be thrown in tepid, several 
times in the twenty-four hours, and may occasionally be advantageously followed by the 
introduction of very weak solutions of iodine, or of nitrate of silver, with a view of modi- 
fying the action of the synovial membrane. Too much caution, however, cannot be used 
in the application of these remedies, as the inflamed membrane is often exquisitely 
sensitive, and intolerant of such interference. 
Whenever there is extensive suppuration, the parts will either recover by ankylosis, 
or the cartilage and bone will become so involved in the disease as to require removal. 
In the former case, the joint should be placed in the best position for future convenience 
and usefulness; while in the latter the affected structures should either be excised, or the 
limb amputated. The choice of the operation must be regulated by circumstances. If 
the inflammation has measurably subsided, and the patient’s strength is not too much 
exhausted, the joint may possibly bear excision ; in all cases of an opposite character, 
removal of the limb will be the safer operation. 
In the milder forms of wounds, unattended with risk to limb or life, the great point is 
to guard against ankylosis, which is so liable to occur even in the most trivial affections 
of the articulations. Passive motion, sorbefacient embrocations, and the gradual use of 
the limb, will be the surest means of success. 
Primary amputation will be required when the joint is severely shattered, whether by 
gunshot or otherwise, and the external opening is unusually large, or complicated with 
lesion of the principal vessels and nerves of the limb. It may be assumed, as a rule, that 
gunshot wounds of the large articulations of the extremities are nearly always fatal if 
amputation is not speedily employed. The same is true, although in a more limited sense, 
of gunshot injuries of the joints of the toes and fingers, in which tetanus and other bad 
effects are prone to ensue. When, as occasionally happens, the articular surfaces are 
covered with foreign matter, which it is impossible to detach without injury to the syno- 
vial membrane, the safest plan will be to amputate the limb. Conservative surgery in 
such a case is decidedly bad surgery. 
./) I 
SECT. II CONCUSSION. I/, Ul 
— J * 
The joints, like other parts of the body, are liable to concussion, the effect of the 
forcible contact of their surfaces; and such accidents may occur in various degrees, from 
the slightest disturbance to the most violent commotion. Blows and falls, operating either 
directly upon the part or indirectly through some intermediate structure, are the most 
common causes of the occurrence. The force inflicting the injury is generally transmitted, 
as is exemplified when a person falls from a great height and alights upon his feet, where 
the force, instead of being expended upon the parts struck, is sent along the leg to the 
knee, and thence through the thigh to the hip, the latter, perhaps, receiving the main 
brunt of the blow. When the concussion is very severe, the joint may be more or less 
contused, and it may even be attended with fracture of the articular extremities of the 
bones. In such an accident, shock is conjoined with contre-coup. The joint, instead of 
transmitting the shock, is severely concussed, the force being concentrated upon its ana- 
tomical elements, the adjoining structures escaping with but little injury, although there 
may occasionally be slight laceration of some of the ligaments. The effect may be limited 
to one joint, or it may involve several, as when a person falls from a considerable height 
and alights upon his feet or knees. In this way excessive shock of the spinal column is 
often produced, every joint being violently shaken, at the same time that more or less of 
the force is transmitted to the spinal cord, its envelops and nerves, causing an amount of 
injury which, if not immediately fatal, is often followed by the most serious consequences. 
Concussion of a joint is occasionally produced by very slight causes. Thus, I have been 
several times consulted on account of severe pain and lameness of the fingers, produced by 
striking the keys of the piano; and there are few persons who have not experienced a 
similar effect in the toes, from knocking their extremities forcibly against a stone or some 
other hard, resisting body. 
When a large joint is severely concussed, the symptoms will be those of ordinary shock, 
and some time may, therefore, elapse before the patient recovers from the immediate 
effects of the injury. In many cases, indeed, the parts continue to be weak, tender, and 
stiff for an indefinite period, if not during the remainder of life. A very singular, if not 
CHAP. JX. CHAP. IX. 
SPRAINS. 
1043 
unique, ease of this kind, occurring in the hip-joint, was recently reported by Dr. W. H. 
Daly, of Pittsburgh, and affords a beautiful illustration of the nature of this class of 
affections. A very strong, muscular man, twenty-three years of age, in the act of jumping 
suddenly out of bed, while the foot was forcibly abducted, and the whole weight of the body 
thrown upon the corresponding side of the pelvis, tore away the round ligament from its 
acetabular attachments, and violently contused the head of the femur at its postero-superior 
circumference over a space of two inches in length by one inch in width. No signs 
of fracture or of dislocation existed, and, what was very remarkable, the man walked 
four miles the day after the accident, although not without severe pain. Violent inflam- 
mation ensued, followed by death from tetanus at the end of thirty-six days. The structures 
around the joint were greatly softened and infiltrated with bloody serum, while the 
articular cartilages at the points of injury were disintegrated, pulpified, and partially 
removed by ulcerative absorption. No pus was found, and the capsular ligament was 
intact. In subjects predisposed to scrofulous disease, a bad form of synovitis is apt to 
arise, followed eventually, if the parts do not receive proper attention, by complete disor- 
ganization of the injured joint. In gouty and rheumatic persons, a slow, chronic inflam- 
mation is not unfrequently set up, causing severe pain and difficulty of locomotion, and 
leading to serious alteration of structure, as ivory degeneration of the bones and cartilages 
and the development of exostoses around the articulation. 
The treatment of this class of injuries is sufficiently obvious. The great point is to 
keep the parts perfectly at rest, in an immovable position, insured, if necessary, by appro- 
priate splints. For the first few days the affected joint should be wrapped up in cloths 
wet with a strong solution of acetate of lead and opium ; or, if the injury has been unusu- 
ally severe, surrounded with a bladder partially filled with pounded ice. Leeches may 
be required when there is danger of active inflammation. Anodynes are given to allay 
pain and spasm. After the primary effects of the injury have passed off, passive motion 
is instituted, the hot and cold douches applied, and free use made of liniments and embro- 
cations, along with gentle exercise, care being taken for some time not to bear much 
weight upon the affected structures. 
SECT. Ill SPRAINS. 
A sprain is the wrenching of a joint in which its ligaments are severely stretched, if 
not partially torn, and more or less injury is done to the parts around. Falls, blows, and 
twists, attended with rotation of the articulating surfaces, or a movement of these surfaces 
in opposite directions, are the most common causes of the accident. 
The joints most liable to sprains are the ginglymoid, or those which admit of motion 
principally in two directions, as the knee, ankle, and elbow. The articulations of the 
toes, thumb, and fingers frequently suffer for the same reason, their functions and exposed 
situation rendering them especially prone to such accidents. The reason why the orbicu- 
lar joints are so seldom affected in this way is their greater latitude and freedom of motion, 
their surfaces being thus enabled to undergo extensive rotation without putting their 
ligaments or the surrounding parts materially upon the stretch, whereas in the hinge-like 
joints the most trivial twist, by opposing a sudden check to their extremities, must neces- 
sarily cause a severe wrench. Moreover, it must not be forgotten that there is an essential 
difference in the structure of the ligaments themselves in the two classes of joints, which 
cannot fail to exert a powerful influence upon the production of the accident in question. 
In the orbicular joints the connecting media are of a fibrous texture, comparatively thin, 
\yielding, and extensible, and, therefore, able, to a considerable extent, to get out of the 
way of injury ; in the ginglymoid, on the contrary, the ligaments are exceedingly firm, 
short, and indisposed to stretch, or, when stretched, incapable of withstanding rupture of 
their fibres. The orbicular joints are, however, notwithstanding their greater latitude of 
motion and the more yielding nature of their ligaments, occasionally severely sprained in 
consequence of the extreme abduction of the limbs. Thus the ilio-femoral articulation is 
sometimes violently sprained by the sudden slipping of the foot outwards, far beyond the 
line of the body, so as to put both the capsular and round ligaments strongly upon the 
stretch, inducing symptoms extremely simulative of dislocation of the head of the bone 
into the thyroid notch. 
It is probable that there is, in every case of severe sprain, more or less injury inflicted 
upon the parts in immediate relation with the affected joint. The muscles and tendons 
must necessarily j articipate in the wrench, sustaining partial displacement, and sometimes 
even slight laceration ; the nerves and vessels are stretched, and the skin is often bruised 1044 
DISEASES AND INJURIES OF THE JOINTS. 
and discolored, especially when the accident lias been the result of external violence. In 
the latter case, the articulating surfaces, being violently brought together, not only ex- 
perience severe shock, but a considerable degree of contusion, thus greatly aggravating 
the suffering. Now and then, indeed, small portions of cartilage, or even of bone, are 
chipped off or partially displaced, but still slightly adherent to the sprained ligament, con- 
stituting what is known as the sprain-fracture, particularly common in the ankle-joint. 
The symptoms denotive of sprain are, the instantaneous occurrence of pain, referred to 
the affected joint, impairment, if not total loss, of motion, and a sense of faintness or sick- 
ness, caused by the shock of the system, which is sometimes extremely severe, even when 
no external injury has been sustained, the accident having been induced merely by a 
wrench or twist of the limb. If some time have elapsed since the accident, there will be 
swelling and tenderness of the integument, as well as of the deeper structures, and prob- 
ably also an indistinct perception of crepitation, depending upon the deposit of plastic 
matter. Discoloration of the surface, from extravasation of blood, is also very common. 
The pain is often excessive, especially soon after the accident, and quite overpowering in 
its effects. 
The oidy accidents with which a sprain is liable to be confounded are dislocation and 
fracture; from which, however, it may generally be readily distinguished by a careful 
manual examination, by the form of the joint, by a comparison of the length of the affected 
limb with that of the sound one, by the history of the cause of the lesion, and, lastly, by 
the fact that the patient is usually able to use the parts, at least to some extent, imme- 
diately after the receipt of the injury. In fracture the most reliable symptom is crepita- 
tion. The examination should always be most thorough, lest a luxation or fracture be 
idtimately found, perhaps when too late to effect reduction, where originally only a sprain 
was suspected. 
When the sprain is slight, the pain gradually subsides, the swelling is resolved, and 
the joint soon regains its accustomed functions. It is far otherwise, however, when the 
injury is of an opposite character, or attended with severe wrenching of the ligaments, 
violent contusion of the articular surfaces, and considerable lesion of the surrounding 
parts. The suffering will then be proportionately great, inflammation will be apt to 
run high, convalescence will be tedious, and the joint may remain weak and tender for 
many months, if not for years. A severe sprain, in fact, is often a much more serious 
accident, as it respects its secondary effects, than a dislocation or a fracture near a joint. 
In neglected or ill-treated cases, and sometimes even when every possible precaution has 
been adopted, the articulation continues not only to be weak and uncomfortable for a long 
time, but the corresponding limb becomes cold, wasted, flabby, and exquisitely sensitive; 
perhaps also the seat of neuralgic pain, subject to severe exacerbation whenever exercise 
is attempted, or there is a change in the weather. Occasionally, indeed, the movements 
of the joint are permanently lost. Conjoined with this local trouble there is generally 
grave disorder of the general health, the patient being extremely nervous, irritable, and 
dyspeptic, fancying himself helpless and disqualified for all useful exertion, both of mind 
and body. The probable cause of all this suffering is the shock or concussion sustained 
by the nerves of the affected joint at the moment of the accident, the effect thus produced 
exercising a pernicious influence upon the nutritive functions of the whole limb, and indi- 
rectly upon the well-being of the general system, especially the great nervous and gan- 
glionic centres. 
Treatment.—The leading indications in every case of sprain, whether light or severe, 
are, first, to limit and combat inflammation, and, secondly, to restore the joint, if possible, 
to its wonted functions. The former is fulfilled by the judicious use of antiphlogistics; the 
latter, by sorbefacients, passive motion, and exercise in the open air. 
As soon as the affected joint has been properly examined, the limb connected with it is 
carefully bandaged, and placed perfectly at rest in an easy, elevated, and relaxed position, 
splints, a wire case, or a wooden box being used, if necessary, to insure more certain 
quietude and support. Sometimes the object is readily attained by laying the limb sim- 
ply upon a pillow, although in warm weather this will be objectionable, as tending to keep 
up too much heat. Fomentations will usually be found to be more agreeable and soothing 
than cold applications, especially during the first few days, in nervous, irritable subjects; 
and the one which I generally prefer is a strong solution of acetate of lead and opium in 
hot water, applied by means of a piece of flannel, arranged in three, four, or six layers, 
and covered with oiled silk, to confine the heat and moisture. Instead of removing the 
cloth whenever it becomes dry, the best plan is to squeeze the lotion upon it from a sponge, 
as this will obviate injurious motion and exposure to the atmosphere. Solutions of chloride 
CHAP. IX. CHAP. IX. 
SPRAINS. 
1045 
of ammonium and opium, a mixture of warm water, laudanum, and alcohol, and thin bags 
of hops, will also be found extremely soothing. Occasionally pounded ice, applied in a 
bladder, is more agreeable than any other local remedy, especially in young, plethoric 
subjects. In sprains of the ankle-joint, excellent effects frequently follow the protracted 
immersion of the limb in hot lye or hot salt water. When the pain and swelling are un- 
usually severe, leeches will be necessary; and great benefit will then also accrue from the 
localized steam bath, applied twice a day for an hour at a time. Anodynes are given to 
allay muscular spasm. Purgatives must not be neglected ; and constitutional excitement 
must be allayed in the usual manner. In short, the antiphlogistic system must be carried 
out in its fullest extent. 
When warm applications disagree, or fail to give relief, they should be replaced by cold, 
consisting either simply of water, of ice, or of some refrigerating mixture. The proper 
rule, in ali cases, is to continue no remedy longer than it is found to be soothing and bene- 
ficial. The bandage must be carefully watched ; judiciously employed, its effects are 
usually highly advantageous, affording support to the injured joint and limb, preventing 
swelling and spasm, and promoting the absorption of effused fluids. 
In the milder forms of sprains, more simple means will, of course, answer, such, tor 
instance, as applications of the tincture of arnica, laudanum, or laudanum and spirit of 
camphor, together with perfect quietude of the affected parts. In cases of this description 
the immediate application of the immovable bandage affords almost instantaneous relief, 
and materially shortens the cure. 
The urgent inflammatory symptoms having been thus dissipated, embrocations, lini- 
ments, or lotions will be of use, the object now beinz the removal of effused fluids and the 
gradual restoration of the functions of the joint. These should be applied at first once, 
and afterwards twice, a day with the bare hand, the friction being regularly increased as 
the pain and tenderness diminish, and it will be well generally to keep the parts wet with 
the medicine by means of a piece of flannel. Whatever local remedies be used, the ban- 
dage must on no account be neglected; for, beneficial as it may have been in the first 
instance, its effects will now be incomparably more so. The limb, weakened by the pre- 
vious suffering, requires tone and support, and there is nothing so well adapted to promote 
this object as the careful and judicious employment of the roller. It should be renewed 
at least once a day. Sometimes the bandage may be advantageously replaced by adhesive 
strips, applied as in dressing indolent ulcers. 
At a still later stage of the treatment, great benefit may be expected from the cold 
douche, the water being pumped upon the part, or poured from a considerable height, and 
the surface well rubbed afterwards with the bare hand, or a piece of coarse flannel. In 
some cases, where a more powerful impression is necessary, it will be found highly advan- 
tageous to precede the cold by the hot douche. Along with these means, the use of the 
bandage is still steadily continued, and it may even be necessary to. persist in the employ- 
ment of stimulating embrocations. In very obstinate cases I have occasionally derived 
marked benefit from the daily application of fish-brine, rubbed on well with the bare 
fingers. Sometimes a blister affords more relief than any other remedy, and now and 
then electricity is advantageous. 
As soon as the disease has reached the chronic stage, the joint must be gently exercised, 
and the patient made to walk about upon crutches in the open air. As great care should 
always be taken, in the acute stage, not to move the parts too soon, so in this its employ- 
ment must not be too long postponed. Motion is the proper stimulus of a joint, as air is 
of the lungs, or food of the stomach, and when, after any injury, it is long neglected, 
serious consequences will be sure to arise. By and by the crutch must be laid aside for 
the cane, and this in turn for the limb, the joint and muscles being gradually forced into 
action. In nervous, hysterical persons this will often be a sore trial, requiring no ordinary 
effort of the will; nevertheless, it must be done; there is no alternative; the parts must 
be used, or they will inevitably remain stiff and tender, and ultimately become worthless. 
Massage is of great value sometimes even in cases of recent sprains, and when properly 
practised, is extremely beneficial, rapidly relieving pain and swelling, and promoting the 
restoration of the functions of the affected joint. It must, of course, not be employed too 
rudely at first, or repeated too frequently. One application a day, or even every other day, 
will be quite sufficient, if continued for fifteen to twenty minutes at a time. 
When there is much constitutional suffering, as there often is in the more severe forms 
of sprains, alteratives and tonics will be needed, the most suitable being blue mass, qui- 
nine, iron, iodide of potassium, and bichloride of mercury. Exercise in the open air must 
not be neglected. 1046 
DISEASES AND INJURIES OF THE JOINTS. 
CHAP. IX. 
SECT. IV. SYNOVITIS. 
Inflammation of the joints, technically called synovitis, is liable to occur in all articu- 
lations, but more especially in the large and more important, and may be induced by 
various causes, both local and constitutional, as exposure to cold, the presence of inter- 
articular bodies, and mechanical violence, as sprains, blows, falls, and contusions. In the 
great majority of cases, however, it arises from the effects of rheumatism, gout, eruptive 
fevers, syphilis, scrofula, and the inordinate use of mercury. 
The symptoms characterizing inflammation of the synovial membrane are, stiffness of 
the corresponding joint, usually greatest in the morning immediately after rising, but 
gradually diminishing upon exercise; pain and tenderness on moving and percussing the 
limb ; swelling and fluctuation of the affected part; a pale, glossy appearance of the skin ; 
inability to maintain the extended position ; and a sense of heat within the articulation. 
As the disease progresses the symptoms increase in severity, and the system, sympathizing 
with the local disorder, is thrown into violent commotion, there being high fever, a full, 
bounding pulse, and an arid state of the skin, with excessive thirst, and all the other phe- 
nomena of inflammatory excitement. In this condition the pain is generally very excru- 
ciating, especially . t some particular spot, depriving the patient completely of appetite 
and sleep, and requiring opiates in large doses for its relief. 
The disease, however induced, frequently comes on in a slow, gradual, and insidious 
manner, even when caused by external injury, being characterized, perhaps, merely by a 
trifling enlargement of the joint, arising from an increase of syno- 
vial fluid within its cavity, or partly from this and partly from 
inflammatory deposits in the surrounding structures, attended with 
some degree of tenderness on pressure, and more or less suffering 
on motion of the affected parts. Eventually, however, yet it may 
not be under several weeks, or even months, the joint assumes a 
soft and really swollen appearance, as in fig. 596, the limb be- 
comes wasted, the functions of the articulation are materially im- 
paired, and all the symptoms are aggravated. 
In rheumatic synovitis the symptoms are usually bold and well 
marked from the start. The attack often comes on in the follow- 
ing manner. The patient, having been exposed to cold, or been 
guilty of some excess in eating or drinking, retires at night with 
some degree of soreness in his joints, commonly attended with a 
general feeling of uneasiness, and wakes up in the morning with 
excessive pain, great tenderness on pressure of the affected parts, 
with considerable discoloration of,the surface, and, probably, utter 
inability to use his limb. He is feverish and uncomfortable ; his 
pulse is strong and full; the skin is hot and dry; the bowels are 
costive ; and the urine is scanty, high-colored, and loaded with 
urates. The joints become gradually more deeply involved ; all 
the local symptoms increase in violence; an abundance of syno- 
vial fluid is effused; and, if the inflammation is not speedily ar- 
rested, suppuration will probably take place, the event being 
preceded and accompanied by rigors and high constitutional excitement. The joints 
most liable to sutler from rheumatic synovitis are the knee, ankle, wrist, and elbow, those 
of the hip and shoulder being seldom involved. The articulations of the fingers also 
frequently suffer, and that of the great toe rarely escapes when the disease in the other 
joints is at all severe. The inflammation often begins simultaneously in several joints; 
or, if it commence in one, it is extremely apt to involve others in its progress, especially 
its fellow of the opposite side. Thus, articular gout or rheumatism of one knee nearly 
always attacks the other knee before it finally ceases. 
In chronic articular rheumatism, calculous concretions are liable to form, especially 
in the joints of the fingers, where they always prove a source of great incovenience and 
suffering. Their character will be specially considered under the head of interarticular 
bodies. 
Syphilitic synovitis belongs to the tertiary form of syphilitic disease, and seldom 
makes its appearance until several years after the primary affection. It is most fre- 
quently met with in persons whose health has become exhausted by profuse courses of 
mercury and habitual intemperance. The larger articulations, especially those of the 
knee and elbow, are its most common seat; but the smaller ones, as those of the fingers, 
Fig. 596. 
Acute Synovitis of the 
Bight Knee. CHAP. IX. 
SYNOVITIS. 
are by no means exempt from it. A good deal of effusion of synovial fluid usually attends; 
the joint, in consequence, is swollen and fluctuating, motion is impeded, the parts are 
tender on pressure, and the patient is harassed by excessive pain, which is always worse 
at night, after he becomes warm in bed. This latter circumstance, together with the 
history of the case, and the coexistence of syphilis in other structures, will always suffice 
to determine the diagnosis. 
Of strumous synovitis particular mention will be made under a separate head; mean- 
while, it is only necessary to state that the disease is almost peculiar to childhood, that it 
most commonly attacks the hip, knee, or elbow, and that it occurs only in persons of a 
strumous predisposition. 
Suppuration, as a consequence of ordinary synovitis, is unusual. Arthritic inflam- 
mation of the joints also rarely terminates in the formation of pus, and a similar remark 
is applicable to articular syphilis ; in scrofulous affections of the joints, on the contrary, 
suppuration is extremely common, and constitutes one of the great dangers of the disease. 
The phenomena which announce the formation of matter are usually unequivocal. 
After the disease has continued for some time, violent rigors set in, followed by high 
constitutional reaction and copious sweats, the patient being delirious, excessively 
restless, and tormented with thirst. All the local symptoms are greatly aggravated, as 
is shown by the severity of the pain, the rapid increase of the swelling, the extraordinary 
heat, and the deep discoloration of the skin. If the pus is not speedily evacuated, 
hectic irritation supervenes, the appetite declines, the sleep is interrupted, the surface is 
drenched with perspiration, colliquative diarrhoea sets in, and death gradually closes the 
scene. This, however, is not constantly the course pursued by the disease. In many 
cases ulceration takes place, and the matter, thus finding vent, ceases to commit further 
ravages, although generally not until the cartilaginous and osseous tissues have become 
deeply involved in the mischief, and the patient, consequently, is doomed to carry out a 
miserable existence, with a stiff joint and a deformed limb, or to perish from the remote 
effects of the disease, after many months, if, indeed, not several years, of great suffering. 
A joint that has once been inflamed from any cause whatever, remains long weak, and 
predisposed to disease, the most trivial circumstance tending to induce relapse, and to 
reawaken the symptoms in all their primitive severity. A frequent repetition of the 
morbid action must necessarily, by degrees, lead to disorganization of the component 
structures of the joint and to more or less extensive adhesions between the contiguous sur- 
faces, eventually followed by complete loss of function. 
The pathological changes which characterize this affection must necessarily vary a 
good deal, according to the nature of the exciting cause, and the duration of the morbid 
action. In the earlier stages of the disease there ordinarily is merely some degree of 
vascularity, along with slight opacity of the affected membrane, and some increase of 
the natural secretion. Here and there a little plastic matter is perceptible, either adhe- 
rent to the inflamed surface, or floating about in the midst of the synovial fluid, which is 
usually, at the same time, more or less turbid, and abnormally thick and viscid. At a 
subsequent period, and especially in the more severe forms of the disease, these morbid 
appearances exist in a still higher degree. There is a greater amount of lymph, the 
vascularity is more intense, as well as more diffused, and the synovial secretion is of a 
dirty, glutinous nature. In some instances pus is freely poured out, and lining mem- 
brane, cartilage, and bone are all involved in the ruinous consequences. In the worst 
cases, the purulent fluid, exciting perforative ulceration, escapes from the joint, the pas- 
sages afterwards remaining fistulous. The surrounding structures are thickened by plastic 
deposits, softened, or softened at some points and indurated at others, and unnaturally 
red and congested. 
Treatment When the disease is one of ordinary character, depending upon traumatic 
causes, or ordinary constitutional derangement, as a depraved condition of the secretions, 
or upon suppression of the cutaneous perspiration, it will generally be found to yield to 
the judicious application of the more common antiphlogistic measures, such as would be 
indicated in common inflammation of other parts of the body. If the symptoms are at all 
urgent, and the patient is young and robust, blood must be freely taken from the arm, 
and the bowels opened with an active cathartic, followed by antimonial and saline prepa- 
rations, with the addition of a sufficiency of morphia to promote perspiration, allay pain, 
and induce sleep. Mercury is administered when there is danger of structural lesion, or 
evidence of plastic effusion, and is carried to the extent of rapid but gentle ptyalism, with 
the hope of saving texture and preventing adhesion. The diet is light and spare; the 
drink cooling and acidulated. 1048 
DISEASES AND INJURIES OF TIIE JOINTS. 
As it respects the local means, the joint is placed in an easy, elevated, and relaxed 
position, over a pillow or bolster, the limb being put up, it' necessary, in splints, or other 
suitable apparatus, for the purpose of more certainly insuring quietude. The rest must 
be absolute and unconditional. If the affected surfaces are permitted to rub against each 
other, even in the slightest degree, the effect must inevitably be to aggravate and protract 
the morbid action. 
Of direct topical applications the most important are leeches and fomentations. Leeches, 
however, are, as a general rule, only necessary in the more urgent cases, attended with 
great pain, heat, and swelling, and then they should be employed freely, in such numbers 
and in such a manner as the violence of the disease and the condition of the system 
may seem to indicate. Cupping is not to be thought of in inflamed joints, as the per- 
cussion attending the operation causes more injury than benefit. In young and otherwise 
healthy subjects, especially in hot weather, cold applications, medicated freely with 
laudanum, are sometimes exceedingly grateful and beneficial, promoting evaporation, 
allaying pain, and opposing swelling ; but, in general, warmth combined with moisture 
will he found to be most soothing and agreeable. The best plan, however, always is to 
consult the feelings of the patient, or to change the applications whenever they cease 
to be beneficial. When these means fail, or when the disease is making rapid progress, 
there is no remedy so capable of affording relief as a blister, large enough to cover 
in the whole joint, well sprinkled with morphia, and retained until it has produced 
thorough vesication, the parts being dressed afterwards with a light, emollient poultice 
or with cloths wrung out of warm water, with a piece of oiled silk over the surface to 
confine heat and moisture. Cantharidal collodion is generally preferable, as a vesicant, 
to the common blister, as the latter is often adapted with difficulty to the shape of the 
affected joint. 
If matter form, it is to be dealt with in the same manner as in other parts of the body. 
It is folly to look upon it in any other light. It is pent up, and, as it is not amenable 
to the action of the absorbents, it must be evacuated as early as possible, before it has 
caused any serious structural evil. The employment of the aspirator generally affords 
excellent results, except when the matter is unusually thick, when an incision must 
be made, not, of course, direct or large, but subcutaneous and small, the orifice being 
immediately closed to prevent the admission of air. A timid, cautious course does not 
answer here ; so long as the pus is confined it must keep up pain, and injure the structures 
with which it lies in contact ; impairing and ultimately destroying their vitality, and 
thus putting both limb and life in imminent peril. The opening should always be made 
at a dependent part, and be repeated from time to time until the matter ceases to accumu- 
late, the joint being well supported in the interval by a bandage, or by a roller and adhe- 
sive strips. In some cases the joint may be so completely distended with pus as to 
demand imperatively a free direct incision for its relief; a course of treatment upon the 
importance of which I have strenuously insisted for more than a third of a century in my 
annual courses of lectures. When ulcerative perforation has taken place, free drainage 
must be established, and it is in such cases that the seton passed through the joint,as recom- 
mended by Sayre, may occasionally be advantageous. In any event, antiseptic dressings 
must be employed. 
The surgeon need not always despair of effecting a good cure even after suppuration has 
taken place, if the above measures are cautiously carried out; the joint will probably be 
stiff’, but it should be recollected that an ankylosed joint is always better than no joint at 
all, provided it is put in a proper position for future usefulness. 
When the disease has passed into the chronic stage, the main reliance must be upon 
the steady, persistent use of the bandage, the douche, stimulating lotions, and friction. 
The joint is showered twice a day, first with hot, and immediately after with cold water, 
when, being dried, it is thoroughly rubbed with some embrocation, or mild mercurial 
ointment, or painted with a weak solution of iodine, and put up in a roller, extending 
from the distal portion of the limb. Passive motion is instituted, and steadily continued 
so as to make gentle and equable friction upon every part, until there is complete restora- 
tion of the functions of the joint. Gentle exercise must be taken upon crutches in the 
open air ; and for a good while, the limb must not be permitted to sustain the full weight 
of the body. In some cases the joint may be advantageously strapped with ammoniac 
and mercurial plaster, or a plaster composed of opium and galbanum, to promote the 
absorption of effused fluids, and lend support to the weakened structures. Compression 
with a wet sponge is also a most valuable remedy in such an event. If the case prove 
obstinate, the fluid may be removed by aspiration, and the joint be subsequently strapped, 
CHAP. IX. CHAP. IX. 
DROPSY OF THE JOINTS. 
1049 
when the remaining symptoms may be scattered by the use of iodide of potassium with a 
minute quantity of bichloride of mercury, given three times a day, and pushed to gentle 
ptyalism. When ankylosis is found to be unavoidable, all motion of the joint should be 
prohibited, and the limb placed in the position in which it is most desirable it should be 
in that event. 
I have said nothing here of counterirritation by tartar emetic pustulation, vesication 
w ith croton oil, and the use of issues, the seton, and the moxa; because, although some- 
times serviceable, these means seldom afford the relief that has been so generally ascribed 
to them. I have certainly not, in my own practice, found them of much advantage, while 
occasionally I have thought they had acted decidedly prejudicially. Pustulation with 
tartar emetic is not only extremely painful, but it not unfrequently, in delicate persons, 
creates nausea and other disagreeable effects, rendering its continuance improper. The 
use of croton oil is hardly less objectionable. An issue may sometimes be established 
beneficially directly over the affected joint with the actual cautery, or the hot iron may 
be drawn linearly over its surface at several points, in a vertical direction. The seton 
should never be used in any articular disease as a counterirritant. 
