ETTrimmmrfpr: m SURGEON GENERAL'S OFFICE LIBRARY. Section... No. 113, NO W.D.S.G.O. ' a-6i3 / < m . m s * * ..a < 1 ft • i m X ELEMENTS OF SURGERY: In ROBERT LISTON, SURGEON TO THE NORTH LONDON HOSPITAL, PROFESSOR OF CLINICAL SURGERY, ETC., ETC., ETC. FOURTH AMERICAN FROM THE LAST LONDON EDITION, WITH COPIOUS NOTES AND ADDITIONS, BV SAMUEL D. GROSS, M.D. PROFESSOR OF SURGERY IN THE MEDICAL INSTITUTE OF LOUISVILLE, SURGEON TO THE LOUISVILLE MARINE HOSPITAL, ETC., ETC. LIBRARY , .... di'N.-aa-iHu-- ; JMustrateji / H ^) Gd J ^) . j WITH NUMEROUS ENGRAVINGS UMlatreljmfa: ED. BARRINGTON AND GEO. D. HASWELL, LOUISVILLE, KY. — JAMES MAXWELL, JR. 1846. WO [Entered, according to Act of Congress, in the year 1846, by Barringtojj & Haswell, in the clerk's office of the District Court for the Eastern District of Pennsylvania.] TO WILLARD PARKER, M.D., Professor of Surgery in the College of Physicians and Surgeons in the City of New York, THIS EDITION OF MR. LISTON'S WORK Es EnscrfbeU, AS A TESTIMONIAL OF RESPECT FOR HIS UNTIRING ZEAL IN SURGICAL PURSUITS, AND OF ESTEEM FOR HIS PRIVATE VIRTUES, BY HIS FRIEND AND FORMER COLLEAGUE, THE EDITOR. 6 PREFACE. it. His " Medicine Operatoire" is nothing but a vast storehouse of research, to which pompous doctors may resort for ancient lore, and prosing teachers for materials for instruction. It details with end- less minuteness the operative methods of every surgeon, great or little, from the age of Hippocrates to the present period, with their various modifications and improvements, not forgetting the " appre- ciations" and labours of the able professor himself. Such produc- tions are well enough in their way ; they form good books of refer- ence, and serve to give us an idea of the rise and progress of sur- gery. Beyond this, however, they are of comparatively little utility ; the great mass of the profession is no more benefited by them than if they had never been written ; few read them, and still fewer un- derstand them. This attempt at erudition pervades, if I mistake not, almost every recent publication on surgery in the French lan- guage. Dupuytren alone is free from it. His writings breathe throughout a different and more independent spirit: he speaks like one accustomed to act and to think for himself; and the result is, that he has accomplished more for French surgery than any other Frenchman since the days of Ambrose Pare. The first edition of the present Treatise was published at Edin- burgh in 1831, some time prior to the author's removal to London. It was originally comprised in three volumes. A second impression, of which this is a reprint, appeared at London in 1840, in a revised and improved form. The favourable reception which the publica- tion has met with in this country, and the desire I have felt to in- troduce it, as a text-book, into the school with which I am connected, have induced me to prepare it for the American press with particular care. Among the additions, properly so called, is an article on Strabismus, and another on Club-foot; two subjects, the former of which was entirely omitted in the English edition, and the latter discussed in a manner altogether incommensurate with the existing state of our knowledge in regard to it. The notes are designed to serve as further illustrations of the text, or to supply deficiencies in relation to certain topics which have been passed lightly over by the author. They might have been extended to almost any number, and it would have afforded me no ordinary gratification, had it been con- sistent with the views and interests of my publishers, to present what might be considered as a tolerably fair outline of American surgery. For such an object ample materials are extant, highly valuable in themselves, and eminently calculated, when they shall be properly embodied, to reflect credit upon the talents, enterprise, and dexterity of out surgeons. It need hardly be added, what is self-evident, that the editor of a work is responsible to the public only so far as his own labours are concerned. He adops only in a general manner, without endorsing all, the views and opinions of his author. S. D. GROSS. Medical Institute of Louisville, May, 1842. PREFACE. The rapid advancement made in the pathology and treatment of surgical diseases demands a perpetual revision and correction of the systematic works devoted to this department of the healing art. Accordingly, text books, various in merit and extent, have ema- nated from the different schools. Several of these have, by suc- cessive editions, kept pace with the science; whilst others have fallen into disuse. In this part of Britain, the systems of Latta, B. Bell, and Allan, occupied the field ; but it being now vacant, I venture to supply the deficiency, by reducing the heads of my lectures into a compen- dium, or guide, for those students who resort to this city. It must appear superfluous to preface such a work by anatomical descriptions, anatomy being now studied more generally, and with greater zeal, than heretofore. Pathology also is more attended to, and better understood. To which circumstances are to be ascribed the improvements in surgical science, as well as in the art of operating. The functions and structure of parts are more frequently preserved uninjured — mutilation is more rarely required — and operations are dispensed with. The wider the extension of pathology, the fewer the oprations will be — thus affording the best criterion of profes- sional attainment. Who will question, that there is more merit in saving one limb by superior skill, than in lopping off a thousand with the utmost dexterity ? To treat surgical diseases as they ought to be treated, the prac- titioner must be thoroughly acquainted with the healthy and morbid structure ; he must also have a mind vigorous and firm from nature, well instructed in the best precedents, and matured by observation. Years are not the measure of experience. It does not follow, that the older a surgeon is, the more experienced and trustworthy he must be. The greatest number of well-assorted facts on a particular subject constitutes experience, whether these facts have been culled in five years or in fifty. It is only from experience, directed and aided by previous study, that accuracy of diagnosis and celerity of decision can be acquired. Besides knowing in what manner to proceed, the surgeon must know well wherefore he acts, and also the precise time at which he should interfere. With knowledge and confidence derived from experience, he will perform such operations as are indispensable for the removal of pain and deformity, or for the preservation of life, with calmness and facility—with safety to his patient, and satisfaction to those who assist in, or witness, his proceedings. Attention to the apparatus is necessary. It should be in good order, simple, and ample. The young surgeon should note down, previously to an operation, whatever, on reflection, can possibly be 8 PREFACE. required. " For in most capital operations, unforseen circumstances will sometimes occur, and must be attended to ; and he who, with- out giving unnecessary pain from delay, finishes what he has to do in the most perfect manner, and that most likely to conduce to his patient's safety, is the best operator." It is seldom necessary to employ much preliminary treatment. From the usual preparative course of bleeding, purging, cooling diet, etc., patients about to undergo capital operations, as lithotomy, suffer more than they can gain. It is of the utmost importance to attend to the state of the patient's mind and feelings. He ought not to be kept in suspense, but en- couraged and assured ; and his apprehensions must be allayed. If this cannot be effected — if he is dejected and despondent — talks of the great risk, and of the certainty of his dying, it is better that the operation be abandoned, or at least delayed. If, on the con- trary, he is confident in the resources of his constitution, and in the ability of his attendant, and looks forward to the advantage to be derived from his own fortitude, then should there be no delay. A mild laxative maybe given, when an empty state of the bowels is desirable, or when they, by acting too soon afterwards, might put the patient to inconvenience or pain, or interrupt the curative process. Attention to after-treatment is of much greater importance. The practitioner is not to rely on success, however well the manual part has proceeded. He must consider his labour only begun, when the operation has finished ; the patient is yet to be conducted, by kind- ness and judgment, through the process of cure. It is thus only that difficult and unpromising cases can be brought to a happy conclusion, and favour and lasting reputation gained. In the present work an endeavour has been made, in the first place, to lay down, correctly and concisely, the general principles which ought to guide the practitioner in the management of consti- tutional disturbance, however occasioned. The observations introduced to illustrate the doctrines inculcated are given as briefly as is consistent with an accurate detail of symp- toms and results. The descriptions of particular diseases have been sketched and finished from nature ; and, it is hoped, with such fidelity, that their resemblance will be readily recognised. To describe all the methods recommended and followed, in the different surgical operations, would occupy more space than can be allotted in an elementary work — would, without answering any good purpose, lead into the wide range of the history and progress of surgery. Such modes of operating are described as have been repeatedly and successfully performed by the Author. If by clear and simple description of the phenomena attendant on morbid action, and of the changes which it produces, — if by. plain rules for the treatment of the diseases, and performing the operations for their alleviation or cure, — he contribute to the progress of sur- gery, and the consequent diminution of human misery, he will con- sider himself fully rewarded for the time and the labour spent on this production. CONTENTS. PART FIRST. PAGE Inflammation ; . . 13 Signs . . • 14 Irritation .... 20 Termination of Inflammation . 25 Adhesion . 25 Suppuration . 29 Mortification 43 Erysipelas . , 54 Furunculus and Anthrax . 64 Inflammation of Mucous Mem- branes .... 66 Inflammation of Serous Mem- branes .... 67 Inflammation of Joints 69 Hypertrophy and Atrophy of the Articular Cartilages, with Ebur- nation . . .76 Scrofulous Disease of Joints . 78 Neuralgic Affections of Joints . 79 Growths from the .Synovial Mem- brane and Loose Substances in Joints ... 80 Affections of Bursas . . 82 Coxalgia ... 83 Alterations of Form in the Head of the Femur . . 88 Inflammation and Diseases of Bone 97 Suppuration in Bone . 98 Caries . . .99 Necrosis . . 106 Fragilitas Ossium .112 PART ries of the Head . 220 Wounds of the Scalp 220 Wounds of the Temporal Artery . 221 Concussion . 223 Compression 231 Fractures of the Cranial Bones 232 W7ounds of the Brain 237 Hernia Cerebri 238 Perforation of the Cranium 240 PAGE Mollities Ossium, Rachitis, &c 113 Arterial System, Affections . 119 Aneurism 121 by Anastamosis . 131 Inflammation of Veins 134 Tumours . . 138 Adipose 141 Fibrous. . 142 Encephaloid 143 Melanoid . 145 Carcinomatous 146 Fungus Haematodes . 151 Painful Tubercle 153 Polypus . . 154 Encysted Tumours . 155 Tumours of Bones . 156 Osteosarcoma 158 Spina Ventosa . . 160 Aneurismal 161 Osseous . 162 Hydatic 164 Wounds . . 167 Tetanus 186 Ulcers . 189 Hospital Gangrene 194 Sloughing Phagedena . 194 Malignant Pustule 197 Ulcers on the Genital Organs, \ vith their Consequences 198 Scalds and Burns . 214 Inflammation of the Scalp . 243 Thickening of the Scalp . 244 Tumours of the Scalp . 248 Diseases of the Eye and its Ap- pendages . . . 249 Inflammation and Abscess of the Lachrymal Passages . 249 Inflammation of the Lachry- mal Sac . . . 250 Fistula Lachrymalis . 252 ECOND. 10 CONTENTS. PAGE Encanthis . . . 256 Encysted Tumours of the Eyelids . . .257 Closure of the Eyelids . 258 Ectropion . . . 258 Entropion . . 260 Trichiasis . . .260 Pterygium . . 261 Diseases of the Eyeball : . 262 Ophthalmia . . 262 Purulent Ophthalmia . 264 Staphyloma . . 266 Inflammation of the Cornea . 266 Pustular Ophthalmia . 267 Ulcers of the Cornea . 268 Leucoma. . . 269 Hernia of the Iris . . 269 Albugo . . .269 Nebula . . .269 Ophthalmia Tarsi . 270 Staphyloma . . . 270 Hydropthalmia . . 277 Exophthalmia . . 277 Internal Ophthalmia . 277 Iritis . . .277 Hypopium . . 278 Choroiditis . . . 279 Amaurosis . . 280 Glaucoma . . . 282 Cataract . . . 282 Artificial Pupil . . 292 Wounds of the Eyeball . 293 Orbital Inflammation . . 295 Tumours in the Orbit. . 295 Strabismus . . . 297 Nasal Polypi . . . 306 Malignant Polypi . . 308 Nose, and Nasal Cavities, Inflam- mation, &c. . . . 313 Noli me tangere . . 315 Ozcena . . . 315 Rhinoplastic Operations . 317 Inflammation of the Antrum Max- illare . . . 322 Lips, Ulcers . . . 324 Congenital Deficiencies . 327 Palate, Congenital Deficiencies . 327 Soft Palate, Tonsils, &c, Inflam- mation, &c. . . . 330 Elongation and Enlargement of the Uvula . . . 332 Chronic Enlargement of the Ton- sils . . . .333 Ulcers of the Palate, &c. . 334 Tongue, Ulcers . . . 335 Inflammation . . 337 Division of Fraenum . . 339 Salivary Ducts, Diseases . 339 Ranula . . .339 Gums, Diseases . . 343 Teeth, Diseases . . 344 Extraction of . . 346 Salivary Ducts, Diseases. Lower Jaw, Diseases Disarticulation Wounds of the Face and Neck . Larynx and Trachea, Diseases Foreign bodies Tracheotomy Pharynx, Diseases Foreign bodies . GEsophagotomy . Ear, Diseases of Foreign bodies Polypus . Deafness .... Bronchocele . Glandular Tumours in the Neck Hydrocele of the Neck Distortion of the Neck Venesection in the Jugular Vein Ligature of the Carotid Artery Arteria Innominata Subclavian Artery Axillary Artery . Brachial Artery Humeral Artery . Wounds of the Palmar Arches . Paronychia or Whitlow Onychia .... Collections in Thecae Ganglia .... Venesection, bend of the arm . Mamma, Diseases Encysted Tumours . Affections of the Chest . Hydrothorax . . Empyema Wounds . Affections of the Abdomen Hernia . Congenital Scrotal Hernia . Hernia Infantilis Inguinal Crural or Femoral Ascites . . Ovarian Dropsy . Artificial Anus Bruises of the Abdomen Wounds of the Intestines Lumbar Abscess Spina Bifida Affections of the Rectum and Neighbouring Parts Hemorrhoids or Piles Distinct Varieties . Inflammation of the Rectum Fistula Stricture . Schirro-contracted Rectum . Prolapsus Ani Treatment of Affections of the Rectum Pruritus of the Rectum . PAGE 346 350 352 359 367 368 372 375 377 378 379 380 380 382 384 385 386 389 390 391 392 397 397 399 399 400 403 405 406 408 410 413 414 414 414 416 416 417 418 418 419 420 447 448 438 451 452 462 464 465 465 466 467 469 471 472 473 474 479 CONTENTS. 11 PAGE PAGE Neuralgia of the Rectum 480 Ligature of the External Iliac 562 Affections of the Mucous Mem- Femoral . 563 branes of the Urinary and Ge- Aneurismal Varix in the Thigh 564 nital Organs 481 House-Maid's Knee 565 Gonorrhoea 481 Cartilaginous Bodies in the Knee- Hernia Humoralis 487 joint .... 566 Inflammation of the Bladder 488 Distortion of the Feet 567 Irritable Bladder 490 Varus 569 Stricture of the Urethra . 490 Valgus . 570 Fistula in Perineo 492 Pes Equinus 570 Retention of Urine 492 Calcaneal 571 Incontinence of Urine 509 Exostosis of Distal Phalanx 574 Gonorrhoea Praeputialis 512 Fractures 575 Phymosis 513 of the Cranium and Face 581 Paraphymosis 513 Spinal Column 583 Hyospadias and Epispadias 517 Clavicle . 587 Chimney-sweeper's Cancer . 517 Ribs . 589 Hydrocele 518 Shoulder . 590 Cirsocele 523 Humerus 592 Haematocele 525 Olecranon 594 Sarcocele 527 Forearm 595 Castration . 529 Pelvis and Lower Calculus Vesicae 530 Extremity . 597 Lithotrity 539 Femur 598 Lithotomy 541 Patella 604 Calculus in the Female . 552 Leg 606 Gonorrhoea in Females 553 Disunited Fracture 609 Gonorrhceal Lichen 554 Dislocations 612 Retention of Urine in Females 555 Lower-Jaw 614 Vesico-vaginal Fistula 556 Upper Extremity 615 Imperforate Vagina . 557 Lower Extremity 623 Contracted Vagina 558 Sprain .... 630 Inflammation of Vagina 558 Bruise 634 Polypus Vaginae . 559 Amputation 635 Diseases of the Uterus 560 Excision of Portions of Diseased Ligature of the Common Iliac Ar- Bones .... 656 tery 561 Excision of Joints 659 Ligature of the Internal Iliac 561 ELEMENTS OE SURGERY, PART FIRST. OF INFLAMMATION. There are few accidents or diseases, to which the human body is liable, which are not preceded or followed by incited action, in- creased circulation, and accumulation of blood in the capillary ves- sels of the part affected ; and these phenomena require to be very attentively studied, and correctly understood, by all who propose practising the healing art. As all the salutary as well as diseased processes which occur in the human body are more or less attended or affected by this action, and as its regulation forms a principal part of the duty of the surgical practitioner, this work cannot be more properly commenced than by treating of its nature, consequences, and management. Inflammation may be defined to be, an unnatural or perverted ac- tion of the capillary blood-vessels of an organ or part of the body, attended with redness, throbbing, swelling, pain, heat, and disorder of functions, as well as with more or less disturbance of the system. Every part of the body is liable to inflammation ; and some wri- ters have divided this action into different kinds, according to the particular tissue which it chiefly involves. But it appears to be al- ways of the same character, though modified by various circum- stances, such as the tissue in which it occurs, the state of the consti- tution, the exciting cause, and the intensity of the action. The usual division of the subject, into Acute and Chronic, is that which it is here proposed to adopt. The term Chronic Inflamma- tion is more properly applicable to a consequence of the Acute: but it is at the same time true, that morbid actions proceed more slowly in some constitutions, and in some parts of the body, than in others; and that changes of structure and morbid products, such as generally result from inflammatory action, even occasionally occur, without the prominent symptoms of inflammation being experienced by the pa- tient or detected by the practitioner. The term Morbid is used in contradistinction to what is called Healthy Inflammation ; but inflammatory action is generally con- nected, more or less, with a diseased or disordered state of some part 2 14 OF INFLAMMATION. of the body. In many circumstances it is highly necessary that a certain degree of incited action of the vessels should occur, and con- tinue for a certain time; as during the uniting of fractures, the adhe- sion of wounds, and the healing of some sores— and thus far it is healthful: when, however, the action becomes excessive, it must, for this reason, be considered morbid, as it frustrates the natural re- parative process; if the action, in fact, proceeds farther than is ne- cessary for reparation, it becomes a disease, and leads to absorption or destruction of parts. In animals possessing the greatest powers of reparation, inflammation, it appears, does not take place at all, or is very slight, and scarcely ever proceeds to suppuration. Redness is the first sign of inflammation to be considered ; this is observed, in the living body, on the surface, or at the extremities of those canals which terminate externally. The inflamed conjunctiva affords a conspicuous example of this appearance. In a subject that has suffered from an internal inflammatory attack, a good opportu- nity is frequently afforded of observing the enlarged and injected state of the vessels on which the red colour depends. But inflam- mation may have existed to a certain degree, and yet the parts may be pale, from the capillaries having emptied themselves into the veins immediately after the patient's death. The paleness may be also in part caused by the influx of the red globules being impeded immediately after death, or when the patient is in articulo mortis, in consequence of the contraction of the vessels, which is well known to occur at that period. It has been said that redness is not essential to inflammation ; for serous vessels may be altered in size and function by this action, and yet not be sufficiently dilated to receive the red globules of the blood. And, again, that serous vessels may be enlarged so as to admit the red globules: and a part that is colourless when in the healthy state may, in consequence, assume a highly red hue when in an inflamed condition. This may be observed in the cornea lucida, which, when violently inflamed, is pervaded by numerous vessels, visible to the naked eye, distended with red blood, ramifying over the whole of it, and freely inosculating with each other. Some have even supposed that these vessels are newly formed, in consequence of inflammatory action. This opinion is, however, erroneous; as the vessels existed in the cornea previously, and are only increased in size, so as to admit of the accumulation of a sufficient number of red particles to render the vessels visible. The speedy, and, in many cases, instantaneous appearance of red vessels where they could not previously be observed, decidedly overturns the opinion that new vessels are in such a case formed. New vessels are seldom formed unless after a breach of structure, or in cases where morbid deposits become vascular. There is no proof of the existence of mere serous vessels in the human body, as any one may ascertain who is accus- tomed to examine the capillaries with a good microscope. Vessels which are so small as to admit only a very few, say one, or at most two rows of globules, would, of course, appear colourless, and these are what have been called serous vessels. The globules of blood are so small as to be invisible to the naked eye; and vessels carrying OF INFLAMMATION. 15 only one series of them would appear colourless. No vessels belong- ing to the sanguiferous system have ever been observed less in cha- racter than a blood globule ; and this, so far as I have been able to observe, is, as nearly as possible, j^ part of an inch. They ap- pear to be flattened discs; and whether those of the human body have a central nucleus or not, seems, as yet, very doubtful. The globules are here shown upon a scale of p-r part of an inch, 4000 r_ # ' linear, and in different positions. They are represented, as seen in the greater number of microscopes, having a central nucleus. Whe- ther, in the blood of mammife- rous animals, or not, this is an opti- cal deception, is not very clearly made out; but in that of reptiles the nucleus is easily demonstra- ble. The redness then is not from error loci, or in consequence of red particles flowing where none flowed before, but from the capil- laries becoming distended and dilated with an unusual quantity of blood, which is stagnated in the central part of the inflamed neigh- bourhood, the inflammatory focus. Throbbing, to a greater or less degree, is always felt in an inflamed part by the patient; and it is frequently so distinct as to be readily perceived by an attentive examination. This arises, probably, from the stagnation of blood in the vessels of the part over-excited, and principally affected by the disease or injury, causing an increase in the collateral circulation ; and it is this rapidly increased action around that gives rise to the signs and symptoms, and constitutes, in point of fact, what is known and recognised as inflammation. The sensation of throbbing is not, however, produced entirely by the ac- tion of the capillary vessels, but in consequence, also, of the larger trunks in the neighbourhood sympathising with these capillaries, and so having their action increased also. The obstruction of the capil- laries in the early stage of inflammation must necessarily cause a greater force of the heart to be expended on the trunks leading to such capillaries; hence the greater impulse and velocity of blood in the circumferential and patent vessels. In fact, when the inflammatory action is extensive or severe, or when the part affected is of much importance to life, the whole circulating system is disturbed, and thus arises the sympathetic excitement of the constitution. The incited action of those vessels in the more immediate vicinity of the inflamed part is well marked in cases of Paronychia. There the digital, the radial, and ulnar arteries, with their branches, beat more violently than usual; and with much greater force, though not more rapidly, than the vessels in other parts of the body. Swelling is caused by the enlarged and overloaded vessels relieving themselves by effusion of part of their contents into the surrounding cellular texture. The effusion varies in extent and consistence, ac- cording to the degree of inflammatory action, and the species of re- sistance offered; at first it is serous, then mixed with fibrin, and con- 16 OF INFLAMMATION. sequently spontaneously coagulable. Cceteris paribus, the &„ the resistance, the less the effusion, and the more violent the inna - matory action ; the chance of its speedy and favourable termination is also more diminished. Even the enlargement of the blooa-vessels produces a certain degree of intumescence previous to effusion. relief to the vessels by effusion giving rise to swelling, when it occurs in loose cellular tissues, may be considered as a beneficent provision of nature. But in vital organs it may be productive of the most serious consequences; as in these, very slight effusion will often en- danger the structure of the organ, destroy its functions, and not un- frequently be attended with fatal consequences. The nature of the effused fluid varies according to the degree of violence and advancement of the action, and is also modified by the texture in which that action occurs. It may consist of serum, lymph, blood, or pus. In inflammation, in short, exhalation, though at first diminished, is soon much increased, whilst the powers of the ab- sorbent vessels are diminished, or at least do not maintain their usual relation to those of the exhalants. Pain is the next symptom enumerated. Here the very common error of supposing that where there is pain there must always be in- flammation may be noticed. Some diseases attended with the most acute pain, as Tic Douloureux and Cramp, are generally unattended with inflammation. Many chronic diseases, too, are accompanied with violent and long-continued paroxysms of pain, without excited circulation of the part. This erroneous opinion often gives rise to highly prejudicial pro- ceedings, as—the exhausting, by copious depletions, the vital powers of patients, already enfeebled by continued disease or treatment — the consequent aggravation of the urgent symptoms — and, the then only termination of the disease and of the practice, death. Again, it is true that we must bleed, in some cases, w-ith the view of preventing the occurrence of inflammation ; yet the prophylactic treatment may be carried too far, as in cases of violent injuries, or after severe operations. In these instances, the immediate abstrac- tion of blood, so far from being beneficial, expedites the dissolution of the patient, or at least greatly retards the cure. Pains arising from local irritations are often treated in a similar way, whilst the re- moval of the cause would be much more likely to restore the natural action of the parts. Though inflammation does not always accompany the sensation of pain, yet the latter, in a greater or less degree, attends inflammatory action; and, perhaps, it is fortunate that it does so. Because, were it not for the occurrence of pain, the patient's attention would not be directed to the disease; he would continue to use the part as if in health, and the affection would thus be much aggravated. Whereas according to the existing provision of nature, pain is felt at the com- mencement of the action, the presence of which the patient is thereby made aware of; and he is compelled to employ such measures for its removal as reason naturally dictates, of which none is more effec- tual than disusing the affected part. The nerves are thus the safe- guards of the various parts of the body in health — their nurses in OF INFLAMMATION. 17 disease. A part deprived of sensation may be used, even to the de- struction of its texture, without producing any impression on the sen- sorium, and consequently without the animal being conscious of it. The presence of pain, as a symptom of inflammation, may be easily explained. The connexion of the vascular with the nervous system is very constant and intimate. Their ramifications accompany each other, and are contained in the same cellular sheath; and without the reciprocal influence of each, neither could perform its functions perfectly. By injecting a limb soon after its separation from an ani- mal, and before its vital heat has departed, spasms of all muscles are sometimes produced ; showing the intimate connexion between these two systems. This, however, is distinct from the contractions of the muscular fibre produced by the application of stimuli. In the former case, the contractions are universal, and induced through the medium of the nerves. In the latter, the irritability of the fibre is excited. When the circulation is excited, the nerves accompanying the af- fected vessels are unusually compressed, and over-stimulated by the circulating fluid, in which, probably, some change takes place, and in this manner unnatural impressions are produced ; the nerves them- selves are likewise the seat of disease, in consequence of the en- largement of the minute capillaries which permeate them. Over- distention of the coats of the vessels may also be supposed to give rise to painful feeling, independently of any affection of the accom- panying nervous trunks. The degree of pain is generally in proportion to the sensibility of the part when in health; it also depends upon the distensibility of the parts affected, and on the intensity of the inflammatory action.- When bones, tendons, &c, which in their uninflamed state are nearly insensible, become inflamed, the painand sufferings are most excru- ciating, owing to the resistance opposed to the dilatation of the ves- sels, and the prevention of the effusion by which they naturally re- lieve themselves- The kind of pain also varies, in consequence of different modi- fications in the action causing different impressions on the sensorium. Pain is not always increased in proportion to the natural sensi- bility of the part; for in some instances the sensibility is rendered much more intense, while in others it is much obtunded. [In the cellular tissue the pain is acute and throbbing ; in the pleura, sharp and lancinating; in the lungs and glandular organs, obtuse and heavy ; in the skin, prurient and smarting; in the bones, dull and gnawing. Sometimes it is persistent, sometimes intermittent, sometimes periodical; and occasionally, again, it is felt at parts very remote from the one originally and mainly affected. Of the latter variety we have a familiar instance in the hip-joint disease of children, in which the earliest symptom complained of is pain in the corresponding knee. In hepatitis, the right shoulder is often the seat of the suffering; in cystitis, the head of the penis.] The last, and, according to some waiters, the only unequivocal symptom of inflammation, is Heat. In extravasation of blood into the cellular texture, as under the conjunctiva, there is redness, swell- 2* 18 OF INFLAMMATION. ing, and occasionally pain; but at first, and unless the action of the blood-vessels be excited, there will be neither heat nor throbbing. In many internal inflammations heat is much complained of; and in Enteritis it has been considered a pathognomonic symptom. [Mr. Hunter endeavoured to settle this point by experiments on the inferior animals. With this view, he made a wound in the right side of the chest of a dog, and placing the thermometer in contact with the diaphragm, ascertained that the temperature was 101.° A large dossil of lint was then thrust into the opening, when the edges were drawTn together with adhesive strips. On the fol- lowing day, wrhen the parts were in a state of inflammation, the foreign substance was removed, and the instrument being again in- troduced, no difference of heat was found to exist. Similar experi- ments were made on the rectum and vagina of an ass, writh like re- sults. Hence Hunter concluded that there was no real increase of temperature. From more recent researches, howTever, it is obvious that this inference of the great English surgeon is at variance with facts. Thus, in erysipelas, furuncle, and anthrax, the thermometer has been observed, in numerous instances, to rise as high even as 107°, being an increase over the average heat of the blood of eleven degrees. Results of a similar nature have been noticed in tetanus, acute rheumatism, and other maladies.] The signs, symptoms, and consequences of inflammation — and amongst others, heat — are modified by the distance of the affected part from the centre of circulation. All actions, healthy, as well as morbid, proceed with more vigour in the superior extremities — in the head, the neck, and the trunk, than in the more remote parts of the body ; for to the former the blood is transmitted more speedily, if not in greater quantity, and is not so liable to be impeded in its return. Hence an arm may bear up under a severe injury, wThich, to an inferior extremity, would prove inevitable destruction. The heat, however, of an inflamed part, is generally supposed to be much greater than it really is. The sensation of beat is considera- ble to the patient, as well as to any observer, whilst the absolute increase of temperature is very slight indeed. It has been proved by the most decided experiments of Mr. Hunter, on the mucous canals of animals, first when in health, and again after violent in- flammation had been excited, that little or no variation of tempera- ture can be observed. The elevation of temperature is probably constant, though only amounting to a degree, or even less. As the blood is the source of heat, wherever an increased quantity is cir- culated, there should, to some extent, be increased heat. The effects of an incited action of the vessels on the system at large must now be adverted to ; or, in other words, that general disturbance in the system which attends inflammatory mcitation .and which occurs in a degree proportioned to the power of the exciting cause, and the kind of texture primarily affected. The functions both of the sanguiferous and nervous systems are de- ranged, producing a state termed Symptomatic or Sympathetic In- flammatory Fever. From some observations of my friend Mr. Gul- liver, it is probable that this state is frequently, if not generally de- OF INFLAMMATION. 19 pendent on changes in the blood consequent on inflammation. A sort of decomposition of part of the fluid and vitiation of the re- mainder ; the fibrin being separated and effused into the injured part for the purposes of reparation, while the blood globules are converted into pus in the capillaries, and mixed with the circulating fluid. Thus the presence of pus in the blood may become the proximate cause of fever; but if an outlet to the matter be estab- lished, if it be discharged by the occurrence of suppuration in a cavity or on a surface, the case is benefited and the constitution relieved. This points to an important principle in practice. Nature puts it in operation in small-pox, for example — how favourable it is for the pustules to come out, and to what danger is not the patient exposed if they are not repelled. During the paroxysm of inflammatory fever all the secretions and excretions are diminished or suppressed ; and hence the hot dry state of the skin, the thirst with foul and dry tongue, the scanty and high coloured urine, and the constipation of the bowels. This last symp- tom, however, though it may arise partially from the diminished se- cretion of mucus, yet is often dependent on disturbance of the func- tions of the brain and nerves. The pulsations of the arteries become rapid and strong, the sanguiferous system being unable to relieve itself by effusion, in consequence of the obstruction of the exhalants. If the extreme vessels are in any way obstructed, and the general circulation in consequence much accelerated, the internal viscera become oppressed, and are interrupted in their functions; and relief is experienced only when relaxation occurs in the vessels upon the surface of the body. Thus, in any violent and continued exertion, there is a sense of oppression in the .chest, and the functions of the encephalon are somewhat disordered, but as soon as perspiration breaks out the relief is instantaneous, and the animal can, without difficulty, persevere in its exertions. In inflammatory fever, the breathing is often difficult, and the appetite declines; the patient is restless and watchful, and when he does sleep, he is not thereby refreshed. In the more violent cases, the sensorial functions are much disturbed; even delirium supervenes, with violent muscular exertion and convulsions, and may be fol- lowed by coma, should the local affection not subside. The delirium attendant on violent diseases and accidents may often be considered a beneficent effect of nature's operations; for the patient, frequently losing all consciousness of his situation, seems to be under the influ- ence of the most pleasing hallucinations, and is freed from the more lamentable state of severe mental as well as bodily affliction. Writers on Inflammation have expatiated at great length on Sym- pathies; and these have been divided into, 1st, The Partial — the Remote, the Continuous, and the Contiguous; — Remote, when parts sympathise, though situated at a considerable distance from each other; — Contiguous, when the sympathetic action seems to be produced, in separate parts, merely from juxta-position ; — Continuous, when the action extends in parts which are of similar texture, and conjoined with that which is primarily affected. — 2d, Universal, where the whole system suffers along with parts of it. For instance, 20 OF INFLAMMATION. the whole system is often disturbed by a deranged state of the ali- mentary canal, and, conversely, the bowels, or the skin, the brain, the osseous or any other of the textures, may suffer from a general disorder. The system sympathises much more with some parts than with others; and we accordingly find that disorder in one part will give rise to alarming constitutional excitement, whilst in another, a much greater derangement in function and structure will apparently be almost entirely disregarded by the constitution. Irritation is an effect of sympathy, and differs from inflammation, inasmuch as the functions of the nervous system, and not those of the sanguiferous, are disturbed ; -— the latter frequently supervenes on the former. Irritation is local, or constitutional. As examples of the strictly local species, may be mentioned that peculiar and dread- fully annoying sensation produced in the alveoli by the presence of a diseased tooth, or the irritation caused by ascarides in the rectum, or by stone in the bladder. But, from this action being dependent on the nervous agency, irritation is frequently produced in a part remote from the source of the action. Thus, if an irritating cause of any kind be applied to the origin of a nerve, the effects of the irritation may be evinced in a part supplied by its extreme branches; while, if the cause is applied to the termination of a nerve, a similar action is produced at its commencement, and in parts supplied by nerves from the same origin. Thus, disease of the hip-joint causes pain in the knee, whilst dentition in children not unfrequently produces fatal effusions at the base of the brain; and again, irritation at the neck of the bladder frequently gives rise to pain in the feet. Local impressions, injuries, or irritations, though apparently of little importance, frequently produce irritation which affects the whole system, and is therefore termed constitutional. Syncope sometimes follows the passing of a bougie along the urethra. We meet with too many instances of constitutional irritation following severe inju- ries or operations, especially if attended with much hemorrhage. In general, there is considerable prostration of strength ; the patient is anxious and restless; his sleep is disturbed; the pulse is weak and fluttering, occasionally intermittent; the tongue is white and loaded; the appetite is gone; the stomach rejects the little food which the patient is able to take; he is startled and annoyed by the slightest external impression. At this period of the disorder, rigors generally occur, and are followed by a sense of heat, and by perspiration; then the above symptoms gradually decrease, and the patient re- covers ; but in certain instances his breathing becomes quick and somewhat oppressed, attended with a peculiar spasmodic elevation of the nostrils; all the secretions are diminished, the intellectual functions become impaired, and there are occasional convulsive twitchings ; coma supervenes, preceded by a low muttering delirium and followed by death. ' This action, as well as every other, is much modified by the im- portance of the part which is the source of the action, and by the constitution of the patient. It is more severe in children than in OF INFLAMMATION. 21 adults. The affection will be more fully detailed, when treating of local injuries, and the management of patients after severe opera- tions. The Causes of Inflammation come next to be considered ; and first, of the proximate cause or theory. The different states of the Vessels, in their healthy and in their incited condition, have given rise to much discussion. In the first place, considerable difference of opinion exists as to the relative share which the heart, the larger arteries, and the capillaries, have in propelling the circulating fluid in a state of health. Some physiologists are inclined to attribute the principal power to the heart, the blood being propelled and re- turned, according to them, almost entirely by the vis a tergo ; while they suppose that the arteries possess merely a degree of elasticity or tonicity. Considering the arteries as elastic tubes, performing an indispensable part in the propulsion of the blood, we will now7 briefly consider their state in inflammation. Passing over the different theories of error loci, spasm, &c, which have at various times been entertained, let us first examine the con- dition of the capillary vessels, for these are primarily and principally concerned. In inflammation, the balance of the circulation is de- stroyed, but a diversity of opinion has existed as to the precise nature of the change which occurs. It has been supposed, and per- haps correctly, that the circulation is, in the first instance, much accelerated in the capillary vessels of an inflamed part; but it has been satisfactorily proved by experiment, that, after inflammation is fairly established, the blood circulates more slowly than in the healthy state of the vessels. There appears, in fact, to be, as in- sisted upon by some writers on the subject, a state of excitement, then of collapse, followed, if the life of the part is not destroyed, by reaction. When a part is stimulated, the circulation is accelerated, and a greater quantity of blood is transmitted by its vessels : if the excitement is speedily removed, they recover themselves, though perhaps a little dilated, and no inflammation ensues. If, for in- stance, a foreign body of any kind gets entangled betwixt the upper eyelid and the bulb of the eye, and it is permitted to remain a few moments only, redness of the whole surface of the conjunctiva takes place, but it is transitory, and disappears entirely some short time after the extraction of the foreign body. If, however, it is per- mitted to continue longer in contact with this sensible surface, the membrane reddens more and more, and becomes thickened. Violent pain, with discharge of tears, and alteration of the secretion from the mucous surface take place, ophthalmia is, in fact, established. If the exciting cause is applied for a sufficient length of time, the ex- treme vessels lose their contractility, they are weakened, become dilated, and the contained blood circulates slowly. ' When inflam- mation is fairly established in a part, the capillaries become con- siderably dilated, and the blood is often completely stagnated in the inflammatory point. In the circumference of this focus, it is accele- rated as formerly noticed: the blood is probably stagnated for two or three days in the capillaries and in the contiguous cellular tissue, when the action is at all violent. It, however, begins to move 22 OF INFLAMMATION. again ; it loses its colouring matter, while stagnated; the fibrin is assimilated to the neighbouring parts, or rather effused, so as to cause the thickening, and the blood globules have possibly undergone a change, and been converted into those of pus. If the disease be of a limited extent, and without breach of surface, they are carried into the circulation very gradually, and in such small numbers as not to. produce injury to the health; otherwise the contamination of the blood by a large quantity of pus causes inflammatory fever. It is probable that the permanent dilatation occurs in consequence of the larger vessels in the immediate vicinity being incited, and propelling more blood into the minute capillaries than they can readily return into the corresponding veins ; and in consequence of so great a de- gree of distention being produced, the vessels are incapable of again speedily contracting ; the blood, also, from being stagnant, becomes of a darker colour. The larger trunks propelling blood into the dis- tended and comparatively inert capillaries, which are incapable of transmitting into the veins the same quantity of fluid wThich they receive, will cause the throbbing or pulsating sensation. The blood circulating in the parts around is sometimes apparently changed in quality ; it is redder, flocculi appear floating in it, and the globules disappear. These last may have been broken down, or partial de- composition may have taken place from a loss of vital power in the vessels themselves. The blood globules are, perhaps, merely compressed ; for when- ever motion is produced in the fluid, they speedily reappear. Fresh globules also find their way into the affected capillaries from neigh- bouring vessels. The alteration in the component parts of the blood has been supposed to depend upon the previous state of the inflamed vessels in which it is contained : it is said soon to reassume its na- tural appearance, when brought into a healthy vessel, and reference is made to experiments on the web of the frog's foot. When once altered, it is, however, questionable if the blood ever reassumes its natural appearance; of course the blood which takes the place of that which was stagnated in the capillaries will be natural. If there have been extensive inflammation, and therefore much altered blood, one of two things will happen, viz., inflammatory fever and its con- sequences, or the discharge of the offending matter (the altered blood) as pus. We may also conclude that the blood of an inflamed part undergoes chemical changes; for when the part becomes gan- grenous, the blood then loses its red colour, and assumes a yellow- ish-brown hue, from the absorption of its colouring matter, which necessarily implies an alteration in its chemical constitution It seems not unlikely, that the change which is early observed in the appearance of the blood of an inflamed part is the commencement of a chemical process, which, if the vessels do not regain their con- tractile power, terminates in the total destruction of the ordinarv properties of that fluid. It is probable that the more modern specu- lators in medical science have paid too little attention to the state of the fluids, and to the fact that, when diseased action occurs in a part its secretions and supplying fluid are very considerably changed ' But the blood in inflammation also undergoes a change, observa OF INFLAMMATION. 23 ble after its removal from the circulation, and especially when the system sympathises with the part affected. The blood, it is gene- rally believed and stated, does not coagulate so quickly as in the natural state, or else, it is said, the red globules, being increased in specific gravity, fall rapidly to the lower part of the containing ves- sel, so that a yellowish crust appears on the surface of the crassa- mentum or clot; and this appearance is termed the inflammatory or buffy coat. The blood extracted from the veins of a patient labour- ing under inflammatory fever often appears to coagulate very quickly; but it contains an unusual proportion of fibrin. In certain states of inflammation, this crust is also much contracted, so that its marginal circumference is at a considerable distance from the sides of the con- taining vessel; its margins also are elevated and inverted : its upper surface is smooth, whilst the under adheres firmly to the coagulum; and in this state the blood is said to be cupped, as well as buffed. The appearance of the buffy coat is not peculiar to the inflammatory state, but is apparently dependent on hurried circulation, however occasioned. It frequently presents itself in blood removed from the circulation during pregnancy, and in several other conditions of the system, apparently altogether unconnected with inflammatory excite- ment. In these circumstances, however, the contracted or cupped appearance of the coagulum is hardly ever observed. An ignorance of the above fact leads to dangerous practice, inasmuch as certain practitioners will bleed, and continue to bleed, for very equivocal inflammatory symptoms, conceiving themselves fully warranted in so doing by the presence of the buffy coat. This coat is often not so apparent in the blood first drawn as in that afterwards abstracted. In inflammation, as was formerly remarked, a greater quantity of blood not only flows into the capillary vessels, but it also escapes from them, or is extravasated. This may occur with or without rupture of the vessels, and to a greater or less extent, according to the violence of the action, and the texture of the part. When local inflammatory action exists to a considerable degree, the general circulation is more or less disturbed. The heart, and the larger vessels supplying the capillaries, which are more imme- diately concerned in the local action, subsequently sympathise with the part affected, and acting with greater vigour than usual, propel the blood into the extreme branches; so that the inflammatory ex- citement may be said to be gradually communicated by the continu- ous sympathy, till the whole sanguiferous system becomes subject to its influence. The degree of this general excitement depends greatly on the texture and function of the part primarily affected. The term Passive Inflammation has been applied to that state in which the larger vessels are not excited, or have ceased to sympa- thise with the capillary branches. The term Chronic Inflammation is properly limited to the consequence of the acute inflammatory action, the part remaining turgid and swollen, the vessels over-dis- tended with dark blood, but with little or no pain, and without heat or throbbing. Congestion is' also employed to denote fulness of the vessels, large as well as small, when no sign of excited cir- culation, or of decided inflammatory action, has occurred. It is 24 OF INFLAMMATION. most frequently used, however, when describing the condl*f°™ e°s*£ internal organ. An over-distention of a particular set o may certainly exist, (as a consequence of inflammation, or alloSeu1^ unconnected with it,) unattended with inflammatory action, inese two states ought to be carefully distinguished from a similar condi- tion of the vessels, attended with inflammation; for practice, which would be beneficial in the one case, is highly prejudicial m the other, and lamentable examples of the non-attention to this distinc- tion are every day observed. . It may here be mentioned, that some have denied the existence of vitality in the blood ; and to some minds it may, perhaps, be difficult to conceive how a fluid should be possessed of this prin- ciple. But no one can either doubt or deny that the blood, in its distribution, in its manner of receiving increase, in the secretions furnished by it, and in its various morbid changes, is governed by certain laws and principles which cannot be explained by those of chemistry or mechanics, but must belong to some other power. It is allowed, and has been promulgated by all authors, that the blood is one of the most active agents in the animal economy — in re- pairing waste, in affording peculiar fluids necessary in that econo- my, in supplying organs with materials for carrying on their func- tions, &c. ; and yet all this, according to some, is accomplished by a dead animal fluid ; no one can plausibly object to the laws by which the blood is governed being referred to the power of life, and to their being called Vital Principles. Certain circumstances give rise to inflammation, and have been called its Exciting or Immediate Causes. Among the external ap- plications producing inflammation, stimulants bear a conspicuous part; the effects of which, in causing this action, are well shown by many experiments that have been performed on the lower animals: by the application of ammonia, spirits of wine, or common salt, for example, to the diaphanous web of a frog's foot. As stimulants usually causing inflammatory action, by their being applied to the surface of the body, may be enumerated acids, alkalies, certain salts, animal substances, such as cantharides, the juices of many plants, many poisons, an excessive degree of heat, &c. Any solid substance, though by no means acrimonious in its quality, may act as an ex- citing cause, as by pressure or friction. Wounds also, especially wThen of considerable size, and occurring whilst the constitution is in an unhealthy condition, give rise to local, and occasionally general, inflammatory action. This action is besides frequently produced by injury from an ob- tuse body causing a bruise or fracture; by the lodgment of extra- neous substances, or of decayed portions of the system, — such as portions of bones, tendons, &c. ; or by irritating matter generated in the system itself, — by concretions, tumours, vitiated secretions &c. One of the most frequent causes of inflammation is cold ; the action of which, however, cannot always be readily explained! In some instances, it appears to act directly on a part, as in inflammation of the mucous membrane lining the organs of respiration ; in others its action is indirect, probably by disturbing the equality of the circula- OF INFLAMMATION. 25 tion, the inflammation occurs in a part distant from the surface the temperature of which had been diminished. In the great majority of instances in which inflammation has occurred, in consequence of very intense cold, it is produced by the sudden application of heat whilst the temperature of the part is greatly below the natural standard, as will afterwards be more particularly illustrated. But the inflammatory action may be produced even though no heat be after- wards applied directly to the part, by its vessels being too rapidly brought into a degree of action similar to that of the surrounding parts which are in their natural condition. Sudden and general diminution of temperature seems to act as an exciting cause, by pro- ducing an instantaneous suppression of the transpiration. Another exciting cause of the inflammation is the retention of the secreted fluids, causing unnatural distention of canals or cavities, and is ex- emplified by cystitis occurring in consequence of retention of urine. Certain states of the constitution are justly supposed to excite inflam- mation, in particular textures. Other exciting causes of inflamma- tion might be enumerated, but these will be more naturally explained, and more fully considered, whilst treating of inflammation of the various tissues and organs. Their effects are various and diversified, according to the intensity of the cause, the structure, function, and sympathies of the part affected, and the state of the system. And it is also to be remembered, that not unfrequently inflammatory ac- tion appears, whilst we can assign no cause for its production. Inflammation is said to terminate in Resolution, Suppuration, and Mortification. The application of the word termination, however, is injudicious; for in general the inflammatory action, though much abated, is not extinguished by the occurrence of suppuration or mor- tification, but often continues in the surrounding parts with unabated intensity ; and not unfrequently several of the terminations occur combined with each other. Adhesion has also been mentioned as a termination of inflamma- tion, but perhaps improperly ; for, although in certain parts of the body, as in the serous cavities, adhesion is produced in consequence of inflammatory action, and during its progress, still the process of adhesion is altogether independent of this action in other textures, such as the cellular. In the uniting of a flesh wound, a certain de- gree of incited action of the blood-vessels is necessary for the accom- plishment of the adhesive process ; but should that incited action reach the inflammatory pitch, the union by the first intention is interrupted, and the wround must heal by granulation with suppuration. The process of adhesion will be more properly attended to when treating of wounds. The various terminations of inflammation are salutary or destruc- tive, according to circumstances; but resolution is, in general, the one most to be desired ; complete resolution, however, perhaps sel- dom occurs ; after the inflammatory action has attained a certain point, this cannot be expected to happen. Resolution takes place in consequence of the re-establishment of the circulation in the capillaries, in which the blood had stagnated ; hence the diminution of the increased action in the larger vessels — 3 26 OF INFLAMMATION. the effused fibrin, at the same time, if there was much swelling, is partly absorbed. The circulation in the part becomes again natural, and the circulating fluid also resuming its healthy properties, the red- ness and sensation of throbbing cease. In consequence of the blood- vessels regaining their contractility, the nervous system is no longer preternaturally stimulated, and thus the increased sensibility is done away with. In short, when inflammation terminates in resolution, the part is left in the same state in which it was previous to the super- vention of the attack. It is not an instantaneous process, but gradual in its completion. Again, it not unfrequently happens, when inflammation has occur- red in the surface, and continued for a short period, that it sponta- neously disappears, and does not again return; the action is said to terminate in Delitescence, and of course this is always a favourable occurrence. But if the inflammation, after having suddenly disap- peared, attacks another part at a distance from that first affected, the change is termed Metastasis. If the inflammation leaves an internal viscus, and appears on the surface of the body; the circumstance is favourable; but if it leaves the latter to attack the former, the result is highly dangerous. Treatment. — In the treatment of inflammation, with a view of procuring resolution, our attention must be first directed to the ex- citing cause : it is, if possible, to be discovered, and removed. Thus, foreign bodies are to be extracted — fractures reduced — strictures divided —unnatural accumulations of fluid withdrawn, &c. In many cases, if the exciting cause is removed, nothing more is required; the inflammation speedily subsides. If the cause cannot be removed, or if, after its removal, the inflammation proceeds unabated the arte- rial action must be reduced by general and local abstraction 'of blood. By general depletion, the action of the whole sanguiferous system is diminished, as well as of those vessels more immediately engaged in the morbid action; but the affected capillaries are still dilated, and less capable than the larger trunks of effective contraction to propel their contents; and are therefore only sufficiently depleted by the local abstraction of blood, by leeches, cupping, punctures, or inci- sions. Blood may be drawn either from arteries or from veins In Arteriotomy, the blood is discharged more rapidly, and its flow'is of longer continuance, than from a vein, so that the system may therebv be almost completely deprived of its circulating fluid ; and perhaps a more speedy impression may be made on the inflammatory action One objection to venesection is, that after frequent and copious venous hemorrhage, the internal vessels become gorged with blood and a disposition to apoplexy is induced. ' [Leeches may be applied to almost any region of the bodv ex- cepting such as are abundantly supplied with loose cellular substance as the eyelids and scrotum ; or traversed by large subcutaneous vdns' Parts in a state of high inflammation must also be avoided, otherwise gangrene may be induced, an effect which I have several times wH nessed in hospital practice: in a case of this kind they should7hi placed in the immediate vicinity of the disease * Previously to applying them, the skin should be thoroughly cleansed OF INFLAMMATION. 27 with a wet sponge, and moistened with a few drops of milk, blood, or sweetened water. Dipping the leeches in table beer is very effec- tive in rendering them lively and active. Having been withdrawn from the water in which they are kept for a quarter of an hour before, they should be held to the part by means of a glass tube, a roll of pasteboard, or a piece of linen. When there is plenty of space, as on the abdomen, chest, or back, and it is designed to use a great number, they may be confined by an inverted tumbler or a wire-gauze cage. They should not, however, be crowded too closely together, as erysipelatous inflammation is apt to arise when this is done ; and they ought not to be touched until they drop off of their own accord. If they remain on too long, their separation may be facilitated by sprinkling them with a little salt or vinegar: pulling them away is painful and liable to occasion irritable sores. The sub- sequent flow of blood, which is generally considerable, especially in children, is to be promoted by cloths wrung out of wTarm water, and reapplied every ten or fifteen minutes for several successive hours. If the bleeding be profuse or continue longer than is desirable, it may be arrested by some styptic powder or lotion, either alone or assisted by a compress and roller. In obstinate cases, it may be necessary to apply the nitrate of silver or chloride of zinc ; or, what is better, because more effective, to use the twisted suture made with a very fine needle and ligature passed through the sides of the little wound.] [Scarification is a very efficient mode of abstracting blood, and one which, in my own hands, has often been attended with the happiest results. It is performed by drawing a sharp thumb-lancet rapidly and lightly over the affected surface, in as many places as may be deemed necessary, and afterwards encouraging the bleeding either by means of a wet sponge or by immersing the part in warm water. Scarification is mainly used in chronic ophthalmia, attended with great vascular turgescence of the lower lid, in scrofulous swellings of the joints, in chronic enlargement of the testicle and epididymis, in irritable ulcers of the leg, in tonsilitis, and in erysipelas.] But bleeding is not to be had recourse to without due considera- tion of the age, strength, constitution, and idiosyncrasy of the patient; if employed, it must be modified according to these ; and it has al- ready been mentioned, that depletion is not always to be persevered in on account of the presence of the buffy coat. [All practitioners are aware how much the formation of the buffy coat is influenced by extraneous circumstances. Of these the most important are the shape and capacity of the receiving vessel, the degree of motion to which the blood is subjected, and the size of the orifice in the vein. Dr. Belhomme, of Paris, who has minutely in- vestigated this matter in a series of one hundred and fifty experiments, has come to the conclusion that a narrow basin, a large orifice, and a full, rapid stream, in the form of an arch, are the external condi- tions most favourable for producing the buffy coat. The results of these researches have since been verified by those of Gendrin and other observers, and they are well worthy of" recollection, as they are calculated to exert an important bearing on the practice of our pro- 28 OF INFLAMMATION. fession. A cupped state of the blood most commonly occurs in asso- ciation with inflammation of the serous membranes and parenchy- matous organs, and may generally be regarded as evincive of a high degree of vascular excitement. Still, not too much stress should be placed upon this appearance, as it is sometimes present in states of the system the very reverse of that just mentioned, in persons, for example, who have been repeatedly bled, or whose strength has been otherwise very much reduced.] Bleeding is materially assisted in reducing the activity of the cir- culation, by the employment of saline purgatives, along with nau- seating doses of antimony. Diaphoretics are of essential service in promoting the action of the exhalants, and thereby relieving the af- fected capillaries. The exhibition of opium is frequently advan- tageous, more especially after depletion, in allaying the painful sensa- tions when severe, and averting reaction, and also in procuring re- freshing sleep, when the patient is anxious and restless. Digitalis has been administered, with the view of reducing the arterial action ; but it has been fully established, that this medicine acts at first as a direct stimulant, and that it is only after its use has been continued for some time that its effects become sedative. The local applications to an inflamed part are sometimes made hot, sometimes cold. The latter will perhaps be at first the more grate- ful to the sensations of the patient. They are, however, with greater propriety employed before inflammatory action is fairly established, and they act by constringing the superficial vessels with which those more deeply seated sympathise to a certain extent; but warm fomen- tations are more pleasant and useful when inflammation has really taken place ; they relieve the pain more effectually, and at the same time promote the cutaneous transpiration; they relax the surface moreover, effusion is thus encouraged, the deeper vessels are so far relieved of their load, and the pressure upon, and stimulation of, the nerves are thus diminished. After the violence of the symptoms has abated somewhat, the vessels still, however, being loaded with blood, the inflammation in fact having become chronic, stimulants may with propriety be applied directly to the affected parts; these are employed, perhaps, with greatest advantage immediately after nl« Tv, V6SSe. ^ unl°aded b? leechinS> scarification, or punc- tures; this practice is borne out by the result of experiment and °hTZ^n- i ? 1S S6en' that after the ves^ls have becomrdilated and the blood has stagnated in them through the inflic^n 0f iniurv or the application of some stimulating substL^ ZI i J Jl of another and different stimulus mme£ ^ of the caDillaries anrl th* ™1 lmrae«J.,ately causes the contract on 01 me capillaries, and the renewal of active circulation During an inflammatory attack, the patient shmiLI h'a „n i little food, and what he does receive must fontinhtt^^ V^ proportion to its bulk. But in many cases ki.nl nutr»*ent in such abstinence, as the patient nTL appe te and^fu?7 f° *?™ In inflammation of deeply-seated parts, such as th/ °°d' , some articulations, it is a frequent mode of assistiL X apParat,us of of resolution to excite inflammatory action in if!?* ?omP1*™ sequently less vital and important part. Th£i?J? ?\ ^d COn' application of stimuli, caustics, caute y, seton &c P ^ by the OF SUPPURATION. 29 It appears that the stimulating substance produces an incited action of the blood-vessels, or a revulsion, according to the older authors, in the part to which it is applied ; and that, consequently, the neighbour- ing arterial trunks, in order to sustain that incited action, supply the part with a larger proportion of their contents than it usually re- ceives ; and the necessary consequence of the stimulated part receiv- ing an additional supply of blood is, that the part originally inflamed receives less. The effect, indeed, seems analogous to that of topical bleeding, with this difference — that it is more permanent. Besides, it determines suppuration on the surface, and so renders it less neces- sary for the vessels to produce pus in a worse situation — the deeper seated parts. But it must be borne in mind, that this method is not to be resorted to in the commencement, or during the active state, of the inflamma- tory action, but only when that action has begun to decline, other- wise the disease maybe much aggravated, instead of being relieved. If, notwithstanding all the means employed to procure resolution, the inflammatory action continues unabated, the result next to be desired and accelerated is Suppuration; and with this view, it be- comes necessary to change the treatment, both local and general. Above all, disuse and a proper position of the affected part must not be neglected. Unless absolute repose is strictly enjoined and attended to, and the return of blood from the inflamed tissues is favoured, very great difficulty will, in the majority of cases, be ex- perienced in removing any of the signs or symptoms of inflammatory action, even by the most energetic means, general or local. This will be more fully insisted upon in the progress of the work, OF SUPPURATION AS A CONSEQUENCE OF INFLAMMATORY ACTION. It has already been stated, that the blood is stagnated in the capil- laries occupying the centre of the inflamed part, as well as extrava- sated in the contiguous cellular tissue. Pus has long been considered as a secretion ; but, from the time of Mr. Hunter downwards, a great similarity between the globules of pus and those of blood has been recognised; the former, however, are spherical, larger, and rougher on the surface, and are not so regular in size as those of blood; their diameter is between —- and ~^ of an inch, although some of the globules may be occasionally seen a little larger or smaller than these measurements. Smaller particles are also detected, the molecules of the pus globules, each of which con- tains two or three. These mole- cules are insoluble in acids, soluble in caustic alkalies, and can be freed from the fibrous capsule in which they are contained, and of which the pus glo- bule is composed, when treated with acetic acid. The appearance of the pus globules and molecules is here shown upon a scale, the squares of 3* 30 OF SUPPURATION. which are -i- of an inch. These small particles were pointed out to me by my friVnd xMr. Gulliver, nearly two years ago, as constituting an important element in suppuration. It results from his observations that the entire pus globule is composed in its central part of these minute molecules, the diameter of which is from y~j-6 to ^-0 of an inch, cemented together, as it were, by a superficial deposit of matter pos- sessing all the properties of coagulated lymph. And these minute nuclei constitute a proximate animal principle, possessing such well marked characters as to justify us in regarding them as peculiar in their nature, and essential to the composition of the pus globule. Thus they resist putrefaction with remarkable pertinacity, are very dense, and spherical in form, and are insoluble in some acids which act with facility on albumen, fibrin, or the blood-corpuscle. They are easily seen by treating a little recent pus with sulphurous acid, which so acts on the pus-globule as to render the nuclei distinctly visible through its fibrinous capsule ; by sulphuric acid the external part of the pus-globule is quickly dissolved, and the nuclei, some- what shrunk, are seen in considerable numbers floating separately about the field of vision. The instrument used by Mr. Gulliver in these observations was a compound achromatic microscope, with a deep object glass, having one-eighth of an inch focal length. In many constitutions, the slightest incited action of the vessels is followed by the formation of pus, and the appearance of a depot of purulent matter is often the first indication that such action has ex- isted ; but in the majority of instances, the deposition of pus is pre- ceded by the usual characters of well-marked inflammatory action. Suppuration occasionally occurs without previous solution of con- tinuity ; for pus is frequently contained in the serous and mucous cavities, when no breach of continuity can be discovered, at least we find a fluid not distinguishable from purulent matter; it may be a vitiated secretion, but still it presents the usual characters of pus. But it occurs, generally, when there has been a previous lesion of struc- ture, and in this case its progress is most distinctly marked. In ex- posed cellular texture, for example, particles of blood are effused; the serum is afterwards absorbed, and the lymph remains; this latter gives transmission to minute vessels which deposit the purulent fluid, whilst others secrete particles of organised matter to form granula- tions in order to repair the loss of substance. This process is often unattended with any great degree of constitutional disturbance, be- lU?e!tfnn eff?se* se\s a b°™<* to the pus, and is the provision against its being mixed in large quantities with the blood. In healthy suppuration the separation of fibrin and pus from the blood in this way seems to have direct relation to each other; and in unhealthy inflammation, when this does not take place, the consequences are mixture of pus with the blood as formerly noticed. In theMatter form of suppuration the fibrin, instead of "being assimilated to the contiguous mass, is mixed with the pus; hence thp n!™ * putrefaction of such discharge, and its dispWtoto L^Z^Ln taneously when evacuated. This kind of suppuration§ * tured generally without thickening of partsTw' beinS ma" pomted out as suppuration independent!* ot^io^S^ OF SUPPURATION. 31 After purulent matter has begun to accumulate under the surface, the pressure thereby occasioned produces condensation of the neigh- bouring cellular tissue, which, along with the previously effused lymph, forms the parietes of the abscess ; and in proportion as the matter accumulates, the cavity enlarges by the successive processes of ulceration of portions of its parietes, by continued effusion of lymph, and by farther condensation of the surrounding parts. Thinning of the parietes takes place by ulcerative absorption, particularly towards the surface — or, if that be difficult, towards a mucous outlet — as is exemplified by the bursting into the bowels or bronchiae of abscess of the liver. But in some instances, when no lymph is previously effused, and no cyst is formed, the matter is not confined, but pervades the cel- lular substance extensively, and is generally followed by more or less sloughing of that tissue, and by great constitutional disturbance. This most frequently occurs in patients of a debilitated habit, in whom the incited action has been so slight as not to cause the effu- sion of lymph, by which nature usually sets bounds to the suppurating process. M. Gendrin advanced the opinion that pus was nothing but trans- formed blood ; but his experiments on frogs are at least doubtful, since Mr. Gulliver, on repeating them, could not by any means in- duce the process of suppuration in these animals. It has been ren- dered probable by this gentleman's observations that suppuration is a sort of proximate analysis of the blood, the fibrin being added to the contiguous parts, as in causing them to swell, forming the cysts of abscesses ; the blood globules altered into pus being discharged as useless and excrementitious matter. Pure pus is heavier than water, of a yellowish-white colour, some- what of the consistence of cream. It is very little inclined to putre- faction, less so, perhaps, than any animal fluid not oily. It is composed of globules, and a clear transparent fluid, coagulable, it has been said, by the muriate of ammonia. When a solution of this salt produces any change, it is by rendering the pus more ropy ; not coagulation, but a sort of gelatinisation follows. It is said also to be sweet and " mawkish to the taste." In unhealthy pus, such as already noticed, or in vitiated muco- puriform secretion, the colour and consistence are different, and flakes, resembling portions of lymph, are seen floating in it: they consist of fibrin thrown off with the pus, instead of being used for reparation and bounding the extent of the abscess ; and by this latter circum- stance such fluid is distinguished from the pure or laudable pus. In purulent matter also, especially that of an unhealthy character, the existence of a quantity of sulphureted hydrogen is indicated by the blackening of silver probes, and of various substances applied to the sore. It is necessary to bear in mind, that a matter resembling pus in many particulars, but in reality differing essentially from it, has generally been regarded as true purulent fluid; from it results, from some observations of Mr. Gulliver, that the pulpy matter, so fre- quently found in the substance of fibrinous clots of the heart and veins, is simply fibrin which has coagulated and passed into the 32 OF SUPPURATION. state of softening, which he regards as a very frequent elementary disease. The subject is one of great interest, because it is connected with the theory of suppuration, and tends to modify materially our views on the pathology of the veins. The symptoms attendant on suppuration vary much according to the nature of the parts involved. In general, it is accompanied with the subsidence of acute pain and fever ; but, in unyielding textures, the increase of swelling, by the formation of purulent matter, is often attended with an aggravation of the symptoms, and with an increase of danger to the structures affected. The pain which accompanies suppuration is dull, and attended with a sensation of fulness and throbbing, and an increase of the tumour ; ultimately the parietes of the abscess become absorbed, and the collection, being more super- ficial, the most careless observer must be convinced of its existence, by the less equivocal signs of fluctuation and pointing. In general, especially when the abscess is deeply seated, a greater or less degree of cedema surrounds it, producing a soft pitting tumour; but not unfrequently, when the degree of excitement is more intense, lymph, instead of serum, is effused, rendering the part more hard and resist- ing : in such cases it may be difficult to discover the existence of purulent matter, and the tactus eruditus, as it is called, will be found of material service ; for, though pus is neither acrid nor corroding, still, if allowed to remain for any long period, much mischief may be caused— the bones may become diseased — muscles and tendons may slough—and the matter may discharge itself, by means of ul- ceration, into certain cavities and canals, and produce very serious consequences. Of the bad effects produced by the pressure and irri- tation of extensive and undisturbed collections of purulent matter, every practitioner must have seen numerous examples. Still, through prejudice, erroneously conceived opinions, or servile imitation, the greatest dread seems, with many, to exist of the practice of giving a free exit to the contents of such depots. The symptoms and sensible signs of suppuration are usually pre- ceded by shivering, recurring at intervals, and commonly terminating in profuse perspiration. But this is by no means an unequivocal sign of the occurrence of suppuration ; and this process very often takes place without any feeling of rigor. The older authors supposed that pus was derived from the solids — or that it was formed by the melting of dead animal matter— or that it was the result of putrefaction ; in accordance with which latter opinion, the term pus was given to the fluid ; but such opinions have long since been justly exploded. Pus is generally supposed to be separated from the blood by the secreting power of the blood- vessels of an exposed and inflamed part, in consequence of their having assumed a new mode of action. The secretion from exposed surfaces is not at first purulent, but is transparent, serous in fact and is somewhat of a gelatinous appearance ; and it is only it is ™ir] after exposure to the atmosphere for some time, and when drvi™ that it presents the appearance of globules. Pus is often formS where the secreting surface has not been exposed to the air • on on mg an abscess, the parietes of which had been previously entire and OF SUPPURATION. 33 not much attenuated, purulent matter of the usual properties is dis- charged. It has been asserted that pus globules may be formed in- dependently of any vital action ; and that, if the serous fluid be removed immediately after its secretion by a granular surface, and kept in a temperature similar to that of the inflamed part, and be at the same time freely exposed to the air, globules will appear in as short a period as when the secretion is allowed to remain in contact with the sore. Some have also supposed that the mere admission of air into the cellular substance causes suppuration ; but this is far from being correct. In chronic purulent depots, however, the ad- mission of air, by favouring putrefaction probably, often produces most serious results: other causes are generally in operation at the same time, as will be afterwards more fully explained. Pus was formerly regarded as irritating and corroding, and was therefore carefully removed from every granulating sore ; but puru- lent matter, though it may prove a source of irritation to the neigh- bouring parts, does not disturb the surface which secretes it, but, on the contrary, protects the tender granulations, and acts as a tem- porary cuticle. A crust is formed by the evaporation of the thinner part of the fluid ; and we frequently see small sores healing rapidly when thus protected. In some instances, we adopt the hint given to us by nature, and produce a scab by the application of powders, lunar caustic, &c. The discharge does not always consist of laudable purulent mat- ter. Pus formed in the diseased part itself has particular characters, according to the tissue involved; thin and grayish in bones, opaque and caseiform in cellular tissue, flocculent in serous, and greenish and thready in mucous membranes ; it is said to be reddish in the liver, and yellowish-gray in muscles. Its sensible properties are various, often very offensive when proceeding from a cavity con- taining decayed bones, and it degenerates in consequence of dis- turbance of the constitution, or of the part affected. It is also fre- quently suppressed, in consequence of overaction in the vessels of the part, or from debility, partial or general. Suppression of a purulent discharge is to be regarded as an un- toward symptom, fraught with considerable danger, being generally followed by the most violent constitutional disturbance. Certain cases would seem to warrant the belief that a species of metastasis occurs: that the matter is absorbed, and again deposited in some other part, perhaps of the utmost importance in the animal economy. The danger arising, when the pus is not separated from the blood has already been averted to. No wonder, if from any cause it does not escape by its accustomed channel, that an effort should be made to deposit it somewhere else, for the temporary relief of the system. The most vascular parts are commonly chosen, as the lungs, spleen, and liver. In the cavities of joints, also, matter is often found in great quantities. This is sometimes indicated by the occurrence of tenderness and swelling for only a short period previously ; but, in other cases, its presence has never been suspected. In purulent col- lections, after wounds from accident or operation, on the suspension of the discharge, the patient becomes affected with severe constitu- 34 OF SUPPURATION. tional irritation, and gradually sinks; the existence of purulent depots in the viscera of the chest or abdomen, being perhaps not indicated by any, unless very equivocal, symptoms, and these ap- pearing only a short time before dissolution. A late writer has en- deavoured to connect this with inflammation of the veins ; but such an opinion is not borne out by observation, although the two circum- stances may occasionally co-exist. In many cases the veins of a limb are found filled with pus, yet their coats present no marks of inflam- matory action having existed in them. Their mouths are open in the wound, from failure of that healthy action by which they would have been closed by coagulated lymph, and the matter appears to be taken up by them as secreted. From the discharge varying according to the state of the system the latter can m general be accurately ascertained by examination of the sores which afflict the patient. In collections of matter not far removed from the surface, the most superficial, and generally the most dependent portion of the parietes appears inflamed; its inner surface is gradually absorbed • and when it has thus become attenuated, a portion of Ve integu- ment sloughs or ulcerates. A communication is established with the diseased parts, through the external surface, thus providing an aper- ture for the evacuation of the matter- of extraneous substances- or of parts of the body which have either mortified, or otherwise \fCZ7 7i°ihe SyStem' In SUch ^^tions, more especially in tt P 7 h^T* genera11^ Seeks the surface> or Extends in the course of the blood-vessels. Cold abscesses, as they are called, often contain as much flaky fibrinous matter as true pus: hence one of the signs of inflamma- tion, swelling is absent; the fibrin being discharged instead of having been added to the neighbouring parts. As formerly remarked, suppuration occurs much more readily in some constitutions than in others; and patients peculiarly liable^ to the formation of abscesses, without any great degree of previous excited action of the blood-vessels, are said to labour underS or Scrofula. These terms are by some used to denote a distil or specific disease, while others consider them merely as a pecu iar state of the constitution. J peculiar The strumous diathesis is said to be marked by hair and irides of a very light colour, and by the skin being of a peculiar whito hue but in some instances, the complexion is unusually dark and sallow The upper lip generally presents a swollen appearance, as also Ae columna and alas of the nose. The organisation throughout is structure.3 * **'* * ^^ °f & hands°me> *ougf°nfL" Constitutions, in every respect strong and originally vigorous may from various causes, become weak, and present many of the symptoms usually termed scrofulous. I recollect a youn* patient born of healthy parents who had enjoyed excellent health,°becoS covered with ulcers and chronic abscesses, in consequence of exno sure to cold during menstruation. ^ expo- To the continued irregular and imprudent exhibition of mercurial OF SUPPURATION. 35 alteratives, as they are called, may be attributed the cachectic and scrofulous constitutions of many thousands of patients of all ages. The strumous'diathesis is said to depend upon a want of balance, or proportion, between the solids and circulating fluids. Want of action and powrer in the organs forming and circulating the blood, disordered digestion, and various other circumstances which it is unnecessary to detail, have also been considered as causes of this state of the constitution. Many suppose that the diathesis, or a disposition to the diathesis, is always congenital; and this opinion is supported by the majority of cases. However, certain circumstances produce a scrofulous habit of body in patients who previously appeared to be vigorous and healthy, and untainted with any peculiar disposition to disease" Of these predisposing causes may be mentioned, a poor diet, an im- pure atmosphere, exposure to damp and cold, inattention to cleanli- ness, the latter circumstance acting sometimes by producing local irritation: in fact, whatever deranges the general health, seems, in many cases, to induce the strumous diathesis. Some constitutions are incapable of resisting any unusual incitement of the vascular system, or of repairing the consequences of the action, or of any injury, in whatever way inflicted. In such individuals, all the parts of the body are deficient in power — some, however, are more so than others, and, consequently, more readily give way ; thus, the lymphatic system, the mucous membranes, the skin, the bones and their coverings, generally suffer in the first instance. Glandular swellings of all kinds, and in all situations, often followed by suppuration, are apt to occur from irritation of various descriptions, but more so in constitutions originally weak, or which have become debilitated by disease or any other cause. The larger glandular tumours are formed by congregation and agglutination of the smaller ones, and by the deposition of adventitious matter in the connecting cellular substance; separation of the smaller tumours composing these, naturally, or under the use of deobstruents exhibited internally, or applied to the surface, is a highly favourable sign, and equally encouraging to the surgeon and the patient. Dentition, the presence of carious teeth, of stumps of teeth; ex- coriations behind the ears, eruptions on the scalp, affections of the lining membranes of the eyelids, mouth, or nose, of the skin of the face, are daily found giving rise to glandular swellings in the neck; whilst irritations in the urethra, excoriation or slight disease about the anus, corns or sores about the feet or toes, produce similar affections of the glands in the groin. Such sources of irritation are, of course, to be looked for in the first instance, and will often materi- ally influence the diagnosis, though too much is occasionally attri- buted to their influence. Such glandular tumours, however, some- times occur spontaneously, or, at least, without any evident cause. They have been mistaken for other diseases, according to their situ- ation— for aneurism, hernia, or venereal bubo; the latter mistake is often committed unintentionally by the ignorant, or designedly by the unprincipled. Tumours formed by the enlargement of glands are frequently pro- 36 OF SUPPURATION. ductive of dangerous consequences. If situated in the neck, they may render breathing and deglutition extremely difficult, and in the event of their suppurating, the purulent matter may be discharged into the trachea or gullet; fatal results have followed the giving way of an abscess into the former canal. The breathing is also seriously impeded by enlargement of the bronchial glands, by the pressure of which the lungs may be much condensed, and unfitted for their functions. The immediate effect of enlargement of the mesenteric glands, is interruption to the passage of the chyle, and a consequent decline of the powers of life. Such tumours in the abdomen have been mistaken for enlargement of the liver, spleen, ovarium, &c. and the most noxious treatment employed. Inflammatory glandular enlargements terminate either in resolution, in delitescence, or in suppuration; sometimes in death of the part. When the tumour, after having attained a certain size, gradually disappears, it is said to be resolved; when, however, it is rapidly discussed, it terminates in delitescence; the difference between the terms being the same as when used to express the corresponding terminations of inflammatory swelling in general. Suppuration is by far the most usual termination, and the matter is frequently evacuated through numerous small apertures, exposing the gland denuded and prominent in the middle of the chasm; in such cases, the gland proves the source of much irritation, and must be destroyed, otherwise the cure is extremely tedious. Though inflamed and swelled lymphatic glands very generally disappear by suppuration, it is to be remarked that the conglomerate glands, though often violently inflamed, seldom, if ever, have pus formed in them ; in mumps, for instance, the action often runs very high, yet abscess of the parotid is rare. The submaxillary salivary glands are often supposed and said to be inflamed and enlarged; the conglobate glands superficial to them are in such cases only affected. J Collections of pus in the lymphatic glands or cellular substance, in patients of a weak constitution, (whether naturally or in consequence of disease,) are attended with little or no pain, or inflammatory action ; and although it is probable that inflammation does precede the formation of such purulent depots, still it is generally so slight as not to attract the attention of the patient or his attendant. The sensation is dull and uneasy, rather than painful; and, even after the accumulation of a considerable quantity of purulent matter, redness of the surface and pointing do not occur to a late period. The con- tained matter is thin, flaky, and of a brownish colour. The col- lections often attain a very great size, and, if improperly treated, terminate in the formation of numerous and extensive sinuses The skin, particularly that of the face, becomes, in very many cases, affected either primarily or secondarily with scrofulous ulcera- tion, which commonly extends to the neighbouring textures. The disease has sometimes been mistaken for cancer, and other affections of a malignant nature, and has received various names accordingly The integuments in the neighbourhood of the ulcer are of a purple hue, and become undermined, from the extension of the disease in OF SUPPURATION. 37 subjacent cellular tissue. The discharge is thin and gleety — the sore is of an unhealthy and debilitated character, and makes but little attempt at reparation; its surface is covered by a viscid fluid, and sloughing occasionally occurs in consequence of the extreme debilility of the parts. Numerous sinuses frequently extend in a superficial direction, and render the cure more tedious and com- plicated. Those of a scrofulous constitution are most liable to be affected with caries, softening, and other diseases of the bones and their coverings ; these, however, will afterwards be treated of, along with ulceration of cartilages, diseases of ligaments and synovial mem- branes, lumbar abscess, &c.; all of which affections, in the plurality of instances, are connected with the strumous diathesis. In the treatment of abscesses, the principal indications are, to re- move any degree of inflammatory action with which the surrounding parts may be affected — to keep the part moist, clean, and at rest — to remove all source of local irritation — to promote and accelerate the progress of the matter to the surface — and, lastly, to give it free vent; for though it sometimes happens that collections of purulent matter disappear, still the occurrence is so rare, that to treat abscess generally when in an advanced stage with the expectation of resolu- tion would be highly injudicious. By blistering and pressure, how- ever, tumours containing a small quantity of purulent fluid, can oc- casionally be discussed. Warm fomentations afford great relief, especially at the commencement, when there still remains a consi- derable degree of surrounding inflammation. These may be either what are termed anodyne, or not; in general, fomentation with cha- momile flowers or hops, contained in a woollen bag, and wrung out of warm water, will be found the most convenient and efficient, and is well entitled to the term anodyne, which is usually applied to others of a complicated, and not more efficacious character. Poul- tices are of material service, particularly when the collection is ad- vancing to maturation; and their composition is of little importance, provided they are moist, warm, and soft. Stale bread soaked with hot water, or an equal quantity of grated bread and linseed meal, (if not adulterated with mustard, as is sometimes the case,) mixed with sufficient quantity of boiling water, form excellent and soothing cataplasms. Their use, however, may be persevered in too long ; for, after an abscess has given way, the suppuration may be kept up in consequence of continuing the poultice. The opening will en- large, the skin become undermined, loose, and flabby, the abscess will extend, while the process of granulation may be in a great mea- sure suspended. In many cases, the poulticing cannot be continued until an opening has formed naturally, and the cure is often much accelerated by the artificial evacuation of the matter. When the abscess is situated deeply, or beneath a fascia, a free and early open- ing must be made. For example, when suppuration has occurred in the cellular tissue beneath the fascia lata of the thigh, it at first na- turally tends towards the surface, but its progress is impeded by the tendinous aponeurosis ; a painful feeling of tension is thereby occa- 38 OF SUPPURATION. sioned, and the matter extends where there is least resistance, making its way in all directions into the surrounding cellular tissue — sepa- rating the muscles—isolating the arterial trunks — burrowing be- neath the fascia over the wThole limb, and producing most serious, and often irreparable mischief, with violent constitutional disturb- ance. The bad effects of delay are again daily witnessed in ne- glected cases of paronychia ; most excruciating pain is produced — the system is seriously affected — the tendons slough, and the mem- ber is rendered useless. By the continued presence of purulent matter, absorption, ulcera- tion, caries, and even death, of bone, is frequently produced, all which might have been prevented by its evacuation. If pus collect in the neighbourhood of cavities or canals, it is of the utmost im- portance that it be early discharged ; and the evil effects of negli- gent and dilatory treatment are well exemplified in the following cases : — A patient had been allowed to suffer for a long time under an extensive abscess at the lower part of the neck, beneath the ori- gins of the sterno-mastoid muscles. The abscess at length gave way externally ; but the patient was at the same time seized with profuse expectoration of pus, and during expiration the air escaped through the external openings in the neck. It was evident that the abscess communicated with the trachea, and it also appeared to have extended deeply into the mediastinum. The patient soon perished, but there was no opportunity of examining the parts. In another case of extensive abscess at the root of the neck, an opening was proposed, but delayed. At length, the abscess gave way sponta- neously ; and from the circumstance of portions of solid as well as fluid ingesta escaping by the external opening, it was evident that the oesophagus had ulcerated. The cure was very tedious, but ulti- mately complete, and apparently much accelerated by free counter openings. In suppuration of the cellular substance in the neighbourhood of the anus, the matter may present itself externally, whilst it is making extensive progress internally; and if a free opening is not made, fistula ani is the result. The propriety of an early evacuation of purulent matter in important, or very sensible organs, such as the eye and testicle, is very evi- dent. The large arterial and venous trunks appear not to suffer from suppuration, for in purulent de- pots we find them entire, and r i • t • t ., • much thickened by copious effu- sion of lymph into their outer cellular coat and sheath • the nerves however, are not so much protected, or do not appear to resist OF SUPPURATION. 39 the pressure and insinuation of pus, and suffer along with the other tissues. The most convenient and effectual mode of opening an abscess is with a sharp-pointed bistoury, and the incision should vary in extent according to the circumstances of the case. The straight instrument, used as described and represented in the "Practical Sur- gery," p. 5*, will be found to answer best in deep-seated collections ; in the more superficial it may be slightly curved. It is used as here shown, only that the edge of the knife should be turned more down- wards before the integument is divided by withdrawing it. The aper- ture must always be made at the most dependent part, which is also, generally, the thinnest; thereby a free exit is allowed to the matter. If the incision be not made in a dependent part, a considerable quan- tity of the matter will be retained within the abscess, and can only be evacuated at the time by squeezing the parts — at all times a very cruel and improper practice — applying compresses, &c, which produce much irritation and unnecessary inconvenience to the patient. The cavity of the abscess inflames, the discharge becomes bloody and putrid, and great constitutional disturbance is apt to follow. When, again, the opening is sufficiently large, properly placed, and the mat- ter flows out through the elasticity of the covering, no air enters, the cyst gradually contracts, and the cure is soon completed. When the abscess has been deeply seated, and the incision made through a considerable thickness of healthy parts, it is sometimes, though very rarely, necessary to introduce a small piece of lint be- tween the edges of the wound, otherwise they may speedily adhere, and the discharge of the matter be in this way prevented. In con- sequence of smart hemorrhage, also, it may be proper to stuff the wound with lint, and retain it for an hour or two ; but in general the practice of stuffing abscesses, or the openings into them, is hurtful. After the incision, as already remarked, it is unnecessary and injurious to discharge the pus by forcibly squeezing the sides of the abscess ; the application of a poultice will promote the evacuation of the mat- ter, and allay the irritation. In chronic abscesses of large size, it is sometimes necessary to make a counter opening — that is, an opening in a part of the tumour opposite to the original opening, in order that the matter may be more completely discharged. Setons introduced into the cavity of phlegmonous abscesses some time after their eva- cuation, are highly injurious, as causing much irritation in parts which are already in a morbid state of excitement; but in chronic collections, which show no disposition to heal, their use may some- times be followed by good effects, on the same principle that they were hurtful in the preceding case ; if they should not cause a suffi- cient degree of. excitement, they may be smeared with some stimu- lating ointment. In extensive collections, in which the matter is not sufficiently evacuated by the external aperture, injections are by some recommended, and, perhaps, occasionally employed : in those ab- scesses which are comparatively recent, and in which the surround- * [Throughout the Elements, the edition of Practical Surgery referred to is that of 1842. Philadelphia.] 40 OF SUPPURATION. ing parts are still in a state of over-excitement, they are quite inad- missible. The employment of setons and injections in any case of abscess is not much to be commended or trusted to. Caustic, the potassa fusa, may be frequently employed with advantage for opening chronic abscesses, especially when they are the consequence of glan- dular enlargement, and undermine the integuments, which show no tendency to adhere to the subjacent parts. The potass is best used in the solid form and well pointed ; not in paste, as is sometimes practised. By its application the unhealthy surface is destroyed, and the surrounding parts are stimulated so as to assume a sufficient de- gree of action to thro w off the portions which have become useless, and to form new and healthy granulations, whilst the surrounding effusion of lymph or serum is for the most part speedily absorbed. But it can never be employed in acute abscesses without aggravating the disease ; and in collections which are deeply seated, it cannot be of much service, for in these a considerable thickness of healthy parts must be destroyed, and if the potass be applied, it will after- wards be necessary to cut through the slough, as was practised by the older surgeons, in order to evacuate the matter and give relief to the patient; or else to continue the application of the caustic for an inordinate space of time, wThich is a practice altogether unnecessary, extremely cruel, and productive of much irritation, constitutional as well as local. A too common result of abscess, when inertly treated, is the for- mation of a Sinus; that is, a canal, the circumference of which is condensed by deposited lymph, and which furnishes a discharge of unhealthy purulent matter, frequently thin and gleety. Several Sinuses frequently unite, and evacuate their contents by one opening. Previously to treating a sinus, its extent must be carefully examined by the probe ; this requires considerable caution, for the full extent of the canal may not be discovered, in consequence of its tortuous course, or from its diverging into collateral branches ; or the probe, by being used too forcibly, may pass into parts altogether unconnected with the morbid cavity. Thus, in exploring a sinus at the lower part of the leg, or in the foot, the probe may be pushed to a consider- able extent beneath the tendinous sheaths of the muscles, and induce the surgeon to adopt treatment unnecessarily severe. In the treat- ment, we may at first employ setons, injections, and graduated pres- sure, as formerly explained; and if these fail, the canal must be freely laid open by the knife — a mode of practice much more effec- tual ; then there is formed a cavity similar to that of a recent abscess, and to be treated accordingly. Incision is most frequently necessary when the sinus exists in adipose substance, in tendinous structure, in parts possessed of little vitality, and in patients of a sluggish and enfeebled constitution. In sinus, as well as in chronic abscess, the potass is of essential service ; a stick of it may be introduced into the canal, and if the sinus is superficial, the integuments maybe divided by this caustic as effectually as by the knife. The indolent and cal- lous surface of the sore is thereby destroyed, and the effects are similar to those which have been already mentioned, when speaking of the use of potass in abscess ; in fact, by its application the sinus is trans- OF SUPPURATION. 41 formed into an acute and open abscess. Foreign bodies, such as dis- eased and dead portions of bones, must be early removed ; for it is to be remembered that these are much more frequently the cause than the consequence of suppuration. The healing of an abscess which has been opened closely re- sembles the process of union by the second intention in a flesh wound; granulations arise, attended by the secretion of pus, the cavity gradually contracts; the surrounding effusion is absorbed along with a portion of the adipose matter; and on the granulations reaching the surface, new skin is formed, and the parts coalesce. After abscesses have been opened, the fomentations, poultices, or warm-water dressing, as recommended in the treatment of ulcers, are to be continued, but only for a limited time. The power of the system must be carefully supported by exposure to a pure atmo- sphere ; by nourishing food ; by the exhibition of wine, tonics, and such medicines as promote digestion. In cases where the system is unusually inert, it may be proper to administer stimulants. The most powerful stimulants are frequently necessary, and by steady perseverance in the use of them, patients have often been saved in very hopeless circumstances. Great attention must be paid to the bowels, and the secretions poured into them, for on the condition and quality of these the state of the constitution materially depends. The internal use of cantharides is often advantageous in chronic suppurations and abscesses, but it is inadmissible in cases where enlarged glands occupy dangerous situations, either externally or internally; unless the tumours are in progress towards resolution, suppuration is certainly induced, and may be productive of the worst consequences. The glands not unfrequently become enlarged during the exhibition of this medicine; and such an occurrence must be watched attentively. In illustration of the good effects of stimuli in certain cases, it may be mentioned that the cavities of abscesses are often speedily effaced by granulations, and that obstinate sores fre- quently contract and cicatrise, after the occurrence of a febrile attack, though they had previously shown no disposition to heal. In glandular swellings, Deobstruents, as they have been called, are used; and with this view, mercury is often had recourse to ; this medicine, however, instead of producing a salutary effect, very gene- rally tends still farther to impair the constitution. Preparations of iodine, exhibited both externally and internally, appear to be some- times of use when the swellings have become stationary, or are in- clined to subside. Iodine may be given in combination or not with iron. It is a medicine exhibited very generally and indiscriminately, and is very much more trusted to than it deserves to be. When the tumours are irritable, fomentations may be employed, and advantage taken of sea-bathing, warm or cold. The common adhesive or soap plaster, spread on soft leather, or the ammoniacal plaster, are often applied with advantage to indolent glandular swellings. Blistering is sometimes resorted to with good effect, and in some situations pressure may be usefully employed. In the treatment of large indolent collections, it was proposed by Mr. Abernethy to make a small and indirect aperture, and to evacu- 4* 42 OF SUPPURATION. ate the contents of the abscess as often as the matter accumulated ; but a degree of constitutional irritation frequently supervenes upon this proceeding, and the discharge becomes bloody, putrid, and mixed with a considerable quantity of gaseous fluid. The discharge of blood probably arises from the" usual support being taken away from the vessels ramifying on the surface of the cavity, in the same way that blood is effused into the cavity of the abdomen, in conse- quence of the too rapid evacuation of the serum in ascites. Suppuration, more especially when extensive and long continued, is attended with a peculiar species of fever, termed Hectic This fever is the remote consequence of local injury, or disease, whereas symptomatic inflammatory fever is the immediate one. The inces- sant and long-continued addition of pus to the blood may be the cause of hectic fever. In cases of pulmonary consumption, pus globules are almost uniformly detected in the blood. This fact has been noticed by Dr. Davy and Mr. Gulliver. The pus is probably carried along the capillaries, where it is always forming in chronic abscesses: in short, all the pus formed is not separated from the blood. Hectic probably arises from the never-ceasing addition of a little pus to the blood, inflammatory fever from the sudden addition of a large quantity. In long-continued disease, particularly internal, the hectic occasionally occurs before the existence of suppuration is indicated; and it does not always supervene upon suppuration, even though extensive. Hectic has been supposed to arise from the absorption of pus ; but pus cannot well be absorbed without disintegration of its particles (and then it would be no longer pus), for their diameter exceeds that of the more minute blood-vessels and absorbents. Ab- scesses occasionally disappear, without this event being followed by any unpleasant symptom. Hectic fever is most apt to arise in constitutions originally weak; and usually either from some incurable disease of a vital organ, or from extensive affection of a part not essential to life ; but it may also be induced without any local assignable cause. The genera] symptoms are those of a low and gradual fever, at- tended with great debility ; the pulse is frequent, unequal, small, and sharp; the general surface is pale; there is flushing of the face, hands, and feet: the skin, at one period, is cold and clammy, sometimes dry and rough — at another, it is bathed in profuse perspiration, especially towards evening ; chills alternate with flushing ; the appetite is much impaired; diarrhoea supervenes; pale-coloured urine is voided in great quantity, often with a lateritious sediment; there is want of sleep, and great anxiety; the eyes are sunk, and of a glassy hue ; the features become changed ; there is great emaciation; the patient, gradually more and more weakened, falls into a state of coma, and expires. A condition, somewhat resembling sympathetic fever, occasionally supervenes in a constitution that has been suffering from hectic when any additional irritation occurs, and this fever has been called 'irrita- tive. The sanguiferous system becomes more excited__the secre- tions are suspended — the sensorium is disturbed; but still the symptoms are accompanied with the peculiar debility characterising OF MORTIFICATION. 43 the state of hectic. It frequently follows the opening of large chronic abscesses by a minute aperture, in the manner formerly described, and is relieved only by free evacuation of the confined matter. In the treatment of hectic, the local disease giving rise to the symp- toms, if it cannot be cured by other means, must be removed by operation. Thus, if hectic is consequent on long-continued, but not extensive, disease of bone, the affected portion is to be taken away ; if from extensive chronic disease of an arm or leg, the limb must be amputated. In general, the removal of the hectic cause is followed by imme- diate melioration of the symptoms, even though the patient has been reduced to an almost moribund condition: the feeble hectic pulse of 120 or 130 sinks in a few hours to 90, and becomes more full and strong; anxiety and restlessness cease, and a patient sleeps soundly the first night after the operation, who for weeks had scarcely closed his eyes; the cold sweats and colliquative diarrhoea immediately subside, and the urine loses its sediment; in effect, all the hectic symptoms disappear, and are succeeded by such as indicate a marked improvement in the power and energy of the constitution; and the rapidity with which these changes take place is in many cases truly astonishing. Nourishing food, wine, tonics, &c, must be given, in the first instance sparingly, and afterwards gradually increased in quantity, according as the stomach can bear them; for it is not to be overlooked, that incautious and too liberal use of them may be pro- ductive of irretrievable evils, as the action of the system may be in- creased beyond its resources, in the same way as the imprudent ap- plication of stimulants to a part debilitated by an excessive degree of cold causes its sphacelation, in consequence of the arterial action induced being greater than what the power of the part can support. The mineral acids maybe useful in checking the inordinate perspira- tion ; opium, astringents, and absorbents, in arresting the diarrhoea; but all are of little avail unless the exciting cause is removed, and to this latter circumstance the attention of the practitioner ought there- fore to be chiefly directed. It is not always quite safe, however, to free the patient at once of a great suppurating drain. Upon the heal- ing up of extensive and long-continued ulcers, it is often necessary, in order to prevent oppression of and congestion in the viscera of the chest, abdomen, or head, to insert an issue or seton, and gradually withdraw it. In amputations also, more especially in patients above the middle period of life, to rid them of disease which has caused hectic and wasting, in consequence of profuse discharge, it is often advisable to keep part of the wound open, so that it may suppurate, heal, and dry up slowly. Mortification, or the death of a part, is also one of the results of inflammatory action, and the term has been subdivided into Gan- grene and Sphacelus. Gangrene is that state in which the larger arterial and nervous trunks still continue to perform their functions ; a portion of the natural temperature remains, and the part may be supposed still capable of recovery. Sphacelus, again, expresses com- plete death, when, putrefaction being no longer resisted, the part 44 OF MORTIFICATION. becomes black, cold, insensible, and fetid; but, in general, the dis- tinction between the terms is not strictly attended to. A division of more importance is into humid and dry, or traumatic and chronic, gangrene; humid or traumatic being applied to mortification produced by external injury; dry or chronic to that resulting from a constitu- tional cause. Mortification is not always a result of inflammation; it is some- times preceded by incited action of the vessels, sometimes not. It follows as a matter of course that if inflammatory action is so violent as to cause stagnation of blood in most or all the vessels of a part, and this is continued, there must be a consequent failure of nutrition, which will terminate in mortification. Humid or traumatic gangrene frequently occurs without previous inflammation, the injury being so severe as at once to deprive the part of its vitality. Dry or chronic mortification is often unpreceded by inflammatory action, or at least it is slight and of very short dura- tion. It is preceded by stagnation, or is at all events coincident with this stagnation, not in the smaller vessels only, but in the trunks leading to the affected part. In humid gangrene, swelling with erethismus generally precedes the death of the parts ; whereas in the dry, whether the surface change colour immediately or not, they shrink immediately. In the former they quickly lose their vitality, and consequently retain a considerable portion of their fluids; in the latter the process is much slower, and they become dry and shri- velled. The most common remote cause of spontaneous mortification is a rigid state of the arteries, most frequently met with in the inferior extremities of elderly persons, in consequence of the deposition of calcareous matter between the internal and middle coat; this calca- reous degeneration may be confined to a part of the limb, or may pervade the whole of it, and even extend throughout the arterial system. There are many cases in which disease of the arteries has existed, though no gangrene occurred; but this by no means invali- dates the assertion, since, when arteries are thus affected, the part cannot withstand sphacelus when exposed to any of its immediate causes. An attempt has been made to connect mortification with an inflamed state of the arterial coats. This opinion is not confirmed by experience. Obstruction from coagulation of their contents, and in- flammation of the venous trunks, sometimes precedes death of the extreme parts in old people, and seems to act as a direct cause. After wet seasons, spontaneous gangrene has prevailed as an endemial disease on the Continent, where rye is a principal article of food. The rye is subject to a disease called Ergot; the grains become large black, and have a horny consistence: and the use of it, when thus diseased, is assigned as the cause of gangrene. The patients who have suffered from the use of this ergot or cockspur rye have ex- perienced pain and heat, with swelling, generally in the lower limbs though occasionally in the upper. These symptoms abating; the parts became cold, insensible, and discoloured, and were gradually separated from the body. The disease attacked patients of both sexes and every age, did not appear to be infectious, and was frequently OF MORTIFICATION. 45 fatal. It has occurred in this country from the use of unsound wheat. A tendency to mortification sometimes arises from a peculiar state of the atmosphere, want of cleanliness, poor and irregular diet, &c. Cancrum oris, for example, and sloughing of the pudendum in chil- dren, occur in those of the poorer classes who live in low, damp, and dirty situations ; and little or no incited action precedes the sloughing. The same may be said of the phagedenic affections of the genital organs. Mortification and ulceration seem to differ merely in this,— in the latter, a part which, from any cause, is unfitted to remain a portion of the living body, is only prevented from dying by absorp- tion just as it is about to lose its vitality; whilst in mortification the part perishes too soon, or in too great quantity, to admit of absorp- tion. Sloughing phagedena is a sort of connecting link. Mortification, to a greater or less extent, may be produced in any constitution, and at any age, by the application of heated substances, caustics, acids, &c. ; by the effusion of acrid matter into the cellular substances, as urine or putrid sanies; by the interruption of the cir- culation and nervous energy, as from ligatures or improperly applied bandages — or by natural strictures, as those in hernia and paraphy- mosis; by continued pressure, more especially in such patients as have, from long suffering and confinement, had the powers of the circulating system weakened ; and by violent contusions, as in frac- tures, compound luxations, and gunshot injuries. A frequent source of mortification, in inclement seasons and climates, is exposure to extreme cold. In this case, the cold is not the direct, but the indi- rect cause; the power of the parts is very much weakened by ex- posure to the low temperature, and is thereby rendered incapable of resisting the incited action which follows the stimulus of sudden transition from cold to heat, even though the degree of increase in temperature should not exceed that of the natural standard. That cold is not the direct cause of mortification, has been undeniably proved by facts derived from military practice. No symptoms of inflammation or gangrene occur when the soldier is on duty, and con- tinuously exposed to severe cold ; but they speedily present them- selves after a rapid thaw has commenced, or after the soldier has imprudently approached a fire. Soon after the half-frozen person has begun to feel a little more comfortable from sudden warmth, he be- comes aware of pain, attended with a sensation of itching in the ex- tremities, generally the lower, which are considerably swollen, and of a dull red colour ; these, and other symptoms of inflammation, are of no long duration, the action speedily runs its course, and the part soon plainly indicates that gangrene has commenced. When gangrene follows the tight application of a ligature, the death of the part seems to depend more on obstruction to the circula- tion of the blood, than on any diminution of the nervous energy, for we do not observe that paralytic limbs are peculiarly liable to gan- grene. The surgeon frequently takes advantage of the fact that a part soon dies when its supply of blood is cut off, or its return in the veins interrupted; and has recourse to ligature for removal of parts, when he considers it inexpedient to employ cutting instruments. Mortification may be produced by the above-mentioned causes, 46 OF MORTIFICATION. either immediately or consecutively; and it will occur in some con- stitutions, or states of constitution, at some periods of life, in some structures, and in some parts of the body, more readily than in others. Inflammatory action is seldom so intense as to terminate in death of the part, unless the power of that part has been diminished by previous local or constitutional disease, or by injury ; and the inflam- mation preceding gangrene is all along attended by symptoms of so well-marked debility, both local and general, that it is frequently designated the Inflammatio Debilis. Of inflammatory affections, the erysipelatous most frequently terminates in gangrene ; in other words, the power of resisting incited action is not so great in the cellular tissue and skin as in other parts of the body. The period at which the symptoms of gangrene appear after an accident varies, in general, according to the severity of the injury. As wTas already observed, the part may be immediately deprived of its vitality — if not, symptoms of gangrene sometimes appear within a few hours after reaction has taken place ; while in other cases, tension, pain, and heat occur, and may continue for a longer or shorter time, according to the degree of power remaining in the part. Tension often exists to a great extent after severe injuries, from extravasation of blood or serum ; the functions of the vessels are thereby interrupted, and gangrene is inevitable. As the action pro- ceeds, the pain and heat often subside — the parts become flaccid — dark-coloured serum is effused beneath the cuticle, forming what are termed Phlyctense — the skin becomes dull and livid — dark streaks extend along the limb, perhaps from the colouring matter of the blood transuding, as in commencing putrefaction in the dead body — air is effused into the subcutaneous cellular tissue, causing a sense of crepi- tation when pressed by the finger— sloughs form, either black or of an ash-colour— and the gangrene involves a greater or less extent of the limb. The mortification is here represented as attackino- a limb that had suffered from compound fracture. The dark part around and above the protruded bone was in a state of sphacelus. The dorsum of the foot and the integument towards the knee were only gangrenous. The patient was advanced in life, and the state of the constitution such as to induce a belief that there was a predisposi- tion to mortification. The removal of the limb was, under the cir- cumstances, reckoned inexpedient. In some instances, the mortifica- tion is most towards the surface ; in others, it is chiefly amongst the deeply seated parts. Sudden cessation of pain is generally regarded OF MORTIFICATION. 47 as an unequivocal sign of the occurrence of gangrene, especially in the internal viscera ; but it not unfrequently happens that the painful sensations suddenly cease, whilst no gangrene supervenes, and that a part mortifies, whilst the pain continues but little abated. In compound fractures, dislocations, or severe bruises of the soft parts, dark-coloured, prominent points occasionally appear, in con- sequence of the effusion of bloody serum beneath the cuticle : in these, however, the fluid is speedily absorbed, and the surface resumes its natural aspect, the cuticle exfoliating and being reproduced ; and it is of consequence to know their real nature, for, if mistaken for the gangrenous phlyctense, the inexperienced practitioner may be alarmed, and, consequently, have recourse to very injudicious practice. When the process of gangrene is checked, the skin immediately beyond the mortified part becomes of a brighter hue, and is affected by a more healthy species of inflammation, which ultimately termi- nates in ulceration, wTith purulent discharge, and thereby forms what is called the line of demarcation between the dead and the living parts ; the process, commencing in the integuments, gradually ex- tends to the deeply seated parts, so that the mortified portion is ultimately attached to the living merely through the medium of bone or ligament. Arteries appear more than any other texture to resist sloughing ; and those leading to a mortified part are found contracted and filled with coagulated blood, so that the spontaneous separation of the sloughs, and even incisions for their removal, made in sound parts, are followed by little or no bleeding. This salutary change in the arteries may be accounted for by supposing, that the inflammatory action which leads to the separation of the dead substance from the living affects the arteries at that point as well as the other structures, causing adhesion of their internal surface, and obliteration of their cavities ; and the natural result is, that the calibre of the artery above the obliterated point gradually diminishes in size, and the blood coagulates up to the nearest collateral branch : but in consequence of extension of the inflammatory action, the collateral branches may also be obliterated to a considerable extent upwards, and thus the contraction and coagulation in the larger trunk will also extend in proportion. Besides, before the line of separation has commenced, arteries cannot transmit their contents into the sphacelated part, any more than into an extraneous body; so that the circulation of the blood in them is as effectually obstructed as if a ligature were tightly applied ; in this way, also, the contraction and coagulation may be accounted for. Mortification is accompanied with great anxiety; coldness and clamminess of the face and extremities; weak, irregular, and hurried circulation; quick, short breathing; a cadaverous expression of countenance; hiccup (which, however, often occurs in very slight sloughing, or when no sloughing has taken place, in external or in- ternal inflammations, extravasations, &c.); by diarrhoea, vomiting, and in hopeless cases, more especially of traumatic gangrene, by delirium and coma ; in fact, almost all the symptoms of severe con- stitutional irritation are more or less fully developed. In some cases, the patients are restless and unmanageable ; in others, low and de- 43 OF MORTIFICATION. iected. The disease often proceeds with fearful rapidity to a fatal termination, the patient becoming comatose from effusion within the cranium; but in other instances, in which the vigour of the consti- tution is greater, and the extent of mischief less, the system bears up under the affection, and a separation is effected between the dead and living parts. The danger is in general to be estimated by a consideration of the size and importance of the part, and of the age and constitution. The destructive consequences of sphacelus arise both from a local and general cause; for the mere application of putrid animal substance to a part still alive —the infiltration, for in- stance, of dark serosity into the cellular tissue in the course of a limb — causes a sort of inflammation attended with symptoms of dimin- ished power, and followed by constitutional disturbance ; whilst the ultimate extinction of life may be imputed to the effect produced on the system by the part previously to its becoming sphacelated, and to the sympathy between the system and the parts which are left in a weak and moribund condition, and which seem endowed with a dis- position to extend the disease. In the treatment of mortification, no one would think of using any means, local or general, so long as the cause remained ; and it there- fore must in the first place be removed, otherwise the mischief may speedily become irreparable ; thus, a stricture must be divided, irri- tating fluids evacuated, foreign bodies extracted, &c. In chronic gangrene the cause is constitutional, and the means employed must be directed accordingly. In general, the power of the constitution requires support, though in cases where much fever is present, it may often be necessary to keep the patient on low diet; exhibit salines and mild purgatives in the first instance. The effects of food should be attentively watched, and its quantity increased or diminished accordingly. On the subsidence of the fever, and when sphacelus has occurred, wine and animal food must be given abundantly. Stimulants, strictly so called, are not admissible until the line of separation be formed, and their exhibition must then be regulated by the circumstances of the case. Opium and other ano- dynes are found necessary during the progress of the disease, to allay irritation and produce sleep ; opium has been recommended on very high authority, that of Mr. Pott, in mortification of the lower limbs. The bowels must be attended to. Peruvian bark was at one time supposed to be a specific in this disease, but experience has not borne out the opinion ; it seldom agrees in substance, and the decoction, with or without the compound tincture of sulphate of quina, will be found much more useful in supporting the power and tone of the digestive organs. After the line of separation has been formed, and not till then, the surgeon may interfere, and assist nature in her work, dividing the exposed bones or ligaments by which the dead parts still adhere to the living; or he may perform amputation immediately below the line of demarcation. Amputation in the sound parts cannot be recommended : for vitality is impaired through- out the system, and more particularly near and above the line of de- marcation, where, though the structure seems entire, yet the incisions are made in parts really diseased, and which would almost certainly OF MORTIFICATION. 49 and speedily mortify. In fact, amputation above the line of separa- tion, in whatever way performed, is seldom if ever productive of advantage in spontaneous gangrene. In order to prevent the occurrence of gangrene after exposure to intense cold, the frigid part must be cautiously and slowly restored to its natural temperature ; first by being either placed in very cold water, or rubbed with snow; afterwards, by the degree of warmth in the applications, and surrounding atmosphere, being gradually increased. In acute gangrene, and in robust constitutions, when the affection arises from over-action, abstraction of blood is had recourse to with marked advantage. In some cases it may be employed, but with due caution, even after sphacelus to a slight extent has occurred. In gangrene, purging and bleeding must not be had recourse to but with the greatest circumspection ; for it ought always to be remembered, that however strongly they may be indicated, the time is not far distant when they will be totally inadmissible, and when the weak- ening effects of depletion will prove highly prejudicial, particularly in cases where the mischief is proceeding rapidly. The loss of blood is frequently beneficial in sloughing phagedena, as is exemplified on the occurrence of spontaneous hemorrhage in such cases. When a portion of a limb, throughout the greater part of its sub- stance, is so injured that it evidently cannot recover, it ought to be removed instantly, and before the constitution has suffered. When gangrene followTs inflammatory action, this is first to be moderated, and then the strength by all possible means supported. When only a portion of the soft parts of the limb is destroyed by mortification, and it is likely that the member may be saved and prove useful to the patient, measures should be adopted to hasten separation of the dead parts, and reparation of the breach in the living. After the separation of sloughs has commenced, the attention of the surgeon is chiefly to be directed towards the constitution ; it must be supported and strengthened by nourishing food, wine, and tonics, or by stimulants, if necessary. Bark in substance, acids, and other supposed antiseptics, are of but little use. The local applications which have been employed are numerous; poultices of all kinds, charcoal, carrot, and effervescing; various lotions to the surrounding parts, spirituous applications, such as several of the tinctures, liniment of turpentine, balsams, &c, with the view of correcting the fetor. But it is evident that such applications to a dead part can be productive of no effect; the only beneficial result that can be expected from such means is removal of the fetid smell, which can be effected, if need be, by sprinkling a solution of the chloride of soda on the body-linens and bed-clothes. Scarifica- tions are sometimes used; when these are made merely into the sphacelated part, they can be productive of good only by allowing the escape of matter ; when they extend more deeply, they are injurious. This practice, however, as will be hereafter noticed, is adopted with the best effects when mortification is threatened. 5 50 OF MORTIFICATION. [To prevent mortification blisters have long been a favourite means with American surgeons. The practice originated, I believe, with the late Dr. Physick, of Philadelphia, early in the present century. To do good, they should be large enough to cover, not only the whole of the inflamed part, but a considerable portion of the sur- rounding surface, and to be kept on until they have produced tho- rough vesication. Blisters are scarcely less serviceable to arrest mortification, after it has made some progress, but in this case they should be placed in contact with the sound skin, not with the dead, as they cannot, when this is done, be productive of any good.] When the sloughs become loose they must be removed bit by bit with scissors; and when the sphacelated part has separated entirely, the healing of the breach is to be promoted by judicious dressing, bandaging, and by proper position. [To expedite the sloughing process, allay the unpleasant fetor, and promote the formation of healthy granulations, I know of no remedy that will answer so well as the nitric acid lotion. It should vary in strength, according to the exigency of the case, from four to twelve drops of the acid to the ounce of water, and a cloth wet with it should be constantly kept in contact with the affected part, taking care to wash it occasionally to rid it of the foul discharges writh which it becomes from time to time impregnated. If necessary, a poultice can be placed over the rag. Under this treatment, particularly when aided by the liberal use of carbonate of ammonia, wine, brandy, and other cordials, I have often been astonished to witness the rapid changes that have taken place, in cases apparently of the most des- perate character.] In mortification of an extremity, in consequence of injury, removal of the part by incision in the sound substance was formerly as much dreaded as in chronic cases before the separation had commenced; but such fears have now subsided, and the practice of delay has been in a great measure relinquished,— amputation being peiformed in the sound part, at a considerable distance from the mortified or even gangrenous tissues, and during the progress of the disease, occa- sionally with a favourable result. If the surgeon defer the operation until a line of separation have begun to form, he will soon discover the danger of his delay; the constitution will, in the majority of cases, rapidly sink under the malady before the progress of the disease is in any measure checked, or any attempt is made to throw off the mor- tified parts. Two cases which lately occurred in my hospital prac- tice, are here introduced from the " Lancet," to show how different the progress is, and how opposite the practice ought to be. Both the patients made excellent and rapid recoveries. " Sarah Arnold, set. 75, was admitted on the 26th of January. She has been a person of great mental and bodily activity, and has enjoyed excellent health from her infancy, until her present illness although necessarily exposed, from the nature of her occupation a gatherer and hawker of watercresses, to all varieties of weather. About six weeks ago, without being more than usually exposed to cold, she was seized with severe rigors. Two days afterwards she began to complain of slight pain, with clinching of the fingers which OF MORTIFICATION. 51 at the same time became discoloured at the tips, and were partially deprived of sensation. This at first did not give rise to much unea- siness, and no treatment was employed ; and it was not until a week after the commencement of the disease, when the discoloration had passed the wrist, and the hand had become dry and shrivelled, and motion and sensation in it were completely lost, that a medical man was called in. Both internal and local remedies wrere then employed, but without in the least retarding the progress of the disease, which in about a fortnight from her seizure had extended a little way above the middle of the humerus, beyond which it did not pass. At pre- sent there is a well-marked line of separation between the living and the gangrenous parts, but there are two livid spots beyond it, on the outer side of the arm; on the inner side, where the disease has ex- tended a little higher up than the outer, suppuration has already commenced. The integuments in the immediate neighbourhood of the diseased parts are slightly reddened and tumefied, and it is there only that she conplains of some slight pain. The hand and wrist are dry and shrivelled, but above this the parts are soft and flaccid. Below the line of demarcation, the extremity is of a dark colour, re- sembling the skin of a negro, and completely deprived of the power of motion and sensation; but she complains of a disagreeable ting- ling, referred to the fingers. The discoloured parts are quite cold, and the pulse cannot be felt, even in the axilla. Though she com- plains much of debility, the system seems to be but little affected. The appetite is very good ; the skin is moderately warm ; the pulse is 98, and of good strength ; the tongue is moist and clean. She sleeps little. B. Haust. c. Sol. M. Morph. gtt. xxv. M. Vini Rub. |iv. Water-dressing to the arm at the line of separation. " 27. She continues the same as yesterday ; slept little, bowels moved twrice ; tongue clean and moist; appetite very good ; pulse as before; heat of skin natural ; intellect clear; no expression of anxiety in the countenance. R. Haust. Con. Vin. Full diet. " 28. The suppuration on the inner side of the arm is more copious, and the discharge is more fetid. The livid spots on the outer side of the arm have not extended, and there is some slight redness around them. Pulse 104, of good strength; tongue clean and moist; heat of skin still natural; appetite good ; bowels moved once since the last report. Continue. A little Sol. Chlor. Calcis to be added to the dressing. 52 OF MORTIFICATION. " 29. The dry and shrivelled state of the extremity has extended as high as the middle of the forearm. The discharge is much the same as before in quantity, but is more fetid. The separation be- tween the gangrenous and the sound parts, which had begun on the outer side of the arm when she was admitted, is extending a little, both towards the inner and the outer side. Pulse 90, of moderate strength ; skin natural; tongue clean and moist; bowels open ; appetite excellent. "30. Much the same as yesterday; sleeps a little better. " 31. The suppuration is more copious ; the discharge extremely fetid. The dead parts on the inner side of the humerus are gra- dually becoming more detached. No change in the appearance of the living spots beyond the line of separation ; pulse 102, of pretty good strength ; bowels continue regular, and the appetite is good. Cont. vinum et haust. " Feb. 2. The separation of the gangrenous parts on the inner side of the arm has advanced a little more since last referred to. The livid spots have disappeared, with the exception of the largest, where a small superficial slough has formed. The diseased parts were removed to-day, the line of separation being fairly established, and suppuration having taken place in a great part of its extent. The soft parts were divided by means of a pair of scissors, cut- ting as near to the living parts as could be done with safety; the bone was then denuded as high up as possible, by passing a bis- toury round it, and it was then divided by the saw. There was no bleeding from the soft parts, and only slight oozing from the bone, which was found to be alive where it was divided. Cont. vinum et haust. " 3. Continues in much the same state as yesterday ; pulse 104, of good strength; tongue clean and moist; bowels moved once ; skin natural; appetite good ; suppuration very free. Cont. " 5. Suppuration copious ; a portion of the dead parts left have separated, and left a healthy florid granulating surface. Continues much the same. " 6. Discharge copious, and much less fetid; bowels regular ■ pulse 100 of good strength ; tongue clean ; appetite good ; wishes for more food. To have an additional chop. Cont alia , !' \ Tn? gIea-f part °f the slouShs have separated,'and have left a healthy florid granulating surface ; no change in the general symptoms. Continue. b " 9- The.stumP lo°ks well, and the posterior part of the cut end of the bone is covered by healthy granulations. "In some notes of this case, kindly furnished me by the late Professor Fergus of King's College, who had an opportunity of watching the appearances for some time before the admission of the patient here, it is mentioned that the flow of blood in the veins was exceedingly slow, and that hard knotty tumours could be felt in the parts before they became sphacelated. These swellings all along preceded the mortification It is mentioned, besides, that he patient had a sor of fit but that ,t could not exactly be ascer- tained whether or not she lost consciousness. Her left arm is said OF MORTIFICATION. 53 to have been motionless from and after that time. There is con- siderable discrepancy in the accounts of the mode of invasion, and of the duration of the disease, before the line of separation became apparent. A period of six weeks is stated in our case-book to have elapsed from the attack to the admission of the patient into this hospital. It would appear, however, from the other history, that not more than three weeks had passed over. The old lady is not very distinct in her account; at one time she makes a statement with great minuteness, and very soon after contradicts herself on almost every point. When pressed on the subject, she states that she got disgusted with her condition, became despondent and care- less about every thing, and that her recollection is not now very good." " S. W., aged 16, was admitted March 12, under the care of Mr. Liston. She is a servant girl, of sanguine temperament and good constitution. On Friday, March 9, she was cleaning the outside of a parlour window, and stood on the sill. The window-sash, upon which she was depending for support, being suddenly drawn down by a person inside, she was precipitated into an area, a distance of fifteen feet. She was immediately picked up, and conveyed to the hospital. The house-surgeon detected a compound fracture of the ulna, and a fracture of the radius, both fractures being a little above the wrist-joint of the right arm. The fracture was adjusted, and the wound, which was inferiorly to, and behind the wrist, dressed in the usual manner. A dose of house-medicine was administered ; suitable directions were given in case of the occurrence of pain or swelling; she was sent home, and desired to remain quiet. The following morning (Saturday) she was visited by the house-surgeon, who found her comfortable, but she had passed a sleepless night. On Sunday morning the affected part became so intolerably painful that she tore off the splints and bandages, wThich one of the dressers of the hospi- tal had a short time before readjusted; in the evening she was in great pain, and the arm was much swollen. " 12. To-day (Monday) she was admitted into the hospital ; water- dressing was applied to the wound. The bandages were reapplied, and an anodyne administered in the evening, with the effects of pro- ducing some rest. " 13. The pain and swelling was so great during the night that the house-surgeon was called up to see her, and ordered the applica- tion of fomentations ; this morning she is much more comfortable. " 14. On removing the whole of the apparatus this morning early, mortification was found to have taken place in the limb ; at the ti ne of Mr. Liston's visit in the middle of the day, the limb was very swollen, the fingers were of a black colour, the foramen livid, there were vesications near the elbow with fetid discharge. There was a good deal of fever with slight delirium ; pulse irregular, quick. Mr, Liston considered the only chance the patient had was the immediate amputation of the limb at the shoulder. The patient's consent having been readily obtained, Mr. Liston proceeded at once to the " Operation. — He first introduced a long double-pointed knife under the acromion, and brought the point out at the lower and pos- 54 OF ERYSIPELAS. terior border of the axilla, by this means the joint was laid open ; the flap thus formed of a portion of the deltoid was raised, and the head of the bone separated from its attachments. The other flap was formed from the integuments and muscles in front. The axil- lary, and one other vessel, required ligature. The edges of the wound were drawn together by three points of suture, and cold- w^ater-dressing applied. One grain of muriate of morphia was grVef' *? the evenin&> several strips of isinglass plaster were ap- plied, and the edges approximated. The delirium ceased after a short but refreshing sleep. " *5- Passed a good night; has had little pain; feels very com- fortable this morning ; she is cheerful, and has little fever ; pulse 86, regular. The wound looks healthy. ' " April 2. Since the above date, the patient has been gradually a3nKnarde'r'neahh ""* Str6ngth' &nd She is n°W able to wal^ nAf lgTG 0CcurrinS affer exposure to cold, amputation should and ttf ^T'86 t0.tin after the line of reparation has formed; th„!il? "fit G Constltutlonal ^mptoms are much less urgent, and enbect °f ?e °P?f tion might be frustrated by its being performed llhX fCh T* 1 Speedil? beCOme spacelated. The amputation maybe performed either at the line of separation by cutting the liga- ments or bones, as was done in the case from which the accompanying sketch was taken, and when the line of separation is well declared! or, if by these means a good covering is not likely to be had for the exposed surface, the incisions may, in these cases hp JSr^f ♦ a propriety made in the living tissues, at t^mK™Sn^X . In gangrene arising from obstruction or injury of Wool^essels toXl^^?****0*^* bG Pe^-ed0e0ari;-t; ii . ™ance ot >™mate success is increased, while the dan»r „f delay >s the same as .„ cases of gangrene caused by severe Injufy. OF ERYSIPELAS. Erysipelas is an inflammation of the external surfon* *„ • j with peculiar symptoms and appearance "The Sdrr?^ modified by the texture in whicfit occur,' ^rlg tote^Zll OF ERYSIPELAS. 55 circumstances attending the disease, it has been divided into several species: phlegmonous, bilious, cedematous, gangrenous, acute, malig- nant, &c. The term Erythema is applied to cases of rash or efflo- rescence, unaccompnnied with fever, swelling, or vesication. Inflammation of the skin only, is marked by bright redness, not circumscribed, and disappearing when pressed. By pressure, the blood-vessels are emptied for a time, the part sinks and becomes pale ; but, on removing the pressure, it soon regains its former colour and relative situation ; when these circumstances concur, the part is said to pit. There is no tension, — the pain is not throbbing, but of a burning or itching kind, and there is often a degree of cedematous swelling. Swelling does not occur to any great extent, however, during the existence of the inflammation in the skin and rete muco- sum ; but the parts sometimes become much swollen after subsidence of the inflammatory action, the vessels having relieved themselves by effusion of serum ; and afterwards the cedematous surface often as- sumes a yellowish hue. In some cases, the serous effusion is from the first more extensive than in others, and hence the term cedema- tous erysipelas, or inflammatory oedema. Upon the decline of in- flammation, a serous fluid is often effused also in great quantity under the cuticle, giving rise to vesications, resembling the blisters produced by the application of boiling water to the skin ; and from this circumstance, erysipelas has been classed amongst cutaneous affections in the order bullse. The erysipelatous redness does not terminate abruptly, and is not defined by a distinct boundary, as some have asserted, but becomes gradually lost in the surrounding parts. It frequently involves the contiguous parts one after another, and extends with great rapidity. It often leaves one part suddenly, and attacks another, either in the neighbourhood, or situated at a considerable distance ; in other words, metastasis takes place. The disease takes on this erratic character without our being able to assign any good reason for it; and this form of the disease is frequently attended by symptoms of typhoid fever. When it disappears sud- denly, or is repelled by cold applications, affections of the internal organs sometimes supervene, as of the bowels, lungs, or brain; the diseased action leaving the external surface, and attacking the deeply- seated organs ; thus, in a case of erysipelas of the ankle and foot, the external symptoms disappeared suddenly, and an affection of the lungs supervened, under which the patient sank; and in erysipelas of the face and scalp, the sudden disappearance of the redness is fre- quently followed by delirium and coma. Again, in acute disease of an internal part, the symptoms are much meliorated, and often en- tirely removed, by inflammation of the skin being induced artificially, or occurring spontaneously. The integuments of the face and head are frequently attacked by erysipelas, in consequence of wounds and bruises of the face or scalp, even though very slight, and it often takes place here spontaneously, as in other parts of the body. Erysipelas commonly arises from constitutional derangement, as is shown by the symptoms which precede it, and also by the efficacy of internal remedies in checking its progress; in such instances, external gg OF ERYSIPELAS. applications, unaccompanied with constitutional treatment, produce little or no effect. It is often produced around a wound by the em- ployment of improper dressing, rancid ointments, or irritating plasters, by a too free use of the part, or by the friction and irritation of the patient's clothes. It occurs most readily in those who live freely, indulging in the imprudent use of spirituous liquors, and whose con- stitutional powers are thereby considerably weakened. It is also said to be sometimes caused by violent passions, as anger or grief; and by exposure to cold, or to heat, — the former acting only as a remote, the latter as an immediate cause. As an example of its oc- curring in consequence of heat, it is a common remark, that cooks, who arejiecessarily much exposed to the fire, are frequently the sub- jects of erysipelas of the face ; but in the majority of such cases, there may be other causes in operation, — the abuse of ardent spirits, and habitual overcharging of the system with stimulating food. It is more commonly met with in summer than in winter. And in certain states of the atmosphere, even in healthy situations, a degree of ery- sipelas is apt to occur after wounds by operation or accident. It is often periodical, especially in females who have ceased to menstruate, always recurring at regular intervals ; it attacks parts of the body, most generally the face, and in some cases monthly, in some once in the year, and in others once every two years. It some- times appears to occur as a natural means of relief from impending affections of more serious nature, as of the system or of internal or- gans. Those who have once been afflicted with the disease become more liable to its attacks. Erysipelas is generally preceded and accompanied with more or less disturbance of the digestive organs. In Bilious Erysipelas, the portion of skin affected is said to present a more yellow colour than in the phlegmonous, the derangement of the digestive organs is greater, and hence the origin of the distinctive term ; fits of shivering occur, the patient complains of a bitter taste in his mouth, and the tongue is furred and of a brown colour. In the Phlegmonous, in which other textures than the skin are often affected, viz., the subcutaneous and intermuscular cellular tissue and the fascise, the pain is more intense, and of a throbbing kind; the swelling is hard, more deeply seated, and more extensive ; there is considerable tension ; and the redness is of a darker hue. Nausea and a bitter taste in the mouth do not precede the erysipelatous ap- pearance, but the skin and tongue are dry, and there is great thirst. When the disease begins to subside, then the foul tongue super- venes, with the bitter taste and nausea. Erysipelas, of a contagious and violent character, frequently occurs, and is apt to spread extensively, in badly aired situations, where a number of patients with sores are crowded together, without due attention being paid to cleanliness and proper dressing Hospital Erysipelas as this species is termed, is nearly allied to that dreadful disease, Hospital Gangrene, and the two affections are often blended. It comes on after operations, or in patients who have sustained an external injury by accident. In unhealthy hospitals it not unfrequently appears in previously sound parts, and without any OF ERYSIPELAS. 57 assignable cause ; and, from its following the slightest wound, re- course cannot be had with safety even to venesection, cupping or leeching. It is a dreadful scourge in many hospitals, mo^re especially during particular seasons of the year—during hot, damp weather, and in spring and autumn, attacking the patients indiscriminately. Of late years Erysipelas appeared in the Royal Infirmary of Edin- burgh, during the wet and changeable summers which prevailed ; some of the cases wTere very severe, and a few terminated fatally. It was very satisfactory, however, to observe that it did not spread as it used to do formerly, that patients occupying the beds imme- diately around those affected, though afflicted with sores and in in- different health, remained exempt from the disease; and that many of the most severe cases did not originate in the house, but were brought from the crowded and unhealthy parts of the city. The same may be said of the disease as it has shown itself in the North London Hospital since it was opened for the reception of patients up to the present time. Hospital Erysipelas is for the most part preceded by violent con- stitutional symptoms, derangement of the chylopoietic viscera, shivering, brown tongue, and a bitter taste in the mouth ; if there is a sore on the body, it assumes a sloughy aspect; the surrounding skin becomes of a dark-red colour, and there is a feeling of tension, accompanied with a burning pain. The erysipelas extends rapidly, and generally terminates in suppuration and sloughing of the cellular substance, or, if inertly treated; in immediate gangrene of the parts. The concomitant fever is generally low, and though, in the first in- stance, the circulation may be vigorous, symptoms of debility will speedily appear. It will be more fully dwelt upon, along with Hos- pital Gangrene. In all cases of erysipelas there is more or less concomitant fever, modified by the extent of the local affection — by the age of the patient — by the previous habits and state of health — by the con- stitution — and by other circumstances. The pulse is accelerated, and is either of a sthenic or asthenic character, according to the state of the system and type of the prevailing fever. There is headache, languor, thirst, restlessness, and even delirium, espe- cially wrhen the face or scalp is the seat of the disease. Erysipelas may terminate in resolution. If this takes place in the first stage of the disease, the redness gradually declines, along with the swelling, the cuticle exfoliates, and the part regains its usual ap- pearance, the skin remaining loose and shrivelled. If it occurs after vesications have formed, the effused fluid is absorbed, a scab forms, and desquamates along with portions of the cuticle. It may terminate in suppuration, when the inflammation has ex- tended to the cellular substance. This termination is most frequent when the disease is situated in an extremity, seldom when in the face, though small purulent collections occasionally form in the eye- lids. Circumscribed collections of pus often present themselves after the disappearance of the erysipelatous inflammation ; but the purulent matter is generally diffused through the filamentous tissue, and is of a thin, unhealthy appearance, and mixed with sloughs of 58 OF ERYSIPELAS. the cellular substance. By the infiltration of matter, the integu- ments, fascise, and muscles are extensively separated from each other, in consequence of which the parts frequently die, their nutri- tive supply being cut off. Acrid sanious matter is often infiltrated extensively into the sub- cutaneous cellular tissue round a wound or sore. The superimposed integuments are of a dark-brown colour, and the part is boggy. Sloughing of the cellular membrane here takes place in consequence of the infiltration, and not from inflammatory action having been established. The affection has been termed Diffuse Cellular Inflam- mation, but a more proper appellation is Diffuse Cellular Infiltration; the cellular tissue, even where treatment is adopted at an early period, can scarcely be prevented from perishing. Erysipelas, if properly treated from its commencement, will sel- dom terminate in gangrene of the skin. This termination is occa- sionally observed, however, in patients whose constitutions have been extremely debilitated. In mild cases of erysipelas, attention to the state of the bowels, and regulation of diet, will often be sufficient to remove the disease. When there is much disorder of the digestive organs, and particu- larly of the biliary secretions, emetics may be given at the com- mencement ; these are productive of but little good in the more advanced stage, and their place is advantageously supplied by nau- seating doses of antimony, combined or not with purgatives. One- eighth of a grain of tartarised antimony may be given in solution every hour, with "Or without a due quantity of the tart, potassse and sodas, or Rochelle salt. The hydrargyrum cum creta is often given with great benefit when the tongue is dry and covered with a brown crust.: it may be combined sometimes advantageously with the com- pound powder of ipecacuanha. With the same view calomel with antimomal powder may be exhibited. The exhibition of saline purges is attended with great good in some severe cases. Such me- dicines tend to subdue any arterial excitement that may exist eva- cuate the bowels promote perspiration, remove the superabundant bilious matter, and serve to restore the healthy functions of the liver In severe cases, more especially of phlegmonous erysipelas, in which there is acceleration of the pulse, and a degree of febrile excite- ment, general bleeding may be had recourse to; but it must be em- ployed with caution, for the symptoms of increased vascular action may arise from constitutional irritation, and not be meliorated by the depletion The practice is superseded by the timeous and free local bleeding from incisions, as will be noticed by-and-by. The exhibi- tion of the extract of aconite in this and other inflammatoryaffec- tions, is often followed by great abatement of vascular excitement so that the necessity for abstraction of blood is done away wi"h The medicine may be given in doses of half a grain in substance or dissolved in pure water, and repeated every third or fourth hour The sensible effect is relaxation of the surface, and frequently pro fuse perspiration ; the arterial pulsations are diminished in frequency and force. The extract of belladonna, in doses of one-sixteenth of a grain, may then be substituted with great advantage, and often OF ERYSIPELAS. 59 with the most extraordinary effect upon the disease. In very many cases, the strength is from the first to be supported by all possible means, by nourishing diet, by the exhibition of wine, quinine, and and other tonics ; more particularly in old people — in constitutions debilitated by disease — in unhealthy situations, and when the fever is of a typhoid kind. Bleeding by leeehes is not admissible, for the leech-bites prove a source of irritation, and are liable to suppurate ; erysipelas has often been produced by leeching. In erythema, the mere outer surface of the skin only being slightly affected, and not to any very great extent, advantage sometimes re- sults from the application of nitrate of silver. A strong solution may be pencilled upon the part, or after being wetted, the affected sur- face may be gently rubbed over with the solid caustic. The pain and uneasy sensations in the part being thereby diminished or re- moved, and extension of the disease seeming to be arrested. Dis- coloration caused by such practice is of little consequence, as des- quamation must follow. It is questionable how far it may be safe to apply lunar caustic to any extensively inflamed surface, more especially of the head and face, lest metastasis should oceur. The inflammatory action in the skin is subdued by the application, whilst it may advance, in the cellular tissue, to suppuration and sloughing, if other means are not adopted; and from the hard and blackened state of the cuticle, the condition of the subjacent parts is not readily perceived. The remedy is only applicable to ery- thema, and most advantageously as a means of bounding it. The line should be drawn at some distance from the affected tissues ; and if so, it is seldom that the disease oversteps it. Local abstraction of blood, by puncture or incision, proves ex- ceedingly beneficial in cases of erysipelas, whatever its degree. It must be borne in mind by the practitioner, when called to treat the disease, that the state of parts is very various, and this may de- pend upon the original nature of the disease, upon its site or dura- tion. The surface of the skin only may be affected — that and the subjacent cellular tissue may be involved, gorged with serous, lym- phatic, or purulent infiltration — there may exist great tension of the parts, with a sloughy state of the cellular tissue, established in addition to suppuration—and, again, there maybe infiltration of the subfascial and intermuscular tissues, leading ultimately to expo- sure and exfoliation of bones or disease of articulations. From inattention to these circumstances, the treatment being often directed to the name of the disease, great discrepancy of opinion, as to the most proper local management, has arisen ; there has ac- cordingly been a controversy as to whether the blood should be drawn from mere punctures from limited incisions, or from long gashes extending from one joint to another. In cases not very severe or extensive, when the skin only is af- fected, the constitutional treatment already mentioned is first to be employed, and then the affected part must be freely punctured with a fine lancet, at numerous points, as recommended by Sir R. Dob- son. These punctures should reach the vascular layer, but not go deeper ; the serous effusion, if there be any, is thereby evacuated — 60 OF ERVSIPELAS. the over-distended vessels are relieved of a considerable portion of their contents — and the cedematous swelling, with the formation of phlyctense, is prevented. The part is afterwards to be fomented for half an hour, or an hour, with bags containing chamomile flowers or hops; the fomentation, repeated at intervals, proves highly grateful to the feelings of the patient, allays any irritation which the making of the punctures may have produced, and keeps the skin perspirable. Under this treatment, every vestige of erysi- pelas will generally disappear in the course of a few days. In more severe cases, especially in the extremities, the parts must be freely incised. The incisions ought to extend through the integuments and cellular substance, and their length and number must be pro- portioned to the extent and severity of the affection. One or two pretty free incisions, if made in the proper place, where the greatest degree of boggishness, marking the disorganised states of the tissues, is discovered, will generally suffice — the vast good and the relief afforded depends partly upon the abatement of the tension, in con- sequence of the evacuation of the effused fluids — upon the unload- ing of the.over-distended blood-vessels of the part, and upon the ac- celeration of the suppurative process, which is often critical. The constitution is, probably, relieved by the suppuration of the wounds, and the consequent drain of the offending particles. Some surgeons have disapproved of long incisions, alleging that they are tedious in healing, and prefer making numerous small ones; but it is difficult to understand how the cure should be more tedious in the one case than in the other, when the actual extent of divided surface is the same. According to my experience, several incisions are made with less pain than a number of trifling scratches, and heal as soon, whilst by the former the purpose of the practitioner is much better fulfilled : the same good effects result from them as from punctures in the more slight cases, if they are made at the commencement of the disease ; and if the affection is in its advanced stage, the effused fluid, and the sloughs, are discharged, and the in- filtration of pus, and destruction of parts in consequence of the matter being confined, are prevented by its being allowed a free exit as soon as it is formed. Incisions then are made both in the early stage of the disease, and after effusion has occurred : in the former case, they are justifiable, because they arrest its progress ; in the latter, they are absolutely necessary, to prevent its injurious effects. The parts are to be fomented, and afterwards covered with a com- mon poultice, containing no oil or grease, or with soft lint satu- rated with tepid water, and covered with oiled silk, to prevent evaporation. When the erysipelas has gone off, the incisions are treated as common wounds, by dressing and bandage. After punctures, or incisions, more or less blood is allowed to flow, according to cir- cumstances. It often escapes from the vessels of the part in great profusion; this, in many cases, may be prejudicial or excessively dangerous. In the extremities the flow can readily be arrested by elevation of the part, or by pressure, for a short period. In ery- sipelas of the face, punctures are preferable to incisions," as by the OF ERYSIPELAS. 61 employment of the former the countenance is no way disfigured ; if, however, in erysipelas of the scalp, the integuments become swollen, and present a puffy feeling, whilst at the same time cerebral symp- toms supervene, free incision or incisions, through the whole thick- ness of the covering, and in the direction of the fibres, mustbemade. If erysipelas be thus actively treated, it may be safely affirmed that the disease will not often, unless accompanied writh symptoms of putrid fever, terminate fatally : if these means are employed early, the constitutional disturbance will be modified or prevented, and no derangement of the cerebral functions will ensue. Powders, such as flour, chalk, and camphor, &c, have been applied to the erysipelatous surface, but are of little use, and, by their irrita- tion, frequently prove injurious on the bursting of the vesicles. They are applied, according to some, with the view of cooling the surface, and after all the part may be seen enveloped in folds of flannel. Cold application, such as the spirituous and evaporating lotions, con- taining vinegar and spirits, liquor acet. ammonia?, Goulard's extract, &c, may, in many cases, afford temporary relief, but their use is fraught with the utmost danger ; for their direct tendency is to pro- duce metastasis, and if that be to an internal organ of importance, the result is too generally fatal. Or if the erysipelas, on leaving the part originally affected, attack another also superficial, the local treat- ment has to be commenced anew. If these lotions are to be em- ployed at all in this disease, they must be made tepid. In case of the translation of erysipelas to any important part, blis- ters may be applied to the surface which it has left, or to any other in the neighbourhood, with the view of recalling the disease to its original and less dangerous situation : the actual cautery has even been recommended. In the great majority of cases, however, such means are unavailing. In Hospital Erysipelas, purging cannot be carried to any great ex- tent with safety, and general bleeding is seldom if ever admissible, unless with patients previously robust and in good health, in whom the disease has occurred in consequence of their being conveyed to a distance and during hot weather, after an accident or wound, and in whom the fever is of a violent inflammatory nature. In civil hos- pitals, the patients are generally in a weak state before the acces- sion of this disease ; and in their case, after the stomach and bowels are regulated, stimulants are more requisite. Great attention must be paid to cleanliness, the sores must be frequently dressed, and the same sponges must not be used for different individuals : in order to prevent contamination by the promiscuous use of sponges, it is better to clean the parts around sores with lint or tow, and to de- stroy immediately such dressings as have been used. The apart- ments must be well ventilated, and those who are affected with the disease should be separated from the rest of the patients. The local application will vary according to the particular circumstances of each case. Strong escharotics may be required to clean the sur- face of the sores, and put a stop to the sloughing. The nitric acid will answer the purpose well, and is less objectionable than some 6 62 OF ERYSIPELAS. remedies that have been used ; such as the arsenical solution, or the red hot iron. . . [Erysipelas occasionally manifests itself as an epidemic. Lalmiel, a French writer, states that the year 1828 was remarkable for the prevalence of this disease in the Insane Hospitals of Paris, which were literally crowded with patients of this description. Velpeau, in 1831, witnesses a similar tendency in the medical and surgical wards of " La Pitie." Blache and Chomel also speak of having seen it epidemic, especially in the autumn of 1818, a year of exces- sive heat and long drought. Within the last two years an epidemic erysipelas has prevailed in various portions of the United States, and carried off a consider- able number of inhabitants. In its more severe and unmanage- able forms, it affects the mucous membrane of the mouth and fauces, constituting what is vulgarly called " black tongue" or " swelled head." In the surgical and medical wards of the Marine Hospital of this city, where, since February, 1844, there have been nearly one hundred cases of the malady, the slightest surgical opera- tion, a leech-bite, a puncture, or even the application of a blister, has repeatedly brought on this inflammation with all its consequences. The idiopathic form of the epidemic, as far as I have had occasion to observe it, generally begins in some part of the face, as the cheek, nose, or eye-lid, from which it spreads, with more or less rapidity, over the scalp, neck, and other regions of the body. The worst cases are those in which the disease is complicated with inflamma- tion of the tongue and throat. Such has been the tendency to this affection that I was compelled, a few months ago, as a precautionary measure, to decline all important surgical operations, the immediate performance of which was not indispensable to the life of the patient. Lying-in females have also been peculiarly prone to peritonitis, and there is reason to believe that this disease, as it has for some time past prevailed in this country, is nothing but a form of epidemic erysipelas of the serous membrane of the abdomen. In most of the cases of epidemic erysipelas which have fallen under my observation, and which amount to upwards of fifty in number, my main reliance, as a topical application, has been upon a solution of iodine, in the proportion of a drachm of the salt to an ounce of alcohol. This was applied freely upon the part once or twice a day, and almost always succeeded, especially if resorted to early, in arresting the disease, and preventing its termiuation in suppuration and gangrene. In some of the cases the inflamed sur- face was circumscribed by the solid nitrate of silver, or touched with a saturated solution of this substance. From considerable observation, however, I greatly prefer the iodine, since its applica- tion is not only less painful, but much more effectual in putting a stop to the morbid action. Very few of my patients were benefited by the lancet; on the contrary, several were decidedly injured by it, the debility consequent upon its employment rendering the system less capable of throwing off the disease. The internal remedies which seemed to do most good were mercurial purgatives and car- bonate of ammonia, in large doses, with Dover's powder, morphia OF ERYSIPELAS. 63 or opium, to allay pain and procure sleep. Brandy, wine, and porter formed valuable and almost indispensable adjuvants. In protracted cases, and in the erratic form of the disease, the exhibition of calomel, carried to the extent of slight ptyalism, frequently put a stop to the inflammation, where other means failed, or were of but doubtful efficacy. With the sulphate of iron, so much lauded by Velpeau in the treatment of the ordinary form of erysipelas, I have no experience, From the statistical facts, however, published by this distinguished surgeon, it would appear to be a remedy of extraordinary efficacy, well worthy of further trial. He employs it both in solution and in the form of ointment. The former is prepared by dissolving nine drachms of the salt in about forty ounces of water ; the latter by incorporating one drachm with an ounce of lard. The iron must be reduced to an impalpable powder before it is mixed with the lard: it is then to be rubbed freely over, and a little beyond the inflamed surface, and renewed three times a day. The solution is employed on compresses, which are moistened every six hours, and secured by a bandage. The essential point is to keep the skin con- stantly wet with it. In this country no remedy is perhaps more frequently employed in the treatment of erysipelas than blistering. In my own practice I have constantly resorted to it for the last fourteen years, and in no instance has it disappointed my expectations. Not only do I consider it as perfectly free from danger, an objection which has sometimes been alleged against it, but I know of no measure so well calculated to afford prompt and effectual relief. My practice is to apply the blister directly to the inflamed surface, together with a small portion of the healthy skin, and to keep it on until it produces thorough vesication. The vesicles are then opened with a needle, and the part covered with a light emollient poultice or the warm-water dressings. In children, and persons of a nervous, deli- cate constitution, or whose health has been previously much im- paired, the blister must be removed in from three to six hours, other- wise serious focal mischief may be induced. This treatment, although applicable to every species of erysipelas, is particularly valuable in the phlegmonous form, no matter where situated, whether in the face, eyelids, scalp, trunk, or extremities. Another remedy which has been extensively employed in this country, is the mercurial ointment, first recommended to the notice of the profession by Dr. Dean and Dr. Little, of Chambersburgh, Pennsylvania. My own experience, however, does not enable me to offer any thing in its favour. Indeed, if at all useful, it can only be so, it seems to me, in the milder forms of the complaint: in the more severe grades it should never be resorted to, as it is far inferior to blistering, or scarification, as practised by Mr. Liston. The oint- ment should be perfectly fresh, and be applied upon soft linen, at least twice a day. Velpeau has recently recommended methodical compression by means of the roller, and from some cases which he has published in illustration of his method it would seem to be en-. titled to further trial.] 64 OF FURUNCULUS AND ANTHRAX. OF FURUNCULUS AND ANTHRAX. Furunculi, or Boils, most generally occur in unhealthy constitu- tions, particularly in those individuals who are habitually addicted to the use of ardent liquors : they seem to arise from, at least they fol- low, disorder of the digestive organs. Their seat is in the skin and subjacent cellular tissue. They generally occur in those parts which are possessed of little vitality, as in the back, buttocks, shoulders, the posterior part of the neck, &c. They are seldom single, are often numerous, and vary in size from a pea to a pigeon's egg. A boil is of a conical form, elevated above the surface of the body ; its base is hard and firm, whilst its apex is acute, soft, of a white colour, and exceedingly painful; the pain experienced in the tumour is severe and burning. From the comparatively trifling nature of the affection, the assistance of the surgeon is seldom required, and hence the apex of the tumour generally gives way either spontaneously, or in consequence of being scratched by the patient, or rubbed by the clothes ; the purulent matter, which is generally small in quantity, and mixed with blood, is thus discharged. This, however, is attended with but little relief in bad forms of the affection ; for at the lower part of the cone is situated a considerable quantity of mortified cel- lular tissue, which must be evacuated before the cavity can heal. In this unhealthy species of inflammation, resolution cannot be ex- pected ; on the contrary, suppuration is the natural termination of the disease, and must be hastened by poultices and fomentations. A simple or crucial opening, according to circumstances, must after- wards be made in the apex of the tumour, so that the sloughs of the cellular tissue may be permitted to escape readily. In the advanced stage, the sloughs are the irritating cause by which the inflammatorv action is prolonged, and on their removal the cavity contracts speedily. If there is much derangement of the digestive organ, it may fre- quently be found necessary to administer an emetic. If the bowels are slow and the liver torpid, calomel and antimony are highly useful, or other mercurial preparations may be given, in combination with active purgatives ; if the state of the secretions is more natural, these medicines may be administered in alterative doses. The mineral acids are often usefully administered, with the view of removing the disposition to the formation of boils. Twenty minims of the aroma- tic sulphuric acid may be given twice or thrice a day in any conve- nient vehicle. Anodynes are occasionally "required. Anthrax or Carbuncle may be considered as a severe form of boil. It occurs in the plague, and is a characteristic symptom. It appears in the same parts, and apparently from the same causes, as the boil. The tumour is of a more flattened form, slightly elevated above the surface, and frequently of great extent; the base is deeply-seated, hard, and unyielding. The integuments are at first of a bright colour, but afterwards assume a dark-red or reddish-brown hue. The pain is violent and burning. The process of suppuration is very tedious and the matter that is formed is small in quantity. If the tumour is not interfered with, ulceration occurs in its surface, producing vari_ OF FURUNCULUS AND ANTHRAX. 65 ous apertures, through which the matter is evacuated, the discharge is thin and unhealthy, excoriating the neighbouring surface ; and the mortified cellular tissue, remaining at the base of the swelling, keeps up the irritation. The extent of a carbuncle is frequently great, both as to width and depth ; on the back, or buttocks, it not unfrequently attains an immense size. In one instance, the whole posterior part of the neck was involved ; the cellular tissue, muscles, and tendons, sloughed ; and the vertebrae were ultimately exposed. In another case, the whole occiput, the posterior and lateral parts of the neck, and the space betwixt the shoulders, exhibited one continuous mass of carbuncle. By making free incisions, procuring early separation of the sloughing parts, and supporting the strength of their constitu- tions, both patients recovered, though considerably advanced in life. It seldom occurs in the face or head, and when it does, it generally proves fatal. In a male patient in the Edinburgh Royal Infirmary, aged forty-eight, a carbuncle of the size of a very large orange was situated in the centre of the forehead ; by active local and constitu- tional treatment, he soon got well. The affection is sometimes attended with typhoid symptoms, rigors, profuse perspiration, nausea, vomiting, disordered bowels, loss of appetite, anxiety, restlessness, difficult respiration, palpitations, faint- ings, pale-white tongue, low pulse, pale or turbid urine, headache, giddiness, drowsiness, and, in severe cases, with delirium. In old or exhausted patients, the prognosis is unfavourable. An early and free incision must be made into the tumour ; if the swelling is large or extensive, the preferable form of incision is the crucial; the ill-formed matter is thus evacuated, the slough exposed, and more readily allowed to escape. If the mortification of the cel- lular tissue be extensive, and the sloughs prove firmly adherent, the free employment of the caustic potass will be found of much service, 6* 66 OF INFLAMMATION OF THE MUCOUS MEMBRANES. the half-dead cellular substance being thereby completely destroyed, and the surrounding parts stimulated to a new and superior degree of action, necessary for the removal of the mortified parts, and repa- ration of the breach of surface. Poultices and fomentations may afterwards be employed, followed by the warm-water dressing, medi- cated or not. The stomach and bowels must be put into proper order by the exhibition of suitable medicines; and the vis vitse maybe still farther supported by the administration of tonics and stimulants. If, after the separation of the sloughs, the exposed surface shall as- sume an indolent or debilitated action, stimulating dressings, such as turpentine liniment, or elemi ointment may be employed. Such practice will be found sufficient to procure a speedy and favourable termination of the disease, in this country, where we have not to combat any of those malignant diseases with which carbuncle is accompanied in other climates. OF INFLAMMATION OF THE MUCOUS MEMBRANES. Mucous Membranes and the skin are analogous in structure, some- what similar in function, and sympathise closely wTith each other in health and in disease. Both are endowed with that peculiar degree of sensibility wThich enables them to bear with impunity the impres- sions of foreign bodies ; and both are protected from the influence of these bodies by an inorganic covering ; the cutis and rete mu- cosum by the epidermis; the corium of mucous membranes by a laminated epithelium. They are the seat of all excretions, and by them all substances are introduced from without into the system. The capillary portion of the vascular system appears to have some- what the same arrangement in both ; the distribution of blood to the mucous membranes being, howrever, more copious. At the com- mencement and extremity of the alimentary canal, they insensibly pass into each other by means of an intermediate structure, of which the prolabium may serve as an example. In particular circum- stances, they change into each other, both in appearance and in function. Thus, in prolapsus of the gut or of the vagina, the dis- charge from the protruded mucous surface after a time subsides, the rugse disappear, the membrane becomes thickened and indurated, and gradually assumes an appearance exactly resembling that of the skin. In natural paraphymosis, the delicate membrane wThich, in the healthy state of parts, lines the internal surface of the prepuce, becomes converted into a cuticular covering. In neglected and long- continued excoriation of the nates, the raw surface, which wTas at first tender and irritable, and discharged a serous fluid, becomes villous, less sensible, and discharges a fluid similar to a mucous secretion. In sinuses also of long duration, the secreting surface becomes changed, so as to resemble a mucous membrane, and the discharge, from being purulent or gleety, becomes mucous, or at least resembles a mucous fluid. A mucous surface, when inflamed, has for a short time, perhaps, at first, its functions suspended; it then furnishes a secretion, in- creased in quantity, and but little changed in appearance from the OF INFLAMMATION OF THE SEROUS MEMBRANES. 67 healthy fluid ; afterwards the discharge resembles purulent matter, and is termed muco-purulent. When, however, the inflammation is violent, the discharge becomes bloody, oris altogether suppressed, and the membrane is thickened. Inflammation of a mucous mem- brane is very apt to spread with great rapidity, in this respect re- sembling the corresponding affection of the skin. It is attended with a sense of itching, and a burning pain. This pain is much increased by the muscles surrounding the parts being thrown into action, as in expelling their contents, more especially if these be of an acrid quality. The membrane is thickened, and of a spongy ap- pearance; its surface is red, and sometimes covered with flakes of lymph ; occasionally it is much softened, and coated with a viscid adherent mucus ; and it would appear, in many instances, that, in acute inflammation, the membrane is generally softened, whilst it becomes indurated from chronic inflammatory action. When the inflammation is violent, and consequently rapid, considerable quan- tities of lymph are effused either on the surface of the membrane, or into the submucous tissue : and the lymph subsequently becoming organised, the membrane is much thickened, and a contraction is the consequence. The functions of a part lined with mucous membrane are more or less deranged, in consequence of the vitiation of the secreted fluid. • In inflammation of this tissue, metastasis is also apt to occur, from one part of the membrane to another, and from the membrane to the external surface. Cynanche, for instance, often follows upon erysi- pelas of the face and scalp, and vice versa. The passages, the internal surfaces of which are invested by a mucous membrane, are those subservient to respiration, nutrition, generation, and the urinary secretions; in other words, the mucous surfaces are the Pneumogastric and the Genito-urinary. Their par- ticular diseases will be treated of hereafter. OF INFLAMMATION OF THE SEROUS MEMBRANES. On such an extensive subject it is unnecessary to enter fully; not that the inquiry is uninteresting, or that a knowledge of the diseases of the internal cavities, and the mode of treating them, is not re- quired of the surgical practitioner before he can enter into practice, with safety to his patients and comfort and satisfaction to himself, but we have a very important class of diseases to bring under review in a limited space, and it is properly the province of others to treat of internal disorders, and to describe the best mode of alleviating or curing them. It is, however, the duty of the surgeon to treat the inflammatory affections of some of the serous membranes, and the consequences of inflammatory action in most of them; and it is therefore highly necessary that he understand the symptoms, pro- gress, and consequences of such actions. The affections of the se- rous membranes are principally under the management of the physi- cian ; but they not unfrequently follow wounds and surgical opera- tions, and the diseases of several of them are purely surgical. In- flammation of a serous membrane is attended with heat and pain. 68 OF INFLAMMATION OF THE SEROUS MEMBRANES. aggravated by motion of the parts and by pressure; the natural se- cretion is increased in quantity, the process of exhalation being incited, and that of absorption weakened ; the serous fluid accumu- lates. The secretion becomes altered in quality, and assumes a milky appearance ; lymph is effused, generally mixed with purulent matter, and floats in the fluid, or adheres to the surface of the mem- brane, which is rough and flocculent. The adherent lymph becomes organised, being penetrated by numerous blood-vessels ; and thus the original membrane is, in many instances, much thickened, chiefly from the addition of new matter, though also from enlarge- ment of its blood-vessels and opening out of the primitive tissues, principally the subserous cellular. When inflamed serous surfaces, wdiich have been altered, both in texture and function, in conse- quence of inflammatory action, remain for a short time in contact with each other, lymph is effused and penetrated by blood-vessels from each surface ; thus the new deposit is organised, and forms a medium of connexion. By this process the parts are intimately united to each other, and consolidated into one mass ; or are merely approximated, and joined, at one or more points, by portions of lymph, in some cases thin and narrow, in others extensive and of considerable thickness ; the adhering bands either extend in a straight direction, from one surface to another, or interlace, forming a sort of network. After adhesions of various kinds have been formed, they are often lengthened and attenuated in consequence of the motion of the parts, as is particularly the case with adhesions between the pleura costalis and pulmonalis. When they have been of consider- able duration, they often resemble the original membrane from wdiich they were deposited, becoming thin and transparent, smooth on their external surface, and furnishing a serous secretion. Not unfrequently, inflammatory action in this tissue terminates in sup- puration ; and the pus, secreted by the membrane, accumulates in the most dependent part of the cavity. By collections of matter, whether serous, sero-purulent, or purulent, within a serous cavity, the functions of the contained viscera are deranged, much impeded, and in many instances morbid actions are excited in them. The inflammation, whether it terminate in resolution, or proceed to se- rous effusion, adhesion, or purulent secretion, is attended with con- stitutional disturbance, and the symptoms arc proportioned to the original intensity of the action, and the extent and kind of its termi- nation. The effusion of lymph, and consequent adhesion, is, how- ever, in many circumstances, a highly salutary process, as in wounds and injuries of the hollow viscera : effusion of their contents being thereby prevented, «and the patient being saved from the danger attending violent inflammation of those cavities and their cover- ings, caused by the escape of a greater or less quantity of irritating extraneous matter. Purulent collections also, in the solid internal viscera, are thus allowed to discharge themselves externally. The nature, symptoms, and consequences of inflammation of serous mem- brane will be more fully considered under the diseases of particular parts. OF DISEASES OF THE JOINTS. 69 OF INFLAMMATION OF TISSUES COMPOSING THE ARTICULATIONS. Inflammation of the synovial surface occurs in consequence of wounds, bruises, or sprains, and often from exposure to cold ; from the latter cause, the knee and elbow joints most frequently suffer, as they are generally more exposed to its influence, and not so well covered with muscular substance as the others. Constitutional dis- eases, such as certain fevers, are followed sometimes by effusion of serous fluid into joints. Purulent matter is also deposited in joints during certain forms of suppurative fever ; and this is attended by rapid change of structure. There is heat, throbbing, pain, and swelling of the part, sometimes redness of the surface, and great constitutional disturbance ; the symptoms and appearances, however, vary much, according to the extent of the joint which is involved. When part of the capsule is affected, the inflammation spreads rapidly over all the surface ; the synovial membranes resembling the serous in this respect, as well as in healthy structure and function. Like the serous, too, they are shut sacs, are smooth on their surface, and furnish a secretion, the synovial, for facilitating the motion between opposing surfaces; it is, however, somewhat more glairy than the serous. Neither, in their healthy state, are possessed of much sensibility, nor are ligaments, tendons, tendinous sheaths, and bursse, which twTo latter textures resemble in every respect the synovial; when inflamed, they become most exquisitely sensible. The incited action of the blood-vessels is followed by increased discharge, which is less glairy and albumi- nous, partaking more of the serous character. When the incited action soon terminates, and the activity of the absorbents is dimi- nished, the fluid accumulates within the joint, producing Hydrops Articuli. This accumulation of fluid in joints may take place without being preceded by any apparent inflammation, and may remain a long time without any visible change of structure in the membrane. The knee is more frequently the seat of dropsy than any other joint. When the action is more violent, and is not actively opposed, lymph is effused on the inner surface of the membrane, or is depo- sited amongst the ligamentous and cellular tissues external to the joint, in consequence of which, the membrane and external liga- ments become thickened, and of an almost cartilaginous consistence. Serum is effused into the more superficial cellular tissue, filling up the hollows around the joint, concealing the protuberances of the bones, and producing a globular swelling. The articulating surfaces become ulcerated, and matter forms within the capsular ligament; or the pus is deposited exteriorly to the joint, and gradually approaches the surface. But although ulceration is so prone to occur in the carti- lages, the synovial membranes do not readily take on this action, unless from the progress of matter, formed within the joint, towards the surface. The synovial lining of the bursse and sheaths of the tendons are extremely indisposed to ulcerate; and it may be re- marked, that, while suppuration without ulceration is common in the synovial membranes, the cartilages, on the other hand, afford frequent instances of ulceration without suppuration, of which more 70 OF DISEASES OF THE JOINTS. particular mention will be made in the sequel. The cartilage is oc- casionally swelled and softened where the disease has long existed. Along with ulceration of the cartilage, a portion of it may become dead, or either state may occur separately ; and in many cases, the substance of the bone also becomes affected, of which two classes of cases may occur, viz., great inflammation on the articular surface of the bone, with separation of the cartilage by the ulcerative process in this situation ; and inflammation of the medullary web, leading to atrophy of the cancelli, collections of pus therein, or even death of a portion of the spongy texture of the bone, as will be more particu- larly treated of in the chapter on diseases of the osseous tissue. These changes often compose the primary disease, and to them the affections of the synovial membrane and other parts succeed. Such occurrences are attended with alarming disturbance of the constitution, with fever, and even with the most threatening and dangerous symptoms, such as delirium and coma. If the patient survive, and the matter be evacuated from the joints by openings into its cavity, hectic fever is almost certain to supervene. An opinion has been broached lately by Mr. Key, that the ulcera- tion of cartilage wras consequent upon the increased vascularity and thickening of the synovial membrane, that the cartilage, in fact, was removed by the action of the vessels ramifying in the membrane, and the prolongations or fringes from it in its diseased condition. Occasionally these fringes correspond, in a remarkable manner, to the breach of surface in the cartilage ; but again, ulceration is fre- quently met with far removed from the membrane. It is also seen, in cases where an opportunity is afforded of making the examina- tion in the earlier stage of disease, that ulceration exists to some extent whilst the synovial membrane is unaffected. And certain cases, in which the cartilage is affected with hypertrophy, and the common form of atrophy of this part in old people, are altogether adverse to Mr. Key's views. When ulceration takes place at a point removed from the attachments of the synovial membrane, it appears to proceed more frequently from the attached than from the free sur- face of the cartilage ; then the adventitious membrane occupying the rugged spaces, and which under the microscope appears highly vas- cular, is connected apparently with the medullary web. In acute inflammation of the synovial membrane, and in cases where the cartilage is ulcerated, the pain is very intense, and the spasms of the limb most distressing. This happens when the surface is ulcerated, and perhaps to no great extent. We know that in the horse an ulcerated hollow in the cartilaginous covering of the navicu- lar bone, not so large as to contain a grain of barley, will cause such lameness and suffering as to render the animal so affected perfectly useless. If he is not destroyed at this stage, as many valuable ani- mals have been, the mischief extends, and terminates in extensive disease of that and the neighbouring bones and articulations. It is different if the disease commence, as it sometimes does, in the hu- man subject, in the cancelli of the bone, and on the attached sur- face of the cartilage, the free surface remaining some time entire and smooth. When the synovial membrane is primarily affected by OF DISEASES OF THE JOINTS. 71 chronic disease, the pain is in general trifling, often not complained of, and swelling of the part, from effusion, into the joint or neigh- bouring bursse, first attracts attention, after it has existed, perhaps, in a slight degree, for a considerable time. The joint is stiff, and pain is experienced from extensive motion ; on this account the patient is disinclined to use it, and it is soon tired by the slightest exertion. The swelling becomes more solid, though still remaining elastic, and the feeling of fluctuation diminishes. Effusion of lymph follows that of serum, the latter having been absorbed ; the motion of the joint is still further impeded, and the articulation is distorted ; the patient keeps the limb in the most easy position, generally that of partial flexion, in which it becomes almost immovably fixed. The cause of the flexed position, which is almost pathognomonic of knee disease, being preserved, seems to be that the limb is insensibly brought into it in order to take the pressure off the interarticular apparatus, the ligamenta mucosa and alaria, — these swell — the muscles of the hamstrings yet contracted from habit, and a difficulty, even after the disease is completely subdued, is often enough expe- rienced in procuring complete extension. The muscles, from disuse, shrink, the adipose substance is absorbed, the shafts of the bones also are diminished in size, get into an atrophied state, as the phrase is, and thus the whole limb is rendered slender and wasted, so as to make the swelling of the diseased articulation still more conspicuous. The bones are softened, and the muscles are of a white colour, as in the limbs of the paralytic or bedridden, and resemble more cellular than muscular tissue. The wasting of the muscles and loss of power often precede the appearance of disease ; this is frequently observed in the shoulder-joint, the deltoid shrinking, and almost disappearing, before any disease in the articulation is suspected by the patient. Not unfrequently, also, this wasting occurs without obvious cause, or any affection of the joint. When the disease is advancing, the patient may feel no acute pain, but merely a reluctance to use the limb ; and from this, if long continued, the muscles, and afterwards the bones, become wasted. Wasting of the limbs in children, often of one of the lowTer, frequently arises from disorder of the bowels, and the irri- tation and debility attendant on teething. This must be distinguished from the wasting accompanying diseased joint. The history of the case, the period at which the weakness of the limb wTas observed, and its appearance, will lead to a correct diagnosis. The swelling is often irregular, being more protuberant at one part than another, from the fluid or the addition of solid matter being ac- cumulated where the least resistance is afforded ; but the slighter in- equalities are generally filled up by oedema of the cellular texture. As the disease proceeds, matter forms in the joint, and is often at- tended with great pain and fever ; or the pus is effused into the bursa?, into the surrounding cellular tissue, or into the filamentous tissue amongst the tendinous sheaths of the muscles in the neighbourhood ; being allowed to remain without an outlet, it at length communicates with the cavity of the joint.. Portions of the cartilages are absorbed, though this, as already noticed, may occur at the very commence- ment of the disease ; the subjacent bone becomes affected by ulcera- 72 OF DISEASES OF THE JOINTS. tion, or perhaps its vitality is partially destroyed. When matter has accumulated, a portion of the capsular ligament generally ulcerates, the pus escapes, and is ultimately discharged externally. When the disease begins with swelling, which is of a chronic character, and produces but little inconvenience, and when the more urgent symptoms supervene after the swelling has continued for a considerable time, there is every reason to suppose that the disease has originated in the synovial membrane, or perhaps in the osseous cancelli, and this is generally met with in poorly fed and strumous subjects. But when the first symptoms have been pain and stiffness of the joint, without change of its appearance, and when the swelling has occurred after these symptoms have been of some duration, then it is probable that the cartilages are the primary seat of mischief. For the most part, however, the symptoms have a general resem- blance in most chronic affections of the joints, and all the apparatus is sooner or later involved. When the cartilage has been extensively absorbed, a grating sensation is felt in moving the articular surfaces of the bones upon each other. In consequence, also, of the softening and disorganisation of the lateral and other ligaments, the affected articulation at length becomes unnaturally loose, w7hich is owTing in some measure, also, to the muscles being wasted and paralysed from pain and disuse. At an earlier stage of the disease, the joint may be rigid from deposition of lymph into the contiguous cellular tissue, and contraction of the muscles. Purulent matter not unfrequently collects in the substance of the bones, which in all cases ultimately become softened in a remarka- ble manner. In many subjects, without actual disease of the os- seous tissue, the heads of the bones are so altered in consistence, are so deficient of earthy matter, as to be easily cut with the knife. It has been a matter of dispute, whether, in this affection, the articulating extremities of the bones are enlarged or not; and the supposition that they are always more or less increased in size, or hypertrophied, has arisen from the extensive effusion and indurated state of the soft parts being mistaken for this enlargement. In the first stages of the disease, they are seldom, if ever, enlarged ; but when ulceration of the bone has occurred, new osseous matter is deposited to a greater or less degree in the neighbourhood of the ulcer, — an attempt by nature towards a cure, but too often an ineffectual one. The bones, in strumous subjects, are often much enlarged, from collection of purulent matter in their substance giving rise to a sort of spina ventosa. I removed the upper extremity of a boy lately on ac- count of extensive disease about the elbow. The ulna to near the wrist was swollen enormously by purulent collections in its medul- lary canal. In cases when the whole of the articulating extremity of the bone is not enlarged, still that portion which is more imme- diately concerned in the articulation is often considerably expanded. Frequently when the knee is the seat of the disease, the lym- phatic glands in the groin are enlarged ; and when the elbow or wrist joints are affected, there is often a similar enlargement of the glands in the axilla: such glandular tumours have not rarely been confounded with those accompanying malignant disease, and mea- OF DISEASES OF THE JOINTS. 73 sures which were absolutely necessary for the salvation of the pa- tient, have thus been delayed or neglected. When the disease is extensive, and has endured for a considera- ble period, hectic fever supervenes, and is aggravated after the ab- scesses give way. The patient becomes much weakened and ema- ciated, and loses his appetite ; the pulse is rapid, with night sweats, diarrhoea, &c. ; and from a continuation of the hectic cause, the life is endangered. In some cases, however, the health is restored, and the disease abates spontaneously ; in others, the disease is arrested, and a complete cure accomplished, by the careful employment of such means as will be afterwards mentioned. The appearances produced by inflammation and consequent dis- ease of the synovial membrane, are the following. In the first stage, the internal surface of the capsular ligament, and the rest of the synovial membrane, is found of a red hue, its formerly colour- less vessels being now made apparent, from enlargement and conse- quent injection with a greater quantity of red blood ; and the serum within the cavity of the joint is more abundant than in the natural state. When the disease has been of longer continuance, the mem- brane is found considerably thickened, its usual smooth glossy sur- face is destroyed, it is irregularly flocculent, and frequently of a light yellow colour. The interarticular adipose tissue also seems to be increased in volume, from being infiltrated with a serous fluid, by the discharge of which the diseased blood-vessels may have attempted to relieve themselves. When the inflammation has been intense, or of long duration, lymph is secreted, and deposited on the external surface of the membrane, forming an intimate union between it and the ligaments, and producing thickening of the external apparatus. Or the lymph is also effused on the inner surface of the membrane, to which it adheres and becomes organised ; this is generally accom- panied by the formation of purulent matter; the organised effusion is often so extensive as to conceal almost the whole of the synovial membrane, excepting portions of its delicate reflexions which in- vest the articulating cartilages. By the lymphatic deposit, to a less degree, the folds also of the synovial membrane adhere to each other, whereby the motion is still farther impeded, and the pain, when attempted, increased. Occasionally the synovial membrane is found enormously thickened, much softened in texture, and of a brown hue, when the disease has been of a very chronic character. Along with these appearances, serum is generally found effused, in a greater or less quantity, into the cellular tissue exterior to the liga- mentous covering. In cases in which the matter has formed and re- mained long within the cavity of the articulation, the synovial mem- brane and the ligaments become blended into one soft mass, the in- ternal surface of which is lined with a thick coating of lymph, as in the case of common abscess. If purulent matter is effused exter- nally, and communicates with the joint, the capsular ligament will be found to have ulcerated and given way at certain points, forming apertures, usually of small size, and with ragged margins. 7 74 OF DISEASES OF THE JOINTS. All these appearances may exist without disease of the cartilages or extremities of the bones; but generally they are also affected at the same time. At first the surface of the cartilage is slightly irregular and rough, and the change is not observed, unless on minute inspection. Afterwards the surface is marked with small depressions, which may be numerous, and are surrounded with irre- gular and somewhat serrated margins. They gradually increase in depth and extent, and the subjacent bone is ultimately exposed at one or more points, as here shown. Often the greater part of the cartilage is removed by absorption ; the bone is exposed, opened out in its texture, softened, of an irregular sur- face, and in some places excavated, contain- ing a thin ichorous fluid ; the process of ulce- ration has also extended to the osseous tissue. Sometimes scales of cartilage of considerable size are either completely detached, having become dead, and been thrown off by the natural process, and are found lying loose in the cavity of the articu- lation ; or they are all but separated, adhering by one or more very slender attachments. The incipient stage of such disease may exist without the syno- vial membrane being much, if at all, affected ; but when the ulcera- tion has made farther progress, all the articulating apparatus is more or less diseased. It may be here remarked, that the synovial mem- brane may be affected for a long period, thickened portions may ex- OF DISEASES OF THE JOINTS. 75 tend over the cartilages, and these may have lymph upon them and yet remain intact. The cure, resorted to by nature, and in which she may be much assisted by the surgeon, is Anchylosis, ligamentous or osseous. New bone is deposited in the neighbourhood of the disease, and the ul- cers become, as it were, cicatrised; the articulating extremities of the bones are joined to each other by a firm osseous matter, either universally disposed or consisting of processes extended between the bones at various points: or again, in consequence of the effusion of lymph into the cellular tissue, and the consequent thickening and in- duration of that and of the fibrous tissue exterior to the joint, this con- necting medium is so strengthened and concentrated as to retain the articulating surfaces in exact apposition ; from one, aad usually from both, of these changes, the joint is securely fixed and rendered im- movable, or nearly so. In complete anchylosis, the cancellous tex- ture of the two bones, after some time, becomes perfectly continuous, so that they in fact constitute but one bone, as seen in the cut, p. 86. A very perfect specimen of anchylosed knee joint is also de- lineated in the cut above. But even after this happens, the disease is still apt to recur from slight causes, the bony or ligamentous union •being disturbed or destroyed, and the original disease attacking the parts with fresh activity ; abscesses form, — may be extensive both in size and number, — and thereby the health is again undermined. So that the patient, after undergoing much suffering and risk, pre- serves, perhaps only for a few years, a limb which is almost useless to him, and which must be removed at last. In other cases, the union is permanent, the disease does not return; by care and time the limb is brought into the most convenient position, and proves of considerable service. The joints are often affected by rheuma- tic and gouty inflammation ; and there are three species of disease, tolerably distinct in their pathological characters, generally attributed to these causes. In one there is a deposit of chalky-looking matter, com- posed chiefly of super-lithate of soda, on the articular surfaces of the synovial membrane and cartilage, but most abundantly in the cellular tissue outside the joint, an affection in which the cartilage is seldom known to ulcerate. In the second, the cartilages are atrophied, as if worn away by attri- tion, the articular surfaces of the bone being much modified in shape, more or less denuded of cartilage, and remark- ably polished and hard, so as to have been compared to porcelain, as will be de- scribed in another section. In the third, the fibrous tissue in the neighbourhood of a joint is primarily affected, the synovial membrane and cartilages not becoming in- volved till the disease is much advanced. It is not uncommon in 76 OF DISEASES OF THE JOINTS. the elbow of middle-aged persons who have been much exposed to the atmospherical vicissitudes, and is sometimes attributed to the effect of mercury or syphilis. The periosteum around the articular ends of the bones becomes swelled and painful; the affection is very slow in its progress; abundant deposition of adventitious bone takes place, often in short spiculae, gradually encroaching around the joint, which ultimately becomes involved. A good specimen is here given. The disease was of twelve months' duration, and was attributable to rheumatic inflammation supervening upon sprain. The affection involves extensively all the bones composing the arti- culation. Although wounds penetrating the larger joints are attended with danger, the synovial membranes are possessed of considerable pow- ers of reparation, and often heal readily after severe injuries. An occasional result of inflammation is adhesion between the layers of the membrane, but this is by no means so frequent as in the serous tissues. The reparative power of cartilage is so low that the best termination that can be expected, from the ordinary forms of ulcera- tion, is union between the abraded surfaces. In experiments which have been made on the lower animals, portions of cartilage which had been removed from their joints were never reproduced, but the functions of the part were soon restored by the cut surface becoming smooth. In like manner there is occasionally to be seen in museums a circumscribed indentation in human articular cartilage, as if it had been destroyed by a small ulcer in this situation, which had cica- trised without any reproduction of the destroyed tissue. ON HYPERTROPHY AND ATROPHY OF THE ARTICULAR CARTILAGES, WITH EBURNATION OF THE SURFACES OF THE BONES. It has been already observed (at page 70), that the cartilages are occasionally swelled and softened in cases of chronic inflammation; and it now remains to notice instances in which they become hyper- trophied or atrophied, apparently without inflammatory action. Although these affections are not likely to come often under the treatment of the surgeon in civil life, yet they are of much impor- tance to the naval or military practitioner, since an accurate know- ledge of them will lead him to institute a careful inquiry when a man complains of inability to sustain the fatigue of marching with the burden of a heavy knapsack ; and they are of considerable inte- rest in a physiological point of view, because they tend to show the inherent vitality of cartilage, and that it is liable to serious organic changes quite independently of diseased action in the surrounding tissues. Some examples of hypertrophy of cartilage, principally affecting that of the patella, have been described by Mr. Gulliver, and figured in the third fasciculus of drawings from the Army Anatomi- cal Museum. In these the cartilage is swelled so as to form a ridge across the articular surface of the bone, the hypertrophied part being perfectly smooth, except where its continuity is interrupted by irre- gular fissures, as if the perpendicular cartilaginous fibres were split DF DISEASES OF THE JOINTS. 77 into bundles of variable size and shape. These cases occurred in young and middle-aged men who died of pulmonary consumption ; and it is probable that the disease would be more frequently found, if it were more frequently looked for, since it does not seem to have been accompanied by any change in the surrounding parts, and would perhaps only be indicated by weakness of a joint rendering it unfit for severe work. The atrophy, or absorption of cartilage, is so frequently seen in the joints of old subjects, that some authors have been disposed to regard it rather as a physiological than a pathological condition. It is, however, unquestionably a disease ; and in the drawings above mentioned, are some specimens of it from a soldier under the mid- dle age. The cartilage seems in the first instance to be opened out in its texture, and numerous little villous processes appear on its surface, often as if its fibres were enlarged after absorption of the substance which connected them. The thinning sometimes takes place in patches, occasionally in grooves, corresponding to the mo- tions of the articular surfaces ; the subjacent bone becomes at lengtis completely denuded, and soon presents a polished porcelain-like surface, which is so remarkable that it is commonly known under the name of porcellaneous deposit. It is obvious that, when the disease has proceeded thus far, the joint must become more or less deform- ed, and its motions considerably impeded. Accordingly, old men are often seen at work with much rigidity of the joints, particularly of the knee, which is frequently projected inwards, from absorption of the cartilage from the outer condyle of the femur and correspond- ing part of the tibia, with a thinning and degeneration of the inner- articular cartilage into a tissue resembling the cellular. The hard, polished, and ivory-like appearance of the articular surface, would lead us to suppose that it contained an unusual quan- tity of earthy matter, yet an analysis by Dr. Davy, here given, shows the contrary. Composition of the Shaft. Composition of the polished Articular Surface. Phosphate of lime, &c. 58*8 Phosphate of lime . 54-2 Animal matter . . 41*2 Animal matter . . 45.8 100-0 100-0 In many instances where the disease is of long standing, a de-. posit of adventitious bone takes place around the articular surfaces, and this may occur to such an extent as to produce anchylosis of the joint, the articular extremities of the bone often presenting several irregular depressions, and becoming variously altered in shapes, as shown in the cuts, p. 88. It is curious that the atrophy of cartilage is generally seen in its early stage to attack the joints in pairs, and to occur also in corre- sponding parts of the articular surfaces ; a fact which coincides with the disposition of caries to appear simultaneously or succes- sively in corresponding molar teeth. 78 OF DISEASES OF THE JOINTS. Of the causes of the disease but little is known, although it is generally attributed, like some other obscure affections, to the effect of rheumatism. It often follows in old people upon long disuse and confinement of a limb to one position, as during the cure of frac- tures. A very valuable specimen was presented to me lately by my friend Mr. Busk, of the Dreadnought hospital ship. The elbow had been apparently subjected to great injury. The radius and ulna had been fractured : the former had united, whilst a false joint had been formed betwixt the portions of the ulna. There is profuse deposit of bone around the elbow-joint, which must have been quite stiff, or nearly so, as regarded flexion and extension; but the end of the radius and corresponding articulation of the humerus are beautifully polished. The polish is not unfrequently seen also upon disunited fractures, as in the neck of the femur. Atrophy of the cartilages has been seen where no rheumatism was ever known to have troubled the patients; and they are more generally disposed to ascribe it to the effect of incessant hard work. At all events it is comparatively rare among women, and in the upper ranks of society ; and the wasting often presents very much the appearance which would result from the effects of attrition, as if the wear of the cartilage had not been supplied by a corresponding reproduction. It is probable, therefore, that the affection is attributable to defective nutrition, somewhat allied to certain changes in the cornea, which are known to proceed from this cause, and which are also unattended by inflammation or the formation of pus. The symptoms of the disease are generally obvious enough in the more advanced stages by the crackling which may be heard when the joint is moved ; and in the early stage a grating maybe felt by a careful manipulation. SCROFULOUS DISEASE OF JOINTS. Affections of the membranes, ligaments, and bones, often occur in persons of weak constitutions, and proceed very gradually. They have been all classed under the general term of white swelling. They most frequently present themselves without any assignable cause, or are attributed to the slightest injuries. The disease generally com- mences in the cancellated texture of the bones: these are soft and light, and contain in their cells a quantity of caseous or tubercular matter. The softness is attributable to an interstitial atrophy of the bony tissue, as well as to an alteration in the proportion of its con- stituents ; the animal matter being in excess, with a corresponding deficiency of the phosphate of lime. There is an increased vascu- larity of the medullary membrane, and the cancellated texture con- tains thin brownish-looking fluid instead of marrow. In cases of disease which has commenced in the cancellated texture, there is hardly any pain at first, and the progress of the disease is remarkably insidious. When the lower extremity is affected, the child is ob- served to limp ; the limb wastes ; it appears to be longer, partly from atrophy of the muscles, partly from relaxation of the ligaments and effusion into the joint. OF DISEASES OF THE JOINTS. 79 The term white-swelling, which ought to be discarded from sur- gery, was at one time made to include all the different affections to which joints are liable in weak constitutions — thickening of the parts, with an external colourless swelling — collections of matter about articulations, with or without an external aperture — effusion of fluids into the cavities of joints, or into the bursse — destruction of cartilage by ulceration, or in consequence of portions becoming dead — absorption, ulceration, caries, or intractable ulceration of the bone adjoining the articulation. Those under twenty years of age are most liable to chronic affec- tions of the joints, and they occur very frequently in children. Great anxiety is often shown by friends of patients to account for chronic disease of a joint, so as to save their whole generation from the im- putation of being tainted with scrofula. It is attributed, sometimes correctly enough, to some injury perhaps trifling; to a sprain, or twist, or squeeze from a tight shoe, or to a bruise from falling ; and it is no doubt true, that young or old people of the most healthy con- stitutions, if thrown out of health from one cause, will present all the appearances of scrofula, and become affected with chronic diseases of the mucous membranes, glands, joints, or bones, from very slight existing causes. Such affections advance slowly ; all the articulations are liable to them ; but those which are most subject to the disease are the hip, knee, ankle, and elbow. Of these, the knee-joint is most frequently affected, probably from the greater extent of cancellated and articu- lating surface. In young persons of unhealthy constitutions, the joints not unfrequently become affected one after another, and super- ficial abscesses form, terminating in open sores. I was obliged to amputate the upper extremity of a young lady a few days ago, in which a metacarpal bone and its articulation, the entire chain of carpal bones, the wrist and elbow joints, were all thoroughly involved in disease. * NEURALGIC AFFECTIONS OF JOINTS. The joints, like other parts of the body, are very often the seat of painful affections, without organic disease existing. These neuralgic affections are often connected with, or followed by, hysterical symp- toms. They frequently also depend upon derangement of the diges- tive organs, — upon the lodgment of irritating matters, sordes, or worms in the intestinal tube ; and when we reflect upon the extent of the lining membrane, the expansion of nervous filaments, and upon the sympathy which they hold with the whole system, we cannot be astonished at the circumstance. Many cases of supposed hip-disease in children, with the symptoms and some of the signs of it, have come under my notice, which have yielded at once to the expulsion of offending matters or worms. Some affections of joints seem to depend upon gouty diathesis; others are intermittent: at one time the joint complained of is hot, and somewhat swollen ; at another cold, and bluish on the surface. In these affections of joints the pain, indeed, is seldom constant: the patient's rest is not broken ; there 08 OF DISEASES OF THE JOINTS. are none of the violent spasms during sleep, which attend upon cer- tain alterations of structure. The pain is equally complained of when the part is touched with the utmost gentleness, or when a thorough and searching examination is made, when the joint is freely moved, and the articulating surfaces of the bones are forcibly squeezed against each other. The pinching of the skin causes pain. There is seldom throbbing, or heat, or swelling; though, after long continuance of the diseased state, these may supervene to a slight extent. The pain complained of is seldom referred to one point, but to a large extent of the limb ; and if the attention is diverted, the examination may be carried to any extent, without complaint being made. Sir B. Brodie, who has done a great service to the profession by directing attention to these nervous affections in his excellent work, and in his lectures, notices that the knee, when the seat of pain, is generally kept in the extended position, and this is very different from what has been s^ted to be the position of one affected by organic disease. The tumefaction following upon local treatment, and espe- cially when leeching and counter-irritants have been employed, is sometimes, as he remarks, very perplexing. This class of diseases generally affects females of delicate organi- sation about the age of puberty, and in whom the menstruation is irregular. Males in delicate health are also subject to similar affec- tions. ON GROWTHS FROM THE SYNOVIAL MEMBRANE, AND LOOSE SUBSTANCES IN THE JOINTS. The synovial membrane is sometimes studded on its inner aspect with loose fleshy or semicartilaginous substances projecting into the cavity of the joint. The entire surface of the membrane is occa- sionally covered with these bodies, which are of a white or yellow- ish colour, and very variable in size and shape ; the smallest pre- senting the form of villi not much larger than those of the jejunum, the largest having somewhat the magnitude and appearance of the appendices epiploicae of the large intestine, while many of an in- termediate size approach in appearance to a lemon-seed. In some instances the membrane is only partially pervaded by them, and they are not unfrequently arranged like a fringe around the edge of the articular surfaces. They are generally very smooth on the surface, which appears to be perfectly continuous, if not identical, with the synovial membrane. Their attachment is frequently broad, and oc- casionally very narrow and pedunculated, often merely filamentous, so that a little further thinning of the part, or slight force acting on the body, would remove it from the capsule, and throw it loose into the cavity of the articulation. The disease has been most fre- quently seen in the knee, and sometimes in the elbow. The affection is obscure in its nature ; it is slow in its progress; the joint is the seat of pain after and during exercise, probably from the morbid processes interfering with the motions of the ar- ticular surfaces. As the disease advances, the joint becomes swelled and elastic, unattended generally by ulceration of the tis- OF DISEASES OF THE JOINTS. 81 sues within or around it. In examining the part, when the articu- lar surfaces are moved on each other, it will be found that their motion is more or less interfered with; and considerable irregu- larity in their action may be felt by the hand placed firmly on the joint during the procedure. Loose bodies may be found in the articulations, particularly in the knee and elbow, under the circumstances just described ; but we often find others of a different structure loose within the capsule, which may be throughout smooth and apparently healthy. These bodies are extremely variable in size, generally rounded or oval, with a polished surface ; many of the smallest present the character of fibro-cartilage or cartilage ; the larger are often more or less mo- dulated, very firm and gristly, and sometimes contain a considerable nucleus of bony matter. The articular ends of the bones are occa- sionally more or less misshapen by the formation around them of knobs of adventitious osseous substance. The disease is common in the knee; and patients frequently go about for years, who will tell you that they have something rolling within the joint, which will often be found on examination to be ac- tually the case. It is obvious that loose bodies in the joint must prove an obstacle to easy progression ; and the smaller ones seem to be particularly so, probably from becoming easily entangled by different parts of the articular apparatus. However difficult it may be to account for the cause of these for- mations, the means by which they may get within the articulation seem obvious enough. If a small knob of coagulated lymph should form on the inner aspect of the membrane, the point of attachment, as has already been noticed, might gradually become narrower, from the motions of the joint or other causes, till the connexion were severed. But there is reason to believe that many of the substances found loose in the joints are formed altogether in the cellular tissue without the capsule ; for it is difficult to conceive that they can in- crease in size, or take on the ossific action in their centre, by an act of independent vitality, after they have been separated from the surrounding parts. Accordingly, dissection has occasionally dis- closed loose bodies within the knee-joint, and others of just the same structure outside the synovial membrane, which was however protruded by their pressure, and appeared to connect some of them by a pedicle only, ready to break and allow the foreign body, with its covering of the membrane, to fall into the cavity of the articu- lation. [The symptoms which denote the presence of a cartilaginous concretion of a joint, as, for example, of the knee, although in general well-marked, are sometimes so obscure that the nature of the disorder eludes the most careful examination. In many cases, especially when the extraneous body is large, the patient experiences little inconvenience ; if, on the contrary, it is comparatively small, and moves back and forth through the joint, or glides between the articulating surfaces, it usually creates severe pain, and may even induce violent inflammation of the synovial membrane. When the concretion gets behind the patella, and the patient is standing or 82 OF DISEASES OF THE JOINTS. walking, he is often seized with a sudden pain, with swooning sen- sations, and is obliged to sit down, to save himself from falling. At night the least motion of the limb will sometimes cause great uneasiness, and rouse the patient from his sleep. While the pain continues, the knee is frequently more or less en- larged ; but the swelling is never so great as to prevent the surgeon from feeling the foreign body, which generally forms a projection under the integuments at the outer or inner part of the joint, and may be easily pushed from one side to the other. Occasionally the concretion slips to a particular part of the articulation, where it cre- ates so little pain and inconvenience that the patient imagines he has got rid of his complaint. After some time, however,' it is forced into another situation, thus causing a renewal of all the for- mer symptoms.] AFFECTIONS OF SYNOVIAL POUCHES OR BURSSE. Bursas are lined by a membrane, greatly resembling the synovial in appearance, function, and disease. They are frequently the seat of inflammation of an acute character; but in most instances the action is of short duration, and generally terminates in an increase and accumulation of the secreted fluid. The attendant pain is very severe, and much increased by any motion of the neighbour- ing parts. Occasionally a portion of the cellular substance,which is exposed to pressure of motion, as over a prominent portion of bone, assumes the appearance of a bursa, secretes a similar fluid, and is similarly affected in consequence of inflammation. These adventitious bursa? are met with in various situations. Bunion is a good example of such a bursa thickened from long-continued pressure. They are seen on the outer ankles of tailors, on the shins of boot-closers, on the forehead, point of the elbow, &c. Disease of the bursse may occur from external injury, and they often become affected subsequently to disease of the neighbouring joint. If the action is violent, lymph is effused on the inner surface, or ex- ternal to its cavity, causing considerable thickening. The sac is thus sometimes all but obliterated. Tumours, originally house- maid's knee, aggravated by continued pressure, are met with over the ligament of the patella in almost a solid state. Occasionally the action terminates in suppuration, pus being effused to a greater or less extent into the cavity; and if allowed to remain or accu- mulate, the abscess extends, and frequently communicates with the neighbouring joint, which may not have been previously diseased. In chronic cases of enlarged bursse, especially of the bursal thecae of the tendons of the wrist or ankle, we not unfrequently meet with loose cartilaginous bodies of various sizes, and of a flattened oval form floating in the accumulated fluid. These have been also supposed to be formed by portions of lymph which have been de- posited on the surface, condensed in structure, and afterwards be- come detached. When inflammatory action has commenced in a bursa, it must be OF DISEASES OF THE JOINTS. 