In rheumatic and gouty affections of the joints the most reliable remedy is the w’ine of 
the seed of colchicum. Its efficacy will generally be greatly increased, especially in young, 
vigorous subjects, if its exhibition be preceded by an active purgative, and the loss often, 
fifteen, or twenty ounces of blood. The best plan is to give one drachm of the wine 
every evening at bedtime in union with one-third to half a grain of morphia, such a 
course being far preferable to smaller doses frequently repeated. Thus administered, it 
rapidly subdues morbid action, relieving pain, depurating the blood, and expelling or 
neutralizing the arthritic poison. When there is much arterial excitement, as evinced 
by a full, bounding, and frequent state of the pulse, the saturated tincture of aconite will 
come in play, from three to four drops being given every three, five, or six hours, either 
alone, or, what is usually better, in union with a minute quantity of antimony and the 
sixth of a grain of morphia, in order to produce a more powerful diaphoretic impression. 
In the use of these several articles, great caution is needful that the dose be not carried 
too far, or the remedy continued too long. 
If, after proper depletion has been practised, the disease be found to be unusually rebelli- 
ous, calomel and opium may be cautiously employed, with a view to gentle ptyalism. In this 
condition of the system, quinine will often be highly serviceable, especially if it be ad- 
ministered in large doses in combination with morphia or Dover’s powder. The alkalies, 
especially* the carbonate of sodium, taken in strong lemonade, are beneficial in neutralizing 
the acid state of the blood and in improving the tone of the stomach. 
As a local application, nothing will be more beneficial than soap liniment with lauda- 
num and aconite, well rubbed on twice a day, and retained constantly upon the affected 
joint with flannel, covered with oiled silk. This may be succeeded, if the disease be 
inclined to linger, by vesication with cantharidal collodion. 
In syphilitic synovitis, the great remedy, as stated elsewhere, is iodide of potassium, 
conjoined, in obstinate cases, with mercury, carried to gentle ptyalism. Other means, 
both general and local, such as have already been adverted to, are not to be neglected. 
SECT. V DROPSY OF THE .JOINTS. 
Dropsy is an accumulation of fluid in the interior of an articulation, generally a result 
of chronic disease of the synovial membrane. It is most common in the ginglymoid 
joints, as the knee, elbow, and ankle, especially the first, which suffers more frequently in 
this way than any other. 
The causes are both local and constitutional. Among the former may be classed different 
kinds of accidents, as sprains, blows, concussion, dislocation, and the presence of inter- 
articular concretions, irritating the synovial membrane, and inducing an inordinate secre- 
tory action in its vessels. Severe and long-continued exercise, attended with excessive 
fatigue of the joints, may also excite the disease. 
The constitutional causes are not always very obvious. Very often the disease is 
associated with, or directly dependent upon, a rheumatic state of the system, as is clearly 
evinced by the consentaneous existence of rheumatic suffering in other parts of the body. 
Gout occasionally produces a similar effect. In tertiary syphilis, it is not uncommon to 
meet with dropsy in several of the joints simultaneously, especially in the knee and 
elbow, and I believe that such an effect will be more certainly brought about if the 
individual has been subjected to severe courses of mercury for the cure of the primary 1050 
DISEASES AND INJURIES OF THE JOINTS. 
CHAP. IX. 
affection. When a strong predisposition to the disease exists, the slightest causes are 
generally sufficient to call it into action. In weak, strumous subjects, it is occasionally 
a sequel of typhoid fever, scarlatina, measles, and smallpox. Suppression of the cutane- 
ous perspiration may also induce it; and in many cases it comes on without any assign- 
able reason. 
The symptoms are generally well marked, the most prominent and reliable, in a diag- 
nostic point of view, being a loss of the natural contour of the joint, and the existence of 
a soft, elastic, and irregularly circumscribed swelling. The skin ordinarily retains its 
normal color, and the motion of the articulation, although considerably impeded, is rarely 
attended with much pain or inconvenience. The tumor affords distinct fluctuation, and 
is most conspicuous where the ligaments of the joint are loose and superficial. In the 
wrist, for example, it is most apparent at the anterior and posterior aspects of the joint; 
in the ankle, in front of the malleolar processes, a short distance above the instep; in the 
shoulder, in the space between the deltoid and pectoral muscles; in the knee, at the sides 
of the patella. In the latter, where the swelling is often double, its shape and consistence 
are materially influenced by the movements of the limb, being softer and more decidedly 
fluctuating in extension than in flexion. Pressure upon the tumor is seldom productive of 
much pain; generally, indeed, it causes merely a little uneasiness, or a sense of tender- 
ness. In cases of long standing there is sometimes considerable enlargement of the sub- 
cutaneous veins, but this is uncommon. 
The progress of these dropsical affections is generally very chronic, many months often 
elapsing before the tumor attains any considerable bulk. Sometimes, however, the reverse 
is true ; in the knee, in particular, frequently large collections occur within a few weeks. 
Their march is usually most rapid in rheumatic and gouty subjects, and after attacks of 
the exanthematous fevers. 
In regard to the diagnosis, the history of the disease, the change in the contour of the 
joint, the fluctuating and indolent character of the swelling, and the comparative freedom 
of motion of the affected structures, will generally serve to prevent error. If, after the 
swelling has been thoroughly scrutinized, any doubt exist it may at once be dispelled by 
the insertion of a very delicate needle, the nature of the escaping fluid being characteristic. 
The most important patholoyical changes in this affection, especially in cases of long 
standing, are opacity and thickening of the synovial membrane, with some degree of 
vascularity, the vessels being spread over the diseased surface in delicate, arborescent 
lines, widely separated from each other. Occasionally slight deposits or patches of lymph 
exist, giving the part a rough, uneven appearance. The cartilages and bones present no 
perceptible changes, nor do the muscles and other parts around the joint, except that they 
are more less displaced by the dropsical distension. When the accumulation is very great, 
the capsular ligaments, pressed upon in every direction, become very much stretched and 
attenuated. Indeed, in the worst forms of the disease they may be so much distended as 
to give way, thus allowing the fluid to diffuse itself among the surrounding structures. 
The dropsical fluid is generally of a pale, yellowish, straw or amber color, and of a ropy, 
unctuous, or sero-oleaginous consistence ; sometimes it is turbid, whey-like, or sanguinolent, 
and intermixed with flakes, shreds, or masses of lymph. Its quantity is variable, depend- 
ing upon the size of the joint, the duration of the case, and other circumstances. In the 
knee it frequently ranges from sixteen to twenty ounces. 
The prognosis is always more favorable, other things being equal, when the swelling is 
recent and small than when it is of long standing, large, and attended with serious lesion 
of the synovial membrane. In the latter case the disease is often extremely obstinate, and 
may become dangerous, as it is liable to be followed by disorganization of the articular 
cartilages and bones. Ankylosis is not uncommon. 
Treatment In the treatment of dropsy of a joint it must be borne in mind that it is 
not a disease, but, like dropsy everywhere else, merely a symptom of disease. Hence, 
the very first and most important object is to remove the cause upon which the presence 
of the fluid depends. The question will, therefore, necessarily arise, in every instance, 
what has been the origin of the affection? Has it been local or constitutional? Upon 
the success with which this question is answered will mainly depend the success of our 
remedies. 
When the affection is of a purely local nature, as when it is caused by a sprain, con- 
tusion, or other injury, topical remedies alone will generally suffice to effect a cure, espe- 
cially if assisted by an occasional purge and a properly regulated diet. The means to be 
chiefly relied upon are, perfect quietude of the affected joint, stimulating embrocations, 
and vesicants. In the milder forms of dropsy, frictions with iodinized lotions, soap lini- MOVABLE BODIES WITHIN THE JOINTS. 
1051 
cnAP. ix. 
merit, camphorated spirit, and mercurial unguents seldom fail to make a rapid and decided 
impression upon the absorbent vessels of the joint, as is shown by the speedy diminution 
of the size and tension of the swelling. They should be rubbed upon the whole of the 
affected surface twice a day with the bare hand until a decided glow is produced, the parts 
being well supported in the interval with the bandage, either alone or aided by wet sponge 
compresses, the compression thus produced powerfully promoting the reduction of the 
effused fluid. When the absorbents have been fairly roused as denoted by the gradually 
decreasing volume of the sac, the inunctions may often be advantageously preceded by the 
cold douche, or by the hot and cold, applied in immediate succession. 
When there is evidence of incited action, as when the surface is hot and tender, re- 
frigerating lotions, consisting simply of cold water, or of water impregnated with acetate 
of lead and opium, must be employed ; for so long as the capillary vessels are in a state of 
irritation, little benefit can be expected from sorbefacients, properly so called. Even 
leeching and brisk purgation may then be necessary. 
In obstinate cases there is no topical remedy at all comparable to a blister, well sprinkled 
with morphia, and retained until the epidermis is thoroughly raised. The discharge is 
promoted by warm water dressings, and the blister is reapplied as soon as the surface is 
partially cicatrized. This method is much more salutary than that of keeping open the 
sore with irritating salves, as it exerts a more direct effect upon the absorbent vessels, at 
the same time that it is much less painful. 
Pustulation with tartar emetic ointment and croton oil, so much vaunted by some prac- 
titioners, is generally hurtful ; and as to issues and setons, their employment is never 
indicated, as the object may always be attained by milder means. 
When the affection is of a rheumatic, gouty, syphilitic, or strumous origin, colchicum, 
mercury, iodide of potassium, and kindred articles, are the means chiefly to be relied 
upon. Dropsy that is symptomatic of fever, or of some of the eruptive diseases, often 
disappears spontaneously, as the patient improves in health and vigor, or readily yields to 
mild measures, particularly tonics, and change of air. Ordinary hydragogue medicines 
afford little, if any, relief in this affection in any of its forms. 
As the joint will necessarily remain weak for a long time after the removal of the fluid, 
it should be well supported with a gum elastic cap, fig. 597, or a suitable bandage, and 
kept cool by frequent ablutions with alcohol and water. Fatigue must, of 
course, be avoided. 
Finally, when the disease is unusually obstinate, relief should be sought 
by evacuating the fluid with the aspirator, or by subcutaneous puncture 
with a delicate trocar or bistoury, inserted in such a manner as to make a 
valve-like opening, at the most superficial and dependent portion of the 
swelling, at least two inches from its boundaries, its point being carried 
along the connective tissue until it reaches the sac. Thus performed, no pos- 
sible injury can result from the operation, while, by removing the fluid, 
over which the absorbents have no longer any control, it affords the only chance of relief. 
The opening is immediately closed with collodion, supported by a compress and bandage; 
and for some days the limb is kept perfectly quiet, light diet being enjoined, and every 
precaution taken to prevent inflammation. Reaecumulation is guarded against by the 
means already indicated. 
I have not been so bold as to use injections for the permanent cure of this affection, 
convinced that the practice must be fraught with danger. The article recommended for 
this purpose, by Bonnet, Velpeau, and others, is tincture of iodine, diluted with two, 
three, or four parts of water, introduced subcutaneously with a syringe, to the amount of 
several ounces, and retained for a few minutes, the joint being pressed slightly during its 
sojourn, in order to bring the solution fully in contact with the diseased sac. It is then 
permitted to flow off spontaneously, when the opening is carefully closed, and the case 
treated upon general antiphlogistic principles. Of the safety, and, consequently, the pro- 
priety of this operation, great doubt is entertained by many practitioners, and, I think, 
justly so; for, although it has succeeded in some cases, it is certain that in others it has 
been followed by such a degree of inflammation as to imperil both limb and life. 
SECT. VI MOVABLE AND ADHERENT BODIES WITHIN THE JOINTS. 
Various kinds of bodies, mostly movable, but sometimes adherent, are liable to form in 
the cavity of the joints, where, interfering with the functions of the opposing surfaces, 
they become a source of much annoyance, and sometimes even of intense suffering. 
Fig. 597. 1052 
DISEASES AND INJURIES OF THE JOINTS. 
CHAP. IX. 
Ambrose Pare, in 1558, was the first to call attention to such bodies, which are divisible 
into several classes, differing materially in their structure. 
1. Tnterarticnlar cartilages, as they are called, or osseous concretions, are liable to 
form in various joints, particularly in the ginglymoid, as the knee, elbow, wrist, and jaw, 
the first, however, being apparently their favorite seat, for it is there that they occur 
most frequently, and attain their greatest bulk. The orbicular joints rarely suffer ; a 
circumstance which probably depends mainly upon the conformation of the articular sur- 
faces opposing their development in the one case, and favoring it in the other. 
The size, number, form, color, consistence, and structure of these bodies are liable to 
much diversity. In the knee, they sometimes acquire the dimensions of the patella, or 
of a hen’s egg. Their number is generally in an inverse ratio to their volume. When 
very large there is often only one, whereas under opposite circumstances there may be 
several dozens. In one case, as many as sixty were found. The largest number I have 
ever known to be removed from one joint was thirty-eight, varying from the volume of a 
pea to that of a pullet’s egg. They are, for the most part, of a whitish, grayish, or pale 
straw color; while their consistence, like their structure, ranges from that of fibro-cartil- 
age to that of bone, with every possible intermediate gradation. Their shape is generally 
very materally modified by that of the joint in which they are developed. Thus, in the 
knee they are often, if, indeed, not commonly, of an irregularly flattened figure, not 
unlike that of the patella, or they resemble a disk, convex on one side, and concave on 
the other, in conformity with the outline of the condyles of the femur and the head of the 
tibia. In many cases, again, even in the knee, they are of a lenticular, rounded, or 
ovoidal shape. Consisting usually of a single mass, they are sometimes marked off into 
several lobules, connected together by condensed connective substance. Their surface 
may be perfectly smooth, or partly smooth and partly rough. 
The structure of these bodies varies. In their earlier stages it is generally fibrous, but 
as they advance in age they assume the character of cartilage, and ultimately that of 
osseous matter. The process of conversion from cartilage to bone is generally very 
gradual, and almost always begins in the centre of the concretion, although occasionally 
it occurs simultaneously both at the centre and at the periphery, or first at the surface and 
afterwards in the interior. When several such bodies coexist, they often exhibit material 
differences in their development; some being comparatively soft, evidently from their 
cartilaginous nature, and others very hard and osseous. 
The immediate cause for these formations is chronic inflammation, leading to the devel- 
opment of neoplasms upon the fringes of the synovial membrane, or to the abnormal pro- 
liferation of the articular cartilage, thus giving rise to what is denominated ecchondrosis. 
The harder varieties, the real osteophytes, as they may be called, have their origin either 
in the periosteum immediately beneath the synovial membrane, or near the border of the 
articular cartilage, from which they are gradually detached, and thrust into the affected 
joint. Finally, there are cases in which, as was shown by the late Mr. Teale, of Leeds, 
these formations are simply fragments of articular cartilage or bone, separated either by 
accident or by a slow process of exfoliation consequent upon external violence. The fact 
that the more ordinary forms of these bodies are susceptible of various transformations 
shows that they have an appropriate circulation, and also that this circulation continues 
in force long after they lose their attachment. The period at which they become loose, 
or floating, depends, no doubt, very much upon the amount of friction to which they are 
subjected, and the amount of atrophy which they experience after their development has 
reached the osseous or cartilagino-osseous point. Their original connection is usually 
effected through the medium of a short, narrow pedicle. 
The size and shape of these bodies are well represented in fig. 598, from a drawing of 
several in a collection of thirty-eight, for which I am indebted to Dr. John T. Berry, of 
Kentucky, who removed them, without any untoward occurrence, from the knee of a negro, 
upwards of thirty-five years of age. When quite young, he received a slight injury upon 
the joint, which, although not painful, was soon followed by considerable enlargement. 
Two years prior to the operation, he perceived a small round movable tumor immediately 
above the external condyle, which was followed in about twelve months by two others 
just above the inner part of the knee. These swellings gave him but little trouble, with 
the exception of some stiffness in the articulation. Occasionally, however, the external one 
changed its position, slipping round to the anterior surface of the thigh, above the patella, 
where it interfered so much with walking that the man was immediately obliged to sit 
down, and push it back into its original position. An incision being made into the external 
tumor, the concretions were readily extracted, having all been contained in one sac, of a MOVABLE BODIES WITHIN THE JOINTS 
1053 
CHAP. IX. 
dense, firm consistence, which occupied the lower part of the front of the thigh, and com- 
municated with the cavity of the joint. There were thirty-eight altogether, from the 
Fig. 598. 
Fig. 599. 
volume of a pea to that of a pullet’s egg, of a whitish, 
glistening appearance, rough or pitted on the surface, and 
of various configurations, as spherical, oval, lobulated, or 
angular. Fig. 599 exhibits several bodies of this kind as 
they lie in the joint attached to the synovial membrane, 
from a specimen in my collection. 
The symptoms declarative of the presence of interarticular bodies are often character- 
istic, particularly when these substances occur in the knee. There are, however, on the 
other hand, cases where the nature of the disorder is so obscure as to elude, at least for a 
time, the most careful examination. The intruder, if large, generally causes but little 
pain, whereas, if it be small, and fioating, it is very liable to be wedged in between the 
articular surfaces, so as to occasion severe suffering, followed, if the accident be fre- 
quently repeated, by violent synovitis. When, for example, the interarticular substance 
slips behind the patella, as the patient is standing or walking, he is often suddenly seized 
with violent pain, which instantly compels him to sit down, in order to save himself from 
falling. In the night, his sleep is liable to be disturbed by any inadvertent movement of 
the limb that may favor displacement of the concretion ; and when the disease has existed 
for a long time, and is attended with much relaxation of the ligaments, any accident of 
the kind, however trivial, is almost sure to produce excruciating agony, often attended 
with syncope. 
When the extraneous substance slips about habitually, it is sure not only to create pain, 
keeping the joint constantly tender and uncomfortable, but also in a state of enlargement, 
both by interstitial deposits in the surrounding structures and by increase of synovial 
fluid. The intumescence, however, is rarely so great as to prevent the surgeon from 
feeling the concretion, or pushing it about from one point to another. In the knee, it 
generally forms a marked projection on the side of the patella, more frequently on the 
external than the internal, its outline being distinguishable both by sight and touch. 
Cases occur in which, retreating to a particular part of the joint, it remains comparatively 
harmless, until it leaves its lurking-place and goes to some other, thus causing a renewal 
of all the former trouble. As the affection progresses, the joint becomes more and more 
tender, swollen, and feeble ; the synovial membrane, constantly fretted by the friction of 
the concretion, pours out an additional quantity of its appropriate secretion ; the ligaments 
become greatly relaxed, and the patient, at first merely limping, is at length rendered 
permanently lame and helpless. 
The most important diagnostic signs are, the suddenness with which the joint is deprived 
of its use, the severity of the concomitant pain, the ability of the surgeon to feel, see, 
and push about the concretion, and the facility with which the patient can generally 
relieve himself by his own efforts. The chronic nature of the disease, the absence of 
external injury, and the frequent recurrence of the symptoms from the most trivial cir- 
cumstances, afiord important collateral evidence of the character of the affection. 
Although the complaint under consideration is not generally dangerous, yet, as it often 
materially interferes with the movements of the joints in which it occurs, and does not 
Loose Articular Concretions. 
AUhcreut Articular Concretions. 1054 
DISEASES AND INJURIES OF THE JOINTS. 
CHAP. IX. 
admit of permanent relief, except by surgical operation, which is itself always hazardous, 
we cannot be too cautious in forming our prognosis. The removal of the concretion, 
unless very small and soft, by absorption, is impossible. 
Treatment The treatment is palliative and radical. So long as the concretion remains 
quiet and does not occasion any material inconvenience, or serious embarrassment in the 
functions of the joint, the most judicious plan is to let it alone, care being taken to support 
the parts with a gutn elastic cap, or some other suitable contrivance, to prevent the sub- 
stance from slipping about, and thus doing harm. The relief afforded, however, is generally 
very transient, and, therefore, other and more efficient measures must be adopted. 
Two procedures are in vogue for the removal of loose cartilages of the joints, the one 
being known as the operation by the direct incision, and the other, devised almost simul- 
taneously by Goyrand and Syme, as the subcutaneous method. Concerning the comparative 
safety of these two expedients various opinions have been expressed ; but it is now well 
ascertained that the preponderance is decidely in favor of the new operation, or the indirect 
method, while the other furnishes a greater number of cures. Thus, of 210 cases collected 
by Dr. Hugo M. Benndorf, of Leipzig, in 1868, in which the direct incision was practised, 
143 recovered without any accidents, 41 ended fatally, and 32 were followed by bad 
symptoms. Of 50 cases treated subcutaneously, 28 were cured, 5 perished, 5 had bad 
symptoms, and in 12 the operation was not completed. It will thus be perceived 
that the direct method furnishes 81 per cent, of cures, against 00 of the subcutaneous, 
with 19 per cent, of fatal issues for the former, and 10 per cent, for the latter. The 
statistics, brought together by llippolyte Larrey, in 1801, attest the same fact. Of 107 
cases, 129 were by the direct incision, and of these 96 were cured, 5 failed, and 28 died. 
Of 38 cases treated subcutaneously, 19 recovered, 14 failed, and 5 terminated fatally. 
Mr. Square, of Plymouth, England, had, up to 1871, operated successfully in 24 cases by 
the indirect method. Dr. G. Gaujot, in 1881, published an analysis of 54 cases treated 
since 1863 by the direct method, of which only 3 ended fatally; and from all I can 
gather upon the subject, it may fairly be assumed that, despite its greater danger, the 
preponderance of authority of the present day is decidedly in favor of the direct incision, 
as affording a better opportunity of removing effused blood than in the subcutaneous 
operation in which more or less is so liable to find its way into the affected joint, and 
where its presence is always productive of mischief. In the cases collected by Gaujot, 
antisepticism did not seem to offer any special immunity from danger. In the time of 
Benjamin Bell, of Edinburgh, early in the present century, extraction of these concre- 
tions was regarded as such a dangerous procedure that that eminent surgeon strongly 
recommended amputation as far preferable. 
One of the great objections to the subcutaneous operation is the difficulty of fixing the 
floating cartilage in a position favorable to its easy and successful extraction. In this 
respect, the direct method possesses a decided advantage. Apart from this consideration, 
experience has shown that the subcutaneous operation, however well performed, is occa- 
sionally followed by high inflammation, imperilling both limb and life. It, nevertheless, 
I conceive, generally merits the preference. Before either operation of so hazardous a 
character is undertaken the patient should be subjected to a most rigid course of treatment, 
consisting of perfect rest of the affected joint, with light diet, and an occasional laxative, 
extending over the better part of a fortnight. 
The subcutaneous section of the knee will serve as a type of the operation upon the 
other joints. The limb being extended upon a table, the foreign body is brought to the 
upper and outer side of the patella, beneath the large external muscle, where it is to be 
securely held by an assistant, either with the fingers or with an acupuncture needle, while 
the surgeon introduces a long, narrow bistoury, from above downwards, into the synovial 
pouch, which is then freely divided, so as to permit the concretion to be pushed through 
the opening into the subcutaneous connective tissue, or among the structures exterior to the 
joint, entirely beyond the serous lining. The puncture is covered with collodion, and a 
compress is gently bound upon the knee, between it and the concretion, the object being 
the promotion of speedy union of the edges of the articular wound. The limb is kept 
perfectly at rest, free use being made of cold water-dressing and other antiphlogisties. 
When the inner wound is healed, the extraneous substance may be removed by simple 
incision ; or, if not a source of inconvenience, it may be allowed to remain in its new 
position, where it will soon become imbedded in plastic material, and so prove compara- 
tively harmless. In some cases, indeed, it is speedily absorbed. 
In the direct operation, the method now generally adopted, performed under antiseptic 
precautions, the wound should immediately be closed with the greatest possible care, with 1055 
CHAP. IX. 
MOVABLE BODIES WITHIN THE JOINTS. 
a view to the effectual exclusion of the air, the great danger after such a procedure. If 
the concretion be still attached, severance should be effected with the knife or scissors, 
any pulling with the forceps being inadmissible. The remarkable tolerance, even of the 
largest joints, after free incision practised for such a purpose, is well shown in the case of 
Dr. Berry, above referred to, in which thirty-eight concretions, some of them of large 
size, were extracted from the knee at one operation, without a solitary bad symptom. 
The after-treatment, in both methods, must be conducted upon the same general prin- 
ciples. During the first eight or ten days the system should be steadily kept under the 
full influence of opium, the diet should be very light and simple, and the affected joint 
should be placed in the most easy and comfortable position, free use being made of leeches, 
vesicants, and lotions of lead and laudanum in the event of inordinate action. If matter 
form, speedy vent should be afforded. Amputation or resection may be necessary when, 
after an attempt has been made to save the joint, life is assailed by hectic irritation, 
pyemia, or gangrene of the limb. 
It has been proposed, in cases of loose articular concretions, by different surgeons, more 
especially by Dieffenbach, Wolf, Jobert, Dumoulin, and Leroy d’Etiolles, to fix the offend- 
ing substance in a harmless portion of the joint by means of steel pins, serrefines, or 
subcutaneous wire ligatures, until it has formed firm adhesions in its new situation. The 
procedure, however, has not met with any favor, as it is not only difficult of execution, 
but sometimes even dangerous, several instances having been recorded in which it was 
followed by violent inflammation and even copious suppuration. 
2. The movable joints are occasionally the seat o['gouty concretions, which, from their 
color and consistence, have received the name of chalk-stones. They are composed of 
urate of sodium, a peculiar fatty matter, phosphate and carbonate of lime, and a minute 
quantity of carbonate of magnesium. In one case, that of an old man, I found these con- 
cretions in nearly all the principal joints of the body, in small amorphous masses of a 
whitish color, and of a .soft, unctuous consistence. Sometimes the concretions are perfectly 
smooth and round; more commonly, however, they are rough and irregular, grooved or 
nodulated. They are generally small, but may acquire the volume of an egg. Their 
origin is always connected with a gouty diathesis. 
The treatment of this form of concretion is chiefly constitutional, directed to the removal 
of the gouty diathesis, with which its origin is so intimately associated. Colchieum and 
aconite, with an occasional mercurial purge, the free use of lemon-juice, and a diet com- 
posed mainly of bread, fish, eggs, milk, and the lighter vegetables, constitute the chief 
remedies. For a long time, means should be employed to depurate the blood, and to keep 
up a healthy state of the digestive organs, with an active condition of the renal secretion. 
If the joint ulcerate, or threaten to do so, extrusion should be effected ; in the former case 
by direct incision, in the latter by the subcutaneous method. 
3. The synovial membrane is occasionally the seat of fibrous tumors. They occur in 
different joints, but principally in that of the knee, where several sometimes coexist, 
varying from the volume of a bean to that of a large almond. On one occasion, I removed 
a growth of this description fully as large as a pullet’s egg. It was of an elongated, 
flattened, pyriform shape, and was attached, by a short, narrow pedicle, to the upper and 
anterior part of the inner condyle. The patient, a man of twenty-seven, had labored 
under synovial irritation for many years, attended with partial ankylosis, and much pain 
and tenderness, which were always aggravated upon the slightest exertion. A subcuta- 
neous incision being made into the articulation, the tumor was detached by a few turns of 
the point of the knife, and immediately extracted with a very delicate, slender pair of 
forceps. The wound, closed with collodion, healed by the first intention, no untoward 
symptom occurring, as far as the joint was concerned. Some erysipelas, however, 
appeared upon the skin, and a week afterwards a large abscess formed at the inner and 
middle part of the thigh, which somewhat retarded recovery. Another tumor, doubtless 
of a similar nature, was found occupying the deeper portion of the joint, but, dreading 
further interference, it was thought best not to meddle with it. The functions of the 
knee were much improved by the operation. The tumor was of a pale greenish color, 
extremely firm and tough in consistence, smooth, glistening, and somewhat vascular on 
the surface, and of a distinctly fibrous structure. 
4. What is known tvs the fimbriated degeneration of the synovial membrane is sometimes 
met with, chiefly in the larger joints, as in those of the knee and hip, and consists of 
innumerable little bodies of all sizes, from a millet seed up to that of a pea, of a pale 
yellowish or whitish color, and bearing a very close resemblance to the epiploic append- 
ages of the large intestine. Of a smooth, glistening appearance, they stud the free surface 1056 
DISEASES AND INJURIES OF THE JOINTS. 
C II A P. IX. 
of the synovial membrane in every direction, being connected to it either by a broad 
base, or, as is more generally the case, by a narrow, slender pedicle. Their structure 
is evidently of a fibrous character, interspersed with fatty cells, the whole originating 
in a deposit of plastic matter, which assumes the peculiar arrangement in question in 
consequence of the friction exerted upon it by the opposing surfaces of the joint in which 
the substance is effused. The accompanying cut, fig. 600, from Pirrie, affords an ex- 
cellent illustration of this form of morbid growth. 
Fig. 600. 
Fig. 601. 
The Synovial Membrane of the Knee-joint 
Studded with Numerous Melon Seed-shaped 
Bodies, the Patella being turned down. 
Fimbriated Growths of the Synovial Membrane. 
The symptoms occasioned by the fimbriated synovial membrane are altogether of a 
mechanical character, consisting of pain and stiffness, and of a grating sensation during 
exercise, along with more or less swelling in and around the joint, from inflammatory 
deposits. There are no diagnostic symptoms, and the treatment must, therefore, be con- 
ducted upon general principles. 
5. Fibroid bodies, of the size and shape of cucumber, squash, or melon seeds occa- 
sionally form in the joints, doubtless in the same manner and from the same causes as the 
larger concretions. The annexed cut, fig. 601, from Druitt, presents a beautiful illustra- 
tion of a remarkable case of these peculiar growths. 
SECT. VII TUBERCULOSIS OF THE JOINTS. 
1. GENERAL OBSERVATIONS. 
Tuberculosis of the joints, formerly known as white swelling, is an extremely common 
affection. Beginning either in the areolar substance of the articular extremities of the 
bones, or in the synovial membrane, or, as, perhaps, not unfrequently happens, simulta- 
neously, or nearly simultaneously, in both of these structures, it is almost peculiar to 
children under ten years of age, and generally pursues a chronic course, although occa- 
sionally it proceeds with so much rapidity as to entitle it to the distinction of an acute 
malady. However this may be, it seldom stops until it has produced the most extensive 
textural ravages, consisting in the destruction, either partial or complete, of the affected 
articulation. Constitutional involvement is usually well marked, especially in the latter 
stages of the complaint, when it is also not uncommon to find serious lesion of some of the 
internal viscera, as the lungs, spleen, and mesenteric glands. The disease, as the name CHAP. IX. 
TUBERCULOSIS OF THE JOINTS. 
1057 
imports, is essentially of a strumous nature, and can, therefore, occur only in persons of a 
strumous diathesis. 
The joints that are most prone to suffer from tuberculosis are the movable, par- 
ticularly the hip, knee, ankle, elbow, and wrist. Those of the tarsus are also remarkably 
liable to it. Sometimes several joints are involved simultaneously; and instances occur 
in which the disease is, apparently, hereditary. 
Etiology The exciting causes of this affection are generally very obscure, if not 
utterly inscrutable. The surgeon, it is true, is often told that the patient, perhaps weeks 
or months before the appearance of the characteristic phenomena, received some injury, 
as a blow, fall, or kick, or that the affected joint had been sprained, bruised, or twisted; 
but such information is usually little reliable, or if such an occurrence really did take 
place, it, probably, exerted little, if any, influence in developing the complaint. Unless 
very severe, it could no more provoke tuberculosis of a joint than a similar injury of the 
chest tuberculosis of the lungs, or of the head tuberculosis of the arachnoid membrane. 
Exposure to cold, intense or protracted, is particularly liable to prove prejudicial in 
persons of feeble constitution, with an impoverished state of the blood. The influence of 
this agency in exciting pulmonary phthisis has long been recognized. Living in damp, 
underground, ill-lighted, and ill-ventilated apartments operates in a similar manner. 
Simple suppression of the cutaneous perspiration, suddenly induced, as when an individual 
is exposed to a strong current of air, is also liable to produce the disease, especially in 
one predisposed to its occurrence. The use of unwholesome food, chronic disorder of the 
digestive apparatus, imperfect assimilation, or inadequate nutrition, protracted courses of 
mercury, and the exhaustion consequent upon copious and repeated hemorrhages, infantile 
cholera, chronic diarrhoea, scarlatina, measles, smallpox, typhoid fever, and in short 
whatever has a tendency to enfeeble the system and derange the blood, are so many 
predisposing causes of the disease, if they do not actually call it into activity. 
It has frequently been asserted that rheumatism might induce this disease, but this is 
questionable. The fact is it is not at all probable that it ever exerts such an influence; for, 
in the first place, it is well known that tuberculosis is exceedingly uncommon in rheumatic 
subjects, and, in the second, that, when disease of the joints shows itself in such persons, 
it is very different from strumous disease. 
Persons of fair complexion, light hair and eyes, a delicate skin, and a languid circula- 
tion, with a tendency to eruptions of the scalp and enlargement of the lymphatic glands, 
are most liable to tuberculosis of the joints. In many cases the strumous diathesis exists 
in a marked degree, the tumid lip and belly, the long eyelashes, the cold extremities, the 
flattened shape of the fingers, and the disordered condition of the digestive organs, afford- 
ing unmistakable evidence of its presence. 
No one who is in the habit of meeting with this disease can fail to notice the different 
temperaments of those who are most subject to its attacks. These are, according to my 
observations, the sanguine and the lymphatic, or a combination of both. In the former, 
the characteristics are, a rosy hue of the countenance, a well-developed muscular system, 
with a tendency, frequently, to a certain degree of embonpoint, a vigorous circulation of 
the skin, warm extremities, and an active state of the intellect. In the latter everything 
is completely reversed. The face is pale, often swollen and pasty, the muscles are soft 
and flabby, the feet are habitually cold, the cutaneous circulation is feeble, the pupils are 
dilated, and the mind is sluggish. In both, but more particularly in the lymphatic, the 
belly and upper lip are often remarkably tumid, and most expressive of the tubercular 
diathesis. These two varieties of temperament, with their modifications, deserve careful 
consideration, as they form the basis of important therapeutic indications in the disease 
in question. 
Morbid Anatomy and Pathology The morbid changes induced by this disease vary 
according to the different stages of its progress, the earlier closely resembling those of 
ordinary inflammation. The synovial membrane, which is commonly first implicated in 
the morbid action, affords evidence of slight vascularity, a few delicate, straggling vessels, 
loaded with blood, being observable upon its surface, with some degree of opacity and 
softening. An appearance of thickening is often imparted to it, from a deposit of lymph, 
which, being poured out, perhaps quite freely, soon assumes a pulpy consistence and a pale 
yellowish or greenish color. Sometimes it is shreddy, tomentose, or filamentous. The 
articular cartilage, if seriously involved in the inflammation, is of a dull whitish or slightly 
grayish aspect and somewhat thickened, softened, and partially separated from its osseous 
connections. The cancellated structure of the bones is abnormally vascular, light, porous, 
humid, and at the same time easily cut and broken. Not unfrequently its cells are dis- 1058 
DISEASES AND INJURIES OF THE JOINTS. 
tended with yellowish tubercular matter, of a semisolid, caseous consistence ; or, this 
substance presents itself in distinct granules free or encysted, and, perhaps, not larger 
than a millet seed. The ligaments usually suffer early, being abnormally red, tumefied, 
and softened. The synovial fluid is generally increased in quantity, but rarely to any 
considerable extent. 
As the disease advances, the alterations become more distinctly defined, for, as the 
disorganizing process is now in full play, its devastating effects are plainly visible in every 
portion of the joint. The lymph increases in quantity, and is often intermixed with sero- 
purulent matter, or thick, greenish-looking pus. The tufts of the synovial membrane are 
converted into soft, gelatinous, fungous, tubercular granulations, which gradually extend 
over the cartilage, imparting to it an ulcerated, or worm-eaten appearance, and eventually 
destroying it. The bony structure is at length also invaded by the granulations, rendering 
it very red, soft, carious, rough, and fragile. The ligaments exhibit well-marked signs of 
inflammation, being loose and spongy at one point, attenuated at another, and, perhaps, 
thickened or hypertrophied at a third. The microscopical appearances of ulcerated car- 
tilage and carious bone, the result of changes wrought during the progress of strumous 
disease of the joints, are well shown in figs. 602 and 603, from Harwell. 
CHAP. IX. 
Fig. 602. 
Fig. 603. 
Section of a Strumous Ulcer of a Cartilage, magnified 
600 diameters. 
Section of Strumous Tibia, the upper portion exhib- 
iting a mere pultaceous Mass, interspersed with dark 
Cells. Nucleated cells are often found in the Lacunae, 
a very large one, the 1.85 of a line in diameter, is seen 
in the lower right corner of the cut. 
The disease having reached its acme, the structures of the joint are completely sub- 
verted, with hardly any trace of their original appearances. Pus is now usually seen, 
often, indeed, in large quantity, with all the qualities of strumous matter. This, how- 
ever, is not always the case ; for, at times, it is thick and pultaceous, caseous, ichorous, 
or sero-sanguinolent. In some instances it is very thin, and almost black, evidently from 
the effects of the necrosed condition of the bones. 
If death take place after a process of recovery has been set up, the joint will be found 
to be filled by a white, fibrous, organized substance, the extremities of the bones being 
ankylosed, or firmly attached by the new matter to the surrounding structures. It is very 
rare for a new socket to be formed, and yet this is not impossible. In time, the artificial 
joint may admit of considerable motion, but, in general, this is extremely restricted. Occa- 
sionally an imperfect ligament is developed around the bony remnants, the surface of 
which may even become slightly tipped with cartilage. Finally, osseous growths, short, 
irregular, and friable, sometimes make their appearance upon the bones in the vicinity of 
the former disease. 
The bodies of those who die of strumous disease of the joints usually exhibit serious 
pathological changes in some of the internal organs, as the direct result of the strumous 
cachexia, generally so well marked in the latter stages of the complaint. The structures 
which, according to my observation, are most liable to suffer, are the lungs, the spleen, 
and the mesenteric and pelvic lymphatic glands, which are sometimes completely crowded CHAP. IX. 
TUBERCULOSIS OF THE JOINTS. 
1059 
with tubercles, in various stages of transformation. Dropsical effusions are also sufficiently 
common, especially in the peritoneal cavity and in the lower extremities. 
Tubercles and cheesy deposits of the lungs are very common ; they often exist in great 
numbers, especially in the summits of these organs, and they always exhibit the same 
characters as in ordinary phthisis. Cavities sometimes form, but death usually occurs 
before they attain any considerable magnitude. The bronchial glands generally partici- 
pate in the pulmonary disease, being enlarged, softened, and tuberculized. Occasionally 
extensive adhesions are found between the lung and costal pleura, with or without serous 
and other effusions. The heart is seldom affected. 
The peritoneum is sometimes extensively tuberculized, and considerable quantities of 
water are often found in its cavity. In children, the lymphatic glands of the pelvis and 
mesentery are liable to suffer from strumous deposits, and similar changes are occasionally 
witnessed in the spleen and kidney. In some instances the latter organs undergo the 
amyloid degeneration. The liver is often cirrhosed and hypertrophied. Now and then 
the glands of Peyer suffer. Tubercular meningitis is occasionally present, especially in 
very young children. The pancreas, stomach, bladder, and prostate gland are usually 
sound. The blood is very thin, and deficient in fibrin and coloring matter. The lower 
extremities, and even the hands, face, and genital organs, are, at times, anasarcous, espe- 
cially when the system has been worn out by tubercular disease of different parts of the 
body. 
Tuberculosis of a joint is, as the name implies, essentially a tubercular disease, and 
consists of tubercular degeneration of the synovial membrane, the result usually of in- 
fection from similar deposits beneath the articular cartilage. Modern investigations have 
conclusively demonstrated that fungous synovitis is not only the expression of a consti- 
tutional vice, but that it is frequently the source of general miliary tuberculosis. Some 
idea of the frequency of tubercular synovitis may be found from the observations of Koe- 
nig, of Gottingen, who proved the existence of local tubercles in not less than 69 out of 
71 examples of white swelling of the hip-joint. Its malignant or infectious nature is 
clearly shown by Billroth, who found that 181, or 25 per cent., of 713 cases of fungous 
synovitis died of pulmonary consumption. These facts have led many modern surgeons 
to resort to early and complete resection of tubercular joints, with the view of preventing 
general dissemination of the disease, or to employ parenchymatous injections of weak solu- 
tions of iodine or carbolic acid with the hope of destroying the vitality of the tubercle 
corpuscles. How far this object may be accomplished is an open question. 
Symptomatology In regard to the symptoms of this disease, they may, for the sake 
of more definite description, be divided into three stages, all tending from bad to worse. 
In the first stage, the patient’s suffering is generally insignificant, and is usually referred 
to the effects of cold, rheumatism, or some slight external injury. The chief complaint 
consists in some trivial pain, either in or about the joint, not fixed or steady, but wander- 
ing and intermittent, and liable to occasional exacerbations. If swelling be present, it is 
also very insignificant. The joint is usually somewhat stiff, and the patient is easily 
fatigued by exercise. The general health is unimpaired, or only slightly implicated. 
By degrees these symptoms assume a more threatening character; for the disease has 
now attained its second stage, as is indicated by the changes wrought in the affected struc- 
tures. The pain is now more severe, as well as more localized and deep-seated, and com- 
monly requires active means for its relief. The patient is annoyed with spasmodic 
twitches, especially at night, and the affected limb is sensibly wasted and flabby. The 
joint is the seat of more or less swelling, attended with marked deformity and fluctuation, 
the result of the presence of an undue quantity of synovial fluid, or of this fluid and of 
lymph. The parts feel abnormally hot, and there is commonly a peculiar glossy, shining 
appearance of the skin, which induced the older surgeons to call this disease “ white swel- 
ling.” There is also, in this stage, usually some degree of enlargement of the subcuta- 
neous veins. The constitutional symptoms keep steady pace with the local affection. 
The appetite and sleep are disordered, tlie bowels are irregular, and there are occasional 
paroxysms of fever, with evidences of emaciation and general discomfort. 
In the third stage of the disease, the symptoms, both local and general, are strongly 
denotive of the horrible ravages of the morbid action. The joint and surrounding struc- 
tures are swollen and enlarged to their utmost, hot, tense, discolored, immovable, exqui- 
sitely tender and painful, distended with pus, or pus and synovial fluid, and freely fluctu- 
ating under pressure. More or less displacement of the articulating surfaces generally 
exists, adding thus still further to the deformity. The pent-up matter, gradually aproach- 
ing the skin, is at length spontaneously evacuated, much to the relief of the parts and 1060 
DISEASES AND INJURIES OF THE JOINTS. 
chap, ix. 
system, but the resulting sinuses, always slow in healing, often continue for years, espe- 
cially when there is much diseased or dead bone. 
The constitutional symptoms in this stage are those of hectic irritation. The patient, 
at least for a time, has regular vesperal exacerbations, the face is flushed, the pulse is 
excited, the sleep is impaired, and tlie surface, during the night, is drenched with copious 
sweats. Rapid emaciation ensues, the strength declines, and there is not unfrequently 
colliquative diarrlnea. Thus life may be gradually worn out by exhaustion, or, the dis- 
charge diminishing, reaction may take place, followed, sometimes even in apparently 
desperate cases, by ultimate recovery. 
Suppuration, however, does not always take place in this stage of the complaint, or, if 
it does, there is either very little matter, or, what there is, is so soon absorbed as not to 
produce any characteristic symptoms. This is the case occasionally even when the 
greatest ravages have been committed. Sometimes the pus is situated altogether exter- 
nally, but this is unusual. In other cases, again, also infrequent, it is formed both exter- 
nally and internally. However this may be, the structures over and around the affected 
joint always participate in the morbid action, becoming hard, condensed, and enlarged 
from interstitial deposits. 
The matter in scrofulous disease of the joints closely resembles the fluid of a cold ab- 
scess, or the pus of a pulmonary cavern, and is often intermixed with small, whitish par- 
ticles, not unlike grains of soft-boiled rice, flakes of lymph, small clots of blood, and even 
the debris of articular cartilage, ligamentous tissue, or osseous matter. When long con- 
fined, it is apt to be very .fetid. Permitted to stand for a while in a vessel, it separates 
into two parts, one at the bottom, solid and granular; the other at the top, fluid, and of a 
pale whey-like or oleaginous aspect. When an abscess of this kind has once fully emp- 
tied itself, the subsequent discharge is often of a gleety character, ichorous, or thin and 
bloody. 
The quantity of matter may be very small, or so abundant as gradually but surely to 
exhaust the system. At times the suppuration is almost entirely suspended, perhaps, 
indeed, for several months, when, either suddenly or gradually, it reappears, and becomes 
as profuse as before. Once established, it has no special limit as to its duration, but may 
last, with hardly any intermission, for years. Whenever the discharge is unusually pro- 
tracted, it may be assumed that there is extensive caries, if not also necrosis of the bony 
structures of the joint, especially if it be attended with an occasional escape of gritty 
substance. 
Prognosis.—Tuberculosis of the joints is essentially a chronic disease, which, after an 
indefinite period, terminates either in recovery or in death. The recovery may be com- 
plete, both as it regards the part and system, or, the local action disappearing, the joint 
may be left weak and ankylosed, and the general health regain its original vigor ; or, as not 
unfrequently happens, particularly after the process of disorganization has commenced, 
both the articulation and the constitution may remain for a long time, if not permanently, 
in a degraded and crippled condition. 
Much, as it respects the result, will depend, in every instance, upon the state of the 
constitution, the presence or absence of complications, and, above all, the duration of the 
disease. Age also exercises an important influence, children living longer, and also hav- 
ing a much better chance of recovery, than young adults and middle-aged subjects, in 
whom, especially the latter, the affection often proceeds with extraordinary rapidity, 
sometimes ending fatally in a few months. When the constitution is naturally feeble, or 
when it has been rendered so by the intensity of the local suffering, the probability of an 
unfavorable termination will be much increased. Imperfect alimentation and intercur- 
rent diseases, as typhoid, intermittent, and eruptive fevers, diarrhoea, dysentery, and ery- 
sipelas, often retard recovery, or hasten the fatal crisis. These and other affections, by 
.establishing a drain upon the system, already exhausted by the local disease, are the 
principal causes of the mortality in tuberculosis of the joints. When the disorder proves 
fatal without such intervention, it will generally be found that death is directly due to 
the depressing effects of tuberculosis of the lungs, lymphatic glands, spleen, or perito- 
neum, so liable to show itself under such circumstances. 
Much of the mortality of this disease, as well as most of the bad effects, both temporary 
and permanent, which it entails upon the affected articulation, results from neglect of 
appropriate management prior to the commencement of the disorganizing process. 
Properly treated at its beginning, it is, generally, as remediable as any ordinary chronic 
inflammation, although not, perhaps, so promptly. The morbid action receding, the 
effused materials are gradually absorbed, and the parts restored to their normal functions. CHAP. IX. 
TUBERCULOSIS OF THE JOINTS. 
1061 
Arrived at its second stage, hardly any course of medication, however judiciously applied, 
will completely avert permanent rigidity, although life may not be at all in jeopardy. 
The morbid impression has already advanced too far to admit of easy recession ; a certain 
amount of structural lesion is present, and the patient will be fortunate if he ever com- 
pletely regains the use of his joint. In the third stage, when the osseous, cartilaginous, 
and other textures are disintegrated and broken down ; when, perhaps, the interior of the 
joint is converted into a large chronic abscess ; when the limb is stiffened or immovable, 
and, finally, when the constitution is worn out by pain and hectic irritation, there will 
not only inevitably be loss of function, but also great danger of loss of life. If, under 
such circumstances, the patient survive, his recovery will be effected at the expense of 
much suffering, too often eventuating in premature decay and dissolution. 
Treatment In the treatment of this affection, it must be remembered that, as it is 
generally, if not invariably, merely a local manifestation of a constitutional vice, topical 
remedies alone will not avail; to prove efficient and truly useful, they must be combined 
with, and aided by, means addressed to the general system, with a view to the improve- 
ment both of the solids and fluids. It would be idle, in the present state of the science, 
to insist upon a course so palpably proper in itself and so long sanctioned by experience. 
\Ve might as well expect to be able to cure consumption, or to ameliorate the condition 
of a person thus affected, by the exclusive employment of counterirritation and other 
external measures, as to cure tuberculosis of the joints without the aid of constitutional 
remedies. Again, in treating this disease it should not be forgotten that it consists of 
different stages, which, although they run imperceptibly into each other, are, nevertheless, 
of vast importance in a practical point of view. 
Whatever may have been the duration of the disease when the treatment is commenced, 
the first and most essential element in its management is repose, absolute, unconditional, 
and persistent, not merely of the joint, but also of the body. Upon this subject there 
must be no compromise. The slightest departure from this injunction would at any period 
of the complaint be of great detriment to the patient’s limb, while, in its more advanced 
stages, when the bones and cartilages are seriously involved and matter exists in the joint, 
it might endanger his life. When the disease is seated in the inferior extremity, recum- 
bency must be observed, not for days or weeks, but months. 
The local remedies must be regulated by the progress of the affection and the condition 
of the constitution. If the disease is in its first stage, if the pain is violent and frequent 
in its recurrence, and if the general health remains unimpaired, we can scarcely fail to 
derive special benefit from the application of leeches, or, in thejr absence, from the use 
of a large blister. The leeches should be scattered over the affected joint, and the flow 
of blood encouraged for some time with cloths wrung out of warm water. Their number 
must depend upon circumstances, but, in general, from three to six will be sufficient for a 
child from three to six years of age. Sometimes a blister may advantageously be applied 
within a few days after the leeching, and I much prefer this mode of counterirritation to 
the employment of liniments, embrocations, croton oil, tartar emetic ointment, and iodin- 
ized lotions, which is always attended with friction, and for that reason is often prejudicial 
to the inflamed structures. By these means, conjoined with a plain, simple diet, consist- 
ing mainly of farinaceous articles, and an occasional laxative of blue mass and jalap, 
almost any case may be radically cured in a few months. If fever be present, or if 
decided plethora exist, as denoted by the state of the pulse, face, and skin, antimonial 
and saline preparations may be given. To relieve pain ami secure sleep, opiates must be 
used with warm anodyne poultices or fomentations, or, what l have found to be of greater 
benefit, a lotion composed of soap liniment, laudanum, and tincture of aconite, applied 
by means of a fold of flannel, kept constantly wet, and covered with oiled silk. Cold 
applications are generally inadmissible both in this and in the other stages of the disease. 
When the skin is unusually dry, or the system more than commonly irritable, the local- 
ized steam bath, carefully administered, with a Dover’s powder at night, is sometimes 
highly beneficial. 
As permanent ankylosis cannot always be avoided, the affected joint should be care- 
fully placed in the best position for future usefulness ; but this is a subject which will 
receive proper attention in a future section. 
Although the treatment now laid down will usually be found to be very serviceable in 
the earlier stages of the complaint, there is, nevertheless, not a little diversity in regard 
to the nature of the internal remedies required in different cases. As already stated, 
there are two distinct classes of patients, the plethoric and the anemic, the former de- 
manding, perhaps, a certain amount of depletion, while the latter will be most benefited 1062 
DISEASES AND INJURIES OF THE JOINTS. 
CHAP. IX. 
by tonics. I have not met with any cases where I thought the use of the lancet was 
indicated, and yet I am not prepared to say whether, when the inflammation and pain are 
very great, in a strong, robust child, soon after the commencement of the malady, vene- 
section, to a small extent, might not be highly beneficial, in preventing suppuration and 
in saving structure; in general, however, the morbid action may be sufficiently repressed 
by saline medicines, in union with a minute quantity of tincture of aconite and tartar 
emetic, assisted, perhaps, by the application of a few leeches to the seat of the disease. 
In the anemic, a very common class of cases, tonics and stimulants are often required at 
the very commencement of the disease, consisting either of quinine and iron, or, what is 
peculiarly valuable, of cod-liver oil, in such doses as shall not prove offensive to the 
stomach. The diet should, of course, be of a corresponding character, with milk punch, 
wine, ale, or porter, to rebuild the system, and thus enable the affected parts the more 
effectually to resist the encroachments of the morbid action. 
Absolute rest cannot be employed too soon in the treatment of joint-disease, and must 
be secured at all hazard, by splints or by extension and counterextension, conducted 
upon the same principles as in fractures of the lower extremities. The best material for 
splints is gutta-percha, plaster of Paris, undressed sole-leather, or trunk-maker’s board, 
soaked in hot water, carefully adapted to the parts, and secured with a common roller. 
When dry, these articles form an admirable case, which may afterwards be padded with 
cotton, or any other soft substance, to ward off' pressure. 
Any malposition of the limb, caused by the contraction of the muscles, that cannot be 
rectified in this way, must be remedied with the tenotome. The effect of such an opera- 
tion upon the future welfare of the part and system is often most striking, the pain and 
spasm being relieved as if by magic, and the limb becoming perfectly docile and manage- 
able, especially if extended by the weight and pulley. 
in the second stage of the affection, the most reliable local remedy is a large issue, to 
secure a free and permanent discharge of matter. If the case has not been seen before 
it has reached this crisis, some of the means already mentioned, as leeching and blister- 
ing, may be tried; but, unless they be promptly beneficial, no time should be wasted in 
their employment. The disease is now thoroughly aroused, and must, therefore, be met 
in the most decisive manner, to prevent its disorganizing and destructive effects. The 
best place, by far, for the issue is the most prominent part of the swelling, which is 
usually either directly over the joint or in its immediate vicinity. The nearer, in fact, 
the discharge is established to the diseased structures, the more likely will it be to be 
useful. The best issue is one made with the actual cautery, heated white, and gently 
pressed upon the part until a suitable eschar is formed ; one about the size of a twenty-five 
cent piece if the patient is very young, or twice that size if he is twelve or fifteen years 
old, being a good average. The slough, which should not extend beyond the subcuta- 
neous connective tissue, generally drops off within the week ; and, during this period, as well 
as afterwards, the parts should be kept constantly covered with an elm or linseed poultice, 
renewed several times in the twenty-four hours. The discharge, if flagging, may be pro- 
moted by savine ointment, by simple cerate containing a few drops of nitric acid to the 
ounce, or, what I prefer, the occasional application, for a few hours, of a small blister. 
In this manner an abundant pyogenic discharge may readily be maintained for an almost 
indefinite period. The cautery may, if necessary, be reapplied at any time during the 
progress of the treatment. 
The hot iron deserves a decided preference, for making an issue in this disease, over all 
other modes of cauterization, as affording not only a more copious and persistent flow of 
pus, but, what is of no little importance, making a much stronger, as well as a more per- 
manent, impression upon the part and system. Although it is not always possible to 
determine how long tlie suppuration should be kept up, it will be well to let it continue 
until there is reason to believe that the violence of the morbid action has completely sub- 
sided. I have never, in any instance, experienced any bad effects from its protracted 
continuance; indeed, quite the contrary has been the case. If the discharge becomes 
offensive, as it often does in warm weather, deodorizers must be used, with a more frequent 
change of dressing. Occasionally the poultice, especially the linseed, causes painful and 
itchy eruptions around the sore, necessitating its temporary suspension, or the substitution 
of some more suitable application. 
Besides these advantages, the raw surface left by this kind of issue affords an excellent 
opportunity for the local application of morphia, tor combating the excessive pain and 
spasmodic twitchings of tlie muscles, which are so common in this complaint, and which 
are much more promptly subdued in this way than when this medicine is administered by TUBERCULOSIS OF THE JOIXTS. 
1063 
CHAP. IX. 
the mouth. The quantity necessary to produce the desired effect will, of course, depend 
upon circumstances; but, in general, from a quarter to a third of a grain will be required 
for a child three or four years old. Sometimes a dose of Dover’s powder will allay the pain 
and quiet the system more effectually than anything else. The diet should be more or 
less nourishing, and tonics freely used, if there is marked debility. 
When the course of the disease is chronic from its very commencement, as indicated 
by the absence of heat, spasmodic, starting pains at night, and freedom from suffering on 
manipulation and pressing the inflamed surfaces together, I know of no measure better 
calculated to restore the swollen, pulpy, and deformed articulation to its normal condition, 
than moderate compression exerted by means of the gum ammoniac and mercurial plaster, 
adhesive strips, or the plaster or water-glass bandage. With such a dressing the 
patient is enabled to go about on crutches and enjoy the benefit of exercise in the open air. 
Professor Hueter, of Griefswald, who has little faith in the ordinary treatment of scro- 
fulous inflammation of the joints, recommends the injection of fifteen drops of a three to 
five per cent, solution of carbolic acid into the affected bone or articulation in the earlier 
stages of the disease, or before suppuration has set in. If the remedy fail, he advises 
total excision. I have myself had no experience in this practice; but have no hesitation 
in pronouncing it to be entirely too exclusive. 
When the disease has reached its third stage, the great point in the treatment is to limit 
suppuration and to promote the absorption of effused fluids, the most important local 
remedies being dilute tincture of iodine, chloride of ammonium, and cantharidal col- 
lodion, along with perfect rest of the affected joint, and the liberal use of anodynes, to 
allay pain and secure sleep. All active and depressing measures, are, of course, out of 
the question, as they would only tend to do mischief. If the quantity of pus is small, this 
treatment may be sufficient to cause its removal, especially repeated vesication; if, on 
the other hand, the accumulation is considerable, the only thing to be done is to afford 
artificial evacuation, subcutaneously, if there be as yet no serious structural lesion, or by 
direct incision when the matter is superficial, and denotive, by its fluctuation and the 
great size of the swelling, that it is likely, if let alone, to burrow and to produce other 
mischief. The extension of pus, in such a condition, is always highly prejudicial both to 
the part and system, keeping up pain, favoring hectic irritation, and rapidly undermining 
the vital powers. When the matter has been evacuated, whether by a valvular or direct 
incision, the opening should immediately be closed with adhesive plaster and a thick com- 
press, wet with oil and supported with a bandage, a full dose of morphia being at the same 
time injected under the skin. When the quantity of matter is unusually great, the best 
dressing, especially when evacuation is effected by a free opening, is an emollient cataplasm 
or warm water, medicated with laudanum and sugar of lead. To prevent undue reaction, 
the system should be steadily kept under the influence of opium, repeated not less than 
twice a day for at least a week, or until the parts and the system have become accustomed 
to their new relations. The strength is sustained by tonics and a suitable diet, pure air, 
and frequent ablutions of the surface with salt water. 
If sinuses form, the best plan is not to interfere with them until the patient is suffi- 
ciently strong to bear the operation, as the pain and loss of blood consequent upon the use 
of the knife would, except in rare cases, more than counterbalance any good that might 
otherwise accrue. Any loose fragments of bone or cartilage should, of course, be promptly 
removed, and a counteropening may also frequently be beneficial. Washing out the 
abscess several times daily with weak solutions of chlorinated sodium, permanganate of 
potassium, nitrate of silver, or similar articles, is especially indicated when the matter 
is thin, ichorous, and fetid. When the suppurative action is in great measure subdued, 
the plastic deposits are best dealt with by sorbefacient plasters, as the ammoniac and 
mercurial, under the influence of which the induration and swelling often disappear with 
astonishing rapidity. When there is much pain, a suitable quantity of morphia may be 
incorporated with its ingredients. 
In the event of a cure, whether spontaneous or artificial, passive motion must, in due 
time, be instituted, to prevent ankylosis. The principles upon which it should be con- 
ducted are the same as in dislocations and fractures of the joints. Much judgment, 
however, is necessary, otherwise the operation may readily reprovoke disease. The 
best plan is to repeat it, at first, only about every fourth day, until the parts have become 
somewhat accustomed to it, when it may be employed more frequently. As the proceed- 
ing is always very painful, especially for some time, it is very important that the patient 
should be anaesthetized. Indeed, without this precaution, it will be impossible to over- 1064 
DISEASES AND INJURIES OF THE JOINTS. 
CHAP, ix. 
come the action of the rigid and contracted muscles, or to break up the morbid adhesions 
in and around the joint. 
When the extremities of the bones are necrosed, or so completely carious as to preclude 
all hope of recovery by time and ordinary means, the soft parts being riddled with sinuses, 
and the discharge copious and exhausting, excision of the diseased parts will be demanded, 
and should, if life be not too deeply undermined, be promptly performed, as most likely 
to rescue the patient from impending death. The disease being thus arrested, tlie part 
and system will be placed in a much better condition for gradual and permanent recovery. 
With proper care it may even be possible to preserve a certain degree of motion between 
the contiguous bones. Excision is more particularly applicable to strumous disease of tbe 
hip and shoulder joints. Good cures, however, occasionally result when the operation is 
performed upon some of the other joints, although I believe that amputation is always 
preferable when there is extensive organic lesion, and life is rapidly ebbing away from 
protracted suffering, or suppuration. 