83 subdued by copious topical bleeding, along with the exhibition of purgatives; in most cases general bloodletting will not be required. After the inflammation has subsided, the parts remain swollen, from the effusion either of serum or lymph ; stimulating applications may then be employed with advantage. In general, the ammoniacal plaster, or the brushing over the surface with tincture of iodine will answer. Blisters are sometimes employed with the same view. In obstinate cases, when the tumour is of no large size, a seton may be passed, retained till suppuration has taken place, and gradually with- drawn. Great risk attends interference with bursse of large size near joints or cysts containing serous or glairy fluid in any situation. Even trifling punctures into such have been sometimes followed by inflammation of the inner secreting surface and violent constitutional disturbance. "When suppuration has occurred, it will in many in- stances be prudent to evacuate the matter by one or more incisions, in order to prevent farther mischief, especially if the bursa, a super- ficial one, is in the neighbourhood of a joint. After the matter has been evacuated, the cavity gradually contracts, and ultimately the bursa is completely obliterated. Diseased bursse, near the surface, and unconnected with important parts, have been dissected out. The operation is not often necessary, and in some situations attended with considerable risk. Tumours, solid or nearly so, arising from diseased bursa of long standing, may sometimes require to be so treated. OF COXALGIA, MORBUS COXARIUS, OR HIP-JOINT DISEASE. This disease has been supposed to commence in the cartilages ; it appears, however, to originate indiscriminately in the cartilage and the bone, as well as in the membrane lining the capsule and investing the cartilage and the ligaments ; but whether it begins in one or other of these tissues, it soon, if neglected, involves them all. It affects patients of all ages, though children under twelve are most generally its victims; and in these it often makes considerable pro- gress without its existence being suspected. The patient is observed to be a little lame, and to be awkward in the use of the affected limb, but he experiences little or no pain in the first instance ; and if he does, it is of a dull kind, and generally referred to other parts. Thus, pain in the knee is generally the prominent symptom of this affection, and occasionally pain is also referred to the ankle, or to the sole of the foot: careful study and considerable experience are here required, to guard the young practitioner _ from error in diag- nosis. Parts remote from the seat of morbid action have often been made the subject of treatment in this and other affections ; the knee, in morbus coxarius, has been leeched, poulticed, blistered, and burnt, and that, too, when this joint was not at all altered in appearance, and showed no symptom of disease. Again, and particularly in adults, the limb is easy only in certain positions, and cannot be moved without great suffering ; pain is also complained of in the groin, and often immediately behind the tro- chanter major. If an examination is made when the patient is thus 84 OF DISEASES OF THE JOINTS. halting, and even though he complains of no pain, the limb is found shrunk, wasted, and lengthened. The elongation of the limb oc- curs mainly in consequence of the inclination of the pelvis towards that side. When the disease has made progress, it has been supposed thatswelling of the apparatus of the joint, and effusion into its cavity, might separate the head of the bone from the acetabulum, when pressure from the trunk was not applied. The lengthening is often great, and its extent and cause are ascertained by ac- curate comparison of the two limbs, laid in contact when the patient is in the re- cumbent posture. The degree of lengthening is here care- fully represented from a recent case. But occasionally, even in the first stage, be- fore destructive ulceration has set in, in consequence of the pain and spasms, the limb becomes remarkably shortened and retracted. This also will be found, on careful examination, to depend, upon the relative positions of the two ossa inno- minata. When the patient stands, the affected limb is considerably advanced before the other, on which the weight of the trunk is chiefly, or entirely supported; the knee is generally bent, and the toes only rest on the ground. In the advanced stages of the disease, and when there is reason to suppose that ulcera- tion of the cartilages has set in, the patient, during progression, moves the affected limb with the hands grasped round the thigh, and in bed it is moved by the aid of the sound one. The spine is frequently affected, becoming bent in different directions, to preserve the equili- brium of the body ; and a deformity of the trunk to a certain degree occurs, which, however, may be in general easily remedied. The nates are much altered ; they become flattened, and those parts which are naturally most prominent are reduced to the level of the others ; the usual niche between the buttock and thigh, in the erect position, is effaced, and the upper part of the thigh is often consider- ably swollen. The alteration is at once manifest on contrasting the healthy with the diseased side. Even from the first, locomotion is difficult: in the morning, the movements of the joint are constrained and stiff; afterwards, however, the patient walks with more ease, though still by very slight exertion the limb is speedily tired, and he is unwilling to use it. Pain is procuced by pressing on the groin, or by tapping on the trochanter, and by pushing the head of the femur forcibly against the acetabulum. The inguinal glands occasionally become enlarged. As the disease advances, the lameness is more apparent; pain is produced and increased by motion, and by any OF DISEASES OF THE JOINTS. 85 attempt to stretch, and more especially to abduct the limb whilst in the recumbent posture. The emaciation of the member becomes more and more visible. The muscles, as it were, are paralysed from inaction and pain, abscesses form, and the constitution then sympa- thises remarkably; hectic fever supervenes, with its usual train of symptoms. The circumstances attending the first stage of the disease in child- hood, in which the limb is lengthened, and there is no decrease, but rather an enlargement of the parts composing the joint, have been already described and illustrated. When, however, absorption oc- curs, and the articulation begins to be destroyed, the second stage of the disease commences, and the limb becomes then sensibly shortened ; the toes are turned inwards or outwards; in many cases there is every appearance of disloca- tion of the thigh upward and back- ward ; and in others the limb is much bent, the toes only reaching the ground. The ultimate position of the limb and degree of shortening will depend much upon the extent to which the head and neck of the femur is destroyed, upon the inclination of the pelvis, and also upon the portion of the acetabulum which is most diseased. The joint becomes tender, the slightest motion causing much pain, and the parts around appear swollen. The patient retains the limb in the most comforta- ble position, and it is generally bent upon the pelvis and inverted. This may arise from relief being afforded when the psoas is relaxed, and the pressure thus removed from the fore part of the joint. In many cases mat- ter forms behind, or rather below the trochanter major, and the collection often attains a large size. When the presence of matter has been ascertained in this situation, it has been recommended that an early opening should be made, on the suppo- sition that the disease arises from an acrimonious discharge into and round the joint, and that, by the matter being allowed to escape, the cause of the disease may be removed. The synovia has been com- pared by one old author to bland oil, the vitiated secretion to oil of vitriol. Though the principle is incorrect, still the rule of practice is important; for in consequence of the long-continued presence of matter, accumulating in a cavity which is not dilatable in proportion to the increase of purulent secretion, the original affection will be much aggravated, and disease induced in the neighbouring parts. But the existence of matter in the joint could only be ascertained to exist in a very emaciated person. The formation of matter is preceded by great pain, and frequent 86 OF DISEASES OF THE JOINTS. startings of the limb during sleep, accompanied with fever, and other symptoms of severe constitutional disturbance. On the es- cape of matter by the natural process from the capsule the painful feelings usually subside. The abscess may appear, as already stated, near the trochanter major, or in the back part of the thigh. Matter sometimes makes its way into the pelvis, through a perforation in the acetabulum, thence it may fall through the sacro-ischiatic notch into the thigh, and find its way under the fascia, nearly to the knee; or again, it may present to the side of the rectum, or even, as I have seen, burst into the bowel and continue to be discharged thus for a long period. If the treatment is neglected, abscess succeeds ab- scess ; and in consequence of the profuse discharge, which may be evacuated from one or many openings round the joint, the patient is at length exhausted, and sinks. In some instances the spontaneous cure by anchylosis occurs, as in the instances from which these sketches are taken. In the one, the head and neck of the bone had been almost entirely destroyed by ulceration, before anchylosis had begun ; in the other, the change is very slight, but the head of the femur and os innominatum are inseparably united by bone, and their cancellated texture runs into each other. Or when the femur has been dislocated, which is a very rare occurrence, the disease some- times gradually abates, and a sort of new joint is formed : the limb, after some time, may thus again become so far useful to the patient. In many cases, the appearance which the various parts of the diseased joint present, are similar to those which have been already described when treating of affections of the joints generally. Fre- quently, however, the osseous tissue in this situation is much more OF DISEASES OF THE JOINTS. 87 extensively affected. Often the whole cartilage on the head of the femur is completely removed, exposing the bone in an ulcerated condition; and when the system has long borne up under the dis- ease, the greater portion of the head, neck, and even of the tro- chanter, is destroyed, the extre- mity of the bone being completely altered in form, and composed of a loose and spongy structure. A similar disorganisation occurs in the acetabulum ; the mucous gland is destroyed, the cartilage is often wholly removed, and the margins of the acetabulum absorbed, a large and flat ulcerated depression merely being left for the reception of the diseased femur ; in other instances the margins remain unaffected, whilst the ulceration proceeds in the centre, and the cavity is thereby much deepened. Not unfrequently the ulceration proceeds farther, and an aperture is formed in the acetabulum, so that matter accumulates within the pelvis. The opening is sometimes so large that the femur is protruded through it. When matter has formed in the soft parts round the joint, portions of the bones of the pelvis, in contact with the pus, are ulcerated to a greater or less extent, and some- times these ulcers are surrounded by deposits of a newT bony matter. From such changes in the osseous parts of the articulation the limb is shortened, sometimes to a great degree, though no disloca- tion has occurred. Indeed, dislocation is by no means so frequent a cause of the shortening as is generally believed. If the head of the femur has been dislocated, and if the disease in the joint has afterwards subsided, the acetabulum is found to be much contracted, with its margins smooth and little elevated, and, if the patient survive for a number of years, it will be almost wholly obliterated. But a portion of the dorsum of the ilium, upward and backward, which is the most fre- quent dislocation in this disease, is gradually absorbed, so as to form a sort of glenoid cavity for the reception of the femur, the ex- tremity of which becomes more solid in texture, and more smooth on its articular surface. The re- maining neck of the bone is in the sketch here given turned forwards, and must have given rise 88 OF DISEASES OF THE JOINTS. to great eversion of the toes. I have seen one other specimen of this form of luxation. The limb is generally, however, inverted ; and what remains of the head of the bone consequently points backwards. The consecutive luxation occasionally, also, though rarely, takes place upon the pubis. Whilst a depression is thus formed, new bone is sometimes deposited round its margins, whereby the cavity is increased in depth, so as to resemble somewhat the ori- ginal acetabulum, the new deposit having become smooth and of a regular form. ON CERTAIN ALTERATIONS OF FORM IN THE HEAD AND NECK OF THE THIGH BONE. When treating of atrophy of the articular cartilages, it was ob- served that, in the latter stages of the disease, the subjacent bone was liable to become denuded, and its articular extremity more or less deformed. Now one of the most interesting of these changes occurs in the head of the thigh bone, which becomes polished on its surface, flattened and expanded, with a corresponding alteration in the acetabulum. In other cases the head of the thigh bone is some- what elongated, and the acetabulum becomes deepened in propor- tion, by a deposition of new bone around its margin, as shown in the above figure, frequently to such an extent as to render the removal of the head of the bone, even after the removal of all the soft parts by maceration, almost impossible without fracture of the edge of the socket. The head of the bone may also become still further misshapen, and anchylosis result; while in some instances the new bony matter presents in the form of nodosities, sometimes pro- jecting towards the cavity of the articulation. This cut represents a OF DISEASES OF 'THE JOINTS. 89 section of the upper end of the femur of a labouring man, aged 49, who had fallen on the trochanter ten years be- fore death, and became gradually lame in con- sequence, with shortening of the limb and anchylosis of the joint, although he had never been confined more than a day or two on account of the injury. But there is another affection in which the femur may be shortened in a comparatively brief space of time from absorption of the intra-capsular portion of its neck, generally succeeding to a fall on the trochanter, and sometimes occurring in young and middle- aged subjects. In treating of fractures of the cervix femoris, it will be observed that retraction of the limb is occasionally delay- ed for a while : hence the importance of an accurate knowledge of those cases in which shortening of the neck of the thigh bone may succeed to an injury short of fracture. The deficiency of accurate anatomical details concerning such cases led to a doubt as to their existence; but this question has been completely put at rest since the history and dissection of two une- quivocal examples by Mr. Gulli- ver ; and the annexed cut repre- sents the changes of form in the head of the bone, the shortening of the neck and comparative length of the femora, in a young man from whom these bones were ob- tained, and who walked about as many others have done, during the progress of the disease. In the above, and in many other cases, the shortening of the neck of the bone is unaccompanied by any absorption of the articular car- tilage of its head. A section of another well marked specimen may be here added. This bone also exhibits approximation of the head to the shaft, and from absorption of the neck. The head is some- what flattened and expanded, but the articular cartilage is entire, and of its natural thickness. The ace- tabulum was diminished in depth, but enlarged laterally, so as to correspond with the alteration of shape in the head of the thigh- bone. The preparation was obtained from a man at 32, who died at the General Hospital at Chatham of pulmonary consumption, after 90 OF DISEASES OF THE JOINTS. a confinement of two years in hospital. Previously to his admis- sion, he had regularly performed his duty as a light infantry soldier, from which it is plain that his limbs were then of equal length, although when the body was examined, the affected femur was up- wards of one inch and a half shorter than the other. From a careful inquiry after his death, it appeared that he had, five years previously, fallen on the trochanter, in con- sequence of which he often complained of pain in the hip, but continued to do his duty long after, never having been confined on account of the accident. It therefore results, that morbid change had taken place during his long confinement in hospital, a circum- stance not very favourable to the recommen- dation by some surgeons of the horizontal posture, as a remedy in such cases, and equally adverse to the opinion of certain con- tinental pathologists, who inform us, that shortening of the neck of the femur is to be attributed to the gradual operation of the super- incumbent weight of the body. In old subjects, particularly in fat women, the neck of the femur is often shortened, and becomes more transverse and brittle than natural, from a true interstitial absorption or atrophy of the osseous tissue. This has sometimes been described as a natural effect of age, but it is undoubtedly disease, for in the greater number of old people the neck of the thigh-bone presents its usual length and obliquity. The affection is obviously a very serious one, as predisposing to frac- ture of the part, under circumstances which render its reunion almost hopeless. Treatment of Affections of the Joints.—After the infliction of a wound, accidental or not, in order to prevent inflammation of a joint from becoming violent, it is of the utmost importance to bring the edges of the wound into close apposition. Sometimes neither local action, nor disturbance of the constitution, supervene on an opening, even of considerable size, being made into a joint, while the slightest puncture often gives rise to the most dreadful symptoms, both local and general. An incised wound, of no great extent, will be sufficiently closed by the careful application of adhesive plaster, and attention to the position of the limb ; but if it is extensive stitches become indis- pensable. The parts must be kept in a state of complete relaxation and rest; cold cloths or iced water, allowed to drop or run over the surface by capillary attraction, should be assiduously applied. The patient's bowels must be freely opened, and he is to be kept on low diet. If inflammatory action occur, bleeding, locally and generally, must be had recourse to energetically, accompanied with warm fomentations to the parts; and, at the same time, preparations of antimony, and other saline medicines, are to be administered inter- nally. If there be reason, from the symptoms, to suspect the formation of matter, the parts ought to be attentively examined, in order to detect its presence; and, when discovered to exist, it must be evacuated OF DISEASES OF THE JOINTS. 91 without delay. In chronic cases, even local bleeding to any great extent is inadmissible. In some a few leeches may be applied, fol- lowed by counter-irritation, with advantage. The employment of counter-irritation is, perhaps, chiefly to be trusted to in the treatment of those more chronic affections of the joints in which, from the painful feelings, there is reason to dread disease of cartilage or bone. Of these, blisters are most in use ; though, from my own experience, I cannot much recommend them. Their constant repetition is exceed- ingly annoying, and the slow progress which is made towards a cure under their use is far from encouraging. Tartrate of antimony, ap- plied in the form either of ointment or of plaster, is generally pro- ductive of much advantage, in the first instance, by causing a great degree of superficial irritation, and relieving the internal parts. After the pustules have been fully developed, its use is to be discontinued till the surface be nearly whole, when it is again to be resumed, if the recurrence of painful feelings should- demand it. Caustic issues have been much praised, and are occasionally beneficial. An eschar is made by the caustic potass applied to the skin, or by rubbing the bichloride of mercury, or any other caustic, into scarifications made by the lancet: the slough separates, and pus is discharged. Instead of promoting a continuation of the discharge, by applying savine ointment, and inserting foreign bodies, or employing other irritating dressings, it is better, when the sore begins to heal, to repeat the ap- plication of the caustic to another part; or, when the issue begins to dry up, to apply for a few hours a pledget of strong antimonial ointment. The employment of the bichloride of mercury, though a most effi- cient escharotic, appears not to be unattended with danger, as in many instances violent purging, with tenesmus and bloody stools, follow its application. When swelling exists without pain, consider- able advantage may be derived from frictions and liniments of various kinds, with careful bandaging. No applications can be of the least avail unless the joint be kept completely at rest. When there is no pain in the joint, when swelling exists, with or without fluctuation, and there is every reason to believe that the ex- tremities of the bones are not much diseased, a cure may be, in general, obtained by the employment of rest, support, and slight superficial excitement. A practice which has been extensively and rather in- discriminately pursued in diseases of joints and of other parts, in affections of synovial membrane, ulceration of cartilage, disease of bone, and even in cases of necrosis, is here detailed. It is useful in proper cases, very hurtful in others. The joint is well washed with soap and water, and afterwards rubbed with camphorated spirits of wine : it is then covered with an ointment spread on lint, and com- posed of equal parts of the unguentum hydrargyri cum camphora and the ceratum saponis — in the majority of cases the mercurial ointment would be better omitted— strips of lead, soap, or adhesive plaster are then applied with a moderate degree of tightness round, from two or three inches below the joint to the same distance above it: these are covered with soap-plaster spread on thick leather,and the whole is surrounded with a bandage, which extends from the 92 ON DISEASES OF THE JOINTS extremity of the limb. The bandage should be put on as far as the joint, before the plasters are applied. The irritation produced on the surface tends to check the deep-seated action, whilst the compression excites the action of the absorbents to remove the effused fluids, and thus to reduce the swelling: by the joint being kept completely motionless, not the least salutary indication of the treatment, the cartilage and bones, if ulcerated, are placed in a condition tending much to expedite their restoration to a natural state. If they are diseased to such an extent that the process of cicatrisation cannot be expected, a cure by anchylosis is, by these means, much more likely to occur. The dressings may be left undisturbed for the space of a week or two ; at which period, and, in many cases, sooner, they will be found much slackened, in consequence of the swelling being greatly reduced. By repetition of the application at intervals, the disease will, in a great many instances, rapidly cease, and the joint resume almost its natural appearance; but the period at which this takes place will be found to vary much according to circumstances. If, however, the plasters produce such irritation as to cause a return of inflammatory action, their use must be discontinued till such action has been subdued by the usual means. If the thickening of the ex- ternal parts has occurred to such an extent as to cause immobility of the joint, or if partial anchylosis has ensued, the limb may be brought to the most convenient position, the knee nearly,but not quite, straight, the elbow half bent, and so on, by the cautious use of a jointed splint, fitted with an extending screw. The practitioner is not to be deterred from having recourse to the above practice, even when matter has collected and burst externally, for sometimes under its employment the cavities of abscesses contract rapidly. After the swelling and other symptoms of disease have subsided", the joint is to be slightly moved, but with great care ; and, by a gradual" increase of the move- ment, the natural motion of the part may be ultimately restored. The great object in treating chronic affections of joints must be to give them support, and prevent motion as much as possible. This is effected pretty well in the articulations, removed from the trunk by the process above described, modified according to circumstances. The filth and smell arising from the plasters often becomes annoving' and, above all, the eruptions and excoriations produced by them prove so troublesome that the application requires to be discontinued The principal and most essential indication, that of securing repose to the affected parts, is frilly as well obtained by the application of well-adjusted splints. These may be formed of lint soaked in a mu- cilage of gum acacia, as described in the Practical Surgery p 150 or coarse linen may be smeared over thickly with a coating of muci' lage mixed with common whiting, and another layer of linen spread over that. This is laid out smooth and allowed to dry ■ nnrtinnc S this sheet are cut to the form of the affected joint, and,' after beinJ moistened, are applied and retained by a roller. A firm caSe i* t) formed, which may be afterwards lined with lint or cotton wadding and so reapplied. The most suitable splints of all are madp f leather prepared without oil, softened in warm water, and put on as above described. They are, when they have become dry, pared and OF DISEASES OF THE JOINTS. 93 well fitted, then lined with wash-leather, and padded as may be re- quired. The employment of these splints gives great relief in cases where further excited action has been lighted up in the joint in con- sequence of the surface of the articulating cartilage having become ulcerated from its free or attached surfaces, or in consequence of matter finding its way into the synovial cavity from the cancelli in the head of the bone. In cases, also, where the painful sensations have existed from the first, and even before any great alteration in the external form of the joint has taken place, indicating primary ulceration of cartilage, this practice affords immediate relief. These splints are easily applicable to the shoulder or hip-joints : and, in the majority of instances, nothing further requires to be done. It appears that Dr. Physick of Philadelphia had been for many years in the habit of confining the motions of the hip-joint by means of hollowed wooden splints, and his practice was marked by very favourable results. It is seldom that local abstraction of blood is at all required, and its employment in cases of morbus coxarius in weak constitutions, which it generally seizes upon, is very questionable. Neither is counter-irritation called for ; and it is only in extreme cases, when the suffering is intense, that small blisters over the fore part of the joint, or a slight drain in that situation, or behind the trochanter, is admis- sible. The nitrate of silver rubbed on the surface causes vesication and discharge; and its early repetition is often followed by good effects. The tincture of iodine, or a liniment containing sulphuric acid, may sometimes be applied with the same view. There is no doubt whatever, that much of the benefit that attends upon counter- irritation, both in the human body and in the lower animals, is to be attributed to the rest that is at the same time enjoined, and often in- dispensable. It is thus that the firing and blistering of horses does good in the majority of the diseases of tendons, bursse, bones, and joints. In some instances, it may be necessary to have recourse to soothing applications, as fomentations to affected joints, and to employ general antiphlogistic means suited to the age, strength, and consti- tution of the patient. In the greater number of cases in young sub- jects, after the stomach and bowels are unloaded, the system must be supported by tonics and nutritious food; none are more beneficial than the preparations of iron. [In the early stage of this affection, the practice recommended by the author is, in general, fully adequate to the gradual removal of the morbid action ; but at a more advanced period it is either insuffi- cient, or worse than useless, because it leads to procrastination or the avoidance of more energetic measures. When the disease is firmly established, the best topical remedy, undoubtedly, is the actual cautery, used in such a manner as to produce an eschar from one to two inches in diameter. For this purpose the iron should be heated perfectly white, and applied directly to the surface where the issue is intended to be made. The pain is severe, but promptly subsides under the use of cold water, or diluted spirits of hartshorn. The separation of the eschar is promoted by an emollient poultice, which forms also the best dressing for the resultant sore. If the sore be- 94 OF DISEASES OF THE JOINTS. comes the seat of neuralgic pains, as I have occasionally known it to do, or if there be much spasmodic twitching in the muscles of the hip and thigh, speedy relief may generally be afforded by sprinkling the raw surface with acetate or sulphate of morphia. If the discharge is defective, it must be re-excited by savin, mezereon, or fly ointment, or a salve composed of an ounce of simple cerate, and ten or twelve drops of nitric acid. An issue made with the hot iron seldom heals under eight or ten weeks, and generally furnishes an abundant flow of thick yellow pus. It may be established at any part of the joint, but the point which I commonly select is where there is most pain, swelling, or tenderness. Since the publication of the last edition of this work I have em- ployed the actual cautery in at least six cases of hip-disease, in all of which it has been instrumental in preventing suppuration and other mischief, notwithstanding the advanced stage of the malady wdien I began the treatment. Physicians may pronounce this practice un- necessarily severe, if not barbarous; it is so, however, only in ap- pearance, not in reality, and I feel no hesitation in declaring that it is far superior to every other method of cure that has ever been de- vised. Independently of the discharge to which the resultant issue gives rise, I am convinced that the shock imparted to the system by the application of the hot iron exerts a most salutary influence in changing and arresting the morbid action of the articular apparatus. The pain and suffering are also, in the aggregate, much less than from the caustic issue, the seton, and other modes of counter-irrita- tion. Let it be remembered that hip-disease, when fully established, admits of no delay; whatever is done must be done promptly and energetically : if the morbid action is not controlled at once, suppu- ration and ulceration must be the inevitable consequences. When the patient is too timid to submit to the actual cautery, a large issue should be made with the caustic potash; or, what is better, the Vienna paste, composed of five parts of potash, and six parts of quick lime, finely triturated, and wet with a small quantity of alcohol. A layer of this, about twro lines thick, and of the proper diameter, is put on the skin, where it is confined by a wall of lard or several pieces of adhesive plaster. If the eschar is intended to be very deep, the paste is permitted to remain on from ten to twenty minutes, other- wise five or six minutes wTill suffice. The application is seldom very painful. Along with this treatment perfect quietude is to be observed ; the diet should be light and moderately nutritious ; and every fourth or fifth night a few grains of calomel and rhubarb should be adminis- tered to keep the bowels and liver in action. Steady but gentle purgation is indispensable. The best internal remedy, especially where a tonic alterant is required, is the iodide of iron in union with tincture of gentian and the fluid extract of sarsaparilla. Lugol's preparation of iodine is also a valuable article. During the whole treatment, the patient must lie upon a soft mattress, and the least motion of the joint prevented.] When the occurrence of anchylosis affords the only hope, this pro- cess ought to be encouraged by rest, and the limb at the same time OF DISEASES OF THE JOINTS. 95 kept in that position which will be most useful in after life ; this will be effected here also by the employment of splints. In cases of disease of the knee, ankle, elbow, or wrist joints, not- withstanding every thing that can be done, the disease often runs its course, abscesses form and give way, the patient's health declines, and he becomes emaciated and hectic. In such cases amputation, when not contraindicated by internal disease, must be had recourse to, as the only remedy. In some few instances, the excision of the diseased extremities of the bones may supersede this operation ; but this will be discussed in a future part of the work. Every circum- stance must be well weighed before mutilation be resorted to; and there can be little doubt that thousands of limbs have been saved by the employment of the means above mentioned, which would have been otherwise doomed to amputation. Hydrops articuli will in general be got rid of by the use of friction, either dry or with liniments; by stimulating plasters or by blisters ; and by the proper application of bandages. Mercurial ointments are used in this affection, and often with very great benefit. Electricity has been recommended. [The treatment of this affection must be chiefly local, although it may sometimes be necessary to resort to constitutional means, espe- cially mercurial purgatives. When dependent upon a gouty or rheu- matic state of the system, the different preparations of colchicum may be exhibited with a prospect of advantage, as also the hydriodate of potash in large doses. As a local remedy, blistering is by far the most prompt and effectual, and worth all the liniments and unguents that have ever been devised. The discharge from the vesicated sur- face may be maintained by savin or tartar emetic ointment; or, what is preferable, the fly may be reapplied as soon as the sore becomes dry. The operation of the blister should be aided with a bandage and a piece of oiled silk, or strips of adhesive plaster, to support the distended ligaments. Should these means fail, or the accumulation be so great as to impede the motions of the joint, and render it pro- bable that absorption cannot take place, a small valvular incision may be made into the most dependent situation of the swelling, to draw off the fluid. Such a step, however, although justifiable under the circumstances here indicated, should not be taken without due reflection.] In neuralgic affections of joints, it is clear that the symptoms are to be combated by general and not by local means, at least of a severe nature. The patient must be amused and occupied, exercise in the open air must be enjoined, and attention paid to diet. The state of the digestive organs and secretions should be looked to, and cor- rected if need be. Medicines directed to the regulation of the func- tions of the uterus are essential in the majority of cases. When there is reason to suspect the lodgment of sordes or worms in the in- testinal canal of children so affected, the balsam of copaiba, in doses of 3ss., or more, on an empty stomach, followed, if need be, by brisk purgatives, will be found to answer admirably. Tonics, such as preparations of iron, of quina, &c, are then given with advantage : many apparently bad cases yield at once to such treatment. As local applications, anodynes, fomentations, or cold lotions are OF DISEASES OF THE JOINTS. employed, according to circumstances. Frictions with gently stimu- lating liniments, belladonna, veratria, &c, may be used as occasion demands. The patient must be encouraged to use the affected limb as much as possible ; and the use of all severe and heroic remedies, as bleeding, blistering, counter-irritation, setons, issues, or moxas, discountenanced. [The treatment of inter-articular concretions is palliative or radical. When the foreign body is of considerable size, and is not productive of much pain or inconvenience, it may be advisable to fix it in its place by making the patient wear a well-adapted laced knee-cap, or a compress and tolerably tight bandage. The relief thus afforded, however, is only temporary, and hence we are sometimes compelled to resort to the knife. Several operations are in vogue ; but as none are free from danger, the surgeon cannot be too much upon his guard, since permanent anchylosis, if not death, instead of the recovery of the patient, may be the consequence of rash interference. Whatever process be employed, there is one point which cannot be too care- fully attended to. I allude to the preparation of the system by absti- nence, rest in the recumbent posture, and a course of gentle purga- tion. The affected joint should be placed upon an inclined plane, and if hot or tumid, twenty or thirty leeches must be applied, fol- lowed by tepid saturnine lotions. The object of this preliminary treat- ment is to put the part in the most favourable condition for bearing the operation, and to obviate, as far as possible, the ill effects of inflammation. In the ordinary operation, the concretion is extracted through a valve-like opening, the object of which is to prevent the ingress of the atmosphere. The limb being extended upon a table, in a hori- zontal position, the foreign body is brought to the supero-internal part of the knee, where it is fixed with the thumb and fore-finger of the left hand. The skin being now drawn over the patella, the sur- geon carries his knife through the integuments in a longitudinal direc- tion, and makes an aperture barely large enough to admitthe passage of the cartilage. When this has been extracted, which is always easily done with a pair of small forceps, or even by the pressure of the finger, the assistant removes his hand, and permits the skin to glide over the wound in the capsule, so as to close it up like a valve, and thus prevent the admission of air. If the concretion adhere to the articular surface of the joint, as is sometimes the case, it should be detached with a narrow probe-pointed bistoury. If there be several of these bodies, they should all, if possible, be extracted through the same opening. When the operation is finished, the edges of the wound are sun- ported by adhesive straps, and the motion of the joint is prevented by means of a sphnt placed along the back part of the limh T Iu compresses, dipped in a mixture of laudanum and water in '^ g portion of an ounce of the former to a pint of the latter *1 pI?" kept upon the parts, and the whole treatment ouebt tn h C.0nstantly antiphlogistic. If symptoms of inflammation arise th .riSorousIy be bled at the arm, and the joint covered with leerho* £atl,ent must is to be prohibited. seethes. Early motion A novel and improved proceeding for the removal of cartilaginouc OF INFLAMMATION OF BONE. 97 bodies was proposed some years ago by Dr. Goyraud of Aix, and about the same period by Mr. Syme of Edinburgh. I have not tried it myself, but it has been pursued in several cases with excellent success by others. It consists in the subcutaneous division of the capsule of the joint, and the lodgment of the foreign body in the cellular tissue, at a point previously prepared for it, and where it may either be permitted to remain, or be removed by a subsequent operation, according to the effects produced by its presence. The incision of the skin and synovial membrane should be made with a small needle-like knife, the cartilaginous body being previously fixed by an assistant at a convenient part of the joint.] OF INFLAMMATION OF BONE, AND DISEASES THENCE ARISING. Bones grow and are nourished by the same means, and are subject to the same laws, with other parts of the system. Like all the tissues of a white colour, particularly when their growth is completed, they are less freely supplied with blood-vessels and nerves than other parts. When incited action of the blood-vessels occurs in the harder textures, sensibility is roused to an exquisite degree, and the healthy and per- verted processes often advance with great vigour and amazing rapidity. Inflammation of bone often arises from external injury, and in some constitutions from very slight causes. Its occurrence is supposed to be favoured by a syphilitic taint, but the inflammatory disposition is much more frequently produced in a system vitiated by the abuse of mercury. From the unyielding nature of the tissue, the pain attendant on inflammatory action is dread- fully excruciating; it is also most violent during the night, even in chronic cases, a circumstance which does not admit of satisfactory explanation. The in- teguments over the inflamed bone are swollen, and the tumour is cedematous; whilst a hard and solid tumefaction exists in the more deeply-seated parts, caused partly by enlargement of the osseous tissue and partly by effusion of lymph into the cellular sub- stance. The bone is imbedded in a gelatinous or lymphatic effusion, situated mostly beneath the perios- teum. This membrane is more vascular than in its natural condition, thickened, and at the same time opened Out in texture. The blood-vessels of the af- fected bone are much increased, both in activity and in size ; and, in consequence of enlargement of the vessels, and thickening of the naturally delicate mem- brane on which the vessels ramify, the bone is swol- len and increased in size; its texture, as shown in the annexed cut, is loose, somewhat resembling the cancellated structure, and its surface is occupied by numerous foramina, which are enlarged in proportion to the size of the vessels which they contain. The limb is often enormously swollen and indurated. The gelatinous effusion beneath the periosteum speedily becomes organised, 98 OF INFLAMMATION OF BONE, nodules of osseous matter project into it, and adhere to the surface of the bone frequently by a narrow neck; these increase in number, gradually assume a solid appearance: the bone is thus thickened, often to a very great extent. It has been supposed that the new osseous matter is deposited by the vessels of the soft parts and of the periosteum ; but there can be little doubt but that it is secreted principally by the vessels which ramify within the substance of the bone, and by the vessels of the periosteum after they have entered the osseous tissue. Thus, in the case of fracture, the new osseous particles lie between the periosteum and bone at a distance from the broken ends, where the vessels are enlarged and increased in activity, or adhere to fragments which have been detached in part and retain their vitality, but not to the under surface of the periosteum. There is no doubt that thin laminae of bone are now and then found attached to the periosteum, or im- pacted within its substance ; but this is to be attributed to that morbid action of the tissue, to which this as well as several other membranes is subject. When bone is extensively affected with inflammation, motion is impaired; the muscles being displaced and retarded in their action by the swelling and irregularity of the bone, by effusion of lymph into their tissue and inter-muscular spaces, and, perhaps, also, by their partaking, in some measure, of the inflammatory action. Any attempt to move the parts very much aggravates the patient's suffer- ing. Occasionally inflammation attacks almost all the bones in the body, and causes great constitutional disturbance, by exhausting the powers of life : it sometimes terminates fatally. Bones become in- flamed from various causes. However it originates, the action ends, as in the other tissues, in resolution, suppuration, or mortification. The effusion by which the diseased vessels naturally relieve them- selves in softer textures cannot here take place so readily, or to such an extent as to prove beneficial: the intensity of the action is with difficulty subdued, and, consequently, resolution is comparatively rare. When it does occur, the parts do not soon regain their natural condition, but often remain considerably swollen and indurated, as is seen in nodes, which continue during the life of the patient, without causing pain or much inconvenience. Suppuration on the surface, or in the centre, and partial or total death of a portion of bone are the most frequent consequences of external injury and incited vascular action; but suppuration in the cancellated texture frequently follows very slight incited action in those of a scrofulous habit. Tubercular matter exists, in all proba- bility, previously, and it leads very often to long continued disease, curable only by operation. The matter may find its way to the surface after long suffering and great constitutional disturbance. Again, it may be confined for months, or even years, the patient suf- fering from time to time the most excruciating agony. The bone becomes thickened towards the surface by new deposit, as the cavity is increased by ulcerative absorption, and relief is only afforded, a correct diagnosis having been formed, by artificial evacuation of the matter. In many cases small sequestra lie in the cavity; and though AND DISEASES THENCE ARISING. 99 the matter escapes naturally, or is evacuated, the patient's strength becomes worn out, and he perishes, unless the limb is removed. So long as dead portions of bone remain, the discharge cannot cease permanently. Fresh collections are apt to form in the soft parts if the original openings close. It is no easy matter to discover or remove sequestra from deeply seated bones. A section of the femur is represented below, showing a cloaca leading to the cavity of an abscess in the medullary canal. The bone is very dense in consist- ence, and irregular on its surface. Suppuration in bones is necessarily connected with loss of sub- stance, and condensation of the surrounding parts; and purulent collections exteriorly, if allowed to press long, or if bound down by unyielding sheaths, will sooner or later produce a breach of con- tinuity, by causing absorption of the outer lamella and the subjacent cancellated texture. A similar effect is produced by aneurismal and some other tumours. Such loss of substance is, in some in- stances, speedily repaired, after removal of the cause, by effusion of new matter from the surrounding blood-vessels of the bone ; thus, in disease in conse- quence of pressure from large aneurism, there is rea- son to suppose that the healing process commences as soon as the aneurismal sac begins to diminish, as after operation. But as has been already observed, the healthy actions are more vigorous in the softer tissues than in bone; and when ulceration has oc- curred in the latter, it is generally attended with weak action, and presents the same general charac- ters as an ulcer in the soft parts, connected with a feeble action of the blood-vessels; the discharge is thin and fetid, absorption gradually proceeds, and there is little or no effort towards reparation. Cavities in bones are necessarily slower in healing than those in the soft parts; the vitality and power of reparation are lower ; and there being no elasticity in the parts, the walls cannot come rapidly together, contract and coalesce. It may tend to prevent confusion of the two different morbid states, if we confine the term ulceration to suppuration in, and absorption of, bone, whilst the vessels retain a considerable power of action, throw out new matter, and procure a reparation of the breach ; and this condition of the osseous tissue exists when the disease is situated in the surface of the bone, and when it has been produced by an ex- ternal cause. On the contrary, the term caries will denote that peculiar kind of ulceration in which reparation is hardly attempted by nature, and is with difficulty obtained by the most active inter- ference ; and this disease will most generally be found to affect the cancellated structure. The comparative frequency of one or other of the terminations of inflammation depends much on the kind of bone implicated. Caries most frequently occurs in the heads of long and in the cancellated structure of the short bones, as unhealthy suppuration most frequently takes place in the loose, fatty, and cellular tissues of 100 OF INFLAMMATION OF BONE, the soft parts. The formation of abscesses in the cancelli is generally preceded by deposit of tubercular matter, isolated or collected in masses, and by the softening of this cheesy substance. When pus has formed in the substance of a bone, the outer lamella, in the end, becomes absorbed, and the effusion undermines the periosteum, which, from the distention, also ulcerates: the matter then spreads into the neighbouring cellular tissue, or makes its way to the surface, and is evacuated, or, what is still worse, it escapes into an articulation. The discharge is often continued, as already stated, in consequence of a dead portion of the cancellated structure being im- bedded either in the carious cavity, or in the soft parts, where they sometimes are lodged for a long period. It was formerly remarked that bones become highly sensible from incited action; hence, during the progress of this disease, which is attended with more or less inflammation, the patient generally suffers most excruciating agony — so great, in general, as to prevent him, perhaps for weeks, from enjoying the least repose. The affected part is considerably swollen, but the enlargement is seldom so general, or so great as in the diseased state of the ligaments and other apparatus of a joint. White swelling, however, may be the precursor of caries; or, in other words, a disease commencing in the bursse, ligaments, synovial membrane, or cartilage, may extend to the bone ; and breach of continuity, attended with weak action, be the consequence. In caries the affected portion appears neither to possess vitality enough to enable it to repair the breach, nor to be sufficiently deprived of vitality to be thrown off by the surrounding parts. Considerable portions of dead bone are occasionally found in carious cavities, in the heads of bones, and even in the vertebral column. Small portions are also detached piecemeal in the progress of ulceration, and discharged; but it is seldom that the whole surface is thrown off, so as to give place to a healthy and reparative action. When the parietes of the cavity have remained a considerable time in this inactive state, the surrounding vessels become more active, and the surface of the cone in the vicinity is studded with nodules of new osseous matter. The disease here delineated affected only a small portion of the cancellated texture of the condyle. An ashy looking substance fills the cavity, and this again was concealed in the recent state by lard- aceous matter. The elbow joint is unaffected, excepting only that, from the deposit of new bone in spiculse and nodules, and the con- densation of the soft parts, almost complete anchylosis had taken place. This deposit is not always limited to the affected bone, if one only be the seat of the disease, but frequently extends to those articulated with it. The soft parts are commonly more or less thickened, and rendered exceedingly dense by effusion of lymph into the cellular texture ; and so great is this thickening sometimes, that the knife is resisted as if by cartilage. The discharge which proceeds from the carious part is generally highly fetid, very AND DI8EASES THENCE ARISING, 101 profuse, is often poured through several openings, and the surround- ing skin is excoriated and generally of a livid colour. The ichorous discharge occasionally dries up for a short period and again breaks out more violently. The surface of the ulcer is, in some cases, occu- pied by soft unhealthy granulations; in others the earthy part of the bone is most prominent. When the parts have been macerated and dried, the disease is often found to have proceeded more in width than in depth, and the absorption has not reduced all points of the diseased surface to the same level, thin portions remaining somewhat elevated, and giving the part a cancellated appearance; and there often project numerous minute osseous fibrillse of considerable length, which intermix with one another, and form a most delicate network. In other instances, the ulceration has extended more deeply and uniformly, and a considerable cavity is formed, with 'rregular margins and surface; not unfrequently it contains dead portions of the cancellated structure, in some of a dark, in others of a light colour; or it is occupied, in the recent state, by a substance resembling lard. The surrounding bone is much softened, and, after maceration, becomes exceedingly light. The disease is generally confined to one or two bones, but occasionally involves a whole chain. It may be limited to a part of one bone in a joint, or may embrace the whole of it. Its extent will depend on the severity of the primary action, or on the degree and duration of the pressure of fluid which has been allowed to exist, whether from the nature of the superincumbent texture or the carelessness of the surgeon. Interstitial absorption of those bones which are in the neighbour- hood of the carious ulceration often occurs in the tarsus and carpus. The superincumbent integuments are livid and cold, and pain is felt in the situation of the bones ; yet they are not affected with continuous ulceration, but portions of their substance are gradually removed by absorption, so that they are much loosened in texture, and may be altogether destroyed, or come to consist merely of a thin and reticu- lated osseous shell, whilst at the same time their cartilaginous surfaces often remain in their healthy condition. The constitutional disorder attendant on caries is at first very great; the sympathetic fever is followed by hectic, under which, and the discharge, many patients sink. The general affection in some degree keeps pace with the local in violence and duration. The irritation is in some cases so great as to destroy the patient in a very few months or weeks ; but not unfrequently a constitution, by no means strong, will be enabled to bear up for a long period under very extensive disease of a bone. The paroxysms of pain and inflam- mation occasion fresh attacks of constitutional derangement: this occurs till the patient's health and strength are exhausted, and he sinks under the disease, or is relieved by the spontaneous or artificial removal of the cause. A natural cure of caries may occur in consequence of the diseased parts so far recovering their natural degree of vascular action as to form granulations and repair the breach; but most frequently it is necessary, for the accomplishment of this purpose, that incited action occur to a very considerable degree; and the diseased parts, already 9* 102 OF INFLAMMATION OF BONE, extremely weak, have not sufficient power to withstand the action, but perish; whilst the action of the surrounding parts, not being in- creased to such a degree as to overcome their powers, throws off the dead, secretes a more bland discharge, and deposits healthy granu- lations, which gradually fill up the cavity. Treatment. — In inflammation of bone, resolution must be brought about, if possible ; the other terminations are to be prevented by all possible means, since they frequently endanger the limb, and even the life, of the patient, and at best, never admit of a speedy cure. To promote resolution, blood must be drawn copiously from the part; and general bleeding may also be required, though in some constitutions it cannot be safely carried to any great extent. After local bleeding, fomentations assiduously applied will tend much to relieve the sufferings of the patient. Purgatives, nauseating doses of antimony, and all safe measures likely to subdue the vascular action, must at the same time be adopted. Free incisions through the periosteum sometimes relieve the pain, and cut short the disease, the distended vessels being thereby emptied ; but such practice is only a last resource, when the action has resisted all other means, and threatens an unfavourable termination. If, notwithstanding the reso- lutive means employed, the inflammation proceeds unabated, and suppuration occurs, the effused pus ought never to be allowed to re- main on the surface of the bone, but must be evacuated by early incision. Otherwise the pressure of the extraneous fluid will causa* absorption of the bone, or detachment of periosteum and superficial necrosis; the absorbed surface will, in its turn, secrete pus, and thus an ulcer will be produced ; and, from the vascular action becoming debilitated in consequence of the previous incitation, that ulcer will in all probability degenerate into caries. Much mischief is produced by squeezing and bandaging tightly tv.e inflamed parts, as can readily be understood ; yet such practice is frequently adopted after suppuration. By it the inflammatory action is excited anew, the formation of matter is very much increased, and however useful such manipulation may be in stiffness of a joint, or mere swelling of bursse, and sheaths of tendons, still, in inflammation and abscess of bones or joints it is extremety prejudicial, and from its indiscriminate employment by those ignorant of the profession, many limbs have been destroyed. General chronic periostitis, which is produced by exposure to cold, or occurs after or during mercurial courses, and is often supposed to be a symptom of syphilis, is relieved by the in- ternal exhibition of the bichloride of mercury, or other mercurial preparations, combined with sarsaparilla and diaphoretics. In many instances such an affection will yield to no other treatment; and thus the practitioner is occasionally obliged to have recourse to a some- what paradoxical practice, that of giving mercury for a disease which seems to have been produced by that mineral. In inflammation of the short bones or.heads of the long bones, if the action do not yield to topical bleeding and becomes chronic, counter-irritants must be employed. Blisters repeated are often useful in subduing the remaining action, and in obstinate cases small caustic issues are sometimes of service. During the adhesion of the eschar, AND DISEASES THENCE ARISING. 103 the best application is a common poultice or water dressing, which, on the separation of the dead part, may be exchanged for any simple ointment, it not being at all desirable in general to check the discharge and heal up the breach of surface. Moxa is sometimes employed to make an issue in these and other cases, but it is not superior in any respect to the potential cautery, whilst its employment is gene- rally very alarming to the patient. The sores following the use of the moxa are in some instances tedious in healing; and this may be ascribed to the vitality of the surrounding parts having been dimi- nished by the application. In cases of atrophy of bone, and where there is reason to suspect the scrofulous or tubercular deposit to be going on, the affected part should not be much used, and means taken to give tone to the system. Preparations of iron are often exhibited with advantage. The combination of iodine with iron may sometimes answer. Ab- scesses should be opened early, so as to prevent extension of the mischief. In abscess in the shafts of the long bones, it is occasionally necessary to make an opening through the outer lamella by the tre- phine, so as to evacuate its contents. Some instructive cases have been given by Sir B. Brodie, illustrative of the good effects of this practice. I subjoin one out of many from my own hospital practice. " W. A., aged 22, was admitted Oct. 26, 1837, under the care of Mr. Liston. He is a policeman of weak conformation. He states that when about six or seven years of age he was first attacked with an aching pain in the right leg, near its middle, and since that period has been subject to three or four attacks every year. These usually were experienced in the spring, during rough, windy, and cold weather, and continued from one to three weeks. The pain was always aggravated at night, and so trifling in the day that he was always able to go about. These attacks ceased to occur when he was between 15 and 16 years of age, and since that time, until last May, he has been free from them. He states that up to about his 16th year the bone of the leg gradually enlarged in its middle portion, but then became stationary, and at the period of entering the police the difference between the bones of both legs was not great; this was about two years ago. Since then he has been accustomed to walk for a considerable length of time daily. During some months he was obliged to do the night work, and then he was much exposed to cold and wet. Last May, while thus engaged, he experienced again an aching pain in the middle of the right tibia ; this was aggra- vated at night; and after a fortnight's duration, during which it be- came gradually worse, he wras obliged to give up his duties in the police, being unable to continue them any longer. At this time he consulted the surgeon of the subdivision with which he was con- nected ; his treatment was fomentations to the leg and aperient medi- cine occasionally. Not being much relieved by this, he afterwards ordered the application of leeches on three several occasions, and mercury to salivation. At the end of three weeks he returned to his duty. In the latter part of September he was again attacked with pain during night duty; this pain increased rapidly in severity, and after three nights he was again obliged to leave duty. He was now 104 OF INFLAMMATION OF BONE, treated again with the frequent and copious application of leeches at different intervals, and likewise took some pills, which did not affect his mouth. This treatment, with frequent fomentations, was perse- vered in for a month, but without permanent benefit, and then he was brought to this hospital. Has never had any syphilitic complaint. " Present state.— Has an enlargement of the tibia about its middle third, of a diffused character, and which seems to extend a good deal inwards and backwards ; in this part he experiences a throbbing and lancinating pain at night; during the day he is in general easy; at night there is considerable heat and swelling in the leg; tongue whitish; appetite good. The following pills were ordered: — B. Bi- chloride of mercury, two grains; powder of gum guiacum, two scruples; oil of sassafras, ten minims; extract of sarsaparilla, four scruples. To be divided into twenty-four pills, of which let two be taken three times a day. Apply eighteen leeches to the affected part. " Nov. 4. The leeches were repeated ; much the same. " 8. Symptoms as before. As he complains of pain over the eye- brow, with nausea, let the mercury be left off. A variety of consti- tutional and local treatment has been pursued during Mr. Liston's absence from the hospital, but without affording any relief; the patient's nights were passed in great agony, and his general health began to suffer. On the 27th, after consultation with Mr. Fisher, the surgeon to the Police Force, Mr. Liston had the patient carried into the operating theatre. He made an incision along the spine of the tibia of about three inches in extent; another shorter one was made to fall on this at right angles from the inner side. The surface of the bone thus exposed was perforated to the depth of fully half an inch by a small trephine. A very dense circle was removed from the perforation ; still the fluid, which was suspected to exist, did not appear. Mr. Liston, encouraged by the intense pain complained of as the process of perforation proceeded, again applied the crown of *he instrument, and after a few more turns, brought out a further circle of considerable thickness, and this was forthwith followed by a flow cf well-digested purulent matter. " 28. Complains of no pain comparatively; slept well last night AND DISEASES THENCE ARISING. 105 after an anodyne draught; has felt much relieved since the opera- tion ; a good deal of matter was discharged from the sore during the night; water-dressing to be applied to the wound. " 30. Slept well without any anodyne the last two nights. The relief afforded by the operation is felt more now than it was at first. The wound discharges a good deal. A tonic mixture, containing infusion of gentian, sulphate of magnesia, and sulphuric acid, was ordered. " Dec. 2. The wound looks florid and clean; granulations are springing up ; general health very much improved. " 4. The edges of the wound are thickened by the granulations; the discharge from the wound still considerable ; feels quite well in health. " 12. The wound continues much the same; the rollers have been discontinued. "14. Feels himself gaining strength daily; can walk without pain; wound is contracting and hard; granulations seem to lessen the depth of the opening in the bone; there appears to be no seques- trum." When caries is fairly established, and the integuments have given way, the best and most successful proceeding is that pointed out by nature — destruction of the diseased portion ; and the means must vary according to the particular circumstances. In many cases, nature seems to wait but for the separation of the sickly parts, either by accident, or by the interference of art. The means are to remove, partially or wholly, the diseased part, or to effect such a change of action as will throw it off. The first indication will be accomplished by trephines, scoops, saws, and forceps; the second by active escha- rotics ; frequently both are required. If there be extensive disease in the medullary canal of a bone, several perforations may require to be made, and these may be con- nected by the use of a small saw, or the cutting forceps. The dis- eased cancelli, thus exposed, can be readily removed by the scoop or graver, as recommended by Mr. Hey, primus, in his excellent work. If, with the probe, it is ascertained that a portion of the cancellated texture has become dead and loose, it is to be removed after dilata- tion of the external opening. It may frequently be difficult to distin- guish in the diffused blood, between what is diseased and what is not; it will often be necessary afterwards to cauterise freely the exposed surface, and for this purpose the oxidum hydrargyri rubrum ought generally to be preferred. The slough will soon be thrown off, and healthy granulations fill up the breach. The application of the actual cautery may be by some considered necessary: at one time I employed this remedy very extensively in caries, and occasionally with very good success; I have since, however, been led to change my opinion, and am now inclined to prefer the potential cautery already mentioned. By the application of the red-hot iron, the dis- eased portion is destroyed effectually, but at the same time the vitality of the surrounding parts is often very much weakened and their power of reparation diminished, so that they are incapable of assuming a sufficient degree of action for throwing off the the dead part; 106 OF INFLAMMATION OF BONE. their action being increased whilst their power is diminished, they may become affected with caries, and thus, instead of being arrested, the original disease will either be increased, or extensive necrosis may take place. The red oxide of mercury is not calculated to pro- duce such bad effects ; it does not spread or insinuate itself into the bony tissue, as liquid caustics are apt to do; and it is sufficiently powerful for complete destruction of the diseased parts. It will be necessary to keep the wound open, by proper dressings, till all the dead portions of bone be discharged, and every part of the parietes of the cavity produce healthy granulations : if the discharge be offen- sive, its fetor may be corrected by the use of spirituous applications, such as the tinctures of myrrh, opium, or aloes, separately or com- bined. After healthy granulations have appeared, and the cavity has begun to contract, light dressing is all that is necessary. In operating on the carpal and tarsal bones for removal of caries, the surgeon must be well acquainted with the connexions and rela- tions of the parts. If one bone is diseased, its removal will be suffi- cient ; if several, the operation becomes more painful and difficult. When one only of the tarsal or carpal bones is almost completely destroyed, and the surfaces of those articulated with it are also more or less affected, it is not sufficient or safe merely to remove the loosely attached portions of the one primarily attacked; the diseased parts of those surrounding it must also be taken away, and it will often be necessary to apply the caustic afterwards. In caries of the distal range of bones, the bases of those supported by them are in general involved, and must also be removed. If one only is diseased, with the base of the metacarpal or metatarsal bone attached to it, the re- moval of these will be enough, and can be accomplished without diffi- culty. Some have recommended the total extirpation of a metacarpal or metatarsal bone, leaving the finger or toe appended; but the member, when thus left unsupported, can never become of any service to the patient, and may be productive of much inconve- nience ; whilst removal of them, along with the diseased bone, renders the operation much more easy of execution. If the whole disease can be extirpated, leaving the surfaces of the surrounding bones covered with healthy cartilage, the use of the caustic is not required, and would be productive of harm; but wherever it is im- possible to avoid encroaching on the cancellated texture, such as of the os calcis, which it would be unsafe or imprudent to take away entirely, its use is then indispensable. After the removal of carious bones, the symptoms soon disappear, and the patient obtains a rapid, and often permanent cure. The instruments for these operations, and the method of performing them, will be afterwards mentioned. In conclusion, it may be remarked that the temporary cicatrix of a sore leading to a diseased bone has a very different appearance from the sound scar which is formed after its removal. The former is bluish, soft, on a level with the surrounding parts, and movable • the latter is depressed, white, and firmly adherent to the bone. Death of bone, or Necrosis, is an effect of violent inflammation, particularly of the medullary web, or external injury; a termination AND DISEASES THENCE ARISING. 107 of inflammatory action in bone corresponding to sphacelation in the softer tissues. It has been observed, that the bones are not exten- sively supplied with blood-vessels, and that their natural powers are inferior to those of the softer parts ; and from this circumstance the frequency of necrosis can be readily accounted for. The short bones and the heads of the long bones, are more vascular than the flattened bones and the shafts of the long ones. Hence necrosis most fre- quently occurs in the latter. Necrosis, fortunately, seldom occurs in the heads of the long bones, or penetrates the separation betwixt the cancelli of the shaft and the epiphysis. Bits of dead bone in the articular ends, however, very often lead to disease in the joint. There are in my private collection a few specimens of necrosis, in which matter found its way into the neighbouring joint, leading to disease of the tissues composing it, and rendering amputation necessary for the preservation of the patient's existence. External injury may produce this disease by causing a violent increase of action, or it may be so severe as at once to deprive part of the bone of its vitality. Destruction of the periosteum, and of the vessels which enter the sur- face of the bone, frequently gives rise to superficial necrosis or exfo- liation. Such a result, however, does not always follow; for we not unfrequently find, when the periosteum has been forcibly torn off, to a considerable extent, by external injury, that the part still retains its vitality. When, however, the bone has been at the same time con- tused, it is extremely probable that external necrosis may occur. Again, when the periosteum has been removed in the most careful manner possible, exfoliation occasionally takes place. If the exposed bone remain of a brownish hue, it will generally retain its vigour; if, on the other hand, the colour is white, it will most probably be cast off. Necrosis may come on at various periods of life, but is most commonly met with in young subjects, in whom the inflammatory action is allowed to make progress before it is noticed or attended to. It may affect the external or internal part of the bone, or nearly its whole thickness. The whole of a bone seldom or ever dies in con- sequence of increased action, and it is not often that the entire thick- ness of any part of it is found to be necrosed. If the entire thickness dies to a great extent, there is no reproduction; the epiphyses approxi- mate, and the limb, if there is only a single bone, must be lost. A large portion of a bone, or numerous small irregular portions, may die ; but still a part of the original shaft remains, and by its vessels reproduction is accomplished. The articulating extremity is very rarely destroyed by this disease. Many writers have talked of death of a bone throughout its whole extent, and, in fact, the term necrosis was originally adopted on this supposition. The progress of necrosis is, as has been said, similar to that of sphacelation. The affected bone gradually changes its colour, and loses its sensibility; a line of demarcation is formed, and ultimately the dead portion is completely detached from the living. Previous to its separation, the surrounding parts, the portions of bone which are not doomed to perish, have commenced forming new osseous matter, which is secreted in nodules, and from continued deposition soon becomes consolidated. The commencement of the process is well 108 OF INFLAMMATION OF BONE, seen in the following sketches from specimens in my collection. The disease, as represented in the two first cuts, was of the most acute kind, and a great part of the shaft of the tibia had perished. This is seen at various points through the sort of cortical deposit of new bone. The new bone, in its turn, secretes a texture similar to itself, whereby the deposit becomes more and more extended, and not un- frequently affords an almost complete encasement to the dead portion, or sequestrum, as represented in the cut on the right hand side of the page. sents quire In general bone dies irregularly, so that the sequestrum pre- an uneven surface, and its margins are rough and serrated by numerous sharp projections, as seen in the one taken from the tibia, and represented here. From the appearance of the dead bone, it was imagined that after its sepa- ration, portions of it were removed by absorption ; and this opinion was strengthened by the thin exfoliations of the external lamina being found perforated at seve- ral points by minute apertures,— worm-eaten, as it was called. These cases of death of inner or medullary shell are irregularly separated, like any other slough; the remaining living outer shell is enlarged by inflam- matory action and deposit. But a dead portion of bone, detached from the surrounding parts, is in every respect an extraneous body, and is not, and cannot be, acted on by the absorbents, any more than a piece of metal, wood, or stone. Some have gone so far as to affirm that portions of foreign bodies, ligatures, &c, are ab- sorbed ; but this opinion is altogether too absurd to re- any contradiction; the knots of ligatures, like portions of glass AND DISEASES THENCE ARISING. 109 or other foreign substance, become surrounded with a dense cyst, and often remain in the body for a long time ; so do portions of dead bone separated by the process here described. A series of experi- ments were made by Mr. Gulliver, in order to put this question at rest, many of which I witnessed and assisted at, and several I also repeated. Setons of bone were inserted and worn for a long time ; thin plates of bone were confined on suppurating surfaces; pieces of bone were inserted in the medullary canal of various animals, and kept there for months, and in one instance for more than a year. These foreign bodies were weighed with the greatest care and accu- racy before and after they were so exposed to the absorbents, and were found unaltered in any respect. A paper, detailing these expe- riments, is published in the Medico-Chir. Transactions. The separation of the dead part from the living is accomplished with greater or less ease, according to the bone which is affected, the state of the constitution, and the general health; in the bones of the superior extremity, this, as well as every other action, proceeds more rapidly than in those of the inferior. It occurs in consequence of absorption of the living parts of the bone, which is in close proxi- mity to the dead. The sequestrum, if large, is not pushed off, as some have supposed, by granulations, deposited on the living mar- gin of the bone. A small portion of the inner shell, when completely- detached, may sometimes be observed to be extruded from a cloaca by granulations from the living bone. During its progress, matter forms, makes its way to the surface, and is discharged through mi- nute, and often numerous apertures, which afterwards become fistu- lous. The soft parts are thickened and indurated, and the integu- ments are red, and sometimes of a livid colour. Formation of matter upon the bone is occasionally the cause of necrosis, the periosteum being destroyed or separated from its con- nexions by the pressure or insinuation of the pus. I have seen seve- ral instances in which it followed neglected erysipelas of the lower extremity. The matter is in general thick and laudable; at first it is secreted profusely, but afterwards in smaller quantity. The external open- ings, or papillse, through which it is discharged, are found to lead to cloacae, or apertures in the new and living bone, which encase the dead, and through these the dead portions can be discovered by the probe; and it will thus be ascertained whether the sequestrum is fixed or detached: when loose, it can sometimes be moved upward and downward in the cavity. When the shaft of a bone is much affected, the whole limb is enlarged, by the inflammation having ex- tended to a considerable distance above and below the portion about to become necrosed. The unshapely appearance of the limb con- tinues until the sequestra are discharged ; for by their presence in- cited action is still continued, and subsides only after their removal. Some time before any portion of bone has become dead, or begun to be separated, great effusion of new bone has, in general, occurred ; thus a preparation has been made for the strengthening of the limb, which, after a considerable portion of the bone has been detached, would otherwise be incapable of supporting the weight of the body. HO OF INFLAMMATION OF BONE, The unnatural bulk of the limb is afterwards much diminished, for the new bone gradually becomes consolidated, and smooth on the sur- face by the action of the absorbents. Nature seems to construct her substitute after the model of the original, and in some instances but very little change can afterwards be observed in the limb. In external necrosis, or death of the outer lamella, reparation is chiefly made by the subjacent parts; and this species of necrosis occurs most frequently in the flat bones. In necrosis involving a greater thickness of the bone, the new matter is also furnished by the subjacent parts, which, however, are materially assisted in the pro- cess by the living bone, which forms the margins of the void caused by the absorbent process for the detachment of the dead portion. The bony matter is deposited with great activity, and frequently columns of the new deposit cross over the sequestrum, binding it firmly down, and rendering it almost immovable, although it may be completely detached from the living parts. It has already been stated, that those vessels which ramify within the substance of the periosteum have no share in the reproduction of bone, but plastic matter is effused by the ramifications extending from the membrane to the bone: this effusion becomes organised, and greatly assists in forming the substitute. It has been formerly remarked, that a limited, and, on after exami- nation, an apparently trifling necrosis of the cancellated structure, may produce the most violent local symptoms; the painful feelings, the discharge, and the thickening of the bone, continue, as long as the cancellated sequestrum remains; severe symptomatic fever is induced, endangering the life of the patient, and often rendering re- moval of the limb absolutely necessary. Occasionally abscesses form at a considerable distance from the necrosed part, and terminate in sinuses, which communicate with the diseased bone, and are consequently long and tortuous, so that exa- mination by the probe is rendered difficult. When necrosis is ex- tensive, there is a risk of fracture occurring, if motion of the limb be permitted before a sufficient quantity of matter has been effused, be- fore nature has had sufficient time for the consolidation of her sub- stitute, and consequently before the new bone has come to resemble the old in thickness and cohesion. Violent inflammatory fever attends the incited action of the vessels of the bone and periosteum which precedes necrosis. But after the abscesses have given way the painful symptoms subside, and the health seldom suffers to any great extent, the system becoming gradu- ally accustomed, as it were, to the new condition of the parts. Hectic supervenes only when the disease is very extensive, and joints be- come involved. Frequently fresh collections of matter form as each piece of bone approaches the surface. When the effusion of new bone has extended to the neighbourhood of a joint, its motion may be very much impeded, and, from the limb being kept in a state of rest for the cure of the necrosis, anchylosis may even occur. Treatment. —- The means of preventing inflammatory action from running high and ending in death of bone have been already alluded to — abstraction of blood, rest, purgatives, and antimonials. When AND DISEASES THENCE ARISING. Ill necrosis has occurred, no interference with the bone is allowable, unless the sequestrum is quite loose, or unless the patient's health is suffering severely under the discharge and irritation. When the se- questrum can be readily moved about, or when, projecting through the external opening, it can be laid hold of by the fingers or forceps, attempts must be made to remove it. The surgeon ought not, how- ever, to allow it to approach the surface, and project externally, for the natural discharge of the sequestrum is a much more tedious pro- cess than the removal of it by art, and by the irritation produced during its spontaneous ejection the inflammatory action is continued, and may prove alarming. Long before it has appeared externally, it must have been completely separated from the living parts, so as to admit of ready extraction by the proper means. When it has been ascertained that the sequestrum is separated, it ought to be laid hold of by forceps, and moved freely upward and downward, so that any slight attachments by which it is connected to the neighbouring parts may be destroyed, whether these be minute filaments which still in some degree retain their vitality, or small portions of newly deposited bone, which are so situated as to prevent the free movement of the sequestrum. In general, no impediment of this nature exists, and the dead bone is easily removed. Before extraction can be accom- plished, it is generally necessary to enlarge freely the external open- ing, in all cases where the dead portion of bone is of considerable size. If, on thus exposing the parts, the sequestrum be found de- tached, but still firmly bound dowTn by the substitute bone, deposited over it either in one continuous sheet, or in irregular columns, this must be divided by a trephine, a small saw, or cutting pliers, before the sequestrum can be extracted. When a dead portion of bone, of considerable length, is exposed at its centre, whilst its extremities are entangled by the old or substitute bone, the division of the exposed part of sequestrum, by means of the cutting pliers, will often be suffi- cient for its removal, the cut ends being seized by the forceps, and one half removed after the other; thus the perforation or removal of any portion of the substitute will be rendered unnecessary. The in- struments, and especially those for extraction, ought to be very power- ful, and suited to the purpose ; for in the employment of inefficient means there is much folly and cruelty. Incisions into a necrosed limb are attended with profuse hemorrhage from the enlarged and excited vessels; and in some cases it is with difficulty arrested, in consequence of retraction of the cut ends of the vessels not taking place within the condensed and indurated parts. Pressure, and an elevated position of the part, will generally be found to answer. When necrosis has been extensive, the limb must be carefully sup- ported by the application of splints and bandage, till the process of reparation be completed, in order to prevent fracture of the re- cently formed substitute. This proceeding is seldom, however, ne- cessary. The treatment may be summed up in a very few words. Prevent the necrosis, if possible ; open abscesses whenever they appear ; en- courage the patient to move the neighbouring joints; support the strength; remove sequestra when loose, but do not interfere till they 112 OF INFLAMMATION OF BONE. are ascertained to be so ; give the limb proper support and rest, when a large sequestrum is formed. When fracture has taken place, when the health has been undermined, or w^hen neighbouring joints have become diseased, amputate, in order to save the life, if it be impossible to save the limb. It is almost superfluous to remark, that leeching and blistering are worse than useless after necrosis has occurred, however useful they may be in prevent- ing it; and that the adoption of measures to promote the dissolution and absorption of the sequestra are glaringly absurd. Necrosis, after amputation, was formerly frequent; but in the present improved state of this operation it is so rare as scarcely to demand separate considera- tion. Such specimens as here depicted are common enough in the collections of those who have prac- tised the old round-about operation; in fact, it is only by this painful and tedious interference of nature that a tolerable stump is formed in many of these cases. Death of a small portion will sometimes, though very rarely, follow even a very well performed amputation, if through any mischance the recovery is slow, and wasting discharge takes place with emacia- tion. It happens sometimes, as when second- ary hemorrhage (that is to say, bleeding after the fourth day) has taken place, that the flaps are separated by the coagula, and it may be impossible to bring the parts together and give them due support; then the muscles, wasted and shrunk, may leave the bone a little, but the exfoliation is but very trifling. The inner shell of bone, as may be seen in the above sketch, perishes more extensively than the outer ; and this arises probably from inflammation of the medullary membrane, in consequence of exposure, or, perhaps, from its being sometimes injured by the operator or assistants seizing the bone rudely to steady the stump, in order to facilitate the ligature of the vessels. In experiments on animals, the dis- turbance and injury of the medullary mem- brane is followed by internal necrosis, thicken- ing of the outer living shell, and effusion be- twixt the periosteum and bone. New bone is also furnished from the medullary canal, as is also shown in the sketch. FRAGILITAS OSSIUM Occurs chiefly in old people, whose bones contain an undue propor- tion of earthy matter, are endowed with little vascularity, and filled OF MOLLITIES OSSIUM, RACHITIS, ETC. 113 with an oleaginous fluid. They contain an undue quantity of phos- phate of lime compared to the gelatin ; and the liability to fracture is further increased by the interstitial absorption of the outer shell. They are in an atrophied state, and this is often in part attributable to disuse of the limbs. This state of the osseous system very often follows upon an attack of rheumatic fever, and is met with in patients who have laboured under cancerous affections. The bones, when in this condition, often break from the slightest force applied; as from the action of the muscles when the patient turns himself in bed, whilst walking across the room, or when endea- vouring to attain the erect posture when seated on a chair. After fracture the process of reunion is extremely slow, and it does not take place at all in patients very old and of worn-out constitution. With a view to prevent the occurrence of fracture when the bones are in this condition, for it is impossible by any treatment to prevent the change in the texture of the bones, the only rational indications seem to be to keep the patient on a generous diet, and to prohibit him from making any great muscular exertion — to avoid, in fact, all circum- stances likely to produce a sudden action of any particular set of muscles. OF MOLLITIES OSSIUM, RACHITIS, ETC. These affections differ only in this, that in the latter the earthy matter is not deposited originally, whilst in the former it is absorbed after having been deposited; in both the result is the same. The latter is peculiar to the very young, the former to those of an ad- vanced age. [Rachitis is emphatically a disease of infancy, being most fre- quently witnessed from the eighteenth to the twentieth month ; it is occasionally congenital, and sometimes, though rarely, it takes place after puberty. Of three hundred and forty-six cases examined by Guerin,* of Paris, three occurred before birth, ninety-eight during the first year, one hundred and seventy-six during the second, thirty-five during the third year, nineteen during the fourth, ten during the fifth year, and five from the sixth to the twelfth. Of these cases one hundred and ninety-eight were observed in the female sex, the re- mainder, or less than one-half, in the male.] Rickets and mollities ossium seem to differ also in this. In the latter there is seldom, if ever, any reparative action. The diseased process of deposit continues in the bone, the softening increases, and the patient ultimately perishes. Whereas, in rickets, the softened and yielding state of the bones is only temporary : after a time earthy matter is deposited in due quantity, and the bones become compact, firm, and solid, capable of supporting the weight of the body, though necessarily permanently bent and deformed, if proper means have not been employed during the softened condition. The thickness of the rickety bone, as Mr. Stanley has shown, takes place on the con- * Memoir on the General Characters of Rachitis, translated by Dr. T. W. Cole.-cott, of Louisville, and published in the Western Journal of Medicine and Surgiry, far January, 1841. 10* 114 OF MOLLITIES OSSIUM, RACHITIS, ETC. cavity, which is the situation where the greatest strength may be added with the least expense of new matter. In the same way the reparation of fractures not accurately adjusted goes on most actively in the concavity formed by their displacement. Softening of the bones is met with at all ages, and in different de- grees. It seems sometimes to be congenital, and combined with hydrocephalus. It often follows dentition, measles, hooping-cough, or other infantile diseases inducing debility. In females it seems to be produced, or at least often accompanied, by the debilitating effects of leucorrhoea, miscarriages, and floodings. Loss of blood, in any way, predisposes to it. Mercury, given in immoderate quantities, produces a softening of the bones; and, in some most remarkable in- stances on record, the free use of common salt was the only cause assigned. When the disease affects children, all the bones generally suffer, those of the extremities as well as those of the trunk ; the limbs become bent in an extraordinary manner, and the heads of the bones are swollen, and appear to be much more so in consequence of the wasted and flabby 'state of the muscles. The child walks with diffi- culty, and in many cases the legs are utterly incapable of supporting the weight of the body, so that he cannot remain in the erect position. The chest and pelvis become deformed, breathing is oppressed, the digestive organs are deranged, and the belly is tumid. The bones of the limbs become flattened as well as bent, and in their concavities as remarked in the preceding cut, new bone is effused, in order that the column of support may be thereby strengthened. The new deposit OF MOLLITIES OSSIUM, RACHITIS, ETC. 115 is of extremely dense consistence, and is effused in greater or less quantity, according to the degree of curvature. The bones of rickety subjects are soft, cellular, and of a brown colour, contain a dark fluid, and are very deficient in earthy matter. As a simple proof of the latter circumstances, it may be mentioned that distortions of the pelvis can be, and often are, accurately imitated by soaking the bones for some time in acid, whereby the earthy matter is extracted. In many instances this component of the bones is almost entirely removed, and soft matter deposited instead ; they then consist merely of an extremely thin external osseous shell, covered by thickened periosteum, and containing a pulpy substance resembling fatty matter. During the progress of the disease, the urine deposits, often in great quantity, a white sediment, which, on analysis, is found to be the phosphate of lime. In rickets the head is generally enlarged to a greater or less degree, and the bones of the cranium are thickened and spongy; not unfrequently the intellectual faculties remain acute. In adolescents and adults the limbs seldom become affected ; the bones composing the spinal column are the seat of the disease, and, along with the distortion of the spine, the position of the ribs is necessarily altered. Certain rare cases have occurred, in which all the bones of the adult were softened to a very great degree. In one remarkable instance, the patient complained of an annoying sense of tightness in the limb most affected, and, on exami- nation, the softened bone was found greatly depressed at that point, as if a strong ligature had been drawn tightly round it. Mr. How- ship, who attended the patient, was so kind as to present me some years ago with a portion of the altered femur, which consists of a fatty-looking substance, and appears to contain little or no earthy matter. [The symptoms which characterise this affection are generally well defined. The face has a yellowish, sallow appearance; the eyes are large and brilliant; the nostrils unnaturally expanded ; the lips, especially the upper, tumid and everted; the head big, and sunk between the shoulders; the chest narrow and contracted; the curva- ture of the clavicle increased; the articular extremities of the bones unusually prominent; the muscles thin and flabby; the motions constrained and difficult; the whole body has a short, stunted- ap- pearance, and the little patient exhibits all the marks of premature decay or old age. The respiration, short and laborious, is performed chiefly by the diaphragm; the abdomen is tense and tumid ; and the skin, which is constantly moist, is often bathed during the night with acid perspiration. The appetite' is weak, the digestion difficult, the thirst considerable, and there is nearly always diarrhoea, or diarrhoea alternating with constipation. The alvine evacuations are of a thin, watery character; the urine is copious, but not high coloured ; the pulse is small and frequent; the action of the heart feeble, the sensi- bility remarkably keen, and the mind uncommonly active. The child feels averse to use his limbs, and the bones are so soft as to be bent with the greatest facility. . The alterations of the osseous tissue have beendivided by Guerin, to. whom we are indebted for the most able and elaborate account of 116 OF MOLLITIES OSSIUM, RACHITIS, ETC. this disease that has yet been furnished, into three stages. In the first, the bones seem to be saturated with a reddish, watery fluid ; a considerable quantity of which is also interposed between their outer surface and the periosteum, on the one hand, and between the me- dullary membrane and their internal walls, on the other. At a more advanced period, this fluid is replaced by a sort of gelatiniform sub- stance, that is particularly conspicuous in the situations here specified, becomes gradually organised and vascular, 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 re- markably enlarged, and the medullary membrane is sensibly altered in its character; the changes which it has undergone being similar, though less in degree, to those of the fibrous envelope just mentioned. The lamellse of the long bones, naturally so hard and compact, are a good deal softened, and the areolar structure greatly rarefied, many of the cells being more than double or even triple the natural size. Similar alterations are observed in the short and flat 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 thickness; and which, by the pressure which it exerts upon the lamellse of the compact tissue, sometimes forces them inwards upon the medullary canal, thus greatly reducing it in size, or even entirely obliterating it. Simulta- neously with these changes the bones are rendered so soft that they may be easily bent, cut, or 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 becomes gradually identified with the pre- existing 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 the natural state, and their firmness— especially in the adult — resembles that of ivory. Hence the term eburnation is sometimes applied to this state of the skeleton.] Though incurvation of the spine occurs in boys, and even in adults, still it is most frequently met with in young females ; and in them it is often induced by their having assumed a bad habit by sitting long in one constrained and awkward posture, as in writing or drawing, without, perhaps, the bones being unnaturally soft in, the first in- stance. It often follows affections of the lower limbs, as of the knee or hip-joint; and is also caused by shortening of a limb, which has been negligently or ineffectually treated after fracture during child- hood, or by the patient being allowed to continue a custom of stand- ing awkwardly on one leg. In a very remarkable specimen in my possession, the curvature seems to have resulted from the tremendous enlargement and consequent weight of the head. The whole skeleton (head, thorax, pelvis, and extremities) is deformed, flattened, and twisted. This may have arisen more readily in consequence of the atrophy of the bones, and retardation of their growth, produced by the long confinement to bed. The number of ossa triquetra in the lambdoidal suture was unusually great. The patient attained the age of twenty-five. Theaffection commenced from birth. OF MOLLITIES OSSIUM, RACHITIS. 117 At first, during slight curvature from such causes, the spine can be brought into its original straight position by the voluntary action of its muscles. After some time, however, the curve cannot be remedied by any effort; interstitial absorption of the bodies of the vertebras towards the concavity of the curve occurs ; they become changed in form, and accommodated to their altered position, as shown in the accompanying sketch ; the muscles also accommodate themselves to the new position, as do also-the various ligaments connected with the spinal column. When the curvature is seated in the dorsal vertebrse it is generally to the right side ; this shoulder is raised, and the chest is protruded, whilst the opposite side is depressed and flattened. The clothes hang loose, or fall off on the left side — the patient rests the weight of his body chiefly on the left leg — on stooping the right scapula projects, and, on examination, is found to be nearer to the spinous processes of the vertebrse than the left. The left cavity of the chest is diminished, and the ribs press upon the heart and lungs, causing difficulty of breathing. To preserve the balance of the body, a curvature occurs below the former, and in the opposite di- rection ; and not unfrequently there is a third incurvation situated above the primary one. The bones of the pelvis become distorted, and are twisted to one side ; or, when the softening is great, and the patient confined to the recumbent position, the introitus of the cavity becomes diminished in the antero-posterior diameter; and, if the patient walk about, the 118 OF MOLLITIES OSSIUM, RACHITIS, ETC. ossa pubis are squeezed together, in consequence of the pressure of the ossa femora against the acetabula. The crests of the ilia are often bent inwards, inconsequence of the pressure of steel apparatus inju- diciously applied with a view of removing deformity. When the bones become consolidated after such distortion, they present most serious obstacles to parturition ; and, most unfortunately, crooked and deformed women possess, it is said, " great aptitude for conception." When, in such females, the untoward circumstance of pregnancy has occurred, it has been necessary, in some, to have recourse to the Caesarean operation, and others have been delivered with the greatest difficulty and danger; notwithstanding wdiich, many of these latter have, after recovering from a long and tedious illness, again become pregnant. In some cases the softened ribs not only compress the organs of the chest, but are also pressed down upon the abdominal viscera, or even into the pelvis. The symptoms arising from such displacement are at first urgent, as can readily be imagined, and are often treated as inflammatory, to the detriment of the patient. After some time, as the state of the patient's health improves, the bones in some degree regain their original firmness, and the curva- tures are rendered permanent. New bone is deposited in the con- cavity of the curve, at first in irregular masses, but afterwards becom- ing condensed, and assuming a more regular form, the column is thereby supported and strengthened. Bending of the spine backward, with depression of the spinous processes, is extremely rare. But curvature forward, with projection of these processes, is by no means uncommon, and is generally sup- posed to be caused by caries of the bodies of the vertebrse ; in many instances, however, it arises from interstitial absorption only. Curvature from caries of the vertebrse, though not so frequent as the curvature from other causes, is met with pretty often. In adults, the curvature from ulcerative absorption is more common than that from softening of the bones. It is attended with the formation of purulent matter, which presents in the loins, at the top of the thigh, or near the anus; the bones may become affected secondarily, though much less frequently, in consequence of the formation and accumula- tion of purulent matter in their neighbourhood. There is pain in the loins ; the patient walks in a stooping posture, and often complains of pain in the knee or thigh. The lower limbs sometimes become. paralytic, as also the sphincters and extremities of the hollow viscera ; this, however, may arise, without curvature, from softening of, or effusion on, the chord, or diseased thickening of its membranes. In some cases the palsy supervenes slowly ; at first the patient has an awkward gait; he lifts his feet high to avoid stumbling, and after- wards puts them down clumsily and suddenly ; the foot, in some cases, is extended, so that the patient is unable to plant the sole on the ground. Retention of urine occurs, and is followed by inconti- nence, with copious deposits. In the treatment of Rachitis, the chief indication to be fulfilled is to support and increase the powers of the system ; and this may be accomplished by affording the patient a generous diet, keeping the AFFECTIONS OF THE ARTERIAL SYSTEM. 119 bowels in good order, enjoining gentle exercise and exposure to pure air, by the assiduous use of frictions, and by supporting the softened bones by properly applied and light machinery. Much mischief may be done by clumsy and heavy apparatus which confine the move- ments of the patient ; the muscles are wasted, consequently the spinal column is weakened, the general health is impaired, and the disease is aggravated. Some have recommended the internal administration of the phosphate and muriate of lime, but their efficacy is extremely doubtful. Preparations of iron seem to answer much better in the greater number of cases. In cases of curved spine, apparently arising from bad habit, the patient should be in no degree confined at writing, or drawing, or music ; her posture while at work or play ought to be attended to, as well as her mode of walking or stand- ing ; and, if awkward, prohibited. Gymnastic exercises of the more gentle kinds ought to be enjoined, such as those wTith poles and light wooden clubs, the turning of a wheel, the exercise with balls, &c. Carrying weights on the head can only be applicable in certain cases. The shoulders, in some instances, ought to be kept back by means of a light back-board ; and in aggravated cases the weight of the shoulders, and sometimes also of the head, must be taken off the spine by a light and well-contrived apparatus. Sea-bathing, good air, out-of-door exercise, and attention to diet, are of material import- ance. Frequently advantage will result from the patient's sleeping on a hard mattress; and, in bad cases, from lying down, when tired, on an inclined plane. In great softening, it will be necessary to confine the patient en- tirely to the recumbent position, and to support the head and shoulders by a light and firm machine. The causes, symptoms, appearances, and treatment of caries of the spine, in its different regions, with or without curvature, will be afterwards considered. OF INFLAMMATION AND OTHER AFFECTIONS OF THE ARTERIAL SYSTEM. During inflammation of arteries, the actions of the vessels are ac- celerated and attended with pain; the internal coat is found to be of a red colour, from increase of its vascularity, and not from its being merely tinged with the colouring part of the blood ; or it is of a yel- lowish hue and rough, from the deposition of lymph on its surface, whilst the external coat is thickened by the infiltration of serum and lymph. When blood-vessels are inflamed from mechanical irritation, lymph is secreted on their internal coat, becomes organised, and obli- terates their calibre ; if deficient in nervous influence and circulating fluid at a particular point, there ulceration of their coats occurs; if violently injured or completely isolated, their coats mortify; and these circumstances must all be calculated on in the surgical treat- ment of arteries. A universal inflammatory state of the arterial coats is said to have existed, and its symptoms have been minutely detailed ; but its occurrence seems to be extremely rare, and the treat- ment is medical. Inflammation is supposed to precede degeneration of the arterial 120 AFFECTIONS OF THE ARTERIAL SYSTEM. coats. As a person advances in life the arteries lose elasticity, and the heart its balance with them; either the one or the other becomes dilated, their parietes are thickened, and the valves are altered in structure ; the enlargement of the vessels is generally greatest towards their origin. The dilatation of arteries, more especially of the inter- nal ones, is often very great; ultimately the internal coat gives way, and the external, with the surrounding tissues, yields in proportion as the blood diffuses itself. The internal tunic is occasionally burst in consequence of violent and sudden muscular exertion ; and, even when the vessels are pretty limber and sound, effusion of lymph, and obliteration of the vessel ensue, or, more frequently, aneurism. Previously to the rupture of the internal tunic, however, there is, in most cases, a morbid alteration in the texture of the vessel. The internal coat becomes dry; its texture is more dense and less elastic, and consequently more brittle. Morbid matter is deposited between the middle and internal coats, and this, by stretching the latter still further, diminishes the elasticity and cohesion of their texture. The deposit is at first to a slight extent and of soft consistence, somewhat resembling condensed fatty matter. Afterwards it increases in quan- tity and consistence, becoming, instead of soft and yielding, dense, hard, and incompressible; in short, calcareous. Though the morbid deposit is at first confined, as above related, its limits are afterwards extended; calcareous matter is insinuated, either in minute particles or in broad, laminae, amongst the fibres of the middle coat, is also found external to it, and occasionally situated in the cellular coat. In fine, the vari- ous component parts of the parietes of the vessel degenerate, according to the degree of advancement which the disease has attained ; and such a con- dition is the predisposing cause to ulceration of the internal coat, and subsequent effusion of blood. The steatomatous, ulcerated, earthy de- generation of the proper coats of an artery, as Scarpa, the celebrated pro- fessor of Pavia, has it, are well ex- hibited in the accompanying sketch. During violent and sudden exertions the more brittle parts may burst, either at a certain point, or throughout the whole circumference of the artery; and on this such results will supervene as on ulceration of the internal tunic. Ecchymosis then takes place under the cellular coat, which becomes thickened, and incorporated with, and strength- ened by, the surrounding tissues; this is the incipient state of an aneurismal tumour. The effusion of blood, gradually increasing, distends the cellular coat, forming the cavity into which it is poured, and produces a tumour of a size proportional to the distensibility of the tunic and the force of the effusion. Sometimes the external coat is separated from the others to a considerable extent by the in- sinuation of blood. An aneurism, however, may exist from simple AFFECTIONS OF THE ARTERIAL SYSTEM. 121 dilatation of a portion of the vessel, gradually increasing, and form- ing a cavity in which the blood accumulates. At one time it was supposed that all spontaneous aneurisms were caused by simple dila- tation of the canal; but such an opinion has been long shown to be incorrect, and the term of true aneurism is now confined by many to that tumour and accumulation of blood consequent on the giving way of the internal coat, and situated externally to the canal of the artery. It is true that dilatation may occur previously to the giving way of the coats, and thus the two causes are combined. The dila- tation occurs from the calibre of the artery being considerably dimi- nished, in the first instance, at the point where its coats have under- gone the calcareous degeneration, and only acts as a predisposing cause to the failure of the coats when thus diseased. When there is mere dilatation, the tumour is generally of an oval form ; but when the internal coat gives way, a lateral prominence is formed, and gra- dually increases in size. The shape of the true aneurism is various: sometimes the tumour is globular, with a narrow neck; and, from this being of considerable length, it becomes difficult, in some situa- tions, as above the clavicle, to ascertain the particular artery which is the seat of disease, the globular extremity of the tumour presenting itself at some distance from the vessel with which its pedicle is con- nected. This is rare, howrever. At other times its form is very irregular, being most prominent at the part where the accumulation of the blood is least resisted. Pulsation in the tumour is distinct from the first, and is painful to the patient; and in the external aneurisms it is so strong as to be perceived by a bystander at a con- siderable distance. The tumour is at first compressible, and com- pletely disappears on firm pressure being applied, either directly to the sac, or to the artery above, the sac being thereby emptied of its con- tents, or prevented from being filled. It may sometimes be difficult to form* an accurate diagnosis, from the circumstance that tumours, not aneurismal, receive a pulsatory movement from an artery or from arteries immediately beneath them; such difficulty is obviated by attention to this simple test — that in an aneurism the pulsation is felt equally in all directions. Besides, if the tumour is movable, it can be partially displaced, so as not to lie immediately over a large artery, and, if it be not aneurismal, it will then be found to possess no pulsation; if it be an aneurism, its pulsation will not be diminished by any change of position. The blood contained within the aneurismal sac, being compara- tively motionless, coagulates, and the coagulum is attached to the inner surface ; at first it contains red globules, but it afterwards loses them, and becomes of a pale hue, consisting solely of fibrin. This coating gradually increases, and attains no small thickness, fresh portions of fibrin being superadded in concentric laminse. These layers are chiefly deposited from the blood within the cavity, but they also appear to receive addition from lymph being effused by the vessels proper to the original parietes of the tumour. By sue thickening, it can be easily conceived that the pulsation will be somewhat lessened. In large aneurisms the accumulation and. de- posit of fibrin may be much greater at some points than at others, 11 122 AFFECTIONS OF THE ARTERIAL SYSTEM. and hence pulsation may be rendered "not equal in all directions." It is not, however, diminished to any great extent; for absorption of one or more points occurs, and the coating is again attenuated. In some rare cases the deposition of fibrin has gone on gradually accumulating, filled completely the aneurismal cavity, and thus ef- fected a spontaneous cure, the remaining solid tumour imperceptibly diminishing by the action of the absorbents. After obliteration of the aneurismal cavity, the fibrin is generally deposited in so great quantity as to occupy the calibre of the vessel above and below the tumour, obstructing the progress of the blood, causing it to flow by the smaller and collateral branches, and effecting a spontaneous cure, somewhat similar to that produced by the artificial application of a ligature. Coagula are seldom formed in the dilated vessel, to what- ever size it may be enlarged, unless there is fissure of the internal coat; for in no other way can a portion of the blood readily become stagnant, while the calibre of the vessel remains pervious. There is in my collection a preparation of dilated aorta, to the coats of which adheres a large firm coagulum. Occasionally, though rarely, a dila- tation of the internal coats is met with accompanied by thinning of the external ones. Of this sort of diverticulum, there is also a good specimen in the collection here alluded to. A spontaneous cure may also be accomplished from the original aneurism being compressed by one of a more recent origin, causing ultimate obliteration of the canal. Of this I recollect one remarkable instance ; the patient was afflicted with an aneurism of the axillary artery, which had attained a large size, and the cure for the disease in this situation being then unknown or unattempted, the patient was considered as lost; but some time after the tumour began to diminish, and disappeared. The patient died; and the cause of death was found to be the giving way of an aneurismal tumour of the arteria anonyma, which was situated so closely to the aneurism of the sub- clavian as to have acted as a mechanical compress, causing oblitera- tion of the vessel at that point. When a cure has been effected, the vessel is found to be converted into a dense and impervious cord at the site of the tumour. The canal above is dilated ; the coats are thickened, especially the middle ; and from the thickening and increased action of the fibres, the internal coat becomes somewhat rugous, the rugse being in a transverse direction. The aneurismal tumour in general increases, and approaches the surface involving and destroying all the intervening textures. If resisted in its enlargement by bone, even this is not sufficient to im- pede its progress; the bone is absorbed, and perhaps ulcerated at the point where it is compressed by the tumour. The osseous is more liable to destruction from this cause than the cartilao-inous tis- sue, contrary to what occurs from compression by abscess Ulti- mately the sac gives way, and its contents are discharged either externally or into an internal cavity or canal, in consequince of its parietes sloughing from the compression made by the tumour- and such termination is instantly fatal. An aneurism of the descending aorta, in a great measure one from dilatation, is here represented : the patient also laboured under AFFECTIONS OF THE ARTERIAL SYSTEM. 123 popliteal aneurism of one limb, and inguinal of the other. He died sud- denly, in consequence of the giving wray of the internal tumour. The escape of blood into the cellular tissue may even take place to such an extent as to prove fatal in a few hours. The disease may also prove fatal by mere com- pression, as of the trachea, impeding breath- ing, and inducing disease of the respiratory organs; or by pressure on the gullet pre- venting the passage of food : in the latter case, however, the dissolution is generally more sudden, in consequence of the com- pressing part of the tumour giving way, and the contents being evacuated into the sto- mach or mouth. If the aneurism compress a plexus of nerves, or the spinal chord itself, the anterior part of the vertebrse having been previously absorbed, paralysis is produced. In consequence of aneurism, the circulation of blood in the vessel is obstructed ; hence the collateral branches above the tumour be- come enlarged, and through them the circu- lation is continued ; by their anastomosis with collateral branches which arise below the seat of the tumour, a por- tion of the fluid is brought back into the canal of the original artery. The circumstance of collateral enlargement used to be distinctly enough demonstrated in amputation, one of the old cures for the disease. The tumour may be suddenly increased by a portion of the parietes giving way,and the blood being propelled into thecellulartissue, which becomes thereby condensed, and supplies the deficiency in the original sac; diffuse is thus superadded to the true or encysted aneurism. The disease is generally accompanied with great pain, the neigh- bouring nerves being much stretched by the enlargement of the tumour, as in the axilla or ham; in these situations also the limb below the aneurism is much swollen from the compression of the ab- sorbents and veins and consequent infiltration into the cellular tissue. Diffused aneurism from wounds, and the other species of the disease, will be afterwards treated of. The peculiar degeneration of the coats of the vessels has been already stated to be the predisposing cause of aneurism ; and the disease may be directly caused by over-excitement of the circulation, or by an over-exertion of the muscles. It is more frequent in males than females.* In men somewhat advanced in life the arteries get * Of sixty-three cases recorded by Mr. Hodgson, in his work on the Diseases of the Arteries, fifty-six were noticed in the male, and seven only in the female. The reason of the more frequent occur- rence of aneurism in men than in women is found in the circumstance of the former being more exposed to all sorts of violence and disease than the latter. — Ed. 124 AFFECTIONS OF THE ARTERIAL SYSTEM. hard and rigid, whilst at the same time the muscles are strong, the general health good, and the whole frame stout and active ; so that the patient is capable of violent muscular action, such as the arteries are ill able to bear, and consequently the internal coat of a vessel yields, and lays the foundation for an aneurism.* The lower limbs being chiefly subject to such exertions, aneurism in them is most fre- quent ;f and for the same reason it is said to be common in those who * The disease is much more frequent in old than in young persons. Of one hundred and eight cases, collected by Dr. Bizot, of Geneva, from the writings of Morgagni, Corvisart, Laennec, Scarpa, Boyer, Hodgson, Richard, and S. Cooper, only a single one occurred before the twentieth year. Fifteen were notieed from the age of twenty to twenty-nine; thirty-five, from thirty to thirty-nine; thirty-one, from forty to forty-nine ; fourteen, from fifty to fifty-nine ; eight, from sixty to sixty-nine; two, from seventy to seventy-nine; and two, from eighty to eighty-nine. Thus it would appear that more persons suffer from this malady from the age of thirty to fifty than during all the other periods of life put together. — Eo. f The following table* wTill place this subject in a clearer and more accurate point of view. It wras drawn up originally by Lisfranc, and exhibits the relative frequency of spontaneous aneurism in the different arteries in 179 cases, excluding those of the aorta: — Popliteal Femoral 7. 8. 9. 10. 11. 12. 13. 14. 15. 16. 17. 18. at the groin. at other points 3. Carotid 4. Subclavian 5. Axillary in the arm-pit. 6. External iliac Innominata . Brachial . Common iliac Anterior tibial . Gluteal Internal iliac Temporal . Internal carotid Ulnar . Fibular . Radial Palmar 59 26 18 17 16 14 5 4 3 3 3 2 2 2 In another table, constructed by Mr. Hodgson, and founded upon sixty-three cases, including, however, twenty-nine of the aorta and innominata, the results are as follows :__ Carotid .... 2 Subclavian and axillary . . 5 Inguinal.... 12 Femoral and popliteal . . 15.__£D * Cyclopsdia of Surgery, vol. i. p. 269. AFFECTIONS OF THE ARTERIAL SYSTEM. 125 ride much on horseback. Degeneration of the coats of the vessels in the superior extremity is extremely rare. This is another reason why spontaneous aneurism seldom assails them. Treatment. — In internal aneurism the only indication which can be followed, with any chance of success, is to favour the occurrence of a spontaneous cure, by abstracting all stimuli, mental and corpo- real, by enjoining complete rest, by keeping the patient on low diet, and by repeated bleeding. Thus the force of the circulation is diminished, and coagulation, it is said, promoted; by this practice aneurisms, the progress of which defies external means, are occasion- ally, though very rarely, cured. Ice and other cold applications to external aneurisms, or those which have made their way to the sur- face, have been recommended to induce coagulation, but their use is not unattended with danger; for they may, in some stages, so far diminish the vitality of the coverings as to cause sloughing, and fatal hemorrhage. In the treatment of aneurisms exterior to the great cavities, import- ant improvements have been made in modern times. No success can be expected to follow palliative and temporising measures, and a cure can result only from operation. Formerly it was the practice to lay open the aneurismal tumour, to search for the extremities of the artery opening into the cavity, and to secure them by a ligature, or close them by pressure, styptics, or both. In some few instances this method had permanent success; but in the majority the operation proved wholly abortive, and not unfrequently fatal. It was necessa- rily tedious in its performance, and attended with much danger, the blood being discharged in great profusion immediately after the open- ing of the sac, and the extremities of the vessels being with great difficulty detected and secured. Besides, the vessels in the imme- diate neighbourhood of the tumour having generally undergone the degeneration already mentioned, were incapable of taking on any healthy action; the application of ligature on a vessel thus circum- stanced could consequently be productive of no advantage. From this method having almost invariably proved unsuccessful, practi- tioners in those days generally preferred amputation, when the tu- mour wras so situated as to allow it; and when the disease occupied a situation in the limb so high as to prevent amputation, the case was deemed incurable, and the patient abandoned to his fate. But amputation was accompanied with circumstances almost equally alarming with those attendant on division of the sac : the hemorrhage was very great; for, as a consequence of obstruction to the free pas- sage of the blood in the aneurismal vessel, the circulation was chiefly carried on by the collateral anastomosing branches, which were there- by so much enlarged, as, on their division, to pour out blood with a profusion resembling that of arteries of the second or third magnitude. Continued pressure was employed as a less hazardous method of cure, but was equally inefficacious; and was also attended with danger, from the risk of sloughing. If the practice ever proved successful, it was only after a tedious perseverance in its use, and long confinement of the patient. [Attempts have been made, at various times, to cure aneurism by 11* 126 AFFECTIONS OF THE ARTERIAL SYSTEM. gradual and systematic compression, applied to the trunk of the af- fected vessel within a short distance of the tumour. Richerand ap- pears to have been the first who put this method in practice, which was afterwards employed with success in two cases, by Dupuytren, at the Hotel-Dieu. It was also employed by Sir William Blizard, but such was the pain that the patient was unable to bear the pres- sure longer than nine hours. Other surgeons also occasionally re- sorted to it, but either from their not having understood the principles on which it is founded, or from the severe suffering consequent upon its use, it never became one of the established operations for the cure of aneurism. In fact, the method had been almost lost sight of, when, in 1842, it was revived and modified by Dr. Hutton of Dublin. As employed by him the compression is applied in a slow and gradual manner; not so much with a view to obliterate the artery, as to promote the coagulation of the blood in the abnormal sac. In the Dublin Medical Press for March, 1845, Dr. Bellingham has reported twelve cases of popliteal and femoral aneurism which were success- fully treated by compression. In most of these cases, enlargement of the articular arteries of the knee coincided nearly with the cessa- tion of pulsation in the tumour, showing that the collateral circula- tion was becoming established. Occurring early during the treat- ment, this is evidently a very favourable sign, as it indicates a speedy cure by the filling up of the aneurismal sac. The compression may be effected by means of a graduated com- press and roller, applied from the toes upwards some distance beyond the tumour. The most recent method, however, consists in the em- ployment of a particular instrument, calculated to bear upon the artery at two distinct points, so that when the pressure becomes painful at one, it may be relaxed, and tightened at the other. The apparatus employed by Dr. Bellingham resembles a carpenter's clamp ; it consists of an arc of steel, having at one extremity an ob- long padded splint, and at the other a nut terminating in a quick screw, to which a tourniquet pad is secured. Compression is for obvious reasons applicable mainly to popliteal and femoral aneurism. It is liable to be attended with severe pain, cedema, excoriation, and even gangrene. Nevertheless, with proper care, it appears to be worthy of trial, especially when there is great degeneration of the arterial tunics, or when the tumour is of very- large size and furnished with unusually thin walls. Moreover, should it fail, its employment does not preclude the ligature; on the con- trary, by retarding the increase of the tumour, and assisting in the establishment of the collateral circulation, it paves the way for the Hunterian operation, and augments the chances for a favourable ter- mination. The procedure should always, if possible, be conjoined with Valsalva's plan of treatment; that is, the patient should keep perfectly at rest, be bled every four or five days at the arm, make free use of digitalis, subsist upon a diet barely consistent with the maintenance of life. These means, by promoting the coagulation of the blood within the tumour, will materially expedite the cure.] The operation of applying a ligature on the vessel at a distance from the tumour, and thus intercepting or weakening the flow of AFFECTIONS OF THE ARTERIAL SYSTEM. 127 blood into the cavity, so as to allow complete coagulation to take place, is of comparatively modern invention, and is the one now practised with almost invariable success. To John Hunter without doubt belongs the merit of proposing and putting it in practice ; it has been claimed also for the celebrated Desault. This operation has been variously modified. Some have advocated the temporary ap- plication of a ligature, conceiving that the effects produced will be as complete and permanent when it has been allowed to remain only for a certain time, as when it is left undisturbed and ultimately sepa- rated by nature. Such a theory, however, has proved to be incor- rect in most of the instances in which it has been reduced to practice on the human subject; and the operation is at best very uncertain, and not to be relied on. Others have employed a double ligature, and some of the Continental surgeons have applied a great many; some were tightened, others left'loose, and looked upon as ligatures of reserve to be tightened, should hemorrhage take place, an occur- rence likely enough to follow their clumsy and unsurgical proceed- ings. A thick broad ligature like tape has also been used, from an ill-grounded apprehension that all the coats of the artery would be cut completely through by the tight application of a thin and firm one. With the same view, a roll of linen or plaster has been inter- posed betwixt the noose and the vessel, and this practice has been advocated even by good surgeons — as Scarpa. Such complications can do no good, and may do much mischief. The artery must be greatly detached from its surrounding connexions before the nume- rous and flat ligatures can be applied, in consequence of which its coats will be apt to slough or ulcerate, and hemorrhage occur. When, from any cause, the vessel has been detached to a greater extent than is sufficient for the passing of one ligature, two ought undoubt- edly to be used, and one applied close to each extremity where it is attached to the surrounding parts. Again, it has been proposed, after the application of a double liga- ture, that the vessel should be cut through betwixt the two deligated points; it being supposed that in this way the closure of each ex- tremity will be more rapid, the cut ends retracting, and being, in fact, in the same circumstances as the extremities of arteries which have been tied on the face of a stump. Mechanical contrivances have also been invented for the compression of the artery,— such as the serrenoeud and presse artere; these, however, are clumsy, insufficient, and often injurious. The single ligature, when properly applied, is the most safe, and preferable to any other, for arresting permanently the flow of blood in a vessel. In its application, the artery must not be separated from its connexions farther than is barely sufficient for the passage of the armed needle beneath it; but the external incision ought to be free, in order that this may be readily effected, and that the operation may be easily and speedily performed. By the firm application of a single ligature, the vessel is rendered impervious; the internal and middle coats are divided, so that the ligature only encircles the outer or cel- lular one, which resists the influence of any moderate degree of force by which it may be tightened. The blood coagulates above the de- 128 AFFECTIONS OF THE ARTERIAL SYSTEM. ligated point,—the coagulum is of greater or less extent, in propor- tion to the vicinity of a collateral branch, and is of a conical form, the apex of the cone pointing to the free portion of vessel. Incited action in the vessel takes place at the delegated point; the divided margins of the internal and middle coats secrete lymph, by which they adhere, and so obliterate the canal of the artery. Lymph is also effused on the external surface, and in this deposit the ligature becomes imbedded. The direct influx of blood into the aneurismal sac is thus intercepted, and time is allowed for coagulation of the blood which it contains; the artery for a considerable distance below the ligature becomes ultimately converted into a firm and impervious chord. The coats of the vessel above the ligature are much thick- ened, and the internal membrane is occupied with the transverse rugae occasioned by projecting fasciculi of the fibres, which are al- ways apparent after obstruction of an artery. If this operation be properly conducted, success must almost uniformly follow. Before determining on its performance, however, the state of the arterial system ought to be examined as carefully as possible; for not unfre- quently the degeneration of the coats is almost universal, and there- fore an artery, or even arteries, may be diseased at more points than one ; and if this aneurismal diathesis exist, the patient may be found to labour under an internal aneurism of the aorta. In such a case, an operation could not with propriety be undertaken for the cure of the external aneurism; there might be no inconsiderable danger of of the patient's death being suddenly accelerated by the operation, the sac of the internal aneurism giving way perhaps during its per- formance : such a circumstance has actually occurred. Ligatures composed of animal substance, such as catgut, have been proposed as preferable to all others, on the supposition that they would be absorbed, and occasion less irritation ; the fallacy of any such theory has already been adverted to. After the ligature has been applied for some time it induces ulceration of the external coat which it envelopes, by which means it becomes detached from the vessel; acting as a foreign body, and causing a slight degree of sup- puration, it makes its way by nature to the surface and is discharged. The period at which it separates may be said to be from the tenth to the twentieth day; sometimes sooner, seldom later. If, however, much of the surrounding parts have been extensively included along with the vessel, a longer period will probably elapse before the sepa- ration of the ligature. One end only of the ligature should be cut away close to the artery, the other being left hanging from the ex- ternal wound; perhaps it is even safer to leave both, unless a third knot is made upon it; thus the extraneous body, when detached, can be gently pulled at so as to hasten the separation: this must be done with very great caution. When both ends are cut short, and the knot closed in, there is a risk of secondary hemorrhage, from the liga- ture causing formation of matter round it, perhaps detaching the vessel from its connexions, and causing ulceration of its coats The operation ought to be performed at as early a period of the disease as possible. Some recommend that it should be delayed in recent cases, with the view of allowing sufficient time for the anas- AFFECTIONS OF THE ARTERIAL SYSTEM. 129 tomosing vessels to enlarge, in order that the circulation may be more vigorous in the smaller branches after obstruction of the prin- cipal vessel. Such delay prolongs the patient's sufferings, which are in many cases extremely acute, and the precaution is altogether un- necessary, as has been amply proved by experience. On the same principle, the previous application of pressure to the vessel has been recommended; but few surgeons, if any, are now afraid of trusting to the resources of Nature when the principal vessel of a limb is ob- literated, and that suddenly, without previous dilatation of the anas- tomoses. Cases are on record, in which the abdominal aorta has been completely obstructed by a natural process, without much im- peding the inferior circulation; and in one remarkable instance of this description, the inconvenience wras so slight that the disease was not suspected during the life of the patient, the lower limbs retaining their usual size and activity. In plethoric habits it may sometimes be prudent to abstract blood, even more than once, previously to the operation. When the ligature is placed immediately below a collateral branch of considerable size, a bloody coagulum is not formed, though adhe- sion may occur; but if the excited action should extend to the col- lateral branch, and its canal become thereby obliterated, a coagulum is speedily deposited. In consequence of the enlargement of the anastomosing branches, and the increasing circulation in them, pul- sation generally returns in the tumour, to a slight degree, some days after the operation. This, however, is by no means a sign that the operation has been ineffectual; for the renewed pulsation almost always disappears in the course of a very short time. In one instance only have I found it assume a more permanent and troublesome aspect; in that case, it recurred about ten months after the perform- ance of the operation, but speedily disappeared under the careful use of a compress and bandage. On account of the aneurismal diathesis, it occasionally happens, that after the cure of one aneurism, another appears in a different situation; in two instances, I operated on both thighs, at a consider- able interval, successively and successfully, for popliteal aneurism in the same patients. [This aneurismal diathesis occasionally exists in an astonishing degree. Thus, Pelletan relates an example in which there were up- wards of sixty tumours of this kind ; and a still more remarkable one is recorded by Mons. J. Cloquet. In this case the number of dila- tations exceeded two hundred, the largest of which were not bigger than a common pea. An instance similar to that in the text occurred at Cincinnati five years ago, in a man between thirty and forty years of age, in whom Professor Mussey secured the right femoral artery for popliteal aneurism. Three years previously the same operation was performed on the left limb for the same affection by Dr. Speer, of Pittsburg.] When the tumour is so situated as not to admit of the application of a ligature between it and the heart, it has been proposed to place the ligature on the distal side of the aneurism, upon the supposition that coagulation will occur within the sac in this case as after the 130 AFFECTIONS OF THE ARTERIAL SYSTEM. common operation.* The practice has been made trial of, but its expediency appears very doubtful; neither has the success attendant upon it been such as is generally supposed : the post mortem exami- nations have been very unsatisfactory in some of the cases. The application, indeed, of a liga- ture in that situation can seldom be of any ad- vantage, the artery being already obliterated, in aneurisms of some standing, a long way beneath the tumour; and it is, perhaps, from this circum- stance that, in such operations, great difficulty has been experienced in securing the vessel, and that it has been thought necessary even to pass a needle under a thick mass, somewhat in the situation of the artery. It would appear, in some instances, that the artery when pervious had even remained untouched, not being even exposed by the burrowing process employed by some of the operators; and that if any vessel was tied, it was not the trunk in which the dis- ease existed. It would appear that a very cor- rect diagnosis had not been formed in some of the cases. The appearance of the vessel after the appli- cation of a ligature above the tumour has been already shown. The obliteration of the sac pro- ceeds, in some cases, very rapidly; it assumes a harder feel, decreases, and disappears; being connected with the vessel by means of a dense impervious chord, to which condition that portion of the artery has been reduced. The anasto- mosing vessels enlarge more and more, carry blood freely from above to below the ligature, and thence to below the tumour; some even passing to the latter situation directly from above the ligature. Along with the muscular and other branches, the neurilemmal vessels also become enlarged, and com- press the nervous filaments; and to this are to be attributed the annoying pains which sometimes occur in a limb after the operation for aneurism. The enlargement of the arteries of the neurilemma can be distinctly shown by dissection. Immediately after the operation, the circulation in the limb cannot be so vigorous as before ; its temperature is consequently diminished, and it possesses less power of resisting the influence of stimuli The limb ought to be kept only moderately warm ; for if too much heat be applied, there is a risk of gangrene. The temperature afterwards rises, and soon gets above the natural standard ; the blood from ob- This is commonly called Brasdor's operation, after the surgeon who devised it. Mr Wardrop, of London, is its greatest advocate. It has proved successful only in a few cases out of upwards of twentv in which it has been performed. — Ed. OF ANEURISM BY ANASTOMOSIS. 131 struction in the internal parts, being chiefly determined to the surface. After the collateral circulation has been completely established, the limb regains its natural temperature. Secondary hemorrhage is occasionally a consequence of this opera- tion ; nor is it to be wondered at, should one ligature only be used, seeing that this is often clumsily applied; the cellular tissue being lacerated, and the vessel detached from its connexions by the use of blunt instruments, directors, and silver knives. When many liga- tures are employed and foreign substances placed in the wound, the patient can scarcely be expected to escape profuse bleeding. If, however, the operation by single ligature be properly performed, and the coats of the artery be sound at the deligated point, the occurrence of secondary hemorrhage must be rare. It generally supervenes when the ligature is about to separate : at first there is a thin bloody discharge, afterwards the quantity of blood is more copious ; it is evacuated at first in a gentle and continued stream, but afterwards per saltum, and in profusion. The discharge not unfrequently stops for a short time, but, on the circulation being excited, it again returns ; and the patient soon dies, unless active measures be practicable, and immediately resorted to. Compression can be of no use ; nor can astringents, nor venesection, which I have actually seen practised in such cases. The application of a ligature betwixt the heart and the open point of the vessel affords the only chance of saving the patient; the surgeon must interfere, and do what is in his power— he cannot look on and see the patient bleed to death. Occasionally the aneurismal sac deviates from its usual structure and appeaiance. Sometimes osseous or calcareous matter is found deposited, to a greater or less extent, in the substance of the parietes of the sac, or between the laminse of fibrin which it contains. The tumour may also occupy unexpected situations, occurring after frac- ture of the bones and laceration of an artery, and perhaps from more slight external injuries. A disease of bone, somewhat resembling aneurism in that tissue, will be afterwards noticed. OF ANEURISM BY ANASTOMOSIS. This disease is generally seated in the external cellular tissue. It has been supposed to attack occasionally the internal organs ; and a case is related in which it was situated in the cellular tissue, between the vagina and rectum. Frequently the congenital marks of children, termed Nsevi, degenerate into this disease : occasionally, though very rarely, it occurs in sound skin and in adults. A good case of this kind will be found in the Practical Surgery, p. 336. When the cutaneous tissue is involved, the colour of the tumour is a dark red, or inclining to purple ; it is irregular on its surface, and has a soft, spongy feel. Often it is raised distinctly above the surrounding parts ; at other times it is flat, scarcely prominent, and seems to enlarge chiefly in a lateral direction. The skin is then frequently unaffected ; pulsation, in some instances, is perceived; often, however, the tumour is of an inactive character, affords no pulsation, and, on being handled, feels like a doughy, elastic intumescence, appearing to be composed 132 OF ANEURISM BY ANASTOMOSIS. of a congeries of distended vessels, in which the blood circulates slowly, and resembling varix. The tumour is formed by enlarge- ment, tortuosity, and increased activity of the capillary and other vessels; in some cases the arteries are chiefly affected, in others the veins. That such is its structure, can be distinctly proved by dissec- tion ; the vessels are found enlarged to many times their natural size, and their coats are much attenuated ; it is certainly not cellular, as some have supposed. The tissue is similar to that of the cavernous and spongy bodies of the penis, and has hence been named erectile. A natural structure of the same kind is met with in the lower animals in different situations. The tumour is much increased on the general circulation being hurried, as by crying in children, by fits of passion, by the excitement of ardent liquors or venery, and during or before the menstrual discharge. On such occasions the surface frequently gives way, hemorrhage ensues, and is often profuse ; in females it sometimes takes the place of the regular discharges. The tumour, in general, increases rapidly in size, and bleeds from time to time ; now and then, however, it becomes stationary, even in circumstances where it could hardly be expected, and remains so during the re- mainder of the patient's life. Again, in children, the surface of the tumour is not unfrequently ulcerated, even to a great extent, without hemorrhage occurring; when such is the case, the ulceration for the most part extends, with surrounding induration and condensation of the parts. The wdiole or part of the adventitious tissue may thus be destroyed ; the parts cicatrise, and a spontaneous cure is sometimes accomplished. In other cases, though the disease is not extensive, frequent and most violent hemorrhage occurs. A hemorrhagic ten- dency also occasionally occurs in affections of a different nature, — a trifling sore pouring out blood on the slightest touch. In some con- stitutions, leech-bites, trifling punctures, or the extraction of a tooth, have been followed by dangerous hemorrhage. The disposition very often exists in many members of the same family, and is sometimes hereditary. Great trouble has been experienced in staying the bleed- ing ; large vessels have been tied without effect, and some patients have even perished notwithstanding every exertion on the part of the attendants. It becomes a difficult matter to treat surgical diseases in such constitutions : openings cannot be made with the knife for the evacuation of matter or any other purpose. A good case will be ound in the Lancet, 1838-39.* The same patient again presented * For some very interesting examples of this hemorrhagic ten- dency, the reader is referred to Mr. Wardrop's excellent little work on Bloodletting, and to the second edition of my Elements of Patho- logical Anatomy. A few years ago a case came under my notice in which fatal hemorrhage was caused by lancing the gums over the two central incisors of the upper-jaw, in a male child between five and six months old. He was labouring at the time under an attack of cholera, so prevalent in our early summer months ; and the day after the operation purpuric spots appeared in different parts of the body, the largest being situated on the abdomen and the scalp just behind the ear. The bleeding was at length arrested by the twisted OF ANEURISM BY ANASTOMOSIS. 133 himself with a very large and deep abscess of the hip, which was opened by caustic, though nearly one inch and a half from the sur- face. It is not easy to account for this disposition to bleed so pro- fusely, or from slight causes. The blood is in a diseased state, pro- bably as in the patient here referred to, in whom it contained pus globules, and coagulated slowly ; there is probably also a want of tone in the vessels themselves. Many such cases are on record. The cause, or causes, of aneurism by anastomosis are also unknown. Tn very slight cases of erectile tumour, or in nsevus threatening to assume an aneurismal action, cold and pressure are sometimes, though very rarely indeed, sufficient for the prevention and removal of the disease. The most effectual remedy is excision, though this can very rarely indeed be had recourse to with safety ; for when the disease is extensive, the vessels in its neighbourhood are much en- larged, and their action increased ; so that any attempt to remove the tumour by the knife is followed by profuse, and often an uncon- trollable flow of blood. When excision is practicable, it ought to be accomplished by cutting very clear of the disease ; the tumour, like every other, must be cut out, not cut into. If the incisions encroach on the substance of the tumour, or are made in the immediate neighbourhood of the diseased part, the tremendous bleeding which invariably ensues will convince the practitioner of the impropriety of his conduct, and rashness of the proceeding. Attempts have been made to arrest the progress of the diseased action, by tying the prin- cipal arterial trunks entering the tumour; but these have proved ineffectual, as might be expected, considering the unusually free and numerous inosculations which then exist. In a few instances, liga- ture of the carotid artery, on the same side with a tumour on the face or head, has put a stop to the disease ; in the others, it has been unavailing. When the tumour is so situated, or of such a size as to render the expediency of excision doubtful, it may often be safely and expedi- tiously removed by ligature. In some cases the tumour is prominent, so that it readily allows of the application of a ligature around its base; in others, it is flat and broad ; in which case, a long needle, or needles, armed with a double ligature, can be passed beneath it, and the ligatures can then be separated, and so disposed as to cause sufficient constriction of the entire mass. — Vide Practical Surgery, p. 331, 336. In many cases, incisions may be made with great ad- vantage, either before or after introducing the ligatures ; the diseased mass is thus more effectually included and strangled, and much pain and deformity are avoided. The disease, however, occasionally suture, made by transfixing the gum with three very small needles, the points of which were broken off close to the jaw, and the threads applied in the usual manner. Notwithstanding this, the child died exhausted on the fifth day, hemorrhage having, in the meanwhile, taken place from the stomach and bowels. It is proper to add, that the infant had been delicate from his birth, and that there was no hereditary predisposition to the singular affection which carried him off. — Ed. 12 134 OF INFLAMMATON OF VEINS. occupies such situations as are totally beyond reach. The applica- tion of potass has been recommended ; and this caustic is certainly sufficiently powerful to destroy the diseased parts ; but its use is attended with danger from profuse hemorrhage. Superficial nsevi may occasionally be got rid of by the application of nitric acid, but it requires to be applied over and over again ; and, after all, some more effectual means must probably be resorted to. Stimulating injec- tions into the substance of the growth have been sometimes employed. Cures, it is said, have followed the use of setons, or the repeated puncturing and breaking up of the tissue with a needle. None of these means are to be depended upon. The cases are innumerable in which I have been obliged to employ the ligature in an effectual manner, combined or not, with incision, where caustics, injections, puncturings, setons, and even imperfectly applied ligatures, had been previously resorted to in vain. Besides, in children, there is as much resistance and crying, and as much anxiety in parents, produced by a slight operation, as by a more effectual one. [In one instance I succeeded perfectly in effecting a cure with the seton. The tumour, about the size of a twenty-five cent piece, occu- pied the vertex, and possessed all the properties of the erectile tissue. The child was eighteen months old, and the swelling had made its appearance a few weeks after birth. Half a dozen coarse silk threads were passed, by means of a curved needle, under the base of the tumour, where they were allowed to remain for nearly a month. Considerable suppuration supervened, followed by the complete ob- literation of the enlarged vessels. In the hands of Mr. Wardrop, of London, the caustic potash applied to the surface of the tumour, as in making issues, appears to have been attended with great success. Dupuytren recommended the actual cautery in the treatment of this affection, and a case has been published by Maunoir in which this method was employed successfully. The operation, however, is too severe ever to come into vogue. Another proceeding, founded pretty much upon the same principle, but entirely free from its dan- gerous effects, has occasionally been practised within the last few years. It consists in plunging into the tumour one or more heated needles, for the purpose of coagulating the blood and exciting the adhesive process. The instruments are heated red instead of white, and they should be furnished with blunt points, so that they may burn their way through the parts rather than cut them. The practice of tying the principal arterial trunks connected with the swelling almost constantly fails, and is rarely resorted to except by ignorant and reckless surgeons.] OF INFLAMMATION OF VEINS. Veins are very susceptible of inflammation, and the action is very apt to extend along the coats rapidly ; in some cases it reaches the right side of the heart, producing most violent symptoms, and speedy dissolution. Inflammation in the venous, as in other tissues, may terminate in OF INFLAMMATION OF VEINS. 135 resolution. Otherwise, lymph is secreted, whereby the coats of the vessel become thickened, and its internal surface aggluntinated, causing obliteration of the canal to a greater or less extent. Suppu- ration also occurs, and the pus may be deposited in a cyst, formed amongst the coats of the vessels; or, as is most frequently the case, it is secreted from the internal coat, and occupies the canal of the vein. It then generally accumulates, its passage into the circulation being prevented by a deposition of lymph sufficient to occupy the calibre of the vessel betwixt the heart and the seat of the purulent matter. The termination in purulent secretion is accompanied with a high degree of constitutional irritation, and typhoid symptoms, more especially if any pus finds its way into the circulation. The integuments in the course of the inflamed vessel or vessels are of a dark red colour, and great pain is caused by pressure. Often there is a considerable cedematous swelling of the limb, occasionally followed by the formation of unhealthy pus, diffused in the cellular membrane, eausing sloughing of that tissue, or of the soft parts more deeply seated. This disease generally follows an accidental wound or operation, as venesection or amputation ; it is also of frequent occurrence after the application of a ligature to the extremity of a vein. Many pa- tients have died of this disease, induced by the application of a liga- ture to the vena saphena major, for the cure of varix. Wounding of large veins ought to be studiously avoided ; and if wounded, the bleeding from them should, if possible, be arrested by pressure. When from any cause the extremity of a large vein in a wound is not closed, when it is not plugged up by plastic matter, pus seems to enter it readily, and by mixing with the circulating fluid, causes dreadful mischief; great constitutional disturbance accompanies the purulent deposits which follow in the solid viscera and in the joints. Inflammation of veins is a very unmanageable disease ; the exhi- bition of purgatives and antimonials will be prudent, in order to evacuate the bowels, produce diaphoresis, and diminish the force of the circulation ; the pain will also be much relieved by the applica- tion of warm fomentations to the affected part. General depletion is not admissible unless at the very commencement of the disease, and local bleeding must be had recourse to with very great caution ; for by copious abstraction of blood, gangrene may be induced, or at least hastened. The limb must be altogether disused and elevated, the patient being kept in a state of complete rest, and not exposed to any excitement or anxiety. Blisters have been applied, but with no good effect. If the vein is much distended, and it is evident that it contains a confined accumulation of pus, it ought to be treated as a common abscess, the matter evacuated by an incision, and various dressings employed, according to circumstances. Such practice I have found successful, and not followed by any untoward symptoms. The abscess is often limited at each extremity by the deposition of lymph in the canal of the vessel; and after the evacuation of its con- tents, the cavity contracts, and the portion of the vessel which has been the seat of suppuration becomes completely impervious. Inflammation of a vein is also occasionally followed by the sudden 136 VARICOSE STATE OF VEINS. appearance of a purulent depot in some part of the body, external or internal, at a distance from the inflamed part. Thus, in inflammation of a vein in the fore-arm, it is not unusual to find an abscess formed suddenly in the axilla on the opposite side ; after amputation, or other capital operation, the patient is often suddenly affected with violent symptoms of disease in the chest, and on examination, ab- scesses will probably be discovered in the substance of the lungs, the existence of which had only been suspected a short time previous to death. Possibly some pus globules, the seeds of disease, may be arrested in their course, through the capillaries of these organs, and thus a foundation be laid for mischief. A very satisfactory expla- nation of these phenomena cannot readily be given. It has already been noticed, that the softening of coagulated fibrin must not be confounded writh suppuration. The fibrinous pulp has commonly been called pus, though erroneously ; and when occurring in the veins, as it frequently does, has been generally described as inflammation and suppuration of the vessel. The distinction is im- portant ; first, because many of the so-called cases of phlebitis are shown to be of a different nature, and secondly, as to the theory of suppuration, on which subject many writers in this country have been engaged in making commentaries on, and compilations of, the French doctrines, which are not deserving of much regard. There exists without doubt a capillary phlebitis, and the vast im- portance of inflammation, and its consequence in these vessels, will be estimated when their great ex- tent and functions are recollected. It is probably in this class of cases especially that the blood becomes contaminated with pus. Veins frequently become dilated or varicose; they assume a tortu- ous course, appear much enlarged, and present an elastic, soft feel, ex- cept in the situation of the valves, where they are more hard and incompressible : occasionally the tortuous windings form a bluish tu- mour of considerable size. The di- latation of the superficial branches is increased by heat, the skin being thus relaxed, so as to give less sup- * tu j-i x .- • ,Port- The llmb is swollen and cede- matous. The dilatation is generally supposed to be confined to ^he ves- sels near the surface, but it appears that the deep-seated ramifications are not exempt from the affection. When a dilatedvein becomes™- VARICOSE STATE OF VEINS. 137 flamed, great pain is felt in the part; the vessel feels like a firm chord, its coats are much thickened, and its cavity proportionally contracted, lymph is effused, and by the canal may be obliterated to a greater or less extent; a spontaneous cure is thus accomplished. In the lower limbs, the disease is often complicated with ulcers; and as long as the veins remain varicose, the ulcers are almost incurable, or if they are brought to cicatrise, the skin soon ulcerates again, and the dis- ease is re-established. The coats of the vessel not unfrequently ul- cerate, and blood is discharged in appalling profusion : such an oc- currence may even prove rapidly fatal. Sometimes, though rarely, skin thinned by pressure from within gives way without previous ul- ceration, and profuse bleeding ensues. The cause of this affection is obstruction to a free return of the blood ; as by tumours, either natural or adventitious, from pregnancy, constipation, &c.; or by the tight application of a ligature round the limb, as of a garter. It often occurs in those who have been in the habit of great muscular exertion, the blood being thereby forced from the deep-seated veins into the superficial. This even occurs, though very rarely, in the upper extremity, and I have witnessed more than one instance of it. Here it is more readily got rid of. Dilatation of venous branches is met with in the scrotum, labium pudendi, lower part of the abdomen, in the neighbourhood of the anus, and at the lower part of the neck. The lower limb is, however, the most com- mon seat of the disease : when the^veins in this situation are dilated, the valves are insufficient to obstruct the calibre of the vessels, and consequently the lower and smaller ramifications have to sustain the column of blood in the superficial veins of the whole limb, its weight not being diminished by the support wdiich, in the natural state of parts, is afforded by the valves ; the disease is thus more and more aggravated. The left limb is generally the one affected ; and this circumstance may probably be explained by the pressure of the sig- moid flexure of the colon on the left iliac vein. In the majority of cases, the palliative treatment can only be adopted. The limb must be used as little as possible, and, if prac- ticable, be kept in a state of complete rest; the veins must also be supported by the application of a bandage, or the wearing of a laced stocking. The Indian rubber bandage worn over the stocking or drawers answers fully as well as any other method. In some instances, the application of cold has been of advantage, by promoting the contraction of the dilated vessels. When pregnancy is the cause, it is needless to commence any method of cure, until the cause be removed; and the same remark is applicable when the affection arises from habitual constipation. The varices occasionally become inflamed, painful, and much swollen, with considerable oedema of the whole limb. Their contents become coagulated, and their coats thickened ; in the end, the swelling abates and the vessels are closed. In certain cases, this spontaneous cure, a radical one, may be imitated by the surgeon ; an escharotic being applied over the trunk of the vein at a healthy point, whereby inflammation is produced in the coats of the vessel, and obliteration of its cavity accomplished : the caustic which will be found most convenient and effectual is the 12* 138 OF TUMOURS. potassa fusa. The caustic may be made into a paste with soap ; or a solid piece, of the size of a split pea, is placed over the vein, and there retained for a few hours by plaster or bandage. The vessel being obliterated, the lower venous branches necessarily pour their contents into those deeply seated ; as they freely communicate with these, they readily empty themselves of their accumulated contents, and soon regain their calibre under the employment of bandaging. When the varicose veins are numerous, as is generally the case, the potass is to be applied to the healthy point of the larger trunk in which they terminate. But the practice is not unattended with danger, for the coats of the vessel may ulcerate in consequence of the applica- tion, and violent hemorrhage eusue ; the degree of inflammation ex- cited may be greater than that intended, and extend so as to give rise to suppuration in the vessel and the most alarming constitutional disturbance. These unfavourable results, however, must be of rare occurrence. Success has, however, followed the practice in innume- rable instances. A much preferable method, as being less painful and unattended with risk, is that of passing needles under the vessel, and twisting a piece of thick and strong silk round them. Two needles should be applied together, at an interval of about half an inch, at whatever points it is thought right to close the vein. Coagulation takes place in the included part, and also frequently for some distance below it; the coats of the vessel are thickened, and its canal closed. The needles are withdrawn before they begin to cut their way out by ulceration, — say at the end of from three to five days, — according as the parts become condensed. The needles suited to the purpose are soft, but tempered at the point, which is spear-shaped; the ends are cut off with pliers after the thread is fixed. Other operations have been performed on the veins, to procure a radical cure of varix ; one or more ligatures have been passed round the vessel, as in the operation for aneurism ; and the vessel has been divided, or a portion of it dissected out, and its cut extremities afterwards either com- pressed or secured. Such proceedings are now almost entirely abandoned. OF TUMOURS. A tumour is a swelling or new production, and not a part of the original composition of the body. Blood may have been effused, and the coagulated part, becoming organised, is increased in size by deposits from the vessels which enter it; or perhaps the blood, the coloured part of it at all events, is taken up and lymph is deposited, which, if not also removed, " undergoes further changes of a se- condary nature, and remains a parasite or new structure." Its structure and growth are modified according to the action which its own vessels assume, independently of the surrounding vascular system. The blood-vessels may enter this new growth by a narrow pedicle ; or it may be of such a form as to present an extensive sur- face, by which it communicates with the surrounding parts, receiving vascular ramifications from them. As the growth of the tumour OF TUMOURS. 139 proceeds, the surrounding parts yield, are condensed, and form an envelope for the new formation; the neighbouring blood-vessels are excited to a greater degree of action, and more blood is poured into the vessels of the tumour ; the action of these in turn is very vigorous, and the increase of the new growth is more and more rapid. They become, it would appear, dilated and tortuous. Morbid enlargement, or rather new productions, often attain an enormous size ; some have weighed, when recent, upwards of 60 or 70 lbs. Tumours differ much in structure ; and though their general appearance may not be dissimilar, one will scarcely be found exactly resembling another. In many cases, the external appearance proves no certain index of the nature of the tumour; sometimes, however, its feel and general external character lead the experienced surgeon to form a correct estimate of its internal structure. It is impossible, by any process of reasoning, to account for the different actions which these growths possess ; and even minute anatomical investigation, either of healthy or morbid structures, has not as yet thrown much light upon the subject. Tumours are divided into Solid and Encysted. The solid are generally enveloped by a dense cellular sheath of the surrounding cel- lular substance, yielding and becoming condensed in proportion as the tumour increases in size; this covering appears as a barrier be- tween the healthy and diseased parts, shutting out the latter, as much as possible, from connexion with the rest of the body, and prevent- ing the former from participating in the injurious tendencies of the latter. Some tumours have no such limit, but extend in the direc- tion where there is the least resistance, hold a free intercourse with the surrounding parts, and impart to them their morbid disposition and action ; others are limited in their situation and communications, but prove dangerous or annoying from their bulk. Some grow ra- pidly, and prove troublesome in a few weeks or months ; others re- main without much increase for years, and produce little or no inconvenience. Occasionally tumours partly resemble the texture in which they grow; those of a fatty nature are frequently found to have their nidus in the adipose tissue ; cartilaginous tumours project from the surfaces of bones or of a joint, are subsequently detached, and lie loose in its cavity; growths of a cellular structure internally, and invested by an apparently mucous lining, protrude from the sur- face of mucous membranes. Others differ, not only from the texture in which they are situated, and from which they derive their nutri- tive vessels, but also from every other part of the healthy structure. In one instance, a congenital tumour was found to be composed of an aggregation of numerous materials, many of them resembling the healthy textures of the body. But again, tumours are constantly met with, composed of matter which in no respect resembles any of the natural tissues of the body: those are what have been called heterologous formations. The simple tumour is mere enlargement of a part, from the infil- tration of solid matter deposited by its blood-vessels. There can be little doubt that the action which lays the foundation of such enlarge- ment is inflammatory : in consequence of inflammation of the tissue, 140 OF TUMOURS lymph is effused into the cellular substance during the progress of the incited action ; and after it has subsided, the dilated and debili- tated vessels probably do not regain their condition, as to size and vigour, but remain somewhat dilated, and continue to free them- selves from portions of their contents; thus the cellular tissue is opened out in proportion as the infiltration advances, and the process may be occasionally accelerated by fresh attacks of subacute inflam- matory action. The patient at first feels pain, heat, &c, as in an inflammatory tumour; these afterwards abate, and ultimately go off entirely; and during the increase of the swelling, little or no pain is experienced, unless when these subacute inflammatory attacks super- vene, and then it is but slight; or unless the enlargement be resisted by an unyielding structure, and then it is acute and troublesome. The size and rapidity of increase in such tumours will vary accord- ing to circumstances; the vessels of the part soon regain their size and action, either by the efforts of nature or of art, so that the tumour will have attained no great size, and be stationary in its progress, being denied the materials necessary for its increase. If the morbid action be thus stopped, the absorbents will remove the newly-formed matter, and restore the parts to their healthy condition. But when the deposition proceeds in a superior ratio to absorption, the new matter becomes organised, and by means of its own vessels, secretes a substance similar to itself, whereby the increase of the tumour be- comes more rapid, and the new structure may attain an enormous bulk. Thus the tumour is formed, not merely by dilatation of capil lary vessels, and extension of its original tissue, but by the fo^ma tion of new matter, which, becoming organised, assumes a secreting power. At first the former circumstance is the chief cause of the enlargement; but after the latter process has existed for some time, the tumour loses much of its resemblance to the primary tissue, as- sumes a more dense structure and a different action, and therefore cannot be designated a simple enlargement. This species of tumour, or rather this enlargement which precedes the formation of a tumour, is chiefly met with in the cellular and glandular structures. Sometimes it is described under the term of cedema solidum. In the scrotum, where the cellular tissue is re- markably loose and extensile, such tumours attain a very large size. They are found in this country, though more frequently in warm climates. I removed one from this situation successfully, which weighed upwards of 44| lbs.; it had been of twelve years' duration and caused much inconvenience to the patient. It is sketched in the Practical Surgery, p. 341. It occurs in the mamma, apparently in consequence of suppression of the menstrual discharge ; the gland becomes enlarged, there is no pain in the tumour, and it feels soft and doughy. When the subcutaneous cellular tissue is the seat of the disease, the tumour is often of considerable extent, but rarely forms a great protuberance. It sometimes is situated in the coverings of the nose, which, as they become enlarged, lose their natural colour and assume a purple hue ; the mucous follicles also are often much enlarged, and occasionally emit a profuse discharge of their secre tions. It can be readily understood that in this situation the tumour OF TUMOURS. 141 is a source of much annoyance, from its partially obstructing respira- tion, and even vision, interfering with the functions of the parts and the comfort of the patient. It has been already observed, that when simple enlargement exists for some time the structure changes. It becomes more dense, and assumes a peculiar action, independent of that of the surrounding parts. It has a harder and more firm feel, and all traces of the texture in which it was formed are destroyed. It may be consi- dered as the next in order to the one already mentioned, both as to the simplicity of its structure and action; but in consequence of its action being independent of those of the neighbouring parts, and liable to change from even slight causes, it is very apt to degenerate into those tumours which are more complex and injurious. ADIPOSE TUMOURS. Another species of tumour seems to be composed almost entirely of fatty matter insinuated amongst extended and delicate cellular substance, and has been therefore termed adipose. It is surrounded by a cyst of dense cellular tissue, and to this it loosely adheres; its blood-vessels are few, and it is of an inactive and innocuous character. It is generally lobulated, and often attains a large size. It is not only irregularly prominent on its outer surface, but in its whole circum- ference, and its lobuli often insinuate themselves to a great depth amongst nerves, blood-vessels, and other important parts; owing to this circumstance they frequently prove a source of the greatest in- convenience from their bulk, for of themselves they are neither hurtful, nor possess any disposition to involve those parts with which they are in contact. This tumour is found only in the cellular and adipose tissues. From its loose connexion with its envelope, it admits of ready removal by operation. A tumour of this kind is here represented, which, but for this circumstance, owing to its awkward situation under the tongue, could not by any possibility have been extirpated. It is fully larger than an orange, and had caused very great suffering. It is not so much lobulated as fatty tumours generally are. The adhesions of adi- pose tumours are, however, rendered firm and more numerous by pressure or external stimulants — in fact,* by whatever induces inflammatory action in its substance or in its surrounding connexions ; and from this cause the extraction is often rendered exceed- ingly difficult. The skin becomes thickened and of a red hue, and the tumour itself is much more vascular. From this cause it is apt to assume a new mode of action, and to change in structure and in character, invariably for the worse. I have removed a few tumours, originally of this benign species, but which had apparently degenerated and 142 OF TUMOURS. assumed a malignant action. In one, distinct indurated bands radi- ating from a central mass of the same kind, are discernible. In two others, as a consequence of pressure, condensation and ultimate softening had occurred. The largest alluded to was removed from betwixt the shoulders of a soldier, and had borne the pressure of his knapsack for eight or ten years. It was attached by a thickish neck, presented the common lobulated appearance of adipose sarcoma; but its external surface, its feel, and section, were very different. The patient does not complain of any pain or uneasiness in the tumour, unless inflammation be excited in it; then the pain and other symptoms are such as attend incited action, and the sensations which are afterwards experienced vary according to the character which the tumour assumes. Certain changes may occur in its texture, though not in its general character or disposition; thus osseous or earthy matter is occasionally deposited in some part of the tumour, while the surrounding adipose substance retains its appearance and density. Suppuration, it is said, has followed inflammatory action, excited in an adipose sarcoma. OF FIBROUS TUMOURS. Fibrous tumours are not uncommon, and are formed in various textures. In general they are composed of a substance of a dirty gray colour and considerable density, through which minute, firm, ligamentous fibres ramify ; in some cases irregularly, in others radi- ating from the centre of the tumour. The^ew format ion s su- rounded by condensed cellular tissue, to which it intimately adheres and does not mingle irregularly with the surrounding parts; in this respect differing from malignant tumours, which occasionally contain OF TUMOURS. 143 fibrous matter. It cannot be considered of an equally innocuous nature with those already described, but is still, in its original state, not of a malignant disposition. After some time, the consistence and structure of such tumours vary : some are of a loose texture, and contain cells; others are hard, and intermixed with cartilaginous matter, or even with bone. In general, the tumour is slow in its progress, though it may attain a very large size, as seen in the cut on the preceding page, if allowed to remain ; occasionally its growth is rapid. Besides those tumours which have been described, there is a num- ber of others not of a malignant disposition, which are so various in their structure as to baffle all attempts to reduce them to a scientific classification. Some are composed of a homogeneous substance of almost cartilaginous consistence and a whitish colour ; some consist of cartilaginous matter, mixed with substance of less density and of a different appearance ; in some, fibrous matter is mixed with a ho- mogeneous glandular-looking substance, partially softened. Some are almost entirely composed of osseous matter ; others contain it in small proportion. It would be endless to enter into a minute detail of the structure of such tumours, for it may be said that their appear- ances vary with their number. In almost all tumours cysts are found, and the internal structure of some tumours consists almost entirely of cysts, or hydatids, as they have been called ; in others, these only occupy certain parts, and compose but a minor feature in the struc- ture. The sacs are generally lined with a delicate and smooth membrane, which is often vascular at various points ; some contain a transparent and glairy fluid, albuminous or gelatinous; some bloody serum; some purulent, some curdy matter, or this mixed with a se- rous or purulent fluid ; some pure blood ; some a fluid like printer's ink ; and not a few are occupied by a dense elastic substance, which, on a section being made of the tumour, rises irregular and ragged above the cut surface. Some tumours are smooth ; others lobulated or tuberculated. OF ENCEPHALOID TUMOURS. The tumour which comes next to be described is decidedly malig- nant. It is the Encephaloid or Medullary Sarcoma. Although these tumours have been called encephaloid and medullary, it must not be understood that their intimate structure has any relation to that of the brain or marrow; for this reason the old term fungoid is perhaps a preferable one, since it leads to no false notion as to their nature, while it expresses a condition which at one time or other is remark- ably characteristic of them. This tumour consists of a homogeneous matter, resembling the substance of the brain in colour and consist- ence. It rarely has a distinct cyst; occasionally it is subdivided by membranous bands. It is always soft, though often more so in some parts than in others ; portions of it being frequently so much softened and broken down as to resemble thick cream in consistence, and these are generally of a darker colour, from being mixed with a 144 OF TUMOURS. greater or less quantity of effused blood. Partial or universal soft- ening only occurs after the tumoUr has existed for some time, for in its original state its structure and density are uniform throughout; and, on making a section of it, some few drops of blood may escape from vessels, the coats of which are of a very delicate nature. Some of these vessels seem to give way, in consequence of the process of softening, for we frequently meet with fluid blood, or masses of fibrin, in the midst of the pulpy matter ; and, when the softening has been extensive, the blood is diffused throughout the whole substance of the tumour, so that it will appear to be chiefly or entirely composed of effused and degenerated blood, as here represented. The mamma and testicle, and the contents of the orbit in children, are the most frequent seats of this disease ; it not unfrequently occurs in the lymphatic glands, and few textures can be considered as exempt from it. The part at first enlarges slowly : but afterwards the disease advances with great rapidity, involving the adjacent parts. In general, the affection is not attended with much pain ; the part has a spongy and elastic feel, and frequently presents an obscure sense of fluctuation, indicating that softening is more or less begun. The skin is tense, generally brownish, and is pervaded by large venous branches. This venous enlargement is al- ways observable in the advanced stage of the disease, before or after ulceration has taken place; it is peculiarly evident in the eyelids, when the contents of the orbit are involved, and is to be attributed to obstruction of the circulation in the deeper vessels. The tumour is increased by the surrounding parts assuming a similar action, and being converted into a similar mass ; and the disease also seems to be propagated by means of the absorbent system, and by the irritation conveyed along the vessels which emanate from the tumour, or from its immediate vicinity. Thus, when the testicle or mamma is affected, the lymphatic glands, both above and below the tumour, and the course of the absorbent vessels, are converted into an encephaloid mass, all traces of their glandular structure being completely destroyed. The same brain- like or cancerous matter is also found in the blood-vessels, large and small. When the disease has been of long duration, the superin- cumbent integuments appear tense, assume a purple colour, and ulti- mately ulcerate; a portion of the pulpy mass then protrudes, of a fungous appearance, the resistance being at that point removed, and the compressed matter relieving itself by the extension of a portion of its substance ; the protruded portion afterwards becomes disco- loured, and sloughs, to be speedily reproduced either by further dilatation, or by actual increase of the tumour ; unhealthy pus is discharged, often mixed with blood, and occasionally slight hemor- rhage occurs ; the integuments become further ulcerated, assume a dull brown colour widely around, and are undermined, presenting a boggy feel. OF TUMOURS. 145 Along with these local symptoms there is a complete subversion of the system,— there being at first symptoms of constitutional irri- tation, afterwards those of hectic and extreme exhaustion. When the lymphatic glands are diseased, the limb beneath is much swollen from cedematous effusion, the return of the blood and lymph being prevented: violent and excruciating pains are experienced in the course of the nerves of a limb ; it also frequently loses its sensation, from those organs being either involved in the disease, or pressed on by the tumour. The vessels in the neighbourhood of the affected parts are materially altered, though they are seldom converted into encephaloid matter ; the arteries are often completely obstructed by coagulating lymph for a considerable extent, and the coagulum not only occupies the principle trunk, but extends into the minute ramifi- cations ; and this explains why hemorrhage seldom occurs, even after ulceration of the tumour is far advanced ; the veins also are fre- quently obstructed in a similar way ; but in many cases they contain a soft and pulpy matter exactly resembling the substance of the tu- mour. The fungus which protrudes after the ulceration of the integu- ments sometimes bleeds, when it would appear that the hemorrhage proceeds from those bloody collections in the substance of the tumour already mentioned. According to my experience, when bloody- points, or cysts containing bloody fluid, exist in a medullary or other tumour which has been removed, and if the diseased matter be re- produced, a bleeding fungus will almost certainly follow. This species of tumour occurs in all ages and in all situations, and during its progress evinces strong proofs of inveterate malignancy : if re- moved early the disease may be arrested; but if the operation be long delayed, a tumour of a similar nature, and more extensive, will almost invariably be produced. In several instances I have removed encephaloid tumours, from the situation both of the mamma and tes- ticle, and the disease did not return ; but in the other cases the result has been as above stated. Encephaloid disease of the internal or- gans frequently supervenes on that of the external parts, and acce- lerates the patient's dissolution; when in such situations they are be- yond the reach of surgical art, and their existence is only, if at all, ascertained, in order to enhance the unfavourable nature of the sur^ geon's prognosis. OF MELANOID TUMOURS. The Melanoid tumour is rather of rare occurrence in the human subject; it originates in the cellular tissue, and most frequently at- tacks the internal viscera; sometimes it occurs in the eyeball, where it has been seen with the encephaloid disease, and occasionally mela- notic matter is diffused amongst the cellular tissue throughout the whole body, even in that of the bones. The external surface of the tumour is generally of a shining and mottled appearance ; internally it consists of a homogeneous black matter infiltrated into the cellular tissue, which is condensed, and in some cases distinctly increased in vascularity. The tumour, seldom of a large size, extends chiefly in a lateral direction. Occasionally it is pretty firm ; in other instances 146 OF TUMOURS. it is soft, broken down, and semifluid. The melanotic matter is not always so deposited as to form a distinct tumour, but frequently seems to be sparsely infiltrated into the cellular tissue ; and occasion- ally it is diffused in so minute a quantity as merely to tinge the part, or form dark streaks. Sometimes it is infiltrated into the substance of an organ, and sometimes it is effused on its surface ; occasionally it is surrounded by a distinct delicate sheath ; usually it is confined by no envelope, excepting the partial condensation of surrounding parts. In the skin it sometimes presents in a tubercular form. The tumour is said to be chiefly composed of albumen, mixed with a peculiar colouring matter. The disease mostly occurs in the trunk, seldom in the extremities ; it is not uncommon in the orbit, and in the internal organs the melanotic deposits are generally both numerous and ex- tensive. There is seldom pain, and the patient seems to suffer chiefly from lassitude and extreme debility, which gradually increase; ana- sarca frequently supervenes ; the functions of the organs affected are much impeded, or even altogether destroyed, and thereby the sinking of the powers of life is accelerated according to the viscera affected and the extent of the disease. Melanosis occurs most frequently in advanced life, though it is not confined to it: whereas encephaloid attacks indiscriminately all ages. OF CARCINOMATOUS TUMOURS. The most malignant and intractable of tumours is the Carcinoma- tous. This term is applied to the disease in its occult state, whilst Cancer, a term pretty indiscriminately employed, may denote its con- dition after ulceration. The wrord scirrhus is often used synony- mously with carcinoma; but the former has been, and still is, im- properly employed to denote indurations and enlargements of struc- tures in all situations, and has been altogether so much abused as to warrant its being erased from the nomenclature of diseases. Carci- noma seldom occurs before the age of thirty, and generally not till a later period of life ; there are instances, however, of its appearance at a much earlier period. Very frequently it is not primary, but super- venes on adventitious formations originally of an innocuous character, and which might have long remained so. All tumours, though at first not of a hurtful tendency, are liable to assume malignant action, either from a constitutional cause, from external injury; or from latent disposition. When it occurs in newly formed parts, the surrounding cellular substance is frequently condensed and thickened, so as to form a cyst round the tumour ; and when it supervenes on chronic tumours, the cysts which enveloped these remain, for some time, as entire and distinct as formerly, though the character of their contents is remarkably changed. Afterwards the cyst may be contaminated with the same disposition as its contents, assume the same action and be converted into a similar substance. When the disease is seated in the lymphatic glands, the cyst is at first distinct, and gradually disappears; whilst in this affection of the conglomerate glands a cyst is at no time perceptible, and the cancerous matter insinuates itself OF TUMOURS. 147 and is lost in the surrounding substance. The carcinomatous tumour is of great density, and communicates a peculiarly grating sensation and noise when cut. In its section there appears a central point, or nucleus, from which dense ligamentous bands of a white colour pro- ceed towards the circumference, diverging in regular succession, as rays of light from a luminous body; or the larger bands subdivide into smaller ones, which follow a similar course with their parent trunk, or ramify regularly ; or, from the first, follow an irregular and intricate course, uniting with and crossing one another, so as to pre- sent a retiform appearance. In general the interposed substance is of a grayish colour, extremely dense, and generally homogeneous, though sometimes granular. Often the ligamentous bands are so numerous, and so intimately interwoven, as to leave little or no room for any intervening substance. Sometimes, and most fre- quently in the advanced state of the tumour, the grayish matter ap- pears to have been broken down and removed, its situation being oc- cupied by a glairy or turbid fluid, by a soft pulpy substance, or by blood; the parieties of such cysts are formed by the whitish bands, wrhich sometimes appear to be much thickened, and coated with a membranous lining. The term gelatiniform cancer has been applied to that kind in which the reticulated texture is filled with glairy-look- ing fluid. Frequently, as has been already observed, the external cyst or covering becomes assimilated to the substance of the tumour, and the ligamentous bands then shoot forward into the surrounding tis- sues, more especially the cellular and adispose, establish a new footing for the disease, and thereby gradually enlarge the boundaries of the original tumour. All parts in its immediate neighbourhood become affected, and none withstand its morbid and destructive influence ; bone, muscle, ligament, skin, and membrane, are successively or simultaneously involved; and even the blood-vessels and nerves. From what has been already said, it is almost superfluous to add that the tumour is most malignant, incessantly encroaching on the neighbouring parts, and imparting to them its own disposition ; and this too frequently continues to exist after the removal of the primary source of the evil. The disease, in its commencement, occupies a minute and limited space, composed, it has been said, of enlarged and varicose capillaries, interspersed with the peculiar matter of cancer. It would even seem that these dilated aneurismal or varicose vessels, in morbid growths, are from the first gorged with what has been called heterologous matter. Judging from the imperfect account which has yet been given of them, it would appear from the obser- vations of Mr. Kiernan, that cancerous growths are entirely vascular in their early stages, — composed, in fact, of capillaries filled with cancerous matter, which shoot from the free surfaces of the membranes in a flocculent or villous form, having no albuminous matrix, as has been commonly imagined in regard to adventitious growths gene- rally: the progress of the cancerous tumour appearing to depend on the multiplication of the capillaries, their becoming remarkably vari- cose, tortuous, and dilated, the dilatation being accompanied by thin- ning, by more or less absorption of their coats, so as to allow of the escape partially of the accumulated matter from their cavities. Thus 148 OF TUMOURS. may be formed a tumour of unlimited extent. As the secerning ves- sels are excited to undue action in all cases where they have to form and supply preternatural growths, it is to be expected that they will in such cases become enlarged. Accordingly, the enlargement both of the smaller arteries and veins in tumours, generally, is a fact with which surgeons who have been in the habit of operating on such parts must be familiar. Farther, the enlargement of the capillaries in inflammation has been shown by the experiments of Hastings, and Thompson ; and Mr. Gulliver, who informs me that he has seen pus in the capillaries of a suppurating surface, remarks, in regard to the observation of Professor Miiller, as to the capillaries having only the diameter of a blood corpuscle, that these vessels become during suppuration sufficiently dilated to admit of rows of pus globules. Thus, during the formation of an ordinary product of inflammation, the capillary vessels are enlarged ; and if excited to still further ac- tivity, and for a more protracted period, in the nutrition and forma- tion of tumours, the minute vessel will become still more dilated, and filled with other materials than purulent matter. In a melanotic eye, which I lately examined with Mr. Dalrymple, there was a part in which the black matter seemed to be contained within the capil- lary vessels. The cancerous tumour afterwards presents a stony hardness, is generally of a globular form, and irregular and unequal in its surface. At a still later period it gradually enlarges, in the way already men- tioned, remains movable for some time, but ultimately becomes fixed by the increased extent of its connexions. By these circum- stances it may, in general, be distinguished from the tumours which, from the first, occupy a wide space, and are firmly fixed by intimate connexions with the surrounding parts. When the tumour has once been developed, its progress is slow and steady, being arrested, or made to recede, neither by the efforts of nature nor by the interfe- rence of art. Pain is generally complained of in the region of the tumour, and is of a lancinating kind, compared by the patient to the passing of sharp instruments through the part; occasionally, however, there is no pain in the new formation, and little inconvenience is caused by it. When the disease is left to itself ulceration occurs, frequently at an early period ; but sometimes only after the tumour has been of long duration. The superimposed integuments appear stretched, change their natural colour, assume a dusky or livid hue, become attenuated, and ultimately give way ; the breach of surface not being caused by tension and pressure, but by the parts having assumed an action similar to that of the tumour. The ulcerated point slowly enlarges, a thin ichorous fluid is discharged the sur- rounding integuments are of a dusky red, and the margins of the ulcer are thickened, callous, everted. Whilst the destructive action proceeds m a lateral direction, it at the same time advances towards the more deeply-seated parts, the cavity becomes excavated irre- gular, and ragged; and the parts seem to be destroyed partlv bv ulceration and partly by sloughing. The exposed surface seldom aims at reparation ; and when it does, the granulations are gravish hard, warty, and endowed with but little vitality; never investing OF TUMOURS. 149 the whole surface, but protruding from certain points, and presenting somewhat of a fungous character. The thin unhealthy discharge becomes profuse, and exhales a peculiarly fetid odour, highly offen- sive to the patient and attendants. By these means the ulcerated cavity may attain an enormous size, presenting a most disgusting and lamentable spectacle. If the patient bear up under the profuse dis- charge, the greater part of the original tumour may be destroyed by the ulceration, and some attempts may be made at cicatrisation; that is to say, the cavity may contract, and granulations be formed: but these are always unhealthy, and, in fact, carcinomatous, and often bleed profusely. New skin is seldom formed, the remaining parts resume their virulency, and the process of destruction again advances, surpassing the former both in extent and rapidity. Along with these local symptoms and appearances, it can be readily understood that the constitution is, from the first, materially affected. The alimentary organs are deranged in function, the patient has a wan and sallow countenance, and is in general weak and much emaciated. After ulceration, the system is still more reduced by the discharge, the patient becomes hectic, and is often afflict- ed with diarrhoea ; along with the other symptoms of extreme debility, the patient may become anasarcous, is affected with cough and dyspnoea, or by other symptoms indicating disease of some internal organ, and is ultimately carried off in a state of ex- haustion. The disease attacks various textures, but perhaps most frequently the mammary gland. The mamma generally diminishes in size from absorption of the fatty matter; the nipple is retracted, often to a great degree, and the surrounding integuments are of a purplish hue, and exude a sanious fluid; at length the nipple is completely destroyed by ulceration. In other instances the tumour is large, and there is a hard oedema of the inte- guments ; the skin is thick, coarse, and of a dark red colour. The tumour soon adheres immovably to the subjacent muscles and ribs, converting the contiguous portion of the former into a substance similar to itself. There may be other varieties in the appearances and symptoms of carcinoma; but the above are those which are most frequently observed, and are sufficient to denote the general character of this species of tumour, and to show its peculiar and inve* terate malignancy. Ulcers or swellings, at first simple, may assume a malignant action, either carcinomatous or of another kind; thus, in one instance, a simple ulcer, produced by a burn, assumed a foul and unhealthy aspect, and ultimately degenerated into a most malignant sore. Vari^ ous malignant actions commence in glands of the conglobate or con^ glomerate kind, at first simply enlarged from irritation or injury. The female breast often becomes indurated from a blow, or from, 13* 150 OF TUMOURS. milk abscess, and remains for a series of years, half a lifetime per- haps, without any perceptible change in the enlargement and indura- tion ; but the tumour frequently is roused into activity at the criti- cal time of life, and malignant action ultimately commences. Ine menstrual period ought to be particularly attended to in affections of the mamma more especially, but also in all tumours and ulcers ; for both during and before it tumours become larger and more painful, the whole system appears to be excited, then relaxed, and all morbid actions seem to possess increased activity. In this disease, as in soft cancer, as it has been called, (and they occasionally pass into each other,) the bloody masses, or sacs contain- ing bloody fluid, are to be dreaded, and when they exist are to be considered as very unfavourable ; for if, on the removal of a carcino- matous tumour, such appearances be found, the disease will certainly return ; a new tumour, of even a worse character than the preceding, will be formed ; a fungus will be protruded, and from this hemor- rhage will occur. The lymphatic glands, both above and below the tumour, generally enlarge early in the disease, become hard, and cut like cartilage, and with a grating noise. Frequently they become converted into a dense and fibrous substance, resembling carcinoma ; sometimes they are softened and broken down at several points, and contain a puru- lent or bloody fluid. They enlarge, coalesce, and form irregular masses, which rise more and more above the surface ; the superim- posed integuments give way, and then occur those destructive ravages by ulceration and sloughing already described. The lymphatic ves- sels entering these tumours and emerging from them feel hard and wiry, as if thickened. The integuments in the neighbourhood of the tumours, and in the course of these absorbents, are of a blue colour, and the veins enlarged and tortuous ; the limb below the enlargement swells and is cedematous. The absorbents often become affected months or even years after the removal of the original and exciting tumour ; the immediate cause being taken away, yet the inherent dis- position to malignant action is too often left, not to be eradicated. In fact, the disease generally returns, either in the original integuments, in the form of tubercles or buds, in the cicatrix, or in the glands; very frequently all are affected. It seems also to spring not unfre- quently from fascia. Such enlargements of the glands have been said to arise, in the first instance, from irritation, and not from any partici- pation in malignant action ; and on this supposition, though in general extremely incorrect, cruel, bloody, and unnecessary operations have been performed. Cancer seizes either the mucous or the cutaneous surface, with hardness and a warty excrescence; this ulcerates, and is surrounded by a hardened base. The process of destruction advances, and the ulcerated part presents the same appearances as those of a sore arising from a similar action in a deeply-seated carcinomatous tumour. The glands also enlarge, and assume the same aspect as if they had been the original seat of the disease. Some pathologists seem disposed to deny this, but apparently on no very sufficient grounds. OF TUMOURS. 151 FUNGUS HSEMATODES Has been much confounded with medullary sarcoma, but the two diseases are materially different. Fungus hsematodes almost always supervenes on other morbid formations, when they have been ulcer- ated and exposed; and the particular formation which most frequently precedes is the medullo-sarcomatous; a bleeding fungus, however, occasionally protrudes from tumours of a different* character, which, though they may have been at first simple, have degenerated, ulcer- ated, and assumed a malignant action. The disease certainly does not occur so frequently as some have asserted; for many, instead of limiting the application of the term to those fungous protrusions which bleed, honour with the appellation of fungus hsematodes every growth which protrudes after the ulceration of a tumour, and every tumour which is usually prominent, of soft consistence, and of a somewhat fungous appearance, although such have never shown any disposi- tion to bleed, either spontaneously, or from irritation. But fungus hsematodes, as the name implies, is truly a fungus which resembles blood; and as bloody or blood-like tumours are formed from the rupture of some vessel of rather a larger size, and as they almost in- variably evince a tendency to profuse hemorrhage, as a necessary consequence of the mode of their formation, the term is correctly applied only to those fungous growths which either have at one time emitted a discharge of blood, and exhibit symptoms of a recurrence of the hemorrhage, or which frequently pour out a quantity of blood, sometimes inconsiderable, but often profuse, and generally altogether uncontrollable. In short, the circumstances necessary to entitle a morbid formation to the appellation of fungus hsematodes are a fun- gous structure and appearance, and hemorrhage proceeding from it to a greater or less degree, and with more or less frequency. Fungi are frequently met with, but there are certainly few hsematoid fungi. The excrescence is generally of a dark colour, resembling a mass of coagulated blood, but of more soft consistence, and its extremity has often a sloughy appearance. It is evidently organised; for, on being injured even in a very slight degree, hemorrhage ensues from the part which has been broken or contused, and frequently the growth bleeds spontaneously. At first the hemorrhage is in general slight, but is often repeated, becomes very profuse, and in most instances cannot be arrested. The vessels in the substance of the morbid mass are diseased in their coats, and have altogether lost their power of contraction ; they give way either spontaneously or by laceration, and by their non-contraction they appear to serve merely as passive tubes, through which the blood is poured out by the active vessels, which supply them; the latter are not exposed to any of the causes which tend to produce speedy obstruction of their canals, therefore continue to transmit their contained fluid through their subservient branches, and from this the uncontrollable nature of the hemorrhage can be accounted for ; from the number of vessels which supply the new structure, and which are thus employed, it can be readily imagined that the hemorrhage will be profuse. In many instances, 152 OF TUMOURS. the application of firm pressure on the limb above the seat of the disease is even insufficient to arrest the flow of blood; and though this may, in some degree, be explained by supposing the continued stream to be venous, still it must be confessed that the disease appears connected with a peculiar hemorrhagic tendency. Frequently the fungus is found to communicate with, or rather to arise from, nume- rous cysts of a glossy appearance, from which also blood is copiously effused. The surrounding tissues are completely disorganised in the immediate neighbourhood, and also much altered in structure for a considerable extent around ; the muscles, besides their disorganisa- tion, have acquired a peculiar brown hue. Sometimes the hemor- rhage does not seem to proceed so much from the fungus as from the subjacent cysts; for when a superficial incision or puncture is made into it, the bleeding is often inconsiderable, and only becomes alarm- ing after masses of coagulated blood have been removed, and the cysts thereby exposed. Occasionally the fungus communicates with a cavity of enormous size, filled with blood, partly coagulated and partly fluid, and from the parietes of which the hemorrhage proceeds. When the disease has supervened on a medullo-sarcomatous tumour, the coagulated blood is mixed with a substance resembling the brain in a state of putrescence. It may supervene on polypous tumours, particularly of the antrum; and of this I have seen several instances. Sometimes it is produced after the removal of a tumour apparently not of malignant character, and in this case it frequently does not appear till the wound has almost cicatrised. When once established, it proceeds with all its virulency. The diseased parts may be re- moved as frequently as they appear; but they will be reproduced, and the disease will assume a still more frightful aspect, both in ex- tent and malignity. In consequence of the repeated and profuse loss of blood, the pa- tient is gradually worn out, becomes hectic, is affected with nausea, vomiting, and indistinct articulation, with all the symptoms of ex- treme debility, and he generally sinks exhausted, or may be suddenly carried off by profuse hemorrhage. The size of the bleeding fungus is extremely various, but it is rarely large; in fact, we frequently find that the most violent hemor- rhage occurs from those of a small size ; and in illustration of this, I shall briefly relate the following case. A man, aged forty, had been afflicted for some time with ulceration in the ham, and exfoliation of the posterior part of the femur. The sore healed ; but about two years afterwards the cicatrix became ulcerated, and produced a very small fungus, resembling, in fact, a minute cluster of exube- rant granulations : from this blood was effused in small quantity, and was easily restrained by the application of a bandage ; but the he- morrhage returned at various intervals for upwards of'a week be- came extremely profuse and altogether uncontrollable. By this' the patient was greatly exhausted, and amputation was rendered abso- lutely necessary. On examining the limb, the lower portion of the femur was found somewhat enlarged, its internal structure completely destroyed, and the periosteum on the inner side much thickened On the posterior and inner oart of the bone, about three inches above OF TUMOURS. 153 its articulation, there was a small fungous tumour of an irregular surface, and of soft consistence, resembling congealed tallow. From this excrescence the blood had been effused into a cyst formed amongst the muscles, and afterwards discharged externally. He recovered from the amputation, and remained well. THE PAINFUL TUBERCLE, Though of small size, and not possessed of malignant action or dis- position, is a tumour of very great interest, on account of the excru- ciating pain with which it is accompanied. It is mostly situated in the subcutaneous cellular tissue, but not unfrequently in the inter- muscular cellular substance ; one tumour of this species which I have removed was so deep as to be in immediate contact with the sheath of the posterior tibial nerve. The tumour, generally of the size of a garden pea, rarely exceeds that of a cherry. It is invested by a dense ligamentous cyst, to which it intimately adheres ; but occasionally the capsule is thin and cellular : in many instances its surface is perfectly smooth, in others it is slightly nodulated. It is not connected with any large nervous trunk ; but minute nervous fibrillse can occasion- ally be traced expanding on its surface, and apparently entering its substance. Internally it is composed of numerous whitish fibres, of considerable density, ramifying irregularly throughout its structure ; and betwixt these is insinuated a firm substance, generally of a gray colour, and frequently of an almost cartilaginous consistence. Such is the structure most frequently observed ; but in this morbid formation, as in all others, the appearances may be said to vary in almost every instance. Sometimes the fibres are indistinct, and of a yellowish or dirty gray colour ; and the interfibrous matter is often found to vary in density and colour in different tumours, being at one time dense and almost transparent, at another opaque and cartilaginous, and sometimes rather soft, brownish, and occasionally tinged with blood. From attentive examination, it appears extremely probable that the enlargement is at first produced by infiltration of lymph betwixt the fibrillse of a nervous twig, which becomes separated and inclosed by the deposit— that they afterwards increase in size — that the inter- fibrous matter is deposited in greater quantity, and is farther con- densed — and that thereby the nervous filaments are still more sepa- rated and extenuated. In short, it would appear that the fibrous matter is nervous, though altered, and that the interposed substance is organised and condensed lymph. The tumour, at first extremely minute, enlarges slowly ; when deep, it can only be obscurely felt, and its existence is with difficulty discovered by manipulation ; but the attending symptoms are so peculiar, and so forcibly developed, as to lead the surgeon at once to an accurate diagnosis. When it is subcutaneous, the skin is rendered slightly prominent, and the size, density, and loose connexions of the growth, are readily ascertained. The slightest pressure causes the most excruciating torments, and totally unmans the patient, even though induced by the most trifling movement of the adjoining muscles. From a fearful and well- 154 OF TUMOURS. grounded knowledge of this circumstance, the patient is extremely anxious to preserve the limb in a state of complete rest, and, in fact, he is often wholly unable to use it; although the part is completely set at rest, still he frequently suffers from paroxysms of severe pain, commencing in the tumour and shooting through the limb. The painful sensations are sometimes very much alleviated by gentle fric- tion with the hand. The disease is most frequent in the extremities, and in the inferior more than in the superior. The larger nervous trunks sometimes become diseased, being af- fected with an enlargement resembling the structure and appearance of the preceding tumour, and such enlargements are termed Neuro- mata. Occasionally a portion of a nervous trunk is thus enlarged, from a blow or wound; and sometimes there can be no cause as- signed. Nerves, when divided, become bulbous on that extremity towards their centre. In stumps this is well seen ; whilst all the tis- sues entering into it, after a time shrink, and become more or less atrophied (bone, muscles, vessels, &c), the extremities of the nerves swell out and present a bulbous appearance. When these tumours are connected to, and only covered by, integument, or when they are adherent to the ligamentous substance covering the bone, and become exposed to pressure, as in badly made stumps, the patient often suf- fers excruciating agony. The nervous trunk above is, in general, slightly enlarged, sometimes has a tortuous course ; and in some in- stances the neurilemmal blood-vessels are considerably increased in size. The same symptoms exist, though in a less acute form, as in the painful tubercle. OF POLYPUS. A common species of tumour is that which is attached to a mu- cous surface, and is called Polypus. Polypi vary in structure and disposition; some are simple and benign, others are most malig- nant. The simple mucous polypus has a shining appearance, being invested by an extremely delicate membrane, in some degree resem- bling the mucous, and moistened by a fluid similar to the mucous secretion ; it is of soft consistence and homogeneous structure They are generally light brown, sometimes grayish, and in some degree diaphanous They are connected to the mucous membrane by a narrow pedicle ; generally occur in clusters, and are of pyriform shape ; one or more are often suspended from one narrow base, and hey seldom attain a large size. They possess but little vascularity, though occasionally minute vessels are seen ramifying pretty freely on their surface and may be considered as almost devoid of sensi- bility. Ihe malignant polypus, on the contrary, is always attached to the mucous membrane and also to the subjacent parts, by means of a broad base; and its form and structure vary according to the par- icular action which it has assumed. Most frequently it is encepha- loid, of an irregular form, and often presenting a cauliflower appear- ance, its surface being studded with numerous excrescences of medu- lary consistence and colour. Such tumours will be afterwards Seated of, as occurring in different situations. ireaiea OF TUMOURS. 155 OF ENCYSTED TUMOURS. Along with these have been classed the enlargements of bursse, sheaths of tendons, &c, but with equal propriety might we include hydrocele and other collections in natural cavities. Encysted tu- mours are almost always situated superficially. The skin is dis- tended, seldom inflamed, and often contains enlarged blood-vessels, which give it a streaked appearance. They consist of an external cyst, which is in some instances extremely thin and delicate, in others dense, of considerable thickness, and composed of fibrous looking substance, occasionally it is almost cartilaginous; the internal struc- ture may be said to be almost always more or less fluid, but varies much in consistence. The tumour is surrounded with condensed cellular substance, which is of greater or less thickness and strength according to the size of the tumour. Some of these tumours are supposed, and on good grounds, to be mere enlargements of the natural mucous follicles, in consequence of obstruction in their ducts, by hardened and vitiated secretion ; the cyst, therefore, will be at first thin and delicate ; its contents will resemble the natural secretion of the follicle, and in many cases may be readily squeezed out. There is a black point on the most prominent part, marking the obstructed orifice of the follicle, and the sac is found at this point to adhere firmly to the skin. Even after all other marks of its original formation have disappeared, the situation of the orifice is sometimes indicated by small dark spots, by depression, or by a minute ulcer. Encysted tumours, or wens, as they have been called, often appear to be hereditary; seldom occur single, and are met with under the surface of all parts of the body. They have been divided into dif- ferent classes, according to the nature of their contents: Atheroma- tous, containing curdy matter ; Meliceritous, containing a substance like honey; and Steatomatous, con- taining fatty matter, generally in a semi- fluid condition. But such terms are not adequate to express the nature of all encysted tumours; they are extremely various in their actions, and their con- tents vary according to the particular secretory action which the lining mem- brane of the cyst assumes ; for the same reason, also, the contents of a tumour will differ in the different stages of its progress. Some contain a thin, fetid, browTn fluid, mixed wTith solid particles, resembling half-dissolved fibrinous mat- ter ; in some the contents are serous, or seropurulent, — in others they are gela- tinous ; whilst in those which have become inflamed from external irrita- tion, the contents are altogether puru- lent, or contain a very considerable proportion of that fluid ; not 156 OF TUMOURS. unfrequently the cyst is covered internally by a layer of calcareous matter, to which similar particles are loosely attached. Sometimes, in consequence of irritation, organisable matter is poured out on the inner surface of the cyst, adheres firmly to its inner surface, and is often disposed in concentric laminae. Sometimes, though rarely, the most prominent parts of the tumour ulcerate, and on the exposed surface is deposited a substance of semifluid consistence and gelatinous appearance, which afterwards increases in density, and ultimately assumes all the characters of horn. This hard excresence in some instances increases only to a slight degree, and afterwards remains stationary; in others it attains a large size, and occasionally assumes a curved or tortuous form, like that of the horns of inferior animals. Horns are generally met with on the forehead, and the scalp may be said to be their seat. The largest which I have seen, measured seven inches in length, and two in circumference ; but others have been removed still larger. In many encysted tumours, hairs grow from' the internal mem- brane of the cyst, often numerous, and are generally found in those situated on the eyelids; in some the hairs are destitute of bulbs, lie loose within the tumour, and are often rolled into a globular form. The adhesions of these tumours are in general very slight and easily broken up, but when seated amongst tendons, or in unyielding parts, they are often extremely firm. Violent inflammatory action may follow injuries of the tumours, or the making of even minute openings into them; suppuration occurs, the discharge is thin, fetid, and often bloody; there is much pain, and frequently severe constitutional irritation. Occasionally a fungus, bleeding or not, is protruded through the aperture ; more frequently, however, the opening heals, and the tumour remains as before. External injuries sometimes appear to check the secreting action, and to excite the absorbents to remove the morbid growths, and this with or without rupture of the cyst. Thus, in the case of an encysted tumour the size of a hen's egg, on'the external lateral ligament of the knee joint, free and pretty rough manipulation was necessary to ascertain its nature and exact situa- tion ; in consequence of which, the tumour gradually disappeared, and no traces of it remained twelve days afterwards. Others of less size, I have known to disappear in a much shorter period. OF TUMOURS OF BONES. The vascular action of bones, in their healthy state, is feeble, but, as in other feeble parts, it is easily excited, and disease of an obsti- nate and unyielding nature is apt to follow. The morbid growths vary much in texture. The most frequent are the osseous, or those of the same structure with the original bone' but even these differ much in the density and arrangement of their particles : they have been termed exostoses. They may be of crreat density, and are then called the hard, or ivory ; these never attain a large size, seldom exceed that of a bean, have a smooth and polished surface, and are of a flattened and hemispheroidal form, their greatest OF TUMOURS. 157 circumference being at the base ; they occur in many of the bones, but generally in those of the cranium and face. Others, being of a more loose and spongy texture, have been called cancellated. These are commonly formed by the bones of the extremities, and often attain a very considerable size; they grow from the periosteum, or from the outer surface of the bone, and are then covered by an expansion of this membrane. Sometimes they adhere by a narrow neck, and expand into a bulbous form, so that they can be very readily removed by operation, and are very apt to be broken off by external injury. Others have a broad and firmer attachment, and are of an irregular shape, often projecting in the form of a large spicula, and at other times assuming a somewhat stalactical appearance. Such frequently prove the source of much inconvenience, by impeding the motions of the muscles, or disturbing the functions of any adjoining organ. They possess no malignant disposition, but are under the same laws, though perhaps in a less degree, with their parent trunk. On making sections of exostoses, and of the bones from which they arise, some appear to be mere enlargements or processes of the parent bone, the cancellated tissue extending itself so as to form the interior of the exostoses, whilst the exterior resembles a proportionate exten- sion of the outer lamina. Others are evidently formed by the depo- sition of osseous matter externally to the outer lamina, many being dense and compact throughout, others containing an internal cancel- lated structure, but which is not continuous with that of the bone, as it is separated by the natural outer lamina. Their formation appears similar to that of the foetal bones: a glutinous matter is effused, becomes dense, and is converted into cartilage; blood-vessels shoot into it, ramify throughout its whole structure in a radiated form, and deposit osseous matter. This deposit increases, and extends from a central nucleus towards the circumference; the cartilage is in part absorbed, and the new structure becomes osseous, and similar to the original tissue by the vessels of which it was formed. These tu- mours, even when they have attained a large size, contain a mixture , of bone and cartilage, covered by a dense fibrous investment. The bony matter is arranged in spicula, adhering to the surface of the shaft or head of the bone, and projecting into the morbid mass: the spaces are filled up by a cartilaginous substance. The growth is sometimes rapid, and the tumour soon becomes troublesome from its immense size. Frequently a bone is much enlarged throughout its whole extent, or the greater part of it, and presents a cancellated texture: some- times, also, it is much thickened, and, at the same time, of great solidity; but such enlargements cannot be considered as tumours of bones, or exostoses, any more than these nodules of new osseous matter, which are effused in consequence of inflammation of the osseous tissue. The most frequent cause of exostoses appears to be external injury; their progress is slow, attended with slight dull pain, and often accompanied with no inconvenience; their existence can be readily ascertained, a hard and immovable body being felt where no bone exists in the natural state of parts; but when the tumour pro- 158 OF TUMOURS. iects into an internal cavity, the diagnosis is rendered obscure. Most frequently, they remain stationary, after having attained a cer- tain size, and are productive of little inconvenience, the surrounding parts having accommodated themselves to the new formation. Occa- sionally, suppuration occurs in the soft parts, the matter comes to the surface, and a troublesome abscess is formed. To this class of tumours would I confine the term exostosis not including those consisting of softer materials, and possessed of a less benign action. OF OSTEOSARCOMA. By this term is meant, an enlargement and alteration in the struc- ture of a bone, accompanied with the deposition of a morbid sarco- matous substance internally. This morbid change appears to be the consequence of inflammation, and its origin is frequently attributed to some mechanical injury or local irritation. In the commencement of the disease, the bone is slightly enlarged, perhaps somewhat thick- ened in its outer lamina?; and on a section of it being made, is found to contain a brown fleshy substance instead of its cancelli. This appears to be formed in consequence of a morbid action, perhaps in- flammatory, of its internal structure. By the pressure of the new formation, the parietes of the bone are pushed outwards, in some cases attenuated, in others thickened by deposition of new osseous matter, inflammatory action having been induced by the pressure. As the internal formation increases, the parietes are extended, and are generally much attenuated, becoming in some places thin as paper, and diaphanous; they also would seem to lose a portion of their earthy matter, for they are flexible, somewhat elastic, and not of their usual density.. Frequently they are in several places de- ficient, and their situation occupied by a membranous expansion, sometimes thin and delicate, but mostly thick and ligamentous: in some cases, the external lamina appears to be converted into a sub- stance resembling the internal growth, with which it is continuous. The investing periosteum is much thickened, and its blood-vessels are enlarged. Occasionally, the deficiency of the bone is not sup- plied by any membranous expansion, and the morbid growth pro- trudes, fungous. The internal structure varies much in appearance; generally it is brown and soft, in some places broken down and mixed with a dark-coloured fluid, or with gelatiniform matter ; some- times it is much more dense, and resembles cartilage ; in others, the cavity contains an ichorous fluid, mixed with small portions of more solid matter; in the advanced stage of the disease, the contents are often of the encephaloid nature, either in its homogeneous and solid form, or softened, broken down, and mixed with blood, or with a lard-like substance. Sometimes the cancelli of the bone, are not de- stroyed, but extended, forming numerous cavities of considerable size, in which the morbid matter is deposited ; in other instances there is no appearance of cancellated structure, and the diseased mass contains rough osseous spicula, some detached, some loosely con- nected with each other, and others projecting from the inner sur- OF TUMOURS. 159 face of the bony parietes of the tumour. At the commencement of the disease, the patient feels acute pain in the part, the constitution is disturbed ; after- wards, the pain becomes more dull, and there is a considerable swelling externally, which feels hard, and slightly elastic ; in the ad- vanced stage, the pain again becomes severe, and is of a lancinating kind, and the system is much deranged, the tumour is softer, often presents a sense of distinct fluctuation, and on being freely handled, is found to crepitate, in consequence of the loose spicula of bone rubbing upon each other. Ultimately, the integuments become tense, livid, or dark- red, ulcerate, and allow a portion of the softened tumour to protrude, in the. form of a frightful fungus; there is profuse dis- charge, thin, and sometimes bloody; there is much constitutional irritation, and the patient is greatly exhausted. Not unfre- quently, during the progress of the disease, especially in the long bones, fracture oc- curs at the diseased part, either from ex- ternal injury, or sudden muscular exertion. This occurred in the case from which the specimen here delineated was obtained some months before the pa- tient submitted to amputation. The morbid structure had not broken through its periosteal investment. The muscles and their interfila- mentous tissue were sound. The patient remained free from any return of the local disease. Bones so affected, when broken, do not unite, the movement of the loose and rough ends is a cause of much irritation: inflammatory action is kindled in the morbid structure, suppuration occurs, the integuments give way, and ulcerate to a greater or less extent, and the advancement of the disease is thus much hastened. The tumour may be safely pronounced malignant; it is true, that for some time it shows no tendency to involve the ad- joining soft parts, further than by the effects of inflammation induced by its pressure ; but then it is limited by the external lamina of the bones, which confines it to the tissue in which it originated; but after this barrier has given way, the tumour projects through the aperture, contaminating the adjacent soft parts, imparting to them a morbid action, and extending also in the cancellated tissue of the shaft of the bone. In some cases, the integuments are tense and discoloured, with large vessels running on their surface ; the tumour feels soft and fluctuating, though the skin may not ulcerate till long afterwards. Perhaps the most common seat of this disease is the under-jaw, but it may occur in any of the bones ; when it has been of chronic duration, not one bone but several are affected; and in one case which I saw, the disease commenced in the under-jaw, which it deformed to a frightful degree; almost every bone in the body was similarly, though less extensively diseased; this could be 160 OF TUMOURS. readily observed during the life of the patient, and was confirmed by dissection. From this, it appears that the affection is not only de- pendent on local causes, but connected with a morbid state of the constitution, predisposing to it, and co-operating with its exciting cause. There are other tumours of bones in some degree resembling, which do not strictly come under the term Osteosarcoma. Some are wholly cartilaginous, the disease commencing in their centre, and in- volving their entire substance, emitting a gelatinous fluid when cut, but containing no cells; others are not uncommon, partly osseous, and partly cartilaginous, containing cells filled with a glairy fluid; others are composed of cartilage, intersected with dense fibrous matter, in a greater or less proportion. In fact, the individual tumours of bones vary as much from one another as those of the softer tissues ; scarcely two are alike in their progress, action, or anatomical characters. Irregular spicula of bone are found in many parts of their structure ; in the same way that portions of bone often exist in tumours having no connexion with the bones; in many places they are softened and broken down, the partitions between the cells are destroyed, and these contain a pulpy mass of a dark sanious appearance. On making a section, they are observed to be continuous with the interior of the bone, which is converted into a substance similar to themselves, or is of a more soft and medullary- character. The external surface becomes tuberculated, the integu- ments are painful, and changed in appearance; they ulcerate, the tubercles burst, the discharge is thin and bloody, the ulceration ex- tends ; not unfrequently a fungus protrudes, and occasionally bleeds ; this may slough, the tumour becomes farther exposed, portions of it die, and are discharged, unhealthy fungous granulations project from amongst the cancelli of the tumour, and emit a sanious putrid dis- charge, often bloody; severe constitutional irritation accompanies this state, the patient becomes hectic, is much exhausted, and sinks, unless the morbid parts be removed. There are also tumours of bones, composed partly of cartilaginous or fleshy, or partly of osse- ous matter, arising from the periosteum and outer shell of the bone, and these often acquire a great magnitude before the diseased mass reaches the interior or medullary part of the bone. SPINA VENTOSA. By this term is understood a mere expansion of a bone from a col- lection of matter in its substance. The disease may be produced by external injury, exciting inflammation, and consequent suppuration in the cancellated tissue ; or in a weakened and unhealthy constitu- tion, the action may be of a chronic nature. The fluid accumulates, the cancelli are broken down, and the much-attenuated parietes of the bone are pressed outwards. Occasionally inflammatory action is exerted on the externa surface, from the pressure of the contained fluid, and minute nodules of bony matter are effused, as if nature OF TUMOURS. 