2. TUBERCULOSIS OF THE JOINTS OF THE HEAD AND TRUNK. 
1. Temporo-Maxillary Joint It is not often that this articulation is invaded by this 
disease, and then almost exclusively in young persons of broken-down constitution, from 
the effects of cold, mercury, or irritation of the teeth. It is distinguished by a puffy 
swelling in front of the ear, or in the temporo-maxillary region, by tension and discolora- 
tion of the skin, and by a dull, heavy pain in the joint, increased by pressure and motion 
of the jaw. During the progress of the disease, the auditory canal becomes greatly dim- 
inished, if not entirely closed, and the seat of a very fetid, purulent discharge, attended 
with loss of hearing, especially when there is much involvement of the temporal bone. 
Finally, abscesses and fistulous openings form, exposing this bone and the condyle of the 
jaw in a carious or necrosed condition. 
In the treatment of this affection special care must be taken to guard against ankylosis, 
otherwise, when recovery occurs, the functions of the joint may be permanently lost. 
Dead bone must be extracted as soon as it is sufficiently detached, and the condyle of the 
jaw may, if necessary, be resected, as in a case under my observation in 1874, in which 
I removed the condyle successfully in a girl seven years of age. When there is much 
involvement of the temporal bone, tbe patient may die from an extension of the disease 
to the brain. 
2. Clavicular Joints The joints formed by the junction of the clavicle with the 
sternum and the scapula are occasionally involved in tuberculosis. The disease is met 
with chiefly in young subjects, and is characterized by the usual phenomena. 
When it attacks the sterno-clavicular articulation, the most prominent signs are, a soft, 
puffy, and elastic swelling at the seat of the disease, and a fixed pain at the same point, 
aggravated by pressure and motion of the scapula, and also somewhat by forced inspira- 
tion and expiration. The head of the collar-bone often presents the appearance of being 
enlarged. In time an abscess forms, and, if its evacuation is neglected, the matter may 
descend into the anterior mediastinum, and thus occasion fatal consequences. Luxation 
of the clavicle can occur only when there is complete destruction of the connecting liga- 
ments, permitting the end of the bone to project upwards or backwards: in the latter case 
it may compress the trachea and oesophagus. 
Tuberculosis of the acromio-clavicular joint is very uncommon, and is characterized by 
the same symptoms as the preceding disease. Care should be taken not to confound these 
affections with rheumatism, to which both these joints are liable. 
The treatment requires nothing peculiar. Resection of the clavicle may be performed 
if this bone is extensively necrosed, or otherwise diseased, or if it injuriously compresses 
the trachea and oesophagus. 
3. Occipito-Atloid and Atlo-Aroid Joints.—Tuberculosis of these articulations, first 
accurately described by Schupke, in 1816, and since then specially investigated by 
Berard, Teissier, and Scbcenfeld, occurs principally in children and young adults, either 
without any assignable cause, or as a consequence of cold or injury. Although it is 
essentially similar to Pott’s disease, it requires separate notice on account of the pecu- 
liarity of some of its effects. 
The disease, whether beginning in the synovial, cartilaginous, or osseous tissue, often 
commits the most frightful ravages, sometimes destroying the greater part of the arch of 
the atlas, the whole of the odontoid process, and, perhaps, even the margins of the occip- CHAP. ix. 
TUBERCULOSIS OF CERVICAL JOINTS. 
1065 
ital bone. What is remarkable, the anterior portions of these structures generally suffer 
much more than the posterior. 
In consequence of the destruction of the ligaments, the occipital bone maybe dislocated 
forwards, backwards, or laterally, displacement by rotation being extremely rare. In 
whatever direction the accident may occur, the encroachment of the parts upon the spinal 
canal is seldom sufficient to cause any serious compression of the cord. The atlas is more 
frequently luxated than the occipital bone, being thrown either forwards or to one side. 
Occasionally the displacement is by rotation. Dislocation backwards is impossible on 
account of the obstacle offered by the odontoid process. In the more severe forms of the 
disease the displacement is sometimes of a mixed character. 
The spinal cord is variously altered, according to the nature and extent of the 
osseous involvement. In some cases it retains its normal structure, while in others it is 
softened and broken down. The dura mater is generally thickened, engorged, fungous, 
ulcerated, or even perforated, and the arachnoid membrane inflamed and incrusted with 
lymph. 
The disease, at its commencement, is characterized by a dull, aching pain, circum- 
scribed, deep-seated, and much increased by motion and pressure. A sense of weight 
and fatigue is experienced in the upper part of the neck, and the patient at length finds 
it difficult, if not impossible, to support his head in walking. Gradually other symptoms 
supervene, the most distressing of which are pain and difficulty in deglutition, dependent 
upon inflammation of the pharynx. The neck now becomes deformed, owing to the 
joint agency of the displacements above alluded to, and of interstitial deposits. The 
posterior muscles are remarkably firm and rigid, and the head is immovably fixed, not 
unfrequently in a very vicious position, being either bent forwards toward the sternum, 
drawn backwards, or inclined to one side. When the disease is fully developed, the pain, 
all along sufficiently distressing, is greatly increased in severity, and radiates about in 
different directions, especially up into the head and down the neck into the shoulders. 
When abscesses form, the patient, in addition to the dysphagia, experiences difficulty in 
speaking, expectorating, and breathing, in consequence of the obstruction of the fauces 
from the accumulating fluid, and from the same cause the tongue is sometimes partially 
protruded from the mouth. The matter is discharged either into the mouth or at the 
back of the neck ; often by several apertures. Occasionally large pieces of bone come 
away with the pus. 
When the spinal cord and its membranes are seriously involved, there will be, in 
addition to the above symptoms, great embarrassment of respiration, lividity of the face, 
and paralysis, first of the superior, and afterwards of the inferior, extremities; together, 
in short, with all the phenomena of a gradual but surely fatal asphyxia. In some cases 
the patient perishes suddenly from an accidental twist of the neck crushing the spinal 
cord. 
The deformity of the neck consequent upon this disease is deserving of special notice 
in a diagnostic point of view. The affected part is much broader than usual, and also 
more protuberant or irregular. When the occipital bone is thrown forwards upon the 
atlas, the depression which naturally exists at the upper part of the neck, between the 
attachments of the two trapezial and the two splenial muscles, is effaced, and the finger 
easily recognizes the posterior arch of the atlas. If, on the contrary, the bone is forced 
backwards, the hollow in question will be found to be increased, and the spinous process 
of the axis less distinguishable. 
The displacements of the atlas are generally easy of recognition. Teissier, who has 
studied the subject with much care, states that when this bone is dislocated forwards, the 
spinous process of the axis forms a prominence more marked and nearer to the occipital 
protuberance than in the natural state, at the same time that the swelling is abruptly 
interrupted at its upper part, where it is surmounted by an excavation. When the dis- 
placement is lateral, the spinous process of the axis will be found to be more in the direc- 
tion of a vertical line, extending from the external occipital protuberance. Finally, one 
of the articular processes of the axis may give way, and thus form a projection in the 
neck, either on the right or left side of the middle line. 
Tuberculosis of these joints may be simulated by the effects of rheumatism and of ex- 
ternal injury, causing pain and stiffness of the neck, with partial, if not complete immo- 
bility of the head. When the disease is far advanced, the diagnosis is unequivocal. 
When recovery takes place, the neck generally remains deformed and protuberant, 
with great impairment of its functions, the affected bones being completely soldered 
together by new osseous matter. DISEASES AND INJURIES OF THE JOINTS. 
CHAP. IX. 
In the treatment of this affection, in addition to the employment of the usual remedies, 
rest and support of the part, by suitable apparatus, are most important elements. The 
head should lie on a level with the trunk, with a thin, elastic pillow under the neck, and 
care should be taken, especially in the more advanced stages of the complaint, that it is 
not suddenly moved in any direction, lest, the ligaments having given way, the bones 
should become displaced, and thus instantly and fatally crush the spinal cord. The re- 
cumbency must be steady and protracted. A circular issue should be established, at an 
early period, with the actual cautery, directly over the diseased joints, and a free discharge 
of matter invited. Advancing abscesses should be promptly opened, in particular if they 
point toward the fauces ; if neglected, they may suffocate the patient by their pressure 
upon the mouth of the larynx, or, bursting unexpectedly, the matter may pass into the 
windpipe, and so induce fatal asphyxia. If an attempt at reposition of the dislocated 
bones should be deemed advisable, the operation must be performed with the greatest 
possible care and gentleness. In the event of recovery, the neck and head must be sup- 
ported for a long time by a proper appliance, to afford the parts a proper opportunity for 
safe and perfect consolidation. 
4. Sacro-iliac Joint The sacro-iliac joint is liable to a very rare form of strumous 
disease, analogous to coxalgia and white swelling of the knee. It was first accurately 
described by Boyer, and very excellent accounts of it have been given by Hahn, Nelaton, 
Erichsen, and Boissarie. 
The disease, which is essentially chronic, is most common between the ages of twelve 
and thirty. Infants seem to be entirely exempt from it. The statistics.of Dr. C. T. 
Poore, of New York, show that children and adults are alike subject to it. Its causes 
are the same as those of scrofulous affections in general. In the great majority of 
cases the lesion comes on spontaneously; but an instance now and then occurs in 
which it is traceable to direct violence, as a blow, kick, fall, or sprain, to the effects of 
cold, or to suppression of the cutaneous perspiration. Injury done to the pelvic bones 
and joints during pregnancy and parturition probably predisposes to its production, 
especially when thefe is a strong strumous diathesis. Certain occupations may also 
possibly favor its development. Thus, Ilahn has narrated three cases, all occurring in 
tailors. 
The pathology of the disease is sufficiently well understood. Whatever the nature of 
the exciting cause may be, struma is unquestionably its intrinsic element. In its earlier 
stages, the disorder is generally limited to the synovial and cartilaginous structures of the 
sacro-iliac symphysis, these structures becoming eroded, and eventually broken down 
into a softened, pultaceous substance, presenting a condition not unlike what occurs in 
the so-called pulpy degeneration of strumous joints, especially that of the knee. As the 
morbid action progresses, the osseous tissues also suffer, as is evinced by their rough and 
denuded appearance, by their abnormal vascularity, and by their infiltrated, spongy, and 
disintegrated character. Caries and necrosis are, however, seldom met with, even in very 
chronic cases, and the ligaments also retain for a long time their integrity. 
The most important symptoms are, pain, swelling, lameness, and deformity of the pelvis 
and limb. To these are superadded, in time, abscesses and sinuses, along with hectic 
fever, which is generally a prominent occurrence. 
Pain is an early symptom ; it is seated in the course of the sacro-iliac symphysis, is 
increased by pressure and motion, and is accompanied by a sense of weakness in the lower 
part of the back and sacrum. The patient feels as if he would drop apart, and finds it 
extremely difficult to support himself in walking, very much as in sciatica or rheumatism, 
for which, at this stage, the disorder is often mistaken. As the disease advances, the 
pain becomes more fixed and severe, and assumes a dull, aching, or gnawing character. 
It does not, except in rare instances, extend down the limb, nor is it aggravated by mov- 
ing the thigh, unless the surgeon neglects to steady the pelvis, when it is often very 
severe. The gluteal region is somewhat flattened, and tender on pressure, especially as 
the finger approaches the seat of the disease. 
The swelling, originally very slight, gradually increases in extent, and, in time, becomes 
a prominent feature. It is putty, elongated from above downwards, and situated in the 
line of the affected joint; not materially involving the gluteal region, nor invading the 
natural hollow behind the great trochanter. When abscesses occur, the form and size of 
the swelling are greatly changed. 
Lameness is an early and prominent symptom. The patient, at first, merely limps, 
and is soon fatigued by exercise. In a very short time, however, his movements become 
much constrained, and he supports himself with great difficulty, leans forward, and CHAP. IX. 
TUBERCULOSIS OF THE SACRO-ILIAC JOINT. 
1067 
employs a cane or crutch. He can put his foot on the ground, but is unable to bear his 
weight upon it, nor can he twist himself suddenly around without great suffering. At 
length his locomotive powers are completely crippled, and he is obliged to keep his bed. 
Pressure upon the iliac bone, or pushing this bone forcibly against the sacrum, always 
causes severe pain. 
The limb on the corresponding side is, from the very first, longer than the other, the 
increase in length varying from six lines to an inch or even an inch and a half, according 
to the duration and violence of the morbid action. The change, however, is not real, but, 
as in coxalgia, merely feigned, depending upon the alteration in the position of the pelvis, 
which is not only considerably depressed, or lower than on the sound side, but also tilted 
forwards and rotated downwards so as to impart an unusual degree of prominence to the 
anterior superior spinous process of the ilium. The limb itself is attenuated, flabby, and 
enfeebled. In progression, it is generally somewhat abducted, flexed at the knee, and 
projected a little forwards, the weight of the body being thrown entirely upon the sound 
side. Upon taking hold of the limb, it can be moved in any direction. 
By and by, after months of suffering, sometimes, indeed, not until after a year or a 
year and a half, matter begins to form, preceded by an increase of local and constitu- 
tional disturbance, ultimately eventuating in severe hectic irritation. The swelling over 
the joint gradually increases in size, and the fluid, which is always of a scrofulous char- 
acter, slowly burrows among the neighboring parts, spreading underneath the gluteal 
muscles, in the direction of the great trochanter, extending into the loin or passing into 
the pelvis, by the side of the rectum, or the rectum and vagina, in the former of which it 
occasionally finds an outlet. When this is the case, flatus may enter the cavity of the 
abscess, and so cause it to become tympanitic. Sometimes the matter, after having 
passed into the pelvis, issues at the sciatic notch, and thus gets, as has been observed by 
Mr. Krichsen, under the gluteal muscles. 
The affections with which sacro-iliac disease is most liable to be confounded are, cox- 
algia, neuralgia of the hip, sciatica, and caries of the spine. From coxalgia it is distin- 
guished, 1st, by the peculiar shape and site of the swelling; 2dly, by the character and 
situation of the pain, which does not affect the limb or knee, as in hip-joint disease ; 3dly, 
by the tardy progress of the morbid action ; 4thly, by the rotated appearance of the pelvis 
and the abnormal prominence of the anterior superior spinous process of the ilium ; othly, 
by the persistence of the ilio-femoral crease ; Gtidy, by the preservation of the movements 
of the hip-joint; and, lastly, by the suffering which the patient experiences when firm pres- 
sure or percussion is applied to the innominate bones. In sacro-iliac disease considerable 
pain is sometimes perceived at the upper and inner part of the thigh, from involvement of 
the obturator nerve in its passage through the pelvis. In both affections there is shortening 
of the limb, but in the sacro-iliac it is never real at any time, while it is invariably so in 
the latter stages of coxalgia, owing to the partial destruction of tlie head and neck of the 
femur. Coxalgia is nearly always a disease of early childhood, whereas sacro-iliac dis- 
ease is seldom observed until after the fifteenth year. 
Neuralgia of the hip occurs chiefly in young females of a nervous temperament and 
hysterical habits, and is, generally, easily distinguished from disease of the sacro-iliac 
synchondrosis, first, by the character of the pain, which is more widely diffused, as well 
as more superficial and irregular; secondly, by the want of intumescence in the course of 
the joint; thirdly, by the coexistence of neuralgia in other parts of the body; and, 
fourthly, by the history of the case. Another important element is the absence of abscess, 
which nearly always occurs in the latter stages of sacro-iliac disease. 
'fhe discrimination between sciatica and this affection is seldom difficult. The chief 
signs of distinction are that, in the former, the pain is confined chiefly to the lumbar 
region, while in the latter it is seated more particularly in the line of the sacro-iliac joint. 
Besides, it is generally more easily amenable to treatment, and is very frequently con- 
nected with a gouty or rheumatico-gouty state of the system. Moreover, in sciatica there 
is no deformity of the pelvis or change in the length of the limb. 
It is barely possible that sacro-iliac disease might be confounded with disease of the 
spine ; but such an occurrence will readily be avoided if the surgeon keep clearly before 
his mind the distinction between the real symptoms of the two disorders. In the former 
there is always more or less intumescence in the line of the sacro-iliac joint, with marked 
deformity of the pelvis and elongation of the limb on the affected side ; in the latter all 
these phenomena are wanting, and the vertebral column is stiff, tender on pressure, and 
excurvated. The most common site of the disease is the dorsal portion of the spine, and, 
if an abscess form, the matter never gravitates in the direction of the sacro-iliac junction. 1068 
DISEASES AND INJURIES OF THE JOINTS. 
CHAP. IX. 
The prognosis is favorable in the early stage of the disease, and a cure is not infrequent 
even when matter has formed. Of 58 cases, collected by Poore, 23 recovered ; and of 18 
in the hands of Sayre, in 6 of which dead bone was removed, all, save one, were restored 
to health. When the treatment has been neglected, the patient, after having lingered for 
months, with an occasional intermission from suffering, is finally worn out by the profuse 
drain and hectic irritation, or by some intercurrent disease, as purulent infection, or tuber- 
culosis of the lungs. 
The treatment of sacro-iliac disease is similar to that of coxalgia. The principal reme- 
dies are rest, recumbency, and confinement of the pelvis, with leeches, iodine, and blisters 
in the early stages of the disorder, followed, if there be not prompt and decided ameliora- 
tion, by the establishment of a long issue, with the actual cautery, in the line of the 
affected joint. Of course, no severe counterirritation is admissible after the parts have 
become seriously disorganized. If abscesses form, no time must be lost in letting out 
their contents by a valvular incision. The strength is supported by tonics, and the con- 
stitution improved by alterants, as iodide of iron, iodide of potassium, and bichloride of 
mercury, with cod-liver oil and other suitable means. 
Professor McGuire, of Richmond, in 1878, reported two cases of this disease in which 
great and immediate relief, and, finally, a perfect cure followed the employment of ex- 
tension and counterextension, conducted upon the same principles as in the treatment of 
fractures. No counterirritation was used. 
3. TUBERCULOSIS OF THE JOINTS OF THE SUPERIOR EXTREMITY. 
1. Wrist-joint.—The characteristic features of tuberculosis of the wrist-joint are well 
depicted in the annexed engraving, fig. 004, from Harwell, the disease having already 
made considerable progress. It will be 
observed that the greatest amount of swell- 
ing and distortion is on the dorsal surface 
of the hand, although there is also a good 
deal of fullness in front and in the hollow of 
the palm, which is often completely effaced, 
especially when the matter gravitates in 
that direction. The thumb and fingers are 
tumefied, stiff, and straight, or nearly so, 
and have a peculiarly elongated appearance. 
Every attempt to move them excites severe 
pain, or pain and spasm. A sense of fluctuation, often very faint and perplexing, is 
usually perceptible, being most distinct on the back of the joint, and caused either by a 
fungous condition of the synovial membrane, or by the presence of an unnatural quantity 
of synovial fluid, or both. The muscles of the limb are wasted and flabby. If matter 
form, it generally experiences not only great difficulty in finding an outlet, but is very 
apt to travel up the forearm and down along the dorsal surface of the hand. Dislocation 
of the bones, in any direction, is uncommon. The head of the ulna, however, is often 
abnormally prominent, but of the radius the styloid process alone is distinguishable. 
The treatment consists in placing the limb in an easy, straight position upon a carved 
splint furnished with appliances for keeping up extension and counterextension, and in 
employing the various measures called for in tuberculosis of other joints. If matter form, 
an early outlet must be afforded, lest it diffuse itself extensively among the soft parts and 
the bones, and so endanger limb and life. Although resection is sometimes available, the 
preference should generally be given to amputation. 
2. Elbow-joint Tuberculosis of this joint generally begins in the structures of the 
humerus, whence it may gradually spread to the ulna and radius, and finally involve the 
whole articulation. Pain, stiffness, and swelling in and around the joint are the promi- 
nent symptoms of the disease. The skin is tense, glossy, and more or less red at the 
focus of the morbid action ; the parts are intolerant of manipulation and motion, and the 
swelling presents itself in the form of two cones, united on a level with the crease of the 
elbow, one apex looking upwards, the other downwards. The osseous prominences are 
completely effaced, except that formed by the olecranon process, on each side of which 
there is usually a good deal of fluctuation, caused by the presence of a large quantity of 
synovial fluid. The limb is wasted both above and below the joint, and the fingers are 
stiff’, swollen, and almost useless. The biceps muscle is rigidly contracted, so as to render 
extension difficult, if not impossible, and the forearm is bent nearly at a right angle with 
Fig. (504. 
Tuberculosis of the Wrist-joint. CHAP. IX. 
TUBERCULOSIS OF THE ANKLE-JOINT. 
1069 
the arm. When matter forms, it is usually discharged at the back part of the joint, at 
the side of the olecranon process, or at the lower part of the arm ; seldom in the forearm 
or in front of the joint. The ulna, owing to the solidity of its connections, is hardly ever 
dislocated, but it is not uncommon for the radius to abandon its relations with the humerus 
when there is much disorganization of their ligaments. In the worst forms of the disease, 
the bones are involved to a great extent; far, indeed, beyond their articular extremities. 
In the treatment of this affection the same principles are to be observed as in articular 
tuberculosis in general. Early recourse should be had to the actual cautery, drawn 
linearly along each side of the joint for three or four inches, and to proper support by 
means of a suitable splint, extending from near the axilla down to the fingers. The fore- 
arm should be placed in a semiflexed position ; matter should be promptly evacuated, 
and every means employed to preserve the usefulness of the limb. Amputation will be 
necessary when the disease is very extensive, or the general health is much impaired; 
otherwise the affected bones may be advantageously dealt with by resection. 
3. Shoulder-joint.—Tuberculosis of this joint is uncommon, and is met with chiefly in 
young persons after the age of eighteen or twenty, beginning generally in the synovial 
membrane and other structures of the humerus, to which it is nearly always limited, 
the glenoid cavity of the scapula rarely suffering. 
The disease is usually announced by more or less swelling, pain, and stiffness in the 
joint, which the patient is generally disposed to ascribe to the effects of rheumatism, cold, 
or some slight injury. As it progresses, the shoulder loses its natural contour, and as- 
sumes a peculiarly rounded appearance, owing to the presence of an undue quantity of 
synovial fluid. The deltoid muscle is gradually flattened and atrophied, and, in fact, the 
whole arm is wasted. The movements of the joint, at first merely restrained, are ulti- 
mately entirely lost. If the morbid action is not arrested, abscesses at length form, point 
and break, leaving thus a number of fistulous openings leading down to the diseased bone, 
which is either carious or both carious and necrosed, not unfrequently to an extent of 
three or four inches. In the worst cases, there is sometimes serious involvement of the 
glenoid cavity of the scapula. 
The pain which attends this disease, early in the attack, is occasionally most keenly 
felt in the elbow, as in coxalgia it is originally seated in the knee. Such an occurrence 
is, however, uncommon, and, therefore, of little diagnostic value. 
The treatment consists in complete repose of the joint, and in the application of leeches 
and blisters, or, if the attack is obstinate, the hot iron. Matter is early evacuated, and 
dead bone or cartilage removed as soon as it is sufficiently detached. In protracted cases, 
dependent upon the presence of carious or necrosed bone, the proper remedy is excision ; 
an operation which, if carefully executed, is not only free from danger, but nearly always 
successful, the patient regaining a good use of his limb. 
4. TUBERCULOSIS OF THE JOINTS OF THE INFERIOR EXTREMITY. 
1. A nkle-joint The most common cause of tuberculosis of this joint is external injury, 
as a sprain, twist, blow, or contusion. Among the earlier local symptoms is a swelling 
just in front of each malleolus, tilling up the hollow which naturally exists there; it 
fluctuates under the finger, and is mainly dependent upon the presence of synovial fluid, 
which, from the peculiar structure of the joint, always accumulates there in larger quantity 
than elsewhere. As the disease progresses, the grooves at the side of the tendo Aehillis 
disappear, and the whole joint becomes enormously enlarged, the heel and other osseous 
prominences losing their distinctive features. This increase of size is owing, not ex- 
clusively to morbid deposits in and around the articulation, but also, at least in part, 
to an expansion of the ends of the bones, as is easily ascertainable by examination. 
When the disease is far advanced, the fluctuation is rendered very faint in consequence 
of the fungous condition of the synovial membrane, the leg is excessively wasted, and 
the foot has a distorted or twisted appearance, as if it were rotated upon its axis, or 
partially dislocated. If suppuration takes place, the matter usually collects in front of 
the joint, diffusing itself more or less extensively in the subcutaneous connective tissue of 
that region. 
In the treatment of this disease, the foot should be placed at a right angle with the leg, 
and the parts well supported with suitable splints, so as to maintain them in an easy, re- 
laxed, and quiet position. Linear cauterization! may be performed ; or, what is preferable, 
a small issue should be established with the hot iron immediately above each malleolus. 1070 
DISEASES AND INJURIES OF THE JOINTS. 
Prompt vent is afforded to pus ; and, if the joint cannot be saved, resection or amputation 
is resorted to, according to the judgment of the surgeon. 
2. Knee-joint This joint, owing to the great size of its articular surfaces, its exten- 
sive motions, and its exposed situation, is, next to the hip, more frequently the seat of 
tuberculosis than any other joint in the body. While the disease is most common in young 
persons before the age of tifteen, it is often met with in young adults, and is generally 
developed under the influence of external violence, as a blow, fall, or twist, acting upon a 
depraved constitution. 
The pain which attends this disease, and which is generally very severe, even at the 
commencement of the attack, is almost invariably situated in the direction of the inner 
condyle of the femur, at the lower part of the patella, or at the inside of the head 
of the tibia; seldom at the outer part of the joint. The great uniformity of this 
occurrence has led to various speculations as to its course, but, as yet, no satisfactory 
explanation has been offered. As in coxalgia, the pain is liable to periodical exacerba- 
tions ; in general, it is of a dull, heavy, gnawing character, and is commonly worse at 
night than in the day, extending up and down the limb, and destroying the patient’s sleep 
and appetite. 
The concomitant swelling is usually very great, and is due partly to interstitial deposits, 
partly to an inordinate increase of the synovial fluid. It is always most conspicuous, 
especially in the earlier stages of the complaint, in front and at the sides of the patella, 
owing to the laxity and yielding character of the tissues at these points. It is in con- 
sequence of this circumstance that the depressions in this situation are generally soon 
completely effaced, or, what is the same thing, replaced by soft, fluctuating bags. A 
similar prominence, often of great size, exists just above the joint, over the lower part 
of the femur, bounded inferiorly by the patella, and on each side by the lateral ligament, 
its anterior wall being formed by the tendon of the extensor muscle. Very little tume- 
faction ever occurs in the popliteal region, even in the more advanced stages of the 
disease. The skin is tense and glossy; the subcutaneous veins are abnormally large; 
the knee is stiff', if not immovable ; and the leg, more or less flexed, is swollen and 
oedematous, while the thigh is remarkably atrophied. In proportion as the ligaments 
yield, the deformity of the joint increases, owing chiefly to the displacement of the head 
of the tibia, which allows the muscles to draw the leg outwards, so as to give it a twisted 
or contorted appearance. Not unfrequently there is an actual enlargement of the heads 
of the diseased bones. 
The fluctuation which constitutes so prominent a symptom in the earlier periods of this 
complaint, often, in great measure, if not entirely, disappears during its progress, owing to 
the adventitious deposits upon the synovial membrane and the absorption of the redundant 
synovial fluid. Whenever this is the case, the swelling, instead of being soft and yielding, 
will be comparatively firm and resisting, but still possess some degree of elasticity, often so 
deceptive as to lead to the idea that the joint contains a good deal of fluid, and which nothing 
but the most careful examination can dispel. 
Pus does not always form in this disease, even when permitted to proceed unmolested; 
on the contrary, there is reason to believe that it is frequently entirely absent. When 
suppuration does take place, the matter may either be absorbed, or it may escape at the 
side of the patella, the lower part of the thigh, or over the head of the tibia; very rarely 
in the ham. In the worst forms of the disease, the whole surface of the joint may be 
riddled with fistulous apertures, leading down to the diseased bones, large portions of wdiich 
are then either carious or necrosed. 
The treatment of tuberculosis of the knee presents nothing peculiar. The same rules 
of practice are to be enforced here as in coxalgia. Rest of the part and system, local 
support and extension by means of splints and the weight and pulley, and cauterization, 
either linear or circumscribed, are of primary .importance, and must be thoroughly enforced 
from the very beginning. 
When the more acute symptoms have subsided, or the disease has assumed a chronic 
form, to enable the patient to exercise in the open air, the requisite extension and rest of 
the joint may be secured by the apparatus of Dr. Sayre, delineated in fig. 605. It con- 
sists of two steel collars, each about one inch wide, which embrace the limb—the one at 
the upper third of the thigh, the other just above the ankle—and admit of adjustment by 
means of a sliding hinge and lock, while they are connected on each side by an extension 
rod, constructed on the rack and pinion principle. To apply this instrument, strips of 
strong, inelastic adhesive plaster, one inch in width, are arranged on the limb in the manner 
represented in fig. 606, and confined to within an inch of their extremities by a roller. 
CHAP. IX. CHAP. IX. 
TUBERCULOSIS OF THE HIP-JOINT. 
1071 
The instrument is then placed in position, the collars fastened sufficiently tight to be com- 
fortable, and the free ends of the plaster turned over them and secured by a roller. The 
connecting rods are extended simultaneously by means of the thumb-screws, the limb 
being thus brought nearly into a straight line, as in tig. 607, freedom from pain, on pres- 
Fig. 605. 
Fig. 606. 
Fig. 607. 
Sayre’s Apparatus for Extension 
at the Knee-joint. 
Mode of applying the Adhesive 
Plaster. 
Apparatus Adjusted. 
sure being brought to bear on the foot, denoting that the requisite degree of extension has 
been effected. The dressing is completed by enveloping the leg in a bandage from the 
toes up to the top of the instrument, to prevent swelling, and by surrounding the joint 
with strips of gum ammoniac and mercurial plaster, so as to exert a sorbefacient action 
upon the swollen and pulpified tissues. When the parts are hot and painful, the applica- 
tion of the plaster should be preceded by saturnine and anodyne lotions. 
When, so far as ordinary treatment is concerned, the case is hopeless, the only resource 
is resection of the affected joint; or, this being inadmissible on account of the great extent 
of the disease, amputation of the thigh, which will make a better and more satisfactory cure. 