161 endeavoured to strengthen those walls which are daily becoming thinner, and more incapable of supporting the weight of those parts which they encircle. The disease differs from Osteosarcoma in the contents being uniformly fluid, generally purulent, though often mixed with more liquid and dark-coloured matter, or with a curdy sub- stance — in the gradual extension of the bone — in no fungus pro- truding after a portion of the attenuated bone has given way, matter being discharged as from a common abscess-; and in the tumour not possessing a malignant disposition. At first there is considerable pain in the part whilst the matter is forming, but afterwards it becomes much less acute, and in many instances there is no inconvenience, except from the bulk of the tumour. Often after having reached no very large size, it becomes stationary, neither recedes or enlarges, and all painful sensations cease ; in other cases it enlarges gradually, attains an enormous size, and produces much disturbance of the con- stitution ; but in suoh instances the patient is generally weak and cachectic. The largest tumour of this species which I have seen, occurred in the lower part of the femur. It measured, in breadth, seven inches, in length, seven and one-fourth. The parietes were composed of an extremely thin lamina of bone, and in this there were numerous deficiencies supplied by delicate ligamentous matter; its cavity was divided into several compartments by thin septa, partly osseous and partly membranous. A representation of the femur so affected is given in the Practical Surgery, p. 350. The patient was a boy of twelve years of age ; amputation of the limb was earnestly advised, the friends objected, he died hectic. ANEURISMAL TUMOURS. Besides these tumours a species of an anomalous character is some- times met with, appearing to arise from an aneurismal or varicose state of the venous radicles or capillaries, and partaking somewhat also of the nature of fungus hsematodes. I shall detail shortly the more important circumstances of one case. The patient, a lad aged sixteen, was admitted into a public hospital on the 7th of November, 1819, on account of a tumour over the left scapula. It was there deemed imprudent and inadvisable to attempt operation ; and, after the application of leeches, he was dismissed at the end of eight days. He then applied to me. The tumour was very large, hard, inelastic, firmly attached to the left scapula, and extending from its spine over all its lower surface. It also stretched into the axilla to within half an inch of the nervous and vascular plexus, and a large arterial trunk could be felt along its under surface. The arm hung useless, and, from the wasting of its muscles, was hardly half the size of the other. According to his own account, the uneasiness produced by the tumour was trifling when compared to the lancinating and excru- ciating pains in the limb. On attempting to move the tumour inde-. pendently of the scapula, crepftation was distinctly perceived, as if from fracture of osseous spicula, A tumour was first perceived about three months previous, situated immediately below the spine of the scapula, about the size of a filbert, of a flat form, and attended 14* 162 OF TUMOURS. with distinct pulsation; it had subsequently increased with great rapidity. About ten days before his admission into the hospital, it had been punctured ; nothing but blood escaped. It was evident, from the rapid growth of the tumour, and the severity of the symp- toms, that the patient would soon be destroyed if no operation were attempted. There were no signs of evil in the thoracic viscera, the ribs and intercostal muscles were unaffected ; though the tumour was firmly fixed to the scapula, yet that bone was movable as the one on the opposite side, and the vessels and nerves in the axilla were quite unconnected with the swelling. The operation was commenced by making an incision from the axilla to the lower and posterior part of the tumour. The latissimus dorsi was then cut across at about two inches from its insertion, so as to expose the inner edge of the tumour, with a view to tie the subscapular artery in the first instance ; in this, however, I was foiled, owing to its depth. The dissection was proceeded with to where the branches from the suprascapular were expected to enter. In detaching the tumour from the spine of the scapula, the knife and fingers suddenly dipped into its substance. This was attended with a profuse gush of florid blood, with coagula ; by a sponge thrust into the cavity, the hemorrhage was in a great degree arrested ; at the same time an attempt made to compress the subclavian failed, on account of the arm being much raised to facili- tate the dissection in the axilla. The patient, exhausted, made some efforts to vomit, and dropped his head from the pillow, pale, cold, and almost lifeless. Then only the nature of the case became apparent. The sponge being withdrawn, one rapid incision completely sepa- rated the upper edge of the tumour, so as to expose its cavity; and directed by the warm gush of blood, a large vessel in the upper cor- ner, which with open mouth was pouring its contents into the sac, was immediately secured. The coagula being removed, by dissecting under the finger, the subscapular artery was then separated, so that an aneurism needle could be passed under it at is origin from the axillary, and about an inch from the sac. After securing this and two other large vessels which supplied the cavity, the tumour was dissected from the ribs without further hemorrhage, cutting the diseased scapula and the under part of the sac. It was then found necessary to saw off the ragged and spongy part of the scapula, leaving only about a fourth part of that bone, containing the glenoid cavity, processes, and half of its spine. The edges of the°wound were brought together, and the patient lifted cautiously to bed. At this time he was pale, almost insensible, and without any pulsation per- ceptible through the integuments in the greater arteries, thouo-h the ends of the vessels in the wound beat very forcibly. Stimulf were employed externally and internally; in the evening his pulse at the wrist was ninety, and soft. The sac of the tumour was composed of bony matter, containing little earth, and arranged in strata of short fibres pointing to the cavity. Its outer surface was smooth, and covered by a dense mem- brane ; whereas the inner to which so equable a resistance was not afforded was studded with projecting spicula. The lower part of the scapula, partially absorbed, lay in the middle of the sac covered OF TUMOURS. 163 by the remains of its muscles and coagula. Very large vessels wTere perceived ramifying on the surface of the tumour. The patient made a rapid recovery, and the wound all but healed. A fungus, however, began to appear in about six weeks, which grew rapidly. This was removed, and the bone cauterised with little good effect. The tumour was soon reproduced. It was proposed to re- move the remainder of the scapula with the extremity, as the only chance, though perhaps a slight one. This was objected to, and he died about five months after the operation, worn out by hemorrhage and profuse discharge. The diseased parts presented the following appearances. Portions of the acromion process, superior costa, and spine of the scapula, were of their natural appearance. But the coracoid process, the glenoid cavity, and the cervix, were entirely destroyed, and their situation occupied by an irregular broken-down tumour, consisting of osseous spicula?, and cancelli, irregularly disposed, and forming cavities which were filled with blood, partly fluid and partly coagu- lated. The head of the humerus was extensively absorbed. The articulating cartilage was almost entirely destroyed, particularly on the inner side, where a large portion of the bony matter had also been removed. The ulcerated surfaces were of a dark, bloody colour. [The first accurate account of osseous aneurism was published in 1826, by Mons. Breschet, in the second volume of the " Repertoire Generate d'Anatomie et de Chirurgie." It has since been noticed by other surgeons, particularly by Professor Lallemand of Montpelier, and Mr. Bell of Edinburgh, and there is reason to believe that it is of more frequent occurrence than is generally imagined. The disease is most commonly seated in the head of the tibia. It has been observed also in the scapula, as in the case mentioned in the text, the femur, wrist, and ankle. The male is more liable to it than the female, and it rarely makes its appearance until after the period of puberty. The cause of the disease has not been satisfactorily explained. In some cases it is produced by external violence, as a blow or fall; in others, especially when seated near a large joint, it is traceable to gouty and rheumatic affections. The enlargement, even in its early stage, is tense and painful; being attended with distention of the superficial veins, swelling of the surrounding structures, and slight discoloration 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 tumours, may be perceived in the affected part. In the ad- vanced stage of the malady the beating is accompanied by a sort of undulating movement, and is easily interrupted by compressing the main artery of the limb, between the tumour and the heart. The enlargement varies in size. In a case mentioned by Mr. Bell, it was more than nine inches in circumference, by upwards of six in length. In some instances, pressure applied to the tumour with the finger imparts a peculiar crackling sensation, not unlike that of dry parch- ment or an egg-shell. The soft parts around the disease are generally cedematous, the whole limb is apt to be swollen, and the motions of 164 OF TUMOURS. the contiguous joints are constrained and painful. Towards the last the general health always seriously suffers. On inspection, the outer table of the bone is found to be consi- derably attenuated, in many parts destroyed, and in some so flexible and elastic as to be bent with the same facility as cartilage, b re- quently the bone is extremely brittle, and may be crushed like an egg-shell. The areolar texture is partially absorbed, and the medul- lary canal filled with coagula, which are often arranged in concentric layers, as in old aneurismal sacs in other situations. The investing membrane in the immediate vicinity of the disease is thickened, as well as preternaturally dense and firm, and the vessels ramifying through the tumour are greatly enlarged. The only effectual remedy for this disease, provided its location be favourable, is amputation. In the early stage relief may possibly be afforded by securing the main artery of the limb. Lallemand relates a case in which ligature of the femoral artery completely arrested an aneurismal affection of the head of the tibia; but this must be re- garded as an exception to the general rule.] [HYDATIC TUMOURS. Another disease of the bones which ought to be introduced here is the development of hydatids, which I described twelve years ago under the name of osteo-hydatidic tumours. The seat of this affec- tion is not confined to any particular class of bones ; though the long are perhaps most prone to it. Its precise nature and origin have not yet been determined ; nor are its symptoms such as to enable us, in the present state of our knowledge, to distinguish it from exostosis, osteosarcoma, and other maladies. Its progress is commonly slow, the surface of the tumour is smooth and regular, the skin exhibits no unusual appearance, and the adjacent textures rarely participate in the morbid action. The hydatids, usually of a globular figure, vary greatly in size and number, and are generally filled with a thin, limpid fluid. They appear to be of the nature of acephalocysts. The prognosis is unfavourable, owing to the difficulty of destroying these parasites, and their constant tendency, wrhen interfered with, to reappear. As soon as the true nature of this tumour is ascertained it should be laid freely open, its contents turned out, and the sac destroyed. For this purpose the sides of the cavity should be seared with the actual cautery, or touched with some of the more powerful escha- rotics,'as the nitrate of silver, or the caustic potash. If these mea- sures fail, and the disease involve the whole circumference of the bone, nothing short of amputation will suffice. This was success- fully resorted to in one of the cases which came under the observa- tion of Mr. Lucas of London.] TREATMENT OF TUMOURS. It may be observed generally, that no benefit can be derived from OF TUMOURS. 165 external applications to tumours, such as friction with liniments or ointments containing iodine, mercury, &c.; and that, therefore, it is injudicious to employ such temporising measures ; for though a tumour at its commencement appear to be of a very harmless nature, yet it may soon assume a most malignant character. If an apparently simple tumour increase, and exhibit symptoms of inflammation, it will perhaps be advantageous to apply leeches, to arrest that incited action which affords the accession of new materials ; this, however, cannot check the morbid activity inherent in the new formation, though it may hold the growth in check a little. If a tumour is to be removed by external applications, it is evident that these must be such as shall prevent the deposit of new matter, and allow the ab- sorbents to remove that wThich already exists; for absorption is always going on in a tumour, though it leaves no evidence of its progress, on account of the deposition of new matter exceeding the removal of the old. I must say that I am unacquainted with any remedies capa- ble of performing the above indication. The removal of a swelled gland may occasionally be accelerated by such means when station- ary, or on the decline, and before cheesy tubercular unorganised matter is infiltrated into its texture ; but to trifle so with a new and independent growth is altogether absurd. The knife only is to be depended upon. Many of the tumours first described have no malignant disposition originally, and only require surgical interference when they produce deformity or inconvenience from their bulk. Yet even these ought not to be allowed to attain any great size, however indolent they may appear at first, and however little pain they may produce ; for there is always a danger of their assuming a malignant tendency, or forming connexions with important parts, so as to render their removal either altogether impracticable, or at least attended with much dif- ficulty. Tumours of every kind, when seated near important organs, must be early removed. Glandular tumours, however, even when of great size and long continuance, are not to be rashly interfered with, when they arise from irritation in the neighbourhood. Those in which it is feared that malignant action has commenced cannot be trifled with ; and the only means which afford a chance of the patient's being effectually delivered from them is an operation. With a view to their complete extirpation, the external incisions ought always to be free, so as to admit of the after-dissection being easily and rapidly performed : they ought also to be made in the direction of the muscular fibres, whether these lie above or beneath the tumour. In this way the margins of the wound are easily brought into apposition, and there retained ; whereas, if the fibres be divided transversely, the wound will gape, and union by the first intention be rendered absolutely impossible. If there is no reason to suppose that the tumour is malignant, little or no integument ought to be re- moved, unless the growth is of a large size ; but, when malignity is dreaded, all the discoloured, tense, and adherent integument, all that is permeated by dilated and tortuous vessels, ought to be taken away, and the incisions made at a distance from the disease. In all cases they ought to commence at the point where the principal ves- 166 OF TUMOURS. sels enter ; these are thus divided at the outset, can be readily se- cured by ligature, or by the fingers of an assistant, and the dissection is proceeded in without risk or interruption from farther hemorrhage. If the opposite course be pursued, the vessels will be divided two or more times during the operation, and thus the performance of it will either be delayed by the application of numerous ligatures, or will be attended with a considerable loss of blood. After the tumour has been exposed it ought to be principally detached m one direc- tion, as in this way its removal will be sooner accomplished, and not first cut on one side and then on another. If malignant pat care should be taken that all the diseased mass be removed, for a minute portion remaining will form a nucleus in which similar dis- eased actions are certain to arise ; in most instances, it will be pru- dent not only to remove the parts actually diseased, but those also which are in immediate connexion with the tumour, though at the time they appear healthy. All important parts must be carefully avoided. After removal of the mass, and the complete cessation of bleeding, the edges of the wound must be approximated, so as to favour union by the first intention ; if this fail, granulation must be promoted, and the wound dressed according to the particular cir- cumstances of the case. All operations on malignant tumours, in their advanced stages, are unwarrantable; they are necessarily painful and severe, and cruel because unavailing; they often, indeed, expe- dite the dissolution of the patient. If the integuments over the tu- mour have ulcerated, and if the lymphatics in the neighbourhood are diseased, the disease if removed will certainly be reproduced, and the succeeding tumour will be still more malignant. The operation ought, if at all, to be performed when the disease is in its incipient state, for then only can success be expected. Exostoses need not to be interfered with, unless they are the source of much inconvenience, either from their size and form, or from their having been detached, and lodged amongst the adjacent soft parts. If loose, they can be removed in the same way as any other extrane- ous body; if firm, their attachment must be divided by a saw, or by cutting pliers, close to the bone from which they spring. Sometimes, as in the scapula or other flat bone, a portion of the original bony tissue can be cut out along with the new growth, and this renders the chance of any return of disease much less likely. Osteo-sarcomatous tumours are to be taken away, along with the part of the bone in which they are imbedded, and, if possible, before the integuments have ulcerated. The incisions must be made, and the bone sawed, at a healthy part. The removal of the entire bone in which the disease has commenced, when practicable, will afford a still better chance of immunity from farther disease. In spina ventosa more is seldom required than to lay open the cavity, give vent to the matter, and then treat the case on the same principles as in abscess of the soft parts. The cellular tumours, partly cartilaginous, partly osseous, ought not to be permitted to remain ; the operation can generally be done without much difficulty ; and thus the danger of their degenerating avoided. Frequently, however, a considerable part of the bone must be removed along with the of Wounds. 167 tumour, since the neighbouring tissue is generally softened, and inti- mately adherent to the diseased part, which it somewhat resembles in structure. In general, regular dissection is unnecessary in the removal of encysted tumours. An incision is made, or an elliptical portion cut out; the contents escape, and the cysts, being then laid hold of by dissecting forceps, is readily separated. In some situations, as on the eyelids, under the tongue, or amongst tendons, the sac, wdiich is thin, is not so easy of extraction ; it is then inseparable, either naturally, or from previous inflammation. Caustic is used with safety to destroy those parts which cannot be detached, and for this purpose the potass is to be preferred. When, however, the tumour is large, a part of the integuments covering it must be removed, otherwise a large cavity will be left, in which pus might accumulate. In this case, the base of the tumour is to be surrounded by two elliptical incisions, and the cyst dissected out entire, leaving only integument sufficient to cover the exposed surface. In the smaller tumours, it is vain to attempt regular dissection ; a portion of the cyst will be left, and the disease reproduced : whereas, by using the potass, the operation is much more speedy, and always successful. The making a minute aperture, and squeezing out the contents, is at best but a palliative measure, and is often followed by severe constitutional disturbance. OF WOUNDS. These vary in extent and nature. The instrument by which they are inflicted, the violence attending the injury, and the nature and importance of the parts divided, or in the neighbourhood of the wound, must all be attended to ; for, from an accurate knowledge of these circumstances, the treatment of the case comes to be conducted accordingly. Wounds are divided into incised, punctured, bruised, and lacerated ; that is, into such as are inflicted by a sharp-edged, sharp-pointed, or an obtuse body. In the first kind, there is greater or less effusion of blood, according to the size and number of the vessels divided. Some extend but a little way beyond the subcuta- neous cellular tissue, and are consequently attended with but slight bleeding; others penetrate to a greater depth, and occasion hemor- rhage from a large vessel, "or other alarming symptoms, by having reached some important organ ; others, though not of so great a depth as the former, may still, on account of their mere extent, be accom- panied with very considerable loss of blood from a number of small branches. It is seldom that fatal effects immediately follow external wounds ; but they may and do occur when blood-vessels of the first class only are cut. They are most likely to prove suddenly fatal when the arteries are only partially divided, and when the large veins accompanying them are also involved. When the artery is cut through, its extremities retract, effusion takes place into the sheath and compresses the orifice ; the formation of a coagulum within the vessel is thus promoted, and the hemorrhage arrested. But, when a portion only of the circumference is divided, the blood continues to 168 OF WOUNDS. flow through the aperture and onwards, as if into a smaller ramifica- tion of itself, no retraction or contraction of the vessel can occur, coagulation is slow, and the bleeding profuse. I have seen a wound of so small a vessel as the internal mammary prove almost instanta- neously fatal. Wounds of the large internal vessels for the most part prove immediately fatal; as wounds of the heart, or the large vessels passing to and from its cavities, at the root of the lungs, or at the upper part of the liver. When the heart, or the vessels within the pericardium, have been divided, it can be readily understood how life should be immediately destroyed, since the blood effused into the cavity of the pericardium by its pressure completely arrests the action of the heart. But occasionally punctured wounds, in such situations, have not been followed by instant death. In such cases, alarming symptoms occur at the time, but subside, and the patient may for some time suffer no uneasiness, but afterwards expires suddenly during muscular exertion, or perhaps in a fit of violent passion. Blood must have been effused into the pericardium at the first, causing symptoms of, or actual, syncope ; but then the aperture in the vessel had become obstructed by coagulum before blood had been poured out in such quantity as to effectually prevent the actions of the heart; at a future period the coagulum gives way, and the subsequent effu- sion is limited only by the pericardial cavity being completely filled. In wounds, hemorrhage is the symptom which most alarms the by- standers, and which demands immediate attention ; but, to operate successfully, the surgeon must divest himself of all fear, and learn to look boldly on the open and bleeding mouths of arteries. Effusion of blood ceases spontaneously, even from considerable vessels, on faintness supervening, and thus many lives are saved ; but as soon as reaction commences it generally recurs, and may prove fatal, un- less proper measures be resorted to. When an artery is divided, its extremity retracts within the sheath, it also contracts, and coagulation occurs; thus the orifice is ob- structed, and a temporary barrier formed to further hemorrhage. The tube, however, is permanently closed by effusion of lymph from its orifice, and consolidation of the surrounding parts. The circumstances which follow division of an artery are these :— The immediate effect is the retraction of its ends within the investing sheath, and a simultaneous contraction of the coats so as to diminish the calibre. From the superior orifice there is necessarily a profuse flow of blood, which is discharged through the sheath that formerly enclosed that part of the vessel which has retracted. After consider- able effusion of blood, the flow becomes slower and less profuse; particles of blood adhere to those filaments which previously con- nected the artery to the sheath, but which were lacerated by the sudden retraction of the divided extremity ; these particles coagulate, and lessen the canal through which the blood is discharged whilst they present an irregular surface, on which the blood continues to be deposited and to coagulate; and thus the aperture in the sheath is ultimately closed This external coagulum is found to commence at the extremity of the artery, where it is of cylindrical form, and shuts up the mouth of the vessel; it then extends along the canal in the OF WOUNDS. 169 sheath, frequently assuming a conical form; and, if a free discharge has been allowed for the blood, it will terminate at the cut margin of the sheath, otherwise it will be found continuous with the coagulum blocking up the external wound. Also, when hemorrhage has been resisted by the shutting of the external wound, blood is infiltrated into the cellular tissue around the bleeding point, and there coagu- lates ; but this circumstance can be productive of little or no pressure on the parieties of the vessel, so as to assist those other natural means which obstruct it. The flow of blood through the divided vessel being prevented, the circulating fluid necessarily passes through the nearest collateral branches, leaving the blood in the extremity of the larger trunk in a state of comparative rest; consequently coagulation occurs in this situation. The internal coagulum, however, is small, and not sufficient to occupy completely the cavity of the vessel; it is of a conical form, its apex being towards the heart, and opposite to the first collateral branch, and its base resting on the external co- agulum, and there adhering to the internal surface of the artery. But, whilst this latter process is advancing, the capillary vessels supplying the cut margins of the artery have begun to act; they throw out coagulating lymph, and continue to do so until their secre- tion has completely filled the vessel immediately opposite to its divided margins ; thus a third and more effectual coagulum is formed, — one of plastic matter situate between the external and internal coagula of blood, and in general closely adherent to them. Lymph is also effused externally to the artery and its sheath, forming a dense stratum, which separates the extremity of the vessel from the external wound ; it becomes organised, forms granulations, and thus the parts are consolidated, and the wound cicatrised. When the artery is permanently obstructed by the adhesion of its cut margins, the external coagulum can be dispensed wTith, and is gradually ab- sorbed. Afterwards all the newly formed parts are condensed, and diminish in size ; the artery contracts, its internal surface ^finally embraces the coagulated blood which lay loose in its canal; its coats appear to be thickened, and it is firm and hard. Ultimately in con- sequence of the continuance of absorption, it becomes much more attenuated, so as scarcely to differ from the surrounding cellular tissue. Similar changes occur in the lower extremity of the divided artery; in general it retracts farther, its orifice is more contracted, and, .the flow of blood being much less profuse than in the superior, the natural means for its temporary closure are sooner accomplished. When an artery has been divided close to the origin of a collateral branch, no bloody coagulum can form internally, for the blood in that situation is necessarily in a state of constant motion. If the hemorrhage is suppressed artificially, either by ligature, or by otherwise well applied pressure, no external coagulum is formed ; there appears only the internal bloody coagulum, the lymphatic effusion, and consolidation of the compressed part. The natural con- traction and retraction cannot occur in vessels partially divided; hemorrhage, therefore, is more violent and dangerous from a partial than from a complete section. Again, transverse wounds are more dangerous than longitudinal ; in the latter, the edges of the wound 15 170 OF WOUNDS, are spontaneously approximated on account of the structure of the vessels, whilst, from the same cause, the margins of the latter con- tinue separate, and, in fact, the aperture is a complete circle ; the lips of an oblique wound will be more or less apart, in proportion as it approaches to the transverse direction. When an artery has been punctured, the wound in the sheath perhaps does not correspond with that in the vessel; blood, therefore, accumulates between the vessel and its sheath, and there coagulates. The wound is thus compressed, its edges kept in contact, and the farther escape of blood prevented ; the lips of the incision are then agglutinated by effused lymph, and cicatrisation occurs. This, however, cannot be expected to take place unless methodical pressure has been applied from the first. Even from small punctures blood is effused under the sheath and into the neighbouring cellular tissue, rapidly, and in such quan- tity as to prevent adhesion. The effusion continues, and a false aneurism is formed. If a considerable part of the circumference has been divided, the lymph may be, and generally is, superabundant, and often to such an extent as to close up the canal of the artery at that point; but, if the aperture is minute and in a longitudinal direc- tion, lymph will seldom be effused in greater quantity than is suffi- cient for the cicatrisation ; and though it should be superabundant, it is afterwards removed by the absorbents. In all cases, the cellular tissue round the wounded point is much thickened and condensed by the deposition of lymph, but this gradually disappears after cicatri- sation has been completed. Sometimes, and generally when the wound has been transverse and large, the process of adhesion is disturbed, and suppuration occurs ; in this case the wound in the vessel communicates with the fistulous track in the externally effused lymph, and maybe the source of troublesome hemorrhage. In other instances of extensive transverse wounds, the undivided slip ulcerates, and the artery becomes obliterated, by means of the same natural processes that occur in complete division. In cases of laceration of an artery, when its coats have been forcibly torn rather than divided, little or no bleeding takes place. The vessel retracts; the lacerated margins of its inner coat become puckered up, so as to contract greatly the orifice of the vessel; the lacerated sheath is pulled out to a point, and closed at a little distance from the divided inner coats. If a large artery is torn asunder in a dead body, this stretching out and contraction of the sheath will prevent injection passing ; in short, the immediate effects of the injury are such as to favour the instant formation of coagula, by which the hemorrhage is arrested until the orifices of the vessel be permanently closed by the adhesive process. Thus, in instances where the whole of an extremity has been torn off, the patients have generally lost but a very small quantity of m From wounds of veins the blood flows, not in a sub-saltatory but m a uniform stream : its colour is dark, and the flow is easily sup- pressed. The common opinion is, that to place a ligature on a vein is dangerous and to be scrupulously avoided. The process of repa- ration besides, in a wounded vein, is different from that in an ar- tery. Veins are less disposed to the secreting action by which OF WOUNDS. 17 adhesion is perfected ; and, when inflamed, the inflammation is ex- tremely apt to extend along the coats of the vessel; which latter circumstance has been ascribed to the great proportion of cellular tissue in their coats. When punctured longitudinally, the lips of the wound remain in contact, and cicatrisation, by means of effused lymph, is soon effected ; in fact, the wound heals by the first inten- tion. But if opened obliquely or transversely, not to a great ex- tent, the immediate result is discharge of blood, and, when this has ceased, a coagulum forms in the wound, the margins of which re- main separate; and this coagulum generally communicates with blood effused into the sheath of the vessel. After some time, the lips of the wound, encircling the coagulum which occupies the aper- ture, and which has temporarily averted the hemorrhage, become somewhat turgid, and increased in vascularity; they then appear to assume a secreting action, by wThich a membranous substance, of ex- treme delicacy, is produced; and the extent of this membrane is increased until it form an expansion, investing the outer surface of the clot; it then becomes thickened, by addition of matter, similar to itself, from the recent vessels which ramify in it. At the same time it forms adhesions to the surrounding cellular tissue, and re- sembles the original tunics of the vein. After being consolidated, so as to prevent the flow of blood through that part, the coagulum, formed to arrest the hemorrhage until a more complete barrier should be furnished, is gradually absorbed. But the membrane long re- mains smooth, thin, and diaphanous, and can be thereby readily dis- tinguished from the original coats. This reparative process is much longer in being finished than the corresponding one in arteries ; and, from what has been stated, it is evident that the two actions differ in other respects than the time requisite to complete them. When a vein has been completely divided, the extremities are closed by means similar to those which have been already detailed in regard to arteries. In many, nay in most instances of hemorrhage from a wounded artery, the surgeon cannot wait for the natural processes by which the flowr of blood is arrested, but must have recourse to immediate and certain means. In division of the smaller arteries, or in minute wounds of the larger, pressure, well applied, will often be sufficient. In both cases it immediately stops the flow: in the former, it pre- vents the blood from penetrating into that portion of the sheath which has been vacated by the retracted artery ; and it being thereby confined, and kept in a state of rest, coagulation soon takes place. At the same time, the compression brings the divided margins of the vessel into close apposition, and thereby permanent closure, by adhesion, is quickly accomplished. In the latter, the mere circum- stance of the escape of blood being prevented, naturally hastens the closure of the minute aperture by the natural process ; and, if the compression be accurate and very firm, the opposite surfaces of the vessel, being brought in contact, may adhere, and the canal be ob- literated at the wrounded point. It is obvious that, in this latter class, pressure can only be of advantage immediately after the in- fliction of the wound, and not when blood is extravasated to a great extent. 172 OF WOUNDS. Pressure may be used along with styptics, or along with escharo- tics, actual or potential. They may be often employed when pres- sure ought not; styptics promote the contraction and retraction of the divided extremities, and thereby expedite the formation of a coagulum. Escharotics form a slough, which, adhering to the extre- mity of the vessel, stops the flow of blood, and the cut margins of the vessel, being stimulated by the application, soon cohere. Active stimulating applications merely cause effusion quickly of coagulated lymph, and thus often arrest hemorrhage from very vascular sur- faces better than the so-called styptics. Not unfrequently, after the separation of the slough, it is found that union has not taken place, and hemorrhage is renewed ; from this circumstance, the remedy cannot be trusted to, except when the divided vessel or vessels are of small size. It may be stated, generally, that these means are of little avail without methodical pressure. In oozing from small ves- sels, pressure may be applied by means of agaric, sponge, or lint. In bleeding from small vessels, where there is general oozing from the surface, and pressure cannot readily be made, applications tend- ing to produce effusion of lymph — stimulants, such as turpentine or craesote, are often remarkably efficacious, and very speedily so ; but in wounds of the larger vessels, the most efficient mean is a gra- duated compress of lint placed immediately on the external wound, and supported by a firmly-applied bandage. The bandage ought to encircle not only the wounded part, but every part of the limb with a uniform tightness, not so great as to arrest the general circulation; the parts are thereby supported, and engorgement prevented. This method, when employed previously to the effusion of much blood into the cellular tissue, has proved effectual in wounds even of the brachial, femoral, and carotid arteries. When blood has been ex- tensively injected into the limb, when the aperture in the vessel has remained pervious, and when a large diffused aneurism exists, bandaging is worse than useless. By its application in such a case the limb becomes discoloured and swells extensively; there is a risk of mortification from impeded circulation. If a small quantity only of blood has escaped, its diffusion and increase may be prevented by the bandage : but a cyst will nevertheless be formed in the cel- lular tissue ; its parietes will communicate with the margins of the aperture in the artery, its cavity with the canal of the vessel • an aneurism of the false kind will be established, and will run the course of one arising spontaneously. A ligature, well applied, is the only means that can be relied on. The immediate effect of a tightly-drawn ligature is to avert the flow of blood, to divide the internal and middle coats at the deligated point, the cellular coat remaining entire, and to narrow the canal for some extent above the point at which it is applied. Coagulation then occurs within the vessel above the ligature, provided there is no collateral branch in the immediate vicinity. The ruptured margins of the internal coat effuse lymph and cohere ; lymph is effused llso in the cellular tissue, exterior to the artery and to the ligature • bv the compression of the ligature ulceration occurs in those parts which it envelopes, and the foreign body is discharged ; but before this occurs, the canal of the vessel has been obliterated by an internal OF WOUNDS. 173 coagulum, and by the effused lymph. Afterwards, the same absorp- tion and consolidation occur as in a divided artery, the orifice of which has closed permanently and spontaneously. When from a punctured wound profuse hemorrhage ensues, there is reason to suspect that an important vessel has been hurt, and the bleeding point must be sought for. After the artery giving out the blood has been discovered, the external wound must be enlarged, so as to expose the vessel, and admit of the convenient application of a ligature. It will not be sufficient to include the vessel above the wounded point, for the lower part will, after some time, be supplied with blood by the collateral branches almost as freely as by the large trunk, and, consequently, bleeding will be renewed. Two ligatures are to be employed, one above, the other below the wound. The wounded vessel must be exposed, as already stated, but not detached more than is sufficient for the application of the ligature ; and at the same time the ligatures ought to enclose nothing but the vessel. Neither ought the ligatures to be placed at any considerable distance, but as close to the wounded point as possible ; otherwise circulation in the included part may be restpred. The ligature, round, narrow, and firm, ought to be tightly applied. Cases of hemorrhage have occurred in which the tying of the vessel immediately above the wound has been successful; but these are few, and by no means afford any authority for the general adoption of such a measure. If the vessel is merely punctured, it is necessary to apply the ligature by means of a blunt-pointed needle, and the parts are to be disturbed as little as possible. If, however, the artery is completely divided, its cut extremities are to be drawn out of their sheath by a hook or forceps, and the ligatures applied close to the connexions of the ves- sel : the vasa vasorum, in the immediate vicinity of the delegated point, being left to carry on those processes by which obliteration is accomplished. In punctured or partial wounds of arteries, it deserves consideration whether the hemorrhage may not be restrained by the application of slight pressure, so regulated as to prevent the flow of blood laterally through the wound, but not so forcibly applied as to stop the onward current of the blood along thefvessel, from the part of the tube above to that below the puncture. Some experiments made by Dr. Davy seem favourable to this view ; as bleeding from the carotid arteries, partially divided transversely, in dogs, was easily arrested by the means above mentioned, the wound of the vessel readily healing, so as to preserve its tube entire ; whereas, when the pressure was increased, the hemorrhage became violent. The sub- ject is mentioned as one worthy of a further experimental investiga- tion. The instrument which will generally be found most useful for laying hold of the vessel is the common dissecting forceps, but a tepa* 15* 174 OF WOUNDS. culum will, in certain circumstances, be more convenient. By far the most convenient machine is that here represented. When no assistant is at hand, and in cases of emergency, the sur- geon provided with this little instrument can tie vessels without the least difficulty; and in operation, when many vessels spring, several of these forceps can be applied ; there is besides this great advantage in their employment, that a clumsy assistant can scarcely include the point of the instrument with the vessel. Hemorrhage from the smaller vessels soon ceases ; and, before reaction occurs, their orifices have generally become so obstructed as to resist the effusion of blood. The effects of ligature on a vein are somewhat different from those on an artery. The inner coat of the former is more dense and elastic, and remains entire, whilst the external and middle are divided. It is puckered by the ligature, and its opposite surfaces are placed in immediate contact: but there is no breach of surface, and adhesion does not occur till the tunic has been divided by ulceration ; then the opposite margins cohere, the vessel is obliterated, and undergoes changes resembling those in an artery similarly circumstanced. The coagulum between the ligature and extremity is of considerable extent, dense, and completely filling the canal of the vein, and, consequently, of a cylindrical form. The edges of the wound, in the soft parts, ought not to be approxi- mated till the bleeding has entirely ceased, and the surface become glazed, for the interposition of the slightest quantity of blood pre- vents union by the first intention. When bleeding has ceased, the divided edges are to be brought together as accurately as possible, and adhesion promoted. The minute vessels assume an action greater than in the healthy state, though not equal to inflammatory action ; they effuse coagulating lymph, by wThich the opposed sur- faces are agglutinated, though the union is at first feeble and easily broken up. Soon the lymph is firmly attached, by newTly-formed vessels, to the surface from which it was secreted; in effect, it be- comes organised, and rendered capable of undergoing, through its inherent powers, the changes necessary for its perfection and stability. Similar processes go on in it as in any sound part of the body ; new matter is deposited, and the superfluous is absorbed. The process of nutrition, however, is not the same in all parts of its substance, that is, the new matter deposited is not exactly similar at all points; but, according as the new secreting vessels proceed from the differ- ent tissues of which the margins of the recent wound are composed, so, in various parts of the new formation, these vessels assume pecu- liar modes of action, one set forming muscular, another cellular tissue, and a third a substitute for skin, formations corresponding to the pri- mary tissues from which the secreting vessels proceed. Thus the vasa vasorum, ramifying on the divided ends of the mi- nute vessels, secrete a substance which is transformed into a set of minute capillaries, and these also, assuming a secretive action, pro- duce an arterial or venous tube, similar to that nourished by the ori- ginal vasa vasorum. By this process the lymph becomes well sup- plied with blood-vessels, those from the opposite surfaces meeting, and freely inosculating with each other. These blood-vessels, as OF WOUNDS. 175 already stated, have been produced from arteries possessing different powers, and hence the newly-formed assume actions similar to those of the primary, and thereby interstitial matter is deposited of its pro- per kind and in its proper place, a cuticular membrane superficially, then cellular tissue, afterwards muscular, and so on according to the primary tissues which had been divided ; these parts do not at first resemble exactly the corresponding natural tissues, but by the con- tinued action of the new vessels and capillaries, they are moulded and prepared for the due performance of their respective functions. If the degree of action necessary for the accomplishment of these processes increase to inflammation, adhesion is interrupted till the action be lowered to its previous standard. From this view it is evident, that, besides a certain excitement of the blood-vessels, it is necessary that the raw margins be in close ap- position, and carefully retained so, for, by ever so slight movement of the parts, the recent and delicate bond of union will be ruptured ; and, if this motion be allowed to continue, adhesion may be at divers times begun, but can never be perfected. Whereas, if the neces- sary precautions are adopted, union is often completed in thirty or forty hours, sometimes sooner, seldom later. From a knowledge of the astonishing powers of nature in repairing injuries, many and im- portant improvements have of late years been made in the practice of surgery. In the majority of instances it is also requisite that the parts be brought in contact soon after division, otherwise granulation will have commenced in the different parts of the wound, and the sur- faces then approximated will not so readily adhere : pus is formed, and, having lodged between the surfaces, acts as an extraneous sub- stance, keeping them apart, and separating them still farther by its accumulation. All foreign bodies in the wound must be removed be- fore adhesion can occur; and, on the same principle, care ought to be taken that no effused blood be interposed. In many cases the margins of the wTound can be accurately adjusted by careful attention to the position of the part, or by the application of a few strips of adhesive plaster; but the latter, from indiscriminate use, often prove the source of much irritation, and totally frustrate the end for which they are designed. When employed, they ought to be narrow and few. If such means be considered insufficient, recourse must be had to a few points of interrupted suture, and these are not productive of bad consequences wdiich have been by some attributed to them. When neatly applied, they can produce but little irritation, more especially if removed as soon as their presence is unnecessary, that is, as soon as adhesion has fairly commenced, and the natural bond of union is of such strength as to need no artificial assistance. By these the edges of the wound are more neatly and suitably placed than by any other means ; they meet easily, without the puckering or over-lapping of each other; and, from the circumstances of sutures obtaining amore just coaptation, they can be sooner discontinued. In most wounds no other dressing is required ; but in some a combi- nation of sutures, adhesive plaster, and compress, is necessary. Of late, I have greatly dispensed with stitches and the common adhesive plaster, using, instead of the latter, slips of glazed riband 176 OF WOUNDS. smeared with a saturated solution of isinglass in brandy, which is much less irritating and more tenacious than the common adhesive compost. The parts are fixed temporarily with a single stitch, or two at most, and cloths dipped in cold water are placed over the wound; the ribands are not applied till the adhesive substance has partly congealed, and the oozing of blood ceased. The divided mar- gins being approximated by the fingers of an assistant, the nhands are laid gently over, and held for a few seconds. Soon after a sut- ficient number have been applied the stitches are withdrawn, being no longer necessary. No other dressing is required unless suppura- tion occur; the ribands will adhere firmly till the completion of the cure, and thus the pain and irritation caused by frequent dressing is avoided. Even the largest wounds, as after amputation, are treated in this manner with the most satisfactory results. Of late years a plaster, made by coating oiled silk with a solution of isinglass, has been used instead ; the glazed surface of the slips is moistened, and applied as here directed. If at any part adhesion fail, suppuration and granulation must follow. The adhesion may be prevented by any of the circumstances already mentioned, or by an unfavourable state of the constitution, the nature of the wound, exposure to bad air, the occurrence of fever, or of a flux, natural or not. The wound may contain foreign matter, blood or the contents of canals may be effused into it, and many other obstacles may exist to retard, or prevent adhesion. Notwith- standing, in all cases, though the chance of union be but small, the parts should be approximated. A great point is gained if certain parts only are brought to adhere, for by their natural attachments the opposite surfaces are preserved in more direct contact than they could otherwise be, and thereby but little space remains to be filled up with granulations. If, on the contrary, the surfaces are not approximated, the flap is diminished in size, and when afterwards placed in contact with the surface from which it was detached, it is found not to correspond, leaving considerable deficiency to be re- paired by the comparatively slow process of granulation. Whereas, if it had been early replaced, partial attachments would probably have been formed by adhesion, the flap thereby retained in situ, and prevented from shrinking, so that but little new matter would be required. Sometimes union does occur, and that speedily, after the flap has remained separate for a considerable time ; and in such cases it may be doubted, whether union is accomplished by adhesion, strictly so called. Most probably it is by this process that the rapid union occurs in such circumstances: the divided parts have assumed an excited action, and effused lymph; during their state of separation, the lymph will become organised when it is connected writh the original parts, just as well as if the surfaces had been in contact; and when they are at length so placed, they will be agglutinated to each other by the outer part of the effused lymph, which still continues soft and unorganised. If motion be then prevented, organisation, which has already commenced in the connecting medium, will pro- ceed undisturbed, converting the agglutination of soft unorganised OF WOUNDS. 177 lymph into firm and permanent union by means of organised tissue. In these circumstances, it is not to be wondered at if adhesion should be completed in a shorter time than when the surfaces are brought together immediately after their division; in each instance the process is the same, only in the one it has to proceed from its very com- mencement, whilst in the other it is previously all but perfected, and after the parts have been put together, the last stage only requires completion. It is only in a particular stage of a granulating surface, that adhesion will take place speedily, when the discharge is dimi- nished, but healthy, and the granulations florid and firm. When a wound is to heal by granulation, the exposed surface at first is dry, painful, and slightly swelled, and afterwards a thin dis- charge of bloody serum is poured out, with relief to the painful sen- sations ; the surface is at this time covered by a thin layer of coagu- lated lymph, and the parts, if approximated, are in the most fa- vourable state for adhesion. Soon, however, the vessels assume a different mode of action, and secrete a fluid which becomes purulent; the effused lymph has been organised, forms a living part of the surface from which it was deposited, and is covered and protected, in its yet delicate condition, by the purulent fluid. This new matter is disposed in numerous small conical projections of a florid colour; and these, by their own power, form others similar to themselves, at the same time discharging purulent matter; so that, in a healthy constitution, the cavity is soon filled by the granulations, which come to the same level as the surrounding integument. Sometimes they are exuberant, soft and spongy, and in this state possessed of little sensibility, and but ill supplied with blood-vessels. At others, they are slow in approaching the surface, and then often morbidly sensible. In all cases, the new matter is very apt to be absorbed, either from the state of the patient's health, or from the nature of the applications; and foreign substances, in a state of solution or minute division, are more readily taken into the system from the raw surface than from the sound skin. When, then, the granulations approach the skin, the sore contracts, the newly formed parts being modelled into a more firm and dense condition by the action of the absorbents. Sometimes, in superficial sores, the skin is seen spreading from several parts near the centre; but at these points portions of the original skin must have remained uninjured, though the others were destroyed, and have formed cutaneous matter as soon as they were on the same level with the surrounding granulations; for these insu- lated portions of skin are not a product of granulations, as some sup- pose, but of a substance similar to themselves. Skin is formed from skin. Thus, where a part of the integuments has been completely removed by operation, or destroyed by accident, no islands of skin are observed during the cure, but the sore is uniformly covered by skin proceeding from its margins. The margins of a healing sore are of a white colour, and adherent to the subjacent parts; but in an unhealthy one the margins are often unsupported, the subjacent granulations are absorbed, and their place is occupied by thin puru- lent matter; the new skin is unable to maintain its independent existence, continues of a dark colour, perhaps for a long period, then 178 OF WOUNDS. wastes away or sloughs. The recent cutaneous matter covering a sore contracts, and the neighbouring old skin is extended ; the new surface is thus diminished; it assumes a slightly puckered appearance, and is termed cicatrix. This is at first pretty vascular, the vessels running straight; after a time they contract and become invisible, and scarcely admit fine injections. Frequently the scar is so far absorbed after some time, as to leave only a firm line, whiter and more dense than the surrounding integument. If union by the first intention does not take place, then all the applications to procure it must be abandoned, all sutures, plasters, compresses, &c, must be dismissed, for they now can do no good, and may be productive of harm; the attention, on the contrary, must be directed to effecting union by granulation: with this view, other means are to be chosen, so that to continue those which were formerly used to promote adhesion would be absurd, when adhesion can no longer be expected. The stitches must then be taken out, when inflammation has gone off, and oedema remains, the parts are to be supported ; and by attention to position, and gentle bandaging, the size of the wound will be diminished. Inflammation must be subdued by the usual means, and suppuration encouraged by fomen- tation and poulticing, or warm water dressing. After inflammation has subsided, tension disappeared, purulent discharge occurred, and granulations formed, the edges of the wound are to be gently brought together, so as to render the quantity of new matter requisite for filling up the cavity as small as possible. Nature wull then accom- plish the union in her own way, and we can only assist and minister to her; for who thinks now of healing wounds by pure force of sur- gery? The dressings ought to be light, the ointment, if any is used, scanty; in some cases the application may be dry; but in many cases various lotions will be found of much advantage. These latter are used of different qualities, according to the nature of the sore ; and these can be of little avail unless evaporation be prevented, by a piece of oil-silk laid on the outer surface of the dressing. In most granulating wounds, they require to be of a mildly stimulating nature, and the one which I have most frequently employed is a weak solution of the sulphate of zinc. The integuments round the wound may be occasionally washed, to prevent excoriation, but no good can accrue from washing the sore; its natural discharge is its best protection, and if superabundant, it can be removed by means of dry lint or tow from the surrounding parts. From bruised and lacerated wounds there is little or no hemor- rhage, but in proportion to the severity of the bruise, is the bleeding slight, and the danger great. The blood-vessels are so torn and twisted as to permit the spontaneous and temporary suppression of hemorrhage to occur almost immediately ; and the larger arteries may escape entirely, owing to their elasticity. Sometimes after bruised wounds, such as those inflicted by gunshot, the large vessels bleed instantly and violently; often, however, hemorrhage occurs only after the sloughs separate, many days after the infliction of Ihe injury, and then it is generally very profuse ; in some instances, limbs are torn, bruised, or shot away, without hemorrhage occurring OF WOUNDS. 179 to any great degree, or at any period. Frequently the vitality of the parts surrounding the wound is much diminished ; and the whole limb is apt to become gangrenous, either immediately, on account of the extreme violence of the injury, or consecutively, from greatly excited action going on in parts whose power of resistance has been much impaired : it often arises also from constitutional peculiarity. The gangrene extends often rapidly, in consequence of the infiltra- tion of putrid serosity into the cellular tissue. In the treatment of bruised wounds, the position of the parts must be carefully attended to ; they must be placed in a state of relaxation. In general, it is unnecessary to retain the margins of the wound in contact, for adhe- sion cannot occur — suppuration must ensue, and is to be desired — and the dead and dying parts must be loosened and discharged be- fore union can take place. Sometimes, as when a large flap has been detached, and the parts not much injured otherwise, approxi- mation ought to be accomplished, for the reasons already mentioned. In almost all cases, and most certainly in those in which the mecha- nical injury has been severe, and its effects extensive, violent inflam- matory action is to be dreaded, and measures must be taken to ward it off: notwithstanding the prophylactic treatment, violent inflamma- tion often comes on, and then recourse must be had to the means proper for the subduing of it. Blood is to be taken from the part, if necessary, and soothing applications used, in the form of fomentation and poultice. The main indications are to prevent extravasation into the substance of the limb, and strongly excited action. When the sloughs begin to separate, emollient poultices promote the sup- puration and discharge of dead matter, and afterwards the sore must be dressed, according to the nature of the case, with the applications most fit for granulating sores in their different degrees of action and advancement. During the after treatment, the sides of the sore ought to be well supported, so as to prevent, as much as possible, suppura- tion from extending along the neighbouring cellular tissue ; but, at the same time, the dressing must not be so tightly applied as to cause irritation. When abscesses have formed in the neighbourhood, the cavities should be freely exposed by incision ; thus a free discharge will be given to the matter, and the cavity brought to granulate from the bottom. During the suppurating stage, the patient's strength must be maintained by generous diet. Punctured wounds are dangerous, from the deep and internal effu- sion of blood and serum which usually attends them. The effusion, which in open wTounds is poured out externally, and moderates and prevents the excited action from exceeding what is salutary, is, in punctured wounds, poured into the substance of the limb to its de- triment. It is followed by severe inflammatory action and profuse suppuration. In order to prevent these untoward results, it was for- merly the practice immediately to dilate the wound ; but this is hurt- ful, for if the wound be deep, as it generally is, dilatation of its whole extent is a proceeding severe in itself, and in its consequences ; whilst if the external part only of the wound is dilated, the operation will entirely fail to effect what is intended. The knife will be used in great good time where a foreign body is found to be lodged in the 180 OF WOUNDS. wound, when tension has occurred, or matter has formed. Some- times the wound heals throughout its whole track by adhesion, with- out any bad symptoms being so much as threatened. Setons, re- commended in this class of wounds, are of no service. It is not the narrowness of the external opening, as is sometimes supposed, that is the cause of all the mischief, but the injury and consequent inflam- mation of deep-seated parts. Poisoned wounds are rare in this country. Wounds by the stings of certain trifling insects produce considerable swelling in some con- stitutions, and when the injury has been inflicted on a loose texture. In some parts of this country, the bite of a small adder causes pain, swelling, and unhealthy suppuration of the part, with some constitu- tional disturbance, but the results are seldom serious, and never fatal. In warmer climates, the bites of some snakes are followed by the most violent symptoms ; in some cases proving fatal in a few hours, in others after a day or two. Great swelling occurs almost immediately, attended with excruciating pain, and extends upward along the limb ; vision becomes impaired, the patient lies in a state of stupor, and ultimately succumbs under convulsions and delirium; the symptoms vary in particular instances according to idiosyncrasies and the state of the constitution when the injury is inflicted. In this country, the bites of rabid animals are more dangerous than those of animals naturally poisonous. Rabies most frequently occur in dogs, and others of that species, such as wolves, foxes, &c. They become dull, sluggish, and irritable; have unnatural appetites and cravings, devouring their excrement and urine ; the stomach is generally found full of chopped straw, pieces of wood, &c. Derangement of the cerebral functions is not complete, — they knowT and obey their mas- ter. They are often not afraid of water, but lap it and go into it readily. From them the disease is communicated to the human subject, and to the lower animals, such as cats, sheep, cattle, and even fowls ; the virus is not communicable, except by the deposition of the saliva on an abraded surface, or into a wound. It is not pro- duced by eating the flesh of a rabid animal. During the first days of the attack, pustules are, it is said, observed under the tongue, but there is no apparent change in the glands. The symptoms of hydro- phobia in man seldom appear before the twentieth day after the in- fliction of the wound, and in some instances they have not presented themselves till after the lapse of months. The most prominent are great restlessness, much irritability and anxiety, and convulsions of the muscles concerned in deglutition, produced either by attempts to swallow, or by fluid being presented to the patient. Ultimately, the spasms become general, are induced by the most trifling exertions or noises, and prove fatal in a few days. Frequently the patient retains his senses throughout, and is fully aware of his lamentable situation ; in other instances, he soon becomes delirious, raves, and threatens his attendants. For this horrible disease we are unacquainted with any cure. In general, profuse bleedings are employed, and large quantities of opium given internally ; every powerful antispasmodic, as well as every valuable medicine, has been made trial of, but in vain: some certainly mitigate the symptoms, but none cure the pa- OF WOUNDS. 181 tient. It has been even proposed to suspend or destroy the function of the nervous system for a time, by the employment of the Wourali poison, keeping up at the same time respiration by artificial means, under the expectation that thus the impression on the system might be got over. The morbid appearances usually observed after death are marks of inflammation of the pharynx and air-passages, and of the mucous surface of the stomach and intestines. It is evident that the disease ought to be prevented if possible, and for its prevention the most efficient measure is timely excision of the affected parts ; and they should be cut out a long period before the constitutional affection comes on : when excision is dangerous, or wholly imprac- ticable, and when the patient does not apply soon after the accident, the injured parts may be destroyed by some active caustic, as the potassa fusa. The nitrate of silver has been strongly recommended and extensively employed by Mr. Youatt, whose experience in this disease is very great. This application should scarcely be trusted to alone. The removal of parts wounded by snakes, even after violent symptoms have appeared, has proved successful, ammonia having been at the same time administered internally. In some instances, arsenic has been found efficacious when given in large doses, and frequently repeated. [In this country wTe have a number of insects, the sting of which is sometimes attended with considerable pain and swelling, or even high inflammatory excitement. Of these, the most common are the bee, wasp, hornet, yellow-jacket, and humble-bee, which all secrete a subtle poison contained in a reservoir in the abdomen, from which it is projected by the barbed dart when in the act of stinging. Severe and even dangerous wounds are occasionally thus inflicted; indeed, in a few instances death has been known to follow', especially in persons of a nervous, irritable temperament. Another insect, from the bite of which a good deal of irritation often results, is the mus- keto, which abounds every where during the hot summer and au- tumnal months, along the water-courses of the western and southern states. The little punctures made by this animal I have known in several instances to degenerate into unhealthy sores, furnishing a thin, sanious discharge, attended with more or less itching, and ex- ceedingly difficult to heal. The late Professor Dorsey mentions a case — that of a lady who previously enjoyed good health — in which the bite of the musketo terminated in gangrene and death. Of the great number of serpents inhabiting this country, only two — the rattlesnake and copperhead — are known to be venomous. Both are very active in warm weather, are furnished with long teeth, and secrete an acrid, virulent poison, of a yellow-greenish colour, which is lodged in a bag or reservoir at the roots of two of the teeth of the upper-jaw. When this poison is fairly infused into a wound of the skin and cellular tissue, it often proves fatal in a few minutes ; in other cases, the patient either recovers, or death does not occur until a later period. The wounds made by the stings and bites of insects are best treated by stimulating lotions, such as salt-water, vinegar, alcohol, haits- 16 1S2 OF WOUNDS. horn, and camphorated spirits. These remedies generally afford prompt relief, and they possess the additional advantage of being always near at hand. Bleeding, purging, and opiates, may become necessary, when, besides much pain and swelling, there is a great degree of constitutional disturbance. When bees and wasps find their way, as they sometimes do, into the oesophagus, causing violent suffering and nervous agitation, almost instantaneous relief may be afforded by making the individual drink large draughts of vinegar or salt and water. When a person has been bitten in one of his limbs by a venomous serpent, a ligature should be immediately applied, as tightly as pos- sible, at a short distance above the wound, which is then to be care- fully excised together with a portion of the surrounding structures. A cupping-glass is next applied, and after this has remained on for several hours, the sore is to be dressed with an emollient poultice or some simple unguent, or fomented with cloths wrung out of warm water and laudanum. The only internal remedy upon which the slightest reliance is to be placed, is arsenic, in the form of Fowler's solution. It should be administered, as was first suggested by Mr. Ireland, an English surgeon, in doses of two drachms every thirty minutes until an ounce or upwards is taken, or until free vomiting and purging ensue.] Wounds received during dissection occasionally have unpleasant consequences from the absorption of animal matter. The absorbents leading from the wounded part become swelled and painful, and in slight cases there are shivering and general indisposition for some days. The more violent symptoms arise from examining bodies which are rather recent, and in which putrefaction is just commencing, and very frequently from inspecting the bodies of females who have died of puerperal diseases. The absorption may take place from punctures made by scissors, the point of a knife, or spiculse of bone, or from old scratches, or chops by the side of the nail or on the hand. There is little Or no danger from an open and bleeding wound, as by the flow of blood the part is completely cleaned ; it is generally from slight punctures that untoward symptoms need be apprehended. Effects similar to those resulting from wounds in dissection often occur in nurses and others who have pricked themselves with pins while Washing foul clothes, or from handling poultices or dressings removed from bad, putrid, or sloughing surfaces. The symptoms already mentioned are soon followed by others more severe : shiver- ing continues, and the patient is seized with vomiting ; the part af- fected, and often the greater part of the arm, becomes red and much swollen ; the cellular tissue is infiltrated with serum often dark and putrescent, abscesses form at various points along the limb to the axilla, and purulent matter is diffused throughout the unhealthy cel- lular tissue, which in many instances sloughs, and gives rise to ex- tensive sores. Typhoid symptoms soon appear, and in the more aggravated cases speedily prove fatal. When such local and con- stitutional symptoms arise, it will generally be found that the patient was of a broken-up constitution previously to the infliction of the OF WOUNDS. 183 wound ; did they solely depend on the inoculation of virus, they would be of very common occurrence, considering that wounds are so frequently received during dissection ; but it is seldom compara- tively that any unpleasant symptoms follow such an accident. In all cases, however, it is prudent to adopt measures in order to prevent absorption of the virus. With this view, the wound is made to bleed by means of pressure or suction, and by the latter method the exposed surface is most effectually purified ; afterwards nitrate of silver may be applied to deaden the surface, and protect it by an eschar. If such means be unavailing, the after symptoms must be encountered as they appear, local inflammation subdued, tension relieved, ab- scesses opened, sloughs removed, &c. General bleeding is seldom admissible, but purgatives and antimonials will prove beneficial at the commencement; afterwards the strength is to be supported, and, if the patient be much reduced, stimulants are to be liberally administered. We shall next treat briefly of gunshot wounds ; under this head are included the contused and the lacerated, caused by splinters, &c. The vitality of the injured surface is generally destroyed at once, whence bleeding seldom occurs, even after whole limbs have been shot away; in some cases, however, hemorrhage is profuse, as when a large artery has been wounded by small shot. The effects on the system are extremely various; some persons are affected with tremors, anxiety, and depression from slight wounds ; while the most severe injuries are often unaccompanied by any disturbance of the nerves. The shock is generally of short duration, disappearing soon, on the patient's being reassured and encouraged, or after his taking a little wine or opium. In gunshot wounds, those inflicted from a distance or close at hand can in general be readily distinguished. In the latter, the wound is large and lacerated, portions of the wadding are impacted, and the skin around is marked with grains of gunpowder. In the former, the wound is small and clean. When a ball passes through a fleshy part, the opening at its entrance is small and de- pressed ; whilst that by which it escaped is open, with everted edges. When it follows a superficial course, its track is marked by a wheal, or elevation of the skin with discoloration. At one time, it was be- lieved that the most serious consequences resulted from a ball passing close past the body without even touching it — that in this way vio- lent concussion of the brain, proving instantly fatal, was produced ; but this notion has been disproved by experience ; part of the head accoutrements, of the hair, of the nose, and of the ears, have been shot away by cannon-balls, and yet no disturbance of the brain has followed either immediately or consecutively. The opinion originated from the circumstance of soldiers having been found dead without any evidence of injury ; but bones are often broken and comminuted by an indirect blow, or by a spent ball, without any breach of sur- face or external sign remaining ; internal injuries indeed — rupture of viscera — more than sufficient to cause instant death, are thus in- flicted without any apparent external lesion. The course of a ball in the body is often very strange, depending on the force with which it is projected, or the resistance which is opposed to it, and on the position of the struck part. Balls often pass 184 OF WOUNDS. under the integument almost completely round the head or chest, having first struck the bone at a very oblique angle. Frequently they remain, lodged along with part of the clothing which they thrust before them. In such cases, they may be immediately removed, their exact situation being previously ascertained by external examination, or by means of a probe. They can generally be extracted through the aperture by which they entered ; but if situated superficially, and at a distance from the opening, this will be more readily accomplished through an incision made upon them ; if allowed to remain, suppu- ration will occur in the neighbourhood, the surrounding cellular tissue wrill be condensed, an abscess will be formed containing the foreign bodies, and by the process of absorption, proceeding in the parts ex- ternal to the abscess, the ball will at last reach the surface, and be discharged. The track is often so extremely tortuous, as to render it impossible to ascertain the situation, or even the existence of the foreign body, which greatly impedes the operation; and, in other instances, it may be necessary to allow the ball to remain undisturbed, on account of its being placed near important parts, which might be injured by any attempt at removal. Foreign bodies often remain lodged in fleshy or membranous parts for years, having become en- veloped in a dense cyst, and having ceased to produce any great irritation. In consequence of the force with which they have been projected, and the resistance which has been opposed to their progress in the body, musket-balls, when extracted, either immediately after the infliction of the injury, or after a considerable time has elapsed, are seldom found to retain their globular form, but are flattened and ragged, and not unfrequently completely divided by the bones on which they have impinged. A bullet maybe divided into numerous fragments on a bone, and part may enter into the osseous substance, whilst other portions penetrate in all directions into the soft parts, and, though sharp and irregular, may remain long in the dense cel- lular cyst which forms over them, without producing pain or incon- venience. There will necessarily be suppuration, and generally dis- charge of dead matter, from gunshot wounds, in consequence of the bruising of the parts by the ball, which may be expected to injure the superficial layer of parts in its tract so severely, that it must slough more or less. Besides, the bones are often splintered by the force with which they are struck, and loose portions of them lodge amongst the mus- cles ; then they are the cause of much mischief, for on account of their long, sharp, and irregular form, they occasion great irritation, suppuration ensues in various parts, sinuses form, and the cure is rendered very tedious. In other cases, the bone is split in a longi- tudinal direction, and, in the cylindical bones, these fissures are often of great extent. Considering the nature of the body which inflicts the injury in a gunshot wound, and the velocity with which it is impelled it is evi- dent that the cure must be in all cases tedious, in consequence of the sloughing and suppuration which is induced, particularly at the aperture through which the ball passed. The foreign body ought always to be removed as early as possible, provided it can be ac- OF WOUNDS. 185 complished without much violence, or injury to the parts. Dilata- tion of gunshot wounds is now had recourse to only to facilitate the removal of balls, splinters, &c, and even with this view, it ought to be employed but to a very slight extent, if at all ; for foreign sub- stances, wThen deeply seated, can be much more easily taken out when the sloughs are separating, and the parts relaxed by suppura- tion ; then, too, they can be more readily reached through a counter- opening, when their situation renders this expedient. In short, the surgeon is not justified in cutting for balls, unless they are easy felt, and not deeply lodged. In order to discover the foreign body, probes will sometimes be required ; the finger often answers the pur- pose best, unless when the wound is of considerable depth. If, on examination, the ball cannot be discovered, and if there is reason to think that it has followed an indirect course, the surgeon will, some- times, be assisted in his search by placing the patient in that posi- tion in which he received the wound, and then judging of the cir- cumstances most likely to affect the foreign body in its passage. In many cases, extraction can be accomplished by means of the finger alone ; in others, forceps and scoops, various in length and size, are indispensable. Afterwards, light dressings are to be employed; and in the first instance, cold applications may prove advantageous in keeping down the inflammatory action ; but wThen inflammation has commenced, and to encourage suppuration, warm fomentations and poultices are to be preferred ; they will in many cases be both more grateful to the patient and more beneficial in their results, wrhen used even from the commencement. Afterwards, it will be neces- sary to afford sufficient support to the parts by bandaging, and to change the applications according to the particular circumstances : — soothing, if the wound be irritable, stimulating, if inert, and gently escharotic, if the granulations be exuberant. In severe injuries of the limbs, the surgeon must be guided by the state of the part, and of the constitution, by the circumstances in which he is placed, as to accommodation, and mode of transportation, &c, in deciding on the removal of the part by amputation, — or on making an attempt to save it, by trusting to, and assisting, the processes of nature. The question, whether to amputate immediately, and on the spot, merely allowing the shock, if any exist, to pass away, or to de- lay till suppuration occur, is now scarcely a matter of dispute. When it is evident, from the extent, violence, and nature of the injury, that there is danger of speedy mortification, or of extensive and severe inflammation and suppuration, amputation is to be instantly per- formed, — delay is inadmissible. In comminution of the hard, with contusion and laceration of the soft parts — where limbs have been shattered and completely detached, or nearly so — in lacerations of parts, including the principal blood-vessels and nerves— fractures of the heads of bones, with openings into the joints^ and in bad com- pound fractures, more especially of the thigh (for all compound frac- tures of the upper part of the thigh are dangerous), amputate at once, When the limb has been retained, and gangrene arises in conse- quence of the external injury, and when there is no reason to sup- pose that any internal cause is also in existence ; or when the vio- 16* 186 OF TETANUS. lence of inflammatory action has subsided, and the patient is become hectic, with profuse purulent discharge, and with disunited bones, then amputate. But, in this latter case, the chance of recovery is not so great, and the proportion of recoveries small; whereas, in the immediate or primary operations, the very reverse holds true. Such is the experience of the greater number of military surgeons. In civil practice, the results are somewhat different; a greater propor- tion of primary amputations are unsuccessful, and the secondary turn out more favourably than the statements of military surgeons would lead one to believe. In all cases, the judgment of the sur- geon must guide him in his determination. The circumstances of the case, and the probable contingencies, must be all duly consi- dered, and he must not proceed with his knife where there exists even a slight chance of preserving the limb. Paralysis occasionally follows wounds of the arm, fore-arm, face, &c, inflicted by accident or operation, and this arises from an import- ant nerve, or set of nerves, being divided. In cases of simple divi- sion, without much separation of the parts, reunion of the nerves may take place, and their functions be restored. If the limb remains paralysed, after cicatrisation of the wound, tepid effusions, friction, dry or with liniment, stimulating applications, &c, may sometimes be advantageously employed. TETANUS Is a disease which occasionally follows a wound, but rarely in this country. It is a spasmodic contraction, with rigidity, of the volun- tary muscles, in some cases involving the whole body, in others the upper part of it only, and in some it is confined to a certain class of muscles. When the extensors are affected, the disease is termed opisthotonos ; when the flexors, emprosthotonos. Complete tetanus is said to exist when the flexor and extensor muscles exactly balance each other, and the body is thereby kept straight and rigid. But when the affection is confined to the muscles of deglutition, and chiefly to those moving the lower jaw, it is called trismus. The disease has besides been divided into acute and chronic, and into traumatic and idiopathic ; the one following wounds, the other arising from internal causes, or circumstances not connected with the lesion of the surface. The disease supervenes at various periods; some- times, though rarely, not long after the infliction of the injury, in other instances after the lapse of eight or ten days, and often when the wound is healing, or nearly cicatrised. In warm climates, where it is of very frequent occurrence, it occasionally seems to be caused by exposure to damp and changeable weather; in children, it super- venes on the slightest irritation. It is often induced by the pre- sence of splinters, or rather bodies of an irritating nature, and by the partial division of nerves. Not unfrequently it occurs after clean wounds, as amputation or venesection ; in the former it may perhaps arise from a nerve being included in the same ligature with an artery, in the latter, from a nervous twig bein«- partially OF TETANUS. 187 divided. The more prominent symptoms are, stiffness of the back of the neck, and contraction of the features ; difficult deglutition supervenes, and the efforts to accomplish it are attended with violent spasms of the muscles of the pharynx and oesophagus. Spasms of the injured limb often precede those of the muscular system gene- rally ; the muscles of the lower jaw become rigid and spasmodically contracted, and by a continuance and increase of the spasmodic ac- tion, the mouth is at last completely and immovably shut. The muscles of the trunk and limbs become affected, and there are violent spasms of particular sets of them, most generally of those situated posteriorly ; thus the body is bent violently backwards, so that its whole weight is supported on two points only, the heels and the occiput. These symptoms are not constant; relaxation occurs, and the patient enjoys a cessation of the malady : but this is only tem- porary ; the painful feelings and the spasms soon return. A symp- tom of the most distressing nature is pain and spasmodic twitching of the diaphragm, impeding respiration, and imparting a shock to the whole system. Occasionally, emprosthotonos occurs, but, so far as my experience goes, the body is much more frequently bent backward ; the muscles are sometimes ruptured by the violence of their own action. The circulating system and sensorial functions are often not much disturbed ; but during the whole course of the disease, the bowels are much constipatad. In most cases of trau- matic tetanus, after four or five days, all the symptoms become ag- gravated ; the countenance is horribly distorted, the spasms of the diaphragm are more frequent and violent, and the patient dies con- vulsed. Sometimes, though rarely, the fatal termination does not take place till the eighteenth or twentieth day. On dissection, the pharynx is found contracted, and bearing marks of acute inflamma- tion. In one case, which fell under my observation, there was ulti- mately great difficulty in breathing and expectorating ; and on ex- amination, the trachea, as well as the pharynx, bore evident marks of inflammation, and were filled with a viscid mucus. In some instances, there are evident marks of inflammation of the spinal chord; the vessels, more especially at the lower part, are found en- larged, tortuous, and engorged with blood ; portions of lymph are seen deposited on the arachnoid covering, and a serous fluid is effused, not unfrequently mixed with blood. Such appearances, however, are not observed in every case of fatal tetanus, and there- fore it cannot be asserted as a fact, that the disease is dependent on a morbid condition of the spinal cord, though in certain cases the two affections co-exist. By some it has been supposed, that in conse- quence of the distended and engorged state of the spinal arteries, the origins of the nerves are stimulated, and that a morbid affection of them ensues, giving rise to the tetanic symptoms ; but want of uniformity in the morbid appearances prevents such a cause from being generally set down as the origin of tetanus. This disease is one of the most intractable with which the surgeon has to contend. In the acute form, time is scarcely allowed for reme- dies ; and in the advanced stage, it is with much difficulty that medi- cine can be received internally. Of course all irritations must be re- 188 OF TETANUS. moved, both local and genera], as far as that can be accomplished. If the patient be robust, and if the tetanic symptoms be ushered in with arterial incitement, general depletion ought certainly to be prac- tised ; and if the symptoms be such as to render the propriety of general bleeding dubious, blood may be abstracted locally, from the back of the head, or along the spine ; and this may be followed by such counter-irritants as act rapidly. At the same time, powerful purgatives must be given, so as to bring the bowels into a better state ; for, as already observed, obstinate constipation is a constant attendant on this disease. But the most important indication is to alleviate and prevent, if possible, the spasms ; and for this purpose, opium is to be administered in large doses, either by itself, or com- bined with camphor or other antispasmodics. By such means, the disease has in some cases been arrested, but in the majority it has proceeded unabated. Some practitioners recommend and employ cold affusion and immersion, whilst others prefer the wTarm bath ; and the latter appears to be the safer application, though neither can be considered as efficacious. Great relief and benefit seem to have accrued from the frequently repeated use of a wTarm bath, with some drachms of the tart, antimonii dissolved in it. I have had only two opportunities of trying this practice ; one a chronic case, wdiere, after the division of the nerves proceeding from the wound, this re- medy, with others, seemed to allay the spasms in a very remarkable manner: the patient recovered. In the other, a very acute case, after the extraction of a splinter from betwixt the thumb and fore- finger, the bath was tried ; the patient felt much comforted by it; but suddenly expired in a violent convulsion, whilst being replaced in bed. Great relaxation follows this remedy, profuse perspiration, and subsidence of the rigidity and convulsive action of the muscles. The practice wTas recommended to my notice by my excellent friend Dr. Stevens, Professor of Surgery at New York. In some cases, it would be worth trial to produce instant vesication by the acetic solu- tions of cantharides or ammonia, and then try the effect of the applica- tion to the blistered surface of some of the alkaloids, such as morphia, aconitine, &c, or belladonna might be applied Some practitioners have used mercurial frictions along the spine, or on other parts of the surface ; while others administer stimulants, and enemata with tobacco and turpentine. When there is reason to apprehend that the symptoms arise in consequence of laeeration or partial division of the nervous trunk, it has been recommended to complete the division of it; and the practice is worthy of adoption, as in some cases it appears to have been successful. Little good can re- sult from scarification of the wound. Amputation of the wounded member has also been proposed, particularly in chronic cases, and in one or two it has succeeded. I have made trial of it in but one in- stance, and in that it failed. Acute tetanus had followed a lace- rated wound betwixt the thumb and forefinger; amputation of the fore-arm was performed, and immediately after the operation the spasms abated ; but they soon returned, notwithstanding the free use of opium, and other remedies, and the patient died. In this case the branch of the median nerve was found partially divided, and its OF ULCERS. 189 cut extremities were thickened and inflamed. During the operation, I wished to abstract a considerable quantity of blood, but the arteries seemed to be so spasmodically contracted, as to permit the flow of a small quantity only. On examination after death, the median nerve was of its natural appearance, excepting at the bend of the arm, where it was of a bright-red colour. No change could be perceived in the brain or spinal chord, though the examination was conducted with the utmost care. OF ULCERS. By ulcer is generally understood a breach of continuity in the soft parts of the body, with secretion of purulent or other fluid. But as suppuration may be independent of ulceration, so may we occasion- ally see a loss of substance like an ulcer on the surface of parts, without the production of pus, or any other morbid secretion, of which some instances are noted in the remarks on Atrophy of Arti- cular Cartilage. Mr. Burns, in his excellent volume on the Princi- ples of Surgery, has extended the term to the reparative process, as well as the destructive; this, if adopted, would lead to confusion and misapprehension. Ulcers vary much in disposition and appearance, follow wounds, abscesses, sloughing, eruptions, &c, and often occur without any previous lesion of the surface. Those most generally met with are comprehended in the following classes: — 1. The simple purulent ulcer, or healthy or healing sore. 2. The weak or sluggish ulcer,—- a sore with undermined integuments and an unhealthy state of the cellular tissue. 3. The indolent ulcer,— a sore with hard elevated edges, and presenting little or no appearance of reparation. 4. The irritable ulcer, — a sore with over-action, and generally affecting only the mere surface of the true skin. Besides these, there are sores connected with diseases of the bones, and others arising from specific action; some are complicated with a varicose state of the veins: the former have been already treated of; the latter are reserved for consideration. Ulcers change their characters, as from simple to irritable, and from indolent to inflamed ; the change depends on situ- ation, on the state of the constitution, and on the treatment which they receive. I. The appearances of the first * class were described when the healing of wounds by granulations was considered, p. 176. They heal more readily on the upper extremities, on the face, neck, and trunk, than on the lower limbs ; for in the former parts the circulation is more vigorous, the natural processes of cure proceed more easily, and are less liable to interruption. The 'sore only requires rest, a clean condition of the surrounding parts, mild and light dressings, and moderate support; dry lint or lotions are preferable to ointments, since the latter are apt to irritate by their rancidity. When the sore is of considerable size, and there is a tendency in the granulations to rise above the level of the surrounding skin or cicatrix, the edges may be protected by very narrow slips of fine old linen or cambric, spread with fresh spermaceti ointment or cold cream ; a pledget of 190 OF ULCERS. dry lint is then laid on, and restrained by a roller. The dressings thus arranged do not adhere, and the tender cicatrix is not ruffled and disturbed ; or a piece of pierced linen spread thinly with unirn- tating ointment may be placed over the sore, and above that dry lint. When the sore has contracted to a small size, and some powder, as starch or calamine stone, or a piece of dry lint, may be applied, so as to allow a scab to form for the protection of the subjacent surface ; but this will, in most cases, be better accomplished by touching the surface lightly with lunar caustic or blue stone ; the fluids on the part are thereby immediately coagulated, a crust is quickly formed, and by covering it with charpie, it is retained in its situation, whilst the process of cicatrisation proceeds beneath it: if a small quantity of matter should be secreted, it readily escapes by the sides of the crust, without disturbing either it or its covering ; the limb should be raised above the level of the trunk. Sores on the lower limbs are always difficult to manage. The reparative process is tedious, on account of their situation; the parts are at a distance from the centre of circulation, their action is weak, the return of blood is tardy, and the same facility is not afforded of restraining the motions of the part as in the upper extremities. In persons of a good constitution, however, the simple purulent sore often heals speedily, even in the lower limbs. Before cicatrisation can take place, it is essential that the granulating surface should be on a level with the sound surface around; this soon takes place when a favourable position is observed, and the part is kept at rest; but by neglect, the new matter is often absorbed. Ap-ain. the healing process CSnnot advance where ihe granulations are exuberant, large, and flabby, and have risen above the proper level: they must be kept in check by due compression, and by astringent lotions, containing salts of zinc, copper, &c. The constant meddling with sores, the touching them w7ith this, that, or the other caustic, is much to be reprobated. Should it be neces- sary to destroy granulations, and bring them down to the surround- ing surface, one good rubbing with the blue stone will generally suffice. If the ulcer is large, the granulations close to the cicatrix should only be destroyed, leaving the centre to be dealt with as the cure advances. During the cure, the patient must be a good deal confined to the recumbent posture ; when erect, a bandage or laced stocking must be applied to the limb ; thus the return of blood is assisted, swell- ing is prevented, and the affected parts placed in a state of com- parative rest. Much pressure ought to be avoided, as it is apt to produce bad effects upon the sore, causing absorption of the granu- lations, thin 'bloody discharge, and great tenderness of the surface. After cicatrisation, the scars may be absorbed, and sores reproduced, by external injuries, or an unhealthy state of the body ; and so much does the state of a sore depend upon that of the general health, that the one is a good index of the other. II. In the second class of sores, or those with weak action, the granulations are flabby, of a pale colour, and possessed of little sen- sibility or vascularity ; the discharge is gleety, and the surface is liable to be destroyed by ulceration or sloughing, upon the slightest OF ULCERS. 191 excitement of the circulation in the part. The surrounding integu- ments are generally of a bluish colour, in consequence of their sepa- ration from the subjacent parts ; and in several places of the neigh- bourhood, small, unhealthy, detached abscesses may exist; at some points of the sore, glairy fluid is seen to ooze out on pressure, and a probe can be passed pretty deeply into the cavity of an abscess in the soft parts beneath. These sores may arise from an unhealthy condition of the cellular tissue, taking place spontaneously, or fol- lowing slight injury ; they are attributable to the state of the con- stitution, and may result from an ulcer, originally of a healthy cha- racter, which has remained long open, in consequence of its great size, or other impediments to its contraction. It is the business of the surgeon, in cases of this description, first to obtain a sound foundation, by destroying the unhealthy skin and cellular tissue ; the free application of caustic potass will answer this end most readily and effectually. Its application is attended with considerable pain, but the practice is more successful and less severe than the removal of the unsound parts by the knife or other means. The small abscesses may be all freely laid open ; the diseased cellu- lar tissue may be cut into, or cut away ; in short, incisions may be made in all directions, and in every portion of the affected part; but still it will be found that the granulations, as they appear, become pale and flabby, that they spring from a loose and powerless base ; matter will again collect; the surrounding skin will again be under- mined ; no progress will be made towards soundness. But by at- tention to the state of the constitution, and the application of potass, the neighbouring sound parts have their actions roused, and the healing is carried on rapidly. After its application, a poultice may be applied for a few days, and followed by water dressing, and then stimulants, both internally and externally employed according to circumstances, the parts being all along well supported. The long continued use of warm fomentations, or poultices, is prejudicial, as tending to diminish still farther the action of the parts ; ointments can be of little service, aad will generally do harm. III. Inlolent»ulcers, which have long exist d, are frequently met with on the lower limbs. Their margins are thick and insensible — their surfaces smooth, hollow, and of a pale colour — the discharge is scanty, and adheres to the surface. A sore, having been long open and neglected, degenerates into this state. Poultices are to be ap- plied for a day or two, to clean the surface, promote the discharge, and soften the callous margins. This is the more necessary, if, as is often the case, the sore, or the surrounding integuments, are inflamed when the paiient applies for relief. Afterwards, the applications must be of such a nature as to moderate the discharge and keep the granulations firm .nd healthy. In such cases only is adhesive plas- ter applicable, and in them it produc s the most beneficial results. Supposing the ulcer to be situated on the fore and middle part of the leg, a bandage should first be firmly applied from the toes to a little below the sore ; the ulcerated part of the limb is then encircled by narrow strips of adhesive plaster, tightly drawn, and with the ex- tremities of each strip crossing immediately over the ulcer. A pledget 192 OF ULCERS. of tow is placed on the plasters to absorb the discharge, and the bandage is brought over dressings, and continued for some way up- ward). By this application, the margins of the sore, it is supposed, are brought nearer to each other, and the ulcerated surface dimi- nished ; the sluggish granulations and the subjacent parts are stimu- lated, and a more vigorous action being excited, the process of re- paration proceeds speedily and effectually ; the surrounding parts, previously turgid and cedematous, are by the pressure brought to the same level with the newly-secreted matter, and new skin is quickly formed. In the previous state of matters, the old skin was much elevated, and an action Was in progress, causing a continuance of that elevation; by the compression, the whole limb is properly sup- ported, serous effusion prevented, absorption excited, and oedema removed ; the living swelling of the lower part of the limb, which might arise from the tightness of the adhesive plaster, is obviated by the bandage being first applied. A feeling of uneasiness in the limb sometimes follows such dressing, but is of short duration; should it increase, so as to amount to pain, the elevation of the limb and the pouring of cold water occasionally over the dressings will soon restore the parts to comfort. Or the adhesive plaster may be slit up behind, immediately after its application ; indentation of the limb being thereby avoided, and sufficient pressure at the same time kept up on the sore. If possible, the dressings ought not to be re- moved before the second day, as much irritation will be produced by their frequent renewal. The benefits arising from this mode of treatment are truly surprising ; the slow and indolent ulcer is speed- ily converted into the simple purulent sore ; the wdiite and recent cutaneous substance encircles small pointed and florid granulations, which bleed from the slightest rudeness of touch ; and the space formerly occupied by an unsightly sore is soon diminished to a small and firm cicatrix. It is only necessary to continue this mode of dressing so long as the granulating surface is below the level of the surrounding surface. Then the object being attained, the de- ranged state of the cellular tissue being got rid of, and the ulcer put in a state favourable for cicatrisation, the sulphate of zinc lotion not over strong may be resorted to ; positive rest and support of the affected part being still enjoined and observed. In the old and de- bilitated, however, in whom the indolent sore most frequently oc- curs, the integuments remain purple and shining, and from very slight causes the cicatrix is absorbed, and breach of surface is re- produced. These sores are often connected with a varicose state of the veins. In all such cases, a degree of compression on the affected limb must be maintained, both during the continuance of the sore, and after it has healed. The usual situation of such sores is on the leg, and the varicose state of the veins does not, in general, extend above the knee; in such cases, a radical cure maybe attained (provided the patient wishes to encounter the attendant risks, rather than submit to a continuance of the disease) by effecting an obliteration of the saphena major vein. The manner of doing this, and its effects, were men- tioned while treating of diseased veins. In some cases, the saphena OF ULCERS. 193 minor is also varicose to some extent, the varices on which must also be obliterated. Sometimes as many as eight or ten needles must be applied, in pairs, before the circulation of a limb can be brought into a right state. IV. In this fourth class of sores, or the irritable from over-action, the sore and its edges are of a jagged, irregular appearance, the dis- charge is thin and bloody, and considerable pain is experienced. This ulcer is very superficial, involving only the surface of the co- rium and the more sensible part of the integument, the papillse, and extremities of the nervous filaments. They often succeed to scaly eruptions, and present a remarkable character and appearance, cica- trising in the centre, whilst they extend towards the circumference. The sore is often covered by an ash-coloured slough ; on the re- moval of which, granulations arise, but these either again slough, or are removed rapidly by the ulcerative process. In the treatment of such sores, complete rest and soothing applications are the means on which most reliance is to be placed. Warm and soft poultices, such as those of arrow-root, fomentations, tepid water-dressing, solutions "of opium, or of extract of poppy, and the occasional use of a local vapour bath to the part, may be enumerated amongst the means best fitted to allay the irritable condition of the ulcer. When the surrounding integuments are swollen, red, painful, in short, evince marks of inflammatory action going on in them, the feelings of the patient will be rendered grateful, and the cure advanced, by abstrac- tion of blood from the parts by punctures. When the nature of the sore is changed, and when cicatrisation has commenced, the treat- ment is similar to that of a simple granulating surface — light dress- ings, due support of the parts, and repression of exuberant granula- tions by the sulphate of copper. The nitrate of silver, applied in sub- stance round and about the ragged edges, is of great service at an earlier period. This practice must be sparingly and seldom resorted to, but it does wonders when judiciously employed. Ulcers are occasionally prevented from healing by the presence of dead portions of tendon, fascia, or cellular tissue, and are accom- panied in general with a bad state of constitution ; in such it is neces- sary to clean the surface by a powerful escharotic, and the best is potass. Otherwise, granulations will be produced quickly, it is true, and in abundance, to supply the original substance ; but then they are flabby and exuberant, new skin is formed slowly, if at all, and the sore does not contract; but by removing the dead or half-dead sur- face, a healthy and firm foundation is prepared, on which is securely and gradually raised the new matter for cicatrisation. But caustics are applied injudiciously to firm and healthy granulations which have not yet reached the level of the surrounding parts ; they are only useful in repressing exuberant granulations, or in destroying half- dead parts, which interrupt or deteriorate the cure: and when em- ployed, it should be effectually, and once for all. Along with the topical treatment of ulcers, internal means are, in most cases, indispensable. Thus, in indolent ulcers, the state of the constitution is often sluggish, and ought to be changed by the exhi- bition of alteratives or stimulants ; with this view, much benefit is 17 194 OF ULCERS. derived from a prudent and restrained use of mercury, from the lytta vesicatoria, from minute and occasional doses of arsenic, from the free exhibition of sarsaparilla, and from generous diet, porter, arid wine. It is, however, altogether impossible to lay down fixed rules for the management of sores ; every one has some peculiarity in its nature and appearance, every one requires some peculiarity in the applications and mode of dressing, and what may suit well one day will often prove inert or injurious on the succeeding. Again, when any one application or internal remedy is found to agree with the sore, it ought not to be changed for fashion's sake, from caprice or routine. In this department of surgery, one practitioner excels another, not by his superior knowledge of the various applications. but by his acuteness in selecting the remedy adapted to the particular state of the sore, and in accommodating the various ointments, lotions, or powders, to the different characters which the ulcer assumes during its progress. The healing of sores is very easy in some con- stitutions, and very difficult in others. Hence, it has been supposed that the long existence of a sore is a salutary process of nature, tend- ing to relieve or prevent some more serious affection, and on this account some are little solicitous to procure its cicatrisation, or at least are careful that the cure shall not be a speedy one. If, indeed, an extensive sore, or a series of sores, be suddenly dried up, the circumstance must be considered as very unfortunate, and the con- sequences may even be fatal ; but such an occurrence is unusual, and the patient may in general be saved by the timely insertion of an issue in the neighbourhood of the sore, or by an active employment of wThat is best calculated to insure a renewed discharge. Some sores have a disposition to extend by sloughing, and such frequently attack the lips and pudenda of weakly children; they are also met with, amongst the lowest class of prostitutes, in the cleft of the nates, in the groin, &c, and in such cases the sore closely resembles hos- pital gangrene. OF HOSPITAL OR CONTAGIOUS GANGRENE, AND SLOUGHING PHAGEDENA. This disease has been long known, and has proved very fatal in crowded and badly-aired hospitals. It may break out at any season, but hot, sultry, and damp weather is most favourable to it. No breach of surface, however small, is secure from its attack. The wound becomes painful and swollen, and loses its healthy, florid ap- pearance ; the granulations are flabby, and appear as if distended with air; vesicles form, containing serum or a bloody fluid ; the pain is stinging ; the secretions are suspended ; and the wound is either altogether dry, or covered with slimy, tenacious, and peculiarly offensive matter. An ichorous discharge follows, the pain increases. The sore assumes a circular form, and its edges are everted ; ery- sipelas attacks the surrounding integuments, often extending over the whole limb, and forming a principal feature of the disease. In fact, violent erysipelas and hospital gangrene are affections very OF HOSPITAL GANGRENE. 195 closely allied to each other, often arising at the same time, and from the same causes. Both are accompanied with great constitutional disturbance ; but in erysipelas, this generally precedes, whilst in hospital gangrene, it follows, the appearance of the malady. The lymphatic glands, in the neighbourhood of the gangrenous part, in- flame and suppurate, the skin gives way, and the gangrene soon seizes the newly-formed sore. Fever supervenes, the pulse is often full and strong, and the surface hot; there is great nausea and thirst; the tongue is brown, and the bowels much disordered. The inflammation and ichorous discharge increase. A thick slough covers the sore, and its fetor is peculiar and intolerable. The burning pain is excruciating. Blood oozes out, and, in the last stage, the hemor- rhage is often copious from large vessels exposed by the ravages of the disease. Now, extensive mortification occurs, the strength fails, the pulse becomes tremulous and indistinct, the features collapse, the surface is bedewed wTith a cold sweat, diarrhoea and hiccough come on, and death puts an end to the patient's suffering. Such is the progress of the disease in those who were previously in perfect health. Often, however, it is attended with typhoid symptoms almost from the be- ginning, in people whose constitutions are wasted, who have long laboured under disease, or who have been long confined in hospital. The important distinction between these cases must influence the treatment; what succeeds in the one will destroy in the other. It is not the name of the disease which is to be combated, but each symptom as soon as it presents itself. Those who have been once afflicted with hospital gangrene are ex- tremely liable to its recurrence, and that too on the same sore ; though the secondary disease is much less acute. This form has been termed Sloughing Phagaedena, and may seize a sore not previously affected with gangrene. The wround, recovering from the first at- tack, and appearing to heal rapidly, with good discharge and healthy face, presents, near its edge, a small dark spot or ulceration, of the size of a small bead or shot, of a circular form, with a ragged edge, excavated surface, and fetid discharge. Several such points may appear; they spread rapidly, unite, and the surface is soon de- stroyed. It is not uncommon to find one part of the sore of a healthy appearance, and even cicatrising, whilst in another part the surface is rapidly disappearing. The patient complains of a burn- ing sensation in the part; suppuration occurs round the edges and beneath the slough, and the dead parts separate ; but the same process again takes place, and another slough forms. The malady proceeds often with a rapid and alarming pace ; the sloughs are soft, pulpy, and reddish, and separate one after another, exposing muscles, nerves, blood-vessels, and bones. Joints are opened into, and the vessels, having been exposed, perhaps for a day or two, give way, and fatal hemorrhage ensues, their cavities not being obstructed with coagula as in sphacelus. The patient is sick, has no appetite, and labours under other symptoms of deranged stomach ; there is rest- lessness, with a small quick pulse, and all the symptoms of a weak- ened and sinking system. The ulceration becomes more rapid, the 196 OF HOSPITAL GANGRENE. discharge is bloody and peculiarly offensive; all the symptoms in- crease in violence, and may proceed for fifteen or twenty days, or terminate in four or five, either in convalescence or death. Hospital gangrene is supposed to arise from a variety of causes; from the state of the atmosphere, moist and hot — from inattention to cleanliness, the parts around the sore being seldom wiped, the matter collecting amongst the dressings, and becoming acrid by pu- trescence— from irritating applications, as rancid ointments—from a too stimulating diet, and from the abuse of wine and spirits— from mechanical irritation, in moving the wounded over rough roads and in bad conveyances, as after great engagements — from specific con- tagion without immediate contact. After being once generated, it is propagated by direct communication, by the application of morbific matter from sponges, dressings, or instruments. It is not easy to say how the disease originates. In the treatment of this scourge, great attention must be paid to cleanliness in all circumstances. Free ventilation must be con- stantly preserved in the apartments of the sick, and fumigations as- siduously employed. The infected ought to be separated from the others, and but few patients placed in the same ward. Stagnant drains and accumulations of filth out of doors are to be removed ; otherwise, during hot weather, the atmosphere becomes much viti- ated. Care must be taken, also, to destroy all the dressings which have been used ; not to employ sponges, but to wipe the surface in the neighbourhood of the sore occasionally with tow, which is to be burnt immediately, being an article of little value, and easily pro- cured. Too much attention cannot be paid to the cleaning of those instruments with which gangrenous sores have been treated, before they be applied to healthy wounds. As to the constitutional treat- ment, the alimentary canal must first be purged of its solid contents, and the secretions afterwards kept in as good a condition as possi- ble. When the wound or sore is surrounded with intense inflam- mation, and when the skin is dry and the pulse strong and full, with all the other symptoms of an inflammatory diathesis, immediate re- course must be had to free abstraction of blood from the system, as thus only can the progress of the disease be efficiently arrested ; and if inflammatory symptoms exist, when there is reason to expect the occurrence of the disease, though no symptom of it has yet appear- ed, then, too, venesection combined with purgatives is demanded, as being the most powerful preventives. Emetics are also recom- mended. When the affection is from its commencement accompa- nied with typhoid symptoms, depleting measures must do irreparable mischief: in such cases, the local pain and irritation will be relieved by the exhibition of opium or camphor, and it may also be of service to preserve a perspirable state of the surface by means of Dover's powder, or other diaphoretics. Preparations of Peruvian bark, the decoction with or without the tincture and acid, or the sulphate of quina, are often given with great advantage — opium is also use- fully exhibited. Vinegar, weak acids, the nitric and muriatic acids diluted, have been used as external applications, and nitrate of sil- ver, the red oxide of mercury, and the actual cautery, have been OF MALIGNANT PUSTULE. 197 applied with the view of removing the diseased parts, and procur- ing a healthy surface. Arsenic in solution, used so as to produce a slough, followed by hot dressings, has been supposed to be service- able. A much safer and more powerful application is the strong ni- tric acid, which sometimes requires to be applied over the diseased surface very freely, and repeated if need be. THE MALIGNANT PUSTULE Is a gangrenous inflammation of the skin, rarely extending to the subcutaneous cellular tissue, and in this respect differs from carbun- cle, which commences and is seated in the cellular texture. It arises from the application of the fluids of animals which have died of putrid diseases common in some marshy and low situations. It is communicated not only by matter from the diseased part, but also by the blood of the animal; thus it is frequently observed in those who handle the recent skin or flesh; and the excrements also appear to be possessed of the poisonous principle. It spreads from one person to another by contact. There is much reason to doubt, whether carrion introduced into the stomach produces this disease, though by some it is maintained that even the respiration of effluvia from putrescent substances produces malignant fever, with fetid eva- cuations and gangrenous patches on the skin. In the West of Scot- land, an instance occurred some years ago, in which several persons lost their lives from eating the flesh of dead animals which had been washed ashore. The occurrence of malignant pustule is rare in this country. Some time since, I met with a well-marked case in a shoe- maker, who had been employed in killing some sickly pigs. Whilst turning over and removing the abdominal viscera of one of them, he had scratched his finger slightly with a pin stuck in his jacket, and he then perceived that the contact of some putrid matter from the intestines caused great pain. On the third or fourth day after- wards, he presented himself with a malignant pustule formed on the hand between the fore and middle fingers. The pain was very in- tense, and the disease seemed to be fast extending. Active treat- ment was employed, and the patient had a speedy recovery. The disease generally attacks the hands, neck, face, or shoulders of butchers and others, who carry, or in some way deal in carrion. It has also taken place in consequence of the hand being introduced into the rectum — a veterinary method of removing scybala -r— of an animal labouring under putrescent disease. A pustule appears on the part affected, containing a serous or a dark-coloured fluid ; and the base ulcerates, extending through the skin to the subjacent parts; at first it is accompanied with a pricking sensation, afterwards the pustule enlarges and becomes brown, and the pain is burning and itching. The vesicle when opened, or when it has burst sponta^ neously, furnishes a few drops of red serum, and the pain is thereby relieved for a few hours. A hard, movable, and circumscribed tubercle forms, without alteration of the surrounding skin. The bottom of the sore is yellow, greenish, or livid, and the sensation is 17* 198 OF ULCERS OF THE GENITAL ORGANS, ETC. that of acute heat and erosion. Phlyctense spread around. The tubercle becomes black in the centre, and an eschar forms ; the pa- tient becomes irritable and languid. The gangrenous point begins to extend, and that alarmingly; great swelling takes place, elastic, red, and shining, more emphysematous than inflammatory or cede- matous. The burning pain is aggravated ; the patient has a feeling of weight and stupor; great constitutional disturbance follows, there is slow fever, with a small pulse, a dry and brown tongue, and un- quenchable thirst; a low muttering delirium ensues, and under these symptoms the patient soon sinks. After death, the fetid body swells rapidly. The disease sometimes terminates fatally in twenty-four hours or less; but- generally the patient's sufferings are more pro- tracted. In the treatment, superficial scarifications are of little avail. The only topical application which can be relied on is a powerful escharotic, applied freely to the part, and at an early stage, before swelling and constitutional affection have been added. By it the parts replete with virus, being immediately deprived of vitality, are soon thrown off. Thus the virulence of the poison is annihilated, it is rendered inert, and is concentrated in the slough, and the sur- rounding parts are stimulated, and receive vigour of action, which enables them to resist any further inroad, and to detach quickly the mortified substance. For this purpose, the most effectual and con- venient escharotic is the caustic potass, but the liquid muriate of ammonia may also be employed. The vesicle is opened, and the caustic applied to the exposed surface ; and, if necessary, the eschar may be afterwards divided, and the remedy reapplied. In the ab- sence of other escharotics, the actual cautery will prove a valuable substitute. After the separation of the slough, the sore is to be dressed with slightly stimulating applications. Bark, camphor, and mineral acids, are given internally, and the patient is enjoined a light diet, with a moderate allowance of wine. OF ULCERS OF THE GENITAL ORGANS, AND THEIR CONSEQUENCES. It were unprofitable to enter here upon the History of Venereal Affections, as it is a subject of no practical utility, still involved in uncertainty, and mystified by disputation. It wall suffice to dessribe the different forms of the disease, and state the treatment applicable to each. During the last century, and in the beginning of this, much greater ravages were produced by the disease than at the present time ; and though this may be, perhaps, partly owing to a change in the poison itself, it is mainly attributable to the mildness of the measures by which it has been, and is opposed. Every form of the affection, as soon as it appeared, was at one time opposed by a counter poison, mercury; and the practitioner relying implicitly on this mineral as a specific, and not being fully aware of its dangerous properties, con- tinued to gorge the system with the supposed remedy, subverting the constitution of his patient, making, in many cases, no impression on the disease, but still persevering in the use of poison equal, if not OF ULCERS OF THE GENITAL ORGANS, ETC. 199 more potent, than the one which it was intended to destroy. The change of treatment has been propitious to our science and to man- kind. But let it not be inferred, that mercury now is, or ought to be, entirely dismissed from the treatment of this disease, or from prac- tice generally: often no other means are effectual; but it should al- ways be prescribed most cautiously and sparingly. The effects of the venereal virus are divided into primary or local, and secondary or constitutional; and these present a great variety in their appearances, characters, and tendencies. They are sometimes modified by the constitution or by the remedies ordered in the first stage : but there can be no doubt that different poisons exist, pro- ducing distinct kinds of ulcers, which again are succeeded by differ- ent constitutional affections. The most common kind of sore is the simple ulcer, at first exca- vated, in consequence of the process of ulceration continuing : after- wards the ulceration stops, and granulations, somewhat fungous, supply its place, so that the surface is raised above the level of the surrounding parts, and has a smooth soft appearance ; there is no hardness of the edges, and there is no tendency to slough or extend by ulceration. Sometimes it commences in the form of a pustule, which soon gives way, discharging its contents, and leaving an ex- posed surface, in which the process of ulceration quickly proceeds; but often it arises from simple abrasion of the surface. Different forms of sores may exist on the glands and prepuce at the same time ; and it is maintained, that one sore may produce another of a different kind, and the same is asserted with regard to eruptions. The simple ulcer, as well as other sores, is produced by the contact of secretions, generally morbid, but often apparently healthy, with a susceptible surface. Sores, with eruption and sore throat, sometimes appear in one or both individuals immediately after marriage, and probably arise from the acrimony of the female secretions, causing tenderness and ulceration of the parts. The application of gonorrhceal matter readily produces the simple ulcer on the glans or prepuce, particu- larly if an abrasion or rawness existed ; and if the matter be allowed to remain on an unbroken surface, a pustule will form and ulcera- tion follow. From this latter cause numerous sores are produced, separated from each other by sound parts, and not extending into one continuous ulcer: and this condition may have been preceded, on the glans, by a rawness of the surface, and a profuse discharge, or by a herpetic eruption on the mucous lining of the prepuce. One man may be affected with gonorrhoea, and another with ulcer, from connexion with the same female, the same day or hour; and it is doubtful whether the effect is not similar, in both cases, viz., ulcera- tion ; for it is supposed that in gonorrhoea, the disharge in some rare cases proceeds from patchy ulceration of the mucous lining of the urethra, similar to the ulceration usually met with on the glands. In examining women who have communicated infection, very often no sores are found, and very little unhealthy discharge. In short, the simple elevated sore may arise from the application of secretions from an unbroken surface, from inoculation of matter from a similar sore, or spontoneously, from inattention to cleanliness. Sores with elevated 200 OF ULCERS OF THE GENITAL ORGANS, surface, more extensive than those of the glans or prepuce, occur on the skin of the penis and scrotum, or in the folds of the thigh; and in women they are often met with in the perineum, or the cleft of the nates. Sores of different kinds arise at different periods after the application of their cause, from a day or two to some weeks, or longer, but the usual time may be said to be from four to eight days. The duration of the simple elevated sore maybe modified by various circumstances —by the constitution of the patient, his mode of living, and the attention paid to the affected part. It seldom remains open above a few weeks, but occasionally it may be seen unhealed at the end of several months in those who lead careless and irregular lives. Such ulcers produce, as readily as any other sores, enlargement of the inguinal glands ; they are a source of irritation, the effects of which may be extended along the lymphatic vessels, to the cluster of glands through which the absorbents pass, so as to cause inflamma- tory action, ending in indurated enlargement; or venereal virus from the sore may be taken up by the lymphatics, deposited in the granu- lar structure, and produce a similar affection. Buboes thus caused are situated in the upper cluster or inguinal glands; if the lower cluster is affected, it is to be presumed that the cause is not in the organs of generation, but in some part of the inferior extremity. From the existence of bubo, nothing can be deduced as to the na- ture of the poison, or the probable effects to be produced on the con- stitution ; for enlargement of glands in the course of their lymphatics will occur from irritation, whether connected with a mild or malig- nant virus, or with one totally devoid of any poisonous quality. From the simple ulcer there arises a constitutional affection, in all respects resembling that which follows gonorrhoea (a disease which will be treated of under affections of particular mucous surfaces); but before attending to this, it will be proper to advert to another form of ulcer, which differs but slightly from the preceding in primary and secondary symptoms. It is a sore with a brown surface, either on a level with, or above the surrounding parts, with defined and elevated edges, with no cartilaginous hardness of base or margins, and with no tendency to spread either by sloughing or by ulceration. Such may occur in the same situation as the simple sores, but they often form on the other surface of the prepuce, or on the scrotum ; and are not unfrequently met with round the orifice of the prepuce, which is a most troublesome situation, as, in healing, they generally produce phymosis. Sores and fissures in this situation are very often kept up by the tense and irritable state of the aperture. The bubo which follows this differs from that caused by the simple sore, in having, after ulceration of the integument, a greater disposition to burrow ; and this tendency is more marked where mercury has been employed. From either of these forms of ulcer, it sometimes happens that constitu- tional affections arise, either during the existence of the sore, or some weeks after it has cicatrised. The usual secondary symptoms are those attendant on a papular eruption. There is fever, with pains referred to the head, to the joints, chiefly the larger ones, and to the chest, which latter symptom is sometimes attended with dyspnoea, This indisposition is followed AND THEIR CONSEQUENCES. 201 by the appearance of a papular eruption, termed lichen, on the face and trunk, the extremities being less thickly studded. The fever subsides in a great measure after the eruption appears and comes fully out; but fresh crops of papulse may appear, and, in this case, the fever continues little abated until the eruption begins to fade. The eruption consists, in the first instance, of simple elevations or pimples of a red colour, and these do not appear at once, but gra- dually : so that some have assumed the form of cones, with minute collections of matter in their apices, whilst others are mere elevations of the cuticle. When they fade the spots are of a copper tint, and become covered with thin scales, in consequence of the cuticle de- squamating ; but this latter appearance can never be confounded with the scaly eruptions following another description of primary sore. In all cutaneous eruptions, attended with any febrile action, there is a tendency to sore throat, with tenderness of the eyes; and this eruption is not exempt from a similar affection : the fauces feel raw and tender, and are pained in deglutition ; on looking into the throat, the mucous surface is found red and swollen, and the tonsils are generally enlarged ; but there is seldom any breach of surface ; and, when this does occur, it is rather entitled to the appellation of exco- riation than of ulceration. Occasionally the surface is covered with a thin coating of lymph, and sometimes this is confined to the situa- tion of the mucous crypts, so as to give a false appearance of small sores. As in a similar affection, unconnected with any discoverable cause, the lymphatic glands, at the angle of the jaw, are not unfre- quently swollen and painful. Such is the usually mild character of this affection ; but if its pro- gress has been interrupted by any means, more particularly by mer- cury, it assumes a more complicated form, and a less tractable nature. If that mineral is administered in the usual style, and at the com- mencement, when the fever and other symptoms are' high, the patient's sufferings are all much aggravated, After the fever has subsided, the eruption will often be found to disappear under the use of mercury; but it is extremely apt to recur, as soon as the sys- tem has shaken itself free from the effects of that medicine. The mercury produces an irritation, which supersedes the eruption, but by frequent repetition its effects on the system diminish: it at last fails to create an irritation more powerful than the disease to which it is opposed, and, consequently, the eruprion does not yield, but during its use is frequently reinforced by fresh crops of papulse. If the eruptive fever, and advanced stage of the disease, are imprudently and suddenly arrested by the use of mercury, by exposure to cold, or by other means, inflammation of the iris or joints often follows, of a very violent form, and not to be easily moderated. No one thinks of repelling measles or other eruptive diseases, and with good reason, for such practice would almost certainly induce serious affections of internal organs. _ For the same reason, every precaution must be used to allow this form of eruption to take its own course, while we merely regulate the constitutional symptoms as they obtrude. Another form of eruption, which occasionally, though much less frequently, results from either of the above mentioned sores, is the 202 OF ULCERS OF THE GENITAL ORGANS, pustular. It is preceded by fever, and consists of rather large pus- tules, separated from one another, and not very numerous. After their apices give way, and the contained pus is discharged, a thin scab is formed, and on its separation a small ulcer is left, which in general soon heals from its margins, leaving a dark-coloured spot to mark its situation. The papular and pustular eruptions are some- times blended ; a few pustules appearing amongst numerous papulse, or vice versa. The pustular disease is not of frequent occurrence ; and in proportion as it approaches the papular, with desquamation, it becomes milder and more easily removed. In it, as in the papular, mercury proves injurious. The phagedenic form of ulcer is the most dreadful and unmanage- able of all; most uncertain in progress, and direful in event, and often rendered still more destructive by the mode of treatment adopted. Fortunately, it is now seldom seen, though not long ago it was well known, as a perpetrator of dreadful havoc, under the name of black pox. It is a corroding ulcer, without hardness of the surrounding parts, presenting no appearance of regeneration of the tissues which have been destroyed. It may follow either upon a pustule or an abrasion. Sometimes it destroys the prepuce and glans in a few days, or again, when chronic, it spreads deceitfully, healing at one part and destroying at another. The ulceration is often deep, penetrating the corpora cavernosa, or the corpus spongiosum urethras: in such cases it is followed with violent hemorrhage, which often produces a great and sudden improvement in the sore. After slow cicatrisation it not unfrequently happens that the scar gives way, and the ulceration returns. Sometimes another character is given to the sore, by the rapid sloughing of the parts. In this modification, a small black spot is first observable, unattended with pain: it enlarges rapidly, and, after no long time, the mortified part separates, exposing an unhealthy surface, which is immediately attacked and progressively destroyed by phagedena. The part may again slough, and, by an alternation of mortification and phagedenic ulceration, the external organs of generation, male or female, may be wholly destroyed. In the present day, however, its ravages are much less extensive and more easily combated than formerly, and it seldom, if ever, proves fatal. One very troublesome case is in my recollection, where the patient suffered two attacks at the interval of two years. During the pro- gress of the disease he was seized with delirium tremens; a bubo formed and ulcerated; a violent hemorrhage occurred from the sore; sloughing and phagedena alternated; and both prepuce and glans were entirely lost. An eruption followed, accompanied with ulcer- ation of the throat and nostrils. He recovered much mutilated. Ulcers originally of a simple character may become affected with phagedena, or sloughing, from the state of the constitution, from mismanagement, or from exposure to an unhealthful atmosphere. But in such cases, after the separation of the slough, the exposed surface is found to be of a healthy granulating character, contrary to what is observed in the originally phagedenic disease. Buboes, AND THEIR CONSEQUENCES. 203 when they occur, have the same malignant action as the primary sore: the breach of surface is extended either by sloughing or by phagedenic ulceration, and the edges of the sore are ragged and undermined. The secondary eruption which follows the phagedenic form is pustular, though differing from that which has been already noticed. The pustules soon give way, and ulcers remain, covered with thick scales or crusts, which sometimes increase, layer by layer, so as to become prominent, dense, and of a conical form, — the rupia promi- nens. After the separation of the crusts the ulcers are found, super- ficial, rather unhealthy, and showing a disposition to extend, chiefly towards the circumference. When healing, the process of cicatri- sation frequently proceeds from the centre of the sore, which is still enlarging at its circumference. The reason for this unusual mode seems to be that ulceration does not commence in the secondary sores till the crusts which cover them have been removed: they then are very superficial, not extending through the thickness of the true skin; and the ulceration does not go on in the centre of the original sore, but towards its margins, so that a portion of true skin remains in the centre of the sore, whilst it is gradually destroyed towards the margins. Then, whilst the surrounding skin, which usually forms the new cutaneous texture necessary for reparation, is gradually and progressively destroyed, the remaining old skin in the sore assumes an excited action, as in ordinary cases, and from it the requisite new texture is formed, and gradually extends over the surface, until it meet with a similar substance, which has been produced by the sur- rounding skin after the ulceration in that quarter has ceased. Thus the general principle that skin is formed by skin is, even in such instances, found to be correct; the healing from the centre not fol- lowing, as some have supposed, the complete destruction of the cuta- neous tissues, but from its having remained unaffected, or nearly so. The appearance of the eruption is preceded by general indisposition, and occasionally by smart fever. It is sometimes extensive, but is in general confined to the upper parts of the body. Ulcers of the throat occur, of a very alarming kind, quickly de- stroying the parts attacked, spreading chiefly towards the posterior part of the fauces, rapidly extending to the pharynx and to the nostrils, and in some instances also involving the larynx. The pendulous velum of the palate and the tonsils are often wholly destroyed, the bones of the nose, more especially the turbinated, are deprived of their coverings, and exfoliate, the osseous and cartilagi- nous portions of the septum are discharged, and the nose becomes sunk, or is supported merely by the columna. The patient's breath is fetid, respiration is in some degree obstructed, a foul ichorous dis- charge flows from the nares, and the surrounding parts are inflamed, swollen, and excoriated. The countenance is greatly disfigured. On looking into the throat, nothing is seen but an extensive ulcerated surface covered with white adherent matter, and exhaling an offen- sive fetor, particularly when the bones are affected. Respiration is nasal, and the speech indistinct. When the larynx becomes affected, the patient may be almost considered as lost: phthisis laryngea is 204 OF ULCERS OF THE GENITAL ORGANS, established, the symptoms and treatment of which will be afterwards mentioned. The mutilating affection of the nose dose not seem to be produced by any other form of the venereal disease, if not in any way aggravated. Along with the eruption and its after effects, severe pains in the articulations, particularly in the knee-joint, often occur, and are always much increased during the night. Nodes seem to be produced only in those cases in which mercury is exhi- bited ; their most usual situation is on the fore part of the tibia ; severe pain is felt in the part, which becomes slightly swollen, and of a bright red colour; the swelling feels dense and firm, being a simple enlargement of the bone. They often occur when the patient is taking mercury, and when, in fact, the constitution is completely saturated with it. This medicine may interrupt the progress of the disease, may remove the eruption and the ulcers of the throat, but it at the same time transfers the disease to deep unyielding parts, to the bones and their coverings, and the fasciae. The last distinct form of the venereal disease is the scaly syphilis, or true pox. The primary sore, termed a chancre, " is somewhat of a circular form, excavated, without granulations, with matter adhering to the surface, and with a thickened edge and base. The hardness or thickening is very circumscribed, not diffusing itself gradually and imperceptibly into the surrounding parts, but terminating rather ab- ruptly." Such is the appearance generally presented by the sore when situated on the glans and prepuce. It generally commences in the form of a pimple, without much surrounding inflammation. Sometimes the ulcerated surface is veryr inconsiderable, but there is always the abrupt and remarkably dense thickness which serves as a distinguishing mark. The non-syphilitic ulcers may have surrounding hardness from the first, or in consequence of the application of stimu- lants and escharotics; but this is diffused into the neighbourhood, and is not, it is said, of that remarkable solidity peculiar to chancre. It is seldom that more than one chancre occurs : the usual situation is on the glans and lining of the prepuce ; but they occasionally form on the outer surface of the prepuce, and on the dorsum penis. In the latter situation the sore assumes a somewhat different appearance: it is, in general, larger, the hardness of the base is not so great, the excavation is less, and the surface is of a livid hue. When allowed to proceed uninterrupted, the livid surface is alternated with that of a light brown or tawny colour. Chancre is an indolent ulcer when compared with the phagedenic or sloughing sore, the ulceration pro- ceeds very slowly, and, in proportion as it advances, the surrounding hardness increases. It is also contumacious and obstinate in taking on any reparative action. Phymosis occasionally takes place, in consequence of chancre situated at the orifice of the prepuce, but not so frequently as when that situation is occupied by superficial sores of a more active nature. Bubo sometimes appears in both groins, or in one ; sometimes on the same side with the sore, often on the oppo- site, and not unfrequently when the sore is healing, or after it has healed. It may suppurate and give way, or may subside without having advanced to suppuration. It differs in no respect from the swelling of the glands from other causes, either in its swelled or open AND THEIR CONSEQUENCES. 205 State. Neither does the occurrence of a bubo render it more proba- ble that constitutional symptoms will follow. Enlargement of the glands is often caused, or at least hastened, by the patient continuing to walk about and exert himself during the existence of a sore, and whilst the absorbents are in an irritable state ; but a bubo may be caused by irritation or excoriation in any way produced ; and it not unfrequently occurs without any apparent cause. In some cases of chancre or other ulcer, the absorbents along the dorsum penis become swollen, and occasionally suppurate. In former times, it was not uncommon for the surgeon to insist that all swellings in the groin were venereal, though no primary sore had ever existed : the virus was said to be absorbed from an unbroken surface ; the patient's system was saturated with mercury ; and the use of that medicine was persevered in, with the view of opposing those symptoms of a ruined system which itself had produced. Such delusions have now happily passed away. The eruption which follows the chancrous form of primary sore is scaly from the commencement, and by this character is readily dis- tinguished from every other venereal affection. It is generally pre- ceded by an efflorescence or discoloration, rendering the skin of a mottled appearance. The scaly eruption is a form either of lepra or of psoriasis. The patches usually do not exceed a sixpence in size, are distinct and separate from each other; their base is of a dark red or coppery hue, the affected skin is not hard or rough, but soft and pliable, and seldom covered with crusts ; as they extend, the edges are slightly elevated at the centre, which alone is covered with thin white scales, appears flattened and somewhat depressed ; when they begin to fade, the margins shrink and become paler, and de- squamation proceeds slowly ; a circular, purplish-red discoloration, with a central depression, remains for some time after the blotches have declined : the depression is permanent, but the discoloration disappears. The smaller patches, which assume a variety of forms, continue for some time of a dark colour, extend towards the circum- ference, become pustular, and at length ulcerate superficially, enclos- ing an area of sound skin. When depressions of the skin, as the folds of the nates, are affected, a scaly eruption does not take place, but soft and moist elevations arise, discharging a whitish matter, varying in form and size, and accordingly receiving various appella- tions, as condylomata, fici, or marisci. From them a secondary form of disease is occasionally communicated. If no decided treatment is resorted to, and if the eruption is consequently permitted to follow its own course, thick crusts form, ulceration proceeds beneath them, the matter is confined, and the patch becomes prominent. Another secondary symptom of chancre is ulceration of the throat, sometimes extensive, but generally situated in the tonsils, or their immediate neighbourhood. The ulcer is not preceded by much pain or swelling : "it is a fair loss of substance, (part being cut out, as it were, from the body of the tonsil,) with a determined edge, and is commonly foul, with thick matter adhering to it, like a slough, which cannot be washed away." Such ulceration may be simulated by excavated sores attending the phagedenic form of disease ; and it oupbt to be 206 OF ULCERS OF THE GENITAL ORGANS, more especially distinguished from an affection to which the tonsil is extremely liable,irregularity of its surface, enlargement, and effusion of lymph, in consequence of chronic inflammation. A more serious part of the secondary disease is affection of the deep-seated parts, ligaments, periosteum, and bones. The bones nearest the surface are principally affected: a swelling gradually forms on the tibia or ulna, without discoloration of the integuments, and without pain occurring till after a long time. The pain is most severe during the night. The inflammation of the periosteum is often very violent, the subjacent bone, as in the head or extremities, be- comes dead, and exfoliates ; but it remains to be seen whether this will take place when mercury is more sparingly, if at all, administered. Ulcers betwixt the toes, occurring along with the above symptoms, are supposed to be venereal: they are unseemly, and peculiarly fetid. [The above symptoms, together with deep-seated tubercles of the skin and mucous membrane, constitute what Mons. Ricord has lately described under the name of tertiary syphilis. They seldom make their appearance under fifteen or eighteen months after the formation of primary sores, and some cases occur even after the lapse of many years. From two to three years may perhaps be considered as the average period for the development of the tertiary form of the disease. This, however, is still an unsettled point.] Such are the affections, local and constitutional, arising from a venereal cause; but the latter may be simulated. Many affections of the skin, mucous membranes, and bones, resembling the venereal disease, may be produced by disorder of the constitution, by a decay of the digestive organs, by unwholesome food, and exposure to in- clement weather, by inattention to cleanliness, and many other cir- cumstances. Morbid poisons, not venereal, but of various kinds, may exist, and cause much mischief. A disease resembling syphilis was produced by the cruel practice of transplanting teeth from sound people into the jaws of persons in the higher ranks of life, whose corresponding teeth were decayed. The latter were the affected party, and that justly. A very infectious disease was at one time common in the poorer parts of Scotland, and known under the name of sibbens, or sivvens, chiefly occurring amongst the poor, ill-fed, badly-clothed, and worse- housed people in the Highlands. It was communicable by very slight contact by kissing the lips of an infected person, smoking the same pipe, drinking out of the same cup, or using the same spoon. Cases of it are still occasionally seen. There are ulcers of the lips, mouth, throat, and nose ; ulcerated patches and warty excrescences in the cleft of the thighs, in the axilla, and round the anus and pudenda. A pustular eruption appears, and terminates in hardened crusts. The same disease is known in Ireland, under the name of button-scurvy; and a similar one, called raddesyge, has been described as occurring on the sea-coasts of Norway and Sweden. In Canada, also, some- thing of a like nature was at one time prevalent. The yaws, at one time common and destructive in the West India Islands, appear to be much of the same nature. Some of these diseases, more particularly AND THEIR CONSEQUENCES. 207 sivvens, are very common amongst children. Even in these days children are not unfrequently born with copper-coloured blotches of the skin and desquamation of the cuticle; or they may come into the world with these appearances, along with affections of the mucous membrane, hoarse voice, redness round the anus, &c. These are forthwith attributed to a syphilitic taint existing in either of the parents; and one or both are put under mercury; but child after child comes into the world in the same plight. Again, the disease is communicated by children to the nurses, and vice versci. All these affections are rendered much more obstinate by full courses of mer- cury: the bones and ligaments become affected in consequence ; but small doses of that medicine may prove useful towards the decline of the disease. Some have believed mercury a certain test of syphilis ; maintaining that the disease, still checked by the specific, is never overcome by the constitution; that it is unchangeable, and regularly and progres- sively growrs worse, where no mercury is employed ; that, opposed by that medicine, it is stationary, and is permanenly cured by ade- quate mercurial influence on the constitution. Whatever were the appearances, if they went off under mercury, the advocates for this practice set them down as those of syphilis, lues, or pox. If they did not yield to that mineral, they were termed syphiloid, pseudo- syphilitic, or mercurial; for they did admit, now and then, that their favourite remedy produced unpleasant effects. Such theory and practice are now very happily exploded. As to the treatment of local venereal affections, it may be, in the first place, remarked, that prevention is better than cure. The means employed for accomplishing this end are very various: oily applica- tions, alkaline and spirituous washes, &c, with a view either of pre- venting the matter from coming into contact with the genitals, or of completely removing it, when it has been but a short time applied. There is one certain method of avoiding disease, which it is unneces- sary to mention. In all affections of the penis, it is of the utmost im- portance to keep its extremity bound up to the abdomen, in order to prevent congestion or inflammatory swelling. Celsus knew this well; " Sursumque coles ad ventrem deligandus est, quod in omni curatione ejus necessarium est;" rest and quiet must be strictly observed; the patient must be confined to the recumbent position, particularly when the sore is irritable, when swelling or bubo has occurred oris threat- ened ; and when the system is excited, and the eruption has com- menced, the bowels must be kept gently open, the patient's diet must be low, and the parts surrounding the sore are to be kept carefully clean. Whatever the nature of the ulcer may be, it is safe and pru- dent, in the first instance, to change its action by the use of the nitrate of silver, or to destroy the surface by the free application of escharo- tics, as nitric acid, or solution of nitrate of mercury: the morbid poison is thus got rid of, and the surrounding parts stimulated to a proper degree of action. This is absolutely necessary in the phage- denic form of ulcer, whether of an acute or chronic nature. But, in most cases, the patient does not apply for medical assistance till the sore has been of so long duration as to preclude all hope of counter- 208 OF ULCERS OF THE GENITAL ORGANS, acting the virus by any local application. The simple superficial sores, and those with elevated margins, must be treated on the same principles as if they were totally unconnected with any specific cause; and the applications must be varied according to the peculiarities of the part affected, and the different appearances which the surface as- sumes, during the progress of cure. Lotion is the form of application found preferable in most cases, and may consist of calomel and lime- water, with mucilage, called the black wash ; of muriate of mercury, with lime-water, called the yellow-wash ; of a solution of sulphate of zinc, with spirit of a solution of nitrate of silver, or of sulphate of copper. The linimentum seruginis or Barbadoes naphtha, are often useful in foul sores. Ointments, if at all, ought to be used sparingly, The application of dry lint, or the sprinkling of a little fine powder, is often all that is requisite. Of course these applications must be varied, according to the particular circumstances of each case. Buboes are to be treated in the same way as any other inflamma- tory swellings ; local means being taken at the commencement to subdue the inflammatory action, and resolve the swelling. Rest is indispensable. When they are stationary, the application of a blis- ter will either cause resolution or suppuration, and so the enlarge- ment will be got rid of, either in the one way or the other. The painting of a rubefacient solution of iodine occasionally on the swell- ing is also useful, and preferable to friction with iodine ointment. When they have passed into a decidedly chronic state, absorption may be promoted by pressure, or, again, means must be taken to hasten suppuration, and the matter which forms is to be early evacu- ated. If suppuration occur in the cellular tissue, and not in the sub- stance of the enlarged gland, neither cicatrisation, nor a permanent cure, can be expected until the prominent and indurated parts have been destroyed by the caustic potass. In phagedena, bread and water poultices or tepid-water dressing are, in the first place, to be applied, and the pain and irritation may be soothed by solutions of opium, or extract of poppy. If bands of skin intersect the ulcerated parts, they are to be divided, as being a source of irritation which prevents healing. If the frsenum prseputii be surrounded by ulcera- tion and undermined, it must be incised for a similar reason. It is often advisable, also, to divide the prepuce. After the process of destruction has ceased, gently stimulating washes will promote con- traction of the sore. It is an important fact, that the majority of primary ulcers can he made to heal without mercury. Cavillers object to the mercurial washes, supposing that they may act by affecting the constitution. The sores with hardened edges, chancres, heal as well as others, when mercury is not employed, but much more slowly. In some mercury is injurious: in chancres it promotes the cure. In any case I would never think of ordering it, unless the progress were very tedious, the ulcer being indolent and contumacious; then mercury may be advantageously used, and moderately continued until the callosity disappear. It is no easy matter to say, judging from the appearance of the ulcer, whether secondary syphilitic symptoms are likely to arise in consequence of it or not, or'what their nature may AND THEIR CONSEQUENCES. 209 be should they occur: they follow upon sores of all characters, and, again, do not appear after what might be set down as the genuine Hunterian chancre. Whatever the nature and appearance of the ulcer may have been in the first instance, should it become station- ary, and show no disposition to heal under local means, mercury may then be given cautiously, and with advantage. Considering that very obstinate sores are now seldom met with, it would seem that very little mercury is required in the treatment of primary vene- real ulcers. During the progress of acute inflammatory action, this medicine should not be given for the primary affection, whatever the nature of the ulcer. Mercury cannot prevent constitutional affections. Constitutional symptoms do not often occur, taking place scarcely in one case out of a hundred of all the forms of sores which present themselves. In the papular form mercury is hurtful, as already re- marked ; it interferes with the natural and mild progress of the affec- tion, frequently gives rise to iritis, and produces pains of the joints and bones. The powers of the constitution, aided by simple reme- dies, are sufficient: the cure may be tedious, but cannot be destruc- tive. Whereas, if mercury be considered as the only specific, its use will be long continued; it will frequently be resumed after it has been dispensed with on the supposition that the virus is destroyed ; and by the effects of excessive mercurial irritation, combined with those of the disease, tampered with and aggravated, the patient may ultimately perish. The fever, which precedes and attends the erup- tion, must be moderated by depletion, antimonial medicines, and purgatives ; but depletion ought not to be carried far, lest the erup- tion be thus checked and disappear; and the patient ought to be carefully removed from external circumstances which might produce a similar effect. After the eruption has come fully out, and the febrile symptoms subsided, it will be sufficient to attend to the gene- ral health, and employ the decoction of sarsaparilla, a medicine which excites the secretions, and more especially promotes diapho- resis. In short, the treatment may be said to consist in allowing the disease, in a great measure, to follow its own course, taking mea- sures to prevent it from being interrupted, and merely moderating such violent symptoms as may precede or accompany it. In the pustular form of eruption the general treatment is the same as in the papular. Mercury is hurtful, and increases the tendency to burrow. When the surface is nearly covered with pustules and ulcers in all stages, desquamation may be hastened by fumigations of sulphur, the general sulphur baths, lotions of sulphuret of potass, nitro-muriatic baths, vapour baths, or by smearing the affected sur- face with equal parts of tar and sulphur ointment. In phagedena the patient ought to be, if possible, placed in an airy and healthful situation. In most cases free blood-letting may- be necessary at the commencement, and will be advantageously fol- lowed by purgatives and antimonials. The patient ought to be strictly confined to his room, and ordered low diet with diluents, Afterwards, the internal use of nitric acid, the decoction of sarsapa- rilla, and an occasional dose of Dover's powder at night, will be 18* 210 OF ULCERS OF THE GENITAL ORGANS, beneficial, particularly if sleep be disturbed with pain of the bones and joints. Mercury, even in small quantities, protracts the disease, and in large doses it hastens the ulceration and sloughing. When all febrile symptoms have subsided, when the ulcers are nearly healed, when no fresh pustules appear, and wrhen desquamation is begun, alterative doses of mercury, as a blue pill or gray powder every second night, may sometimes be ventured upon, will tend to hasten the cure, and will not, possibly, be followed by any unpleasant symp- toms. The safe course is to promote the secretions by some safe substitute—preparations of sarsaparilla, ipecacuanha, taraxacum, &c. In fact, in all scaly eruptions, whether scaly from their commence- ment, or having become so in their latter stages, and previously to their disappearance, mercury, prudently administered, will be useful by expediting the cure, and not injurious by deranging the system. The tar or citrine ointments may be applied to the eruptions and cu- taneous ulcers. For the ulcers of the throat, unless in a sloughing state, the lunar stone appears to be almost a specific, removing the irritability of the sores, and protecting them from further irritation by coagulating the discharge, which then more effectually covers and protects them. The application requires to be repeated every second or third day, as, by the frequent and necessary motions of the parts, the crust loosens and separates, leaving the surface exposed and irritable. At the same time the sore will contract very considerably under each successive crust. The lunar stone may also be applied in solution ; or a solution of the bichloride of mercury in spirits or laudanum may be used, in the proportion of from four to six grains to the ounce, or stronger. The solution of the nitrate of mercury is sometimes employed with advantage. Fumigation of the throat with the red sulphuret of mercury has been extolled as a powerful means of check- ing the alternating sloughing and ulceration wdiich often accompany the ulcers of these parts, but the propriety of its employment is doubtful; the system is thereby rapidly put under the influence of the mineral, which, as already remarked, generally aggravates the violent disturbance under which the constitution labours. More permanent good may be expected from means taken to remedy the constitutional evils than from such violent remedies as are directed against the affected part, but which also produce a baneful effect on the system. In ulcers of the nostrils, with fetid discharge, snivel- ing, exfoliation of the inferior spongy bones, affections of the palate, &c, the nitrate of silver is also very efficacious ; or the affected parts may be occasionally touched with a hair pencil, dipped in a liniment composed of lime-water, olive oil, and the golden ointment. They ought to be frequently washed with tepid water, and all sources of irritation must be removed. If the patient be in the habit of taking snuff, the practice must be abandoned, and the powder al- ready impacted in the nostrils removed. If there be carious teeth or stumps in the upper jaw, the sores can scarcely be expected to heal till these be extracted, as constant irritation is kept up by them. When the affection proves obstinate, a recourse to mercury is recom- mended by some writers ; but this will make bad worse. Sarsapa- AND THEIR CONSEQUENCES. 211 rilla in these cases, with attention to diet and air, will always prove a better alterative than any form of mercury. It may be combined, according to circumstances, with the nitric or nitro-muriatic acids, or with the hydriodate of potass, in which many practical men have greatfaith. This medicine is employed in cachexia, following or not the use of mercury, and is directed against eruptions, sore throat, and pains in the limbs. The constitutional symptoms of the scaly disease, or true pox, when they occur, which is now but seldom, are decidedly benefited by a prudent employment of mercury. It may be administered exter- nally or internally, though the latter method is the one generally adopted. It may be introduced into the system under various forms, according to the particular circumstances of the case, or the ideas of the practitioner. The most common form, and the simplest, is the pil. hydrargyri; but for this may be substituted hydrargyrum cum creta, Plummer's pill, or calomel with antimony. In painful affec- tions of the bones, with or without swelling, the muriate of mercury (bichloride) is the form which I have found most efficacious; one- eighth of a grain of the muriate being given thrice a day in a pill; or the medicine may be given in solution. The iodide of mercury is also a very useful medicine in some cases. It is impossible-, and would be absurd, to lay down any precise rules as to the quantity of mercury which is necessary for the cure of pox ; in some patients the system is with difficulty put under its influence, whilst in others a single grain will produce salivation, constitutional disturbance, and eczema. When the mouth becomes affected the mercury ought to be discontinued; much harm and no good resulting from the medicine being pushed to profuse salivation ; the tongue swells hideously, the teeth loosen, and portions of the jaw die and ex- foliate. It is sufficient that the system be under the influence of mercury ; and that circumstance is marked by the tenderness of the gums. If, after the medicine has been disused, the disease does not appear to recede, it may be resumed in the same moderate way as before ; but there certainly can be no use in continuing mer- cury after the symptoms of venereal affection have ceased. Nodes may still exist, portions of bone may be dying, abscesses forming, and various other changes of structure going on, but these are no reasons for a continuance of the mercury. If they have originated from the venereal affection, that cause has been removed, and the diseased actions will now proceed altogether independently of their original cause. Mercury proved beneficial in removing a disease of which they are not a part but a consequence ; and, if that medi- cine be now blindly persevered in, the only effect will be to ruin the constitution, and thereby greatly retard the cure of those affec- tions, which, if the natural powers of the system had been merely supported, or in a great measure left to themselves, would have soon ceased to annoy the patient or alarm the antisyphilitic mercu- rialist. Slight swellings and pains of the bones often yield to local ab- straction of blood, friction, and the internal use of the compound decoction of sarsaparilla. Nodes, however, sometimes continue to 212 OF ULCERS OF THE GENITAL ORGANS, enlarge, and occasion much pain, notwithstanding these means ; and in such circumstances much relief will be afforded by airee in- cision over the affected part, from whatever cause the swelling may proceed. When the pain has subsided, and the swelling remains stationary, a decrease of it may be sometimes effected by a blister. [It is somewhat surprising that the author has made no mention, in connexion with this subject, of the iodide of potassium, so justly lauded by Mons. Ricord and some other French surgeons. For the last two years or more I have been constantly in the habit of em- ploying this article in tertiary syphilis, in mercurial disease of the bones, and in chronic rheumatism, in which, I am convinced, it is as much of a specific as quinine is in intermittent fever, and miasmatic neuralgia. The medicine, to produce its full effects, should be administered in much larger quantities than are recom- mended in our treatises on the Materia Medica. In my own prac- tice, I usually commence with ten grains repeated three or four times a day, and gradually increased until it amounts to a scruple, or even half a drachm. Exhibited in doses of this size, it- is truly surprising how rapidly, in most instances, it affords relief. Patients who have laboured under nodes and nocturnal pains for months, whose health has become greatly impaired, and who have not slept soundly perhaps for weeks together, have often perfectly recovered under this treatment in less than a fortnight. A very de- cided improvement generally takes place within the first forty-eight hours, the local uneasiness diminishing, and the sleep being ren- dered more refreshing. The medicine should not be laid aside as soon as the patient experiences relief, but be continued for several weeks after the symptoms of the malady have subsided. By ne- glecting this precaution a relapse will occasionally occur. The best vehicle for it is distilled water with a small quantity of simple syrup. Mons. Ricord administers it dissolved in hop-tea, made with an ounce of hops to a pint of boiling water ; this is allowed to stand for four hours, when thirty-six grains of the salt are added, and the whole drunk during the course of the day. When given in the large doses above mentioned, it is said to be sometimes productive of diarrhoea or gastric irritation ; but no such effects have followed its employment in my own hands, and I presume therefore that they are exceedingly rare. Should they take place, the quantity must be lessened, or the medicine entirely suspended for a few days. In obstinate cases of tertiary syphilis it may be necessary to ex- hibit along with this medicine the compound decoction of sarsapa- rilla, or some of the preparations of mercury, such as the proto- ioduret, deuto-chloride, or cyanuret. The first may be given in doses of from one-half a grain to a grain, the second, from one- eighth to a fourth of a grain, and the last, from one-sixteenth of a grain to a grain, twice or three times a day. How the iodide of potassium acts in producing its beneficial effects in the dis- eases in which it is now so extensively used by our French brethren as well as by some of the practitioners of our own country, has not yet been explained. That it is a powerful alterant must be ad- AND THEIR CONSEQUENCES. 213 mitted, and that it greatly improves the condition of the digestive organs is equally certain. Of the bad effects of mercury on the constitution much might be said. Treatises have been written on mercurial pox, a species re- ported to be much the most violent; and others have detailed an accumulation of evils, under the title of mercurial disease. There is no doubt that extensive, deep, and sloughy ulcers of the throat are produced by mercury ; and of this I witnessed the following un- exceptionable instance: — The fauces presented one extensive mass of ulceration, sloughing at its margins, and the uvula was almost detached. The patient was an old and emaciated woman, who neither had, nor could be supposed to have, any venereal com- plaints. She employed herself in coating mirrors with quicksilver. and to that she ascribed her malady. In fact, her system had been long under the influence of mercury, in consequence of her occupa- tion. When I visited her, her daughter and husband, the latter of whom was paralytic, and almost bedridden, were affected, from the same cause, with a pustular eruption of the face, with disease of the nostrils, and snivelling. Another old woman had numerous and deep ulcers of the fauces, tongue, and lips, having been kept unmercifully under mercury for nine continuous months. She had, besides, taken it from time to time, for upwards of four years, though her sole com- plaint was slight sore throat. Pains of the joints, too, I believe, are attributable to the use of mercury. That medicine has no power to prevent the occurrence of nodes, for these often form during its action. Affections of the periosteum are very frequent in horses and other lower animals, and also easily excited in some human sub- jects who have neither had pox nor been put under mercury ; but in no instance of venereal disease have I observed serious affections of the bones wdiere mercury had not been given. Even the advocates for mercurialising speak of mercurial nodes. It has been asserted that nodes do not occur when mercury has been given for liver or other complaints; but they do form under such circumstances, though not so frequently as when the medicine has been exhibited during venereal symptoms. A cachectic state is often induced by a continued use of mercurial preparations, or at least by mercury and disease together, in constitutions not originally strong. It is marked by pale lips ; bloodless conjunctiva ; a rough anserine skin ; a relaxed state of the mucous membranes ; hemorrhages from these, particularly from the gums, which may prove fatal, as I have my- self witnessed ; exfoliations of the alveolar processes ; slimy stools ; pale urine ; pains of the limbs ; sores, showing great indolence, or even assuming malignant action ; dropsical symptoms, and other evils, of which a lengthened catalogue might be made out. Such symptoms were often met with when mercury was exhibited for every trifling or suspected sign of disease arising from carnal con- junction. On this subject, Mr. Samuel Cooper has well remarked : " Experience has fully convinced me, that in no forms of chancre, nor in any other stages of the venereal disease, is it proper to exhibit mercury in the unmerciful quantity, and for the prodigious length of time, which custom, ignorance, and prejudice, used to sanction in 214 OF SCALDS AND BURNS. former days. Violent salivation ought, at all events, to be for ever exploded. When I was an apprentice at St. Bartholomew's Hospi- tal, most of the venereal patients in that establishment were seen with their ulcerated tongues hanging out of their mouths, their faces prodigiously swelled, and their saliva flowing out in streams. The wards were not sufficiently ventilated, and the stench was so great, that the places well deserved the appellation of foul. Yet, notwith- standing mercury was thus pushed (as the favourite expression was), it was then common to see many patients suffer the most dreadful mutilations, in consequence of sloughing ulcers of the penis; other patients, whose noses and palates were gone ; others who were co- vered with nodes and dreadful phagedenic sores." This woful pic- ture is not exaggerated, and cannot be too strongly impressed on the minds of young practitioners. A small quantity of mercury will affect violently some constitutions ; as of those who have been in warm climates, or who have taken much of the drug, even in this country. Eczema Rubrum, a disease resulting from external causes, but which may also be produced by mercury, often arises from but a very small quantity of that medicine even applied externally. It most frequently affects the scrotum and upper and inner parts of the thighs. It is preceded by heat and itching in the part; a diffused redness appears, and the affected surface is rendered rough by the eruption of numerous minute vesicles. In a short time, these vesi- cles, if not ruptured, attain the size of a pin's head, and the included serum becomes opaque and milky. The affection soon extends over the rest of the body in successive large patches, and is accom- panied with considerable swelling of the integuments, tenderness of the skin, and itching. The vesicles burst, and discharge a thin acrid fluid, which renders the surrounding surface painful, inflamed, and excoriated. The discharge becomes thicker, adhesive, and fetid, and by its drying, partial yellowish incrustations are formed. The disease terminates in desquamation, and in some cases, the hair and nails are also lost. It is preceded and accompanied with smart fever, and general disorder of the system. Erethismus is another occasional consequence of mercury, cha- racterised by remarkable depression of strength ; small, quick, and often unequal pulse ; anxiety, sighing, and trembling; a pale con- tracted countenance, and occasional vomiting. While in this state, sudden exertions are apt to prove fatal. OF SCALDS AND BURNS. Different degrees of injury are inflicted on the surface from the application of heated solids or fluids. The term scald is generally confined to the effects of heated fluids, whilst burn denotes the con- sequences of the application of a heated solid, or of ignited com- bustible matter; the latter class of accidents is, in general, the more serious, yet the former, though not injuring the skin deeply, gives rise to the most alarming symptoms when a large extent of surface OF SCALDS AND BURNS. 215 is affected. A slight degree of heat is productive only of redness of the surface, with a sharp hot pain, and these symptoms may sub- side with or without vesication. However, effusion of serum under the cuticle often takes place almost immediately after the contact of the heated body — the cuticle may be destroyed by the intensity of the injury — or the true skin may die, either partially or throughout its whole thickness, and the subjacent parts be at the same time in- jured to a greater or less depth. But parts, not severely injured at first, may afterwards perish, violent inflammatory action being ex- cited, which terminates in sloughing. The neighbouring parts have their vitality much diminished, by the direct influence of the injury; and hence, when these parts come to be the seat of increased action, sloughing almost inevitably ensues, from the want of corresponding power. From the same cause, subsequent sores are tedious in heal- ing, being so far debilitated as to be unable to assume full vigour ; even slight ulcerations following vesication contract very slowdy ; the granulations are flabby, and the discharge profuse and thin. The inflammation is often at first very violent, and kept within bounds with difficulty. Burns of the trunk, particularly of the genital or- gans, are to be considered as attended with much danger. And ex- tensive burns and scalds, wherever situated, are always to be dread- ed. Violent constitutional irritation takes place, dyspnoea is apt to occur, with effusion into the chest of serum, or a sero-purulent fluid; and the nervous system ultimately becomes oppressed. Great sink- ing of the vital powers is generally the immediate consequence of extensive and severe burns ; there is shivering, weakness of the pulse, cold extremities, anxiety, and vomiting, requiring the exhibi- tion of warm drinks, and even sometimes of cordials, opium, or strong stimulants. These must, however, be given with a sparing hand, or the depression following the excitement is with difficulty got over. Nor can it be matter of surprise that such serious effects occur, when we reflect on the extreme sensibility, and highly or- ganised state of the affected part, and the important functions which it is intended to perform, as well as those sympathies which it holds with internal parts, on which life principally depends. In trifling burns cold applications are generally used — as im- mersing the part in cold or iced water. A great variety of remedies are employed, spiritous, watery, acid, alkaline, cold or hot; some apply a coat of cotton or flour, some of tar or pitch, and they state that when these artificial crusts separate, the skin is found healed beneath ; in fact, every practitioner, and almost every individual, possesses a favourite application for this very common accident. Some have recommended holding the part to the fire, or plunging it into hot liquid ; but this practice, and all similar, are too'-severe ever to become general, when milder means prove equally effectual. Perhaps the most common applications are, a mixture of lime-water and olive oil, or the ceratum acetatis plumbi. The vesicles, when left to themselves, burst, expose an irritable surface, and the acrid discharge from them excoriates the surrounding skin. Their con- tents ought to be evacuated by a small puncture, and the cuticle being left carefully undisturbed, a scab soon forms, by which the 216 OF SCALDS AND BURNS. part is protected while healing. In extensive injuries of the skin, where the cuticle has been altogether destroyed, finely carded cotton is sometimes applied ; it is of use in somewhat the same way as the cuticle in the former instance, and being a sort of cushion over the part, prevents it from being irritated by bed or body clothes, or by the patient's resting on it. It soon becomes soaked with the dis- charge, and must either be frequently changed, or become a recep- tacle for pus to putrefy in, and maggots to breed ; on account of these circumstances it is objectionable. Dusting the part with com- mon flour, starch, or hair powder, is equally advantageous, and much more convenient; relief is afforded by its immediate applica- tion ; the parts are cooled ; the flour, absorbing the discharge, is soon formed into crusts, which effectually protect the surface; and the after-secretion readily escapes from beneath this, no more moisture being imbibed than is merely sufficient for the encrusta- tion. The artificial covering ought not to be removed until com- pletely detached, by purulent matter accumulating beneath it; then its presence can be of no service, and its removal is accomplished by fomentation or poultice, and without pain to the patient; whereas, by pulling off the crusts shortly after their formation, as some do, whilst they are adherent to the surface, and protecting it from injury, much pain is given to the patient, the raw surface is irritated, and made liable to overaction ; a useful application is taken away to make room for another, and, perhaps, not so congenial. After the spontaneous separation, fresh flour may be again sprinkled over the suppurating surface, and, if the affected part is small, it may heal under this application. But when, in burns of considerable extent, suppuration is fully established, and granulations have begun to arise, tepid-water dressing, and lotions, are to be applied as to any other granulating sore ; for the reasons already assigned, the appli- cations require to be of a gently stimulating nature. In severe cases, there is first extreme depression of the powers of life, under which patients sometimes sink; but most frequently this state is obviated by the employment of cordials or stimulants. But these ought to be administered with caution, for reaction soon com- mences, and often increases to well-marked inflammation, requiring for counteraction low diet, and even bleeding. In such cases gentle laxatives are preferable to purgatives, as by the latter the patient is obliged to make frequent movements, and those are always painful. Stimulants have been strongly recommended, at first powerful, and afterwards gradually weaker, so as, it was said, to restore the balance between the affected parts and the system ; and the latter is again to be excited in order to meet the increased action which the parts assume. The practice is founded on fancy, and cannot become general, being in its first part cruel, and in its second absurd. Whilst debility exists, stimulate cautiously ; when overaction ensues, adopt those measures which are best calculated to subdue excitement; this is common sense, and the common practice. [In my own practice I have found nothing so useful in the treat- ment of burns and scalds as the carbonate of lead, in the form of OF SCALDS AND BURNS. 217 white paint.* How this substance produces its beneficial effects,— whether simply by preventing the injurious impression of the atmo- sphere, or also by obtunding the. nervous sensibility of the part, — has not been determined. The probability is that it acts in both ways. However this may be, I know of no application which so speedily allays pain, prevents the formation of vesicles, and puts a stop to inflammation. I have seen the patients, literally agonised with suf- fering, become perfectly composed, and even cheerful, within a few minutes after the burned surface was thoroughly painted. In fact, it generally acts like a charm. The best mode of applying the white lead is by means of a large camel's hair pencil, or what answers equally well, and can always be readily obtained, a soft muslin or linen mop. With this the affected surface is covered with a layer sufficiently thick to conceal it from view. If vesicles exist, their contents must be evacuated with a fine needle, and the part dried with a soft sponge, or carded cotton, otherwise the lead will not adhere. The dressing is completed by covering the painted surface with a piece of old muslin or linen, and confining it with a moderately light roller. I have on several occasions used carded cotton instead of muslin, but have usually found it objectionable, on account of its tendency to imbibe the secretions and keep up too much heat. For the same reason, when the burn is deep, and the discharge likely to be con- siderable, the thin compress here recommended should be perforated with numerous holes, so as to afford a proper drain. The number of dressings, or the frequency with which they are repeated, must depend upon circumstances. In superficial burns, one application will often be sufficient: if the lesion, however, involve the deeper layers of the skin, or extend entirely through its substance, it should be renewed at least once in the twenty-four hours. Whenever the dressings become saturated with secretions, the part is rendered painful, and the system irritable. In mild cases, the paint and epi- dermis form a sort of dry incrustation, which usually drops off in three or four days, leaving the surface beneath entirely well, or of a slightly excoriated appearance. The lead of the shops is very stiff, and consequently unfit for use. Before it is laid on, it should be well mixed with linseed oil, in the proportion of about one ounce of the former to a drachm of the latter, or until it is of the consistence of thick cream. When the linseed oil is not at hand, olive oil may be advantageously used as a substitute. It is not merely to the milder forms of burns and scalds that this remedy is applicable ; it maybe beneficially employed whatever be the extent or depth of the injury. When the skin is converted into a cinder or an eschar, it matters not what we use ; the contact of the atmosphere can do no harm, and the great indication, so far as the local treatment is concerned, is to promote the detachment of the slough, and establish granulation. After this process has fairly commenced, or even before, the paint again constitutes, ac- • See the Editor's paper on this subject in Dr. Bell's Bulletin of Medical Science July, 1845. 19 218 OF SCALDS AND BURNS. cording to my experience, the most soothing and eligible applica- tion that I know. In the case of a negro woman, 16 years of age, who had a sloughing burn, extending, on the one hand, from the umbilicus to the lower part of the face, and, on the other, as far out on each side as on a line with the axilla, the only application I used was the white lead paint, applied, at first every other day, and afterwards, as the discharges became more abundant, once a day, until the cicatrisation was completed. The period occupied by this process was upwards of five weeks ; and although the quan- tity of diluted lead consumed was upwards of a quart, no unplea- sant effects whatever ensued from its application. It is particularly- important in all cases of this kind that the dressings be frequently renewed, that is, at least once in twenty-four hours, otherwise they will become stiff, offensive, and a source of more or less suffering. When the sore is very large, it is best to expose only a part of it at a time. The external use of white lead is regarded by many practitioners as extremely dangerous, on account of the risk of absorption ; I have never, however, in a solitary instance witnessed any bad effects from it. In some of the cases in which I have either employed it myself or seen it used by others, the injury occupied a large extent of surface, and penetrated nearly, — in some places entirely,—the whole thickness of the skin. I am convinced, therefore, that the , danger is greatly overrated, if not altogether imaginary. Granting, however, that the application is not devoid of danger, all unplea- sant effects may be obviated by the occasional exhibition of a dose of sulphate of magnesia, which, while it keeps the bowels in a solu- ble condition, operates as a counter-poison, by forming the inert sulphate of lead. With the same view, free use might be made of the sulphate of alumen. From the great efficacy of white lead, prepared and applied in the manner above mentioned, a certain quantity of this article ought constantly to be kept on hand on board our steamboats, in brewe- ries, soap-factories, and similar establishments, where burns and scalds are of such frequent occurrence. It might thus always be employed with the least possible delay, a matter of no little moment, both as respects the immediate comfort of the patient, and, in many cases also, his ultimate recovery.] During the process of healing, position of the parts ought to be carefully attended to ; contraction of the cicatrices, and cohesion of opposed surfaces often causing unseemly deformities. Surfaces opposed to each other, and naturally separate, may be prevented from uniting by dressing interposed ; and contraction of joints is to be guarded against by keeping the limb extended by splints and bandages. Where deformity has occurred, the hardened cicatrix which is in fault may be either divided or excised, and by paying attention to position in the after-treatment, the evil may be greatly lessened. In the case of contracted joints, it is not necessary to excise the whole or greater part of the callous web ; simple division is suffi- cient, if carried deep enough, through the altered and condensed cuta- neous tissue. A horrid case of deformity is sketched on the next page, and from a very horrid and atrocious scoundrel, the companion and assistant of Messrs* Burke, Hare, and Co., the Thugs of the Modern OF SCALDS AND BURNS. 219 Athens. In such a deformity the art of surgery could not avail. In others, however, the cicatrix is not so extensive ; it is separated into bands, by the division of which the position of the head and lip is improved, and the comfort of the patient much enhanced. In one case, in which I operated with success very lately, the scar, though extensive, was remarkably soft and pliable, as much so as the finest kid leather. [Where the cicatrice is very extensive, old, and callous, the best mode of procedure is to dissect it out, and supply its place by sound skin taken from the contiguous surface. A highly interesting case, in which this autoplastic operation was successfully employed, is related by friend, Dr. Miitter, Professor of Surgery in Jefferson Medical College, Philadelphia.* The patient, an adult, received a severe burn when five years of age, in consequence of which she •was unable to throw her head backwards or to the left side, or to close her mouth for more than a few seconds at a time for twenty- three years. Her right eye was also forced from its natural posi- tion, and the clavicle of the corresponding side was completely im- bedded in the cicatrice ; the chin, from shortness of the bands, was drawn to within an inch and a half of the top of the sternum. After removing the whole of the contracted part, and dividing completely on one side and partially on the other, — the shortened sterno-cleido-mastoid muscles, the wound, which was six inches in length by five and a half in width, was covered with a flap of sound skin from the top of the right shoulder. This was retained by seve- ral twisted sutures and adhesive straps. No unfavourable symptoms supervened, and the edges united by the first intention. The patient was relieved of nearly all inconvenience ; and twelve months after the operation the flap had not undergone any contraction.] + American Journal of the Med. Sciences, July, 1842, p. 67-79. PART SECOND. OF PARTICULAR SURGICAL SUBJECTS. INJURIES OF THE HEAD. Wounds of the Scalp are attended and followed by more dangerous symptoms than wounds of the integuments on any other part of the body. This is in a great measure attributable to the nature and connexions of the parts. The subcutaneous fatty matter is con- densed, and closely attached to a firm and unyielding tendinous expansion; and betwixt these tissues and the pericranium, a loose cellular tissue is interposed, so as to allow of free motion of the parts. They are highly vascular, with the exception of the occipito-frontalis fascia, and between them and the internal parts, as is well known, a tree communication exists. Injuries of these coverings, though at first apparently trifling, and consequently looked upon as of no im- portance, and unattended with danger, often assume a very alarming character. No injury of the head, in fact, is too slight to be despised, or too severe to be despaired of. Punctured and lacerated wounds, more especially those penetrating all the layers of covering, are frequently followed by violent and ex- tensive inflammation of all the tissues, with severe constitutional disturbance, and with delirium and other symptoms denoting func- tional derangement of the brain. The swelling is often extensive, involving the whole scalp, together with the integuments of the tace, and completely shutting the eyelids. In some cases resolution may be accomplished, but the most frequent termination is extensive infiltration of purulent matter into the cellular or even into the more deep structures, with sloughing of the tendinous expansion. Col- lections of matter frequently form in the loose cellular tissue of the eyelids, when the parts are affected with inflammation, whether su- perficial or deeply seated. As to treatment, after the infliction of an injury, the scalp ought to be shaved, and the wound cleansed of coagula and foreign sub- stances. If a large flap of integument is detached, it should be re- placed, and retained as nearly as possible in its natural situation ; and if, for this latter purpose, slips of uninitiating adhesive plaster and methodical compression prove insufficient, it will be necessary to employ a very few points of interrupted suture ; these, however, must INJURIES OF THE HEAD. 221 be removed at an early period, that is, when either adhesion or sup- puration has commenced, and ought, if possible, to be altogether dis- pensed with, being apt in this situation to produce injurious effects by their irritation. Light dressing is afterwards applied. On the accession of swelling, heat, and pain, the parts are to be well fomented with a hot decoction of chamomile flowrers, or hops, and afterwards covered with a warm and soft poultice ; and should these symptoms continue, the fomentation ought to be frequently repeated. Fomen- tation and poultice are also the best applications when a day or two has elapsed between the receipt of the injury and the patient's appli- cation for cure. The constitutional symptoms are to be moderated, and may, in many instances, be averted, by the exhibition of antimonials and purgatives ; and by general bloodletting, when demanded, and authorised by the symptoms, and the state of the constitution. Punc- tures or incisions are to be employed according to circumstances, in order to lessen the vascular congestion of the part, and prevent the formation of matter, to evacuate it if already secreted, or to relieve inflammatory tension and promote the formation of pus at the incised parts where erysipelatous inflammation is threatened, healthy sup- puration in such circumstances often appearing to be critical. In many unpromising cases of lacerated scalp, when a great part of the cranium has been exposed, and partially deprived of its periosteum, a rapid cure has taken place without the formation of much matter. The detached scalp, though much torn and bruised, ought not at first to be removed, it being more prudent to leave nature to determine how much must be destroyed. After the sloughs, if any have separa- rated, and granulation has commenced, the loss of substance is rapidly repaired in this region, more especially when the patient is young and healthy. General or partial support, by bandaging, is required in many cases, as by a handkerchief, split cloths, or a roller applied in various forms. Wounds of the Temporal Artery are either the result of accident, or made intentionally for the purpose of abstracting blood ; and it may be here proper to make a few remarks regarding this latter cir- cumstance. When it is wished to take away blood from the head, no one thinks of opening the trunk of the temporal artery : its ante- terior branch is generally chosen. By some the vessel is first exposed by means of a scalpel, and then opened with a lancet. But prelimi- nary incisions are altogether unnecessary. The vessel ought not to be cut entirely through, and the incision should extend obliquely across its course ; and care is to be taken that the external aper- ture shall be larger than that in the cellular tissue involving the artery, as thus the blood escapes freely, and no risk is incurred of its becoming infiltrated into the surrounding parts. When the branch is of the ordinary size, a sufficient quantity of blood is readily obtained from it ; but, if from its small size, or a faulty form of inci- sion, blood does not flow freely and quickly, a cupping-glass may be applied, and its lower edge slightly raised. This latter precaution is absolutely necessary, for if neglected, little or no blood can escape, the artery being firmly compressed against the cranium by the edge of the exhausted glass. No other mode of cupping ought to beprac- 222 INJURIES OF THE HEAD. tised on the temples, for the cupping by scarification is here both unwarrantable and unnecessary — unwarrantable because tne cica- trised scarifications leave an unseemly and permanent mark on a prominent part of the countenance, —and unnecessary, since there can be no occasion for six or eight incisions when one is tully suffi- cient. The bleeding may be readily stopped, after the requisite quantity has flowed, by a small graduated compress placed over the wound, and retained by bandages, which surround the head, and are afterwards twisted and brought under the chin in order to increase the security. If by these means the bleeding is not readily restrained, the vessel may be divided throughout its whole circumference, by entering the lancet at the original wound, and moving its point later- ally. Then compression is to be again employed, by the assistance of which the natural processes for closing the divided extremities are speedily accomplished. When this artery has been injured by external violence, the wound of the integuments is generally large, and the bleeding profuse. In such cases, both ends of the vessel must be pulled out by means of forceps, and tied separately ; afterwards the integuments are to be approximated and supported. Unpleasant consequences sometimes result from the simple operation of opening the temporal artery, and occasionally also from accidental wounds of that vessel. The integuments unite, and may soon heal; but, from the compression not being sufficient, a small quantity of blood is insinuated into the cellular tissue, which becomes condensed for a considerable extent around the wound, and ultimately a sac is formed, which communicates with the ununited opening in the artery, and is consequently filled with sanguineous clots ; in short, an aneurismal tumour is formed. For the cure of this untoward occurrence, the artery may be tied between the heart and tumour, as in the case of spontaneous aneurism; but in consequence of the free inosculation which exists between the numerous ramifications of the artery, this measure may not prove successful, and it will be found necessary, either then, or afterwards, to secure the vessel beyond the tumour. But there is another mode of procedure. From the tumour being ge- nerally small and circumscribed, excision of the whole of it can be ef- fected easily, and so as to leave but a slight scar; this operation is not liable to failure, and is not more severe ihan the first mentioned. After the removal of the diseased part by elliptical incisions, the two ends of the artery are to be included in separate ligatures, and the edges of the wound kept together. A more troublesome accident sometimes takes place, — ulceration of, and over, the vessel, with effusion of serous and purulent fluids into the surrounding cellular tissue, often to a great extent. A pro- fuse flow of blood bursts from the ulcerated surface, perhaps twelve, fifteen, or twenty days after the vessel had been opened, and if active means are not speedily adopted, the hemorrhage by its recur- rence may prove very dangerous. In such cases compression is of no avail; the bleeding may be stayed for a time by these means, but, upon the circulation becoming again active, fresh hemorrhage must and does take place; the parts around are separated and en^oro-ed INJURIES OF THE HEAD. 223 more and more, the blood escapes in alarming quantities, and the pa- tient is saved only by the occurrence of syncope. To search for, and make a clean dissection of the wounded part of the vessel in such cases, is impossible. Along and deep incision must be made through the swollen and diseased parts in the course of the arterial branch, and a ligature passed under it, on each side of the ulcerated point, by means of the common curved suture-needle, or of one in a fixed han- dle. The ligatures should be at a considerable distance from each other, in order that they may surround healthy parts of the vessel ; after they have been firmly tied, all risk of further hemorrhage is gone. Of course, the ligature should enclose as little as possible of the parts surrounding the artery. A poultice is perhaps the best appli- cation for a few days, and under its soothing influence the effects of the continued compression, which had been previously employed, soon subside. The after applications must be varied, according to the appearances which the part presents. Laceration of a large or small blood-vessel is a frequent conse- quence of bruise of the scalp. — Blood is effused, and the surround- ing parts are thereby separated to a greater or less extent; and thus a tumour is formed, either rapidly, or slowly, according to the size of the injured vessel. The swelling is in general large, soft in the cen- tre, and hard towards its circumference ; the blood in the latter situa- tion being coagulated, and firmly impacted in the condensed cellu- lar tissue, whilst in the centre it is fluid, or at least partially so, and occupies a free cavity. These characters of the tumour are apt to mislead a careless or inexperienced examiner, the feel being in some degree similar to that attending fracture with depression, but still easily distinguishable from it by attentive and experienced manipula- tion. By pressing the finger or thumb firmly on the centre of the tumour, the blood is displaced, and the bone felt distinctly. In slight cases of this affection, no treatment is required, as the tumour is of no importance, and soon disappears, by the effused blood being ab- sorbed. When, however, the swelling is accompanied with unplea- sant symptoms, cold applications are to be made to the part, and low diet, with occasional purgatives, enjoined. If inflammatory symp- toms occur, local abstraction of blood may be necessary, followed by hot fomentations to the part. When the pain has ceased, and the swelling is not speedily removed, absorption is promoted by stimulat- ing applications, such as fomentation with a solution of the muri- ate of ammonia in a decoction of the anthemis nobilis, in the propor- tions of |ss. to Ibii.; a spirit lotion containing the tincture of arnica montana, in the proportion of one part to fifteen or twenty of water, will be found a good application in many such cases. Such tumours may ultimately require to be laid open, in conse- quence of the blood putrefying and becoming mixed with purulent secretion. Under no other circumstances is incision warrantable, as unhealthy, troublesome and tedious suppurations are sure to follow. Of Concussion. — Concussion in a greater or less degree, attends most injuries of the head. The functions of the brain are either disturbed or suspended ; there is loss of sensibility, of volition, and frequently of the power of motion. The confusion of intellect or 224 INJURIES OF THE HEAD. stunning may disappear in a short time, or may continue, though diminished in intensity, for many days, and even for weeks ; it is sel- dom, however, that the functional disorder exceeds in duration two or three days, and in general it disappears before that length of time has elapsed. The stupor is seldom complete ; the patient can per- haps be roused, though with difficulty, so as to answer questions by a hurried monosyllable, or make signs in regard to the seat of pain, or for such things as he may suppose himself to be in need of. At first the circulation is weak ; the pulse is fluttering, often intermitting, and scarcely to be felt in the extremities; the countenance is pale, and the surface cold ; there is occasional vomiting, a symptom which seldom occurs when compression of the brain exists, and the breath- ing is difficult, though scarcely ever stertorous. The pupils are generally contracted, but not uniformly so; one pupil may be con- tracted and the other dilated ; at first, they are insensible to light, neither dilating when in darkness, nor contracting further when the light is suddenly increased ; not unfrequently a considerable degree of squinting exists. The muscles are neither much relaxed, nor spasmodically contracted. After a time, the circulation is restored, and the heat of the surface returns, with more or less of regained sensibility. The pulse either becomes altogether natural, or else more slow or more rapid than in health. The circulation is then easily excited ; by even raising the patient in bed, the pulsations of the carotids are increased, in some cases, by fifteen or twenty beats. Sensibility returns, always very gradually, and in some cases more slowly than in others; frequently the patient becomes quite collected after the lapse of some hours, or a few days, but in other instances a degree of mental confusion remains for many weeks ; occasionally the intellect continues weak for a lengthened period, and sometimes even for the remainder of life. When the insensibility has begun to diminish, the patient can be roused with less difficulty ; if pinched, he complains of it by uttering some inarticulate sounds, or by attempting to move himself further from the quarter whence he supposes the injury to come ; he answers, though with unwillingness, loud questions regarding the pain which he suffers, and points to the part where it is chiefly felt. As the stupor goes off, symptoms of inflammatory action, or a threatening of it in a greater or less degree, manifest themselves. The pulse becomes more rapid and sharp, the skin is hot and dry, the face is flushed, the conjunctiva is redder than usual, and the pupils are often much contracted: the patient is restless, and tosses about in bed; mutters confusedly to himself; often attempts to enact a part in some fanciful scenes which he supposes to be passing around him, or talks rapidly and incoherently concerning circumstances which have for- merly occurred. His flitting ideas are often of an alarming nature ; he endeavours to get out of bed, and struggles violently if opposed. He frequently puts his hand towards his head, and gives other in- dications of suffering acute pain in that region, much increased by any movement of the part. Such symptoms are often followed by vomiting and rigors, and too frequently by convulsions, more furious delirium, and coma. On INJURIES OF THE HEAD. 225 examination after death, an increased vascularity of the cerebral membranes is observed ; there is an effusion of gelatinous-looking matter on the surface of the membranes, and in the cellular tissue beneath the arachnoid. In more advanced cases, thin patches of lymph, or more extensive strata of it, cover the arachnoid and the inner surface of the dura mater ; a piriform fluid is found effused between these membranes, and sometimes blood and matter are de- posited in some part of the cerebral substance ; bloody serum is effused into the cavities, and at the base of the brain. The above symptoms and appearances sometimes follow injuries not at first thought severe, but are most frequently the result of such as are at- tended with lesion of the bone, or of the internal parts. It is not at all improbable that concussion is produced after a manner somewhat resembling the following. The brain has a natural tendency to remain at rest, but is liable to be brought into a state of commotion by impulses on the cranium being communicated to it. When a slight blow is inflicted on the skull, only a slight commotion of the brain is induced, the cranial contents are, as it were, slightly jumbled, and a temporary and trifling confusion of its functions follows. When, however, the stroke is more severe, the brain is separated from its cranial attachments, both at the point struck and at the part directly opposite, — it is thrown upon itself towards its centre ; its substance is thereby condensed, its diameter in the direction of the impulse is diminished, and a separation be- tween the brain and cranium is formed at each extremity of that diameter. By post mortem examinations, it has been ascertained that condensation of the substance of the brain does exist in cases of severe concussion. Such commotion may be sufficient to cause instant extinction of life, or the brain may gradually resume its former condition, or with only such slight incited action as may be required to reunite the dura mater with the inner table of the skull. Extravasation of blood or serum is extremely liable to occur in such cases, the vessels being either compressed, stretched, or otherwise thrown out of their natural relations along with the other cranial contents, reparation can only take place by absorption of the ex- travasated fluid, and gradual deposition of plastic matter. When extravasation takes place to a greater extent, compression is the consequence, as will be more fully explained further on. Perhaps the brain does not recover itself gradually, but suddenly ; the impulse, which was at first directed from the circumference towards the centre, now acting from the centre towards the circumference ; and then the propulsions and recoilings maybe repeated, though gradually lessen- ing in their intensity, until the effect of the original impulse is lost, and all vibration consequently ceases. But concussion may be caused by an impulse received not immediately on the cranium, but on some other part of the body, as when a person falls from a con- siderable height and alights on the feet or buttocks ; and in such a case also its effects maybe indirectly communicated to it through the brain, and may produce equally violent effects without there ever being any appreciable lesion of the cerebral matter. The circulation may be merely disturbed, or laceration of the 226 INJURIES OF THE HEAD. brain may occur with extravasation of blood into its substance. It may present the appearance of having been bruised, or the tear of its substance may be extensive. A multitude of minute vessels may be torn without the substance of the brain being much broken, in which case bloody specks will be observed over a large surface of the interior of the organ. In many fatal cases no change in the state, either of the vessels or of the cerebral surface, is perceptible on minute examinations. The organ in these cases has been merely disturbed and shaken, without visible rupture or hurt having oc- curred. Again, many patients are supposed to labour under con- cussion only, in whom fracture of the base of the cranium, or ex- travasation of blood on the surface, or into the substance of the brain, are discovered after death. It is always difficult to distin- guish between the effects of mere concussion and those of compres- sion of the brain by extravasated fluid ; for, in the greater number of cases, the symptoms of both affections are blended together. In both there is insensibility from the first; but if an interval of sen- sibility occur, diagnosis is rendered more easy and certain, it being a fact well verified by experience, that the state of stupor which precedes the return of correct intellectual function is the effect of concussion, and that there is every reason to believe that the in- sensibility into which the patient subsequently sinks, is caused by compression of the brain ; if compression existed from the first, the stupor might not be of longer duration than if it were the effect of concussion, but its stillness would not be interrupted by any restoration of mental exercise, however short. Remarkable effects sometimes result from commotion of the brain; the patient may suffer loss of vision or of hearing, either partial or complete; or partial paralysis may occur ; of the muscles, for instance, supplied by the portio dura. In many cases such affections may be supposed to arise from compression of nerves, or other lesion subsequent to and caused by the effects of concussion, and probably connected wTith fracture of the base of the cranium. Again, it occasionally happens that the senses are rendered more acute than previously, and of this I shall mention an example which came under my own observation. An old nurse sustained fracture of the vertex, with slight depression of the broken part, in consequence of some rub- bish having fallen on her from a considerable height. Stupor, along with the other symptoms of concussion, was the immediate effect of the injury, but disappearing in two or three days. Her hearing, which previously to the accident had been long so obtuse as to render it necessary for her to discontinue her employment, became so intensely acute, that the most trifling noise became a source of pain. She gave immediate orders for the clock to be stopped, the ticking of which annoyed her greatly. Her hearing gradually be- came of the natural intensity, and continued perfect. In this case there can be little doubt that restoration of a sense which had long remained dormant arose entirely from cerebral commotion, for no discharge of blood or other fluid occurred from the ears, by which cerumen accumulated in these organs might have been displaced. People sometimes forget languages from hurts of the brain, whilst INJURIES OF THE HEAD. 227 they retain memory in other respects: or, rather, the memory on certain things becomes injured, but remains quite perfect on others. Treatment. — Whilst the circulation remains depressed after in- juries of the head, or of other parts of the body, it is a common practice to abstract blood; but it is one which cannot be too much reprobated, for it is attended wTith great risk, and can be produc- tive of no benefit; the feeble remains of vital power, whilst strug- gling as it were against the depressing cause, may by depletion be quickly annihilated, when the vigour which they still retained might have been sufficient, if encouraged and supported, to over- come those effects of external injury which had so far reduced them. When a patient is seen insensible, it is highly proper and neces- sary to examine carefully the trunk, head, and limbs, in order to ascertain whether either fractures or displacements have occurred ; for it is by no means creditable to the care or science of a surgeon to be made aware of such accidents when the patient regains his senses, after the lapse perhaps of weeks, and wdien they can be remedied, if at all, with much difficulty. In the first stage of concussion, as was already observed, the cir- culation is much weakened, and it is therefore necessary to adopt means for sustaining and strengthening it; and with this view, warmth is to be applied to the surface, more especially to the ex- tremities and epigastrium. When the powers of life appear to be failing, stimulants must be administered internally. Perhaps the most convenient stimulant is ardent spirit, the only objection to its use being that, when impru- dently given in large quantities, its effects, though at first stimulant, become sedative; it ought to be given in small quantities, and at short intervals. Other stimuli, as preparations of ammonia, may be given by the mouth ; and much advantage will often be found to follow the employment of a turpentine enema, free motion of the bowels, as well as excitement of the system, being thereby pro- cured. Stimuli, however, should always be used with much caution and prudence, and never, unless fully warranted by the train of symp- toms under which the patient is labouring at the time ; when the circulation is restored in the limbs, and is becoming throughout steady and more natural, all sources of excitement must be aban- doned and carefully avoided, as there is considerable risk of reac- tion proceeding to too great a height. The patient is to be kept quiet in a darkened room, cold applications made to the head, pre- viously shaved, and free motion of the bowels procured by neutral salts with antimony, or by other purgatives not of an irritating na- ture, and not given in such doses as to prove violently* cathartic. Enemata are in some cases preferable, and are always a valuable adjunct, to the employment of purgatives by the mouth ; they pro- cure evacuation from the larger intestines, in which feculent matter chiefly accumulates; they ought to contain assafcetida and turpen- tine ; with these additions more salutary effects are produced than from mere evacuants. The latter ingredient would seem, by its 228 INJURIES OF THE HEAD. local stimulus, to impart energy to the bowels sufficient for the cor- rect performance of their functions, while the former tends to allay spasm and irritation, both locally and generally. If the circulation becomes unduly excited, abstraction of blood from the system, in sufficient quantities and at proper intervals, is absolutely necessary; and the depletion must be regulated by the symptoms and circumstances of each case. The action will in gene- ral be more speedily and effectually moderated by one copious bleed- ing at the commencement, than by repeated bleedings to a less ex- tent. An easy and open state of the bowels is of much importance in the excited stage. Mercurial preparations are sometimes useful, as they are known to possess the power of causing the absorption of coagulated lymph and serum, and probably of preventing their effusion. In cases where insensibility continues after the arterial excitement has been subdued, counter-irritation on the head or the back of the neck is often useful, as the application of blisters, or the rubbing in of antimonial ointment. These are supposed to act by causing an unusual influx of blood to the surface, producing a change in that fluid by the copious purulent, serous, and lymphatic secretions from the irritated part, and thereby diminishing the distended and engorged state of the internal vessels, which might produce considerable com- pression of the brain. If, at a late period in the case, the powers of life begin to flag, stimulants must be again had recourse to, and may now be pushed pretty freely, there being less risk of inordinate action ensuing, and much reason to fear that life can be prolonged only by the continued use of powerful means for the excitement of the system. Nor ought thg surgeon to cease stimulating, though the vital powers continue to diminish in spite of the treatment, and though the circumstances of the case may be so hopeless as to lead him to suppose that death can- not be further delayed ; for many patients, who would otherwise have necessarily perished, have, by the continued use of stimuli, re- covered under my care their sensibility, and been ultimately restored to health. Separation of the dura mater from the cranium, with more or less extravasation of blood between, sometimes takes place as a conse- quence of blows on the head, even though not severe. The blood may be absorbed, or an unhealthy abscess may form between the bone and membrane, attended with violent, dangerous, and, if ne- glected, fatal results. The internal mischief is not without external marks of its occurrence. If the scalp is undivided, a puffy tumour forms; and, when it has been injured, the wound degenerates, its surface is pale, and the discharge gleety ; the exposed bone appears white and dry. It is also preceded by general disorder of the system, by restlessness and fever ; there is sickness, occasional vomiting, shivering, pain of the forehead and back of the neck; in some cases, delirium and convulsions, and perhaps partial paralysis, and ulti- mately coma. All these symptoms, however, may exist without in- dicating precisely either the existence or the site of abscess, as I experienced in the following cases. A middle-aged man was brought intoxicated into the Royal In- INJURIES OF THE HEA.D. 229 firmary with a lacerated wound of the scalp, over the upper part of the occipital bone, on the right side of the mesial line. For thirteen days after the accident he did well, walking about the wards in good health, with the wound healing kindly ; but on the fourteenth he be- came affected with hot skin, restlessness, slight incoherency, severe pain in the head, and intolerance of light, with a full but not quick pulse. A vein was opened, but after three ounces of blood had flowed, he was seized with rigors, vomiting, and violent convulsions ; and these symptoms again occurred after the application of leeches to the head. Rigors returned at various intervals ; stupor supervened and gradually increased. He became delirious on the eighteenth. A considerable part of the bone was exposed and dead, and there was a puffy swelling of the scalp around the wound. On the nine- teenth he lay insensible. A portion of the dead bone was removed by the trephine, and the dura mater was found covered with lymph, but no appearance of effused blood or pus could be perceived. He seemed to suffer nothing from the operation, but continued insensible, passing his urine and feces in bed, with dilated pupils, quick breath- ing, and subsultus tendinum ; his pulse, which had previously never been above 80, now rose to 100. He died on the morning after the operation. On dissection, the right hemisphere of the brain was found of the healthy appearance ; but four ounces of pus lay over the left hemisphere, between the dura mater and arachnoid, which latter membrane was of a granular appearance; there was also a small sloughy spot of the dura mater over the left anterior lobe. — Awoman, aged 40, fell down and sustained a wound of the scalp on the upper part of the occipital bone on the left side ; she suffered but little from the accident, and- continued to live freely and irregularly. Seven days after the injury she was seized with shivering : and on the ninth day she lay comatose, voiding her feces and urine involuntarily. The wound was pale and gleety, and the surrounding scalp puffy ; the bone was bare and white ; pupils dilated ; pulse slow. The trephine was applied, and fluctuation felt beneath the exposed dura mater, which wras otherwise unchanged in appearance ; the mem- brane was divided by a trifling crucial incision, but only a small quantity of bloody serum escaped. Shortly after the operation she became quite sensible, but again sank into a state of stupor, with slightly stertorous breathing and contracted pupils. However, all traces of coma disappeared next day, and she recovered soon and perfectly, apparently without having received either benefit or injury from the operation of trephine. Purulent collections under the cranium, between the bone and dura mater, are not of very frequent occurrence, when symptoms are well watched and treatment properly conducted. But these collec- tions certainly may and do occur, and usually at a considerable pe- riod after the accident; many such cases are related by the older authors. Their attendant symptoms are materially different from those of extravasated blood ; in the latter case, all the symptoms of compression ensue immediately after the effusion has occurred, and that is generally very shortly after the injury. But matter is not formed till after a considerable period has elapsed ; it is not attended 20 r r » 230 INJURIES OF THE HEAD. with symptoms of compression suddenly supervening, but is preceded by restlessness or febrile excitements ; and in the later stages only of the affection do the symptoms of cerebral compression manifest them- selves. By the external injury, those blood-vessels by which the dura mater is attached to the skull, and by which it communicates with the pericranium and more external parts, are lacerated, or other- wise materially injured, inflammatory action is excited in the con- necting medium, unhealthy suppuration ensues, and by the accumu- lation of matter, the membrane is completely separated from the cranium, and generally participates in the morbid action. It may ultimately slough and give way, and the matter will then be effused internally. A-similar process goes on in regard to the bone and its pericranium, a tumour forms externally, and the bone, being deprived of its supply of blood, necessarily dies, either in part, or throughout its whole thickness. When an external wound exists, the altered appearance of the bone, with the sloughy state of the detached peri- cranium, gives evident w7arning of the mischief which is proceeding internally. The general symptoms of suppuration are the same, whether the collection forms in the substance of the brain, or on its surface. Per- haps the symptoms are not so severe, nor the collection so speedily fatal, when in the substance of the brain, as when situated immedi- ately under the bone, or at the base of the cranium. The external marks already mentioned, are generally indicative of the site of such internal collection, but not uniformly. Formation of matter in the diploe of the skull, in consequence of external injury, is of rare occurrence ; and when it does occur, some- what similar symptoms and appearances ultimately ensue as when the suppuration commences between the bone and dura mater. Sometimes the abscess under the bone is of a chronic nature, as in the following case : — The patient, a boy, set. 11, received a blow on the vertex, after which a puffy tumour formed in the injured scalp, and was freely incised. He afterwards became subject to epileptic fits, which wrere relieved by copious evacuation of matter from the wound. Exfoliation of the cranium occurred ; one small sequestrum was separated, which involved the whole thickness of the bone, and a collection of matter between the dura mater and skull-cap was thereby exposed. The contained matter was evacuated, and the wound was carefully dressed, with the view of procuring adhesion between the membrane and bone, but without effect. The dura mater was ascertained to be extensively detached around the open- ing ; it was found necessary to remove a large portion of bone by means of the trephine and cutting pliers, and then the dura mater soon became united with the integuments of the head. Many months afterwards, the patient complained of severe pain in the back of the neck; an abscess formed in that situation, and, pointing under the right scapula, was opened. Weakness of the right arm and of the inferior extremity suddenly supervened, and the patient gradually sank. On examination after death, the cervical portion of the spinal cord was found much softened, with infiltration of purulent matter into its substance. The deficiency in the cranium was supplied by a INJURIES OF THE HEAD. 231 ligamentons expansion, to which the dura mater and scalp adhered intimately. Of Compression of the Brain. — Compression is produced by extra- vasation within the cranium of blood or other fluid, by the lodgement of a foreign body on the surface of the brain, or in its substance, or by displacement inwards of portions of the cranial bones ; and these causes are usually the effects of external injury. It may either follow the injury instantaneously, or supervene some time thereafter. Many examples have occurred of a patient, at first insensible, with symp- toms of concussion, having had the functions of the brain restored almost entirely, and again having relapsed very quickly into a coma- tose state, in consequence of extravasation of blood. The whole cir- culation is at first lowered by the shock of the commotion, and the blood scarcely flows in the cerebral vessels; but on its restoration, blood is poured out from the lacerated vessels, or from those which have been so injured in their coats as to be unable to witstand the increasing impulse of their contents. As was already observed, the symptoms of compression are often mixed up with those of commo- tion, but, when an interval of sensibility has occurred, mistake in diagnosis can scarcely occur. Compression is attended with slow, stertorous breathing; a distinct slow pulse ; a relaxed state of the limbs, features, and sphincters; and dilated pupil. Total insensi- bility to external impressions attends compression of the brain, what- ever the cause of it may be. These symptoms may, and do some- times, gradually disappear after a time. But they may continue - v unabated, and the patient may gradually sink under them. Or, again, his dissolution may be pre- ceded byr excited circulation and furious delirium, the vital powers recovering from their first depres- sion, only to become roused into violent and destructive action, again to sink to a still lower ebb, and be ultimately annihilated. Extravasation is most commonly met with on the lateral parts of the brain in the situation here in- dicated ; the coagulum is perhaps extensive, reaching to the base of the skull, in consequence of rup- ture of the middle meningeal ar- tery, with or without fracture of the parietal bone. Little or nothing can be done in cases of compressed brain from extravasation. We possess no means of preventing the effusion, and though we did, the mischief has generally taken place before the patient can receive assistance. Again, the site of the extravasation can seldom be ascertained ; and, should that objection to the propriety of surgical interference not exist, still the coagulated blood cannot be evacuated even after ex- tensive removal of the bone. If the coagulum is small, it may be 232 INJURIES OF THE HEAD. gradually and wholly absorbed, or the brain may become accustomed to the pressure of what remains. It is the surgeon's duty to take means for averting inflammatory action, and to subdue or moderate it when it has been excited. The symptoms arising from displaced bone may be relieved by surgical operation ; but we must premise some observations on fracture, before speaking of the treatment necessary in such cases. FRACTURES OF THE CRANIAL BONES. At an early period of life the bones are soft and elastic ; they yield readily under external violence, and it requires a great and direct force to produce fracture of them. Late in life, when the diploe dis- appears, the external and internal tables come in contact; the bone is brittle, and solution of continuity in it is easily effected. And it is wisely so arranged, for thus in the recklessness of childhood and youth, severe blows on the cranium, which are then of so frequent occurrence, are seldom attended or followed with danger ; whilst the aged are taught by experience to avoid the unfortunate consequences so apt to result from even a slight blow on the then brittle cranium, by cautiously preserving themselves from exposure to violence. Solutions of continuity in the cranium, caused by external force, are either attended with depression or not. Fissures, mere capillary rents in the bone, may take place at the part of the cranium which is struck, or on the side opposite to that to which the force is applied. They will be found either short and limited by sutures, or extending in different directions through several sutures, as from the vertex to the base of the skull, and terminating perhaps in the foramen mag- num. Fissures in the upper part of the cranium are of themselves attended with comparatively little danger ; they produce of themselves no claim to attention, and really require none. But the force which gave rise to the injury of the bone may have disturbed the internal parts ; and though the patient may have recovered from the first shock and the immediate effects of the violence, severe and danger- ous consequences often result, and at a late period from the infliction of the injury. Fractures of the base of the skull are the result of great force ap- plied to the lateral parts of the head, to the vertex, or to the base itself through the spinal column. A blow inflicted by an obtuse body on the top of the head, whilst it is at rest and fixed —by pro- ducing expansion of the lateral parietes, and forcing the base down upon the upper part of the spinal column—may have the effect of breaking up the connexions of the bones at the base, which is the weakest part of the cranium, and splintering them to a greater or less extent. Again, if a person falls from a height, he perhaps alights on some part of his trunk, as the buttocks, and this coming to a state of rest, whilst the head is still in projectile motion, the spinal column is driven towards the cavity of the cranium, and the same effects are thereby produced as in the preceding instance. Or the patient alights on his head, and the base of the cranium is then impinged upcm by INJURIES OF THE HEAD. 233 the weight of the whole trunk, as well as by the force of the project- ing power, and in this case also the base is frequently broken up. In the sketch here given, showing extensive fracture of the occipital and sphenoid bones into the foramen magnum, the patient, a bricklayer, fell from a ladder on the vertex. He lay comatose for some days before death: there was found exten- sive extravasation over the mid- dle lobes and cerebellum. Con- cussion has resulted from falls when the person has alighted on his nates or feet; but the symp- toms attendant on fracture of the base are more generally those of compression of the brain. In this accident the bones are sel- dom displaced to any great ex- tent; the dura mater is gene- rally lacerated, its blood-vessels, and frequently its sinuses are wounded, and blood is consequently effused at the base of the brain where injury is most fatal. The upper part of the brain may bear pressure to a considerable degree without bad consequences en- suing, but compression at the origins of the nerves is always highly dangerous and generally fatal. Bleeding from the nose, mouth, and ears, when attended with other circumstances and symptoms evinc- ing a violent injury and consequent cerebral disturbance, has been considered as decisive of fracture at the base having occurred. But we find that such bleeding happens in slight injuries unattended with any circumstances or consequences to induce a belief that so serious an injury has taken place: and again, in cases where dissection has shown most extensive fracture in the temporary, sphenoid, and seth^ noid bones, no blood had issued from their external openings. Frac- ture of the base of the skull generally proves fatal, but many cases are met with in which there is reason to believe that it had taken place, and yet the patients have recovered with perhaps partial para- lysis. Of this I lately met with a good example in the case of a girl seven years of age, whose head had been squeezed between a wall and the bark of a cart, and thereby considerably flattened. She lay insensible for several days, with all the symptoms of compression, and with blood flowing in small quantity from the nose, mouth and right ear. An extensive abscess formed over the right temporal bone. She ultimately recovered, but remained affected with para- lysis of the right side of the face and amaurosis of the left eye ; sen- sation in the paralysed parts being quite perfect. Fractures of the upper part of the cranium are generally attended with displacement to a greater or less extent, and with wound of the cranial coverings, The size of the depressed portion, the depth to 234 INJURIES OF THE HEAD. which it is displaced, and the extent of wound, will depend upon the nature and intensity of the force applied. When both tables are broken, the fracture of the inner is almost always more extensive than that of the outer one, as fissures will extend farthest in the most brittle part. A broken fragment, comprehending the entire thickness of the skull, presents generally a much larger portion of the inner than of the outer table, so much so that the piece would sometimes not admit of removal, though perfectly detached, without enlarging the opening in the outer table. Fractures, with depression of a consider- able portion of one of the flat bones, are sometimes unattended with any alarming symptoms. The effects of the injury soon disappear, and even in cases where the depression has been very considerable, and where, from the escape of brain, it was evident that both this organ and its membranes had been seriously injured, no bad symp- toms have occurred to retard the patient's recovery. Symptoms of compressed brain, however, may generally be expected to attend depression of any considerable portion of bone below its natural level. Still the brain may become accustomed to the pressure, and the symp- toms may gradually subside without surgical interference. And if the indications of compression are not very alarming, the coma not very profound, a little delay is allowable, means being taken to avert inflammatory action : for danger is not imminent, the cure may not be expedited by operative aid, and there is chance of injury resulting from rash interference. But it is in general necessary to remove the cause of the symptoms, to elevate the depressed bone, and take away those portions which may be detached. It has been said that we must be regulated in our proceedings very much by the existence or not of external wound ; that we must be cautious in cutting down upon fractures of the cranium wdiere there is no wound, and so converting a simple into a] compound fracture. In fact, so much is the danger increased, it is alleged, by the existence of wound, that the symptoms must be very urgent indeed which would demand division of the integuments in order to admit of examination of the fracture, the application of the trephine, or the elevation of the bone ; whilst, on the contrary, if the fracture is exposed by the accident, very slight symptoms will fully warrant performance of the operation of trephine. In other words, it is said that simple fractures should be left to nature, unless under very urgent and alarming circumstances, and that compound ones ought almost always to be interfered with. But the facts are otherwise. The greatest danger of compound fractures of the cranium does not arise from the admission of air. It is not the wound of the scalp, but the mechanical irritation of the brain and its mem- branes that proves dangerous. Injuries of the cranium inflicted by sharp bodies, such as divide the scalp and cause compound fractures, are generally attended with splintering of the internal table, and require the trephine. The existence of this sort of frac- ture of itself, without a single bad symptom, without any present disturbance of the sensorial functions, is a sufficient warrant for the application of the trephine, so as to permit the removal of the INJURIES OF THE HEAD. 235 detached portions of the inner table : and this should be done before inflammatory symptoms have shown themselves. The brit- tleness of the internal layer of the skull is well known. In frac- tures inflicted with sharp and pointed instruments, as a bayonet or pike, the corner of a sharp stone, or the heel of a horse's shoe, the external opening is often very small, it is a mere puncture ; in the bone there is a central depression, from which fissures proceed around in a radiated form, and hence the injury has been termed punctured, or starlike fracture. But though the external wound is apparently insignificant, the vitreous table is extensively separated, and, perhaps, broken into innumerable minute and sharp spicula. These sharp portions are driven down upon the dura mater, and by them the membrane is often severely lacerated. If these be not removed soon after the accident, inflammatory action is almost invariably lighted up on the surface of the brain ; and we can- not expect to allay or avert such action by general antiphlo- gistic means, however energetically applied, so long as their excit- ing cause remains. It is in such cases, I repeat, that the operation of trephining is imperiously called for. Sometimes, however, pa- tients are found to recover from punctured fracture of the cranium, without the operation having been performed, as in the following case, the only one so terminating with which I have met: — On the 4th September, I was consulted by a gentleman, aged 35, who had received a punctured fracture of the cranium, on the 29th of August; a heavy dung fork had fallen from the top of a haystack, and struck him on the upper part of the head. Immediately after the accident he became confused, but not insensible; he lost the power of motion in the right lower extremity, but almost instantly regained it. Next day the right arm became weak, and when I saw him, he was almost wholly unable to move it: he could not bend his fingers, nor raise the arm, and he retained the power of exercising but very slight motion in the elbow-joint. There was a small wound of the scalp, nearly healed, over the posterior part of the left parietal bone, close to the sagittal suture, and nearly mid- way between its two extremities. A probe passed down to, and through, the bone ; and there was slight swelling of the scalp around the wound. He had felt pain in the right ear, and in the forehead, whilst stooping, for some days after the accident. No blood had ever escaped from the ear. A fit of shivering occurred on the night following the injury, but never returned. He soon re- covered completely. I subjoin a case of an opposite description. A coachman was knocked down, late on a Saturday night, and fell with his head on the corner of a stone on which masons had been recently working. After being carried to his lodgings, he recovered from the stupor produced by the combined causes of liquor and blows ; and next morning he went to have his head dressed by an apothecary, who with difficulty extracted a fragment of the stone from the wound of the head. The patient then drove a party to church, and probably drank some more whisky during the day. He afterwards felt in- disposed, and was seized with sickness and shivering in the after- 236 INJURIES OF THE HEAD. noon. On Monday he was in a violent fever, and I saw him in the evening. He had been delirious, but was now lying in a state of stupor. There was a hole in the right parietal bone, capable of ad- mitting the point of the little finger, and many loose fragments of bone were left lying on the dura mater; a trephine was applied, and numerous spicula were removed. Afterwards, the circulation became much excited, he wras bled copiously, and antimony was exhibited in nauseating doses; but he died early on Wednesday morning. On dissection, there were found marks of violent inflam- matory action on the surface of the hemispheres. The vessels were unusually numerous and highly engorged, and lymyh and pus were effused in considerable quantity ; the arachnoid was opaque, and the cerebral substance was somewhat softened. Had the opera- tton been performed at an earlier period, there is every probability that the inflammation, which proved fatal, would have been averted, as in the following instance : — A quarryman received a blow from a sharp stone of considerable size, which rolled down a precipitous bank, and struck him on the vertex. He lay insensible for half an hour, but recovered, and followed his occupation during the rest of day. In the evening he came for advice. There was a small wound in the scalp, and the subjacent bone was fractured exactly in the same manner as in the former instance, but he felt no uneasy symptoms whatever. The consequences likely to result from such an injury, and the necessity for trephining, were represented to him ; he agreed, and the operation was performed on the spot. Many sharp fragments of the inner table were extracted ; he pro- ceeded home, never had abad symptom afterwards, and consequently required no treatment save dressing of the wound. The operation, if undertaken early, will, in all probability succeed in averting future evil, more especially if the dura matter be not wounded. As a proof of the unfavourable nature of this latter cir- cumstance, I give the following case : — A young man, aged 18, re- ceived a kick on the forehead from a horse, September 9th. He re- mained perfectly sensible, and did not fall to the ground. Shortly after, he was seized with a vomiting, which recurred at intervals; his pulse was regular, but feeble ; pupils dilated. On the centre of the forehead, there was an irregular wound, which extended to the root of the nose ; and on introducing the finger, the os frontis was found fractured, and a small portion of it comminuted and depressed. The trephine was applied, and several detached portions were re- moved with some difficulty, from beneath the undepressed portion of the bone. A spiculum had lacerated the dura mater, and penetrated the substance of the brain, to the depth of half an inch ; on removing it, a small portion of cerebral matter escaped. The fracture extended apparently in the direction of the right orbit. In the afternoon, the pulse was sixty-four, of good strength, and the pain in the wound had slightly increased. He was bled to fourteen ounces, and ordered an antimonial solution. Afterwards, the pain of the head increased, the pulse rose, the scalp around the wound became the seat of puffy swelling, and several small abscesses formed: the antiphlogistic regimen was rigorously followed, and the abscesses were freely INJURIES OF THE HEAD. 237 opened as soon as they began to form. On the 21st, a portion of the brain had sloughed, and there was some appearance of fungus cerebri; an incision was made into a swelling over the right temporal muscle, and rviii. of blood allowed to flow. On the 22d, several portions of brain were discharged, the pulse was 100, and intermitting. Next day, he was delirious, and a hernia cerebri protruded, of sloughy appearance, and considerable size ; pulse, 142. Soon afterwads he became comatose; and died early in the morning of the 23d. On dissection, the integuments and pericranium surrounding the aperture in the frontal bone were found much thickened, and infiltrated with pus and serum. The dura matter at the wound had a sloughy ap- pearance. There was great effusion of purulent matter, under the dura mater, investing the right hemisphere of the brain ; the corres- ponding tunica arachnoidea was thickened and opaque ; and between it and the pia mater there was considerable deposition of lymph and pus. The fungus was collapsed, of a dark colour, soft consistence, and connected with the anterior lobes ; the surrounding cerebral matter was much softened, and mixed with pus. The fracture extended through the orbitar plate of the right os frontis, over which lay two small spicula of bone; and a similar fragment was situated over the right optic nerve. Many cases illustrating the danger of punctured fracture might be related, but are unnecessary, inasmuch as they would lead to the mere repetition of such facts as have been already stated. Fracture of the external table alone must be rare, but we occa- sionally see in museums specimens exhibiting a small portion of the outer table driven into the subjacent cancelli, without any fracture of the inner table. This kind of injury belongs entirely to that period of life in which the diploe is of considerable thickness. The treatment would of course be simply that adapted to contusion or concussion. It is also possible for a blow on the head to produce fracture of the brittle inner table, the outer table remaining entire. However un- common such a form of injury may be, as its effects may possibly be very serious, it is right to bear it in mind. A splinter of the inner table thus driven into the dura mater might cause violent symptoms and even death. Wounds of the Brain. — Laceration of this organ to a slight extent, with more or less extravasation of blood, often takes place, without external wound, and when the patient has symptoms of concussion only. In such cases, the blood may be absorbed, and the lesion repaired, without permanent impairment of the sensorial func- tions. Wounds of it, along with fracture of the skull, are often very extensive; and portions of its substance may be either severely injured, or entirely separated. Loss of substance, even to a con- siderable extent, in the upper part of the hemispheres, may occur, without bad symptoms or consequences ensuing. The exposed surface of the brain granulates, and is healed as other parts of soft structure. Generally, however, untoward symptoms result sooner or later in such cases. Hemorrhage occurs from the injured part, and a clot protrudes from the external wound. Or the cerebral substance in the neighbourhood of the wound softens, and becomes converted 238 INJURIES OF THE HEAD- into a semi-fluid mass, often mixed with pus ; and a fungous growth, connected with the disorganised matter, gradually protrudes through the aperture in the cranium, and is repressed with difficulty. If removed by knife or ligature, it is rapidly reproduced. Pressure is the only means left by which to attempt its retardation ; and this, too, is generally ineffectual; for if not very moderate the effects of com- pression extend from the fungus to the whole of the brain, and an impairment of the sensorial functions in a greater or less degree necessarily results. The formation of such a growth is generally attended with shivering, sickness, and fever, by a weak, rapid, and irregular pulse ; the strength declines, convulsions and delirium supervene, and coma terminates the symptoms.* [Of thirty-three cases of hernia cerebri analysed by Dr. Gurdon Buck of New York, only two occurred in the female. The age of the youngest was two years and a half; of the oldest, forty; seventeen were twelve years or under; nine from thirteen to twenty years ; and seven, twenty-one or upwards. The seat of the wound giving rise to the disease, occupied, in fourteen cases, some part of the frontal re- gion ; in seventeen the parietal; and in two the occipital. In four- teen cases the brain was lacerated, and a portion of its substance dis- charged ; in five it was wounded without loss ; in one its surface was simply denuded ; in ten there was no exposure ; and in three its con- dition is not noticed. The dura mater was torn in twenty-one cases, and in another perforated ; the cranium in all, except one, was broken into several fragments ; and in twenty-four the scalp was more or less lacerated ; in another it was pierced ; in three there was no solution of continuity ; and in five no mention is made of its condition. The period of the appearance of the morbid growth from the oc- currence of the injury varied in different individuals. In eleven cases it manifested itself prior to the sixth day ; in fifteen between the seventh and twelfth ; and in five between the twelfth and twenty- fifth. . In one instance it did not begin until the eighth week; in another the time is not specified. The earliest period of its appear- ance was the third day, and that in two cases only ; in more than three-fourths it commenced on or before the twelfth day. The average period was the ninth day from the accident. In regard to the volume of the tumour, it varied from half an inch in diameter to a mass measuring six, by three and a half inches upon the surface, and two and a half in thickness. In twenty-two cases in which the dimensions are stated, the tumour in five wras of the size of a hen's egg; in eight it exceeded that magnitude ; and in nine it fell short of it. The morbid growth was dissected only in eleven of the cases ; in nine of these it consisted of cerebral substance, in which the cortical and medullary tissues were distinctly recognised, and in the other two it was composed of coagulated blood of a fibrous tex- ture. In seven cases the tumour assumed a sloughing character ; in five it yielded a fetid, sanious discharge ; in one it bled freely on the slightest touch ; in three it was enveloped by the pia mater ; and in three others the surface was coated with a layer of clotted blood. In * New York Journal of Medicine and Surgery, No. 4. INJURIES OF THE HEAD. 239 the centre of the largest tumour a cavity existed, filled with an ounce of limpid serum, and lined by a transparent, glistening membrane. The general symptoms, indicative of disturbance of the vascular system, and of the cerebral functions, may be next considered. In twenty-three cases there was more or less excitement of the heart and arteries; in four none was apparent; and in the other six the symp- toms are not stated. " In fourteen cases some one or more of the following symptoms of disturbance of the brain and nervous system were present: coma, delirium, pain in the head, general irritability, and insensibility. In six paralysis of the side of the body opposite to the injury was superadded to the preceding symptoms ; and in two convulsions. Three cases were remarkable as presenting some strik- ing exceptions to the general characteristics, and are, therefore, de- serving of more particular notice ; one of them, from the circumstance that there was no apparent shock to the nervous system, not even as the immediate effect of the injury, though its severity was so great that several fragments of bone and pieces of coal penetrated the brain, causing a discharge of three or four teaspoonfuls of its substance. In another the patient remained in a state of complete insensibility and general paralysis for twenty-three days, the hernia appearing on the seventh day, and no inflammatory symptoms supervening. The third case exhibited a character of most frightful violence. Besides paralysis of one side, there were spasmodic actions of the muscles of the face and of all the limbs ; nausea, retching, quivering of the eye- lids, fixed eyeballs, strabismus, grinding of the teeth, alternate con- traction and dilatation of the pupils, intolerance of light and sound, and other signs of the most alarming nervous commotion, often threatening to terminate life." Of the thirty-three cases in question, seventeen recovered, at a period varying from three weeks to four months ; and sixteen termi- nated fatally, on an average, about the twenty-fourth day. More young persons recovered than old. Of the'sixteen fatal cases, eleven were examined, and exhibited the following lesions; in eight the portion of the brain subjacent to the hernia was softened, pulpy, more or less disorganised, and sometimes intermixed with clots, while in the account of the other three no notice is taken of its condition. In eight other cases there were signs of acute inflammation of the arach- noid membrane, as indicated by thickening, opacity, adhesions to the dura mater, and deposits of lymph or pus. The portion of the dura mater around the opening through which the fungous mass protruded was thickened, black, and sloughy, in three of the eleven cases in question. In four the ventricles were filled with bloody serum ; in one there was a large abscess in the brain full of pus, and lined with a false membrane. In one case a clot of blood was found between the dura mater and the cranium ; in four the fracture extended through the base of the skull; and in one of these the edges of the osseous aperture, through which the hernia protruded, were rounded off by absorption. In respect to the general treatment, it was uniformly antiphlogis- tic consisting of the abstraction of blood by venesection and leeching, and the use of purgatives, proportioned to the urgency of the inflam- 240 INJURIES OF THE HEAD. matory symptoms. The local means employed were, excision of the hernial tumour, the application of the ligature, pressure, and caus- tics, either singly or together. In one of the cases that resulted favourably a spontaneous cure took place after copious hemorrhage from the morbid mass, excited by an accidental attack of vomiting. In another, after the ineffectual use of the nitrate of silver and other escharotics, the ligature was applied and gradually tightened from day to day; in five pressure alone was sufficient; in two the pres- sure was conjoined with lime-water ; and in one with the nitrate of silver. In seven other favourable cases excision was resorted to, either once, or repeatedly, accompanied with pressure ; in some dilute nitric acid — twenty drops to the ounce of water —lime- water, or nitrate of silver, were employed in addition. In the six- teen cases that terminated fatally the local treatment was, pressure alone in two; in five excision with pressure ; in two the ligature ; in one both ligature and excision ; and in another escharotics. In five no mention wras made of the local means.] Perforation of the Cranium is not often resorted to since the treat- ment of injuries of the head has become better understood. In former times, the operation of trepan was performed frequently, and many seemed to rate the dexterity and science of a surgeon by the number of holes which he was able to bore in the skull of an unfor- tunate patient. It ought never to be performed, unless the necessity for, and the propriety of, the proceeding be clearly indicated. It used to be practised in a most unlimited manner for fissure : cracks were sought for with the greatest care, rules were propounded to enable the surgeon to distinguish fissures from the cranial sutures, and from furrow made in the bone by periosteal vessels; and the trepan wras frequently applied over each part of the fissure, however extensive it might be, the only apparent end of the operation being to widen very materially the solution of continuity in the cranium. It wTas also resorted to in cases of compression without fracture, with the view of discovering the effused fluid, and removing it; but, as was already stated, it is unwarrantable in such cases ; and much more so in concussion, for which latter accident, however, it has been occasionally performed. I met with a case some years since, in wrhich the patient was certainly not much benefited by such active practice. The operation is of itself attended wTith danger, and likely, under many circumstances, to aggravate the patient's symptoms, and diminish his chance of recovery. The cranium must be perforated, however, when the existence and site of abscess under the bone is distinctly marked ; and in such cases the practitioner is much to blame if he does not give his patient a chance of recovery by the operation ; many are lost by its not being performed, and the following case is a striking example of such negligent practice. A young female fell from a great height amongst some rubbish, and sustained a severe blow on the leftside of the os frontis, a considerable portion of which was thereby denuded. She seemed to be doing well for some time; but about the eighth day- after the accident, pain in the head, with vertigo, rigors, and sick- ness, febrile excitement, and a white and dry state of the bare por- INJURIES OF THE HEAD. 241 tion of the bone, supervened. She was depleted copiously, but, not- withstanding all the symptoms indicating formation of matter under the exposed bone were present, the operation of trephine was deemed inadvisable. Severe rigors continued; she became affected with spasmodic twitchings of the muscles of the face, and stiffness of the jaw, neck, back, and breast, and was, in short, allowed to die. On the dissection, the dura mater below the diseased bone was found separated to a very considerable extent, and the cavity was filled wTith thin purulent matter ; the abscess extended along the superior longi- tudinal sinus, and communicated with this vessel through an ulcerat- ed aperture; the canal was filled with pus, as far as its junction with the transverse sinus, near which point its cavity was obstructed, and the abscess limited by a firm plug of lymph. A small abscess had formed between the bone and pericranium, above the extensive col- lection within ; the internal table of the diseased bone was fractured and slightly depressed, and its fractured edge was rough, sharp, and projecting. But the operation may sometimes fail to prove beneficial; the brain may have become diseased, as well as its membranes, or the patient may not recover from the irritation caused by the abscess, and the depressing tendency of the antiphlogistic treatment which may have been put in force, previously to the formation of matter. But still there is a probable chance, after the collected matter has been eva- cuated by the operation, of the dura mater granulating, the cavity filling up, the membrane becoming adherent to the cranium around the aperture, and the patient regaining his former health and vigour. If, after removing a portion of bone on account of symptoms of suppuration in that situation, the dura mater be found adherent, and of a healthy appearance, the surgeon is scarcely justified in going deeper in search of effused fluid : the evils liable to result from wounds of the dura mater have been already mentioned, and illustrat- ed byr an example. The operation of trephine must also be resorted to in cases of punctured fracture. One perforation will generally be sufficient to enable the surgeon to remove the detached fragments of the inner table. In fractures with depression, when the brain is oppressed and its functions suspended, means must be taken to elevate the displaced portion or portions to their natural level, and so remove the pressure. For the accomplishment of this purpose, it may or may not be neces- sary to divide the integuments. If they are entire, which is rarely the case, a crucial incision must be made, or one in the form of the letter T, and the flaps raised, so as to show the extent of depression. No portion of the integuments ought to be cut away ; the prepara- tory process of scalping, formerly in use, has been abandoned as cruel and unnecessary. If a wound already exists, but is not sufficiently large, it may be dilated in such a direction as appears most likely to facilitate the after part of the proceedings. The elevation can often be then effected by judicious application of the lever, its point being carefully placed under the depressed portion, and the sound part of the bone being made the fixed point on which the instrument acts. 21 242 INJURIES OF THE HEAD. Those depressed portions which are completely detached, must be removed ; but those which adhere, either to the dura mater, or to the scalp, ought to be left after having been raised to their former sites, as they will furnish a large contribution towards the filling up of the deficient parieties. Reparation of the skull, when a small por- tion is removed, or when a single narrow fracture exists, is effected by bone ; but when the opening is large, the deficiency is always repaired by a dense ligament, to which the dura mater and integu- ments adhere. By employing a small saw — represented in both ancient and modern surgical works — so as to widen the fracture, or remove-a projecting corner of bone, sufficient room may be obtained for the introduction of the lever and the removal of splinters. In old subjects, the bones are brittle, and a small corner maybe readily re- moved by pliers, or cutting forceps, so as to allow the depression to be raised. But it may be necessary, in order to elevate portions that are wedged under the sound part of the cranium, to take away a con- siderable portion of the latter. One or more circular pieces must be removed by the trephine, and, it may, perhaps, be necessary to cut out the parts between these apertures, by means of the straight-edged saw. The size of the crown of the trephine must be varied according to the object which is in view. The trepan is now disused, and the trephines best suited to the purpose are those fluted on the side of the crown, with the perforater made to slide and fix by means of a pro- per screw. The centre pin, or perforator, is fixed on a sound and firm part of the bone, and the edge of the crown made to project slightly over the fractured margin. A few turns will suffice to fix the instrument. The saw is then made to turn steadily and lightly, pres- sure being made when the instrument is moving from left to right, until a pretty deep sulcus is made. The centre pin is then withdrawn, the saw being sufficiently retained by its own groove. The centre pin can scarcely be used at all in children, the cranium being at that age soft and thin. I once had occasion to operate with an old-fashioned trepan, at a distance from town, on a child with abscess under the bone, occasioned by a punctured wTound from the point of a spinning top. The centre pin was long, very sharp, and screwed in : and, if it had been used, would have perforated skull, dura mater, and nearly half an inch of the brain, before the saw could come in contact with the bone. I was obliged to use the crown of the tre- pan, without a centre pin. In patients at the middle period of life, a different feeling and sound is communicated to the operator after having cut through the outer table of the skull. Whether this change is experienced or not after getting to some depth, he ought to proceed cautiously, moving the saw lightly, quickly, and sharply, in the direction of the teeth, and using no pressure. The operator should not be hurried, for he is apt to do harm if he is ; there is no inducement to make great haste, for the patient does not suffer much if any pain. After every two or three turns of the saw, it is prudent to examine the track with the flat end of a probe, or with a toothpick. If the perforation is found to be completed at any point, then the instrument is to be inclined to DISEASES OF THE SCALP. 243 those which are undivided ; and the fluted crown allows of this being- done with great facility. After the circle of bone is separated on all sides, it is to be removed by forceps, or by means of the lever ; and the sharp points ought to be taken from the edge of the perforation by means of the latter instrument, otherwise the dura mater may be fretted and torn when following the natural motions of the brain. The lever must be strong, and simple in its construction. And after a sufficient space of bone has been removed, its point is to be intro- duced cautiously under the part that requires elevation ; the edge of the sound bone at various points affords a fulcrum, and by perse- vering and steady efforts, the object of the operation will be*accom- plished. The dressing of the wound should be simple ; the integu- ments are made to cover the aperture, or as much of it as possible, and due support is given by compress and bandage. The after-treat- ment must be varied and conducted according to circumstances. It may become necessary to repress the granulations, or else to soothe the wound and abate inflammatory action in the surrounding parts. Perhaps incisions may be required, to prevent the formation of matter, and destruction of the cellular tissue, and of the tendinous expansion, or to evacuate fluid already secreted. The patient's strength may require support. He may stand in need of stimulants; or, on the contrary, the most active means may be required to subdue vascular action, and prevent the evil consequences which would result to the important parts within the cranium from such over action. Inflammation of the Scalp occurs either spontaneously, or in con- sequence of external injury, though slight; and is generally met with in those who have lived freely and irregularly, and are of a bad habit of body. It is more dangerous than inflammation of any other part of the surface, on account of the sympathy and connexion which exists between the parts affected and those situated internally : fre- quently, at an early stage of the affection delirium occurs, with violent fever. In slight cases, in which the external surface merely is affected, there is a little swelling, and but little pain or fever. But when all the pericranial coverings are involved, the symptoms are uniformly severe. The swelling is elevated and puffy, and extends to the eyelids, to the face, and, in some cases, even to the neck ; the constitutional symptoms run high, and there is considerable risk of the patient dying comatose. If he recover, and if the disease is little interfered with, but allowed to take its own course, much sero-puru- lent fluid is infiltrated into the cellular tissue, which generally perishes, along with a greater or less portion of the tendinous expan- sion lost by sloughing. Often, in neglected cases, a large abscess forms, separating perhaps one-half of the scalp, and bulging over the ear. The constitutional treatment must vary according to the nature of the symptoms which present themselves; in some cases they show great vascular excitement, and in others they bear unequivocal evi- dence of general debility from the first. In slight cases of the local affection, it is sufficient to relieve the tension, and abstract blood and effused serum by means of a few punctures, and afterwards to use warm fomentations. More violent cases require free incision in the 244 DISEASES OF THE SCALP. direction of the fibres of the occipito-frontalis muscle, and thus only can destruction of the parts be averted ; the incision must necessarily be deep, for the scalp is often swollen to the thickness of one or more inches. When a depot of matter has formed, it must be evacuated early, otherwise there is a risk of the bone becoming extensively de- nuded and exfoliation ensuing. Chronic thickening of the Scalp is a consequence, by no means un- frequent, of slight injurfes in those of strumous habit, but may also occur without any assignable cause. In delicate subjects it is often attended with chronic periostitis of other bones besides those of the cranium. The patient perhaps complains of pains about the shoulders, in the tibiae, femora, the tuberosities of the ischia, the sternum, the cervical vertebras, or in the clavicles and ribs. He can- not bear pressure on some points without suffering the most excru- ciating agony. The pain is also much increased by motion of the parts, as by coughing when the ribs are affected. Such painful affections of parts external to cavities are often mistaken for diseases of the internal organs, and are treated as such by violent bleedings, purgings, and starvation, to the still farther impairment of the patient's constitution. The symptoms are frequently and correctly attributed to exposure to cold and moisture, sleeping in a damp bed, sitting with wet clothes or on the cold ground ; but such affections are very apt to occur in those whose constitution has degenerated into that pecu- liar cachectic state formerly mentioned, after mercurial courses, whe- ther short or severe ; or in those who for some real or fancied de- rangement of the digestive organs have persevered in swallowing, for months or even years, the universal panacea of some practi- tioners, Plummer's or blue pill. The bones and their coverings, of even the best constituted, can scarcely resist a perseverance in such a course. The swelling of the scalp is often general, and is slightly cedema- tous ; some points are more elevated than others, feel soft, and are the seat of extreme pain when pressed upon. But such affections frequently flit from one part to another; what was most unsound, at one time, recovering itself, and painful swellings attacking that which was comparatively free of disease. The same holds true in regard to the other bones at the commencement of the affection ; but when much change of structure takes place, then the pain and swell- ing become fixed. The pains are most severe during the niofit, being then so violent as to deprive the patient of rest, and even pre- vent him from placing his head on the pillow: they abate towards morning, and remain tolerable during the day. They are always aggravated by change in the atmosphere from dryness to moisture, and the prevalence of easterly winds is peculiarly distressing to patients afflicted with such diseases. The swelling is composed of thickened and vascular periosteum with cedematous integuments. The bone too is often increased in size, and condensed, from con- tinuance of increased vascular action ; and its surface is roughened in consequence of its texture being opened out, and new bone having been deposited. Death of portions of the bone often follows, either DISEASES OF THE SCALP. 215 spontaneously, or after slight bruises received during the continuance of the disease. A few accidental blows on the head, and a perse- verance in the use of mercurial alteratives for a series of years, gave rise to the state of matters represented in the accompanying illustra- tions. The large dead portion represented was removed some months before death. Here the deficiency in the cranial bones is partly owing to ulceration, partly to death of portions of them. The patient's health becomes un- dermined by want of sleep and continual suffering ; and he may at the same time have relaxation of the mucous sur- faces, with increased discharge from them, produced by the same cause as occasioned the affection of the coverings of the bones. He may be subject to a relaxed or ulcerated state of the throat, increased or caused by the slightest exposure ; and may have hemorrhage from the nostrils copious expectoration, mucous stools, &c. The periosteal affection alone is a troublesome and serious complaint. When the pains are fixed and violent, we are sometimes obliged to give small doses of the bichloridum hydrargyri at first, even though there is reason to think that mercurial medicines, perhaps impru- dently or carelessly administered, have brought the constitution into its present morbid condition. The good effects of this medicine are. well marked and speedy. The patient is freed from the nocturnal pain, gains flesh, and the swellings subside. It ought not to be resorted to however, unless in severe cases, when the disease eannot otherwise be successfully combated ; and when used, it should not be continued longer than is necessary for the removal of the more urgent symptoms : when the pains begin to yield, it is time to dis, continue the medicine. Great care is necessary on the part of the patient; he must industriously avoid exposure to moist atmosphere, and ought to be well and warmly clothed ; wearing flannel, chamois leather or both, on the trunk and extremities. A patient treated with the corrosive sublimate of mercury is perhaps more subject to recurrence of the affection, after imprudent exposure, for a consi- derable time afterwards, than if simple and less powerful means had been employed A cure can often be effected by the exhibition of the compound decoction of the woods, Wlth or without antimony, 246 DISEASES OF THE SCALP. Moderate diet and strict abstinence from wine and other internal stimulants should be enjoined ; the patient, soon experiencing the good effects of temperance, is exceedingly willing to restrict himself to a somewhat antiphlogistic regimen. In cases of violent fixed pains, with swelling and threatening of matter forming, incision may be sometimes practised with relief to the patient, but is not to be had recourse to unless there is a risk of the bone suffering. Local abstraction of blood is advantageous, and may, if necessary, be followed by counter-irritation, as the application of blisters or sinapisms. Friction with stimulating substances, or with opiate liniments, is often useful when the disease begins to yield, the pain and puffiness of the parts being thereby dispelled. The hair should be kept short during the eure, and ought not to be allowed to grow till the scalp is firm and sound. The disease is often so far advanced that, in spite of the most active treatment, abscess forms in one or more points ; and, on the matter being evacuated, the bone is found denuded. Exfoliation is then very likely to take place. Exfoliation generally follows denudation of the bone by accident, but not uniformly. When the periosteum is stripped off by violent injury, the bone in some cases does not lose its natural colour; gra- nulations arise from the exposed part, and it again becomes covered without any part of its substance having been destroyed. Again, careful removal of the periosteal covering, as in excising a tumour or ulcer by the knife, may be followed by death of the outer table of the skull; small portions only separating in some cases, whilst in others a large part of the bone, and of considerable thickness, perishes. The cranial bones may in part become dead throughout their entire thickness, and separate, either after a severe bruise, or in conse- quence of inflammatory action following injury or arising from dis- ease. The process of separation is either speedy or tedious, accord- ing to the vigour of the constitution. The deficiency is repaired, in a great measure, from the subjacent bone, when its wThole thickness is not thrown off. But when the breach is complete, the surrounding parts assume the reparative action ; the granulations from the dura mater and integuments coalesce, and a dense membrane fills up the space. The denuded bone should be kept covered and moist, and for this purpose lint frequently wetted with tepid water is the best dressing: spirituous or greasy applications can do no good. A free discharge for the matter should be afforded, and the wound kept clean. If the exfoliation goes on slowly, perforation in the dead bone may be made at different points down to the living parts, with the view of expe- diting the process. Exfoliations are sometimes retained by surround- ing granulations overlapping their edges and confining them in their situation ; or are fixed by atmospheric pressure, after separation has taken place from the parts underneath by the action of the absorb- ents, in the same way as a boy's leathern sucker becomes firmly fastened to the stone to which it is applied. In such circumstances a small screw may be fixed into a perforation carefully made in the bone, and thus the dead part may be lifted out without pain or diffi- DISEASES OF THE SCALP. 247 culty, when otherwise it might have lain for many weeks, keeping up the discharge. In this way the large sequestrum, represented at p. 245, was extracted from its bed. The powdered red precipitate of mercury may be occasionally sprinkled on the parts surrounding the dead portion, in order that the granulations embracing it may be destroyed, and the part more completely detached. The general health must be all along carefully attended to. Sarsaparilla with guaiac, sassafras, mezereon, &c, is often useful, more especially if pains in other parts continue to annoy the patient. Under such me- dicines he in general improves very rapidly in appetite, flesh, and strength. The scalp is sometimes, though rarely, the seat of malignant ulcer. In the early stage the ulceration is not of great extent, and affects only the soft parts ; perhaps it is confined at first to the common in- tegument, but is extremely apt to extend to the deeper layers which invest the cranium, and even to the bone itself. It is by no means uncommon to find the cranium very extensively diseased, though the affection originated in the superimposed soft parts. Such ulceration of the bone is of a peculiarly destructive nature ; it is a disease of the osseous tissue, corresponding to the most malignant ulceration of the soft parts. The bone around the ulcerated cavity is spongy and soft, its margin is irregular, and bristles with numerous spiculse; the centre is composed of soft morbid deposit, entangling small portions of bone which have become detached, and flabby, almost lifeless granulations shoot from the distempered mass. Such disease, when the patient does not soon succumb to its virulence, advances to a frightful extent, affecting a large surface, destroying the whole thick- ness of the bone, and even exposing the internal parts. In a case of this description, which occurred in the Royal Infirmary under my care, the anterior half of the cranium was totally destroyed, the left orbit contained a putrid mass, consisting of the disorganised eye mixed with pus and bloody fluid ; the dura mater was exposed, and sloughed at several points, and the unhealthy discharge from the parts lodged on the surface of the brain. In malignant diseases of scalp, as of other parts, the lymphatics become secondarily affected : the absorbents feel hard and thickened, the glands in the neighbour- hood enlarge and ulcerate, and the sore thereby formed, soon assumes the characters of decided malignancy, — hard everted edges, an angry surface, and fetid thin discharge. Before the disease has become very extensive in the scalp, and when it is still limited to the superficial parts, it may be removed by the knife; the incisions being made at a considerable distance from the margins of the ulcer, so that those parts which may be supposed to have assumed a disposition to malignant action, may be taken away along with the ulcer. In more advanced cases, it may be ne- cessary that the incisions should extend in depth to the bone ; and it may be prudent to insist on a portion of the bone exfoliating^ the periosteum being removed, and some potential cautery applied to the exposed surface,-^ as the alumen ustum, oxydum hydrargyri rubrum, &c. The actual cautery cannot be applied with safety to the cranium. Even where the integuments only are removed, and 248 DISEASES OF THE SCALP. that to a small extent, and in a proper form, it is vain to think of approximating the parts and procuring union by adhesion; the wound must granulate. There is no difficulty in suppressing he- morrhage ; either ligature or temporary pressure may be employed according to circumstances. Mild dressings are to be applied, and proper support afforded. The parts should be kept clean, and for that purpose the surrounding scalp must be shaved repeatedly. Tumours of the Scalp. — Tumours of a sarcomatous nature are seldom met wTith in this situation, but the adipose are not so unfre- quent. The latter are easily removed, being seldom of large size, and their attachments being loose, unless when they have been irri- tated by accident or maltreatment. When sarcomatous growths do occur, they are to be excised, with those precautions which were formerly mentioned when treating of tumours generally. Vascular growths not unfrequently form in the scalp, and attain considerable size ; in general they are either congenital, or the de- generations of naevi materni. They may be so extensive as to for- bid surgical interference ; or they may be so indolent, may partake so much of the nature of simple varix, as not to warrant it. If small, they can be readily removed by the knife, the incisions be- ing made rapidly, and wide of the diseased structure. If the tumour be prominent, extensive, and at all active, the employment of liga- ture is a more safe and equally effectual practice-. One or two ligatures may suffice to encircle the swelling, or, as in other parts of the body, it may be necessary to pass a great many double ones beneath the part, to separate their extremities, and to tie them to each other around the base of the tumour, the last being drawn so as to tighten all the others. Little benefit can be expected from tying, either at once or at different periods, the larger arte- rial trunks whose ramifications supply the diseased structure, the inosculation amongst the vessels around the tumour being so ex- tremely free. But, in cases where the disease cannot be otherwise combated with any hope of success, ligature of Tthe common carotid, on the affected side, may be tried as a last resource. The practice has proved successful in some cases of this disease, involving parts of the head and face to such an extent, or in such a situation, as to forbid any attempt at removal of the growth. Encysted tumours frequently form in the scalp, and, if undis- turbed, become large ; they seldom occur singly. The disease ap- pears in many cases to be hereditary, and it frequently happens that several members of one family are at the same time afflicted with it. The contents of the tumonrs vary as to consistence, but are generally atheromatous. The cyst is thick, and loosely con- nected with the surrounding cellular tissue ; but as the tumour in- creases, the adhesion often becomes firm and intimate, more espe- cially towards the skin. When the tumour is of small size, it is unnecessary to adopt any preparatory measures for its removal, not even to shave the scalp ; the surface may be cleared a little with scissors. The swelling is transfixed, in the direction of the fibres of the occipito frontalis, by means of a curved sharp-pointed bis- DISEASES OF THE EYE. 249 toury, and its internal structure is exposed by the knife being car- ried outwards. The soft contents are evacuated, and the sac is easily extracted by means of common dissecting forceps. The integuments are then laid down and retained in apposition, no sutures being necessary, and in many cases the wound heals by adhesion ; sometimes a small coagulum forms between the edges of the wound, and is detached some days afterwards ; then slight suppuration ensues. In larger tumours, however, a straight and narrow knife is perhaps the most convenient instrument for ac- complishing removal. The part is transfixed, and in most cases it is necessary to take away an elliptical portion of the integu- ments, a part of the cyst corresponding to which is of course si- multaneously removed; the remainder of the sac is pulled out by the forceps. If the adhesions at certain points are firm, they may be touched with the extremity of the knife, so as to expedite the extraction ; and if after the operation there is reason to believe that the whole of the secreting surface has not been taken away, a pointed piece of caustic potass may be applied to the suspected parts. If the tumour is very large, the cyst can often be removed without difficulty unopened, sufficient integument being left to cover the exposed surface. In consequence of such operations on the scalp, erysipelas often supervenes, and precautions ought there- fore to be adopted to prevent its occurrence, by a little prepara- tion beforehand, by keeping the patient's bowels freely open, con- fining him to moderate and mild diet, and avoiding exposure to moist atmosphere and easterly winds. Osseous tumours of the cranium seldom attain any great size, and are in general neither troublesome nor dangerous. Small ivory exostoses are the tumours most frequently met with in this situation, and require no treatment whatever. Tumours of malignant character occur, though rarely ; commenc- ing either in the diploe of the skull or on the surface of the dura mater, soon enlarging, and involving the parts around. Two or more sometimes form in one patient; they are attended with excru- ciating pain, and rapid destruction of the bone, and are followed by extinction of life either at an early or remo e period. They are entirely beyond the reach of surgery ; as are also those tumours, oc- casionally met with in children, which project through the cranial sutures and contain fluid ; such are analogous to the disease named spina bifida, hereafter to be spoken of. I may here remark, that puncture of the brain, with the view of abstracting fluid in chronic hydrocephalus, is an operation not often likely to be followed by success, and it may even accelerate the fatal issue. Some cases are recorded in which benefit is said to have arisen from the practice. Pressure was applied and kept up after the eva- cuation of the fluid. DISEASES OF THE EYE AND ITS APPENDAGES. Of Inflammation and Abscess of the Lachrymal Passages. — In former times, all affections of the lachrymal passages, and of the parts 250 DISEASES OF THE EYE. in the neighbourhood, were denominated fistula lachrymalis, and were all treated nearly in the same manner, by opening the sac, and inserting probes, knives, terebr8e,scalpra, caustics, and red-hot irons ; the anatomy of the various parts being then ill understood, and the opinions as to the origin and nature of the diseases being founded on erroneous theories regarding the defluxion of the acrid humours, for- mation of imposthumes, fungous growths, &c. The term, however, which was indiscriminately applied to all diseases in the inner corner of the eye, accompanied with derangement of the lachrymal secretion, is now confined to a distinct form of disease, as will afterwards be mentioned. Inflammation sometimes occurs in the loose cellular tissure covering the lachrymal sac,—whilst that cavity remains free from all disease,— and is attended with some obstructions to the passage of the tears in their natural course, on account of the eyelids becoming swollen, from an extension of the inflammation. The morbid action resembles erysipelas in its nature, and usually terminates in unhealthy suppu- rations ; thin purulent matter lodges in the opened out cellular mem- brane, a soft boggy tumour is formed, and the superimposed inte- guments become of a bluish colour, as in the case of other scrofulous collections. Though the affection is at first unconnected with the lachrymal sac, this organ may ultimately be involved. It may become the seat of a like unhealthy' inflammation, and matter may consequently form within its cavity; or, on account of the pressure of interstitial deposit around, the parietes of the sac may ulcerate before the abscess of the cellular tissue in front has discharged externally. Thus, the cavities of the lachrymal sac, and of the external abscess, will con- municate with each other. If, after an external aperture has been made either by nature or by art, any doubt exist as to whether the sac is involved or not, such doubt will soon be removed by dexterous use of the probe. In the treatment of this affection, it will be necessary, at the com- mencement, as in all other local inflammatory diseases, to attempt the accomplishment of resolution, by attention to the general health, local abstraction of blood, and warm fomentations. When matter has formed, it ought to be evacuated as soon as possible by a small incision, as there will then be less risk of the deeper parts becoming secondarily affected ; or if the integuments have sloughed, and the matter has been discharged spontaneously, the natural opening may be enlarged either with the knife, or with the caustic potass. If it be discovered that the lachrymal sac is opened into, the same treat- ment is necessary as if it remained entire ; the matter is to be allowed free exit, and granulation encouraged ; in most cases, the aperture in the sac is soon repaired, and the parts heal as quickly and soundly as if the disease had been confined to the external cellular tissue. Light dressing during the cure, preferable in all cases, is more espe- cially necessary in this situation. Of Inflammation of the Lachrymal Sac. — When the lachrymal sac becomes inflamed, it enlarges considerably ; the swellino- is small, hard, circumscribed, deeply seated, and extremely painful, more espe- DISEASES OF THE EYE. 251 cially on pressure. At first the integuments are of their natural appearance, the increased action being confined to the sac, but they are soon involved, and often to a considerable extent; they become red and swollen, and as the surrounding parts are affected, the swell- ing increases. In some cases, the eyelids, the caruncle, and the con- junctival covering of the eye, participate in the inflammatory action. The inflammation is in most instances caused, or at least preceded, by some obstruction in the nasal duct, in consequence of which, the tears are interrupted in their natural course downwards, and either accumulate in, and distend the sac, or flow over on the cheek, the puncta lachrymalia remaining open. After increased vascular action has been produced, the lachrymal secretion is increased to a greater or less degree, and much inconvenience is caused to the patient by the profuse discharge following an unnatural course. When inflam- mation is intense, lymph is effused into the passages, producing ob- struction sometimes complete. The mucous lining of the nasal duct becomes swollen, from the vascular excitement, either throughout its wdiole extent, or at one point only ; and in either case the flow of the tears must be interrupted, either partially or wholly, according to the degree of swelling. The vitiated secretion of the part may also contribute towards narrowing the canal, by lodging and concreting there. But a more complete and permanent obstruction is formed by effusion of lymph, under or on the mucous lining, as happens in other canals of similar construction : and in this case also, the stric- ture may be partial or complete, according to the quantity of effused matter, and the extent of surface affected. As the inflammation abates, mucous fluid is copiously effused from the surface of the sac, and the swelling increases, though the pain is less. The collected fluid may be partially evacuated through the puncta, either spontaneously, or in consequence of the patient instinc- tively pressing with his finger on the swollen part; or the puncta may be obstructed by the same causes as the nasal duct, and then the discharge of the fluid is prevented in both directions; it conse- quently accumulates still more, and causes greater bulging. Fluc- tuation is perceptible, and the collection protrudes outwards and for- wards, being least resisted in these directions. It is seldom that the puncta are obstructed, and consequently the swelling does not attain any great size, the sac being relieved by some of its contents always flowing upwards, after a certain degree of distension. As the inflam- mation farther subsides, the mucous secretion diminishes, and the accumulation and swelling are less: in fact, the patient may at this period prevent a tumour from forming in the corner of his eye, by from time to time pressing gently on the sac, and forcing the lachry- mal secretion upwards, as it begins to accumulate. This state of matters may continue for a long period, without causing much incon- venience, and getting neither better nor worse ; the patient is merely obliged to apply his finger and handkerchief more frequently to his eye than would otherwise be required. In almost all cases, the ob- struction of the nasal duct is complete, or nearly so, and consequently the fluid cannot pass downwards into the nose, though it may occa- sionally appear to do so, on account of the discharge from the Schnei- 252 DISEASES OF THE EYE. derian membrane being increased at the same time with that of the lachrymal sac. The ductus ad narem, though wide in the skeleton, is of very limited dimensions in the living body, and is in consequence readily made impermeable to mucous fluid, by even slight thickening of its lining membrane. It has been already observed that the above-mentioned condition of the parts may continue, for a considerable period ; but in other cases purulent matter soon forms within the distended sac ; or, at least, the contents of that organ are so altered in colour and consist- ence as to resemble intimately purulent fluid. The secretion may- or may not be pus, probably it is not in some cases ; but as the de- cision of this point is practically unimportant, the description of it as purulent can scarcely be objected to. In most cases, when the puncta either are or become clear, no suppuration, or deterioration of mucus into fluid like pus, occurs; merely chronic distention of the sac continues, the patient being able to avert incited action, by occa- sionally squeezing out the contents, and thereby removing tension. There is merely an Epiphora; or, as it is otherwise called, Blenor- rhcea, or Stillicidium lachrymarum. The last term is by some ap- plied to increased lachrymal secretion, without affection of the sac, the tears being, secreted more quickly than the puncta can carry them away, and consequently running over on the cheeks, excoriating the surface, and producing an irritable condition of the eye. The sim- ple epiphora may be of long duration, yet the parts are extremely liable to assume inordinate action, in consequence of slight injury, or exposure to cold; thus suppuration wrill ensue. When purulent matter forms, fluctuation becomes more distinct, the pain increases, and there is slight headache and fever. The in- teguments inflame more and more, and, if the case is neglected, ulti- mately give way by sloughing. A small ragged opening, often in- direct, is formed, and the contents of the sac are not thereby all discharged ; the thinner fluid only escaping, whilst the more viscid remains and clogs- the aperture. The swelling is not much dimi- nished ; the margins of the aperture thicken, become indurated, and contract, the purulent contents of the sac are gradually discharged, and the tears afterwards flow through the opening. The parts are now in that condition to which the term Fistula lachrymalis is with propriety applied. The swelling of the canal may gradually subside,.the tears resume their wonted course, and the opening may then contract, and the parts cicatrise ; but frequently the fistula remains open for a long period, gradu- ally diminishing in diameter, and only a small passage, almost imperceptible, ultimately remaining, through which a few drops of lachrymal fluid are occasionally discharged. Some- times the fistula closes entirely without the obstruction of the nasal duct having been removed, and the lachrymal sac remains in conse- quence distended ; then the tears or mucus, either clear or turbid, can generally be squeezed through the puncta. DISEASES OF THE EYE. 253 It frequently happens that the meibomian glands are the seat of morbid action, along with the lachrymal passages ; their secretion is changed, becoming in some cases thick and caseous, in others puri- form. By some, affection of the meibomian glands has been consi- dered as the cause of inflammation and abscess of the lachrymal sac. This opinion, however, cannot be agreed to, for the diseases are not always coexistent; and besides, the affection of the surface of the lachrymal sac and ductus ad narem is as likely to be the consequence of morbid action, extending upwards from the nostrils, as of morbid secretion from the eyelids blocking up and irritating the puncta and the lachrymal passages. Disease of the meibomian glands in the under eyelid often exists along with disease of the lachrymal pas- sages, but the latter is generally the primary affection ; the conjunc- tival covering of the eyelid is at the same time inflamed, swollen, and often granulated. In some cases of abscess in the lachrymal sac, before the integu- ments give way, the subjacent bone becomes diseased in consequence of the pressure of the confined matter; portions are affected by necrosis, and after their separation considerable deformity is pro- duced. The exfoliation is often very tedious, and is attended with discharge of fetid thin fluid from the nostril, and from the ill-condi- tioned lachrymal fistula. Fistula lachrymalis is often merely one of the symptoms of disease in the bones of the nose, with obstruction of the nasal duct, — as in patients who have suffered from mercury. Treatment. — In the treatment of epiphora or blenorrhcea — that is, chronic collection of a mucous fluid in the lachrymal sac, with weeping of the eye — a primary object of attention is the state of the general health. The habit of the patient will commonly be found weak, and, if not decidedly strumous, at least inclining towards that diathesis. In such cases the digestive organs must, if possible, be brought into a vigorous state by tonics and nourishing regimen. The local treatment chiefly consists in applying stimulants to the internal surfaces of the palpebrae and lachrymal sac. For this purpose, solu- tions of stimulating and astringent substances, termed collyria, and various ointments are employed. At first they ought to be used of rather a mild nature, and their stimulating power must be afterwards increased gradually. The applications are placed between the eye- lids, and, becoming mixed with the natural secretion, pervade the diseased surfaces; and, being taken up by the puncta lachrymalia, are afterwards conveyed into the sac. It was formerly the custom to inject the fluids into the sac: but this is unnecessary so long as the puncta canaliculi remain pervious, and the permeability of these can be readily ascertained by means of a small probe. Permanent pressure on the sac can be productive of no good effect, and is ex- tremely liable to do harm. The repeated application of very small blisters over the sac has been found useful. Introducing minute gold probes through the puncta has been much recommended, but in the generality of cases can be of little service. The probes are too limber for removing mechanical obstruction, or 22 254 DISEASES OF THE EYE. for affecting in any way the contracted or strictured duct. But passing of the probe may tend to remove the irritability of the passage, as happens in the urethra, and thence some relief may follow. Much dexterity is required in using either the probe or syringe. The puncta are often very small, and it is in general necessary to dilate them by means of the point of [a common pin, before any instrument can be passed through them into the sac. The points of the probe being introduced into the punctum, either superior or inferior, must be first carried towards the nose for about 2-10ths of an inch, the instrument being lightly held betwixt the fore and middle fingers of the right hand. It is then directed downwards and backwards. Care must be taken to prevent entanglement in folds of the membrane. Should obstruction be felt, the instrument is with- drawn a little, and then carefully and gently carried in the right direction. The small syringe is managed with one hand, whilst, with the fore-finger of the other, the punctum not occupied by the pipe is compressed. Neither can much or any benefit be expected to follow attempts to force obstruction in the lachrymal passages, by the weight of a column of mercury. A plan of dilating and rectifying the nasal duct by styles introduced through the puncta has been proposed, but scarcely de- serves to be mentioned as a means of cure. When suppuration is threatened with increase of the swelling, inability of the patient to empty the sac by pressure, redness of the integuments, &c, an early opening should be made into the tumour, in order to prevent further and more serious mischief. A small opening into the sac cannot be productive of so much injury as forcible dilatation of the canaliculi, followed by and causing ulcera- tion. The point of a straight narrow bistoury is to be entered into the sac, and carried on into the nasal duct, the knife being pushed downwards, backwards, and a little inwards, in the direction of that passage. The point to be punctured can always be readily ascer- tained by feeling for the firm ligament which attaches the orbicularis palpebrarum to the nasal process of the superior maxillary bone, as the upper orifice of the ductus ad narem is situated immediately be- low this tendon ; by introducing the knife below the ligament, and within the sharp edge of the orbit, and then carrying it forward in the direction already mentioned, the surgeon cannot fail to enter the nasal duct. The knife should be followed by a probe, and ought not to be entirely withdrawn till the probe is fairly lodged in the duct, otherwise the surgeon will experience much difficulty in the after proceedings. If the knife be not pushed into the duct, a blunt instrument can scarcely be introduced afterwards. Some force is required, but is not hurtful, provided it be made in the proper direc- tion, so as to remove the obstruction in the duct without injuring the bones and other parts in the neighbourhood. After the operation, some drops of blood should escape from the corresponding nostril, showing that it has fairly entered this passage ; or the patient being made to expire forcibly, the nostrils being at the same time com- pressed with the fingers, air, blood, and mucus, are forced upwards through the opening made. DISEASES OF THE EYE. 255 Many and various modes have been pursued with a view of securing a pervious state of the nasal duct. Instruments of different kinds have been introduced through the puncta, through the opening in the sac, and through the termination of the duct under the spongy bone, and have been retained for a longer or shorter period, according to the fancy, or theory, or plan of the surgeon. The first of the methods of introduction is abandoned, as already stated. By the ancients the passages in fault were got rid of altogether, being either cauterised or destroyed by escharotics. The passing of probes into the duct from its lower aperture is useful in removing trifling obstructions caused by concretion of deteorated mucus, or slight thickening of the lining membrane, and in chronic dilatation of the sac with probable contraction of the duct. But, at the same time, it is an operation requiring much dexterity, and which ought not to be attempted till after much practice on the dead body. The first introduction of the instrument is always the most difficult, from obstruction by a valvular projection of the mem- brane at the lower orifice, the use of which in the healthy state of the parts must be apparent. Destruction of it, renders after-introduc- tion of instruments much more easy. But the preferable practice is making an opening into the sac, and then introducing instruments from the upper orifice of the duct; more especially in cases where the swelling and pain are considerable. The instruments employed for dilatation of the passage are tubes and styles. The tubes are made either of silver or gold, of equal calibre throughout, and of the same length as the passage. For some time after their introduction they cause much irritation ; this gradu- ally diminishes, and the wound heals over them. But, according to my experience, the effects are not satisfactory. The irritation which they at first occasion generally subsides, but abscess again occurs, with much swelling, and it becomes necessary to remove the foreign body. Again, the tube sometimes becomes obstructed by thickening and concretion of the discharge, and then, when it is necessary to re- move it, the process is found to be by no means an easy one ; a free incision is required ; a screw must be fastened into the tube, or, when that cannot be accomplished, the foreign body must be laid firmly hold of with strong forceps; altogether the extraction is very painful, and often extremely tedious. In short, the practice of intro- ducing tubes does not appear to be founded on sound surgical prin- ciples. After extensive and impartial trial of both the tubes and style, I decidedly prefer the use of the latter. On the point of the bistoury being fairly lodged in the lachrymal duct, a probe is passed along it; the knife is then withdrawn, and the passage is gently dilated by the probe. The probe again is followed by the style, which should be made of silver, of the same thickness throughout, of the same length as the duct, and with a flattened head placed obliquely to the body of the style. The size of the style should be at first small, and gradually increased. The irritation caused by the first introduction is in many cases very severe, but the parts soon accommodate them- 256 DISEASES OF THE EYE. selves to the presence of the foreign body ; the pain and swelling diminish, as also the discharge. If a large style be pushed forcibly in at first, violent inflammatory action will ensue, and much mischief may be produced. After irritation has gone off, the tears pass readily down in the nose by the sides of the style, according to the laws of capillary attraction, little or no fluid escapes from the external open- ing, the wound contracts around the instrument, and, its head being covered with black wax, no deformity is produced. The instrument should be removed from time to time, cleaned, and replaced. When, by the continued use of styles gradually increased in size, the duct has been dilated to its full extent, and appears restored to a sound condition, the instrument may be withdrawn, and afterwards intro- duced only occasionally. The external aperture, which has become fistulous from the long presence of the foreign body, then begins to contract, and, on its completely closing, the tears continue to follow their usual course, and the disease is overcome. But sometimes a small fistulous aperture remains, and there appears to be a disposition towards the renewal of the affection ; in such a case, a small style, not exceeding a thin gold probe in diameter, should be introduced every evening, and retained for some hours: this causes little or no inconvenience to the patient, and insures the permeability of the canal. Such is the method by which a permanent cure may often be ob- tained, and which, in my opinion, is preferable to the use of tubes. If these are to be employed, they should, as already mentioned, be nearly of equal calibre throughout; the external opening must not be allowed to close for a considerable time after the introduction of the instrument; and the tube must be kept pervious for some time by a style introduced through it. But by these means, wrhich are essen- tial for the success of the practice, the main advantage arising from the use of a tube, viz., little irritation being produced at first, and the parts being allowed to close soon over it, are completely done away with. The practice of perforating the os unguis never can be required; it is cruel, unnecessary, and unsurgical. Sometimes the lachrymal passages are entirely destroyed. In such cases, it has been found that no great inconvenience arises from their obliteration, as the lachrymal gland ceases, in a great measure, to secrete fluid, and the conjunctival secretion, after having performed its office, evaporates from the surface. In truth, the lachrymal gland always enjoys long periods of repose, and is only called into active exercise of its functions occasionally, as the eye in its ordinary con- dition is sufficiently lubricated by secretion from its conjuncrival covering. The treatment of fistula lachrymalis, as has been wTell remarked by an eminent author, must be varied and regulated according to cir- cumstances ; — by the degree of obstruction in the duct, by the state of the coverings of the sac, of the sac itself, and of the subjacent bone, and by the general state and habit of the patient. Encanthis is a tumour situated in the corner of the eye. The DISEASES OF THE EYE. 257 caruncula lachrymalis appears to be the original seat of the disease, at least it is involved at an early period. The growth is at first small, and appears to be simple enlargement of the caruncle: it is of a reddish colour, and its surface is studded with numerous granula- tions. It often attains a very considerable size ; and, on account of its propinquity to the lachrymal passages, is accompanied with wa- tering of the eye, the puncta being either in- volved in the growth, or compressed or dis- placed by it. Sometimes the: whole inner corner of the eye, from the margin of the cornea to the inner junction of the eyelids, is occupied by the granulated swelling: and in such cases it is not uncommon for the tumour to extend itself outwards, in the form of a lunated appendage, on the under surface of each lid ; thereby the motions and functions of the ball are much impeded, and a prominent deformity is occasioned. In most instances the growth seems to be a simple enlargement of structure, and is of a benign nature ; but sometimes it is firm, hard, of rather .a livid hue, with a smooth slimy surface, and is decidedly malignant, — enlarging, and gradually involving the surrounding parts. Cancerous ulceration, attacking and destroying the eyelids, and the parts around the ball of the eye, often commences in the situation of the caruncle, or in a wart on the edge of the lid. Cancer, though a rare and uncommon disease of the eyeball, frequently seizes on the appendages of the eye, extending rapidly in all directions, and often completely detaching the ball by ulceration. Warty tumours also occur on the conjunctiva of the lids, or of the ball, and are inconve- nient as a source of much irritation to the neighbouring parts, even though of a benign nature in themselves. Extirpation, by means of a small pointed knife, or curved scissors, is the only means to be relied on for the cure of such warty tumours, and of encanthis. The growth must be fixed and pulled outwards with a small hook, and carefully dissected away ; the eyelids, and, if necessary, the ball of the eye, being kept fixed with the fingers, or by means of a speculum: the fingers are generally sufficient, and more convenient than any instrument. If from the appearance of the parts, and from induration surrounding the tumour, malignant action has evidently taken place, or is dreaded, then the incisions must be made wide-of the base of the .swelling. For malignant, open, and extensive ulcerations, nothing can be done farther than to allay the pain and soothe the constitutional disturbance. On the whole encanthis is a rare disease ; however, I have seen, and operated on' several instances of it. Encysted Tumours of the Eyelids. — These occur beneath the con- junctival lining of either the upper or under lid, but most frequently m the former. They form rapidly, but seldom attain any very con- siderable size ; and may be found to contain, along with "glairy fluid, a mixture of pus, or curdy matter. The contents, however, are generally glairy, rarely atheromatous. The cysts are very thin 258 DISEASES OF THE EYE. and adherent, and the tumour projects externally, forming a dusky red elevation of the integuments. They cause considerable deform- ity, watering of the eye, and stiffness and difficulty in moving the lids. On everting the eyelid, the contents of the tumour are seen shining through the distended conjunctiva, and present a bluish appearance. They are seldom single, and are not remediable but by operation. It is improper to attempt their extirpation from without, as there is a cer- tainty of cutting completely through the eye- lid, the inner covering of the cyst being merely attenuated conjunctiva. The lid is to be everted, and an incision made into the prominent and thin cyst with the point of a cataract knife ; the contents can then be readily scooped out with the end of a probe. It is impossible to dissect out the tender cyst entire, and, when this is attempted, the cure can seldom be perma- nent. If, after incision and discharge of the contents, nothing farther is done, the disease will almost certainly return, in conse- quence of the remaining cyst reassuming a secreting action. The only effectual and radical cure is the application of a finely-pointed piece of caustic potass to the interior of the cyst, after discharge of the contents and cessation of bleeding. The cyst is thereby com- pletely destroyed. A slip of soft lint, dipped in oil, is interposed betwixt the lid and and eyeball, for an hour or two, in order to pro- tect that delicate organ from the caustic. The wround suppurates and heals kindly, and no mark is visible, the incision having been made from within. I have had no instance of return of the disease since adopting this practice ; and I have operated on many which had been previously treated by other and ineffectual means. The laceration of the cyst with a pointed probe is sometimes followed by a permanent cure, but it cannot be depended upon. Closure of the Eyelids may be either congenital, or a consequence of injuries, as burns of the parts. The closure may be complete or partial. In general it is partial, though perhaps extensive ; and the adhesions can be readily separated by the point of a knife, or small probe having been previously introduced beneath ; or a small and narrow probe-pointed bistoury may be conveniently used for the purpose. In the after-treatment means must, of course, be taken to prevent the lids from again adhering. Ectropion, or eversion of the eyelids, may be produced, merely by swelling of the conjunctival lining protruding the lid : or the lid may be relaxed, and the conjunctiva may swell in consequence of repeated inflammation of the parts, caused by frequent and careless exposure; or the disease may be the result of contraction, by cica- trisation of the integuments of the face, as after burns, extensive superficial wounds in the neighbourhood of the eye, or the effect of periosteal disease of the orbit. The affection may exist to a greater or less degree, being in some instances scarcely visible, and not DISEASES OF THE EYE. 259 In troublesome, whilst in others, the eyelashes lie on the upper part of the cheek, and the swollen granulated con- junctiva is exposed. The lower lid is gene- rally the one which is affected. The disease may exist in both eyes, or only in one. In strumous habits both are frequently affected in a slight degree ; and the upper lid, too, is sometimes turned a little outwards. When eversion is of long continuance, and com- plete or almost so, the conjunctival covering of the ball of the eye, and of the cornea, be- comes dry and wrinkled ; in short, the mem- brane completely changes its character, and becomes cuticular. a lad who laboured eleven years under eversion of the upper and lower lids — arising from ab- scess and exfoliation of the ex- ternal angular process of the os frontis, following a blow re- ceived when a boy — the con- junctiva was hard, wrinkled, scaly, and exactly similar to cuticle : this change of the mem- brane also extended over the whole cornea. The surface of the eye had lost its lustre, arid vision was much impaired, the patient being able to distingnish only very bright objects. By such cases, continuity of the con- junctiva with the outer layer of the cornea is beautifully demon- strated. Some of the most intractable of all cases of eversion are the re- sult of burns. The constantly increasing contraction of the cicatrix draws either the upper or the lower lid far from its natural situa- tion, and produces frightful deformity. The tarsal cartilages are greatly extended, and in any operation for the relief of the patient it is necessary to remove a portion before the lid can be properly adapted. Great inconvenience is caused by the state of eversion : the sur- face of the eyeball is subject to inflammation, in consequence of being insufficiently protected ; the changes of its investing mem- brane is a serious evil; and in some cases the cornea becomes ex- tensively ulcerated, unusually vascular, and opaque. When the conjunctiva only is in fault, the deformity is slight, and the state of matters is readily ameliorated by excision of the re- laxed portion. This is done by sharp curved scissors. As the wound gradually contracts, the eyelid is drawn inwards, and, on cica- trisation taking place, the parts have become restored to their.healthy condition. Care, however, should be taken that too much of the swollen conjunctiva is not removed, otherwise the subsequent contrac- tion may cause inversion of the lid. Combined with the above prac- tice, relaxation of the lid itself will in many cases be remedied by removal of a portion of it in the form of the letter V, by means of a 260 DISEASES OF THE EYE. sharp-pointed bistoury : the edges of the incisions are afterwards put together by a point of interrupted suture. When eversion arises from a cicatrix of the integuments, the part in fault may be. divided ; but a temporary benefit only can be procured. For, during the healing of the wound, the parts again contract; and, though a portion of the conjunctiva is at the same time removed, the contraction internally will hardly counteract that which is going on externally. In order fully to obviate the evil of this contraction of the cicatrix in invete- rate cases of ectropion, a form of plastic operation may be successfully resorted to. The cicatrix being dissected out, and the tarsal car- tilage brought neatly into position, a piece of integument from the temple or cheek may be adapted, and a portion of a new eyelid formed. The parts may sometimes be brought into a good position without the necessity of borrowing any portion of integument. A V-shaped incision can be made, the apex pointing downwards, so as to loosen the under lid ; and after it has been drawn upwards and put straight, the edges of the lower part of the exposed space are united by suture. Entropion, or inversion, consists in the turning in of the tarsal margins of the lids, and generally takes place during inflammation and swelling of the conjunctival lining of the lid. During violent inflammation of the lid the conjunctiva and integuments are much swollen, and bulge out externally ; by the projection the margin is forced mechanically towards the ball, and entropion takes place. . But in this state of matters, should the lid be by any chance everted, and not replaced, then the bulg- ing is from the conjunctival surface, and prevents the margin from regaining its former site, and permanent eversion or ectropion occurs. In fact, inversion and eversion, like phymosis and paraphy- mosis, exist from the same parts being put in different relation to each other. More permanent entropion is caused by the contraction which follows removal of tumours from the under surface of the lids, or destruction of large portions of the conjunctiva. The disease is most frequently met with in the upper lid. Trichiasis consists in a vicious bend of the eyelashes, or in a su- pernumerary growth in the rows or numbers of individual cilia, whereby they are inverted, and sweep the surface of the conjunc- tiva covering the cornea; thus great distress is caused by the friction of the hairs and edge of the lid on the sensible surface of the eyeball, and inflammation is frequently kindled and kept up by the continued irritation ; it is accompanied by its.usual distress- ing symptoms when seated in that organ, and too often followed by a greater or less number of untoward consequences. Sometimes only one or two hairs are at fault; in other instances, the half of the eye- lash grows inwards ; and sometimes there is a double row of cilia ; one set "being in the usual position, whilst the other projects against the eyeball. If proper means are not taken to remedy the evil, and DISEASES OF THE EYE. 261 moderate the irritation which it produces, the cornea becomes thick- ened and changed in structure ; and vision, at first impaired and in- distinct, may be entirely lost. The symptoms may be for a time palliated by plucking out the faulty hairs, abstracting blood from the loaded vessels, and subse- quently using ointments or collyria, — the best of which, perhaps, is the solution of nitrate of silver. In some cases it may be necessary to employ counter-irritation, as blistering the nape of the neck ; and in all the general health must be strictly attended to. Other means may be required, and will be mentioned when treating of chronic ophthalmia. The permanent cure of the disease is effected either by removal or by destruction of the roots of the cilia. The whole edge of the eye- lid, or the offending part of it, is removed with a sharp narrow bis- toury, the operator steadying the parts by laying hold of the cilia with the fingers of his left hand. It is necessary to remove the mere edge only, the cilia and their roots, and not the whole of the tarsal cartilage, as has been proposed. Inversion of the lid, from contraction of a cicatrix in the conjunc- tiva, may be counteracted, by destroying with caustic, or removing with cutting instruments, a portion of the outer integuments, cor- responding to the internal cicatrix. Forceps with broad points are used for taking up a fold of the skin, and an oval portion is then excised with a knife or scissors, cutting instruments being less painful and more precise than caustics. Of the latter, the sulphuric acid has been particularly recommended for this purpose. The contraction of the wound releases the cilia from fhe power of the internal cicatrix, and the parts are restored to their healthy state. The term Pterygium is employed to denote a thickened and vas- cular state of part of the conjunc- tiva. The diseased portion is gene- rally of a triangular form, commenc- ing at the inner corner of the eye, extending towards the cornea, gradu- ally diminishing in breadth, and ter- minating in a sharp apex, either at the margin of the cornea, or some- where between its margin and cen- tre. The thickening is seldom great, but the vessels which traverse the thickened part are numerous, en- larged, and tortuous — are, in fact, varicose. The base of the'ptery- gium is always on the circumference of the eye, generally 'at the inner corner, and its apex is seldom, if ever, situated beyond the centre of the cornea; frequently the sclerotic conjunctiva alone is anected. lhe motions of the eye are little disturbed by the disease, but vision is materially impaired when a considerable part of the cornea is covered. Pterygium is in general single, but sometimes, though very rarely, there are two or more pterygia in one eye ; and, in such cases, the patient's vision is seriously affected, in cons* 262 DISEASES OF THE EYE. quence of the apices of the different pterygia uniting and coalescing on the cornea, and investing the greater part of that organ with a thick and dark shade. When several occur, they sometimes unite throughout their whole extent, and cover the half or more of the eye. This disease is very common amongst negroes and persons residing in equatorial climates. When the pterygium is of considerable size, extending over the cornea, the only remedy is excision. The apex of the web is laid hold of and pulled outwards by forceps or a hook, and the whole dis- eased part is then carefully dissected off with scissors, the incisions commencing at the apex, and being carried on to the base. The wound gradually contracts ; and though an opaque cicatrix must form on the corneal surface, the speck is of much less dimensions than the space formerly occupied by the pterygium. If the web be thin and not exceedingly vascular, it may be sufficient to make a semicircu- lar section of it transversely by means of a hook and scissors, be- tween its base and the margin of the cornea ; its growth is thereby arrested, and there is a probable chance of its beginning to diminish, and ultimately disappearing. When it is small and so situated as to cause no impairment of vision, it is prudent and good practice not to interfere with it at all. Diseases of the Eyeball are numerous and various in their nature. Some are acute, others chronic ; and their attack is either sudden, or slow and insidious. Most of them are attended with pain and other annoying symptoms, and some cause loss of vision. Some are cured by internal means ; others require surgical operations ; and the cure is either complete and permanent, or palliative and tempo- rary. Some destroy the organ, and others, still more malignant, cause extinction of life. All require much attention and care. Of Ophthalmia, or Inflammation of the Eye. — The symptoms and appearances of ophthalmia vary much according to the par- ticular texture or textures affected. They require to be minutely at- tended to, that the treatment may be varied in such a way as to obviate any bad consequences which may be threatened. The great impor- tance of the organ, and the danger to its structure and functions which is likely to occur from any other termination of the affection than resolution, must never be lost sight of. We shall first treat of inflammation of the more external parts of the ball, an affection generally less dangerous than inflammation of the interior, but at the same time of more frequent occurrence, and produced by slighter causes. Inflammation of the conjunctiva occurs in many individuals during very warm and sunny weather. At such a period, the eye is often excited by reflection of intense light from the surface of the earth ; and is irritated by sudden exposure to a degree of light to which it has not been previously accustomed. Different directions of the sun's rays, and different kinds of light, seem to exert different influ- ences on the organ. The rays are most hurtful when they do not DISEASES OF THE EYE. 263 fall in a perpendicular direction on the eye, but slopingly or horizon- tally. Strong light from the moon, and light reflected from scarlet, are also particularly injurious. Undue exertion of the eye weakens it, and renders it prone to become inflamed. The eyes of infants are often violently inflamed, in consequence of imprudent exposure to light before they have been gradually accustomed to its sti- mulus. Again, inflammation is caused by imprudent exposure of the eye directly to cold, or by exposure of other parts causing sup- pression of their discharges, whether natural or not. Inflammation of the conjunctiva often follows suppression, however occasioned, of the menstrual or hemorrhoidal discharges, as also suppression of discharges from the urethra, from the schneiderian membrane, or from behind the ears. Irritations in the neighbouring parts, as in the mouth during dentition, may also excite the disease. Immedi- ate irritations, however, are the most frequent cause, as the lodge- ment of extraneous bodies on the surface of the organ — particles of sand, dust, snuff, pepper, or gunpowder, minute insects, loose or inverted eyelashes. By the presence of such substances, the eye is often kept in a very irritated state for a long period. The most vio- lent conjunctival inflammation is sometimes produced by contact of gonorrhceal matter through carelessness. Occasionally metastasis of inflammation takes place from one eye to another ; so that a person may be seen one day with severe inflammation of the right, and on the following day with a similar affection of the left, aud the right entirely free from disease. Another cause, sometimes met with, of inflammatory action of the conjunctiva, is the lodgement of large foreign bodies in the orbit, with or without destruction of the eye ; as splinters of wood, straws, rusty iron nails, sharp portions of stone, &c, penetrating the globe of the eye, or parts in the immediate neigh- bourhood. Upon removal of the cause, the redness, discharge of tears, pain, &c, sometimes subsides without inflammation having been established, the vessels of the part regaining their contractility; but if the cause is continued for any considerable time, the effects do not rapidly abate. Wounds and other injuries of the organ are gene- rally followed by inflammation. But a simple clean wound or punc- ture made with a fine instrument, as in many operations, and in a favourable constitution, frequently produces little or no excitement of the part. The degree of excitement must of course depend upon the nature of the wound, the structure of the parts involved, the lodge- ment or not of the body by which the wound is inflicted, and many accidental circumstances. The eye may be injured by acids or by lime, and the textures acted upon chemically : again, the mem- brane may be wounded by pieces of hot metal, and then the destruc- tive action is both chemical and mechanical; in both cases active in- flammation of the injured conjunctiva is kindled. The state of the pa- tient's constitution modifies very much inflammatory action of the eye, however induced ; and it has been observed, that dark eyes bear injury or incited action better than those of a light hue. Not unfrequently conjunctivitis is a secondary affection, accompanying eruptile diseases, as measles or small-pox. In considering the disease, it is necessary to keep in mind the loose 264 DISEASES OF THE EYE. connexion of the membrane with the subjacent parts, as well as its own texture and functions. In conjunctival inflammation, the patient first feels a degree of pain and stiffness in moving the organ ; and has always a feeling as if a foreign body were present, whether such is the case or not. There is also a degree of itching with a sensation of fulness in the part, and this is followed by redness of the membrane, becoming more and more intense. If the disease gain ground, the colour changes to a darkish red or purple hue. To the redness succeeds heat, with profuse and hot lachrymation. Then swelling supervenes, often to a great extent: the vessels, both veins and arteries, are much gorged, and effusion of serum or blood takes place into the loose cellular tissue which connects the conjunctiva to the sclerotic. In some cases, the effusion in this situation is very considerable; lymph as well as blood is deposited, and a bulging forwards of the conjunctiva is produced; the stretched membrane becomes thickened, of a raw granulated appearance, and a bright scarlet hue, and the cornea appears sunk in the midst of the swelling, and almost hid by- it : this state of matters is termed Inflammatory Chemosis, and only occurs when the excitement is very intense. Blood is frequently effused beneath the conjunctiva in small quan- tity, in consequence of a bruise or other injury of the eye, — from violent exertion, as during coughing, — or from a less degree of in- flammatory action than in the preceding case; but the swelling thereby occasioned is comparatively trifling, and the effusion is, in general, speedily absorbed. To this affection the term Ecchymosis is attached. In inflammation of the external parts of the eye, the redness begins from the margins of the organ, and gradually diffuses itself towards the cornea. Such is not the case in inflammation more deeply seated. There is intolerance of light in a slight degree, and the patient is in- clined to keep the eyelids shut. At first the discharge from the con- junctiva and meibomian glands is increased and changed, and flows occasionally over the cheek, producing a scalding sensation. When the eyelids are at rest, as during the night, they become glued to- gether by the viscid fluid from the meibomian follicles ; but, if the inflammation increases in intensity, the discharge is arrested. * In external inflammation there is more or less constitutional dis- turbance, proportioned to the violence of the action and the irrita- bility of the system. In most instances the patient complains of headache. The above symptoms subside along with the inflammation; but, if this has been at all severe or protracted, distention of the vessels to a considerable degree continues, and the ophthalmia becomes chronic. This change from acute to chronic takes place at various periods of the affection, according to the intensity of the action, the nature of the cause, and the irritability of the constitution. And again, the second state of* ophthalmia may revert to the first, acute inflammation being rekindled by fresh irritation of the organ. Purulent Ophthalmia most frequently occurs in warm climates, DISEASES OF THE EYE. 265 and is attended from the first with profuse puriform discharge from the conjunctiva. In the natural state of the organ, the conjunctival discharge is pellucid, and so small in quantity as to be indiscernible ; but in this disease it possesses all the external characters of pus, and is secreted in large quantity. The affection commences generally in the under eyelid, with a feeling as if sand or foreign bodies were lodged in the eye. The parts swell very much, and the eyelids become more or less inverted, in consequence of serous effusion into their cellular texture. Frequently the patient experiences an exa- cerbation of the complaint about three or four hours after each meal. Though the disease usually commences in the conjunctival lining of the eyelids, the external coverings of the ball are often seconda- rily affected. In some cases the bulb becomes the seat of lancinating pains ; its coats give way; the humours are discharged ; and the eye sinks, with immediate relief to the patient from the more urgent symptoms, but at the same time with irreparable loss of vision. In other instances the effects are less injurious to the structure of the organ, but equally so to the sense of vision: the cornea becomes dull, and ultimately opaque, or ulcerates, or partially sloughs; the swollen conjunctival surface of the lids is covered with granulations, and secretes a copious puriform discharge, with or without eversion, according to the degree of swelling. At first the lids are more or less inverted, on account of cedematous swelling of the cellular tissue : in the latter stages they are everted by thickening and turgescence of the conjunctiva. This membrane is at first villous and of a dull red colour, relaxed, and its vessels enlarged, and loaded; afterwards it becomes hard, almost warty, and continues to discharge puriform fluid. The latter state of the lining of the lid produces disease of the cornea, opacity of a greenish colour, or an ulcer with intolerance of light, and other symptoms of disorganisation proceeding in that tissue. The disease is supposed to be contagious, and was the scourge of the British army for many years after the campaign in Egypt. In that country it seems to be caused by exposure to cold and damp during the night, and the intense rays of light during the day, more especially when these causes act on eyes which have not been accustomed to such vicissitudes. After its invasion, it is com- municable to others by contact of the morbid secretion ; and in indi- viduals who have been once affected the disease is very apt to recur when they are crowded together in unhealthy situations. A disease of equal malignity, and resembling in all respects the Egyptian ophthalmia, occurs from the application of gonorrhceal matter to the conjunctiva, or on sudden suppression of the gonorrhceal discharge, —metastasis of the action sometimes takes place from the urethral membrane to the conjunctiva. The eye is seldom saved from the destructive effects of the violent inflammation which follows the contact of the morbid fluid. Of all forms of purulent ophthalmia, the gonorrhceal is the most rapid in its course and destructive in its effects. Children are not unfrequently the victims of purulent ophthalmia — he ophthalmia neonatorum. Immediately after birth the conjunc- tival lining of the eyelids seems unusually red and turgid, and a great degree of swelling soon takes place, so as to render suppuration of the 266 DISEASES OF THE EYE. eyelids very difficult. Occasionally eversion of the lids occurs, when the child cries, from sudden and forcible contraction of the strong external fibres of the orbicular muscle. In general, the lids soon relapse into their former situation ; but sometimes the eversion remains, if the internally projecting tumour of the conjunctiva is allowed to become still more swelled from strangulation, caused by the outer margin of the reflected lid. The inflammation spreads over the ball; and, in general, the swelling of the conjunctiva, being greatest at the circumference of the eye, bulges out the eyelids, and turns in their margins. Puriform matter is secreted copiously, and is confined, more especially when, from inattention, the margins of the lids are allowed to become glued together. They often adhere so firmly as to require a very considerable force for their separation, and when opened the matter gushes out as if from the cavity of an abscess. From confinement of the matter the inflammation is still more increased, and the cornea involved. Whitish specks form on it, or it ulcerates, and the ulcers make their way into the anterior chamber of the eye ; or portions of it slough, causing partial loss of the organ and openings into the chamber, in consequence of which the aqueous humour is discharged, and the cornea sinks and becomes flaccid. In many instances the cornea becomes opaque, changed in texture, and increased in thickness, so as to form a convex projection from betwixt the eyelids, termed Staphyloma ; the sclerotic coat also is occasionally affected in a similar manner. A frequent cause of purulent ophthalmia in chil- dren is imprudent exposure of the eyes to strong light, the parent or nurse not remembering that the organ must be gradually accustomed to the stimulus. Exposure to cold may also induce the inflammatory action. The application of leucorrhceal or gonorrhceal matter to the eyes of the child, whilst passing through the vagina of the mother, is perhaps the most common cause of the disease. A very unhealthy state of the constitution ac- companies the affection; the scalp and other parts of the surface are frequently covered with eruptions. A singular result sometimes follows the purulent ophthalmia of infants. A small opaque spot is observed on the capsule of the lens, which remains through life a cen- tral spurious capsular cataract. Inflammation of the Cornea supervenes on simple conjuncti- val inflammation, and frequently on the purulent. The vessels of the part, both veins and arteries, previously carrying single, and therefore invisible blood corpuscles, become much dilated, are filled with numerous globules, and hence are rendered red and conspicuous to the unassisted eye. Writers on ophthalmic surgery, in their rage for refinement, speak of three kinds of this inflammation — inflammation of the external or conjunctival covering, of the middle tunics or cor- nea propria ; and lastly, of the third coat, the capsule of the aque- ous humour; such distinctions, however, are found to effect no good practical end, and it is unnecessary to follow them. Oneparticu- DISEASES OF THE EYE. 267 lar layer of the cornea may be first attacked, but the whole structure soon becomes involved. The inflammation generally commences in the conjunctival covering. Vision is necessarily much obscured from even slight inflammatory affection of the cornea. Part only of the organ may be affected, but frequently the whole is involved. Some- times only one or two vessels remain dilated ; but still, they passing over the centre of the cornea, render vision indistinct. Opacity of the cornea, to a greater or less degree, always attends dilatation of its vessels. In inflammation of the internal and middle tunics of the cornea, most of the large vessels which traverse it are seen to be continua- tions of those that ramify in the conjunctival covering; while the anastomic vessels derived from the sclerotic coat are smaller and less apparent than those of the conjunctiva. The cornea, and the sclerotic immediately surrounding it, frequently appear to be almost entirely covered with meshes of their dilated capillaries. At first the whole cornea has a cloudy appearance ; but as the disease advances portions become distinctly opaque, and at these points either lymph or pus is effused. Sometimes matter collects between the laminae, distends them, and, causing ulceration, discharges itself either into the anterior chamber or externally. Inflammation of the cornea arises frequently from lodgement of a foreign body in it; and ulcers of it are often produced by a similar cause. If the extraneous matter is not removed soon after its insertion, nature commences her endea- vours to detach it, and the process employed is ulceration. Some- times, however, a sac is formed around the foreign body as in other parts, and no ulcer is produced. Ulceration of the cornea also takes place in order to afford an exit to matter formed between its layers deeply or superficially. Deep abscess of the cornea is by no means a rare consequence of violent inflammatory action in the part. A minute opaque spot is at first seen ; this extends, assumes a yellow colour, and does not change its situation on the head being moved. The internal lamella? may ulcerate in consequence of the pressure ; but this seldom happens ; the matter is discharged externally. Suppuration in this situation is often attended with much pain.6' Abscess of the surface of the cornea is of more frequent occurrence than one more deeply seated ; from its external covering yielding readily to the pressure of the accumulat- ing matter, it generally assumes a pustular form. The fluid in such cases is sometimes absorbed, and no vestige of disease remains in the parts ; but more frequently the apex of the pustule gives way, and an ulcer is the consequence. A similar result takes place if an artificial opening is made for evacuation of the matter ; and it may be con- sidered as a good rule in practice not to interfere with collections in the cornea, as there is a probable chance of the matter being absorbed and the cornea regaining its transparency; while it is certain that breach of its surface, in such cases, though made by the most delicate instrument, will give rise to ulceration. Pustular Ophthalmia's at some seasons frequently met with : small pustules, sometimes numerous, form on the conjunctiva, whilst that membrane is turgid and its vessels dilated; the sclerotic conjunctiva 268 DISEASES OF THE EYE- around the cornea is their most common situation, but sometimes almost the whole conjunctival surface appears studded with them. When the cornea is affected, the pustules frequently give way, and produce ulceration ; and when the pustules are numerous, and sur- rounded by much vascularity, the part becomes opaque as well as ulcerated. In weak constitutions Ulcers of the Cornea occur from slight causes, — exposure to strong light, intemperance, inverted or irre- gular ciliae, a granulated state of the lining of the lids, or from mo- mentary irritation of the part by extraneous matter. The ulcer appears at first circular, but during its progress it often becomes of an irregular form ; its surface is depressed and ragged, and can rea- dily be seen by directing the patient to fix the eye, and then looking at the part from one side. The edges are elevated ; and the surface, which is of an ash colour, discharges an acrid colourless fluid, as in similar affections of all surfaces that are covered with a delicate, tense, and exquisitely sensible expansion. Sometimes the ulcer is very minute and superficial, and enlarges very slowly, if at all; but in other instances it extends rapidly in depth and size, with great pain and irritability of the organ, and intolerance of light. Occa- sionally their increase is expedited by partial sloughing. At first, when the ulcer is minute, the part often retains its natural transpa- rency. But as the disease advances, when the sore spreads super- ficially either by the sloughing or the ulcerative process, or by both, the cornea becomes opaque, often to a considerable extent, around the ulcerated part; and if the ulcer extends deeply, so as to perforate the tunics, the aqueous humour escapes, the iris falls forward, and the pupil becomes distorted : in either case vision is impaired or de- stroyed. In some cases great relief follows discharge of the humour, and the consequent flaccidity of the cornea, the ulcers seeming to have been prolonged and irritated by the fulness of the chamber. Sometimes an ulcer will penetrate the laminae of the cornea, even to the aqueous membrane. This latter tissue may resist the ulcerative process, and will then be pushed forward into the opening by the pressure of the aqueous fluid. This is the hernia of the aqueous mem- brane, so called, instances of which have been known to acquire a considerable size before the bag has given way. Abrasion of the conjunctival covering of the cornea is produced by accident, or follows incited action of the vessels. The abraded surface either ulcerates, or contracts and heals kindly, with or with- out opacity of the part. Breach of surface in the cornea, — whether an ulcer, an abrasion, or a raw surface, caused by the giving way of a pustule, or of a small abscess, — is constantly liable to irritation, on account of not being protected by mucous membrane and mucous discharge : even the contact of the tears irritates, and keeps up in- flammatory action in the membranes. When the ulcerative process ceases, lymph is effused, and a grayish halo forms around the sore ; the ash colour of the surface of the sore disappears, and is succeeded by florid granulations, extremely minute, which fill up the cavity; cicatrisation follows in due time, with subsidence of all the symptoms and appearances of inflammation. There remains, however, an DISEASES OF THE EYE. 269 opaque speck of a pearly hue corresponding to the sore, but occupy- ing rather less space. When the cornea is perforated by ulceration, the sore sometimes shows no disposition to heal, becoming a fistulous aperture through which the aqueous humour is from time to time discharged. By this condition of parts vision is much impaired, the cornea being always more or less flaccid. Touching the fistulous opening with the nitrate of silver, reduced by scraping to a very fine point, will often promote a healthy action in the tissue, and effect adhesion of its sides. The pearly speck which remains after cicatrisation of a corneal sore is termed Leucoma, and is permanent. It is generally of a uniform colour, but occasionally a black speck is perceptible in some part of it. For, when an ulcer lays open the anterior chamber, part or the whole of the aqueous humour is evacuated, and the iris falls forward ; a portion of the iris falling into the opening, provided this is not in the centre of the cornea, closes it up, and becomes adherent to that part. If the opening is large, the prolapsus of the iris is con- siderable ; and in some cases this membrane being pressed on by the humours, is forced through the opening in the form of a small bag. This change of position is termed Hernia of the Iris ; and the dark sacculated portion of the iris which projects from the surface of the cornea is called Myocephalon, from its resem- blance to the head of a fly. The myocephalon may remain for a considerable time, or may sphacelate and drop away. The pupil is thus rendered irregular, is perhaps nearly obliterated or is drawn down behind the opaque part, and thereby rendered totally useless to the patient. The impairment of vision caused by Leucoma depends on the size and situation of the speck. The disease is irremediable, though the thin cloudy opacity, which frequently surrounds the leucoma, may be dis- sipated. The operation of artificial pupil is sometimes required, in order to afford a degree of vision in this affection of the cornea, -— as well as in the speck of a similar appearance occasioned by effusion and organisation of lymph betwixt the deep lamellae of the cornea, and which is termed Albugo. Albugo occurs during the intensity of inflammatory attacks. It also is surrounded occasionally by thinner opacity, but not depressed and unequal on the surface, as leucoma sometimes is. Large and tortuous vessels are generally seen passing into albugines,but meshes of dilated vessels are seldom present. When the affection is recent, it sometimes disappears under^proper treatment, especially in young subjects ; but the albugo is by no means so readily removed as the Nebula, or thin cloudy opacity which is the frequent consequence of obstinate chronic dilatation of the conjunctival vessels. Nebula is superficial, and consists of mere thickening of the conjunctival cover- ing, from lymph having been effused. It impairs vision, but does not destroy it, for the affected part remains semitransparent. In strumous constitutions specks of the cornea are often accom- panied with ulceration of the edges of the palpebral, and destruction 270 DISEASES OF THE EYE. of the ciliae — the ophthalmia tarsi. The margins of the eyelids are red and slightly tumid, and discharge an acrid fluid ; the ciliae are matted together ; pustules form at their roots ; the bags which secrete them are laid open and destroyed, and they consequently fall out. The affection is often of long duration, and may be in part prolonged by vitiated secretion from the meibomian glands. During its pro- gress it excites very considerable irritation in the whole eye, and, as has been already stated, opacities of the cornea not unfrequently ac- company it. Veins become enlarged, and varicose on the conjunc- tiva, as also their minute ramifications on the clear part of the ball ; small reddish lines appear on the cornea, and around them is " dif- fused a thin, milky, or albuminous humour," which destroys its trans- parency at that part. Such spots may be solitary or numerous, and darken the cornea either partially or entirely. They are always sur- rounded with a fasciculus of enlarged veins. In elderly people a dim opaque ring, of a grayish colour, some- times encircles the margins of the cornea, and is called Arcus Senilis; but this can scarcely be looked upon as a disease. Sometimes the cornea presents a spotted appearance ; and this state of the organ is generally attended by obstinate inflammatory action in the part. The affection, however, is rare. I have seen several instances of it: in one, both corneae were spotted, and sight was almost destroyed, without much irritability of the organ. The dis- ease yielded to external stimulants, and the internal use of the bichloride of mercury. It is met with in a chronic and very intrac- table form. The cornea may sometimes be rendered dim by over-distention, the aqueous humour being unusually copious. Occasionally sloughing takes place in the cornea from over-action. It is dangerous to the structure and functions of the organ, according to the extent to which it occurs. Ossification of the cornea is said to take place ; but few cases are on record, and these were in very old people. The cornea sometimes becomes conical to a great degree in per- sons considerably advanced in life. The cone has its apex in the centre of the organ, seems thick and crystalline when viewed laterally, and when looked on from the front has a sparkling.appearance. In some cases it is opaque in the centre, and occasionally its surface is irregular. Vision of objects at any distance is very indistinct; those placed within an inch or two of the eye are most distinctly seen, especially if looked on through a small aperture. The disease usually affects both eyes, though not al- ways in an equal degree. The patients cannot judge accurately of distance, and see objects multiplied and disfigured. Staphyloma has been already alluded to as an occasional conse- DISEASES OF THE EYE. 271 quence of purulent ophthalmia in children. The cornea is thickened, prominent, and opaque ; and in most cases vision is either much im- paired or entirely lost. The prominence varies in different cases, being sometimes very little elevated beyond' the natural state of the part, while in other instances it protrudes from between the eyelids. After having attained a certain size it often becomes stationary ; but very frequently it continues to enlarge gradually. When the promi- nence is large, much inconvenience arises from the eyelids not being allowed to close ; and the eye, being thereby deprived of its natural covering, is extremely liable to become inflamed from external irrita- tion. When one eye is affected with staphyloma, the other not unfrequently becomes similarly diseased. Dropsy of the anterior chamber, or Hydrophthalmia, occasionally takes place in persons of weak constitutions. The aqueous humour is either secreted in greater abundance than it usually is, or absorp- tion is diminished. The cornea gradually accommodates itself to the increase of the fluid behind, and becomes wider and more prominent, but retains its transparency; in looking at the eye, the anterior chamber is seen evidently enlarged, and occasionally the aqueous humour is of a turbid appearance. There is little or no pain in the eyeball, but the patient complains of an annoying sense of fulness and tension in the part. In consequence of the vitreous humour also accumulating, the whole organ is ultimately enlarged considerably, and its motions are thereby much impeded. At first, vision of near objects is impaired, whilst the patient sees very distinctly those placed at a distance ; ultimately sight is entirely lost. Exophthalmia, or protrusion of the eye, attends the preceding disease, and is also a consequence of various other morbid actions in the globe and its neighbourhood, especially from the pressure of tumours in the orbit. The chronic enlargement of the bulb is noticed more fully in the succeeding chapters. Treatment of External Ophthalmia, and its Consequences.__The exciting cause, if such exist and can be discovered, ought in the first place to be removed. The surface of the organ and of the pal- pebrae should be carefully examined, either with the naked eye or with a magnifying glass, in order to detect any small extraneous body which may be lodged in the part. In examining the inner sur- face of the palpebrae, it is necessary, to produce complete eversion to bring the parts completely into view ; and the most convenient method of accomplishing this is to lay hold of the ciliae between the finger and thumb, and reflect the lid over a silver probe placed along its base. This can, by a little practice, be accomplished readily without using a probe, and even by the fingers of one hand only This is the more necessary, as small particles of foreign matter lodge more frequently on the palpebral conjunctiva than on any other part If a particle of glass, metal, stone, &c, be discovered, it should be gently removed by the flattened extremity of a silver probe or by a scoop, a fine needle, or a delicate brush. In some cases washing the surface by means of a small syringe, filled with a bland fluid, is ex- tremely useful; as when an impalpable powder has been thrown into the eye, and can with difficulty be removed, in consequence of 272 DISEASES OF THE EYE. spasmodic contraction of the eyelids preventing exposure of the parts. The application of an emollient poultice, with the addition ofhyoscya- mus, is beneficial when it has been found impossible to remove the whole of a fine powder- When particles of lunar caustic have, by accident, come in contact with the eye, they are to be removed, as soon after insertion as possible, by a fine hair pencil dipped in oil or fresh butter, — not in water. Small loose bodies are generally car- ried, by the increased lachrymal secretion, along the sulcus formed by the apposition of the eyelids, to the inner canthus, and there dis- charged. And, in order to favour this natural process for removing extraneous matter, the patient should be directed to keep the eyelids shut, and as quiet as possible, to cover them with his hands, and to blow his nose forcibly: thus the greater number of the extraneous particles will be got rid of. Those which remain lodged in the mem- branes must be speedily removed by those artificial means which have been already enumerated. If entropion is the cause of the in- flammation, the eyelashes are either plucked out, or completely de- stroyed by removal of their roots. The inflamed organ should be carefully protected from the stimulus of strong light; the patient is to be placed in a darkened room, and the eye protected by a thin green shade. The shade, however, may be worn too long, so as to induce an extremely wTeak and tender state of the organ. If there be good grounds for believing that the incited action has been caused by suppression of any discharge, that should be encou- raged to return, and the cause of the suppression must be avoided. If a gonorrhoea have been suddenly arrested by the employment of stimulating injections, these must be instantly discontinued; and some have even gone so far, in such cases, to introduce bougies impregnated with gonorrhceal matter, in order to procure a renewal of the discharge. In cases of suppression of purulent discharge from the ears, or the surrounding parts, followed by external ophthalmia, a blister or sinapism should be applied in the neighbourhood of the part from which the discharge formerly issued. When the menstrual evacuation has been arrested, leeches and fomentations should be applied to the pudenda, or around the anus, and emena- gogues administered internally ; the patient should be placed in a quiet and well ventilated apartment, and kept free from any emotions of the mind ; all noise and other source of irritation should be studi- ously avoided. If the incited action in the eye do not subside, as it often will not on removal of the exciting cause, recourse must immediately be had to very active means for its subjugation ; for in no other organ does inflammatory action proceed more rapidly to an unfavourable ter- mination. By timely use of antiphlogistic means, those consequences of external ophthalmia, which we have already treated of, may be avoided ; and, with respect to most of them, it is much better to pre- vent their occurrence, than combat them, after they have been allowed to take place. The eye is more valuable to a great proportion of people than a limb; and the surgeon is very culpable if he be not master of this part of his profession, and able to undertake the man- agement of every disease and accident to which the eye is liable. DISEASES OF THE EYE. 273 " In cases of inflammation the general treatment is the same ; but each variety requires peculiar attention during the cure, depending on the structure and function of the tissue affected. In the first stage of external ophthalmia, active antiphlogistic mea- sures must be put in force. In full habits, and cases of intense action, general bleeding must be employed, even to fainting, from the veins of the arm or the neck, or from the temporal artery, — and repeated, if necessary, according to circumstances. Blood is sometimes ab- stracted by cupping from the temples or the nape of the neck ; but it is a painful and uncertain mode of emptying the vessels. Local bloodletting, in many cases, suffices to moderate the action; in all it is most beneficial and important, after the employment of general de- pletion. The application of leeches to the inner canthus is the most effectual method of abstracting blood locally, as at that point the venous return is made from the eye. If placed on the temples, they can produce very little benefit; if on the outer surface of the eyelids, ecchymosis follows, on account of the extreme looseness of the cellular tissue in that situation. Or the angular vein at the inner canthus may be opened with a lancet, and a considerable quantity of blood thereby abstracted from the seat of the disease. Leeches applied to the conjunctiva of the lower lid are sometimes advan- tageous ; but leeching and scarification are more useful in the chronic stage ; and the latter is injurious in acute ophthalmia. Saline pur- gatives, and antimonial medicines, a very material part of the anti- phlogistic regimen, must not be omitted. Enemata, with occasional pediluvia, are much recommended by some continental writers. In bilious habits emetics, followed by mercurial purges, will be found very useful. With respect to topical treatment, warm applications are found to afford decided relief in the first stage, and are in conse- quence generally used. By some, however, cold water, or water with vinegar, is applied from the first. Poultices, whether warm or cold, prove annoying from their weight. w-rm fomentations, simple or anodyne, are preferable, and may be repea.ed according to the feel- ings of the patient; or the eye may be exposed to the steam of water. When by these means the violence of the symptoms has abated, as usually happens in the course of a very few days, the organ must be gradually accustomed to its natural stimulus, light. The shade must be discontinued, and the room no longer darkened ; and now leeching becomes of great service, while the evacuation is to be followed by gently stimulating or astringent applications, so as to produce contrac- tion of the still dilated, though partially emptied vessels. Various col- lyria may be employed for this purpose. Solutions of the sulphate of zinc of muriate of mercury, of sulphate of alum, of acetate of lead, or of the lapis divinis-wine of opium-the citrine ointment or the unguentum oxydi hyarargyri rubri, &c. - or stimulating vapours of various kinds Camphor is a good addition to many of the appli- cations The collyria may be cold, or slightly warmed ; and maybe dropped into the outer canthus, flowing over the eye, and escaping by the inner canthus, according to the natural course of the fluids of the eye; or they may be inserted at the inner canthus, the head being immediately afterwards inclined so as to allow the fluid 274 DISEASES OF THE EYE. to pass towards the external canthus ; or they may be applied by means of an eyeglass. Warm fomentations and other relaxing reme- dies, however useful during the first stage, are worse than useless, are hurtful in the highest degree, when the affection has passed into a chronic state ; as also are antiphlogistic means, and exclusion of light, — remedies so essentially necessary in the first stage. In ophthalmia, attended with profuse purulent discharge, the structure of the eye is in great danger of being destroyed, from the intensity of the action, and its liability to extend to the deep parts of the organ : the most active practice is required from the first. Co- pious general depletion, ad deliquium, must be quickly had recourse to ; and the patient must be freely purged, and kept in a state of par- tial nausea for some time, by exhibition of antimonals. After general bloodletting, the repeated application of leeches to the inner can- thus is necessary, in order to empty sufficiently the vessels of the part. Where the chemosis is so extensive as to bury the cornea, as it were, beneath the folds of the swollen conjunctiva, sloughing of the trans- parent tunic is frequently threatened. In order to arrest this fatal result, much good is often obtained by division of the chemosis. A sharp-pointed bistoury is passed through the swollen membrane, and radiating incisions practised, commencing at the corneal margins, and directing them towards the circumference of the globe. Sometimes four or even five of such divisions are called for, while care is taken not to wound the sclerotic coat beneath. A considerable quantity of blood is sometimes lost by this procedure, and, the chemosis subsid- ing, the cornea is saved. Infusion of tobacco, solutions of acetate of lead, and nitrate of silver, aether, and laudanum, have been used as applications to the eye from the very commencement of the affection; but the propriety of the practice appears very questionable. Blister- ing the nape of the neck proves highly beneficial, after the employ- ment of the antiphlogistic measures ; and in many cases it is necessary to keep up discharge from the blistered surface for some time. On subsidence of the violent symptoms, the swelled conjunctiva is to he attacked with escharotics and stimulants, as the nitras argenti, sul- phas cupri, or various collyria ; then only can such applications be advantageous; at an earlier period they must do harm. They repress the exuberant granulations which may have formed, or may be forming on the conjunctiva of the eyelids, promote contraction of the dilated vessels, diminish the relaxation of all the tissues, and stimulate the now dormant action of the part into a healthy state of excitement. Gently stimulating collyria may be injected betwixt the lids, by means of a small syringe. In granulated conjunctiva, it is sometimes necessary to remove a greater or less part of the diseased membrane by escharotics, the knife, or scissors; and after this has been accomplished it is well to encourage bleeding to a slight extent. In removing part of the palpebral conjunctiva, care must be taken to avoid injuring the cartilage of the tarsus ; and in the lower lid, not to take away too large a portion, lest entropion should occur during cicatrisation. In hospital practice^ the infected should be separated from the healthy; and promiscuous use of towels and sponges must not be allowed. DISEASES OF THE EYE. 275 In Purulent Ophthalmia of Children, antiphlogistic means must be pursued, if the patient is seen during the first stage of the disease ; but children do not bear depletion well. After the discharge is esta- blished, the surface of the eye must be kept free of matter, by fre- quent injection of a bland, tepid fluid ; and stimulating or astringent collyria should be applied three or four times a day. When Inflammation of the Cornea is established, it is exceedingly difficult to procure contraction of the vessels. Active antiphlogistic measures must be employed in the acute stage ; and in the chronic, stimulant applications are to be had recourse to. As, however, cor- neitis is frequently kept up in its chronic form, from deficient con- stitutional power in strumous habits, strict attention must be paid to the diet and secretions of the patient. Mild mercurial alteratives, diaphoretics, and tonics combined, will often effect a cure, where all local treatment has been tried in vain. When a large plexus of ves- sels remain dilated on the part, the most effectual method of removal is to divide them as they ramify on the sclerotic, by means of scissors Or a fine knife, and afterwards to employ stimulating applications. The irritability of ulcers on the cornea is diminished by the appli- cation of nitrate of silver, in solution or substance. If in solution, the application is used in the proportion of three to ten grains of the salt to the ounce of distilled water ; if in substance, a"portion finely point- ed is generally applied to the sore, which may be afterwards be- smeared with a little oil or simple ointment, in order to confine the action of the nitrate to the ulcerated part. It is not necessary, but on the contrary, hurtful to rub the caustic freely on the sore ; a very slight application is sufficient to coagulate the secretions on the part, and form a covering for protection of the surface. In two or three days afterwards, when the temporary covering has become detached, and when the irritability of the sore has in consequence returned, it will be necessary to repeat the application, but not till then. On each ap- plication, and few are in general required, the sore is found reduced in size considerably. The collyrium nitratis argenti is very useful in many obstinate cases of affections of the eye and eyelids, the strength of the solution being varied, according to circumstances. In Albugo and Leucoma, proposals have been made for excising, scraping, or perforating the opaque part; but the cure by such means is worse than the disease, as a raw surface is left larger than the previous opacity, and the cicatrix which must inevitable form also occupies a larger space, and is equally opaque. Leucoma and Al- bugo are incurable diseases, though the opacities may become some- what thinner, by natural processes, after the lapse of a long period. Nebula, however, are often removable. During the treatment of them, or rather, before beginning to treat them, it is of the utmost importance to attend to the state of the surface of the eye, and of the lids and eyelashes. Stimulating substances may be applied in cases where the opacities are thin ; powders of calomel, aloes, sugar, &c, have been blown into the eye: stimulating lotions or ointments are preferable ; one containing the nitrate of silver, with the addition of a proportion of the liq-sub-acet. plumbi, is sometimes used with ad- vantage. These, however, are often of no avail, unless the dilated 276 DISEASES OF THE EYE. vessels, when such exist, are divided or a portion dissected out; afterwards stimulants will be efficacious, and must be used assidu- ously. Then the vessels may require to be divided again and again. In Ophthalmia tarsi, gently stimulating ointments or lotions are to be used, and in obstinate cases much advantage will result from the application of blisters behind the ears and to the nape of the neck, or from the insertion of a seton in the latter situation. In children it is necessary to correct the state of the bowels, scarify teeth, and re- move other irritating causes to which that tender age is liable. Sloughing of the Cornea should, of course, be prevented, if pos- sible, by subduing the incited action before it has attained such in- tensity as to overcome the power of the part. The slough is slow in separating when the constitution has been much weakened; sometimes tonics and stimulants, both external and internal, are re- quired to hasten the process of separation. When the surface has at length become clean, the same treatment is required as to an ulcer of the part. Conical Cornea. — This deformity can scarcely be cured, nor can any optical contrivance effectually remedy the disturbance of vision. When the apex of the cone is opaque, the removal of the pupil to the circumference by operation affords the best chance of assisting the sight of the patient. When staphyloma is small, neither impeding the motions of the eye, nor preventing its being protected by the lids, no surgical inter- ference is called for, as the loss or impairment of vision cannot be re- medied, and as no other inconvenience than blindness is produced by the change of form in the part. But when the diseased cornea projects from between the eyelids the prominence must be diminished, on account of the deformity which it occasions, and in consequence of the eye being deprived of its natural protection of the lids, and being thereby exposed to constant irritation. In such cases it is necessary to take away a portion of the cornea, that the eye may be so diminished in bulk as to retract within the eyelids ; the size of the part removed must be proportioned to the degree of protrusion. A cornea-knife is passed into the prominence, and carried forwards so as to transfix the part, in a direction from the external to the inner canthus ; and by the knife being carried on, with its cutting edge looking downwards, a flap of the cornea is made. This flap is then laid hold of by means of forceps, and removed either with the knife or with scissors. The aqueous humour immediately escapes, and in most cases the crystalline lens and vitreous humour are also discharged. The eye consequently shrinks, and retracts within the palpebral The cut margins of the cornea soon assume a reddish appearance — they form granulations, the wound contracts gradually, and ultimately closes; but the eye is necessarily much shrunk, and totally useless as an organ of vision. Generally suppuration takes place, causing com- plete disorganisation of the parts; and the preceding inflammatory action may be so intense, and attended with so much constitutional disturbance, as to require active measures for its moderation. De- formity may be in a great measure removed by adapting an artificial eye to the shrivelled remains of the natural one. When it is neces- DISEASES OF THE EYE. 277 sary to remove only a small part of the cornea, the aqueous humour alone escapes, and during the cure of the wound the patient not un- frequently enjoys a tolerable degree of vision ; but after the wound has completely closed, vision is again lost completely. Hydrophthalmia, also, is a disease in which little hope can be enter- tained of materially benefiting the patient. In the slighter cases, in which no very annoying symptoms accompany the affection, vision may be improved by the use of optical instruments ; mercurial pre- parations may be employed in moderation, with the view of promot- ing absorption of the superabundant fluid. When the disease has made considerable progress, temporary relief may be obtained from puncturing the cornea at its lower part, so as to discharge the accu- mulated aqueous humour; but a cure can scarcely be expected from such a practice, however often the paracentesis may be repeated. In the worst cases the pain is so excruciating, and the system so much disturbed by the local affection, as almost to warrant the destruction of the organ, in order to relieve the patient; but, after all, even such severe measures will most probably prove unavailing. In Exophthalmos the treatment must vary according to the circum- stances which cause the protrusion of the eyeball. Of Internal Ophthalmia. — Inflammation of the internal parts of the eyeball sometimes supervenes on conjunctival inflammation, and then the distinctive characters of the two affections are not percep- tible. When inflammatory action attacks the deep parts primarily, the external ciliary vessels ramifying on the sclerotic coat are seen, enlarged, shining through the conjunctiva ; and, as they advance towards the clearer part of the eye, they form a zone of a pink colour, whose vessels run in a straight direction towards the margin of the cornea; but between the zone and the cornea a distinct white line is often interposed. Then large arborescent and reticulated vessels soon appear on the white part of the eye ; and from their being more su- perficial than the first, and of a brighter hue, it is obvious that they belong to the conjunctiva. They also approach the clear part of the eye, and, if numerous, obscure the former vessels — as also the red zone and white line — for they pass over them, and reach the corneal margins, and often go beyond it, in continuous ramifications. The sclerotic, in consequence, assumes a pink-red colour, and the cornea becomes dim. The iris may be primarily and principally affected, and, if so, the disease is termed Iritis ; but in most cases all the other internal parts suffer more or less. The iris changes its appearance, becomes of a dusky hue, either in part or throughout, and red vessels are some- times distinctly seen in it; from gray or blue it changes to a greenish colour, and when formerly black or brown it becomes reddish. The size of the pupil diminishes, and the contraction is often irregular, when the inflammatory action is intense. The iris swells perceptibly, and the pupil loses its dark colour, or is almost entirely closed, either from effusion of lymph, or from inflammation and consequent opacity of the crystalline lens and its capsule. The iris projects forwards, and diminishes the capacity of the anterior chamber ; the pupil is irre- 278 DISEASES OF THE EYE, gular, and often assumes an angular appearance ; and the irregularity becomes permanent from adhesion of the pupillary margin of the iris to the capsule of the lens, lymph being effused and organised, and forming a firm uniting medium between the parts. Occasionally ad- hesions form at the middle of the iris, and cause so great contraction as to give the pupil an appearance of being double. Of course irre- gularities of the pupil are most distinct when the part is dilated either spontaneously or by the application of belladonna. Tubercles sometimes form on the iris, and not unfrequently it presents a granu- lated appearance. From the commencement of the inflammatory attack the patient feels great pain in the organ and in the forehead, and there is great intolerance of light. There is a feeling of tension of the eyeball, followed by deep throbbing pain increasing every in- stant. As the disease advances, the cornea is rendered opaque by the fulness of the chambers, and the aqueous humour becomes turbid and of a milky appearance ; or lymph is effused into the anterior chamber, and floats about in flaky portions. Occasionally the vessels of the iris are so distended as to give way, causing effusion of blood into the chamber, often in considerable quantity. More frequently, however, puriform fluid is deposited, occasioning the appearance termed Hypopium. The pus is either fluid or of a thick curdy consistence : when fluid and thin, it mixes with the aqueous humour, rendering it white and opaque ; if of firmer con- sistence, it lodges"in the lower part of the chamber, but changes its position, and mixes partially with the humour, on the head being moved ; when dense and curdy, it remains separate from the humour, and its position is not altered by motions of the head. During the progress of the inflammatory action, all the symptoms increase ; the pain shoots to the top of the head, and is much aggra- vated by pressure on the eyeball. Of course vision is materially im- paired. Constitutional disturbance always accompanies the affection, and exists in a greater or less degree .according to the extent of the disease. The iris may be primarily affected, but the other textures, both external and more deeply seated, too often become involved; and in aggravated cases the whole eyeball suffers. When the most internal parts, as the choroid coat, the retina, and the vitreous humour, are affected, sudden and bright flashes of light disturb the patient, whilst vision is rapidly lost, and for ever. Occasionally the intense over-action terminates in suppuration of all the affected textures, and the eyeball soon becomes completely disorganised. In Rheumatic Ophthalmia the appearances of the diseased eye are similar to those in ophthalmia produced by any other cause. But the affection is accompanied with, and seems to arise from rheumatic diathesis. There is pain in many of the joints, and frequently in the scalp and portions of the face, increased on hanging the head, and by pressing the.parts. The pains are remittent, supervene at night, and subside in the morning, In general the ophthalmia is external; but in severe cases the internal parts become affected, and the eye is sometimes lost by giving way of the cornea. Internal ophthalmia is often occasioned by wounds inflicted either accidentally or by operation. Laceration of the iris in the extraction DISEASES OF THE EYE. 279 of cataract, or an improper performance of the operation for cataract with a needle, is by no means an unfrequent cause of the affection. Iritis often occurs during the exhibition of mercury in undue quan- tities, and is said also to be a symptom of syphilitic taint. It is, in many cases, preceded by cutaneous eruption, and seems to be the consequence of the eruption being repelled, or interfered with in its progress. Choroiditis. — The choroid membrane is sometimes primarily affected ; but more frequently the inflammation of this tunic is the consequence of sclerotitis, or the disease last described. When the result of the former cause, it generally takes on the rheumatic type. The early symptoms are zonular redness of the sclerotic, accompanied by a general impairment of vision, so that the patient expresses him- self as if looking through gauze or some dark network. Presently the sight becomes more and more impaired, until a complete amau- rosis results. The pupil is generally in a semi-dilated state, and, instead of presenting the intense black hue of the healthy eye, it reflects a greenish-gray colour, dependent upon the effusion of a turbid fluid between the choroid and retina. The nervous structures, becoming thus pressed upon, lose their sensibility to light, and are paralysed. This form of inflammation is generally chronic, and im- perceptibly advances to the iris anteriorly, and to the retina within ; the ultimate termination being complete glaucoma. Various dull and heavy pains accompany this affection ; and, in the latter stages, acute circum-orbitar neuralgia is the most distressing concomitant. By long-continued chronic inflammation the sclerotic coat appears to lose its powers of resistance — the accumulating fluid pushes before it the weakened tunic, and Staphyloma Scleroticce is produced. This pro- trusion of the external tunic sometimes takes place in various parts, and to a considerable extent, so that the figure of the globe is en- tirely lost. The thinning of the sclerotic at these points allows the dark hue of the choroid to shine through, and this, together with the bunched-like appearance of the protruded portions, has entailed upon it the name of Staphyloma Racemosum. Treatment. — In the first stage of internal ophthalmia, active treatment, properly conducted, should be successful in averting the progress of the disease; in the latter stages, there is every chance 280 DISEASES OF THE EYE. of vision being entirely lost. The treatment must be actively anti- phlogistic, consisting of general and local bleeding, the internal use of purgatives and antimonial medicines, and strict abstinence. A free use of mercury internally is said to check the disease, and, in its advanced stages, to produce absorption of effused lymph. But the inflammation can be subdued without the aid of that mineral, though its effects are often powerful; and a recollection of the bad effects which are so apt to follow its employment renders a prudent surgeon cautious in having recourse to it. Mecurial ointment, with opium, rubbed on the forehead, immediately above the affected eye, gives great relief. The same relief follows friction with oil, in which the muriate or other salts of morphia is dissolved. When the incited action declines, the extracts of belladonna, hyoscyamus, or stramonium, rubbed on the eyelids and brow, procure dilatation of the pupil, and thereby tend to prevent its further contraction; but whilst acute inflammation exists, the pupil is not dilatable ; and it is consequently an encouraging symptom when the pupil begins to yield to the influence of these medicines. In hypopium it is sometimes necessary to evacuate the pus when effused in large quan- tity, in order to prevent the injurious effects that its pressure might occasion ; but, if the quantity be small, there is a good chance of its being removed by absorption. In suppuration of the eyeball, whilst the other eye remains sound, it may be prudent to open the cornea, and allow a free exit for the matter, in order to prevent the healthy eye from becoming affected. In the staphyloma of the scle- rotic coat, when the eye, as it were, is affected by a sort of chronic dropsy, (and this disease is met with at various periods of life), the tension and bulk of the organ may be diminished by occasional puncture. The opening may be kept pervious by the introduc- tion of a conical probe from time to time. I have more than once introduced a silk thread through the most dependent and promi- nent part of the globe with good effect. The organ ultimately shrinks. Amaurosis implies an impairment of vision more or less com- plete, arising from ^disease in the brain, in the optic nerve, or in the retina, whether consisting of change or destruction of structure, or derangement of function. Vision may be diminished or lost by organic disease in the coats or humours of the eye, or by morbid formations in the orbit; but to such the term Amaurosis does not strictly apply. But, after establishment of the disease, other tex- tures of the eye may, and often do, become affected. Usually one eye at first is amaurotic ; but the other soon participates, and ulti- mately vision is impaired or entirely lost in both. The disease may occur idiopathically, or be symptomatic of other affections. The general symptoms of amaurosis are the following. Head- ache is felt for some time, either constant, or, as is most commonly the case, occasional, and most severe in the forehead : in many cases the pain is at times most excruciating. The eyesight gradu- ally becomes weak ; distant objects are unusually obscure, or not at all observed ; and those which are near cannot be accurately dis- DISEASES OF THE EYE. 281 cerned. For a short time the vision may seem to be restored, but soon it diminishes more and more, all objects seem to be enshroud- ed in a mist, at first thin and shadowy, but gradually becoming opaque and- impenetrable; or a feeling is communicated of dark network obstructing the view. Unnatural impressions are made on the retina; flashes of strong light, or luminous sparks, appear to dart across the eyes; darkened spots are seen where none exist; gnats, flies, or other minute bodies, various in colour and brilliancy, seem to flutter before the face ; or a single dark speck intercepts the vision. Usually the pupil is dilated and the iris insensible to the stimulus of light; and the former has not its natural translucent aspect, but is dull and cloudy. But the state of the pupil cannot be accurately determined in amaurosis, for not unfrequently it is much contracted, and in many cases the iris retains both its natural ap- pearance and the full exercise of its functions. The disease either advances to complete blindness, or stops in its destructive progress, leaving the patient with impaired vision to a greater or less degree. When the disease is established, pain in the head and eyes usually either ceases quickly and entirely, or gradually abates. Amaurosis is sometimes temporary, occurring at regular inter- vals ; and, during its accession, it often varies in intensity. With some patients strong light is intolerable, and vision is best in the twilight; others court sunshine, finding their eyesight thereby much improved ; accordingly, the former are said to labour under nycta- lopia, the latter under hemeralopia. Some can discern the shape of objects, but either have no perception of the colours, or mistake the individual colours; others not only see all objects indistinctively, but conceive them distorted, double, or extensively multiplied: in some one-half of the object looked upon is obscured — and fre- quently there is strabismus, in consequence of the paralysis being only partial. Organic amaurosis (that depending on organic disease) may arise from the change of structure consequent on inflammatory action in the retina, whether chronic or acute — from atrophy of that mem- brane and of the optic nerve — from extravasation into the sub- stance of the nerve, or compression of it by morbid formations — from softening or suppuration of the nerve and its connexions — or from various diseases of the encephalon. Functional amaurosis may proceed from temporary plethora about the optic nerve and retina — from intense and long continued use of the organ — from de- rangement of the digestive apparatus — from general debility, how- ever induced — from excessive influence on the system of poisons or powerful medicines—from concussion of the nervous and cere- bral substance, or from long continued irritation in the neighbour- hood of the eye. Amaurosis may also follow injuries of various kinds. In the treatment of organic amaurosis but little can be done, and that little is unsatisfactory. In the functional form, however, vision may be improved, if not wholly restored, by removal of the exciting cause, and the carefully avoiding of such circumstances as seem to predispose to the affection. After due constitutional treat- 282 DISEASES OF THE EYE. ment, considerable benefit is often derived from counter-irritation ; and I have in many cases witnessed the good effects of blistering the temples and besprinkling the raw surface with the powder of strychnine, — a practice very far from nugatory. On removing the blister, the cuticle and lymphatic effusion beneath are carefully scraped away, and from one-eighth to one-half of a grain of the powder dusted over the exposed cutis. The sprinkling is repeated daily, and the dose gradually increased. When the surface dries, a fresh blister is applied, and the use of the powder resumed. It may be employed, when gradually increased, to the extent of two grains on each temple ; but, if spasmodic twitchings and constitu- tional disturbance begin to show themselves, it must be imme- diately abandoned, and not resumed till after some days, and even then in diminished doses. In not a few cases, both of com- plete amaurosis, and of vision impaired to such an extent that the patient could merely distinguish light from darkness, I have by this practice succeeded in restoring the sight completely; in others vision has been very much improved. Still, by far the greater number of amaurotic patients are incurable; and even those who have derived benefit from strychnine are, I am strongly inclined to suspect, exceedingly liable to relapse. In the treatment of functional amaurosis, it will be necessary to investigate minutely the causes on which the defective vision may depend. Thus we may find a congestive state of the retina or brain, arising from suppressed natural discharges, as the menstrual flux, or the sudden suppression of habitual but morbid discharges, as the healing of an old ulcer, &c. Again, amaurosis may be the result of irritation in some portion of the alimentary canal, as from the presence of worms. Patients who have long laboured under imperfect amaurosis have occasionally been suddenly relieved by the discharge of a tape-worm. Difficult and painful dentition in children not unfrequently gives rise to this disease. Hence the treatment of functional amaurosis will necessa- rily vary with the cause ; and no general rule can, with any propriety, be laid down as to our selection of remedial measures. Glaucoma, or green cataract, is a disease of the hyaloid membrane and vitreous humour probably depending on a varicose state of the blood-vessels. The pupil is usually dilated, irregularly oblong, the iris being narrowed towards the upper and inner side. There is a dull shining appearance at the bottom of the eye, not fixed as in cataract, but varying according to the position of the light. The lens becomes opaque and greenish as the disease advances, vision gradually diminishes, and the iris is immovable. After sight is lost, the patient has a perception of a luminous appearance in the organ when pressed upon. Both eyes are generally affected, one after the other ; headache, often violent, attends the disease ; many remedies, both external and internal, may be tried on recommendation, though without effect: the disease seldom, if ever, admits of cure. Of Cataract, or opacity of the crystalline lens and its capsule, at- DISEASES OF THE EYE. 283 tended with partial loss of vision. — The disease is, in general, gradual in its progress : but sometimes it advances rapidly, as when occasioned by a blow or wound. When slow, the opacity commences in the centre of the lens, and extends gradually towards the circum- ference. Before any change can be perceived in the organ, the pa- tient sees objects as if covered with a mist or veil; and, as the opa- city becomes distinct, vision is gradually impaired. During the day, vision is very indistinct, as the pupil is contracted, and the rays of light reach the retina only through the opaque centre of the cataract. But during twilight vision improves, as then the pupil becomes di- lated and admits of transmission of light through a portion of the transparent vitreous humour, as well as through the semi-opaque mar- gins of the crystalline lens: for a similar reason, it is also more dis- tinct after the application of belladonna or hyoscyamus either to the eye or to its neighbourhood. In the ordinary state of the parts, a clear black ring is often visible around the opacity, either from the margins of the lens being unaffected, or from the posterior surface of the pupillary portion of the iris being pushed forwards by enlarge- ment of the lens. Patients, having become aware of the great im- provement of vision caused by dilatation of the pupil, are often con- tented to use narcotic remedies externally, so long as they retain their dilating influence — and, strange to say, they do not soon lose it — instead of submitting to any operation. As cataract advances, even luminous bodies cannot be accurately distinguished, though the situa- tion from which the light proceeds is perceived ; thus the patient in a clear light may have an indistinct perception of a candle or win- dow, and in some cases even of the bars of the windows. The motions of the iris are not affected, unless, in rare cases, when the cataract is large and compresses the iris ; or when the functions of the third pair of nerves have been in any way impaired; or when the iris has been the seat of acute inflammation. Cataract may be confounded with other diseases of the eye, as with amaurosis. But, in amaurosis, opacity, when it exists, is deep, concave, greenish, or of a metallic appearance ; whereas, in cataract, it is of a more or less white colour, convex, and situated immediately behind the pupil. Cataract may be lenticular only, the lens being opaque whilst its capsule remains transparent. In such a case the disease is slow in its progress, and the opacity uniformly commences in the centre of the lens, and gradually extends to the circumference. The degree of opacity varies in different cases, from cloudy dimness to complete whiteness. In general the predominant hue is white or grayish, but not unfrequently the opacity is of several colours, and occasionally of a mottled appearance. The consistence also of lenticular cataract varies, being sometimes fluid, occasionally extremely dense and almost osseous, but most frequently of caseous consistence. When fluid, the cataract is of larger sjze than the healthy lens ; when caseous, the part usually retains its former dimensions ; and when dense, the lens is often considerably diminished in size. The motions of the pupil are seldom, if ever affected. Cataract may be entirely capsular, the capsule being opaque, 284 DISEASES OF THE EYE. whilst the lens either remains free of disease, or has been removed by natural or artificial processes. The opacity in this case does not always commence in the centre, but frequently begins at the margin, and is of a spotted or mottled appearance, and in general not uni- formly opaque. No black ring around the opacity is observed, though the pupil be dilated ; and the motions of the iris are sometimes slow. The opaque spots are said sometimes to move when the position of the head is changed. The anterior portion of the capsule, the pos- terior, or the whole, may be affected ; but the anterior is the part which most commonly becomes opaque in the first instance. In many cases both lens and capsule are affected; and then the cataract is termed capsulo-lenticular. Occasionally the diseased lens, in such circumstances, is of fluid consistence ; and in many cases is spotted. Portions of lymph, organised or not, lodged in the posterior cham- ber, have by some been termed spurious or adventitious cataract; since, when the pupil is shut by such effusion, the appearances pre- sented are somewhat similar to those caused by opacity of the lens, or of its capsule. Such deposits, however, can readily be distin- guished from true cataract, being in general of a yellowish colour, in close contact with the posterior surface of the iris, and, when organ- ised, often streaked with red vessels. Generally, too, the pupil is irregular from adhesions between the lymph and the papillary margin of the iris. Cataract would, in some cases, appear to be hereditary,* and fre- quently it is a congenital affection. In very young children it may- be caused by imprudent exposure to strong light. In adults it often seems to be produced by the action of strong reflected light, as by exposure to intense fires in forges, glasshouses, &c, or by a dependent * Dr. Maunoir, of Geneva,a relates a curious instance, strongly corroborative of the occasional hereditary tendency of this affection. While investigating this subject, he became acquainted with the history of a woman whose grandfather, uncle, two aunts, and two cousins, all on the paternal side, had had cataract, and who had all been operated upon. She herself, at the age of twenty, was attacked with it. Finally, out of four children which she had, one was born with cataract; and, what is remarkable, neither her father, mother, nor sisters, had ever had any affection of the kind. The same writer states that Roux once operated for this disease upon three brothers, whose father and grandfather had suffered similarly. A brother, much younger than themselves, had the affection in its incipient stage. Instances more frequently occur in which several members of a family are affeqted with cataract, without any traceable hereditary predisposition on the part of either parent. Professor Drake met with a case not long ago, where five out of nine children were blind from this cause ; and last autumn I operated on two boys and a girl from Mississippi, who had lost their sight in a similar manner. — Ed. » Essay on Cataract, translated by Dr. Dowditcb of Boston. DISEASES OF THE EYE. 285 position of the head, accompanied with exposure to light. People advanced in life are most subject to the disease.* It is not anunfrequent consequence of internal ophthalmia, and almost invariably follows the slightest wound or most delicate puncture of the lens: it often occurs after slight injury of the lens or its capsule, inflicted during attempts to form an artificial pupil. Cataract may occur rapidly from exten- sive dilatation of the lenticular vessels ; or from such an injury of the eye as causes laceration of the vessels supplying the capsule and lens, detaches them from their other connexions, and consequently leaves them without a nutritive source. Cataract sometimes, though rarely, disappears spontaneously, being absorbed ; but most frequently an operation is required to remove the opaque body from the axis of vision, though no hurry is necessary in having recourse to it. The chance of success from operation must depend very much on the state of the different parts of the eye, on the kind of cataract, and on the state of the constitution. Many re- medies, external and internal, and mercury amongst the rest, have been employed with the view of dissipating cataracts; but all are of no use. An operation, of one kind or another, only can be relied on. * The two subjoined tables, the one constructed by Mons. Mau- noir, and the other by Professor Fabini, demonstrate the immense influence which age exerts upon the production of cataract: — Table I. From 20 to 29 years 30 39 ... 5 patients. . 3 40 49 . 11 50 59 . 25 60 69 . 41 70 82 Table II. . 27 112 From 1 to 10 years 11 20 14 patients 16 21 30 18 31 40 18 41 50 51 51 60 . 102 61 70 172 Above 70 109 500 It has been said that men are more liable to cataract than women ; the difference, however, if any, is probably very slight. Thus, in the first table, 61 were males and 60 females ; in the second, 268 were males and 232 females. — Ed. 286 DISEASES OF THE EYE. And still, even in favourable cases, and in the best hands, the' con- tingencies attending operation are so great that success cannot be absolutely promised or expected. The mode of operating, and the kind of operation, must be varied according to circumstances ; and great experience is required to determine the proper course of pro- cedure in each case. Steadiness is absolutely necessary both in the patient and operator, in order that the proceedings may be carried to a happy conclusion. The operator must have a good eye; a steady, light, and skilful hand ; a fine touch ; courage and caution— qualifi- cations necessary in all surgical operations, and in none more so than in those on the eye. When cataract is spontaneous, and vision not altogether lost, the patient being able to distinguish bright objects, though unable to direct his steps or followr his avocation — when the pupil is quite sensible to the application or abstraction of light, or to the use of bel- ladonna, &c, — when all the external parts are sound, the cornea clear, the chambers of the proper size, and no°reason to suspect that the retina is affected — the prognosis in regard to the effects of operation is good. When, on the contrary, the organ or the constitution is not sound — when the patient is irritable in habit or temper, or subject to gouty, rheumatic, or catarrhal complaints—when headache has preceded the opacity, and vision is gone, or nearly so, with flashes of light seeming to pass before the eyes — the prognosis is very unfa- vourable. But even total blindness must not always be considered as an indication of operation proving useless ; for sometimes the retina recovers its sensibility after removal of the cataract, and thus sight has been restored in very hopeless cases. There is no objection against operating, though one eye only is affected. By some, opera- tion is recommended as prudent, with a view of preventing the opposite eye from suffering by sympathy; whilst others consider it more safe to refrain from operating, lest violent inflammatory action should follow, and by extending to the other eye, cause disease there. However, when the cataractous eye does not present such appear- ances as forbid operation, I conceive it both prudent and safe to re- move the obstruction to vision, provided after-treatment is carefully attended to, and all untoward symptoms actively combated as soon as they appear. There is still a considerable difference of opinion on the subject; but the patient being anxious to get rid of an incon- venience and deformity, often decides for the surgeon. When hoth eyes are cataractous, a question arises as to operating on both eyes at once. From my own experience I should say, that both eyes ought not to be operated on at one time : if they are, there is great risk of violent inflammation being established, and of the opera- tion failing to restore vision. Immediately after one eye has been operated on, the other becomes very unsteady, and is altogether in an unfavourable state for operation ; and, if interfered with, the chance of a happy result is but slight. But by operating on each eye at different times, much less risk is incurred, and the chance of success is doubled.* Cataract may be operated upon at all ages, excepting * This expression admits of some modification. In young persons DISEASES OF THE EYE. 287 infancy and the period of dentition. In congenital cataract, the eyes acquire an uncontrollable rolling motion, and, if operation be delayed till the patient has attained a considerable age, such motion cannot be afterwards prevented. In such cases, therefore, the disease should be attacked as soon as dentition is completed, for then an operation can be undertaken with as little risk of injury to the organ as at a more advanced age ; and a child of twenty months or two years is unconscious of what is intended, and can be more readily secured than at any after period ; besides the best period for education is lost if an operation be not done early.* Cataract is not remediable but by surgical operation. It may be removed altogether by incision of the tunics of the eye, and extrac- tion of the opaque body ; or by the introduction of a needle, it may be displaced from the axis of vision, or so disturbed as to be acted on and removed by the absorbents. Operation with the needle is more generally applicable than that with the knife, and is more easily performed. But much mischief may be done with a needle, if the operator be not both cautious and dexterous ; by unskilful use of it many eyes have been lost. In operations for cataract on the adult, the patient, having the eye which is not the subject of operation covered, may be seated on a low chair, opposite and near to a north window, in order that clear light may be obtained. His head is supported on the breast of an intelli- gent assistant standing behind. The upper eyelid is raised by the assistant's fore and middle fingers of the left or right hand, applied so as to stretch the lid over the bulb ; and the other hand is placed under the patient's chin, to steady the head. The eye may be very well fixed by the fingers of the right or left hand of the operator him- self. He is, in that case, more conveniently placed behind or above the patient's head. The use of a speculum, for elevating the lid or fixing the ball, is seldom admissible ; and, if the eye be so unsteady or sunk as to require it, the surgeon ought not to attempt extraction. No one method can be exclusively followed ; by a man of judgment, experience, and skill, the operation will be varied according to cir- cumstances. The operation may be performed with the needle. The cataract is either depressed or reclined, and is then said to be couched. De- pre ssion is preferred by many good authorities in surgery. The with good constitutions, whose previous health has been good, and wTho have not been subject to ophthalmia, I should not hesitate to operate on both eyes at the same time. In six or eight cases, in which I have lately followed this practice, no unpleasant effects what- ever occurred: in all the inflammation was exceedingly mode- rate. — Ed. * In congenital cataract there can be no valid reason for postponing the removal of the opaque lens even to as late a period as that men- tioned in the text. The operation is perfectly simple, unattended with risk, and may be performed within six or eight weeks after birth.—Ed. 288 DISEASES OF THE EYE. needle is introduced at a line — or a line and a half, so as to avoid the ciliary processes — from the junction of the cornea with the scle- rotic, towards the external canthus, and below the transverse diameter of the eye ; and the opaque lens, if solid, is entangled with the point of the instrument, and pushed into the lower part- of the ball. Thus the opaque body is removed from the axis of vision, so as not to obstruct the passage of rays of light to the retina ; and, in successful cases, it is highly probable that the lens, after being detached and displaced, is altogether removed by the absorbents. Violent inflammation occasionally takes place after the operation, followed with destruction of the eye from the suppuration ; or the iris becomes paralytic ; or the pupil closes, and sight is gradually lost; or the cornea becomes flaccid, with congestion of the vessels and turbidity of the humours. The needle should be of a conical form, thickest towards the handle, so as to prevent the humours from escaping during its introduction. It should also be straight, ex- cepting a short curvature of its point, rather slim than otherwise, and not longer than from an inch to an inch and a quarter. The ex- tracts of belladonna or stramonium should be used in all cases, pre- viously to determining upon operations, in order to ascertain the state of the humours, the size of the cataract, and whether adhesion of the iris to the capsule of the lens exist or not. Dilatation so produced is allowed to disappear almost entirely before the operation is pro- ceeded in. It is sometimes necessary to steady the eye by means of a speculum, and the wire one of Pellier is the best. By pushing the needle, held like a writing pen, gently forwards, and towards the inner canthus, in a direction almost parallel with the iris, its point is seen in the posterior chamber, opposite the pupil. The instru- ment is then fixed in the opaque lens, and the cataract is depressed obliquely downwards ; the needle is disentangled by a gentle twist- ing motion, and then withdrawn in the same direction as it was en- tered. Before depressing, it is necessary to lacerate the capsule of the lens, and this is accomplished by giving the needle a rotatory motion, and moving its point in different directions; the anterior portion of the vitreous humour is at the same time disturbed. Lace- ration of the capsule may be too great, and allow the lens to escape entire into the anterior chamber ; inflammatory action is in conse- quence excited, and subsides only when an opening has been made in the cornea, and the offending body extracted. If the cataract rise to its original situation on withdrawing the needle, it should be again depressed, and kept down by the instrument for a short time ; and when the needle is then removed, its point should be very carefully disentangled. The lens is said frequently to regain its usual situation, a considerable time after the operation ; but in many such cases, the opacity in the pupil is not occasioned by the lens, but by the capsule having become opaque. It is said to have arisen, when very solid, twenty or thirty years after depression ; and that in many cases no absorption of it occurs. When the vitreous humour has become disorganised, the lens often floats about, arising and falling with the motions of the head. In reclination, the point of the needle is placed on the upper and DISEASES OF THE EYE. 289 anterior surface of the lens; and by raising the handle, and pushing the point slightly forward towards the inner part of the eye, the lens is removed by the axis of vision, placed inferior to it, and has the relative situation of its surfaces changed — its anterior surface be- coming the upper, and the posterior the under: the superior, poste- rior ; and the inferior, anterior. Solid cataracts only can be depressed or reclined. When a cataract is fluid, it is sufficient to puncture, or lacerate slightly, the anterior part of the capsule ; as then the opaque contents will be diffused through the aqueous humour, and soon removed by the absorbents. Should the capsule become opaque, after the removal of its contents, the needle must be at a future period introduced ; the capsule is to be lacerated and reduced to'minute shreds, so that it may escape into the anterior chamber. In the soft or case- ous cataract, displacement is not easily effected; and the surgeon must rest satisfied with exposing a part or the whole of it to the ac- tion of the aqueous humour. The above operations may be had recourse to when — from diminution of the anterior chamber, adhesions of the iris, a morbid state of the pupil, and the temper of the patient— extraction can- not be attempted. When the cataract is small, it is immaterial how it is displaced ; when large and solid, reclination is to be pre- ferred. The operator is obliged to decide as to the mode of finish- ing the operation, after he has introduced the needle, and thereby as- certained the consistence of the cataract. If it is so soft as to permit the needle to move in all directions, it is impossible to displace it; it must be be broken up, and left in situ. In the mode of operation termed keratonyxis, the needle is in- troduced through the cornea, about two or three lines from its margin,* and the cataract is either depressed or broken up for solu- tion. Depression through the cornea is, however, an operation not to be recommended, as the surgeon has much less command over the motion of his instrument, necessary in this form of procedure, than where it is introduced through the sclerotic coat. The pupil is previously dilated by belladonna, and the dilatation should be continued for some time afterwards. The puncture may be made at any part of the corneal circumference ; it soon heals, and leaves no scar. The operation can be performed without much distur- bance of the organ, and it is applicable when the cataract is soft or fluid, as in children, or its consistence doubtful. Young subjects should be placed recumbent during the operation, and rolled up in in a sheet, so that they can have no command over their limbs. Extraction, in favourable circumstances, and in dexterous hands, * This, I suppose, must be a typhographical error. The author can certainly not mean that the instrument should be introduced at the centre of the cornea, as would inevitably happen if we were to carry out his directions. The proper point is the lower and outer part of the cornea, about a line anterior to its junction with the scle- rotic coat. — Ed. 25 290 DISEASES OF THE EYE. is a beautiful operation, and most satisfactory ; but ought not to be undertaken unless the surgeon has perfect confidence in himself. It can be resorted to only in adults, great steadiness on the part of the patient being absolutely necessary. The case, too, must be judi- ciously chosen. The conjunctiva must be sound, and indeed almost no operation on the eye should be undertaken unless this membrane is in a healthy condition ; the cornea should be transparent in every ' part— the anterior chamber of a proper size — the pupil regular — the iris steady, and not protruded— and the cataract solid ; there should be no rolling motion of the eyeball, and no adhesions of the iris. I repeat, the iris should be steady, for a tremulous motion of it indicates disorganisation and fluidity of the vitreous humour ; in such a case, the humour can with difficulty be prevented from escaping ; or the lens may fall into the bottom of the eye, and all efforts to remove it will then prove abortive. And though such descent of the lens should not occur, still the organ is in a very unfavourable state for operation, being apt to become affected with deep inflam- mation, followed by complete amaurosis, or by closure of the pupil. The patient is prepared for the operation by moderate living, and at- tention to the secretions and digestive organs, for some time pre- viously ; and after the operation leeching maybe necessary either as a precautionary measure, or when inflammation has occurred. Im- mediately before having recourse to any of the operations for cata- ract, a small blister may be applied with advantage behind one or both ears, and kept open for some few days, as a precautionary measure against inflammatory action in the organ operated upon. The operator is usually seated immediately before the patient, and so that his breast may be on the same level with the patient's head ; if not ambidextrous, he may often be obliged to assume very awk- ward attitudes. The recumbent position, however, is preferred by many operators, and has the great advantage in the superior steadi- ness of the head of the patient. The hand of the surgeon may also be rested on the back of the couch, as if ambidextrous, he will inva- riably take his position behind the patient, in order that he may have the command of the upper eyelid in his own hands. The incision is made either in the lower or upper half of the cornea. The knife should have a very keen edge, and become gradually broader and thicker, from its point backwards : in using a narrow instrument there is danger of the aqueous humour escaping. The best knife is Beer's, well made. The light must be good, the patient's head completely steadied, the eye well fixed by the fingers of the as- sistant, and the other one covered by a bandage. No speculum should be employed, and the pupil should not be dilated by bella- donna. The surgeon, supporting his elbow on his knee, or resting his fingers on the cheek of the patient, holds the knife like a writ- ing pen — in the right hand, if the left eye is to be operated on, in the left, if the opposite (that is to say, if he sits before his patient: if, however, he places himself behind, this must be reversed)— and ascertains the steadiness of the organ by touching the cornea gently with the side of the knife. The cornea is punctured about a line from its margin, and near the outer extremity of its transverse DISEASES OF THE EYE. 291 diameter, the point of the knife being directed towards the centre of the eye, lest it should enter between the laminae. The knife is then passed through the anterior chamber, with its side parallel to the iris, and its point is brought out at that part of the cornea ex- actly opposite to where it entered: transfixion is thus completed, and by pushing the knife, steadily forward, without any sawing mo- tion, a semicircular section is effected. As soon as transfixion is accomplished, the operator has complete command of the eye, and all pressure should be taken off— the assistant should now merely keep the eyelid raised. Should the edge of the knife not come easily through the cornea, its passage may be assisted by pressure with the finger-nail. After the pupil has been allowed to dilate, by covering the eye for a few seconds with the hand, the capsule must be opened suffi- ciently for the escape of the lens. The eyelids are gently raised, a fine curved needle, or curette, is introduced through the incision, and by it a crucial wound is made in the capsule. The lens is then either entangled in the point of the needle and withdrawn, or very gentle pressure is made on the globe, so as to force out the lens ; and, should it not readily pass through the wound of the cornea, it can be removed from the anterior chamber by a small scoop. After removal, the eye is allowed to rest; then careful examination is made ; and, if any opaque substance remain, it is extracted by the needle or scoop. If the capsule is opaque, it must be taken away along with the lens. Before closing the eyelids the corneal flap should be carefully adjusted, and any matter lodged between the divided surfaces removed ; loose eyelashes are to be taken away, inverted ones should be previously extracted, and the mar- gin of the lower lid should beso placed as not to disturb the flap. In transfixion, the point of the knife should not be brought out too low, nor too much towards the centre of the cornea; and care should be taken to avoid entanglement of the iris. When the iris falls for- ward so as to come under the edge of the knife, and be in danger of division should transfixion be proceeded in, pressure may be made on the cornea, so that the remaining aqueous humour may repress the iris from its untoward situation ; or the knife maybe withdrawn, and the operation delayed till the eye has become quiet, and the in- flammation, if any, has subsided ; or the incision may be completed with a blunt-pointed narrow knife, or with probe-pointed scissors. Division of the capsule by the point of the knife during transfixion has been practised ; but it is an unsafe, though dexterous, measure. In opening the capsule care should be taken not to separate its attach- ments, otherwise it will become opaque, and thereby passage of light to the bottom of the eye will be again obstructed. Neither should much pressure be used for extrusion of the lens ; for, in the case of a large and firm cataract, the iris may be lacerated, and the humours escape. When any of the vitreous humour has escaped, in consequence of its cells having been broken down, and its tenacity diminished, the eye soon fills again, but good vision is hardly to be expected. After the operation, applications to the eye should be very light; 292 DISEASES OF THE EYE. a rag dipped in cold water, and renewed occasionally, is suffi- cient. All stimnlants of the organ, as light, should be avoided, and antiphlogistic treatment adopted. Should violent pain super- vene, bleeding, both local and general, and other means for sub- duing inflammatory action, must be had recourse to. The eyelids should not be raised or exposed for at least three days, unless in extraordinary circumstances. Belladonna is of use when gradual contraction of the pupil occurs. In very favourable cases, vision is completely restored in the eye ; in others, the functions of the two eyes do not correspond, and vision is confused : the patient requires to wear a convex glass before the one which has been operated on. The operation of making an artificial pupil is far from being uni- formly successful, and ought not to be had recourse to unless vision is entirely lost, or so much impaired as to be insufficient for the guidance of the patient's steps. It is necessary on account of cen- tral opacity of the cornea—leucoma with entanglement of the iris — and entire closure of the pupil, or diminution of it, with conceal- ment of the remainder by corneal opacity. It may be required after badly performed extraction of a cataract, the iris being entangled in the scar of the incision, at a distance from the junc- tion of the cornea with the slerotic ; or on account of closed pupil from inflam- mation, when, perhaps, the cornea is all clear. The operation is varied according to the size of the anterior chamber, the presence or absence of the crystalline lens, the extent of sound cornea, and the condition of the iris. Interference is useless when disease of the retina is suspected, from the extent of the previous disease — from violent inflammation, with or without discharge of part of the contents of the eyeball. Three distinct methods of operation are pursued. I. Simple division of the iris, or corotomia, may be practised when the iris is stretched, as after extraction. It is performed by introduc- ing a small knife, like a needle, through the anterior or posterior chamber, — the surgeon being in this regulated by the size of the anterior chamber and the presence or absence of the lens,— pushing its point through the iris, or cut- ting that membrane vertically, horizontally, or both, to an extent sufficient for the tranmission of light. If the anterior chamber be of its natural size, a small opening may be made in the cornea with a cataract knife, or a double-edged broad and thin one ; and through this opening small scissors may be intro- duced for division of the iris. II. Corectomia, or cutting out a portion of the iris, so as to make the opening oval, square, or angular. This is performed by intro- ducing, through an aperture in the cornea, scissors and forceps, or hooks, double or single — the latter to lay hold of the iris, the for- DISEASES OF THE EYE. 293 mer to divide it. After the escape of the aqueous humour, a por- tion of the iris may be made to protrude ; and, on the projecting portion being cut off, the membrane, with a proper opening in it, regains its natural situation, in consequence of discharge of the humour from behind. This operation is applicable only in few cases ; the whole, or the greater part, of the cornea must be clear, and the anterior chamber not diminished in size, so that sufficient room may be afforded for the introduction of instruments between the iris and the concave surface of the cornea. In those cases where the natural pupil remains along with a still transparent lens, while vision has been destroyed by a central opa- city of the cornea, the use of sharp and pointed instruments is forbid- den. Sharp hooks or scissors would endanger wound of the crystal- line, and the case becoming complicated with traumatic cataract. The blunt hook, as proposed and used by Mr. Tyrrell, is here to be pre- ferred. A small opening is made through the cornea, as the most convenient part, and the hook carefully introduced and entangled in the existing pupil: the iris is then drawn to the corneal wound, and either left entangled in the section, or removed by a pair of curved scissors. A pupil is thus formed opposite to the remaining trans- parent portion of the cornea. III. Corodialysis, or separation of the iris from its ciliary attach- ments, is the method most easily performed, and most generally applicable. The eye is fixed either with the fingers or with a specu- lum ; and a curved needle, perhaps more curved than that usually employed for cataract, is introduced either behind or before the iris, and at the upper, outer, inner, or lower part of the ball, as circum- stances may require. An artificial pupil at the lower part is by much the most useful; but, if the lower part of the cornea is opaque, it must be made opposite to the inner or outer clear part. The point of the needle is entangled in the attached margin of the iris, and by raising the hand quickly, and partially withdrawing the instrument, the connexions are separated to a sufficient extent. Effusion of blood into the chamber, and to a considerable extent, follows these pro- ceedings ; and it is only after its absorption that it can be ascertained Whether benefit is likely to result or not. After all these opera- tions, inflammatory action requires to be kept down by antiphlogistic measures, abstraction of blood, purgatives, antimonials, and, perhaps, mercurial preparations. It is questionable whether belladonna can be useful in preventing closure of an artificial pupil, Wounds of the Eyeball and its Neighbourhood. —Wounds near the eye, though unimportant in themselves, require considerable at- tention, on account of the eye, or its appendages, being likely to suffer in consequence. Thus, transverse wounds of the forehead or eye- brow, if their edges be not approximated accurately and soon, may cause prolapsus of the eyelids; or the eyelids may become swollen and turgid, or erysipelatous, in consequence of inflammatory action attacking the wound. When wounds of the forehead are in a per- pendicular direction, their margins are easily preserved in apposition, having little tendency to retract, and there is no risk of the relative 25* 294 DISEASES OF THE EYE. situation of the eyelids being altered. If there be considerable loss of substance in the lower part of the forehead, from the nature of the wound, when inflicted, or from its having become the seat of un- healthy suppuration, on cicatrisation of the part the eyelid will be drawn upwards, and perhaps more or less everted. There is reason to believe that a degree of blindness, and even complete amaurosis, has been caused by wound of the eyebrow, the superciliary nerve having been contused, wounded, or otherwise injured ; or the func- tions of the eyeball may be disturbed by concussion from injury. Paralysis, also, of the levator palpebrae superioris, or of several of the muscles belonging to the eyeball, may follow injury of the forehead and neighbouring parts, from either laceration or concussion of the nerves. Wounds of the eyelids, particularly when neglected, may cause much change of relative situation in the parts, and thereby produce both inconvenience and deformity. In some instances, the relative position of the puncta lachrymalia is altered by the cica- trices of the eyelids or tarsal cartilages, when the original wound has been imperfectly adapted : hence results an incurable epiphora. In wounds, such as those above mentioned, it is of great import- ance to bring the raw edges into contact, and retain them so ; and, in most cases, one or more points of interrupted suture are necessary. Adhesive plaster may be at the same time applied, but of itself is in- sufficient to effect permanent coaptation. Wounds of the eyeball, however slight, require much attention, being inflicted on an important and highly sensible organ, and there being always a risk of destructive inflammatory action. If the breach of surface be clean, simple, and superficial, rest of the parts will in general be sufficient to effect a cure. Lacerated wounds, and such as penetrate into the interior of the eyeball, cannot be expected to heal without morbid action having been excited : inflammation must be anxiously looked for, and actively combated as soon as it appears. When a foreign body lodges in the wound, it must be early removed. But in certain cases it is imprudent to attempt extraction of foreign matter ; as when a small shot, or other minute substance, has lodged in the interior of the eyeball. In such circumstances we can only adopt such measures as prevent and subdue morbid excitement. The organ may remain a little disturbed for a short period, but vio- lent inflammatory action soon occurs, and, though subdued for a time, again breaks forth, and, by its successive attacks, may ultimately destroy the eyeball. Frequently all endeavours to avert untoward results are unavailing, and the functions of the organ are more or less impaired—the cornea may become opaque, the iris may protrude, the pupil may become irregular, contracted, or obliterated — the crystalline lens may lose its transparency, amaurosis may occur from injury of the retina, the humours may be evacuated, and the eye sink in its socket. The entrance of a large foreign body into the orbit may displace the globe, and cause it to protrude between the eye- lids : in such a case the body should be removed and the ball gently replaced ; vision may be soon regained ; but, if the protrusion has been such as to cause much stretching of the optic nerve, blindness more or less complete remains. Fatal effects may follow wound of DISEASES OF THE EYE. 295 the eye, on account of the foreign body, as a sharp-pointed instru- ment, penetrating the thin parietes of the orbit, splintering the bone, and injuring the brain. Orbital Inflammation. — Inflammation seldom attacks the parts situated between the orbit and the eyeball; but, when it does, the affection is very serious. The action is very acute, and proceeds rapidly to suppuration. The pain is excruciating, extends to the whole head, accompanied with a sensation of extreme tension in the orbit, and is much increased by the slightest motion of the eye : and from the matter accumulating around the ball, and being confined to the unyielding orbit, by the dense fibrous expansion which extends from the margin of the orbit to the interior surface of the eyeball, the globe is pushed forwards, and distends the lids. The palpebrae become erysipelatous, and swollen by serous effusion. Violent in- flammatory fever occurs; and, as the disease advances, all the symp- toms are aggravated, and become almost intolerable. The globe is farther protruded, and the retina is insensible to light. At length the accumulated matter makes its way to the surface, and is dis- charged, giving great relief to the patient, and permitting the pro- truded globe to regain its situation. The inflammation seldom extends to the eyeball. In the early stage of this affection, the most decidedly antiphlo- gistic measures are imperiously called for. When fluctuation can be felt, or when the symptoms indicate that suppuration has taken place, whether fluctuation is perceptible or not, an early opening into the affected part should be made through the dense orbital ligament. Thus a free exit is allowed for the matter, the patient is instanta- neously relieved, and the extent of the local mischief is limited. It is unsafe to wait for the spontaneous evacuation of the matter: such a process is necessarily tedious, and, before it has been accomplished, the orbital bones may have become diseased ; they may have given way at certain points, and the matter may have escaped within the cranium. The artificial opening should always be free, and deep if necessary. Tumours in the Orbit. — Sarcomatous tumours occasionally form in the cellular tissue of the orbit. They occur at all periods of life, and may, by slow and gradual increase, cause the eyeball to pro- trude and disturb its functions ; or their growth is rapid, and accom- panied with great suffering. In some cases, the eye is made to pro- trude to a great degree, and by the extension of the optic nerve vision is impaired ; in others, the patient is totally blind at the com- mencement of the disease. Yet the eye may be displaced to no small extent without amaurosis following. The optic nerve appears to bear a good deal of extension without disturbance of its functions. The majority of tumours in this situation are of rapid growth, their structure is soft and medullary, they sooner or later furnish a fungus, and, though removed at an early period, are generally reproduced. The exophthalmos is often the first indication of such a growth, and it is sometimes greater in the early part of the disease than after- wards, when the fascia passing down from the edge of the orbit has given way. The malignant tumours are most frequently met with 296 DISEASES OF THE EYE. in childhood, though morbid growths of a bad kind form in the eye- ball at different periods of life. They often follow the infliction of a blow or wound. The patient's sight speedily declines, without any known cause ; there is pain in the forehead, temple, and eyeball; the ball protrudes, perhaps slightly, and at first is not otherwise changed ; but on careful examination a dimness can be perceived deep in the eye. The opaque body approaches the pupil and fills it, and may in this state be mistaken for disease of the crystalline lens; but the tumour soon pushes forward the iris, and fills the anterior chamber. It has an irregular surface covered with flocculi. Blood- vessels are observed ramifying on it, and by this it is distinguished from cataract, should the accompanying symptoms not have pre- viously convinced the surgeon of the nature of the disease. If not interfered with, the cornea ulcerates, a fungus appears, often grows with great rapidity, and may either furnish not a drop of blood, or bleed profusely. The eyelids are cedematous and permeated by large venous branches. Abscesses form around ; the lymphatics of the neck are involved ; and the patient succumbs. The original tumour may possess the usual structure of medullary sarcoma, may be of a melanotic nature, or may contain a mixture of both ; or it is of harder consistence, containing cells filled with bloody, glairy, or other fluid. The whole coats of the eye are seldom involved : part remains sound, but compressed and disfigured by the morbid mass, and the humours are either absorbed or discharged. Circumscribed tumours, exterior to the ball, and surrounded by a cellular cyst, may be removed by careful and cautious dissection, without injury to the important parts. A free incision is made along the edge of the orbit, in the course of the fibres of the sphincter oculi. The tumour is exposed, laid hold of with a hook or small vulsellum, and separated from its attachments by a knife, the edge of which is directed towards the new growth. A man, aged 26, had laboured under blindness with exophthalmos for eighteen months. A tumour could be felt above the eyeball, which I dissected out, along with the lachrymal gland, to which it adhered- It was of medullo-saracoma- tous structure, and of the size of a plum ; at one point it contained amass of coagulated blood. After its removal, the eye resumed its places and functions. The patient remains well; but such favourable cases are rare. If the affection be more extensive, it may be necessary to remove all the contents of the orbit; but, in disease involving the entire structures, there is little chance of the patient remaining free from it: it almost uniformly returns, as is also the case whenever the disease has commenced in parts of the eyeball. The optic nerve is often affected at an early period: its cut surface is unsound ; and from this, again, springs a fungus which grows rapidly. But under many cir- cumstances the surgeon is not only justified in removing the orbital contents, but called upon to do so. The operation, though cruel and painful, need not be tedious. The commissure of the eyelids is divided with the point of a bistoury, and the fore part of the ball laid hold of firmly and deeply with a vulsellum — that is, forceps pro- vided with a double hook at each extremity of the blades. A straight STRABISMUS. 297 bistoury is then entered at the margin of the orbit, pushed down to the base, as near as possible to the entrance of the optic nerve, and carried round the tumour rapidly, the blade towards the handle being made to move more quickly than the point. The nerve is cut across, and, after the removal of the morbid mass, the cavity is sponged out and examined. The lachrymal gland, and other soft parts, particularly if altered in texture, are raised with a hook, and removed by means of curved scissors. In young subjects, and in adults, when the disease is far advanced, the parieties of the orbit are thin, softened, and attenuated by pressure; the knife should there- fore be used cautiously, and it is, perhaps, safer to finish excision with a narrow curved and probe-pointed bistoury, after having penetrated to the bottom of the orbit with a sharp-pointed knife; all other curious and crooked knives are useless. Bleeding is restrained by charpie, pressed firmly and quickly into the cavity, and supported by compresses and bandage ; but, before introducing the dossils, all coagula and fluid blood should be carefully sponged out. After- wards, excited vascular action, with pain in the head and wound, may in some subjects require abstraction of blood, the exhibition of purgatives and antimonials, and immediate removal of the dressings, followed by fomentation and poultice. When matters proceed favourably, the charpie is removed gradually as suppuration ad- vances, and the granulations are supported with light dressing, either dry, or moistened with some slighty astringent lotion. The dis- charge will gradually cease, and the granulated surface cicatrise under the level of the eyelids. In such circumstances, the deformity may be remedied, after the parts have become quiet, by the adapta- tion of an artificial eye of enamel, made so as to resemble exactly the other eye. It is worn without inconvenience, removing at night like artificial teeth or a wig, and cleaned and replaced in the morning. Such a substitute is also useful when the humours have been evacu- ated, or the organ destroyed, by injury or the effects of inflammation, Too frequently the morbid growth is reproduced, and that rapidly. It maybe restrained by escharotics, the red oxide of mercury, potass, acetate of lead, acids, or the actual cautery; but the patient is thereby put to much pain without a chance of ultimate benefit. It is too true, that the hopes of a cure after the extirpation of the eyeball for malignant disease, are defeated by the prior existence of a similar affection within the cranium. In the majority of cases, death has occurred from tumours of greater or less extent, along the course of the optic nerve, or their tract; behind the commissure, and extending to the optic lobes and even cerebellum. [STRABISMUS. Strabismus, or squint, as it is vulgarly designated, may be defined to be an aberration from the natural direction of the optic axis, by which the consent between the eyes is destroyed, and vision more or less impaired. The resulting deformity varies in different cases, from the slightest possible cast to the most disagreeable obliquity. The affected organ may be turned inwards or outwards. 298 STRABISMUS. upwards or downwards, according to the muscle upon the derange- ment of which the squint depends. When the eye is directed in- wards, it constitutes what is called convergent strabismus ; if on the other hand, it inclines outwards, it is said to be divergent. The up- ward and downward obliquities have not received any particular names. As might be supposed, these different forms of strabismus do not occur with equal frequency. On the contrary, two of them are so rare that I have not yet met with an instance, though I have examined the eyes of a very considerable number of persons la- bouring under this infirmity. These two forms are the upward and downward, both of which, but especially the latter, are so seldom witnessed that their occurrence may well be doubted, except as the result of external violence. The most common variety of strabismus by far is the convergent, in which the eye is directed inwards, or inwards and upwards. Of 536 cases collected from various sources by a writer in the Philadel- phia Medical Examiner, 506 were of this description, a proportion which fully accords with my own but more limited observation. The degree of obliquity may be very moderate, or so great that when the person looks directly forwards with the sound eye the cornea of the other shall be almost entirely concealed at the inner canthus. It is worthy of remark, that in this form of the lesion, at least so far as my own experience goes, the organ rarely, if ever, inclines downwards, but nearly constantly somewhat in the opposite direction. Next in point of frequency is the divergent form, which, however, is comparatively rare. Of 866 cases reported in the work above alluded to, it was noticed only forty-four times ; and thus far I have myself seen only three or four examples of it. The eye in this variety of strabismus is seldom drawn out very far, nor is it so apt to be attended with the same amount of upward obliquity as the con- vergent. It seems to be the general sentiment of writers on strabismus, that, in the great majority of cases, only one organ is affected. Thus, in the article in the Philadelphia Examiner, before adverted to, it is stated that the distortion occurred 459 times in one eye, and only 47 times in both. Dr. Dix, of Boston, in a small treatise on strabis- mus, makes a similar remark. Of 50 cases which fell under his notice, the lesion is said to have been limited to one eye in 36. Now I am convinced from a good deal of experience that nothing can be more unfounded than this opinion, which is to be deprecated the more because it is calculated to lead to very serious errors in prac- tice. I unhesitatingly assert, that in nearly all instances, at least of convergent squint, both organs are implicated, though not in an equal degree. Usually — perhaps always — one is more affected than the other, which the patient, therefore, regards as his good eye, as it is the one which he constantly employs in viewing objects. Nor is it surprising that this should be the case, when we recollect the remarka- ble sympathy existing between these structures, and the fact that when one eye is diseased the other is very liable to take on morbid action also. Amaurosis of one eye is very often followed by a similar STRABISMUS. 299 malady of the other, and the same is true of cataract and some other affections. In the natural state there is a perfect agreement between the optic axes, produced by the harmonious action of the straight muscles, but when this consent is destroyed, as it is in strabismus, the eyes lose their parallelism, and the distortion in question is the consequence. As was previously intimated, one eye is commonly more affected than the other, and, this if I mistake not, w'ill be found to be the left, though it is impossible, in the existing state of the science, to indicate the proportion. Mr. Lucas thinks that the proportion in favour of the left eye is as three to two ; Dr. Phillips of Leige, on the other hand, maintains that the right organ is more frequently involved than the other. It rarely happens that both eyes become deranged simultaneously; on the contrary, one generally squints, first, and after a while the lesion begins in the other, the interval being pro- bably very short. Whether strabismus occurs with equal frequency in both sexes, is still an unsettled question. Of thirty-two cases on which I have operated, only five were females, whereas in the fifty cases published by Dr. Dix, of Boston, only nineteen were males, thus exhibiting a most remarkable disparity in reference to thispoint. The difference, if any, is perhaps not great either way, and, as it is of no practical importance, it need not be pursued any farther here. The exciting causes of this affection are numerous and diversified. One of the most frequent is imitation. Nearly one-seventh of all the cases that occur are probably induced in this manner. Hence our schoolrooms may be regarded as a fruitful source of mischief, one cross-eyed child being often the cause of strabismus in many others, merely from that habit of imitation to which the young are so much ad- dicted. Ophthalmia, by whatever cause induced, is another, and that a very common source of this distortion. I have seen repeated in- stances of this kind, and many others are mentioned by authors. Convulsions, eruptive diseases, such as measles and scarlet fever, hooping-cough, derangement of the digestive organs, injury on the eye, and difficult dentition, may all be enumerated as so many causes of the lesion in question. Frequently it arises without any assign- able reason, and when the individual is in the most perfect health. Occasionally it is congenital, or, what is more probable, makes its appearance within a few days after birth. It is supposed that strabismus is occasionally hereditary. This is doubtful; for if we sometimes meet with cross-eyed children whose parents, one or both, are similarly affected, it by no means proves that the distortion was transmitted to them in the manner of certain maladies. It only shows a coincidence, which may be explained, in most instances, on the assumption that the children have acquired the obliquity by imitation, or by some other cause, not that it was entailed upon them previously to birth. In the same manner we may satisfactorily account for the existence of strabismus in several members of the same family, of which a remarkable instance has recently come under my own observation. Of three brothers, one has three children affected with it, another two, and a third one. 300 STRABISMUS. The parents have all sound eyes, and so have the uncles and aunts, except one, on whom I operated successfully several months ago. Last autumn I operated for cataract on three children belonging to a gentleman from Mississippi, wrho informed me he had six others at home, of whom three were affected with strabismus. Both parents, as well as their immediate relatives, are free from the affection. Strabismus essentially consists in a contracted state of one or more of the muscles of the eye. This, as was before intimated, is com- monly the internal rectus. The shortening varying according to the extent of the squint, is always attended with a corresponding elonga- tion of the opposite muscles, so that it gradually loses, either in whole or in part, its antagonising influence. How this affection is brought about, in the first instance, is still unknown, though it is probable that it depends upon some lesion of the nerves which supply the mus- cles of the eye, rather than upon any actual lesion of these fleshy bundles themselves. Be this as it may, when the resultant distortion is permanent, the affected muscle, from being constantly engaged in holding the eye in its unnatural position, acquires a corresponding de- gree of development, in accordance with a law of the animal economy that, in proportion as an organ is exercised, will be its size and strength. The more frequent occurrence of convergent strabismus is owing, doubtless, to the fact, that the internal straight muscle is not only larger and stronger than the others, but that it is inserted much nearer the cornea, deriving thus two important mechanical advantages. One of the most disagreeable effects of strabismus is the deformity to which it leads, rendering the individual an object of constant ob- servation and ridicule. Were this confined to infancy and childhood, if would be of comparative little consequence, but when wre reflect that it continues through life, and that it is a source of incessant mor- tification, the influence which it exerts upon the temper and disposi- tion of the sufferer must often be of the most unhappy kind. A still more serions effect, however, is the impairment of the vision of the affected eye, which never entirely absent, sometimes amounts nearly to a total loss, from the insensibility of the retina, which is sometimes as complete as in confirmed amaurosis. In another series of cases the person is myopic, or sees objects only at a short distance. In some instances, again, there is double vision, or objects appear in- distinct, and run as it were into each other, the image painted on the retina being confused and imperfect. The distortion in question can be remedied only by surgical operation, it having no tendency to a spontaneous cure. On the con- trary, it generally manifests a disposition to increase, particularly in children of a nervous excitable temperament. In fact, the very worst forms of squint I have ever witnessed were in persons of this description. The question then arises, at what age ought we to operate ? My opinion decidedly is, the sooner the better. Provided the child be in good health, and not under one year of age, I would not hesitate a moment to resort to the knife for'its relief." And why should we ? The operation itself is not particularly painful, and if it be done at an early period it will commonly be necessary to perform STRABISMUS. 301 it only on one eye, whereas, if it be postponed till the age often or twelve, as some have suggested, we shall not be able to effect a cure without dividing the corresponding muscle of the opposite side. Moreover, the sight in the meantime will become considerably im- paired, the retina will lose its insensibility and the individual be an object of ridicule and insult; all of which may be thus obviated. But it may be urged that a resort to the knife at this tender age will be both difficult and dangerous ; difficult, because of the struggles of the little patient, and dangerous because of the great susceptibility of the nervous system. In regard to the first of these points, it may be stated, that the resistance, however great, may be easily enough surmounted by proper management; and, as it respects the latter, that it has been vastly overrated. Operations much more severe are frequently performed even at a much earlier period. I have seen the primitive carotid artery successfully tied in an infant of less than six months; and I have myself repeatedly operated, with similar results, for hare-lip, and that too in the very worst forms of that mal- formation. I do not, therefore, in these objections, see sufficient reason for deferring the division of the affected muscle. The instruments which I employ for the operation, are two lid- holders, a double sharp-pointed hook for fixing the eye, a pair of dissecting forceps for pinching up the conjunctiva, and a scalpel or pair of scissors. The surgeon should also be provided with two or three small sponges and a basin of cold Water. The lid-holders (Fig. 1.) are each about six inches long, made of steel with an ivory handle, quite slender, and curved at the extremity, which is fashioned after the manner of a fenestrated speculum, and not more than a third of an inch in width. These instru- ments may be conveniently replaced by a common speculum and the fingers of an assistant; still, they are very useful, and I prefer them to any other contrivance. The hook for fixing the ball is double (Fig. 2.) resembling that contained in some of the older eye-cases. It ought not to exceed five inches in length, and should be provided with a movable slide, to allow of the proper separation of the branches, each of which, two lines in width, terminates in a short hook as delicate as the finest needle. The forceps need not be quite the ordinary size ; and, as to the scissors, the common pocket- case pair will answer the purpose much better than a curved or more delicate instrument. The knife I rarely use. A curved director (Fig. 3.) is serviceable, as it enables the operator to judge of the ex- tent of his incisions. In performing the operation, the patient may be either in the semi- erect or reclining posture, with his head supported by an assistant, or properly elevated by pillows. I generally prefer the latter, as the eye is more manageable, and the patient less apt to faint than when sitting. The face should look towards the light, and the sound eye be covered with a bandage, to enable the patient the better to roll the other outwards. If the surgeon be ambidexter, it does not matter where he stands: but if he uses one hand more adroitly than the other, he should place himself on the right side when he wishes to operate on the left eye ; and, conversely, on the left if he wants to 26 302 STRABISMUS. operate on the right. Only two assistants are necessary; one• of whom, standing at the head of the patient, elevates the upper lid, and fixes the eye by inserting the sharp hook into the sclerotic coat, about two lines behind the cornea ; the branches of the instrument Fig. 1. Fig. 3. being separated one-fourth of an inch, and the interval between them accurately corresponding with the horizontal axis of the eye. This precaution is important, and should never be neglected, otherwise it will by no means be so easy to find the affected muscle. The points of the hook should be fairly implanted into the substance of the STRABISMUS. 303 sclerotic tunic, but no more. If it be passed simply through the con- junctiva, it will be impossible to steady the eye, to say nothing of the danger of lacerating that membrane, and thus inflicting unneces- sary pain upon the patient. On the other hand, if it be pushed through the fibrous coat, violent inflammation might be set up. The other assistant, placed on the side of the affected eye, depresses the lower lid, and hands the sponge to the operator. It is sometimes more convenient to let this assistant steady the eye. Every thing being thus arranged, the operator pinches up a small fold of the conjunctiva, just behind the hook, or, in other words, about three lines behind the cornea, and makes a verticle incision into it with the knife or scissors, as he may prefer. Relinquishing the forceps, the edges of the wound will at once retract, exposing thereby a surface from four to six lines in length by two or three in breadth. At this moment there is us'ually some degree of hemorrhage, amounting often to more than half a teaspoonful, especially if the incision has been made too far back near the semilunar valve, where the parts are always more vascular than further forward. To arrest this a small sponge, pressed out of cold water, should be re- peatedly applied ; or if it prove troublesome, the operation may be suspended until it ceases. The ocular fascia* is next divided, when the muscle, now fairly exposed, is to be cut across writh the scissors, one of the blades of which is passed behind it. The moment this is accomplished, the eye from the force exerted, upon it by the hook, springs to- wards the opposite side, and the muscle retracts within its sheath, especially if it has been tho- roughly liberated from its connexions with the surrounding parts. To effect this, which I regard as of paramount importance, the scis- sors should be carried for some distance around the ball, nearly as far, indeed, as the margins of the adjacent straight muscles. As soon as the affected muscle is divided, the eye usually at once resumes its natural position in the orbit, moving, if the other be sound, in perfect harmony with it. Occasionally, however, it retains some degree of its original obliquity ; in which case it becomes necessary to reapply the instruments, to ascertain the cause of it. This will generally be found to depend upon an imperfect division of the muscle, or of the surrounding cellular tissue, by which the muscle is prevented from retracting sufficiently within its sheath. In some instances it remains without any assignable cause, but rarely beyond a few minutes, or, at farthest, a few hours. The operation being over, the eye is bathed in cold water, to rid it of any blood that may remain in the wound, and the patient is con- fined in a dark apartment. Low diet should be enjoined for a few days, and, if inflammation arise, recourse must be had to antiphlo- * See Elements of Pathological Anatomy, vol. i., p. 489, for description of this fascia. 304 STRABISMUS. gistic measures. In no case have I yet been obliged to abstract blood ; a dose of aperient medicine being all that was required. Locally cold or tepid water may be used, as may be most agreeable to the patient's feelings. When there is a good deal of pain in the eye, with more or less constitutional disturbance, such as slight shivering, headache, and nausea, warm drinks and an opiate will be required. The ecchymosis which attends this operation, and which is sometimes considerable, demands no particular treatment: no inconvenience arises from it, and it commonly disappears in a few weeks. I have never known suppuration or abscess to follow the division of the muscles of the eye; such an occurrence implies unusual violence, and cannot be too much condemned. The same remark is applicable to the wounding of the sclerotic coat, and the es- cape of the humours of the organ ; an accident which has happened several times in the hands of ignorant bunglers. A few hours after the operation is completed, the margins of the incision become coated w7ith coagulating lymph, which is sometimes effused in such quantities as to give rise to considerable pain and a sensation like that produced by the presence of a foreign body. The vessels in the parts around are somewhat enlarged, there is more or less lachrymation, and the lids feel stiff and uncomfortable. The sclerotic coat at the bottom of the wound remains visible for five or six days, when it becomes covered with granulations, which, uniting with those at the sides, gradually fill up the gap; the whole process, from the commencement to the completion of the cicatrisa- tion, occupying from three to four weeks. Now and then the process of cicatrisation is retarded by the deve- lopment of fungous granulations. When this is found to be the case, they should be snipped off with the scissors ; a procedure decidedly preferable to the application of the nitrate of silver, which is not only painful but rarely effective. It has been recommended by some surgeons that, as soon as the soreness occasioned by the operation has subsided, the patient should begin to turn his eye in a direction opposite to that in which it was held by the contracted muscle, and that these efforts should be con- tinued daily until it regains its natural position in the orbit. In my early cases, before I had devoted much attention to the subject, I adopted and acted upon this suggestion, but the result in every in- stance disappointed me. Nor do I now perceive any good reason for following it, since it does not seem to me to be founded upon cor- rect principles. Where the eye still retains some degree of obliquity after the operation, it may be positively assumed that the section of the affected muscle, or of the fascia by which it is invested, has been imperfect; and when this is the case it would be in vain to expect complete success. Again, the eye operated on may be en- tirely straight, and yet not move in concert with the other This I have witnessed repeatedly, and hence my invariable rule is to di- vide at once the corresponding muscle of the opposite side, for the reason already mentioned — that the distortion generally involves both organs. J The operation for strabismus is liable to occasional failure the principal causes of which may be thus enumerated:—1. Imperfect STRABISMUS, 305 section of the affected muscle, or of the ocular and submuscular fasciae. To this subject, I have already several times alluded, and it is not necessary, therefore, to offer any further remarks concerning it in this place, than to say that the operator should never neglect to divide these structures most thoroughly. In bad cases the scissors must be carried up and down as far as the contiguous straight mus- cles, so as to denude completely the sclerotic coat for more than one- third of its circumference. The fasciae must be effectually raked up, otherwise it will be impossible for the muscle to retract fully within its sheath. 2. Excision of a portion of the conjunctiva, eventuating in contraction of this membrane during the process of cicatrisation, may be stated as another cause of failure. As there can be no neces- sity for such a procedure, since it does in nowise facilitate the opera- tion, I need hardly say that it should be studiously avoided. 3. Stra- bismus is sometimes complicated with other diseases, such as con- vulsions, epilepsy, hydrocephalus, and analogous lesions. When this is the case, the operation cannot be performed with any prospect of success, and had better be declined altogether. The existence of amaurosis does not necessarily lead to failure ; if cataract be present, it should be broken or depressed either at the time of the operation or before. 4. But the most powerful cause of all, in my opinion, and one which has not been sufficiently insisted upon by writers, is the co- existence of strabismus in both eyes, and the fact that our operative procedures are usually limited to one of these organs ; a circumstance at variance alike with good practice and common sense. In several instances in wdiich only partial success attended my efforts, the whole difficulty was fairly ascribable to this cause ; and so thoroughly am I persuaded of its importance, that I have laid it down as a rule never to operate on one eye only when it is certain both are affected. The only exception to this is where the patient is very young, when the section of a single muscle will sometimes, though even then not always, be sufficient. 5. A fifth cause of failure is the readherence of the posterior extremity of the muscle to an unfavourable point of the sclerotica, by which it is again enabled to exert an undue influ- ence over the movements of the eye. The manner of obviating this occurrence has been already indicated. The effect upon vision is at first rather disagreeable, at least in some instances. It is only by degrees that the affected organ recovers its functions, and in many casts a considerable period must necessarily elapse before this is brought about. Occasionally, in fact, the retina, from long disease or other causes, is so effectually paralysed that the sight is never restored, and it is in instances of this description that a slight return of the distortion may be looked for, however well the operation may have been executed Another effect sometimes witnessed is double vision. This is obviously dependent upon a want of agreement between the optic axes, and rarely lasts more than a few days, unless the obliquity has been only partially remedied. The only other effect which it is necessary to notice here, as attend- ant upon this operation, is a peculiar prominence of the eye. This is generally well-marked, though not equally so in all cases, and im- parts to the organ a full, bold expression ; it is accompanied with a 26* 306 POLYPUS OF THE NOSE. considerable separation of the lids, and is caused by the liberation of the organ from its confined situation. The preceding remarks have special reference to convergent stra- bismus ; with slight modifications they are applicable to the other forms of the lesion. From the more exposed situation of the eye the outer straight muscle is much more easily approached and divided than the internal; as to the relative facility of operating on the upper and lower, I can say very little from personal experience, but should suppose the difference, if any, to be trifling. As to the oblique mus- cles, I have not had occasion to divide them in a single instance, nor should I, from the knowledge I have on the subject, deem such a step necessary, it being very doubtful whether they have any agency in the production of strabismus. In several instances in which these fasciculi were divided by Lucas, Calder, and others, no impression whatever was made upon the distortion, and nearly all surgeons agree in the opinion that they should not be interfered with. Attempts have been recently made to disparage the operation for strabismus, on the ground of the alleged tendency of the eye to re- turn to its original malposition, or the occurrence of a new deviation. No proof, however, of such a result, founded upon an adequate number of statistical facts, has been given to the profession. In my own cases, so far as my information extends, not a single relapse has taken place where the operation was performed on both eyes, although nearly a year has expired since some of them submitted to it. Con- firmatory of this, it may be stated that Dr. F. B. Dixon* of Norwich, England, has recently published a list of forty-one cases of convergent strabismus, in thirty-one of which, twelve months after the division of the internal rectus, both eyes were perfectly natural ; in five, where one organ alone was operated on, there was slight obliquity of the other ; in two the squint was changed to a leer, and in three others, the eye returned to its former malposition. These results, which are in the highest degree gratifying, are sufficient to show that the opera- tion in question, first performed by Professor Dieffenbach of Berlin, in October, 1839, deserves to be classed among the established resources of surgery, which rarely exhibits such an amount of suc- cessful terminations.] Of Nasal Polypi..— These tumours vary in texture and disposition, as formerly stated : but the soft mucousaor benign polypus is, fortu- nately, by much the most frequent. Generally a great many coexist in one or both nostrils, growing from different parts of the Schneide- rian membrane. Sometimes there is but one tumour, of a large size ; and in some cases a large cyst, containing colourless fluid, fills the nostrils. When numerous, they are in different stages of growth, and generally adhere to the membrane by a narrow neck, though sometimes several are attached by the same pedicle. It is not un- common to remove ten or twelve polypi, or even a greater number, before the nostril is cleared. The parietes of the narrow passage betwixt the anterior and posterior nares is their most common situa- * Boston Medical anJ Surgical Journal, Dec. 29th, 1841, POLYPUS OF THE NOSE. 307 tion, though their bases may proceed from the cells of the superior spongy bone. The membranous covering of the inferior spongy bone, or of the anterior cavity of the nostril, is often at the same time relaxed : in- deed, this of itself causes slight obstruction to the passage of air, and may be mistaken for polypus by the patient and the unexperienced. Projection of the cartilaginous septum to one side, with thickening of its covering, may also give rise to the same mistake. This for- mation is not uncommon, indeed it is rather frequent; and the pro- jection is generally to the left side, with corresponding depression of the right. The circumstance may perhaps be accounted for by the pressure of the thumb overbalancing that of the fingers in the habi- tual practice of clearing the emunctory. In polypus, the passage of air is obstructed, the patient feels as if labouring under a common cold — his head is stuffed : in cold and dry weather air passes through the cavity, though with difficulty; in a damp day the obstruction is complete. The tumour evidently in- creases, comes lower down, and even projects upon the lip. There is watering of the eyes, the lachrymal secretions being prevented from flowing into the nostrils ; and, in cases of old standing, the patient is deaf, from the pressure of the tumours on the extremities of the Eustachian tubes. The latter symptom is not constant, but depends on the position of the tumours. I recollect an old gentle- man, an elder of the kirk, afflicted with nasal polypus, who for thirty years had not heard his clergyman, though for twenty of these years he had" attended service regularly, and from a sense of duty. On removal of the tumours hearing was perfectly restored. 308 POLYPUS OF THE NOSE. The nose changes its form, is expanded and flattened. If the dis- ease is extensive, and particularly if the tumour is malignant, the bones are separated, the eyes are protruded, and pushed outwards ; indeed, the face is so distorted as to have been compared to that of a frog. Even in the benign form, when of long duration, great deformity of the features is produced, and the patient rendered very uncomfortable. Besides the symptoms already detailed, he suffers from acute pain in the forehead—he breathes loudly and with difficulty, particularly when asleep — he has lost the sense of smell, and does not relish food or drink— and there is often pro- fuse discharge of a dirty mucous fluid, both externally and into the pharynx. Soft mucous polypus may exist for many years, without depress- ing the palate, or projecting into the fauces. The anterior nasal cavity is its most frequent seat, and it widens and fills up the fis- sure between the anterior and posterior cavities : frequently it pro- jects backwards, but is not visible, though it may be felt with the finger behind the soft palate. Its growth is slow. It may become malignant, as well as other adventitious structures equally simple; but such an occurrence is extremely rare. It may exist for many years; and, when at length removed, will be found of simple structure ; and, if the operation be well conducted, no reproduc- tion will take place. The tumours are supposed to be easily re- generated ; but the truth is, that they are seldom eradicated com- pletely. In general some are left, and these, emerging from the narrow space or cells in which they were confined, soon become fully developed—they expand, and speedily take the place of those which were removed. They can never be got rid of at one sitting: the operation requires repetition once and again ; and of this the patient should at the first be made aware. Malignant Polypi are met with in different degrees of advance- ment. Many are firm and fibrous, with an irregular surface and wide attachment — do not grow with great rapidity — furnish a sanious and bloody discharge, and give rise to painful feelings. If interfered with, their increase is accelerated. If removed com- pletely, reproduction may not take place. Tumours with broad bases, and of soft medullary consistence, at- tended with extensive change in the structure of the membrane, and softening of the bones and cartilages, grow very rapidly, fill the cavities and expand them, giving rise to great deformity, as seen above. They show themselves on the face, through the nostrils — protrude through the floor of the orbit — get into the mouth be- hind the palate, through the tuberous processes of the superior maxil- lary bone — or project through the alveolar processes. The discharge from them is profuse and fetid, and in some cases blood flows in no small quantity. Such growths usually commence in one or other of the sinuses connected with the cavity of the nose — sometimes, though rarely, in the frontal sinus. When seated in the antrum maxillare, pain is experienced in the cheek for a short time before swelling occurs. Soon the part enlarges, its coverings are thickened, the POLYPUS OF THE NOSE. 309 bony cavity expands, and the patient's sufferings are excruciating. The teeth loosen, and sanious matter is discharged from their roots. The tumour extends into the nostril, and soon runs the course al- ready mentioned. Malignant disease sometimes, though rarely, commences in the anterior cavity of the nostril. No satisfactory cause can be assigned for the appearance of either the benign or malignant form of polypus. The nostrils can be readily cleared of benign polypi, but sel- dom completely, as already stated, by one operation: in several cases, wTherein only one or two tumours obstructed the cavities, I have had no occasion to repeat my interference. If the attach- ments are broad and extensive, a small curved blunt-pointed bis- toury, or probe-scissors, may be employed for their separation. Sometimes the tumours can be pushed off by the finger, or by a probe with a blunt and forked extremity : then they either are blown out by the patient, or fall into the posterior cavity, thence into the pharynx, and are coughed up or swallowed. In cases such as are usually met with, forceps and a small vulsellum are the best instru- ments. The forceps should be about half the size of those gene- rally used or sold by cutlers as polypus forceps. The patient is seated facing a good light and the body of the prominent tumour is laid hold of by the vulsellum ; the forceps are then introduced, with the blades expanded, and carried backwards so as to reach its neck, which is then to be firmly grasped by the instrument, and gently twisted, so as to separate its connexions with the mem- brane. No force, no jerking or pulling is allowable. It may happen, even with the gentlest and most careful management, that a small fragment of bone comes away along with the tumour ; but this generally can or should be avoided: the cure is not rendered more certain by such an occurrence, as has been supposed. One tumour being thus detached, the same process is repeated with the others, till the cavity is cleared so far as hemorrhage or the patient's fortitude will admit. Both nostrils, if, as is usually the case, both are stuffed, may be emptied at the first sitting, so as to enable the patient to blow through them. When the tumours fill- ing the passage to the throat have been removed, so as to allow the ready egress and ingress of air, and when the forceps can be passed along the floor of the cavity, and are expanded and shut without meeting any obstruction, examination is to be made with the finger. In those who have long laboured under the disease, the fissure betwreen the cavities is so much expanded as to admit the little finger easily, and by it the situation of the remaining tumours is ascertained, and instruments guided to thern. After the operation the nostrils are stuffed gently with lint, to pre- vent the access of cold air ; and, if the hemorrhage be profuse, long pieces of lint pushed well back will generally be sufficient to arrest it: if not, theposterior cavity must be plugged from behind. It is pru- dent to prepare for the stuffing posteriorly in bad cases in which vio- lent hemorrhage may be expected. Instruments with springs, &c, have been contrived for the purpose, but are useless, and cannot al- ways be had. A loop of thin flexible wire, or of thick catgut, is passed 310 POLYPUS OF THE NOSE. along the floor of the nostril, and on reaching the throat is caught by the finger, or by a hook or forceps, and brought into the mouth. A piece of strong thread is then attached to the wire or catgut, and the latter is withdrawn; one extremity of the thread hanging from the nostril, the other from the mouth. To the middle of the thread a piece of lint rolled up to the size of the point of the thumb is affixed, and this is pulled back into the mouth, and directed into the posterior nares with the fingers; by the pressure of these, and by pulling at the thread, the dossil is firmly wedged into the aper- ture. Lint is preferable to sponge, as being more easily removed ; the sponge swells, and is apt to produce inconvenience. The plug must be well proportioned to the opening: if too large, it cannot be lodged in its situation ; if too small, it does not fill it, and may- be pulled through altogether. It should be smaller, of course, for young subjects and females than in adult males. It may be neces- sary to close both nostrils in this manner, when both are bleeding profusely, or when they communicate through an aperture in the septum. The anterior cavity is then closed writh lint, and the he- morrhage, however violent, is completely commanded. The poste- rior plug is removed on the second or third day by pulling the oral extremity of the thread, and, if need be, by pressing through the nostril with a strong probe. Plugging may be required in epistaxis from other causes, when other means, as cold applied to the surface of the body, and astringent injections to the part, have failed. The latter remedy is not much to be depended upon. The operation for polypus may be repeated when the parts have recovered, and the pain and discharge ceased. Ere then the patient again finds himself unable to propel air easily through the nostril, and, on examination, grayish, shining tumours are again visible. The same process of extraction is repeated until all are eradicated. Escharotics may be then applied wTith some advantage, but must be used with caution, and not of too active a nature ; nitrate of silver and the red oxide of mercury are those commonly employed. But it is questionable whether these applications have any effect in preventing the future growth of the tumours. The malignant form of the disease, even in a very early stage, is unmanageable ; the tumours, if removed, are speedily reproduced, and the fatal termination may be accelerated by the interference. I have removed tumours from the antrum maxillare, and from the frontal sinus: but the parts became soon occupied by morbid growths of a more formidable character than the preceding ; the membrane and bone appear to assume a disposition to degenerate such, and the fungous protrusions cannot be kept down with escharotics, nor with the actual cautery ; nor, after free removal with cutting instruments, have escharotics, however freely applied, any effect in counteracting the inherent disposition to the disease, and preventing its re- currence. The antrum, when filled with such tumours, is easily laid open. The cheek is divided perpendicularly from over the inferior orbitary foramen to the mouth, and the soft parts are dissected from off the bone. The cavity may then be exposed by means of a small tre- DISEASE OF THE ANTRUM. 