3. Hip-joint.—Tuberculosis of this articulation, usually called coxalgia, femoro-coxal- 
gia, or hip-joint disease, is most frequent from the third to the seventh year. Cases occa- 
sionally occur before the twelfth month, and now and then an instance is seen after 
puberty, or even after the age of twenty, but this is uncommon. The oldest case that I 
have ever witnessed was that of a man twenty-six years of age. Of 1818 cases, analyzed 
by Dr. Y. P. Gibney with reference to this subject, 1002, or 88£ per cent, were under 
fourteen years. Both sexes are liable to it, probably nearly, if not quite, in an equal 
degree, at least such would seem to have been the fact in the cases analyzed by Dr. Gib- 
ney ; the affection has sometimes been noticed in several members of the same family. 
The causes of coxalgia are the same as those which provoke strumous disease in other 
parts of the body. The most common are external injury, as sprains, falls, or blows, 
exposure to cold, inadequate food and clothing, and wasting maladies, as cholera, chronic 
diarrhoea, dysentery, scarlatina, measles, and different kinds of fevers. In many cases it 
arises spontaneously, or without any obvious causes. 
It is seldom that both hip-joints are involved in this affection, either simultaneously or 
successively. During its progress, however, it becomes occasionally complicated with 
other strumous maladies, as Pott’s disease of the spine, psoas abscess, ophthalmitis, pul- 
monary phthisis, and degeneration of the lymphatic glands of the neck, mesentery, and 
other parts of the body. 
It is seldom in the power of the surgeon to ascertain the starting point of this disease, as 
few opportunities occur for examining the parts in the earlier stages of the morbid action. 
Nevertheless, enough is known to show that the articular cartilage of the head of the femur 
is the structure which most generally suffers first. In some cases the disease undoubtedly 
begins in the synovial membrane, in the interarticular or capsular ligament, in the aceta- 
bulum, or even in the cancellated tissue of the femur or ilium. However this may be, all 
the component elements of the joint become sooner or later involved in the disorganiza- 1072 
DISEASES AND INJURIES OF THE JOINTS. 
tion, the disease extending from one structure to another, although probably not with 
equal facility or rapidity. 
Symptomatology.—Tuberculosis of the hip-joint maybe described as consisting of three 
stages, each characterized by distinctive symptoms and pathological changes, as well as 
requiring peculiar treatment. As this division is not imaginary, but real, it is deserving 
of the greatest attention. 
The symptoms of the disease, in its first stage, are usually of so obscure and stealthy a 
character as to render it very liable to be mistaken for other affections of the joint. The 
first circumstance which commonly attracts attention, especially if the patient is a child, 
is a feeling of fatigue after exercise, with slight pain in the knee, and a disposition to drag 
the limb, thus giving the gait a stiff, awkward appearance. In this manner the case may 
progress for several weeks, or, indeed, even for several months, with, perhaps, hardly any 
perceptible aggravation. The child still goes about, taking his accustomed exercise, and 
manifesting the same interest as formerly in his out-door amusements. Gradually, how- 
ever, the pain increases; there is now a distinct limp; and the sleep is disturbed by spas- 
modic twitches of the extremity. The pain is usually referred to the knee, particularly 
to its inner side, and is either sharp and lancinating, or dull, heavy, and aching. It is 
sometimes felt in the very depths of the joint, but more frequently it is superficial, as if it 
were immediately beneath the integument. Exercise, or motion of any kind, always 
increases it, and it is generally worse at night than in the day; damp states of the atmos- 
phere, suppression of the cutaneous perspiration, and disorder of the digestive organs, 
also frequently aggravate it. The knee, on inspection, is found to be free from swelling 
and discoloration, and commonly quite tolerant of rough manipulation, as motion, pres- 
sure, and percussion. Occasionally the pain is of a neuralgic nature, and distinctly peri- 
odical in its recurrence, very similar, in this respect, to the paroxysms of an intermittent 
fever; the attack, perhaps, coming on early in the evening, and, after having continued 
for a few hours, returning about the same time next day. This form of pain is most fre- 
quent, according to my observation, in persons living in a malarial atmosphere. 
It is not often, however, that the pain, whatever may be its character, is entirely con- 
fined, at this stage of the disease, to the knee; or, if it is at first, that it remains there 
exclusively for any length of time. In general, it extends also to the thigh and leg, 
sometimes along the front, now along the sides, especially the inner, and now along the 
posterior surface, in the direction, apparently, of some nervous trunk, as the femoral, 
obturator, saphenous, or sciatic. I have met with cases where the pain was felt most 
keenly at the tendo Achillis, immediately above the ankle-joint, and in one instance it was 
distressingly severe over the instep. Sometimes, again, it seems to shift from one of these 
points to another, being, perhaps, most violent at one period in the knee, and at another 
in the thigh, leg, or foot. 
The occurrence of pain in the knee may be explained by the irritation of the nerves 
that are distributed to the hip-joint. Thus, the round ligament receives a filament from 
the obturator nerve, which sends a branch to the inner side of the knee as well as to its 
interior. Inflammation of the synovial covering of the ligament necessarily involves its 
nervous supply, and the sensation of pain is experienced either at the inner side of the 
knee or in the interior of the joint. When the anterior portion of the capsule and its 
synovial membrane are primarily affected, the suffering is generally referred to the outer 
side of the knee, as branches are distributed to that locality from the femoral nerve, which 
also sends articular branches to the front of the hip-joint. Anomalous pains experienced 
at other situations may also be explained by nervous irritation. The posterior portion of 
the hip-joint is supplied by filaments from the great sciatic trunk, which sends branches 
not only to the back of the knee, but to the entire lower extremity, so that pain may be 
felt at any of the points supplied by that nerve, when the inflammation is seated at the 
posterior surface of the articulation. A knowledge of these anatomical facts renders great 
aid in the diagnosis of individual cases, and serves to prevent those curious mistakes, 
which not unfrequently occur, of medicating parts which are free from disease. 
After some time, varying from a few weeks to as many months, the pain shifts to the hip 
and its neighborhood ; or, if it do not entirely forsake the knee, it is generally less con- 
stant and severe there than it was in the first instance, or soon after the commencement of 
the morbid action. Commonly it is most intense and persistent directly over the articu- 
lation, deep-seated, and of a dull, gnawing character. At times it is perceived most keenly 
in the sciatic notch, between the great trochanter and the spine of the ilium, or in the 
upper and outer part of the groin. Occasionally, again, it exists simultaneously at all 
these points, although not in an equal degree ; or, as it leaves one, it fastens itself upon 
CHAP. IX. CHAP. IX. 
TUBERCULOSIS OF THE HIP-JOINT. 
1073 
another. In rare cases the pain appears in the hip before it shows itself in the knee, thigh, 
or leg. Pressure upon the gluteal region and the groin, motion of the affected joint, and 
percussion of the knee, the leg being flexed at a right angle, or of the sole of the foot, the 
limb being extended, always augment the pain, and lead to the detection of its seat. 
As yet, there is no sensible impairment of the general health; the appetite is good, and 
the various tissues retain their normal condition. The muscles of the affected hip and 
limb are, perhaps, a little thinner and softer than natural, but these changes are usually 
slight, and hence they often elude detection. 
In the second staye of the complaint, the most prominent local phenomena are, an 
increase of pain in the hip and knee, flattening of the buttock, etfacement of the gluteo- 
femoral crease, abduction, outward rotation, and apparent elongation of the limb, with 
spasmodic twitching and wasting of its muscles. 
The pain, hitherto seated chiefly in the knee, now also affects the hip, or, if it existed 
there previously, as, indeed, is not unfrequently the case, it becomes sensibly aggravated. 
It is particularly violent at night, often for hours interrupting sleep, and is attended with 
the most distressing spasmodic twitches of the muscles of the limb, which thus greatly 
augment the local and general suffering by the sudden and forcible apposition of the in- 
flamed articular surfaces. The pain at one time is fixed, deep, aching, gnawing, or boring; 
at another, erratic, sharp, or lancinating, darting about in different directions, now through 
the joint, then down the limb, and then through the groin, or back along the course of the 
sciatic nerve. It is most distressing when the bone is inflamed immediately beneath the 
articular layer, and sets in much earlier than when the synovial membrane is primarily 
affected, thereby furnishing a clue to the diagnosis as to which of these structures is first 
involved. Occasionally it is most severe in the lumbar region, in the lower part of the 
pelvis, in the situation of the acetabulum, or at the upper and inner part of the thigh. Some- 
times, as before remarked, it is of a neuralgic character, coming, going, and recurring at 
particular periods. Derangement of the digestive apparatus, exposure to cold, and damp 
states of the atmosphere, have a tendency to aggravate and protract it. The pain in the 
knee, instead of disappearing, generally increases in violence, 
at the same time that it becomes more frequent and fixed. 
The sleep is habitually disturbed by unpleasant dreams, and 
the patient often wakes up in great alarm, crying and scream- 
ing. Occasionally he is partially delirious from pain and 
fever. He sleeps by snatches, and usually feels fatigued and 
unrefreshed in the morning. Spasmodic twitching, jerking, 
or starting of the limb is a prominent symptom, seldom entirely 
absent in any case. Sometimes, indeed, it sets in at a very 
early period, and continues, with more or less violence, during 
the whole progress of the malady. It is particularly distress- 
ing in the muscles of the thigh, but often affects also those of 
the hip and leg. 
Along with these symptoms there is frequently loss of appe- 
tite, with disorder of the secretions, and more or less fever 
at night. The bowels are usually inclined to be constipated, 
the urine is scanty and high-colored, the skin is rather arid, 
especially in the evening, and there is often considerable thirst. 
As the disease advances, the fever increases, and is frequently 
followed by copious sweats. The jwitient loses fleshand strength, 
he is peevish and irritable, and his countenance has a care- 
worn appearance. Although such is ordinarily the state of the 
system, in the second stage, especially after the disease has 
made considerable progress, yet there are cases in which there 
is hardly any constitutional disturbance whatever, except what 
results from the want of sleep. 
The local phenomena at this stage of the malady are un- 
mistakable. The buttock of the affected side is found to be 
remarkably flattened, as is shown in fig. 608, so as to be in 
striking contrast with the sound one. It is much broader, 
as well as considerably longer, than in the natural state; the 
gluteal muscles are soft and flabby, and the skin is preternatu- 
rally loose, from the absorption of the subcutaneous fat. The gluteo-femoral crease, so 
prominent in the natural state, is completely effaced, giving the thigh and hip an appear- 
Fig. 608. 
Appearance of the Nates and 
Limb in Hip-joint Disease, in its 
Earlier Stages. 1074 
DISEASES AND INJURIES OF THE JOINTS. 
ance of continuity, as if they were fused together, and the internatal fold is inclined 
towards the affected side. The muscles of the thigh and leg are also wasted, and, in 
fact, the whole limb is very sensibly attenuated, evidently owing to want of exercise and 
perverted nervous action, leading to atrophy of their substance. 
Marked elongation of the corresponding limb, with abduction and outward rotation, 
now exists, and is so constant an occurrence that it may, along with several of the other 
symptoms above described, be considered as pathognomonic. The extent of the elonga- 
tion varies, on an average, from half an inch to an inch and a half, in rare cases it may 
amount to two inches, and even two inches and a half. It is observed both in the erect 
and in the recumbent posture, but is commonly more conspicuous in the former than in 
the latter. Several explanations have been offered of this phenomenon, all, at first sight, 
more or less plausible. Thus, it has been attributed to the presence of an unusual quan- 
tity of synovial fluid, the product of inflammatory action, by which the head of the thigh- 
bone is partially pressed out of its socket, and the corresponding limb projected beyond 
the level of the sound one; but that this theory is not true is proved by the fact that 
there are frequently large accumulations of this kind in other joints, as the elbow and 
knee, without jrroducing any such effect. That it is due to a relaxed condition of the 
ligaments and muscles of the joint is also, 1 am persuaded, an unfounded idea. A third 
opinion, and, in my judgment, the only correct one, is that the elongation is due to the 
position of the pelvis, which, through the agency of the abductor muscles of the thigh, is 
thrown downwards and forwards, thereby producing a difference in the level of the two 
hips, that of the affected side being always lower than that of the sound side. 
Finally, there is generally, in this stage of hip-joint disease, a marked depression, or 
hollow, in the lumbar region, with a slight inclination of this portion of the spine toward 
the sound side, and an unusual prominence of the belly. The inferior portion of the 
spinal groove is also more distinct than natural. 
In the third stage the nature of the disease is no longer doubtful, whatever it may have 
been previously. The symptoms are characteristic of the extensive and frightful mischief 
that has been effected within the joint. Matter now forms, and, by its pressure upon the 
inflamed structures, greatly aggrav ates the suffering. The suppuration is indicated by an 
increase of pain ; by a sense of throbbing and tension, deep and persistent; by severe 
swelling of the gluteal region, generally most prominent at the centre of the articulation; 
by oedema of the subcutaneous connective tissue; and by a remarkably turgid and 
enlarged condition of the subcutaneous veins. The affected joint is intolerant of the 
slightest motion or manipulation, and the patient is unable to raise himself up or turn in 
bed without the greatest agony. Every attempt to flex or extend the limb is attended 
with similar results. The constitutional disturbance is always in proportion to the local 
suffering, and violent rigors, followed by high fever and copious sweats, are rarely absent. 
Sometimes, however, the abscess forms in a quiet and insidious manner, without any of 
the severe symptoms that usually accompany the suppurative process in this and other 
varieties of inflammation. As the matter increases in quantity it gradually works its 
way towards the nearest surface, its approach being denoted by the occurrence of a cir- 
cumscribed, erysipelatous blush. Here there is generally distinct fluctuation, and the 
parts, feeling soft and boggy, soon yield at one or more points, followed by the escape of 
the contents of the sac. 
The site at which the matter, when left to itself, obtains a vent, varies in different 
cases. Most generally it escapes at the gluteal region, either directly over the joint, or 
in its immediate vicinity. The other situations at which it is most liable to discharge 
itself are the upper and back part of the thigh, a short distance below the great trochan- 
ter, the superior and external part of the groin, the sciatic notch, and the upper and inner 
surface of the thigh. Occasionally it escapes at several points, either simultaneously or 
successively, leaving thus a number of orifices, with a corresponding number of sinuses. 
These passages are sometimes very long and tortuous, and in old cases are always 
lined by a false membrane. I recollect one instance in which there were nine distinct 
openings, and another in which there were as many as twelve ; two at the upper part of the 
thigh, and one just below the crest of the ilium, the remainder being scattered over the 
gluteal region. 
The matter sometimes escapes both externally and internally. When the bottom of 
the acetabulum is perforated, it may pass into the rectum, bladder, or vagina ; or, instead 
of this, it may collect in a sort of pouch, between the inner surface of the iliac bone and 
the soft parts of the pelvis. 
CHAP. IX. CHAP. IX. 
TUBERCULOSIS OF THE HIP-JOINT. 
1075 
The changes in the limb and hip, represented in fig. 609, in this stage of the disease, 
are striking and characteristic. The extremity, now actually shorter than natural, is 
much attenuated from the wasting of its fatty and muscular 
tissues, and remarkably disfigured in its appearance, the 
heel being considerably elevated, and the ball of the foot 
and toes alone touching the ground when the patient makes 
an effort to stand. The degree of shortening is variable, 
and not always by any means in proportion to the destruc- 
tion of the head and neck of the thigh-bone, the acetabu- 
lum, and the connecting ligaments, which forms so promi- 
nent a feature of the disease at this period. While in some 
instances it does not exceed an inch, or, at most, an inch 
and a quarter, in others it amounts to twice and even thrice 
that extent. One-third, and sometimes even one-half of 
this, as I have satisfied myself by careful examination, is 
generally attributable to the elevation of the pelvis on the 
affected side. The position of the foot is variable. Some- 
times it looks directly forwards or outwards, but much more 
commonly it inclines inwards. These differences are due 
to the nature and extent of the ravages experienced by the 
hip-joint. When the acetabulum has suffered most severely, 
the foot usually turns more or less out; if, on the contrary, 
there has been much destruction of the head and neck of 
the femur, and the cotyloid cavity is only slightly involved, 
the limb generally inclines strongly inwards, as in traumatic 
iliac luxations. 
The thigh is generally bent upon the pelvis, the angle of 
flexion varying from the slightest perceptible change to 45°. 
In most cases it inclines somewhat towards the sound limb, 
and occasionally, although rarely, it overlaps or crosses it. 
Sometimes, on the other hand, it stands off' widely and in a most unseemly manner from 
its fellow, as in the case of one of my patients, a woman, aged twenty-five, in whom the 
knees were habitually upwards of fifteen inches apart, the affected thigh forming a right 
angle with the pelvis, while the foot, in the erect position, was at least six inches from 
the floor. 
The thigh, moreover, is always in a painfully rigid state, depending upon the contracted 
condition of the muscles of the hip and limb, and the formation of adhesions between the 
remnants of the superior extremity of the femur and the surrounding parts. Ily taking 
hold of the knee, a slight degree of flexion may, perhaps, be produced, but to abduct the 
thigh, or to move it backwards, is generally impracticable; besides, every effort of the 
kind is attended with excruciating suffering. Owing to the shortening of the hamstring 
muscles, the leg is commonly bent on the thigh, and, for the same reason, the flexor mus- 
cles usually draw the heel upwards towards the leg. In all confirmed cases of hip-joint 
disease, there is invariably a compensating curve in the lumbar or dorso-lumbar portion 
of the spine, caused by the manner in which the patient holds himself in sitting and 
walking. 
The great trochanter generally lies directly over the acetabulum, or in its immediate 
vicinity, forming a hard, firm, immovable, or nearly immovable, prominence, the nature 
of which cannot be mistaken. In regard to the head and neck of the femur, they are, 
as stated elsewhere, usually completely annihilated, or so much wasted as to exist only in 
a rudimentary form. It has generally been alleged that there is, in this stage of the dis- 
ease, more or less displacement of this bone ; but the facts collected by the late Dr. 
March, of Albany, in the extensive museums of the United States and of Europe, as well 
as in private practice, conclusively prove that dislocation of the femur, as a consequence 
of this affection, in any direction, is exceedingly rare. A true luxation, such as occurs 
in the normal state of the parts from injury, is, in fact, impossible, from the very nature 
of the morbid alterations in the superior extremity of this bone. During the progress of 
the disease, the remnant of the neck, which is usually of a rounded, conical shape, and 
frequently not more than three-quarters of an inch in length, ordinarily places itself over 
the acetabulum, to the margins of which, and to the adjacent parts, it becomes, in the 
event of recovery, ultimately united. That it is occasionally drawn up beyond this point, 
especially when there has been complete destruction of the upper border of the acetabu- 
Fig. 609. 
Shortening, Swelling, and Charac- 
teristic Deformity of the Advauced 
Stage of Coxalgia. DISEASES AND INJURIES OF THE JOINTS. 
CHAP. IX. 
lum, backwards towards tlie sciatic notch, forwards upon the pubic bone, or downwards 
and forwards into the thyroid foramen, is unquestionable. Dislocation, however, in most 
of these directions, can only take place in those cases where there has been extensive 
suppuration, with separation or destruction of the soft [tarts, allowing the superior extrem- 
ity of the bone to move about, in search, as it were, of a new position. The upward 
displacement is, undoubtedly, the most frequent, but even this is extremely rare. In one 
of my cases the end of the thigh-bone projected above the acetabulum, where it had 
formed for itself a superficial socket in the iliac bone, admitting of very slight motion. 
The true cause, then, of shortening, in the third stage ot the disease is not dislocation, 
but destruction, partial or complete, of the head and neck of the thigh-bone, along with 
a certain degree of elevation of the corresponding hip. 
The changes produced in the affected limb by upward displacement are strikingly illus- 
trated in tig. CIO, from a clinical case. The foot is inverted and elevated, the ball resting 
upon the opposite instep; the knee is bent, and in advance of its 
fellow ; the thigh is firmly flexed on the pelvis, rotated inwards, and 
adducted, its axis forming an acute angle with the transverse axis of 
the pelvis; the limb is shortened to the extent of two inches and a 
half, the amount of true shortening, however, amounting, by actual 
measurement, to only one inch ; the buttock is more full than nor- 
mal, and pointedly prominent at its external and upper portions; the 
gluteo-femoral fold is drawn upwards, and the internatal crease is in- 
clined towards the sound side ; while the summit of the great tro- 
Fig. 610. 
Fig. 611. 
Upward Displacement 
in the advanced Stage of 
Coxalgia. 
Extensive Malposition of the Limbs in the advanced Stage of Coxalgia. 
chanter lies above its natural level. Fig. 611, from Druitt, exhibits, in a striking degree, 
the extraordinary attitude which the limbs may assume in the advanced stages of coxal- 
gia. The dotted lines indicate the course of the incisions made in the removal of the head 
of the diseased bone. 
The state of the general health, in this stage of the disease, is in strict accordance 
with the local ravages. The pallid countenance, the wasted muscles, the impaired appe- 
tite, the loss of strength and sleep, and the copious night sweats, too clearly indicate the 
exhausted condition of the system, and the gradual approaches of death. Serious com- 
plications, as colliquative diarrhoea, dropsical effusions, and pulmonary phthisis, often 
arise during the progress of the case, and thus greatly aggravate the suffering. Exces- 
sive anemia is nearly always present. Serious disease of the liver occasionally exists, 
the organ being enlarged, congested, and in a state of fatty or amyloid degeneration. The 
kidneys are also sometimes extensively involved, but, on the whole, less frequently than 
might be supposed. They are most liable to suffer when the system is pervaded by the 
tubercular dyscrasia. 
Diagnosis Although the symptoms of this disease are usually well marked, espe- 
cially if some time has elapsed, it is extremely liable to be diagnosticated erroneously. CHAP. IX. 
TUBERCULOSIS OF THE HIP-JOINT. 
1077 
The inexperienced practitioner, misled by the seat of the pain, too often contents him- 
self with a most superficial examination, and, taking this as tlie basis of his therapeutic 
indications, is very apt to misapply his remedies, addressing them, perhaps, solely to 
the knee, which is only sympathetically involved, when they ought to be directed ex- 
clusively to the hip, the actual seat of the morbid action. Numerous cases, illustrative 
of the truth of this remark, have fallen under my observation, and there are few sur- 
geons in extensive practice who have not, like myself, had occasion to lament the great 
mischief that has thus been entailed. In a malady so grave as this an error of diagnosis 
may be fraught with the worst consequences both to the part and system, eventuating, 
as it necessarily must, in the loss of precious time ; for it but too often happens that, 
when the true nature of the disease is discovered, all our efforts to arrest its progress are 
unavailing. 
The affections with which this disease is most liable to be confounded, or which may, 
at least for a time, obscure its diagnosis, are sprains and rheumatism of the ilio-femoral 
articulation, psoas abscess, purulent collections in the vicinity of the hip and in the upper 
part of the thigh, and inflammation of the periosteum of the great trochanter. 
A sprain, twist, or contusion of the hip-joint may, if followed by considerable inflam- 
mation, give rise to severe pain and stiffness, seriously weakening, if not completely 
disabling, the part. The patient, in attempting to walk, raises the hip of the affected 
side and relaxes the corresponding limb, by bending the knee and retracting the heel, 
very much as in the earlier stages of tuberculosis. The muscles, also, by degrees become 
flabby and attenuated, and there is a sensible diminution of the temperature of the 
cutaneous surface. The gluteo-femoral crease is eventually effaced, and even the general 
health may suffer. The signs of distinction are, the history of the case, the absence 
of (min in the knee, the greater latitude of motion, the absence, in general, of constitu- 
tional disturbance, and, lastly, the fact that the foot, although everted, is usually easily 
rotated on its axis, whereas in strumous disease of the hip-joint, it is commonly pretty 
firmly fixed. 
Rheumatism of the hip-joint, chronic and subacute, is generally caused by cold, or by 
sudden suppression of the cutaneous perspiration, and is seated principally in the liga- 
mentous and synovial structures, the cartilaginous and osseous being seldom involved, 
except in very severe and protracted cases. The pain, which runs down the front of the 
thigh, is dull, heavy, or aching; the gait is limping ; the pelvis is higher on the affected 
side than on the sound, and the limb exhibits, in the main, the same attitude as in lame- 
ness from sprains and contusions, with this peculiarity that the foot is always strongly 
everted, while in the former case it is generally inclined inwards. The patient in the 
morning complains of stiffness in the hip, which usually diminishes very sensibly after 
exercise, but is sure to return in the evening if there has been much exertion or fatigue. 
The muscles of the thigh are attenuated, but more firm than in tuberculosis, while those 
of the leg often retain their normal bulk; the gluteo-femoral fold is effaced; the limb, 
owing to the obliquity of the pelvis, appears shorter, often from one to two inches, than 
natural; the great trochanter is uncommonly distinct; and a creaking noise is generally 
heard if the head of the thigh-bone is forcibly moved upon the acetabulum. Now, although 
these phenomena bear a very close resemblance to those of strumous disease of this articu- 
lation, yet the absence of severe suffering at night, and at all times at the knee, the marked 
relief afforded by gentle exercise, the trifling annoyance from pressure, percussion, and 
motion, even when rudely performed, and the rarity of rheumatism in children, together 
with the frequent coexistence of this disease in other parts of the body, will generally be 
sufficient to prove that the affection is not tubercular. 
It is not often that psoas abscess is mistaken for coxalgia ; for, although the matter 
which is formed in its latter stages occasionally points at the outside of the groin, or at 
the upper and inner part of the thigh, there is always the most marked difference in the 
character of the two swellings, independently of other symptoms. In psoas abscess the 
tumor is usually, at least in its earlier stages, situated above Pou part’s ligament, while 
in hip-joint disease it is commonly below ; in the former it always sensibly diminishes 
and sometimes even entirely disappears under pressure and recumbency, but quickly 
reappears when the pressure is removed, or when the patient raises himself up; in the 
latter, on the contrary, it never changes its position, or, if it do, it is in consequence 
solely of the force of ulceration, absorption, and gravitation; in psoas abscess the swelling 
receives a distinct impulse on coughing, laughing, and crying, which is not the case in 
tuberculosis of the hip-joint. 
Again, in psoas abscess the principal pain is in the loins; it is fixed there, and is 1078 
DISEASES AND INJURIES OF THE JOINTS. 
CHAP. IX. 
always greatly increased by the erect posture, as well as by every attempt to extend 
the corresponding limb. In coxalgia the pain is most severe in the knee, or in the knee 
and hip. In psoas abscess there is at no period any change in the position of the great 
trochanter, nor any alteration in the length of the limb; in hip-joint disease, on the con- 
trary, especially in its more advanced stages, these are prominent symptoms. Finally, 
psoas abscess occurs nearly always after puberty, whereas the other affection is most 
common in early childhood. 
Sometimes large deposits of pvs take place in the connective tissue of the nates, or 
beneath the gluteal muscles, and, forming a prominent tumor in the direction of the ilio- 
femoral articulation, may thus simulate abscess of the joint from tuberculosis. These 
accumulations are commonly the result of external injury, or of a phlegmonous, rheumatic, 
or erysipelatous state of the system, and are, therefore, in general, easily distinguished by 
their history, by the rapidity of their progress, by the severity of the local distress, and 
by the comparatively prompt recovery of the parts after the evacuation of their contents. 
Cold abscesses of the nates, besides being exceedingly infrequent, exhibit none of the diag- 
nostic signs of articular disease, especially such as pain in the knee, or pain in the hip-joint 
upon rotating the thigh, so characteristic of the latter malady. It is only when they depend 
upon caries of the innominate bone that the distinction would be likely to beattended with 
difficulty, and in this case a thorough exploration with the probe would probably furnish 
the requisite light. 
Finally, diagnostic embarrassment, to an annoying extent, occasionally arises from 
periostitis of the great trochanter, especially in persons of a rheumatic or gouty habit of 
body. The fibrous membrane of this portion of the femur becomes exquisitely painful 
and tender to the touch, under the slightest motion and percussion, and the disease, ex- 
tending above the neck of the bone and the capsular ligament of the joint, causes distress 
and difficulty in walking, with elevation of the corresponding side of the pelvis, similar 
to what is seen in coxalgia. The soft parts around are swollen and puffy, giving the hip 
an increased breadth and thickness; by and by suppuration takes place, sinuses form, and 
small portions of the bone separate and come away. Unless the case is well managed, the 
joint is rendered stiff, and the patient does not regain his health for a long time. The 
signs of distinction are, the persistence of the gluteo-femoral crease, the coexistence of 
rheumatism or gout in other regions, and the fact that the disease usually occurs later in 
life than coxalgia. 
Effects similar to those of rheumatism of the great trochanter sometimes arise from 
inflammation of the synovial burse in this situation. The affection is characterized by 
pain, tenderness, and swelling, by flexion of the thigh upon the j>elvis, by difficulty in 
progression, and by other symptoms simulative of coxalgia. The disease, which occasion- 
ally terminates in extensive suppuration, is most common in young, strumous subjects, 
and is often directly due to external injury, as a blow or fall, causing severe contusion of 
the parts. The diagnosis rests mainly upon the history of the case, and in thorough ex- 
ploration of the joint and neighboring structures. 
l»ut it is chiefly in the very early stages of this affection that erroneous views of its 
diagnosis are liable to be formed ; when it is fully established, the phenomena are generally 
too well marked to be mistaken. It has been seen that the very first symptom, in every 
case, is pain in the knee ; so uniform and constant, indeed, is this occurrence, that it 
must be regarded as pathognomonic, and yet, as was previously stated, it rarely happens 
that it is referred to its true source. Instead of being considered sis an expression of 
disease of the hip-joint, it is too often regarded merely as an effect of neuralgia, rheuma- 
tism, or injury of the knee, to which, accordingly, the treatment is exclusively directed. 
Its great value, as a diagnostic, is totally overlooked, and thus the disease is allowed to 
progress at the only time almost when it admits of prompt and radical cure. 
In order to avoid this serious and too common mistake, a most thorough examination 
should be made in every case presenting the slightest suspicion of the existence of tuber- 
culosis of the hip-joint. The very fact that there is pain in the knee, severe in degree, 
and of frequent recurrence, should of itself excite the alarm of the surgeon, more especi- 
ally if, added to this, there is a limp in the gait, an increase of suffering after slight 
exercise, and disturbed sleep at night. If the diagnosis is obscure, the examination must 
be repeated, again and again, until it is perfectly cleared up. To conduct the investiga- 
tion properly, the patient must be completely stripped, and viewed both behind and in 
front, as he stands on the floor. If there is any flattening of the nates, unusual promi- 
nence of the trochauter, or change in the gluteo-femoral fold, it will be sure to be detected, 
and so, also, if there is any alteration in the attitude, size, or length of the corresponding TUBERCULOSIS OF THE HIP-JOINT. 