311 phine ; but this instrument is scarcely ever required, the parieties being so softened as to yield easily to the knife ; pliers or cutting forceps may be useful in enlarging the cavity. By the guidance of the finger, the attachments of the morbid growths are separated with a blunt-pointed bistoury ; and a scoop is used to turn out the diseased mass. The root of the tumour is then touched with a red-hot iron, and by this implement, or by dossils of lint, the hemorrhage is easily arrested. But such operations, considering the result of those which have been practised, are scarcely justifiable. It has been proposed for this disease to remove the tumour, along with its investment — to separate and dissect out the superior maxil- lary bone. It is a very severe operation, and one which puts the patient's life in imminent jeopardy, from profuse hemorrhage or con- stitutional disturbance. In one case, the surgeon began the operation after having tied the common carotid of the affected side ; but, hav- ing made the incisions of the cheek and palate, was obliged to de- sist, on account of the violent bleeding ; eight days after, the common truuk of the temporal and internal maxillary was tied on the opposite side, the incisions repeated, but the result was the same ; the growth increased, and the patient perished. The disease is very insidious in its progress, and has gained much ground before the patient becomes alarmed and applies for surgical aid. The parietes in the antrum are expanded and softened ; the tumour has projected behind through the tuberous process, upwards through the plate of the orbit, or inwards to the nostril; and has contaminated by its presence and contact all the neighbouring parts. Then removal of the maxillary bone, or of all the bones in that side of the face, can be of no service. The disease is seldom if ever seen by the surgeon early enough to admit of any operation being practised with the least chance of ultimate success. At a sufficiently early period, the removal of the bone — of the parietes of the cavity containing, and from which the tumour has grown, must without doubt afford a better chance, and is, in every point of view, to be preferred to the old operation de- scribed above of what was called trephining the antrum. In one case of soft and brain-like tumour filling the antrum, and evidently commencing there, I succeeded in removing the entire disease. The patient remained sound. I have more than once seen the operation performed for this soft and malignant growth of only some months standing ; portions of the bone and tumour crumbled under the fingers of the operator—The operation was harsh, painful, and appalling—the cases hopeless. Execution of the manual part is not attended with serious difficulty, and it can seldom be necessary to tie arteries previously. To expose the bone, the cheek is divided from the angle of the mouth, to the origin of the masseter, and a second incision made from the inner canthus to the edge of the upper lip near the mesial line, detaching the alae of the nose from the maxillary bone. The flap of the cheek thus formed is dissected up, and the nasal process of the maxillary bone and the body of the os malae are divided with a saw, or with strong cutting pliers. An incision having been made through the covering of the hard palate, near the mesial line, 312 DISEASE OF THE ANTRUM. a small convex-edged saw is applied to the bone ; and the alveolar process is cut through by the pliers after extraction of the middle and lateral incisors. The bone is then pulled downwards and forwards, and its remaining adhesions separated by means of the knife or pliers. This last part must be accomplished rapidly, so as to reach the vessels, and arrest the hemorrhage. During the progress of the operation, cut branches of the fascial and temporal are commanded by ligature or pressure, and the violence of the hemorrhage is moderated by compression of the carotids. After removal of the bone, the deep vessels, branches of the internal maxillary, are secured either by ligature, or by firm pressure with charpie or dossils of lint. The fascial flap is replaced, brought together over the charpie by which the cavity is filled, and united by interrupted or convoluted suture. Cures by such proceedings, in such cases, are reported ;• the patients do not always die immediately after the operation ; but there is reason to complain of want of candour as regards the ultimate result. The disease, is said to have been arrested by ligature of the com- mon carotid ; the allegation is not borne out by facts, nor is it easy to discover on what principle the practice was adopted. Such.a result is not to be expected a priori, nor to be relieved without farther trial; and these trials are not likely to be made. The superior maxilla is liable to become the seat of other tumours beside the preceding. It may be occupied by fibrous tumour, com- mencing in the bone, or in the alveoli. The tumour feels hard, and very often not encroaching upon the antrum, is evidently circum- scribed, and presents a smooth and botryoidal surface. It has not that disposition to involve neighbouring parts, hard as well as soft, but may remain long without extending farther than the superior maxillary bone, and occupying only a part of it. In such a case, excision of the maxillary bone is warrantable, and ought certainly to be performed ; for there is no risk of the parts being extensively contaminated. I met with one instance of it in the latter situation a good many years ago. The patient was a female, about twenty-five years of age. The tumour was of four years' duration, and its origin was attributed to a severe bruise of the cheek upon the corner of a table. The teeth had loosened soon after the injury, and the disease commenced in the gums. When she applied, there was a hard prominent swelling in the forepart of the maxillary bone, and a firm tumour involved the gums on the same side, and a part of the hard palate : the disease had made much progress during the previous six months, but had evidently none of the malignancy of the soft tumours which originate in, or early involve, the cavity of the antrum: at first it had possibly been of the nature of epulis. I re- moved the bone in the same way as already described, and had the satisfaction to find the disease completely taken away. The he- morrhage was restrained by compression behind the angle of the jaw during the incisions, and not more than giii. of blood were lost. The tumour, when cut into, presented a homogeneous and fibrous appear- ance ; atone or two points, softening had begun, and a small quantity of pus had been deposited. The external wound healed by the first DISEASES OF THE NOSE. 313 intention, and the internal cavity granulated kindly. The patient remains perfectly free of disease, and bears little mark of so serious a disease or of so severe an operation. Within the last four or five years I have repeated the operation for this disease very often, and with uniform success. The cases are recorded in the Medico-Chi- rurgical Transactions, vol. xx., in the Lancet, and Practical Sur- gery, to which the reader is referred for further information on the subject. One of the tumours had attained an enormous size, and weighed nearly four pounds. Of Inflammation, Abscess and Ulceration of the Nose, and Cavi- ties connected with it. — Inflammation may be excited in the nose by external injury, as a bruise, or fracture, or displacement of the bones. The acute symptoms are swelling and discoloration of the integuments, turgescence of the Schneiderian membrane, which covers the septum narium and the turbinated bones, and consequent obstruction to the passage of air. Unless active measures are pur- sued, abscess follows, with great swelling and obstruction ; and ex- tensive loss of substance, with deformity, may ensue. Unless the acute symptoms, the short duration of them, and the rapid super- vention of tumour be considered, the swelling may be mistaken for polypus. The septum suffers more than other parts of the nose, from the concussion produced by a blow, and is in general more seriously affected by the morbid action which is induced. Matter is effused beneath the membrane, in one or both sides, usually in both, and tumours are thereby formed, which project into the cavities of the nostrils; when attentively examined, fluctuation is felt, and, if the affection has existed for a considerable time, the abscesses are found to communicate with each other, the septum having been absorbed or necrosed at one or more points. An individual received a severe 27 314 DISEASES OF THE NOSE. blow over the extremity of the ossa nasi, and a slight wound was produced. The breathing soon became obstructed, by swelling in the nostrils, and great pain in the part was complained of. A large tumour formed on the septum, and completely filled the cavities; it was opened, and a great quantity of matter evacuated. The septum was destroyed by ulceration to a considerable extent, and a slight falling down of the middle of the nose followed. Such cases are of common occurrence. Independently of any vice in the constitution, ulceration of the nostrils may be induced by injury, and proceed until great ravages are effected, if the treatment be hot properly conducted. A young gentleman, playing at ball, was struck accidentally on^the nose with the flat part of his companion's hand. Inflammation took place, externally and internally, and the passage of air was obstructed, abscess formed, and the matter was evacuated spontaneously ; ex- tensive ulceration ensued ; the cartilage and bone became affected, portions of them separated, and a bloody fetid sanies flowed from the nostrils. All the cartilaginous and part of the bony septum were destroyed ; the morbid action ceased after having continued for a long time ; but the organ was curtailed, sunk on the face, and alto- gether much deformed. In this case I first proposed, and some time afterwards performed, for the first time, the operation for the forma- tion of a new columna nasi from the lip. The alae, as well as the septum, may suffer from external injury, indeed the whole cartilaginous part of the nose may be destroyed. Incited action must be subdued by abstraction of blood from the external parts, or from the Schneiderian membrane, leeches being applied in sufficient numbers, and repeated. Should suppuration not be prevented, the abscess, particularly when internal, must be early opened ; the surgeon is, perhaps, somewhat to blame, if the patient, having been under his care from the first, sustains any deformity. If abscess has formed on both sides of the septum, each must be opened freely; afterwards, hot fomentations are to be used, and the cavity should be frequently cleansed by the injection of a bland and tepid fluid. Intractable ulceration of the nostrils is often induced by trifling irri- tations or injuries in constitutions, either originally unsound, or ren- dered so by imprudent conduct; slight blows on the prominent part of the organ produces swelling with discoloration, and that is follow- ed by abscess and ulceration. Internal ulceration is frequently caused by the continued use of snuff, *or the presence of other irritat- ino- matters, — by irritation communicated from diseased gums or alveoli, or from decayed or crowded teeth, particularly the incisors of the upper jaw — by sturnps in any part of the mouth, or the pivot- ing of artificial teeth on them— or by introducing the dentist's per- forator, with the view of destroying the nerve of a tooth. I have seen ulceration, and loss of substance in the skin, membranes, and bones of the face, arising from each and all of these causes. The ulceration occasionally commences, even in yToung subjects, in a wart or fissure on the integuments of the nose or upper lip ; it thence extends to the alee and floor of the nostrils; the cartilages, DISEASES OF THE NOSE. 315 and even the bones, are destroyed ; the discharge is thin, acrid, bloody, and fetid, and the action is with much difficulty controlled. The disease is met with of various degrees of severity and malignancy ; it m;\y cease spontaneously, may appear to be arrested by constitu- tional and local treatment, or, resisting all means employed against it, may go on consuming portions of the face, both hard and soft; destroying the nose, lips, and eyelids, and ultimately the bones in their neighbourhood. Horrid cases are occasionally met with, in which scarcely the vestige of a feature is discernible — the patient is nourished, and life is often protracted for a long period, by food conveyed over the root of the tongue, through funnels or tubes. Noli me tangere, and lupus, are names applied to the advanced stages of the disease. Ozozna, which denotes the internal ulceration of the nose, or rather the discharge indicating such, is generally of long continuance. The discharge is at one time profuse, at another scanty ; sometimes it ceases almost entirely, but the accompanying fetor, of a most dis- gusting nature, is still perceptible on aproaching the patient, or coming within the influence of the air expired over the diseased surface ; the stench is particularly offensive when portions of bone are separating. The bones may die either from inflammatory action in them running high, or from being uncovered and deprived of sup- port by ulceration of the investing membrane. In many cases the dis- ease is not arrested till the cartilaginous and bony septum, the turbi- nated bones, the hard and soft palate, and frequently the aveoli, are completely destroyed. The patient, if he live, is in a miserable plight; — his countenance is deformed and ghastly ; the situation of the nose is occupied by a large dark and foul sore ; the discharge is profuse and weakening ; the expired air is as a pestilence to him- self and those around; speech is almost unintelligible ; breathing is difficult; the strength is gradually exhausted ; and the spirits sink under the harrowing impression of misery. All these ills result more frequently from the injudicious employment of mercurial prepa- rations than from any other cause. In almost every instance, the predisposition to such frightful ulcerations has been induced by the use of mercury, and can readily be traced to it. . Exposure to atmospheric changes, during, or after the exhibition of mercury, may render the mucous surface and the covering of the bones more susceptible of the disease; that medicine may be given with the utmost precaution, but for long after the constitution cannot shake off its influence ; and too frequently more of the poison is adminis- tered for disease produced by it. Ulceration of the tonsils, and other parts in the fauces, often coexist with disease of the nostrils. Ulceration of the nostrils is arrested with difficulty. It cannot be expected to cease till dead parts have separated, become loose, and fall out, or are removed by art. Portions of the bones, forming the floor of the nostril, can often be removed, when dead, through ulcerated apertures in the palate ; whilst others are brought away through the nostrils, there being generally sufficient space allowed for their discharge —the nasal cavities being laid into one by de- struction of the columna, and more or less of the septum. Dcca- 316 DISEASES OF THE NOSE. sionally the ossa nasi, or parts of them, escape through an opening in the superimposed integuments ; sometimes they cannot be dis- charged otherwise, as in the following case : —Matter had come to the surface over the nasal process of the frontal bone, an incision was made for its evacuation, sequestra were found loose, and some extracted ; one was pushed down with the view of pulling it through the nostrils, but this was found closed from the effects of small-pox. Various applications to the ulcerated cavities are employed. In- jections of spiritous and aromatic lotions are used to wash away the discharge and correct the fetor, as diluted tincture of myrrh, or of aloes, a lotion containing a proportion of kreasote, the sulphate of zinc, solutions of the chlorides of lime or soda, &c. Applications, soothing or stimulant, are made to the exposed sores according to their appearance and disposition. When the ulcer is of an angry and irritable aspect, it is to be touched lightly with the nitrate of silver, in substance or solution, and then covered with a bread and water poultice. Fowler's solution of arsenic is useful in some cases, when the object is to clean or destroy the surface ; this is also effected by a slight application of the potass. A very manageable and efficient escharotic is the chloride of zinc. It is mixed with an equal quan- tity of dried plaster of Paris or flour, and made into a paste, with a few drops of water for application. Black wash sometimes agrees well, as also a liniment of olive oil and lime-water, with citrine oint- ment (three parts of the former ingredients to one of the latter), or the sulphate of zinc lotion. When the sore is very indolent, showing no signs of granulation, it may be touched occasionally with spirit of turpentine, either pure or combined with alcohol, and afterwards covered with an ointment composed of ung. cerae and spir. terebin- thinae ; under this application ulcers often heal, after having resisted all others. But nitrate of silver applied gently, and repeated at the interval of two or three days, will, in the majority of cases, be found the most efficient remedy, combined with the simple dressing of tepid water. Constitutional treatment must not be neglected. When the disease cannot be traced to mercurial action, small doses of the bichloride of mercury are allowable when excitement is required. The arsenical solution given internally sometimes produces good effects. In foul internal disease of the nostrils wnth cachexia, no medicine exerts so beneficial an influence on the general health and local disease, as sarsaparilla, exhibited either in decoction, in extract, or in powder. Loss of substance, from ulceration or injury, is repaired by surgical operation. A portion of integument is borrowed from some other part, and by the adhesive process is made to cover and supply the deficiency. Such operations were contrived and practised by Sici- lian and Italian surgeons some centuries ago, and were revived in our day in Germany. The integument was borrowed from the upper part of the arm ; it has sometimes not been applied imme- diately, but detached gradually, and allowed to thicken, to change its consistence, and to become more vascular, previously to its adapta- tion to the mutilated organ. When considered sufficiently prepared, RHINOPLASTY OPERATIONS. 317 it has been shaped so as to fit accurately, though still remaining attached at one point to the arm ; the cicatrised edges of the deficient parts should then be made raw, and the new substance affixed by suture ; the original attachment is preserved entire, and the patient kept in a constrained position — the arm and head being approxi- mated and bound together by apparatus — for many days, till union occurred. Then the flap is separated entirely, and the new nose moulded into its proper form, by subsequent paring and com- pression. The Rhinoplastic operation, introduced from India—where from time immemorial it has been practised by one of the castes — has superseded the preceding, and is variously modified. It is less diffi- cult in execution, not so liable to failure, and more easily undergone by the patient. The same preparation of the flap is not required, though it is said that the Indian operators are in the habit of pre- viously pummelling, with the heel of their slipper, the integument to be used for the new nose, so as to excite the circulation, and pro- duce thickening; from the similarity of texture in the integument of the face, its application to the new situation is not much observed. The apex and alae can be readily repaired by a flap of proper shape and dimensions from the forehead. The cicatrised edges where the nose formerly rested, must in the first place be dissected off pretty deeply, so as to be prepared for the attachment of the new appen- dage. The size of the lost organ, and the dimensions necessary for its replacement, are then to betaken into consideration. It is recom- mended to make a mould in wax of the part, and after flattening it out, to use it as a guide for the incisions. But a piece of card or soft leather is more convenient; this having been cut of the proper size and form, is laid down on the forehead, the part representing the root of the nose resting between the eyebrows. It is held firmly by an assistant, whilst the surgeon traces its dimensions first with ink, or at once with a knife carried deeply through the integuments. T1i:j pattern is then removed, and the flap dissected down, being laid hold with the finger and thumb, or with a hook. It is then twisted round, the lower part being left undisturbed. This attachment at the root of the nose may be narrow and long, so as to admit of its being twisted, but it is not to be cut thin ; it must embrace the fibres of the corrugator supercilii, so that its vascular supply may be abundant. The incision on the side opposite to which it is proposed to make the turn may be brought a little lower than the other, so as to facilitate the twisting. After bleeding has ceased, the flap is applied to its new situation, and retained in apposition with the raw edges of the truncated organ by a few points of interrupted or convoluted suture ; a little oiled lint is placed in the nostrils to support the flap, but no other dressing should be applied. To cover the part with pledgets of lint smeared with ointment, and adhesive strap, can answer no good purpose ; and the subsequent removal of such must endanger the adhesion. The attention must now be directed to the wound of the forehead ; the lower part is easily brought together, and retained by a stitch ; thereby the whole surface is diminished, and what re- mains will soon be repaired by granulation. It is at first dressed 27* Jk<0J 318 RHINOPLASTY OPERATIONS merely with a pledget saturated with tepid water, afterwards some stimulating lotion may be gradually added. The operation should not be performed in very cold wreather, and even in summer the patient should be enjoined not to leave his chamber. The lint may be removed in three or four days, and then, too, some of the stitches may perhaps be dispensed with. The flap will be found adherent, but loose, and raised by every expiration ; very soon granulations rise from the inner surface, the part derives support from below, and becoming firm, preserves its form well. It will be necessary during the cure to keep the nostrils of their proper size and shape, by means of dossils of lint, or well-fitted tubes. Nothing has as yet been said of the columna. In the Indian opera- tion it is provided for by a slip purposely brought dowrn from the forehead, and attached to the point which the root of the original columna occupied. Their flap is shaded as in the following figure. In the greater number of forheads, an encroachment must be made on the hairy scalp, in order to obtain this part of the flap ; and after bringing it down and ingrafting it into the lip, there is a risk of its not adhering, as happened in a case on which I operated now many years ago. Besides during the healing of the internal surface, it will be difficult to prevent it from shortening, and turning inwards upon itself, and thus pulling down the apex of the nose. In the case to which I alluded, a columna was made, after consolidation of the rest of the organ, from the upper lip, as will be immediately explained; and in again per- forming the operation for resto- ration of the whole nose, I should proceed on the plan of taking only a flap sufficient for the apex and alae from the forehead, and should borrow the columna from the lip. In this way the risk of failure will be diminished, and the form of the lip materially im- proved. The columna might be provided at the same time with the other parts; but it would be more advisable to delay this part of the operation till a few weeks after adhesion of the other flap has been perfected. Since writing the preceding observations, I have in a very great many instances performed the operation according to the plan here proposed, and with the most perfect success. The form of the nasal flap was this. The little projection was made in order to be turned down, so as to form the tip of the nose ; as well as to constitute a convenient attachment for the columna, which was subsequently to be made. J In separating the connexion with the forehead, a thin wed<>e- RHINOPLASTY OPERATIONS. 319 like portion is removed, and the raw surfaces after the cessation of bleeding, are laid in apposition, and retained by gentle compres- sion. But this should not be done till the new nose is consolidated and perfect. Restoration of the columna is an operation which, in this, and other civilised countries, must be even more frequently required than the restoration of the whole nose. This latter operation came to be practised in consequence of the frequency of muti- lations as a punishment; the punish- ment for some of our sins is left to na- ture, and she generally relents before the whole of the organ disappears. The column is very frequently destroyed by ulceration, a consequence, as before stated, of injury or of constitutional derangement. The de- formity produced by its loss is not far short of that caused by destruc- tion of the whole nose. Happily, after the ulceration has been checked, the part can be renewed neatly, safely, and without much suffering to the patient. The operation which I have for some years practised successfully, and in a great many instances, is thus per- formed ;— The inner surface of the apex is first pared. A sharp- pointed bistoury is then passed through the upper lip, previously stretched and raised by an assistant, close to the ruins of the former columna, and about an eighth of an inch on one side the mesial line. The incision is continued down in a straight direction, to the free margin of the lip ; and a similar one, parallel to the former, is made on the opposite side of the mesial line, so as to insulate a flap composed of skin, mucous membrane, and interposed substance, about a quarter of an inch in breadth. Thefraenulum is then divided, and the prolabium of the flap removed. In order to fix the new co- lumna firmly and with accuracy in its proper place, a sewing-needle — its head being covered with sealing-wax to facilitate its introduc- tion — is passed from without through the apex of the nose, and ob- liquely through the extremity of the elevated flap ; the small spear- pointed hare-lip needle answers even better ; a few turns of the thread suffice to approximate and retain the surfaces. It is to be ob- served, that the flap is not twisted round as in the operation already detailed, but simply elevated, so as to do away with the risk of failure. Twisting is here unnecessary, for the mucous lining of the lip, form- ing the outer surface of the columna, readily assumes the colour and appearance of integument, after exposure for some time, as is well known. The fixing of the columna being accomplished, the edges of the lip must be neatly brought together by the twisted suture. Two needles will be found sufficient, one being passed close to the edge of the lip ; and they should be introduced deeply through its substance ; two-thirds at least of its thickness must be superficial to them. Should troublesome bleeding take place from the coronary 320 RHINOPLASTY OPERATIONS. arteries, a needle is to be passed so as to transfix their extremities. The whole cut surface is thus approximated ; the vessels being com- pressed, bleeding is prevented ; and firm union of the whole wound is secured. The ligature of silk, which is twisted round the needles, should be pretty thick, and waxed ; and care must be taken that it is applied smoothly. After some turns are made round the lower needle, the ends should be secured by a double knot; a second thread is then to be used for the other needle, and also secured. With a view of compressing and coaptaring the edges of the interposed part of the wound, the thread may be carried from one needle to the other, and twisted round them several times; but in doing this, care must be taken not to pull them towards each other, else the object of their application will be frustrated, and the wound rendered puckered and unequal. Last of all, the points of the needles are to be cut off with pliers. No farther dressing is required ; as previously remarked, no good end can be answered by any application, and the separation of dressing may afterwards be troublesome ; discharges from the neigh- bouring passages are retained by it, fetor is produced, and union interrupted. The needles may be removed on the second or third day ; their ends are cleared of coagulated blood, and after being turned gently round on their axis, they are to be cautiously with- drawn, without disturbing the thread or the crust wrhich has been formed about them by the serous and bloody discharge. This often remains attached for some days after the removal of the needles, and forms a good protection and bond of union to the tender parts. Some care is afterwards required from the surgeon and patient in raising up the alee, by filling them with lint, and thus compressing the pillar, so as to diminish the cedomatous swelling which takes place to a greater or less degree in it, and to repress the granulations- It is besides necessary to push upwards the lower part of the column, so that it may come into its proper situation ; and this is done by the application of a small roll of linen, supported by a narrow bandage passed over it and secured behind the vertex. Independently of the great improvement produced on the patient's appearance by the restoration of the lost part of so important a fea- ture, it may be observed, that, when the columna has been destroyed, the lip falls down, is elongated, and becomes tumid, particularly at its middle, so that borrowing a portion from it materially ameliorates the condition of the part; the cicatrix being in the situation of the natural fossa, is scarcely observable. The alee of the nose, deficiencies in the upper, anterior, or lateral parts of the organ, in the forehead, &c, may be supplied from the neighbouring integument, on the same principle as the preceding re- pairs. In many of these operations the flap can be so contrived and cut out, as that it can be applied without its attachment being -twisted. The form of such flaps is here given. It is merely necessary to bring the portion which has been dis- sected from the subjacent parts of the forehead, cheek, or lip, to the part prepared for its reception, by effacing the angle betwixt it, and the connecting slip. A flap to supply the greater part or even the whole of the organ may be thus transplanted. RHIOPLASTIC OPERATIONS. 321 The integuments covering the apex and alae of the nose are some- times opened out in texture by interstitial deposit, forming a lipoma- tous tumour, lobulated, discoloured, and intersected by fissures. The sebaceous follicles are enormously enlarged, so as sometimes to ad- mit the point of a small quill. On making a section of the parts, accu- ^ mulatlons of sebaceous or atheromatous matter are found inclosed in cysts of considerable capacity. Turgid veins ramify superficially ; and the surface is of a reddish blue or purple colour, varying its hue from time to time, according to the state of the health and the changes in the circulation. The enlargement often attains great mag- nitude, producing much deformity. Vision is obstructed, and the introduction of food, both solid and liquid, interfered with ; the lobes tumble into the wineglass, spoon and cup, and sometimes they are so elongated as to require being pulled aside, in order to uncover the mouth. Breathing is also impeded more or less, by encroachment on the nasal orifices. The disease may be often attributable to hard living; but many, not intemperate, labour under it. It is desirable to have the tumour removed, even before it has be- come large : and it can readily be conceived that local applications must fail in bringing the skin and cellular tissue into a healthy con- dition. Incision is required. If both sides of the nose are affected, a small scalpel is carried down in the mesial line through the altered structure, and, whilst an assistant places his finger in the nostril, the surgeon lays hold of the integument with a sharp hook, and care- fully dissects away the diseased parts, first on one side, and then on the other, so that they may correspond exactly, or present the same uniform appearance. The vessels are then tied, and sometimes a considerable number bleed smartly; oozing may continue, but is readily suppressed by continued pressure, the nostrils being well stuffed. Afterwards such dressings are to be employed as agree with the stages of the sore. After cicatrisation, the comfort and ap- pearance of the patient are much enhanced ; and there is no risk of reproduction — the disease is one of the skin, and all that is affected has been removed. Sketches taken from one, of very many patients, on whom I have operated for the removal of this shocking deformity, are given in the Practical Surgery, p. 306—8. 322 INFLAMMATION OF THE ANTRUM MAXILLARE. Inflammation of the antrum maxillare is occasionally met with : but the surgeon is more frequently called upon to treat the conse- quences of this action in it. The symptoms of inflammation of the antrum are violent throbbing pain, referred to the part affected, to the temple, and to the teeth implanted in the alveolar processes that form the lower part of the cavity ; the side of the face is swelled from infiltration of the soft parts, and the Schneiderian membrane of the corresponding nostril is generally observed red and swollen. The affection can frequently be traced to exposure to cold ; it may be the result of external violence ; but is usually on extension of dis- ease in the sockets of depraved teeth. Unless active and early mea- sures are taken to subdue the inflammatory attack, the antrum be- comes distended by increased and vitiated discharge from its lining membrane. The swelling of the cheek becomes more apparent, since, to increased infiltration of the soft parts, enlargement of the cavity is superadded. The enlargement of the side of the face, and the bulging into the orbit are seen in the accompanying cut. The membrane covering the small aperture through which the antrum and nostril communicate partakes of the ge- neral thickening, and thus no outlet is left for the accumulating fluid. The escape of matter from the nostril, on the head being turned to the opposite side, has been laid down as an indica- tion of accumulation or abscess in the antrum; the statement is incorrect, and is a result of surgery being pro- fessed by those who have not prac- tised it, but judge of morbid states and their signs and symptoms by the healthy condition of parts only. In the skeleton, fluid no doubt will run over from the osseous shell, in some positions of the skull; but it cannot escape from the cavity when covered with membrane, and that membrane subject to vital actions. In short, the symptom is not observable in the disease in question.* Extensive ulceration of the parietes of the antrum to- * This opinion is certainly erroneous. That the obstruction occa- sionally exists in the situation adverted to, cannot be doubted, but that it does so constantly, or even generally, is not true. When the lining membrane of the antrum is inflamed, it does not follow that it must be so throughout its entire extent; most commonly, indeed, there is reason to believe that the morbid action is circumscribed, and hence when matter forms it may readily, in many cases, find its way into the nose. In it only where the whole of the mucous lining is involved, or that portion of it which covers the inner wall of the antrum, that the edges of the communicating aperture will be likely to be so much thickened as to produce complete obstruction. It is difficult to conceive how Mr. Liston could have committed such an error. — Ed. INFLAMMATION OF THE ANTRUM MAXILLARE. 323 wards the nose may, perhaps, take place, as a consequence of the accumulation, and the matter may then escape by the nostril, if not allowed an exit otherwise ; but such is not a common occurrence. In general, the cavity is considerably enlarged before the matter comes to the surface. If not interfered with, it usually escapes through the sockets of decayed teeth, or the anterior thin parietes being^absorbed, it comes down by the side of the canine or small molar teeth, and is discharged slowly, so as to annoy the patient by its flavour and fetor, without the abscess being emptied, or a chance of cure afforded. Accumulations of fluid sometimes take place in this cavity, give rise to great enlargement of the sinus, and continue for many months, without pain or much inconvenience, and without any matter escap- ing. The bony parietes are attenuated, yield to slight pressure, and return to their original level with a crackling noise, such as is pro- duced by parchment. The contained fluid is thin, grayish, and con- tains flocculent solid particles. In short, the antrum maxillare is occasionally the seat of chronic as well as of acute abscess. Cancerous ulceration sometimes takes place in the cavity ; the matter is not long confined, the parietes soon soften, the teeth drop out, the alveolar processes disappear, and a large opening is formed, which furnishes a fetid, sanious discharge. In inflammation of the antrum, carious teeth must be removed, blood must be abstracted from the neighbourhood of the affected part -r- leeches being applied to the gums, the Schneiderian membrane, and the integuments — and fomentations to the cheek should be fre- quently and assiduously employed. When the cavity has become distended with fluid—mucous, muco-purulent, or purulent — such must be evacuated without delay; and the opening must be of such size, and so situated, that the fluid may escape as soon as secreted. In removing diseased or crowded teeth opposite the part, an opening may be made from the extremities of the fangs having projected into the cavity ; it is in a good situation, but cannot easily be made of sufficient size : an aperture of but small extent may be sufficient for the draining of an abscess in soft parts, but here the divided texture is unyielding, and the perforation must be free. Bad teeth are taken away with the view of abstracting a source of irritation which may give rise to, keep up, or induce a return of collection in the antrum ; but extraction of sound teeth, to obtain an exit for the matter, is not warrantable. Even when they are extracted for a different reason, and discharge of matter follows, the surgeon must not be contented, but must make another and more efficient opening. The membrane of the mouth is to be divided on the forepart of the maxillary bone, immediately above the first small grinder, and a large perforator then pushed into the antral cavity ; little force is required, for the parietes are soft and partially absorbed. The perforation should be of a size sufficient to admit the little finger ; thereby a free and dependent exit is allowed for the concrete as well as the fluid matter. Curdy and very offensive stuff is sometimes found in great abundance in this cavity if the discharge is very fetid, and long of drying up, and if there is an appearance of disease in the osseous parietes, injections 324 ULCERS OF THE LIPS. into the cavity may be required, though seldom. They are occasion- ally useful in dislodging the atheromatous matter. In general the discharge gradually diminishes, the membrane of the antrum resumes its healthy condition and functions, and the aperture in its parietes is shut by a fine ligamentous substance. Ulcers of Lips. — The prolabium is liable to ulceration from various causes; from long-continued irritations, as sharp corners of teeth, rugged tartar on the external surfaces of the teeth, the habitual use of a short tobacco-pipe ; from external violence ; from the appli- cation of acrid matter ; or from an ulcerative disposition unconnected with external circumstances. The constant and free motion of the parts is prejudicial to healing, and consequently the sores often remain long open. Though ulcers on the lips are generally of a bad cha- racter, it does not follow that all are so. Many are simple ; but these, after remaining long, are apt to degenerate. Others from the first assume malignant action, and unfortunately they are more fre- quently met with than simple and well-disposed sores. The malig- nant sore often commences in a warty excrescence which ulcerates at the base ; the ulceration extends, the warty appearance is succeeded by ragged and angry fleshy points, the surrounding parts become indu- rated, and the stony hardness spreads. The appearance which the sore presents is that of open cancer, described at page 150, and re- presented above. The ulceration may either be limited in depth and extent to a small part of the lip, or may involve the greater part of the prolabium, and that wuthout much induration. It is generally situated on the right side of the lower lip ; sometimes in the angle of the mouth ; the upper lip is rarely affected. I have removed a few malignant ulcers from this last situation. Sooner or later the lymphatic glands participate in the disease ; a chord of in- durated lymphatic vessels is felt passing over the jaw in the course of the fascial artery, and the glands with which these are more im- ULCERS OF THE LIPS. 325 mediately connected, soon enlarge and become hard. This disease, though by some pathologists said to be " improperly called cancer," differs apparently in no respect in its progress, and is in all respects as malignant as the disease commencing in any other structure and in any other way. Indurated swellings over the jaw, lymphatic or not, usually depend on the labial disease ; they in some instances increase very slowly, in others acquire such volume as to induce by their pressure on neighbouring parts alarming and dangerous symp- toms at an early period. Without much increase of size they some- times attach themselves firmly to the bone, and involve it in the dis- ease. The malignancy seems to acquire fresh virus, the skin ulcerates with fetid discharge, all the neighbourhood is speedily infected, and the patient sinks slowly under the evil. Simple ulcers of the lips may be made to heal readily, — by ab- stracting the exciting cause, preventing the motion of the lip by the restraint of a bandage, disusing the part as much as possible, and by employing such applications to the sore as are best suited to the character and appearance which it may present; but it must be borne in mind that all remedies can be of little service unless motion of the lip be prevented. Sores of a bad kind must be attacked early, otherwise no hope of success can be entertained. Escharotics are not to be trusted to ; the knife is the only effectual means of removing the disease. When the sore does not involve much of the lip, the molar teeth having been lost, and the alveolar process absorbed, the cheeks are thus rendered flabby and relaxed : in such circum- stances, all the diseased part is taken away with facility, and the features are not thereby deformed, but rather improved. The part cut away resembles the letter V, the angle being towards the chin : this form of incision is preferable, on account of the diseased portion being chiefly in the prolabium, and the parts afterwards coining together very neatly and readily. The lip is stretched by the ope- rator and his assistant laying hold of the prolabium on each side of the portion destined to be taken away ; a narrow straight bistoury is passed through the lip, at the angle of the form of incision ; and the operator, standing in front of the patient, makes the first incision towards himself, by bringing the knife up to the prolabium. He then takes hold of the part to be removed, and laying the edge of the knife on the prolabium at the other side of the induration, cuts down to the point where the instrument originally entered. The incisions must always be made far from the indurated parts. The edges of the wound are retained in apposition by means of convoluted suture, as formerly described. When the wound is extensive, as when a considerable part of the cheek is involved, approximation may be accomplished by a few points of interrupted suture, and afterwards the parts may be more securely and accurately fixed by convoluted sutures placed between the interrupted. When a large portion of the cheek is removed, as for disease which had commenced at the angle of the mouth and extended around, all the parts cannot be brought into contact, and some of the deficiency remains to be filled up by granulation. The neighbouring parts stretch, and the deformity that may be the immediate result of the operation in a great measure 28 326 FORMATION OF NEW LIP. disappears after some time. In cases of superficial and malignant ulceration of great extent, no attempt can be made to bring the parts together after excision ; great deformity, and almost total closure of the mouth, would be the consequence. The diseased parts must be freely removed (for this is the primary and essential part of the ope- ration, all other considerations yielding to it), and the deformity will prove much slighter than might be supposed : granulations arise, and considerable reparation of the lost parts thence ensues. Still there is a risk of the sore, at first healthy and active, gradually assuming the nature of that for which the incisions were made. It may be necessary to remove the whole lip, or the greater part of it. Hence arises much inconvenience to the patient; he is much reduced by the profuse secretion and loss of saliva ; the surrounding parts are excoriated and irritable ; his clothes are wetted ; his speech is very indistinct; his teeth become thickly coated with tartar ; and he is, in short, kept in a state of constant annoyance. The part may be supplied from under the chin ; but this reparative operation should not be performed at the same time with the removal of the original and carcinomatous lip. By making two operations with a considerable time intervening, the chance of success is greater, and indeed the difficulty is much diminished. After removal of the dis- ease, allow the parts to fill up by granulation and contract as far as they will, then form a new lip. I have done so in several instances ; in one case, the parts had perished by external violence ; in another, they had been destroyed by some powerful escharotic. A piece of soft leather, of the size and shape of the under lip, is placed under the chin, and a corresponding portion of the integuments is reflected up- wards, an attachment being left at the symphysis menti. The cal- lous margins of the space formerly occupied by the original lip are pared; and the flap having been twisted round, is adapted to the edges of the wound and retained by points of interrupted or convoluted suture. To insure adhesion, the attachment at the chin should be left thick and fleshy; the flap should not consist of mere integument, but contain no small share of the subcutaneous cellular and adipose tissues, in order that circulation may be vigorous in the part. The integuments below the chin are naturally loose, and con- sequently the margins of the wound there are readily approximated. The flap soon becomes cedematous and remains so for some weeks ; it must be supported by a compress and bandage. After adhesion of its upper part is completed, the mental attachment, which prevented the lower portion from uniting, is to be removed; a bistoury is intro- duced beneath the non-adhering point, and carried down so. as to di- vide the attachment, which is then removed by a second stroke of the knife. The lower part of the flap is now laid flat and close to the chin, and supported by a bandage. In the adult union may be retarded by the edges of the flap twisting inwards, and interposing the hairs upon them between the opposed surfaces; when such is the case, the offending margins must be pared away. The advantages of such an operation, when successful, are too evident to require detail. Removal of glands in the neck or beneath the jaw, that have be- CONGENITAL DEFICIENCIES. 327 come diseased in consequence of malignant disease in the lip, is at- tended with danger, and not followed by any benefit. But for this disease I have known most bloody and cruel operations undertaken, — even portions of the jaw to which the glandular tumours adhered have been cut out. Such proceedings cannot be too strongly reprobated. Congenital Deficiencies of Lips, Palate, fyc. — Congenital defi- ciency of the lip uniformly occurs in the upper one ; it is either simple or complicated. Frequently there is only a fissure on one side of the mesial line. This may, though seldom, be combined with divi- sion of the soft or of the hard palate ; or there may be a fissure on each side of the mesial line, with an intervening flap. The flap may be either of the same length as the rest of the lip, or more or less shortened ; and it may be either free, or attached to part of the al- veolar process. In such cases as the latter, the central alveolar pro- cesses and teeth often project considerably beyond the arch of the hard palate, greatly increasing the deformity. The deficiency of the lip produces a disgusting and a horrible deformity of the counte- nance ; and when there is division of the palate, the voice is indis- tinct, or almost unintelligible. The simple fissure of the lip, without deficiency of the palate, is easily remediable by operation. As already mentioned, the .fissure is to one side of the mesial line ; and its edges, covered by a conti- nuation of therprolabium, are rounded off at their lower part. The operation is not attended with much loss of blood, nor is it very painful. It can be performed at any period of life, but in young chil- dren it is not advisable to have recourse to more severe operations on these or other parts. Children bear the loss of blood badly, and their nervous system is apt to be shaken ; convulsions, are induced, and often terminate fatally. The most proper age for removing de- formity by operation is from two and a half to four years ; there is then no danger incurred, and during the growth of the individual the parts recover more and more their natural and healthy ap- pearance. The operation for single harelip consists in paring off freely the edges of the fissure, and removing completely the rounded corners at the free margin, thus. This is most neatly, quickly, and easily accomplish- ed by passing a straight bistoury through, from without inwards, so as to penetrate the membrane of the mouth, above the angle of fissure. The parts are stretched by the fingers of the surgeon or assistant, whilst the instrument is carried downwards, so as to detach a flap composed of the edge and rounded corner. Unless the rounded portions are taken clean away, an unseemly notch is left in the prolabium, wherein the natural structure is prominent. A similar proceeding is followed on the opposite side. Hemorrhage is prevented by the assistant making gentle pressure whilst he stretches the lip. Two sewing needles, the 328 CONGENITAL DEFICIENCIES. heads covered with a small nodule of sealing wax, are introduced as directed after the operation for removal of diseased parts in the lower lip, and the twisted suture completed. For some years I have used pins made purposely ; they are spear-pointed and tem- pered near their points. From their length they can be easily in- serted without being fixed in a handle, or provided with a head. One needle should always be passed close to the free margin of the lip. No further dressing is required, for reasons already assigned. The forceps of different kinds for holding the edge during its re- moval are worse than useless ; and paring with scissors is to be re- probated, as an effectual means of preventing immediate union. By the plan above recommended, bruising is avoided, and union takes place rapidly. . Fissures, more or less extensive, of the hard palate, generally at- tend double harelip. The position and size of the intermediate por- tion of the lip, and of the superior maxillary bone, are various ; and the operator, in forming his plan of procedure, must be guided by the state of the parts. If the fissures are not very wride —if the intermediate portion of bone, that ad- hering to the septum narium, is not pro- minent— and if the soft parts covering this are free and long, the operative pro- cedure is simple. Two such operations as are described for single harelip, the latter performed at an interval of some weeks, are required. Thereby the in- tervening flap is united first to one side, and then to the other. If the flap is short and free, without osseous projection, the operation maybe concluded at once, thus: — The edges are pared on both sides, and the parts brought together as in single harelip, the small intervening flap not preventing appo- sition below. One pin is passed at the prolabium, the other tra- verses the flap. In all cases, in fact, the operation may be con- cluded at once. When the bone projects, and the flap is long, the parts may be rendered favourable for the operation by gentle and continued pres- sure ; the osseous prominence being reduced, so as to restore the natural position of the soft parts. When, as not unfrequently occurs, there is projection of the bone, and the soft and hard parts seem to be incorporated with the apex of the nose — when, in short, little or no intermediate flap exists, the protruding portion of bone may be removed by cutting forceps down to the level of the palatine arch; and then the soft parts can be brought together by one operation, as for single harelip. In some cases, when the space between the palatine plates of the superior maxillary bone is wide^ it may be necessary, by mechanical contrivance, fitting on metallic apparatus possessing a strong sprino- to approximate the bones before attempting to unite the lip. The cases must be very rare, where the soft parts cannot be otherwise brought together: when they can be united, their equable and con- CONGENITAL DEFICIENCIES. 329 tinued pressure will have the effect of gradually approximating the hard parts. When the hard palate is deficient, the patient is subjected to great inconvenience from food escaping into the cavities of the nose, and, in later life, horrid wretchedness of articulation occurs. It can rea- dily be understood, that surgery is of very little *a.vail here. Re- course must be had to mechanical contrivance. A plate of metal (gold or platina), or a piece of ivory, or of sea-horse bone, may be fitted to the opening, and retained either by accurate adaptation, having sponge or caoutchouc attached to the upper surface, or by wires, elastic or not, resting on the neighbouring teeth. It may be made of a piece with artificial teeth, if any are required. The sponge is objectionable, as retaining the discharge, and thereby im- parting an unpleasant odour to the expired air. But it is no easy matter, and often altogether impracticable, to retain such apparatus when the soft palate is also deficient. The time at which such con- trivance is to be adapted may admit of some dispute. If done early in life, the natural tendency of the parts to approximate may be in- terfered with and subverted ; if dispensed with till a later period, the patient gets into a habit of snuffling and speaking so indistinctly, that the closing of the aperture is productive of little or no im- provement. Perhaps the period of commencieg the child's educa- tion should be delayed till he be seven, eight, nine, or even ten years of age, and then the artificial palate may be applied advan- tageously in every respect. Fissure of the soft palate is usually accompanied with separation of the bones from which it is suspended. The size of the fissure is various, and depends very much upon the state of the hard parts. In some cases, the extent of separation is great; in others, the edges are readily approximated by making the patient throw the muscles into action. The latter class admit of operation with a view to per- manent union of the edges of the fissure. But it is a proceeding which, to insure success, requires not only great steadiness, cool- ness, and dexterity on the part of the operator, but the utmost cou- rage, submission and self-denial on the part of the patient. These qualifications can scarcely be expected in patients under twelve or fourteen; and, consequently, the operation should not be attempted till after that time of life. Before proceeding to operate, it should first be ascertained that the fissure is not of such extent as to prevent apposition of its edges, without great dragging of the parts ; for, if the separation be wide, temporary approximation may perhaps be effected by ligatures strongly applied, but the apposition will not be complete or accurate throughout the whole fissure, and adhesion will not take place ; the palate will be too much stretched, as to throw off the ligatures by ulceration at the transfixed points of its margins. The patient must be made aware of the nicety of the operation, of the responsibility that rests upon himself, and be exhorted to steadiness and patience. A single exclamation of pain may subvert the whole proceedings. He is seated opposite to a strong light, and made to open the mouth wide ; if necessary, the jaws may be kept separate by a wooden 2S* 330 INFLAMMATION OF FAUCES. wedge, placed so as not to interfere with the operator. The head is thrown back, and held steadily by an assistant. The operator depresses the tongue by the forefinger of the left hand. A long, narrow, sharp-pointed bistoury is passed through the velum, close to its attachment with the palatine plate, and about a sixteenth part of an inch from the edge of the fissure; it is then carried downwards to the point of the uvula, so as to detach a narrow slip from the whole edge. The same is done on the opposite side of the fissure during the proceeding, and to facilitate it the point of the uvula on each side may be held by long and properly pointed forceps. After allowing the patient a short rest, the coagula and mucus are cleaned away from the parts, to prepare for union. Long bent needles, in fixed handles, and armed, are passed through the pared edges on each side. On one side the ligature is thin, the opposite thick and strong; the former is attached to the loop of the latter, and with- drawn, leaving the strong ligature passed through both apertures; and by this the margins are gradually approximated, and retained by a firm knot. A second point of suture, and a third, if necessary, is applied in the same way, and as represented in the " Practical Sur- gery," p. 558. Or a single short curved needle maybe used. It is introduced by means of aportaiguille, with a long handle, and passed through, first from the outside of one edge, and then from the inside of the other. A ligature, either of thread or of pewter wire, can thus be conveyed at once; if the latter is employed, it is secured by twist- ing, and the ends cut off by pliers ; the needle is attached to the wire by a female screw in its end. It is advisable to make incisions in the direction of the fissure on each side, through the mucous lining, in order to take off the strain from the stitches. Afterwards, success depends on the patient. All attempts at articulation, and even deglutition, must be strictly forbidden for three, four, or five days. Inflammation of the Soft Palate, Uvula, and Tonsils, requires in general little surgical treatment. Reiterated attacks may sometimes be traced to the progress of a wisdom-tooth, or to the presence of stumps in the posterior part of the upper or lower jaw. Perhaps the most common cause is sudden suppression of the discharges from the skin, aud from the adjoining mucous surfaces, in consequence of exposure to cold. The affection is accompanied with pain and diffi- culty in swallowing, and frequent and difficult excretion of mucus. The secretion of the. saliva is increased, the attempts to swallow it are frequent, and the inflamed parts being thereby put in motion, the pain is aggravated. From the inflammatory action extending along the Eustachian tube, the patient describes the pain as shooting towards the ear. The parts are red, and soon become swollen ; in some cases to so great an extent,"as completely to prevent deglutition ; occasionally the breathing is impeded; but the inflammatory swelling must be very great indeed, to obstruct the openings into both mouth and nostrils, and thereby threaten suffocation. The voice is hoarse, croaking, and husky; and, when the swelling is considerable, the patient speaks only in a whisper. The internal swelling is often accompanied by an external painful tumour of the lymphatic glands, INFLAMMATION OF FAUCES. 331 and the pain is much increased by external pressure. There is more or less concomitant fever, preceded by slight shivering. Removal of the local cause, and mild antiphlogistic measures, are usually sufficient to effect resolution, and put a stop to the disease. General bleeding will seldom be required ; blood is abstracted locally, either by scarifying the internal surface, or by applying leeches at the angle of the jaw. Fomentations afford much relief, and may be applied either externally, or internally by inhalation of the steam of water, or of water and vinegar. The greatest benefit is experienced from this remedy during the early stage, it being then employed either to promote salutary effusion and effect resolution, or at a later period to forward the secretion of purulent matter. At the same time, antimonials, purgatives, warm drinks, diaphoretics, and the pediluvium, are not to be neglected. In the relaxed state of the parts, after subsidence of the violent symptoms, stimulating and as- tringent gargles may be used with advantage. But in neglected cases, or those originally violent, suppuration, sometimes extensive and dangerous, occurs in the cellular tissue, betwixt the pillars of the soft palate, or betwixt the layers of the velum. The swelling thereby formed may be so large as to impede the passage of air by both the mouth and nostrils. The mouth is opened with difficulty and pain ; deglutition is seriously impeded, or altogether impracticable; the voice is weak and indistinct; and the countenance is swollen and discoloured. Life is endangered by the risk of the purulent matter bursting out suddenly during the painful and laborious efforts at respiration, and escaping into the air pas- sages ; fatal results have thus taken place, and to prevent such the abscess should be opened early. When the swelling is large, and attended with alarming symptoms, the matter is most conveniently evacuated by a flat and long trocar and canula. If the abscess be small, and the breathing not affected, there will be no danger in allowing the collection to burst spontaneously. Suppuration may also occur in the external glandular tumour, or in the surrounding cellular tissue. When sloughing to any extent takes place, it is in patients of an extremely debilitated habit of body, or when the affection is attendant on disease of a malignant character. Metastasis may take place to the larynx, to the trachea, or to the lungs, either spon- taneously, or in consequence of repellant applications. Chronic abscesses are occasionally met with in these parts, or be- hind the upper part of the pharynx, unconnected with disease of the subjacent bones. The matter must be evacuated as soon as its ex- istence is ascertained. No great accumulation should be allowed to take place in any situation, far less in the immediate neighbourhood of important parts. [These abscesses are sometimes acute, the suppuration occurring as a consequence of active inflammation.' They are seated in the submu- cous cellular substance, and often acquire a large size; at first there is merely soreness in the throat and pain in swallowing, but when matter begins to be poured out difficulty of breathing is superadded, from the pressure which it exerts upon the epiglottis and mouth of the' larynx, and if it be not speedily evacuated the patient may die from 332 ENLARGEMENT OF THE UVULA. suffocation. As soon as fluctuation is recognised, or even before if there be much swelling and difficulty of respiration, relief should be afforded by a free incision, made with a sharp-pointed bistoury with the back towards the tongue, which is to be depressed with the fore- finger of the left hand.] Scarification of the tonsils and surrounding membrane is seldom re- quired. A lancet concealed in a canula, with a spiral spring to with- draw its point, is used for this purpose, and for opening abscesses ; but dangerous and fatal results may ensue, and have actually followed such incisions of these parts. A sharp instrument directed outwards, made to penetrate either by the rash thrust of an ignorant and careless practitioner, or by a hurried movement of an unsteady patient, may reach the common trunk of the temporal and internal maxillary arte- ries, or even the internal carotid. The sheathed lancet may be use- ful in the hands of such as are not habituated to the use of instruments; but scarification of the parts and puncturing of abscesses can be ef- fected safely by a straight, sharp-pointed bistoury, covered with a slip of lint to within three-quarters of an inch of its point. The pa- tient's head is steadied by an assistant, the point of the instrument directed backwards, not at all outwards, and its edge upwards so as to avoid wounding the tongue, which is also to be kept out of the way by the forefinger of the left hand. NewT formations about the isthmus faucium are rarely met with. Small warty excrescences, and small pendulous, fatty, or polypous tu- mours, are occasionally seen. These, if productive of inconvenience, can be easily removed by cutting instruments. Enlargements of the uvula and tonsils are common, impeding de- glution, and producing indistinct and burring articulation. If large, respiration is interfered with. Elongation and Enlargement of the Uvula attends inflammatory at- tacks in the fauces, but may continue for a long time afterwards. The organ is increased in volume, both in length and in breadth, from in- terstitial deposition of new organised substance, and from unusual vas- cularity. The inconvenient size produces nausea and cough ; it is even said that the tumour has, in some instances, got entangled in the rima glottidis, suffocating the patient, or at least giving rise to the most alarming symptoms. In some cases the elongation appears to have kept up cough and expectoration for months or years. The parts may be touched with a bit of sponge, dipped in the tinct. muriatis ferri ; but a more useful remedy is the powder of alum, ap- plied either on a spatula, or by insufflation. Astringent decoctions, or solutions, are of little use. But in cases of large and long-continued enlargements, the swelling cannot be expected to subside under such treatment, and recourse must be had to curtailment by cutting instru- ments, of which the bestforthis purpose are long blunt-pointed scissors and forceps, with hooked points. The patient is then made to open his mouth wide ; the surgeon then introduces the instruments into the mouth, and watching an opportunity when the uvula is nearly station- ary, suddenly seizes and clips offa sufficient portion. This is followed by instant relief. Frequently an cedematous swelling of the uvula, of a crystalline ap- ENLARGEMENT OF TONSILS. 333 pearance, resembling a large grape, accompanies ulceration in the neighbourhood; puncturing of the part, and attention to the cause of the affection, are sufficient for the cure. When the blood-vessels of the uvula are in a state of chronic enlargement, scarification is also employed with advantage. Chronic Enlargement of the Tonsils occasionally takes place in chil- dren, but generally in persons from eighteen to twenty-four years of age, or in such adults as are subject to irritations in the neighbour- hood of the organs. A delicacy of constitution is supposed to be in- dicated by the affection. One or both tonsils may be enlarged, usu- ally both. The surface of the tumour is irregular ; the mucous folli- cles are enlarged, and often filled with sebaceous matter. The swell- ings in each side gradually approach each other, meet, and by nar- rowing the isthmus, seriously interfere with the functions of the parts. Little pain is felt, and that is dull, occasionally shooting the ear. Respiration is at all times fettered, and during sleep noisy. Occasion- ally the swellings exceed their usual size, from some accidental ex- citement of the circulation. They may subside very considerably on the removal of the cause, or abatement of its operation, for there is nothing malignant in their nature. It is true, as I have seen, that the tonsils may be involved in malignant disease spreading from the neighbouring parts ; but in the affection under consideration, no mark of malignancy appears, as far as I know. There is mere enlarge- ment and opening out of the texture, without much, if any, change in structure or consistence ; the part may be cut into without the risk of exciting unhealthy action, and the divided surface cicatrises readily. Deobstruents, and iodine, as the most efficient, maybe given, with perhaps some effect. In the adult, when the affection is troublesome, permanent, and of long duration, the exuberant matter must be re- moved, and this is accomplished either by ligature or by incision. The former method is the more difficult, tedious, painful, inconveni- ent, and dangerous. It is seldom that one ligature, with a simple noose, suffices ; it is necessary to transfix the tumour, and separating the portions of the ligature, to include the upper and under halves in distinct nooses. The latter method is the preferable. It is not re- quisite to cut out the whole tonsil, and there is risk in attempting such a measure, but that part only is removed with projects beyond the arches of the palate and the natural level of the gland. Long curved scissors may be employed, but the straight probe-pointed bis- toury is more convenient; and this, to insure security, may be blunted to within an inch and a half of its point, or rolled so far in lint. To facilitate incision, the tumour is laid hold of by a sharp hook, or, what is better, by a vulsellum. Occasionally violent at- tempts at retching occur during the operation ; butthere is little pain or hemorrhage. The complicated machines invented for this purpose are worse than useless. The healing of the sore is hastened by fomentations and mild gargles, and by either stimulating or soothing applications, as circumstances require. Excision of the tonsils is said to produce the bad effects of chang- ing the pitch of the voice— taken from the high, and adding to the 334 ULCERS OF THE PALATE. low notes. I have performed the operation, as above described, on professional vocalists, to remedy indistinctness of articulation and constant hoarseness, with the desired effect, and without alter- ing either the pitch, quality, or compass of the voice. No doubt, unpleasant results might follow extensive incisions of the parts, as division of the anterior fold of the palate, and removal of the whole tonsil; but by paring off the prominent parts of the glands no risk is incurred. Ulcers of the Palate, &c, are said to have arisen almost uniformly from contamination of the system, following sores on the genital organs. Now, at least, they seldom and scarcely ever occur from this cause, unless most execrable practice has been resorted to. Foul and extensive ulcers of the membrane of the mouth, of the tongue, of the gums, and of the folds of the palate, are common in those who have used mercury recently; and those whose constitutions have been saturated with mercury, or who have taken only alterative doses for a considerable time, are for a long while liable to ulceration of these parts on exposure to moisture and cold — one set of sores healing, but others soon breaking out. It is, indeed, very rare to meet with sores in these situations that are not thus accounted for: cer- tainly such as are by recurrence deep, extensive, and troublesome, are not seen unless in those who have suffered from mercurial medi- cines. Slight excoriations are not uncommon in individuals of the soundest and most untained systems ; but even in very young sub- jects, if the sore is of considerable size, and slow in healing, it will generally be found that some preparation of mercury, probably calo- mel, had been given previously, and perhaps without precaution and care. Calomel, as well as other forms of the mineral, is too often and too freely given, and without proper consideration ; the ruin of many good constitutions is attributable to this cause, and to this cause alone. How long mercurial poisons continue to exercise a prejudicial influence on the constitution, is a question not easily de- termined. In many, its dominion is long and powerful. Frequently its effects are developed years after its exhibition, from accidental circumstances, such as change in the mode of living, derangement of the stomach, and its appendages, exposure to inclement weather, change of climate, &c. Sores form in various situations, between the pillars of the fauces — in the site of the tonsils— on the uvula, and by its side — on the posterior and anterior surfaces of the pendulous velum ; sometimes the ulceration appears to have extended from the nostrils. Often the uvula is entirely lost; it is not long since I saw two uvulae, in one day, as black as a bit of coal, surrounded by ulceration, and just about to drop away. Ulceration of the posterior surface of the velum is marked by dark redness, and swelling of the anterior. Sometimes it happens, that by deepening of the ulcers, the velum is perforated at one or more points, and the edge of the opening healing, a perma- nent deficiency remains. The whole of the soft palate may be de- stroyed, either by one extending ulceration, or by repeated attacks. When cicatrisation takes place, the posterior nares are narrrowed, de- ULCERS OF THE NOSE. 335 formed, or even completely closed. Along with ulceration of tne fauces, abscesses frequently form in the coverings of the hard palate ; they are either the consequence or the cause of necrosis of part of the bone. Whatever their origin, more or less of the bone with which the matter is in contact, dies and separates ; and thus openings are established between the cavities of the mouth and nostril. This is productive of great inconvenience, the patient speaks very indis- tinctly and, when taking food, a part of the more fluid ingesta returns by the nostrils. During the progress of exfoliation, the breath is intolerably fetid. Such is an outline of mercurial products in the mouth. Eruptions and ulcers on the surface of the body often accompany or follow them ; and the patient gets into a bad state of health — becomes, in short, cachectic. The state of the system must be ameliorated if possible ; and chiefly by attention to the digestive organs. These may be improved by such medicines as ipecacuanha, taraxacum, gentian, rhubarb, scam- mony, aloes, given in various doses and combinations, according to the circumstance of the individual case. The first two possess many of the good qualities of calomel, in regard to the biliary secre- tion, and leave no evils behind them. Sarsaparilla is a most import- ant remedy, and the form of its exhibition should be varied when its effects begin to diminish. The different applications which may- be made to the sores have been mentioned formerly ; of them all, the nitrate of silver is the most generally useful, either in solution or in substance. It is used at intervals of two or three days, not to destroy living texture, but to diminish irritability and dispose to heal. If there be no great loss of substance, deficiency in the soft parts may be repaired by operation after the ulcerative disposition has ceased. In deficiency of the palate— during the progress of the ulceration in the bone and the parts investing it, and for some time after it has ceased -—the inconvenience is lessened by filling the opening with crumb of bread softened, and made into a paste by kneading; this must be frequently renewed, otherwise it collects discharge, and be- comes offensive. After cicatrisation of the margins, and contraction of the opening, a metallic plate may be fitted in. Ulcers of the Tongue.—-Such as are not of a malignant kind are readily healed on improving the state of the digestive organs and general health. The state of the organ indicates that of the chylo- poietic viscera, it enjoys intimate sympathy with the other parts of the alimentary canal, and why it should suffer from derangements of them is readily understood. The sores may be continued by local irritations, as by friction on encrusted tartar, or sharp or decayed portions of teeth, or by repeated application of heat, as in smoking. In consequence of long-continued irritation, like similar ulcers of the lips, they take on malignant action. The malignant ulcer generally occurs in patients past the meridian of life. Yet I have seen the greater part of the tongue involved in carcinomatous swelling in young subjects ; from one girl, twelve years of age, I was obliged to remove one-half of the organ vertically. Stony induration surrounds the exposed surface to a considerable extent, and the 336 ULCERS OF THE TONGUE. sore presents all the characteristic appearances of cancer. In many cases the induration precedes ulceration, in others follows it. A most extensive and dreadful disease of the organ is here re- presented ; along with induration of the whole organ, ulceration had penetrated like a tunnel from the apex to the base ; oedema of the glottis supervened. Sooner or later the absorbents are affected, becom- ing swollen, painful, and hard ; and, as in malignant affections of other parts, the dis- position and action is not limited to those in the immediate neighbourhood of the pri- mary disease. The tongue is subject to simple induration, wThich is totally uncon- nected with malignant disposition, and subsides on improvement of the digestive organs; occasionally repeated leeching of the part accelerates the cure. Enough has already been said about removing the local irritating cause, when such can be discovered ; and the maxim, though most important, need not be formally repeated in regard to affections of the tongue. The simple ulcer heals under the usual applications to sores or mucous surfaces, the general health being at the same time attended to. For malignant disease, nothing but very early removal of the part can avail. But this is not always either advisable or practicable : the disease may have involved the organ too extensively, and the lymphatics may have too widely participated in the action. When the diseased part is small, and nothing contraindicates surgi- cal interference, it may be removed by the bistoury ; usually the bleeding is very slight, but if troublesome it is easily arrested by the cautery. When the disease is extensive, ligatures are to be em- ployed. During the process a vulsellum is useful for grasping the morbid part, and securing the organ. The ligatures should be strong, and are introduced by needles in fixed handles. They may either be passed at once, or be preceded by finer ones, by which they are afterwards drawn through. The tongue is transfixed be- yond the induration, and if one ligature is sufficient, its noose is divided, and the parts tied separately, so as to include the mass. But frequently several ligatures are required, and their portions must be so disposed as not only to isolate all the indurated and ulcerated part, but also some of the neighbouring sound structure. They are tied firmly, to cut off vitality as completely as possible, and at once. Considerable swelling and profuse salivation follow, but gradually subside. In a short time fresh ligatures are passed through the old perforations, and drawn from time to time, till the part sloughs and drops away. This will not be found necessary if incisions are made betwixt the parts of the ligature in the first instance, so as to permit of their being tightly drawn. The swelling may be relieved by hot fomentations, and opiates mitigate the pain. The discharge is pro- fuse and fetid. A weak solution of the chloride of soda, vinegar ENLARGEMENT OF THE TONGUE. 337 with honey, or a solution of the mel boracis, maybe used as gargles. The healing of the wound is to be promoted by applications suited to the appearances which it may assume. Inflammation of the Tongue occasionally occurs during certain eruptive diseases, and sometimes in consequence of accidental cir- cumstances, as stings in the part from venomous insects; but it is not a common affection, and is generally produced by the abuse of mercury. When that poison was used more freely than now, the disease in question was by no means rare. It was then customary to see patients who were made to spit some gallons in a day, for the cure of a venereal affection, supposed or real, with their faces swollen, and their tongues portruding from their mouths, enormously enlarged. This consequence of the exhibi- tion of mercury is more apt to occur in some constitutions than in others, and I have seen it produced in a violent form by the pa- tient's taking only two Plummer's pills. In this case the patient, an old gentleman of broken constitution, had been filled brimful of mercury, over and over again, for one dis- ease or another in warm climates. The tongue swells rapidly, fills the mouth, and protrudes of a brown colour, from effused serum, with great enlargement of the papillae. The patient is unable to speak, deglutition and respiration are much impeded, and thirst is excessive. In some instances the inflammation proceeds to suppuration, but the more general termina- tion is resolution. In the more mild cases, a cure will generally be procured by eva- cuating the bowels freely by means of saline purgatives, and by local abstraction of blood ; the blood may be obtained either from the ap- plication of leeches, from opening several of the enlarged superficial veins, or from slight scarifications. Afterwards astringent lotions may be employed. But in more severe cases of glossitis, the tumour is productive of very great inconvenience to the patient, and is not unattended with danger; the difficulty in breathing may amount almost to suffocation, and in such the treatment must be active. Several free incisions are to be made longitudinally on the dorsum of the tongue ; from these the effused fluids are evacuated, a con- siderable quantity of blood escapes, and consequently the tumour speedily subsides. Superficial incisions are not sufficient, and the practitioner should not shrink from cutting tolerably deep ; for al- though the wounds may appear ghastly in the engorged and tumid condition of the organ, yet when the swelling subsides, and the tongue regains its usual bulk, their size, as in other situations, is so remarkably diminished, that they resemble trifling scarifications, and, in some instances, are almost imperceptible. Their extent and num- ber must vary according to the size of the tumour, and the urgency of the concomitant symptoms. If such practice should fail in dimi- nishing the swelling, and affording relief to the respiration, it may 29 338 ENLARGEMENT OF THE TONGUE. become necessary to perform tracheotomy. If the inflammation ter- minate in suppuration, the abscess must be treated on the same prin- ciples as those occurring in other parts of the body. The tongue is also subject to gradual and permanent enlargement. A remarkable case of this nature occurred to me some years ago, and I shall here detail it shortly. The patient was a male, aged 19. The tongue was of a very large size, compressible and elastic, pro- jected three or four inches from the lips and completely filled the cavity of the mouth. It was of a dark brown hue, in some places livid ; its surface was rough, at some points granulated, at others fissured, and at many traversed by large venous trunks. At the back part of the dorsum the papillae were much enlarged, granulated points were numerous, and several plexuses of dilated blood-vessels ramified immediately beneath the investing membrane. There was occasional bleeding from an ulcerated fissure near the centre of the dorsum, and also from the lateral parts of the protruded portion: in the latter situation, several cicatrices were visible. Saliva flowed in a continuous stream from the apex of the tumour. The lower jaw, much separated from the upper, was elongated and unusually narrow; the teeth, particularly those in front, were placed at a distance from each other, were covered with tartar, and projected almost horizon- tally from the sockets. A depression was felt at the symphisis men- tis, as if the two portions of the jaw were asunder, and the inter- vening space occupied by ligamentous matter. The enlargement was congenital, and the organ swelled rapidly, it was stated, every three months, to a much larger size, and subsided gradually. The bleeding was most frequent and profuse when the swelling was greatest, and then too he suffered much pain in the part. Articula- tion was very indistinct, and could be understood only by those who were accustomed to be near him. He swallowed, and even masti- cated pretty freely. From the periodical enlargement and diminu- tion, from the repeated hemorrhages, and from erectile tissue being visible on many parts of the surface, I considered the structure of the tumour to be in part similar to that of aneurism by anastomosis, and to be throughout extremely vascular. I therefore did not attempt removal by incision, but in the fir§t instance intercepted its vascular supply by tying both lingual arteries. The tumour was not affected immediately on the application of the ligatures, but soon beo-an to diminish gradually. Every thing was proceeding favourably0; but, on the seventh day, the tongue was attacked with inflammatory swelling, which advanced unsub- dued, notwithstanding the most ac- tive treatment. Sloughing com- menced at the apex, and appeared extending backwards ; I then iso- lated the protruding portion of the organ by ligature, and thus removed it in three or four days. At that time he complained of no pain, and felt very comfortable. But his system became much disor- dered soon after; abscesses formed rapidly over both wrists and on the DEPOSITION OF EARTHY MATTER. 339 hands, unhealthy infiltration of the cellular tissue took place at the root of the tongue, and amongst the deep muscles at the upper part of the neck, the parts became gangrenous, and he died. Dissection showed that the greater part of the tumour was composed of erectile tissue. A sketch of the lower jaw is here appended, in order to show the alter- ation in form, both at the symphysis and in the rami, which had resulted from the pressure of the organ and the necessarily constant open condition of the mouth. Enlargement of the tongue occasionally takes place in young sub- jects, a sort of simple hypertrophy, which often proceeds to a very great extent. The increase goes on in a remarkable manner after the organ is extruded beyond the lips, so that the patient is incapa- ble of covering it. Portions of the swelling of a V shape have been removed in such cases, and the edges of the wound put together. But by well managed and continued pressure the absorption of the swelling has been brought about, the organ has been reduced within the oral aperture, and a cure has then rapidly followed. Division of the Frcenum Linguce is sometimes, though rarely, re- quired. Division can be necessary only when the fraenum is so short as to confine the point of the tongue, prevent free motion of the organ, and thereby cause indistinctness of articulation. Infants are often supposed by anxious mothers to have their tongues unduly confined, when no such malformation exists; in such circumstances, it is almost needless to observe that the part ought not to be interfered with. And even when there is confinement, division should not be had recourse to, unless the child is prevented from taking nourishment. The operative procedure is simple and safe. The tongue is raised towards the palate, either by a spitula or split card — or, what is better, by the fingers — and the fraenum is cut across to a sufficient extent by blunt-pointed scissors. Ranula is a swelling produced by accumulation in, and distention of the extremity of the combined ducts of the sublingual and sub- maxillary glands. The extremity of the duct contracts, or is com- pletely closed, and in consequence of the saliva and mucus (the one the secretion of the gland, the other of the duct) collect, distend the canal, and cause thickening of the parietes. Thereby a tumour is formed, which, in some instances, attains a very large size, displacing in some measure the neighbouring parts, and incommoding the tongue in particular. Indistinct utterance and impeded deglutition result. The orifice of the duct, if discovered, is to be dilated gradually by occasional introduction of variously sized probes. Often it is neces- sary to make a small incision in the situation of the orifice, and in- troduce a bit of gum-elastic bougie, by continuing the use of which for some time, permanency of the opening may be obtained. Deposition of Earthy Matter — principally phosphate of lime — not unfrequently takes place in the extremity of the submaxillary and sublingual ducts, and the concretion so formed is often of con- 340 TUMOURS UNDER THE TONGUE. siderable size ; some are larger than an almond. The colour is either white or yellowish, and the surface either smooth or roughened by nodules ; in all the calcareous matter is friable, and disposed in con- centric layers. They are of the same nature as the earthy deposits, called tartar, which form on those teeth opposite to the extremities of the salivary ducts. The foreign body produces uneasiness in the mouth, swelling, and indistinctness of speech ; occasionally painful swelling of the salivary gland and surrounding parts takes place. Concretions also form, though very rarely, in the extremity of the parotid duct, and are -attended with like inconvenience ; of this I have seen only two cases. The foreign body is easily removed ; an incision is made through the membrane of the mouth, and the concretion dislodged by forceps, a scoop, or the fingers. The saliva regains its course, and irritation subsides. Sometimes the foreign body is exposed by ulceration, and might ultimately escape from its bed spontaneously. A figure of a salivary calculus of considerable size is here given. When the concretion is small, its extraction is not so easily accomplished as might be sup- posed. It is apt to slip back out of reach, so that it cannot be seized, brought forward and extracted either by scoops or forceps. The flow of saliva must be promoted by giving the patient something to masticate ; the probability is, that the foreign body will then be presented, and perhaps expelled, if the opening of the duct has been previously dilated. A young lady was brought to me lately suffering great uneasiness from the presence of a concre- tion, not larger than a millet-seed. She complained of great pain under the jaw on seeing any thing savoury, that, as the vulgar phrase is, made her mouth water. Various unsuccessful attempts had been made to remove it. A small incision of the surface of the duct was made, but the foreign body eluded the grasp of the forceps, and com- pletely disappeared. The patient was given a bit of bread to chew, and almost immediately the concretion was expelled. Tumours, unconnected with the salivary ducts, occasionally form in the loose cellular tissue under the tongue. They may be either sarcomatous or encysted ; the former are rare. I have removed several solid tumours, principally adipose, from this situation. They were loosely connected, and taken away without almost any dissec- tion ; indeed they were lifted out with the fingers, after division of the membrane of the mouth and of the cellular cyst which surrounded them. One was as large as an orange, and of a flattened form. The tongue had been displaced by the swelling, and articulation, deglu- tition, and breathing impeded. The patient, an old lady, had a good recovery. The case had been by some mistaken for ranula; and I mention this circumstance, lest others may reckon more on the situa- tion of a swelling, than on its feel and other external characters. A sketch of the tumour is given at page 141. Encysted tumours below the tongue are common. The cysts are generally thin and adherent, the contents albuminous and glairy. TUMOURS OF THE GUMS. 341 They attain a large size, and prove very inconvenient. Occasionally the cysts are thick and more loosely attached; such usually contain atheromatous matter. I removed one uncommonly large, from the ,/ inner surface of which numerous hairs were growing. Encysted tumours here can seldom be removed by dissection; the depth of their situation, their firm connexion, the awkward situation in which the patient is necessarily placed, and the risk of hemorrhage, forbid the surgeon from attempting regular extirpation. A more simple and equally effectual procedure is as follows: — The mem- brane of the mouth and the cyst are divided by the point of a bis- toury ; and if the tumour be large, and the distention great, an oval portion of the parietes may be cut out. The contents are thus eva- cuated. The bleeding is allowed to cease, and the cavity having been wiped out clean, a stick of caustic potass is applied to the sur- face, so as to annihilate the cyst effectually. This I believe to be the only radical and safe mode of removal ; after any other, the tumour is certain to be reproduced. It has been recommended to pass a seton, so as to excite inflammatory action, and lead to obliteration of the cyst. I have made trial of this practice, but most dangerous swelling ensued, the mouth was rapidly filled, and the system alarm- ingly shaken ; after all the disease was not eradicated. Tumours beneath the tongue, however originating, occasionally inflame, and become the seat of unhealthy abscess. A large and painful swelling forms, and projects under the chin. The matter gra- dually approaches the surface, and perhaps evacuates itself imperfectly into the mouth, or the integuments give way, and afford an external issue. In such cases, an early incision from the mouth may prevent the interna] mischief, and the disfiguration of the countenance which would otherwise ensue may, in short, limit the suppuration ; at a later period a free opening requires to be made below the chin, in the mesial line, and in the direction of the muscular fibres. A ready drain is thus obtained for the matter, and the cavity of the abscess gradually contracts. Tumours of the Gums are usually hard, and not inclined to increase rapidly. They are of the same consistence as the parts to which they are attached, and grow either inwardly, outwardly, or both. They surround one or more teeth, which at last become loose, the alveolar processes then soften, and form part of the swelling. These may degenerate, and grow rapidly, or the tumour may be soft (tumor mali moris) from the first. The attention of the patient is directed to the part by the occurrence of discharge from about the teeth, which loosen one after another. A soft tumour arises from the sockets after either extrusion or extraction of the teeth, it grows rapidly, and involves more and more of the gums and alveolar pro- cesses. Angry ulceration attacks the prominent part of the swelling ; the bone is softened to a considerable extent around; the dis- charge is thin, bloody, and profuse. Ultimately the lymphatics be- come affected, neighbouring parts are contaminated, malignant ac- tion acquires a firm footing, and extends, the patient becomes hectic, and dies. 29* 342 INFLAMMATION AND ABSCESS OF THE GUMS. Each kind of tumour should be removed freely and early ; the untoward results of the latter have been already mentioned : and I believe, that if the former be allowed to proceed unchecked, the tu- mour may ultimately extend to the bone, and osteosarcoma of the jaw, more or less extensive, be established. The disease must be at- tacked, at an early period of its existence, and teeth, sockets and soft parts taken freely away, by means of a strong knife and saw, or cutting forceps. After excision, the actual or potential cautery should be applied, otherwise the disease is apt to recur. Portions of involved bone, which may have escaped the knife, are by the caustic made to exfoliate. When the potassa fusa is used for the purpose of destroy- ing what cannot be readily reached by the knife, and when it is pushed into the alveoli and applied to the altered gum, its action must be limited by the immediate use of vinegar, diluted or not. Inflammation of the Gums and neighbouring parts is attended with violent pain, swelling, and throbbing, difficulty in opening the mouth, headache, and fever. Inflammation of the soft parts runs its course speedily, and, as the cause is seldom removed during the exis- tence of the inflammatory action, generally terminates in suppuration, so giving rise to what is termed parulis or gumboil. Frequently the inflammation extends to the sockets of the teeth, which seldom resist the action long, but from their low degree of vitality soon be- come necrosed ; and by the presence of the dead portions of bone, a fresh accession is given to the disease. Severe pain is experienced on touching the teeth whose alveoli are.affected ; they project and become loose ; purulent matter is secreted, and oozes out between the loosened teeth and diseased gums. Abscesses form, and point in different situations ; the gums are tumid and spongy ; through the openings in them the bone can be felt bare, and the purulent matter is situated within or around the alveoli, and under the mucous mem- brane and cellular tissue which invest them. When the inflammation has been either intense from the first, or of long duration, it not unfrequently happens that abscesses form within the substance of the jawbone, and occasionally to a considerable ex- tent — a portion of the bone having become inflamed, and the action terminating in suppuration and partial caries. This is more apt to occur in the inferior than in the superior maxillary bone ; and, if allowed to proceed, the osseous cyst containing the purulent matter gradually enlarges, the plates of the bone are separated and ex- panded, the parieties become attenuated, and the affec- tion is termed spina ventosa. Purulent collections in this situation also seem, in many instances, to arise from, or at least to be preceded by, the formation of a cyst around the decayed root of a tooth. Such cysts are generally of small size, and py riform shape; externally they are smooth, membraneous and of rather a delicate texture ; internally, they are lined by lymph of soft consistence, and con- tain purulent matter. In fact, they are purulent depots, which form in consequence -of inflammation around the fangs of the teeth, and from which the matter is occasionally discharged through a small CARIES OF THE TEETH. 343 aperture at the upper part of the cyst, and by the side of the affected tooth. They sometimes attain a very considerable size. Mercury is perhaps the most common cause of this disease ; but it is also produced by certain operations on the teeth, and by the presence of carious teeth or of stumps. Caries of the Teeth is an extremely common affection, and in some instances seems to arise from an unhealthy state of the consti- tution : but it is most frequently produced by the teeth having suf- fered from chemical agents, as when the mineral acids have been taken for a considerable time as medicines, or when the individual is in the habit of consuming sweetmeats, and confections. Sometimes the disease remains almost stationary, and may give little or no an- noyance for a number of years ; in other instances, its progress is very rapid. A portion of the tooth gradually decays, and this isat first unattended with any uneasy sensation ; but when, from continuance of the destructive process, the central cavity has been exposed, the pain is excruciating, attended with headache, and swelling of the surrounding soft parts. In general the progress of the disease may be arrrested by removing the diseased portion, and stuffing the ca- vity, before any pain has been felt. But after the central cavity of the tooth has been exposed, filled with fungous mass, as here seen, or from their growing in a faulty direction, and pain consequently ex- perienced, the most effectual remedy is extraction. The patient from whom the specimen below was obtained, perished in consequence of the extensive abscesses of the mouth and neck, consequent upon the awkward position of the wisdom tooth. From the presence of carious teeth, or decayed portions of teeth, many evils both local and general ensue, besides inflammation and abscess. They are frequently the cause — and the sole cause — of violent and continued headaches ; of grandular swellings in the neck, terminating in, or combined with abscess ; of inflammation and en- largement of the tonsils, either chronic or acute; of ulcerations of the tongue or lips, often assuming a malignant action from continued irritation ; or painful feelings in the face, tic doloureux, pains in the tongue, jaws, &c.; of disordered stomach, from affection of the nerves, or from imperfect mastication ; and of continued constitutional irrita- tion which may give rise to serious diseases. Along with abscess of the gums, purulent matter often collects in the cellular tissue of the cheek or of the chin. In the latter situation 341 CARIES OF THE TEETH. the inflammation and suppuration are often caused by the teeth in the front or side of the lower jaw being too much crowded together. When the teeth are crowded together, the patient, of course, cannot be effectually benefited till one or more of them are extracted, and sufficient space allowed for development of the others. The abscess gives way, and discharges its contents often both externally and in- ternally, and a fistula remains, which cannot be got rid of, unless, as in most other affections, the cause be removed. The cavity of the abscess must be opened into either from without or within, and after the subsequent irritation has subsided, the cause must be removed ; carious teeth or stumps are not to be taken away during the inflamed state of the parts, but after the pain and inflammation has subsided in consequence of free evacuation of the purulent matter. After these have abated, and not till then, the offending bodies are to be extracted, both in order to procure a more speedy and effectual cure, and with a view to prevent recurrence of the disease. If a portion of the jaw has become necrosed, the sequestra are to be extracted as they become loose,and openings and counter-openings must be made, according to circumstances, so as to afford a free outlet to the matter. The extraction of teeth, the crowns of which have not been de- stroyed, is accomplished most readily by the dexterous use of vari- ously shaped forceps. Stumps may be occasionally extracted also by forceps, but the lever is generally required to loosen them from their sockets. The old key instrument and pelicans are now super- seded by those above mentioned. [There is no subject of greater importance to the country prac- titioner than the extraction of the teeth ; an operation, which, from his insulated situation, he is constantly obliged to perform. Like the operation of venesection, it may be executed well or indifferently, and precisely as he does the one or the other will be the measure of his standing with his patients. The following observations in rela- tion to this subject are condensed mainly from the excellent work of Mr. Bell, " The Anatomy, Physiology, and Diseases of the Teeth," which should be in the hands of every physician in the country. Mr. Bell thinks that the separation of the gum from the teeth, as a preliminary measure, is unnecessary; a view in which I must en- tirely disagree with him. That it materially facilitates the removal of the organ from its socket, ample experience has long since con- vinced me. The operation may be performed with a gum-lancet, or, what I have always preferred, a sharp penknife, which should be passed completely round the neckof the tooth, down to the alveolar margin of the jaw-bone. In the removal of the first teeth in children the previous separation of the gum is unnecessary. The incisors of the upper jaw will require the use only of a small pair of straight forceps, the application of which is extremely simple. As the roots of these teeth are conical, and generally perfectly round, they will require merely a slight rotation, when they may be drawn downwards in the direction of the socket. The forceps should be placed as high on the root as the alveolar process will admit, and pressed so firmly as to prevent the blades from slipping, while at the same time care is taken not to crush the tooth. CARIES OF THE TEETH. 345 The extraction of the lower incisors is effected in a very different manner. The roots of these teeth being very much flattened later- ally, it is obvious that they cannot be dislodged upon the principle of simple rotation in the socket. When the tooth is even, or nearly so, with the others on each side of it, the best instrument will be the hawk's-bill forceps, of very small size, and with narrow blades. The instrument being fixed as low on the neck of the tooth as pos- sible, a gentle but firm movement is to be made forwards, so as just to separate the organ from the back part of the alveolar cavity, and then, continuously with this motion, the tooth is at once to be raised out of the socket. The superior cuspid and bicuspid teeth may generally be removed by means of the same straight forceps as the incisors. The extrac- tion of the former will be considerably facilitated, by giving a sight degree of rotation previous to its actual dislodgement from the socket. The bicuspids, on the contrary, have flatter sides, and less solid roots, will not allow of any degree of rotation ; and must therefore be dislodged, by first of all moving them a little outwards towards the cheek, so as to destroy the attachment to the inner alveolar plate, and then, by a perpendicular pull, they may be lifted directly from the socket. The cuspids of the lowTer jaw are to be removed by the same means as the incisors. For the extraction of the bicuspids the key is the best instrument. The claw, placed in the usual position, should be rather small, and the fulcrum well covered with lint. The removal of the first and second molars of the upper jaw will generally be best effected with a pair of large forceps, slightly bent at the blades. In applying this instrument to the teeth in question, the edges must be thrust as far under the border of the gum as possible, and a firm, steady hold taken of the tooth. It is then to be dislodged by first a steady, gradual bearing outwards until it is slightly moved, when, with a contrary motion into its former position, followed by a firm pull downwards, the tooth is removed with considerable facility. The corresponding teeth of the lower jaw may be extracted by the same means, or with a pair of hawk's-bill forceps, the longer blade of which is to be placed on the inner gum. The operator standing on that side of the patient from which the organ is to be removed, and having taken a firm hold, first moves the tooth a little outwards towards himself, and then, with a steady and continuous movement, draws it almost straight from the socket; a motion which the incli- nation of the handle will greatly facilitate. The wisdom-teeth are best extracted with the forceps ; their roots are small, and but little force is required for their removal. When the crowns of any of the teeth are so entirely destroyed that the forceps and the key are alike insufficient to remove the roots which remain, the elevator, as it is called, will be found a very simple and efficient means to effect it. The edge of the instrument is to be in- serted between the root and the alveolus, so far as to secure a sure hold, and the root is then to be lifted, as it were, from the socket, by resting the instrument upon the alveolar process, or even upon the side of a neighbouring tooth. There is not the least danger of injur- 346 SPINA VENTOSA OF THE JAW. ing the latter if care be taken not to depend too exclusively, nor to bear with too much force upon it.] ... Spina Ventosa of the Jaw often originates, as before mentioned, in a small cyst at the root of a decayed or dead tooth. An enormously large one extracted along with the stump attached is here shown ; it is sketched from a specimen in the collection of Mr. Nasmyth, of Edinburgh. The disease is usually situated on one side of the lowrer jaw ; but sometimes occurs in the upper, and is at first unconnected with the cavity of the antrum. Inflammation has taken place in the internal structure of the bone ; matter is secreted by the medullary vessels, and collects in the can- cellated texture. Purulent formation advances, the cancelli are broken down, the external laminae of the jaw are extended, pro- truded, and attenuated ; and then the internal cavity enlarges, con- taining pus, perhaps mixed with other fluids, and with disorganised particles of bone. Sometimes the collection proceeds slowly, and the expansion of the bone is gradual and uniform ; in other instances, the swelling rapidly attains a large size. As the disease advances, the bony parietes become remarkably thin and delicate, particularly at the more prominent parts of the tumour ; and at many points bone is deficient, and its place supplied by membranous expansion. Oc- casionally alteration of structure takes place in the cyst; solid matter is added, either bony or fibro-cartilaginous, and morbid action pro- ceeds in the new deposit. In acute cases, in which the secre- tion and distention are rapid, severe pain is felt in the part at the first, and usually continues but little unabated ; when the swelling is slow and gradual, considerable pain is experienced during the in- flammatory stage, but soon diminishes, or ceases entirely. In every instance the features are deformed, and the functions of the mouth more or less impeded. Osteosarcoma may supervene on spina ventosa— morbid action oc- curring in the parietes, and morbid deposit ensuing, as in the fol- lowing instance : — The patient was a male, aged twenty-one. Swelling had existed for a considerable time at the posterior part of the lower jaw on the left side. The wisdom tooth and last large grinder, their pulps probably having been blighted, never appeared, and the swelling occupied their situation. The bone was expanded on each side ; the upper surface of the tumour was soft, its growth had been gradual, and no great pain or uneasiness was experienced. I cut out an oval portion of the cyst where it projected into the mouth, and well-digested matter was evacuated ; a seton was then passed out near the angle of the jaw, and worn for some weeks. The plates of the bone approximated, the cavity contracted, and the discharge ceased. Two years afterwards rapid swelling took place in the same situation, suppuration occurred, and the matter was again discharged by incision ; the tumour then subsided. Again inflammatory swell- ing occurred twelve months afterwards ; the same course was fol- lowed and the patient relieved. A hard swelling now occupies the SPINA VENTOSA OF THE JAW. 347 jaw from its angle to the canine tooth, it is increasing in size ; the necessity for its removal is apparent, and has been decided upon. Very shortly after writing the above, the patient submitted to the disarticulation and removal of fully half of the jaw, represented here. He made a rapid recovery, and showed himself to me and the pupils at the hospital a short time since, and fully five years from the time of the operation, in remarkably good health, and very little deformed by his loss. His whisker effectually conceals the mark of the incisions. But in general, after free evacua- tion of the purulent matter from a bony cavity, even of a very large size, the space between the parietes diminishes rapidly, the distend- ed and attenuated bone contracts and is condensed, the new depo- sition is absorbed, and the parts regain their natural and healthy ap- pearance. In the slighter cases of spina ventosa, removal of the offending teeth or portions of teeth, is generally sufficient; the matter escapes freely enough from the sockets, and the discharge soon ceases. When the cavity is considerable and its parietes thin, a counter- opening at the base of the jaw is required ; and it is often of advan- tage to introduce a small cord from the opening in the mouth through the counter-opening, and to continue its use for a short time, draw- ing it backwards and forwards in the cavity occasionally. For mak- ing the counter-opening and placing the seton at the same time, a strong needle in a fixed handle is most convenient. This practice I have employed in a good many instances, and can confidently re- commend as successful. In a large spina ventosa, not complicated with solid growth, the parietes may be removed freely and with safety ; the cavity is dressed to the bottom, and gradually fills up by granulation. The division of the integuments to expose the tu- mour must vary according to the circumstances of the case ; the in- cision of the bone will generally be accomplished by a strong bis- toury. Such procedure will seldom fail in procuring a cure, and is less severe, less dangerous, and productive of less deformity, than division of the jaw and entire removal of the diseased portions, an operation which can very seldom be warranted for spina ventosa. In the following case, the tumour was the largest of this kind which I have met with in the jaw, and yielded to the treatment just noticed. The patient was a male, aet. 48 ; he applied to me in 1821. The tumour had been of three or four years' duration, equalled a large fist in size, and involved the left side of the lower jaw at the junc- tion of the ramus with the body of the bone. The sac extended behind the coronoid process, and downwTards, through the substance of the jaw, amongst the hyoid muscles. Several carious teeth and stumps wTere imbedded in the swelling; the projection was chiefly lateral, the parietes wTere yielding, and the line of the jaw could be traced from below. There was occasional slight discharge of puru- 348 OSTEOSARCOMA. lent matter from the neighbourhood of the involved teeth. The cheek was laid open, and the bony and cartilaginous parietes of the cavity completely removed ; the bleeding from the bony surface was arrested by cautery and pressure. The soft parts united kindly, and the patient obtained a rapid, per- fect and permanent cure, returning home with the cheek united in ten days after the operation. Solid Tumour of the Lower Jaw — Osteosarcoma — commences in the internal structure of the bone, frequently in the neighbourhood of stumps. The origin may be traced to external injury of the part; or the disease may take place in the jaw, either along with osteo- sarcomatous tumours of other bones, or subsequently to their de- velopment ; in such circumstances a peculiar disposition of the system is the only cause that can be assigned. The tumour gene- rally occupies the lateral parts of the bone. Its growth may be either slow or rapid, and is attended with dull uneasiness, rather than acute pain. At first the morbid deposit is confined to the can- cellated texture, but as it increases the external laminae are distend- ed, and at last give way at one or more points, and the tumour pro- trudes fungous into the mouth. . The consistence of the mass is various, it may be soft and brain-like, or cartilaginous, mixed with bone and fibrous matter in various proportions ; but the anatomical characters of these tumours have been already detailed, and need not be here repeated. The features are much deformed, the swelling seriously incommodes the neighbouring parts; the teeth loosen and drop away, and fungi arise from the rockets ; a fetid, thin, sometimes bloody discharge is secreted copiously, and the health declines. The part protruding around the gums is deeply indented by the teeth of the upper jaw; it separates the jaws to a greater or less ex- tent, prevents closure of the lips, induces salivation, and impedes the taking of nourishment. The tumour is one of those which are apt to be reproduced, and if unmolested, gradually undermines the system, and ultimately the patient perishes very miserably. At one time every instance of it was regarded as hopeless ; but of late a great many tumours, in various stages of advancement, have been removed successfully by British and foreign surgeons. In some instances, the portion of the jaw containing the morbid growth has been sawn out; in others, one half of the bone, or more, has been removed by disarticulation, after being divided be- yond the diseased part. A very few weeks ago, I had occasion to remove fully three-fourths of this bone, from the site of the first" large molar on the left side to the condyle of the right. The pa- tient, an elderly female, is convalescent. The operation is severe, and to a spectator shocking enough ; but it can be undertaken with safety, and in most cases with almost a certainty of favourable ter- mination. In no other way, assuredly, can the disease be eradi- cated. Partial excisions, applications of the cautery, &c, only hasten the malignant process. To expose the tumour and admit of the bone being readily divided, incision of the soft parts requires to be extensive. And OSTEOSARCOMA OF THE JAW. 349 previously to determining on the plan of operation, the extent of the disease must be ascertained accurately. If, for example, the tumour is included between the lateral incisor tooth and last molar on the same side— these teeth must be extracted to permit division at these points. A semilunar incision may then be made along the base of the jaw, the horns of the incision pointing upwards and passing over the space which was occupied by the extracted teeth. The flap is dissected up, and the membrane of the cheek divided along the line of incision. The bistoury is then carried along the inside of the bone so as to divide the membrane of the mouth and separate the attachments of the muscles. The tongue is pushed aside, and a copper spitula placed under the jaw at the part to be divided, in order that the soft parts may not be injured during the sawing. A small narrow saw, or one commonly known by the name of Hey's, is applied to the bone at the points where the teeth were extracted, and by a few motions of this instrument a notch is made of no great depth ; a pair of strong cutting pliers are placed in the track, and by them division of the bone is accomplished with equal neatness, and much more rapidly than if the use of the saw had been continued. The pliers should be strong in every point, and the handles long, to afford the advantage of a powerful lever. In edentulous subjects, as the one alluded to above, there is no ne- cessity far using the saw at all: the bone is at once and easily cut by the forceps. The chain saw has been recommended for performing the section of the bone, but I have not yet seen one to be depended on; it is not only slowT, but uncertain, in its ope- ration. The incisions may be made otherwise. The cheek may be divided by passing through it a long narrow bistoury, close to the anterior edge of the masseter muscle, and carrying the instrument forwards, and through at the angle of the mouth. From each extremity of this incision another is made downwards, the anterior one inclining forward, the other backwards. By reflection of the flap thus formed, the bone is exposed more easily, rapidly, and perfectly, than by the former mode of incision. The objection to this mode of procedure is the deformity occasioned by the scars, though, if care be taken, in putting the edges together, this is very slight indeed, and not re- markable. In either method, no artery, except the fascial, requires to be se- cured by ligature. After division of the bone, the attachments of the tumour which may not have been separated previously, are cut with the bistoury, the cavity is filled lightly with charpie, and the incisions are carefully and neatly put together, and retained by points of interrupted and twisted suture ; the latter form of suture being adopted at those points where accurate coaptation is most im- portant. The symphysis of the lower jaw has been removed, and its extirpa- tion may again be rendered necessary, either on account of tumour commencing in its internal structure, or from disease of the sockets extending deeply and approaching the base. I removed it in a case of malignant disease, by which, and by the applications used as reme- 30 350 OSTEOSARCOMA OF THE NOSE. dies, great ravages had been made on the under lip ; the gums and alveoli were involved, as also the bone, to a considerable extent, without any apparent affection of the lymphatics. Nothing untoward occurred in the operation, and the case was proceeding favourably ; but after some weeks the patient was seized with violent erysipelas of the face and head, and perished. One objection to the operation is, that the muscular attachments of the tongue to the symphysis can- not be divided without some risk ; the antagonist muscles are un- restrained ; the os hyoides and root of the tongue may be drawn backwards upon the fore part of the vertebrae, so as to close the air- passage, and cause suffocation. This is guarded against by the in- troduction of a thick ligature. The disposition to retraction soon ceases. Disarticulation of one side of the jaw is not unfrequently neces- sary ; it is absolutely required when the tumour encroaches upon and involves the angle and ramus. It is a more severe operation than excision of part of the bone, and attended with greater risk; yet it may be advised and undertaken with very fair and probable chance of ultimate success. The incision of the cheek is made to incline more upwards than those recommended for partial excision, and is extend- ed to every articulation of the jaw ; from this point, another is made in the direction of the ramus, and prolonged to an inch or more be- yond the angle. A third incision is made perpendicular to the first, or to the lower lip, over that part of the bone in front which is to be divided. The flap is turned down, and the muscles and membrane of the mouth separated from the bone opposite to the last incision ; after which, the finger is passed through to complete the detachment. A preferable form of incision along the posterior border of the ramus and under the base of the jaw and tumour to over the point at which the bone is to be sawn, but without division of the lip, is recom- mended in the Practical Surgery. This method I have practised repeatedly ; the cicatrix is then completely out of sight, and in the male is entirely covered and concealed. During the cure, also, the dis- charges escape more readily, the opening being quite dependent. The bone is then divided at that point by the saw and pliers, the tooth in the line of the track having been extracted previously to the commencement of the operation. The cut end of the jaw is laid hold of by the left hand, and depressed, and the bistoury carried backwards along the internal surface, to effect detachment as far as the angle. The bone is still more depressed, and the temporal muscle cut from the coronoid process. The mass is thus loosened and forced downwards and backwards on the neck ; the forepart of the capsule is then cut, and the bone twisted out. Separation of the remaining attachments is completed by a few rapid strokes of the knife, and the whole mass removed. Hemorrhage is then to be permanently arrested, but instead of immediately tying every open mouth which presents itself, it is sometimes better to expose the common trunk of the internal maxillary and temporal arteries—which is easily effected, as it emerges from under the digastric muscle— and to pass a liga- ture beneath it by means of an aneurism needle. This is more quickly done than the applying of ligatures to the many branches of this OSTEOSARCOMA OF THE JAW. 351 trunk which have been divided. The other vessels — the fascial, branches of the lingual, &c.— are then tied, the cavity is filled with charpie, and the incisions of the soft parts are carefully closed. In these, union by the first intention usually takes place nearly through- out the whole extent; suppuration occurs from the deep wound ; the charpie is dislodged gradatim, and removed ; granulations spring up : and, after some time, the cavity is obliterated. The cheek must necessarily fall inward very considerably, but the deformity is not to be compared to that caused by the tumour. During granulation, the patient is made comfortable by the frequent use of tepid gargles, lodgement of pus in the mouth being thereby diminished. Articu- lation and mastication are not so perfect as when the jawT was entire and sound ; but the patient gradually becomes accustomed to the want, and these functions improve. A contrivance described in the Practical Surgery is used to prevent the remaining portion of jaw from being drawn towards the mesial line, and to keep the teeth opposite to those of the corresponding side of the upper jaw. Partial paralysis of the side of the face necessarily follows, for there is no possibility of accomplishing disarticulation of the jaw without di- viding many branches of the portio dura. Supposing that the portion of the jaw between the angle and sym- physis had been removed on account of osteosarcoma, and that the ramus subsequently became affected, it is no easy matter to effect disarticulation, as I have experienced. —The patient was a female, aged 30, of delicate constitution, and subject to toothache from in- fancy. I removed an osteosarcomatous tumour, extending from the angle to the canine tooth, on the right side. Division was made wide of the existing disease, and the sawn surfaces appeared quite healthy; but about five months afterwards, symptoms of return oc- curred in the ramus, and ten months after the first operation disar- ticulation was indispensable. The operation was accomplished with very considerable difficulty, on account of there being no lever to overcome the action of the temporal muscle. After separating the attachments as much as possible, an attempt was made to force down the coronoid process, from under the zygoma, by pushing the lower end of the bone backwards, in order to divide the insertion of the temporal muscle ; but this proved ineffectual. The capsular ligament of the joint was then divided, and the bone with, difficulty turned over from behind, forwards. It was then detached underneath the coronoid process, pulled down from under the zygoma, and the tem- poral muscle at length divided at its insertion. In none of these operations is there a necessity for preliminary exposure and ligature of either the carotid artery or its branches ; by so doing, a great addition is made to the patient's sufferings, the real operation is only commenced when the patient supposes it should have been finished, and he is thus annoyed and worn out. The flow of blood is easily moderated, or altogether arrested, by the pressure of an assistant's fingers against the forepart of the vertebrae, below the angle of the jaw. The position of the patient is either recumbent, with the fae- turned from the operator, or sitting with the head supported and steadied. 352 WOUNDS OF THE FACE AND NECK. The instruments required are, a very strong, sharp-pointed bis- toury, for division of the soft parts ; saws, of which Hey's is to be preferred for notching the bone; strong and long pliers, for com- pleting its section; an aneurism needle, for securing the common trunk of the temporal and internal maxillary artery ; dissecting and artery forceps, hooks, blunt and sharp, narrow copper spatulae, liga- tures, &c. Wounds of the Face and Neck. — Accidental wounds of the face may involve the more important blood-vessels and nerves, and inter- fere with the eye or its appendages, with the nose, or with the mouth. Injury of these parts is to be avoided in incisions premedi- tated for the removal of disease or deformity ; and, in such premedi- tated wounds, the line of incision should always be, if possible, in the direction of the muscular fibres. The bleeding seldom proves troublesome ; pressure on the vessels, as they pass over the bones, arrests it temporarily; and ligature is seldom required, accurate adaptation of the divided surfaces proving sufficient for effecting permanent closure of the divided branches. Paralysis, more or less extensive, follows division of the nerves and muscles. But paralysis of the face also arises from a variety of other causes; it often remains after injuries of the head, probably in consequence of extravasation on the brain ; it attends on morbid formations in the substance of the brain, or in its membranes, and follows loner-con- tinued irritation in the neighbourhood of the nerves. Paralysis from the last mentioned causes is not likely to be recovered from ; that following simple division of nerve, may disappear after a considera- ble time, the nervons tissue reuniting, and resuming its functions. When there is reason to suppose that the nervous function is alone deranged, while the structure remains sound and the continuity un- dissolved, advantage may follow the application of strychnine to a raw surface over the course of the affected nerves. In Tic Doloureux, division of the nerves of the face, as they pass out of the foramina, is seldom resorted to; nor ought it to be prac- tised, unless at the urgent request of the patient, and after all other means have failed to afford relief; and even then the operation is scarcely warrantable, since it may be said never to have succeeded in affording permanent relief. We must trust to milder measures, to the removal of local irritations, to paying strict attention to the digestive organs, to the administration of purgatives, tonics, and anodynes ; occasionally benefit has resulted from the external use of the nitrate of silver, applied so as to cause very slight vesication. Ointments containing veratria and aconitine have been used with advantage, and the endermic application of the salts of morphia has also been found useful. Spasmodic action of the muscles of the face, without pain some- times follows wounds and other injuries of the nerves which'supply them ; and sometimes no cause can be assigned for the occurrence In this affection, also, the application of nitrate of silver to the integu- ments over the nerves may sometimes be made with advantage Division of the parotid duct, or wound of the gland itself is occa- WOUNDS OF THE NECK. 353 sionally followed by the formation of a fistulous aperture, discharging saliva over the cheek. We endeavour to prevent this by accurate union of the recent wround. After the fistula has formed, an opening is to be made from it into the mouth, and kept pervious; the exter- nal aperture is then closed by suture after excision of the smooth edges, or is made to contract by the repeated application of a heated wire ; pressure alone is of little use. All wounds of the face are to be put into the most favourable state for healing without granulation, so that deformiiy may be prevented as much as possible. The twisted suture is best adapted for this purpose ; more accurate coaptation being thereby obtained than by the interrupted form. In extensive wounds, the parts may be brought somewhat into their proper position by a few points of in- terrupted suture; twisted sutures are then placed in the intervals, and the isinglass plaster is of use in closing those points which may still gape slightly; in many cases the greater part of the approxi* mation may be accomplished by isinglass plaster alone. [I have been in the habit, for many years, of keeping the edges of incised wounds of the face, forehead, and eyelids, in contact with gold pins finer than the most delicate sewing-needle. They should be from an inch to an inch and a half in length, and be provided with heads of sealing-wax, by which they can be more easily carried across the skin than in any other way. From the materials of which they are composed they are entirely exempt from oxidation, which is not the case with the common needle ; and I am con- vinced, from ample experience, that wounds thus healed are seldom attended with permanent deformity, from the formation of unsightly scars.] Deep wounds behind the angle of the jaw, and at the lateral and lower parts of the neck, are highly dangerous ; indeed they are almost certainly and immediately fatal, as can readily be understood when the large blood-vessels and important nerves are considered which have their course in these parts, and which must be either wounded or completely divided. The bleeding has in some cases been arrested by immediate ligature of the divided extremities of the vessel, by firm and permanent pressure, or by pressure at first, and ligature of the trunk of the vessel on the recurrence of hemorrhage after the lapse of many days ; of these methods immediate ligature of each extremity is certainly the safest and best. In lacerated wounds violent hemorrhage may take place some time after the infliction of the injury, from ulceration or sloughing of a large artery ; in such circumstances either permanent pressure may be resorted to, or liga- ture applied to the vessel above and below the open point. Dissections for the removal of morbid growths in the situations just mentioned must be conducted with muoh caution, and with a full recollection of the relative anatomy. Unless the tumour be tolerably loose and defined, it ought not to be interfered with. But it is to bo recollected that tumours of these parts are bound down by their con* densed coverings—the platysma myoides and cervical fasciae ; and that, after division of these, the tumour, if not intimately incorpor« 30* 354 WOUNDS OF THE NECK. ated with the neighbouring tissues, is loosened, and often enough can be readily detached. From constant external pressure, tumours growing rapidly spread amongst the deep parts, and often form firm attachments. The parotid is displaced, and almost entirely absorbed, by the pressure of tumours growing out of the lymphatic glands which are lodged on its anterior surface. Such tumours attain a large size, and occupy the exact situation of the parotid: on their removal, the space betwixt the angle of the jaw and the mastoid process is com- pletely exposed, and the styloid and pterygoid processes can be dis- tinctly felt. From these circumstances many have been led to believe that they have dissected out the parotid ; but this and the other sali- vary glands seldom if ever degenerate. And if the parotid do be- come the seat of carcinoma or medullary sarcoma, it is impossible to remove it writh either safety or advantage. Even in the healthy state, removal of the parotid is a troublesome dissection; and the difficulty must be greatly increased, when enlargement has taken place from disease, when neighbouring parts are involved, when firm and deep connexions have been formed, and important structures encroached upon. I have taken away many tumours from the site of the paro- tid, and some of large size, but would scarcely attempt, or boast, as some have done, of having removed the diseased gland itself. The incisions for the removal of the tumours of which we have been speaking, are to be made in the direction of the fibres of those muscles which are interposed betwixt them and the integuments, in the direction of the blood-vessels and nerves, and towards those points where the vessels are expected to enter the diseased mass. Attention to the last recommendation is important in order to save blood. For when the trunks of the arteries are divided at the commencement of the dissection, they are easily securedtemporarily by the fingers of an assistant: the operation is proceeded in and accomplished with scarcely any further hemorrhage, and in many instances no other vessels require ligature ; whereas, if an opposite course be pursued, the same vessels will be divided three or four different times; the hemorrhage will be greater, and the operation delayed. By cutting also in the direction of the vessels and nerves, fewer arteries are divided, and nerves are less apt to be injured, than if the incisions were made across. Wounds inflicted with the view of effecting suicide are generally on the fore and upper part of the neck, and their severity depends on the resolution of the individual. Some penetrate the integuments merely, and are consequently of slight extent ; there is little bleed- ing, and the edges are easily brought together, after the cessation of bleeding and when the surfaces are glazed, by inclining the head forwards, and introducing a few points of suture. Others divide the muscles, and branches of the lingual or of the superior thyroid arteries ; such wounds are gaping, more extensive than the former, and accompanied with smart hemorrhage. Some penetrate the mouth, separating the os hyoides, tongue, and epiglottis, from the thyroid cartilage. Occasionally the wound is lower, through the thyroid, or betwixt that cartilage and the cricoid ; and sometimes WOUNDS OF THE NECK. 355 through these into the gullet; it is seldom lower. Such are truly horrible ; the countenance is contorted, and presents a frightful ex- pression ; inspiration is difficult, hurried and noisy, and at each expiration blood frothed with air is forcibly ejected from the wound. I have seen wounds of the trachea, near the top of the sternum, but without extensive division of the lateral parts: large wounds, such as are usually made at the upper part of the neck, could not be in- flicted here without division of the large vessels, and instant death. Some determined suicides reach the vessels even high in the neck, dividing every thing down to the vertebrae; immediate dissolution takes place from loss of blood. But, in general, mere opening of the air-passage is all that is aimed at, there being a vulgar notion that this is sufficient for the extinction of life. A considerable quantity of blood is lost, though the branches only of the external carotid are wounded, and the loss may prove fatal; but the hemorrhage gene- rally ceases on syncope taking place; and if the patient be then discovered, means should be immediately adopted for perma- nently arresting it. Its recurrence may cause death, on the patient recovering fron the first faint; or he may die some days after from the effects of loss of blood. Hemorrhage, though to no very alarming extent, is always to be dreaded in those advanced in life; though in most cases the fatal result is not attributable solely to the bleeding, but is expedited by other circumstances, as defective supply of proper nourishment, and an unfavourable state of the mind. Some patients seem to be going on most favourably towards a cure, but, within two days after the injury, are suddenly seized with difficult breathing, and die in a few minutes. On examination of such, blood is sometimes found in the ramifications of the bronchial tubes, and the lungs can contain little or no air ; or the bronchial tubes and ramifications are loaded with adherent mucus: in either case the patients die from asphyxia. In others, nothing remarkable is observed ; perhaps passage of the air may have been prevented by inspissated mucus lodging in the windpipe around the wound, and closing the aperture, or by faulty adaptation of the divided surfaces. Likewise, during motion of the head, or attempts to swallow, either the upper or lower part of the windpipe may change its relative position ; the continuity of the tube will be thereby destroyed, either partially or wholly, and suffocation ensue. When the wound is large and transverse, as the majority of such wounds are, there is dif- ficulty in freeing the air-passage from mucus. This result becomes evident, when we consider how coughing is effected in the healthy state of parts —■ that the upper part of the windpipe is contracted by its own muscles, and the air driven through by sudden action of the muscles of the chest, in a forcible and small stream, so as to carry the mucus along with it. This process cannot be accomplished when the muscles employed in contracting the orifice of the larynx are injured, or when an opening is formed below the glottis, through which the patient breathes, either wholly or in part. In other cases, death is more slow. The patient is seized with dyspnoea, great anxiety, and occasional spasmodic action of the muscles of respiration, which symptoms gradually become more 356 WOUNDS OF THE NECK. urgent and alarming. They are attributable to awkward position of the parts, to swelling around the wound, inflammatory or cedematous and rapid or slow, or to bronchitis. To the latter affection patients breathing through artificial open- ings in the larynx or trachea are peculiarly subject, probably from the inspired air not being heated, as in natural respiration, before it enters the bron- chial tubes. A view from behind is here intro- duced of the larynx of a patient who some wTeeks previously attempted suicide by wounding the fore- part of the neck. By some mismanagement the edges of the incision were kept asunder, and they cicatrised. The patient was seized with difficult breathing; the inspirations were rare, long, and laborious ; he had threatening of suffocation during his disturbed sleep. These symptoms were disre- garded. He started up suddenly in the night, caught hold of the patient in the next bed, and fell down in a state of asphyxia, from which he could not be recovered. The cedematous swelling of the rima glottidis is remarkable ; beyond that is seen the rounded opening betwixt the thyroid cartilage and epi- glottis, which is in a normal state. The bleeding is to be arrested as speedily as possible by ligature, and the patient placed in bed with the head and shoulders raised. the edges of the wound are brought together by attention to the position of the head ; but, provided the patient breathes easily with the wound open, closure should not be attempted till after eight, ten, or twelve hours, — that is, not until all oozing of blood has ceased ; the time depends on the extent to which the air-tube has been divided. There is little chance of immediate union taking place ; and the wound not being approximated when recent and bleeding, does not diminish the chance, but on the contrary aug- ments it. Adhesion is prevented by the insinuation of air and mucus betwixt the edges, by frequent motion of the edges on each other, by the slightest change in the position of the head, either rotatory or nodding, by the action of the muscles of the os hyoides, and by attempting to swallow food or saliva. Every circumstance is opposed to complete approximation and immediate union of transverse wounds of the throat. Plasters and bandages surrounding the part are inapplicable, and unwarrantable from the interruption thereby caused to breathing and circulation; they likewise prevent the escape of mucus and air! Emphysema is apt to occur in consequence, and may prove trouble- some ; the cellular tissure of the neck becomes filled, so as to inter- fere with free respiration, and the infiltration of air extends over the face and chest. Neither can many stitches be used without bad effects. The coiners of an extensive wound may be kept too-ether by points of suture ; and one may be placed at the middle, thr'ouTh the integuments only, to prevent overlapping or inversion of the edges. The head is placed in a comfortable position, inclined for- WOUNDS OF THE NECK. 357 wards, and secured by a bandage passed round it, with the ends brought down and fixed to a band round the chest. In many cases the patient requires to be watched attentively, to have the motions of his hands restrained byproper means, in order to prevent him from interfering with the wound, or committing other insane acts which might prove dangerous. The state of the breathing and of the pulse must be strictly attended to ; inflammatory symptoms must be actively combated, and swelling prevented from gaining a dangerous extent, by bleeding, general and local. But depletion is indeed very seldom necessary, the loss of blood in the first instance proving a pretty effectual preventive of inflammation ; it is more frequently requisite to administer nourishment or even stimulants ; but these must be given gradually in those advanced in life, and in those who have lost much blood. The slightest difficulty or noisiness of breathing must be closely watched, and on the occurrence of any alarming symptoms, energetic measures adopted. Swelling about the wound, producing difficult expectoration and a diminished current of air, may require the making of a longitudinal opening into the trachea below the wound, and the insertion of a tube. Thus the respiration is quickly relieved ; and the patient is soon able to regulate the size of the aperture ; he is readily taught to apply his finger over part of the orifice of the tube, when it is wished to clear the passage from mucus. The operation of tracheotomy should be had recourse to in such cases without hesi- tation or delay ; there is no danger from its performance, but much from its being withheld. If the mouth or gullet have not been opened by the cutting in- strument, or only slightly, the patient may be allowed to swallow naturally; though it is true that even the slightest motion of the parts affects the wTound injuriously. But, as already observed, im- mediate union is not to be expected ; swallowing, or attempting to swallow, saliva, produces an involuntary action of the muscles, quite as prejudicial as the swallowing of liquids in large quantity does ; and these motions cannot be prevented, since the patient has no control over them, If the wound of the mouth or gullet is exten- sive, portions of the ingesta are apt to interfere with the air-tube, par- ticularly if the wound is high, and the epiglottis cut away or dis- figured. In such cases, soups and other nutritious fluids are con- veyed through an elastic tube, passed by the mouth over the root of the tongue to beyond the injured part, and introduced only when it becomes necessary to administer food; or a small tube may be passed by the nostril, and retained. If the wound is very severe, and the necessity for thus conveying nourishment likely to continue long, the latter method is adopted ; it is more difficult in execution than the former, but when the instrument is once passed, no further trouble is given to either the patient or surgeon. Small quantities of nourishment are to be given frequently, of such strength as the symptoms indicate ; many patients have died from inattention on this score. Many have died suddenly and unexpectedly (though this should not be, if symptoms and circumstances were attended to) 358 WOUNDS OF THE NECK. from the effects of apparently slight wounds ; whilst others have recovered, when recovery was unlooked for, after dreadful injuries, and these perhaps not treated in the most approved manner. In illustration, I shall briefly detail, though it did not fall under my own observation, an interesting and remarkable case of recovery. A criminal under confinement attempted suicide by transverse wound of the throat. The larynx was severed at the upper part of the cricoid cartilage, and the cut extremities had retracted at least three inches; the oesophagus was also cut across, but the extent to which it had receded was not ascertained. A large quantity of blood had been lost; attempts were made to bring the parts to- gether, but were abandoned on account of the violent dyspnoea wbich was induced. The attendant endeavoured in vain to pass an elastic gum tube into the gullet, from the nose and from the mouth. The patient was kept alive by nutritious enema. On the second day after the accident, the cut extremities of the larynx were approximated by two ligatures; and, the retraction being thereby diminished, it was then discovered there was another wound between the cricoid cartilage and the trachea. All ingesta by the mouth passed through the upper wound. On the fifth day, the ligatures separated, and the larynx again retracted. On the sixth, an elastic gum catheter was passed into the inferior cut ex- tremity of the gullet, and through this nutritious fluids were regu- larly administered. The wound granulated, and filled up in some measure ; the patient continued to receive both air and nourish- ment through tubes introduced downwards from the wound in the throat. Whilst pouring in food, saliva was secreted in the mouth in great profusion. The sense of smelling remained tolerably acute, and he also possessed the power of imperfect whispering articulation. When, from the untoward circumstances of the case, or from ne- glect, the opening in the windpipe remains long open, and becomes fistulous, the larynx contracts, and the voice is in a great measure lost, the patient breathes almost entirely by the natural opening, and all the respiratory functions are conducted imperfectly. But even this state of parts may admit of remedy, as is exemplified by the following ease : Elizabeth Oswald, aged twenty-seven, attempt- ed suicide in 1826, and wounded the larynx through the crico-thy- roid ligament. She was under treatment for several months ; but was at length abandoned with loss of voice, breathing entirely through a silver tube placed in the original wound. On her apply- ing to me, I found the larynx had contracted ; an exceedingly mi- nute aperture, not capable of admitting a common dressing probe, extending from the wound towards the glottis, constituting all that remained of the upper part of the natural air-passage at this point. Small bougies were introduced from the wound into this diminutive canal ; and by gradually increasing their size, the passage was brought to its natural diameter in less than three months. Part of the trachea below the wound had also contracted considerably, and was dilated by similar means. A long oesophagus tube was introduced by the wound in the mouth, WOUNDS OF THE NECK. 359 there laid hold of and drawn upwards, and then pushed down into the trachea, so that it extended from the mouth to some inches be- low the wound of the trachea. Its introduction was followed by a severe fit of coughing, which lasted about half an hour. The tube, nine inches long, and equal in diameter to the largest oesophagus tube, was retained in the windpipe for fifteen days, during which it caused great salivation; the teeth loosened, and the strength was extremely reduced. The callous edges of the wound were removed by incision, and the opening closed by suture. The tube was removed on the tenth day thereafter, and the patient breathed well. Within a few hours, however, respiration became difficult, and tracheotomy (be- low the isthmus of the thyroid) was performed. A silver tube was introduced into this recent longitudinal opening, and retained for five days, when it was replaced by a smaller one. After twenty days, this tube was also removed, and in a short time afterwards the wound closed completely. The patient continued to breathe with ease through the larynx, and slowly recovered her voice. When agitated, or after sudden and violent exertion, her inspira- tions are a little longer than natural, but in other respects the cure is complete. She was in very good health some years after the re- storation of the air-tube. Laryngitis, cynanche trachealis, most frequently occurs in children, and in them it is termed croup; but it also, though rarely, attacks adults. The voice is brazen, hoarse, and croaking; the cough is barking, and the countenance suffused. Inspiration is long, painful, effected with much difficulty, and attended wTith a wheezing or rat- tling noise. Expiration, on the contrary, is easy. Difficult inspiration is a symptom common to all affections of the larynx, and admits of ready explanation. The membrane lining the glottis is thickened, and covered also by a viscid mucus; the pas- sage is thus much contracted ; the muscles, by the action of which the rima is opened, participate in the inflammatory action, and are thereby incapacitated for the full performance of their func- tions. While inspiration is thus difficult, expiration is more easy, all the powerful muscles of the chest combining to empty the lungs of the little air which they receive. In croup, there is confusion and pain of the head, the lips are of a livid hue, and the veins of the neck are much distended. Respir- ation is extremely laborious, the chest and nostrils heave, and all the auxiliary muscles of respiration are called into play. Sleep is broken and unrefreshing ; the patient starts much alarmed, from a feeling of impending suffocation, aud catches at the nearest object. The circulation is accelerated, and becomes weak and irregular as the disease advances. A common cause of croup is exposure to cold and damp; but the frequency of its occurrence in children is attributable to dentition. Dentition induces a long catalogue of infantile diseases, and is inti- mately connected with most cases of croup* Children are besides of a peculiarly irritable system ; and in them disorder of the digestive 360 WOUNDS OF THE NECK. organs may, in many instances, be considered as at least a predis- posing cause, and in all cases it is a constant attendant on the disease. It may also be occasioned by inflammatory action extending to the larynx and trachea from a neighbouring surface ; from the fauces, for instance. In some instances, inflammatory swelling has been pro- duced by the direct application of stimuli to the membrane; as by the patient inadvertently swallowing boiling water, and a portion of the hot fluid, or rather, of the steam being drawn into the windpipe, It is supposed that certain slight degrees of this affection are to be as- cribed to spasm ; in nervous and hysterical females, paroxysms of slight difficulty in breathing are not of unfrequent occurrence, and in them it may be ascribed, with much probability, to a spasmodic ac- tion. The expiration may be then performed with difficulty, and occasionally there is almost complete aphonia. In children, dyspnoea, apparently dependent on spasm, is produced by some affection of the base of the brain. The most desirable termination of the disease is of course resolu- tion— the cough, pain, and uneasiness subsiding, and the constitu- tion gradually attaining its former state of composure. Too frequently, however, the inflammatory action proceeds unabated, and terminates in effusion of lymph, which is generally of great extent, adhering to the surface of the mucous lining, and forming what is termed a false or adventitious tubular membrane. On the occurrence of lymphatic formation, dyspnoea is much aggravated; and the second stage of the disease is then said to have commenced. Occasionally the pa- tient sinks before effusion has taken place. . The extent to which the pseudo-membranous deposit occurs is extremely various ; in some cases it is confined to the larynx, or to the upper part of it; in others it lines the whole of the windpipe, and often is prolonged, either in flakes or tubes, into the ramifications of the bronchi. In general, it is not at every point adherent to the mucous membrane, but more or less detached, particularly at its inferior extremity, by a quantity of vitiated mucus which intervenes between it and the mucous surface, and is intimately adherent to the latter. The mucous membrane is also slightly elevated by effusion into the subjacent cellular tissue. By the formation of false membrane, the symptoms may be so much increased as to cause speedy dissolution ; but in many cases, the pa- tient's strength is not altogether exhausted, and the extraneous sub- stance by its irritation causes frequent and violent attempts to expec- torate, by which the lymph is not unfrequently expelled either entire or in irregular portions ; the relief thereby afforded, though consider- able, is in general temporary, for lymph is speedily redeposited, or there is a profuse muco-purulent expectoration, and the patient suc- cumbs. It has been already stated that a portion of the false mem- brane is usually detached from the lining membrane of the canal, and from this the existence of the membrane is in general easily recognised; for on its being moved by the passage of air in the canal, a peculiar sound is frequently audible, and has been compared to that made by the movement of the valve or clapper of a pump. When perceived during inspiration, it indicates that the membrane is detached at its superior extremity ; when in expiration, that the separation has oc- DISEASES OF THE WTNDPIPE. 361 curred inferiorly. A fatal termination may suddenly take place, in consequence of the detached extremity being so displaced by the pas- sage of the air as to form a complete valve, obstructing respiration, and causing death by suffocation. When the inflammation extends into the bronchi and substance of the lungs, laborious breathing and the mucous rattle occur. The bronchi are obstructed by vitiated mucus, or by lymph, and serum is effused at the base of the brain ; and from either or both of these circumstances the patient soon perishes. In children the gums should be looked to, and if swollen or tender, they must be freely scarified ; this always affords relief, and often forms the most important part of the treatment. The bowels must be completely freed from the fetid dark-coloured matter which they contain ; and if this be effected at an early period, it will generally be sufficient to arrest the progress of the disease. Calomel is the medicine usually preferred, not only from its excellent qualities as correcting and purging out the vitiated secretions, but also on account of its supposed effect of preventing lymphatic effusion. To the procuring of copious evacuations from the stomach and bowels, the attention of the practitioner ought to be chiefly directed at the commencement. With the same view emetics are of much service. The warm bath will be of use in promoting the cutaneous discharge, and assisting to allay irritation. When the in- flammatory symptoms are violent, bleeding both local and general is indispensable, and must be had recourse to early; for during the commencement only of the disease can it be of service. The first, or acute, inflammatory stage is of but short continuance, speedily terminating in effusion ; and when this has occurred, the symptoms all denote debility of the system, and will be irreparably aggravated by depletion. The most effectual mode of abstracting blood, is by opening the external jugular vein, and this may be followed by the application of leeches to the fore part of the neck ; in the second stage of the disease, their place is to be supplied by blisters, and other counter-irritants. Much benefit will be derived from the continued use of nauseating doses of the tartrate of antimony ; in the first stage the vascular action will be thereby subdued, and in the second the medicine acts as a powerful expectorant, determines to the surface, and promotes the evacuations from the bowels. Often, however, the disease defies all sanative measures, and advances unsubdued to a fatal termination. Tracheotomy has been both proposed and performed in this disease. Recourse to it is not warrantable till the later period of the affec- tion, and then it will be found unavailing. If performed early, there is found no obstruction to respiration that can be removed ; it can therefore be of no service, and is not required. If it be un- dertaken at a more advanced period, lymph will most probably be found to extend below the incision ; the bronchial tubes and the sub- stance of the lungs are then the principal seat of the disease, and consequently the operation is futile, at least in children. When first I entered on practice I was several times prevailed on to perform trache- otomy on children labouring under croup: the results were unsuccess- ful, and from my own experience I cannot recommend the practice, 362 DISEASES OF THE WINDPIPE. The fauces and larynx of children are occasionally injured, as stated above, by the attempt to swallow by mistake boiling water, and inhaling the steam. The alarming symptoms follow m a very few hours, in consequence of the formation of numerous minute vesicles, with swelling, from effusion of serum into the submucous tissue. Great pain is generally experienced at the moment, but after crying violently the child may fall asleep and awaken croupy, and with threatened suffocation. By this time inflammatory action has been fairly established, the submucous effusion has begun to take place, and it is this that gives rise to the danger. The excited ac- tion is to be combated by leeching and exhibition of calomel in small doses, with or without opium, frequently repeated, so as to arrest the lymphatic effusion, which is apt to supervene. When these means fail, tracheotomy must be resorted to without delay. The fauces and upper part of the larynx are only involved at first; this practice is sound, and good success may be expected from the operation. The breathing has been suddenly suspended in children by the at- tempt to swallow acrid fluids, such as alkaline solutions, or concen- trated acids. Cynanche laryngea, in adults, is of comparatively rare occurrence ; at least that kind of inflammation of the windpipe, which in children is so rapid in its progress, and so prone to terminate in effusion of lymph, is not often met wTith in persons of an advanced age. In- flammatory affections of the larynx and trachea are, however, by no means unfrequent in adults ; but are of a very different charac- ter, as to symptoms, progress, and termination, from that affection which is strictly denominated croup. Pain is felt in the region of the windpipe, and is aggravated by pressure on the forepart of the neck, by speaking, and by deglutition ; expectoration is increased, and ultimately assumes a muco-purulent character; the voice is al- tered in tone and strength, and occasionally there is complete apho- nia. Frequently these symptoms, after having con- tinued for a short time, gradually subside ; if not, the mucous membrane, particularly in the upper part of the larynx, becomes thickened and considerably soft- ened in texture, with effusion of serous fluid in the subjacent cellular tissue, and apparently in the sub- stance of the membrane itself. In consequence of such effusion, the difficulty of breathing is much in- creased. Occasionally lymph is effused on the surface of the membrane ; but this is seldom met with, and when it does take place, is generally confined to the upper part of the larynx. The larynx and trachea of an old lady of seventy years is here shown, with very extensive false membranes blocking up the bronchi; a large portion besides were coughed up. The spe- cimen, a rare one, is in my collection. The effusion of serum is often abundant, causing protrusion of the mucous membrane, and narrowing of the canal; and when it is limited to the upper part of the larynx, as frequently happens, the disease is termed CEdema DISEASES OF THE WINDPIPE. 363 Glottidis. In this affection, the majority of the symptoms, which have been already enumerated as attendant on laryngitis, are all pre- sent, and in an aggravated form. Inspiration is extremely difficult and sibilant, and occasionally the patient experiences a sensation, as if a foreign body wTere lodged in the passage, and had changed its position on the muscles of the part being put in motion. The symp- toms of oedema come on gradually in some cases, in others with alarming rapidity. They often follow ulcerations of the soft palate, and of the root of the tongue, as shown in treating of diseases of that organ, occurring on the patient being exposed to cold or mois- ture, or supervening rapidly when discharge from the ulcerations is by any accident suddenly suppressed. The difficult breathing, with cough and violent attempts at expectoration, takes place in paroxysms, and often to so alarming a degree as to threaten immediate suffoca- tion, especially during the night. The patient, if he has fallen asleep, often starts up suddenly, and catches at the nearest object, having dreamed probably of drowning or strangulation. Deglutition is seriously impeded, the strength is exhausted, the body is emaciated, the features become contracted, and evince great anxiety. As al- ready stated, the serous effusion is chiefly situated in the upper part of the larynx, particularly on the lips of the glottis, and on the in- ferior surface of the epiglottis ; and on introducing the finger, a soft swelling can be felt beneath this cartilage. Perhaps the following sketch exhibits the most complete instance of cedematous swelling of the rima glottidis to be found in collections of morbid anatomy. The patient was brought to the Royal Infirmary labouring under all the symptoms of the disease in a very ag- gravated form. Tracheotomy was per- formed without delay, and with instant relief. The patient fell into a quiet and profound sleep, which lasted for six or seven hours. He started up suddenly and fell down dead ; probably the end of the tube had become obstructed by mucus. It is scarcely to be supposed that the patient could have breathed at all with such a state of parts at the top of the air-tube, as here represented. Could any of the swelling have come on in the interval betwixt the perform- ance of the operation and his sudden death ? In some instances, the disease rapidly proceeds to a fatal termination, the glottis being speedily and entirely shut by the swelling; in others, the patient lingers for weeks, or even months. Depletion, local and general, especially the former, if employed on the first appearance of the inflammatory symptoms, will often arrest their progress; but if practised at a more advanced period, it can be productive of no benefit, and if any advantage does follow, it is merely temporary. Sometimes considerable benefit will be derived 364 DISEASES OF THE WINDPIPE. from the use of blisters, or from the unguentum tartratis antimonii being rubbed on the sides of the neck and over the larynx, so as to produce an eruption of numerous pustules. When all hopes of pro- curing resolution have passed, and when the urgent symptoms occa- sionally threatening suffocation supervene, tracheotomy should be performed without delay ; and it ought to be borne in mind, that the more early this operation is resorted to, the greater is the chance of success. It has been repeatedly stated, that the disease is con- fined to the larynx, and, in most instances, to the upper part of it; so that, by making an opening in the windpipe below the thyroid gland, the disease is situated above the incision, the patient breathes through a canal which is in its healthy state, the affected parts are set at rest, and from their remaining comparatively motionless the disease often subsides spontaneously ; if not, the various applications to the ?parts can be employed much more successfully than before ; for wThen the parts remain subject to constant irritation from the movements neces- sary for respiration and nutrition, all medicines and all topical appli- cations are generally productive of little or no benefit. But if the incisions be made into the crico-thyroid membrane, we shall, in most instances, cut into the very middle of the disease ; at any rate the affected parts can be at no great distance from the incision, and the irritation of the tube will be a sufficient cause to excite inflam- matory action in parts contiguous to the original disease, and already disposed to assume a similar action ; thus the disease may be ex- tended. I have performed tracheotomy on a very considerable num- ber of patients afflicted with oedema glottidis, and I may say with al- most uniform succcess. The disease was speedily subdued, and in most of them there was no great difficulty in closing the artificial aperture, and restoring natural respiration. The relief afforded by the operation is almost instantaneous ; the performance of it, if skilful, is attended with no danger ; and want of success will generally be found to proceed from its having been too long delayed. In consequence of laryngitis, or of long-continued irritation in the neighbourhood, the mucous membrane becomes indurated and subse- quently ulcerates ; or ulceration may extend from the fauces. In some cases, the ulcers of the larynx are few, and of slight extent; in others, they are more numerous and of considerable width and depth ; and in some there is extensive and uninterrupted destruction of the surface, surrounded by thickened and elevated mucous mem- brane. This disease is termed Phthisis Laryngea. It is character- ised by constant tickling cough with expectoration of purulent mat- ter ; by pain in the region of the larynx increased on pressure ; by great prostration of strength, with general sinking of the vital powers and frequently by hectic fever. From extension of the ulceration, the vocal chords, the ventricles of the larynx, and the mucous folds form- ing the rima glottidis, are more or less injured, and frequently altogether obliterated; partial or complete aphonia is the consequence. In phthisis laryngea, especially when advanced, swelling from serous effusion, to a greater or less degree, almost certainly supervenes, the oedema is found in the upper surface of the epiglottis, beneath the mucous membrane, upper and forepart of the pharynx, and occa- DISEASES OF THE WINDPIPE. 365 sionally also in the lips of the glottis — an effect of the contiguous ulceration, — in the same way as oedema glottidis supervenes on ulceration of the lining membrane of fauces and pharynx; the usual train of symptoms denoting phthisis laryngea may thus be interrupted by those of oedema of the glottis becoming (each paroxysm) more and more urgent, terminating in suffocation or relieved by tracheo- tomy. From the reasons which have been already stated, inspiration is performed with difficulty, and accompanied with a wheezing, and rattling sound, resembling the passage of air through a narrow aper- ture lined with viscid fluid. Deglutition is difficult; and, from the inactive state of the muscles which naturally close the glottis during swallowing, and from the greater or less destruction of the epiglottis, a portion of the fluid taken by the mouth escapes into the windpipe, produces violent coughing, and is ejected by the mouth or nostrils. As the disease advances, the lungs become affected, the patient is incapacitated for ordinary exertion by the dyspnoea which ensues, he grows weak and languid, and seems, in fact, to labour under phthisis pulmonalis. Not unfrequently the two diseases are combined ; but, in the majority of cases, the affection of the lungs supervenes on that of the larynx. Ulcers with tubercular bases are very frequent about the ventricles of the larynx in subjects dead of pulmonary phthisis. The chordae vocales are thus often exposed- The affection of the lungs is perhaps attributable to frequent and harassing cough, occa- sioned by the state of the larynx and ejection of profuse vitiated secretions. When the ulceration extends deeply, portions of the cartilages sometimes become diseased ; the soft parts surrounding them are destroyed, they become necrosed, and are expectorated along with a quantity of highly fetid purulent fluid. In some instances, the ex- pectorated portions are osseous, of loose texture, irregular margins, and dark colour, exhaling an odour intolerably fetid. It sometimes happens that the ulcerations proceed still more deeply, perforating the parietes of the canal, and establishing a communication betwixt the windpipe and gullet; or, if the perforation is anteriorly, the commnnication is with the cellular tissue on the forepart of the neck, abscess forms which may attain a large size and be productive of much inconvenience and danger. The disease has been frequently produced by mercury, when the abuse of that mineral was common; its abuse is still far from un- common. The symptoms may be mitigaied by counter-irritation. The parts covering the trachea should not be subjected to counter-irritation ; in consequence of repeated blistering, the application of irritating ointments, effusion and thickening of the cellular tissue is caused, and this may prove a serious obstacle in the performance of trache- otomy, should that afterwards, as is too likely, be required. Setons may be inserted on the sides of the neck, and applications made over the box of the larynx. But tracheotomy affords the only hope- of permanent relief; and if performed at an early period, if the lungs are not the seat of tubercular disease, as they too frequently 31* 366 DISEASES OF THE WINDPIPE- are, there is every reason to expect that it will prove successful. It is followed by the beneficial results mentioned when speaking of the preceding disease, and the nitrate of silver can be applied to the more external ulcers, along with the internal use of sarsaparilla, &c. Ulcers, which there is every reason to suppose had been both exten- sive and deep, have healed even after the discharge of portions of dead, sometimes ossified, cartilage. The symptoms abate ; the pa- tient recovers, though in general with imperfect voice, as might be expected. It may even be practicable to employ topical applications to the ulcers within the cavity of the larynx, as in the following case, which, though unsuccessful, shows the advantages to be expected from similar procedure adopted at a more early period. T. C, aged 22, had laboured under the symptoms of phthisis laryngea for five months previous to his application. He was much emaciated, and experienced great difficulty in swallowing, on account of the irritation induced in the region of the glottis ; he had occasional cough, purulent sputa, and aphonia almost complete. The larynx was painful when pressed, the epiglotits was seen to be cedematous, and the general symptoms were of a hectic character. The oedema of the epiglottis was reduced by scarification. The symptoms increased, notwithstanding counter-irritation and tonic remedies. The stethoscopic indications regarding the chest were so far favourable. Tracheotomy was performed, and the patient felt very much re- lieved in consequence. On the tenth day after the operation, the inner surface of the larynx w7as touched with a strong solution of the nitrate of silver, applied by means of a bit of lint wrapped round the end of a probe slightly bent, and introduced upwards from the wound. The solution was applied every'second or third day, and under its use the patient was remarkably benefited. He swallowed, spoke, slept, and looked better; the purulent sputa diminished, and the cough abated. He complained of less pain in the larynx, and seemed to be regaining strength, though slowdy. But after the lapse of several weeks, from imprudent exposure to cold, evident symptoms of bronchitis supervened, under which his constitution, already shattered, speedily sank. The larynx was found extensively ulcerated, but at a number of points there were distinct marks of recent cicatrisation. The state of the lungs clear- ly showed that phthisis pulmonalis had not only commenced, but made considerable progress. The practice here detailed has been repeated again and again with good success. Dyspnoea is caused by other circumstances besides those already mentioned ; some rare cases are met writh in which warty excres- cences have grown from the seat of the vocal chords: a beautiful specimen from the collections of my friends, Messrs. Grainger and Pilcher, is here delineated. Dyspnoea frequently arises from paralysis of the muscles of the larynx, in consequence of effusion at the base of the brain, from long-continued irritation, as from an irritating cause seated in the month, and in old people from a general decay of the animal powers. In the last case, it is generally a symptom of ap- proaching dissolution, as is the dysphagia which often attends it. FOREIGN BODIES IN THE WINDPIPE. 367 Severe dyspnoea is sometimes caused by external violence. A fine healthy child aged eight, in running across the street fell, and struck the larynx with great force upon a large stone. She wTas taken up quite life- less, and some time elapsed before respira- tion was at all established. A gentleman finding her face livid, opened the temporal artery, and applied leeches to the throat, with some relief. I saw her about three hours after the accident. The breathing, inspiration more particularly, was]exceeding- ly difficult; and this appeared to proceed not only from the injury to the larynx, probably occasioning loss of power in the muscles, but from the collection of some fluid in the trachea and its ramifications. The child was evidently in such a state that, unless active measures were resorted to, and that speedily, a fatal termination would soon take place. Tracheotomy was performed ; a quantity of coagulated blood and bloody mucus was evacuated from the opening; and when the discharge and coughing had ceased, a tube was introduced. In eight days the tube was withdrawn, the aperture closed ; and no unfavourable symptom recurred. In the museum at Chatham is a larynx showing fracture of the thyroid cartilage from the kick of a horse. The immediate consequence was great difficulty of breath- ing and rapid general emphysema. The patient, a young soldier, died soon after the injury. Large or irregular foreign bodies, as coins, pebbles, portions of stone or of coal, seeds of fruit, &c, put heedlessly into the mouth, are apt to become impacted in the rima glottidis, and give rise to severe and dangerous dyspnoea, or even cause sudden dissolution. Smaller and smooth substances pass through into the trachea. Such acci- dents happen most frequently to children. Peas, beans, small shells, &c, slip into the air-passages, are obstructed for a short time in the rima, but are soon forced by the convulsive actions of the patient into the trachea, and frequently lodge in the right bronchus, it being more capacious, and more a continuation of the trachea than the left; or they remain loose in the trachea, and are moved up and down by the passage of the air. Immediately on their introduction, most violent coughing takes place, respiration is convulsive and imperfect, the patient writhes in agony, and is in dread of instant suffocation ; the countenance becomes inflated and livid, and most strenous • efforts are made by nature to expel the foreign body. At length he is exhausted, and an interval of perfect quiet ensues ; but this is soon interrupted by renewed attempts at expulsion. After a time, the in- tervals of repose increase in duration, and in many cases are so long 368 TRACHEOTOMY. continued, as to lull the patient and his friends into a belief that the windpipe contains no extraneous substance. But still violent fits of coughing supervene from time to time, and the dyspnoea is very alarming ; on attentive examination the presence of this foreign body may be ascertained beyond doubt by the peculiar noise produced by its movements in the passage ; at the same time, thin mucus is copi- ously discharged from the lining membrane. Occasionally the foreign body becomes so placed in the canal as to form a complete valve, and then the labours of the patient to dislodge it are most painfully severe ; if they fail he is suffocated. During laborious breathing the neck sometimes becomes emphysematous. The parts may at length get accustomed to the presence of the foreign body, and all uneasiness subside. But danger, though not immediate, still remains. Foreign bodies have remained for years without causing much inconvenience; but in such cases they have generally7 settled in some remote ramifi- cation of the bronchial tubes; abscess commonly, sooner or later, takes place around, purulent expectoration follows, all the symptoms of pulmonary phthisis are established, the patient becomes hectic, and dies. The existence of the foreign body, when suspected, is to be ascer- tained by accurate and attentive examination along the forepart of the neck, and by listening carefully to the sounds which may be pre- sent in the trachea ; but the urgency and continuance of the symp- toms will seldom leave the surgeon to entertain a doubt. If he attentively watch the patient, he can scarcely be mistaken. It has been recommended to examine the oesophagus previously to adopt- ing active measures, a large foreign body impacted in that passage being capable of materially obstructing respiration by compression of the trachea ; and it is safe and prudent to follow7this recommendation whenever the least uncertainty exists regarding the real nature of the case. When a foreign body has lodged in the windpipe, tracheotomy should be had recourse to without delay. In general, the offend- ing substance presents itself immediately after the division of the trachea, and is expelled by a strong current of air. But in some cases it maybe necessary to introduce instruments — probes, scoops, or small forceps — upwards or downwards to dislodge and extract the body. A case in which a foreign body, which had lodged in the right bronchus for about six months, was successfully extracted, is detailed fully in the Lancet, and noticed shortly in the Practical Surgery, p. 416. A little blood from the wound may cause cough- ing for some minutes, but this soon ceases ; the would is closed after a few hours, respiration is completely re-established, and all that the surgeon has then to combat are the evil effects on the mucous membrane which the contact of a foreign body may have occasioned. Tracheotomy is, in nearly all cases, preferable to laryngotomy. In disease of the windpipe, as formerly stated, it is better to cut into a sound part of the passage, or at least as far as possible from the seat TRACHEOTOMY. 369 of the disease. When an adult, for example, labours under acute laryngitis, the effused lymph is generally confined to thelarynx, as was already mentioned ; an opening below the thyroid gland is removed from the effusion, and by means of it the patient breathes through the natural tube yet sound ; whereas, if the opening is made in the crico-thyroid membrane, the surgeon frequently cuts into the middle of the diseased part; little or no benefit follows, and if the danger is not increased, equivocal good is all that can be expected from such an operation. Tracheotomy is also preferable for the re- moval of foreign bodies, unless it is certain that the body is impacted in the rima, for in such circumstances laryngotomy is much more suitable. In tracheotomy, the incision of the tracheal rings can be extended with much less injury than can division of the laryngeal cartilages, when the largeness of the foreign body, its being firmly fixed, or other circumstances, require that the wound be of consider- able size. The risk of danger in the one operation is not much greater than in the other. Division of the crico-thyroid membrane and skin is effected by one incision ; there is nothing important in the way of the knife. In very young children, when suffocation is threatened, as from the effects following upon the attempt to swallow very hot fluids, and the inhalation of steam, this operation may with great proprietybe performed. Tracheotomy, on the contrary, requires to be proceeded in more carefully, particularly in children, in whom the neck is short, and the trachea deep. The tube is moreover very small, and not easily steadied. I had occasion, not long since, to open the passage in a child under sixteen months old, who had tried to swallow the contents of a teapot recently filled with boiling water. The difficulty experienced in such cases is often very great. Obstacles may also be presented by the thyroid and other veins being distended, and the soft parts are perhaps tumid and infiltrated with serum. The patient, if adult, should be seated with the trunk erect, and by throwing back the head, space in the neck is gained. In a female on whom I operated some years since, this advantage could not be ob- tained on account of induration in the belly of the sterno-mastoid mus- cle, with contraction. The incision of the integument is commenced in the mesial line over the cricoid cartilage, and carried downwards, an inch in the adult, but proportionally shorter in children. The cellular tissue is divided by a few touches with the point of the in- strument (a small scalpel or bistoury); the finger is then introduced to separate the sterno-hyoid muscles, and to feel for any stray vessels which may be in the way ; for the thyroid arteries sometimes cross the line of incision, and it may happen that some of the larger arteries of the neck, by following an unusual course, become liable to injury, if the operation were rashly performed. The plexus of veins on the forepart of the neck is pushed downwards, and the isthmus of the thyroid gland, if it exist, is displaced slightly upwards ; thus the rings of the trachea are cleared. The patient is desired to swallow his saliva, in order to elongate and stretch the windpipe ; and the surgeon, seizing the favourable opportunity, pushes the point of the knife, with its back towards the top of the sternum, into the tube at 370 TRACHEOTOMY. the lower part of the incision. The instrument is carried steadily upwards, so as to divide three or four rings. It is not at all neces- sary to cut out any part of the rings of the trachea as recommended by some writers ; contraction of the tube may afterwards result; nor can any good purpose be served by making the opening crucial. If the operation has been undertaken for the removal of a foreign body, its object is usually accomplished immediately on division of the rings ; if not, the substance must be dislodged by proper instru- ments, as was previously remarked. The opening is allowed to close after the oozing of blood has entirely ceased ; but its edges must be kept asunder till then, lest the blood be drawn into the bron- chial tubes, which occurrence, however slowly it take place, is always dangerous. The union and cicatrisation of such longitudinal wounds are soon accomplished ; they close permanently in a few days, even after having been open for many weeks with a foreign substance interposed between their edges. The same obstacles do not interfere as in transverse wounds ; on the contrary, every cir- cumstance is in favour of rapid union. When the object of the operation is to relieve respiration, impeded by disease in the superior part of the canal, a silver tube, of conve- nient curve, length, and calibre, is introduced into the wound im- mediately on the knife being withdrawn, and secured by tapes at- tached to the rings at the orifice of the tube, and tied round the neck. Frequently a violent fit of coughing, alarming to the patient, follows the introduction, in consequence of some blood having entered the trachea. But on the ejection of some frothy mucus, mixed with blood, the patient becomes quiet and tranquil, breathes easily, and feels composed and relieved. The form of the tube—the calibre gradually increasing from below towards the orifice — completely prevents any farther ingress of blood, by the uniform compression which it makes on the edges of the wound. The secretion of mucus in the trachea is increased by the presence of the foreign body, but the patient easily frees himself from its annoyance, being instructed to place his finger on the orifice of the tube, so as to narrow the aperture, when he wishes to cough and expectorate. In those cases where the operation has been performed without there being dimi- nution of calibre of the upper part by swelling or otherwise, expectora- tion through the tube is more difficult. Mucus, however, is apt to adhere to the inner surface of the tube, and thereby obstruct breath- ing ; to prevent this, it is necessary occasionally to introduce a feather, or a probe wrapped round with lint, for some hours after the operation ; the attendance of an assistant may be necessary for this pu.-pose, but the patient readily undertakes the duty himself, on being made aware of its necessity. A double tube has been recommended, to facilitate the keeping of the passage clear, the inner one being oc- casionally withdrawn, cleaned, and replaced. But this is not in ordinary cases necessary. The frequent introduction of a feather, or probe, is sufficient for some hours after the operation, and in a very short time the patient finds that he breathes freely, though the tube is removed for a few minutes, in order to be cleaned. At first, TRACHEOTOMY. 371 a funnel-shaped tube is used, to compress the edges of the wound and prevent oozing, as already mentioned ; afterwards, one of uni- form calibre is more easily coughed through. The patient should be kept in an atmosphere of warm and equal temperature, and it is also prudent to place some cloth of very loose texture over the tube, that the temperature of the respired air may resemble as much as possible that passing through the whole track of the windpipe ; thus bronchitis may be averted. In some cases, the necessity for continuing the tube speedily goes off, the larynx, in consequence of rest, having recovered its healthy state and action. After eight or ten days, on taking out the tube, and closing the aperture in the trachea, the patient breathes and speaks well, and continues to do so. In other instances, the difficult breathing recurs soon after with- drawal of the tube, the morbid state of the laryngeal mucous mem- brane having not been wholly removed. In such circumstances, the tube must be replaced and continued, but a smaller one suffices, less mucus is secreted, and a considerable quantity of air passes through the larynx ; in short, the patient requires merely a small tube to ob- viate the danger which might arise from complete closure of the artificial opening, and to compensate for the narrowness of the natural canal. He speaks tolerably well, on placing his finger over the ori- fice of the tube. In course of time, the larynx may recover, and the tube be no longer necessary. In some cases, a tube of certain size must be wTorn during the re- mainder of life ; and it does not generally cause much inconvenience. Attempts to discontinue its use give rise to dreadful suffering ; the difficult breathing, threatened suffocation, and horrible feelings dur- ing the night, all recur. The box of the larynx has fallen in, as it were, in consequence of having been long disused, and is unable to resume its functions to their full extent. Besides, great, though gradual, change of structure has in all probability taken place. In several such cases, I have attempted to restore the natural dimensions of the passage, by the occasional introduction of bougies, gradually increased in size ; but in none have I completely succeeded, except in the case of attempted suicide which has been already detailed shortly. In all, my attempts were at first followed by encouraging amelioration, but untoward symptoms occurring forced me to abandon them, though repeatedly persevered in. In one man, I succeeded in restoring natural respiration and closing the opening in the neck, but this was not of long continuance ; a fresh accession of difficult breathing made renewal of the artificial opening absolutely necessary within a few months. Still the results are not such as to forbid fur- ther trials; and at any rate, it is now well understood that much greater freedom may be safely used with the air-tube than was for- merly imagined ; yet it must be acknowledged that little benefit can be expected to follow such, or any treatment, in many cases of con- traction of the canal, from long continued disease. The larynx and trachea obtained from the patient whose case is alluded to above are here represented. The poor fellow had worn a small silver tube 372 TRACHEOTOMY. in an opening in his windpipe for many years. It was originally introduced on account of long-continued disease of the larynx, with dreadful suffering and constant sense of impending suffocation. He could not be made to dispense with the tube entirely, as he felt im- mediately on the wound closing a threatening of return of his painful and dangerous symptoms. A small one wTas sub- stituted for that at first used. He led a very irre- gular life, used a vast quantity of opium, and no small amount of spirituous liquors. He used to be out in the open air occasionally all night, and suf- fered repeatedly under attacks of bronchitis. He Was under treatment again and again in the hospital, on account of rheumatic affection and deranged di- gestive organs. He used occasionally to present himself complaining of difficult breathing, and stat- ing that his silver tube wTas too short. He could articulate tolerably well when he stopped with his finger the orifice of the silver tube ; at all times a part of the respired air passing through the natural channel. Latterly, he used to suffer from threaten- ing of suffocation, and he used to relieve himself of the cause of this, viz., the inspissated and ropy mucus which got entangled in the trachea, then not suspected tobe in a diseased state, bypushingthrough the opening in his neck and into the bronchi, long turkey's feathers ; of these he carried a good store, and some are now in my possession. This feat he performed without causing the slightest excitement or coughing. Ultimately, and about twelve years after the operation had been performed, he died, principally from diseased viscera. His liver was enormously enlarged and altered in structure ; the larynx is seen to be very much contracted at two points. The tube is observed to be considerably dilated below the contractions. The introduction of tubes into the larynx has been supposed likely to supersede bronchotomy in some cases ; and it is said that their presence does not produce so much irritation as has been stated. But the practice must, in all cases, be most troublesome to the sur- geon, and painful to the patient; and, in my opinion, continuance of it is in the great majority of cases impracticable. Besides, it is difficult, and not unattended with danger. Bronchotomy is quite safe, and not likely to be followed by such suffering to the patient, or by any other unpleasant consequence, to which the other method is liable. Pharyngitis. — Inflammation of the pharynx is of rare occurrence. The inflammation may extend from neighbouring parts, or be pro- duced by the direct application of an irritating or stimulating cause, as the lodgement of foreign bodies, of pins, fish-bones, seeds, por- tions of hard food ; or by the application of acrid fluids to the mem- brane, acids, hot water, &c. In one instance which I met with, it PHARYNGITIS. 373 occurred in a very violent form, in consequence of a large and sharp portion of an earthenware plate having been swallowed so far by the patient whilst eating his porridge, and becoming firmly impacted in the lower part of the pharynx. I have seen a considerable num- ber of instances in which the disease was produced by the swallow- ing of soap lees, a fluid, it would appear, highly acrid, occasioning a severe degree of inflammation, and even destroying a portion of the parietes. A man employed by the police in fumigating houses during the prevalence of cholera, had given to him as a practical joke a glass of sulphuric acid instead of whisky. He suffered at the time, as may be supposed, most excruciating pain, violent inflammation super- vened, followed by a stricture of the gullet. Deglutition is difficult and painful; an exquisite degree of pain is occasioned by pressure on the sides of the neck, and the circulation is more or less excited. Redness and swelling of a portion of the mucous membrane can be observed on looking into the fauces. The changes which occur in the membrane are similar to those produced in the windpipe by inflammation. Resolution will generally be effected by the application of leeches to the neck, the exhibition of purgatives and diaphoretics, and strict observance of the antiphlogistic regimen. If the inflammation does not soon subside, it sometimes happens that constriction of the passage occurs, either from thickening or cedematous swelling of a portion of the mucous membrane, or from effusion of lymph, and adhesion of the opposed surfaces. The com- mon seat of stricture, as in other mucous canals, is that portion of the tube which is naturally the narrowest, the lower part of the pharynx and commencement of the oesophagus, immediately behind the cricoid cartilage : occasionally it takes place in other parts of the canal. In general, the contraction is of small extent, and unaccompanied with much thickening around. The tube immediately above the con- stricted point is more or less dilated, and often to so enormous a size as almost to resemble a first stomach. In the majority of cases, the parietes of this pouch are attenuated; but occasionally they are much thickened, and the seat of a purulent collection, which subsequently opens into the general cavity. In cases of long standing, ulceration often occurs, usually limited to the neighbourhood of the stricture. When the parts immediately below the stricture are ulcerated, the circumstance is often attributed to the retching which generally at- tends the disease ; but it appears to be the result of morbid action, seated in the parts themselves, similar to the ulcerative process in the larynx following inflammatory affection. But ulceration occurs as frequently above the stricture as below it; and, besides the natu- ral cause to which it is referable, is often produced, or at least aggra- vated, by injudicious or unskilful attempts to remove the constriction. Though the ulcers seldom enlarge to any great extent, yet, in some rare cases, a portion of the parietes of the canal is perforated, and a communication thus established with the trachea, or with the cellu- lar substance amongst the muscles of the neck. Or the ulcers, from 32 374 STRICTURE OF THE GULLET. either long continuance, or inherent disposition, may assume a ma- lignant action, extend rapidly in both width and depth, throw out fungous and unhealthy granulations, form sinuous false passages, and produce a most horrible and intractable disease. But strictures are often of temporary duration, and appear to depend on spasmodic contraction of the circular muscular fibres of the tube. And dys- phagia may also arise from an opposite condition of the fibres — from paralysis, in consequence of cerebral affection, a fatal symptom in any disease. The prominent symptom of stricture of the oesophagus is difficult deglutition. Some patients can swallow only liquids; and when an attempt is made to get over any solid substance, this is stopped at the contraction, and completely obstructs the passage. In such cases patients will frequently apply for relief, in order that the portion of food may be pushed through the narrow portion of the canal; w7ith the accomplishment of this many are quite satisfied, and are unwill- ing to submit to farther treatment, obstruction to solid matter being the only inconvenience experienced. But when contraction is great, and the involved portion of the canal almost obliterated, little food of any kind can pass into the stomach, the patient becomes feeble and emaciated, and ultimately dies from inanition. The subjects of this affection are generally far advanced in years, and in them it often occurs without any evident cause. If pharyngitis have subsided, either spontaneously or after anti- phlogistic treatment, and symptoms of stricture supervene, the ex- istence or non-existence of this latter disease must be ascertained by gentle and cautious introduction of a gum-elastic bougie or ivory- ball probe. If stricture exist, the descent of the instrument will be resisted at the contracted point, and most frequently at the lower part of the pharynx : this, in the adult, will be at a distance of about nine inches from the incisor teeth. When the seat of the stricture is ascertained, a bougie is to be introduced, sufficiently small to pass through it; and when this has been pushed beyond", the disease, if unattended with malignant disposition or action, is completely in the power of the surgeon. After sufficient time has been allowed for the irritation following the first introduction to subside, a larger bougie is to be passed, and retained as long as its presence can be endured, rhurpractice must be continued, till by gradual increase of the bougie, the canal is dilated so as to admit readily an instru- ment sufficient to distend the gullet in its healthy state. Thus the passage will be gently and gradually dilated, till it regain its origi- nal calibre. The process is partly mechanical, but also greatly de- st mulatedM1 fl *T°V' I7 *" preSenCe °f the h°^ <& V"** ™ stimulated, the fluid, which may be effused beneath the mucous mem- brane or into its substance, is absorbed, and the new solid matter^ also gradually removed by increased ac'tion of the absorbed Bu if the bougie be rudely and forcibly introduced, or too long retained he absorbent action from being salutary becomes morbd,Ld ulcer- ation is established, which may proceed to destroy the parietes o the canal, so producing an additional and equally formidable d ease o FOREIGN BODIES IN THE GULLET. 375 if the ulcerative action subside, the parts will cicatrise and conse- quently contract, so giving rise to a new stricture, and narrowing the canal to an equal or greater extent than formerly. Before introducing the bougie, the head must be thrown as far back as possible, as here seen, and brought to a horizontal po- sition, that the natural curve of the upper part of the canal maybe lessened, and the passage of the instrument thus facilitated. It is of consequence also to keep the point of the bougie pushed back towards the vertebrae (the patient being desired to make an effort to swallow), and to grasp the larynx with the left hand and pull it gently forwards, that there may be no risk of the instrument passing into the wind- pipe, instead of into the gullet; if such a mistake should happen, the surgeon will soon be apprised of it by the violent and convulsive coughing which is generally induced, though not always. Bougies armed with caustic have been recommended, but are unnecessary, the simple bougie being sufficient to remove the disease, if skilfully employed ; besides, their use is not unattended with danger, ulcer- ation being frequently produced. In very bad cases, in which the stricture is long in yielding to the means already mentioned, and the nutriment which the patient is able to swallow is necessarily small, — when the canal is altogether obliterated either at one point or to a considerable extent, as has sometimes happened, and when there is consequently little hope of success from any treatment — the strength of the patient may be supported, and life prolonged for some time, by the use of nutritive enemata. Dysphagia may also be caused by tumours in the oesophagus; but as these are generally of a medullary structure, and consequently endowed with malignant action, the treatment can only be palliative — there is no hope of a radical cure. Dysphagia may arise from an aneurismal tumour of the arch of the aorta, or of the large arterial trunks passing off from it, pressing on the oesophagus, and so narrowing its calibre. * In such cases, also, no hope of success from any treatment can be entertained ; often the case terminates fatally in a very sudden manner, in consequence of the aneurismal tumour giving way at the point which protrudes on the gullet; the contents are discharged into the stomach, or ejected by the mouth. If treatment by bougies be attempted in dysphagia arising from such a cause, the practitioner not being aware of the nature of the disease, the fatal issue will be fearfully hastened — a very unpleasant consequence of any practice. Foreign bodies lodged in the oesophagus produce difficult degluti- tition, and, if large, may obstruct the passage completely ; much irri- 376 FOREIGN BODIES IN THE GULLET. tation is also caused to the parts with which they are in contact, and inflammatory action kindled in them. A large substance firmly im- pacted likewise creates difficulty of breathing, by compressing the posterior part of the trachea. Indeed every consequence is of such an annoying nature, as to render dislodgement and removal of the offending substance necessary, though there were no apprehension of danger from its long-continued presence. The proceedings must be varied according to the consistence, form, size, and situation of the foreign body. There are a great many instruments for effecting dislodgement and extraction, but the great majority of them are more curious and ingenious than applicable to the purpose intended; few are of any use. A probang, mounted with a bit of sponge, or with an ivory ball — a blunt flat hook attached to a whalebone probe — and long curved forceps, constitute the whole useful apparatus. The feelings of the patient are generally sufficient to mark the posi- tion which the body occupies; he is made to throw the parts into action, by attempts to swallow the saliva, and during the attempt to point to the seat of pain. But by this both patient and surgeon may be deceived, for pain and a feeling of foreign matter being lodged often remain at a fixed point, after the body has passed down; simi- lar deception occurs in other situations, as in regard to extraneous substances in the eye, urethra, &c. Small and sharp substances seldom remain long in the oesophagus, but readily descend into the stomach and intestines; they then either escape along with the feces, or, as sometimes happens, penetrate the parietes of the alimentary canal, generally near its termination. On leaving the stomach or the intestines, by gradual perforation, they frequently travel great distances in the trunk or limbs, without causing much inconvenience, — effusion of lymph surrounding them, and filling up their track. They will appear, long after their insertion, at a far distant point, approach the surface, and gradually make their wray through the integument, or be readily extracted. When they enter from the surface, also, they often come within reach long afterwards, and far from their point of entrance. Needles, thus travelling, become oxidised. They are easily removed, on coming near the surface, by fixing them with the fingers, and making a small incision over the more superficial extremity. A needle may sometimes be taken out, by making pressure on both ends, and so forcing the point thj-ough the integument. Small pointed bodies, needles, pins, fish-bones, &c, often get entangled in the root of the tongue or in the folds of the palate; on opening the mouth they can be seen, and are easily brought away. If lodged in the pharynx, they can be reached by the finger. The patient is seated with the head thrown back, and the jaws extended; the finger is introduced with determination, regardless of attempts to vomit, and swiftly passed into all the sinuosities by the side of the epiglottis, into the pouehes betwixt'the os hyoides and cornua of the thyroid cartilage, so that no part is left unsearched. The substance when felt, may be extracted with the finger by entangling it in the point of the nail; or curved forceps may be introduced, and applied conveniently to the body by the guidance of the finger. Great care 02S0PHAG0T0MY. 377 and caution are required in dislodging the foreign body, when both ends, as is often the case, have penetrated the parietes ; if it be rudely grasped and pulled, the parts are lacerated ; or it breaks, and the surgeon, after bringing out the portion held in the forceps, may find great difficulty in detecting and disentangling the other. I have often found it very troublesome to remove delicate needles entire. When they are beyond the reach of the finger, it is of no use to attempt their removal; the patient suffers great pain during the endeavour, and there is no chance of successful issue ; besides, the surgeon is apt to bring discredit on himself. Coins may be removed by the forceps, or by the hook, if lodged at the narrow part of the passage behind the cricoid cartilage ; if lower, they generally defy attempts at extraction, and slip into the stomach gradually. Halfpennies, halfcrowns, &c, pass readily along the alimentary canal, and are voided in a short time. Tendinous or cartilaginous portions of hard meat, when within reach of the finger, can be laid hold of by the curved forceps, and pulled up. Smaller and soft portions, if impeded in the passage, as when it has been narrowed by previous disease, are dislodged and pushed down by the cautious use of a small probang or oesophagus bougie. In the introduction of any instrument, attention should always be paid to the steps advised when treating of stricture of the gullet. CEsophagotomy is an operation that may, under some peculiar circumstances, be required. When a foreign body is of such a nature that when once lodged in the gullet, it cannot be removed either upwards or downwards, without serious lesion of the parts, and, when breathing is impeded by its projection, incision of the oesopha- gus may be warrantable. The operation is easily accomplished. An incision of about three inches is made in the superior triangular space of the neck, on the leftside, — the gullet usually inclining to the left of the mesial line. It is commenced opposite to the os hyoides, and carried downwards parallel with the trachea; the use of the knife is continued till by cautious dissection the wound is brought to the level of the common sheath of the large vessels. Assistants sepa- rate the edges by thin and broad copper spatula?, and the cavity is frequently sponged. The larynx is pulled aside, and turned a little over on its axis; the pharynx is thus exposed. During the latter part of the dissection, the laryngeal nerves and thyroid arteries must be looked for and avoided. The foreign body is felt through the parietes, and these are laid open to an extent sufficient for its extrac- tion. It is advisable to nourish the patient for some days afterwards through an elastic tube passed by the mouth or nares into the gullet, with its extremity one or two inches beyond the wound. Its intro- duction requires caution; an instance is on record of a tube being passed with the view of conveying nourishment, in which the surgeon did not discover that its extremity had slipped into the larynx till after the injection of some fluid. It is recommended to wait for some minutes before proceeding to inject, and that, if during that time no air pass through the tube, the instrument may be considered certainly 32* 378 AFFECTIONS OF THE EAR. in the oesophagus. It is seldom that the opening of the oesophagus will close by the first intention, and therefore accurate approximation of the external wound need not be attempted. Removal of noxious matter from the stomach is now successfully practised by the aid of instruments. This is required when the ex- citability of the organ has been impaired or destroyed, and emetics in consequence do not act. It is unnecessary here to treat of the emetics which act most quick- ly, or which are most proper in different cases, nor of antidotes for various poisons. Many stomach-pumps have been contrived, and their merits have caused much rivalry ; but they are all constructed on much the same principle. People, too, seem to indulge the in- ventors, by swallowing deleterious substances much more frequently than before. There has been a demand for cases of poisoning, and the supply has kept pace pretty well with the demand. Now-a- days twenty seem to attempt suicide by poison for one that did so long ago. Most vegetable narcotics — those which do not act with great rapidity, can be removed mechanically; but some of the mineral poisons are heavy and difficult of solution, and are not so readily ex- tracted. Read's apparatus appears to me the simplest and the best, for this and various other purposes. Ample directions for its use are given along with the instrument. Inflammation and Abscess of the Ear are either deep-seated, or confined to the external meatus. Suppurations in the internal parts — in the cavity of the tympanum, or in the mastoid cells — are often attended with the most violent symptoms, excruciating pain, fever, delirium. Such are highly dangerous in their consequences. Col- lections nearer the surface, under the membrane lining the meatus, are, though not so dangerous, also attended with great suffering and severe constitutional symptoms. The disease may occur at all ages, but is most common in children during dentition; in them it is often accompanied with convulsions and head symptoms, leading to a suspicion of hydrocephalus being established. The symptoms are all much relieved on the occurrence of copious purulent ^.dis- charge. Suppuration in the organ of hearing often follows eruptive dis- eases ; and both ears, or one, may continue to discharge for a long time. There is always more or less derangement of the functions of the parts. When the disease is external, perhaps hearing may not be much affected; but when, as often happens, the ossicula, nervous expansions, membrane, parieties, are all destroyed or injured, hear- ing is lost, or rendered at least very obtuse. Purulent discharge often continues for the rest of the patient's life, at one time scanty, at another profuse, and preceded or accompanied by inflammatory symptoms. Openings form over the mastoid process, communicating with the cells; and these are often connected with abscess betwixt the dura mater and pars petrosa of the temporal bone. Abscesses, too, of the middle lobe of the cerebrum, or in the cerebellum, are AFFECTIONS OF THE EAR. 379 sometimes evacuated through the meatus auditorius. • In all cases, but in the last more particularly, the patient suffers extremely on the discharge being suppressed, and is again relieved on its recurrence. At length, fever, and delirium, may supervene, terminating in coma and death ; I have dissected many who have perished in this man- ner. Or, after long continued discharge from the meatus, perhaps with paralysis of one side of the face, a soft tumour of the dura mater will be found lying over the pars petrosa, having caused extensive absorption of the bone, and exposed the semicircular canals, cochlea, tympanum, &c, filled with purulent matter. Abscess of the tympa- num itself discharges long ; and large, flabby, soft granulations fill up the meatus, very different in appearance from the solid tumours which sometimes occupy that situation. Ordinary earache—inflammation extending along the meatus externus, and confined to the lining membrane —will be relieved by leeching behind the auricle, and by assiduous and regular fomen- tation afterwards. But suppuration is seldom prevented. The abscess may sometimes be opened and with great relief. If deeply seated the parts are soothed by fomentation and poultice, till spontaneous eva- cuation of the matter occurs ; this is then to be washed away, from time to time, by the injection of a warm and bland fluid ; the abscess gradually closes, and the discharge slowly disappears. In cases of long-continued discharge, it is generally impossible to ascertain from what depth the matter comes, and there is always great risk in using means to arrest its flow. The patient must submit to the annoyance. The discharge can be moderated, or altogether suppressed by injec- tions of astringent salts, but the practice is unsafe, and in most cases unwarrantable. The parts are to be kept clean by frequent ablution with tepid water, lime water, or other bland fluids ; and cotton or wool may be worn in the meatus to take up the discharge, and prevent bad effects from cold. Discharge from the external meatus, and about the auricle, is often kept up by irritation in the mouth, in both children and adults ; this should be looked to, and the offending cause removed if possible. Foreign bodies are frequently lodged by children in the meatus auditorius externus — peas, beads, shells, shot, pins, &c. By awk- ward attempts at removal they are pushed deep into the cavity ; and the membrane of the tympanum is sometimes broken, as indicated by effusion of blood, and swelling of the parts. Violent inflammatory symptoms may be caused by such substances, and will be seriously aggravated by unsuccessful attempts at extraction. Sometimes they are allowed to remain for days or weeks ; in such circumstances seeds swell, separate, and begin to throw out a germ, thus fixing themselves more firmly in the passage. They are easily removed at first, by a small silver scoop, of convenient size and form ; and even at a later period, a determined, though not forcible, attempt with the instrument will be followed with success. The scoop is gently and gradually insinuated betwixt the membrane and foreign body; and on its handle being then raised the body is extruded. It is seldom that any excitement follows extraction by this method : but if large and powerful instruments be introduced, and force applied, the parts 380 AFFECTIONS OF THE EAR. may sustain severe injury, and troublesome consequences ensue: in- deed such proceedings have proved fatal. Foreign bodies are also occasionally impacted in the nostrils: the procedure above described is to be adopted. Sometimes they are discharged by the posterior nares during attempts at extraction. Polypus of the meatus auditorius externus is generally of pretty firm consistence, pyriform, sometimes slightly lobulated and warty- looking; it adheres by a narrow neck to the parietes of the tube near the margin of the membrana tympani, is attended with slight dis- charge, and with deafness to a greater or less extent. Extraction is the only means of cure. The body of the tumour is depressed and pulled outwards by the flat end of a probe slightly bent; delicate forceps are introduced gently, and passed up to the neck of the polypus, which is then firmly grasped ; by combining slight twisting with gentle extractive force, it is readily removed. Or a flat scoop, with a sharp round edge, is passed along till ob- structed, and by slight rotatory motion of the edge, the neck of the tumour is divided. After a day or two, a mild escharotic may be applied with the view of preventing reproduction; a bit of charpie sprinkled with the oxidum hydrargyri rubrum may be pushed up to where the tumour was attached, and the application may be repeated several times, one or two days intervening. Even after this the tumour sometimes returns, again rendering extraction necessary. Deafness is attributable to various causes besides those already mentioned. Accumulation of cerumen in the external meatus is the most common. The cerumen is often mixed with wool, and other extraneous substances, which the patient may have been in the habit of introducing as preservatives from cold, and thus a large and firm plug is formed, completely blocking the meatus. It is removable by the assiduous injection of tepid water, the best solvent of cerumen. The whole may not be brought away by the first sitting ; but the injection must be repeated again and again, till the membrane of the tympanum is free. A powerful syringe is required. By the use of a speculum, the condition of the external tube and membrane of the tympanum can be ascertained. But it is perhaps unnecessary to en- large farther here on this subject, for such is the division of labour in these days, that a distinct profession is founded on the operation of squirting water into the external ear; it is true that other opera- tions are talked of by these Aurists, as they style themselves, but the advantage to be derived from any of them is often very doubtful. They talk of deafness as arising from a deficient secretion of ceru- men, from dryness, or from eruptions in the meatus ; and heating stimulant applications are poured in — oils, ointments, mercurial salts, acetic acid, garlic, &c, all combined. They even go so far as to recommend mercurials to correct the state of the general health to improve or rectify the functions of the chylopoietic viscera the assistant chylopoietic, and the whole of the digestive organs, upon derangement of which, say they, many cases of deafness depend. The fools who apply to such charlatans certainly deserve to have their pockets well drained, but ought scarcely to be poisoned by them. AFFECTIONS OF THE EAR. 381 It has been proposed to pass probes and tubes into the eustachian tubes, to re-establish their continuity if obliterated, or dilate them if partially closed. No doubt deafness often depends on obstruction of this outlet from the tympanum, the requisite reverberation being perhaps thereby impeded. It may be closed by swelling of the lining membrane, by inspissated mucus, by destruction of its ex- tremity from ulceration, by the cicatrisation of ulcers in the imme- diate neighbourhood, by congenital deficiency, or by pressure of neighbouring swellings, or of morbid growths, producing temporary or permanent obstruction. None but the first two causes could pos- sibly admit of the use of the probe, and even then it can scarcely be required. By removal of the cause of such turgescence at the end of the tube, or in the neighbouring parts, — which can often be de- tected, being local, — by counter irritation, &c, a cure is much more likely to be effected than by the introduction of probes. Not that the operation is exceedingly difficult; for, after practice on the dead body, a probe can readily be passed into the eustachian tube of the living from the nostril. The instrument is fixed in a handle, with its point slightly bent, and on the handle there should be a mark to show the direction of the point; the distance of the termination of the tube from the nasal orifice ought also to be marked. The instrument is passed along the floor of the nostril, and then its point is directed upwards and outwards, whilst the handle is pressed towards the septum narium. It has been proposed, moreover, to force a stream of cold and condensed air into the internal ear, and to apply ethereal vapours to the cavity of the tympanum. The attempts have been made on an extensive scale in all sorts of cases, and quite indiscrimi- nately. This plan of curing deafness has been wrell advertised, and unblushingly puffed in scientific and other journals. Not one case of deafness in a hundred probably depends upon any affection of the eustachian tube : vitiated mucus cannot even be displaced by injec- tion of air or other fluid, unless the membrane of the tympanum be ruptured; this has indeed been accomplished by the operation in question, and then the mucosity could only be forced into the cavity of the tympanum, so as, if possible, to make matters worse. Nervous deafness, like functional amaurosis, may sometimes be relieved or even removed entirely by stimulating frictions, or the application of strychnine to a raw surface behind the auricle, and by attention to the general health. Puncture of the Tympanum has been recommended as a remedy for deafness arising, or supposed to arise, from obstruction of the eustachian tube ; but I believe it has not succeeded in above one out of twenty cases. The puncture is apt to close very soon; and though the hearing may be improved for a short time, the advantage gained soon disappears. The means of keeping the puncture open are not easily applicable ; perhaps the most effectual is to touch the edges occasionally with pencil-pointed lunar stone. The puncture is generally made with a short-pointed trocar, such as is used for hydrocele. The canula is passed down to the membrane, and placed on one side of its centre, lest the long head of the malleus should be interfered with. The trocar is then pushed on gently, and 382 BRONCHOCELE. should penetrate but a very short distance, for fear of injuring the important parts at the bottom of the cavity. By some a sharp-point- ed probe is used, passed through a quill; or an instrument about the same size with the probe is made for the purpose, with a canula to fit. But these are by much too small; even the puncture with a trocar closes, notwithstanding the application of nitrate of silver. I have lately used a sort of punch, such as is employed for making holes in leather, of a pretty large size, and neatly made, with the edge very keen, and on a small stalk. This is introduced ; and when obstructed, having reached the bottom of the canal, an at- tempt is made, with a rapid turn of the hand, to cut out a portion of the membrane. I have thus succeeded in improving immensely the hearing of one gentleman, enabling him to hear at four or five times the distance he could formerly. He had repeatedly submitted to punctures before I saw him ; and, previously to the operation with the punch, I passed through the membrane a trocar, made large, and well-pointed for the purpose ; but notwithstanding this, and the application of the nitrate of silver, I was unable to preserve the ad- vantage gained longer than a very few days. In suitable cases, the operation is worthy of trial, being unattended with pain or any dan- gerous consequences. M. Fabricci has contrived a very ingenious little instrument for the purpose ; by it the piece of membrane is fixed by a small screw, before being punched out. Bronchocele is not rare in some districts of Great Britain, but un- attended with the same peculiarities of countenance and mind as in some other countries.* The majority of those affected come from mountainous districts. The disease generally commences early in life, and females are more subject to it than males ; indeed almost all who present themselves are females. The tumours are of various sizes, involving either the whole gland, or only a part. One lobe is usually in a state of greater advancement than the other. The swelling is for the most part soft and yielding, the integuments are thin and movable, and large veins shine through them. It is un- attended with pain, or any great inconvenience, though sometimes it equals in size the patient's head, or nearly so, and then it is trou- blesome from bulk alone. In general, there is little or no obstruc- tion to deglutition or respiration, and the health is not impaired. The tumour is always of slow growth, at length becomes stationary, and the patient gets reconciled to the deformity. Its structure is that of the simplest form of tumour, a genuine hypertrophy, and it is seldom that its action degenerates. It is often made up also partly of cysts containing serosity, or glairy albuminous fluid. Internal remedies have been prescribed, with the view of arresting the growth, and promoting absorption of the enlarged thyroid — burnt sponge— muriate of lime — muriate of baryta, &c. The use * In this country goitre is most common in the mountainous dis- tricts of Pennsylvania, Virginia, New York, Connecticut, New Hampshire, and Vermont. It is very rare in the natives of the western and southern states. —Ed. BRONCHOCELE. 383 of iodine, externally and internally, has in many cases been attend- ed with beneficial effects. Tumours have diminished, and even dis- appeared entirely, during the employment of this medicine ; but in others, the diminution has been either trifling or none. The inser- tion of setons has been strongly recommended ; and many patients are said to have been thus cured. I have tried this plan in one case only; it certainly had the effect of diminishing the swelling; but for some time great trouble was experienced from bleeding, when- ever the cord was drawn, and the patient afterwards became much weakened by the profuse discharge. The proposal to tie the thy- roid arteries, for the cure of bronchocele, has been put in practice, but without a favourable result. [I have in three instances succeeded completely, and in another partially, in curing goitre of long standing, by the internal and ex- ternal use of iodine; and am disposed to place more reliance upon this remedy in the treatment of this affection than upon any other with which I am acquainted. To be beneficial, it should be admi- nistered in large doses, and be continued for at least three or four months. The local remedy wdiich has best succeeded in my hands consists of equal parts of iodine and of camphorated mercurial ointment, rubbed thoroughly upon the surface of the tumour twice a day.] Extirpation of such growths has been repeatedly attempted ; but the patients, almost without exception, have perished from hemor- rhage, under the hands of the knivesmen. The immense supply of blood afforded to the gland in the healthy state must be kept in mind, as also the enlargement of the vessels proportional to the in- crease of the part. Not arteries alone, but enormous veins, are to be encountered. The tumour is in the vicinity of important organs, and of the trunks of large vessels and nerves, and probably has be- come attached to them. In short, the operation is attended with such risks, with so absolute a certainty of almost fatal result, as not to be warranted under any circumstances, far less for removal of de- formity only. Enlargement of the isthmus alone gives rise to more severe symp- toms apparently, and may warrant an attempt at removal ; but this can scarcely be accomplished altogether by incision. Such is my impression, and under this impression I proceeded very cautiously in a case of this nature with which I had to deal. — J. R., a rat-catcher, aged forty-seven, from the Highlands, was admitted into the Royal Infirmary. The isthmus of the thyroid gland was enlarged to the size of a goose's egg. The tumour was extremely hard and irregu- lar on its surface, but not painful when touched ; it appeared to be adherent to the trachea, and did not admit of much motion. The voice was considerably impaired, and breathing much impeded, in- spiration being difficult and attended with a loud wheezing noise. On making unusual exertion, even though inconsiderable, the dys- pnoea was much increased ; and on ascending a height, or even re- maining for some time in a stooping posture, it amounted almost to suffocation. There was no pain or uneasiness in the larynx or trachea. The disease was of three years' duration. A seton had 384 ABSCESS OF THE NECK. been introduced, but effected no diminution, and rendered the tumour more dense and less movable than formerly. I surrounded the lower part of the tumour by two semicircular incisions, and, dissect- ing cautiously beneath its base, detached it from its more loose con- nexions, not interfering with the central portion and its connexion to the trachea. During the progress of the dissection, the blood flowed most profusely from both arteries and veins, but was restrained by securing the former with a ligature, and compressing the latter with sponge. An armed needle wras then passed through the centre of the tumour, as close to the trachea as possible, and its remain- ing attachment enclosed by the separate portions of the ligature firmly applied. Every thing proceeded favourably. The tumour soon came away; the wound healed with a firm cicatrix, and in about a month the patient went home well. I met him by chance, in Aberdeen, twelve months afterwards, free of complaint, and breath- ing easily under all circumstances, his neck presenting ho vestige of the tumour. Glandular Tumours of the Neck, as formerly noticed, arise from various irritations; and some constitutions are more subject to them than others. The nature of the enlargement is dependent on the cause ; it may be simple or malignant. Simple swellings often attain a large size ; the lymphatic glands in both spaces of the neck, and on one or both sides, get immensely enlarged, the cellular tissue around is infiltrated with solid matter, and all matted together. Great de- formity is produced; the head is turned with difficulty, and twisted to one side ; often there is not much pain. After some time, the swelling becomes looser than before ; its various portions separate, and gradually disappear; or the centre becomes soft, suppuration spreads extensively, and the surrounding hardness either goes off, or becomes partial. Discussion of the swelling is to be promoted, and, if possible, the cause removed ; and fomentation, friction, pressure, internal stimu- lants are to be employed, according to the state of the parts, along with what are called deobstruents, in the first instance. When sup- puration cannot be arrested, the attention must be directed to pre- vent the integuments from being destroyed. With this view, the abscess should not be permitted to give way spontaneously, lest an opening be formed whose cicatrisation would cause deformity and leave a stain on the race and generation. An artificial aperture'must be made early ; and in the upper and most exposed parts of the neck this should be in the direction of the folds, and small. When, many and extensive collections have formed," when the in- teguments have been undermined and attenuated before advice is sought, it is impossible to prevent deformity. The knife and potass are required, for reasons assigned in the preceding part of this work ; and the detached glands, as well as the thinned skin, stand in need of their free application. Deep-seated collections may originate in glandular disease, or com- mence in the cellular tissue ; they occasionally follow transverse wounds of the neck. Great infiltration of the cellular tissue super- HYDROCELE OF THE NECK. 385 venes over the trachea and sternum, and also under the fasciae ; puru- lent matter is secreted in the cells, and the parts are extensively separated ; sloughing is prevented only by free and early incision. The nature and extent of the coverings of an abscess seated deeply in the neck are to be kept in view — the platysma myoides, the superficial and deep cervical fasciae. Collections under these inter- fere with the functions of the neighbouring parts, and are attended with great pain, which is somewhat relieved by resting the chin on the sternum, and so relaxing the fasciae. The matter makes its w-ay to the top of the sternum, and generally points on the outside of the sterno-raastoid muscles. But before the integuments become thin, the parts have been seriously injured — the cellular tissue has sloughed, the muscles have been separated from each other, with unhealthy purulent matter interposed — the trachea, the oesophagus, or the mediastinum, opened into. Such cases have been formerly alluded to. The lymphatic glands, situated amongst the fat and cellular tissue between the deep and superficial cervical fasciae immediately above the sternum, may become enlarged. When the tumour is large, breathing is impeded by compression of the parts beneath, and pain and much inconvenience are endured on account of its limited situa- tion and resisting investments. Purulent collections in the anterior mediastinum and under the sternum are scarcely remediable. These are chronic or acute. One of the great dangers following the operations on the larger vessels at the root of the neck, in which the deep fascia is necessarily divided, is infiltration into, and acute abscess of, the anterior mediastinum. In chronic collections the parietes of the cavity on one side are fixed, on the other have constant motion ; and thus the surfaces, however healthy and well disposed, are prevented from coming together and adhering. The discharge continues, and at length wears out the patient, pulmonary affection perhaps supervening. The same unfa- vourable causes operate in other situations, in the iliac fossa, and in chronic collections under the cranium. In chronic abscess of the me- diastinum, no dependent opening can be obtained, unless by perfora- tion of the sternum. This is perh'aps warranted by cedematous swelling over some part of the bone, indicating, along with other symptoms, the existence of matter beneath. Purulent collections sometimes form in the substance of the sternum, communicate with the mediastinum, and involve the lower part of the neck. The thymus gland is said to be liable to chronic enlargement in young subjects of weak constitution, causing serious impediment to respiration and deglutition ; the tumour is confined above and ante- riorly, and consequently presses backwards on the trachea and gullet. Suppuration may take place in the swelling, and the matter ultimately be diffused in the mediastinum. [HYDROCELE OF THE NECK. An encysted tumour of the neck, to which the term hydrocele has been applied by some writers, is met with in both sexes and at 33 386 DISTORTION OF THE NECK. various periods of life. Its progress is usually slow, and it generally arises without any assignable cause. Occasionally it has appeared to be congenital, but this must be considered as a rare exception. The tumour, seldom larger than a walnut, may acquire the volume of a Seville orange. When this is the case, it may impede respira- tion and deglutition, or even the return of the blood from the head. Its contents are of a serous or oily character, with an intermixture of flakes of lymph, and the cyst itself varies in thickness from the fourth of a line to a quarter of an inch or more. Externally it is more or less intimately connected to the cellular substance in which it is developed, while its internal surface often exhibits a rough, reticulated aspect, not unlike the false membrane of pericarditis. In cases of long standing the cyst is very firm and tough, or almost gristly, and closely adherent. The skin covering the tumour seldom undergoes any change, unless it is very large, when it is apt to be- come attenuated at some points and thickened at others. The sub- cutaneous veins may also then present a tortuous and distended ap- pearance ; but this is far from being generally the case. The characters by which hydrocele of the neck may be distin- guished from other affections are, absence of pain and tenderness on pressure, slight fluctuation, the slow progress of the tumour, years generally elapsing before it attains much development, and, above all, the history of the case. When the tumour projects outwardly over the carotid artery, it might be mistaken for aneurism, from which, however, it may, in general, be readily discriminated by the elevation of the entire swelling from the impulse of the blood, and by the wrant of that alternate expansion and retrocession which are present in genuine aneurism. When seated over the thyroid gland, or in its substance, it may be confounded with bronchocele. In all cases, where any doubt remains as to its true nature, an exploring needle or trocar should be introduced, which will at once determine the diagnosis. The treatment of this affection, like that of the vaginal tunic of the testicle, may be palliative or radical. The former consists in evacu- ating the fluid, from time to time, with the knife or trocar ; the latter, in injecting some stimulating fluid, such as wine and water, or a solution of iodine, or nitrate of silver; or, what is better, introducing a seton, and keeping it in the sac until it is obliterated by adhesive inflammation. Incision and extirpation have been practised success- fully by Flaubert, Delpech, Jobert, and other surgeons.] Distortion of the Neck arises from a variety of causes, and is either temporary or permanent. The head is often kept in an unnatural position for weeks by glandular swelling. Enlargement of the super- ficial glands, at the upper part of the neck, induces the patient to turn his head to the opposite side ; swellings lower in the neck, and deep seated, require relaxation of the coverings, and the head is con- sequently twisted to the same side. Either rigidity, or spasmodic action, or both, of the sterno-mastoid muscles, displaces the head and twists the neck. The head is either bent forward, or turned to one side; usually, the chin is twisted over the shoulder, on the side op- DISTORTION OF THE NECK. 387 posite to the offending muscle. Induration of the muscle is some- times met with, also causing distortion; it may terminate in abscess, or after a long time be discussed. The cause of the spasmodic action in the muscle is sometimes ap- parent, sometimes very difficult to be detected. Sources of irritation at the extremities of neighbouring and communicating nerves are to be looked for and removed; and the spasms are to be moderated, as much as possible, by external and internal remedies. Opiate frictions, and the application of the nitrate of silver over the course of suspected nerves, are sometimes followed with benefit, and may be accom- panied by the internal administration of antispasmodics, though the efficacy of these is often doubtful. When the head has been for a long period, perhaps many years, turned to one side, from any cause, the muscle on that side naturally becomes shortened, and a change takes place in the form of the bones. If the patient is still young, the deformity may, in a great measure, if not entirely, be remedied. Division of the shortened muscle was a favourite operation of old surgeons for the cure of wry-neck, and may be resorted to with ad- vantage in some cases. One of the heads, or both, may require to be detached from the sternum and clavicle. It is only in cases where the muscle is in fault, it being shorter than usual, that benefit can be expected from this proceeding. It is a very simple operation, and can be effected by a mere puncture of the skin betwixt the two portions. By the cautious use of a blunt and flat probe or director, the cellular tissue under the origins of the muscle is separated ; this is followed by a narrow and blunt-pointed knife, by which the attachments to the clavicle and sternum are cut across. Distortion of the neck is most frequently produced by some vice in the bones, as curvature, from softening, attended with deformity of the trunk or of the limbs. In such cases, the twist is generally to the right side, the ear approaching the shoulder. No treatment can be effectual, unless the other curvatures are corrected; for the head is placed so to preserve the equilibrium of the body. The head is to be supported, and its weight removed from the vertebral column by a curved iron rod, attached to the back of stays fastened on the loins, leathern straps passing from the top of the rod under the chin and over the occiput. By the use of such apparatus for a consider- able time, the vertebral column may regain its perpendicular direc- tion, and all deformity of the neck be consequently removed. The application of such a machine is required after the division of the sterno-mastoid, so that the head may be kept straight until the mus- cle is reunited of a proper length, and any change in the form of the bones may be got over. In slight cases, this treatment is not re- quired ; on giving support to the trunk, and raising the shoulders to an equal level, the muscles of the back, perhaps stimulated by powerful and repeated friction, gradually bring the column into its proper form. Then the position of the head to one side is no longer required to balance the body. But.a cure can be expected only, when no material change has taken place in the form of the indivi- dual bones. Excurvation of the cervical vertebrae, — bending of the head for- 388 DISTORTION OF THE NECK. wards, and perhaps a little to one side, generally to the right, — takes place as a consequence of disorganisation of the ligaments and connecting fibro-cartilages of the vertebra?, with subsequent ulcera- tion of the bones. The disease generally occurs in the superior ver- tebrae ; of the articulation of the atlas with the occiput, or with the vertebrae dentata, or in the articulation of the latter with the one below. The articulations on the left side are usually affected first. There is stiffness, pain, and swelling of the soft parts covering the affected bones, attributed perhaps to exposure to cold, as when sit- ting in a draught, and supposed to be merely crick of the neck. The posterior cervical muscles are weakened, and the head is bent forwards. The patient is unable to support his head by the muscu- lar action, and when in the erect position places his hands on the temples, to prevent it from dropping, and to keep it steady. Diffi- culty of swallowing is a prominent symptom from the first, as can readily be imagined when the close application of the constrictors of the pharynx to the fore-part of the affected bones is kept in re- membrance. The position of the head also renders deglutition awk- ward. The disease is attended with great suffering, evinced by marked anxiety of the countenance : and the pain is most violent during the night. The complaint is too frequently trifled with at the commencement, being not understood, nor its danger appreciat- ed. The swelling increases, with pain, and the chin falls down on the sternum. The patient grows emaciated, and perhaps becomes weak in the lower limbs, and even in the upper; the feces and urine are imperfectly retained. Occasionally, abscess forms behind the upper part of the pharynx, increasing the pain and the difficulty of deglutition. On making an examination through the openings by which the abscess has emptied itself spontaneously, the bone is felt bare ; and portions, even large, of the vertebrae, or vertebra, are, after some time, discharged, so as to expose the theca of the spinal cord. Even in such circumstances patients have lingered on, and that for so long a period as to allow of some unprincipled fool advertising a perfect recovery. The termination of caries of the cervical vertebrae, often without any appearance of abscess, is in general fatal and sudden. The head, slipping from its support, falls forwards or to a side, causing immediate and complete paralysis of the whole body ; dissolution soon follows. On examination, the articulating surfaces of the ver- tebrae are found displaced, and the shreds of ligaments which con- nected them ruptured. The atlas is separated from the occiput; or the processus dentatus, escaping from its situation, in consequence of destruction of its confining ligaments, is found compressing the medulla oblongata. This process is very often destroyed almost en- tirely, or it is so far detached by ulceration at its root as to be easily broken off. The disease in general seems to commence in the articu- lations, whereas in the vertebrae with larger bodies, abscess and ul- ceration have their foundation, and origin more frequently in the de- posit of tubercular matter in the cancellated texture of the bones. In other instances, the termination may be more slow and gradual; the patient is worn out by long suffering and continued purulent EXTERNAL JUGULAR. 389 discharge ; change of structure takes place in the theca vertebralis, or in the medulla itself; serous effusion occurs at the base of the brain ; the patient's sensations are blunted, and he loses the use of his limbs gradually; his intellect fails, and coma supervenes, fol- lowed by death. Active and early interference can alone arrest, subdue, or prevent the dreadful consequences of the disease above described ; it is quite intractable in its later stages. Confinement to the recumbent posture, and strict rest of the affected parts must be enjoined ; and blood is to be abstracted locally, once and again, according to cir- cumstances ; afterwards counter-irritation is to be employed, and repetition of moxas or of caustic issues is the most efficacious. When the painful feelings have subsided, and some impression has been made on the disease, the patient appearing to convalesce, the head must ,be supported by a proper machine for a long time. He will thus be enabled to use his limbs, to move about, and repair his general health, the weight of the head being taken from the weak- ened column. The External Jugular vein may require to be opened for the ab- straction Of blood in affec- tions of the head ; or when venesection cannot be readi- ly performed at the bend of the arm, from the small and indistinct condition of the veins in children, or in peo- ple loaded with fat. The vein is made to rise by pres- sure with the finger or thumb, as seen in the accompanying cut, above the clavicle. The lancet is passed through the integuments and platysma myoides into the vessel, mid- way between the jaw and clavicle. After a sufficient quantity of blood has been withdrawn, the pressure below is re- moved, and the edges of the wound are put together with a bit of court plaster, or by means of a compress and bandage lightly ap- plied. [To obtain a full stream of blood, the lancet should be carried ob- liquely upwards and outwards, by which means the fibres of the platysma-myoid will be cut across, instead of being divided verti- cally, and the edges of the incision will retract so as to form a much larger orifice. The pressure below the opening should not be re- moved until the wound has been closed, to avoid the introduction of air into the vein, an accident which may occur when this precaution is neglected.] Ligature of the common Carotid may be required for the cure of 33* 390 LIGATURE OF THE CAROTID. aneurism at the angle of the jaw ; or on account of hemorrhage from deep wounds in the same situation, when, from any circumstances, the divided extremities of the vessels cannot be secured. A deep incision of the angle of the jaw, towards the base of the cranium, not only divides important branches of the carotid, but may also wound the vertebral arteries where they project in a tortuous fashion, betwixt the dentata and atlas, or betwixt the latter bone and the occiput. Ligature of the common carotid has been had recourse to, in order to stop bleeding from the mouth, nostrils, and other parts connected with the face, — for the cure of large 'or deep-seated aneurism by anastomosis, — and as a preliminary step to the removal of large and firmly attached morbid growths of the face or neck. This last pro- ceeding, as already remarked, does not in any way enhance the pa- tient's safety, whilst it adds much to his suffering. The carotid has also been tied for the cure of aneurism at the root of the neck, when it was impossible to place a ligature betwixt the tumour and the heart. My opinion regarding this practice I have given formerly, when treating of aneurism in general. For aneurism at the angle of the jaw, the point of deligation must in a great measure depend on the size of the tumour. The artery is most conveniently reached where it is crossed by the omo- hyoideus ; and, when deligation at this point is both practicable and eligible, the vessel is exposed at the upper edge of the muscle. But circumstances may require the ligature to be placed much lower. The patient is placed, either sitting or lying, with the head thrown back, and turned slightly to the side opposite the tumour. An in- cision is made in the upper triangular space of the neck, and in the course of the vessel, midwray betwixt the sterno-mastoid muscle and the muscles covering the forepart of the larynx. Its extent depends on the thickness of the neck — on the muscular development and quantity of fatty matter, whether the neck be long or short. From two to three inches wTill in general afford sufficient space. The first sweep of the scalpel penetrates the skin, platysma-myoides, and cel- lular tissue. The cervical fascia is then divided carefully, with the hand unsupported. During the incision, the parts should be a little relaxed by attention to the position of the head. The sheath of the vessels is exposed by cautious division of the cellular tissue which occupies the space betwixt it and the cervical fascia. Thin copper spatulae, bent to suit the purpose, are used to keep the edges of the wound apart. In general there is very little bleeding ; but, that the operator may be sure of what he cuts, it is necessary frequently to clear the cavity with a bit of soft sponge. Each step of the operation should be slowly and surely accomplished ; the least hurry is culpable. When the slight oozing has ceased, the common sheath, — which is distinctly seen, with the descendens noni lying on its forepart,__is to be opened to a slight extent with the point of the knife — the'hand steady and unsupported, and no director used. The descendens noni is left to the inner side. The internal jugular vein, swelling up on account of the struggles and hurried respiration of the patient has in some cases been found troublesome at this period of the ope- LIGATURE OF THE ARTERIA INNOMINATA. 391 ration, rendering the opening of the sheath and the use of the needle difficult. I have not met with any such obstacle in the cases in which I have been concerned. The aneurism needle should be slightly curved, with a perforation near the point; and the point should neither be bulbous, nor at all sharp, but all of the same thick- ness, and well blunted at the extremity and edges. It is introduced, carrying a firm round ligature of flax or silk, well waxed through the opening in the sheath, betwixt the par vagum and the artery, and from the outer side. The point is moved very slightly from side to side, and carried under the artery; no force being used, as it is un- necessary, and apt to be injurious. The instrument is thus gently insinuated, not thrust, through the cellular tissue, and made to ap- pear on the opposite side of the vessel, with its point towards the trachea. It ought to be passed close to the arterial coats, and care must be taken to avoid including within its track part of the common sheath, or the descending branch of the ninth. Unless the surgeon be indeed very rash, there is little risk of the vein or par vagum being injured; to include them along with the artery would argue no small degree of most deplorable ignorance. The loop of the liga- ture is laid hold of either with the fingers, with forceps, or with a small blunt hook, and drawn towards the surface of the wound. It is then divided, and one-half retained, whilst the other is withdrawn along writh the needle. The vessel must not be raised up from its situation, or detached from its cellular and vascular connexions, more than is merely sufficient for transmission of the needle. A single knot is cast upon the remaining half of the ligature, passed down, and tied firmly on the vessel, by the forefingers of the operator. This is secured by the finger of an assistant, whilst the ends are again passed through, so as to complete the reef-knot, and run down tight as before, the assistant slowly withdrawing his finger to make way for the ligature. A third knot may be made to insure security ; but it is seldom, if ever, necessary. As already observed, every thing must be done with deliberation and caution, and the operation may be thus safely concluded in a very few minutes. One end of the ligature may be cut away close to the knot, or both brought out of the wound. The edges of the wound are put together, after all oozing has ceased, by one or two stitches, and the intermediate ap- plication of isinglass plaster; bandaging is unnecessary, and might be hurtful. The patient is placed in bed, with the head elevated considerably, so as to relax the neck. The wound will probably heal by the first intention, excepting in the immediate neighbourhood of the ligature ; and the separation of this may be looked for from the tenth to the twentieth day. Then all risk of danger may be con- sidered as past. Ligature of the Arteria Innominata has been practised in very few cases. It may possibly be required for aneurism of the subcla- vian, or of the root of the carotid ; or for large axillary aneurism, greatly raising the shoulder, and involving the parts at the root of the neck. The patient should be placed recumbent, with the head well thrown 392 LIGATURE OF THE SUBCLAVIAN. back. An incision from two inches and a half to three inches in ex- tent is made in the course of the carotid, terminating over the sub- clavicular articulation. If the incision is made more towards the inner border of the left mastoid muscle, greater space is gained. From that point, another is carried along the upper margin of the clavicle, to the extent of an inch and a half. The sternal attachment of the sterno-mastoid muscle is separated, the cervical fascia divided, the cellular tissue betwixt the sterno-hyoid muscle separated, and the vessel exposed. During the dissection, the internal jugular vein, the par vagum, and the recurrent branch, the inferior thyroid artery, and the arterial distributions from the thyroid axis, must be carefully avoided. The operator should, by free external incisions, make a dissection sufficiently spacious to admit of his seeing the bottom of the wound distinctly as he proceeds. It is necessary that he not only feel but see what he is about to cut; groping in this situation, and amongst such important parts, is unsafe, to say the least of it. Caution in passing the needle is here required equally as in ligature of the carotid. In such deep wounds the aneurism needles of Weiss, Bremner, Mott, or Gibson, may perhaps be found useful; but in general the common one is sufficient, and has always answered my purpose perfectly. During the dissection, it must be borne in mind that the pleura is not far from the edge of the knife. In one case of aneurism above the clavicle, and close to the outer border of the sterno-cleido mastoid muscle, and of the anterior scalenus, I exposed the arteria innominata by a cautious dissection; but, instead of sur- rounding that vessel, applied ligatures to the root of the subclavian and of the carotid. This latter was closed with the view of insuring the formation of a clot in the arteria anonyma. The patient suffered under abscess of the mediastinum, inflammation of the heart and pericardium, and ultimately he had repeated hemorrhage from the wound. The arteria innominata and the root of the two vessels were obstructed by firm coagulum. The blood had come from the distal end of the subclavian, and had been furnished by the regurgitation through the vertebral, thyroid, mammary, &c. Ligature of the Subclavian Artery is required for the cure of axil- lary aneurism. That portion of the vessel within the scalenus and outside of the pneumogastric nerve is unfavourable for operation, in consequence of many branches being given off in an exceedingly short space. Besides, important veins and nerves are in the imme- diate vicinity. And though these were avoided, and the vessel reached and tied, still there would be no likelihood of a favourable result; obliteration of the vessel would not be expected to take place at the deligated point, one or more collateral branches arising close to the ligature. On the outside of the scalenus there is no such ob- jection. But the vessel is deep, even in the healthy state, and much more so when aneurism has appeared in the axilla, and has attained but even a small size. But again, when the tumour is laro-e the shoulder is much elevated, and firmly fixed in its exalted level so as greatly to increase the depth of the vessel. The shoulder is to be depressed as much as possible, and the head LIGATURE OF THE SUBCLAVIAN. 393 thrown to the opposite side. An incision is made along the upper margin of the clavicle, and a second perpendicular to the first. These must be proportionate to the size of the patient, and the sup- posed depth of the vessel. It is better to err in making the external incisions too large than too small; neither the pain nor the duration of the cure is much increased thereby. But, by an opposite course, both the difficulties and the dangers of the operation are rendered far greater. The external jugular vein must be avoided if possible by the knife; it should be detached slightly, and pulled inwards. The supra-scapular artery, running in a line with the clavicle, ought also to be saved; it acts a principal part in performing the anasto- mosing circulation after ligature of the trunk ; and, although the arm would receive a sufficiency of blood from other branches, it is well to keep this entire — not to mention the trouble which wound of it would occasion the operator, by constantly filling his incisions with blood, and the delay caused by the application of ligatures to the bleeding extremities. Its division can easily be guarded against, and should be avoided. The subclavian vein is not in the way ; it is lower down under the clavicle than where the surgeon requires to introduce his instruments. The fascia and cellular tissue are divided carefully, until the cervical plexus of nerves appears, and then the artery is to be looked for on the same level with the plexus, and towards its sternal margin. But, in cutting for this or any other vessel, it must be recollected that pulsation is a very uncertain guide. It is communicated to the neighbouring parts, and often is scarcely to be felt at all, or is at least very indistinct. In any situation pul- sation is very perceptible before division of the integuments, and other superimposed parts; but after resistance has been removed by exposure of the vessel, it ceases almost entirely. The sense of touch is the principal guide, and, to experienced fingers, the feel of nerves is different from that of arteries. The ligature has been passed round one of the cervical plexus, as happened in one of my own cases ; the mistake was, however, not without its use, for, on dis- covering that it was a nerve, I retained the ligature, no knot having been cast, and by it pulled the nerve out of the way, so as to allow of the artery being more readily secured. The artery is felt as it crosses over the first rib, and by pressure there, pulsation in the arm is stopped ; sometimes it may be even seen. The knife, guided by the finger, is then used very cautiously to prepare the vessel for ligature. The vessel may be found unsound, and dilated to a further extent than had been expected ; and then it may be necessary to trace it towards the heart, and even to divide the scalenus anticus in part, the phrenic nerve being kept free from injury, in order to expose a sound portion for the application of the ligature. This was found necessary in one of my own cases, and also in one operated on by the Baron Dupuytren. A blunt-pointed needle is passed, either plain or with a separable point, and the knots made as was formerly de- scribed. A piece of strong wire doubled, and either notched or per- forated at the extremities, affords assistance in securing the knots in so deep and contracted a space. Various kinds of serre-nceuds and needles have been recommended; but the simpler the instruments 394 LIGATURE OF THE SUBCLAVIAN. employed are, and the less a surgeon depends on them, the more likely is he to succeed in his undertaking. During the time that this sheet was passing through the press, a ease of aneurism above the right clavicle came under treatment in the hospital, on which it was proposed to perform the operation of tying the trunks of the subclavian and carotid as they pass off from the innominata. The necessary incisions were made, but the inno- minata was found wanting. After some troublesome dissection, the subclavian artery, which appeared to have come off irregularly, was discovered crossing from the left to the right side, to take its place betwixt the scaleni, rather more than half an inch behind the caro- tid, and close upon the forepart of the vertebrae. The ligature was placed on the mesial side of the pneumogastric nerve, and close to it. Up to this, the twenty-second day, the case is going on most favourably. [I am induced to subjoin the following example of axillary aneu- rism for which the subclavian artery wras tied, in the belief that, from the unique manner of its termination, it will be interesting and in- structive to the reader. The particulars of it, together with an ana- lysis of twenty-six other cases reported by different surgeons, will be found in the Western Journal of Medicine and Surgery for June, 1841. Daniel Monday, a married negro, thirty-six years of age, of a stout muscular frame, and a brickmaker by occupation, consulted me, in February, 1841, for a circumscribed, pulsating tumour, pro- duced by the recoil of the butt-end of a yager, and situated be- neath the right pectoral muscle, extending from the clavicle down towards the cartilage of the fourth rib. It was of an irregular, coni- cal shape, and about the volume of a large fist, measuring fully four inches at its base in one direction, by three and a half in the other. In its feel it was tense, as w7ell as inelastic ; the blood rushed into it with a whizzing noise, and the pulsation was so distinct that it could be seen at the distance of some feet from the patient. The clavicle was thrown above its natural level; the whole limb, from the top of the shoulder to the ends of the fingers, was benumbed, painful, and almost deprived of powder; the pectoral muscle was much stretched; and the patient constantly inclined his head towards the affected side, keeping the elbow nearly at a right angle, and supporting it carefully with the opposite hand, to prevent tension of the tumour. The swelling of the limb, however, was slight; the temperature was also good, and the pulse at the wrist was nearly as distinct as in the natural state. For the last four weeks the pain was almost inces- sant ; it was particularly severe at the chest and shoulder, and had become so agonising of late as to deprive him of sleep, and even prevent him from lying down. The appetite was also much im- paired, and the countenance expressive of the deepest distress. The tumour had grown with great rapidity during the last two months ; and, as there was danger of its bursting, an operation was at once decided upon. The patient was placed upon a narrow table of moderate height, LIGATURE OF THE SUBCLAVIAN. 395 the head and chest being elevated with pillows, and the face turned slightly towards the opposite side, while an assistant pulled at the wrist, to depress the affected shoulder. The integuments over the clavicle being stretched upon the chest, I made my first incision along the centre of that bone, beginning near the sternal origin of the mastoid muscle, and passing out towards the acromion process of the scapula for about three inches and a half; thus dividing at one stroke the skin, cellular substance, and fibres of the platysma- myoid. The parts being allowed to retract, left the lower margin of the cut parallel, and on a level with the superior border of the clavicle. A second incision, about two inches in length, was car- ried along the posterior edge of the sterno-mastoid muscle, at a right angle with the preceding. The triangular flap thus formed was then dissected up and held away, care being taken not to interfere with the external jugular vein, or any of the smaller arteries of the neck. Having advanced thus far, the cervical aponeurosis was detached from the clavicle by cautious strokes of the handle of the scalpel, which laid bare the brachial plexus of nerves and the omo-hyoid muscle. At this stage of the operation a small vein, a branch of the subclavian, was divided, and, although it bled very little, it was immediately secured by a temporary ligature. Taking the omo-hyoid for my guide, I divided the loose cellular substance in the triangular space bounded above by the muscle just mentioned, by the clavicle below, and by the anterior scalene muscle internally, and thus ap- proached the artery as it passed over the first rib. The vessel here lay at some distance from the inferior branch of the brachial plexus of nerves, rather deeply behind the collar-bone ; and with a com- mon aneurism needle, armed with a double ligature of saddler's silk, no difficulty was experienced in securing it, the instrument beincr carried from before backwards and from below upwards. The ligature was then drawn very firmly with the fingers, and tied with a double knot within a few lines of the anterior scalene muscle: as soon as this was accomplished, all pulsation in the sac, as well as at the wrist, ceased. One end of the ligature being cut off, the other was left protruding at the inner angle of the wound, the edges of which were closed by three sutures and adhesive strips. Not half an ounce of blood was lost during the operation, which lasted twenty minutes. The patient being put to bed, the limb was laid in an easy posi- tion, and wrapped in cotton wadding. In less than an hour the temperature, which had been considerably depressed, was thoroughly restored ; the pain and numbness had greatly abated; and the poor fellow expressed himself more comfortable than he had been for a month. In less than twenty hours the tumour was quite solid ; the ligature came away on the morning of the thirteenth day; and the patient was in all respects convalescent, the swelling having dimin- ished fully one-half in size. No untoward symptoms of any kind occurred until the morning of the twenty-seventh day, when the patient was suddenly seized with intense pain in the right side of the chest, attended with short, hurried, and laborious respiration, quick and tense pulse, great anxiety of countenance, prostration of 396 LIGATURE OF THE SUBCLAVIAN. the vital powers, and entire subsidence of the aueurismal tumour. Being absent from town, he was kindly visited by my friends, ur. T. LT Caldwell and Dr. S. B. Richardson, until he expired, early on the thirty-first day after the operation. The body carefully examined after death, was somewhat ema- ciated ; the wound had completely cicatrised, and the pectoral mus- cles were a good deal wasted, though in other respects unchanged. The subclavian artery terminated abruptly at the outer margin of the scalene muscle, where the ligature had been applied, its calibre be- ing closed by a mass of solid fibrin, about one-third of an inch m length, which adhered firmly to the lining membrane, and thus pre- sented an effectual barrier to the passage of the blood. Between this and the thyroid axis the vessel was occupied by a dark coagulum, which, as it was loose, was probably formed only a short time before death. Beyond the seat of the ligature the artery had a rough ragged appearance, and was sufficiently pervious to admit of the ready pas- sage of a small probe into the aneurismal sac. Superiorly the tumour was overlapped by the brachial plexus, 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 perceptible, the structures involved in the operation being consolidated by plastic lymph. The aneurismal tumour placed im- mediately 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 com- municated by means of an oval aperture, one inch and three- quarters in length by an inch and a half in width, with the pleuritic cavity ; it was situate between the first and second ribs, nearly equi- distant between the sternum and the spine, and was the result obviously of ulcerative absorption induced by the pressure of the tumour. Both ribs wrere 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, es- pecially at the part corresponding with the apex of the tumour. The right thoracic cavity contained nearly three quarts of bloody- looking serum, intermixed with flakes of lymph and laminated clots; the latter of which were of a reddish brown colour, and had evi- dently escaped from the aneurismal sac. The pleura exhibited signs of extensive inflammation; and the right lung was greatly reduced in volume, from the compression of the effused fluid. The left lung was considerably engorged, and at one or twTo points almost hepa- tised. The heart and pericardium were sound, as were also the ab- dominal viscera, and the larger arterial trunks. From the description of this operation in the text, it will be seen that Mr. Liston recommends two incisions, as performed in the above case. Were I to be again called upon to tie the subclavian artery above the clavicle, I should certainly omit the verticle incision, from a conviction that it is altogether unnecessary : it does not expediate the operation, nor does it facilitate the application of the liga- ture.] LIGATURE OF THE AXILLARY. 397 The axillary portion of the brachial artery cannot require to be tied for true aneurism. Were the aneurism seated at the border of the axilla, and the upper portion of the vessel beneath the clavicle free, the best, wisest, and safest proceeding is to tie the subclavian. Then, the shoulder not being raised, the vessel is not so deep as when the aneurism involves the whole axilla. The incisions are not so deep nor so extensive, and do not implicate so important neigh- bouring parts as those for ligature of the artery ; and besides, the vessel is tied farther from the diseased part. The axillary artery may be tied on account of wounds, either im- mediately upon the infliction of the injury, or some time afterwards. The dissection is difficult, the vein being much in the way, and the vessels surrounded by nerves, and intimately connected with them by dense cellular tissue. The artery is more involved at the middle portion of the axilla than at the superior and inferior ; at that point, too, the cephalic vein, as well as the axillary, impedes the operator. To reach the upper portion of the artery, much muscular sub- stance must be divided. An extensive incision, in the course of the vessel, is made through the integuments. The pectoralis major is got through by separation and division of the fibres, the incision in it being made with as little cross-cutting, as possible. Part of the pectoralis minor, probably the superior half of the muscle, must also be cut. The parts are then exposed, the vein to the inner side of the artery, and the nerves interlaced. The vessel is carefully iso- lated at one point, and there secured. It is almost impracticable to reach the middle portion of the axillary — supposing the vessel to be divided into three equal por- tions— without injurious interference with the nerves. If operating with the view of tying the extremities of the vessels wounded at this point, the probability is that the nerves have been divided along with the artery, and then the proceedings are more simple. The incisions are made in the direction of the bleeding point; this is reached, and each extremity of the vessel securely tied. The lower third of the artery is less involved with the vein and nerves, and can be reached without division of muscular fibres. The arm is abducted and elevated as much as possible. The axilla is thus exposed. A free incision is made in the course of the vessel, which, by cautious dissection, is brought into view; it can then be dealt with as may be required. Spontaneous aneurism is of rare occurrence, lower in the brachial artery than its axillary portion. However, it is sometimes met with at the bend of the arm. But the aneurismal tumour in this situation is more frequently the consequence of wound of the vessel, inflicted whilst opening a superimposed vein. The mode of pro- ceeding in venesection, the precautions to be employed, and the evils that sometimes follow this little operation, will be treated of by-and-by. Wounding of the artery is not so common an accident now as formerly. Venesection is not so universally and unnecessa- rily resorted to as formerly, and is performed by better instructed practitioners. Puncture of the brachial artery, at the bend of the arm, is not 34 398 INJURIES AT THE BEND OF THE ARM. uniformly followed by extravasation of blood, or by the formation of aneurism. That it is wounded is known by the impetuous and saltatory flow of florid blood, accompanied with a wheezing noise. In such circumstances, the thumb is placed firmly over the wound; the fingers separately, the hand and the forearm of the patient are all supported by uniform bandage ; and a graduated compress, sup- plying the place of the thumb, is firmly applied, and must be re- tained for many days. Thus extravasation is effectually prevented. But the measures must be adopted instantly, before the edges of the opening are rounded, and any quantity of blood has escaped into the cellular tissue ; the apparatus must be well applied and retained. When pressure is required on any point, it is absolutely necessary to give support to the lower part of the limb, as was formerly insisted on ; and the proceeding is, if possible, more necessary in this case, the requisite pressure being very great. If ordinary compression only, sufficient to prevent the flow of blood through the opening in the integuments, is applied, blood is extravasated into the cellular tissue, breaking it up, and causing condensation beyond ; fluid blood accumulates in the space thus formed, the surrounding cellu- lar tissue is more and more condensed, at length constituting a firm sac, confining the fluid, and communicating with the opening in the artery ; in fact, a pulsating and gradually increasing aneurism is established. Or a sac is formed, into which blood is propelled from the artery, and which also communicates with the opening in the vein. This state of parts is denominated varicose aneurism ; it is very rare. Or, again, no extravasation takes place, and the artery and vein unite by lymph effused around the openings, the wounds remain- ing unclosed, and forming a permanent communication between the vessels. Thus, a portion of the arterial contents is constantly being injected into the vein, producing a thrilling sensation, but little or no tumour. The passage of the blood, through the narrow aperture, is also accompanied by a peculiar noise, closely resembling that caused by the motion of the fly-wheel in a musical box. The dis- ease is termed aneurismal varix, and is not so rare as the precedino-. For this treatment is seldom requisite. In recent cases of false aneurism, the sac may be cut into, the vessels exposed, and tied above and below the opening. This is recommended from its being found that the tumour is sometimes slow of disappearing after ligature of the vessel at a distance above. But when the tumour is of considerable duration and size, contain- ing coagula, and the surrounding parts are separated and altered in structure, there is no doubt as to the propriety of tying the humeral near its middle — as also, in the case of spontaneous aneurism. The vessel is not deep, but much entangled with nerves and vein's. A free incision is made over its course, dividing the skin, cellular tissue, and fascia ; the sheath is opened, and a ligature passed round the exposed artery. But it must be recollected that high division of the humeral is not uncommon, and, before casting the knots pres- sure should be made on the vessel with the finger against the loop of the ligature, and the effects on the tumour watched ; if pulsation WOUNDS OF THE PALMAR ARCHES. 399 cease, and the tumour become flaccid, the ligature should be se- cured ; but, if no effect is produced on the swelling, high division is demonstrated, and the other branch must be looked for. Pulsa- tion is certain to return in the tumour, after a few days, and if slow in again disappearing, gentle pressure should; be employed — the arm, hand, and fingers being previously bandaged, to prevent infil- tration of the limb. [I had occasion, in 1841, to tie the humeral artery, for a wound inflicted upon it in bleeding at the bend of the arm, in a youth eigh- teen years of age, from one of the border counties of this state. The accident had occurred about six weeks previously with a thumb- lancet. It was soon followed by great swelling and discoloration of the limb, which gradually extended dowTnwards nearly to the middle of the forearm and upwards as far as the axilla. The pain was excessive, the appetite much impaired, the sleep constantly in- terrupted, and the countenance blanched, and expressive of great suffering. About the fourth week a large opening formed at the seat of the original orifice, from which upwards of a quart of thick grumous blood wTas discharged. He was brought to town on the "27th of December, and placed under the care of my friend, Dr. Drane. At this time his health was frightfully deranged ; his strength was much exhausted ; he had not slept for several nights ; and the whole limb, benumbed and excessively painful, was swollen from the wrist to the shoulder. The parts pitted under pressure, two small foul-looking ulcers existed at the bend of the arm, the skin was discoloured, and fluctuation could be distinctly felt all the way up from below the elbow to the insertion of the deltoid muscle. With the assistance of Dr. Drane, an incision, five inches in length, was made over the course of the humeral artery ; and after much difficulty, owing to the confused state of the parts, a ligature was placed above and below the orifice, which was found to be at least six lines long! All the grumous blood, amounting to nearly a quart, was squeezed out, when the edges of the wound were brought together with adhesive strips and a roller extending from the wrist upwards. Very little sloughing took place ; and, notwithstanding the exhausted condition of the patient at the time of the operation, he made a very speedy recovery.] Wounds of the radial and ulnar arteries may require their being exposed and tied at various points and at various periods — shortly after the accident, or after the lapse of many weeks — on the occur- rence of secondary bleedings, or after the formation of false aneurism. This is accomplished by incision in the course of the wounded vessel, sacrificing as few muscular fibres as possible. Nevertheless, the in- cision must always be free, to enable the surgeon to effect his purpose readily. Wounds of the Palmar Arches, and of the branches proceeding from them to the extremities of the metacarpal bones, are exceed- ingly common ; as also wounds of the radial artery betwixt the thumb and forefinger, of the arteria radialis indicis, and of the superficial volar branch. The opening in the integuments and palmar aponeu- 400 PARONYCHIA. rosis is usually narrow, and the hemorrhage copious ; it is generally arrested by pressure, not always well or efficiently applied. * rom these circumstances, blood is extravasated extensively into the deep cellular tissue, blood continuing to escape from the artery, and being either imperfectly discharged, or completely confined. Great swell- ing, with tension and acute tenderness, takes place ; in fact, rapid inflammatory action is kindled in the infiltrated parts, and unhealthy abscesses form; the matter ultimately reaches the surface, but by that time ulceration or partial sloughing has taken place at the wounded part of the vessel; profuse and repeated hemorrhages take •place, and are with difficulty controlled. The patient becomes weak and pale. The greater part of the forearm may become involved in the inflammation, terminating in infiltration of the cellular tissue, and the formation of diffuse abscesses. In the first instance, instead of trusting to pressure, — which al- most uniformly disappoints expectation, does not prevent internal bleeding, and"leads to a severe form of inflammatory action, — it is better at once to enlarge the wound, and tie the wounded vessel above and below the injured point. Thus all bleeding is effectually prevented, and the risk of unfavourable consequences done away with. But after inflammatory swelling has commenced, such a pro- ceeding is difficult, often almost impossible, and generally fruitless. The parts are then full of blood, lymph, serosity, and pus, separated from each other, and changed both in appearance and structure ; the vessel is either not visible on account of the infiltration around, or its coats are so diseased as to be incapable of holding a ligature At any period it is unsafe, and unwarrantable to dive, pretty much at random, with a sharp needle, amongst tendons, nerves, arteries, and veins, writh the hope of so including the wrounded branch. In some cases of secondary bleeding—if no great inflammatory action has taken place, and no abscesses have formed —the wound may be dilated freely, and compression made on the bleeding point by dossils of lint filling the wound completely, and supported by a ban- dage. This dressing, retained for some days, often succeeds per- fectly ; permanent obstruction of the vessel, and consolidation of the parts immediately around, having been accomplished by the effusion and organisation of lymph. When this methdd fails — and when the case is more advanced, with pain, and swelling, and abscess — weakening of the circulation in the part, is found to be effectual. The main artery is to be obstructed at a distance from the wounded part. It is needless to tie the radial or the ulnar, or both ; for still blood will be poured in by the interosseous and its anastomoses. The humeral must be secured in the middle of the arm, as has been practised in many instances, and with uniform success. Thus the bleeding is arrested until the wounded vessel recovers, and becomes permanently closed by salutary effusion ; then the inflammatory action, and its consequences in the surrounding parts, must be tueated on the general principles of surgery. Paronychia or Whitlow, designates inflammatory action and its consequences, in the structures composing the fingers. The mere PARONYCHIA. 401 surface maybe the seat of the inflammation of the cellular tissue, or the fibrous structure between that and the sheath of the tendons ; or the firm and true sheath of the tendons, and the synovial surface ; or the investing membrane of the bone, the bone itself, and the articu- lating surfaces and apparatus may be involved secondarily, or from the first. The inflammatory action may commence in any of these structures, but if uncontrolled, ultimately attacks the greater number, or all of them. The deeper seated the action, the more violent are the symptoms, and the greater the danger to the member. In the cutis vera of the fingers, there is a plentiful distribution of nerves of sensation ; and consequently, in superficial whitlow, the pain is often severe, with throbbing, and an occasional feeling of itching. The part is swelled and red, and the redness is diffused. After a short continuance, the swelling increases at some points, often about the root of the nail, from effused fluid betwixt the cuticle and rete muco- sum ; the fluid is sometimes serous, generally sero-purulent. In the deeper-seated inflammation, the pain, throbbing, heat, and swelling, are all greater. The pain is more intense, and almost intolerable, allowing the patient little or no rest; and the throbbing extends to the vessels of the hand and forearm. A considerable degree of fever attends. The action either involves one phalanx, or extends over the whole finger, and ultimately attacks the hand. The palm is hard, pained, and swelled ; and in advanced cases, swelling takes place above the annular ligament. Often the surface of the back of the hand is also inflamed, and the cellular tissue loaded with serum. The disease, if not actively and properly treated, terminates in a very short time; in two or three days suppuration takes place, with sloughing of the cellular tissue, of the sheaths of the tendons, and of the tendons themselves, Either ulceration or necrosis — often both in combination — occurs in the phalanges ; or the apparatus of one or more of the articulations is destroyed. Ab- scesses also form in the palm, on the back of (the hand and finger, and sometimes under the fascia of the forearm. The separa- tion of portions of one of the tendons is not always followed by loss of motion in the finger; neither is exfoliation of the greater part of the distal phalanx always attended with much deformity or shortening, a nucleus be- ing often left from wdiich bone may be produced. But des- truction of the whole flexor or extensor tendons of one of the middle or proximal phalanges, or destruction of one of the articulations connecting them, is not only attended with great suffering, but followed by total uselessness of the part. The wounds may, after a tedious process, heal up ; but 34* 402 PARONYCHIA. the finger remains deformed and immovable, in a contracted or ex- tended position, as may be. . The disease may be occasioned by bruises or punctures, the in- strument with which the puncture is inflicted being impregnated, or not, with some putrid animal matter. Violent inflammatory action almost uniformly follows opening of the articulations, and also lacerated wounds over the joints. Compound fractures and dislo- cations of the phalanges are certainly followed by a severe form of inflammation. But the disease is met with in all degrees of in- tensity, occurring without any assignable cause. It prevails in spring and autumn; and is common in hard-working people, in butchers, cooks, &c. In superficial whitlow, the bowels must be attended to, and blood may be abstracted locally, either by punctures or by the application of leeches along the side of the finger, hot fomentation being assidu- ously and regularly employed afterwards. Or the nitrate of silver maybe rubbed lightly over the discoloured parts ; frequently the in- flammation maybe arrested, and resolution speedily effected, by this simple application, laxative or purgative medicines being at the same time administered, as required. The collections which form are evacuated by simple division of the cuticle, and this, when hard, should be clipped away ; poultices are used for a short time, and then the raw surface is dressed simply, and the finger bandaged daily. The hand should be kept constantly elevated. The swelling is soon reduced, the cuticle is regenerated, and free motion of the finger returns gradually. In more severe cases, fomentation and copious abstraction of blood by leeching, at a very early stage, may effectually suppress the in- flammatory action ; but patients seldom apply till after the opportu- nity for this treatment has passed. When tension has occurred, whether purulent matter has formed or not, a deep and free longitu- dinal incision must be made, including the affected tissues. This is uniformly followed by great relief, all the violent symptoms subside, and the action is limited ; the effusion, if any, escapes, and the affected blood-vessels are emptied — further suppuration is prevented, and the tissues are perhaps saved from destruction. Fomentation and poultice are used till the swelling begins to disappear and the dis- charge to diminish ; and the hardened cuticle is removed, when detached. The cure is completed by bandaging, and such applica- tions to the wound as its appearance may render suitable. Should inflammation recommence and extend, or abscess threaten in other parts, recourse must again be had to free incision, followed by the treatment already described. Destruction of the articulating apparatus, with ulceration of the opposed surfaces of the bones, is indicated by indolent swelling around, by unhealthy and profuse discharge, by distinct grating being produced on motion, and by marked and unnatural looseness of the joint. In such circumstances, amputation of the finder above the diseased part is fully warranted. But if the patient is obstinate in refusing to submit, or if he is in that rank of life where stiffness of the finger is of no great consequence, the member should he kept ONYCHIA. 403 steady in a convenient position, so as to favour anchylosis. By splints and bandaging it is preserved in a state of semiflexion, so that, after the cure by anchylosis, it may not be in the way when the patient lays hold of any thing, as it would be were it bent into the palm, nor exposed when the other fingers are bent, as must be the case were it kept quite straight. Still the finger is often very useless — worse than useless — when stiff either from loss of the tendons or from destruction of the joint; and more particularly when its position is awkward. So much inconvenience does it give rise to, that patients, who peremptorily refused amputation whilst the case was recent, often return, after a tedious and painful cure by anchylosis, solicit- ing removal of the deformed and annoying member. When the thumb, however, is the seat of disease, it is of great moment to save any part of it. A stiff joint in the thumb is of less consequence than in a finger ; it can still be brought to oppose the rest of the hand in seizing and retaining hold of objects. To promote anchylosis, the affected articulation must be kept at perfect rest, and for a very con- siderable time. By pursuing this practice, the thumb, represented at page 397, though in a very bad state, the joint being thoroughly disorganised, was preserved. In severe cases of whitlow, all the fingers, the whole hand, and even the wrist, long remain rigid ; but the rigidity is gradually dissipated by friction, and by motion, at first gentle and passive. Chronic thickening and contraction of the palmar aponeurosis occurs occasionally, and, in some cases, to such an extent as to dis- able the hand almost entirely. The ringers are permanently bent, the palm is hard, and the integument puckered. The most severe examples which I have witnessed occurred in those who were in the frequent habit of playing keyed or stringed instruments; in others no cause could be assigned. Frictions with all kinds of oils and compound liniments, plasters, ointments, &c, have been tried as remedies for this affection, but in vain. The tendinous slips passing to the contracted fingers have been divided, and the origin of the palmar fascia has been cut across, but without permanent benefit. Indeed I believe the disease to be incurable. The term Onychia is sometimes, and not without good reason, desig- nated maligna: it is applied to ulceration about the nail. Some of such sores are small, and not indisposed to heal; others are very ob- stinate. They occur at all periods of life, frequently during infancy. They usually commence in a small and irritable tumour or granula- tion by the side of the nail, or at its root, with swelling and redness around. This may follow bruises or laceration and removal of the nail, extravasation under it, and the various injuries of the part. The disease is also met with in the toes, most frequently the great one, causing much lameness ; then it is generally owing to the pres- sure of tight shoes. In many cases the ulceration is extensive, shreds of the nail projecting through the angry surface ; there is considerable loss of substance; the discharge is thin, bloody, acrid, and abominably fetid ; the edges of the sore are jagged, and the in- 404 ONYCHIA. teguments around are of either a bright or a dark red, according to the state of the disease. Sometimes the bone is exposed, and in- volved in ulceration ; or, instead of having lost substance, it is found of an unusually spongy and open texture, and with recent os- seous matter superadded. A violent burning pain attends the dis- ease when advanced ; the absorbents are irritated and inflamed, and the glands enlarge along their course. The general health is often impaired in consequence ; frequently the disease occurs in those of broken-up constitution, along with sores and eruptions on other parts of the surface, ulcerations of the mucous membranes, and other indi- cations of cachexia. By judicious exhibition of purgatives, antibilious medicines, and preparations of sarsaparilla, and by regulation of diet, the general health may be improved. The edge of the nail, when in contact with the ulcerated surface, must be removed — more especially when the great toe is affected; not that any undue growth is the cause of the disease, but because the sore, pressing on the sharp edge, pro- duces much pain, and keeps up the morbid action. About one- third in breadth of the nail should be taken away; one blade of strong and sharp-pointed scissors is passed along beneath the nail as far as its root, and by rapid approximation of the other blade the part is divided ; the isolated portion is then laid hold of by dissect- ing forceps, or small flat-mouthed pliers, and pulled away by the root. This should be performed as quickly as possible, for the operation, though trifling, is attended with most acute pain ; it is quite effectual, the relief is great, and almost immediate. The nail may also be removed by scraping and paring • but this method is not so effectual as the preceding, and almost equally painful. After- wards the best application to the ulcerated surface, as to other irri- table sores, is the nitrate of silver, either used solid and followed by poultice, or employed in the form of lotion. The remedy is almost specifac ; very few cases prove obstinate under it. Sometimes it may be of advantage to alternate it with the black wash, I* pro- tracted and unyielding cases, removal of the whole matrix of the n? ffiracrdl^r6^^6 Palnfd and tedi0- «d it. elhcac) doubtful. When the sore is of a weak character dis- charging a glairy secretion, studded with soft flabby granulation connected with unsoundness of the neighbouring celluhr tissue sur^ rounded by undermined integument, °and by Lnsiderabie bog^ COLLECTIONS IN THE THECJE. 405 soft swelling, free application of the caustic potass is highly bene- ficial. When the bone is denuded, and involved in ulceration, the phalanx should be amputated. Unhealthy children are subject to disease of the phalanges, and of the metatarsal and metacarpal bones, excited by slight injury, or originating without apparent cause. Often more than one bone is affected. There is great swelling of the soft parts around the dis- eased bone, indolent, and not painful ; at first hard and white, after- wards more yielding, and of a dark-red hue at one or more points. Imperfect suppuration takes place, the integuments ulcerate, and the cavity of the abscess leads to the exposed bone ; a portion of this generally dies, and is a long time in separat- ing." Great addition of bony matter is deposit- ed around, in irregularly aggregated nodules; and a large shell is so formed, partially investing the sequestrum. This affection may be termed scrofulous necrosis. Or the bone does not die, but is exposed and ulcerated super- ficially ; or a considerable cavity forms in its interior, apparently from tubercular deposits and suppurative degeneration of the can- cellated structure. The secretion from the ulcerated surface is thin, acrid, and often bloody; and new osseous matter is studded around. The surface of the rest of the bone is unusually open in texture, whilst its interior is condensed, and the cancelli are filled with lardy substance. This form may be called scrofulous caries. Abscesses in the soft parts form one after another, several of the bones are often affected at the same time, superficial abscesses and affections of the joints and bones often take place in other parts, and the patient grows weaker and weaker. Whilst the surgeon attends to the general health, and employs palliative local applications, nature frequently effects a cure. The sequestrum ultimately separates, or the ulceration gives way to more healthy action. New bone fills up the cavity, the redundant osseous deposit gradually diminishes, the openings in the integuments close, and the swelling subsides. In some rare cases, it may be necessary to take away the offending part, in consequence of the health alarm- ingly declining. Collections in the Theca of the flexor tendons are occasionally met with. Those of the thumb and forefinger are most frequently af- fected. The swelling often attains considerable size. The fluid is colourless and glairy, mixed with small cartilaginous bodies of a flattened form, and the size of mustard seeds, or split peas. The swelling sometimes extends under the annular ligament, and under the fascia of the forearm. Alternate pressure on the different parts of the swelling is attended by a very peculiar sensation. Motion of the parts is seriously retarded. Accumulation of the fluid is not prevented by any means. Punc- ture has been practised successfully in several instances, in others a 406 AFFECTION OF THE FINGER. good deal of inflammatory action followed. On the escape of the fluid, the motions of the parts are so far regained. Ganglia are collections in the bursae, of various sizes, about the wrist. They are situated more frequently on the fore than on the back part. Sometimes they occur, small, on the sides of the fingers. At first they are attended with pain, afterwards with inconvenience only. The swelling is usually globular ; but when large, as on the back of the wrist, the form is rendered irregular by the pressure of the tendons. The cyst is generally of considerable thickness, the fluid glairy and albuminous. They present an unseemly appearance, and when awkwardly situated, retard the motions of the limb. Fre- quently they form without apparent cause ; sometimes they are attri- buted, and perhaps rightly, to a twist or over-exertion of the wrist, like windgall in hard-wrought horses, who have been put to work when young, and before their full strength has been attained. The affection is most frequently met with in females of the lower ranks; in them the structure of the limbs is more delicate than in males, and they are often obliged to use great exertions with the upper ex- tremities before the growth of the body is completed. Friction is of no use. Continued pressure on the swelling, by coins or small pieces of lead bound down for weeks or months, is very seldom followed by cure. If the tumour is placed over a bone, sud- den and firm compression should be made with the thumb, so as to rupture the cyst, or with the same view it may be struck sharply by an obtuse body. The contents are thus extravasated into the cellular tissue, and are speedily absorbed; the cyst inflames, and becomes obliterated. Sometimes the excitement is insufficient for complete closure of the cyst, and the swelling returns. When the cyst is thick, the tumour of long duration, and the person impatient of pain, it may be punctured by a cataract needle of any kind ; one thin and double- edged is probably the most convenient. The instrument is intro- duced through the skin, at some distance from the swelling ; and, by moving the point of the needle after penetation, the cyst is divided freely. The needle is withdrawn, and the orifice closed by the finger. The contents are then squeezed into the cellular tissue, and this is followed by the same favourable results as in the preceding method. Removal of such tumours by dissection is unnecessary, and also attended with risk. I have removed several large ones by incision ; but the whole cyst can seldom be taken away, and there is great risk of inflammation ensuing, followed by sloughing of the tendons, or by rigidity of the part. From my experience of the unfavourable con- sequences of incision, I should not again adopt such a proceeding. Setons have been passed through the swellings, but I cannot attest either their efficacy or their safety. Exostoses of the phalanges of the fingers are rarely met with. Sometimes bony enlargement occurs, involving many of the pha- langes along with several of the metacarpal bones. In such cases, both hands are often similarly diseased, and other parts of the osse- ous system also affected. When the tumour is limited to one or two SPINA VENTOSA. 407 fingers of one hand, then to get rid of the deformity and inconveni- ence, the patient may desire its removal. The whole of the bone affected should be taken away, lest the disease be reproduced. Spina ventosa, acute or chronic, more frequently the latter, is sometimes met with in the metacarpal bones, or in the phalanges. The same treatment is applicable here, as that already detailed in regard to similar affections of the lower jaw. Amputation above the tumour may sometimes be necessary. The hands of infants are sometimes found deformed, turned in- wards, as the feet are more frequently. Some of the carpal bones are compressed, from the awkward position of the limb, but become properly developed, if the parts are placed in their proper position as soon as the deformity is observed, and kept so. But the displace- ment is unmanageable if long neglected. Congenital deficiency of the fingers is a deformity and inconvenience, but cannot be remedied. Adhesion of one or more of the fingers, even to their points, is met with occasionally as a congenital affection. Separation is readily accomplished ; but the dressing requires to be carefully attended to, Adhesions may result from careless management of extensive abra- sion or ulceration, or from a burn, and such are not so easily reme- diable. Superfluities may be abridged. Some children are born with two thumbs or two little fingers; these have generally only a cutaneous attachment to the rest of the hand, and that is easily di- vided by the knife or scissors. The redundancy should properly be removed by the obstetrical practitioner, as soon as it is observed. The Bursa over the Olecranon Process is liable to enlargement, by gradual accumulation of the secretion, in consequence of habitual pressure on the elbow. The contents are either serous or glairy> usually the latter, and the swelling is indolent. But acute swelling not unfrequently takes place in this situation, from external injury; then the tumour is formed rapidly, there is heat and pain in the part, and the integuments are discoloured around ; in such cases the bursa is filled with pure blood, or with a sero-purulent and bloody fluid. Inflammation of the bursa often follows bruises and lacerated wounds, and is apt to extend to the forearm and arm ; causing extensive and deep effusion, great tension of the parts, and severe constitutional disturbance. In the chronic cases of bursal enlargement, pressure is to be avoided; and by the permanent application of ammoniacal or of a gum and mercurial plaster, absorption of the fluid may in general be procured — the swelling disappearing as gradually as it arose. If the collection is large and obstinate, repeated blistering may be had recourse to; and if that fail, a seton may be passed through the cavity. But the last-mentioned practice is sometimes followed by more action than is desirable, inflammation of the surrounding cellular tissue supervening, and abscesses forming, perhaps extensive. When the collection is purulent, a free open- ing is to be made into the bursa, and the case treated in other respects as a common abscess. If indolent swelling of the cellular tisssue, and spongy thickening of the synovial surface of the bursa, 408 VENESECTION. remain after incision, the application of the caustic potass may be re- quired. In extensive and acute inflammation spreading to the sur- rounding parts, free incisions are often necessary, along with proper constitutional treatment, in order to prevent destruction of the cellular tissue and skin. Venesection, at the bend of the arm, is too often resorted tOjby thoughtless or ill-educated practitioners, to the detriment of the patient; as after accidents before reaction has occurred, in local pains not inflammatory, &c. It is very often had recourse to by those who have no correct ideas of the actions of the animal economy, who have not within their heads a peg to hang an idea upon ; or, if they have, they are too lazy to think and to combine their ideas, so as to come to a proper conclusion regarding what is the most proper and judicious course to be pursued in any one case. They follow a routine, and bleeding is too generally the commencement of it. But venesection is absolutely required in many cases, and must often be the principal dependence of the surgeon for removing or preventing evil consequences. After injuries, when the circulation has been restored, particularly when parts important to life are in- volved — in the first stage of inflammatory attacks, wTith violent con- stitutional disturbance — in inflammatory affection of vital or import- ant organs — in these, bleeding is employed to an extent sufficient to control the action. But even in such circumstances, the practi- tioner must be cautious not to push depletion too far, but to stop short at the proper time, so that the life of the patient may not be endangered, nor his health impaired, more by the treatment than by the disease. Venesection is usually^ practised on either the basilic or the cepha- lic vein, or else on the median basilic or the median cephalic. The vein is made to rise by obstructing the return of the blood by a ligature on the arm, applied not so tight as to prevent the flow in the arterial branches. A vessel re- moved from the inner side of the tendon of the biceps, — that is to say, not over or near the brachial artery, is to be pre- ferred. But sometimes none sufficiently large or distinct can be perceived unless in that situation, and then great caution is necessary in making the puncture; the patient's arm must be held very steady, and care taken that the instrument does not transfix the vein. The branch chosen should also be fixed ; one which rolls under the finger is pierced with difficulty. The vessel is secured by the thumb of one hand placed immedi- ately below the point to be punctured, whilst the lancet is held loosely betwixt the thumb and forefinger of the other; • , c • , , a?CJ the surSeon should by practice ac- quire the use of either hand for this and other minor operations, beim* VENESECTION. 409 thereby saved much trouble and awkwardness. The right hand is used for the right arm of the patient, the left for the left. The lancet should be in very good order, not too spear-pointed, fine, and with a keen edge. The blade, placed at right angles with the handle, and held lightly, as above mentioned, is entered perpendicularly to the vessel. The puncture is made deep enough to penetrate the vein, and then the edge is carried forward more than the point, that the opening in the integuments may be more free than that in the vein. The most convenient line of incision is obliquely across. The pres- sure of the thumb is relaxed whenever a utensil is conveniently placed for the reception of the blood ; and the arm is kept in the same position as during incisions, that the openings in the integument and vein may correspond. Unless this be attended to, the skin will overlap the puncture in the vessel, and thus the stream wTill be com- pletely obstructed, or at least the blood will not come away so smartly as at first. The blood may also cease to flow quickly from over-tight- ness of the ligature, and from threatening of syncope ; in the former case the ligature is adjusted, in the latter the patient is placed in the recumbent position. When the superficial veins are emptied, the blood flowing by those deep-seated is to be directed to the wound by muscular action : with this view the patient is made to grasp the lancet-case, or any other solid body in his hand, and turn it round. If the opening in the integument is too small, the flow gradually di- minishes, and at length stops, in consequence of blood being insinu- ated into the cellular tissue, coagulating, and so forming what is termed a thrombus, which plugs the wound. When a sufficient quantity has been obtained, the ligature on the arm is removed, and pressure made below the wound. The integuments around are washed and dried ; and two or three small compresses of lint placed on the opening, one above the other, are retained by a riband or narrow bandage applied in the form of the fig. 8 ; the bandage should be so tight as to prevent the escape of blood, without arresting the flow towards the heart. The arm should be dis- used for a few hours, and after twenty-four or thirty-six hours the ban- dage may be removed, when the opening will usually be found closed. Besides puncture of the humoral artery, or of its branches, other unpleasant circumstances may follow this little operation. The thrombus — a small bloody tumour from infiltration into the cellular tissue around the opening in the vein — proves troublesome, as al- ready remarked, by preventing the flow, and may render a fresh opening necessary, either in the same arm or in the other. After- wards it generally disappears gradually by absorption ; or the open- ing in the integuments may not close, and the coagulum be separat- ed and discharged after some days. Inflammation and abscess round the opening sometimes super- venes. It is treated by fomentation, poultice, and rest, and the matter must be evacuated by free incision. Inflammation of the surface, with diffuse infiltration into the cellular tissue, is also met with after venesection ; the treatment of such an affection is the same as when it occurs in other situations and circumstances. The symptoms and consequences of inflammation of the vein have 35 410 AFFECTIONS OF THE MAMMA. been already detailed. The affection is attended with great pain, and with swelling from effusion into the cellular tissue around the course of the vessel ; the integuments are inflamed and tense ; sero- purulent secretion soon takes place in the infiltrated cellular tissue, both deep and subcutaneous, followed by sloughing, and separation of the skin from its subjacent connexions ; even death of the muscu- lar structure sometimes ensues — the pectoral muscles have been found black and soft. The local treatment must be active. Inci- sions are made early into intense parts to prevent internal mischief; and if the vein in the neighbourhood of the wmind be filled with pus, it should be laid open freely. The evacuation of the matter affords great relief; afterwards bread poultices or water-dressings are to be applied to the wonnds, the other parts should be assidu- ously fomented, and attention given to the position of the limb. The bowels are to be attended to, and the secretions promoted by mercurials wTith stimulants, as camphor with calomel, or the hydrar- gyrum cum creta. When the tongue gets moist at the edges, tonics and stimulants of a more permanent and powerful action are neces- sary. I have not witnessed any bad effects of venesection attributable to puncture of the tendon or fascia, or to partial division of twigs of the cutaneous nerves. In spasmodic or painful affections arising from the latter cause, slight extension of the incision is recommend- ed, so as to divide entirely the injured branch. Inflammatory tumour of the Mamma occurs generally during lac- tation ; and is attributable to injury, perhaps slight, during the then excited state of the secreting vessels—to sudden exposure to cold — to interruption to the flow of the secretion. It occurs, however, independently of this state— sometimes at the age of puberty, dur- ing the development of the gland—or at other periods of life, either spontaneously, or in consequence of external violence. The last class of cases are usually more severe than those first alluded to ; some are more indolent than others; almost all are preceded by shivering. There is swelling of the part, a sensation of weight in it, and dull pain ; then throbbing heat, and increase of suffering. The surface is inflamed, and the nipple concealed by the tumes- cence. The milk cannot be withdrawn. Fever attends, more or less violent. Such tumours seldom if ever subside or are resolved ; suppuration takes place, and the matter generally comes to the sur- face at more than one point. This abscess originates in the sub- stance of the gland ; but collections occasionally form in the cellular tissue beneath the mamma, either spontaneously, as in bad constitu- tions, or in consequence of injury. In either case, and particularly in the latter, the swelling is great, and the suppuration extensive ; troublesome and tedious sinuses remain unless early and free open- ings are made. Leeching is of little use in mammary swelling during lactation ; cold and evaporating lotions seem to do harm by producing deter- mination from the surface to the deeper parts. The gland is to be kept as free from secretion as possible, and supported by a handker- AFFECTIONS OF THE MAMMA. 411 chief tied round the neck ; moderate diet should be enjoined, and laxatives given occasionally. Fomentations are beneficial at first, but are superseded by poultice when matter appears to have formed and to be making its way to the surface. Two or more openings are generally necessary, to afford free outlet to the matter ; indeed, an incision is indicated wherever the integuments are elevated, thin, and shining. Afterwards poulticing is continued for some days, and succeeded by other suitable applications. The discharge seldom ceases, so long as the secretion of milk is encouraged. Adolescent males are sometimes affected by troublesome fulness and uneasiness of the mammillae. Little or no treatment is required, the inconvenience subsiding gradually and spontaneously. Indolent enlargements of the mammary gland occur, though rarely. They sometimes attain an immense size ; and are often attributable to the menstrual discharge having been inopportunely arrested. Such tumours have, from their great bulk, required extir- pation. Sarcomatous tumours of various kinds are met with, either in the cellular tissue under the mamma, or in the substance of the gland — tumours not of the gland, though in it. Such are generally traced to injury, as to a bruise by falling against the corner of a table or chair, an accidental push from the elbow of another, &c. Simple sarcoma is the most frequent formation ; but I have encountered tu- mours, thus situated, of a worse nature — reproduced, though freely and fully removed ; in fact, taken away along with the gland and neighbouring adipose substance. The gland itself is most frequently affected by carcinoma. Some- times it is attacked by, or involved in, medullary sarcoma; and bloody tumours are also met with. In some cases, the gland is en- larged and softened, and penetrated by cysts of greater or less size, and more or less numerous, containing a fluid either serous, albumi- nous, bloody, or thin and black. The appearance and progress of carcinomatous and other tumours have been already described. The mamma is more frequently the seat of malignant disease than any other gland ; it is frequently ex- cited, and much exposed to injury. Often the induration following abscess remains stationary for several years, and at length takes on a new action, forms morbid deposit, and is of rapid growth. The disease seldom occurs in young subjects ; though I have met with several well-marked cases under thirty. Before that time of life, the tumour is o-enerally of a strumous nature, and this should not be confoundecf with the malignant; for the one is remediable under the influence of constitutional means, the other is not. Malignant dis- ease is in most cases developed about the period when the menstrual discharge ceases; when the discharge is irregular previously to its entire cessation, the mamma is excited, and then hardness is percep- tible. The disease also forms, though seldom, long after the " criti- cal period," but in such cases its progress is usually slow. It oc- curs also, and not unfrequently, in those who have never had the mamma excited by lactation ; the mammilla is also subject to malig- nant disease in males advanced in life. 412 AFFECTIONS OF THE MAMMA. When the malignant nature of the disease is recognised, the tu- mour should be extirpated without delay, before it has made much progress — before it has contracted extensive adhesions, or contami- nated the lymphatics. The circumstances rendering interference un- advisable have been fully spoken of when treating of tumours gene- rally. If the patient is a female; the period of the menstrual dis- charge, if still regular, must be attended to, and avoided ; indeed this maxim should apply to every operation on the female. The most favourable time for operating is some days after the cessation. The position of the patient should be sitting, unless the dissection is expected to be tedious ; but it ought not to be so, — the extirpa- tion of glands, or the detachment of the tumour from parts to which it may have contracted firm adhesions, can alone cause delay ; and when these circumstances exist, interference is not allowable. Any warrantable operation on the mamma can be completed in a very few minutes. Two elliptical incisions are made from the border of the pectoral muscle, in the direction of the fibres, embracing the nipple and any portion of the integument which may be adherent or altered. The surgeon need never hesitate to sacrifice the nipple, for in this disease it can be of no further use ; besides the malig- nant action is apt to return in it when saved, it being almost al- ways adherent to the tumour ; it must be removed. The incisions are made quickly with either a scalpel, or a sharp-pointed and broad bistoury ; the lower should be the first, that the flow of blood may not interfere with it and obscure its course. This is carried at once through the skin and subjacent adipose tissue, and then the upper is made rapidly, to get over the most painful part of the operation as soon as possible. The dissection is next proceeded in, from the axillary region forwards, and the tumour detached first on one side, and then on the other. A few strokes of the knife will separate the remaining cellular attachments to the fascia of the muscle, or of the fascia to the muscle. The surface of the wound and of the extir- pated mass should be carefully examined, so that no part may re- main whose structure is altered. The vessels are tied ; and after oozing has ceased, if sufficient integument have been saved, the edges of the wound are put together and retained. The patient is placed in bed, with the head raised and the arm slung. Operation is scarcely justifiable when it is evident that the absorb- ents are affected. Yet a small glandular tumour on the border of the axilla, without any enlargement more deeply seated, maybe removed along with the mamma. With this view, the incision should be made so as to include the tumour, and detach it previously to the mamma being interfered with. But when swelling has taken place deep in the axilla, it is impossible to ascertain its exact extent, and it may be considered very certain that a chain of altered and en- larged glands lie along the course of the axillary vessels The whole of such a tumour cannot be taken away, and, in removing even the more prominent and accessible parts of it, there is a great risk of wounding the axillary vein. This blunder, I have seen committed more than once, and I have also seen the vein the artery and the majority of the nerves, all included in one ligature in order AFFECTIONS OF THE MAMMA. 413 to stop the bleeding. I need scarcely add that the patients soon perished. When enlarged glands are perceptible above the cla- vicle, or in the intercostal spaces, the practitioner who would advise interference with the original tumour must be grossly ignorant, or very unprincipled. After removal of the mamma for carcinoma, in favourable circum- stances, some patients remain healthy. Those practitioners who do not recognise the malignant disease, and operate for every tumour, and at all ages, have boasted of great success. But it is not so with those of mature experience. The disposition to malignant action often remains latent for many months, sometimes for many years, and at length becomes fully developed. The disease may return in the skin ; the cicatrix hardens, ulceration occurs, and makes pro- gress. Or tubercles form in the cellular tissue, enlarge, and involve the skin. Or the glands become tender and swell; and the swelling is often unattended with uneasiness, ffidema of the hand and fore- arm, to a great extent, may have existed for a considerable time, and on examination extensive glandular tumours are detected in the axilla and above the clavicle. These, perhaps, ulcerate ; or cough and hectic cut off the patient. In short permanent riddance from mammary carcinoma.is scarcely to be expected by operation, or any other means. Neither are operations for medullary and bloody tumours of the mamma more successful in their results ; though I have certainly witnessed permanent cures under unpromising circumstances, — when the tumours were large, of long duration, and even ulcerated. [Encysted tumours of the breast containing milk are sometimes met with. They are commonly produced by closure of one or more lactiferous ducts, either from the effusion of lymph, or some other accidental formation, or from external pressure. The swelling, which generally arises during the early months of lactation, may be globu- lar, ovoidal, Or pyriform, and rarely exceeds the size of an orange. It is almost always attended with a peculiar sense of distention, and distinctly fluctuates under the finger. On cutting into it the contents are found to be of a whitish colour, and of the consistence of milk, cream, or whey ; the quantity ranging from a few drachms to several ounces. A most singular and instructive case of this disease is reported by my distinguished friend, Professor Parker, in the New York Medical Gazette, for January, 1842. The woman, who was thirty years of age, was the mother of five children, the youngest nine months old, and had always enjoyed good health. The swelling occupied the right breast, and was first noticed about three months after her confinement: it was free from pain, and without tenderness on pres- sure. The skin was a little more vascular than in the sound state, the veins were enlarged, and there was evident fluctuation. The child had nursed from both breasts.. With a trocar, not less than three quarts of milk were drawn off at one operation! Professor Parker requested the woman to wean her child, and to return to his clinique in a week. At the expiration of this period the fluid had re- accuinulated to the amount of three pints. In a fortnight thereafter 35* 414 AFFECTIONS OF THE MAMMA. it was evacuated a third time, but in what quantity is not stated. Since then, as the professor has recently informed me, he has not heard from his patient; and it is, therefore, uncertain how much, if any, she has been benefited by the operations in the way of a per- manent cure. , Small swellings of this kind rarely require any treatment beyond the application of some stimulating embrocation, to promote the ab- sorption of the effused fluid. When the accumulation, however, is very large, as in the case above mentioned, it will be necessary not only to evacuate the milk, but to obliterate, if possible, the sac. This may be done, I conceive, either by stimulating injections, such, for example, as are used for the radical cure of hydrocele, by the introduction of the seton, or by laying open the tumour, and wear- ing a tent. In the former case, which, on the whole, I should prefer, assistance might be derived from methodical compression. Dimi- nishing the quantity of milk by weaning the child would be an im- portant preliminary step.] AFFECTIONS OF THE CHEST. Inflammation of the pectoral serous tissue would come to be con- sidered more properly in a work exclusively on the practice of physic ; but the affection not unfrequently occurs in consequence of wounds or other external injuries, and its terminations must be shortly noticed. Effusion of serum may take place into the cavities, attended with subsidence of the symptoms of pleuritis. In such circumstances, the lung collapses, either entirely, or still admits a small quantity of air ; and, if the collection lodge for a considerable time, that side of the chest enlarges. When the cavity is not quite full, the fluid is heard to be troubled, and on motion of the trunk a sound of splashing is perceived. Part of the cavity mayr be occupied with air which has escaped from an opening in the lung ; or halitus may be extricated from the accumulated secretion. There are other signs, sufficiently, distinct, imparting a knowdedge of such effusion. The previous his- tory of the case leads to a shrewd suspicion. The chest is unna- turally immovable, as well as enlarged ; the intercostal spaces are widened, and ultimately protuberant; there is dulness on percussion, and no respiratory murmur perceptible in those parts where there is fluid ; the sounds are natural in that part of the lung which is per- meable to air, and distended. Suppuration often is the result of the incited action ; and purulent matter forms in the cavity of the pleura, generally without breach of surface. The membrane is covered with lymph, more or less ex- tensively organised. Empyema is established ; suppuration may take place in the substance of the lungs, and from ulceration the matter may escape, in small quantity at a time, into the bronchial tubes, giving relief to the patient; or it may be poured in profusely and suddenly, so as to cause instant suffocation ; or it may work its way into the cavity of the pleura, and occupy the same place as if it had been secreted by that membrane. Or, again, if the lung adhere to AFFECTIONS OF THE CHEST. 415 the costal pleura, the matter may approach the surface of the body, by the aid of interstitial absorption of the intervening parts, and the collection may then be opened, like a common superficial abscess, by division of the integuments only. When the pleura is full, the chest enlarges, the integuments be- come cedematous; and if, from the preceding and collateral circum- stances, no doubt exist of the presence of matter, paracentesis may be performed with a chance of relieving and saving the patient. The patient is placed horizontally, with the shoulders slightly ele- vated ; and the affected side should be as dependent as possible, that he may be readily turned over on his face should the breathing become embarrassed. The position of the diaphragm, in regard to the inner surface of the false and lowrer true ribs, must be kept in view. When the distention is great, this important muscle is dis- placed ; it is pushed downwards, carrying before it the viscera in the upper part of the abdomen ; it is thus removed far from the place at which the incision is usually made. The point of election, as it is called, is between the fifth and sixth ribs, and midway between the sternum and the spine. An incision is made through the integu- ments, over the upper edge of the sixth rib, an inch and a half in extent; in this situation there is no risk of wounding the intercostal artery. If the operator intend to shut the cavity as soon as the fluid has been discharged, the integuments are drawn upwards previously to making the incision, in order that they may afterwards overlap the wound. A cautious opening is then made through the intercostal muscles, and the pleura punctured. This is immediately followed by forcible ejection of fluid. The wround of the pleura is then enlarged by a probe-pointed knife. The thrust of a trocar, or sharp-pointed bistoury, is here inadmissible, as in some cases the diaphragm, perhaps the liver or stomach, or even the lung, might be wounded. The fluid at first escapes rapidly ; afterwards it is ejected chiefly during expiration. After its discharge, a tent is placed in the wound, over which a compress is put, and the chest is firmly bandaged. The closure cannot be maintained safely longer than twenty-four hours; the dressing must be undone, the tent removed, and the matter again allowed to flow. I would certainly not recommend any attempt to heal the wound by the first intention. In consequence of continued closure, the secretion soon becomes very profuse, mixed with blood, and of a putrid nature ; irritative fever is established. The treatment principally consists in obtaining gradual, and at the same time free, evacuation of the fluid, restraining the motions of the chest, and supporting the general strength. As the discharge ceases, the lung may in part expand ; it may, however, continue collapsed, become consolidated, and the chest fall in. In neglected cases, absorption of the intercostal substance takes placs ; the integu- ments bulge outwards, and distinct fluctuation is perceived. The skin has been allowed to become thin, and even to give way, without the nature of the case being known; but this can be the result only of ignorance or of inattention. In such cases the ribs have been denuded, and become necrosed to a large extent, — the sequestra separating slowly and in fragments, and causing long-continued and 416 AFFECTIONS OF THE ABDOMEN. wasting discharge. It is plain, therefore, that pointing of matter should never be waited for. Chronic collections are occasionally met with of some years' duration, and producing great enlargement of the chest. Surgical interference with such is less likely to prove beneficial than with the acute. Wounds of the large blood-vessels of the chest, or of the cavities of the heart, are almost immediately fatal. Mere punctures, how- ever, of these parts, have closed for a time, and in some cases even permanently. All wounds of the chest, though not involving blood- vessels of a large size, are productive of severe consequences — effusion of blood or bloody fluids into the cavities, escape of air into the external cellular tissue, collapse of the lung, and inflamma- tion and its results, are always to be dreaded. The danger is not uniformly tantamount to the extent of injury inflicted. Individuals have recovered from extensive wounds causing profuse hemorrhage, and great displacement and laceration of the parts ; whilst, from much slighter injuries, untowrard and fatal consequences have quickly resulted. Wounds may penetrate the chest, and be continued into the abdomen ; the stomach, liver, and intestines — one or all —may be perforated as wrell as the lung ; in such cases the hemorrhage is in general speedily fatal. Injury of the intercostal arteries, and of the mammary and its branches, is attended with serious bleeding. It is easily arrested, however, by pressure. A piece of fine linen is pushed into the wound, followed by charpie, so as to form a small bag within the chest, a little larger than the opening ; by pulling this gently outwards and fixing it, efficient pressure is made on the bleeding vessel. At the same time the motions of the chest are to be restrained by bandaging ; indeed this is necessary in almost all injuries of that part. When reaction has been established, antiphlo- gistic treatment must be pursued, and it generally requires to be extremely active. Bloody, serous, or purulent fluids, lodging in the cavity of the pleura, are to be evacuated, if need be, either by in- cision or by enlargement of the original wound. In the course of the cure hectic usually supervenes to a greater or less degree, and requires the reverse of the previous treatment. AFFECTIONS OF THE ABDOMEN. Inflammation of the peritoneum, when idiopathic, is generally treated by the physician. But it occurs in consequence of wound, obstruction from hernia, or affection of the lower bowels. There is a burning heat in the belly ; the pain is constant and increasing, much aggravated by the slightest pressure or exertion of the abdo- minal muscles, and the patient, in consequence, lies with these mus- cles in a state of relaxation. The pain is of a very different cha- racter from that arising from spasm, induced by the irritating nature of the intestinal contents, which supervenes in paroxysms, and is relieved by pressure or by evacuation. In inflammation the coun- tenance is very anxious, and generally pale ; the extremities are cold and bathed in perspiration; the patient vomits frequently ; and OF HERNIA. 417 the bowels are generally constipated. The pulse is small, wiry, and rapid. Hernia has been classed with tumours. It is a swelling, but of a peculiar kind, and attended in some states by peculiar symptoms. The term rupture is in common use instead of hernia, but was at first applied from a false notion of the disease. There is a descent of viscera, but not often rupture of the parietes. By hernia is meant protrusion or escape of the contents of any cavity, but the term is most frequently applied in regard to the abdomen. The protrusion may occur at various parts of the abdomen ; through the diaphragm, constituting Phrenic Hernia ; through the umbilicus, constituting Exomphalos ; through the dilated apertutes for transmission of ves- sels, constituting Ventral Hernia ; through the inguinal canal, con- stituting Inguinal Hernia; through the crural aperture, constituting Crural or Femoral Hernia. The most frequent forms are the inguinal and crural, — the effects of pressure or action of the muscles on the abdominal contents being concentrated towards the lower part of the cavity. It is but rarely that the bowels protrude through the sacroischiatic notch, or through the obturator foramen, or by the side of the vagina, or betwixt the bladder and rectum. It is of great importance for the student to study attentively and reflect on both the healthy and morbid anatomy of this disease. When a hernia is strangulated, there is an absolute necessity for early interference ; the bowels are obstructed, and their action inverted ; feculent vomiting ensues, and enteritis is threatened, with all its dan- gerous consequences. He may meet with the affection at a very early period of his practice, and may be so situated as to command no assistance or advice ; he must be guided by his own judgment, and knowledge. He should be well aware of the relations of the parts to each other, and the changes likely to have been occasioned by the disease. If through delay, the patient loose his life, or if an operation be attempted, and its object improperly accomplished, or not accom- plished at all, his reputation may be blasted. But if he interferes skilfully, and at the proper time, and save his patient, relieving him at once from all his painful and dreadful symptoms, great credit and professional fame may be in consequence acquired. An examination of the healthy anatomy is not sufficient; many changes take place, which mere anatomical and physiological knowledge could never anticipate. Extraordinary displacements and adhesions occur. The parts are altogether changed; and repeated examination of the mor- bid state alone can impart the requisite knowledge to one previously well acquainted with the healthy structure. In consequence of laceration or separation of fibres, hernia may occur suddenly, and even in the best formed parts, from very violent exertion — as in leaping, wrestling, pulling, lifting heavy weights ; from sudden exertion of the abdominal muscles in any way ; from blows, &c. Or the protrusion may come on gradually after slight exertions, where the tendons are naturally weak or deficient; or it may be slowly induced by repeated and almost constant muscular action, as in urinary, intestinal, and pulmonary complaints ; in such 418 OF HERNIA. cases, slight pain is usually felt at the site of the protrusion before the tumour is perceived. The disease is often congenital. But the com- mon cause of abdominal hernia is powerful action of the abdominal muscles, compressing the viscera to a greater or less degree, and with more or less suddenness ; the viscera resisting the compressing force, react on the parieties, and these, yielding at the points which are naturally weak or deficient, permit enlargement of the coerced cavity by protrusion of part of the contents. When the compression and reaction are sudden and violent, the protrusion is the same ; but when the former are not sufficient to overcome the cohesion of the parieties by a single occurrence, by repetition the morbid end is gra- dually effected, the hernia is proportionally slow in making its ap- pearance, and gradual in its increase. To understand the nature of congenital scrotal hernia, the student must recollect that the testicle in the foetus is lodged in the cavity of the abdomen immediately below the kidneys, and resting on the psoas muscle ; that it gradually descends into a process of perito- neum, called spermatic, wdiich extends from the general peritoneal cavity down towards the scrotum, and which ultimately constitutes the tunica vaginalis. The orifice of this peritoneal pouch not closing immediately after the descent, may permit a fold of intestine to slip into its cavity, and remain in contact with the testicle. Or the testi- cle may, though rarely, contract in the abdomen an adhesion to a portion of the bowel, and in its descent bring this along with it. In either case the bowel remains in its new situation, and constitutes con- genital hernia. Hernia infantilis differs from the hernia congenita, and is a kind of protrusion peculiar to the early period of infancy. In the con- genital form the protruded intestine is in immediate contact with the testicle, and surrounded by the-tunica vaginalis testis; but in hernia infantilis a process of peritoneum is interposed betwixt the intestine and the vaginal coat. The affection occurs after the ab- dominal aperture of the spermatic process has closed, but before the rest of that process has become incorporated with the spermatic ves- sels and the surrounding cellular tissue. In fact, only the perito- neum proper has closed, and forms the septum between the cavities of the abdomen and of the tunica vaginalis ; but being insufficient to withstand the impulse of the abdominal contents, yields before it, and descending along with the protruding portion of bowel, forms its envelope, or the proper hernial sac, within the cavity of the tunica vaginalis. Such is the opinion generally adopted in regard to the nature of hernia infantilis ; but its accuracy is doubtful. It seems more pro- bable that the bowel, covered by a fold of peritoneum, is protruded into the cellular tissue of the spermatic chord, after closure and con- traction of the spermatic process, and descending till it reach the upper and posterior part of the tunica vaginalis, adheres to this tunic, bulges it forward, and is covered by it. On cutting down in such a case, the hernial tumour may appear to be lodged within the tunica vaginalis ; whereas the bowel is actually placed exterior to the tunic and behind it. Indeed, the case is similar to the common scrotal OF HERNIA. 419 hernia, only the tumour is behind, not anterior to the vaginal coat. And this relation of parts is more apt to occur in the infant than in the adult; for in the former the testicle does not for some time descend fully into the scrotum, and whilst it is lodged in the groin a fold of peritoneum protruded into the spermatic chord may soon contract adhesion with the tunica vaginalis, afterwards descending along with it and the testicle. The subjoined case illustrative of the preceding statement, came under my observation in 1814.— J. S., aet. 21, was admitted into the Royal Infirmary, with symptoms of strangulation which had been of eight days duration. The hernia had existed from infancy; it was on the right side, and tolerably large. In the operation, on dividing the integuments and various coverings, a sac was opened, which proved to be the tunica vagi- nalis, containing the testicle, a considerable quantity of serum, and a large, smooth, transparent tumour above the testicle and behind the posterior layer of the tunica vaginalis. The operator was puzzled, but finally determined on cutting into this tumour ; it proved to be the hernial sac, covered by the tunica vaginalis, containing three or four ounces of serum and a portion of omentum. The protrusion could not be returned ; after relieving the stricture, the ^ omentum was cut away, and the bleeding vessels tied separately. The patient died on the third day after. An analogous case is on record ; and a third has been related to me by an old and experienced surgeon ; in that instance, both the anterior and posterior }ayer of the tunica vagi- nalis, together with the true sac, were simultaneously divided ; omentum and intestine protruded into the vaginal coat, and for a time the opening through the posterior part of that cavity and sac was mistaken for the inguinal ring. On extension of the incision, the nature of the case became more apparent, the stricture was re- lieved, and the protrusion reduced. A case, in many respects similar to those above described, occurred a few years ago in my practice at the North London Hospital. It is recorded in the Lancet and in the Practical Surgery. Children are sometimes born with deficiency of the umbilicus, and protrusion of bowel into the loose cellular tissue of the umbilical chord ; the disease is termed congenital exomphalos. Almost all the viscera of the abdomen and pelvis are liable to pro- trusion — the stomach —the spleen — the omentum — the great and small intestines, and even some of their most fixed parts —the ovana — the bladder. Also right portions of the viscera occasionally es- cape on the left side of the parieties, and the left at the right. Hernial protrusion has received different names, according to the nature of its contents. When composed of a portion of intestine, it is termed Enterocele ; Epiplocele, when composed of omentum ; and Entero-epiplocele, when both intestine and omentum have es- caped ; and as already observed, different names are also applied, ac- cording to the situation of the protrusion. The inguinal and crural forms of hernia being the most common, will chiefly occupy our attention. The inguinal is divided into true or oblique inguinal, and into direct or ventro-inguinal. In the oblique, the protrusion passes along the inguinal canal. This course 420 OF HERNIA. is in young persons short; but as the muscles become developed it is lengthened to about two inches, reckoning from the external ring to the funnel-like opening through the transverse fascia. The appear- ance of the swelling in this canal leads to diagnosis betwixt the oblique and direct hernia ; but in chronic cases this distinction is often in a great measure done away with. In large and old oblique ruptures the neck of the tumour is shortened, and the openings of the canal are approximated and more in a direct line. They are also immensely dilated, being often enlarged to such an extent as to ad- mit all the fingers of the hand, when placed in a conical form,— and this even in the living body, the loose integument receding along with the tumour. The epigastric artery is situated behind the neck of the sac, on its inner side ; and it is much displaced inwards in cases of old standing. The direct hernia passes through the parieties opposite to the external ring, and does not come in contact with the spermatic chord until it has reached that point. Its neck is short, and the epigastric artery is on its outer side. The coverings of the two tumours are different. Those of the oblique are such as the chord possesses — a prolongation of the transverse fascia, a covering from the cremaster muscle, fibres from the edge of the external ring, and the superficial fascia of the abdomen. The direct has only the last. A very old woman was operated upon in the North London Hospital a few days ago, for strangulated hernia of several days standing. The tumour was high in the inguinal region; on cut- ting down upon it, the tendon of the external oblique was found to cover it completely. The external ring was occupied by a mass of fatty matter, which probably had been displaced. The tendon was divided, and the sac of considerable size, exposed. The opening through which the protrusion had taken place was very small, and situated a good deal to the mesial line of the internal aperture of the canal. The hernia was at the time of operation supposed to be ven- tro-inguinal. The patient was relieved for a time, but eventually sunk exhausted. An opportunity was thus unfortunately afforded of verifying the opinion formed. The hernia had two proper coverings, the superficial abdominal fascia and the tendon of the external oblique. The opening was inside the epigastric. The portion of bowel which had been extruded and returned was very tender, but it had adhered to the peritoneum, close to the place where it had been confined. The oblique inguinal, when recent and small, is termed Bubono- cele; but when large it generally descends into the scrotum — oscheocele —of course exterior to the tunica vaginalis; and in females in the labium. The tumour often attains an immense size, from continued application of the causes that produced it, —labo- rious occupations, or straining of muscles in any way. When of long duration, and not attended to, it is not uncommon for the swelling to hang as low as the middle of the thigh, or even down to the knee! In such cases, the testicles often are wasted, and the penis concealed ; indeed the skin of the penis, as well as of the lower part of the ab- domen, is stretched over the tumour. Crural or femoral hernia is, on the contrary, seldom larger than a small apple. Sometimes, but OF HERNIA. 421 very rarely, the tumour is of large dimensions. I have seen one containing the transverse arch of the colon, the omentum, and a yard and a half of small intestine. The tumour is represented some pages further on. When a very large hernia remains always full, the cavity of the abdomen diminishes in size : in fact, it adapts itself to its contents ; and this must be kept in mind when interfering with such cases. Inguinal hernia most frequently occurs in males, the femoral in fe- males ; and the reason of this is obvious on comparing the size of the inguinal and crural openings in the sexes. In the male, the inguinal opening is much larger than the femoral; in the female, the femoral is the larger,—the inguinal is small, containing only the round ligament of the uterus. The causes of hernia act equally on both openings, and therefore it is to be expected that protrusion will take place where there is the least resistance, where the parieties are most deficient. Hernia can seldom be mistaken for any other swelling, by one at all acquainted with his profession, and who makes his examination attentively. The history, and the mode of its appearance, are to be attended to. The swelling proceeds from above — at times it recedes on the patient lying on his back and making pressure on the swelling — a distinct impulse is communicated to it on exertion of the abdo- minal muscles, as in coughing — the tumour is generally elastic, and its neck can be felt extending from the lower abdominal aperture. Also, the two kinds, inguinal and crural, can scarcely be confounded with each other ; the former is above, the latter below, the ligament of Poupart. It will be proper, however, to enumerate shortly the diseases for which hernia may be mistaken. Cirsocele may be confounded with inguinal hernia. Cirsocele, being a varix of the spermatic veins, enlarges on coughing and during the erect posture, like hernia ; but in genera] the composition of the tumour can be ascertained by the feel which it imparts when handled, — the veins feel like a handful of earth-worms. Besides, the swelling is made to disappear, on emptying the dilated veins by pressure up- wards ; and, if the surgeon then firmly compress the inguinal aper- ture, the tumour will rapidly reappear, on account of the venous flow being interrupted, particularly if the patient exert his abdominal mus- cles, or assume the erect posture. Whereas, had hernia existed, the swelling could not have been reproduced ; and, on the patient being directed to cough, a distinct impulse would have been felt with the finger. Hydrocele of the tunica vaginalis may be confounded with scrotal hernia, if its distinctive characters be not understood or at- tended to. The pyramidal swelling presents an equal surface, fluc- tuates, and is generally diaphanous ; its formation is gradual, com- mencing at the lower part, and slowly ascending ; the testicle cannot be readily felt at the bottom of the scrotum ; there is no swelling at the inguinal canal, and the cord is felt free ; the tumour is not affected by the position, motions, or exertions of the patient. These circum- stances plainly indicate the nature of the case. Bubo, sarcocele, and acute swelling of the testicle, are sufficiently distinguished from hernia by their situation, form, feel, and history, and cannot be con- 36 422 OF HERNIA. founded with it save by the profoundly ignorant. Hydrocele of the spermatic chord is more likely to lead to deception when large ; but it is generally small and circumscribed, involving the middle of the chord, leaving the inguinal aperture free, and the upper part of the spermatic chord distinct. Besides, whatever may be its size, its for- mation is always slow and indolent, — it is never capable of being pushed into the abdomen, and it is unaffected by those circumstances which contribute to mark hernia. But hydrocele of the chord and hernia may coexist, as in the following instance : — A gentleman had swelling in the course of the spermatic chord for many years, while in a warm climate. Bandages were applied, and great pain thereby occasioned. After his return to this country, pain in the belly and vomiting seized him on a Monday morning, and continued with more or less violence till the Sunday following. Then the vomiting became feculent, the belly excruciatingly painful and tender, the tumour tense, and the pulse weak. A physician opposed operative measures, having been convinced that his former complaint was a hydrocele of the chord. But I conceived that the symptoms warranted cutting down on the parts, and did so. A hernia was found containing omentum and a fold of bowel; a hydrocele of the chord lay along- side of it. Crural hernia has been mistaken for bubo, and vice versa. Lumbar abscess and varix of the femoral vein are also supposed to resemble it in some measure. The situation and form of the tumour in lumbar abscess is very different from those of hernia ; and the mode of exami- nation recommended in regard to cirsocele is equally applicable to the detection of dilated femoral vein. The distinctions between crural hernia and bubo are too obvious to require mention. Patients with unreduced hernia are constantly in great danger; as bruising of the swelling, or accumulation of feces in the protruded bowel, are likely to occasion very unpleasant consequences. They are generally troubled with indigestion, flatulence, and constipation; a slight degree of constriction at the neck of the tumour produces an obstruction to the intestinal contents ; the viscera in the sac have not due support and pressure, hence accumulations take place in them, and may be productive of serious and even fatal effects. No protru- sion, in which these circumstances are likely to occur, should be allowed to exist, if possible. So afraid were the ancients of allowing hernia to remain unreduced, that it was their custom to cut all patients labouring under rupture who would submit to the opera- tion ; and this wTas generally performed by itinerant quacks. They returned the protrusion without opening the sac, and then the neck of the tumour was either stitched up, or tied along with or without the spermatic chord. The actual cautery, and the most powerful caustics, were also applied to the parts by some, and dreadful were the effects; yet after the neck of the sac had been destroyed, and perhaps the bone exposed and exfoliated, protrusion again took place by the side of the cicatrix. By many, castration was considered necessary for the cure of scrotal hernia. Such harsh measures were founded on erroneous and imperfect ideas of the nature of the disease, which are not often to be met with in the present day. Operations, OF HERNIA. 423 for unincarcerated hernia are not justifiable, and those who have operated in such circumstances give a very unfavourable account of the experiment. The external applications employed to reduce hernia are various. Some are supposed to produce corrugation of the integuments, and contraction of the cremaster muscle, and thereby to force up the pro- truded intestine ; others are of an astringent character, and their ad- ministrator may gravely believe and say, that by them he expects to tan the living scrotum, to reduce the hernia, and to present an insu- perable obstacle to its reproduction. But all such means are vision- ary, and practically ineffectual; no external or internal remedy can attenuate and reduce the hernial sac, remove adhesion, or produce contraction of the tendinous and rigid apertures. Herniae are either reducible or irreducible. A hernia is said to be reducible, when the protruded bowel or viscus readily returns into the abdomen on the application of pressure to the swelling, or on the patient assuming the recumbent posture. When recent, the swelling may not be made to disappear without considerable diffi- culty ; but, after the disease has become of long duration, the aper- ture through which the protrusion has taken place dilates and is re- laxed, and admits of the ready passage of the hernial contents ; such tumours are usually of considerable size. But reducible herniae should not be permitted to enlarge, since their protrusion can be prevented by simple and safe means ; after reduction, a properly fitted bandage, termed a Truss, is applied over the aperture and canal, and by the compression thus made the opening is rendered impervious to the abdominal viscera. In inguinal hernia, the pad of the truss must make equable compression over the whole of the canal ; in the other species, the aperture is less extensive, and the pressure more direct. Perseverance in the use of a well-adapted truss is highly necessary in children from the first, so that a chance may be afforded of permanent cure by contraction of the opening and development of the surrounding parts. In young persons the canal is short, and almost direct, and from its becoming oblique and elongated during growth, prevention of protrusion may be effected. Descent must never be allowed during such attempts at cure. But in adults such a fortunate result can scarcely be expected : the truss must be constantly worn during the day— in bed it may be disused — and the patient must rest satisfied with thereby escaping those dangers to which protrusion of the hernia would render him always liable. Great care should be taken to ascertain in the morning, be- fore the truss is applied, that no protrusion exists. If the opening be not much dilated, it may contract even in adults when protrusion is sedulously prevented. The patient will also require to avoid the causes of hernia. If he is subject to cough, or labours under bad urinary disease, by which the abdominal muscles are called frequent- ly and fully into action, there is no chance of a cure ; nothing but the continued use of a truss will afford safety. Hernia is rendered irreducible, 1. By the formation of adhesions between the sac and the included parts. 2. By induration of the protruded omentum, and by accumulation of fat in it, or in the ap- 424 OF HERNIA. pendiculae of protruded large intestine. 3. By contraction of the ab- dominal cavity from long-continued displacement of a large portion of its contents. 4. By the nature and connexions of the protruded part, as in hernia of the sigmoid flexure, or of the caput ccecum coli. 5. By firm compression of the abdomen. 6. By the tightness of the opening giving rise to engorgement of the protruded parts. 7. By accumulation of feces, solid or fluid, in the protruded portion of bowel. With care, some of these causes may be got over, and the tumour re- duced. In irreducible hernia the use of a bag truss is indispensable to prevent increase of the protrusion. In irreducible femoral hernia of small size, a hollow pad with a weak spring is used with advan- tage, to give support to the contained parts, prevent farther protru- sion, and guard the tumour against external violence. The patient must avoid violent exertion, keep his bowels open, and be careful of his diet; he is always in danger, and should know it. Many have lost their lives from blows otherwise not dangerous ; and even strain- ing at stool is sufficient to force additional portions of viscera into the neck of the sac, and thereby induce most serious distress. Ruptures often come down during an attack of bowel complaint, or after a dose of purgative medicine. The term incarceration of hernia is employed to indicate a slight degree of strangulation, when the hernial contents are confined from any cause, and wffien the circulation in the protruded bowel and the course of the feculant matter are nevertheless uninterrupted. By many it is applied indiscriminately with strangulation. Strangulation arises, not from any change in the neck of the sac or in the tendinous aperture, but from increase of volume in the pro- truded parts, caused by accumulation of the solid, fluid, or gaseous contents of the bowel, followed by interruption to its circulation ; or the interruption to the flow of blood may precede the distension. The circulation is more readily retarded or arrested in the veins than in the arteries, and consequently the engorgement of the bowel is at first caused by venous turgescence ; but when the flow in the arteries is at all impeded, the infiltration and exudation become more rapid, and the part quickly perishes —sphacelates. The symptoms which accompany and indicate strangulation are of a very imposing nature, and cannot be neglected ; and it is fortunate that such is the case, for no disease is fraught with greater or more immediate danger to the patient, or requires more the early interference of a skilful and expert surgeon. The tumour becomes tense and painful, and the integu- ment is sometimes red and shining; the pain is much increased by pressure, and extends over the abdomen, but continues most severe near the neck of the swelling ; sickness and inclination to vomit quick- ly follow ; the patient feels languid ; his countenance soon assumes a contracted anxious appearance ; the circulation is hurried ; the pulse beats wiry and hard, though at first it may have been full. If relief is not afforded, all the symptoms are speedily aggravated ; vomiting comes on, and is frequent; no discharge can be procured from the upper bowels, though the lower may be, and often are, evacuated by injections or by natural efforts: if the upper bowels evacuate downwards, the strangulation cannot be of the whole calibre of the OF HERNIA. 425 gut, but only of a part. Pain and heat in the tumour and belly in- crease ; and the former becomes very tender, and tense as a drum. The circulation is more hurried, and restlessness and intolerable anxiety supervene. The patient becomes worse and worse every hour; feculent matter in large quantity is vomited or gulped up with great distress, and is commixed with bile, with vitiated mucous secre- tion from the stomach and bowels, and with whatever may have been recently swallowed ; in fact, the peristaltic action of the alimentary canal above the strangulated part is inverted, and all the contents are ejected. Troublesome hiccough comes on, and the symptom is by many considered as a sure sign of gangrene having taken place ; but it is often present when the bowels are quite free from tenderness or tendency to gangrene. The extremities grow coldish ; the pulse is unequal and fluttering, and with difficulty counted at the ankles. The countenance sinks, and assumes a leaden hue ; the pain abates suddenly: the eyes are glassy : the tumour becomes flaccid, and is often livid and emphysematous. Now, the bowel may recede, and feculant evacuation take place, with some relief; but the patient, after lying some time insensible, expires. All this may occur either within a few days after the occurrence of strangulation, or not till after the expiration of many days. The rapidity of the symptoms and the danger are influenced by the size of the tumour and the condition of its neck, and by the nature of its contents. In small recent herniae, the advance from bad to worse is usually very rapid, the aperture through which protrusion has taken place being small, and producing a great degree of. constriction when distention and engorgement occur. When the neck of the tumour is large, and completely oc- cupies the aperture previously to the strangulation, the progress of the symptoms is also rapid, for a similar reason ; but if the hernia be large and of long standing, and if the protruded parts are not bulky at the point of protrusion, the constriction is in general not very se- vere, and the distressing consequences advance more slowly. The symptoms are not so violent in epiplocele as in enterocele. In many instances of the former, the intestinal discharges are never ob- structed, though great irritation and inflammation may be induced by the strangulation. There is also less danger in entero-epiplocele than in enterocele, compression of the bowel being in the former in stance diminished by the intervening omentum. It is scarcely necessary to observe, that, when the train of symp- toms just detailed commences in any case, the surgeon must imme- diately and anxiously inquire as to the existence of external hernia, for often the disease is concealed, particularly by females; all parts where protrusion is likely to occur must be examined attentively. At the same time the surgeon must bear in mind that pain of the ab- domen, with symptoms resembling those of strangulation — in fact, that enteritis, with obstruction, may exist along with hernia, but in- dependent of it. A person with hernia is as liable as any other, if not more so, to inflammatory attacks in the abdomen from a variety of causes. The portion of bowel in the tumour may participate or not in the general abdominal affection ; if unaffected it may be reduced ; it is neither painful nor tense. Again, in large ruptures, inflamma- 36* 426 OF HERNIA. tion of the contents may take place without strangulation, and without affection of parts within the abdomen. All circumstances bearing on the case must be well considered by the surgeon, before making up his mind as to the nature of the affection. Returning the contents of the hernia into the abdomen is the only effectual means of counteracting the direful effects of strangulation; and the propriety of an early recourse to this measure must be quite apparent. It is indispensable, and no delay is warrantable. The means for accomplishing it must be varied, according to the state of the parts, the duration of strangulation, and the general symptoms. The most simple method, and that which should first be attempted in ordinary cases, is the taxis; that is, reduction by pres- sure with the hand. In this the position of the patient is ^of import- ance ; it should be such as effects relaxation of the tendinous Jstruc- tures through which the hernia has protruded, and through which it is to be returned. With this view he is placed on his back, with the shoulders and pelvis elevated, and in crural hernia the thigh is bent on the trunk, and turned towards the opposite side ; thus the aperture is relaxed along with the fasciae which compose it. Long ago, the positions into which the patients were forced for the cure of hernia were various, and generally awkward; they all tended to- wards more or less complete inversion of the erect posture, and thus it was supposed that the abdominal bowels, dragged on those pro- truded, and thereby assisted reduction. But the viscera are equally pressed on in every position of the body ; it is not they, but the ex- ternal parts, that are affected by change of posture. During the at- tempts at reduction, the patient should be exhorted not to strain or resist, but to relax his muscles; and it will be well to engage him in conversation, that he may not have an opportunity of keeping his lungs distended, and thereby acting forcibly7 on the abdomen. At first the pressure should be general, applied either with one hand or with both, according to the size of the tumour, so as to diminish the contents. If air be heard gurgling at the neck of the swelling, the chance of success may be considered good, for a return of part of the bowel's contents is thereby indicated. Then a gentle kneading should be made at the neck with the fingers of one hand, while with the other general pressure is kept up. The impression made is at first slight and gradual ; out, when a portion of the bowel returns, the rest of it slips up suddenly. The return of omentum is always slow, and the last part requires as much manipulation as the first. The direction of the pressure must be varied according to the case. In inguinal and ventro-inguinal hernia, it is made in the direction of the neck of the sac ; in the former upwards, and outwards, in the latter upwards and backwards : and previously the body of the tu- mour should be brought into the same line with its neck. In crural hernia the pressure must first be made towards the centre of the thigh, so as to bring the whole tumour into the same direction with its neck, and then upwards. In umbilical, the pressure is straight back- wards. Small herniae, and those of recent origin, are with difficulty reduced ; their neck is narrow, and the passage proportionately small ; the crural are usually of this description. In all herniae, after OF HERNIA. 427 strangulation has existed for some time, and adhesions formed, par- ticularly at the neck, reduction is almost impossible. The taxis is to be neither attempted nor persevered in after the hernia has become tender and inflamed. No good can be done by it, and the patient's chance of recovery by operation is much dimi- nished. Even when no pain is felt in such circumstances, any de- gree of force must be prejudicial. Mortification of the bowels is often hastened in consequence of the taxis being unskilfully em- ployed by ill-informed persons, who are often determined, at all risks, and at all stages of the affection, to accomplish speedy reduction of the viscera. The surgeon will take care to inform himself of all par- ticulars—>as to the duration of strangulation, the previous state of the tumour, if it was all, or only in part reducible, as to its size, &c. — before proceeding in any way. Great mischief is likely to accrue from the tumour being handled, perhaps roughly, by many people. If the taxis is gone about, however, in proper time, and in the right way, it ought almost always to prove successful. It is very desira- able indeed that this should be the case, seeing that all the bad symptoms in ninety-nine out of a hundred cases instantly subside ; whereas, after the reduction by incision, there is always great risk from the opening of the peritoneal sac alone. Certain means may assist the taxis, but they should not be long continued or often repeated. Venesection can be employed only in strong plethoric patients, in the very first stage of strangulation, and before the patient is exhausted by the distressing symptoms. It is had recourse to in order to induce syncope, or any approach to it; during which general relaxation takes place, and reduction may be attempted with advantage. With that view the patient is placed erect, and a large orifice made in the vein of one or both arms, so that a moderate quantity of blood suddenly abstracted may have a powerful effect on the system. In several cases I have found this practice beneficial, but am inclined to say that, in general, it will not be followed with success. In a favourable case, one attempt of this kind may be made, but not repeated. In many states of the consti- tution, and in the latter stages of the disease, bad consequences must follow the practice. But in regard to it or any other remedy, it would be folly to lay down positive general rules ; what may prove useful in one or two instances may answer very badly in the majority of cases that come under treatment. Local bloodletting can have no effect in diminishing the size of strangulated parts ; though in inflam- mation of the contents of the tumour, without strangulation, no more powerful means can be employed. Purgatives have been recommended with the view of extricating the bowel by increased peristaltic motion ; but the symptoms will, to a certainty, be aggravated by their use. Purgative enemata can do little good ; if in small quantity, they empty only the rectum ; if large, they may reach the strangulated part, but will scarcely have the effect of extricating it. Emetics, in full or nauseating doses, have been supposed to be indicated in this affection as well as in ileus; but there is in general enough of sickness and vomiting without them, and it is often diffi- 428 OF HERNIA. cult enough to allay the vomiting even after removal of the ob- struction. The warm bath is greatly trusted in by some, and in many cases it proves a valuable and useful auxiliary to the taxis. It acts bene- ficially by inducing general relaxation, or even syncope ; during which, whilst all resistance of the compressing powers upon the con- tents is suspended, pressure on the tumour can be employed to good advantage. By steady perseverance, whilst the patient is in the bath, a great majority of strangulated herniae may be reduced. But neither the general nor the local application of heat, or any other known means, save the edge of the knife, can relax tendinous aper- tures farther than can be effected by attention to position. Irrecover- able and most precious time may be wasted in preparing the bath ; and for this reason such means should never be resorted to, unless they can be commanded at the shortest notice. Fomentations can do no good. The apertures can be neither re- laxed by heat, nor contracted by astringent applications. By the local application of heat, the size of the parts composing the hernia will be augmented, the flatus being rarified, and the effusion and engorge- ment encouraged. The cold bath, and the dashing of cold water on the surface, near the seat of the disease, have been tried in some rare cases with most marked success ; but this is a practice not generally to be relied on. It can act only by producing sudden and powerful contraction of the coverings, and uniform pressure thereby on the contents. It is, per- haps, only applicable to scrotal hernia. Cold has been applied to the tumour, and even ice, so as to produce frost-bite, but little faith can be placed in such ; the practice becomes dangerous after inflamma- tion has existed for some time, the application diminishing the weak- ened powers of the parts, and accelerating gangrene. Opium has been given by the mouth, and tobacco by the lower extremity of the alimentary canal; the former may sometimes prove advantageous, but the latter had better be dispensed with. The tobacco is thrown up either as an enema, or in the form of vapour; but the former method is generally preferred. A drachm of the leaves is infused in a pound of water for ten minutes, and one-half of the liquid injected ; if this prove insufficient to prostrate the patient, the rest is administered after the lapse of a short interval. But many- people have thus been poisoned, and the indiscriminate employment of the supposed remedy cannot be too strongly reprobated ; its effects are most severe and unmanageable ; the state of collapse is most complete and alarming, and it is often difficult, if not impossible, to bring the patient out of it — to procure reaction. In some cases reduction may be accomplished during the state of extreme debility which follows its use, but I have often seen it fail, and have wit- nessed the operation afterwards performed on the patients, who were at the time without pulsation, and from whom little blood flowed after the incisions; they never, of course, rallied, and sunk rapidly. Indeed the patient is always in a very unfavourable state for opera- tion after the exhibition of the tobacco enema, though certainly in a very favourable state for reduction being attempted. The strong OF HERNIA. 429 objection to the medicine I conceive to be its being so extremely un- manageable ; it is impossible to say whether the depression of the vital powers that must ensue will be just sufficient to induce that relaxation »and debility necessary or favourable to reduction, or whether it will proceed uncontrollable to such a degree as to extin- guish life. In general it produces intolerable nausea and depression, universal relaxation of the muscles, coldness of the surface, with clammy exudation, vomiting, violent retching, vertigo, and perhaps insensibility. Were I so unfortunate as to be the subject of stran- gulated hernia, I should certainly have no tobacco used. After un- successful trials of the taxis, I might submit to be bled ad deli- quium, and have a surgeon to attempt reduction during syncope ; if somewhat more advanced in life, I should prefer the warm bath ; if taxis then failed, I should certainly be operated on in a very fewr minutes afterwards. If the surgeon, after mature consideration, make up his mind as to the course of practice he would wish pur- sued in his own case, he wTill be fully alive to the necessity of im- pressing the utility of it on his patients, and have little difficulty in persuading them to submit to his proposals. No time should be dis- sipated in administering purges or clysters, or in cold or warm ap- plications. If the tumour is not very tender, make one good trial of the taxis, not long continued ; if a warm bath can be readily commanded, place the patient in it, and employ the taxis when he begins to feel faint. If foiled, and the patient can bear depletion well, the strangulation being recent, try a full bleeding to syncope ; it may save depletion afterwTards, and at all events the patient will be none the wTorse for it. Having failed, as may probably be the case, operate without delay. The operation, as regards the immediate consequences, is neither formidable nor dangerous of itself; the delaying of it is attended with the most serious and irretrievable mischief. It ought to be performed within a very few hours after the occurrence of strangulation, and, in most instances, without putting off time with the means considered auxiliary to the taxis. Under urgent circumstances, it may be ne- cessary to operate within a quarter of an hour after seeing the pa- tient, as I have often done. In ordinary cases, time must be taken to converse with the patient and his friends, to convince them that all those means likely to assist reduction, and render an operation unnecessary, have been tried. The surgeon must not appear to be in a hurry, though he puts off no time unnecessarily; otherwise his motives may be misconstrued. The necessity for operating early is greater in small than in large herniae, in crural than in inguinal. The groin and neighbouring parts are to be shaved, and the patient placed in the recumbent posture, with the shoulders slightly elevated. The mode of opera- tion must be varied according to the nature of the tumour, its size, and other circumstances. The operation for inguinal herniae is conducted as follows : — The patient is placed recumbent on a table, or in private practice, on the side of a bed, his shoulders supported by pillows, and his feet resting 430 OF HERNIA. upon a stool. An incision is commenced about an inch above the external abdominal ring, and continued to the bottom of the tumour. This latter part of the procedure, however, is applicable only to small and moderately-sized herniae ; in large tumours the wound is not made so low, for in them the bowels may be irreducible, from the quantity protruded, and the contracted state of the abdominal cavity ; in such cases the incision should be only to such an extent as is suffi- cient to enable the operator to reach the stricture. The first cut is carried through the skin and fatty matter, not deeper. The layers are then divided successively, with the hand unsupported ; and this is done only at the middle and projecting part of the swelling. It is unnecessary to prolong the incision of the layers along the whole extent of the wound in the integuments, at this stage of the proceed- ings. In the direct hernia, which is of rare occurrence, there is but one proper layer, — that furnished by the superficial abdominal fascia : not unfrequently there is an imperfect additioual envelope, furnished by fibres from the edge of the external ring ; sometimes the tumour does not escape through the external ring, and is then of course covered by the tendon of the external oblique ; of this I have seen but one instance, and that in a female ; but in a common in- guinal hernia there are three or four, and these are thickened more or less according to the size and duration of the tumour. The divi- sion of these layers must necessarily be conducted with great care and caution. At length the sac is exposed. This is opened by pinching up a portion betwixt the nails of the thumb and forefinger, or with dissecting forceps, and then cutting with the blade of the knife laid horizontally. On wounding the sac, there is usually evacuated a small quantity of brownish serous fluid. The probe- pointed bistoury is then taking up, and insinuated into the opening; and by this instrument, guided on the forefinger of the left hand, the sac and its coverings are divided up to near the ring, and down to near the bottom of the tumour. The hernial contents are thus exposed. These are unravelled, and examined attentively; if only brownish-red, from accumulation of the venous blood, of unbroken surface and unadherent, they are fit to be reduced. The stricture is felt for with the forefinger of the left hand, and into it either the point of the finger or the nail is gently insinuated. The protruded parts, if voluminous, are held down by an assistant; and along the forepart of the finger is passed a probe-pointed, narrow, and slightly curved knife. In carrying this upwards, the blade is placed flat on the finger, and its point, and no more, is passed through the contracted part; its edge is then turned forwards, its back resting on the finger ; and by raising the handle gently, a slight incision is made into the more resisting fibres, in the direction of the mesial line. The instru- ment is withdrawn with the same caution as in its introduction. The finger now enters easily, and by raising it gently and repeatedly the parts are dilated. It is then passed upwards to the site of the internal ring : and if this be found narrow and contracted, the edge. of the knife to be directed against it in a similar way, and dilatation to a sufficient extent effected. Now reduction is to be commenced, and in doing so the same precautions are to be observed as in the OF HERNIA. 431 employment of the taxis. The hernial sac ought in the first place to be fixed by the fingers of the assistant placed in the bottom of it, so that it maybe prevented from sliding up along with the contents. A neglect of this rule is often observed to lead to much embarrassment. The parts seem to have passed back into the general cavity; but on withdrawing the pressure they fall down again from the canal, along with the sac which had slipped up so far with them. In general, the omentum, if any, is put back first, and then the bowel; but this must depend on the relative quantity7 of the parts, and other circumstances. With the right hand the bowel is to be compressed as uniformly as possible ; and, if at all obstinate, its reduction may perhaps be accelerated by pulling down a small portion at the neck, so as to facilitate the return of the fecal contents. By gentle pressure with the forefingers one portion is put back after another : it is wrong to attempt sudden and entire reduction ; it should be gradual and suc- cessive. In many cases, from adhesion, or from the bulk and nature of the hernia, the parts, though sound, cannot or ought not to be re- duced ; a portion may be got back, but part requires to remain. This can often be ascertained beforehand by properly conducted and previous inquiry into the history of the case, as to the duration of the disease, and the period at which the whole tumour could be made to disappear. In such cases, the stricture should always be freely relieved. When the bowel is mortified, and its contents effused into the sac, care is to be taken not to detach or disturb the adhesions at the neck, and the bowel should be opened so as to allow of free discharge. When the bowel or omentum is compa- ratively sound, though irreducible, the surgeon must rest contented with relieving the stricture ; then cover the parts with the integu- ments, and promote union of the wound. If it be considered neces- sary to remove condensed and tuberculated omentum, it is cut off, and separate ligatures of fine thread are applied to every bleeding vessel on the cut surface; the whole mass is not to be included in one noose, as was formerly the practice. In the operation for femoral hernia, the position and preliminaries are the same as for inguinal. A longitudinal incision is made from above the margin of Poupart's ligament to a little below the middle and most prominent part of the tumour. This is crossed by another at its lower extremity, the whole resembling in figure the letter j^ inverted ; and the two flaps so marked out, are reflected. Some- times a single incision, from above the neck of the tumour to the lower border of it, is sufficient to afford room for the after proceed- ings. For some years past I have performed an incision along the course of the ligament of Poupart, with another falling from it over the body of the tumour like the letter T, with the transverse part a little awry. In cases of very large femoral hernia, such as that seen on the next page, the incisions, as in the large inguinal tumour, must be made over the situation of the femoral ring, and to a limited extent. In this case the symptoms had existed for eight days, and had been latterly very urgent, there being profuse feculent vomiting, and great depression of the powers of life. There was a large mass of bowel protruded : this was all returned, and the patient, though 432 OF HERNIA. well advanced in life, made a rapid recovery. A cast was obtained after her death, which happened several years afterwards. It is seldom indeed that femoral hernia at- tains such a size. I have seen it in the male, however, nearly one half the size of the swelling here shown. The tumour is often not larger than a walnut, seldom exceeding the size of a small apple. One layer is found covering the sac, furnished by the strong and dense cellular tissue which occupies the space under the crural arch and falci- form process of the fascia lata : it is generally denominated the fascia propria, and has been described improperly, it would appear, as the sheath of the femoral blood-vessels ; at the lower part of the tumour it is generally wanting. It is care- fully divided, so as to expose the sac. This not unfrequently is thickened very considerably, a quantity of dense fatty matter being intimately incorporated with it; but in general it is thin, and ap- pears of a dark colour, in consequence of the bowel and effused bloody serum being seen through it. It is opened with great cau- tion, part of it being raised and touched wTith the edge of the knife held horizontally, or nearly so. The aperture thus formed, is enlarged by means of the probe-pointed knife, which is carried upwards along the forefinger of the left hand. Some recommend that the sac should be left undivided, and that the stricture should be relieved by passing the knife on the outside ; others, that only the neck of the sac should remain entire, and the stricture be attacked also on the outside of the peritoneum. But this appears an unne- cessary and unprofitable precaution. The extreme difficulty of re- turning the sac is now well known and generally acknowledged ; indeed, reduction of it, whether opened or not, is practicable only in recent cases. Its neck, besides, is firmly constricted ; and the bowel may and will remain strangulated when returned along with its sac, for the peritoneum long retains the contraction at its strictured point. This stricture cannot be well relieved unless the neck of the sac is cut along with the resisting fibres exterior 4o it. After the sac has been opened, the forefinger of the left hand is passed up to the crural ring ; and it should be recollected that this opening is very small, even in most cases in which a hernia of ordinary size has existed for some time. It is capable of great dilatation, gradual howTever, so that, in very old and large ruptures, it may admit two or three fingers easily. But in general only the nail of the finger can be insinuated into it; and this is a better and safer conductor for the knife than a grooved director. The edge of the stricture is felt very sharp ; the point of OF HERNIA. 433 the finger is turned towards the pubes, and along it a narrow, blunt- pointed, curved bistoury is passed in close contact, and with the edge towards the pubes ; its mere point is pushed beyond, and then the position of the blade is changed : its back is turned upon the finger. This slight motion is of itself often sufficient to relieve the constriction on the protruded parts, and permit their reduction ; if not, a few more fibres are cut by raising the handle of the knife gently from the palm of the hand. The direction of this incision is towards the tuberosity of the pubes, inwards and forwards. Thus only the crescentic portion of the crural arch is cut; and the divi- sion of this produces sufficient relaxation of the neighbouring parts. There, is danger in cutting directly forwards, particularly in the male, at least if the incision be made to any considerable extent; there is a risk of wounding the spermatic chord, and the obturator artery has also been met with in a few instances coursing round the neck of the sac. This distribution of the artery, however, is rare, and can occur only when the epigastric and obturator arise by a long common trunk, and even then it may not encircle the neck of a her- nia, as I have witnessed. Occasionally a vessel of considerable size passes round the opening, connecting the epigastric with the obtu- rator, when these arteries follow their usual course ; and this also may surround the neck of the sac. If vessels should exist in this situation in a person the subject of operation, as has not happened so far as I know, they would be felt by the finger used to conduct the knife. And the bistoury should never be passed — for there is no necessity for it — through the opening so far as to meet with a vessel, even if awkwardly placed. The danger of cutting forward and to any extent has already been spoken of; such incision can answer no good purpose. The stricture is not in Poupart's ligament — though at one time it was proposed to cut this through without interfering with the tumour at all — but in the crural arch under- neath, and in a manner independent of the strong tendinous chord and expansion. The crural arch is formed by the junction of the fasciae of the thigh and abdomen, superficial and deep. It is insert- ed into the linea ileo-pectinea, where the tendon of the external ob- lique has no connexion, and is strengthened by fibres from the in- ternal oblique, transverse, and recti muscles. The crural aperture formed by this arch is relaxed by flexion and inversion of the thigh, and by relaxation of the abdominal parietes. And this fact requires to be attended to, after operation as well as during the taxis, so as to facilitate replacement of the protruded parts. The same attention to the state of the parts in judging of the pro- priety or not of reduction after operation, and the same after treat- ment, both general and local, is requisite in crural hernia, as in ingui- nal. When the parts are reduced, the edges of the wound are brought together by means of a few7 stitches ; a graduated compress, of pro- per dimensions, is applied, and retained by a spica bandage. If this is neglected, there is a risk of the parts again descending. After- wards large mild enemata are to be administered, and, after some hours, purgatives, so as to procure copious and free evacuation of the bowels. In many cases after reduction, the bowels cannot by 37 434 OF HERNIA. any means be got to act downwards. This seems sometimes to arise from a sort of paralytic state of the fibres of the part which has been extruded and compressed. Again, it often arises from an indentation of the coats of the bowel at the point where they have been tightly embraced and compress- ed by the sharp edge of the opening, as here represented. The engorged and dark state of the upper portion of bowel contrasts well with the lower, which is generally empty, con- tracted, and pale. If the stomach continue unsettled, a sinapism may be applied to the epigastrium, or solid opium exhibited. Sub- sequently it may be necessary to bleed locally, or generally, or both ; in other cases the strength from the first requires support. After cicatrisation, a well adapted truss must be constantly worn. Umbilical hernia is generally congenital. The tendinous parietes are often deficient to a great extent, and there is consequently much fulness along the umbilical chord. The plan of embracing such tumours in children by ligature, as at one time extensively practised, is now abandoned, there being much risk of peritoneal inflammation and fatal issue. The surgeon is now content with reducing the hernia, and applying a truss, to prevent displacement, as in other forms of protrusion ; and if this be done in early life, and the appa- ratus carefully wTorn, the opening contracts, and the patient may ultimately be cured. The tumour may become strangulated, though rarely in the adult; it is generally large, and almost solely- occurs in females. The sac has no covering but the skin and cellular tissue and fatty matter. A small incision is made through the sac and its investments, either on one side of the tumour, or in the mesial line at its lower aspect. The stricture is then divided with care, the parts reduced, the wound approximated, and a compress applied. Open- ing the tumour throughout its whole extent is hazardous and unne- cessary. The same remarks apply to the proceedings in cases of ventral hernia. In corpulent females the tumour is sometimes scarce- ly prominent, and is only discovered as a flattened cake through the fatty matter. The contents of hernia are often in a very bad state, either dark- coloured throughout, or studded with dark tender spots. Lymph is often effused all over the parts, gluing them to one another, and to the sac This effusion, which generally takes place to the greatest extent at the neck of the sac, is a wise provision made by nature against the accidents of the disease ; inasmuch as a barrier is thereby formed between the cavity of the abdomen and the extruded parts, preventing, in a great measure, the destruction of the latter from af- fecting the abdominal viscera. For example, a portion of protruded intestine sloughs, the feculent matter is effused, and, had not this OF HERNIA. 435 adhesion to the neck existed, the gut might have slipped back into the abdomen, its contents would have escaped there, and a fatal re- sult would have been the inevitable consequence. Still, notwith- standing the salutary effusion, the bowel may ulcerate at its upper part, and, giving way within the belly, produce rapid death. The bowel, where embraced by the stricture, is contracted and thick- ened, and dilated above. At the lower part of this dilatation the coats are apt to give way by ulceration, even after incision of the constricting parts and reduction. The contraction does not disap- pear quickly. In some cases it continues to such an extent as to keep up obstructions to the fecal matter, and cause a fatal issue from this cause alone, as noticed above. Often on opening the sac, in long neglected cases, a discharge takes place of fetid air and thin feculent matter, the bowel has mor- tified either entirely or in patches ; in the latter case presenting the appearance of having been perforated at various points. Few con- stitutions can bear up under such mischief. In some, if an opening be not made, the integuments slough, and the patient rallying after discharge from the bowel takes place, recovers after losing a portion of integument of intestine, and perhaps of omentum. In others, and they constitute the majority, the system sinks, before discharge from the bowel is effected, by sloughing of the external parts. The surgeon is called on to operate in the worst possible circum- stances, provided the patient is not in articulo mortis. Even after many days of feculent vomiting the bowels may be found tolerably healthy. The sac must be opened carefully, and the stricture is to be relieved without disturbing the adhesions that have formed. The bowel when dead, or evidently gangrenous, is to be opened, and the discharge of feces by the wound promoted. If returned into the abdomen, the sloughs will separate in all probability, and feculent effusion take place, causing death in a very few hours. Sometimes the patient lingers longer than could be expected, and I have known a female survive upwards of a hundred hours after the occurrence of effusion into the abdomen, from the giving way of an ulcer in the stomach. The dressing should be light, and the patient's strength must be supported in every way, by the mouth, and by the anus when the injured part is high in the canal. The separation of the sloughs is to be encouraged. The extent of sloughing need not dis- hearten the surgeon, for large portions of bowel, several feet in length, have mortified, and the patients recovered, with artificial anus, either temporary, or for life. In artificial anus, when this has followed upon destruction of the bowel to a considerable extent, the intestine has contracted firm ad- hesion to the hernial sac at the opening in the abdominal parietes : through the opening in the bowel exterior to this the feculent matter is discharged externally, and by the adhesion is prevented from being effused into the abdominal cavity. The protruded bowel in which the sphacelation has occurred may be said to be thereby- divided into an upper and an under portion, — one, the upper, dis- charging, the other, collapsed and empty ; these lie parallel to each other, in close contact, and usually adhering, from the abdominal or 436 OF HERNIA. crural ring downwards, to each other, and to the hernial sac. The hernial sac seldom sloughs entirely; in almost every case its neck remains sound ; to this remaining part the intestine adheres. The deficiency in the integuments and cellular tissue, through which the feculent matter escapes, gradually contracts, and the aperture in that portion of the hernial sac which is exterior to the intestine also diminishes ; but at the same time dilatation takes place in the imme- diate vicinity of the intestinal orifices, so that a funnel-like cavity is formed for the evacuation of feces, extending from the opening in the bowel to the opening in the skin — its narrowest part being at the latter situation, its most capacious surrounding the intestine. The cellular tissue intermediate between the integument and hernial sac becomes condensed, and forms a membranous lining. By this cavity an imperfect communication is established between the two portions of bowel, part of the feculent matter returning through the lower intestinal orifice, and part escaping externally. But this com- munication must be indeed very imperfect at first, since the two por- tions of bowel lie parallel to each other, and their coalescing sides form an acute angular projection into this funnel-shaped cavity. The lower portion is necessarily much diminished in calibre, being in a great measure unaccustomed to the usual distention, and its collapsed orifice is retracted a little higher than that of the superior. On account of these circumstances feculent matter cannot pass straight onwards from one portion of bowel to the other, but must first tra- verse the funnel-shaped cavity; and even then it is but a small quantity that reaches the rectum. Indeed in most cases of artificial anus, nothing but occasional flatus passes by the original outlet for weeks or months. After some time the bowel retracts, but cannot leave the adhesion in the groin ; by this retraction the orifices may be brought in a more direct line with each other, and the natural passage of the feces be somewhat assisted. When one or more slight patches of discoloration are observed after division of the sac, it maybe returned, it being most probable that the parts will recover after removal of the stricture. When any portion has given way, of course no one can contemplate reduction ; and when the whole calibre has sloughed it is absurd to attempt se- paration of the adhesions which must exist, dividing the external from the internal parts. In mortification of a protruded knuckle, or part only of the calibre of bowel, the symptoms are at first severe. These are vomiting, pain, and symptoms of enteritis ; perhaps the bowels are obstructed for some time, but evacuation again takes place, as happened in the following remarkable and instructive case. A gentleman, nearly eighty years of age, was, during the action of medicine, sud- denly seized with pain in the groin. A very small tumour was ob- served— he became sick—and when I visited him for the first time two days after, he had no further evacuations from the bowels, he vomited constantly bilious fetid matter, and he began to complain of pain in the abdomen. Pressure was kept upon the tumour, which pro- truded at the crural aperture, for some time, with the effect of dimi- nishing its size very considerably. On returning in a couple of hours OF HERNIA. 437 with Sir B. Brodie, with the intention of cutting down upon the swelling, the bowels had been freely relieved, the vomiting had en- tirely ceased, and there was not the slightest vestige of tumour to be perceived or felt, on the most attentive examination. The patient had a good night, but in the morning had a recurrence of the symp- toms; these continued, and a fatal termination shortly occurred ; still no tumour could be detected before or after death. It was sup- posed that the obstruction might have been caused by a continuance of the constriction of the bowel, where it had been nipped by the stricture. On a post-mortem examination, there was found an ex- ceedingly small portion of the coat of the bowel still entangled in the crural ring, whilst a larger por- tion, which bore marks of having been protruded, was thus entangled, and confined to the spot. The bowel, though not completely ob- structed, was narrowed by the confinement of part of its parietes. Abscess often occurs externally to a small swelling of this nature, and on the giving way of the in- tegument, matter, flatus, and thin feces are discharged. A fecal fistula remains for some time ; but, by the aid of lymph and granulations, the breach in the parieties of the bowel is repaired gradually, the feces resume their natural course, and the external opening heals. When the whole calibre has sloughed, and even when a large ex- tent of bowel has come away, there is stilf a chance of the patient recovering from the artificial anus by natural means, after the lapse of many months. As already remarked, the intestinal orifices retract, and come more into a straight line. A mucous discharge occurs from the lower bowels along with the passage of flatus, and at last part of the feces is voided by the rectum. The discharge from the external opening diminishes, and ultimately ceases, perhaps only a minute fistula remaining, through which a few drops of fluid, sometimes feculent, sometimes limpid, may occasionally escape. The funnel-shaped cavity previously contracts into a narrow fistula. This desirable result may, be assisted and hastened by gentle pres- sure ; and, after the feculent discharge has nearly ceased from the fistulous opening, the healing of this may be accelerated by the cautery lightly applied. It has been proposed to destroy the pro. jecting septum between the two portions of bowel, either by ligature or by the pressure of forceps; but this should not be at- tempted unless nature seems unable to effect a cure. The former method consists in including a considerable part of the septum in ligature, so as to induce condensation of the parts by effusion of lymph and destruction of the projecting portion. This has not been found very successful. The application of forceps presents a more rational expectation of cure. The external opening is dilated, and 37* 438 ARTIFICIAL ANUS. the situation of the septum ascertained. One blade of metallic forceps, with blunt serrated edges,— Dupuytren's,— is passed into the one intestinal orifice, and the other into the opposite ; the handles of the instrument are then approximated, locked, and fastened with a screw, and by means of the last mentioned part of the apparatus the degree of pressure is regulated. Pain of the abdomen, furred tongue, loss of appetite, sickness, vomiting, and constitutional irri- tation, generally follow this proceeding, but gradually subside on the employment of enemata and fomentations, and on lessening the pressure of the forceps. The septum cannot long withstand the continued compression, and by its destruction the chance of cure is greatly augmented. The proceeding is, besides, not so dangerous as might at first be supposed ; for effusion of lymph takes place to a considerable extent above the part grasped by the forceps, gluing the portions of bowel firmly to each other, and forming a new barrier against any of the feculent matter escaping inwardly. Attempts may be made to repair the loss of substance in the skin by paring the edges of' the opening, and affixing a flap taken from the neighbourhood. There is a greater chance of recovery from the inconvenience of artificial anus after hernia than after wounds. If the opening in the bowel be near the stomach, the patient will die from inanition. When it is lower in the intestinal tube, nutrition is more perfect, and the patient can be further supported by nutritive enemata. When no natural cure is likely to take place, the inconvenience will be palliated by a truss with a soft pad being wrorn, so as to retain the feces till a favourable opportunity occurs for evacuation ; or a soft plug of lint may be inserted into the aperture, and retained by a compress and roller. Prolapsus of the mucous membrane of the gut sometimes takes place through the artificial anus, and is reduced with difficulty. The use of a truss or tent, already mentioned, will tend to prevent the occurrence. Great attention to cleanliness is required when the opening cannot be closed. Operations for other kinds of hernia, if discovered during life, are to be conducted on similar principles with those for inguinal and crural. The surgeon must be guided by his anatomical knowledge. No positive rules can be given. [In artificial anus* caused by a gangrened rupture, the two ends of the bowel are surrounded and closely embraced by a sort of mem- branous pouch, to which Scarpa, who first described it, has applied the name of infundibulum or funnel.] It is formed by the prolongation of the peritoneum which constituted the neck of the hernial sac, and varies very much in its shape, dimensions, and direction, its base being at the bowel, and the apex at the skin. It is generally very firm and dense in its structure, and from one to two lines in thickness. according to the extent of the previous inflammation ; externally it is intimately united to the margins of the abnormal opening, and in- ternally it presents a smooth villous surface, not unlike thafof an old * See the editor's Experimental and Critical Inquiry into the Nature and Treatment of Wounds of the Intestines, p. ISO, Louisville, 1843. t Treatise on Hernia, Memoir Fourth, p. 288. ARTIFICIAL ANUS. 439 fistulous track. The feculent matter from the upper orifice is poured into this cavity, and thence, when the artificial anus is closed, it is carried, after describing a half-circle, into the lower end of the canal. This membranous pouch is always wanting when the disease is the effect of a penetrating wound, and occasionally even when it is the consequence of a gangrened hernia: in both cases the gut adheres immediately to the edges of the opening in the muscles and integu- ments. The most interesting circumstance connected with this funnel-shaped cavity is the influence which it exerts upon the repara- tive process, or spontaneous cure, which is always so much the more prompt and perfect in proportion as it is larger and longer. Interposed between the two extremities of the intestine, and formed by the justa-position of their sides, is the ridge, septum, ox partition, which Scarpa has described under the name of the promontory, and Dupuytren under that of the eperon, spur, or buttress. It consists of two angular or crescentic folds composed each of four lamella?, of which the inner two are of a serous nature, and firmly united together by plastic matter, for an extent varying from one to six, eight, or even twelve lines. The outer layers are of a mucous character, and are continuous with the lining membrane of the tube, of which they * aa, Opening of the artificial anus, and point of union between the skin and the mucous membrane; b, upper end of the intestine; c, lower end of the intestine; d, the septum, eperon, or ridge, formed by the walls of the two contiguous cylinders; ee, parietes of the bowel;/, the ligament or cord formed by the mesentery;^-, the cul-de-sac between the peritoneum of the intestines and of the abdominal walls, into which hernia occasionally protrude. 440 ARTIFICIAL ANUS. form a part. Dividing the bottom of the funnel, where it is situated, into two unequal parts, this septum juts Out nearer to the surface of the abnormal opening in proportion as the loss of intestinal substance has been more considerable, and the change in the direction of the tube more marked. It is small, and scarcely perceptible, when the gut has been merely pierced by a wound, or slightly affected by an eschar, but large and prominent, when the lesion, whatever it may be, involves the whole circumference of the canal.* In the former case, the two orifices of the bowel are separated by a kind of gutter or groove, wdiich .directs the transit of the fecal matter from the one to the other, and greatly facilitates the attempts at cure; in the latter, the septum forms a projecting angle or buttress, which conducts the contents of the upper orifice towards the abnormal outlet, and which nothing but art can break down or surmount. When the two lamellae of which this septum is composed are viewed posteriorly, or from within the belly, we find that they gradu- ally recede from each other, leaving thus a triangular interval be- tween them, the apex of which corresponds to the point of separation, and the base with the abdominal cavity. The surfaces of these lateral layers, which are, in fact, nothing but the parietes of the affected cylinders of the bowel, are invested by a reflection of the peritoneum, and afford attachment to a process of the mesentery. From the manner in which this membrane is stretched between the spinal column and the concave side of the intestinal convolutions, it follows that it is always more or less dragged on when the gut is protruded from the belly, forming a sort of cord by which the body is inclined forwards, and the tube drawn inwards. A constant traction is thus kept up, wdiich varies in degree in different cases, and which has occasionally been sufficient to destroy the adhesions between the bowel and the wall of the abdomen, causing fatal effusion into the cavity of the peritoneum.f The first and most important object to be attended to, in the treat- ment of this affection, is to prevent the escape of fecal matter at the artificial anus ; or, if this cannot be done, to apply some apparatus for receiving and retaining it. When the disease has been caused by a wound, or when the bowel has been only partially destroyed by gangrene, the former of these indications is generally easily fulfilled by means of a piece of gum-elastic, several lines thick, shaped like a nipple-shield, and large enough not only to cover the external ori- fice, but to extend some distance beyond it. This, being soft and flexible, readily accommodates itself to the various movements of the body, and answers the purpose much better than leather, tin, brass, or sheet-lead, recommended by some surgeons. It should be re- tained by a graduated compress and bandage ; or, what would be better, a common truss with a broad pad perforated in the centre for receiving the knob on the gum-elastic plate. To derive full benefit from this apparatus it might be so constructed as to have a projection on its posterior surface, carefully fitted into the abnormal opening. * Dupuytren, Diet, de Med. et Chir. Pratiques, T. iii. p. 130. f Dupuytren, Legons Orales, T. ii. p. 207. — London Medico Chir. Review, vol. ix, p. 315. ARTIFICIAL ANUS. 441 which it would thus more effectually close, at the same time that it would prevent the protrusion of the bowel, so liable to occur when the parts are imperfectly supported, or when the patient is in the erect position. When the feces cannot be made to pass along the natural channel, in consequence of the inordinate size of the septum between the two ends of the bowel, the patient may generally be rendered very com- fortable by wearing an apparatus for their reception and temporary retention. The older surgeons were in the habit of using, for this purpose, receptacles of leather, or horn, which were fastened round the body by bandages of particular construction. These contrivances, however, rarely fulfilled the intention for which they were constructed, as it was found not only difficult to adapt them accurately to the parts, but from the facility with which they imbibed moisture they soon became offensive, and required to be often renewed. The most perfect apparatus of this kind, perhaps, was constructed many years ago, by Juville, a celebrated Parisian truss-maker. It is delineated in his " Traite des Bandages Herniaires," and has occasionally been worn with great benefit. In its construction it is exceedingly compli- cated, and it is scarcely possible to convey a correct idea of it with- out a plate. It is composed of a common inguinal truss, the pad of which is made of ivory, and rests upon the margins of the artificial opening. To a hole in the centre of the pad is fitted a tube of gum- elastic, which is furnished with a valve, and directs the fecal matter to a silver receiver, fastened to the inner part of the thigh. The silver receptacle is of a flattened conical shape ; it is three inches in length by two inches and a half in breadth, and may be unscrewed and emptied without disturbing the rest of the instrument. The valve in the tube opens by its own weight when the patient is in the erect position, but shuts when he lies down, and prevents the accu- mulated fecal matter from reflowing into the artificial anus. When the apparatus is properly adjusted it is said to answer so well that the patient is able to pursue his ordinary occupation, and to escape the inconveniences arising from the discharge of feculent and other matter. If, notwithstanding the use of an apparatus of this kind, the feces are diffused over the surrounding surface, the utmost attention must be paid to cleanliness. Without this no comfort can be expected. If allowed to remain in contact with the skin, even for a short time, the acrid discharges not only induce pain and irritation, but they render the patient loathsome to himself, and disgusting to his friends. In fact, there is no situation in which a human being can be placed which is more pitiable and distressing, or better calculated to excite our sympathy. When inflammation arises, either in the part itself, or in the neigh- bouring integuments, it is to be combated by frequent ablutions, emollient poultices, and anodyne fomentations. If it part.ikes, as it sometimes does, of an erysipelatous character, it may be necessary, in addition to these means, to use leeches and blisters. The callo- sities which are so apt to form on the surface of the sore should be re- moved wTith the knife or scissors ; escharotics are to be avoided, as 442 ARTIFICIAL ANUS. they always give rise to severe pain, and rarely afford much relief. When the skin is ulcerated, fissured, chapped, excoriated, or studded with pustules, it should be thoroughly cleansed with a soft sponge and tepid water, after which it must be anointed with simple cerate, and covered with a slippery elm or linseed poultice. These dress- ings are to be continued as long as may be necessary, and renewed twice or three times in the twenty-four hours. Fistulous tracks, when they exist, must be incised, and their edges pared, to put them in a condition favourable to cicatrisation. The cure is sometimes much retarded, if not entirely prevented, by the perforated state of the parts; the skin, perhaps, is indurated and dis- organised, and fecal matter issues at various points, keeping up con- stant irritation and distress. In such a case it may become necessary to remove the affected structures, bowel and all, with the knife, to reduce them to the nature of a simple wound. Inanition is seldom to be apprehended when the artificial anus is seated in the large intestine, or low down in the small. In either event, abundant time is usually afforded to the chyliferous vessels for taking up the nutritious portion of the ingesta, and conveying it to the proper receptacles, before the contents of the tube reach the ab- normal outlet. When this, however, is situated higher up, the case may present a very different aspect, as the chymous matter may- escape too soon to enable the system to be much benefited by it. This circumstance is always known by the soft and lactescent nature of the discharge, by the voracious appetite, and by the progressive emaciation. The patient eats three or four times the accustomed quantity of food, his hunger is never appeased, he is thin and hag- gard, and has but little strength. To support life, which is occasion- ally much endangered by this occurrence, the individual must be kept perfectly quiet, the diet must be light, nutritious, and easy of digestion, the irritability of the bowels must be allayed by anodynes, and the outer opening must be wrell protected with an obturator. In bad and intractable cases, threatening life, advantage might be de- rived from the use of nutritious injections. When the bowel becomes prolapsed, as it is apt to do when the opening is not properly closed, the reduction is usually effected with great facility, by placing the patient on his back, and making gentle and well-directed pressure upon the part with the fingers of one hand, while the bowel is held between the thumb and fingers of the other. In more obstinate cases, the replacement may be attempted by syste- matic compression, while the patient is lying on his back ; this will have the.effect of emptying the protruded gut of its blood, and will often succeed after other and more simple means have failed. When the reduction is impracticable, the gut should be supported by a well adjusted apparatus, and the patient should refrain from laborious ex- ertion, from laughing and coughing, irregularities of diet, and from every thing tending to increase the swelling. When symptoms of strangulation arise, the most rigorous antiphlogistic measures are to be adopted ; blood is to be abstracted, both generally and locally, the patient is to be placed in the warm bath, and cloths, wrung out of tepid water, are to be constantly applied to the affected part. In ARTIFICIAL ANUS. 443 a word, the case is to be treated precisely as when the strangulation is produced by ordinary causes. When these remedies fail, relief must be attempted by an operation. The patient lying upon his back, near the edge of the bed, the surgeon takes a bistoury which he passes along the forefinger of the left hand, and makes a free in- cision through the integuments around the base of the tumour, which is generally sufficient to remove the stricture. Should this, however, be found not to be the case, it will be necessary to extend the in- cision into the end of the bowel, at its union with the margin of the abdominal orifice. Soon after the stricture is divided, the tension of the part subsides, the faeces flow out externally, the pain disap- pears, and the gut gradually becomes reducible. Artificial anus is susceptible of spontaneous cure. Of this numer- ous examples are on record, and there is scarcely a surgeon, at all ex- tensively engaged in practice, whojias not met with cases of it. The faeces, after having passed for weeks or months through the orifice in the abdomen, gradually resume their natural channel, the artificial anus closes up, and at length all that remains is a small cicatrice, in- dicating the situation of the former injury. Before we attempt the radical cure of an artificial anus by any method of treatment, however simple, it is proper that some attention should be paid to the general health of the patient. If this be much deranged, it is obvious that it should be rectified, otherwise the case may proceed badly, or even terminate fatally. The secretions are to be restored ; the diet is to be regulated ; the bowels must be moved by mild aperients ; and any local irritation that may exist is to be combated by frequent ablutions, anodyne fomentations, and emollient poultices. Leeching will seldom be necessary. This preliminary treatment is particularly called for when we wish to put in execution the operation of enterotomy, autoplasty, or even the more simple one of the seton. When the abdominal orifice is too small to admit of the ready ap- plication of the enterotome, the use of the plug, or the passage of the seton, it must be dilated with linen tents or gum-elastic bougies. The foreign substances should not be introduced too frequently, or too forcibly, or for too long a time ; and their use should not be attempt- ed until the parts are divested of their tenperness and irritability. By proceeding cautiously in this manner, taking care gradually to in- crease the size of the tent, the abnormal passage may generally be dilated to the requisite extent within from two to four weeks. When the edges of the track are very thick and callous, the treatment will be greatly expedited by excising them. After the operation has been performed, the patient must lie for sometime quietly upon his back, with the legs and knees drawn up, to relax the abdominal muscles and prevent undue compression of the parts. The diet must consist of nourishing broths or light soups, soft boiled rice, tapioca, arrow-root, or boiled milk and grated cracker. For his drink he may use demulcent fluids, as gum water, or flaxseed tea ; the bowels should be calmed by anodynes, and the natural stools promoted by stimulating enemata. In short, every thing is to be done to avoid inflammation, both in the parts more im- mediately concerned, and above all in the peritoneum. 444 ARTIFICIAL ANUS. Of the various operations that have been devised for the radical cure of this loathsome and disgusting affection, the first that attracts our attention is the suture. The idea of employing enteroraphy is generally supposed to have originated with Lecat. However this may be, it is certain that a female labouring under this infirmity was under the care of that celebrated surgeon in 1739, and would have been subjected to this treatment had she not become tired of the nu- merous attempts that had been made to replace the protruded and adherent gut. Desault, in the latter part of the last century, endeavoured to cure this disease by compression.* He was aware that the chief obstacle to the reparative process was the septum between the two ends of the tube, by which the feculent and other matters were diverted from their proper channel, and forced out at the preternatural orifice in the wall of the abdomen. The removal of this projecting piece consti- tutes, therefore, a most important indication in the treatment. To fulfil this, Desault used long linen tents, which he introduced and fixed in the two ends of the gut, taking care to renew them as often as they, became soiled and offensive, which generally happened once or twice in twenty-four hours. In this manner he gradually effaced the abnormal angle, and brought the two cylinders into a straight line ; at the same time he dilated the lower orifice, and thus placed it in a more favourable condition for receiving air and fecal matter. Along with these means he kept the outer opening closed by a well- adjusted compress, for the two-fold purpose of preventing the escape of the feces, and forcing them on towards the rectum. When the dilatation was sufficiently advanced and the intervening septum nearly effaced, he discontinued the long tents, and merely retained the external plug, applying it more superficially lest it should inter- fere with the transmission of the contents of the tube, and so become an obstacle to the restorative process. If it succeeds, the good ef- fects of this method" are announced by slight colicky pains and rum- bling noises in the belly, followed at first by a discharge of wind, and soon after by feculent and mucous matter. In proportion as the natural passages are re-established the outer orifice diminishes in size, and the griping subsides. The cure is expedited by a light but nu- tritious diet, perfect rest, and an occasional enema. Although this method of treatment has been repeatedly attended with the happiest results, it is obvious that it cannot be employed with a prospect of success in all cases. Of this Desault himself was fully aware, and he has enumerated, the following circumstances as particularly calculated to oppose the cure, or as so many contra-in- dications: first, where the gut has suffered great loss of substance; secondly, where the intervening septum is too short, prominent, or difficult to be broken down; and thirdly, where the ends of the bowel, one or both, have contracted such firm adhesions externally as to render it impracticable to effect their reduction. In addition to these considerations it maybe remarked that the process is generally very tedious, and well calculated to exhaust the patience both of the surgeon and the sufferer. * Surgical Works ; Translated by Smith, vol. i. p. 306. Philadelphia, 1814. ARTIFICIAL ANUS. 445 A more effectual and less tardy expedient than that of Desault was proposed, near the close of the last century, by Schmalkalken, a German surgeon ; and soon after by Dr. Physick, of Philadelphia. It consists in perforating the septum with a seton introduced by means of a curved needle, and allowed to remain long enough to excite adhesive inflammation between the two contiguous cylinders of the bowel. The period necessary for this varies from a week to a fortnight, at the expiration of which the foreign body is withdrawn, and the portion of the partition lying between the outer orifice and the opening of communication excised with a pair of scissors or other suitable instrument. In executing the operation, it is of no little importance that the track made by the instrument is accurately filled by the thread or tape, otherwise fecal matter might be effused into the peritoneal cavity. The seton ought to be carried as high up as possible, and care taken that it do not embrace a neighbouring fold of the intestine. Dupuytren proposed to destroy the septum by means of an instru- ment called the enterotome, and which is thus described in the se- cond volume of his surgical lectures. It consists of a screw and two branches, each aboutseven inches long. One of these, which is called the male branch, as it is received by the other, has a blade four inches in length, three lines in breadth, and half a line in thickness at its edge, which is undulated, and terminated by a spheroidal button. At the junction of the blade with the handle is a mortise several lines in extent; the handle itself is from two to three inches long, and has another mortise four lines broad, which runs nearly from one end to the other. The female branch is somewhat shorter. It is composed of two blades, of the same length, breadth, and thickness as the small blade, which is received in the gutter, groove, or sheath between them. The bottom ^ of this gutter is undulated, to correspond with the irregu- larities of the male branch, and at the extremity is a cavity for lodging the sphe- roidal button of the latter. At the union of the groove with the handle 38 446 ARTIFICIAL ANUS. is a moving pivot, which passes into the mortise of the other branch, and the handle itself is terminated by a hole to receive the screw. This last part of the enterotome, a screw of several threads, is an inch and a half long, and ends by an oval plate ; it is placed in the mor- tise of the male branch, and fixed in the. female, its use being to separate or close at pleasure the two blades. The accompanying wood-cut conveys an accurate idea of the nature of thisinstrument. a represents the male blade, b the female blade, c the joint, d the moving pivot, e the handles, and / the screw by which the branches are shut and locked. Before applying this instrument the surgeon satisfies himself of the precise situation of the lower opening of the gut, which it is by no means always easy to do, and places the patient upon his back near the edge of the bed, with the abdominal muscles completely relaxed. Taking one of the blades he conveys it upon the fore-finger into one of the orifices, to the requisite depth, and gives if to an assistant. The other, is then introduced in the same manner into the other extremity of the tube, when they are joined together, like a pair of obstetric forceps, by putting the tenon of the one into the mortise of the other. The partition must be embraced to an extent of one, two, or three inches, according to the nature of the case ; and the pressure, which is regulated by the screw, should be strong enough to destroy the vitality of the part the first few hours, as this will prevent pain and inflammation. It should afterwards be in- creased every forty-eight hours, until the enterotome falls off, which it usually does from the seventh to the tenth day, along with the mortified portion of the partition. The operation is rarely attended or followed by any unpleasant symptoms, and the opening which it leaves generally affords free passage to the fecal matter from one extremity of the bowel to the other. From a statement published by Dupuytren, it appears that from the time he first employed this'instrument until 1824, twenty-one operations had been performed by himself, and twenty by other practitioners. Three-fourths of the cases were caused by gangrene from strangulated hernia, and the remainder by penetrating wounds, with more or less loss of substance of the tube. Of the whole number thus treated three only died ; one from supposed fecal effu- sion into the abdomen, one from indigestion, and one from acute peritonitis. Of the thirty-eight that survived, none experienced any ill effects except a few who had colicky pains, nausea and vomiting, but were promptly relieved by effervescing draughts, leeches to the anus, and fomentations to the belly. The success was not equally great in all the cases. Twenty-nine were radically cured in from two to six months, and the rest retained,'in spite of all that could be done, fistulous openings, which compelled them constantly to wear a compress and bandage, to prevent the escape of air, mucus bile, and even teces. « It would thus appear," says Dupuytren "that the mortality from the use of the enterotome'is one in four- teen ; or, if we exclude the case of indigestion, which cannot be iairly ascribed to the application of the instrument, it is reduced to one in twenty; a result much more favourable than that which usually attends the great operations of surgery."] ASCITES. 447 In Ascites, or accumulation of fluid in the peritoneal cavity, the surgeon is not unfrequently called upon to relieve the patient, when the abdominal parietes are much distended, and the functions of the viscera of the abdomen and thorax interrupted. He must, however, exercise his own judgment in regard to the case, and convince him- self of the propriety of operating. He must examine into the symp- toms, and ascertain that the tumour is really caused by accumula- tion of fluid in the bag of the peritoneum. In ascites, the abdomen has swelled slowly and uniformly, and distinct fluctuation is felt when the hand is placed on one side of the swelling, and gentle tapping made at the other. There is considerable difficulty of breathing, un- easiness in the abdomen, usually increased by pressure, thirst, and scanty secretion of urine. It ought to be remembered that other affections have been confounded with ascites, and lamentable ope- rative mistakes committed in consequence. Trocars have been thrust into the belly for lympanitis, either of the bowels or of the peritoneum — for solid tumours of the viscera — for enlargement of the ovaria. As already hinted, the operation of tapping the abdomen is to be undertaken only when the distention is very great, when the func- tions of the thoracic and abdominal viscera are interfered with, and when diuretics, and other means of getting rid of the fluid, have failed to diminish the accumulation. The trocar employed is either flat, with a spring steel canula, or round ; wdien the latter is used, and the abdominal parietes are not very tense, a small incision is first made with a lancet or bistoury; a large trocar with blunted edges and point can then be readily and safely introduced ; the flat one enters easily, and requires no previous wound, but does not permit so rapid and free a flow. The point usually chosen for the puncture is either in the linea alba, a little below the umbilicus, the bladder being previously emptied, — a precaution which should always be attended to, though in general there is little danger of wounding this organ — or midway betwixt the superior anterior spinous process of the ilium and the umbilicus, with the view of penetrating the parietes in the linea semilunaris. The latter situation, however, can seldom be obtained with accuracy, for the parietes yield irregularly. Little bleeding follows the puncture at either point; but the risk of hemor rhage is greater at the latter, for branches of the circumflex artery may be wounded. More serious bleeding is liable to occur, from the veins ramifying on the abdominal viscera giving way, on removal of their support, as the serum flows off. Fainting also, may take place from accumulation in the branches of the vena portarum, unless the fluid is withdrawn slowly, and the precaution adopted of support- ing the parietes with a broad baud both during and after evacuation. Bandages are made for this purpose, with tapes and straps attached, and are well fitted for it. Three or four yards of flannel, however, with each end split, are equally effectual, and can always be readily- obtained— a consideration of consequence in the choice of all ap- paratus. After the hand has been applied, a person is placed on each side to tighten it gradually by steady pulling at the ends, which are carefully crossed behind. An opening is made in the cloth, opposite to where it is proposed to puncture, and the operation is 448 OF OVARIAN DISEASE. then proceeded in. Sometimes the flow is impeded by the omentum or a fold of bowel falling forward on the canula, and closing or di- minishing the opening; this is remedied by passing a tube along the canula, closed at the extremity, but perforated at the sides near it, and about half an inch longer than the canula. After the cavity has been emptied, the patient is placed recumbent, and a long broad flannel bandage applied over the whole abdomen, and retained, so as to prevent shifting, by straps passed over the shoulders and under the perineum. Collections occur in the ovaria. The fluid is generally glairy, sometimes thick and gelatinous, often turbid and dark coloured. Not unfrequently the main cyst is subdivided, either by membranous septa, or by an aggregation of smaller cysts of the nature of hydatids. The swelling is at first on one side, and gradually rises out of the pelvis; often it remains long movable ; it increases, becomes more fixed, and ultimately fills the abdomen, displacing the viscera, and giving rise to feelings of much uneasiness, deformity, and loss of health. The cyst is generally thick ; sometimes it is thin at one or more points, and this may give way, causing effusion of the contents into the peritoneal sac. Fluctuation is perceptible in many cases; in others it is obscured by the thickness of the cyst and viscidity of its contents. Many such swellings may be punctured both with advan- tage and with safety, but generally the tapping requires frequent repetition. Some patients require tapping, merely as a mean of improving the figure and relieving uneasy feelings, once, twice, or thrice a year; their existence is not much embittered or abridged by the disease. A large round trocar is necessary for the purpose ; and the puncture is made at the softest and most prominent point of the tumour, a small incision through the integument being premised. The ovaria become enlarged by degeneration of their structure and the addition of solid matter in great abundance. The consistence and structure of such tumours are very various ; they are sometimes, though rarely, medullary, often fibrous, with or without cysts, some- times melanotic. In the majority there are cysts, varying in size, number, and contents; sometimes the bag contains hydatids, or it is filled with curdy matter, sometimes with glairy colourless fluid, sometimes with a turbid and flaky serum, sometimes with blood; and in them, as well as in the enlargement from accumulated fluid^ though perhaps more rarely, are occasionally found teeth, hair, and membranous looking matter; some are intermixed with bone, carti- lage, and fat. The situation and attachments of such tumours cannot be correctly ascertained by examination during life, far less can their internal structure and dispositions be arrived at. Indeed an accurate diagnosis is exceedingly difficult, if not impossible. Innumerable mistakes have been made, which have led to most unjustifiable pro- ceedings. In one case, the abdomen was, after two or'three dry tappings, opened by an incision from the ensiform cartilage to the pubes; the viscera were turned over and over, but no tumour could be discovered. The woman was sewed up, and did not die The following was a still more complete failure in diagnosis. In a case Of ovarian disease. 449 of large tumour of the belly, many persons accustomed to manipulate abdominal swellings considered that extra- uterine conception had taken place ; and that the child had come to maturity and perished. The history of the case countenanced the supposition; the symptoms had been such as indicate impregnation. The woman, to avoid exposure, went to a distance to be relieved of her burden, which was becoming more and more troublesome and bulky. The usual period passed over. It was thought that the head and thorax of an infant could then be felt readily through the parietes, and perhaps some one might have been found heroic enough to have divided them and ex- plored the tumour. The young woman, however, was in the last stage of phthisis, and soon died. A wonderfully tuberculated omentum, a very small portion of w7hich is here represented, filled the peritoneal cavity ; the uterus and its appendages were quite healthy. Operation has also been proposed, when, on dissection, the liver was found to com- pose the abdominal spelling. Such cases, a long list of which might be given, render the prudent surgeon very cautious in his diagnosis of abdominal tumours, and chary of operative interference with them. The abdomen has been opened as already stated, and the result has been such as to render the perpetrator indictable for culpable homicide, and to qualify him for such punishment as his rash and reckless conduct richly deserved. A less severe censure might have sufficed, had not the example been followed by similar proceedings, and equally direful results ; and these have been such as to render any condemnatory remarks not only justifiable but absolutely necessary. A great many unfortunate women have, I am afraid, been sacrificed to a desire for false reputation. The attempts to remove abdominal tumours by incision of the parietes were some time ago very numerons ; and, as might have been expected, the issues were highly unsatisfactory- to those concerned. Such doings, however, were recorded in print, represented in plates, and more- over, puffed and placarded ad nauseam. The majority of those who were thus "dissected, to see what part was disaffected," perished within forty-eight hours. One woman survived for some time, after having been subjected to this operation, improperly so termed. In her there was a tumour, but of such a size, and so connected, that it could not be removed. A second survived the extirpation of one ovarium ; and the other, also diseased, was left for a further exhibit tion of daring intrepidity. It is not easy to conceive how the propo- sal could have been seriously entertained by any sane individual, far less put into practice and persevered in, when disaster after disaster 38* 450 OF OVARIAN DISEASE. crowned every attempt. It is my opinion, and I believe that I ex- press the sentiments of a very large portion of the profession, that the repetition of any such incisions and gropings would be unpardonable. —1. On account of the difficulty, nay, impossibility, of forming a correct diagnosis; of ascertaining with certainty what organ is in- volved ; of ascertaining the structure and disposition of the tumour, if any, and to what part it is adherent. 2. Because the ovarian dis- ease in general, even though extensive, does not threaten imminent- ly a fatal termination, being slow in its progress, and the greater number of the swellings being not of a malignant nature. The solid tumours are sometimes of a bad kind, as already stated; but en- largement by fluid is much more frequent in the ovaria than that by solid and new matter. 3. If the tumour be malignant, it will be im- possible to ascertain to what extent the parts are involved by the diseased action, or whether the lymphatics are affected or not. There is a strong probability of the lymphatic system being involved, even at a very early period : and then the extirpation of the tumour — sup- posing the mass to be so situated as to admit of removal without difficulty or danger — cannot be attended with any advantage; in every point of view, therefore, interference is inadvisable. 4. The operative attempt is attended with imminent danger. There is almost a certainty of the patient being almost instantly destroyed by it as shown by the sad experience of the past. " We are not the arbi- ters of life and death of those who apply to us for relief. If people die in consequence of disease it cannot be helped. They submit to it because they know it is inevitable. But wre had better refrain from making such experiments as may probably destroy them, and bring disgrace upon the profession." [Although I fully concur in the sentiments expressed in the text, yet I feel satisfied that the extirpation of the ovary is, under certain circumstances, not only justifiable, but highly proper. The great difficulty consists, not so much in the performance of the operation, as in knowing when it is absolutely indicated. That there are cases which do not admit of the knife, or rather, where the knife ought to be withheld, all educated, honest, and reflecting surgeons are agreed. The diagnosis of ovarian tumours is confessedly difficult, and hence no practitioner, however skilful, should ever think of re- sorting to the knife, unless all doubt is removed concerning the na- ture of the case. If he operates in the dark, discomfiture and dis- grace will be almost sure to be the result. In general, it may be stated that the employment of the knife is justifiable only in those cases where the tumour is perfectly free from adhesions ; and where the general health is so much undermined as to render it almost certain that the patient will die, if not speedily relieved of her disease. Under such circumstances, I should not hesitate to interfere, although the issue might be unfavourable ; I should feel that I had done my duty. Many operators content themselves with small incision, for fear of inflicting unnecessary violence upon the peritoneum ; others, on the contrary, make as large an opening as possible. In some of the cases recorded within the last few years, the knife wTas carried INJURIES OF THE ABDOMEN. 451 the whole length of the linea alba; the belly, in fact, was literally " ripped open;" and yet such is the power of nature, a considerable number of the patients thus treated recovered. Although I have long been of the opinion that surgeons have entertained too much dread of peritoneal inflammation after injuries and wounds of the abdomen, still, I cannot but regard such extensive incisions as altogether senseless and reprehensible. The opening should undoubtedly be sufficiently large to afford the operator an abundance of room, but beyond this the knife should not be carried.] Bruises of the abdomen are apt to be followed by inflammation of the contained parts, particularly of the serous membrane. Occasion- ally lacerations of the viscera, both solid and floating, but more fre- quently of the former are produced by bruising or squeezing of the abdomen, as by a blow, or by a heavy body passing over ; they may also follow a violent concussion of the parts by falling from a height. The liver is the organ most frequently torn, and death is commonly the result, rapid, and principally from hemorrhage. The laceration is generally on the convex surface ; extravasion takes place under the peritoneal covering ; or this is torn, and the effusion is into the abdominal cavity. When the quantity of blood is not so great as to cause speedy dissolution, the patient may survive for some time, and even ultimately recover. Reaction is slow, the patient continuing a long time pale, exhausted, and almost pulseless; there is tenderness in the hypogastric region, with swelling. The spleen is liable to similar injury, and pours out a large quantity of blood. The gall-bladder has sometimes been torn, as also portions of the small intestines, by a blow or a kick, or by a heavy body passing over the abdomen, as the wheel of a loaded wragon. The escape of the contents is followed by sickness, rigour, quick, weak, and indis- tinct pulse, most excruciating pain, a sense of heat diffused all over the abdomen, and rapid sinking of the powers of life ; a fatal termi- nation generally occurs within twelve hours. The same train of symptoms supervenes when the contents of the intestinal canal have been effused into the peritoneal cavity, through an opening in the stomach or bowel, caused either by slow destruction of the coats, the peritoneum giving way last, or by a rapid ulceration or sloughing process, as in hernia. The patient may live in agony for a day or two, but death generally takes place much within twenty-four hours. The same may be said of the rupture of the bladder, from external violence, with effusion of urine into the peritoneal sac. No treat- ment is of any avail; venesection hastens the sinking. Fomentation over the abdomen, and sedatives either by the mouth or by the anus, soothe the patient, and render his last moments more calm. Penetrating wounds of the peritoneal cavity, if they reach the solid viscera and large vessels connected with thern, are attended with effusion of blood externally and internally, in quantities propor- tioned to the size of the external aperture, the importance of the ves- sels concerned, and the, vascularity of the part. The patient may perish from the bleeding, either instantly or after some time ; or in- flammation and its consequences supervene in the violent form and 452 INJURIES OF THE ABDOMEN. destroy him at a more remote period. The mere opening of the peritoneal cavity, and to a very slight extent, without the slightest injury of the contained parts, is often attended with a great shock to the system, and is followed by inflammatory action, which may run on to a fatal issue, in spite of the most active and judicious manage- ment. The inflammatory symptoms are to be combated by free ab- straction of blood ; in short, the utmost endeavours must be made to keep the action within bounds. When the intestines are wounded, the injured part may protrude ; or the relative size of the openings through the parietes and bowel may be such, that the intestinal con- tents do not escape into the peritoneal bag. A natural cure some- times takes place by adhesion of the surface of the bowel to the lining of the parietes round the wound, feculent matter continuing to be dis- charged externally ; after a time the opening may contract, and the discharge diminish and ultimately cease; or an artificial anus may be permanently established, and this is not so easily cured as that following upon hernia. Wounds of the intestines, whether transverse or longitudinal, attended with feculent escape into the peritoneal cavity, are not uniformly fatal. Effusion of lymph takes place around, gluing the wounded bowel to the peritoneal surface of a neighbour- ing fold, or forming a sort of pouch within which the extravasation is limited. The treatment consists in absolute rest, and most rigid antiphlogistic regimen ; manual interference with the wounded part is not generally advisable. [The symptoms of a wounded bowel necessarily divide themselves into two classes^ into those, namely, which are furnished by the sys- tem at large, and those which are peculiar to the part more directly and immediately implicated. In regard to the first, they are such, generally, as denote a severe shock of the nervous system, but as they are common to this and other injuries, they are of little conse- quence in enabling us to make out the diagnosis. In almost all in- stances there is nausea, either alone, or accompanied with vomiting; these symptoms often make their appearance within a few minutes after the infliction of the wound, and continue with great obstinacy for several successive days, or, in fatal cases, until death relieves the patient of his suffering. They are commonly more violent and dis- tressing in lesions of the small than of the large bowel, owing to the more delicate organisation of the former than of the latter, and to its more intimate connexion with the stomach and the sympathetic nerves. The prostration of the vital powers is not always in propor- tion to the extent of the wound, or the danger of the case. Some persons, it is well-known, suffer much more severely from a slight than others do from a violent injury, for reasons which cannot always be explained, but which may be supposed, generally, to be depend- ent upon some constitutional peculiarity. Reaction is often post- poned for ten or fifteen hours after the occurrence of the accident, and until it is fairly established there is sometimes a constant ten- dency to syncope, with an alarmed and agitated state of the mind, which it is almost impossible to calm or subdue. The countenance under such circumstances has a pale, anxious, and haggard expres- sion ; the pulse is small, frequent, and tremulous ; the skin is bathed INJURIES OF THE ABDOMEN. 453 with clammy perspiration; the extremities are cold; the patient tosses about in his bed ; the thirst is urgent, as is also the desire for cool air; there are griping pains in the abdomen ; and occasionally the discharges from the bowels are involuntary. Conjoined with these symptoms there is sometimes slight delirium with partial blind- ness or indistinctness of vision. The local symptoms of a wounded intestine are often as equivocal as those which are furnished by the constitution. This must, indeed, always be the case when there is no protrusion of the tube, or when the external opening is so small, or its direction and situation are such, as to prevent effectually the escape of feces or other matters. It not unfrequently happens that an instrument enters the abdomen, and passes out at the opposite side, directly in the course of the bowels, without in any w7ise interfering wTith them. Many interest- ing and instructive cases of this kind are recorded by writers on military surgery, as well as by civil practitioners, and several will be quoted hereafter in illustration of this part of the subject. The most characteristic signs of this lesion are, unquestionably, the escape of feces, bile, food or fetid air from the external wound, and the sud- den development of tympanites. The latter symptom, which does not appear to have been sufficiently insisted upon by systematic wai- ters, as very few, if any, mention it, is often present when the others are absent, and may therefore be regarded as in some degree patho- gnomonic. Jobert thinks it is the most valuable and positive sign of a wound of the intestine that we can have when there is no external opening, or only so small a one as not to permit the egress of ster- coraceous or other substances. He relates several instances from his own practice and that of others, in which, by this phenomenon alone, the diagnosis was clearly established. The tympanites supervenes at various periods, from a few minutes to several hours, after the occurrence of the accident, and is always attended with a hollow, drumlike sound on percussion, with tenderness on pressure, and diffi- culty of respiration. Tympanites, however, does not attend all traumatic injuries of the intestinal canal. When the opening is very small, amounting rather to a puncture than a wTound, the escape of gas will either be entirely prevented, or occur only in a small degree, owing to the protrusion of the mucous membrane, which, as was seen in a previous part of this essay, is a constant phenomenon in lesions of this description. A sort of valve is thus formed, which opposes an effectual barrier to the egress of fecal matter, intestinal secretions, and even air. A discharge of blood from the anus is another symptom which, in connexion with some of those already pointed out, is of considerable importance in the discrimination of the lesion before us. Still, as it may, and often does attend other injuries, it cannot be regarded as at all characteristic. The quantity of blood evacuated occasionally amounts to many ounces. In a case which I saw along wTith Pro- fessor Mussey and Dr. Williams of Cincinnati, at least two pints of fluid and grumous blood were discharged during the first three days. It began to pass off seven hours after the occurrence of the injury, nearly unmixed with feces, and comparatively fresh in its appear- 454 INJURIES OF THE ABDOMEN. ance. What was subsequently evacuated was of a darker colour, and more firmly coagulated, as if it had been retained for some time in the bowel. Equally equivocal is hematemesis, or vomiting of blood, which may be enumerated as another, though by no means constant symptom of traumatic lesion of the alimentary tube. The degree of pain accompanying wounds of the intestines varies remarkably in different individuals, being very slight in some, and exceedingly severe in others. In most instances it is of a colicky character, though occasionally it is dull and aching, and it is almost constantly increased by pressure, by coughing, and by a full inspir- ation, especially if some hours have elapsed since the infliction of the injury. The wound is occasionally complicated with hemorrhage into the peritoneal sac, caused by lesion of the epigastric or internal mam- mary artery, of some of the branches of the mesentery or omentum, of the aorta or vena cava or of some of their immediate offsets. Unless the abdominal wound be large, very little blood, if any, will appear externally, but it will flow into the serous cavity, where it will occupy the intervals between the intestinal convolutions, descend into the pelvis, or be extensively diffused among the viscera. The amount and rapidity of the effusion will vary in proportion to the size of the wound and the volume of the vessel concerned. When the vessel is very large and the opening considerable, the hemorrhage may be instantly fatal, or death may ensue in a few hours. In cases of an opposite character, the symptoms will be less urgent, and the patient probably suffer no inconvenience, save what results from the temporary debility and faintness. The blood will soon coagulate, and by the pressure which it exerts upon the orifice of the bleeding vessel, a mechanical obstacle will be opposed to its further effusion. When the quantity of fluid poured out is considerable a tumour is sometimes formed, which may be easily detected by its promi- nence and hard feel. If the patient survive the immediate shock of the accident, he may die from inflammation, caused by the clotted blood acting as an extraneous substance. At other times the coagula are absorbed, or they become encysted by an exudation of plastic lymph. In the diagnosis of a wTounded bowel, important information may frequently be obtained, in regard to the direction, extent, and depth of the lesion, by a careful consideration of the shape and size of the vulnerating body. When the outer opening is so large as to admit the finger, it will generally be easy to determine whether the injury reaches the cavity of the abdomen : probing with instruments is quite inadmissible ; it can do no good, and may occasion much harm. It need hardly be observed that it is highly proper, in every inquiry of this kind, to place the patient as nearly as possible into the posture in which he was at the moment of the accident. When the wounded bowel protrudes atjthe external opening, the diagnosis is at once ob- vious, as the nature and extent of the injury may fje determined by- simple inspection. The lesion, in the absence of pathognomonic symptoms, ought to be suspected when nausea and vomiting occur INJURIES OF THE ABDOMEN. 455 after penetrating wounds of the abdomen, accompanied with griping pains, great debility and faintness, jactitation, extreme anxiety, and cold sweats. The case is plain enough when there is a discharge of the contents of the alimentary tube, or a sudden development of tympanites. It not unfrequently happens that an instrument or a ball enters the abdomen, and passes out at the opposite side, without, in the slight- est degree, interfering with the bowels or other viscera. Many in- teresting cases of the kind are related by writers. The prognosis of wounds of the intestines must necessarily be in- fluenced by a great variety of circumstances, such, particularly, as the extent of the mischief, the nature of the vulnerating body, and the state of the patient's health at the time of the accident. A small and simple lesion will be much more likely to turn out favourably than one involving a large surface, or one complicated with injury of some other organ, or the perforation of a large vessel. It is also less serious in an incised than in a contused or lacerated wound, and in a superficial than a deep one. Persons occasionally perish from the most trivial accidents of this kind, from the mere shock proba- bly of the nervous system ; they lie in a pale and exhausted condi- tion, and death takes place unpreceded by reaction. On the other hand, recovery sometimes occurs under circumstances apparently the most desperate and unpromising. No certain rule can, therefore, be laid down in respect to the prognosis of wrounds of this description ; wbich, however, must always be considered as severe accidents, likely to be followed by the worst consequences. Wounds of the large bowel wTere regarded by the ancient surgeons as less serious than those of the small; a view in which most modern authors seem to concur. The reason of this difference is, first, the more fixed condition of the lower portion of the tube ; secondly, its more capa- cious calibre ; and thirdly, the more solid nature of its contents. These circumstances may all be supposed to be favourable to the prevention of the effusion of fecal matter. Extravasation will also be less apt to occur when the bowel is empty than wdien distended. When the contents of the bowel are effused over the peritoneum, death is sure to take place from the effects of inflammation. Occa- sionally, as was before intimated, life seems to be destroyed by the shock sustained by the nervous system within a few hours after the accident, and before the constitution has had time to rally. The fecal extravasation, when slight, is sometimes limited by the depo- sition of plastic lymph, and the discharge of it is ultimately pro- moted by the formation of an abscess; or chronic action is estab- lished in the serous membrane, and the patient, after weeks or months of suffering, sinks under the exhausting influence of the malady. In the great majority of instances, however, death is in- duced by acute peritoneal inflammation. The symptoms presented are violent burning pain of the abdomen writh great tenderness on pressure ; intense thirst; a sharp, frequent, and contracted state of the pulse ; constipation of the bowels ; coldness of the extremities; constant wakefulness ; great anxiety and restlessness. In the latter stages there is generally some degree of nausea with occasional vo- 456 INJURIES OF THE ABDOMEN. miting; the pulse is weak and fluttering ; the surface is bathed with a cold clammy sweat ; the features are collapsed ; the breathing is oppressed and laborious ; the belly extremely tense and tumid; the patient is harassed with cough, his strength rapidly forsakes him, and he dies under all the symptoms of one sinking under the effects of mortification. The attack rarely continues beyond forty-eight hours, and often terminates fatally in a much shorter period. The appearances after death are always well marked when the disease has been protracted. The peritoneal surface is highly inflamed, the bowels are covered with lymph, and the abdominal cavity usually contains a small quantity of turbid serum. The intestinal coils are frequently united to each other and to the neighbouring parts, and on penetrating the belly there is almost always an escape of fetid gas. In the management of injuries of this kind, the surgeon, as was long ago observed by Mr. Travers, cannot too strictly attend to the following points; first, the accurate closure of the intestinal wound ; secondly, the careful reduction of the protruded part ; and, thirdly, the union of the divided integuments. The treatment of the two wounds is thus made perfectly distinct, the internal suture falls into the bowel, and the wffiole process is materially simplified. The closure of the internal wound may be effected either with the glover's suture, as it is called, or with the interrupted suture, as modi- fied and improved by Lembert. Either of these methods will an- swer the purpose, and they should both be excuted in the most care- ful manner, with a long slender sewing needle, armed with a waxed and strong but very delicate silk thread. In making the glover's or continued suture, the instrument should be carried through the cel- lulo-fibrous lamellae, between the muscular and mucous membranes, and not across all the tunics, as is generally advised by authors. The INJURIES OF THE ABDOMEN. 457 lips of the wound should be held parallel with each other dur- ing the operation, and the stitches, drawn with considerable firmness should not be more than a line, or at farthest, the eighth of an inch apart. The needle is to be introduced at a short distance, say half a line, from the peritoneal edge of the opening, and brought out at a corresponding point on the opposite side. The first stitch should be one line from one angle of the wound, and about the same distance from the other, care being taken to secure each with a double knot, and to cut off the extremities of the suture close to the surface of the tube. The continued suture is exhibited in the annexed figure. In the method of Lembert, the number of needles employed corre- sponds with the number of sutures designed to be made ; each is armed with a separate ligature. The annexed drawings will fully explain the nature of the operation, which is performed in the fol- lowing manner. A short stitch, including only the peritoneal and muscular coats, is to be taken up on one side of the wound, distant about a quarter of an inch from its edge ; the needle is then carried across the solution of continuity, and a similar stitch taken up on the opposite side ; in this way one suture is to be placed after the other, the interval between each two varying from two to three lines, and when they are all arranged they are to be drawn firmly together and tied with a double knot. By this proceeding, the incision is com- pletely closed, the serous surfaces are intimately approximated, and the lips of the wound are inverted or turned inwards, forming a kind of valve, about the twelfth of an inch long, within the tube. The ends of the threads are cut off close to the knots. My conviction, founded on numerous experiments upon dogs, and a careful examination of a great many published cases, is that the above are the only sutures which should be thought of in the manage- ment of this class of injuries. Whichever of them be employed, the operator should never lose sight of the important principle, already 39 458 INJURIES OF THE ABDOMEN. adverted to, of closing the opening in the bowel in such a manner as to prevent the escape of fecal matter. By guarding against this oc- currence, the patient will run comparatively little risk of perishing from peritoneal inflammation. The ligatures employed in sewing up a wounded intestine are detached at a period varying from ten days to three or four weeks, according to the nature of the suture. When the extremities are cut off close to the knots, they invariably fall into the cavity of the bowel, and are finally discharged along with the feces; if, on the other hand, they are brought out at the external opening, they pass off in that direction instead of the one just mentioned. When the Opening in the gut is small, not exceeding three or four lines in extent, the margins may sometimes be advantageously en- circled with a ligature, with the ends cut off close to the peritonea] surface. Sir Astley Cooper tied up an aperture in this manner in the human subject, in a case of strangulated hernia, and the patient recovered without a bad symptom. Professor Gibson, of the Uni- versity of Pennsylvania, states that he has performed a similar ope- ration with similar results. My experiments on dogs convince me that the plan is a good one. The ligature should be drawn pretty firmly, to prevent it from slipping, and the ends must be cut off close to the knot. It generally makes its way into the bowel in from eight to ten days. When the bowel is completely severed, or mortified in its entire calibre, the edges, after being properly prepared, should'be brought in contact, and retained by the continued or the interrupted suture. Cases of this kind, although apparently desperate, are not always of so hopeless a.character as might at first sight be supposed. This is shown, not only by experiments on the inferior animals, but by wdiat occurs in the human subject, in sphacelated hernia, and in intussus- ception. In the former, the greater part, or even the whole, of the circumference of the tube may be destroyed, and yet the patient ulti- mately recover, with perhaps the temporary inconvenience merely of an artificial anus ; and in the latter, large pieces are not unfrequently detached without any serious suffering, save what is experienced during the antecedent and concomitant inflammation. In my mor- bid collection is a preparation of this kind, evidently a portion of the colon, nearly a foot long, which was discharged by a child six years old, who, notwithstanding, made a speedy and perfect recovery. Thirty-five cases of a similar character, collected from the writings of different pathologists, have been reported by Dr. Thomson of Europe.* In a dog, from which I removed two inches and a half of the ilium, and treated the edges of the wound with six interrupted sutures, complete recovery took place, unattended with a single bad symptom. The threads were introduced at equal distances from each other, with a small sewing-needle, and the ends cut off close to the knots. Four months after the operation, being in good health, and the outer wound entirely healed, he was killed. Externally the bowel was perfectly smooth and natural, as if no injury had ever been * See the Editor's Elements of Path. Anatomy, vol. ii. p. 260. INJURIES OF THE ABDOMEN. 