1079 
CHAP. IX. 
limb. If the patient be now requested to walk, the amount of limping will be discovered, 
as well as the manner in which lie raises and moves the leg and foot. To complete the 
investigation, the patient is stretched out on the door, or on a hard lounge, with a view 
of ascertaining the amount of suffering produced by rotating the head of the thigh-bone 
upon the acetabulum, and also by bringing these parts forcibly into contact with each other 
by percussing the knee, the leg being flexed, or the sole of the foot opposite the ankle, 
the foot being bent on the leg. The patient being next turned upon his abdomen, the 
hip is thoroughly examined, first, with reference to the condition of its soft parts, and, 
secondly, as to the amount of sensibility of the component structures of the joint; finally, 
if there is any obliquity of the pelvis, it may easily be observed both in the erect and in 
the recumbent posture; while any change in the length of the affected limb may be 
determined by extending a piece of tape, or other suitable band, from the anterior superior 
spine of the ilium to the inner side of the lower extremity of the patella, or from the former 
point to the sole of the foot, placed at a right angle with the leg. The difference in the 
length of the measure on the two sides will give tlie difference in the length of the affected 
and sound limbs. Actual shortening may generally be easily detected by laying the patient 
upon his back, and raising the knees at a right angle with the pelvis, where it will be seen 
that the one on the side affected does not project as far up as the one on the sound side. 
The attitude of the limb generally affords important information. Early in the disease 
it is usually slightly abducted, and rotated outwards, whereas in the more confirmed 
stages, especially when the head and neck of the femur have been partially or completely 
destroyed, it is always strongly adducted, as well as materially shortened, very much as in 
a traumatic iliac luxation. There will also, in such a case, be unusual prominence of the 
great trochanter, and great elevation of the heel. The situation of the sinuses which form 
during the progress of coxalgia deserves careful consideration in regard to the seat of the 
osseous disease, or the particular bone involved in the morbid action. Thus in a general 
way, it may be inferred that, when the track lies at the upper and outer part of the 
thigh, in the direction of the tensor muscle, the upper extremity of the femur is the bone 
affected; when the sinus oj>ens upon the gluteal region it implies the existence of disease 
in the iliac bone, or in this bone and in the femur; a sinus above Poupart’s ligament is 
usually denotive of disease of the ramus of the pubes, and one in the perineum of disease 
of the ischium. To these rules, of course, occasional exceptions occur. In the exami- 
nations of these sinuses a vertebrated or articulated probe will be of great service, as it 
can be made to follow their sinuosities much more readily than a straight instrument. 
Valuable information as it respects the extent of the ravages produced in hip-joint 
disease may occasionally be obtained by digital explorations of the rectum, or the rectum 
and vagina. Such examinations are particularly demanded when the existence of pelvic 
abscess is suspected, or when there is serious disorganization of the iliac bone and its 
periosteum, or great involvement of the pelvic lymphatic glands. The use of chloroform 
will often be of great service in conducting the movements of the limb while the patient 
is recumbent, especially when the parts are very painful and intolerant of manipulation. 
Morbid Anatomy.—The anatomical changes which occur in coxalgia are essentially 
similar to those witnessed in strumous affections of the joints generally. They are usually 
more conspicuous, in every stage of the malady, in the head and neck of the femur than 
in the innominate bone, which, however, often suffers very severely during the progress 
of the morbid action. 
When the disease has attained its acme, the synovial membrane, the round ligament, 
the articular cartilages, and the head and neck of the thigh-bone, with the margins, and 
frequently, also, the bottom of the acetabulum, are partially destroyed, if not completely 
annihilated. In the more severe cases the cotyloid, transverse, and even the capsular 
ligament are entirely absorbed, the surrounding parts are extensively separated by the 
ulcerative and suppurative processes, numerous fistulous openings exist, and the gluteal 
muscles are transformed into dense, firm bodies, of a pale-reddish, yellowish, or whitish 
color. Sometimes, especially when the disease is of long standing, these muscles undergo 
the fatty degeneration. Occasionally both trochanters are absorbed ; or there is extensive 
caries of the innominate bone; or the head and neck of the thigh-bone are necrosed ; or 
the joint contains numerous fragments of bone and cartilage ; or, the bottom of the aceta- 
bulum being perforated, the matter extends into the pelvis, and passes off' by the rectum. 
In children, prior to the completion of the ossific process, the hip-bone is sometimes 
separated, at the acetabulum, into its three primitive pieces; and epiphyseal sequesters 
of the head and neck of the femur are also occasional occurrences. 
When the head and neck of the femur are absorbed, the remnant of its superior ex- 1080 
DISEASES AND INJURIES OF THE JOINTS. 
CHAP. IX. 
tremity usually lies across the acetabulum, or in its immediate vicinity. Occasionally it 
is drawn up a little beyond this cavity, against the surface of the ilium, resting in a slight 
depression, which, however, bears only a very faint resemblance to a new socket. Instances 
have been observed in which it was forced backwards into the sciatic notch, forwards upon 
the pubic bone, or downwards into the thyroid foramen. 
When the disease has expended itself mainly upon the 
acetabulum, the head of the thigh-bone may retain its 
original position, or it may even be pushed into the 
pelvic cavity. The ravages produced by this disease, 
in its earlier stages, in the acetabulum and the head 
and neck of the femur, are well illustrated in the an- 
nexed cut, fig. 612. 
An examination of the bodies of those who die from 
the effects of coxalgia always reveals important lesions 
of some of the internal organs. In 18o8, I published 
an elaborate paper upon tuberculosis of the hip-joint, 
accompanied by an account of the post-mortem appear- 
ance of five cases, the ages of which were, respectively, 
nine, ten, twelve, twenty-three, and twenty-six years, 
in every one of which there were numerous tubercles in 
the lungs, either in a crude, softened, or ulcerated con- 
dition. The spleen, in three of the cases, was crowded 
with tubercles, and in nearly all tubercles were present 
in the pelvic and mesenteric glands. The liver was 
similarly affected in one of the cases, the kidneys in 
two, and the bronchial lymphatic glands in one. The 
peritoneum, in one of the cases, was studded with 
tubercles, and its cavity contained three quarts of serous 
fluid. These cases, so far as they go, clearly prove the 
connection of coxalgia with a strumous state of the system, either as cause or effect. 
Amyloid degeneration of the kidneys is not infrequent in the more advanced stages of 
the disease, and, together with tubercular meningitis, is a considerable source of its 
mortality. Many children perish from mere exhaustion, worn out by profuse suppuration, 
loss of appetite, night sweats, and hectic irritation. 
No one who has studied the pathology of this disease can doubt its tubercular character. 
The researches of Billroth, Koenig, Bidder, Volkmann, and other German investigators 
clearly point to this conclusion; and similar evidence is afforded by the elaborate statistics 
of Dr. Gibney, showing as they do a large percentage of hereditary influences. Many 
American, English, and French surgeons are converts to this doctrine, and it may safely 
be predicted that the time is rapidly approaching when this belief will become general, 
if not universal. The fact that external injury often acts as an exciting cause of the 
disease does in no wise invalidate the truth of this opinion. Traumatism, in any ease, is 
simply an exciting cause, and nothing more; wholly inoperative when there is no local 
or constitutional vice or predisposition. “ It is impossible for a physician,” says Gibney, 
“ to be long connected w ith a dispensary or hospital in a large city without coming to the 
conclusion that some vice, either hereditary or acquired, must underlie the constitutions 
of the vast majority of the poor who lack medical assistance.” For some recent views 
upon this subject, the reader may with advantage consult a paper by Mr. John Croft, of 
St. Thomas’s Hospital, in the Transactions of the Pathological Society of London for 1881. 
Prognosis.—As there are no mortuary statistics of this affection, it is impossible to 
state, with any degree of precision, the mean duration of fatal cases, or the relative 
proportion of deaths to recoveries. My opinion, founded upon numerous observations, is 
that the mortality from coxalgia is slight in almost any event, even when there has been 
palpable neglect in regard to its treatment. The prognosis is generally most unfavorable 
in feeble, anemic children, with a tumid upper lip and a protuberant abdomen, the offspring 
of strumous parents, or of persons whose system is thoroughly impregnated with the syphi- 
litic poison. Young adults seldom ever recover, if suppuration occur ; the whole system 
soon becomes involved in the disease, and they rapidly sink under the profuse discharge 
and hectic irritation. Few children die before the eighteenth month. The case is always 
more likely to terminate unfavorably when the disease involves the acetabulum, or the 
acetabulum and the surrounding osseous tissue, than when it is limited to the head and 
neck of the femur. Primary disease of the acetabulum is also a much more serious 
Fig. (J12. 
Changes wrought in tho Acetabulum and 
Head of the Thigh-bone in Coxalgia. CHAP. IX. 
TUBERCULOSIS OF THE HIP-JOINT. 
1081 
occurrence than secondary disease, or disease consequent upon disease of the thigh-bone. 
Under the present improved inode of treatment, more lives are saved than formerly, as 
well as more useful limbs retained. If the disease has been neglected, and recovery 
occurs, the individual will be permanently deformed and crippled, and a long time will 
elapse before he will be able to regain his health. The hip is often completely ankylosed 
without the previous formation of an abscess. 
The angle which the limb forms with the body in cases of recovery, varies, according 
to Gibney, from 90°, as the minimum, to 150°, 1G0°, or even 170°, as the maximum. 
The shortening is generally very slight when there is no serious structural change in the 
articular surfaces; when the reverse is the case, and especially when there is great de- 
struction of the head and neck of the thigh-bone, the shortening may amount to two, 
two and a half, three, and even four inches. The disease sometimes lasts for many years, 
and yet the patient may finally recover, enjoying, perhaps, tolerably fair health during 
the remainder of his life. 
Treatment.—Although the treatment of coxalgia involves the same principles as that 
of tuberculosis of the joints in general, there are certain points to which it is necessary 
to direct special attention, growing out of the peculiar structure and situation of the 
articulation, the frequency with which it is assailed by this disease, and the tender age of 
those who are most obnoxious to its attacks. 
Rest of the affected joint, as well as of the whole body, is of primary importance, and 
should be attended to without delay. The restraint must not be limited to a few days or 
weeks, but be continued so long as there is the slightest evidence of active disease. In 
order to render the patient as comfortable as possible, and enable him to endure his pro- 
tracted confinement without detriment or inconvenience, a suitable bed provided with slats 
and a firm but elastic mattress must be secured. A common trundle-bed, about four feet 
in width, will answer every purpose, and is, in every respect, preferable to the common 
bed, especially if the patient be a child, as he will thus be less liable, if he should roll 
out, to hurt himself. The sheet should be well fastened at the sides, that it may not 
become rumpled, and the pillow should be very thin, so that, while it affords adequate 
support to the head and shoulders, no undue weight may be thrown upon the trunk and 
pelvis. The confinement, however rigid, will not prove irksome ; with the aid of toys 
and other sources of amusement the little patient will generally in a few days become 
reconciled to this new mode of life. 
With strict attention to this point, the disease, if in its incipiency, may generally be 
easily arrested without any formal treatment, excepting, perhaps, the occasional exhibition 
of a laxative and a proper regulation of the diet. If the joint is stiff, and painful on 
pressure, a few leeches may be applied, or the skin may be thoroughly painted once a day 
with dilute tincture of iodine, or a small blister may be raised, and the raw surface 
sprinkled with morphia. A diaphoretic and anodyne draught may, if fever exist, be 
administered at bedtime. The best laxative, in this stage of the disease, is calomel, in 
doses of one to two grains with twice that quantity of jalap. The diet must be very plain 
and simple, especially if the patient be, in other respects, well conditioned. General 
bleeding will seldom be required, unless the suffering is extremely severe and the blood 
decidedly thick and abundant, when the loss of a few ounces cannot fail to be highly 
beneficial. 
To control the spasmodic action of the muscles, and thus afford more perfect repose to 
the diseased joint, the limb should be confined by a splint, extending from near the crest 
of the ilium to within a short distance of the ankle, and so constructed as to cover in 
nearly the whole of the affected buttock. The most suitable materials are wire gauze, 
gutta-percha, undressed sole-leather, or trunk-maker’s board, soaked in hot water, care- 
fully moulded to the hip, thigh, and leg, and kept in place with adhesive plaster and a 
common roller. When dry, these substances form an admirable case, which, if properly 
padded, effectually wards off pressure and prevents excoriation. To render any con- 
trivance of this kind thoroughly efficient by placing the affected joint in a state of perfect 
repose, beyond the spasmodic action of the muscles of the thigh, extension and counter- 
extension must for some time be steadily maintained in the same manner as in the treatment 
of fractures of the lower extremity, that is by adhesive plaster, pulley and weight, and 
by elevation of the foot of the bed. The weight should vary according to the age of the 
patient, from two to four, six, or eight pounds, its effect being carefully watched, otherwise it 
may give rise to great discomfort, if not serious detriment. Dr. Physick, who was the first to 
insist upon the necessity of absolute rest in the treatment of coxalgia, used a splint of carved 1082 
DISEASES AND INJURIES OF THE JOINTS 
CHAP IX. 
wood, very light, well padded, and carefully adapted to the size and 
shape of the hip and limb. When the patient is in a condition to 
exercise in the open air, there is no apparatus that answers so 
good a purpose for securing quietude to the affected joint as that 
of I)r. Sayre, or one that can he used with greater ease and com- 
fort. It consists, as seen in fig. G13, of two pieces of corrugated 
steel, the lower of which is made to slide within the upper by 
means of a key, thereby forming a splint which extends from the 
crest of the ilium to two inches above the condyles of the femur. 
To the upper end of the splint is attached, by means of a ball 
and socket joint, a padded, concave steel plate, which rests upon 
the pelvis just below the crest of the ilium, and to each extremity 
of which the perineal band, made of buckskin, stuffed with hair, 
and terminating in elastic webbing, is secured by buckles. At 
the lower end of the splint are a roller and buckle intended to 
receive a webbing stitched to the retaining adhesive plaster, while 
two semicircular steel bands pass from this portion across the 
front of the thigh to another straight piece which rests on the 
inner side of the limb, parallel with the outer bar, and also ter- 
minates in a roller and buckle. A strap which extends poste- 
riorly from the inner to the outer rod, is intended to secure this 
portion of the apparatus when it is adjusted. 
To apply the instrument, two fan-shaped pieces of strong, inelastic adhesive plaster, 
with webbing sewed on to their narrow ends, are required, long enough to reach from the 
perineum to within two inches of the inner condyle and from the great 
trochanter to a similar point on the outer side of the limb. These having 
been secured by a roller, the splint is laid over the thigh, and the web- 
bing, attached to the plaster, fastened over the rollers to the buckles on its 
lower end, the traction being completed by securing the posterior strap. 
The perineal band is then buckled on, and extension is made with the 
key, to such a degree as to render the patient comfortable. With the 
assistance of a crutch, he may, with this contrivance, exercise during the 
day in the open air, while at night, as he lies in bed. the requisite degree 
of extension may readily be effected by means of a pulley, cord, and 
weight, attached to the limb in the usual manner. In connection with 
exercise in the open air, I may mention, with special emphasis the in- 
genious method of treatment recommended by Dr. Joseph C. Hutchison, 
of Brooklyn, and now much employed in this, it’ not also in other countries. 
It simply consists in removing the weight of the body from the affected limb to the sound 
one by means of an elevated shoe and a pair of crutches as seen in figs. 615 and 616. By 
this very simple arrangement the affected limb is suspended during progression and main- 
tained in an easy and relaxed position. At night extension may be applied or not, 
according to the absence or presence of muscular spasm. Dr. Hutchison’s shoe is the 
one ordinarily used for shortened legs provided with a steel plate corresponding to the 
sole, to which it is attached by two upright rods from two and a half to three inches in 
length, so as to raise the foot from the ground. In order to avoid vicious position and 
keep the joint thoroughly at rest, this treatment should be supplemented by the appli- 
cation of the posterior splint of Thomas, represented in fig. 617. The only objection 
to this contrivance is that it renders sitting very awkward, to obviate which Dr. 
Willard has devised the admirable apparatus, depicted in fig. 618, which is particularly 
adapted to the earlier stages and milder forms of the disease, where gentle motion is 
permissible, and ankylosis is to be prevented. It is made of perforated leather, and con- 
sists of two pieces, one corresponding with the thigh, and the other with the hip and 
pelvis, connected by a hinge-like joint, which may be hooked or unhooked at pleasure. 
It is accurately moulded to the surface, and is laced down in front of the thigh and abdo- 
men. 
In the second stage of the affection, the great topical remedy is an issue made with the 
actual cautery, applied to the most prominent part of the swelling, or as nearly as possible 
to the focus of the morbid action. The eschar, which should be from half an inch to an 
inch in diameter, usually drops off in six to eight days; the sore, besides furnishing an 
ample supply of thick pus, affords an excellent surface for the endermic use of morphia, 
Fig. 613. 
Sayre’s Apparatus. 
Fig. 614. CHAP. IX. 
TUBERCULOSIS OF THE HIP-JOINT. 
1083 
now so necessary for allaying the violent pains and spasmodic twitchings of the muscles. 
If the discharge flag, it can easily be reexcited with some stimulating unguent. It should 
Fig. 616. 
Fig. 617. 
Fig. 615. 
Hutchison’s Shoe. 
be maintained in full force until the severity of the disease has completely subsided. The 
quantity of morphia necessary to compose the parts and system is, according to the age 
and other circumstances of the patient, from a quarter to a 
third of a grain sprinkled upon the surface of the issue 
once or twice a day. If the general health suffer from 
want of exercise, the limb may be put up in a suitable 
apparatus, and the child sent into the open air. 
The violent contraction of the muscles, so common in 
this stage of the complaint, and a source of so much pain 
and distortion, may generally be promptly relieved by 
the use of the tenotome. The muscles that are most 
frequently at fault are, the sartorius, pectineal, and short 
adductor, which, if they do not yield under the influence 
of chloroform, should be thoroughly divided near their 
origin, until all resistance to the extension of the limb is 
overcome. 
In the third stage of the disease, when abscesses exist 
in and around the joint, accompanied by hectic irritation, 
the indications plainly are to evacuate the matter and to 
support the system. The knife should be introduced in 
such a manner as to make a valvular incision, as in an 
ordinary strumous collection, the opening being imme- 
diately closed with adhesive plaster, and the operation re- 
peated at intervals of six, eight, or ten days, until all 
tendency to reaccumulation has disappeared. The object 
should be, while affording free discharge to the pent-up 
fluid, to permit as little air to penetrate the joint as possi- 
ble. Undue reaction must be prevented by full and 
sustained doses of opium until the part and system have 
accommodated themselves to their new relations. Quinine and iron, cod-liver oil, beef 
essence, milk punch, and elixir of vitriol will afford material aid in maintaining the 
Hutchison’s Shoe Applied. 
Thomas’s Posterior Splint, 
Fie. C18. 
Willard’s Splint. 1084 
DISEASES ANI) INJURIES OF THE JOINTS. 
CHAP. IX. 
strength at this trying juncture. Any dead hone that may exist must for obvious rea.-ons 
at once be removed. When the pus lias been evacuated, the affected parts should be 
supported with some sorbefacient and slightly stimulating plaster, as the soap, galbanum, 
or ammoniac and mercurial, the latter being the best. The sinuses about the joint may 
be injected with a weak solution of iodine, iodide of iron, nitrate of silver, bichloride of 
mercury, permanganate of potassium, or chlorinated sodium. If numerous, and not too deep, 
they may often be advantageously laid open, provided it can be done without pain and 
the loss of blood. As soon as the patient is able, he should exercise in the open air; and 
the affected joint should be moved to prevent ankylosis. 
When the parts in and around the joint are so much diseased as to render recovery by 
the ordinary means entirely hopeless, the ordy thing that remains to be done is excision. 
The operation, the statistics of which will be given in a future chapter, may be conve- 
niently performed by making a curvilinear incision, from four to five inches in length, 
perpendicularly over the joint, in a line with the great trochanter, separating the parts, 
and cutting off the diseased structures with the saw or pliers. If more room be required, 
the incision may be crucial, or in the form of a X or V- The flaps are afterwards 
approximated with stitches and adhesive strips, and the immobility of the limb is secured 
by appropriate splints, pads, and bandages, as in fracture of the thigh-bone. 
Important information on the comparative value of the expectant plan of treatment and 
excision in disease of the hip-joint has recently been published by a committee of the Clinical 
Society of London. Of 384 cases treated by prolonged rest, extension by weights, and 
opening abscesses, 100, or 20 per cent., died, 87 of the deaths having occurred in 200 of 
the cases in which suppuration was present: 190 of the patients were reported as cured or 
as convalescing, while in 88 the disease was still in progress. Of the 200 cases in which 
suppuration had taken place, 33.3 per cent, died, while of 45 cases of excision performed 
by Mr. Croft, 40 per cent, were fatal. In favor of excision, however, it may be said that 
the movements of the limb are more frequently retained, as well as more extensive, than 
when the expectant plan is pursued; on the other hand, however, the limb is less firm 
and less useful for the purpose of progression. 
When, as occasionally happens, a sequester exists in the neck of the femur, whether as 
the result of actual necrosis, or of epiphyseal disjunction, excision should give way to the 
ordinary operation for the removal of dead bone. Such an occurrence is by no means 
infrequent, and the surgeon should, therefore, spare no pains to ascertain the true con- 
dition of the parts before lie adopts so severe a measure as excision. 
When the acetabulum is involved in the disease, it should be dealt with in the same 
manner as the femur, every particle of morbid structure being removed with the pliers, 
gouge, chisel, and scraper. With proper care, there will be no danger whatever of injur- 
ing any of the contents of the pelvis, inasmuch as the periosteum and connective tissue 
are always so greatly indurated and thickened during the progress of the disease as to 
serve as a strong wall of defence. When, as is sometimes the case, after such an opera- 
tion, the blood oozes from numerous points, a prompt and effectual stop may usually be 
put to the flow by means of hot water or of Monsel’s salt, applied upon wet cotton. 
When the patient has been exhausted by protracted suffering, and life is fast ebbing 
away, it has been proposed, as a dernier resort, to amputate at the hip-joint; and the 
records of surgery contain several examples in which the operation was performed success- 
fully. I should, nevertheless, hesitate before undertaking so grave a procedure, the more 
especially as the same end may generally be more readily attained by the more simple 
and less dangerous operation of excision. It is only, indeed in cases of great disorganiza- 
tion, deformity, or wasting of the limb, rendering it utterly useless as an organ of pro- 
gression, or interfering more or less seriously with the ordinary movements of the body 
that, in my opinion, amputation should be preferred to excision of the head, or head and 
neck of the femur. 
The deformity of the limb and pelvis, consequent upon the disease, may often be very 
materially relieved, if not completely removed, after the morbid action has measurably 
subsided, by careful extension and counterextension of the limb, by means of a weight 
and pulley, conjoined with passive motion, and the use of suitable apparatus when the 
patient begins to exercise in the open air. One of the best contrivances for this purpose 
is that depicted in the adjoining cut, tig. 619, one of the many ingenious inventions of 
the late Professor Pancoast. In tig. 620, the apparatus, which should always be as light 
as is consistent with strength and durability, is exhibited as applied to the patient. It 
is of course laid aside at night, and before it is readjusted in the morning, the limb should CHAP. IX. 
CHRONIC RHEUMATIC ARTHRITIS. 
1085 
always be well washed and rubbed. It is hardly necessary to add that the exercise should 
be as gentle as possible, that it should be taken with the aid of a crutch, and that it 
should never be carried to fatigue. The disease which too often slumbers may be easily 
reawakened, if these precautions be not rigidly enforced. 
Fig. 619 
Fig. 620. 
Pancoast’s Apparatus for Coxalgia. 
Splint Applied. 
The adhesions of the joint and of the surrounding structures are most easily broken up 
with the aid of an anaesthetic. Unless great attention be bestowed upon the case for a 
long time after the active disease has vanished, great and irremediable deformity will be 
inevitable. 
Much, if not irreparable, injury is often inflicted upon the part and system by inju- 
dicious passive motion in the treatment of coxalgia. It is only, or mainly, in the earlier 
stages of the disease that such efforts will be at all likely to prove beneficial. AVhen the 
joint has undergone serious structural changes, as when the disease is well advanced in 
its second stage, in which there is always more or less destruction of the synovial mem- 
brane, if, indeed, not also of the articular cartilages, the only rational thing to be done 
is to place the corresponding limb in the best position for future usefulness, and to favor 
the occurrence of ankylosis instead of adopting measures to prevent it. The altered 
structures in such a condition cannot possibly be reclaimed by any skill, however great or 
well directed, of the surgeon, and hence any attempts that may be made with a view of 
reestablishing motion must inevitably end in failure, if not, in what is much worse, in 
the rekindling of morbid action. It is, as it were, taking the case out of nature’s hands, 
and thwarting her efforts at a cure by rendering the affected joint permanently motionless. 
In the propriety of this advice all surgeons of experience will, I am sure, concur. 
SECT. VIII.—CHRONIC RHEUMATIC ARTHRITIS. 
The joints are liable to a peculiar form of disease, known under the name of chronic 
articular rheumatism, or chronic rheumatic arthritis, first systematically described by Dr. 
R. W. Smith and I)r. R. Adams, of Dublin, the latter of whom has published an able 
and elaborate treatise upon it. It occurs in both sexes, chiefly in elderly and middle- 
aged subjects among the laboring classes, although it is also occasionally observed in the 1086 
DISEASES AND INJURIES OF THE JOINTS. 
higher orders of society, especially in the indolent and habitually intemperate in eating 
and drinking. The joints most prone to sutler are those of the hip, knee, wrist, and 
fingers, one of which only may be affected, or a number may be implicated simultaneously, 
or in more or less rapid succession. Sometimes the disease leaves one articulation, and 
fastens itself upon another; but, in general, when it has once effected a firm lodgment it 
holds on to it pertinaciously, now and then remitting, but seldom entirely intermitting, at 
least not for any length of time. Ill-fed and ill-clothed persons, living in moist, under- 
ground apartments, or in damp, confined alleys, are particularly liable to it. A gouty or 
rheumatic predisposition probably favors its outbreak. 
The immediate cause of the disease is generally suppression of the cutaneous perspira- 
tion from exposure to cold, or from long-continued immersion of the feet in water, as often 
happens in the laboring classes. Occasionally its origin is traceable to external injury, 
as a blow, sprain, or concussion. In the female it is sometimes apparently dependent 
upon irregularity of the menses; and in both sexes it is frequently connected with dis- 
order of the digestive apparatus, as dyspepsia, constipation, or derangement of the biliary 
secretion. 
The disease often, if not ordinarily, approaches in a slow and stealthy manner, the first 
symptoms being usually merely a sense of soreness and stiffness of the affected joint, 
with slight derangement of the general health. As it progresses, the loeal distress assumes 
a more marked and open character; what was before only a feeling of uneasiness now 
becomes a source of real pain and distress. The joint gradually growing rigid, moves 
with great difficulty, and a careful examination seldom fails to detect fluctuation, depen- 
dent upon the presence of synovial fluid, an early product, and generally the principal 
one, of inflammation in its milder forms. When the effusion is considerable, it will neces- 
sarily seriously change the contour of the affected joint, the synovial membrane bagging 
across the ligaments, as is so apt to happen when the disease is seated in the knee, 
wrist, or elbow. It is seldom that pus forms in any case, even if unusually severe and 
protracted ; but plastic matter is often poured out in large quantity, and it is the presence 
of this substance that causes the remarkable rigidity which so constantly attends the com- 
plaint in its more severe grades. Spasmodic twitchings of the muscles in the neighbor- 
hood of the affected joint commonly set in at an early period of the inflammation, and 
constitute a source of great distress, effectually interrupting sleep, and requiring large 
doses of anodynes for their relief. 
The pain in chronic rheumatic arthritis is often excessive; it is always increased by 
motion and pressure, and is usually materially aggravated at night. It is of a dull, heavy, 
aching character, and frequently extends in different directions, but especially along the 
eourse of the larger nerves, which it sometimes follows to their very extremities. The 
general health suffers severely; the patient is feverish, and deprived of appetite and 
sleep; the bowrels are constipated ; and the skin is hot and arid. The urine, however, 
although commonly scanty and high-colored, does not deposit any lithic acid, a circum- 
stance which remarkably distinguishes this disease from gout and rheumatism, properly 
so called. 
In old cases of this disease, or in the strictly chronic form of it, the general health, 
although perhaps somewhat impaired, is comparatively good, and the patient may even 
grow fleshy and ruddy. Ilis locomotive powers, however, are greatly deranged, and he 
is, in consequence, often obliged to use crutches. The affected joints are habitually ten- 
der, sore, and distorted, not unfrequently presenting an appearance of being partially dislo- 
cated. Such a change is particularly liable to occur in the fingers, but is also occasionally 
noticed in the hip, shoulder, and other large articulations. Exostoses sometimes spring 
from the sides of the affected joints and serve to add to the deformity, already sufficiently 
great. The synovial burses are also apt to suffer, becoming inflamed, enlarged, and dis- 
tended with fluid. The muscles, in consequence of their perpetual inactivity, become 
atrophied and powerless. Wlmt strikes the observer as very peculiar, amidst these changes, 
is the entire absence of cretaceous deposits in and around the disabled joints. 
Chronic rheumatic arthritis is essentially an inflammatory malady. The affected struc- 
tures, if examined in the earlier stages of the disease, will be found to exhibit indubitable 
evidence of vascular injection of the synovial membrane, and of the presence of synovial 
fluid, with here and there, perhaps, a patch of lymph, or more or less of this substance 
intermingled with the other secretion. Pus, as already stated, is seldom seen. When the 
disease is permitted to go on unchecked, great structural changes gradually take place, 
consisting in the removal, either partial or entire, of the synovial membrane and articular 
cartilages, and the conversion of the extremities of the bones into a hard, ivory, or por- 
CHAP. ix. CHAP. IX. 
CHRONIC RHEUMATIC ARTHRITIS. 