459 inflicted upon it; the mucous membrane was of the same appearance as elsewhere, with the exception of a small depression corresponding with the edges of the wound. After the sutures have been properly secured, the protruded parts, especially if covered with dirt, feces, or blood, are carefully cleansed with tepid water, squeezed upon them by means of a sponge held some distance off. The stream thus produced is well calculated to detach the foreign substance, whatever it may be, without the risk of inducing additional irritation. In no case should the bowel be sponged or wiped. If the extraneous matter adhere with much firm- ness, it may be picked off wrifh a pair of forceps. The patient, during the reduction, should lie upon his back, with the head sup- ported by a pillow, the pelvis should be higher than the knees, and the lower extremities bent at the hips and knees. When these arrangements are effected, the surgeon, standing at the side of the bed, takes the bowel into the left hand, while with the right he gently pushes it back, taking care to begin with the part which was protruded last, or which is nearest the wound. These efforts are to be continued until the whole slips into the abdominal cavity. When the omentum is prolapsed along writh the bowel, it should always be reduced last, and care taken to spread it out as much as possible over the parts which it naturally covers. This may generally be easily done by means of the index finger of the right hand introduced into the peritoneal sac, and is calculated to prevent the subsequent protrusion of the membrane between the edges of the wound, a cir- cumstance wdiich is very apt to occur when this precaution is neglected. When the outer opening is too small to admit of the ready return of the extruded parts, it must be enlarged with a probe- pointed bistoury. The bowel having been replaced, the edges of the external wound are approximated, and kept in contact with adhesive straps, aided by a compress and broad roller. There are few cases in which sutures are called for. Should it become necessary, however, on account of the great size of the wound, to employ them, care must be taken not to injure the peritoneum, or to let them remain beyond forty-eight hours, for fear of their exciting undue irritation. The quilled suture may occasionally be required, but in general the interrupted is preferable. After the bowel has been restored to its natural situation, the first and most important object is to guard against the occurrence of peritoneal inflammation, as it is upon this that the safety of the case mainly depends. Perfect quietude in the recumbent posture, the early and copious abstraction of blood, especially if the patient be plethoric, or the wound extensive, and the most rigid observance of the antiphlogistic regimen, are the means upon which our reliance is to be placed in the first instance. If the bowels be not evacuated spontaneously in six or eight hours after the parts have been returned, a stimulating enema should be thrown into the rectum, but under no circumstances should the alimentary canal be disturbed by the ad- ministration of purgative medicines by the mouth, as these, however mild, will be likely to cause griping pains and to interfere with the 460 INJURIES OF THE ABDOMEN. reparative process. This plan is to be persisted in for at least three or four days, when a dose of castor oil may be given, or, which would be better, an ounce of sulphate of magnesia or soda. The more fluid the alvine matters can be rendered the less likely will they be to be arrested at the affected part, to derange the sutures, or to disturb the healing process. All drastic articles must be sedu- lously avoided, on account of their tendency to create gastric irri- tation, and to excite undue peristaltic action of the bowels; two circumstances concerning which we cannot be too much on our guard. The pulse should be attentively watched, and as soon as reaction is fully established, blood must be taken from the arm by a large orifice, and while the patient is in the semi-erect posture. The amount to be abstracted must vary according to the indications of the case, particularly the age and constitution of the individual, the return, continuance, or increase of the local pain, the force and frequency of the pulse, and the extent of the injury. The first bleed- ing ought, in general, to be tolerably copious, but after this eight or ten ounces at each repetition will be sufficient. In this way we prevent inflammatory action, or moderate it, where it has already taken place, without inducing too much prostration. It should be recollected that the pulse in peritonitis is hard, wiry, and contracted, and that the practitioner, if he be not fully aware of this, will be apt to fall into the error of omitting the abstraction of blood at a period when it is loudly called for, and when it can alone be of any avail in arresting the progress of the malady. General bleeding, however, is not always admissible. The shock which the system has received may be unusually severe; the reaction may be tardy and imperfect; and the patient may perhaps be for several days in a dozing state, with a weak and tremulous pulse, cold extremeties, and great pallor of the countenance. In such a case, instead of taking blood from the arm, the practitioner must content himself with fomentations to the abdomen, consisting simply of warm water, or of water in which hops, opium, or poppy heads have been infused, and frequently re- newed. Even leeches are scarcely to be thought of. Where the stomach is irritable, mustard poultices are to be applied to the epi- gastric region; and if the patient is unable, as he occasionally is, to void his urine, it must be drawn off with the catheter. If cough be present, it is to be combated by the usual means, and not allowed to progress, as the concussion thus induced might prove highly detri- mental. When the patient is harassed with colicky pains, relief may be attempted by laudanum or the salts of morphia, but as the effect of these and similar articles is to create constipation, they should be employed as sparingly as possible. The tenesmus which is sometimes present is to be allayed by anodyne injections or sup- positories; and where there is much discharge of blood from the bowels, the acetate of lead may be administered in large and re- peated doses. When there is much tumefaction of the abdomen with gastric irritability, and tenderness on pressure, Baron Larrey* advises cup- * Surgical Essays, translated by Dr. Revere, p. 235. INJURIES OF THE ABDOMEN. 461 ping, aided by camphorated and oily embrocations, emollient cata- plasms, and anodyne' enemata. In a case, apparently of the most hopeless character, in which this practice was put in force, the disease yielded in a very short time, not, however, without vesication of the whole surface of the abdomen. With cupping I have no experience in the treatment of peritoneal inflammation, traumatic, or otherwise, but it seems to me that it would be attended with so much suffering. to the patient as to preclude its employment in most, if not in all cases of the kind. Leeching wrould certainly be preferable. The diet must be of the most simple nature. For the first fortnight or three weeks, it should consist chiefly of amylaceous articles, as arrow root, tapioca or sago ; afterwards it may be more nutritious, but must still be fluid. Solid, stimulating, or flatulent food is not to be used for several months after the accident. Cases are recorded where, from disregard of this precaution, the patient fell a victim to his imprudence, when he was apparently out of all danger. As a constant drink, nothing is better than cold water, flax-seed tea, slippery-elm water, or a solution of gum arabic, simple or acidulated. In a word, the patient should be half-starved, and as much depleted as is consistent with the restorative process. Our treatment must be prompt and energetic. No time is to be lost, or the case will slip out of our hands. The great error with most practitioners is that they do not abstract blood sufficiently early, or before peritoneal inflammation is thoroughly established, or has made such inroads upon the system as to render it impossible to arrest its progress. The dressings must be light, simple, and unirritating. If there be a discharge of feculent matter, as there may be when the internal wound has not been properly sewed up, or even where there has been no protrusion in the first instance, it should be disturbed as little as possible, until there is reason to believe that the bowel has contracted firm adhesions to the surrounding parts. By disregarding this precaution fatal effects might ensue from the extravasation of the matter into the peritoneal cavity. During the whole treatment the utmost attention should be paid to cleanliness. As the external opening diminishes, means are to employed to prevent the escape of feces, by which the patient will be rendered more comfortable, and the healing process expedited. When the patient is well enough to sit up or walkabout, the weak^ ened parts should be supported by a compress and broad bandage, or, what is better, a good truss, which should be worn day and night, to prevent the separation of the edges of the sore, and the protrusion of the contents of the abdomen. This caution, as has been justly observed by Mr. Benjamin Bell, ought to be persisted in for a con- siderable time after the cure has been completed. By a want of attention to this point, very troublesome cases of hernia have oc- curred, which might otherwise have been obviated, Patientj who have recovered from wounds of this kind must pay particular attention to their bowels, which should be kept in a soluble condition, and on no account be allowed to be costive, even for a single day. They should also be extremely temperate in their diet, and carefully masticate their food before it is swallowed. All rough 39* 462 OF LUMBAR ABSCESS. exercise, as riding on horse-back, jumping, running, and even rapid walking, must be avoided.] Lumbar Abscess is generally chronic; the collection of matter is gradual and slow. Sometimes it is acute, and rather rapid in its ap- pearance. It may originate in the sheath either of the psoas or of the iliacus muscle; more frequently it seems to form behind these, and is connected with diseased bone. The precursory symptoms are often not particularly attended to; these are rigors and pain of the loins. As the disease advances, the patient feels great pain in the erect position, and in general the pain is aggravated by extending the thigh. Thickening and slight glandular enlargement takes place in the groin ; there is an evident fulness there ; and then swelling appears on the inner side of the femoral vessels, beneath the pubal portion of the fascia lata. This swelling is more prominent in the erect position, and is also increased by exertion of the abdominal muscles; an impulse is given to it on coughing. As it advances, and comes more to the surface, fluctuation is perceived. This is the most common site in whirh the abscess presents itself; but it is not unfrequently met with on the outside of the vessels, either lower or higher in the thigh, above Poupart's ligament, in the loins over the crest of the ilium, and occasionally the matter is insinuated under the pelvic fascia and appears by the side of the anus. Large and neglected collections may work their way to the surface in two or three of these situations at the same time. The disease is often attributable to a sprain or wrench of the loins, or to exposure to cold and over-fatigue. Occasionally the mischief is confined entirely to the soft parts ; the vertebrae, a portion of the os innominatum, or the sacrum, may be denuded and of irregular surface, but this is evidently the result of the pressure of the abscess. A striking example of this, and of the extensive destruction of parts which this affection sometimes produces, may be shortly stated.— A very large lumbar abscess formed within a few weeks, in conse- quence of great and continued fatigue and exposure to bad weather. At first it had been trifled with. At last it was opened in the usual situation in the thigh, and a vast quantity of matter evacuated. Thirty-six hours afterwards, the patient was suddenly suffocated by a flow of purulent matter into and through the air passages. On dissection, the cavity of the abscess was found to be immense, open- ing through the diaphragm into the lung which was adherent, and communicating with the bronchi. The forepart of the lumbar ver- tebrae was exposed, and in some parts stripped of the theca; but there were no cavities in the bone, and no disease of the interposed cartilages. Such cases are now and then met with, of abscess in the loins not originating in any vice either of the bones or of any other part of the apparatus of the spinal column. Most frequently, how-' ever, the collections have their foundation in ulceration of the bodies of the vertebrae. The patient has had tenderness in the part, weak- ness of the back and of the lower limbs, and increase of pain on pressing or striking some particular spinous processes — perhaps slight excurvation. Then pain in extending the thigh supervenes, followed by swelling and other signs of abscess. This is preceded OF LUMBAR ABSCESS. 463 generally by deposit of tubercular matter in their cancellated tex- ture. Sometimes the disease seems to originate in the ligaments and articulating surfaces; occasionally portions of the bone perish, and are found lying in the cavity of the abscess, as seen in this specimen, taken from a young subject. When the bodies of the vertebrae are attacked by ulcerative absorption, and sometimes the disease is very extensive, in- volving perhaps four, five, or six of the bones, there is more or less curvature of the spine outwardly — excurvation. If the dis- ease affects one or two bones, and their bodies are almost destroyed, then the pro- jection is sharp and angular. When the disease is more extensive the curve is greater, and more gradual ulceration sometimes ex- ists to a considerable extent in one articula- tion, without change of form externally in the spinal column, and sometimes without any great collection of pus. When curvature commences there is very generally more or less weakness of the limbs, though curvature, whether from ulceration or interstitial absorption, is by no means of necessity attended by any degree of paralysis. The power of motion of parts supplied by nerves in the neighbourhood of disease is dimi- nished earlier in general than the sensation, in consequence, possibly, of the mischief commencing in the anterior part of the bodies of the vertebrae. It is wonderful to what extent disease may extend in the vertebral column, without much impairment of the functions of the 464 • OF SPINA BIFIDA. spinal chord, and how perfectly the functions are restored in cases where it has suffered. The lumbar vertebrae are those most fre- quently affected, but the ulceration may also be either' in the dorsal region or in the pelvis. Diseases of the last lumbar vertebra at its con- nexion with the sacrum, or disease of the sacrum itself, is attended with abscess around, which descends into the pelvis, displacing the bowel, and appearing by the side of the buttock. Such abscesses may have been allowed to come to the surface, and to discharge their contents spontaneously ; or they may have been at a late period opened either at one point or at several. In these circumstances, the discharge is generally profuse, long-continued, and attended with exhaustion and hectic, gradually but surely de- stroying the patient. But, by good management, a perfect and per- manent recovery may in many cases be obtained. When the vertebrae are affected, absolute rest must be enjoined and enforced ; and a drain is to be established by the sides of the spinous process, either by moxa, potassa, or seton—it is immaterial which. The discharge is kept up by occasionally dressing the issue for a few hours with an acrid ointment, so as to reproduce a slough. When the abscess begins to present, it should be opened as early as possible, and a free exit allowed to the matter: the discharge should be at no time con- fined. The opening of the cavity, and again shutting it up, how- ever carefully conducted, is in almost every instance followed by alarming and hazardous results. Rapid accumulation of putrid and bloody matter takes place, and air is extricated within the cavity; the vessels of the cyst, being unsupported, part with their contents; irritative fever is lighted up, with rapid pulse, anxious countenance, and delirium. These symptoms are relieved only by immediate evacuation of the fluid. Some slight constitutional disturbance fol- lows the making of a free opening, but quickly subsides ; then the discharge improves in quality, becomes more pure and unmixed, diminishes in quantity and gradually ceases. During the discharge the strength requires support: and the attention to the original mis- chief must not be neglected or intermitted. Spina Bifida is a congenital fluctuating tumour, with deficiency of the subjacent vertebrae. It is usually situated in the lumbar region, sometimes in the dorsal, and often over the sacrum. The size of the swelling varies according to the age of the child, and the extent of deficiency in the parietes of the spinal canal. The spinous pro- cesses are either imperfect or altogether wanting, and over the space so formed the tumour is situated. Its contents are usually of a serous character, thin and colourless; sometimes they are turbid and flaky. The parietes seem to be a continuation, or protrusion, of the membranes of the spinal chord, thickened and somewhat altered in structure, and usually in close contact with and adherent to the in- teguments. By pressure the size of the tumour is diminished; but, if firm or long continued, unpleasant effects are apt to result.' There is often debility of the lower limbs, and the disease is not unfrequently coexistent with hydrocephalus. Children writh this affection seldom live more than a few years. OF HEMORRHOIDS OR PILES. 465 The application of gentle, uniform, and continued pressure affords support to the parts, and prevents increase of the tumour; and, under this palliative treatment, life may be both rendered more comfortable and prolonged. It has been proposed to combine continued pressure with occasional puncturing of the cyst by means of a fine needle, with the view of diminishing the tumour and ultimately obtaining entire obliteration of the cyst. The practice has been made trial of, and the result may warrant repetition; caution, however, is ne- cessary, for the too free opening of the tumour is often followed by a rapidly fatal issue. A case occurred to me not long since, in which the tumour, of large size, was situated over the sacrum. The fluid was evacuated by a small trocar and canula, the parietes shrank, and a very satisfactory cure resulted. AFFECTIONS OF THE RECTUM AND NEIGHBOURING PARTS. Of Hemorrhoids or Piles. — Piks are blind, furnishing no dis- charge except a mucous or puriform fluid ; or open, pouring out a greater or less quantity of blood from time to time. They are usually of small size, invested by mucous membrane, thickened, congested, and consequently of. a dark colour ; and either within the sphincter or projecting extensively. Internally they may sometimes consist of blood, coagulated or not, effused between the mucous and mus- cular coats of the intestine ; but in general their inner structure is venous, at least in the first instance. Branches of the hemorrhoidal veins, ramifying near the inner surface of the gut, become varicose, probably from their superior trunks being compressed by hardened feculent matter or other obstructions. The varix protrudes the super- imposed mucous membrane ; and at first the excresence is composed of the dilated venous trunks containing fluid blood, and invested by the membrane, which inflames, thickens, loses its villous character, and discharges a vitiated secretion. In this stage the tumour is easily compressible, and by pressure may be made to disappear al- most entirely, the communications between the varicose vessels and the trunks above being still unobstructed, But inflammatory action is soon kindled in the incommoded venous branches, as frequently happens in varix of the lower extremities ; their coats become changed, are thickened, effuse lymph externally and internally, ad- here to one another, and are ultimately matted into one confused and solid mass : the contained blood coagulates, becoming fibrinous, the whole tumour feels hard and firm, and often is exceedingly painful. At length all traces of venous structure disappear; the tumour seems to consist chiefly of effused lymph, condensed cellular tissue and coagula. In not a few instances, however, the contents of the veins remain partially fluid, and a communication exists between the vessels of the tumour and those of the surrounding parts. That such is the usual structure of piles I am convinced, from re- peated and careful dissection of the tumours. [My own observations and dissections have demonstrated to me that there are two distinct and well marked varieties of hemor- 466 OF HEMORRHOIDS OR PILES. rhoidal tumours ; one of which essentially consists in an enlarge- ment of the capillary vessels of the mucous and submucous cellular tissue, the other in the formation of a small sac filled with fluid, coagulated, or organised blood. The latter, situated at the verge of the anus, or immediately within it, are composed partly of skin, partly of mucous membrane ; they vary in size, from a pea to that of a small marble, are of a red florid complexion, hard and ten- der to the touch, and exquisitely painful when inflamed. The blood which they contain is at first fluid, but soon coagulates, and ulti- mately, if allowed to remain, becomes organised. Hence, in cases of long standing, the tumour is generally of a hard gristly con- sistence, pale, and free from pain, producing no other than me- chanical inconvenience. In the other variety, the tumour is situated within the bowel, from six lines to two inches above the external orifice. Consisting, as was before intimated, in a varicose condition of the capillary vessels, especially the venous, it is soft and compressible, of a deep purple colour, extremely liable to bleed, and of various sizes, from a small bean to that of an almond or upwards. It rarely occurs as an isolat- ed swelling, but in groups or clusters, as many as six or eight being sometimes situated upon a surface not more than an inch and a half or two inches in diameter.] The neighbouring parts often swell and inflame. Sometimes one or two tumours only exist; or they occur in numbers, clustered to- gether, and form a large irregular mass, inflamed, and often ulcerated. Acute pain is experienced in the part, when touched and after strain- ing at stool j by straining too such as are attached within the sphinc- ter are pushed out, together with folds of the mucous membrane, and, if allowed to remain, are constricted by the sphincter, swell in consequence, ulcerate or slough, and discharge blood. The bleed- ing often is very violent in such cases, or when the tumour is punc- tured ; the blood flowing in great quantity, and a rapid stream. The hemorrhage is often periodical, both in males and females ; in the latter, it would seem occasionally to take the place of the men- strual flux. The soft bluish tumours that are compressible, and fluctuate when large, furnish blood more readily and profusely than the hard and tuberculated. Much irritation is produced by piles, and some of them are more irritable than others. There are often extensive excoriations of the nates around, and profuse discharge from the raw parts, particularly when the tumours are external. In such cases, flat, hard, warty ex- cresences often form in the cleft or the nates, and increase the iririta- tion ; and these are termed fici, mariscae, and condylomata. In internal piles a frequent desire to go to stool is induced, and more or less of the mucous coat of the rectum is protruded and swollen. The tumour, along with the protruded portion of bowel, may become strangulated if not replaced. By such or other causes inflammation is excited, which often extends to the neighbouring parts, and terminates in abscess ; but this is not so apt to occur from tu- mours seated high in the rectum as from those about the verge of the anus. INFLAMMATION OF THE RECTUM, 467 The usual cause of piles is obstruction to the return of blood in the hemorrhoidal veins ; and this may be occasioned by advanced preg- nancy, habitual distention of the colon and sigmoid flexure, with hardened feces, or tumours of the abdominal viscera. Inflammation of the Rectum is attended with excruciating pain, burning heat, and a feeling of contraction, increased very much when the parts are thrown into action by evacuation of the contents of the bowel, or of the bladder. The heat may be felt on introducing the finger, with the view of examination ; by doing so, dreadful torture is produced, and such manipulation should not be had recourse to unless there is a suspicion of foreign matter lodging in the part, by removal of which the action might be cut short. The bladder is often affected sympathetically ; there may be frequent desire to empty it, or else retention of its contents : this latter occurrence not unfre- quently follows operations on the bowel, as for the removal of he- morrhoids, by ligature or extensive incision, which is neither war- rantable nor requisite. The inflammation extends to the cellular tissue round the rectum, with swelling and increased pain ; the pain is aggravated by pressure, and the patient is unable to sit erect. As the painful symptoms abate, puriform discharge from the membrane of the gut takes place, and often is very profuse. The morbid ac- tion sometimes extends to the other intestines, attended after a time with mucous or even bloody evacuations. When the affection is confined to the rectum, the feces and vitiated secretion are distinct from each other, and the former are usually of their natural appear- ance ; but when the other intestines participate, to a greater or less extent, the feces are fluid, and intimately mixed with the morbid secretion. . Ulceration of the mucous coat, with continued discharge, often supervenes. Sometimes the peritoneal coat of the bowel is affected secondarily, and then the pain is much more acute and more aggra- vated by pressure. Patients affected with hemorrhoidal swellings, — the action of whose bowels is irregular, and in whom the vessels about the anus are congested, — are peculiarly liable to inflammation and abscess in the rectum or its neighbourhood, from the application of cold or wet to the surface, particularly that of the lower part of the body. Asca- rides often produce violent irritation in the extremity of the rectum, both in children and in adults ; and the morbid excitation is com- municated to the bladder, as will afterwards be noticed. Not unfre- quently the inflammation is induced by a foreign body, either lodging in the cavity of the bowel or imbedded in its coats — as hardened feculent matter, alvine and biliary concretions, bones of small ani- mals, needles, pins. Effusion often takes place into the loose cellular tissue round the bowel, with hard swelling, followed by unhealthy and extensive suppuration. Rigors generally precede the formation of matter, and violent fever almost always attends, abating, along with all the pain- ful feelings, on evacuation of the fluid. Still the discharge continues, and the patient is kept uncomfortable and unhappy. Resolution can 468 INFLAMMATION OF THE RECTUM. very rarely be produced; suppuration is the almost uniform termi- nation of the action, and in persons of bad habit this sometimes occurs in these parts without any assignable cause, and without previous warning. The purulent collections are often very exten- sive, both externally and internally, the integuments are all under- mined, and in some cases it is difficult to ascertain the depth of the abscess, even with the aid of a long probe. ' Owing to the loose nature of the texture surrounding the gut, abscesses near the anus often attain a great size, and extend deeply before there is much external indication of their existence ; a hard- ness is felt on pressing the fingers deeply by the side of the tuber- osity of the ischium ; this is at first obscure, but gradually becomes more developed ; and at last a small dark red spot appears, indi- cating that the matter has approached the surface, and is most superficial at the part. But the surgeon should not wait for the pointing here, as the matter may burrow much previously, and ab- scess form in the substance of the sphincter, or exterior to it. If the matter does not cause ulceration of the coats of the intestine, and escape into its cavity, pointing takes place, and the pus is dischurged externally, in general through a small opening. The matter is of a very offensive odour. The external aperture, and even the whole cavity of the abscess, may be at a distance from the gut, but in most cases the matter is close to it: its coats are denuded, and often ulcer- ated through. The surrounding degree of induration, the quantity of contained matter, the extent of the cavity, and the situation of the opening, vary almost in every instance. Cases occur of induration, often very extensive, in the neighbour- hood of the anus, on one or both sides, with dark discoloration of the integuments, and burning pain. The affection resembles car- buncle. The precursory symptoms are soon followed by partial suppuration, and extensiva sloughing of the cellular tissue. At first there is excitement of the system, but symptoms of debility, and flag- ging of the vital powers, soon present themselves — irregular pulse, delirium, disordered stomach, hiccough, vomiting, and cold extremi- ties. The disease is one of great danger, and the patient can be saved only by free and early incision, and the judicious employment of stimulants. In some instances the inflammation is merely superficial, seated merely in the integuments, and followed by slow collection of matter. It is indeed seldom that a cavity formed by abscess near the anus fills up entirely, however large and free the opening into it may have been. The parietes contract, but the hardness around is not entirely dissipated ; the opening may close for a little while, but is soon found again discharging, and may continue to do so for months or years. A sinus is thus formed. Fresh collections and openings, either exter- nally or internally, are apt to occur, with extensive induration of the cellular tissue, and disease of the gut. Instead of a single sinus, a number of collateral ones are formed, all running into the main canal, like branches to a common-sewer, or by-lanes opening into one spacious street. The disease is one of frequent occurrence amongst females; and often from a false sense of delicacy its exist- FISTULA. 469 ence is not declared till it has advanced to a state of truly horrible perfection. Fistula is generally the consequence of abscess in the cellular substance near the anus. By the term is understood a sinus or track, with narrow orifice and hard parietes, discharging thin gleety mat- ter. If the track extends from the cavity of the gut to the surface, flatus must often pass through the narrow and tortuous canal, and, from a peculiar noise being produced by its passage, the name of Fistula has probably been adopted. The term cannot be properly applied to recent cavities of abscesses, but only when their sacs have contracted, their lining has become callous, and their discharge thin and almost colourless. The fistula may be one of three varieties—blind external, blind internal, complete. The first denoting that the sinus opens exter- nally, but does not communicate, either at its origin or elsewhere, with the cavity of the bowel. The second, that it communicates with the bowel, but does not open externally. The last, that it both communicates with the bowrel and opens externally. Some contend that fistulae are are always complete, that they commence from within, and that the internal opening is always at one particular point; but such, according to my experience, is far from being the case. Fistulae occur in children, though rarely ; generally in people ad- vanced in life. The cavity of the sinus, after long continuance, be- comes coated with an expansion resembling mucous membrane, and secretes a discharge of mucous character. In every case, it is necessary that the surgeon should ascertain, as accurately as possible, the extent and nature of the fistula; and, with this view, examination with the probe is requisite. The probe is introduced into the canal, when the fistula is an external one, and directed through its windings, so as to discover its direction, length, and divarications; the guidance of the instrument is facilitated, and the information augmented, by the fore-finger being placed in the rectum. Sometimes all the by-paths cannot be detected, until the orifice of the canal is enlarged. When the fistula is complete, the probe, entered at the external extremity, can be passed into the bowel so as to be felt by the finger in the rectum ; but it must be remembered that the internal opening is not always at the inner ter- mination of the sinus, but often seated more externally—the cellu- lar tissue being destroyed to a considerable-extent above it, so as to form a large unhealthy abscess, communicating with the main track of the fistula. But the gut may not be opened into, though denuded to a large extent, and forming part of the walls of the sinus; and in some instances, the sinus may not come within a considerable dis- tance of the bowel. An internal fistula is more difficult of detection. The symptoms leading to a suspicion of its existence are — puriform discharge from the bowel, increased on going to stool, and then accompanied with tenesmus ; pressure on the side of the anus, causing pain, and some- times an augmentation of discharge ; and in many instances hard- 40 470 STRICTURES. ness, deeply seated, is felt. On introducing the finger into the rec- tum, the aperture in the coats of the bowel is perceived, or a part of the bowel feels more boggy and tender than the rest; through this point a curved probe, introduced along the finger, may be passed into the sinus, and being then directed downwards, reaches the outer extremity of the canal, causes the integuments to project, or is rea- dily felt from the surface. The internal opening is usually imme- diately within the sphincter, seldom higher.* The discharge, in ge- neral, is rather profuse, the bowel is very irritable, desire to eva- cuate it is frequent, and the feces are often tinged with blood. There is a sensation of itching about the fundament, the heat of the parts is felt by the patient to be increased, he is unable to bear pressure there, and sits on one buttock; in most cases the bladder sympa- thises considerably. The giving way of the bowel may be produced by ulceration commencing in the mucous membrane, but is more fre- quently the result of inflammatory action in the surrounding cellular tissue. The aperture is the seat of acute pain when pressed upon, and during evacuation of the bowel. Great light is thrown on such cases by the use of a proper speculum. But its introduction can seldom be borne in cases of inflammation, abscess, or recent fistula. In ulceration of the coats within the sphincter it is useful. Consi- derable information can certainly be obtained by the finger ; but to the sense of touch, however acute, it is better, when admissible, to add that of vision. The speculum, made of silver or steel, and having its internal surface highly polished, is introduced gently into the anus, and expanded fully ; and by changing the situation of the instrument, and holding a light so as to illuminate the interior, the surface of the bowTel for five or six inches above theanus can be examined accurately, as if it were an external part of the body. Simple indurations and contractions of the lower part of the bowel follow' long-continued irritation and inflammation of its parietes. The part is not an uncommon seat of stricture, and sometimes the bowel is constricted at two or more points near each other ; frequently the * Until recently it was the opinion of surgeons, almost universally, that the fistula opened into the bowel at the distance of from two to three inches from the anal outlet; an error which ofted led to severe and hazardous operations, by which the unfortunate patient was sometimes rendered miserable for life. Mons. Ribes of Paris, who was the first to investigate the subject in a careful and extended manner, ascertained that the internal orifice is generally situated im- mediately above the place where the lining membrane of the rectum unites with the skin, sometimes a little higher, but never more than five or six lines. In eighty subjects affected wiih this malady it did not exceed this elevation, and in a considerable number it was not higher than a third or fourth of an inch. In my own operations and dissections I have rarely found the internal aperture more than a line or two above the internal sphincter muscle. The observations of the late Professor Bushe, of New York, tend to a similar conclu- sion. — Ed. STRICTURES. 471 stricture is extensive and firm, in other cases it is narrow, consisting merely of a thin band. It is often complicated with fistula ; if so, the internal aperture is immediately above the stricture, and is caused by ulceration ; abscess sometimes forms above the stricture, destroys the coats of the bowel at that point, burrows around, and not unfre- quently points at a great distance from its origin ; or sloughing and ulceration may take place in the coats of the bowel, and feculent matter be discharged through the opening of the abscess. In fe- males, the vagina may be opened into in consequence of unhealthy suppuration in the cellular tissue, between that organ and the gut. The existence of stricture is in general readily ascertained by ex- amination with the finger; its most common situation is here shown ; the medical practitioner must not suppose that every obstruction, however slight, to the passage of a bougie into the bowel is owing to organic disease ; the top of the sacrum naturally projecting for- wards on the commencement of the rectum, in some degree opposes the entrance of any large body, and this circumstance is laid hold of by the unprincpled or ignorant; the patient is very often declared to labour under stricture of the bowel, when none exists. Some prac- titioners discover stricture in almost every patient with disordered digestion; the whole digestive apparatus is certainly thrown into disorder by obstruction in the lower part, but this obstruction is for- tunately rare. In cases of tight stricture, the bowels are distended with feces and flatus ; and if evacuation is not procured vomiting ensues, followed by enteritic symptoms, as in strangulation of the higher bowels. The gut above the stricture is always more or less dilated. The symptoms which lead the surgeon to suspect the existence of stricture, are — difficulty in voiding the excrements ; a long time oc- cupied in the evacuation, with pain and much straining; small thin portions of feculent matter coming away, when the matter is consist- ent; discharge of puriform fluid, mixed with a slimy mucus; itching and heat in the parts ; and irritability of the urinary organs. Strictures of the urethra and rectum often coexist, as exemplified by the following case : — A middle-aged man, when in Holland, la- 472 SCHIRRO-CONTRACTED RECTUM. boured under a very deep and extensive fistula in ano. Sinuses were divided in all directions, and some healed ; one, however, re- mained open, leading towards the gut from near the tuberosity of the ischium on the left side. He was desired to keep this open by means of bougies, which, as many were used, he manufactured himself out of cloth and plaster. On one occasion a portion passed deeply, and could not be extracted ; but his alarm at this occurrence w-as ap- peased on being told that the foreign body would be absorbed. His condition at that time was very miserable ; and inflammation was often excited in the parts, with fresh collections of matter. At the same time, he laboured under stricture of the rectum and urethra. He applied to me fifteen years after the commencement of the dis- ease. Then the most troublesome symptom was a constant itching in the perineum, and round the anus, preventing sleep, and causing much excoriation from involuntary scratching; besides, he was an- noyed by seminal emissions, and frequent desire to make water. I first divided a small internal fistula, and some time afterwards ope- rated on a large complete one ; in the latter instance, a foreign body was felt deep in the wound, the incision was extended, and a large portion of bougie, firmly impacted, was with some difficulty with- drawn. Some days after, other portions of bougie were extracted along with numerous hairs; and these continued to be discharged for many weeks. The symptoms were much relieved. An occa- sional itching remained, but disappeared after the cure of a very bad stricture in the urethra. He recovered perfectly from the complica- tion of d'seases. Schirro-contracted Rectum, a malignant and truly horrible disease, may be the consequence of inflammatory action, or of neglected stric- ture. The neighbouring parts are involved in cartilaginous indura- tion ; the surface of the bowel is lobulated and ulcerated, its cavity is contracted, and the discharge is profuse, sanious, bloody, and putrid ; there is frequent desire to void the contents of the gut, but in general nothing but flatus and puriform fluid is evacuated ; when feces do pass, dreadful pain is excited, and continues for some time. The difficulty of voiding feculent matter becomes greater and greater, frequent attacks of ileus occur, and in one of them the patient ex- pires. During the progress of the disease, the functions of the blad- der become disturbed ; change of structure in it and in the vagina takes place ; and frequently the cavities of the rectum, bladder, and vagina are laid into one by inveterate and malignant ulceration. The affection is more common in females than in males, and rarely occurs in young persons. The countenance has the sallow hue pecu- liar to carcinoma, and in the advanced form of the disease becomes still more cadaverous from profuse discharge of matter and frequent hemorrhage. The cellular tissue, anterior to the rectum, is liable to become the seat of tumour. Malignant medullary formations occasionally form here, causing most distressing symptoms; by displacing the bowel they may obstruct its canal, and simulate stricture or schirro-con- traction. PROLAPSUS ANI. 473 Prolapsus Ani. Folds of the lining membrane of the lower por- tion of the rectum are apt to protrude during evacuation, as already mentioned, in those labouring under hemorrhoids. These are readily replaced, and the painful feelings relieved, if the attempts be made before swelling and engorgement of the vessels and cellular tissue take place. Protrusion, however, is sometimes to a great extent; the sphincter is relaxed, and the lower part of the bowel is retained within it with difficulty ; indeed there is often more of the lining membrane of the gut without the sphincter than within it. The mu- cous lining becomes insensible, thickened, and white ; and the pa- tient is subject to attacks of inflammation, with additional swelling, excoriations, and ulcers of the parts. Slight protrusion is very com- mon, and patients who have long laboured under it are in the habit of reducing the bowel after every stool, in the intervals wearing a supporting bandage. They are subject, however, to constant unea- siness, and more or less puriform discharge from the parts ; often there is a flow of blood while at stool ; the health is undermined, and comfort diminished ; all exertions are gone through with diffi- culty, and undertaken with reluctance. During exertion protrusion is almost certain to occur, and apt to be increased. The part most commonly prolapsed in time becomes hard, thick, and in a measure insensible ; and new7 folds appear on extraordinary straining at stool, in coughing, or any exertion of the abdominal muscles. Tumours occasionally grow from the coats of the rectum, and are of various consistence. They may be either vascular, or deposited in consequence of increased vascular action, and afterwards increased by addition of solid matter. They are to be removed either by liga- ture or incision, according to their situation, nature, and attach- ments. Foreign bodies may lodge in the rectum — as bones, portions of hard indigestible meat, &c, introduced by the mouth—or clyster- 40* 474 TREATMENT OF DISEASES OF THE RECTUM. pipes, bougies, &c, which have been passed up per anum. From being the source of constant irritation, and obstructing the functions of the part they demand removal. Alvine concretions are now rare ; they are usually situated in the caput caecum coli, sometimes in the sigmoid flexure, or in the arch of the colon; they may descend into the rectum, and lodge there. Children are sometimes born with the anus imperforate, the ex- tremity of the rectum being covered merely by integument, or the bowel terminating an inch or two above the usual site of the anus ; or the rectum may be wholly deficient. In the last case, the colon may end in a blind sac at the fundus of the bladder, or it may open either into that viscus or into the vagina. Treatment of Affections of the Rectum. — In the treatment of hemorrhoids, the cause should be removed if possible ; and this may suffice for the cure. When the tumours are recent and small, they may be made to disappear by the use of astringent ointments or de- coctions, as of galls, kino, oak-bark, and by sedulous attention to cleanliness of the part. In inflamed tumours, blood may be extracted by leeches or punctures, and hot fomentations afterwards used. Re- cent hemorrhoids are sometimes got rid of at once by the puncture of a lancet,* by which a clot of grumous blood is discharged, with immediate subsidence of the swelling, and abatement of pain. When constriction of the internal tumours or folds of bowel by the sphincter has occurred, the tumour should be replaced if possible. In irrita- bility of the sphincter, a bougie is sometimes used w-ith advantage ; and incision of the muscle, by which rest is afforded to the parts, will often effect a cure, after the failure of all other means : this is essen- tial when rugged ulcers or fissures occupy the orifice ; the division may be made on either side, certainly not in the mesial line. In most cases, the tumour must be got rid of by the knife or ligature. When the piles are internal, removal by ligature is to be preferred ; the patient being made to strain, and thereby bring the tumours as low as possible, a ligature is placed round the base of the swelling, provided its form conveniently admits of it; otherwise the base is pierced by a fixed needle armed wTith a double ligature, the separate portions of which are applied tightly to the corresponding parts of the base. This operation is very inconsiderately and indiscriminately employed. It can only be warrantable when the tumours are so large as to obstruct the orifice so perfectly as to prevent evacuation, unless they are extruded. Before proceeding to this measure, the * This is undoubtedly the treatment which should always be adopted in the sacculated variety of the disease, as it is not only free from danger, but affords the most speedy and effectual relief. If the blood, upon the presence of which the irritation and swelling mainly depend, be allowed to remain, it finally becomes organised, and s > incorporated with the walls of the tumour that it is impossible to dispose of it in any other way than by excising the whole excres- cence.— Ed. TREATMENT OF DISEASES OF THE RECTUM. 475 bowels should be emptied by mild and repeated purgatives, and af- terwards all stimuli should be avoided. It is imprudent to apply ligature to several tumours at once, for serious consequences will most probably ensue, inflammation of the bowel, obstinate constipa- tion, and general excitement.* Excision of such piles is contrain- dicated by the risk of profuse hemorrhage. The bleeding is into the cavity of the bowel, a coagulum is there formed which encour- ages the flow; and from this cause, and the peculiar situation of the bleeding point, it is with difficulty-arrested. When the tumours are external, ligature may certainly be adopted ; but here there is no ob- jection to the use of the knife, and excision is much less painful and more speedy. The tumours, along with protruded portions of the mucous lining of the rectum that cannot be reduced, and are changed in structure and function, are readily taken away by the rapid stroke of sharp curved scissors. Or they may be laid hold of and stretched, and their base divided by one or more sweeps of a bistoury. The removal of these tumours, or of a portion of the loose fold of skin or altered mucous membrane which occupies the sphincter in the direc- tion of the bowel, is in general followed by a cure of the prolapsus. The sphincter now acts fully, and on the cicatrisation of the open sur- face contraction of the tissues occurs to such an extent as to produce a permanent cure without interference with the internal parts. Should hemorrhage follow upon the removal of external tumours or folds, the surgeon has it completely under command. Pressure by a large gra- duated compress is generally sufficient. In inflammation of the rectum, the exciting cause often is not dis- covered ; when detected it should be removed without delay. In simple inflammation of the part with violent fever, general bleeding may be required ; and in all cases blood should be abstracted locally and freely. Leeches are to be applied to the verge of the anus, and the lower part of the perineum, and hot fomentations afterwards used. Internal antiphlogistics are at the same time not to be ne- glected. In retention of urine, or great irritability of the bladder, in consequence of the affection of the rectum, the perineum should be leeched and fomented, perhaps, also, the lower part of the abdo- men ; the use of the catheter should be avoided if possible. When induration takes place in the cellular tissue by the side of the anus, or in the perineum, suppuration must in all probability occur, and poultices, with occasional fomentation, are to be used, though only * My own experience does not accord, in this instance, with that of the distinguished author. I can recall to mind at least six or eight cases, several of them in delicate females in dilapidated health, in none of which I used less than two ligatures, and in some as many as three or four, without any serious consequences whatever. When the tumours are numerous, it can never be necessary to tie more than three or four at a time, since the inflammation thus induced generally exter Is to those around and effects their obliteration. It is always preferable, indeed, to repeat the operation, than to run the risk of producing too much irritation. — Ed. 476 TREATMENT OF DISEASES OF THE RECTUM. for a short time ; for, as already mentioned, pointing of the matter is not to be waited for in this situation ; incision must be had re- course to early, in order to prevent bad consequences. Leeching is sometimes used here, as in purulent formations in other parts, from gross ignorance of the real state of matters ; and sometimes their use is continued after fluctuation is distinct, and until the pus begins to ooze through the leech-bites; such is very useless and very dan- gerous practice ; in most cases the internal parts are extensively de- stroyed before the matter comes spontaneously to the surface. In the carbunculous state of the cellular tissue, near the rectum, with extensive infiltration, dark integument, and a tendency to sloughing, an early and free opening must be made wherever matter is suspected to have formed, however deeply seated, and in what- ever quantity, and whether the parts are indurated or not; nothing but mischief can result from delay. When the cellular substance is destroyed, the incision must be proportionally extensive, to afford a free exit for slough as well as matter. During the suppuration which follows, the system will require good support, and most probably a free administration of stimuli. It has been recommended that, in abscess extending along the gut, the cavities of the bowel and abscess should be at once laid into one by incision. I have done so, but always found the cure to be tedious. It is better that the matter should first be evacuated through an ex- ternal opening, that the painful symptoms and constitutional disturb- ance should be allowed to subside ; and that after the cavity has contracted, and the extent of the sinus has been ascertained, the operation should be performed. In the operation the knife is now employed ; but in former times the ligature and cautery were in constant use. The old surgeons supposed that there was something malignant in the hardness and callosity attending this disease, and were not contented with opening the cavities, but endeavoured to dissect out the whole parts; and, if foiled in this, they finished the work with a red-hot iron. Indeed the practice of excision was re- cently in vogue in the Parisian hospitals. But the operation for fistula has been much simplified. The bowel is generally so much separated from its connexions as to be incapa- ble of again adhering, or of furnishing granulations; and, though capable, healing is effectually prevented by the frequent motion of the parts caused by the action of the sphincter and levator of the anus. One side of the cavity is fixed, whilst the other is in mo- tion. It becomes necessary to lay the cavities of the bowel and of the fistula into one. This can generally be effected with great ease ; a salutary degree of excitement follows the use of the knife, rest to the parts is procured, the edges are allowed to retract and adhere to the opposite surface, and the wound heals quickly from the bottom. The surgeon, in his operative procedure on these parts, must use both hands equally well, otherwise he must vary his position, and often put his patient in a very awkward predicament, more particu- larly if a female. The patient is placed in a stooping posture, with the legs unbent, or kneeling on a chair, and resting his arms on its back, the fundament being turned towards the light. The surgeon TREATMENT OF DISEASES OF THE RECTUM. 477 inserts the finger, well soaped and oiled, into the rectum, and with the other hand insinuates a curved probe-pointed bistoury into the sinus, using the instrument merely as a probe. Having reached the extreme depth of the canal, the direction of the instrument's point is changed so as to apply its cutting surface to the coats of the bowel, at that part. The instrument on being thus passed into the bowel is fixed by the finger, and by drawing both outwards, the coats of the bowel and the parts intervening between them and the sinus are divided. All collateral sinuses extending towards the perineum and buttock must be freely divided, for they cannot be expected to contract otherwise. Such is all that is necessary in the generality of cases ; but it is evident that the steps of the operation, and the extent and number of incisions, must be varied according to cir- cumstances. A great part of the affected bowel may be pulled down by a director before being cut, as is sometimes done ; but the prac- tice is useless and painful. Should hemorrhage take place, it may be restrained by stuffing the wound gently with lint; if this fail, the bleeding vessels are to be secured by ligature ; but this is seldom necessary. The bdwels should be well cleared out before the ope- ration, so that two or more days may pass over without the parts ^ being required to perform their functions; and, if the bowels are naturally loose, opiates maybe administered. Afterwards copious evacuation is to be procured by enemata or gentle laxatives. It is necessary to prevent the external part of the wound from adhering, until the whole has contracted equally, and begun to be filled up by granulations from the bottom ; and with this view a piece of lint is interposed between the margins. Stuffing the wound daily with large dossils of lint, smeared or not with irritating ointments, is at- tended with much pain, and certainly impedes the cure. The dress- ing should be simple and light, and introduced with gentleness and care. The first should be allowed to remain undisturbed till spon- taneously discharged along with the feculent matter. In the greater number of cases, a second: interposition of dressing is all that is re- quired. In all cases, dressing should not be continued long ; but as the cavity gradually contracts, discharging laudable pus, and be- coming coated with healthy florid granulations, the interposed pledgets should be daily diminished, and soon omitted entirely. If the surgeon continue long to stuff the wound it cannot contract, will become callous as before, and a fistula will be reproduced. Injec- tions into the wound, or the application of lint soaked in a gently stimulating lotion, are often beneficial in promoting contraction. But, as already stated, most fistulas get well after proper incision, with but one or two dressings, and without any after application except- ing abundance of soap and water. During the cure, the general health must be kept vigorous, and the state of the bowels strictly attended to. In ulcer of the mucous lining, with irritability' of action in the bowel, injections of tepid or cold water are useful, by removing irri- tating matters from the part. By means of a speculum ani the ulcer can be readily exposed ; it may be touched occasionally with the nitrate of silver, in substance or solution, or, if very indolent, with a 478 TREATMENT OF DISEASES OF THE RECTUM. solution of the bichloride of mercury. When the irritation is very great, and the lower part of the bowel frequently in a state of spas- modic action, the sphincter may be divided so as to allow the parts to remain quiet; and anodyne suppositories or soothing enemata will then be used with much greater advantage than previously. To ob- tain reparation of breach of structure in any part, rest is a principal part of the treatment; and in the case of the rectum and other mu- cous canals it is pre-eminently required. Strictures of the rectum are treated by bougies of wood, plaster, or elastic gum, introduced at intervals, and gradually enlarged. The bougie should be smooth in the surface, and rounded at the point; also slightly curved, so as to suit the figure of the bowel; and with a narrow neck, so as to remain without the irritation caused by dis- tention of the sphincter. At first it should be of such a size as can without much difficulty be pushed past the stricture, and, as this re- laxes, the size of the instrument must be proportionally increased till it completely fills the bowel when dilated to the natural calibre. The bougie may at each time be retained from a quarter of an hour to an hour, according to the feelings of the patient. Suppositories and enemata are at the same time employed ; the latter to clear out the lower bowels, the former to allay the irritation which accompa- nies the disease, and which maybe increased temporarily by the bougies. When the stricture is callous, and will not yield by dilata- tion, it may be divided with the knife, and notched at various points of its circumference ; and, when the parts have begun to granulate, recourse to the bougie will soon effect a cure. When fistula and stricture coexist, both are got rid of at once by the usual operation for the former, and by the after treatment peculiar to each. In malignant contractions of the gut, all that can be done is to palliate the disease by anodynes, administered by the mouth, or ap- plied topically. Injections, bland, and occasionally anodyne, tend to diminish irritation; bougies aggravate the disease. At the com- mencement, the diseased parts may be removed by the knife or by- ligature, and relief and exemption follow, at least for a time ; but no operation is warrantable in this or any other cancerous affection, when the morbid action has gained ground, and the disease is ex- tensive. Female patients have by some been cruelly treated ; the vagina and diseased bowel have been laid into one loathsome ca- vity, and though the patients have continued to pass excrement and discharge through this cloaca, with the symptoms undiminished, themselves miserable and obnoxious to others— still such cases have been reported as cures ! In prolapsus ani, the protruded parts are to be carefully reduced, and kept so by means of a compress supported by a T bandage ; often a spring with a pad is used with advantage. In inflamed pro- lapsus, with ulceration of the mucous coat, the patient is confined to the recumbent posture, and soothing applications employed ; and when thus the irritation has been removed reduction is performed ; but the bowel seldom remains up till after the ulcerations have been healed. In chronic obstinate cases,, the altered parts within the verge are removed by the knife or scissors with safety ; contraction TREATMENT OF DISEASES OF THE RECTUM. 479 attends the cicatrisation, and so further protrusion, as already no- ticed, is prevented. [Much may be accomplished in chronic cases by means of astrin- gent injections, of which the best perhaps is a solution of alum in a decoction of oak-bark, in the proportion of two drachms of the one to a pint of the other. From two to three ounces of this should be thrown up the rectum twice a day; the bowels being at the same time kept in a soluble state by gentle laxatives, and the patient com- pelled to void his feces in the standing posture. In cases of an in- veterate kind, in which the ordinary remedies prove unavailing, the operation of Dupuytren, which consists in cutting away some of the radiating folds of the skin around the anus, generally affords prompt and effectual relief. When the protruded part is large, it may be necessary to excise from four to six of these folds, and to prolong the incisions into the rectum as far as the junction of the skin with the mucous membrane. The object of this operation is to produce a diminution of the orifice of the anus, which it does by the cica- trisation and contraction of the little wounds made in the operation.] By the speculum ani, assisting the eye and finger, the nature and position of foreign bodies in the rectum are ascertained, and their removal facilitated. They are to be extracted by the finger, by a scoop, or by forceps. It has been proposed by some to cut into the colon from behind, so as to open that part of the bowel which is un- connected with the peritoneum, when it is distinctly ascertained that alvine concretions lodge there. This might be put in practice when the case is clear and the symptoms urgent, but, as already observed, such foreign bodies are now very rarely met with. In imperforate anus, when the bowel terminates high, it has been proposed to cut through the abdominal parietes, and open the sigmoid flexure, so as to establish an artificial anus. The proceeding is un- warrantable, both in congenital deficiency and in malignant disease of the bowel. There is no doubt a possibility of life being thus pro- longed, but it is by no means probable, and scarcely desirable. In the more common cases, the bowel is opened, and the meconium evacuated, by a slight and safe incision in the site of the anus. Even through a considerable depth of soft parts, the impulse of the fluid in the bowel is distinctly felt during exertion of the abdominal mus- cles. If incision through the ineguments and cellular tissue prove insufficient, a sharp-pointed bistoury is pushed onwards in the direc- tion of the bowel, under the guidance of the forefinger of the left hand, carefully avoiding the bladder, vagina, and uterus, as also the vessels within the pelvis. To reach the bowel is an object of great consequence, yet the risk incurred in its accomplishment must be considered, and the incisions made within certain limits. The open- ing scarcely requires to be kept pervious by the use of bougies, the functions of the parts being sufficient for the establishment of the anus. [Persons often suffer from pruritus or itching of the anus, or in the parts immediately around. The affection is most common in old people, and in such as are of a weakly constitution. Women who have recently ceased to menstruate are also prone to it. The ex- 480 NEURALGIA OF THE RECTUM. citing causes are generally ascarides, hemorrhoidal excrescences, and a morbid state of the alvine secretions. Sometimes the skin around the anus is covered with an eruption of papulae, or even tubercles, the former of which are often attended with vesication and the dis- charge of a thin, watery, irritating humour. Patches of a similar de- scription are occasionally seen on other parts of the cutaneous sur- face ; as the scrotum, thighs, back, and even the face and neck. The pruritus, which is often very troublesome on retiring at night, so much so, indeed, as to prevent the patient from sleeping for hours, usually subsides after a few months, but is certain to return from the slightest irregularity in the. diet, from fatigue, loss of rest, or from exposure to heat. " From constant rubbing the skin about the anus becomes thick, dense, and furrowed, even when there are no hemor- hoidal tumours. The furrows assume a radiated direction, and con- verge in the anus ; they vary in number from six to ten, and are from a quarter of an inch to an inch in length."* In the treatment of this affection the first object should be to ascer- tain, and, if possible, to remove, the exciting cause. Proper atten- tion should then be paid to the general health, which, as was before stated, is often much impaired. Under such circumstances tonics may be demanded, such as iron, bark, or quinine, either alone or combined with blue-mass, sarsaparilla, or Plummer's pill. The latter articles are particularly serviceable when there is an eruption around the anus. The most useful topical remedies are, a solution of ace- tate of lead and laudanum, yellow-wash, the nitrate of silver, and the ointment of the proto-ioduret of mercury. Cold ablutions also afford great relief, and are indispensable to the patient's comfort. Neuralgia of the rectum is occasionally met with. It is most common in persons of a nervous, irritable temperament, from the age of thirty to forty-five or fifty, and who are subject to similar attacks in other parts of the body, particularly the face, stomach, testicle, or mamma. It is characterised by paroxysms of pain, which is usually described as of a tearing, burning, or lancinating nature, situated at the extremity of the rectum, from which it frequently extends to the sacrum, the loins, pubes, and genito-urinary organs. Defecation is painful, and the urine is discharged in jets or drops, attended with a burning or scalding sensation. The attacks commonly subside in eight or ten hours, but recur with tolerable regularity about the same period the following morning or evening, though sometimes not until the second or third day. During the intermissions the patient is, in great measure, free from pain, and passes his feces and urine without difficulty. The affection often continues for years, and the paroxysms are then apt to be more frequent and irregular. A remarkable instance of this disease is given by the late Pro- fessor Bushe. His patient was a middle-aged physician, of active habits, in tolerable health in other respects, but of a nervous tempera- ment, and subject to occasional attacks of neuralgia of the face sto- mach, and testicles. Several times a year he would be seized'with * Bushe on the Rectum, p. 220. URINARY AND GENITAL ORGANS. 481 pain at the extremity of the rectum and at the pubes, accompanied with frequent desire to void his urine ; sometimes he suffered excru- ciating torments at the end of the penis, or posterior part of the urethra. The attacks generally subsided in twelve or twenty-four hours, and were almost always either preceded or followed by neu- ralgia in other situations. No remedies were of any avail. In an- other case —that of a nervous female, thirty-five years of age—the pain was seated over a spot about the size of a shilling, on the left side of the bowel, less than half an inch above the verge of the anus. For weeks the pain would almost wholly subside, when it recurred with extreme violence ; her distress was generally greatest towards evening, and was always much increased during defecation. Mr. Mayo of London mentions the case of a man who laboured for seve- ral years under paroxysms of neuralgia of the rectum and the teeth. The attacks came on frequently during the day, without any assign- able cause. Neuralgia of the rectum, as of other parts of the body, is almost invariably attended with a deranged condition of the digestive appa- ratus, and hence a mild but systematic course of purgation consti- tutes a primary object in the treatment. On no account should the rectum be allowed to become distended with fecal matter. After due attention has been paid to the secretions of the stomach, liver, and bowels, the best remedies will be quinine, iron, arsenic, strych- nine or nux vomica, stramonium, the warm bath, and blisters to the sacrum. During the paroxysm, hot fomentations, anodyne injections, and opiate suppositories will be beneficial. In spite, however, of these and other means, the disease often continues for years with little mitigation, baffling the skill of the surgeon, and compelling the patient to spin out a miserable existence.] Affections of the Mucous Membranes of the Urinary and Genital Organs. — It has been previously observed, that these membranes closely sympathise with the skin and with the mucous linings of the digestive organs. Stimulating substances introduced into the sto- mach frequently produce irritation of the urinary organs ; and if the stimulants be employed in large quantities, and continued for some time, inflammation of the mucous membrane, investing the bladder and urethra, will be induced, with vitiated and increased secretion from the parts. In children, dentition is a common cause of urinary irritation ; and not unfrequently discharge from the urethra comes on during the cutting of the teeth. The application of acrid matters, as cantharides, to the skin, will occasion unpleasant effects in the uri- nary organs; and these unpleasant and distressing symptoms often supervene upon disappearance of cutaneous diseases. In short, the practitioner, in attending to affections of these parts, must ever bear in mind the close sympathy which exists between them and the external surface, the stomach, and the intestines, particularly the lower. Of Gonorrhoea, or Inflammation of the Urethra. — The morbid action is usually limited to the extremity of the canal, seldom extend- 41 482 GONORRHOEA. ing more than two or three inches from the orifice. There is itching and heat at the orifice, with swelling and redness of the glans, and of the lips of the urethra, and generally the whole penis appears more full than natural. When making water, the patient experi- ences acute heat and pain, often most agonising—chiefly referable to the extremity of the passage, and extending for two or three inches backwards. The urine is discharged in a small and scattered stream, the anterior part of the urethra being diminished in calibre by the swollen and turgid state of its lining membrane. The dimi- nution may be in part caused by spasm of the muscles surrounding the canal in consequence of the morbid excitement in it; or by fear, as the patient dreads making water, well knowing the excruciating pain which he must in consequence undergo. During erection, there is great increase of pain. The lips of the urethra, and the glans around, are often tender, and partially excoriated through neglect of ablution. There is seldom, if ever, any breach of structure in the canal; there is discharge of increased and vitiated secretion, without ulcerative absorption ; the matter is poured out from the relaxed, but entire, mucous membrane. In severe cases, the erections are abnormal, and attended with - much pain, constituting chordee. This troublesome symptom usu- ally occurs during the night; the inflamed membrane is stretched, and great pain is felt along the course of the urethra. From exten- sion of the inflammation to the vascular tissue around the canal, and effusion of lymph into it, the penis is bent downwards during erec- tion, the corpus spongiosum not admitting of so complete distension as the corpora cavernosa. Sometimes a portion of the spongy body is obliterated permanently by the effusion, causing deformity of the organ, and imperfect erection. I have also seen the penis bent to an inconvenient extent from a similar affection of the corpora ca- vernosa. After the uneasy and painful sensations have continued for some time, puriform matter, of a greenish or yellow colour, is secreted by the inflamed membrane, and discharged in profusion. The discharge changes very much as to quantity and quality, according to the in- tensity of the action and duration of the disease, and is also modi- fied by the constitution of the individual. When the discharge is suppressed, either from the imprudence of the patient, or from bad treatment, the inflammation is much increased ; and when the secre- tion returns it is in general thin and bloody. As the disease abates, the matter becomes thick, ropy, and less abundant, is seen only in the morning, and in quantity little more than sufficient to glue toge- ther the lips of the orifice; ultimately it loses its whitish or streaked appearance, becoming clear and colourless. The first attack of the disease is generally the most severe. In neglected cases, the prepuce swells often to a great size. During the progress of the gonorrhoea there is always a tendency to serous infiltration in the prepuce ; and if the patient walk much without supporting the organ, or have the part exposed to friction, swelling will inevitably take place. From this cause Phymosis and Paraphymosis are apt to recur—affections that will be afterwards GONORRHOEA. 483 described: The inguinal glands often enlarge, but such swelling is generally small, and seldom suppurates. Induration and enlargement sometimes occur along the urethra from effusion of lymph, or from obstruction and distension of the lacunae. Suppuration may take place at these points, and the matter escape either into the urethra or externally. Swelling of the lym- phatics of the penis is by no means uncommon in severe or neglected cases of gonorrhoea; a hard chord, tender, and extremely painful when pressed, is felt running along the dorsum penis, and termi- nates in the inguinal cluster of glands, which are in general also affected. Inflammation and abscess under the strong tendinous sheath that envelopes the penis occasionally follows the affection of the lymphatics. The whole penis swells greatly, wTith fever and much pain ; the matter is confined, burrows under the unyielding sheath, and appears either at the junction of the glans and prepuce, or over the symphysis pubis. Occasionally the inflammation is not confined to the extremity of the urethra, but pervades its whole extent, in consequence of mal- treatment, neglect, or idiosyncrasy. On this account, abscess in the perineum, or over that part of the urethra which is covered by the scrotum, in no uncommon consequence of a badly managed clap; the inflammatory action extending from the urethra to the cellular tex- ture exterior to it. The formation of matter is preceded by fever and great pain; the patient is unable to sit; and occasionally retention of urine takes place. The part affected feels hard, and extremely painful when pressed ; it gradually softens, and at last fluctuates and points. But if the matter form deeply, behind the bulb and in the cellular texture beneath the perineal fascia, or in the situation of Cowper's glands, it may be a long time of appearing externally. Fluctuation should never be waited for ; and in most cases, there are distinct enough signs of the presence of matter long before fluctua- ation can be felt. Some people are much more liable to inflammation of the urethra than others, and many are exposed to the ordinary causes of go- norrhoea without suffering, whilst perhaps they are readily affected by such animal poisons as produce disease of the prepuce and glans. Patients often give very ridiculous accounts of the way in which their clap is contracted. They will say that the infection was re- ceived in a common necessary, that the disease was produced by a blow, by a strain of the back, by taking drugs that did not agree with them, by drinking out of the same cup or smoking the same pipe with an affected person, by wearing tight boots, falling into a dirty pond, &c. They will exert their ingenuity to the utmost, in order to de- ceive their surgeon, and attempt preserving their moral character un- tainted. Discharge from the urethra may be occasioned by dentition, &c, as already mentioned; or may take place from calculi passing along and getting fixed, in the urethra, or from irritations about the anus. Inflammation of the passage not unfrequently arises, to a greater or less extent, from the acrimonious condition of the urine. The most common cause, however, is the application of irritating matter to the lining membrane; and this may take place during coition with 484 GONORRHOEA. females suffering from leucorrhcea, or during their menstrual dis- charge ; but gonorrhceal matter is the specific virus, and the applica- tion of it to the orifice of the urethra is by far the most frequent cause of inflammation of the canal. Irritating substances injected into the passage may, and often do, produce or aggravate the inflam- matory action. Besides all this, irritability of the urethra is common in gouty individuals. Gonorrhoea has been termed virulent when caused by gonorrhceal infection — simple, when induced by irritations such as those pre- viously enumerated ; the distinction is seldom attended to, and is of no practical importance. It has been supposed that the poison which produces chancre is the same with that which gives rise to gonor- * rhcea, the action being modified by the texture in which the virus is lodged : such an opinion has been found to be wholly untenable. Gonorrhoea supervenes at various periods after exposure to the in- fection, from twenty-four hours to six or eight weeks, but generally in from ten to twenty days ; often the time cannot be correctly as- certained ; much depends on the idiosyncratic susceptibility of the urethra, on the degree of acridity in the matter applied, and other contingent circumstances. When the discharge becomes more clear and thin, and the inflam- matory symptoms have disappeared, the disease is termed Gleet. The passage remains contracted in some degree, from relaxation of the mucous surface ; there is a desire to make water more frequently than usual, and the urine is passed in a tortuous or scattered stream ; in many cases the discharge continues profuse. There is now no pain nor scalding during the passage of urine, but these are readily reinduced by slight excess ; perhaps there is a trifling chordee. After connexion, the discharge returns as if fresh infection had been caught, though such be not the case ; both in simple gleet, and in that attend- ing stricture, the seemingly virulent symptoms come on speedily, often appearing within a few hours after the coitus. In gleet the matter is no longer green or yellow, but whitish and flaky ; the glo- bules are contained in a mucous instead of a serous fluid. The dis- ease it usually attendant on stricture, but occurs frequently without any organised contraction, the discharge being furnished by the ves- sels of the surface, which have become wreak and relaxed in conse- quence of previous excited action. In feeble constitutions, inflam- mation of the urethra is almost always followed by long-continued and intractable discharge. • • • A practitioner is not unfrequently asked when the infection of gonorrhoea is not communicable, anil if an individual in whom the discharge is very slight, or has just disappeared, is likely to contami- nate a healthy female. The question is a difficult one to answer. In general it is prudent to err, if at all, on the safe side — by express- ing doubts, and dissuading from intercourse until all discharge shall have entirely ceased for a considerable time. Discharge is often brought back, as already observed by the excitement of s :xual con- nexion. In simple inflammation of the urethra, with discharge, little or no treatment is required ; if the patient keep quiet, and avoid the causes GONORRHOEA. 485 which give rise to the affection, the symptoms will disappear in a short time. But virulent gonorrhoea is often very unmanageable, particularly if it has been allowed to follow its own course, and con- sequently to make head before it is attacked. It is no easy matter to arrest it after the parts have got into the habit of furnishing dis- charge, and particularly if it has been aggravated by thoughtless- ness and imprudence of the patient. All violent exercise should be avoided, as also indulgence in venery and liquors. A great variety of remedies, both external and internal, have been employed. General bleeding has been recommended, but never can be required in simple clap. If the bladder, or other important organ, become affected, depletion will be indispensable. Abstraction of blood by leeches from the perenium may be required, when from any cause the inflammation extends beyond its usual seat; and great relief is afforded by afterwards employing hot fomentations, or the bidet, and by diaphoretics given internally. Mercury was used in clap by those who conscientiously believed that the disease was the same as what they called syphilis. But it had been better far for mankind had snch a term or the notions associated with it, never been- broached ; or at least had mercury never been considered as neces- sary for the cure of affections of the genital organs. In gonorrhoea mercury may do much harm ; it never can do good, either in the way of cure or prevention. The disease has often been contracted, whilst the system was saturated with the mineral. Frequent and vio- lent purgings with'neutral salts — a common plan of treatment amongst the unprofessional and inexperienced — are hurtful; the extremity of the rectum is irritated, and may inflame, and the urethra from intimate sympathy, will suffer accordingly. Turpentine, copaiba, cubebs, buchu, &c, have been long employed in all forms of the disease.; of these, copaiba, administered from the first, and not after the inflammatory symptoms have subsided, is perhaps the one chiefly to be relied on. It may be taken pure with a little water or bitter tincture, or mixed with an equal part of honey ; the copaiba may be given in gelatinous capsules, or made into pills with magnesia ; it should be given at bedtime, and in a large dose, from a drachm to two drachms. The medicine may with prudence be continued after the disappearance of the discharge, though its beneficial effects are scarcely observable, excepting during the inflammatory stage. An unpleasant eruption, resembling urticaria, sometimes follows its em- ployment; it appears on the inside of the lips, and on the glans penis, and if the drug is continued, the eruption spreads over the whole surface. • Cubebs, though somewhat similar to copaiba in its virtues, often disappoints the practitioner. -The two medicines may be given very advantageously together, made into a confection, and a bolus of it taken occasionally in wafer paper. This class of remedies, in- stead of stimulating, diminish greatly the irritability of the urethra or the other parts of the urinary organs. In severe cases it is of im- portance to increase the quantity of urine, and thereby diminish its acrimony, by the free employment of diluents, mucilaginous drinks, and alkalis ; on this principle, infusion of linseed, containing more or less of nitrous aether, is very efficacious. The patient suffers much 41* 486 GONORRHOEA- when the urine is scanty, and contains a large proportion of saline particles. Rest and moderate diet are of paramount importance as means of cure. Support of the penis, by a suspensory bandage, or otherwise, should always be attended to when the patient takes ex- ercise, for many bad consequences will thereby be avoided ; indeed, it is a measure requisite in all affections of the organ, and particularly in gonorrhoea — when the prepuce, or even the whole penis, is liable to swell enormously. By low diet, and the frequent use of warm bathing of the part, or of the whole surface, the disease often disap- pears rapidly ; but when the cure is supposed complete, a hearty meal and a few glasses of wine will suffice to bring it back with all the violent symptoms. Cooling washes applied, externally to the penis are of little use, and will seldom be long submitted to by the patient. Fluids injected into the urethra, so as to be applied to the affected part of the mu- cous membrane, are much more efficacious. When slightly stimula- ting, the relaxed membrane is constringed by them, the action in the part is changed, and a healthy secretion ensues ; such are appli- cable after the inflammatory symptoms have subsided. But in many instances astringent injections are of much service from the very com- mencement ; the morbid action seeming to be arrested and the parts quickly brought into a healthy condition. Yet the use of such is not unaccompanied with risk, and the mildest are sometimes hurt- ful; the incited action is apt to extend along the passage; the discharge may be suddenly suppressed, and inflammation of the blad- der or testicle will generally supervene ; in short, the prominent symp- tom, discharge, may be arrested, but at the same time such violent inflammatory action may be induced as will be followed by change of structure in the canal, callosities, contractions, abscess, &c. The injections may contain nitrate of silver, sulphate of copper, sulphate of iron, sulphate of zinc, acetate of zinc, super-sulphate of alumina, or bichloride of mercury, in various proportions, or vegetable astrin- gents may be used, as kino, galls, &c: their strength may be gradu- ally increased according to their effects. These solutions and infu- sions are injected by means of either a small syringe, or an elastic bottle, fitted with an ivory tube, the point being smooth and rounded. This is carefully introduced into the orifice of the urethra, and the patient is recommended to press on the canal with his finger to pre- vent the fluid from passing farther than an inch or two. It may be thrown in two, three, or four times during the dav, according to cir- cumstances, and retained for a few minutes ; at each time the" patient should make water immediately before. The quantity injected at one time should not exceed a teaspoonful; more is unnecessary, and may do harm. By passing bougies or other instruments along the canal during active inflammation much mischief is done. When ex- citement has gone off, and discharge remains, advantage may be ob- tained by the internal administration of lytta or other stimulants. When contraction of the passage is suspected, or when, in spite of all means, no progress is made towards a cure, slight discharge continu- ing long without pain, and probably furnished by a relaxed portion of the membrane, recourse must be had to the occasional introduction HERNIA HUMORALIS. 487 of a full sized bougie. Cold bathing, local or general, is sometimes useful. If during the violent symptoms the discharge be from any cause suddenly suppressed, inflammation of the bladder, swelled testicle, or both, are to be dreaded ; and endeavours should be made without delay to procure its return, as by leeching the perineum, fomenta- tions, and the general warm bath. The Consequences of Gonorrhoea occur in parts closely connected with the urethra by sympathy and function ; or they are such as affect the constitution. Of Hernia Humoralis, or swelled testicle. Pain and swelling oc- cur in the epididymis, and soon affect the body of the testicle. The pain is most excruciating, the unyielding nature of the tunica albu- ginea preventing the vessels from relieving themselves fully, and inducing compression of the enlarging organ. Effusion takes place into the cavity of the tunica vagi- nalis, and thereby the tumescence is still more increased, this tunic from its great dilatibility readily accom- modating itself to the accumulation of fluid within. Sometimes the effu- sion is bloody, more generally serous, and not unfrequently composed of serum more or less tinged with blood. The epididymis remains enlarged longer than any other part, often during the remainder of life. Sick- ness, vomiting, and violent fever attend the progress of the swelling. Pain in the lower part of the abdo- men is not infrequent, and may be mistaken and treated for enteritis. The spermatic chord becomes enlarged and tender. The pain is much increased when the patient assumes the erect posture, from the enlarged and pendulous gland stretching the inflamed chord. Un- easy feeling are complained of in the back, and pain there is some- times so acute as to be compared by the patient to the sawing of his loins asunder. When the inflammation is violent, and effusion into the substance of the gland extensive, suppuration may occur; and in infirm constitutions this is not an infrequent, though remote, conse- quence of hernia humoralis. The testicle is said to be rendered use- less by the supervention of this disease. Certainly it is in danger of having its functions destroyed when the incited action is intense and the effusion great, and particularly if suppuration follow. The dis- ease may be induced by violent exercise during inflammation of the urethra, bruising of the organ, suppression of gonorrhceal discharge, the imprudent introduction of bougies, the use of strong urethral in- jections, or debauchery of any kind, during inflammatory gonorrhoea. In the treatment, complete rest occupies a prominent station. The 488 HERNIA HUMORALIS. inflamed organ must be supported ; and all means which may have been employed with the view of checking gonorrhceal discharge must be abandoned. General bleeding may be necessary when the system is much excited; and in all severe cases blood should be abstracted copiously from the part, by the application of leeches or the opening of the scrotal veins, and the organ is afterwards to be fomented for some time, and then enveloped in a warm poultice. The bowels must be kept open, the diet must be very low, and the value of an- timonial medicines as a powerful remedy in all inflammatory affec- tions must not be overlooked. Cold applications are of little or no service at any period of the disease, and frictions with mercury and camphor had better be dispensed with. When the violent symptoms have subsided, bathing the part with a tepid solution of the murias ammonias is often useful; or it may be rubbed gently with an oint- ment containing a small portion of iodine, or with a liniment of soap and camphor, with tincture of iodine. Much relief is experienced from interposing between the scrotum and suspensory bandage a soap plaster, or one composed of equal parts of the gum and mercurial plasters; thereby the organ is defended from irritating friction and motion, and slight stimulation is produced and kept up on the sur- face. Blisters promote discussion if the swelling become indolent, but are very annoying to the patient. They require repetition, but generally are in the end effectual; perhaps the rest necessary during their use is of as much benefit as the application. [When the pain is considerable, the camphorated liniment with morphia, laudanum, or belladonna, will be of great service. It should be rubbed upon the scrotum every four or five hours, avoiding of course injury to the inflamed testicle and epididymis. When the acute symptoms of the disease have subsided, under the treatment recommended in the text, the most efficacious practice is compression of the enlarged organ, by strapping it with the gum and mercurial plaster. Dr. Fricke, of Hamburg, pursues this plan in the very com- mencement of the inflammation, however severe, with the effect often of curing his patients in a few days. The plaster should be cut into narrow strips, not more than half an inch in width, and be applied in a circular manner round the testicle, which is to be previously drawn to the bottom of the scrotum. The first piece is to be placed round the insertion of the cord, just above the epididymis, and after the whole organ has been thus enveloped, another series of strips is to be applied from below upwards, to confine the first, and more completely equalise the pressure. Great care is to be taken not to pucker the skin, which should be previously divested of hair. "If the pressure of the plaster occasions pain or irritation, the strips are to be removed till the inflammation and sensibility are diminished. In many instances the patient experiences almost immediate relief from the application." This remedy, which has been .recently claimed by a European writer as new, appears to have been em- ployed, with marked success, in the Pennsylvania Hospital, in the early part of the present century.] Inflammation of the Bladder and posterior part of the Urethra INFLAMMATION OF THE BLADDER. 489 may arise from other causes than suppressed or badly treated gonor- rhoea ; but, however induced, its symptoms and consequences are the same. The presence of calculi or other foreign bodies, over- distension, &c, will be treated of hereafter, as causing irritation and inflammation of the viscus. Much vesical irritation is often produced and kept up by disease of the kidney. When inflammation of the bladder is slight, it is attended by un- easy feelings referred to the perineum, pelvis, and glans penis ; fre- quent desire to empty the organ ; pain felt acutely before evacuation of the urine, and relieved immediately afterwards ; scanty secretion of acrid and highly coloured urine; a discharge of slimy, tenacious mucus, either pure or voided along with the urine. In severe cases, most excruciating pain is experienced during the discharge of the contents of the bladder. The urine is often bloody ; in general it is of a milky appearance, containing lymph or pyriform matter, and vitiated secretion from the lining membrane. Micturition is almost constant, small quantities being voided at a time. Sometimes the inflammation extends to the ureters and pelves of the kidneys, caus- ing violent pains in the loins, nausea, occasional vomiting, and colicky affections. In very violent cases lymph is effused on the inner surface of the bladder, and may become organised ; but such effusion is rare. I met with one remarkable instance of it in my own practice, and have seen several others. An old pensioner fell from a scaffolding, and sustained a severe contusion of the back. Retention of urine came on ; it was drawn off regularly for some weeks, but then severe pel- vic symptoms supervened, and at last nothing but a small quantity of purulent matter flowed through the catheter. The symptoms be- came urgent, the bladder was very much distended, and rose to the umbilicus ; all endeavours to evacuate the urine per urethram failed, the instrument being always closed by the thick pus, and I was ob- liged to open the bladder pretty freely above the pubes. Much purulent matter mixed with fetid urine escaped from the wound, as also a false membrane which invested the mucous coat of the viscus. The membrane presented aflocculent appearance, in some places dis- tinctly fibrous, in others was thin and transparent; its internal surface was irregular, as if from the decomposition of minute granules of recent lymph. The patient died exhausted,after having survived about three weeks, voiding his urine partly by the wound, and partly per uretham. It should perhaps be mentioned, that those who saw him immediately after the accident supposed that blood was extensively effused into the bladder, and attempted to extract the suspected extravasation by means of an exhausting syringe through a catheter, probably not passed into the bladder. Occasionally, though rarely, the inflammation extends to the peri- toneal covering of the bladder, and thence to the external surface of the intestines. The bladder becomes thickened, and lymph is effused between its coats, from repeated attacks of inflammation, or from long continued irritation in consequence of resistance to the expulsion of its contents. The mucous membrane is thickened, relaxed, and of a flocculent ap- pearance ; the fibres of the muscular coat are enlarged, and, bulging 490 STRICTURE OF THE URETHRA. out, form projections along their course; the mucous membrane is extended often to a considerable extent between the projection of the enlarged muscular fasciculi, forming pouches. The cavity of the organ is generally diminished in proportion to the thickening of its parietes, and there is a loss of balance betwixt the retaining and ex- pelling powers. Irritable bladder is generally a symptom of some other affection. There is profuse mucous discharge ; frequent micturition ; pain, in- creased by distension of the organ, and relieved by evacuation. The coats are more vascular than in the natural state ; sometimes the muscular is strengthened, and ulceration of the mucous mem- brane is not infrequent. Occasionally this latter tunic is the seat of tumour. In the treatment of inflammation of the bladder, after removal of its causes, antiphlogistic means occupy a prominent situation, and are to be regulated according to circumstances. Leeches to the perineum and hypogastrium —soothing injections into the rectum— opium or hyoscyamus, either by the mouth or in the form of suppository — fomentation and the warm bath — are all valuable remedies in this affection. When injections into the rectum are used, they should not exceed three or four ounces, and they should contain from thirty to sixty drops of laudanum, or a corresponding quantity of the liquor opii sedativus. But an anodyne suppository is perhaps more simple and more efficacious. The effect of these remedies is almost instan- taneous ; all pain goes off; the patient becomes quiet, loses all recol- lection of his former sufferings, and often remains in a state of great comfort for twelve or sixteen hours. The suppository may be re- peated as need be ; the preferable time for its exhibition is the hour of sleep. Camphor, given by the mouth in full doses, is a powerful remedy for allaying irritation of the bladder, from whatever causes induced; as is copaiba, less nauseous and more trustworthy than cubebs or buchu. The copaiba will often remove speedily the most intense irritation, when all other means have failed. The bowels are to be kept gently open, and all stimuli disused ; diet should be low, drink copious and bland. Washing out the bladder with anodyne or other fluids, and the application of blisters to the perineum and neigh- bouring parts have been recommended, but are often more injurious than useful. Of Stricture of the Urethra. — By stricture is understood a nar- rowing or contraction of a mucous canal, from deranged action, or from morbid alteration of its structure. It may arise from relaxation and turgescence of the parietes, or from effusion of lymph either under the lining membrane, or on its surface. Spasmodic stricture has been spoken of by some writers, but is most probably an imagi- nary disease. An irritable urethra, in which organic, disease does not exist to any great extent, may contract at some point, diminish the stream of urine, and prevent the introduction of instruments, or retain them by closing firmly round, and in such circumstances the obstruction does probably depend on spasm of the muscular fibres surrounding the urethra; yet to such a state of the canal the term stricture connot be applied with any degree of propriety. STRICTURE OF THE URETHRA- 491 True, organic, or permanent strictures of the urethra vary in their degree of constriction, becoming tighter when irritated by improper treatment, hard living, or exposure to damp or cold ; indeed all mu- cous canals are sensibly affected by cold and damp. From these causes a combination may be produced of permanent stricture and spasmodic action ; but, as already hinted, it would perhaps be well that this latter term, applied to urethral stricture, were forgotten, in- stead of remaining a convenient excuse for want of knowledge or dexterity. Spasms of canals and cavities, unusual membranes, ad- hesions, sacs, and cysts, are too often met with in the practice of surgery, and are said to prevent the practitioner from accomplishing the objects of his operations, so as to put the patient to a great deal of unnecessary suffering, and even endanger his life. The old writers supposed that obstruction of the urethra arose from growths, warts, caruncles, or carnosities in the passage ; and even in the present day such causes would sometimes appear to be more accredited than they ought; small excrescences do sometimes form on the membrane, though very rarely. The true stricture is the result of inflammatory action in the part: at first possibly serous effusion takes place beneath the membrane, and elevates it into an cedematous swelling, which, according to its extent, obstructs the canal; the lymph is deposited both beneath the membrane and external to it, becomes organised, and forms a per- manent and more unyielding obstruction. Strictures are of various kinds. The bridle stricture is rarely met with ; a membranous band of organised lymph is said to traverse the canal, and, according to the thickness of this membrane, the flow of urine is more or less impeded ; in the majority of cases the morbid formation is thin and delicate, but still sufficient to scatter and diminish the stream. When a soft bougie is introduced, it is resisted by the stricture, and on examining the instrument when withdrawn, the transverse and cen- tral impression on its point marks the existence of the bridle. The urethra is sometimes narrowed by a circular membranous ring pro- jecting into its canal, composed of swollen mucous membrane with subjacent effusion, and presenting the appearance of a thread having been tied round the passage. Other strictures occupy a considerable portion of the urethra, from a quarter of an inch to two inches or more; differing from the preceding only in the effusion and mem- branous swelling being more extensive. Others are irregular, the contraction being not uniform at the narrowed point, and sometimes only one side of the canal is affected. Some are very firm and gristly the effused lymph having become much condensed after organisa- tion ; others are less dense in their structure, and exceedingly elastic. From repeated attacks of inflammation at the constricted part, and around, additional lymph is effused and organised, and thus the ex- tent and tightness of the stricture is increased. The urethra is generally constricted at those parts which are natu- rally the tightest; at the orifice — betwixt three, and four inches from it—and betwixt six and seven inches from that point; the most frequent site is perhaps anterior to the sinus. Contraction of the orifice is frequently the consequence of cicatrisation, and generally 492 STRICTURE OF THE URETHRA. proves obstinate ; in some cases the smaller probe is passed wit difficulty. Considerable portions of the anterior part of the canal suffer contraction from the effect of ulceration ; and congenital mal- formations of the orifice give rise to many affections both of the ure- thra and bladder. Contractions in different parts of the canai depend much upon one another. . f .. When a tight stricture exists, the passage anteriorly is never lully distended, and becomes permanently contracted in consequence ; whilst more or less dilatation is produced behind the tight part, wherever that may be. The enlargement often is very great, the urine lodges in the cavity formed by dilatation, and can be pressed out in a stream, or dribbles away after the patient supposes that he has done making water. Mucous and sabulous deposits often lodge in it; and calculi are occasionally retained there, may attain a large size, and may give rise to very unpleasant and even dangerous symp- toms. Not unfrequently ulceration takes place behind the stricture, and the urine becomes insinuated into the cellular texture; but this tissue immediately around is in general condensed previously to the giving way of the canal, and so prepared by lymphatic effusion as to oppose effectually extensive infiltration Such is not the case, as wrill afterwards be explained, when solution of continuity in the urethra, or of the cyst of an abscess, takes place in consequence of distension of the bladder. In the gradual escape of urine by ulceration behind the constricted point — the urethra being neither altogether obstructed, nor nearly so — abscess forms in the cellular tissue, exterior to the ulcerating part. The suppuration is often slow in its progress, and imparts to that part of the perineum a stony hardness. Repeated collections of matter may form, and, if the cause be not removed, numerous openings will form in the scrotum and perineum, and through them fetid matter and urine will constantly and involuntarily distil. The patient is reduced to a miserable state ; the neighbouring parts are excoriated, and exhale a noisome odour, his body and bed-clothes are soaked and rotted by the discharge, and the atmosphere to a con- siderable distance around offends the nostrils. Fistula in perineo is established. Ulceration and perforation of the urethra from stricture seldom takes place anteriorly to the scrotum ; but ulceration often is induced there by retaining instruments long in the passage, and may be fol- lowed by sloughing of the integuments, abscess in the cellular tissue, or both. Occasionally the urethra communicates with the rectum in consequence of ulceration, escape of urine into the cellular tissue, and formation of matter. The symptoms of stricture are often much re- lieved after the formation of fistulous openings ; and the cure can then be much more easily accomplished than formerly, the passage being less irritable. When the fistula is free and open, allowing the urine to escape readily the natural passage contracts and will be- come almost entirely obliterated, unless means are taken to dilate it and to diminish the unnatural opening. Neglected aggravated cases are met with in which the urine has passed entirely through the false passages for years, the urethra and penis, anterior to the stric STRICTURE OF THE URETHRA. 493 ture, being both rendered completely useless; but even such cases can, by proper management, be relieved, or permanently cured. Ulceration of the urethra, originating in consequence of stricture, may proceed even after the stricture is removed, and give rise to abscess and fistula. Many patients labour under stricture, and even tolerably bad ones, without being aware of it. But the surgeon is led to suspect the existence of stricture, by complaints which the patients wish to be relieved of, and which they often suppose to arise from totally dif- ferent causes— pains in the loins or hips, indolent swelling of the testicle, or of the inguinal glands, irritability about the fundament, gleet. On inquiring about the stream of urine, the patient may de- clare that it is as good as possible ; and may say so without intend- ing to deceive, for the stream diminishes so gradually, that the pa- tient is not aware till after he is relieved that he has been voiding his urine in a very shabby and imperfect manner. On questioning further, it is discovered that the stream is forked or twisted, or di- vided into several small ones ; that there is frequent desire to empty the bladder, during the night particularly ; and that at first the urine comes away only in drops. A longtime is occupied in passing even a small quantity of urine, and the patient has to strain much ; in bad cases he is almost always obliged to go to the water-closet when in- clined to make water, lest the contents of the rectum be evacuated by the great exertion of the levator ani and abdominal muscles, ne- cessary to overcome the obstruction in the urethra. By the strain- ing hernia is also frequently induced. In consequence of the almost constant endeavours to overcome the resistance afforded by the stricture, the bladder becomes much strengthened in the coats, and diminishes in size. All the coats are affected, but particularly the muscular; the surface becomes fascicu- lated ; the fibres grow fleshy and strong, and are collected in large bundles. Cysts form, often of a large size ; some are caused by in- terlacement of the enlarged muscular fibres, others are produced by outward protrusion of the mueous coat. This membrane being, by excessive muscular action in the viscus, pushed between the en- larged fasciculi, dilates into a bag, and forms a cyst of greater or 42 494 3TRICTURE OF THE URETHRA. less size, communicating with the cavity of the bladder, generally by a narrow neck ; the protruded membrane is thickened by new de- posit, and ultimately the parietes of the cyst, in some degree, re- semble those of the bladder. Cysts of this description are usually situated near the fundus of the organ, and often attain a large size ; in some cases the cyst nearly equals the bladder in capacity; and the two seem to form one large organ contracted near the middle. The secretion from the surface of the bladder and cysts becomes vitiated, is much increased in quantity, and passes off along with the urine or after it — sometimes in solution, often separately. In severe cases the ureters and pelves of the kidneys dilate, and their mucous surfaces also contribute to furnish the discharge, in general slimy, ropy, and tenacious, sometimes puriform. Discharge also takes place from the stricture, or rather from the dilated portion behind it; it is a kind of gleet, very apt to be increased by excess in drink- ing and venery. After debauchery, the stream of urine — which was previously not much affected, at least to the patient's observa- tion — comes to be very small; and frequently the urine can be voided only in drops, and that with much labour. Besides, the ba- lance between the retaining and expelling powers of the bladder is often lost, and either incontinence or retention of urine is the con- sequence. Though the urine be much obstructed, even when the stricture is not very tight, the flow of the semen is not; the degree of contraction must be very great to prevent ejaculation of the latter fluid. Indeed, during the healthy state of the parts, the whole urethra is much narrowed, as well as shortened, during semi- nal emission in coitu, from forcible action of the surrounding fibres, and injection of the corpus spongiosum ; and the momentary con- traction of the passage in such circumstances is perhaps greater than almost ever occurs in consequence of disease. Sometimes the seminal fluid passes back into the bladder, from an inverted action of the canal, and is evacuated along with the urine ; nocturnal emis- sion is a frequent concomitant of stricture. That an inverted or sort of antiperistaltic motion sometimes exists in the urethra, is shown by a soft bougie being in such cases drawn into the bladder after having been passed but a short way into the urethra. In cases of bad stricture, the complexion is sallow, the counte- nance anxious and the general expression of the features so peculiar as to be almost pathognomonic. The lowTerlimbs become emaciated and weak. Gout often accompanies stricture, and paroxysms of it are induced by irritation of the urethra; the canal itself is said to be sometimes affected with a gouty action. Stricture may be caused by inflammation or long-continued irrita- tion of the urethra, however induced — by mismanaged virulent gonorrhoea — by stimulating acrid injections—by piles and other irritations about the fundament — by calculi passing along the ure- thra. That gonorrhoea is a very frequent cause of stricture has been long known — " If the case be slubbered over, and long delayed, caruncles arise in the urethra, and in progress of time a carnosity." The passage or lodgment of calculi in the canal has induced stric- ture even in children : and calculus in the bladder is supposed some- STRICTURE OF THE URETHRA. 495 times to produce disease in the urethra, and vice versa. Strictures are often caused by falls or blows on the perineum, and such cases are of the. very worst kind ; in some the urethra becomes almost entirely obliterated ; in most the stricture is extensive and callous ; and in all the disease is overcome with difficulty. When stricture is suspected, the urethra must be examined. A soft white-wrax bougie is very well adapted for ascertaining the state of the parts, but must be used very gently. If pushed forwards rashly and with force, the instrument yields before the stricture, and when withdrawn, is found twisted like a screw, or doubled backwards on itself. The vessels of the urethra may be torn, and hemorrhage, with great pain, ensue. The bougie should be slightly curved in its farther extremity, warmed either at the fire or by friction with the fingers, and wrell oiled, previously to its introduction. It is then passed softly along the canal till its progress is arrested ; thus the situation of the structure is ascertained. Then a little more pres- sure is employed for a short time ; if the instrument have not be- come insinuated into the constricted part, it will resiliate on removal of the pressure from its free extremity ; if it is passed into or beyond the stricture, it is firmly grasped by that part of the urethra, and re- tained ; thus we discover the degree of contraction ; and from the extremity of the bougie receiving and retaining the impression made on it by the contracted part, we can form an accurate diagnosis re- garding the nature and extent of the stricture. The information thus acquired is afterwards acted on. The principles on which the cure is to be conducted are the same in almost all cases ; but the particulars of the treatment must vary7 according to circumstances. In slight cases, the gentle introduction of a moderately-sized bougie produces a cure by removing the irri- tability or susceptibility of the surface; the relaxed membrane is stimulated by the distension made with a bougie, and soon regains its natural tone. It may be necessary to repeat the introduction of the bougie a few times, at considerable intervals. In tight organic stricture something more is required ; the constricted part must be dilated gradually. Much dexterity and management is often required to pass an instrument through a tight stricture, particularly if inflamed ; and in such circumstances the attempt should not be made but on good grounds, and to relieve urgent and dangerous symptoms; but after a bougie or catheter, however small, has been got past, the dis- ease is completely under the control of the surgeon, and a cure must follow if the treatment be properly conducted, and if the bladder and kidneys have remained tolerably sound. The effect of an instrument passed through an organic stricture is to remove the irritability of the lining membrane, to excite the absorbents to remove the newly- formed parts, and to dilate the passage : it may be supposed to act in some measure on the same principle as a bandage applied to a swelled extremity. The instruments introduced must be gradually- enlarged till one readily passes of the full size ; that is, one that enters the orifice with some difficulty, and fully distends the rest of the canal. Numerous contrivances have been employed for the dilata- tion of strictures ; but the preferable instrument is a silver catheter, 496 STRICTURE OF THE URETHRA. or a sound made of silver, of steel, or of plated metal. A soft or gum-elastic bougie is sometimes useful in ascertaining the nature and situation of the stricture ; but in the treatment it must give place to the metallic, slightly conical at the point. This, in the hand of a well-qualified person, can be more surely and readily directed than a flexible one, and in its use there is less risk of injury being inflicted on the passage ; besides, it does not yield to the action of the dis- eased part. The practitioner must be provided with a full assort- ment of catheters and metallic bougies, each one differing from the other in size ; for, as already observed, the size of the instrument passed must be gradually increased ; and besides, the calibre of the canal varies much in different individuals ; what is a full size for one person may be but a triflle in the urethra of another. The bougies are arranged by what is termed a size-plate, or gauge, a flat piece of metal, containing fifteen or sixteen circular perforations, which commence about the size of a small crow-quill, and gradually enlarge in diameter. These apertures are numbered, and the bougie which fills one has the corresponding number imprinted on it. By reference to the numbers, the surgeon is at once made aware of the progress he has made towards a cure. In the more common and simple cases, a regular and gradual ascent in this scale is all that is required, allowing a proper interval to elapse betwixt the introductions. But in tight and unyielding stricture, small, firm, silver catheters are required. One of these of a size proportioned to the contraction of the canal — and the calibre often must be extremely minute — is passed through the stricture or strictures by dexterous, persevering, and at the same time gentle pressure in the proper direction. If the diseased part be anterior to the bulb, it can be grasped between the fingers of the left hand, whilst with the right the instrument is insinuated into it; thus the part is steadied, and the course of the catheter made more certain and safe. If it be posterior, assistance in the introduction, and information as to the direction and progress of the instrument are obtained by the forefinger of the left hand being placed in the bowel; and this is the more necessary when the stricture is of an elastic nature. Consider- able experience is requisite to enable the surgeon to be aware 6f the progress he is making with the instrument, and whether or not it is advanced fairly in the canal ; much information as to this is imparted by the sense of feeling. If the point of the instrument be within the contracted part, it will be felt embraced and obstructed, and on withdrawing the pressure, it will be stationary ; if it have not entered the stricture, but is pushing it before it, resilience will be felt as soon as the pressure is either diminished or removed. The sensation imparted when the instrument has left the canal and is entering into a false passage, is of a peculiar grating nature' and when once felt, will scarcely be forgotten or mistaken. By means of a good knowledge of the natural course of the urethra, and an acquaintance with the feelings just alluded to, but which cannot be graphically described, the surgeon of experience is enabled to avoid blunders, and to pass an instrument with safety through the tightest strictures. It is, however, an operation of very great difficulty in STRICTURE OF THE URETHRA. 497 aggravated cases, perhaps the most difficult in surgery ; facility in passing the catheter is acquired only by practice and experience. The greatest caution is required, along with considerable fortitude and perseverance. When the instrument has been fairly lodged in the bladder, it is to be retained. A tape is attached to each of the rings at the neck of the catheter, is brought under the thigh, and fastened to a bandage passed round the waist; this simple retentive apparatus is quite effec- tual, and suits the erect as well as the recumbent posture. A peg, of metal or wood, is placed in the mouth of the catheter, that the patient may be kept dry, and at the same time have it in his power to relieve the bladder as often as necessary. The instrument should be retained for twenty-four hours at least, and, if the patient can bear it, for forty-eight, or even more. At first it occasions considerable uneasiness, pain, and excitement, but these gradually subside; when severe, they may be allayed by opiates. The parts make efforts to get rid of the foreign body, and these efforts are salutary. Discharge takes place from the membrane, and oozes by the side of the catheter; relaxation occurs, often to a very great extent; and, on moving the handle of the instrument, it is found to be not only less firmly grasped, but to possess considerable freedom of motion in the contracted part. Thus a most successful inroad is made upon the disease, and the after treatment thereby happily abridged. The instrument is with- drawn, and time afforded for the parts to become quiet. After the lapse of two, three, or four days, according as the uneasy feelings disappear, a larger instrument is introduced, and retained perhaps for half an hour; and the successive introduction of instruments—sounds being now adopted — at proper intervals, and in proper graduation, is continued as in ordinary cases. Sometimes, though rarely, the good effects of the first introduction and retention of the instrument quickly disappear, the stricture becoming tight and unyielding as before; when this takes place, the practice is to be repeated, but not till after several days, and then the instrument will be retained with advantage for a longer time than before, provided no untoward symp- toms are caused by its lodgement. There are very few strictures, indeed, which will not yield to this treatment, when judiciously planned and perseveringly followed. Fistulous openings generally close in a short time, when once the urethra has been widened. Their contraction may sometimes, how- ever, prove slow and imperfect, even after the stricture has been en- tirely removed, and the application of the cautery may be requisite ; to accomplish this, when the opening terminates in the rectum, a speculum ani is required, by which to view the aperture, and ascer- tain its site, and along which to pass the heated wire with safety to the bowel. The cautery is not to be applied so as to produce an ex- tensive slough, and much loss of subslanoe, but lightly to the edges. On the separation of the superficial eschar, the margins are raw, ex- cited, and swollen, with a disposition to granulate; and during cica- trisation of the sore, considerable contraction takes place, independent of the formation of new matter. After the contraction thus effected has occurred to its full extent, and not before, the cautery is reap-- 498 RETENTION OF URINE. plied; and by a few repetitions of the instrument at long intervals, the opening is brought to close. ; , At one time attempts to destroy the contiaction of the uretira, by the application of caustic to the stricture, were in great vogue ; but the total inefficiency of such practice is now generally acknowledged. The armed bougie was in many cases applied hundreds of times, at considerable intervals; and the mode of treatment, though trying, tedious, and hurtful to the patient, must have proved useful to the surgeon— but to him alone. Years were spent in such trifling, and not unfrequently serious consequences followed this treatment, or rather neglect, of the disease. Cutting catheters are dangerous, as well as inefficient for the cure of stricture ; thrusting at the end of a long stricture can avail but little, and in the hands of most practi- tioners the instrument is as likely to perforate the coats of the urethra as to enter the stricture. Incision of stricture may be required in retention of urine, scarcely otherwise. The practice is noticed under the treatment of retention. In stricture anterior to the scrotum, it is well to avoid incision, if possible, as it generally is so, for a wound there is healed with diffi- culty, if at all. Retention of Urine is not to be confounded with suppression of the secretion from the kidneys, arising from disorder of the structure or function of these organs. The kidneys perform very important func- tions in the animal economy, and complete suppression of their secretion under any circumstances is a very suspicious and dangerous occurrence. In the healthy state of the urinary organs, when the powers of each correspond, the urine passes without almost any exertion on the part of the patient; the action of the levator ani and abdominal muscles is scarcely required. But when either structure or function is dis- ordered, the balance between the parts is upset; additional assistance is necessary for expulsion of lhe contents of the bladder. The symp- toms of retention differ according to the state of the parts and the cause which has induced it. The bladder varies in size, and in dis- tensibility. In some cases the organ yields readily to the accumu- lation of fluid within it, rising high in the belly, reaching even the umbilicus, and forming a large, oval, tense, fluctuating swelling, ap- parent to the most careless and casual observer. The swelling and fluctuation are in such circumstances so distinct, that the disease has actually been mistaken for ascites. Again, all the symptoms of re- tention may exist, and all its bad consequences result, without any apparent swelling of the abdomen. But then the distended bladder can always be felt by the finger introduced into the vagina or rectum; indeed, its posterior fundus bulges in towards the cavity of the gut, in every case, before it ascends upwards in the abdomen. Sickening and agonising pain, with great anxiety and ineffectual straining, generally attend distention of the bladder to any great degree. When the distention is allowed to continue, urinous fever supervenes the circulation is accelerated, the patient perspires profusely, and exhales a urinous odour; delirium comes on, followed by sinking and if RETENTION OF URINE. 499 the cause is not removed, coma terminates the distressing train of symptoms. In other instances the painful feelings subside after some time, and the urine is discharged involuntarily from the urethra. The ureters lose the valvular structure of their vesical terminations, and become dilated ; the pelvis and infundibula of the kidneys also enlarge, and all are distended by the accumulating urine. On re- lieving the bladder artificially, the pressure is taken off the secreting part of the kidneys, their secretion is generally renewed with great vigour, and the bladder is again filled rapidly. If the bladder is not relieved, the secretion of urine is suppressed. In many cases the urethra — the bladder more rarely — sloughs or ulcerates, unless preventive measures are adopted, and extravasa- tion of urine takes place into the cellular tissue of the pelvils, of the perineum, of the groins, of the lower part of the abdominal parietes — into the cellular substance of the scrotum, and of the penis — the parts infiltrated depending of course on the point at which the urinary canal has given way. Under such circumstances the patient is sometimes rapidly destroyed, the extravasated urine appearing to induce speedy sinking, similar to the effects of inoculation with a most virulent poison. If the urine escapes into the cavity of the abdomen, the patient inevitably perishes, and that very speedily ; and when the cellular tissue of the pelvis is the seat of the extrava- sation, little hope can be entertained of recovery, though the fatal termination may not be so rapid as in the former case. When the urine is effused into more external parts, as into the perenium or scrotum, the danger is also imminent, if the fluid is allowed to ac- cumulate and become extensively infiltrated ; but when it freely es- capes externally, either spontaneously- or by incision, there need in general be no great apprehension of immediate danger. In such cases the aperture in the urethra is found to be at first irregular and ragged ; afterwards its inner surface becomes rounded off, and a papilla pre- sents externally. The infiltrated cellular tissue is dark, fetid, broken down, and soft, sometimes seemingly in part dissolved by the putre- scent urine ; and, when the patient has survived a considerable time, it frequently resembles closely in appearance a portion of suppurated lung. When active practice is not adopted after extravasation of urine has taken place, the cellular tissue around sloughs along wTith the integuments ; rapid depression of the powers of life ensues, wrth great disturbance of the sensorial functions. Death very soon re- lieves the patient from his sufferings; some few struggle through, and recover, after losing the coverings of the penis, of the testicle, and of the perineum. The causes of retention are many ; but the surgeon must know them all, as the treatment must vary according, to the cause. They may be divided into such as weaken the power of expul- sion, and, into such as impede the progress of the urine in the urethra. Retention of urine is caused by paralysis of the bladder, from over- distension, from injury or disease of the spinal chord, from pressure on the spinal chord or nerves. In such cases the bladder often at- tains a very large size. At first the accumulation produces all the 500 RETENTION OF URINE. uneasy symptoms formerly mentioned, but after some time these sub- side, and the urine drains away according as it is secreted, without, however, the original accumulation and tumour being diminished. This state of the urinary system is very common in old people, who neglect natural calls to empty the viscus during the night, or while sitting socially after dinner. The uneasiness gradually goes off, and when they at length think of making water, none can be got to flow. Sometimes they remain in this state — the bladder full, and becoming more and more distended — for days, drinking gin and water, juni- per tea, or other popular remedies. Incontinence then takes place, and the dribbing of the urine affords considerable relief; this state of matters is often allowed to continue for weeks. Thus the powrer of expulsion may be lost for ever, though sometimes it is regained even under very unfavourable circumstances. I recollect attending a man upwards of eighty, labouring under retention of urine with inconti- nence, and whose bladder required relief by the catheter for ten or twelve days ; at the end of that period the bladder regained its ex- pulsive power and retained it; and cases are on record in which the power of expulsion has returned after the lapse of several months. Retention thus induced is often complicated with disease of the pros- tate gland or of the urethra. The patient, perhaps, has been for a long time incapable of emptying his bladder completely; a portion of the urine always remains in the most dependent part of the viscus, and the quantity retained becomes greater and greater, until from some slight cause the power of expulsion is lost entirely. In these cases the bladder, though much increased in capacity, is also much thickened. Retention from inflamed urethra, attended with swelling and spasm about the neck of the bladder, is preceded by hardness and tender- ness in the course of the urethra, and a smarting felt when a drop of urine passes along. Retention not unfrequently takes place during gonorrhoea, from the dread which the patient has of making water; and from the swelling of the lining membrane. Retention from abscess in the perineum was formerly noticed. Retention from injuries in the perineum. The urethra is either severely bruised, perhaps lacerated, or torn completely across ; and if the patient attempts to make water before proper means are adopted, blood and urine are extravasated into the cellular tissue exterior to the canal. In cases of slighter injury, retention may occur on account of the inflammatory swelling of the parts super- vening secondarily. Retention from stricture of the urethra is of very frequent occur- rence, and most difficult to manage. The state of the urethra and bladder in this disease has been already adverted to, but it is neces- sary to bear in mind the thickening of the latter, and the dilatation which uniformly takes place behind the stricture. All the urgent symptoms of retention may, in this case, arise from the accumulation of but a few ounces of urine. The bladder contracts frequently and very forcibly, causing great suffering. Temporary relief is expe- rienced when the urethra gives way by ulceration, and the urine becomes extravasated into the cellular texture; the patient gets up RETENTION OF URINE. 501 and, if in the dark, thinks that the stricture has yielded, and that he is passing urine naturally. But soon he feels a glowing heat in the perineum ; the parts swell and become livid ; violent constitutional symptoms come on, the discoloration advances, the integuments slough, ill formed matter is discharged, and disorganised cellular tissue mixed with putrid sanies is exposed. The parts exhale a uri- nous odour, which, when once smelt by the practitioner, can never afterwards be mistaken. Occasionally cedematous swelling of the penis takes place, particularly of the prepuce, when it has been pulled at and bruised during the patient's effort to make water, and this must not be confounded with infiltration of urine; I have seen it occur some time after the bladder has been relieved by the catheter. Infiltration of putrid serosity into the cellular tissue of the prepuce, the subcutaneous tissues of the penis, scrotum, and lower part of the abdomen, occasionally also takes place to a great extent, after the bladder has been relieved by the catheter, the coverings are de- stroyed, and the patient may, even despite of active treatment, perish in consequence. In such cases, a small quantity of urine may pos- sibly have escaped into the cellular tissue before the bladder has been relieved, so as to commence the mischief. Retention from the lodgment of calculi. Temporary obstruction to the flow of urine is sometimes experienced from calculus in the bladder. Complete and fatal retention has arisen from calculi having become impacted in the urethra, and been allowed to remain there, blocking up the passage entirely. Retention from affections of the prostate gland and neck of the bladder, inflammatory or indolent. In acute inflammation of the prostate gland and cervix vesicae, the other parts around swell, the mucous membrane becomes turgid, and the mucous secretion is in- creased. Suppuration may take place, and an abscess, chronic or acute, form in the substance of the gland, or in the cellular tissue ex- terior ; the parietes of the abscess may give way, and the matter dis- charged into the bladder, into the rectum, or into the cellular tissue of the perineum. Bloody and mucous discharge from the urethra, frequent desire to make water, sudden stoppage of the urine whilst making water, pain in the glans penis, and other symptoms of stone in the bladder, followed a fall on the back. Afterwards, a tumour pointed into the rectum, and was opened ; purulent matter was pro- fusely discharged, and afterwards urine escaped through the aperture. The patient died in three weeks, from irritative fever, with gastro- enteritic symptoms. Along with thickening of the bladder, and dis- ease of its mucous coat, there was found a large abscess of the cellular tissue, communicating with an abscess in the third lobe of the prostate gland, and that with the cavity of the bladder. When the affection is less acute, the prostate slowly enlarges, from opening out of its texture, and deposition of new matter in the in- terstices, it becomes hypertrophied. The whole gland may enlarge uniformly, but generally one part protrudes more than the others. When the third lobe enlarges, it necessarily projects into the bladder, or into the prostatic portion of the urethra, and there, acting like a valve, causes much more formidable obstruction to the flow of urine 502 RETENTION OF URINE. than does enlargement of the lateral lobes ; the obstruction is the more complete the greater the distention of the bladder. At first, this lobe is but slightly prominent, and of a conical form ; but as it enlarges, its regularity of shape disappears, the tumour is nodulated, and in general somewhat pyriform. It occasionally projects to one side of the passage. The affection is seldom met with, unless in old people. In consequence of prostatic enlargement, pain is felt in the peri- neum, with occasional throbbing, and a sense of weight; there is frequent desire to make water, the bladder is irritable, and discharges ropy mucus. There is more or less irritation of the lower bowels ; there is an almost constant desire to empty the rectum, from a feeling of fulness there, and pain often severe, is felt on going to stool; when the enlargement is great, the bowel is considerably compressed, and the feces, when solid, are passed flattened like portions of tape. Fre- quently there is a thin mucous discharge from the urethra. In making water, the urine, as it were, hesitates, and after a wdiile passes away, at first in drops, and afterwards in a scanty and irregular stream ; pain is felt at the point of the penis, in the loins and hips, and often in the inside Df one or both thighs. On attempting to pass the cathe- ter, its extremity is obstructed in the prostatic region, and the swelling can be felt by the finger introduced into the anus. Examination of the tumour, per anum, is very often a painful proceeding; it is best accomplished after a catheter or sound has been introduced. The disease is often coexistant with calculus in the bladder. The tumour is very seldom malignant, but proves both troublesome and danger- ous from its size. The bladder may become distended in consequence, though retaining the power of partially relieving itself; or the urine may come away involuntarily after some time ; or retention may be complete, and, if not relieved, the bladder may slough. It is to be recollected, that in retention of urine, from whatever cause, and particularly in that arising from prostatic enlargement, the urethra is elongated, and the bladder rises into the abdomen like the gravid uterus. The reason of such change of relative situation is sufficiently obvious, being chiefly mechanical. Fungous, or other tumours, furnishing blood or vitiated puriform matter, now and then grow from the internal surface of the bladder, unconnected with the prostate gland. Worms, too, occasionally lodge in the bladder. Either of these circumstances may induce re- tention of urine. Another cause of obstruction is hernia of the bladder. There is no disease in which the patient is more liable to be ' bungled out of his life,' than in retention of urine. Great credit is to be gained by judicious and skilful management of the various stages, and by expert use of the catheter in difficult cases, when other practitioners, perhaps, after being foiled, have proposed oper- ations alarming to the patient, and, in themselves, dangerous. In no disease are patients more grateful for relief, for in this the agony is often unbearable. Immediate abatement of all painful symptoms follows skilful and prompt measures ; and the superior science of one man over others is made apparent to the most ignorant observer. RETENTION OF URINE. 503 In over distended bladder from paralysis, the catheter can in gene- ral be passed without difficulty. It should be of a large size, and its introduction should be repeated as often as nature calls for relief, perhaps three or four times during the twenty-four hours, until the viscus regains its tone ; and this, unless irrecoverably lost, will generally be restored in a few weeks at most. Repeated introduc- tion of the instrument is here preferable to the retaining of it; the latter measure should always be avoided, unless absolutely indis- pensable, for a foreign body lodging in the urethra and neck of the bladder must always be a source of more or less irritation; and ex- perience shows that the bladder sooner recovers its tone when the instrument is introduced only to draw off the urine, when the un- comfortable feelings of distention come on, than when it is constant- ly retained. The patient soon learns to pass the instrument himself, and thereby saves the surgeon from frequent attendance, whilst at the same time, the bladder is opportunely relieved. Stimulants, as the tinctura lyttae, given internally, with external friction, blistering, and the application of strychnine to the raw surface, may contribute to- wards restoration of the muscular power of the organ. Injections into the bladder have been recommended, but are both hurtful and inefficient. Enemata, containing turpentine, or other stimulating fluids, are of service. In retention from inflamed urethra, the catheter should, if possi- ble, be dispensed with. The introduction of it is excruciatingly painful, and will certainly aggravate the original affection. Blood should be abstracted both from the system and from the perineum ; fomentations, with the wTarm bath or the hip bath, are afterwards to be employed. The retention is usually induced by hard exercise, or intemperance in living; these of course must be abandoned, and their opposites enjoined. Camphor alone, or combined with opium or hyosciamus, is to be given internally in large doses. Opium may also be useful, administered in the form of an enema or suppo- sitory. If relief is not soon afforded by such soothing measures, the bladder must be relieved by the catheter; and if the surgeon be foiled in the introduction of this, as he ought not to be, the only re- source is to puncture the bladder from the rectum — a harsh mea- sure, to be sure, and one not indicative of surgical talent, but still preferable, in the eyes of both patient and practitioner, to death. In retention from abscess in perineo, a little delay is allowable under the employment of palliatives,, when the affection is acute. The abscess must be freely opened as soon as its seat is discovered : and until the evacuation of the matter, the use of the catheter should be deferred if possible. In cases of chronic abscess, the catheter must be used, and does no harm. In retention from injury of the perineum, the catheter should be passed before the patient attempts to make water, and the instru- ment must be retained ; thus extravasation of urine in addition to the blood into the cellular tissue will be avoided. If extravasation has occurred, the perineum, scrotum, or other parts, must.be freely incised wherever the urine has been effused, in order to prevent the direful effects of lodgement of that fluid; and then the catheter 504 RETENTION OF URINE. should be passed and retained as in the former instance. If the surgeon be foiled in introducing an instrument, as he may be, and if the prostate be sound, the bladder must be relieved by puncture from the rectum. Retention from stricture is, as already observed, the most difficult to manage. No time can be put off in bleeding or warm bathing, in giving internal remedies, or exhibiting enemata. The viscus is making violent exertions to relieve itself, and if these are left unas- sisted, or not rendered unnecessary, they may prove the patients destruction. The system may be drained of blood, and the body parboiled, without the patient being relieved. The case requires immediate and decided practice ; for whilst the surgeon is consult- ing about what is to be done, the urethra may give way, and the patient be lost. The discharge of a small quantity of urine may follow the introduction of small flexible bougies, up to the contract- ed point, but the bladder is not relieved. The throwing of cold water on the thighs may, in slight cases, induce such contraction of the expelling muscles as may overcome the resistance in the urethra, and this method has been had recourse to after failure with ths ca- theter ; but he must be a very poor surgeon indeed who is foiled, when such practice afterwards proves successful. Immediate recourse must be had to the firm silver catheter, pro- portioned in size to the tightness of the stricture, and the difficul- ties afforded to its introduction must be overcome by skill and per- severance ; it is no easy matter to pass the instrument in many cases, and particularly when ineffectual attempts have been made previously. By gentle insinuation, and perseverence in moderate pressure, properly directed, the obstacle can always be overcome,— and that without the infliction of any injury to the parts. I may here observe, that I have never yet been foiled in passing the ca- theter, though very many severe and difficult cases have fallen to my lot; in other words, I have never been obliged to abandon my attempts to obtain an exit for the urine by its natural passage, and, as a last resource, to mutilate and endanger a patient by making an unnatural aperture in his bladder. Yet circumstances may soon occur to me in which the introduction of an instrument along the urethra shall be impossible ; no man, it has been said, can be al- ways wise or always fortunate ; and he who pretends to invariable success must be either a knave or a fool. Should the surgeon fail in passing the catheter, the bladder must be relieved at all hazards ; and if the prostate be sound, puncture by the rectum may be performed. This is neither a difficult nor a dan- gerous operation, else it would not be so often resorted to ; it does not require so much skill and management as does the passing of a catheter. Neither is it painful to the patient; the parts to be per- forated are thin, there is scarcely any effusion of blood, and all is done in the dark. But it is an operation which should never be thought of, unless as a last and desperate remedy; it is one in which I have had no personal experience, though when a student of sur- gery I have seen it done a few times. The procedure gives tempo- RETENTION OF URINE. 505 rary relief, but then the urethra still remains to be put into a proper condition ; a man cannot always void his urine and excrement through one common cloaca. If the urethra be cleared, the recto- vesical aperture may soon close. After the bladder is relieved, the urethra may become quieter, and admit of an instrument being more easily passed ; but it is of very great consequence to effect the intro- duction of a catheter at the first. Rather than puncture the bladder, the stricture should be cut down upon, and an opening made into the dilated part of the urethra be- hind the obstruction. A firm silver catheter is passed down to the stricture, and retained there by an assistant; an incision in the line of the central raphe — supposing the constricted part to be in the peri- neal region—is made over the extremity of the instrument, the con- tracted part of the urethra is divided, and the catheter passed on into the bladder. Thus, even in the worst cases, the natural canal is at once established. In every instance of difficulty and complication, the catheter, however passed, should be retained for two or more days. The above is the only admissible mode of puncturing by the perineum. It has been proposed to reach the bladder from the peri- neum either by extensive incisions or by the random thrust of a long trocar; the latter mode is unscientific, the former is unnecessarily painful, serious, and difficult; both are dangerous, and to be avoided. The symptoms of extravasation of urine have been already detailed. The practice must be bold, and adopted without hesitation or delay. No bulging or fluctuation in the perineum is to be waited for. It is to be kept in view, that the escape of urine into the open cellular tissue may occur in a case of bad stricture, from rapid ulceration or sloughing, without any of the dilated portion of the canal behind, induration or abscess having preceded it; in the greater number of cases the infiltration arises from the going way of the parietes of a cavity communicating with the canal. Urinary infiltration thus super- venes upon urinous abscess. Extravasation can never be mistaken or overlooked by a man of any experience, and who is endowed with common observation. The effect and extent of the perineal fascia must be borne in mind ; it diminishes or precludes—when the point at which the urethra has given way is inferior to it — external ap- pearance of the mischief, and by confining the deleterious fluid in- creases the infiltration internally. A free and deep incision holds out the only chance of relief; punctures or trifling scratches are worse than useless; neither is there any need of passing bougies or cathe- ters, or of puncturing the bladder. The following instructive case may be briefly detailed. A man applied at a public hospital for relief, with a large swelling in the hypogastrium, occasioned by extensive infiltration of urine into the cellular tissue of the abdominal parietes. The tumour was mistaken for distention of the bladder, and a long trocar was plunged in above the pubes without a drop of urine escaping. The patient died during the night. The bladder was found contracted, and the external cel- lular tissue of the abdomen full of urine, from the giving way of the urethra. When judicious and energetic practice is adopted without delay, 43 506 RETENTION OF URINE. patients often make wonderful recoveries. The following may serve as an example: — An elderly man laboured under retention, and his bladder became distended to a very great degree ; attempts had been made to relieve him, but proved unsuccessful. A catheter was passed, and retained for three days. During my absence in the country retention again occurred, followed by extravasation. On my return I found him insensible, but immediately turned him round in bed, and opened the perineum freely, giving vent to fetid urine, sloughs, and matter. Next day he wTas delirious, and knew no one; he hiccoughed, and had cold extremities; " he fumbled with the sheets," and " his nose was as sharp as a pen." A physician in attendance, well acquainted with disease, declared that he could not live six hours. But the urine had a free exit, the hiccough ceased on the exhibition of spiritus ammoniae aromaticus, and wine and brandy were poured into him liberally, the only favourable symptom being, that he still retained the power of swallowing — when that is lost, all is generally lost. He took soup along with the stimulants readily and greedily, and, to the astonishment of every one, reco- vered rapidly; afterwards the stricture was got rid of, and restoration to perfect health completed. Many cases of similar import might be related, all showing the great danger of extravasation of urine, and the advantage of early and decided treatment. I once also witnessed, in the Royal Infirmary, an unexpected recovery from extravasation into the corpus spongiosum urethrae. This occurrence is always attended with most imminent risk; and is generally the result of re- tention from stricture. The urine escapes into the bulb, or anterior to it. Alarming constitutional symptoms quickly supervene ; rapid sinking is threatened. The wrhole penis, scrotum, and perineum are swoln, but the swelling is hard, and most marked in the glans and along the course of the urethra. The glans blackens, unhealthy ab- scesses form in the spongy body, and before these give way, or at least before the sloughs begin to separate, the patient usually perishes. The man to whom I allude, however, recovered, retaining a part of the penis, as well as a considerable portion of its integuments; the rest sloughed and were discharged. In regard to retention from swelling at the neck of the bladder, it may be observed, that spasm of that part of the viscus has been, by some, considered as a cause of the affection ; it is not easy to explain or understand how this should occur, and such an idea is a bad one for him to entertain who enters on the treatment of the disease. The capacity of the bladder varies much in cases of enlarged prostate : in general the organ bears a good deal of distention, and the urgent symptoms do not appear rapidly. Nevertheless, it is the duty of the surgeon, immediately on being called, to relieve the bladder. When the prostate is very large, and retention has continued long, it is im- possible to reach the cavity by a common catheter. Those who em- ploy this instrument in such cases are often much puzzled; they con- tinue long in their fruitless endeavours, and, from rashness, o-enerally produce a discharge of much blood, but no urine; they then become alarmed on finding the instrument always filled with coagulum, and suppose that blood has been effused into the bladder, and tha't the RETENTION OF URINE. 507 symptoms of retention have been thus introduced. A catheter is to be used, which is two or three inches longer than the common one, possessing a larger curve, of such a size as to admit of being passed easily, and not so small as to render it liable to interruption from en- tanglement in the lacunae of the urethra. The posterior part of the urethra is elongated to no slight extent by the enlargement of the prostate, and, besides, the wrhole canal is stretched by the distended bkdder rising high in the abdomen. In short, the bladder is farther away from the surgeon than it is in other cases of retention, and he requires an instrument proportionally long in order to reach it. No time is to be put off. A cautious and persevering endeavour must be made to bring away the urine by the natural passage. Force is prejudicial and unnecessary. It is true that the projecting third lobe of the prostate has not unfrequently been perforated by the catheter, and no unpleasant consequences have resulted, the urine continuing to flow, perhaps freely, through the artificial opening there; but still it is always an injury, often an unnecessary injury, and as such to be avoided. The catheter is to be passed steadily on till it approaches the prostatic region; it is then to be guided by the forefinger of the left hand, introduced into the rectum, and when the point is lost in passing through the gland, the instrument is carefully carried for- ward by depressing the handle, and, if long enough, it will infallibly reach the urine and relieve the bladder. It must, indeed, be a very extraordinary case in which the bladder cannot be reached with the catheter. When enlargement of the prostate, whether of the whole gland or principally of the third lobe, presents an insuperable obstacle to the passage of the catheter, and when the surgeon has taken care to assure himself that such is the case, I conceive that he ought to per- forate the gland in the direction of the natural course of the urethra, uot with the catheter, but with an instrument better adapted for the purpose — a long canula, or catheter with open end, very slightly curved towards the extremity, provided with two wires, one blunt and bulbous at the extremity, the other pointed as a trocar, both made so as to project a short way beyond the end of the canula. The canula is passed on to the resisting body, its orifice occupied by the bulbous wire, which is then withdrawn, and its place supplied by the trocar, the instrument being held steadily in the- proper direction. The trocar, or stilet, is pushed forwards along with the canula ; the former is then withdrawn, and the latter retained. This proceeding I consider quite safe in the hands of an experienced surgeon, one well acquainted with the urinary passages — but not otherwise. It is in every way preferable to puncture of the bladder above the pubes, to puncture behind the prostate, or to puncture of the prostate along with wound of the rectum. As before noticed, I never have had occasion to puncture the blad- der but once — and that was above the pubes, and for an unusual affection of the bladder, the particulars of which have been already detailed. The result of the experience of several eminent surgeons, both in this country and abroad, is similar. Elastic gum catheters have been recommended in this affection, 508 RETENTION OF URINE. and it is said that after the instrument has been passed to the prosta- tic region, its entrance into the bladder is facilitated by gently with- drawing the stilet, the point of the catheter being thereby curved upwards, and, as it were, lifted over any central projection of the pros- tate that may impede its straightforward introduction. But accord- ing to my experience, this instrument is far inferior to the firm and long silver catheter. In all cases of retention when the urine cannot be brought away per vias naturales, and when no farther assistance or advice can be procured immediately, the surgeon should puncture the bladder rather than leave the patient to his fate; and the operation should be per- formed early. He must not temporise till all chance of recovery has gone by. By not operating till late, in this or any other disease, when by the delay no reasonable chance of saving the patient remains, our department of the profession is brought into discredit and contempt. Delay is more dangerous than even the worst mode of making and opening into the bladder; and while life exists, the patient should have his chance. Some defer extreme measures from day to day, either from hesitation or from a false hope that matters may ulti- mately change for the better, but the delay of one hour is in many cases most hazardous. In retention from disease of the prostate extravasation of urine is more dangerous — more certainly fatal__ than in other circumstances. Here a part of the vesical parietes gives way by sloughing, and the fluid is effused within the ilio-vesical fas- cia ; in other cases the extravasation is usually beyond that fascia, and beneath the fascia of the perineum. Puncture by the Rectum is, in cases of enlarged prostate, inadmis- sible and highly dangerous; the operator must either perforate the gland, or enter the cavity of the abdomen. Even in the healthy state of parts, there is very little space between the posterior part of the prostate and the reflection of the peritoneum. The operator having ascertained that the prostate is sound, and the rectum empty, intro- duces the fore and middle fingers of the left hand into the bowel, and along these passes a trocar and canula from four to five inches in length, of moderate calibre, and of a curve rather greater than that of the sacrum. He places the point of this instrument on the part to be perforated, and fixes it there, the point of the trocar being hitherto withdrawn within the canula; the stilet is then protruded, and both carried onwards into the bladder. The part to be perforated is immediately behind the prostate and in the mesial line Puncture above the Pubes is easily enough performed when the bladder is capacious, but it is at best a dangerous operation The wound is made through loose cellular tissue ; urinary extravasation into that tissue is apt to occur, and often proves fatal. If the bowels are inflamed, or evince a tendency towards inflammatory action the danger is increased, for a formidable wound is made in the immediate vicinity of the bowels. Ihe operation has been resorted to when the catheter might have been passed without much difficulty ; this state- ment may appear harsh, but it is too true, and can be borne out by indisputable -facts I is brought forward more as a caution to the young than as a reflection on the senior members of the profession INCONTINENCE OF URINE. 509 Some patients have recovered from the operation, and lived in misery for months and years, passing their urine through a canula retained in the wound. An incision is made above the symphysis pubis, in the mesial line, dividing the integuments and cellular tissue, to the extent of from one to two inches ; on thus exposing the coats of the bladder, a flat trocar with a canula is pushed into the cavity of the viscus, at the lower part of the wound ; the trocar is withdrawn, and the urine evacuated. The treatment of enlarged prostate is palliative — attention to the general health, the occasional administration of anodyne suppositories or enemata, prevention of accumulation in the lower bowels, either by gentle laxatives or the throwing up of bland fluid, and the avoiding as far as possible all sources to excitement, of mind as well as body. The radical cure, it has been said, is extirpation of the gland, but the cool proposal of such an operation would indicate either ignorance, or dereliction of principle, or mental obliquity, or all combined. In retention from effusion of blood into the cavity of the bladder, a long catheter will sometimes evacuate the urine, and after some time also the blood ; for the latter, though at first coagulated, ultimately becomes dissolved in the urine, and passes off along with it, even through a catheter of no very large calibre. Should this fail, and the symptoms continue urgent, an exhausting syringe should be employed, well adapted to the extremity of the catheter. After the urine has been thus evacuated, should a suspicion remain of coagula being still in the bladder, tepid water may be injected with the view of promoting the breaking down of the clots, and then the exhaustion may be repeated. Incontinence of Urine, as already observed, is a common result of distention of the bladder and of stricture. But it also occurs as a primary affection, particularly in young people, from irritability of the posterior part of the urethra not suffering the urine to accumu- late within the bladder as in ordinary circumstances. It is sometimes removed by the application of a blister to the perineum, and by the patient attending to empty the bladder at intervals during the night. Attention to the state of the bowels is necessary- in such cases. The clearing them of worms or sordes, and the exhibition of tonics is sometimes also useful. Children, and even mothers, sometimes have recourse to a more effectual method, the application of a tight ligature round the penis. But of the folly and danger of such practice, the following may serve as an example. A. R., when 8 years old, passed a brass curtain-ring over his penis to prevent incontinence of urine during the night, and thereby escape chastisement, to which he had been frequently subjected. Great swelling soon took place round the ring, and he was unable to remove the jugum. He experienced much pain and difficulty in voiding his urine ; the integuments under the ring gradually ulcerated, the ring appeared to sink into the sub- stance of the penis, and the swelling subsided. The integuments met and adhered, the foreign body was concealed, and all uneasiness soon ceased. The penis performed well all that was required of it; the urine passed easily, and after a while he became the father of a 43* 510 INCONTINENCE OF URINE. fine family. When between fifthy and sixty years of age, he applied to me. For some years previously difficulty in making water had been coming on, and frequent desire to pass it in the night-time ren- dered him very uncomfortable. He was under the necessity of having a vessel constantly in bed, and was generally disturbed every half hour. The penis had become very unserviceable, and he was now anxious to have the ring removed. A broad hard substance was felt surrounding the penis, close to the symphysis ; an incision was made into the urethra at that part, and a calculus easily extracted. The uneasy symptoms quickly disappeared, and the patient recovered with a small fistula at the incised part, which could have been removed without difficulty, had not ail treatment been obstinately resisted. The calculus resembled a prune in size, of a crescentic form, with one of the apices detached, and was apparently composed of uric acid, coated with the ammoniaco-magnesian phosphate. On making a section of it, about two-thirds of the brass curtain-ring, partially decomposed, were found firmly impacted in the centre. It would appear that a portion of the ring had speedily made its way into the urethra, had been acted upon and washed away by the urine; while the remainder, coming more gradually in contact with that fluid, had become incrusted with deposit, and formed the nucleus of the calculus. It is strange that the penis should have been efficient, — that the erectile tissue should have remained pervious — after having been cut completely through near the Symphysis. [The text makes no mention of involuntary omissions of semen, so common in young men between the age of puberty and twenty- five. The frequent occurrence of the affection, and the great im- portance of earlyr treatment, are reasons which demand a brief notice of it in this place. The great cause of this disorder is masturbation, but it may also be produced by excessive venery, gonorrhoea, stricture of the urethra, stone in the bladder, hemorrhoids, fissure of the anus, and, perhaps, also by the presence of ascarides. The irritation on which it more directly depends is seated at the neck of the bladder, the ejaculatorv ducts, and the seminal vesicles, the mucous membrane of which is in a state of morbid sensibility similar to what is occasionally witnessed in the eye, nose, and fauces. Masturbation is a common vice among youth, and when it is once established, it is liable to be followed by the most serious consequences, both as it respects the health and the happiness of the individual. At first the emissions are strictly volun- tary ; they take place under the influence of a lascivious dream, or an excited state of the brain, and they are attended by the usual feel- ing. By-and-by, however, as the local irritation increases, they oc- cur without sensation, and without consciousness, either during sleep, or while the patient is at the water-closet. When the habit°is fully formed, there may be five or six discharges a week, or even as many as two or three in the twenty-four hours. The disease may continue in this state for years without any decided abatement. The seminal fluid itself, although secreted in preturnatural quantity, is without ro- piness, and very thin characterised by a strong odour. It is hardly to be expected that an affection which keeps up such INCONTINENCE OF URINE. 511 a constant drain upon the system, should continue long without seriously disturbing the general health. Among the earlier symp- toms denotive of this circumstance is derangement of the digestive organs, attended with constipation of the bowels, occasional head- aches, and nervous tremors. At a more advanced period, the pa- tient is harrassed with palpitation and dizziness, his sleep is disturbed at night, his extremities are cold, his body exhales a peculiar semi- nal odour, he shuns society, and becomes a prey to gloom and des- pondency. The erections are imperfect, the testes waste, and there is a feeling of numbness or coldness of the thighs, scrotum, and per- ineum. Impotence more or less complete, is one of the most com- mon effects of this disorder in protracted cases. The treatment of this affection should be commenced as early as possible. The longer it is deferred the more danger will there be of permanent impotence and wretchedness. As a local application the best remedy is cauterisation, without this, in fact, nothing can be done with a prospect of a radical cure. Before resorting to the caustic, the urethra should be well explored with a bougie, or silver catheter, to ascertain the precise seat of the irritation. This will sometimes be found in front of the membranous portion of the urethra, but in geneneral it is further back, at the neck of the bladder, or more properly speaking at the orifices of the ejaculatory ducts, and the anterior extremity of the gallinaginous crest, and is often so great that the patient shrinks from the mere contact of the instrument. Occasionally the morbid sensibility is diffused over the whole surface of the urethra, from one end to the other, and when this is the case the passage of the bougie is liable to be followed by excessive pain and even syncope. When the seat of the irritation has been ascer- tained, the caustic — a bit of nitrate of silver — inserted in one of Lallemand's instruments, is to be carried down to the requisite dis- tance, and held there until the patient begins to complain of smarting or burning pain, when it is cautiously withdrawn — from twro to five minutes will usually suffice, and in some cases we are obliged to re- move the instrument much sooner. When the operation is finished, the patient is requested to drink a tumblerful or two of gum water, with a small quantity of nitrous aether, to keep at rest for ten or twelve hours, and to observe the antiphlogistic regimen. If the pain is considerable, or if strangury supervene, a drachm or two of the camphorated tincture of opium, or half a grain of morphia, may be taken. I usually repeat the operation once a week until I have reason to believe that the morbid sensibility of the part is entirely destroyed. The number of applications must of course vary in different cases, but in general two or three will suffice. Cold bathing, general and local, is often beneficial in this affection. Sitting in a tub, and dashing the cold water against the perinaeum, scrotum, penis, and inside of the thighs is useful. In some instances I have found marked relief from cold clysters, repeated twice in the twenty-four hours. When the patient is plethoric, as is sometimes the case in the early stage of the disease, leeches may be applied to the perinaeum, followed, if the local excitement is unusually great, by blisters, tartar-emetic frictions, a small seton, or an issue. When the 512 GONORRHOEA PRjEPUTIALIS. morbid sensibility of the urethra is very extensive, obstinate, or per- sistant, the cauterisation should be aided by the injection twice a day, of a weak solution of the nitrate of silver and opium, lhe propor- tions whch I commonly employ are two grains of one to a gram and a half of the other to the ounce of rose water. Sulphate of zinc, creasote, and acetate of lead also answer extremely well in cases of this kind. The injection should be forced as far back as possible, and be retained two or three minutes in the canal. A total abandonment of masturbation, and temporary abstinence from sexual intercourse, are indispensable measures. Without this it is in vain for the surgeon to proceed with his treatment. The pa- tient must sleep upon a hard mattress, and everything stimulating, whether in the form of food, drink, or medicine, must be carefully avoided. The bowels must be regulated by mild aperients, and on no account be allowed to become constipated. Exercise in the open air, either on foot or in a carriage, is an important auxilliary. Riding on horse-back is to be interdicted, as it has a tendency to create un- due excitement in the genital apparatus. When there is great prostration of the system with restlessness and loss of sleep, tonics, such as quinine and the aromatic tincture of the citrate of iron, with hyoscyamus or opium, are indicated. In such cases, a change of air and the daily use of the shower-bath greatly promote recovery. The diet should be light but nutritious, and the patient should be allowed a glass of generous wine at dinner. When by the above measures, the system has regained its natural tone, and the sexual apparatus its accustomed vigor, the best guar- antee against a relapse will be marriage. Upon this point, however, the practitioner cannot be too much upon his guard.] Of Gonorrhoea Prceputialis vet spuria. — By this term is under- stood discharge of puriform matter from the lining membrane of the prepuce, and from the surface of the glans, accompanied with an itching and smarting sensation. The affection may arise from mere inattention to cleanliness, the natural secretion being allowed to col- lect and deteriorate ; or from the application of acrid matter, gonor- rhceal, or leucorrhoeal. It often attends discharge from the urethra, and is usually met with in those who, from the natural tightness of the prepuce, uncover the glans with difficulty, if at all. It may oc- cur without impure connexion ; mucous discharge accumulates, be- comes acrid from stagnation, and is washed away by profuse secre- tion of puriform matter; the parts then become quiet, and resume their healthy functions, but are apt from slight causes to be again the seat of discharge. Generally the surface of the prepuce and glans are relaxed and turgid, but ihere is no breach of continuity ; in ne- glected cases there is superficial patchy ulceration, and sometimes a deep and sloughing sore. The matter is often confined by tightness of the praeputial orifice, and mischief thereby occasioned by the glans ; a large purulent collection forms, and, if the case is neglected, ul- ceration takes place, either of the glans or of the prepuce, or of both; the latter becomes thin and at length gives way ; the aperture thus formed extends, and occasionally is of such a size as to admit of pro- PHYMOSIS AND PARAPHYMOSIS. 513 trusion of the glans. GSdematous swelling generally takes place to a great extent in such cases. The glands of the groin sometimes swell, and through inattention may suppurate. The absorbents of the penis may also become turgid and painful. Tenderness of the glands and prepuce often exists, in a greater or less degree for years; in such circumstances the affection may be termed gleet of the prepuce, and is usually the consequence of irritable urethra. The treatment consists in cleanliness and rest, applying astringent washes to the parts, and suspending the organ. When swelling of the prepuce or inflammation of the lymphatics is threatened, constant rest must be enjoined. In obstinate cases, disease of the urethra is to be suspected as the cause, and the state of that canal should there- fore be ascertained ; if derangement of structure or function is de- tected, then means must be forthwith adopted for its removal, the applications to the prepuce and glans being at the same time not neglected. Mercury can be of no use. Phymosis and Paraphymosis are often connected with gonorrhoea of the prepuce, or of the urethra. The edge of the prepuce may be rendered tight by inflammation, swelling from effusion, or cicatrisa- tion of sores ; the tightness also attends irritability of the urethra par- ticularly in young subjects ; often it is congenital. The affection is termed Phymosis when the prepuce occupies its natural relative situa- tion, but cannot be drawn back so as to uncover the glans. The contraction exists in various degree ; sometimes the orifice is so tight that the flow of urine is obstructed, the praepeutical cavity becoming swelled and distended every time the patient attempts to make water. In other instances the uninjected glans can be exposed either in part or entirely, though with difficulty. In consequence of the praeputial cavity being frequently filled with urine, in cases of great contrac- tion, urinary concretions have even formed or been detained there or in the orifice of the urethra, giving rise to very annoying, and some- times alarming, symptoms. In consequence of phymosis, the urethra and bladder may become diseased. It is often attended with pro- fuse puriform discharge, with sores of different kinds, or with warty excrescences on the glans and prepuce ; sometimes the whole sur- face is completely covered with granulated prominences of various sizes, some large, but the majority small, some broadly attached, others suspended by narrow necks; all generally furnish discharge of thin acrid matter. Adhesion may take place between the raw surfaces of the prepuce and glans, provided the parts be not fre- quently displaced for the purpose of ablution. Paraphymosis arises from the same state of the orifice of the pre- puce as the former affection, only the parts are in different relations to each other. In phymosis the prepuce covers the glans, the tight part is anterior to it; in paraphymosis the prepuce is reflected over the glans, the tight part acts as a ligature round the penis behind the glans, and such swelling speedily arises in consequence of the constriction so as to prevent reduction. The glans and lining mem- brane of the prepuce swell anteriorly to the stricture, the integuments of the penis swell behind, and the stricture is depressed and con- 514 PHYMOSIS AND PARAPHYMOSIS. cealed between. The cellular tissue there is necessarily very loose, so as to admit of free motion and change of relative position, and consequently the engorgement is often very great. The infiltration is at first serous, and the swelling is easily compressed ; but, from continuance of the inflammatory action, lymph is effused, and be- comes organised, and the turgescence is more solid and unyielding. When the stricture is very tight, the patient cachectic and irregular in his mode of life, and the case injudiciously or inertly treated, sloughing takes place rapidly, or phagedenic ulcerations occurs ante- rior to the stricture. But in most cases the prepuce is not so tight as to cause complete strangulation, yet obstructs the flow of blood sufficiently to induce swelling of the included parts, breach of sur- face more or less extensive, and an unhealthy appearance of the ulceration. The ulceration, is generally in the neighbourhood of the stricture, at first limited and superficial, but increasing both in depth and extent so long as the cause remains. The stricture is not situ- ated anteriorly to the swelling, as has been sometimes supposed, but near its middle — where the tight orifice of the prepuce grasps the penis, and causes a depression in the swelling. On separating the anterior and posterior tumours, the stricture is readily exposed, though previously effectually concealed. In slight cases of phymosis, the orifice may be dilated by frequent fomentation, and perseverance in withdrawing the prepuce as far as possible. When ulceration or secretion of matter has occurred, astringent injections, at first mild, and gradually strengthened, should be frequently thrown into the praeputial cavity. Suspension of the penis should be enjoined, along with rest— of the whole body, as well as of the affected organ in particular. When much inflamma- tion exists, antiphlogistic remedies must be put in force, followed by fomentations. In bad cases the prepuce must be divided in order to expose the seat of morbid secretions, of ulceration, and vegetations. The preferable situation for incision is close by the side of the fraenum, much less deformity ensuing than when the prepuce is divided either laterally or in front. The flaps are at first loose and flabby, but shrink as the cedematous swelling subsides. A straight director is introduced within the praeputial orifice—the groove pointing down- wards— and passed down to the reflection, close to the fraenum ; a sharp-pointed curved bistoury is slid along the groove till it also reaches the reflection ; by raising the handle and pushing it forwards, the integuments are transfixed there, and withdrawal of the knife by a rapid sweep completes the incision. Care must be taken not to pass the director into the urethra instead of into the praeputial cavity. It is very seldom that ligature is required to arrest bleeding. Should the cellular tissue of the divided part not have been the seat of solid effusion, the integument and the lining membrane of the prepuce separate, leaving a large raw surface ; and to prevent this a small suture should be passed between the membrane and skin on each side of the wound ; these may be withdrawn on the second or third day, the cellular tissue having then become solidated, so as not to admit of retraction. A warm bread poultice, or water dressing, is the best application for the first few days ; afterwards healing of the PHYMOSIS AND PARAPHYMOSIS. 515 Cut surfaces may be promoted by the application of a gently stimu- lating lotion. Should oedema of the prepuce remain, this may soon be effaced by bandaging. By this operation sufficient space is ob- tained for uncovering the glans, under any circumstances ; and be- sides, to this part of the organ is still preserved its natural investment, not in the least curtailed either in size or in efficiency — the glans can be uncovered and covered at will; whereas by any other mode of incision the unseemly flaps always fall away, leaving the greater part of the glans constantly uncovered, and placing the patient, if not in a worse, at least in the same predicament, as if he had been subjected to regular circumcision. There is danger in allowing the state of phymosis to exist long; it has been already observed, that this condition of the parts predisposes to ulceration, vegetations, and morbid secretions ; but besides, ex- perience has shown, that very many cases of cancer of the penis are attributable to phomosis, either congenital, or of long duration. In all cases, when the orifice of the prepuce is so tight as not to admit of exposure of the glans, the operation is expedient, the existing state of parts being very inconvenient; but it becomes a matter of absolute necessity, when there are extensive sores on the prepuce or glans, when there is much tumefaction or hardening of the parts, when uri- nary concretions lodge in the praeputial cavity, or in the orifice of the urethra, when vegetations or warts form on the glans, and when the praeputial orifice is so contracted as seriously to impede the flow of urine. In paraphymosis there is a necessity for early interference, in order to save the organ ; indeed active and decided measures are as impe- riously called for here, as in the case of strangulated hernia: and it ought to be remembered that the organ is one of importance, and that its loss would render most people very miserable. To attempt relaxation by fomentations, and such like, is absolutely folly; the stricture cannot yield to such remedies; and, from increase of swell- ing, strangulation will become more and more complete. Cold, too, is incapable of reducing the swelling; cold, or astringents, cannot possibly diminish the size of the vessels, whilst return of the blood in them is prevented by tight stricture ; and so long as the stricture remains, the serous effusion cannot subside, but will increase. Be- sides, the application of cold may hasten the occurrence of gangrene, inasmuch as it tends to diminish the power of parts which are already in a weakly condition. The parts must be instantly replaced. With the fingers of the right hand, the surgeon grasps the glans, and by firm and continued pressure diminishes its volume, whilst writh the left he endeavours, by steady pulling, to reflect the swollen prepuce over the glans, which he is at the same time pushing back, as well as lessening. By uniformity and perseverance in these manipulations, more than by any force, replacement will often be accomplished. He will be able to judge, from the duration of the disease, and from the appearance and feel of the parts, whether simple reduction, that is, without having recourse to the knife, be practicable or not. In some cases, particularly when gangrene is immiment, and when the ulceration is extensive, there is danger of materially injuring the 516 CANCER OF THE PENIS. glans, if attempts at reduction are injudiciously persevered in. When he is foiled in reduction, or deems the attempting of it impru- dent, the stricture must be divided; and in this simple operation great errors are often committed from ignorance of the nature of the disease, and of the relative situation of the parts. It is necessary to divide only the edge of the prepuce, which, from being reflected, alone composes the stricture. The anterior and posterior swellings are to be separated as far as possible, and in the very bottom of the depression between them the stricture is exposed; a slight incision, a scratch, through this, either with the point of a bistoury, or with a lancet, is sufficient; the tight edge of the prepuce — the only part in fault—is divided, and then, by the process already detailed, reduc- tion can be readily effected. After reduction, a minute notch in the extreme edge of the prepuce is the only deformity visible, except the swelling. But if, from ignorance of the true seat of the stricture, extensive incisions have been made, pretty much at random, the organ may be considerably disfigured — and that unnecessarily. By fomentations, rest, and low diet, the effusion will be dissipated in a very few days. Reduction is difficult when the contraction has con- tinued for some time, and the tissues have become glued together by effused lymph. Malignant ulcer, with induration of the surrounding parts, and contamination of the lymphatics, occurs occasionally on the glans penis, or on the lining membrane of the prepuce. As before ob- served, it is most frequently met with in those who have laboured under congenital phymosis ; in that state of the organ, its extremity is apt to inflame, swell, and ulcerate, in consequence of accumulation and acrimony of the secretions from the membrane of the prepuce; indolent swellings form in the groin ; and in one case, I recollect, these assumed a malignant action, a frightful ulcer formed, and the patient was destroyed, after division of the prepuce, and after the ulceration on it had been long healed, and the part had apparently become quite sound. Early removal of the diseased part, by incision wide of the indurated and altered structure surrounding the ulcer, is the only means of saving the patient, of preventing glandular inguinal tumour, ulceration of it, hemorrhage, hectic, and death. When the prepuce solely is involved, removal of this is sufficient, either entirely or in part, as circumstances may demand. When the glands and coverings, as also the body of the organ, are involved, amputation is to be performed, provided the lymphatics still appear unaffected. In this operation the integuments must be freely removed, otherwise the cut orifice of the urethra will be obstructed by their puckering and contraction during cicatrisation of the wound. With this view, the skin is drawn forwards and stretched by the left hand, and then with one sweep of a long knife a transverse incision is made at once through all the parts composing the organ. Two or three vessels by the side of the septum may require ligatures. The skin retracts con- siderably, leaving the cut surface free ; the wound granulates, con- tracts and cicatrises. It is advisable to cut the urethra a little longer than the body of the organ. If diminution in the canal of the urethra CHIMNEY-SWEEPER'S CANCER. 517 be threatened during the cicatrisation, it is to be obviated by the oc- casional use of a short conical bougie. Imperfections about the orifice of the urethra are by no means un- common. Often there is a mere vestige of the orifice of the urethra in the natural situation, the opening being situated half an inch or a whole inch behind, and on the lower part — Hypospadias ; in such cases the prepuce is generally short. Sometimes the urethra is deficient to a great extent, terminating immediately before the scrotum, or even behind it. A child had passed no water thirty hours after its birth. The bladder was dis- tended. The genital organs were imperfect; the urethra was wanting, and the penis wTas diminutive and abnormal. A small trocar was passed from the vestige of the orifice onwards, in the proper course, guided by the finger in the rectum. The urethra seemed to have terminated at the bulb ; the canula reached this, and was retained for twenty-four hours. Afterwards the urine passed readily through the canal, partly natural, but principally artificial, and the power of retaining it became perfect. In adults the hypospadias is inconvenient; the orifice is often contracted, and the whole parts are irritable ; and the ejaculation of the seminal fluid is unsatisfactory to the parties concerned. The deficiency may be repaired in some measure, when there is abun- dance of skin to spare, but no rules can be laid down for such irregular operations. Imperfection of the urethra anteriorly, on the dorsum, is rare — Epispadias. The following is rather a remarkable instance : — The man wras aged 26, robust and healthy. The whole extent of the urethra anterior to the pubes was exposed superiorly, there being a wide fissure through the corpora cavernosa and glans. The penis was retracted considerably, so that the posterior part of the fissure lay beneath the symphysis pubis. The numerous lacunae of the urethra were beautifully distinct, and the mucous membrane was seen covered by their secretion. When the patient made water, the urine, after emerging from beneath the pubes, divided into nu- merous small streams, some of which spread over the side of the penis, while others passed along the exposed urethra. The callous margins of the fissure, formed by the corpora cavernosa and glans, were carefully pared, and, a catheter having been introduced, the raw surfaces were retained in apposition by suture. The wound healed perfectly, almost entirely by the first intention ; and the organ both looked well and proved efficient. The malformation was congenital, and was considered by the patient as analogous to harelip ; but the story related to account for it in consequence of an impression made in his mother's imagination, was not very plau- sible. The disease of the external parts of the male genital organs, commonly called Chimney-sweeper's Cancer, is one of a formidable and intractable nature, but fortunately not very often met with. The scrotum is the part usually attacked. A wart forms, generally 44 518 HYDROCELE. at the lower part, assumes an irritable appearance, and quickly de- generates into open ulceration of a malignant character. The ulcer extends rapidly, consuming the neighbouring integument, and in- volving the testicle and other subjacent parts in induration and en- largement. The induration extends along the spermatic chord, and the lymphatics participate in the diseased action at an early period. The discharge from the sore is acrid, sanious, and possessed of much fetor ; sometimes fungi protrude, but more commonly the surface is excavated and smooth. Not unfrequently the skin sur- rounding the ulcer is studded, to a considerable extent, with nu- merous clusters of warts, of an unhealthy and angry aspect. A very aggravated specimen of the disease is here represented. The general health is soon undermined, and the disease advances from bad to worse with the usual certainty and rapidity of malignant action. It seldom occurs till after the age of thirty or forty ; and though most fre- quent in chimney-sweeps, is not pecu- liar to them. No treatment can be expected to arrest its progress at an advanced stage ; the only opportunity of saving the patient is at the com- mencement of the disease, when the affected part is small, and before the lymphatics have become involved. Local application and internal reme- dies are not to be trusted to ; in the early stage the parts may be excised. An incision is made wide around the wart or ulcer, and the included parts are dissected away to a considerable depth. When the tes- ticle has become affected, the chance of success is much diminished ; but still, if the inguinal glands appear sound, and the chord tolerably free, castration is to be performed as the last, though desperate, means of eradicating the disease. By Hydrocele is meant a tumour caused by accumulation of fluid either in the chord or within the cavity of the tunica vaginalis testes. It has been divided into diffused and encysted. By the former term is understood effusion and accumulation of serum in the cellu- lar tissue, the cells gradually dilating to accommodate the increas- ing fluid, and ultimately becoming converted into vesicles of large size: the parts around are thickened and condensed. This affection is very rarely a local one, but almost uniformly combined with and torming a part of anasarca arising from constitutional causes When the swelling proves troublesome, it may be diminished by drawing off the fluid through one or several punctures; in the chronic form of the disease free incision is attended with risk, and is besides un- necessary. The scrotum is sometimes distended rapidly- by effusion of serum often of a putrescent and acrid nature. This affection supervenes upon ulcers or sinuses m the groin, perineum, or neighbourhood of HYDROCELE. 519 the anus, in patients out of health. It occurs also occasionally as a consequence of injury of the genital organs, or interferes with bad strictures, without any disease of these parts, and without the least cause for the suspicion of the urine having escaped into the cellular tissue. This, together with the skin, is destroyed, and the tes- ticles exposed. The only chance of saving the tissues consists in early and free incision of the most dependent part of the swelling, generally the inferior and posterior. Some cases and remarks on this subject will be found in the Medico-Chirurgical Transactions, vol. xxii., p. 288. Encysted hydrocele of the chord occurs in children more frequently than in adults. The fluid is thin and clear, and contained in a dis- tinct cyst, of a smooth, shining, serous appearance internally-; this cyst may be either an unobliterated portion of the congenital spermatic process, or composed of thickened and condensed cellular tissue, strengthened exteriorly by the expansion of the cremaster muscle. The tumour is seldom large, usually of an oval form, and situated nearly midway between the testicle and groin ; causing no pain, but proving inconvenient simply from its bulk and situation ; fluctuating, and sometimes partially diaphanous; evidently circumscribed, the chord both above and below being natural to both sight and touch ; not altered by change of posture or by muscular exertion. Some- times it encroaches both on the groin and on the testicle, but even then attentive manipulation readily distinguishes it from swellings connected with these parts. Discharge of the fluid by means of a small trocar and canula, not only dissipates the swelling, but often effects a permanent cure, particularly in young persons—the cyst either ceasing to exercise a secretory function, or becoming obliter- ated. If reaccumulation take place, the treatment is to be conducted on the same principles as in hydrocele of the vaginal coat. Hydrocele of the tunica vaginalis is exceedingly common, particu- larly amongst labouring people, and occurs apparently with equal frequency at all ages. It is a gradual accumulation within the tunica vaginalis of a fluid partaking more or less of the serous cha- racter, furnished by the exhalants of that membrane,—-but whether from excessive secretion or deficient absorption, it is difficult to de- termine. It is probable that the accumulation is the result of excited action in the part, for its origin is most frequently attributable to ex- ternal injury — blows or bruises, followed by rapid swelling, which, after a time, subsides, leaving perhaps some enlargement of the tes- ticle, or of the more superficial tissues, and succeeded by the gra- . dual appearance of the disease in question. Sometimes it is attributed to powerful and habitual muscular exertion, as in blowing wind in- struments, lifting heavy weights, &c.; and perhaps the impediment to the venous return, so produced, may be the cause of the effusion. The accumulation, as already stated, is gradual, and consequently the formation of the swelling is proportionally slow. It commences at the lower part of the scrotum, and by degrees ascends, at first globular, afterwards of a pyriform shape ; after it has attained a con- siderable size, the testicle cannot be felt in its usual situation, for it is now plaped not at the bottom of the bag bqt towards its middle 520 HYDROCELE. and posterior aspect, and if the tumour be tense it can scarcely be felt at all. The raphe is displaced to the opposite side, the usual puckering of the scrotum has disappeared, and the tumour feels light in proportion to its size. On manipulation it is found yielding and elastic, and in all ordinary cases a distinct fluctuation is communi- cated to the fingers during alternate pressure. And by using the hand as a shade, the rays of light are made to permeate the swelling, rendering it more or less transparent according to the thickness and density of the covering, and the hue of the contained fluid. It is seldom that the distention of the vaginal coat is to such an extent as to reach the groin, consequently the spermatic chord is felt to be free, as also the inguinal aperture ; and even when the swelling does reach so high, the upper part is the least tense, permitting displace- ment of the fluid and distinct perception of the chord. The patient complains of a sense of dragging and weight in the parts, and of uneasiness and inconvenience during exertion, but seldom of pain. When large, the tumour is necessarily covered by borrowed integu- ment, often so as almost entirely to conceal the penis. In many cases the testicle is increased in size and indurated, and sometimes this enlargement forms a considerable part of the swelling. Occa- sionally the spermatic veins are varicose ; and this has been, by some, considered one of the causes of the disease. Hydrocele is occasion- ally complicated by the presence of hernia, when a careful examina- tion must be instituted in order to understand the exact share each disease has in the production of the swelling. In cases of very slow increase, and in persons of advanced age, the vaginal coat and its investments are not unfrequently much thickened, so as to obscure the sense of fluctuation, and destroy the transparency of the tumour. Sometimes deposit of earthy matter takes place between the layers of the membrane, rendering it hard, rigid, and in a measure osseous; in such cases cholesterine has been found in the contained fluid ; sometimes the cavity is intersected by membranous filaments, deli- cate and reticulated ; sometimes complete septa subdivide it into several compartments. The fluid is generally thin, albuminous, and of a straw colour; in some cases paler, and coagulating on cooling, being gelatinous ; in others of a dark colour, probably from admix- ture of blood. The treatment is either palliative or radical. The former consists in evacuating the fluid from time to time, according as the feelings of the patient demand it; in children this simple tapping is often suc- cessful in preventing return of the disease. But here the disease often enough disappears under the use of a stimulating lotion, as a strong solution of the muriate of ammonia. The swelling is grasped from behind by the left hand, and com- pressed so as to render the middle and fore part tense and promi- nent; into this a trocar and canula are plunged, piercing the cover- ings in a perpendicular direction, and then inclining the canula upwards, the stilet having been partially withdrawn, so as to avoid wounding the testicle. The venous branches apparent on the surface must be of course avoided. When fairly passed within the cavity, the trocar is withdrawn entirely, and the fluid escapes through the HYDROCELE. 521 canula—gentle pressure being employed towards the conclusion. The wound usually heals in a few hours. Various means of radical cure have been proposed — incision, seton, caustic, and the injection of stimulating fluids. Incision and the seton are now abandoned, and do not require notice. The application of caustic perhaps may prove efficient in children when tapping has failed, and in youths ; an aperture is thus made, through which the fluid escapes, and at the same time considerable excitement is induced, which may pre- vent reproduction. I at one period made trial of it in several in- stances, and generally with success ; but am now inclined to avoid it, having more than once experienced much difficulty in keeping within moderate bounds the inflammatory action which succeeded its application. Injection is now generally practised ; and if care- fully performed, it is unattended w-ith risk, and is almost invariably successful. Various fluids may be employed — cold water, wine, wine and water, spirits, a solution of the sulphate of zinc, &c. I have generally used pure port wine; and have scarcely ever seen its effects either excessive or deficient. I can remember very few cases in which the disease returned after this injection. Having ascer- tained that the testicle is. sound, or but slightly enlarged — for injec- tion of the tunica vaginalis is incompatible with diseased testicle — the fluid is drawn off by means of a round trocar. The canula is left in the wound, and to it is adapted the nozzle of a brass stop-cock attached to a small elastic bottle. By means of these instruments the wine is injected in sufficient quantity to distend the tunic mode- rately, taking care that the extremity of the canula is completely within the cavity, otherwise the cellular tissue will be injected, and violent inflammation ensue, terminating in unhealthy suppuration and sloughing. By turning the cock, the wine is retained until the pa- tient begin to feel pain shooting upwards to the loins, when it is to be evacuated. He may not feel any uneasiness, however, and then it will be necessary to draw off the fluid and inject a fresh quantity. If this, too, fail, a more stimulating fluid must be used, a solution of sulphate of zinc, spirits and water, or pure ardent spirits. It is sup- posed that this treatment is effectual by inducing adhesive inflamma- tion, and obliteration of the cavity by adhesion of the tunica vagi- nalis to the tunica albuginea; but this does not by any means frequently happen. There may in some cases be a little lymph de- posited, but not in sufficient quantity to cause adhesion. The ex^ citement following injection seems to change the action in the parts without altering their structure or relation—to re-establish the healthy balance between the exhalants and absorbents. Its first effect is to produce increase of swelling from fresh effusion into the cavity of the tunica vaginalis, accompanied with redness of the integument and considerable pain — sometimes with slight fever. This fluid, however, is quickly absorbed — usually in from four to six days —■ the swelling subsides, as also the pain, and the patient remains free of the disease. Whilst this salutary action is in progress, the recum- bent posture must be strictly enjoined, along with low diet and sus- pension of the organ ; and sometimes, though rarely, it may be neces- sary to have recourse to more active means to moderate inflammation, 44* 522 HYDROCELE. Should the excitement appear insufficient after a day or two, the surfaces may be rubbed against each other with the fingers, and gently squeezed, or the patient may be directed to walk about occa- sionally through his room until pain is felt. If the disease return, as need scarcely be dreaded, injection is to be repeated, either again with wine, or with a more potent fluid. [The principal objection to this method is, that it is not always successful, and that it requires, in some cases, to be repeated again and again before a sufficient amount of adhesive action is induced to obliterate the vaginal sac. Moreover, by carelessness on the part of the surgeon, the canula may slip out of the vaginal sac, and so allow the fluid to pass into the cellular substance of the scrotum, where, if it be not speedily evacuated by free incisions, it is sure to occasion gangrene. But this is not all. The operation, even when well per- formed, is sometimes followed by violent inflammation and suppura- tion ; in one instance, indeed, I knew it to be productive of tetanus. The patient, a stout, robust mechanic, about twenty-six years of age, whom I saw twice in consultation, was doing apparently well during the first eight days after the operation; wdien, owing to exposure to cold, the symptoms of the disease in question manifested themselves, and in less than twrenty-four hours the man expired. Upon exami- nation after death, the vaginal tunic was found to be considerably thickened, and its cavity to contain several ounces of sero-sanguino- lent fluid, intermixed with a small quantity of unhealthy-looking pus. No adhesions had taken place between the opposite sides of the sac. A case of a similar kind is alluded to by Sir George Ballingall, in his u Outlines of Military Surgery." The operation by injection has, I know7, many advocates, both in this country and in Europe ; and, when well-executed, is generally unattended with risk, if not always successful. The fact, however, that it may be followed by serious mischief, with occasional loss of life, should be sufficient to deter the practitioner from resorting to it, more especially when we reflect that we are in possession of another remedy, not only entirely devoid of danger, but always, so far as my observation extends, most effective. This remedy is the seton, which I have been in the habit of employing, in repeated instances, for some years past, and from which I have never experienced any other than the most happy results. The operation is perfectly sim- ple, the amount of inflammation produced by the presence of the foreign body may be easily regulated, and there is no danger of sloughing of the scrotum, much less of the development of tetanus, or other mischief. In performing the operation, a large round trocar is introduced at the usual place, and after the fluid has been thoroughly evacuated, the instrument is again conveyed along the canula to the upper and fore part of the scrotum, for the purpose of effecting a counter-open- ing, which should be from an inch and a half to two inches from the first. The trocar is now withdrawn, when an eyed-probe, armed with a skein of silk or piece of tape, is passed along the tube, upon removing which the operation is completed. The seton need seldom CIRSOCELE. 523 be retained longer than four or five days; during which period, as well as for some time subsequently, the recumbent posture should be enjoined, along with suspension of the scrotum, and the usual anti- phlogistic means. When the inflammation, tenderness and swelling have considerably abated, the reduction of the tumour may be pro- moted by the daily inunction of equal parts of iodine and campho- rated mercurial ointment.] The term Cirsocele is applied to varix of the spermatic veins. The affection seldom extends to the inguinal aperture, and is usually situated on the left side. The tumour is somewhat pyriform, the larger extremity resting on the testicle, and by its peculiar appearance and feel its structure is at once apparent; the veins are seen through the integument. Pressure from below upwards, during the recum- bent posture, diminishes the swelling ; pressure above augments it, particularly if the patient change his posture, and exert the abdomi- nal muscles. Sometimes a dull pain in the back is complained of, relieved by suspension of the. scrotum, and often wasting of the tes- ticle slowly advances. In some cases the swelling attains a large size, elongating the scrotum, and proving a source of very great un- easiness to the patient — so great that some have requested and urged castration Commonly it is sufficient to wear a bag truss, and avoid all causes of irritation to the parts; thus increase of swelling is pre- vented, and the inconvenience rendered trifling. If pain, with redness of the integument, and additional enlargement, should supervene, rest and the recumbent posture must be enjoined for a time, combined perhaps with low diet and local depletion. But in cases of large in- convenient tumour, accompanied with atrophy of the testicle, rather than accede to the wishes of the patient and perform castration, the treatment recommended many centuries ago may be put in practice — the application of a heated wire to the veins. Tie upper part of the tumour is grasped and made prominent, the veins are separated as much as possible from the other parts composing the chord, and a small-pointed cautery, a glover's needle, for example, is inserted at several points. This is followed by some pain, and increase of swelling. Inflammation and obliteration of the veins is produced at the cauterised points, the swelling gradually diminishes, and ultimately a dense chord is all that remains. The cure is radical, and I have never seen the effects prove too severe. Rest and antiphlo- gistic regimen are of course necessary for some days after the appli- cation ; abstraction of blood will seldom be required. Within the last few years I have been in the habit of passing two needles under the veins at an interval of about half an inch from each other, and twisting a thread firmly over them and the superimposed integuments. Of course the other parts of the chord are held aside by the finger and thumb, and the needles are withdrawn within a few days; as soon, in short, as consolidation of the interposed substance has taken place. This operation is preferable to any other. [In upwards of one hundred cases of hydrocele examined by Mons. Breschet of Paris, only one occurred on the right side. With 524 CIRSOCELE. this result, the experience of nearly every practitioner must coincide. Cirsocele may take place at any period of life, in the young as well as in the old ; but it is most common, by far within the first ten years after puberty, or during the period of the greatest excitement of the genital system. In twenty-seven cases observed by Mons. Landouzy, in which this subject was particularly noticed, seven occurred between the ages of nine and fifteen; seventeen between fifteen and twenty- five ; three between twenty-five and thirty-five. Cirsocele appears to be occasionally hereditary. Professor Blandin of Paris, in an able article on this disease, in the " Diet, de Medicine et Chirurgie Pratiques," refers to three brothers with whom he wTas personally acquainted, who were all exempted from military duty on account of the existence of this malady: the father was similarly affected. An analogous case is mentioned in an inaugural disser- tation published a few years ago at Paris. The causes of cirsocele are, venereal excesses, masturbation, pro- tracted exercise on foot or horseback, contusions of the scrotum, in- flammation of the testicle, and mechanical obstacles to the return of the blood to the spermatic veins, whether produced by the presence of a tumour, fatty accumulations of the omentum or mesentery, or the wearing of tight and ill-constructed trusses. Of these the first two are probably the most frequent and influential. Indeed, I am per- suaded, from considerable experience, that this is the case. How these causes act in developing this affection admits of ready expla- nation. Their tendency is not only to determine an abundant afflux of blood to, and consequent congestion in, the genital organs, but to produce more or less fatigue in the muscles of those parts, especially in the cremaster and dartos, together with a loss of nervous innerva- tion, which diminish their power and contractile energy. The testicle being thus insufficiently sustained sinks down by its own weight, into the scrotum, which, with the spermatic vessels, is there- by kept in a state of constant relaxation. Heat acts in a similar manner, and produces similar results. Hence cirsocele is more frequent in hot than in temperate climates, and worse in summer than in winter. Although the symptoms of this affection are usually well marked, yet it is sometimes liable to be confounded with other lesions. The malady for which it is most apt to be mistaken is inguinal hernia especially that variety of it in which the omentum is concerned. The best way in such cases is to place the patient on his back, and hold up the scrotum until the vessels are entirely emptied of their con- tents ; the finger is then applied against the external ring and the patient requested to rise, when, if the disease be cirsocele, the sper- matic veins will immediately refill, while, if it be hernia, the bowel will be unable to descend. The progress of this disease is usually tardy, years elapsing before it causes much suffering or inconvenience. In some instances, how- ever, it increases with great rapidity, and gives rise to severe local disorder, wTith more or less constitutional derangement. One of the most serious and unpleasant effects of this disease is atrophy of the HEMATOCELE. 525 testicle and epididymis, produced by the pressure of the enlarged veins; it may exist in various degrees, from the slightest softness and diminution of volume to almost entire wasting of the organ, and occasionally, though rarely, affects both sides simultaneously. A gloomy and melancholy state of mind, sometimes bordering upon alienation, frequently attends this condition of the testicle. The least objectionable operation, in my opinion, is that of tying the affected veins, after having carefully separated them from the spermatic artery, vas deferens, and nerves of the testicle. The ves- sels may be ligatured at one or more points, according to the extent of the enlargement: and, by carefully excluding the structures just mentioned, there will be no danger of cutting off the nervous and vascular supply, as must necessarily happen, in some degree, in the proceeding recommended by Mr. Liston, and which must therefore lead to further wasting of the testicle ; a circumstance which should be most sedulously avoided. The external incision need not exceed an inch and a half in length. I am induced to subjoin the following account of a novel but harsh operation for the cure of cirsocele, lately devised by Mons. Breschet of Paris, not from any belief or hope that it will be generally adopted, but because it has made some noise in the surgical world. It is founded upon the anatomical arrangement of the part, or the facility with which the varicose vessels can be isolated from the spermatic artery and vas deferens, and afterwards compressed so as to obliterate 'heir calibre. This is effected by means of a forcepswith flattened plates, which are worked by a screw. The pressure is applied in a gradual manner, but with sufficient force to destroy the vitality of the scrotum and of the affected vessels. The instrument is usually removed in from six to eight days, during which the patient is left on his back, cold lotions are applied to the scrotum, and the case treated on general principles. When the sloughs are detached, the edges of the sore are approximated by adhesive strips, and the person is permitted to walk about. In this way Breschet is said to have operated successfully in more than a hundred cases; the average period required for a complete cure being twenty-three days. I have never performed this operation, the severity of which is such as to induce the belief that very few persons in this republican coun- try would submit to it. An American surgeon, Dr. F. Hamilton, of New-York, has recently recommended castration for the relief of this affection, and has published several cases in which he performed the operation in illustration of its efficacy. This is certainly a radi- cal mode of doing business, but in my opinion a very objectionable one.] Hematocele is an effusion of blood, either into the cellular tissue of the scrotum, or within the tunica vaginalis, or in both. It is generally the consequence of a bruise or wound. From the loose nature of cellular tissue, the effusion into it is apt, if proper attention be not given, to take place to a great, and, to the patient and friends, alarming extent. This I have witnessed after the operation for 526 HEMATOCELE. hernia, and after removal of the testicle — bleeding from some small artery contiuues, the blood is by the dressings or pressure prevented from escaping externally, it is consequently extravasated into the cellular structure,' giving rise to tumour, often of a very dark colour; and in some cases this swelling, occurring after the operation for hernia, has been mistaken for re-descent of the bowel The blood must either be absorbed or discharged. Absorption is the more safe and desirable, but necessarily tedious, and more or less thickening and enlargement may remain for a long time. Discharge, whether spontaneous or by incision, is usually followed by unhealthy suppu- ration of the infiltrated and partially broken down cellular tissue, sloughing of it, tardy separation of the dead parts, and tedious, per- haps exhausting, flow of matter. Haernatocele of the vaginal coat may supervene on hydrocele, in consequence of external injury; or bloody effusion may take place from the vessels of the membrane, from sudden abstraction of their customary support, after evacuation of the serous fluid, and whether injection has been resorted to or not; —as happens in careless tapping for ascites. Some of the diagnostic marks of hydrocele are thereby lost; there is no translucency of the swelling, and fluctuation is either indistinct, or altogether imperceptible. The appearance of the con- tents varies according to the time wrhich has elapsed betwixt their discharge and the occurrence of the extravasation ; if short, coagula float in a thin bloody fluid; if considerable, the liquid is thick, dark, and putrid. Bloody effusion into the scrotal cellular tissue produces a dark appearance of the integuments, and the swelling has a doughy feel. At one or more points, where the cells are broken down and much blood has collected, fluctuation is per- ceived more or less distinct. The treat- ment consists of rest, the recumbent posture, support of the swelling on a small cushion, and the employment of fomentation when the parts are painful. The absorption proceeds slowly; and after some time, when all painful feelings have ceased, stimulant embrocation may be used, with the view of expediting it; a solution of the muriate of ammonia, of the sulphate of alumina, or of other as- tringent stimulating salts, may be em- ployed in strength proportioned to the feelings of the patient and the progress of the case. If the tumour suddenly become painful, and increase in size, indicating putrefaction of the"blood, and commixture of it with puriform matter, a free incision is to be made, and poultices applied. When the parts have become quiet, and suppuration has been established, poulticing is to be discontinued, and mild and b>ht dressing employed. ° When, on tapping a hydrocele, the fluid is found to be bloody, SARCOCELE. 527 injection is not to be resorted to, though the other circumstances of the case should appear favourable. Rest is enjoined ; and a radical cure is not to be attempted till the fluid has collected a second or perhaps a third time, and become colourless. Acute inflammation of the testicle, from sympathy with the urethra, and sudden suppression of discharge from the anterior part of the canal, has been already treated of. The inflammation may also be the result of external violence. When the urethra is diseased, the testicle is irritable, and its circulation easily excited. After subsidence of the inflammatory attack, swelling, particularly of the epididymis, or of the posterior part of the gland, seldom altogether disappears. The new matter is not entirely absorbed ; and thickening and indu- ration remain, to an extent depending on the violence of the action and the propriety of the treatment. Enlargements of the body of the gland are generally attributed to injury. But often they occur without such cause being assignable ; and may be the result of chronic excited action, kindled in deposit produced by a previous acute inflammatory attack. Such indolent swellings attain considerable size. The tumuor is of an irregular surface, and feels hard and unyielding ; there is always more or less effusion of fluid into the cavity of the tunica vaginalis, adding to the bulk of the swelling. Indeed, the size and consistence of the tumour can be correctly ascertained only after evacuation of this fluid. Many of these tumours, as already observed, are of firm consist- ence ; others are soft and doughy. They occur at the middle period of life, or before it. Some are resolved easily, and by ordinary at- tention. Others enlarge, notwithstanding the most judicious treat- ment; they gradually soften, and at length fluctuation becomes ap- parent. Curdy matter is evacuated by incision, perhaps mixed with a small quantity of thin unhealthy matter; and from the wounds projects a pale fungous growth furnishing profuse discharge. The gland has now lost all appearance of its original structure; a section of it pre- sents a homogeneous surface, of a grayish colour, and soft consistence, at some places broken down and mixed with tubercular matter and pus. The fungus is of the same nature as the rest of the tumour, but softer, and often with puriform depots in its base. In this dis- ease there is nothing malignant; it occurs in people" of impaired or originally weak constitution, and is generally known as the scrofu- lous testicle. In the more simple swellings, the gland at some points retains its original texture, but the greater part has no tubulous appearance, and seems to consist principally of lymphatic deposit, dense, pale, and equable. Such often accompany and are attributable to a diseased state of the urethra, — part of the canal being in an irritable and con- tracted state; and all efforts to discuss them usually prove fruitless, unless the urethra have been previously restored to a healthy condi- tion. The soundness of this canal is therefore to be inquired into in the first instance, and if stricture, or irritability independent of con- traction, be discovered, the practice must be directed towards it. The urethra being sound, counter-irritation is to be applied to the testicle; 528 SARCOCELE. and the part should be suspended, though not in function altogether; walking exercise, and the friction which it occasions, must be avoided as much as possible. A gum and mercurial plaster protects the part, and induces a moderate irritation of the surface usually sufficient to dissipate the swelling slowly; if ineffectual, either repeated blistering, or the insertion of a seton under the integuments, may be had recourse to — from either or both much benefit is often derived. In obstinate cases the recumbent, posture must be enjoined. In general, slight enlargement and induration of the epididymis remains. The scrofulous swelling often does not yield to the means for discussion, but advances to suppuration. The abscess is to be opened, and the unhealthy contents discharged ; endeavours are then to be made to effect closure by granulation, and after that counter-irritation may dissipate the tumour, or at least diminish its size. If protrusion occur, as generally happens, it may be cut away ; and by then keeping the granulations on a level with the integument, either by pressure or escharotics, at the same time attending to improvement of the general health, cicatrisation may be procured, though tedious; or escharotics may be used from the first, instead of the knife. For example, sprinkling the fungous surface occasionally with the acetate of lead, I have found in several instances effectual; repeated slough- ing of the protruded matter takes place ; it sinks to the level of the integument, and ultimately below it, and then the employment of slightly stimulating dressing induces contraction and closure. Not unfrequently the testicle is attacked by swellings of a more serious nature — medullary sarcoma is common, as also both fibrous and soft tumours, writh cysts; scirrhus is more rare. These morbid alterations may take place at once — that is, the swelling may be from the first malignant — or they may supervene on tumours originally simple and benign. The tumour increases with the usual rapidity ; to describe minutely the successive stages, would be but repetition of what has been already stated more than once, in treating of similar diseases in other organs. The medullary tumour often attains a very large size before the integuments give way; it may in some cases be mistaken for hydrocele, unless the history be attended to, and careful manipulation made : elasticity must not be confounded with fluctua- tion. After ulceration has taken place, the formation of a bleeding fungus is not uncommon : indeed, the testicle is one of the most fre- quent seats of fungus haematodes. The inguinal glands are in general affected early, and swell to a large size, ulcerating extensively, bleed- ing, and throwing out fungi; not unfrequently the chord feels free and soft, presenting to all appearance a healthy structure between the inguinal and scrotal swellings. In the advanced stages of scir- rhous testicle, the chord and its integument are thickened and hard. The progress of this tumour is slower than that of the medullary, but equally certain. The cystic sarcomata, when fibrous, may remain long apparently in an indolent state, and without affection of the lymphatics; but when soft, the cystic contents are often bloody, the medullary matter soon breaks down, and then the integuments yield and the malignant advance is rapid. It need searcely be observed' CASTRATION. 529 that in such cases nothing but the knife, used at an early period, when the tumour is yet latent and the lymphatics uninvolved, can save the patient. Castration must be performed ; and even this is in too many cases insufficient to annul the malignant disposition of which the parts have become the seat. As already stated, it must be had re- course to before hard and knotted swelling in the groin, with thick- ening and induration of the chord, has commenced, otherwise it can be of no avail. The patient is placed recumbent. An incision is commenced a little above the inguinal aperture, and carried downwards; on reaching the tumour it is inclined to one side, so that with a similar one on the opposite side an eliptical portion of integument may be included. This is always necessary when the tumour is adherent to its coverings, or when a fungus has been protruded. One straight incision may be sufficient for the removal of the tumour; it is some- times necessary to take away more or less skin, so that a large, loose, and flabby bag may not remain after the extirpation. This prelimi- nary wound penetrates only through the skin and cellular tissue, and should be made rapidly. At its upper part the chord is then to be cut down upon, exposed, and divided ; but the division should not be made until the chord has been isolated for some distance, so as to afford a firm hold to an assistant and not before the assistant has se- cured it firmly in his fingers, otherwise it may retract within the in- guinal canal, rendering the bleeding from the spermatic artery troublesome. The dissection is now to be continued downwards, rapidly, and yet cautiously: the tumour is detached on all sides, and removed along with a sufficient quantity of integument. In dis- secting off its posterior surface, care must be taken not to wound the septum of the scrotum. All adherent skin must be taken away, and in the case of fungus, the incision of the integument must be wide of the projecting part. But, at the same time, unnecessarily extensive removal of skin is always to be avoided, otherwise there will some- times be a difficulty in covering the root of the penis and the re- maining testicle. The assistant has, during the extirpation, retained his firm grasp of the chord, so restraining hemorrhage from that quarter ; now the branches, generally two, of the spermatic artery are pulled out by the forceps, and a ligature applied to their ex- tremities, inclosure of any of the surrounding parts being studiously avoided. To tie veins, artery, nerves, vas deferens, and cellular tisssue, in one mass, would lead to most serious mischief, not to men- tion the immediate and excruciating pain occasioned. It has been recommended either to pass a temporary ligature round the chord, before its division, to prevent retraction, or to tie the artery before it is cut across. I have never found either practice necessary; the latter retards the operation; the fingers of an assistant are generally as effectual as a ligature, and inflict less injury to the parts, and less pain to the patient. Should the chord slip, there can be but little difficulty in pulling it down again by means of a hook ; at the worst, slight extension of the incision upwards may be necessary. The scrotum is to be sponged clean of coagula, and its bleeding vessels secured ; they are often numerous. The incision is brought together 45 530 CALCULUS VESICA. by several points of suture, and cold cloths applied. In no opera- tion is secondary bleeding more frequent, occurring within an hour or two after reaction has been established, and the patient begun to get warm in bed. The flow is always from the scrotal vessels in the lower part of the wound, and often profuse. The dressing must be partially undone, so as to expose the vessels, and permit of the appli- cation of ligature. On this account it is well not to approximate the lower part of the wound in the first instance, but to fill the cavity with charpie or dry lint, retaining this until risk of hemorrhage has passed over, or better still to have the wound quite open for five or six hours, and then to bring the edges together. The upper part of the incision often heals by the first intention, but this is seldom effected in the lower ; suppuration takes place, and the cavity fills up slowly by granulation. Indeed, attempts to procure primary union of the scrotal wound are scarcely to be recommended ; they are very seldom effectual; and should bleeding take place, the pa- tient is either put to much pain, by removal of the stitches, and sepa- ration of the edges, or the blood is confined, accumulates in the cavi- ty, and is infiltrated into the cellular tissue, producing much tumour, wdiich terminates in extensive and unhealthy suppuration. Such re- tardation of the cure is avoided by open dressing of the lower part of the wound from the first. Not unfrequently infiltration of the cellular tissue over the chord takes place writhin a few days after the operation, extending upwards, under the superficial fascia of the abdomen, wTith discoloration of the integument, diffused doughy swelling, and much irritation of the system. Matter soon collects at one or more points. Early incision will check the advancement of this affection, followed by fomenta- tion, and poultice, and attention to the constitution. Collection of the matter* should never be waited for; and when depots have formed, a free and dependent opening should be made early. Some- times the patient may perish, exhausted by the profuse discharge and the disturbance of the system, in cases that have been neglected, or in which infiltration is rapid and extensive and the powers of life weak. Calculus Vesica. Morbid action of the kidneys, producing altered secretion of the urine and deposition from it, takes place in conse- quence of derangement of the digestive organs — often occasioned by the free use of acids, or of ascescent diet, such as fruit tarts, or drink containing a great quantity of saccharine matter. Many causes, which have not as yet been well ascertained or understood, seem to influence and predispose to calculous disorders. The prevalence of these affections in particular districts has been attributed to the quality of the water, or to the use of peculiar food or beverages ; but such opinions, in all probability, have been adopted neither on very good grounds, nor after due inquiry and consideration. The county of Norfolk, and the eastern part of Scotland from the Frith of Forth northwards, are districts very similarly situated, exposed to cold and piercing winds, and appear to furnish a greater number of cases of stone than the rest of Great Britain with Ireland to boot The rea CALCULUS VESICAE. 531 son of this, as already stated, has not been satisfactorily explained. But this disorder, like gout, seems also to adhere to families, to be transmitted from one generation to another. Some children seems almost to come into the world labouring under calculus. The symp- toms are noticed very soon after birth, and often patients labouring under stone are presented to the surgeon at the tender age of twelve or eighteen months. [Of 5376 calculous cases mentioned by Civiale,* 2416 were chil- dren, 2167 adults, and 793 old persons. Of these 1946 occurred before the age often, 943 from ten to twenty, 460 from twenty to thirty, 330 from thirty to forty, 391 from forty to fifty, 513 from fifty to sixty, 577 from sixty to seventy, 199 from seventy to eighty, and 17 after eighty. Children are more subject to this affection in certain districts than in others ; and the same is true in regard to adults. The greater proportion of calculous cases in Wirtemberg, in the mountains of Switzerland, the Neapolitan States,, and in some of the provinces of England, occur in young persons, from causes which have not hitherto been explained. In the United States a larger number of children are afflicted with this disorder in Kentucky, Tennessee, and Alabama, than perhaps in any other sections. In very warm or cold latitudes, on the contrary, adults, and, above all, old people appear to be most liable to it. Whether this affection is actually hereditary or not is not yet fully- decided. Facts certainly warrant the inference that it is. Thus, Civiale relates the case of a man on whom he practised lithotrity, whose mother had had the stone, and one of whose children died of it. He also performed the operation on two brothers, whose grand- father and two uncles had laboured under the disorder. Prout speaks of a family of which the grandfather and father were affected with uric acid calculi, and who had a son, aged thirteen years, that was very much predisposed to the same disease.] The depositions from the urine are various. The deposit chiefly- affecting children is of a dark colour, dense, hard, and crystallised ; but one lighter coloured, and more friable, sometimes precedes the formation of this dark concretion. As seen here, the nu- cleus is surrounded by an oxalate of lime calculus, and then follows layer after layer of urate of ammonia. The dark sand or stone is occasionally, though much more rarely, met with in older individuals ; but in them the red, dark brown, yellow, and white deposits are more common. 'And in them, too the diathesis or dispo- sition to the formation of one or other variety evidently alternates, as is well demonstrated by section of urinary concretions. An alternating calculus is here represented. * Treatise on Calculous Affections ; MS. translation by Dr. Colescott. 532 CALCULUS VESICAE. lillliilit 11 m mmmi The red deposit, by much the most common, at least in adults, consists principally of uric acid, solu- ble by solutions of the alkalies. The brown and yellowish are also composed of uric acid, often in combination with a be afterwards put; the lower limbs require longer time-for consolidation than the upper. In the treatment of fracture, as in solution of continuity in the soft parts, great advantage is gained by placing the disjoined parts as nearly in their original position as possible, retaining them so, and allowing of no motion. These indications ought to be accomplished very soon after the accident; many evils are thus prevented — the further laceration of the soft parts, the inflammatory effusion into all the tissues, and the consequent startings and spasms of the muscles. This cannot be too much insisted on. There is much folly and ab- surdity in allowing a broken limb to lie unrestrained — leaving the ends of the bones displaced, the one riding over the other —whilst attempts are being made to keep down the inflammation, by applying leeches, cold lotions, or large poultices—all perfectly ineffectual so lon „ 1 >, The average period of the existence of the fracture in the above cases was nearly twelve months and a half, the longest ten years, the shortest six weeks. The mean period of the retention of the seton was seven weeks and three days. In one instance — that of a frac- tured humerus — it was left in thirteen months, notwithstanding which it finally failed. The average time required for the cure was nearly three months, the longest eight months, the shortest three weeks. Arterial hemorrhage occurred in two of the cases; in ten, severe fever, erysipelas, or profuse suppuration. Of thirty-eight cases in which resection was performed, twenty-four were cured, one improved, seven failed, and six died. The seat of the injury was as follows : — 12 were in the femur, of which 7 were cured. 6 » Jeg, „ 5 „ 12 ,, humerus, ,, 6 ,, 7 ,, fore-arm, ,, 5 ,, and 1 improved. 1 » jaw, „ 1 „ The longest period of the existence of the fracture in these cases was five years, the shortest ten weeks, the average thirteen months and nineteen days. The average time required for effecting a cure was four months, the shortest one month, the longest thirteen months. In seventeen of the cases other methods of treatment had been in- effectually tried : in six the resection was followed by erysipelas, in one by phlegmasia dolens, and in two by profuse suppuration and abscesses. Of thirty-six cases treated by pressure and rest, twenty-nine were cured, one improved, and six-failed. The seat of fracture was ■— In 13 cases in the femur, of which 9 were cured. >j 7 ,, leg, ,, / ,, ,, 12 ,, humerus, „ 9 „ „ 4 „ fore-arm, „ 4 „ The average duration of the fracture in the above cases was five months and twelve days, the longest twenty-two months, the short- est four weeks. The mean period required for a cure was nine weeks, the longest nine months, the shortest eighteen days. In one 612 DISLOCATIONS. of the cases the treatment was-JDroductive of excoriations, in three of severe pain and inflammation. \ Cauterisation of the ends of the fragments, after free exposure of them by the knife, was successfully employed in six cases; in two others 'it completely failed. The article most frequently used was the caustic potash. Frictions succeeded in eleven cases. From a careful analysis of all the circumstances connected with the preceding cases, one hundred and thirty-nine in number, and of which the above is an abstract, Dr. Norris has deduced the following conclusions: — 1. That non-union after fracture is most common in the thigh and arm. 2. That the mortality after operations for its cure follows the same laws as after amputations and other great operations on the extremities, the danger being in proportion to the size of the limb and the proximity of the injury to the trunk. 3. That failures after operations are more frequent in the humerus than in other bones, and in middle-aged and elderly- persons than in young ones. 4. That the seton, variously modified, is safer, speedier, and more successful than resection or caustic. 5. That incising the soft parts previously to introducing the seton augments the danger, but renders the cure more certain and expeditious. 6. That, allow- ing the seton to remain in for a long time exposes to accidents, and does not facilitate the cure. 7. That the seton is least successful in the femur and humerus.] Dislocations. — Some joints are so contrived — their composing bones are so notched into one another, and connected by such pow- erful apparatus — and they are crossed by tendons, and tied together by ligaments in such a manner,— that dislodgement can scarcely be effected but by the most violent means. Nothing short of immense force is sufficient, and the displacement is uniformly attended with fracture of portions of the bones, or of their processes. Other bones are loosely joined, permitting free and unrestrained motion in all or in many directions, and but little force, applied in particular directions, suffices to separate and luxate them. In every joint the processes are liable to be broken, and the attachments of the ligaments to be torn off; ligamentous tissue withstands a greater degree of sudden violence than the osseous. The synovial membrane, and the fibrous tissue exterior to it, are almost always torn in complete luxation ; but the extent of laceration varies in different joints, according to the direction of luxation and the degree of displacement. The rent may- be small, closely embracing the neck of the bone ; or there may be an extensive gap on the side opposite to that on which the luxation has taken place. In an articulation surrounded by muscular sub- stance, there is also laceration of this to a greater or less extent. In some individuals, dislocation is very apt to occur, perhaps from peculiar laxity of fibre ; and if in any person luxation of the joint has once been produced, the accident is apt to occur again and again from but slight causes. In general, the mobility of the luxated joint is much diminished ; the limb is either shortened or lengthened ; its contour is changed ; the injury is attended with violent pain ; the patient is sick and pale ; DISLOCATIONS. 613 the system receives a shock, from which it gradually recovers after some time. Then swelling, from effused blood, takes place; and this is followed, after some hours, by excited action of the vessels and farther effusion, giving rise to a greater stiffness and pain on attempts at motion. If no means are taken to replace the bone, and painful feelings subside along with the swelling, the limb remains long useless, and is the seat of occasional lancinating pains, but at last motion and utility are to a certain extent restored by the forma- tion of a new joint — the head of the bone, and the parts on which it rests, mutually accommodating themselves to each other, by de- grees, and permitting a limited extent of motion. Post mortem ex- amination, years after the occurrence of the injury, shows change in the form of the bones — the head is flattened, and in the bone on which it lies there is a corresponding depression, formed partly by the deposition of newr matter, partly by absorption of the old ; in dislocation on the dorsum of the ilium, for example, there is excava- tion by absorption opposite to the centre of the head of the femur, and round this new osseous matter is deposited so as to form the cavity into a cup resembling the acetabulum. New processes are formed for the attachment of the muscles, and the old are absorbed to a remarkable extent. There are also new ligaments ; and a sort of capsule is formed by condensation of the surrounding cellular tissue. The new articulating surface becomes quite smooth internally, and is covered, if not by a cartilage, by a smooth substance which answers the purpose tolerably well ; the old is gradually filled up and obliter- ated, the prominences being absorbed, and the cavity occupied by new deposit. These changes do not take place so rapidly as is generally supposed ; the cartilage and synovial surface are not much altered for months after the occurrence of luxation ; and if replace- ment be effected, the functions of the parts are soon performed as be- fore the injury. In some articulations, on account of the formation of the opposed surfaces, attempts at reduction prove ineffectual after the lapse of two or three weeks; in others, of more simple construction, it may be accomplished after some months. The simple mode of reduction is to put the patient off his guard, so that the muscles may be in a state of relaxation, and then to move the limb artfully in the proper direction, without much force. Occasionally, the bone is pulled into its place by the action of the muscles, during the patient's efforts to place the limb in a comfortable position. Considerable force, how- ever, is sometimes required in even recent luxations of large joints, and means must also be taken to weaken the muscular power. The patient, if young and robust, may be bled to syncope, or placed in the warm bath till a sense of fainting supervenes; or an enema of tobacco infusion may be administered, and smoking of tobacco may have the same effect when the patient has not been addicted to the noxious habit; or antimonial solution maybe given in nauseating doses. Several or all of these methods may be necessary in some cases, particularly if the dislocation be of long standing. When thus general exhaustion has been procured, counter extension and extension are to be had recourse to. The former consists in having 52 614 LUXATION OF THE CLAVICLE. the patient, and the bone next to the trunk, fixed immoveably by fitting lacques and belts ; and the latter is made by one or more as- sistants, or, if need be, with the help of pulleys. During extension, advantage is in many cases grained by lateral force and by rotation of the limb, the bone being thereby moved from its position, and brought within the sphere of muscular action, by which it is drawn suddenly into its proper place. In some cases, there is no doubt but considerable laceration is occasioned by the efforts at reduction, and perhaps this is in some degree necessary to a successful issue — as when the capsule has been slightly lacerated by the accident, and in consequence interposes an obstacle to the head of the bone slip- ping into its socket. After reduction, inflammatory action in the articulation and its neighbourhood is to be expected, to a greater or less degree, particularly when much force has been employed, and means must be taken to avert this ; local remedies are generally sufficient, along with perfect rest. In luxation of the lower jaw, both articulating ends are most fre- quently dislodged. They can escape in but one direction, forwards into the temporal fossa?; when both are dislodged, the mouth is widely open, and fixedly so, the chin is drawn downwards and backwards. When one is displaced, the jaws are partially opened, the chin is twisted to a side, and immoveable. Great pain is experi- enced from the pressure of the condyles of the bone on the temporal muscles, from stretching of the fibres of the pterygoids, and from interruption to the functions, by pressure, of the contiguous blood- vessels and nerves. Mastication is impossible, the speech is altered, and indeed articulation may be said to be impracticable. It is supposed by the vulgar that the accident is particularly apt to happen to infants and young persons. Nurses are in consequence careful, when a child yawns, to support the chin, and pronounce an accompanying blessing. The articulating cavity is then shallow, yet luxation must be rare in young subjects. In my own experi- ence no instance of dislocated jaw has occurred but in adults ; and then, either from over-opening of the jaws, or from powerful muscu- lar action during depression of the inferior maxilla. The nature of the injury is at once known ; and the displacement is easily remedied. But I have met with instances where, through ineffectual attempts at reduction, the unnatural position has been allowed to continue for many hours, to the great distress of the indi- vidual. The object in view is to depress the ramus — one or both, as may be — and to raise the chin. This is effected by pressure with the thumbs on or in the situation of the molar teeth, whilst with the fingers the jaw is moved upwards and backwards. The thumbs need not be protected by a glove, as is generally recommended ; on the bone resuming its place, they are easily slipped into the space betwixt the jaw and the cheek. There is no necessity for bandag- ing, as retentive apparatus; the patient is not likely to yawn for some time after. Luxation of the clavicle, at either end, is produced by force applied to the point of the shoulder. It is seldom that the sternal extremity LUXATION OF THE SHOULDER-JOINT. 615 is separated from its connexions. When this accident does happen, it is easily recognised ; the end of the bone is prominent and loose, and is distinctly felt riding over the top of the sternum. Replace- ment is effected by bringing back the shoulder ; but the bone is with difficulty retained in the proper position, and is long in becoming fixed; a certain degree of deformity is ever after present. Displacement of the scapular extremity is by no means rare, and occurs to a greater or less extent, according to the laceration of the ligaments. If those only are torn which connect the end of the bone to the acromion, there is mere rising of the end. But if—as is often the case when the violence has been great, as in a fall either from a height or with great velocity —the conoid and trapezoid ligaments connecting the tuberosity of the bone with the coracoid process, have given way, then the end of the bone projects, pushes out the del- toid, and gives rise to considerable flattening of the shoulder. The arm falls forwards, and cannot be moved but with pain ; nor is the patient able to raise it by its own muscular power. If the surgeon grasps the middle of the bone, he finds the end moveable ; and the evident and deforming projection puts an end to any doubt regard- ing the nature of the case. The bone is readily reduced by raising the arm, and carrying the scapula backwards. The limb must be retained in the proper position for many weeks, if a cure without interruption, and with as little deformity as possible, is desired ; but after the utmost care and patience, there still remains, in almost every case, some projection more than before the accident. The ligaments are slow in uniting, and the union is imperfect and weak. The requisite apparatus is the same as for fractured clavicle, but must be retained for a longer time. The patient experiences great relief from the limb being put up in this manner and maintained so ; and inflammatory action, with much of the swelling, is averted. The inferior angle of the Scapula occasionally escapes from under the border of the latissimus dorsi, usually with some laceration of the muscular fibres. The displacement is occasioned by raising the arm above the head to an unusual extent. The angle of the bone pro- jects considerably, and the muscle is felt playing beneath it distinctly during motion of the parts; the movements of the limb are limited and painful. The parts may be brought into their original position by pressing the angle of the scapula towards the ribs, whilst the arm is much raised ; and the bone is afterwards confined in its pro- per place by a broad bandage passed pretty tightly round the chest. The retentive apparatus must be continued for a considerable time, and in some cases a cure may be so effected ; but in general the bone soon regains its former unnatural position, and continues to do so, however often and however easily it may be replaced. The parts gradually become accustomed to the change in relative posi- tion, and little inconvenience is experienced. Luxation of the Shoulder-joint is prevented, by the arrangement and structure of the parts, from taking place in any direction ex* cepting tow-ards the axilla — downwards into the hollow of the arm- pit, downwards and forwards under the lower border of the pecto- 616 LUXATION OF THE SHOULDER-JOINT. ral muscle. Occasionally, though very rarely indeed, displacement occurs backwards. On the anterior and inferior aspects, the articu- lation is not supported, as at its other sides, either by muscular sub- stance or by processes of bone. The accident is occasioned some- times, though rarely, by direct violence, as by a blow on the back part of the' shoulder; and of such I have seen a few examples. But, in almost every instance, the displacement is caused by force applied to the distal extremity of the humerus; either immediately, as by falling on the elbow, or through the forearm, as when a person endeavours to break a fall by stretching out the arm, and alights with the whole weight of the body on the palm. The accident may also result from forcible abduction of the extremity, particularly when the power is applied near the extremity of the Jimb. There is laceration, to a greater or less extent, of the capsule, and of the muscles immediately investing the fibrous tissue round the articu- lating cavity. Without disruption, complete luxation cannot exist — the articulating surfaces cannot be separated, nor can the head of the humerus be altered in position ; subluxation, or, in other words, a sprain, may occur in such circumstances, but true luxation cannot. Bruises of the shoulder, with or without fracture, either of the scapula or of the upper part of the humerus, must not be mistaken for dislocation, for the consequences of such a blunder are fearful. In both descriptions of accident, the appearances of the limb are somewhat similar, and hence the examination requires to be particu- larly accurate and careful. In both there is flattening of the shoulder, but in fracture there is crepitus, motion to an unnatural extent, though painful, and greater suffering during manipulation ; in dislocation no crepitus at all resembling that in fracture can be perceived, the mo- tions of the limb are very limited, and the displaced head of the bone can almost always be felt. The direction of the force, too, as already observed, when on the subject of fracture, is an important assistant in diagnosis ; from falls or blows upon the shoulder we may expect fracture, from falls on the elbow or palm, luxation. In dislocation an indistinct feeling, sometimes amounting to obscure crepitation, is occasionally perceived during rotation of the limb ; and this arises from one or more of the tendinous attachments of the muscles having, during their disruption, torn away a portion of their osseous attach- ment. Great pain attends on dislocated humerus, from the head of the bone compressing and stretching the axillary plexus; and the inter- ruption to the flow of the blood produces tingling at the points of the fingers, numbness of the whole limb, and after a time swelling of the hand and forearm. Flattening of the shoulder, and depression un- der the acromion, are the most prominent marks of displacement having occurred, and are at once apparent. They are more dis- tinctly perceived on comparing the two shoulders ; then the acromion on the affected side stands remarkably outwards. The projection is not so apparent when the immediate swelling from effused blood has been fully formed, but the hollow under the acromion can be felt through any quantity of extravasated blood. The arm admits of very- little motion, is lengthened and abducted. The* elbow cannot be LUXATION OF THE SHOULDER-JOINT. 617 brought close to the side, and attempts to do so are productive of great suffering. The patient has little or no muscular command over the upper arm. Rotation and elevation of the limb require consider- able force, and are practicable onby to a very limited extent: during attempts at the former, as already mentioned, obscure crepitus is sometimes perceived. The abduction is most remarkable in the dislocation directly downwards; and in this form of the accident, the fingers easily detect the head of the bone lying in the axilla, deep, yet distinct, particularly during attempted rotation. When the head of the bone lies forward by the eoracoid process, and under the pectoralis major, it can be felt, and the prominence occasioned by it can be clearly seen in thin people, before swelling has occurred, and after its subsidence. The bone sometimes lodges in an intermediate situation, and then the signs peculiar to each form of displacement are mixed. When reduction is not accomplished, the bloody swell- ing first occurs to obscure the signs ; this may in part subside, but then the inflammatory supervenes ; both after a time disappear, the muscles waste, and then all the signs are very apparent. After some weeks, the motions of the limb become more extensive, not in con- sequence of the head of the humerus having changed its position, or returned into the glenoid cavity, but from the scapula moving on the ribs more freely, and to a greater extent than usual. At last, but not till after a long period, considerable motion betwixt the bones can be effected, the scapula, where the head of the humerus rests, having furnished an adventitious cavity, to which the latter has adapt- ed itself. But free motion can never be regained, for the move- ments that are affected are chiefly produced by the action of the mus- cles of the scapula. Replacement, even in very recent cases, sometimes is accomplish- ed with difficulty in those whose muscles are fully developed. But in general a successful result will follow7 simple measures, particular- ly if the patient is taken unawares— as by rotating the arm with one hand whilst the fingers of the other are placed in the axilla, then sud- denly lifting the head of the bone outwards, and at the same time performing abduction — the patient being all along assured that he will not be put to pain, and that there is no intention of attempting reduction. In this manner reduction may often be accomplished by the surgeon and one assistant; the trunk and scapula being fixed by the assistant, either grasping the patient in his arms, or holding a sheet or towel passed round the body, close to the axilla, whilst the surgeon extends and rotates the extremity, and at the same time lifts the head of the bone from its situation. The rotation is made by using the forearm, bent to a right angle, as a lever : thus considerable power can be exerted on the head of the bone, and the long head of the biceps muscle — the stretching of which, no doubt, affords an ob- stacle to reduction — is at the same time relaxed. In luxation down- wards, there is no more successful method than that by counter ex- tension with the heel in the axilla, and extension by the surgeon grasp- ing the wrist. The patient is placed recumbent, on a couch or on the floor, and the surgeon sitting by his side, lodges his heel in the axilla, and with both hands extends the arm; after a short continu- 52* 618 LUXATION OF THE SHOULDER-JOINT. ance of extension, he performs a sudden and powerful combination of both movements, and so jerks the bone into its natural position. In some recent, and in all old cases, it is necessary to apply considera- ble force, steadily, and for a long time, so as to tire out the muscles, and dislodge the head of the bone. An assistant effects this by means of pulleys. These are fixed to a laque, applied above the elbow, with a clove-hitch, and to a ring fastened either in the wall or to a post; two small iron rings which can be screwed into a beam are useful in private practice, and should always accompany the pul- leys. When all is prepared, the assistant pulls the end of the rope steadily, and with considerable power, whilst the surgeon rotates the limb, and endeavours to lift the head of the bone, at the same time regulating the degree of extension. The directing of the degree and continuance of the force is not the least difficult part of the proce- dure, for, when excessive, there is a risk of the axillary nerves and artery giving way ; such accidents have happened, and been accom- panied with serious and even fatal consequences; and from lacera- tion of other tissues, the muscular, fibrous, or cellular, fatal inflam- mation and abscess have resulted. The surgeon is therefore called upon to exercise judgment and discretion — not to continue extension to a pernicious extent, and not to abandon attempts at reduction too soon, leaving his patient disabled for life. For making counter-ex- tension to the extension by pulleys, a broad strong belt is useful, per- forated near the middle for transmission of the injured arm ; it is pas- sed round the body so as to fix the trunk and scapula, coming under the axilla of the sound side, and being then fastened by means of a hook to a ring in the wall. Luxations of the shoulder-joint may be, and have been, reduced after the lapse of two or three months ; but the difficulty increases, and the chance of success diminishes, in proportion to the time which has elapsed since the date of the accident. And in deciding upon making the attempt, many circumstances are to be wreighed and considered — the patient's period of life and his occupations, the state of the parts, the degree of motion that has been acquired, and the treament, if any, which has been previously followed. Perhaps the most important consideration is regarding the state of the parts, as indicated by the degree of motion. If the movements be to such an entent as to favour the supposition of the head of the bone having been furnished with a new recipient cavity, to which it has in a great measure accommodated itself, and that the glenoid cavity has, from disuse, become altered, the surgeon can scarcely hope for advantage to his patient from attempts to break up the new articulating apparatus, and reestablish the old. The patient will, most probably, be put to a great deal of pain and some danger, without experiencing improvement to the limb ; indeed the motions and power may prove less than before. In old men, too, force suf- ficient for reduction cannot be employed without great risk of lacer- ation of nerves, blood-vessels, and muscles. But if the patient be young, the motions still limited, and the articulation apparently not changed by solid effusion, reduction may be attempted with a fair prospect of success, and without injury. In all such cases, how- LUXATION OF THE SHOULDER-JOINT. 619 ever, the surgeon must watch every step of the proceedings, and have sufficient experience to stop short of inflicting irreparable mis- chief. No standard can be fixed for the degree of force that is ne- cessary and safe; he may be foiled, even after the most powerful efforts, in a dislocation of two or three weeks' duration; whilst, by the use of but slight force, he may succeed in one of as many months. Much assistance is obtained by the means formerly ad- verted to, as auxiliary, by weakening the muscular energy. Of these, nauseating doses of antimony are most generally employed, and being the most safe, may be recommended to be tried first; and if these fail to produce the desired effect, the patient may be bled freely, if he be young and robust, more especially since this will assist to avert the inflammatory action likely to follow the vio- lent reduction. Tobacco produces the most complete prostration of muscular power, and may consequently be resorted to in extreme cases ; but it ought, if possible, to be avoided, as its use is far from being void of danger. The warm bath cannot always be procured ; when at hand, it merits adoption, being both safe and effectual, par- ticularly if combined with antimony or bleeding. The extension should not be commenced till these means have begun to take effect, but every thing should be prepared, so that it may be applied at a moment's warning. After all attempts at reduction, whether suc- cessful or not, it is necessary to moderate the inflammation that en- sues, by local bleeding and fomentation, combined, if necessary, with nauseating laxatives ; general depletion is seldom required. Luxations of the Elbow-joint is an extremely common accident, particularly in young persons, before the bony processes have been fully formed. It is produced by wrenches, or by force applied to the farther end of the forearm, the bones neither breaking nor bend- ing. Sometimes, though very rarely, it is caused by direct vio- lence, as in a fall, and then may be combined with fracture of one or both bones of the forearm ; but in other circumstances, fracture and luxation can scarcely coexist. In general, both bones of the forearm are displaced backwards, sometimes a little to the ulnar side. The coronoid process occupies the cavity for the reception of the olecranon, and the head of the radius lodges behind .the ex- ternal condyle ; the extremity is shortened, and looks twisted ; it is slightly flexed, and in the middle state between pronation and supi- nation. Unnatural lateral motion can be produced, but flexion is im- practicable, the limb cannot be brought quite into the extended state, and rotation is difficult and painful. Swelling soon takes place, and consequently the hollows are filled up, and the processes of the bones obscured. Yet the olecranon and inner condyle can always be recognised and felt, and their relative position ascertained ; the form of the end of the humerus, its hollows, and its prominences, can be distinctly discerned, both before and after the swelling, the 620 LUXATION OF THE RADIUS. soft being stretched over the bone ; and by rotating the limb with one hand, whilst the other is placed over the outer and back part of the joint, the situation of the head of the radius is detected. Thus the relations of the bones to one another are discovered ; and this must be done at once, whatever pain may be produced by the examination, for it is a saving of suffering in the end. Yet the nature of this injury would seem difficult of detection — a fact scarcely intelligible by any one who is careful in his manipulations, and who possesses common observation, and a sound knowledge of anatomy. Many cases of unreduced luxation are met with; I have seen it in both elbows of the same person ; and I have had a dozen of cases, in as many months, of unreduced elbows shown too late for attempts at reduction. The frequent occurrence of such blunders is the more lamentable, as it is almost impossible to replace the bones after three or four weeks ; indeed, I have been foiled at the end of two weeks. The parts soon accommodate themselves to their new position, the olecranon process shortens, motion rapidly increases, and the bones get more and more secure in their new re- lations,— osseous matter being deposited laterally, forming cavi- ties for their lodgement, and new ligamentous matter confining them thereto. After a time, flexion can be made to a right angle; and the limb becomes tolerably useful. By unsuccessful attempts to restore the natural position, inflammation is excited ; and thus the salutary processes, commenced by nature for reparation of the displacement, are interrupted and delayed ; in young persons such disease of the joint may be produced as might lead to loss of the extremity. Luxation of the Radius alone, backwards on the outer condyle, is sometimes met with; but this bone is seldom singly displaced far from its original site. A hollow is felt below the end of the humerus, on the outer and fore part, and there is a corresponding prominence behind; the head of the bone is found unnaturally moveable on rota- tion, and this motion is difficult and painful; the arm is extended, presenting a twisted appearance, and flexion is very limited. Exten- sion is to be made, along with pronation. Sometimes the radius is displaced forwards. The coronoid pro- cess of the ulna is occasionally broken off; there is no deformity during flexion of the elbow, but when the limb is extended, the olecranon is drawn upwards. In luxation of both bones, reduction is much facilitated by position of the arm. The arm and forearm are entended, and the limb is brought well behind the trunk, so as to relax the triceps; then the surgeon performs extension and counter-extension, pulling the fore- arm with one hand, whilst he pushes with the other placed on the scapula. If the force thus employed prove insufficient, as it seldom will in recent cases, the patient may be placed on his face, on a couch, and on the limb being brought into the favourable position already noticed, counter-extension may be made by the heel planted against the inferior costa of the scapula, whilst the rist is pulled with both hands. It is seldom necessary to employ pulleys, excepting in LUXATION OF THE WRIST. 621 cases of old standing ; if so, the only peculiarity in their application to this joint is the direction of the force, backwards. And this I consider to be a very material part of the manipulations, for, by attention to it, I have succeeded after previous failures, — after great force had been applied, causing excoriation and swelling of almost the whole limb. In luxation of the radius, backwards, flexion and pronation, combined, if necessary, with extension, will generally effect replacement. Dislocation at the Wrist is very unfrequent. The articulation is naturally strong, admitting of little motion, the bones being accu- rately fitted to each other, whilst the retaining ligamentous apparatus is both copious and unyielding ; on this account greater force is re- quired to effect displacement here than at either the elbow or shoulder- joints, and violence applied to the hands usually causes fracture of one or both bones of the forearm, not luxation of their extremities. Luxation, however, sometimes occurs, either from violent twisting, or from falling on the palm of the hand ; and the displacement may be either of both bones or of one. In the latter case, it is almost uniformly the radius that suffers ; in the former, the luxation is forwards. Dislocation of the distal extremity of the radius is generally pro- duced by a sudden wrench or twist. The bone is felt loose and prominent, sometimes riding over the upper part of the carpus. The position of the hand is towards pronation, supination cannot be performed, and, on attempting it, great pain is occasioned. Reduc- tion is readily accomplished, by pulling the palm with one hand, whilst with the other the head of the bone is pressed backwards into its situation. Displacement of both bones is more frequently the result of a fall on the palm, with the hand bent much backwards. In this case there are two projections, so distinct as at once to mark the true nature of the accident, one anteriorly, formed by the ends of the radius and ulna, the other posteriorly by the carpus; above the pos- terior prominence there is a considerable depression. Here also reduction is easy; it is sufficient to perform simple extension with one hand, whilst with the other the wrist is moulded into its proper form. The after treatment, however, requires attention, for extensive laceration of tendinous and ligamentous tissue, perhaps combined with fracture of the bony processes to a greater or less extent, must have taken place to admit of displacement; in consequence violent inflammation is to be expected, and means must be taken to avert it. On account of this laceration, also, mere reduction is not sufficient, retentive apparatus must be applied; as soon as the limb has been made straight, a pasteboard splint is to be applied on each side, as in fracture of the forearm, and retained with a roller, a wooden splint being placed exteriorly until the pasteboard hardens. This precau- tionary measure is also necessary to avert redisplacement in disloca- tion of the radius singly; in both accidents the apparatus should be retained for at least a fortnight. Afterwards, passive motion, gradu- ally increased and combined with friction, is requisite to prevent stiffness of the joint. 622 LUXATION OF THE FINGERS. In mere sprain of the wrist, large swelling soon forms anteriorly, from extravasated blood, resembling somewhat projection of the bones, and so leading towards fallacy in diagnosis; indeed it is not unreasonable to suppose that dislocation here does not occur so frequently as is imagined. Fracture also near or through the distal extremity of the radius, an accident formerly mentioned as exceed- ingly common from falls on the hand, is very apt to be mistaken for luxarion. On this account, and because in every injury of the wrist the parts are soon obscured by bloody swelling, there is a strong necessity for early and accurate examination. Subluxation not unfrequently occurs ; in other words, the attach- ments of the bones of the forearm to each other are broken up, and their extremities separated to an unnatural distance. The accident is distinctly marked by the deformity, the absence of hard projection, and by the unusual space between the radius and ulna occupied by a soft and yielding swelling. Replacement is accomplished much in the same manner as in complete luxation, the bones being compressed towards each other with one hand, whilst extension is made with the other; afterwards splints must be applied and retained. Compound luxations of the wrist are occasionally met with, and, like, compound fractures in this situation, are always troublesome, and often terminate unfavourably. The soft parts are sparing, pos- sessed of little vitality, and much injured by the accident; conse- quently reparation proceeds very slowly, and is generally superseded by unhealthy and profuse suppuration, perhaps accompanied with more or less sloughing of tendons and integument. If the ends of the bones protrude bare, shattered, and split, they should be removed by means of either the saw or the cutting pliers, previously to attempts at reduction ; the wound should then be approximated, and the cure conducted on ordinary principles. Sometimes a single bone of the Carpus is displaced, usually back- wards. It is quite loose and moveable, and is easily replaced, but in almost every case redisplacement occurs, the bone at one time occupying its proper situation, at others forming an inconvenient and unseemly prominence on the back of the wrist, diminished by exten- sion, and increased by flexion of the joint. The accident, however, is rare. I have never seen simple dislocation of any of the metacar- pal bones. Dislocation of the Fingers is produced by force applied to the ex- tremities of the phalanges ; the displacement is always backwards, excepting at the middle joint, where the bone of the middle phalanx is sometimes, but very rarely, luxated forwards. The remarkable pro- jection on the back part of the finger marks the nature of the accident, even to the most careless observer. Reduction is accomplished by extension combined with flexion. In the case of the distal phalanges, it may sometimes be necessary to fasten a cord to the tip of the finger, in order to obtain sufficient extending power. After replacement the application of temporary splints and bandage is prudent. Cora- pound luxations, however carefully treated, almost uniformly come to amputation. LUXATION OF THE HIP-JOINT. 623 Luxation of the first joint of the thumb is rather an uncommon accident, and is not easily managed. The base of the first phalanx is displaced backwards upon the distal extremity of the metacarpal bone, causing a remarkable prominence on the dorsal aspect, and a corresponding depression on the palmar. The thumb is shortened, deformed, and almost immoveable ; the swelling and pain are severe. This displacement is generally produced by the application of force to the point of the thumb, as in falling on it, or in coming against a resisting body with the thumb straight. The deformity is such as at once to apprise even the most inattentive or inexperienced of the true nature of the injury ; but the treatment is very difficult and puzzling even in the hands of the best informed surgeons. The base of the bone seems to slip through the lateral ligaments, and remain firmly locked in their embrace ; and these being very strong, and in a state of complete tension, defy all usual attempts at reduction. The end of a silk handkerchief, or thick soft cord, is to be attached to the distal extremity of the displaced phalanx, by means of the clove- hitch ; and with this extension is made, either by the surgeon alone, or by one or more assistants, — frequently several are required. Counter-extension is made by the surgeon or assistant grasping the forearm, or another handkerchief may be passed betwixt the thumb and forefinger for an assistant to hold on by. The extending force should be made in a direction towards the palm, and almost uniformly requires to be great and long continued, even in recent cases. The bone may occasionally be jerked into its place by a sudden attempt at flexion of the joint, during steady pulling that has been continued for some time. But cases have occurred in which all attempts have proved ineffectual, and it has been found necessary to divide one of the lateral ligaments. From what has been already stated, the rea- son why this proceeding should facilitate reduction is sufficiently ob- vious. I had recourse to it in one instance, — one in which difficulty of reduction was not to have been expected. The accident was very recent, not an hour had elapsed ; the patient was an old man, and very drunk ; no resistance to the reductive measures could have been offered by muscular energy ; yet very powerful force was ap- plied and persevered in without avail. At last the external lateral ligament was divided by the point of a very narrow and fine bistoury, and then replacement was immediate and easy. Some inflammation followed, but was kept within bounds, and the man regained the use of the articulation. In other cases, again, the bone is replaced by the use of but very slight force, provided it be applied, as already stated, in a direction towards the palm of the hand. The last phalanx is equally liable to luxation in the thumb as in the fingers, and has no peculiarity of treatment. Luxation of the Hip-joint. — The great strength of the ligaments, the depth and fitness of the body and cartilaginous cavity for the reception of the head of the bone, and the great power of the mus- cles surrounding the articulation, render dislocation here both diffi- cult and rare. The accident is generally produced by great and sudden force, applied either to the distal end of the femur, or to 624 LUXATION OF THE HIP-JOINT. the farther extremity of the limb, as by falling from a considerable height, by the foot slipping whilst the person is supporting a heavy weight, by falls from or with a horse, &c. The luxation, in a great majority of cases, takes place upwards and backwards, the head of the bone lying on the dorsum of the ilium. The limb is shortened to the extent of from an inch and a half to two inches and a half, the toes are turned in, the thigh is slightly bent upon the pelvis, and very firmly fixed. Before swelling has occurred, and also after it has subsided,"the head of the bone can be felt lying under the gluteus. The trochanter is evidently out of place, being depressed, and lying farther up and back than usual. This is strikingly observable on com- paring the injured limb with the opposite. Attempts to move the limb and effect rotation produce great pain. Large swelling soon fol- lows, along with greater stiffness and immobility. If the head of the bone is not replaced, the pain gradually subsides, and, after some months, freedom of motion is regained to a slight extent; the patient is able to walk, but with a great halt. At first, reduction is accomplished with no great difficulty. Within a very short time after the occurrence of the injury, before the patient had recovered from the shock, whilst he still lay sick, faint, and powerless, I have succeeded in-effecting reduction of the femur quite unassisted, — extending with one hand, grasping the thigh behind, and, at the same time, rotating it outwards by pressure of the forearm on the leg, counter-extension being made by the left hand on the symphysis pubis. When a few hours have intervened, assistance and apparatus are requisite. The patient is secured by a broad band, — a common sheet suits very well, — passed under the perineum. The lacque is fixed above the knee, with a knot that will not run, a towel wrung out of cold water being applied next to the skin, in order to increase the security of the hold and prevent excoriation. A well- padded broad iron ring, tightened on the limb by a screw, and provided with suitable straps for attachment of the pulleys, is very useful, — fully more convenient than the common woollen lacque. Extension may be made by one or more assistants; but this may prove ineffectual, and it is better at once to have recourse to the pulleys: these are not alarming to the patient, and, being efficient, will in the end materially diminish his suffering. The extension should be gradual, steady, and persevering; the rotation of the limb during extension should be principally outwards, effected by laying hold of the ankle, and using the leg as a lever. This motion is pe- culiarly successful when the bone has yielded a little to the extension, when it has changed its place, and come nearly on a line with the cotyloid cavity. In some cases, even of no long standing, auxiliary means are required, — bleeding, antimony, &c, as formerly noticed. In old cases, no attempts at reduction should be made until the patient has been brought into a relaxed state, approaching to collapse, by one or more of the auxiliary means, and by such as are best suited to the particular circumstances of the case; in such instances also the extension, rotation, &c, must be persevered in for some time,— they are not at once successful. Frequently, particularly in recent cases, reduction is accompanied and indicated by an audible and LUXATION OF THE HIP-JOINT. 625 perceptible snap, occasioned by the head of the bone slipping into the cotyloid cavity; the motions are again readily performed, and the limb resumes its proper length and shape. The muscular and articulating apparatus must be kept quiet for some time afterwards ; a band should be passed round the knees, and the patient strictly confined to the recumbent posture; at the same time, fomentations are to be used about the joint, to the perineum, and to the part where the lacque was applied. It is rarely necessary to have recourse to abstraction of blood from the neighbourhood of the articulation. There is no great risk of the bone again escaping from its situation. I have but once witnessed such an accident. A female suffered luxation of the hip nearly a month previously to her admission into the Royal Infirmary, and reduction was unavoidably deferred for three days more. It was accomplished without dfficulty, and the usual precautions were afterwards adopted; but next day it was discovered that luxation had again taken place. The patient had cunningly contrived to have ardent spirits brought to her, and in- dulged freely in these, got out of bed, and slipped down. Replace- ment was again effected, more easily than before; the limbs were firmly secured to each other, confinement to bed and no farther in- dulgence in liquor were strictly enjoined, and after thirteen or four- teen days the limb fully regained its functions. Luxation of the hip downwards or forwards, the head of the femur lying in the thyroid foramen, is generally produced by a fall under a heavy load, the thigh being at the same time forcibly ab- ducted. I have also seen it occasioned by a fall with a restive horse. The limb is elongated considerably, and advanced a little forwards ; the trochanter major is depressed, the toes are inclined neither out- wards nor inwards ; the limb is immoveably fixed, and this most unequivocally marks the nature of the accident. The limb is lengthened when the trochanter major is split off, as also when severe bruise of the glutei has been inflicted without breach of continuity in any part of the bone, and without displace- ment. In the first stage of morbus coxarius, too, a somewdiat similar appearance and position of the limb is presented; there is lengthening, but then there is also more or less wasting of the muscles, more mobility than in the dislocation, and a marked history attached. Complicated cases occasionally occur — as when a patient who has been labouring under hip-joint disease, perhaps not in an aggravated form, falls heavily, and on being lifted up is found to be incapable of moving the joint, the limb at the same time being elongated, and having a distorted appearance. An instance of this nature impressed strongly- upon me the great necessity for accurate diagnosis in the first instance, and that such was to be acquired only by taking every circumstance into consideration. A young man was engaged in cleaning a slaughter-house, standing on two blocks of wood with his legs considerably apart. One of the blocks suddenly slipped from under him, and he fell with his limbs spread. He was carried home in great pain, and next day I was asked to visit him. The limb was elongated, and the hip flattened ; the joint was stiff, and attempts at motion produced great pain ; but by perseverance 53 626 LUXATION OF THE HIP-JOINT. the limb could be put in various positions, and the trochanter was not so much depressed as in luxation downwards. By cross-examination it was discovered that the patient had halted in walking for many weeks previously, had felt as if the limb was longer than the other, had pain in the groin and knee ; in fact, morbus coxarius had been advancing, and the pain, immobility, and greater elongation had been occasioned by the fall, causing violent excitement of the morbid action previously in progress. Dreadful consequences must have resulted from mistake in diagnosis and practice founded upon it. I have observed, in other cases, great and rapid elongation of the limb in consequence of injury to the hip-joint previously diseased ; and I have known instances in which persevering and forcible efforts were made to reduce the supposed luxation. The reduction is in many cases difficult. In young and muscular individuals, after the lapse of some hours, when reaction has occurred, the muscles are rigidly contracted, and the head of the bone is not easily dislodged. Extension, made to a certain extent and continued, is not so useful or essential here as in other forms of luxation of this joint. Adduction, carrying the injured thigh quickly and forcibly over the other, is generally successful; and the reduction is favoured by at the same time raising up the neck of the bone, by means of a towel or wooden roller passed under the upper part of the thigh. There is also no such advantage from rotating the bone as in other luxations. It is very often necessary, even in recent cases, to adopt measures to weaken muscular exertions ; and again, in cases of three weeks' duration, I have found no difficulty. The head of the bone, when dislodged from the foramen obturato- rium, may slip past the cotyloid cavity, for it is impossible to regulate its direction ; it comes to be acted upon by muscles which have been displaced, some being compressed and partially paralysed, whilst others are excited ; they have been put out of their usual condition and relation, and act irregularly. The head of the bone may, from this cause, get into the sacro-ischiatic notch. This has occurred to me ; but I have found no difficulty in removing it from thence, and effecting reduction satisfactorily. Displacement into the sacro-ischiatic notch is attended with great and remarkable inversion of the toes, slight shortening of the limb, the prominence of the head of the bone felt under the gluteus maxi- rnus. It is the least common form of luxation. Reduction is attempted by extension and rotation outwards, at the same time pulling the head of the bone towards the acetabulum by means of a towel passed under the thigh. Luxation of the head of the femur on the pubes is perhaps more frequent than any other, excepting that on the dorsum of the ilium. The limb is not much shortened, the toes are everted, the trochanter major is depressed, and nearer to the anterior superior spinous process of the ilium than usually, and the head of the bone is both seen and felt prominent in the groin. Much pain, swelling, and sometimes more or less paralysis of the limb, are occasioned by this displacement; the femoral artery and vein lie immediately interior to the head of the bone, and are compressed, and the crural nerves are stretched over CONGENITAL LUXATION OF THE HIP-JOINT. 627 it. In attempting reduction, rotation inwards should be employed during extension, accompanied with endeavours to lift the'upper part of the bone towards the acetabulum. [Congenital Luxation of the Hip-joint is sometimes met with, though on the whole a very rare affection, especially in this country. Female children are more apt to suffer from it than males, and it is also more common in such as are of a scrofulous habit than in such as are endowed with a good constitution. Of twenty-six cases of this malformation observed by Dupuytren, not above three or four were males; a disproportion probably not altogether dependent upon chance. The immediate causes of this variety of displacement are, first, shortness, total absence, or extreme obliquity of the neck of the thigh-bone; secondly, partial or entire obliteration of the cotyloid cavity; thirdly, deficiency, extraordinary elongation, or complete absence of the round ligament. The characters of this malformation are, shortening of the affected limb, unnatural projection of the great trochanter, ascent of the head of the femur into the iliac fossa, inversion of the leg, and obliquity of the pelvis. The motions of the joint, particularly those of abduc- tion and rotation, are constrained and imperfect ; the muscles of the upper part of the thigh are retracted, or drawn towards the iliac erest; the limb is thin, wasted, and out of all proportion to the rest of the body ; the tuberosity of the ischium is almost uncovered, and consequently unusually prominent; the upper part of the trunk is thrown backwards, while the lumbar portion of the spine projects forwards, being concave behind ; the pubes is placed almost hori- zontally on the thighs ; and the ball of the foot alone touches the ground when the child stands erect. In the recumbent posture, when the weight of the trunk is taken off, and the muscles are relaxed, most of the symptoms of the luxation disappear, and the limb may be shortened or elongated at pleasure. In walking, the body is inclined towards the sound side, and the head of the dislocated bone sinks towards the cotyloid cavity by its own w7eight. As age advances, the limb becomes shorter, in consequence of the femur ascending higher and higher on the ilium ; the obliquity of the pelvis augments ; and the power of locomotion, already so much impaired, is completely destroyed. Congenital dislocation of the hip-joint may, in general, be easily distinguished from other accidents or maladies, by the affection being observed at or soon after birth, by the obliquity of one or both thighs ; by the absence of pain, swelling, and ulceration ; by the head of the femur being displaced without any external violence ; and by the ability of the surgeon to lengthen or shorten the limb at pleasure. In disease of the hip there is always more or less pain, with a fever- ish state of the system, and gradual failure of the strength ; the parts about the joint are tense and swollen ; the limb, at first somewhat lengthened, becomes afterwards shortened, and cannot be extended without the greatest suffering; and the motions of the ileo-femoral articulation are forever impaired. The post-mortem appearances vary. In general, the cotyloid cavity is partially obliterated, or entirely deficient, being replaced by 628 LUXATION OF THE KNEE. a small, irregular, osseous prominence, devoid of cartilage and syno- vial membrane ; the head of the femur, often flattened at its antero- internal aspect, rests in a sort of superficial fossa on the dorsal surface of the ilium ; the round ligament, as was before remarked, is elon- gated, partially worn away, or even altogether absent; and the surrounding muscles are either atrophied, transformed into a species of yellowish fibrous tissue, or preternaturally developed. In the latter case, their action is preserved ; in the former, it is very much restricted, or totally impeded. The prognosis is always unfavourable, as the patient dies either young, or remains permanently lame and deformed. The treatment can be only palliative ; and as the weight of the trunk is the main agent in aggravating the displacement, repose is obviously indicated : but it is not necessary to confine the patient to the recumbent posture ; since, in the act of sitting, there is no stress on the femur, the body resting principally on the tuberosities of the ischia. Dupuytren thought favourably of the cold bath ; it should be strongly impregnated with salt, and the body immersed for three or four minutes at a time. He was also in the habit of using a well-stuffed belt, about four inches wide, for surrounding the pelvis and fixing the great trochanters ; thus binding the ill-adapted parts together, keeping them at the same height, and preventing that continued motion to which they are otherwise so much exposed.] Luxation of the Bones of the Leg — separation of them from the end of the femur — seldom occurs. It can be the effect only of great violence and great laceration. Most frequently fracture is concomi- tant, perhaps with wound ; and such accidents require amputation, either primarily or secondarily. Sub-luxation, from laceration of the internal lateral ligament, is not so unfrequent. It is most common in females, the natural conformation of their thigh-bones disposing them to bend inwards ; and from falling awkwardly, particularly if carrying a weight, the ligament is apt to give way. The limb is pained, deformed, and unable to support the body, and swelling to a considerable extent soon follows. Reduction is extremely easy ; and the parts are retained in site by the application of a wooden splint, to either the outer or the posterior side of the joint, the leg and foot being previously bandaged. The joint remains long weak, and never recovers entirely ; a sustaining apparatus, fitted on the out- side retained by straps, and with a joint opposite to the articula- tion, is required to be constantly worn when the patient washes to use the limb. Luxation of the Patella is spoken of by some as common. Others of much experience have not met with a single instance of it. I have never seen this accident. The bone, it is said, may be displaced outwards, inwards, or upwards. The first form of luxation is the most frequent, and is caused by a severe fall, with the foot twisted outwards and the knee inwards. Displacement inwards is produced by direct violence applied to the outer part of the bone, or by the foot being turned inwards in a fall. Displacement upwards can occur LUXATION OF THE ANKLE__BONES OF THE TARSUS. 629 only after laceration of the ligamentum patella?, the bone being then drawn up by the unresisted action of the muscles on the fore part of the thigh. In dislocation outwards, the bone has been found " resting with its inner edge upon the outer surface of the condyle, the fore part facing obliquely forwards and inwards." In this last form of accident, sudden, forcible, and complete flexion of the limb is said to produce immediate reduction, In dislocation outwards or in- wards, the muscles are to be relaxed by raising the heel, extend- ing the limb, flexing the thigh, and then forcing the bone to its proper site by manipulation. In the dislocation upwards with rup- ture, the limb is to be kept extended and raised, and the bone is brought as nearly into its place as possible, by bandaging. When a peculiar laxity of the apparatus about the joint exists, whether as a cause of luxation or not, the support of a well-made knee-cap is re- quired. As formerly stated, Dislocation of the Ankle cannot take place in- wards or outwards, without fracture of the end of the tibia or of the fistula, either above the articulation, or where they project by the sides of the astragalus for the greater security and strength of the joint. Subluxation, however, or sprain, may occur without injury of the bones : in this accident, should the parts not have spontane- ously resumed their original situation, no difficulty is experienced in putting them to rights ; simple manipulation is sufficient. Occa- sionally, the foot is luxated forwards, by force applied either to the heel or to the fore part of the leg whilst the limb is fixed. The heel is shortened, the foot elongated ; indeed the marks of the injury are so distinct, that comparison of the limbs is sufficient for diagnosis. Luxation may also take place backwards ; and in this case the heel is elongated and the foot shortened. In these accidents it is not un- frequently found that one or other malleolus has given way, or that the lower end of the tibia is split. Reduction is sometimes difficult. Extension is to be made by grasping the foot and pulling whilst the limb is fixed, at the same time making pressure either backwards or forwards, as may be required. To retain the bones in their proper situations, it is always necessary, at least prudent, to apply a paste- board or leathern splint to each side of the limb, particularly when fracture of the malleoli is conjoined. Displacement of the Bones of the Tarsus may result from great force ; for example, when the foot is squeezed under a heavy weight, one or more bones may escape from their connections, and project. Reduction of such displacement is exceedingly difficult at any period, and becomes almost impossible when inflammatory action is allowed to supervene previously to attempts being made. The astragalus is sometimes pushed out of its place ; though it is difficult to conceive how, to a bone so hid and so firmly connected, such force should be applied as to cause protrusion of it from its natural situation. It has been found lying on the dorsum of the foot, causing swelling, lame- ness, great pain, shortening and deformity of the limb ; and the shape of the bone, can in such circumstances, be distinctly felt and seen 63* 630 SPRAIN. through the integument. As already observed, reduction is almost impracticable, and, with the view of remedying deformity, it has been proposed to cut out the displaced bone ; but as to the expediency of such practice I can give no opinion. I have seen but one instance of displacement of this bone back- wards, and most probably another will never occur to me. A heavy- young man, in a state of utter intoxication, fell backwards down a stair, and in the fall his foot became entangled in the railing. The astragalus was found lying betwixt the back of the tibia and the tendo-Achillis, its upper articulating surface facing forwards, the lower in contact with the tendon. All attempts to reduce the bone proved fruitless. Violent inflammatory action followed, but was re- duced by active measures ; and the limb ultimately became very useful ; in fact, though not till after many months, little lameness or shortening was perceptible. By Sprain is understood subluxation or partial displacement of a joint, with stretching, and more or less laceration of the articulating apparatus — ligaments, tendons, sheaths, and bursa?, being all involv- ed in the injury. Sometimes small portions of the processes of bone are separated, being torn away, attached to ligament or tendon. All joints, both large and small, are liable to the accident. In the proxi- mal, or in the middle joints of the finger, for example, one or other lateral ligament is stretched or torn ; the finger is twisted to a side ; the joint is swelled ; and the swelling with pain, is of long continu- ance, perhaps increased by repeated twists, or by imprudent use of the joint. The elbow and shoulder are" frequently sprained, as also the hip and knee ; but the injury most frequently occurs in the wrist, and ankle. It is generally occasioned by a fall, the foot or hand coming awkwardly to the ground, the muscles being at the time re- laxed and unprepared ; by over exertion in lifting heavy weights ; by entanglement and twisting of the limb, &c. The ankle is often sprained by what is called a false step ; the fore part of the foot comes in contact with an obstacle unexpectedly, the foot is twisted under the limb, the weight of the body is thrown on the apparatus of one side of the joint, and this is in consequence immoderately and unna- turally stretched. Violent pain immediately occurs, and the patient is sick and faint. Discoloration and rapid swelling take place from extravasation of blood into the cellular tissue, into the sheaths of the tendons, and perhaps into the synovial pouches, in consequence of laceration of the blood-vessels. Effusion of serum and increased se- cretion of synovia afterwards occur, from incited action of the ves- sels. Thus the joint is deformed. Attentive examination is required to guard against mistakes; the existence or non-existence either of displacement or of fracture must be at once ascertained by determined and perfect manipulation ; the parts must be pressed and moved, to such an extent as is necessary, notwithstanding the pain thereby oc- casioned, and notwithstanding the resistance afforded by the patient. It has already been stated that luxation of the wrist is not uncom- mon: that separation of one bone of the forearm from the other, and transverse fracture or splitting of the radius, at the distal extremity SPRAIN. 631 are accidents by no means rare. Great disfiguration follows simple sprain, much swelling taking place on the fore part of the limb from effusion under the fascia, and there is also much serous and bloody infiltration of the cellular tissue on the back of the hand and forearm. In the ankle, the ends of the bones must be carefully examined, and also the fibula in its whole extent, that the existence or non-existence of fracture maybe ascertained, and that the surgeon may be guided to a correct mode of treatment. If the joint is not put at rest imme- diately, the extravasation is increased, and, in consequence, the pain and inflammatory swelling also ; and parts of the joint at first not in- volved in the injury may thus be made to suffer. Many diseases of synovial membrane and articulating cartilages are attributable, and can be traced, to badly managed sprains ; and in some constitutions, but slight injury, combined with a little bad treatment, suffices to des- troy a joint. When the case is well managed, the pain is never great, and soon abates: the sw-elling after a few days slackens ; the discoloration becomes greater, the serum being absorbed, and the effused blood shining through the skin ; the integuments appear green, blue, red, purple, — these hues either being present all at the same time, or occurring successively ; the discoloration often extends far from the joint. The mobility and strength of the joint are recover- ed gradually. Perhaps no injury is more frequently mismanaged, by those both in and out of the profession. Every old woman thinks she can cure a sprain ; most absurd and hurtful measures are resorted to ; the injured parts are kept in motion; cold lotions and cold effusions are employed, and at the same time stimulating frictions ; probably at- tempts are made, either by leeching or by puncturing, to extract the effused blood ; and many similar follies are committed.. The proper treatment certainly appears to consist principally in absolute rest and position. If there is any displacement it must be rectified im- mediatelyr. If there is any fracture or if there is a tendency to redis- placement after reduction ; or if the patient is restless either from folly or from insensibility, as when the head has been injured by the accident, when the patient is under the influence of strong liquors, or when he labours under delirium tremens,—a splint or splints must be applied to secure immobility of the parts, at the same time without such compression as may interfere with swelling from effu- sion ; the effusion is a salutary process, and should be encouraged, not repressed. By absolute rest and elevation of the limb, the ex- tent of the swelling is limited, and inflammation warded off. Fo- mentations properly employed, afford much relief; at first they proba- bly encourage the serous effusion. The integuments soon become relaxed, during the regular use of fomentation, and tension and vas- cular action subside, as also pain. The swelling then abates, and is no longer hard; it pits on pressure, and the skin has a puckered ap- pearance. Then gentle friction becomes advantageous, and uniform support should be afforded by the application of a flannel roller. The longer the limb is disused, the more perfect and rapid is the re- covery, provided the rest of the cure be properly conducted. In general nothing more than what has been stated is required. But if 632 SPRAIN. the limb be moved, or stimulated in any way, early, then necessity will arise for antiphlogistic measures— perhaps venesection, certain- ly copious and repeated abstraction of blood by leeches, accompa- nied with fomentations, and the internal exhibition of antimonials, purgatives, &c. When such is the case the cure is tedious, the joint long remains swelled and stiff, the patient is lame and incapable of exertion. Leeching or puncturing at an early period, with the view of allow- ing extravasated blood to escape, is useless and hurtful. The effused and coagulated blood cannot be evacuated, and suppuration, followed by destruction of the cellular tissue, has often been the consequence of such ill-advised proceedings. Friction with stimulating liniments, or even simple friction, at an early period, is also hurtful, as tending ■ to excite vascular action, and to convert simple swelling into inflam- matory. The application of cold at any period is of little use, and ought certainly to be avoided immediately after the injury, as adding to the sufferings of the patient, and interfering with the natural pro- cesses which have commenced for the reparation of that injury. In limbs that have remained stiff after severe and mismanaged sprains, the dashing of water, either cold or tepid, has been strongly recommended. The practice is not ineffectual; the vessels of the surface are excited, perhaps as by other friction, and perhaps by the reaction which follows the chill. But the limb is apt to become rheumatic ; and, on this account, the state of matters wrill not be improved by this proceeding, unless it be resorted to with proper precautions. In severe sprains there is reason to think that sometimes even the tendons yield a little — that many of the fibres give way, and that thus the tendon is thinned and elongated. Such injury hap- pens often in horses, in what is called breaking down. In them the tendon is occasionally snapped entirely through, and the ends" widely separated. The same occurs in the human subject. Separa- tion of the muscular fibres, however, is rare ; laceration of the tendon itself, or separation of the tendon from the muscle, is more common. The yielding of the broad tendons on the upper and fore, lateral and under parts of the abdomen, affords an example of laceration of tendinous fibre from violent exertion. The tendons of the limbs are more frequently injured, and in the lower oftener than in the upper. I have more than once seen the tendon of the biceps torn in violent exertion. In the thigh, too, some fibres occa- sionally give way from a similar cause. The supra-muscular fascia in the arm and thigh is apt to give way at one or more points dur- ing powerful exertion of the muscles, causing deformity by protru- sion of muscle through the torn space. But it is in the apparatus for extending the foot, and raising the weight of the body, that laceration of tendon most frequently takes place. The accident is uncommon till after the middle p*eriod of life, when the body has become heavier, when muscular exertions have been less habitually practised and when the fibre has grown more rigid. The person in raising himself over some slight obstruction in walking, perhaps at- tempting to pass a small ditch or stile, suddenly " breaks down." SPRAIN. 633 Or in dancing, — an amusement which he has long discontinued — a sudden snap is felt, with immediate lameness and slight pain in the back of the limb ; swelling and discoloration follow ; and these symptoms and signs vary in intensity according to the extent of the injury. Laceration may have been slight; the pain, swelling, and lameness are proportional, and at first an inconsiderable void can be felt at the upper part of the tendinous termination of the gastro- cnemii. Sometimes no change is perceptible, and in such cases some have been of opinion that the slender tendon of the plantaris has given way and caused the lameness ; but this is doubtful, and it seems more probable that stretching and yielding has taken place in some part of the tendon of the gastrocnemii, which had been in powerful action — probably, the tendinous and muscular tissues have been separated to a slight extent. Occasionally the tendo- Achillis is found completely torn through, and its upper end re- tracted ; in such cases a large space is occasioned at the injured part, when the knee is extended and the foot bent. Sometimes the tendo-Achillis is cut through ; I have seen both completely divided in the same individual — he received a wound by a cutlass across the back of both limbs, while endeavouring to escape from the mate of a vessel, in which he had been stealing. In rupture without breach of surface, the torn blood-vessels pour out their contents into the cellular tissue to a considerable extent, and if a proper mode of cure be not adopted immediately, inflammation quickly supervenes ; and this is apt to terminate very unfavourably in the infiltrated tissue. The tendon is united by the deposition of new matter, and the conversion of this into substance resembling the original structure from the vessels of which the deposit has taken place. The quan- tity of new formation necessarily depends on the extent of lacera- tion and the space thereby occasioned. That such reparation of tendon does take place, and that to a very great extent occasion- ally, is placed beyond all doubt by the results of veterinary prac- tice. " Knuckling over," in horses is occasioned by contraction of the flexor tendon ; the heel does not reach the ground, and in order to effect this the tendon has been in many instances complete- ly divided, The cut ends immediately separate, to the extent of some inches, and after a time this large space is filled up by a sub- stance similar to tendon ; so similar, indeed, that on post mortem examination, some years afterwards, a careless observer could scarcely distinguish any difference in the appearance of the various portions of the tendons. The same is observed after the operations for deformity of the foot in the human subject. The treatment of lacerated tendon consists in placing the parts so as to relax the muscles whose tendons have suffered. In rupture of the tendo-Achillis, the knee should be bent and the foot extended, relaxing the muscle and approximating the separated ends. This is readily and conveniently affected by placing a slipper on the foot, and attaching to its heel a firm band, which is then fastened to a ring or strap placed on the thigh. This apparatus must be worn for six or eight weeks. Afterwards a high-heeled shoe should be used 634 BRUISE. for some time ; or if the union be still weak and imperfect, a splint may be placed on the fore part, resting on the dorsum of the foot and the fore part of the leg. Bruise. — The effects of bruises or contusions are, separation of the cellular connexions, rupture of blood-vessels, and effusion of their contents into the cells ; a cavity, often large, is thus formed partly by the direct injury, and partly by the subsequent effusion, and this is quickly filled wi'th blood, partly fluid and partly coagulated. Im- mediate tumour forms ; and the integument is discoloured, often beyond the principal swelling, The injury may, or may not, be at- tended with division of the integuments, or with fracture or dis- placement of the bones; but all injuries of the hard parts are at- tended with more or less bruising of the soft. Bruise is most fre- quently produced by a blow, and is most severe when the violence is resisted by an unyielding part, as by bone; a squeeze between two bodies, particularly if they be in motion, also inflicts extensive contusion. The swelling continues to increase for some time, and then gradually disappears along with the pain. As the tumour sub- sides, the discoloration increases ; the thinner parts of the effusion have been absorbed, and the clot then shines through the skin, im- parting to it various hues. Bruise may be followed by inflammatory action. Then effusion is increased, bloody fluid is poured both into the cavity and into the unbroken cellular tissue, the whole parts become extremely tender, the surface inflames, and the excited action is apt to terminate unfa- vourably in the various tissues. Not unfrequently sloughing takes place, both of the skin and of the cellular tissue and fatty matter, with unhealthy suppuration and infiltration ; and constitutional dis- turbance accompanies. All this is likely, nay, certain, to follow ad- mission of air into the cavity filled with effused blood, whether by accidental wound or by intentional division of the integument. Med- dlesome surgery is unfortunate here, as well as in many other cases. After scarifications, punctures, leechings, or incisions, the blood often seems to undergo a putrefactive process, and unhealthy sup- puration is quickly established. Sometimes the clot is not entirely absorbed, and considerable swelling remains for a long time, perhaps with slight tenderness of the part; a foundation is thus laid for abscess, either chronic or acute. Frequently the inflammatory action following on bruise is not so violent and rapid as that above described, but is limited in its consequences chiefly to the effusion of coagulable lymph. This may not be altogether absorbed along with the other effusion, it may become organised, and be the nucleus or germ of a new growth, of a tumour contrary to nature — deposit increases in and around the nucleus, and this formation, though at first of a simple nature, may become rapid in its growth, and may assume a troublesome or even a malignant action ; and sometimes all this may occur at an early period, before the attention either of the patient or of the practitioner has been drawn to the action or to its effects. Many tumours can be traced to the effects of a bruise. AMPUTATION. 635 In the treatment of bruise, the parts should be placed in a state of absolute rest, and methodically fomented. Local bleeding is seldom required, and is of little use ; at first it is hurtful. When, from the extent or number of the bruises, fever follows, general antiphlogistic measures must be resorted to. Cold and astringent applications, and other repercussives, as also stimulants, are pernicious in the first stage, and are not very useful at any time. Opening of the cavity must be carefully avoided, excepting when absorption has ceased, when the tumour has increased and become painful, and when the effused blood is putrescent, and unhealthy suppuration has com- menced. Then the cavity should be opened freely, and by poul- ticing, the clots and sloughs are got quit of; afterwards the parts must be supported, as also the strength of the patient. When from long want of use, in tedious cases, the parts have become cold, shrunk, and weak, as also happens in sprain, friction, champooino-, tepid affusion, passive motion, and voluntary motion short of giving pain, will all be of use as tending to restore the circulation, the ner- vous energy, and the muscular development. If cedema remain bandaging or a laced support will be required. Amputation. — Every endeavour, which skill and experience can suggest, must be made before mutilation of the body, by the removal of even the smallest portion of one of its members, is resorted to. But there are cases in which mutilation, though a harsh remedy, is still indispensable for the saving of life. There are others in which it is prudent and proper to resort to operation, in consequence of a member becoming perfectly unserviceable, and likely to impair the usefulness of the individual. Such are very bad and complicated fractures and luxations — laceration of the soft parts of a limb to such an extent as to impress the experienced surgeon with a certainty that in a short time gangrene must ensue, and render the success of any attempt to save life very problematical. When the extent of injury is such that, though gangrene may not be dreaded, yet it is plain that extensive suppurations and exfoliations must necessarily take place, a question may arise as to whether immediate amputation is to be performed or not. This will be decided by the circum- stances in which the patient is placed, and often also by his own feelings upon the subject. He may choose to run some risk, and endure much suffering, with even a very slight chance of ultimately preserving his limb. In cases of traumatic gangrene of the chronic form, amputatisn is not only justifiable, but imperative ; as also in those cases of severe fracture in which the patient is sinking under profuse discharge, with disunited bones. And the same absolute necessity for operation exists in many diseased joints, and in some diseased bones, when the patient's safety would otherwise be endan- gered, or when, on mature consideration, it is evident that the mem- ber, if retained, must for ever be an encumbrance, and worse than useless. Certain tumours of bones, tumours involving joints, tumours and ulcers of the soft parts of a malignant nature, and without ap- preciable disease of the lymphatic system, will also demand recourse to the amputating knife. Patients, too, will be met with, who, after 636 AMPUTATION. undergoing all the suffering attendant on disease of long duration — as exfoliation of bone and sloughing of tendons, following deep sup- puration — will, to get rid of the annoyance of the stiff and deformed member, or part of a member, not only submit to, but urge and insist on, the removal of the offending part. Amputation will also occasionally be required for badly-formed stumps, as those in which the end of the bone protrudes through ulcer of the integument, and is necrosed — or those in which the bone has been sawn of an in- convenient length. Many precautions are to be observed in this operation. It is not to be commenced without due consideration as to the position of the operator, and of his assistants — their several duties — the form of incision — the length of the stump — the difficulties, if any, which may be expected, and the best means of obviating them. The most prominent objects are, to save undue effusion of blood, to effect the incisions with as little suffering to the patient as possible, and to make them of such a form as to cover the end of the bone effectually — so that pressure may, after a time, be borne without risk of ulcera- tion of the soft parts, or exfoliation of the bone. In all cases, and in all situations and circumstances, hemorrhage can be restrained during completion of the incisions, and during the employment of means to close the cut ends of the vessels, by means of very slight but exact pressure on the trunk of the principal vessel. The point at which this is to be applied should be at as short a distance as possible above the place of incision, and at the same time above the origin of any branches which must be cut. Not the slightest pressure should be made until the instant when the inci- sions are about to be commenced, so that no venous congestion may take place in the limb. All the blood in the limb, below the incisions, must necessarily be lost. The veins are more easily com- .pressed than the arteries, and pressure, made a short time before the operation, may arrest the return of the blood, whilst it may not com- pletely stop its influx ; thus engorgement of the lower part of the limb is produced, and the quantity of blood that must be lost is in- creased. For a similar reason, pressure sufficiently firm to stop arte- rial hemorrhage, is to be continued till the principal branches are tied, and then entirely removed; for the continuance of even slight pressure will increase the flow from the surface of the stump — blood, flowing in, and being arrested in its venous return, trickles out through the open ends of the veins. If a circular band be used for the compres- sion, such as the screw tourniquet, it should be put on quickly, and screwed up at once, and then the incisions should not be delayed one instant after ; there should be no relaxation of the pressure at any part of the operation ; and as soon as the principal vessels have been secured, the apparatus should be altogether removed — otherwise as already stated, rapid oozing will continue from the face of the stump It is my confirmed opinion, that much more blood is lost from the us< of a tourniquet than without it. I would rather trust to a no very effi cieut assistant, than put on a tourniquet. It is evident that com- pression on the whole circumference of a limb must completely in- terrupt venous return, and cause the increase of hemorrhage already use AMPUTATION. 637 mentioned ; whereas pressure on only two points of the same cir- cumference, as is effected by the hand of an assistant, is not liable to this objection. Besides, the latter mode is more quickly applied, and more readily removed, causes infinitely less pain to the patient, and is equally effectual in arresting the flow in the main arterial trunk. Neither does it interfere with the due contraction and retraction of the divided tissues. The incisions should always be made rapidly ; and after their completion, the surgeon, if distrusful of his assist- ant, or if his hand has become cramped and tired, may himself grasp the limb and compress the vessel, giving the forceps or ligatures to another. The first step in the operation is to arrange the measures for temporary arrestment of the bleeding. The patient is placed in a favourable position, either sitting or lying, as may be most convenient for the particular amputation, and is firmly secured by one or more assistants ; all the apparatus must be in good order and conveniently placed, and an assistant should be stationed to attend to them, and hand those required. The compressor and the operator are each at their post, and ready to act in concert. The incisions may be made either from without inwards, or from within outwards, after trans- fixion of the limb. The latter mode is to be preferred when practica- ble, as requiring less pressure; the parts are more stretched than in the former method, are therefore more easily and rapidly cut, and con- sequently less pain is inflicted. To the inexperienced transfixion may appear cruel, it may appal them, but in reality it is almost unattended with pain ; it is rapidly executed, and renders the operator capable of completing his work with great quickness and little suffering, and at the same time with neatness and precision. The knife should be of a size and length proportioned to the incisions, straight-backed, and with a good point; of a form to pass through readily, yet strong, and not too broad. With one sweep of this, the incisions are made at once, through the muscles, through the cellular and fatty tissues, and through the integuments — or vice versa, if the mode from without inwards be preferred. By these parts being cut rapidly and at once, their connexions with each other are not separated, the cut surface is smooth, and the parts are in the most favourable state for becoming agglutinated and consolidated ; the bone is more deeply covered, and the stump of a handsomer and more useful shape, than when the parts are cut successively and with detachment. The operator places himself so that he may grasp the part to be removed, during the sawing of the bone, without change of position. The incisions are made with the left hand free ; but as soon as the saw is in the right, the left should take firm hold of the limb below the wound. During the operation, the limb is supported by an as- sistant, either sitting or kneeling before the patient; but the regulating of the position of the limb, during sawing, is not to be intrusted to him alone. He may, from anxiety to facilitate the action of the saw, snap the bone and splinter it when it has been little more than half divided ; or, from dread of this, he may lock the instrument, and so delay completion of the operation. The management of the lower part of the limb should always be by the person using the Saw. This 54 638 AMPUTATION. instrument should have its teeth well set, and be provided with a work-man-like handle. It is worked steadily and not hurriedly, with very slight pressure, and that pressure employed only when pushing forw-ards. Before its application, all the soft parts must necessarily be divided completely ; and this is done by carrying the knife, after formation of the flaps, round the bone, with its edge rasping on it, and as high up as possible. The instrument is then placed accurately on the point thus exposed, close to the soft parts, and during the sawing the flaps are well retracted by the hands of an assistant. The saw may be worked either horizontally or vertically ; the latter direction is to be preferred, for thus, w-hen the section is nearly com- pleted, the uncut part of bone is deep, and less likely to snap on the weight of the limb being allowed to operate, or when undue pressure is made downwards. If splintering of the bone have occurred, whether from neglect of the foregoing precautions, or by other accident, the sharp projecting parts should be taken away, and the cut surface made quite smooth by means of the bone pliers ; and with this in- strument also, the sharp edge of the bone may be rounded off, in cases where subsequent pressure might cause ulceration or sloughing of part of the integument of the stump. The arteries are tied close to their connexions. The cut ends are laid hold of with the dissecting forceps, or by those represented at page 173, and pulled out; a small firm thread, either of linen or silk, is then applied tightly, and one end immediately cut away close to the reef-knot. Separation of the ligatures generally takes place from the sixth to the tenth or twelfth day; they produce little discharge or irritation during their presence, and no source of irritation connect- ed with them is left behind. But when both ends are cut away close to the knot, separation is often long of taking place, and though the parts may heal over them kindly enough, the stump never can be considered sound till all are discharged. Probably several of these knots remain deeply imbedded after cicatrisation of the integument, and when the patient considers himself cured, and is moving about the room or ward, actively and cheerfully, painful hardness forms deeply, part of the stump reddens and swells, matter forms, and at length the insignificant origin of the mischief is discharged; and this may occur more than once. Generally such suppurations are limited, and soon cease ; but occasionally the abscess formed round the knot is extensive, deep and free incision is required, the filling up of the cavity is necessarily slow, the cure is long protracted, and both prac- titioner and patient are disappointed and annoyed. Besides the sup- purations thus occasioned, though slight in extent, may, when in the neighbourhood of a principal arterial branch, cause ulceration of the coats of the vessel, producing troublesome hemorrhage at a late pe- riod. All these untoward consequences of cutting off both ends I have experienced in a series of cases, and from the results of a faith- ful comparative trial of both methods, I am now fully determined al- ways to leave one end of the ligature hanging from the lips of the wound. No one now, it is presumed, dreams of the absorption of ligatures, whether composed of animal substance or not; therefore the catgut AMPUTATION. 639 ligature, at one time much recommended, has no superiority over the Jinen or silk thread, — besides it is not so convenient of appli- cation. Twisting or bruising the cut ends of arteries has been long known as effectual in arresting bleeding. Vessels of a large size can be so treated with sufficient facility, and they may not bleed after ; but well-tied ones are much more secure. The smaller cannot be pulled out and twisted, ligatures must be used for them ; and the applica- tion of one or two more ligatures, namely to the large arteries as well as the small, will add to the patient's safety, and to the operator's comfort and peace of mind, and can have little effect in increasing irritation. I have made trial of the method of torsion after amputa- tion, and for the above reasons, and because the manipulations are more tedious, I disapprove of the plan, and decidedly prefer the liga- tures. I am not aware that the proposal of leaving the vessels both untwisted and without ligature has been tried in this country ; one would think that it must always be troublesome, and not unfrequent- ly hazardous. In some cases, as when the incisions are made in the neighbour- hood of diseased bone, the soft parts are so condensed that the ves- sels cannot be pulled out by means of forceps ; they are to be transfixed by a sharp hook or tenaculum, and a ligature is then ap- plied round the parts which the instrument holds ; or the vessels may be encircled by a thread passed round by means of a curved needle ; in both methods more or less of the surrounding tissues must neces- sarily be included in the noose, though always as little as possible. Sometimes an artery of the bone, whether sound or inflamed, bleeds sharply ; in such circumstances the application of ligature is impossi- ble, and I have occasionally been obliged to insert a wooden peg into the opening ; to this a chord is attached by which it can be removed after a few days. When bleeding has been satisfactorily arrested, the surface of the wound is to be cleaned of coagula, either with the fingers or with a warm and soft sponge, the ligatures are brought to a margin at con- venient points, and the edges of the integument are then put together by interrupted sutures — two, three, or more, according to the extent of the wound. They need not be numerous, for they are only tempo- rary, effecting partial approximation, and showing the line in which the parts are to be brought together by the after dressing. The stump is then covered with lint soaked in cold water, and this appli- cation is renewed frequently so long as any trickling of blood con- tinues. Farther dressing is delayed for six or eight hours, when the oozing has entirely ceased, and the visible cut surface become glazed. Under this management, there is less chance of bleeding breaking out afresh than when the limb is encompassed by bandages and pledgets of lint, perhaps compressed so as to interfere with the return of the blood, and heated by superfluous dressings. If bleeding to any ex- tent should occur, as there is always a risk of, after the patient has become warm and comfortable in bed, and reaction has been esta- blished, there is but little pain or annoyance in reaching the bleeding point and taking measures to stop the flow ; the few stitches are soon 640 AMPUTATION. clipped away, and then the surface of the w-ound is completely ex- posed, and ligatures can be applied to those vessels which require them. Then, after removing all coagula, sutures are placed in the same perforations, and the stump is in as favourable a state as previ- ously. I now generally leave the wound quite open, until all risk of hemorrhage has ceased, and if one or two stitches are required, these are put in at the time of applying the plaster. After six or eight hours, as already stated, any clots that have formed are to be taken away gently, and the glazed edges of the wound are then brought accurately and neatly together by the adhe- sive composition already recommended, — with the difference of its being spread upon slips of oiled silk, which I have found to be more pliable, and altogether preferable to the glazed riband. Interstices are left for the sutures and the ends of the ligatures, and the latter may now be abridged slightly. This mode of keeping the edges in contact I can confidently recommend from experience. The plasters are much more adhesive than those in common use, do not irritate, and are not loosened by discharge. After twelve, or twenty-four hours, often much earlier, the sutures are clipped through and re- moved. No other dressing is required till the end of the cure, pro- vided this proceed favourably. The part is kept cool, and the slight discharge which occurs in a day or two is wiped up from time to time, if it be in such abundance as to reach the oiled cloth over the pillow on wdiich the stump is laid. No disturbance of the parts is necessary as when ointments, bandages, and compresses are employ- ed, or straps that require frequent removal and reapplication. The patient suffers comparatively nothing ; and the surgeon is saved much troublesome and dirty work,— for union by the first intention sel- dom fails. Bleeding within a few hours after the operation, before excited action of the vessels has commenced, is easily arrested by exposure of the surface, removal of all clots, for by these hemorrhage is en- couraged, and by including the open vessels in ligatures. For the accomplishment of this, the period and mode of dressing, above re- commended, afford great facility, as has been already ooserved. Hemorrhage at a later period is not common. It happens occasion- ally in consequence of the stump having acquired an unhealthy con- dition, from sloughing, — or from abscess, as when this occurs round ligatures which have been retained, along with the slough of the vessel and cellular tissue, both ends having been cut away. The matter formed during separation of the ligature in the usual way, escapes readily along the protruding end, but when there is merely a knot, the integuments have most probably closed over, there is no direct outlet; the matter is confined, and causes ulceration of the coats of the vessel as well as of the surrounding tissues. In this kind of hemorrhage, it is needless to attempt finding the bleeding point by tearing open the stump, separating any adhesions that may have formed, causing much pain and retardation of cure. And even though the bleeding vessel or vessels could be found, they are not in a state to hold a ligature. The artery is surrounded by sloughing cellular substance, its coats are tender, and in no condition to assume AMPUTATION. 441 a healthy action necessary for permanent closure after deligation. If ligature is applied, the included part quickly separates, and then the vessel is as open as before. Astringents, and even the cautery, are useless. Ligature of the main arterial trunk, above the origin of branches supplying the stump, so as to weaken for a time the cir- culation, is found to be effectual. I have had recourse to this in many eases, and uniformly with success. Some years ago, several occurred in the Royal Infirmary, within a very short time of one an- other ; it was during rather an unhealthy season, and at the time I was making trial of cutting off both ends of the ligatures. They were all after removal of the lower limb; one patient died—the amputation was high, through the trochanter minor, and the vessel tied secondarily was the common iliac ; this had the effect of com- pletely arresting the hemorrhage, but the previous loss of blood proved too much for the system to recover from; transfusion was had recourse to, and produced temporary benefit. The others, cases of amputation below the knee, made most favourable recoveries after ligature of the superficial femoral, and in more than one the stump healed very rapidly after its readjustment. Indeed, it is not unfre- quently found that when the flaps are separated, from whatever cause, and replaced when the granulations have appeared, there fol- lows a rapid union and cure. When healing by the first intention has failed, fomentation and poultices are generally the most grateful and beneficial applications for a day or two. Afterwards, when suppuration has been fairly established, and the stump begins to be flabby and cedematous, simple dressing and uniform support by bandaging are required, sometimes along with compresses on particular points to prevent lodgement of matter. Sometimes the secondary hemorrhage is not an arterial and rapid flow, but a slow and continued oozing from a cavity, ulcerated, dark, and angry, round the end of the bone ; this seems to arise from dis- eased action in the cancellated tissue of the bone. Removal of the coagula, stuffing the cavity with dry lint, and the application and continuance of firm pressure, generally suffice for its arrestment. Hitherto, these general observations on amputation have regarded the operation by flaps only ; the circular method has not been men- tioned. The reason is, that the circular amputation has been, it is hoped, in a great measure abandoned in this country. And its in- feriority to the method by flaps is so obvious, and so generally ac- knowledged, that detail of the different steps of the operation is, I conceive, here altogether unnecessary. It is more tedious in per- formance, more painful to the patient, does not afford so good a covering for the end of the bone, and consequently not so conve- nient and useful a support for an artificial limb, and the cure of the wound is protracted. The stump is almost always conical, the end of the bone is, ultimately at least, covered only by integument, and from even very slight pressure this is apt to ulcerate ; exfoliation of the bone follows to a greater or less extent, or unhealthy ulcer of the soft parts continues, along with caries of the bone, and partial death of its surface; and at length it becomes necessary- either to perform 54* 642 AMPUTATION. a second amputation or to curtail the length of the bone. It may sometimes succeed tolerably well when there is but one bone : when there are two, it is altogether inadmissible. In very muscular limbs, when amputation is demanded on account of destruction of the bones and joints,' with laceration of the soft parts, as when the patient is not required to have pressure made on the stump, it suits well to make the flaps of integument only, and to cut the muscles short, as will be noticed more fully afterwards. The advocates for the circular amputation, my excellent friend Sir George Ballingall, and others wish it to be believed, (and this is their main argument,) that the exposed surface of the flaps is much greater than that in their favour- ite method. Some of the philosophers of the Modern Athens have been appealed to, and have measured, it is said, the area of the one and the other, and given their verdict in favour of the round about AMPUTATION OF THE FINGERS. 643 incision. The accompanying drawings from nature, and the corre- sponding diagrams, speak pretty plainly in favour of the other method. In the first there is a cone formed by the cut skin and muscles, with a corresponding hollow and ragged cavity ; and the second set shows two smooth, nearly triangular surfaces, which the said philosophers may measure and report upon at their leisure. Various accidents and disease require removal, either primary or secondary, of the fingers, or of parts of them. Amputation is most easily accomplished at the articulations, and ought therefore always to be performed at these points, when the circumstances of the case permit. The last phalanx'may require removal either on account of severe injury, or from incurable disease, as onychia maligna, necrosis, caries, &c. The operation is one by single flap, and may be con- ducted in one of two ways. The doomed phalanx is grasped, on its anterior and posterior aspects, by the fore and middle fingers of the left hand ; and the articulation is flexed almost to the full extent, in order that incision into it may be facilitated. A straight, narrow, and sharp-pointed bistoury is carried in a semicircular sweep over the back part of the joint, so as to divide the integuments, and open completely the articulating cavity. The remaining ligamentous in- vestments of the joint are divided by one or more additional touches of the knife, so as to loosen the base of the phalanx. The fingers of the left hand are then changed from the fore and back parts of the phalanx to its sides, the edge of the knife is passed behind the base of the bone, and the surgeon, by carrying the blade forwards and downwards, forms a flap of sufficient dimensions to cover the wound, and remove the offending part. There is seldom any trouble from hemorrhage ; no ligatures are required. The flap is turned up so as to form a cushion over the exposed surface of the middle pha- lanx, and is retained so by the adhesive composition formerly men- tioned, or by one or two turns of a linen bandage. The other me- thod of operation is the reverse of the preceding. The joint is ex- tended, the bistoury is made to transfix close to the joint and at its anterior part, and by then carrying it downwards and forwards, as before, a similar flap is formed ; this is retracted by an assistant, and with one sweep of the knife the articulation is divided from before backwards. By either method the flap is the same. By- similar procedure the amputation at the middle articulation is per- formed. It is sometimes an object to save as much as possible of the proximal phalanx, when amputation is rendered necessary by dis- ease of the middle articulation, or of the distal extremity of the bone. In such cases, two semicircular flaps are made by cutting from with- out, either on the lateral, or on the thenal and anconal aspect, and the bone is divided either by a small saw or by the cutting pliers. The flaps are retained in apposition, and the bleeding arrested by- bandaging. Amputation at the proximal articulation is also performed by double flap. In the previous operations an assistant steadies and supports the hand" ; in this he has likewise to bend the rest of the fingers, and to separate as widely as possible those neighbouring to the one about 644 AMPUTATION OF THE FINGERS. to be removed. The operator seats himself before the patient, grasps the finger so as to manage its movements with the left nand> an.(J holding the knife perpendicularly, with its point upwards, lays it over the knuckle, and carries it obliquely upwards so as to °Pfn that side of the articulation. He then pushes the finger towards the opposite side, and with the point of the knife completes the loosen- ing of the articulation ; for this the blade of the instrument should never be employed, otherwise the integument will be cross-cut and mangled. After separation of the base of the phalanx by the point, the blade is passed behind, and carrying it downwards and outwards, a flap is formed similar to the first—both proportioned to the size of the wound which they are to cover, and the bone which they are to protect. The fingers may also be removed by the oval method, as described and delineated in the Practical Surgery. The flaps are retained in contact by bringing the neighbouring fingers towards each other. This also suffices, in general, to suppress the bleeding, but sometimes one or both digital arteries require ligature. At first, cold cloths are probably the best applications, with the view of stopping the oozing, and warding off inflammatory action. Vascular excite- ment is very apt to follow this amputation, when performed for dis- ease of the finger, as after neglected or severe whitlow ; the soft parts in which the incisions are made are generally infiltrated and condensed, and prone to inflammation. The surface around is red, tense, and shining, on the second or third day; the back of the hand, the palm, and perhaps the forearm, are then involved in in- flammation of the surface, and infiltration of the cellular tissue ; and in all probability, free incisions, followed by poultice and fomenta- tion, will be necessary to restore the parts to quietude. Such con- sequences are to be guarded against as much as possible, by atten- tion to the system, and by avoiding all irritating dressing. ♦ The phalanges of the thumb are removed in the same manner as those of the fingers. Amputation of the metacarpal bone is accom- plished thus. The thumb is grasped by the fingers of the left hand and so managed. The bistoury, held in the same manner as for amputation at the proximal articulation of the finger, is placed with its point on the web betwixt the thumb and forefinger, and carried in one sweep rapidly upwards in a slightly oblique direction, till it is stopped by the ostrapezium. The point is used to effect disarticu- lation, the member being at the same time pushed steadily outwards; the blade is then placed behind the base, carried downwards close to the side of the bone, and is not to be brought out till sufficiently low down for forming a flap to cover the whole wound. The flaps may be formed otherwise, and much more handsomely, by transfixion of the ball of the thumb, as shown in the Practical Surgery, p. 360. After arresting the hemorrhage, the flap is laid smoothly down, and retained in its proper position by bandage or slips of the adhesive plaster. The metacarpal bone of the little finger is removed by the same method of incision as for the thumb. In amputation of the fingers, the incisions sometimes require to extend beyond the proximal articulation, on account of disease having involved that part; in other words, it may be necessary to AMPUTATION OF THE FOREARM. 645 remove more or less of the metacarpal bone along with the finger. The method of incision will vary according to the extent to which the bone is diseased. When the operation is required for disease of merely the distal extremity, the incisions are made in the same form as for amputation of the joint, only they are on each side sufficiently high to be beyond diseased bone. They may either be made from below upwards in the usual way, or be commenced at their highest point on the dorsum of the metacarpal bone. After the soft parts have been separated from the bone, by a few touches of the knife after formation of the principal incisions, removal is completed either by the cutting pliers or the metacarpal bow-saw — the former I have found the more convenient instrument. It is applied perpendicularly, and should always have its smooth surface in contact with the part to be retained, otherwise the cut part will be rough and irregular. Section is completed more rapidly than by the saw, and, by attention to the above precaution, the stump is equally smooth, if not more so. The wound is brought and retained in contact by approximation of the fingers. But in taking away any considerable portion of the metacarpal bone, it is of importance to preserve the palm uninjured. With this view, the knife is entered over the centre of the bone on its dorsal aspect, above the diseased part, and carried straight down- wards till near the articulation, when it is made to diverge for the formation of lateral flaps ; the integuments in the track of the longi- tudinal wound are then dissected backwards, so as to expose the bone completely, and the bistoury is passed round the bone through- out its whole extent, the edge being kept close to it, — in order that the soft parts may be separated, and that without unnecessary- width of wound or implication of the palmar arches and branches proceed- ing from them. Then the bone is clipped at the proper point by the cutting pliers ; or the section of the bone may be performed before separation of the soft parts from its under surface, as, by raising the cut end, this part of the operation may be facilitated. Here the metacarpal saw is Inapplicable. Before quitting this part of the amputations, it may be observed, that no good can result from taking away a metacarpal bone and leaving a finger, or from removing a proximal phalanx and leaving the distal. The parts so left can be of no use, they have no support - and the muscles cannot act upon them : they must prove an incum- brance, and as such will either form the subject of a second amputa- tion, or remain a proof of the unsuccessful result of the first. Amputation in the forearm may be necessary at various points, on account of accident or disease, but should never be resorted to, in either case, so long as part of the hand can be saved. The preser- vation of even a small portion of this useful member, even of one finger or a part of one, is of great importance to the patient. When, however, this is hopeless, all must be removed ; and, if the wrist be sound, amputation may be performed at that joint. Hitherto, no mention has been made of the temporary suppression of bleeding, for in the amputations detailed there is scarcely ever any necessity for adopting such measures ; but in those of the forearm and arm, a 646 AMPUTATION OF THE FOREARM. steady assistant must be placed ready to compress the humeral artery as soon as the incisions are commenced ; in the case of the forearm, the pressure is made on the lower portion of the artery; in the arm, the point of pressure will necessarily depend on the point of removal. The patient may be either seated or recumbent. One assistant corn- presses, another steadies the limb in the supine position. The surgeon holds the hand in his left, standing on the inside of the right limb, and on the outside of the left. Suppose the right wrist is to be operated on, — the end of the ulna is felt for, and at that point the knife is entered, and drawn across the wrist on its dorsal aspect in a semilunar direction, the convexity of the curve of course pointing towards the fingers. The joint is opened by retracting and dissecting back the flap so formed ; the knife is then passed behind the scaphoid and lunar bones, which are exposed and turned out by division of the ligaments, and by rapid and gentle sawing motion downwards and forwards, a flap of sufficient size is then formed on the palmar aspect. The dorsum of the hand may be so diseased or injured as not to afford sufficiency of sound parts for a posterior flap ; in such circumstances the anterior must be made proportionally large, that it may alone cover the ends of the bones. After suppression of the bleeding, the flaps are approximated by one or two points of suture ; these are afterwards removed, and their place supplied by the adhe- sive plaster. Amputation, at any point between the wrist and elbow-joints, re- quires, in all, the same method of incision, but the nearer to the elbow the better is the stump ; at the wrist the flaps are composed princi- pally of integuments and tendons, and the cushion so formed for the bones is very inferior to one of muscle. Compression is made and the limb steadied as before ; the surgeon w-ifh his left hand grasps the wrist, and places the forearm in the middle state between prona- tion and supination. In the right forearm, the knife, held perpen- dicularly, is entered over the centre of the radius, and its point, after reaching the bone, is inclined inw-ards so as to pass round it; trans- flixion is then made, the knife passing close to the palmar surface of the bones, and emerging at a point opposite to its entrance ; and then by rapid motion downw-ards and inwards, a proper flap is formed. The instrument is again introduced over the radius, at a little distance from the upper part of the first wound, and passed on the opposite side of the bones, emerging also in the first incision and at a similar point; another flap is made. These are retracted, the knife is swept round the bones, and passed freely between them, to divide the re- maining muscular substance, and after this has been completed, the saw is applied. During the sawing it is well to preserve the limb in the same position as during the incisions, and to apply the instrument perpendicularly; thus both bones will be divided at once, and the risk of splintering diminished. In transfixion, great care is required that the point of the knife pass across, not between, the bones, and with this view a slight change of position is useful; during the trans- fixion of the inner flaps, the surgeon, as soon as he feels the knife rounding the radius, rotates the forearm gently inwards, and in trans- fixing for the outer flap similar rotation is made outwards. In this AMPUTATION OF THE ARM. 647 situation, and others where the soft parts are less thick in one aspect than the other, it is by much a preferable plan to make a flap first, by cutting from without inwards, as already described in regard to the wrist, and then to transfix for the formation of the second flap. This is delineated in the Practical Surgery, p. 367. Sometimes slight difficulty is experienced in tying the interosseal artery. The flaps are brought together, and treated in the way already mentioned. In all amputations of the upper extremity, it is of importance, and indeed a rule scarcely to be departed from, to leave as much of the limb as possible ; for here the longer the stump, the more useful is it to the patient. In accordance with this maxim, amputation at the elbow-joint may be required, when either disease or injury extends too high for amputation in the forearm, but not too high for the for- mation of an anterior flap over the joint. The limb is steadied in the supine position, compression being made near the middle of the humeral artery; the knife is passed horizontally across the condyles close to the bone, and brought downwards and forwards to a suffi- cient extent for the production of a flap, which is alone to form the protecting cushion. The joint is then cut through, the knife is passed down till obstructed by the olecranon, and with one sweep a semi- circular incision of the posterior integument is made. All soft parts in this line are divided, and then the saw is applied to the olecranon process. This amputation is easy, rapid, and beautiful in execution ; and, w-hen the flap is sufficiently large, — as it always may be, for there is no wrant of soft parts in front,—the stump is w-ell formed and useful. The flap is laid dow-n, and attached by suture to the integument posteriorly; in due time the adhesive dressing is applied. The circumstance of a secreting surface forming the stump does not seem detrimental, either here, or in the wrist-joint. The synovial fluid soon ceases to distil, and union is not interrupted by it. There is no necessity for scarification, or scraping the cartilage, with the view of hastening cessation of secretion and granulation of the surface. Amputation of the arm is performed by the formation of lateral flaps, at any- point below the insertion of the deltoid muscle. Com- pression is made on the upper part of the humeral, or on the axillary- artery. The limb is held well separated from the side; and care should be taken that, when so raised, its height be convenient to the operator. The knife is entered perpendicularly to the shaft of the bone, passed fairly down to it, and then inclined along its side ; the operator now grasps the limb below the line of incision with the left hand, and pulls the muscles towards him — it is supposed that the rio-ht arm is being amputated, the surgeon standing on the inside, and an assistant supporting the forearm — and then completes trans- fixion, inclining the handle of the knife towards himself, in order that its point may pass round the bone and emerge at as distant a point in the circumference of the limb as possible. By a rapid sawing motion, downwards and inwards to the proper extent, the inner flap is formed ; and by attention to the grasping of the muscles and the inclination of the knife, its base is so large as to admit of the more easy performance of accurate transfixion for the outer — that is, the 648 AMPUTATION OF THE SHOULDER-JOINT. instrument is more easily brought through the same incision. The assistant seizes the extremity of the inner flap as soon as formed, and retracts it, but only to a slight extent; it is simply held out of the way. If it be pulled backwards, as in retraction during sawing, the formation of the second will be much impeded. The knife is again entered about half an inch below the commencement of the first in- cision, and by inclining the handle the point is brought round the bone, and made to appear on the opposite side also in the first inci- sion ; this is facilitated by pulling the soft parts outwards with the left hand. Then the outer flap is completed. The knife is swept rapidly round the bone, so as to expose it completely at the upper part, the assistant at the same time retracting the flaps fully. The saw is applied, the arteries tied, the flaps approximated, and the operation completed. In performing the second transfixion, the reason why the knife is entered lower than in the first, is, that cross-cutting of the corners of the wound is thereby avoided. For a long time I w-as surprised and annoyed to find many stumps present an unseemly cross-cutting of the integument at the upper parts, particularly after approximation of the flaps, although the incisions seemed tohave been made smoothly and accurately. It is occasioned by the sawing process for making the second flap, and when this is commenced at the same height as for the first, irregularity of incision at the upper part is unavoidable. The precaution, however, of making the second transfixion con- siderably lower than the first I have found quite effectual. The disparity between the bases of the flaps is readily and quickly reme- died, after their formation, by a sweep of the knife upwrards on the lower side. Irritable and painful stumps are more frequently met with after the amputations of the arm and forearm than any other. The occurrence, however, is less common than formerly, and this may be fairly attributed to the improvements in the operation — to the method by flaps having superseded the circular, and nothing but the arteries being surrounded in ligature. Still the affection is occa- sionally met with, and there can be none more painful and trouble- some. Generally, no obvious cause can be found for the attack of this malady ; but in some of the cases there would seem to be a con- stitutional and innate tendency, as it were, towards this irritability of the cut and bulbous extremities of the nerves — as in the following case : — A gentleman, aged 53, underwent amputation of the thumb, in consequence of laceration of the hand. Amputation was very soon afterwards performed at the middle of the forearm, on account of hemorrhage and infiltration of the hand, after fruitless attempts to secure the arteries. After cicatrisation of the wound, he complained of great pain in the stump, and in the situation where the tourniquet had been applied. Amputation of the arm was then performed, but the stump was not well made. The pain returned, and he applied to me, with the view of again submitting to amputation. It was performed nearer to the shoulder-joint, and in order to guard against recurrence of the disease, the nerves were laid hold of, pulled out- wards, and cut across as high as possible. The patient was relieved AMPUTATION AT THE SHOULDER-JOINT- 649 of many of his sufferings, and continued tolerably comfortable for nearly two years ; again, however, the painful symptoms have re- turned, though in a slighter degree. On examining the removed stump, all the nerves, particularly the musculo-spiral, were found greatly enlarged in their extremities, and intimately adherent to the cicatrix and the ligamentous covering of the rounded extremity of the humerus. More desperate operations have even been performed to free patients from irritable stump. The lower limb has been hacked off bit by bit, even to the coxo-femoral articulation, without much, if any, relief. Such operations are hardly warrantable. Amputation at the shoulder-joint is more frequently required for accident than for disease. It has always been the custom to trust for suppression of bleeding, during this operation to the hands of an as- sistant ; and when the method has been found effectual in the case of the large axillary artery, why should it be objected to, on the score of inefficiency, in the minor amputatations ? particularly when it is evident, putting efficiency out of the question, that it is preferable to compression by the tourniquet, or any other circular apparatus ;— more quickly applied and relaxed ; less painful, less formidable; al- ways ready, and independent of the instrument maker. The com- pression is made above the clavicle, so as to secure the subclavian, where it passes over the first rib. The thumb of a steady assistant is placed deeply into the cavity of the lower triangular space of the neck, immediately above the first large sinuosity of the clavicle. The pressure thus made is quite effectual; but as it requires to be firm and uniform, and as there is always a risk of the thumb giving way from exhaustion, it is better to interpose some mechanical contrivance when the assistant is either diffident or inexperienced. The best apparatus for this purpose is a common door key. A bit of lint or cloth is wrapped round the handle, and this part is then pressed down on the vessel. As in other amputatations, the pressure is not commenced till the knife is about to enter. The flaps may be double on the outer or inner aspects, or one may be made sufficiently large to cover the whole wound. The patient is seated on a chair, and secured by a person placed behind. The arm is raised a little from the side, and supported by an assistant. Two oblique incisions are made, commencing high on each side of the shoulder, and converging gradually till they meet near the inser- tion of the deltoid. The triangular flap, so marked out, is dissected rapidly upwards, close to the bone, and kept raised by an assistant. The person supporting the arm then uses it as a lever, carrrying it downwards and backwards ; the joint, thus made more palpable, is cut into by a semicircular sweep of the knife across it; the head of the bone is now dislocated, and the rest of the capsule and fibrous tissue exterior to it divided ; the blade of the knife is insinuated be- hind the head of the bone, and carried rapidly through the remaining soft parts. In no amputation can I conceive any necessity- for sus- pending the incisions, in order to secure vessels, provided the pressure is well applied, and the knife used dexterously. Here very little blood should be lost. The vessels divided in the formation of a flap 55 650 AMPUTATION OF THE TOES. are small, and the axillary is not cut till the incisions are nearly com- pleted; as soon as the limb has dropped, the surgeon places his finger on the mouth of the artery, and then applies his ligature as quickly as possible ; the pressure may now be removed, and the minor ves- sels secured leisurely. The flap covers the wound completely, and is easily retained. Or two flaps may be made by transfixion. In operating thus on the right limb, the surgeon, standing in front of the patient enters the knife a little below the point of the acromion, passes it across the outer aspect of the joint, .and by inclination of the handle outwards, makes its point to appear on the inside of the outer margin of the ax- illa ; by carrying it downwards and outw-ards to a sufficient extent, the outer flap is formed. This is immediately elevated by an assist- ant, and then the arm is pushed upwards, and across the chest, so as to render the joint more accessible ; the ligaments are cut, the bone disarticulated, the knife passed beyond its head, and placed with the edge parallel to the shaft of the humerus, and the arm restored to its former position ; the inner flap is then made by carrying the instru- ment downwards and inwards. In the left limb the knife is entered on the inside of the outer border of the axilla, and brought out below and in front of the extremity of the acromion, reversing the order of the former incisions; after the outer flap has been so formed, the joint is cut across, the knife passed beyond the head of the bone, and the inner flap made as before. Accidental injury, as already stated, is the most frequent cause for amputation at this part, and this will always influence the method of incision. There is nothing peculiar in the after treatment of the stump. But it ought always to be remembered, that the operation is one of great severity ; that a large part of the body has been suddenly re- moved ; that, consequently, there is risk of the mere shock being dangerous, and of an untoward constitutional condition supervening — and, therefore, the after attendance should be zealous and careful. The phalanges of the toes are removed in the same way as those of the fingers. This latter operation may be required on account of bad onychia, large exostosis or injury. This and the other must also AMPUTATION OF THE FOOT. 651 be removed on account of diseased bone, such as here represented with affection of the interposed joint. The osseous shell formed by the enlargement of the original tissue encasing a segmentum is well represented. In the amputation at the proximal joint, it is to be recollected that the extremity of the metatarsal bone lies more re- moved from the web of integument betwrixt the toes than the meta- carpal bone does from that of the fingers. The incision upwards, therefore, requires to be deeper ; but in other respects the operations are precisely the same. In amputating at the proximal articulation of the great toe, there is often a difficulty in obtaining a sufficient covering for the wound, on account of the presence of the sesamoid bones, and the general bulging of the heads of the bones. The knife is entered on the dor- sum of the metatarsal bone, about half an inch above the joint, and then inclined to each side, marking out lateral flaps of considerable length ; these are then reflected, — in making the outer, the instru- ment being dexterously passed round the sesamoid bone, — and the disarticulation completed. In removing the great toe, along with the metatarsal bone, the bistoury is entered over the articulation of the metatarsal bone with the tarsus, and carried straight downwards, along the centre of the dorsum of the bone, till near its extremity ; it is then inclined to each side, in the manner described for amputation of the metacarpal bones. The integuments are dissected off on each side of the longitudinal ineision, and the knife run up along the inside of the bone, till stopped by the tarsus. The surgeon now presses the toe outwards, so as to assist the disarticulation ; and after this has been completed, the bistoury is carried downwards, close to the outside of the bone, and not brought out till past the lower articulation. The external flap thus formed is then laid accurately down, so as to cover the wound, and retained. The preferable mode of making the flap, so as to expose the metatarsal bone for division or disarticulation, is well illustrated in the Practical Surgery, p. 375. The entire bone must be removed in such cases as that here sketched. In cases in which the shaft is comparatively sound, and the disease is princi- pally seated in the articulation with its distant extremity, the shaft may be divided with the cutting forceps at a point sufficiently re- moved from the disease. The operations on the other metatarsal bones are the same as those on the metacarpal. They may be removed, either entirely or in part, along with the corresponding phalanges, by operative procedure similar to that practised on the hand. 652 AMPUTATION OF THE LEG. Sometimes disease of the foot is not so extensive as to require or justify removal of the whole organ ; the metatarsal bones are not involved throughout their whole extent. The same remark applies to injury by accident. In such circumstances, amputation is per- formed at the articulation of the metatarsal bones with the tarsus. The operator first ascertains the exact site of these joints, and then transfixes the foot at that point, passing the knife close along the plantar aspect of the bones; carrying the instrument downwards, a sufficient flap is formed to cover the stump, or a semicircular flap may be made and reflected by cutting from without inwards. The integuments on the dorsum are then divided in the line of articula- tion, the joints divided successively, and the parts removed. The flap is raised, adjusted, and retained. In dividing the articulations, it is to be recollected, that the base of the second metatarsal bone, reckoning from that of the great toe, is lodged considerably higher than the others; and, therefore, the knife must be inclined upwards at that point, or else the use of the saw is requisite. The stump thus formed proves exceedingly useful : the subsequent lameness is not great; the heel and tarsus compose a very efficient support for the weight of the body, and the flexion is unimpaired ; by attention, too, the deformity may be in a great measure concealed. In short, the surgeon who amputates above the ankle, for disease or injury not extending to the articulation of the metatarsus with the tarsus, is guilty of a serious error. The disease may reach higher than is compatible with the preced- ing operation, and yet it may be possible to save the heel. In such cases amputation is performed in the articulations of the os calcis with the os cuboides, and of the astragalus with the os naviculare. The plan of the incisions is the same as that for the operation at the bases of the metatarsal bones. No amputation is more frequently performed than that of the leg. Operation near the ankle is inadmissible ; sufficiency of soft parts, for the protection of the stump, cannot be procured lower than the calf. Incision is completely limited to two points, either immediately below the tuberosity of the tibia, or in the bellies of the gastrocnemii. The former is the situation to be preferred in hospital practice, and amongst the lower orders generally ; the latter is suitable to the better classes of society, that is, to those who can afford to purchase an expensive artificial support. The amputation below the tibial tuberosity being the most frequently required, will with propriety, be described first. Suppose the right leg is to suffer : — The opera- tor places himself on its inner side, according to the general rule formerly iuculcated, and grasps the lower part of the limb with his left hand, an assistant supporting the foot at a proper height, and controlling motion. The knife is entered over the fibula, on its outer aspect, and carried upwards along that bone for an inch and a half, or two inches ; it is then brought across the limb in a semilunar direc- tion, the convexity of this incision pointing towards the foot, and after reaching the inner and lower part of the tibia transfixion is performed, the instrument being pushed along the posterior surface AMPUTATION OF THE LEG. 653 of the bones, and made to emerge at the upper part of the fibular incision. By then carrying the knife downwards, a posterior and larger flap is formed sufficient to cover the stump. All this is effected by uninterrupted sweeps of the knife, that is, without ever removing the point or edge from the track of incision. The integuments on the fore part are then dissected upwards a little, by a few touches of the knife, so as to form a small semilunar flap ; at this part of the operation there is no necessity for laying down the knife and using a bistoury. The muscles in the interosseous space are then com- pletely divided, and the knife swept round the bones to detach the soft parts still uncut. The saw is applied, either in a horizontal or perpendicular direction ; I prefer the latter for reasons already as- signed. The vessels are secured, and there are generally but three — the popliteal, and two sural. I now generally aim at cutting the vessel before it divides, and seldom fail in doing so. There is then possibly the popliteal only requiring ligature, and there is less chance of secondary hemorrhage. This has occurred, so as to prove fatal at a considerable period after the operation, in consequence of the posterior tibia being cut close to its origin, and no clot having formed in it. Before adjusting the flap, it is well to assist nature in round- ing off the end of the tibia, and thereby prevent danger to the in- tegument ; with this view the sharp anterior ridge of the bone is cut away and rounded off by means of the pliers. This must be done sparingly if at all, and with great caution. The nipped surface is liable to exfoliation, or the medullary web is apt to be injured, and this is inevitably followed by more or less death of bone. To some the fibular incision may appear unnecessary; but I have long prac- tised it from conviction of its advantage. It is an excellent mark for transfixion, and assists greatly in preventing entanglement of the knife betwixt the two bones ; besides the soft parts in this situation must be divided at one or other step of the operation, and hence the procedure cannot be objected to on the ground of causing un- necessary wound. In operating on the left limb, there is not the same danger in transfixion, and consequently so long a preliminary incision on the inside is not requisite ; in other respects the steps of the operation are the same as for removal of the right. In muscular subjects two semilunar flaps had better be made, one from the ante- rior aspect of the limb, the other from the posterior, the muscles being cut short in the ham, and the incision made to reach the pop- liteal artery. It has been proposed to excise the head of the fibula after forma- tion of the flap, instead of sawing it across at a corresponding point with the tibia. At one time I put this modification into extensive practice, with the effect of improving the appearance of the stump very considerably ; but in several cases, untoward consequences took place. Discharge of synovia occurred on the second day, fol- lowed by very profuse suppuration, which proved of long continu- ance, and very exhausting ; in more than one case, the joint became anchylosed, rendering the stump very inefficient as a means of sup-i port, in consequence of being fixed at an inconvenient angle ; and one patient sank, exhausted by the profusion of the discharge. I 55* 654 AMPUTATION OF THE LEG. then^found, from repeated examination of the parts on the dead sub- ject, that it was very difficult, nay impossible, to excise the head of the bone without dividing the capsular ligament, and wounding the synovial pouch, or opening a bursal cavity, beneath the popliteus muscle, communicating with that of the knee-joint. It is scarcely necessary to add, I have since wholly abandoned this method of operation. It has been already observed that high amputation of the leg is preferable amongst the working classes. The limb is of much greater use to the patient than were the stump longer; he is able to follow his occupation with greater ease and security, and at less expense, by resting on the knee, than by using the artificial limb applied to the middle of the leg. The wealthier patient, however, can afford a more expensive support, and a less efficient, though more handsome continuance of the limb suffices. In such circum- stances, amputation is performed at the middle of the leg; after cicatrisation, the artist supplies an artificial support resembling the natural limb; and thus the motion of the knee is preserved. The same directions apply to this operation as to that immediately below the knee. In amputation of the thigh, the same method of incision is fol- lowed as in amputation of the arm. But, according to the point of removal, the direction of the flaps varies. If in operating high in the limb the flaps be made laterally, there will be imminent risk of the bone protruding through the upper part of the wound; for the patient uniformly raises the stump towards his abdomen. No anta- gonist muscular power is left to oppose the action of the muscles in- serted into the trochanter minor, and the elevation of the stump is involuntary : it always occurs to a remarkable extent in young per- sons. On this account, anterior and posterior flaps are here far preferable to the lateral; for then the more the stump is raised, the better is the end of the bone covered—the anterior flap folds over it. Transfixion is therefore made horizontally; and the posterior flap should be a little longer than the anterior. But in the lower part of the limb, lateral flaps are not only not liable to the same objection, but preferable to the anterior and posterior. In the neigh- bourhood of the knee-joint, the softs parts consist almost entirely of ligamentous tissue on the fore and back part, and proper cushions can be obtained only from the sides. Transfixion is therefore made perpendicularly. Thus the bone wull be w-ell covered by parts likely soon to adhere ; and there is no risk of protrusion, for mus- cles are left to counteract the elevators, and there is sufficient lever in the limb whereby to control its motions. And it may be here mentioned, that after all amputations, when startings of the mus- cles are not only painful, but disturb the position of the stump, the limb should be bound down by a broad band, passed across it a short w-ay above the wound, and fastened firmly at each end to the bed or pillow ; at the same time anodynes are to be adminis- tered. I have long since come to the conclusion that the femur in amputation should not be sawn lower than its middle ; the me- thod by anterior and posterior flap is therefore the only one appli- cable. AMPUTATION OF THE HIP-JOINT. 655 Amputation at the hip-joint is deservedly ranked amongst the most formidable operations in surgery. It ought, therefore, never to be performed but as a last and necessitous resource for the salvation of life. At the same time, when necessity for it is obvious and ac- knowledged, and no other means can be of any avail, hesitation and delay should never take place ; otherwise the last and only chance of saving the patient will pass away, and the operation, when at length performed, will but hasten his exit from this world, — and besides inflict an injury to science, by intimidating practitioners, and affording subject of reproach and ridicule to the thoughtless and un- informed part of the public. I prefer the formation of anterior and posterior flaps, — as follows ; — The patient is placed recumbent on a firm table, his nates resting on, or rather projecting a little over, the front edge. The sound limb is separated from the one to be re- moved, and held aside by an assistant. Or it is secured to the foot of the table by a towel, the necessity for an additional assistant being thus done away with, and more freedom in his movements afforded to the operator. Indeed, in all amputations of the lower extremity, this is the preferable method of fixing the sound limb. The other limb is supported by an experienced and intelligent assistant, who understands, and is able to perform the movements to facilitate the different steps of the operation. The compression is intrusted also, to an experienced and steady assistant, who, standing by the patient's side, presses firmly with one or both thumbs on the femoral artery, where it passes over the pubes ; and in this more than in any other operation should the pressure be delayed till the instant of incision, for otherwise the blood lost in the limb will be immense. Trans- fixion, by a knife proportioned in size to the dimensions of the limb, is made horizontally, the instrument being passed in a somewhat semi- circular direction, so as to include as much of the soft parts as possi- ble ; an anterior flap is made by cutting downwards. During the passage of the knife across the joint, the assistant rotates the limb a little, so as to facilitate the bringing of the instrument out with its point well inwards ; in the left limb the rotation will be inwards, in the right, outwards. After formation of the flap, the assistant abducts forcibly, and presses downwards ; the joint is opened, the round liga- ment cut, the capsule divided, and the blade of the knife placed be- hind the head of the bone and the large trochanter ; the posterior flap is then made rapidly. After transfixion for the superior flap, and when the sawing motion downwards has advanced but a little way, the compressing assistant shifts one of his hands into the incision, im- mediately behind the back of the knife, and so obtains a firm grasp of the femoral artery previously to its division. He retains this hold, at the same time retracting the flap, during the rest of the operation. As soon as the limb has been separated, the surgeon secures the ves- sels on the posterior flap, partly by his fingers, partly by compression with a large sponge, and ligatures are applied as quickly as possible. The femoral is secured last; for, as long as the assistant retains his hold hemorrhage from it is not to be dreaded. Thus, when both sur- geon and an assistant are quick and cool, the operation may be com- pleted with the loss of much less blood than might be expected. I 656 EXCISION OF DISEASED BONES. have had occasion more than once to perform this operation, and thus speak from experience. In cases of accidental injury requiring this operation, the lever use of the limb must frequenty be wanting ; and in such cases, too, the parts may be so injured as not to afford flaps anteriorly and posteriorly. In these circumstances, the surgeon must be guided by experience and judgment in adopting the mode of procedure which appears most applicable ; in ordinary cases the ope- ration above detailed appears the preferable. Excision of diseased portions of bones, is practised occasionally with the view of removing a source of irritation and exhaustion from the system, without sacrifice of a limb. When the operation proves successful, the benificial effect on the general health is as remarkable and rapid as after removal of the hectic cause by amputation ; the pulse falls and grows firmer, diarrhoea and sweating cease, the hectic flush leaves the cheek; in short, the constitution makes a com- plete and successful rally. It is had recourse to in order to take away disease in the following situations, — in the cancellated articu- lating extremity of a long bone, in part or the whole of a short bone, and in part or the whole of long bones. Even a long bone, from one articulating surface to the other, may be removed ; the metacar- pal bone of the thumb, and the metatarsal bone supporting the great toe, may, for example be taken away in their whole extent. I have seen these bones so treated, but the result was unsatisfactory. As has already been observed, the part of the member that is left is without support, and not under the influence of muscle; it is conse- quently loose and useless. Operation for the removal of necrosed, or softened and ulcerated portions of the carpal and tarsal bones, is sometimes successful. But operative interference, either with these, or with more extensive and formidable articulations, is not advisable unless the soft parts are not largely involved, and when the general health is tolerably good — the patient either having suffered less than usual, or having rallied and begun to gain strength after exhaustion by discharge and fever. If the ligaments, bursse, and cellular tissue are much affected, as is often the case, there is no chance of discharge ceasing, and the pa- tient regaining health, even though the bone be removed to any ex- tent— a second operation will be required, namely amputation above the diseased parts. And when this becomes requisite, after failure of the first to restore or even improve the health, the patient is apt, as has too often been the case to sink under the accumulation of suffer- ing. He might, even though much exhausted, have been able to bear up against the shock of one and a successful operation, but he cannot endure that of a second, or perhaps third, serious and pro- tracted attack of the knivesman. The disappointed hope of a cure from the first operation is a secondary, though nevertheless a sure contributor towards the unfortunate issue. No particular rules can be laid down for the operative procedure. By converting two or more natural openings into one, extending the iacisions as much as possible in the direction of the limb and of the muscles and tendons, and avoiding the course of the larger EXCISION OF DISEASED BONES. 657 blood-vessels and nerves, room is made for an accurate examination of the diseased parts. A strong and firmly pointed knife is required for these incisions, for the soft parts are much consolidated, and are cut with difficulty. The extent of disease is ascertained both by the probe and by the finger, and farther measures, if necessary, are then adopted for complete removal. Loose portions of bone are taken away; and often large sequestra of the cancellated tissue are found lying in the cavity, either loose or easily separable ; for ex- traction, forceps and the fingers, and sometimes a lever, are required. A firm scoop is useful for removing such portions of diseased can- cellated tissue as are still continuous with the shaft of the bone. When an opening in the cancellated tissue, leading to an internal sequestrum is minute, enlargement is effected by means of either the trephine or the cutting pliers: afterwards, gouges, gravers, &c, may sometimes be useful in operating on the soft texture under- neath,— but they are seldom requisite. The bleeding from the soft parts is free ; the vessels do not retract, and may require the application of a needle and ligature. That from the bone is easily arrested by pressure : the cavity is filled with charpie or with dos- sils of lint, and these are supported by a bandage. Some days after, this dressing is removed, having been previously softened and loosened by fomentation and poultice. The cavity should now be examined carefully, to ascertain whether or not all the diseased parts have been taken away ; it is then dressed daily from the bot- tom. If parts of the surface assume an unhealthy aspect, the gra- nulations being either backward or flabby, to these escharotics should be applied — the most suitable is the red oxide of mercury. Gradually the cavity fills up, and a depressed, firm, and permanent cicatrix is obtained. It need not excite surprise, however, if, in not a few cases, after matters have proceeded apparently very favoura- bly for some time, the surface become pale, soft, and glistening ; the discharge thin, acrid, and profuse ; the integuments around tumid and discoloured, — if, in short, the disease be in no long time fully reestablished. The tarsal and carpal bones are often the subjects of this opera- tion. In a few cases I have removed several, in others one or a portion of one, with success. In one instance the greater part of the astragalus was taken away, along with the ends of the tibia and fibula. There remained, in consequence, a large opening across the joint, through which a cord was passed, to facilitate gradual and piecemeal discharge of remaining portions of diseased bone. The articulation could actually be seen through. The seton was gradually diminished and the aperture closed. The foot was thus preserved, and the leg was but little shortened ; the limb proved strong and extremely useful, but the ankle-joint retained little or no power of motion. I have also again and again trephined the os calcis, and removed large portions of it; the cuboid likewise has been taken away, along with the base of the metatarsal bone or bones in connection with it; in some of these cases an excellent cure followed, in others amputation of the foot was afterwards ne- cessary. 658 EXCISION OF DISEASED BONES. Some have ventured to cut away the articulating ends of the bones composing the knee-joint. This may be accomplshed with- out much difficulty. The patella is either removed entirely or turned to a side, the ligamentous and tendinous attachments are divided, and the ends of the bones thus [exposed, by cutting close to and towards them, little risk is incurred of wounding the blood- vessels and nerves in the popliteal space. The saw is readily ap- plied in a horizontal direction. After tying the vessels, and ap- proximating the edges of the wound, the limb is placed in the straight position, and retained fixedly so by the application of splints. Much constitutional disturbance is to be expected, as well as profuse and 'tedious suppuration. There are few surgeons so rash as to have recourse to this operation. One or two patients, it is true, have lived in spite of it, retaining the limb in a tolerably useful state. But in others, — and these constitute the majority, — amputation was after all required, and that proved insufficient to save the pa- tient. In short, the results of excision of the knee-joint do not jus- tify its repetition. The articulating ends of the bones composing the shoulder-joint have been removed ; and this may be done with advantage, on account either of disease or of injury. This joint is, like others, liable to ulceration of the cartitages, either primary, or in conse- quence of abscess and degeneration of the soft parts around. The disease is attended usually with painful feelings increased by mo- tion, and the patient is indisposed to attempt motion. Sometimes merely weakness of the limb is complained of, and the attention is drawn to the wasted appearance of the muscles particularly of the upper arm ; the deltoid seems shrunk almost to nothing. The mo- tions above the shoulder are lost; and abduction is impracticable. Much pain is produced by pushing sharply the articulating sur- faces into contact, and is further increased by rotation. The en- forcement of strict and absolute rest of the joint, the establishment of a drain in the soft parts immediately neighbouring, and atten- tion to the general health, often prove sufficient to arrest the pro- gress of this disease. If, however, it is neglected, abscess forms sooner or later. On cutting into this, and introducing the finger, the joint is discovered to be open ; the head of the bone is found detached from the soft parts, and unsupported. Or this state of parts may be ascertained to exist by examination through a sinus, either with a probe, or with the finger after dilatation. In these circumstances, an attempt may be made to check disease, andr pre- serve the arm, by excision of the obnoxious parts of the bone. And this kind of operation is also justifiable when the head of the humerus has been shattered by musket-shot; or when it has been exposed and injured by a splinter, or by a large shot, and the joint laid open. The situation and course of the incisions will be so far regulated by the openings or wounds already existing. They should always be made in the direction of the fibres of the deltoid and the posterior aspect of the articulation is preferable to the ante- rior. One incision, from the back of the acromion process to near the insertion of the muscle, is sufficient to expose the head of the INDEX. Abdomek, affections of, 416 injuries, 451, 461 Abscess, 31 lumbar, 462 Adhesion, 25 Albugo, 269 Amaurosis, 280 Amputation, 635 arm, 647 fingers, 643 foot, 652 forearm, 645 hip-joint, 655 leg, 652 shoulder-joint, 649 thigh, 654 Anchylosis, 75 Aneurism, 121, 124 by anastomosis, 131 popliteal, 129, 563 axillary, 394 osseous, 163 Aneurismal varix, thigh, 564 Anthrax, 64 Antrum maxillare, inflammation of, Anus, pruritus, 479 artificial, 438 Arterial system, diseases, 119, 124 Articular cartilages, atrophy and hypi trophy, 76 Artificial anus, 438, 446 Artificial pupil, 292 Ascites, 447 Axillary aneurism, 394 Bladder, inflammation of, 489 irritable, 490 Blenorrhcea, 253 Bone, diseases, 97 fractures, 575 Brasdor's operation, 130 Bronchocele, 382 Bruise, 634 Bubo, 204 Bubonocele, 420 Bunnion, 566 i^Burns, 414 56 Bursse, diseases of, 82 inflammation of, 565 Calculus, in the female, 552 salivary, 340 vesicae, 530 Carbuncle, 64 Carcinomatous tumours, 146 Caries, 99 Castration, 529 Cataract, 282, 283, 285 Chancre, 204 Chemosis, 264 Chest affections, see Thorax. Chimney-sweeper's Cancer, 517 Choroiditis, 279 Cirsocele, 421 Club-foot, 569 Compression, 231 Concretions, salivary ducts, 340 Concussion, 223 Congestion, 23 Corectomia,292 Corneitis, 266 2 Corodialysis, 293 Corotomia, 292 Coxalgia, 83 Croup, 359 •- Cynanche trachealis, 359 Deafness, 380 Delitescence, 26 Dislocations, 612 ankle, 629 carpus, 622 clavicle, 614 elbow-joint, 619 fingers, 622 hip-joint, 623 congenital luxation, 627 lower-jaw, 614 pattella, 628 radius, 620 shoulder-joint, 615 tarsus, 629 wrist-joint, 621 Distortion of the feet, 567 660 EXCISION OF JOINTS. am sorry to add, that all which has been written on it is not deserv- ing of unreserved belief. Many patients have, after long and severe suffering, preserved the arm to little purpose ; others have been ne- cessitated to submit to another operation — amputation after all; some have died after the first, others after the second mutilation. The operation is attended with no difficulty in execution, and this in some measures accounts for its frequent, and it is to be suspected, indiscriminate performance of late years. The incisions are made on the posterior aspect of the joint. One is placed in the mesial line, extending from about two inches above the olecranon to the same distance below it; and from this flaps are raised, by making either a cross-cut in the middle, or one at each extremity-; in the one case the flaps are four, and triangular; in other two, and quad- rangular; by either method the bones are readily exposed. A more simple form of incision, as described in the Practical Surgery, will often be found to suffice. The joint is opened and dislocated, and the soft parts separated to the necessary extent from the bones. The ulnar nerve is avoided by dissecting close to the bone. The dis- eased portions are then sawn off. The wound is closed, and the arm kept bent. This operation I have performed pretty often, the cases being carefully chosen for it, and the success has been highly satis- factory. By the sanguine supporters of this operation, the after-treat- ment is advised to be conducted so as to secure motion in the new articulation. From this I would dissent, for if the articulating ends of the bones have been' actually cut off, the motion may be exten- sive enough certainly, but both joint and limb will be almost alto- gether impotent. It would be better to procure anchylosis in the bent position, than to have the arm dangling like a flail; in the one case the limb will be useful ; in the other, ornament, and that too of an equivocal kind, is all that it can boast. Even anchylosis, in most cases can be brought about only after a lapse of a long period. In the more severe affections of this joint, amputation of the limb is the operation which must ultimately be had recourse to, if the patient survive ; and it is better to perform this at once, than after the experiment of excision has been tried and found wanting. I know that parents have too often had to regret and mourn bitterly their having departed from sound advice, and lent themselves to such experimental trials on their offspring. IN Abdomen, affections of, 416 injuries, 451, 461 Abscess, 31 lumbar, 462 Adhesion, 25 Albugo, 269 Amaurosis, 280 Amputation, 635 arm, 647 fingers, 643 foot, 652 forearm, 645 hip-joint, 655 leg, 652 shoulder-joint, 649 thigh, 654 Anchylosis, 75 Aneurism, 121, 124 by anastomosis, 131 popliteal, 129, 563 axillary, 394 osseous, 163 Aneurismal varix, thigh, 564 Anthrax, 64 Antrum maxillare, inflammation of, 3 Anus, pruritus, 479 artificial, 438 Arterial system, diseases, 119, 124 Articular cartilages, atrophy and hypi trophy, 76 Artificial anus, 438, 446 Artificial pupil, 292 Ascites, 447 Axillary aneurism, 394 Bladder, inflammation of, 489 irritable, 490 Blenorrhoea, 253 Bone, diseases, 97 fractures, 575 Brasdor's operation, 130 Bronchocele, 382 Bruise, 634 Bubo, 204 Bubonocele, 420 Bunnion, 566 /Burns, 414 56 EX. Bursse, diseases of, 82 inflammation of, 565 Calculus, in the female, 552 salivary, 340 vesicae, 530 Carbuncle, 64 Carcinomatous tumours, 146 Caries, 99 Castration, 529 Cataract, 282, 283, 285 Chancre, 204 Chemosis, 264 Chest affections, see Thorax. Chimney-sweeper's Cancer, 517 Choroiditis, 279 Cirsocele, 421 Club-foot, 569 Compression, 231 Concretions, salivary ducts, 340 Concussion, 223 Congestion, 23 Corectomia,292 Corneitis, 266 2 Corodialysis, 293 Corotomia, 292 Coxalgia, 83 Croup, 359 - Cynanche trachealis, 359 Deafness, 380 Delitescence, 26 Dislocations, 612 ankle, 629 carpus, 622 clavicle, 614 elbow-joint, 619 fingers, 622 hip-joint, 623 congenital luxation, 627 lower-jaw, 614 pattella, 628 radius, 620 shoulder-joint, 615 tarsus, 629 wrist-joint, 621 Distortion of the feet, 567 662 INHKX. Distortion of the varus, 569 valgus, 570 pes equinus, 570 calcaneal, 571 Ear, diseases of, 378 foreign bodies in, 379 polypus, 380 Eburnation, 76, 115 Ectropion, 258 Eczema rubrum, 214 Emprosthotonos, 186 Empyema, 414 Encanthis, 256 Encysted tumours, 155, 341, 413 of eyelids, 257 of the breast, 413 Enterocele, 419 Entero-epiplocele, 419 Entropion, 260 Epiphora, 252 Epiplocele, 419 Epispadias, 517 Erethismus, 214 Erysipelas, common, 54 hospital, 57 phlegmonous, 56 Erythema, 55 Excision, diseased bone, 656 of joints, 659 Exomphalos, 419 Exophthalmia, 271 Exostosis, 156 of distal phalanx, 574 Eye, diseases, 249 Fever, hectic, 42 inflammatory, 19 irritative, 42 Fistula lachrymalis, 252 in ano, 469, 470 in perineo, 492 Fractures, 575 clavicle, 587 cranium, 232, 581 compound, 576, 579 disunited, 609 face, 581 femur, 595 humerus, 592 metacarpal bones, 596 olecranon, 594 patella, 604 pelvis, 597 phalanges, 596 radius, 595 ribs, 589 scapula, 588 shoulder, 590 simple, 576 spinal column, 583 sternum, 590 tarsus, 607 Fractures of the tibia and fibula, 60? ulna, 595 Fraenum linguae, division of, 339 Fragilitas ossium, 112 Fungus hsematodes, 151 Furunculus, 64 Ganglia, 406 Gangrene, 43 Genital organs, affections of, 481 Glaucoma, 282 Gonorrhoea, common, 482 in females, 553 praeputialis vel spuria, 512 Gonorrhceal lichen, 554 Gums, inflammation, 342 tumours, 341 Gunshot wounds, 184 Hare-lip, 327 Haematocele, 525 Hemorrhage, 132, 171 Hemorrhoids, 465 distinct varieties, 465 Hectic fever, 42 Hernia, 417 of the iris, 269 cerebri, 238 congenital exomphalos, 419 scrotal, 418 crural, or femoral, 420 infantilis, 418 inguinal, direct, 419 oblique, 419 scrotal, 419 umbilical, 434 humoralis, 487 Hospital gangrene, 194 Humeral artery, 399 Hydatic tumours, 164 Hydrocele, 421 of the neck, 385 Hydrops articuli, 69 Hydrophthalmia, 271 Hydrothorax, 414 Hypopium, 278 Hypospadias, 517 Incontinence of urine in females, 509 Inflammation, 13 Injuries of the head, 220 Iritis, 277 Irritation, 20 Irritative fever, 42 Joints, diseases of, 69 growths from synovial membranes, 80 hip-joint disease, 83, S3 loose cartilages, 81 neuralgic affections, 79 scrofulous disease, 78 INDEX. 663 Keratonyxis, 289 Larynx, foreign bodies in, 367 ulceration, 365 Laryngitis, 359 Leucoma, 269 Leucorrhcea, 553 Ligature of arteries, 125 axillary, 397 brachial, 397 carotid, 389 femoial, 163, 563 humeral, 399 iliac, 561 of innominata, 391 subclavian, 392, 396 Lips, congenital deficiencies, 327 ulcers, 324 Lithotomy, 541 Lithotrity, 539 Lower jaw, osteosarcoma, 348 spina ventosa, 346 Lumbar abscess, 462 Lupus, 315 Luxations, see Dislocations. Malignant pustule, 197 polypi, 308 Mamma, diseases, 410 encysted tumours, 413 Melanosis, 145 Metastasis, 26 Mollities ossium, 113 Morbus coxarius, 83 Mortification, 43 Mucous membranes, inflammation, 66 Myocephalon, 269 Nasal polypi, 306 naevi, 131, 134 Nebula, 269 Necrosis, 106 Neuralgia of the rectum, 480 Neck, hydrocele, 385 distortion, 386 Noli me tangere, 315 Nose, diseases, 313 CEdema glottidis, 362 CEsophagus, foreign bodies, 375 stricture, 374 CEsophagotomy, 377 Onychia, 403 Opisthotonos, 186 Ophthalmia, 262 neonatorum, 265 purulent, 264 tarsi, 270 Osseous aneurism, 163 Osteosarcoma, 158 Otitis, 278 Ovarian dropsy, 448 Ozoena, 315 Palate, congenital deficiencies, 327 ulcers, 334 Paracentesis abdominis, 447 Paraphymosis, 513 Paronychia, 400 Periostitis, 97 Pes equinus, 570 Phagaedena, sloughing, 194 Pharyngitis, 372 Phlebitis, 134 Phlegmonous erysipelas, 56 Phthisis laryngea, 364 Phymosis, 513 Piles, 465 Polypus, 154 nasal, 306 ear, 380 Prolapsus ani, 473 Pruritius of the anus, 479 Pterygium, 261 Puncture of the bladder, 508 Pus, 29 Pustule, malignant, 197 Rachitis, 113, 116 Ranula, 339 Rectum, affections, 465 inflammation, 467 schirro-contracted, 472 neuralgia, 480 Resolution, 25 Retention of urine, 498 in females, 555 Rhinoplastic operations, 317 Rickete, 113 Sarcocele, 527 Scalds, 214 Scrofula, 34 Serous membranes, inflammation, 67 Sinus, 40 Sphacelus, 43 Spina bifida, 464 Spina ventosa, 160 Sprain, 630 Strabismus, 297 Staphyloma, 270 Stillicidium lachrymarum, 252 Stricture of the oesophagus, 374 rectum, 471 urethra, 490 Struma, 34 Subclavian artery, 392, 396 Suppuration, 29 Sympathies, 19 Syphilis, 199 tertiary, 206, 212 Teeth, caries, 343 extraction, 345 Testis, inflammation of, 487 Tetanus, 186 Tertiary syphilis, 206, 212 664 INDEX. Thecse, collections of fluid in, 405 Thorax, affections of, 414 Thrombus, 409 Tongue, inflammation of, 337 ulcers, 336 Tonsils, abscess of, 330 enlargement, 333 inflammation of, 331 Trachea, foreign bodies in, 360 stricture, 374 Tracheotomy, 368 Trichiasis, 260 Trismus, 186 Tubercle, painful, 153 Tumours, 138 adipose, 141 of the antrum, 312 of bones, 156 carcinomatous, 144 encephaloid, 143 encysted, 155, 340, 413 fibrous, 142 melanoid, 145 aneurismal, 161 osseous, 162 hydatic, 164 in the neck, 384 in the orbit, 295 painful tubercle, 153 of the scalp, 248 Tympanum, puncture of, 381 Ulcers, 189 of the genital organs, 198 indolent, 191 irritable, 193 Ulcers of lips, 324 Urethra, stricture of, 490 Urinary organs, affections of, 481 Urinary calculi, 530 Uterus, affections of, 560 Uvula, elongation of, 332 Vagina, affections of, 558 Valgus, 570 Varicose aneurism, 398 , veins, 136 Varix, aneurismal, 398 of thigh, 564 Varus, 569 Vein, external jugular of, 389 Veins, inflammation of, 134 Venesection, bend of the arm, 408 jugular vein, 389 Vertebral column, diseases of, ^63 Vesico-vaginal fistula, 556 Whitlow, 400 Wounds, 167 by stings of insects, 181,182 of the brain, 237 bruised and lacerated, 178 of the face and neck, 352 gunshot, 183 of the palmar arches, 399 poisoned, 180 punctured, 174 of the scalp, 220 of the temporal artery, 221 of the intestine, 452 Wry neck, 387 END. 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It is done up in a strong paper cover, and each work labelled on the < back; thus obviating the immediate necessity of binding. ; In addition to the above, the Subscribers will receive the Bulletin of Medical < Science, a monthly Journal — Terms, $5 per annum, in advance. Subscribers must notify their intention to discontinue before the close of any one i < year. 1 " Our profession is under many obligations to Dr. Bell, of Philadelphia, whose < judgment, independence, and learning fit him very eminently for the editorial tripod, ! ' which he has occupied for many years. As a critic his decisions are entitled to hi«h | | respect, and the works which have been re-published by his directions have been I A stamped with so much excellence, that it is a sufficient passport to public favour that A J'\ a volume has appeared in the Select JMtdkul Library."—Western Journal of Medicine I'M p) and Surgery. Q f\ " This is another reprint (Nunneley on Erysipelas) in the Select Medical Library, I) My edited by John Bell, M.D. On a previous occasion, we drew attention to the singu- '; \y larly happy exercise of judgment displayed, at all times, by this learned brother in \j V his selections of works for the profession on this sideofthe Atlantic, and this opinion V , has, in the interim, been still more decidedly confirmed. So judicious has Dr. B. S been in all these decisions, that we are warranted in saying, from no little knowledge ; on the subject, that the simple fact, that a volume has appeared in I)is ' Library,' ! ! secures it a character for excellence, which could not be more than attained by a \ ! simultaneous review in its favour by all the medical journals in the country."__N. Y. ( Journ.of.Ucd. and Collat. Sciences. They also publish, by the same editor, The Bulletin of Medical Science is published monthly, in numbers of thirtv-six pages. It is supplied to the Subscribers to the Select Medical Library without any addi- tional cost, on their remitting^ce dollars, the subscription price of the Library for one year. Those who wish to take the Bulletin alone, will have it sent to their address for $1 per annum, payable in advance. Clubs will be furnished with six copies of the Bulletin for $5. Any gentleman ordering or purchasing works published by the subscribers to the amount of $10, will be entitled to a copy for one year, gratis. %* Catalogues of Barrington & Haswell's Publications sent to any part of the United States, gratis, if B. & II. are furnished with the Post-office direction of those desiring them. ;Ci MEDICAL PUBLICATIONS. ANATOMY. Professor Samuel D. Gross, M.D. NEW EDITION ELEMENTS OF PATHOLOGICAL ANATOMY. By Prof. SAMUEL D. GROSS, M.D., Professor of Surgery in the Louisville Medical Institute, Ky. Late Professor of General Anatomy, Physiology, and Pathological Anatomy in the Medical Department of the Cincinnati College. Illustrated by 50 Coloured Plate figures, and 250 Engravings on Wood by the first artists. 1 super-royal 8vo. vol., extra sheep. " It is a noble volume, both by its intrinsic merits, its pictorial illlustrations, and the entire mechanical execution."—Bull, of Med. Science. '■That it will henceforth be regarded as a standard work, and introduced into the library of every physician of the interior who aims either to educate his pupils thoroughly, or keep himself informed on the improvements of this essential branch of medical and surgical I science, we cannot doubt."—West. Journ. of Med and Surg. j\ " This second edition is from the press of Barrington and Haswell, in a mammoth 8vo. of 822 /'\ pages illustrated by very accurate and very elegant drawings, some of which are colored to vie *, \X:> with nature in delicacy of tints."—Bost. Med. and Surg. Journ. {S " We regard it as one of the most valuable works ever issued from the American press, and it H does great honor alike to the author, and the country of his birth."—N. Y. Journ. of Med. V lij " We have spoken in high terms of it because it possesses real and desirable excellencies."—Phil a. \il Med. Exam. u •' We can strongly recommend his ' Elements of Pathological Anatomy' to the attention of he J pathological inquirer."—Amer. Med. Lib. and Intel. DISSECTOR'S GUIDE. Edward J. Chaisty, M.D. THE LONDON DISSECTOR, OR 'GUIDE TO ANATOMY: jFoc t&e 2Esc of Stutrents. Comprising a Description of the Muscles, Vessels, JVerves, Lymphatics, and Viscera of the Human Body, as they appear on Dissection: With Directions for their Demonstration. By EDWARD J. CHAISTY, M.D. REVISED AND CORRECTED. 1 vol. 12mo. muslin. " Although there are several of these dissecting-room companions, there is not one in the whole catalogue that wears better, from its intrinsic value? than the old London Dissector. With the improvements of this excellent edition, carefully revised, it will prove a very economical as well as certain assistant; and it therefore commends itself to the student."—Boston Med. and Surg. Jour. B=- BARRINGTON &. HASWELL'S John Neill, M.D. OUTLINES OF THE ARTERIES, With short Descriptions : Designed for the Use of Medical Students. With Coloured Engravings. By JOHN NEILL, M.D., Demonstrator of Anatomy in the University of Pennsylvania; Physician to Wills's Hospital; Lecturer on Anatomy ; Member of the Philadelphia Medical Society, etc., etc. *** This beautiful little work is a perfect chart; where the artery and its name are seen side by side. " This book should be in the hand of every medical student: It is cheap, portable, and precisely the thing needed in studying an important, though difficult part of Anatomy "—Boston Med. and Surg. Journ. " " Its chief excellency, however, is its mode of reference, in which it differs from the usual method of numbering the different vessels, and referring to their numbers in the accompanying explanation."—Med. Exam. " The drawings ate very distinct and well coloured- The idea of this work was a happy one, and, we trust, for the benefit of students, that the author will extend it to the veins, nerves, &c"—Amer. Journ. of Med. Sciences. "As a help to the Medical Student, we can cheerfully recommend it-"— Western Lancet- Extract from a Letter of Prof. Webster, dated Geneva, Oct. 13*/t, 1845. "I have examined it, and think it a very useful work, so much so that I shall re- commend it to my class, and adopt the arrangement in my description of that system." " We recommend every Student of Medicine to purchase a copy of this work, as a labor-saving machine, admirably adapted to refresh the memory, with knowledge gained by lectures, dissections, and the reading of larger works."—X. Y. Jour. Med. " This work is from the pen of a Philadelphia anatomist, whose familiar knowledge of the subject has been aided by the press, the result of which is a volume of great beauty and excellence. Its fine execution commends it to the student of Anatomy. It requires no other recommendations."—West. Journ. of Med. and Surg. OUTLINES OF THE NERVES, With short Descriptions : Designed for the Use of .Medical Sltideiits. With Engravings. By JOHN NEILL, M.D., Demonstrator of Anatomy in the University of Pennsylvania ; Physician to Wills's Hospital; Lecturer on Anatomy; Member of the Philadelphia Medical Society, etc., etc. "This volume is as beautiful as it is useful, —one in which both author and pub- lishers have united their efforts for the especial bt.nefit of the student, to whom a more acceptable work could not be offered, for facilitating an adequate acquaintance with the elements of neurology. Like that on the arteries, it lias the distinctive recom- mendation of the names being affixed to the trunks and ramifications of the nerves, and in this way, of saving a deal of trouble and time, and of impressing them more firmly on the memory. "The engravings are in the best style, and the paper and type correspond ; and yet, notwithstanding these evidences of what might seem luxurious indulgence in tasteful decoration, the volume is sold at a price which would be thought extremely low for one made up in the commonest fashion, and with the crudest pencil sketches."—Bul- letin of Med. Sciences. " We would advise every student of Medicine to procure it, while studying this por- tion of anatomical structure."—N. Y. Journ. of Med. " Enabling the student to identify the individual nerves in almost any part of the body, without additional assistance."—Boston Med. and Surg. Journ. i&=— MEDICAL PUBLICATIONS. PHYSIOLOGY AUD HYGIENE. ANIMAL CECONOMY. John Hunter. OBSERVATIONS ON CERTAIN PARTS OF THE ANIMAL (ECONOMY, INCLUSIVE OF SEVERAL PAPERS FROX THE PHILOSOPHICAL TRANSACTIONS, ETC. Br JOHN HUNTER, F.R.S., Etc With Notes, by RICHARD OWEN, F.R.S. 1 vol. 8vo. sheep. CLIMATE. Sir James Clark ON THE SANATIVE INFLUENCE OF CLIMATE. 1 vol. 8vo. sheep. " It is unnecessary to gay anything of this work, as its value is too well known to the profession to require any fostering at this period. The present edition is greatly superior to its predecessors." — Western Lancet. " For amount of information, variety of details, and important instruction relative to the interest- ing subject to which it is devoted, we believe this work is unequalled. It has been reprinted in an elegant cheap form."—Gazette. PATHOLOGY Geo. Freckleton, M.D., OUTLINES OF GENERAL PATHOLOGY. By GEO. FRECKLETON, M.D. Fellow of the Royal College of Physicians, &c. John Hunter. A TREATISE ON THE BLOOD. INFLAMMATION, AND GUNSHOT WOUNDS. By JOHN HUNTER, F.R.S. With Notes, by James F. Palmer, Senior Surgeon to the St. George's and St. James's Dispensary, &c, &c. 1 vol. 8vo. sheep. 1* i&i BARRINGTON &. HASWELL'S Wm. Thomson, M.D. HISTORICAL NOTICES ON THE OCCURRENCE OF INFLAMMATORY AFFECTIONS OF THE INTERNAL ORGANS AFTER EXTERNAL INJURIES AND SURGICAL OPERATIONS. By WM. THOMSON, M.D., Etc James Macartney. A TREATISE ON INFLAMMATION. By JAMES MACARTNEY, F.R.S., F.L.S., Etc. F. Magendie, M.D. LECTURES ON THE BLOOD, AND ON THE CHANGES WHICH IT UNDERGOES DURING DISEASE. By F. MAGENDIE, M.D. M. Gihert. CHANGES OF THE BLOOD IN DISEASE. TRANSLATED FROM THE FRENCH OF M. GIBERT, By JOHN H. DIX, M.D., M.M.S.S. 1 vol. 8vo. half sheep. "The treatise of M. Gibert iselaborate, and exhibits a very good viewof the relations of the blood to the morbid conditions of the system."—Western Lancet. " This is one of the best treatises on the changes of the blood in disease. It has been elegantly translated from the French by Dr. Dix, of Boston, and is published for a mere trifle, by the enter- prising firm of Barrington & Haswell, of Philadelphia. It is a most valuable addition to a medical library."—W. Gazette. CONSTIPATION. John Burne, M.D. A TREATISE ON THE CAUSES AND CONSEQUENCE OF HABITUAL CONSTIPATION. By JOHN BURNE, M.D., Fellow of the Royal College of Physicians, Physician to the Westminster Hospital, etc. 1 vol. 8vo. muslin. «^Fo/S^meAnnrestine^ase^illustrativeofthiswork'lheauth°r is indebted to Dr. Williams, Dr. B™lie'Mr & Mcr Morgan, Mr. Taunton, Dr. Roots, Sir Astley Cooper, Sir Benjamin Brodie, Mr. Tupper, Mr. Bailer, Dr. Paris,Mr. Dendy, Dr. Hen. U. Thomson,"&.c.-Preface. -=m MEDICAL PUBLICATIONS. HYSTERIA. Thomas Laycock. AN ESSAY ON HYSTERIA. BEING AN ANALYSIS OF ITS IRREGULAR AND AGGRAVATED FORMS INCLUDING HYSTERICAL HEMORRHAGE AND HYSTERICAL ISCHURIA. With numerous Illustrative and Curious Cases. By THOMAS LAYCOCK, House Surgeon to the York County Hospital. 1 vol. 8vo. muslin. iETIOLOGY. Aretaeus ON THE CAUSES AND SIGNS OF ACUTE AND CHRONIC DISEASE. FROM THE GREEK, By T. F. REYNOLDS, M.B., F.L.S,, Etc. 1 vol. 8vo. sheep. " The correct detail of symptoms, the nervous style, the graphic delineation of disease, displayed in this author's work, the poetic and quaint fancies scattered throughout, give a certain value and interest, that may fairly excuse an attemDt to reinvest part of them in a vernacular garb." " We certainly have no hesitation in recommending this curious volume to the notice of our readers. Its price is a mere trifle."—New York Lancet. SEMEIOLOGY. Professor Schill. OUTLINES OF PATHOLOGICAL SEMEIOLOGY. TRANSLATES FROM THE GERMAN OF PROFESSOR SCHILL, With Copious Notes, By D. SPILLAN, M.D., A.M., Etc. 1 vol. 8vo sheep. " The si«*ns of disease exhibited by the principal tissues and organs, are treated of n a succinct and comprehensive manner, by Dr. Schill, and as a work of daily reference to assist in distinguishing diseases, it cannot he too highly commended."— Bait. Journ. " A n elegant and accurate translation of a very ingenious and instructive work. We do not know any other source from which we can so easily and profitably obtain all that is really useful in the sonieiol >"y of the ancients; and the erudite translator and editor has so very creditably supplied the deficiencies of the author's abrige of the labours of modern workers, in this most imporiant department of modern science, that we cau in good conscience commend the book as one of un- equivocal merit."—New York Lancet. BARRINGTON &, HASWELL'S MATERIA IVEZSDICA AND THBRAPSUTICS. John Bell, M.D. A PRACTICAL DICTIONARY OF MATERIA MEDICA : Including the Composition, Preparation and Uses of Medicines ; and a large number of Extemporaneous Formulas: together with important Toxicological Observations. ON THE BASIS OF BRANDE's DICTIONARY OF MATERIA MEDICA AND PRACTICAL PHARMACY. By JOHN BELL, M.D., Lecturer on Materia Medica and Therapeutics, &c, &c 1 vol. 8vo. sheep. "Dr. Brande's is an excellent work, and with the retrenchments, additions, and alterations of Dr. Bell, may be regarded as one of the most valuable works on the Materia Medica we now possess. It has an important advantage over many of the treatises on this subject, in giving a large number of prescriptions for the administration of the principal articles. This renders it especially valuable to the young practitioner." —Bait. Jour. James Johnstone, M.D. A THERAPEUTIC ARRANGEMENT AND SYLLABUS OF MATERIA MEDICA. By JAMES JOHNSTONE, M.D., Fellow of the College of Physicians,aud Physician to General Hospital, Birmingham. Small vol. 8vo. " This book cannot but be particularly useful to those who intend to lecture or write upon the Materia Medica; as well as to the students for whose particular use it is prepared "—Brit and For. Med. Rev. Henry Clutterbuck, M.D. LECTURES ON BLOODLETTING. By HENRY CLUTTERBUCK, M.D. 1 vol. 8vo. half sheep. A. Turnbull, M.D. THE MEDICAL PROPERTIES OF THE NATURAL ORDER RANUNCULACE*. ETC. By A. TURNBULL, M.D. MEDICAL PUBLICATIONS. THEORY AND PRACTICE OF MEDICINE. Bell and Stokes. jet n w n E) n i? e @ sr • LECTURES ON THE THEORY AND PRACTICE OF PHYSIC. By JOHN BELL, M.D. Lecturer on Materia Medica and Therapeutics ; Member of the College of Physicians, Philadelphia, and of the American Philosophical Society, etc., etc.; and WM. STOKES, M.D., Lecturer at the Medical School, Park Street, Dublin ; Physician to the Meath County Hospital, etc., etc. Third American Edition, much enlarged and improved. 2 vols. 8vo. sheep. f " Few Medical works issued from the American press, within the same period, have had more currency, or been more highly approved by the profession. This edition of the Lectures is marked by substantial improvements, which will enhance the value of the work to the practitioner. Dr. Bell is just the man to keep his book up to the present state of medical science, and his readers have the comfortable as- surance that they have before them all the light of recent discovery."—Western Journ. of Med. and Surg, " Dr. Bell has bestowed much industry on the present edition. He has supplied many marked deficiencies in the former." '' Those by our friend and fellow towns- man, to which we more particularly refer, exhibit much learning and research, judicious discrimination, and a thorough acquaintance with the diseases and practice of this country. More need not be said to entitle him to the thanks of the profession for his share in this publication."—Med. Examiner. " The first gentleman is known for his profound attainments, and the accuracy and ability which he brings to bear on all subjects on which the powers of his mind are exercised. The other, a resident of the city of Dublin, has rarely been excelled in writing on the practice of medicine. When the former editions were issued, a heartfelt pleasure was expressed at their appearance; and we have equal gratification in seeing that they were appreciated by the medical public — the evidence of which is certain, from the circumstance that this improved and enlarged edition is required to meet the demand. " These acceptable lectures are in two large, compactly-printed octavo volumes."— Boston Med. and Surg. Journ. " We cordially recommend such of our readers as have not yet supplied them- selves to procure a copy of the present edition of these lectures, for we feel confident that they will never regret the time as lost, that they may devote to their perusal. The work is gotten up in the usually neat and appropriate style of the enterprising publishers, and printed on good paper and clear type."—N. Y. Journal, of Medicine. " With such additions and improvements, we consider the work one of the best of its kind with which we are acquainted."—Maryland Med. cf Surg. Journ. " The work has now assumed the form of a quite complete system of medicine, equally valuable as a text-book to the student, and a book of reference to the practitioner." " We know of no book of the kind which we would more readily place in the hands of a student, or to which we would more readily refer the practitioner, for a hasty investigation of a subject."—NewEng. Quart. Jour. " Our favourable opinion has already been expressed, and we will only add, that our estimate of their excellence has been heightened by repeated examinations. For all the qualities which the student or practitioner can desire in a work for study and reference, these lectures may be safely recommended, as comprising as much as could be brought within their limits of sound opinion and judicious practice." — West. Jour. BARRINGTON & HASWELL'S Alex. D. Gait. M.D. PRACTICAL MEDICINE. Illustrated by Cases of the Most Important Diseases. Edited by JOHN M. GALT, M.D., From the Papers of ALEXANDER D. GALT, M.D. For many years an extensive practitioner in Williamsburg, Va. 1 handsome vol. 8vo. sheep. Charles J. B. Williams, M.D. PRINCIPLES OF MEDICINE: Comprehending General Pathology and Therapeutics* By CHARLES J. B. WILLIAMS, M.D., F.R.S. With numerous additional Notes, Explanatory and Critical, by the Editor of the Select Medical Library and Bulletin of Medical Science. 1 vol. 8vo. sheep. "We consider, in fact, that in producing it, Dr. Williams has still further enhanced his already high character with the profession and the public."—Med. Chir. Rev. " Tt is without a competitor in our language, and fills most successfully a decided gap in our medical literature."—Philad. Med. Exam. " We would advise no one to set himself down in practice unprovided with a copy. Even amrfng the old and experienced practitioners, we venture to say that there are few who will not benefit by a perusal of this work."—Brit, and For. Med. Rev. " The reader will derive greater pleasure, and more useful practical knowledge from this book than from any other treatise on the subject that we are acquainted with.''—Dub. Jour. or Med. Scien. "We would gladly see Dr. Williams's valuable book in the hands of every practitioner, satisfied as we are, that the cultivation of these branches, in addition to those more commonly studied, is the only method by which practical medicine can be severed from empiricism."—Western Lancet. "In consideration of the advances made in recent years in the multitudinous subjects com- prised in this branch of medicine, a special treatise must surely be quite acceptable; and this one, including the notes, more copious than usual, of the annotator, cannot fail to reward the reader both with pleasure and profit."—N. Y Jour, of Med. and the Collat. Sciences. Henry Holland, M.D. MEDICAL NOTES AND REFLECTIONS. By HENRY HOLLAND, M.D., F.R.S., Fellow of the Royal College of Physicians, and Physician Extraordinary to the Queen. MEDICAL PUBLICATIONS. William Heberden, M.D. COMMENTARIES ON THE HISTORY AND CURE OF DISEASES. By WILLIAM HEBERDEN, M.D. New and Handsome Edition, 1 vol. 8vo. "This medical classic composes the October No. of Bell's Select Medical Library, and will be welcomed by every reader-"—West. Journ. of Med. and Surg. " All who admire sound clinical knowledge; all who wish to obtain unadulterated facts collected at the bed-side, and untinctured with speculation or theory, will not fail to avail themselves of this masterly production of the renowned Heberden."—N. Y. Journ. of Med. Davidson and Hudson's ESSAYS ON THE i SOURCES AND MODE OF ACTION OF FEVER. A "The volume before us abounds in details of a highly instructive kind, and manifests a vigorous A\ and healthy tone of investigation, which, even in its indirect eflfects, cannot but be beneficially felt /' V\ by the American reader."—Bulletin of Med. Science. i I " Dr. Davidson evinces an intimate acquaintance with the subject which he treats, and embodies r\ in his essay a large amount of valuable matter. The subject is one of intrinsic interest, and will Al, well repay the student for the time and labour devoted to its examination."— Western Lancet. S. H. Dickson, M.D. ON DENGUE: HI'S mmS^f@3IS>'S'a IPAinH®ILi®@'2"p ^.ME) 'imEA.'EWmmSo By S. HENRY DICKSON, M.D., Professor of the Institutes and Practice of Medicine in the Medical College of S.C. 1 small vol. 8vo. muslin. John Macrobin, M.D. INTRODUCTION TO THE STUDY OF PRACTICAL MEDICINE : Being an Outline of the Leading Facts and Principles of the Science. J small vol. 8vo. half sheep. " Dr. Macrobin's work is largely made up of the principles of medicine, embracing the Patho- logy and etiology of disease, and may therefore be esteemed a nucleus around which the student may, with advantage, gather a more extended system."— Western Lancet, 11 BARRINGTON &. HASWELL'S ^-------_--------------.------------------------------------------------------------------------------------------------>■ INDIGESTION. Robert Dick, M.D. DERANGEMENTS, PRIMARY AND REFLEX, ©5? Tmm @m®^.i5ri ©if ns3i©iiiii,E©ifo By ROBERT DICK, M.D., Author of" A Treatise on Diet and Regimen." 1 vol. 8vo. sheep. " Tt is the fullest, most comprehensive, and decidedly the best account of derangements of the digestive organs that we have encountered. While it embraces all that is important or interesting to be found in the writings of other authors, it contains much original information, which the physician will find of great practical usefulness.'—Western and Southern Medical Recorder. " We recommend this volume most warmly to the attention of our readers."—London Lancet, No. 937. " This volume may, in fact, be denominated with no small degree of propriety an encyclopedia of dyspeptic disorders, and we unhesitatingly commend it, as the most useful and comprehensive treatise on this class of diseases with which we are ac- quainted."—N. Y. Lancet. " We have perused this work with pleasure and instruction. It is decidedly the best compilation in the English language on the extensive class of disorders and dis- eases comprehended under the term dyspepsi.i, united with a very large proportion of original matter, both in the form of able comments on other writers, and practical information derived from the author's own experience."—Med.-Chir. Rev. EPIDEMICS OF THE MIDDLE AGES. I. F. C. Hecker, M.D. EPIDEMICS OF THE MIDDLE AGES. From the German of I. F. C. HECKER, M.D., Translated by R. G. BAB1NGTON, M.D., F.R.S. NO I.--THE BLACK DEATH IN THE FOURTEENTH CENTURY. -'Hecker's account of the' Black Death,' which ravaged so large a portion of the globe in the fourteenth century, may be mentioned as a work worthy of our notice, both as containing many lnterestingrtetails of this tremendous pestilence, and as exhibiting a curious specimen of medical hypothesis."— Cyclopedia of Practical Medicine. NO- H.--THE DANCING MANIA. ''Medical History has long been in need of the chapter which this book supplies- and the &K0itaW^.n r<^e',ie(1 at a b,;,ter season' °n thK whole- thevolume ought to be popular; to the profession it must prove hidily acceptable, as convey ne so much infor- mation, touching an important subject which had almost been suffered to be buHed in oMi- yion, and we think that to Dr. Babineton especial thanks are due for having nXral"od'o MEDICAL PUBLICATIONS. A TETANUS. Thomas Blizard Curling. A TREATISE ON TETANUS. BEING THE ESSAY FOR WHICH THE JACKSONIAN PRIZE WAS AWARDED. By THOMAS BLIZARD CURLING, Assistant Surgeon to the London Hospital, etc., etc. 1 vol. 8vo. muslin. " This book should be in the library of every surgeon and physician. It is a valuable work of reference. It does not pretend to originality, for originality on such a subject was not wanted. But a compendium of facts was wanted, and such a compendium is this volume. We cannot part from Mr. Curling without thanking him for the information we have received."— Med. Chir. Rev. INSANITY. I. G. Millingen. APHORISMS ON THE TREATMENT ANDlMANAGEMENT OF THE INSANE, WITH CONSIDERATIONS ON PUBLIC AND PRIVATE LUNATIC ASYLUMS, POINTING OUT THE ERRORS IS THE PRESENT SYSTEM. By I. G. MILLINGEN, M.D., Late Medical Superintendent of Lunatic Asylum, Hanwell, Middlesex, etc. 1 vol. 8vo. sheep. "Dr. Millingen, in one small pocket volume, has compressed more real solid matter than could be gleaned out of any dozen of octavos on the same subject. We recommend his vade mecum as the best thing of the kind we ever perused."—Dr. Johnson's Review. CHEST. Wm. Stokes, M.D. A TREATISE ON THE DIAGNOSIS AND TREATMENT OF DISEASES OF THE CHEST. By WM. STOKES, M.D., M.R.I.A., Etc. Second Edition, with an Introduction and Numerous Notes, BY THE AMERICAN EDITOR. 1 vol. 8vo. sheep. "Altogether this is one of the most useful of the publications that have recently issued from the press,—one that should be studied by every man who presumes to treat the class of diseases on which it is written. It is delightful, indeed, to contemplate the sound pathology and rational therapeutics which it inculcates; — so ditferent from the swelling egotism, the groundless assertions, the illogical conclusions, and often empirical treatment, recommended in some of the modern works on these and other important medical subjects."—Med. Examiner. " The present edition has been much enriched both by the author and editor. No inconsiderable patt of the book is made up of Dr. Bell's notes, and it now constitutes one of our most useful treatises on the diseases of the chest, characterized by sound pathology and rational therapeutics."—New York Journal of Medicine. " So well-known are the writings of Dr. Stokes, that no effort of the medical press in this country is necessary to increase their circulation. Young practitioners would find this volume a pathological guide, which they would be unwilling to part with, when made familiar with its intrinsic value."—Boston Med. and Surg. Journ. aaa=— 2 13 BARRINGTON &. HASWELL'S G. Hume Weatherhead, M.D. A PRACTICAL TREATISE ON THE PRINCIPAL DISEASES OF THE LUNGS. CONSIDERED ESPECIALLY IN RELATION TO THE PARTICULAR TISSUES AFFECTED, ILLUSTRATING THE DIFFERENT KINDS OF COUGH. By G. HUME WEATHERHEAD, M.D., Member of the Royal College of Physicians, Lecturer on the Principles and Practice of Medicine, and on Materia Medica and Therapeutics, etc., etc. 1 vol. 8vo. muslin. W. W. Gerhard, M.D. LECTURES ON THE DIAGNOSIS, PATHOLOGY, AND TREATMENT OF DISEASES OF THE CHEST. By W. W. GERHARD, M.D., Lecturer on Clinical Medicine in the University of Pennsylvania, etc. 1 vol. 8vo. sheep. 2d edition just ready. NOTICES TO THE FIRST EDITION. " A series of clinical lectures—concise, lucid, and eminently instructive. We have no more able expositors of diseases of the chest than Dr. Gerhard, and any work of his on these important subjects is certain of grateful acceptance by his professional brethren."—New York Lancet. " To our readers, therefore, we recommend the book of Dr. Gerhard as the fullest and most judi- cious manual, in relation to the diseases of the chest, which they can procure."—Western and Southern Recorder. " These lectures constitute a useful and practical digest of the existing knowledge of the diseases of the chest (lungs and heart)."—Bulletin of Medical Science. Charles J. B..Williams, M.D. LECTURES ON THE PHYSIOLOGY AND DISEASES OF THE CHEST5 INCLUDING THE PRINCIPLES OF PHYSICAL AND GENERAL DIAGNOSIS, Illustrated by an Exposition of their Physical Signs. WITH NEW RESEARCHES ON SOUNDS OF THE HEART. By CHARLES J. B. WILLIAMS, M.D. Fourth edition, in preparation. 1 vol. 8vo. sheep. " Evidently written by a man thoroughly acquainted with his subject."—Lancet. " We strongly recommend this work to the attention of auscultators."—Med. Chir. Rev. A" I gladly avail myself of this opportunity of strongly recommending this very valuable work."— Dr. Forbes's Translation of Laennec. ^ " Of all the works on this subject, we are much inclined to prefer that of Dr. Williams."—Med. Gazette. 14 MEDICAL PUBLICATIONS. .THE HEART. T. A. Aran. A PRACTICAL MANUAL ON DISEASES OF THE HEART AND GREAT VESSELS. Translated from the French, By WILLIAM A. HARRIS, M.D. " This is an excellent epitome of a large and important class of diseases—especially as to diagnosis."—Med. Chir. Rev. "The Treatises of Senac, of Corvisart, of Laennec, of Bertin, of M. Bouillaud, of M. Gendrin, and especially the excellent work of an observer whom death has pre- maturely removed from the field of science (Dr. Hope), have been our principal guides."—Extract from the Preface. " This work, though issued under the modest title of a manual, is yet so comprehen- sive as to afford minute instruction on every point of which it treats."—Philad. Med. Examiner. " We do not know of any production in which so much positive knowledge has been compressed within moderate limits, and yet clearness of description presented, as in this manual.''—Bulletin of Med. Science. " We hope this manual, comprising, as it does, a summary of what has been published in more elaborate works, will be extensively read, and that the study of it may lead to a more correct appreciation of the character of these diseases."—West. Jour, of Med. and Surg. " The present treatise will prove of great value, as it really contains all that is well known on this most difficult yet important branch of pathology and therapeutics."—West. Iiaacet. I\ John Marshall, M.D. (3 PRACTICAL OBSERVATIONS '() t(l ON DISEASES OF THE HEART, LUNGS, STOMACH. LIVER, ETC. U OCCASIONED BY SPINAL IRRITATION: J AND ON THE NERVOUS SYSTEM IN GENERAL, AS A SOURCE OF ORGANIC DISEASE. | Illustrated by Cases. \ By JOHN MARSHALL, M.D. 1 vol. 8vo. muslin. CUTANEOUS DISEASES. Samuel Plumbe. APRACTICAL TREATISE ON DISEASES OF THE SKIN, Their Constitutional Causes and Local Character, etc. By SAMUEL PLUMBE, Late Senior Surgeon to the Royal Metropolitan Infirmary for Children, &c. a Illustrated with Splendid Coloured Copper-plate and Lithographic Engravings. New edition, greatly enlarged, in preparation. Plumbe on Diseases of the Skin.—"This excellent Treatise upon an order of diseases, the pathology of which is, in general, as obscure as the treatment is empirical, has just been repub- lished, editediy Dr. John Bell, of this city. We hail with pleasure the appearance of any new work calculated to elucidate the intricate and ill-understood subject of skin-diseases. The late Dr. Mackintosh, in his Practice of Physic, recommends it as the 'best pathological and prac- tical treatise on this class of diseases, which is to be found in any language.'"—Phil. Med. Exam. "This work is one of the most excellent on the Diseases of the Skin in the English language." — West. Jour, of Med. and Phys. Sciences. 13-^ ~ ~ _=^ BARRINGTON &. HASWELL'S «*---------------------------:---------------------------------------------------------------------■----------—------------------------------------- Thomas Nunneley. A TREATISE ON THE NATURE, CAUSES, AND TREATMENT OF ERYSIPELAS. By THOMAS NUNNELEY, Lecturer on Anatomy, Physiology, and Pathology in the Leeds School of Medicine, Surgeon to the General Eye and Ear Infirmary, &c, &c. 1 vol. 8vo. sheep. "Nothing short of a perusal of the entire book will do justice to the author or reader."— Western Lancet. " The work in its entireness is one which will be accounted necessary to every physician's library."—Western Journ. of Medicine and Surgery. " Did our space allow, it would be both interesting and profitable to enter into a full analysis of this work; but we would advise our readers, one and all, to purchase it, and thus judge of its value from a personal examination of its pages."—N. Y.Jour. Med. and Collat. Sciences. " Mr. Nunneley contends, and we think with success, that puerperal fever and ery- sipelas are one and the same disease, modified by the seat of the inflammation." — N. Orleans Med. Jour. CLINICAL MEDICINE. P.M. Latham, M.D. LECTURES ON SUBJECTS CONNECTED WITH CLINICAL MEDICINE. By P. M. LATHAM, M.D., Fellow of the Royal College of Physicians, and Physician to St. Bartholomew's. 1 vol. 8vo., newly arranged and enlarged, in preparation, sheep. " We strongly recommend them [Latham's Lectures] to our readers; particularly to pupils attending the practice of our hospitals."—Lond. Med. Gas. Graves and Gerhard. CLINICAL LECTURES. By ROBERT J. GRAVES, M.D., M.R.I.A., Professor of the Institutes of Medicine in the School of Physic, Trinity College, Dublin. WITH ADDITIONAL LECTURES AND NOTES, By W. W. GERHARD, M.D., Lecturer on Clinical Medicine to the University of Pennsylvania, Physician to the Philadelphia Hospital, Blockley, &c. 1 vol. 8vo. sheep. "In the volume before us, a series of clinical lectures by Dr. Gerhard is given, and forms a most appropriate and acceptable addition to those of Dr. Graves. Between these two distinguished physicians we can trace many points of resemblance. We find in both the same professional zeal, — the same powers of close and correct observation, — the same discriminating tact, — the same disregard of idle theory,—and the same decision in the application of right principles. No stu- dent or practitioner should be without this volume. It is in itself a library of practical medicine." —JV. Y. Lancet. -=ag MEDICAL PUBLICATIONS. G. Andral's CLINIC ON DISEASES OF THE ENCEPHALON- ABDOMEN. CHEST. Either of the works can be had separate — each forming a distinct volume. Three vols. 8vo. sheep. « The ' Cliniaue Medicate' is the great work of its distinguished author. It is an immense store- house of invaluable information in pathology and therapeutics. No medical library can be complete without it; and every physician, with the smallest pretensions to scientific attainment, or who is desirous of discriminating disease accurately, and of treating it skilfully, should study its pages by *" Andr^afs^extensive researches in pathology entitle all his works to the careful considera- tion of the profession ; and all must agree that this great philosopher has enriched the science with many important truths, derived from that fruitful source, clinical observation and induc- tion.''— Western Lancet. URINARY DISEASES. Rohert Willis, M.D. URINARY DISEASES AND THEIR TREATMENT. By ROBERT WILLIS, M.D., Physician to the Royal Infirmary for Children, etc., etc. "Our notice of Dr. Willis's work must here terminate. It is one which we have read and trust again to read with profit. The history of discovery is successfully given ; cases curious and important, illustrative of the various subjects, have been selected from many new sources, as well as detailed from the author's own experience, chemical analyses, not too elaborate, have been afTorded, which will be most convenient to those who wish to investigate the qualities of the urine in disease ; the importance of attending to this secretion in order to a proper un- derstanding of disease is strongly insisted upon: in short, a book has been composed, which was much required, and which we can conscientiously and confidently recommend as likely to be useful to all classes of practitioners."—.Brit. % For. Med. Rev. ci.,_- SURGERY. Abraham Colles. THE COURSE OF LECTURES ON SURGERY, Delivered in the Royal College of Surgeons m Ireland, By the late ABRAHAM COLLES, M.D., For Thirty-four years Professor of Surgery in the College^ From notes collected and repeatedly revised hy SIMON M'COY, ESQ., F.R.C.S.I. " We feel assured that no medical library in the kingdom will long remain devoid of these volumes."—Dublin Hospital Gazette. " We have no hesitation in affirming that they constitute a belter body of surgery than is to be found in any volume which has been offered to the American profession in so accessible a form."—Western Journ. Med. $■ Surg. " We have concluded our perusal of these lectures with a very high opinion of the judgment and surgical acumen of the late Professor Colles, and can confidently recommend the work as one replete with sound doctrines and practical facts."—Loud. Med. Gaz. "The volume before us is evidently the work of a man of accurate observation and ex- tended experience : not the closet production of a compiler who has acquired his knowledge of diseases only from the recorded observations of others."—JV. Y. Journ. of Med. " They are characterized by great vigor of thought, with a singular simplicity of expression, which will fix the attention of the most careless reader. "Those who wish to study surgerv. stripped of its technical verbiage, must read these lec- tures as they fell from the lips of this distinguished Irish professor."—JV. O. Med. and Surg. Journ. BARRINGTON &. HASWELL'S Professor Gross, M.D. .usr EsiPumnEsni^iFAiLi ashd GMnmmAJL m@wimi,S' ISTO THE NATURE AND TREATMENT OF WOUNDS OF THE INTESTINES. By SA3IUEL D. GROSS, M.D., Professor of Surgery in the Louisville Medkal Institute. Illustrated by Engravings. 1 vol. 8vo. muslin. " We consider it a valuable contribution to our literature, and as worthy of the feign reputa- tion of the author."—Philad. Med. Exam. " We dismiss the ' Experimental Inquiries,' fully persuaded that the valuable truths with which they abouud, will be the best recommendation to the medical public."—N. 0. Med. Jour. Liston and Gross. ELEMENTS OF SURGERY. By ROBERT LISTON, Fellow of the Royal College of Surgeons in London and Edinburgh, Surgeon to the Royal Infirmary, Senior Surgeon to the Royal Dispensary for the City and County of Edinburgh, Professor of Surgery in the London University, etc., etc Edited by SAMUEL D. GROSS, M.D., Professor of Surgery, Louisville Medical Institute. Author of Elements of Patho- logical Anatomy, etc., etc. Fourih American, from the last London Edition, with upwards of one hundred and sixty illustrative Engravings. 1 vol. 6vo. sheep. " We must not forget to mention that the volume is rendered still more attractive by the addition of numerous wood engravings (some of them introduced by Dr. Gross), all finely executed. These will be found of very considerable advantage to the student, materially assisting him in compre- hending the explanation of morbid structure. Another admirable feature, is the printing of the notes in type of the same size as that of the text. This obviates almost entirely whatever objec- tions can be alleged against foot-notes."— Western Jour, of Med. and Surg. " We are here presented with a republication of Mr. Liston's admirable and much praised work on Surgery, which has been subject to the alembic of a critical and learned friend, Dr. Gross. He has added 'copious notes and additions,' such as the progress of surgery in the United States demands in order to meet the wants of the surgeon. Professor Gross has also given an entire article on Strabismus, and another on Club Feet, which were wholly omitted in the English copies. They may be regarded important, inasmuch as they give a completeness to an otherwise unfinished treatise. The execution of the book is good; the paper firm, and well secured in the binding. The plates are uniformly well executed, and the impressions distinct."—Boston Med. and Surg. Jour. "In another essential feature this edition is greatly improved. With the principles is taught also with it the practice of surgery; and both morbid structure and operations are doully described ; first by the author and editor, and next by the graver of the artist."—Bull. Med. Scien. "Mr. Liston's reputation as a clear, accurate, and scientific surgical writer, is so widely known and admitted, that formal panegyric is quite unnecessary. Dr. Gross has discharged his duties as editor, with all the sound sense" accurate discrimination, and experienced judgment, which all who knew him expected. The additions and notes are indeed profitable and interesting ; and our only regret is, that they are not still more numerous than they are. The volume is inscribed to Profes- sor Parker, of the College of Physicians and Surgeons in this city,—the beauty of its typography, and • getting up,' will be readily taken for granted by all who know the publishers—and t lie illus- tri;llve engravings are executed in a style very creditable to American art."—JV. Y. Lancet. " Mr. Liston has seen much, thinks accurately, and speaks independently. From a volume written by such a man, more really valuable practical instruction is to be derived than from )',?. oks tn!lt were ever compiled."— Western and Southern Med. Recorder. 'This is a work of established reputation. It has gone through two editions in Great Britain, and the same number in this country. The additions of the American edition are copious, and add materially to the value of the work."—Jimer. Jour. Med. Sciences. "The author is bold and original in his conceptions, accurate in deductions, plain and con- cise in style ; a combination of good qualities not often found united in a single volume. The. notes and additions by Prof. Gross, are well arranged and judicious, supplying some evident fl deficiencies in the original work."— Western Lancet. \\ MEDICAL PUBLICATIONS. Sir Astley Cooper, Bart. LECTURES ON THE PRINCIPLES AND PRACTICE OF SURGERY. By FREDERICK TYRRELL, Esq., Surgeon to St. Thomas's Hospital, and to the London Ophthalmic Infirmary. Fifth American, from the last London Edition. 1 vol. 8vo. sheep. John Hunter. LECTURES ON THE PRINCIPLES OF SURGERY. By JOHN HUNTER, F.R.S. With Notes, By JAMES F. PALMER, Senior Surgeon to the St. George's and St. James's Dispensaries, etc., etc. With Plates, 1 vol. 8vo. sheep. " We cannot bring our notice of the present volume to a close without offering our testimony to the admirable manner in which the editor and annotator has fulfilled his part of the under- taking. The advancements and improvements that have been effected, up to our own day, not only in practical surgery, but in all the collateral departments, are constantly brought before the reader's attention in clear and concise terms."—Brit, $ For. Med. Rev. VENEREAL. John Hunter, F.R.S. TREATISE ON THE VENEREAL DISEASE. With Notes, By Dr. BABINGTON. With Plates. 1 vol. 8vo. " Under the hands of Mr. Babington, who has performed his task as editor in a very exemplary manner, the work has assumed quite a new value, and may now be as advantageously placed in the library of the student as in that of the experienced surgeon."—Brit. Sc For.Med. Rev. " The note9, in illustration of the text, contain a summary of our present know- ledge on the subject; the manner in which these notes are constructed is at once clever and perspicuous; and the modes of treatment prescribed, spring from a right apprehension of the disease. We would recommend to the reader the note on the primary venereal sore; the note itself is an essay in every word of which we fully concur."—Med. Gaz. BARRINGTON &. HASWELL'S THE SPINE. R. W. Bampfield. ON CURVATURES & DISEASES OF THE SPINE, INCLUDING ALL THE FORMS OF SPINAL DISTORTION. By R. W. BAMPFIELD, One of the Surgeons to the Royal Metropolitan Infirmary for Diseases of Children. Edited by J. K. MITCHELL, M.D., Professor of the Practice of Medicine in Jefferson Medical College of Philadelphia, &c, &o. " The very best treatises on spinal diseases and their treatment extant."—Med. Exam. " We heartily recommend this book to all who feel an interest in the matter, and especially in these days of degenerating specialties."—Neio York Journal of Medicine. " The treatise is a very valuable one, and we cheerfully recommend it to the pro- fession." — New Orleans Med. Journ. TH E EAR. George Pilcher. A TREATISE ON THE STRUCTURE, ECONOMY, AND DISEASES OF THE EAR. BEING THE ESSAY FOB WHICH THE FOTHEHGILLIAIT GOLD MEDAL WAS AWABDED BT THE MEDICAL SOCIETT OF IOXBOS. By GEORGE PILCHER, Late Lecturer on Anatomy, Lecturer on Surgery at the Theatre of Anatomy and Medi- cine, Webb St., Borough, and Senior Surgeon to the Surrey Dispensatory. First American, from the Second London edition, with Notes and numerous Illustrative Plates. 1 vol. 8vo. sheep. " The perusal of this work has afforded us much pleasure — A work was wanted to place the whole subject within the grasp of all persons who chose to devote some little exclusive or particular study to the diseases of the ear, and this has fairly and well supplied the place."—Med. Chir. Ret. " Mr. Pilcher is an experienced, well-informed, and able practitioner, and his treatise on the ear deserves to be ranked amongstthe best which have appeared upon the interesting, but too generally neglected, department of surgery to which it relates."—Maryland Med. and Sukg. Journ. "This is a most valuable treatise, illustrated with elegant plates, is a standard work, and must have a great sale in its present form. It tells all about the anatomy and diseases of the ear."— #. Y. Herald. GUMS. George Waite. THE GUMS: WITH LATE DISCOYEBIES ON THEIH STRUCTURE. GROWTH. CONNECTIONS, DISEASES. ANO SYMPATHIES. By GEORGE WAITE, Member of the London Royal College of Physicians. 26 MEDICAL PUBLICATIONS. TEETH. Just published. Fox & Harris. THE NATURAL HISTORY AND DISEASES OF THE HUMAN TEETH. By JOSEPH FOX, M.R.C.S.L. Member of the Society of Medicine, Paris ; Lecturer on the Structure and Diseases of the Teeth, at Guy's Hospital; and Surgeon-Dentist to their Royal Hignesses the Dukes of Kent and Sussex. First American from the Third London Edition. Remoddeled, nith an Introduction, and nearly two-thirds of additional matter. ByCHAPIN A. HARRIS, M.D.,D.D.S. Professor of Practical Dentistry and Dental Pathology in the Baltimore College of Dental Surgeons; Member ofthe Medico-Chirurgical Faculty of Maryland; Author of Principles and Practice of Dental Surgery, &c, &c. Illustrated with Thirty Plates. 1 vol., super-royal, 8vo. sheep. John Hunter. A TREATISE ON THE TEETH. By JOHN HUNTER. With Notes, by THOMAS BELL, F.R.S. With Plates. 1 vol. 8vo. muslin. " The treatise on the teeth is edited by Mr. Bell, a gentleman accomplished in his art. Mr. Bell has studied his subject with the greatest minuteness and care; and in appropriate notes at the foot of the page corrects the author with the air of a gentleman, and the accuracy of a man of science. The matter contained in these short notes forms an ample scholum to the text; and withoht aiming at the slightest display of learning, they at the same time exhibit a readykr.owledge on every point, and an extensive information both of comparative anatomy and pathology."—Med. Gazette. ¥ BARRINGTON &. HASWELL'S _*----------------------- MINOR SURGERY. Henry H. Smith, M.D. MINOR SURGERY: o®, mmsa ©ss vmm wynssx-mAX Bwsnui ®i? ran ®wm®:i»o By HENRY H. SMITH, M.D., Lecturer on Minor Surgery, Fellow of the College of Physicians, etc., etc Illustrated by numerous Engravings. 1 vol. 18mo. muslin. " And a capital little book it is.....Minor Surgery, we repeat, is really Major Sur- gery, and any thing which teaches it is worth having. So we cordially recommend this little book of Dr. Smith's."—Med. Chir. Rev. " This beautiful little work has been compiled with a view to the wants ot the pro- fession in the matter of Bandaging, &c, and well and ably has the author performed his labours."—Med. Examiner. . . . "Tostudents we would particularly recommend Dr. Smith's work; and with it in their possession, they would be able to carry out to great advantage the advice of an eminent professor of a neighbouring city — ' Provide yourselves each with half a dozen rollers, and after your day's study is over, just before going to bed, amuse yourselves by bandaging each other. It is the only way to acquire an art, ignorantly underrated, but of immense importance.' "—Boston Med. and Surg. Journ. "This is an excellent Treatise on Bandaginc,and will prove of great assistance to the student and to the country practitioner." " The book is very handsomely illustrated with a great number of excellent wood-cuts. The paper and type are good. We repeat, in conclusion, our very favour- able estimation of its merits."—Med. Exam. " We vemure to" predict for this little volume a successful career, for we have here a means adapted to an end " " Here are furnished to the student all the various inventions and modifica- tions of bandages and apparatus, more especially by the American Surgeons, Fhysick, Dorsey, Gibson, Barton, Coates, Hartshorne, and N.R.Smith."—N. Y. Jour, of Med. _ " We have no hesitation in asserting, that it is an excellent, we were going to say indispensable, aid to all those who wish to qualify themselves for the practice of surgery."—Bull, of Med. Science. MIDWIFER'S' AND DISEASES OF WOMEN, Robert Lee. LECTURES ON THE THEORY AND PRACTICE OF MIDWIFERY. DELIVERED IN THE THEATRE OF ST. GEORGE'S HOSPITAL. Bx ROBERT LEE, M.D., F.R.S., Fellow of the Royal College of Physicians, London; Physician to the British Lying-in Hospital; and Lecturer on Midwifery at St. George's Hospital. Illustrated with numerous Wood Engravings. 1 vol. 8vo. " Dr. Lee's former reputation for large practical knowledge of obstetrics is fully sustained in the present work." " The style is plain and clear, and the facts and cases are presented with due succinctness. One important feature is the introduction of tables of the results of certain operations, as of craniotomy, and of certain diseases of the puerperal state, as puerperal fever; which constitute a statistical basis for future observations and a present support for active and available practice."— Bulletin of Medical Science. " Dr. Lee is too good and sensible an author to be reviewed. He should be read. He has already, though but a young man, become illustrious by his earlier works." —Pkilad. Med. Exam. " We can cheerfully commend it to the notice of students of medicine."—Western Lancet. " It is the production of a highly cultivated and practical mind, and has been ela- 22 MEDICAL PUBLICATIONS. borated with a degree of judgment and care which must render the Lectures a valu- able record of professional learning and experience."—Western Journal of Med. Sciences. " While they are Well adapted for the instruction of the student of midwifery, the Lectures of Dr. Lee may be consulted by the young practitioner with much satisfac- tion and profit. The wood engravings, by which the text is accompanied, are well executed, and communicate a very accurate idea of the subjects they are intended to illustrate."—Amer. Jour. Med. Science. " Every passage will indicate in the author a discriminating, practical mind, en- lightened by learning, and extensive observation." "It is a storehouse of facts from which the student may enrich his mind, and to which the practitioner may apply to refresh his memory."*- Western Jour. " The aim of the publishers was to give to the profession one of the very best systems of midwifery in the language for the least money — to place a volume of unquestionable excellence within the reach of every medical man in the country. They have been successful."—Ibid. "The present production of Dr. Lee will always rank high, as the offspring of a vigorous mind, stored with all the learning relating to the subject, and enriched with the results of the most extensive experience." — N. Orleans Med. Jour. PRINCIPLES James Blundell, M.D. LECTURES ON THE AND PRACTICE OF MIDWIFERY. By JAMES BLUNDELL, M.D. Edited bt Charles Severn, M.D. 1 vol. 8vo. sheep. " The eminently fluent and agreeable style — the large and accurate information —the great experience, and original mind of Dr. Blundell, have secured for him a very enviable reputation as a public lecturer. It is impossible to read these lectures without being delighted —it is equally im- possible to avoid being instructed. Were these discourses more generally diffused and studied here — were their sound and judicious directions recollected, and their salutary cautions observed, we would hear of fewer cases of malpractice. This work forms a complete system of midwifery, with the diseases of the puerperal state and of the infant.''—N. Y. Lancet. Robert Collins, M.D. A PRACTICAL TREATISE ON MIDWIFERY. CONTAINING THE RESULTS OF SIXTEEN THOUSAND SIX HUNDRED AND FIFTY-FOUR BIRTHS, OCCURRING IX THE DUBLIN LYING-IN HOSPITAL. Bt ROBERT COLLINS, M.D., Late Master of the Institution. 1 vol. 8vo. sheep. "The author of this work has employed the numerical method of M. Louis ; and by accurate tables of classification, enables his readers to perceive, at a glance, the consequences of the diversified conditions, in which he saw his patients. A vast amount of information is thus contained,which is invaluable to those who duly appreciate precision in the examination of cases."—Bait. Ckron. Robert Gooch, M.D. A PRACTICAL COMPENDIUM OF MIDWIFERY, Being the Course of Lectures on Midwifery, and on the Diseases of Women and Infants delivered at St. Bartholomew e Hospital. By the late ROBERT GOOCH, M.D. PREPARED BY GEORGE SKINNER, Member of the Royal College of Surgeons, London, 1 vol. 8vo. sheep. l^==- 23 BARRINGTON &, HASWELL'S PUERPERAL FEVER. Gordon, Hey, Armstrong, Lee, and Meigs. THE HISTORY, PATHOLOGY, ANO TREATMENT OF PUERPERAL FEVER AND CRURAL PHLEBITIS. By Drs. Gordon, Hey, Armstrong, and Leb. With an Introductory Essay By CHARLES D. MEIGS, M.D., Professor of Obstetrics and the Diseases of Women and Children in the Jefferson Medical College, Philadelphia. I vol. 8vo. sheep. " We have peculiar satisfaction, in announcing the publication of this very judiciously arranged series of treatises, on one of the most important and interesting diseases, which demand the atten- tion of the physician." "Dr. Meigs's Introductory Essay is concise and judicious, and will be read with profit. He speaks in the highest terms of commendation of Dr. Gordon's invaluable treatise — a treatise which cannot be too generally diffused and studied. Altogether this volume presents the most acceptable and useful compend of the doctrines and practice of the best authorities, with regard to ' Puerperal Fever,' with which we have ever met."—N. Y. Lancet. " We are pleased to see the republication of these valuable monographs upon Puer- peral Fever. As they are all of them Essaysfounded upon an extensive observation, and contain a very large number of recorded cases, they must always be valuable." — Neio England Journal of Medical Science. " Taken in connexion, the treatise it comprises present an invaluable mass of facts in relation to Child-bed Fever, without an acquaintance with which no one can, with propriety, be considered fully qualified to undertake its management."—Journal of Medical Science. UTERUS. Waller, Lisfranc, and Ingleby. LECTURES ON THE FUNCTIONS AND DISEASES OF THE WOMB. By CHAS. WALLER, M.D., Bartholomew's Hospital. ON DISEASES OF THE UTERUS AND ITS APPENDAGES. By M. LISFRANC, La Pitie Hospital. ON DISEASES OF THE PUERPERAL STATE. By J. T. INGLEBY, Edinburgh. 1 vol. 8vo. sheep. " We can very cordially recommend them as affording a concise and practical exposition of the pathology and treatment of a most imporiant class of diseases, and which cannot be too attentively studied."—N. Y. Lancet. " The present volume contains a short and succinct practical account of the principal morbid states.either of the functions or the structure of the womb, the best methods of distinguishing them, and the means which experience has shown to be the most effectual in removing them. The reader will find that he obtains, in a small compass, a distinct view of the nature and treatment of each disorder."—Edinb. Med. and Sure. Journ. MEDICAL PUBLICATIONS, 1 TO XXCOLOGtr. Robert Christison, M.D. A TREATISE ON POISONS IN RELATION TO MEDICAL JURISPRUDENCE, PHYSIOLOGY, AND THE PRACTICE OF PHYSIC. By ROBERT CHRISTISON, M.D., F.R.S.E., Professor of Materia Medica in the University of Edinburgh, &c, &c. "We cannot but hail with satisfaction a new edition of this standard classical book. It merits are too well acknowledged for it to be necessary to say anything further in its behalf. Wherever Toxicology is known as a science, Professor Christison's Treatise is received as an authority of the greatest weight." — Lancet. " It has, for a long period, been in the hands of barristers, who have not failed to make a good use ofit in the cross examination of medical witnesses; and we believe there are few medical men who venture into the witness box on a trial for poisoning, without having at least consulted it respecting some point on which their evidence is likely to be impugned."— Lond. Med. Guz. " Such is a most imperfect sketch of this most valuable work. It would be an ac- quisition to any medical library, and we think particularly so to our friends in this part of the world.'' — New Orleans Mtd. Journ. " The First American from the Fourth Edinburgh edition of this unsurpassed work has appeared. The American profession will have within their reach the ablest treatise in the language on the subject of poisons."— Western Journal. "The work of Professor Christison being recognised, by common consent, as the standard authority on this subject, it is unnecessary to do more than announce its publication."— New York Journal of Medicine. "It would be a work of supererogation, at the present day, to speak of the merits of this work. It has long and justly been regarded as one of our standard authori- ties " — Med. Exam. " Dr. Christison's is a very superior guide for the general practitioner and student." — Med. Chir. Rev. " A work abounding in original observations and opinions, exhibiting the science of Toxicology in its present advanced state, and entitled therefore to take the first rank in its class, is what might have been looked for from his pen."— West. Jour. Med. Sciences. " We are free to say that it is the best book on the subject in the English lan- guage."— Western Lancet. '■ This book is of the very highest authority on the subject of poisons, and may be said to exhaust it."—Western. Law Library. "The author has, with singular industry, brought within the compass of a single volume,every variety of useful information and illustration connected with the subject. It is an invaluable addition to the Library of the Advocate." —Am. Law Library. " It has now deservedly become a standard authority in courts of law; and, on all difficult questions connected with toxicology, it is a work for reference to judges, barristers, and medical practitioners."—Brit, and For. Med. Rev. Extract from a letter of Chief Justice Taney, dated Baltimore, July 28, 1845. " The whole subject is clearly and well arranged, and the symptoms, effects, and tests of different poisons very fully and plainly stated. Accept my thanks for the book. It cannot fail, I think, to be generally consulted and approved by those who, from professional duty, or any other motive, may be culled upon to investigate the difficult, and often painfully delicate subject, of which it treats." Extract from a letter of Judge Story, dated Cambridge, April 18, 1845. " I return you my sincere thanks for your kindness in presenting me with a copy of Professor Christison's Treatise on Poisons. It appears to me to be a most valu- able and important work on the subject, and full of interest, not only to the medical profession, but to lawyers. I have rarely examined any book with more satisfaction ; and I shall certainly recommend it to be purchased for our Law Library at Cam- bridge, as eminently deserving a high rank for the students of Medical Jurispru- dence.' Nor can I doubt that it will receive the general patronage of the public." BARRINGTON & HASWELL'S «3—-----------------------------------------------------------------------------------------*»■ DISEASES OF CHIZ.DB.EZff. Evanson and Maunsell. PRACTICAL TREATISE ON THE DISEASES AND MANAGEMENT OF CHILDREN. Br RICHARD T. EVANSON, M.D., Professor of Medicine, — and HENRY MAUNSELL, M.D., Professor of Midwifery — in the College of Surgeons, Ireland. EniTEn bt D. F. CONDIE, M.D. From the Fourth Dublin Edition. 1 vol. 8vo. sheep. *' The second chapter embraces the Management and Physical Education of Chil- dren. This chapter ought to be printed in gold letters, and hung up in the nursery of every family. It would save many lives, and prevent much suffering." —Medico- Chirurg. Rev. " As this Practical Tieatise on the Diseases of Children has before been made known to the medical public, we dare not suppose it a new thing to any intelligent practi- tioner in this country ; still, there may be those who do not own a copy—and to such there is nothing ungenerous in saying we wish that they may always have it in their power to consult such authority."—Boston Med'and Surg. Journ. " The present edition is enlarged, and in its present form constitutes one of the best works on the subject in our language.''—Philad. Med. Exam. I Michael Underwood, M.D. A TREATISE ON THE DISEASES OF CHILDREN. WITH DIRECTIONS FOR THE MANAGEMENT OF INFANTS. Bt the late MICHAEL UNDERWOOD, M.D. Bt S. Merriman, M.D., and Marshall Hall, M.D., F.R.S., Etc. with notes, bt john eell, m.d., etc., of Philadelphia. From the Ninth English Edition, with Notes, 1 vol. 8vo. sheep. Thomas J. Pettigrew. ON SUPERSTITIONS CONNECTED WITH THE HISTORY AND PRACTICE OF MEDICINE AND SURGERY, By THOS. JOSEPH PETTIGREW, F.R.S., F.S.A., Doctor of Philosophy to the University of Gbttingen, &c, &c. I vol. 12mo. " The book will prove instructive, not only on account of the extensive learnine which it displays, but the numerous and curious facts which it develops."—JV. Orleans Med Jour " Mr. Pettigrew's book is amusing to such as are inclined to smile, and instructive to'those who are willing to reflect."—Med. Chir. Rco. " From the follies of the past we may derive wisdom for the future, and there is much in the volume before us that may be profitably used for this purpose."—Med. Exam. " It is the common-place book of a literary physician with a running commentary' giving a unity and continuity to the mosaic."—Brit, and For. Med Rev. " We do not know of pleasanter reading, either for the physician in the between- whiles of professional labour, or for the general reader who loves to study human nature in its external and often eccentric workings."—Bull. .Med Science "We heartily commend this little work to the curious of all classes of readers "— N. Y. Journ. Med. and Coli.at. Sciencf.s. "We take leave of his book, from which we have derived not only entertainment but instruction. —West. Journ. J ****** MEDICAL PUBLICATIONS. J. L. Ludlow, M.D. A MANUAL OF EXAMINATIONS UPON ANATOMY AND PHYSIOLOGY, SURGERY, PRACTICE OF MEDICINE, CHEMISTRY, MATERIA MEDICA, OBSTETRICS, ETC. Designed for the Use of Students of Medicine throughout the United States. By J. L. LUDLOW, M.D. 1 vol. 12mo. "In this ' Manual of Examinations' the questions are clearly put, and, with few exceptions, well and distinctly answered." " The Manual will be found to be equally available at the three schools in Philadelphia, as at the two in New York, or those of Louisville, Lexington, and Cincinnati, or of Charleston, Augusta, and New Orleans, not to mention the numerous confreries for teaching down East." —Bull. Med. Science. " We have no hesitation in saying, that Dr. Ludlow's Manual is decidedly the best, both in relation to compreiiensiveness and general accuracy, that has yet been published in this country."—JVestcrn Lancet. " Dr. Ludlow discovers a minute knowledge with all the leading departments of professional lore, which he imparts agreeably. He is careful to be exact, without being redundant in any paragraph."—Boston Mad. and Surg. Jour. " Between all the classes whose comfort the Student's Manual is designed to pro- mote, we should think it would obtain not a little currency."—West. Journ. Jas. W. Dale, M.D. IS MEDICAL SCIENCE FAVOURABLE TO SCEPTICISM! By JAMES W. DALE, M.D. of Newcastle, Dei.. Pamphlet. G. R. B. Horner. M.D.. U.S.N. MEDICAL AND TOPOGRAPHICAL OBSERVATIONS UPON THE MEDITERRANEAN and upon PORTUGAL, SPAIN, AND OTHER COUNTRIES. BvG. R. B. HORNER, M.D., Surgeon U. S. Navy, and Honorary Member of the Philadelphia Medical Society. With Engravings. 1 vol. 8vo. muslin. " An uncommonly interesting book is presented to those who have any disposition to know the things medical in Portugal, Spain, and other countries," and " will doubtless be read, also, with marked satisfaction by all who have a taste for travels."—Bost. Med. and Surg. Jour. John G. Malcolmson, M.D. CLINICAL REMARKS ON SOME CASES OF LIVER ABSCESS PRESENTING EXTERNALLY. By JOHN G. MALCOLMSON, M.D., Surgeon Hon. E. I. C. Service, Fellow of the Royal Asiatic Society, and the Geological Society, London. 1 vol. 8vo. A 37 MEDICAL PUBLICATIONS. Thomson and Twining. DISEASES OF THE LIVER AND BILIARY PASSAGES. By WILLIAM THOMSON, One of the Physicians of the Royal Infirmary of Edinburgh ; AND CLINICAL ILLUSTRATIONS OF THE LIVER AND SPLEN. By WILLIAM TWINING, Surgeon of General Hospital of Calcutta, &c, &c. 1 vol. 8vo. sheep. " The work before us is an excellent compilation of the subject of hepatic affections, functional and structural; and, as such, it is infinitely more valuable to practitioners and students, than any original essay, however ably executed. We cannot do better, therefore, than stronsly recemmend the work as the best in the English language, on the imporiant subjects of which it treats."— Medico-Chirurg. Rev. Win. C. Wells, M.D. N ESSAY ON DEW, And several appearances connected with it. By WILLIAM CHARLES WELLS, M.D., F.R.S. JOHW HUNTER'S WORKS. Comprising his Lectures on the Principles of Surgery ; A Treatise on the Teeth ; Treatise on the Venereal Diseases ; Treatise on Inflammation and Gunshot Wounds ; Observatio7is on Certain Parts of the Animal (Economy; and a full and comprehensive Memoir. Each of the Works is edited by men of celebrity in the Medical Science, and the whole under the superintendence of JAMES F. PALMER, Of the St. George's and St. James's Dispensary. 4 vols. 8vo. This is the only complete edition of the works of the distinguished physiologist ever published in this country. " One distinctive feature of the present edition of Hunter's works has been already men- tioned, viz.; in the addition of illustrative notes, which are not thrown in at hazard, but are written by men who are already eminent for their skill and attainments on the particular subjects which they have thus illustrated. By this means, whilst we have the views of John Hunter in the text, we are enabled by reference to the accompanying notes, to see wherein the author is borne out by the positive knowledge of the present day, or to what extent his views require modification and correction. The names of the gentlemen who have in this manner assisted Mr. Palmer, are guarantees of the successful performance of their task."—Med. Gaz. Drewry Ottley. THE LIFE OF JOHN HUNTER, F^R.S. By DREWRY OTTLEY, 1 small vol. 8vo. " In the summing up of Mr. Hunter's character, Mr. Ottley exhibits equal judg- lent and candour."—Brit, and For. Med. 28 S82=- -=a Any person ordering Books to the value of Ten Dollars from the following list, and remitting the amount free of postage, will be entitled to the Bulletin of Medical Science for one year, gratis. LIST OF WORKS SUPPLIED AS SELECT MEDICAL LIBRARY EXTRAS, —BY MAIL. 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Ludlow's Student's Manual . . . . . • • $1 60 j Pettigrew's Superstitions Connected with the History and Practice of Medicine j and Surgery . . . • • • 50 < Lee's Observations on the Principal Medical Institutions and Practice^ >, of France, Italy, and Germany, Bouillaud on Acute Articular Rheumatism in geueral. Translated from > . 80 } the French, by James Kitchen, M.D. . . . . ) ^ Practical Obsei vations on Diseases of the Heart, Lungs, Stomach, ) \ Liver, &c. By John Marshall, M.D., «fcc. . . \ V . 80 \ Weatherhead oh Diseases of the Lungs . . . . ) jj Smith's Minor Surgery . . , . . . . 1 00 Davidson and Hudson's Essays on the Sources and Mode of Action of Fever . . .. • • • • • .80 Macrobin's Introduction to the Study of Practical Medicine . . 70 Sir James Clark on the Sanative Influence of Climate • . .80 Changes of the Blood in Disease. By M. 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Ingleby, Edinburgh, | 1 vol. 8vo. J Aphorisms on the Treatment and Management of the Insane ; by J. G. Mil- lingen, M.D. ....•••• 1 00 45 1 00 2 50 3 00 , 1 60 . 1 40 1 60 1 75 1 16 38 A Practical Dictionary of Materia Medica. By John Bell, M.D. 1 vol. 8vo. 2 25 1 00 Outlines of Pathological Semeiology. Translated from the German of Prof. Schill. 1 vol. 8vo. .....••■ Aretams on the Causes and Signs of Acute and Chronic Disease. From the Greek. 1 vol. 8vo. ........ Blundell's Lectures on the Principles and Practice of Midwifery. Edited by Charles Severn. 1vol. 8 vo. ..... Christison on Poisons ..•••••• Colles' Surgical Lectures ...... Heberdeu's Commentaries . )n the Arteries. Coloured Plates . Nerves. Plates ..•••• 50 WORKS IN PREPARATION. On the Diseases of Females : With special reference to their Hy- gienic Prevention and Treatment. By John Bell, M.D. In this work, the author will take pains to point out the hygienic measures required for the prevention of the diseases to which, by her anatomical and physiological peculiarities, the female is liable, independently of the merely sexual organs. The differ- ences in the nervous system, state of the blood, &c, indicate the necessity of differences, or, at any rate, notable modifications in both her physical and medical treatment. From birth, her future destiny and exposures, as mother, ought to receive more attention, in reference to the laws of hygiene, than has hitherto been given to the subject. The relative frequency of the dis- eases of the sex in different periods of life, and the value of particular modes of treatment, will be tested as much as possi- ble by statistical returns; thus correcting the fluctuations of opinion and the obtrusions of hypothesis. Principles and Practice of Medical Jurisprudence. 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BARRINGTON & HASWELL ALSO PUBLISH A VERY POPULAR EDITION OF THE OLD AND NEW TESTAMENT Without Note or Comment, in large type, 1 vol. 8vo. This edition is put up and may be had either with or without the Apocrypha, Con- cordance, Psalms, or Plates. . . . Their fine edition is of superior workmanship, and the paper on which it is printed has all of the firmness, consistency, and colour of the best European. They are in all styles of binding. AN EXPOSITION OP TH1 OLD AND NEW TESTAMENT. Wherein each chapter is summed up in its contents ; the sacred text inserted at large, in distinct paragraphs; each passage reduced to its proper heads; the seuse given, and largely illustrated. WITH PRACTICAL REMARKS ASD OBSERVATIONS, By MATTHEW HENRY. Edited by the Rev. Geo. Burder, and the Rev. Joseph Hughes, A.M.; with the Life of the author by the Rev. Samuel Palmer. TO WHICH IS PREFIXED A P REF ACE, By ARCHIBALD ALEXANDER, D.D., Professor of Theology in the Seminary at Princeton, New Jersey. First American edition, 6 vols, super 8vo. This work has elicited so decidedly the approbation of the most judicious men of the principal denomination of Christians in the United States, that the publishers deem it unnecessary to offer now many of the numerous recommendations they have received from various quarters. The following will serve to show the universal opinion with regard to this work ; From the Rev. S. H. Cone, Pastor of the Oliver Street Baptist Church, New York. " I have examined the stereotype edition of Matthew Henry's Exposition of the Old and New Testament, and take pleasure in bearing testimony to its typographical -=s THEOLOGICAL PUBLICATIONS. neatness and accuracy, and the comparative cheapness of price at which it is now offered to the American public. " Witfyreference to the intrinsic excellence of the work itself, it needs not my feeble commendation. The wise and good unite in saying, that it is calculated to render those who read it wiser and better; and having frequently derived from it edification and comfort myself, I do sincerely hope you may succeed in circulating it extensively among my fellow-citizens." The following vivid delineation of its characteristic qualities is from the pen of the Rev. Dr. Alexander, of Princeton : " A characteristic of this Exposition of a more important kind than any that have been mentioned, is, the fertility and variety of good sentiment manifest throughout the work. The mind of the author seems not only to have been imbued with excellent spiritual ideas, but to have teemed with them. It is comparable to a perennial foun- tain, which continually sends forth streams of living water. Iu deriving rich instruc- tion and consolation from the sacred oracles, adapted to all the various conditions and characters of men, the author displays a fecundity of thought, and an ingenuity in making the application of divine truth, which strikes us with admiration. The resources of most men would have been exhausted in expounding a few books of the Bible; after which little more could have been expected than common-place matter, or a continual recurrence of the same ideas ; but the riches of our Expositor's mind seem to have been inexhaustible. He comes to every successive portion of the sacred Scriptures with a fulness and freshness of matter, and with a variety iu his remarks, which, while it instructs, at the same time refreshes us. Even in his Expo- sition of those books which are very similar in their contents, as the gospels for ex- ample, we still fine a pleasing variety in the notes of the commentator. It is difficult to conceive how one man should have been able to accomplish such a work, without any falling off in the style of execution." The Rev. Edward Bickersteth says —" There is in Matthew Henry a glow of love, a full exhibition of the sense, a happy reference to the passage expounded, and lively cheerfuluess, which will ever make his work popular, useful, and indis- pensable." Dr. Doddridge 6ays,— " Henry is, perhaps, the only commentator so large that deserves to be entirely and attentively read through. The remarkable passages, I think, should be remarked. There is much to be learned from this work in a specu- lative, aud still more in a practical way." Dr. Edward Williams says, — " It is an incomparable work, and too well known to need a discriminating character." The Rev. Dr. Thomas Hartwell Home, in his valuable Introduction to the Study of the Scriptures, says, " that its high and generally known value is so just and exten- sive, that it needs no recommendation." The Rev. Adam Clarke, the Commentator, says, — " The Rev. Matthew Henry, a very eminent dissenting minister, is author of a very extensive Commentary on the Old and New Testaments, and one of the most popular works of the kind ever pub- lished. It is always orthodox, generally judicious, and truly pious aud practical." Extract of a letter from the Rev. Francis Wayland, President of Brown University. "I am gratified to hear of your intention to present the religious public with an American edition of Henry's Commentary. I know of no work of the kind iu any language which combines more sound good sense with fervent and deep-toned piety." r CONCHOLOGIST'S FIRST BOOK OR, A SYSTE M OF TESTACEOTJS MALACEOLOGY. Arranged expressly for the Use of Schools. With Coloured Illustrations of two hundred and fifteen Shells, presenting a correct type of Genus. A beautiful 12mo. vol. f EEUnY'S MAXIMS. Law's Call. A SERIOUS CALL TO A B3EYOUE AMB HOLY 3LIEJF1E. ADAPTED TO THE STATE AND CONDITION OF ALL ORDERS OF CHRISTIANS. Bt WM. LAW, A.M. Nineteenth edition, with some account of the Author. Confession of Faith. THE CONSTITUTION OF THE PRESBYTERIAN CHURCH IN THE UNITED STATES OF AMERICA, Etc., Etc., Etc. As ratified by the General Assembly, at their Session in May, 1821, and amended in 1833. 35 DOTEB. SELECTION OF E7MHS. THE PSALMS OF DATID. IN METRE. Translated and diligently compared with the Original Text, and former transla- tions ; more plain, smooth, and agreeable to the text, than any heretofore. Allowed by the General Assembly of the Kirk of Scotland. 32mo. fflHl IF©2BME HXQXDEg PRACTICAL FORMS FOR EVERY MAN OF BUSINESS. Jf\ Containing-Three Hundred of the most approved Precedents. f) \V By a Member of the Philadelphia Bar. u GHEES TESTAMENT. By WILSON. LES AVENTURES DE TELiEMAQ,I7E FILS D' UL YS SE. Par M. FENELON. KOtlVELLE EDITION, PAH M. CHAS. LE BRUN. NATIONAL LIBRARY OF NLM 031^07 5 ;•'«»<: ^i:--:: l': z-'-il ft';: >fU f -'••:; .-i : ic »; i' t f; -• : ■ r - -rr"U i< ■•:• ;L'.:i:::5??«f5c:-.ir-r-??-?H*"^*:^^ ■'' t ?i f-: ;•<»:?■:■-;i-Mf1fj3a «**£?*« ■ ■ :t: i : i* *: rfr»3 v^tj^ci-cT t, t * is ;< *<•><• * PC t*c r* \ i ::. ;'■■ i '« :