1087 
eellaneous substance, totally destitute of its normal qualities. In many cases the ends of 
the bones have a beautiful polished aspect, being perfectly smooth and glistening; while 
in others they are remarkably rough and tuberculated, or beset with exostosic incrusta- 
tions. The interarticular fibro-cartilages are generally completely destroyed, and the 
funicular ligaments often undergo partial absorption, while the capsular are liable to 
become stretched and relaxed, thus allowing the bones to slip away from each other, and 
produce an appearance of partial dislocation. Finally, fibroid, fibro-cartilaginous, and 
osseous growths, of various shapes and sizes, are extremely prone to form in the interior 
of joints thus affected. 
What is the pathology of this disease? That it is of an inflammatory nature, is un- 
questionable ; but how it is produced, or what the peculiar condition of the system is 
which predisposes to its development, or which keeps the affection in play after it has been 
fairly established, are circumstances in its history of which we are totally ignorant. 
The diagnosis is commonly very easy, especially in the more chronic forms of the dis- 
ease. The history of the case, the excessive obstinacy of the disease, and the gradual fail- 
ure of the functions of the affected joint, together with its distorted appearance, and the 
absence of cretaceous deposits in the structures around the articulation, and of lit hie acid 
in the urine, always readily distinguish it from ordinary gout and rheumatism, the only 
maladies with which it is at all liable to be confounded. 
The prognosis is generally most unfavorable. In the milder forms of the disease, and 
in its earlier stages, a cure is certainly occasionally practicable, but under opposite circum- 
stances the patient almost invariably remains a cripple for life, as it is impossible by any 
mode of treatment at present known to effect restoration of the disorganized structures of 
the affected joints. 
Treatment In the treatment of this affection, everything depends upon the efficiency 
with which the case is met in its earlier stages; for, after the morbid action has made 
serious inroads, all that can, in general, be expected from remedial interference is a miti- 
gation of suffering, seldom anything like a complete, permanent cure. Unfortunately it 
but too often happens that the disease has occasioned great disorganization of the affected 
structures before the practitioner is afforded an opportunity of taking it in hand. Con- 
sidering its inflammatory character, the course of treatment to be adopted is indisputably 
the antiphlogistic, directed not to the part merely, but also, and in an especial manner, to 
the state of the general system, which, whatever may be the real pathology of the disor- 
der, is always more or less extensively implicated. In this country there are few cases 
of chronic rheumatic arthritis which will not, in their earlier stages, bear active depletion 
by the lancet, purgatives, diaphoretics, and antimonials. The quantity of blood taken 
from the arm must, of course, depend strictly upon the condition of the constitution, as 
to the existence or absence of plethora, anorexia, and other evidence of vascular disturb- 
ance. Mercurial purgatives administered in efficient doses, in union with jalap or rhu- 
barb, and compound extract of colocynth, are among the most reliable means that can be 
employed for arresting the morbid action ; and it would be difficult to conceive of any 
case in which they can altogether be dispensed with. At the same time, however, they 
must be used with caution. The improvement of the secretions always forms an impor- 
tant indication, and there is no class of remedies so likely to do this promptly and effec- 
tually as purgatives. After the violence of the disease has been moderated by these means, 
the most efficient prescription, according to my observation, is a combination of morphia, 
antimony, and veratrum viride, given in full and sustained doses, until it makes its specific 
impression upon the heart and nervous system. Half a grain of morphia, with one-sixth of 
a grain of tartar emetic, and ten drops of tincture of veratrum viride, *s a fair average 
quantity for an adult, to be repeated once or twice in the twenty-four hours, according to 
the severity of the suffering, or the effects of the remedy, which should, of course, always 
be carefully watched. Administered in this way, it promptly subdues pain, produces 
perspiration, and reduces vascular excitement. When this result has been brought about, 
the medicines are given in smaller or less frequently repeated doses, until the necessity 
for their exhibition entirely ceases. 
Colehicum is seldom of any material benefit in this disease in any of its stages; for, 
although the disorder unquestionably generally partakes of a rheumatic or gouty nature, 
yet, as already stated, there is rarely any lithic acid deposit in the urine, or cretaceous 
formation within the joints, and this is probably one, if not the principal, reason of the 
inefficiency of the medicine. Dover’s powder may occasionally be employed with great 
benefit ; and salicin is also worthy of trial. 
Among the more important topical remedies are leeches and fomentations, medicated 1088 
DISEASES AND INJURIES OF THE JOINTS. 
CHAP. IX. 
with acetate of lead, opium, and aconite. Local steam baths are sometimes highly bene- 
ficial, the vapor being conducted by means of a tula; to the inflamed parts. Cold appli- 
cations are rarely admissible, from their tendency to shock the system and to cause 
metastasis. As the disease declines, dilute tincture of iodine and steady, systematic com- 
pression with the bandage will be found serviceable; and, at a still later period, passive 
motion may be instituted, the parts around the joint being at the same time well douched 
and shampooed, to promote the absorption of effused fluids and the restoration of impaired 
function. 
In the more advanced chronic forms of the affections the main reliance of the practi- 
tioner must be upon a proper regulation of the diet, which must be chiefly of a mild, 
farinaceous character, with a little white meat or fish at dinner; the preservation of the 
secretions by the occasional exhibition of a few grains of blue mass, or calomel; the 
steady, persistent use of iodide of iron, either alone or in union with iodide of potassium; 
and a residence in a dry, genial climate, exempt from sudden and severe vicissitudes. A 
sojourn for several months at the Ilot Springs of Arkansas, with the daily use of the warm 
baths obtainable at that place, often proves serviceable. If the general health is much 
broken, cod-liver oil with iron and quinine may be required, the body being incased in 
flannel, and gentle exercise taken in the open air, to prevent ankylosis, which is always so 
much favored by inactivity in all articular affections, of whatever character. 
When the disease is followed by permanent ankylosis, an attempt may be made to place 
the corresponding limb in proper position by separating the ends of the bones by means 
of the perforator and chisel, as advised in the section on ankylosis; or, if the case do not 
admit of such interference, excision might be practised, as was done, although unsuccess- 
fully, in an instance of this kind, by liidewald, in 1770. Ilis patient, a man of fifty 
years old, was in bad health at the time, and died from the conjoint effects of suppuration 
and hemorrhage after amputation, performed as a dernier resort. I am not aware that an 
operation for such an object has been employed by any other surgeon, and yet it is easy 
to perceive that cases might arise rendering a resort to the knife highly proper. 
CHRONIC RHEUMATIC ARTHRITIS OF PARTICULAR JOINTS. 
Although this disease may, as already stated, occur in any of the joints, it is by far 
most frequent in those of the carpus and fingers, where it is always readily recognized by 
the pain, stiffness, and permanent distortion which it occasions. The elbow, wrist, and 
ankle-joints rarely suffer from it. When the malady is constitutional, the sterno-clavicu- 
lar and acromio-clavicular articulations are liable to be invaded, and it then often requires 
more than ordinary care and skill to determine the diagnosis, especially if the parts have 
recently been subjected to local injury, as a blow or fall, thus exciting doubt as to whether 
the affection is one of rheumatism, dislocation, or fracture. In a practical point of view, 
however, it is chiefly in the lower jaw, spine, elbow, hip, and knee that the disease is of 
much interest. 
Chronic Rheumatic Arthritis of the Lotcer Jaw.—In the lower jaw the disease is fre- 
quently symmetrical, although it rarely exists in an equal degree on both sides. The 
subjects are usually elderly men, after the fiftieth year, who have been exposed to all 
kinds of hardships. Among the earlier symptoms is a slight degree of stiffness in the 
joint, which is soon succeeded by pain, and by a creaking, crackling, or grating sensation, 
particularly annoying during eating, and often so loud as to be heard at some distance. 
The cause of this sensation is evidently an absence of synovial fluid. The condyloid 
process increases in size, and forms a distinct knob in front of the ear. The mouth is 
opened with difficulty, mastication is greatly restricted, and the chin and face are distorted 
from the destruction of the articular eminences, allowing the external pterygoid muscles 
to drag the bone out of its natural position. When both joints are affected the chin is 
elongated, but if only one suffers the jaw is thrown towards the opposite side, very much 
as in a traumatic unilocular dislocation. The pain is generally worse at night than in 
the day, as well as in damp than in dry weather, and there is often considerable enlarge- 
ment of the lymphatic glands of the upper part of the neck. The fibro-cartilage is 
destroyed; the surfaces of the joint, divested of their natural coverings, are of a porcel- 
laneous hardness; the articular eminences are flattened, if not entirely wasted ; and the 
condyles are enlarged and disfigured. 
The diagnosis is determined principally by the age of the patient, the gradual changes 
in the joint, face, .and chin, and the symmetrical character of the attack. CHAP. IX. 
CHRONIC RHEUMATIC ARTHRITIS. 
1089 
Chronic Rheumatic Arthritis of the Spine.—This disease occasionally invades the 
spine, especially the cervical and dorsal divisions; the subjects are generally elderly per- 
sons, and the attack is commonly associated with the same affection in other regions of the 
body. The most distressing forms of the disease are met with in the lower part of the 
neck and the upper part of the back, where it often causes great deformity, the curvature 
being a combination of the posterior and lateral varieties. The trunk, in time, becomes 
greatly arched, and the patient is unable to stand erect, or to turn his head from side to 
side. The earlier symptoms are, gradually increasing pain and stiffness, and a crackling 
noise heard on motion of the affected joints. 
The diagnosis rests upon the history of the case, as the age of the patient, the absence 
of local tenderness, or, what is tantamount to this, the tolerance of the parts under rough 
manipulation, and the fact that the patient does not experience any marked pain if the 
spine be forcibly concussed through the skull as he sits upon his chair. 
Chronic Rheumatic Arthritis of the Shoulder—When this disease attacks the shoulder, 
it may come on either as an independent affection, as when it is caused by external vio- 
lence, or, as is more generally the case, it coexists with chronic arthritis of some of the 
other articulations. The earlier symptoms are, stiffness of the joint, with a crackling 
sensation on moving the arm, a deficiency of synovial fluid, more or less pain, especially 
at night, and in damp states of the atmosphere, and gradual wasting of the deltoid 
muscle. As the disease proceeds, the joint becomes more and more rigid, from the 
dryness of its surfaces, and the effects of plastic deposits, the shoulder presents a wasted 
appearance, the acromion and coracoid processes stand out in bold relief, and the move- 
ments of the arm are restricted within the most narrow limits. The patient can still 
abduct the limb slightly, but he finds it impossible to elevate it to a horizontal level, or to 
carry it behind the trunk. The head of the humerus is generally a little raised, as well 
as somewhat nearer the middle line than natural, the scapula is unusually mobile, and a 
remarkable depression exists at the posterior part of the joint. 
The diagnosis is established by the history of the case. When the disease is constitu- 
tional, its coexistence with similar attacks in other joints is sufficiently denotive of its 
character. When it is caused by injury, it may be confounded with tuberculosis, from 
which, however, it may readily be distinguished by the crackling sound that attends the 
movements of the arm, and by the. fact that the parts are much more tolerant of pressure 
and rude manipulation. In caries of the joint the slightest motion is productive of intense 
pain, there is more swelling, with greater constitutional disturbance, and the affected 
structures ultimately run into suppuration, an effect which is never witnessed in chronic 
rheumatic arthritis. 
When a person, affected with this disease, is so unfortunate as to meet with a fall or 
blow upon the shoulder, the surgeon may find it very difficult, if not impossible, unless he is 
fully acquainted with the previous history of the case, to determine whether the affection 
is one merely of sprain, fracture, or dislocation. 
The head of the humerus, partly absorbed, flattened, and nodulated, is denuded of 
cartilage at oue place, porous at another, and eburnized at a third. In very old cases it 
generally rests against the under surface of the acromion and coracoid processes, in a 
kind of socket formed for its accommodation. These processes themselves are often greatly 
changed ; sometimes they are much enlarged and roughened, at other times completely 
wasted. The glenoid cavity is expanded and excavated, while its margin is elevated into 
a sharp, irregular ridge. Sometimes all these parts are soldered together by osseous matter. 
The soft structures around the joint are materially altered, the muscles are pale, wasted, 
and flabby, the long head of the biceps is destroyed, the tendons have a macerated appear- 
ance, as if their fibres were separated into their original elements, and the capsular liga- 
ment is thickened and perforated, or hypertrophied at one point and atrophied at another. 
Chronic Rheumatic Arthritis of the Hip This affection is nearly always met with in 
elderly persons laboring under the rheumatic diathesis. For this reason it frequently co- 
exists with the same disease in other parts of the body. Sometimes, however, it is limited 
to one of the hip-joints, and is then generally caused either by external violence, or by 
suppression of the cutaneous perspiration. Falls and blows upon the great trochanter 
occasionally give rise to it. Mules are by far its most frequent subjects. 
The earliest evidence of the disease is a stiffness in the joint, which is generally most 
annoying in the morning when the patient gets out of bed, but which gradually diminishes 
after exercise, provided this is not carried to severe fatigue, which always produces an 
opposite effect. At first there is little or no pain, but after a while this becomes a promi- 
nent and distressing symptom. It is either dull and aching or of a gnawing or boring 1090 
DISEASES AND INJURIES OF THE JOINTS. 
CHAP. IX. 
character, and is most severe in the joint and in the great trochanter, from which, how- 
ever, it radiates in different directions, as up into the gluteal region and down along the 
thigh, often as far as the knee and even the leg. It is increased by motion and exercise, 
is worse at night than in the daytime, and is influenced by the state of the atmosphere. 
The patient walks very lame, and, as he supports the weight of his body upon the sound 
limb, the affected one is drawn up in such a manner as to give it a shortened appearance. 
The foot is strongly everted, the power of rotation is lost, the buttock is flattened, the 
gluteo-femoral crease is effaced, the muscles of the thigh are attenuated, and a crackling 
sensation is perceived on moving the joint. The patient cannot stoop when he stands, 
and when he sits he is compelled to stretch out his leg. The trochanter is unusually 
prominent, and progression is painful and restricted. Great shortening of the limb at 
length takes place, often amounting, apparently, to two and a half or even to three inches, 
but, in reality, seldom exceeding one-third of that amount, and depending mainly upon 
the wasted condition of the head and neck of the thigh-bone. 
The principal affections with which this disease is liable to be confounded are tubercu- 
losis and sciatica. From the former it may usually be readily distinguished by the fact 
that the malady nearly always occurs in elderly subjects, by its frequent coexistence with 
similar attacks in other parts of the body, by the peculiar crackling sensation produced 
on moving the joint, by the absence of heat, swelling, and tendency to suppuration, by the 
greater tolerance of the parts under rude manipulation, by the flattening of the nates, by 
the remarkable prominence of the trochanter, and by the natural appearance of the calf 
of the leg. In sciatica the pain is seated in the sacro-lumbar region ; it is generally of a 
neuralgic character, is often very severe at night, and always extends along the outer and 
posterior part of the thigh. The motions of the hip-joint are unimpaired, and the limb 
retains its natural length and direction. 
The joint, in the confirmed stage of the disease, is greatly changed in its structure. Its 
surfaces, completely denuded of cartilage, are remarkably altered in their shape, and ex- 
hibit a rough, porcellaneous appearance. The head of the femur, especially its tip, is 
reduced in size, and often worn down to a mere stump. Sometimes it is quite conical. 
The neck of the bone is shortened, unusually horizontal, and eburnized. The acetabulum 
is deformed, scooped out, and scabrous at its margin. The round ligament is annihilated, 
while the capsular is thickened and perforated, partially destroyed or hypertrophied and 
inlaid with bony matter. The muscles around the joint are thin, pale, and flabby. In 
very old cases, the articular surfaces are frequently connected together by stalactites and 
osseous bridges. 
The changes wrought in this disease are beautifully illustrated in the annexed cut, fig. 
G21. The head of the femur is greatly altered in shape, the neck is much shortened, 
and the whole contour of this portion of 
the bone is in an abnormal condition. 
The acetabulum is materially reduced 
in size, and the brim is very rough and 
elevated into a high ridge. 
Chronic Rheumatic Arthritis of the 
Knee This disease usually begins as 
an ordinary attack of synovitis. The 
pain, at first very slight, gradually in- 
creases, and is generally most severe at 
the inner part of the joint, particularly 
over the inner condyle. The stiffness 
progresses until, at length, it amounts 
almost to complete ankylosis ; the knee 
is deformed, and crackles when moved ; 
the hamstring muscles are rigidly con- 
tracted ; the leg is strongly everted; 
and the tibia is partially dislocated from 
the femur. The patella is often consid- 
erably displaced, and foreign bodies, or 
cartilaginous concretions, may occasion- 
ally be detected in the joint. 
The diagnosis is based upon the chro- 
nicity of the disease, the absence of any 
tendency to suppuration, the marked eversion of the leg, the dislocated appearance of the 
Fig. 621 
Effects of Chronic Rheumatic Arthritis of the Hip-joint. ANKYLOSIS. 
1091 
CHAP. IX. 
knee, the singular condition of the ligament of the patella, which forms a distinct band 
in front of the joint, and the tuberculated state of the margins of the patella and of the 
condyles of the femur. 
The disease not unfrequently appears at a very early age. I have repeatedly witnessed 
it in children, especially in boys, before the fifteenth year, and in one instance as early as 
the twelfth. 
Treatment To the treatment of this affection, as it occurs in these different articula- 
tions, little is to be added to what has already been said in regard to the subject in gen- 
eral. The most important internal remedies, especially in the earlier stages of the attack, 
after venesection, are mercurial purgatives and anodyne diaphoretics, followed, in due 
time, by a regular course of alterants, especially the iodide of potassium. In chronic 
arthritis of the lower jaw the best local means are leeches and a series of small blisters in 
front of the ears. When the disease attacks the spine, dorsal recumbency will be neces- 
sary, and should be observed for a long time, otherwise horrible deformity may be the 
result. A similar plan of treatment, in addition to the use of splints, will be required 
when the disease involves the hip, knee, or ankle. The elbow and forearm should be 
well supported in a sling, when it affects the shoulder. Passive motion, friction, sham- 
pooing, douching, and electricity come in play at a later period of the disease, and some- 
times afford marked relief. Contracted tendons, muscles, and aj>oneuroses are divided 
with the tenotome. When the case is of long standing, all that can be done is to mitigate 
suffering. 
SECT. IX ANKYLOSIS. 
Several varieties of this complaint are met with, as the complete and incomplete, in the 
former of which all motion is annihilated, while in the latter motion still exists, although 
in a very limited degree. There is another form of stiffness, in which the structures of 
the joint retain their normal characters, but are prevented from being exercised by dis- 
ease in the neighboring tissues, a circumstance which has induced the division of anky- 
losis into true and false, or intraiirticular and extraarticular. This classification is not 
only more philosophical than the other, but is of the greatest practical importance, as it 
leads to a just appreciation of the etiology of the disorder, and also, as a necessary conse- 
quence, topro[>er therapeutic indications. The terms complete and incomplete refer, in fact, 
merely to different degrees of the same complaint, and might be very well replaced by 
the words fibrous and osseous, as more expressive of the true nature of the ankylosis. 
1. IntradrticulartAnkylo$is Intraiirticular ankylosis may be produced by whatever 
has a tendency to excite inflammation in the synovial membrane of a joint, with a dei>osit 
of plastic matter upon its free surface. Hence it may arise from all kinds of external 
injury, as wounds, sprains, blows, and contusions; the presence of interarticular bodies; 
luxations, especially neglected ones; and fractures which involve the joints, or are situ- 
ated in their immediate neighborhood. Gout, rheumatism, syphilis, and struma also act 
as exciting causes; but of all these causes, as well as others that might be referred to, 
there are none which so frequently occasion ankylosis, permanent and irremediable, as 
fractures and dislocations. Protracted disuse powerfully disposes to the occurrence of 
stiffness of certain articulations, especially those of the fingers, wrist, and elbow. I am 
aware that the force of this influence has been denied, but certainly not upon just grounds; 
for experience has shown, and my own observation has repeatedly verified the fact, that 
this circumstance alone is often capable of producing ankylosis of a very obstinate and 
intractable character. Such an event need not surprise us if we remember that motion is 
the appropriate stimulus of an articulation, and that more or less of this is just as neces- 
sary to its healthy action as food is to the stomach, light to the eye, or sound to the ear. 
When motion is suspended for any length of time, the synovial membrane becomes dry 
and stiff, and, eventually taking on inflammation, pours out plastic matter, which effectu- 
ally obliterates its cavity and so induces permanent ankylosis, on the principle that when 
the function of a part is destroyed its structure is essentially changed in its character, if 
not completely annihilated. 
All joints are liable to this variety of ankylosis, but it takes place much more easily in 
the ginglymoid than in the orbicular, and among the former, it is more frequently wit- 
nessed in the knee, elbow, and wrist than in any others. Several joints are sometimes 
involved in the occurrence, especially when it arises from gout, rheumatism, or syphilis; 
and instances have been noticed in which nearly every articulation in the body was com- 
pletely ankylosed, the skeleton forming almost one rigid piece. 
In every case of intraiirticular ankylosis a series of alterations must necessarily take 1092 
place before the loss of function can be complete. The first step always consists in the 
effusion and organization of plastic matter, and the second in the gradual conversion of 
this matter, first, into fibrous tissue, then into cartilage, and finally into bone, the latter 
forming the ultimate link in the morbid chain. A fibrous ankylosis generally terminates, 
at no distant period, in osseous ankylosis, the change from one to the other being regularly 
progressive until the process is completed, this being the method which nature adopts to 
effect a cure when any serious accident befalls a movable articulation. 
These adhesions and transformations vary in extent, not less than in structure and con- 
sistence. Sometimes they are very limited, a considerable portion of the synovial mem- 
brane remaining sound, or being only slightly affected by disease, and then the connection 
between the opposing surfaces is generally easily broken up, so that ultimately the joint 
may regain its original functions. In a second series of cases, again, the fibrous or fibro- 
ligamentous bands are not only more numerous, but they extend from different points of 
one articular cartilage to the other, and thus either obliterate the synovial cavity, or, at 
all events, completely destroy its usefulness. Finally, in a third class of cases, the new 
tissue becomes the receipient of osseous deposits, which, gradually increasing in quantity, 
in time usurp the place of the synovial membrane and cartilage, and ultimately solder the 
ends of the two bones firmly together. Hence, if a section be made of what was once 
the joint, the areolar and solid structures will be found to be inseparably blended, their 
junction being no longer indicated by the thin layer of 
compact substance which originally invested their heads. 
These changes are well seen in fig. 622, from a specimen 
in my cabinet. The femur and tibia are firmly united to 
each other and to the patella, the three forming one solid 
piece. 
Treatment The treatment of this variety of ankylosis 
must vary according to the nature and extent of the 
tissues upon which it depends, and also, in no inconsider- 
able degree, upon the character of the articulation. 
When the case is of recent standing, when the adhesions 
are weak and of limited extent, and when the joint is not 
too complicated in its structure, a reasonable hope may 
be entertained that the new tissues may be broken up, 
and brought fully under the action of the absorbents, so 
that, in due time, and with proper diligence, the functions 
of the joint may be measurably, if not completely, re- 
established. Under opposite circumstances, however, a 
cure will not only be difficult, but generally impracticable. 
Much may be done in most cases of intraarticular 
ankylosis, in the way of prevention, by the steady and 
persistent use of sorbefacients and passive motion. The 
attendant inflammation having been divested of its vio- 
lence, the plastic deposits must be disposed of before they 
have an opportunity of becoming firmly organized, and 
the only way in which this can be effected is by frictions with stimulating lotions, aided 
by the cold or hot douche, and by rubbing the articular surfaces gently against each other, 
at first once every forty-eight hours, and then once or twice a day, until all the matter 
has been absorbed, and the synovial membrane has regained its primitive characters. 
Much more skill and attention are required in these cases than the surgeon is generally able 
or willing to bestow, and it unfortunately too frequently happens that their entire man- 
agement is confided to persons who are wholly ignorant of the manner in which it should 
be conducted. The consequence is that a great deal of harm is commonly done, which 
it is impossible subsequently to rectify by any mode of treatment, however carefully carried 
out. For the most part, indeed, the time for successful interposition has gone by when 
the case falls into judicious hands. 
When, through neglect, mismanagement, or unavoidable circumstances, the movements 
of the joint have become greatly impaired, or when the case has already attained a certain 
degree of chronicity, instead of abandoning the patient to his fate, an attempt should be 
made to break up the adhesions by forcible means, not forgetting, however, that they 
must, nevertheless, be conducted with a certain degree of gentleness in order to prevent 
mischief. The patient being thoroughly anaesthetized, the distal portion of the limb is 
DISEASES AND INJURIES OF THE JOINTS. 
CHAP. IX. 
Fig. 622. 
Osseous Aukylosis of the Knee-joint. ANKYLOSIS. 
1093 
CHAP. XX. 
moved with one hand, while the proximal, or that nearest to the trunk, is firmly steadied 
with the other, at the same time that it rests upon a smooth, solid surface, so as to afford 
a better fulcrum for the part to move upon. Thus, when we wish to break up the adhe- 
sions in ankylosis of the knee, the thigh is firmly pressed upon the table, while the leg, 
drawn away from its edge, is alternately flexed and extended to as great a degree as may 
be compatible with safety. In operating on the elbow a similar procedure is adopted, the 
arm being the fixed,and the forearm the movable point. Much muscular power is frequently 
required to conduct these movements, and yet the greatest care must be taken so to dis- 
tribute this power as not to produce any mischief. Not long ago, in one of my cases at 
the College Clinic, I was so unfortunate, in attempting to remedy an ankylosed elbow, as 
to fracture the humerus immediately above the joint, the accident being announced by a 
loud snap, very different from the crackling noise which attends the severance of fibrous 
bands. The patient, a woman sixty-five years of age, had dislocated her elbow nearly 
three months previously, and the bone had no doubt become softened and brittle from an 
extension of the inflammation. Such an occurrence is not always avoidable; for I am 
very sure that in the case in question much less force was used than I had often employed 
on similar occasions without any such mishap. 
The amount of force and the length of time during which it should be continued must 
vary according to the circumstances of the case, especially the strength and extent of the 
adhesions. The efforts should always be very gentle at first, and gradually increased as 
the parts are found to yield. If the joint be tender, it may be necessary to spend a few 
days in preliminary treatment, as dieting, purging, and, perhaps, even bleeding. The 
subsequent managment must be of a strictly antiphlogistic character, and the repetition 
of the operation must depend upon the effects of the first trial; at all events, it should 
now be conducted with great gentleness, and rather with a view to a passive than an 
active result. In many cases it will be found advantageous, after the first efforts, to extend 
the joint by an angular splint, worked by a screw, and worn steadily until the object is 
attained, the degree of tension being regulated at will by the patient himself. Apparatus 
for fulfilling these indications is delineated in the accompanying sketches. Fig. 623 
Fig. 623. 
Fig. 624. 
Kolb6’s Apparatus for the Kne 
Modified Stromeyer’e Splint for the Elbow. 
represents Kolbe’s contrivance for straightening the knee, and fig. 624 that of Stromeyer 
for rectifying ankylosis of the elbow. 
Of the comparative harmlessness of these operations a good idea may be formed by 
the statistics furnished by Professor Nussbaum, of Munich. Of 110 cases of forcible 
extension of the knee, the condyles of the femur gave way in 82, and the tibia just below 
the attachment of the patella in 7, and yet no evil results ensued in a solitary one. I 
have myself broken up ankylosed joints in very numerous instances without any serious 
effects. Nevertheless, all such operations should be conducted with the utmost caution, 
especially when performed with the aid of machinery, as they may eventuate not only in 
fracture of the bones, either at the articulation or in its immediate vicinity, but give rise 1094 
DISEASES AND INJURIES OF THE JOINTS. 
CHAP. IX. 
to consequences still more disastrous, as violent inflammation, erysipelas, gangrene, and 
even loss of life. 
Finally, when it is found that there is no possible chance of effecting a cure, but that 
ankylosis is inevitable, every effort, compatible with safety, should be made to place the 
affected limb in a situation most conducive to its future usefulness. Thus, the hand should 
be extended in a straight line with the forearm in ankylosis of the wrist; the forearm 
bent at a right angle with the arm in ankylosis of the elbow ; and the arm brought close 
to the antero-lateral aspect of the body in ankylosis of the shoulder. In ankylosis of the 
hip, the thigh is slightly flexed upon the pelvis; when the knee is concerned, the leg is 
inclined somewhat backwards ; and in ankylosis of the ankle, the foot is placed at a right 
angle to the leg ; the parts being found to be most serviceable when held in these several 
positions. Particular occupations may, however, render it proper to deviate from these 
rules. Thus, Mr. Bryant, had under his charge a painter who desired that his arm might 
be ankylosed in the straight position ; and a turner, whose leg, at his own request, was 
allowed to remain at a right angle with the thigh, as he was thus the better enabled to 
move his wheel. 
Osseous ankylosis of the hip-joint was formerly considered as incurable, except by 
certain operations, one of which consists in dividing the bone, as originally proposed and 
successfully executed by Dr. John Rhea Barton, in 1820. 11 is patient, a sailor, twenty- 
one years of age, had lost the use of his hip-joint, by an injury from a severe fall on 
shipboard. The thigh was drawn up nearly at a right angle with the pelvis, the knee 
projecting inwards across the sound limb, and the foot presenting forwards. All attempts 
at correcting the malposition having failed, a crucial incision was carried through the 
integument, over the most prominent part of the great trochanter, when, raising the flaps 
thus defined the muscles connected with this portion of the bone were detached, a passage 
being thus made both in front and behind the femur for the easy introduction of the finger. 
With a saw constructed for the purpose, the bone was divided through the great trochanter 
and a part of its neck in a transverse direction. The wound being lightly dressed, the 
limb was placed in a fracture apparatus, and the case managed upon strictly antiphlogistic 
principles. Passive motion was instituted at the end of three weeks, and repeated, from 
time to time, for four months, when the artificial joint had acquired such a degree of 
motion that the man was able to walk merely with the aid of a cane. The wound had 
healed, and he could not only rotate and abduct the foot, but carry it forwards and back- 
wards over an area of upwards of twenty inches. Gradually, however, the use of the new 
joint was completely lost. 
Dr. J. Kearney Rodgers, of Newr York, in 1830, modified the procedure of Barton, by 
excising a disk of bone from between the trochanters of a man forty-seven years old. The 
operation was successful, and the motions of the new joint persisted tor two years and 
a half. 
Professor Sayre, in 18(12, removed a plano-convex piece of bone from between the tro- 
chanters, as shown in fig. 625, from Erichsen, and then rounded off the upper end of the 
lower fragment, so as to imitate the form of a superficial enar- 
throdial articulation. One of the great merits of the procedure 
is the point of transverse section, through which the attachment 
of the psoas and iliac muscles is preserved for the purpose of 
flexion. In his first case some necrosis occurred, but six years 
subsequently the patient enjoyed a good use of the limb. In a 
second case there was limited necrosis up to the date of the death 
of the patient from lung complications, six months after the 
operation, when the parts were found to be furnished with a 
capsular ligament, articular cartilages, and a synovial membrane. 
Of 17 cases of Barton’s, Rodger’s, and Sayre’s open opera- 
tions, 7 died, and in one performed by Professor Post, and which 
was an example of the first method, the femoral artery and vein 
were found on death from gangrene to be hooked over the divided 
end of the bone. This large mortality, when considered in con- 
nection with the extreme rarity with which a movable false joint 
has resulted, is quite sufficient to condemn these procedures for 
the simpler and more successful subcutaneous osteotomies. 
Professor Yolkmann, in 1873, modified the procedure of Rod- 
gers, by making an incision along the posterior face of the great trochanter, separating 
the periosteum for two-thirds of its circumference, and removing with chisels and gouges 
Fig. 625. 
Lines of Section in Sayre’s 
Operation for Ankylosis of 
Hip-joint. ANKYLOSIS. 
1095 
CHAP. IX. 
a triangular piece from just below the trochanter, and then forcibly breaking the 
inner circumference of the hone, after which he brought the limb parallel to the longitu- 
dinal axis of the body, and retained it in this position until consolidation had taken place. 
Of twelve operations conducted by Volkmann in this way, under antiseptic precautions, 
all recovered. 
Mr. William Adams, of London, in 1870, reported the case of a man, twenty-four 
years of age, upon whom he had some months previously successfully performed subcu- 
taneous division of the neck of the thigh-bone within the capsular ligament, on account 
of ankylosis of the hip-joint attended with extreme deformity. The instruments employed 
were a long tenotomy-knife, and a narrow saw with a cutting edge an inch and a half 
in length, fig. 626. After the section of the bone in the direction shown in fig. 627, it 
was necessary to divide the tendons of several of the femoral muscles in order to straighten 
the limb. The wound was slow in healing; but no severe inflammation or deep suppura- 
tion followed the operation, and bony ankylosis, with the limb in a straight position, was 
obtained. Of 34 cases in which this operation has been performed, only 3 proved fatal, 
one from pyemia, one from profuse suppuration, and one after consecutive amputation at 
Fig. 626. 
Fig. 627. 
Adams’s Saw for Subcutaneous Division of the Neck of the Femur. 
the hip-joint. The procedure is particularly adapted to those 
cases in which the head and neck ot‘ the bone preserve tlueir 
normal size, as when the ankylosis is the result of rheumatism 
or injury. Instead of making a clean section of the bone with 
a saw, Billroth resorts to the chisel and forcible fracture. 
When the neck of the femur is materially altered in form, 
or partially destroyed, changes which frequently occur in tuber- 
cular osteitis, the shaft of the bone should be divided subcu- 
taneously with Adams’s saw just below the lower trochanter, 
as was originally practised by Gant, in 1872 ; or the section 
may be made with the chisel, as recommended by Maunder, 
the former instrument, however, being preferable. The pro- 
cedure is comparatively safe, having been uniformly successful 
so far as I have have been able to learn. Under similar cir- 
cumstances, Harwell prefers to make an oblique section, be- 
gining just above the small and terminating a little below the middle of the square 
face on the outer aspect of the great trochanter. Both of his patients recovered with 
useful limbs. 
The most recent of the operations for the relief of bony ankylosis of the hip-joint, is 
that of Volkmann, which consists in forming a false-joint in the following manner : An 
incision having been made along the posterior surface of the great trochanter, the bone 
is divided one inch below the upper border of that epiphysis, the interior of the neck of 
the femur is fractured, and the head of the bone is removed by scooping out the interior 
of the acetabulum with a gouge. The upper end of the femur is next rounded off with 
a chisel and reduced in diameter to the size of the shaft of the bone, and then placed in 
the cotyloid cavity. The limb is subsequently extended by weights, and early passive 
motion resorted to. Volkmann has resected the joint in this way six times, and all the 
patients were enabled to walk and sit without elevating the pelvis. 
The operation of Dr. Barton, above described, was modified by him, in 1835, in such 
a manner as to render it particularly applicable to the relief of deformity of the lower ex- 
tremity, dependent upon ankylosis of the knee-joint. The case was one of complete bony 
ankylosis, in a medical man whose leg was flexed nearly at a right angle with the thigh, 
and who recovered with an excellent use of his limb. 
The operation, as performed by I)r. Barton, consists of four distinct stages. In the 
first, a triangular flap is formed of the soft parts in front of the limb, consisting of the 
integument and the extensor muscles, by making two horizontal incisions, one just above 
the superior border of the patella, and the other two inches and a half higher up, down 
to the bone. This flap, which has a broad base on the inside of the thigh, is then dis- 
sected up, and held out of the way. The next step is to remove a V-shaped portion of 
Showing the Point where the 
Neck of the Femur is Divided 
in Adams’s Operation. 1096 
DISEASES AND INJURIES OF THE JOINTS. 
the femur, which is easily clone with a narrow saw, care being taken not to divide the 
bone completely, for fear of injuring the popliteal artery, as happened in a case reported 
by Professor liied, of Jena. In the third stage the bone is fractured by gently extend- 
ing the limb; and, lastly, the flap is replaced and secured by suture. The dressing 
is completed by putting the limb upon a double inclined plane, where it is retained 
for the next ten days, or until the ends of the broken bone are enveloped in plastic 
matter, when it is placed nearly in the straight position, in a suitable apparatus for 
insuring quietude. The patient is usually able to rise, and walk about on crutches, in 
six weeks, or much sooner, if the immovable dressing is applied. 
The sawing of the bone constitutes one of the leading objects of interest in this opera- 
tion ; if the wedge-shaped piece is too large, there is a possibility of non-union, whereas, 
if it is too small, it may be impracticable to straighten the limb sufficiently. In order to 
avoid these contingencies, all that is necessary is to measure the angle of deformity, and 
then to saw out a portion of bone equal to the complement of that angle. The adjoining 
cut, fig. G28, will aflbrd a better idea of the nature of the operation than any description 
of it, however elaborate. 
Dr. J. Kearney Dodgers modified this operation by connecting the ends of the bone with 
silver wire, on the supposition that the procedure would tend to expedite their reunion. 
Slich a measure, however, is hardly required if 
proper care be taken to keep the limb well secured 
during the after-treatment. 
Of 16 cases of this operation, of which the re- 
sults have transpired, 14 recovered and 2 perished, 
respectively of hectic irritation and exhaustion. 
The success would thus seem to be eminently flat- 
tering. 
In 1844, Dr. Guidon Buck, of New York, in a 
case of complete synostosis of the knee with the 
limb at a right angle, so modified and extended 
the procedure of Barton as to remove the condyles 
of the femur, the head of the tibia, and the patella, 
in a wedge-shaped piece, thereby bringing the leg 
almost in a straight position. The patient, a man 
twenty-two years of age, suffered considerably from subsequent inflammation and suppu- 
ration ; but at the end of six months the bony union at the knee was firm, and the limb 
shortened five inches. This operation has been practised in 30 cases, of which 5 proved 
fatal. The best result obtained from it, was in a case reported by Dr. Heuser, in which 
firm, osseous union took place in ten weeks, the man being afterwards able to pursue bis 
vocation of a chamois hunter. 
An operation for the relief of bony ankylosis of the knee, based upon the same principles 
as that of Dr. Barton, but differing f rom it in some essential particulars, was performed by 
the late Professor Pancoast at the Clinic of the Jefferson Medical College in the winter 
of 1859, the patient being a youth on whom extension had previously been tried in vain. 
It consisted in perforating with a stout gimlet the femur subcutaneously, through a single 
opening, at half a dozen points, just above the knee, and then forcibly breaking the bone. 
The limb was placed in appropriate apparatus, the upper end of the inferior fragment 
forming an angle with the apex projecting into the ham. A large abscess formed at the 
seat of fracture, but, with this exception, the case progressed favorably, and the boy made 
a good recovery, the foot coming down well, and the limb being nearly as straight as 
could be desired in such a condition of the knee-joint. In a case in the hands of Professor 
Agnew extensive suppuration also ensued, but the lad, after much suffering, finally got well. 
An operation similar to the above was performed by Professor Brainard, in 1860, upon 
a man twenty-three years of age ; but in this case the femur was divided through its con- 
dyles by means of a perforator. The patient recovered with a good limb. In a second 
case, one of false ankylosis of the knee, the patella was detached subcutaneously from the 
femur and tibia, and excellent motion of the joint obtained. 
The operation of perforating the femur subcutaneously, and then forcibly fracturing the 
bone, has been performed only, so far as I know, in six instances, all of which recovered 
with useful limbs. 
In 1861 I extended these subcutaneous operations to perforation of the joint itself, 
with disruption of the osseous adhesions between the bones entering into its composition. 
The instrument with which the operation is conducted, exhibited in fig. 629, consists of 
CHAP. IX. 
Fig. 628. 
Barton’s Operation. CHAP. IX. 
ANKYLOSIS. 
1097 
a shaft of well-tempered steel, four inches and a half in length, the point of 
which is one-sixth of an inch in breadth, and presents on each side an oblique 
groove with cutting edges, so that it acts as a gouge as well as a drill. This 
is fitted into a firm handle, its proximal extremity being large, smooth, and 
rounded, so as to rest comfortably in the palm of the hand. In some in- 
stances, as when the bony connections are so firm as to resist the action of 
the drill, a narrow, sharp-pointed chisel, or Adams’s saw may be used as a 
substitute. Whatever may be the form of the instrument, great caution must 
be exercised in operating on the posterior surface of the joint, lest it slip and 
injure the popliteal vessels. 
The following case, transcribed from my clinical records, exemplifies the 
mode of performing the operation, the trifling suffering which generally follows 
it, and the after-treatment. A man, twenty-two years of age, was admitted 
into the hospital of the Jefferson Medical College, on the 30th of October, 
18(> 1, on account of bony ankylosis of the left knee, t he leg being flexed at nearly 
a right angle with the thigh. Nine years previously, while engaged in mow- 
ing, he accidentally opened the joint with a scythe, the injury being followed 
by violent inflammation and constitutional disturbance. During his prolonged 
confinement, the limb was placed in a very bent position, in which it became 
stiffened, compelling him to use a crutch. A scar marked the site of the 
original wound, and the integument about the joint was indurated, and the 
seat of the cicatrices of old sinuses. 
The diagnosis was synostosis of the knee, and was based on the absolute 
immobility succeeding traumatic inflammation, a fixed state of the patella, a sensation to 
the touch of thorough consolidation of the articulation, the absence of tension and resistance 
of the Hexor muscles on attempts at forcible extension, and freedom from pain both in front 
and behind the joint during similar efforts. 
Chloroform having been administered, a longitudinal incision, hardly half an inch in 
length, was made over the outer surface of the knee, near its middle, in a line with the 
groove between the head of the tibia and the external condyle of the femur, down to the 
two bones. Through this opening the drill was in- 
troduced, and passed on to the opposite side, when 
it was moved about in such a manner as to cut 
through and break down the osseous connections 
between the femur and the tibia on the one hand, 
and the femur and the patella on the other. The 
union was exceedingly firm ; but after much diffi- 
culty, it was finally overcome, and by forcible ex- 
tension of the limb, the parts yielded with a crack- 
ling noise. The small wound was carefully closed 
with two twisted sutures and collodion, and a roller 
carried from the toes to within a short distance of 
the groin. The leg was brought to an angle of about 
45° with the thigh, and laid in an easy position upon 
its outer surface, a thick pillow being placed behind 
the knee. No blood was lost in the operation, and 
no pain experienced. Half a grain of sulphate of 
morphia was administered as soon as the effects of 
the anesthetic had passed off, and recumbency, light 
diet, and cooling drinks enjoined. 
No constitutional disturbance followed the pro- 
cedure, the entire immunity from suffering being, 
doubtless, due to the fact that the natural structures 
of the joint had been completely destroyed. For 
four days the limb was allowed to remain perfectly 
quiet, when an extending apparatus was applied, and 
the leg was straightened daily several degrees. On 
the tenth day when the dressings were removed, the 
wound was found to be perfectly united, and at the 
expiration of three weeks the patient was permitted 
to go about on crutches. In the sixth week he was discharged well. At this time 
bony union was firm, the knee being slightly flexed, and the leg shortened one inch. 
Fig. 629. 
Bone-I’erfo- 
rator. 
Fig. 630. 
Result of Operation for Synostosis of the Knee 1098 
DISEASES AND INJURIES OF THE JOINTS. 
CHAP. IX. 
The adjoining sketch, fig. 030, from a photograph, exhibits the appearance of the limb, 
two years after the operation. The muscles were as plump and as well developed as in 
the sound member. 
This operation has been done successfully in seven instances, five having occurred in my 
own practice. In two of the latter preliminary division of the hamstring tendons was 
demanded, and in all firm bony union was procured with about one inch of shortening, 
which was deemed advisable to render locomotion less awkward. The treatment was 
not any longer than that required for simple fracture of the femur, the mean duration of 
confinement in bed having been twenty-three days, and the average length of time, in 
which the patient was unable to walk without artificial aid, ten weeks. In only one in- 
stance was the resulting traumatic fever alarming, and its occurrence could only be referred 
to the fact that the synostosis was not complete. The operation, indeed, should only be 
performed when the ankylosis is osseous throughout, as this renders the joint perfectly 
tolerant of rough interference. In such cases the synovial membrane and cartilages are 
destroyed, and the bones forming the articulation are firmly soldered together, as it were 
into one continuous piece, as in fig. (522, page 1092. Under ordinary circumstances, 
where the bond of union is soft, or the ankylosis false, and the least particle of motion is 
preserved, so rude a procedure would be attended witli great risks, if not followed by fatal 
results, and could not be too strongly condemned. 
2. Kxtraarticular Ankylosis.— In extraiirticular ankylosis, the spurious ankylosis of 
some authors, the articular structures retain, at least for a time, their normal charac- 
ters, but their functions are impaired or suspended by the diseased condition of the sur- 
rounding parts. Several distinct causes may induce such a result, of which muscular 
contraction, vicious cicatrices, osseous deposits, and the pressure of new growths, or 
aneurismal tumors, and paralysis of the articular muscles, are the most common and 
efficient. 
o. Of the several causes here enumerated as capable of producing rigidity of a joint, 
permanent contraction of the muscles and tendons, which naturally influence and control 
its movements, is the most frequent. Examples of this are constantly met with in gout, 
rheumatism, fractures, and dislocations, where, from an extension of the inflammation 
which attends these diseases and accidents, motion is greatly impeded, if not completely 
destroyed, by this occurrence. The influence exerted by permanent contraction of the 
muscles is well illustrated in clubfoot and analogous distortions, where the joints are not 
only crippled in their functions, but greatly changed in their form and relations, giving 
the limb that peculiar aspect, from the resemblance to which it derives its name. Similar 
effects may be caused by the contraction of the aponeuroses. 
j3. Secondly, a joint may become stiff from a vicious cicatrice, as that, for instance, of a 
burn or scald. The tendency of the new substance is to continue to contract until in 
many cases it produces the most hideous deformity, stretching the soft parts to their 
utmost capacity, and drawing the neighboring articular surfaces completely out of their 
natural position. The morbid adhesions formed after ulcerative ptyalism generally give 
rise to distressing and often irremediable ankylosis of the temporo-maxillary articulation. 
y. In gout, rheumatism, and other affections, as well as in certain accidents, the motions 
of the joints are occasionally destroyed by the formation of osseous bridges, extending 
across the articulation from one bone to the other. Such an occurrence is most frequently 
met with in the sacro-iliac symphyses, and in the joints of the vertebrae ; it sometimes 
occurs also in the more perfect joints, especially tlie ginglymoid. In fractures, followed 
by exuberant callus, the muscles and tendons, in the vicinity of the neighboring joint, may 
be so completely imprisoned by the new matter as to cause ankylosis of the worst kind. 
6. Ankylosis may be produced, in greater or less degree, by the development of various 
kinds of tumors, or morbid growths, in the neighborhood of an articulation, or in direct 
contact with it, interfering with its functions, and ultimately, if not removed, perhaps 
annihilating them. Thus, an aneurism of the popliteal region may cause stiffness of the 
knee, and a sarcoma of the jaw, partial ankylosis of the the temporo-maxillary joint. 
f. Finally, paralysis of the muscles of a joint may induce a certain degree of ankylosis ; 
cases are constantly observed where, from long disuse of an articulation from this cause, 
its functions are permanently lost. The shoulder-joint frequently becomes stiff' and use- 
less, from palsy of the deltoid interfering with its natural movements. 
It is extremely probable that the most of the causes here enumerated may, if long con- 
tinued, induce permanent ankylosis, in consequence of the operation of the general patho- 
logical law, that, when a part ceases to perform its functions, it gradually degenerates, and 
is ult imately completely deprived of its characteristic attributes. Nature abhors everything 1099 
CHAP. IX. 
NEURALGIA. 
that is useless, and, when a joint is once rendered passive, the synovial membrane, losing 
its secreting faculty, becomes dry, and is at length converted into fibrous tissue. 
The treatment of extraarticular ankylosis must be regulated by our knowledge of the 
nature of the exciting cause, which should, therefore, always be clearly ascertained before 
any attempt be made to interpose any curative agents. Thus, if it be found to depend 
upon contraction of the muscles, tendons, or aponeuroses, whether singly or unitedly, the 
only remedy, in confirmed cases, is their subcutaneous division ; whereas, in recent cases, 
it may often be relieved by a course of friction, douching, and passive motion, aided by 
gentle exercise on the part of the patient. Vicious cicatrices must be cut out, and, if 
possible, replaced by new substance ; such a procedure, however, is not always practicable, 
and, therefore, most cases of this description proceed from bad to worse until they are 
rendered wholly irremediable. Osseous bridges, circles, or bands may occasionally be 
removed w ith the saw and pliers; morbid growths are exsected, or, as in aneurism, the 
artery leading to it is tied ; and paralysis of the muscles is relieved by stimulating fric- 
tions, the cold douche, shampooing, and electricity, the general health being at the same 
time improved by tonics, alterants, and exercise in the open air. 
SECT. X NEURALGIC AND HYSTERICAL AFFECTIONS. 
The joints are occasonally the seat of neuralgia, although not nearly so often as is 
generally imagined, especially if it be regarded as an independent lesion. As a compli- 
cation of coxalgia and other articular affections it is sufficiently frequent. Jt is not 
improbable that in many of the cases in which it is referred to the joints, it is in reality 
situated altogether exterior to them, in the structures immediately around, and not in 
those directly concerned in their composition. Its most common sites by far are the knee 
and hip. As an independent affection, neuralgia is most frequent in young, delicate, 
nervous females, soon after the appearance of the menses, of the derangement of which 
it is occasionally an exponent. No period of life, temperament, habit, or occupation, 
however, is exempt from it. The attacks are sometimes strictly periodical, precisely like 
those of an intermittent fever, coming and going regularly once a day, or every forty- 
eight hours; but more frequently they are irregular, the patient being tormented nearly 
incessantly, the pain being now slight, now severe, and then, perhaps, again entirely 
absent, although never very long at one time. The paroxysms are often coincident with 
neuralgia in other parts of the body, alternating with it, usurping its place, or going on 
with it simultaneously. is either of a dull, heavy, aching character, or sharp, 
lancinating, and darting, dying about in fits and starts, in different directions, almost 
with the rapidity of lightning. It is usually attended with more or less soreness and 
tenderness on pressure, motion, and percussion, and sometimes with a slight degree of 
tumefaction or puffiness of the parts around the affected joint, which often entirely disap- 
pears in the intervals of the attacks. Motion also is usually somewhat impeded, and, 
when the hip is involved, there may even be considerable deformity of the lower part of 
the spine and of the pelvis. In the more aggravated cases the whole limb may be 
swollen, tender, and disabled ; and then there is commonly also a sense of numbness, 
extending to the very extremity of the member. The general health is not always 
appreciably affected; often, how'ever, there is marked disorder of the digestive organs, 
with a sallow state of the skin, headache, constipation, and derangement of the renal 
secretion. In the female the symptoms are often of an hysterical character, and are 
liable to frequent exacerbations in consequence of the peculiar state of the mind, which 
is generally morbidly sensitive, and absorbed in selfishness and disagreeable fore- 
bodings. 
It is of great moment to discriminate carefully between neuralgic and other affections 
of the joints, inasmuch as a wrong diagnosis may lead to serious errors in practice, in- 
ducing, perhaps, the employment of harsh measures when gentle alone are required ; or, 
on the other hand, allowing the patient to move about and exercise the joint when he 
ought to observe the most perfect quietude. In general, the history of the case, the 
peculiar nature of the pain, the suddenness of the attack, the absence of constitutional 
disturbance, and the perfect freedom of motion of the affected joint, when the surgeon 
takes hold of the limb and attempts to carry it about in different directions, especially 
when the patient is under the influence of anaesthesia, will serve to distinguish it from 
organic disease of the articulations. When, however, there is any doubt respecting the 
real nature of the complaint, the examination should be repeated again and again, and 1100 
DISEASES AND INJURIES OF THE JOINTS. 
CHAP. IX. 
varied in every possible manner, so as to elicit the true state of the case. In many 
instances the best diagnostic is the success or failure of antineuralgic remedies. 
In the treatment of articular neuralgia the first object should be to ascertain, if possible, 
the nature of the exciting cause, and then to direct our remedies accordingly. Attention 
to the diet, bowels, and secretions should, throughout, be kept prominently in view. The 
malady very often has its origin in a vitiated state of the alimentary canal, or in the sup- 
pression of some important habitual discharge, by correcting or restoring which the 
symptoms frequently disappear without any further effort. In general, however, anti- 
neuralgic remedies, properly so called, will be needed, and of these the best, unquestion- 
ably, are quinine, strychnia, and arsenious acid, in doses varying from three to five grains 
of the first, with the sixteenth of a grain of the second, and the tenth of a grain of the 
last, three times daily. When there is marked evidence of anemia, iron may be advan- 
tangeously combined with these articles. If, on the other hand, the patient is plethoric, 
from the sixth to the eighth of a grain of tartar emetic may be added to each dose, with 
a view to its relaxing and diaphoretic effects. Morphia also forms a valuable adjuvant, 
and can rarely be dispensed with. Colchieum often proves very serviceable, affording 
prompt relief when everything else fails. It is particularly valuable when the disease 
partakes of a rheumatic or gouty character. 
As topical remedies the most reliable are, soap liniment, with a liberal addition of 
laudanum and chloroform, kept constantly upon the part with a piece of flannel; the 
steam of hot water, conveyed to the joint from a tube connected with a boiler near the 
bed; frictions with atropia, veratria, or aconite ointment ; and the employment of 
electricity. Leeches may be used when the articulation shows evidence of being in- 
flamed, although they will generally be found to afford only very transient relief. Motion 
of the affected limb, especially in protracted cases, is usually highly beneficial, and should 
not be neglected. 
The hysterical form of this affection appears to be much more common in England than 
in America, where, judging from personal observation, it is quite infrequent, both in town 
and country. Sir 11. C. lirodie, who was the first to call attention to it, declares that, 
among the higher classes of society in London, at least four-fifths of the female patients, 
supposed to labor under disease of the articulations, labor merely under hysteria. The 
pain, generally excessively severe, is aggravated by the slightest motion and pressure, and 
is usually confined to one particular spot, from which, however, it is liable to shift to other 
points. It is frequently associated with exquisite morbid sensibility of the surface, and 
is commonly located, not in the joints, but in the parts aroupd them ; often, indeed, appar- 
ently in the skin, or in the skin and muscles. Spinal irritation often exists, the extremi- 
ties are cold, the pulse is small and feeble, the countenance is pale, the breathing is, at 
times, much embarrassed, the bowels are irregular, and the stomach is oppressed with 
flatulence. The disease is most common in young girls soon after the age of puberty. 
Intense pain is sometimes experienced in the joints, especially in the ilio-femoral, as a 
residt of endometritis. A probe introduced into the womb causes excessive suffering, 
darting with the rapidity of lightning into the hip, groin, and pelvic region. Occasionally 
a certain amount of tumefaction exists, but, generally, the parts have a perfectly normal 
appearance, and hence the true nature of the case is seldom fully comprehended by the 
professional attendant. 
In the treatment of this disease assabetida and valerian often prove highly efficacious, 
especially if combined with chalybeate tonics. When the disease is associated with dis- 
order of the menstrual function, great advantage will generally accrue from an occasional 
aloetic purge and the steady use of the compound iron mixture. Bromide of potassium, 
in large doses, is an excellent remedy, particularly serviceable in cases attended with loss 
of sleep and general nervous disorder. Chloral, too, often affords great and immediate 
relief. In many cases these two articles may be advantageously exhibited together. Mono- 
bromide of camphor, in doses of three to five grains, twice a day, occasionally affords 
marked benefit, and is sometimes highly efficacious. The cold bath, change of air, resi- 
dence at the sea shore, and exercise on horseback, are often serviceable in effecting relief, 
lirodie relates a number of cases in which the disease was almost cured by an accident, 
as a fall or blow upon the affected articulation. The suffering of the joints, dependent 
upon endometritis, always promptly disappears upon the removal of the exciting cause. CHAP. IX. 
DISLOCATIONS. 
1101 
SECT. XI.—DISLOCATIONS. 
1. GENERAL CONSIDERATIONS. 
A dislocation, or luxation, is the sudden and forcible removal of one articular surface 
from another, either as an effect of external violence, of inordinate muscular contraction, 
or of a diseased condition of the component structures of the affected joint. 
As all joints are necessarily composed of two or more bones, the question naturally 
arises, which should be considered as the luxated one? Upon this subject all surgical 
authorities are, I believe, agreed. In every accident of this description the bone nearest 
the trunk is regarded as the fixed bone, and the one articulated with it as the dislocated. 
Thus, in luxation of the shoulder-joint, the scapula retains its normal position, either 
actually or supposititiously, while the humerus is thrown off the glenoid cavity, at one 
time in this direction, and at another in that. In dislocation of the elbow, the ulna and 
radius are forced away from the humerus, the latter serving as the fixed point. The same 
rule obtains in regard to all the articulations of the inferior extremity. 
Dislocations are divisible into simple and complicated, complete and incomplete, primi- 
tive and consecutive, recent and old, single and double. When the accident occurs before 
birth it is designated by the term congenital. 
A luxation is said to be simple when it is unaccompanied by anything more than a 
slight rupture of the ligaments, or of the ligaments and muscles. Although such an acci- 
dent is usually produced by external force, as a blow or fall, it may occasionally arise 
purely from muscular, action, especially when it is favored by disease of the affected 
joint. 
In a complicated dislocation there is, in addition to the loss of relation between the two 
contiguous surfaces, some serious lesion of the soft parts, as, tor example, a wound com- 
municating with the displaced bone or opening directly into the articulation, laceration of 
important vessels or nerves, contusion of the skin and muscles, or fracture of the luxated 
bone. When the wound penetrates the affected joint, the accident is usually called a 
compound dislocation. 
A complete luxation is one in which the head of a bone, totally removed from its cor- 
responding articular surface, effects a lodgment in a new situation, as, for instance, when 
the head of the humerus is forced down into the axilla, resting against the border of the 
scapula, below the glenoid cavity. In an incomplete luxation, on the contrary, the articu- 
lar surfaces, although they have lost their relative position, remain still partially in contact 
with each other. 
In primitive dislocation, the displaced bone remains in the position into which it was 
originally forced ; in consecutive, it abandons its first situation, and is fixed in another. 
Such an accident, however, can oidy happen, as a rule, when the luxation depends upon 
some organic disease of the articular surfaces, allowing them gradually to separate from 
each other, either by the mere weight of the corresponding limb, or by the action of the 
neighboring and associated muscles. In the traumatic form of the injury such an event 
must be exceedingly rare, although we must admit its possibility, the dislocating agent 
forcing the bone at once to the greatest verge of its displacement; or, as not unfrequently 
occurs, its further progress is effectually arrested by some opposing osseous prominence or 
some tensely strung soft part, as a tendon, muscle, or fibrous membrane. Luxation of 
the knee-joint from caries of the articular surfaces furnishes a characteristic exemplifica- 
tion of these two kinds of displacement. In this accident the head of the tibia gradually 
forsakes the condyles of the femur, slipping back into the popliteal region, whence, in 
time, it is- drawn up against the posterior surface of the bone by the flexor muscles, thus 
suffering secondary luxation. A similar occurrence, although exceedingly uncommon, 
may, nevertheless, happen in a very robust subject in traumatic dislocation of the hip, 
shoulder, or lower jaw, where the force is barely sufficient to lift the head of the bone out 
of its socket upon, but not over, its rim, from which it is afterwards removed either by 
mere muscular contraction, or by the conjoint influence of this and the weight of the part 
connected with the displaced bone. 
The terms recent and old refer merely to the duration of the injury, and might seem, 
at first view, to require no particular explanation. The propriety of this, however, will 
be rendered at once obvious if the question be asked, when does a dislocation become 
old? does it become old in a few days, or weeks, or months? So far as mere time is 
concerned, no lesion of this kind can be regarded as old unless it has existed for at least 
from six to twelve months ; but if we look at the subject in reference to the ability of the 1102 
DISEASES AND INJURIES OF THE JOINTS. 
CHAP. IX. 
surgeon to restore the affected joint to its natural relations, it will be found that, while 
one dislocation may not be old at the end of several months, another may become so 
within the first few weeks. Thus, a luxated shoulder may frequently be successfully 
reduced after a lapse of two months, or even considerably later, whereas if an attempt be 
made to restore a dislocated elbow at the end of one-third or even one-fourth of that time, 
signal failure will generally follow. The import of these two terms, then, is one of much 
greater importance than has commonly been admitted, having, practically considered, a 
positive value and significance. 
A single dislocation is one in which only one joint is involved ; in the double form of 
the accident, on the contrary, the corresponding joint is likewise affected. The lower 
jaw suffers more frequently in the latter way than any other bone, but a similar displace- 
ment is also occasionally witnessed in the humerus, ulna, radius, clavicle, femur, and 
fibula. Double luxations may be complete or incomplete, simple or complicated. 
Joints which a